Peritoneal Dialysis Catheter Placement Using an Ultrasound-Guided Transversus Abdominis Plane Block.

BACKGROUND: Peritoneal dialysis (PD) catheter placement is usually performed using general or local anesthesia. We present our PD catheter placement experience using an ultrasound-guided transversus abdominis plane (TAP) block, which is a regional anesthesia technique. METHODS: In this study, we analyzed 33 patients from our center with ESRD who underwent PD catheter placement using a TAP block between June 2011 and April 2014. RESULTS: The TAP block was successful for 29/33 (87.9%) patients. Four patients (12.1%) had pain at the incision site and required general anesthesia. There were no anesthesia-, surgery- or catheter-related complications. CONCLUSION: ESRD patients have a substantial number of comorbidities that can be negatively influenced by general anesthesia. Because regional anesthesia has no systemic effect, this procedure could be recommended for this group of patients. A TAP block is an effective, safe method and can be used as the principal anesthesia technique for PD catheter placement.

Transurethral incision of the bladder neck in a woman with primary bladder neck obstruction after kidney transplantation.

Voiding dysfunction is frequently seen in the early posttransplant period. Among other causes, this condition can arise due to bladder outlet obstruction. Primary bladder neck obstruction (PBNO) is a possible but very rare cause of bladder outlet obstruction. We present the case of a 52-year-old woman who, after kidney transplantation, presented with PBNO. The diagnosis was established based on symptoms, uroflowmetry, and multichannel urodynamics with electromyography. The transurethral incision of the bladder neck was made at the 5- and 7-o'clock position. After the operation, the maximal flow rate was significantly increased, and postvoid residual urine was decreased compared to the preoperative findings. The patient was followed for 5 years, and her voiding improvement is persistent. This is the first reported case of PBNO treated with a transurethral incision of the bladder neck in a posttransplantation female patient.

Bilateral wünderlich syndrome caused by spontaneous rupture of renal angiomyolipomas.

Wünderlich syndrome (WS) is a urological emergency characterized by retroperitoneal hemorrhage. In most cases, bleeding occurs from a renal angiomyolipoma (AML) and may be the first manifestation of the disease. We report a female patient with bilateral WS due to the metachronous rupture of renal AMLs. Because the patient was stable and the tumor was not malignant, treatment was conservative. Follow-up revealed the full recovery of kidney function and the resolution of the hematoma.

Different presentations of renal cell cancer on ultrasound and computerized tomography.

Renal cell carcinoma (RCC) is the most common malignant tumor of the kidney. The major goal of imaging techniques is to correctly differentiate between benign and malignant renal lesions. We present the cases of six patients with renal masses that were interpreted completely differently based on ultrasound (US) and computerized tomography (CT) findings.From January 1st, 2008 to March 1st, 2014, 307 patients from our center underwent nephrectomy for RCC. In all patients US and CT were performed before the operation.In six patients, the US indicated a focal, solid renal lesion that was interpreted by CT as a cystic lesion (Bosniak II-III). Because discrepancies were evident, renal biopsies were performed. The biopsies revealed RCC in the six patients, all of whom underwent subsequent nephrectomy. All of the patients were confirmed to have macroscopically solid RCC without any cystic components.In most cases, CT is the most accurate diagnostic technique for the clinical diagnostic classification of renal masses. In cases where US characterizes a renal lesion as solid, despite CT findings of a cystic lesion, kidney biopsies are recommended. The 6 cases reported here support our belief that, in diagnostic processes of RCC, these techniques should be complementary used.

[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.

Impact of NK cell count on bladder cancer recurrence.

PURPOSE: The aim of the present study was to evaluate the prognostic value of the local NK cell count in patients with recurrent non-muscle-invasive bladder cancer. METHODS: The archival paraffin-embedded primary tumor specimens were derived from retrospectively-selected patients, who were treated between 1996 and 2001 for bladder cancer. The study group consisted of 46 patients who developed recurrent disease during their first two post-operative years. The control group consisted of 27 patients who did not develop recurrent disease during their first two post-operative years. Specimens were assessed immunohistochemically with standard "ABC" technique. The frequency of NK cells was expressed as total number, estimated for each tumor by counting the positive NK cells in 10 high-power representative fields. Statistical analysis was done using Kruskal-Wallis test. RESULTS: Patients with recurrent non-muscle invasive bladder cancer in general have significantly higher values of stromal NK cell count than the control group. Patients with single tumor and smaller tumors show a statistically significant difference in NK cell count between study and control group. There also exists a statistically significant difference in stromal NK cell count in patients with clinical stage Ta tumor. CONCLUSIONS: Our results confirm an association of the bladder wall NK cell count in bladder cancer patients with the natural history of disease. Further well-performed, reproducible, large, prospective investigation stratified by clinical parameters, such as tumor number and diameter, is needed to display the true value of this marker in the clinical work-up of bladder cancer patients.

