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

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

Prostate volume and urinary discomforts in elderly.

Occasional doubts about the real effect of the prostate volume on the urinary discomforts that elderly have been experiencing required additional assessment of these parameters. The aim of this study was to re-evaluate relationship between the urinary discomforts of the elderly and the prostate volume in comparison with age. Results of the group of 79 patients observed within one-year period were analyzed. In assessing their urinary discomforts the International Prostate Symptom Score (IPSS) was calculated, the ultrasound prostate volumetry was performed, and both of these parameters where compared with age. Statistical analysis of the results confirmed significant positive correlation between the prostate volume and age, positive correlation between IPSS and age, as well as between prostate volume and IPSS.

Diagnostic accuracy of ultrasound T-staging of the urinary bladder cancer in comparison with histology in elderly patients.

Urinary bladder cancer (UBC) is dominantly the cancer of the elderly occurring primarily in the 6h, 7!h and 81h decade of life. The aim of this study was to evaluate diagnostic accuracy of ultrasound T-staging (UTS) of UBC in dhe group of elderly patients. In 152 elderly patients referred to transabdominal ultrasound examination in two different facilities (76 each) due to various symptoms (primarily painless gross or microscopic haematuria) UBC was diagnosed. Initial UTS at the moment of detection was performed and compared with final histological T-staging (HTS). A high level of conformity between UTS and HTS was detected. In a total of 152 patients with UBC there were 115 (75.66%) patients with complete match between the UTS and HTS, 24 (15.79%) patients with minimal variation within one stage, and 13 (8.55%) patients with one stage difference between the UTS and HTS. The best result was established for the stage T1, where the accuracy was 94.5%. In other stages the accuracy was between 84.9% and 91.8%. The Youden's index for all the stages was over 0.6. UTS has a high diagnostic accuracy, especially for stages T1 and T2. It is extremely useful tool in differentiating the superficial UBC from the muscle-invasive one, being of significant importance in planning the further treatment of elderly patients and having important role in choosing appropriate surgical approach.

The role of negative pressure wound therapy in patients with kidney transplantation.

Kidney transplantation is the best treatment modality for patients with end-stage renal disease. Wound healing is impaired in these patients, and factors such as immunosuppression, older age and comorbidities have a negative impact on wound healing. Recently, negative pressure wound therapy has become an important wound management technique. We present two patients with wound healing issues in the early posttransplant period. In both patients, an imrnunosup- pressive treatment was administered, which included tacrolimus, mycophenolate mophetil and high-dose corticosteroids with anti-IL-2 induction therapy. Postoperatively, the wounds became inflamed with dehiscence. Negative pressure wound therapy was successfully applied to aid the wound healing. The treatment duration period was two weeks for one patient and three weeks for the other. After the treatment period, the wounds were significantly improved and were closed. After the secondary wound closures, the posttransplant course was uneventful in both patients. Presently, one and three years after the transplantations, both patients have well functioning kidneys. According to our limited experience, negative pressure wound therapy is a feasible and effective dehiscence wound treatment following kidney transplantation.

[Clinical guidelines for diagnosing, treatment and monitoring patients with bladder cancer--Croatian Oncology Society and Croatian Urology Society, Croatian Medical Association]. / Klinicke upute za dijagnostiku, lijecenje i pracenje bolesnika oboljelih od raka mokracnog mjehura Hrvatskoga Onkolokog Drustva i Hrvatskoga Uroloskog Drustva Hrvatskoga Lijecnickog Zbora.

Urothelial cancer is the most common bladder cancer. Hematuria is the most common presenting symptom in patients with bladder cancer. The most common diagnostics of bladder cancer is performed by transurethral resection of bladder after which pathohistological diagnosis is set. It is necessary to determine whether the cancer penetrated in muscle layer (muscle-invasive cancer) or not (muscle-noninvasive cancer). Decision on therapeutic modality depends on the clinical stage of disease and on prognostic and risk factors. For muscle non-invasive bladder cancer transurethral resection is preferred with or without intravesical instillation of Bacillus Calmette-Guérin (BCG). For invasive cancer the method of choice is radical cystectomy. Radiotherapy is used in radical and palliative purposes. Metastatic disease is most frequently treated by chemotherapy metotrexate/vinblastine/doxorubicine/cisplatin (MVAC) or gemcitabine/cisplatin (GC). The purpose of this article is to present clinical recommendations to set standards of procedures and criteria in diagnostics, treatment and follow up of patients with bladder cancer in the Republic of Croatia.

Lower cyclooxygenase-2 expression is associated with recurrence of solitary non-muscle invasive bladder carcinoma.

