Pneumatic wedge gripper (wedge grip) with manual retraction of the PKR-560 type drive (PKR-560 M, PKR-560 MU, PKR-560 MOR) is designed for mechanized gripping in the rotor of tubing, drilling, heavy-duty and casing pipes, as well as for transferring rotation from the rotor to the drill string and cleaning the outer surface of the pipes.

The PKR-560 wedge gripper is used in drilling rigs of BU2000, BU2500, BU3000, BU4000, BU5000, BU6500 classes, equipped with a rotor with a 560mm bore.

The PKR-560 wedge grip consists of a sleeve, two conical bushings, wedges with dies. The bush and liners are stationary relative to the table, and the wedges with dies can move along the inclined grooves of the liner. When moving downward, the wedges slide along the inclined grooves of the insert and approach in the radial direction. Under the action of the radial force arising in the wedges from the column's own weight, the dies clamp the pipe, and the column is held in the rotor; to release the clamped pipe, the wedges move upwards simultaneously with the pipe string being lifted by the hook.

The PKR-560 wedge grip is driven by a pneumatic cylinder fixed to the rotor frame bracket. The rod of the pneumatic cylinder is connected to the short arm of the lever, the long arm of the lever at the end has a fork-like shape and is put on the rollers of the annular frame, with which the posts are connected, moving in the vertical guide grooves of the bushing.

The upper ends of the struts in the PKR-560 wedge grip are reinforced in the traverse, which is connected by levers to the wedges; under the action of compressed air supplied to the piston cavity of the pneumatic cylinder, the piston rod turns the lever counterclockwise, while the annular frame, together with the struts, traverse and levers, move upward and raise the wedges. The reverse movement of the wedges in the PKR-560 is carried out when compressed air is supplied to the rod cavity of the pneumatic cylinder and the lever is turned clockwise. The levers provide radial movement of the wedges when they are raised and lowered.

The weight of the drill string held by the PKR-560 wedge gripper is limited by the permissible contact pressure between the rams and the pipe body. To reduce contact pressures, use elongated wedges and special dies that cover the pipe with a minimum gap between their longitudinal ends. In some designs, 6 wedges are used instead of 3, which contributes to a more even distribution of contact pressure.

At the request of the customer, the PKR-560 wedge is equipped with a 140-146 mm wedge with 60, 73, 89, 102, 114, 127, 140, 146 mm dies, 12 of each size, or a 168-178 mm wedge with 168, 178 mm dies 12 pcs. every size.

Scheme of wedge grip PKR-560 (PKR-560 M):

2.1 PURPOSE OF THE PNEUMATIC WEDGE

CAPTURE PKR-560

The purpose of the complex

The set of equipment for working with pipes is designed for screwing, unscrewing, holding on weight, storing, feeding and ejecting pipes. This complex includes the following mechanisms and equipment: a rotor with a roller insert and a pneumatic wedge grip PKR 560 M, an auxiliary winch LV, an automatic drilling wrench, stationary AKB-ZM2, a pneumatic pendant wrench PBK-4, machine wrenches with pneumatic spark plug breakers, PRS and a receiving bridge with shelving. On drilling rigs BU 2900/175 DEP and BU 2900/200 EPK-BM, two types of rotors are used: R-560 (Figure 1) and R-360.

Purpose and design of the R-560 rotor

The rotor is designed to transfer rotation to the drill pipe string during drilling, fishing operations, to sense the reactive moment while drilling with downhole motors and to support the pipe weight on the table during tripping and lowering of the casing string.

1, 13 - body; 2, 18 - ball bearing; 3 - table; 4 - wheel;

5 - roller insert; 6 - roller; 7 - flooring; 8 - gear wheel;

9 - filler neck; 10 - roller bearing; 11, 24, 25 - gasket;

12 - drive shaft; 14 - sealing ring; 15 - cork;

16 - ball shut-off valve; 17, 19, 26, 30 - bolt; 20 - bar;

21 - insert; 22- covers; 23 - nut; 27 - handle; 28, 29 - arrow;

Figure 1. Rotor R-560

The rotor housing (Figure 1) is the main part on which all other parts are mounted. It perceives and transfers to the base of the drilling rig all loads arising during drilling and during tripping operations.

Pneumatic wedge gripper PKR-560

Pneumatic wedge grip bracket PKR-560 (Figure 2) is bolted to the rotor body.

Specifications

Pneumatic wedges are installed in the rotor, serve to grip the pipes and keep them from turning. Pneumatic wedges can be in two versions: with manual drive retraction or with mechanized retraction. The housing is installed in the hole of the rotor table. WITH outside the body has four vertical slots that serve as a guide for guide strips associated with the ring.

Liners with a centralizer are installed in the inner hole of the body, which are sockets for wedges. Wedges, pivotally connected to the holders, are attached last to the upper ends of the guide strips. On the inner surface of the liners there are inclined planes that serve as guides when the wedges move and support when gripping the pipe string. The wedges are equipped with serrated dies that provide a secure grip on the pipes. Three dies are installed in each wedge, with the middle die with longitudinal and transverse notches, and the upper and lower ones with only transverse notches.

The control cylinder is installed on a rotary bracket attached to the rotor. The pneumatic cylinder is fixed on the bracket with an axle. A lever is mounted on the control cylinder bracket, the long end of which is connected to the ring by means of rollers, and the short end to the pneumatic cylinder. With the help of a cylinder and a lever, the ring with the bar and wedges is raised or lowered. The pneumatic cylinder is controlled by a control valve.

