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Tilliashayhov Mirzagaleb Nigmatovich, director, of Republican Specialized Scientific Practical Medical Center of Oncology and Radiology Rahimov Nodir Maxammatqulovich, senior researcher, of oncourology departments of Republican Specialized Scientific Practical Medical Center of Oncology and Radiology Tilliashayhova Rano Mirzagalebovna, research assistant, of the department of Republican Specialized Scientific Practical Medical Center of Oncology and Radiology E-mail: [email protected]
LONG-TERM RESULTS OF MODIFIED SURGICAL ACCESS TO REGIONAL LYMPH NODES AND MAIN VESSELS IN THE TREATMENT OF RENAL CELL CARCINOMA
Abstract: Metastases of the kidney cell cancer in the regional lymph nodes are not uncommon - 15.3% and methodically performed advanced lymphodissection in these patients is the method providing the best immediate and long-term results. The development of the technique of extended lymph node dissection in renal cell carcinoma, as well as a small number of postoperative complications, makes it possible to use it in all patients with renal cell carcinoma.
Keywords. Carcinoma, metastases, radical nephrectomy.
Annually, there are 189.1 thousand of new cases of RCC malignancies and an increase of morbidity. In Russia, in 2003, and 91.1 thousand of deaths from this disease are registered in 15 thousand of patients were identified, and 7.9 thousand died the world. In the USA, the number of RC incidents was 16.2 due to this disease. In 2014, 22234 patients with malignant per 100000 among the males and 8.0 per 100000 among the neoplasms of the kidney were identified. The standardized in-female population. There was an increase in the incidence of dicator of the incidence of the Russian population with renal renal cell carcinoma (RCC) in the male population to 55.1%, cell carcinoma (RCC) is 9.7 cases per 100,000 population. In in women to 55% in Russia from 1993 till the end of 2003. 2014, 8430 people died from the RCC. Approximately in 50% Nowadays, this nosology occupies the second place in terms of cases this disease already has or acquires a late generalized of the growth rate among all the malignancies in Russia. This character. In this case, the 5-year survival of patients from the tendency is associated with both improved diagnosis of organ time of detection of distant metastases varies from 5 to 10 [5].
In recent years there has been an increase in the incidence rate from 1.7 in 2012 to 1.9 in 2016, in Uzbekistan as well.
Table 1. - Contingents of patients with malignant neoplasms for renal cell carcinoma, registered in the Republic of Uzbekistan
Years Absolute number of newly diagnosed patients %of the total number of newly diagnosed patients Morbidity per100000 of the population Mortality per100000 of the population One annual mortality
2012 505 2.6 1.7 0.8 0.4
2014 243 2.6 1.8 0.9 0.4
2016 608 2.8 1.9 0.9 0.5
Despite the concept of radical nephrectomy was first proposed by Gregore in 1905, the widespread usage of radical nephrectomy in clinical practice began in the late of 60s of the last century thanks to the works of C. S. Robson and his colleagues. They showed that the longest period of life is noted in patients with RCC who underwent radical ne-
phrectomy [3, 7]. If there is no question of need for radical nephrectomy with renal cell carcinoma, up to the present time there are still disputes among urologists about the choice of operative access. Two methods are fundamentally compared: transperitoneal and extraperitoneal. [3, 8]. It must be assumed that during choosing an access should be
LONG-TERM RESULTS OF MODIFIED SURGICAL ACCESS TO REGIONAL LYMPH NODES AND MAIN VESSELS IN THE TREATMENT OF RENAL CELL CARCINOMA
minimally traumatic and ensure maximum availability of the operation object.
The aim of studying the immediate results of treatment of renal cell carcinoma of the kidney, by developing and implementing a new method of surgical access to the main vessels and regional RCC lymphoblasts.
Materials and methods: 96 patients were treated in the Republican specialized scientific and practical medical center of oncology and radiology (RSSPMCO&R), as well as in its Tashkent city branch from 2010 till 2015.
There is a predominance of men 51 (53.1%) against 45 (46.9%) women, the ratio is 1.1: 1.0. The age range is from 21
to 75 years, the average age of patients was 56.0 ± 1.3 years. Table 2.- Distribution of patients with kidney cancer by gender and localization of the process
Left kidney Right kidney Totally
males females males females males females
Patients' distribution abs. 26 33 25 12 51 45
% 27.1 38.4 26 12.5 53.1 46.9
Analysis of the data in Table 3 showed that out of 96 patients participating in the study, 51 (53.1%) men and 45 (46.9%) women had a tumor process. It was found that there was no fundamental difference in the localization of the process and gender when comparing all the data. The number of patients with metastatic lesion of regional lymph nodes was revealed: N1-10 (10.5%), N2-6 (6.2%).
In the remaining 80 (83.3%) patients, regional lymph nodes were intact. Duration of the disease before admission to the department was as follows: up to 3 months - 32 (33.3%), from 3 to 6 months - 25 (26%), from 6 months to 1 year - 29 (30.2%) and over 1 year - 10 (10.4%). As it can be seen, large number of patients entered the period of more than 3 months. The number of these patients was 66.6%, which is a prognostic adverse factor. It is revealed by the history of the disease that only 52 (54.2%) patients had the correct diagnosis, and the remaining 44 (45.8%) had a kidney tumor during the admission to our department. Despite a characteristic clinical picture, it was identified in the clinic of the (RSSPMCO&R) with ultrasound and radiological examination.
