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Preparation and processing of human allogenic dermal matrix for utilization in reconstructive surgical procedures.

AIM: This article presents the development of a novel preparation and processing method as well as indication for clinical applications of human allogeneic acellular dermal matrix, which was developed originally in the Central Tissue Bank (CTB) for use in burn medicine and reconstructive surgery. METHODS: Acellular dermal matrix (ADM) is a biological material assigned for utilization in several surgical procedures due to its unique structure and advantageous properties. The article focuses on a novel preparation and processing method developed by CTB, which differs in its impact on the structure, biological and biomechanical properties of the final ADM compared to the wide range of commercially available ADM products and currently available ADM products of other tissue banks. RESULTS: The ubiquitous acellular allogeneic dermal collagen matrix is the main substance participating in advantageous properties facilitating the use of ADM in numerous indications from dermal replacement and soft tissue augmentation to more extensive surgical reconstructive procedures. Dermal substitutes play an essential role in the reconstruction of full-thickness skin defects, both in acute and chronic wounds, defects of fasciae, peritoneum, etc., and there is a strong evidence that they can improve the final scar quality as well. Differences in preparation methods of ADMs are recently causing concerns among surgeons utilizing the ADMs. We present three different cases with favourable outcomes by using human acellular ADM grafts. CONCLUSIONS: Although ADMs did not fulfil all of the requirements for an ideal dermal substitute, their applications have been advanced for diverse indications in soft tissue reconstructions and augmentations. Early revascularization of the allografts reduces bacterial contamination. Research and development of new generation of acellular dermal matrices with incorporated autologous in vitro cultured cells will likely yield new products and give new hope for continued improve-ments in functional and cosmetic outcomes (Fig. 9, Ref. 60).

Natural polyphenols improve erectile function and lipid profile in patients suffering from erectile dysfunction.

OBJECTIVES: Erectile dysfunction (ED) is characterised as the inability to achieve or maintain an erection to complete sexual intercourse. ED may be considered as an early complication of diabetes mellitus (DM). The aim of this study was to assess the effect of registered food supplement, natural polyphenolic extract from the French maritime pine bark, Pycnogenol (PYC) on erectile function and lipid profile in ED patients. METHODS: 53 patients with ED were divided into two groups (32 with DM, 21 non-DM) in randomised, blinded and placebo-controlled study. During 3-month intervention with PYC or placebo and one month after the end of the intervention patients were investigated for ED with validated questionnaire International Index of Erectile Function-5 (IIEF-5); lipid profile, glycaemia was analysed in each group. RESULTS: In a randomised, blinded and placebo-controlled study, we found that natural polyphenolic extract, Pycnogenol improved erectile function in DM group by 45 % compared to the NDM group, where the improvement was also significant, but only by 22 %. Total cholesterol, LDL-cholesterol and glucose level was lowered by PYC in patients with DM. Glucose level was not affected by PYC in non-DM. Placebo showed no effect on monitored parameters in both groups. CONCLUSION: Administration of Pycnogenol leads in improvement of erectile function in patients with ED and diabetes (DM group) by 45 %, in NDM group by 22 %, in lowering of total-, LDL-cholesterol by 20 % and 21 % and glycaemia by 22 % in DM (Tab. 2, Fig. 2, Ref. 19).

Role of oxidative stress, adiponectin and endoglin in the pathophysiology of erectile dysfunction in diabetic and non-diabetic men.

Erectile dysfunction (ED) and diabetes mellitus (DM) share common pathophysiological risk factors including endothelial dysfunction which together with hyperglycemia contribute to the increased oxidative/glycooxidative stress. A reduced NO concentration is insufficient for relaxation processes in the penis. Chronic inflammation and endoglin are involved in the regulation of endothelial function. Adiponectin from the adipose tissue has anti-inflammatory effects. Our study aimed to investigate the relation between erectile function in patients with and without DM and the oxidative stress, hormone adiponectin, and endothelial dysfunction marker endoglin. Men (n=32) with ED evaluated by the International Index of Erectile function (IIEF-5) questionnaire (17 without DM (NDM); 15 with type 2 diabetes mellitus (DM)) and 31 controls were included. Advanced glycation end products (AGEs), 8-isoprostanes (8-isoP), protein carbonyls, antioxidant capacity, adiponectin and endoglin were determined in the blood. DM patients compared to NDM patients and controls, had increased levels of glucose, C-reactive protein, triacylglycerols, 8-isoP, AGEs, endoglin and BMI. IIEF-5 score, NO and adiponectin levels were decreased. We are the first to find out that endoglin shows a negative correlation with erectile function in NDM, but not in DM patients. Endoglin can be considered as endothelial dysfunction marker in nondiabetic men suffering from ED.

