ÓÄÊ 616.62-006.6-08-059
213463
ÎÐÃÀÍÎÇÁÅÐIÃÀÞ×Å ÊÎÌÏËÅÊÑÍÅ ËIÊÓÂÀÍÍß
ÕÂÎÐÈÕ ÍÀ Ì’ßÇÎÂÎ-IÍÂÀÇÈÂÍÈÉ ÐÀÊ
ÑÅ×ÎÂÎÃÎ ÌIÕÓÐÀ
Ñ.Î. Âîç³àíîâ 1, Â.Ñ. Ñàêàëî 1, Ç.Â. Ãàöåðåë³ÿ 2, Â.Â. Ìðà÷êîâñüêèé 2, À.Â. Ñàêàëî 1,
Þ.Þ. Êóðàíîâ 2, À.Â. Êîíäðàòåíêî 2, Ï.Ì. Ñàë³é 2, ß.Â. Ëåâ÷èøèí 2, Á.Ì. Íàâðîöüêèé
1
ÄÓ «Iíñòèòóò óðîëî㳿 ÍÀÌÍ Óêðà¿íè»
2
ÊÍÏ «Êè¿âñüêèé ì³ñüêèé êë³í³÷íèé îíêîëîã³÷íèé öåíòð»
Âñòóï. Ðàê ñå÷îâîãî ì³õóðà (ÐÑÌ) ïî-
ñ³äຠ9-òå ì³ñöå â ñòðóêòóð³ îíêîëîã³÷íî¿ çà-
õâîðþâàíîñò³ ó ñâ³ò³ ³ 2-é ñåðåä óñ³õ îíêîóðîëî-
ã³÷íèõ çàõâîðþâàíü. Ó 30% âèïàäê³â âïåðøå âè-
ÿâëåíîãî ÐÑÌ âèçíà÷àºòüñÿ ³íâàç³ÿ â ì’ÿçîâèé
øàð. ˳êóâàëüí³ îïö³¿ º äèñêóòàáåëüíèìè òà
â³äçíà÷àþòüñÿ çíà÷íîþ âàð³àáåëüí³ñòþ, ÿêà
âêëþ÷ຠòðàíñóðåòðàëüíó ðåçåêö³þ ñå÷îâîãî
ì³õóðà, ðàäèêàëüíó àáî ïàðö³àëüíó öèñòåêòîì³þ,
íåîàä‘þâàíòíó, àä‘þâàíòíó õ³ì³îòåðàï³þ òà/àáî
ïðîìåíåâó òåðàï³þ [NCCN guidelines, 2019]. Ðà-
äèêàëüíà öèñòåêòîì³ÿ ç òàçîâîþ ë³ìôàäåíåêòî-
쳺þ º çîëîòèì ñòàíäàðòîì ó ë³êóâàíí³ ì‘ÿçî-
âî-³íâàçèâíîãî ÐÑÌ [1]. Íåçàäîâîëåí³ñòü ðåçóëü-
òàòàìè öèñòåêòî쳿, ñîö³àëüíà äåçàäàïòàö³ÿ, íèçüêà
ÿê³ñòü æèòòÿ, íàÿâí³ñòü ñóïóòíüî¿ ïàòîëî㳿 ³
â³äìîâà ïàö³ºíò³â â³ä çàïðîïîíîâàíî¿ öèñòåê-
òî쳿, ðîáëÿòü àêòóàëüíèì âèâ÷åííÿ êîìá³íàö³é
ð³çíèõ ìåòîä³â ë³êóâàííÿ ì‘ÿçîâî-³íâàçèâíîãî
ðàêó ñå÷îâîãî ì³õóðà (̲ÐÑÌ). Ïðîòÿãîì îñ-
òàííüîãî äåñÿòèë³òòÿ ç’ÿâëÿºòüñÿ âñå á³ëüøå
ïóáë³êàö³é ñòîñîâíî ïàðö³àëüíî¿ öèñòåêòî쳿
(ðåçåêö³¿ ñå÷îâîãî ì³õóðà) ÿê ìîæëèâî¿ àëüòåð-
íàòèâè ðàäèêàëüí³é öèñòåêòî쳿 ç êðàùèìè ïî-
êàçíèêàìè ÿêîñò³ æèòòÿ òà íèæ÷èì ð³âíåì óñê-
ëàäíåíü [2]. ×àñòîòà ïàðö³àëüíî¿ öèñòåêòî쳿 çà-
ëèøàºòüñÿ ñòàá³ëüíîþ ïðîòÿãîì îñòàííüîãî äå-
ñÿòèë³òòÿ – â ìåæàõ â³ä 7 äî 10% óñ³õ âèêîíà-
íèõ îïåðàòèâíèõ âòðó÷àíü ó ÑØÀ çà äàíèìè
äîñë³äæåíü Íàö³îíàëüíîãî êàíöåð-ðåºñòðó
(National Cancer Database). Âàæëèâî çàçíà÷èòè,
ùî âèêîðèñòàííÿ ëèøå îäíîãî ç âèùåíàçâàíèõ
ìåòîä³â ë³êóâàííÿ â ÿêîñò³ ìîíîòåðàﳿ ìຠã³ðø³
îíêîëîã³÷í³ ðåçóëüòàòè.
Ìåòà äîñë³äæåííÿ: ïîêðàùèòè áåçïîñå-
ðåäí³ òà â³ääàëåí³ îíêîëîã³÷í³ ðåçóëüòàòè ë³êó-
âàííÿ ó õâîðèõ íà ì’ÿçîâî-³íâàçèâíèé ÐÑÌ
øëÿõîì îáμðóíòóâàííÿ ïîêàçàíü äî âèáîðó îðãà-
íîçáåð³ãàþ÷èõ îïåðàòèâíèõ âòðó÷àíü ç àä‘þâàíò-
íîþ õ³ì³îïðîìåíåâîþ òåðàﳺþ.
Ìàòåð³àëè òà ìåòîäè äîñë³äæåííÿ. Ïðî-
òÿãîì 2008–2019 ðð. â Êè¿âñüêîìó ì³ñüêîìó
ÓÊÐÀ¯ÍÑÜÊÈÉ ÍÀÓÊÎÂÎ-ÏÐÀÊÒÈ×ÍÈÉ ÆÓÐÍÀË ÓÐÎËÎÃIÂ, ÀÍÄÐÎËÎÃI ÒÀ ÍÅÔÐÎËÎÃIÂ
DOI: 10.26641/2307-5279.24.3.2020.
2
êë³í³÷íîìó îíêîëîã³÷íîìó öåíòð³, ÿêèé º áà-
çîþ ÄÓ «²íñòèòóò óðîëî㳿 ÍÀÌÍ Óêðà¿íè» áóëî
