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THE CONCLUSION

The radical cystectomy is a standard method of treatment is muscular-invasive RMP. This statement is based on a number of clinical observations:

• RTS with regionarnoj limfodissektsiej provides the best indicators of the remote survival rate in a combination with low degree of local relapses (S.A.

Boorjian et al., 2013; M.S. Eisenberg et al., 2013; S.H. Culp et al., 2014).

• the Mortality and frequency of complications after RTS for last decades have essentially decreased.

• the Schmincke's tumour shows the tendency of resistance to radial therapy, even in high doses (S.H. Culp et al., 2014).

• System chemotherapy in the form of monotherapy or in a combination with organosohranjajushchimi treatment methods show the worst remote survival rate and the big frequency of local relapses in comparison with RTS (T.M. Morgan et al., 2012).

• the Radical cystectomy provides exact pathomorphologic stadirovanie a primary tumour of MT (p a stage) and the status regionarnyh LU, that allows to define patients requiring in adjuvantnoj polychemotherapies (F.C. Burkhard et al., 2011).

Along with muscular-invazivnym RMP, RTS it is shown at relapsing superficial tumours possessing high risk of advance, at the BTSZH-REFRACTORY cancer in situ, T1G3, and as at extensive papilljarnom superficial RMP refractory to an endoscopic resection and-or intravesical chemotherapy or an immunotherapy.

These tumours aggressive by the nature with a lethality more potential. The majority of relapses occur within the first 2-3 years after RTS. Frequency of local relapses makes 4-29 % which have been kept away

Metastasises of 22-38 % (R.K. Lee et al., 2014). So-called relapses VMP make 3-8 %, urethras of 6-10 % from the general number of relapses (A.P. Mitra et al., 2011). It is considered, that it is new tumours of a dysregulation ekstravezikalnogo urotelija grow out and arise usually in 2-3 years after MT extirpation.

After RTS patients RMP have a necessity of reconstruction of the bottom urinary ways. One of the first methods of abduction of urine was ureterosigmoanastomoz (J.Simon, 1852). Advantage of this method javletsja controllable allocation of urine together with fecal masses, i.e. kontinentsija is carried out by a proctal sphincter. However, in due course after transplantation of ureters in a sigmoid intestine there is a deterioration of function VMP and kidneys. Besides, mixing of fecal masses and urine predraspolaget to high risk of development of an adenocarcinoma of a colon. Some updatings ureterosigmoanastomoza on purpose have been developed to reduce frequency of the complications bound to this operation. Mainz pouch II or sigma rectum pouch updating consists in detubuljarizatsii a rectosigmoid site and antirefljuksnoj implantations of ureters. The purpose of this updating is creation of the tank of low pressure and protection VMP and kidneys.

At kontinentnoj a dermal derivation the tank of low pressure from detubuljarizirovannogo a segment of an intestine with the functional efferent mechanism preventing the consensual efflux of urine is framed. Kontinentnye dermal rezervury differ depending on type efferetnogo the mechanism, a used segment of an intestine. Obvious advantage is that it kontinentnyj the type of abduction of urine and is not present necessity of application of external adaptations.

However, the regular intermittent self-catheterization through an ostomy is required. Patients should be able independently be catheterized. In spite of the fact that this method of a derivation of urine is superseded OTS, kontinentnaja the dermal derivation is used at impossibility of performance ortotopicheskogo a method of abduction of urine. In particular at tumour diffusion on PZH, prostatic department of an urethra at men, on mocheispuskatelnyj the channel at women, presence positive intraoperatsionnogo surgical edge, a nonfunctioning urethra (a stricture mocheispuskatelnogo the channel).

Ortotopichesky neotsistisy are framed from a segment ileal, a colon or from a stomach segment. Detubuljarizirovannyj neotsistis it is anastomosed with an urethra, kontinentsija it is carried out external cross-section-striatal rabdosfinkterom. The Ortotopichesky method of a derivation of urine was initially applied only at men. At women OTS with urethra conservation it was not applied in connection with fear vyskogo risk of local relapse, emiction dysfunctions. In process of accumulation of experience and the best understanding of the mechanism kontinetsii at women OTS became widely will be applied at women. Ortotopichesky reconstruction of MT at women has started to be carried out with the beginning of 90th years of last century. Selection of patients has great value in success ortotopicheskoj reconstruction. The method choice dervatsii urine in general and formation ortotopicheskogo neotsistisa in particular after RTS at patients RMP should not kompromentirovat the oncologic control. Therefore it is important to study frequency local retsidivirovanija at patients after RTS with various methods of a derivation of urine, to investigate survival rate of patients RMP after RTS depending on degree of an invasion of a tumour, at presence and otsustvii metastasises in regionarnye LU. Gastrotsistoplastika is exclusive operation and it is carried out in the individual centres in the world at the limited number of patients. It is considered, that urodinamika gastric neotsistisa the probability of development of an incontience of urine much more above differs from ileal. Thereupon studying of the remote complications, functional results, studying of various kinds ortotopicheskogo neotsistisa and definition of an optimum way of its formation is the important problem.

