[Risk factors for complications of ureterolithotripsy].

AIM: to determine main risk factors for complications of ureterolithotripsy. MATERIALS AND METHODS: a retrospective analysis of the results of 545 ureteroscopies performed in 506 patients with ureteral stones over the past 7 years at the urological clinic named after M.F. Vladimirsky was carried out. The relationship between preoperative and intraoperative factors and complications of ureterolithotripsy was analyzed. RESULTS: The overall complication rate was 22.4%. The risk of intraoperative complications was proved to increase (p<0.05) along with the stone size, location in proximal ureter, stone impaction for more than 3 weeks and the degree of hydronephrosis. No preoperative stenting or nephrostomy tube prior to ureteroscopy was associated to an increased risk of intraoperative complications (RR=2.88; p=0.03). Patients with preoperative drainage of upper urinary tract has lower probability of intraoperative complications (OR=0.35; p=0.03). The risk of developing stricture and ureteral obliteration in uncomplicated ureteroscopy was minimal (RR=0.008, p=0.0001). Small ureteral perforation and pronounced mucosal inflammation around the stone have the similar influence on the risk of complications, which was more than 7.5 times (p=0.0001) higher than in uncomplicated ureteroscopy. Large ureteral perforation was associated with the highest risk of stricture formation and ureteral obliteration, which was 64 times (p=0.0001) higher than in uncomplicated ureteroscopy. CONCLUSION: The rate of complications of ureterolithotripsy directly depends on the following factors: size and location of the stone, the stone impaction, pre- and intraoperative (nephrostomy tube) drainage of the upper urinary tract, the degree of hydronephrosis, level of bacteriuria and intraoperative trauma complications.

[Validation of the Russian version of the ureteral stent symptoms questionnaire (USSQ) for the evaluation of quality of life and stent-related symptoms].

INTRODUCTION: Ureteral stents are frequently used in urology practice and have a significant impact on health-related quality of life (QoL). In 2003 . Joshi et al. developed the specific questionnaire for evaluation of QoL and stent-related symptoms, namely Ureteral Stent Symptoms Questionnaire (USSQ). USSQ consists of 40 questions and 2 visual analog scales (VAS), divided into 6 domains. Over the past decade, this questionnaire has been translated into 9 languages. A Russian version of the questionnaire has not been developed yet. AIM: To perform linguistic validation of the Russian version of the USSQ. MATERIAL AND METHODS: Linguistic validation of the original USSQ was performed through a standard process including translation, back translation and pilot study. A total of 103 patients undergone ureteral stent placement and successfully filled in the Russian USSQ at weeks 1 and 4 after stenting, and at week 4 after stent removal. In addition, 30 healthy people filled in the same questionnaires twice at 3-week intervals, as a control group. To evaluate reliability, validity and sensitivity to change of the Russian USSQ, statistical analysis was performed. External criteria included validated questionnaires (EQ-5D, IPSS and pain VAS). RESULTS: Content validity was approved by experts and proved during patients interviewing. Reliability test-retest was satisfactory for urinary symptoms, body pain, general health, and work performance domains (p<0,001 between test and retest evaluation). USSQ domains showed good correlations between each other (correlation coefficient was 0,80-0,94). Cronbach's alpha coefficient of internal reliability was 0.73-0.95. Correlation between other instruments and corresponding USSQ domains was good (p<0,001), proving criterial validity. Sensitivity to changes after stenting and stent removal was also good for most domains (p less or equal 0,001). CONCLUSION: Russian version of USSQ is a valid, reliable and sensitive instrument for the assessment of QoL and stent-related symptoms and is ready for application in the routine clinical practice.

[Bilateral acute purulent destructive pyelonephritis after retrograde ureteroscopy and lithotripsy].

