SACRAL NEUROMODULATION IN TREATING OVERACTIVE BLADDER PATIENTS - FIRST-TIME APPLICATION IN CROATIA.

Sacral neuromodulation (SNM) is a safe, efficacious, and minimally invasive advanced therapy that involves electrical stimulation to sacral nerve root to modulate neural pathway. Indications for SNM include symptoms of overactive bladder (OAB), urinary incontinence, urinary retention, urgency and frequency and, regarding bowel dysfunction, fecal incontinence . In Europe and Canada, indication is also established for chronic constipation. The mechanism of action is still not fully elucidated and complete understanding is yet to be determined. It is proposed that SNM modulates neural circuits in both central and peripheral pathways, thus having an impact on the brain, as well as on the bladder-targeting neuronal activity. Another possible significant effect on irregular bladder activity is through inhibition of the bladder afferent pathways by stimulation of the pudendal nerve. Over the past two decades, with more than 300 000 treated patients, SNM has confirmed its efficacy to relieve refractory OAB symptoms, as well as urinary retention or fecal incontinence. First SNM applications in Croatia were uneventful and we are glad to offer our patients this novel therapy in the future.

MANAGEMENT OF PROSTATE CANCER IN KIDNEY TRANSPLANT RECIPIENTS.

Kidney transplantation is the treatment of choice in eligible patients with end-stage kidney disease. Prostate cancer (PC) is the second most common cancer in men worldwide. The prevalence of chronic kidney disease worldwide is 13.4%. The management of localized PC in these patients is challenging due to immunosuppressive therapy and pelvic graft localization. High graft and recipient survival rates have resulted in higher numbers of these patients in our everyday practice. A retrospective analysis of male patients who had undergone kidney transplantation at our center between 2002 and 2022 and were diagnosed and treated for PC was performed. We analyzed the incidence, treatment methods, and follow-up of PC patients in this population. A total of 1079 male patients were transplanted. PC was diagnosed in 12 patients (8 after and 4 before transplantation). The incidence of PC was 1.11%. Radical prostatectomy was performed in 11 patients, and one patient was treated with radical radiotherapy. Eleven patients had stable graft function; 1 graftectomy was performed, unrelated to PC. Three patients were indicated for salvage radiotherapy, one is in process for prostate-specific membrane antigen positron emission tomography (PSMA PET CT), and 7 patients are in follow-up and without recurrence. Radical prostatectomy is a safe treatment method for localized PC in kidney transplant recipients, which does not impair graft function and survival.

Leydig Cells in Patients with Non-Obstructive Azoospermia: Do They Really Proliferate?

BACKGROUND: Non-obstructive azoospermia (NOA) is a form of male infertility caused by disorders of the testicular parenchyma and impaired spermatogenesis. This study aimed to investigate the nature of Leydig cell changes in patients with NOA, especially whether their actual proliferation occurred. METHODS: 48 testicular biopsies from infertile patients with NOA and 24 testicular biopsies originating from azoospermic patients suffering from obstructive azoospermia (OA) were included in the study. Leydig cells and their possible proliferative activity were analysed by immunohistochemistry and morphometry (stereology). RESULTS: Unlike in the OA group, Leydig cells in NOA patients were sometimes organised into larger clusters and displayed an abundant cytoplasm/hypertrophy. Moreover, significant fibrosis of the interstitial compartment was demonstrated in some NOA samples, often accompanied by inflammatory cells. Stereological analysis showed no increase/proliferation of Leydig cells; on the contrary, these cells decreased in number in the NOA group. CONCLUSIONS: The decrease in the number of Leydig cells can be explained by previous inflammatory changes within the testicular interstitium and consequent interstitial fibrosis. The interstitial fibrosis might have a deteriorating effect on Leydig cells.

Sexual Dysfunction in Patients with Epilepsy.

