[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.

[Effectiveness of laparoscopic repair of primary strictures of ureteropelvic junction].

AIM: To evaluate the effectiveness of laparoscopic repair of primary strictures of ureteropelvic junction (UPJ) depending on baseline renal function of the ipsilateral kidney. MATERIALS AND METHODS: The study analyzed results of 134 patients (78 women and 56 men, age from 18 to 56 years) who underwent various types of laparoscopic repair of the UPJ stricture from 2012 to 2015. Depending on the surgical technique all patients were divided into three groups: group 1 (n=34) underwent spiral flap technique by Culp and DeWeerd, group 2 (n=59) - Anderson-Hynes pyeloplasty and group 3 (n=41) had antevasal dismembered pyeloplasty. All interventions ended with internal ureteral stenting for up to 6-8 weeks. Also, all patients were divided into three subgroups, depending on the degree of renal function deficiency - less than 25%, 25-50%, and 51-75%. Treatment effectiveness criteria included the following parameters: complete relief of the pain syndrome, a decrease in the degree of pyeloectasia, stabilization or improvement of the functional state of the renal parenchyma (according to radioisotope renography), and the absence of recurrence of the UPJ stricture. RESULTS: The overall effectiveness of UPJ laparoscopic reconstruction was 94.7% (127 of 134). The effectiveness of the treatment was independent of the surgical technique, the initial thickness of the renal parenchyma and the degree of PCS dilatation. There was an inverse correlation between the treatment effectiveness the degree of kidney function deficiency. CONCLUSION: In patients with hydronephrosis secondary to UPJ stricture, the effectiveness of surgical treatment is mainly determined by its timeliness. The best treatment results were observed in patients with better renal function. The degree of renal function deficiency should be considered the main prognostic factor for the effectiveness of the forthcoming operation.

[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.

[Antiulcer prevention in urological practice].

This article is a detailed analysis of the studies of Russian and foreign authors on the epidemiology, clinical features, pathogenesis, risk factors of stress-induced disease of the mucosa of the upper gastrointestinal tract. Also in the article the approaches to drug prevention of this complication are considered. Currently, there are several groups of drugs are suitable for use for this purpose. However, the choice of a specific drug is difficult because of insufficient knowledge of the matter. Data on the incidence and natural history of erosive and ulcerative complications in patients urological profile is limited and very controversial.

[Estimation of the contractile function of the upper urinary tract by multichannel impedance ureterography before and after endoureteropyelotomy].

We studied qualitative and quantitative characteristics of the upper urinary tract (UUT) contractile function examination with multichannel impedance ureterography (MIUG) in patients given roentgenoendoscopic treatment for stricture of the ureter and pelvoureteral segment (PUS) for prognosis of the disease outcome and decision on further therapy. UUT function was studied with MIUG in 12 patients with stricture of the upper third of the ureter and PUS during and 1-2 months after endoureteropyelotomy. UUT peristalsis was assessed qualitatively (direction of peristaltic wave, rhythm of peristalsis, wave shape) and quantitatively (amplitude of ureteral contractions, frequency of peristalsis, wall tonicity). Ureteral peristalsis disorders of different severity were found in the majority of patients. UUT contractile function improved after treatment in 83% patients. The improvement concerned wave shape, peristalsis amplitude, a relief of wall tonicity, frequency of contractions). MIUG can objectively assess UUT function in patients with ureteral and PUS stricture, predict efficacy of roentgenoendoscopic treatment early after surgery. MIUG is intended for diagnosis of UUT contractile disorders undetected by x-ray, for objective control over quality of therapy, for formulating indications to pathogenetic treatment.

[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.