The Efficiency of Extracorporeal Shock Wave Lithotripsy (ESWL) in the Treatment of Distal Ureteral Stones: An Unjustly Forgotten Option?

Introduction The optimal management of distal ureteral stones remains a matter of debate since current guidelines favor ureteroscopy over extracorporeal shock wave lithotripsy (ESWL). We aimed to evaluate the efficiency of ESWL for distal ureteral stones and to identify factors that affect treatment outcomes. Materials and methods The retrospective study included records of 115 patients with distal ureteral stones, 5 mm to 18 mm in size, undergoing 223 ESWL sessions as an outpatient procedure. Early fragmentation and three-month follow-up stone-free rate (SFR) was assessed through radiographic imaging. Treatment was successful if there were no residual fragments or they were ≤4 mm, three months after the last session. Results The mean ±standard deviation (range) stone size was 9.68 ±3.10 (5.00-18.0) mm. The mean body mass index (BMI) was 24.3 ±2.67 (18.4-29.8) kg/m² with a significant correlation between BMI and stone size (r2 =0.324, p <0.001). Patients underwent ESWL an average of 1.7 ±1.36 times (1-5), while 68 patients (59.1%) became stone-free after one session. The overall SFR was 82.6%; for patients with stone sizes ≤10 mm and >10 mm, it was 99% and 9.4%, respectively. Cumulative SFR after the second session was 77%. In 20 (17%) patients the treatment was a failure. Complications occurred in 10.4%, while auxiliary procedures were needed in 8.7% of cases, both significantly affected by the stone size (p <0.001). The efficiency quotient (EQ) was 0.76. Treatment outcome was significantly different depending on stone size, BMI, number of sessions, complications, and auxiliary procedures (p <0.001, p =0.022, p <0.001, p <0.001, p <0.001, respectively). Univariate regression analysis identified stone size and BMI as significant predictors of treatment outcome (odds ratio (OR) 3.84, 95% confidence interval (CI): 2.31-8.97, p =0.001, and OR 1.25, 95% CI: 1.04-1.54, p =0.024, respectively). Conclusions Extracorporeal shock wave lithotripsy continues to be a safe and effective option for managing simple calculi in distal ureters with a diameter of ≤10 mm. The stone size and BMI remain significant predictors of treatment outcome.

Renal Tuberculosis Following Intravesical Bacillus Calmette-Guérin (BCG) Immunotherapy for the Treatment of Bladder Cancer.

INTRODUCTION: Non-muscle-invasive bladder cancer (NMIBC) is usually effectively treated with transurethral resection (TUR), most often followed by intravesical instillation of bacillus Calmette-Guérin (BCG) or intravesical chemotherapy. Although the precise mechanism of BCG immunotherapy is still unclear, a local immune response is presumed. However, a number of severe side effects and complications are related to intravesical immunotherapy. AIM: Aim of this report is to present rare case of the renal granulomatous disease in a patient previously treated with intravesical instillation of BCG immunotherapy, following TURBT. In addition, we performed review of previously reported cases of renal granulomas following intravesical BCG immunotherapy. CASE REPORT: A 79-year-old man was presented to Urology Clinic due to clinically verified tumor of the urinary bladder. After transurethral resection of bladder tumor, histopathological analysis revealed the diagnosis of papillary urothelial high-grade pT1 carcinoma. Intravesical BCG immunotherapy was initiated, according to protocol currently used in our institution. Upon completion of therapy with BCG, we re-examined the patient and, using ultrasound, found a change in the right kidney, resembling moth bites not seen on CT scan before TURBT. Additionally, CT-guided core-needle biopsy of the affected kidney was performed, and the specimen was sent for histopathological analysis, which revealed chronic necrotizing granulomatous inflammation. Antituberculotic therapy was initiated for 6 months. Upon completion of antituberculotic therapy, control CT-scan was performed at follow-up, indicating regression of changes on the right kidney. CONCLUSION: This case report emphasizes the importance of consistent implementation of follow-up protocol and the identification of lesions during the asymptomatic period and enables the proper treatment of the disease. To reduce the incidence of adverse effects of BCG treatment for bladder tumors, an individualized approach is needed.

Pixel Prostate Software as a Reliable Tool in Depicting Spatial Distribution and Determination of the Prostate Cancer Volume.