The problem of urinary stone disease and acute destructive pyelonephritis remains to be relevant in the current urologic practice. The acute pyelonephritis is the most common infectious and inflammatory complication after retrograde ureteroscopy. According to data of leading urologists in Russian Federation and worldwide, the incidence of acute purulent pyelonephritis ranges from 0.1 to 0.2%. Infectious and inflammatory complications of retrograde ureteroscopy often require urgent interventions. Acute pyelonephritis can result in destructive changes in the renal parenchyma. In case of ineffective conservative measures, pyelonephritis can progress into sepsis with the development of multiple organ failure. Therefore, infectious and inflammatory complications require to start combined antibacterial, anti-inflammatory and detoxification therapy, as well as to resolve any upper urinary tract obstruction. If acute pyelonephritis leads to destructive phase with a formation of a carbuncle or an abscess in the kidney, an open surgery is indicated. Despite being minimally-invasive, retrograde ureteroscopy can lead to serious complications requiring an open surgical intervention. In some cases, the severity of the patients condition may require nephrectomy.

[An adaptation of the CLAVIENDINDO classification of complications for contact ureterolithot- ripsy].

AIM: to study an adaptability of the Clavien-Dindo classification of complications for contact ureterolithotripsy. MATERIALS AND METHODS: A total of 506 patients with ureteric stones who were undergone 545 endoscopic interventions in the Urologic Department of "MONIKI" named after M.F. Vladimirsky were included in retrospective analysis. RESULTS: Complications of grade 1, II, IIIa and IIIb were noted in 39 (7.1%), 24 (4.3%), 15 (2.8%) and 14 cases (2,6%), respectively. Among the complications of grade IVa, an acute pyelonephritis was complicated by the septic shock. The complication of grade IVb developed in 1 case (0.2%). There were no complications of Grade V. The Clavien-Dindo classification allows to grade only postoperative complications and attempts to adapt it for the assessment of intraoperative complications can lead to the distortion of study results. CONCLUSION: The uncontrolled use of the Clavien-Dindo classification in all areas of surgery can lead to a decrease in its accuracy, thereby reducing its value as fairly universal tool. In our opinion, a further work aimed to the development of strict criteria for the different grades of complications of the Clavien-Dindo classifications is needed. We believe it is possible and necessary to develop a single tool for the assessment of complications of typical interventions within a single surgical area.

Soluble Ligand of the Immune Checkpoint Receptor (sPD-L1) in Blood Serum of Patients with Renal Cell Carcinoma.

The content of the soluble ligand of the immune checkpoint receptor (sPD-L1) was determined in the blood serum of 106 patients with renal cell carcinoma and 11 patients with benign kidney tumors by direct ELISA (Human sPD-L1 Platinum ELISA; Affimetrix, eBioscience). The control group included 19 healthy men and 18 women. Serum level of sPD-L1 significantly surpassed the control values in both patients with primary renal cancer (p<0.0001) and in patients examined during disease progression (p<0.05). In patients with benign kidney tumors, the level of this marker was significantly higher than in the control (p<0.05), but lower than in patients with renal cell carcinoma. The sPD-L1 level significantly increased with disease stage (p<0.001); it was higher in the presence of metastases in regional lymph nodes irrespective of their number (N1 or N2) than in the absence of metastases (N0); it was also increased in patients with distant metastases (M1) and patients with grade III-IV tumors in comparison with grade III-IV tumors (p<0.05). The highest sPD-L1 levels were recorded in patients with tumor size corresponding to T2 and T3 and decreased in patients with T4 tumors. Thus, sPD-L1 level in patients with renal cell carcinoma correlated with tumor grade and metastasizing and can be considered as a promising marker in monitoring of the effect of anti-PD1/PD-L1 therapy.

[Complications of contact ureteral lithotripsy].

Shows the current real time terminology and variants of systematization and grading of complications of contact ureteral lithotripsy (CULT). Research papers related to complications of CULT published over the last three decades were analyzed. Currently there is no clear terminology, classification, systematization and grading of CULT complications. The terms used are deficient because they do not adequately characterize specific complications of CULT. For example, some researchers define a complete ureteral avulsion as a defect at two levels, but others interpret it as a defect of the ureter at only one level. And the use of such terms as extravasation of the contrast media and/or migration of the stone outside of the ureter is groundless because these complications occur only after the perforation of the ureter wall. Therefore, these conditions are complications not of CULT but of the ureteral wall perforation. Presently, the classical classification of CULT cannot be adequately used, since it is low-structured. Universal instruments (PULS, Satava, Clavien-Dindo) have low specificity and sensitivity to CULT complications and limited possibilities of their application. Both developers of different scales of systematization of CULT complications (PULS; Satava; Clavien-Dindo) and EAU consider further international randomized studies warranted for their greater integration and adaptation.

