[Current approach to management of staghorn nephrolithiasis. Literature review. Part 2].

Data on predictors and methods for resolving the complications of surgical treatment of staghorn nephrolithiasis are presented. New information on the features of the morphological and functional state and individual platelet reactivity in patients undergoing surgical treatment is described. Thrombotic and hemorrhagic complications, intra- and postoperative bleeding, as well as prediction of PNL results in patients with staghorn stones are also discussed.

[Complications of retrograde intrarenal sugery in patients with low pole kidney stones].

A lot of patients with nephrolithiasis have calculi at low pole calyces. One of the best and safety operative options of such category is retrograde intrarenal surgery (RIRS). RIRS is wide spread in current clinical practice. But not rarely it corresponded with different grade complications. Current literature review is dedicated to predictors of complications due to RIRS in patients with low pole calculi.

[Autologous kidney transplantation after ureter avulsion during ureterolithotripsy].

Currently, when performing ureterolithotripsy in patients with proximal ureteral stones, urologist should be ready for intraoperative complications and be able to use various methods to diagnose them. Ureteral avulsion is an extremely rare, but the most serious complication of endoscopic procedures. Clinical observation of autologous kidney transplantation performed after ureteral avulsion with good functional and clinical results is presented.

[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.

[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.

[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.

[The changes in urine microflora in patients with urinary stone disease].

INTRODUCTION: Since the results of treatment of chronic pyelonephritis (CP) depend on timely and rationally selected targeted antibiotic therapy, when choosing a treatment regimen, it is necessary to rely on the local data obtained by monitoring the state of microflora in a particular hospital. AIM: to monitor the changes in urine microflora in patients with urinary stone disease. MATERIALS AND METHODS: A total of 598 isolated bacteria and yeast-like fungi from patients with urinary stone disease who were treated in the Department of Urology during different time periods (1997-1999, 2010-2014 and 2015-2017 yy) were analyzed. A comparison of the urine microbiota in patients with single kidney stone (n=154) and staghorn stone (n=147) for the period 2015-2017 yy. was carried out. RESULTS: The significant changes of gram-positive and gram-negative bacteria were found with a tendency to decrease in the proportion of the latter (from 80.6% to 50.6%, p<0.05) due to a decrease in the proportion of P. mirabilis and complete absence of Enterobacter spp, Serraciae spp and Citrobacter spp. as well as an increase in the number of gram-positive bacteria (from 18 to 48.7%, p<0.05) owing to increase in the proportion of E. faecium + E. faecalis. During observation period, E. Coli has remained the leading pathogen (26.4+/-0.32%). During observation period, a permanent fourfold prevalence of gram-negative bacteria in clinically significant concentrations (>104 CFU/ml) was found: E. coli (36.8+/-4.1%). The proportion of K. Pneumonia increased from 8.5% to 17.4%, and proportion of P. mirabilis decreased from 20.3 to 10.4%. Despite a significant increase in the proportion of Enterococcus spp. (from 4.6 to 26.6%) in the general population, the incidence of microorganisms in clinically significant concentrations during analyzed period remained unchanged and did not exceed 8.46+/-4.76%. In patients with single stones and patients with staghorn stones there was no significant difference in the proportion of analyses with clinically significant concentrations of bacteria fer (p>0.05). The percentage of analyses with clinically significant concentration was 70.06%, while in all patients with urolithiasis it was 59.7%. In patients under and over 60 years old, the largest number of bacterial pathogens were represented by E. coli. (29.7% and 32.1%, respectively). CONCLUSION: E. Coli remains the leading bacterial causative agent of calculous pyelonephritis, both in the general population and in analyses with clinically significant concentrations of bacteria. There were no significant differences in urine microflora in patients with staghorn and single stones.

[The first domestic lithotripter URAT-: to the 30th anniversary of introduction].

This article is a historical overview of our recent past describing the enormous theoretical and experimental contribution of the research staff members who took part in the development of the first domestic lithotripter "Urat-".

[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.

[Psychological aspects of treating staghorn nephrolithiasis using percutaneous and retrograde nephrolithotripsy].

