OCT4 immunohistochemistry after staging laparoscopic retroperitoneal lymphadenectomy for testicular tumor.

Twenty to thirty percent of patients with clinical stage I testicular tumor have metastases in the retroperitoneum. The aim of this study was to evaluate the role of OCT4 immunohistochemistry in histopathologic diagnosis of lymph node metastases in patients with nonseminomatous germ cell testicular tumors. All clinical stage I patients with staging laparoscopic retroperitoneal lymphadenectomy from 2001 until 2009 were included. Archived materials of dissected lymph nodes were reassessed and additional immunohistochemical staining with OCT4 antibody was performed in patients diagnosed as free from metastases. Each slide was visually estimated for the percentage of tumor cells showing nuclear immunoreactivity for OCT4. The study included 93 patients, of which 30 (32.3%) had initially positive retroperitoneal lymph nodes. Of the remaining 63 patients, materials were missing for 5 patients, so additional immunohistochemical staining was performed in 58 patients. Of these, two (3.4%) patients were OCT4 positive, suggesting a conclusion that they were initially misdiagnosed as stage I and metastasis free. OCT4 proved its value in detecting retroperitoneal metastases. Staging laparoscopic retroperitoneal lymphadenectomy for nonseminomatous germ cell testicular tumors in clinical stage I is a reasonable option for selected patients.

Laparoscopic partial nephrectomy with diode laser: a promising technique.

OBJECTIVE: The aim of this study was to evaluate application of diode laser in laparoscopic partial nephrectomy (LPN), and to question this technique in terms of ease of tumor excision and reduction of warm ischemia time (WIT). BACKGROUND DATA: LPN is the standard operative method for small renal masses. The benefits of LPN are numerous, including preserving renal function and prolonging overall survival. However, reduction of WIT remains main challenge in this operation. In order to shorten WIT, many techniques have been developed, with variable results. PATIENTS AND METHODS: We performed a prospective collection and analysis of health records for patients who were operated on between March 2011 and August 2012. Inclusion criteria were single tumor ≤ 4 cm, predominant exophytic growth and intraparenchymal depth ≤ 1.5 cm, with a minimum distance of 5 mm from the urinary collecting system. RESULTS: We operated on 17 patients. Median operative time was 170 min. In all but two patients, we had to perform hilar clamping. Median duration of WIT was 16 min. Pathohistological evaluation revealed clear cell renal cancer and confirmed margins negative for tumor in all cases. Median size of the tumor was 3 cm. Median postoperative hospitalization was 5 days. Average follow up was 11.5 months. There were no intraoperative complications. One postoperative complication was noted: perirenal hematoma. CONCLUSIONS: Laser LPN is feasible, and offers the benefit of shorter WIT, with effective tissue coagulation and hemostasis. With operative experience and technical advances, WIT will be reduced or even eliminated, and a solution to some technical difficulties, such as significant smoke production, will be found.

Trends in prostate cancer incidence and mortality in Croatia, 1988-2008.

AIM: To describe and interpret prostate cancer incidence and mortality trends in Croatia between 1988 and 2008. METHODS: Incidence data for the period 1988-2008 were obtained from the Croatian National Cancer Registry. The number of prostate cancer deaths was obtained from the World Health Organization mortality database. We also used population estimates for Croatia from the Population Division of the Department of Economic and Social Affairs of the United Nations. Age standardized incidence and mortality rates were calculated by the direct standardization method. To describe time trends of incidence and mortality, joinpoint regression analysis was used. RESULTS: Average age-standardized incidence rate between the first and last five-year period doubled, from 19.0/100,000 in 1988-1992 to 39.1 per 100,000 in 2004-2008. Age-standardized mortality rate increased by 6.9%, from 14.5 to 15.5 per 100,000. Joinpoint analysis of incidence identified two joinpoints. The increasing incidence trend started from 1997, with the estimated annual percent of change (EAPC) of 12.9% from 1997-2002 and of 4.1% from 2002-2008. Joinpoint analyses of mortality identified one joinpoint. Mortality trend first decreased, with EAPC of -3.0% from 1988-1995 to increase later with EAPC of 2.0% from 1995-2008. CONCLUSION: The incidence of prostate cancer in Croatia has been on the increase since 1997. Trend in mortality is increasing, contrary to the trends in some higher-income countries. An improvement in the availability of different treatment modalities as well as establishing prostate cancer units could have a positive impact on prostate cancer mortality in Croatia.

Pilot study of the association between the HLA region and testicular carcinoma among Croatian patients.

