Autoaugmentation of urinary bladder – a case report

Cilj: Radom smo željeli prikazati pacijenta s izrazito smanjenim kapacitetom i complianceom mokraćnog mjehura i posljedično značajno narušenom kvalitetom života, koji je uspješno liječen autoaugmentacijom mokraćnoga mjehura. Prikaz slučaja: Pacijent u dobi od 36 godina javio se na urološki pregled zbog izrazitih smetnji mokrenja koje su trajale posljednje tri godine. Prevladavajuće smetnje bile su frekvencija, nikturija, urgencija i urgentna inkontinencija. Zbog opisanih smetnji pacijent se psihički promijenio, a zbog čestih i bolnih nagona na mokrenje nije mogao obavljati obaveze iz privatnog i poslovnog života. Nakon opsežne laboratorijske, mikrobiološke i slikovne obrade te nakon neuspješnog konzervativnog liječenja pacijentu je predloženo kirurško liječenje. Učinjena je autoaugmentacija mokraćnog mjehura. Poslijeoperacijski tijek bio je uredan. Pri otpustu iz bolnice frekvencija mokrenja bila je četiri do pet puta dnevno, nikturija jedan do dva puta, a prosječni volumen izmokrenog urina oko 400 ml. Rasprava i zaključak: U pažljivo probranih pacijenata autoaugmentacija mokraćnog mjehura može značajno poboljšati kvalitetu života pacijenata s izrazito smanjenim kapacitetom i complianceom mokraćnog mjehura. Ovaj kirurški zahvat najčešće prolazi bez težih komplikacija, a kako ne zahtijeva uporabu crijevnih segmenata, u slučaju neuspjeha moguće je naknadno pristupiti enterocistoplastici, ortotopnoj ili supravezikalnoj derivaciji mokraćnog mjehura.Aim: To present a case of a very reduced capacity and compliance of urinary bladder in a young men who was successfully treated with bladder autoaugmentation. Case report: Thirty six years old male patient came to urology department complaining of iritative lower urinary tract symptoms. Dominant symptoms were frequency, nicturia, urgency and urge incontinence. Symptoms were so severe that patient was psychologically altered and his private and professional life suffered. After extensive workup and after failure of conservative treatment, autoaugmentation cystoplasty was performed. The postoperative course was uneventful. At the time of discharge from hospital he had frequency of four to five times daily and two times by night. Average voided volume was 400 mL. Discussion and conclusion: In selected cases, bladder autoaugmentation significantly improves quality of life in patients with reduced bladder capacity and compliance. Surgical procedure is safe and free of severe complications. Since the procedure is extraperitoneal and there is no need for use of intestinal segments, it is always possible to perform ileocystoplasty, orthotopic or supravesical urine diversion using intestinal segments

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

Expression of Bone Morphogenetic Protein-7, It´s Receptors and Smad1/5/8 in Normal Human Kidney and Renal Cell Cancer

Bone morphogenetic proteins (BMPs) are cytokines which are important for kidney homeostasis but also have role in the some renal diseases and renal cell carcinoma (RCC)1–5. In the last three decades incidence of RCC was constantly increased and the role of different molecular biomarkers in RCC is explored1. We analyzed expression of BMP-7, their receptors (BMPR-IA, BMPR-IB, BMPR-II) and proteins of their signaling pathway (pSmad1/5/8) in sixteen renal cancer samples and paired normal tissue. Tissue samples were analyzed by immunohistochemistry and Western blot. BMP-7, BMP receptors and pSmad1/5/8 were expressed in all structures of normal kidney but dominantly in the proximal tubular cells. In the cancer samples their expression was also noticed. Comparison of BMPs between different tissue showed increased expression of BMPR-IB and pSmad 1/5/8 and decreased expression of BMP-7 and BMPR-II in RCC compared to normal kidney. BMPR-IA was detected with immunohistochemistry but with Western blot attenuated signal was presented. BMP-7, BMP receptors and pSmad1/5/8 were showed in normal kidney and RCC. Detected alterations of BMP-7, BMP receptors and pSmad expression in RCC suggested their possible role in tumorigenesis of kidney cancer

Osteoprotegerin kao rani predskazatelj mineralno-koštanog poremećaja u bolesnika s kroničnom bubrežnom bolesti

