OSTEOPROTEGERIN AS AN EARLY SIGN OF CHRONIC KIDNEY DISEASE-MINERAL AND BONE DISORDER.

Chronic kidney disease (CKD) is among the most significant health problems, with the associated cardiovascular disease and bone metabolism disorders being the leading cause of morbidity and mortality in these patients. The aim of the study was to determine markers of bone turnover in patient sera (phosphates, calcium, alkaline phosphatase, parathyroid hormone and osteoprotegerin (OPG)) in all stages of kidney failure including kidney transplant recipients. We also wanted to determine whether dialysis vintage affects recovery of bone markers one year after transplantation. There were 164 study patients, whereas 30 healthy individuals served as a control group. Serum OPG progressively increased with decline of the glomerular filtration rate. The highest OPG concentration was recorded in dialysis group. We observed a statistically significant OPG increase in stage 2 CKD. In kidney transplant group, there was positive correlation between OPG and dialysis vintage. We also found that serum OPG was lower in patients treated with dialysis for less than 4 years prior to transplantation. We confirmed that CKD-mineral and bone disorder began in stage 3 CKD with parathyroid hormone and OPG elevation, and a statistically significant OPG increase in stage 2 CKD might be an early sign of CKD-mineral and bone disorder. Dialysis vintage longer than 4 years is associated with more significant disturbances in mineral and bone metabolism.

DIFFERENT APPROACHES TO MANAGING UROLITHIASIS IN KIDNEY TRANSPLANT PATIENTS - A CASE REPORT.

Urolithiasis is a rare urologic complication after kidney transplantation, and its diagnosis and treatment can be challenging for clinicians. In our 52-year-old male patient, graft hydronephrosis was found six months after transplantation. The patient had recurrent urinary tract infections followed by macrohematuria and an increase in creatinine levels. Computerized tomography revealed a 13-mm diameter stone in the ureter of the transplanted kidney as the cause of obstruction. Percutaneous nephrostomy was placed in the graft to solve the obstruction. Initial endoscopic treatment with a retrograde approach failed. An antegrade approach through a previously placed nephrostomy was not successful either. By a repeated retrograde approach, laser lithotripsy was performed successfully. The patient has been monitored for six months and has stable graft function without hydronephrosis or stones. As in our patient's case, the diagnosis and treatment of urolithiasis in kidney transplant patients is challenging, and minimally invasive procedures are the treatment of choice.

Case Report: Synchronous Removal and Implantation of Peritoneal Dialysis Catheter Using Bilateral Transversus Abdominis Plane Block.

Background: Peritoneal dialysis (PD) surgery include PD catheter insertion and removal. Both procedures require the use of anesthesia. The end-stage renal disease (ESRD) patients usually have severe comorbidities. The general anesthesia, because of its negative systemic effect, should be omitted in this vulnerable group of the patients. Transversus abdominis plane (TAP) block as a newer method of regional anesthesia is a technique without systemic effect and recently started to be used in ESRD patients for PD catheter placement and/or removal. Here we report a patient in whom we for the first time simultaneously removed and implanted a PD catheter by using a bilateral transversus abdominis plane block. Case Presentation: The patient was an 80-year-old man who was admitted for removal of malfunctioned PD catheter. Since the patient opted for staying on PD simultaneous implantation of catheter was planned. Because of his age and significant comorbidities, general anesthesia was avoided and bilateral TAP block become our option. In the same anesthesia, using bilateral TAP block, the old PD catheter was removed and a new one was implanted. Until now the patient is on regular PD without any complications. Conclusion: The TAP block could be used as a primary anesthetic technique in ESRD patients for PD surgery even for synchronous removal and implantation of PD catheter.

Kidney Transplants from Elderly Donors: The Experience of a Reference Center in Croatia.

