Variations in Nitric Oxide and Endothelin Serum Levels in Extracorporeal Shock Wave Lithotripsy-Treated Patients.

INTRODUCTION: Renal vasculature is extremely sensitive to vasoconstrictor effects of endothelin (ET), while nitric oxide (NO) has special role in several pathological renal conditions. AIM: The aim of this study to examine the presence, character, and degree of changes in NO and ET levels in the serum of extracorporeal shock wave lithotripsy (ESWL)-treated patients with nephrolithiasis. PATIENTS AND METHODS: This study included a total of 60 patients that were divided in two groups: Group I (n = 24), in which a total of 2000SWs were administered; 0-2 units; (0.5 units per each 500SWs), and Group II (n = 36), in which a total of 4000SWs were administered; 0-4 units; (0.5 units per each 500SWs). RESULTS: In the Group I median NO serum concentration increased in relation to pretreatment levels (39.04 ± 8.29 µmol/L) specifically 30 min, 60 min, and 24 h following the treatment (39.11 ± 12.60), (41.80 ± 6.89), and (46.33 ± 9.03), where concentration growth after 24 h was statistically significant P < 0.01. The NO serum concentration in the Group II increased in relation to pretreatment levels (38.90 ± 10.33 µmol/L) after 30 min (48.71 ± 30.09), 60 min (54.57 ± 39.76), and 24 h (97.95 ± 72.07). The NO concentration increase after 60 min and 24 h is statistically significant, respectively, P < 0.03 and P < 0.0001. CONCLUSION: NO and ET serum levels are changing under the influence of ESWL, and that the NO and ET changes are directly correlated with the number of administered shock waves and administered energy.

Extracorporeal shock wave lithotripsy effect on renal arterial resistive index changing.

Aim To investigate a correlation between resistive index (RI) level changes following extracorporeal shock wave lithotripsy (ESWL) in treated and non-treated kidneys depending on the ESWL treatment intensity. The study was conducted on 60 subjects, which were divided in two groups according to age and treatment protocol. Results In the group of patients younger than 55 years of age there was a significant increase in mean RI values, on the first (p=0.001) and second day after the treatment (p=0.007). In the group older than 55 years of age, the resulting increase in mean RI levels was also significant on the first (p=0.003) and second (p=0.011) day following the treatment. The RI values in the non-treated kidney on the first day after the treatment grew significantly (p=0.033). In the group older than 55, RI values in the non-treated kidney grew significantly on the first day after the treatment (p=0.044). In the group who received 2000 SWs, RI levels grew significantly (p=0.044) as well as in the group who received 4000 SWs during the treatment, where the significance was more pronounced (p=0.007). Conclusion There is a correlation between RI changes and the degree and localization of changes in vascular elements of the kidney. Post-ESWL treatment changes are existent and reversible, over a period of one week after the treatment.

Actual Contribution of Free to Total PSA Ratio in Prostate Diseases Differentiation.

OBJECTIVES: To determine significance and sensitivity of the Free to Total prostate specific antigen (PSA) ratio (%fPSA) in diagnosis of prostate cancer and to correlate its sensitivity and specificity with diagnosis. METHODS: Research included 220 patients, who had indication for biopsy (Clinic for Urology, University Clinical Center Sarajevo). RESULTS: Average age of patients was 64.6 ± 8.1 years. Kruskal Wallis test indicates that there is a significant difference in age in relation to the diagnosis (KW χ2=12.508; p=0.006). The correlation between the %fPSA level and diagnosis is positive and statistically significant (r=0.211; p=0.002) in the sense that cancer patients have the lowest %fPSA. Analysis of the sensitivity at 95% specificity of %fPSA compared to particular diagnosis shows the highest sensitivity for prostate cancer - 20.61% (8.35-31.02) with statistically significant AUC p<0.05. Analysis of %fPSA test in detecting prostate cancer, at cut-off values ≤ 0.16, shows a sensitivity of 72.3% and specificity of 50.4 (at cut-off values <0.07, sensitivity is 8.4%, and specificity is 97.8%). CONCLUSION: PSA is organ specific but not cancer specific marker, whose total value, as well as the %fPSA serve as a basis, with a digitorectal exam, in the detection of prostate cancer. By increasing the cut-off values sensitivity of %fPSA increases and specificity decreases. %fPSA has a relative importance in the detection of prostate cancer, and should not be used as a guideline, without prior clinical examination.