AIM: To investigate the level of anxiety and the severity of asthenic state in patients with staghorn nephrolithiasis treated by of minimally invasive therapies - percutaneous nephrolithotripsy (PNLT) and retrograde nephrolithotripsy (RNLT). PATIENTS AND METHODS: This study analyzed the psychological state of 150 patients with staghorn nephrolithiasis aged 25 to 75 years before and after PNLT and RNLT. Testing was performed at baseline, at 5-7 day of hospital stay (average time of preparing for surgery) and after treatment with the use of various questionnaires: Anxiety Scale, Asthenic conditions scale and Pain questionnaire. RESULTS: The follow-up findings shower positive changes, including reduction in the level of anxiety and severity of asthenia in patients of different age groups. The decrease in anxiety level and severity of fatigue was associated with decreased rates of neuropathic component of pain. CONCLUSION: The psychological state of patients with staghorn nephrolithiasis depends on the characteristics of minimally invasive methods of treatment and requires attending physicians and medical personnel to take into consideration the mental and emotional state of patients.

[UROLOGICAL ASPECTS OF THE FOX - FORDYCE DISEASE].

The article presents the description of the clinical observation of the patient 28 years old with multiple granulomatous eruptions on the skin of the scrotum, accompanied by itching and pain when walking. Surgical treatment consisted of excising the skin of the scrotum and substitution dermatoplasty was performed. Fox - Fordyce disease was confirmed by histological examination of tissue removed: advanced cystic sebaceous gland duct with calcifications in its lumen was revealed. The were no relapses during follow-up of 15 months.

[VESICOURETERAL REFLUX INTO SMALL KIDNEY DIAGNOSTIC AND THERAPEUTIC PARADIGM].

The causes of renal size reductionin children by 20 percent or more from the age norm include abnormalities of urodynamics of upper (UUT) and lower (LUT) urinary tract, combined with vesicoureteral reflux (VUR) and infra-vesical obstruction (IVO). Several issues regarding diagnosis and choice of treatment in children with small kidneys depending on the severity of functional abnormalities and the presence of comorbidities still remain controversial. 101 children with small kidneys accounting for 3.1% of the entire number of urologic patients admitted to the clinic were followed for 25 years. 78 (77.2%) patients were simultaneously diagnosed as having ipsilateral vesicoureteral reflux (VUR) (2.4% of the total number of hospitalized children). Moreover, contralateral VUR was found in 63% of patients. In 5.1% of children, anomalies of the contralateral kidney were identified: lumbar dystopia (3.8%), duplication of the renal pelvis and ureter (1.3%). Combination with IVO was found in 25.5% of cases. 75 (96%) children with vesicoureteral reflux into the small kidney were operated on. Reconstructive plastic surgery was made in 72 (92%) those patients. Indications for conservative management were identified in patients with intermittent VUR of I-II degree into small kidney or both kidneys. In case of detection of IVO, initial surgery was carried out to eliminate the obstruction. Conservative therapy was aimed at getting rid of the inflammatory process, restoring the function of kidney and bladder, and at the treatment of concomitant vulvovaginitis. In the absence of positive results of 6-8 months of conservative treatment or in case of the negative clinical course, the operation was considered justified. Indications for antireflux surgery were the failure of conservative therapy for intermittent VUR into small kidney or both kidneys, the presence of VUR of III-V degree into one or both kidneys. In cases of bilateral VUR antireflux surgery was performed simultaneously. Indications for nephrureterectomy were complete loss of kidney function, a combination of several unfavorable prognostic signs, namely a significant reduction of the renalsize (renal area less than 30% of the age norm); severely impaired kidney function (reduced contribution to the total accumulation of up to 10% or less); the presence of ultrasonic and radiographic evidence of secondary shrinkage; pronounced abnormalities of UUT urodynamics; failure of treatment of frequent and severe pyelonephritis exacerbations. It is shown that VUR is often combined with a decreased renal size, creating difficulties in selecting treatment tactics and determining the prognosis of the disease further. The proper strategy is to prevent disease progression and reduce the need for organ-removal surgery in children.

[EFFECTIVENESS OF EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY IN PATIENTS WITH UROLITHIASIS OF A SOLITARY KIDNEY].

