[Improvement of quality of life of patients with internal stents by changing the shape of the stents].

Transurethral stenting of the ureter was made in 130 patients (51 males and 79 females, aged 19-81, mean age 51.3 years) after contact ureterolithotripsy (n=86), endoureterotomy (n=13) and endopyelotomy (n=31). All the patients received internal polyuretanic stents (size N 6 F) made by one company. The patients were randomized into two groups by the shape of the stent. Group 1 (n=65) received a modified mono-pigtail stent made of the standard polyuretanic double-pigtail stent by cutting off 2-4 cm of the distal end and distal (vesical) curl. In group 2 (n=65) stenting was made with standard double-pigtail stent. Questionnaire survey was made 2 weeks after stenting, 1 month before stent removal and 1.5 months after stent removal. In the postoperative period 12 patients of group 2 (18.5%) developed acute pyelonephritis resultant from vesicorenal reflux. In other cases pyelonephritis was managed by draining bladder with urethral catheter. In group 1 vesicoureteral reflux was absent, but in 3 cases (4.6%) there was an attack of acute pyelonephritis because of obstruction of the intramural (not intubated by the stent) part of the ureter with fragments of the crushed concrement. This attack required urgent ureterolithoextraction and removal of the stent in 2 cases, transcutaneous nephrostomy in 1 case. Mean postoperative stay in the hospital was 3.1 +/- 0.6 in group 1 and 6.7 +/- 1.2 (p = 0.001) days in group 2. The comparison of the stent-related symptoms 2 weeks after stenting and before stent removal showed that severity of the symptoms was significantly greater in group 2 vs group 1 (21.3 and 9.6, respectively). Thus, the proposed mono-pigtail stent reduces severity of stent-related symptoms 2.5 times and improves quality of life. Further prospective studies are planned for final assessment of efficacy of the modified stents and their influence on quality of life.

[Transurethral holmium enucleation of prostatic adenoma].

Laser (holmium) enucleation of the prostate (LEP) for infravesical obstruction caused by prostatic adenoma up to 60 cm3 in size was made in 42 patients in the Moscow city urological hospital N 47 from January to July 2009. Transurethral resection (TUR) of the prostate was made in 42 matched controls. All the patients from both groups have undergone the same standard clinical and laboratory examination before the treatment, 1, 3 and 6 months after it. Duration of surgery was shorter in the TUR group (42.4 +/- 26.1 min vs. 74.8 +/- 39.7 min). Washing system operated longer in the TUR group (23 +/- 7 vs. 10 +/- 5 h). The LEP group patients stayed in the hospital for much shorter time (3.1 +/- 1.2 days vs 4.6 +/- 1.8 days). No significant differences between the groups by basic postoperative parameters were found 1, 3 and 6 months after the operation. Postoperative complications were rare in both groups. Hemorrhagic complications were absent in the LEP group. This makes it possible to recommend LEP for patients with coagulopathy. Trauma of the bladder occurred in 1 case of LEP because of a complicated technique of LEP and the absence of conventional endoscopic reference points characteristic for TUR. Thus, our initial experience with transurethral LEP in comparison with TUR leads us to the conclusion that LEP is effective and safe in surgical treatment of patients with prostatic adenoma. Further gain of experience with LEP conduction may make this method alternative to open adenomectomy.

[Comparison of the results of magnetic resonance urography and other examination methods in patients with iatrogenic injuries of the ureter and pelvis-ureteral segment].

MR urography was made in 25 patients (age 24-70, mean age 48.6 years, 20 females, 5 males) with iatrogenic injury of the upper urinary tract (UUT). A comparison group consisted of 15 patients without nephrostomic drainage who had no contraindications for intravenous contrast preparations. MR urography was performed in frontal and sagittal projections. The examination was made before and 20 min after intravenous injection of 20 mg diuretic. Five patients received additionally excretory MR urography with intravenous injection of magnevist (0.2 ml/kg, 3 ml/s just before the examination). Mean duration of urography was 21 (18-23) min. The results were compared to findings of ultrasound or x-ray investigations, diapevtic ureteroscopy or open surgical intervention. The results were similar to those of x-ray CT. In patients with ureteral obliteration MR urography was less informative than joint antegrade and retrograde ureteropyelography as the ureter could not be visualized beneath the injury. In 2 patients examined with intravenous urography and x-ray CT, definite length of ureteral stricture was obtained only with MR urography. In 5 patients with hydronephrotic transformation MR urography was much more informative than excretory urography. MR urography provided information sufficient for diagnosis. Sensitivity of MR urography and that with diuretic load was 86.8 and 92.3%, respectively. MR urography, even without contrast enhancement, provides images with high resolution sufficient for visualization of the ureter distally of the stricture and is a method of choice in patients with subnormal renal function, intolerance to iodine-containing contrast media, with hyperthyroidism and pregnant women after the first trimester.

[X-ray endoscopic diagnosis and treatment of iatrogenic injuries of the upper urinary tract].

X-ray endoscopic diagnosis and treatment of iatrogenic pelvoureteral injuries (PUI) were made in 200 patients (age 18-70 years, mean age 41.7 years, 68(34%) males, 132(66%) females). Preoperative examination was standard for obstructive diseases of the upper urinary tract (UUT). The end stage of the diagnosis included diapevtic transurethral ureteropyeloscopy or percutaneous nephroureteroscopy. In 57 (28.5%) patients x-ray and endoscopic diagnoses did not coincide. A total of 250 x-ray endoscopic operations were conducted. Direct dissection of the UUT stricture (obliteration) was made with a "cold" knife in 38.8% cases, with an uncinate electrode--in 14.8%, with a Ho laser applicator--in 46.4% cases. Patients with ureterovaginal (uterine) fistulas after relief of the obstruction have undergone ablation and coagulation of the fistula. UUT draining and splinting of the dissection zone were performed with "inner" stents 608 Fr in diameter and 24-28 cm long as well as with endopyelotomic stents 6-7 Fr with extention to 12-14 Fr. Draining of the kidney after percutaneous operation was made with pigtail drains 7-12 Fr and a long (35-50 cm) intubation drain tube 12-16 Fr in diameter. The drainage continued 4-12 weeks. Control examination took part in 6-12 months. Good and satisfactory results were achieved in 186 (88.2%) cases. Endourological reoperation was made in 33 patients, three times operative intervention was conducted in 6 patients. Basing on our findings, we have developed prognostic criteria of efficacy of PUI roentgenoendoscopic treatment which was effective in short strictures (obliterations) of the UUT in relatively intact renal function, absence of manifest UUT hypotension, when performed 3 weeks to 3 months after iatrogenic injury.

[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.

[The etiological and pathogenetic bases of nephrolithiasis]. / Etiologicheskie i patogeneticheskie osnovy nefrolitiaza.

A new outlook on etiology and pathogenesis of nephrolithiasis regards renal tubular acidosis (RTA) as the basic pathogenetic factor of nephrolithiasis. These conclusions were made basing on the findings on blood and urine glycolysis enzymes, lactic acid, acid-base metabolism, titrated acids, ammonium. RTA stages responsible for the variety of the forming concrement and two groups of nephrolithiasis etiological factors (acting on epithelial cell of the nephron and involved in urinary processes) are distinguished.