Urologiia

Introduction. Radiation therapy is one of the main methods of treating pelvic malignant tumors, which provides good oncological results. Specific features of the pelvic anatomy may result in various radiation injuries of adjacent organs, which are complicated by genitourinary fistulas, post-radiation fibrosis with the formation of hydronephrosis, microcyst, reducing the quality of life.

Aim. To describe the relevance and importance of the correct choice of surgical treatment in patients with post-radiation urinary tract injuries.

Materials and methods. The group of irradiation injuries of the urinary tract included 60 patients aged 39–65 years. 19 (31.7%) women with various post-radiation ureteral injurie, who underwent reconstructive surgery using isolated bowel segments, were included in the study group.

Results. Substitution of the ureter by intestinal segment in patients with extensive post-radiation ureteral strictures provides good functional results. During follow-up computed tomography, an absence of urinary tract obstruction was confirmed in 16 (84.2%) patients, while in 3 (15.8%) cases an obstruction was diagnosed, followed by nephrectomy due to loss of function in 1 woman (5.3%). When assessing renal function using the dynamic nuclear scintigraphy, improvement in function was revealed in 14 (73.7%) patients, stabilization in 2 (10.5%), deterioration in 3 (15.8%). Histological examination revealed that inflammatory infiltration and the absence of a clear margins of the stricture area were more pronounced in patients who had had internal ureteral stent prior to reconstruction. A number of clinical cases demonstrating the treatment tactics of this group of patients is presented in the article.

Conclusion. Based on the extensive experience of two centers and long follow-up, we suggest scientifically proven approach to surgical treatment of radiation injuries of the urinary tract, the implementation of which will significantly improve medical and social rehabilitation.

Introduction. The treatment tactics of patients with recurrent urethral stricture requires an integrated approach. An increase in the treatment efficiency is possible not only through improvements in surgical technique, but also by influencing the pathogenetic mechanisms of the formation of urethral stricture and stimulating regeneration.

Aim. To evaluate the efficiency of reconstructive procedures using platelet-rich plasma in patients with recurrent urethral stricture.

Materials and methods. A comparative analysis of the results of surgical treatment of patients with recurrent urethral stricture with and without the use of platelet-rich plasma, who were treated at the University Clinic of Urology of Russian National Research Medical University named after N.I. Pirogov, was carried out. A total of 60 patients were included in the study. They were divided into the control (n=30) and the main group (n=30). There were no differences in length, median age, and localization of urethral stricture. The median maximum urinary flow rate preoperatively was 4.7 ml/s (1.7–11). According to etiological factors, there were 45 iatrogenic (75%), 7 traumatic (11.7%), 2 infectious strictures (3.3%) and 6 patients with hypospadias (10%).

Results. In the main group, end-to-end anastomotic urethroplasty was performed in 17, augmentation urethroplasty in 9, multi-stage urethroplasty/perineal urethrostomy in 4 cases. In the control group, end-to-end anastomotic urethroplasty was done in 24, augmentation urethroplasty in 4, multi-stage urethroplasty in 2 patients.

Efficiency in the main group was 93.3%. In 2 cases, recurrence of the stricture was seen. In the control group, the efficiency was 76.7%. There were 7 recurrences. The median period of catheterization was 14 and 7 days in the control and experimental groups, respectively. The frequency of infectious complications (urethritis, epididymitis, infected wound) was 6 times lower in the main group.

Median Qmax in the control group during follow-up was (min-max) 19.85 ml/sec (9–23.8), compared to 24 ml/sec (10–40) in the main group.

Conclusion. A combination of urethroplasty with a use of platelet-rich plasma improves the treatment outcomes of patients with recurrent urethral stricture. Reducing the length of bladder catheterization due to the stimulation of regeneration and the organization of the extracellular matrix allows to reduce the frequency of recurrence by 3 times. A decrease in the frequency of infectious complications also improves the results of surgical treatment, reduces the risk of recurrence and improves the quality of life of patients.

Aim. To investigate the factors influencing the choice of penile prosthesis and to evaluate the results of surgical treatment of patients suffering from erectile dysfunction (ED).

Materials and methods. Surgical results of penile prosthesis implantation in 348 patients were reviewed. The analysis included such factors as age, weight, height, body mass index (BMI) and the type of prosthesis.

Results. It was found that younger patients who tended to have an active lifestyle preferred three-piece prostheses, while older patients tended to favor one-piece prostheses. Weight, height and BMI do not affect the development of ED. A direct correlation between low patient height and increased risk of prosthesis failure and subsequent complications was found. When the patient was circumcised, there were no infections or mechanical failure after implantation.