[Questions of terminology, systematization and grading of complications of contact ureteral lithotripsy].

AIM: To investigate the advantages and disadvantages of the current variants of systematization and grading of complications of contact ureteral lithotripsy (CULT) and develop a working classification of CULT complications. MATERIALS AND METHODS: The study analyzed results of 545 fluoroscopy-guided endoscopic procedures performed at the MRRCI Clinic of Urology from 2008 to 2015 in 506 patients with ureterolithiasis. RESULTS: The proposed and implemented classification and terminology of CULT complications unifies the diagnostic and management algorithm. This tool is more systematic and structured than the classical classification and universal methods of systematization and grading of CULT complications (classifying CULT complications in "major" and "minor", PULS scale, Satava and Clavien-Dindo grading systems). Given the lack of clear grading of ureteral rupture, it was divided into amputation (two-level rupture) and avulsion (one-level rupture). Using such term as extravasation of the contrast media and/or migration of the stone outside of the ureter is groundless because these complications occur only after the perforation of the ureteral wall. Therefore, these conditions are complications not of CULT, but of the ureteral wall perforation. The ureteral perforation was classified into macro- and micro-perforation. CONCLUSION: The existing terminology, classification and grading of the CULT complications should undergo a more detailed analysis. None of the existing classifications of CULT complications afford them to be fully staged and systematized. The working classification of complications of CULT developed at the M.F. Vladimirsky MRRCI Clinic of Urology warrants a multi-center prospective study to validate it and investigate its effectiveness.

[IPSS-QOL questionnaire in assessing symptoms and quality of life in patients with anterior urethral stricture].

RELEVANCE: The IPSS-QOL questionnaire is frequently used to assess symptoms and quality of life of men with urethral strictures. However, the psychometric properties of the questionnaire in assessing these patients have not been evaluated. AIM: To test the psychometric properties of the IPSS-QoL questionnaire in assessing patients with anterior urethral strictures. MATERIAL AND METHODS: Thirty five men with anterior urethral strictures self-completed the IPSS-QoL questionnaire. The reliability of the questionnaire was estimated by computing Cronbachs coefficient and the "point-scale" correlation coefficients. Validity was assessed by the "external criteria" - the correlations between the questionnaire scores and objective indicators - maximum urinary flow rate (Qmax) and residual urine volume (Ures), between QoL scores and index values and EQ-5D scores using a VAS rating scale. RESULTS: The content validity of the IPSS-QoL was assessed by experts and patients: the storage symptoms were found insignificant for patients with anterior urethral stricture, while the symptoms of primary importance (post-micturition dribbling) were not covered. Cronbachs coefficient of reliability was 0.65 (0.55-0.69 with one of the questions removed), i.e. it was below the generally accepted threshold of 0.7. The "point-scale" correlation coefficients ranged from 0.146 to 0.585; for 2 of the 7 questions they were lower, than the conventional threshold of 0.2, showing the internal inconsistencies of the questionnaire. The construct validity assessment showed no correlation between the questionnaire scores and objective indicators Qmax (R=0.178, p=0.306), Ures (R=-0.074, p=0.673). Correlations between QoL scores and index values and EQ-5D scores on the VAS were weak and statistically insignificant: R=-0.26, p=0.18 and R=-0.21, p=0.27, respectively. CONCLUSION: IPSS-QoL questionnaire in assessing men with anterior urethral stricture does not have sufficient reliability and validity. Its design does not allow for adequate assessment of all the symptoms, reliability indices are unsatisfactory, the questionnaire scores do not correlate with objective indicators. This questionnaire cannot be recommended for evaluating health status and quality of life of this category of patients.

[Quality of life as an effectiveness criterion of surgical treatment for anterior urethral strictures].