Transurethral bladder neck incision in women with primary bladder neck obstruction.

BACKGROUND: Bladder outlet obstruction is an uncommon condition in women. Primary bladder neck obstruction is one of the functional causes of bladder outlet obstruction. We evaluated surgical treatment in our patients with primary bladder neck obstruction. PATIENTS AND METHODS: We retrospectively evaluated the medical data of 47 female patients from the Department of Urology who underwent transurethral incision of the bladder neck from January 2000 to December 2012. All patients underwent transurethral bladder neck incision at the vesical neck and proximal urethra at the 5- and 7-o'clock positions. We compared symptoms and urodynamic parameters before and after the operation. RESULTS: Out of 47 female patients who underwent the operation, primary bladder neck obstruction was diagnosed in 42. The mean age was 44.3 ± 16.8 (range: 21-78) years. The postoperative maximal flow rates were significantly increased (20.6 ± 3.9 vs. 7.6 ± 3.2 mL/s, P < 0.0001), and the postvoid residual urine was decreased (31.3 ± 7.8 vs. 132.1 ± 22.24 mL, P = 0.0002) compared with preoperative findings. Improvement was evident in most patients (83.3 %). A repeat operation had to be performed in seven patients (16.7 %). Operative therapy failed in one patient (2.4 %). DISCUSSION AND CONCLUSIONS: The diagnosis of primary bladder neck obstruction in women is based on typical symptoms, uroflowmetry and multichannel urodynamics, including electromyography. Videourodynamics is obligatory in doubtful cases. Transurethral bladder neck incision is an effective therapy for female patients with primary bladder neck obstruction, and if necessary, a second procedure can be safely performed.

Surgical treatment of kidney cancer in elderly.

The aim of this study was to analyze our patients over the age of 70 suffering from kidney cancer that had undergone surgical treatment. During the 2000-2012 period 634 patients with kidney cancer were treated, 197 of whom were over the age of 70. In this group there were 117 (59.4%) men and 80 (40.6%) women. In most of these patients (156 patients--79.2%) the clear cell type of renal carcinoma was diagnosed. According to TNM classification the dominant stages were Tlb in 62 patients (31.8%) and T1a in 48 patients (24.6%). The most common grade was G2 (73 patients--37%). Radical nephrectomy was performed in 103 (52.3%) patients, simple nephrectomy in 86patients (43.7%), enucleation of the tumor and resection of the kidney in 6 (3.1%) patients, while in 2 patients the tumor was inoperable. Early postoperative compli cations developed in 21 (10.8%) patients. They included complications in distant organs in 11 (5.6%) patients and surgical complications in 10 (5.4%) patients. Five patients (2.6%) died during early postoperative period. Surgery is recommended treatment for elderly patients with kidney cancer with complications comparable with those in younger patients.

EGFR protein overexpression correlates with chromosome 7 polysomy and poor prognostic parameters in clear cell renal cell carcinoma.

BACKGROUND: The role of epidermal growth factor (EGF) and its receptor (EGFR) in the pathogenesis and progression of various malignant tumors has long been known, but there is still disagreement concerning prognostic significance of EGFR expression in clear cell renal cell carcinoma (CCRCC). The present study was designed to analyze more objectively the protein EGFR expression in CCRCC and to compare its value with EGFR gene copy number changes and clinicopathologic characteristics including patient survival. METHODS: The protein EGFR expression was analyzed immunohistochemically on 94 CCRCC, and gene copy number alterations of EGFR by FISH analysis on 41 CCRCC selected according to distinct membrane EGFR staining. RESULTS: Membrane EGFR expression in tumor cells was heterogeneous with respect to the proportion of positive cells and staining intensity. FISH analysis did not reveal EGFR gene amplification, while polysomy of chromosome 7 found in 41% was associated with higher EGFR membrane expression. Moreover, EGFR overexpression was associated with a higher nuclear grade, larger tumor size and shorter patient's survival, while there was no connection with pathological stage. CONCLUSION: In conclusion, the protein expression of EGFR had an impact on prognosis in patients with CCRCC, while an increased copy number of chromosome 7 could be the possible reason for EGFR protein overexpression in the absence of gene amplification.

