Cystic dysplasia of the rete testis accompanying ipsilateral renal agenesis in a young adult: a case report.

A 31-year-old man with left-sided testicular pain lasting a couple of months was referred to our urology department due to a suspected testicular tumor. Physical examination showed a hard, thickened, and small left testis on palpation with a diffuse, inhomogeneous ultrasonographic appearance. After a urologic examination, a left-sided inguinal orchiectomy was performed. The testis, epididymis, and spermatic cord were sent to pathology. Gross examination revealed a cystic cavity filled with brown fluid and the surrounding brownish parenchyma measuring up to 3.5 cm in diameter. Histologic examination showed a cystically dilated rete testis lined with cuboidal epithelium and a positive immunohistochemical reaction to cytokeratins. Microscopically, the cystic cavity was a pseudocyst filled with extravasated erythrocytes and abundant clusters of siderophages. The siderophages extended into the testicular parenchyma, surrounding the seminiferous tubules and spreading out around the ducts of the epididymis, which were also cystically dilated with siderophages inside their lumina. On the basis of clinical data, histological, and immunohistochemical analysis, the patient was diagnosed with cystic dysplasia of the rete testis. The literature shows an association between cystic dysplasia of the rete testis and ipsilateral genitourinary anomalies. Therefore, our patient underwent a multi-slice computed tomography scan, which revealed ipsilateral renal agenesis, a right seminal vesicle cyst reaching up to the iliac arteries, and a multicystic formation cranial to the prostate.

History of Urology at the Sestre Milosrdnice University Hospital Center.

The history of Croatian urology clearly shows its affiliation to the medical and civilizational circle of the Western world. The Department of Urology at the Sestre milosrdnice University Hospital Center is the oldest urology institution in the Republic of Croatia. The Department was established in 1894, when the new Sestre milosrdnice Hospital was open in Vinogradska cesta in Zagreb. It was then that doctor Dragutin Masek founded the so-called III Department, which, in addition to treating urology patients, also treated patients with conditions of the ear, nose and throat, eye diseases and dermatologic conditions. Dragutin Masek had already realized that medicine would soon be divided into fields and had assigned younger doctors joining the III Department to specific fields. As a result, urology was given to Aleksandar Blaskovic, who founded the first independent department of urology in Croatia in 1926. In 1927, he was appointed Professor of urology at the Zagreb School of Medicine, where he established the first department of urology and was giving lectures and practicals. Under his leadership, the Department of Urology was given the status of a Clinic, a teach-ing department, the first of its kind in Croatia. Owing to all his activities in the field of urology, the history remembers him as the "father of modern Croatian urology". Over the course of the following years, department chairs had changed, but luckily for the patients, approach to work had not. Conscientiousness, trust, competence and charity. After all, charity is the idea that the hospital carries even in its name, after the Sisters of Charity who had founded it. In all the decades, the Department of Urology has been following global development paths, objectively legging behind top facilities in the world by only a few years. Overall professional and scientific urology activities culminated in 1998, when the Clinic became the Reference Center of the Ministry of Health of the Republic of Croatia for prostate cancer, and in 2011, when it became the European Board of Urology Certified Center. All that has been achieved could not have been done without wholehearted help and cooperation of the nurses, as well as every other department employee from the beginnings of urology until today. Despite its rich history, the Department does not rest on laurels. Today, it is a modern urology department together with its European role models.

20 Years of the Reference Center for Prostate Tumors of the Ministry Of Health at the Department of Urology in Sestre Milosrdnice University Hospital Center.

The Department of Urology at the Sestre milosrdnice University Hospital Center is the oldest urological institution in the Republic of Croatia and this part of Europe. Today, the Department is a modern tertiary healthcare institution, where the most complex methods of urological practice are performed using modern medical devices and highly sophisticated technology. In 2011, our urology specialist education program was certified by the European Board of Urology (EBU) as the only one of its kind in Croatia. The program was recertified in 2017. The Department runs a program for the early detection of prostate cancer and performs more than 240 radical prostatectomies annually, which is the highest number of such interventions in Croatia. The aim of this study is to present the work and the activities of the Reference Center for Prostate Tumors of the Ministry of Health at the Department of Urology in Sestre milosrdnice University Hospital Center over the last 20 years. The database of the Reference Center for Prostate Tumors of the Ministry of Health at the Department of Urology in Sestre milosrdnice University Hospital Center was reviewed. During the twenty-year period, approximately 15,000 prostate interventions were performed due to benign and malignant diseases. Of this, 7,374 transrectal ultrasound guided prostate biopsies, 2,632 radical prostatectomies with open retropubic access, 3,988 transurethral prostate resections and 1,097 open suprapubic adenomectomies were performed. With the achieved scientific and professional results in monitoring, studying and improving the prevention, diagnosis and therapy of prostate tumors, as well as with the professional conditions and personnel, the Department of Urology in Sestre milosrdnice University Hospital Center truly justifies the title of the Reference Center for Prostate Tumors of the Ministry of Health of the Republic of Croatia awarded to it in 1998.