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.Kronična bubrežna bolest (KBB) važan je javnozdravstveni problem pri čemu su kardiovaskularne komplikacije i poremećaj mineralno-koštanog metabolizma vodeći uzroci pobola i smrtnosti ovih bolesnika. U ovom istraživanju mjerene su koncentracije biljega koštane pregradnje (kalcij, fosfati, alkalna fosfataza, paratireoidni hormon i osteoprotegerin (OPG)) u različitim stadijima kronične bubrežne bolesti uključujući i bolesnike nakon transplantacije bubrega. Temeljem tih rezultata namjera je bila odrediti u kojem je stadiju KBB potrebno započeti liječenje poremećaja mineralno-koštanog metabolizma. Također smo željeli utvrditi utječe li vrijeme provedeno na dijalizi na oporavak mineralno-koštanog metabolizma nakon učinjene transplantacije bubrega. U istraživanje je bilo uključeno 164 bolesnika te 30 zdravih ispitanika u kontrolnoj skupini. Utvrdili smo kako je koncentracija OPG-a obrnuto proporcionalna glomerularnoj filtraciji. Najviše koncentracije OPG-a utvrđene su u dijaliznoj skupini bolesnika, a statistički značajan porast koncentracije OPG-a utvrđen je već u drugom stadiju KBB. Također je utvrđeno da koncentracija OPG-a pozitivno korelira s vremenom trajanja hemodijalize. Ovim istraživanjem potvrdili smo da poremećaj mineralno-koštanog metabolizma počinje u trećem stadiju KBB. Statistički značajan porast koncentracije OPG-a u drugom stadiju KBB mogao bi biti rani znak poremećaja mineralno-koštanog metabolizma. Trajanje dijalize duže od četiri godine povezano je sa značajnijim poremećajem mineralno-koštanog metabolizma

The development of panurothelial carcinoma after kidney transplantation in patient with endemic nephropathy

Cilj: Endemska nefropatija (EN) je kronična bubrežna bolest koja nastaje zbog dugotrajnog izlaganja aristolohičnoj kiselini. EN je povezan s razvojem terminalnog stadija bubrežne insuficijencije, ali i s razvojem karcinoma urotela, poglavito gornjeg dijela mokraćnoga sustava. U radu ćemo prikazati pacijenticu s endemskom nefropatijom, u koje se nakon presađivanja bubrega razvio panurotelijalni karcinom. Prikaz slučaja: U 76-godišnje pacijentice s EN-om je 2013. godine učinjena uspješna kadaverična transplantacija bubrega. Nakon transplantacije otkriven joj je površinski karcinom mokraćnoga mjehura koji je više puta liječen transuretralnim putem. Zbog pojave karcinoma u gornjem dijelu mokraćnoga sustava učinjena joj je i obostrana nefroureterektomija. Unatoč promjeni imunosupresivne terapije i kirurškom liječenju razvila se metastatska bolest uz letalni ishod tri godine po transplantaciji uz funkcionirajući presadak. Zaključak: U pacijenata s EN-om može doći do razvoja panurotelijalne bolesti, a posebno su ugroženi pacijenti u kojih je učinjena transplantacija bubrega. U ove skupine pacijenata vrlo je važna prijetransplantacijska obrada, kao i praćenje nakon transplantacije bubrega.Aim: Endemic nephropathy (EN) is a chronic kidney disease caused by long-lasting exposure to aristolochic acid. EN is linked to the development of end-stage renal disease but also with the development of urothelial carcinoma, especially upper urinary tract carcinoma. We present a rare case of patient with EN who developed panurothelial cancer after kidney transplantation. Case report: In a 76-year-old woman with EN, a successful kidney transplantation was performed in 2013. After the transplantation, superficial bladder cancer was diagnosed and therefore treated with transurethral resection a few times. Later on, carcinoma of the upper urinary tract was also diagnosed so the bilateral nephroureterectomy was performed. Despite modified immunosuppression and surgical treatment, the metastatic disease was developed and the patient died three years after the transplantation, with the graft still being functional. Conclusion: Patients with EN have a higher risk of developing panurothelial carcinoma. Special attention must be given to EN patients who had kidney transplantation. In this group of patients, special considerati on must be emphasized on pretransplant evaluation and follow-up after kidney transplantation