BACKGROUND: Patients with epilepsy commonly report sexual dysfunction (SD) and reproductive difficulties. This study aimed to evaluate the relationship between epilepsy, antiepileptic drugs (AEDs) and SD, and its association with the quality of life and depressive symptoms. SUBJECTS AND METHODS: This was a prospective study carried out in a tertiary healthcare centre. SD was evaluated using the internationally acclaimed questionnaire Arizona Sexual Experiences Scale (ASEX) that was successfully translated into Croatian and validated for this purpose. Depressive symptoms and quality of life were evaluated using the Hamilton Rating Scale for Depression (HAM-D17) and Quality of life in epilepsy-31 inventory (QOLIE-31). RESULTS: Of 108 patients (68 (63 %) women, 40 (37 %) men, mean age 39.54±15.91 (range18-80) years) with epilepsy, 16 (14.8%) had focal, 38 (35.2%) generalized and 44 (40.7%) both types of epilepsy. Mean overall total score on the ASEX questionnaire was 11.94±5.61 (mean total score women 12.85±6.00, mean total score men 10.4±4.55), with 48 reporting that they had sexual activity in the past week. Nine (8.33%) patients (7 (6.48%) women, 2 (1.85%) men, mean age 47.66±19.33 (range 25-80) years) had a score 19 and above, 38 (35.18%) patients (27 (25%) women, 9 (8.33%) men, mean age 46.82±17.78 (range 19-80) years) individual score 5 and above on any one item, and 33 (30.55%) patients (26 (24.07%) women, 7 (6.48%) men, mean age 48.87±17.8 (range 19-80) years) had an individual score 4 and above on any three items. Significant correlations were found between SD and older age (p=0.001) and between more pronounced symptoms regarding SD on ASEX and female gender (p=0.000). There were no significant correlations between the type of epilepsy and SD, nor between the AEDs (old generation vs. modern) and SD. Significant correlations were found between the SD and more pronounced depressive symptoms (p=0.003) and between the SD and a lower quality of life (p=0.001). CONCLUSIONS: Results of our study suggest SD is experienced by around one-third of patients in our group, which is similar to the previous percentage of SD reported in the community sample. Women were found to experience more pronounced symptoms of SD on ASEX. Symptoms of SD were found to be significantly correlated with older age, female gender, lower quality of life and depressive symptoms, while no significant correlations were found with the type of epilepsy and the AEDs.

Reinke's crystals in perivascular and peritubular Leydig cells of men with non-obstructive and obstructive azoospermia: a retrospective case control study.

AIM: To analyze the differences in the population of perivascular and peritubular Leydig cells (LC) and the number of Reinke's crystals (RCs) in the testicles of infertile men with non-obstructive and obstructive azoospermia. METHODS: This retrospective case-control study was conducted on the testicle tissue of infertile men with obstructive (n=10) and those with non-obstructive azoospermia (n=100). Stereological analysis was performed on 7-µm paraffin sections. Measurements were carried out by using the Weibel multipurpose test system. RESULTS: Patients with non-obstructive azoospermia had a higher total/absolute number of LCs in the perivascular space (P=0.034). In these patients, no significant difference was found in the total and absolute number of RCs between the peritubular and perivascular space. Patients with obstructive azoospermia had around three times higher absolute number of RCs in both the peritubular and perivascular spaces (P=0.002; P<0.001) than non-obstructive group. CONCLUSION: Our results suggest that in patients with non-obstructive azoospermia LCs migrated or had different densities in the peritubular and perivascular space compared with patients with obstructive azoospermia. Moreover, the lower number of RCs could imply their utilization by LCs in testosterone production.

Improvement of Sexual and Reproductive Function in Men with Spinal Cord Lesion.

The aim of the review is to establish sexual and reproductive functions in men with spinal cord lesion (SCL). Many sexual and reproductive dysfunctions may be found in these patients including individual's low self-esteem, delay of orgasm, erectile or ejaculatory disorder and abnormalities of semen, which are characterized by lower sperm motility or viability. Owing to improvements in physical medicine and rehabilitation, the focus has been shifted from keeping patients alive towards ensuring the quality of life and improvements of sexual dysfunctions and later reproduction. Erectile dysfunction can be treated by using phosphodiesterase-5 inhibitors, intracavernosal injections, vacuum devices and penile prostheses. Semen can be retrieved from anejaculatory patients by medically assisted methods utilizing penile vibratory stimulation, electroejaculation, prostate mas-sage, or surgically. Although there is low chance for pregnancy in natural way in most of SCL pa-tients, fatherhood is possible through the introduction of assisted medical management. By use of various medical, technical and surgical procedures for sperm retrieval combined with assisted reproductive methods, high pregnancy rates have been reported comparable to those in able-bodied subfertile patients. Nevertheless, future studies are needed to improve semen quality and methods of assisted ejaculation in patients with SCL.

Hypoproteinemia as a prognostic risk factor for arteriovenous fistula failure.