âèêîíàíî 254 â³äêðèò³ ïàðö³àëüí³ öèñòåêòî쳿. Ó
âñ³õ âèïàäêàõ ä³àãíîç áóëî âñòàíîâëåíî çà ðå-
çóëüòàòàìè ÓÇÄ, ÊÒ àáî ÌÐÒ, ÒÓÐ á³îïñ³¿ ïóõ-
ëèí ñå÷îâîãî ì³õóðà ç ìåòîþ âåðèô³êàö³¿ ä³àã-
íîçó òà âèçíà÷åííÿ ðîçïîâñþäæåíîñò³ ïóõëèí-
íîãî ïðîöåñó. Ó ïîäàëüøîìó áóâ ïðîâåäåíèé ðåò-
ðîñïåêòèâíèé àíàë³ç ³ñòîð³é õâîðîáè 120
ïàö³ºíò³â. Çã³äíî ç TNM-êëàñèô³êàö³ºþ ðîçïîä³ë
ïàö³ºíò³â áóâ íàñòóïíèì: Ò2a–Ò2b – 72 (60%),
Ò3à–T3b – 43 (35,8%), T4a–T4b – 5 (4,2%). Ó âñ³õ
ïàö³ºíò³â ìîðôîëîã³÷íî áóëî ï³äòâåðäæåíî óðî-
òåë³àëüíó êàðöèíîìó ð³çíîãî ñòóïåíÿ äèôåðåí-
ö³þâàííÿ ïóõëèíè. Çà ñòóïåíåì äèôåðåíö³þâàí-
íÿ ïóõëèíè ðîçïîä³ëÿëèñü: ç âèñîêèì ñòóïåíåì
(G1) – 2 (1,6%), ïîì³ðíèì (G2) – 46 (38,3%),
íèçüêèì (G3) – 72 (60,1%). Áóëà âèêîíàíà ðà-
äèêàëüíà öèñòåêòîì³ÿ ç ³ëåîöèñòîíåîïëàñòèêîþ
42 (13,3%) ïàö³ºíòàì (ãðóïà I). Ïàðö³àëüíà öèñò-
åêòîì³ÿ ç àä‘þâàíòíîþ ïðîìåíåâîþ òåðàﳺþ
(ÑÂÄ â³ä 45 äî 70 Ãð, ïðè ðàçîâ³é äîç³ 1,8–
2,0 Ãð) âèêîíàíà ó 41 (49,2%) ïàö³ºíòà (ãðó-
ïà II). Ó 37 (37,5%) õâîðèõ ïðîâåëè ïàðö³àëüíó
öèñòåêòîì³þ ç àä‘þâàíòíîþ õ³ì³îòåðàﳺþ (çà
ñõåìîþ: 70–100 ìã/ì2 öèñïëàòèíó – â ïåðøèé
äåíü, 1000 ìã/ì2 ãåìöèòàá³íó – â 1,8 òà 15 äí³â).
Öèêëè ïîâòîðþâàëè êîæíèé 21 äåíü (ãðóïà III).
Ó I ãðóï³ âñ³ì ïàö³ºíòàì áóëà âèêîíàíà òàçîâà
ë³ìôàäåíåêòîì³ÿ. Ó ïàö³ºíò³â II ³ III ãðóï, ÿêèì
áóëà âèêîíàíà ïàðö³àëüíà öèñòåêòîì³ÿ, ó 23
(49,9%) – ïðîâåäåíà òàçîâà ë³ìôàäåíåêòîì³ÿ ç
ìåòîþ ñòàä³þâàííÿ çàõâîðþâàííÿ òà âèçíà÷åí-
íÿ ïîêàçàíü äëÿ ïðîâåäåííÿ àä’þâàíòíî¿ õ³ì³î-
ïðîìåíåâî¿ òåðàﳿ. Ç íèõ ó 9 âèïàäêàõ áóëî âèÿâ-
ëåíî ìåòàñòàòè÷íå óðàæåííÿ òàçîâèõ ë³ìôîâóçë³â.
Ðåçóëüòàòè òà ¿õ îáãîâîðåííÿ. Ñï³ââ³äíî-
øåííÿ ÷îëîâ³ê³â ³ æ³íîê ñòàíîâèëî 5:2. Ñåðåäí³é
â³ê ïàö³ºíò³â áóâ 72 ðîêè (â³ä 45 äî 80 ðîê³â).
Çàãàëüíèé ñòàí õâîðèõ îö³íþâàëè çà øêàëîþ
ECOG: 0 áàë³â – 53 (44,2%), 1 áàë – 62 (51,7%),
2 áàëè – 5 (4,2%) õâîðèõ. Ðîçì³ðè ïóõëèííîãî
201
óðàæåííÿ áóëè â³ä 15 äî 70 ìì (â ñåðåäíüîìó –
36±12,5 ìì. Ïîïåðåäíº õ³ðóðã³÷íå ë³êóâàííÿ ÒÓÐ
ñå÷îâîãî ì³õóðà áóëî ïðîâåäåíî 86 (71,7%) õâî-
ðèì. Ïîçèòèâíèé êðàé ðåçåêö³¿, ë³ìôîâàñêóëÿð-
íà ³íâàç³ÿ, ìåòàñòàòè÷íå óðàæåííÿ ðåã³îíàðíèõ
ë³ìôîâóçë³â, ñòóï³íü äèôåðåíö³þâàííÿ ïóõëèíè,
ãëèáèíà ³íâà糿 (ðÒ) áóëè êðèòåð³ÿìè äëÿ ïðî-
âåäåííÿ àä’þâàíòíî¿ õ³ì³îïðîìåíåâî¿ òåðàﳿ. Ïðè
îö³íö³ îíêîëîã³÷íèõ ðåçóëüòàò³â äîòðèìóâàëèñü
ðåêîìåíäàö³é ªâðîïåéñüêî¿ àñîö³àö³¿ óðîëîã³â
äëÿ ïàö³ºíò³â ³ç ̲ÐÑÌ ï³ñëÿ îðãàíîçáåð³ãàþ-
÷îãî êîìïëåêñíîãî ë³êóâàííÿ [2019]. Ñòàòèñòè÷-
íèé àíàë³ç çä³éñíþâàëè çà äîïîìîãîþ ìåòîäó