I - under the floor of the drilling rig; II - to the receiver of the drilling rig

5 - control cylinder bracket; 6 - control cylinder;

7 - rotary bracket; 8 - lever; 9 - axis; 10 - ring;

11 - stabilizer; 12 - wedge; 13 - holder

Figure 2. Pneumatic wedge gripper PKR 560 M-OP

The pneumatic gripper can be mounted on the rotor if the level of the rotor table surface does not rise above the drilling floor by more than 500 mm, and the rotor beams are extended to more than 780 mm. The installation of the wedge grip must be done with the installation of a bracket with a pneumatic cylinder and a lever. Check the free movement of the pneumatic cylinder along the bracket. The bracket with the pneumatic cylinder is retracted to the extreme left position and fixed with the axle. After that, a housing with guide strips and a ring is installed in the rotor hole. The cylinder bracket is brought to the front position, ensuring that the rollers of the lever fall into the groove of the ring. Connect the air hoses. The guide bars are raised to the upper position and wedges are installed on them. After installing all four wedges, a test lifting and lowering is performed. By turning the control cylinder rod, the wedges in the raised position are set vertically so that the toothed surface is parallel to the gripped pipe.

Among the primary tumors of the kidney it is necessary to distinguish

• renal cell carcinoma (RCC) developing from the epithelium of the tubules and collecting ducts of the kidney, and
• malignant tumors of the collecting system of the kidney (renal pelvis and calyces) presented mainly by transitional cell carcinoma.

Renal cell carcinoma (RCC) accounts for approximately 2-3% of all malignant neoplasms. Men get sick 1.5 times more often than women. Also, RCC develops more often in the urban population than in the rural population. RCC occurs predominantly in people between the ages of 50 and 70, but it can not be seen in adolescents and young children.

The incidence of RCC in the world is gradually increasing, this increase is approximately 1.5-5.9% per year. In addition, in most countries of the world, there is a slight increase in survival with this pathology. It is believed that the main reason for the increase in the number of cases and the improved prognosis in RCC is the widespread use of ultrasound diagnostic methods, which has been noted in recent decades. This leads to early detection of asymptomatic forms of RCC. Currently, 25-40% of all RCC cases are discovered incidentally. Nevertheless, about 25% of patients already have metastases at the initial treatment, and after surgical treatment of localized and locally advanced forms of renal cell carcinoma, half of the patients develop distant metastases.

Kidney cancer was first described by G. Konig in 1826. Subsequently, in 1855, S.R. Robin and in 1867 W. Waldeyer came to the conclusion that the source of RCC is the epithelium of the kidney tubules. In 1883, P. Grawitz, noting that lipid-rich RCC cells are similar to adrenal cells, concluded that kidney tumors originate from the remains of adrenal tissue. This fundamentally incorrect assumption led to the use of the term "hypernephroma" to refer to these tumors. In addition, RCC is synonymous with Gravitz's tumor and renal adenocarcinoma.

Distinctive features of the RCC from other malignant tumors - an unpredictable course, frequent development of paraneoplastic syndromes, resistance to radiation and chemotherapy, and the possibility of exposure to immunotherapy. In RCC, cases of a long, tens of years stable course of the metastatic process have been described; cases of spontaneous regressions of metastases without any treatment are relatively often observed.

Etiology and pathogenesis

A large number of potential etiological factors have been identified that contribute to the appearance of RCC (viral infections, chemical and industrial hazards, dietary habits). However, epidemiological studies have not shown a significant effect of these factors on RCC. Tobacco smoking is one of the most proven risk factors for RCC.

In smokers, the risk of developing renal cell carcinoma (RCC) increases 1.4-2.3 times compared with nonsmokers. Obesity, especially in women, and abuse of phenacetin-type analgesics are associated with an increased incidence of RCC. With regard to the influence of occupational factors, the risk of this disease is increased among workers in the metallurgical industry, leather production and those who work with asbestos and cadmium.

It should be emphasized that the influence of the above factors is not very large and is not shown in all studies. In patients with end-stage chronic renal failure who are on chronic hemodialysis for a long time, the kidneys undergo cystic degeneration in 35-47% of cases. In the epithelium lining these cysts, renal cell carcinoma (RCC) develops about 30 times more often than healthy people... In addition, genetic factors in the development of RCC are known, manifested in cases of familial kidney cancer. These include von Hippel-Lindau syndrome, familial papillary kidney cancer, and familial clear cell RCC. These cases are characterized by the development of the disease at a young age, bilateral kidney damage and multicentric tumor growth. When studying the first two forms of familial kidney cancer, the role of genetic factors in the development of RCC was elucidated.

Von Hippel-Lindau Syndrome (FGL) is the most common form of familial RCC, inherited in an autosomal dominant manner. Typical manifestations of this syndrome are the development of a clear cell variant of RCC, kidney cysts, pheochromocytomas, retinal angiomas, hemangioblastomas of the brain and spinal cord, cysts, and pancreatic cancer. Genetic studies have shown that the cause of this disease is a mutation in a gene located on the short arm of the 3rd chromosome. It turned out that the discovered FGL gene belongs to a group of suppressor genes and encodes the synthesis of an intracellular protein that plays an important role in the regulation of the cellular response to various damaging factors, such as hypoxia and starvation. The FGL gene mutation has been shown to be present in 25% of sporadic clear cell RCCs.

Familial papillary cancer kidney is not associated with a mutation in the FGL gene. Studies at the US National Cancer Institute have shown that activation of the protooncogene MET, located on the long arm of chromosome 7, is responsible for this form of kidney cancer. The same changes are observed in cases of sporadic papillary RCC.