INTRODUCTION: Any vascular access is of limited duration with many factors which influence survival in patients on chronic hemodialysis (HD). Hypoproteinemia as a marker of chronic illness is common among chronic HD patients. Our aim was to analyze the survival of the primary arteriovenous fistula (AVFs) and the risk factors which influence their patency and to test the hypothesis that patients with normal values of serum proteins have lower risk of AVF failure compared to patients with hypoproteinemia. METHODS: Seven hundred thirty-four consecutive patients were included who underwent creation of an AVF. The patients were prospectively followed-up for 2 years. Only patients with AVF function after a month from its creation were analyzed. The patients were divided into two subgroups, with normal and low serum protein levels (<65 g/L). FINDINGS: At follow-up 497 (67.7%) AVFs were still functional while 237 (32.3%) AVFs failed due to thrombosis or stenosis. Serum proteins and AVFs created on the forearm were positive predictors while diabetes was a negative predictor of longer AVF survival (P < 0.001; P = 0.003; P = 0.043). When comparing patients with normal and low serum protein levels (<65 g/L), mean survival time was significantly longer in patients with normal serum levels (P < 0.001). DISCUSSION: In this study, hypoproteinemia was an independent prognostic marker for AVF failure at 2 years. Hypoproteinemia, based on our results, is an independent, more sensitive and prognostic marker of possible vascular access failure than the presence of other common factors which influence shorter AVF survival.

Socio-demographic characteristics and lifestyle habits of pregnant women smokers.

The aim of this study was to describe anthropometric, clinical, socio-demographic characteristics and lifestyle habits of pregnant smokers in comparison to pregnant nonsmokers. During years 1999-2003, 1,435 pregnant smokers and 4,772 pregnant nonsmokers were interviewed after delivery with a questionnaire. They were recorded clinical, anthropometric and socio-demographic data, smoking status, labor outcome, maternal and fetal hemoglobin concentrations for each patient. The two groups were comparable in anthropometric and clinical characteristics, duration of pregnancy and mode of delivery, except for birth weights, which were significantly lower in newborns of smokers. Maternal hemoglobin concentrations were significantly lower in smokers, but fetal hemoglobin concentrations were significantly higher in babies of smokers. The proportion of pregnant women who smoked during pregnancy was higher among urban women, among women with lower educational level and among unemployed subjects in comparison with nonsmokers. The pregnant women who smoked during pregnancy were more often caffeine and alcohol consumers. To further reduce smoking during pregnancy it is important to continue to promote smoking cessation among teenagers.

Comparison of fetal plasma cortisol level between eutrophic and hypotrophic newborns.

We tested two groups of singletons born at term: fifty-six eutrophic newborns and 56 hypotrophic subjects. They were selected randomly from all newborns delivered by vaginal route between 8 and 14 hours. Excluded were preeclampsia, diabetes, labours longer than 12 hours and newborns with malformations. Written informed consent was obtained from all women and data were collected before and after labour. Umbilical cord blood samples were obtained immediately following the delivery and plasma cortisol concentrations were measured by radioimmunoassay. The groups did not differ significantly regarding maternal age, parity, gestational age and Apgar score, but birth weight was significant differed (p < 0.001). In addition, eutrophic newborns had significantly elevated cortisol levels (457.7 nmol/L, 321.8-696.6 nmol/L) compared with hypotrophic newborns (320.5 nmol/L, 215.1-578.7 nmol/L, p < 0.001). The role of fetal cortisol in intrauterine growth restriction (IUGR) pregnancy and labour is uncertain, but fetal plasma cortisol levels may be lower in IUGR newborns.

Uterine artery embolization for the treatment of uterine fibroids.

Uterine artery embolization can be regarded as a less invasive procedure for the treatment of fibroids compared with myomectomy, hysterectomy, and laparoscopic myolysis. The aim of this study was the evaluation of safety and efficacy of uterine artery embolization and of womens' opinion about this treatment. After gynecological examination sixty-nine premenopausal women underwent uterine artery embolization. All procedures but four were technically successful; three women underwent unilateral embolization because of vascular malformation and one of them had an allergic reaction to contrast medium. Of the 69 patients: 58 went home the day after embolization, and 11 within first week. The follow-up examinations after 3, 6 and 12 month showed a significant reduction of uterine and fibroid volume with significant improvement of bleeding. Therefore, according to this report, uterine artery embolization is a successful, minimal invasive treatment of myoma that preserves the uterus and requires shorter hospitalization and recovery times than surgery.