Despite essential achievements in operative urology, anesthesiology, pharmacotherapy, the big number of clinical and functional researches, till now it is not framed optimum ortotopichesky neotsistis which under the characteristics would correspond to normal MT. As there are unresolved problems of diagnostics, preventive maintenance, correction of late postoperative complications after various methods of a derivation of urine, disorders of an emiction after OTS.

Results of clinical observations of 352 patients RMP which have been operated are put in a basis of the present work and the Russian Federations on the basis of an urology department of a city multi-field hospital № 2 with 1995 for 2013 All patient were observed in urological clinic GBOU VPO SZGMU by it I.I.Mechnikova MZ is made RTS with various methods of a derivation of urine. Men was 303 (86,0 %), women 49 (14,0 %). The age of patients of a male fluctuated from 32 till 78 years and has on the average made 57,7±7,3. The age of the operated women was in a range from 24 till 78 years, on the average - 51,2± 4,7 years. In all cases the indication for MT extirpation was RMP.

At two (0,6 %) women and 19 (5,4 %) men at pathomorphologic research of postoperative preparations urotelialnyj the cancer has not been verified, that corresponds to a stage pT0N0. At a preoperative stage by this patient it has been executed ROUND and in all cases there was an is muscular-invasive form of a neoplasm that was the indication to RTS. The superficial form of a tumour (pT1N0) was at 22 (6,3 %) patients. Muscularly-invazivnaja organoogranichennaja limfonegativnaja (pT2N0) at 159 (45,0 %) patients. ekstravezikalnoe diffusion of a tumour in the absence of metastasises in LU took place at 76 (21,5) patients, accordingly a stage pT3N0 at 34 (9,8 %) and a stage pT4N0 at 42 (11,7 %) patients. Metastasises in regional LU have been diagnosed at 74 (21,2 %) the patients operated by us.

Ortotopichesky methods of a derivation of urine have been used at our patients more often. In general, they have been executed at 259 (73,5 %) patients. Formation ortotopicheskogo neotsistisa from a stomach segment on method Mitchell-Hauri is executed at 13 (3,7 %), in own updatings at 11 (3,1 %) patients. The Ortotopichesky ileocystoplasty has been executed at 211 (59,8 %) patients. On method Hautmann (W-shaped) at 36 (10,2 %), on Studer - at 55 (15,6 %), S-shaped - at 83 (23,5 %), on the VIP (Vesica Ileale Padovana) - at 4 (1,1 %), Y-shaped - at 11 (3,1 %) and U-shaped or the ileocystoplasty on method Camey II has been executed - at 22 (6,3 %) patients. Ortotopichesky neotsistis from a segment of a sigmoid intestine on method Reddy has been generated at 24 (6,8 %) patients. In the presence of contraindications for OTS (necessity uretrektomii at involving by a tumour of a neck of MT at women, positive surgical edge of an urethra (at men and at women), dysfunction rabdosfinktera) to patients was carried out kontinentnaja a dermal derivation of urine. In total this method of abduction of urine has been executed 11 (3,1 %) to patients. As efferent mechanisms kontinentsii in overwhelming majority of cases by us it was used cherveobraznyj a process, only at one patient has been generated invaginirovannyj the ileal valve. Transplantation of ureters in a sigmoid intestine was used basically at early stages and has been executed at 42 (12,0 %) patients. The ureterocutaneostomy was carried out at serious, complicated, with started stage RMP of patients. In total this method of a derivation of urine is executed at 40 (11,3 %) patients.

The radical cystectomy with excision of MT, a paravesical fat, PZH, seed blisters, regionarnoj tazovoj limfadenektomiej is executed at 263 (86,8 %) men. prostatosberegajushchaja the cystectomy is executed at 40 (13,2 %) patients. Completely PZH it is left at 19 (6,2 %), the prostate apex is kept at 21 (7,0) patients. From 49 (14,0 %) the women operated with us at 18 (5,2 %) localisation and a tumour stage have allowed to keep a uterus, appendages, a forward wall of a vagina. At 31 (8,8 %) patients at ekstripatsii MT internal genitals have been removed.

