[Surgical treatment of purulent gestational pyelonephritis long-term results].

For 20-year period surgery on the kidneys in purulent pyelonephritis was conducted in more than 130 pregnant women. Pyelonephritis was represented by apostematous nephritis and carbuncules with purulent parenchymal fusion. Long-term results (2 to 13 years) were studied in 75 women. Depending on the disease severity, nephrostomy or nephrectomy was performed (61 and 14 cases, respectively). Treatment results were assessed by excretory urography, ultrasound and radionuclide investigations of the kidneys, results of urine bacterial test. The treatment efficacy criterion was the absence of bacteriuria, recurrence of cystitis and acute pyelonephritis in the operated or contralateral kidney. Pathology was not detected in 30 of 55 females after nephrostomy. The rest 25 females had bacteriuria (n = 10), cystitis exacerbations (n = 4), repeated attacks of pyelonephritis (n = 11). Patients with urinary infection activity as shown on urograms and echoscopy had caliceal deformation, atonic dilation of the pelvis and ureter of the operated kidneys. These findings in combination with clinical manifestations of the disease indicate torpid course of pyelonephritis which developed after purulent renal inflammation in pregnant women. Women with a single kidney after nephrectomy had no symptoms of urinary infections, disturbed nitrogen excreting and concentration function. Recurrent pyelonephritis causing disability was observed in cases when by severity of pyoinflammatory process nephrectomy should have been made.

[Intensive therapy in complicated forms of purulent gestational pyelonephritis].

The experience with 65 cases of purulent gestational pyelonephritis (PGP) is reviewed. The efficacy of PGP intensive therapy depends on early surgical elimination of the source of bacteriemia and sepsis. Choice of the surgical technique should be based both on extension of destructive changes in the kidney and severity of the complications. In some cases it is necessary to perform nephrostomy with sanation of the pyonecrotic foci in the kidney, in the other--it is necessary to perform urgent nephrectomy. Three basic components of pre- and postoperative intensive care should be considered: antibacterial treatment, infusion-transfusion therapy and efferent detoxication. Etiotropic therapy is conducted with three antibiotics injected intravenously and intramuscularly to provide effective concentrations of the drugs in the blood, urine and affected organs. PGP medication is based on inhibitor-defended penicillines and cephalosporines of the third-forth generation. Combined use of these antibiotics is effective in 95% cases. If the condition is life-threatening, carbapenems, fluoroguinolones, aminoglycosides and metronidasol can be applied. Detoxication is provided by 24-h infusion of crystalloids, concentrated glucose solutions (10-20%) with insulin, transfusion of fresh frozen plasm, albumin, protein. Plasmapheresis accelerates recovery, diminished nephrectomy rate by 14% and obstetric complications 1.8 fold, enables physiological term of delivery (37-39 weeks) in significant reduction of postnatal complications. Lethal outcomes were absent.

[Bilateral focal purulent pyelonephritis of pregnancy].

A clinical course of bilateral purulent pyelonephritis was analysed in 22 gravidas. The diagnosis of destructive renal lesions in gravidas is based on the findings of ultrasound investigation, chromocystoscopy, clinical and bacteriological examinations of renal urine obtained at separate catheterization of the ureters. Ultrasonic monitoring of the renal parenchyma is of key importance in specification of affection of each kidney. Treatment of gravidas with purulent lesion of both kidneys is combined, open operation being the main method. Two-stage surgery in renal carbuncles in the gravidas has some advantages. Surgical sanation of purulent foci and nephrostomy should be done first of all in the kidney with most severe alterations. Operation on the contralateral kidney is indicated after stabilization of the main clinico-laboratory indices and improvement of the gravida's health. The interval between kidney operations is 7-9 days, on the average. Bilateral nephrostomy resulted in a good pregnancy and delivary outcome in 17 cases. Removal of one of the affected kidneys after bilateral nephrostomy was indicated in 3 women. This stopped purulent intoxication and provided physiological delivary with normal fetus. The most severe clinical course of pyelonephritis and pregnancy was observed in 4 cases with purulent pyelonephritis of the solitary kidney. The other one was removed at nephrectomy. Preterm delivary occurred in 3 of these cases. One case was lethal. Thus, good outcome of therapy was achieved in 21 gravidas.

