[Postoperative urological complications of transurethral electrosurgical interventions on the prostate for adenoma].

The aim of the study was comparison of urological complications after transurethral resection and its low-invasive alternatives: vaporization, rotoresection, vaporization resection, prostatic incision. Case histories were studied of 5401 patients operated endoscopically for prostatic adenoma in 1991-2003. Standard TUR was made in 5003 patients, incision--in 112, vaporization--in 119, vaporizing resection--in 107, rotoresection--in 60 patients. Of early complications after TUR hemorrhage was the most dangerous, hemotransfusion was made in 3.9% cases. No hemorrhagic complications occurred in rotoresection, no hemotransfusions were made in vaporization and vaporizing resection, prostatic incision was complicated by hemorrhage only in 0.9% cases. By infection complications rate (0.9-7.5%), the differences were not significant. Of late complications, sclerosis of the urinary bladder cervis was most frequent (10.7-11.2%) after rotoresection and vaporizing resection, urethral stricture--after TUR (6.9%). By number of complications, incision was least invasive. Thus, basic problem after TUR is hemorrhage. Low-invasive alternative methods resolve this problem. But they have limitations. The best way out is improvement of intraoperative hemostasis during TUR.

[Intraoperative urological complications in transurethral surgical interventions on the prostate for benign hyperplasia].

Wide clinical introduction of endoscopic methods in management of lower urinary tract (LUT) diseases is explained both by their high efficacy and relative safety. In spite of perfection of endourological tools, no large-scale clinical trials have been performed of late analyzing the rate of complications of endoscopic treatment of benign prostatic hyperplasia (BPH). A total of 5401 transurethral endoscopic operations were made in BPH patients. The spectrum of endoscopic operations made in the Research Institute of Urology (1991-2003) and Krasnodar Regional Hospital N 1 (1998-2003) covered the following operations: transurethral prostatic resection (5003-92.6%), transurethral prostatic incision (112-2.1%), transurethral rolling electrovaporisation of the prostate (119-2.2%), transurethral vaporizing resection of the prostate (107-1.98%), transurethral rotoresection of the prostate (60-1.1%). Overall number of intraoperative complications was 191 or 3.5%. Most frequent complications were closed and open perforation of the prostatic capsule (1.6 and 0.4%, respectively), a mechanical trauma of the prostate and urethra (0.3 and 0.15%, respectively), development of the syndrome of water intoxication (0.13%), intraoperative blood loss compensated by hemotransfusion (0.5%). Rare complications comprised injury of the ureteral ostia (0.09%), rupture of the urinary bladder (0.02%). Thus, transurethral endoscopic surgery is characterized by high safety, a trend to lowering of the number of intraoperative complications in transurethral endoscopic operations. Adherence to specification and TUR techniques leads to minimization of serious complications number.

[Endoscopic operations in invasive cancer of the urinary bladder].

Long-term results of conservative treatment of 153 patients with invasive cancer of the urinary bladder were studied retrospectively. The patients had stage T2 (n=121, 79.1%), T3 (n=26, 17%), T4 (n=6, 3.9%). All the patients had transitional cell cancer. GI, G2 and G3 tumors were registered in 104 (68%), 35 (24%) and 12 (8%) cases, respectively. 88 (57.5%) patients received combined treatment, 65 (42.5%) patients--only surgery. In the patients with a small invasive tumor of the urinary bladder subjected to surgery alone (TUR-vaporization), overall 5-year survival was 70.4%. In patients with advanced cancer of the urinary bladder who had received curative radiotherapy in case of superficial residual tumor had TUR-vaporization of the urinary bladder overall 5-year survival was 76.5%. In patients exposed to large-fraction (TFD 20-25 Gy) preoperative radiotherapy followed by TUR-vaporization, survival at this moment was 84.6%. Three-year overall and recurrence-free survival at stage T2 was 97.5 and 47.4%, respectively; at stage T3 and T4 overall 3-year survival was 57.1 and 26.6%, respectively. Thus, the conclusion is that transurethral electrosurgery in conservative therapy of patients with invasive cancer of the urinary bladder is a promising approach.