Êàïëàíà-Ìåéåðà. ϳñëÿîïåðàö³éí³ óñêëàäíåííÿ
áóëè êëàñèô³êîâàí³ çã³äíî ç Êëàâ³åí-ijíäî. Çà-
ãàëüíà âèæèâàí³ñòü â ãðóï³ õâîðèõ ï³ñëÿ ïàðö³-
àëüíî¿ öèñòåêòî쳿 ç àä‘þâàíòíîþ õ³ì³îïðîìå-
íåâîþ òåðàﳺþ áóëà ñóòòºâî âèùîþ (ð=0,003)
ïîð³âíÿíî ç ïàö³ºíòàìè ç öèñòåêòî쳺þ. Ñåðåä-
íÿ òðèâàë³ñòü ñïîñòåðåæåííÿ ñêëàäàëà 5,7 ðîê³â.
ϳñëÿîïåðàö³éíó ÿê³ñòü æèòòÿ îö³íþâàëè çà
ñïåöèô³êîþ EORTC (ªâðîïåéñüêà îðãàí³çàö³ÿ
äîñë³äæåííÿ òà ë³êóâàííÿ ðàêó) QLQ-C30. Ñë³ä
â³äçíà÷èòè, ùî âñ³ ãðóïè ïàö³ºíò³â, ÿê³ îòðèìóâàëè
îðãàíîçáåð³ãàþ÷å ë³êóâàííÿ, ïðîäåìîíñòðóâàëè äî-
ñòàòíüî âèñîêèé ð³âåíü ïñèõîåìîö³éíîãî ñòàíó,
çàäîâ³ëüíå ñå÷îâèïóñêàííÿ òà çáåðåæåíó åðåêòèëüíó
ôóíêö³þ, îñîáëèâî â ãðóï³ ïàö³ºíò³â â³êîì äî
52 ðîê³â ï³ñëÿ ïàðö³àëüíî¿ öèñòåêòî쳿 ç àä’þâàíò-
íîþ õ³ì³îòåðàﳺþ. Ó ïîäàëüøîìó ïàö³ºíòàì ïðî-
âîäèëè öèñòîñêîï³þ òà öèòîëîã³þ ñå÷³ ÷åðåç 3 ì³ñÿö³
ï³ñëÿ ïàðö³àëüíî¿ öèñòåêòî쳿, êîæí³ 3 ì³ñÿö³ äî
2 ðîê³â, ïîò³ì êîæí³ 6 ì³ñÿö³â äî 5 ðîê³â, à â ïî-
äàëüøîìó – ùîð³÷íî, äîòðèìóþ÷èñü âêàç³âîê ªÀÓ
ùîäî ̲ÐÑÌ ç âèñîêèì ðèçèêîì ðåöèäèâ³â òà
ïðîãðåñóâàííÿ õâîðîáè.
Ó ïðîöåñ³ ðåòðîñïåêòèâíîãî âèâ÷åííÿ
120 ³ñòîð³é õâîðîáè ïàö³ºíò³â íà ̲ÐÑÌ ï³ñëÿ
ðàäèêàëüíî¿ öèñòåêòî쳿 ç ³ëåîöèñòîíåîïëàñòè-
êîþ, ïàðö³àëüíî¿ öèñòåêòî쳿 ç òàçîâîþ ë³ìôà-
äåíåêòî쳺þ òà àä‘þâàíòíîþ ïðîìåíåâîþ àáî
õ³ì³îòåðàﳺþ áóëî äîñÿãíóòî 5-ð³÷íî¿ çàãàëü-
íî¿ âèæèâàíîñò³ ó 50%; 53%; 68% ïàö³ºíò³â
â³äïîâ³äíî. Êàíöåðñïåöèô³÷íà âèæèâàí³ñòü ñêëà-
äàëà 56%; 54%; 66% â³äïîâ³äíî. Áåçðåöèäèâíà
3- òà 5-ð³÷íà âèæèâàí³ñòü õâîðèõ íà ̲ÐÑÌ çàëåæíî â³ä ìåòîä³â ë³êóâàííÿ
3-ð³÷íà âèæèâàí³ñòü
Ïàðàìåòðè Ãðóïà I, Ãðóïà II, Ãðóïà III,
n=42
Çàãàëüíà âèæèâàí³ñòü 72%
Êàíöåðñïåöèô³÷íà âèæèâàí³ñòü 79%
Áåçðåöèäèâíà âèæèâàí³ñòü 67%
202 ÓÊÐÀ¯ÍÑÜÊÈÉ ÍÀÓÊÎÂÎ-ÏÐÀÊÒÈ×ÍÈÉ ÆÓÐÍÀË ÓÐÎËÎÃIÂ, ÀÍÄÐÎËÎÃI ÒÀ ÍÅÔÐÎËÎÃIÂ
âèæèâàí³ñòü áóëà 60%; 36%; 38% õâîðèõ â³äïî-
â³äíî (òàáë.1).
Ðàäèêàëüíà öèñòåêòîì³ÿ äîçâîëÿº äîñÿã-
íóòè ì³ñöåâî¿ ðåì³ñ³¿ çàõâîðþâàííÿ ó 50–
70% õâîðèõ. Îäíàê òàêå ë³êóâàííÿ êîíòðîëþº
ïåðåá³ã çàõâîðþâàííÿ íå á³ëüøå, í³æ ó 50% õâî-
ðèõ. Ïðîãðåñóâàííÿ çàõâîðþâàííÿ áóëî ïîâ’ÿçà-
íå ç ì³ñöåâèì ðåöèäèâîì àáî ðîçâèòêîì â³ääà-
ëåíèõ ìåòàñòàç³â, íå âèÿâëåíèõ íà ìîìåíò ïåð-
âèííîãî âñòàíîâëåííÿ ä³àãíîçó. Ó ãðóï³ ðàäè-
êàëüíî¿ öèñòåêòî쳿 ó 14 õâîðèõ áóëî ò³ëüêè
ñïîñòåðåæåííÿ, ó 5 (11,9%) ïàö³ºíò³â âèíèê ëî-
êàëüíèé ðåöèäèâ, â³ääàëåí³ ìåòàñòàçè áóëè âè-
ÿâëåí³ ó 16 (38,1%) õâîðèõ, à êîìá³íàö³ÿ ì³ñöå-
âèõ ðåöèäèâ³â òà â³ääàëåíèõ ìåòàñòàç³â – ó 7
(16,7%) ïàö³ºíò³â. Òàêòèêà ë³êóâàííÿ ïðè ïðî-
