Background. Surgical treatment after chemotherapy is extremely difficult technically and should only be performed in a specialized medical center. The postoperative period after these surgical interventions is aimed not only at minimizing complications, but also at early mobilization and rehabilitation of patients. The principles of fast-track surgery, or ERAS (Enhanсed Recovery After Surgery) significantly reduce the incidence and degree of complications after various surgical interventions. However, the results of studies on the use of fast track in retroperitoneal lymphadenectomies have not yet been presented.Aim. To determine the effect of enhanced recovery program on treatment outcomes in patients with germ cell tumors of the testicle after retroperitoneal lymphadenectomy.Materials and methods. Retrospective analysis of 2 groups of patients (n = 93) treated at the N.N. Petrov National Medical Research Center of Oncology (Saint Petersburg) was performed. In the 1st group of patients, standard postoperative care after retroperitoneal lymphadenectomy was performed; in the 2nd group, fast track elements were used. Since the introduction of the ERAS protocol into clinical practice (September 2017), all patients have been included in the 2nd group.Results. The presence or absence of preoperative preparation did not affect the incidence of intraoperative complications (p = 0.031). There were significant differences in the duration of hospitalization between the 1st and 2nd groups –15.3 and 11.9 days (p = 0.03), respectively. Assessment of the pain syndrome using the Numeric Rating Scale for Pain (NRS) showed that median pain level in the 1st group was significantly higher than in the 2nd group: 5 ± 1.5 and 3 ± 1.7, respectively (p = 0.04), which indicates a more severe and less controlled pain syndrome in the 1st group of patients. The rate of infectious complications in the postoperative wound in the 2nd group was 3 cases versus 13 in the 1st group (p = 0.009). The rate of lymphorrhea in 2nd group was significantly lower (p = 0.003), median drainage duration was higher in 1st group (p <0.05). In the 2nd group, 70.6 % of patients did not require drainage, which was an important factor in rapid rehabilitation.Conclusion. The use of fast-track principles in patients after retroperitoneal lymphadenectomy significantly reduces the incidence of postoperative complications and rehabilitation time.
Рак мочевого пузыря (РМП) занимает 10 место в структуре онкологической заболеваемости в мире, ежегодно регистрируется 573000 новых случаев этого заболевания и 213000 случаев смертей [1]. У 25–30 % больных РМП при первичном обращении выявляется опухоль, инвазирующая мышечный слой мочевого пузыря и глубже, где золотым стандартом лечения является радикальная цистэктомия (РЦЭ), ассоциированая с высоким уровнем развития периоперационных и отдаленных осложнений [2]. Цель исследования. Изучить частоту развития инфекционных осложнений в период 30-90 дней после РЦЭ в хирургическом стационаре, работающим по протоколу раннего послеоперационного восстановления пациента (ERAS).
Introduction. The key treatment for high-risk non-invasive bladder tumor or invasive urothelial cancer remains radical cystectomy (RCE), which provides the best survival rates. At the same time, the incidence of infectious complications in a number of studies reaches 33%, which in most cases causes repeated hospitalizations and disrupts the Enhanced Recovery After Surgery (ERAS) guidelines. Therefore, research into effective alternations of antibiotic prophylaxis remains relevant.Materials and methods. The MACS trial is a Russian Phase 3 study with a prospective randomized set of participants to assess the incidence of infectious complications after RCE in the context of the ERAS guidelines (intermediate data snapshot after including 39% of the data). Detailed inclusion and exclusion criteria are published on ClinicalTrials. gov, ID – NCT05392634. The study has been approved by the Local Ethics Committee, No. 1/129 of April 28, 2022. Statistical data processing was performed with StatPlus:Mac LE.Results and discussion. 36 patients were included in the study (39% of the expected sample). For the period from May 30, 2022 to February 01, 2023. A heterotopic Bricker reservoir was formed intracorporeally in 83.3% of cases (30/36), an orthotopic J-pouch reservoir was created in 13.8% of cases (5/36) and in 2.9% of cases (1/36) the urodereating stage was completed with ureteral clipping. No significant differences were revealed in urine bacterial contamination before surgery. However, in group A, the incidence of positive bacterial cultures, when the ureteric intubators were removed, was 2-fold higher than in the prolonged antibiotic therapy group: 7/14 cases (50.0%) and 3/12 cases (25.0%), respectively. In group B, the risk of complications in the prolonged antibiotic therapy group reduced by 47% within 30 days after RCE (HR 0.53 (95CI %: 0.21-1.32).Conclusion. An intermediate data snapshot in MACS study revealed that RCE was associated with a high risk of early postoperative infectious complications. The prognostic significance of systemic inflammation indices as predictors of infectious complications subject to further evaluation in the remaining 61% of cases.
Objective. Radical nephrectomy with thrombectomy of the inferior vena cava is the preferred treatment for renal cell carcinoma with an tumor thrombosis. We describe our experience and presentreview of the literature evaluating the feasibility and safety of laparoscopic nephrectomy with inferior vena cava thrombectomy.Materials and methods. The study included 37 patients who underwent laparoscopic radical nephrectomy with level I–III thrombectomy for renal cell carcinoma in our institution from 2018 to 2021. We analyzed the clinical, radiographic, intraoperative, pathological and postoperative parameters of the patients. The literature was reviewed by the Medline search engine, PubMed, with a review of publications on laparoscopic radical nephrectomy with inferior vena cava levelI–IIIthrombectomy.Results. The mean operation time was 275 ± 60.1 min, the median blood loss was 450 ± 81.6 ml (≥50 % of the circulating blood volume – 32.4 %). Intraoperative complications were observed during 10 (27.0 %) operations. Postoperative complications developed in 29.7 % of patients and reached gradesIII–IV according to the Clavien–Dindo scale on 13.0 % ill. All patients are activated according to the fast track rehabilitation program. The average hospital stay was 5 days. A literature review identified clinical cases and small series demonstrating the technical feasibility and safety of laparoscopic radical nephrectomy with thrombectomy in selected patients.Conclusion. Laparoscopic radical nephrectomy with thrombectomy is a technically feasible approach in carefully selected patients with level I–III tumor thrombosis. Optimal patient selection, extensive experience in laparoscopy and specialized centers are essential for the safe use of thistechnique.
The ureter is a unique tubular structure, extremely sensitive to exogenous influences and directly affects to renal function. The injuries of the ureter remain one of the most difficult problems requiring an extraordinary surgical approach in urology. Extended strictures and obliterations of the ureters of various origins in the absence of timely treatment are accompanied by irreversible changes in the upper urinary system and renal parenchyma. Obstructive uroteropathy with transformation of the ureter wall, pelvis and kidney parenchyma in the case of oncology disease is caused directly by the tumor itself or invasive growth or complication of treatment. Therefore, the determination of indications and algorithms for ureteral reconstruction are cornerstone problem in urology daily practice.
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