Usefulness of Total PSA Value in Prostate Diseases Diagnosis.

INTRODUCTION: Analysis of total value of prostate specific antigen (PSAT), with the unavoidable digital rectal examination (DRE) is the basis of prostate cancer detection. AIM: The aim of this study was to determine the specificity and sensitivity of the total value of PSAT in the diagnosis of prostate cancer. The aim was also to determine the significance of PSAT in diagnosis of benign prostate hyperplasia, precancerous conditions and inflammatory and atrophic changes of the prostate. MATERIAL AND METHODS: Data were collected from the "Register of PH biopsy" of Clinic of Urology, CCU Sarajevo. RESULTS: Analysis of correlation between the diagnosis and the PSAT value shows statistically significant negative correlation (r =-0,186; p = 0.006) in the sense that the value of the PSAT is highest in cancer patients, and the lowest in patients with benign prostatic hyperplasia. PSAT increases with age (r = 0.152; p = 0.025). For prostate cancer optimal sensitivity and specificity for PSAT value occurs at cut off value of> 8.6 ng /mL. Values lower than 2 ng/mL and higher than 10 ng/mL are most specific, and PPV increases with increasing value of PSAT. PSAT at values of <2 ng/mL and > 10 ng/mL are at high levels of specificity, and value > 10 ng / mL is also of high sensitivity in the detection of prostate cancer, and in this moment these values represent the optimal mode for the subsequent treatment. CONCLUSION: PSAT has a relative significance in the detection of prostate cancer, and should not be used as a guideline without DRE.

Clinical importance of independent prognostic factors for renal parenchymal carcinoma and a possibility of predicting the treatment outcome.

AIM: To determine the influence of independent predictors (nuclear grade, patient's general condition, tumor size) on survival of patients suffering from renal cancer. METHODS: The study included 158 patients treated for renal parenchymal carcinoma in the period between 01. 01. 1998 and 31. 12. 2011. The patients' general condition was evaluated using the ECOG staging system. Nuclear grade (NG) was assessed by the Fuhrman criteria. Prognostic factors were tested applying the Cox regression analysis and based on the significance independent predictors were determined. RESULTS: The total survival rate of patients with renal parenchymal carcinoma was 81.2% after one year, 77.6% after 5 years and 70.4% after 10 years. In patients with NG 1 the survival rate after 5 years was 100%, whereas the survival in patients with NG2, 3 and 4 was 98%, 48% and 0%, respectively. The survival rate in patients with ECOG 0 and 1 after 5 years was 100%, while in patients with ECOG 2 and 3 stage of the disease the survival rate was 68% and 25%, respectively. In patients with a tumor node less than 40 mm, ten-year survival rate was100%, whereas the ten-year survival rate in patients with the tumor node sized 40 to 70 mm was 87%, and in patients with the tumor node over 70 mm ten-year survival rate was 66%. CONCLUSION: Multivariate analysis has established that the size of the tumor node, patient's general condition and nuclear grade are independent predictors of disease outcome.

Clinical importance of dependent prognostic factors for renal parenchymal carcinoma and a possibility of predicting the treatment outcome.