INTRODUCTION: Cancer of the prostate (PCa) is the second most common cancer-related cause of death among men and the most common non-cutaneous malignancy in Western countries. Numerous papers have been published on the topic of various aspects of this disease; however, rather little has been written on the diagnostic and prognostic value of the prostate cancer obtained from needle biopsy. AIM: To examine the utility of Pixel Prostate software in determining the volume and topographic distribution cancer of the prostate (PCa), and to analyze it with other variables that are characteristic for PCa. METHODS: retrospectively, 75 patients data and postoperative prostate specimens were analyzed, after determining topographic distribution and cancer volume (PCa), using PixelProstate software. RESULTS: Mean VPCa was 6.99 cm3 (0.14-29.7; median 4.51), and mean percentage cancer volume relative to prostate volume (%VPCa) was 16% (0.1-67.2%; median 13%). 71% of the patients had T2 stage, while the rest had T3 stage. Apex involvement was present in 65% of the patients, while central zone involvement and extraprostatic extension were present in 23.5% and 22.7% of the patients, respectively. Preoperative Gleason score undergrading was present in 27 (36%) patients, while bilateral PCa finding was increased from 51% to 87%, postoperatively. The most discriminant variable according to the prediction of %VPCa>10% had preoperative bilateral needle biopsy findings, with AUC of 0.75 (<.001), with sensitivity and specificity of 84% and 70%, respectively; (+LR 2,8; PPV of 74%; NPV of 82%). %VPCa showed good correlation with prostate specific antigen (PSA) and PSA-density. CONCLUSION: A possibility of precise spatial orientation and volume characterization of the PCa by PixelProstate software was shown. Simultaneously, with time, a clinician, experienced by PP software feedback, gets better insight for the planning of future prostate biopsy, as an important factor in clinical decision making.

Penile Compression Release Index Revisited: Evaluation and Comparison with Other Noninvasive Tools in the Prediction of Bladder Outlet Obstruction in Men with Benign Prostatic Enlargement.

AIM: To determine the discriminatory power of penile urethral compression-release index (PCRI), clinical prostate score (CLIPS) and bladder outlet obstruction index 2 (BOON2) for the detection of bladder outlet obstruction (BOO), and the associated bladder abnormality in patients with benign prostatic enlargement (BPE). MATERIAL AND METHODS: In study was included of 135 patients with proven BPE underwent urodynamic measurement (UDM) and PCR maneuver. PCR Index was calculated following the formula: (Qs-Qss)/Qss x 100(%). CLIPS score was calculated based on non-invasive variables (prostate volume, maximal urinary flow, residual urine and voided volume), while BOON2 was calculated using the formula intravesical prostate protrusion (IPP)-3 x Qmax-0.2 x mean voided volume. UDM results were plotted on Schaefer and URA nomograms. RESULTS: A comparative analysis was made using ROC curves. The area under the curve (AUC) for PCRI is 0.85 (PTP 91.3%), while AUC for CLIPS and BOON2 is 0.8 (PTP 77.6%) and 0.82 (PTP 74.5%), respectively. PCRI with the cut-off point of 96% clearly distinguishes obstructed patients with normocontractile detrusor and the presence of detrusor overactivity (DO), versus those unobstructed. CLIPS (>10) shows good BOO prediction, but without the possibility of distinguishing between detrusor contractility grade and the occurrence of DO. BOON2 has shown that impaired contractility has influence on this number in obstructed patients. CONCLUSION: PCRI is a very good noninvasive urodynamic test for a group-wise detection of BOO in patients with BPE and associated bladder co-morbidities; it is therefore superior in comparison with to CLIPS or BOON2.

Short-term results after local application of steroids and anesthetics in patients with painful spine conditions.

INTRODUCTION: Spinal pain is the most common of all chronic pain disorders. Imaging studies can be used to determine whether a pathological process is associated with the patient's symptoms. OBJECTIVE: To determine the short-term efficiency of local instillation of steroids in patients with painful spine conditions. MATERIALS AND METHODS: A prospective study included 35 patients with diagnosis of lumbar or cervical radiculopathy, or cervical and lumbar syndrome at the Department for the Physical Medicine and Rehabilitation, Department for the Orthopedics and Traumatology, and Department for the Neurosurgery, Clinical Canter University of Sarajevo (KCUS). A clinical examination, visual pain scale (VAS) and Oswestry Disability Index (ODI) were performed prior to the needle procedure and seven days after it. Descriptive and comparative statistics were used for comparison of pre and post-interventional results. This procedure was done for the first time in our region. RESULTS: The males and females were equally represented in this study (17:18). The patients were 29 to 80 years old. The highest number of patients have been between 40-60 years, older then that have been 44.2% of patients, and younger only 8.5%. Patients have complained about the radicular pain along the legs or arms or back or neck pain. Most of them had disc herniation-57.14%, 8.57% had bulging disc, 8.57% had spinal canal stenosis, 5.71% had fasetarthrosis, rest of them had combination of those conditions. There was a statistically significant difference between the value of ODI score before procedure and 7 days later (26 +/- 10:16 +/- 12; p < 0.001). The difference was also statistically significant in VAS values (7 +/- 1:1 +/- 1; p < 0.001). DISCUSSION: Our study suggests that needle instillation of steroid and lidocaine is effective in short-term pain occurs in different painful spine conditions (Sy cervicale, lumbare and radiculopathy). It is valuable alternative to the classic methods of physical and drug therapy. It can also postpone surgical treatment, and it is very useful in situations of diffuse degenerative changes when is very important to define exact source of pain, like for instance in hip-spine syndrome.

