RSDTM Department (radiologic surgical diagnostic and treatment methods) arranges the latest surgical, endosurgical, endourological, laparascopic, electrosurgical, ultrasound, R-scopic and urodynamic equipment to diagnose and treat patients with urological, oncourological, andrological, urogynecological, ginecological and surgical diseases, moreover, the department has established the new area of surgical orthopedics – knee joint arthroscopy.
Surgery block involves five surgery rooms equipped with endoscopic stands, laser, ultrasound and radiological equipment. Due to the presence of highly qualified morphological service at the Centre, it is possible to implement urgent intraoperative histological analysis. This permits to conduct organ preserving surgery or, otherwise, serves as the indication to extend surgical interference.
The department delivers medical care within the frame of compulsory medical insurance (when indicated, to patients, residing in the countryside and in the presence of appointment issued by health care facility at the place of residence), and voluntary medical insurance as a part of fee-based services.
Head of the Department Trusov Petr Vladimirovich, phone number 299-90-11 from 4.00 p.m. till 7.00p.m.;
Basic diagnostic and treatment techniques of our department:
Malignant retroperitoneal tumours: adrenal, renal, renal pelvic and urethral duct neoplasms. There are also conventional open and laparoscopic surgeries, both nephrectomy and nephro-preserving operations.
Bladder cancer..The department resources include equipment to perform photodynamic diagnostics of bladder cancer, which enables to diagnose bladder disease at preclinical stage. The following operations are performed at the department: bladder TUR (transurethral resection), radical cystectomy with the formation of urinary reservoirs in men and women. Superficial bladder cancer is associated with conservative intravesical immune and chemotherapy.
Testicular cancer.Involves the full range of diagnostic testing followed by further orchifuniculectomy with final disease staging and lymphadenectomy, if required.
Transrectal multifocal needle biopsy of prostate and seminal vesicles followed by morphological, immunological investigation are carried out to verify the diagnosis. Operations to conduct: laparoscopic radical prostate vesiculectomy, retropubic radical prostate vesiculectomy in localized (Т1-Т2) and regional Т3 prostatic cancer.
Laparoscopic radical prostate vesiculectomy is the first to be executed in Russia at our department.
Laparoscopic diagnostic lymphadenectomy for the oncological staging of urogenital system diseases are also performed.
Benign prostatic hyperplasia (BPH):.
Endoscopic methods of treatment:
- transurethral prostatic resection: mono- and bipolar;
- transurethral prostate incision;
- transurethral prostate electrovaporization;
- contact cystolithotripsy.
Conventional operative interventions:
- transvesical prostatectomy;
- retropubic prostatectomy.
Bladder stone disease:
Laparoscopic urethral and pelviolithotomy;
Endoscopic methods of treatment:
- Percutaneous needle nephrostomy under ultrasound and R-control;
- Nephroscopy, contact nephrolithotripsy, nephrolitholapaxy, nephrolithoextraction (which includes coral nephrolithiasis), minipercutaneous laser nephrolithotripsy;
- Fibrourethropyeloscopy, laser lithotripsy;
- Urethroscopy, contact laser urethrolithotripsy, urethrolithoextraction;
- The performance of retrograde and antegrade urethropyeloscopy in the setting of endoscopic operating room;
- Ureteral stenting with J-J-stents and stents with antireflux protection.
Conventional “open” treatment techniques: the performance of complicated surgical assistance in coral nephrolithiasis.
Reparative plastic urology:
Laparoscopic methods of treatment:
- Laparoscopic plastics of ureteropelvic junction for the treatment of strictures, vascular conflicts and UPJ impaired development;
- Marsupialization of renal cysts, with an option of express-cytological and morphological studies;
Endoscopic methods of treatment:
- Transurethral endourethropyelotomy;
- Balloon dilatation of UPJ strictures, urethral ducts;
- Transurethral correction of ureterocele;
- Internal optical urethrotomy, urethral tunnelization.
“Conventional” operative interventions:
- In the impaired development of upper and lower urinary tracts;
- Reparative plastic surgeries in the traumas of urinary tract;
- Urethral plastics in extended strictures and obliterations with the use of autografts (oral mucosa, skin flaps).
- Treatment of the various forms of erectile dysfunction (phalloendoprosthesis replacement), testicular replacement;
- Surgical management of Peyronie’s disease;
- Diagnostics and treatment of the varicose vein dilatation of spermatic cords (varicocele)
Diagnostics and treatment of urogenital fistula:
- Reparative plastic operations in urethral distractions;
- Surgical treatment of relapsing chronic urethritis and cystitis in women;
The main area of activity involves operative treatment of malignant, benign lesions, premalignant and underlying genital diseases in women.