At inspection of patients before operation were applied clinico-laboratory, ultrasonic, radiological,

radionuklidnye, endoscopic, tool, morphological, immunohistochemical and urodinamicheskie research methods.

Urodinamichesky researches were made for studying of changes of functioning neotsistisa, the bottom urinary ways to various terms of the postoperative period at patients after OTS. The estimation rezervuarnoj and evakuatornoj functions ortotopicheskogo neotsistisa depending on a method of operation and terms of the postoperative period is made. The treatment of results of researches was spent according to terminology of the international society of studying kontinentsii. Function kontinentsii urine was estimated on the basis of terminology ICS, on classification McGuire and Hautmann.

Local relapse in a small basin after RTS we observed at 33 (9,4 %) patients after RTS. Local tazovyj relapse we defined according to KT or MRT, as fabric density formation> 2 sm below an aorta bifurcation. Among them men was 27 (82,0 %), women-6 (18,0 %). The age of men fluctuated from 43 till 73 years, middle age 58,7±11,7 years. At women middle age has made 50,0±7,8 years, an age range from 24 till 65 years. The median of time from the moment of operation before occurrence tazovogo relapse has made 7,0 (1,5 45,7) months. At 19 (57,6 %) our patients were ekstrapuzyrnoe diffusion of a tumour or metastatic lesion LU. At 14 (42,4 %) patients RMP were organoogranichennyj,

limfonegativnyj. Besides, the median of time from the moment of RTS to tazovogo relapse essentially correlated with a pathomorphologic stage. It has made 14,9 months at a stage pT2, N +. From 33 patients, at 20 (60,5 %) tazovye relapses have been diagnosed on the basis of clinical semiology and at 13 (39,5 %) by results research KT or MRT. From 20 patients with symptoms at 7 (21,2 %) demonstrated pains (in a perineum, in a side, in the bottom of a stomach, a back, with irradiatsiej in a foot), at 5 (15,1 %) an edema of the bottom extremity, at 3 (9,0 %) an intestine paresis, at 1 (3,0 %) constipations. At 4 (12,0 %) patients it is executed relaparotomija concerning enteric impassability and intraoperatsionno it is diagnosed tazovyj relapse. The recurrent tumour was localised on a lateral wall of a basin at 14 (42,5 %) patients, in presakralnoj areas - at 4 (12,1 %), pararektalno - at 5 (15,2 %), in an ileal fossa - at 2 (6,0 %) and some localisations by a uniform conglomerate were at 8 (24,2 %) patients. At the majority sick 30 (91,0 %) the gradation of a primary tumour was G2 and G3-4. It is obvious, that the moderate and low differentiation, in a combination to a high stage that underlines the aggressive nature of a primary tumour, are characteristic for patients with local tazovym relapse after RTS. Besides, the number of patients with local relapse depends on a disease stage, the above a stage, the more percentage parity of patients with tazovym relapse (at pT2aN0 - 6,9 %, at pT4aN0 - 12,8 % and at N + - 14,8 %). Dependences of frequency local retsidivirovanija from a method of a derivation of urine it has not been taped. The median of time from the moment of RTS before diagnostics tazovogo relapse has made 7,0 months. The median of time from the moment of diagnostics of local relapse to mors of the patient is equaled to 4,5 months. Thus, local tazovyj relapse after RTS, arises at limfopolozhitelnyh patients with ekstravezikalnym diffusion of a primary tumour of gradation G2-G3 is more often. At local tazovom relapse survival rate exclusively low, that is confirmed by our own researches and data of other authors.

For the purpose of improvement of diagnostics RMP at men we had been developed and patented a new way of diagnostics of degree of invasion RMP (the patent for the invention № 2332168 from 27.08.2008 years). At the given method of diagnostics receive a histological material. Preliminary on urethral catheter Foleja established in aseptic conditions MT fill with a warm solution of an antiseptic (usually Furacilinum solution). Carry out transrectal ultrasonic research by means of the ultrasonic gauge with the biopsy attachment strengthened on it. The ultrasonic gauge enter into a rectum ampoule, make neoplasm visualisation on a surface of a wall of MT. Combination of the image of the basis of a tumour and the image of the biopsy channel, obrazuemogo is carried out by the ultrasonic gauge and a biopsy attachment, immerse a tissue extractor in the biopsy channel, an external part of a needle strengthen in an alignment of a biopsy pistol. Make "shot", take biopisjnuju a needle and receive the histological material containing a tissue of a wall of MT and the basis of a tumour. Biopsy "shots" can be executed repeatedly. After end of procedure of a biopsy of MT empty on earlier ustanovlenomu to a catheter. The urethral catheter is left for 1-2 days. Before procedure the antibacterial preparation of a wide spectrum of action, usually tavanik 0,5 a day is perorally prescribed. The given method, as well as at any method of diagnostics has advantages and disadvantages. This method can be used only at men, high-grade for patogistologicheskogo a biopsy material it is possible to take researches only from a back wall of MT, the status regional LU out of the competence of this method.

