[Results of percutaneous nephrolithotomy using two accesses in the treatment of patients with staghorn stones].

INTRODUCTION: In order to improve clinical efficiency and reduce the risk of postoperative complications in patients with staghorn stones, we compared the results of original technique of biportal percutaneous nephrolithotomy (PCNL) with the standard PCNL. MATERIALS AND METHODS: The total of 221 patients with staghorn stones of K3-K4 was included in the study. The biportal PCNL was used in 109 patients, while the control group consisted of 112 patients. Inclusion criteria were stone size more or equal 2 cm, age over 18 years, absence of coagulopathy and width of the renal parenchyma more or equal 1 cm. On 1st postoperative day, ultrasound or plain urography was performed, while in patient with radiolucent stones, multi-slice computed tomography was used. In addition, complete blood count and biochemical profile were done. The main difference from the standard PCNL with sequential renal tracts is the simultaneous creation of the main and additional accesses when performing biportal PCNL. This method allowed two surgeons to simultaneously and synergistically perform lithotripsy and stone extraction from two accesses using a standard nephroscope in the main tract of 24 Ch and a miniaturized nephroscope in the additional tract of 16.5 Ch. RESULTS: The stone-free rate in the group of biportal PCNL was 80.7% (n=88), compared to 72.3% in the control group (n=81). Secondary interventions and additional procedures were required in 29 (26.6%) and 40 (39.2%) cases, respectively. The total number of infectious and hemorrhagic complications was higher in the control group. DISCUSSION: According to our data, significant advantages are observed in the group of biportal PCNL compared to the standard technique. CONCLUSION: Biportal PCNL can be recommended as a promising advancement of the technique traditionally used in the clinical practice.

[Bacteriophage Therapy of Urological Infections].

A literature review dedicated to the problem of bacteriophage therapy for infectious and inflammatory diseases, including urological infections, is presented. Considering the growth of antibiotic resistance, the search for alternative treatments is relevant. Current data about bacteriophages and mechanism of their action, difference of virulent and temperate phages is given, as well as mechanisms of bacteria resistance to phages and ways of its overcoming. The history of phage therapy for infectious diseases from the beginning of the 20th century to the present days is presented. Pharmacokinetic studies of phages after oral administration are given. Moreover, we described our 30 years experience on of clinical use of bacteriophage cocktails in the treatment and prevention of urological infection. In addition, problems of phage therapy are discussed, including immunological issues and the advantages of bacteriophages over antibiotics.

[Prevention of infectious and inflammatory complications after percutaneous nephrolithotomy].

INTRODUCTION: Given the increase in antibiotic resistance of uropathogens, one of the urgent problems is a development of optimal antimicrobial prophylaxis for surgical interventions, as well as an adequate regimen of antibiotic therapy after percutaneous nephrolithotomy (PCNL). AIM: to determine an effective perioperative antimicrobial prophylaxis for PCNL in patients with kidney stones. MATERIAL AND METHODS: A total of 90 patients with staghorn or multiple large kidney stones who underwent PCNL were included in the study. Before PCNL, urine culture was performed in all patients in order to determine the sensitivity not only to antibiotics, but also to bacteriophages. In addition, urine was taken for additional microbiological studies after the puncture of the collecting system, as well as on the 3rd and 7th day after PCNL. All patients were divided into three groups of 30 patients depending on the regimen of perioperative prophylaxis. In group 1, patients were prescribed ciprofloxacin 1000 mg i.v. intraoperatively, then 1000 mg i.v. q.d. for 3-5 days. In the group 2, patients received one dose of cefotaxime + sulbactam (1.0 g + 0.5 g) 2 hours before PCNL i.m. In the group 3, a polyvalent pyobacteriophage purified was given orally 1 hour before PCNL in a dose of 40 ml and the same dose was used t.i.d. for 3-5 days postoperatively. RESULTS: In all three groups of patients, the following infectious complications were evaluated: acute pyelonephritis, systemic inflammatory response syndrome (SIRS) and urosepsis. There were no serious infectious and inflammatory complications in the early postoperative period among all patients. SIRS developed on days 1-3 after PCNL in 26.6%, 20% and 20% of patients in group 1, 2 and 3, respectively. However, by days 4-7 after PCNL, there was normalization of blood cells count (leukocytes, neutrophil band cells), temperature and general condition. CONCLUSION: Different regimens of antimicrobial prophylaxis for PCNL have the same efficiency. The development of SIRS on days 1-3 after PCNL is correlated not only with the antimicrobial agents used and the route of their administration (intravenously, intramuscularly and orally). Most likely, the development of SIRS is more associated with surgical trauma.