Operative intervention is performed predominantly via laparoscopic approach. In a number of instances the preference may be given to laparatomy (open) or vaginal approach.
UTERINE BODY CANCER.
The following factors form the volume and the method of surgical intervention in uterine body cancer: the stage of lesion development; the differentiation grade of tumour cells; patient’s age; the presence of underlying diseases.
In laparoscopic approach, the operation is performed with the use of specific equipment. At first, abdominal cavity is filled with the gas so that surgeon could gain sufficient access to uterus, after that though the small incisions the laparoscopic tools and video camera are inserted through the abdominal cavity for the purpose of hysterectomy. The doctors watch the entire operative course on a monitor, which provides maximum precision of their actions and surgical safety. Hysterectomy is performed transvaginally. Any operational extend may be implemented by means of laparoscopic technique. The given method is preferable as it is well tolerated by patients. Moreover, laparoscopic hysterectomy is rarely associated with complications.
Prognostication in uterine body cancer depends on the stage of disease; the grade of tumour cell differentiation, patient’s age and the presence of underlying diseases. Recently, we have managed to achieve rather high five-year survival rate in patients with uterine body cancer. But this includes only women who seeked medical attention at the first and the second disease stages. In these cases, five-year survival rate makes 86-98% and 70-71%, respectively.
- The following diagnostic surgical interventions associated with the given pathology are implemented at the RADC Department of radiologic surgical diagnostics and treatment:
- diagnostic hysteroscopy (facilitated in tumour diagnosing, determination of its extension in uterus.)
- separate diagnostic curettage (enables precise determination of a diagnosis, definition of tumour structural type). The given information coordinates patient’s management.
In case of diagnosis determination, uterine body cancer, radical operative intervention is implemented based in the international recommendations: laparoscopic total hysterectomy with bilateral oophorectomy and pelvic lymphadenectomy.
We perform radical surgery both as the first treatment stage and after preoperative radiotherapy.
The key factor, which governs the choice of treatment option in cervical cancer – the disease state according to the classification of International federation of obstetricians and gynecologists. Surgical method as the separate variant can be employed in IA1, IA2, IB and rarely IIA stages. Operation extend depends on the depth of invasion (tumour diffusion beyond basal membrane), tumour expansion itself, the presence of metastases in pelvic and para-aortic lymph nodes. At IA1 stage in patients under 35 years old (the maximum tumour size – not more than 7 mm, and the depth of invasion 3 mm maximum) it is possible to perform cervical conization or radical hysterectomy. Conization means the partial excision of cervix in the shape of a cone. This operation is aimed to preserve reproductive function, though with the remaining risk of cancer recurrence. At IA2 (the maximum tumour size – not more than 7 mm, and the depth of invasion – 5 mm maximum), IB1 (4 cm tumour maximum), IB2 (tumour with the size over 4 cm in the greatest dimension) and IIA stages (the tumour resides in uterine cervix and the upper third of vagina) it is indicated to perform radical hysterectomy with the resection of pelvic nodes. During the given operation, in addition to uterine with adnexa and lymph nodes, there takes place the excision of the upper third of vagina, along with the part of uterine and parametrium fat ligament and adipose tissue, which surrounds cervix. In the presence of metastases in lymph nodes, post-operative treatment is supplemented by radiation or simultaneous radiation chemotherapy.
Usually, the multimodal treatment is implemented at IB and IIA stages with varied sequence of operations and radiation therapy.
Until more recent times, this type of operations was performed with the use of conventional “open” approach. Though, nowadays, laparoscopic approach is also actively introduced for the treatment of the given pathology.
Ovarian cancer takes the fifth place for the frequency of cancerous diseases in women. It is diagnosed in one woman per total of 55 and stands as one of the most spread causes of death as compared to the other types of genital cancer.
Surgical intervention represents the first step in the treatment of ovarian cancer.
The operation for ovarian cancer prosecutes two basic targets. The staging of tumour, which is the determination of its extension outside ovaries, stands as the first target. At that, there takes place the excision of both ovaries, uterus (this type of operation is named as hysterectomy) and both uterine tubes (the operation is named as bilateral bilateral salpingo-oophorectomy with simultaneous resection of the given organs on both sides). Apart from that, there takes place the resection of omentum or its entire tissue (so called omentectomy). Omentum represents the flap of adipose tissue, which covers abdominal cavity organs as an apron.