[Nephrureterectomy with endoscopic resection of the urinary bladder, ureteral ostium and terminal part in papillary tumors of the upper urinary tracts]. / Nefruéktomoiia s éndoskopochekoi rezektsiiei mochevogo puzyria, ust'ia i terminal'nogo otdela mochetochnika pri paplliarnykh opukholiakh verkhnikh mochevykh putei.

Short- and long-term results of endoscopically assisted nephrureterectomy were studied in 15 patients (7 males and 8 females aged 31-79 years) with papillary tumours of the upper urinary tracts (UUT). Of them, 11 patients have undergone transurethral endoresection of the urinary bladder, ostium and terminal part of the ipsilateral ureter followed by nephrureterectomy from the lumbotomic approach (technique 1) and 4 patients had nephrureterectomy followed by endoscopic intervention (technique 2). Results of standard open nephrureterectomy with resection of the bladder were analyzed retrospectively for 25 patients with papillary tumors of the UUT taken as control. It was found that transurethral endoscopic resection of the bladder, ostium and terminal part of the ipsilateral ureter in nephrureterectomy for papillary tumors of the UUT facilitates the performance, decreases duration and aggression of surgical intervention, diminishes number of complications, shortens hospital stay of the patients and their rehabilitation. Technique 1 is thought more ablastic and simple in performance.

[Operative treatment of benign prostate hyperplasia: modern aspects]. / Sovremennye aspekty operativnogo lecheniia dobrokachectvennoi giperplazii predstatel'noi zhelezy.

A retrospective analysis was made of the treatment results for the last 5 years of 879 patients with benign prostatic hyperplasia (BPH), 214 (24.3%) of whom had undergone transvesical adenomectomy while 665 (75.7%) had undergone transurethral resection (TUR) of the prostate. Adenomectomy had rather high effectiveness but was less safe than endoscopic intervention (higher lethality, more frequent development of myocardial infarction, pulmonary artery thromboembolism, postoperative hemorrhage). Patients operated for BPH are at risk of postoperative urethral stricture and sclerosis of urinary bladder cervix. Prebladder and postoperative stress urine incontinence appear only after open operations in BPH.

[Endoscopic and X-ray endoscopic technologies in urology]. / Endoskopicheskie i rentgenoéndoskopicheskie tekhnologii v urologii.

Present-day urology in the Russian Federation combines achievements of classic surgery with innovations of the last two decades which radically changed approaches to treatment of many urological diseases. Wide introduction in clinical practice of low invasive endoscopic and roentgenoendoscopic (endourologic) techniques is a standard for urology progress worldwide. N. A. Lopatkin, academician of Russian Academy of Medical Sciences, contributed much to advances of domestic urology. He has organized endourological service as a basis of further technological progress, introduction of low-invasive methods alternative to traumatic open surgical interventions.

[Diagnosis and treatment of recurrent surface cancer of the urinary bladder (early repeated cystoscopy and biopsy)]. / Diagnostika i lechenie retsidivov poverkhnostnogo raka mochevogo puzyria (ranniaia povtornaia tsistoskopiia i biopsiia).

In spite of some achievements in the field of oncourology, the problem of diagnosis and treatment of surface cancer of the urinary bladder (SCUB) remains urgent because of early recurrence and progression after TUR (50 and 30%, respectively). Repeated cystoscopy and biopsy early after surgery enable the physician to establish a real stage of SCUB (invasion into the bladder wall--criterion T and cell differentiation--criterion G). Early accurate staging of the disease allows design further policy of treatment. Early repeated cystoscopy and biopsy detected recurrence of transient cell SCUB in 51 (24.75%) patients. In 20 (9.7%) patients recurrent tumor located at the site of the previous operation. In other places recurrences were detected in 31 (15.05%) patients. Recurrent tumor was found in 23 (11.16%) cases at stage Ta and 28 (13.6%) patients at stage T1; in 15, 30 and 6 patients with high, moderate and low malignancy grade (22.06, 24.79 and 35.29%, respectively). SCUB progression developed in a total of 15 (7.28%) patients: by T criterion (T1-T2a) in 9 (4.37%) patients and by criterion G (G2-G3) in 6 (2.91%) patients. Thus, early repeated cystoscopy and biopsy detect early residual and recurrent SCUB facilitating design of further treatment policy.

