Prostate cancer and kidney stones

Features of surgical treatment of patients with a combination of prostate cancer and ureteral stone

Alyaev Yu.G., Pshikhachev A.M., Shpot E.V., Akopyan G.N., Chinenov D.V. I.M

Introduction. The presence of a ureteral stone in patients with prostate cancer (PCa) poses a task for the surgeon to determine the nature and sequence of surgical treatment of this category of patients.

The purpose of the study. To determine the tactics of treating patients with prostate cancer in combination with a ureteral stone.

Materials and methods. For the period from 2006 to 2015. In the clinic of urology, 1602 patients were operated on for prostate cancer, among which 54 (3.4%) patients had concomitant urolithiasis. In 36 (2.2%) patients from this group at the time of hospitalization there were indications for surgical treatment for both diseases. In 17 (47.2%) patients, the stone was located in the ureter.

Results. The leading clinical manifestations of ureteral stone were: in 9 (52.9%) patients - renal colic, in 4 (23.5%) - dull pain in the lumbar region, in 3 (17.6%) - acute obstructive pyelonephritis. In 1 patient, a ureteral stone was diagnosed by chance during examination for prostate cancer. In 15 (88.2%) patients, prostate cancer was localized, in the rest it was locally advanced. In the majority (94.1%) of patients, first of all, surgical treatment was performed aimed at getting rid of the ureteral stone. Only 1 patient with acute obstructive pyelonephritis caused by a stone in the upper third of the ureter underwent drainage of the upper urinary tract (UUT) with a stent catheter followed by radical prostatectomy (RP) due to a high risk of progression. In the postoperative period, 2 sessions of extracorporeal shock wave lithotripsy (ESWL) were performed with complete removal of stone fragments. For ureteral stones, the majority (82.4%) of patients underwent contact ureterolithotripsy (URL) or ESWL. 2 (28.6%) patients underwent percutaneous nephrolithotripsy due to large stones in the upper third of the ureter (in one case, the stone was previously displaced into the kidney during drainage of the upper urinary tract with a stent catheter for acute obstructive pyelonephritis).

Surgical treatment for prostate cancer in 53.0% of patients was performed in the volume of open, and in 23.5% - laparoscopic radical prostatectomy (RP). 4 (23.5%) patients underwent high-intensity focused ultrasound ablation of the prostate. Among the patients of this group there were also 2 patients with bilateral stones of the upper urinary tract. One patient with bilateral ureteral stones (without obstruction on one side) underwent successive ESWL sessions with complete removal of stone fragments, followed by open RP. The second patient with a ureteral stone on one side and a stone of the opposite kidney also successfully underwent ESWL sessions on both sides against the background of a catheter-stent on the side of the ureteral stone, followed by open RP at the second stage. In 2 patients with prostate cancer, in addition to ureteral stones, bladder stones were detected. One of them underwent laser cystolithotripsy and URSL at the first stage, then open RP. Another patient also underwent laser cystolithotripsy with simultaneous percutaneous ureterolithotripsy, and the second stage - open RP.

Conclusion. If a ureteral stone is detected in patients with prostate cancer, initially therapeutic measures should be aimed at ridding the patient of a ureteral stone, followed by surgical treatment of prostate cancer in the second stage. In the case of a high risk of progression of the tumor process and the expected long time for the patient to get rid of the ureteral stone, surgical treatment for prostate cancer should be carried out as the first stage against the background of drainage of the upper urinary tract.

Features of surgical treatment of patients with unilateral combination of stone and kidney tumor

Determination of treatment tactics for a combination of a kidney tumor and urolithiasis is an urgent task due to the variety of these combinations, the lack of clear recommendations for the treatment of this category of patients, the extremely scarce number of observations, and the rapid development of minimally invasive treatment methods.

During the period from 2006 to 2014, we observed in our clinic 42 patients with a combination of a tumor and a kidney stone, who had indications for active surgical treatment for both a kidney tumor and urolithiasis. In 15 patients out of 42, there was a unilateral kidney lesion with a tumor and a stone.

Sequential surgical treatment was performed in 8 patients. 6 of them were initially operated on for a kidney tumor, 2 - for a stone. The rest of the patients underwent a one-stage operation.

