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Том 6, № 1 (2010)


6-13 278

The high rate of recurrences after transurethral resection of the bladder is a key problem in the treatment of patients with superficial tumors. The main reasons for the high rate of recurrences are diffuse urothelial neoplastic changes, cancer in situ, possible tumor cell implantation at surgery, and non-radical removal of a tumor itself. As of now, the most important ways of solving the problem, among which there are a lot of endoscopic modes, include increased radicality of primary tumor removal (bipolar electrosurgery, electrovaporization, laser resection and ablation), more precise intraoperative disease staging (Raman spectroscopy, optical coherence tomography), identification of invisible neoplasms by standard methods (photodynamic diagnosis, narrow-spectrum imaging), monitoring of primary tumor removal radicality (early recystoscopy and bladder biopsy), photodynamic therapy, urinary retention elimination, by saving the patient from infravesical obstruction, as well as urinary cytology, use of diagnostic markers (BTA test and others), adjuvant immunochemotherapy, radiotherapy, etc. By taking into account the data available in the literature and their findings, the authors consider possible ways of reducing the recurrence rate of superficial bladder carcinoma.


14-18 636
The urgency of the study was determined by the unsolved problems in the radiation evaluation of the local extent (stage) of a tumor and related surgical treatment policy. The results of a preoperative complex radiation study of 217 patients with urinary bladder cancer, including 134 men and 83 women, are presented. Based on the data of comprehensive preoperative examination, the authors define clear criteria for choosing a surgical treatment. A functional procedure for ultrasonography in varying urinary bladder filling is proposed to evaluate the degree of tumor invasion.
18-22 249
The paper considers whether magnetic resonance imaging (MRI) can be used in the complex diagnosis of urinary bladder cancer. It analyzes the authors' data based on bladder MRI findings in 79 patients with histologically verified bladder neoplasms. The possibilities of lowfield- strength MRI are compared with those of high-field-strength MRI, transabdominal ultrasonography, and computed tomography.
23-27 279
Criteria for sociomedical examination of patients who have undergone cystectomy with operations of urinary diversion have been currently insufficiently developed. Based on the standard criteria used for sociomedical examination, the authors identify criteria for defining the restricted working ability and disability groups in patients after cystectomy. Estimating the disability group and restricted working ability in patients with urinary bladder cancer after cystectomy should be based on a strictly individual approach, by keeping in mind the complete cancer prognosis, on the integrated assessment made by an expert and a patient himself, on the use of criteria for estimating the quality of life while assessing the degree of restrictions of the basic categories of vital activity. Thus, the estimation should yield an obvious, quantitative result to make an extremely accurate and objective sociomedical examination, which is fully reflected in the use of the questionnaire proposed by us.