Sickness Impact Profile (SIP) Score, a Good Alternative Instrument for Measuring Quality of Life in Patients with Ileal Urinary Diversions.

OBJECTIVE: To determine the effectiveness of the use of the SIP score and the quality of life impairment in patients with ileal conduit and orthotropic ileal derivations by Hautmann and AbolEnein/Ghoneim. METHODS: Prospectively evaluated 146 patients in different age groups. In 66 patients ileal conduit derivation was performed, in 20 patients orthotropic derivation using Hautman technique was recorded and in 20 of them AbolEnein/Ghoneim was used. Prior to examining patients with urinary diversions, 40 patients with minor urological symptoms not requiring any active treatment, were surveyed in order to validate SIP score. Six months after the operation, all patients with urinary diversions filled the SIP score questionnaire. RESULTS: Using Crombach's Alpha equation the high reliability of SIP questionnaire was proven. Average scale value was 0,93. Using descriptive statistics mean values of all categories and dimensions of the SIP questionnaire of examined patients were determined, calculated according to the questionnaire manual being converted to percentage. Total value of SIP score for the ileal conduit group was 34,76% and in orthotropic derivation 18,52% respectively. For Hautmann procedure total SIP score was 18,35% and for AbolEnein/Ghoneim 18,7%. In the control group total SIP score was 9%. The most influential dimensions on the total score of ileal conduit were physical and psycho-social, while independent dimension did not significantly influent total SIP score. CONCLUSION: Taking into consideration the lack of questionnaires on quality of life for urinary derivations, SIP score as a general disease influence to the quality of life questionnaire represents a reliable alternative for objectification and quantification of the quality of life upon urinary derivation. According to this instrument, orthotropic derivations provide significantly better quality of life compared to ileal conduit.

Impact of complications and bladder cancer stage on quality of life in patients with different types of urinary diversions.

GOAL: Determine correlation between complications and stage of the disease and their impact on quality of life in patients with different types of ileal urinary derivation after radical cystectomy, and upon estimation of acquired results, to suggest the most acceptable type of urinary diversion. PATIENTS AND METHODS: In five year period a prospective clinical study was performed on 106 patients, to whom a radical cystectomy was performed due to bladder cancer. Patients were divided into two groups, 66 patients with ileal conduit derivation and 40 patients with orthotopic derivation, whereby in each group a comparison between reflux and anti-reflux technique of orthotopic bladder was made. All patients from both groups filled the Sickness Impact Profile score six months after the operation. All patients had CT urography or Intravenous urography performed, as well as standard laboratory, vitamin B12 blood values, in order to evaluate early (ileus or subileus, wound dehiscence, bladder fistula, rupture of orthotopic bladder, urine extravazation) and late complications (VUR, urethral stricture, ureter stenosis, metabolic acidosis, mineral dis-balance, hypovitaminosis of vitamin B12, increased resorption of bone calcium, urinary infection, kidney damage, relapse of primary disease), so as disease stage and it's impact on quality of life. RESULTS: From gained results we observe that each category of SIP score correlates with different rate of correlation with the type of operation, group, T, N, and R grade, except work category. Average value of SIP score rises depending on the type of operation and T stage. It is notable that there is no difference in T1 stage, no matter the type of operation. So the average value of SIP score in T1 stage for conduit was 20.3, for Abol-Enein and Ghoneim 17.25 and Hautmann 18.75 respectively. Average value of SIP score in T2 stage for conduit was 31, for Abol-Enein and Ghoneim 19.1 and Hautmann 17.8. Average value of SIP score in T3 stage for conduit was 38.03, for Abol-Enein and Ghoneim 18.75 and Hautmann 19.5. SIP score for T4 was present only in patients with conduit performed and average value od SIP score was 40.42. There is a high level of correlation of late complications and psychosocial and physical dimension with their parameters, while for an independent dimension of correlation is not significant. Early complications have insignificant correlation in all categories of SIP score. CONCLUSION: Upon analyzing quality of life and morbidity, significant advantage is given to orthotopic derivations, especially Hautmann derivation with Chimney modification, unless there are no absolute contraindications for performing this type of operation. Factors which mostly influence quality of life are cancer stage, type of derivation, late complications and patient age. SIP score, as a well validated questionnaire, are applicable in this kind of research.

