At the present time tactics of surgical treatment of patients with bladder and kidney cancer and severe concomitant cardiovascular diseases is debatable. The indications for simultaneous operation or stage tactics of surgical treatment including the sequence of surgical interventions are still discussing [1-20].

The problem of surgical tactics in patients with bladder and kidney cancer in combination with abdominal aortic aneurysm is discussed in most number of publications. The frequency of oncourological diseases in patients with abdominal aortic aneurysm is 0.44-6.9% in according to different authors' data. But small number of published observations does not allow to determine surgical tactics uniquely in these patients [6, 10, 11, 16, 19].

Like this some authors report about safe simultaneous operation through one surgical access with minimal number of complications in case of kidney cancer and infrarenal aortic aneurysm. Herewith aortic surgery is performed primary because it excludes aortic rupture during oncological surgery. The risk of kidney cancer progression between surgical stages, need for repeated anesthesia and surgery are absent in this tactics. At the same time in some observations sequential tactics was preferable. Surgery for aortic aneurysm was performed primary because of its' life-threatening character especially in case of aortic dissection. Operation for kidney cancer was carried out in case of small size and asymptomatic aneurysm in some observations. Sequential tactics was differ insignificantly from one-stage interventions with less number of postoperative complications and low mortality [4, 6, 13, 15, 19].

Some authors prefer simultaneous operation in case of combination of bladder cancer and infrarenal aortic aneurysm. In most patients surgery for aortic aneurysm was performed primary for exclusion of aortic rupture during cystectomy. In some cases radical cystectomy with pelvic lymphadenectomy and ureterostomy without intestinal reservoir was performed primary for decreasing of risk of aortic prosthesis infection. Aortic replacement was carried out secondarily. At the same time other authors preferred sequential tactics with primary aortic surgery because of technical difficulties and risk of aortic prosthesis infection. Such approach excluded aortic prosthesis infection because of fibrosis development at the time of cystectomy. Also it excluded aneurysm rupture during oncological operation. At the same time authors reported about adhesive process in abdominal cavity after first operation, difficulties during ureters preparation and pelvic lymphadenectomy in case of delayed operation [3, 8, 9, 14, 18].

In recent years use of endovascular aortic stenting for aortic aneurysm decreased traumatism of surgery and time lag between surgical stages in case of comorbidities. But the issue of indications for this surgery in oncourological patients remains open because of small number of observations [9, 10, 12, 17, 20].

It is still discussed medical tactics in patients with bladder or kidney cancer in combination with severe ischemic heart disease or valvular defect. Need for two operations in different anatomical areas and through various surgical accesses including cardiopulmonary bypass during cardiosurgical stage brings up a question about expediency of one-stage operations. At the same time simultaneous operations were performed with small number of complications and minimal mortality in some observations according to some authors' data. Cardiosurgical interventions without cardiopulmonary bypass for example CABG by using of off pump-technique decreased severity of cardiovascular stage. Also it decreased risk of one-stage surgical treatment of patients with comorbidities [1, 2, 5, 7].

Thus there is small number of observations in literature, absence of single opinion about surgical tactics in patients with bladder and kidney cancer on background of severe concomitant cardiovascular diseases. According to this fact we presented our experience of treatment of these patients.

Fifteen patients with kidney cancer and 2 patients with bladder cancer and severe concomitant cardiovascular diseases have been examined and cured in Institute of clinical oncology of Russian Cancer Research Center them.N.N.Blokhin for the period from 1998 to 2012.

Age of patients with kidney cancer was from 39 to 80 years (on the average 62.2 years) and from 56 to 67 years in patients with bladder cancer (on the average 61.5 years). All patients were male.

Kidney or bladder tumor was detected during physical examination or planning of surgical treatment for cardiovascular diseases in 64.7% of patients. Severity of cardiovascular disease was determined during preparation for surgical treatment of kidney or bladder cancer in 23.5% of patients. Aortic aneurysm was revealed during surgery for kidney cancer in 11.8% of patients or kidney cancer and aortic aneurysm were diagnosed during physical examination for gastro-intestinal bleeding.

The tumor was localized in left kidney in 8 (53.3%) patients, in right kidney - in 7 (46.7%) patients.

In 9 (60%) cases tumor was diagnosed in upper pole of kidney. Complicated neoplastic process was revealed in 4 (26.7%) patients.

Tumor lysis and macroscopic hematuria were observed in 3 cases including 1 patient with neoplastic thrombosis of renal vein. Neoplastic thrombosis of inferior vena cava to the level of diaphragm was detected in

1 patient. Cancer of single left kidney was observed in 1 patient. It was diagnosed exophytic tumor in both patients with bladder cancer. In one observation tumor was localized on the lateral, posterior walls and neck of urinary bladder. In another case tumor was detected only on left lateral wall of urinary bladder. Herewith bladder cancer was associated with macroscopic hematuria in the first patient and with microscopic hematuria - in the second patient.

