[Retro and extraperitoneoscopic operations in urology--initial experience].

Retroperitoneoscopic approach is gradually becoming the method of choice in many urologic diseases. In this article we analyse and present the first cases of urological retroperitoneoscopic operations performed in the Department of Urology of the University Hospital "Akeksandrovska". For the period from May 2006 to March 2009 35 extra- and retroperitoneoscopic operations were performed. A 26 retroperitoneoscopic decortications (unroofing) of renal cysts with different localization were performed. 5 pieloplasties without interruption of pieloureteral segment (3 by Fenger method. 2 cases with Y-V pyeloplasty), 2 ureterolithotomies, 1 pyelolithotomy and one radical extraperitoneoscopic prostatectomy. The mean operative time in retro-peritoneoscopscopic decortications of renal cysts was 49.62 minutes (15 to 95 minutes), and in pyeloplasties, ureterolithotomies and pyelolithotomies, mean operative time was 88.00 minutes (65 to 150 minutes). The average pararenal drainage secretion was 138 ml for 24 hours (from 50 ml to 150 ml. The average blood loss was 86 ml (from 50 ml to 120 ml). In one case conversion was required because of technical problems and little experience of the team. Postoperatively in 5 cases (13.51%) we observed subcutaneous emphysema. The benefits of retro-extraperitoneoscopic urological operations are associated with lower morbidity, short stay in hospital, shorter recovery period and less pronounced pain syndrome.

[Local recurrence of the renal cell carcinoma in renal fossa after complete radical nephrectomy. What are the risk factors?].

The local recurrence of the renal cell carcinoma in renal fossa after complete radical nephrectomy is uncommon. According to the latest articles related to this issue it ranges between 2% and 4%. For the period of 1999-2005 we evaluated 11 patients who underwent surgery for isolated renal cell carcinoma recurrence, all of them without clinical presence of distal metastases. 9 of the patients were operated for their first time in our department, and only two in other hospitals. These 9 patients represent 1.41% of the whole number of radical nephrectomies for RCC (637) which took place in our department for the same period of time. The tumor stage of the primary tumor varied from T1 to T3a. In addition lymph node dissection was performed on 7 of the patients. The average time for developing clinically significant fossa recurrence was 18 months. The current article has the purpose to present newer the data for the factors, which may be directly related to the risk of developing local recurrence in the renal fossa after complete radical nephrectomy--the initial tumor stage of the RCC, the relationship between the primary tumor and the histological type of the recurrent masses.

[Could the transrectal prostate biopsy predict the rate of positive lymph nodes in prostate cancer patients?].

Since 1989, when Hodge and al. demonstrated transrectal ultrasound guided prostate biopsy, it has become a "gold standard" for the diagnosis of prostate cancer. According to the experience gained in the period 1999-2003 in the Department of Urology-Medical University, Sofia, in a prospective follow-up of 20 prostate cancer patients, we found relationship between the positive tru-cut biopsy cores and the rate of positive lymph nodes.

[Single stage reconstructive operations of the male urethra]. / Ednoaktni rekonstruktivni operatsii vurkhu muzhkata uretra.

UNLABELLED: The male urethra with its anatomic and tissue characteristics demands a differential approach in its reconstruction. The single stage operations, with using of a different plastic material as a treatment of some diseases of the male urethra (hypospadias, strictures), are already quite common to the urological practice. The authors are offering a retrospective analysis to the reconstructive operations of the male urethra with using a plastic material from the preputium and the skin of the penis. MATERIALS AND METHODS: For a period of 10 years 94 patients were followed ont: hypospadias--51 (53.9%); strictures--27 (28.7%); fistulas--16 (18%). Were described different operative techniques, but in all patients were used a one stage act. In patients with hypospadias we used five different techniques according to the sort of hypospadias. In patients with strictures we used three methods: with preputial flap; with circular flap from the dorsum of the penis and with a parallel longitudinal to the urethra flap from the ventral surface of the penis. RESULTS: From the first group of patients we had 17 (33.3%) with anterior hypospadias, 28 (54.9%) with middle, and 6 (11.8%) with posterior hypospadias. We achieved a full correction of the penis in 96.1% of the cases. We marked postoperative fistulas in 7 (13.7%) patients. In the second group of patients we marked 4 (14.8%) cases with postoperative Fistulas; restrictures in 2 (7.4%) cases and diverticul of the urethra in 1 (3.8%) case. In the third group fistulas were formed after urethroplasty in 11 (68.7%) cases and traumas and uroflegmons in 5 (31.3%) cases. We marked refistulisation in 5 cases. CONCLUSIONS: The urethroplasty with pedicular skin flaps from the preputium and the skin of the penis is a method of choice in patients with anterior strictures of the urethra. The single stage reconstructive operations of the male urethra are quite effective and promising.