OBJECTIVES: To analyze the distribution of HLA alleles and HLA microsatellite alleles in Croatian patients with testicular carcinoma, compare it with that of healthy controls and investigate whether the polymorphism within the HLA region could be associated with the development of testicular cancer. METHODS: Genomic DNA was isolated from the peripheral blood of 24 patients with testicular germ cell tumors (TGCT). Patients and controls were typed for HLA class I and class II polymorphism by the PCR-SSO method. Nine HLA microsatellites were analyzed by PCR and electrophoresis in an automated sequencer. RESULTS: No significant deviation in the distribution of frequencies at HLA class I alleles was observed between patients and controls. Among HLA class II alleles, a statistically significant increase in the frequency of the HLA-DPB1*1701 allele was found among patients. The frequency of the HLA-DRB1*07-DQA1*0201-DQB1*0202 haplotype was increased in patients in comparison to the controls. Analysis of HLA microsatellites showed an increased frequency of D6S291-3 allele (p(corr) = 0.0455, OR = 3.05) among patients. CONCLUSIONS: The observed association of the disease and the DPB1*1701 allele as well as with the D6S291-3 allele suggests that this part of the HLA region might be involved in the pathogenesis of TGCT. Our data provide a basis for further studies about the correlation between the HLA region and testicular cancer.

Visualization of Reinke's crystals in normal and cryptorchid testis.

Within the human testis, Reinke's crystals are found in Leydig cells but their nature and function are poorly understood. The aim of our study was to investigate the properties of Reinke's crystals in man with the normal morphology of the testis (control group) and infertile patients diagnosed with cryptorchidism. 20 biopsies from infertile patients and six biopsies from men with regular spermatogenesis (20-30 years.) were used. Sections of the testis tissue were stained with haematoxylin and eosin and a modified Masson's method. Specimens were observed by bright field, confocal and transmission electron microscopy (TEM). The number of Reinke's crystals in investigated groups was determined applying stereological methods. In both groups, Reinke's crystals were noted within the cytoplasm and nuclei of Leydig cells. Some "free" crystals were found within the interstitial space, outside Leydig cells. Confocal microscopy proved to be very useful in the assessment of the shape and 3D reconstruction of the crystal. TEM analysis confirmed a hexagonal form of the crystal, while crystallographic data on sections of 70-300 nm thickness provided a better insight into the organization of the crystal lattice. Stereological analysis revealed a significant increase in the number of crystals in cryptorchid testes when compared with controls. Increased number of crystals in cryptorchid specimens leads to the assumption that the prolonged exposure to higher (abdominal) temperature might stimulate enzymes involved in the synthesis of the proteins of the crystal. However, the exact molecular nature of the crystal lattice remains in both normal and cryptorchid testis obscure.

[ISKRA guidelines on antimicrobial treatment and prophylaxis of urinary tract infections--Croatian national guidelines]. / ISKRA smjernice antimikrobnog lijecenja i profilakse infekcija mokracnog sustava--hrvatske nacionalne smjernice.

These guidelines refer to diagnosis, antimicrobial treatment and prophylaxis of urinary tract infections in adults and children older than 12 years of age and cover lower urinary tract in females, uncomplicated pyelonephritis, complicated UTI with or without pyelonephritis, asymptomatic bacteriuria and recurrent UTI. These guidelines do not cover sexually transmitted diseases. The guidelines are primarily intended for use by general practitioners and specialists working in primary health care and hospitals. The members of the Working Group for the development of guidelines on antimicrobial treatment and prophylaxis of urinary tract infections were appointed by the Croatian Ministry of Health and Social Welfare. The project was financially supported by the Dutch government and professional assistance was provided by international consultants. The evidence for this guidelines is based on a systematic review of the literature, local antibiotic resistance data, the existing clinical protocols on the treatment and prophylaxis of UTIs, as well as suggestions and comments made by colleagues physicians during more than 50 continuous medical education courses held in the last three years on antimicrobial treatment and prophylaxis of UTIs. Draft version of the guidelines was available for comments on the web site http://iskra.bfm.hr and during the two-month piloting period the guidelines were widely presented to general practitioners, specialists working in primary care and hospitals--urologists, gynecologists, infectious disease specialists, nephrologists. The final version of the guidelines was approved by the Intersectoral Coordination Mechanism for the Control of Antimicrobial Resistance (ISKRA) Board.

The role of Chlamydia trachomatis in prostatitis syndrome--our experience in diagnosis and treatment.

