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the Choice of operative treatment

In many Russian urological hospitals the relation to organosohranjajushchim to operations concerning a kidney tumour still unfairly constrained.

Long time was considered, that as the best method of treatment localised and mestnorasprostranennoj kidney tumours, the radical nephrectomy including excision of a kidney by the uniform block with a tumour, a surrounding fatty tissue, an adrenal and fascias within fascia Gerota with regionarnoj limfodissektsiej (Robson C.J is., Churchill B.M., Anderson W., 1969). Only at a functional unique kidney or a pathology kontralateralnoj kidneys it was necessary to use organosohranjajushchy the approach.

In most cases the preference is given to excision of the amazed organ, as to the most reliable and correct method of treatment. Principal causes which force urologists/oncologists to refuse kidney conservation at treatment of neoplasms of early forms, are insufficient preoperative informativnost about prevalence of tumoral process (mutual relation of a neoplasm with CHLS and vessels, an invasion of a capsule of a tumour etc.), high possibility of occurrence of technical problems at resection performance, especially at a stage of achievement of a definitive hemostasis and possible postoperative complications: a bleeding, formation of urinary fistulas, etc. (Thompson R.H., Leibovich B.C., Lohse C.M., 2005).

Tactics of treatment of patients with a kidney tumour remains, till now, problem and discussed. There is no common opinion in questions of operative access at a resection of a tumour of a kidney, expediency of performance limfadenektomii. As there is no common opinion in the questions bound to treatment of initially widespread forms of disease.

On experience OSO at tumours of kidneys have informed N.A.Lopatkin, A.S.Pereverzev, V.A.Golubchikov, I.A.Gorjachev. Authors notice, that though quantity of observations is rather insignificant, the given kind of treatment can be recommended at patients young and middle age and is absolutely shown at patients with a unique or unique functioning kidney, and the survival rate over 5 years has made 86 % (Lopatkin N.A., Janenko E.K., Borisik V. I, Safarov R. M, Gorjachev I.A., Smart guys of Century A, Dubrovin V. N, 1995).

J.G.Aljaev and co-authors (M, 2005) allocate compelled (obligatory) and elektivnye (selective) indications.

Authors carry a tumour of a unique functioning kidney to obligatory indications, RP against chronic renal insufficiency and bilateral RP. To elektivnym to indications situations of stage TlbNOMO of tumoral process have been carried and at Т3а.

Now many authors in details describe ways of performance organosohranjajushchih interventions, their results and complications are studied, achievements of operative treatment in compelled and elektivnyh groups are estimated and compared, and also comparison with NE (Fergany A.F is spent., Hafez K.S., Novick A.C., 2000; Villani U., Pastorello M., 1991). In 1992 F. Steinbach and co-authors (Steinbach F., Stockle M., Muller S.C., 1992), on the basis dvadtsatiodnogoletnego experience, have analysed and have compared results organosohranjajushchih operations on compelled and elektivnym to indications at 140 patients with RP. The 5-year-old rakovo-specific survival rate in the compelled group has appeared is high enough (84,5 %), in elektivnoj to group it has made 96 % (Steinbach F., Stockle M., Muller S.C. 1992). In similar research A. Kural and co-authors (Kural A.R., Demirkesen O.

2003) have estimated and have compared results organosohranjajushchih operations on elektivnym and to the compelled indications. Both groups practically did not differ neither on the size of a tumour, nor on duration of an operative measure, on ischemia time. Complications met in the compelled group, than in elektivnoj is more often. The indicator of a creatinine of blood after operation in both groups did not differ from the initial. The general and rakovo-specific survival rate was above in elektivnoj to group (100 and 100 %), than in compelled (85 and 95 %) (Kural A.R., Demirkesen O., 2003).

For today the basic methods organosohranjajushchego surgical treatment are the enucleation and a nephrectomy. The combination together these two methods — enukleorezektsija (excision of tumoral knot with obodkom a healthy parenchyma) in some cases is required. The enucleation is the most simple way of excision of tumours of a kidney. As a rule, the given reception is used at the patients having well expressed capsule and the located tumour is mainly extrarenal. At the given technique it is not required to some authors of the time termination organnogo a blood flow (Pereverzev A.S., 1997). By means of an enucleation method it is possible to remove a tumour from various segments of a kidney. One of the reasons which constrain more frequent use of the given method, uncertainty in radicalism is.

In publication M. Carini and co-authors results of an enucleation of a tumour of the kidney executed on elektivnym to indications to 71 patient with tumours 4-7 have been presented see in the greatest measurement (Carini M., Minervini A., Lapini A., 2006). In one case after operation it has not been taped bleedings, or urinary zatekov. Five - and eight-year rakospetsifichnaja the survival rate has made 85,1 and 81,6 % accordingly. At average terms of observation of 74 months, the disease progression is noted in 14,9 %. Authors do a conclusion, that the enucleation of a tumour of a kidney is a comprehensible approach to excision of tumours in the size 4-7 This method see provides the high rakovo-specific survival rate comparable to that at nefrekto - mii, and is not bound to the raised risk of local relapse in comparison with a nephrectomy concerning tumours less than 4 sm in the greatest measurement.