The use of European Randomized study of Screening for Prostate Cancer calculator as a diagnostic tool for prostate biopsy indication.

BACKGROUND: It is a well-known fact, that too many men are having prostate biopsy performed with negative biopsy results. The decision to undertake prostate biopsy is usually based on prostate specific antigen (PSA) level and digital rectal examination (DRE). A risk-based strategy may reduce the numbers of unnecessary prostate biopsies. METHODS: Retrospective statistical analysis of data from 195 men undergoing their initial prostate biopsy from 1.1.2015 to 31.12.2015 based on elevated PSA ≥ 4.0 ng/ml and/or abnormal DRE were included. Subsequent risk stratification using the European Randomized study of Screening for Prostate Cancer calculator (ERSPC) was used with the intent to calculate the accuracy of ERSPC with the aim to avoid unnecessary (negative) prostate biopsies. RESULTS: The specific values of sensitivity and specificity in this cohort were 94.34 % and 24.72 %. In direct comparison of PSA and ERSPC calculator, the differences between sensitivity, specificity, negative predictive value and false omission rate as negative were statistically insignificant, but the positive predictive value was on the edge of statistical significance (p = 0.054), slightly in favor for ERSPC calculator. CONCLUSION: PSA still remains the single most predictive factor for identifying men with an increased risk of prostate cancer to be detected on prostate biopsy, but using other risk factors included in ERSPC can considerably reduce the numbers of unnecessary biopsies on initial screening (Tab. 4, Fig. 2, Ref. 23).

Radiotherapy of prostate cancer in renal transplant recipients: single-center experience.

This study analyzed the long-term outcomes of localized prostate cancer in renal transplant recipients after radiotherapy treatment - mainly brachytherapy. We retrospectively analyzed clinical data of renal transplant recipients between 2003 and 2016 at a single tertiary center, and identified four patients with high serum PSA level during regular follow-up, 1-108 months after primary renal transplantation. The mean age of patients with detected high serum PSA level with 9.25µg/l median was 59.05 years. All four patients had functioning grafts. To prove prostate cancer, they underwent trans-rectal prostate biopsy, with no complications. Histological evaluation identified prostate adenocarcinoma (Gleason 6-7, stage T1-2cN0M0) in three patients. The biopsy in the fourth patient was negative and he therefore had trans-urethral prostate resection. Histological evaluation of resected prostate tissue revealed prostate adenocarcinoma (Gleason 7, 4+3). All patients began treatment with androgen deprivation therapy. Three patients were indicated for permanent prostate brachytherapy (BT) with iodine-125 (125I) seeds and the trans-urethral resection patient was referred for external beam radiotherapy (EBRT). After a mean follow-up of 49 months (range, 30-73), all patients, irrespective of type of radiotherapy, were in complete clinical and biochemical remission, with undetectable PSA levels. The kidney grafts remained functional, with a mean creatinine level of 99 µmol/l (range 64-123) and a glomerular filtration rate of 1.17 ml/s/1.73 m2 (range, 0.89-1.59). Radiation-induced late adverse effects were reported in two BT patients; one had clinically significant urine incontinency and the other suffered urethral stricture. Localized prostate tumor was identified in all reported patients, and all received radiotherapy plus androgen deprivation. All patients were disease-free at the time of the last follow-up. Therefore, combined BT and twelve months androgen deprivation appears both safe and effective for patients with prostate cancer after kidney transplantation.

Results of long term testosterone replacement therapy in men with abdominal obesity, erectile dysfunction and testosterone deficiency.