Surgical treatment included various combinations of methods. It should be noted that despite the damage to the organ by two serious diseases, organ-preserving surgery was performed in 80% of patients with an ipsilateral combination of stone and kidney tumor.Only 3 patients with a combination of pathologies underwent nephrectomy.

Clinical examples

A 46-year-old patient was admitted to the clinic with intermittent pain in the lumbar region on the right. Magnetic resonance imaging revealed an intrarenal tumor in the right kidney.

Computed tomography revealed 2 stones of the right kidney, stenosis of the ureteropelvic segment, hydronephrosis on the right.

In 3D computer modeling, it was found that the cause of hydronephrosis is urovasal conflict.

The tumor is adjacent to the upper cup, in which one of the stones is located. Given the completely intrarenal location of the tumor and possible difficulties with its visualization, it was decided to refrain from laparoscopic surgery.

After mobilization of the kidney and upper urinary tract, the area of narrowing of the ureteropelvic segment was determined, and the pelvis and upper third of the ureter were resected. As expected, the kidney tumor was not visualized.

Attempts to extract stones from the cups "blindly" using stone catchers were unsuccessful, and therefore, using a nephroscope, the stone of the lower calyx was visualized and removed, the stone of the upper calyx was removed using a flexible ureteropyeloscope.

Next, an intrarenal tumor was visualized using an ultrasound scanner, the boundaries of the tumor were outlined, and a planar resection of the kidney was performed.

Last of all, plastic surgery of the pelvic-ureteral segment was performed.

The second patient, 59 years old, was examined for leukocyturia and found a tumor and stones in the left kidney. The tumor was localized in the lower segment of the kidney along the posterior surface, adjacent to the lower calyx, in which two stones were localized with a maximum size of 7 and 16 mm. Given the localization of the tumor, retroperitoneoscopic resection of the left kidney is planned. Considering the inevitable opening of the lower calyx during the treatment, if technically possible, calicolitoextraction is planned.

As expected, the lower calyx was opened intraoperatively. The stone was visualized and removed. A second smaller stone was visualized and removed. Further calicoscopy revealed no other stones. The resection area was sutured in two rows with a continuous suture.

The next patient, 62 years old, with a rather rare comorbidity, came to our clinic with a request to perform an organ-preserving operation. The patient refused the proposed nephrectomy at the place of residence. The patient had a tumor, a staghorn stone and a cyst of the right kidney.

The contralateral kidney also showed cysts and an asymptomatic lower calyx stone.

Based on MSCT, a computer simulation of the pathological process was performed.

Taking into account the desire of the patient, the preserved function of the right kidney, as well as the damage to the contralateral kidney by a stone and cysts, various methods of organ-preserving surgery were discussed. Due to the complex configuration of the stone and the completely intrarenal nature of the pelvis, simultaneous open resection of the kidney and pyelocalicolithotomy raised doubts about the technical feasibility of complete and safe removal of the stone, created a risk of bleeding, and was associated with a high risk of nephrectomy. Considering the above, a decision was made to carry out the operations in stages.

According to three 3D modeling data, it was revealed that during virtual resection of the kidney, the upper calyx intimately adjacent to the tumor was opened, in which the upper horn of the coral-like stone was located. During a real resection, this would cause technical difficulties in its suturing and would create conditions for the formation of urinary leakage. Drainage of the kidney in such a situation, when the entire pyelocaliceal system is filled with staghorn stone, using a stent catheter or nephrostomy, would also be fraught with technical difficulties and could not guarantee an adequate outflow of urine.

Taking into account the above, as well as the small size of the kidney tumor, the absence of clinical manifestations, including gross hematuria, the first stage was percutaneous nephrolithotripsy on the right.

The stone was completely removed from access through the back lower cup.

After six weeks, the second stage was laparoscopic resection of the right kidney.

According to computer simulation, it was revealed that the tumor zone is fed by two upper segmental branches of the renal artery. The intraoperative picture completely coincided with the data of computer simulation, which made it possible to perform kidney resection under conditions of selective clamping of the above segmental renal arteries.