In the literature also there are the publications devoted to comparison of efficiency of an enucleation and a nephrectomy. In research W. Morgan and co-authors (Morgan W.R., Zincke H., 1990) at comparison of two methods it has been shown practically identical five years' bezretsidivnaja survival rate of the patients subjected to an enucleation of a tumour and a nephrectomy.

A certain intermediate variant between an enucleation and a nephrectomy is the technique enukleorezektsii, i.e. excisions of tumoral knot with a site of an adjoining healthy parenchyma. The given technics is simple, accessible and can be used at any localisation of the tumoral centre. The thickness of a layer of an adjoining parenchyma subject to excision, according to different authors, makes from 3 to 10 mm and till now is a discussion subject (Steinbach F., Stockle M., Muller S.C., 1992; Pereverzev A.S., 1997; Aljaev J.G., Krapivin A.A., 2001). So, judging by the publication

Z. Akcetin and the co-authors who have estimated survival rate of 86 patients, subjected organosohranjajushchej operations, it has not been noted correlations between survival rate and quantity of a deleted parenchyma (Akcetin Z., V., Elsasser D.).

At a choice of access and a nephrectomy method it is necessary to consider localisation and the sizes of a neoplasm. The majority of authors prefer laparoskopicheskomu to access at tumours less than 3 sm, mainly growing extrarenally (Jeschke K., Peschel R., Wakonig L., Urology 2001). However some surgeons consider possible performance laparoskopicheskoj nephrectomies at neoplasms to 5 sm, even at the central localisation of a tumour (Desai M.M., Gill I.S., Kaouk J.H., 2003). The retrospective analysis 1029 opened and 721 laparoskopicheskoj the resections, executed in three clinics of the USA, has not taped differences in survival rate, however has shown authentically big frequency of presence of positive edge of a resection, bleedings and necessity of repeated interventions, and also the big duration of a thermal ischemia in group laparoskopicheskih operations (Moinzadeh A., Gill A.M., Finelli A., 2006). The impossibility of performance of a radical resection in situ sometimes dictates necessity of application of an extracorporal nephrectomy. Basic advantages of a method are ideal visualisation of all departments of the allocated kidney, a sufficient stock of time, and also possibility of performance of a radical intervention. Great volume, technical complexity and appreciable duration of operation, and also potential complications from vascular and urinary anastomoses are considered as essential disadvantages of an extracorporal resection.

J.G.Aljaev (J.G.Aljaev, 2005) allocates 3 kinds organosohranjajushchih operations at a kidney tumour:

1. The nephrectomy - an oncotomy with a normal site of a renal parenchyma, width 1-1,5 see

2. Enukleorezektsija - an oncotomy with a normal parenchyma, thickness

0. 4.0,7 see

3. An enucleation of tumoral knot an oncotomy within a pseudo-capsule.

As J.G.Aljaev (J.G.Aljaev, 2005) allocates 3 kinds of a nephrectomy at a tumour:

1. At tumour localisation in the top or bottom segment of a kidney when the neoplasm replaces all segment made a plane nephrectomy.

2. If the tumour was localised in one of kidney segments made a sphenoidal nephrectomy. More often a sphenoidal resection ovypol - njali at tumour localisation on an external contour of an average part of a kidney.

3. If the tumour is localised in the top or bottom segment and extends mainly to front or kzadi when the segment part remains intact the face-to-face nephrectomy can be executed.

At resection any kind observance of following general principles is necessary: the control over renal vessels, minimum time of an ischemia, an oncotomy within healthy tissues, tight ushivanie opened CHLS kidneys, a careful hemostasis and concealment of defect of a renal parenchyma by muscularly-fastsialnym, fatty or peritoneal flap (Novick A.C., 1998).

At nephrectomy performance standard it is considered, that the space from visible edge of a tumour makes not less than 1 the given position see recently However absence of advantages concerning frequency of local relapses is challenged by a number of the researchers who have shown, at observance of this rule (Li Q.L., Guan H.W., Zhang Q.P., 2003). So, N. Piper and co-authors have published data according to which local relapse has developed only at 1 of 11 patients who had distance from a tumour to edge of a resection less 1 mm.

Z. Akcetin and co-workers. (Akcetin Z., V., Elsasser D., 2005), executed a nephrectomy concerning a cancer to 126 patients, have not taped authentic influence of size of a space from tumoral knot on survival rate.

