[Analysis of surgical complications of reconstructive plastic surgery according to the ClavienDindo classification].

INTRODUCTION: The systematization of surgical complications has long been a serious problem since different types of surgical procedures have specific complications, in addition to general consequences. Created in 1992 and improved in 2004, the Clavien-Dindo classification was successfully validated in surgical centers in different countries and recognized as an important tool for the qualitative assessment of surgical complications. AIM: To improve reconstructive procedures by systematizing complications based on the ClavienDindo classification. MATERIALS AND METHODS: The results of substitution ileocystoplasty in 95 patients with contracted bladder due to tuberculosis and other diseases are presented. In 50 (52.6%) cases, the length of the bowel segment was 30-35 cm (group 1, main), while in 45 patients (47.4%) a segment of 45-60 cm was chosen (group 2, control). RESULTS: Early complications of grade II developed in 11 (22.0%) patients in the group 1 and in 13 (28.9%) in group 2, while grade III in 5 (10.0%) and 6 (13.3%) cases, respectively. Complications of IIIb grade were seen among patients of the main group in 9 (18.0%) cases compared to 12 (26.7%) in the control group. Severe complications of IVa and IVb grades were documented with the same frequency in both groups, in one case each. Complications of V grade (death) were recorded only in the group 2. Late complications were registered in 63 out of 94 patients. In group 1, there were 26 complications (16 somatic and 10 surgical), while in group 2, a total of 37 complications (24 somatic and 13 surgical) were seen, which indicates a significant higher rate in the control group (p<0.05). In group 1, transurethral resection of urethral-enteric anastomosis and ureteral reimplantation were performed less frequently than in group 2, while transurethral resection of the prostate was done with the same frequency. At the same time, percutaneous nephrostomy was required more often in the group 1 (6% vs. 4.5% in the group 2). After intestinal cystoplasty with a shortened fragment of the ileum, the voiding volume was significantly lower but corresponded to the physiological value (more than 150 ml). In this group, there was sufficient capacity of neobladder with a minimum amount of residual urine, effective emptying, satisfactory urinary continence, and low intraluminal pressure, which contributes to the protection of kidneys from reservoir-ureteral-pelvic reflux. The serum chloride level after surgery was 106.2+/-0.4 in the group 1 compared to 109.7+/-0.3 in the group 2, while base excess was -0.93+/-0.3 and -3.4+/-0.65, respectively (p<0.05). CONCLUSION: Early serious postoperative complications according to Clavien-Dindo were registered with approximately the same frequency in both groups, while late complications developed significantly more often in the group 2. The urodynamic parameters of a neobladder formed from ileum segment of 30-35 cm are satisfactory. In addition, a decrease in the length of the intestinal segment prevents the development of hyperchloremic metabolic acidosis.

[Laparoscopic ONLAY ureteroplasty using buccal mucosa graft for long recurrent stricture of the upper third of the ureter].

Long strictures of the upper third of the ureter are most often recurrent and occur after endourological and reconstructive procedures. The lack of native tissues and an impossibility of substitution by bowel segment in some cases dictates the use of alternative surgical techniques. Our first experience of laparoscopic onlay ureteroplasty using buccal graft for long stricture of the upper third of the ureter is described in the article. The length of the stricture was 6 cm. The operation time was 210 minutes, while blood loss volume was less than 100 ml. The patient did not have any surgical complications. Drains were removed in timely manner. The patient was discharged from the hospital in a satisfactory condition on the 8-th day. The ureteral stent was removed after 4 weeks. Kidney ultrasound was performed on a monthly basis. According to IVU after 4 months, the anastomosis was completely patent. This method can be considered as an alternative to more complex procedures in selected patients.

[Surgical treatment of tuberculosis of the kidney with a total lesion of the ureter].

The study was aimed to improve the efficiency of surgical treatment of renal tuberculosis with total lesion of the ureter. The clinical course and the results of surgical treatment of 104 patients with extended or multiple ureteral strictures of specific (n=92) and non-specific (n=12) etiology. Thirty-five patients with nephrotuberculosis underwent percutaneous needle-guided nephrostomy (PNGNS), 79 underwent surgery with removal of organs: open nephrectomy with lumbar access (48), combined nephroureterectomy (31). According to the evaluation the glomerular filtration rate after PNGNS, value less than 10 ml/min led to performing nephrectomy, more than 10 ml/min - ureteroplasty. It was established that combined nephroureterectomy has significant advantages in the case of specific kidney disease, despite a long duration as compared with a nephrectomy. Removal of the kidney with ureter in patient with nephrotuberculosis is the prevention of persistent dysuria, empyema of ureter stump, its possible malignant transformation, and contributes to significant improvement of quality of life of the patient. Of the 35 patients after CHPNS, 25 underwent intestinoplasty of ureter: ileum was used in 23 patients, appendix- in 2 patients. It is shown that reconstructive surgery using small intestine allows to release 92% of patients from a lifetime external drainage of the kidney.

