Malignant Skin Melanoma in Croatia

Global heating and increased solar ultraviolet irradiance have caused an increase in number of many diseases, particularly skin malignant diseases. Aim of this study was to investigate the influence of climate changes on the health of the population of the Primorsko-goranska and Istria Counties. We gathered and analyzed data about the frequency of skin malignant melanoma in the period of eight years (1998–2005). The data were collected from the Croatian cancer registry. The incidence of malignant skin cancer was estimated overall, by age group and gender. We found that the incidence of the skin melanoma was approximately the same in both counties during the period 1998–2005. However, significant increase has been noted when compared to the situation in the period 1977–1996 (p=4.95 E–13) The incidence of malignant skin melanoma has risen during the last ten years. It is differently distributed between gender and age groups in Primorsko-goranska and Istria County. It can be related to climate changes, but also to different ways way of life between these two counties

Surgical Treatment of Kidney Cancer in Elderly

The aim of this study was to analyze our patients over the age of 70 suffering from kidney cancer that had undergone surgical treatment. During the 2000–2012 period 634 patients with kidney cancer were treated, 197 of whom were over the age of 70. In this group there were 117 (59.4%) men and 80 (40.6%) women. In most of these patients (156 patients – 79.2%) the clear cell type of renal carcinoma was diagnosed. According to TNM classifi cation the dominant stages were T1b in 62 patients (31.8%) and T1a in 48 patients (24.6%). The most common grade was G2 (73 patients – 37%). Radical nephrectomy was performed in 103 (52.3%) patients, simple nephrectomy in 86 patients (43.7%), enucleation of the tumor and resection of the kidney in 6 (3.1%) patients, while in 2 patients the tumor was inoperable. Early postoperative complications developed in 21 (10.8%) patients. They included complications in distant organs in 11 (5.6%) patients and surgical complications in 10 (5.4%) patients. Five patients (2.6%) died during early postoperative period. Surgery is recommended treatment for elderly patients with kidney cancer with complications comparable with those in younger patients

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

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

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

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

Preemptive kidney transplantation from living donor

Preemptivna transplantacija bubrega je vrsta transplantacije koja se radi prije početka dijalitičkog liječenja. Ona omogućuje bolju kvalitetu života i značajno smanjenje troškova liječenja u odnosu na dijalizu, a također je uz nju vezano bolje preživljenje, kako presatka, tako i bolesnika. Prikazali smo 26-godišnjeg bolesnika koji ima kroničnu bubrežnu bolest (KBB) uzrokovanu IgA nefropatijom. Bubrežna funkcija bolesnika je unatoč primijenjenoj imunosupresivnoj terapiji postupno slabila tijekom vremena, ali je jedan napadaj akutnog enterokolitisa doveo do značajnog i trajnog slabljenja bubrežne funkcije. Kod bolesnika se tada počelo razmišljati o nadomještanju bubrežne funkcije. Bolesnikova majka je prihvaćena kao živi darivatelj. Lijevi bubreg majke je transplantiran u desnu ilijačnu jamu. Operacija i rani postoperacijski tijek prošli su bez komplikacija. Postoperacijski, a kao indukcijska terapija, koristila su se monoklonska protutijela protiv interleukina 2 sa standardnom trojnom imunosupresivnom terapijom koja se sastojala od kortikosteroida, mikofenolat-mofetila i takrolimusa. Godinu dana nakon transplantacije bolesnik ima dobro funkcionirajući presadak bez ikakvih kirurških ili imunoloških komplikacija. Zaključno može se reći da je preemptivna transplantacija bubrega efikasna metoda liječenja pacijenta s kroničnim bubrežnim zatajenjem i treba biti preporučena u svih bolesnika u kojih se može učiniti transplantacija.Pre-emptive kidney transplantation is the type of transplantation that is performed before starting dialysis. It allows a better quality of life to the patient and significant reduction of costs in comparison with dialysis, and also is connected with higher survival rate of graft and patient. We present a 26-year-old patient diagnosed with chronic kidney disease (CKD) due to IgA nephropathy. His kidney function, despite of immunosuppressive therapy, gradually decreased in time but an onset of acute enterocolitis has lead to significant and permanent deterioration of kidney function with the forthcoming need for renal replacement therapy. His mother was accepted as a living kidney donor. The left kidney of the mother was transplanted to the right iliac fossa of the patient. The operation went without any complications. The postoperative course was uneventful with induction therapy with monoclonal antibody against interleukin 2 receptor and standard triple immunosuppressive therapy consisting of corticosteroid, mycophenolat mofetil and tacrolimus. One year after the transplantation, the patient has a good functioning kidney transplant without any surgical or immunological complications. Conclusively, pre-emptive kidney transplantation is an effective treatment for patients with end-stage renal disease and it should be recommended to all patients where this type of treatment is possible

Preemptive kidney transplantation from living donor

Preemptivna transplantacija bubrega je vrsta transplantacije koja se radi prije početka dijalitičkog liječenja. Ona omogućuje bolju kvalitetu života i značajno smanjenje troškova liječenja u odnosu na dijalizu, a također je uz nju vezano bolje preživljenje, kako presatka, tako i bolesnika. Prikazali smo 26-godišnjeg bolesnika koji ima kroničnu bubrežnu bolest (KBB) uzrokovanu IgA nefropatijom. Bubrežna funkcija bolesnika je unatoč primijenjenoj imunosupresivnoj terapiji postupno slabila tijekom vremena, ali je jedan napadaj akutnog enterokolitisa doveo do značajnog i trajnog slabljenja bubrežne funkcije. Kod bolesnika se tada počelo razmišljati o nadomještanju bubrežne funkcije. Bolesnikova majka je prihvaćena kao živi darivatelj. Lijevi bubreg majke je transplantiran u desnu ilijačnu jamu. Operacija i rani postoperacijski tijek prošli su bez komplikacija. Postoperacijski, a kao indukcijska terapija, koristila su se monoklonska protutijela protiv interleukina 2 sa standardnom trojnom imunosupresivnom terapijom koja se sastojala od kortikosteroida, mikofenolat-mofetila i takrolimusa. Godinu dana nakon transplantacije bolesnik ima dobro funkcionirajući presadak bez ikakvih kirurških ili imunoloških komplikacija. Zaključno može se reći da je preemptivna transplantacija bubrega efikasna metoda liječenja pacijenta s kroničnim bubrežnim zatajenjem i treba biti preporučena u svih bolesnika u kojih se može učiniti transplantacija.Pre-emptive kidney transplantation is the type of transplantation that is performed before starting dialysis. It allows a better quality of life to the patient and significant reduction of costs in comparison with dialysis, and also is connected with higher survival rate of graft and patient. We present a 26-year-old patient diagnosed with chronic kidney disease (CKD) due to IgA nephropathy. His kidney function, despite of immunosuppressive therapy, gradually decreased in time but an onset of acute enterocolitis has lead to significant and permanent deterioration of kidney function with the forthcoming need for renal replacement therapy. His mother was accepted as a living kidney donor. The left kidney of the mother was transplanted to the right iliac fossa of the patient. The operation went without any complications. The postoperative course was uneventful with induction therapy with monoclonal antibody against interleukin 2 receptor and standard triple immunosuppressive therapy consisting of corticosteroid, mycophenolat mofetil and tacrolimus. One year after the transplantation, the patient has a good functioning kidney transplant without any surgical or immunological complications. Conclusively, pre-emptive kidney transplantation is an effective treatment for patients with end-stage renal disease and it should be recommended to all patients where this type of treatment is possible