[Experience in the clinical application of semirigid mini-urethral endoscopes in the diagnosis and treatment of urinary bladder diseases]. / Opyt klinicheskogo primeneniia poluzhestkikh miniureterorenoskopov v diagnostike i lechenii mochekamennoi bolezni.

We compared efficacy and safety of clinical application of modern semirigid miniureterorenoscopes (MURS) and standard hard-lens ureterorenoscopes (URS). The results of 335 transurethral endoscopic operations on the ureter have been analysed. Positive results of ureteroliths elimination by lithotripsy and lithoextraction were observed in 100 (77.5%) patients of group 1 (hard-lens URS) and in 175 (94.6%) patients of group 2 (semirigid MURS). Ureteral perforation occurred 3 times more often in group 1 patients than in group 2 (3.1 and 1.08%, respectively). A total number of complications observed in group 1 and 2 in the course of transurethral ureterolithotropsy and lithoextraction reached 6.3 and 1.08%, respectively. Ureterolithotomy was performed in group 2 eight times less frequently than in group 1 patients (2.1 and 17.9%, respectively). Ureteropyeloscopy made by semirigid MURS is a valuable therapeutic and diagnostic aid which raises efficacy of transurethral endoscopic manipulations, significantly lowers traumaticity of the upper urinary tracts and reduces to minimum the number of intra- and postoperative complications.

[Endotomy in treating strictures of the upper urinary tract]. / Endotomiia v lechenii striktur verkhnikh mochevyvodiashchikh putei.

The analysis of outcomes of 102 operations of transurethral and percutaneous endotomy in 100 patients is provided. Primary strictures of the upper urinary tract (UUT) were detected in 26 cases. Postoperative strictures existed up to 3 months in 19 cases, 3 to 12 months in 21 cases and at least 12 months in 36 cases. The causes of the strictures lie in previous surgical interventions on the UUT. Of the 102 endoscopic operations, 49 ones were conducted via percutaneous approach, nephrostomic fistula was used in 11 cases. In 42 endotomies the approach to UUT strictures was transurethral, a "cold knife" was applied in 78 operations, electric current in 24 cases. Follow-up for 12 months to 9 years documented good and satisfactory results in 90 (90%) patients. Open operative intervention was necessary for elimination of the intraoperative complication in 1 case, of the postoperative one also in 1 case. The remaining endotomy complications were treated conservatively. Reoperations due to endotomy failure were made in 8 cases of 10. Endotomy of UUT strictures is indicated in primary and early postoperative strictures 0-1 cm in size located at any site of normally developed UUT accessible for rigid endoscopic instruments from percutaneous or transurethral approaches.

[Endoscopic recanalization in treating ureteral obliteration]. / Endoskopicheskaia rekanalizatsiia v lechenii obliteratsii uretry.

For diagnosis of urethral obliteration we have developed a method of complex examination including x-ray and ultrasound investigations, NMR-tomography of the small pelvis and perineum. This method provides maximal significant information about defects in the urethra and adjacent tissues and organs. Endoscopic urethral recanalization was performed in 86 patients with urethral obliteration aged from 7 to 78 years. Good and satisfactory results were achieved in 46 (53.49%) and 34 (39.53%) cases, respectively. Unsatisfactory results were obtained in 6 (6.98%) patients. Two of them had enuresis, 3 developed recurrent obliteration and 1 patient died. He suffered from concurrent cardiovascular disease and died early after surgery of hemorrhage and myocardial infarction. Secondary urethral stricture after endoscopic urethral recanalization was observed in 36 (41.86%) patients. Repeated internal optic urethrotomy and chronic urethral bouginage in combination with medication at the stage of rehabilitation resulted in stabilization of the urethral lumen in 34(94.4%) patients. Serious intraoperative complications arose in 3 (3.49%) patients: perforation of the rectum (1 patient), TUR syndrome (1 patient), prostatic perforation and hemorrhage (1 lethal outcome). The complications were in all the cases explained by erroneous direction of the endoscope movement, obliteration length more than 3 cm and underestimation of the severity of the patient's condition.