As expected, during the resection, the upper calyx was opened, now free of calculus, which was sutured with a separate row of sutures.

Excision of the wall of the cyst of the lower segment of the kidney was also performed.

At the control examination after 6 months, there is no tumor and stones in the right kidney, the kidney function is satisfactory, dynamic monitoring is carried out.

Thus, in the presented clinical observations, it has been demonstrated that the use of a combination of modern minimally invasive technologies for combined kidney diseases allows performing organ-preserving operations with minimal trauma to the organ and a good functional result.

Chronic prostatitis and kidney health - the connection between the two systems

The availability of information about diseases and their treatment has caused many men to try to visit doctors less. In the event of symptoms that are similar to signs of inflammation of the prostate, many people buy advertised products and drink them in the right course. In the same way, some act in the event that they suspect a lesion of the excretory system. The opinion that treatment of the prostate will have a good effect on the excretory organs and vice versa is fundamentally erroneous. Prostatitis and kidneys are indeed closely related, and the first disease often extends the pathological process to the paired organ. But still, we are talking about completely different systems and they need special approaches.

Article content

Relationship between prostate inflammation and kidney function

The prostate gland is located directly under the bladder, its body wraps around the urinary canal. Any changes in the prostate, accompanied by its swelling or increase in size, lead to the fact that the process of urine outflow is disturbed. If at the initial stages discomfort during urination becomes a consequence of this phenomenon, then after some time the situation becomes more complicated. Violation of the normal course of processes leads to an increase in the concentration of fluid in the bladder, which causes inflammation of the mucous membrane of the walls of the organ. Pretty soon, the microbial flora joins the inflammation, provoking an infectious lesion.

If the prostate only slightly increased in size, but at the same time it became inflamed and prostatitis began, this poses no less danger for the excretory organs. The close connection of the two systems in this case can also cause the development of an infectious process on the mucous membrane of the walls of the excretory organs. At the initial stage, this only reduces the usual functionality of the system and causes inconvenience. Ignoring the problem in both cases is fraught with the passage of bacteria along the ascending path to the kidneys and serious damage to one or both elements. That is why it is so important to start the treatment of prostatitis on time and carefully monitor the performance of the excretory organs.

The reverse scenario is also possible .. Fortunately, just getting microbes into the prostate may not be enough for the development of the disease. The body is able to self-cleanse by developing a special secret. But even a slight impact of harmful external factors (hypothermia, decreased immunity) is sometimes enough to trigger unwanted processes.

Signs of illness - how to understand what the problem is?

The connection between the prostate and the kidneys can also be traced in the fact that in the case of damage to these organs, a similar clinical picture often develops. Symptoms can even occur as a result of exposure to the same factors, such as hypothermia. This significantly complicates the diagnosis and requires a doctor's consultation.

As with prostatitis, and lesions of the excretory organs, the following manifestations can be observed:

• The process of urine outflow is disturbed. The urge to go to the toilet becomes more frequent, the act itself is complicated by pain, often you have to strain. There are both false urges and a nighttime need for regular emptying of the bladder.
• The nature and composition of urine changes. Depending on the localization of the problem, its stage and the degree of prevalence, various impurities may appear in the liquid. It can be a protein that makes the composition cloudy, blood, pus, mucus. The smell of the product often changes. It becomes harsh, putrid, like chemicals, rotten fish or antibiotics.
• The temperature is rising. The inflammatory process in any case leads to an increase in temperature. Its vastness and the degree of penetration of pathogens into tissues affect the level of numbers.
• Soreness appears in the pubic area. This is not an obligatory symptom, sometimes pain occurs only with tension or during urination. The phenomenon can be pulling, cutting, stabbing, local or with irradiation to neighboring tissues or organs.
• Purulent discharge appears from the urethra. Another optional manifestation that occurs against the background of a serious mucosal lesion, but it can be present both with prostatitis and with kidney diseases.

Comparing all the above points, it is difficult to say unequivocally what exactly worries a man in a particular case. To make a final diagnosis, it is necessary to pass a series of tests, undergo an examination by a urologist and visit a functional diagnostics room.Based on the results of the research, a specialist will prescribe a therapy aimed at eliminating a specific pathology.

