DIFFERENT APPROACHES TO MANAGING UROLITHIASIS IN KIDNEY TRANSPLANT PATIENTS - A CASE REPORT.

Urolithiasis is a rare urologic complication after kidney transplantation, and its diagnosis and treatment can be challenging for clinicians. In our 52-year-old male patient, graft hydronephrosis was found six months after transplantation. The patient had recurrent urinary tract infections followed by macrohematuria and an increase in creatinine levels. Computerized tomography revealed a 13-mm diameter stone in the ureter of the transplanted kidney as the cause of obstruction. Percutaneous nephrostomy was placed in the graft to solve the obstruction. Initial endoscopic treatment with a retrograde approach failed. An antegrade approach through a previously placed nephrostomy was not successful either. By a repeated retrograde approach, laser lithotripsy was performed successfully. The patient has been monitored for six months and has stable graft function without hydronephrosis or stones. As in our patient's case, the diagnosis and treatment of urolithiasis in kidney transplant patients is challenging, and minimally invasive procedures are the treatment of choice.

Kidney transplantation using a colon pouch (Mainz pouch III): a case report.

Kidney transplantation is the most efficient method of renal replacement therapy. When this method is performed, native urinary bladder is the preferred urinary reservoir. However, in some patients with an anatomically and functionally abnormal lower urinary tract, the urinary bladder cannot be used for transplantation. In these patients, urinary diversion should be performed before kidney transplantation. We present a case of a 32-year-old male patient with orthotopic kidney transplantation performed using a colon pouch (Mainz-pouch III). He was born with severe anomalies including sacral agenesis, anorectal atresia, and hypospadias, which were corrected during childhood. Neurogenic bladder with severe vesicoureteral reflux led to end-stage renal disease. This dysfunctional bladder was unsuitable for kidney transplantation, and a staged approach for future transplantation was chosen. The first step was the creation of urinary diversion. Due to a short appendix, we created a continent, colon pouch (Mainz pouch III). Two years later, orthotopic kidney transplantation was performed using a right cadaveric kidney. The renal vessels were anastomosed to the aorta and inferior vena cava and the pyelon to the native ureter. Four years after transplantation, the patient has stable renal function without any complications. This is the first documented case of using Mainz-pouch III as a reliable option for kidney transplantation in selected patients.

THE ROLE OF LYMPHADENECTOMY IN PROSTATE CANCER PATIENTS.

Prostate cancer is one of the most important men's health issues in developed countries. For patients with prostate cancer a preoperative staging of the disease must be made. Involvement of lymph nodes could be assessed using imaging methods (CT or/and MRI), however, newer methods also exist (PET/CT, PSMA PET/CT). For some patients during radical prostatectomy a pelvic lymphadenectomy is recommended. Pelvic lymphadenectomy is indicated in intermediate- and high-risk group patients and with increased probability of lymph node invasion. The most used prediction tools for preoperative assessment of lymph nodes are Briganti and MSKCC nomograms and Partin tables. Pelvic lymphadenectomy can include different lymph nodes group, but extended lymphadenectomy is the recommended procedure. In 1-20% of patients, the lymph node invasion is present. Pelvic lymphadenectomy is primarily a diagnostic and staging method, and in minority of patients with positive lymph nodes it can be a curative method, too. In other patients with positive lymph nodes adjuvant therapy (radiotherapy and androgen deprivation therapy) can be beneficial.

[Cystine urolithiasis: recommendations for diagnosis, treatment and recurrence prevention]. / Cistinska urolitijaza: preporuke za dijagnostiku, lijecenje i prevenciju recidiva.

Cystine lithiasis is a diagnostic and therapeutic challenge. This consensus document has outgrown of discussion of experts in nephrology and urology. It is our hope that this document will be of use for all physicians who are facing this disturbing type of urolithiasis. So far, in our national literature there have been no comprehensive documents dealing with this entity and we believe that not only nephrologists and urologists will benefit, but also specialists in internal medicine and general practitioners.

[Orthotopic kidney transplantation--a case report]. / Ortotopna transplantacija bubrega--prikaz bolesnika.

Kidney transplantation is the treatment of choice in patients with end-stage renal disease. Heterotopic kidney transplantation is the most common technique used. Some patients with severe vascular pathology of iliac vessels or retained iliac fossae after previous transplantations are no more candidates for heterotopic kidney transplantation. In these patients, the orthotopic kidney transplantation represents an appropriate alternative. We present a patient with end-stage renal disease and severe atherosclerosis of iliac vessels which preclude heterotopic transplantation. In our patient a successful orthotopic kidney transplantation was done.

