Metastasis of Prostate Adenocarcinoma to the Testis.

INTRODUCTION: Prostate carcinoma is the most frequently diagnosed carcinoma in the male population. The most typical places of the metastases are pelvic lymphatic glands, bones and lungs, and very rarely it metastasizes into a testis. The prognostic importance of testicular metastasis of prostate cancer is not yet well-known, due to a very few published cases. According to the known facts, it is certain that a metastasis of the prostate carcinoma into a testis is a sign of an advanced disease. CASE REPORT: This work presents a 48-year-old patient, to whom an adenocarcinoma of the prostate has been proven by the pathohistological finding of transrectal biopsy, performed due to the elevated level of prostate-specific antigen (PSA). Nine years after the initial diagnosis, due to a gradual rise of PSA and tumorous enlargement of the left testis, left inguinal orchectomy and right orchectomy were performed. Metastatic dissemination of prostate adenocarcinoma into a testis was determined by a pathohistological analysis of the left testis. CONCLUSION: The metastasis of the prostate carcinoma into a testis, as a rare localization of the metastatic dissemination, after additionally performed orchectomy along with further oncological therapy, can provide a continuation of a good life quality as well as a control of the disease in a longer time period.

An Aggressive Retroperitoneal Fibromatosis.

INTRODUCTION: Aggressive fibromatosis (AF) is a heterogeneous group of mesenchymal tumors that have locally infiltrative growth and a tendency to relapse. The clinical picture is often conditioned by the obstruction of the ureter or small intestine. Diagnosis is based on clinical, radiological and histological parameters. A CASE REPORT: We report a case of male patient, aged 35 years, with the retroperitoneal fibromatosis. He reported to the physician because of frequent urination with the feeling of pressure and pain. Computed tomography revealed the tumor mass on the front wall of the bladder with diameter of 70mm with signs of infiltration of the musculature of the anterior abdominal wall. Endoscopic transurethral biopsy showed proliferative lesion binders by type of fibromatosis. The tumor was surgically removed in a classical way. The patient feels well and has no recurrence thirty-six months after the operative procedure. CONCLUSION: The complete tumor resection is the therapeutic choice for the primary tumor as well as for a relapse.

Radical cystectomy in eldery.

BACKGROUND/AIM: Radical cystectomy is the method of choice for the treatment of muscle invasive bladder cancer. This major surgery is associated with many complications, especially in older patients. The aim of this study was to analyze preoperative comorbidity, and intraoperative and postoperative complicatons in patients older than 75 years. METHODS: This clinical, retrospective study included 46 patients over 75 years, who underwent radical cystectomy. Indications for surgery, and complications during and after the surgery were followed up. RESULTS: Preoperatively, anemia caused by hematuria was registered in 76% of the patients. In 52% of the patients urine derivation was performed by ileal conduit, in 35% by ureterocutaneostomy and in 13% orthotopic ileal neobladder was created. The average duration of surgery was 190 (120-300) min. A total of 76% of the patients were treated by blood supstitution intraoperatively, average 630 (310-1230) mL. Concerning pathological stage of transitional cell carcinoma of urinary bladder, 26% of the patients had T2, 4% T3a, 52% T3b, and 14% T4a stage. In one case, planocellular carcinoma was diagnosed by patohistological examination, and in 2 cases prostate carcinoma was incidentally found. The average duration of hospitalization was 16 (8-35) days. CONCLUSION: The main reason for cystectomy in patients over 70-and 80 years was gross hematuria caused by bladder cancer, with consecutive anemia which could not be solved using endoscopic treat- ment or blood supstitution. As expected, a prolonged stay in hospital after cystectomy, and a higher rate of complications were recorded in this population.

[Post-voiding residual urine and capacity increase in orthotopic urinary diversion--standard vs. modified technique].