Which is a better indicator of bladder outlet obstruction in patients with benign prostatic enlargement--intravesical protrusion of prostate or bladder wall thickness?

OBJECTIVE: To determine the correlation of intravesical prostatic protrusion (IPP) and bladder wall thickness (BWT) with clinical and urodynamic parameters, as well as their sensitivity and specificity with regard to bladder outlet obstruction in patients with a benign prostatic enlargement (BPE). MATERIALS AND METHODS: 111 patients with lower urinary tract symptoms and confirmed BPE completed the International Prostatic Symptom Score (I-PSS), as well as a transabdominal ultrasound to determine their prostate volume, a grade of IPP and BWT. All the patients were then subjected to the complete urodynamic studies (UDS). RESULTS: The IPP showed a good correlation with the prostate volume (r = 0.61) and serum PSA (r = 0.48); p = 0.0000, free uroflowmetry (r = -0.27; p = 0.004), as well as the determinants of urodynamic obstruction: bladder outlet obstruction index-BOOI (r = 0.36; p < 0.0001), and ICS and Schaefer obstruction class nomograms (rho = 0.33 and rho = 0.39, respectively; p < 0.001), while the BWT showed only a statistical correlation with age (r = 0.23; p = 0.02) and serum PSA (r = 0.4; p = 0.0000), regardless of an significant correlation with the IPP (r = 0.45; p = 0.0000). The ANOVA test showed a significant difference between the IPP grades for the observed clinical and urodynamic variables with an increase in significance for IPP>10 mm. The area under the ROC curve in the prediction of obstruction for the IPP is 0.71 (sensitivity 59.6, specificity 81.4), while the AUC for the BWT is 0.61 (sensitivity 64.5, specificity 59.2). The stepwise logistic regression model shows that most significant independent variables for the obstruction are the IPP, Q(max) free and age, with the area under the ROC curve of 0.78 (95% CI 0.695 to 0.856). CONCLUSION: The IPP higher than 10 mm as a non-invasive predictor of infravesical obstruction shows good correlations with clinical and urodynamic parameters, while the specificity and PPV against obstruction are significant. Despite a good correlation with IPP, the BWT is only a modest indicator of obstruction.

Bladder outlet obstruction number: a good indicator of infravesical obstruction in patients with benign prostatic enlargement?

The objective of our study was to evaluate bladder outlet obstruction number (BOON) in order to predict infravesical obstruction in patients with benign prostatic enlargement (BPE). Two hundred patients with proven BPE from daily urological practice at the Urology Department of the Sarajevo University Clinical Centre were covered by a prospective study in period 2009-2011. All patients completed International Prostatic Symptom Score, their mean voided volume urine was determined from frequency-volume chart and their prostate volume was determined by transabdominal ultrasound. Subsequently, the patients had free uroflowmetry and they underwent complete urodynamic studies. BOON was calculated using the formula: prostate volume (cc)-3 x Qmax (ml/s)-0.2 x mean voided volume (ml). A satisfactory area under the curve (AUC) was obtained for the prediction of obstruction according to bladder outlet obstruction index, Schaefer obstruction class nomogram and group specific urethral resistance factor , with AUC of 0.83 (p<0.001). Following the comparison of different cut-off values of BOON according to the obstruction, the BOON >-20 has been found to be the most accurate obstruction indicator (sensitivity 76.5% and specificity 68.2%), with posttest probability of 77%. The BOON may be used in daily urological practice as a valid, non-invasive indicator of infravesical obstruction in patients with BPE, with a possibility of correct classification of obstruction in approximately 75% of the cases. Transabdominal ultrasound has shown to be applicable to the BOON formula in determining prostate volume.

The significance of the influence of aging and infravesical obstruction caused by benign prostatic enlargement on detrusor impairment.