[Retrograde balloon dilatation as a minimally invasive treatment for ureteral stricture]. / Retrogradna balonska dilatacija kao minimalno invazivni oblik lijecenja stenoze uretera.

Ureteral stricture is not a common urologic condition. Balloon dilatation represents one of the least invasive methods for treatment of ureteral strictures. We retrospectively analysed 24 patients with ureteral strictures treated with retrograde balloon dilatation in our department. The etiology of stricture was iatrogenic in 11 (45.8%) patients, post-TBC in one (4.2%), congenital in one (4.2%), retroperitoneal fibrosis in one (4.2%) and unknown in 10 (41.6%) patients. Twelve (50%) patients had a stricture of pelvic, 9 (37.5%) lumbar, and 3 (12.5%) of terminal ureter. In all patients retrograde balloon dilatation has been performed. Only complication related to the procedure was febrility in 4 patients (16.7%). Restrictures were noted in 12 (50%) patients, who consequently have been treated surgically, or had to be stented. Retrograde balloon dilatation, as a safe and relatively effective treatment, is proposed as the first choice in patients with short ureteral strictures.

Kidney transplantation in elderly patients.

The Eurotransplant Senior Program (ESP) allocates kidneys from elderly donors to elderly recipients (> or = 65 years old). During the last 39 years, 922 kidney transplantations were performed in our transplant center. We retrospectively analysed patients included in the ESP from the our center. Eleven patients > or = 65 years old recieved kidney from donors 65 years old. Cold ischemia time was approximately 15 hours. Dual kidney transplantation was performed in one patient. Appropriate immunosuppressive protocol was given to all patients. Surgical complications were relatively common and included dissection of renal artery (1 patient), thrombosis of renal artery (1 patient), ureterovesical obstruction (1), lymphocele (1), bleeding (1), acute abdomen (2) and wound dehiscence (1). One rejection episode was registered. Delayed graft function was observed in the two patients with full recovery of kidney function. Seven patients until now have good functioning graft. Four kidneys were lost. One patient died because of pneumonia. Kidney transplantation in elderly is feasible procedure but with greater number of complications than usually.

[Surgical procedure and urologic complications after 922 kidney transplantations: our experience]. / Kirurski postupak i uroloske komplikacije nakon 922 transplantacije bubrega: nase iskustvo.

Between January 30 1971 and January 30 2011 922 kidney transplants were performed at our center, 360 (39%) from living related donor and 562 (61%) from cadaver. During first eight years an ureteroureterostomy was routinely used. The notable incidence of urological complications (fistula 11%, complications of stenting 10.7%, stenosis and lithiasis 4%) was observed after 140 transplantations. Majority of these complications (60%) were treated conservatively. A significant reduction in this incidence (P<0.001) was achieved (fistula 1,28%, complications of stenting 0,26%, lithiasis 0.12%) by introducing an extravesical ureteroneocystostomy by Lich-Gregoire. Stenosis had the highest incidence (4,23%). Majority of complications (76%) were treated surgically. A native ureter was commonly used in replacing the transplant ureter. In majority of patients an end-to-end pyelo(uretero)stomy was performed. Two patients were reoperated because of fistula, and the third had a prolonged healing. In last nine patients with urological complications an end-to-side pyelo(uretero)stomy was done. There was no urinary leakage. The safety of method results probably from an intact native ureter which has normal blood irrigation.

[Lymphocele and renal transplantation]. / Limfocele i transplantacija bubrega.

Lymphoceles are a well-known surgical complication of kidney transplantation. We retrospectively analyzed patients with lymphoceles among our renal transplant recipients. During the last 39 years, we performed 922 renal transplantations. Lymphoceles were diagnosed and treated in 45 (4.9%) patients. We used the following methods: percutaneous drainage with instillation of povidone-iodide in 36 (80%), percutaneous drainage with instillation of tetracycline in one (2.2%), percutaneous aspiration in four (8.9%) and surgical treatment in four (8.9%) patients. In all four (8.9%) patients with relapse, secondary procedure was successful. In total, open surgery was done in five (11.1%) and laparoscopy in four (8.9%) patients. Percutaneous drainage of lymphoceles, with or without the instillation of a sclerosant, is the first-line treatment. Laparoscopic fenestration of lymphoceles has become an alternative to percutaneous drainage, especially in case of post-drainage relapse.