RELEVANCE: Recent trends in the contemporary medicine have shown a growing request for the personalized choice of treatment and evaluation of its results. PROM-USS questionnaire has been designed for patients undergoing surgical correction of anterior urethral strictures to measure the treatment success using patient reported outcomes in numerical terms. AIM: To test the effectiveness of different surgical modalities for anterior urethral strictures using patient reported outcomes. MATERIAL AND METHODS: Ninety men self-completed the PROM-USS questionnaire after surgical treatment of anterior urethral strictures. Mean and median follow-up was 6-132 months and 72 months, respectively. Measures included lower urinary tract symptom score, overall quality of life (QOL) and overall health, and patient satisfaction with treatment. RESULTS: At the median follow-up of 72 months after surgery for anterior urethral stricture, the survey findings showed LUTS total score 7.4+/-1.2 and urination score on VAS scale 2.3+/-1.1. Sixty-five (72%) of the men believed that residual LUTS did not significantly affect their quality of life. Fifteen (17%) and 10 (11%) patients reported a slight and moderate/strong negative impact of urinary symptoms on their quality of life, respectively. The EQ-5D score of overall health state on VAS was 73+/-4.2 out of 100, the EQ-5D score of the overall quality of life was 0.79+/-0.2. Seventy-eight (86.7%) of 90 men were satisfied (32.2% very satisfied and 54.5% satisfied) with the surgery results, and 12 (13.3%) were dissatisfied. Reasons for dissatisfaction were the emergence of new problems (post-micturition dribbling) with an overall improvement of urinary symptoms (5) and the lack of improvement in urinary symptoms (7). Among patients treated with OIU, 79% were satisfied, which was significantly less than in groups of men who underwent anastomotic urethroplasty - 89% (p<0.05) and substitution urethroplasty using a buccal mucosal grafting - 95% (p<0.05). CONCLUSION: The patient-reported outcomes showed that surgery for anterior urethral stricture is highly effective and characterized by a long term patient satisfaction and quality of life.

[VALIDATION OF THE RUSSIAN VERSION OF THE QUESTIONNAIRE TO ASSESS THE EFFECTIVENESS OF SURGICAL TREATMENT OF PATIENTS WITH ANTERIOR URETHRAL STRICTURE (PATIENT-REPORTED OUTCOME MEASURE FOR URETHRAL STRICTURE SURGERY (PROM-USS): A PILOT STUDY].

Currently, the patient-reported outcome measures are widely used for the analysis of the effectiveness of treatment. In 2011, the questionnaire to assess the effectiveness of treatment of men with anterior urethral stricture (PROM-USS) was proposed. Study objective: during validation to perform pilot testing of the Russian version of the PROM-USS questionnaire for determining its psychometric properties (reliability, validity and sensitivity). The study involved 35 men with anterior urethral stricture, who completed PROM-USS questionnaires before and 6 months after surgery. The questionnaire consists of 14 questions and 2 visual analogue scales (VAS), combined in 2 domains: 1--evaluation of lower urinary tract symptoms (LUTS), 2--assessment of the quality of life; questionnaire also includes questions about treatment satisfaction. The reliability, validity and sensitivity of the PROM-USS questionnaire were assessed. High intraclass correlation (ICC) coefficients (0.7-0.96) and Cronbach's α = 0.76, indicated reliability of the questionnaire. The correlation coefficient between LUTS scoring and an index of maximum urine flow rate (Qmax)--R = -0.81 (p < 0.05) confirmed the criterion validity. After the surgery, the total LUTS scoring decreased from 14.0 ± 0.72 to 5.66 ± 0.58 (P < 0.05); VAS EQ-5D index increased from 51.43 ± 5.3 to 71.42 ± 7.64 (P = 0.01) with an increase of Qmax from 3.4 ± 0.3 to 17.9 ± 0.9 ml/s (P < 0.001), indicating the sensitivity of questionnaire to changes. Ninety-four percent of men were satisfied and very satisfied with the result of the surgery; 88% had residual LUTS not affecting the quality of life or affecting slightly. For the final conclusions about the feasibility of this tool, further studies involving a larger number of patients are required.

