Georgian Medical News

GEORGIAN MEDICAL NEWS

No 2 (143), 2007

This issue was supported by Aversi Ltd.

ÅÆÅÌÅÑß×ÍÛÉ ÍÀÓ×ÍÛÉ ÆÓÐÍÀË ÒÁÈËÈÑÈ - ÍÜÞ-ÉÎÐÊ “Georgian Medical News” is a Georgian-Russian-English-German monthly journal and carries original scientific articles on medicine and biology, which are of experimental, theoretical and practical character. “Georgian Medical News” is a joint publication of GMN Editorial Board and The International Academy of Sciences, Education, Industry and Arts (U.S.A.). “Georgian Medical News” is included in the international system of medical information “MEDLINE” which represents the central electronic database of the world medical scientific literature. The journal is stored in the funds of US national library. It is listed in the catalogue of The Central Scientific-Medical Public Library of Russian Feder- ation and world-wide catalogues: “Ulrich’s International Periodicals Directory” and “Medical and Health Care Serials in Print”. Articles from the bulletin are under review of scientific and technological informative journal of the Russian Academy of Sci- ences.

“Georgian Medical News” - åæåìåñÿ÷íûé íàó÷íî-ìåäèöèíñêèé ðåöåíçèðóå- ìûé æóðíàë, â êîòîðîì íà ðóññêîì, àíãëèéñêîì è íåìåöêîì ÿçûêàõ ïóáëèêóþòñÿ îðè- ãèíàëüíûå íàó÷íûå ñòàòüè ýêñïåðèìåíòàëüíîãî, òåîðåòè÷åñêîãî è ïðàêòè÷åñêîãî õà- ðàêòåðà â îáëàñòè ìåäèöèíû è áèîëîãèè, ñòàòüè îáçîðíîãî õàðàêòåðà, ðåöåíçèè; ïå- ðèîäè÷åñêè ïå÷àòàåòñÿ èíôîðìàöèÿ î ïðîâåäåííûõ íàó÷íûõ ìåðîïðèÿòèÿõ, íîâøå- ñòâàõ ìåäèöèíû è çäðàâîîõðàíåíèÿ. “Georgian Medical News” ÿâëÿåòñÿ ñîâìåñòíûì èçäàíèåì ñ Ìåæäóíàðîä- íîé Àêàäåìèåé Íàóê, Îáðàçîâàíèÿ, Ècêóññòâ è Åñòåñòâîçíàíèÿ (IASEIA) ÑØÀ. “Georgian Medical News” âêëþ÷åí â ìåæäóíàðîäíóþ ñèñòåìó ìåäèöèí- ñêîé èíôîðìàöèè “MEDLINE”, êîòîðàÿ ÿâëÿåòñÿ öåíòðàëüíîé ýëåêòðîííîé áàçîé äàí- íûõ ìèðîâîé ìåäèöèíñêîé íàó÷íîé ëèòåðàòóðû. Æóðíàë õðàíèòñÿ â ôîíäàõ áèáëèî- òåêè êîíãðåññà ÑØÀ; âõîäèò â êàòàëîã Ãîñóäàðñòâåííîé Öåíòðàëüíîé íàó÷íî-ìåäè- öèíñêîé áèáëèîòåêè Ðîññèéñêîé Ôåäåðàöèè è Âñåìèðíûå êàòàëîãè Ulrich’s International Periodicals Directory è Medical and Health Care Serials in Print. Ñòàòüè èç æóðíàëà ðåôåðèðóþòñÿ â ðåôåðàòèâíîì æóðíàëå Âñåðîññèéñêîãî èí- ñòèòóòà íàó÷íîé è òåõíè÷åñêîé èíôîðìàöèè Ðîññèéñêîé àêàäåìèè íàóê (ÂÈ- ÍÈÒÈ ÐÀÍ) è õðàíÿòñÿ â åãî áàçå äàííûõ ïî ìåäèöèíå.

“Georgian Medical News” - fhbc yjdtksdbehb cfvtwybthj cfvtlbwbyj htwtypbht,flb ;ehyfkb, hjvtkibw hecek, byukbceh lf uthvfyek tyt,pt mdtyylt,f tmcgthbvtynekb, stjhbekb lf ghfmnbrekb [fcbfsbc jhbubyfkehb cfvtwybthj cnfnbt,b vtlbwbybcf lf ,bjkjubbc cathjib, vbvj[bkdbsb [fcbfsbc cnfnbt,b, htwtypbt,b. “Georgian Medical News” ofhvjflutyc thsj,kbd ufvjwtvfc fii-bc vtwybtht,bc, ufyfskt,bc, bylecnhbbc, [tkjdyt,bcf lf ,eyt,bcvtnydtkt,bc cfthsfijhbcj frfltvbfcsfy (IASEIA) thsfl. “Georgian Medical News” itydfybkbf cfvtlbwbyj byajhvfwbbc cfthsfijhbcj cbcntvf “MEDLINE”_ib, hjvtkbw ofhvjflutyc vcjakbjc cfvtlbwbyj cfvtwybthj kbnthfnehbc wtynhfkeh tktmnhjyek vjyfwtvsf ,fpfc. byf[t,f fii_bc rjyuhtcbc ,b,kbjstrbc ajylt,ib\ itcekbf hectsbc atlthfwbbc cf[tkvobaj wtynhfkehb cfvtwybthj ,b,kbjstrbc rfnfkjucf lf cfthsfijhbcj rfnfkjut,ib “Ulrich’s International Periodicals Directory” lf “Medical and Health Care Serials in Print”. ;ehyfkib ufvjmdtyyt,ekb cnfnbt,b htathbhlt,f hectsbc vtwybtht,fsf frfltvbbc cfvtwybthj lf ntmybrehb byajhvfwbbc bycnbnenbc htathfnek ;ehyfkib lf byf[t,f vtlbwbybc vjyfwtvsf ,fpfib. ÌÅÄÈÖÈÍÑÊÈÅ ÍÎÂÎÑÒÈ ÃÐÓÇÈÈ

Åæåìåñÿ÷íûé ñîâìåñòíûé ãðóçèíî-àìåðèêàíñêèé íàó÷íûé ýëåêòðîííî-ïå÷àòíûé æóðíàë Àãåíòñòâà ìåäèöèíñêîé èíôîðìàöèè Àññîöèàöèè äåëîâîé ïðåññû Ãðóçèè, Àêàäåìèè ìåäèöèíñêèõ íàóê Ãðóçèè, Ìåæäóíàðîäíîé Àêàäåìèè Íàóê, Èíäóñòðèè, Îáðàçîâàíèÿ è Èñêóññòâ ÑØÀ. Èçäàåòñÿ ñ 1994 ã. Ðàñïðîñòðàíÿåòñÿ â ÑÍÃ, ÅÑ è ÑØÀ

ÍÀÓ×ÍÛÉ ÐÅÄÀÊÒÎÐ Ëàóðè Ìàíàãàäçå

ÃËÀÂÍÛÉ ÐÅÄÀÊÒÎÐ Íèíî Ìèêàáåðèäçå

ÍÀÓ×ÍÎ-ÐÅÄÀÊÖÈÎÍÍÀß ÊÎËËÅÃÈß Èãóìåí Àäàì - Âàõòàíã Àõàëàäçå, Íåëëè Àíòåëàâà, Òåíãèç Àõìåòåëè, Ëåî Áîêåðèÿ, Íèêîëàé Ãîíãàäçå, Ïàëèêî Êèíòðàèà, Òåéìóðàç Ëåæàâà, Äæèàíëóèäæè Ìåëîòòè, Êàðàìàí Ïàãàâà, Íèêîëàé Ïèðöõàëàèøâèëè, Âàëüòåð Ñòàêë, Ôðèäîí Òîäóà, Êåííåò Óîëêåð, Ðàìàç Õåöóðèàíè, Ðóäîëüô Õîõåíôåëëíåð, Ðàìàç Øåíãåëèÿ

ÍÀÓ×ÍÎ-ÐÅÄÀÊÖÈÎÍÍÛÉ ÑÎÂÅÒ Ìèõàèë Áàõìóòñêèé (ÑØÀ), Àëåêñàíäð Ãåííèíã (Ãåðìàíèÿ), Àìèðàí Ãàìêðåëèäçå (Ãðóçèÿ), Êîíñòàíòèí Êèïèàíè (Ãðóçèÿ), Ãåîðãèé Êàâòàðàäçå (Ãðóçèÿ), Ãåîðãèé Êàìêàìèäçå (Ãðóçèÿ), Ïààòà Êóðòàíèäçå (Ãðóçèÿ),Âàõòàíã Ìàñõóëèÿ (Ãðóçèÿ), Òåíãèç Ðèçíèñ (ÑØÀ), Äýâèä Ýëóà (ÑØÀ)

Website: www.geomednews.org www.viniti.ru

The International Academy of Sciences, Education, Inducstry & Arts. P.O.Box 390177, Mountain View, CA, 94039-0177, USA. Tel/Fax: (650) 967-4733

Âåðñèÿ: ïå÷àòíàÿ. Öåíà: ñâîáîäíàÿ. Óñëîâèÿ ïîäïèñêè: ïîäïèñêà ïðèíèìàåòñÿ íà 6 è 12 ìåñÿöåâ. Ïî âîïðîñàì ïîäïèñêè îáðàùàòüñÿ ïî òåë.: 93 66 78. Êîíòàêòíûé àäðåñ: Ãðóçèÿ, 380077, Òáèëèñè, óë.Àñàòèàíè 7, IV ýòàæ, òåë.: 995(32) 39 37 76, 995(32) 22 54 18, 39 47 82, Fax: +995(32) 22 54 18, e-mail: [email protected]; [email protected]; [email protected]

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© 2001. Àññîöèàöèÿ äåëîâîé ïðåññû Ãðóçèè © 2001. The International Academy of Sciences, Education, Industry & Arts (USA) GEORGIAN MEDICAL NEWS Monthly Georgia-US joint scientific journal published both in electronic and paper formats of the Agency of Medical Information of the Georgian Association of Business Press; Georgian Academy of Medical Sciences; International Academy of Sciences, Education, Industry and Arts (USA). Published since 1994. Distributed in NIS, EU and USA.

SCIENTIFIC EDITOR Lauri Managadze

EDITOR IN CHIEF Nino Mikaberidze

SCIENTIFIC EDITORIAL COUNCIL Hegumen Adam - Vakhtang Akhaladze, Nelly Antelava, Tengiz Akhmeteli, Leo Bokeria, Nicholas Gongadze, Rudolf Hohenfellner, Ramaz Khetsuriani, Paliko Kintraia, Teymuraz Lezhava, Gianluigi Melotti, Kharaman Pagava, Nicholas Pirtskhalaishvili, Ramaz Shengelia, Walter Stackl, Pridon Todua, Kenneth Walker

SCIENTIFIC EDITORIAL BOARD Michael Bakhmutsky (USA), Alexander Gënning (Germany), Amiran Gamkrelidze (Georgia), Konstantin Kipiani (Georgia), Giorgi Kavtaradze (Georgia), Giorgi Kamkamidze (Georgia), Paata Kurtanidze (Georgia),Vakhtang Maskhulia (Georgia), Tengiz Riznis (USA), David Elua (USA) CONTACT ADDRESS IN TBILISI Tbilisi, Georgia 380077

GMN Editorial Board Phone: 995 (32) 39-37-76 7 Asatiani Street, 4th Floor 995 (32) 22-54-18 995 (32) 39-47-82 CONTACT ADDRESS IN NEW YORK D. & N. COM., INC. Phone: (516) 487-9898 111 Great Neck Road Fax: (516) 487-9889 Suite # 208, Great Neck, NY 11021, USA Fax: 995 (32) 22-54-18

WEBSITE www.geomednews.org www.viniti.ru Ê ÑÂÅÄÅÍÈÞ ÀÂÒÎÐÎÂ!

Ïðè íàïðàâëåíèè ñòàòüè â ðåäàêöèþ íåîáõîäèìî ñîáëþäàòü ñëåäóþùèå ïðàâèëà:

1. Ñòàòüÿ äîëæíà áûòü ïðåäñòàâëåíà â äâóõ ýêçåìïëÿðàõ, íà ðóññêîì èëè àíãëèéñêîì ÿçû- êàõ, íàïå÷àòàííàÿ ÷åðåç ïîëòîðà èíòåðâàëà íà îäíîé ñòîðîíå ñòàíäàðòíîãî ëèñòà ñ øèðèíîé ëå- âîãî ïîëÿ â òðè ñàíòèìåòðà. Èñïîëüçóåìûé êîìïüþòåðíûé øðèôò - Times New Roman (Êè- ðèëëèöà), ðàçìåð øðèôòà - 12. Ê ðóêîïèñè, íàïå÷àòàííîé íà êîìïüþòåðå, äîëæíà áûòü ïðèëîæå- íà äèñêåòà ñî ñòàòü¸é. Ôàéë ñëåäóåò îçàãëàâèòü ëàòèíñêèìè ñèìâîëàìè. 2. Ðàçìåð ñòàòüè äîëæåí áûòü íå ìåíåå ïÿòè è íå áîëåå äåñÿòè ñòðàíèö ìàøèíîïèñè, âêëþ÷àÿ óêàçàòåëü è ðåçþìå. 3. Â ñòàòüå äîëæíû áûòü îñâåùåíû àêòóàëüíîñòü äàííîãî ìàòåðèàëà, ìåòîäû è ðåçóëüòàòû èññëåäîâàíèÿ è àñïåêòû èõ îáñóæäåíèÿ. Ïðè ïðåäñòàâëåíèè â ïå÷àòü íàó÷íûõ ýêñïåðèìåíòàëüíûõ ðàáîò àâòîðû äîëæíû óêàçûâàòü âèä è êîëè÷åñòâî ýêñïåðèìåíòàëüíûõ æèâîòíûõ, ïðèìåíÿâøèåñÿ ìåòîäû îáåçáîëèâàíèÿ è óñûïëåíèÿ (â õîäå îñòðûõ îïûòîâ). 4. Òàáëèöû íåîáõîäèìî ïðåäñòàâëÿòü â ïå÷àòíîé ôîðìå. Ôîòîêîïèè íå ïðèíèìàþòñÿ. Âñå öèôðîâûå, èòîãîâûå è ïðîöåíòíûå äàííûå â òàáëèöàõ äîëæíû ñîîòâåòñòâîâàòü òàêîâûì â òåêñòå ñòàòüè. Òàáëèöû è ãðàôèêè äîëæíû áûòü îçàãëàâëåíû. 5. Ôîòîãðàôèè äîëæíû áûòü êîíòðàñòíûìè è îáÿçàòåëüíî ïðåäñòàâëåíû â äâóõ ýêçåìïëÿðàõ. Ðèñóíêè, ÷åðòåæè è äèàãðàììû ñëåäóåò ïðåäñòàâëÿòü ÷åòêî âûïîëíåííûå òóøüþ; ôîòîêîïèè ñ ðåíòãåíîãðàìì - â ïîçèòèâíîì èçîáðàæåíèè. Íà îáîðîòå êàæäîãî ðèñóíêà êàðàíäàøîì óêàçûâàåòñÿ åãî íîìåð, ôàìèëèÿ àâòîðà, ñîêðàù¸ííîå íàçâàíèå ñòàòüè è îáîçíà÷àþòñÿ âåðõíÿÿ è íèæíÿÿ åãî ÷àñòè. Ïîäïèñè ê ðèñóíêàì ñîñòàâëÿþòñÿ îáÿçàòåëüíî íà îòäåëüíîì ëèñòå ñ óêàçàíèåì íîìåðîâ ðèñóíêîâ. Â ïîäïèñÿõ ê ìèêðîôîòîãðàôèÿì ñëåäóåò óêàçûâàòü ñòåïåíü óâåëè÷åíèÿ ÷åðåç îêóëÿð èëè îáúåêòèâ è ìåòîä îêðàñêè èëè èìïðåãíàöèè ñðåçîâ. 6. Ôàìèëèè îòå÷åñòâåííûõ àâòîðîâ ïðèâîäÿòñÿ â ñòàòüå îáÿçàòåëüíî âìåñòå ñ èíèöèàëàìè, èíîñòðàííûõ - â èíîñòðàííîé òðàíñêðèïöèè; â ñêîáêàõ äîëæåí áûòü óêàçàí ñîîòâåòñòâóþùèé íîìåð àâòîðà ïî ñïèñêó ëèòåðàòóðû. 7. Â êîíöå êàæäîé îðèãèíàëüíîé ñòàòüè äîëæåí áûòü ïðèëîæåí áèáëèîãðàôè÷åñêèé óêàçàòåëü îñíîâíûõ ïî äàííîìó âîïðîñó ðàáîò, èñïîëüçîâàííûõ àâòîðîì. Ñëåäóåò óêàçàòü ïîðÿäêîâûé íîìåð, ôàìèëèþ è èíèöèàëû àâòîðà, ïîëíîå íàçâàíèå ñòàòüè, æóðíàëà èëè êíèãè, ìåñòî è ãîä èçäàíèÿ, òîì è íîìåð ñòðàíèöû. Â àëôàâèòíîì ïîðÿäêå óêàçûâàþòñÿ ñíà÷àëà îòå÷åñòâåííûå, à çàòåì èíîñòðàííûå àâòîðû. Óêàçàòåëü èíîñòðàííîé ëèòåðàòóðû äîëæåí áûòü ïðåäñòàâëåí â ïå÷àòíîì âèäå èëè íàïèñàí îò ðóêè ÷åòêî è ðàçáîð÷èâî òóøüþ. 8. Äëÿ ïîëó÷åíèÿ ïðàâà íà ïóáëèêàöèþ ñòàòüÿ äîëæíà èìåòü îò ðóêîâîäèòåëÿ ðàáîòû èëè ó÷ðåæäåíèÿ âèçó è ñîïðîâîäèòåëüíîå îòíîøåíèå, íàïèñàííûíå èëè íàïå÷àòàííûå íà áëàíêå è çàâåðåííûå ïîäïèñüþ è ïå÷àòüþ. 9. Â êîíöå ñòàòüè äîëæíû áûòü ïîäïèñè âñåõ àâòîðîâ, ïîëíîñòüþ ïðèâåäåíû èõ ôàìèëèè, èìåíà è îò÷åñòâà, óêàçàíû ñëóæåáíûé è äîìàøíèé íîìåðà òåëåôîíîâ è àäðåñà èëè èíûå êîîðäèíàòû. Êîëè÷åñòâî àâòîðîâ (ñîàâòîðîâ) íå äîëæíî ïðåâûøàòü ïÿòè ÷åëîâåê. 10. Ê ñòàòüå äîëæíû áûòü ïðèëîæåíû êðàòêîå (íà ïîëñòðàíèöû) ðåçþìå íà àíãëèéñêîì è ðóññêîì ÿçûêàõ (âêëþ÷àþùåå ñëåäóþùèå ðàçäåëû: âñòóïëåíèå, ìàòåðèàë è ìåòîäû, ðåçóëüòàòû è çàêëþ÷åíèå) è ñïèñîê êëþ÷åâûõ ñëîâ (key words). 11. Ðåäàêöèÿ îñòàâëÿåò çà ñîáîé ïðàâî ñîêðàùàòü è èñïðàâëÿòü ñòàòüè. Êîððåêòóðà àâòîðàì íå âûñûëàåòñÿ, âñÿ ðàáîòà è ñâåðêà ïðîâîäèòñÿ ïî àâòîðñêîìó îðèãèíàëó. 12. Íåäîïóñòèìî íàïðàâëåíèå â ðåäàêöèþ ðàáîò, ïðåäñòàâëåííûõ ê ïå÷àòè â èíûõ èçäàòåëüñòâàõ èëè îïóáëèêîâàííûõ â äðóãèõ èçäàíèÿõ.

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Articles that Fail to Meet the Aforementioned Requirements are not Assigned to be Reviewed. avtorTa sayuradRebod! redaqciaSi statiis warmodgenisas saWiroa davicvaT Semdegi wesebi:

1. statia unda warmoadginoT 2 calad, rusul an inglisur enebze, dabeW- dili standartuli furclis 1 gverdze, 3sm siganis marcxena velisa da striqonebs Soris 1,5 intervalis dacviT. gamoyenebuli kompiuteruli Srifti Times New Roman (Êèðèëëèöà); Sriftis zoma – 12. statias Tan unda axldes disketi statiiT. faili daasaTaureT laTinuri simboloTi. 2. statiis moculoba ar unda Seadgendes 5 gverdze naklebsa da 10 gverdze mets literaturis siis da reziumes CaTvliT. 3. statiaSi saWiroa gaSuqdes: sakiTxis aqtualoba; kvlevis mizani; sakv- levi masala da gamoyenebuli meTodebi; miRebuli Sedegebi da maTi gansja. eqsperimentuli xasiaTis statiebis warmodgenisas avtorebma unda miuTiTon saeqsperimento cxovelebis saxeoba da raodenoba; gautkivarebisa da daZinebis meTodebi (mwvave cdebis pirobebSi). 4. cxrilebi saWiroa warmoadginoT nabeWdi saxiT. yvela cifruli, Sema- jamebeli da procentuli monacemebi unda Seesabamebodes teqstSi moyvanils. cxrilebi, grafikebi – daasaTaureT. 5. fotosuraTebi unda iyos kontrastuli; suraTebi, naxazebi, diagramebi - dasaTaurebuli da tuSiT Sesrulebuli. rentgenogramebis fotoaslebi war- moadgineT pozitiuri gamosaxulebiT. TiToeuli suraTis ukana mxares fanqriT aRniSneT misi nomeri, avtoris gvari, statiis saTauri (SemoklebiT), suraTis zeda da qveda nawilebi. suraTebis warwerebi warmoadgineT calke furcelze maTi N-is miTiTebiT. mikrofotosuraTebis warwerebSi saWiroa miuTiToT oku- laris an obieqtivis saSualebiT gadidebis xarisxi, anaTalebis SeRebvis an impregnaciis meTodi. 6. samamulo avtorebis gvarebi statiaSi aRiniSneba inicialebis TandarT- viT, ucxourisa – ucxouri transkripciiT; kvadratul fCxilebSi unda miuTi- ToT avtoris Sesabamisi N literaturis siis mixedviT. 7. statias Tan unda axldes avtoris mier gamoyenebuli samamulo da ucxouri Sromebis bibliografiuli sia (bolo 5-8 wlis siRrmiT). anbanuri wyobiT warmodgenil bibliografiul siaSi miuTiTeT jer samamulo, Semdeg ucxoeli avtorebi (gvari, inicialebi, statiis saTauri, Jurnalis dasaxeleba, gamocemis adgili, weli, Jurnalis #, pirveli da bolo gverdebi). monografiis SemTxvevaSi miuTiTeT gamocemis weli, adgili da gverdebis saerTo raodenoba. 8. statias Tan unda axldes: a) dawesebulebis an samecniero xelmZRvanelis wardgineba, damowmebuli xelmoweriTa da beWdiT; b) dargis specialistis damowmebuli recenzia, romelSic miTiTebuli iqneba sakiTxis aqtualoba, masalis sak- maoba, meTodis sandooba, Sedegebis samecniero-praqtikuli mniSvneloba. 9. statiis bolos saWiroa yvela avtoris xelmowera, romelTa raodenoba ar unda aRematebodes 5-s. 10. statias Tan unda axldes reziume inglisur da rusul enebze aranak- leb naxevari gverdis moculobisa (saTauris, avtorebis, dawesebulebis miTiTe- biT da unda Seicavdes Semdeg ganyofilebebs: Sesavali, masala da meTodebi, Sedegebi da daskvnebi; teqstualuri nawili ar unda iyos 15 striqonze naklebi) da sakvanZo sityvebis CamonaTvali (key words). 11. redaqcia itovebs uflebas Seasworos statia. teqstze muSaoba da Se- jereba xdeba saavtoro originalis mixedviT. 12. dauSvebelia redaqciaSi iseTi statiis wardgena, romelic dasabeWdad wardgenili iyo sxva redaqciaSi an gamoqveynebuli iyo sxva gamocemebSi.

aRniSnuli wesebis darRvevis SemTxvevaSi statiebi ar ganixileba. GEORGIAN MEDICAL NEWS No 2 (143) Ôåâðàëü, 2007 ãîä

Ñîäåðæàíèå:

ÍÀÓÊÀ ...... ñòð. 7

Íàó÷íûå ïóáëèêàöèè:

Hohenfellner R. NERVE INJURIES IN UROLOGICAL SURGERY ...... ñòð. 7

Pertia A., Nikoleishvili D., Trsintsadze O., Gogokhia N., Managadze L., Chkhotua A. PROGNOSTIC SIGNIFICANCE OF p27 (KIP1) EXPRESSION IN RENAL CELL CARCINOMA ...... ñòð. 12

Chkhotua A., Maglakelidze N, Managadze L. KIDNEY TRANSPLANTATION IN GEORGIA: A SINGLE CENTRE EXPERIENCE WITH LIVING-RELATED DONORS ...... ñòð. 17

Karazanashvili G., Muller S. IS RADICAL PROSTATECTOMY AN OPTION IN HIGH-RISK PROSTATE CANCER PATIENTS? ...... ñòð. 21

Tchokhonelidze I. MORTALITY DIFFERENCES BETWEEN HEMODIALYSIS AND PERITONEAL DIALYSIS AMONG ESRD PATIENTS IN GEORGIA ...... ñòð. 27

Veshapidze N., Alibegashvili M., Chigogidze T., Gabunia N., Kotrikadze N. DYNAMICS OF THE PROTEIN SPECTRUM CHANGES IN BLOOD ERYTHROCYTES OF MEN PATIENTS WITH PROSTATE ADENOCARCINOMA AFTER PLASTIC ORCHECTOMY ...... ñòð. 30

Nikoleishvili D., Pertia A., Tsintsadze O., Gogokhia N., Chkhotua A. DOWN-REGULATION OF p27(KIP1) CYCLIN-DEPENDENT KINASE INHIBITOR IN PROSTATE CANCER: DISTINCT EXPRESSION IN VARIOUS PROSTATE CELLS ASSOCIATING WITH TUMOR STAGE AND GRADES ...... ñòð. 34

Nazarishvili G., Gabunia N., Gagua G. PREVALENCE OF URINARY INCONTINENCE IN WOMEN POPULATION ...... ñòð. 39

Ujmajuridze N., Ujmajuridze A. POSTERIOR VERTICAL LUMBOTOMY, A CLINICAL CASE ...... ñòð. 43

Íàó÷íûé îáçîð:

Kochiashvili D., Sutidze M., Tchovelidze Ch., Rukhadze I., Dzneladze A. COMPARTMENT SYNDROME, RHABDOMYOLYSIS AND RISK OF ACUTE RENAL FAILURE AS COMPLICATIONS OF THE UROLOGICAL SURGERY ...... ñòð. 45

Íàó÷íûå ïóáëèêàöèè:

Äçèäçèãóðè Ä.Â., ×èãîãèäçå Ò.Ã., Ìàíàãàäçå Ë.Ã., Àñëàìàçèøâèëè Ò.Ò., Êåðêåíäæèÿ Ñ.Ì. ÈÑÑËÅÄÎÂÀÍÈÅ ÏÎ×Å×ÍÛÕ ÁÅËÊÎÂÛÕ ÊÎÌÏËÅÊÑÎÂ, ÏÎÄÀÂËßÞÙÈÕ ÝÊÑÏÐÅÑÑÈÞ ÃÅÍÎÂ Â ßÄÐÀÕ ÃÎÌÎÒÈÏÈ×ÅÑÊÈÕ ÊËÅÒÎÊ ...... ñòð. 50

Ìàíàãàäçå Ë.Ã., Õâàäàãèàíè Ã.Ã., Àáäóøåëèøâèëè Ê.Î., Ìàíàãàäçå Ã.Ë., Áåðóëàâà Ä.Ò. ÒÐÀÍÑÓÐÅÒÐÀËÜÍÎÅ ËÅ×ÅÍÈÅ ÄÎÁÐÎÊÀ×ÅÑÒÂÅÍÍÎÉ ÃÈÏÅÐÏËÀÇÈÈ ÏÐÅÄÑÒÀÒÅËÜÍÎÉ ÆÅËÅÇÛ ÁÎËÜØÈÕ ÐÀÇÌÅÐÎÂ ...... ñòð. 53

Ìøâèëäàäçå Ø.Ò., Óäæìàäæóðèäçå À.Í., Ìàíàãàäçå Ã.Ë., Øòàêëü Â. ÐÀÄÈÊÀËÜÍÀß ÏÅÐÈÍÅÀËÜÍÀß ÏÐÎÑÒÀÒÝÊÒÎÌÈß – ÎÏÅÐÀÒÈÂÍÀß ÒÅÕÍÈÊÀ, ÏÅÐÂÛÅ ÐÅÇÓËÜÒÀÒÛ ...... ñòð. 58

Âàðøàíèäçå Ë.Î., Òåâçàäçå Ê.Ã., Äæèí÷àðàäçå Ã.Ð., Ìàíàãàäçå Ã.Ë. ÝÔÔÅÊÒÈÂÍÎÑÒÜ ÝÊÑÒÐÀÊÎÐÏÎÐÀËÜÍÎÉ ÄÈÑÒÀÍÖÈÎÍÍÎÉ ËÈÒÎÒÐÈÏÑÈÈ ÏÐÈ ÌÎ×ÅÊÀÌÅÍÍÎÉ ÁÎËÅÇÍÈ ...... ñòð. 64

Õóñêèâàäçå À.À., Êî÷èàøâèëè Ä.Ê. ÊÎËÈ×ÅÑÒÂÅÍÍÛÅ ÈÇÌÅÍÅÍÈß ÒÅÑÒÎÑÒÅÐÎÍÀ È ÏÐÎÑÒÀÒÑÏÅÖÈÔÈ×ÅÑÊÎÃÎ ÀÍÒÈÃÅÍÀ ÏÐÈ ÅÃÎ ÌÀËÎÉ È ÂÛÑÎÊÎÉ ÏËÎÒÍÎÑÒÈ Ó ÌÓÆ×ÈÍ Ñ ÐÀÊÎÌ ÏÐÎÑÒÀÒÛ ...... ñòð. 67

Ñóëõàíèøâèëè Â.À. ÏÐÈÌÅÍÅÍÈÅ ÏËÀÔÅÐÎÍÀ Â ËÅ×ÅÍÈÈ ÁÎËÜÍÛÕ ÌÎ×ÅÊÀÌÅÍÍÎÉ ÁÎËÅÇÍÜÞ ÅÄÈÍÑÒÂÅÍÍÎÉ ÏÎ×ÊÈ ...... ñòð. 70

Ïàïàâà Â.Ë., Êî÷èàøâèëè Ä.Ê., ×îâåëèäçå Ø.Ã., Õàðäçåèøâèëè Î.Ì. ÈÑÑËÅÄÎÂÀÍÈÅ ÏÐÎÑÒÀÒÑÏÅÖÈÔÈ×ÅÑÊÎÃÎ ÀÍÒÈÃÅÍÀ Â ÊÐÎÂÈ È ÝÏÈÒÅËÈÈ ÏÐÎÑÒÀÒÛ ÏÐÈ ÄÎÁÐÎÊÀ×ÅÑÒÂÅÍÍÎÉ ÃÈÏÅÐÏËÀÇÈÈ ÏÐÅÄÑÒÀÒÅËÜÍÎÉ ÆÅËÅÇÛ ...... ñòð. 73

Ñëó÷àè èç ïðàêòèêè:

×îâåëèäçå Ø.Ã., Êî÷èàøâèëè Ä.Ê., Ãîãåøâèëè Ã.Ã., Ãåòòà Òüåðè, Ëàáàáèäè Àëèì ÑËÓ×ÀÉ ËÅÉÄÈÃÎÌÛ ÏÐÈ ÌÓÆÑÊÎÌ ÁÅÑÏËÎÄÈÈ ...... ñòð. 76

Äæàïàðèäçå Ñ.À., Äæàïàðèäçå Ñ.Ñ. ÐÅÄÊÈÉ ÑËÓ×ÀÉ ÄÎÁÐÎÊÀ×ÅÑÒÂÅÍÍÎÉ ÎÏÓÕÎËÈ ÓÐÀÕÓÑÀ Ó ÁÅÐÅÌÅÍÍÎÉ ...... ñòð. 80

Hohenfellner R. THE NATIONAL CENTRE OF UROLOGY IN TBILISI ...... ñòð. 82

Õîõåíôåëëíåð Ð. ÄÅßÒÅËÜÍÎÑÒÜ ÍÀÖÈÎÍÀËÜÍÎÃÎ ÖÅÍÒÐÀ ÓÐÎËÎÃÈÈ ÃÐÓÇÈÈ ...... ñòð. 83

6 GEORGIAN MEDICAL NEWS No 2 (143) Ôåâðàëü, 2007 ãîä

ÍÀÓÊÀ

Íàó÷íàÿ ïóáëèêàöèÿ

NERVE INJURIES IN UROLOGICAL SURGERY

Hohenfellner R.

Mainz University School of Medicine, Mainz, Germany

Paresthesis. Caused by patient’s placement or wound re- Remember: six important nerves arising fromTh12 – l5 tractor are reversible following days even weeks. drill from Para vertebral through the M. psoas located in the retroperitoneum and traveling later in an lateral and Partial lesions. The nerve sheet is intact. Reversible, nerve anterior direction on the surface of the abdominal wall: regeneration: 1 mm/day. there are: 1. iliohypogastricus, 2. ilioinguinalis, 3. Geni- tofemoralis, 4. femoralis, 5. N. cutaneus femoralis latera- Complete lesion. Following nerve suture or nerve interpo- lis, 6. obturatorius. (Lesion of the N. ischiadicus is ex- sition the prognosis remains questionable complicated by tremely rare). neuroma later on. As closer the lesions are at the point from where they Symptoms. Causalgia. Nerve lesion combined with lesion are arising - para vertebral – like in kidney surgery [3] or of Nn. splanchnici: extreme burning pain, maximum after lymphadenectomy as higher the risk of motoric deficien- weeks, decreasing later on. cy later on. However in the periphery on the fare end of the nerve branches sensory lesions are less severe. No- Posttraumatic neuralgia: located mostly in legs: long per- tice also double innervation of muscles: N. ilioinguina- sistent dump pains. lis and iliohypogastricus or N. obturatorius and N. femoralis as well as double sensoric innervations of some Neuroma Following complete lesion with or without nerve regions which may compensate deficiency symptoms suture or nerve interposition: extremely painful. Revision like N. ilioinguinalis and iliohypogastricus in the geni- necessary. tal region) [5].

Table 1. Nervus Obturatorius

Nerve Location Injury paravertebral medial of M. psoas Obturatorius (below plexus Lumbodorsalis) Extended lymphanenectomy, radical L2-L5 Pelvic surgery and laparoscopy. Fig. 6, Fig. 7 Later on: Fossa obturatoria, Lig. Cooper.

Remarks: Indirect lesion got also observed in “radical Remember: most important nerve of the muscle of the small TUR Prostate” (prostatitis): Capsula perforation: ostitis pelvis. Also: main function for the hip adduction and cir- ossis pubis causing Spasm of M. abductor Femoral and cumduction (M. Gracilis, M. Pectineus, M. Obturator ext., hip contraction. TUR-B: in tumors located more lateral M. Adductor magnus) [5]. Most symptoms in direct le- in spinal anesthesia. sions are temporary therefore reconstruction by suture or nerve interposition is unnecessary.

Table 2. Nervus Femoralis

Nerve Location Injury Psoas hitch (rare) n. femoralis Between m. psoas and m. iliacus Hernia repair L1-L4 lateral and dorsal: a. et v. femoralis Extreme abduction, self retractor compression of Lig. inguinal.

Remarks: sometimes located inside the m. psoas a deep by Hernia fixation are reported. Severe motoric dys- suture may cause the lesion. Also rare cases of lesions function! M. quadriceps: knee flexion, m. iliopsoas: hip

flexion, m. pectineus = abduction and outside rotation The sensory part is less severe n. saphenous, inside (see also n. obturatorius) m. vastus: to lift up the leg! of the leg.

Table 3. Nervus Genito-Femoralis Nerve Location Injury m. psoas labia maj., scrotum, penis genitofemoralis Ramus genitalis: sensoric, motoric Contraction of labia maj. L1-L2 ramus femoralis: location more lateral. Cremaster Rare lesion in urological surg.

Remarks: reported in psoas hitch op. Hernia repair and Remember: double sensoric innervations from n. ilioin- neurinoma near ureter stump in kidney transplantation. guinalis also of scrotum, labium and penis.

Table 4. Nervus Cutaneus Femoris Lateralis

Nerve Location Injury n. cutaneus femoralis lateralis Between fascia of m. iliacus

L2-L3 and crista iliaca

Remarks: lesion caused by hyperextension in lithotomy, severe burning pain ant. lat. side of the femur, thight. Revision neurolysis. Table 5. Nervus Pudendalis Nerve Location Injury Between lig. sacrotuberous (below) and lig. n. pudendalis sacrotuberous (above) through Alcock’s S2-S4 canal and m. transversalis perineum n. perinealis: sensoric: perineal region, skin of scrotum. Motoric: m. bulbospongiosum: Branches ejaculation n. dorsalis penis: sensoric – penis.

Remarks: Pudendaus anesthesia used in pelvic pain (1,4). ations causing loss of sensation of glans penis and cold- Lesion of n. dorsalis penis in induratio penis plastica oper- ness (2,6).

Table 6. Kidney exploration from a supracostal approach mostly if medial extended

Nerve Location Injury n. intercostalis lower rim of the rib Skin nerves: parestesia, hyperreflexia: T11-T12 No. 11 or 12 reversible within 3 to 6 month Fig. 1, Fig. 2 motor paralysis of abdominal wall n. iliohypogastricus Between m. transversalis and m. muscles (also in colostomies located lat T12-L1 obl. internus in the abdominal (wall) mostly in Fig. 3, Fig. 4 combined injure with n. ilioinguinalis distal from iliohypogastricus, Paralysis of abdominal wall only in n. ilioinguinalis T12-L1 below fascia of m. obl. externus combined with iliohypogasricus

Table 7. Kidney exploration Nerve Location Injury n. iliohypogastricus see above: mostly in second. perforates m. psoas, located on m. quadratus lumborum T12-L1 Operations. Scar tissue between later on between m. transvesus and m. internus Fig. 5 fatty capsule and kidney Perforates m. psoas together with n. iliohypogastricus n. ilioinguinalis see above: motor. paralysis of located below it on m. quadratus lumborum, later on T12-L1 abdominal wall see inguinal region

8 GEORGIAN MEDICAL NEWS No 2 (143) Ôåâðàëü, 2007 ãîä

Nn. intercost.

Th: VII correct X VIII

X Incision IX X incorrect X X X XI Fig. 3. Supracostal incision: if extended distally and medially: risk of iliohypogastric nerve injury (between oblique XII intern and transverse muscle) or ilioinguinal lesion

Fig. 1. The lower six intercostal nerves between the oblique transverse and intern abdominal muscle: motor innervations of the abdominal wall. (abdominal wall re- laxation, hernia formation). The sensible cutaneous branches: 7, 8, and for the infraumbilical region subcostalis 12

Plex. lumbodors.

iliohypogast.

ilioinguinal. femoralis

obturatorius

cut. fem. lat. genitofemoralis ramus femoralis

ramus genitalis

N. femoralis

Fig. 4. Topography of relevant nerves 1. Th12 intercos- Fig. 2. relevant head zones: referred pain in renal colic. tal, 2. ilioinguinal nerve 3. iliohypogstric nerve 4. femo- Th9-L2 (intarcutaneus injection of monocoffeinum – pain ral nerve 5. lumbodorsal plexus 6. obturatoric nerve 7. extinction) phenomenon for several minutes! Head zones Genitofemoral nerve, branches: a. femoral b. genital, 8. in biliary colic Th6-Th10 cutaneus femoral lateral nerve

Diaphragma

M. psoas

subcostalis 12 Plex. lumbodors.

iliohypogast. N. femoralis

ilioinguinal.

obturatorius Fig. 7. Obturatoric nerve distally: obturartor fossa cut. fem. lat. risk: local lymph node resection (do not reconstruct

genitofemoralis when due to outside rotation of leg: spontaneous re- ramus femoralis covery) ramus genitalis

Fig. 5. Topography. ilioinguinalis and iliohypogastricus (mixed nerves perforate the psoas located on the quadratus lumbar muscle). Risk: renal redo operations scar tissue backside of the kidney. Cutataneous femoral lateral nerve located on the iliacus. Risk: hyperextension in lithotomy. Genitofemoral nerve on the psoas muscle, risk: psoas hitch. Obturator nerve medial of psoas muscle, risk: extended lymph node resection

M. psoas

cut. fem. lat. iliohypogast. M . iliacus

genitofemoralis N. ilioinguinal. obturatorius

ramus fem oralis

ramus genitalis

N. fem oralis

Fig. 8. Topography, parainguinal incision. Risk: a. ilioinguinal nerve sensible branch: remember double (triple) genital skin innervation by ilioinguinal and genital branch of genitofemoral nerve also. Pull out sensible branches in case of lesion. b. ilioinguinal: sensible Fig. 6. Obturator nerve: high risk extended lymph node branch. (see above). c. genitofemoral nerve, genital resection branch sensible (see above)

10 GEORGIAN MEDICAL NEWS No 2 (143) Ôåâðàëü, 2007 ãîä

SUMMARY

NERVE INJURIES IN UROLOICAL SURGERY

Hohenfellner R.

iliohypogast. Mainz University School of Medicine, Mainz, Germany

ilioinguinalis It is well known that surgical procedures are followed by different complications, connected with nerve injury at the site of wound. In case of complete lesion due to nerve suturing or nerve interposition the prognosis remains questionable and may be genitofemoralis complicated by neuroma later on. The symptoms of nerve dam-

ramus femoralis age are Causalgia (in case of combined with lesion of Nn. splanch-

ramus genitalis nici: extreme burning pain, maximum after weeks, decreasing later on); Posttraumatic neuralgia: located mostly in legs: long persistent dump pains; and Neuroma Following complete lesion with or without nerve suture or nerve interposition: extremely painful and usually revision is necessary. During the surgical access to the kidneys n. Intercostalis 11-T12, n.Iliohypogastricus T12-L1, n. Ilioinguinalis T12-L1, n. Iliohypogastricus T12-L1, n. Ilioinguinalis T12-L1 may get damaged, in case of groin incision – n. Cutaneus femoralis lateralis L2-L3, n. Pudendalis S2- S4 and in Psoas Hitch procedure – n. Genitofemoralis L1-L2, n.Femoralis L1 – L4, Obturatorius L2-L5.

Key words: nerve injuries, urological surgery, causalgia.

Fig. 9. Sensible areas of the iliohypogastric, ilioinguinal ÐÅÇÞÌÅ and genitofemoral nerve ÏÎÂÐÅÆÄÅÍÈß ÍÅÐÂÎÂ Â ÓÐÎËÎÃÈ×ÅÑÊÎÉ REFERENCES ÕÈÐÓÐÃÈÈ

1. Costello A.J., Brooks M., Cole O.J. Anatomical studies of the Õîõåíôåëëíåð Ð. neurovascular bundle and cavernosal nerves // BJU Int. – 2004. – N 94(7). – P. 1071-6. Øêîëà ìåäèöèíû Óíèâåðñèòåòà Ìàèíöà, Ãåðìàíèÿ 2. Kumar S., Duque J.L., Guimaraes K.C., Dicanzio J., Loughlin K.R., Richie J.P. Short and long-term morbidity of L4, n. Obtu- Èçâåñòíî, ÷òî ðàçëè÷íûe îñëîæíåíèÿ õèðóðãè÷åñêèõ îïåðà- ratorius L2-L5. öèé îáóñëîâëåíû ïîâðåæäåíèåì íåðâîâ â îïåðàöèîííîé îá- 3. Lepor H., Gregerman M., Crosby R. et al: Precise localization ëàñòè. Â ñëó÷àå ïîëíîãî ïîâðåæäåíèÿ íåðâíîãî ñòâîëà âî of the autonomic nerves from the pelvic plexus to the corpora âðåìÿ èíòåðïîçèöèè èëè ëèãèðîâàíèÿ ïðîãíîç íåÿñåí. Ñèìï- cavernosa: A detailed anatomical study of the adult. òîìàìè ïîâðåæäåíèÿ íåðâîâ ìîãóò ÿâëÿòñÿ êàóçàëãèÿ, íå- 4. Lue T.F., Zeineh S.J., Schmidt R.A., Tanagho E.A. Neuro- âðàëãèÿ èëè íåèðîìà, êîòîðûå ðàçâèâàþòñÿ ïîñëå ëèãèðî- anatomy of penile erection: its relevance to iatrogenic impotence âàíèÿ èëè èíòåðïîçèöèè íåðâíîãî ïó÷êà. Íàëè÷èå áîëåé â // J Urol. – 1984. - N131. – P. 273–280. ýòèõ ñëó÷àÿõ äèêòóåò íåîáõîäèìîñòü ïðîâåäåíèÿ ðåâèçèè 5. Shafik A., el-Sherif M., Youssef A., Olfat E.S. Surgical anato- ðàíû. Â ñëó÷àå îïåðàöèè íà ïî÷êå âîçìîæíî ïîâðåæäåíèå n. my of the pudendal nerve and its clinical implications // Clin Intercostalis 11-T12, n.Iliohypogastricus T12-L1, n. Anat. – 1995. – N 8(2). – P. 110-5. Ilioinguinalis T12-L1, n. Iliohypogastricus T12-L1, n. Ilioinguinalis 6. Wallner C., Maas C.P., Dabhoiwala N.F., Lamers W.H., T12-L1; ïðîâåäåíèå ðàçðåçà â îáëàñòè ïàõà ìîæåò áûòü ñâÿç- DeRuiter M.C. Innervation of the pelvic floor muscles: a reap- âàíî ñ ïîâðåæäåíèåì n. Cutaneus femoralis lateralis L2-L3, n. praisal for the levator ani nerve // Obstet Gynecol. – 2006. – N Pudendalis S2-S4 à îïåðàöèÿ Psoas Hitch – n. Genitofemoralis 108(3 Pt 1). – P. 529-34. L1-L2, n.Femoralis L1 – L4, n. Obturatorius L2-L5.

Íàó÷íàÿ ïóáëèêàöèÿ

PROGNOSTIC SIGNIFICANCE OF p27(KIP1) EXPRESSION IN RENAL CELL CARCINOMA

Pertia1 A., Nikoleishvili1 D., Trsintsadze2 O., Gogokhia3 N., Managadze1 L., Chkhotua1 A.

1National Centre of Urology, Departments of Adult Urology and 2Department of Pathology; 3Tbilisi State Medical Academy, Department of Laboratory Diagnosis

Renal cell carcinoma (RCC) accounts for about 3% of all tion consisted of 70 consecutive patients treated at our adult malignancies and it is the most lethal of the urolog- institution from 2003 to 2004. The patients were divided in ical cancers [1,2]. Despite a substantial progress in un- 2 groups: group I: 24 normal human kidney tissue samples derstanding the basic biology of RCC, still many aspects resected from patients of different ages due to renal cell of the disease remain unclear. This especially concerns carcinoma (67%) and kidney trauma (33%), and group II: the prognostic markers of tumor recurrence and patient 46 RCC samples received from 41 radical and 5 partial ne- survival. Numerous molecular and chromosomal markers phrectomies. have been evaluated for this purpose, however, there is no consensus regarding their significance in RCC The mean age of patients in Group I was 53,4±17 years [5,14,15,20,21]. Tumor stage and grade are currently rec- (range 21-80 years); 63% were male and 37% were female. ognized as independent prognostic factors of the dis- Majority (83%) of the patients underwent scheduled ne- ease. However, the assessment of tumor grade may vary phrectomies due to the kidney tumours; 4 kidneys were substantially due to subjectivity of the observer resected because of traumatic injury; none of them had [14,15,21], and the TNM classification of the disease has the clinical signs of renal insufficiency or other co-morbid- been recently questioned [7]. Some authors considers ities. The serum creatinine values were normal in all pa- that a chromophobic variant of RCC has a better progno- tients. All of them were free of diabetes. 6 out of 24 individ- sis than a conventional variant but most authors argued uals were hypertensive. Morphological evaluation revealed with this sentence [14,15,21]. Therefore, detection of new, mild to moderate degree of age-associated pathological more sensitive and specific prognostic markers predict- changes in 6 persons. ing the clinical behavior of the tumor is of utmost importance [5,14,15,20,21]. The mean patient age in Group II was 50,8±10,9 years (range 20-68 years) (p- NS vs. Group I), 48% were male Recent advances in cell-cycle evaluation have led to the and 52% were female. The mean follow-up is 15 months identification of proteins responsible for the regulation of (range: 2-24 months). Demographic and clinical data of cell proliferation. Indeed, several markers of this origin have the patients are presented in table 1. Radical nephrecto- been evaluated in various human malignancies including my without adjuvant immunotherapy was performed in RCC [15,20,23]. all patients. None of them had the renal insufficiency or other substantial co-morbidities. The serum creatinine p27 is a cyclin-dependent kynase inhibitor gene (CGKIG) values were normal in all patients. All of them were free of of a Cip/Kip family which can negatively control the cell diabetes. 2 patients had lymph node and 1 patients dis- cycle through inhibition of cyclin and cyclin-dependent tant metastases at the time of surgery. 14 out of 47 (30,4%) kynase (CDK) complexes [13,22,24]. It has been shown tumors were discovered incidentally, 24 (51,1%) were that p27(KIP1) can provide additional prognostic informa- symptomatic and the rest 3 patients (6,4%) had a system- tion in multiple different tumors [2,3,6,11]. There is increas- ic disease symptoms. Morphologic evaluation revealed ing evidence that low expression of p27 is an important 40 (87%) clear cell, 3 (6,5%) papillary RCCs, 2 (3,75%) clinical marker of disease prognosis in various tumor types chromophobe and 2 (3,75%) oncocytomas. All patients [2,4,6,17,26]. Very few studies have evaluated the value of (control as well as study group) were operated in one p27 in RCC however, with different and often conflicting department and all removed kidneys were sent to the results [1,8,9,16,18,19,22,25,26]. Department of Pathology of the same institution (Nation- al Center of Urology). The majority of the tumors were The goal of the current study was to analyze the ex- clear cell (conventional) carcinomas. The same team of pression of p27 in benign and malignant (RCC) renal personnel according to the single protocol has techni- tissue samples and also in different histological types cally processed all the tissue specimens. Disease recur- of RCC. rence was defined as evidence of measurable disease on imaging (CT, MRI, bone scan or ultrasound) and histo- Material and methods. Patient groups. The study popula- logical evaluation of suspected lesions.

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Tissue sampling and immunohistochemistry. Informed evaluated blindly by two of the authors (O.T. and A.C.) consent for using the surgical tissues for future scien- using a microscope (Olympus B201), under X20 and X40 tific research was obtained from all patients. The study magnification objectives. Only nuclear staining was con- design was approved by the internal review board of sidered as positive and was counted. The whole tissue the institution. area of the same size was evaluated and scored semi- quantitatively according to a 4 point scale of 0 to 4: no Resected kidney specimens from the patients of Group I staining – 0, mild (<30% cells positive) – 1, moderate were evaluated macroscopically. After sampling accord- (31-50% cells positive) – 2 and strong staining (>50% ing to the main disease, 1,5x2 cm tissue samples contain- cells positive) – 3. ing cortex and medulla were taken from 2 separate, most distant from the tumor and macroscopically normal kid- Statistical analysis was performed using a computer soft- ney regions. The samples were fixed in 4% formaldehyde ware (SPSS 12.0 for Windows, Lead Technologies Inc. 2003. and embedded in paraffin. 4-5μm thick serial sections were Chicago, Il.). Normality of data distribution was examined stained with haematoxylin and eosin (HE), according to with the Kolmogorov-Smirnov test. Age-dependency of conventional techniques. The sections were analyzed by the marker expression was analyzed by the Spearman cor- the pathologist (O.T.) to exclude oncological or other relation. Marker expression in Group I and Group II was pathological changes. Only kidneys considered normal compared with a Mann-Whitney test. A possible associa- and with acceptable age-associated morphological tion of the gene expression with the clinical parameters changes (mild interstitial infiltration and/or tubular atro- (stage, grade, disease symptoms and tumor histology) was phy) were further immunohistochemically evaluated and analyzed with a Kruskal-Wallis test. p values less than included in the study. 0,05 were considered significant. In case of a significant difference means of the data were compared with non-par- Resected kidneys from the patients of Group II were eval- ametric comparison of ranks. uated macroscopically. The maximal tumor size was meas- ured and 1,5 x 2cm tissue samples were taken for further Recurrence-free and cancer-specific survival was estimat- assessment. Specimens were fixed, stained and evaluated ed with the Kaplan-Meier method. The patients who died by the pathologist according to conventional technique. of other reason were censored at the date of death. The The tumors were staged according to the AJCC classifica- prognostic value of different clinical parameters on dis- tion system and graded according to Fuhrman’s grading ease recurrence and patient death was analyzed with the system [7]. log-rank test. The additional investigated prognostic factors were classified as follows: age at diagnosis (≥65 years 4μm thick sequential tissue sections were used for immu- vs. <65 years), tumor size (≥8 cm vs. <8 cm), histological nohistochemistry. Tissue samples were deparaffinised in type (clear cell papillary, chromophobe, cystic RCCs) nu- xylene and rehydrated in graded ethanol. Endogenous per- clear grade (Grade 1, Grade 2, or Grade 3), pathological oxidase was blocked by incubation in 1% hydrogen perox- TNM stage (T1, T2, or T3), disease symptoms (inciden- ide. Sections were pretreated by the microwave antigen tally discovered, local or systemic), and loss of p27 ex- retrieval procedure (4 cycles for 5min each at 600- pression (staining absent or present). Values of p<0.05 700 watt) in 10mmol/L of boiling citrate buffer solution were considered statistically significant. All p values were (pH 6,0). The necessary amount of buffer was added af- two-sided. ter each cycle to ensure the complete coverage of the slides. Afterwards, tissue sections were incubated for 1h Results and their discussion. p27 was expressed to vari- at room temperature with anti-p27(KIP1) (Oncogene, Clone ous degrees by all structures of normal kidney tissue. The DCS72, Cat. #NA35) antibody diluted (1:100) in phos- gene expression was detected in interstitial, tubular epi- phate-buffered saline (PBS). After PBS washing, tissue thelial and vascular endothelial cells as well as in parietal, sections were revealed using the Biotin-Streptavadin visceral epithelial and mesangial glomerular cells of nor- detection system (Star 2006, Serotec Ltd.). Samples were mal kidneys. In the RCC samples there was considerable developed with liquid diaminobenzidine + substrate-chro- heterogeneity with regard to p27 staining intensity. Only mogen system (Serotec Ltd., BUF022) and counterstained nuclear staining was considered as appositive staining for with haematoxylin. RCC. Loss of expression of p27 was noticed in 14 cases (31,1%), mild stainig was revealed in 8 (17,7%) , moderate Human tonsil tissue was used as a positive control in – 13 (28,8%) and strong expression was detected 10 and antigen-free PBS as a negative control, according cases (22,2%). to the established protocols of immunohistochemical staining. A Spearman correlation analysis was performed to check the age-dependency of p27 expression in the groups. The Sample scoring and statistical analysis. Slides were positive correlation of p27 expression with age was de-

tected in the control group (Rho=0,504, p=0,0180). The cor- † relation matrix for the RCC group did not revealed age- dependent changes in the gene expression.

A comparison of the intensity of marker expression in con- 40 trol and study groups showed that the gene was signifi- * 35 cantly higher expressed in normal than in RCC tissue sam- 30 ples (p=0,0045). 25 Intensity of p27 expression was negatively correlated with 20 3 maximal tumor size (fig. 1). It was significantly decreasing Mean p27 rank 15 2 with increasing tumor stage (p=0,0196) and grade (p<0,0001) 10 (fig. 2). 5 1 0 Symptoms Histology 250 225 * p=0,031 vs. 3, † p=0,041 vs. 1 200 Rho=-0,438, p=0,004 175 Symptoms:1 – incidental, 2 - local, 3 – systemic. 150 Histology: 1 – clear cell, 2 - papillary, 3 – oncocytoma 125 100 Fig. 3. p27 scores according to the disease symptoms at

Tumor volume Tumor presentation and tumor histology 75 50 5 patients (10%) during follow-up period had a dis- 25 ease recurrence. The baseline p27(KIP1) expression level 0 in these patients was significantly lower than in non- -,5 0 ,5 1 1,5 2 2,5 3 3,5 P27 Score recurrent tumors (p=0,04). Disease-related related death was observed in 4 cases (fig. 4). The baseline Fig. 1. Spearman correlation analysis of p27 vs. tumor size p27(KIP1) expression level in these patients was significantly lower than in alive patients (p=0,0106). The Log-Rank analysis showed that loss of p27(KIP1) ex- 35 pression were the risk-factors of oncological patient 30 ‡ death (p=0,005) (fig. 5). 25 Survival Plot 20 * †

Mean p27 rank 1,0 15 Ω 0,9 10 0,8

5 0,7 0,6 0 PT G 0,5

1 2 3 Surviving 0,4 *p=0,048 vs. 1, † p=0,032 vs. 1. ‡ p=0,007 vs. 1, 0,3 Ωp<0,0001 vs. 1 and 2 0,2 0,1 Fig. 2. p27 scores according to the tumor pathological 0,0 0 5 10 15 20 25 stage and grade Followup The disease presentation was associated with intensity of the gene expression, in that the patients with systemic, Log-Rank p=0,0106 metastatic symptoms (anemia, loss of weight etc.) had sig- 1. High intensity p27 expression (High curve); nificantly less marker expression than incidentally discov- 2. Low intensity of p27 expression (Low curve) ered tumors (p=0,0301). The marker expression was significantly higher in oncocytoma’s as compared with conven- Fig 4. Kaplan-Meier cancer-specific survival curves ac- tional RCCs (p=0,0378) (fig. 3). cording to the p27 expression intensity status

14 GEORGIAN MEDICAL NEWS No 2 (143) Ôåâðàëü, 2007 ãîä

Survival Plot proteins known as cyclin-dependent kinase inhibitor genes 1,0 which play an important role in cancer generally [2,13,17,26] 0,9 and in genitourinary carcinoma in particular [3,4,6]. p27 is 0,8 one of the member of Cip/Kip family of CDKIGs. Its prog- 0,7 nostic value has been evaluated in different human malig- 0,6 nancies [2,13,17,26]. It has been shown, that loss of p27 0,5 protein predicts a poor prognosis for breast, colon, gastric, lung and esophageal cancers (Anticancer 12). De-

Surviving 0,4 creased p27 expression has also been linked to increasing 0,3 tumor grade, stage and poor survival in bladder and pros- 0,2 tate cancers [3,6]. 0,1 0,0 0 5 10 15 20 25 Only few studies evaluated the value of p27 in RCC with Followup controversial results. Low p27 and increased retinoblasto- ma protein expression were the two independent prognostic factors of poor outcome in RCC (Haitel et al) [8]. Expres- Log-Rank p=0,0005 sion of p27 was inversely correlated with tumor size. The 1. Loss of p27 expression (Low curve). tumor stage and low p27 expression were the factors de- 2. Existing of p27 expression (High curve) termining disease-specific survival [19]. A progressive loss of nuclear p27 expression has been detected with increas- Fig. 5. Kaplan-Meier cancer-specific survival curves ac- ing tumor grade but the association between low p27 ex- cording to the loss of p27 expression pression and disease-specific survival has not been detected (36 own). Hedberg and coauthors found an inverse The lack of prognostic markers predicting disease outcome correlation between p27 expression and tumor size. Pa- is one of the most important problems in RCC. To date, tients with low p27 tumors had a poor survival [9]. The tumor stage, grade and the patient performance status have same authors have examined several cell cycle proteins been identified as the most reliable and useful prognostic and found that low cyclin D1 and p27 expression were markers. Tumor stage, which reflects the anatomical spread associated with high grade, large tumor size and poor prog- of the disease, has been shown to have the greatest im- nosis (10). The patients with low p27 expression and Skp2 pact on clinical behavior of the tumor [14,15,21]. However, immunoreactivity had a less favorable outcome in clear the staging system of RCC has been changed several times cell cancers [18]. Moreover, progression of RCC from stage in the last decade. In 1997, the International Union Against T1a to T1b was associated with significantly decreased Cancer (IUCC) and the American Joint Committee on Can- p27 expression [16]. The results of above studies are con- cer (AJCC) proposed a TNM system that is now recom- flicting showing association between p27 expression and mended for RCC. That was a revision of the 1992 TNM tumor size stage and grade [1,9,10,18], stage only [19,16], system. The 1997 system was modified in 2002. Yet, this and no association with clinical parameters at all [8]. With modified version was recently criticized and called for re- regard to prognostic significance, association between low vision [7]. Almost all histopathological tumor grading sys- p27 expression and poor prognosis has been detected by tems have shown that the tumor grade has an independ- almost all authors [1,6,8,9,10,18,19]. ent prognostic value in RCC [14,15,21]. However, subjectivity in reproducibility of the tumor grade is a major prob- In contrast to the above mentioned studies we evaluated lem and controversy still exists concerning its association the prognostic value of loss of p27 expression. It was de- with survival [14,15,21]. tected in 29% of RCC specimens. We found that loss of p27 activity is a risk-factor of tumor recurrence and patient With the better understating of molecular biology and ge- survival. This result corresponds with the numerous other netics of RCC numerous new markers have been evaluated studies showing the prognostic value of p27 expression in [14,15,20,21,23]. One of the new and promising directions breast, colon, gastric, lung and esophageal cancers for future research in this area is evaluation of the cell [3,4,13,17,26]. In the Cox hazard regression model loss of cycle regulatory proteins. The cell cycle is a process that p27 expression was the strongest predictor of cancer-free allows an ordered replication of each cell’s genome fol- patient survival. The significant association was found lowed by its division into two daughter cells. Dysregula- between p27 expression and tumor stage and grade in action of the cycle results in rapid cellular proliferation and is cordance with other reports [9,10]. It should be mentioned a hallmark of cancer development [22,24]. The cycle is con- that the majority of published studies were done on the trolled by a cascade of positive and negative regulatory clear cell subtype of RCC. Only two reports analyzed ex- elements. Passage through the cell cycle requires cyclin- pression of p27 in different histological subtypes of RCC CDK complexes [22,24] CDKs are regulated by a group of [10,18]. The value of p27 as a marker to separate chromo-

© GMN 15 ÌÅÄÈÖÈÍÑÊÈÅ ÍÎÂÎÑÒÈ ÃÐÓÇÈÈ CFMFHSDTKJC CFVTLBWBYJ CBF[KTYB phobe from the clear cell subtype has been identified [10,18]. cer. – 2002. – vol. 20. – N 102(6). – P. 601-7. In the current study we could show that the gene expres- 10. Hedberg Y., Ljungberg B., Roos G., Landberg G. Expression sion was significantly higher in oncocytomas as compared of cyclin D1, D3, E, and p27 in human renal cell carcinoma with conventional RCCs. The new finding of this study is analysed by tissue microarray // Br J Cancer. – 2003. – vol. 6. – N 88(9). – P. 1417-2. the difference of p27 expression according to the disease 11. Janzen N.K., Kim H.L., Figlin R.A., Belldegrun A.S. Sur- manifestation type. The patients with systemic symptoms veillance after radical or partial nephrectomy for localized (anemia, loss of weight etc.) had significantly less marker renal cell carcinoma and management of recurrent disease // expression than incidentally discovered tumors. Urol Clin North Am. – 2003. - N30. – P. 843. 12. Jemal A., Tiwari R.C., Murray T., Ghafoor A., Samuels A., The results of this study show, that eexpression of p27 Ward E. et al. Cancer statistics, 2004. CA // Cancer J Clin. – is significantly decreased in RCC as compared with nor- 2004. - N54. – P. 8. mal kidney tissue. Intensity of the gene expression is 13. Kawamata N., Morosetti R., Miller C.W. et al. Mo- associated with clinical parameters: tumour size, stage, lecular analysis of the cyclin-dependent kinase inhibitor gene p27/Kip1 in human malignancies // Cancer Res. – grade, disease presentation (symptomatic vs. inciden- 1995. - N55. – P. 2266–2269. tal) and tumour histology. It has been shown for the 14. Kontak J.A., Campbell S.C. Prognostic factors in renal cell first time to our knowledge that the loss of p27 expres- carcinoma // Urol Clin North Am. – 2003. - N30. – P. 467. sion is a risk-factor for disease recurrence and the strong- 15. Lam J.S., Shvarts O., Leppert J.T., Figlin R.A., Bellde- est predictor of cancer-specific survival. Prospective grun A.S. Renal cell carcinoma 2005: new frontiers in stag- studies are needed to confirm the prognostic value of ing, prognostication and targeted molecular therapy. – 2005. the marker in patients with RCC. – N 173(6). – P. 1853-62. 16. Langner C., Ratschek M., Rehak P., Tsybrovskyy O., Zige- REFERENCES uner R. The pT1a and pT1b category subdivision in renal cell carcinoma: is it reflected by differences in tumour biology? // BJU Int. – 2005. – N 95(3). – P. 310-4. 1. Anastiadis A.G., Calvo Sanchez D., Franke K.H., Ebert 17. 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SUMMARY factors of oncological patient death (p=0,005).