[Multi-tract percutaneous nephrolithotomy in the management of staghorn stones].

AIM: To compare the results of a single tract versus multi-tract percutaneous nephrolithotomy (PNL) MATERIALS AND METHODS: Over a period of 6 years, a total of 2,264 PNLs was performed at the N.A. Lopatkin Scientific Research Institute of Urology and Interventional Radiology, of which 875 PNLs were done for stage K3-K4 staghorn calculi. Among them, 244 (27.7%) patients underwent multi-tract PNL. We included 873 patients in our study. The median stone size was 59 (46; 88) mm. Two, three and four percutaneous tracts were used in 165 (67.6%), 63 (25.8%) and 14 (5.7%) patients, respectively. In 126 of 244 (52%) patients, a set for mini-percutaneous surgery with 14.5 and 15.5 Ch tubes was used as additional access. RESULTS: The effectiveness of single and multi-track PNL was 53.6%, and 83.8%, respectively. The mean operating time for PNL using one, two, three and four percutaneous tracts was 77.2+/-29.9, 85.7+/-26.9, 116.6+/-28, and 144.0+/-12.2 min, respectively. The median length of hospital stay for single and multi-track PNL was 6.6 (5.4, 8.7) vs. 10.2 (8.6, 12.3) days. Intra- and early postoperative infectious complications occurred in 101 (16.1%) and 54 (22.4%) patients, who underwent single and multi-track PNL, respectively. Bleeding occurred in 88 (13.9%) and 50 (20.8%) patients, respectively. After single and multi-track PNL, 54 (8.6%) and 21 (8.8%) patients needed a blood transfusion, respectively. CONCLUSION: Multi-track PNL is highly effective as a treatment modality for patients with complex forms of nephrolithiasis. Using the mini-tool significantly reduces the risk of bleeding when performing the additional access.

[Analysis of clinical effectiveness and risk factors for complication of percutaneous nephrolototripsia in patients with a solitary kidney].

RELEVANCE: Management of patients with large and staghorn stones of a solitary kidney is widely debated among urologists and has not been sufficiently investigated, which determined the relevance of this study. MATERIALS AND METHODS: The study comprised 80 patients with large (>20 mm) and staghorn stones of an anatomically or functionally solitary kidney. Of them, 58 patients underwent percutaneous nephrolithotripsy (PNL), and 22 had open surgery. The criterion of the treatment effectiveness was the complete stone clearance or small residual fragments sized less than 3 mm. The safety criterion was the absence of intra- and postoperative complications, according to Clavien-Dindo grading system. The study analyzed the following factors influencing the effectiveness and safety of PNL: the number of accesses; nephroscope diameter; use of a nephroscope sheath; type of lithotripter; size, density, type and composition of the stone. RESULTS: Percutaneous nephrolithotripsy demonstrated statistically significantly better safety results compared with open surgery with comparable effectiveness. Long-term stone recurrence rate after PNL and open surgery was 10.4 and 18.2%, respectively. PNL resulted in a statistically significant improvement in the kidney function while it worsened after open surgery. The effectiveness of PNL depends on the stone type and size and the kind of lithotripter. It was 7.5 times greater for a large stone than for staghorn calculi and 4.6 times higher for stones sized less or equal 45 mm than for those sized > 45 mm. Ultrasonic lithotripter was 2.2 times more effective than another type of lithotripter. The safety of PNL depends on the nephroscope diameter, of a sheath, the number of accesses, the type of lithotripter and the type of stone. Using a 24-Ch nephroscope was 3.6 times safer than that with a diameter greater than 24-Ch; not using a sheath was 3.2 times safer than using it; one access was 3 times safer than at multiple ones; using an ultrasound lithotripter was 2.7 times safer than with another type of lithotripter; treating a large stone was 2.1 times safer than a staghorn stone. CONCLUSION: The study findings can be used to optimize the treatment of patients with large and staghorn stones of a solitary kidney.