Presence makroskopicheski pure surgical edge, at nephrectomy performance, according to several authors, allows to refuse urgent histological research which because of the big number of false positive and false-negative results, should be carried out at the discretion of the operating surgeon (Duvdevani M., Laufer M., Kastin A., 2005). Also absence of correlation between positive edge of a resection and risk of relapse, is underlined in work of the French surgeons (Timsit M.O., Bazin J.P., Thiounn N., 2006.).

Complications after a resection of a tumour of a kidney basically are bound to technical features of carrying out of a surgical intervention - mobilisation of renal vessels, duration of their crossclamping, volume of a deleted renal parenchyma, reconstruction CHLS. So, in a series of observations

R.Thompson And the co-authors, the included 823 patients subjected to a nephrectomy, early complications are registered in 6,9 %, late - in 24,6 % cases (Thompson R.H., Leibovich B.C., Lohse C.M., 2005).

One more important factor, making immediate impact on function of an operated organ, is duration of the period of an ischemia. In the literature there is no uniform view on the given point of view. So, R. Thompson and co-authors (Thompson R.H., Leibovich B.C., Lohse C.M., 2005), analyzing the experience opened nefronsberegajushchih operations, notice, that at time of a thermal ischemia over 20 minutes, patients had more than early postoperative complications, than at time of an ischemia 20 minutes there are less. Duration of an ischemia from above authentically enlarges 30 minutes risk of development of renal insufficiency in the postoperative period (Volkova M. I, 2006) . There are also other data, 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 later work K.S. Hafez and co-authors have estimated influence of the size of a tumour on results of a resection of a tumour of a kidney at 485 patients. This research has shown, that at patients with tumours less than 4 sm the five years' specific survival rate has made 96 %, that essentially above, than at PKR more 4см in diameter (86 %, p=0,001). Appreciable difference in frequency of the taped relapses between these two groups is Besides, taped. (Hafez K.S., Fergany A.F., Novick A.C., 1999).

Even later A.F. Fergany and co-authors have estimated results of a nephrectomy at 107 patients localised PKR, observable 10 years and more. Tumours caused symptoms in 68 % of patients, and indications to kidney conservation were compelled at 90 % of patients. The 5-year-old specific survival rate in the general group of patients has made 88,2 %, 10-year-old — 73 %, similar indicators at patients PKR to 4 sm — 98 and 92 % accordingly, without dependence from indications to conservation of an opposite kidney (Fergany A.F., Hafez K.S., Novick A.C., 2000).

Among forecast factors the greatest value on the remote results degree of prevalence of a tumour, a bilateral lesion in comparison with unilateral and the sizes of a tumour had differentiation degree on Fuhrman. The same group of authors has established, that localisation of a tumour of a kidney (peripheric or in the heart of a parenchyma) does not render essential influence on the forecast (Hafez K.S., Novick A.C., Butler B.P., 1998). Without dependence from tumour localisation, organosohranjajushchee treatment and nefrek - tomii are equally effective at single tumours of a kidney in the sizes 4см and less.

The survival rate essentially differed at RP in stage T^N0M0 (the sizes of a tumour of 4 sm and less) in comparison with T1bN0M0 (the sizes of a tumour from 4 to 7 sm). However, differences in frequency of relapses and specific survival rate at organosohranjajushchem and organounosjashchem treatment, between these subgroups it has not been taped. Authors do a conclusion about safety of a nephrectomy at tumours to 7см without a capsule invasion. Nevertheless, exact to - and intraoperatsionnoe stadirovanie, excluding diffusion of a tumour for kidney limits, is rather difficult problem that interferes with wide use of these data in clinical practice for today.

J.G.Aljaev and A.A.Krapivin have generalised experience of urological clinic MMA of I.M.Setchenov, having compared results of a resection of a tumour of a kidney at 50 patients and a nephrectomy at the same quantity of patients (Aljaev J.G., Krapivin A.A., 2005). At comparison of 5-year-old survival rate, it has appeared, that at degree of local diffusion рТ1, results organosohranjajushchego treatments surpass those organounosjashchego, without dependence from the sizes of a tumour. At рТ3а comparative results of treatment depend on the size of a tumour. So, at small (< 4см) опухолях выживаемость выше при органосохраняющем лечении, а при больших (>4см) — at a nephrectomy. From the literature not clearly, whether wear differences in survival rate statistically authentic character. A number of researches says that the operation type at RP can influence quality of a life of patients. So, P.E. Clark and co-authors have studied answers to post dispatch of questionnaires of quality of a life (SF-36) and influences of stress from the diagnosis a cancer (Impact of Events Scale) at patients after a nephrectomy and a nephrectomy. Though between groups there were no differences in indicators of the general quality of a life, it was revealed, that the more was at the patient of the remained parenchyma of a kidney, the above patients estimated feeling of own physical health and worried about relapse (Clark P.E less., Schover L.R., Uzzo R.G., 2001).

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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

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