OBJECTIVE: to analyze the influence of aging and infravesical obstruction on cystometric characteristics of patients with lower urinary tract symptoms (LUTS) and proven benign prostatic enlargement (BPE). METHODOLOGY: A retrospective analysis was performed of basic characteristics of randomly chosen 213 patients with LUTS caused by BPE and urodynamic findings made in period 2005-2009 at the Urology Department of the Sarajevo University Clinical Center. The patients were divided into groups based on their age (<60 years/46 patients, 60-69 years/95 pat., and >70 years/72 pat.), and the degree of bladder compliance loss (<20 ml/cmH2O-76 patients, 20-40 ml/cmH2O-57 pat., and >40 ml/cmH2O-80 pat.). All patients had International Prostate Symptom Score (IPS-S) completed, prostate volume measured transabdominally, free uroflowmetry, as well as complete urodynamic study (UDS) findings--cystometry and pressure/flow studies (PFS). The PFS data were plotted on L-PURR, URA and ICS nomogram, bladder contractility index (BCI) and obstruction coefficient (OCO) were calculated for each patient. RESULTS: There was no statistically significant difference of IPS-S, prostate volume and postvoid residual urine among the age groups. Qmax (ml/sec.) declines significantly with age (mean 11.9 vs. 10.3 vs. 7.9, ANOVA p < 0.001), along with statistically significant decrease of cystometric capacity (mean 331 ml vs. 293 mi vs. 264 ml, p = 0.001), bladder compliance (BC-ml/cmH2O) (mean 35.3 vs. 31 vs. 26.5, p = 0.013), with increased incidence of detrusor overactivity (DO) (21.7% vs. 32.6% vs. 45.8%, chi2 test for trend p = 0.006), followed by a higher incidence of obstruction (URA > or = 29 cmH2O) (37% patients vs. 61% patients vs. 72.2% patients Chi2 for trend=13.8; p = 0.0002), along with noticeable reduction of BCI (117 vs. 121 vs. 106; p = 0.02). Patients with severe BC damage (<20 ml/cmH2O) showed a difference with respect to the degree of obstruction and age, along with decreased cystometric capacity and higher incidence of DO, while the difference in IPP-S was insignificant. OCO with cut-off point of 1 showed significant difference with regard to age (66.3 vs. 66.6 years, T test, p = 0.015), prostate volume (45 cc vs. 51.8 cc, p = 0.007) and incidence of DO (26% vs. 43.4%, p = 0.02). CONCLUSION: the degree of bladder compliance loss and incidence of obstruction increase with age, as reflected in decreased bladder capacity, decreased urine voided volume and increased incidence of DO, along with noticeably impaired detrusor contractility.

Influence of the prostate volume, prostate specific antigen density and number of biopsy samples on prostate cancer detection.

AIM: Establish the main differences in the prostate volume, prostate specific antigen density (PSAD), number of biopsy samples in patients with primarily or rebiopsy detected prostate cancer. MATERIALS AND METHODS: In the 2007-2009 period, at the KCUS Urology Clinic, there were 379 TRUS guided prostate biopsies in 323 patients with known prostate volume. The total of 56 patients (17.3%) underwent the first rebiopsy, primarily due to precancerous lesions. The mean prostate volume, ranges of prostate size, PSAT, PSAD and the number of biopsy samples were analysed retrospectively, and the main characteristics in patients with primarily and rebiopsy diagnosed Pca were evaluated as well. RESULTS: The first biopsy cancer detection rate was 29.6% (112/379). The rebiopsy detection rate was 30.3%. There was no statistically significant difference in the prostate volume and the number of biopsy samples among the total number of patients with prostate cancer against the group with benign (suspected) findings. There was a higher Pca detection rate in patients with the prostate volume < 40 cm3 and 40-60 cm3, against the group with the prostate volume > 60 cm3. PSAD was significantly higher in patients with PCa (0.24 vs. 0.18; p = 0.013). The total of 27.2% of the patients with negative biopsy findings and 48% of the patients with diagnosed Pca had PSAD > 0.15. PSAD showed sensitivity and specificity in prostate cancer detection of 50% and 75%, with PPV of 48%. Furthermore, the patients with PSAD >0.15 had a higher Gleason score versus the patients with PSAD < 0.15 (6.7 +/- 2.4 vs. 5.9 +/- 1.7; p < 0.003). A comparison of the main characteristics in patients with primarily and rebiopsy detected prostate cancer gave a statistically significant difference only in the number of biopsy samples (10.9 vs. 14.1, p <.0000). CONCLUSION: Patients with a smaller prostate volume, lower PSAD and a higher number of biopsy samples in rebiopsy have a higher chance of prostate cancer detection. PSAD carries a higher specificity in rebiopsy decision, and a higher PSAD is related to a higher Gleason score.