[Endoscopic methods for the correction of ureteral strictures].

The comprehensive examination and treatment of 80 patients aged 19 to 63 years with strictures of the ureteropelvic junction (UPJ) and ureter obstruction was performed. 23 patients underwent probing with ureteral stenting, 30 patients underwent balloon dilation of strictures under fluoroscopic guidance, 18 patients--endoureteropielotomy with "cold" knife, 9 patients underwent endoureteropielotomy using holmium laser. Correction of ureteral stricture with the removal of the stone was performed in 6 patients. It was found that efficiency of the methods increases in the following order: balloon dilatation (73.3%), dissection using "cold" knife (77.8%), probing with ureteral stenting (82.6%), and laser endoureteropielotomy (100%). In general, endoscopic correction of ureteral contractions is a minimally invasive treatment option for restoring its continuity, without perfoming traumatic surgery in 80% of patients with UPJ and ureteral strictures, including complicated by stone formation.

[Role of supravesicular urine diversion in the treatment of patients with renal and urethral tuberculosis].

The article presents the results of the survey, etiopathogenetic and surgery treatment of 73 patients with nephrotuberculosis complicated by tuberculous ureteritis. Patients were divided into 4 groups. 1-3 Groups of patients underwent urine diversion by percutaneous puncture nephrostomy, open nephrostomy and internal stent placement. Patients in Group 4 not underwent surgery with urine diversion. It was found that the long-term etiopathogenetic therapy against the background of retention changes resulted in progression of changes and loss of renal function in 63% of cases. Early urine diversion, depending on its method allows preserving the functional ability of the kidneys in 70.8 to 94.4% of cases. The combination of early renal drainage with antituberculous polychemotherapy is significantly superior to conservative treatment, leads to a rapid reduction of chronic renal failure (CRF) and allows to subsequently perform the greatest number of reconstructive operations: in 62.6% of cases after the external drainage and in 73.3%--after internal drainage (p < 0.05). At the same time, good results of plastics were achieved only in patients undergoing a two-stage surgical treatment, and poor results (relapse of stricture, progression of hydroureteronephrosis or CRF) were significantly more often observed (60%) in patients without urine diversion (p < 0.05).

[Surgical correction of overactive bladder resistant to standard therapy].

Surgical treatment was given to 45 patients with overactive bladder: transurethral detrusorotomy was made in 21 patients (group 1), bladder hydrodilation (BH) was made in 24 patients (group 2). Detrusorotomy was performed by transurethral median cut of the bladder posterior wall by needle electrode leading to destroyment of intramural sympathic and parasympathic nervous fibres. Hydrodilation of the bladder was made under intravesical pressure equal to systolic arterial pressure with 2 min exposure. On day thirty after the operation regress of the lower urinary tract symptoms was registered in 20 (95.2%) patients of group 1 and 11 (45.8%) patients of group 2. Urge to voiding (UV) disappeared in 90.5% patients of group 1 and in 45.8% of group 2 (p < 0.05), the number of patients with miction pain reduced 6-fold and 1.9-fold, with UV--8.5 and 1.2-fold, respectively (p < 0.05). The number of diurnal mictions in group 1 decreased 3.2-fold vs 1.9-fold in group 2. The bladder size in urgency in group 1 patients increased 2.5-fold, the pressure fell also 2.5-fold. In group 2 these parameters changed only 1.2 times (p < 0.05). Cystometry recorded recurrent detrusor overactivity in 13 (54.2%) patients after hydrodilation and only in 3 (14.3%)--after cut of the bladder wall (p < 0.05). Thus, transurethral detrusorotomy in overactive bladder resistant to conventional treatment is much more effective than hydrodilation. The operation is low invasive and is well tolerated. Simple performance and good short-time results are advantages of this technique.

[Obstructive uropathy in nephrotuberculosis and the results of its surgical correction].

In 2000 to 2006, one hundred and fifty-eight patients with active nephrotuberculosis, including 24 without obstructive uropathy, 70 with obstruction at the level of the upper ureter third, and 64 with that at the level of the lower ureter third, were examined. It was shown that papillites, pyonephroses, and specific paranephritis were prevalent when a specific process extended to the upper ureter third. Involvement of the lower ureter third resulted in the most significant renal destruction that was bilateral in 75% of cases with a large proportion (51.4%) of complete organ destruction and complications of the underlying disease. The effectiveness of organ-removing operations was higher in ureteritis of the upper third of the ureter and that of reconstructive operations was higher in ureteritis of the lower third. Surgical treatment for nephrotuberculosis in distal obstruction induced no regression of renal failure in 24% of cases, its progression being observed in 8%. Every five patients were reoperated on; more than 29% of the patients underwent bilateral operations; the proportion of organ-removing interventions turn to be highest.