ãðåñóâàíí³ ï³ñëÿ ðàäèêàëüíî¿ öèñòåêòî쳿 ïåðåä-
áà÷àëà âèêîðèñòàííÿ ñèñòåìíî¿ ïàë³àòèâíî¿ ïî-
ë³õ³ì³îòåðàﳿ ³/àáî ïðîìåíåâî¿ òåðàﳿ.
²ç 41 õâîðîãî, ÿêèì ïðîâåëè ïàðö³àëüíó
öèñòåêòîì³þ ç àä’þâàíòíîþ ïðîìåíåâîþ òåðà-
ﳺþ, ó 25 (59,5%) áóëà òàêòèêà ò³ëüêè ñïîñòå-
ðåæåííÿ. 10 (23,8%) õâîðèì, ó ÿêèõ âèÿâèëè
íå³íâàçèâíèé ëîêàëüíèé ðåöèäèâ, ïðîâåëè ÒÓÐ
ñå÷îâîãî ì³õóðà òà âíóòð³øíüîì³õóðîâó õ³ì³î-
òåðàï³þ (ì³òîì³öèí Ñ 40 ìã) àáî ñèñòåìíó õ³ì³î-
òåðàï³þ. ²ç 7 (16,66%) ïàö³ºíò³â, ó ÿêèõ âèÿâëå-
íèé ì’ÿçîâî-³íâàçèâíèé ëîêàëüíèé ðåöèäèâ, ó
6 (14,29%) âèêîíàëè ðÿòóâàëüíó öèñòåêòîì³þ,
îäèí õâîðèé – â³äìîâèâñÿ â³ä ïîäàëüøîãî ë³êó-
âàííÿ. ³ääàëåí³ ìåòàñòàçè íå ñïîñòåð³ãàëè.
Ó ãðóï³ ïàö³ºíò³â ï³ñëÿ ïàðö³àëüíî¿ öèñò-
åêòî쳿 ç àä’þâàíòíîþ õ³ì³îòåðàﳺþ ó 19
(51,3%) íå áóëî âèÿâëåíî ðåöèäèâ³â ³ âñ³ âîíè
æèâóòü ç³ çáåðåæåííÿì ñå÷îâîãî ì³õóðà. Ó 6
(16,2%) õâîðèõ âèÿâëåíî ïîâåðõíåâèé ëîêàëü-
íèé ðåöèäèâ, ÿêèì ïðîâîäèëè ò³ëüêè ÒÓÐ ñå÷î-
âîãî ì³õóðà. Ó 5 (13,51%) õâîðèõ áóâ âèÿâëåíèé
ðåöèäèâ ì’ÿçîâî-³íâàçèâíîãî ðàêó, ÿê³ ïåðåíåñ-
ëè ðÿòóâàëüíó öèñòåêòîì³þ ç àä’þâàíòíîþ ïîë³-
õ³ì³îòåðàﳺþ. Ó 7 õâîðèõ âèÿâëåí³ ìåòàñòàçè â
ðåã³îíàðí³ òà â³ääàëåí³ ë³ìôîâóçëè. Âñ³ âîíè îò-
ðèìóâàëè õ³ì³îïðîìåíåâå ë³êóâàííÿ.
Ó ãðóï³ ç êîìá³íîâàíèì ë³êóâàííÿì õâîð³
ìàþòü ñå÷îâèé ì³õóð ç íîðìàëüíîþ ôóíêö³î-
Òàáëèöÿ 1
5-ð³÷íà âèæèâàí³ñòü
Ãðóïà I, Ãðóïà II, Ãðóïà III,
n=41 n=37 n=42 n=41 n=37
66% 80% 50% 53% 68%
68% 75% 56% 54% 66%
46% 52% 60% 36% 38%
íàëüí³ñòþ îðãàíà ïðè â³äñóòíîñò³ â³äòåðì³íîâà-
íî¿ òîêñè÷íîñò³ ï³ñëÿ õ³ì³îòåðàﳿ.
Çàñòîñóâàííÿ àä’þâàíòíî¿ õ³ì³îïðîìåíåâî¿
òåðàﳿ ñïðèÿº ï³äâèùåííþ çàãàëüíî¿ òà êàí-
öåðñïåöèô³÷íî¿ âèæèâàíîñò³. Ðåçóëüòàòè ë³êó-
âàííÿ õâîðèõ, ÿê³ ïåðåíåñëè îðãàíîçáåð³ãàþ÷å
êîìïëåêñíå ë³êóâàííÿ ïîð³âíÿíî ç ïàö³ºíòàìè
ï³ñëÿ ðàäèêàëüíî¿ öèñòåêòî쳿 ïîêàçàëî, ùî ó
ïåðøîìó âèïàäêó ÷àñòîòà óñêëàäíåíü áóëà ìåí-
øîþ òà ÿê³ñòü æèòòÿ âèùîþ. Äîñâ³ä ñâ³ä÷èòü, ùî
îðãàíîçáåð³ãàþ÷å êîìïëåêñíå ë³êóâàííÿ ̲ÐÑÌ
ìîæå çàáåçïå÷èòè àäåêâàòíèé êîíòðîëü íàä çà-
õâîðþâàííÿì ³ äîçâîëÿº äîñÿãíóòè äîâãîòðè-
âàëîãî çáåðåæåííÿ ñå÷îâîãî ì³õóðà, çàáåçïå÷óþ-
÷è çàäîâ³ëüíèé ñîìàòè÷íèé ñòàí òà âèñîêó ÿê³ñòü
æèòòÿ (òàáë. 1).
Íà ñüîãîäí³ â³äñóòí³é êîíñåíñóñ â³äíîñíî
êðèòåð³¿â â³äáîðó õâîðèõ äëÿ ðàäèêàëüíî¿ àáî
ïàðö³àëüíî¿ öèñòåêòî쳿 â ïîºäíàíí³ ç àä‘þâàíò-
íîþ õ³ì³î- àáî ïðîìåíåâîþ òåðàﳺþ [3–5]. Äåÿê³
ïðîòîêîëè áàçóþòüñÿ íà ìîæëèâîñò³ îðãàíîçáå-
ð³ãàþ÷îãî êîìïëåêñíîãî ë³êóâàííÿ ̲ÐÑÌ
(NCCN, 2019), ùî ïîêðàùóº âèæèâàí³ñòü õâî-
ðèõ, ¿õ ÿê³ñòü æèòòÿ ³ çìåíøóº ÷àñòîòó öèñòåê-