Clinical decision making in renal pain management.

OBJECTIVES: To determine the optimal medication for the treatment of renal colic using evidence based medicine (EBM) parameters (RR, ARR, NNT, NNH, ARI, RRI). SAMPLE AND METHODOLOGY: During 2010, an ITT study was conducted on 400 outpatients of the Sarajevo University Clinical Center Urology Clinic in order to investigate renal colic pain relief drugs. Each group consisting of 100 patients was administered either Metamizol amp. i.v., or Diclofenac amp. i.m., or Butylscopolamine amp. i.v., while 100 patients belonged to the placebo group that was given distilled water (aqua redestilata). All patients completed visual analogue pain scale (VAPS) from 0 to 10 prior to and after the treatment. RESULTS: Using EBM parameters Diclofenac Na and Metamizol were shown to be the most efficient in the treatment of renal colic. In these two groups, relative risk (RR) was 21 and 8,5% respectively; Absolute Risk Reduction (ARR) was 74 and 86% respectively, and Number Needed to Treat (NNT) was 1 for both groups, while chi-squared (X2) test has shown that there is no statistically significant difference between these two drugs when it comes to their effect. In the Butylscopolamine group, RR was 81; ARR 18%, while NNT was 5. With respect to side effects, only in his group it was shown that Relative Risk Increase (RRI) was 84, ARI 83%, while Number Needed to Harm (NNH) was 2. CONCLUSION: The most optimal medication for the treatment of renal colic according to EBM parameters is Diclofenac Na, followed by Metamizol. Butylscopolamine is not recommended for the treatment of renal colic.

Does the combination of intravesical prostatic protrusion and bladder outlet obstruction number increase test accuracy according to benign prostatic obstruction at the individual level?

OBJECTIVE: Determine diagnostic power and intercorrelation between bladder outlet obstruction number (BOON) and intravesical prostatic protrusion (IPP ) as non-invasive predictors of infravesical obstruction in patients with lower urinary tract symptoms due to benign prostatic enlargement. MATERIAL AND METHODS: Prospective study during 2009-2010 analyzed data of 110 patients with proven benign prostatic enlargement. Prostate volume and IPP were determined by transabdominal ultrasound, and patients underwent complete urodynamic studies (UDS). BOON was calculated using the formula: prostate volume (cc)-3 x Qmax (ml/s)-0.2 x mean voided volume (ml). RESULTS: There is a statistically significant correlation between the values of IPP and BOON (Spearman's rank correlation coefficient rho=0.48, p=0.0001). BOON is a more sensitive (sensitivity 82.4%, specificity 66.1%), while IPP is a more specific factor (sensitivity 58.8%, specificity 81.4%) in the group-wise prediction of bladder outlet obstruction (BOO). Positive predictive value in the diagnosis of obstruction increases at the individual level combining the cut-off values for BOON>-30, with IPP >10 mm (PP V 86.8%). Owing to a good correlation of IPP with different definitions of urodynamic obstruction, IPP was included in the BOON formula instead of prostate volume. This number was arbitrarily called BOON2. The combination of IPP >10 mm and cut-off value for BOON2 >-50 showed that 88.6% of the patients were accurately classified in the zone of obstruction (mean IPP 14.9 mm), while BOON2<-50 carried a high NPV. CONCLUSION: The combination of cut-off values for BOON and IPP increases test accuracy according to BOO at the individual level, thus facilitating clinical decision making regarding diagnostics and optimal choice of therapy in patients with BPE. Owing to its good correlation with obstruction determinants, IPP can be included in the formula for BOON instead of prostate volume.

Extracapular extension predictors of prostate carcinoma for 2-10 ngr/ml PSA values.

