[Lantox treatment of neurogenic dysfunction of the bladder].

We studied correction of micturition disorders in 9 patients with neurogenic dysfunction of the bladder resistant to conservative treatment. Four patients had neurogenic detrusor hyperactivity and 5 patients had detrusor-sphincter dyssynergia. Injections of botulinic toxin preparation (lantox) were made in the wall of the bladder under endoscopic control in detrusor neurogenic hyperactivity. Women with detrusor-sphincter dyssynergia received transperineal injections of lantox in the region of external urethral sphincter. Men received botulinic toxin directly into the region of external urethral sphincter in urethroscopy. Positive results were achieved in all the cases confirming high efficacy of the method.

[Function of the urinary bladder detrusor after injection of botulinic toxin].

The effect of botulinic toxin of type A (BoNT) on urinary bladder (UB) function was studied during operation in situ in healthy rats using the method of infusion cystomanometry after a single injection of the toxin into the UB wall 3 to 30 days after the injection. Contractility of the muscular fragments in vitro was assessed in the isometric regimen in electric stimulation, depolarization of cellular membranes by ion [K+] excess, addition of noradrenalin (10(-5) M). In response to botulinic toxin injection 47-64% rats vs control animals (23%) operated on without toxin had no phasic UB contractions, detrusor pressure (Pdet) after the infusion was higher which indicated retension. In rats with intact UB contractility, contractions were stronger (Pdet 24-34 cm H2O), but rare (3-5/min) vs controls (19 cm H2O, 5/min, respectively). Contractility in vitro in response to electric stimulation regressed by 60-85% after toxin infusion. Contractility in solution [K+] regressed less (by 65, 36, 16% in 3, 10 and 30 days, respectively). No significant changes of noradrenalin-induced reactions were found. The results illustrate possible direct myogenic effect of the toxin on detrusor muscle.

[Long-term results of endoscopic treatment of urethral strictures].

The aim of the study was assessment of efficacy of internal urethrotomies made in Research Institute of Urology and city urological hospital N 47. A total of 802 endoscopic operations were performed in 644 male patients aged from 16 to 89 years (mean age 58.6 years) with urethral stricture in 1994-2004. Internal optic urethrotomy was made in 733 cases with a cold knife, in 52--with electric knife and in 17 cases--with laser. Endoscopic urethral resection was conducted in 47 cases. The strictures (0.5-8 cm long, mean 1.4 cm) located most frequently in the bulbous urethra (n=426, 66.1%). Short-term results (12 months) of endoscopic treatment of urethral strictures showed that efficacy of the primary internal urethrotomy conducted according to the authors' technique reached 80.4%. Endoscopic reoperations (from 1 to 6) were performed in 98 (19.6%) patients. A complete rehabilitation (follow-up 9 years maximum) including stenting was achieved in 95.1% patients. In 32 (4.9%) patients endoscopic and rehabilitation measures failed to bring about satisfactory clinical outcomes. These patients were treated with open urethroplasty. Thus, internal optic urethrotomy is an effective therapeutic method. After primary urethrotomy recurrences of the strictures to be reoperated reach 19.6%. These can be successfully managed by endoscopic reoperations and rehabilitation measures.

[Roentgenoendoscopic therapy of ureteral injuries after obstetric-gynecological surgery].

Ureteral injuries as a complication of obstetric-gynecological operations occur in 0.37% of cases and are accompanied by formation of stricture or ureteral obliteration, development of uretero-vaginal fistula. Roentgenoendoscopic technologies offer a new solution of the problem of restoration of ureteral passability and elimination of urogenital fistulas. Roentgenoendoscopic treatment of ureteral injuries was made in 14 patients: for obliteration of the lower third of the ureter in 5 cases, stricture of the lower third of the ureter in 9 cases, stricture in combination with uretero-vaginal fistula. The length of the injury varied from 0.2 to 1.5 cm (mean--0.6 cm). Two patients have undergone optic buerginage of ureteral stricture followed by balloon dilation, 7 patients--optic endoureterotomy, 5--ureteral recanalization. Three patients with ureterovaginal fistulas had one-stage fistula fulguration. The operations finished with internal stenting for 6-18 weeks. Normal urine passage recovered in 12 of 14 (85.7%) patients. The fistula disappeared in 3 patients. Thus, roentgenoendoscopic treatment of ureteral injuries after obstetric-gynecological surgery produce positive results in most cases and raises quality of the patients' life.

[Endotomy in treating strictures of the upper urinary tract]. / Endotomiia v lechenii striktur verkhnikh mochevyvodiashchikh putei.

The analysis of outcomes of 102 operations of transurethral and percutaneous endotomy in 100 patients is provided. Primary strictures of the upper urinary tract (UUT) were detected in 26 cases. Postoperative strictures existed up to 3 months in 19 cases, 3 to 12 months in 21 cases and at least 12 months in 36 cases. The causes of the strictures lie in previous surgical interventions on the UUT. Of the 102 endoscopic operations, 49 ones were conducted via percutaneous approach, nephrostomic fistula was used in 11 cases. In 42 endotomies the approach to UUT strictures was transurethral, a "cold knife" was applied in 78 operations, electric current in 24 cases. Follow-up for 12 months to 9 years documented good and satisfactory results in 90 (90%) patients. Open operative intervention was necessary for elimination of the intraoperative complication in 1 case, of the postoperative one also in 1 case. The remaining endotomy complications were treated conservatively. Reoperations due to endotomy failure were made in 8 cases of 10. Endotomy of UUT strictures is indicated in primary and early postoperative strictures 0-1 cm in size located at any site of normally developed UUT accessible for rigid endoscopic instruments from percutaneous or transurethral approaches.