OBJECTIVES: Our country Croatia is among the global leaders regarding deceased donation rates, yet we are facing organ shortage and concurrently a sharp decline in our acceptance rates for kidney offers. To reevaluate our organ acceptance policy, we retrospectively analyzed the factors that influenced the posttransplant outcomes of kidneys from elderly deceased donors at our center during a 20-year period and the changes to our organ acceptance criteria during Eurotransplant membership. MATERIALS AND METHODS: We studied all kidney transplants from donors ≥60 years old during the two 5-year episodes of Eurotransplant membership from 2007 to 2017 (period II and period III) and compared those data to data from the decade before Eurotransplant membership (period I, 1997-2007). Differences in acceptance rates and reasons for the decline of kidney offers between the two 5-year periods of Eurotransplant membership were analyzed. RESULTS: In period I, 14.1% of all kidney allografts were obtained from donors ≥60 years old; in period II and period III the rates were nearly 2-fold higher (27.0% and 25.7%, respectively; P = .007 and P = .008). During the first 5-year period of Eurotransplant membership (period II), we accepted significantly more grafts from marginal donors with a higher number of human leukocyte antigen mismatches compared with period I. Consequently, the 3-month survival rate of kidneys from donors ≥60 years old dropped from 91.1% to as low as 74.2% (P = .034). After application of morestringent human leukocyte antigen matching, especially in human leukocyte antigen DR, and morestringent donor acceptance criteria in period III, graft survival improved to 91.1%. CONCLUSIONS: Our experience indicates that careful selection of kidneys from elderly deceased donors and allocation to human leukocyte antigen-matched recipients is important to improve transplant outcomes.

Semantic Segmentation of Urinary Bladder Cancer Masses from CT Images: A Transfer Learning Approach.

Urinary bladder cancer is one of the most common cancers of the urinary tract. This cancer is characterized by its high metastatic potential and recurrence rate. Due to the high metastatic potential and recurrence rate, correct and timely diagnosis is crucial for successful treatment and care. With the aim of increasing diagnosis accuracy, artificial intelligence algorithms are introduced to clinical decision making and diagnostics. One of the standard procedures for bladder cancer diagnosis is computer tomography (CT) scanning. In this research, a transfer learning approach to the semantic segmentation of urinary bladder cancer masses from CT images is presented. The initial data set is divided into three sub-sets according to image planes: frontal (4413 images), axial (4993 images), and sagittal (996 images). First, AlexNet is utilized for the design of a plane recognition system, and it achieved high classification and generalization performances with an AUCmicro¯ of 0.9999 and σ(AUCmicro) of 0.0006. Furthermore, by applying the transfer learning approach, significant improvements in both semantic segmentation and generalization performances were achieved. For the case of the frontal plane, the highest performances were achieved if pre-trained ResNet101 architecture was used as a backbone for U-net with DSC¯ up to 0.9587 and σ(DSC) of 0.0059. When U-net was used for the semantic segmentation of urinary bladder cancer masses from images in the axial plane, the best results were achieved if pre-trained ResNet50 was used as a backbone, with a DSC¯ up to 0.9372 and σ(DSC) of 0.0147. Finally, in the case of images in the sagittal plane, the highest results were achieved with VGG-16 as a backbone. In this case, DSC¯ values up to 0.9660 with a σ(DSC) of 0.0486 were achieved. From the listed results, the proposed semantic segmentation system worked with high performance both from the semantic segmentation and generalization standpoints. The presented results indicate that there is the possibility for the utilization of the semantic segmentation system in clinical practice.

On Urinary Bladder Cancer Diagnosis: Utilization of Deep Convolutional Generative Adversarial Networks for Data Augmentation.

Urinary bladder cancer is one of the most common urinary tract cancers. Standard diagnosis procedure can be invasive and time-consuming. For these reasons, procedure called optical biopsy is introduced. This procedure allows in-vivo evaluation of bladder mucosa without the need for biopsy. Although less invasive and faster, accuracy is often lower. For this reason, machine learning (ML) algorithms are used to increase its accuracy. The issue with ML algorithms is their sensitivity to the amount of input data. In medicine, collection can be time-consuming due to a potentially low number of patients. For these reasons, data augmentation is performed, usually through a series of geometric variations of original images. While such images improve classification performance, the number of new data points and the insight they provide is limited. These issues are a motivation for the application of novel augmentation methods. Authors demonstrate the use of Deep Convolutional Generative Adversarial Networks (DCGAN) for the generation of images. Augmented datasets used for training of commonly used Convolutional Neural Network-based (CNN) architectures (AlexNet and VGG-16) show a significcan performance increase for AlexNet, where AUCmicro reaches values up to 0.99. Average and median results of networks used in grid-search increases. These results point towards the conclusion that GAN-based augmentation has decreased the networks sensitivity to hyperparemeter change.

Using multi-layer perceptron with Laplacian edge detector for bladder cancer diagnosis.