BACKGROUND/AIM: Ever since the time when the first orthotopic urinary diversion (pouch) was performed there has been a constant improvement and modification of surgical techniques. The aim has been to create a urinary reservoir similar to normal bladder, to decrease incidence of postoperative complications and provide an improved life quality. The aim of this study was to compare post-voiding residual urine (PVR) and capacity of the pouch constructed by standard or modified technique. METHODS: In this prospective and partially retrospective clinical study we included 79 patients. In the group of 41 patients (group ST) pouch was constructed using 50-70 cm of the ileum (standard technique). In the group of 38 patients (group MT) pouch was constructed using 25-35 cm of the ileum (modified technique). Postoperatively, PVR and pouch capacity were measured using ultrasound in a 3-, 6- and 12-month period. RESULTS: Postoperatively, an increase in PVR and pouch capacity was noticed in both groups. Twelve months postoperatively, PVR was significantly smaller in the group MT than in the group ST [23 (0-90) mL vs. 109 (0-570) mL, p < 0.001]. In the same period the pouch capacity was significantly smaller in the MT group than in the ST group [460 (290-710) mL vs. 892 (480-2 050) mL, p < 0.001]. CONCLUSION: Postoperatively, an increase in PVR and pouch capacity was noticed during a 12-month period. A year following the operation the pouch created from a shorter ileal segment reached capacity of the "normal" bladder with small PVR. The pouch created by standard technique developed an unnecessary large PVR and capacity.

Short ileal segment for orthotopic neobladder: a feasibility study.

OBJECTIVES: The objective of this study was to present the construction of a neobladder with a modified pouch technique using 25-35 cm of terminal ileum. METHODS: Thirty-eight patients whose pouch was constructed from 25-35 cm of terminal ileum (short pouch [SP] group) were prospectively evaluated vs 41 patients whose pouch was constructed from 50-70 cm of terminal ileum (long pouch group). Pouch volume, post-void residual (PVR) volume, need for catheterization, continence and voiding frequency were evaluated at 3 and 12 months after surgery. RESULTS: SP group patients had significantly smaller pouch capacity (440 vs 840 mL, P < 0.001) at month 12, and smaller PVR at postoperative months 3 (11 [0-43]vs 40 [0-147] mL, P < 0.001) and 12 (10 [0-90]vs 72 [0-570] mL, P < 0.001). SP group patients had significantly higher voiding frequency on postoperative month 3 (10 vs 9, P < 0.001) and 12 (7 vs 6, P < 0.005). Continence was significantly improved in the SP group compared with the long pouch group after 12 months (63.2% vs 34.1%, respectively, P = 0.034). Full continence improved significantly over time (P < 0.001) in the SP group, from 26.3% at month 3 to 63.2% at month 12. CONCLUSION: A pouch constructed from 25-35 cm of terminal ileum provides adequate capacity, smaller PVR, satisfactory continence and a better 24-h voiding frequency pattern during the first postoperative year.

Fournier's gangrene.

BACKGROUND: Fournier's gangrene (FG) represents a necrotizing infection of the skin and subcutaneous soft tissue of the external genitalia and perineum. It arises as a result of propagation of anorectal, urogenital and skin infections. The principles of treatment include improving general condition of a patient, debridement of wound, excision of necrotic tissue, combined antibiotic therapy, hyperbaric oxygen therapy and reconstructive procedures. It is a rare but very serious condition which regardless to aggressive treatment can lead to a lethal outcome in up to 20-30% of patients. CASE REPORT: Since the year 2000 we have treated six patients with FG. We presented the course and positive treatment outcome in a 65-year-old male patient with numerous comorbid conditions, nonregulated insulin-dependent diabetes, hypertension, previous myocardial infarction, chronic viral hepatitis and thrombocytopenia, rehabilitation was complicated with heart failure, atrial fibrillation and pulmonary thromboembolism. The treatment consisted of two extensive debridement of the wound with removing necrotic tissue, drainage, consolidation of state of health, correction of his blood sugar levels and thrombocytopenia, antimycotic and combination of three antibiotics and hyperbaric oxygen therapy. In two delayed surgical procedures reconstruction of a large defect of the urethra was performed. CONCLUSION: A patient with numerous and serious comorbid conditions with FG could recover as a result of teamwork of urologists, infective medicine specialists, cardiologists, endocrinologist, vascular and plastic surgeons.

[On 10-year experience in the use of direct and antireflux techniques of anastomosis of ureter and orthotopic intestinal neobladder after radical cystectomy].

