Posttraumatski prijapizam: prikaz slučaja, terapijske opcije i pregled literature

A rare case of posttraumatic high-flow priapism is presented. A 20-year-old man underwent diagnostic procedure with color Doppler sonography and angiography. On color Doppler sonography and selective and supraselective angiographic images, arteriocavernosal fistula and pseudoaneurysm were detected in the proximal part of the right cavernous body. Complete detumescence of the penis was achieved by selective embolization with microcoil. No recurrence was observed and postoperative erectile function was incompletely restored. The clinical, diagnostic and therapeutic peculiarities of this rare condition are presented, along with review of the literature on the topic.Prikazuje se rijedak slučaj bolesnika s posttraumatskim arterijskim (neishemičnim) prijapizmom. U 20-godišnjeg muškarca provedena je dijagnostička obrada obojenim Doppler ultrazvukom i angiografija. Na obojenom Doppler ultrazvuku, te na selektivnim i supraselektivnim angiografskim snimkama potvrđeno je postojanje arteriokavernozne fistule i pseudoaneurizme. Nakon selektivne embolizacije postignuta je potpuna detumescencija penisa. Poslijeoperacijski nije bilo povrata prijapizma i došlo je do nepotpunog oporavka erektilne funkcije. Prikazane su kliničke, dijagnostičke i terapijske osobitosti ovoga rijetkog slučaja, uz pregled relevantne literature

Strano tijelo u mokraćnom mjehuru kao ishod samokateterizacije: prikaz slučaja

Foreign bodies inside urinary tract are a relatively rare condition in our practice. There are several reports published and in most cases the reason for self insertion of an object was autoerotic stimulation or psychiatric illness. Self treatment by homemade instruments is a rarely seen scenario. A 62-year-old man presented to our department complaining of lower urinary tract symptoms. On examination, a foreign body was detected inside the urinary bladder. Urethral stricture was also detected for which the patient had been previously treated on several occasions. The patient stated that he had attempted self catheterization using a homemade catheter. He had succeeded in emptying his bladder; however, the catheter entered the bladder completely and was irretrievable to him. Sachse urethrotomy was performed following retrieval of the foreign body. No psychiatric illness was detected in our patient. The patient’s postoperative course was uneventful.Strana tijela unutar mokraćnog sustava su relativno rijetko stanje u našoj praksi. U većini objavljenih slučajeva razlog umetanja stranog tijela je autoerotska stimulacija ili psihijatrijska bolest. Umetanje stranog tijela kao povod za rješavanje mokraćne opstrukcije je rijedak događaj. Bolesnik u dobi od 62 godine javio se na našu kliniku zbog simptoma donjeg mokraćnog trakta. Tijekom pregleda otkriveno je strano tijelo unutar mokraćnog mjehura. Kod bolesnika je u više navrata rađena unutarnja uretrotomija, a jednom otvorena operacija uretre s terminoterminalnom anastomozom. Bolesnik je naveo da je pokušao samokateterizaciju s improviziranim kateterom. Uspio je riješiti mokraćnu opstrukciju, no dio stranog tijela je zaostao u mokraćnom mjehuru. Nakon dodatne obrade učinjena je unutarnja uretrotomija po Sachseu s ekstrakcijom stranog tijela iz mokraćnog mjehura. Psihijatrijskih bolesti se kod bolesnika ne nalazi

Liječenje Fournierove gangrene : prikaz slučaja i pregled literature

A 65-year-old man was referred to our department with clinical signs of septic shock and necrotizing soft tissue infection of the scrotal, perianal and right inguinal region. Initial presentation was a typical Fournier’s gangrene. Because of the life-threatening condition, the initial treatment was extensive removal of necrotic tissue. Antibiotic therapy was administered and several debridements of the wound were done afterwards. Three weeks after the initial treatment, wide wound defects of the perianal, scrotal and inguinal regions were closed secondarily and the patient was discharged from the hospital. Fournier’s gangrene is a surgical emergency. Although rare, it remains a life-threatening disease. Rapid and accurate diagnosis remains the key component in achieving successful outcome. Early aggressive surgical intervention together with fluid, hemodynamic and nutritional support and broad-spectrum antibiotics is the essential management to reduce mortality.Šezdesetpetogodišnji muškarac je primljen u našu ustanovu s kliničkom slikom septičkog šoka i nekroze u skrotalnom, perianalnom i desnostranom ingvinalnom području. Postavljena je dijagnoza Fournierove gangrene. Zbog lošeg općeg stanja bolesnik je odmah kirurški zbrinut, učinjena je opsežna nekrektomja. Antibiotska terapija je ordinirana, a nakon prve operacije je učinjeno nekoliko debridmana rane. Sedamnaest dana nakon operacije su postavljeni sekundarni šavi, a 23. dana bolesnik je otpušten na kućnu njegu. Fournierova gangrena je hitno kirurško stanje te, iako je rijetka, predstavlja tešku i za život opasnu bolest. Brza i točna dijagnostika uz agresivnu kiruršku terapiju i opetovane debridmane te antibiotici širokog spektra i dalje su ključ uspješnog liječenja