[Use of alpha1-adrenergic blockaders in treating voiding disorders after transurethral resection of the prostate]. / Primeneie alpha1-adrenoblokatorov dlia lecheniia narushenii mochespuskaniia u bol'nykh posle transuretral'noi rezektsii predstatel'noi zhelezy.

Removal of infravesicular obstruction by transurethral resection (TUR) of the prostate rapidly eradicates obstructive symptoms but irritative symptoms persist. We studied the effect of alpha 1-adrenoblockers (A1AB) in respect of optimization of TUR effects. The trial was performed in 1998-2002 and included 197 patients treated surgically (TUR) for benign prostatic hyperplasia (BPH). 96 patients received no A1AB in the postoperative period (group 1). 52 patients took terazosine (group 2) and 49 patients were given tansulosine (group 3). IPSS symptoms and QoL estimation were registered monthly, the patients recorded the urination. After 3 and 6 months after TUR, maximal urination rate (MUR) and residual urine were assessed. It was found that MUR and QoL did not differ significantly between the groups but in groups 2 and 3 a fall in the overall score by IPSS was greater. The positive symptomatic improvement was achieved due to relief of the symptoms of urinary bladder filling corresponding to an increase in physiological capacity of the organ, the difference being significant (p < 0.05).

[Endoscopic treatment of bladder diverticula]. / Endoskopicheskoe lechenie divertikulov mochevogo puzyria.

Transurethral endoscopic incision of the urinary bladder's diverticular neck has been performed in 29 patients aged 44 to 90 years (mean age 65 years). 25(86.2%) patients had verified concomitant diseases and high anesthesia risk prohibiting radical surgery. According to preoperative diagnosis, the volume of the diverticula ranged from 20 to 700 ml, the diameter of the neck--from 0.3 to 2.0 cm. 10 patients had multiple diverticula. Uroflowmetry registered the maximal urinary flow rate (Qmax) within 2.1-5.3 ml/s. In all the patients surgery was performed under epidural anesthesia, simaltaneously with transurethral resection (TUR) of benign prostatic hyperplasia in 18 patients, with TUR of the urinary bladder neck or incision of the prostate because of its sclerosis in 11 patients. In 2 cases there was also TUR of the bladder for papillary cancer involving the bladder wall and the diverticulum, in 6 cases one-stage pneumatic or mechanical cystolithotripsy was performed. No intraoperative complications occurred. After the operation all the patients resumed normal micturition. Control examination after 6-48-month follow-up Qmax rose to 14.1-23.0 ml/s. Neither ultrasound investigation nor cystography detected diverticulum in 13 patients. The size of the diverticulum diminished in size in 16 patients. Residual urine in large diverticula (14 patients) was 50 ml maximum. 12 months after the operation 1 patient developed recurrent sclerosis of the prostate with reappearance of residual urine. He was reoperated (TUR of the prostate) without incision of the neck of the diverticulum. Postoperative complications were the following: mild electric burn of the thigh (1 case), acute epididimitis treated conservatively (1 case) and early postoperative bleeding which required endoscopic revision of the bladder and coagulation of the bleeding vessel from the cut neck of the diverticulum (1 case). Thus, transurethral incision of the bladder's diverticular neck is effective and low-traumatic intervention which in patients with severe somatic pathology is an alternative to the open surgery, while in patients without such pathology it does not complicate open operation (diverticulectomy) if it becomes necessary.