[Endoscopic treatment of complete obliteration of posterior urethra]. / Endoskopsko lechenie na pulnata obliteratsiia na zadnata uretra.

The authors shared their experience in regard of treatment of complete urethral obliteration. In a 14-year they diagnosed and treated 37 patients (aged 22-74 years) with obstruction of the lower urinary tract as a result of complete urethral obliteration. The etiology include 14 patients after perineal urethral trauma, in 10 patients the main cause was urethral inflammation of posterior urethra, in 8--as a consequence of transurethral surgery and in 5--after suprapubic prostatectomy. Main diagnostic methods they used were retrograde urethrography and urethroscopy with 0 degree fiberoptic. In all patients an endoscopic incision of fibrotic tissue was carried out thus the entering the bladder cavity was successful. In some patients operative technique with a Benique through cystostomy cannel and bladder neck just opposite to the urethrotome knife was used. In three patients (8.2%) the procedure failed due to the massive urethral hemorrhage. They report recurrent urethral strictures in 24 patients (64.8%), treated with visual urethrotomy. The continence was compromised in 6 patients (16.2%).

["Fossa" carcinoma - a relapse or "rest" carcinoma of the kidney?]. / "Fossa" kartsinom't - retsidiv ili rest na karetsinoma na b'breka?

The local relapse represents a unique variant of the advanced stage of a disease (A Esrig et 1992). Presumably, "fossa" carcinoma may result from incomplete resection or persisting tumor in the regional contiguous lymph nodes (JB D Kernion 1978). The average time interval for a relapse to occur is 31 months after nephrectomy, and in most patients it becomes manifest with symptoms, such as losing weight, fatigability and lumbar discomfort (D Esrig et al 1992). In cases with local recurrence a long-term survivorship may be attained by resorting to aggressive surgical intervention (S Tanguag et al 1996). This is a report on twenty-three patients with "fossa" carcinoma covering the period 1994 through 1999, with a total of 425 patients with renal carcinoma operated during the same period of time. All patients undergo operation--lumbar access is used in 22 cases, and transperitoneal--in one. In one patients resection of colon is necessitated, whereas in five the neoplastic mass hardly lends itself to complete excision, with enucleation alone being done. At follow-up study the survival terms are as follows: up to 1 year--18 patients, up to 3 year--16 patients, up to 5 year--12 patients.

[Endoscopic treatment of complete obliteration of posterior urethra]. / Endoskopsko lechenie na p'lnata obliteratsiia na zadnata uretra.

The authors shared their experience in regard of treatment of complete urethral obliteration. In a 14-year they diagnosed and treated 37 patients (aged 22-74 years) with obstruction of the lower urinary tract as a result of complete urethral obliteration. The etiology include 14 patients after perineal urethral trauma, in 10 patients the main cause was urethral inflammation of posterior urethra, in 8--as a consequence of transurethal surgery and in 5--after suprapubic prostatectomy. Main diagnostic methods they used were retrograde urethrography and urethroscopy with 0. fiberoptic. In all patients an endoscopic incision of fibrotic tissue was carried out thus the entering the bladder cavity was successful. In some patients operative technique with a Benique through cystostomy cannel and bladder neck just opposite to the urethrotome knife was used. In three patients (8.2%) the procedure failed due to the massive urethral hemorrhage. They report recurrent urethral strictures in 24 patients (64.8%), treated with visual urethrotomy. The continence was compromised in 6 patients (16.2%).

[Some etiologic factors in condom-induced allergic contact balanitis]. / Prouchvane vurkhu niakoi etioloichni faktori na alergichniia kontakten balanit ot prezervativi.