PROGNOSTIC SIGNIFICANCE OF p27(KIP1) EXPRESSION Eexpression of p27 is significantly decreased in RCC as com- IN RENAL CELL CARCINOMA pared with normal kidney tissue. Intensity of the gene expression is associated with clinical parameters: tumour size, stage, Pertia1 A., Nikoleishvili1 D., Trsintsadze2 O., grade and disease presentation. Loss of p27 expression is a risk- Gogokhia3 N., Managadze1 L., Chkhotua1 A. factor for disease progression.

1National Centre of Urology, Departments of Adult Urology and Key words: renal cancer, CDKI gene, p27(Kip1). 2Department of Pathology; 3Tbilisi State Medical Academy, De- partment of Laboratory Diagnosis ÐÅÇÞÌÅ

The importance of cyclin-dependent kinase inhibitor genes (CD- ÏÐÎÃÍÎÑÒÈ×ÅÑÊÎÅ ÇÍÀ×ÅÍÈÅ ÝÊÑÏÐÅÑÑÈÈ KIG) in benign and malignant urological diseases is a subject of ÈÍÃÈÁÈÒÎÐÀ ÊËÅÒÎ×ÍÎÃÎ ÖÈÊËÀ p27(KIP1) ÏÐÈ intense ongoing investigation. The goal of the current study was ÏÎ×Å×ÍÎÊËÅÒÎ×ÍÎÌ ÐÀÊÅ to analyze the expression of p27(Kip1) CDKIG in benign and malignant renal cells and assess their possible association with Ïåðòèÿ1 À.Ð., Íèêîëåèøâèëè1 Ä.Î., Öèíöàäçå2 Î.Â., Ãî- different clinical parameters. ãîõèÿ3 Í.À., Ìàíàãàäçå1 Ë.Ã., ×õîòóà1 À.Á.

Expression of p27(Kip1) CDKIG was evaluated and compared in 1Íàöèîíàëüíûé öåíòð óðîëîãèè èì. À. Öóëóêèäçå, îòäåëå- 24 normal human kidneys and in 46 renal cell carcinoma (RCC) íèå ïîäðîñòêîâîé óðîëîãèè; 2îòäåëåíèå ïàòîëîãèè; 3Òáè- samples. Intensity of the gene expression was compared be- ëèññêèé ãîñóäàðñòâåííûé ìåäèöèíñêèé óíèâåðñèòåò, êà- tween the groups and possible association was analyzed with ôåäðà óðîëîãèè the cancer clinical parameters. Öåëüþ èññëåäîâàíèÿ ÿâèëîñü èçó÷åíèå ýêñïðåññèè The gene was significantly higher expressed in normal than in p27(Kip1) ïðîòåèíà ïðè ïî÷å÷íîêëåòî÷íîì ðàêå (ÏÊÐ) è RCC tissue samples (p=0,0045). Intensity of the marker ex- âûÿâëåíèå êîððåëÿöèîííîé ñâÿçè ìåæäó ýêñïðåññèåé pression in RCC was negatively correlated with tumor size ïðîòåèíà è äðóãèìè ïðîãíîñòè÷åñêèìè ôàêòîðàìè ÏÊÐ. (Rho= -0,438, p=0,0051) and associated with stage and grade Ýêñïðåññèÿ ïðîòåèíà â îïóõîëåâûõ òêàíÿõ èçó÷åíà â 46- (p=0,0488 and <0,0001, respectively). The patients with è ñëó÷àÿõ. Íîðìàëüíàÿ ïî÷å÷íàÿ òêàíü ÿâëÿëàñü êîíò- symptomatic disease had significantly less marker expres- ðîëüíûì ìàòåðèàëîì. Ðåçóëüòàòû èññëåäîâàíèÿ ïîêàçà- sion than incidentally discovered tumors (p=0,0301). The ëè, ÷òî ýêñïðåññèÿ p27(Kip1) ïðîòåèíà èíòåíñèâíåå â íîð- marker expression was significantly higher in oncocytomas ìàëüíîé ïî÷å÷íîé òêàíè ïî ñðàâíåíèþ ñ îïóõîëåâîé as compared with conventional RCCs (p=0,0378) The base- (p=0,0045) è íàõîäèòñÿ â íåãàòèâíîé êîððåëÿöèîííîé line p27(Kip1) expression level in these patients was signifi- ñâÿçè ñî ñòàäèåé è ñòåïåíüþ äèôôåðåíöèàöèè ÏÊÐ (ñî- cantly lower than in non-recurrent tumors (p=0,04). Disease- îòâåòñòâåííî ð=0,0051 è p=0,0001). related related death was observed in 4 cases. The baseline p27(Kip1) expression level in these patients was significantly Óðîâåíü p27(Kip1) ïðîòåèíà èçíà÷àëüíî áûë íèçêèì â òåõ lower than in alive patients (p=0,0106). The Log-Rank anal- ñëó÷àÿõ, êîãäà áîëåçíü ðåöèäèâèðîâàëà â ïðîöåññå íà- ysis showed that loss of p27(Kip1) expression were the risk- áëþäåíèÿ (p=0,0106).

Íàó÷íàÿ ïóáëèêàöèÿ

KIDNEY TRANSPLANTATION IN GEORGIA: A SINGLE CENTRE EXPERIENCE WITH LIVING-RELATED DONORS

Chkhotua1 A., Maglakelidze2 N, Managadze1 L.

1National Center of Urology, Departments of Urology and 2Nephrology

The success rate of kidney transplantation (Tx) has im- decades have led to a substantial improvement in the out- proved dramatically and it has become the treatment of come of kidney Tx. The use of new immunosuppressive choice for patients with end stage renal disease [2]. Ad- regimens (CsA or FK based) not only substantially im- vances in immunosuppressive therapy during the last two proved the graft survival, but also decreased the incidence

of various complications and increased the number of po- In this paper we present the results of 37 living renal trans- tential transplant candidates including more high-risk pa- plants performed at our institution during the last 7 years. tients (diabetic, elderly etc). Unfortunately, with the permanently growing demand for Tx, the supply of kidneys Material and methods. The data of 37 patients who un- has remained stable and severe organ shortage subse- derwent living donor kidney Tx at the National Centre quently occurred [4,10]. This is the major problem of kid- of Urology from January 2000 to December 2007 have ney Tx today [5,8]. Several solutions to these problems been collected and analysed. All transplants were per- have been reported and some of them have been tried, but formed from genetically related donors. 21 patients organ deficiency still exists. The situation is even getting (56,7%) were male and 16 (43,3%) were female. The mean steadily worse as the list of potential recipients awaiting recipient age was 27±11 years and the mean donor age organ Tx continues to grow by about 20% per year [5]. was 49±9 years. Only 1 (2,7%) patient was diabetic. 65% Currently more than 70000 patients are on the UNOS na- of them were dialysis dependent (54% haemo and 11% tional patient waiting list for kidney Tx [12]. peritoneal) at the time of Tx. All patients received the first kidney graft. Although the renal Tx is done in Georgia from 1995, it is legally permitted since March 2000. The national law allows organ Tx The most frequent form of donation was parent to child from cadaver, as well as living donors. Both, living related and (89,2%). In 2,7% of cases organ was offered by sibling and unrelated (spousal only) Tx can be performed in the country. in 5,4% - by cousin and uncle each (table 1).

Table 1. Types of donor/recipient relationship Relationship N % Parent 32 86,5 Cousin 2 5,4 Uncle 2 5,4 Sibling 1 2,7

All transplants were performed according to ABO compat- tively 500 mg of IV Solumedrol was given immediately be- ibility and negative direct cross-match. Blood transfusions fore the reperfusion. Standard triple immunosuppressive were never used prior to Tx. The HLA antigen typing and protocol with CsA, Cellcept (CC) and Prednisolone (Pred) PRA tests were not performed. was started on the first postoperative day (POD). CsA dose was adjusted according to the whole blood medication lev- All patients and donors were studied according to proto- els. Standard dose of CC was 1000 mg twice a day. Pred. was cols accepted at our Centre. Assessment of potential do- started with the dose of 250 mg/d and gradually decreased nor renal function, infectious disease profiling, serum bio- until a dose of 30mg at the end of the first month. chemistry, complete blood count, urinalysis and coagulation studies were followed by aortography and/or CT an- Acute rejection episodes were diagnosed by clinical pa- giography and intravenous urography to identify renal and rameters like decreased urine output and increased serum upper urinary tract anatomy. All transplant operations were creatinine (Cr) levels in the absence of urinary tract ob- approved by the ethical committee of the Ministry of struction, infection, dehydration or drug induced toxicity. Health of Georgia. Vascular resistance on renal arteries was evaluated by Doppler ultrasonography. Rejection episodes were treat- Operative procedure. All donors and recipients were ad- ed with bolus doses of steroids for 3 days. mitted at the hospital on the evening before surgery. Dur- ing the night donors received IV hydration with 2 litters of The patients were followed for a mean of 29,5 months (range: lactated Ringer’s solution. Unilateral nephrectomy with the 1,5-85 months). The following parameters were analysed: retroperitoneal approach was done under general anaes- early and late posttransplant complications, rejection rate, thesia. Kidney graft was flushed with cold Ringer’s solu- the most recent Cr, patient and graft survival rates. tion and kept in mixed ice-water solution until the Tx. Im- plantation was performed into either iliac fossa using end Results and their discussion. The types of early and late to side anastomosis between the renal and external iliac postoperative complications, their treatment modalities and vessels. The donors were discharged from the hospital outcomes are presented in table 2. Haemorrhage, gastro- one week after the operation and were further followed by intestinal bleeding and graft thrombosis were the most nephrologist. important early postoperative complications. Two (5,4%) patients developed delayed graft function and needed di- Immunosuppressive protocols. Immunosuppression for all alyses for 21 days. Graft function was completely recov- recipients was initiated 3 days before surgery. Intraopera- ered and both patients are dialysis-free.

18 GEORGIAN MEDICAL NEWS No 2 (143) Ôåâðàëü, 2007 ãîä

Table 2 Types of postoperative complications and their outcome Complication N (%) Treatment Outcome Early Haemorrhage 2 (5,4) Transplantectomy (1), revision and control (1) Return to dialysis (1), death (1) GI bleeding 4 (10,8) Conservative treatment (3), fibrogastroscopy Recovery with coagulation (1) Graft thrombosis 2 (5,4) Transplantectomy (1) Return to dialysis (1), death (1) Acute graft failure 2 (5,4) Dialysis+conservative treatment Recovery Acute rejection 1 (2,7) Steroid bolus Graft loss Urine leak 2 (5,4) Uretherocystoneostomy Recovery Uretheral stricture 2 (5,4) Uretherocystoneostomy Recovery Lymphocele 3 (8,1) Sclerotherapy (2), marsupialization (1) Recovery (2), graft loss (1) RAS 1 (2,7) Stenting, open angioplasty Return to dialysis HUS 1 (2,7) Plasmapheresis CAN Acute liver failure 1 (2,7) MARS Death Late CAN 3 (8,1) Conservative treatment Return to dialysis (1) Bacterial sepsis 3 (8,1) Conservative treatment Recovery (2), CAN (1) CMV sepsis 2 (5,4) Conservative treatment Recovery (2), death (1)

GI - Gastro-intestinal, RAS – renal arterial stenosis, HUS – hemolytic-uremic syndrome, CAN – Chronic allograft nephropathy, CMV – cytomegalovirus, MARS - molecular adsorbent recirculating system On the whole 6 (16,2%) biopsy proven acute rejection ep- ter-in-low. Thus, chemical immunosuppression allowed the isodes have been detected, of whom 5 were successfully physicians to accept both, related and unrelated donors treated with bolus steroids. One episode of steroid-resist- for kidney Tx. ant rejection was developed, which lead to subsequent graft loss. Two developments have impacted dramatically the fate of living donor kidney Tx: implication of donor-specific blood The mean value of the most recent serum Cr level is transfusion and the advent of Cyclosporine A immuno- 1,6±1,1g/dl (range: 0,7-6,2g/dl). suppression. Possibility to reveal the sensitised patients before Tx, and improved posttransplant immunosuppres- On the whole 4 (10,8%) patients died, of whom 2 (5,4%) sion gave substantial preference to living donors with with functioning graft. 1, 2 and 3 year patient survival for comparison to cadaver ones and improved the clinical re- the whole group was 89,2%. The overall mean patient sur- sults [1,9]. vival was 27,4±3,6 months. According to 1996 UNOS Scientific Renal Transplant Reg- 6 grafts were lost during the study period. Reasons for the istry report, the one-year graft survival rates of one haplo- graft loss were: vascular thrombosis, acute nonrespond- type matched siblings and unrelated donors are identical ing rejection, main disease recurrence and CAN. 1, 2 and 3 (92%) and higher than that of cadaver kidney transplants year graft survival for the whole group was 89,2%, 83% (84%) [3]. 3 year graft survival rate of spousal (85%) and and 83%, respectively. The overall mean graft survival was other unrelated (81%) transplants were in the range of 1 22,8±3,2 months. haplotype matched living donor Tx (82%) and significantly higher than the results of cadaver Tx (70%) [11]. The use of living kidney donors was started in the earliest days of renal Tx, when dialysis therapy was not routinely According to the 12-year experience of Washington Uni- available. The very first living unrelated kidney transplants versity School of Medicine, number of rejections, most were reported by Kuss in 1951 [6]. The kidneys were from recent Cr and 1 and 5 year graft survival rates were similar patients who underwent nephrectomies for benign renal in living related and unrelated donor transplants. Survival diseases. As no immunosuppression was available at that data were significantly higher than that of cadaver Tx time the results were dismal. (93,1% and 85,9% vs. 84,6% and 70,7%, respectively) [7].

With the advent of total body irradiation and the use of 6- In the current paper we analysed early and late postopera- mercaptopurine and cortisone, the very first successful tive results of the living kidney Tx performed at our institu- transplants from living unrelated donors were reported by tion during the last 7 years. Results of our study show, that the same author in early 60’s [6]. These were emotionally vast majority of the donors in Georgia are represented by related donors, hasband to wife and brother-in-low to sis- parents followed by other relatives. There was no case of

© GMN 19 ÌÅÄÈÖÈÍÑÊÈÅ ÍÎÂÎÑÒÈ ÃÐÓÇÈÈ CFMFHSDTKJC CFVTLBWBYJ CBF[KTYB spousal donation up to now and this donor source should 7. Lowell J.S., Brennan D.C., Shenoy S. Living-unrelated renal trans- be more actively used to increase the number of transplants. plant provides comparable results to living related renal transplant: a 12-year single-center experience // Surgery. – 1996. - N119. – P. 538. The incidence of most postoperative complications in our 8. Rapoport F.T., Anaise D. Organ donation – 1990 // Trans- plant. Proc. – 1991. - N23. – P. 899. series is identical, or even lower than in the developed 9. Sollinger H.W., Burlingham W.J., Sparks E.M.F. et al. Donor-specif- countries. The relatively high rate of haemorrhages (in- ic transfusions in unrelated and related HLA mismatched donor-recip- cluding GI bleeding) and lymphoceles have been detected ient combinations // Transplantation. – 1984. - N38. – P. 612. in our series. However, there is a clear tendency towards 10. Spital A. The shortage of organs for transplantation: where do decrease of these complications in the recent years. This we go from here? // N. Engl. J. Med. – 1991. - N325. – P. 1243. has been achieved by improvement in surgical technique 11. Terasaki P.I., Cecka M.J., Gjertson D.W., Takemoto S. High and routine preoperative use of fibrogastroscopy. survival rates of kidney transplants from spousal and living unrelated donors // N. Engl. J.Med. – 1995. - N333. – P. 333. The acute rejection rate (16,2%) was in the range well- SUMMARY matched with the immunosuppression regimen used in these patients (CsA+CC+Pred). Vast majority of them were suc- KIDNEY TRANSPLANTATION IN GEORGIA: A SINGLE cessfully treated with bolus steroids. One graft (2,7%) was CENTRE EXPERIENCE WITH LIVING-RELATED DONORS lost due to the steroid-resistant rejection. Unfortunately, monoclonal antibodies are not available in Georgia yet. Chkhotua1 A., Maglakelidze2 N, Managadze1 L.

The patient and graft survival rates in our series are compa- 1National Center of Urology, Departments of Urology and 2Ne- rable with that reported in the literature. It is worth to men- phrology tion that we represent here the results from the beginning of 37 patients underwent living donor kidney Tx at the National renal transplant program at our institution. The transplant Centre of Urology from January 2000 to December 2007. All outcomes have substantially improved in the last years. For transplants were performed from genetically related donors. The instance, the mortality rate associated with kidney Tx has mean follow-up was 29,5 months. The following parameters were decreased form 38% in 1995-200, to 5,4% in 2000-2007. analysed: early and late posttransplant complications, rejection rate, the most recent Cr, patient and graft survival rates. Haemor- In conclusion, our results show that on the background of rhage (5,4%), gastro-intestinal bleeding (10,8%) and graft throm- contemporary immunosuppression it is possible to take all bosis (5,4%) were the most important early complications. 6 advantages of the living kidney Tx like: decreased cold (16,2%) episodes of acute cellular rejection were detected of whom ischemic time, advanced planning of operation with ad- 5 were treated successfully with bolus steroids. Two (5,4%) patients developed delayed graft function and needed postoperative justment of recipient and donor health parameters, and dialyses. The mean value of the most recent serum Cr level is initiation of immunosuppression prior to Tx. The results of 1,6±1,1g/dl (range: 0,7-6,2g/dl). 1, 2 and 3 year patient survival kidney Tx will steadily improve with progress in surgical for the whole group was 89,2%. 1, 2 and 3 year graft survival for technique and experience and can achieve the acceptable the whole group was 89,2%, 83% and 83%, respectively. The level. The pool of living-unrelated (spouses etc.) donors mortality rate associated with kidney Tx has decreased form 38% should be wider used by encouraging them to donate. in 1995-200, to 5.4% in 2000-2007. The results of kidney Tx can achieve the acceptable level with improving surgical technique and experience. The pool of living-unrelated (spouses etc.) donors REFERENCES should be wider used to increase the number of transplants. Key words: kidney transplantation, living donor. 1. Anderson C.B., Tyler J.D., Sicard G.A. et al. pretreatment of allograft recipient with immunosuppression and donor-specific ÐÅÇÞÌÅ blood // Transplantation. – 1984. - N38. – P. 664. 2. Cecka J., Terasaki P. The UNOS scientific renak transplant ÐÅÇÓËÜÒÀÒÛ ÒÐÀÍÑÏËÀÍÒÀÖÈÈ ÏÎ×ÊÈ Ñ ÈÑ- registry 1991. // In: Terasaki P.I. (ed). Clinical transplants 1991. ÏÎËÜÇÎÂÀÍÈÅÌ ÆÈÂÛÕ ÄÎÍÎÐÎÂ - Los Angeles: UCLA Tissue Typing Laboratory. – 1991. – P. 1. 3. Cecka J.M. The UNOS Scientific Renat transplant Regis- ×õîòóà1 À.Á., Ìàãëàêåëèäçå2 Í.Ä., Ìàíàãàäçå1 Ë.Ã. try// Clin.Transplant. – 1996. – P. 1-14. 4. Evans R. Need, Demand and supply in kidney transplantation: A 1Íàöèîíàëüíûé öåíòð óðîëîãèè èì. À. Öóëóêèäçå, îòäåëå- review of the data, an examination of the issues and projections through íèå óðîëîãèè è 2îòäåëåíèå íåôðîëîãèè and the year 2000 // Semin. Nephrol. – 1992. - N12. – P. 234. 5. First M.R. Transplantation in nineties // Transplantation. – Ïðîèçâåäåíà òðàíñïëàíòàöèÿ ïî÷êè 37-è áîëüíûì çà 2000- 1992. - N53. – P. 1. 2007 ãã. Âñå äîíîðû è ðåöèïèåíòû áûëè ãåíåòè÷åñêèìè ðîä- 6. Kuss R. Human renal transplant memories, 1951 to 1981. // ñòâåííèêàìè. Ñðåäíÿÿ ïðîäîëæèòåëüíîñòü íàáëþäåíèÿ ñî- In: Terasaki P.I. (ed). History of transplantation: 35 Years Rec- ñòàâèëà 29,5 ìåñÿöåâ. Êðîâîòå÷åíèÿ èç àíîñòîìîçà (5,4%), ollection. - Los Angeles: UCLA Tissue Typing Laboratory. – æåëóäî÷íî-êèøå÷íûå (10,8%), òðîìáîç òðàíñïëàíòàòà (5,4%) 1991. – P. 39.

20 GEORGIAN MEDICAL NEWS No 2 (143) Ôåâðàëü, 2007 ãîä

áûëè ñàìûìè çíà÷èìûìè ïîñòîïåðàöèîííûìè îñëîæíåíèÿ- âàåìîñòü òðàíñïëàíòàòà – 89,2%, 83% è 83%, ñîîòâåòñòâåí- ìè. Âûÿâëåíî 6 (16,2%) ñëó÷àåâ îñòðîãî îòòîðæåíèÿ òðàíñ- íî. Óðîâåíü ëåòàëüíûõ èñõîäîâ ïîñëå òðàíñïëàíòàöèé â Ãðó- ïëàíòàòà, èç íèõ 5 óñïåøíî âûëå÷åíû ïóëüñ-ñòåðîèäàìè. Ó çèè ñíèçèëñÿ ñ 38% â 1995-2000 ãã. äî 5,4% â 2000-2007 ãã. 2-õ (5,4%) èç îáùåãî ÷èñëà áîëüíûõ íàáëþäàëàñü îñòðàÿ íå- Óñîâåðøåíñòâîâàíèå îïåðàòèâíîé òåõíèêè è îïûòà âåäåíèÿ äîñòàòî÷íîñòü òðàíñïëàíòàòà ñ íåîáõîäèìîñòüþ ïîñòîïåðà- áîëüíûõ ïîçâîëÿò äîñòèãíóòü ðåçóëüòàòîâ ïî òðàíñïëàíòà- öèîííîãî äèàëèçà. Ñðåäíèé óðîâåíü êðåàòèíèíà â êðîâè ñî- öèè ïî÷êè çàïàäíûõ ñòðàí. Ãåíåòè÷åñêè íåðîäñòâåííûå äî- ñòàâèë 1,6±1,1 ã/äë. Îäíà, 2-õ è 3-ãîäè÷íàÿ âûæèâàåìîñòü íîðû äîëæíû ÷àùå ïðèâëåêàòüñÿ ñ öåëüþ óâåëè÷åíèÿ êîëè- ïàöèåíòîâ ñîñòàâèëà 89,2%, à îäíà. 2-õ è 3-ãîäè÷íàÿ âûæè- ÷åñòâà òðàíñïëàíòàöèé.

Íàó÷íàÿ ïóáëèêàöèÿ

IS RADICAL PROSTATECTOMY AN OPTION IN HIGH-RISK PROSTATE CANCER PATIENTS?

Karazanashvili1 G., Muller2 S.

1Tbilisi State Medical University, 2University hospital of Bonn

Prostate cancers with unfavorable clinical data, stage T3 Until recently surgery for high-risk prostate cancer was and/or PSA>20ng/ml and/or Gleason ≥8, fell into the so- avoided due to two reasons: 1. the potential for incomplete called high-risk group. Why these patients are of especial excision of the local tumor and 2. High incidence of lymph interest? Long-term survival exceeds 90% in patients with node metastasis. This raises the question under which con- intermediate- and low-risk prostate cancer while men in ditions a properly executed radical prostatectomy in high the highest risk group have a 25% chance of dying from risk prostate cancer might provide a better course of action? their disease before 5 years and up to a 50% risk of death from prostate cancer at 10 years [1]. Radical prostatectomy in cases of T3 prostate cancer Grate interest represents the long follow-up, largest, single in- In cases of clinical T3 or more stage and/or pretreat- stitutional data presented by Mayo clinic in 2005 [4]. De- ment PSA>20ng/ml and/or biopsy Gleason score ≥8 most partment of urology at this institution has advocated rad- researchers are talking about the high-risk of pathological prostatectomy for clinical T3 prostate cancer patients ically locally advanced disease. However, postopera- for over 20 years. They analyzed 5562 men managed surgi- tively, the rate of tumor spread into the lymphatic sys- cally (1987-1997), of which 841 were represented with clin- tem is not low in these cases, it is about 25-33% [2-5]. ically T3 diseases, without metastasis. The follow-up peri- Thus these men are not only at risk of locally advanced, od reaches 15 years. The data demonstrates that 85%, 73% but at risk of metastatic disease as well. Accordingly and 67% of cT3 prostate cancer patients at 5, 10 and 15 seems that more appropriate would be to speak about years where free of local and systemic disease. Further- the high-risk of advanced disease in above mentioned more, the overall (90%, 76%, 53%) and cancer-specific sur- cohort of prostate cancer patients. This is very impor- vival (CSS) (95%, 90%, 79%) for patients with cT3 disease tant to realize, when planning the treatment strategy. at 5, 10 and 15 years was only moderately lower than that However the treatment options for high-risk men usual- in patients with cT2 disease (95%, 82% and 61%, and 99, ly steak with those for locally advanced prostate can- 96% and 92%, respectively) during the same period. Strati- cer. Common treatment options usually include hormo- fied by pathological stage, patients staged pT3 had a statis- nal therapy (HT), radiation therapy (RT) or a combina- tically significantly different CSS from pT2, but those staged tion of both. Radical prostatectomy (RP) has not been pT3/4 had a 10- and 15-year CSS of 89% and 80% with adju- considered as the standard treatment strategy in these vant therapy. For patients with cT3 disease, RP was part of cases. Locally advanced prostate cancer is associated a multimodal approach to disease eradication or control, with high risk of subclinical metastasis and disease pro- which included HT or radiotherapy at some time after RP in gression; therefore watchful waiting is rarely advocat- 58% and 27%, respectively. Thus as a part of this multimo- ed in these cases. Currently there is no consensus on dal approach, to patients who once felt doomed to die from the most appropriate treatment of high-risk prostate the disease, RP achieved CSS rates which approach those cancer [6]. in patients with cT2 disease undergoing RP.

Survival data from 8887 men (1987-1999 yy.) with 15 year PSA production varies according to grade and volume of follow-up is presented by Swedish authors using the data cancer and with coexisting BPH tissue. Tumors that arise from Prospective Population-Based National Prostate in the transition zone may acquire a greater volume than Cancer Registry [7]. This is extremely valuable study, their peripheral zone counterparts and may be better dif- while truly population-based, prospective cohorts are ferentiated than peripheral zone tumors of equivalent vol- scarce in the literature. Even the most well performed, ume, while producing much higher PSA levels than other- randomized, controlled trial usually suffers from recruit- wise expected for organ-confined cancer [11]. ment bias (i.e., it is not known what happens to the patients who are not part of the randomization). In this study There are few published data on the long-term survival for the treatment methods included - watchful waiting, hor- patient cohorts managed by radical prostatectomy and monal therapy, radiation therapy, radical prostatectomy. evaluated in the context of serum PSA >20 ng/ml at diag- Cancer specific mortality at 15 years was 56% for all pa- nosis. Ou and coauthors have found that after RP PSA tients. Projected 15 year CSS was 66% for nonmetastatic >50 ng/ml patients had shorter freedom from PSA failure T1-T3 disease (2098 men). 15 Year CSS and overall sur- than PSA 20,1-50 ng/ml patients (p=0,004) [12]. The au- vivals where calculated separately for watchful waiting, thors recommend the classification of high-risk PC patients hormonal therapy, radiation therapy and Radical prosta- into two sub-groups PSA 20,1–50 ng/ml and PSA>50 ng/ml. tectomy. The worst CSS possessed Radiation therapy Selected men with PSA 20,1-50 ng/ml may be effectively (54%), watchful waiting and hormonal therapy were rela- treated by radical prostatectomy. tively similar (about 60%) and the best CSS data was discovered among the patients underwent radical pros- Thus high PSA values do not reflect necessarily inopera- tatectomy (about 79%). Although there may have been bility of the tumor and PSA >20ng/ml still is not absolute difficulties in making direct comparisons between treat- contraindication to radical prostatectomy. ment groups due to differences in prognostic factors and possibly in other confounding factors, the Cox analysis Radical prostatectomy in cases of high-grade prostate can- revealed that undergoing radical prostatectomy was an cer. High-grade prostate cancer is associated with a high inci- independent factor that implied a lower risk of dying from dence of cancer progression, in part related to the high rate of prostate carcinoma (relative risk, 0,40). lymph node metastases. Therefore some centers have reject- ed RP and advocated the need for alternative therapies, such The largest Mayo and Sweduisch data are in harmony re- as conformal external beam radiotherapy with or without pel- garding 15 year survival data after radical prostatectomy, vic irradiation, hormonal therapy and brachitherapy either in both cases it was about 80% [4,7]. These investigations alone or as multimodal protocol, comprising two or more treat- are clearly indicating, that radical prostatectomy can be ment strategies [13-15]. However the Kupelian et al have considered as the part of multimodal treatment in cases of showed, that biopsy Gleason score 8 prostate cancer pa- clinical T3 prostate cancer. tients may benefit almost the same way of RP as of RT [16]. 5 Year biochemical recurrence free survival (bRFS) in RP group Radical prostatectomy in cases of PSA >20ng/ml. Al- was almost the same as in – RT, 42% versus 47% accordingly though PSA > 20 is associated with lower rates of disease (HT was given as part of the initial treatment in 53% of pa- free survival and higher rates of advanced disease, numer- tients). But 8 year local recurrences rate was 2 times lower ous noncancerous pathophysiological factors influence after RP compared with RT (12% versus 6%). RP overcame RT the leakage of PSA into serum. Often inflammation iatro- also as a monotherapy – without adjuvant androgen depriva- genic manipulation and physiological variations can sig- tion 5 Year bRFS was 43% to 29% in use of RP. Soloway and nificantly alter PSA level [8,9]. coauthors are reporting similar 5 year bRFS of 41%, but with significantly lower local recurrence rate after RP [17]. Also, two genes control PSA production by the prostate gland. One gene makes the protein itself. The second However biopsy Gleason score is not reliable data for de- gene, which was the focus of Cramer’s study, controls cision-making about the treatment strategy. The rate of how much PSA is made [10]. This is called the promoter overstaging by prostate biopsy is very high - 45-55% of gene, in which researchers discovered eight important men with biopsy Gleason score ≥8 have a lower Gleason single nucleotide polymorphisms. Men with some of score in the radical prostatectomy specimen [18, 19]. Cor- these polymorphisms had higher PSA levels, while men respondingly they have more favorable long-term outcome. with the others had lower levels. None of the men had Also the biopsy score was not independent preoperative prostate cancer. Although each single nucleotide poly- variable predicting the risk of biochemical progression at 5 morphism alone could affect the PSA level, they were and 10 years [5,18]. more potent in certain combinations. One particular combination produced PSA levels 50% greater than another So the rejection of RP in favor of RT, which is based on combination, for instance. biopsy data (Gleason score ≥8) seems not wise.

22 GEORGIAN MEDICAL NEWS No 2 (143) Ôåâðàëü, 2007 ãîä

Radical prostatectomy in cases of T4 and/or lymph-node Feasibility of radical prostatectomy in cases of high risk positive prostate cancer. Metastatic prostate cancer, which prostate cancer. In the largest single institutional Mayo is the precursor of most deaths from the disease, is treated series on radical prostatectomy in cT3 disease the main most commonly with hormonal therapy. Generally the pri- intraoperative complication was rectal injury (1,6%), which mary tumor is never treated. There is evident that control- was closed primarily in all cases with no need for colosto- ling other primary neoplasms affects patient survival, for my [4]. Hospitalized blood transfusion was required in 29%. example in cases ovarian or breast cancer. But, there are After RP, 75% of the reporting patients had no erectile few data on the role of radical prostatectomy in the man- function, reflecting the infrequent use of a nervesparing agement of metastatic prostate cancer. Bader et al report- technique (26%). Urinary continence at 1 year was ing on 367 patients with clinically organ confined pros- achieved in 79% of men, with few (6%) having severe uri- tate cancer, which have been underwent meticulous pel- nary incontinence (≥2pads/day). Bladder neck contrac- vic lymph node dissection and radical prostatectomy [2]. ture occurred in 11,2% and urethral stricture in 3,2% of the None of the patients received immediate adjuvant thera- men. Davidson et al. prospectively analyzed 188 consecu- py. Of the patients 92 (25%) had histologically proven tive RP and found no significant difference in complication lymph node metastases. Median follow up was 45 months. rates for patients with cT3 and clinically localized disease Time to prostate specific antigen relapse, symptomatic [21]; the overall mortality rate was 1,5%. Of those men with progression and tumor related death were significantly 1 year of follow-up, 5,9% remained with some incontinence affected by the number of positive nodes. The authors and 32% had narrowing of the anastomosis requiring dilata- concluded that meticulous pelvic lymph node dissection, tion, and potency was retained in 43%. Thus RP is quite particularly in patients with micrometastases, seems not save procedure in high-risk prostate cancer patients. only to be a staging procedure, but may also have a positive impact on disease progression and long-term dis- RT vs. RP in cases of high risk prostate cancer. Although ease-free survival. Serni and coauthors reporting on 45 there are no prospective randomized studies comparing lymph-node positive men treated with RP and adjuvant the effectiveness of radiation therapy and radical prosta- HT. The 3 and 5 years survival where quite high – 72,6% tectomy, some nonrandomized studies are available. Ku- and 60,5% respectively [5]. pelian and coauthors have compared the effectiveness of RT and RP [22]. They presented the analysis of 1,865 con- Patients with clinical T4 undergo radical prostatectomy secutive patients treated in the Cleveland Clinic Founda- infrequently. Although generally, it is not considered ef- tion. No adjuvant therapies where used following the local fective in rendering a cure, surgery sometimes is performed treatment. The data clearly shows that treatment dose bel- either to enhance the local control or to “debulck” the low 72 Gy should be considered as inadequate to control lesion. There is a lack of information regarding the out- the localized disease. But RT with treatment doses over 72 comes of RP in Patients with cT4. In this regard grate inter- Gy was almost so effective as RP in high risk group [16, est represents the data presented by Jonstone et al., which 22]. However the comparison of recurrence free survival comparing the effectiveness of RP with the other treat- after RP and RT is difficult because of absent of reliable ment options in1089 patients with clinically T4 disease failure definition after RT. When PSA cutpoint of 0,5 ng/ml [20]. The patients who undergo RP for cT4 prostate cancer was used as the sign of cancer recurrence in high risk may have increased 5 year survival (72,6%) compared with group, not excluding cases with neoadjuvant HT, then RP patients who receive RT alone (61,8%) or HT (41,5%) and produced the better results compared with RT in univari- their survival is comparable to that achieved by patients ate analysis. Southwest Oncology Group (Study 8894) ex- who receive combined RT and HT (71,1%). However the amined the impact of radical prostatectomy and radiother- benefit of RP appears to be limited to a relatively small apy on the outcome in patients with metastatic prostate subset of patients who have regional lymph node exten- cancer in the context of a randomized clinical trial [23]. The sion. Interestingly, adjuvant therapy does not appear to group randomized 1,286 men with metastatic prostate can- improve survival for patients after RP for cT4 prostate cancer to orchiectomy and placebo or orchiectomy and fluta- cer. Also, of 72 men with clinically T4 PC, which underwent mide. The impact of previous radical prostatectomy or ra- to RP, in 24 (33%) cases the pathologic stage was down- diotherapy on survival was studied. Previous radical pros- graded to T3 disease. tatectomy in patients with metastatic prostate cancer was associated with a statistically significant decrease in the These data is showing, that selected patients with T4 pros- risk of death (hazard ratio 0,77) relative to those who did tate cancer and subclinical metastatic disease can benefit not undergo earlier prostatectomy. Surprisingly, conversely of radical prostatectomy. Also not really preoperative over- previous radiotherapy was associated with 22% greater risk staging takes place, while clearly this misclassification is of death relative to those who had previously undergone not limited only to surgical patients, rather surgical pa- prostatectomy. The study raises the question of whether tients represent only group for which the accuracy of clin- control of the primary tumor impacts the ultimate outcome ical staging can be evaluated. in patients with advanced prostate cancer. However, it must

be stressed that this intriguing observation was a second- clinical trials comparing the effectiveness of RT and RP ary analysis of a phase III study. That is why this observa- with adjuvant HT. tion must be replicated in other data sets before patients with advanced cancer alter their treatment decision. Historically, chemotherapy has not been viewed as having a crucial role in the management of patients with pros- The presented data rising the judgments, pros and cons tate cancer. The failure of a variety of regimens to show for RT and RP. Eliminating the prostate might reduce the significant responses and survival benefits in the hormone- potential for late dissemination of radioresistant prostate refractory population led many researchers to believe that cancer cells and simplify the use of serum PSA levels in chemotherapy should not be considered standard for ad- the follow-up. For about quarter of patients who are over- vanced prostate cancer patients, with the exception of staged clinically, it eliminates the over treatment of organ- participation in clinical trials for select patients. However, confined disease with combined hormonal and radiothera- recently have been shone that Taxans, particularly Do- py, which is the current standard treatment for cT3 dis- cetaxel, improves survival in patients with hormone-refrac- ease. With close follow-up and serial PSA measurements, tory prostate cancer. The drug binds to tubulin, stabilizes the remaining patients harboring pT3 disease may avoid microtubule formation and inhibits depolymerization. Al- castration and the deleterious effect that this has on qual- though the survival benefit was a modest 2 months, the ity of life, until the PSA becomes detectable [4]. On the results hold the promise that docetaxel based treatment in other hand, patients with N+ disease, which unless bulky earlier-stage disease may provide a longer survival advan- is difficult to detect with modern imaging techniques, can tage because it is clear from other tumors, notably colon initiate early HT, which has been found to improve surviv- and breast cancer, that agents active in the metastastic al over delayed HT in patients with N+ disease [24]. Oppo- setting can prove to be even more beneficial when used in nents of surgical treatment have cited a lack of benefit if patients with earlier stage disease [28-30]. the prostate is not completely excised, an increased incidence of micro metastasis, and increased surgical morbid- Also, the mitoxantrone (which also acts on cell microtubuls) ity. Wide-field irradiation has therefore become the stand- and either prednisone or hydrocortisone have shone better ard accepted treatment, but as a monotherapy, radiothera- pain-control over steroids alone in patient with hormone- py has had limited long term success [4]. However, it is refractory prostate cancer. Unfortunately the studies did clear that high risk patients do poorly with monotherapy not demonstrate significant impacts on overall survival [29]. of any type and would be best served with multimodal However, the early application of chemotherapeutical regi- therapy in the setting of a clinical trial. mens in high risk prostate cancer patients led to positive influence on survival. Recently Wang and coauthors have Systemic therapy. Many high-risk patients have occult published randomized study comparing adjuvant mitoxantro- metastases at presentation and will not be cured by local ne combined with maximum androgen blockade in high risk therapies alone. Thus because the majority of patients with prostate cancer patients (T3-T4) and in metastatic cases high-risk prostate cancer fail with distant disease, it is clear [31]. For men with localized disease, the median survival that improved systemic therapy is needed in conjunction was longer in the hormonal therapy plus adjuvant mitox- with local treatment. Systemic treatment approaches to the antrone arm than in the hormonal therapy-alone arm (80 vs. patient with high-risk localized prostate cancer can include 36 months). In contrast no survival advantage was seen hormone therapy, chemotherapy and new treatment mo- with mitoxantrone in patients with documented metastatic dalities such as immuno and antiangiogenesis therapies. disease. This result one more suggests a possible role for early initiated chemotherapy in managing newly diagnosed, Androgen ablation is the best studied systemic therapy. high-risk prostate cancer, but the trial was very underpow- Neoadjuvant HT followed by RP has been viewed as a ered and did not include local therapy in either arm. means of increasing cure rates. All 7 published randomized, placebo-controlled trials that included 1400 patients and The abovementioned findings have promoted the initia- compared HT followed by RP with RP alone reported a tion of clinical trials on adjuvant or neoadjuvant chemo- decrease in rates of positive surgical margins, but none therapy to improve the effect of radical prostatectomy in demonstrated any improvement of in biochemical relapse patients with high-risk prostate cancer. The Cancer and free survival or overall survival. Adjuvant HT after radia- Leukemia Group B (CALGB) 90203 studies is phase 3 neo- tion therapy represents the standard treatment for local- adjuvant radical prostatectomy trial designed to assess ly advanced prostate cancer today, however many pa- the role of docetaxel in patients with high-risk localized tients still relapse, develop androgen-resistant disease disease. These trials, along with the Southwest Oncology and eventually die from there disease [24-26]. Adjuvant Group (SWOG) 9921 trial, which will assess the potential HT after radical prostatectomy in high risk prostate can- for adjuvant mitoxantrone, are paving the way for earlier cer cases, eventually it seems mandatory to improve the systemic treatment. Also there are some other running tri- treatment results [27].However there are no randomized als organized by industry.

24 GEORGIAN MEDICAL NEWS No 2 (143) Ôåâðàëü, 2007 ãîä

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Prostate-specific antigen (PSA) value change after antibacterial therapy of prostate inflammation, therapies is changing in favor of early application of the new as a diagnostic method for prostate cancer screening in cases of agents. Whether this approach will result in the improved PSA value within 4-10 ng/ml and nonsuspicious results of digital survival rates needs to be farther investigated. rectal examination / Eur. Urol. - 2001. - N 39(5). - P. 538-43. 9. Karazanashvili G., Abrahamsson P.A. Prostate specific anti- Conclusions: gen and human glandular kallikrein 2 in early detection of pros- The optimum treatment strategy for high risk prostate can- tate cancer // J Urol. - 2003. - N 169(2). - P. 445-57. cer remains unknown. 10. Cramer S.D. et al. 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SUMMARY

IS RADICAL PROSTATECTOMY AN OPTION IN HIGH-RISK PROSTATE CANCER PATIENTS?

Karazanashvili1 G., Muller2 S.

1Tbilisi State Medical University, 2University hospital of Bonn

Long term survival of men with high-risk (T3 and/or prostatectomy in high risk prostate cancer might provide a PSA>20ng/ml and/or Gleason ≥8) prostate cancer is still far better course of action? Systemic review has shone that high from satisfaction. Common treatment options for these pa- risk prostate cancer men can be successfully treated with tients usually include hormonal therapy, radiation therapy or radical prostatectomy. However radical prostatectomy can a combination of both. Radical prostatectomy has not been not be considered as the monotherapy in this cohort of pa- considered as the standard treatment strategy in these cases, tients, but as a part of multimodal treatment, which can in- while the potential for incomplete excision of the local tumor clude radiation, hormonal and chemotherapies. and high incidence of lymph node metastasis. This raises the question under which conditions a properly executed radical Key words: prostate cancer, high-risk, radical prostatectomy.

ÐÅÇÞÌÅ

ßÂËßÅÒÑß ËÈ ÐÀÄÈÊÀËÜÍÀß ÏÐÎÑÒÀÒÝÊÒÎÌÈß ÌÅÒÎÄÎÌ ÂÛÁÎÐÀ Â ËÅ×ÅÍÈÈ ÁÎËÜÍÛÕ ÐÀÊÎÌ ÏÐÅÄÑÒÀÒÅËÜÍÎÉ ÆÅËÅÇÛ ÂÛÑÎÊÎÃÎ ÐÈÑÊÀ?

Êàðàçàíàøâèëè1 Ã.Ã., Ìþëëåð2 Ø.Ê.

1Òáèëèññêèé ãîñóäàðñòâåííûé ìåäèöèíñêèé óíèâåðñèòåò; 2Óíèâåðñèòåòñêèé ãîñïèòàëü Áîííà, Ãåðìàíèÿ

Îòäàëåííûå ðåçóëüòàòû ëå÷åíèÿ áîëüíûõ ðàêîì ïðåäñòàòåëü- æèò âûñîêèé ðèñê íåïîëíîãî óäàëåíèÿ îïóõîëåâîãî îáðàçîâà- íîé æåëåçû âûñîêîãî ðèñêà (Ò3 è/èëè PÑA >20 ìã/ìë è/èëè íèÿ îïåðàòèâíûìè ìåòîäàìè. Â ñâÿçè ñ ýòèì, âîçíèêàåò âîïðîñ ñóììà Ãëèññîíà ≥8) íåóäîâëåòâîðèòåëüíû. Ëå÷åíèå ýòèõ - â êàêèõ ñëó÷àÿõ ðàäèêàëüíàÿ ïðîñòàòýêòîìèÿ ìîæåò îêàçàòü áîëüíûõ îáû÷íî ïîäðàçóìåâàåò ãîðìîíàëüíóþ è ëó÷åâóþ áëàãîïðèÿòíîå âëèÿíèå íà ýôôåêò ëå÷åíèÿ áîëüíûõ ðàêîì ïðî- òåðàïèþ èëè êîìáèíàöèþ ýòèõ äâóõ ìåòîäîâ. ñòàòû âûñîêîãî ðèñêà? Ñèñòåìíûé àíàëèç ëèòåðàòóðû ïîêàçû- âàåò, ÷òî ðàäèêàëüíàÿ ïðîñòàòýêòîìèÿ ìîæåò óñïåøíî ïðèìå- Ðàäèêàëüíàÿ ïðîñòàòýêòîìèÿ äî íàñòîÿùåãî âðåìåíè íå ðàñ- íÿòüñÿ ó áîëüíûõ ðàêîì ïðåäñòàòåëüíîé æåëåçû íå â êà÷åñòâå ñìàòðèâàëàñü ñòàíäàðòíûì ìåòîäîì ëå÷åíèÿ áîëüíûõ ðàêîì ìîíîòåðàïèè, à ñêîðåå êàê ÷àñòü ìóëüòèìîäàëüíîé òåðàïèè â ïðåäñòàòåëüíîé æåëåçû âûñîêîãî ðèñêà. Ïðè÷èíîé òîìó ñëó- ñî÷åòàíèè ñ ëó÷åâîé, ãîðìîíàëüíîé èëè õèìèîòåðàïèåé.

26 GEORGIAN MEDICAL NEWS No 2 (143) Ôåâðàëü, 2007 ãîä

Íàó÷íàÿ ïóáëèêàöèÿ

MORTALITY DIFFERENCES BETWEEN HEMODIALYSIS AND PERITONEAL DIALYSIS AMONG ESRD PATIENTS IN GEORGIA

Tchokhonelidze I.

Department of nephrology, National Centre of Urology

The survival of dialysis patients who reach end-stage re- In addition to the first mode of dialysis to be used for nal disease (ESRD) has improved substantially over the each patient, documentation was made of the date of last decade in Georgia because of advances in dialysis any switch or switches in mode of dialysis that each technology and new peritoneal dialysis solutions. Al- patient underwent. Because the primary objective of though, renal transplantation offers the best hope to pa- the original study was to assess the effect of comor- tients with ESRD, only a small amount of these patients in bidity on survival of patients with end-stage renal dis- Georgia get this opportunity (about 10 living donor- kid- ease, data pertaining to the dose of dialysis was not ney transplantations per year), leaving the majority to re- systematically recorded as part of the study protocol. ceive either hemodialysis or peritoneal dialysis. For these However, in most cases, the volume dialysate used per patients defining the optimal modality strategy at ESRD day by peritoneal dialysis and the number of hours per onset is critical component of patient management to en- week of dialysis for those patients on hemodialysis sure optimal survival. In terms of an individual patient’s was available. abilities, medical problems or geographic location one modality of dialysis is frequently preferable to another, Documentation was made of date of death, renal trans- but still exists controversy regarding which treatment, if plantation, loss of renal function as of January 1, 2007. either, results in greater patient survival times [2,3]. Co- morbidity has an important effect on differences in surviv- Time-dependent Cox regression equations compared the al of peritoneal and hemodialysis patients. So each patient mortality risks of hemodialysis with peritoneal dialysis. had a detailed assessment of comorbid illness prior to his Covariates for adjustment included age, gender, diabetic or her dialysis treatment and was followed until death or status, myocardial infarction, cardiac failure, peripheral end of the study. vascular disease, malignancy. Patient survival times on peritoneal dialysis and hemodialysis were compared at Materials and methods. 210 hemodialysis and 95 perito- successive 12-month intervals during follow-up and cen- neal dialysis patients were enrolled in this study who un- sored at death, transplantation or at the end of 3 years derwent dialysis treatment in the nephrology department whichever came first. All statistical tests are two-tailed, of national centre of urology in Tbilisi between January with a P value of less than 0,05 taken to indicate statisti- 2004 and December 2006. A detailed description of each cal significance. patient’s diagnosis and clinical status was recorded on a standard form. The following data were collected at study Results and their discussion. Three hundred and five entry: initial mode of dialysis (hemodialysis or peritoneal patients were enrolled in this study. Peritoneal dialysis dialysis), date of first dialysis for end-stage renal disease, was used by 9% of patients as baseline, 21 % at twelve original renal disease, pattern of onset of renal failure months and 26,5 % at twenty four months. The mean (acute, acute-on-chronic, or chronic), age, sex, presence follow-up was 24 months, with a maximum follow-up time and duration of diabetes, presence of a treated arrhythmia, of 36 months. presence of history of angina, presence of history of myocardial infarction, presence of history of congestive heart Table 1 indicates the characteristics at study entry failure, presence or history of peripheral vascular disease, according to the initial mode of dialysis therapy. The presence of chronic lung disease, presence of cerebral dis- spectrum of original cause of renal failure was similar ease, presence of liver disease, presence of malignancy, in both groups of patients at baseline, although a serum albumin, weight, height, clinical impression of mal- higher proportion of peritoneal dialysis patients had nutrition, presence of systemic sepsis. These comorbidity diabetes mellitus (38,1% vs. 23,4% p=0,005) and more data were used to calculate a prognostic score for patients hemodialysis patients had their etiology classified as starting maintenance dialysis therapy. This score incorpo- unknown (36% vs. 12% p=0,01). Difference were rated an individual patient’s age, hypertension, cardiac present in the proportion of patients with acute-on failure, coronary artery disease, arrhythmia, malignancy, chronic onset of renal failure, myocardial infarction peripheral vascular disease. and cardiac failure.

Table 1. Characteristics at study entry according to first modality of dialysis used Variable Hemodialysis (n=210) Peritoenal dialysis (n=95) Male (%) 59,0 48,0 Diabetes (%) 23,4 38,1 Acute or acute-on-chronic onset (%) 12,9 2,6 Cardiac failure (%) 28,6 18,2 Myocardial infarction (%) 14,3 3,2 Peripheral vascular disease (%) 16,7 9,8 Malignancy (%) 5,4 4,7 Arrhythmia (%) 9,1 3,1 Age (years) Body mass index (kg/m²) 53±15 51±12 Hemoglobin (g/dl) 25,7±4,5 24,3±2,5 Diastolic blood pressure(mmHg) 10,0±1,5 9,8±1,7 Systolic blood pressure (mmHg) 85,3±15,1 82,5±10,5 The total comorbidity 150,5±20,5 145,5±15,5 3,6±0,2 3,1±0,2 Etiology of renal failure (%) Glomerulonephritis (primary or secondary) 32,5 31,5 Diabetes 23,4 38,1 Hypertension 7,5 5,5 Polycystic kidney 5,1 1,9 Tubulointerstitial disease 12,5 2,0 Other 9,0 7,0 Unknown 10,0 14,0

The total comorbidity was higher in hemodialysis com- day was 8,0 L/day, but for patients without residual renal pared to peritoneal dialysis patients at baseline (3.6, 95% function 10,0 L/day. CI, 3.4 to 3.8 vs. 3.4, 95% CI, 3.2 to 3.6, p<0,005),12 months (3.5, 95% CI,3.3 to 3.7 vs. 3.3, 95% CI, 3.1 to 3.5, p=0,001, Overall mortality was 12,1%. 5,5% of the patients in the co- p<0,005) and 24 months (3.3, 95% CI, 3.1 to 3.5 vs. 3.1, 95% hort underwent renal transplantation within the study period. CI, 2.9 to 3.3, p<0,009; fig. 1). Table 2 indicates the principle outcomes according to the mode of dialysis in use in 2004, 2005 and 2006. The mortality was similar in the groups defined by the mode of dialysis.

Analysis of the cause of death showed no differences between hemodialysis and peritoneal dialysis patients: 78,3±2,1% died of cardio-vascular and cerebro-vascular complication in hemodialysis paitents vs. 74,3±2,2,% peritoneal dialysis patients (p<0,001), 14,1±1,6% died of sepsis in hemodialysis group vs. 15,1±2,2% in peritoneal dial- Fig. 1. Total comorbidity score values for patients on ysis group (p<0,002 ); 5,4±1,1% died of malignancy in he- peritoneal dialysis versus hemodialysis according to the modialysis group vs. 4,7±1,2% in peritoneal dialysis patients modality in use at baseline, 12 months and 24 months (p<0,01), and 2.6±0,25% - unknown reason in both groups. The cause of switch from hemodialysis to peritoneal dialy- For hemodialysis patients the mean number of hours per sis was poor vascular access, and from peritoneal dialysis week of treatment was 12,5 h/week; for peritoneal dialysis to hemodialysis - treatment resistant peritonitis. patients the mean volume of dialysis solution used per

Table 2. Principal outcomes according to modality of dialysis used in 2004, 2005 and 2006 2004 2005 2006 Outcome HD(N=165);PD(n=28) HD(N=163);PD(n=64) HD(N=181);PD(n=81) Death 13 (7,8%) 2 (7,1%) 7 (4,3%) 3 (4,6%) 9 (4,9%) 3 (3,7%) p =0,001 =0,001 NS Renal Transplant 3 (1,8%) 1(3,5%) 6 (3,7%) 0 6 (3,3%) 1(1,2%) p =0,001 NS NS Switch of therapy 1(0,6%) 2 (7%) 1(0,6%) 2 (3%) 1(0,5%) 2 (2,5%) p NS NS NS Abbreviations are: HD, hemodialysis,; PD, peritoneal dialysis; NS, difference nor statistically significant

28 GEORGIAN MEDICAL NEWS No 2 (143) Ôåâðàëü, 2007 ãîä

The adjusted Cox survival curves for peritoneal dialysis curves, indicate to not significant difference in survival and hemodialysis-treated patients in diabetic and non-di- between the hemodialysis and peritoneal dialysis patients. abetic patients as shown in Figure 2, was not significantly poorer for peritoneal dialysis compared with hemodialysis Because this study is not a randomized trial, there are ob- during the follow-up time. viously many differences contributing to selection bias in dialysis modality choice that cannot be adjusted for. Dif- ferences in socioeconomic status, education, family supports and patients attitudes are examples of variables that likely influence patient outcomes, but that are not account- ed in our study. Also, the current study was not designed to investigate the influence of dialysis adequacy. Data pertaining to this were not systemically collected as part of the study protocol. Even if adequacy data were available, it would not be simple matter to compare dialysis dosage data for hemodialysis and peritoneal dialysis given the fundamental differences in solute clearance and adequacy measurements. Fig. 2. Adjusted Cox survival curves for ESRD diabetic and non-diabetic patiens treated with peritoneal dialy- Based on the results of the study, it is to conclude that: sis vs. hemodialysis 1.hemodialysis and peritoneal dialysis, as two different modalities of renal replacement therapy in the patients with In this 36 months follow-up study of 305 patients is dem- ESRD, are associated with similar overall survival rates; onstrated, that there are not a significant mortality differ- and 2. the apparent survival advantage of peritoneal dial- ences between peritoneal dialysis and hemodialysis. When ysis may be due to lower comorbidity and a lower burden comorbidity was taken in account, there was no survival of acute onset ESRD at the inception of dialysis. advantage associated with either therapy. These data correlates with the data of Murphy et al [4], who in the cohort REFERENCES of Canadian dialysis patients has shown, that comorbidity has an important effect on differential survival in hemodi- 1. Bloembergen W., Port F.K., Mauger E.A. et al. A comparison of alysis and peritoneal dialysis patients and that advantage mortality between patients treated with hemodialysis and perito- of peritoneal dialysis is due to lower comorbidity. neal dialysis // J Am Soc Nephrol. - 1995. - N6. - P. 177-183. 2. Foley R.N., Parfrey P.S. et al. Mode of dialysis therapy and In the study of Bloembergen et al [1], was reported a high- mortality in end-stage renal disease // J Am Soc Nephrol. - 1998. er risk of death in patients treated with peritoneal dialysis - N9. - P. 267-76. 3. Gokal R., Jakubowski C. et al. Outcome in patients on contin- relative to hemodialysis. May be the main cause of it was uous ambulotary peritoneal dialysis and hemodialysis: 4-Year the poor water control, which increases the risk of cardio- prospective analysis of a prospective multicenter study // Lan- vascular disease in peritoneal dialysis patients. The same cet. - 1987. - N2. - P. 1105-9. results were in our department, during the observation time 4. Murphy S.W., Foley R.N. et al. Comparative mortality of between 1999 –2002, before inserting the glucose polymer- hemodialysis and peritoneal dialysis in Canada // Kidney Int. – containing solution, Icodextrin 7,5%, in peritoneal dialysis 2000. – N57. – P. 1720-6. treatment modality. The advance in peritoneal dialysis tech- 5. Vonesh E.F., Moran J. Mortality in end-stage renal disease: A nology and more accurate prescription of treatment – tailor- reassessment of differences between patients with hemodialy- ing the solute types and the number of exchanges accord- sis and peritoneal dialysis // L Am Soc Nephrol. - 1999. – N10. - P. 354-65. ing to patients peritoneum transport modality and adequacy, has dramatically improved the outcome of peritoneal di- SUMMURY alysis patients. Of course, peritonitis is still the main cause of switching the patients from one modality of dialysis to MORTALITY DIFFERENCES BETWEEN HEMODIALY- another. But the survival was the similar in the both modal- SIS AND PERITONEAL DIALYSIS AMONG ESRD PA- ities of renal replacement therapy, which was more effected TIENTS IN GEORGIA by the comorbidity in each individual. Tchokhonelidze I. Vonesh et al [5] suggested that younger diabetics on peri- Department of nephrology, National Centre of Urology toneal dialysis do better and older diabetics on peritoneal dialysis do worse compared to their hemodialysis coun- Comparisons of mortality rates in patients with end-stage renal terparts. Our results, as was shown by the age, sex, myo- disease (ESRD) on peritoneal dialysis and hemodialysis have cardial infarction and malignancy adjusted Cox survival been inconsistent. The aim of the study was to reveal the possi-

© GMN 29 ÌÅÄÈÖÈÍÑÊÈÅ ÍÎÂÎÑÒÈ ÃÐÓÇÈÈ CFMFHSDTKJC CFVTLBWBYJ CBF[KTYB ble effect of comorbidity on differential survival in these two mortality was similar in the groups defined by the mode of dialysis. groups. 210 hemodialysis and 95 peritoneal dialysis patients Based on the results of the study, it is to conclude that, hemodialy- were enrolled in this study who underwent dialysis treatment in sis and peritoneal dialysis, as two different modalities of renal re- the nephrology department of national centre of urology in Tbi- placement therapy in the patients with ESRD, are associated with lisi between January 2004 and December 2006. Peritoneal dial- similar overall survival rates in Georgia. The apparent survival ad- ysis was used by 9% of patents as baseline, 21 % at twelve vantage of peritoneal dialysis may be due to lower co-morbidity months and 26,5 % at twenty four months. The mean follow-up and a lower burden of acute onset ESRD at the inception of dialysis. was 24 months, with a maximum follow-up time of 36 months. The total co-morbidity was higher in hemodialysis compared to perito- Key words: end-stage renal disease, hemodialysis, peritoneal neal dialysis patients at baseline, 12 months and 24 months. The dialysis, comorbidity, dialysis mortality.