òîì³é [6, 7]. Îäíàê ïóõëèíè, ùî ï³äëÿãàþòü îðãà-
íîçáåð³ãàþ÷³é îïåðàö³¿, ìîæóòü áóòè á³ëüø íèçü-
êî¿ Ò ñòà䳿. ßê ïðàâèëî, òàê³ ïóõëèíè ìàþòü
á³ëüø ñïðèÿòëèâèé ïðîãíîç.
Ó 15–20% õâîðèõ íà ÐÑÌ ñïîñòåð³ãàþòü
îäíî- ÷è äâîá³÷íèé ã³äðîíåôðîç [8, 9], ùî çíè-
æóº êàíöåðñïåöèô³÷íó ³ çàãàëüíó âèæèâàí³ñòü
õâîðèõ [9]. Äåÿê³ äîñë³äíèêè ðîçãëÿäàþòü ã³äðî-
íåôðîç ÿê â³äíîñíå ïðîòèïîêàçàííÿ äî õ³ì³î-
ïðîìåíåâî¿ òåðàﳿ [10, 11].
óäðîíåôðîç ìîæíà ðîçãëÿäàòè ÿê íåçà-
ëåæíèé ïðîãíîñòè÷íèé ôàêòîð áåçðåöèäèâíîãî
âèæèâàííÿ ÿê ó õâîðèõ ï³ñëÿ öèñòåêòî쳿, òàê ³
ï³ñëÿ ïàðö³àëüíî¿ öèñòåêòî쳿 ÐÑÌ [12]. Õâîð³
ç ã³äðîíåôðîçîì, ÿê ïðàâèëî, ìàþòü á³ëüø âèñî-
êèé ðèçèê åêñòðàâåçèêàëüíî¿ ñòà䳿 õâîðîáè, ç
ðîçïîâñþäæåííÿì íà òàçîâ³ ë³ìôîâóçëè. Òàêèì
õâîðèì ïîêàçàíî õ³ì³îïðîìåíåâå ë³êóâàííÿ, ùî
äຠïîçèòèâíèé åôåêò ó 50% âèïàäê³â [13, 14].
Êîìá³íàö³ÿ ãåìöèòàá³íó ç öèñïëàòèíîì (GC)
ïîêàçàëà åôåêòèâí³ñòü ³ íå ïîã³ðøóâàëà íèðêî-
âó íåäîñòàòí³ñòü. Îäíàê ïðè íàÿâíîñò³ õðîí³÷-
íî¿ íèðêîâî¿ íåäîñòàòíîñò³ ìîæíà âèêîðèñòî-
âóâàòè êîìá³íàö³þ ãåìöèòàá³íó ç êàðáîïëàòè-
íîì. Íà íàøó äóìêó, ã³äðîíåôðîç íå ïîâèíåí
ðîçãëÿäàòèñü ÿê ïðîòèïîêàçàííÿ äî âèêîíàííÿ
ïàðö³àëüíî¿ öèñòåêòî쳿 ó õâîðèõ íà ÐÑÌ.
Ñåðåä ³íøèõ ôàêòîð³â, ÿê³ ðîçãëÿäàþòü ÿê
ìîæëèâ³ ïðè÷èíè â³äìîâè â³ä îðãàíîçáåð³ãàþ-
÷èõ âòðó÷àíü, º ìóëüòèôîêàëüí³ñòü ïóõëèíè ³
ïðèñóòí³ñòü Ñà in situ (CIS), ùî ï³äâèøóº ðè-
çèê ëîêàëüíîãî ðåöèäèâó [14]. Íà ñüîãîäí³
â³äñóòí³ ðàíäîì³çîâàí³ äîñë³äæåííÿ â³äíîñíî
âèÿâëåííÿ CIS çà ìåæàìè ïóõëèíè ó õâîðèõ íà
̲ÐÑÌ ³ äîö³ëüíîñò³ àä‘þâàíòíî¿ ÕÒ ï³ñëÿ ïàð-
ö³àëüíî¿ öèñòåêòî쳿 [15].
Óðîòåë³àëüíèé ðàê ìîæå âèíèêàòè â äè-
âåðòèêóë³ ñå÷îâîãî ì³õóðà. Òàê³ ïóõëèíè ìàþòü
äåÿê³ îñîáëèâîñò³, ÿê³ âêëþ÷àþòü òðóäíîù³ ä³àã-
íîñòèêè ó âèïàäêó âóçüêî¿ øèéêè äèâåðòèêóëà.
³äñóòí³ñòü ì’ÿçîâîãî øàðó â ñò³íö³ äèâåðòèêó-
ëà óñêëàäíþþòü âèçíà÷åííÿ ïàòîëîã³÷íî¿ ñòà䳿
õâîðîáè. Õâîð³ ç ³íòðàäèâåðòèêóëÿðíèì ÐÑÌ
ââàæàþòüñÿ íå çîâñ³ì âäàëèìè êàíäèäàòàìè äëÿ
îðãàíîçáåð³ãàþ÷î¿ òàêòèêè ë³êóâàííÿ [15]. Ðå-
òåëüíà â³çóàë³çàö³ÿ ñëèçîâî¿ ñå÷îâîãî ì³õóðà
ãíó÷êèì öèñòîñêîïîì º åôåêòèâíèì ñïîñîáîì
âèÿâëåííÿ ðåöèäèâ³â ï³ñëÿ îðãàíîçáåð³ãàþ÷èõ
õ³ðóðã³÷íèõ âòðó÷àíü ç àä‘þâàíòíîþ õ³ì³î- àáî
ïðîìåíåâîþ òåðàﳺþ.
Âèñíîâîê
Îñíîâíèìè ïîòåíö³éíèìè ïåðåâàãàìè
îðãàíîçáåð³ãàþ÷èõ âòðó÷àíü (ÒÓÐ, ïàðö³àëüíà
öèñòåêòîì³ÿ) â êîìá³íàö³¿ ç àä‘þâàíòíîþ ïîë³-
õ³ì³îòåðàﳺþ ³/àáî ïðîìåíåâîþ òåðàﳺþ º
ïîêðàùåííÿ ÿêîñò³ æèòòÿ õâîðèõ ïðè çàäîâ³ëü-
íèõ áåçïîñåðåäí³õ ³ â³ääàëåíèõ îíêîëîã³÷íèõ
ðåçóëüòàòàõ.