Pathological anatomy

Macroscopic kidney tumor most often they have a rounded shape and sizes from several millimeters to tens of centimeters, sometimes they take up half abdominal cavity... Decay and cystic degeneration of the tumor are observed in 10-25% of cases, in 10-20% of cases, calcifications are detected in the tumor, located in the thickness of the tumor, in contrast to cysts, where calcifications are located in the periphery. Kidney tumors usually grow slowly, compressing the surrounding parenchyma, resulting in pseudocapsule formation, and stretching the fibrous capsule of the kidney. Germination of the kidney capsule indicates a more unfavorable prognosis and reflects the aggressive nature of the tumor.

Gerot's fascia is very rare in RCC, only in cases of highly malignant tumors. In this case, the tumor can grow into the lumbar muscles, neighboring organs (liver, spleen, pancreas, intestines), vertebral bodies and the side wall of the abdomen. A unique feature of kidney cancer is its tendency to spread through large veins in the form of a tumor thrombus, which is observed in 10% of cases. A tumor thrombus usually fills the lumen of a vein without growing into its wall (floating thrombus), spreads through the bloodstream from the renal vein to the inferior vena cava and can reach the right heart and even the pulmonary artery. Bilateral renal tumors occur in 2-4% of cases. In 10-20% of patients with RCC, multicentric tumor growth is observed, most often with papillary histological variants and hereditary forms of kidney cancer.

In 1993, the previous classification of RCC, which divides tumors into four types - clear cell, granular (dark cell), tubulopapillary, and spindle cell (sarcomatous), was replaced by a new classification based on the achievements of molecular genetic research and the study of hereditary forms of RCC.

According to modern views, there are five variants of kidney cancer:

1. clear cell (typical),
2. papillary,
3. chromophobic,
4. collecting duct cancer and
5. unclassified RCC.

Sarcomatous kidney cancer is a poorly differentiated variant of other histological types.

Kidney cancer options

Clear cell (typical) kidney cancer

Clear cell (typical) kidney cancer accounts for 70-80% of all RCC. In section, these tumors have a characteristic yellowish color, which reflects the high content of lipids in their cells. These tumors are rich in blood vessels (hypervascular). With this variant of kidney cancer, a pathology of the 3rd chromosome or a mutation of the FGL gene is detected in the genotype of tumor cells.

Papillary Renal Cell Carcinoma (RCC)

Papillary RCC occurs in 10-15% of cases. The prognosis for this form of RCC is relatively favorable. In the past, small papillary renal tumors were often classified as renal adenomas. These tumors are characterized by multicentric growth (up to 40%) and poor blood supply (hypovascular picture on the angiogram). Common genetic disorders in this form of kidney cancer are trisomy of the 7th and 17th chromosomes, the loss of the Υ-chromosome, and activation of the MET-protooncogene on the 7th chromosome.

Chromophobic Renal Cell Carcinoma (RCC)

Chromophobic RCC appears to develop from the cortex of the collecting duct. This variant of RCC occurs in 4-5% of cases. Electron microscopy reveals many vesicles containing mucopolysaccharides in the cytoplasm of cells, which makes tumor cells chromophobic. The predictive value of this RCC option has not yet been precisely determined.

Collecting duct cancer

Collecting duct cancer (Bellini) occurs in less than 1% of all RCC cases, predominantly at a young age. These tumors develop from the medulla of the kidney, often the diagnosis is made in advanced stages. Tumors are difficult to treat, which makes the prognosis for this form of RCC poor.

Unclassified cases of kidney cancer

Unclassified cases of kidney cancer that cannot be categorized as RCC are as yet unexplored variants of RCC. Among benign tumors kidney most often occurs oncocytoma, adenoma and angiomyolipoma of the kidney.

Oncocytoma (eosinophilic adenoma) of the kidney

Oncocytoma (eosinophilic adenoma) of the kidney accounts for 3 to 7% of all kidney tumors. Oncocytoma is a round, well-circumscribed tumor, microscopically composed of eosinophilic cells, which is due to the high content of mitochondria in them. A stellate scar is often found in the center of the tumor; angiography reveals the radial course of the arteries in the tumor, which makes it look like a spoked wheel. Despite a good prognosis and a benign course of oncocytoma, cell atypia and invasion of the kidney capsule are sometimes noted. Unfortunately, there are no reliable methods for making a diagnosis of oncocytoma before surgery, so most urologists adhere to aggressive surgical tactics if this disease is suspected.

Small kidney adenomas

Small adenomas of the kidney are found at autopsy in 7-23% of cases. Most often, adenomas are small in size, well limited, homogeneous in cellular characteristics, with a papillary or tubulopapillary structure. Currently, most morphologists agree that there are no reliable morphological and immunohistochemical criteria that would clearly differentiate adenoma and renal cancer. Previously, it was believed that the criterion for the benignity of a tumor is its size less than 3 cm, but later it was shown that up to 5% of such tumors can metastasize. Thus, the diagnosis of renal adenoma is controversial today. Most experts agree that any solid epithelial renal tumor is potentially malignant and should be treated surgically in compensated patients.