[Surgical treatment of neuromuscular dysplasia of the ureter].

Ten clinical cases of neuromuscular dysplasia of the ureter (NMDU) are reported. Eight patients were young (24-38 years), two--of the middle age (41-58 years). NMDU was bilateral in two patients. Ureteral achalasia of the congenital solitary kidney occured in one case. One 28-year-old female with megaureter of the solitary kidney had interstitial cystitis. Clinical picture of the disease was characterized primarily with acute pyelonephritis, pain and secondary urolithiasis. Surgical treatment consisted in resection of the affected part of the ureter with modeling of the lumen of the latter on the drainage and Boari plastic repair. Bilateral Boari operation was made in 2 patients. In one case of ureteral achalasia and ureterocele direct ureterocystoanastomosis was created with good result. Sigmocystoplasty with transplantation of the solitary kidney ureter into the intestinal transplant was made in the patient with scar contracture of the detrusor and megaureter. Functional result of the operation was good. Complications were registered in 4 patients, 2 of which were reoperated. In nine patients of ten good and satisfactory functional results were obtained.

[Correction of ureteropelvic segment stenosis by Kuchere: the operative technique and results].

Efficacy of surgical correction of stenosed pelviureteral segment (SPS) in 30 patients with hydronephrosis was analysed. Twenty three patients have undergone extended resection of the extrarenal pelvis together with SPS. Repair of the pelviureteral segment in these patients was made by Kuchere technique. Histologic examination of resected SPS detected advanced sclerosis of all the layers of the ureteral and renal pelvis walls in chronic mucosal inflammation. The operative technique is described. Postoperative complications were absent. The control examination upon discharge and 1-15 year follow-up results registered good functioning of the operated-on kidney with rehabilitation of the calyceal-pelvic structure. Plastic operation was successful due to creation of a wide anastomosis between the resected renal pelvis and the ureter with obligatory renal drainage using nephrostoma. In other 4 cases of SPS strictures graft plastic operations were made. Good functional results were achieved in 3 patients. The long-term results favour resections and creation of pelviureteral anastomosis by Kuchere.

[Long-term results of reconstructive surgeries in iatrogenic injury of the urinary tracts].

Various reconstructive surgeries were performed in 21 patients because of intraoperative injuries of the urinary tracts. In 4 patients trauma of the ureter and urinary bladder was associated with obstetric operations (Cesarean section, hysterectomy). In 13 cases injury of the ureter was the consequence of hysterectomy due to cancer (4), hysteromyoma (4), prolapses of the uterus (1), extirpation of the stump of the uterine cervix (1), electrocoagulation of the ureter (2) and adnexectomy (1). In 4 patients ligation of the ureter complicated surgery for cancer of the sigmoid colon (1) and rectum (1), diverticular disease of the colon (1) and portal hepatic cirrhosis with severe ascites. Surgical policy was organ-saving. Only in 3 patients with severe acute pyelonephritis surgical treatment was performed in two stages with preliminary nephrostomy. In the rest cases primary reconstructive surgeries were used. Reconstructive surgeries saved the kidney as a functioning organ.

[Diagnosis and conservative treatment of acute pyelonephritis in diabetes mellitus].