Liječenje Fournierove gangrene : prikaz slučaja i pregled literature

A 65-year-old man was referred to our department with clinical signs of septic shock and necrotizing soft tissue infection of the scrotal, perianal and right inguinal region. Initial presentation was a typical Fournier’s gangrene. Because of the life-threatening condition, the initial treatment was extensive removal of necrotic tissue. Antibiotic therapy was administered and several debridements of the wound were done afterwards. Three weeks after the initial treatment, wide wound defects of the perianal, scrotal and inguinal regions were closed secondarily and the patient was discharged from the hospital. Fournier’s gangrene is a surgical emergency. Although rare, it remains a life-threatening disease. Rapid and accurate diagnosis remains the key component in achieving successful outcome. Early aggressive surgical intervention together with fluid, hemodynamic and nutritional support and broad-spectrum antibiotics is the essential management to reduce mortality.Šezdesetpetogodišnji muškarac je primljen u našu ustanovu s kliničkom slikom septičkog šoka i nekroze u skrotalnom, perianalnom i desnostranom ingvinalnom području. Postavljena je dijagnoza Fournierove gangrene. Zbog lošeg općeg stanja bolesnik je odmah kirurški zbrinut, učinjena je opsežna nekrektomja. Antibiotska terapija je ordinirana, a nakon prve operacije je učinjeno nekoliko debridmana rane. Sedamnaest dana nakon operacije su postavljeni sekundarni šavi, a 23. dana bolesnik je otpušten na kućnu njegu. Fournierova gangrena je hitno kirurško stanje te, iako je rijetka, predstavlja tešku i za život opasnu bolest. Brza i točna dijagnostika uz agresivnu kiruršku terapiju i opetovane debridmane te antibiotici širokog spektra i dalje su ključ uspješnog liječenja

Rijedak slučaj karcinoma bubrega u bolesnika s križanom distopijom i fuzijom: radiološka i kirurška problematika

Crossed-fused renal ectopia is an uncommon condition and cases of malignant tumors in such anomalies are extremely rare. A case of renal cell carcinoma in a patient with crossed-fused-ectopia is reported. The patient was successfully treated with partial nephrectomy following isthmus division. Radiologic investigations and operative findings are presented. It is thought to be the fourth reported case of renal cell carcinoma in crossed-fused ectopia.Križana distopija bubrega je neuobičajena anomalija koja se rijetko susreće u kliničkoj praksi. Incidencija tumora u ovim anomalijama iznimno je rijetka. Prikazan je slučaj karcinoma bubrega u bolesnika s križanom distopijom i fuzijom bubrega. Bolesnik je uspješno liječen djelomičnom nefrektomijom s razdvajanjem fuziranih bubrega. Raspravlja se o dijagnostičkoj i terapijskoj problematici ove rijetke bolesti. Prema našim saznanjima ovo je četvrti prikaz slučaja u literaturi

Evolution of the Clinical Presentation and Outcomes after Radical Prostatectomy for Patients with Clinically Localized Prostate Cancer – Changing Trends over a Ten Year Period

We demonstrate the evolution of the clinical presentation and outcomes for patients with clinically localized prostate cancer (PC) treated with radical retropubic prostatectomy (RRP) at our department, emphasizing epidemiologic significance of changes during the 10-year period.We assessed the annual trends for changes in patients age, preoperative prostate specific antigen (PSA), preoperative versus postoperative stages and Gleason grades, organ confined status and surgical margin status. A total of 488 RRPs were performed from January 1996 to December 2005 with the annual frequency increased from 8 to 129 (1512.5%). Mean patient age increased from 61.5 to 66.12 years in 2005, with the percentage of men aged more than 70 years increased from 12.5 to 26.5%, respectively. The detection of PC based solely on pathological PSA levels (as indication for prostate biopsy) rose impressively from 25.5 to 70% and the rates of postoperative organ- confined disease also increased significantly from 25 to 74.7%. Mean preoperative PSA decreased from 16.7 to 9.89 ng/mL. On the contrary, there was an increase in percentage of patients with preoperative PSA values ranging from 4 to 10 ng/mL (from 20 to 65.4%). Positive surgical margin rate decreased from 49.4 to 25% and percent of patients receiving neoadjuvant therapy decreased from 78.5 to 5.4%. Proportion of patients who were undergraded decreased from 75.1 to 31.7%. The rates of understaging have remained relatively stable over the years. During the study period, PC was increasingly detected by prostate biopsy on the basis of a pathological PSA level only and shifted significantly to more organ- confined stages with more favourable outcomes for pathological variables due to a more accurate assessment of clinical stage prior to surgery, reduced use of neoadjuvant therapy and improved surgical technique. Our data also argue strongly that routine PSA testing should be expanded and not restricted