Modified extensive anterior vaginal wall repair for cystocoele.

We describe a new transvaginal technique for cystocoele repair. We prospectively evaluated patients with moderate and high-grade cystocoele who underwent repair with the new transvaginal repair between 2000 and June 2009. Preoperative evaluation included history and physical examination using the Pelvic Organ Prolapse Quantification, urine culture, residual urine measurement, urodinamycs and cystoscopy. We performed the repair in 76 patients with a mean age of 65.24 years (range, 36 to 84 years), wit anatomical cure in 72 (95%) patients. Four (5%) patients had recurrent cystocoele, 3 (4%) patients claimed residual sensory urgency and 4 (5%) stress urinary incontinence (SUI) after the operation. The operation is safe, simple, and provides good anatomic results with minimal complications.

Radical surgical treatment of the urinary bladder cancer in patients over the age of 60--our experiences.

The goal of the paper was the analysis of patients over the age of 60 suffering from the urinary bladder cancer that underwent radical surgical treatment of the urinary bladder and establishing urine derivation. In the 1972-2008 period 2405 patients with the urinary bladder cancer were treated, 296 (12.3%) of whom underwent radical surgical treatment. The average age was between 60 and 80 years--in 207 (70%) patients. In our patients there were 190 patients (91.6%) with transitional cell cancers. According to TNM classification, T3 stage in 92 (44.4%) patients and T2 stage in 85 (41%) patients were predominant in our study. According to histological criteria, the most common stage was G3 stage--in 151 (73%) patients. Radical cystectomy or combined with urethrectomy was performed in 178 (86%) patients. Unfortunately, in 12% of them (T3 and T4 stages) the inner iliac blood vessels were tied off due to a progressive cancer. The outer supravesical urine derivation (Bricker, U-tubing nephrostomy, and ureterocutaneostomy) was done in 163 (78.7%) patients. The inner derivation (Coffey, ureteroileosigmoidostomy, Mainz-Pouch II) was performed in 17 (8.2%) patients and neovesica (Hautmann, Studer) in 24 (11.5%)patients. There were 74 (35.7%) patients with early postoperative complications. Among them the most dominant were the surgical complications--in 28 (13.5%) patients and distant organ complications--in 22 (10.6%) patients. In 75 (36%)patients with negative nodes the survival rate was 55% after five years. In 73 (35%) patients with positive nodes the survival rate was 27% after five years.

Transrectal sonography in prostate cancer detection--our 25 years experience of implementation.

Prostate cancer is a leading public health problem of male population in developed countries. Gold standard for prostate cancer diagnosis is true cut biopsy guided by transrectal ultrasound. Aim of this study was to determine sensitivity, specificity, accuracy, positive and negative predictive value of transrectal sonography (TRUS) in prostate cancer detection. The analysis was made for two time periods, before and after routine implementation of prostate specific antigen (PSA) in prostate cancer diagnostics. From 1984 to 1993 TRUS guided prostate biopsy was performed in 564, and from 1994 to 2008 in 5678 patients. In the second period PSA was routinely used in prostate cancer diagnostics. In the first period by TRUS we have made an exact diagnosis of prostate cancer in 18.97% of patients what was confirmed by biopsy. 4.61% ware false positive and 11.34% ware false negative. In the second period prostate cancer was recognized in 30.34% of patients, confirmed by biopsy. False positive cases ware 6.11% and false negative 29.31%. Sensitivity of transrectal sonography in the first period was 62.57%, specificity 94.2%, accuracy 86.2%, positive predictive value 80.45% and negative predictive value 87.72%. In the second period sensitivity was 50.87%, specificity 91.93%, accuracy 73.84%, positive predictive value 83.24% and negative predictive value 70.39%. Based on our experience we can conclude that prostate cancer is mostly found in the peripheral zone. Smaller tumors are hypoechoic and bigger tumors are hyperechoic. Prostate cancer lesions are impossible to differentiate from chronic prostatitis only by TRUS. Implementation of PSA has significantly decrease sensitivity, accuracy and negative predictive value of TRUS in prostate cancer detection. TRUS guided true cut biopsy is a gold standard in prostate cancer diagnostics.