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Íàöèîíàëüíûé öåíòð óðîëîãèè èì. À. Öóëóêèäçå, îòäåëåíèå íåôðîëîãèè

Èìåþòñÿ âçàèìîèñêëþ÷àþùèå äàííûå î ÷àñòîòå ñìåðòíîñòè ïåðèòîíåàëüíîì äèàëèçå ñîñòàâëÿëî 9% îò îáùåãî êîëè÷åñòâà ñðåäè ïàöèåíòîâ ñ õðîíè÷åñêîé ïî÷å÷íîé íåäîñòàòî÷íîñòüþ, íàáëþäàåìûõ ïàöèåíòîâ, ïî èñòå÷åíèþ 12 ìåñÿöåâ - 21%, à ÷å- íàõîäÿùèõñÿ íà ãåìîäèàëèçå è ïåðèòîíåàëüíîì äèàëèçå. Öå- ðåç 24 ìåñÿöà – 26,5%. Ñðåäíåå âðåìÿ íàáëþäåíèÿ ñîñòàâèëî ëüþ äàííîãî èññëåäîâàíèÿ ÿâèëîñü îïðåäåëåíèå âîçìîæíî- 24 ìåñÿöà, ìàêñèìàëüíîå – 36 ìåñÿöåâ. Îáùèé ïîêàçàòåëü êî- ãî âëèÿíèÿ ñîïóòñòâóþùèõ çàáîëåâàíèé, ò.å. êîìîðáèäíîñòè ìîðáèäíîñòè áûë âûøå ó ïàöèåíòîâ, íàõîäÿùèõñÿ íà ëå÷åíèè íà âûæèâàåìîñòü áîëüíûõ â âûøåóêàçàííûõ ãðóïïàõ. Â èñ- ãåìîäèàëèçîì ïî ñðàâíåíèþ ñ áîëüíûìè íà ïåðèòîíåàëüíîì ñëåäîâàíèå áûëî âêëþ÷åíî 210 ãåìîäèàëèçíûõ ïàöèåíòîâ è äèàëèçå â íà÷àëå, ñïóñòÿ 12 è 24 ìåñÿöåâ. Ïîêàçàòåëè ñìåðòíî- 95 ïàöèåíòîâ, íàõîäÿùèõñÿ íà ëå÷åíèè ïåðèòîíåàëüíûì äèà- ñòè â îáåèõ ãðóïïàõ áûëè îäèíàêîâûìè. Ïîëó÷åííûå äàííûå ëèçîì â íåôðîëîãè÷åñêîì îòäåëåíèè Íàöèîíàëüíîãî öåíòðà óêàçûâàþò íà îäèíàêîâóþ âûæèâàåìîñòü ïàöèåíòîâ ñ òåðìè- óðîëîãèè. Âðåìÿ íàáëþäåíèÿ èñ÷èñëÿëîñü ñ ÿíâàðÿ 2004 ã., íàëüíîé ïî÷å÷íîé íåäîñòàòî÷íîñòüþ, íàõîäÿùèõñÿ íà ëå÷åíèè âêëþ÷àÿ äåêàáðü 2006 ã. Áàçèñíîå êîëè÷åñòâî ïàöèåíòîâ íà ãåìîäèàëèçîì è ïåðèòîíåàëüíûì äèàëèçîì.

Íàó÷íàÿ ïóáëèêàöèÿ

DYNAMICS OF THE PROTEIN SPECTRUM CHANGES IN BLOOD ERYTHROCYTES OF MALE PATIENTS WITH PROSTATE ADENOCARCINOMA AFTER PLASTIC ORCHECTOMY

Veshapidze N., Alibegashvili M., Chigogidze T., Gabunia N., Kotrikadze N.

Departments of Exact and Natural Sciences and Medicine, Iv. Javakhishvili Tbilisi State University One of the most important issues of modern oncology cytes, decrease in the level of glutathione and ATP, the is the search of specific characteristics which reflect quantitative changes of cholesterol and activation of lipid process of cancerogenesis in the organism. One of such oxidation processes might cause disorders in cytoskeleton directions is the investigation of erythrocytes in the protein components and various kinds of molecular chang- peripheral blood. es in membrane proteins. The later will have a negative effect on erythrocytes deformation ability, on their functional It is well known that the best determinant of erythrocyte activity and on their life duration. On the other hand these membrane viscosity and plasticity is the cytoskeleton [1]. It changes may cause important disorders in cellular homeos- is also known that some metabolic disorders in erythro- tasis and development of some pathological processes [12].

30 GEORGIAN MEDICAL NEWS No 2 (143) Ôåâðàëü, 2007 ãîä

Studies done on male patients with prostate adenocarci- Protein fraction of 95 KD molecular weight was found both noma (CaP) (before orchectomy) reveal essential changes before and after orchectomy and in the control group 90 in erythrocytes structural, functional and morphological KD protein fraction was observed as well (fig.). parameters. Therefore it was interesting to determine whether these morpho-structural and functional parame- It is known that 90 KD molecular weight protein fraction ter changes in erythrocytes somehow affect the plastic corresponds to the 3rd protein line, which is one of the orchectomy. For this purpose the membrane protein spec- important components of cytoskeleton and participate in trum was studied and comparative analyses of given re- anion transportation (chloride - bicarbonate inorganic phos- sults with preoperational data was done. phate anyone transportation). Besides this, it is known that the protein of the 3-rd line plays an important role in Material and methods. For experimental research blood the erythrocytes metabolism and also helps erythrocyte erythrocytes of 15 male patients with prostate adenocarci- to maintain its shape [5]. Also relationship of the 3-rd line noma before and after plastic orchectomy and the 15 prac- protein-protein and protein-lipid interactions plays an im- tically healthy men (control group) 60-75 years of ageold portant role in maintaining stability in cytoskeleton struc- were studied. The stage of disease was diagnosed in the ture [14]. Correspondingly, destabilization of cytoskele- Georgian National Centre of Urology after histological and ton could take place in case when protein–protein and ultrasound tests. protein-lipid interactions are destroyed and also when some molecular anomalies are found in the 3-rd line of protein Revealing of the erythrocytes membrane was performed fraction [5]. Destabilization of cytoskeleton clinically is by Hast‘s method [4]. Protein concentration was detected exposed by the erythrocytes changed shape. In some cas- by method of Lowry [10]. Electrophoresis of the proteins es defect of the 3-rd line proteins of various changes in in dissociation conditions was performed at 10-25% gradi- anion transportation processes is observed in lipid layer ent of polyacrilamide gel, with 0,1% natrium disulfate (sds) [7]. If we’ll take into account all mentioned above hypoth- using system “Lammli”[9]. Electrophoresis was performed esis, that in CAP-case erythrocytes 95 protein fraction of by “Hoefer scientific instruments SE-200” device during molecular weight both before and after orshestomy (fig.) 3,5 hours. Gel was stained by Cumassie Blue G-250). The might be the damaged from of 3-d line protein, contrary to following markers of were used for electrophoresis: Thy- this in the control group molecular weight has been in- reoglobulin (330KD), Katalaze (60KD), Lactatdehydro- creased (Mr.=95 KD) and its damage might be attributed to genaze (36KD), Pheritin (18,5KD). the disorders in erythrocytes membranes and also it will point to some changes in transportation mechanism in the Results and their discussion. Experiments showed that 3-rd line protein [7]. One of the proves of this hypothesis after plastic orchectomy, separation of by electrophore- is that, in case of CaP, both before and after orchectomy, sis of erythrocyte membrane bands of protein compo- along with decreased number of normocytes we observed nents were existed. The bands corresponding to eryth- increase in accantocytes percentage compared to the con- rocyte membrane protein components were numerated trol group [15]. in gel according to their disposition from cathode to anode: 95KD, 80KD, 48 KD, 36 KD, 28 KD, 24 KD and The second protein fraction, which was found after 18 KD protein fractions according to their molecular plastic orchectomy in erythrocytes cytoskeleton is 80 weight (fig.). KD molecular weight protein, this was also found in control group and in CaP patients (before orchectomy) (fig.). It is known that 80 KD molecular weight protein fraction corresponds to 4,1 protein line basic isophorm (4,1 a;). This protein is globular protein that occupies 5% of erythrocytes cytoskeleton protein weight and in complex with 4.1 protein line isophorm (4,1b; Mr. =78 KD) plays an important role in maintaining stability of membrane [2]. It is established that 80 KD protein fraction of molecular weight corresponds to 4.2 protein line (palidin) isophorm (4,21; Mr.=80 KD), which regulates structure stability and1 plasticity of cytoskeleton’s protein, it is also responsible for erythrocytes shape and ability of deformation [11,13]. A lot Fig. Electrophoreogram of blood erythrocyte membrane of data revealed that 4,2 protein line molecular defects proteins, in 10-25% Polyacrylamide gel with Sodium or its deficit coincides with the 3-rd protein anomalies dodecylsulphate; a - control group; b - CaP (before or- and clinically is exposed by appearance of shaped chechtomy); c - CaP (after orchechtomy) changed cells in peripheral blood – appearance of path-

ological shaped erythrocytes and increase in their tein fraction, should be the signal that organisms con- number. From all said above we can suggest that 80 dition is improving at this stage of post operational pe- KD protein fraction of molecular weight, which was riod (~ 4-6 month after operation) and so progression of found in control group (fig.) may be regarded as 4.1 disease is lowered. Considering the fact that it is impos- protein line basic isophorm or 4.2 protein line basic iso- sible to get absolute recovery of patient after plastic phorm, thought in both cases 80 KD molecular weight orchectomy we can suppose that disappearance of 35 protein fraction web and the shape maintenance of eryth- KD molecular weight protein fractions in erythrocyte rocytes. As for CaP (before and after orchectomy ) (fig.) membranes and exposure of 36 KD molecular weight in given pathology 80 KD molecular weight protein frac- protein fractions (different from control group and sim- tion might be 4.1 protein line basic isophorm (4,1a), be- ilar to CaP case) after plastic orchectomy will be due to cause in case of CaP, the 3-rd line proteins molecular postoperative period. defect (which was exposed in given pathology) causes the deficit of 4,2 line protein which by its part is ex- On the electophoregram of erythrocytes 35 KD molecu- posed in erythrocytes shape changes, that is also lar weight protein fraction corresponds the 6-th line pro- proved our experiments. Particularly, in CaP-case, as be- tein (gliceroldehid-3-phospate dehidrogenaze) the given fore so after orchectomy, we observed a substantial in- protein is an enzyme of glycogen and participates in ox- crease in the percentage of shape changed pathological idation process of hemoglobin, accordingly in CaP-case, erythrocytes compared to control group [15]. as before so after orchectomy, the lost of this protein might point to the suppression of erythrocytes metabo- Concerning 48 KD molecular weight protein fraction, which lic activity. was found in the erythrocyte membrane cytoskeleton after plastic orchectomy experiments reveal that it was spe- As for 36 KD molecular weight proteins, this protein cific only for control group and was not found in CaP case fraction participates in the process of normal cell trans- (before orchectomy) (fig.). formation into tumor cells, and are also called tumor marker proteins , That is also proved by our studies. It’s established that usually erythrocytes membrane Experiments that were done in previous years revealed includes 48 molecular weight protein fractions (4,9 line that 36 KD molecular weight protein fraction was fixed protein). This is phosphoprotein which provides the in benign prostate tumor (BHP) and CaP-case. Accord- interaction between spectrin and action and affects ingly after plastic orchectomy exposure of mentioned their polymerization ratio. Besides the fact, that there protein fraction on the erythrocytes electophoregramy is practically nothing known about the function of during post operation period might be regarded as a above mentioned protein fraction, some authors sug- risk factor for hormone-resistant tumor’s further progest that this protein fraction participate in the proc- gression. esses that strengthen cytoskeletons protein web [3], corresponding 4,9 lines protein disappearance in pa- As it is seen from the screen of erythrocytes electrophore- thology might provide decreasment of stability in sis, in CaP-patients after plastic orchectomy (as before erythrocytes membrane. orchectomy) 28 KD, 24KD and 18 KD lower molecular weight protein fractions are exposed. Considering all said above, it can be suggested that in the cytoskeleton of erythrocyte membranes after plastic or- It is established that hemoglobin is a precursor of low chectomy, 48 KD molecular weight 4.9 protein exposure molecular weight peptides. So far more than 150 biolog- will point to the stability of erythrocytes membranes, that ically active peptides have been studied [8], thus it has by its part in case of pathology will point to the similarly of not been yet revealed if all correspondingly is due to the erythrocytes electrophoresis picture. The fact-that 120 low molecular peptide formation. One of the most dam- KD molecular weight protein fraction was not exposed in aging and at the same time regulative factors in erythro- erythrocyte cytoskeleton after plastic orchectomy, which cytes membrane is activation of lipid oxidation process- was specific only for CaP-case (before orchectomy) and es. It’s known that intensification of lipid oxidation caus- was not exposed in control group, might prove our sug- es the destruction processes in erythrocytes membrane. gestion (fig.). It is known that the intensification of lipid oxidation processes causes acceleration of erythrocytes mem- As it is known normally 120 KD molecular weight pro- brane destruction. Particularly, in the lipid hydrophobic tein is not found in erythrocytes membranes cytoskele- layer creation of hydroxide polar groups destroys inter- ton. It is established also that mentioned protein frac- action between phospholipids and permeability of mem- tion is exposed only in tumor pathologies. Concluding brane. So the enhancement of lipid oxidation processes from all said above we suggest that after plastic orchec- causes changes not only in phospholipidal but also in tomy, disappearance of 120 KD molecular weight pro- membrane proteins and this ends with polymerization

32 GEORGIAN MEDICAL NEWS No 2 (143) Ôåâðàëü, 2007 ãîä of proteins. The later causes an activation of membrane 6. Jarolim P., Palek J., Amato D., Hassan K., Sapak P., Nurse protease and is the reason of hemoglobin degeneration G.T., Rubin H.L., Zhai S., Sahr K.E., Liu S.C. Deletion in [8] considering all said above there is a possibility that erythrocyte band 3 gene in malaria-resistant Southeast Asian in CaP-patients (as before so after orchectomy) low ovalocytosis // J. Proc. Natl. Acad. Sci. USA. – 1991. - vol. 88. - P. 11022-11026. molecular weight protein fraction that was exposed on 7. Kay M.M., Bosman G.J., Lawrence C. Functional topogra- erythrocytes electrophorogram, might be regarded as phy of band 3: specific structural alteration linked to functional dismembered proteins, mainly hemoglobin fragments, aberrations in human erythrocytes // J. Proc. Natl. Acad. Sci. that appear after protein polymerization and responsi- USA. – 1988. - vol. 85. - P. 492-496. ble for this is an activation of lipid oxidation process in 8. Klenova N.A., Elistratova O.J. Polyakova J.L. Formation of erythrocytes. peptides connections in erythrocytes after oxidative stress // J. “Vestnik”. – 2004. - vol. 5. – P. 163-169. The low molecular weight proteins normally are not char- 9. Laemmli V. K. Cleavage of structural proteins during assem- acteristic for specific erythrocyte membranes and they are bly of the head of bacteriophage T4 // J. Nature. – 1997. - vol. 227. - P. 680-685. mainly found in aged erythrocytes-accantocytes. Our ex- 10. Lowry O.H., Rosebrough N.J., Farr A.L., Randall R., j. Pro- periments prove the given hypothesis. Particularly in CaP- tein measurement with the Folin phenol reagent // J. Biol. Chem. patient, as before so after orchectomy compared to con- – 1951. - vol. 193. - P. 265-275. trol group essential increase in accantocytes percentage 11. Marchesi S.L., Conboy J., Agre P., Letsinger J.T., of peripheral blood was observed [15]. Marchesi V.T., Speicher D.W., Mohandas N. Molecular analysis of insertion/deletion mutations in protein 4.1 in ellip- It is supposed that normalization of erythrocytes electro- tocytosis. I. Biochemical identification of rearrangements in phoresis screen and its similarity to the control group (dis- the spectrin/actin binding domain and functional characteri- appearance of 120 KD molecular weight and 48 KD molec- zations // J. Clin. Invest. – 1990. - vol. 86. - P. 516-523. 12. Palek J., Sahr K.E. Mutations of the red blood cell ular weight appearance) at this stage of post operational membrane proteins: from clinical evaluation to detection period (~ 4-6 month after operation) might be regarded as of the underlying genetic defect // J. Blood. – 1992. - vol. general improvement in patients organism. 80. - P. 308-330. 13. Sung L.A., Chien S., Fan Y.S., Lin C.C., Lambert K., Zhu Thus, according to obtained results and existed literature L., Lam J.S., Chang L.S. Human erythrocyte protein 4.2: iso- we tried to represent all changes and all molecular defects form expression, differential splicing, and chromosomal as- in erythrocyte protein spectrum that take place in CaP men signment // Blood. – 1992. - vol. 88. - P. 11022-11026. patients after plastic orchectomy, this gives us an oppor- 14. Tanner M.J. Molecular and cellular biology of the eryth- tunity to study more details the function of separate pro- rocyte anion exchanger (AE1) // J. Semin Hematol. – 1996. - vol. 30. - P. 34-57. tein fractions. Given results can be used in practical med- 15. Veshapidze N., Khutsishvili E., Alibegashvili M., Cx- icine, as one of the additional diagnostic test to reveal omelidze M., Artsivadze K., Chigogidze T., Managadze L., progressive tumor in postoperative period. Zurabashvili Z., Kotrikadze N. Dynamics of alterations of some structural indices in the erythrocytes in the men, with REFERENCES prostate adenocarcinoma foloving plastic orchectomy // J. Proc. Georgian Acad. Sci.,Biol. – 2002. - Ser.A - vol. 30. - 1. Chasis J.A., Mohandas N. Erythrocyte membrane Deform- N4. - P. 477-487. ability and stability: twodistinct membrane properties that are independentlyregulated by skeletal protein associations // J. Cell SUMMARY Biol. – 1986. - vol. 105. - P. 343-350. 2. Conboy J., Marchesi S., Kim R., Agre P., Kan YW., Mohan- DYNAMICS OF THE PROTEIN SPECTRUM CHANGES das N. Molecular analysis of insertion/deletion mutations in IN BLOOD ERYTHROCYTES OF MALE PATIENTS protein 4.1 in elliptocytosis. II. Determination of molecular WITH PROSTATE ADENOCARCINOMA AFTER PLAS- genetic origins of rearrangements // J. Clin. Invest. – 1990. - vol. 86. - P. 524-530. TIC ORCHECTOMY 3. Goodman S.R., Shiffer K.A., Casiria L. et.al Identification of the molecular defect in the erythrocyte membrane skeleton of Veshapidze N., Alibegashvili M., Chigogidze T., Gabu- some kindreds with hereditary sperocytosis // J. Blood. – 1982. nia N., Kotrikadze N. - vol. 60. - P. 772-784. 4. Hast I., Iliva I., Effect on the erythrocytes of the Ca2+/Mg Departments of Exact and Natural Sciences and Medi- 22+ -ATP-ase activity // J Molecular and Cellular Biochemis- cine, Iv. Javakhishvili Tbilisi State University try. – 1989. - vol. 1. - P. 87-93. 5. Ideguchi H., Okubo K., Ishikawa A., Futata Y., Hamasaki We have studied erythrocytes electrophoresis profiles in pa- N. Band 3-Memphis is associated with a lower transport tients with prostate adenocarcinoma before and after plastic rate of phosphoenolpyruvate // J. Haematol. – 1992. - vol. orchectomy and in healthy men to detect changes in the protein 82. - P. 122-125. spectrum of erythrocytes.

Our investigations have shown that during this pathology pro- tion), which indicates to the normalization of the condition of tein spectrum of erythrocytes structure undergoes substantial the whole organism. changes. This is demonstrated by losing of 35 KD molecular weight protein fraction and by appearance of 36 KD molecular It was detected that the synthesis of lower molecular protein weight protein fraction on the erythrocytes electrophoregram. fractions, on the one hand is influenced by rising of accantocytes percentage and on the other hand by the activation of the lipid It should be noted, that after plastic orchectomy we can see the oxidation process in erythrocytes membrane. relative normalization of erythrocyte’s electrophoresis picture and it’s approaching to the data of the control group (losing of Key words: prostate adenocarcinoma, plastic orchectomy, eryth- 120 KD protein fraction and appearance of 48 KD protein frac- rocytes, protein spectrum.

ÐÅÇÞÌÅ

ÄÈÍÀÌÈÊÀ ÈÇÌÅÍÅÍÈÉ ÏÐÎÒÅÈÍÎÂÎÃÎ ÑÏÅÊÒÐÀ ÝÐÈÒÐÎÖÈÒÎÂ Â ÊÐÎÂÈ ÏÀÖÈÅÍÒÎÂ Ñ ÀÄÅÍÎÊÀÐÖÈÍÎÌÎÉ ÏÐÎÑÒÀÒÛ ÏÎÑËÅ ÏËÀÑÒÈ×ÅÑÊÎÉ ÎÐÕÈÝÊÒÎÌÈÈ

Âåøàïèäçå Í.Ë., Àëèáåãàøâèëè Ì.Ð., ×èãîãèäçå Ò.Ã., Ãàáóíèà Í.Ã., Êîòðèêàäçå Í.Ã

Òáèëèññêèé ãîñóäàðñòâåííûé óíèâåðñèòåò èì. È. Äæàâàõèøâèëè, ôàêóëüòåò òî÷íûõ è åñòåñòâåííûõ íàóê, ôàêóëüòåò ìåäèöèíû

Ñ öåëüþ âûÿâëåíèÿ èçìåíåíèé â ïðîòåèíîâîì ñïåêòðå ýðèò- ìèè îáíàðóæèâàåòñÿ îòíîñèòåëüíàÿ íîðìàëèçàöèÿ ýëåêòðî- ðîöèòîâ íàìè èçó÷åí ýëåêòðîôîðåçíûé ñíèìîê ýðèòðîöè- ôîðåçíîãî ñíèìêà ýðèòðîöèòîâ è ïðèáëèæåíèå äàííûõ ê ïî- òîâ ïðàêòè÷åñêè çäîðîâûõ ìóæ÷èí è ïàöèåíòîâ ñ àäåíîêàð- êàçàòåëÿì êîíòðîëüíîé ãðóïïû (ïðîòåèíîâàÿ ôðàêöèÿ 120 öèíîìîé ïðîñòàòû ïîñëå ïëàñòè÷åñêîé îðõèýêòîìèè. KD ìîëåêóëÿðíîé ìàññû è ïðîòåèíîâàÿ ôðàêöèÿ 48 KD ìî- ëåêóëÿðíîé ìàññû). Âûøåèçëîæåííîå óêàçûâàåò íà óëó÷- Èññëåäîâàíèÿ ïîêàçàëè èçìåíåíèå ïðîòåèíîâîãî ñïåêòðà øåíèå îáùåãî ñîñòîÿíèÿ îðãàíèçìà. Óñòàíîâëåíî, ÷òî ïîÿâ- ñòðóêòóðû ýðèòðîöèòîâ ïðè ýòîé ïàòîëîãèè, óêàçûâàþùåå ëåíèå ïðîòåèíîâûõ ôðàêöèé ñ íèçêîìîëåêóëÿðíîé ìàññîé íà ïðîãðåññèðîâàíèå çàáîëåâàíèÿ. Ïîòåðÿ ïðîòåèíîâîé (28 KD, 24KD, 18KD) îáóñëîâëåíî, ñ îäíîé ñòîðîíû, ïîâû- ôðàêöèè ñ ìîëåêóëÿðíîé ìàññîé 35 KD è âûÿâëåíèå ïðîòå- øåíèåì ïðîöåíòíîãî êîëè÷åñòâà àêàíòîöèòîâ, à ñ äðóãîé - èíîâîé ôðàêöèè ñ ìîëåêóëÿðíîé ìàññîé 36 KD ïîäòâåðæäà- àêòèâàöèåé îêèñëèòåëüíûõ ïðîöåññîâ ëèïèäîâ â ýðèòðîöè- þò âûøåñêàçàííîå. Ñëåäóåò îòìåòèòü, ÷òî ïîñëå îðõèýêòî- òàðíîé ìåìáðàíå.

Íàó÷íàÿ ïóáëèêàöèÿ

DOWN-REGULATION OF p27(KIP1) CYCLIN-DEPENDENT KINASE INHIBITOR IN PROSTATE CANCER: DISTINCT EXPRESSION IN VARIOUS PROSTATE CELLS ASSOCIATING WITH TUMOR STAGE AND GRADES

Nikoleishvili1 D., Pertia1 A., Tsintsadze2 O., Gogokhia3 N., Chkhotua1 A.

1National Centre of Urology, Department of Urology and 2Department of Pathology; 3Tbilisi State Medical Academy, Department of Laboratory Diagnosis

Prostate cancer (PCa) is the most commonly diagnosed ed mortality in the male population [4]. The management malignancy and the second leading cause of cancer-relat- of patients with PCa depends on an accurate assessment

34 GEORGIAN MEDICAL NEWS No 2 (143) Ôåâðàëü, 2007 ãîä of the biological potential of the tumor. Tumors that will fined; 4 (20%) patients had pT3 disease. At the mean follow- progress and influence the patient survival should be dis- up of 21 months (range: 1-23 months) all patients are alive, 2 tinguished from those that will not affect prognosis with- of them (10%) developed a biochemical (PSA) recurrence. out treatment. To date, tumor stage, Gleason score and the serum PSA level are the most recognized predictors of the The mean age of the patients in group III was 71±2 years disease outcome. However, the current physical and radi- (range 68-74 years). All of them were diagnosed as locally ological examination techniques are mostly inadequate for advanced (T3-4) and/or metastatic disease and were treat- correct clinical staging [9], and the assessment of tumor ed with surgical castration. The mean duration of hormon- grade may vary substantially due to subjectivity of the otherapy was 11,8±7 months (range: 5-22 months). All pa- observer [8]. tients had a stable disease without clinical signs of hormone-refractory tumor. One patient died of other than can- The studies performed in the last decade have provided cer reasons. The mean PSA level at the time of investiga- the new mechanisms of prostate cancer development and tion was 15ng/ml (range: 1,4-32 ng/ml). The mean follow- new theories of cancer progression have emerged [4]. up is 12 months (range: 5-22 months). However, the mechanisms by which hormone refractory cancer develops and progresses are still not completely Tissue sampling and immunohistochemistry. Informed con- understood. Despite the new treatment directions, hor- sent for using the surgical tissues for future scientific re- mone-escaped PCa remains incurable disease leading to search was obtained from all patients. The study design was patient death soon after diagnosis [7]. approved by the internal review board of the institution.

Special interest has been recently devoted to the impor- Resected prostate specimens from the patients of Group I tance of cell cycle regulating proteins in cancer develop- were fixed in 4% formaldehyde and embedded in paraffin. (KIP1) ment [5]. p27 is a cyclin-dependent kynase inhibitor 4-5μm thick serial sections were stained with haematoxylin (CGKI) of a Cip/Kip family which can negatively control the and eosin (HE) according to conventional techniques. The cell cycle through inhibition of cyclin and cyclin-dependent sections were evaluated by the pathologist (O.T.) to ex- kynase complexes [5]. Several studies have examined clude oncological or premalignant pathological changes (KIP1) p27 expression in the radical prostatectomy specimens (PIN etc.). Only BPH specimens with acceptable morpho- as a predictor of the disease recurrence, however, with dif- logical changes (mild stromal infiltration and/or inflamma- ferent and often conflicting results. While the majority of tion etc.) were further immunohistochemically evaluated (KIP1) these studies found that p27 status was an independ- and included in the study. ent predictor of biochemical failure [2], others reported that (KIP1) p27 could not predict the treatment outcome [12]. Resected prostates from the patients of Group II were evaluated macroscopically. 1,5x2cm tissue samples including (KIP1) In the current study we evaluated the expression of p27 peripheral prostate zones were taken for further assess- CDKI in BPH, PCa and HTPCa tissue samples. Intensity of ment. Specimens were fixed, stained and evaluated by the the marker expression was analyzed and compared in epi- pathologist according to conventional techniques. The thelial, stromal, vascular and ductal cells separately. Pos- tumors were staged according to the UICC 2002 TNM clas- sible association of intensity of the expression with the sification and graded with the Gleason grading system [17]. disease clinical parameters has also been assessed. The patients, who underwent surgical castration as a hor- Material and methods. The study population consisted of monotherapy for the treatment of advanced PCa and with 58 consecutive patients treated at our institution from 2003 the stable disease, were included in Group III. TURP was to 2004. The patients were divided in 3 groups: group I - 32 performed in all patients for the treatment of infravesical patients with BPH; group II - 20 primary prostate cancer obstruction. The mean duration from the castration to (PCa), and group III - 6 hormonally treated PCa patients. TURP was 7,25 months. Resected prostate specimens were fixed, stained and evaluated according to the conven- The mean age of the patients from group I was 66,7±8 tional techniques. years (range: 50-79 years). All of them underwent scheduled TURP due to the clinical diagnosis of BPH. Morpho- Representative HE stained sections were examined by the logical evaluation confirmed the diagnosis of BPH in all pathologist for the histopathological characteristics of the patients. The mean follow-up in this group was 21 months lesions to be further evaluated immunohistochemically. (range: 1-23 months). 4 μm thick sequential tissue sections were used for immu- The mean patient age in group II was 68±5 years (range 55- nohistochemistry. Tissue samples were deparaffinised in 74 years). Radical prostatectomy was performed in all pa- xylene and rehydrated in graded ethanol. Endogenous tients. The majority (80%) of the tumors was organ con- peroxidase was blocked by incubation in 1% hydrogen

peroxide. Sections were pretreated by the microwave anti- 90 gen retrieval procedure (4 cycles for 5min each at 600- 80 †

700 watt) in 10mmol/L of boiling citrate buffer solution 70 (pH 6,0). The necessary amount of buffer was added af- 60 ter each cycle to ensure the complete coverage of the slides. Afterwards, tissue sections were incubated for 1h 50 p27 p27 (KIP1) 40 at room temperature with anti-p27 (Oncogene, Clone * DCS72, Cat. #NA35) antibody diluted (1:200) in phos- 30 phate-buffered saline (PBS). After PBS washing, tissue 20 ‡ Ω sections were revealed using the Biotin-Streptavadin 10 detection system (Star 2006, Serotec Ltd.). Samples were 0 developed with liquid diaminobenzidine + substrate-chro- TS SS ES VS DS mogen system (Serotec Ltd., BUF022) and counterstained BPH PCa HTPCa with haematoxylin. *p=0,001 vs. PCa and HTPCa, † p<0,0001 vs. PCa and Human tonsil tissue was used as a positive control and p=0,0355 vs. HTPCa, ‡ p=0,0179 vs. PCa, Ω p=0,0073 antigen-free PBS as a negative control, according to the vs. PCa established protocols of immunohistochemical staining. Fig. 1. Comparison of p27(KIP1) expression in various pro- Sample scoring. Slides were evaluated blindly by two of static cells between the groups the authors (O.T. and A.C.) using a microscope (Olympus B201), under X20 and X40 magnification objectives. Only Association of p27(KIP1) expression with different clinical nuclear staining was considered as positive and was count- parameters was analyzed next. No association was found ed. The whole tissue area of the same size was evaluated with: patient age, prostate volume, PSA level, uroflowme- and scored. Total (TS), epithelial (ES), stromal (SS), vascular try parameters and residual urine (data not shown). In the (VS) and ductal (DS) expression of the marker was evaluat- PCa group intensity of the marker expression in epithelial, ed separately, by calculating the respective scores. Total vascular and ductal prostatic cells was negatively associ- p27(Kip1) expression (TS) was evaluated semi-quantitatively ated with the tumor stage: with increasing stage the pro- according to the following scoring system: score 1, 0-25%; tein expression was significantly decreasing (fig. 2). score 2, 26-50%; score 3, 51-75%; and score 4, ≥76% of total cells positive. The percent of positive acini were counted for the epithelial score (ES). The stromal expression (SS) p27 was assessed by the following scoring system: no expres- 50 sion – 0, mild – 1, moderate – 2 and strong expression – 3. 45 The total number of crosscut blood vessels and prostatic 40 35 (KIP1) ducts which were positive for p27 were counted in vas- 30 † cular (VS) and ductal scores (DS), respectively. 25 20 3 15 Statistical analysis was performed using computer soft- 10 2 ware (SPSS 12.0 for Windows, Lead Technologies Inc. 2003. 5 * ‡ Ω 1 0 Chicago, Il.). TS ES VS DS

Results and their discussion. Comparison of intensity of *p=0,0453 for 1 vs. 3. † p=0,0229 for 1 vs. 2, and p27(KIP1) expression in various prostatic cells of BPH, PCa p=0,0199 for 1 vs. 3. ‡ p=0,0256 for 1 vs. 3. and HTPCa groups is shown in (fig. 1). The total expression Ω p=0,0367 for 1 vs. 3 of the protein was significantly higher in BPH as compared with PCa and HTPCa patients (p=0,001). The difference be- Fig. 2. Intensity of p27 expression in various prostatic tween PCa and HTPCa was not statistically significant. cells according to the tumor stage p27(KIP1) was significantly higher expressed in epithelial, ductal and vascular prostatic cells of BPH as compared with Expression of p27(KIP1) was associated with tumor grades. PCa (p<0,0001, p=0,0179 and 0,0073, respectively). The stro- The marker expression in epithelial, vascular and ductal mal expression of the marker was not different between the cell was significantly decreasing with increasing Gleason groups. Epithelial expression was significantly increased in score 1, Gleason score 2 and the Gleason sum (fig. 3). As- HTPCa as compared with PCa (p=0,0460). sociation of the protein expression in stromal cells was not statistically significant.

36 GEORGIAN MEDICAL NEWS No 2 (143) Ôåâðàëü, 2007 ãîä

16 90 pression was assessed in the whole tissue area without * separating between different prostatic cells. Thus, the ques- 14 † 80 tion in which tissue structures expression of the gene is 12 70 60 clinically important remains unanswered. The value of CD- 10 ‡ 50 KIs in hormonally treated PCa has not been studied yet. 8 40 Mean rank Mean score Mean 6 (KIP1) 30 In the current study we have shown that p27 is signif- 4 icantly up-regulated in BPH as compared with PCa and Ω 20 2 10 HTPCa. The difference was significantly higher in all tis- 0 0 sue structures except the prostatic stroma. This can be 2457 explained by the relatively low proliferative activity of stro- Gleason Sum mal cells in comparison with epithelial and vascular en- TS VS ES DS dothelial cells. p27(KIP1) was significantly higher expressed in epithelial cells of HTPCa as compared with primary PCa which may indicate on a triggering effect of castration on *p=0,046 for 2 vs. 5 and p=0,009 for 2 vs. 7. p=0,046 for the CDKIs expression. The influence of hormonotherapy 7 vs. 4 and p=0,027 for 7 vs 5. † <0,0001 for 2 vs. 4, 5 and on the CDKIs has been evaluated in only one experimen- 7. p=0,0020 for 7 vs. 3 and p=0,0011 for 7 vs. 5. ‡ tal study showing the up-regulation of p27(KIP1) after cas- p=0,0085 for 2 vs. 5 and p<0,0001 for 2 vs. 7. p=0,0278 tration in nude mice xenografts [6]. This effect should be for 7 vs. 4 and p=0,0012 for 7 vs. 5. Ω p=0,0023 for 2 vs. further evaluated in clinical studies with higher number 5 and p<0,0001 for 2 vs. 7. p=0,0032 for 7 vs. 4 and of hormonally treated PCa patients. Low patient number p=0,0008 for 7 vs. 5 in Group III could be the reason why the difference did not reach significance in other prostatic cells. We have Fig. 3. Expression of p27(KIP1) in different prostatic cells detected the negative association of p27(KIP1) expression according to the Gleason sum with tumor stage and grades. Again, this association was found in epithelial, vascular and ductal prostatic cells, Prostate cancer is a curable disease with extremely varia- showing their functional activity in PCa. Decreasing vas- ble clinical course. The substantial number of cancers will cular expression of the gene and its association with clin- stay indolent and will not affect the patient survival even ical parameters can be explained by the theory of tumor without treatment. Therefore, the search for prognostic neoangiogenesis. Additional investigations with specif- markers of the tumor aggressiveness is essential for opti- ic markers (Von Willebrandt factor, CD31 and CD34) are mal treatment of each individual patient. To date, tumor needed to prove this. stage, Gleason grade and the serum PSA level have been identified as the most reliable prognostic markers. Howev- The follow-up time in our study is not big enough to ana- er, the clinical staging of PCa is not always accurate and lyze the prognostic significance of the marker in recur- the subjectivity in reproducibility of the tumor grade re- rence-free and cancer-specific survivals. Further studies mains the major problem [8]. Furthermore, many of the tu- with more patients and longer follow-up are needed to as- mors will show the similar clinical and histological charac- sess in which cells the gene expression is associated with teristics and it is important to have additional, more sensi- the survival data. tive markers of tumor’s clinical behavior [11]. In conclusion, it has been shown by the results of the The ongoing studies focus on the research of molecular current study, that down-regulation of p27(KIP1) CDKI ex- mechanisms of carcinogenesis and tumor progression. The pression in PCa is detected in epithelial, vascular and duc- cell cycle regulatory proteins are new and promising mark- tal, but not the stromal prostatic cells. Intensity of the ers for future research in this area. Indeed, several cell gene expression in these cells is associated with tumor cycle markers have been evaluated which play important stage and grades. Hormonotherapy of PCa may cause re- role in cancer generally [5] and in genitourinary carcinoma activation of the CDKIs. in particular [10]. Acknowledgments: This study was supported by grants p27(KIP1) is one of the member of Cip/Kip family of the CD- from GlaxoSmithKline and GMP Georgia. KIs. There are few studies evaluating the value of p27(KIP1) in PCa with controversial results [2,12]. A potential short- REFERENCES coming of these studies is that they assessed the marker expression level qualitatively with a various cut points (10% 1. Cheng L. at al. The cell cycle inhibitors p21WAF1 and to 50%) of positively stained cells to predict the disease p27KIP1 are associated with survival in patients treated by prognosis [1]. Moreover, in all former studies the gene ex- salvage prostatectomy after radiation therapy // Clin Cancer

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DOWN-REGULATION OF p27(KIP1) CYCLIN-DEPENDENT Ýêñïðåññèÿ ìàðêåða èçó÷åíà â: à) 32-õ ïðåïàðàòàõ äîáðîêà- KINASE INHIBITOR IN PROSTATE CANCER: DIS- ÷åñòâåííîé ãèïåðïëàçèè ïðîñòàòû (ÄÃÏ), á) 20-è ïðåïàðàòàõ TINCT EXPRESSION IN VARIOUS PROSTATE CELLS ðàêà ïðîñòàòû (ÐÏ) è â) 6-è ïðåïàðàòàõ ðàêà ïðîñòàòû ïîñëå ASSOCIATING WITH TUMOR STAGE AND GRADES ãîðìîíàëüíîãî ëå÷åíèÿ (ÃÐÏ). Ýêñïðåññèÿ ìàðêåðà èññëå- äîâàíà òàêæå â ðàçëè÷íûõ ñòðóêòóðíûõ êëåòêàõ òêàíè ïðî- Nikoleishvili1 D., Pertia1 A., Tsintsadze2 O., Gogokhia3 N., ñòàòû: â ýïèòåëèè àöèíóñîâ, ïðîòîêàõ, êðîâåíîñíûõ ñîñóäàõ Chkhotua1 A. è ñòðîìå. Òêàíåâîé ìàòåðèàë äëÿ èññëåäîâàíèÿ çàáèðàëñÿ ïóòåì òðàíñóðåòðàëüíîé ðåçåêöèè ïðîñòàòû è ðàäèêàëüíîé 1National Centre of Urology, Department of Urology and 2De- ïðîñòàòýêòîìèè. partment of Pathology; 3Tbilisi State Medical Academy, Depart- ment of Laboratory Diagnosis Îöåíèâàëàñü èíòåíñèâíîñòü ýêñïðåññèè p27(Kip1) â çàâèñè- ìîñòè oò ðàçíûõ êëèíè÷åñêèõ ïàðàìåòðoâ çàáîëåâàíèÿ: âîç- The goal of the study was to analyze the expression of p27(KIP1) ðàñò ïàöèåíòà, ñòàäèÿ çàáîëåâàíèÿ, îáúåì ïðåäñòàòåëüíîé cyclin-dependent kinase inhibitor protein (CDKI) in different æåëåçû, óðîâåíü ïðîñòàòñïåöèôè÷åñêîãî àíòèãåíà, êîëè- cells of benign, malignant and hormonally treated prostate can- ÷åñòâî îñòàòî÷íîé ìî÷è è ñòåïåíü äèôôåðåíöèàöèè ðàêà cer tissue and assess their possible association with different ïðîñòàòû. clinical parameters. Expression of p27(KIP1) CDKI was evaluated and compared in: 32 BPH, 20 prostate cancer (PCa) and 6 hor- Èíòåíñèâíîñòü ýêñïðåññèè p27(Kip1) äîñòîâåðíî ïîâûøàëàñü monally treated prostate cancer (HTPCa) tissues. Intensity of ïðè ÄÃÏ ïî ñðàâíåíèþ ñ ÐÏ è ÃÐÏ. Â íàøåì èññëåäîâàíèè the expression was compared between the groups and associa- âïåðâûå óñòàíîâëåíà ïîëîæèòåëüíàÿ âçàèìîñâÿçü ìåæäó tion was soughed with the cancer clinical parameters. Total ex- èíòåíñèâíîñòüþ ýêñïðåññèè p27(Kip1), ñòàäèåé è ñòåïåíüþ äèô- pression of p27(KIP1) was significantly higher in BPH as com- ôåðåíöèàöèè ÐÏ. Âïåðâûå âûÿâëåíî, ÷òî ãîðìîíàëüíîå ëå- pared with PCa (p=0,0002) and HTPCa (p=0,0324). The dif- ÷åíèå ðàêà ïðîñòàòû ñïîñîáñòâóåò ïîâûøåíèþ èíòåíñèâíî- ference between PCa and HTPCa was not significant. p27(KIP1) ñòè ýêñïðåññèè ìàðêåðà â òêàíè ïðåäñòàòåëüíîé æåëåçû. Îò- was higher expressed by epithelial, ductal and vascular prostatic ìå÷åííûå îñîáåííîñòè ýêñïðåññèè ìàðêåðà, â îñíîâíîì, íà- cells of BPH as compared with PCa (p=0,0001, 0,0101 and áëþäàëèñü â ýïèòåëèè, êàíàëüöàõ è êðîâåíîñíûõ ñîñóäàõ ïðî- 0,0224, respectively). The stromal expression of the marker ñòàòû.

38 GEORGIAN MEDICAL NEWS No 2 (143) Ôåâðàëü, 2007 ãîä

Íàó÷íàÿ ïóáëèêàöèÿ

PREVALENCE OF URINARY INCONTINENCE IN WOMEN POPULATION

Nazarishvili G., Gabunia N., Gagua G.

National center of Urology, Tbilisi Urinary incontinence (UI) is a widely spread disease; By the time of physical exertion (such as coughing, laughing, statistical data it occurs in every 5-th, 6-th woman. It is not sneezing, etc). Urge incontinence is defined as involuntary only a medical, but also a social problem. Therefore the ear- loss of urine preceded by sudden urge to void. lier reveal of the disease is very important, for the right and in time treatment and for avoiding operation necessity. One of the classic studies of UI incontinence prevalence was conducted by Thomas et al, by postal survey to select- The prevalence of urinary incontinence is defined as the ed health districts in the London boroughs and neighbor- probability of being incontinent within the defined popu- ing health districts in the late 1970s. In that survey inconti- lation group within a specified period of time among wom- nence was defined as involuntary excretion or leakage of an of all age groups, it is reasonable to state that the prev- urine in inappropriate places or at inappropriate times twice alence of UI increases with age and increasing debility: it or more a month, regardless of the quantity of urine lost. is highest among groups of people who are older, debili- Incontinence was further subdivided into regular UI for a tated and institutionalized loss twice or more per month, and occasional for less than twice per month. The response rate from this postal survey There are several types of incontinence: stress incontinence, was excellent, at 89%. Table 1 shows the prevalence rates urge incontinence, mixed incontinence, night incontinence from regular and occasional incontinence in women aged 15 etc.; Therefore in epidemiological studies, as in clinical in- to more than 85 years. There appear to be three aged tiers to vestigations, the type of UI must be defined. In women the prevalence of regular incontinence in women: the first population most common type of incontinence is stress and level is at 15-34 years, when the prevalence is lower (4-4,5%); urge incontinence. In general, incontinence is considered the second tier is at 35-74 years (prevalence 8,8-11,9%); the of be the stress type when the urine loss was experienced at third is at 75 years and older (16%) [7]. Table 1. Prevalence of urinary incontinence (UI) in women Age group (year) Regular UI (%) Occasional UI (%) Total UI (%) 15-24 4,0 11,9 15,9 25-34 5,5 20,0 25,5 35-44 10,2 20,7 30,9 45-54 11,8 21,9 32,9 55-64 11,9 18,6 30,5 65-74 8,8 14,6 22,4 75-84 16,0 13,6 29,6 >85 16,2 16,2 32,4 In a more focused epidemiological study on UI, Diokono and nence was defined as urine loss of any volume beyond the his group [3] performed face-to-face household interviews respondent’s control, with a minimum frequency of six times with respondents who were 60 years and older, living in their within the last 12 months. A total of 1955 respondents partic- households in the community of Washtenaw County, Mich- ipated, as participation rate of 65,1%. Table 2 shows that, in igan in the mid 1980 s. This epidemiological study was intitled this community, the prevalence of UI in woman aged 60 years Medical, Epidemiological and Social Aspects of aging, now or older was 37,6%. There was no significant difference in the better known as the MESA project. In this project, inconti- rates between any age groups in this sample [3]. Table 2. Prevalence of urinary incontinence in women aged 60 years and over Age Continent Incontinent Total 60-64 193 (60,9%) 124 (39,1%) 317 65-69 192 (65,3%) 102 (34,7%) 294 70-74 111 (58,7%) 78 (41,3%) 189 75-79 105 (62,5%) 63 (37,5%) 168 80-84 64 (64,6%) 35 (35,4%) 99 85+ 50 (64,1%) 28 (35,9%) 78 Total 715 (62,4%) 430 (37,6%) 1145 © GMN 39 ÌÅÄÈÖÈÍÑÊÈÅ ÍÎÂÎÑÒÈ ÃÐÓÇÈÈ CFMFHSDTKJC CFVTLBWBYJ CBF[KTYB

Despite that by the MESA survey Diokono et al [3] in Washtenaw County, Michigan reported the prevalence of thy types of clinical incontinence encountered among their respondents. The most common type reported by these women ages 60 years and older was the mixed stress and urge type (55,5%), followed by the stress type (26,7%), than the urge (9,0%) and other (8,8%) types.

By European epidemiological researches, also stress incontinence is the most prevalent type of incontinence reported by women. However, the proportion with urge incontinence increases with age to the point where stress and urge incontinence are almost equally common in old age (26% and 22%, respectively, in those aged 75 years or over). Fig. 2. Prevalence of urge incontinence (-) pure urge; (-) pure urge + combined stress and urge The symptoms of stress incontinence may occur alone or in combination with urge incontinence. Among the According to the literature data, there is a relationship, few reliable studies available, that of Yarnell et al. is although not a strong one, between symptom severity fairly consistent with others in showing a rise in prev- and the perception of bother: 14% of women with mild alence across the reproductive years with a mid-life incontinence have been found to be worried by their con- peak and a subsequent decline (fig. 1). The pattern is ditions, compared with 24% with moderate and 29% with similar for stress incontinence alone and stress com- severe incontinence. Urinary incontinence can have a bined with urge incontinence, except that in combina- significant effect on an individual’s life. The strategies tion there is also a progressive increase with age. This that people adopt to manage the condition sometimes pattern suggests a connection between GSI and the involve exhaustive, time-consuming rituals of frequent reproductive and the menopausal periods followed by toileting, changing and washing garments, and avoid- “recovery” in a proportion of cases before age-related ance of social contacts-which can ultimately render the factors become dominant. Recovery may occur natu- individual socially isolated [8]. rally, in response to treatment or by adaptation (e.g. avoidance of provocation). There are more methodological rigorous studies, which suggest that between 1 and 5% of the population suffer some restriction in their daily social activities as a result of urinary incontinence. Activities most commonly affected are shopping, visiting friends and sporting activities. Relationships may be affected, particularly sexual relationships, as incontinence can occur during coitus. Mental distress is also a frequently reported outcome of urinary incontinence: women with incontinence experience shame and embarrassment, loss of self-esteem, anxiety and depression [4].

It is often estimated that between one-fifth and one-third of women with incontinence have actually spoken to a doctor (table 3). Consultation rates increase with increasing severity and impact of incontinence, but the association is not strong. A major reason of this discrepancy between patient’s perceptions of the problem and help-seek- Fig. 1. Prevalence of stress incontinence (-) pure stress; ing behaviors are misconceptions of the etiology and nat- (-) pure stress + combined stress and urge ural history of the condition. Many women view incontinence as the inevitable result of childbearing and older In keeping with other studies, urge incontinence (either age, and consider it an inappropriate use of consulting alone or in combination with stress incontinence) shows time. There is a general lack of awareness of the range of a progressive increase with age, with no decline in mid- treatments, as others do not consult a doctor because they life (fig. 2) [8]. fear surgery. Unfortunately, these views are often rein-

40 GEORGIAN MEDICAL NEWS No 2 (143) Ôåâðàëü, 2007 ãîä forced by health professionals: for example, 17% of one told that UI is a common phenomenon which increases sample of incontinent women had sought help, only to be with age and nothing can be done. Table 3. Extent of use of services by women with urinary incontinence

Author/year Age (year) Percentage of incontinent sample who sought help Lagro-Janssen16 (1990) 50-65 32 Harrison 15 (1994) 20+ 13 Yarnell2 (1981) 18+ 9 Brocklehust25 (1993) 30+ 47 Samuelsson 17 (1997) 20-59 9 Seim26 (1995) 20+ 20 Rekers19 (1992) 35-79 28

In summary, most studies suggest that 20-30% of woman in old age (29% and 25%, respectively, in those aged 60 experience some leakage of urine, but only 7-12% perceive years), but at 70 years and more the most prevalent type is this to be problematic in some way, whereas 1-4% suffer mixed incontinencre. actual restriction to their daily activities as a result of incontinence; 4-10% of women have spoken to a doctor at some stage about incontinence [6].

Take into account these data, we decided to do statistical work about prevalence of urinary incontinence in women of 20 years and older in Tbilisi, Georgia. Such kind of investigation was performed firstly in Georgia. For that we used special survey. By preliminary data situation is very hard, problems with UI occur in every 4-5-th woman.

At the first step we asked 20 years and older 500 women. We used ‘Low Urinary Tract Functional Survey, which is \ simple for filling and informative for us. This survey is widely used in USA and Europe. It consists with eight questions and is absolutely anonymous.

Fig 3 shows the prevalence rates for urinary incontinence aged 20 to more than 60 years. There appear to be three Fig 4. Prevalence of stress incontinence, urge inconti- aged tiers to the prevalence of UI in women: the first level nence and combined stress +urge incontinence in wom- is 20-30 years, when the prevalence is lowest (5%); the en by age group: a) 25+, b) 25-34, c) 45-54, d) 60-70, second tier is at 30-60 years (prevalence 8-15%); the third e) 70+ is at 60 years and older (38%). 38% Besides of this, the researches was performed in special institutions, located in Tbilisi, where socially undefended old people is walking and eating one time in a day. Also these institutions have their constant contingent, who lives 8-15% there permanently. We performed face-to-face interviews with this group of old people (60 years >) and tried to 5% detect the various problems connected to their micturition. There appear that the prevalence of micturition problems have 70% of this contingent. The most prevalent type 20-30 years 30-60 years 60 years > of UI is mixed incontinence-35%, and almost equally per cents have urge and stress incontinence – 15% and 12%, Fig 3. Prevalence rates for urinary incontinence the rest 8% have problems with day and night polakiuria.

In Tbilisi the most prevalent type of incontinence is stress Such a high prevalence of UI in old people depend also on incontinence alike to Europe and also the proportion of associated factors and connected with the main disease: urge incontinence increases with age to the point where primarily, these include dementia, depression, anxiety and stress and urge incontinence are almost equally common poor mobility [2].

In summary, it should be noted that to perform such epide- 3. Diokno A.C., Brock M.B., Herzog A.R. Prevalence of urinary miological research in Georgia is very important, for earlier incontinence and other urologic symptoms in the noninstitu- revealing of UI, for detecting of etiological factors and tionalized elderly // J Urol. – 1986. - N136. – P. 1022-1025. choosing right management, it means that we should per- 4. Lagro-Janssen A.L.M., Debruyne F.M.J., Van Weel C. Value of the patient‘s case history in diagnosing urinary incontinence form selection of the patients and choose for them the in general practice // Br J Urol. – 1991. - N67. – P. 569-572. optimal method of treatment. 5. Milne J.S., Williamson J., Maule M.M., Wallece E.T. Urinary symptoms in older people // Mod Geriatr. – 1972. - N2. – P. 198. REFERENCES 6. Sandvik H., Kveine E., Hunskaar S. Female urinary Inconti- nence: physiological impact, self care, and consultations // Scand 1. Burgio K.L., Matthews K.A., Engel B.T. Prevalence, inci- J Caring Sci. – 1993. - N7. – P. 53-56. dence and correlates of urinary incontinence in healthy, mid- 7. Thomas T.M., Plymat K.R., Blannin J., Meade T.W. Prevalence dleaged women // J Urol. – 1991. - N146. – P. 1255-1259. of urinary incontinence // Br Med J. – 1980. - N281. – P. 1243. 2. Campbell A.J., Reinken J., McCosh L. Incontinence in the 8. Yarnell J.W.G., Stleger A.S. The prevalence, severity and fac- elderly: prevalence and prognosis // Age Ageing. – 1985. - N14. tors associated with urinary incontinence in a random sample of – P. 65-80. the elderly // Age Ageing. – 1979. – N8. – P. 81-85.

SUMMARY

PREVALENCE OF URINARY INCONTINENCE IN WOMEN POPULATION

Nazarishvili G., Gabunia N., Gagua G.

National center of Urology, Tbilisi

Urinary incontinence among women population is widely revealing and exact diagnostic for timely and correct treatment. spread disease, it occurs in every 5-th, 6-th woman. The frequency of disease is rising with age. Especially high percent- Data of our epidemiological researches corresponds to the for- age of disorder occurs in older respondents (60 years and >). eign reference data.

Urinary incontinence is not only a medical, but also a social prob- Key words: urinary incontinence, prevalence rate, stress incon- lem. Therefore, this disease is very actual problem and needs earlier tinence, urge incontinence, mixed incontinence.

ÐÅÇÞÌÅ

ÐÀÑÏÐÎÑÒÐÀÍÅÍÈÅ ÍÅÄÅÐÆÀÍÈß ÌÎ×È ÑÐÅÄÈ ÆÅÍÑÊÎÉ ÏÎÏÓËßÖÈÈ

Íàçàðèøâèëè Ã.È., Ãàáóíèà Í.Ã., Ãàãóà Ã.À.

Íàöèîíàëüíûé öåíòð óðîëîãèè èì. À. Öóëóêèäçå Íåäåðæàíèå ìî÷è - øèðîêî ðàñïðîñòðàíåííîå çàáîëåâàíèå ñðåäè âïåðâûå ïðîâåäåíî ýïèäåìèîëîãè÷åñêîå èññëåäîâàíèå ñ ïðè- æåíñêîãî íàñåëåíèÿ, êîòîðûì ñòðàäàåò êàæäàÿ 5-6-àÿ æåíùèíà. ìåíåíèåì îïðîñíèêà. Íà ïåðâîì ýòàïå îïðîøåíî 500 æåí- Â çàâèñèìîñòè îò âîçðàñòà ÷àñòîòà çàáîëåâàíèÿ óâåëè÷èâàåòñÿ. ùèí. Îñîáåííî âûñîêèé ïðîöåíò íàðóøåíèé îòìå÷àåòñÿ ó ðåñïîíäåí- òîâ ïîæèëîãî âîçðàñòà (>60 ëåò). Äèñôóíêöèÿ âûâåäåíèÿ ìî÷è Èçó÷åíèå ðàñïðîñòðàíåíèÿ íåäåðæàíèÿ ìî÷è ó æåíùèí ñ ÿâëÿåòñÿ íå òîëüêî ìåäèöèíñêîé, íî è ñîöèàëüíàÿ ïðîáëåìîé. ó÷åòîì âîçðàñòà âûÿâèëî, ÷òî â âîçðàñòíîé ãðóïïå îò 20 äî 30 ëåò ïîêàçàòåëè ðàñïðîñòðàíåíèÿ íåäåðæàíèÿ ìî÷è ñàìûå Ñ öåëüþ ñâîåâðåìåííîãî è öåëåíàïðàâëåííîãî ëå÷åíèÿ íå- íèçêèå - 5%, îò 30 äî 60 ëåò – 8-15%, à âûøå 60 ëåò – 38%. îáõîäèìà ðàííÿÿ äèàãíîñòèêà çàáîëåâàíèÿ. Â ñâÿçè ñ ýòèì, ñ öåëüþ âûÿâëåíèÿ ÷àñòîòû ðàñïðîñòðàíåíèÿ íåäåðæàíèÿ ìî÷è Ðåçóëüòàòû ýïèäåìèîëîãè÷åñêîãî èññëåäîâàíèÿ ñîãëàñóþò- ñðåäè æåíñêîé ïîïóëÿöèè â âîçðàñòå âûøå 20-è ëåò, íàìè ñÿ ñ äàííûìè çàðóáåæíûõ àâòîðîâ.