Ñïèñîê ë³òåðàòóðè

1. Muscle-invasive and Metastatic Bladder-Cancer. EAU Guidelines. Edn. presented at the EAU
Annual Congress Barcelona. EAU Guidelines Office, Arnhem. The Netherlands. 2019.
2. Fahmy O., Khairul-Asri M.G., Schubert T. et al. A Systematic Review and Meta-Analysis on the
Oncological Long-Term Outcomes After Trimodality Therapy and Radical Cystectomy With or Without
Neoadjuvant Chemotherapy for Muscle-Invasive Bladder Cancer. Urol Oncol. 2018. Vol. 36, No. 2. P. 43–53.
3. Ploussard G., Daneshmand S., Efstathiou J.A. et al. Critical analysis of bladder sparing with trimodal
therapy in muscle-invasive bladder cancer: a systematic review. Eur. Urol. 2014. Vol. 66. P. 120–137.
4. Ma B., Li H., Zhang C., Yang K. et al. Lymphovascular invasion, ureteral reimplantation and prior
history of urothelial carcinoma are associated with poor prognosis after partial cystectomy for muscle-
invasive bladder cancer with negative pelvic lymph nodes. Eur. J. Surg. Oncol. 2013. Vol. 39. P. 1150–1156.
Doi: 10.1016/j.ejso.2013.04.006.

ÓÊÐÀ¯ÍÑÜÊÈÉ ÍÀÓÊÎÂÎ-ÏÐÀÊÒÈ×ÍÈÉ ÆÓÐÍÀË ÓÐÎËÎÃIÂ, ÀÍÄÐÎËÎÃI ÒÀ ÍÅÔÐÎËÎÃI 203

 5. Capitanio U., Isbarn H., Shariat S.H. et al. Partial cystectomy does not undermine cancer control
in appropriately selected patients with urothelial carcinoma of the bladder: a population-based matched
analysist. Urology. 2009. Vol. 74. Ð. 858–864.
6. Knoedler J., Frank I. Organ-sparing surgery in urology: partial cystectomy. Curr. Opin. Urol. 2015.
Vol. 25. P. 111–115.
7. Knoedler J.J., Boorjian S.A., Kim S.P. et al. Does partial cystectomy compromise oncologic
outcomes for patients with bladder cancer compared to radical cystectomy? A matched case-control
analysis. J. Urol. 2012. Vol. 188. P. 1115–1119.
8. Smaldone M.C., Jacobs B.L., Smaldone A.M., Hrebinko R.L. Long-term results of selective partial
cystectomy for invasive urothelial bladder carcinoma. Urology. 2008. Vol. 72. P. 613–616.
9. Rudel C., Weiss C., Sauer R. Organ preservation by combined modality treatment in bladder
cancer: the European perspective. Semin. Radiat. Oncol. 2005. Vol. 15. P. 28–35.
10. Chiang Y., Cheng J.C., Huang C.Y. et al. A role of multimodality bladder-preserving therapy in
patients with muscle-invasive bladder cancer plus hydronephrosis with or without pelvic nodal involvement.
J Formos Med Assoc. 2017. Vol. 116. P. 689–696.
11. Leibovici D., Kassouf W., Pisters L.L. et al. NCCN Guidelines 2019: Organ preservation for
muscle-invasive bladder cancer by transurethral resection. Urology. 2007. Vol. 70, No. 3. P. 473–476.
12. Mohamed H.À., Salem M.A., Elnaggar M.S. et al. Trimodalities for bladder cancer in elderly:
Transurethral resection, hypofractionated radiotherapy and gemcitabine. Cancer Radiother. 2018. Vol. 22,
No. 3. P. 236–240. Doi: 10.1016/j.canrad.2017.09.013.
13.Giacalone N.,Shi pley W.U.,Clayman R.H. et al.Long-term Outcomes After Bladder-preserving
Tri-modality Therapy for Patients with Muscle-invasive Bladder Cancer: An Updated Analysis of the
Massachusetts General Hospital Experience Eur Urol. 2017. Vol. 71, No. 6. P. 952–960. Doi: 10.1016/
j.eururo.2016.12.020.
14. Holzbeitrlein J.M., Lopez-Corona E., Bochner B.H. et al. Partial cystectomy: a contemporary
review of the Memorial Sloan-Kettering Cancer Center experience and recommendations for patient
selection. J. Urol. 2004. Vol. 172. P. 878–881.
15. Rudel C., Grabenbauer G.G., Kuhn R. et al. Combined-modality treatment and selective organ
preservation in invasive bladder cancer. J Clin Oncol. 2002. Vol. 20, No. 14. P. 3061–3071.