Since the beginning of 1999, over 1500 patients with symptoms of chronic prostatitis were examined at Dr. Fran Mihaljevic University Hospital for Infectious Diseases in Zagreb. In almost all of these patients urethral swabs and quantitative segmented bacteriologic cultures and microscopy of expressed prostatic secretion (EPS) or voided bladder urine3 (VB3) were performed as described by Meares and Stamey. Urethral swabs, EPS or VB3 were examined for the presence of Chlamydia (C.) trachomatis by McCoy culture and Lugol stain or by immunofluorescent typing with monoclonal antibodies. In the majority of patients C. trachomatis was demonstrated in parallel in EPS or VB3 by DNA/RNA hybridization method. Normal white blood cell count viewed per high power field<10 was found in 362 (68%) of 536 patients with symptoms of chronic prostatitis and C. trachomatis detected in EPS or VB3. These findings additionally suggest that C. trachomatis can be suspected as a causative pathogen in all categories of chronic prostatitis syndrome. Furthermore, this paper summarizes the results of five previously published clinical studies on the efficacy and tolerability of various treatment schemes for chronic chlamydial prostatitis, conducted from the beginning of 1999 until the end of 2003.

[Laparoscopic treatment of functioning adrenal tumors]. / Laparoskopsko lijecenje funkcionalno aktivnih tumora nadbubrezne zlijezde.

INTRODUCTION: Laparoscopy is now a widely used method for removal of functioning and non-functioning adrenal tumors. This paper reports our experience in laparoscopic transperitoneal removal of functioning adrenal tumors including pheochromocytoma, Cushing's disease and aldosteronoma. METHODS: Between May 2001 and April 2006, 29 patients underwent laparoscopic adrenalectomy for pheochromocytoma. In 37 patients (10 patients with bilateral adrenalectomy) adrenalectomy was performed for Cushing's disease, while 28 patients had aldosteronoma. In 2 patients adrenalectomy was performed for virilizing adenoma. RESULTS: All laparoscopic adrenalectomies were finished successfully, and no open surgery was necessary. Major postoperative complications were not observed. Mean hospital stay was 3 days. No patient required blood transfusion. CONCLUSIONS: Laparoscopic adrenalectomy for functioning adrenal tumors proved a safe and minimally invasive procedure. Laparoscopic adrenalectomy, in comparison with open surgery, has numerous advantages, including a shorter length of stay, shorter time to return to preoperative level of activity, better cosmetic effect, and decrease in postoperative pain.

The role of unusual pathogens in prostatitis syndrome.

A total of 1442 patients with symptoms of chronic prostatitis were examined over a 4-year period at the Outpatient Department for Urogenital Infections, University Hospital for Infectious Diseases "Dr. Fran Mihaljevic", Zagreb, Croatia. An infectious aetiology was determined in 1070 (74.2%) patients. In 561 of 1070 (52.4%) patients the inflammatory finding (>10 WBC/hpf) was found in expressed prostatic secretions (EPS) or voided bladder urine (VB(3)). Normal, <10 WBCs/hpf was found in 362 of 536 (67.5%) patients with symptoms of chronic prostatitis in whom Chlamydia trachomatis was detected in EPS or VB(3), in 51 of 151 (33.8%) patients with isolated Trichomonas vaginalis and in 40 of 72 (55.6%) patients with isolated Ureaplasma urealyticum. Escherichia coli was the causative pathogen in 95, Enterococcus in 68, Proteus mirabilis in 37, Klebsiella pneumoniae in 16, Streptococcus agalactiae in 19, and Pseudomonas aeruginosa in 3 patients with chronic prostatitis. Other patients had a mixed infection. In patients with chronic bacterial prostatitis (CBP) caused by E. coli, P. mirabilis, K. pneumoniae, E. or S. agalactiae, an inflammatory finding was regularly found in EPS or VB(3).

Comparative randomized pilot study of azithromycin and doxycycline efficacy in the treatment of prostate infection caused by Chlamydia trachomatis.

The study included 125 adult patients (> 18years of age) who had symptoms of chronic prostatitis and proven presence of Chlamydia trachomatis. The presence of C. trachomatis was confirmed in expressed prostatic secretion or in voided bladder urine collected immediately after prostatic massage by a DNA/RNA hybridization method and/or by isolation on McCoy culture and then by immunofluorescent typing with monoclonal antibodies. The patients were randomized in the ratio 2/1; azithromycin/doxycycline, to receive a total of 4.0 g azithromycin over 4 weeks, given as a single dose of 1 x 1000 mg weekly for 4 weeks or doxycycline 100 mg b.i.d. for 28 days. Patients' sexual partners were treated at the same time. Clinical and bacteriological efficacy was evaluated 4-6 weeks after the end of therapy. In the group of patients with chlamydial infection of the prostate, there was no significant difference between the eradication rates (azithromycin 65/82, doxycycline 33/43; P = 0.82) and the clinical cure rates (azithromycin 56/82, doxycycline 30/43; P = 0.94) of the two antimicrobials.