The article presents results of extracorporeal shock wave lithotripsy (ESWL) in 62 patients with urolithiasis of a solitary kidney. In 50 (80.6%) patients calculi were located in the kidney and in 12 (19.4%) patients in the ureter. Effectiveness of ESWL at 3 month follow-up was 85.5%, which is somewhat lower than in patients with two healthy kidneys due to the choice of sparing low-energy modes of lithotripsy. The effectiveness of ESWL depended on the size of the original calculi (p<0.0001), and the baseline urodynamics of the upper urinary tract (p<0.0001). The rates of complications (32.3%) and auxiliary procedures (16.1%) were relatively low, due to the usage of pre-drainage of the kidney before a session of ESWL in patients with large and multiple calculi. There was no correlation between the occurrence of complications during treatment and the clinical form of a solitary kidney (p>0.05). In patients with stones larger than 1 cm and a moderate baseline abnormalities of the upper urinary tract urodynamics ESWL was less effective (p<0.0001), they had increased time of lithotripsy (p=0.013), more sessions (p<0.0001), complications (19.4%, p=0.043) and auxiliary manipulation (9.7%). Nevertheless, the duration of stay in hospital in the postoperative period did not correlate with the size of calculus (p=0.504). Extracorporeal shock wave lithotripsy is a highly effective and safe treatment of stones of a solitary kidney. Rational choice of indications and contraindications for the use of ESWL in a specific clinical situation is of great importance.

[PERCUTANEOUS CYSTOLITHOTRIPSY: THE FIRST CLINICAL EXPERIENCE].

This paper reviews results of examination and treatment for benign prostatic hyperplasia (BPH) and infravesical obstruction in 16 patients observed in Department of Urology of Zhukovsky CCH in 2013-2014. Most operated patients required particularly careful approach to the surgery planning due to advanced age and multiple comorbidities. Treatment of all patients was carried out in a single therapeutic session performed in two stages. Percutaneous cystolithotripsy was performed on the first stage and subsequently transurethral resection of the prostate (TURP) was carried out. It was found, that combination of minimally invasive percutaneous approach and TURP is the most sparing way to restore lower urinary tract urodynamics and eliminate bladder stones in all operated patients. With appropriate patient selection and a clear definition of indications, proposed treatment combination is a promising and effective strategy in management of patient with urolithiasis with infravesical obstruction and BPH.

[FEATURES OF PERCUTANEOUS NEPHROLITHOTRIPSY IN PATIENTS WITH UROLITHIASIS OF SOLITARY KIDNEY].

The article describes the results of percutaneous nephrolithotomy (PCNL) in 49 urolithiasis patients with a solitary kidney. In 44 (89.8%) patients the calculi were located in the kidney, in 5 (10.2%) patients - in the upper third of the ureter. The calculi were single (18; 36.7%), multiple (14; 28.6%) or stag-horn (17; 34.7%). Efficiency of PCNL estimated immediately after surgery and at the end of the third month of observation was 75.5 and 93.9%, respectively. Stone size (p=0.594), the baseline state of urodynamics of the upper urinary tract (p=0.205) did not affect the renal clearance at PCNL. Enlargement of initial calculus size positively correlated with the number of required treatment sessions (p=0.013), duration of surgery (p<0.0001), and the length of postoperative hospital stay (p<0.0001). Complications were common (44.9%), but the auxiliary manipulations were performed infrequently (26.5%). No associations were found between the size of calculus, the number of complications and secondary manipulations (p=0.361). No correlations were found between the clinical form of a solitary kidneywith urolithiasis and the occurrence of complications during the treatment course (p=0.121), as well as between the presence of complications and the cause of the "loss" of the contralateral kidney (p> 0.05). Thus, percutaneous nephrolithotripsy is a highly effective method modality of treatment of solitary kidney urolithiasis. Appropriate selection of indications and contraindications for PCNL, preoperative preparation, surgical technique, postoperative patient management are of great importance.

[Comparative clinical and morphological characteristics of incidental and symptomatic renal cell carcinoma].

Over the last two decades, marked increase in detection of incidental or asymptomatic renal cell carcinoma (RCC) in developed countries was observed. The study included 268 patients aged from 25 to 92 years with RCC, which underwent evaluation and treatment in urology clinic MRSRCI for the past 5 years. There were no significant differences in the frequency of histological types of RCC between incidental and symptomatic tumors. Among incidental neoplasms with clear- cell structure, tumor with small size--up to 4 cm (T1a stage) and moderate to high degree of differentiation (G 1-2 according Fuhrman) were predominant. Papillary variant of RCC was detected at a higher stage of the disease and characterized by a high degree of nuclear atypia, which indicates its high malignant potential. Chromophobe RCC was usually diagnosed at T3 stage. The average age of men and women with chromophobe RCC was 46.5 +/- 6.8 years; there were no age difference in patients with symptomatic and incidental RCC. Among the benign tumors of the kidneys, angiomyolipoma was most commonly diagnosed--in 13 (53.8%) cases. Thus, incidental tumors have a better prognosis than symptomatic tumors.