AIM: To raise efficacy of conservative treatment of patients with acute pyelonephritis (AP) which developed in the presence of diabetes mellitus (DM). MATERIAL AND METHODS: Elderly patients (n = 218, 182 females and 36 males) with DM and AP enered the study. DM type 1 and 2 were diagnosed in 41 and 177 of them. Pyelonephritis was diffuse-purulent, pyodestructive, calculous, pyocalculous. RESULTS: Conservative treatment was made in 160 patients, surgical treatment--in 58. Lethal outcomes (14 cases) were registered as a rule in patients with bilateral pyodestructive pyelonephritis. CONCLUSION: AP is a severe complication of DM. The severity of DM decompensation and metabolic disorders is proportional to AP severity. AP in diebetics runs often an asymptomatic course and the diagnosis is difficult. Therapeutic policy is individual with consideration of a clinical course. Positive results were achieved in 80% patients.

[Surgical policy in acute purulent pyelonephritis in patients with diabetes]. / Khirurgicheskaia taktika pri ostrom gnoinom pielonefrite u bol'nykh sakharnym diabetom.

Efficacy of treatment of 208 diabetic patients with acute pyelonephritis was analyzed. Surgical treatment was performed in 58 patients (43 with insulin-non-depended and 15 with insulin-depended types). All the patients were divided into 4 groups depending on forms of pyelonephritis: non-destructive (116 patients), purulent-destructive (58), calcllious (34), purulent-calculous (10). Algorithm of differential diagnosis between non-destructive and purulent-destructive forms of acute pyelonephritis in diabetic patients are presented. It is demonstrated that surgical treatment is the main method in complex therapy of purulent-destructive forms. Rational surgical policy is substantiated. In patient with diabetes and purulent pyelonephritis nephrectomy is more expediently. Nephrostomy may be used only in light forms of diabetes with local destructive forms ofapostematosic nephritis. Radical surgical policy permitted to achieve positive result of treatment in majority of patients. Lethal outcomes were seen in two-sided lesion of kidneys with apostems, and carbuncles.

[Injuries of the urinary bladder: tactics and results of treatment]. / Travmaticheskie povrezhdeniia mochevogo puzyria: taktika i rezul'taty lecheniia.

A retrospective analysis of 87 cases of isolated traumas and multitraumas of the urinary bladder treated in 1986-2002 covered 69 men and 18 women aged 21-79 years. Young and middle-aged patients (20-50 year olds) prevailed. Isolated traumas of the bladder were diagnosed in 52 patients (4 extra- and 48 intraperitoneal trauma), 35 patients had multitraumas (7 extra- and 28 intraperitoneal trauma). Isolated traumas were most frequently caused by beating (79.4%), multitraumas--by road accidents (79.2%). Examination included catheterization of the bladder, ultrasonic investigation, x-ray contrast studies, laparocentesis, laparoscopy. Injury of the bladder combined with fractures of skeletal bones, craniocerebral trauma, abdominal injuries. Surgery was made in 86 cases, bladder drainage was made by cystostomy, transurethral drain was conducted in 17 patients. Bladder surgery was combined with abdominal operations in 14 patients. Three operations were delayed. Out of 87 patients 67 was cured. 20 (23%) patients died. Lethal outcomes were mostly due to progression of traumatic shock.

[Injuries of the urogenital system]. / Travmy organov mochepolovoi sistemy.

To analyse the results of treatment of isolated and concomitant urogenital injuries, a retrospective analysis was made of 608 case histories for patients treated in 1986-2000. Of them, 530 patients were males, 78 were females, the age ranged from 16 to 70 years, most of the patients were 20 to 50 (71.2%) years of age. Most frequently the injury was inflicted by beating. Fall from the height, transport accidents ranked second among the causes of injury (17 and 14.3%, respectively). Stab and gunshot injuries occurred in 4.4 and 8% cases, respectively. Ultrasound and x-ray methods were employed for examination. An isolated injury was found in 481 patients, the rest had urogenital injury and skeletal (53%), craniocerebral (25%), abdominal (20%) lesions. 29 patients had a severe concomitant wound: urogenital injury combined with abdominal, skeletal, cranial lesions. Surgery was performed in 267 patients. The rest patients received conservative treatment. Most of the operations were made on the kidney and urinary bladder because of rupture. In some patients these interventions were conducted during laparotomy and were combined with abdominal intervention (44 cases). 25 patients with the compound injury underwent 2-stage operations. 552 patients were cured. 56 (9.2%) lethal outcomes were due to progression of traumatic shock. This low percent of lethality may be explained by an optimal choice of treatment policy in the above patients.