References

1. Muscle-invasive and Metastatic Bladder-Cancer. EAU Guidelines. Edn. presented at the EAU
Annual Congress Barcelona. EAU Guidelines Office, Arnhem. (2019). The Netherlands.
2. Fahmy, O., Khairul-Asri, M.G., Schubert, T., et al. (2018). A Systematic Review and Meta-Analysis
on the Oncological Long-Term Outcomes After Trimodality Therapy and Radical Cystectomy With or
Without Neoadjuvant Chemotherapy for Muscle-Invasive Bladder Cancer. Urol Oncol., 36, 2, 43–53.
3. Ploussard, G., Daneshmand, S., Efstathiou, J.A., et al. (2014). Critical analysis of bladder sparing with
trimodal therapy in muscle-invasive bladder cancer: a systematic review. Eur. Urol., 66, 120–137.
4. Ma, B., Li, H., Zhang, C., Yang, K., et al. (2013). Lymphovascular invasion, ureteral reimplantation
and prior history of urothelial carcinoma are associated with poor prognosis after partial cystectomy for
muscle-invasive bladder cancer with negative pelvic lymph nodes. Eur. J. Surg. Oncol., 39, 1150–1156.
Doi: 10.1016/j.ejso.2013.04.006.
5. Capitanio, U., Isbarn, H., Shariat, S.H., et al. (2009). Partial cystectomy does not undermine cancer
control in appropriately selected patients with urothelial carcinoma of the bladder: a population-based
matched analysist. Urology, 74, 858–864.
6. Knoedler, J., & Frank, I. (2015). Organ-sparing surgery in urology: partial cystectomy. Curr. Opin.
Urol., 25, 111–115.
7. Knoedler, J.J., Boorjian, S.A., Kim, S.P., et al. (2012). Does partial cystectomy compromise oncologic
outcomes for patients with bladder cancer compared to radical cystectomy? A matched case-control
analysis. J. Urol., 188, 1115–1119.
8. Smaldone, M.C., Jacobs, B.L., Smaldone, A.M., & Hrebinko, R.L. (2008). Long-term results of
selective partial cystectomy for invasive urothelial bladder carcinoma. Urology, 72, 613–616.
9. Rudel, C., Weiss, C., & Sauer, R. (2005). Organ preservation by combined modality treatment in
bladder cancer: the European perspective. Semin. Radiat. Oncol., 15, 28–35.

204 ÓÊÐÀ¯ÍÑÜÊÈÉ ÍÀÓÊÎÂÎ-ÏÐÀÊÒÈ×ÍÈÉ ÆÓÐÍÀË ÓÐÎËÎÃIÂ, ÀÍÄÐÎËÎÃI ÒÀ ÍÅÔÐÎËÎÃIÂ

 10. Chiang, Y., Cheng, J.C., Huang, C.Y., et al. (2017). A role of multimodality bladder-preserving
therapy in patients with muscle-invasive bladder cancer plus hydronephrosis with or without pelvic
nodal involvement. J Formos Med Assoc., 116, 689–696.
11. Leibovici, D., Kassouf, W., Pisters, L.L., et al. (2007). NCCN Guidelines 2019: Organ preservation
for muscle-invasive bladder cancer by transurethral resection. Urology, 70, 3, 473–476.
12. Mohamed, H.À., Salem, M.A., Elnaggar, M.S., et al. (2018). Trimodalities for bladder cancer in
elderly: Transurethral resection, hypofractionated radiotherapy and gemcitabine. Cancer Radiother., 22, 3,
236–240. Doi: 10.1016/j.canrad.2017.09.013.
13. Giacalone, N., Shi pley, W.U., Clayman, R.H., et al. (2017). Long-term Outcomes After Bladder-
preserving Tri-modality Therapy for Patients with Muscle-invasive Bladder Cancer: An Updated Analysis of
the Massachusetts General Hospital Experience Eur Urol., 71, 6, 952–960. Doi: 10.1016/j.eururo.2016.12.020.
14. Holzbeitrlein, J.M., Lopez-Corona, E., Bochner, B.H., et al. (2004). Partial cystectomy: a contemporary
review of the Memorial Sloan-Kettering Cancer Center experience and recommendations for patient
selection. J. Urol., 172, 878–881.
15. Rudel, C., Grabenbauer, G.G., Kuhn, R., et al. (2002). Combined-modality treatment and selective
organ preservation in invasive bladder cancer. J Clin Oncol., 20, 14, 3061–3071.