UNLABELLED: Purpose of the research is to establish which clinical and biopsy parameters could predict extra-capsular spread of prostate carcinoma for 2-10 ng/ml PSA values, in patients submitted to radical retropubic prostatectomy. METHODOLOGY: In the period of 30 months, 80 patients were treated with radical retro-pubic prostatectomy with bilateral pelvic lymphadenectomy, for whom clinical, biopsy, radiological and biochemical analysis were positive to organ limited tumor. Serum PSA, fpsa/tpsa, PSAD,values are evaluated, and other parameters as number of positive biopsies, percentage of positive biopsies, localization of positive biopsies, and perineural invasion and biopsy Gleason score. RESULTS: from total number of 80 patients with 2-10 ng/ml PSA, 7 (9%) patients had extra-capsular spread of prostate carcinoma. Upon using multivariate regression analysis, following parameters were proved as significant predictors of extra-capsular spread: biopsy Gleason score, number of positive biopsy samples and invasion, while serum PSA, FPSA/TPSA ratio, PSAD, prostate age and volume have not shown as significant predictors for extra-capsular extension. CONCLUSION: Biopsy GS, perineural invasion and number of biopsy samples are statistically significant predictors of extra-capsular spread of prostate carcinoma for 2-10 ml PSA. Percentage of positive biopsies, tumor length in a sample and the localization of positive biopsies are on the borderline of statistical significance and as such should be taken into consideration.

Prostate cancer detection rate and the importance of premalignant lesion in rebiopsy.

OBJECTIVE: Establish the prostate cancer (PCa) detection rate and the premalignant lesion incidence, as well as their importance in cancer detection at the first rebiopsy. MATERIALS AND METHODS: In the period 2006-2008, at the CCUS Urology Clinic, there were 585 prostate biopsies performed in 515 patients. 12% of the patients underwent the first biopsy due to premalignant lesion findings. The main characteristics of the patients--age, prostate specific antigen (PSAt)-total and PSA ratio (PSAr), the number of needle biopsies, Gleason score and the role of premalignant lesions in diagnosis of PCa at the first rebiopsy were processed retrospectively. RESULTS: Primarily detected PCa amounted to 32.4% (167/515), while the rebiopsy showed the detection rate of 35.7% (25/70). No statistically significant age or PSAt and PSAr difference was observed, while there was, however, a difference in the number of biopsy samples, 11 (6-18) vs. 12 (8-20) and in the Gleason score (6.5 vs. 5.9) among the observed groups (p < 0.05). Atypical small acinar proliferation (ASAP) and high grade intra epithelial neoplasia (HGPIN), were found in 4.95% and 7.2% of the cases, while the ASAP + HGPIN combination was found in 1.5% of the cases. The PCa detection rate at the first rebiopsy in patients with ASAP, HGPIN and ASAP + HGPIN lesions was 50%, 23.6% and 50%, respectively. The ANOVA test showed a statistically significant shorter time period for rebiopsy in ASAP+HGPIN patients than that of patients with ASAP and HGPIN lesions. CONCLUSION: A repeated positive biopsy establishes PCa in patients with lower PSAt values and the Gleason score, which is followed by an increased number of biopsy samples. ASAP and ASAP + HGPIN lesions carry a higher specificity of75% and 91%, respectively, while the PPV in prostate cancer detection for HGPIN is low (24%).

Acute renal failure and ureteral leak after open surgery aortoiliac aneurysm repair.

We present a case of 52 year old male with an acute renal failure that took place 4 days after open transabdominal surgery repair of infrarenal abdominal aneurysm along with aneurysm of left common iliac artery and dilatation of left external iliac artery. Patient was subjected to 13 hemodialysis treatments that resulted in satisfactory recovery of renal function. One month after aneurysm repair he developed the right ureteral leak, consequently urinoma and acute renal failure once again. We suppose that ureteral leak was related to segmental ischemic necrosis of right ureter but not to traction or other iatrogenic ureteral injury. Percutaneous nephrostomy and insertion of ureteral stent was resulted in complete recovery of renal function.

Values of prostate specific antigen in patients with operable prostate carcinoma.

BACKGROUND: Prostate specific antigen (PSA) has significance in diagnostics of the prostate cancer, establishing stage of the disease and follow up of results of the treatment with different methods. Increased PSA levels in serum is not characteristic only for persons who have prostate cancer but also of those with benign conditions, especially in range of 4.0 ng/mL to 10.0 ng/ml, where we see a lot of results superposition. Marker determination of free and total PSA-ratio FPSA/TPSA and total PSA and prostate volume--PSA density was introduced for improvement of the sensitivity of PSA. Purpose is to analyze demonstrators of the concentration of PSA and its fraction in patients with histologically confirmed and radically removed prostate cancer, and to establish its correlation with advancement and differentiation of the disease. WORK METHOD: The investigation was done in 80 patients with histologically confirmed, prostate cancer clinical stage T1-2, NO, MO, initial PSA level of 2-10 ng/ml and performed radical prostatectomy. RESULTS: Out of 80 patients, 6 of them (9%) had total serum PSA level within referral values (<4 ng/ml). There were 55 patients (68%) with values of ratio FPSA/TPSA from 0 to 0.15, 18 (23%) patients had values between 0.16-0.19 and 7 (9%) patients had values above 0.20 ratio FPSA/TPSA. Fifty patients (62%) had PSA density in values to 0, 15, and 30 patients (38%) had values above 0.15. According to completed multiple regression analysis values of PSA, ratio FPSA/TPSA and PSA density had no statistically significant correlation with extra-capsular invasion and lymphatic metastasis, which points out that as it is, they do not contribute to its prediction. CONCLUSION: Significant number of patients with histologically proven and radically removed prostate cancer had serum PSA level within normal referral values. PSA density and ratio FPSA/TPSA can help in differentiating malignant from benign changes in prostate in PSA values to 10 ng/ml but not with absolute safety since significant number of patients with proven cancer had these parameters in level range characteristic for benign diseases.