We had been developed and patented a new way of formation ortotopicheskogo neotsistisa from a segment of an ileal intestine. This way can be applied at patients with diverticulum Mekkelja. The new way of creation ortotopicheskogo neotsistisa from a segment of an ileal intestine is called «the Way ortotopicheskoj ileocystoplasties at patients with diverticulum Mekkelja freely located in an abdominal cavity» the patent for the invention № 2408305 from 10.01. 2011 the Technical result of our way ITSP with use of diverticulum Mekkelja consists that the diverticulum serves as a new physiological neck neotsistisa.

Is a cone-shaped funnel, as a natural neck in native MT. Diverticulum Mekkelja is some kind of cherveoobraznym a small bowel process. In some cases patients have a short mesentery of a small bowel, and the isolated segment of an ileal intestine does not reach an urethra. Diverticulum Mekkelja serves some kind of "insert" between an urethra and ortotopicheskim the tank. Thus, it, liquidates this disadvantage, and does technically vypolnimuju ortotopicheskuju a plasty. Rezetsiruja a segment of an ileal intestine with diverticulum Mekkelja eliminiruetsja the anatomic substrate carrying in danger of development of various heavy pathological processes. This result is reached by that at our way of surgical treatment of patients RMP with diverticulum Mekkelja, the diverticulum is not exsected, and is a component neotsistisa. nedetubuljarizirovannyj the diverticulum is continuation of the spherical tank and settles down caudally in relation to it. Serves some kind of "insert" between an urethra and actually neotsistisom.

The way developed and patented by us ortotopicheskoj ITSP has a number of essential advantages, namely:

1. Diverticulum Mekkelja being a cone-shaped funnel serves as a new physiological neck neotsistisa, as a neck in natural MT.

2. At patients with a short mesentery of a small bowel diverticulum Mekkelja serves some kind of "insert" between an urethra and ortotopicheskim neotsistisom.

3. Rezetsiruja a segment of an ileal intestine with diverticulum Mekkelja eliminiruetsja the anatomic substrate carrying in danger of development of various heavy pathological processes.

At men after RTS and formations ortotopicheskogo neotsistisa have been studied by various segments of a gastroenteric tract the basic urodinamicheskie indicators. At an estimation of memory function of artificial MT at men after GTSP, ITSP and STSP the augmentation of volume of the first desire and the maximum capacity within the first 12 months after an operative measure has been noted.

Indicators of endoluminal pressure within the first 12 months katamnesticheskogo observations at all men after formation ortotopicheskogo neotsistisa gradually decreased. Komplaentnost or the extensibility of a wall of the tank was authentically above after ITSP and was enlarged in process of volume augmentation neotsistisa and decreases vnutrirezervuarnogo pressure. In 3, 6 and 12 months after operation this indicator at men has made 27,3±5,7 ml/sm Н2О, 50,1±7,1 ml/sm Н2О and 73,9±5,4 ml/sm Н2О. After GTSP the similar tendency was observed, but indicators were authentically less - 11,7±3,7 ml/sm Н2О, 19,8±3,0 ml/sm Н2О and 23,9±4,1 ml/sm Н2О, accordingly in 3, 6 and 12 months after operation. Komplaentnost after STSP it had intermediate indicators in 3, 6 and 12 months after operation sootvestvenno has made: 20,1±3,7 ml/sm Н2О, 31,5 ±4,7 ml/sm Н2О and 41,0±5,9 ml/sm Н2О.

In the remote terms indicators remained invariable on an extent more than 3 years of observation. Pressure changes inside neotsistisov in various points were stable also their changes had statistically not significant character. The highest authentic indicators vnutrirezervuarnogo pressure took place after GTSP. Pressure at the maximum capacity and maximum vnutrirezervuarnoe pressure in 2 years after an operative measure in gastric neotsistise was equaled sootvestvenno 42,9±8,3 sm Н2О and 48,0±7,9 sm Н2О, and after ITSP - 31,5±8,0 sm Н2О and 40,8±9,5 sm Н2О. These characteristics after STSP have made 35,1±8,8 sm Н2О and 45,0±6,2 sm Н2О. In 4 years pressure at the maximum capacity and maximum vnutrirezervuarnoe pressure after GTSP have made 45,8±9,3 sm Н2О and 54,6±7,2 sm Н2О, after ITSP-34,0yo7,3 sm Н2О and 45,1±8,2 sm Н2О. After STSP these indicators were accordingly equaled 37,8±3,9 sm Н2О and 48,0±5,5 sm Н2О. Ortotopichesky neotsistis from a segment of an ileal intestine still possessed the greatest komplaentnostju - 71,9±8,2 ml/sm Н2О in 4 years after reconstruction. After GTSP 21,0±4,2 ml/sm Н2О and after STSP 42,4±8,1 ml/sm Н2О for 48 month of observation katamnesticheskogo the period.