42 GEORGIAN MEDICAL NEWS No 2 (143) Ôåâðàëü, 2007 ãîä

Íàó÷íàÿ ïóáëèêàöèÿ

POSTERIOR VERTICAL LUMBOTOMY, A CLINICAL CASE

Ujmajuridze N., Ujmajuridze A.

National Center of Urology, Tbilisi

Posterior vertical lumbotomy was proposed by Simon in The renal artery and vein then are legated and divided 1870. Lurz in 1956 modified this approach. In 1965 Gil- close to the hilius of the kidney, where they are most Vernet published his experience with modified posterior accessible. On occasion, with particularly high-lying kid- vertical lumbotomy – approach to the kidney and upper neys, it may prove easiest to secure the vascular supply ureter was performed without incising the muscle mass- initially and then to deliver the upper renal pole into the es. Several modifications were proposed afterwards by wound to complete the nephrectomy. other authors (Andaloro and Lilien, Novick, Pansadoro, Gittes and Belldegrum) with different varieties of patient Since the renal pelvis and ureter are situated dorsally exposition and skin incision. Posterior vertical lumbotomy cellent exposure also is obtained with this incision for was also used in transplantology for bilateral nephrecto- pyelolithotomy, pyeloplasty or upper third ureterolithoto- mies in recipients. Nevertheless, this approach is less my. In some of these cases it will not be necessary to di- popular than traditional flank incision as the last one gives vide the costovertebral ligament or to mobilize the upper possibilities for wider exposition and better manipulation pole of the kidney. The exposure provided by the lumbot- on upper urinary tract. omy incision is especially helpful when dissection into the sinus renalis is indicated to perform extended puelolithot- By posterior vertical lumbotomy Patient may be placed in omy for intrarenal or branched calculi. the lateral position with the table flexed to extend the lumbar region. A vertical lumbal incision along the lateral mar- Material and methods. We have operated a group of pa- gin of the m. sacrospinalis is used as described by Gil- tients with different diseases using posterior vertical lum- Vernet and Freed. The incision begins at the upper margin botomy approach. Results of these operations were ana- of the 12th rib superiorly and follows a gentle lateral curve lyzed according to different criteria and compared with the to the iliac crest inferiorly. The incision is carried through results of operations using flank incision (table 1). the lumbodorsal fascia just lateral to the sacrospinalis and quadratus lumborum muscles, which are then retracted 444 patients (249 females and 195 males) were operated at medially to approach the renal fossa. To obtain better ex- our institution using Gil-Vernet modification of Posterior posure superiorly the costovertebral ligamentous attach- vertical lumbotomy, from September 1986 to February 2007 ment of the 12th rib is severed and the incision is opened (Table 2). Mean age of patients was 48.6 years (range 7 to widely with a retractors. This maneuver allows generous 76). 27 patients were operated bilaterally. On the whole 471 lateral retraction of the 12th rib and provides the same approaches were done. 7 different operations were per- exposure as resecting the rib, which has not been neces- formed. Of them: 260 pielonephrolithotomy, 83 ureterolithot- sary in our experience. Care is taken to avoid injury to the omy, 55 renal cystectomy, 18 nephrectomy, 33 dismembered pleura and subcostal vessels. pyeloplasty for ureteropelvic junction obstruction, 13 nephropexy. In 63 patients with obstructed upper urinary tract When bilateral nephrectomy is done patient is placed in percutaneous nephrectomy was done preoperatively. the prone position with the table flexed to increase the distance between the 12th rib and the iliac crest. Gerota’s Results and their discussion. The results of operations fascia is entered and the readily accessible lower pole of with posterior vertical lumbotomy were compared to the the kidney is mobilized. After the ureter is legated and same number of patients operated by us with flank inci- divided gentle downward traction is applied to the prox- sion according to following criteria: mean operative time, imal ureter, which allows the upper portion of the kidney number of doses of postoperative parenteral analgesics, to be mobilized more easily. Most end stage kidneys are duration of postoperative hospitalization, length of skin contracted in size with a compromised parenchymal vas- incision and complications like wound infection and inci- cular supply, and a large No. 2 chromic suture can be sional hernia. inserted safely through the lower renal pole with minimal bleeding. Downward traction then is applied to this liga- Operating time in the group with posterior vertical lumbot- ture to facilitate mobilization of the upper renal pole addi- omy was significantly lower than in patients with flank tionally. The entire kidney is delivered easily into the incision. The difference between these groups in higher in incision before securing the renal vessels in most cases. the use of analgesics – more than 2 times in favor of poste-

rior vertical lumbotomy. Postoperative hospital stay was also less complications. It also provides early rehabilitation and lower in this group. Length of incision show, that posterior return to work of the patients. vertical lumbotomy is much less traumatic than flank incision. As to postoperative complications, wound infection is From anatomical point of view posterior vertical lumboto- almost twice rare with posterior vertical lumbotomy and there my provides direct approach to the renal pelvis and upper were no incisional hernia noted in this patients (mean fol- ureter and in the hands of experienced surgeon possibili- low-up 14 years, range: 1-15 years), while it was seen in ties for any kind of manipulation. In the beginning this 12,1% of patients operated with flank incision. approach seems difficult, but with the experience, difficult operations are possible to perform. For instance, besides In all patients with posterior vertical lumbotomy, disease the tradicional indications of this approach (pelvic and was corrected in one procedure. Dynamic ileus lasted no upper ureter calculi), operations like renal cystectomy, ne- more then 2 days, more cardiovascular and respiratory prob- phrectomy, dismembered pyeloplasty for ureteropelvic junc- lems were noted with flank incision, then by vertical lum- tion obstruction, nephropexy and ureterolisis was done botomy, probably due to early activation of patients after by us. Obesity, staghorn nephrolitiasis and need of neph- posterior vertical lumbotomy. rostomy were not contraindications. Nephrectomies were performed in case of high grade hydronephrosis with cor- Comparative analysis of operations done with posterior tical aplasia (after a preliminary urinary drainage) or renal vertical lumbotomy and flank incision on our patients show, hypoplasia. Contraindications for posterior vertical lum- that posterior vertical lumbotomy is much less traumatic botomy were tumors, pyonephrosis and previously oper- incision. It has more “quiet” postoperative course with ated kidneys.

Table 1. Comparative analysis of posterior vertical lumbotomy and flank incision for operations on upper urinary tract

Mean Mean Mean length Mean postop. Wound operating parenteral of skin Incisional Approach Hospitalization infection time analgesics incision hernia (%) (days) (%) (mins.) (doses) (cm) Posterior vertical 87,4** 2,3* 8,1** 5,4* 7,3** 0* lumbotomy Flank incision 112,6** 5,8* 10,2** 16,2* 13,3** 12,1*

*p<0,01; **p<0,05

Table 2. Operations with Gil-Vernet modification of Posterior vertical lumbotomy, from September 1986 to February 2007 (National Centre of Urology)

Operation type Patient Num. Pielonephrolithotomy 260 Ureterolithotomy 83 Renal cystectomy 55 Nephrectomy 18 UPJ pyeloplasty 33 Nephropexy 13 Others 9 Total 444

In conclusion, our experience shows, that posterior verti- 2. Lurz H. Ein muskelschonender Lumbalschnitt zur Freilegung cal lumbotomy is less traumatic approach, gives possibil- der Niere // Chirurg. – 1956. - N27. – P. 125. ities for free manipulation on upper urinary tract, good 3. Gil-Vernet J. New Surgical concepts in removing renal calculi results and low morbidity. // Urol Int. – 1965. - N20. – P. 255. 4. Andaloro V.A., Lilien O.M. Posterior approach to the kidney // Urology. – 1975. - N5. – P. 600. REFERENCES 5. Novick A.C. Posterior surgical approach to the kidney and urether // J. Urol. – 1980. - N124. - P. 192. 1. Simon G. Exstripation einer Niere am Menschen // Deutsche 6. Pansadoro V. The posterior lumbotomy // Urol Clin N Amer. Klinik. – 1870. - N22. – P. 137. – 1983. - N10. – P. 573.

44 GEORGIAN MEDICAL NEWS No 2 (143) Ôåâðàëü, 2007 ãîä

7. Gittes R.F., Beldegrum A. Posterior lumbotomy: Surgery for Key words: lumbotomy, urether, tra. upper tract calculi // Urol Clin N Amer. – 1983. - N10. – P. 625. 8. Freed S.Z., Veith F.J., Soberman R., Gliedman M.L. Simul- ÐÅÇÞÌÅ taneous bilateral posterior nephrectomy in transplant recipients // Surgery. – 1970. - N68. – P. 468. ÑÐÀÂÍÈÒÅËÜÍÀß ÎÖÅÍÊÀ ÐÅÇÓËÜÒÀÒÎÂ ÇÀÄÍÅÉ 9. Kropp K.A. Posterior approach to the kidney // Surg Clin N ÂÅÐÒÈÊÀËÜÍÎÉ ËÞÌÁÎÒÎÌÈÈ È ÎÏÅÐÀÖÈÉ Amer. – 1971. - N51. – P. 251. ËÞÌÁÀËÜÍÛÌ ÄÎÑÒÓÏÎÌ

SUMMARY Óäæìàäæóðèäçå Í.Ñ., Óäæìàäæóðèäçå À.Í.

POSTERIOR VERTICAL LUMBOTOMY, A CLINICAL Íàöèîíàëüíûé öåíòð óðîëîãèè èì. À. Öóëóêèäçå CASE Â íàöèîíàëüíîì öåíòðå óðîëîãèè ñ 1986 ïî ôåâðàëü 2007 Ujmajuridze N., Ujmajuridze A. ãîäà ïðîîïåðèðîâàíî 444 áîëüíûõ (249 æåíùèí, 195 ìóæ- ÷èí, ñðåäíèé âîçðàñò - 48,6 ëåò) ñ çàáîëåâàíèåì âåðõíèõ National Center of Urology, Tbilisi ìî÷åâûõ ïóòåé. Äëÿ äîñòóïà ê ïî÷êå è âåðõíåé òðåòè ìî- ÷åòî÷íèêà áûëà ïðèìåíåíà çàäíÿÿ âåðòèêàëüíàÿ ëþìáî- From 1986 till February 2007 in National Center of Urology 444 òîìèÿ (ÇÂË). 27-è áîëüíûì ïðîâåäåíû ñèìóëüòàííûå îïå- patients were operated (249 women and 195 men, mean age 48.6 ðàöèè ñ îáåèõ ñòîðîí. Ïðîâåäåíà 471 îïåðàöèÿ, èñïîëüçóÿ years) with upper urinary tract diseases. For access to the kidney and óêàçàííûé äîñòóï. Ïðîèçâåäåíî ñðàâíåíèå ÇÂË ñ ëþì- upper urether posterior vertical lumbotomy approach was performed. áàëüíûì äîñòóïîì (ËÄ) ñ ó÷åòîì ðàçëè÷íûõ ïàðàìåòðîâ 27 patients were operated bilaterally. Total 471 operations were done (ïðîäîëæèòåëüíîñòü îïåðàöèè, ðàñõîä àíàëüãåòèêîâ, äëè- by this approach. The results of operations with Posterior vertical òåëüíîñòü ãîñïèòàëèçàöèè, äëèíà ðàçðåçà, ðàíåâàÿ èíôåê- lumbotomy were compared with flank incision for a variety of pa- öèÿ, ÷àñòîòà ðàçâèòèÿ ïîñëåîïåðàöèîííîé ãðûæè). Ïî âñåì rameters (mean operative time, number of doses of postoperative ïàðàìåòðàì ÇÂË ïðåâîñõîäèò ËÄ. Âûøåóêàçàííîå ïîçâî- parenteral analgesics, duration of postoperative hospitalization, wound ëÿåò çàêëþ÷èòü, ÷òî ÇÂË ìåíåå òðàâìàòè÷íà è äàåò âîç- infection, incisional hernia). Comparative analysis show, that poste- ìîæíîñòü óñïåøíî ïðîâîäèòü îïåðàöèè íà âåðõíèõ ìî÷å- rior vertical lumbotomy is much less traumatic incision. âûõ ïóòÿõ.

Íàó÷íûé îáçîð

COMPARTMENT SYNDROME, RHABDOMYOLYSIS AND RISK OF ACUTE RENAL FAILURE AS COMPLICATIONS OF THE UROLOGICAL SURGERY

Kochiashvili D., Sutidze M., Tchovelidze Ch., Rukhadze I., Dzneladze A.

Department of Urology, Central University Clinic after N. Kipshidze Tbilisi State Medical University

Compartment syndrome (CS) is a condition in which the impairment, possible renal failure and death [2]. Arteries perfusion pressure falls below the tissue pressure in a and their subdivisions bring freshly oxygenated blood to closed anatomic space with subsequent compromise of the tissues, and the associated venous system returns circulation and function of tissues. Each muscle or muscle deoxygenated blood to the venous circulation. The arteri- group is enclosed in a compartment bound by relatively al blood system continues to bring blood into the com- rigid walls of bone and fascia. The compartments of the partment, but the low pressure system - that is the blood lower leg and the volar forearm are particularly prone to vessels with a low intra-luminal pressure (veins and their developing elevated compartment pressures. CS develops subdivisions) - is restricted. When this occurs it is further through a combination of prolonged ischaemia and reper- compounded by the release of fluid from the blood ves- fusion of muscle within a tight osseofascial compartment sels, resulting in a further rise in compartment pressure [13]. Untreated CS can lead to tissue necrosis, functional and perpetuating the cycle. Oedema within a closed com-

partment will increase the pressure within that compart- tions, which can reach extremely high levels. A rise in se- ment, eventually compromising the vascular supply. Such rum myoglobin levels and the presence of myoglobinuria compromise will lead to further ischaemia and oedema for- are also indicators of rhabdomyolysis. Gabow et al found mation, and a vicious cycle will be established as cells that 33% of the episodes of rhabdomyolysis led to acute become deprived of oxygen. Severe metabolic complica- renal failure., This case clearly shows that prolonged sur- tions may present after reperfusion when the damaged gery in the lithotomy position can lead to the development membranes continue to leak, aggravating oedema forma- of a compartment syndrome with subsequent rhabdomy- tion and increasing the pressure in the closed osteofascial oly-sis. Preventive measures such as good positioning and compartment [4]. Damage to limbs, particularly the legs, re- peroperative repositioning of the patient, early recogni- lated to nerve damage and unchecked intra-compartmental tion of this complication and initiating correct therapy by pressures were documented as long ago as 1872 by Richard compartment decompression and forced diuresis with man- von Volkmann. The combination of nerve- related damage nitol and furosemide can prevent acute renal failure. and CS causing contracture related to a supracondylar frac- ture is still referred to as Volkmann contracture. Although more commonly associated with trauma or surgery on the limbs, CS has been reported as a complication Compromising surgical positions can be a cause of rhab- of some positions adopted for surgery, particularly the domyolysis. During the last decade two other patients lithotomy and knee-chest positions [6,8,10-14]. Various developed a compartment syndrome with rhabdomyolysis papers identify serious complications following surgery, after prolonged surgery in the lithotomy position, one with particularly during lithotomy or Lloyd Davies positions serious renal failure. Several different surgical positions during urological surgery. It has even been reported as have been described as risk factors for intra-or postopera- occurring in a 6 year-old patient [2]. The consequences for tive rhabdomyolysis, as a result of the development of a the patient are devastating, often requiring multiple fasci- compartment syndrome .The risk of compartment syndrome otomies, with chronic pain and weakness the frequent re- and rhabdomyolysis is especially high when there are oth- sult [17,18]. The possibility of developing CS and rhab- er risk factors, such as obesity, peripheral vascular dis- domyolysis is especially high in the presence of other risk ease and prolonged operation time. A compartment syn- factors including obesity, peripheral vascular disease, dia- drome is defined as a condition in which increased pres- betes mellitus, chronic alcoholism, myodistrophies, uses sure within a limited space impairs capillary perfusion of some medicines, such as hypolipidemic (statins, phibrates) the tissue within that space. Prolonged pressure on parts or others and prolonged duration of surgery [19]. CS has of the body touching the operating table, in most cases also been described in instances of drug overdose where the extremities, shoulders and gluteal regions, will cause persons have remained in one position for several hours, muscle injury with subsequent edema and ischemia. Ede- with the force supplied by the weight of their body on the ma formation in a closed compartment will cause a rise in extremity being the causative mechanism for the syndrome compartmental pressure, further impairing the circulation developing [19]. and eventually leading to the development of a full-blown compartment syndrome with rhabdomyolysis [2,5-8,10-13]. Risks in the perioperative environmen - the lithotomy position is commonly used to access the pelvis and peri- Rhabdomyolysis is the disruption of the skeletal muscle neum during urological, colorectal, and gynecological sur- fibers, which results in their lysis. Somatic muscle system gery. Lower limb compartment syndrome is caused by ab- makes up approximately 40% of the body weight. Rhab- normal increases in intracompartmental pressures within a domyolysis develops as a result of damage to the skeletal non-expansive fascial space and has been recognized af- muscular fibres. The damage is sufficient to alter the integ- ter prolonged elevation of the lower limbs during surgical rity of the sarcolemma, resulting in the release into the procedures in the lithotomy position. Reports of well leg bloodstream of toxic intracellular components. As the re- compartment syndrome (WLCS) after procedures in the sult of the lysis occurs muscle cell swelling, followed by lithotomy consist of individual cases or small series. Com- decrease in intravascular volume, also pigment induced partment syndrome is a potentially devastating complica- ARF and other complications such as passive back-diffu- tion resulting in permanent disability and even death. We sion of glomerular ultrafiltration, and direct toxicity on tu- undertook a survey of consultant urologists in the UK to bular epithelium and the juxtaglomerular apparatus with estimate the incidence of lower limb compartment syndrome consequent renin release and presumed renal vasocon- after use of the lithotomy position and to identify risk fac- striction have all been proposed [3,419]. tors for its development.

Rhabdomyolysis is generally accompanied by a triad of Variations on the lithotomy position are used for many elevated plasma creatine phosphokinase (CPK), CPK-MM, procedures. The Lloyd Davies position and modified lithot- orthotoludin-positive urine and pigmented granular casts. omy Trendelenburg (with additional head-down tilt) pro- The most striking change is a rapid rise in CPK concentra- vide optimal combination approaches (abdominal and peri-

46 GEORGIAN MEDICAL NEWS No 2 (143) Ôåâðàëü, 2007 ãîä neal) for complex urological, colorectal and gynaecologi- the lower legs when they have recovered consciousness cal surgical procedures. The overall incidence of compart- or a few hours after surgery. Some patients have described ment syndrome after major pelvic surgery in the lithotomy pain despite postoperative epidural anaesthesia. The pa- position has been estimated at 1 in 3500 cases1 but this tient’s leg(s) may appear tense and swollen. The level of may be higher in urological surgery. To date a total of 16 pathological pain is found to be far greater than the ordi- urological patients with WLCS have been described in the nary postoperative pain to be expected from the surgical world literature. The development of a WLCS is a rare but intervention [15]. significant complication after major surgery performed in either the low (Lloyd-Davies), standard, or exaggerated The diagnosis of CS requires a high index of clinical suspi- lithotomy position. WLCS typically presents postopera- cion and the typical presentation postoperatively includes tively with leg pain out of proportion to the clinical find- leg pain out of proportion to clinical findings [13]. Atten- ings. The classic findings of calf swelling, paraesthesia, tion should be paid to the patient who continues to com- weakness of toe flexion, and pain during passive toe ex- plain of pain after receiving analgesia or states that the tension are late and may suggest an established compart- pain is continually increasing [14]. Early diagnosis can ment syndrome and the presence of foot pulses does not affect outcome. It is possible that an initial diagnosis of show that the compartment is well perfused. The normal deep vein thrombosis (DVT) may impede the correct one. range of compartment pressure during an operation is be- The measurement of compartment pressures will confirm tween 0 mm Hg and 10 mm Hg. The definitive diagnosis of suspicions of CS, while venous Doppler studies will con- a compartment syndrome is made by a direct measurement firm a DVT. There is no clear definition of a precise pres- of intracompartmental pressure. This can be done by us- sure/time limit for irreversible muscle and nerve damage. ing either a transducer tipped catheter or by a convention- Normal limb intra-compartment pressure (ICP) at rest is on al fluid filled system. Compartment syndrome is attributa- average less than 20 mmHg. Goldsmith St McCallum [5] ble to prolonged impairment of lower limb perfusion sec- discuss pressures above 45 mmHg causing CS; other au- ondary to a rise in compartment pressure. A reduction in thors cite 30 mmHg as a threshold. Matsen states that perfusion pressure causes tissue ischaemia. Ischaemia may ICPs greater than 30 mmHg generally are agreed to require be followed by reperfusion with subsequent capillary leak- intervention. It is important to compare compartment pres- age and tissue oedema. A vicious circle of tissue oedema sures against the patient’s diastolic pressure - if it is ele- and further impairment of perfusion then occurs. Once vated to within 10-30 mmHg of the diastolic pressure, or compartment pressure rises above 50 mm Hg for more than 30-40 mmHg of the mean arterial pressure, irreversible dam- four hours irreversible neuromuscular damage will occur age may occur. It is difficult to ascertain if one or all com- although damage is reversible up to two to three hours. In partments of a limb are affected. our study only two cases of WLCS occurred after operations that lasted for less than four hours. The diagnosis of compartment syndrome requires a high index of clinical suspicion. Timing of identification and Compartment syndrome occurred after radical cystectomy intervention with compartment syndrome is crucial to a and urinary diversion in 51 cases and was rare in proce- positive patient outcome. It is possible that an initial diag- dures lasting less than four hours. The incidence of com- nosis of deep vein thrombosis (DVT) may interfere with partment syndrome after cystectomy was estimated at the correct diagnosis. The measurement of compartment around 1 in 500 cases. Risk factors for its development pressures will confirm the suspicions of compartment syn- included: Intraoperative hypotension, Blood loss/hypo- drome while venous Doppler studies will confirm a DVT. volaemia, Peripheral vascular disease, Prolonged opera- Remember the “6 P’s” of compartment syndrome: tion, Muscular calves, High body mass index, obesity. 1. Paresthesia; Subtle first symptom Number of cases - Surgery 2. Pain; 1. Cystectomy Radical - high incidence 3. Pressure: 2. Prostatectomy - rare • Involved compartment or limb will feel tense and warm on 3. Urethroplasty Other - rare palpation • Direct compartment pressure of 30-40 mmHg as meas- Signs and symptoms. CS usually presents after reperfusion ured by a wick, continuous infusion, or injection method of a limb, and pain and swelling may not occur immediate- such as the Stryker monitor – normal intracompartmental ly. The first signs usually occur after the patient has re- tissue pressure is 0-10 mmHg. gained consciousness, undergone their post- anesthetic • Differential pressure of greater than 30 mmHg – diastolic care episode and returned to the ward. Often several hours blood pressure minus compartment pressure – as long as are reported as uneventful before the first signs and symp- diastolic pressure remains high enough or at least 30 mmHg, toms are reported [5,8,10-14]. The first suspicions are usu- the compartment will be perfused and there may not be a ally aroused when a patient complains of severe pain in need for surgical decompression.

• Whiteside’s theory suggested that the development of Surgical decompression is the standard treatment of es- compartment syndrome depends not only on intra-com- tablished CS. Immediate surgical intervention is required partmental pressure but also depends on systemic blood to stop the rise in compartment pressures and damage by pressure – diastolic pressure minus compartment pressure performing fasciotomies (surgical incisions of the affected should be > 30 mmHg. compartments). As soon as the fascia is sectioned, or surgically split open by an incision through all the layers Example 1: down to, and including, the fascia, the compartmental con- 80=patient diastolic B/P tents can bulge, thus allowing pressures to decline along -20=direct compartment pressure with reinstitution of the normal circulatory pattern. When 60=differential pressure (adequate compartment perfusion) diagnosed and treated early, full recovery usually follows.

Example 2: Pearse et al [11] discuss the current recommendations for 80=patient diastolic B/P treatment, advocating prompt release of intra-compartment -60=direct compartment pressure pressure by fasciotomy. Delays greater than eight hours 20=differential pressure (inadequate compartment per- may limit the efficacy of the treatment. Early diagnosis fusion) benefits from early treatment. Fasciotomies are not benign procedures - they may lead to chronic venous insufficien- 4. Pallor cy due to impairment of the calf muscle pump. Late sign Pale, grayish or whitish tone to skin During fasciotomy it is vital to identify and protect the Prolonged capillary refill (>3 seconds) peroneal nerve. Wounds are usually left open initially, be- Cool feel to skin upon palpation due to lack of capillary ing protected by suitable sterile dressings. Inspection of perfusion the wound after 48 hours may necessitate further necrotic tissue excision. Delayed skin closure or skin grafting may 5. Paralysis become treatment options. Adequate analgesia and anti- Late sign biotic cover are essential for improving outcomes. May start as weakness in active movement of involved or distal joints In cases where treatment and prophylaxis of renal failure Leads to inability to move joint or digits actively associated with rhabdomyolysis is suspected or diag- No response to direct neural stimulation due to damage nosed, prompt fluid and metabolic correction is essential to re-establish a good urine output. Goldsmith & McCa- 6. Pulselessness llum [5] advocated that “Early, aggressive fluid replace- Late sign ment, guided by CVP monitoring, is required and often Very weak or lack of palpable or Doppler audible pulse large positive fluid balances are necessary. Mannitol has Due to lack of arterial perfusion further beneficial actions in being a renal vasodilator and intravascular expander”. Other warning signs of Compartment Syndrome: Fractured blisters: represent areas of necrosis of the epi- Bocca et al [2] also support a mannitol infusion to induce dermis and separation of the skin layers. Occur as the body an osmotic diuresis. However, others have disagreed in attempts to relieve the pressure in the compartment. the past - Maher (1994) states that hypertonic mannitol Laboratory findings: elevated serum creatinphosphokinase has not been proven effective in clinical studies. Debate and Potassium due to cell damage; myoglobinemia, my- continues and actual treatment will depend on the individ- oglobinuria. ual clinician. Dialysis may be necessary if these methods Elevated temperature due to ischemia/necrosis of tissue of treatment fail. and possible infectious response. Elevated WBC (white blood cell count) and ESR (erythro- REFERENCES cyte sedimentation rate) levels due to the severe inflam- matory response. 1. Anglen J., Banoventz J. Clinical Orthodedics & Related Re- Lowered Serum pH levels due to acidosis. search. – 1994. - N301. – P. 239-42. Stretch pain or pain on passive extension or hyperexten- 2. Bocca G., van Moorselaar J., Wout F., van der Staak F., Mon- sion of digits (toes or fingers, depending on the site). nens L. Compartment Syndrome, Rhabdomyolysis and Risk of Acute Renal Failure as Complication of the Lithotomy Position // Journal of Nephrology. – 2002. – N 15(2). – P. 183-185. Treatment. Medical decompression may be instigated if 3. Bywaters E.G.L. 50 years on: the crush syndrome // BMJ. – CS is suspected and intra-compartment pressures are only 1990. – N301. – P. 1412-15. marginally increased. A mannitol infusion has been report- 4. Gabow P.A., Kaehny W.D., Kelleher S.P. The spectrum of ed as effecting a complete resolution [13,14]. rhabdomyolysis // Medicine. – 1982. – N61. – P. 141-52.

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5. Goldsmith M.I., McCallum // Anaesthesia. – 1996. – N If repositioning is impossible to execute, the head-down tilt 511(11). – P. 1048-1052. position should be reversed every two hours, for a short period 6. Gershuni D.H., Yaru N.C., Hargens A.R. et al. Ankle and knee of time, to allow more natural perfusion of the lower limbs to position as a factor modifying intracompartmental pressure in the occur. Raza et al recommend that if the anticipated procedure human leg // J Bone Joint Surg Am. – 1984. - N66. – P. 1415–20. duration is beyond four hours, the legs should be removed from 7. Lachmann E.A., Rook J.L., Tunkel R. et al. Complications supports every two hours for a short period to prevent reper- associated with intermittent pneumatic compression // Arch Phys fusion injury. The use of Allen stirrups is preferred to calf sup- Med Rehab. – 1992. - N73. – P. 482-5. ports or metal skids. 8. Leventhal I., Schiff H., Wulfsohn M. Rhabdomyolysis and acute renal failure as a complication of urethral surery // Urolo- Turnbull and Mills suggest that we should certainly review gy. – 1985. – N26 – P. 59-61. our use of compression stockings and intermittent compres- 9. Mubarak S.J., Hargens A.R. Acute compartment syndromes sion devices when operating on patients in the Lloyd Dav- // Surg Clin North Am. – 1981. - N63. – P. 539-65. ies position. 10. Mumtaz F.H., Chew H., Gelister J.S. Lower limb compartment syndrome associated with the lithotomy position: concepts and It will be deemed negligent to misdiagnose (ie: mistake for a perspectives for the urologist // BJUI. – 2002. - N90. – P. 792–9. DVT) or delay treatment (by prolonged re-assessment) of CS 11. Pearse M., Harry L., Nanchahal J. Acute Compartment Syndrome postoperatively when patients have been subjected to proof the Leg // British Medical Journal. – 2002. - N325. – P. 558-559. longed surgery in these abnormal positions. Delayed or missed 12. Pfeffer S.D., Halliwill J.R., Warner M.A. Effects of lithoto- diagnosis may not only be limb-threatening (and cause a very my position and external compression on lower leg muscle com- protracted hospital stay) - it can be life-threatening. With to- partment pressure // Anesthesiology. – 2001. - N95. – P. 632–6. day’s current knowledge, surgeons undertaking prolonged sur- 13. Raza A., Byrne D., Townell N. Lower limb compartment gery in abnormal positions must be aware of this, fortunately syndrome after urological pelvic surgery // J Urol. – 2004. - rare, complication. N171. – P. 5–11. 14. Raza A., Byrne D., Townell N. Acute Compartment Syn- Practice guidelines within perioperative care should reflect cur- drome After Urological Pelvic Surgery // Journal of Urology. – rent knowledge and ensure that risk is minimized. Patients who 2004. – N 171(1). – P. 5-11. take legal action if they have experienced this condition may be 15. Ryland Scott J., Daneker G., Lumsden A.B. Prevention of awarded substantial costs against negligence if lack of care can be compartment syndromes associated with the dorsal lithotomy proven or diagnosis has been delayed. position // Am Surg. – 1997. - N63. – P. 801–6. 16. Tal A., Lask, J., Keslin, J., Livine, P.M. Abdominal Com- Key words: compartment syndrome, rhabdomyolysis, acute partment Syndrome: urological aspects // British Journal of Urol- renal failure. ogy International. – 2004. - N93. – P. 474-477. 17. Turnbull D., Farid A., Hutchinson S. et al. Calf compartment ÐÅÇÞÌÅ pressures in the Lloyd-Davies position: a cause for concern? // Anaesthesia. – 2002. - N57. – P. 905-8. ÓÐÎËÎÃÈ×ÅÑÊÈÅ ÎÏÅÐÀÖÈÈ, ÎÑËÎÆÍÅÍÍÛÅ 18. Verdolin M.H., Toth A.S., Schroeder R. Bilateral lower ex- ÊÎÌÏÀÐÒÌÅÍÒÍÛÌ ÑÈÍÄÐÎÌÎÌ, ÐÀÁÄÎÌÈÎËÈ- tremity compartment syndromes following prolonged surgery ÇÎÌ È ÎÑÒÐÎÉ ÏÎ×Å×ÍÎÉ ÍÅÄÎÑÒÀÒÎ×ÍÎÑÒÜÞ in the low lithotomy position with serial compression stockings // Anesthesiology. – 2000. - N92. – P. 1189-91. Êî÷èàøâèëè Ä.Ê., Ñóòèäçå Ì.Ã., ×îâåëèäçå Ø.Ã., Ðó- 19. Warrell D., Cox T., Firth J., Benz E. Oxford Textbook of õàäçå È.Ð., Äçíåëàäçå À.Â. Medicine 4th ed. – 2003. - vol. 3. - Sections 18-33. – P. 257. Òáèëèññêèé ãîñóäàðñòâåííûé ìåäèöèíñêèé óíèâåðñèòåò, SUMMARY äåïàðòàìåíò óðîëîãèè

COMPARTMENT SYNDROME, RHABDOMYOLYSIS Êîìïàðòìåíòíûé ñèíäðîì (ÊÑ) ðàçâèâàåòñÿ ïðè äëèòåëüíîé AND RISK OF ACUTE RENAL FAILURE AS COMPLICA- èøåìèè ñêåëåòíûõ ìûøö è â áîëüøèíñòâå ñëó÷àåâ âñòðå÷à- TIONS OF THE UROLOGICAL SURGERY åòñÿ ïðè íåêîòîðûõ óðîëîãè÷åñêèõ îïåðàöèÿõ â óñëîâèÿõ ïðîäîëæèòåëüíîãî íàõîæäåíèÿ ïàöèåíòà â ïîçèöèÿõ Lloyd Kochiashvili D., Sutidze M., Tchovelidze Ch., Rukhadze I., Davies èëè Òðåíäåëåíáóðãà. ×àñòî ÊÑ è îñòðîé ïî÷å÷íîé Dzneladze A. íåäîñòàòî÷íîñòüþ (ÎÏÍ) îñëîæíÿåòñÿ ðàäèêàëüíàÿ öèñòýê- òîìèÿ (1:500), ïðîñòàòýêòîìèÿ è äð. óðåòðîïëàñòè÷åñêèå îïå- Department of Urology, Central University Clinic after N. Kip- ðàöèè. Ñèíäðîì îáíàðóæèâàåòñÿ òàêæå â ñëó÷àÿõ äëèòåëü- shidze Tbilisi State Medical Universiti íûõ îïåðàöèé (4 ÷àñà). Îñíîâíàÿ öåëü, êîòîðàÿ äîëæíà ïðå- ñëåäîâàòüñÿ - íå äîïóñòèòü ïîñëåîïåðàöèîííûõ îñëîæíåíèé Current knowledge related to the risk of CS when operating in ÊÑ è ÎÏÍ, ÷òî äèêòóåò íåîáõîäèìîñòü : 1) îïðåäåëèòü ïàöè- these positions (Lloyd Davies and Trendelenburg tilt) is such that åíòîâ ñ ðèñê ôàêòîðàìè (ñîñóäèñòûå ïàòîëîãèè, ñàõàðíûé it can be deemed negligent to keep patients in this position (with äèàáåò, ìèîäèñòðîôèè, õðîíè÷åñêèé àëêîãîëèçì è äð.); legs higher than the heart) when not absolutely necessary. If it 2) âûÿâèòü íàëè÷èå ñèíäðîìà íà ðàííåì ýòàïå; 3) ìåíÿòü means repositioning and redraping, thus adding a few extra min- ïîçèöèþ ïàöèåíòà (1-2 ðàçà íà íåñêîëüêî ìèíóò) âî âðåìÿ utes to the episode and costing a small amount in additional drapes, îïåðàöèè; 4) îáåñïå÷èòü äîñòàòî÷íóþ ïåðôóçèþ ïî÷åê (â/â surely this is a small price to pay for excellent perioperative care? òðàíñôóçèè - êîíòðîëü ÖÂÄ è äèóðåçà).

Íàó÷íàÿ ïóáëèêàöèÿ

ÈÑÑËÅÄÎÂÀÍÈÅ ÏÎ×Å×ÍÛÕ ÁÅËÊÎÂÛÕ ÊÎÌÏËÅÊÑÎÂ, ÏÎÄÀÂËßÞÙÈÕ ÝÊÑÏÐÅÑÑÈÞ ÃÅÍÎÂ Â ßÄÐÀÕ ÃÎÌÎÒÈÏÈ×ÅÑÊÈÕ ÊËÅÒÎÊ

Äçèäçèãóðè1 Ä.Â., ×èãîãèäçå2 Ò.Ã., Ìàíàãàäçå2 Ë.Ã., Àñëàìàçèøâèëè3 Ò.Ò., Êåðêåíäæèÿ1 Ñ.Ì.

1Òáèëèññêèé ãîñóäàðñòâåííûé óíèâåðñèòåò èì. È. Äæàâàõèøâèëè; 2Íàöèîíàëüíûé öåíòð óðîëîãèè èì. À. Öóëóêèäçå; 3Èíñòèòóò ýêñïåðèìåíòàëüíîé ìîðôîëîãèè èì. À.Í. Íàòèøâèëè ÀÍ Ãðóçèè

Çà ïîñëåäíèå äåñÿòèëåòèÿ â ïðàêòèêó óñïåøíî âíåäðå- Ìàòåðèàë è ìåòîäû. Ìàòåðèàëîì äëÿ èññëåäîâàíèÿ íû íîâûå ìåòîäû äèàãíîñòèêè çàáîëåâàíèé ïî÷åê. Íå- ñëóæèëè ïî÷êè èíòàêòíûõ áåëûõ êðûñ (150-170 ã) è ïîñò- ñìîòðÿ íà ýòî, ïî ñåé äåíü íå äîñòèãíóòî çíà÷èòåëüíûõ îïåðàöèîííûé ìàòåðèàë ÷åëîâåêà. Êðîìå òîãî, èñïîëü- óñïåõîâ â îáëàñòè èõ ëå÷åíèÿ. Íåðåøåííîé îñòàåòñÿ çîâàëè ïî÷å÷íóþ òêàíü áåëûõ êðûñ (120-130 ã), êîòî- ïðîáëåìà ëå÷åíèÿ îíêîëîãè÷åñêèõ çàáîëåâàíèé, ýòèî- ðûì ïðîâîäèëè îäíîñòîðîííþþ íåôðýêòîìèþ. ßäðà ëîãèÿ êîòîðûõ èçó÷åíà íåäîñòàòî÷íî è, ñëåäîâàòåëüíî, ïî÷å÷íîé òêàíè âûäåëÿëè ïî ìåòîäó Øîâî è ñîàâò. [5], õèðóðãè÷åñêîå ëå÷åíèå îñòàåòñÿ åäèíñòâåííûì ðàäè- ìîäèôèöèðîâàííîãî Ãèîðãèåâûì è ñîàâò. [1]. Êîëè÷åñ- êàëüíûì ñïîñîáîì. Èñõîäÿ èç ýòîãî, îäíèì èç âàæíåé- òâî ÄÍÊ â ÿäðàõ îïðåäåëÿëè ïî ìåòîäó Ñàäîâñêîãî è øèõ íàïðàâëåíèé ñîâðåìåííîé îíêîóðîëîãèè ÿâëÿåòñÿ Øòàéíåðà [16]. Äëÿ èçó÷åíèÿ òðàíñêðèïöèîííîé àêòèâ- ïîèñê íîâûõ ñïîñîáîâ ëå÷åíèÿ. íîñòè â ÿäðàõ ïî÷å÷íûõ ýïèòåëèîöèòîâ èñïîëüçîâàëè ÐÍÊ-ñèíòåçèðóþùóþ òåñò-ñèñòåìó. Ñèíòåç ÐÍÊ îöåíè- Èçâåñòíî, ÷òî ïðè÷èíîé ðàçâèòèÿ òÿæåëûõ çàáîëåâà- âàëè ïî âêëþ÷åíèþ ìå÷åíîãî ïðåäøåñòâåííèêà [14C]- íèé, âêëþ÷àÿ ðàê, ìîæåò áûòü óòðàòà èëè îñëàáëåíèå UTF â êèñëîòîíåðàñòâîðèìóþ ôðàêöèþ [8]. êîíòðîëÿ ïðîöåññîâ ïðîëèôåðàöèè è äèôôåðåíöè- ðîâêè. Îäíèì èç ìåõàíèçìîâ, ñ ïîìîùüþ êîòîðîãî Äëÿ âûäåëåíèÿ ÏÁÊ ïðèìåíÿëè ìåòîä ñïèðòîâîãî îñàæ- îñóùåñòâëÿåòñÿ ðåãóëÿöèÿ ýòèõ ïðîöåññîâ, ÿâëÿåòñÿ äåíèÿ áåëêîâ [4]. Ïîýòàïíûì íàñûùåíèåì 96î ýòàíî- âçàèìîäåéñòâèå êëåòêè ñ ðîñòîâûìè ôàêòîðàìè. Â ëîì âîäíîãî ãîìîãåíàòà òêàíåé ïîëó÷àëè 81% ñïèðòî- íàñòîÿùåå âðåìÿ èññëåäîâàíèÿ, ïîñâÿùåííûå èäåí- âóþ ôðàêöèþ, êîòîðóþ êèïÿòèëè íà âîäÿíîé áàíå òèôèêàöèè ýíäîãåííûõ ðîñòîâûõ ôàêòîðîâ, îñòàþò- (100îÑ) â òå÷åíèå 20 ìèí., îõëàæäàëè è çàòåì öåíòðèôó- ñÿ íà ñòàäèè èíòåíñèâíîãî èçó÷åíèÿ. Â ëèòåðàòóðå, â ãèðîâàëè - 15 ìèí. (600 g). Ñóïåðíàòàíò çàìîðàæèâàëè â îñíîâíîì, îïèñàíû ôàêòîðû, ñòèìóëèðóþùèå ïðî- æèäêîì àçîòå è çàòåì âûñóøèâàëè â àäñîðáöèîííî-êîí- ëèôåðàöèþ ýïèòåëèîöèòîâ [6,7,12]. Îäíàêî, äàííûå î äåíñàöèîííîì ëèîôèëèçàòîðå. ÏÁÊ ïîëó÷àëè â âèäå ôàêòîðàõ, èíãèáèðóþùèõ äåëåíèå ïî÷å÷íûõ êëåòîê, ñâåòëî-ñåðîãî, ëåãêî ðàñòâîðÿþùåãîñÿ â âîäå, ïîðîø- ìàëî÷èñëåííû. Íåîáõîäèìîñòü èçó÷åíèÿ ýòèõ ôàê- êà, êîòîðûé õðàíèëè â õîëîäèëüíèêå ïðè 4îÑ. Êîíöåíò- òîðîâ âûäåëÿåòñÿ ñâîåé àêòóàëüíîñòüþ, òàê êàê ïðî- ðàöèþ áåëêà â ÏÁÊ îïðåäåëÿëè ïî ìåòîäó Ëîóðè [14]. áëåìà íåîïëàñòè÷åñêèõ çàáîëåâàíèé îñòàåòñÿ âñå åùå íåðàçðåøåííîé. Æèâîòíûì ïîä íàðêîçîì ïðîâîäèëè îäíîñòîðîííþþ íåôðýêòîìèþ. ÏÁÊ (200ìêã/0,2ìë) ââîäèëè èíòðàïåðè- Ðàíåå íàìè áûëî ïîêàçàíî, ÷òî êëåòêè ïî÷åê ïîëîâîç- òîíåàëüíî äâàæäû, çà 30 ìèíóò, äî è ïîñëå îïåðàöèè. ðåëûõ áåëûõ êðûñ ñîäåðæàò áåëêîâûé êîìïëåêñ (ÁÊ), Æèâîòíûõ äåêàïèòèðîâàëè ïîä ýôèðíûì íàðêîçîì ñïó- êîòîðûé èíãèáèðóåò ðîñò ãîìîòèïè÷åñêèõ êëåòîê [10]. ñòÿ 6 ÷àñîâ ïîñëå îäíîñòîðîííåé íåôðýêòîìèè. Ïîêàçàíî, ÷òî ÁÊ ïî÷åê êðûñ ïîäàâëÿåò ïðîöåññ òðàíñ- êðèïöèè â ÿäðàõ êëåòîê ïî÷êè. Ïî÷å÷íûé áåëêîâûé êîì- Äëÿ ñðàâíèòåëüíîãî àíàëèçà ÏÁÊ ïðèìåíÿëè ìåòîä õðî- ïëåêñ (ÏÁÊ) òàêæå èíãèáèðóåò ñèíòåç ÐÍÊ â ÿäðàõ, âû- ìàòîãðàôèè ãèäðîôîáíîãî âçàèìîäåéñòâèÿ [15]. Ñòà- äåëåííûõ èç ðàêîâûõ êëåòîê (ðàê ïî÷êè RÑÑ) ÷åëîâåêà öèîíàðíîé ôàçîé ñëóæèë ìîäèôèöèðîâàííûé ôåíèëü- [9]. ÏÁÊ îáëàäàåò ñïîñîáíîñòüþ èíãèáèðîâàòü ïðîëè- íûìè ãðóïïàìè ãèäðîôèëüíûé ïîëèìåðíûé ñîðáåíò ôåðàòèâíóþ àêòèâíîñòü ãîìîòèïè÷íûõ êëåòîê êàê in HEMA BIO Phenyl-1000 (ðàçìåð ÷àñòèö 10 ìêì). Ïîä- vivo, òàê è in vitro. Â ÷àñòíîñòè, ïîêàçàíî, ÷òî ÏÁÊ êðû- âèæíàÿ ôàçà ïðåäñòàâëÿëà ôîñôàòíûé áóôåð(pH ), â

ñû ïóòåì ïîäàâëåíèÿ ýêñïðåññèè ãåíîâ â G1-ôàçå, âû- êîòîðûé ââîäèëè ñóëüôàò àììîíèÿ. Ýëþèðîâàíèå âå- çûâàåò èíãèáèðîâàíèå ôàçû ñèíòåçà ÄÍÊ è, ñîîòâåò- ëîñü ñ ïîäâèæíûìè ôàçàìè, ìîëÿðíîñòü êîòîðûõ ïî

ñòâåííî, äåëåíèå êëåòîê ìîíîñëîéíîé êóëüòóðû (NH4)2SO4 ìåíÿëàñü îò 2,0 Ì äî 0,0 Ì (äî ÷èñòîãî áóôå- (ÌÄÑÊ) [2]. ðà). Äîñòîâåðíîñòü äàííûõ îöåíèâàëè ïî êîýôôèöèåí- òó Ñòüþäåíòà (ð<0,01). Öåëüþ èññëåäîâàíèÿ ÿâèëîñü ñðàâíèòåëüíîå èçó÷åíèå ïî÷å÷íîãî áåëêîâîãî êîìïëåêñà, ïîëó÷åííîãî èç ïî- Ðåçóëüòàòû è èõ îáñóæäåíèå. Â ïðåäûäóùèõ ðàáîòàõ ÷å÷íûõ òêàíåé áåëûõ êðûñ è ÷åëîâåêà. íàìè áûëî óñòàíîâëåíî, ÷òî èíãèáèðóþùåå âëèÿíèå

50 GEORGIAN MEDICAL NEWS No 2 (143) Ôåâðàëü, 2007 ãîä

ÏÁÊ îáóñëîâëåíî íàëè÷èåì â íèõ ïî÷å÷íîãî ôàêòîðà [11]. Èñõîäÿ èç ýòîãî, ñ öåëüþ óñòàíîâëåíèÿ íàëè÷èÿ àêòèâíîãî êîìïîíåíòà â ÏÁÊ ÷åëîâåêà, ìû ïðîâåëè ñðàâíèòåëüíîå èçó÷åíèå äåéñòâèÿ ÏÁÊ êðûñ è ÷åëîâå- êà íà òðàíñêðèïöèîííóþ àêòèâíîñòü èçîëèðîâàííûõ ÿäåð êëåòîê ïî÷åê èíòàêòíûõ êðûñ. Â ðåçóëüòàòå èññëå- äîâàíèÿ áûëî óñòàíîâëåíî, ÷òî ÏÁÊ, ïîëó÷åííûé èç ðàêîâûõ êëåòîê ïî÷åê ÷åëîâåêà íå âûçûâàåò ïîäàâëå- íèÿ ñèíòåçà ÐÍÊ â ñèñòåìå èçîëèðîâàííûõ ÿäåð ïî÷åê èíòàêòíûõ êðûñ (ðèñ. 1,I), òîãäà êàê, ÏÁÊ êðûñ ïîäàâëÿ- åò ÐÍÊ-ñèíòåçèðóþùóþ àêòèâíîñòü ÿäåð ãîìîòèïè÷åñ- êèõ êëåòîê ïî ñðàâíåíèþ ñ êîíòðîëüíûì ïîêàçàòåëåì, â ñðåäíåì, íà 40% (ðèñ. 1,II). 120 % 100 Ðèñ. 2. Âëèÿíèå ÁÊ ïî÷åê êðûñ (I) è ÁÊ ðàêîâûõ êëåòîê ïî÷åê ÷åëîâåêà (II) íà òðàíñêðèïöèîííóþ àêòèâíîñòü 80 ÿäåð ïî÷å÷íûõ êëåòîê íåôðýêòîìèðîâàííûõ êðûñ

60 Áûëî èçó÷åíî òàêæå äåéñòâèå ÁÊ êëåòîê ãèäðîíåôðîòè- ÷åñêè èçìåíåííûõ ïî÷åê ÷åëîâåêà. Óñòàíîâëåíî, ÷òî, â 40 îòëè÷èå îò ÁÊ ðàêîâûõ êëåòîê, ÁÊ êëåòîê ãèäðîíåôðî- òè÷åñêè èçìåíåííûõ ïî÷åê ÷åëîâåêà ïîäàâëÿåò ñèíòåç 20 ÐÍÊ â ÿäðàõ êëåòîê ïî÷åê áåëûõ êðûñ (ðèñ. 3). Èíòåíñèâíîñòü ñèíòåçà ÐÍÊ, ÐÍÊ, ñèíòåçà Èíòåíñèâíîñòü 0 ê12 Ê-êîíòðîëü %

% 120 120 Ðèñ.1. Âëèÿíèå ÁÊ ïî÷åê êðûñ (I) è ÁÊ ðàêîâûõ êëåòîê ïî÷åê ÷åëîâåêà (II) íà òðàíñêðèïöèîííóþ àêòèâíîñòü 100 100 ÿäåð ïî÷å÷íûõ êëåòîê áåëûõ êðûñ 80 80 Ñîãëàñíî ëèòåðàòóðíûì äàííûì, ðîñòîâûå ôàêòîðû 6060 âàæíû êàê äëÿ ðåãóëÿöèè íîðìàëüíîãî, òàê è ðåïàðà- òèâíîãî ðîñòà. Îäíàêî, ìèòîãåííàÿ àêòèâíîñòü ýòèõ ôàê- 4040 òîðîâ çíà÷èòåëüíî ðàçëè÷àåòñÿ. Íà ïðèìåðå ïå÷åíè 20 áåëûõ êðûñ ïîêàçàíî, ÷òî ïîñëå ðåçåêöèè âîññòàíîâè- 20 òåëüíûé ðîñò îðãàíà íà÷èíàåòñÿ ñ àêòèâàöèè ãåíîâ ðàí- 0 íåãî îòâåòà [3,8,13]. Ïèê òðàíñêðèïöèîííîé àêòèâíîñòè Ðèñ. 3. Âëèÿíèå ÁÊ ãèäðîíåôðîòè÷åñêè èçìåíåííûõ (I) Èíòåíñèâíîñòü ñèíòåçà ÐÍÊ, ÈíòåíñèâíîñòüÐÍÊ, ñèíòåçà

Èíòåíñèâíîñòü ñèíòåçà ÐÍÊ, ÐÍÊ, ñèíòåçà Èíòåíñèâíîñòü 0 ýòèõk12 ãåíîâ ïðîÿâëÿåòñÿ íà 6-îé ÷àñ ïîñëå îïåðàöèè. èëè ðàêîâûõ ïî÷å÷íûõ êëåòîê (II) íà òðàíñêðèïöèîí- Ïîêàçàíî,ê12 òàêæå, ÷òî ïèê òðàíñêðèïöèîííîé àêòèâíîñ- íóþ àêòèâíîñòü ÿäåð ïî÷åê áåëûõ êðûñ Ê-êîíòðîëü Ê-êîíòðîëüòè ãåíîâ ðàííåãî îòâåòà ìåíåå âûðàæåí â êëåòêàõ òêà- íåé ñ íèçêîé ïðîëèôåðàòèâíîé àêòèâíîñòüþ, êàêîâîé Ïîëó÷åííûå äàííûå óêàçûâàþò íà ïðèñóòñòâèå â äàí- ÿâëÿåòñÿ ïî÷êà [8]. Îäíàêî, óñòàíîâëåíî, ÷òî îäíîñòî- íîì êîìïëåêñå ïî÷å÷íîãî ôàêòîðà (ÏÔ), êîòîðûé ïî- ðîííÿÿ íåôðýêòîìèÿ â ÿäðàõ êëåòîê îñòàâøåéñÿ ïî÷êè äàâëÿåò ñèíòåç ÐÍÊ â ñèñòåìå èçîëèðîâàííûõ ÿäåð. Äëÿ âûçûâàåò ñòèìóëÿöèþ ñèíòåçà ÐÍÊ. Èñõîäÿ èç âûøå- ñðàâíèòåëüíîãî àíàëèçà ÏÁÊ ïðèìåíÿëè ìåòîä õðîìàòî- ñêàçàííîãî, ìû èññëåäîâàëè âëèÿíèå ÏÁÊ êðûñû è ÷å- ãðàôèè ãèäðîôîáíîãî âçàèìîäåéñòâèÿ. Ïðèâåäåííûå ëîâåêà íà ñèíòåç ÐÍÊ â ÿäðàõ êëåòîê îñòàâøåéñÿ ïî÷êè, íà ðèñ. 4 õðîìàòîãðàììû ïîêàçûâàþò ãèäðîôèëüíûå è ïîñëå óäàëåíèÿ îäíîãî èç ïàðíûõ îðãàíîâ (îäíîñòîðîí- ãèäðîôîáíûå êîìïîíåíòû ÁÊÏ êðûñû (ðèñ. 4.1), ÁÊ íÿÿ íåôðýêòîìèÿ). Èç ïðåäñòàâëåííûõ íà ðèñ. 2 äèà- êëåòîê ãèäðîíåôðîòè÷åñêè èçìåíåííûõ ïî÷åê (ðèñ. 4.II) ãðàìì ñëåäóåò, ÷òî ÏÁÊ êðûñû èíãèáèðóåò ïðîöåññ è ÁÊ ðàêîâûõ êëåòîê ïî÷åê ÷åëîâåêà. Èç ðèñóíêà 4.I ñëå- òðàíñêðèïöèè â ÿäðàõ êàê èíòàêòíûõ, òàê è ñòèìóëèðî- äóåò, ÷òî ÁÊÏ êðûñû ñîäåðæèò ãèäðîôèëüíûé êîìïî- âàííûõ ê ïðîëèôåðàöèè êëåòîê ïî÷êè êðûñ (ðèñ. 2.I). íåíò ñî âðåìåíåì óäåðæèâàíèÿ 5,5 ìèí. (ïî âðåìåíè Ñïîñîáíîñòü ÏÁÊ ÷åëîâåêà èíãèáèðîâàòü ñèíòåç ÐÍÊ óäåðæèâàíèÿ ñîîòâåòñòâóþùèé öèòîõðîìó - Ñ). Ðàíåå íå áûëà îáíàðóæåíà è â ýòîé ñåðèè îïûòîâ (ðèñ. 2.II). íàìè áûëî ïîêàçàíî, ÷òî ãèäðîôèëüíûé êîìïîíåíò

ÿâëÿåòñÿ áåëêîì ñ ìîëåêóëÿðíîé ìàññîé 12 êÄà [2,11]. ÿäåðíîãî ãåíîìà íà ðàííûõ ñòàäèÿõ ðåãåíåðàöèè ïå÷åíè // Ïîâûøåíèå ôîíà ÷åðåç 30 ìèí. óêàçûâàåò íà ïðèñóò- Áèîõèìèÿ. - 1980. - Ò. 45. - Ñ. 565-658. ñòâèå ãèäðîôîáíîãî êîìïîíåíòà â ÁÊ. Àíàëîãè÷íûå 4. Balazs A., Blazsek I. Control of cell proliferation by endog- êîìïîíåíòû ïðèñóòñòâóþò â ÁÊ êëåòîê ãèäðîíåôðîòè- enous inhibitors // Akademia Kiado. – Budapest: 1979. - C. 302. 5. Chauveau J., Moule Y., Rouiller Ch. Isolation of pure and ÷åñêè èçìåíåííûõ ïî÷åê (ðèñ. 4.II). unaltered liver nuclei: Morphology and biochemical composi- tion // Exp. Cell Res. - 1956. - vol. 11.- P. 317-321. 6. Ferrara N., Houck K.A., Jakeman L.B., Winer J., Leung D.W. The vascular endothelial growth factor family of polypeptides // J Cell Biochem. - 1991. - vol. 47. - P. 211-218. 7. Folkman J., Shing Y. Angiogenesis // J Biol Chem. - 1992. - vol. 267. - P. 10931-10934. 8. Dzidziguri D., Chelidze p., Zarandia M., Cherkezia E.O., Tumanishvili G. The transcriptional activity and ultrastrukture of various nucleolar types isolated from normal and partially hepatectomized rat hepatocytes // J. Epith. Cell Biol. – 1994. - vol. 3. - P. 54-60. 9. Dzidziguri D., AslamaziSvili T., Chxobadze M., Khorava P., Chigogidze T., Managadze L. The influence of protein factor of white rat on transcriptional activity of intact and tranformed cells // Proc. Georgian Acad. Sci. Biol. Ser. – 2004. - vol. 2. - P. 65-69. 10. Dzidziguri D., Chigogidze T., Chxobadze M., Mepharishvili A., Khurodze P., Managadze L. The study of proliferative in- hibitory factor of kidney epitheliocytes. // In: IV internat. Sci. conf. “The actual questions of theoretical and practical medicine and biology”. - Tskaltubo. 2002. - P. 134-136. 11. Giorgobiani N., Dzidziguri D., Rukhadze M., Rusishvili L., Tumanishvili G. Possible role of endogenous growth inhibitors in regeneration of organs: searching for new approaches // Cel Biol Intern. - 2005. - N 29(12). - P. 1047-1049. 12. Leung, D.W., Cachianes G., Kuang W.J., Goeddel D.V., Fer- rara N. Vascular endothelial growth factor is a secreted angiogen- ic mitogen // Science. - 1989. - vol. 246. - P. 1306-1309. 13. Lodish H., Berk A., Zipursky S.L., Matsudaira P., Baltimore D., Darnell J.E. Molecular Cell Biology. - New York: W.H. Free- Ðèñ. 4. Õðîìàòîãðàììà ÁÊ êëåòîê ïî÷åê èíòàêòíûõ man and Company. – 2000. - P. 526-527. êðûñ (I), ãèäðîíåôðîòè÷åñêè èçìåíåííûõ (II) è ðàêî- 14. Lowry D.H., Rosenbrough N.J., Farr A.L., Randell R.J. Pro- âûõ ïî÷åê ÷åëîâåêà (III) tein measurment with the folin phenol reagent // J. Biol. Chem. - 1951. - vol. 193. - P. 265-275. Òàêèì îáðàçîì, ñîãëàñíî ïîëó÷åííûì íàìè ðåçóëüòà- 15. Queiroz J.A., Tomaz C.T., Cabral J.M.S. Hydrophobic in- òàì, ïî÷å÷íûå êëåòêè ÷åëîâåêà ñîäåðæàò àíàëîãè÷íûé teraction chromatography of proteins // J.of Chromatography. - ôàêòîð áåëêîâîé ïðèðîäû, êîòîðûé íå ýêñïðåññèðóåò- 2001. - vol. 87. - P. 143-159. ñÿ â ðàêîâûõ êëåòêàõ. ÏÔ íå îáëàäàåò âèäîâîé ñïåöè- 16. Sadowski P.D., Steiner J.W. Electron Microscopic And Bio- ôè÷íîñòüþ è ïîýòîìó åãî ìîæíî âêëþ÷èòü â îïèñàí- chemical Characteristics Of Nuclei And Nucleoli Isolated From Rat Liver // Cell BIol. – 1968. - vol. 37. - P. 147-164. íîå íàìè ðàíåå [2,11] ñåìåéñòâî ôèëîãåíåòè÷åñêè êîí- ñåðâàòèâíûõ áåëêîâ, äàëüíåéøåå èññëåäîâàíèå êîòîðûõ SUMMARY âíåñåò çíà÷èòåëüíûé âêëàä â ïîíèìàíèå áèîëîãè÷åñ- êèõ îñíîâ ðàêà. KIDNEY PROTEIN COMPLEXES THAT INHIBIT GENE EXPRESSION IN THE NUCLEI OF HOMOTYPIC ËÈÒÅÐÀÒÓÐÀ CELLS

1. Ãåîðãèåâ Ã.Ï., Åðìîëàåâà Ë.Ï., Çáàðñêèé È.Â. Êîëè÷å- Dzidziguri1 D., Chigogidze2 T., Managadze2 L., Aslamazish- ñòâåííîå ñîîòíîøåíèå áåëêîâûõ è íóêëåîïðîòåèäíûõ ôðàê- vili3 T., Kerkenjia1 S. öèè è êëåòî÷íûõ ÿäðàõ ðàçëè÷íûõ òêàíåé // Áèîõèìèÿ. - 1960. - Ò. 24. - âûï. 2. - Ñ. 318-322. 1I.Javakhishvili Tbilisi State University, 2Tsulukidze National 2. Äçèäçèãóðè Ä.Â., Èîáàäçå È.Ð., Àñëàìàçèøâèëè Ò.Ò., Òó- Center of Urology, 3A.Natishvili Institute of Experimental Mor- ìàíèøâèëè Ã.Ä. Áàõóòàøâèëè Â.È., ×èãîãèäçå Ò.Ã., Ìàíà- phology, Georgian Academy of Sciences ãàäçå Ë.Ã. Ñðàâíèòåëüíîå èçó÷åíèå âëèÿíèÿ ýíäîãåííûõ ïî- ÷å÷íûõ ôàêòîðîâ íà ïðîëèôåðàòèâíóþ àêòèâíîñòü ýïèòåëè- The comparative study of protein complexes (PCs) isolated by îöèòîâ // Öèòîëîãèÿ. - 2005. - ò. 47(6). - Ñ. 497-500. alcohol extraction from white rat and human nephrocytes (post- 3. Ïëàòîíîâ Î.À., Ëèñèöà Ý.Ã. Îñîáåííîñòè òðàíñêðèïöèè operational material) have been performed. It has been shown

52 GEORGIAN MEDICAL NEWS No 2 (143) Ôåâðàëü, 2007 ãîä that PCs of white rat cells inhibit RNA synthesis in the nuclei of that the active component of PCs (12 kDa protein factor) which intact as well as nephrectomized (unilateral nephrectomy) ani- had been detected earlier has not been shown up in cancer cells mals. The same effect has been shown while studying the PCs of of human kidney. patients with hydronephrotic kidneys. At the same time the inhibition of transcription has not been detected in case of RCC Key words: kidney, protein factor, inhibition, transcrip- kidney cancer cell PCs. The chromatography studies revealed tion.