[Results of treatment of isolated and combined trauma of urogenital system]. / Rezul'taty lecheniia izolirovannoi i sochetannoi travmy organov mochepolovoi systemy.

Retrospective analysis of treatment results of 608 patients with trauma of organs of urogenital system (UGS) was carried out. Beating was the cause of trauma in 55% cases, fall from height--in 17%, transport trauma--in 14.3%, knife wound--in 4.4%, gunshort wound--in 1.3%. Isolated trauma of UGS was in 481 (79.1%) patients. In other patients combined injury of UGS with injury of skeleton's bones (53), cranium and brain (25), abdominal organs (20) was diagnosed. In 29 patients severe combined trauma of UGS, abdominal organs, skeleton bones and cranium was seen. Surgeries were performed in 267 patients. Surgeries on kidney and urinary bladder due to their disruption predominated. In 44 patients these surgeries were combined with ones on abdominal organs. Surgery was performed in two stages in 25 patients with combined trauma of UGS and other organs. From 608 patients 552 (90.2%) cured. Lethal outcome was in 56 (9.2%) patients due to progressive traumatic shock.

[Acute pyelonephritis in diabetes mellitus]. / Ostryi pielonefrit pri sakharnom diabete.

The authors present treatment policy in acute pyelonephritis (AP) associated with diabetus mellitus (DM) and analyse treatment efficacy basing on the material on 214 patients. A clinical course of AP in the presence of DM has some specific features. The disease manifests primarily with clinico-laboratory signs of DM decompensation. Lack of insulin therapy effect in DM decompensated patients indirectly points to acute, especially purulent, pyelonephritis. High temperature, abnormal leukocytic blood picture, leukocyturia, hypercreatininemia in patients with insulin-resistent DM demands urological examination. Renal and urinary pathology is prompted by x-ray picture of atonic dilation of the caliculopelvic system and ureter in neuropathy. Vesicoureteral reflux, tower-like deformation of the urinary bladder, ureterohydronephrosis in DM patients are readily diagnosed with cystography, excretory urography and ultrasonic investigation. Therapeutic policy must be based on pyelonephritis form, severity of DM and efficacy of conservative therapy. No response to therapy, increasing academia and intoxication show failure of conservative treatment and absolute necessity of surgery. In extended purulent acute pyelonephritis preference is given to primary nephrectomy. The differentiated policy of acute pyelonephritis treatment led to DM remission and therapeutic response in 84.6% patients. Total lethality was 15.4%. Its cause was a severe condition of the patients.

[Surgical treatment of complicated forms of coral-like nephrolithiasis]. / Operativnoe lechenie oslozhnennykh form korallovidnogo nefrolitiaza.

The paper presents the results of operative treatment of complicated coral nephrolithiasis in 22 patients. Organ-saving operations were made in exacerbation of pyelonephritis with pyoseptic intoxication, severe renal failure with hyperazotemia. Partial nephrolithotomy (semisectional), sectional nephrolithotomy, resection of the kidney and coral calculus and calicolithotomy were made in 10, 1, 5 and 1 patients, respectively. As a rule, nephrolithotomy was completed with renal drainage by nephrostomy. After resection of a renal segment nephrostomy was not necessary. Postoperative complications did not occur. These occur only in 2 patients with bilateral coral calculi after nephrolithotomy and pyelolithotomy (urinary fistulas). To correct them, nephrostomy was made. One lethal outcome was caused by cardiovascular failure. The above surgery led to normalization of nitrogen-eliminating function of the operated kidney, elimination of intoxication and improvement of the patient's condition. Efficiency of the above operations recommends allows to recommend them for treatment of severe coral nephrolithiasis.