An endourologic approach to complete ureteropelvic junction and ureteral strictures.

BACKGROUND AND PURPOSE: Complete stricture of the ureteropelvic junction (UPJ), ureter, or both represents a secondary upper tract obstruction and is a challenge for surgical management. The endourologic repair of these complete strictures remains controversial because of the many unsatisfactory results in the literature. The aim of this study was to achieve recanalization of the ureter or the UPJ using endourologic techniques to prove durable success of this technique. PATIENTS AND METHODS: We present data on the 21 patients with complete UPJ or ureteral strictures treated over 5-year period. The length of the obliterated portion of the ureter or UPJ ranged from 0.3 to 1.7 cm. The stricture was at the UPJ level in 12 patients (57%), in the upper ureter in 3, and in the lower ureter in 4. The technique was a combined approach, with antegrade introduction of the guidewire and retrograde cold-knife incision in the majority of the cases. In five cases, the incision was carried out in the reverse direction with a guidewire introduced retrograde up to the stricture level. An originally designed 6F to 7F polyethylene double-J stent with a movable 12F to 16F silicon sheath or percutaneous tube was placed at the completion of the procedure. RESULTS: The follow-up period ranged from 6 to 48 months. Recanalization was achieved in 17 patients (81%), of whom 14 became symptom free. Other surgical outcomes necessitated open surgical intervention (pyeloplasty, nephrectomy) in two patients. One patient developed a clinically significant recurrent urinary tract infection and deterioration of kidney function. Thus, the overall success rate of the endourologic management of the complete UPJ and ureteral strictures was 67% in our series. CONCLUSION: Endourologic management with retrograde or antegrade pyeloureterotomy can be successful in patients with short (up to 1.0-cm) obliterative strictures who are without extensive hydronephrosis and with preserved renal function.

[Radiographic-endoscopic diagnosis and treatment of obliterations of the upper urinary tract]. / Rentgenoéndoskopicheskaia diagnostika i lechenie obliteratsii verkhnikh mochevykh putei.

Potentialities of x-ray endoscopic diagnosis and treatment of upper urinary tracts (UUT) obliterations were studied in 26 and 21 patients, respectively. The causes of obliteration were previous urological, surgical, gynecological operations, radiotherapy (one case). Percutaneous or transurethral UUT recanalization was performed in 5 and 16 patients, respectively. The length of the obliteration varied from 0.3 to 1.7 cm. It was located at the level of ureteropelvic segment in 13(62%), in the upper third of the ureter in 4(19%) and in the lower third of the ureter in 4(19%) patients. UUT endoscopic recanalization was successfully performed in 17(81%) patients. The operation took 60-90 minutes. Minor complications were corrected conservatively. Control examination was made after 6 to 15 years follow-up. The result was assessed as positive in the absence of clinical symptoms, recurrent stricture(obliteration), in improvement or no change in renal function. These criteria were met in 14(66.7%) patients. One patient has undergone nephrectomy because of highly deficient renal function and dislocation of the nitinol spiral outside recanalization zone. Two patients live with drained kidney in spite of UUT restored patency. The method proved effective and can be used as first-line therapy in short obliteration (< 1 cm), relatively intact renal function and in the absence of UUT marked hypotonia, more so as the failure does not complicate further surgery. Combined x-ray endoscopic diagnosis is presently most significant in determination of complete stricture(obliteration) of ureteropelvic segment and the ureter, its length and location.

[Application of resectoscope of Marberger type with cutting and vaporizing loops in the treatment of benign prostatic hyperplasia]. / Primenenie rezektoskopa tipa Marberger s rezhushchimi i vaporiziruiushchimi petliami v lechenii dobrokachestvennoi giperplazii predstatel'noi zhelezy.

One of the latest achievement in the design of tools for TUR is introduction of a new resectoscope constructed by M. Marberger. Its oval loops can remove 30% more tissue than it is made by a standard resectoscope with semicurcular loops. 203 patients with benign prostatic hyperplasia (BPH) were operated using Marberger resectoscope, 54 BPH patients were operated using a standard resectoscope. 12-month follow up results of both TURs did not differ much. The advantage of the new tool is quicker removal of the tissue.