INTRODUCTION: In this article, the authors evaluate subjective and objective results of long testosterone replacement therapy (TRT) and possible risk. METHODS: In a single center study, the authors treated 69 men with testosterone deficiency syndrome (TDS). The average age was 57.84 years and the follow-up period was 94.62 months. All men had at beginning a complete urological and internal examination. All the men were treated with three-month i.m. injections of 1000 mg testosterone undecanoate. The men were regularly checked according to the EAU guidelines. RESULTS: All of the men on treatment felt much better. Weight and waist circumference during monitoring showed a mild improvement. Excellent results were on red blood cells. Glucose, HDL cholesterol, triglycerides had stable values. PSA slightly increased and testosterone was within the normal range. In two men during treatment, we found a prostate cancer (low risk). Bone mineral density (BMD) of lumbar spine revealed a significant improvement. CONCLUSION: TRT had multiple positive effect on affected men with TDS. Our long-term results showed a long mild improvement during the time. Authors concluded that long term treatment had multiple benefit for affected men (Fig. 11, Ref. 13).

Lipoprotein particle sizes in patients undergoing kidney transplantation.

Asymptomatic atherosclerotic disease is prevalent in the middle-aged group of kidney transplant recipients. In order to improve the estimation of their cardiovascular risk, dyslipidaemia pattern is very important to be evaluated. Knowledge of the lipid particle spectrum in patients undergoing kidney transplantation could help the clinicians to timely start intervention and prevention of atherosclerosis with an early hypolipidemic statin treatment (Tab. 2, Ref. 20).

Multiple endocrine neoplasia 2A (MEN 2A) syndrome.

INTRODUCTION: In the MEN 2A syndrome, which is the most common of the three types of MEN, three endocrine systems are affected simultaneously or subsequently by the development of tumours manifested by medullary thyroid gland carcinoma, pheochromocytoma (often bilateral) and hyperparathyroidism. MATERIAL AND METHODS: 27 patients from 3 families affected by MEN 2A syndrome were examined clinically (by detecting the effects of catecholamine overproduction), biochemically (screening for metanephrine and normetanephrine in the serum), visualization (CT, MRI, MIBG, PET CT) and some of them also genetically (DNA fragment analysis obtained by PCR amplification). RESULTS: Familial incidence of pheochromocytoma was confirmed in 10 patients (4 males, 5 females and one girl) aged 6 to 54 years (average 22.8 years) . In 5 patients, the pheochromocytoma occurred on both sides, in one patient, with genetically proved MEN 2A syndrome, only one adrenal gland was affected by pheochromocytoma. In 10 patients, mutations were detected in the exon 10, 11 and 16 RET of the proto-oncogene in the centromeric region of the 10th chromosome. After proper preparation, 5 patients underwent bilateral adrenalectomy (unilateral adrenalectomy in one patient). Histological examination of the removed tumours in all cases excluded the malignant pheochromocytoma.The first of the operated patients (54 yr) died after surgery for cardiovascular failure. Others have lived 5 to 15 years after bilateral adrenalectomy without signs of local recurrence of the disease, and have no clinical signs of over-production of catecholamines. CONCLUSION: Bilateral pheochromocytoma and thyroid carcinoma are indications for detailed clinical and genetic examination of all family members. Bilateral adrenalectomy with lifetime supplementation of adrenal hormones is indicated in symptomatic patients and/or patients asymptomatic with tumours larger than 3 cm in diameter (Tab. 1, Fig. 11, Schema 1, Ref. 31).

Testosterone replacement therapy (TRT) and its effect on bone marrow. How serious is it and is there a true polyglobulia?

INTRODUCTION: TRT in men with testosterone deficiency syndrome (TDS) had multiple positive effects and restore a quality of life of affected men. Polyglobulia is the most common dose-limiting adverse effect of TRT, but the mechanisms of TRT-mediated erythropoesis remain unclear. In this study, we evaluated long term haematological side effects of TRT: polyglobulia, elevated hemoglobin (Hb) and haematocrit (Ht). METHODS: In a cross-sectional descriptive study, the authors treated 69 men with TDS and the average age 59 years and the follow-up period 81.32 months. The men were treated with three-month i.m. injections of 1000 mg testosterone undecanoate. The elevated values were: Hb above 176 g/l, Ht above 0.52 and erythrocytes (Ery) above 6.0 mil/mcl. RESULTS: 21 out of 69 patients (30.43 %) had an increased Hb, Ht or Ery during treatment. The interesting fact was that only five men (7.24 %) had increased the number of Ery (true polyglobulia). No men with elevated level of Hb, Ht or Ery had other side effects (like thrombosis). CONCLUSION: It is still not clear, why in some men on TRT the feedback does not work and bone marrow production of red blood cells continues even if the upper limit is reached. Authors expect that only 7% of men had true polyglobulia, other men had elevated Hb or Ht. Based on our own experience we recommend a regular check of men on TRT on order to avoid possible serious side-effects (Tab. 1, Fig. 2, Ref. 25).

