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Chapter 4. DISCUSSION of RESULTS

The present research is based on studying of results of treatment by the patient with tumours of the kidneys which were on inspection and treatment in unit of transplantation of kidney GAUZ RKB MZ RT since 2004 till November, 2013.

In the work we have analysed data of patients with tumours of the kidneys located bilaterally, at a unique kidney and in a combination with HBP from an opposite side: MKB, cysts, contracted kidneys and others not differentiated.

As shows the analysis of the given researches, the kind of surgical access is one of the major stages of an operative measure.

For the purpose of reduction travmatichnosti surgical treatment of tumours of kidneys, access has been introduced in clinical practice: high slanting ljum - botomija with resection ХІ of a rib. The anatomic estimation of applied access specifies on small travmatichnost as does not damage large nerves and vessels. The analysis of objective parametres of an operational wound specifies in sufficient accuracy of a projection of a cut over an operation zone. The presented access frames a sufficient surgery field, allows to manipulate under a constant direct vision, to bare all surface of a kidney, and renal vessels are projected practically in the wound centre. Advantage of the given method is absence of necessity of opening of a pleural cavity, a section of a diaphragm and possibility of full allocation of a kidney that allows to dilate possibility of performance of a nephrectomy at various localisation of neoplasms.

For prevention of development of renal insufficiency conservation of the maximum volume of a renal parenchyma in the conditions of minimum time of an ischemia is required. Modern clinical data predpologajut safe time of a thermal ischemia of 20 minutes and more than two hours for holodovoj (Guazonni G., 2009). There are also other data, about that that in need of overlapping of a renal blood flow duration of a thermal ischemia should not exceed 20 minutes, holodovoj - 35 minutes (R. Houston, C. Novick. 2007). According to domestic authors, in particular Petrova S.B. and co-authors, time of a thermal ischemia makes 20 minutes (S.B.Petrov, 2006). Researches and on animals who have shown have been executed, that the thermal ischemia of 30 and 60 minutes on funtsionalnuju ability of kidneys does not influence, and at an ischemia of 90 minutes SKF is restored in 1-7 weeks (Jablonski P., et al., 1983; Tsuji Y., et al., 1993; Laven B.A., et al., 2004). In our cases holodovaja the ischemia has averaged 20-30 minutes after clamp applying on a renal leg against protivoishemicheskoj protection (obkladyvanie "crumbs" of ice of all kidney, leaving only area of an operational intervention). By means of our technique we have achieved timely restoration of function of a kidney after a declamping Satinsky from a renal leg and in 90 % of cases of good functional ability of a kidney after its resection.

Intraoperatsionnyh complications, lethal outcomes were not. To three patients the resection of a unique kidney more than 2/5 is executed, that has led to transfer into a program hemodialysis of one patient and two is executed 7и 10 sessions of a program hemodialysis, with the subsequent constant level of a creatinine of blood of 200 mkmol/l and urea of 15 mmol/l in a current of three years.

Disease advance is taped at 5 (3,9 %) from 162 patients, on the average in 26 months after the treatment termination.

Local relapse is diagnosed for one (1,5 %) with stage T2N0M0 c the verified histology - the clear cell cancer, the remote metastasises - at 2 (5,4 %) patients T2N0M0 and Т1ЬШМ0 according to which histologies the clear cell and zernisto-cellular cancer accordingly is taped.

We develop tactics organosohranjajushchih operations at tumours of the kidneys located from both parties and at chronic illness of kidneys from an opposite side (a drawing 64).

Drawing 64. Treatment tactics at a tumour of a kidney and HBP an opposite side.

At a lesion of opposite organ HBP in definition of indications to OSO the great value has presence of renal insufficiency.

At patients with a tumour of a kidney and presence of concrements from an opposite side, first of all it is necessary to define sequence of medical tactics (a drawing 64). At patients with a kidney tumour at revealing HBP from an opposite side, first of all it is necessary to define

Sequence of medical actions then it is necessary to solve a question on character of a course of operation on the kidney amazed with a tumour.

For more correct formation of medical tactics of patients with bilateral tumours of kidneys, it is necessary to estimate not only the present condition of both kidneys, but also their functionality (a drawing 65).

The wrong estimation of reserve possibilities of an opposite organ can lead to irreparable consequences at performance OSO.

It is necessary to give especial value to reserve possibilities of an opposite kidney as the critical estimation of an opposite organ with revealing of its latent functional insufficiency defines expediency organosohranjajushchego the operative grant.

If concerning a kidney tumour it is executed OSO the situation is not critical as at patients with a unique kidney. It is necessary to notice, that possibility of a lesion of an opposite organ after sometimes long enough time after an oncotomy, is the weighty indication in favour of performance OSO.

Drawing 65. Treatment tactics at bilateral tumours.

At a tumour of one kidney and a lesion another, it is necessary to define sequence of operative measures at a tumour of a kidney and disease kontralateralnogo an organ; what kind of operation (organosohranjajushchaja or organounosjashchaja) depending on a condition of an opposite kidney.