Prognostic values of morphological and clinical parameters in pT2-pT3 prostate cancer in elderly people.

Prostate cancer is a disease of elderly men, the incidence of which increases in an age dependent manner. This study presents the correlation of clinical and morphological parameters in locally confined (pT2) and locally advanced (pT3) prostate cancer. We analyzed a group of elderly men treated with radical prostatectomy in the period 1999-2008 in the University Hospital Rijeka. We found no statistical association between pT stage and age categories, preoperative prostate-specific antigen, digitorectal examination and biopsy Gleason score. There was a significant correlation of higher Gleason score in prostate specimens after radical prostatectomy and a higher frequency of a positive surgical margin in tumors with pT3 than in pT2 stage (p = 0.003; p = 0.011 respectively). Recurrence-free survival was shorter in patients with tumors with positive surgical margins as well as in patients with pT3 stage (p = 0.030; p = 0.001 respectively). We conclude that higher tumor grade and positive surgical margins are indicators of a worse prognosis in our patients.

[Kidney transplantation in a patient with urinary diversion]. / Transplantacija bubrega u bolesnika s urinarnom diverzijom.

Kidney transplantation is the most efficient treatment in patients with end-stage renal disease. Transplantation in patients with urinary diversion is an effective treatment for patients with chronic renal insufficiency and abnormal lower urinary tract. Graft and patient survival is comparable to that with classical ureterovesical anastomosis. We present one patient with urinary diversion (ileum conduit) who was successfully transplanted in our center two years ago.

Influence of insolation on osteoporosis progression in androgen deprived nonmetastatic prostate cancer patients.

Prostate cancer is a major public health problem in all the developed countries. Increasing numbers of men with nonmetastatic prostate cancer are receiving long-term androgen deprivation therapy (ADT). ADT is associated the loss of bone mineral density and a increased risk of bone fractures. The standard recommendations for male bone health include above all optimizing calcium and vitamin D intake, and exercise. Vitamin D3 is an essential factor in the maintenance of bone health and calcium homeostasis. The main supply of vitamin D3 is obtained through photosynthesis in the skin. The aim of this study was to investigate the influence of insolation on osteoporosis progression in androgen deprived nonmetastatic prostate cancer patients. We divided our androgen deprived prostate cancer patients in 2 groups. The first group (A) consists of 224 patients with insolation rate less then 3 h per week. The second group (B) consists of 174 patients with insolation rate greater then 10 h per week. With a questionnaire we determined, that patients from both groups were 70 to 80 years old, body mass index was 25-30 kg/m2, androgen deprivation was 4-6 years and received no vitamin D supplements. In the group A 21.86% suffered pathologic fractures do to osteoporosis. In the group B 10.92% patients suffered from osteoporotic bone fractures. The risk for pathological bone fractures is significantly greater in the group A. In conclusion higher insolation in androgen deprived nonmetastatic prostate cancer patients significantly decreases the osteoporosis progression and the risk of pathologic bone fractures.

Prognostic significance of vascular endothelial growth factor expression in clear cell renal cell carcinoma.

The purpose of this investigation was to analyze and correlate the immunohistochemical pattern of vascular endothelial growth factor (VEGF) expression with the average of microvessel density (MVD) and other clinicopathologic parameters in clear cell renal cell carcinoma (CCRCC) in order to determine its prognostic significance. Surgical specimens of 93 CCRCC were immunohistochemically analyzed for VEGF expression, MVD with anti-CD31, and Ki 67 proliferative index. VEGF expression was recorded as the percentage of positive tumor cells (<75% and >75%) and as diffuse or perimembranous VEGF expression according to cytoplasmic distribution. Sixty-three (68%) RCC had <75% and 30 had (32%) >75% of VEGF expression. A diffuse cytoplasmic pattern of VEGF expression was found in 61(66%) RCC and a perimembranous one in 32 (34%) RCC. Statistical analysis showed that tumors with >75% of VEGF expression were characterized by lower MVD value (p=0.034), higher nuclear grade (p=0.018), and higher Ki 67 proliferation index (p=0.023). Moreover, a higher nuclear grade of tumor cells was characterized by diffuse cytoplasmic VEGF distribution (p=0.005). This tumor model did not confirm the postulated simple relationship between VEGF overexpression and angiogenesis through high microvessel count. However, the study results indicated that overexpression of VEGF was a worse histologic prognostic parameter in CCRCC.