Nitroso-sulfide coupled signaling triggers specific vasoactive effects in the intrarenal arteries of patients with arterial hypertension.

In normotensive conditions, it has been confirmed that S-nitrosothiols (RSNO), can interact with hydrogen sulfide (H2S) and create new substances with specific vasoactive effects. This interaction could also represent a new regulator signaling pathway in conditions of hypertension. Until now, these effects were studied only in normotensive rats, and they have not been carried out in humans yet. We investigated the vasoactive effects of the products of the H2S/S-nitrosoglutathione (S/GSNO) interaction in lobar arteries (LA) isolated from the nephrectomized kidneys of patients suffering from arterial hypertension and in renal arteries (RA) of spontaneously hypertensive rats (SHR). The changes in the isometric tension of pre-contracted arteries were evaluated. Acetylcholine-induced vasorelaxation of LA was reduced compared to the effect induced by an NO donor, sodium nitroprusside suggesting an endothelium dysfunction. While 1 µmol/L Na2S had a minimal effect on the vascular tone, the concentration 20 µmol/L evoked a slight vasorelaxation. GSNO at 0.1 µmol/L induced vasorelaxation, which was less pronounced compared to the effect induced by 1 µmol/L. The S/GSNO products (final concentration 0.1 µmol/L) prepared as the mixture of GSNO (0.1 µmol/L) + Na2S (1 µmol/L) induced a higher vasorelaxation compared to GSNO (0.1 µmol/L) alone only in the 5th minute and without the differences in the speed. On the other hand, the S/GSNO products (final concentration 1 µmol/L) prepared as the mixture of GSNO (1 µmol/L) + Na2S (10 µmol/L) induced a higher and faster vasorelaxation compared to the effect induced by GSNO (1 µmol/L) alone. In RA of SHR this S/GSNO products induced similar vasorelaxation (higher and faster than GSNO) with involvement of HNO (partially) and cGMP as mediators. However, the products of the H2S/NO donor (DEA NONOate) manifested differently than S/GSNO indicating the unique interaction between GSNO and H2S. In this study, we confirmed for the first time that specific vasoactive effects of coupled nitroso-sulfide signaling were also triggered in human arterial tissue. We suggest that in hypertension, H2S in interaction with GSNO regulated a vasoconstrictor-induced increase in arterial tone towards a stronger vasorelaxation compared to GSNO alone or H2S alone.

Neutrophil-to-lymphocyte ratio as a predictor of preoperative tumor staging in testicular germ cell tumors.

OBJECTIVES: The aim of our study was to evaluate associations of elevated preoperative neutrophil-to-lymphocyte ratio (NLR) with testicular germ cell tumors (GCT) characteristics other than cancer specific survival (CSS) and progression free survival (PFS). BACKGROUND: NLR was recently presented as a widely available and inexpensive marker of poor prognosis in several types of solid tumors. Previous study showed no predictive value of NLR for CSS and PFS in testicular GCT. METHODS: Association of high NLR with histological type of tumor, presence of metastatic disease preoperatively and worse than T1 stadium in TNM classification preoperatively was analyzed in 103 patients who underwent radical orchiectomy for testicular GCT. RESULTS: No statistically significant difference in the prevalence of seminomas and non-seminomas neither in the group with NLR≥4 (p=0.6698) nor in the group with NLR<4 (p=0.9115) was detected. Similarly, no statistically significant difference in the prevalence of metastatic and non-metastatic disease in the group with NLR≥4 (p=0.2008), however statistically significant higher prevalence of non-metastatic disease in the group with NLR<4 (p=0.0001) was found. There was a statistically significant higher number of patients with worse than T1 stadium in patients with NLR≥4 (p=0.0105), but not significant difference in the group with NLR<4 (p=0.0956). CONCLUSION: The results of our study showed that NLR lower than 4 predicts non-metastatic disease and NLR higher or equal 4 predicts worse than T1 stadium (Tab. 3, Ref. 12).