Angiomyolipoma (AMJI) of the kidney

Angiomyolipoma (AMJI) of the kidney is a benign tumor consisting of mature adipose, smooth muscle tissue and blood vessels. AML occurs in 0.3% of the population, more often in women. In 20% of cases, AML is detected in patients with tuberous sclerosis, a hereditary disease characterized by dementia, epilepsy, adenomas of the sebaceous glands and the frequent development of multiple AML of the kidneys. AML has a characteristic X-ray picture, which consists in the presence of areas of fat density in the tumor on CT. This picture is almost pathognomonic for AML, although areas of fat have been described in several cases of kidney cancer. On ultrasound examination, the tumor is hyperechoic and gives an acoustic shadow. The course of AML is benign, characterized by slow growth. However, it can be complicated by spontaneous rupture of the tumor and retroperitoneal bleeding, in some cases leading to hemorrhagic shock and death. To determine the indications for the treatment of AML, it is necessary to take into account the fact that small tumors (less than 4 cm in the largest dimension) grow slowly and rarely lead to bleeding, while tumors over 4 cm grow faster and often have a high risk of complications. Therefore, for patients with AML more than 4 cm in the largest dimension, it is advisable to offer removal of the tumor, and in case of smaller tumors, dynamic observation is recommended. When planning an operation, preference should be given to an organ-sparing approach.

Clinical picture

Localization of the tumor in the retroperitoneal space, inaccessible for palpation and capable of accommodating a large volume of tissue, leads to the fact that symptoms associated with local tumor growth occur when the tumor reaches a large size.

Before the advent of imaging techniques in medicine, the diagnosis of RCC could be suspected based on the classic triad of symptoms:

• back pain
• macrohematuria,
• the presence of a palpable tumor.

All these symptoms indicate an advanced stage of RCC and are rare today. More often, individual symptoms that make up the classic triad are determined. Most tumors are now detected incidentally by ultrasound examination, usually performed for nonspecific complaints. All signs of RCC can be divided into local growth, metastatic, and paraneoplastic symptoms. The most often observed gross hematuria, which can appear against the background of complete well-being.

The mechanism of hematuria is associated with tumor growth into the renal cavity system and vascular destruction. Often, after hematuria in the kidney area, acute pains occur due to obstruction of the ureter with blood clots, which disappear after the worm-like blood clots pass with urine. Such a manifestation of the disease in the form of hematuria, complicated by renal colic, makes it possible to establish from which side the kidney is affected.

The characteristic features of hematuria in renal cell carcinoma are:

• sudden onset,
• profuseness,
• intermittent character,
• often painless course,
• the presence of clots (most often worm-shaped),
• the appearance of a sharp pain syndrome after hematuria.

Lumbar pain is the second most common classic symptom of kidney cancer. The pain can be dull in nature, which is associated with stretching of the fibrous capsule of the kidney or compression of the lumbar plexus nerve plexus by the tumor. Acute pain in the lower back, like renal colic, is usually associated with bleeding into the renal pelvis and the formation of clots that prevent the flow of urine. It should be noted that in urolithiasis, gross hematuria can be observed after the onset of pain; in kidney tumors, gross hematuria usually precedes renal colic. The rarest and most late symptom of the classic triad is a palpable tumor, which is also characteristic of a common tumor process. Local tumor growth, leading to compression of the testicular vein, or damage to the renal vein by a tumor thrombus can lead to the development of varicocele on the affected side. The defeat of the IVC by a tumor thrombus contributes to edema in the lower extremities, but this is rare, since, as a rule, collateral blood outflow has time to develop.

Often, kidney cancer is detected in patients seeking help for symptoms associated with the development of metastases. So, with massive damage to the retroperitoneal lymph nodes, lymphostasis can be observed in the lower extremities. In patients with RCC, there is an increase in supraclavicular lymph nodes, bone pain, pathological fractures, and neurological disorders with brain damage.

RCC is distinguished by a high incidence of various paraneoplastic syndromes, which gave reason to call kidney cancer a “therapeutic tumor”. Kidney tumors can develop in large quantities renin, erythropoietin, 1,25 dihydroxycholecalcitriol (vitamin D3), prostaglandins, human chorionic gonadotropin, insulin, various cytokines and other substances that can lead to such phenomena as hypercalcemia, hyperthermia, erythrocytosis, hypertension, anemia, cahexia coagulopathy and liver dysfunction, not associated with its metastatic lesion (Stauffer's syndrome). All these conditions are stopped after radical removal of the tumor. The return of these symptoms, as a rule, indicates a relapse of the disease or the development of distant metastases.

Renal cell carcinoma (RCC) diagnostics

The tasks of examining a patient with a presumptive diagnosis of renal cell carcinoma (RCC) include X-ray confirmation of the diagnosis of kidney cancer, assessment of the extent of the tumor and, in the case of planning surgical treatment, assessment of the function of the contralateral kidney. The examination program includes the determination of a number of laboratory parameters, the use of ultrasound, X-ray and radioisotope imaging methods and, in rare cases, a puncture biopsy of the tumor.

Among the laboratory parameters when examining a patient with RCC, the most important are the level of creatinine in the blood, which reflects the total renal function; the level of alkaline phosphatase, which rises in the presence of metastases in the liver and bones of the skeleton; and the level of calcium in the blood, which often rises in RCC and causes the development of the paraneoplastic syndrome, which complicates the course of the disease.

Most kidney tumors are detected by ultrasound, which is screening for this pathology. The diagnosis is confirmed by computed tomography of the abdomen with or without contrast enhancement bolus. Additional research methods (magnetic resonance imaging, renal angiography, inferior venacavagraphy and tumor biopsy) are rarely used for limited indications.

Contrast-enhanced CT is best for assessing the local extent of the tumor, the condition of the regional lymph nodes, the venous system, and the abdominal organs. Lung health is assessed by x-ray chest... Bone scintigraphy, X-ray of the bones of the skeleton, CT of the brain are performed according to indications in the presence of symptoms characteristic of a possible damage to these organs.