Histopathological Outcomes after Radical Prostatectomy for Prostate Cancer Based On a New Grading System.

One of the main reasons for the introduction of a new grading system was Gleason sum 7, which differed significantly in the prognosis of the disease depending on the primary Gleason. The aim of this study was to compare grade group 2 and grade group 3, and the impact of cancer percentages in final pathology reports after radical prostatectomy on the occurrence of T3 stage of the disease after radical prostatectomy of clinically localized prostate cancer. The study covered 365 patients with clinically localized prostate cancer who underwent radical retropubic prostatectomy (RRP) over the period of two years. The average percentage of carcinomas found in pathology reports after RRP was 20.1%. With the increase in the grade group, the average percentage of carcinomas in pathology reports increased significantly, p <0.001. With regard to grade groups 2 and 3, irrespective of cancer percentages in pathology reports, more cases of T3 stage were found in grade group 3 when compared to grade group 2, which was statistically significant (p <0.001). However, grade group 2 and grade group 3 patients with ≤10% cancer occurrences in final pathology reports after RRP did not show any statistical significance in the occurrence of T3 stage, p=0.96. Prognostic differences in grade group 2 and grade group 3 patients after RRP are significant, but not in all cases, because of their dependence on the percentage of cancer in the final pathology report after RRP of clinically localized prostate cancer.

Transobturator Advance® Sling Suspension for the Treatment of Postprostatectomy Stress Urinary Incontinence.

Stress urinary incontinence (SUI) continues to present a major complication after radical prostatectomy. Suburethral slings represent one of the less invasive options for postprostatectomy SUI, and a more recent addition is a transobturator sling, the AdVance®. We report our results with the AdVance® sling for the management of postoperative SUI. The evaluation was conducted on 47 patients with AdVance® implant for SUI in our institution (November 2010 - June 2017). Measurements included age, etiology of SUI, duration of SUI, follow-up and pad use per day (PPD) pre- and postoperatively. Patients were classified as cured if they used no pads or 1 PPD for security reasons, or as improved if 1-2 PPDs were used and if there was a 50% reduction in pad use per day postoperatively. In our series we observed a reduction of mean PPD of 5.1 (2-8) to 1.7 (0-4) postoperatively. After follow-up and according to our criteria, the cure rate was 51.1% (24/47) and the improvement rate 27.5% (13/47). The overall success rate was 78.6% (37/47). No improvement was observed in 21.4% (10/47) of patients. Failure rates after sling placement for patients with addi-tional treatments following prostatectomy were much higher (60% (3/10) for radiation therapy and 66.7% (4/10) for urethral stricture disease). Our results show favourable cure and improvement rates and are comparable to results from larger series. The most appropriate candidates for the AdVance® sling are patients with mild to moderate postprostatectomy SUI. The results may be even better in patients without additional treatment following prostatectomy, such as radiation therapy or surgery for stricture disease.

[AUTONOMIC DYSREFLEXIA].

Autonomic dysreflexia (AD) is a syndrome that occurs in patients with high spinal cord lesion. It is caused by activation of sympathetic nervous system by a noxious stimulus below the level of injury, usually consisting of distention and/or irritation of the bladder or constipation. Sympathetic system activation leads to blood pressure elevation because compensatory mechanisms cannot properly regulate blood pressure due to the spinal cord lesions. The most important manifestation of AD is arterial hypertension because of the possible cerebrovascular and cardiovascular complications, including death. Initial treatment consists of recognition of the symptoms and resolution of the cause. In patients with high blood pressure antihypertensive therapy is initiated (with nifedipine, captopril and nitroglycerin). Prevention is also a very important task, with the goal of influencing all possible triggers of this condition, specially micturition and colon disorders. One of the most important tasks is educating patients, their caregivers and health professionals about AD.