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ÈÑÑËÅÄÎÂÀÍÈÅ ÏÎ×Å×ÍÛÕ ÁÅËÊÎÂÛÕ ÊÎÌÏËÅÊÑÎÂ, ÏÎÄÀÂËßÞÙÈÕ ÝÊÑÏÐÅÑÑÈÞ ÃÅÍÎÂ Â ßÄÐÀÕ ÃÎÌÎÒÈÏÈ×ÅÑÊÈÕ ÊËÅÒÎÊ

Äçèäçèãóðè1 Ä.Â., ×èãîãèäçå2 Ò.Ã., Ìàíàãàäçå2 Ë.Ã., Àñëàìàçèøâèëè3 Ò.Ò., Êåðêåíäæèÿ1 Ñ.Ì.

Ïðîâåäåíî ñðàâíèòåëüíîå èçó÷åíèå áåëêîâûõ êîìïëåêñîâ ÁÊ êëåòîê ïàöèåíòîâ ñ ïàòîëîãè÷åñêè èçìåíåííûìè ïî÷- (ÁÊ), âûäåëåííûõ ìåòîäîì ñïèðòîâîé ýêñòðàêöèè èç êëå- êàìè (ãèäðîíåôðîç). Ïîäàâëåíèå ïðîöåññà òðàíñêðèïöèè òîê ïî÷åê áåëûõ êðûñ è ÷åëîâåêà (ïîñòîïåðàöèîííûé ìà- íå îáíàðóæåíî â ñëó÷àå ÁÊ îïóõîëåâûõ êëåòîê (ðàê ïî- òåðèàë). Óñòàíîâëåíî, ÷òî ÁÊ êëåòîê áåëûõ êðûñ ïîäàâ- ÷åê RCC). Ìåòîäîì õðîìàòîãðàôèè âûÿâëåíî, ÷òî îáíà- ëÿåò ñèíòåç ÐÍÊ â ÿäðàõ ïî÷å÷íûõ êëåòîê èíòàêòíûõ è ðóæåííûé íàìè ðàíåå àêòèâíûé êîìïîíåíò ÁÊ (áåëêîâûé íåôðýêòîìèðîâàííûõ (îäíîñòîðîííÿÿ íåôðýêòîìèÿ) æè- ôàêòîð - ìîëåêóëÿðíàÿ ìàññà 12 Êä) íå ïðîÿâëÿåòñÿ â ÁÊ âîòíûõ. Àíàëîãè÷íûé ýôôåêò ïîëó÷åí ïðè èññëåäîâàíèè ðàêîâûõ êëåòîê ïî÷êè ÷åëîâåêà.

Íàó÷íàÿ ïóáëèêàöèÿ

ÒÐÀÍÑÓÐÅÒÐÀËÜÍÎÅ ËÅ×ÅÍÈÅ ÄÎÁÐÎÊÀ×ÅÑÒÂÅÍÍÎÉ ÃÈÏÅÐÏËÀÇÈÈ ÏÐÅÄÑÒÀÒÅËÜÍÎÉ ÆÅËÅÇÛ ÁÎËÜØÈÕ ÐÀÇÌÅÐÎÂ

Ìàíàãàäçå Ë.Ã., Õâàäàãèàíè Ã.Ã., Àáäóøåëèøâèëè Ê.Î., Ìàíàãàäçå Ã.Ë., Áåðóëàâà Ä.Ò.

Íàöèîíàëüíûé öåíòð óðîëîãèè èì. À. Öóëóêèäçå

Äîáðîêà÷åñòâåííàÿ ãèïåðïëàçèÿ ïðîñòàòû (ÄÃÏ) - ïðî- ëîãîâ (ÀÀÓ) [2,10]. Â ïîñëåäíèå ãîäû îïóáëèêîâàíû ãðåññèðóþùåå çàáîëåâàíèå, êîòîðîå ñóùåñòâåííî ñíè- ðàáîòû, êîòîðûå ïîñâÿùåíû ÒÓÐÏ ïàöèåíòîâ ñ àäåíî- æàåò êà÷åñòâî æèçíè ïàöèåíòîâ, à â äàëåêîçàøåäøèõ ìîé áîëüøèõ ðàçìåðîâ [3,8]. Ñîãëàñíî ýòèì èññëåäîâà- ñëó÷àÿõ âûçûâàåò îñëîæíåíèÿ: îñòðóþ è õðîíè÷åñêóþ íèÿì, ÒÓÐ àäåíîìû áîëüøèõ ðàçìåðîâ - äîñòàòî÷íî çàäåðæêó ìî÷è, õðîíè÷åñêóþ ïî÷å÷íóþ íåäîñòàòî÷- ýôôåêòèâíûé è áåçîïàñíûé ìåòîä õèðóðãè÷åñêîãî âìå- íîñòü (ÕÏÍ), àçîòåìèþ. Õèðóðãè÷åñêîå ëå÷åíèå ÄÃÏ øàòåëüñòâà, õîòÿ åäèíîãî ìíåíèÿ ïî äàííîìó âîïðîñó ïîêàçàíî â ñëó÷àå íåýôôåêòèâíîñòè ìåäèêàìåíòîçíîé íå ñóùåñòâóåò. òåðàïèè. Îòêðûòàÿ ïðîñòàòýêòîìèÿ è òðàíñóðåòðàëüíàÿ ðåçåêöèÿ ïðîñòàòû (ÒÓÐÏ) ÿâëÿþòñÿ îñíîâíûìè õèðóð- Öåëüþ íàøåãî èññëåäîâàíèÿ ÿâèëîñü èçó÷åíèå ðå- ãè÷åñêèìè ìåòîäàìè ëå÷åíèÿ. Áîëüøèíñòâî óðîëîãè- çóëüòàòîâ òðàíñóðåòðàëüíîé ðåçåêöèè ïðîñòàòû áîëü- ÷åñêèõ êëèíèê âûïîëíÿþò ÒÓÐÏ ïàöèåíòàì ñ ïðîñòà- øèõ ðàçìåðîâ ïî ìàòåðèàëàì Íàöèîíàëüíîãî öåíòðà òîé âåñîì â ïðåäåëàõ 25-80 ãð., à â ñëó÷àÿõ áîëåå áîëü- óðîëîãèè. øèõ ðàçìåðîâ ïðèáåãàþò ê îòêðûòîé àäåíîìýêòîìèè, ÷òî ðåêîìåíäîâàíî ãàéäëàèíàìè Åâðîïåéñêîé àññîöè- Ìàòåðèàë è ìåòîäû. Ñ ÿíâàðÿ 2001 ãîäà ïî äåêàáðü 2002 àöèè óðîëîãîâ (ÅÀÓ) è Àìåðèêàíñêîé àññîöèàöèè óðî- ãîäà 522-óì ïàöèåíòàì ñ ÄÃÏ âûïîëíåí ÒÓÐÏ. Áîëü-

íûå â çàâèñèìîñòè îò âåñà ïðîñòàòû ðàñïðåäåëåíû íà ñòè “Ïóðèñîëü”. Ïðèìåíÿëñÿ ýëåêòðîíîæ Fx 150 w ïðè ïÿòü ãðóïï. Ïåðåä îïåðàöèåé âñå áîëüíûå áûëè îá- ðåçåêöèè è 60 w ïðè êîàãóëÿöèè. Âñå îïåðàöèè âûïîë- ñëåäîâàíû: ïðîâåäåíî ðåêòàëüíîå ïàëüöåâîå èññëåäî- íåíû ãðóïïîé îïûòíûõ óðîëîãîâ, ñî ñòàæåì âûïîëíå- âàíèå (ÐÏÈ), òðàíñàáäîìèíàëüíîå óëüòðàçâóêîâîå èñ- íèÿ ÒÓÐÏ áîëåå 10-è ëåò. ñëåäîâàíèå (ÒÀÓÈ) ñ öåëüþ îïðåäåëåíèÿ îáúåìà ïðî- ñòàòû è íàëè÷èÿ îñòàòî÷íîé ìî÷è, óðîôëîóìåòðèÿ Âñåì áîëüíûì ñ öåëüþ ïðîôèëàêòèêè ïàðåíòåðàëüíî (Qmax), îáùèé àíàëèç êðîâè è ìî÷è. Ïåðåä îïåðàöè- íàçíà÷àëè àíòèáèîòèêè. Â ñëó÷àÿõ, êîãäà ðåçåêöèÿ äëè- åé, èñïîëüçóÿ ìåæäóíàðîäíóþ ñèñòåìó ñóììàðíîé ëàñü áîëåå 60 ìèíóò, â/â ââîäèëè 20 ìã ôóðîñèìèäà. îöåíêè ñèìïòîìîâ ïðè çàáîëåâàíèÿõ ïðåäñòàòåëüíîé Ôèêñèðîâàëè âðåìÿ îïåðàöèè, è îïðåäåëÿëè ìàññó ðå- æåëåçû è êà÷åñòâà æèçíè (I-PSS), êîëè÷åñòâåííî îöå- çåöèðîâàííîé ïðîñòàòû. Ïîñëå îïåðàöèè óðåòðàëüíî íèâàëèñü ñèìïòîìû çàáîëåâàíèÿ. Ïðåäîïåðàöèîííî, óñòàíàâëèâàëè êàòåòåð Ôîëåÿ 20-22 Fr è íàäëîáêîâî - âñåì ïàöèåíòàì âûïîëíåíà óðåòåðîöèñòîñêîïèÿ ñ öå- 16 Fr. Ïðîìûâàíèå ìî÷åâîãî ïóçûðÿ ïðîäîëæàëîñü äî ëüþ èñêëþ÷åíèÿ ïàòîëîãèè óðåòðû è ìî÷åâîãî ïóçû- ïðåêðàùåíèÿ ãåìàòóðèè. Óðåòðàëüíûé êàòåòåð óäàëÿ- ðÿ. Â èññëåäîâàíèå áûëè âêëþ÷åíû ïàöèåíòû ñ ìàñ- ëè, êàê ïðàâèëî, íà 2-îé èëè 3-èé äåíü. Âûïèñûâàëè ñîé ïðîñòàòû 25 ñì3 è áîëåå. Áîëüíûå ñ ïîäîçðåíèåì ïàöèåíòà ÷åðåç äåíü ïîñëå óäàëåíèÿ êàòåòåðà. Q max, èëè ïîäòâåðæäåííûì äèàãíîçîì ðàêà ïðîñòàòû è ìî- I-PSS è íàëè÷èå îñòàòî÷íîé ìî÷è îöåíèâàëèñü ÷åðåç ÷åâîãî ïóçûðÿ, ñòðèêòóðîé óðåòðû, ðàíåå îïåðèðî- òðè ìåñÿöà è ÷åðåç ãîä ïîñëå îïåðàöèè. âàííûå ïî ïîâîäó ïðîñòàòû è ñ ñåðüåçíûìè ñîïóò- ñòâóþùèìè çàáîëåâàíèÿìè [1] â èññëåäîâàíèå íå Ðåçóëüòàòû è èõ îáñóæäåíèå. 101 ïàöèåíò èç 522-õ áûë âêëþ÷åíû. èñêëþ÷åí èç èññëåäîâàíèÿ: 11 - ââèäó ðàíåå ïðîâåäåí- íûõ îïåðàöèé íà ïðîñòàòå, 29 - ñ ñîïóòñòâóþùèìè çà- ÒÓÐÏ âûïîëíÿëñÿ ïîä ïåðèäóðàëüíîé àíåñòåçèåé ñ èñ- áîëåâàíèÿìè, 8 – ñî ñòðèêòóðîé óðåòðû, 53 – ñ äèâåðòè- ïîëüçîâàíèåì ìîíèòîðà âûñîêîãî ðàçðåøåíèÿ (Sony êóëîì èëè êàìíÿìè ìî÷åâîãî ïóçûðÿ. Îñòàëüíûå (421) Trinitron), âèäåîêàìåðû ñèñòåìû Urocam. Âñå ÒÓÐÏ ïàöèåíòû áûëè ðàñïðåäåëåíû íà ïÿòü ãðóïï: I ãðóïïà - âûïîëíÿëèñü íà ôîíå “íèçêîãî äàâëåíèÿ” ïðè íàäëîá- 163 ïàöèåíòà ñ ïðîñòàòîé ðàçìåðîì â ïðåäåëàõ îò 25 äî êîâîé òðîàêàðíîé (Reuter) ýïèöèñòîñòîìèè (16 Fr). Ðå- 60 ñì3, II ãðóïïà - 156 áîëüíûõ ñ ïðîñòàòîé - îò 61 äî çåêöèÿ ïðîñòàòû âûïîëíÿëàñü ðåçåêòîñêîïîì 24-27 Fr 100 ñì3, III ãðóïïà - 48 ïàöèåíòîâ ñ ðàçìåðîì ïðîñòàòû (ïðè ìàëåíüêèõ ðàçìåðàõ ïðîñòàòû èñïîëüçîâàëè 24 Fr, îò 101 äî 150 ñì3, IV ãðóïïà - 47 ïàöèåíòîâ (151-200 ñì3) à ïðè áîëüøèõ - 27 Fr) ñî ñòàíäàðòíîé ïåòëåé ñ èñïîëü- è V ãðóïïà - 7 ïàöèåíòîâ ñ ïðîñòàòîé áîëåå 201 ñì3. Â çîâàíèåì ïîäîãðåòîé äî 370 Ñ èððèãàöèîííîé æèäêî- òàáëèöå 1 ïðèâåäåíû äàííûå äî îïåðàöèè. Òàáëèöà 1. Êëèíè÷åñêàÿ õàðàêòåðèñòèêà áîëüíûõ äî îïåðàöèè

I ãðóïïà II ãðóïïà III ãðóïïà IV ãðóïïà V ãðóïïà

n=163 n=156 n=48 n=47 n=7 70,4 72,3 74,8 75 Âîçðàñò 65,5 (42-78) (53-80) (54-81) (53-84) (70-76) 82,4 (61- 175,2 (150- 272 Ðàçìåðû ïðîñòàòû (ñì3) 49,8 (25-60) 128 (101-150) 100) 200) (200-333) 2,11 4,29 (0,11- PSA 2,84 (0,1-14) 6,08 (0,2-21,5) 12,73 (3,92-27) (0,1-8,8) 17,5) 8,4 8,8 7,3 6,8 4,8 Qmax (1,2-11,3) (1,1-12,1) (0,3-10,3) (1,2-9,8) (4,6-5,3) 20,5 21,7 22,6 23,4 22,3 I-PSS (18-24) (18-24) (17-24) (17-23) (18-24) 254,2 (100- 344,3 Íàëè÷èå îñòàòî÷íîé ìî÷è 226,3 (50-900) 296 (250-900) 350 (150-700) 1100) (100-1000) Çàäåðæêà ìî÷è 39 (23,4%) 43 (27,6%) 15 (31,3%) 17 (36,2%) 2 (28,6%)

Ïðîäîëæèòåëüíîñòü îïåðàöèé â I ãðóïïå áûëà çíà÷è- (3,1%) ïàöèåíòàì, ó îäíîãî (0,6%) ïàöèåíòà íàáëþäà- òåëüíî ìåíüøå, ÷åì â îñòàëüíûõ 4-õ ãðóïïàõ, à ìàññà ëîñü íåäåðæàíèå ìî÷è, à ó 2-õ (1,2%) ðàçâèëàñü ñòðèê- ðåçåöèðîâàííîé ïðîñòàòû çíà÷èòåëüíî áîëüøå ó áîëü- òóðà óðåòðû. Âî II ãðóïïå îñëîæíåíèÿ íàáëþäàëèñü ó íûõ V ãðóïïû. Îñëîæíåíèÿ íàáëþäàëèñü âñåãî ó 52-õ 19-è (12,2%) áîëüíûõ èç 156-è. Â 12-è (7,7%) ñëó÷àÿõ (12,4%) ïàöèåíòîâ èç 421-ãî; â I ãðóïïå - â 18-è (11,4%) ïîòðåáîâàëàñü ãåìîòðàíñôóçèÿ, ó 2-õ (1,3%) ðàçâèëàñü ñëó÷àÿõ èç 163-õ, èç íèõ ó 10-è (6%) áîëüíûõ îòìå÷àëîñü ñòðèêòóðà óðåòðû, à â îäíîì ñëó÷àå (0,6%) - íåäåðæà- èíòðàîïåðàöèîííîå êðîâîòå÷åíèå, ÷òî ïîòðåáîâàëî ãå- íèå ìî÷è. Ïîâòîðíàÿ êîàãóëÿöèÿ ïîòðåáîâàëàñü â 4-õ ìîòðàíñôóçèè. Ïîâòîðíàÿ êîàãóëÿöèÿ ïðîèçâåäåíà 5-è (2,6%) ñëó÷àÿõ. Â III ãðóïïå ó 6-è (12,5%) èç 48-è áîëü-

54 GEORGIAN MEDICAL NEWS No 2 (143) Ôåâðàëü, 2007 ãîä

íûõ îòìå÷àëèñü îñëîæíåíèÿ, â ÷àñòíîñòè, èíòðàîïåðà- Â V ãðóïïå ó îäíîãî áîëüíîãî èç 7-è íàáëþäàëîñü èíò- öèîííîå êðîâîòå÷åíèå ó 4-õ (8,3%), ñòðèêòóðà óðåòðû - ðàîïåðàöèîííîå êðîâîòå÷åíèå, ÷òî ïîòðåáîâàëî ãåìî- ó îäíîãî (2,1%). Ïîâòîðíàÿ êîàãóëÿöèÿ ïðîèçâåäåíà òðàíñôóçèè. îäíîìó (2,1%) áîëüíîìó. Ñóùåñòâåííûõ ðàçëè÷èé â êîëè÷åñòâå è êà÷åñòâå îñ- Ó áîëüíûõ IV ãðóïïû îñëîæíåíèÿ îòìå÷åíû â 7-è ëîæíåíèé, à òàêæå â ïðîäîëæèòåëüíîñòè êàòåòåðèçà- (14,7%) ñëó÷àÿõ èç 47-è. Â 4-õ (8,5%) ñëó÷àÿõ íàáëþäà- öèè è ïîñëåîïåðàöèîííîì âðåìåíè íàõîæäåíèÿ â ñòà- ëèñü èíòðàîïåðàöèîííûå êðîâîòå÷åíèÿ, â òîì ÷èñëå öèîíàðå ìåæäó èññëåäóåìûìè ãðóïïàìè íå âûÿâëå- ïîâòîðíàÿ êîàãóëÿöèÿ âûïîëíåíà â 2-õ (4,3%) ñëó÷àÿõ. íî (òàáëèöà 2).

Òàáëèöà 2 Êëèíè÷åñêàÿ õàðàêòåðèñòèêà áîëüíûõ ïîñëå îïåðàöèè I ãðóïïà II ãðóïïà III ãðóïïà IV ãðóïïà V ãðóïïà

n=163 n=156 n=48 n=47 n=7 Ñðåäíåå âðåìÿ îïåðàöèè 35 (15-45) 45,8 (25-50) 57,8 (45-70) 59,4 (50-85) 70 (60-90) Ñðåäíÿÿ ìàññà ðåçèöèðîâàííîé 25 47,3 62,7 91,2 158,2 òêàíè (15-35) (26-57) (55-110) (70-145) (120-180) Ñðåäíåå âðåìÿ óäàëåíèÿ êàòåòåðà 2 (2-5) 3 (2-5) 3 (2-6) 3 (3-5) 4 (3-5) Ñðåäíåå âðåìÿ âûïèñêè èç 3 (3-5) 4 (4-5) 5 (4-5) 5 (4-6) 6(5-7) ñòàöèîíàðà Êîë-âî îñëîæíåíèé 18 (11,4%) 19 (12,2%) 6 (12,5%) 7 (14,7%) 1 (14%) êðîâîòå÷åíèÿ, êîòîðûå 10 (6%) 12 (7,7%) 4 (8,3%) 4 (8,5%) 1 (14%) ïîòðåáîâàëè ãåìîòðàíñôóçèþ Êîë-âî ïîñëåîïåðàöèîíûõ 2 (1,2%) 2 (1,3%) 1 (2,1%) 0 0 ñòðèêòóð óðåòðû Êîë-âî ïàöèåíòîâ ñ íåäåðæàíèåì 1 (0,6%) 1 (0,6%) 0 1 (2,1%) 0 ìî÷è

Ïîâòîðíàÿ êîàãóëÿöèÿI ãðóïïà II ãðóïïà 5 (3,1%) III ãðóïïà 4 (2,6%) IV ãðóïïà 1 (2%) V ãðóïïà 2 (4,3%) 0 Äàííûå ïîñëå 3-õ ìåñÿöåâ n=163 n=156 n=48 n=47 n=7 16,1 16,8 16,5 15,2 16,2 QmaxÂðåìÿ ðåçåêöèè ñòàòèñòè÷åñêè ðàçëè÷àëîñü ìåæäó íà÷èíàÿ ñ I ãðóïïû ïî V âêëþ÷èòåëüíî. I è V ãðóïïàìè - (13,6-19,6)áîëåå äëèòåëüíûì (15,6-17,9) áûëî â V ãðóï-(14,6-18,8) (14,3-18,6) (14,3-18,3) I-PSSïå è ñîñòàâèëî, ñîîòâåòñòâåííî, 7,6 (5-11) 35 8,2 è 70(4-10) ìèíóò. Ìåæ- 8,5 (5-11)Ïîñëå 3-õ 7,7 ìåñÿöåâ (5-11) è 1 ãîäà 5 (4-7)áîëüíûå áûëè îáñëåäîâà- PVRäó II, III è IV ãðóïïàìè 28 (0-150) ñòàòèñòè÷åñêè 26 (0-100) äîñòîâåðíûõ 10 (0-60)íû ñ îïðåäåëåíèåì 12 (0-50) Qmax, 5 (0-25) I-PSS è íàëè÷èÿ îñòàòî÷- Äàííûå ÷åðåçðàçëè÷èé 12 ìåñ, íå âûÿâëåíî. ×òî êàñàåòñÿ ñðåäíåé ìàñ- íîé ìî÷è. Âî âñåõ 5-è ãðóïïàõ îòìå÷àëîñü óëó÷øå- 19,1 18,8 18,3 18,3 17,5 Qmaxñû ðåçåöèðîâàííîé òêàíè, òî îíà óâåëè÷èâàëàñü íèå óêàçàííûõ ïîêàçàòåëåé (òàáëèöà 3). (16,2-23,5) (14,8-23,2) (14,2-22,5) (15,3-23,5) (15,5-21,4) I-PSS Òàáëèöà 2 (1-3) 3. Êëèíè÷åñêèå 3(1-5) ïîêàçàòåëè áîëüíûõ 2,5(1-4) ñïóñòÿ 3 2 è(1-3) 12 ìåñÿöåâ ïîñëå 2 (1-4) îïåðàöèè PVR 0,2 (0-20) 3,2 (0-35) 2,6 (0-25) 2,1 (0-40) 4 (0-30)

Íåñìîòðÿ íà òî, ÷òî èäåàëüíûì ìåòîäîì ëå÷åíèÿ ðîâ 5 àëüôà-ðåäóêòàçû, ñ ïîìîùüþ êîòîðûõ ñíèæà- ÄÃÏ ÿâëÿåòñÿ ÒÓÐÏ [3,9,10], â Åâðîïå è ÑØÀ çà ïîñ- åòñÿ ïðîãðåññèðîâàíèå ÄÃÏ. Ñ ðàçâèòèåì íîâûõ, ëåäíèå ãîäû ñóùåñòâåííî ïîíèçèëèñü ïîêàçàòåëè ìåíåå èíâàçèâíûõ ïðîöåäóð, ïðè ñîõðàíåíèè ýôôåê- ñëó÷àåâ ïðèìåíåíèÿ óêàçàííîãî ìåòîäà îïåðàòèâ- òèâíîñòè ëå÷åíèÿ áîëüøîå âíèìàíèå óäåëÿåòñÿ ñíè- íîãî âìåøàòåëüñòâà, ÷òî îáóñëîâëåíî øèðîêèì âíå- æåíèþ äî ìèíèìóìà îñëîæíåíèé ÒÓÐÏ è ñòîèìîñ- äðåíèåì â ïðàêòèêó àëüôà-áëîêàòîðîâ è èíãèáèòî- òè ëå÷åíèÿ.

Â íàñòîÿùåå âðåìÿ, íàèáîëåå äèñêóòàáåëüíûì ÿâëÿåò- æàíèå ìî÷è â ðàííåì ïîñòîïåðàöèîííîì ïåðèîäå - ñÿ âûáîð ìåòîäà îïåðàòèâíîãî ëå÷åíèÿ äîáðîêà÷å- 3,7%. Íà íàøåì ìàòåðèàëå ÷àñòîòà îñëîæíåíèé áûëà ñòâåííûõ àäåíîì áîëüøèõ ðàçìåðîâ, â ÷àñòíîñòè, ðå- íèæå, ÷åì ïîñëå àäåíîìýêòîìèè, òàêæå êàê è ñðîêè óäà- øåíèþ âîïðîñà âûïîëíåíèÿ àäåíîìýêòîìèè èëè ÒÓÐÏ ëåíèÿ êàòåòåðà è ïîñëåîïåðàöèîííîãî ïðåáûâàíèÿ [8,11] â çàâèñèìîñòè îò ïîêàçàíèé. Ñîãëàñíî ïîñëå- áîëüíîãî â ñòàöèîíàðå. äíèì äàííûì, ïîêàçàòåëè ñìåðòíîñòè ïîñëå îòêðûòîé ïðîñòàòýêòîìèè è ÒÓÐÏ ñóùåñòâåííî íå îòëè÷àþòñÿ Íàìè ïðîâåäåíû èññëåäîâàíèÿ ñ öåëüþ ñðàâíåíèÿ ïîñò- (<0,25%) [5]. ×àñòîòà îñëîæíåíèé ïîñëå ÒÓÐÏ ñîñòàâ- îïåðàöèîííûõ ðåçóëüòàòîâ ó áîëüíûõ ñïóñòÿ 3 è 12 ìå- ëÿåò 18%, à ïîñëå àäåíîìýêòîìèè - îò 10% äî 40% [5,6]. ñÿöåâ. ×åðåç îäèí ãîä îòìå÷àëîñü ñòàáèëüíîå óëó÷øå- Â ïîñëåäíèå ãîäû, âíåäðåíèå íîâûõ òåõíîëîãèé (âè- íèå èññëåäóåìûõ ïîêàçàòåëåé ïî ñðàâíåíèþ ñ äàííûìè, äåî ÒÓÐÏ, ëàçåðíûå òåõíîëîãèè, íåãåìîëèçèðóþùèå íàáëþäàåìûìè ïîñëå 3-õ ìåñÿöåâ. Âî âñåõ 5-è ãðóïïàõ èððèãàöèîííûå æèäêîñòè), ïðèìåíåíèå òàê íàçûâàå- óëó÷øèëèñü ïîêàçàòåëè Qmax, I-PSS è êîëè÷åñòâà îñòà- ìîãî “íèçêîãî äàâëåíèÿ” ÒÓÐÏ, íàðÿäó ñ óìåíüøåíè- òî÷íîé ìî÷è; ñóùåñòâåííûõ îòëè÷èé ìåæäó ãðóïïàìè åì âðåìåíè îïåðàöèè, ïîçâîëèëî óâåëè÷èòü ìàññó ðå- íå îòìå÷åíî (òàáëèöà 3). çåöèðîâàííîé òêàíè, ÷òî äî ìèíèìóìà ñíèçèëî êîëè- ÷åñòâî îñëîæíåíèé è ðàñøèðèëî ïîêàçàíèÿ ê òðàíñó- Mebust et al. [6] ñ÷èòàþò ÷òî â ñëó÷àÿõ, êîãäà âåñ ïðî- ðåòðàëüíîìó ëå÷åíèþ äîáðîêà÷åñòâåííûõ àäåíîì ñòàòû áîëåå 45-è ãð, à âðåìÿ îïåðàöèè - 90 ìèíóò, çíà- áîëüøèõ ðàçìåðîâ. ÷èòåëüíî óâåëè÷èâàåòñÿ ðèñê îñëîæíåíèé ïîñëå ÒÓÐÏ. Ïî äðóãèì äàííûì [4], òîëüêî âîçðàñò âëèÿåò íà ðåçóëü- Ïî ïîñëåäíèì äàííûì ãàéäëàéíîâ ÅÀÓ è ÀÀÓ, ëå÷åíèå òàòû ÒÓÐÏ. Ýôôåêòèâíîñòü ÒÓÐÏ çàâèñèò îò âîçðàñòà ÒÓÐÏ îãðàíè÷åíî âåñîì ïðîñòàòû äî 60-70 ãð. [2,10]. ïàöèåíòà è âåëè÷èíû Qmax äî îïåðàöèè. Ñëåäîâàòåëü- Îòêðûòàÿ ïðîñòàòýêòîìèÿ ðåêîìåíäóåòñÿ ïðè ïðîñòàòå íî, ðàçìåðû ïðîñòàòû è âðåìÿ îïåðàöèè íå èìåþò ñó- âåñîì áîëåå 80 ãð., à òàêæå â ñëó÷àÿõ íàëè÷èÿ â ìî÷åâîì ùåñòâåííîãî âëèÿíèÿ íà ÷àñòîòó îñëîæíåíèé è ýôôåê- ïóçûðå áîëüøèõ êîíêðåìåíòîâ èëè äèâåðòèêóëîâ [7]. òèâíîñòü îïåðàöèè [4]. Ìû ðàçäåëÿåì ìíåíèå Hakenberg et al. [4] î òîì, ÷òî â óñëîâèÿõ âûñîêîêà÷åñòâåííîé ñî- Ñëåäóåò îòìåòèòü, ÷òî â ðåñïóáëèêå Ãðóçèÿ â òå÷åíèå âðåìåííîé òåõíîëîãèè, ïðè ÒÓÐÏ "íèçêîãî äàâëåíèÿ" ïîñëåäíèõ 15-è ëåò îêîí÷àòåëüíî íå ðåøåíà ïðîáëå- è âûñîêîé êâàëèôèêàöèè õèðóðãè÷åñêîãî ïåðñîíàëà, ìà äèñïàíñåðèçàöèè, â ðåçóëüòàòå ÷åãî íå óäàåòñÿ ïðî- ðàçìåðû ïðîñòàòû è âðåìÿ îïåðàöèè íå âëèÿþò íà ÷àñ- âåäåíèå ðàííåé äèàãíîñòèêè è, ñëåäîâàòåëüíî, ñâî- òîòó îñëîæíåíèé è ýôôåêòèâíîñòü îïåðàöèè. Áîëüøîå åâðåìåííîãî ëå÷åíèÿ ÄÃÏ. Ââèäó òÿæåëîãî ýêîíî- çíà÷åíèå ïðèäàåòñÿ çàìåíå àäåíîìýêòîìèè ìåíåå èí- ìè÷åñêîãî ïîëîæåíèÿ áîëüøèíñòâà ïàöèåíòîâ, íà- âàçèâíûìè ìåòîäàìè ëå÷åíèÿ ÄÃÏ, õîòÿ îíà åùå ñî- çíà÷åíèå äëèòåëüíîãî, äîðîãîñòîÿùåãî ìåäèêàìåí- ñòàâëÿåò 32% îò âñåõ îïåðàöèé ïðè ÄÃÏ [7]. òîçíîãî ëå÷åíèÿ âåñüìà îãðàíè÷åíî. Íàáëþäàåòñÿ ïîçäíÿÿ îáðàùàåìîñòü áîëüíûõ. Èç îáñëåäîâàííûõ Ïî ìàòåðèàëàì íàøåé êëèíèêè, âíåäðåíèå íîâûõ òåõ- áîëüíûõ 27,7% îïåðèðîâàíû ïî ïîâîäó îñòðîé çà- íîëîãè÷åñêèõ ñðåäñòâ è îñîáåííî ÒÓÐÏ “íèçêîãî äàâ- äåðæêè ìî÷è. Èñõîäÿ èç âûøåèçëîæåííîãî, ó íàñ ëåíèÿ” ïîçâîëÿþò ïðîâîäèòü îïåðàòèâíîå ëå÷åíèå äîá- íàêîïèëñÿ áîëüøîé îïûò ïî ëå÷åíèþ ÒÓÐÏ áîëüøèõ ðîêà÷åñòâåííîé ãèïåðïëàçèè ïðîñòàòû áîëüøèõ ðàçìå- ðàçìåðîâ. Ñ âíåäðåíèåì ñîâðåìåííûõ âûñîêîêà÷å- ðîâ òàêæå óñïåøíî, êàê ïðè ñòàíäàðòíîì ÒÓÐÏ. Ïî ñòâåííûõ òåõíîëîãèé, èððèãàöèîííîé æèäêîñòè “Ïó- íàøåìó ìíåíèþ, ÒÓÐÏ ñëåäóåò ñ÷èòàòü íàèëó÷øèì ðèñîëü” è îñîáåííî ÒÓÐÏ “íèçêîãî äàâëåíèÿ”, íà õèðóðãè÷åñêèì ìåòîäîì ëå÷åíèÿ ýòîãî çàáîëåâàíèÿ íàøåì ìàòåðèàëå íå íàáëþäàëîñü íè îäíîãî ñëó÷àÿ íåçàâèñèìî îò ðàçìåðîâ ïðîñòàòû. êëèíè÷åñêîãî ïðîÿâëåíèÿ ÒÓÐ-ñèíäðîìà, ÷òî ïîçâî- ëÿåò íàì áîëåå àêòèâíî ïðèìåíÿòü ýòîò ìåòîä ëå÷å- ËÈÒÅÐÀÒÓÐÀ íèÿ ó áîëüíûõ ñ äîáðîêà÷åñòâåííîé ãèïåðïëàçèåé ïðîñòàòû áîëüøèõ ðàçìåðîâ. 1. American Society of Anesthesiologists: New classification of physical status // Anesthesiology. – 1963. - N24. – P. 111. Ïðè ðåçåêöèè ïðîñòàòû ðàçìåðîì áîëåå 60 ñì3 òðåáó- 2. AUA Practice Guidelines Committee: AUA guideline on manage- åòñÿ áîëüøå âðåìåíè, ÷òî, ïî íàøèì äàííûì, íå âëèÿåò ment on benign prostatic hyperplasia (2003). Chapter 1: diagnosis and treatment recommendations // J Urol. – 2003. - N170. – P. 530. íà êîëè÷åñòâî îñëîæíåíèé. Íàøè äàííûå ñîîòâåòñòâó- 3. Barba M., Leyh H., Hartung R. New technologies in TURP þò ñòàíäàðòàì ÒÓÐÏ [10]. // Curr Opin Urol. – 2000. - N10. – P. 9. 4. Hakenberg O.W., Pinnock C.B., Marshall V.R. Preoperative Ïî äàííûì Serreta et al. [7,11], ïîñëå îòêðûòîé ïðîñòà- urodynamic and symptom evaluation of patients undergoing òýêòîìèè ïðîäîëæèòåëüíîñòü êàòåòåðèçàöèè ñîñòàâëÿ- transurethral prostatectomy: analysis of variables relevant for ëî 5 äíåé, ñðåäíåå ïðåáûâàíèå â ñòàöèîíàðå ïîñëå îïå- outcome // BJU Int. – 2003. - N91. – P. 375. ðàöèè - 7 äíåé. Ãåìîòðàíñôóçèÿ ïðîâîäèëàñü â 8,2% 5. HolmanC.D., Wisnewski Z.S., Semmens J.B., Rouse. I.I. Bass ñëó÷àåâ, ñòðèêòóðà óðåòðû íàáëþäàëàñü â 5%, à íåäåð- mortality and prostate cancer risk in 1956 men after surgery for BPH // BJU. – 1999. - N84. – P. 37.

56 GEORGIAN MEDICAL NEWS No 2 (143) Ôåâðàëü, 2007 ãîä

6. Mebust W.K., Holtgrewe H.L., Cockett A.T.K. Transurethra Therefore, TURP can be considered as an effective and safe prostatectomy: immediate and postoperative complications. A procedure for patients with large prostate glands. comparative study of’ l3 participat institutions evaluating 3.885 patients // J Urol. - N141. – P. 243. Key words: benign prostatic hyperplasia (BPH), transurethral 7. Moody J.A., Lingeman J.E. Holmium laser enucleation for resection of the prostate (TURP). prostate adenoma greater than 100 gm: comparison to open prostatectomy // J Urol. – 2001. - N165 - P. 459. ÐÅÇÞÌÅ 8. Muzzonigro G., Milanese G., Minardi D., Dellabela M. Safe- ty and efficacy of TURP glands up to 150ml: a prospective ÒÐÀÍÑÓÐÅÒÐÀËÜÍÎÅ ËÅ×ÅÍÈÅ ÄÎÁÐÎÊÀ×ÅÑÒÂÅÍ- comparative study with 1 year of followup ÍÎÉ ÃÈÏÅÐÏËÀÇÈÈ ÏÐÅÄÑÒÀÒÅËÜÍÎÉ ÆÅËÅÇÛ 9. Roehrborn C.G., Bartsch G., Kirby K., Andriole G., Boyk de ÁÎËÜØÈÕ ÐÀÇÌÅÐÎÂ la Rosette J. et al. Guidelines for the diag’nosis and treatment of’ benign prostatic hyperplasia: a comparative. intenrnational over- Ìàíàãàäçå Ë.Ã., Õâàäàãèàíè Ã.Ã., Àáäóøåëèøâèëè Ê.Î., view // Urology. – 2001. - N58. – P. 642. Ìàíàãàäçå Ã.Ë., Áåðóëàâà Ä.Ò. 10. de la Rosette J.J., Alivizatos G., Madersbacher S. Peradd M., Thomas D. Desgranddwmps F. at. al. EAU guidelins, benign pro- Íàöèîíàëüíûé öåíòð óðîëîãèè èì. À. Öóëóêèäçå static hyperplasia (BPH) // Eur. Urol. – 2994. - N4. – P. 256. 11. Serreta V., Morgia G., Fondacaro I., Curto G., Lo bianco A., Äîáðîêà÷åñòâåííàÿ ãèïåðïëàçèÿ ïðåäñòàòåëüíîé æåëåçû Pirritano D. et al. Open prostatectomy for BPH enlargement is (ÄÃÏ) ÿâëÿåòñÿ îäíèì èç íàèáîëåå ÷àñòûõ çàáîëåâàíèé ó the Sauthern Europe in the Late 1990s contens series of 1800 ìóæ÷èí. Äàííîå çàáîëåâàíèå õàðàêòåðèçóåòñÿ ðàçëè÷íûìè interventions // Urology. – 2002. - N60. – P. 623. ñèìïòîìàìè, ñâÿçàííûìè ñ íàðóøåíèåì ïàññàæà ìî÷è ïî íèæ- íèì ìî÷åâûì ïóòÿì. Ïðè÷èíîé íàðóøåíèÿ ìî÷åèñïóñêàíèÿ SUMMARY ÿâëÿåòñÿ èíôðàâåçèêàëüíàÿ îáñòðóêöèÿ. Â îñíîâå îáñ-òðóê- öèè ëåæèò óâåëè÷åíèå ïðîñòàòû â ðàçìåðàõ ñ ïîñòåïåííûì SOME ASPECTS OF TRANSURETHRAL RESECTION OF ñóæåíèåì ïðîñâåòà ìî÷åèñïóñêàòåëüíîãî êàíàëà. Õèðóðãè- LARGE BENIGN PROSTATIC HYPERPLASIA ÷åñêîå ëå÷åíèå ÄÃÏ ïîêàçàíî ïàöèåíòàì, èìåþùèì îñëîæíå- íèÿ, íå ïîääàþùèåñÿ ìåäèêàìåíòîçíîé êîððåêöèè, èëè îòêà- Managadze L., Khvadagiani G., Abdushelishvili K., Mana- çûâàþùèõñÿ îò êîíñåðâàòèâíîãî ëå÷åíèÿ. Îòêðûòàÿ àäåíî- gadze G., Berulava D. ìýêòîìèÿ è òðàíñóðåòðàëüíàÿ ðåçåêöèÿ ïðîñòàòû (ÒÓÐÏ) ÿâëÿþòñÿ îñíîâíûìè õèðóðãè÷åñêèìè ìåòîäàìè ëå÷åíèÿ. National Centre of Urology, Tbilisi Öåëüþ íàøåãî èññëåäîâàíèÿ ÿâèëîñü èçó÷åíèå ðåçóëüòàòîâ Benign prostatic hyperplasia (BPH) is a progressive disease òðàíñóðåòðàëüíîé ðåçåêöèè äîáðîêà÷åñòâåííîé ãèïåðïëà- that affects the quality rather than the quantity of life of men. çèè ïðåäñòàòåëüíîé æåëåçû áîëüøèõ ðàçìåðîâ. There are two methods of surgical treatment of BPH: transurethral resection of the prostate (TURP) and open prostatectomy. Âíåäðåíèå íîâûõ òåõíîëîãè÷åñêèõ ñðåäñòâ, îñîáåííî ÒÓÐÏ “íèçêîãî äàâëåíèÿ”, äàåò âîçìîæíîñòü ïðîâîäèòü In this study we investigated the safety and efficacy of TURP îïåðàòèâíîå ëå÷åíèå ïðè äîáðîêà÷åñòâåííîé ãèïåðïëàçèè for large prostate glands. To analyze our clinical data we can ïðîñòàòû áîëüøèõ ðàçìåðîâ òàêæå óñïåøíî, êàê ïðè ñòàí- conclude introduction of technological innovations, especially äàðòíîì ÒÓÐÏ. of “low pressure” TURP, have made it possible to perform TURP for large prostates so safely as for recommended vol- Íà íàø âçãëÿä, ÒÓÐÏ ìîæíî ñ÷èòàòü íàèëó÷øèì õèðóðãè- umes. Also our trial has demonstrated that complications after ÷åñêèì ìåòîäîì ëå÷åíèÿ ýòîãî çàáîëåâàíèÿ íåçàâèñèìî îò TURP were within admissible limits of standard TURP. ðàçìåðîâ ïðîñòàòû.

Íàó÷íàÿ ïóáëèêàöèÿ

ÐÀÄÈÊÀËÜÍÀß ÏÅÐÈÍÅÀËÜÍÀß ÏÐÎÑÒÀÒÝÊÒÎÌÈß – ÎÏÅÐÀÒÈÂÍÀß ÒÅÕÍÈÊÀ, ÏÅÐÂÛÅ ÐÅÇÓËÜÒÀÒÛ

Ìøâèëäàäçå Ø.Ò., Óäæìàäæóðèäçå À.Í., Ìàíàãàäçå Ã.Ë., Øòàêëü Â.

Êëèíèêà ôîíäà Ðóäîëüôà, Âåíà; Íàöèîíàëüíûé öåíòð óðîëîãèè èì. À. Öóëóêèäçå

Ðàê ïðîñòàòû ÿâëÿåòñÿ ÷àñòûì îíêîëîãè÷åñêèì çàáîëå- ìåíÿëèñü, ò.ê. íè îäíî èç ýòèõ èññëåäîâàíèé íå ïîçâîëÿ- âàíèåì ñðåäè ìóæ÷èí, çàíèìàþùèì ïî ñìåðòíîñòè åò îïðåäåëèòü ëîêàëüíóþ èíâàçèþ ðàêà ïðîñòàòû [4,19], âòîðîå ìåñòî ïîñëå ðàêà ëåãêèõ [15]. Èçâåñòíî, ÷òî ñà- îäíàêî ÿäåðíî-ìàãíèòíûé ðåçîíàíñ ñ ðåêòàëüíûì äàò- ìûì ýôôåêòèâíûì ìåòîäîì ëå÷åíèÿ ëîêàëèçîâàííîãî ÷èêîì ÿâëÿåòñÿ ñàìûì òî÷íûì íåèíâàçèâíûì ìåòîäîì ðàêà ïðåäñòàòåëüíîé æåëåçû ÿâëÿåòñÿ ðàäèêàëüíàÿ ïðî- äëÿ îïðåäåëåíèÿ ñòåïåíè ëîêàëüíîãî ðàñïðîñòðàíåíèÿ, ñòàòýêòîìèÿ [25]. Îò÷åòëèâàÿ òåíäåíöèÿ ñîâðåìåííîé îñîáåííî â ñåìåííûå ïóçûðüêè [22], îäíàêî èññëåäîâà- õèðóðãèè ê ðàçðàáîòêå, ñîâåðøåíñòâîâàíèþ è âñå áî- íèå íå âñåãäà äîñòóïíî è ðóòèííîå åãî ïðèìåíåíèå îñ- ëåå øèðîêîìó ïðèìåíåíèþ ìèíèìàëüíî èíâàçèâíûõ ïàðèâàåòñÿ [21]. Êîìïüþòåðíàÿ òîìîãðàôèÿ áîëåå øè- ìåòîäîâ îïåðàòèâíîãî ëå÷åíèÿ îáóñëîâèëà ïîâûøåí- ðîêî ïðèìåíÿåòñÿ äëÿ âûÿâëåíèÿ ìåòàñòàçèðîâàíèÿ â íûé èíòåðåñ ê ïåðèíåàëüíîé ïðîñòàòýêòîìèè, îòâå÷à- îðãàíû è ëèìôàòè÷åñêóþ ñèñòåìó áðþøíîé ïîëîñòè þùåé ïðàêòè÷åñêè âñåì êðèòåðèÿì ìàëîèíâàçèâíîãî [17], à òàêæå äëÿ âûáîðà äîçû îáëó÷åíèÿ ïåðåä ïðîâå- õèðóðãè÷åñêîãî âìåøàòåëüñòâà. äåíèåì ëó÷åâîé òåðàïèè [17]. Â ñòàíäàðòíûé ïåðå÷åíü äèàãíîñòè÷åñêèõ ìåòîäîâ íå âõîäèëî ñêàíèðîâàíèå êî- Íåñìîòðÿ íà òî, ÷òî ïåðèíåàëüíûé äîñòóï ïðè îïåðà- ñòåé, ò.ê. â ñëó÷àÿõ, êîãäà ÏÑÀ <20íã/ìë, à ñòåïåíü àíàï- öèÿõ íà ïðåäñòàòåëüíîé æåëåçå áûë ïðåäëîæåí áîëåå ëàçèè îïóõîëè íèçêàÿ èëè ñðåäíÿÿ, â 99% ñëó÷àåâ ìåòà- 100 ëåò òîìó íàçàä [1,2,3,29] ðåêîìåíäàöèÿ øèðîêîãî ñòàçèðîâàíèÿ â êîñòè íå ïðîèñõîäèò [28]. ïðèìåíåíèÿ ïðîìåæíîñòîé ðàäèêàëüíîé ïðîñòàòýêòî- ìèèè ñòàëà âîçìîæíà ëèøü ïîñëå ðàçðàáîòêè ñîâðå- Íàìè óñòàíîâëåíû ñðåäíÿÿ ïðîäîëæèòåëüíîñòü îïåðà- ìåííûõ ìåòîäîâ ðàííåãî âûÿâëåíèÿ ðàêà ïðåäñòàòåëü- öèè, êîëè÷åñòâî ïåðåëèòîé êðîâè è êðîâåçàìåíèòåëåé, íîé æåëåçû [14,16,18,26]. êîëè÷åñòâî êîéêî-äíåé, ÷àñòîòà îïåðàöèîííûõ îñëîæ- íåíèé. Ïðîèçâåäåíî ñðàâíåíèå ïðåä- è ïîñòîïåðàöè- Öåëüþ íàñòîÿùåãî èññëåäîâàíèÿ ÿâèëàñü îöåíêà ðå- îííîé ïîòåíöèè è êîíòèíåíöèè. çóëüòàòîâ ðàäèêàëüíîé ïðîìåæíîñòíîé ïðîñòàòýêòî- ìèè êàê ùàäÿùåãî, ìàëîèíâàçèâíîãî ìåòîäà õèðóð- Ïðåïàðàòû èçó÷àëèñü â ïàòîìîðôîëîãè÷åñêîé è ãèñòî- ãè÷åñêîãî ëå÷åíèÿ ðàííèõ ôîðì ðàêà ïðåäñòàòåëüíîé õèìè÷åñêîé ëàáîðàòîðèè Íàöèîíàëüíîãî öåíòðà óðî- æåëåçû . ëîãèè ñ ïîìîùüþ ìèêðîñêîïà «Olympus Â201» Õ40 (Ãåð- ìàíèÿ). Ìàòåðèàë è ìåòîäû. Çà 2001-2004 ãã. â Íàöèîíàëüíîì öåíòðå óðîëîãèè ñ öåëüþ ëå÷åíèÿ àäåíîêàðöèíîìû Îïåðàöèîííàÿ òåõíèêà. Ïðè ïîäãîòîâêå ê îïåðàöèè ñëå- ïðîñòàòû áûëà ïðîâåäåíà ðàäèêàëüíàÿ ïåðèíåàëüíàÿ äóåò èñêëþ÷èòü ñòðèêòóðó óðåòðû. Ïðè ïîäãîòîâêå êè- ïðîñòàòýêòîìèÿ 9-è ïàöèåíòàì. Â èññëåäîâàíèå áûëè øå÷íèêà ïî ñòàíäàðòíîé ñõåìå, çà äåíü äî îïåðàöèè íà- âêëþ÷åíû áîëüíûå ñ êëèíè÷åñêè ëîêàëèçîâàííûì ðà- çíà÷àëè ëåâîìèöåòèí èëè ýðèòðîìèöèí ïåðîðàëüíî. Äëÿ êîì ïðîñòàòû, ïðîñòàòñïåöèôè÷åñêèé àíòèãåí (ÏÑÀ) ïðåäóïðåæäåíèÿ òðîìáîýìáîëèè, çà 12 ÷àñîâ äî îïåðà- êîòîðûõ ñîñòàâëÿë íå áîëåå 10 íã/ìë, à ñóììà Ãëèññîíà öèè, ââîäèëè èíúåêöèþ íèçêîìîëåêóëÿðíîãî ãåïàðèíà, - ìåíüøå 7-è. Âîçðàñò âàðüèðîâàë â ïðåäåëàõ îò 53 äî 71 íèæíèå êîíå÷íîñòè îáìàòûâàëè ýëàñòè÷íûì áèíòîì. Çà ãîäà (ñðåäíèé âîçðàñò 64). Äëÿ äèàãíîñòèêè çàáîëåâà- ÷àñ äî îïåðàöèè ïðîèçâîäèëàñü èíúåêöèÿ àíòèáèîòèêà. íèÿ ïðèìåíÿëèñü ñëåäóþùèå áàçèñíûå èññëåäîâàíèÿ: ðåêòàëüíàÿ ïàëüïàöèÿ ïðåäñòàòåëüíîé æåëåçû, îïðåäå- Îïåðàöèÿ ïðîèçâîäèòñÿ ýíäîòðàõåàëüíî èëè ñ ïðèìåíå- ëåíèå â êðîâè ÏÑÀ. Äëÿ îêîí÷àòåëüíîé äèàãíîñòèêè íèåì äóáëüàíåñòåçèè (ýíäîòðàõåàëüíûé+ïåðèäóðàëüíûé). ïðîâîäèëàñü òðàíñðåêòàëüíàÿ áèîïñèÿ ïðîñòàòû. Ìà- òåðèàë èçó÷àëñÿ ïàòîìîðôîëîãîì. Áèîïñèÿ ïðîâîäè- Ïàöèåíò ðàñïîëàãàåòñÿ â ìàêñèìàëüíî ñîãíóòîé ëèòîòî- ëàñü ñòàíäàðòíî, ïîä òðàíñðåêòàëüíûì óëüòðàñîíîãðà- ìè÷åñêîé ïîçå. Ïîä êîï÷èê ïîìåùàëè ïîäóøêó, ÷òîáû ôè÷åñêèì êîíòðîëåì. Â êàæäîì ñëó÷àå çàáèðàëè 6 èëè áåäðåííàÿ êîñòü ñ ïîçâîíî÷íèêîì ñîñòàâèëà óãîë ≈750, à 8 ñðåçîâ. Ýõîñêîïè÷åñêè îïðåäåëÿëñÿ îáúåì ïðîñòàòû, ïðîìåæíîñòü ïðèíÿëà âåðòèêàëüíîå ïîëîæåíèå. ýõîãåííîñòü, èíâàçèÿ â êàïñóëó èëè ñåìåííûå ïóçûðü- êè. Ñòàíäàðòíàÿ êîìïüþòåðíàÿ òîìîãðàôèÿ òàçîâîé Â ìî÷åâîé ïóçûðü òðàíñóðåòðàëüíî ñòàâèëñÿ ðåòðàê- ïîëîñòè è ìàãíèòíî-ðåçîíàíñíîå èññëåäîâàíèå íå ïðè- òîð Lowslåó è îòêðûâàëè áðàíøè. Íà êîæå ïðîèçâî-

58 GEORGIAN MEDICAL NEWS No 2 (143) Ôåâðàëü, 2007 ãîä

äèëè ðàçðåç îâàëüíîé ôîðìû íà 2-3 ñì âûøå àíàëü- ïóçûðÿ è åå ïðåïàðèðîâàíèå. Íà ñåìÿâûâîäÿùèå ïðî- íîãî îòâåðñòèÿ, ëàòåðàëüíóþ ãðàíèöó ðàçðåçà ñîñòàâ- òîêè íàêëàäûâàëè êëèïû, âûäåëÿëè ñåìåííûå ïóçûðüêè ëÿþò ñåäàëèùíûå áóãðû. Ïîäêîæíàÿ êëåò÷àòêà è æè- è èññåêàëè âìåñòå ñ ïðîñòàòîé. Ïðîâîäèëè ôîðìèðîâà- ðîâîé ñëîé ðàññåêàëè îñòðûì ñïîñîáîì. Ýëåêòðî- íèå øåéêè ìî÷åâîãî ïóçûðÿ, ïîñëå ÷åãî íàêëàäûâàëè íîæîì îòêðûâàëè fossa ischiorectalis ëàòåðàëüíî àíàñòîìîç ìåæäó øåéêîé è óðåòðîé. Ê øâàì, íàëîæåí- centrum-tendineum. Ïîä êîíòðîëåì ïàëüöà, ýëåêòðî- íûì íà âåíòðàëüíîé ïîâåðõíîñòè, äîáàâëÿëè øâû äîð- íîæîì ïåðåñåêàëè centum-tendineum. Ïîñëå âèçóà- çàëüíîé ÷àñòè â ïîçèöèè 4-õ, 6-è è 8-è ÷àñîâîé ñòðåëêè ëèçàöèè áóëüáóñà, âûäåëÿëè m.transversus perinei (ðèñ. 6). Â ìî÷åâîé ïóçûðü òðàíñóðåòðàëüíî âñòàâëÿëè superficialis è ïåðåñåêàëè åãî ôèáðîçíûå ïó÷êè (ðèñ. 1). 18 ch ñèëèêîíîâûé è 16 ch ýïèöèñòîñòîìè÷åñêèé êàòå- Îòêðûâàëè m.reñtourethràlis, ïîñëå ÷åãî âûÿâëÿëè òåð. Ïîñëå ãåìîñòàçà è îñìîòðà ïðÿìîé êèøêè, â ðàíó m.levàtîr ani, êîòîðûå ðàçúåäèíÿëè ëàòåðàëüíî êðþ÷- âñòàâëÿëè äðåíàæ ãèïà Penrose èëè âàêóóì-äðåíàæ. Ïó÷- êàìè è â ðàíó âñòàâëÿëè ðåòðàêòîð Young, ïîñðåä- êè m.levater ani àäàïòèðîâàëè ìåæäó ñîáîé è âîññòàíàâ- ñòâîì ÷åãî îáåñïå÷èâàëè ïîäõîä ê äîðçàëüíîé ïî- ëèâàëè öåëîñòíîñòü m.rectouretralis. Ñøèâàëè centrum âåðõíîñòè ïðîñòàòû. tendineum.