The presence of contralateral kidney function can be determined by contrast-enhanced CT or excretory urography or radioisotope renography is used for this purpose.

Excretory urography

Excretory urography was widely used to diagnose kidney cancer in the days preceding the widespread use of ultrasound and CT. Signs of a kidney tumor are an increase in the shadow of the kidney, its rotation and displacement by the tumor, deformation of the calyx-pelvis system and amputation of the calyces. The diagnostic significance of such signs is insufficient, since they are observed only in large tumors, and can also occur in benign pathology. Today, excretory urography is of greatest importance as a method for assessing the function of the contralateral kidney.

Ultrasound examination (ultrasound)

Ultrasound examination (ultrasound) is currently widely used as a screening method for suspected kidney tumor or nonspecific back pain. The advantages of this research method are its low cost, availability, non-invasiveness, and absence of radiation exposure. Ultrasound can clearly differentiate a simple kidney cyst from a solid tumor or suspicious lesion that requires further examination with CT. The characteristic echographic signs of a malignant neoplasm of the kidney are the unevenness of the contours of the tumor formation, reduced echogenicity, heterogeneity of the structure due to the presence of cystic areas and calcifications. Often, with a large tumor, a hypoechoic area is found in its center, which is a zone of necrosis. Cystic tumors can have irregular thick walls and echo-dense nodules different sizes in the walls of the cyst. It is believed that ultrasound is less reliable than CT, because visualization of the tumor can be difficult due to its shielding by the ribs or in obese patients, whose retroperitoneal lymph nodes are often poorly visualized due to gas contained in the intestine. In addition, the results of the study largely depend on the qualifications of the doctor performing the ultrasound. With ultrasound, the inferior vena cava and the right heart are well visualized, which makes it possible to reliably determine the upper border of the tumor thrombus in RCC.

Computed tomography (CT)

Computed tomography (CT) is currently the treatment of choice for the diagnosis and staging of RCC. CT can differentiate kidney cancer and angiomyolipoma based on the detection of areas of fatty density in the tumor. Using a bolus of contrast agent helps differentiate kidney cancer and complex cysts. In addition, CT can assess the condition of the retroperitoneal lymph nodes, renal and inferior vena cava, liver, adrenal glands, lungs and mediastinum. In a native, non-contrast study, tumors are visualized as a solid mass with a heterogeneous structure and areas of liquid density (decay) and calcifications in the center of the tumor. Assessment of CT scans usually requires the administration of a contrast agent. After native scanning and determination of the zone, 100-150 ml of iodine contrast agent is injected intravenously at a rate of 3 ml / s, after which the study is repeated. At the same time, there is an increase in the image at the beginning of the cortical layer of the kidney, then the cerebral and finally filling the renal calyx-pelvic system with contrast. Bolus contrast enhancement leads to a non-uniform enhancement of the image of solid kidney tumors and a clearer delineation of them from the surrounding renal parenchyma, which is considered a pathognomonic sign for renal epithelial tumors. Taking into account the rarity of benign tumors and the lack of clear criteria for differentiating them from cancer, all solid masses of the kidney, whose density increases after intravenous administration of a contrast agent, should be considered renal cancer, unless proven otherwise after morphological verification.

The use of helical CT has made it possible to obtain a clearer image of the tumor. This method allows the examination to be completed in a short time and avoids breathing movements during the scan. Modern computer programs make it possible to perform three-dimensional image reconstruction, which contributes to better planning of the course of the kidney resection.

Magnetic resonance imaging (MRI)

Magnetic resonance imaging (MRI) can also be used to diagnose and stage kidney tumors. With the advent of contrast agents for MRI, this study began to roughly correspond to CT in terms of diagnostic capabilities. MRI gives a better image of a tumor thrombus in the renal and inferior vena cava. Contrast-enhanced MRI can be used in patients who are allergic to iodine contrast media or with renal insufficiency, in which the administration of iodine contrast is contraindicated. Nevertheless, MRI is a more expensive, complex and time-consuming research method, which limits its use in patients with kidney cancer.

Renal angiography

Renal angiography is rarely used today. Until the era of widespread development of CT, angiography was one of the main methods for diagnosing RCC. The classic signs of RCC were the hypervascular nature of the tumor, a large number of small tortuous vessels and arteriovenous shunts. Currently, spiral CT with bolus injection of contrast avoids this invasive study, since it makes it possible to obtain a three-dimensional reconstruction of renal vessels in the arterial phase.

Percutaneous biopsy

Percutaneous tumor biopsy under ultrasound or CT is also rarely used. Although a kidney biopsy is rarely complicated by bleeding or dissemination of the tumor, this procedure cannot be used to differentiate between malignant and benign kidney tumors due to a large number false negative results in RCC. The indication for aspiration biopsy of a renal mass is currently a suspected abscess or an infected renal cyst. Trephine biopsy is performed in cases of differential diagnosis of kidney cancer with metastatic tumors or kidney lymphoma.

Classification

The ΤΝΜ-classification is currently applicable.

ΤΝΜ-classification

Category ΤΝΜ is established based on physical examination and radiological diagnostic methods. Regional lymph nodes are retroperitoneal lymph nodes: lateroaortic, preaortic, retroaortic, laterocaval, precaval, retrocaval, interaortacaval, lymph nodes of the hilus.