[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.

[Retrograde balloon dilatation as a minimally invasive treatment for ureteral stricture]. / Retrogradna balonska dilatacija kao minimalno invazivni oblik lijecenja stenoze uretera.

Ureteral stricture is not a common urologic condition. Balloon dilatation represents one of the least invasive methods for treatment of ureteral strictures. We retrospectively analysed 24 patients with ureteral strictures treated with retrograde balloon dilatation in our department. The etiology of stricture was iatrogenic in 11 (45.8%) patients, post-TBC in one (4.2%), congenital in one (4.2%), retroperitoneal fibrosis in one (4.2%) and unknown in 10 (41.6%) patients. Twelve (50%) patients had a stricture of pelvic, 9 (37.5%) lumbar, and 3 (12.5%) of terminal ureter. In all patients retrograde balloon dilatation has been performed. Only complication related to the procedure was febrility in 4 patients (16.7%). Restrictures were noted in 12 (50%) patients, who consequently have been treated surgically, or had to be stented. Retrograde balloon dilatation, as a safe and relatively effective treatment, is proposed as the first choice in patients with short ureteral strictures.

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.

[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.

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.

Primary large-cell neuroendocrine carcinoma of the scrotum.

Neuroendocrine tumors (NETs) mostly develop from the neural crest cells but a few arise from neuroectoderm. They are common in the lungs and gastrointestinal tract but rare in the genitourinary tract. A 78-year-old man with no family history of malignant or hereditary diseases presented with a 3-month history of a rapidly growing asymptomatic scrotal nodule and swelling in the groin. He had a negative history of sexually transmitted disease and of trauma, fungal infection or chronic irritation in the scrotal area; there was no history of radiotherapy or exposure to chemicals or arsenic. Both the scrotal and groin lesions were excised with a minimum of 1.2 cm of normal skin. Examination of the specimen revealed a confined poorly differentiated large-cell neuroendocrine carcinoma with a metastasis to the inguinal lymph nodes. Three months after the excision we found a local recurrence. The recurrent tumor revealed tumor tissue concurrent with the primary lesion. To the best of our knowledge, there have been no previously published case reports on neuroendocrine tumor of the scrotum.

Comparison of results of surgical treatments of primary inguinal hernia with flat polypropylene mesh and three-dimensional prolene (Phs) mesh--one year follow up.

The aim of this study was to compare the results of the surgery of inguinal hernias using flat polypropylene mesh and three-dimensional prolene (PHS) mesh. The study included two groups of 40 male patients, aged 18-50 years, with the diagnosis of inguinal hernia. One group was operated with a flat polypropylene mesh, while the second group was operated with three-dimensional prolene (PHS) mesh. The study has shown that the operation with three-dimensional prolene mesh lasted 15 minutes longer and that the patients had stronger inflammatory response. Statistically, there was no significant difference in post-operative pain intensity, post-operative use of analgesics, length of hospitalization, return to daily activities, early and late post-operative complications. No recurrence was registered in any of the groups. The analysis of results indicates that there is no difference in treatment of inguinal hernia with flat polypropylene and three-dimensional prolene (PHS) mesh.

Modified extensive anterior vaginal wall repair for cystocoele.

We describe a new transvaginal technique for cystocoele repair. We prospectively evaluated patients with moderate and high-grade cystocoele who underwent repair with the new transvaginal repair between 2000 and June 2009. Preoperative evaluation included history and physical examination using the Pelvic Organ Prolapse Quantification, urine culture, residual urine measurement, urodinamycs and cystoscopy. We performed the repair in 76 patients with a mean age of 65.24 years (range, 36 to 84 years), wit anatomical cure in 72 (95%) patients. Four (5%) patients had recurrent cystocoele, 3 (4%) patients claimed residual sensory urgency and 4 (5%) stress urinary incontinence (SUI) after the operation. The operation is safe, simple, and provides good anatomic results with minimal complications.