BACKGROUND: A new modality is necessary to prevent recurrence of superficial bladder cancer after complete transurethral resection because of the high recurrence rate even with current prophylaxis protocols. METHODS: In order to analyze the predictive value of cyclooxygenase-2 (COX-2) expression and tumor infiltrating lymphocytes (TILs) in recurrence of this disease tumor specimens from 127 patients with solitary papillary non-muscle invasive bladder cancer (NMIBC), 78 with recurrent disease and 49 without recurrence during follow up of minimum 5 years, were retrieved for tissue microarrays construction and immunohistochemical analysis. COX-2 expression was scored according to Allred's scoring protocol, while presence of TILs was categorized as absent (no) or present (yes) on whole tissue sections. RESULTS: COX-2 immunoreactivity was presented in 70 (71%), weak in 16% and strong in 55% of cases, while 29 (29%) tumors were negative. TILs were present in 64 (58%) NMIBC, while 44 cases (41%) did not reveal mononuclear infiltration in tumoral stroma. Statistical analysis demonstrated a higher proportion of patients with recurrence in the group with the COX-2 score 0, and lower in the group with score 2 (p=0.0001, p=0.0101, respectively). In addition, a higher proportion of recurrent patients in the group with no TILs, and lower proportion in the group with TILs were found (p=0.009, p=0.009, respectively). Univariate and multivariate analysis revealed overexpression of COX-2 and presence of TILs as negative predictors. CONCLUSION: Patients with lower COX-2 expression and absence of TILs in NMIBC need to be followed up more vigorously and probably selected for adjuvant therapy. VIRTUAL SLIDE: The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1411318819790406.

[Kidney transplantation--a successful story started 110 years ago]. / Transplantacija bubrega--110-godisnja uspjesna prica.

Organ transplantation is one of the most important medical achievement of the 20th century. Emerich Ullmann performed on March 7th 1902, in the Vienna, the first successful kidney transplantation. It was an autotransplantation in a dog, with a transposition of a kidney in the neck region. Graft function persisted over the next five days. Only the few months later Alexis Carrel performed in Lyon another succcessful kidney autotransplantation in a dog. Carrel was interested in the vascular anastomosis improvement. He developed the triangulation technique of vessel anastomosis and so called Carrel patch. Since then both techniques have become a standard in kidney transplantation. Carrel was awarded with Nobel Prize in Physiology and Medicine in 1912 for his innovatory work in the field of transplantation and vascular surgery. These experimental transplantations preceded kidney transplantation in the humans which has become a routine operative procedure.

The association between the recurrence of solitary non-muscle invasive bladder cancer and tumor infiltrating lymphocytes.

AIM: To evaluate whether tumor infiltrating lymphocytes (TIL) in biopsy specimens are associated with the clinical outcome of non-muscle invasive bladder cancer. METHODS: We retrieved tumor specimens from 115 patients with solitary papillary non-muscle invasive bladder cancer treated between 1996 and 2006 and constructed tissue microarrays. Patients were divided in two groups: those with recurrent disease (N=69) and those without recurrent disease (N=46) during the follow up of minimum 5 years. All patients were treated with initial transurethral resection and none received adjuvant therapy. Immunhistochemical staining was performed with anti-CD3, CD4, CD8, and Granzyme B (GrB). The CD4+:CD8+ and GrB+:CD8 ratios were determined. RESULTS: Tumor infiltrating lymphocytes were predominantly observed within cancer stroma, and only rare individual cells were observed intraepithelially. The group without recurrent disease had lower levels of CD3+ and CD8+ lymphocytes than the group with recurrent disease (P=0.0001, P=0.0002, respectively). The CD4+:GrB+ and GrB+:CD8+ ratios were significantly higher in patients without recurrent disease (P=0.0002, P=0.039, respectively). CONCLUSION: This study revealed a possible connection between TIL number and bladder cancer recurrence. TIL subset ratio showed different patterns in recurrent and non-recurrent tumors, which is why it could become a useful a prognostic clinical index if our findings are confirmed in randomized trials.

mRNA expression of bone morphogenetic proteins and their receptors in human renal cell carcinoma.

INTRODUCTION: Bone morphogenetic proteins (BMPs) have been studied in several cancers, but only limited information is available about renal cell carcinomas (RCCs). We determined the expression of mRNA of several BMP ligands and BMP receptors (BMPRs) in healthy kidney tissue and RCCs, and data were compared to clinicopathological parameters. MATERIAL AND METHODS: Sixty-four samples of RCCs and healthy renal tissues were prospectively examined. The expression of BMP2, BMP4, BMP6, BMP7, BMPRIA, BMPRIB and BMPRII mRNA was determined using semiquantitative reverse transcriptase-polymerase chain reaction. RESULTS: The expression levels of different BMP ligands and BMPRs were considerably higher in RCCs than in normal kidney tissue. BMP ligands showed elevated expression in clear-cell RCCs, whereas all three BMPRs showed higher expression levels in non-clear-cell RCCs. In clear-cell RCCs, the expression levels of BMP2 progressively increased and expression levels of BMP6, BMP7 and BMPRIB were lost with higher tumor stage. CONCLUSIONS: All BMPs and their receptors have stronger expression levels in RCC. The expression level of BMP2 is strongly elevated in kidney cancer.

Primary testicular necrotizing vasculitis clinically presented as neoplasm of the testicle: a case report.

We present a case of necrotizing vasculitis with the testicle as the isolated affected organ. A 25-year-old man, pretreated for epididymo-orchitis, presented with a presumed testicular neoplasm. Radical orchiectomy was performed and diagnosis of necrotizing vasculitis was established. In the absence of any other sign of systemic disease, the diagnosis of isolated necrotizing vasculitis of the testis was confirmed. Two years after the operation, the patient showed no symptoms of systemic disease.