In this paper, the urinary bladder cancer diagnostic method which is based on Multi-Layer Perceptron and Laplacian edge detector is presented. The aim of this paper is to investigate the implementation possibility of a simpler method (Multi-Layer Perceptron) alongside commonly used methods, such as Deep Learning Convolutional Neural Networks, for the urinary bladder cancer detection. The dataset used for this research consisted of 1997 images of bladder cancer and 986 images of non-cancer tissue. The results of the conducted research showed that using Multi-Layer Perceptron trained and tested with images pre-processed with Laplacian edge detector are achieving AUC value up to 0.99. When different image sizes are compared it can be seen that the best results are achieved if 50×50 and 100×100 images were used.

Kidney transplantation using a colon pouch (Mainz pouch III): a case report.

Kidney transplantation is the most efficient method of renal replacement therapy. When this method is performed, native urinary bladder is the preferred urinary reservoir. However, in some patients with an anatomically and functionally abnormal lower urinary tract, the urinary bladder cannot be used for transplantation. In these patients, urinary diversion should be performed before kidney transplantation. We present a case of a 32-year-old male patient with orthotopic kidney transplantation performed using a colon pouch (Mainz-pouch III). He was born with severe anomalies including sacral agenesis, anorectal atresia, and hypospadias, which were corrected during childhood. Neurogenic bladder with severe vesicoureteral reflux led to end-stage renal disease. This dysfunctional bladder was unsuitable for kidney transplantation, and a staged approach for future transplantation was chosen. The first step was the creation of urinary diversion. Due to a short appendix, we created a continent, colon pouch (Mainz pouch III). Two years later, orthotopic kidney transplantation was performed using a right cadaveric kidney. The renal vessels were anastomosed to the aorta and inferior vena cava and the pyelon to the native ureter. Four years after transplantation, the patient has stable renal function without any complications. This is the first documented case of using Mainz-pouch III as a reliable option for kidney transplantation in selected patients.

THE ROLE OF LYMPHADENECTOMY IN PROSTATE CANCER PATIENTS.

Prostate cancer is one of the most important men's health issues in developed countries. For patients with prostate cancer a preoperative staging of the disease must be made. Involvement of lymph nodes could be assessed using imaging methods (CT or/and MRI), however, newer methods also exist (PET/CT, PSMA PET/CT). For some patients during radical prostatectomy a pelvic lymphadenectomy is recommended. Pelvic lymphadenectomy is indicated in intermediate- and high-risk group patients and with increased probability of lymph node invasion. The most used prediction tools for preoperative assessment of lymph nodes are Briganti and MSKCC nomograms and Partin tables. Pelvic lymphadenectomy can include different lymph nodes group, but extended lymphadenectomy is the recommended procedure. In 1-20% of patients, the lymph node invasion is present. Pelvic lymphadenectomy is primarily a diagnostic and staging method, and in minority of patients with positive lymph nodes it can be a curative method, too. In other patients with positive lymph nodes adjuvant therapy (radiotherapy and androgen deprivation therapy) can be beneficial.

Treatment of Kidney Stone in a Kidney-Transplanted Patient with Mini-Percutaneous Laser Lithotripsy: A Case Report.

We report a case of a kidney-transplanted patient with urolithiasis treated with mini-percutaneous laser lithotripsy. The patient presented with renal dysfunction and graft hydronephrosis. Diagnostic procedures revealed ureterolithiasis as a cause of obstruction, and percutaneous nephrostomy was inserted as a temporary solution. Before surgery, the stone migrated to the renal pelvis. Mini-percutaneous laser lithotripsy was successfully performed, and during surgery, all stone fragments were removed. Six months after successful treatment, the patient has good functioning and stone-free graft.

Correlation of tumor-associated macrophages and NK cells with bladder cancer size and T stage in patients with solitary low-grade urothelial carcinoma.

OBJECTIVE: The aim of the present study was to correlate the level of tumor-infiltrating immune cells with bladder cancer size and T category in patients with solitary low-grade non-muscle invasive bladder cancer (NMIBC). PATIENTS AND METHODS: Between 1996 and 2006, 115 patients with solitary low-grade NMIBC after transurethral resection of the bladder without adjuvant therapy were retrospectively identified from the institutional database. Tumor specimens were retrieved and tissue microarrays were constructed. Immunhistochemical staining for tumor-infiltrating immune cells with anti-CD3, CD4, CD8, CD20, CD56, CD68, and granzyme B (Gr B) was performed. RESULTS: Immune cells were predominantly observed within the cancer stroma. Statistically significant higher levels of CD56 cells in small tumors and CD68 cells in T1 tumors (p = 0.0310, 0.0151, respectively) were established. CONCLUSION: The current study propose a possible correlation of CD56+ and CD68+ cells with bladder cancer size and stage in patients with solitary low-grade NMIBC.

