The dissertation solves an important scientific and practical problem which is to improve the efficiency of detection of sentinel lymph nodes of the prostate through the use of fluorescent intraoperative imaging and determine their role in the diagnosis of lymphatic metastases of prostate cancer, which allows to optimize the volume and value for improvement of technologies of management of oncourological patients in clinical conditions.
The work is based on the study of the results of examination, treatment and dynamic monitoring of 436 patients with prostate cancer. The study contained two areas - retrospective and prospective. A retrospective study of the diagnostic efficacy of limited and complication profile of pelvic lymphadenectomy in 377 patients. The prospective part of the study included 57 patients with prostate cancer, who underwent surgery in the period from 2018 to 2020 in the amount of radical prostatectomy with enlarged or limited pelvic lymphadenectomy, including the use of detection and removal of sentinel lymph node in 33 cases group).
Preoperative examination of all patients included general clinical, laboratory examination, ultrasound examination, computed tomography, magnetic resonance imaging. The diagnosis was confirmed histologically in 100% of patients.
The experimental study used 35 three-month-old male Wistar rats, studied the distribution of fluorescent dyes (fluorescein, indocyanine) in the lymphatic system of the prostate.
Based on ROC analysis, a statistically significant, sufficient prognostic ability of prostate-specific antigen level was predicted to predict the probability of metastasis to regional lymph nodes with optimal cut-off point, PSA> 18.4 ng / ml at sensitivity Se = 61.54% and specificity Sp = 69.18 %. The obtained data show that in the presence of the level of total PSA above 18.4 ng / ml, the diagnostic efficiency of limited TLAE increases.
In the experimental part, a model was developed to study the blood circulation and lymph circulation of the prostate, in particular the verification of the sentinel lymph node. After modeling the inflammatory process in the prostate, inlocyanine green spread faster and the rate was 0.38 ± 0.08 cm / min, which may indicate increased lymph flow during inflammation. Thus, the presence of a concomitant inflammatory process helps to increase the rate of lymph outflow, which should be taken into account when planning surgical interventions when calculating the time of removal of sentinel lymph nodes.
In order to determine the significance of sentinel lymph nodes and to standardize the technology of their verification, a prospective study of 57 men aged 49 to 78 years who received treatment in the amount of radical prostatectomy with enlarged or limited pelvic lymphadenectomy.
It was found that sentinel lymph nodes were located most often 28 (85%) in the bifurcation of the common iliac artery with slight variations in the medial and lateral direction by 1-1.5 cm. In 2 (6%) cases, sentinel lymph nodes were found in the area of the occlusal fossa , 3 (9%) above the external iliac artery 1 cm cranially from its bifurcation. The number of SLV ranged from 1 to 4 on each side (1.70 ± 0.17 1.33 ± 0.14 on the right and left, respectively).
It was found that the most significant factor influencing the time of the guard nodes is the patient's body mass index. A direct correlation of residence time with BMI was established: on the right –r = 0.49; p = 0.029; left - r = 0.47; p = 0.035. The average residence time of sentinel nodes probably (p <005) differed at normal body weight (BMI up to 25 kg / m2), excess (BMI up to 30 kg / m2) - 29.0 (23.0; 33.0) minutes, with obesity and art. (BMI up to 35 kg / m2).
Significant correlations of moderate force between the presence of metastatic sentinel nodes and manifestations of lymphadenopathy (r = 0.72, p <0.001), the number of positive biopsies in the primary biopsy of the prostate (r = 0.50, p = 0.003)
Ranking on the Kulbak (I) informativeness index showed that the first places among the indicators that determine the probability of metastatic risk of sentinel lymph nodes are: the presence of lymphadenopathy (I = 3.37), preoperative PSA levels above 19 ng / ml and the number of positive results biopsies over 5 (I = 1.88). The obtained criteria can be used as classifiers when deciding on the patient's susceptibility to the risk of metastasis to regional lymph nodes and justification of indications for the choice of the scope of surgery at the individual level.