Clinical cases presenting allergic contact balanitis from condoms are studied using a combination of patch testing and chemical analysis by gas chromatography and high-resolving liquid chromatography to identify the causative agents involved. It has been previously established that zinc ethylphenyl dithiocarbamate (ZEPC)--a dithiocarbamate-type accelerant (DTC)--is an etiological factor in the event of contact allergy to condoms. Later it is confirmed that DTCs, such as zinc dimethyl dithiocarbamate (ZDMC), zinc diethyl dithiocarbamate (ZDEC) and zinc dibutyl dithiocarbamate and amines, such as dimethylamine (DMA), diethylamine (DEA) and piperidine (PIP) are likewise implicated in condom-induced contact balanitis. As shown by the investigation along this line, although thiurams are believed to be more allergenic, as compared to the corresponding DTCs and amines, both DTCs (ZDMC, ZDEC, ZDBC, ZEPC) and amines (DMA, DEA and PIP) are noteworthy etiological factors of allergic contact balanitis from condoms.

[Continent derivation of urine (a Modo) Mainz II]. / Kontinentna derivatsiia na urinata tip (a Modo) Maints II.

The improved intestinal dissection technique and antibiotic agents, and the development of new resorptive suture materials have led to renewed surge of interest in ureterosigmoidostomy as a practicable procedure for continent derivation. Based on data from urodynamic assessment of diverse forms of urinary derivation, M Fisch and R Hohenfellner in 1991 propose a modification of the classical technique of ureterosigmoidostomy, coined with the term Sigmarectum pouch or Mainz pouch (M Fisch, R. Wammack, R Hohenfellner 1991). Over the period 1992 through 1999, 46 operations type "Mainz II" are performed in the Department of Urology--University Hospital "Alexandrovska". The series includes 41 men and 5 women with age range 42 to 80 years. All patients present urinary bladder tumors. The usual surgical technique is used. The severest postoperative complications include: urinary fistulae--3 (6.52%), local relapse--4 (8.69%) and distant metastases--2 (4.35%). In six patients the outcome is fatal (0.7%). This type of continent derivation following cystectomy is recommended since it is convenient, practically atraumatic and well tolerated by the patients. Complications encountered seldom necessitate operative intervention.

[Strictures of the urethra--the etiological factors and therapeutic management]. / Strikturi na uretrata--etiologichni faktori i terapevtichno povedenie.

Strictures of the urethra pose problems still disputable in the literature owing to the variety of etiological factors involved, and difficulties encountered in choosing the most adequate therapeutic approach. Ninety-six patients presenting urethral stricture are studied over a 5-year period (1991-1995). The commonest causes of stricture formation are postinflammatory (51 per cent), postoperative (34.4 per cent) and posttraumatic (14.6 per cent). The study covering 578 patients, treated by transurethral resection for other disease during the aforementioned period, shows that postoperative strictures develop in 2.6 per cent of them. In 81.2 per cent of cases the stricture involves the anterior urethra, and in 18.8 per cent--the posterior. The presence of multiple strictures is found in 27.1 per cent. Visual internal urethrotomy is the operative procedure most frequently used--in 85.4 per cent of cases. In 3.1 per cent urethroplasty with a pedicled preputial flap is performed. Recurrences are recorded in 7.3 per cent. Emphasis is laid on the direct interdependence existing between etiological factors and pathoanatomical stage having an essential practical bearing on the choice of optimal therapeutic approach.

[The treatment of severe and complicated urethral strictures]. / Lechenie na tezhkite i uslozhneni strikturi na uretrata.

Stricture of the urethra is produced by a cicatrix causing narrowing of the urethral lumen subsequent to trauma or inflammation. The strictures are considered as serious whenever the meatus is involved, and total--in the event of obliteration of the urethra (H. Sachse, 1978). The complications are associated with perineal, scrotal or suprapubic fistulae (C. Devine, P. Devine 1989). This is a report on 37 men presenting severe complicated strictures of the urethra, treated over the period 1981-1995 in the Clinical Center of Urology. According to underlying cause the strictures are divided in: postoperative--7 cases, iatrogenic--6, inflammatory--1, traumatic--23, and patients with scrotal fistulae--3. The patients are operated using a combined method through open and endoscopic manipulation; in 3 cases plastic repair of the urethra with a preputial flap is done. The overall results are estimated as good.