Occurrence of malignancies after kidney transplantation in adults: Slovak multicenter experience.

Malignancies are one of the three major causes of renal recipient´s death with a functioning graft after cardiovascular diseases and infections. Among the variety of risk factors, including conventional and specific to transplant recipients, the duration of immunosuppressive therapy, the intensity of therapy, and the type of immunosuppressive agent all have an impact on development of post-transplant malignancy. The aim of our retrospective study was to document the incidence, the type of malignancies, the patient/graft survival in the group of kidney transplant recipients in Slovak Republic, and to identify the factors which influenced the outcome. We analyzed the data of 1421 patients who underwent renal transplantation from deceased or living donors in the period from 2007 to 2015 in the Slovak transplant centers. The incidence of malignant tumors was 6%, the malignancy was diagnosed in 85 patients at the age of 54.1 ± 9.8 years, more frequently in men (68.2 %; P < 0.0001). The mean time of malignancy occurrence was 45 months after transplantation. The most frequent malignancies were skin cancers- basal cell carcinoma (BCC) in 17.6%, squamous cell carcinoma (SCC) in 8.2%, and malignant melanoma (MM) in 2.4% of patients, followed by non-skin tumors such as renal cell carcinoma (RCC) in 16.5%, cancer of colon in 12.9%, prostatic cancer in 9.4%, breast cancer in 9.4%, cancer of lung in 7.1%, post-transplant lymphoproliferative disease (PTLD) in 2.4%, cancer of urine bladder in 2.4%, and cancer of sublingual gland in 1.17% of patients. Surgical treatment was used in 40% of patients, chemotherapy in 7.1%, radiotherapy in 2.4%, treatment with biological agents in 15.3%, combined therapy in 29.4% and palliative treatment in 5.9% of patients. 55.3% of patients underwent conversion from other immunosuppressive agents into mTORi at the time of malignancy occurrence. The remission was achieved in 48.2% of patients, 28.2% of patients were in the oncology treatment in the end of the year 2015, and 23.5% of patients died. There was no difference in the kidney function at the time of malignancy occurrence (s-creat 133.7 ± 59.8 µmol/l) and one year later (s-creat 131.1 ± 47.9 µmol/l) (P = 0.7768). The patients after successful treatment more frequently suffered from BCC (P = 0.0140), did not undergo palliative treatment (P = 0.0033), but were more frequently treated surgically (P < 0.0001).

Impact of Trough Levels of Tacrolimus on Kidney Function and Graft Survival in Short and Longer Periods After Renal Transplantation.

BACKGROUND: Optimizing immunosuppressive treatment in the early posttransplant period is important for achieving long-term graft function and survival. MATERIAL AND METHODS: There were 205 renal transplant recipients involved in this study. Patients were divided into groups according to the induction therapy (no induction vs basiliximab/daclizumab vs rabbit antithymocyte globulin), maintenance therapy at the time of transplantation (tacrolimus [TAC] vs cyclosporine), the average trough TAC levels in months 4 to 6 after TO and serum creatinine 5 years after renal transplantation. RESULTS: The incidence of acute rejection was significantly higher in cyclosporine than in TAC group of patients (P = .0364). The average TAC levels on elapsed time after transplantation significantly decreased (P < .0001). Five years after renal transplantation, there were higher TAC levels (5.6 ± 0.7 ng/mL) in the group with "zero" low levels than in the group with "zero" high levels (4.6 ± 1.1 ng/mL), which was statistically significant (P < .0001). We did not find any difference in graft and patient survival in posttransplant years 2 to 5 according to TAC levels or the induction treatment. CONCLUSIONS: In our study, we have confirmed that better graft function 5 years after transplantation was connected with higher trough tacrolimus levels on elapsed time after renal transplantation.

Activation of the ER stress and calcium signaling in angiomyolipoma.