POSTAVLJANJE KATETERA ZA PERITONEJSKU DIJALIZU PRIMJENOM REGIONALNE ANESTEZIJE: ULTRAZVUČNO VOĐENI TAP BLOK

Peritoneal dialysis (PD) is an established method for renal replacement therapy in patients with end-stage renal disease (ESRD). Transversus abdominis plane (TAP) block is a regional anesthesia technique, since recently used for PD catheter placement. The main aim of this study was to evaluate the efficacy of PD catheter placement using ultrasound-guided TAP block. We studied 43 ESRD patients from our center that underwent PD catheter placement under TAP block between June 2011 and December 2014. TAP block was successful in 38 (91.4%) of 43 patients. The remaining five (8.6%) patients required general anesthesia. All procedures were performed without complications. ESRD patients have a substantially greater number of comorbid conditions compared to general population, many of which are adversely influenced by general anesthesia. Opposite to general anesthesia, regional anesthesia has no systemic effect and using this technique may prove beneficial in this group of patients. In conclusion, TAP block is an effective method for PD catheter placement and should be especially considered in ESRD patients with major comorbidities.Peritonejska dijaliza (PD) je učinkovita metoda nadomjesne terapije bubrežne funkcije u bolesnika koji se nalaze u terminalnom stadiju bubrežnog zatajenja (ESRD). Transversus abdominis plane (TAP) blok spada u regionalnu anesteziju i nedavno se počeo primjenjivati i i kod implantacija katetera za PD. Cilj ove studije bio je procijeniti učinkovitost postavljanja katetera za PD uz pomoć ultrazvučno vođenoga TAP bloka. Analizirali smo 43 bolesnika s ESRD iz našega centra u kojih je postavljen kateter za PD uz pomoć TAP bloka između lipnja 2011. i prosinca 2014. godine. TAP blok bio je uspješan u 38 (91,4%) od 43 bolesnika. U ostalih pet bolesnika bilo je potrebno primijeniti i opću anesteziju. Svi zahvati su prošli bez komplikacija. Bolesnici s ESRD imaju značajan i uvećan broj popratnih bolesti u odnosu na opću populaciju, od kojih se mnoge mogu pogoršati djelovanjem opće anestezije. Za razliku od opće anestezije, regionalna anestezija nema sistemskog učinka te uporaba ove tehnike može biti korisna u ove skupine bolesnika. Zaključno, TAP blok je učinkovita metoda kod postavljanja katetera za PD, pogotovo u bolesnika s ESRD koji imaju brojne popratne bolesti

KIDNEY TRANSPLANTATION IN PATIENTS WITH PREVIOUSLY PERFORMED URINARY DIVERSION AND BLADDER AUGMENTATION

U nekih bolesnika s kongenitalnim ili stečenim poremećajima donjeg dijela mokraćnog sustava neophodno je prije transplantacije učiniti odgovarajuću urinarnu derivaciju ili augmentaciju mjehura. Prikazat ćemo naša iskustva u bolesnika u kojih je učinjena transplantacija bubrega koristeći urinarnu derivaciju ili augmentaciju mjehura. Na Klinici za urologiju Kliničkog bolničkog centra u Rijeci, između 30. siječnja 1971. i 17. svibnja 2018. godine ukupno smo učinili 1135 transplantacija bubrega. Retrospektivno smo analizirali bolesnike u kojih je učinjena transplantacija bubrega koristeći urinarnu derivaciju ili augmentirani mokraćni mjehur. Do sada je u 6 takvih bolesnika (ilealni konduit – 3 bolesnika, Mainz-Pouch I - 1 bolesnik, Mainz-Pouch III – 1 bolesnik, augmentacija mjehura s kolonom – 1 bolesnik) učinjena transplantacija bubrega. Uzrok disfunkcije donjeg dijela mokraćnog sustava bio je: neurogeni mjehur (3 bolesnika), karcinom mokraćnoga mjehura (2 bolesnika) i valvule stražnje uretre (1 bolesnik). Jednogodišnjeg preživljenja presatka bilo je 83 %, a bolesnika 100 %. Jedan bolesnik je četiri godine nakon transplantacije umro zbog mezotelioma pleure uz funkcionirajući transplantat. U svih ostalih bolesnika transplantat je i dalje funkcionalan. Bolesnicima s urinarnom derivacijom ili augmentacijom mjehura može se uspješno dati transplantat. Iako se radi o kirurški zahtjevnom zahvatu, dugotrajni rezultati su podudarni s rezultatima transplantacije u standardnoj populaciji te je neophodno poticati uvrštenje ovih bolesnika na listu čekanja za transplantaciju bubrega.Kidney transplantation is the most effective treatment for patients with end-stage renal disease. The prerequisite for kidney transplantation is the normal lower urinary tract system. In some patients with congenital or acquired disorders of the lower urinary tract, it is necessary to form adequate urinary diversion or bladder augmentation. This should be done prior to kidney transplantation. We present experience from our center with renal transplantation using urinary diversion or bladder augmentation. At Department of Urology, Rijeka University Hospital Centre, 1135 kidney transplantations were performed between January 30, 1971 and May 17, 2018. We retrospectively analyzed transplant patients with urinary diversion or bladder augmentation. During the observed period, we performed 6 kidney transplantations in patients with urinary diversion or bladder augmentation. Ileum conduit was performed in 3 patients, and Mainz pouch I and Mainz pouch III in one patient each. One patient had bladder augmentation with colon. The cause for urinary reconstruction was neurogenic bladder (3 patients), bladder cancer (2 patients) and posterior urethral valve (1 patient). Transplantation was heterotopic in five patients and orthotopic in one patient. One-year graft survival was 83% and one-year patient survival was 100%. In one patient, graftectomy was performed because of venous thrombosis. One patient died four years after transplantation because of pleural mesothelioma but with functional graft. All other grafts are still in function (1-23 years after kidney transplantation). Patients with urinary diversion and bladder augmentation could be successfully transplanted. Instead of more complicated operation, long-term results are comparable with the results of standard transplant population. This must encourage us to include patients with urinary diversion and bladder substitution on the waiting list for kidney transplantation

