[Antibacterial prophylaxis with fosfomycin at the time of the urethral catheter removal after radical prostatectomy (prospective randomized trial)].

AIM: To evaluate the effect of antibacterial prophylaxis using oral fosfomycin during the removal of a urethral catheter after radical prostatectomy on the development of urinary tract infection, severity of leukocyturia and bacteriuria, as well as the severity of lower urinary tract symptoms. MATERIALS AND METHODS: A single-center, non-blind, prospective, randomized controlled trial was carried out. The main group included 40 patients, and the control group included 37 patients. In the group 1, patients received two doses of oral fosfomycin, 3 g, namely in the evening on the day of catheter removal (the first dose) and 48 hours after catheter removal (the second dose). In the group 2, patients did not receive any antibacterial prophylaxis after urethral catheter removal. The endpoints of the study were confirmed episodes of urinary tract infection within 1 month after removal of the urethral catheter, leukocyturia and bacteriuria in urinalysis/urine culture) and severity of the lower urinary tract symptoms assessed by IPSS questionnaire. RESULTS: In the group 2, urinary tract infection was noted in 17.1%, while in the group 2 only in 2.6% of patients (p=0.032). Leukocyturia and bacteriuria were significantly less common in the group receiving antibacterial prophylaxis with fosfomycin (18.4% vs. 48.6%, respectively; p=0.006). Positive urine culture was observed in 7.9% vs. 25.7%, respectively (p=0.035). Four weeks after removal of the urethral catheter, the average IPSS score was significantly higher in the group 2 (13.2 vs. 9.5 points; p=0.002). There were no cases of allergic reaction and pseudomembranous colitis associated with C. difficile in both groups. Diarrhea cured with sorbents was noted in 2 patients (5.2%) in fosfomycin group. CONCLUSION: Antibacterial prophylaxis using two oral doses of fosfomycin 3 g on the day of urethral catheter removal and 48 hours after catheter removal after radical prostatectomy appears to be an effective scheme that reduces the incidence of urinary tract infection and the severity of lower urinary tract symptoms, and is characterized by a minimal risk of adverse events. It is necessary to carried out further research and develop clear recommendations for antibacterial prevention in urological interventions requiring prolonged urethral catheterization.

[Fournier`s gangrene: evolution of representations about pathogenesis, current state diagnosis and treatment].

The article is devoted to one of the rare forms of necrotizing fasciitis - Fourniers gangrene (FG). In chronological order, key aspects related to epidemiology, etiology, pathogenesis, classification, clinic, diagnosis and treatment are highlighted, according to extensive literature. It is postulated that according to modern scientific provisions, Fournier gangrene is a private clinical model of critical conditions in surgery, which is characterized by progressive purulent-necrotic lesion and putrefactive decay of soft tissue and fascial structures and is accompanied by phenomena of systemic endotoxicosis (sepsis) and high mortality, varying from 35 to 76-86%. It is declared that the trigger pathogenetic mechanism of the development of FG is disseminated thrombosis of the microcirculatory bed of the superficial fascia of the scrotum due to intravascular invasion of various strains of causative microbes. The methods of clinical, laboratory and instrumental diagnostics and methods of treatment are described, taking into account modern achievements of evidence-based medicine. Based on a multifactorial analysis of literature data and their own experience, the authors stated that the cornerstone that completely affects the outcome of treatment and prognosis of the disease is a multidisciplinary approach to solving diagnostic and therapeutic and tactical tasks with the participation of doctors of related specialties (surgeon, resuscitator, radiologist, cardiologist, coloproctologist, urologist, microbiologist). It is shown that the unshakable priority of treating patients with FG is still urgent surgical intervention in the format of "aggressive surgery", which provides for extremely wide excision of necrotic and non-viable tissues, followed by programmed (stage-by-stage) rehabilitation necrectomy. The issues of laser irradiation and hydropressive wound treatment with ozonated saline solution are touched upon. Adjuvant wound treatment using vacuum therapy and hyperbaric oxygenation are given.

[Surgical approach for colon perforation and traumatic ruptures at the multifield hospital]. / Khirurgicheskaya taktika pri perforatsii i travmaticheskikh razryvakh obodochnoi kishki v usloviyakh mnogoprofil'nogo statsionara.