From our point of view, bilateral RP is the absolute indication to organosohranjajushchej operations. But thus there is a question on the party of the first operation. Medical tactics at such patients depends on age and the general condition, character of growth, quantity and localisation of tumoral knots in both kidneys. The question on a choice of the party of initial operation at bilateral synchronous RP remains for today rather dis - kutabelnym. We consider, that the choice of the party of an initial intervention should be based on the general approach, namely expression of clinical implications of a tumour from each party, a somatic condition of the patient, its age, and also, on the tumour characteristic: the sizes, localisation and a direction of growth which tumour stages quite often mismatch. At the expressed clinical semiology (a megalgia, a massive gross hematuria) the operative measure should be carried out on the party of a larger lesion with a view of fast and adequate normalisation of a condition of the patient and creation of conditions for its preparation for operation on a kidney with protivopozhnoj the parties.

At asymptomatic bilateral RP or at slightly expressed clinical implications, the least lesion (defined on the basis of a disease stage), how many more convenient from the technical point of view of realisation OSO is necessary to spend the first operation on the party not so much. It allows to reduce preparation for surgery terms on an opposite kidney and to carry out last against rather good functioning rezetsirovannoj kidneys that reduces to a minimum threat of occurrence OPN in the nearest postoperative period, possible at operation on a unique kidney at preliminary excision more amazed.

Thus, as shows our experience, at bilateral RP only active surgical tactics with wide use OSO allows to achieve life prolongation, to improve quality of a life, to do without ZPT.

We make the analysis of functional changes in the remote and early time intervals at patients with a unique kidney, bilateral tumoral a lesion of kidneys and in the presence of HBP from an opposite side on SKF, calculated under formula Kokrofta-Golta (the chart 11).

The chart 11. Dynamic changes SKF in dynamics at patients with a kidney tumour.

110

100

SKF, 90 ml/mines/1,73m80

70

60

50

Initially 1 week 3 years

? A resection of a unique kidney (76-70-73)

? A bilateral resection of kidneys (90-85-97)

? A nephrectomy + NE on the other hand (79-67-77) ■ Patients with HBP (85-78-76)

The given chart of indications SKF on the early and remote time intervals shows, that the nephrectomy concerning a tumour is a defensible method of treatment of patients with the given pathology as promotes conservation of functional ability of the rest of a kidney and provides satisfactory quality of a life to the patient.

From 27 patients with a tumour of a unique kidney at 10 patients it was observed prorostanie tumours in CHLS. To all these patients the nephrectomy with partial resection CHLS is executed. Observation over the given group of patients has made 3 years; a recurrent tumour it has not been noted. SKF has made in rannii (week after operation) and the remote time intervals (in 3 years) 70 and 72 ml/mines/1,73 of m, and according to a renogram of 75 % and 68 %. Analyzing data of biochemical indicators of the analysis of blood (a creatinine and urea) all group of the given patients (table 10), it is possible to draw a conclusion, that the nephrectomy concerning a tumour at patients with a tumour of a unique kidney renders approximately in half of cases time reduction of a functional condition of kidneys what it is possible to judge and on SKF under formula Kokrofta-Golta in dynamics (the chart 3).

Resection to 2/5 unique functioning kidneys patients have transferred quite well. The kidney Rest, according to SKF (the chart 3) and a radioisotope renogram, as on early (70 ml/mines / 1,73 м2; 75 %), and on the remote terms till 3 years (73 ml/mines/1,73 of m; 69 %), functioned quite normally.

To three patients the nephrectomy more than 2/5 is executed, that has led to transfer into a program hemodialysis of one patient and two is executed 7 and 10 sessions of a program hemodialysis, with the subsequent growth of a creatinine of blood in 5 years to 200 mkmol/l and urea to 15 mmol/l.

At patients with a tumour of a unique kidney it is accompanied by occurrence of difficulties at a choice of tactics of treatment. Certainly, the "gold" standard of surgical treatment is organosohranjajushchaja operation thanks to which performance it is possible to keep kidney function, that in turn allows to avoid performance ZPT and to keep quality of a life.

Thus, cancer revealing in the unique remained kidney should not cause refusal of operative treatment as only active surgical tactics allows to achieve favorable results of treatment from this category of patients.

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A source: Hamitov Denis Dinarovich. Tactics of surgical treatment of patients with bilateral tumors of the kidneys, a tumor of a single kidney and patients with a kidney tumor in combination with chronic kidney diseases on the opposite side. Thesis for the degree of candidate of medical sciences. Kazan 2014. 2014

More on topic Chapter 4. DISCUSSION of RESULTS:

  1. CHAPTER 5 DISCUSSION of RESULTS of RESEARCH
  2. Chapter 4. DISCUSSION of RESULTS
  3. THE CHAPTER V. DISCUSSION OF RESULTS.
  4. CHAPTER 3. RESULTS And THEIR DISCUSSION
  5. Chapter 4. Discussion of results and the conclusion
  6. the CHAPTER IV DISCUSSION of the RECEIVED RESULTS
  7. CHAPTER 5. DISCUSSION OF THE RECEIVED RESULTS
  8. Chapter 4. DISCUSSION of the RECEIVED RESULTS
  9. the CHAPTER III. RESULTS And DISCUSSION
  10. Chapter 4. Discussion of the received results
  11. Chapter 4 Discussion of the received results
  12. CHAPTER 5. DISCUSSION OF THE RECEIVED RESULTS
  13. CHAPTER 4. DISCUSSION of the RECEIVED RESULTS
  14. CHAPTER 4. DISCUSSION of the RECEIVED RESULTS
  15. Chapter 4. DISCUSSION of the RECEIVED RESULTS
  16. the Chapter IV Discussion of the received results