Ovarian cancer in some cases extends the surrounding tissues. Certain lymph nodes of small pelvis and abdominal cavity are also excised in order to access local extension of cancer cells. If there is fluid in abdominal cavity or pelvis, it is sampled for analysis.
All the samples of tissues and fluid obtained in the course of operation are submitted to laboratory in order to detect cancerous cells in it. It is crucially important to identify the stage, as every stage of ovarian cancer has specific treatment option.
The second, equally important target of operation is associated with the excision of the largest possible tumour volume. This operation is named as cytoreductive. For some patients, whose cancerous tumour has already spread far beyond ovaries, this type of surgical intervention is of critical importance. The purpose of cytoreductive operation resides in the reduction of tumour size to 1 cm in diameter at the most. Potential for survival upon successive implementation of the given operation is usually higher as compared to the preservation of the larger volume of tumour tissue.
The RADC Department of radiologic surgical diagnostic and treatment methods conducts operative interventions for ovarian cancer at the low tumour stage using both laparoscopic and conventional approach.
Uterine myoma represents benign represents hormone-dependent tumour in women of reproductive age from 30 to 45. Initial origin of the tumour is intramuscular, and then, depending on the direction of growth, there can be intramural (in the uterine wall thickness), submucosal (growing towards endometrium) and subserous nodes (which expand towards abdominal cavity). It should be borne in mind that myoma represents multiple tumour. Even if at the certain stage there are only 1-2 nodes of myoma, the absence of relevant treatment may sooner or later result in the appearing of the other nodes.
Indications of surgical treatment of patients with uterine myoma include: large sizes of myoma; rapid growth of myoma; submucosal nodal location; pedunculated subserous node; malnutricion, necrosis of myomatous nodule; cervical myoma; uterine myoma and menometrorrhagia, which anematize the patient; myomatous growth in postmenopause; adjacent organ dysfunction.
- The department of RSDTM offers different types of operative treatment related to uterine myoma:
- 1. We perform hysteronresection in the presence of submucous uterine myoma. The given surgical intrauterine operation is associated with the use of specific surgical armaments to perform highly-precise procedures in uterine cavity under video monitoring.
- 2. Laparoscopic conservative myomectomy is the operation for excision of myomatous nodules through the small-sized punctures in abdominal wall. This operation is advantageous for women who plan pregnancy or want to preserve their menstrual function.
- 3. Laparoscopic uterine hysterectomy (resection of the entire organ).
- diagnostic hysteroscopy (enables detection of endometrioid foci and assists in the determination of its expansion in uterus).
- separate curettage with histological examination aimed to deliver a precise diagnosis. Nonetheless, the diagnostic value of hysteroscopy with diagnostic curettage ranges from 30 to 92%.
- 1. laparoscopic enucleation of ovarian cysts
- 2. laparoscopic resection of ovary (partial resection of organ)
- 3. laparoscopic ovariectomy, adnexectomy (ovarian, uterine adnexa resection)
- Particular lifestyle associated with excessive static leg load.
- Sedentary life
- Dishormonal states
- Lower extremity injuries
- Unexampled accuracy and efficiency of the procedure.
- Maximum safety for patient.
- No need for general or spinal anesthesia.
- Near-complete absence of hematomas (bruises), pain syndrome – this is achieved by means of strict local and “soft” procedural VNUS impact on venous wall, free of surrounding tissue damage.
- Maximum cosmetic result.
- Meniscal injury
- Damage of anterior and posterior cruciate ligament
- Cartilage damage and diseases
- Diseases of synovial sheath of joint
- Loose bodies of joint
- Diagnostic and treatment renal biopsy under ultrasound control.
- Placing of arteriovenous fistula in patients with CKD.
Endometriosis (endometrioid disease, adenomyosis) the emergence of tissue similar to endometrium and subject to cyclical changes out of uterine body mucosa. There can be genital (pathological process is localized in internal and external genital organs) and extragenital (the progression of endometrioid implants in other bodily organs and systems of a woman) endometriosis. In its turn, there can be internal (uterine body, isthmus, interstitial segments of uterine tubes) and external (external genital organs, vagina and exocervix, retrocervical area, ovaries, uterine tubes, abdominal membrane, which covers pelvic organs) endometriosis, and also there can be mixed form of endometriosis (adenomyosis).