OBJECTIVE: To analyze postoperative outcomes in patients with colon perforation and traumatic ruptures at the multifield hospital. MATERIAL AND METHODS/: The study included 93 patients aged 24-85 years with colon perforation and traumatic ruptures. All patients were divided into 3 groups depending on the cause of colon perforation: group 1 - 43 (46.2%) patients with colon cancer, group 2 - 27 (29%) patients with ulcerative colitis, group 3 - 22 (23.6%) patients with traumatic ruptures following blunt abdominal trauma. Cause of colon perforation was unclear in 1 (1.1%) case. Diagnostic algorithm included routine clinical and laboratory methods and modern minimally invasive endoscopic surgical technologies (ultrasound, CT, MRI, colonoscopy, laparoscopy). RESULTS/: Ninety (96.8%) out of 93 patients with colon perforation underwent surgery. Postoperative mortality was 41.5%, 46.1% and 31.8% in all groups, respectively. Overall postoperative mortality was 40%. CONCLUSION: Bowel resection with colostomy is preferred for colon perforation regardless the cause of injury because this procedure ensures the best immediate results. Palliative suturing of perforations with colostomy or delivering the affected colon segment on anterior abdominal wall are accompanied by high mortality and should be used for strict indications in severely ill patients.

Trends in the seasonal variation of paediatric fractures.

PURPOSE: The incidence of paediatric fractures is known to peak during the summer as a consequence of unsupervised physical activity. A more sedentary lifestyle is a potential cause for changes in paediatric seasonal fracture frequency and severity. The aim of this study was to evaluate the current seasonal variations of paediatric fractures in order to determine resource allocation in hospitals, community clinics and prevention programs. METHODS: A single institutional review of historical data of all patients aged 0 to 16 years that were diagnosed with fractures between April 2014 and July 2017 in the emergency department of a level 3 orthopaedic trauma centre was conducted. In all, 3484 fractures were reviewed, of which 2991 were included. We stratified fractures according to patients' variants and the hour, day and month with respect to holidays, weekends and weather. RESULTS: While the fracture rate on school days was 6.62 per day, the fracture rate during the summer vacation was 4.45 (p < 0.01). Hot weather was correlated with low fracture rates. The peak hours of admission were 12:00 to 13:00 and 18:00 to 22:00, with more moderate differences during non-school periods. CONCLUSION: The local seasonal variation of paediatric fractures has a bimodal distribution, with similar nadirs during both summer and winter. These rates might reflect a shift to a more sedentary lifestyle during the summer vacation. The presented data can assist in improving the value of injury prevention measures and medical resources allocation. LEVEL OF EVIDENCE: II.

COMPLICATIONS OF TERMINAL COLOSTOMY IN PATIENTS WITH TUMOROUS LARGE INTESTINE ILEUS AND THEIR SURGICAL MANAGEMENT.

The article analyzed the structure, incidence rate and results of surgical treatment of paracolostomal complications in 69 patients out of 134 (aged from 23 to 77 years old). The patients were divided into 2 groups according to the variant of terminal colostomy. The single-barrel colostomy was formed by classical (intraperitoneal) method using «proboscis¼ design in 58 patients (43,3%) of the first group. Various complications were developed in the area of colostomy in 42 (72,4%) patients. The single-barrel flat colostomy was applied at the skin level using the method modified by the authors in 76 (56,7%) patients of the second group. The authors designed the method of controlled intra- and postoperative decompression and lavage of the colon by a new model of aspiration-irrigation device in order to unload the colon through colostomy. There were noted complications in the area of colostomy in 27 (35,5%) cases. The developed rational method of terminal colostomy formation, upgrading the ways of intra- and postoperative decompression and lavage of the colon facilitated to decrease of the rate of postcolostomy complications more than two times (from 72,4 to 35,5%). The author's method led to optimization of immediate and long-term results of surgical treatment.

[Fournier's gangrene-variety of clinical model of critical states in surgery].

The investigation based on a retrospective analysis of the treatment results of Fournier's gangrene (FG) in 27 patients aged from 34 till 82 years old. There were 27 patients. Diseases of colorectal zone were the nosological reasons of FG in 15 patients. Diseases of urogenital tract had 10 patients with FG. The development of FG was determined by closed trauma (1 patient) and a gunshot wound of the perineum and the scrotum in one patient. The slowly progressive (limited) forms of the disease were noted in 15 patients, although the rapid progressive (extensive) forms were in 12 patients.All the patients had the clinical manifestations of the disease and at the same time laboratory indices indicated a presence of generalized infection and they were characterized by symptoms of systemic inflammatory response syndrome (SIRS). There were 6 patient, who died out of 27.The lethality consisted of 22.2%. The reasons of the death were an infection-toxic shock (1 case), a progressive endotoxicosis (3 cases) and a pulmonary artery thromboembolism (2 cases). The results obtained testified that early diagnostics and the active strategy with radical surgical d-bridement of necrotic suppurative foci combined with programmed (staged) sanitation necrosectomy, complex system of local wound treatment, the rational antibacterial therapy, a task-specific and syndrome correction of dyscrasia could be the actual ways to improve the treatment results in patients with FG.

[POSTOPERATIVE INTRAABDOMINAL COMPLICATIONS IN COLON CANCER SURGERY COMPLICATED BY BOWEL OBSTRUCTION AND PERFORATION OF THE TUMOR].