28-32 300
Objective: to define a possible correlation between Mycoplasma infection persistence and prostate cancer (PC). Subjects and methods. Two hundred and fifty males aged 45 to 83 years (mean age 65.50.71 years) with suspected PC were examined. In all the patients, polyfocal prostate biopsy from 12 points was carried out, by additionally taking 2 tissue columns from the peripheral area of both lobes. The basic material was referred for morphological study; the two additional columns were tested for Mycoplasma DNA by a polymerase chain reaction (PCR) and real-time PCR. The study was blind. According to the morphological findings, the patients were divided into 2 groups: 1) those with chronic prostatitis, prostate adenoma, low-grade prostatic interstitial neoplasia (PIN); 2) those with high-grade PIN (HG-PIN), PC. There were no age differences between the groups (p = 0.05). Results. The standard procedure for PCR was applied to 127 subjects. Twenty-six (20.5%) of the 127 subjects with suspected PC were found to have Mycoplasma infection, Mycoplasma being detected in 21 (26.2%) of the 81 patients with verified HG-PIN and PC. Mycoplasma hominis was encountered in 19 (15%) patients of the 127 subjects with suspected PC and this infection was present in 16 (20%) of the 81 patients with verified HG-PIN and PC. Comparison of the frequency of HG-PIN and PC in the patients of general group (60%) and in those with Mycoplasma infection (80.8%) revealed significant differences (p = 0.031). HG-PIN and PC were also significantly more frequently seen in the patients with Mycoplasma hominis (84.2%) that in the general patient group (60%) (p = 0.033). There were no significant differences in the frequency of HG-PIN and PC between the patients from the general group (60%) and those with Mycoplasma genitalium (71.4%) (p = 0.05). The patients with verified PC and HG-PIN were more frequently found to have Mycoplasma hominis (20%) than Mycoplasma genitalium (6.2%), which further drew our closer attention to just this pathogen. The real-time PCR was used in 123 subjects to detect Mycoplasma. HG-PIN and prostate adenocarcinoma were revealed in 63 of the 123 patients with suspected PC, Mycoplasma hominis was seen in 46 (37%). The frequency (n=46) was 73.9%. The frequency of HG-PIN and PC was significantly higher in the patients with isolated Mycoplasma hominis DNA that in those without this pathogen (p < 0.001). Conclusion. Thus, the investigation showed a significantly higher correlation in the frequency of HG-PIN and PC in the patients with Mycoplasma infection that in the general study patients with suspected PC. This was supported by the use of both the standard procedure for Mycoplasma DNA determination and real-time PCR diagnosis.
33-38 312
Objective: to evaluate the prognostic value of microvascular and perineural invasion on radical prostatectomy specimens in prostate cancer patients. Subjects: 144 patients with prostate cancer pT1-4N0-1M0 underwent radical prostatectomy at the Cancer Center in 1997 to 2008. The median age was 60.06.4 (43-73) years. The median preoperative PSA level was 10.413.7 (0.8-95.7) ng/ml (PSA<10 ng/ml; n = 67 (46.5%), PSA ≥10 ng/ml; n = 77 (53.5%). Histological study verified adenocarcinoma in all specimens. The median Gleason score was 6.01.4 (Gleason score <7; n = 112 (77.8%), Gleason score ≥7; n = 32 (22.2%)). Extracapsular tumor extension was revealed in 47 (32.6%), seminal vesicle invasion in 13 (9.0%), regional lymph node metastases in 9 (6.3%), positive margin in 9 (6.3%), microvascular invasion in 58 (40.3%), perineural invasion in 61 (42.4%) of the 144 cases. The median follow-up was 36.615.2 months. Results: microvascular invasion was associated with an increase of Gleason score≥7 rate from 15.1 to 32.8% (p=0.015), extracapsular extension rate from 17.4 to 55.2% (p<0.0001), seminal vesicle invasion rate from 1.2 to 20.7% (p<0.0001) and category N+ rate from 3.5 to 10.3% (p=0.095). Perineural invasion was associated with an increase of extracapsular extension rate from 19.3 to 50.8% (p<0.0001) and seminal vesicle invasion rate from 0.0 to 21.3% (p<0.0001). Microvascular and perineural invasion did not influence positive margin rate (p>0.05). Prostate cancer recurrence developed in 19 (13.2%) of the 144 patients. Relapses were registered more frequently in patients with microvascular (from 8.1 to 20.7% respectively, p=0.028) and perineural (from 8.4 to 19.7% respectively; p=0.043) invasion. Five-year overall, specific and PSA recurrence-free survival in a group of 144 patients was 97.6, 98.3, and 82.1%, respectively. Microvascular invasion significantly decreased 5-year PSA recurrence-free survival from 90.0 to 66.8% (p=0.050), but this difference did not translate into a statistically significant reduction in overall (98.8 and 96.0%, respectively, p=0.812) and specific (100.0 and 96.0% respectively, p=0.251) survival. Perineural invasion was associated with a significant decrease in 5-year PSA recurrence-free survival from 92.4 to 68.2% (p=0.045). Overall (100.0% and 94.1% respectively, p=0.090) and specific (100.0% and 95.7% respectively, p=0.217) survival differences between the groups without and with perineural invasion did not reach statistical significance. Conclusion: microvascular and perineural invasion is associated with the worst pathological findings in prostatectomy specimens, higher recurrence rate and lower PSA recurrence-free survival in patients with prostate cancer pT1-4N0-1M0.
39-44 263
Objective: to determine the optimal technique of laparoscopic nerve-sparing radical prostatectomy (RPE). Materials and methods. The PubMed database was used to examine matters on the anatomy of the prostate, its surrounding structures, and different techniques of laporoscopic RPE (LRPE). This has led to the conclusion that the Brussels technique provides better results in nervesparing at LRPE. In July 2008 to July 2009, 17 laparoscopic radical prostatectomies (15 patients underwent extrafascial prostatectomy, 2 patients had interfascial prostatectomy) were performed using the Brussels technique via transperitoneal approach; the results were prospectively evaluated. Results. The mean follow-up was 5.3 months so we cannot adequately assess the results now. The health status of the patients was evaluated using the questionnaires (International Continence Society and International Index of Erectile Function-5) filled in by them before and after surgery. Four of 5 patients who had been followed up for more than 6 months were continent, 1 patient used 1 pad. Out of 2 patients with a median follow-up of 2 months who had led a sexual life before surgery (International Index of Erectile Function-5 greater than 20 scores), erection was preserved in one patient after bilateral nerve-sparing prostatectomy and not preserved in the other after unilateral one. Conclusion. Anterior approach to the prostate provides better control of the neurovascular bundles in the seminal vesicular region. The modified Brussels technique is more preferable in performing LRPE.
45-49 496
The incidence of urinary incontinence after radical prostatectomy is 0.8 to 87%. This category of patients has pelvic floor muscle weakness and reduced perineal reflex. The treatment of these patients uses a pelvic floor exercise system that is to enhance muscle tone and to develop strong reflex contraction in response to a sudden rise in intraabdominal pressure. Pelvic floor muscle training belongs to first-line therapy for urinary incontinence occurring within 6 to 12 months after prostatectomy. The ability to control pelvic floor muscle knowingly and to train them allows one not only to increase the closing capability of sphincter mechanisms, but also to suppress involuntary detrusor contractions. We used this method in 9 patients who had undergone radical prostatectomy. The duration of pelvic floor muscle training under control was up to 25 weeks. During this period, the symptoms of incontinence were relieved. No contraindications or adverse reactions have put this method in first-line therapy for post-prostatectomy urinary incontinence.
50-51 261
The proportion of men with multiple primary malignancies (MPM), by involving the prostate, is 9.3% of all the patients with prostate cancer in the Altai Territory. When prostate cancer is found, the lung, skin, oral cavity, and digestive tract should be examined to reveal secondary tumors. When primary malignancy is detected in these organs, the prostate should be more meticulously examined. In patients with double metachronic nonsystemic MPM with the involvement of the prostate, the disease is more frequently detectable in the 60-69 year age group.