Renal cell carcinoma was observed in 13 (86.7%) patients, transitional cell cancer of pelvis - in 1 (6.7%) patient. Morphological variant of tumor was not defined in one patient who was not operated for kidney cancer. Tumor anaplasia of the II degree was revealed in 12 (80%) patients. Transitional cell cancer of the II and III degrees was observed in both observations with bladder cancer.

Kidney cancer I stage was mainly recognized in 8 (53.3%) patients, stage IV - in 4 (26.7%) patients, stage III - in 2 (13.3%) patients and stage II - in 1 (6.7%) patient (table 1).

Bladder cancer confirmed to the first (Pt1N0M0) and the second (pT2N0M0) stages.

Severe concomitant cardiovascular diseases in patients with kidney and bladder cancer were presented by coronary artery disease (CAD) in 9 (52.9%) of 17 patients, aortic aneurysm - in 6 (35.3%) cases. Combination of coronary artery disease with Leriche syndrome was observed in 1 patient and with significant stenosis of internal carotid artery - also in 1 (5.9%) patient.

At the time of surgery angina pectoris functional classes III-IV was revealed in 3 (33.3%) of 9 patients with kidney and bladder cancer, unstable angina - in 2 (22.2%) patients. Angina pectoris functional class III, painless myocardial ischemia (PMI), stable angina pectoris functional class II or combination PMI with angina pectoris functional class II were presented by 1 (11.1%) patient. All patients with with kidney and bladder cancer and severe concomitant CAD had myocardial infarction in anamnesis. One infarction was in 6 (66.7%) of 9 cases, recurrent myocardial infarction - in 3 (33.3%) patients. Time limitation of the last myocardial infarction varied from 0.8 month to 6 years. All patients had significant lesion of coronary arteries including single-vessel - in 1 patient, two-vessel - in 2 patients, three-vessel - in 4 patients, four-vessel - in 1 patient and six-vessel - in 1 patient. It was revealed critical stenosis of anterior interventricular artery in 8 (88.9%) of 9 patients. At the same time critical stenosis of anterior interventricular artery was combined with critical stenosis of left coronary artery trunk in one of them.

Five patients (55.6%) had coronary arteries lesions of the first level. Four patients had target affected arteries of the first and the second levels. Aortic aneurysm in patients with kidney and bladder cancer was localized in thoracic (1 case) and abdominal (5 cases) parts. Posttraumatic aneurysm with diameter 8 cm in descending thracic aorta was placed distal to the left subclavian artery. There were not clinical symptoms of aneurysm in this case. Abdominal aortic aneurysm was located below mouths of renal arteries in all 5 patients. Dissecting aneurysm with diameter more than 10 cm has been complicated by fistula with inferior vena cava and dissection of renal arteries intima in 1 observation. Aneurysm was accompanied by intensive lumbar pain spreading in inguinal region. In other 4 patients there was asymptomatic infrarenal aortic aneurysm with diameters 4, 5, 5.2 and 6.2 cm.

2 (11.8%) of 17 patients with kidney cancer had a combination of significant stenoses of coronary arteries with stenosis of left internal carotid artery 80% and right internal carotid artery 60% accompanied by chronic cerebral ischemia. And one patient had CAD with Leriche syndrome, occlusion of both superficial femoral arteries and ischemia of lower extremities II stage. In the first patient CAD was characterized as stable angina pectoris I functional class with significant stenoses of 2 coronary arteries of the first and second levels. He underwent three myocardial infarctions. Stenosis of left internal carotid artery 80% was determined by ulcerated atherosclerotic plaque. The second patient had angina pectoris III functional class with six-vessel critical lesion of coronary arteries of the first and second levels including left coronary artery trunk. He complained to symptoms of intermittent claudication through 100 m.

Signs of multifocal atherosclerosis were diagnosed in 15 (88.2%) of 17 patients with kidney and bladder cancer. Preferred lesion of brachiocephalic arteries was revealed in 10 (58.8%) of 17 cases and lesion of iliac arteries - in 9 (52.9%) of 17 patients.

15 patients were operated for kidney and bladder cancer with severe concomitant cardiovascular diseases. Simultaneous operations were performed in 3 (20%) patients. A consistent strategy was applied in 12 (80%) patients including 1 (6.7%) case with simultaneous aorta-femoral bypass surgery and nephroureterectomy after preliminary CABG. Surgery for kidney cancer was not performed in 2 (11.8%) of 17 cases because of death after CABG or disclaimer operation after carotid arteries stenting.

Performed operations are presented in table 2.

