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Yusupbekov Abrorbek Axmedjanovich, Deputy Director of Republican Specialized Scientific Practical Medical Center of Oncology and Radiology, Uzbekistan Rahimov Nodir Maxammatqulovich, Senior Researcher of oncourology departments of Republican Specialized Scientific Practical Medical Center of Oncology and Radiology, Uzbekistan Tilliashayhova Rano Mirzagalebovna, researcht of the department of Republican Specialized Scientific Practical Medical Center of Oncology and Radiology, Uzbekistan E-mail: evovision@bk.ru
TO CHOOSE THE CAPACITY OF SURGICAL METHOD FOR LOCAL RENAL CARCINOMA
Abstract: The organ preserving operations at the kidney cancer do not influence significantly on the frequency oflocal and regional metastasizing at identical parameters of one-year lethality at RNE. Besides, the kidney resection results in significant improvement of quality of life in the patients that promotes to early medical - social rehabilitation. Keywords: kidney cancer, localized cancer, nephrectomy, partial resection.
Despite of the achievements in the clinical oncology, the question of a choice of volume of surgical treatment at an early cancer of a kidney has been remained to be debatable. The supporters of both organ removing and organ preserving surgeries submit their arguments, which come to the radicalism and improvement of quality of life of the patients. Last years many authors consider performance of organ preserving operations at "small" tumors (d = 4 cm) as to be not only radical, but also more safe method, from the point of view of postoperative complications and lethality, in comparison with nephrectomy [1, 4, 5]. However, as the experience of many researchers shows, the performance of this or that method in the persons above 50 years has been far from the resolving until now. In particular, a variety of opinions and absence of uniform opinion about volume of operation is based on presence of multiple accompanying pathology at the elderly age that undoubtedly aggravates the burden of the postoperative period [2, 3, 6]. Besides in the literature practically there are no information on performance of resection of a kidney at T1 stage cancer based on voluminous clinical material.
The estimation of potential advantages at a choice of a type of kidney resection in the patients above 50 years of age is the purpose of the present research.
Materials and methods: 132 patients with verified renal cellular carcinoma at stage T1a-b, N0-1, M0 who underwent nephrectomy or kidney resection in the urologic departments of RSRPMC of oncology and radiology and Tashkent branch
for the period from 2009 for 2016. The complex diagnostics included clinical examination and instrumental investigations. Needle biopsy of a tumor of diameter to 4 cm was made under the control of ultrasonography. In tumors of diameter, more than 4 cm biopsy was not made, taking into account an opportunity of hematoma occurrence that can deform the true sizes of a tumor during operation. In the completely positive result of biopsy was received in 89 of 95 biopsies performed (11%), that allowed verification before the operational diagnosis of cancer. As a whole, analyzing results after operational histo-logical conclusion with the data obtained before operational needle biopsy came to the conclusion, that informativity of the needle biopsy accounted for 93-95% of the patients.
Except for needle biopsy, all patients underwent Doppler examination, ultrasonography of kidney vessels that allows determination a degree of vessels involvement into tumorous infiltration or presence of tumorous thrombus. It should be noted that presence of a blood clot in the renal vein with the help of Doppler and ultrasonography was revealed in 8 of 74 patients with T1b stage.
Depending on volume of surgical intervention all patients were divided into 2 groups of comparison: 1 - basic groups consisted of38 patients, which were performed organ preserving operation - kidney resection; 2 - control group included 94 patients, who were carried out nephrectomy.
Resection of kidney and nephrectomy were maid by transabdominal access, except for several cases of palliative
TO CHOOSE THE CAPACITY OF SURGICAL METHOD FOR LOCAL RENAL CARCINOMA
nephrectomy by lumbar approach at the weakened patients of elderly age. At performance of various variants of kidney resection (fig. 2) we consider that it is obligatory to apply renal pedicle on the turnstile with consequent hypothermia of a resection zone. During formation of hemostatic suture the resection zone was sutured through all parenchyma; and by a tightening installed narrowing local microvessels. Irrespective of a kind of resection hemostatic stage of operation was finished by application of 8-shaped suture with consequent tamponade of a zone of резекции with preparation Lagoden.
The pathomorphological investigation of the removal tumor was performed according to standardized technique of P. Quieke and co-authors (14), where the basic characteristics were definition of tumorous cells in the line of resection, the depths of tumor invasion, presence of tumorous impairment in the regional lymphatic nodes and cellular thrombus structure. Statistical analysis was carried out with use of program SPSS16 (SPSS Inc.Chikaga, Illinois, USA).