[Replacement plastic reconstruction of extended ureteral stricture using buccal mucosa autograft].

The potentials for the use of free buccal mucosa graft in reconstruction plastic surgery of extended uretral stricture are evaluated. From 2007 to 2013, 9 operations in 8 patients (mean age 54,5+/-7,2 years) were performed. The average length of cicatricial uretral stricture was 5,1+/-0,7 cm. 1 patient has lesion in the upper third of the ureter, 4 patients - in the middle portion, and 4 patients - at the bottom portion. The causes of extended uretral stricture were following: long standing calculi (n=3), ureteral injury after ureterolithotripsy (n=2) and after bringing down the calcuus using loop (n=1), radiotherapy (n=3, one patient had bilateral injury). All patients underwent plastic reconstruction of ureter using buccal mucosa graft by "on-lay" type. During the follow-up (median, 42 months, from 3 to 72 months), in 7 (88,9 %) of 8 patients (8 operations) ureteral strictures relapses were not observed. They all had satisfactory renal excretory function without the pronounced violations of passage of urine along the ureter. The excretory urography showed moderate expansion of the ureter at the site of operation in 6 of them. Due to the progression of secondary renal scarring, one patient underwent nephrectomy 1.5 year after reconstruction plastic surgery. In this patient, pronounced anatomical and functional changes in the kidney occurred before the operation. Application of the buccal mucosa graft in reconstruction plastic surgery in extended uretral stricture is high effective due to the relatively low level of early and late postoperative complications and low recurrence rate.

[Incidental renal cell carcinoma: clinical and morphological features].

This article is devoted to the evaluation of features of incidental, or asymptomatic renal cell carcinoma (RCC). The study included 268 patients with RCC aged 25 to 92 years who underwent examination and treatment in the urological clinic MRSRCI for the last 5 years. 163 (60.8%) patients had incidental renal tumors (Group 1), 105 (39.2%)--symptomatic renal tumors (Group 2). In incidental renal tumors, tumor nodule was smaller compared with symptomatic RCC--5,74 +/- 3.0 vs 6.4 +/- 3.6 cm. Stage I and II disease was diagnosed in 130 (79.7%) patients in Group 1 and only in 69 (65.7%) patients in Group 2 (P < 0.05). No significant differences in the distribution of the degree of nuclear atypia according Fuhrman nuclear grade were identified. The organ preservation surgery were performed more frequently in incidental RCC than in symptomatic RCC, in 47 (28.9%) and 21 (20%) cases, respectively; in addition, regional and distant metastases were diagnosed less frequently. With this in mind, it should be suggested that incidental tumors have a better prognosis than tumors with clinical manifestations.

[Kidney transplantation in recipients with renal carcinoma].

Transplantation of the kidney in patients with renal carcinoma is disputable. The article presents the results of kidney transplantation in different cancer lesions of the patient's kidneys. Seven case histories of patients with primary renal tumors are retrospectively analysed. A clinical case of development of the tumor of own kidney in a patient after transplantation is reported. A time factor of kidney transplantation after tumor removal in a recipient is discussed.

[Successful combined surgical treatment double giant ureterocele complicated by double ureterohydronephrosis, cascade lithiasis and uterine myomatosis].

A case is reported of a 58 year old patient with a diagnosis: double giant ureterocele, secondary multiple calculi of the right ureterocele, calculus of the inferior calyx of the right kidney, calculus of the terminal part of the left ureter, double ureterohydronephrosis, chronic pyelonephritis, multiple calcifying myoma of the uterus. A combined single-stage operation (panhysterectomy, deletion of multiple calculi of the right ureterocele, deletion of the calculus of the left ureterocele, crosscut right ureterectomy with excision of ureterocele, right ureterocystoneostomy by Leadbetter-Politano, installation of the double J-stent into the right kidney, crosscut and longitudinal left ureterectomy with excision of ureterocele, left ureterocystoneostomy by Leadbetter-Politano, installation of intubating drainage into the left ureter, cystostomy) followed by extracorporeal shock-wave lithotripsy were performed in this adult patient with combined pathology of the urinary system.