52-58 426
Objective: to evaluate the outcome of retroperitoneal lymph node dissection (RLND) in disseminated testicular non-seminoma patients with residual metastases after induction chemotherapy. Material and methods. The RLND performed in 1983 to 2007 were analyzed in 367 testicular non-seminoma patients with residual retroperitoneal masses after ineffective induction chemotherapy. The median age was 26.06.9 years. Orchidectomy was performed in all patients. Category N1 was regarded in 12 (3.3%) patients, N2 in 79 (21.5%), N3 in 238 (64.9%), Nx in 38 (10.4%). Distant metastases were present in 133 (36.2%) cases. The baseline tumor marker level was elevated in 328 (89.4%) patients (S1 in 169 (46.0%), S2 in 108 (29.4%), S3 in 51 (13.9%), Sx in 39 (10.6%)). According to the IGCCCG prognostic model, 149 (40.6%) patients were classified as good prognostic group, 100 (27.2%) as moderate, 77 (21.0%) as poor ones; the prognostic group was not defined in 41 (11.2%) cases who had started treatment at another facility due to data unavailability. After orchifuniculectomy, all patients received induction cisplatin-based chemotherapy which resulted in tumor shrinkage <50% in 70 (19.1%), 51-90% in 166 (45.2%), and >90% - in 29 (7.9%) cases. The response was not properly assessed in 102 (27.8%) cases. CT scan revealed residual retroperitoneal masses after chemotherapy in all patients (<2 cm - 52 (14.2%), 2-5 cm - 166 (45.2%), >5 cm - 149 (40.6%)). The tumor markers level remained elevated following chemotherapy in 70 (19.1%) cases. All patients underwent RLND (complete in 295 (80.4%) cases). Radical RLND demanded resection of adjacent organs in 22 (5.9%) cases. Extraretroperitoneal metastases were removed simultaneously with retroperitoneal tumor in 22 (5.9%) patients. Postoperative chemotherapy was administered in 100 (27.2%) cases. The median followup was 82.1 (3-188) months. Results. Complications developed in 31 (8.5%) of the 367 of patients. Mortality rate was 0.6% (2/367 cases). Resection of the adjacent organs did not influence mortality rates. Histology revealed necrosis in 149 (40.6%), teratoma in 141 (38.4%), cancer in 77 (21.0%) specimens. The significant predictive factors for necrosis were normal levels of markers following chemotherapy, a residual mass size of < 2 cm, tumor shrinkage >90% (the accuracy of the logistic model for probability of necrosis in the removed specimen was 78%). Discordant pathologic findings between the retroperitoneum and other metastatic sites were in 3 (13.6%) of 22 cases. Ten-year overall, specific and progression- free survival (PFS) was 92.1, 92.4, and 46%, respectively. A poor and moderate prognostic group IGCCCG (p<0.0001), incomplete resection of residual mass (p<0.0001) and presence of cancer in the removed specimens (p<0.0001), initial retroperitoneal masses >5 cm (p=0.042), presence of extraretroperitoneal metastases (p<0.0001), category S>S1 (p<0.0001), positive marker levels after induction (p=0.048) were found to have an adverse impact on PFS. Removal of residual extraretroperitoneal metastases after chemotherapy improved progression-free survival (p=0.022). Postoperative chemotherapy did not influence survival significantly. Multivariate analysis confirmed the predictive value of the radicality of RLND (p=0.036). Conclusion. Radical RLND improves the results of combined treatment in metastatic testicular non-seminoma. It is expedient to make resection of the adjacent organs and extraretroperitoneal metastasectomy in order to achieve a complete removal of residual masses. Whether adjuvant chemotherapy should be used in cases with cancer in residual mass is under discussion.