T - primary tumor

TX - The primary tumor cannot be assessed.
T0 - no data on the primary tumor.
T1a is a tumor not more than 4 cm in greatest dimension, limited by the kidney.
Tib - the tumor is more than 4 cm, but does not exceed 7 cm in the largest
measurement, limited by the kidney.
T2 - tumor more than 7 cm in the largest dimension, limited
kidney.
T3 - the tumor spreads to large veins or invades the adrenal gland or surrounding tissues, but does not go beyond Gerota's fascia.
T3a - tumor invasion of the adrenal gland or perirenal tissue - within the fascia of Gerota.
T3b - The tumor spreads to the renal vein or inferior
the vena cava below the diaphragm.
T3c - the tumor spreads to the inferior vena cava above
diaphragm.
T4 - the tumor extends beyond Gerota's fascia.

N - regional lymph nodes

NX - Regional lymph nodes cannot be assessed.
N0 - no metastases in regional lymph nodes.
N 1 - metastasis in one regional lymph node.
N2 - metastases in more than one regional lymphatic
node.

Μ - distant metastases

MX - Distant metastases cannot be assessed.
M0 - no distant metastases.
M1 - distant metastases.

Histopathological classification

In the histopathological classification, the pT, pN and pM categories correspond to the T, N and M categories. Histological examination of the material after regional lymphadenectomy should include 8 or more lymph nodes. If, on a histological examination, the lymph nodes are without metastases, but their number is less than 8, then they are classified as pN0.

G - histopathological differentiation

GX - The degree of differentiation cannot be assessed.
G1 is a highly differentiated tumor.
G2 - moderately differentiated tumor.
G3 - poorly differentiated tumor.
G4 - undifferentiated tumor.

Grouping by stage

Stage I T1 N0 M0
Stage II T2 N0 M0
Stage III T1 N1 M0
Stage III T2 N1 M0
Stage III T3 N0 N1 M0
Stage IV T4 N0 N1 M0
Stage IV Any T N2 M0
Stage IV Any T Any N M1

Development of production and investment programs for public utility companies - producers of goods and services in the field of heat supply

Development of production and investment programs for public utility companies - producers of goods and services in the field of heat supply

L. D. Solovyova, Deputy Director - Head of the Department for Regulatory Regulation of the Utilities Sphere of the Housing and Utilities Department of the Ministry of Regional Development of the Russian Federation (report at the International Forum "Russian Heat Supply: Problems and Development Trends")

General issues of the development of public utilities

A lot has been said and written about the existing problems of the housing and communal complex. And if literally two years ago the situation could be characterized by the phrase: “We have a lot of projects, but we have no money,” now everyone says: “We have a lot of money, but we have no projects, nowhere to invest”. At the same time, there are still high risks for investors of investing in communal infrastructure systems (Fig. 1). Reducing risks is possible due to the transition to secured public-private financing (Fig. 2).

As a rule, when an investor comes, he comes with his interest in a certain organization of the communal complex (OCC) and this is enough for him to start making money. His interest is not tied to the interests of the city, not tied to the interests of the development of other utilities. There is a certain imbalance - "pulling over" financial resources. Therefore, it is very important for the effective interaction of government bodies with resource-supplying organizations.

State control in accordance with Federal law dated December 30, 2004 No. 210-FZ "On the principles of regulation of tariffs for the organizations of the communal complex" should be carried out through the integrated development program (PCR). The presence of a PCR is a prerequisite in many Federal laws for the provision of federal support. This is also recorded in the provisions on the provision of subsidies for interbudgetary transfers, developed by the Ministry of Regional Development of the Russian Federation. The first RCCs of municipalities have already begun to enter the Ministry of Regional Development of the Russian Federation, but you cannot look at them "without tears", for example, some of them consist of only a few pages.

It is necessary to clearly understand that the GKR is an integral part of the Master Plan for the Development of a Municipal Formation, and the norms prescribed in the Town Planning Code indicate that by 2010 all municipal formations must have Master plans for their development.

From January 1, 2009, the maximum index of payment of citizens will be set by the subject Russian Federation... Only the aggregate index of payment for utilities... In the near future, the Ministry of Regional Development of the Russian Federation is to submit to the Government of the Russian Federation a draft resolution on the calculation of limit indices. A prerequisite for the establishment of limit indices in the draft resolution is the presence of the GKR and the law of the constituent entity of the Russian Federation on the criteria for the availability of tariffs for the consumer. These are the two main factors that will influence regulation.

Integrated development program

In accordance with Federal Law No. 210-FZ, the program for the integrated development of communal infrastructure systems (SCI) of the municipality is a program for the construction and modernization of the SCI, which ensures the development of these systems in accordance with the needs of housing and industrial construction, improving the quality of supplied goods (services provided) and improvement of the ecological situation in the territory of the municipality.

The anti-ship missile system solves the following tasks:

■ determination of target indicators for the development of SKI;

■ determination of priorities and sequence of development of SKI;

■ balanced development of SKI;

■ ensuring the environmental safety of SKI development.

For the municipality, the PKR is a tool for integrated management and optimization of the development of the SKI, which allows you to link the goals and rates of development of the SKI of the city (electricity, heat supply, water supply), identify problem points and, in conditions of limited resources, optimize them to solve the most pressing problems.

At no other level of power there is more such a function as the organization of electricity, heat, water, gas supply. It should be borne in mind that this function is not a “planning meeting” in the morning with the deputy head of a municipal formation responsible for providing housing and communal services, and this is not a daily redistribution of funds to pay for or repair something. There is no development of one resource without the development of another, interconnected with it. It is impossible to build elements of a water supply or heating system without sources of generation. You cannot talk about heat energy, for example, without gas. This is a whole complex, and the authorities of the municipality must understand this.