At patients after ITSP komplaentnost and intraljuminalnoe pressure the best conditions for urodinamiki VMP and urine deduction, owing to low indicators vnutrirezervuarnogo frame pressure. At an estimation oporozhnenija pressure inside neotsistisa, abdominal pressure, the maximum rate of an emiction was estimated.

Within the first year of the postoperative period gradual depression of the maximum rate of an emiction after all kinds OTS became perceptible. In the remote period after RTS and cystoplasties the maximum rate of an emiction and volume of a residual urine after all methods of formation ortotopicheskogo neotsistisa varied a little. These changes were statistically neznachimy.

In the remote terms of observation the same tendency remained: the residual urine maximum quantity was in neotsistisah from a segment of an ileal intestine - 112± 38,7 ml, minimum after GTSP-46,5yo17,1 ml. Urodinamichesky indicators after STSP occupied intermediate position, the residual urine volume made 85,3±14,9 ml. As day and night deduction of urine at patients after various kinds OTS has been studied. Day inkontinentsija at the patients studied by us has made after GTSP - 18,2 %, after ITSP-8,4 %, after STSP-16,7 %. An urine incontience at night: after GTSP - 63,6 %, after ITSP-55,9 % and after STSP-58,3 %.

At women within the first year katamnesticheskogo the observation period statistically authentic augmentation of volume indicators took place at all kinds neotsistisa. At pressure studying inside neotsistisa at the moment of the first desire and at the maximum capacity its gradual depression has been diagnosed. But this depression had statistically not significant character. Essential changes were at studying of indicators of the maximum pressure at reduction neotsistisa.

After STSP for 3 month of observations pressure has made 55,0±49,0 sm Н2О, in a year of observation indicators have made 46,5±9,4 sm Н2О. After ITSP in 3 months pressure at the maximum reduction was equaled 48,5±6,9 sm Н2О, in a year already 38,0±8,6 sm Н2О. For 3 month of observations after GTSP indicators made 60,5±8,0 sm Н2О and for 12 month depression has occurred to 49,6±8,5 sm Н2О. At volume augmentation there is a pressure reduction inside neotsistisa. Significant changes are verified at the analysis of the maximum pressure inside neotsistisa. In process of pressure decrease inside neotsistisa indicators kontinentsii improve. After GTSP indicators kontinentsii are worse in comparison with neotsistisami from other intestinal segments. It will be explained by small volume gastric neotsistisa and a high pressure in its lumen that causes an urine incontience. After ITSP the least intraljuminalnoe pressure and the greatest capacity neotsistisa. At patients with neotsistisom from a segment of an ileal intestine good indicators of deduction of urine, also frequency of a chronic delay of an emiction however increases. The extensibility (komplaentnost) walls neotsistisa also changes for a year katamnesticheskogo observations. The greatest komplaentnostju possess neotsistisy after ITSP. Their extensibility increases with 25,8±6,0 ml/sm Н2О to 65,4±9,5 ml/sm Н2О. After STSP komplaentnost varies with 21,7±6,0 ml/sm Н2О on 3 month to 42,3±8,5 ml/sm Н2О in a year katamnesticheskogo observations. And after GTSP the extensibility of a wall gastric neotsistisa varies with 12,8±6,0 ml/sm Н2О on 3 month only to 24,9±8,0 ml/sm Н2О in a year after operation. In kept away katamnesticheskom the period (2, 3 and 4 years) after change operation urodinamicheskih parametres were insignificant and statistical were not authentic. Urodinamichesky indicators after all kinds OTS remained stable. Simultaneously in process of capacity reduction in all neotsistisah (after GTSP, ITSP and STSP) intraljuminalnoe pressure slightly grew up. Komplaentnost walls neotsistisa after GTSP for 2 and 4 years remained low and underwent statistically insignificant changes. Indicators komplaentnosti after GTSP, have accordingly made 23,8±6,4 ml/sm Н2О and 21,6±8,5 ml/sm Н2О. After STSP, the extensibility of walls also did not reach high indicators and for 2 and 4 years katamnesticheskogo observations has made 41,0±6,8 ml/sm Н2О and 39,6±4,5 ml/sm Н2О. After ITSP komplaentnost for 2 and 4 years after operation has made 65,8±9,0 ml/sm Н2О and 58,3±4,4 ml/sm Н2О. At an estimation oporozhnenija ortotopicheskogo neotsistisa essential value such indicators, as quantity of a residual urine had, abdominal pressure, pressure inside neotsistisa and the maximum rate of an emiction. The greatest quantity of a residual urine in 1 year after operation at women after ITSP - 110,4± 58,0 ml was authentic. In 12 months after GTSP and STSP the quantity of a residual urine was less - 33,5±6,4 ml and 76,1±10,5 ml, accordingly. In the remote period after operation of significant differences of indicators of the maximum rate of an emiction and quantity of a residual urine in groups it did not become perceptible. These indicators remained stable throughout all term of observation.