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

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

[The history of kidney transplantation at Susak hospital]. / Povijest transplantacije bubrega u Bolnici na Susaku.

Kidney transplantation is the most efficient method of renal replacement therapy. Development of kidney transplantation occurred in the second part of the 20th century. At Susak hospital, the first experimental surgical acts on animal models started in 1996. The first kidney transplantation from living related donor at Susak hospital was performed on January 31, 1971. One year later, first transplantation from cadaveric donor was performed. In the last 40 years, development of transplantation medicine in Rijeka and Croatia was successful and Rijeka has become one of the top transplantation centers in Croatia today. Since 2007, Department of Urology has become Referral Center for Kidney Transplantation of the Croatian Ministry of Health and Social Welfare.

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

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

[The role of CT peritoneography as diagnostic tool in patient on peritoneal dialysis with dialysate leakage]. / Uloga CT peritoneografije u dijagnostici propustanja dijalizata u pacijenta s peritonejskom dijalizom.

Peritoneal dialysis (PD) can be considered as first method for dialytic treatment because improved quality of life and patient survival compared to hemodialysis. The most frequent complications of PD are peritonitis, peritoneal catheter exit site infection and mechanical complications as dialysate leakage. We present a 62 year old female patient with end-stage renal disease caused by poststreptococcal glomerulonephritis. One month after laparoscopic placement of peritoneal catheter patient started with continuous ambulatory peritoneal dialysis. Few weeks after starting the procedure enlargement of anterior abdominal wall close to the exit site of peritoneal catheter was noticed. Enlargement was disappeared after decreasing intraabdominal pressure with lowering volume of dialysate. Also, patient started with automated peritoneal dialysis (APD), but after abdominal straining enlargement of anterior abdominal wall was present again. Computed tomography of abdomen and pelvis with placement of contrast in dialysate (CT peritoneography) was performed. Imaging revealed dialysate leakage from peritoneal cavity to subcutaneous tissue. PD was temporarly stopped, peritoneal catheter removed and hernioplasty was made. After four weeks new peritoneal catheter was implanted and APD was successfully started (without dialysate leakage). CT peritoneography have important role as diagnostic tool for discovering dialysate leakage. If conservative management was unsuccessfull, surgical treatment is necessary.

Penile metastases of prostate cancer.

Prostatic adenocarcinoma metastasizing to the penis is rare. A case of prostatic adenocarcinoma with metastases to the glans penis is presented. In this case, penile metastases developed nine years after the diagnosis of prostate cancer with regional lymph node metastasis.

Kidney transplantation in elderly patients.

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

Our experiences in treatment of prostate carcinoma in patients over the age of 70.

The goal of our study was to present our long-standing experience of the treatment of prostate carcinoma in patients over the age of 70. During the 20 years period (from 1991 to 2010) we diagnosed the prostate carcinoma in 1998 patients. More than 58% of the patients were over 70 years old. The most frequent symptoms of the prostate carcinoma were frequent urination and backache. At the first examination 36% of the patients had both prostate lobes involved, and 27% of them had metastases. The most frequent ones (26%) were those in the bone system (pelvis and spine), while in only 1% metastases were found in solid organs (lungs and liver). According to the TNM classification, T1 and T2 were diagnosed in 818 (71%) patients. Histopathological examination discovered Gleason score 2 in 70% of patients and Gleason score 3 in 24% of them. Most often the combination of castration and antiandrogen therapy (in 68% of the patients) and the combination of castration and Estracyt therapy (in 19% of the patients) were applied. In conclusion, intensified efforts should be made in promoting preventive urological examinations because of the great number of patients (27%) with metastases at the first examination.

An unusual case of acute urinary retention.

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

Expression of bone morphogenetic protein-7, its receptors and Smad1/5/8 in normal human kidney and renal cell cancer.

Bone morphogenetic proteins (BMPs) are cytokines which are important for kidney homeostasis but also have role in the some renal diseases and renal cell carcinoma (RCC). In the last three decades incidence of RCC was constantly increased and the role of different molecular biomarkers in RCC is explored'. We analyzed expression of BMP-7, their receptors (BMPR-IA, BMPR-IB, BMPR-II) and proteins of their signaling pathway (pSmad1/5/8) in sixteen renal cancer samples and paired normal tissue. Tissue samples were analyzed by immunohistochemistry and Western blot. BMP-7, BMP receptors and pSmad1/5/8 were expressed in all structures of normal kidney but dominantly in the proximal tubular cells. In the cancer samples their expression was also noticed. Comparison of BMPs between different tissue showed increased expression of BMPR-IB and pSmad 1/5/8 and decreased expression of BMP-7 and BMPR-II in RCC compared to normal kidney. BMPR-IA was detected with immunohistochemistry but with Western blot attenuated signal was presented. BMP-7, BMP receptors and pSmad1/5/8 were showed in normal kidney and RCC. Detected alterations of BMP-7, BMP receptors and pSmad expression in RCC suggested their possible role in tumorigenesis of kidney cancer.

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

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