Izbor operativne metode za liječenje primarnog vezikoureteralnog refluksa

Results of ureteral reimplantation in infants with primary vesicoureteral reflux (VUR) were retrospectively reviewed and evaluated. From January 1991 till December 2000, a total of 156 patients with primary VUR underwent ureteral reimplantation at University Department of Urology, Sestre milosrdnice University Hospital, Zagreb, Croatia. The indications for surgery were high-grade reflux, breakthrough urinary tract infections, and non-compliance with medical treatment. Ureteral reimplantation was performed according to Cohen.s method (134/156) and Gil-Vernet (22/156) transvesical method. Out of 156 patients treated for primary VUR, 57 patients presented with left sided VUR and 40 with right sided VUR, whereas 52 patients required treatment for bilateral VUR, giving a total of 219 VUR repairs. Five patients had ureteral duplication accompanied by one sided VUR, whereas two patients had ureteral duplication accompanied by bilateral VUR. Out of the 156 surgically treated patients 2 (1.28%) presented with recurrent VUR, 3 (1.93%) with contralateral VUR, 5 (3.2%) patients were treated for urinary tract infection postoperatively, and none of our patients presented with stenosis. The overall complication-free percentage of surgically treated VUR in our study was 93.6%, while 96.8% were successfully treated for VUR. The present results show that transvesical ureteral repairs in infants are safe and very effective for the prevention of urinary tract infections. After surgical treatment in infancy, the individual renal growth of children with primary VUR is stable.Proveden je retrospektivni pregled i procjena rezultata reimplantacije uretera u dojenčadi s primarnim vezikoureteralnim refluksom (VUR). Od siječnja 1991. do prosinca 2000. godine ukupno je 156 bolesnika s primarnim VUR podvrgnuto reimplantaciji uretera na Klinici za urologiju Kliničke bolnice Sestara milosrdnica u Zagrebu, Hrvatska. Indikacije za operaciju bile su refluks visokog stupnja, masivna infekcija mokraćnog sustava te nepridržavanje medikamentnog liječenja. Reimplantacija uretera provedena je prema Cohenovoj metodi (134/156) i Gil-Vernetovoj transvezikalnoj metodi (22/156). Od 156 bolesnika liječenih zbog primarnog VUR 57 ih je imalo lijevostrani VUR, a 40 desnostrani VUR, dok je 52 bolesnika imalo obostrani VUR, tj. ukupno 219 popravaka zbog VUR. Petoro bolesnika je imalo duplikaciju uretera praćenu jednostranim VUR, dok ih je dvoje imalo duplikaciju uretera praćenu jednostranim VUR. Od 156 kirurški liječenih bolesnika dvoje (1,28%) ih je došlo s ponovljenim VUR, troje (1,93%) s kontralateralnim VUR, petoro (3,2%) ih je poslijeoperacijski liječeno zbog infekcije mokraćnog sustava, dok se stenoza nije razvila ni u jednog od naših bolesnika. Sveukupni postotak kirurški liječenog VUR bez komplikacija u našoj studiji je iznosio 93,6%, dok je postotak uspješnog izlječenja VUR bio 96,8%. Ovi rezultati pokazuju kako je transvezikalni popravak uretera u dojenčadi siguran i vrlo učinkovit u sprječavanju infekcije mokraćnog sustava. Rast pojedinog bubrega u djece s primarnim VUR je stabilan nakon kirurškog liječenja u dojenačkoj dobi

Analiza isplativosti uvođenja biopsije prostate navođene multiparametrijskom magnetskom rezonancom