Epidemiology of prostate cancer in the mediterranean population of Croatia--a thirty-three year retrospective study.

Prostate cancer is a major public health problem of the male population in all the developed countries. This non-skin cancer is the foremost one facing man today. Prostate cancer has become the second leading cause of cancer death2. In this study we investigated changes in the prostate carcinoma incidence and manifestation during a thirty-three years period. The study included 1226 cases of prostate cancer diagnosed from 1972 to 2005 in the Primorsko-Goranska County, Croatia. The age-adjusted incidence of prostate cancer increased from 1.69 per 100,000 men annually in 1972 to 137.58 per 100,000 men annually in 2005, which is an 81.4-fold increase. The percentage ofpatients with bone metastases on the first medical examination decreased from 1972 (75%) to 2005 (15%). The most of the patients with bone metastases at the first medical examination were between 30 and 50 years old. Early detection measures, such as prostate specific antigen testing and transrectal ultrasound guided prostate biopsy combined with the raised public awareness of the disease, most probably resulted in an increase of incidence.

Transurethral bladder neck incision in women with primary bladder neck obstruction.

BACKGROUND: Bladder outlet obstruction is an uncommon condition in women. Primary bladder neck obstruction is one of the functional causes of bladder outlet obstruction. We evaluated surgical treatment in our patients with primary bladder neck obstruction. PATIENTS AND METHODS: We retrospectively evaluated the medical data of 47 female patients from the Department of Urology who underwent transurethral incision of the bladder neck from January 2000 to December 2012. All patients underwent transurethral bladder neck incision at the vesical neck and proximal urethra at the 5- and 7-o'clock positions. We compared symptoms and urodynamic parameters before and after the operation. RESULTS: Out of 47 female patients who underwent the operation, primary bladder neck obstruction was diagnosed in 42. The mean age was 44.3 ± 16.8 (range: 21-78) years. The postoperative maximal flow rates were significantly increased (20.6 ± 3.9 vs. 7.6 ± 3.2 mL/s, P < 0.0001), and the postvoid residual urine was decreased (31.3 ± 7.8 vs. 132.1 ± 22.24 mL, P = 0.0002) compared with preoperative findings. Improvement was evident in most patients (83.3 %). A repeat operation had to be performed in seven patients (16.7 %). Operative therapy failed in one patient (2.4 %). DISCUSSION AND CONCLUSIONS: The diagnosis of primary bladder neck obstruction in women is based on typical symptoms, uroflowmetry and multichannel urodynamics, including electromyography. Videourodynamics is obligatory in doubtful cases. Transurethral bladder neck incision is an effective therapy for female patients with primary bladder neck obstruction, and if necessary, a second procedure can be safely performed.

Matrix metalloproteinases 2 and 9 immunoexpression in prostate carcinoma at the positive margin of radical prostatectomy specimens.

The aim of this study was to evaluate the expression of matrix metalloproteinase 2 (MMP-2) and matrix metalloproteinase 9 (MMP-9) in prostate cancer in the main tumor mass and tumor cells at the positive margin as well as the influence of these biomarkers on the biochemical recurrence of the disease in prostatectomy patients. Tissue microarrays of 120 archival prostate carcinoma samples were immunohistochemically evaluated for MMP-2 and MMP-9 expression and compared with clinicopathological parameters. Tumors with positive surgical margins showed significantly higher overall expression of MMP-9 versus tumors with negative resection margins (P = 0.0121). MMP-9 expression was significantly elevated in tumors from patients who had biochemical recurrence (P = 0.0207). In the group of patients with negative margins, MMP-9 expression above the cut-off value was significantly associated with recurrence (P = 0.0065). Multivariate analysis indicated that MMP-9 is a good predictor of biochemical recurrence (odds ratio = 10.29; P = 0.0052). Expression of MMP-2 in tumor cells was significantly higher at the positive margins than in the main tumor mass (P = 0.0301). The present results highlight the potential value of MMP-2 and MMP-9 expression for predicting the behavior of prostate tumors after prostatectomy with both positive and negative surgical margins.

An unusual case of acute urinary retention.

A 47-year-old male was referred to Emergency Department of our hospital for acute urinary retention. Physical examination showed electrical cable with proximal part introduced into the urethra. Plain abdominal radiograph demonstrated a metallic object in the pelvis and the patient underwent an operation. We used suprapubic cystostomy approach, and the wire was removed from the bladder and urethra.