A RARE CASE OF SQUAMOUS CELL CARCINOMA IN URINARY BLADDER DIVERTICULUM SUCCESSFULLY TREATED BY BLADDER-SPARING SURGERY.

The aim is to report a rare case of squamous cell carcinoma arising in a urinary bladder diverticulum and present recent literature overview of treatment options. A 56-year-old man presented with intermittent hematuria. Ultrasound examination indicated primary carcinoma in the urinary bladder diverticulum. Diagnosis was confirmed with cystoscopy and computed tomography. Transvesical diverticulectomy with regional lymphadenectomy was undertaken. Two years after initial treatment, the patient was well without evidence of tumor relapse. This report implicates that although aggressive surgical approach is recommended in the majority of bladder diverticulum tumors, simple diverticulectomy may be indicated in selected, confined cases.

Validation of Epstein Biopsy Criteria for Insignificant Prostate Cancer in Contemporary Cohort of Croatian Patients.

Only few reports validated contemporary Epstein criteria for insignificant prostate cancer, and only one being from Europe. Patients with insignificant prostate cancer should be offered active surveillance and spared radical treatment. In our study we tested Epstein biopsy criteria for predicting unfavorable final pathology and biochemical relapse in low risk prostate cancer patients, who were eligible for active surveillance but where treated with radical prostatectomy. Between January 2003 and January 2008, 586 patients were subjected to radical prostatectomy in our institution. Among them, 106 where eligible for active surveillance according to Epstein biopsy criteria for insignificant prostate cancer. We analyzed the presence of adverse pathological findings in the final pathohistological specimen after radical prostatectomy which excludes low risk disease. Adverse pathohistological findings were noted in 41 (38.6%) patients, who could have been offered active surveillance. During the follow up of 48 (12-72) months, biochemical relapse was noted in 6 (5.6%) patients. Although active surveillance is becoming more popular because of the long natural course of prostate cancer and fear of overtreatment of patients with indolent course of disease, both doctors and patients must be aware of potentially significant disease in this group and limitations of current preoperative criteria defining low risk patients.

Intravesical foreign body as a result of self catheterization: case report.

Foreign bodies inside urinary tract are a relatively rare condition in our practice. There are several reports published and in most cases the reason for self insertion of an object was autoerotic stimulation or psychiatric illness. Self treatment by homemade instruments is a rarely seen scenario. A 62-year-old man presented to our department complaining of lower urinary tract symptoms. On examination, a foreign body was detected inside the urinary bladder. Urethral stricture was also detected for which the patient had been previously treated on several occasions. The patient stated that he had attempted self catheterization using a homemade catheter. He had succeeded in emptying his bladder; however, the catheter entered the bladder completely and was irretrievable to him. Sachse urethrotomy was performed following retrieval of the foreign body. No psychiatric illness was detected in our patient. The patient's postoperative course was uneventful.

Effect of histological inflammation on total and free serum prostate-specific antigen values in patients without clinically detectable prostate cancer.

PURPOSE: We are often confronted with patients in the "gray zone" (prostate-specific antigen [PSA]<10 ng/mL) whose biopsies reveal no malignancy but only inflammation. We investigated the relationship between histological inflammation and total PSA (tPSA), free PSA (fPSA), and percentage of free PSA (f/tPSA) levels in patients without prostate cancer (PC). MATERIALS AND METHODS: We studied 106 men with tPSA<10 ng/mL who had undergone biopsy that was negative for PC and who had no clinical prostatitis. Inflammation observed at biopsies was scored for inflammation type in each biopsy core by use of a four-point scale and was then correlated with tPSA, fPSA, and f/tPSA. RESULTS: Different patterns of inflammation were found in each set of biopsies. Regression factor analysis was used to form two groups according to inflammation type: more chronic and more acute. Median tPSA, fPSA, and f/tPSA levels in the more chronic and more acute inflammation groups were 6.4 ng/mL, 1.09 ng/mL, and 15%, and 7.3 ng/mL, 0.79 ng/mL, and l2%, respectively. A significant difference was found in fPSA (p=0.003) and f/tPSA (p<0.001), whereas the difference in tPSA was not significant (p=0.200). Total PSA correlated with fPSA (r=0.4, p<0.001) but not with inflammation type (r=0.12, p>0.010). A correlation existed between inflammation type and fPSA (r=-0.31, p=0.001) and f/tPSA (r=-0.43, p<0.001) in that the fPSA and f/tPSA were lower in the group with more acute inflammation. CONCLUSIONS: Subclinical inflammation has a significant influence on fPSA in patients with tPSA<10 ng/mL but without PC or clinical prostatitis. Subclinical inflammation is not characterized by elevated tPSA alone but also by a decreased fPSA, a tendency similar to that in PC.