Discussion. Our results emphasize the importance of an individual approach to the selection of a penile prosthesis, taking into account the physical characteristics and preferences of each patient. Such a factor as short stature is associated with a more limited space for placing the prosthesis pump, which requires consideration when selecting a prosthesis and preparing it for implantation during procedure. Young patients usually choose three-piece prostheses owing to their ability to enlarge the penis during sexual intercourse and to reduce its rigidity and size after sexual intercourse. For older patients, one-piece prostheses are the primary choice due to the age-related surgical risks and affordability of this type of prosthesis.

Conclusions: Our results show the importance of further investigation and taking into account all the different factors that influence the development of ED and the outcome of penile prosthesis implantation.

Aim. To assess the possibility of interpreting machine learning models to predict the early results of laparoscopic nephron-sparing surgery (NSS) in kidney tumors with consideration of surgical learning curve.

Materials and methods. The results of 320 consecutive laparoscopic NSS in patients with localized kidney tumors, performed by 4 surgeons, were analyzed. The construction of a machine learning model taking into account surgical learning curve was carried out based on the extreme gradient boosting (eXtreme Gradient Boosting). To identify significant factors and interpret the prognostic ability of the model, the SHapley Additive exPlanations method was used with a calculation of the Shapley value. Three groups of factors were chosen as an array of input data. The first group included demographic and clinical characteristics of patients, such as age, gender, Charlson comorbidity index, body mass index, preoperative glomerular filtration rate (GFR). In the second group, there were morphometric indicators of the kidney tumor, including RENAL. Nephrometry Score, PADUA (Preoperative Aspects and Dimensions Used for an Anatomical), C-index (Centrality index score), absolute tumor volume, localization of the tumor in relation to the kidney surface. In addition, factors associated with surgical learning curve, such as case number and perioperative results last 10 procedures, were analyzed. The target variables were duration of the procedure, warm ischemia time, and postoperative GFR after 24 hours.

Results. The SHAP method allows a visual interpretation of a machine learning algorithm based on the extreme gradient boosting for individual prediction of early perioperative outcomes of laparoscopic NSS in patients with renal tumors. For the calculated new features “complexity”, “slope angle” and others using the SHAP method, the high significance in building predictive models for target variables was confirmed, and an interpretation of the influence of specific features on the target variable in the constructed machine learning models was also given.

Conclusion. The SHAP method showed good practical results that coincide with the observations of specialists. The use of such solutions will allow in the future to introduce machine learning models to form clinical decision support systems.

Sclerosing oleogranuloma of the penis is a rare benign condition characterized by the formation of rough and dense infiltrates in the male genital area following injection of foreign materials under the skin for the purpose of augmentation. It predominantly affects males of reproductive age. Diagnosis is based on patient’s history, examination and histological findings. Treatment involves excision of the granuloma and affected tissues with surgical margins followed by reconstruction of the penis and scrotum.

A clinical case of the treatment of giant oleogranuloma of the penis and scrotum in a 21-year-old man clinically manifested by painful multiple lesions under the skin with ulceration along the coronal sulcus, pain, deterioration of the quality of life and cosmetic issues is presented in the article. For surgical treatment, the one-stage Sapozhkov-Reich procedure was performed for the first time at the urology department of the Republican Hospital named after V.A. Baranov, Petrozavodsk.

Keywords: sclerosing lipogranuloma of the penis, sclerosing lipogranuloma of the scrotum, penis augmentation, injections into the penis, vaselinome, one-stage Sapozhkov-Reich procedure

Author contributions. Simanov R.N. – idea, concept and design of writing the article, literature review, collection and processing of information and materials, description of a clinical case, analysis of patient carts, surgical treatment, writing text and preparing illustrative materials for publication; 60% of the work. Malyshev E.V. – surgical treatment, collection and processing of information, description of a clinical case; 20% of the work. Smirnova D.V. – collection and processing of clinical data, assistance in writing an article, preparation of a description of histological examination and micropreparations, creation of microphotographs, preparation of illustrative materials for publication; 20% of the work.

Introduction. Metastatic castration-resistant prostate cancer (mCRPC) is the most severe form of prostate cancer, developing in about 30% of patients; standard approaches of its treatment often remain ineffective. The development of theranostics principle and the discovery of the prostate-specific membrane antigen (PSMA) make it possible to implement a new approach in the treatment of patients with mCRPC – PSMA-targeted therapy. It is based on the use of a specific radionuclide (alpha or beta-minus emitter) associated with a ligand (radioligand) that binds to PSMA and has a targeted effect on tumor cells. One of the advantages of this technique in mCRPC is simultaneous diagnostics and treatment of the disease (the basic principle of the theranostics). The high specificity of PSMA-targeted therapy in combination with increased expression of PSMA by cancer cells allows to treat numerous distant metastases, slowing down the progression of the disease and improving the patient’s condition.