Ðèñ. 1. Ïîïåðå÷íûé ðàçðåç ôèáðîçíûõ ïó÷êîâ Ðèñ. 2. Âåðòèêàëüíîå ðàññå÷åíèå íàðóæíîãî ëèñòêà m.transversus perinei superficialis fascia Denonvillie, ïîçâîëÿþùàÿ ïðåçåðâàöèþ íåðâî- âàñêóëàðíîãî ïó÷êà Íåðâíî-ùàäÿùåé òåõíèêîé âñêðûâàëè fascia denonvillier âåðòèêàëüíî ïî ñðåäèííîé ëèíèè (ðèñ. 2). Íåéðîâàñêó- ëÿðíûå ïó÷êè ïðåïàðèðîâàëè âìåñòå ñ ôàñöèÿìè ëàòå- ðàëüíî. Ïîñëå âñêðûòèÿ âíóòðåííåãî ëèñòêà fascia denonvillier ïîëíîñòüþ âèçóàëèçèðóþòñÿ ñåìåííûå ïó- çûðüêè. Íà ëàòåðàëüíûå «íîæêè» ïðîñòàòû íàêëàäûâà- ëè ëèãàòóðó, êîòîðóþ ïåðåñåêàëè. Çàäíþþ ñòåíêó óðåò- ðû ðàññåêàëè ñêàëüïåëåì íà 3 ìì äèñòàëüíî îò âåðõóø- êè ïðîñòàòû (ðèñ. 3). Â óðåòðó âñòàâëÿëè êàòåòåð, êîòî- ðûé ïîäòÿãèâàëè ââåðõ ñ öåëüþ õîðîøåé âèçóàëèçàöèè âåíòðàëüíîé ÷àñòè óðåòðû. Â ìî÷åâîé ïóçûðü âñòàâëÿëè ïðÿìîé ðåòðàêòîð Lîwsley. Óðåòðó ïåðåñåêàëè ïîëíîñ- òüþ, íàêëàäûâàëè øâû íà âåíòðàëüíóþ ÷àñòü ïî ïîçè- öèè ÷àñîâ öèôåðáëàòà 9, 12 è 3 (ðèñ. 4). Äî íàëîæåíèÿ øâîâ çàáèðàëè äèñòàëüíóþ ÷àñòü óðåòðû äëÿ ìîðôîëî- ãè÷åñêîãî èññëåäîâàíèÿ. Ïîñëå ðàññå÷åíèÿ ïóáîïðîñ- òàòè÷åñêèõ ñâÿçîê ðåòðàêòîð Lîwsley ïîäòÿãèâàëè âåíò- ðàëüíî è âûäåëÿëè äîðçàëüíóþ ïîâåðõíîñòü ïðîñòàòû, ïîñëå ÷åãî ðåòðàêòîð Lîwsley ïîâîðà÷èâàëè íà 900 è ïîä êîíòðîëåì áðàíøåâ îòñåêàëè øåéêà ìî÷åâîãî ïóçûðÿ Ðèñ. 3. Ëèãèðîâàíèå ëàòåðàëüíûõ “íîæåê” ïðîñòà- (ðèñ. 5). Â ïðîñòàòè÷åñêóþ ÷àñòü óðåòðû âñòàâëÿëè êàòå- òû è ðàññå÷åíèå óðåòðû íà 3 ìì äèñòàëüíåå âåðõóø- òåð, ÷òî îáåñïå÷èâàëî âèçóàëèçàöèþ øåéêè ìî÷åâîãî êè ïðåäñòàòåëüíîé æåëåçû

Ðèñ. 4. Íàëîæåíèå øâîâ íà âåíòðàëüíóþ ÷àñòü óðåò- Ðèñ. 5. Ïîâîðîò ðåòðàêòîðà Lîwsley íà 900 è ïîä êîíò- ðû ïî ïîçèöèè ÷àñîâ öèôåðáëàòà 9, 12 è 3 ðîëåì åå áðàíøåâ ïàëüïàöèÿ øåéêè ìî÷åâîãî ïóçûðÿ

Ðèñ. 6. Àíàñòîìîçèðóþøèå øâû íà äîðçàëüíîé ÷àñòè óðåòðû â ïîçèöèè ÷àñîâîé ñòðåëêè 4, 6 è 8

Ðàííèé ïîñëåîïåðàöèîííûé ïåðèîä. Ïîñëå ðàäèêàëüíîé îáû÷íî - â ïåðâûé èëè íà âòîðîé äåíü îïåðàöèè. Ïàöè- ïåðèíåàëüíîé ïðîñòàòýêòîìèè, â òå÷åíèå 24-õ ÷àñîâ ïà- åíòîâ àêòèâèðîâàëè â ðàííåì ïîñòîïåðàöèîííîì ïåðè- öèåíòàì íàçíà÷àëè æèäêóþ äèåòó. ×òî êàñàåòñÿ ïîñòîïå- îäå, ÷åðåç äåíü - äâà ïîñëå îïåðàöèè. Óðåòðàëüíûé êàòå- ðàöèîííîé àíàëüãåçèè, áîëüøèíñòâî àâòîðîâ íå ñ÷èòà- òåð äîñòàâàëè ñïóñòÿ òðè íåäåëè ïîñëå îïåðàöèè. þò íåîáõîäèìûì îñòàâëÿòü ïåðèäóðàëüíûé êàòåòåð è îãðàíè÷èâàþòñÿ íàçíà÷åíèåì àíàëüãåòèêîâ (â òîì ÷èñëå Ðåçóëüòàòû è èõ îáñóæäåíèå. Ñîãëàñíî ïàòîìîðôîëî- íàðêîòèêîâ) â âèäå èíúåêöèé èëè ïåðîðàëüíî [23]. Ìåä- ãè÷åñêîìó äèàãíîçó ïàöèåíòû áûëè ðàñïðåäåëåíû ñëå- ïåðñîíàë ñòðîãî ïðåäóïðåæäàëè íå ïðèìåíÿòü ëåêàðñòâà äóþùèì îáðàçîì pT2a – 2 ïàöèåíòà (22,22%), pT2â – 5 per rectum è íå ïðîâîäèòü ïðîìûâàíèÿ ìî÷åâîãî ïóçû- (55,6%), ðÒÇà – 1 (11,1%) è ðÒ3â – 1 ïàöèåíò (11,1%), ðÿ. Äðåíàæ óäàëÿëè ïîñëå ïðåêðàùåíèÿ âûäåëåíèé, (òàáëèöà 1). Òàáëèöà. Ðàñïðåäåëåíèå ïàöèåíòîâ â çàâèñèìîñòè îò pT êàòåãîðèè è ñóììû Ãëèññîíà Ïî pT êàòåãîðèè: Êîëè÷åñòâî ïàöèåíòîâ pT2a 2 (22,2%) pT2b 5 (55,6%) pT3a 1 (11,1%) pT3b 1 (11,1%) Ïî ñóììå Ãëèññîíà: Gs - 3 (1+2) 1 (11,1%) Gs - 5 (3+2) 5 (55,6%) Gs - 7 (3+4) 2 (22,2%) Gs - 7 (4+ 3) 1 (11,1%) 60 GEORGIAN MEDICAL NEWS No 2 (143) Ôåâðàëü, 2007 ãîä

Ïðîäîëæèòåëüíîñòü îïåðàöèè êîëåáàëàñü â ïðåäåëàõ îò Ïîñëåîïåðàöèîííûå îñëîæíåíèÿ. Â ëèòåðàòóðå íàìè 95 äî 180 ìèí., â ñðåäíåì 130 ìèí. âûÿâëåíû äàííûå î ñòàòèñòè÷åñêè äîñòîâåðíîì ïðåèìó- ùåñòâå â ãðóïïå ïåðèíåàëüíîé ïðîñòàòýêòîìèè ïî êîëè- Êîíòèíåíöèÿ. Äåðæàíèå ìî÷è ÿâëÿåòñÿ çíà÷èìûì ÷åñòâó êîéêî-äíåé, ïðîäîëæèòåëüíîñòè óðåòðàëüíîé êà- êðèòåðèåì îöåíêè óñïåøíîñòè õèðóðãè÷åñêîãî ëå÷å- òåòåðèçàöèè, ïîòåðè êðîâè è ãåìîòðàíñôóçèè [15]. íèÿ ðàêà ïðîñòàòû. Ïðè ðàäèêàëüíîé ïðîñòàòýêòîìèè ÷àñòî èñïîëüçóþò êàê ðåòðîïóáèêàëüíûé, òàê è ïåðè- Ñðåäè îñëîæíåíèé ïåðèíåàëüíîé ïðîñòàòýêòîìèè ñðàâ- íåàëüíûé ïîäõîäû. Ïîñëå ïðîâåäåííîé ïðîñòàòýêòî- íèòåëüíî âûñîê ðèñê ïîâðåæäåíèÿ ïðÿìîé êèøêè. Ïî ìèè ñòåïåíü êîíòèíåíöèè îöåíèâàåòñÿ ñïóñòÿ 6 è 12 äàííûì ðàçíûõ àâòîðîâ, îí êîëåáëåòñÿ â ïðåäåëàõ 1- ìåñÿöåâ [15]. Ïî äàííûì ðàçëè÷íûõ àâòîðîâ, ñòåïåíü 11% [11,27], õîòÿ ïîâðåæäåíèå ìîæíî óñïåøíî óñòðà- èíêîíòèíåíöèè ïîñëå ðàäèêàëüíîé ïåðèíåàëüíîé ïðî- íèòü èíòðàîïåðàöèîííûìè ïåðâè÷íûìè øâàìè [7,13]. ñòàòýêòîìèè êîëåáëåòñÿ â ïðåäåëàõ 4-8% [8,9,24,27,30]. Ðèñê ðàçâèòèÿ ñòðèêòóðû àíàñòîìîçà íèçîê è âàðüèðó- Ïî äàííûì Weldon è ñîàâò. [27], êîíòèíåíöèÿ âîçâðà- åò â ïðåäåëàõ îò 1 äî 7% [11,27], íèçîê òàêæå ðèñê ðàçâè- ùàåòñÿ ñïóñòÿ ìåñÿö ó 23% ïàöèåíòîâ, 6 ìåñÿöåâ - ó òèÿ óðåòðî-ðåêòàëüíîé ôèñòóëû (≈1%). Â íàøåì èññëå- 90%, ñïóñòÿ 10 ìåñÿöåâ – ó 95%. Èíêîíòèíåíöèÿ îñòà- äîâàíèè òàêèõ îñëîæíåíèé íå îòìå÷åíî. åòñÿ, â îñíîâíîì, ó áîëüíûõ ñâûøå 69-è ëåò. Ïî äàí- íûì Haab è ñîàâò. [11], ñïóñòÿ 3 ìåñÿöà ïîñëå îïåðà- Ïî ðåçóëüòàòàì îäíîãî íåðàíäîìèçèðîâàííîãî èññëå- öèè, êîíòèíåíöèÿ íàáëþäàëàñü ó 71% ïàöèåíòîâ, ñïó- äîâàíèÿ ïîòåðÿ êðîâè âûøå â ãðóïïå ñ ðàäèêàëüíîé ñòÿ 6 ìåñÿöåâ - ó 88%. Àíàëèç ëèòåðàòóðíûõ äàííûõ ðåòðîïóáèêàëüíîé ïðîñòàòýêòîìèåé (565 ìë v.s. ïîêàçûâàåò, ÷òî ðàííÿÿ èíêîíòèíåíöèÿ áîëåå âûñîêàÿ 1475ìë, ð<0,001) [8,30]. Ñòåïåíü èíòðàîïåðàöèîííûõ â ãðóïïå ðàäèêàëüíîé ïåðèíåàëüíîé ïðîñòàòýêòîìèè, êðîâîïîòåðü â íàøåì èññëåäîâàíèè íå îïðåäåëÿëàñü. ÷åì ðàäèêàëüíîé ðåòðîïóáèêàëüíîé ïðîñòàòýêòîìèè, Òðàíñôóçèÿ ïîòðåáîâàëàñü â 7-è ñëó÷àÿõ, â ñðåäíåì, îäíàêî ñëåäóåò îòìåòèòü, ÷òî ñòåïåíü âîññòàíîâëåíèÿ íà îäíîãî ïàöèåíòà áûëî ïåðåëèòî 427 ìë. ýðèòðîöè- êîíòèíåíöèè âûøå â ñëó÷àÿõ ðàäèêàëüíîé ïåðèíåàëü- òàðíîé ìàññû. íîé ïðîñòàòýêòîìèè [5]. Áèîõèìè÷åñêèé ðåöèäèâ è ñìåðòíîñòü. Ïðàêòè÷åñ- Íà íàøåì ìàòåðèàëå ïîñòîïåðàöèîííàÿ èíêîíòèíåí- êè íå âûÿâëåíî ðàçíèöû ïî îïóõîëåïîçèòèâíûì ãðà- öèÿ îòìå÷àëàñü ó 4-õ (44,4%) ïàöèåíòîâ. Êîíòðîëü ÷å- íèöàì ìåæäó ðåòðîïóáèêàëüíîé è ïåðèíåàëüíîé ðåç ìåñÿö âûÿâèë èíêîíòèíåíöèþ òîëüêî ó 2-õ ïðîñòàòýêòîìèåé [20]. Â ðåòðîñïåêòèâíîì àíàëèçå (22,2%), ÷åðåç 6 ìåñÿöåâ - ó 1-ãî (11,1%) ïàöèåíòà, ó 177-è ïàöèåíòîâ, ñðåäè êîòîðûõ ðàäèêàëüíàÿ ïðîñòà- êîòîðîãî ïîëíîå íåäåðæàíèå îñòàëîñü íà ïðîòÿæå- òýêòîìèÿ ó 122-õ áûëà ïðîâåäåíà ïåðèíåàëüíî, à ó íèè âñåãî ãîäà. 55-è - ðåòðîïóáèêàëüíî, íå îáíàðóæåíî ñòàòèñòè÷åñ- êè äîñòîâåðíîé ðàçíèöû â äàííûõ îïóõîëåïîçèòèâ- Ïîòåíöèÿ. Â ëèòåðàòóðå èìåþòñÿ ïðîòèâîïîëîæíûå íûõ ãðàíèö (29% v.s. 31%, ð<0,803). Àíàëèç ëîêàëèçà- äàííûå î ñîõðàíåíèè ýðåêöèîííîé ôóíêöèè. Martis è öèè ïîçèòèâíûõ ãðàíèö òàêæå íå âûÿâèë ðàçëè÷èé ñîàâòîðû ïîëó÷èëè ëó÷øèå ðåçóëüòàòû ïðè ðåòðîïó- [8]. Ñòàòèñòè÷åñêè íåäîñòîâåðíîå ðàçëè÷èå ïîëó÷è- áèêàëüíîé ïðîñòàòýêòîìèè [15]. Weldon è ñîàâòîðû ïðî- ëè Boccon-Gibod è ñîàâò. [6], êîòîðûå ïàöèåíòîâ ñ àíàëèçèðîâàëè äàííûå 220-è ïàöèåíòîâ ñ ïåðèíåàëü- Ò1c è Ò2à ñòàäèÿìè ðàçäåëèëè íà 2 ãðóïïû. 48-è áîëü- íîé ïðîñòàòýêòîìèåé. Ó ïàöèåíòîâ ñ "õîðîøåé" ïðåäî- íûì áûëà ïðîâåäåíà ðàäèêàëüíàÿ ïåðèíåàëüíàÿ ïðî- ïåðàöèîííîé ïîòåíöèåé, êîòîðûì áûëà ïðîâåäåíà íå- ñòàòýêòîìèÿ, 46-è – ðàäèêàëüíàÿ ðåòðîïóáèêàëüíàÿ ðâîùàäÿùàÿ îïåðàöèÿ, ñîõðàíåíèå ïîòåíöèè íàáëþäà- ïðîñòàòýêòîìèÿ. Îïóõîëåïîçèòèâíûå ãðàíèöû íà- ëîñü â 50% ñëó÷àåâ, ÷åðåç 2 ãîäà - â 70%. ×åðåç 2 ãîäà íå áëþäàëèñü ó ïàöèåíòîâ â 56% è 61%. ñîîòâåòñòâåííî. îáíàðóæèâàëîñü ðàçëè÷èé â äàííûõ óíèëàòåðàëüíîé è Îäíàêî íàëè÷èå õèðóðãè÷åñêè âûçâàííûõ ïîçèòèâíûõ áèëàòåðàëüíîé ùàäÿùåé îïåðàöèé (68% v.s. 73%) [27]. ãðàíèö çíà÷èòåëüíî âûøå â ãðóïïå ïåðèíåàëüíîé Ïî äàííûì äðóãèõ àâòîðîâ, ÷åðåç ãîä ïîñëå ðàäèêàëü- ïðîñòàòýêòîìèè (43% v.s. 29%, ð<0,005) [6]. Èñõîäÿ èç íîé ïåðèíåàëüíîé ïðîñòàòýêòîìèè ïîòåíöèÿ ñîõðàíè- âûøåèçëîæåííîãî, ðàäèêàëüíóþ ïåðèíåàëüíóþ ïðî- ëàñü ó 77% ïàöèåíòîâ [8]. ñòàòýêòîìèþ ñ òî÷êè çðåíèÿ èñõîäà ìîæíî ñ÷èòàòü õèðóðãçàâèñèìûì âìåøàòåëüñòâîì. Íà îñíîâàíèè Íàøå èññëåäîâàíèå íå ñòàâèëî öåëüþ ñðàâíåíèÿ ïðåä- íàøåãî ìàòåðèàëà â 2-õ (22,2%) ñëó÷àÿõ îòìå÷àëîñü è ïîñòîïåðàöèîííîé ïîòåíöèé. Ïðè âûïîëíåíèè îïå- íàëè÷èå îïóõîëåïîçèòèâíûõ ãðàíèö. Â îáîèõ ñëó÷àÿõ ðàöèè, â îñíîâíîì, ïðåäïî÷òåíèå îòäàâàëîñü ñîáëþäå- èìåë ìåñòî áèîõèìè÷åñêèé ðåöèäèâ: ó îäíîãî áîëü- íèþ îíêîëîãè÷åñêîãî ðàäèêàëèçìà, ïîýòîìó çàðàíåå íå íîãî ñïóñòÿ 6 ìåñÿöåâ, ó âòîðîãî - 12. Îáîèì ïàöèåí- ïëàíèðîâàëîñü ïðîâåäåíèå íåðâîùàäÿùåé ïåðèíåàëü- òàì ïðîâåäåíà ïëàñòè÷åñêàÿ îðõèýêòîìèÿ. Ïåðâûé íîé ïðîñòàòýêòîìèè. Òîëüêî â îäíîì ñëó÷àå, ó ìîëîäî- áîëüíîé ñêîí÷àëñÿ ïî ïîâîäó ðàêà ïðîñòàòû ñïóñòÿ ãî ïàöèåíòà ïîñëå ïðîâåäåíèÿ íåðâíîùàäÿùåé îïåðà- 32 ìåñÿöà. 3-ëåòíÿÿ îïóõîëåñïåöèôè÷åñêàÿ ïðîäîëæè- öèè, áûëà ñîõðàíåíà ïîòåíöèÿ. òåëüíîñòü æèçíè ñîñòàâèëà 7 (77,8%) ñëó÷àåâ.

Ðàäèêàëüíàÿ ïåðèíåàëüíàÿ ïðîñòàòýêòîìèÿ ÿâëÿåòñÿ 17. Platt J.F., Bree R.L., Schwab R.E. The accuracy of CT in the íàèëó÷øèì àëüòåðíàòèâíûì ïîäõîäîì ê ëå÷åíèþ ðàí- staging of carcinoma of the prostate // Am J Roentgenol. – 1987. íåé ñòàäèè ðàêà ïðåäñòàòåëüíîé æåëåçû, êîòîðàÿ ïî- - N149. – P. 315-318. çâîëÿåò ñîáëþäàòü îíêîëîãè÷åñêèé ðàäèêàëèçì ïðè êëè- 18. Reiner W.J., Walsh P.C. An anatomical approach to the surgical management of the dorsal vein and Santorini’s plexus during íè÷åñêè ëîêàëèçîâàííîì ðàêå ïðîñòàòû ñ ñîõðàíåíè- radical retropubic surgery // J Urol. – 1979. - N147. – P. 1574. åì êîíòèíåíöèè è ïîòåíöèè [15]. Â ñëó÷àÿõ, êîãäà ïî- 19. Rifkin M.D., Zerhouni E.A., Gatsonis C.A., Quint L.E., ñðåäñòâîì ëèìôàäåíýêòîìèè (îòêðûòî èëè ýíäîõèðóð- Paushter D.M., Epstein J.I., Hamper U., Walsh PC., McNeil ãè÷åñêè) âûÿâëåí óçëîâîé ñòàòóñ, ïðåäïî÷òèòåëüíåå BJ. 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J Urol. – 1994. - N152. – P. 1174. 5. Bishoff JT., Motley G., Optenberg SA., et al. Incidence of 25. Villavicencio H., Segarra J. Perineal prostatectomy // Ann fecal and urinary incontinence following radical perineal and ret- Urol (Paris). – 2006. – N 40(5). – P. 317-27. ropubic prostatectomy in a national population // J Urol. – 1998. 26. Walsh P.C., Donker P.J. Impotence following radical prosta- - N160. – P. 454. tectomy: Insight into etiology and prevention // J Urol. – 1982. 6. Boccon-Gibod L., Ravely V., Vordos D., et al. Radical prosta- - N128. – P. 492. tectomy for prostate cancer: The perineal approach increases 27. Weldon V.E., Travel F.R., Neuwirth H. Continence, potency the risk of surgically induced positive margins and capsular inci- and morbidity after radical perineal prostatectomy // J Urol. – sions // J Urol. – 1998. - N160. – P. 1383. 1995. - N153. - P. 1565. 7. Boeckmann W., Jakse G. Management of rectal injury during 27. Wolff J.M., Bares R., Jung P.K., Buell U.U., Jakse G. Pros- perineal prostatectomy // Urol Int. – 1995. - N55. – P. 147. tatic specific antigen as a marker of bone metastasis in patients 8. Frazier H.A., Robertson J.E., Paulson D.F. Radical prostate- with prostate cancer // Urol Int. – 1996. - N56. – P. 169-173. ctomy: The pros and cons of the perineal versus the retropubic 28. Young H.H. The early diagnosis and radical cure of the pros- approach // J Urol. - 1992. - N147. – P 888. tate: Being a study of 40 cases and presentation of a radical 9. Gibbons R.P., Correa R.J.Jr., Brannen G.E. et al. Total prostatecto- operation which was carried out in four cases // Bull Johns Hop- my for localized prostate cancer // J Urol. – 1984. - N131. – P. 73. kins Hosp. – 1905. - N16. – P. 315. 10. Gray M., Petroni GR., Theodorescu D. Urinary function 29.Zippe C.D., Rackley R.R. Non-nerve sparing radical prosta- after radical prostatectomy: a comparision of the retropubic and tectomy in the elderly patient: Perineal vs. retropubic approach perineal approaches // Urology. – 1999. – N 53(5). – P. 881-90. // J Urol. – 1996. - N155. - P. 400. 11. Haab F., Boccon-Gibod L., Delmas V., Toublanc M. Perineal versus retropubic radical prostatectomy for T1, T2 prostate SUMMARY cancer // Br J Urol. – 1994. – N 74(5). – P. 626-9. 12. Harris M.J. The Anatomic Radical Perineal Prostatectomy: RADICAL PERINEAL PROSTATECTOMY - SURGICAL An Outcomes-Based Evolution // Eur Urol. – 2006. - 30. TECHNIQUE, FIRST RESULTS 13. Lassen P.M., Kearse W.S. Rectal injuries during radical perineal prostatectomy // Urology. – 1995. - N45. – P. 266. Mshvildadze Sh., Ujmajuridze A., Managadze G., Stackl W. 14. Levy D.A., Resnick M.I. Laparoscopic pelvic lymphadenectomy and radical perineal prostatectomy: A viable alternative to rad- Rudolf Fund Clinic, Vienna; Al. Tsulukidze National Centre of ical retropubic prostatectomy // J Urol. – 1994. - N151. – P. 905. Urology 15. Martis G., Diana M., Ombres M., Cardi A., Mastrangeli R., Mastrangeli B. Retropubic versus perineal radical prostatectomy in Prostate cancer is the most common malignancy in men and the early prostate cancer: Eight-year experience // J Surg Oncol. – 2007. second leading cause of cancer death. Radical prostatectomy is 16. Parra R.O., Isorna S., Perez MG., et al. Radical perineal the most effective treatment for localized prostate cancer. With prostatectomy without pelvic lymphadenectomy: Selection cri- increasing use of minimally invasive treatment methods, clinical teria and early results // J Urol. – 1996.- N155. – P. 612. outcomes are becoming important assessment tools to compare

62 GEORGIAN MEDICAL NEWS No 2 (143) Ôåâðàëü, 2007 ãîä one option to another. Perineal prostatectomy is modified to months incontinence was manifested in 1 (11,1%) patient. Post- incorporate contemporary surgical ideas, including preservation operative potency was reached in one case. Margins were pos- of cavernosal nerve bundles, sphincteric urethra at the prostatic itive in 2 (22,2%) cases. In both cases was manifested biochem- apex, and the bladder neck. ical relapse. One of these patients died after 32 month from surgery. According our results 3-year tumor specific survival During 2001-2004 in National Centre of Urology radical perine- was in 7 (77,8%) patients. al prostatectomy was performed in 9 patients. The mean age of the patients was 64 years (range: 53-71 years). All operations Radical perineal prostatectomy is an excellent alternative ap- were carried out with curative purpose for the treatment of proach for radical surgery in the treatment of early prostate localized prostate cancer. In all cases prostate specific antigen cancer. This method of prostatectomy is able to achieve com- (PSA) was <10 ng/ml, Gleason score <7. There were analyzed plete cancer resection while preserving urinary and sexual func- operative time, volume of blood transfusions, duration of hospi- tion in the majority of men presenting with clinically localized tal stay, peri-operative complications, pre and postoperative prostate cancer. The simplicity and minimally invasive nature of potency and urinary continence. this procedure contribute to a short recovery and low overall cost of therapy. The radical perineal prostatectomy is a cost- The distribution of pT categories was: pT2a-2 (22,2%); pT2b- efficient, outcome-effective minimally invasive method of treat- 5 (55,6%); pT3a-1 (11,1%); pT3b-1 (11,1%). The mean opera- ing men with localized prostate cancer. tive time was 130 minutes (range 95-180 minutes). The middling volume of blood transfusion per patient was 427 ml. At 12 Key words: localized prostate cancer, minimally invasive treatment, radical perineal prostatectomy.

ÐÅÇÞÌÅ

ÐÀÄÈÊÀËÜÍÀß ÏÅÐÈÍÅÀËÜÍÀß ÏÐÎÑÒÀÒÝÊÒÎÌÈß – ÎÏÅÐÀÒÈÂÍÀß ÒÅÕÍÈÊÀ, ÏÅÐÂÛÅ ÐÅÇÓËÜÒÀÒÛ

Ìøâèëäàäçå Ø.Ò. Óäæìàäæóðèäçå À.Í. Ìàíàãàäçå Ã.Ë. Øòàêëü Â.

Êëèíèêà ôîíäà Ðóäîëüôà, Âåíà; Íàöèîíàëüíûé öåíòð óðîëîãèè èì. àêàä. À. Öóëóêèäçå

Ðàê ïðîñòàòû ÿâëÿåòñÿ ñàìûì ÷àñòûì îíêîëîãè÷åñêèì çàáî- Â çàâèñèìîñòè îò ïàòîìîðôîëîãè÷åñêîãî äèàãíîçà ïàöèåí- ëåâàíèåì, çàíèìàþùèì ïî ñìåðòíîñòè âòîðîå ìåñòî ïîñëå òû áûëè ðàñïðåäåëåíû ñëåäóþùèì îáðàçîì: pT2a – 2 ïà- ðàêà ëåãêèõ. Èçâåñòíî, ÷òî ñàìûì ýôôåêòèâíûì ìåòîäîì ëå- öèåíòà (22,22%), pT2â – 5 (55,6%), ðÒÇà – 1 (11,1%) è ÷åíèÿ ëîêàëèçîâàííîãî ðàêà ïðåäñòàòåëüíîé æåëåçû ÿâëÿ- ðÒ3â – 1 ïàöèåíò (11,1%). Ïðîäîëæèòåëüíîñòü îïåðàöèè åòñÿ ðàäèêàëüíàÿ ïðîñòàòýêòîìèÿ. Â ñîâðåìåííîé ìåäèöèíå êîëåáàëàñü â ïðåäåëàõ îò 95 äî 180 ìèí. (â ñðåäíåì 130 âñå áîëüøå âíåäðÿåòñÿ ìèíèìàëüíîå èíâàçèâíîå âìåøàòåëü- ìèí.). Òðàíñôóçèÿ êðîâè ïîòðåáîâàëàñü â 7-è ñëó÷àÿõ, â ñòâî. Êëèíè÷åñêèé èñõîä ÿâëÿåòñÿ çíà÷èìûì àðãóìåíòîì äëÿ ñðåäíåì, íà îäíîãî ïàöèåíòà áûëî ïåðåëèòî 427 ìë ýðèòðî- ñðàâíåíèÿ ðàçíûõ ìåòîäîâ ëå÷åíèÿ. Ìîäèôèöèðîâàííàÿ ïå- öèòàðíîé ìàññû. Íà íàøåì ìàòåðèàëå ÷åðåç ãîä èíêîíòèíåí- ðèíåàëüíàÿ ïðîñòàòýêòîìèÿ ïîäðàçóìåâàåò ïðåçåðâàöèþ êà- öèÿ îòìå÷àëàñü ó 1-ãî (11,1%) ïàöèåíòà. Òîëüêî â îäíîì ñëó- âåðíîçíîãî íåðâíîãî ïó÷êà, ñôèíêòåðà óðåòðû è øåéêè ìî- ÷àå ó ìîëîäîãî ïàöèåíòà ïîñëå ïðîâåäåíèÿ íåðâîùàäÿùåé ÷åâîãî ïóçûðÿ. îïåðàöèè áûëà ñîõðàíåíà ïîòåíöèÿ; â 2-õ (22,2%) ñëó÷àÿõ îò- ìå÷àëîñü íàëè÷èå îïóõîëåïîçèòèâíûõ ãðàíèö. Â îáîèõ ñëó÷à- Çà 2001-2004 ãã. â Íàöèîíàëüíîì öåíòðå óðîëîãèè ñ öåëüþ ÿõ èìåë ìåñòî áèîõèìè÷åñêèé ðåöèäèâ. Îäèí áîëüíîé ñêîí- ëå÷åíèÿ àäåíîêàðöèíîìû ïðîñòàòû áûëà ïðîâåäåíà ðàäè- ÷àëñÿ ïî ïîâîäó ðàêà ïðîñòàòû ñïóñòÿ 32 ìåñÿöà. 3-ëåòíÿÿ êàëüíàÿ ïåðèíåàëüíàÿ ïðîñòàòýêòîìèÿ 9-è ïàöèåíòàì. Â èñ- îïóõîëåñïåöèôè÷åñêàÿ ïðîäîëæèòåëüíîñòü æèçíè ñîñòàâèëà ñëåäîâàíèå áûëè âêëþ÷åíû áîëüíûå ñ êëèíè÷åñêè ëîêàëè- 7 (77,8%) ñëó÷àåâ. çîâàííûì ðàêîì ïðîñòàòû, ïîêàçàòåëü ïðîñòàòñïåöèôè÷åñ- êîãî àíòèãåíà êîòîðûõ ñîñòàâëÿë íå áîëüøå 10 íã/ìë, à ñóì- Ðàäèêàëüíàÿ ïåðèíåàëüíàÿ ïðîñòàòýêòîìèÿ ÿâëÿåòñÿ íàèëó÷- ìà Ãëèññîíà - ìåíüøå 7-è. Âîçðàñò âàðüèðîâàë â ïðåäåëàõ îò øèì àëüòåðíàòèâíûì ïîäõîäîì ê ëå÷åíèþ ðàííåé ñòàäèè ðàêà 53 äî 71 ãîäà (ñðåäíèé âîçðàñò 64). Íàìè óñòàíîâëåíû ñðåä- ïðåäñòàòåëüíîé æåëåçû, êîòîðûé ïîçâîëÿåò ñîáëþäàòü îíêî- íÿÿ ïðîäîëæèòåëüíîñòü îïåðàöèè, îáúåì ïåðåëèòîé êðîâè è ëîãè÷åñêèé ðàäèêàëèçì ïðè êëèíè÷åñêè ëîêàëèçîâàííîì ðàêå êðîâåçàìåíèòåëåé, êîëè÷åñòâî êîéêî-äíåé, ÷àñòîòà îïåðàöè- ïðîñòàòû ñ ñîõðàíåíèåì êîíòèíåíöèè è ïîòåíöèè. Ìåòîä îáåñ- îííûõ îñëîæíåíèé, ñðàâíåíà ïðåä- è ïîñòîïåðàöèîííàÿ ïî- ïå÷èâàåò êîðîòêèé ñðîê ðåêîíâàëåñöåíöèè è íàèìåíüøåå ÷èñ- òåíöèÿ è êîíòèíåíöèÿ. ëî êîéêî-äíåé, ÷òî îòðàæàåòñÿ íà ñòîèìîñòè ëå÷åíèÿ.

Íàó÷íàÿ ïóáëèêàöèÿ

ÝÔÔÅÊÒÈÂÍÎÑÒÜ ÝÊÑÒÐÀÊÎÐÏÎÐÀËÜÍÎÉ ÄÈÑÒÀÍÖÈÎÍÍÎÉ ËÈÒÎÒÐÈÏÑÈÈ ÏÐÈ ÌÎ×ÅÊÀÌÅÍÍÎÉ ÁÎËÅÇÍÈ

Âàðøàíèäçå Ë.Î., Òåâçàäçå Ê.Ã., Äæèí÷àðàäçå Ã.Ð., Ìàíàãàäçå Ã.Ë.

Íàöèîíàëüíûé öåíòð óðîëîãèè èì. À. Öóëóêèäçå

Ìî÷åêàìåííàÿ áîëåçíü îäíà èç ÷àñòûõ ïàòîëîãèé ñðå- æåíùèí 713 (43,3%). Èç íèõ äåòåé áûëî 55 (3,3%). Âîç- äè óðîëîãè÷åñêèõ çàáîëåâàíèé. Âíåäðåíèå ñîâðåìåí- ðàñò âàðüèðîâàë â ïðåäåëàõ îò 1 äî 93-õ ëåò. Îáùåå êîëè- íûõ òåõíîëîãèé âíåñëî ñóùåñòâåííûå èçìåíåíèÿ â ìå- ÷åñòâî ïðîâåäåííûõ ñåàíñîâ - 3391 (â ñðåäíåì – 2,1). Â íåäæìåíò ëå÷åíèÿ ýòîé ïàòîëîãèè. Â 80-å ãîäû ïðîøëî- ñëó÷àÿõ âíóòðèïî÷å÷íîãî ðàñïîëîæåíèÿ êàìíåé êîëè- ãî ñòîëåòèÿ øèðîêî ðàñïðîñòðàíèëñÿ ìåòîä äèñòàíöè- ÷åñòâî óäàðîâ ñîñòàâèëî 2000-3500, ïðîäîëæèòåëüíîñòü îííîé ëèòîòðèïñèè, ïðåäëîæåííûé íåìåöêèì èññëå- ñåàíñà - 20-35 ìèí., ïðè ëîêàëèçàöèè êàìíÿ â ìî÷åòî÷íè- äîâàòåëåì Chaussy. Â Ãðóçèè ýêñòðàêîðïîðàëüíàÿ ëè- êå ïðîäîëæèòåëüíîñòü ïðîöåäóðû ñîñòàâèëà 30-45 ìèí., òîòðèïñèÿ âïåðâûå áûëà âíåäðåíà â ã. Áàòóìè â 1989 ã. â îáîèõ ñëó÷àÿõ ÷àñòîòà óäàðîâ – 80-100 â ìèíóòó [6]. Ìîùíîñòü ýíåðãèè, ïðèìåíÿåìàÿ äëÿ äðîáëåíèÿ ïî- Ýêñòðàêîðïîðàëüíàÿ äèñòàíöèîííàÿ ëèòîòðèïñèÿ ñ ó÷å- ÷å÷íûõ êîíêðåìåíòîâ, ñîñòàâëÿëà 12,75 êâ, äëÿ ìî÷å- òîì íåîñëîæíåííûõ ñëó÷àåâ è ðàçìåðîâ ÿâëÿåòñÿ “çîëî- òî÷íèêà - 15 êâ. Ëèòîòðèïñèÿ, â îñíîâíîì, ïðîâîäèëàñü òûì ñòàíäàðòîì” â ëå÷åíèè ìî÷åêàìåííîé áîëåçíè. Ýòî íà ôîíå ñåäîàíàëüãåçèè, ðåäêî – âåíîçíîé àíåñòåçèè, ó âûñîêîýôôåêòèâíàÿ, íåèíâàçèâíàÿ, ùàäÿùàÿ, ôèíàíñî- äåòåé ìëàäøåãî âîçðàñòà - ïîä îáùåé àíåñòåçèåé. âî äîñòóïíàÿ, àìáóëàòîðíî âûïîëíÿåìàÿ ïðîöåäóðà [1]. Ôîêóñèðîâàíèå êàìíÿ ïðîâîäèëîñü ïîñðåäñòâîì ðåí- Öåëüþ èññëåäîâàíèÿ ÿâèëñÿ àíàëèç äàííûõ ýôôåêòèâ- òãåíîñêîïèè èëè óëüòðàñîíîãðàôèè. Ôîêóñèðîâàíèå íîé ýêñòðàêîðïîðàëüíîé óäàðíîâîëíîâîé äèñòàíöèîí- ðåíòãåíåãàòèâíûõ êàìíåé ìî÷åòî÷íèêà îñóùåñòâëÿëè íîé ëèòîòðèïñèè ïðè ìî÷åêàìåííîé áîëåçíè ïî ìàòå- êîíòðàñòèðîâàíèåì [3]. Áåññèìïòîìíîå òå÷åíèå íàáëþ- ðèàëàì Íàöèîíàëüíîãî öåíòðà óðîëîãèè çà 2003-2006 ã. äàëîñü ó 424-õ (25,7%) áîëüíûõ, ñ ñèìïòîìàòèêîé (ïî- ÷å÷íàÿ êîëèêà, ëèõîðàäêà, ìàêðîãåìîòóðèÿ) ó 1221-ãî Ìàòåðèàë è ìåòîäû. Â ñòàòüå îáñóæäàþòñÿ äàííûå ëå- (743%) ïàöèåíòà, èç íèõ â 202-õ (12,3%) ñëó÷àÿõ îòìå÷à- ÷åíèÿ 1645-è ïàöèåíòîâ çà 2003-2006 ãã., êîòîðûì ïðî- ëàñü âûðàæåííàÿ èíôåêöèÿ ìî÷åâûõ ïóòåé. âåäåíà ýêñòðàêîðïàëüíàÿ óäàðíîâîëíîâàÿ äèñòàíöèîí- íàÿ ëèòîòðèïñèÿ (ESWL) ëèòîòðèïòîðîì III ïîêîëåíèÿ Èç êëèíèêî-ëàáîðàòîðíûõ èññëåäîâàíèé áîëüíûì ñòàí- Dornier Compact Delta êàê àìáóëàòîðíî, òàê è â óñëîâè- äàðòíî ïðîâîäèëèñü: îáùèé àíàëèç êðîâè è ìî÷è, êðå- ÿõ ñòàöèîíàðà. Ãîñïèòàëèçèðîâàíû áûëè ïàöèåíòû, ñ àòèíèí êðîâè, êîàãóëîãðàììà, ÝÊÃ, óëüòðàñîíîãðàôèÿ ðàçâèâøåéñÿ èíôåêöèåé ìî÷åâûâîäÿùåé ñèñòåìû, àíó- è îáçîðíàÿ ðåíòãåíîãðàôèÿ ìî÷åâîé ñèñòåìû, ýêñêðå- ðèåé âñëåäñòâèå îáñòðóêöèè êàìíåì, à òàêæå áîëüíûå, òîðíàÿ óðîãðàôèÿ (íå ïðîâîäèëàñü ïðè ðåíòãåíïîçè- êîòîðûì ââèäó ñèëüíîé ïî÷å÷íîé êîëèêè ñ öåëüþ êó- òèâíûõ êàìíÿõ ìî÷åâîé ñèñòåìû) è ðåäêî êîìïüþòåð- ïèðîâàíèÿ áîëè òðåáîâàëîñü êîíñåðâàòèâíîå ëå÷åíèå íàÿ òîìîãðàôèÿ. (èíòðàìóñêóëÿðíàÿ, âíóòðèâåííàÿ àíàëüãåçèÿ) èëè êà- òåòåðèçàöèÿ ìî÷åòî÷íèêà. Èç 1719-è êàìíåé ðåòãåíïîçèòèâíûõ îáíàðóæåíî 1452 (84,5%) ðåòãåíåãàòèíâûõ – 267 (15,5%). Â òàáëèöå 1 ïðåä- Ñðåäè 1645-è ïàöèåíòîâ ìóæ÷èí áûëî 932 (56,7%) – ñòàâëåíà ñõåìà ëîêàëèçàöèè êàìíåé.

Òàáëèöà 1. Ïîêàçàòåëè ëîêàëèçàöèè êàìíåé Ïî÷êà ìî÷åòî÷íèê âåðõíÿÿ ñðåäíÿÿ íèæíÿÿ ìî÷åâîé âåðõíÿÿ ñðåäíÿÿ íèæíÿÿ ìî÷åâîé ÷àøêà ÷àøêà ÷àøêà ïóçûðü òðåòü òðåòü òðåòü ïóçûðü 63 118 182 642 272 138 303 1 (3,7%) (6,9%) (10,6%) (37%) (15,8%) (8,02%) (17,5%) (0,06%)

Òàáëèöà 2. Ïîêàçàòåëè ðàçìåðîâ êàìíåé 3-5 ìì 5-10 ìì 10-15 ìì 15-20 ìì 20- 25 ìì > 25 ìì 119 402 616 363 165 54 (6,9%) (23,4%) (35,8%) (21,1%) (9,6%) (3,1%)

64 GEORGIAN MEDICAL NEWS No 2 (143) Ôåâðàëü, 2007 ãîä

Ñðåäè 1645-è ïàöèåíòîâ ñ îäíîé ïî÷êîé áûëî 37 (23%), áîëüíîãî, ÷àñòè÷íî óñïåøíîå - â 91-îì (5,5%) ñëó- îáñòðóêöèÿ íàáëþäàëàñü ó 1298-è (7,8,9%) ïàöèåíòîâ, ÷àå. Â ýòîé ãðóïïå îáúåäèíèëèñü áîëüíûå ñ êàìíåì áåç îáñòðóêöèè – 491 (29,8%), ñ ðàçäâîåííîé ïî÷êîé – â ëîõàíêå ïî÷êè, ó êîòîðûõ ïîñëå äèñòàíöèîííîé ëè- 13 (0,8%), ïîäêîâîîáðàçíîé ïî÷êîé – 6 (0,4%), ó 1-ãî òîòðèïñèè èñ÷åçëà âûçâàííàÿ êàìíåì îáñòðóêöèÿ, áîëüíîãî îòìå÷àëàñü äèñïîçèöèÿ ïî÷êè. îäíàêî îïðåäåëåííûå ôðàãìåíòû êàìíÿ ìèãðèðî- âàëè â íèæíþþ ÷àøêó è èõ èçâëå÷åíèå â ïîñëåäóþ- Äî ESWL – êîíñåðâàòèâíîå ëå÷åíèå ñ öåëüþ êóïèðîâà- ùåì íå óäàëîñü. íèÿ áîëè ïðîâîäèëîñü 1398-è (85%) ïàöèåíòàì, àíòèáè- îòèêîòåðàïèÿ – 472-óì (28%), êàòåòåðèçàöèÿ – 18-è Íåçàâåðøåííîå ëå÷åíèå (ïàöèåíòû ïî ñâîåé èíèöèà- (1,1%), ñòåíòèðîâàíèå ìî÷åòî÷íèêà - 67-è (4,1%), ïåð- òèâå íå îáðàòèëèñü â êëèíèêó) îòìå÷àëîñü â 262-õ êóòîðíàÿ íåôðîñòîìèÿ – 51-ìó (3,1%). (15,5%) ñëó÷àÿõ. Áåçðåçóëüòàòíîå ëå÷åíèå - â 81-îì (4,9%) ñëó÷àå, èç íèõ â 31-îì ñëó÷àå ïîòðåáîâàëàñü óðåòðîðå- Ðåçóëüòàòû è èõ îáñóæäåíèå. Èç 1645-è ñëó÷àåâ óñ- íîñêîïèÿ, 49-è - îòêðûòàÿ îïåðàöèÿ, ïåðêóòàëüíàÿ íå- ïåøíîå ESWL (store - free) áûëî ó 121-ãî (73,6%) ôðîëèòîëàïàêñèÿ – 7-è ñëó÷àÿõ. Òàáëèöà 3. Ïîêàçàòåëè îñëîæíåíèé ïîñëå ESWL Äîðîæêà êàìíÿ Ãåìàòîìà Ïèåëîíåôðèò Ìàêðîãåìàòóðèÿ Íåñíÿòàÿ êîëèêà 62 (3,8%) 15 (0,9%) 59 (3,6%) 7 (0,4%) 77 (4,7%)

Â áëèæàéøèé ïåðèîä ïîñëå ESWL ïî ïîâîäó ðàçëè÷íûõ Ñðåäè ìåòîäîâ èññëåäîâàíèÿ ïðåäïî÷òåíèå îòäàâàëîñü îñëîæíåíèé (áîëü, ãåìàòóðèÿ, ïèåëîíåôðèò è ò.ä.) êîí- óëüòðàñîíîãðàôèè è ðåíòãåíîëîãè÷åñêèì èññëåäîâàíè- ñåðâàòèâíîå ëå÷åíèå ïîòðåáîâàëîñü â 168-è (10,2%) ñëó- ÿì. Â 3-õ ñëó÷àÿõ áûëè äîïóùåíû äèàãíîñòè÷åñêèå ÷àÿõ, íåôðîñòîìèðîâàíèå ïðîâåäåíî â 19-è (12%), ñòåíòè- îøèáêè (â 2-õ ñëó÷àÿõ îòìå÷àëàñü ñòðèêòóðà ëîõàíî÷- ðîâàíèå – 7-è (0,4%), óðåòðîðåíîñêîïèÿ – 3-õ (0,2%), êàòå- íî-ìî÷åòî÷íèêîâîãî óãëà, â îäíîì - òåðìèíàëüíûé ãèä- òåðèçàöèÿ ìî÷åâîãî ïóçûðÿ – 5-è (0,3%), îòêðûòàÿ îïåðà- ðîíåôðîç). Ó ýòèõ áîëüíûõ â ïîñëåäóþùåì áûëà ïðî- öèÿ ïî ïîâîäó íàðàñòàþùåé ãåìàòîìû – 3-õ (0,2%) ñëó÷à- âåäåíà îòêðûòàÿ õèðóðãè÷åñêàÿ îïåðàöèÿ. ÿõ, ÷òî ñîãëàñóåòñÿ ñ ìåæäóíàðîäíûìè ñòàíäàðòàìè [4]. Äî ESWL ó áîëüíûõ ñ êëèíè÷åñêèìè ñèìïòîìàìè Ïî äàííûì Íàöèîíàëüíîãî öåíòðà óðîëîãèè Ãðóçèè çà ïðîâîäèëîñü êîíñåðâàòèâíîå ëå÷åíèå: àíàëüãåçèÿ, 2003-2006 ãã., îïåðàöèé îòêðûòûì ñïîñîáîì ïðîâåäåíî ñïàçìîëèòèêè, àíòèáèîòèêîòåðàïèÿ, êàòåòåðèçàöèÿ â 346-è ñëó÷àÿõ, ÷òî ñîñòàâëÿåò 17,4% îò îáùåãî ÷èñëà ì/ò, ïåðêóòàííàÿ íåôðîñòîìèÿ, ñòåíòèðîâàíèå. Ñî- áîëüíûõ. Óäåëüíûé âåñ îòêðûòûõ îïåðàöèé â íàøåé ãëàñíî ñòàíäàðòàì, ïðè íàëè÷èè êàìíÿ áîëüøå 20-è êëèíèêå ïî ñðàâíåíèþ ñ êëèíèêàìè Çàïàäà (5-8%) ïî ìì ðåêîìåíäóåòñÿ ñòåíòèðîâàíèå. Â íàøåì ñëó÷àå ñåé äåíü îñòàåòñÿ âûñîêèì, ÷òî, î âñåé âåðîÿòíîñòè, íåîáõîäèìîñòü ñòåíòèðîâàíèÿ áûëà îáóñëîâëåíà îä- îáóñëîâëåíî ïîçäíåé îáðàùàåìîñòüþ áîëüíûõ â êëè- íîé ïî÷êîé. Â äðóãèõ ñëó÷àÿõ ñòåíòèðîâàíèå ÿâè- íèêó è ïî ïðè÷èíå òÿæåëûõ ñîöèàëüíûõ óñëîâèé. ëîñü âûáîðîì áîëüíûõ. Ïàöèåíòàì ïðåäîñòàâëÿëàñü ïîëíàÿ èíôîðìàöèÿ î òîì, ÷òî ñòåíòèðîâàíèå ïðå- Ïåðêóòàííàÿ íåôðîëèòîëàïàêñèÿ, êàê ìåòîä âûáîðà â äîòâðàùàåò ïî÷å÷íóþ êîëèêó â ïåðèîä ìèãðàöèè ëå÷åíèè ìî÷åêàìåííîé áîëåçíè, âîçîáíîâèëàñü ñ 2006 ôðàãìåíòîâ êàìíÿ, âîçìîæíîñòü ðàçâèòèÿ ïèåëî- ã., ÷åì è îáúÿñíÿåòñÿ áîëüøîå ÷èñëî îòêðûòûõ îïåðà- íåôðèòà, õîòÿ â òî æå âðåìÿ ñòåíòèðîâàíèå ìîæåò öèé, âûïîëíåííûõ â íàøåé êëèíèêå. Çà 2003-2006 ãã. ýê- âûçâàòü âîñõîäÿùóþ èíôåêöèþ, ðåôëþêñ, èðèòàöè- ñòðàêîðïîðàëüíàÿ óäàðíîâîëíîâàÿ ëèòîòðèïñèÿ ïðîâå- îííûé ñèíäðîì, óâåëè÷åíèå âðåìåíè îñâîáîæäå- äåíà 1645-è ïàöèåíòàì, îòêðûòàÿ îïåðàöèÿ ïî ïîâîäó íèÿ îò êàìíåé. Ïðè âîçìîæíîñòè èñïîëüçîâàíèÿ ñî- ìî÷åêàìåííîé áîëåçíè – 346-è áîëüíûì (èç íèõ ïî ïî- âðåìåííûõ àíòèáèîòèêîâ øèðîêîãî ñïåêòðà äåé- âîäó áåçóñïåøíîé ESWL - 49 ïàöèåíòàì), ïåðêóòàííàÿ ñòâèÿ è äîñòóïíîñòè ñèëüíûõ îáåçáîëèâàþùèõ ïðå- íåôðîëèòîëàïàêñèÿ – 18-è (ââèäó áåçóñïåøíîé ESWL – ïàðàòîâ, áîëüøèíñòâî áîëüíûõ âûáèðàëî ëå÷åíèå 7-è), à óðåòðîðåíîñêîïèÿ – 90-à (ïî ïîâîäó áåçóñïåø- áåç ñòåíòà. Ïî íàøèì äàííûì, çà êîðîòêèé ïåðèîä íîé ESWL – 31-ìó) áîëüíûì. ïîñëå ESWL èç 1645-è ïàöèåíòîâ íåîòëîæíàÿ ïåðêó- òàííàÿ íåôðîñòîìèÿ ïîòðåáîâàëàñü 19-è (12%) áîëü- ESWL îñîáåííî âûñîêîýôôåêòèâíà â ïåäèàòðè÷åñêîé íûì, ñòåíòèðîâàíèå – 7-è (0,4%), êàòåòåðèçàöèÿ ì/ò ïðàêòèêå (îò 1-ãî äî 14-è ëåò). Çà 2003-2006 ã. ESWL ïðî- – 5-è (0,3%) ïàöèåíòàì. âåäåíà 55-è äåòÿì (ñåàíñû ïðîâîäèëèñü êàê ïîä îáùåé, èíòðàâåííîé àíåñòåçèåé, òàê è íà ôîíå ñåäîàíàëüãåçèè). Ðåçóëüòàòû ëå÷åíèÿ íåèçâåñòíû â 262-õ (15,9%) ñëó- Ïîëíîå îñâîáîæäåíèå îò êàìíåé ïîñëå ïåðâîãî ñåàíñà ÷àÿõ. Èç íèõ íåêîòîðûå áûëè èíîñòðàíöàìè, êîòîðûå áûëî äîñòèãíóòî ó 89% áîëüíûõ, ïîñëå ïðîâåäåíèÿ ïî- îñòàâèëè ñòðàíó, äðóãèå, íåñìîòðÿ íà íàøè ìíîãî- âòîðíûõ ñåàíñîâ â 100% ñëó÷àåâ. ðàçîâûå èçâåùåíèÿ, íå îáðàùàëèñü â êëèíèêó.

Âûñîêàÿ ýôôåêòèâíîñòü è íàèìåíüøàÿ èíâàçèâíîñòü session varied from 30 to 45 minutes. From 1719 stones 1452 äèñòàíöèííîé ëèòîòðèïñè÷åñêîé àïïàðàòóðû ïîñëåä- (84,5%) were X-Ray positive and 267 (15,5%) were X-Ray íåãî ïîêîëåíèÿ îáóñëîâëåíû âûñîêîé òî÷íîñòüþ ôî- negative. êóñèðîâêè è ïðèöåëà, ïðèìåíåíèåì ñðàâíèòåëüíî ìåíü- ESWL was successful (stone free) in 1211 (73,6%) and semi øåé óäàðíîé ñèëû. Ñîîòâåòñòâåííî óìåíüøèëîñü ÷èñ- successful in 91 (5,5%) cases; Semi successful group includ- ëî ñóáêàïñóëÿðíûõ ãåìàòîì è äðóãèõ îñëîæíåíèé. Ïî ed patients, which became desobstructed after ESWL, but the ñðàâíåíèþ ñ àïïàðàòàìè I ïîêîëåíèÿ íåñêîëüêî óâåëè- some of the stone fragments were dislocated into lower calyx ÷èëàñü ïðîäîëæèòåëüíîñòü ñåàíñîâ [2,5]. and were not eliminated. Unfinished treatment (Patient dis- appeared after the initial sessions) were in 262 (15,9%) cas- Òàêèì îáðàçîì, íà îñíîâàíèè ïðîâåäåííîãî èññëåäî- es. 81 cases were not successful. 31 patients from this group âàíèÿ ñëåäóåò çàêëþ÷èòü, ÷òî ýêñòðàêîðïîðàëüíàÿ óäàð- underwent urethrorenoscopy, 49 patients – open surgery an íîâîëíîâàÿ äèñòàíöèîííàÿ ëèòîòðèïñèÿ â óñëîâèÿõ 7 – PNL. In conclusion, ESWL is the “golden” standard treat- ïðàâèëüíî ïðîâåäåííîãî èññëåäîâàíèÿ è ìåíåäæìåí- ment of Urinary stone disease in cases of carefully performed examination and management. Careful study of every single òà ÿâëÿåòñÿ “çîëîòûì ñòàíäàðòîì” â ëå÷åíèè ìî÷åêà- case, gives as the possibility to avoid expensive and invasive ìåííîé áîëåçíè. Ñîîòâåòñòâóþùèé ïîäõîä ê êàæäîìó procedures and reduce the risk of complications. èíäèâèäóàëüíîìó ñëó÷àþ ïîçâîëèò èçáåæàòü ïðîâåäå- íèÿ äîðîãîñòîÿùèõ èññëåäîâàíèé, èíâàçèâíûõ ïðîöå- Key words: ESWL - extracorporal shock wave lithotripsy, PNL äóð è óìåíüøèòü îæèäàåìûå îñëîæíåíèÿ. – percutaneous neprolithotomy.

ËÈÒÅÐÀÒÓÐÀ ÐÅÇÞÌÅ

1. Clayman R., McLennan B.L., Garvin T.J., Garvin T.D. et al. ÝÔÔÅÊÒÈÂÍÎÑÒÜ ÝÊÑÒÐÀÊÎÐÏÎÐÀËÜÍÎÉ ÄÈÑ- Lithostar: an electromagnetic, acoustic shockwave unit for extra- ÒÀÍÖÈÎÍÍÎÉ ËÈÒÎÒÐÈÏÑÈÈ ÏÐÈ ÌÎ×ÅÊÀÌÅÍ- corporeal lithotripsy // J Endourol. – 1989. - N3. – P. 307-313. ÍÎÉ ÁÎËÅÇÍÈ 2. Chow G.K., Streem S.B. Extracorporeal lithotripsy—update on technology // Urol Clin N Am. – 2000. - N27. – P. 315-322. Âàðøàíèäçå Ë.Î., Òåâçàäçå Ê.Ã., Äæèí÷àðàäçå Ã.Ð., Ìà- 3. Lalak N.J., Moussa S.A., Smith G., Tolley D.A. The Dornier íàãàäçå Ã.Ë. Compact Delta lithotriptor: the first 150 ureteral calculi // J Endourology. – 2002. – N 16(9). - P. 645-648. Íàöèîíàëüíûé öåíòð óðîëîãèè èì. À. Öóëóêèäçå 4. Taylor A.L., Oakley N., Das S., Parys B.T. Day care ureteroscopy: an observational study // BJU Int. – 2002. – N 89(3). – P. 181-185. Â ñòàòüå îáñóæäàþòñÿ äàííûå 1645-è ïàöèåíòîâ, êîòîðûì çà 5. Tiselius H.G., Ackermann D., Alken D., Buck C., Conort P., 2003-2006 ãã. ïðîâåäåíà ýêñòðàêîðïîðàëüíàÿ óäàðíîâîëíî- Gallucci M. Guidelines on urolithiasis // Eur. Urol. – 2001. - âàÿ äèñòàíöèîííàÿ ëèòîòðèïñèÿ (ESWL) ëèòîòðèïòîðîì N40. – P. 362-371. III ïîêîëåíèÿ Dornier Compact Delta êàê àìáóëàòîðíî, òàê è 6. Tiselius H.G. Anaesthesia free insitu extracorporeal shock wave â óñëîâèÿõ ñòàöèîíàðà. Èç 1645-è áîëüíûõ 932 (56,7%) áûëè lithotripsy of ureteral stone // J Urol. – 1991. – N 146(1). - P. 8-12. ìóæ÷èíû, 713 (43,3%) – æåíùèíû, 55 (3,3%) - äåòè. Âîçðàñò ïàöèåíòîâ êîëåáàëñÿ â ïðåäåëàõ îò 1 äî 93 ëåò. Îáùåå êîëè- SUMARRY ÷åñòâî ñåàíñîâ 3391 (ñðåäíåå êîëè÷åñòâî ñåàíñîâ 2,1). Êîëè- ÷åñòâî óäàðîâ ïðè ïî÷å÷íîé ëîêàëèçàöèè êàìíåé ñîñòàâèëî THE EFFICACY OF EXTRACORPORAL SHOCK WAVE 2000-3500, äëèòåëüíîñòü ñåàíñîâ - 20-35 ìèí. Ïðîäîëæè- LITHOTRYPSY IN URINARY STONE DESEASE òåëüíîñòü ïðîöåäóðû ïðè ëîêàëèçàöèè êàìíÿ â ìî÷åòî÷íè- êå ñîñòàâèëà 30-45 ìèí. Èç îáùåãî êîëè÷åñòâà 1719-è êàì- Varshanidze L., Tevzadze K., Jincharadze G., Mana- íåé, ðåòãåíîïîçèòèâíûõ áûëî 1452 (84,5%) ðåòãåíîíåãàòèí- gadze G. âûõ – 267 (15,5%). Óñïåøíàÿ ESWL (stone-free) áûëà â 121-îì (73,6%) ñëó÷àå, ÷àñòè÷íî óñïåøíàÿ - â 91-îì (5,5%). Â ýòîé National Center of Urology, Tbilisi, Georgia. ãðóïïå îáúåäèíèëèñü áîëüíûå ñ êàìíåì â ëîõàíêå ïî÷êè, ó êîòîðûõ ïîñëå äèñòàíöèîííîé ëèòîòðèïñèè èñ÷åçëà âûçâàí- Extracorporal Shock Wave Lithotrypsy (ESWL) is “golden” íàÿ êàìíåì îáñòðóêöèÿ, îäíàêî îïðåäåëåííûå ôðàãìåíòû standard therapy among the various methods of treatment of êàìíÿ ìèãðèðîâàëè â íèæíþþ ÷àøå÷êó è èõ èçâëå÷åíèå â urinary stone disease. ïîñëåäóþùåì íå óäàëîñü.

We have evaluated 1645 patients with urinary stone disease Íåçàâåðøåííîå ëå÷åíèå (ïàöèåíòû ïî ñâîåé èíèöèàòèâå íå who underwent ESWL from 2003 to 2006, with third genera- îáðàòèëèñü â êëèíèêó) îòìå÷àëîñü â 262-õ (15,5%) ñëó÷à- tion Dornier Compact Delta lythotriptor. 932 (56,7%) of them ÿõ. Áåçðåçóëüòàòíîå ëå÷åíèå - â 81-îì (4,9%) ñëó÷àå, èç were male and 713 (43,3%) were female, 55 (3,3%) of all íèõ 31-ìó ïàöèåíòó ïîòðåáîâàëàñü óðåòåðîðåíîñêîïèÿ, were children. Patients’ age varied from 1 to 93 years. The 49-è - îòêðûòàÿ îïåðàöèÿ, 7-è ïàöèåíòàì ïåðêóòàííàÿ íå- total amount of sessions performed were 3391 (mean 2,1). In ôðîëèòîëàïàêñèÿ. case of renal calculi the amount of shocks was 2000 – 3500 and the duration of session varied from 20 to 35 minutes. In Òàêèì îáðàçîì, ñëåäóåò çàêëþ÷èòü, ÷òî ýêñòðàêîðïîðàëü- case of urethral calculi – 3000 – 4500 shocks, duration of íàÿ óäàðíîâîëíîâàÿ äèñòàíöèîííàÿ ëèòîòðèïñèÿ â óñëîâè-

66 GEORGIAN MEDICAL NEWS No 2 (143) Ôåâðàëü, 2007 ãîä

ÿõ ïðàâèëüíî ïðîâåäåííîãî èññëåäîâàíèÿ è ìåíåäæìåíòà àëüíîìó ñëó÷àþ ïîçâîëèò èçáåæàòü ïðîâåäåíèÿ äîðîãîñ- ÿâëÿåòñÿ «çîëîòûì ñòàíäàðòîì» â ëå÷åíèè ìî÷åêàìåííîé òîÿùèõ èññëåäîâàíèé, èíâàçèâíûõ ïðîöåäóð è óìåíüøèòü áîëåçíè, Ñîîòâåòñòâóþùèé ïîäõîä ê êàæäîìó èíäèâèäó- îæèäàåìûå îñëîæíåíèÿ.