AIM: To determine an influence of dependent predictors (clinical presentation, stage, pH type) on survival of patients suffering from renal carcinoma. METHODS: The research included 158 patients who had been treated for carcinoma of renal parenchyma in the period between 1 January 1998 and 31 December 2011. A disease stage was determined according to the guidelines of the American Joint Committee on Cancer (AJCC). Prognostic factors were tested by the Cox regression analysis, and dependent prognostic factors were determined based on significance. RESULTS: Patient survival was significantly different in relation to the clinical presentation of the disease (p less than 0.0001). Length of patient survival significantly differs with regard to the clinical stage of the disease (p less than 0.0001). The length of patient survival significantly differs depending on a pathohistological type of cancer (p=0.0027) and after five years it was much longer for patients with the conventional cancer type as compared with the chromophobe type, 80.3% vs. 61.5%, respectively. The total survival rate of patients with renal parenchymal cancer is 81.2% after one year, 77.6% after 5 years and 70.4% after 10 years. CONCLUSION: The manner of detection, clinical stage and pathohistological type of the disease did not meet requirements for independent predictors. Success of the therapeutic treatment depends on the manner of the renal cell carcinoma presentation, pathohistological type and tumor stage.

Preoperative kidney tumor embolization as procedure for therapy of advanced kidney cancer.

INTRODUCTION: Preoperative kidney tumor embolization is standard procedure for therapy in advanced kidney cancer. Preoperative embolization has a goal to reduce intraoperative bleeding and also to shorten the time of surgery. MATERIALS AND METHODS: We retrospectively observed 50 patients between 2000-2011, in which the preoperative embolization was performed. Mean age of patients was 64 years. All patients with preoperative embolization were compared with the group of 51 patients from Urology Sarajevo, who underwent nephrectomy without preoperative embolization. RESULTS: Symptoms that are dominating among patients were haematuria and pain. Analysis of mean size of tumors based on CT evaluation showed statistically significance in between the biggest size of tumors in group from Hamburg (9.11±3cm) and the smallest size of tumors in Sarajevo group (4.94±1.6cm) p=0.0001. Reason for this is difference in selection of patients for treatment in Hamburg from Sarajevo. CONCLUSION: Kidney as functional finishing organ is extremely suitable for transcatheter therapeutic procedures. The gold standard in the treatment of advanced and metastatic tumor is the nephrectomy. As preparation for nephrectomy in metastatic cancer total capillary embolization is performed. After embolization, surgery is shorter, procedure can be done 24-48 hours after embolization or delayed nephrectomy done 2-3 weeks after the intervention.

Extracorporeal shock wave lithotripsy and intravenous contrast media application for localization of radiolucent calculi.

BACKGROUND AND PURPOSE: The present study was carried out to compare the efficacy of ESWL treating radiolucent ureteric calculi visible in the ureter after application of contrast media. MATERIAL AND METHODS: Medical records of 47 patients who had verified ureteric calculi by intravenous urography and retrograde pyelography were included in this study. Patients had undergone ESWL treatment after application of contrast media. Patients were divided in two groups, different in focusing the shock waves either at the end and below contrast shadows of the column of contrast medium visible in the ureter. 23 patients from group 1 were treated with shock waves focused on the end of contrast medium column and 24 patients from group 2 were treated with shock waves focused below contrast shadow of the contrast column. RESULTS: The stone free rate after 1 month were 9% and after 3 months were 14% greater in group 2 (89%) than in group 1 (75%). There were no allergic reactions to the contrast medium. Distributions of age, gender, treatment and diagnostic methods had been in both groups compared. CONCLUSION: ESWL of radiolucent ureteric calculi with application of contrast media is effective and safe. Shock waves focused below contrast shadow of the contrast column had better stone free rate than focusing at the end of the column.

Transrectal ultrasound-guided prostate biopsy, periprostatic local anesthesia and pain tolerance.

