Modification of the Kock's pouch for bladder replacement.

AIM: To describe a modification of the Kock's pouch and present our clinical experience in its application. METHOD: After isolating an adequate ileal segment, the bowel is split by a longitudinal incision, with both ends remaining unopened for about 3-4 cm in length. Previously anastomozed ureters are inserted into the proximal end so that a nipple valve is created. The distal unsplit end serves for a direct anastomosis with the urethra. During the past 9 years, this surgery was performed in 41 patients who underwent radical cystectomy due to invasive carcinoma. Seventeen patients died for unknown reasons or were lost to follow-up. The remaining 24 were included in the follow-up for a period of 7 months to 6 years post surgery. RESULTS: Half of the patients included in the follow-up urinated spontaneously, with post void residuals less than 120 mL and no need for catheterization. Four patients did not urinate spontaneously and needed continuos catheterization, whereas 8 patients had post void residuals of 150-200 mL and needed catheterization once a day or once a week. None of the patients had a stricture at the site of ureteroileal anastomosis. CONCLUSION: We believe that our modification of the Kock's pouch makes the uretero-intestinal anastomosis much easier to perform; both ureters are inserted into the unsplit bowel end, thus preventing reflux; anastomosis with the urethra is performed under visual control; and direct anastomosis of widely opened distal end of the bowel reduces the possibility of scar stenosis.

Using buccal mucosa for urethral reconstruction in primary and re-operative surgery.

OBJECTIVE: Urethral reconstruction using buccal mucosa grafts finds increased broader use in patients with congenital or acquired urethral defects. The authors present their experience of 20 such treated patients. 12 repeatedly operated patients (11 congenital defects, 1 war injury) showed urethral defects of 4.5-20 cm in length. In 8 patients, 6 with hypospadias and 2 with prior straightening of the penis due to penoscrotal transposition, a urethral defect length of 2.5-7 cm had to be bridged. METHOD: For 2 patients a tubularized buccal mucosa free graft was used and for 18 patients the onlay method was partly or wholly used. In 1 patient a tubularized preputial island flap was used in addition to a buccal mucosa free graft. The urethral meatus was placed at the tip of the glans in all patients. RESULTS: Postoperatively a coronary fistula occurred in 1 patient. In 2 patients anastomotic strictures were seen after 18 and 60 days, respectively. One patient had a meatal stenosis and one splitting of the glans wings. With a mean follow-up time of 27 months, no further complications have been observed. CONCLUSION: The use of the buccal mucosa graft for urethral reconstruction is a successful method with a low incidence of complications. The indications arising from this operating method should, in our opinion, lead to the increased and broader use of this treatment method for congenital and acquired urethral defects.

War injuries of the ureter.

During the 18 months of war in Croatia, from 1991 until 1992, 4,425 wounded patients were treated at Clinical Hospital Osijek. Urogenital injuries were present in 115 treated patients (2.6%), and among them ureteral injuries were present in 11 patients (9.5%). The ureteral injuries were discovered by chance during exploratory abdominal surgery performed for other accompanying injuries. Ureteroureteral anastomosis was done in three cases. In three cases ureterocystoneostomy was performed. Exploration only was performed in three cases and nephrectomy was performed in two cases. It is important to emphasize that in three cases with contusions of the ureter wall that were not surgically reconstructed, the final result was ureteral stenosis. Moreover, in one case the final result was complete obliteration of the ureteral lumen.

[War wounds of the external genital organs]. / Les blessures de guerre des organes génitaux externes.

During the 18 months of war in Croatia, from May 1991 to November 1992, 4425 wounded persons were treated at Osijek hospital in Croatia. 115 (2.6%) had urogenital injuries, including 32 cases (27.8%) of genital lesions, which were treated immediately after treatment of the associated visceral lesions. A conservative surgical attitude was adopted allowing preservation of wounded testes in almost one half of cases. A free rectus abdominis aponeurosis flap on the defect of the tunica albuginea gave good immediate results, but its secondary distension altered the aesthetic result and impaired erection.

War injuries of the kidney.

Between 2 May 1991 and 2 November 1992, 4425 wounded people were treated at the Clinical Hospital of Osijek, Croatia. A hundred and fifteen (2.6 per cent) had a urogenital injury, 64 (56 per cent) of whom had penetrating kidney injuries. Sixteen (25 per cent) of this 64 were caused by gunshot wounds and 48 (75 per cent) by fragments of mines, mortars or grenades. The majority of the 64 kidney injuries had also associated injuries of some other major organ system, particularly in the abdomen, with only three cases of isolated kidney injury. In 53 patients (82.8 per cent) surgical access was by transabdominal incision, in nine (14 per cent) by extraperitoneal flank incision and in two cases thoracophrenolaparotomy was also performed. Nephrectomy was performed in 16 patients (25 per cent). In 46 (75 per cent) an organ-sparing procedure was done: kidney sutures in 28 (43.8 per cent), kidney resection in five (7.8 per cent) and exploration only in 15 (23.4 per cent). Intrahospital deaths occurred in 11 (18 per cent), seven in the operating theatre. An evaluation of the 6-month follow up for 90 per cent of the surviving patients is presented. It seems that the frequency of renal war injuries was lower than usually reported. Associated abdominal injuries justified surgical access by transabdominal incision. The high mortality rate is explained by a large number of associated injuries and by the proximity of the battlefield with resulting rapid transport of patients (average 52 min), which excluded the possibility of separating out the moribund patients. Long-term follow up confirmed the benefits of the conserving surgical approach.