[Surgical treatment of nephrotuberculosis in the present-day epidemiological situation].

The article presents data on the structure of operative interventions and assessment of the role of an early kidney decompression in management of renal tuberculosis complicated by urethritis. It was found that such eradicative techniques as nephrectomy and nephruretherectomy still prevail. Early drainage of the kidney for its decompression allows preservation of the kidney and following reconstructive surgery in 70.6% of cases. The number of early and later complications considerably decreased.

[Surgical urinary and male genital tuberculosis].

A total of 209 and 188 patients with urogenital tuberculosis were operated on in 1985-1987 (Period 1) and in 2005-2007 (Period 2), respectively. The mean age of patients with nephrotuberculosis has increased by 10 years in the past 20 years. The total number of operations has retained as before: organ-removing operations have decreased from 61.1 to 27.3% and reconstructive plastic ones increased from 9.7 to 23%. Epididymectomy remains to be a major intervention for genital tuberculosis, with thrice-fold reduction in their number. The specific features of the course of tuberculosis of the kidney and upper urinary tract were studied in 158 patients. The disease complicated by obstructive uropathy takes a more severe course than the uncomplicated disease, which causes a rise in the number of nephrectomies from 25 to 40.5%.

[The results of orthotopic plastic reconstruction of the urinary bladder with gastric and iliac graft].

To compare the results of postoperative plastic reconstruction of the urinary bladder (PRUB) with gastric and iliac graft, we studied 205 patients (150 males, 73.2%; 55 females, 26.8% aged 23-72 years, mean age 62.1 +/- 0.5 years) who had undergone orthotopic PRUB. Artificial bladder was created in 26 (12.7%) patients of a stomach pedicle segment, in 174 (84.9%)--of a detubulated iliac segment, in 5 (2.4%)--of a sigmoid segment. Early and late postoperative complications in using small intestinal segment reached 14.0 and 10.4%, respectively, lethality being 2.6%; in using gastric segment made up 3.9 and 8.7%, respectively, lethal outcomes were absent. Patients after PRUB had neither disorders of acid-base balance nor defects in electrolytic balance of blood. Urodynamic parameters were close to physiological ones. Thus, satisfactory clinical and functional results of urinary bladder orthotopic reconstruction even in long-term follow-up confirm advantages of orthotopic reconstruction of the lower urinary tracts in diseases of the urinary bladder.

[Urodynamics of artificial urinary bladder].

Radical cystectomy with creation of orthotopic reservoir from various segments of gastrointestinal tract was made in 120 patients (99 males, 21 females, age 37-74 years) with muscular-invasive cancer of the urinary bladder (UB) in 1996-2004. Replacement of UB was made according to the Studer and Hautmann method in 38 and 27 patients, respectively. S-cystoplasty was performed in 31 patients. The gastric segment was used for creation of the reservoir in 24 patients. Three patients died. Three to twelve month follow-up recorded the best functional results in patients after Studer cystoplasty.

[Surgical treatment of patients with micro-cystitis of tuberculous and other etiology].

The urinary bladder was reconstructed by using different segments of the gastrointestinal tract in 45 patients aged 21 to 72 years. The indication for surgery was microcystis of tuberculous and other etiology in 28 (62.2%) and 17 (37.8%) patients, respectively. The overall post-operative mortality was 2.2% (1 patient). Early and late complications were observed in 17.8 and 30.4% patients, respectively. Analysis of the causes of complications has indicated that they are associated with the urine diversion method and with the scope of urinary bladder resection. Seven repeated operations were performed. Augmentation cystoplasty should follow subtotal microcystectomy. For correction of azotemia and for prevention of stricture in the early postoperative period, the neocystis should be continuously irrigated with antiseptic solutions in order to eliminate urine, mucus, and blood clots.

[Diagnosis and treatment of urinary bladder dysfunctions in patients with nephrotuberculosis].

A combined, including urodynamic, study was made in 129 patients with abnormal reservoir function of the urinary bladder (UB). Of them, 82 patients had nephrotuberculosis (NT). Cystoscopy was made in 93 patients, endovesical multifocal biopsy of the bladder wall-- in 23. Correction was conducted with alpha-adrenoblocker alfusozine. In NT, sensory functional disorders of UB prevail (60%). The degree of fibrous-inflammatory involvement of the bladder wall by biopsy findings and severity of urodynamic disorders do not correlate (r < 0.03). Miction recovered in 81.5% patients with NT taking alfusozine. Ileocystoplasty (n = 20) was made in treatment failure and total UB fibrosis. Long-term pathogenic action of specific infection on the neuroreceptor system of the UB may cause defects in its activity. Complex urodynamic investigations of the lower urinary tracts in NT patients identify the type of the disorder and help in making choice of pharmacological or surgical correction. Alfusoxine is a drug of choice in UB hypersensitivity.