We have evaluated objectively pain tolerance in transrectal ultrasound-guided prostate biopsy (TRUS) using local periprostatic per rectal anesthesia as compared to the conventional method. From November 2008 to May 2009, 90 patients underwent transrectal ultrasound-guided prostate biopsy at Department of Urology, Clinical Center University Sarajevo. 90 patients who fulfilled the inclusion criteria were randomized into 3 groups of 30 patients each. Group 1 received periprostatic local anesthesia with 2% lidocaine, group 2 received Voltaren supp placed in rectum an hour before biopsy while group 3 received no local anesthesia. Pain scale responses were analyzed for each aspect of the biopsy procedure with a visual analog scale of 0-none to 10-maximal. There was no difference between the 3 groups in pain scores during digital rectal examination, intrarectal injection and probe insertion. The mean pain scores during needle insertion in group 1 receiving periprostatic nerve block and in group 2 receiving Voltaren supp were 3,10 +/- 2,32 and 5,15 +/- 2,01 respectively. In group 3 (no local anesthesia), mean pain scores were 6,06 +/- 2,95 which was found to be significantly different (p < 0,001). However, morbidity after the biopsy was not statistically different between all 3 groups. TRUS-guided prostate biopsy is a traumatic and painful experience, but the periprostatic blockage use is clearly associated with more tolerance and patient comfort during the exam. It is an easy, safe, acceptable and reproducible technique and should be considered for all patients undergoing TRUS biopsy regardless of age or number of biopsies.

Effects of extracorporeal shockwave lithotripsy on renal vasculature and renal resistive index (RI).

OBJECTIVE: It is known that ESWL can promote acute renal injuries and long-term complications of renal vasculature. Effects on renal vasculature can be evaluated by color Doppler ultrasonography measuring renal resistive index (RI). This prospective study aimed to determine the influence of number of delivered SW-s, used kV and changes in renal resistive index. PATIENTS AND METHODS: Total of 60 normotensive patients, 38 males (63%) and 22 females (37%), with renal stones 6-18 mm in size were included in this study. Median age was 42.3 years (range 22-55). RI was measured at interlobar artery before, 1, 3, 5 and 30 days after treatment on treated and contra lateral non-treated kidney. Patients were divided in two groups: Group I (N=25) received 2000 SWs; 0-2 units; (0.5 unit each 500 SWs) Group II (N=35) received 4000 SWs, 0-4 units; (0.5 unit each 500 SWs). RESULTS: In treated kidneys RI significantly increased first and second day after treatment from 0.62 +/- 0.05 at baseline to 0.67 +/- 0.05, p < 0.001 at first and 0.66 +/- 0.05, p < 0.007 on the second day after treatment. Increase of RI seven days after treatment is not significant (0.62 +/- 0.05). The contra lateral, non-treated kidney showed significant changes in RI only first day after treatment (0.64 +/- 0.05), p < 0.01. One month after the treatment RI is on normal values in both kidneys. CONCLUSIONS: Resistive index-RI is important parameter in evaluation of renal vasculature. Patients treated by ESWL showed a temporary increase in RI two days after the treatment and only first day in contra lateral non-treated kidney--probably caused by release of substance with vasoconstriction properties (need further investigations).

Incidental prostate cancer in patients undergoing radical cystoprostatectomy for bladder cancer.

The objective of this work is to verify the incidence of incidental prostate adenocarcinoma in patients who underwent radical cystoprostatectomy for invasive bladder carcinoma. We have retrospectively reviewed patients who underwent radical cystoprostatectomy for infiltrative bladder tumors in period between 2003 and 2007 year, 94 men with bladder cancer underwent radical cystoprostatectomy at Urology Clinic-University of Sarajevo Clinics Centre. Mean age of patients was 67 years, with age limits ranging between 48 and 79 years. Pathohistological evaluation was used for all specimens from RCP. We found that 9,57% of cystoprostatectomy specimens in patients with bladder cancer also contained incidental prostate cancer. This result was much lower than overall mean frequency of incidentally detected prostate cancer in other series of cystoprostatectomy cases (range, 23%-68%). In conclusion we recommended digital rectal examination (DRE) and prostate-specific antigen (PSA) test as part of the bladder cancer work up and complete removal of the prostate at cystoprostatectomy to prevent residual prostate cancer.