ORTHOTOPIC KIDNEY TRANSPLANTATION – A CASE REPORT

Transplantacija bubrega najbolji je oblik liječenja bolesnika u završnom stadiju kroničnoga bubrežnog zatajenja. Najčešće se radi heterotopna transplantacija bubrega s implantacijom presatka u ilijakalnu ložu. U nekih bolesnika, zbog prethodnih transplantacija ili izražene ateroskleroze ilijakalnih krvnih žila, heterotopna transplantacija nije moguća. Prikladna alternativa za te pacijente jest ortotopna transplantacija. U članku izvješćujemo o bolesniku s jako izraženom aterosklerozom ilijakalnih arterija, kojemu smo učinili uspješnu ortotopnu transplantaciju bubrega.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

KIDNEY TRANSPLANTATION IN PATIENTS WITH PREVIOUSLY PERFORMED URINARY DIVERSION AND BLADDER AUGMENTATION

U nekih bolesnika s kongenitalnim ili stečenim poremećajima donjeg dijela mokraćnog sustava neophodno je prije transplantacije učiniti odgovarajuću urinarnu derivaciju ili augmentaciju mjehura. Prikazat ćemo naša iskustva u bolesnika u kojih je učinjena transplantacija bubrega koristeći urinarnu derivaciju ili augmentaciju mjehura. Na Klinici za urologiju Kliničkog bolničkog centra u Rijeci, između 30. siječnja 1971. i 17. svibnja 2018. godine ukupno smo učinili 1135 transplantacija bubrega. Retrospektivno smo analizirali bolesnike u kojih je učinjena transplantacija bubrega koristeći urinarnu derivaciju ili augmentirani mokraćni mjehur. Do sada je u 6 takvih bolesnika (ilealni konduit – 3 bolesnika, Mainz-Pouch I - 1 bolesnik, Mainz-Pouch III – 1 bolesnik, augmentacija mjehura s kolonom – 1 bolesnik) učinjena transplantacija bubrega. Uzrok disfunkcije donjeg dijela mokraćnog sustava bio je: neurogeni mjehur (3 bolesnika), karcinom mokraćnoga mjehura (2 bolesnika) i valvule stražnje uretre (1 bolesnik). Jednogodišnjeg preživljenja presatka bilo je 83 %, a bolesnika 100 %. Jedan bolesnik je četiri godine nakon transplantacije umro zbog mezotelioma pleure uz funkcionirajući transplantat. U svih ostalih bolesnika transplantat je i dalje funkcionalan. Bolesnicima s urinarnom derivacijom ili augmentacijom mjehura može se uspješno dati transplantat. Iako se radi o kirurški zahtjevnom zahvatu, dugotrajni rezultati su podudarni s rezultatima transplantacije u standardnoj populaciji te je neophodno poticati uvrštenje ovih bolesnika na listu čekanja za transplantaciju bubrega.Kidney transplantation is the most effective treatment for patients with end-stage renal disease. The prerequisite for kidney transplantation is the normal lower urinary tract system. In some patients with congenital or acquired disorders of the lower urinary tract, it is necessary to form adequate urinary diversion or bladder augmentation. This should be done prior to kidney transplantation. We present experience from our center with renal transplantation using urinary diversion or bladder augmentation. At Department of Urology, Rijeka University Hospital Centre, 1135 kidney transplantations were performed between January 30, 1971 and May 17, 2018. We retrospectively analyzed transplant patients with urinary diversion or bladder augmentation. During the observed period, we performed 6 kidney transplantations in patients with urinary diversion or bladder augmentation. Ileum conduit was performed in 3 patients, and Mainz pouch I and Mainz pouch III in one patient each. One patient had bladder augmentation with colon. The cause for urinary reconstruction was neurogenic bladder (3 patients), bladder cancer (2 patients) and posterior urethral valve (1 patient). Transplantation was heterotopic in five patients and orthotopic in one patient. One-year graft survival was 83% and one-year patient survival was 100%. In one patient, graftectomy was performed because of venous thrombosis. One patient died four years after transplantation because of pleural mesothelioma but with functional graft. All other grafts are still in function (1-23 years after kidney transplantation). Patients with urinary diversion and bladder augmentation could be successfully transplanted. Instead of more complicated operation, long-term results are comparable with the results of standard transplant population. This must encourage us to include patients with urinary diversion and bladder substitution on the waiting list for kidney transplantation