Íàó÷íàÿ ïóáëèêàöèÿ

ÊÎËÈ×ÅÑÒÂÅÍÍÛÅ ÈÇÌÅÍÅÍÈß ÒÅÑÒÎÑÒÅÐÎÍÀ È ÏÐÎÑÒÀÒÑÏÅÖÈÔÈ×ÅÑÊÎÃÎ ÀÍÒÈÃÅÍÀ ÏÐÈ ÅÃÎ ÌÀËÎÉ È ÂÛÑÎÊÎÉ ÏËÎÒÍÎÑÒÈ Ó ÌÓÆ×ÈÍ Ñ ÐÀÊÎÌ ÏÐÎÑÒÀÒÛ

Õóñêèâàäçå À.À., Êî÷èàøâèëè Ä.Ê.

Òáèëèññêèé ãîñóäàðñòâåííûé ìåäèöèíñêèé óíèâåðñèòåò, äåïàðòàìåíò óðîëîãèè

Ðàê ïðîñòàòû ïðåäñòàâëÿåò îäíî èç ñàìûõ ðàñïðîñò- Âûñêàçàíî ïðåäïîëîæåíèå [1], ÷òî ïðè ýòîì ñóùåñòâó- ðàíåííûõ îíêîëîãè÷åñêèõ çàáîëåâàíèé. Ñìåðòíîñòü, þùèå êàê â ìåòàñòàçèðóþùèõ, òàê è ýïèòåëèàëüíûõ êëåò- âûçâàííàÿ ýòèì çàáîëåâàíèåì, ñîñòàâëÿåò 9% îò âñåõ êàõ ïðåäñòàòåëüíîé æåëåçû ðåöåïòîðû òåñòîñòåðîíà ïîä- ñëó÷àåâ ëåòàëüíûõ èñõîäîâ îò ðàêà ñðåäè ìóæ÷èí [2]. âåðãàþòñÿ ìóòàöèè èëè àìïëèôèêàöèè, ââèäó ÷åãî îíè Âíåøíèå ôàêòîðû âëèÿþò íà êëèíè÷åñêîå ñòàíîâëå- ñòàíîâÿòñÿ êîíñòèòóöèîíàëüíî àêòèâíûìè è âîñòðåáó- íèå ðàêà ïðîñòàòû. Òî÷íîå îïðåäåëåíèå ýòèõ ôàêòîðîâ þò ìåíüøåå êîëè÷åñòâî òåñòîñòåðîíà [1]. ïî ñåé äåíü îñòàåòñÿ ñïîðíûì, îäíàêî ñëåäóåò îòìå- òèòü, ÷òî âûñîêîå ñîäåðæàíèå æèðîâ ìîæåò ïîâûøàòü Íå âûçûâàåò ñîìíåíèÿ, ÷òî àíäðîãåíû èãðàþò âåäóùóþ âåðîÿòíîñòü ðàçâèòèÿ ðàêà ïðîñòàòû [3]. Hamalainen è ðîëü â ñòàíîâëåíèè ðàêà ïðîñòàòû, îäíàêî èõ çíà÷åíèå ñîàâò. [4] óñòàíîâèëè, ÷òî êîíöåíòðàöèÿ àíäðîñòåíäèî- â èíäóêöèè íåî- è ãèïåðïëàñòè÷åñêèõ ïðîöåññîâ íå íà, òåñòîñòåðîíà è ñâîáîäíîãî òåñòîñòåðîíà óìåíüøà- âûÿâëåíî. Ýòèîïàòîãåíåç óêàçàííûõ ïàòîëîãèé ôîðìè- åòñÿ ïðè ïîòðåáëåíèè äèåòè÷åñêèõ æèðîâ. Èññëåäîâà- ðóåòñÿ ðàçëè÷íûìè ïóòÿìè. Îäíàêî ñâÿçü ìåæäó öèð- íèå ýòîé ïîïóëÿöèè âûÿâèëî óìåíüøåíèå ñëó÷àåâ ðàêà êóëèðóþùåé êîíöåíòðàöèåé òåñòîñòåðîíà è èíèöèàöè- ïðîñòàòû. åé çàáîëåâàíèÿ, åå òå÷åíèåì è ïðîãðåññèðîâàíèåì íå èçó÷åíà. Íå óñòàíîâëåíà òàêæå êîððåëÿöèÿ òåñòîñòåðî- Ðàê ïðîñòàòû àíäðîãåí÷óâñòâèòåëüíûé è ðåàãèðóåò íà íà â êðîâè ñî ñòàäèÿìè çàáîëåâàíèÿ, íà÷àëüíûìè è ðàç- ãîðìîíàëüíóþ òåðàïèþ. Ýòè õàðàêòåðèñòèêè îïóõîëè âèòûìè ôîðìàìè ïàòîëîãèè. ïðîñòàòû óêàçûâàþò, ÷òî ñòåðîèäíûå ãîðìîíû, â îñ- íîâíîì, àíäðîãåíû, èãðàþò çíà÷èòåëüíóþ ðîëü â êàð- Öåëüþ èññëåäîâàíèÿ ÿâèëîñü óñòàíîâëåíèå çíà÷åíèÿ öèíîãåíåçå ïðîñòàòû ÷åëîâåêà. Òî÷íûé ìåõàíèçì, ÷å- èçìåíåíèé òåñòîñòåðîíà â ñòàíîâëåíèè ðàêà ïðîñòà- ðåç êîòîðûé àíäðîãåíû âëèÿþò íà ýòîò ïðîöåññ – íåèç- òû; èçó÷åíèå êîððåëÿöèè ìåæäó òåñòîñòåðîíîì è âåñòåí [2]. ïëîòíîñòüþ ïðîñòàòñïåöèôè÷åñêîãî àíòèãåíà ó ìóæ- ÷èí, áîëüíûõ ðàêîì ïðîñòàòû. Ëå÷åíèå ðàêà ïðîñòàòû, îñîáåííî â ñëó÷àÿõ, êîãäà ðàç- âèâàþòñÿ ìåòàñòàçû â êîñòíûõ èëè ìÿãêèõ òêàíÿõ, íîñèò Äëÿ äîñòèæåíèÿ óêàçàííîé öåëè áûëè ïîñòàâëåíû ïàëëèàòèâíûé õàðàêòåð. Ýôôåêòèâíîñòü ëå÷åíèÿ çàâè- ñëåäóþùèå çàäà÷è: èçó÷åíèå êîíöåíòðàöèîííûõ èç- ñèò îò ÷óâñòâèòåëüíîñòè ýïèòåëèàëüíûõ êëåòîê ïðåäñòà- ìåíåíèé òåñòîñòåðîíà è ïðîñòàòñïåöèôè÷åñêîãî àí- òåëüíîé æåëåçû ê àíäðîãåíàì, êîòîðûå ÿâëÿþòñÿ èíäóê- òèãåíà (ÏÑÀ) äî êàñòðàöèè è ïîñëå íåå â ñûâîðîòêå òîðàìè ïðîëèôåðàòèâíîé àêòèâíîñòè ýòèõ êëåòîê. Àíòè- êðîâè ïàöèåíòîâ ñ ðàêîì ïðîñòàòû, ÏÑÀ êîòîðûõ àíäðîãåííàÿ òåðàïèÿ èëè êàñòðàöèÿ íà îïðåäåëåííîå áûëî ìåíüøå 0,3 íã/ìë/ã, à òàêæå ó ïàöèåíòîâ ñ ÏÑÀ âðåìÿ âûçûâàåò ðåìèññèþ îïóõîëè, îäíàêî ïðè ïðîãðåñ- áîëüøå 0,3 íã/ìë/ã. ñèðîâàíèè îïóõîëè, êîãäà àíäðîãåíçàâèñèìîå ñîñòîÿíèå ïåðåõîäèò ñïåðâà â àíäðîãåí÷óâñòâèòåëüíîå, à ïîòîì ãîð- Ìàòåðèàë è ìåòîäû. Íàìè èññëåäîâàí 61 áîëüíîé, êî- ìîíðåôðàêòîðíîå èëè àíäðîãåííåçàâèñèìîå, ïðîöåññ òîðûì íà îñíîâå äèãèòàëüíî-ðåêòàëüíîãî îáñëåäîâà- àíäðîãåííîé àáëàöèè ñòàíîâèòñÿ áåçðåçóëüòàòíûì [5,6]. íèÿ, îïðåäåëåíèÿ ÏÑÀ, òðàíñðåêòàëüíîé óëüòðàñîíîã-

ðàôèè ïðåäñòàòåëüíîé æåëåçû è ãèñòîìîðôîëîãè÷åñ- äîì. Äëÿ óñòàíîâëåíèÿ åãî êîíöåíòðàöèè â ñûâîðîòêå êîãî èññëåäîâàíèÿ áûë óñòàíîâëåí äèàãíîç ðàêà ïðî- êðîâè ïðèìåíÿëàñü òåñò-ñèñòåìà P51 – Testosteron RIA ñòàòû. Ïàöèåíòàì ïðîâîäèëîñü ñêàíèðîâàíèå êîñòåé è – mat Byh – Malin; ÷óâñòâèòåëüíîñòü – 0,6 íìîëü/ë; ãðà- êîìïüþòåðíàÿ òîìîãðàôèÿ. Îáñëåäîâàíèå âñåõ áîëü- íèöû îïðåäåëåíèÿ 2-50 íìîëü/ë; ó çäîðîâûõ ìóæ÷èí â íûõ âûÿâèëî ëîêàëüíî ðàñïðîñòðàíåííûé ðàê (T3) è âîçðàñòå 20-80 ëåò íîðìàëüíûå ïîêàçàòåëè òåñòîñòåðî- ðàê ñ øèðîêîðàñïðîñòðàíåííûìè ìåòàñòàçàìè íà êîëåáëþòñÿ â ïðåäåëàõ 9-20 íìîëü/ë. (T3NxM1-T4). Íà îñíîâå ïîëó÷åííûõ ðåçóëüòàòîâ áîëü- íûì ïðîâîäèëàñü òîëüêî ïàëëèàòèâíàÿ îïåðàöèÿ – êàñ- Ïîëó÷åííûå äàííûå îáðàáîòàíû ñ èñïîëüçîâàíèåì òðàöèÿ. Èññëåäîâàíèÿ ïðîâîäèëèñü â äèíàìèêå äî êàñ- ñòàòèñòè÷åñêîé ïðîãðàììû One Way ANOVA. òðàöèè è ïîñëå íåå (â ïåðèîäå îò 6 ìåñÿöåâ äî 1 ãîäà). Âîçðàñò ïàöèåíòîâ êîëåáàëñÿ â ïðåäåëàõ 55-85 ëåò. Ñ æà- Ðåçóëüòàòû è èõ îáñóæäåíèå. Ïðè ìàëîé ïëîòíîñòè ëîáàìè íà ìî÷åâûâîäÿùóþ ñèñòåìó îíè ëå÷èëèñü â ÏÑÀ, äî êàñòðàöèè, ñðåäíèé ïîêàçàòåëü â ñûâîðîòêå êëèíèêå ñ 1998 ã. ïî ñåé äåíü. êðîâè ñîñòàâèë 14,3±6,5 íã/ìë, à òåñòîñòåðîíà – 35,4±2,4 íìîëü/ë. Ñïóñòÿ 6 ìåñÿöåâ ïîñëå êàñòðàöèè óêàçàí- Äëÿ îïðåäåëåíèÿ ÏÑÀ â ñûâîðîòêå êðîâè áûëà èñïîëü- íûå ïîêàçàòåëè çíà÷èòåëüíî ïîíèçèëèñü è ñîñòàâèëè, çîâàíà èììóíîôåðìåíòíàÿ òåñò-ñèñòåìà (ELISA, ñîîòâåòñòâåííî, ÏÑÀ – 3,8±1,5 íã/ìë, òåñòîñòåðîí – TANDEM E) ôèðìû Hyrbritesch. Îïðåäåëåíèå òåñòîñ- 5,46±1,4 íìîëü/ë. Îòìå÷åííûå èçìåíåíèÿ ïðèâåäåíû òåðîíà ïðîâîäèëîñü ðàäèîèììóíîëîãè÷åñêèì ìåòî- â òàáëèöå 1. Òàáëèöà 1. Ïîêàçàòåëè êîíöåíòðàöèè ÏÑÀ è òåñòîñòåðîíà â ñûâîðîòêå êðîâè ïðè ìàëîé ïëîòíîñòè ÏÑÀ<0,3 äî è ïîñëå êàñòðàöèè Ïëîòíîñòü ÏÑÀ Ñð. ïîêàçàòåëü òåñòîñòåðîíà Ñðåäíèй ïîêàçàòåëü ÏÑÀ Äî êàñòðàöèè n=32 <0,3 íã/ìë/ã 35,4±2,4 íìîëü/ë 14,3±6,5 íã/ìë Ïîñëå êàñòðàöèè n=32 <0,3 íã/ìë/ã 5,46±1,4 íìîëü/ë 3,8±1,5 íã/ìë

Ïðîâåäåííûé ñòàòèñòè÷åñêèé àíàëèç ïîêàçàë, ÷òî ó ïà- è òåñòîñòåðîíà (äî êàñòðàöèè è ïîñëå íåå) îòìå÷àåòñÿ öèåíòîâ ñ ìàëîé ïëîòíîñòüþ ÏÑÀ, ó êîòîðûõ âûÿâëåí âûñîêèé êîýôôèöèåíò êîððåëÿöèè (r=0,708, äèàãðàì- ðàê ïðîñòàòû, ìåæäó ïîêàçàòåëÿìè êîíöåíòðàöèé ÏÑÀ ìà 1).

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Äèàãðàììà 1. Êîððåëÿöèÿ ìåæäó ïîêàçàòåëÿìè ÏÑÀ è òåñòîñòåðîíà ïðè ìàëîé ïëîòíîñòè ÏÑÀ Ïîêàçàòåëè êîíöåíòðàöèè ÏÑÀ è òåñòîñòåðîíà â ñûâîðîòêå êðîâè ïðè âûñîêîé ïëîòíîñòè ÏÑÀ äî è ïîñëå êàñòðà- öèè ïðèâåäåíû â òàáëèöå 2.

Òàáëèöà 2. Ïîêàçàòåëè êîíöåíòðàöèè ÏÑÀ è òåñòîñòåðîíà â ñûâîðîòêå êðîâè ïðè âûñîêîé ïëîòíîñòè ÏÑÀ>0,3 äî è ïîñëå êàñòðàöèè

Ïëîòíîñòü ÏÑÀ Ñð. ïîêàçàòåëü òåñòîñòåðîíà Ñðåäíèй ïîêàçàòåëü ÏÑÀ Äî êàñòðàöèè n=29 >0,3 íã/ìë/ã 36,5±5,4 íìîëü/ë 44,97±7,5 íã/ìë Ïîñëå êàñòðàöèè n=29 >0,3 íã/ìë/ã 7,31±1,4 íìîëü/ë 35,85±6,5 íã/ìë

Êàê âèäíî èç òàáëèöû 2, ïîñëå êàñòðàöèè, íåñìîòðÿ íà òåëüíî. Êîíöåíòðàöèÿ ÏÑÀ äî êàñòðàöèè ñîñòàâëÿëà òî, ÷òî òåñòîñòåðîí â ñûâîðîòêå êðîâè çíà÷èòåëüíî 44,97±7,5 íã/ìë, à ïîñëå êàñòðàöèè – 35,85±6,5 íã/ìë. óìåíüøèëñÿ, ïîíèæåíèå óðîâíÿ ÏÑÀ áûëî íåçíà÷è- Ïðîâåäåííûé ñòàòèñòè÷åñêèé àíàëèç ïîêàçàë, ÷òî ó

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áîëüíûõ ðàêîì ïðîñòàòû ñ âûñîêîé ïëîòíîñòüþ ÏÑÀ, íà (äî êàñòðàöèè è ïîñëå íåå) âûÿâëåí íèçêèé êîýôôè- ìåæäó ïîêàçàòåëÿìè êîíöåíòðàöèé ÏÑÀ è òåñòîñòåðî- öèåíò êîððåëÿöèè (r=0,209, äèàãðàììà 2).

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Äèàãðàììà 2. Êîððåëÿöèÿ ìåæäó ïîêàçàòåëÿìè ÏÑÀ è òåñòîñòåðîíà ïðè âûñîêîé ïëîòíîñòè ÏÑÀ

Òàêèì îáðàçîì, íàøèìè èññëåäîâàíèÿìè óñòàíîâëå- estimates of national incidence for 1990 // Eur. J Cancer. – 1997. íî, ÷òî â ñëó÷àå ìàëîé ïëîòíîñòè ÏÑÀ, êîýôôèöèåíò - N33. – P. 1075-1107. êîððåëÿöèè ìåæäó êîëè÷åñòâåííûìè äàííûìè ÏÑÀ è 3. Denis L., Morton M.S., Griffiths K. Diet and its preventive òåñòîñòåðîíà âûøå (r=0,708), ÷åì ïðè âûñîêîé ïëîòíî- role in prostatic disease // Eur Urol. – 1999. - N35. – P. 377-387. 4. Hamalainen E., Adlerereutz H., Puska P., Pietinen P. Diet and ñòè ÏÑÀ (r=0,209). serum sex hormones in healthy men // J. Steroid Biochem. – 1984. – N 20(1). – P. 459-64. ËÈÒÅÐÀÒÓÐÀ 5. McNeal J.E., Bostwick D.G., Kindrachuk R.A., Redwine E.A., Freiha F.S., Stamey T.A. Patterns of progression in prostate 1. Bentel J.M., Tilley W.D. Androgen receptors in prostate can- cancer // Lancet. – 1989. – P. 60-3. cer // J Endocrinol. – 1996. - N151. – P. 1-11. 6. Russell P.J., Bennett S., Stricker P. Growth factor involve- 2. Black R.J., Bray F., Ferlay J., Parkin D.M. Cancer incidence ment in progression of prostate cancer // Clinical Chemistry. – and mortality in the European Union: cancer registry data and 1998. – vol. 44. - N4. – P. 705–723.

SUMMARY

QUANTITATIVE CHANGES OF TESTOSTERONE AND PROSTATE-SPECIFIC ANTIGEN AT LOW AND HIGH DENSITIES OF PSA IN MEN WITH PROSTATE CANCER

Khuskivadze A., Kochiashvili D.

Department of Urology, Tbilisi State Medical University In 61 patients with prostate cancer quantitative changes of tes- weak correlation was documented for the patients with prostate tosterone and prostate-specific antigen (PSA) in blood serum at cancer and high density of PSA. low and high densities of PSA have been investigated. It was shown that a high coefficient of correlation has been established Key words: testosterone, prostate-specific antigen, prostate in patients with prostate cancer and low density of PSA, but cancer.

ÐÅÇÞÌÅ

Õóñêèâàäçå À.À., Êî÷èàøâèëè Ä.Ê.

Òáèëèññêèé ãîñóäàðñòâåííûé ìåäèöèíñêèé óíèâåðñèòåò, êàôåäðà óðîëîãèè

Èññëåäîâàíû êîëè÷åñòâåííûå èçìåíåíèÿ òåñòîñòåðîíà è ïðî- ïëîòíîñòüþ ÏÑÀ ìåæäó êîíöåíòðàöèÿìè ÏÑÀ è òåñòîñòåðî- ñòàòñïåöèôè÷åñêîãî àíòèãåíà (ÏÑÀ) â ñûâîðîòêå êðîâè ïðè íà (äî êàñòðàöèè è ïîñëå íåå) îáíàðóæèâàåòñÿ âûñîêèé êî- âûñîêîé è ìàëîé ïëîòíîñòè ÏÑÀ ó 61-ãî áîëüíîãî ðàêîì ýôôèöèåíò êîððåëÿöèè, à ó ïàöèåíòîâ ñ âûñîêîé ïëîòíîñ- ïðîñòàòû. Îêàçàëîñü, ÷òî ó áîëüíûõ ðàêîì ïðîñòàòû ñ ìàëîé òüþ ÏÑÀ – íèçêèé êîýôôèöèåíò êîððåëÿöèè.

Íàó÷íàÿ ïóáëèêàöèÿ

ÏÐÈÌÅÍÅÍÈÅ ÏËÀÔÅÐÎÍÀ Â ËÅ×ÅÍÈÈ ÁÎËÜÍÛÕ ÌÎ×ÅÊÀÌÅÍÍÎÉ ÁÎËÅÇÍÜÞ ÅÄÈÍÑÒÂÅÍÍÎÉ ÏÎ×ÊÈ

Ñóëõàíèøâèëè Â.À.

Íàöèîíàëüíûé öåíòð óðîëîãèè èì. À. Öóëóêèäçå

Ôóíêöèîíàëüíîå ñîñòîÿíèå åäèíñòâåííîé ïî÷êè, îñ- Îñíîâíûì ñèìïòîìîì ó îáñëåäîâàííûõ áîëüíûõ ÿâëÿëàñü òàâøåéñÿ ïîñëå íåôðýêòîìèè, ÿâëÿåòñÿ àêòóàëüíîé ïðî- áîëü, ïðîÿâëÿþùàÿñÿ â âèäå ïî÷å÷íûõ êîëèê - â 18-è (42,1%) è áëåìîé ñîâðåìåííîé óðîëîãèè [1,6,10]. ïîñòîÿííîé áîëè òóïîãî õàðàêòåðà - â 24-õ (57,9%) ñëó÷àÿõ.

Ñðåäè óðîëîãè÷åñêèõ çàáîëåâàíèé åäèíñòâåííîé ïî÷- Ó áîëüøèíñòâà áîëüíûõ (n=27) ïî÷å÷íàÿ êîëèêà ñîïðî- êè îäíî èç ïåðâûõ ìåñò çàíèìàåò ìî÷åêàìåííàÿ áî- âîæäàëàñü ïîâûøåíèåì òåìïåðàòóðû (64,3%). ëåçíü (ÌÊÁ), ëå÷åíèå êîòîðîé âñå åùå îñòàåòñÿ âåñüìà òðóäíîé è íåðåøåííîé çàäà÷åé [2,5]. Ìàêðîãåìàòóðèÿ îòìå÷åíà ó 5-è (11,9%) áîëüíûõ. Ó áîëüøèíñòâà áîëüíûõ - 34 (80,9%) îòìå÷àëàñü ïèóðèÿ. Îñíîâíîé îïàñíîñòüþ ÿâëÿþòñÿ ïîñëåîïåðàöèîííûå îñëîæíåíèÿ, ñâÿçàííûå ñ ôóíêöèîíàëüíîé íåäîñòàòî÷- Ãèïî- è èçîñòåíóðèÿ îáíàðóæåíû ó âñåõ áîëüíûõ. Ðå- íîñòüþ åäèíñòâåííîé ïî÷êè [3,4,7]. àêöèÿ ìî÷è áûëà êèñëîé ó 28-è (66,7%), à ùåëî÷íîé – ó 14-è (33,3%) áîëüíûõ. Ñ ó÷åòîì ýòèõ îáñòîÿòåëüñòâ, îñîáîå çíà÷åíèå ïðèîá- ðåòàåò ïðèìåíåíèå ëåêàðñòâåííûõ ñðåäñòâ, êîòîðûå çà- Ïðè áàêòåðèîëîãè÷åñêîì èññëåäîâàíèè ìî÷è â áîëü- ùèùàþò ïî÷êó îò èøåìè÷åñêîé àëüòåðàöèè âî âðåìÿ øèíñòâå ñëó÷àåâ (n=18) âûñåèâàëàñü êèøå÷íàÿ ïàëî÷- îïåðàòèâíîãî âìåøàòåëüñòâà [8,9] è ñïîñîáñòâóþò ñòè- êà (42,8%) è âóëüãàðíûé ïðîòåé (n=15-35,7%). ìóëÿöèè âîññòàíîâëåíèÿ ôóíêöèè åäèíñòâåííîé ïî÷- êè â ïîñëåîïåðàöèîííîì ïåðèîäå. Ó 11-è (26,2%) áîëüíûõ â àíàìíåçå îòìå÷àëîñü ñàìî- ñòîÿòåëüíîå îòõîæäåíèå êàìíåé, ó 2-õ (4,8%) áîëüíûõ Öåëüþ äàííîãî èññëåäîâàíèÿ ÿâèëîñü èçó÷åíèå âëè- òàêèå ÿâëåíèÿ ïîâòîðÿëèñü íåîäíîêðàòíî. ÿíèÿ ïëàôåðîíà íà âîññòàíîâëåíèå ôóíêöèè åäèí- ñòâåííîé ïî÷êè â ïîñëåîïåðàöèîííîì ïåðèîäå ó Ïðè ýõîñêîïè÷åñêîì è ðåíòãåíîëîãè÷åñêîì îáñëåäîâà- áîëüíûõ ñ îáñòðóêòèâíîé íåôðîïàòèåé, âûçâàííîé íèÿõ îäèíî÷íûå êàìíè ëîõàíêè âûÿâëåíû ó 13-è (31%) ìî÷åêàìåííîé áîëåçíüþ. áîëüíûõ, ó 24-õ (57,1%) - ìíîæåñòâåííûå êàìíè ëîõàí- êè, ó 5-è (11,9%) îïðåäåëÿëèñü êîðàëëîâèäíûå êàìíè. Ìàòåðèàë è ìåòîäû. Íàìè îáñëåäîâàíû 42 ïàöèåíòà ñ ÌÊÁ åäèíñòâåííîé ïî÷êè (êîíòðîëüíàÿ ãðóïïà - 23; îñ- Àçîòåìèÿ ñâûøå 35 ìêìîë/ë íàáëþäàëàñü ó 20-è (47,6%), íîâíàÿ ãðóïïà, êîòîðûì ââîäèëñÿ ïëàôåðîí - 19 ïàöè- îò 34 äî 40 ìêìîë/ë - ó 15-è (35,7%), è ñâûøå 40 ìêìîë/ë åíòîâ). Æåíùèí - 23, ìóæ÷èí 19. – ó 7-è (16,7%) áîëüíûõ.

Ïî âîçðàñòó áîëüíûå ðàñïðåäåëèëèñü ñëåäóþùèì îá- Êîíöåíòðàöèÿ êðåàòèíèíà â ïëàçìå êðîâè îò 1,5 äî 1,8 ðàçîì: äî 30 ëåò – 2 (5,3%) áîëüíûõ, îò 31 äî 40 - 11 íàáëþäàëàñü ó 11-è (26,3%), îò 1,8 äî 2,5 – ó 22-õ (52,6%) (26,3%), îò 41 äî 50 - 20 (47,4%), îò 51 äî 60 ëåò - 9 è ñâûøå 2,5 – ó 9-è (21,1%) ïàöèåíòîâ. (21%) áîëüíûõ. Íåïîñðåäñòâåííîé ïðè÷èíîé àçîòåìèè (n=36) â áîëüøèí- Ïî äëèòåëüíîñòè ïîðàæåíèÿ åäèíñòâåííîé ïî÷êè ÌÊÁ ñòâå ñëó÷àåâ (85,7%) áûëî íàðóøåíèå ïàññàæà ìî÷è è áîëüíûå ðàñïðåäåëèëèñü ñëåäóþùèì îáðàçîì: îò 1 äî îáîñòðåíèå ãíîéíî-âîñïàëèòåëüíîãî ïðîöåññà â ïî÷êå. 2 ëåò – 4 (10,5%), îò 2 äî 4 ëåò – 12 (26,3%), îò 4 äî 6 ëåò - 22 (52,7%) è ñâûøå 6 ëåò - 4 (10,5%) áîëüíûõ. Ïëàôåðîí ââîäèëñÿ â òå÷åíèå 10 äíåé â äîçå 40 ìã, 3 ðàçà â äåíü, âíóòðèìûøå÷íî (n=19). Èññëåäîâàëèñü îñíîâ- ÌÊÁ â îñòàâøåéñÿ åäèíñòâåííîé ïî÷êå ó âñåõ ïàöè- íûå ïàðàìåòðû ôóíêöèîíàëüíîãî ñîñòîÿíèÿ ïî÷åê (êëè- åíòîâ íàáëþäàëàñü ïîñëå óäàëåíèÿ êîíòðàëàòåðàëü- ðåíñ êðåàòèíèíà, îñìîòè÷åñêè àêòèâíûõ âåùåñòâ, íàòðèÿ, íîé ïî÷êè ïî ïîâîäó êàìíÿ â ïî÷êå ñ ðàçâèòèåì ãèä- ýêñêðåòèðóåìûå èõ ôðàêöèè, ðåàáñîðáèðóåìàÿ è ýêñê- ðîíåôðîçà (37 áîëüíûõ), à òàêæå ïî ïîâîäó ïèîíåô- ðåòèðóåìàÿ ôðàêöèè âîäû), êîòîðûå ïðîÿâëÿëèñü íà ðîçà ïî÷êè (5 áîëüíûõ). 7-îé è 14-ûé äíè ïîñëå îïåðàòèâíîãî âìåøàòåëüñòâà.

70 GEORGIAN MEDICAL NEWS No 2 (143) Ôåâðàëü, 2007 ãîä

Îïåðàòèâíîå âìåøàòåëüñòâî âêëþ÷àëî ïèåëîëèòîòî- ãðóïïå ), ò. å. â àáñîëþòíîì èñ÷èñëåíèè (â íîðìå êëèðåíñ ìèþ (n=28), ïèåëîëèòîòîìèþ ñ íåôðîëèòîòîìèåé êðåàòèíèíà ðàâåí 80-110 ìë/ìèí) ìàññà äåéñòâóþùèõ íå- (n=12), óðåòåðîëèòîòîìèþ (n=2). ôðîíîâ (ÌÄÍ) ñîñòàâëÿåò îêîëî 50-55% îò åå ôèçèîëîãè- ÷åñêîé íîðìû. Îäíàêî ñëåäóåò ó÷åñòü, ÷òî ïî ñðàâíåíèþ Ðåçóëüòàòû è èõ îáñóæäåíèå. Àíàëèç ïîêàçàòåëåé ôóí- ñ èñõîäíûìè äàííûìè è ïîêàçàòåëÿìè êîíòðîëüíîé ãðóï- êöèîíàëüíîãî ñîñòîÿíèÿ ïî÷êè âûÿâèë, ÷òî êëèðåíñ ïû ýòîò ïðèðîñò ÿâëÿåòñÿ äîâîëüíî ñóùåñòâåííûì. êðåàòèíèíà, â ñðåäíåì, ñîñòàâëÿë 31,5±4,7 ìë/ìèí. Ïðè ýòîì îïðåäåëÿëèñü äîñòàòî÷íî ðåçêèå íàðóøåíèÿ îñ- Ñóùåñòâåííûìè îêàçàëèñü ðåçóëüòàòû àíàëèçà ñîîòíî- ìîðåãóëèðóþùåé, âîäîâûäåëèòåëüíîé è ýëåêòðîëèòî- øåíèÿ ñîñòîÿíèÿ ðåàáñîðáöèè «îñìîòè÷åñêè ñâîáîä- âûäåëèòåëüíîé ôóíêöèé ïî÷åê. Îñîáåííî ñòðàäàëà âî- íîé» âîäû, â ñðåäíåì, â êàæäîì íåôðîíå è ÌÄÍ. Ìåæ- äîâûäåëèòåëüíàÿ ôóíêöèÿ ïî÷êè. äó ýòèìè ïîêàçàòåëÿìè âûÿâëåíà êîððåëÿöèÿ. Â êîíò- ðîëüíîé ãðóïïå ýòè ñîîòíîøåíèÿ âûðàæåíû ñëàáî è Îêàçàëîñü, ÷òî â ãðóïïå áîëüíûõ, êîòîðûì ââîäèëñÿ íå ìîãóò áûòü îöåíåíû êàê ïîëîæèòåëüíûå. ïëàôåðîí, êëèðåíñ êðåàòèíèíà êî âòîðîé íåäåëå ïîñëå îïåðàòèâíîãî âìåøàòåëüñòâà óâåëè÷èâàëñÿ (òàáëèöà), äî- Ïîâûøåíèå ÌÄÍ ñîïðîâîæäàëîñü íàðàñòàþùèì ïî- ñòèãàÿ ñòàòèñòè÷åñêè çíà÷èìîé ðàçíèöû ïî ñðàâíåíèþ âûøåíèåì ðåàáñîðáöèè «îñìîòè÷åñêè ñâîáîäíîé» ñ êîíòðîëüíûìè äàííûìè. âîäû. Îäíàêî ñëåäóåò îòìåòèòü, ÷òî â èññëåäóåìûå ïå- ðèîäû ñâÿçè ìåæäó ýêñêðåòèðóåìîé ôðàêöèåé ïðî- Êëèðåíñ êðåàòèíèíà íå äîñòèãàë 60 ìë/ìèí - (â ãðóïïå ôèëüòðîâàííîãî íàòðèÿ è ðåàáñîðáöèåé «îñìîòè÷åñ- áîëüíûõ ãäå ââîäèëñÿ ïëàôåðîí 58,1±5,9, â êîíòðîëüíîé êè ñâîáîäíîé» âîäû íàìè íå îáíàðóæåíû.

Òàáëèöà. Ñðåäíèå çíà÷åíèÿ èññëåäóåìûõ ïàðàìåòðîâ ôóíêöèè ïî÷êè â ïîñëåîïåðàöèîííîì ïåðèîäå

Ñðåäíèå Âðåìÿ ïîñëå äåáëîêèðîâàíèÿ ïî÷êè (äíè) Èññëåäóåìûå ïàðàìåòðû âåëè÷èíû Êîíòðîëüíàÿ ãðóïïà Èññëåäóåìàÿ ãðóïïà n=19 è åäèíèöû èçìåðåíèÿ èññëåäóåìûõ n=23 ïàðàìåòðîâ äî 7-îй äåíü 14-ûй äåíü 7-îй äåíü 14-ûй äåíü îïåðàöèè 58,1±5,9 Êëèðåíñ êðåàòèíèíà ð <0,05 31,5±4,7 39,8±6,2 1 35,1±6,1 40,1±4,2 (ìë/ìèí) ð 2<0,05

Êëèðåíñ îñìîòè÷åñêè àêòèâíûõ âåùåñòâ 5,8±0,7 5,0±0,95 4,7±0,8 5,6±0,3 5,1±0,7 (ìë/ìèí) Ýêñêðåòèðóåìàÿ ôðàêöèÿ îñìîòè÷åñêè àêòèâíûõ 5,2±0,4 4,95±0,7 4,5±0,63 5,05±0,9 4,8±0,03 âåùåñòâ (%) Êëèðåíñ íàòðèÿ (ìë/ìèí) 0,3±0,05 0,35±0,07 0,4±0,09 0,35±0,04 0,37±0,06 Ýêñêðåòèðóåìàÿ ôðàêöèÿ 0,59±0,06 0,66±0,08 0,6±0,05 0,54±0,08 0,62±0,07 íàòðèÿ (%) Ýêñêðåòèðóåìàÿ ôðàêöèÿ 0,39± 0,32±0,07 0,4±0,056 0,42±0,1 0,36±0,05 âîäû (%) 0,08 Ðåàáñîðáèðóåìàÿ ôðàêöèÿ 2,3±0,1 2,8±0,07 3,4±0,15 2,6±0,07 3,0±0,09 âîäû (%)

ð1- ñòàòèñòè÷åñêàÿ çíà÷èìîñòü ïî îòíîøåíèþ ê èñõîäíûì äàííûì;

ð2 – ñòàòèñòè÷åñêàÿ çíà÷èìîñòü ïî îòíîøåíèþ ê êîíòðîëüíûì äàííûì Ñëåäóåò îòìåòèòü, ÷òî â èññëåäóåìîé ïîäãðóïïå Ñëåäóåò ïîëàãàòü, ÷òî íàðóøåíèå ýêñêðåöèè «îñìîòè- óäåëüíûé âåñ ìî÷è ïîñëå äåáëîêèðîâàíèÿ ïî÷êè íà ÷åñêè ñâîáîäíîé» âîäû îïðåäåëÿåòñÿ, â îñíîâíîì, ïî- ôîíå ðàçâèòèÿ ïîëèóðèè ïðîÿâëÿåò òåíäåíöèþ ê ïî- âûøåííîé äîñòàâêîé æèäêîñòè â äèñòàëüíûé îòäåë íå- âûøåíèþ è, â ñðåäíåì, ñîñòàâëÿåò 1012. Â êîíò- ôðîíà, à íå ïîâðåæäåíèåì ôóíêöèè îñìîòè÷åñêîãî êîí- ðîëüíîé ãðóïïå îí íå ïðåâûøàåò 1010. Äàííàÿ òåí- öåíòðèðîâàíèÿ ìî÷è. äåíöèÿ ñòàíîâèòñÿ ïîíÿòíîé ñ ó÷åòîì äèíàìèêè èç- ìåíåíèÿ êëèðåíñà îñìîòè÷åñêè àêòèâíûõ âåùåñòâ è Òàêèì îáðàçîì, ðåçóëüòàòû èññëåäîâàíèÿ âûÿâèëè, ÷òî ðåàáñîðáèðóåìîé ôðàêöèè «îñìîòè÷åñêè ñâîáîä- ïëàôåðîí ñïîñîáñòâóåò âîññòàíîâëåíèþ ôóíêöèè ïî÷êè íîé» âîäû. ó áîëüíûõ ñ ÌÊÁ åäèíñòâåííîé ïî÷êè ïîñëå îïåðàòèâíî-

ãî ëå÷åíèÿ è âîññòàíîâëåíèÿ ïàññàæà ìî÷è. Ïðè ïðèìå- There was detected correlation between “osmolar free” water íåíèè ïðåïàðàòà â ïîñëåîîïåðàöèîííîì ïåðèîäå îòìå- reabsorbtion in each nephron and mass of the active nephrons. ÷àåòñÿ óëó÷øåíèå êëóáî÷êîâîé ôèëüòðàöèè (îò 31,5±4,7 â In control group these correlations are weak and couldn’t be èñõîäíîì ïåðèîäå äî 58,1±5,9 ìë/ìèí ê 14 äíþ ïîñëå îïå- evaluated as positive one. ðàòèâíîãî âìåøàòåëüñòâà; â êîíòðîëüíîé ãðóïïå, ñîîò- In both groups we couldn’t detect correlation between excretion âåòñòâåííî, îò 31,5±4,7 äî 40,1±4,2 ìë/ìèí). Ïëàôåðîí ñëå- fraction of filtered Natrium and reabsorbtion of “osmolar free” water. äóåò ïðèìåíÿòü ó áîëüíûõ ñ ìî÷åêàìåííîé áîëåçíüþ åäèí- ñòâåííîé ïî÷êè ñ öåëüþ ñòèìóëÿöèè âîññòàíîâëåíèÿ åå Plaferon positively influences process of stimulation of restora- ôóíêöèè â ïîñëåîïåðàöèîííîì ïåðèîäå. tion of a renal function at post-operative period in patients with nephrolithiasis of the only kidney and to restoration of the urine ËÈÒÅÐÀÒÓÐÀ passage. After using Plaferon at post-operative period we can detect the better function of the glomerular filtration and other 1. Beranek J.T. Hyperplastic renal capillaries in obstructive ne- investigated parameters, which differs from those in control group. phropathy // Lab Invest. – 1988. – N 59(2). – P. 296. 2. Coar D. Obstructive nephropathy // Del Med J. – 2005. - Plaferon should be used in patients with nephrolithiasis of the N 63(12). – P. 743-9. only kidney for stimulation of restoration of a renal function at 3. Gotoh H., Masuzaki H., Taguri H,Ishimaru T. Effect of ex- postoperative period. perimentally induced urethral obstruction and surgical decompression in utero on renal development and function in rabbits Key words: nephrolithiasis of the only kidney, renal function, // Early Hum Dev. – 1998. – N 52(2). – P. 111-23. Plaferon. 4. Hvistendahl J.J., Pedersen T.S., Hvistendahl G.M., Djurhuus J.C., Frokiaer J. Reduced renal vascular resistance in response to ÐÅÇÞÌÅ verapamil during gradated ureter obstruction in pigs // Urol Res. – 2001. – N 29(5). P. 350-8. ÏÐÈÌÅÍÅÍÈÅ ÏËÀÔÅÐÎÍÀ Â ËÅ×ÅÍÈÈ ÁÎËÜÍÛÕ 5. Kawada N., Moriyama T., Ando A., Fukunaga M., Miyata T. ÌÎ×ÅÊÀÌÅÍÍÎÉ ÁÎËÅÇÍÜÞ ÅÄÈÍÑÒÂÅÍÍÎÉ Increased oxidative stress in mouse kidneys with unilateral ure- ÏÎ×ÊÈ teral obstruction // Kidney Int. – 1999. – N 56(3). – P. 38-47. 6. Klahr S. Urinary tract obstruction // Semin Nephrol. – 2001. Ñóëõàíèøâèëè Â.À. – N 21(2). – P. 133-45. 7. Kribben A., Edelstein C.L., Schrier R.W. Pathophysiology of acute Íàöèîíàëüíûé öåíòð óðîëîãèè èì. À.Öóëóêèäçå renal failure // J Nephrol. – 2002. - N12. - Suppl 2. – P. 142-51. 8. Schlueter W., Batlle D.C. Chronic obstructive nephropathy // Èçó÷åíî âëèÿíèå ïëàôåðîíà íà âîññòàíîâëåíèå ôóíêöèè Semin Nephrol. – 1988. – N 8(1). – P. 17-28. ïî÷êè ó ïàöèåíòîâ ñ ìî÷åêàìåííîé áîëåçíüþ (ÌÊÁ) åäèí- 9. Schmidt A., Bayerle-Eder M., Pleiner H., Zeisner C., Wolzt ñòâåííîé ïî÷êè. Èññëåäîâàíî 42 ïàöèåíòà ñ ÌÊÁ åäèíñòâåí- M., Mayer G., Schmetterer L. The renal and systemic hemody- íîé ïî÷êè (êîíòðîëüíàÿ ãðóïïà - 23; èññëåäóåìàÿ ãðóïïà, namic effects of a nitric oxide-synthase inhibitor are reversed by êîòîðûì ââîäèëñÿ ïëàôåðîí- 19 ïàöèåíòîâ). a selective endothelin(a) receptor antagonist in men // Nitric Oxide. – 2001. – N 5(4). – P. 370-6. Â ãðóïïå áîëüíûõ, êîòîðûì ââîäèëè ïëàôåðîí, êëèðåíñ êðåàòè- 10. Orikasa S., Fukuzaki A. Obstructive nephropathy // Ryoiki- íèíà êî âòîðîé íåäåëå ïîñëå îïåðàòèâíîãî âìåøàòåëüñòâà óâå- betsu Shokogun Shirizu. – 2004. - N17. – Pt. 2. – P. 688-90. ëè÷èëñÿ (58,1±5,9 ìë/ìèí) è äîñòèã ñòàòèñòè÷åñêè çíà÷èìîãî ðàç- ëè÷èÿ ñ êîíòðîëüíûìè äàííûìè (40,1 ± 4,2 ìë/ìèí ; ð<0,05). SUMMARY Ìåæäó ïîêàçàòåëÿìè ðåàáñîðáöèè «îñìîòè÷åñêè ñâîáîäíîé» USING PLAFERON IN PATIENTS WITH NEPHROLITHI- âîäû, â ñðåäíåì, â êàæäîì íåôðîíå è ìàññîé äåéñòâóþùèõ ASIS OF THE ONLY KIDNEY íåôðîíîâ âûÿâèëàñü êîððåëÿöèÿ. Â êîíòðîëüíîé ãðóïïå ýòè âçàèìîñâÿçè âûðàæåíû ñëàáî è íå ìîãóò áûòü îöåíåíû êàê Sulkhanishvili V. ïîëîæèòåëüíûå.

National center of urology, Tbilisi Â îáåèõ ãðóïïàõ ñâÿçè ìåæäó ýêñêðåòèðóåìîé ôðàêöèåé ïðîôèëüòðîâàííîãî íàòðèÿ è ðåàáñîðáöèåé «îñìîòè÷åñêè We have studied the influence of the Plaferon on the stimulation ñâîáîäíîé» âîäû íàìè íå âûÿâëåíî. of restoration of a kidney function in patients with nephrolithiasis of the only kidney. The researches were performed in 42 Ïëàôåðîí ñïîñîáñòâóåò âîññòàíîâëåíèþ ôóíêöèè åäèíñòâåí- patients with nephrolithiasis of the only kidney (control group íîé ïî÷êè ïàññàæà ìî÷è ó áîëüíûõ ÌÊÁ ïîñëå îïåðàòèâíî- – 23; group accepted Plaferon – 19 patients). ãî ëå÷åíèÿ. Ïðè ïðèìåíåíèè ïðåïàðàòà â ïîñëåîîïåðàöèîí- íîì ïåðèîäå îòìå÷àåòñÿ óëó÷øåíèå êëóáî÷êîâîé ôèëüòðà- In group of the patients, which accepted Plaferon, the creatinine öèè è äðóãèõ èññëåäóåìûõ ïàðàìåòðîâ ïî ñðàâíåíèþ ñ êîíò- clearance after two weeks from the operation was increased ðîëüíîé ãðóïïîé. Ïëàôåðîí ñëåäóåò ïðèìåíÿòü ó áîëüíûõ (58,1±5,9 ml/min) and achieve statistically main differs from ÌÊÁ åäèíñòâåííîé ïî÷êè ñ öåëüþ âîññòàíîâëåíèÿ åå ôóíê- those in control group (40,1 ± 4,2 ml/min; ð<0,05). öèè â ïîñëåîïåðàöèîííîì ïåðèîäå.

72 GEORGIAN MEDICAL NEWS No 2 (143) Ôåâðàëü, 2007 ãîä

Íàó÷íàÿ ïóáëèêàöèÿ

ÈÑÑËÅÄÎÂÀÍÈÅ ÏÐÎÑÒÀÒÑÏÅÖÈÔÈ×ÅÑÊÎÃÎ ÀÍÒÈÃÅÍÀ Â ÊÐÎÂÈ È ÝÏÈÒÅËÈÈ ÏÐÎÑÒÀÒÛ ÏÐÈ ÄÎÁÐÎÊÀ×ÅÑÒÂÅÍÍÎÉ ÃÈÏÅÐÏËÀÇÈÈ ÏÐÅÄÑÒÀÒÅËÜÍÎÉ ÆÅËÅÇÛ

Ïàïàâà1 Â.Ë., Êî÷èàøâèëè1 Ä.Ê., ×îâåëèäçå1 Ø.Ã., Õàðäçåèøâèëè2 Î.Ì.

1Òáèëèññêèé ãîñóäàðñòâåííûé ìåäèöèíñêèé óíèâåðñèòåò, êàôåäðà óðîëîãèè; 2êàôåäðà ïàòîëîãè÷åñêîé àíàòîìèè

Îöåíêà æåëåçèñòîãî êîìïîíåíòà, â ÷àñòíîñòè, ëóìè- êó ñ ñèìïòîìàìè íèæíèõ ìî÷åâûõ ïóòåé. Ñóììà áàë- íàëüíîãî ýïèòåëèÿ ïðè äîáðîêà÷åñòâåííîé ãèïåðï- ëîâ ïî øêàëå ïðîñòàòè÷åñêèõ ñèìïòîìîâ (IPSS) îöå- ëàçèè ïðåäñòàòåëüíîé æåëåçû (ÄÃÏÆ) ïðîâîäèòñÿ ñ íèâàëàñü ïî ðàáîòå [2]. Â çàâèñèìîñòè îò IPSS èññëå- ó÷åòîì èììóíîãèñòîõèìè÷åñêèõ îñîáåííîñòåé ýêñ- äóåìûé êîíòèíãåíò áûë ðàçäåëåí íà 2 ãðóïïû: I ãðóï- ïðåñèè ïðîñòàòñïåöèôè÷åñêîãî àíòèãåíà (ÏÑÀ). Êàê ïà – ïàöèåíòû ñ óìåðåííîé IPSS (n=6); II – ïàöèåíòû ñ èçâåñòíî, ýïèòåëèîöèòû, áåç èñêëþ÷åíèÿ, ïðîÿâëÿ- âûðàæåííîé IPSS (n=42). Âîçðàñò ïàöèåíòîâ êîëåáàë- þò ÏÑÀ-ïîçèòèâíîñòü. Èììóííîãèñòîõèìè÷åñêîå ñÿ â ïðåäåëàõ îò 50 äî 75 ëåò. Â 20-è ñëó÷àÿõ ïàöèåíòàì îïðåäåëåíèå ýêñïðåññèè ÏÑÀ äàåò âîçìîæíîñòü òî÷- ïðîâåäåíà àäåíîìýêòîìèÿ, à â 28-è ñëó÷àÿõ – òðàíñó- íîé äèôôåðåíöèàöèè áàçàëüíî-êëåòî÷íîé ãèïåðïëà- ðåòðàëüíàÿ ðåçåêöèÿ (ÒÓÐ). çèè îò ïðîëèôåðàöèè ëóìèíàëüíîãî ýïèòåëèÿ [1,4,5,9]. Èññëåäîâàíèÿ ïîñëåäíèõ ëåò [6-8,10,11] ïî- Óðîâåíü ÏÑÀ â êðîâè îïðåäåëÿëñÿ â ïåðèôåðèéíîé êàçûâàþò äîñòîâåðíóþ êîððåëÿöèþ ìåæäó óðîâíåì êðîâè èììóííîôåðìåíòíûì ìåòîäîì. Äëÿ èììóíî- ÏÑÀ â êðîâè è êîëè÷åñòâîì ìàêðîôàãîâ â òêàíè ïðî- ãèñòîõèìè÷åñêîãî èññëåäîâàíèÿ îïåðàöèîííûé ìàòå- ñòàòû, òàêæå îáðàòíóþ êîððåëÿöèþ ìåæäó óðîâíåì ðèàë ïîìåùàëñÿ â 12% íåéòðàëüíûé ôîðìàëèí, à ïîñ- ñâîáîäíîãî ÏÑÀ â êðîâè è êîëè÷åñòâîì T è B ëèì- ëå ôèêñàöèè è ñîîòâåòñòâóþùåé îáðàáîòêè - â ïàðà- ôîöèòîâ. Ñëåäóåò îòìåòèòü òàêæå, ÷òî îïðåäåëåíèå ôèí. Çàòåì íà ðîòàöèîííîì ìèêðîòîìå ãîòîâèëèñü êîíöåíòðàöèè ÏÑÀ â êðîâè ïðèìåíÿåòñÿ â êà÷åñòâå ñðåçû òîëùèíîé 4-5 ìêì è îêðàøèâàëèñü ãåìàòîêñè- ìàðêåðà ïðîöåññà äèñïëàçèè ïðîñòàòû, ìàëèãíèçà- ëèíîì è ýîçèíîì, òàêæå ïèêðîôóêñèíîì ïî ìåòîäó öèè è ðåöèäèâà â ïîñòîïåðàöèîííîì ïåðèîäå. Â ïîñ- Âàí-Ãèçîíà. Ïðîâîäèëàñü èììóíîãèñòîõèìè÷åñêàÿ ëåäíèå ãîäû ñòàëî èçâåñòíûì, ÷òî êîððåëÿöèè ìåæ- àâèäèí-áèîòèí-ïåðîêñèäàçíàÿ ðåàêöèÿ (LSAB), â êî- äó ïîâûøåíèåì êîíöåíòðàöèè ÏÑÀ è çëîêà÷åñòâåí- òîðîé âûÿâëÿþùåé ñèñòåìîé áûëà Dako Chem Mate íûì ðîñòîì â ïðîñòàòå íå íàáëþäàåòñÿ [7], ò.å. ïðè- Detection Kit Peroxidase (DAB) [3]. ÷èíà ïîâûøåíèÿ ÏÑÀ â êðîâè íå âñåãäà èçâåñòíà. Èììóíîãèñòîõèìè÷åñêîå èññëåäîâàíèå ÏÑÀ ïîä- Ðåçóëüòàòû è èõ îáñóæäåíèå. Ïðîâåäåííûå íàìè èñ- òâåðæäàåò, ÷òî îòìå÷åííûé àíòèãåí íå âñåãäà ïðè- ñëåäîâàíèÿ ïîêàçàëè, ÷òî ïðè ëþáîì âàðèàíòå ÄÃÏÆ ñóòñòâóåò â àöèíàðíîì (ëóìèíàëüíîì) ýïèòåëèè è ëóìèíàëüíûé ýïèòåëèé, êàê ïðàâèëî, ïðîÿâëÿåò ÏÑÀ- ïðåäñòàâëÿåòñÿ ìàðêåðîì íîðìû. ïîçèòèâíîñòü (òàáëèöà, ðèñ. 1-6). Íåãàòèâíîñòü èììó- íîãèñòîõèìè÷åñêîé ðåàêöèè íàáëþäàëàñü â ó÷àñòêàõ Èñõîäÿ èç âûøåèçëîæåííîãî, öåëüþ íàøåãî èññëåäî- àòèïè÷íîé ãèïåðïëàçèè ýïèòåëèÿ, êîãäà ïðîëèôåðàòèâ- âàíèÿ ÿâèëîñü îäíîâðåìåííîå èññëåäîâàíèå êîíöåíò- íûé ýïèòåëèé ïðåäñòàâëåí áàçàëüíûìè êëåòêàìè. Ñòå- ðàöèè ïðîñòàòñïåöèôè÷åñêîãî àíòèãåíà â êðîâè è åãî ïåíü ýêñïðåññèè êîëåáàëàñü ìåæäó ñëàáîé, óìåðåííîé èììóííîãèñòîõèìè÷åñêîé ýêñïðåññèè â òêàíè àäåíî- è âûñîêîé. Ïî ñòåïåíè ýêñïðåññèè ñëó÷àè ÄÃÏÆ âåñü- ìàòîçíîé ïðîñòàòû. ìà âàðèàáåëüíû. Áîëåå òîãî, ïðè îäíîì è òîì æå ãèñòî- ëîãè÷åñêîì âàðèàíòå (æåëåçèñòûé, ôèáðîçíî-âàñêóëÿð- Ìàòåðèàë è ìåòîäû. Íàáëþäàëèñü 50 ïàöèåíòîâ, ñðå- íûé, óçëîâîé, äèôôóçíûé) â ðàçëè÷íûõ ó÷àñòêàõ ïðî- äè íèõ ó 48-è îòìå÷àëàñü ÄÃÏÆ, à 2-îå – ñîñòàâèëè ÿâëÿëàñü îñîáàÿ ñòåïåíü ýêñïðåññèè ÏÑÀ, êîòîðàÿ âà- êîíòðîëüíóþ ãðóïïó. Ïàöèåíòû îáðàòèëèñü â êëèíè- ðèàáåëüíà è ïðè âûðàæåííîì IPSS.

Òàáëèöà. Ïîêàçàòåëè ÏÑÀ â êðîâè è ýïèòåëèè â ãðóïïàõ ñ ðàçëè÷íûìè ïîêàçàòåëÿìè IPSS

ÏÑÀ â ÏÑÀ â эïèòåëèè, ñòåïåíü эêñïðåññèè, (%) Ãðóïïà IPSS ñûâîðîòêå ñëàáàÿ óìåðåííàÿ âûñîêàÿ êðîâè, íã/ìë óìåðåííàÿ IPSS (n=6) 15,2±2,8 4,9±2,0 1 (20,0%) 5 (80,0%) - âûðàæåííàÿ IPSS (n=42) 24,7±3,2 15,1±6,7 7 (16,6%) 33 (78,6%) 2 (4,8%)

Ðèñ. 1. ÄÃÏÆ, ýêñïðåññèÿ ÏÑÀ óìåðåííîé ñòåïåíè ïðè Ðèñ. 2. ÄÃÏÆ, ýêñïðåññèÿ ÏÑÀ âûñîêîé ñòåïåíè ïðè óìåðåííîé IPSS, èììóíîãèñòîõèìè÷åñêàÿ ðåàêöèÿ, óâå- óìåðåííîé IPSS, èììóíîãèñòîõèìè÷åñêàÿ ðåàêöèÿ, óâå- ëè÷åíèå – x 400 ëè÷åíèå – x 400

Ðèñ. 3. ÄÃÏÆ, ïðåðûâèñòàÿ ýêñïðåññèÿ ÏÑÀ â ó÷àñò- Ðèñ. 4. ÄÃÏÆ, ïðåðûâèñòàÿ ýêñïðåññèÿ ÏÑÀ â ëóìè- êå äèñïëàçèè ëóìèíàëüíîãî ýïèòåëèÿ, èììóíîãèñòî- íàëüíîì ýïèòåëèè ïðè äèñïëàçèè ñðåäíåé ñòåïåíè, õèìè÷åñêàÿ ðåàêöèÿ, óâåëè÷åíèå – x 400 èììóíîãèñòîõèìè÷åñêàÿ ðåàêöèÿ, óâåëè÷åíèå – x 400

Ðèñ. 5. ÄÃÏÆ, ñëàáàÿ ïðåðûâèñòàÿ ýêñïðåññèÿ ÏÑÀ â Ðèñ. 6. ÄÃÏÆ, ïðåðûâèñòàÿ ýêñïðåññèÿ ÏÑÀ â ïîñòàò- ðåòåíöèîííûõ æåëåçàõ, âèäíû àìèëîèäíûå òåëüöà, ðîôè÷åñêèõ ìåëêèõ àöèíàðíûõ ó÷àñòêàõ ãèïåðïëàçèè, èììóíîãèñòîõèìè÷åñêàÿ ðåàêöèÿ, óâåëè÷åíèå – x 400 èììóíîãèñòîõèìè÷åñêàÿ ðåàêöèÿ, óâåëè÷åíèå – x 400

Ñðàâíåíèå ñòåïåíåé ýêñïðåññèè ÏÑÀ â òêàíè è åãî êîí- ëÿåòñÿ óìåðåííàÿ èëè ñëàáàÿ ýêñïðåññèÿ. Ñëåäóåò îò- öåíòðàöèè â êðîâè ïîêàçàëî, ÷òî èçìåíåíèå êîíöåíòðà- ìåòèòü, ÷òî âûñîêèé óðîâåíü ÏÑÀ â êðîâè ñîîòâåòñòâó- öèè â êðîâè áîëåå âàðèàáåëüíî, ÷åì ýêñïðåññèÿ â òêà- åò óìåðåííîé ýêñïðåññèè è âòîðè÷íûì âîñïàëèòåëü- íè. Ïîñëåäíÿÿ, â îñíîâíîì, óìåðåííàÿ, ðåäêî âñòðå÷à- íûì äåñòðóêòèâíûì èçìåíåíèÿì. Êàê èçâåñòíî, ÏÑÀ åòñÿ ñëàáîé èëè âûñîêîé. Êðîìå òîãî, êîíöåíòðàöèÿ ïðåäñòàâëÿåò ñîáîé ñïåöèôè÷åñêóþ ñåðèíïðîòåàçó, êî- ÏÑÀ â êðîâè ðåçêî ïîâûøåíà, òîãäà êàê â òêàíè ïðîÿâ- òîðûé ñèíòåçèðóåòñÿ â ëóìèíàëüíîì ýïèòåëèè. Óñèëå-

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íèå èëè îñëàáëåíèå åãî ýêñïðåññèè ìîæåò áûòü âûçâà- ËÈÒÅÐÀÒÓÐÀ íî óñèëåíèåì èëè îñëàáëåíèåì åãî ñèíòåçà, ÷òî, ñî ñâî- åé ñòîðîíû, ìîæåò èìåòü ìíîãî ãåíîìíûõ è ýêñòðàãå- 1. Camici M. Prostate cancer and prostate specific antigen screen- íîìíûõ ïðè÷èí. ×òî êàñàåòñÿ êîíöåíòðàöèè ÏÑÀ â êðî- ing // Minerva Med. – 2004. – N 95(1). – P. 25-34. âè, îíà îïðåäåëÿåòñÿ ïðè ïåðåõîäå ýòîãî ôåðìåíòà â 2. Walsh P., Retik A., Stamey Th., Vaghan D. Campbell’s Urol- êðîâü, ÷åìó ñîïóòñòâóåò àïîïòîçíàÿ ñìåðòü ýïèòåëèÿ â ogy. - Philadelphia: W.B. Saunders Co. - 1995. 3. DAKO Cytomation // Catalogue. – 2005. - N204. - P. 139. íîðìàëüíîé òêàíè. Òàê êàê íîðìàëüíàÿ êîíöåíòðàöèÿ 4. Festuccia C. et al. Epithelial and prostatic marker expression ÏÑÀ â êðîâè (≤4,5 íã/ìë) äîëæíà áûòü îáóñëîâëåíà ýòèì in short-term primary cultures of human prostate tissue sam- ïðîöåññîì, ýêñïðåññèÿ ÏÑÀ â ýïèòåëèè íå âñåãäà íàõî- ples // Int J Oncol. – 2005. – N 26(5). – P. 1353-1362. äèòñÿ â êîððåëÿöèè ñ óðîâíåì ýòîãî ôåðìåíòà â êðîâè. 5. Gelmini S. Real-time RT-PCR for the measurement of pros- Òàêèå ïðîöåññû, êàê âîñïàëåíèå, îïóõîëü, ìåõàíè÷åñ- tate-specific antigen mRNA expression in benign hyperplasia êîå âîçäåéñòâèå ïðè ìàññàæå èëè äðóãèå ëå÷åáíûå âîç- and adenocarcinoma of prostate // Clin Chem Lab Med. – 2003. äåéñòâèÿ, êîòîðûå âûçûâàþò ïîâðåæäåíèå èëè äåñòðóê- – N 41(3). – P. 261-265. 6. Gumus B.H. et al. Does asymptomatic inflammation increase öèþ ëóìèíàëüíîãî ýïèòåëèÿ, ìîãóò ñòàòü ïðè÷èíîé PSA? A histopathological study comparing benign and malig- ïîâûøåíèÿ óðîâíÿ ÏÑÀ â êðîâè. Íàìè çàôèêñèðîâà- nant tissue biopsy specimens // Int Urol Nephrol. – 2004. – íî, ÷òî âûðàæåííàÿ ìàêðîôàãàìè èíôèëüòðàöèÿ â òêà- N 36(4). – P. 549-553. íè àäåíîìû êîððåëèðóåò ñ ïîâûøåííîé ýêñïðåññèåé 7. Heung Y.M.M. et al. The detection of prostate cells by the ÏÑÀ â ëóìèíàëüíîì ýïèòåëèè. Ýòî îáúÿñíÿåòñÿ óñèëå- reverse transcription-polymerase chain reaction in the circula- íèåì ìàêðîôàãàìè ñèíòåçèðóþùåé ôóíêöèè ÏÑÀ ýïè- tion of patients undergoing transurethral resection of the pros- òåëèÿ, ïî íåèçâåñòíîìó ïî ñåé äåíü ìåõàíèçìó. tate // BJU Int. – 2000. – N 85(1). – P. 65-69. 8. Jung K. et al. Molecular forms of prostate-specific antigen in Òàêèì îáðàçîì, èññëåäîâàíèå ýêñïðåñèè ÏÑÀ âûÿâèëî, malignant and benign prostatic tissue: biochemical and diagnostic implications // Clin Chem. – 2000. – N 46(1). – P. 47-54. ÷òî óêàçàííûé àíòèãåí íåïîñðåäñòâåííî ó÷àñòâóåò â 9. Patel D., White P.A.E., Milford Ward A. A comparison of six íàðóøåíèè ðåãóëÿöèè ðîñòà, âñëåäñòâèå ÷åãî â ïàòîãå- commercial assays for total and free prostate specific antigen íåçå ÄÃÏÆ îí ïðåäñòàâëÿåòñÿ ìàðêåðîì èëè êðèòåðèåì (PSA): the predictive value of the ratio of free to total PSA // äëÿ õàðàêòåðèñòèêè ôóíêöèîíàëüíîãî ñòàòóñà ÄÃÏÆ è BJU Int. – 2000. – N 85(6). - P 686-689. èìååò âåñüìà áîëüøîå çíà÷åíèå äëÿ ëå÷åíèÿ è ïðîãíîçà. 10. Phipps S., Habib F.K., McNeill A. Quantitative morpho- metric analysis of individual resected prostatic tissue specimens, Êîëè÷åñòâåííûé äèñáàëàíñ ìåæäó ýêñïðåññèåé ÏÑÀ â using immunohistochemical staining and colour-image analysis òêàíè è åãî óðîâíåì â êðîâè óêàçûâàåò íà òî, ÷òî îïðå- // BJU Int. – 2004. – N 94(6). – P. 919-921. äåëåíèå ÏÑÀ â êðîâè áåç åãî èììóíîãèñòîõèìè÷åñêî- 11. Steuber T. et al. Association of free-prostate specific antigen subfractions and human glandular kallikrein 2 with volume of ãî èññëåäîâàíèÿ â òêàíè ìåíåå äîñòîâåðíî è íå äàåò benign and malignant prostatic tissue // Prostate. – 2005. – ïîëíîöåííîãî ïðåäñòàâëåíèÿ î ñóùíîñòè ïàòîëîãèè N 63(1). – P. 13-18. ïðåäñòàòåëüíîé æåëåçû.