As mentioned above, the RCC - necessary condition to receive financial support at the federal level. For example, in accordance with the Federal Law of July 21, 2007 No. 185-FZ "On the Fund for Assistance to the Reform of the Housing and Utilities Sector", the approval of tariffs and surcharges based on the GKR is a prerequisite for receiving funds from the said Fund, and in accordance with the Federal Law dated July 24, 2008 No. 161-FZ "On assistance to the development of housing construction" - a condition for the allocation land plots for housing construction.

PCR is a management tool (including through further monitoring) of private enterprises. The PCR allows you to influence development plans and the motivation of private companies that own infrastructure facilities, in the interests of the city, which is practically impossible by other methods; allows (through monitoring) to evaluate and control the activities of these companies.

From the standpoint of the authorities of the municipal entity, the management of an enterprise is possible only if it is a municipal enterprise (MUP), and if the infrastructure elements are transferred to a private enterprise, then management becomes impossible. But this position is wrong. If the RCC is built correctly, the illusion of lack of control disappears. It is through the PKR that the municipality manages any enterprise of any form of ownership. It would be even better for the municipality if it were a private enterprise, since for mistakes made by a private enterprise, it pays for its own funds, and mistakes of municipal unitary enterprises are compensated for by the budget of the municipality.

PCR is a tool and a necessary basis for effective tariff setting. The RCC and the investment and production programs of the JCC drawn up on its basis are the rationale for setting tariffs.

For investors, the PKR is also a tool within which he can make a decision “where to enter, how to enter and how much it costs”. Investors receive a "signal" from the authorities about where investments in infrastructure will be needed, as well as a government-approved infrastructure development plan with priorities for several years ahead. The GKR approved by the representative body of the municipality and approved on its basis by the JCC investment programs and tariffs (including long-term ones) are a legitimate mechanism for guaranteeing the required level of tariffs for the investor for the period laid down in the GKR.

There is a position of the heads of administrations of the constituent entities of the Russian Federation and municipalities, which can be expressed by the phrase: "You give us money, and we will figure it out ourselves." At the same time, many cannot even name the reasonable amount of the necessary funds and the timing of their development. In this case, the GPC is also a tool for the investor that provides the ability to control the results of their investments.

Monitoring

In accordance with the order of the Ministry of Regional Development of the Russian Federation of April 14, 2008 No. 48 "On Approval of the Methodology for Monitoring the Implementation of Production and Investment Programs of Communal Complex Organizations", these programs of municipalities will be monitored directly, without the participation of a constituent entity of the Russian Federation. There is nothing surprising in this, as a result - the enterprise looks like "in the palm of your hand". So far, only investment programs will be monitored for heat supply organizations, but over time, an agreement may be reached with the Federal Tariff Service (FTS) to extend this monitoring to production programs.

The bodies regulating the tariffs of the organizations of the utilities complex now have a tool that allows, based on the monitoring results, to revise the tariffs, and not only "plus", but also "minus", which will not be very pleasant for resource-supplying enterprises. Moreover, the revision is possible for the period of regulation. Minus tariffs will be revised, because in all our orders, regulations and laws it is written that any investment or production program is, first of all, the achievement of specific goals. If in the production program the goal is to save energy, expressed in a certain number of percent, then the regulatory authorities after a certain time must verify the results obtained with the declared ones. In the event that the values ​​specified in the investment program are not achieved, no explanation of the reasons (accident, Cold winter etc.) will not help and tariffs will be reduced. Regulatory bodies will not immediately, not this year, but they will certainly master this regulatory instrument.

It is also necessary to reconsider the idea of ​​the investment program. In accordance with Federal Law No. 210-FZ, this is, to a greater extent, a program not of an enterprise, but of a municipality. The enterprise does not need an investment program. The municipality issues a technical task, and the enterprise realizes its desire for something, using only the production program.

The example of Moscow is surprising, in connection with the establishment of the amount of payment for connection to heating networks, despite the fact that the city investment program has not been approved. At the same time, the connection fee is set only when there is an approved investment program and the amount of the fee is calculated only in accordance with the scope of this program.

Methods for developing anti-ship missiles

In order to develop a full-fledged anti-ship missile system, a significant amount of time, money and highly qualified developers are required. Therefore, for the period of the transitional period, it will be possible to develop a simplified program, with the condition that in the future there will be a transition to a full RCC (Fig. 3). The only difference will be that the so-called simplified RCC will not contain promising schemes for the development of SQI, but at the same time it will have a sufficiently detailed analysis of the SQI.

Prospective schemes for the development of communal infrastructure is a detailed study of the development of engineering systems of urban infrastructure:

■ detailing the territory of the settlement and drawing up electronic models;

■ with calculations to ensure the regulatory reliability of the provision of a utility service (resource);

■ with specific technical solutions(specific configurations and diameters of pipelines, type of equipment at sources, their placement on the territory);

■ with agreement on land allocation;

■ with obtaining preliminary technical conditions for connection to electric, heat and gas networks;

■ with an assessment of the impact on environment and the development of mitigation measures.

As a result of the development of a complete RPC, specific packages of investment projects are obtained. A municipality can quite calmly put objects of a specific attraction of investments for a competition, because the land has already been drawn up, preliminary technical conditions etc., i.e. everything that is often missing in today's projects. The complete RPC will allow simply announcing investment tenders for attracting any investor and for sufficiently long investment periods.

It does not matter which of the two options will be used to create the RCC - in any case, the Russian legislation has already formed the legal framework for the implementation of these measures.