Long-term outcome after surgical kidney revascularization for fibromuscular dysplasia and atherosclerotic renal artery stenosis.

PURPOSE: At a time of minimally invasive surgery in urology, the role of surgical kidney revascularization in the management of renal artery disease has changed during the last decade. Our experience with surgical kidney revascularization, and the long-term clinical outcomes of fibromuscular dysplasia (FMD) and atherosclerotic renal artery stenosis are reviewed. MATERIALS AND METHODS: The study group comprised 140 patients with renovascular hypertension, 72 with FMD and 68 with atherosclerotic renal artery disease, who underwent surgical revascularization between 1982 and 1999. The indications for surgical revascularization were the treatment of hypertension and the preservation of renal function in 17 patients with renal artery occlusion, 55 with ostial stenosis, 52 with branch stenosis, 6 with bilateral artery stenosis, 7 with solitary kidney renal artery stenosis and 3 with solitary kidney renal artery occlusion. RESULTS: Postoperative blood pressure and renal function were monitored for 1 to 17 years (mean 11.3). Long-term blood pressure control was observed in 93% of patients with FMD and in 71% of those with atherosclerosis. Improvement or stabilization of renal function was observed in 92% of patients with FMD and in 68% of those with atherosclerosis. The preoperative estimated glomerular filtration rate compared to postoperative was significantly increased in both groups. CONCLUSIONS: Surgical kidney revascularization is effective in secondary hypertension with a high long-term efficacy in the normalization of blood pressure and in the preservation of renal function, especially in patients with a solitary or 1 functional kidney.

[Guidelines for antimicrobial treatment and prophylaxis of urinary tract infections]. / Smjernice antimikrobnog lijecenja i profilakse infekcija mokracnog sustava.

Recommendations for antimicrobial treatment and prophylaxis of urinary tract infections (UTI) have been made according to the results of investigation of resistance of the most frequent causative agents of UTI to antimicrobial drugs. This investigation has been conducted for the past seven years by the Committee for monitoring bacterial resistance to antibiotics in the Republic of Croatia, with consensus of eight professional societies of the Croatian Medical Association. Uncomplicated cystitis is treated 1, 3, or 7 days, complicated 7 days, pyelonephritis 10-14 days, and complicated UTI 7 to 14 days, rarely longer. For the treatment of cystitis fluorokinolons, nitrofurantoin, betalactam antibiotics, and in the fields of lower resistance trimethoprim/sulfamethoxazol are being used. Single treatment with fluorokinolons is administered to otherwise healthy young women with normal urinary tract in whom cystitis symptoms have been present for less than 7 days. Empiric antimicrobial treatment of pyelonephritis, recurrent and all complicated UTI must be reviewed after urine culture finding is obtained. In the treatment of bacterial prostatitis and febrile UTI in males, the drug of first choice is ciprofloxacin. Asymptomatic bacteriuria (AB) is treated in pregnant women, newborns, preschool children with urinary tract abnormalities, before invasive urologic and gynecologic procedures, in kidney transplant recipients, and in the first days of short term urinary bladder catheterization. Recommendations for the treatment of AB in patients with diabetes mellitus have been controversial in the past two years. Antimicrobial prophylaxis is administered mostly one hour prior to the diagnostic or therapeutic invasive urological procedure, using selected antimicrobial agents.

Comparative analysis of azithromycin and ciprofloxacin in the treatment of chronic prostatitis caused by Chlamydia trachomatis.

A total of 89 patients, (>18 years), with symptoms of chronic prostatitis and inflammatory findings as well as the presence of Chlamydia trachomatis confirmed by DNA/RNA DIGENE hybridization method and/or by isolation, McCoy culture and Lugol stain in expressed prostatic secretion or in voided bladder urine collected immediately after prostatic massage, were examined. The patients were randomized to receive a total of 4.5 g of azithromycin for 3 weeks, given as a 3-day therapy of 1 x 500 mg weekly or ciprofloxacin 500 mg b.i.d. for 20 days. Patients' sexual partners were treated at the same time. Clinical and bacteriological efficacy were evaluated 4-6 weeks after the end of therapy. Significantly higher eradication (36/45: 17/44; P=0.0002) and a significantly higher clinical cure (31/45: 15/44; P=0.0021) were achieved in the group of patients treated with azithromycin than in the ciprofloxacin group.

The transcriptional co-activator cAMP response element-binding protein-binding protein is expressed in prostate cancer and enhances androgen- and anti-androgen-induced androgen receptor function.