Without dependence from a way of formation ortotopicheskogo neotsistisa within the first 12 months after operation there was a reduction vnutrirezervuarnogo pressure. Most the high pressure was after GTSP, the least after ITSP. neotsistis from a segment of a sigmoid intestine occupies intermediate position. The more low the pressure generated actually by a wall neotsistisa, both accordingly and more low endoluminal pressure, the a larger strain of muscles of a forward abdominal wall is necessary for evacuation of urine from it. Thus, at pressure decrease inside neotsistisa rising of the abdominal pressure necessary for oporozhnenija becomes perceptible. The greatest abdominal pressure at ITSP, and the least after GTSP. Accordingly, STSP occupies intermediate position.

From the basic positions urodinamiki "ideal" ortotopichesky neotsistis should have low endoluminal pressure, sufficient capacity, a residual urine minimum quantity, effective oporozhnenie, good kontinentsiju. In our opinion, the best method ortotopicheskoj derivations is formations neotsistisa from a segment of an ileal intestine.

For the purpose of improvement of results RTS with the subsequent OTS we had been developed and patented a new way of surgical treatment RMP at women. The patent of the Russian Federation for the invention № 2332933 from 10.09.2008 the Short of a new way RTS consists in the following. Directly ahead of RTS, on an operating table, in horizontal position on a back with divorced feet, transuretralno in MT it is got operational tsistorezektoskop. MT cavity looks round. Immediately under a direct vision a loop of a resectoscope of MT it is cut from mocheispuskatelnogo the channel on 0,5 sm more distally a neck, thus urethra cutting off occurs under the direct visible control. The electroresection on an urethra circle provides thermal coagulation of possible micrometastasises and the control of a local hemostasis. TSistorezektoskop leaves and in MT catheter Foleja is established. MT extirpation is carried out. Intraoperatsionnoe preparation excision is considerably simplified, the cranial traction of MT with a proximal urethra for its extraction is required only. It reduces operation time, eliminiruetsja necessity any dissektsii round an urethra, decreases travmatizatsija tissues and the majority of nervous fibers innervirujushchih an urethra remains. The risk decreases

Postoperative incontience of urine. The technical result of our invention consists in simplification of technics of performance RTS at women. The visual endoscopic control of cutting off of MT from mocheispuskatelnogo the channel is provided, necessity is excluded

intraoperatsionnoj dissektsii along an urethra. Postoperative deduction of urine as a result improves and duration of an operative measure decreases.

As the remote considered results in 30 days after an operative measure. In ortotopicheskoj to group strictures ureterorezervuarnyh and uretrorezervuarnogo an anastomosis most often took place. Strictures ureterorezervuarnyh anastomoses have complicated the late postoperative period after GTSP at 3 patients, after ITSP - at 13 and after STSP - in 3 cases. In total at 15 (5,8 %) patients are executed a repeated operative measure in this occasion with positive takes. Strictures uretrorezervuarnogo an anastomosis have arisen after GTSP in 1, after ITSP - in 3 and after STSP - in 1 case. All 5 (2,0 %) patients are repeatedly successfully operated.

Untied with a method of abduction of urine in ortotopicheskoj to group late complications have arisen at 11 (4,3 %) patients. Conservative treatment was effective at 2 (1,6 %) patients, operative were required at 9 (3,5 %). Have died in connection with these complications 2 (0,8 %) patients.

The derivations of urine of complication bound to a method in ortotopicheskoj to group have arisen at 78 (30,0 %) patients. Conservative treatment has been successfully spent in 42 (16,2 %) cases, operative treatment was necessary at 32 (12,3 %) patients. One (0,4 %) the patient has died.