[Reconstruction of long recurrent strictures of the anterior urethra with a free transplant of buccal mucosa].

The study included 18 patients with recurrent strictures of the anterior urethra. In 16 patients the recurrence arose after several endoscopic operations for inflammatory urethral strictures, in 2--after plastic repair of the stricture by loganson and plastic treatment of hypospadia. The strictures varied in length from 3 to 16 cm. Ventral flap of buccal mucosa was used for plastic reconstruction in 16 patients, dorsal flap--in 2 patients. Follow-up lasted from 1 to 15 months. All the patients were cured. The intubation drainage was removed 4-7 weeks after the operation. Qmax elevated, on the average, from 4.79 +/- 0.78 to 29.5 +/- 1.94 ml/s. The recurrence developed only in 1 patient 6 months after the plastic repair. The patient was successfully operated (internal optic urethrotomy). Thus, short-term outcomes of urethroplasty with buccal transplant showed this operation to be highly effective in correction of long recurrent strictures of anterior urethra in males.

[The TVT operation in injury of the pelvic ring]. / Operatsiia TVT pri travmaticheskom narushenii tazovogo koltsa.

The authors report a case of a woman with combination of stress urinary incontinence (SUI) with posttraumatic rupture and divergence of the pubic joint. The latter led to relaxation of the pelvic base and urethral ligaments resultant in SUI. The patient was treated surgically (a modified TVT operation). This rare case demonstrates possibility of SUI development consequently to trauma of the pelvic ring and a TVT operation efficacy made in non-standard setting.

[Comparative analysis of open and endoscopic operative procedures outcomes for posterior urethra obliteration in males]. / Sravnitelnyi analiz rezultatov otkrytykh i éndoskopicheskikh operatsii pri obliteratsiiakh zadnei uretry u muzhchin.

Endoscopic recanalization of posterior urethra (PU) obliteration (a novel method) was compared to open reconstructive-plastic operations. 242 patients with PU and vesicular cervix obliterations entered the study. 93 patients of group 1 have undergone open reconstructive-plastic operations, 149 patients of group 2 were operated endoscopically (endoscopic recanalization under transrectal ultrasonic control). Before surgery the patients were examined using standard tests, sonourethrography and intraoperative transurethral ultrasonic investigation were added. Recurrence rate in group 1 and 2 was 29.1 and 16.8%, respectively. The following complications were observed in group 1: acute pyelonephritis (22.5%), enuresis (14%), orchoepididymitis (9.7%), urinary fistulas (5.4%). The patients needed long-term postoperative immobilization (10-16 days, mean 14.8 +/- 1.1 days). After endoscopic recanalization under transrectal ultrasonic control, group 2 patients developed acute pyelonephritis (4.8%), orchoepididymitis (4%), orthostatic enuresis (4%), short-term urethral fever (85.9%). Bed regime in this group was necessary for 1-2 days (1.3 +/- 0.4 days). Mean postoperative hospital stay was 2.5-fold less in group 2. The conclusion is made that endoscopic recanalization under transrectal ultrasonic control has advantages over open reconstructive-plastic surgery: less frequent pyoinflammatory complications, enuresis, the absence of such complications as impotence, short penis, formation of urinary fistulas.

[Algorithms of diagnostic radiation methods in current urological pathology]. / Diagnosticheskie algoritmy luchevykh metodov issledovaniia pri urologicheskoi patologii v sovremennykh usloviiakh.

Based on the results of 3600 studies using all basic methods of modern radiation diagnosis, the authors show it necessary to develop diagnostic algorithms applicable to certain groups of urological diseases (urolithiasis, inflammatory processes and bulky masses in the kidney). This necessity has recently stemmed from the advent of new technologies of radiation diagnosis and from the expediency of using a certain method at the specific stage of examination. At the same time, the authors underline the importance of using standardized examination programmes (algorithms) in practice, which is also due to the fact that unreasonable use of the whole set of new radiation techniques that are of highly diagnostic value may bear great material costs.