[MINI-PERCUTANEOUS NEPHROLITHOTRIPSY ­ OUR FIRST EXPERIENCE]. / MINIPERKUTANA NEFROLITOTRIPSIJA ­ NASA PRVA ISKUSTVA.

Urolithiasis is a significant problem in the developed countries due to the increased number of patients with stones. Just a few decades ago open surgery was the only surgical treatment which is today, in most cases, replaced with minimally-invasive methods. One of these new methods is mini-percutaneous nephrolihotripsy. We present four patients in whom mini-percutaneous nephrolithotripsy was performed. In all patients the stone was located in the renal pelvis. In three patients the stone was in the native kidney and in one in the transplanted kidney. In all patients laser lithotripsy was successfully performed. On the control x-ray the residual fragments were not found in any patients. Mini-percutaneous nephrolithotripsy is a minimally-invasive method which is successfull in the treatment of nephfrolithiasis in native and transplanted kidneys.

10-year survival of a patient with metastatic prostate cancer: Case report and literature review.

Prostate cancer is the most common malignancy in men. The 5-year relative survival for all stages combined is 98.8%. Patients diagnosed with metastatic prostate cancer have median survival from 2 to 3 years. We describe a case of 64-year old man who clinically presented with inguinal lymphadenopathy. Because of elevated PSA levels biopsy of prostate was done and adenocarcinoma was diagnosed. Biopsy of inguinal lymph nodes confirmed the diagnosis of prostate cancer. Hormonal treatment was started and at the most recent follow-up, 10 years later, the patient is asymptomatic with no clinical signs of disseminated disease.

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.

The effect of 5alpha-reductase inhibition with finasteride and dutasteride on bone mineral density in older men with benign prostatic hyperplasia.

Testosterone is converted to dihyrotestosterone by two isoenzymes of 5alpha-reductase. Finasteride and dutasteride are 5alpha-reductase inhibitors commonly used in the treatment of benign prostatic hyperplasia. We compared indices of bone mineral density in 50 men treated with finasteride, 50 men treated with dutasteride and 50 men as control. Bone mineral density of spine and hip were measured using dual energy X-ray absorptiometry. Bone formation was assessed by measuring serum osteocalcin and bone resorptionby measuring serum C-terminal telopeptide of collagen type 1. In addition serum total testosteron and estradiol were determined. The dutasteride group had significantly higher mean bone min- eral density, mean bone mineral content, mean T score, mean Z score at femoral neck and mean total hip Z score than control. Mean total testosterone and estradiol levels were higher in the dutasteride group. There were no significant dif- ferences between the groups in lumbar spine bone density parameters or bone turnover markers. Our results provide evidence that long-term 5alpha-reductase suppression does not adversely affect bone mineral density. Dutasteride therapy could have beneficial effect on bone density.

[Use of new materials in the treatment of chronic post-traumatic wounds]. / Primjena novih materijala u lijecenju kronicnih posttraumatskih rana.

Postoperative infection and the presence of osteosynthetic material in human body pose a major problem for patients and operators. Previously, it was considered that osteosynthetic material must be removed, and only then the expected full infection recovery could occur. However, removal of osteosynthetic material in unhealed fractures complicates bone fracture healing, as well as infection recovery. Nowadays, it is indicated to place an external bone fixator and in case of soft tissue recovery access to reosteosynthesis. The negative pressure wound therapy has brought new opportunities for treatment of this type of infections without the need of osteosynthetic material removal. Direct and indirect effects of negative pressure wound therapy create optimal healing conditions. Local use of new materials, transforming powder (Altrazeal) and topical hemoglobin spray (Granulox), provide and improve physiological conditions for appropriate and safe healing.

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.

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.

Prostate volume and urinary discomforts in elderly.

Occasional doubts about the real effect of the prostate volume on the urinary discomforts that elderly have been experiencing required additional assessment of these parameters. The aim of this study was to re-evaluate relationship between the urinary discomforts of the elderly and the prostate volume in comparison with age. Results of the group of 79 patients observed within one-year period were analyzed. In assessing their urinary discomforts the International Prostate Symptom Score (IPSS) was calculated, the ultrasound prostate volumetry was performed, and both of these parameters where compared with age. Statistical analysis of the results confirmed significant positive correlation between the prostate volume and age, positive correlation between IPSS and age, as well as between prostate volume and IPSS.