CT PERITONEOGRAFIJA – DIJAGNOSTIČKA METODA U OTKRIVANJU “SLATKOG HIDROTORAKSA” U BOLESNIKA NA PERITONEJSKOJ DIJALIZI

Peritoneal dialysis (PD) can be considered as the first method to start dialysis treatment because it improves the patient quality of life and survival compared to hemodialysis (in the first two years). Hydrothorax is a rare complication of PD. We present a 66-year-old female patient diagnosed with end-stage renal disease caused by chronic tubulointerstitial nephritis. One month after peritoneal catheter had been inserted, the patient started continuous ambulatory PD. Several weeks after PD had been introduced, the patient complained of cough and weight gain. Chest x-ray revealed pleural effusion on the right side and pleural puncture proved a high concentration of glucose in the aspirate, and the diagnosis of ‘sweet hydrothorax’ was made. Additionally, computerized tomography (CT) peritoneography clearly showed contrast leak from peritoneal cavity to thoracic cavity. PD was stopped and the catheter for PD removed. Now, the patient is on the waiting list for kidney transplantation. ‘Sweet hydrothorax’ is a rare complication of PD and CT peritoneography is the most sensitive noninvasive diagnostic tool. In most patients, PD is replaced by hemodialysis, although surgical treatment is also possible.Peritonejska dijaliza (PD) se može smatrati metodom dijalitičkog izbora, jer u odnosu na hemodijalizu poboljšava kvalitetu života i preživljenje bolesnika u prve dvije godine. Hidrotoraks je rijetka komplikacija PD. Prikazujemo 66-godišnju bolesnicu kojoj je dijagnosticiran završni stadij kronične bubrežne bolesti uzrokovan kroničnim tubulointersticijskim nefritisom. Jedan mjesec od postavljanja katetera za PD bolesnica je započela s dijalitičkim liječenjem. Nekoliko tjedana od početka dijalitičkog liječenja bolesnica se počela žaliti na kašalj i porast težine. RTG snimka prsnih organa pokazala je desnostrani pleuralni izljev. Njegovom punkcijom dokazana je visoka koncentracija glukoze u aspiratu te je postavljena dijagnoza “slatkog hidrotoraksa”. CT peritoneografija je nedvojbeno pokazala da kontrast iz abdominalne šupljine ide u pleuralnu. PD je zaustavljena, a kateter za PD izvađen. Sad se bolesnica nalazi na listi čekanja za transplantaciju bubrega. “Slatki hidrotoraks” je rijetka komplikacija bolesnika na PD, a CT peritoneografija je najosjetljiviji neinvazivni dijagnostički test. U većine bolesnika PD se zamijeni hemodijalizom, ali je moguće i kirurško liječenje