In neortotopicheskoj to group at 5 patients after the MOUSTACHE the reflux of various degree of expression took place entero-mochetochnikovyj. After transplantation of ureters in a sigmoid intestine ascending infection MVP is characterised by a persistent and serious current. In two cases conservative therapy was spent. In one of these cases at carrying out of conservative therapy the positive take is received and the patient has recovered. In the second, despite spent treatment, the patient has died against infection MVP complicated by an urosepsis and progressing multiorgan insufficiency. Operative treatment was required from three patients. One of patients has died against an urosepsis. Against treatment it was possible to achieve positive takes from a two. The pyelonephritis took place after kontinentnoj a dermal derivation of urine at 2 (18,1 %) patients, after transplantation of ureters on a skin at 4 (10,0 %) patients. Against conservative therapy infectious-inflammatory process was successfully stopped. In total late untied with a method of abduction of urine of complication in neortotopicheskoj to group have arisen in 7 (7,4 %) cases. Conservative treatment is spent at 2 (2,1 %), operative at 5 (5,3 %) patients. Against these complications 2 (2,1 %) the patient have died. The abductions of urine bound to a method have occurred at 21 (22,5 %) the patient. Conservative treatment is spent at 10 (10,7 %), operative at 11 (11,8 %) patients. The lethality has made 2,1 %.

On classification Clavien after OTS postoperative conditions I and II gradation at which conservative treatment was spent, were observed at 15 and 18 patients, accordingly. That has totally made 12,6 % of patients after OTS. Most often in the remote postoperative period complications IIIB of degree on classifications Clavien demanding operative correction with application of the general anaesthesia - 37 (14,2 %) patients took place. The complications, the demanded operative measures under local anaesthesia were at 2 (0,7 %) patients. The group with III degree of complications was the most numerous - 39 patients, or 14,9 % from the general number of patients after OTS.

After neortotopicheskih methods of abduction of urine the most numerous were complications IIIB of degree on classifications Clavien demanding operative correction with application of the general anaesthesia - 13 (14,0 %) patients. The late complications which have not demanded endoscopic or surgical correction, were at 9 (9,6 %) patients (I and II degree). As 4 (4,3 %) patients were in V group at which the remote postoperative period has become complicated serious complications entailed mors of the patient.

Urodinamika VMP after various methods of abduction of urine in the remote postoperative period it has been studied at 107 patients. According to the accepted international designation for the analysis of a condition of kidneys and ureters used renally-mochetochnikovuju unit (PME), so-called in the English-speaking literature - renal units, to corresponding 1 functioning kidney and 1 ureter which in the sum have made 208 PME.

At dynamic nefrostsintigrafii during all term of observation 103 (49,5 %) PME had stable and normal indicators: time of accumulation of an isotope made 3,85±0,17 minutes, duration of the period of semideducing was equaled 10,57±0,12 minutes. At research 48 (23,2 %) PME with moderate expansion CHLS were observed normal accumulation and insignificant retardation its deducing from CHLS, the semideducing period has made 13,5±0,9 minutes (p> 0,05). Appreciable disturbance of evacuation of a preparation from a kidney is taped in 57 (27,3 %) PME from 82 PME at 41 patients. In 25 PME at ultrasonic and a X-ray inspection has been diagnosed GUN late stages as consequence of a stricture mochetochnikovo-rezervuarnogo an anastomosis, and in 32 PME - against a rezervuarno-mochetochnikovo-renal reflux. In 26 PME 13 patients had minor alterations at a scintigraphy (T maks. = 5,8±0,5; T / = 18,7± 1,3 minutes) And enough of a renal parenchyma according to ultrasonic. In 31 PME 28 patients had an expressed depression of accumulation of a preparation in renal parenchyma (T maks. = 28,7±2,6; T / = 41,8± 5,3 minutes), advance HPN with a thinning of a renal tissue and nephrosclerosis signs. Thus, at functional research 208 PME at 107 patients in the remote postoperative period of various degree retentsionnye changes VMP took place in 105 PME. In 31 PME at 28 patients it was the reason of advance HPN. At 21 patients with strictures ureterorezervuarnogo an anastomosis in the remote period repeated operative measures are executed. The repeated operative measure was required from 3 patients with rezervuarno-mochetochnikovo-renal refluxes, in 13 cases there was effective a conservative therapy.