[Search for new modes of antibiotic prophylaxis of septic complications after percutaneous nephrolithotripsy].

The risk of infectious and inflammatory complications after PNL is based on presence of microorganisms in the form of biofilms inside the stone. Destruction of stones during surgery or lithotripsy may be a trigger for the growth of microorganisms that are integrated into the biofilms, and the migration of bacteria and their toxins in the blood flow under pressure of irrigation fluid can cause septic complications. The danger of infectious and inflammatory complications after percutaneous interventions for kidney stones requires a search for specific antibiotics for antimicrobial prophylaxis and efficient modes of their administration. The results of a comparative study of pharmacokinetic parameters of ciprofloxacin, and the effectiveness of two modes of administration (bolus dosing and prolonged intravenous administration) at a dose of 1000 mg are presented.

[Experience in the use of mineral water "Naftusya" of Zbruchansk field in the treatment of patients with uroliths].

The study has evaluated the effect of combined treatment including slightly mineralized hydrocarbonate-magnesium-calcium mineral water "Naftusya" of Zbruchansk field on the urinary system of 47 adult patients with urolithiasis and chronic pyelonephritis aged 24 to 76 years and 3 children of different age groups. 14 patients dropped out of the study group after 1-3 days after the start of treatment due to the negative reaction of the gastrointestinal tract to the reception of water; thus, study group consisted of 36 patients. At baseline, kidney or ureteral stones were diagnosed in all patients. For adult patients, water was administered at a dose 200 ml 3 times a day, for children--50-150 ml 3 times a day, 30-40 minutes before meals for 7-20 days. Examination of patients was performed using laboratory, ultrasound and radiographic methods. It was revealed that against the background of complex treatment, discharge of small stones, their fragments and urinary sand have occurred 1-3 days earlier than with standard treatment. There was no effect on calcium and inorganic phosphate metabolism. The trend to uric acid crystalluria and reducing the pH of urine was revealed. Statistically significant reduction of leukocyturia and erythrocyturia was identified. 60% of patients had a disappearance of bacteriuria or reduction of the titer of bacteria. The results led to the conclusion of advisability of use of mineral water "Naftusya" of Zbruchansk field in the complex treatment of inflammatory processes in the urinary system and for stimulation of discharge of ureteral stones with sizes enabaling to presume their independent discharge.

[The role of ozone therapy in prevention of pyoinflammatory complications after transurethral resection of prostatic adenoma].

The study of efficacy of ozone therapy (OT) in preparation of patients with prostatic adenoma (PA) and cystostoma for transurethral resection (TUR) of PA included 20 PA patients with cystostomic drainage who had undergone PA TUR and preoperative preparation with OT sessions. The control group consisted of similar patients but without ozone pretreatment. OT efficacy was assessed by the rate of pyoinflammatory complications (PIC), results of immunological examination, positive changes in prostatic secretion, urine analysis, total blood count, degree ofbacteriuria. In the study group PIC (acute urethritis) developed in 1 patient, in the control--in 6 patients (3 cases of acute urethritis, 2 cases of acute prostatitis and 1 case of acute epididymitis). OT led to lowering of mean values of leukocyturia from 18.1 +/- 0.6 to 14.3 +/- 0.7 on the day of operation, to 10.9 +/- 0.7 after 4 days and to 8.7 +/- 0.6 on postoperative day 8 versus from 18.8 +/- 0.8 to 15.4 +/- 0.7, to 15.8 +/- 0.6 and 13.5 +/- 0.6, respectively. Mean control count of leukocytes in prostatic secretion fell in both groups. OT reduced bacteriuria. Number of bacteria to the day of operation decreased in both groups, but complete elimination of the agent from urine on day 8 was not achieved in the controls. The study group exhibited a rise in the absolute count of blood leukocytes, lymphocytes and ESR diminishing. OT raised significantly the phagocytic count and activity, concentration of mature T-lymphocytes (CD3), T-helpers (CD4), cytotoxic T-lymphocytes (CD8), B-lymphocytes (CD20), T-NK-cells (CD16), T-lymphocyte activation markers (CD3+, CD16+, CD56+, CD3+, CD25+, HLADR+, CD3+. The concentration of IgG, IgM, IgA remained high. Thus, the results of ozone application before PA TUR appeared promising in prevention of postoperative PIC.