Can the same treatment be given in both cases?

Similar symptoms of diseases of the prostate and excretory organs do not mean that in all cases one treatment regimen can be dispensed with. Some types of medicines and manipulations can really come in handy in both cases. This applies to antibiotics, antispasmodics, painkillers, immunostimulants. In both situations, anti-inflammatory drugs are applicable, but only if indicated. In addition, many more medical directions can be useful to combat profile ailments.

The table shows the features of the treatment of prostatitis and diseases of the urinary system:

Another important point is the use of alternative medicine.. So you should not self-medicate, especially if the diagnosis is only suspected, but not yet confirmed completely.

Diseases of the kidneys and prostate require the use of different natural products, and violation of this rule can lead to an aggravation of the situation

Is the prostate or kidneys affected - how to determine?

It is better to leave the doctor to deal with what hurts a man in a particular case - the prostate or the excretory organs. Even a clinical picture that is clear at first glance is not a guarantee of a correct diagnosis. And yet there are several points, paying attention to which you can suspect an ailment with the maximum degree of confidence. The main thing is not to forget to tell the specialist during the examination about all your complaints, sometimes even the nuances play an important role in the process of diagnosing pathologies.

Peculiarities of the clinical picture

The first thing men pay attention to in case of violation of the functionality of the prostate or kidneys is frequent urination. But few people know that under the influence of factors such as stress, hot weather, active fluid intake or being in a cool room, this indicator can also increase. These are only features of physiology, they are not related to diseases of the urogenital area. It is better to pay attention to other, more informative points.

Here are the main nuances that help to differentiate prostate diseases from lesions of the kidneys and other organs of the excretory system:

After evaluating the listed points, you can get a rough idea of which system was affected in a particular case. There is another important point that many people ignore. Frequent trips to the toilet, provoked by the active use of liquids against the background of thirst, may indicate diabetes. In this case, neither the prostate nor the kidneys will be affected.

Informative examination methods

Despite the fact that the clinical picture in these conditions can be very similar, due attention is paid to it when making a diagnosis. However, in any case, additional research is required. General tests are required: blood and urine. In case of suspicion of a bacterial infection, a bakposev of biological material is carried out in order to identify the sensitivity of the pathogen to antibiotics. If you suspect a lesion of the prostate gland, blood is taken to determine the level of PSA.

A lot of useful information can be obtained from instrumental methods for studying the organs of the abdominal cavity and small pelvis. Necessarily performed ultrasound of the kidneys, bladder, prostate gland. In the latter case, it is best to use transrectal technology, which is characterized by maximum information content. Innovative computer approaches can also help in making a diagnosis: MRI, CT. They allow not only to identify the problematic organ, but also to determine the degree of its damage, the involvement of neighboring tissues and systems.

Regardless of the clinical symptoms, it will not be superfluous to conduct a rectal examination of the prostate gland with a finger. A simple technique allows you to get a general idea of the state of the organ in just a few seconds, assess its size, shape, texture and soreness. Sometimes the patient is shown a prostate massage, which allows you to collect the secret synthesized by the organ. This substance is also sent for study.

Danger of prostatitis for excretory organs

Statistics show that diseased kidneys do not provoke prostatitis so often. But the defeat of the excretory organs against the background of inflammation of the prostate gland often occurs. It is especially dangerous to ignore the chronic process, in which there is no vivid clinical picture, and the provocative factor does not disappear anywhere. The disease continues to proceed in a latent or lubricated form, which gives it the opportunity to move to neighboring tissues, organs, and systems. Despite the relative remoteness of the kidneys from the prostate, they are at maximum risk.

Problems with urine outflow

Due to the peculiarities of the location of the prostate, any changes in the state of the organ necessarily affect the quality of urination. The inflamed glandular mass can noticeably increase in size, constricting the urethra. The result is a violation of the outflow of fluid from the bladder. Stones, which are often formed in a diseased male organ, also pose a danger to the functioning of the excretory organs. They are not ways to block the urethra, but they can damage the tissues and even the sphincter, leading to a number of negative consequences.