Almost all patients were treated for any chronic inflammatory diseases of the kidneys before treatment in the polyclinic of the RSMPSM &R. It should be noted that there is a tracing of late diagnostics and errors in medical tactics, this in turn led to the fact that patients with this pathology are late sent to specialized institutions. All patients underwent radical-extended nephrectomy.
The upper-median and middle-median incision of the skin is performed up to 20-22 cm. The peritoneum is dissected, Segal wound extensor is established. Revision. In the case of damage to the right kidney, the ascending and transversely dividing part of the large intestine is mobilized; the loops of the intestines are moved back by a moist towel up and to the left. After this, the back of the peritoneum is opened over the projection of the aorta from the level of the aortic bifurcation; the top with the dissection of the Treitz's ligament is opened beyond the peritoneal space review. Then, extended lymph node dissec-
tion is performed. We removed at the tumor of the right kidney lymph nodes of the first order, 2-3, lateral-caval 3-4, retro-caval 2-4, then lymph nodes of the second order: interaorta-caval 3 to the level of the upper spleen and the upper iliac 3 lymph nodes in total 14-19 lymph nodes are removed.
With the left-sided location of the tumor, the descending, transverse colon goblet is mobilized. The loops of the intestines are moved more medially, the pancreas is also mobilized, the cellulose surrounding the aorta and the inferior vena cava. After this, the back of the peritoneum is opened above the projection of the aorta from the level of bifurcation, the top with the dissection of the Treitz's ligament is opened beyond the peritoneal space. The left renal vein is allocated and taken to the tourniquet after this begins lymph-dissection. Lymphatic nodes of the first order are removed from the aortic site of the left renal vein before the beginning of a. mesenteric inferior 6-7, retroaortal 1-2, preaortal 10-12, lymph nodes of the second order: retro-lymph nodes up to the level of the upper herniated artery 2-4, interaortacaval 3, upper ileal 3 lymph nodes in the sum of 24-30 lymph nodes.
In the course of lymphatic dissection, it is separately bandaged, crossed and stitched a. and v. Renalis, review. Hemosta-sis. The kidney is mobilized, the gonadal artery, the ureter in the lower third, is bandaged and crossed. Nephrectomy is performed.
Results. The character of the histological form of the kidney tumors established after the operation by morphological examination was as follows: the clear cell cancer in 77 (80.2%), papillary cancer in 8 (8.3%), unclassifiable cancer in 4 (4.2%), chromophobic cancer - in 7 (7.3%). It should be noted that the final diagnosis is possible only based on histo-logical examination.
The criteria for evaluating the effectiveness of surgical treatment are the time and frequency of metastases and tumor recurrences in the postoperative period.
Studying the long-term results of the surgical treatment of kidney cancer, we found that the significance of the volume of lymph node dissection made acquires a definite value.
Out of 11 patients with kidney cancer who had the first clinical stage, metastases were not observed in the postoperative period. Out of 24 patients with the second stage, metastases were subsequently found in 1 (4.2%) in the second year of follow-up. Out of 50 patients with the third stage, metastases were subsequently detected in 9 (18.0%). Of these, in the first year, 4 (8.0%), in 5 (10.0%) in the second year of follow-up.
Out of11 patients with the fourth stage, metastases were subsequently detected in 3 (27.3%) patients - in 2 (18.2%) in the first and in 1 (9.1%) in the second year of follow-up. In total, of the 96 patients in the third group, 13 (13.5%) had a progression of the disease in the postoperative period.
Another important criterion for the effectiveness of the treatment is the time and frequency of loco-regional metastasis (relapse).
Table 3.- Time before appearance of metastases in
The development of the technique of extended lymph node dissection in renal cell carcinoma, as well as a small
Out of 96 patients, relapse of the disease was detected in only 2 (2.1%) patients and the occurrence of relapses was noted in the first year of observation, it should be noted that these 2 patients had a tumor of T4 size, that is, they went beyond Gerota's fascia.
Conclusions. In tumors of the kidney size T1, we recommend performing selective lymphatic dissection that is, removing first-stage lymph nodes for precise staging. When tumors T2-4N0-2Mo recommend performing extended lymph node dissection on the level of the diaphragm cruises to the iliac artery bifurcation RCC metastases to regional lymph nodes are not uncommon - 15.3% and systematically extended lymph node dissection made in these patients it is a method of ensuring the most immediate and best long-term results.
patients of the third group depending on the stage
number of postoperative complications makes it possible to use it in all patients with renal cell carcinoma.
Stage Number of patients Metastasis
Intervals months)
12 24 36 Totally
I 11 0 0 0 0
II 24 abs. 0 1 0 1
% 0 4.2 0 4.2
III 50 abs. 4 5 0 9
% 8.0 10.0 0 18.0
IV 11 abs. 2 1 0 3
% 18.2 9.1 0 27.3
Totally 96 abs. 6 7 0 13
% 6.3 7.3 0 13.5
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