Croatian experience in the treatment of 629 urogenital war injuries.

During the war in Croatia, from April 1991 until November 1993, 33,468 wounded persons were reported, and 24,865 of them were hospitalized. Out of the total number of the hospitalized persons 588 wounded suffered 629 injuries of the urogenital system. This study reports on the experience in the treatment of such injuries at 17 urological and surgical institutions.

Urogenital wounds during the war in Croatia in 1991/1992.

There were 142 war injuries to the urogenital organs in 115 of 4,425 wounded patients treated at our clinical hospital during 18 months of warfare in Osijek, Croatia. Kidney injury was the most common (64 cases) and urethral injury (4) the least common, with a relatively large number of ureteral injuries (11). Two-thirds of the injuries were associated with other trauma, most frequently abdominal injuries. The mortality rate was high (15.6%), explained by the proximity of the battlefield and resulting rapid patient transport (average 52.21 minutes), which excluded the possibility of separating out the moribund cases, as well as the exceptional destructive power of modern explosives and firearms, and associated wounds of the vital organs. Of the wounded 60% were members of the Croatian armed forces, 1 was a member of the United Nations Professional Force and 39.13% were civilians. Surgical intervention was characterized by a tendency toward conservation and the avoidance of organ sacrifice. Thus, nephrectomy was performed in only a quarter of the cases of renal injury. Nevertheless, orchiectomy was performed in two-thirds of the cases of testicular injury. In 5 of 8 cases of corpus spongiosum injury the tunica albuginea was primarily reconstructed with free transplantation of the fascia lata. For ureteral injury resection with primary suture yielded good results in contrast to stents without resection in cases of ureteral wall contusion, which resulted in ureteral stenosis in our patients.

[Destruction of the General Hospital in Osijek by the Federal Army (13-17 September 1991)]. / Razaranja Opce bolnice u Osijeku od strane federalne armije (od 13. rujna do 17. rujna 1991).

The article provides documentation on destroyment of General Hospital of Osijek in the period from September 13th until September 17th 1991. By heavy artillery of the Federal army, primarily from garrison "M. Stanivukovic" the Hospital was shut 94 times and unnumbered times by bullets from light weapons. Most of the hospital Wards are destroyed and for a time being General Hospital Osijek works mostly in the shelters and other underground facilities. Intensity of the assault on the Hospital shows that, in spite of many humanitarian war regulations, it was a primary target for Federal army artillery.

Extracorporeal shockwave lithotripsy (ESWL)--a report on the first 500 patients.

This paper presents the results of the treatment of the first 500 patients treated with the second generation lithotriptor SIEMENS "LITHOSTAR". In 500 patients with 607 stones 521 treatments were performed in 799 sessions. Six months after the ESWL treatment 522 out of 607 stones (86%) were desintegrated completely, i.e. 87.2% of the patients were stone-free. The best results were obtained with solitary pelvic (95.51%) and ureteral stones (95.8%). In 52 patients (10.4%) complications due to obstruction were successfully solved by endoscopic procedures. These results clearly present ESWL as the best method in the treatment of urolithiasis patients.

Crystal growth of calcium oxalate in urine of stone-formers and normal controls.

In this study, the relative crystal growth rate (Vcr) of calcium oxalate (Caox) and a number of other parameters were determined in 17-h daily (d) and 7-h nocturnal fractions (n) of whole urine from 20 recurrent Caox stone formers (SF) and 29 age-matched male normal controls (NC). Vcr, which was determined by the gel crystallization method (GCM), showed the largest difference between SF and NC among all parameters under investigation. Mean values (+/- SD) obtained for Vcr were: 0.73 +/- 0.58 (SF-d)/0.21 +/- 0.22 (NC-d; P less than 0.001) and 0.63+/- 0.58 (SF-n)/0.24 +/- 0.25 (NC-n; P less than 0.01). Significantly higher concentrations of Ca and lower concentrations of thermodynamic and kinetic effectors of Caox crystal growth were responsible for the higher crystal growth rates observed in SF as compared with NC, i.e., they should be partially causative in Caox urolithiasis. However, other properties of urine or the urinary tract (potentially, crystal agglomeration and adhesion) must be accounted for in the genesis of Caox stones.