Results and discussion: The analysis of the data obtained shows, that according to gender parameters the groups of comparison had no significant differences: in both groups the men prevailed, the ratio in relation to women was 3:1. Median of age gradation according to groups of research was 61 and 60.5 years. In both groups, there were patients of more senior age that was characterized by presence of one or several accompanying pathologies. On the basis of complex investigation it was established, that among the patients exposed to OPO (organ preserving operations) in 76.3% of cases the tumor located in the upper or lower poles of the kidney and only in 23.7% of cases in the middle segment.
The analysis of the data obtained shows, that according to gender parameters the groups of comparison had no significant differences: in both groups the men prevailed, the ratio in relation to women was ~ 3:1. Median of age gradation according to groups of research was 61 and 60.5 years. In both groups there were patients of more senior age, that was characterized by presence of one or several accompanying pathologies. On the basis of complex investigation it was established, that among the patients exposed to OPO (organ preserving operations) in 76.3% of cases the tumor located in the upper or lower poles of the kidney and only in 23.7% of cases in the middle segment.
It is necessary also to note, that in group of the patients undergoing to OPO in 13 (34.2%) patients the tumor located in the middle-dorsal segment of a kidney. At localization of a tumor in the middle segment of a kidney 35 (37.28%) patients were performed radical nephrectomy. In 2 cases at resection of kidney there were revealed increased regional lymph nodes which had no effect on a choice of a volume of operation. Similarly, the sizes of neoplasm did not influ-
ence significantly on the choice of operation for the benefit of kidney resection, as in this case the type of growth of the tumor was the main factor. According to our data in 52.6% of the patients, who underwent the RP, there was observed extrarenal growth of the tumor against 50% of the patients with intrarenal growth of the tumor, who were carried out nephrectomy.
The early postoperative complication were observed in 7.7% and 5.35% of the patients respectively to groups of research. The formation of urinary fistula (2.6%) and bleeding from a zone of resection (2.6%) appeared to be the most typical complications after RP. In group 2 there were found more often purulent complications.
The time of operation was directly proportional to volume and character of the operation carried out. In group 1 the duration of operation varied from 95 up to 110 minutes with average median of duration 90 minutes. The same parameter at nephrectomy differed from the basic group, having made median 103 minutes. The postoperative lethality accounted for 2.6% in group 1, and 1.1% in group 2. The parameter of one-year survival at a stage T1 was 2.6% and 2.2%, respectively, in group 1 and 2.
The study of the long-term results showed, that three-year survival was much higher in group 2 (99.7%) in comparison with group 1 (89.5%). However, to five-year borderline the change of parameter of survivability for the benefit of the patients with OPO (76.3%) against (73.8%) patients with PH was observed. Median without the metastatic period has made 8,6 months in the 1-st group against 7.2 months in the second group. In one patient (%) in the 1-st group there were revealed metastases of disease in 10.5 months. Despite of early satisfactory results in the patients of the basic and control groups, the estimation of quality of life showed significant distinctions between them. In 6 months after operation the degree of activity according to EGOC1-2 degrees accounted for 84.2% in group 1 and only 52.1% of cases in group 2.
Thus, the comparative analysis of results after resection of kidney and radical nephrectomy testifies to opportunities for improvement of quality of life in the patients due to organ preserving operations without significant increase in frequency of postoperative complications.
Conclusions:
1. At T1 stage of cancer of a kidney with mainly extrarenal or mixed type of tumor growth the performance of organ preserving operations is more rational.
2. According to duration and results the kidney resection at T1 stage can be alternative to the radical nephrectomy that is the essential factor in the elder age group of the patients with presence in them of the accompanying pathology.
References:
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3. Teplov A. A., Rusakov S. V., Cmirnova S. V. Organ - preserving treatment of the patients with kidney cancer // Russian Oncological Journal.- 2010.- No. 4.- P. 4-9.
4. Doehn Grünwald V., Steiner T. The Diagnosis, Treatment, and Follow-up of Renal Cell Carcinoma.- 2016.- Vol. 113(35-36).- P. 590-6. doi: 10.3238/arztebl.2016.0590.
5. Schenck M., Eder R., Rübben H., Niedworok C., Tschirdewahn S. Organ and kidney function preservation in renal cell carcinoma // Urologe A.- 2014.- Vol. 53(9).- P. 1329-43. doi: 10.1007/s00120-014-3558-5.
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