Aim. Review of the main approaches to the use of PSMA and radionuclides to treat patients with mCRPC as part of PSMA-targeted therapy.

Conclusions. The most preferred method to treat patients with mCRPC is β^--radionuclide therapy, since β^--radiation isotopes have a «crossfire effect» and relatively low toxicity and are available for use. The most optimal radionuclide from the group of β^-emitters is lutetium-177 – ¹⁷⁷Lu (PSMA radioligands: ¹⁷⁷Lu-PSMA-617 and ¹⁷⁷Lu-PSMA-I&T). Despite the large number of β^--radionuclide therapy advantages, it is also possible to use α-radionuclide therapy; actinium-225-²²⁵Ac (PSMA radioligand: ²²⁵Ac-PSMA) therapy is more toxic to the body, however, it can be considered as a second line or escape medication for patients with mCRPC and previous ineffective β^--therapy.

This review highlights modern aspects of the pathogenesis, diagnosis and treatment of bladder leukoplakia. The search was conducted using Medline, PubMed, and EMBASE databases. Data from a literature search indicate that leukoplakia of the bladder (LMP) is one of the controversial diseases of the urinary system, which is characterized by dystrophic and proliferative changes in the urothelium of Lieto’s triangle. The authors of various studies focus on the involvement of infectious and inflammatory diseases of the bladder in the development of this condition in the presence of predisposing factors.

Up to a quarter of all hospitalized patients undergo bladder catheterization, regardless of the department profile. Injuries related to this procedure represent up to 32% of all urethral injuries and may compromise or worsen the patient’s treatment. The most frequent causes of iatrogenic injury in this context are unintentional balloon inflation in the urethra or the creation of a false passage. The purpose of our work was to identify the most effective methods to prevent these injuries.

Articles containing the following information were selected: iatrogenic injuries of the urethra, the effectiveness of injury prevention methods, various devices and drugs. The work also included reviews evaluating the effectiveness of various catheterization techniques and data on the significance of the type and material of the catheter.

We reviewed about 20 papers that discussed the frequency of iatrogenic injuries, their early and long-term consequences and ways to prevent them. Urethral strictures are the most common complication of catheterization in the long-term period (78%). The remaining 22% had no consequences. Most researchers agree that the most effective way to prevent injury is the correct catheter insertion technique and the use of additional assets in the form of anesthetic gels-lubricants. In cases of difficult catheterization, modified techniques with different types of catheters can help: catheters with a curved tip or made of more rigid materials. Safety valves that prevent the balloon inflation in the urethra, or visus catheters that help to detect and solve the problem safely, can prevent a traumatic effect.

As a result of our work we have found several approaches to reduce the frequency of injuries. The most accessible and easiest way is to follow the catheterization algorithms, the second and important way is to use proper premedication in the form of gels with anesthetics. In cases of complex catheterization, use a Coude or silicone catheter, and in cases that do not allow catheterization without visual control, use visus catheters.

Introduction. Recurrence of non-muscle-invasive bladder cancer (NMIBC) occurs in 70% of cases, and the risk of progression to muscle-invasive bladder cancer is 20%. Intravesical BCG therapy is indicated in order to increase relapse-free survival in patients with intermediate and high-risk NMIBC. We carried out a survey of Russian urologists on the use of intravesical BCG therapy in the treatment of NMIBC, and also presented the regulatory framework for the use of BCG for the treatment of bladder cancer.

Aim. To evaluate the use of intravesical BCG therapy among urologists of the Russian Society of Urology.

Results. According to the results of a survey of 145 urologists, 46 (32%) do not prescribe BCG therapy to patients with NMIBC. Most of them (63%) have more than 10 years of experience. The main reasons why urologists do not recommend BCG therapy are the lack of conditions (74%), an absence of the drug (20%), fear of adverse reactions or development of tuberculosis infection of themselves and medical staff (2%), absence of recommendations for BCG therapy from an oncological dispensary (2%). The most commonly prescribed drugs for intravesical instillation areImuron-vac (69%), Uro-BCG-medac (29%), OncoTICE BCG (2%). Only 8% of doctors did not report difficulties during therapy. The most common reason for the refusing from BCG therapy was the lack of conditions in the medical facilities.

Conclusions. According to the survey, one third of doctors do not prescribe BCG therapy due to the lack of conditions or a shortage of the drug. An increase of relapse-free survival of patients with NMIBC is possible by providing conditions for intravesical immunotherapy.