In patient K., 63 years old, aortic aneurysm and kidney tumor were diagnosed by using of computer tomography during physical examination for recurrent gastro-intestinal bleeding in 2008. It was revealed saccular aneurysm of infrarenal aorta 40 mm distal to mouths of renal arteries with width 52 mm and length 60 mm. An aneurysm extended to the bifurcation.

It was detected tumor with diameter to 1.5 cm in middle one-third of left kidney and node with diameter about 1.5 cm in left epinephros. Such signs did not permit to exclude left kidney cancer with metastases in left epinephros (fig. 1 on colored inset).

In view of absence of another severe concomitant diseases and possibility of surgery through one access for both diseases with minimal risk of purulent complications the decision about simultaneous operation was taken. The patient was operated 09.02.09 in thoracic department of Russian Cancer Research Center. Aorta replacement was performed as the first stage because of risk of aneurysm back wall rupture. After midline laparotomy mesentery with intestine were taken up. Infrarenal abdominal aorta with aneurysm diameter 6 cm were extracted (fig. 2 on colored inset).

Aorta was mobilized above aneyrysm and 1 cm distal to mouths of renal arteries. Right and left common iliac arteries were extracted. It was performed aorta and iliac arteries cross-clamping after previous introduction of heparin 5000 ED. Aneurysmal sac was dissected longitudinally. Parietal thrombus was removed. It was performed bifurcational replacement with forming of distal anastomoses after proximal anastomosis. Duration of ischemia was about 1 hour, right branch of prosthesis was open in 40 minutes.

Prosthesis was covered with walls of aneurysmal sac. It was used bifurcational «Intervascular» silver-coated prosthesis. Then parietal peritoneum was dissected along the descending colon. Left kidney was mobilized on the lateral and back walls. Renal vena and artery, suprarenal vessels were extracted, tied up and cut. Ureter was tied up and cut. It was performed left-side nephradrenalectomy, hemostasis. The drainage was installed in removed kidney bed (fig. 3 on colored inset).

Duration of surgery was 4 hours and 30 minutes including 2 hours for aortic replacement and 40 minutes for nephradrenalectomy. Blood loss was 3,500 l.

Gastric bleeding from multiple erosions developed on the 10th day of postoperative period. It was stopped by using of therapy. The patient was discharged in satisfactory condition on the 21 day after surgery. Histological study showed subcapsular kidney tumor with diameter 1.7 cm. The tumor had solid-cystic structure of renal cell carcinoma II degree of anaplasia without infiltration of renal capsule and perirenal tissue. It was revealed nodal cortical hyperplasia in epinephros. Kidney cancer prevalence conformed to pT1aN0M0 (stage I).

Patient is observed without signs of kidney cancer progression and symptoms of concomitant cardiovascular diseases for 57.2 months after surgery.

It was performed CABG in six patients with severe concomitant cardiovascular diseases by using of stage tactics. Coronary angioplasty with stenting were used in 2 patients, resection of dissecting aneurysm of abdominal aorta and iliac arteries with aorta-femoral bifurcational replacement including prosthetics of renal arteries and inferior vena cava defect suturing - in 1 patient. One patient was operated with linear replacement of abdominal aorta. Internal carotid arteries stenting was done in 1 case. Endovascular aorta replacement was applied in 2 cases.

Nephrectomy was performed in 6 patients with kidney cancer. Kidney resection was done in 2 cases. Bilobectomy with palliative nephrectomy are used in 1 observation. Prostatectomy with cystureterectomy, pelvic lymphadenectomy, appendectomy, Bricker's operation and transurethral resection of bladder were applied in case of bladder cancer.

Cardiovascular stage was performed primary in case of consistent strategy in 10 patients. Primary surgery for kidney cancer and subsequent coronary angioplasty with stenting were done in 1 patient. Time domain was from 0.7 to 6.7 months (on the average 3.2 months).

Patient K., 71 years old, got head injury, chest injury and complicated fracture of right tibia in an accident

40 years ago. Lungs fluoroscopy showed expansion of aorta shadow and echocardiography revealed expansion of descending aorta to 4.5 cm about 15 years ago. The patient was not examined and treated. It was diagnosed left kidney tumor and central cancer of lung (?) during survey for urinary retention and low grade temperature in 2009. The patient was hospitalized in thoracic department of RCRC for surgical treatment. Tumor of left kidney lower pole with diameter to 8 cm and tumor of right lung intermediate bronchus complicated by middle and lower lobe atelectasis were diagnosed by using of X-ray imaging and CT-angiography. Moreover it was diagnosed descending aorta aneurysm with diameter to 8 cm. It was located distal to the mouth of left subclavian artery (fig. 4 on colored inset).

Bronchoscopy identified obturating exophytic tumor of intermediate bronchus. Cytological examination of biopsy material revealed carcinoid cells.