[Endoluminal ultrasonography in diagnosing and treating upper urinary tract diseases]. / Endoliuminal'naia ul'trasonografiia v diagnostike i lechenii zabolevanii verkhnikh mochevykh putei.

Endoluminal ultrasound scanning (EUS) of the upper urinary tracts (UUT) with intracavitary catheter sensor was performed in 15 patients (7 men and 8 women) aged 21 to 61 years. In 8 patients EUS was diagnostic (in one patient it was made twice, in 2 cases--in combination with ureteroscopy and biopsy), in 7 patients it was a diagnostic stage of the following surgical intervention, in 6--in combination with roentgenoendoscopic correction of strictures of the ureteropelvic segment (UPS) and in 1--in combination with transurethral pyelolithotripsy. A total of 16 procedures were made: 15 transurethral and 1--percutaneous. Endoluminal ultrasonography was conducted not only of the whole ureter but also of renal calycopelvic system (RAPS) which presented endosonographic semiotics of UUT. EUS has diagnosed urate concrement in 4 cases, "cross" vessels which narrowed UPS in 3 cases with late hydronephrotic transformation. In one patient EUS was carried out in combination with ureteroscopy and biopsy as a control examination 6 and 18 months after transurethral endoresection of ureteral tumor. In 6 patients with UPS strictures EUS was made for diagnosis of suspected cross vessels before endopyelotomy. No complications during EUS were encountered. Pilot experience with intracavitary ultrasonography of the UUT shows its high diagnostic potential and clinical value. This technique details inner structures of the ureter and RAPS with adjacent tissues due to minimal distance between the sensor and studied object.

[Endoscopic treatment of bladder diverticula]. / Endoskopicheskoe lechenie divertikulov mochevogo puzyria.

Transurethral endoscopic incision of the urinary bladder's diverticular neck has been performed in 29 patients aged 44 to 90 years (mean age 65 years). 25(86.2%) patients had verified concomitant diseases and high anesthesia risk prohibiting radical surgery. According to preoperative diagnosis, the volume of the diverticula ranged from 20 to 700 ml, the diameter of the neck--from 0.3 to 2.0 cm. 10 patients had multiple diverticula. Uroflowmetry registered the maximal urinary flow rate (Qmax) within 2.1-5.3 ml/s. In all the patients surgery was performed under epidural anesthesia, simaltaneously with transurethral resection (TUR) of benign prostatic hyperplasia in 18 patients, with TUR of the urinary bladder neck or incision of the prostate because of its sclerosis in 11 patients. In 2 cases there was also TUR of the bladder for papillary cancer involving the bladder wall and the diverticulum, in 6 cases one-stage pneumatic or mechanical cystolithotripsy was performed. No intraoperative complications occurred. After the operation all the patients resumed normal micturition. Control examination after 6-48-month follow-up Qmax rose to 14.1-23.0 ml/s. Neither ultrasound investigation nor cystography detected diverticulum in 13 patients. The size of the diverticulum diminished in size in 16 patients. Residual urine in large diverticula (14 patients) was 50 ml maximum. 12 months after the operation 1 patient developed recurrent sclerosis of the prostate with reappearance of residual urine. He was reoperated (TUR of the prostate) without incision of the neck of the diverticulum. Postoperative complications were the following: mild electric burn of the thigh (1 case), acute epididimitis treated conservatively (1 case) and early postoperative bleeding which required endoscopic revision of the bladder and coagulation of the bleeding vessel from the cut neck of the diverticulum (1 case). Thus, transurethral incision of the bladder's diverticular neck is effective and low-traumatic intervention which in patients with severe somatic pathology is an alternative to the open surgery, while in patients without such pathology it does not complicate open operation (diverticulectomy) if it becomes necessary.

[Radiographic-endoscopic diagnosis and treatment of obliterations of the upper urinary tract]. / Rentgenoéndoskopicheskaia diagnostika i lechenie obliteratsii verkhnikh mochevykh putei.

Potentialities of x-ray endoscopic diagnosis and treatment of upper urinary tracts (UUT) obliterations were studied in 26 and 21 patients, respectively. The causes of obliteration were previous urological, surgical, gynecological operations, radiotherapy (one case). Percutaneous or transurethral UUT recanalization was performed in 5 and 16 patients, respectively. The length of the obliteration varied from 0.3 to 1.7 cm. It was located at the level of ureteropelvic segment in 13(62%), in the upper third of the ureter in 4(19%) and in the lower third of the ureter in 4(19%) patients. UUT endoscopic recanalization was successfully performed in 17(81%) patients. The operation took 60-90 minutes. Minor complications were corrected conservatively. Control examination was made after 6 to 15 years follow-up. The result was assessed as positive in the absence of clinical symptoms, recurrent stricture(obliteration), in improvement or no change in renal function. These criteria were met in 14(66.7%) patients. One patient has undergone nephrectomy because of highly deficient renal function and dislocation of the nitinol spiral outside recanalization zone. Two patients live with drained kidney in spite of UUT restored patency. The method proved effective and can be used as first-line therapy in short obliteration (< 1 cm), relatively intact renal function and in the absence of UUT marked hypotonia, more so as the failure does not complicate further surgery. Combined x-ray endoscopic diagnosis is presently most significant in determination of complete stricture(obliteration) of ureteropelvic segment and the ureter, its length and location.