An additional risk is also an infection that can pass to the mucous membrane of the urinary canal. As a result, the entire system will begin to suffer from foci of inflammation, its functionality will decrease. In the ascending path, microbes often reach the bladder, causing cystitis. Traditionally, this condition is considered a "women's disease" and because of the similarity of symptoms to prostatitis, people rarely pay sufficient attention to its diagnosis and treatment. The pathology gradually develops and worsens, turning into a hemorrhagic or other complicated form.

Ignoring the violation of the outflow of urine can lead to stagnation of fluid and overflow of the bladder. Getting an injury in the lower abdomen creates the risk of developing a critical condition - rupture of the bladder. Lack of timely assistance is fraught with peritonitis, which often leads to death. Do not ignore the fact that all of these conditions cause pronounced discomfort and cause unbearable pain.

The appearance of blood in the urine

This symptom may be overt or covert. In the first case, the color of urine changes and the appearance of blood in it is determined by the naked eye. In the second, a blood test is required to confirm hematuria. Both scenarios are dangerous, because in any case they indicate damage to the mucous membrane up to the blood vessels. Even a one-time detection of a symptom is an indication for a visit to the doctor, regardless of whether its appearance is associated with the prostate or excretory organs.

The danger of this symptom is not only in the development of anemia, which will negatively affect the general condition of the body. The spread of the pathogenic process deep into the tissues leads to a change in their texture, which increases the risk of the formation of a malignant neoplasm at this site. In addition, tissue destruction will lead to more pronounced and severe bleeding. After some time, whole clots can be found in the urine. Such formations can also block the urethra, causing stagnation of urine and overflow of the bladder.

Development of cystitis and urethritis

Most often, the cause of the development of prostatitis is an infectious factor. Microbes that actively multiply in the tissues of the prostate, on their own or with a secreted secret, will enter the urethra. There they will begin to try to attach to the surface of the mucosa and penetrate into the thickness of the tissues. Even a slight weakening of the immune system, beriberi, injury or hypothermia will be enough for the efforts of pathogens to succeed. The result will be the development of urethritis - an unpleasant, protracted disease that can provoke more serious negative consequences.

Cystitis - inflammation of the bladder - is just one of these consequences. The infection passes to the mucosa of the organ, causing pronounced characteristic symptoms. It is noteworthy that this disease is characterized by approximately the same clinical picture as for prostatitis. Many men often take the sudden development of the condition as an exacerbation of chronic inflammation of the prostate and try to cope with it on their own with the usual methods and medicines. Such experiments are fraught with the further spread of the infection and its transition to the kidneys.

Pyelonephritis against the background of prostatitis

Infectious prostatitis is often the cause and provocateur of pyelonephritis. This disease is characterized by inflammation of the tubules of the kidney, the pelvis of the organ and its parenchyma. The course can be acute or chronic. There are several types of the disease, each of which is characterized by its own characteristics and potential risks. Depending on the level of body resistance, only one organ or both kidneys can be affected.

It is noteworthy that the causative agents of pyelonephritis are able to penetrate into the kidneys not only ascending, moving from the source in the form of the prostate gland through the bladder and ureters. Sometimes they reach the final point with the flow of blood or lymph. The disease is characterized by pain in the kidney area on the part of the affected organ or on both sides. Unlike prostatitis, cystitis and urethritis, the nature of pain is more muffled, even dull and paroxysmal.Another special point - problems with urine outflow are not typical for pyelonephritis, but they can occur when kidney damage is accompanied by cystitis, urethritis or exacerbation of prostatitis.

Development of urolithiasis

Inflammation of the prostate gland, leading to problems with the outflow of urine, can cause a man to develop urolithiasis. Representatives of the stronger sex, instead of going to the doctor and starting specialized treatment, often simply try to consume less liquid. In fact, this will not reduce the severity of their discomfort, but will only create additional negative conditions inside the body. The kidneys will begin to suffer from a lack of fluid, the concentration of urine will increase. Due to the accumulation of salts in the body, stones will begin to form, accumulating in the bodies of paired organs.