After GTSP can develop gipokalijemichesky gipohloremichesky a metabolic alkalosis. Parietal cells of a gastric segment continue to cosecrete in a lumen neotsistisa ions H + and Cl ". In parallel to it system liberation in a blood flow of bicarbonates HCO3" occurs parietal cells. Clinically expressed metabolic alkalosis has arisen at one (4,1 %) the patient in the remote period after GTSP, against a chronic ischuria (to the patient the cystectomy has been executed prostatosberegajushchaja). Kislotoobrazovanie in neotsistise is the reason of a dysuria and it is shown in the form of a hematuria-dysuria syndrome. Treatment as hyperacidurias and a symptomatic metabolic alkalosis effectively at use of blockers Н2-гистаминных of receptors (Cimetidinum, ranitidin, famotidine), blockers of a hydrogen pomp (omeprazol, pantoprozol, lansoprazol, rabeprazol). As an important point is normalisation of level of electrolytes of a blood plasma and disturbance liquidation oporozhnenija neotsistisa, a chronic ischuria, by for example intermittirushchej self-catheterizations.

At 7 (3,3 %) patients after ITSP clinically significant metabolic acidosis has developed. The mechanism of development of a metabolic acidosis at these patients is caused by long contact of a mucous ileal intestine to urine. Clinically significant metabolic acidosis has developed at 2 (8,2 %) patients after ortotopicheskoj STSP and at 1 (2,4 %) the patient after the MOUSTACHE. The mechanism of development of a metabolic acidosis at STSP and the MOUSTACHE, is similar as at ITSP. Especially expressed metabolic giperhloremichesky the acidosis was at patients with presence of a residual urine, a chronic delay of an emiction. There is reabsorbtsija enterocytes an ammonium ion (NH4 +), hydrogen ion (N +) and Sodium chloridum ion (Cl ") from urine. On the other hand there is a loss in a lumen neotsistisa from a sodium enterocyte (Na +) and bicarbonate (HCO3-). Sodium is allocated in exchange for hydrogen ion, and bicarbonate for Sodium chloridum ion. In development of a metabolic acidosis in these

Patients the important role bicarbonate allocation, and Na + - H + a pomp, which zakachivaet plays not hydrogen ions in exchange for sodium. As the important role in glut of an organism by excess of protons belongs to an ammonium ion. All these electrolytic movings conduct to development giperhloremicheskogo a metabolic acidosis. With an acidosis we bind the low interest of patients to preventive work which we conduct with our patients. Preventive reception of baking soda (bicarbonate sodium) 2-6 gramme a day prevents this metabolic change. At residual urine presence we instruct and we train patients to carry out an intermittent self-catheterization. In an ileal intestine potassium absorption essentially above, than in the thick. Therefore gipokalijemija, against a metabolic acidosis, it is characteristic at STSP. After the MOUSTACHE and STSP with the preventive purpose we also prescribed all patient reception of sodium of bicarbonate of 2-6 gramme daily. These can explain the low interest of development of a metabolic acidosis at our patients in groups after the MOUSTACHE and STSP.

Thus, in our group of patients clinically expressed metabolic acidosis has arisen at 3,3 % of patients after ITSP, at 8,2 % after STSP. After the MOUSTACHE the metabolic acidosis took place at 2,4 % of patients. At 2,4 % of patients after GTSP the late postoperative period has become complicated clinically expressed metabolic alkalosis.

During the 18-year-old period of observation with 1995 on 2013 (later 3 months and more) after RTS with various methods of a derivation of urine have been interrogated 192 patients: 127 after OTS, 9 after kontinentnoj a dermal derivation of urine, 29 after the MOUSTACHE and 27 - after transplantation of ureters on a skin. Calculation of the sum of mean scores of the basic indicators of quality of a life has shown, that the highest indicators of quality and the general standard of living at patients RMP after RTS and various methods of a derivation of urine were at patients after ortotopicheskoj reconstruction of MT and kontinetnoj a dermal derivation of urine on method Mainz-pouch. The lowest standard of living was noted by patients after transplantation of ureters on a skin. Thus, at comparison of various variants of a derivation of urine after RTS at patients RMP from the point of view of social, psychological, medical adaptation on the basis of international questionnaires EORTC QLQ-C30 (quality of life questionnary core 30 of european organisation for research and treatment cancer) and FACT-G version 4 (functional assessment of cancer therapy general) quality of a life was the highest in group of patients after OTS.

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A source: SERGEEV Alexey Vjacheslavovich. the RADICAL CYSTECTOMY: the CHOICE of the METHOD of the DERIVATION of URINE And the REMOTE RESULTS. The dissertation on competition of a scientific degree of the doctor of medical sciences. St.-Petersburg.

More on topic THE CONCLUSION:

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  7. the Pathomorphologic conclusion
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