The article presents a retrospective analysis of the results of surgical treatment of postoperative intraabdominal complications in 42 patients with colon cancer complicated by bowel obstruction and perforation of the tumor. The pyoinflammatory processes such as peritonitis and abscesses of abdominal cavity took a leading place in the structure of postoperative complications according to the authors. Method of "closed" decompression and intraluminal irrigation of the large intestine without wide opening of organ lumen was developed and applied into practice as perioperative prophylaxis of pyoinflammatory processes. These measures allowed reducing the rate of postoperative intraabdominal complications from 19.2 to 7.7%.

[Fournie's disease in the light of modern ideas].

The results of treatment of scrotum gangrene (Fournier's disease) in 25 patients aged from 34 to 82 years are presented in the article. The diseases of colorectal zone were nosological reasons of Fournier's disease in 13 patients, the diseases of urogenital tract - in 10 cases. Development of Fournier's disease was associated with closed trauma in 1 patient, and 1 case was associated with gunshot wound of perineum and scrotum. Slowly progressing forms of the disease were detected in 14 patients, fulminant and rapidly progressing variants - in 11 patients. Diabetes mellitus of different severity were identified in 6 patients. Clinical picture and laboratory data evidenced about systemic infection in all patients. Non-clostridial anaerobic microbes were the main exciters of pio-necrotic process (92%). 6 patients died. Mortality was about 24%. Toxic shock was the reason of death in 1 patient, progressing endotoxemia - in 3 cases, pulmonary embolism - in 2 cases. The authors consider that early diagnosis and active tactics of radical treatment of pio-necrotic hearth in combination with programmed (phased) remedial necrectomy are effective methods for improvement of treatment results. Also such ways as complex system of local wound treatment, focused and multicomponent therapy of systemic and metabolic disorders of homeostasis are very important in complex treatment of patients.

Closed reduction and internal fixation for intertrochanteric femoral fractures is safer and more efficient using two fluoroscopes simultaneously.

The purpose of the study was to assess whether using two fluoroscopes simultaneously in closed reduction and internal fixation of a stable intertrochanteric fracture reduces radiation and operation time. Patients who sustained a stable intertrochanteric femoral fracture were operated in our institution with closed reduction and internal fixation. They were randomly allocated to be operated with the assistance of one or two fluoroscopes. With one device, the radiology technician controlled and moved it to the desired anterior-posterior or axial view. With two fluoroscopes, one was positioned in the anterior-posterior view and the other in the axial view, both controlled by the surgeon. Total radiation and operation time were collected for all patients and compared between the two groups. A total of 27 patients participated in the study. One fluoroscope was used for 13 surgeries and two in 14. Total radiation time was shorter with two fluoroscopes compared to the use of one (36.6±8.6s versus 51.2±18.9s, respectively; p<0.02), as was total operation time (24.3±4.2min and 34.7±11.9min, respectively; p<0.01). Working simultaneously with two fluoroscopic devices is safer for the medical team in the operating theatre, because it decreases the patient's radiation exposure, wound exposure time, and anaesthesia time. It saves operating room time and fluoroscopy personnel during the operation. When operating on hip fractures that are planned to be reduced and fixated, we recommend working with two fluoroscopes simultaneously.

[Features of diagnostics and surgical strategy of diaphragmatic rupture in patients with closed chest and abdominal polytrauma].

The article presents results of diagnostics and surgical treatment of diaphragmatic rupture in 32 victims with an estimation of diagnostic value of different instrumental methods of investigation and the efficacy of surgical approach. The correct interpretation of typical clinical and instrumental signs in consideration with trauma mechanogenesis allowed diagnostics of diaphragmatic rupture before the operation in 17 (53.1%) cases. It was observed that an undiagnosed rupture of the left hemidiaphragm caused a formation of posttraumatic diaphragmatic hernia in 2 (6.2%) patients. The laparotomy was applied in 28 patients as a surgical approach and thoracotomy--in 2patients. The laparotomy and after that thoracotomy were performed on one patient. The thoracotomy and laparotomy were carried out on the second patient in turn. The authors consider the laparotomy as optimal variant of surgical approach in acute period of trauma. The postoperative lethality was 15.6%.

[Modified method of inguinal hernioplasty].

The work is devoted to the hernioplasty method, which provides the strengthening of back wall of the inguinal canal by autogenous tissues, which were the walls of the hernial sac. After dissection of hernial sac, two muscle flaps were formed and fixed to transverse fascia on the whole perimeter of the inguinal canal. The control group consists of 64 patients and main group - 66 (90.4%). The Liechtenstein operation was performed in control group. In contrast, the method, suggested by the authors, was used in the main group. The patients with hernioplasty were carefully and sufficiently examined in order to make an objective comparative analysis of the results. The results of the review allow the authors to confirm, that the suggested hernioplasty method provides stable local homeostasis of tissues and high quality of life.