[Orthotopic replacement of the urinary bladder in females].

Orthotopic cystoplasty for various diseases of the urinary bladder was made in 58 females aged 22 to 78 years (mean age 52.5 +/- 5.8 years) in 1996-2005. Surgery was indicated in muscular-invasive cancer of the bladder (n = 35, 60.3%), microcystis (n = 21, 36.3%), bladder atonia (n = 1, 1.7%), vesicovaginal fistula (n = 1, 1.7%). The reservoir was made of iliac segment in 50 (86,2%) patients, of gastric body - in 8 (13.8%) patients. Postoperative complications arose in 7 (12.1%) patients, late complications occurred in 4 (6.8%). Postoperative lethality was not registered, 12 months later 3 (5.2%) patients died of cancer progressiion. Day continence after ileo- and gastrocystoplasty was 93.3 and 87.8%, night - 45.2 and 32.8%, respectively. Urodynamics was satisfactory. Chronic continence occurred in 3 (5.6%) patients. Satisfactory clinical and functional results of artificial reservoir creation in females support advantages of this method of urine derivation. Gastrocystoplasty is a promising method of urinary bladder replacement. It is important to assess function of the lower urinary tract before operation. Reservoir-vaginal fistula is a new kind of urogenital fistulas. It is treated by transvaginal fistuloraphy.

[Plastic repair of the urinary tract with intestinal graft].

Enteroplasty of the urinary tract was made in 224 patients (175 male and 49 female, age 21-72 years): enteroplasty of the ureter (n = 25), augmentation cystoplasty (n = 38), replacement of the urinary bladder after radical cystectomy for cancer (n = 161). The grafts were made of the small intestine segments--149 (66,5%), sigmoid--45 (20%), stomach--25 (11.2%), appendix--3 (1.3%). Total postoperative lethality reached 2.7%. Early and late complications occurred in 26.8 and 32.2% patients, respectively. In half the cases complications were related to the derivation method. Fifty three reoperations were made, most frequent of them was percutaneous nephrostomy. Thus, use of gastrointestinal tract segments for replacement of the urinary tract provides adequate urine outflow from the kidneys, close to natural micturition. Introduction of advanced methods of urine derivation prevents formation of urinary fistulas and improves quality of the patients' life.

[Replacement of the urinary bladder by the stomach body].

In the period from 2001 through 2004 plasty of the urinary bladder was performed in 24 patients using a. et v. gastroepyploici dexter. Mean age of the patients (18 men and 6 women) was 58.2 years. Gastrocystoplasty in 18 patients was performed after radical cystectomy for urinary bladder cancer, in 6 patients for neurogenic and small urinary bladder. The authors' original modification with a complete transversal resection of the stomach body taken together with the lesser curvature was used in operations on 10 patients. Early postoperative complications developed in one patient, late ones--in two patients, there were no lethal outcomes. Positive functional results were noted in all patients within the terms of observations from 2 through 22 months. Good quality of life was noted in all of them.

[Surgical treatment of obstructive urinary tract diseases in patients with pulmonary tuberculosis]. / Khirurgicheskoe lechenie obstruktivnykh zabolevanii mochevyvodiashchikh putei u bol'nykh tuberkulezom legkikh.

The paper presents the data of an examination of 92 patients [males (59-64.1%) and females (33-35.9%)] with active pulmonary tuberculosis concurrent with obstructive urinary tract diseases of various etiology. The patients' age ranged from 39 to 90 years (mean 58.2 +/- 2.5 years). Seventy-six (82.0%) patients suffered from infiltrative tuberculosis; 12 (13.0%) and 4 (4.3%) patients had cavernous and fibrocavernous tuberculosis, respectively. A relationship was found between pulmonary tuberculosis and obstructive urinary tract diseases leading to uniform changes in the upper urinary tract. The use of currently available methods for examination and treatment to eliminate infra- and supravesical obstruction permits performance of surgical interventions in patients with active pulmonary tuberculosis.

[Surgical treatment of renal tuberculosis]. / Operativnye metody lecheniia nefrotuberkuleza.

The analysis of the results of surgical treatment of 178 patients with destructive nephrotuberculosis indicates that operative methods are justified in the treatment of nephrotuberculosis as they provide cleansing of the infection focus, restoration of renal and urinary tract function, help to avoid long-term and massive chemotherapy. Organ-preserving and reconstructive operations on the kidneys and urinary tracts in early disease.