Ðåôåðàò Summary

Î Ð Ã À Í Î Ñ Î Õ Ð À Í ß Þ Ù Å Å
ÊÎÌÏËÅÊÑÍÎÅ ËÅ×ÅÍÈÅ ÁÎËÜÍÛÕ
ÌÛØÅ×ÍÎ-ÈÍÂÀÇÈÂÍÛÌ ÐÀÊÎÌ
ÌÎ×ÅÂÎÃÎ ÏÓÇÛÐß
Ñ.À. Âîçèàíîâ, Â.Ñ. Ñàêàëî,
Ç.Â. Ãàöåðåëèÿ, Â.Â. Ìðà÷êîâñêèé,
À.Â. Ñàêàëî, Þ.Þ. Êóðàíîâ,
À.Â. Êîíäðàòåíêî, Ï.Í. Ñàëèé,
ß.Â. Ëåâ÷èøèí, Á.Ì. Íàâðîöêèé
Öåëü. Óëó÷øèòü íåïîñðåäñòâåííûå è îòäà-
ëåííûå îíêîëîãè÷åñêèå ðåçóëüòàòû è êà÷åñòâî
æèçíè áîëüíûõ ìûøå÷íî-èíâàçèâíûì ðàêîì
ìî÷åâîãî ïóçûðÿ ïóòåì îáîñíîâàíèÿ ïîêàçàíèé
ê âûáîðó îðãàíîñîõðàíÿþùèõ îïåðàòèâíûõ
âìåøàòåëüñòâ ñ àäúþâàíòíîé õèìèîëó÷åâîé
òåðàïèåé.
Ìàòåðèàëû è ìåòîäû. Ïðîâåäåí ðåòðîñïåê-
òèâíûé àíàëèç 120 èñòîðèé áîëåçíè ïàöèåíòîâ.
42 ïàöèåíòàì âûïîëíåíà öèñòýêòîìèÿ, 78 – ïàð-
öèàëüíàÿ öèñòýêòîìèÿ ñ àäúþâàíòíîé ÕÒ èëè
ëó÷åâîé òåðàïèåé. Ïàöèåíòû áûëè ðàñïðåäåëå-
íû íà 3 ãðóïïû. Ïðè ñðàâíèòåëüíîì àíàëèçå
èññëåäóåìûõ ãðóïï áûëà ïðîâåäåíà îöåíêà îí-
êîëîãè÷åñêèõ ðåçóëüòàòîâ ëå÷åíèÿ.
Ðåçóëüòàòû. Ïàöèåíòû, ïåðåíåñøèå ÷àñòè÷-
íóþ öèñòýêòîìèþ (ðåçåêöèþ ìî÷åâîãî ïóçû-
ðÿ) ñ àäúþâàíòíîé õèìèîòåðàïèåé, ïðîäåìîí-
ñòðèðîâàëè ñðàâíèòåëüíî ëó÷øèå îòäàëåííûå
îíêîëîãè÷åñêèå ðåçóëüòàòû ñ äðóãèìè äâóìÿ
ãðóïïàìè íà 15%. Ñðåäíÿÿ ïðîäîëæèòåëüíîñòü
íàáëþäåíèÿ ñîñòàâëÿëà 6 ëåò. Ïðè îöåíêå îíêî-
ëîãè÷åñêèõ ðåçóëüòàòîâ ïðèäåðæèâàëèñü óêàçà-
íèé Åâðîïåéñêîé àññîöèàöèè óðîëîãîâ äëÿ ïà-
öèåíòîâ ñ ìûøå÷íî-èíâàçèâíûì ðàêîì ìî÷å-
ORGAN-SPARING MULTIMODALITY
TREATMENT IN MUSCLE-INVASIVE
BLADDER CANCER
S.O. Vozianov,V.S. Sakalo,
Z.V. Gatserelia, V.V. Mrachkovskyi,
A.V. Sakalo, Yu.Yu. Kuranov,
A.V. Kondratenko, P.M. Salii,
Ya.V. Levchyshyn, B.M. Navrotskyi
Goal. Improving short- and long-term
cancer outcomes, quality of life, and reduce
complication rate after treatment of patients with
muscle-invasive bladder cancer by justifying the
indications for organ-sparing surgery with
adjuvant chemotherapy.
Materials and methods. A retrospective analysis
of 120 patients who underwent organ-sparing surgery
was performed. Patients were divided into 3 groups.
In the comparative analysis of the studied groups,
the assessment of oncological results, quality of life
and postoperative complications
Results. Patients who underwent partial
cystectomy of bladder with adjuvant chemotherapy,
showed better in comparison to two other groups
remote oncological results by 20%. The mean follow-
up was 6 years. The evaluation of oncological results
was performed due to the guidelines of the European
Association of Urology for patients with MIBC after
organ-preserving multimodality treatment. Indicators
of erectile function and quality of life in the main
group were better than in two other groups.
Conclusions. The presented results of the study
suggest that organ-preserving treatment with chemo-
radiation therapy of muscle-invasive bladder cancer
is an alternative method of treatment.

ÓÊÐÀ¯ÍÑÜÊÈÉ ÍÀÓÊÎÂÎ-ÏÐÀÊÒÈ×ÍÈÉ ÆÓÐÍÀË ÓÐÎËÎÃIÂ, ÀÍÄÐÎËÎÃI ÒÀ ÍÅÔÐÎËÎÃI 205

âîãî ïóçûðÿ ïîñëå îðãàíîñîõðàíÿþùåãî êîìï- Keywords: organ-preserving treatment,
ëåêñíîãî ëå÷åíèÿ. muscular-invasive bladder cancer, chemoradiation
Âûâîäû. Ïðåäñòàâëåííûå ðåçóëüòàòû èñ- therapy.
ñëåäîâàíèÿ ñâèäåòåëüñòâóþò î òîì, ÷òî îðãàíî-
ñîõðàíÿþùåå ëå÷åíèå ìûøå÷íî-èíâàçèâíîãî
ðàêà ìî÷åâîãî ïóçûðÿ â ñî÷åòàíèè ñ õèìèîëó-
÷åâîé òåðàïèåé ÿâëÿåòñÿ àëüòåðíàòèâíûì ìåòî-
äîì ëå÷åíèÿ.
Êëþ÷åâûå ñëîâà: îðãàíîñîõðàíÿþùåå
ëå÷åíèå, ìûøå÷íî-èíâàçèâíûé ðàê ìî÷åâîãî
ïóçûðÿ, õèìèîëó÷åâàÿ òåðàïèÿ.

Àäðåñà äëÿ ëèñòóâàííÿ

Ç.Â. Ãàöåðåë³ÿ
E-mail: zurab2930@gmail.com

Íàä³éøëà 31.07.2020.
Àêöåïòîâàíà 02.09.2020.

206 ÓÊÐÀ¯ÍÑÜÊÈÉ ÍÀÓÊÎÂÎ-ÏÐÀÊÒÈ×ÍÈÉ ÆÓÐÍÀË ÓÐÎËÎÃIÂ, ÀÍÄÐÎËÎÃI ÒÀ ÍÅÔÐÎËÎÃIÂ