SUMMARY

PROSTATE-SPECIFIC ANTIGEN IN SERUM AND PROSTATE EPITHELIUM IN BENIGN PROSTATIC HYPERPLASIA

Papava1 V., Kochiashvili1 D., Tchovelidze1 Ch., Khardzeishvili2 O.

1Department of Urology, TSMU; 2Department of Pathological Anatomy, TSMU

The aim of our investigation was the simultaneous study of con- sia, when proliferated epithelium is presented by basal cells. Ex- centration of prostate-specific antigen (PSA) in serum and its pression degree varried between weak, moderate and high. The immune-histochemical expression in the adenomatous prostatic comparison of PSA expression degrees in tissue and its blood tissue. 50 patients have been investigated. In 48 patients benign levels shown that the change of blood concentrations was more prostatic hyperplasia (BPH) has been diagnosed, and 2 patients variable, than expression in tissue. Quantitative imbalance be- served as controls. Investigated patients were divided by 2 groups: tween them indicates that determination of blood PSA without 1st group – patients with moderate IPSS (n=6); 2nd group – immune-histochemical investigation is less reliable and does not patients with expressed IPSS (n=42). The results of our investiga- give a valuable insight about the essence prostate pathology. tions shown that at any variant of BPH lumine epithelium, as a rule, were PSA-positive. Negativeness of immune-histochemical Key words: prostate specific antigen, immune-histochemical reaction was observed in areas of epithelium atypical hyperpla- expression, BPH, prostate adenoma, IPSS.

ÐÅÇÞÌÅ

Ïàïàâà1 Â.Ë., Êî÷èàøâèëè1 Ä.Ê., ×îâåëèäçå1 Ø.Ã., Õàðäçåèøâèëè2 Î.Ì.

1Òáèëèññêèé ãîñóäàðñòâåííûé ìåäèöèíñêèé óíèâåðñèòåò, êàôåäðà óðîëîãèè; 2êàôåäðà ïàòîëîãè÷åñêîé àíàòîìèè

Öåëüþ íàøåãî èññëåäîâàíèÿ ÿâèëàñü îöåíêà êîíöåíòðàöèè òèâíîñòü èììóíîãèñòîõèìè÷åñêîé ðåàêöèè íàáëþäàëàñü â ïðîñòàòñïåöèôè÷åñêîãî àíòèãåíà (ÏÑÀ) â êðîâè è åãî èì- ó÷àñòêàõ àòèïè÷íîé ãèïåðïëàçèè ýïèòåëèÿ, ãäå ïðîëèôåðà- ìóíîãèñòîõèìè÷åñêîé ýêñïðåññèè â òêàíè äëÿ ëå÷åíèÿ è ïðî- òèâíûé ýïèòåëèé ïðåäñòàâëåí áàçàëüíûìè êëåòêàìè. Ñòå- ãíîçà äîáðîêà÷åñòâåííîé ãèïåðïëàçèè ïðåäñòàòåëüíîé æå- ïåíü ýêñïðåññèè êîëåáàëàñü ìåæäó ñëàáîé, óìåðåííîé è âû- ëåçû (ÄÃÏÆ). Èññëåäîâàíèå ïðîâîäèëîñü ó 50-è ïàöèåí- ñîêîé. Ñðàâíåíèå ñòåïåíåé ýêñïðåññèè ÏÑÀ â òêàíè è åãî òîâ, ñðåäè êîòîðûõ ó 48-è îòìå÷àëàñü ÄÃÏÆ, äâîå ñîñòàâè- êîíöåíòðàöèè â êðîâè ïîêàçàëî, ÷òî èçìåíåíèå êîíöåíòðà- ëè êîíòðîëüíóþ ãðóïïó. Â çàâèñèìîñòè îò õàðàêòåðà IPSS, öèè â êðîâè áîëåå âàðèàáåëüíî, ÷åì ýêñïðåññèÿ â òêàíè. èññëåäóåìûé êîíòèíãåíò áûë ðàçäåëåí íà 2 ãðóïïû: I ãðóï- Êîëè÷åñòâåííûé äèñáàëàíñ ìåæäó ýêñïðåññèåé ÏÑÀ â òêà- ïà – ïàöèåíòû ñ óìåðåííîé IPSS (n=6); II – ïàöèåíòû ñ âû- íè è åãî óðîâíåì â êðîâè óêàçûâàåò, ÷òî îïðåäåëåíèå ÏÑÀ ðàæåííîé IPSS (n=42). Ïðîâåäåííûå íàìè èññëåäîâàíèÿ ïî- â êðîâè áåç åãî èììóíîãèñòîõèìè÷åñêîãî èññëåäîâàíèÿ â êàçàëè, ÷òî ïðè ëþáîì âàðèàíòå ÄÃÏÆ ëóìèíàëüíûé ýïè- òêàíè ìåíåå äîñòîâåðíî è íå äàåò ïîëíîöåííîãî ïðåäñòàâ- òåëèé, êàê ïðàâèëî, ïðîÿâëÿåò ÏÑÀ-ïîçèòèâíîñòü. Íåãà- ëåíèÿ î ñóùíîñòè ïàòîëîãèè ïðîñòàòû.

Ñëó÷àé èç ïðàêòèêè

ÑËÓ×ÀÉ ËÅÉÄÈÃÎÌÛ ÏÐÈ ÌÓÆÑÊÎÌ ÁÅÑÏËÎÄÈÈ

×îâåëèäçå1 Ø.Ã., Êî÷èàøâèëè1 Ä.Ê., Ãîãåøâèëè1 Ã.Ã., Ãåòòà 2 Òüåðè, Ëàáàáèäè3 Àëèì

1Òáèëèññêèé ãîñóäàðñòâåííûé ìåäèöèíñêèé óíèâåðñèòåò, óðîëîãè÷åñêèé äåïàðòàìåíò; 2Ïàðèæñêèé óðîëîãè÷åñêèé öåíòð; 3Ðåãèîíàëüíàÿ áîëüíèöà ã. Ñàíñ, Ôðàíöèÿ

Ëåéäèãîìà – ðåäêàÿ îïóõîëü ÿè÷êîâîé òêàíè, ñîñòàâëÿ- Ñëåäóåò îòìåòèòü, ÷òî òîëüêî äâà òèïà îïóõîëè ÿè÷êà åò îò 1 äî 3% âñåõ îïóõîëåé ÿè÷êà [7,9]. Îïóõîëü ëåéäè- ìîãóò áûòü îòíåñåíû ê ýíäîêðèííûì: îïóõîëè êëåòîê ãîâûõ êëåòîê ó âçðîñëûõ âñòðå÷àåòñÿ â 75% ñëó÷àåâ, â Ëåéäèãà, ïðîäóöèðóþùèå òåñòîñòåðîí è ýñòðàäèîë è îñíîâíîì, â âîçðàñòå îò 20 äî 50 ëåò, â äåòñêîì âîçðàñòå íåñåìèíîìíûå ãåðìèíîãåííûå îïóõîëè ÿè÷åê, ïðîäó- îò 5 äî 9 ëåò - â 25% ñëó÷àåâ [1,7]. Îíà âõîäèò â ãðóïïó öèðóþùèå õîðèîãîíàäîòðîïíûé ãîðìîí (ÕÃÃ) [4,6,10]. îïóõîëåé ñåðòîëåâûõ êëåòîê, íàçûâàåìûõ îïóõîëÿìè ñå- ìåííîãî êàíàòèêà è ñòðîìû. Çà ïîñëåäíèå ãîäû ÷àñòîòà âûÿâëåíèÿ ëåéäèãîìû óâå- ëè÷èëàñü çà ñ÷åò îáðàùàåìîñòè â êëèíèêó ïî ïîâîäó Ó âçðîñëûõ ëåéäèãîìà ÷àùå ïðîÿâëÿåòñÿ â âèäå ñèìï- áåñïëîäèÿ èëè íàðóøåíèÿ ñåêñóàëüíîé ôóíêöèè – èì- òîìîâ ãèïîãîíàäèçìà, äâóñòîðîííåé ãèíåêîìàñòèè, êî- ïîòåíöèè, ëèáèäî [8,9]. òîðàÿ ìîæåò áûòü è àñèììåòðè÷íîé. Îíà, îáû÷íî, ïðî- ÿâëÿåòñÿ çà íåñêîëüêî ëåò äî ìàêðîñêîïè÷åñêè ïàëüïè- Ïàòîëîãîàíàòîìè÷åñêè äîáðîêà÷åñòâåííàÿ îïóõîëü ðóåìîé îïóõîëè, èìïîòåíöèè, ñíèæåíèÿ ëèáèäî è áåñ- Ëåéäèãà ìàëåíüêèõ ðàçìåðîâ âûñòëàíà òîëüêî ìîíî- ïëîäèÿ, âûçâàííîãî îëèãîàñòåíîòåðàòîñïåðìèåé èëè õðîìíûìè ëåéäèãîâûìè êëåòêàìè ñ ðåäêèìè öèòî- àçîîñïåðìèåé [3,6,9,10]. íóêëåàðíûìè àíîìàëèÿìè [6,9,10]. Ãèñòîëîãè÷åñêàÿ

76 GEORGIAN MEDICAL NEWS No 2 (143) Ôåâðàëü, 2007 ãîä

äèàãíîñòèêà çëîêà÷åñòâåííîé ôîðìû çàòðóäíåíà, òàê Ñ 1990 ïî 2006 ãã. â êëèíèêå áîëüíèöû Tenon (Ïàðèæ), â êàê êîëè÷åñòâî ìèòîçîâ, öèòîíóêëåàðíûõ àíîìàëèé, îòäåëåíèè óðîëîãèè è â óðîëîãè÷åñêîì äåïàðòàìåíòå îòñóòñòâèå ëèìèòà êàïñóëû - ïðåäñòàâëåíû ðåäêî. Èì- Òáèëèññêîãî ãîñóäàðñòâåííîãî ìåäèöèíñêîãî óíèâåð- ìóíîãèñòîëîãè÷åñêèå ïðèçíàêè ïðàêòè÷åñêè èäåí- ñèòåòà â òå÷åíèå ïîñëåäíèõ íåñêîëüêèõ ìåñÿöåâ ïðî- òè÷íû ïðè äîáðîêà÷åñòâåííûõ è çëîêà÷åñòâåííûõ êîíñóëüòèðîâàíû è îáñëåäîâàíû 1745 áîëüíûõ ïî ïî- ôîðìàõ. Íàëè÷èå ñîñóäèñòûõ ýìáîëîâ – ñàìûé èí- âîäó áåñïëîäèÿ. Ñðåäè íèõ ó 4-õ îáíàðóæåíà ëåéäèãî- ôîðìàòèâíûé ïðèçíàê çëîêà÷åñòâåííîñòè è âûÿâëÿ- ìà, ó òðîèõ èç íèõ - ïðè ïàëüïàöèè è ýõîãðàôèè ÿè÷êà. åòñÿ â 75% ñëó÷àåâ [4,9]. Èíòåðåñ âûçûâàåò ÷åòâåðòûé áîëüíîé ñ äâóñòîðîííèì âàðèêîöåëå (ñòàäèÿ III ñëåâà, ñòàäèÿ II ñïðàâà), â âîçðàñ- Ìû ïðèâîäèì ñëó÷àé îáíàðóæåíèÿ ëåéäèãîìû ïðè òå 33-õ ëåò, ó êîòîðîãî âî âðåìÿ ýêñïëîðàöèè ìîøîíêè ýêñïëîðàöèè ìîøîíêè ó áåñïëîäíîãî ìóæ÷èíû ñ äâó- áûëà ñëó÷àéíî îáíàðóæåíà ëåéäèãîìà. Â òàáëèöå ïðè- ñòîðîííèì âàðèêîöåëå. âåäåíû äèàãíîñòè÷åñêèå, êëèíè÷åñêèå, áèîëîãè÷åñêèå è òåðàïåâòè÷åñêèå õàðàêòåðèñòèêè 4-õ áîëüíûõ.

Òàáëèöà. Äèàãíîñòè÷åñêèå, êëèíè÷åñêèå, áèîëîãè÷åñêèå è òåðàïåâòè÷åñêèå õàðàêòåðèñòèêè áîëüíûõ ëåéäèãîìîé Âîçðàñò Ñïåðìîãðàììà Òåñòîñòåðîí ÔÑÃ Ãèñòî- Ñïåðìàòîãåíåç Ëå÷åíèå è (Ò) íîðìà - íîðìà - ëîãèÿ ýâîëþöèÿ 3-10 íã/ ìë; 4-10 Ýñòðàäèîë ìÌÅ/ìë; (Ý2) íîðìà - ËÃ 20-60 ïã/ ìë íîðìà - 1-5 ìÈÅ/ìë 34 ã. îëèãîàñòåíîòåðàòîñïåðìèÿ Ò - 6,7 ÔÑÃ - Óçåë ãèïå Ñèíäðîì ýíóêëåàöèÿ íã/ìë; Ý2 - >52 ðïëàçèÿ Ñåðòîëåâûõ ñïðàâà íåò 43 ïã/ìë ìÌÅ/ìë; ëåéäèãîìà êëåòîê ðåöèäèâà ËÃ - >15 1 ñì (íàáëþä. 3 ìÈÅ/ìë ãîäà) 32 ã. àçîîñïåðìèÿ Ò - 5,97 ÔÑÃ - pT1 çàäåðæêà îðõèäýêòîìèÿ íã/ìë; Ý2 - >31; ËÃ 22 ìì ìàòóðàöèè ñëåâà íåò >82 ïã/ ìë -4,6 ðåöèäèâà 8 ìÈÅ/ìë ëåò 37 ë. àçîîñïåðìèÿ Ò - <1,9 ÔÑÃ - çëîêà÷åñòâ Ñèíäðîì Îðõèäýêòîìèÿ íã/ìë; Ý2 – 7,6 2,5 ñì Ñåðòîëåâûõ õèìèîòåðàïèÿ 52 ïã/ìë ìÌÅ/ìë; pT2 êëåòîê VAB-VI óìåð ËÃ - 4,5 ÷åðåç 6 ìÈÅ/ìë ìåñÿöåâ 33 ã. îëèãîàñòåíîòåðàòîñïåðìèÿ Ò - <2,1 ÔÑÃ - pT1 ãèïîñïåðìàòîãåíåç Ýíóêëåàöèÿ, íã/ìë; Ý2 - >12,6; 8 ìì ðåöèäèâ ÷åðåç >75 ïã/ìë ËÃ - 3,8 6 ëåò â äðóãîì ìÈÅ/ìë ÿè÷êå, îðõèäýê. ñïðàâà 5 ëåò íàáëþäåíèÿ

Ó ÷åòâåðòîãî áîëüíîãî íà ñïåðìîãðàììå îòìå÷åíà îëè- íûé ðàçðåç áåëîé îáîëî÷êè íèæíåãî ïîëþñà ÿè÷êà. ãîàñòåíîòåðàòîçîîñïåðìèÿ - êîëè÷åñòâî ñïåðìàòîçîè- Îáíàðóæåí óçåë äèàìåòðîì 8 ìì, òâåðäûé, õîðîøî êàï- äîâ - 6,5 ìèë./ìë, ïîäâèæíîñòü - 20% çà 1 ÷àñ, ñïóñòÿ 4 ñóëèðîâàííûé, æåëòî-êîðè÷íåâîãî îòòåíêà. Ïðîèçâåäå- ÷àñà - 5%, àòèïè÷åñêèå ôîðìû ñîñòàâèëè 80%. íà ýíóêëåàöèÿ óçëà â 0,5 ñì îò îïóõîëè. Ñðî÷íîå ãèñòî- ëîãè÷åñêîå èññëåäîâàíèå ïîêàçàëî íàëè÷èå äîáðîêà- Ñîãëàñíî ïðîòîêîëó, ïðèìåíÿåìîìó â îòäåëåíèè, áîëü- ÷åñòâåííîé ëåéäèãîìû. Ïðè ïëàíîâîì ãèñòîëîãè÷åñ- íîìó ïðîâåäåíà ìèêðîõèðóðãè÷åñêàÿ îïåðàöèÿ êîððåê- êîì èññëåäîâàíèè äèàãíîç ïîäòâåðäèëñÿ – ïîä ìèêðî- öèè âàðèêîöåëå è ýêñïëîðàöèÿ ìîøîíêè, à òàêæå äâó- ñêîïîì îáíàðóæèâàëèñü ìîíîìîðôíûå ëåéäèãîâûå ñòîðîííÿÿ äâîéíàÿ áèîïñèÿ ÿè÷êà. Ïðè îáñëåäîâàíèè êëåòêè ñ ðåäêèìè öèòîíóêëåàðíûìè àíîìàëèÿìè. Ðåä- ëåâîãî ÿè÷êà â íèæíåì ïîëþñå îáíàðóæåí òðóäíî ïàëü- êî íàáëþäàëèñü èíòðàöèòîïëàçìàòè÷åñêèå âêëþ÷åíèÿ ïèðóåìûé óçåë, ââèäó ÷åãî íàìè âûïîëíåí ðàñøèðåí- – êðèñòàëëû Ðåéíêå (Reinke), (ðèñ.1).

äîñòè÷ü áåðåìåííîñòè ñïóñòÿ äâà ãîäà; åñòåñòâåííûì ïóòåì ðîäèëàñü äåâî÷êà - 3 êã 200 ã.

Áîëüíîé ïîñòîÿííî íàõîäèëñÿ ïîä íàáëþäåíèåì (ïàëü- â ïàöèÿ, ãîðìîíàëüíûé ñòàòóñ, ýõîäîïïëåðîãðàôèÿ ìî- øîíêè).

à Ñïóñòÿ øåñòü ëåò ïîñëå îïåðàöèè â ïðàâîì (êîíòðàëà- òåðàëüíîì) ÿè÷êå îáíàðóæåí îïóõîëåâûé óçåë äèàìåò- ðîì 1,8 ìì. Áîëüíîé áûë ñðî÷íî ïðîîïåðèðîâàí, èñ- à ñëåäîâàíèå ex-tempo ïîäòâåðäèëî íàëè÷èå äîáðîêà÷å- ñòâåííîé ëåéäèãîìû ïðàâîãî ÿè÷êà; ïðîèçâåäåíà âû- ñîêàÿ îðõèäýêòîìèÿ ñïðàâà. Â íàñòîÿùåå âðåìÿ áîëü- íîé íàõîäèòñÿ ïîä íàáëþäåíèåì â òå÷åíèå 6-è ëåò è íèêàêèõ ñèìïòîìîâ áîëåçíè íå íàáëþäàåòñÿ. Ðèñ. 1. Áîëüíîé 33-õ ëåò. Ãèñòîëîãè÷åñêàÿ êàðòèíà ýíóêëèðîâàííîãî óçëà. Ãåìàòîêñèëèí-ýîçèí õ40. Ìî- Îïèñàííûé ñëó÷àé ïîêàçûâàåò, ÷òî ýíóêëåàöèÿ ëåéäè- íîìîðôíûå ëåéäèãîâûå êëåòêè ñ ðåäêèìè ìèòîçàìè ãîìû ÿâëÿåòñÿ ïðèáëèçèòåëüíî ðàâíîöåííîé àëüòåðíà- (à) è öèòîíóêëåàðíûìè àíîìàëèÿìè (â) âêëþ÷åíèÿìè òèâîé îðõèäýêòîìèè, êîòîðàÿ ïðåäëàãàåòñÿ ìíîãèìè êðèñòàëëîâ Ðåéíêå àâòîðàìè [1,5,8,9]. Ó÷èòûâàÿ íàëè÷èå êàïñóëèðîâàíèÿ è äîáðîêà÷åñòâåííîñòü îïóõîëè, à òàêæå ïðîáëåìó áåñ- Ïî äàííûì äâóñòîðîííåé äâîéíîé áèîïñèè ÿè÷êà ñïåð- ïëîäèÿ, âàæíà âîçìîæíîñòü ñîõðàíåíèÿ ÿè÷êà. ìàòîãåíåç ÷àñòè÷íî ñîõðàíåí – ãèïîñïåðìàòîãåíåç + çàäåðæêà ìàòóðàöèè íà ñïåðìàöèò II (ðèñ. 2). Îäíàêî, âî èçáåæàíèå ðàçâèòèÿ ðåöèäèâà, ïðîâåäåíèå ýòîé òàêòèêè îïðàâäàíî òîëüêî ïîä ñòðîãèì äèíàìè- ÷åñêèì íàáëþäåíèåì.

ËÈÒÅÐÀÒÓÐÀ

1. Henderson C., Ahmed A., Sesterheenn I., Belman A., Ruston H. Enucleation for prepubertal leydig cell tumor // J Urol. – 2006. – N 176(2). – P. 703-5. 2. Caron P.J., Bennet A.P., Plantavid M., Louvet J.P. Luteiniz- ing hormone secretory pattern before and after removal of Ley- dig cell tumor of the testis // Eur. J. Endoc. – 1994. - N131. – P. 156-159. 3. Colpi G.M., Carmignani L., Nerva F., Guido P., Gadda F., Castiglioni F. Testicular-sparing microsurgery for suspected testicular masses // BJU Int. – 2005. – N 96(1). – P. 67-9. Ðèñ. 2. Ãèñòîëîãè÷åñêàÿ êàðòèíà áèîïñèè ÿè÷êà. Ãå- 4. Daniel L., Lechevallier E., Liprandi A., De Fromont M., Pelis- ìàòîêñèëèí-ýîçèí Õ40. Ãèïïîñïåðìàòîãåíåç è çàäåð- sier J.F., Coulange C. Tumeur maligne à cellule de Leydig sécrétant æêà ñïåðìàòîãåíåçà íà ñïåðìàöèò II de la progestérone // Prog. Urol. - 1998. - N8. – P. 1047-1050. 5. Danjou P., Cavrois G.., Gilliot P., Rigot J.M., Mazeman E. Tumeurs testiculaires à cellules de Leydig à priori bénignes : Ó÷èòûâàÿ ìîðôîëîãè÷åñêîå ñòðîåíèå, êàïñóëèðîâàíèå énucléation ou orchidectomie radicale? // Prog. Urol. - 1993. - è ðàçìåðû îïóõîëè, à òàêæå ïðè÷èíó îáðàùåíèÿ áîëü- N3. – P. 234-237. íîãî â êëèíèêó èç-çà ïðîáëåì áåñïëîäèÿ, áûëî ðåøåíî 6. Davidoff M.S., Schulze W., Middendorff R., Holstein A.F. ïðîèçâåñòè ýíóêëåàöèþ è ñîõðàíèòü ëåâîå ÿè÷êî. The Leydig cell of the human testis – a new member of the diffuse neuroendocrine system // Cell Tissue Res. – 1993. - Äàëüíåéøàÿ ýâîëþöèÿ áîëåçíè èìååò ñëåäóþùóþ èñòî- N271. – P. 429-439. ðèþ: ýñòðàäèîë íîðìàëèçîâàëñÿ ÷åðåç 48 ÷àñîâ, òåñòîñòå- 7. Gana B.M., Windsor P.M., Lang S., Macintyre J., Baxby K. ðîí - ÷åðåç ìåñÿö; îáúåì è ðàçìåðû ÿè÷êà, êîòîðûå áûëè Leydig cell tumor // Br. J. Urol. – 1995. - N75. – P. 673-685. óìåíüøåíû, íîðìàëèçîâàëèñü ÷åðåç äâà ìåñÿöà. ÔÑÃ <10 8. Horstman W.G., Haluszka M.M., Burkhard T.K. Manage- ment of testicular masses incidentaly discovered by ultrasound ìÌÅ/ìë äîñòèã ñâîåé íîðìû ñïóñòÿ äâà ìåñÿöà. // J. Urol. – 1994. - N151. – P. 1263-1265. 9. Kalfon A., Abram F., Kirsch-Noir F., Tchovelidze C., Arvis G. Îòìå÷åíî ÿâíîå óëó÷øåíèå ñïåðìîãðàììû (ýôôåêò Les tumeurs testiculaires à cellu. 10. Middendorff R., Mayer B., ëå÷åíèÿ âàðèêîöåëå): 27,5 ìèë./ìë, ïîäâèæíîñòü - 40%, Holstein A.F. Neuroendocrine characteristics of human Leyding àòèïè÷íûå ôîðìû - 40%, ÷òî â äàëüíåéøåì ïîçâîëèëî cell tumours // Andrologia. – 1995. - N2. – P. 351-355.

78 GEORGIAN MEDICAL NEWS No 2 (143) Ôåâðàëü, 2007 ãîä

SUMMARY ÐÅÇÞÌÅ

CASES OF LEYDIG CELL TUMOR IN MALE INFERTILITY ÑËÓ×ÀÉ ËÅÉÄÈÃÎÌÛ ÏÐÈ ÌÓÆÑÊÎÌ ÁÅÑÏËÎ- ÄÈÈ Tchovelidze1 Ch., Kochiashvili1 D., Gogeshvili1 G., Getta Thiery2, Lababidi Halim3 ×îâåëèäçå1 Ø.Ã., Êî÷èàøâèëè1 Ä.Ê., Ãîãåøâèëè1 Ã.Ã., Ãåòòà Òüåðè2, Ëàáàáèäè Àëèì3 1Department of Urology, Tbilisi State Medical University, Geor- gia; 2Paris Urology Center, France;2Sens Regional Hospital, 1Òáèëèññêèé ãîñóäàðñòâåííûé ìåäèöèíñêèé óíèâåðñèòåò, Sans, France óðîëîãè÷åñêèé äåïàðòàìåíò; 2Ïàðèæñêèé óðîëîãè÷åñêèé öåíòð; 3Ðåãèîíàëüíàÿ áîëüíèöà ã. Ñàíñ, Ôðàíöèÿ 1745 patients at the Department of Urology of Tenon Hospital (Paris, France) from 1990 to 2006 and at the department of Ñ 1990 ïî 2006 ãã. â êëèíèêå áîëüíèöû Tenon (Ïàðèæ), â urology of Tbilisi State Medical University (Georgia) during îòäåëåíèè óðîëîãèè è â óðîëîãè÷åñêîì äåïàðòàìåíòå Òáè- last several months have been examined and counseled on male ëèññêîãî ãîñóäàðñòâåííîãî ìåäèöèíñêîãî óíèâåðñèòåòà â infertility. Leydig cell tumor was found in 4 patients, among òå÷åíèå ïîñëåäíèõ íåñêîëüêèõ ìåñÿöåâ ïðîêîíñóëüòèðîâàíû them 3 by palpation and testicle echography, fourth patient (at è îáñëåäîâàíû 1745 áîëüíûõ ïî ïîâîäó áåñïëîäèÿ. Ñðåäè the age of 33) with bilateral varicocele (III stage at the left, II íèõ ó 4-õ îáíàðóæåíà ëåéäèãîìà, ó òðîèõ èç íèõ - ïðè ïàëü- stage at the right) was more interesting for us. Leydig cell tumor ïàöèè è ýõîãðàôèè ÿè÷êà. Èíòåðåñ âûçûâàåò ÷åòâåðòûé áîëü- was found out at the scrotum exploration. Oligoteratozoosper- íîé ñ äâóñòîðîííèì âàðèêîöåëå (ñòàäèÿ III ñëåâà, ñòàäèÿ II mia (OATS) has been distinguished from his spermogram. Micro- ñïðàâà), â âîçðàñòå 33-õ ëåò, ó êîòîðîãî âî âðåìÿ ýêñïëîðà- surgical bilateral correction of varicocele and scrotum explora- öèè ìîøîíêè áûëà ñëó÷àéíî îáíàðóæåíà ëåéäèãîìà, íà ñïåð- tion, and double-sided double biopsy of testicle have been car- ìîãðàììå îòìå÷åíà îëèãîàñòåíîòåðàòîñïåðìèÿ (OATS). Áîëü- ried out. During examination of the left testis the hardly palpa- íîìó ïðîâåäåíà ìèêðîõèðóðãè÷åñêàÿ îïåðàöèÿ êîððåêöèè ble node has been found out in the lower pole. We became com- âàðèêîöåëå è ýêñïëîðàöèÿ ìîøîíêè, à òàêæå äâóñòîðîííÿÿ pelled to make enlarged incision of tunica alba of the testicle äâîéíàÿ áèîïñèÿ ÿè÷êà. Ïðè îáñëåäîâàíèè ëåâîãî ÿè÷êà â lower pole. After that it was found out the solid, well encapsu- íèæíåì ïîëþñå îáíàðóæåí òðóäíî ïàëüïèðóåìûé óçåë, ÷òî lated and yellow-brown node (8 mm in diameter). The node ïîñòàâèëî íàñ ïåðåä íåîáõîäèìîñòüþ ïðîâåäåíèÿ ðàñøèðåí- enucleation away from tumor by 0.5 cm has been carried out. íîãî ðàçðåçà áåëîé îáîëî÷êè íèæíåãî ïîëþñà ÿè÷êà. Îáíà- Exact histological investigation confirmed the presence of Ley- ðóæåí óçåë äèàìåòðîì 8 ìì, òâåðäûé, õîðîøî êàïñóëèðî- dig cell tumor. In 6 years after surgical operation the tumor node âàííûé, æåëòî-êîðè÷íåâîãî îòòåíêà. Ïðîèçâåäåíà ýíóêëåà- 1.8 mm in diameter has been found out in right (contra lateral) öèÿ óçëà â 0,5 ñì îò îïóõîëè. Ãèñòîëîãè÷åñêîå èññëåäîâàíèå testis. The patient was urgently operated, ex-tempo investiga- äîêàçàëî íàëè÷èå äîáðîêà÷åñòâåííîé ëåéäèãîìû. ×åðåç tion confirmed the presence of Leydig cell tumor in right testicle øåñòü ëåò ïîñëå îïåðàöèè â ïðàâîì (êîíòðàëàòåðàëüíîì) ÿè÷- – high orchidectomy at the right has been carried out. Now, êå îáíàðóæåí îïóõîëåâûé óçåë äèàìåòðîì 1,8 ìì. Áîëüíîé patient has not any symptoms of disease during 3.5 years of ñðî÷íî ïðîîïåðèðîâàí; èññëåäîâàíèå ex-tempo ïîäòâåðäè- observation. Given case shows that the enucleation of Leydig ëî íàëè÷èå äîáðîêà÷åñòâåííîé ëåéäèãîìû ïðàâîãî ÿè÷êà - cell tumor proves to be equivalent alternative of orchidectomy, ïðîèçâåäåíà âûñîêàÿ îðõèäåêòîìèÿ ñïðàâà. Â íàñòîÿùåå which is suggested by many authors. Taking into account the âðåìÿ (ñïóñòÿ 3,5 ãîäà ïîñëå îïåðàöèè) ê.ë. ñèìïòîìîâ áî- presence of encapsulation and tumor benignity it is important to ëåçíè íå îáíàðóæåíî. Äàííûé ñëó÷àé ïîêàçûâàåò, ÷òî ýíóê- have opportunity of the testicle preservation due to infertility ëåàöèÿ ëåéäèãîìû ÿâëÿåòñÿ ïî÷òè ðàâíîöåííîé àëüòåðíàòè- problems. âîé îðõèäýêòîìèè, êîòîðàÿ ïðåäëàãàåòñÿ ìíîæåñòâîì àâòî- ðîâ. Ó÷èòûâàÿ íàëè÷èå êàïñóëèðîâàíèÿ è äîáðîêà÷åñòâåí- However, this tactics must be carried out under strong observa- íîñòü ýòîé îïóõîëè è ïðîáëåìó áåñïëîäèÿ - âàæíà âîçìîæ- tion due to the opportunity of relapse even in several days after íîñòü ñîõðàíåíèÿ ÿè÷êà. surgical operation. Ïðîâåäåíèå ýòîé òàêòèêè ðåêîìåíäóåòñÿ òîëüêî ïîä ñòðî- Key words: leydig cell tumor, male infertility, varicocele, testic- ãèì äèíàìè÷åñêèì íàáëþäåíèåì âî èçáåæàíèå ðàçâèòèÿ ular biopsy, Spermatogenesis, ART. ðåöèäèâà.

Ñëó÷àé èç ïðàêòèêè

ÐÅÄÊÈÉ ÑËÓ×ÀÉ ÄÎÁÐÎÊÀ×ÅÑÒÂÅÍÍÎÉ ÎÏÓÕÎËÈ ÓÐÀÕÓÑÀ Ó ÁÅÐÅÌÅÍÍÎÉ

Äæàïàðèäçå Ñ.À., Äæàïàðèäçå Ñ.Ñ.

Òáèëèññêèé ãîñóäàðñòâåííûé ìåäèöèíñêèé óíèâåðñèòåò, öåíòðàëüíàÿ êëèíèêà èì. Í. Êèïøèäçå, äåïàðòàìåíò óðîëîãèè

Îïóõîëü óðàõóñà ïî ñåé äåíü ñ÷èòàåòñÿ ðåäêî âñòðå÷à- äíåé ñòåíêå ìî÷åâîãî ïóçûðÿ (ðèñ. 1). Ïîñðåäñòâîì êîì- þùèìñÿ çàáîëåâàíèåì è ñîñòàâëÿåò 0,01% ñëó÷àåâ îò ïüþòåðíîé òîìîãðàôèè ïîäòâåðæäåí äèàãíîç îïóõîëè âñåõ îíêîëîãè÷åñêèõ çàáîëåâàíèé è 0,34% ñëó÷àåâ ðàêà óðàõóñà (ðèñ. 2). Ó÷èòûâàÿ, ÷òî îïóõîëè óðàõóñà, â îñ- ìî÷åâîãî ïóçûðÿ [5,6]. íîâíîì, çëîêà÷åñòâåííîãî õàðàêòåðà, ïðîèçâåäåíî èñêóñ- ñòâåííîå ïðåðûâàíèå áåðåìåííîñòè ìåòîäîì ìàíóàëü- Ñîãëàñíî ëèòåðàòóðíûì äàííûì, ñâûøå 90% âñåõ ñëó- íîé âàêóóìàñïèðàöèè, à çàòåì ïàöèåíòêà íàïðàâëåíà â ÷àåâ îïóõîëåé óðàõóñà ïðèõîäèòñÿ íà àäåíîêàðöèíîìó óðîëîãè÷åñêóþ êëèíèêó äëÿ äàëüíåéøåãî ëå÷åíèÿ. åãî ñëèçèñòîé, ðåäêî íà ñàðêîìó, åùå ðåæå íà äîáðîêà- ÷åñòâåííûå îïóõîëè [4]. Îïóáëèêîâàíî [2] 15 ñëó÷àåâ îïóõîëè óðàõóñà, êîòîðûå áûëè âûÿâëåíû çà ïîñëåäíèå 14 ëåò. Âî âñåõ ñëó÷àÿõ êîíñòàòèðîâàí ðàê. Àâòîðû îò- ìå÷àþò, ÷òî â ßïîíèè çà ïîñëåäíèå 20 ëåò òàêèõ ñëó÷àåâ áûëî îáíàðóæåíî 75 è â ëå÷åíèè ýòîãî çàáîëåâàíèÿ àâòîðû ïðåäïî÷òåíèå îòäàþò öèñòýêòîìèè, ÷òî ïîäòâåð- æäàåòñÿ õîðîøèìè îòäàëåííûìè ðåçóëüòàòàìè.

Â Èñïàíèè áûëî îïóáëèêîâàíî [1] îïèñàíèå åäèí- ñòâåííîãî ñëó÷àÿ äîáðîêà÷åñòâåííîé îïóõîëè, â ÷àñò- íîñòè, ëåèîìèîìû óðàõóñà. Àâòîðû îòìå÷àþò, ÷òî â ëèòåðàòóðå èìè îáíàðóæåíî òîëüêî 6 àíàëîãè÷íûõ ñëó÷àåâ. Îïèñàí [3] òàêæå ñëó÷àé ëåèîìèîìû óðàõó- ñà ó 39-ëåòíåé æåíùèíû, ðàçìåðîì 21õ20õ12 ñì, êîòî- ðàÿ äî îïåðàöèè áûëà äèàãíîñòèðîâàíà êàê îïóõîëü Ðèñ. 1. Îïóõîëü óðàõóñà íà ïåðåäíåé ÷àñòè ìî÷åâîãî ÿè÷íèêà è òîëüêî ñóáîïåðàöèîííî áûë ïîñòàâëåí ïóçûðÿ (äàííûå ÓÇÈ) îêîí÷àòåëüíûé äèàãíîç.

Â ëèòåðàòóðå [7] íàìè îáíàðóæåíî îïèñàíèå îäíîãî ñëó- ÷àÿ àäåíîêàðöèíîìû óðàõóñà ó æåíùèíû, áåðåìåííîé íà ìàëûõ ñðîêàõ. Åé ïðîâåëè ïàðöèàëüíóþ öèñòýêòîìèþ, óäàëåíèå ìàòêè ñ ïîñëåîïåðàöèîííîé ðàäèîòåðàïèåé.

Äèàãíîñòèêà îïóõîëåé óðàõóñà íå ïðåäñòàâëÿåò îñîáûõ òðóäíîñòåé, îäíàêî, ÷àñòî áîëåçíü ïðîòåêàåò áåç âèäè- ìûõ ñèìïòîìîâ è â áîëüøèíñòâå ñëó÷àåâ îáíàðóæèâà- åòñÿ áîëüíûìè â âèäå ïàëüïèðóåìûõ îïóõîëåâèäíûõ îáðàçîâàíèé, ðàñïîëîæåííûõ â ñòåíêå áðþøèíû ïî ñðåäíåé ëèíèè íèæå ïóïêà, èëè ïðè ýõîñêîïèè ìî÷åïî- ëîâûõ îðãàíîâ.

Â îòå÷åñòâåííîé ëèòåðàòóðå ñëó÷àåâ îïóõîëåé óðàõóñà Ðèñ. 2. Îïóõîëü óðàõóñà íà ïåðåäíåé ÷àñòè ìî÷åâîãî íàìè íå îáíàðóæåíî. ïóçûðÿ (äàííûå ÊÒ)

Ïðèâîäèì íàøå íàáëþäåíèå: áîëüíàÿ Â.Ë., 19 ëåò. Â Áîëüíîé â íàøåé êëèíèêå áûëà ïðîâåäåíà öèñòîñêî- ìàðòå 2006 ãîäà äëÿ óñòàíîâëåíèÿ áåðåìåííîñòè áîëü- ïèÿ; ñìîòðîâîé öèñòîñêîï ïðîøåë óðåòðó ñâîáîäíî. íîé ïðîâåäåíî óëüòðàçâóêîâîå îáñëåäîâàíèå â æåíñ- Åìêîñòü ìî÷åâîãî ïóçûðÿ ñîñòàâèëà 250 ìë, ñëèçèñòàÿ - êîé êîíñóëüòàöèè. Áûëà îïðåäåëåíà áåðåìåííîñòü ñðî- íîðìàëüíàÿ, óñòüÿ ìî÷åòî÷íèêîâ - íîðìàëüíîãî ðàñ- êîì â 11 íåäåëü, îáíàðóæåíà òàêæå îïóõîëü íà ïåðå- ïîëîæåíèÿ, ñîêðàùàþòñÿ ïåðèîäè÷íî. Íà ïåðåäíåé

80 GEORGIAN MEDICAL NEWS No 2 (143) Ôåâðàëü, 2007 ãîä

ñòåíêå ìî÷åâîãî ïóçûðÿ îòìå÷àåòñÿ áóãðèñòîå âûïÿ- diagnosed as an ovarian tumor // Europ. Journ. of Obstetrics and ÷èâàíèå ðàçìåðîì 2õ2 ñì ñ íåèçìåíåííîé ñëèçèñòîé. Gynaecology & Reproduct. Biology. – 2001. - N100. – P. 94-95. Ïàëüïàòîðíî íà ñðåäíåé ëèíèè íèæå ïóïêà âûÿâëÿëîñü 4. Gockel B., Dettmar H. Mukoses Adenocarzinom des Urachus áåçáîëåçíåííîå îáðàçîâàíèå ðàçìåðîì ñ ãðåöêèé îðåõ. // Urol. ausg. B. – 1983. – vol. 23. - N4B. – P. 187-191. 5. Pinthus G.H., Haddad R., Trachtenberg J. et al. Population Ïðîèçâåäåíà áèîïñèÿ äàííîãî îáðàçîâàíèÿ: ãèñòîïà- based survival data on urachal tumors // J. Urol. – 2006. - N òîìîðôîëîãè÷åñêîå çàêëþ÷åíèå - ôèáðîìèîìà óðàõó- 175(6). – P. 2042-7. ñà. Îáùåêëèíè÷åñêèé àíàëèç ïàòîëîãè÷åñêèõ îòêëîíå- 6. Rosen L., Hoddick W., Hricak H., Lue T. Urachal carcinoma íèé íå âûÿâèë. // Urol. Radiol. – 1985. – vol. 7. - N3 – P. 174-177. 7. Van Casterenk K., Van Mensel K., Joniau S. et al. Urachal Áîëüíàÿ áûëà ïîäãîòîâëåíà è ïîä ýïèäóðàëüíîé àíåñ- carcinoma during pregnancy // Urology. – 2006. - N 67(6). – vol. òåçèåé ïðîèçâåäåíà îïåðàöèÿ ïàðöèàëüíîé öèñòýêòî- 1290. - P. 19-21. ìèè ñ ðåçåêöèåé ïåðåäíåé ñòåíêè ìî÷åâîãî ïóçûðÿ è óäàëåíèåì ïîëíîñòüþ óðàõóñà äî ïóïêà âìåñòå ñ ëî- SUMMARY êàëüíûì ëèñòêîì ïàðèåòàëüíîãî ïåðèòîíåóìà. Ìî÷å- RARE CASE OF BENIGN URACHUS TUMOR DURING âîé ïóçûðü áûë çàêðûò íàãëóõî, â óðåòðó âñòàâëåí êàòå- PREGNANCY òåð Ôîëåÿ. Óäàëåííàÿ îïóõîëü óðàõóñà ïðåäñòàâëÿëà ñîáîé ïëîòíîâàòîå îáðàçîâàíèå ñ áëåäíîñåðîâàòûì Japaridze S., Japaridze S. îòòåíêîì. Central University Clinic After Academic N. Khipshidze, De- Ïîñòîïåðàöèîííûé ïåðèîä ïðîòåêàë áåç îñëîæíåíèé. partment of Urology. Îïåðàöèîííàÿ ðàíà çàæèëà ïåðâè÷íûì íàòÿæåíèåì. Âîññòàíîâëåíî ôèçèîëîãè÷åñêîå ìî÷åèñïóñêàíèå. We described rare case of urachus fibromyoma at the 11th week of pregnancy. Urachus tumor was occasionally revealed during ultrasonographic examination. It was shown in previous studies Ãèñòîïàòîìîðôîëîãè÷åñêîå èññëåäîâàíèå âûÿâèëî, ÷òî that 90% of urachus tumors are malignant, so was decided on îáñëåäîâàííûé ìàòåðèàë ñîñòîèò èç ôèáðîçíîé ñîåäè- artificial abortion, by the method of manual vacuum aspiration. íèòåëüíîé òêàíè, â êîòîðîé âûÿâëÿþòñÿ ïëàñòû ïëîñêî- After the abortion patient was sent to the urologic clinic, and êëåòî÷íûõ ìûøå÷íûõ âîëîêîí, ðàñïîëîæåííûõ â ðàç- after biopsy was revealed diagnosis of fibromyoma of urachus. íûõ íàïðàâëåíèÿõ. Çàêëþ÷åíèå – ôèáðîìèîìà óðàõóñà. It was performed operation of partial cystectomy with excision of urachus tissue up to umbilicus. The decision of artificial abor- Äàííûé êëèíè÷åñêèé ñëó÷àé èëëþñòðèðóåò äîñòàòî÷- tion performance in these cases is disputable. íî ðåäêèé ñëó÷àé äîáðîêà÷åñòâåííîé îïóõîëè óðàõóñà Key words: urachus tumor, pregnancy, fibromyoma. ó áåðåìåííîé. Ñ÷èòàåì öåëåñîîáðàçíûì äî ïðîâåäå- íèÿ èñêóññòâåííîãî àáîðòà ïðîèçâîäèòü áèîïñèþ îïó- ÐÅÇÞÌÅ õîëè óðàõóñà è, â ñëó÷àå óñòàíîâëåíèÿ äèàãíîçà äîáðî- êà÷åñòâåííîãî óðàõóñà, ñòàâèòü âîïðîñ î ñîõðàíåíèè ÐÅÄÊÈÉ ÑËÓ×ÀÉ ÄÎÁÐÎÊÀ×ÅÑÒÂÅÍÍÎÉ ÎÏÓÕÎ- áåðåìåííîñòè. Îäíàêî, òàê êàê áåðåìåííîé ïðîèçâåäå- ËÈ ÓÐÀÕÓÑÀ Ó ÁÅÐÅÌÅÍÍÎÉ íî íå ñîâñåì áåçîáèäíîå äëÿ ïëîäà èññëåäîâàíèå – êîì- ïüþòåðíàÿ òîìîãðàôèÿ, â äàííîì ñëó÷àå ïðîâåäåíèå Äæàïàðèäçå Ñ.À., Äæàïàðèäçå Ñ.Ñ. èñêóññòâåííîãî ïðåðûâàíèÿ áåðåìåííîñòè ñ÷èòàåì îïðàâäàííûì. Íà íàø âçãëÿä, ïðîâåäåíèå áèîïñèè îáåñ- Òáèëèññêèé ãîñóäàðñòâåííûé ìåäèöèíñêèé óíèâåðñèòåò, öåíòðàëüíàÿ êëèíèêà èì. Í. Êèïøèäçå, äåïàðòàìåíò óðî- ïå÷èò çàáëàãîâðåìåííîå óñòàíîâëåíèå âèäà îïóõîëè ëîãèè óðàõóñà (çëîêà÷åñòâåííàÿ èëè äîáðîêà÷åñòâåííàÿ) è â çàâèñèìîñòè îò äèàãíîçà ðåøàòü âîïðîñ ñîõðàíåíèÿ Îïèñàí ðåäêèé ñëó÷àé ôèáðîìèîìû óðàõóñà ó æåíùèíû ñ áåðåìåííîñòè. 11-íåäåëüíîé áåðåìåííîñòüþ. Îïóõîëü óðàõóñà áûëà îáíà- ðóæåíà ñëó÷àéíî ïðè ýõîñêîïèè. Ó÷èòûâàÿ, ÷òî ñâûøå 90% ËÈÒÅÐÀÒÓÐÀ ñëó÷àåâ îïóõîëè óðàõóñà çëîêà÷åñòâåííîãî õàðàêòåðà, áîëü- íîé áûëî ïðîèçâåäåíî èñêóññòâåííîå ïðåðûâàíèå áåðåìåí- 1. Arrufat Boix J.M., Garcia R.M., Mignol F.V. et al. Urachal íîñòè è îíà áûëà íàïðàâëåíà â óðîëîãè÷åñêóþ êëèíèêó, ãäå Leiomyoma / Arch. Esp. Urol. – 1992. - N 45(3). – P. 251-3. ïîñëå áèîïñèè áûë óñòàíîâëåí äèàãíîç ôèáðîìèîìû. Áîëü- 2. Asano K., Miki J., Yamada H. et al. – Carcinoma of urachus: íîé ïðîâåëè ïàðöèàëüíóþ öèñòýêòîìèþ ñ óäàëåíèåì óðàõó- report of 15 cases and review of literature – is total cystectomy ñà äî ïóïêà. the treatment of choice for urachal carcinoma? // Nippon Hinyokika Gakkai Zasshi. – 2003. - N 94(4). – P. 487-94. Àâòîðû ñòàâÿò âîïðîñ î öåëåñîîáðàçíîñòè èëè íåöåëåñîîá- 3. Dansuk R., Unal O., Kars B. et al. A urachal leiomyoma mis- ðàçíîñòè ñîõðàíåíèÿ áåðåìåííîñòè â òàêèõ ñëó÷àÿõ.

THE NATIONAL CENTRE OF UROLOGY IN TBILISI

Hohenfellner R.

Mainz University School of Medicine, Mainz, Germany As a frequent Visiting Professor since 1986 and honoured Last not least a specialist who trained many years in West- by the University to become an Honorary Doctor it’s my ern Europe performs Endourology. For benign prostates a pleasure to give a short introduction for this issue. TUR up to 200 grams are performed in less than one hour.

Within a period of twenty years the Institution got an in- The institute has a diagnostic centre for Ultrasound avail- ternational reputation for one of the best Clinics in the able also for outside patients with an excellent reputations eastern part of the world. The way to become an outstand- as well as a unit for radiology, pathology and laboratory ing Institution was long and hard. Today a team of excel- diagnostic. lent Urologists are working together with L. Managadze the chairman of the Institution. The spectrum of Subspe- The new operations Theatres located on one floor have cialties is remarkable and presents the modern Strategy of sex boxes and a radiological unit for Endourology. subdivisions under one roof. “There is a big difference between a good urologist and a Oncology is divided in Testicular Cancer, Bladder and pros- bad urologist but almost no difference between a good tate Cancer as well as kidney cancer. Each team has inter- urologist and no urologist“ because the patient has only national connections and participates with study groups one choice. around the world. Extended Radical Surgery and adjuvant Chemotherapy is performed and the Intensive Care Sta- The reason for this successful development was 1. An tion is one of the most modern one you can find. excellent education in general surgery and urology. 2. Pol- yglot: for international connections 3.Diplomatic: in the Stone treatment is important in this stone endemic area. difficult political situations of this country. 4. Specializa- More than five hundred Patients are treated success- tion: to proceed successfully with new developments in fully every year with the modern stone machine. The urology. Credit has to be given for Prof. Laurent Mana- minimal invasive PNL was reintroduced in 2006 by Visit- gadze who understood from the beginning how important ing professors from Europe and is now performed by it is to bring a team of young talented urologists together specialists from the Institute. Nevertheless staghorn who are able to cover the broad spectrum of urology. How- stones are still frequently treated by open renal organ ever I have some closing remarks concerning Organisa- sparing surgery with intraoperative Ultrasound and tion and management. Doppler Equipment. Flying a single engine airplane for more than thirty years I More than 10 kidney transplantations are performed every year learned how important it is that to follow the Checklist in by a specialist trained for many years in international trans- the handbook every time before starting the engine. plantation centres. Background is a Centre for Dialysis located on one floor of the building with 26 places for Dialysis. Therefore I tried to transfer this routine procedure in the daily work of a young Urologist. In 2006 a separate ward for paediatric urology got opened and mother –child units are available. The spectrum cov- It was my privilege to take part in the processes of devel- ers all forms of severe congenital malformations and treat- opment at the National Centre of Urology in Tbilisi to work ed by a colleague who trained for many years in Europe with the young promising Doctors and I am thankful for and overseas. the livelong friendship I earned.

82 GEORGIAN MEDICAL NEWS No 2 (143) Ôåâðàëü, 2007 ãîä

ÄÅßÒÅËÜÍÎÑÒÜ ÍÀÖÈÎÍÀËÜÍÎÃÎ ÖÅÍÒÐÀ ÓÐÎËÎÃÈÈ ÃÐÓÇÈÈ

Õîõåíôåëëíåð Ð.

Ìåäèöèíñêàÿ øêîëà ïðè Óíèâåðñèòåòå Ìàéíöà, Ãåðìàíèÿ

ßâëÿÿñü ó÷àñòíèêîì ïðîöåññà ðàçâèòèÿ Íàöèîíàëüíî- îòêðûòî îòäåëåíèå ïåäèàòðè÷åñêîé óðîëîãèè ñ ïàëà- ãî öåíòðà óðîëîãèè â Òáèëèñè â òå÷åíèå äâàäöàòè ëåò, òàìè ìàòü-äèòÿ. Êðîìå òîãî, ëå÷àòñÿ âñå ôîðìû âðîæ- àâòîð îòìå÷àåò âñåìèðíóþ ñëàâó è ðåïóòàöèþ, êîòî- ä¸ííûõ óðîäñòâ. Â íàñòîÿùåå âðåìÿ, ñïåöèàëèñò ñî ñòà- ðóþ Öåíòð çàñëóæèë ïîñòîÿííûì ñòðåìëåíèåì ê ñî- æåì ðàáîòû â âåäóùåé êëèíèêå Åâðîïû çàíèìàåòñÿ âåðøåíñòâó. Øèðîêèé äèàïàçîí ïîäðàçäåëåíèé, ñî- âíåäðåíèåì ýíäîóðîëîãèè â ïðàêòèêó ëå÷åíèÿ. Èíñòè- áðàííûõ ïîä îáùåé êðûøåé Öåíòðà óðîëîãèè, ñîîò- òóò èìååò ïðåêðàñíûé äèàãíîñòè÷åñêèé öåíòð, îñíà- âåòñòâóåò óðîâíþ ñîâðåìåííûõ òðåáîâàíèé, ïðåäúÿâ- ùåííûé ïî ïîñëåäíåìó ñëîâó òåõíèêè. Îñîáî ñëåäóåò ëÿåìûõ ê ìåäèöèíñêèì ó÷ðåæäåíèÿì ïðè ëå÷åíèè îòìåòèòü øèðîêîå ìåæäóíàðîäíîå ñîòðóäíè÷åñòâî ìå- óðîëîãè÷åñêèõ ïðîáëåì. Îíêîëîãèÿ âêëþ÷àåò òåñòè- äèêîâ, áëàãîäàðÿ êîòîðîìó ñîòðóäíèêè Öåíòðà ïðîõî- êóëÿðíûé ðàê, ðàê ìî÷åâîãî ïóçûðÿ è ðàê ïðîñòàòû, äÿò ñòàæèðîâêó â âåäóùèõ êëèíèêàõ ìèðà. à òàêæå ðàê ïî÷êè. Â öåíòðå ïðîâîäÿò ðàäèêàëüíóþ õèðóðãèþ è âñïîìîãàòåëüíóþ õèìèîòåðàïèþ, à îòäå- Ïðåäïîñûëêîé äîñòèãíóòûõ ñîòðóäíèêàìè Öåíòðà óñ- ëåíèå èíòåíñèâíîé òåðàïèè Öåíòðà ÿâëÿåòñÿ îäíèì èç ïåõîâ ÿâëÿþòñÿ ãëóáîêîå çíàíèå îñíîâ îáùåé õèðóðãèè ñàìûõ ñîâðåìåííûõ â ñòðàíå. Â öåíòðå óñïåøíî ïðî- è óðîëîãèè, âëàäåíèå èíîñòðàííûìè ÿçûêàìè äëÿ óñòà- âîäèòñÿ ëå÷åíèå ìî÷åêàìåííîé áîëåçíè - ýíäåìè÷åñ- íîâëåíèÿ ìåæäóíàðîäíûõ ïðîôåññèîíàëüíûõ ñâÿçåé, êîé äëÿ ðåãèîíà. Áîëåå 500 ïàöèåíòîâ â ãîä èçëå÷èâà- íåïðåðûâíîå ïîâûøåíèå ïðîôåññèîíàëüíîé ñïåöèà- åòñÿ îò ýòîé ïàòîëîãèè ñ ïîìîùüþ ñîâðåìåííûõ òåõ- ëèçàöèè ñ ó÷åòîì ðàçâèòèÿ íîâûõ òåíäåíöèé â óðîëî- íîëîãèé. Öåíòð äèàëèçà íà 26 êîåê ïîçâîëÿåò ïðîâî- ãèè. Ñëåäóåò îñîáî îòìåòèòü ðîëü ïðîôåññîðà Ëàâðåí- äèòü áîëåå 10 òðàíñïëàíòàöèé â ãîä. Â 2006 ãîäó áûëî òèÿ Ìàíàãàäçå êàê ðóêîâîäèòåëÿ Öåíòðà.

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