[Initial clinical studies of the preparation Immucyst for immunotherapy in patients with carcinoma in situ (CIS) of the bladder]. / Nachalni klinichni prouchvaniia na preparata Immucyst za imunoterapiia pri bolni s kartsinom in situ (CIS) na pikochniia mekhur.

Over a 12-month period, thirteen patients, 10 men and 3 women, with recurrent surface transitional cell carcinomas of the urinary bladder in conjunction with CIS, are picked out and subjected to treatment. Distribution of the patients: primary multiple carcinomas combined with CIS, Ta-T1/G1-G2-4 cases; recurrent multiple carcinomas, with CIS, Ta-T1/G2-two, recurrent multiple carcinomas, combined with CIS, Ta-T1/G2-five, and T1/G3-two cases. In all instances transurethral resection (TUR) of both visible carcinomas, and CIS areas, is performed. Induction Immucyst therapy is carried out according to protocol: 3 vials BCG vaccine, dissolved in 50 ml serum, inserted intravesically once weekly over 6 weeks. The fluid is retained by the patients for up to 2 hours. Therapy is commenced within 7-14 days after TUR. Cystoscopy, cytology and biopsy of suspected areas ar done at 3, 6 and 12 days. Six of the patients reported on undergo 12-month follow-up study. The remainder (6 cases) are followed up for periods ranging from 3 to 6 months. At the actual stage of study, twelve patients are free of recurrences, and present negative cytological findings. One patient alone with carcinoma stage T1/G3 develops recurrence, treated with TUR and laser coagulation followed by immunotherapy. Two thirds of the patients sustain transitory pollakiuria and dysuria, and one third-subfebrile temperature persisting for 48 hours.

[The place of interventional ultrasound in urology]. / Miastoto na interventsionalniia ultrazvuk v urologiiata.

The search for new methods of diagnosis, treatment and prognosis and their introduction in practice is a stable process in world urologic practice. It was not until after the first echographic apparatuses were produced in the fifties that the introduction of interventional ultrasound in urology became feasible. The authors set themselves the task to study and summarize the possibilities of this method for treatment of diseases of the kidneys, upper urinary tract, bladder and prostate. Renal cysts were diagnosed by ultrasound in 312 patients; in 229 of them percutaneous puncture was performed under ultrasound control. To reduce relapses, different sclerosing substances were applied, peak success being obtained with tetraolean. For establishing the exact cause of obstruction of the upper urinary tract the authors used antegrade pyelography under ultrasound control in 92 patients. Percutaneous nephrostomy for drainage of the upper urinary tract, a new endourologic operation was performed in 67 patients. To raise the radical approach to transurethral resection of the prostate and of bladder tumors, intraoperative transurethral ultrasound control was adopted for all patients operated by this technique.

[Inhalation treatment with low doses of heparin in bronchial asthma patients]. / Inkhalatorno lechenie s niski dozi kheparin na bolni s bronkhialna astma.

The efficacy of the inhalation treatment of bronchial asthma with low heparin doses was studied in 107 patients 18 to 65 years of age (mean age 43.9 years), men 46 (46.99%), women 61 (57.09%), duration of the disease from 1 up to 18 years. 29 patients (27.10%) had atopic bronchial asthma, 78 patients (72.90%) had mixed and infectious-allergic bronchial asthma. In all patients the disease was in a state of aggravation with various degree of bronchial obstruction. The results of the study show that heparin applied by inhalation in low doses of 5000 U in the course of 10-12 days is highly effective. Positive effect was found in 101 patients (94.39%) and in 84 of them (78.50%) it was considered as very good. Marked good effect was registered in patients who received corticosteroids simultaneously and their doses could be reduced or their application discontinued. It is suggested that the good results of the heparin inhalation treatment were to some extend due to the environmental conditions of the region of Sandanski, South West Bulgaria, where the study was carried out. The resort zone Sandanski is well known for its bioclimatic conditions which are favourable for the treatment of non-specific respiratory infections.