- The department of radiologic and surgical diagnostic and treatment methods of RADC performs the entire range of advanced diagnostic operative interventions for the given pathology:
The width of operative intervention in endometriosis may vary. At our department the interventions in young women are aimed to preserve reproductive or, at least, hormonal function: the resection of endometrioid foci, decollement with uterus and uterine adnexa sparing. Patients with unrealized reproductive functions are directed to special gynecological departments.
Additionally, the younger age group usually involves combination treatment of endometriosis — focal resection with pre- and postoperative hormonotherapy. In response to the given therapeutic regimen, we observe the size reduction of endometrioid foci, its blood supply and surrounding inflammatory response in the way that facilitates the execution of operation and prevents the emergence of the later adhesive process. Furthermore, preoperative treatment may abate the activity of endometrioid foci.
The prescription of hormone therapy in postoperative period in postoperative period is associated with the regression of residual microscopic local endometriosis, enhances operation results, and, thus, promotes the prevention of disease recurrence.
For elderly patients, we perform radical operations with the resection of uterus, ovaries and visually accessible local endometriosis. These operations are also performed in the failure of hormonal therapy and disease progression after conservative surgical treatment.
Surgical intervention in endometriosis may be performed with the use of both laporatomy and laparoscopic access. Due to the fact that the RADC Department of RSDTM is fitted with advanced equipment, which enables the performance of complicated operative interventions, most of cases are based on laparoscopic approach.
Laparoscopy ensures better visibility, more gentle tissue manipulations, minor intensity of adhesive process, and the lower morbidity.
Ovarian cyst represents a widespread disease in women of child-bearing age. At that, 30% cases of cyst formation are diagnosed in women with regular menstrual cycle and 50% - with disturbed. In menopausal period the disease is diagnosed among 6% of women.
Depending on their nature, there are functional and organic cysts. The first type is characterized by temporary nature and is formed because of minor ovarian malfunctioning. Functional cyst is usually treated by oral hormonal drugs and its self-elimination last one-two months. But there can also be cysts, which does not eliminate for more than two months and which require surgical intervention. They are commonly referred to as organic.
Surgical method as the basic option is frequently used for the treatment of complicated organic cysts. Current technologies in that cases offer laparoscopic intervention, which is associated with minimum damage of healthy tissues, reducing post-operative complications to zero and minimizing the duration of hospitalization. Anyway, during the performance of operations the doctors when possible try to preserve patient’s ovary and reproductive functions.
- The RADC Department of radiologic surgical diagnostic and treatment methods provides the following types of operations in cysts and benign tumours of uterine adnexa:
During operation for uterine adnexa (ovary and uterine tube) it is compulsory to perform urgent histological examination to deliver the precise type of a tumour: benign, borderline or malignant. This helps to prevent repetitive operative treatment when revealing borderline or malignant adnexal tumour. In case of their detection, the department of RSDTM we perform radical operations, as well as high-technology options: total laparoscopic hysterectomy, omentectomy (resection of uterine with adnexa, greater omentum).
The treatment of gallstone disease — laparoscopic cholecystectomy, endoscopic treatment of choledocholithiasis (common bile duct stones), biliary strictures, percutaneous bile duct drainage.
The experience of multi-year researches under the guidance of European and American gastroenterologists and surgeons has demonstrated the inefficiency of conservative treatment in gallstone disease (GSD). Remedial measures recommended by outpatient doctors, which are aimed at stone “resorption”, do not prevent the emersion of biliary colic, but may also induce the process due to increased stone motility followed by biliary duct blockage. Indeed, long-standing treatment of GSD threatens with complications and the progression of inflammatory process in the abdominal cavity organs adjacent to gall bladder, thus, complicating further surgical interventions and deteriorating its outcomes. Nowadays, there is proven relation between the progressions of diabetes mellitus in women with chronic presence of stones in gall bladder. For this reason, it is not to be supposed that the implementation of conservative treatment for years may give the desired effect.
Upon the referral to RADC surgeon or gastroenterologist, the patient undergoes abdominal ultrasound investigation in order to diagnose the following: the presence of stones and polyps in gall bladder and biliary ducts, their quantity and dimensions, total volume, gall bladder form and sizes, the depth of its wall and the presence of stenosis in it, the grade of inflammatory changes; and also to access the functions of gall bladder. For the main indications, we may perform spiral computed tomography that helps to access the state of both gall bladder state and the other organs of abdominal cavity. Advanced laboratory facilities can determine the extent of bile duct, liver and pancreas injury based on several analyses (inclusive of blood chemistry panel).