All this is a rather lengthy process, but then it takes years to treat it. This situation is especially dangerous for those people who initially have a predisposition to urolithiasis. Ignoring health problems, they will regularly suffer from the movement of stones through the ureters. Often, especially in men, the elements grow to such a size that conservative treatment is no longer able to cope with them. We have to carry out surgical operations to remove them in order to prevent an emergency.

Inconspicuous and dangerous hydronephrosis

One of the most unpleasant consequences that can develop against the background of prostatitis. It is not so easy to diagnose, for a long time the condition goes unnoticed, without a pronounced clinical picture. At a certain stage, nothing can be done with it, and in some cases it is even necessary to resort to the removal of a kidney or its transplantation. This is due to the necrosis of the tissues of the organ and its inability to continue to fulfill its purpose. Very often, the disease is detected quite by accident, conducting a diagnostic examination of the patient for urolithiasis or renal colic.

Pathology develops against the background of a violation of the outflow of urine from the organ, which is often due to an increase in the volume of the prostate gland. The concentrate continues to return to the renal pelvis, stretching them, reducing functionality. After some time, the element will atrophy and cannot be restored. Simultaneous damage to both kidneys does not happen so often, but this moment cannot be ruled out. The condition is accompanied by pain in the area of one of the paired organs, the appearance of blood in the urine, increased blood pressure, swelling of the tissues.

Renal failure

This condition is included in the group of emergency, or critical. It can be acute and chronic, characterized by a rapid decrease in the efficiency of organs or a complete cessation of their work. This happens due to severe damage to the kidney tissue and its inability to further process the fluid, producing urine. Usually, only a very advanced form of chronic prostatitis, which has been ignored for a long time or subjected to improper therapy, leads to such a development of events.

The main danger of the condition is the fact that it affects not only the kidneys, its negative impact extends to the entire body. The chronic form of the disease reduces the functionality of all vital organs and systems of the human body. Signs of the disease are pain and aches throughout the body, soreness in the heart and kidneys, the appearance of blood in the urine in large volumes, severe swelling of tissues, vomiting and nausea. Without timely qualified assistance, this can lead to the death of a person. Treatment requires narrowly focused, emergency, complex and long-term.

What to treat - prostatitis or excretory system?

It happens that the defeat of the prostate gland coincides with the development of the disease in the organs of the urinary system. Many patients believe that they first need to cope with the condition, which occurs in a more acute form, and only then move on to solving an additional problem. Such experiments on health can cause cyclical development of the same diseases. A properly designed therapy regimen is able to include a solution to all existing problems at once without creating an excessive load on the body. Only an experienced urologist who is familiar with all the nuances of the situation can develop such a plan.

It is noteworthy that the treatment of prostate diseases improves the functioning of the kidneys and other excretory organs, and vice versa. The fight against infection with antibiotics can take place in several directions at once. The main thing is to choose the optimal form and concentration of the drug. Taking uroseptics not only facilitates the outflow of urine, but also increases local immunity, which is also useful for prostatitis.Carrying out local physiotherapy, especially with the use of heat, also gives excellent results in both cases.

It turns out that actions carried out in one direction give a good result in the fight against the second situation. The main thing is not to try to speed up the process by changing the doctor's testimony or making additions to the scheme drawn up by him. Traditional medicine is really capable of giving excellent results, but their intake must be agreed with the urologist so as not to provoke the development of complications.

Prevention of potential complications

It is not so easy to prevent the spread of the infectious process that develops in the prostate to the excretory organs. Especially if you ignore the course of the disease at its start. Only by contacting a doctor in time, you can count on the fact that the pathology will be localized and eliminated without risks to neighboring systems.

Here are a few more recommendations, the observance of which will reduce the likelihood of connecting the urethra, bladder and kidneys to the disease process against the background of prostatitis:

Given the close relationship between the prostate gland and the kidneys, if one organ is affected, it is necessary to conduct a complete diagnosis of the second. A man who visits a urologist at least once a year for a preventive examination has a higher chance of maintaining his health for a long time. If he develops some kind of pathological condition in the urogenital area, it will be detected at an early stage, which will allow timely action to be taken. In addition, at least once every six months, general urine and blood tests should be taken to assess the general condition of the body.