[Reconstructive-reparative operations in injuries of the urinary tract in obstetrical, gynecologic and abdominal surgery]. / Rekonstruktivno-vosstanovitel'nye operatsii pri povrezhdenii mochevykh putei v akushersko-ginekologicheskoi i abdominal'noi khirurgii.

Different reconstructive operations were performed in 20 patients for intraoperative traumas of the urinary tract. 4 patients had injured ureter and urinary bladder. The damage was done in the course of obstetric operations (cesarean section, uterine extirpation). In 12 cases the ureter was injured in uterine extirpation for cancer (n = 4), myoma (n = 4), prolapse of the uterus, (n = 1), extirpation of uterine cervix stump (n = 1), ureteral electrocoagulation (n = 1) and adnexectomy (n = 1). In 4 cases ligation of the ureter complicated surgical interventions for cancer of the sigmoid colon (n = 1) and rectum (n = 1), diverticulosis of the colon (n = 1) and portal cirrhosis of the liver with evident cirrhosis (n = 1). Surgical policy in the treatment of intraoperative urinary tract injuries was organ-saving. Only in 3 patients with severe acute pyelonephritis surgery was two-staged with prior nephrostomy. In the rest cases primary reconstructive operations were made. Two patients with bilateral injury of the ureters after uterine extirpation have undergone transabdominal bilateral reimplantation of the ureters by Boari in Gregoir's modification. Reconstruction of pelvic ureter was often made by using a urinary bladder graft (Boari's technique). In 1 female patient with extensive vesicovaginal fistula resultant in detruzor corrugation sigmocystoplasty was made with a good result. Serious complications after the reconstruction were absent. Urinary fistulas formed in 4 cases. In 3 of them they closed without surgical intervention. In 1 patient, to close urinary fistula complicating ureterocystoanastomosis Boari's operation was conducted with a favourable outcome. Reconstructive operations saved the kidney function.

[Surgical tactics in complicated forms of acute purulent pyelonephritis in pregnancy]. / Operativnaia taktika pri oslozhnennykh formakh ostrogo gnoinogo pielonefrita beremennykh.

Out of 3000 pregnant women observed in 1986-1999, pyodestructive forms of pyelonephritis were diagnosed in 120 women. They were treated surgically. The policy of the treatment depended on the degree of pyoseptic intoxication, severity of toxic affection of the parenchymatous organs, severity of pyodestructive changes in the kidney. Plasmapheresis expanded indications to organ-saving operations, effectively and quickly arrested purulent intoxication. Various organ-saving operations have been successfully performed in 77(64.1%) pregnant women. In 12 patients nephrostomy was uneffective. In these patients a second nephrectomy was made. Primary nephrectomy was made in 37 cases of life-threatening pyoseptic intoxication. Hard to treat bilateral pyodestructive forms of pyelonephritis were detected in 15(12.5%) women. Bilateral nephrostomy with cleaning of purulent infection foci was effective in 9 patients. It is shown that early surgical detoxication of the most affected kidney prevents development of extended pyodestructive alterations in the contralateral kidney and avoid surgical intervention.

[The surgical treatment of suppurative destructive forms of acute pyelonephritis in pregnant women]. / Operativnoe lechenie gnoino-destruktivnykh form ostrogo pielonefrita beremennykh.