Continuous increase of the cost of medical services around the world has become a major topic in the world today. Multiparametric prostate MRI has recently become a new standard in prostate cancer detection, especially in repeated biopsy settings. The method, although superior in cancer detection rates, is costly and requires additional training and equipment. The purpose of our study was to determine the costs and benefits that arise when introducing this method in prostate cancer diagnostics. Repeated prostate biopsy was performed in 101 consecutive patients in the period from 1 October 2016 to 1 July 2017. Patients were divided into two groups based on whether prostate mp-MRI was performed or not. The prices of specific procedures were obtained from the billing service of the Sestre milosrdnice University Hospital Center and patient models were created to determine financial costs and benefits. The cost of the entire diagnostic process per patient in the non-MRI group was HRK 1.931,05 and HRK 1.848,42 in the mpMRI group, or 4.28% less. Prostate mpMRI and subsequent mpMRI guided biopsies can reduce the overall cost in prostate cancer diagnostics despite the procedure itself being an additional cost. This is achieved by omitting prostate biopsies in patients with low malignancy risk.Kontinuirani rast troškova medicinskih postupaka aktualna je tema i razlog zabrinutosti u cijelome svijetu. Ciljana, multiparametrijskim magnetom (mpMRI) navođena biopsija prostate polako postaje standard u dijagnostici karcinoma prostate, pogotovo kod ponovljene biopsije. Iako superiorna klasičnoj, sistemskoj biopsiji prostate, navedena metoda zahtijeva skupu dodatnu opremu i vješte, educirane kliničare. Naš cilj je analizirati ekonomsku isplativost uvođenja multiparametrijske magnetne rezonance prostate i posljedične kognitivno mpMRI-om navođene biopsije prostate u dijagnostički protokol bolesnika sa inicijalno negativnom sistemskom biopsijom prostate, kod kojih postoji daljnja klinička sumnja na karcinom prostate. U periodu od 01.10.2016. do 01.07.2017 kod 101 uzastopnog bolesnika s povišenim PSA i/ili pozitivnim DRP, a nakon negativne prve TRUS biopsije učinjena je druga, ponovljena biopsija prostate. Bolesnici su podijeljeni u dvije skupine ovisno o tome dali je učinjen mpMRI prostate ili ne. Učinjena je analiza broja i troškova posjeta specijalisti urologu kao i broja i troškova ordiniranih pretraga za svaku skupinu. Tijek kliničkih postupaka standardiziran je na temelju prosjeka za pojedine promatrane skupine te preračunat na 100 bolesnika za svaku skupinu radi lakše usporedbe rezultata. Kalkulacije su vršene na temelju dobivenih modela. Prosječna cijena obrade bolesnika u skupini bez mpMRI-a iznosi 1931,05 HRK dok u sa mpMRI-em iznosi 1848,42 HRK tj. 4,28% manje. Iako mpMRI prostate pojedinačno predstavlja značajan dodatan trošak u dijagnostici karcinoma prostate, kod bolesnika sa inicijalno negativnom biopsijom prostate isti omogućava velikom broju bolesnika izbjegavanje biopsije te posljedično smanjenje ukupnog troška

DIJAGNOSTIČKI ZNAČAJ BIOPSIJE PROSTATE VOĐENE KOGNITIVNOM FUZIJOM MULTIPARAMETRIJSKE MAGNETNE REZONANCE I TRANSREKTALNOG ULTRAZVUKA (mpmri-TRUS) KOD BOLESNIKA S PRETHODNO NEGATIVNOM TRUS VOĐENOM BIOPSIJOM