59-64 233
To evaluate the role of the repeat transurethral resection (TUR) of the bladder in the management of non-muscle invasive bladder cancer (NMIBC), the medical literature was sought for, by using the PubMed database. The selected full text sources were analyzed. Repeat TUR carried out 1-6 weeks after primary surgery permits detection of residual tumor in 33-76% of cases, identification of muscle invasive bladder cancer in 4-28% of the patients with the primary diagnosis of NMIBC, more precise estimation of tumor extent, and modification of treatment policy in 4-33% of cases. Furthermore, repeat TUR allows estimation of the risk of further cancer progression and selection of patients for immediate radical cystectomy. Overall, this approach can improve the results of treatment of patients with NMIBC.
65-69 381
The rate of a biochemical and clinical recurrence at stage T1-T2 is 25-35%. Experience with surgical treatment for stage T3 cancer shows that 33.5-66% of patients a positive surgical margin and 7.9-49% of patients have a metastatic lymph node lesion. One of the further treatment options is teleradiotherapy (TRT) for a removed prostate area, which is performed immediately after surgical treatment and in case of a biochemical or clinical recurrence both alone and in combination with others treatments (hormonal therapy, chemotherapy, etc.). The paper presents the data of basic international studies of adjuvant radiotherapy after radical prostatectomy. The results of the therapy depend on the baseline level of prostate-specific antigen, the interval between the start of radiotherapy and surgery, the stage of the disease, and other prognostic factors. A number of investigations of the use of TRT, hormonal therapy, chemotherapy, and their combinations in the adjuvant mode are ongoing. This will provide answers to what combinations of adjuvant therapy may increase survival and improve quality of life in patients with prostate cancer.
69-75 340
The authors provide the proceedings of the 2005 First International Society of Urological Pathology Consensus Conference and the basic provisions that differ the modified Gleason grading system from its original interpretation. In particular, we should do away with Gleason grade 1 (or 1 + 1 = 2) while assessing the needle biopsy specimens. Contrary to the recommendations by Gleason himself, the conference decided to apply stringent criteria for using Gleason grades 3 and 4. This is due to the fact that these grades are of special prognostic value so it is important to have clear criteria in defining each Gleason grade. Notions, such as secondary and tertiary Gleason patterns, are considered; detailed recommendations are given on the lesion extent sufficient to diagnose these components.



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