Estimated time costs for a city with a population of 150 thousand. the development of a simplified RCC scheme will take about 2-3 months, and a complete scheme will take about 8 months.

Components of anti-ship missiles

As mentioned above, the GKR is the main part of the Master Plan for the Development of the Municipal Formation, therefore, it must necessarily include a forecast of geographically distributed demand. Both in a simplified and in a complex (complete) scheme, the RCC is the basis of the basics.

The forecast of geographically distributed demand for utilities (heat, electricity, drinking water, etc.) is formed on the basis of the use of GIS technologies associated with the city geographic information system.

Forecasting geographically distributed demand is based on the principle of forming a calculated element of territorial division (planning quarter, cadastral quarter, BTI quarter, production or industrial zone, etc.). In each element of territorial division, the demand for resources is modeled, based on the analysis of town planning plans for the development of the housing sector, social sphere, and industry.

In the future, there will be a widespread transition to the representation of municipal infrastructure (CI) systems in the form of electronic models. There are regions and municipalities that are already carrying out such work. Electronic models are structured databases of engineering infrastructure elements tied to the territory, which make it possible to carry out all the necessary engineering calculations for the design of heat supply systems. They contain Full description heating networks and their facilities (diameters of pipelines, lengths, years of installation, years of major repairs, sectioning fittings, etc.). An electronic model is a tool for developing projects for the development and reconstruction of engineering facilities, taking into account all the systemic constraints of urban planning. Accordingly, if electronic models are developed, then you can experiment: combine circuit elements, disconnect, do analyzes and make forecasts.

Combining models of geographically-distributed demand for resources and electronic circuits of engineering communications and head facilities allows solving the problems of optimal provision of the urban environment with energy resources. In this case, demand forecasts are combined and then the most rational approaches to the development and reconstruction of engineering systems are developed. On the basis of the combined models, the problems of redistribution of the heat (electrical) load between the sources are solved. different types, with the main objective function - reducing costs and losses in their production and transport.

For each option for the development of the electric, heat and water supply system, a set of certified models is used, which makes it possible to establish all the effects from the implementation of the most rational scheme, ensuring that the permissible limits of environmental impact are not exceeded.

In connection with the excitement that has arisen around the sale of quotas for greenhouse gas emissions, a situation may arise when in 5 years these quotas will have to be bought back, but at a much higher price. To prevent this from happening, an analysis of the development of electricity, heat and water supply systems for the municipality is urgently needed now.

When discussing the problem of energy supply, as a rule, issues of excess or lack of capacity are considered, and very rarely - issues of reliability, especially in heat supply. So, for example, at one of the conference calls on the preparation for the heating season when deciding difficult question connected to the power supply, the answer was that the reliability of the power supply is not really a problem, since in which case you can always use a mobile power generator. Such an idea of ​​reliability now exists in many municipalities, therefore, the GPC must necessarily include an assessment of the reliability of the provision of services and resources of the SKI. It is necessary to consider possible emergency scenarios and develop projects for the construction of emergency heat and water supply schemes.

As a result of the use of electronic models in the form of tables and graphs, we can see the stages of project implementation: the receipt of money, the amount of work, the timing of implementation, etc. You can plan everything and manage everything. And if it becomes clear that the demands of the municipality are so great that they cannot be realized in 3-5 years, then it is possible to create a program for both 7 and 9 years. But all this can be understood only by analyzing the existing electronic model.

A very important issue for the municipality is the abolition of economic management. It will be necessary to form a municipal treasury, consisting of networks and infrastructure facilities, which will be transferred to the management of private companies. The formation of the treasury of the municipality, the formation of the revenue side of its budget - this is also associated with the GKR.

Another important component of the GPC is the development of long-term tariff projects and the assessment of the effectiveness of investments. Such precedents already exist. Last year, the FTS set three-year tariffs for GUP Vodokanal of St. Petersburg in connection with the implementation of the enterprise's program, and this year in the Kirov region. three-year tariffs have been established for heat supply organizations by a separate order of the Federal Tariff Service. But talking about long-term tariff setting, taking into account our inflation, taking into account our fluctuating economy, is quite difficult. At the same time, if the preparation of the RCC is carried out in full, then this will allow us to avoid the risks that are included in the concept of long-term tariffs, and therefore, we will get a tariff process that can really work reliably.

The PCR necessarily includes an assessment of the affordability of housing and communal services and the purchasing power of the population (Fig. 4). The entire project is selected by iterative procedures and changes in logistics so as not to exceed the minimum purchasing power of the population of housing and communal services.

RPC also includes:

■ logistics and aggregate investment assessment;

■ assessment and optimization of the use of own and borrowed funds for the implementation of projects;

■ assessing the reduction in operating costs in the course of project implementation;

■ assessment of existing and prospective indicators and indicators of the effectiveness of the functioning of the OCC.

Interaction regulations

Regulatory bodies created in municipalities are obliged, first of all, to draw up regulations for their work, i.e. rigidly write down all the features of their interaction with the OCC. And if, for example, in the production program of the OKK did not include measures related to the current operation in order to ensure a high-quality continuous supply of services, and an accident occurred in the winter, then only the OKK is to blame. But if the organization included all the necessary measures in the program, and the regulatory authorities considered the measures insignificant and "cut out" some of them in order to reduce costs (for example, motivating this by the need for significant costs in connection with the upcoming elections), then in this case the authority is to blame regulation. But all changes must be recorded in writing, and all these issues must be taken into account in the interaction regulations.