[Transurethral plasmokinetic resection and vaporization is a new method of treatment of prostatic adenoma].

Clinical efficacy and safety ofplasmakinetic resection and vaporization were studied in 28 patients with prostatic adenoma (mean age 68 years, mean size of the prostate 65 cm3). Complaints by IPSS scale, quality of life index, results of uroflowmetry and prostatic ultrasonography were assessed before surgery (transurethral plasmakinetic resection and prostatic vaporization) and 1, 3, 6 and 12 months after it. Twenty-five and 15 patients after 6 and 12 months after the operation were examined with the following results: IPSS was 6 scores, on the average (22.5 scores before the operation), quality of life index--3.1 (5.3 scores). Qmax was in 3 months 20 ml/s, on the average (7.5 ml/s), residual urine was under 35 ml (130.7 ml). Pilot results point to high clinical efficacy and safety of plasmakinetic resection and vaporization in patients with prostatic adenoma. Therefore, further studies of the method and accumulation of clinical experience are necessary.

[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.

[One-stage transurethral resection of the urinary bladder and the prostate in patients with superficial cancer of the urinary bladder combined with benign prostatic hyperplasia].

Combination of urinary bladder cancer (UBC) with benign prostatic hyperplasia (BPH) is a prognostically unfavourable factor. To assess clinical efficacy of one-stage transurethral resection of UBC and BPH in combination with adjuvant immunotherapy, we examined 181 patients with UBC stage Tis, Ta-T1 and BTH. All the patients have undergone one- and two-stage endoscopic operations. TUR of the urinary bladder and the prostate was made in 87 patients. Stage-by-stage TUR of the urinary bladder and TUR of the prostate were made in 94 controls. We conducted postoperative immunotherapy with BCG vaccine (imuron) as an adjuvant therapy in 114 (63%) patients. Postoperative UBC recurrence occurred in 124 (68.5%) patients: 49 (56.3%) patients of the study group and 75 (79.7%) controls (p < 0.05). Reoperation (TUR of the urinary bladder) was performed in all cases of UBC recurrence. Five-year survival in the study group was 71% and 68.0% survived in the control group (p > 0.05). The conclusion is made that in combination of superficial UBC with BPH indications appear for TUR of the urinary bladder and TUR of the prostate with adjuvant immunotherapy. Early elimination of infravesical obstruction lowers UBC recurrence rate and improves the patients' quality of life.

[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.

[Transurethral rotoresection - a new method of benign prostatic hyperplasia treatment]. / Transuretral'naia rotorezektsiia v lechenii dobrokachestvennoi giperplazii predstatel'noi zhelezy.

Karl Storz company (Germany) offers a novel endoscopic technology in the treatment of benign prostatic hyperplasia (BPH) i.e. rotoresection which combined mechanic and electrosurgical methods of removal of the hyperplastic tissue. The operation is performed with application of a special rotoresectoscope connected with a rotor electrode which, in its turn, is connected with mechanical rotor generator making it to rotate and with powerful electrogenerator (radiotome). The hyperplastic tissue is removed both mechanically (by high-frequency rotation of the rotor tip) and due to electrovaporization with simultaneous coagulation of the underlying tissue layers. Transurethral rotoresection was performed in 40 patients with BPH. Intraoperative and postoperative complications were not observed. Examination at discharge and 1 month after surgery showed a 4-fold decrease in the prostatic symptoms by IPSS scale, residual urine decreased 3-fold, maximal urine flow rate rose 2.5-fold. Transurethral rotoresection combines effective removal of BPH tissue with minimal intraoperative bleeding. It is a good alternative to conventional TUR. For more detailed evaluation further studied are needed.