BACKGROUND/AIM: Today, radical cystectomy is the method of choice in treatment of muscle invasive bladder carcinoma in stage T2-T4a, No-Nx, Mo, and orthotopic derivation is for patients the most comfortable derivation of urin. From 1888 when Tizzoni and Foggi performed the first orthotopic derivation on animals, and 1913 when Lemoin declared the first orthotopic derivation in humans there has been a constant improvement and modification of orthotopic urinary diversion after radical cystectomy which significantly decrease the number and severity of postoperative complications. The aim of this study was to compare complications regarding the direct and antireflux ureter-neobladder anastomosis. METHODS: This retrospective study included 79 selected patients operated over the last ten years having medical records available. Previously, we excluded the patients with prior radiation therapy, systemic illness, diabetes mellitus, previous history of calculosis and metabolic disorders etc. Hautmann orthotopic technique was used in almost 70% of the patients. We analyzed complications regarding direct and antireflux ureter-neobladder anastomosis with a median follow-up period of 4.72 years. We followed-up the appearance of unilateral and bilateral hydronephrosis, forming of renal stones in the patients without previous history of renal calculosis, and renal insuficiency caused by stenosis on the site of anastomosis. We used the Kolmogorov Smirnov test, Mann-Whitney U test, Student's ttest i chi2 test for statistic analysis. RESULTS: The median age of the patients was 68.2 years. Totally 88.61% of the patients were male and 11.39% were female. The direct anastomotic technique secundum Wallace was used in 43.03% of the operated patients and antireflux technique secundum Le Duc in 56.97%s. Renal deterioration caused by stenosis on the site of the ureter-neobladder anastomosis was statistically significantly higher in the antireflux anastomosis compared to direct anastomosis (chi2= 4.71, p = 0.0299). No one of the patients with direct anastomosis had poucho-ureteral reflux higher grade than gr III. CONCLUSION: In our study, complication as renal deterioration as a result of stenosis on the site of the ureter anastomosis was significantly more common in the group of patients exposed to antireflux technique.

[Evaluation of the depth of infiltration of urothelial carcinoma in the vesical wall obtained by transurethral intravesical echotomography].

BACKGROUND/AIM: Transitional cell carcinoma (TCC) is the most frequent tumor of the bladder and represents 95-98% of blader neoplasams and 2-3% of all carcinomas in the body. In urogenital oncology more frequent is only prostatic cancer. Evaluation of the depth of infiltration of urothelial carcinoma in the vesical wall represents the clinical base in treatment planning and prognosis. Clinical investigation and convential radiological procedures have a low level of accuracy in estimating the local growth of the tumor. The aims of our investigation were to determine the depth of infiltration of urothelial carcinoma in the vesical wall in the investigated group of patients by transurethral intravesical echotomography (TIE) and computerised tomography (CT scan) and to compare results obtained by both methods with pathohistological (PH) results, and, based on the difference of the results determine which method was more accurate in the evaluation of the depth of infiltration of urothelial carcinoma in the vesical wall. METHODS: Thirty patients with TCC of the bladder both genders, aged 51-81 years were involved in our investigation. In all of these patients, radical cystectomy (RC) was performed. This was neccessary to provide the defintive PH result. Transurethral intravesical echotomography was performed by ultrasound scanner type 1846 Bruel and Kjaer, sond type 1850, and the CT scan was perfomed by Pace plus, General Electric, U.S.A. The specimen for the definitive PH result obtained by RC includes all standards of the TNM classification. RESULTS: Using CT scan, the most frequent was T1 stage (17 patients or 56.68%). Using TIE, the most frequent was T2 stage (22 patients or 73.33%). After RC the most frequent was T2 stage (21 patients or 70%). The Kolmogorov-Smirnov test, showed a high significant difference between the results obtained using CT and definitive PH results after RC. The same test showed no statistically significant difference between the results obtained using TIE and definitive PH results. The sensitivity and accurance of TIE compared to definitive PH results was 93.3%, but using CT it was only 33.3%. CONCLUSION: There was a significant difference between the results obtained using CT and TIE. The results obtained by TIE were in closer relation with the definitive PH results than the results obtained by CT scan. TIE provides more precise evaluation of the depth of infiltration of urothelial carcinoma in the vesical wall than CT scan. We conclude that the use of this procedure in local staging in TCC is justified and represents the clinical basis in the treatment planning and disease outcome prognosis.