[Vaporizing resection - a new treatment of benign prostatic hyperplasia]. / "Vaporiziruiushchaia rezektsiia" - novyi metod lecheniia dobrokachestvennoi giperplazii predstatel'noi zhelezy.

Though transurethral resection (TUR) remains a routine treatment for benign prostatic hyperplasia (BPH), its complications observed in up to 18% of patients necessitate active search for novel endoscopic methods. Vaporizing resection (VR) is among them. It makes use of two electrosurgical techniques of tissue removal--resection and vaporization--which provide adequate removal of the tissue and good coagulation. VR was made in 84 BPH patients aged 57-82 years. 19 of them had epicystostomy. 1-year follow up examination showed that complaints index by IPSS scale diminished from 21.9 to 4.6, life quality--from 3.9 to 1.1, urine residual volume--from 118 to 19 ml, maximal urination rate Qmax increased from 6.7 to 18.5 ml/s. Thus, the scheme of BPH patients' examination, the operative technique and indications in VR are the same as in TUR, while the course of the postoperative period, frequency and type of complications are typical for electrovaporization: minimum of hemorrhagic complications, low probability of TUR-syndrome, less severe postoperative period, etc.

[Electrovaporization in the treatment of bladder cancer]. / Elektrovaporizatsiia v lechenii raka mochevogo puzyria.

Specialists of the Research Institute of Urology have practiced combination of transurethral resection (TUR) with electrovaporization in endoscopic treatment of bladder cancer (BC) since 1995. A total of 46 patients with transient cell BC (29 males and 17 females aged 49-87) stage Ta-T1 (32 patients) and T2-T3b (14 patients) underwent TUR or electrovaporization (if morphologically verified) of the exophytic part of the tumor. In addition, electrovaporization of the base of the tumor was made. Main indications for such treatment were standard indications for TUR in contraindications for more radical treatment. 6-24-month follow-up was possible in 23(71.9%) patients with superficial BC (group 1) and in 9(64.2%) patients with invasive BC (group 2). Endoscopically, the recurrence was detected in 3(13%) and 5(55.5%) patients of group 1 and 2, respectively. They were reoperated on with electrovaporization. It is inferred that TUR-vaporization of the bladder is an effective endoscopic treatment of superficial BC. Electrovaporization is a good palliative treatment in patients with invasive BC when radical surgery is impossible. It inhibits the progression of the disease, prevents hemorrhages due to the tumor destruction, reduces intraoperative blood loss, improves endoscopic visualization. It may also increase the operation ablasticity.

[The endoscopic treatment of extensive urethral strictures and obliteration of the urethra and bladder neck]. / Endoskopicheskoe lechenie protiazhennykh striktur uretry, obliteratsii uretry i sheiki mochevogo puzyria.

Extensive urethral strictures, obliteration of the urethra and bladder cervix are thought to be the most complicated urological diseases. They occur more frequently in young and middle-aged persons consequently to pelvic and perineal traumas or they are complications of surgical interventions. Open surgery often cause complications such as suppuration of the operative wound, emergence of urinary fistulas, enuresis, recurrence of the structure or obliteration. Negative results of these operations are also shortening of the penis, erectile dysfunction causing serious social dysadaptation. Current advances in endoscopic instruments and imaging provided design of endoscopic techniques able to represent an effective alternative to open surgical interventions in urethral strictures, obliteration of the urethra and bladder cervix. The experience gained in the Clinic of the Research Institute of Urology in the practice of updated and novel endoscopic interventions aimed at recovery of urethral patency (strictures longer than 1 cm--inner optic urethrotomy, obliteration of the urethra and bladder cervix--endoscopic recanalization) has proved the advantages of the endoscopic techniques over open operative interventions. They are most cost-effective, result in better outcomes, bring about no erectile dysfunction.