The evolution of partial nephrectomy for kidney tumors--are we abandoning the basic principles of Robson's radical nephrectomy?

Fifty years ago, Robson introduced radical nephrectomy (RN) setting the gold standard for treating kidney tumors. Experience has shown that partial nephrectomy (PN) can be equally effective with the advantages of preserving kidney function and avoiding unnecessary nephrectomies for benign tumors. The purpose of this report is to demonstrate the evolution of clinical presentation and choice of treatment for patients with kidney tumors at our department, emphasizing changes in the PN utilization trends. Clinical data were abstracted for the years 2002, 2007 and 2012. We assessed annual trends for changes in the choice of operative treatment related to tumor size, pathologic stage and diagnosis. During the study, there was an increase in the share of T1 tumors, from 46.6% in 2002 to 69.8% in 2012. The rate of PN increased more than ten-fold, from 2.7% in 2002 to 31.7% in 2012. The annual rates of PN for T1 tumors increased even more, from 6.6% in 2002 to 46.7% in 2012. Opposite to RN group, there was an increase in the mean tumor size in PN group (from 1.8 cm in 2002 to 3.9 cm in 2012). The rate of RN for benign tumors was reduced impressively from 85.7% in 2002 to 23.1% in 2012. Our data argue strongly that PN should be expanded and not restricted. Robson's principles have been partially deserted over the last decade; however, proving that PN is superior to RN still remains to be elucidated.

Primary osteosarcoma of bladder diverticulum mimicking intradiverticular calculus: a case report.

There is a well-documented relationship between urinary bladder diverticula and intradiverticular neoplasms. The great majorities of these tumors are urothelial carcinomas, but may also be of glandular or squamous type. Sarcomas occurring within bladder diverticula are exceptionally rare and highly malignant lesions, with only 20 well documented cases published in the literature to date (including carcinosarcomas). We report a case of osteosarcoma of the bladder diverticulum in a 68-year old man, which clinically mimicked intradiverticular calculus. To our knowledge, this is the second case described in the literature to date, and the first in English literature.

Synchronous rectal adenocarcinoma and bilateral clear cell renal carcinoma.

A 69-year-old man was admitted for resection of rectal adenocarcinoma diagnosed by colonoscopy. Preoperative computed tomography scan and abdominal ultrasonography revealed bilateral renal tumors measuring up to 2 and 2.8 cm in largest diameter, respectively. The patient underwent partial colectomy and bilateral partial nephrectomy. Microscopically, rectal adenocarcinoma penetrated the submucosa, without invasion of the muscularis propria. Both renal tumors were clear cell renal carcinomas of Fuhrmann nuclear grade 2. To our knowledge, this is the first case of synchronous adenocarcinoma of the rectum and bilateral clear cell renal cell carcinoma described in the literature to date.

Management of fournier's gangrene: case report and literature review.

A 65-year-old man was referred to our department with clinical signs of septic shock and necrotizing soft tissue infection of the scrotal, perianal and right inguinal region. Initial presentation was a typical Fournier's gangrene. Because of the life-threatening condition, the initial treatment was extensive removal of necrotic tissue. Antibiotic therapy was administered and several debridements of the wound were done afterwards. Three weeks after the initial treatment, wide wound defects of the perianal, scrotal and inguinal regions were closed secondarily and the patient was discharged from the hospital. Fournier's gangrene is a surgical emergency. Although rare, it remains a life-threatening disease. Rapid and accurate diagnosis remains the key component in achieving successful outcome. Early aggressive surgical intervention together with fluid, hemodynamic and nutritional support and broad-spectrum antibiotics is the essential management to reduce mortality.