Progression of human prostate cancer toward therapy resistance occurs in the presence of wild-type or mutated androgen receptors (ARs) that, in some cases, exhibit aberrant activation by various steroid hormones and anti-androgens. The AR associates with a number of co-activators that possess histone acetylase activity and act as bridging molecules to components of the transcription initiation complex. In previous reports, it was shown that the transcriptional co-activator CREB (cAMP response element-binding protein)-binding protein (CBP) enhances AR activity in a ligand-dependent manner. In the present study, we have investigated whether CBP modifies antagonist/agonist balance of the nonsteroidal anti-androgens hydroxyflutamide and bicalutamide. In prostate cancer DU-145 cells, which were transiently transfected with CBP cDNA, hydroxyflutamide enhanced AR activity to a greater extent than bicalutamide in the presence of either wild-type or the mutated AR 730 val-->met. In two sublines of LNCaP cells that contain the mutated AR 877 thr-->ala and overexpressed CBP, increase in AR activity was observed after treatment with hydroxyflutamide but not with bicalutamide. Anti-androgens did not influence AR expression in cells transfected with CBP cDNA, as judged by Western blot analysis. Endogenous CBP protein was detected by Western blot in nuclear extracts from the three prostate cancer cell lines, LNCaP, PC-3, and DU-145, all derived from therapy-resistant prostate cancer. In addition, CBP was expressed in both basal and secretory cells of benign prostate epithelium, high-grade prostate intraepithelial neoplasia, and prostate cancer clinical specimens, as evidenced by immunohistochemical staining. Taken together, our findings demonstrate the selective enhancement of agonistic action of the anti-androgen hydroxyflutamide by the transcriptional co-activator CBP, which is a new, potentially relevant mechanism contributing to the acquisition of therapy resistance in prostate cancer.

Aetiology of chronic prostatitis.

A total of 388 patients with symptoms of chronic prostatitis and inflammatory findings in expressed prostatic secretion (EPS) or in a urine sample collected immediately after prostate massage, were examined over a 2 year period at the Outpatient Department for Urogenital Infections, University Hospital for Infectious Diseases 'Dr Fran Mihaljevic', Zagreb, Croatia. The infective aetiology was determined in 276 (71.13%) patients. Chlamydia trachomatis was the causative pathogen in 109 patients, Trichomonas vaginalis in 52, Escherichia coli in 26, enterococci in 25, Proteus mirabilis in 14, Klebsiella pneumoniae in six, Streptococcus agalactiae in eight, Ureaplasma urealyticum in seven patients with chronic prostatitis. Other patients had a mixed infection.

[Classification, diagnosis and treatment of prostatitis syndrome]. / Klasifikacija, dijagnostika i lijecenje sindroma prostatitisa.

The term prostatitis syndrome refers to a number of conditions affecting the prostate. Prostatitis syndrome is clinically manifested through symptoms of the lower urogenital tract and perineum. Basic factors in the classification of prostatitis syndrome are clinical symptoms and signs, and the presence of leukocytes and bacteria in selectivelly collected urine samples and in expressed prostatic secretion obtained by the Meares and Stamey localization technique. Antimicrobial therapy is indicated in patients with acute bacterial prostatitis, chronic bacterial prostatitis and chronic inflammatory nonbacterial prostatitis, which also includes bacterial prostatitis unproved by classical methods. Empirical antimicrobial treatment should be initiated immediately in patients with acute bacterial prostatitis and in patients with acute exacerbation of chronic bacterial prostatitis. Targeted antimicrobial therapy is administered in patients with chronic bacterial prostatitis after obtained microbiological results, and empirical antimicrobial therapy lasting for 2-6 weeks in patients with chronic inflammatory nonbacterial prostatitis. Because of their broad spectrum of activity and pharmacodynamic and pharmacokinetic characteristics, fluoroquinolones, ciprofloxacin and ofloxacin are first choice antimicrobial drugs for the treatment of prostatic inflammatory diseases. The efficacy of administered antimicrobial treatment should be followed up 4-6 weeks (early follow-up) and 6 months (late follow up) after the end of antimicrobial therapy. The treatment of a noninflammatory chronic pelvic pain syndrome without proved infection includes phytotherapy, hygienic-dietetic measures, microwave thermotherapy, alpha-adrenergic blocking agents, muscle relaxants, analgesics, non-steroidal antiflogistics, 5-alpha-reductase inhibitors, modified living habits, psychotherapy and antispasmodic analgesics. All patients with chronic types of prostatitis syndrome should avoid drinking alcohol, carbonated beverages, spices, cycling, colds, especially sitting on cold surfaces.