In view of aneurysm big sizes and high risk of rupture we made a decision about aortic surgery as a first stage. Descending aorta replacement was impossible because of middle and lower lobe atelectasis of right lung. In this connection descending aorta aneurysm stenting was performed 25.02.10 as a first stage.

Surgical access was done via femoral artery. System Valiant TF3838C200X was installed beginning at left subclavian artery mouth. Control angiography detected off the aneurysm of main flow, the main flow through the thoracic part unchanged. There were not any complications in postoperative period. The patient was discharged at the 4^th day after surgery in a satisfactory condition. Right-side lower bilobectomy was performed 19.04.10 over 1.8 years after aorta stenting in thoracic department of RCRC. There were not any complications in postoperative period. The patient was discharged at the 10^th day after surgery. Histological study revealed renal cell carcinoma metastasis II degree of anaplasia invading the wall of bronchus and bifurcational lymph node. There were renal cell carcinoma metastases in parenchyma of upper lobe of right lung. Left-side palliative nephrectomy was performed 12.07.10 as the second stage in RCRC. There were not any complications in postoperative period. The patient was discharged at the 9^th day after surgery. It was diagnosed tumor with sizes 8×7×5.5 cm and structure of renal cell carcinoma without metastases in lymph nodes during histological study. Such structure conformed to IV stage (pT2aN0M1). Multiple courses of immunotherapy were applied in future. The patient died of kidney cancer progression over 39.1 months after surgical treatment. It was observed metastases in bones.

Complications in intra- and postoperative periods developed in 9 (52.9%) of 17 patients. 2 (11.8%) of 17 patients died.

Complications in intra- and postoperative periods developed only in 1 (25%) of 4 patients in case of simultaneous operations. There were not deaths. Gastric bleeding from multiple erosions developed at 10^th day in patient after bifurcational replacement of abdominal aorta for infrarenal aneurysm and left-side nephradrenalectomy. Bleeding was stopped by using of therapy. The patient was discharged at the 21st day after surgery in satisfactory condition.

In case of consistent strategy complications in intra- and postoperative periods developed in 8 (57.1%) of 14 patients. 2 (14.3%) of 14 patients died including case of CABG before simultaneous surgery. Complications during cardiovascular stage were diagnosed in 4 (28.6%) of 14 patients with death in 1 (7.1%) case. Complicated intra- and postoperative periods were revealed in 5 (45.5%) of 11 patients after surgery for kidney or bladder cancer. 2 patients were not operated for kidney cancer because of death after CABG in one case and waiver of operation in other case. 4 patients were operated simultaneously. 1 (9.1%) of 11 patients died. On both stages complications developed in 1 (9.1%) of 11 cases.

Complications of cardiovascular stage are presented by thrombosis of right renal artery prosthesis with development of renal failure in 1 patient, myocardial infarction with death in other patient and macroscopic hematuria or renal failure in 2 patients.

Postoperative period after surgery for kidney or bladder cancer was complicated by renal failure in one patient, in other patient - deep vein thrombosis of lower limbs with following pulmonary embolism. One patient had eventration with need for emergency operation. Pancreatitis, renal and cardiopulmonary decompensation, pulmonary embolism were diagnosed in postoperative period which was an immediate cause of death. Transient myocardial ischemia and paroxysmal atrial fibrillation were diagnosed in 2 patients after surgery.

Thus mortality associated with myocardial infarction or pulmonary embolism was 5.9% in all group of patients with kidney or bladder cancer and severe cardiovascular diseases (1 of 17 patients died). At the same time successful surgical treatment of concomitant CAD and aortic aneurysm allowed to avoid myocardial infarction or aneurysm rupture in all patients operated for kidney or bladder cancer. This fact points on high efficiency of surgical tactics.

7 (50%) of 14 patients died in long-term period. At the same time 2 patients died after surgery and 1 patient with unknown long-term results of treatment were excluded from the analysis. The cause of death in long-term period was tumor progression in 3 (21.4%) of 14 patients, cardiovascular disease - in 2 (14.3%) of 14 cases. The cause of death is unknown in 2 (14.3%) of 14 cases. Other 7 (50%) patients are under observation without signs of kidney or bladder cancer progression and severe concomitant cardiovascular diseases.

Overall 1-, 3-, 5-years survival calculated by the method of Kaplan-Meier was 100, 73.3 and 52.4% respectively (fig. 5).

Both patients with bladder cancer survived 3 years.

One of them was under observation for more than 36.5 months without signs of tumor progression. Other patient died after 70.7 months because of unknown reason.

Thus surgical treatment of severe concomitant CAD and aortic aneurysm is effective method for prevention of myocardial infarction or aneurysm rupture during and after cancer surgery in patient with kidney and bladder cancer. Simultaneous operations were performed safely in selected patients. Overall 3- and 5-years survival were 73.3 and 52.4% respectively.