The paper presents the results of surgical treatment of pyodestructive pyelonephritis diagnosed in 111 puerperae and gravidae. Suppurative nephritis, carbuncle and abscess of the kidney ran as unilateral (94 patients, 84.7%) or bilateral (16 patients, 14.4%) process. The diagnosis of pyodestructive pyelonephritis of the solitary kidney was made in 1 gravida. The outcomes of pyodestructive pyelonephritis in puerperae and gravidae depend primarily on individual approach to therapy. Different operative interventions warranted a complete response in 97.3% of the gravidae. 96 of 108 gravidae operated on the kidneys delivered viable neonates. Early operative interventions in many cases preserved the kidney and prevented septic complications. Pyodestructive changes restricted to 1-2 segments of the kidney were effectively treated by nephrostomy. Bilateral pyodestructive pyelonephritis should be managed step-by-step starting at the side of the most evident symptoms. Two-stage bilateral lumbotomy with nephrostomy in combination with antibacterial therapy and plasmapheresis eliminated septic complications thus allowing normal development of the fetus. Nephrectomy is the best treatment in advanced pyodestructive lesion with severe life-threatening septic intoxication.

[The late results of organ-preserving operations in acute hemorrhages in patients with bladder cancer]. / Otdalennye rezul'taty organosokhraniaiushchikh operatsii pri ostrykh krovotecheniiakh u bol'nykh rakom mochevogo puzyria.

Surgical aid in acute hemorrhage due to cancer of the urinary bladder was rendered within 1986-1994 to 65 patients (53 males and 12 females) aged 30-50, 51-60, 61-70 and over 70 years (10, 11, 24 and 20 cases, respectively). The majority had the disease stage T2 and T3. In 42 (64.6%) patients with profuse hematuria complicated by bladder tamponade an urgent resection was performed: segmental in 22, hemiresection in 8, open bladder electroexcision of the tumor in 10 patients. 2 patients had sigmoid cancer with bladder involvement managed by subtotal resection of the bladder and resection of the sigmoid colon. Nephro- or cystostomy was performed because of grave condition (purulent pyelonephritis, azotemia) in 23 patients (35.4%). Total postoperative lethal outcomes made up 33.3% (14 patients): 6 patients died early after surgery, 8 patients 6 months to 8 years later. 27 patients (64.3%) are alive. Of them 10 are 5-8-year survivors. These patients had cancer stage T2 and T3 with tumor location on the lateral wall. In three 4-year survivors there were tumor recurrences 2 and 3 years after surgery which were treated by transurethral resection and electroexcision on the open bladder. Long-term outcomes of urgent surgery show that different kinds of resection of the bladder may be effective in the treatment of acute hemorrhages from bladder tumors.

[The surgical outcomes in complicated urolithiasis]. / Iskhody khirurgicheskogo lecheniia oslozhnennoi mochekamennoi bolezni.

Complicated nephrolithiasis and ureterolithiasis were surgically treated in 87 and 79 patients aged 18-80 years, respectively. Of them elderly patients constituted 62%. Unilateral calculi occurred in 90.9%, coral calculi in 21 patients. Of 195 complications observed acute purulent pyelonephritis (PP) developed in 150 patients. It proved to be the most threatening and frequent complication. Therapeutic policy and choice of surgery were decided upon with consideration of the stone location, anatomic and functional status of the kidneys, preexisting somatic pathology, age of the patient. Because most severe pyelonephritis was reported in patients with nephroliths and prepelvic ureter, these patients have undergone nephrectomy most often (47%). Conservative surgery has been performed in 53%, pyelolithotomy without renal drainage in 9 (5.4%) patients with non-destructive pyelonephritis. Calculous pyodestructive pyelonephritis should be treated early according to the scheme: cleaning of the purulent foci, removal of the stone and nephrostomy. Used in 23 (13.9%) patients, this scheme failed (lethal outcome) only once. PP in patients with ureteroliths required two-stage treatment. Early nephrostomy (stage 1) preserved the kidney and prevented septic complications in 37 patients. Extracorporeal lithotripsy of ureteroliths (stage 2) is beneficial in clinically cured pyelonephritis and is indicated only in functioning nephrostomy. Conventional ureterolithotomy is valid in cicatricial ureteral stenosis in need of plastic surgery. Renal drainage and surgical elimination of the obstruction in the urinary tracts or on-demand nephrectomy resulted in a 90.4% cure. Hospital lethality in septic complications of calculous PP was 9.6%.