With the proven diagnosis of gallstone disease it is necessary to implement timely implementation of minimally invasive surgical techniques. Investigations suggest that the surgical treatment performed during the early stages of a disease result in better outcomes, the treatment course is more successful and associates with lower risk of complications and higher cosmetic effect. The optional selection of surgical intervention in GSD us guided by overall physical well-being and the degree of operative risk, rather than patient’s age. Nowadays, our Centre is fitted with state-of-the-art equipment and surgical treatment of gallstone disease in 99% of cases is performed laparoscopically – through four “punctures” in anterior abdominal wall, and in some cases – through one “puncture” in umbical region. Commonly, the patient is discharged from the hospital two-three days after the operation. The absence of “sick” gall bladder does not exert negative impact on patient’s quality of life. In postoperative period, the organism rather quickly compensates the deficiency of this “gall reservoir”; however it already exists without this time bomb in abdominal cavity.
The treatment of hernias having various localizations – laparoscopic and “open” hernioplasty with the use of reticular allograft.
The department of RSDTM performs laparoscopic hernioplasty – minimally invasive operative technique for the treatment of anterior abdominal wall hernia, which consists in the closure of hernial orifice with sieve graft having the access from abdominal cavity with the use of laparoscopic equipment.
The advantages of hernioplasty over the conventional option
The key advantages of laparoscopic hernioplasty comprise the absence of extended traumatizing skin incision and high cosmetic effect due to making only three incisions in anterior abdominal wall with the length of 0.5 – 1.0 cm and, as the consequence, near-complete absence of pain in postoperative period. It is particularly advisable to perform laparoscopic hernioplasty in patients with bilateral inguinal hernias due to the fact that the hernioplasty on the opposite side is performed through the same incisions, while conventional hernioplasty of two inguinal hernias is associated with two incisions having up to 10 cm in length.
The frequency of relapses after laparoscopic hernioplasty is substantially lower as compared to the standard stretching (“open”) techniques of hernioplasty using mesh implants.
Indications for the performance of laparoscopic hernioplasty: the presence of inguinal hernias, particularly, bilateral, small and midsized, postoperative ventral hernia in the absence of massive adhesion in abdominal cavity.
As a rule, the patient’s stay at the hospital after laparoscopic hernioplasty does not exceed 5 days. Operation time: 45-90 minutes. Disability period: an average of 14 days.
The resection of abdominal cavity lesions, hepatic and spleen cysts.
Diagnostic needle liver biopsy under ultrasound control
Conventional and minimally invasive operations in lower extremity varicose vein disease
Varicose vein disease in the most general terms is understood as the defective expansion of lower extremity superficial veins. While disease progression, along with venous dilation itself, there takes place other disease manifestations – edema, dermatitis, trophic ulcer.
In order not to miss the disease onset, it is necessary to keep a sharp lookout for your legs. The fundamental cause of disease development implies inborn connective tissue failure, which covers the structure of venous wall.
- The following factors promote disease onset and progression:
If you have relatives suffering from varicose vein disease and if there are any manifestations of the given risk factors, it is necessary at least once a year to consult surgeon-phlebologist.
Where relevant, after primary examination, RADC phlebologist may refer you for the triplex ultrasonography of lower extremity venous system, which enables objective definitions of indications for any treatment option of varicose vein disease.
For the treatment of lower extremity varicose vein disease we use the technique of radiofrequency endovasal obliteration and microphlebectomy combined with sclerosing therapy.
Nowadays, the procedure of radiofrequency vein obliteration (RFO or VNUS) is the most advanced alternative approach to the treatment of varicose vein disease. This minimally invasive technique is based on radio-frequency radiation produced by specific equipment, which is transferred to the vein by catheter. By the action of radio waves, there takes place the heating of varicose vein, it deflates and subsequently resolves (substituted with connective tissue). The procedure is performed without general anesthesia with outpatient hospitalization and leaves patient with little if any isolation from the habitual life style.
As a rule, the procedure of RFO is combined with microphlebectomy – the excision of subcutaneous varix in the area of hips and lower thighs through the “punctures”, which makes it possible to reach the desired medical and esthetic result.
- Advantages over the other techniques:
Several minutes after the operation the patient stands up and moves by himself. Just “in a couple of days”, the patient may return at his job. Sporting activities are allowed a week later.
The only restrictions in the use of the given techniques include too large varicose veins and excessive tortuous veins. In this case the treatment is performed with the use of advanced modifications of phlebectomy (vein removal).
IV. OPERATIVE ORTHOPEDICS
- Knee joint arthroscopy is performed for the following problems: