History of Urology at the Sestre Milosrdnice University Hospital Center.

The history of Croatian urology clearly shows its affiliation to the medical and civilizational circle of the Western world. The Department of Urology at the Sestre milosrdnice University Hospital Center is the oldest urology institution in the Republic of Croatia. The Department was established in 1894, when the new Sestre milosrdnice Hospital was open in Vinogradska cesta in Zagreb. It was then that doctor Dragutin Masek founded the so-called III Department, which, in addition to treating urology patients, also treated patients with conditions of the ear, nose and throat, eye diseases and dermatologic conditions. Dragutin Masek had already realized that medicine would soon be divided into fields and had assigned younger doctors joining the III Department to specific fields. As a result, urology was given to Aleksandar Blaskovic, who founded the first independent department of urology in Croatia in 1926. In 1927, he was appointed Professor of urology at the Zagreb School of Medicine, where he established the first department of urology and was giving lectures and practicals. Under his leadership, the Department of Urology was given the status of a Clinic, a teach-ing department, the first of its kind in Croatia. Owing to all his activities in the field of urology, the history remembers him as the "father of modern Croatian urology". Over the course of the following years, department chairs had changed, but luckily for the patients, approach to work had not. Conscientiousness, trust, competence and charity. After all, charity is the idea that the hospital carries even in its name, after the Sisters of Charity who had founded it. In all the decades, the Department of Urology has been following global development paths, objectively legging behind top facilities in the world by only a few years. Overall professional and scientific urology activities culminated in 1998, when the Clinic became the Reference Center of the Ministry of Health of the Republic of Croatia for prostate cancer, and in 2011, when it became the European Board of Urology Certified Center. All that has been achieved could not have been done without wholehearted help and cooperation of the nurses, as well as every other department employee from the beginnings of urology until today. Despite its rich history, the Department does not rest on laurels. Today, it is a modern urology department together with its European role models.

20 Years of the Reference Center for Prostate Tumors of the Ministry Of Health at the Department of Urology in Sestre Milosrdnice University Hospital Center.

The Department of Urology at the Sestre milosrdnice University Hospital Center is the oldest urological institution in the Republic of Croatia and this part of Europe. Today, the Department is a modern tertiary healthcare institution, where the most complex methods of urological practice are performed using modern medical devices and highly sophisticated technology. In 2011, our urology specialist education program was certified by the European Board of Urology (EBU) as the only one of its kind in Croatia. The program was recertified in 2017. The Department runs a program for the early detection of prostate cancer and performs more than 240 radical prostatectomies annually, which is the highest number of such interventions in Croatia. The aim of this study is to present the work and the activities of the Reference Center for Prostate Tumors of the Ministry of Health at the Department of Urology in Sestre milosrdnice University Hospital Center over the last 20 years. The database of the Reference Center for Prostate Tumors of the Ministry of Health at the Department of Urology in Sestre milosrdnice University Hospital Center was reviewed. During the twenty-year period, approximately 15,000 prostate interventions were performed due to benign and malignant diseases. Of this, 7,374 transrectal ultrasound guided prostate biopsies, 2,632 radical prostatectomies with open retropubic access, 3,988 transurethral prostate resections and 1,097 open suprapubic adenomectomies were performed. With the achieved scientific and professional results in monitoring, studying and improving the prevention, diagnosis and therapy of prostate tumors, as well as with the professional conditions and personnel, the Department of Urology in Sestre milosrdnice University Hospital Center truly justifies the title of the Reference Center for Prostate Tumors of the Ministry of Health of the Republic of Croatia awarded to it in 1998.

Transobturator Advance® Sling Suspension for the Treatment of Postprostatectomy Stress Urinary Incontinence.

Stress urinary incontinence (SUI) continues to present a major complication after radical prostatectomy. Suburethral slings represent one of the less invasive options for postprostatectomy SUI, and a more recent addition is a transobturator sling, the AdVance®. We report our results with the AdVance® sling for the management of postoperative SUI. The evaluation was conducted on 47 patients with AdVance® implant for SUI in our institution (November 2010 - June 2017). Measurements included age, etiology of SUI, duration of SUI, follow-up and pad use per day (PPD) pre- and postoperatively. Patients were classified as cured if they used no pads or 1 PPD for security reasons, or as improved if 1-2 PPDs were used and if there was a 50% reduction in pad use per day postoperatively. In our series we observed a reduction of mean PPD of 5.1 (2-8) to 1.7 (0-4) postoperatively. After follow-up and according to our criteria, the cure rate was 51.1% (24/47) and the improvement rate 27.5% (13/47). The overall success rate was 78.6% (37/47). No improvement was observed in 21.4% (10/47) of patients. Failure rates after sling placement for patients with addi-tional treatments following prostatectomy were much higher (60% (3/10) for radiation therapy and 66.7% (4/10) for urethral stricture disease). Our results show favourable cure and improvement rates and are comparable to results from larger series. The most appropriate candidates for the AdVance® sling are patients with mild to moderate postprostatectomy SUI. The results may be even better in patients without additional treatment following prostatectomy, such as radiation therapy or surgery for stricture disease.

Effect of histological inflammation on total and free serum prostate-specific antigen values in patients without clinically detectable prostate cancer.

PURPOSE: We are often confronted with patients in the "gray zone" (prostate-specific antigen [PSA]<10 ng/mL) whose biopsies reveal no malignancy but only inflammation. We investigated the relationship between histological inflammation and total PSA (tPSA), free PSA (fPSA), and percentage of free PSA (f/tPSA) levels in patients without prostate cancer (PC). MATERIALS AND METHODS: We studied 106 men with tPSA<10 ng/mL who had undergone biopsy that was negative for PC and who had no clinical prostatitis. Inflammation observed at biopsies was scored for inflammation type in each biopsy core by use of a four-point scale and was then correlated with tPSA, fPSA, and f/tPSA. RESULTS: Different patterns of inflammation were found in each set of biopsies. Regression factor analysis was used to form two groups according to inflammation type: more chronic and more acute. Median tPSA, fPSA, and f/tPSA levels in the more chronic and more acute inflammation groups were 6.4 ng/mL, 1.09 ng/mL, and 15%, and 7.3 ng/mL, 0.79 ng/mL, and l2%, respectively. A significant difference was found in fPSA (p=0.003) and f/tPSA (p<0.001), whereas the difference in tPSA was not significant (p=0.200). Total PSA correlated with fPSA (r=0.4, p<0.001) but not with inflammation type (r=0.12, p>0.010). A correlation existed between inflammation type and fPSA (r=-0.31, p=0.001) and f/tPSA (r=-0.43, p<0.001) in that the fPSA and f/tPSA were lower in the group with more acute inflammation. CONCLUSIONS: Subclinical inflammation has a significant influence on fPSA in patients with tPSA<10 ng/mL but without PC or clinical prostatitis. Subclinical inflammation is not characterized by elevated tPSA alone but also by a decreased fPSA, a tendency similar to that in PC.

The association of inflammatory markers with cerebral vasoreactivity and carotid atherosclerosis in transient ischaemic attack.

OBJECTIVES: Inflammatory mediators have an important role in the pathogenesis of stroke. Increased activity of inflammatory mediators initiates the development of atherosclerosis independently of other risk factors, thus compromising brain microcirculation and causing transient ischaemic attack (TIA). The aim of our study was to evaluate the relationship between serum level of cellular adhesion molecules (ICAM-1), interleukin-6 (IL-6) and C-reactive protein (CRP) with carotid intima-media thickness (IMT) and breath-holding index (BHI) in subjects with transient ischaemic attack. We also aimed to assess the difference of those markers between TIA patients and disease-free control individuals. DESIGN AND METHODS: The study included 45 TIA patients and 36 disease-free controls matched for age, gender and vascular risk profile. The degree of carotid atherosclerosis was assessed by colour Doppler with measurements of carotid IMT. Transcranial Doppler (TCD) ultrasound was performed in order to assess BHI. IMT, TCD, BHI and serum concentrations of ICAM-1, IL-6, and CRP were measured for all study subjects. RESULTS: Inflammatory markers IL-6, ICAM-1 and CRP were significantly higher in TIA patients than in disease-free controls (P<0.001, P=0.026, P<0.001, respectively). TIA patients had significantly lower values of BHI and higher IMT relative to disease-free control individuals (P<0.001). CONCLUSIONS: TIA is associated with higher ICAM-1, IL-6 and CRP, pointing to the marked inflammatory response to cerebral ischaemia. Inflammatory markers are associated with higher IMT and lower BHI, indicating the insufficient cerebral perfusion due to the underlying atherosclerotic disease. Our findings highlight the key significance of inflammation in the early response to ischaemia during the transitory ischaemic episode.

Cognitive performance in asymptomatic patients with advanced carotid disease.

OBJECTIVE: : In the absence of stroke or transient ischemic attack, patients with advanced carotid stenosis or occlusion (ICAs/o) are considered asymptomatic, yet they are prone to mostly subtle cognitive impairment. BACKGROUND: : The Mini-Mental State Examination (MMSE) often fails to detect mild cognitive impairment. The Montreal Cognitive Assessment (MoCA) is more sensitive in recognizing such changes. METHODS: : Scores on the MoCA and MMSE were compared in 70 asymptomatic patients with ICAs/o and 70 controls matched for demographic variables and vascular risk factors. RESULTS: : MMSE scores fell mostly within the normal range in both patients and controls. Differences were significant for total MoCA scores (P<0.001). Patients with ICAs/o performed worse on visuospatial and executive function (P=0.018), abstraction (P<0.001), and delayed recall (P<0.001). Lower MoCA scores were associated with diabetes (odds ratio=6.41; 95% confidence interval, 1.277-32.220; P=0.024) and older age (odds ratio=0.86; 95% confidence interval, 0.780-0.956; P=0.004). Patients with diabetes performed worse on delayed recall (P<0.001), and patients with hypertension were worse on the MoCA naming subtest (P=0.04). CONCLUSIONS: : The MoCA successfully identified reduced cognitive status in patients with ICAs/o. The MoCA subtest scores revealed a pattern of cognitive impairment similar to that documented in other studies using more extensive neuropsychological tests. MoCA could be used as part of the clinical evaluation of patients with ICAs/o.

New modification of transurethral incision of the prostate in surgical treatment of bladder outlet obstruction: prospective study.

AIM: To analyze long-term effects of short and shallow incision of the prostate, a new modification of transurethral incision of the prostate (TUIP), as a method of resolving bladder outlet obstruction and preserving anterograde ejaculation and potency. METHOD: Fifty patients with symptoms of bladder outlet obstruction caused by a small benign prostate tumor of less than 30 g estimated weight were included in a nonrandomized, prospective study and underwent transurethral incision of the prostate. In the patients with normal sexual activity (n=28), short and shallow incisions were made, limited to the prostatic urethra and reaching to the fibrous capsule. In sexually inactive men (n=22), longer and deeper incisions were made, extending from below the urethral orifice upward to the verumontanum and in depth to the perivesical and periprostatic fat. All incisions were made at 5 and 7 o clock. Preoperative and postoperative evaluations performed 1, 3, 6, 12, 18, 24, 30, 36, 40, 48, 54, 60, 66, and 72 months after surgery were based on the International Prostate Symptom Scores (I-PSS), uroflowmetry, patients overall assessment of surgery outcome, and a sexual function questionnaire. RESULTS: Median follow-up was 42 months (6-72 months). There was a significant improvement in urinary peak flow rates and I-PSS decreased significantly during the follow-up period in both groups (p<0.05). Surgery outcome was rated satisfactory by all patients, with no difference between the groups. All 28 patients sexually active before the surgery retained their sexual activity after surgery; only one developed retrograde ejaculation. Two patients, one from each group, underwent further urologic treatment (transurethral resection of the prostate) 36 and 42 months after transurethral incision of the prostate, respectively. CONCLUSION: Transurethral short and shallow incision at 5 and 7 o clock is an effective method for long-term relief of bladder outlet obstruction in patients with small, benign prostate tumor. It has equally good long-term outcome as the classic long and deep transurethral incision but with fewer complications. None of the patients operated by this new method had lost potency and only a single one developed retrograde ejaculation.