The aim of this prospective clinical study was to determine the detection rate of prostate cancers by multiparametric magnetic resonance and transrectal ultrasound (mpMRI-TRUS) cognitive fusion biopsies in patients with a previously negative TRUS-guided biopsy. Between 1 October 2016 and 1 July 2017, in 101 consecutive patients with elevated antigen (PSA) and/or positive digital rectal examination and after a negative first TRUS biopsy, a second, repeated prostate biopsy was performed. In 24 patients, cognitive fusion mpMRI-TRUS biopsy of the prostate with 8-10 system cores and 1-3 target biopsies was performed, in line with the European Association of Urology guidelines. In 77 patients, only a classic, repeated TRUS guided biopsy was performed. In patients with mpMRI, the detection rate according to PIRADS-v2 reporting system was: PIRADS 1, n = 0; PIRADS 2, n = 0; PIRADS 3, n = 0; PIRADS 4, n = 6/8 (75%); and PIRADS 5, n = 2/3 (67%). In the group of patients with MR-TRUS cognitive fusion biopsy, the prostate cancer detection rate was 8/24 (33%), while in the control group the detection rate was 12/77 (16%), which was statistically significant (t test, p = 0.037, CI 95% is 0.01 to 0.37). Patients with PIRADS ≤ 3 (54%) could have avoided the biopsy.U ovoj prospektivnoj kliničkoj studiji cilj je odrediti stopu detekcije raka prostate biopsije vođene kognitivnom fuzijom multiparametrijske magnetne rezonance i transrektalnog ultrazvuka (mpMRI-TRUS) kod bolesnika s prethodno negativnom TRUS vođenom biopsijom. U razdoblju od 1. 10. 2016. do 1. 7. 2017. kod 101 uzastopnog bolesnika s povišenim prostata specifičnim antigenom (PSA) i/ili pozitivnim digitorektalnim pregledom, a nakon negativne prve TRUS biopsije je učinjena druga, ponovljena biopsija prostate. Kod 24 bolesnika učinjena je, u skladu sa Smjernicama Europskog urološkog društva, prethodna mpMRI i potom kognitivna fuzijska biopsija prostate s 8-10 sistemskih cilindara i 1-3 ciljane biopsije prema mpMRI nalazu. Kod 77 bolesnika je učinjena samo klasična, ponovljena TRUS biopsija bez prethodne slikovne obrade. Kod bolesnika s mpMRI, stopa detekcije raka prema PIRADSU-v2 je PIRADS 1, n = 0; PIRADS 2, n = 0; PIRADS 3, n = 0; PIRADS 4, n = 6/8 (75%) i PIRADS 5, n = 2/3 (67%). U skupini bolesnika s MR-TRUS kognitivnom fuzijskom biopsijom stopa detekcije raka prostate je 8/24 (33%), dok je u kontrolnoj skupini stopa detekcije 12/77 (16%), što se pokazalo statistički značajnom razlikom (t test; p=0.037, CI 95% je 0.01 to 0.37). Bolesnici s PIRADS ≤ 3 (54%) su mogli izbjeći biopsiju

Povijest urologije u bolnici Sestara milosrdnica

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 Mašek 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 Mašek 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 Blašković, 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 teaching 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.Prošlost hrvatske urologije jasno određuje njezinu pripadnost medicinskom i civilizacijskom krugu zapadnoga svijeta. Klinika za urologiju KBC “Sestre milosrdnice” najstarija je urološka ustanova u Republici Hrvatskoj. Osnovana je 1894. kad je otvorena nova Bolnica sestara milosrdnica u Zagrebu u Vinogradskoj ulici. Te je godine dr Dragutin Mašek osnovao tzv. III Odjel na kojem su se operativno zbrinjavali osim uroloških bolesnika, bolesnici sa bolestima uha, grla i nosa, sa očnim i dermatološkim bolestima. Dragutin Mašek već tada je vidio da će se medicina uskoro dijeliti na uža područja, pa je dolaskom mlađih liječnika na III. odjel njima prepuštao određena područja, tako da je urologiju preuzeo Aleksandar Blašković koji 1926. godine osniva prvi samostalni odjel za urologiju u Hrvatskoj. Imenovan je 1927. za profesora urologije na Medicinskom fakultetu u Zagrebu gdje osniva prvu katedru za urologiju i vodi predavanja i vježbe. Pod njegovim vodstvom Odjel za urologiju dobio 1943. godine status Klinike za urologiju, prve u Hrvatskoj. Temeljem svih tih aktivnosti na urološkom području povijest ga pamti kao „oca moderne hrvatske urologije“. U godinama koje slijede čelnici urologije su se mijenjali, a svjetonazor u radu na sreću bolesnika ne. Savjest, povjerenje, stručnost i milosrđe. Uostalom, to je znamen koji bolnica nosi u svom imenu. Svih tih desetljeća Klinika za urologiju je pratila suvremene svjetske pravce razvoja, objektivno kasneći tek nekoliko godina za vrhunskim ustanovama u svijetu. Cjelokupna stručna i znanstvena urološka djelatnost kulminira 1998. godine, kada Klinika postaje Referentni centar za tumore prostate Ministarstva zdravstva Republike Hrvatske i 2011. godine kada je postala Centar obuke Europskog odbora za urologiju (European Board of Urology). Sve postignuto ne bi se moglo ostvariti bez svesrdne pomoći i suradnje medicinskih sestara i drugih djelatnika klinike od prvih početaka urologije do današnjih dana. Unatoč bogatojj prošlosti, Klinika ne živi na uspjesima svojih prethodnika. Danas je ta urologija zajedno s njezinim uzorima europska moderna urologija