Using verapamil as protective factor in renal ischemia reperfusion injury during anatrophic nephrolithotomy.

Anatrophic nephrolithotomy (ANL) in the selected cases represents the method of choice in the treatment of staghorn calculi. We evaluated postoperative outcome of patients subjected to standard ANL that received 10 mg of Verapamil immediately before declamping renal artery, due to prevention of reperfusion injury. From 2002 to 2005, 18 nephrolithotomies were performed on 15 patients, in the Urology Clinic, University of Sarajevo Clinics Centre. Preoperative evaluation included intravenous urography and radionuclide renal scans which had been repeated 6 months after the operations. 10 males and 5 females were operated with mean age of 45 years. Urography and renal scans showed severe calyceal distortion and infundibular stenosis in 83% cases, complicated with ureteropelvic junction obstruction in 55% cases. Chronic kidney failure was present in 60% patients. Mean operative time was 150 minutes, with mean cold ischemia time of 61 minutes and mean blood loss of 300ml. There were five minor postoperative complications. Residual small calculi were found in 3 patients. Kidney function was stabilized in the patients suffering from chronic kidney failure, which was proved by radio nuclide imaging. ANL improved by using calcium channel blockers as a protective factor for reperfusion injury proved to be a good treatment choice with a low level of complications and noticeable stabilization and improvement of kidneys function.

Management of chronic nonbacterial prostatitis/chronic pelvic pain syndrome.

Chronic nonbacterial prostatitis/chronic pelvic pain syndrome is unsatisfactorily defined and insufficiently studied illness. Also, the treatment success is questionable and therefore, this illness is a therapeutical problem for urologists--which medications are the best choice in treating this uncomfortable condition? This paper presents results of prospective, open, analytical, comparative study that was performed on 90 patients with diagnosed chronic nonbacterial prostatitis/chronic pelvic pain syndrome. Patients were divided into three groups and were treated with two medications ciprofloxacin (C), doxazosin (D) and combination of ciprofloxacin + doxazosin (C+D). The effects were measured using symptom questionnaire for prostate illnesses of the National Institute for Health - USA (NIH-CPSI). During the basic evaluation, sum ranging from 0 to 43 was calculated for each patient. This number is called total sum NIH-CPSI (National Institutes of Health Chronic Prostatitis Symptom Index) of the questionnaire, which generates the questions from 1 to 9. The most significant change occurred in C+D group where the total sum changed from 18-38 in the beginning to 5-31 at the end of the treatment (55,1% (p<0,001)). Significant changes were also found in D group where the change was 46, 4% (p<0,001). At the end of the treatment no significant change was registered in C group (p<0,005): p<0,001--significance threshold. Combination of ciprofloxacin + doxazosin proved to be the best choice for treatment.

Surgical treatment and complications of penile fractures.

Paper goal is to determine complications after urgent surgical treatment of patient with penile fractures, by using circumferential-degloving technique (degloving penile skin to root of penis). In period between 1998-2006 year, 23 patients have been treated as urgent cases with clinically proven penis fracture, age between 18 and 35. Patients were treated in 3 medical centers in Bosnia and Herzegovina(Sarajevo, Tuzla and Zenica). All 23 (100%) patients were injured during sexual intercourse. In the case of 20 (86,9%) patients partial rupture of corpus cavernosum was verified. Two (8,6%) patients had a complete rupture of urethra and it was primary sutured. In 22 cases (95,6%) spontaneous erection appeared, and in the case of 2 (8,6%) patients penile curvature was verified. Urgent surgical treatment is the best therapy choice, which enables preservation of erection in great number of cases in patients with penile fracture.