Renal angiomyolipomas (AMLs) are uncommon benign tumors that occur sporadically or as a part of tuberous sclerosis complex (TSC). Risk of life threatening hemorrhage is the main clinical concern. Although several evidences suggest that hyper-activation of the mammalian target of rapamycin complex 1 (mTORC1) signaling pathway is crucial for these tumors, modulation of other metabolic pathways might affect tumor growth and progression. Therefore, we aimed to further characterize angiomyolipoma by TSC1/TSC2 expression, hypoxic status, expression of endoplasmic reticulum (ER) stress markers and calcium transport from the ER through the inositol 1,4,5-trisphosphate (IP3) receptors. Despite our expectations, angiomyolipoma were not hypoxic, as determined by absent expression of the carbonic anhydrase IX, which is a reliable marker of hypoxia. This was in accord with very low expression of TSC1 (that is associated with HIF activation) and a high expression of TSC2. Angiomyolipoma specimens also showed a significant upregulation of an anti-apoptotic marker Bcl2 when compared to healthy kidney tissue supporting the induction of pro-survival signaling. Moreover, angiomyolipoma specimens showed the overexpression of the ER stress markers XBP1, CHOP and ATF4 as well as of the mediators of calcium metabolism, namely the type 1 and 2, but not the type 3 IP3 receptors. These data suggest that the ER stress response, survival and calcium metabolism-related pathways but not hypoxia is an important component of the angiomyolipoma pathogenesis.

Extremely rare tumour--malignant mesothelioma of tunica vaginalis testis.

INTRODUCTION: Malignant mesothelioma of tunica vaginalis testis is an extremely rare tumour. It is often caused by exposition to asbestos, however, more often its occurrence is sporadic. The diagnosis is usually set secondarily during hydrocele surgery. This type of tumour should be considered in cases with with atypical hydrocele, especially haematocele or atypical shape of seminal covering. RESULTS: A case of an asbestos-exposed patient with described disease and long-term hydrocele is presented. The number of patients is so small that the guidelines are limited due to low statistical power (Fig. 2, Ref. 14).

Impact of kidney transplantation on restless legs syndrome.

AIM: Our study was to assess the impact of kidney transplantation on restless legs syndrome (RLS) in end stage renal disease (ESRD) patients. METHODS: A total of 75 patients after a successful kidney transplantation (39 males, 36 females) were assessed consecutively. All patients completed the self reported questionnaire focused on RLS 6 months after kidney transplantation with investigation of selected laboratory parameters. The questionnaire met the International Restless Legs Syndrome Study Group criteria for RLS diagnosis. RESULTS: 30 (40.54%) out of 75 patients met the RLS diagnostic criteria. From this RLS positive group, 8 (26.7%) of them reported a complete regression of symptoms, 13 (43.3%) reported symptoms relief, 6 (20.0%) were without any change and 3 (10.0%) reported worsening of symptoms after kidney transplantation. In the RLS positive group, the majority of patients (26-86.7%) reported the occurrence of the symptoms in the evening and 21 (70.0%) of RLS positive patients reported the onset of symptoms after the onset of renal disease. CONCLUSION: Although the secondary RLS in EDRS patients is very common, it is often unrecognized or misdiagnosed. We concluded that kidney transplantation, except the primary benefit to kidney replacement and to its function, has a secondary impact on other conditions such as RLS (Tab. 5, Fig. 4, Ref. 17).

Inflammatory pseudotumour of urinary bladder - a rare cause of massive macroscopic haematuria.

PURPOSE: Authors analyzed their experience with urinary bladder tumours. This article discusses clinical and histopathological diagnostics and treatment procedures, and follow up of patients with rare benign urinary bladder tumours. METHODS: 406 patients with bladder tumours were treated in our department between January 2000 and December 2008. 322 patients had superficial tumours and 84 had primary invasive tumours. All patients who underwent transurethral resections of these tumours were operated under general or spinal anaesthesia. The resected specimens were histologically examined in the department of Pathology. RESULTS: 399 of the 406 patients had urothelial bladder cancer, 7 patients had a histologically uncommon type of bladder tumour, one female was diagnosed with sarcomatoid bladder cancer, one patient had a histologically confirmed feochromocytoma of the urinary bladder. Two males had epidermoid carcinoma. One female had a histologically described uncommon benign pseudoneoplastic lesion, chararacteristic for endosalpingiosis. Another two patients were diagnosed with inflammatory myofibroblastic tumour of the urinary bladder. Both patients presented with gross macroscopic haematuria. Authors performed complete transurethral tumour resections, which required several sessions and the deliberation of a blocked ureter through nephrostomy in one case. CONCLUSION: More than 98 % of all treated patients had urothelial bladder cancer in different stages and grades. Two patients had rare benign inflammatory proliferation of the bladder wall which formed large tumorous bleeding masses obstructing the ureter in one case. These types of bladder tumour could be treated conservatively with meticulous long term follow up similarly to patients with bladder cancer (Tab. 1, Fig. 4, Ref. 15). .

Arterio-venous fistula with pseudoaneurysm of renal artery.

INTRODUCTION: The authors describe a rare but potentially severe, sometimes even life-threatening complication occurring after various invasive renal interventions. The cause that gives rise to a fistula formation between close branches of renal artery and vein is an injury of these vessels during resection of a localised renal tumour, renal biopsy, percutaneous nephrostomy, and even blunt injury of the kidney. Blood flows under pressure from renal artery, pushes the surrounding renal parenchyma open, and creates a cavity varying in size and shape. This pseudoaneurysm may communicate with the collecting system of the kidney, in which case it may lead to haematuria, one of the typical symptoms of arteriovenous fistula. MATERIAL AND METHODS: The authors observed this complication in 8 patients (6 males aged from 56 to 70, average 61.7, and two females aged 28 and 54). In 7 patients, the fistula developed after resection of a localised renal tumour, in one patient after percutaneous nephrolitholapaxy of a stone in the kidney. The fistulae manifested themselves between 7 an 21 days after surgery by massive haematuria in 4 patients and by intermittent macroscopic haematuria in 3 patients. In one patient the fistula was asymptomatic while the pseudoaneurysm at the place of pathological connection of renal veins was found during ultrasonographic examination after renal resection. RESULTS: In all patients, the diagnosis of arteriovenous fistula and pseudoaneurysm of renal artery was achieved by ultrasonographic and/or CT examinations. The highest diagnostic value can be ascribed to digital subtraction renoangiography by Seldinger method that subsequently allowed active treatment by introducing an endovascular coil. By this method we cured 5 fistulae. In two patients, urgent nephrectomies were needed because of massive life-threatening haematuria. One of arteriovenous fistulae underwent spontaneous thrombosis. CONCLUSION: The symptomatic arteriovenous fistula requires fast and precise diagnosis subsequently enabling efficient treatment. Endovascular manipulation is a method allowing the preservation of kidney affected by arteriovenous fistula with renal artery pseudoaneurysm (Fig. 7, Ref. 21).

Bone mineral density, pathological fractures and bisphosphonate therapy in prostate cancer patients on androgen deprivation therapy.

OBJECTIVES: The aim of the study is to evaluate the changes of bone mineral density (BMD), incidence of pathological fractures and to asses the effect of bisphosphonate therapy in prostate cancer patients (PCa) on androgen deprivation therapy (ADT) with the use of LHRH. METHODS: In this prospective study bone mass density (BMD) was assessed by dual x-ray absorptiometry (DXA) in 97 PCa patients and 89 patients of compared group. DXA was examined at baseline and patients in the study group were subjected to ADT. PCa patients with osteoporosis were treated by calcium, vitamin D, and bisphosphonate and the subsequent DXA was made after 10 months. All other PCa patients (non-osteoporotic) had DXA examined every 12-14 months. RESULTS: Patients of the study group had significantly lower baseline L1-L4 and total hip BMD (p=0.028, p=0.022). BMD was significantly lower in L1-L4 and total hip (p=0.004, p<0.001, resp.) after 10-14 months and in L1-L4, femoral neck, and total hip (p=0.001, p=0.037, p< 0.001, resp.) after 20-26 months of ADT. After the treatment for osteoporosis with bisphosphonate a significant increase of BMD (p=0.04) was found in a total of 23 patients. Overall, the incidence of fractures after 20-26 months of ADT was 8.5 %. CONCLUSIONS: Osteopenia is very common in hormone naive PCa patients. There was a significant loss of BMD after 12 months of ADT which was progressive while the patients were on ADT. Bisphosphonate therapy was effective after 20 months of treatment. The incidence of pathological fractures was 7-fold higher in the study group.