Analysis of Climate Change Impact on Water Supply in Northern Istria (Croatia)

This paper analyses impacts of climate change and anthropogenic pressure on groundwater resources in the Mirna river catchment used for water supply in Northern Istria (Croatia) up to 2050. Using Regional Climate Models simulations and hydrologic model, the future average annual and the characteristic (in critical period) water resource availabilities were calculated. Current and five future water demand scenarios were analysed. Water Exploitation Index (WEI) and modified Characteristic Water Exploitation Index (CWEI) were calculated. In 2050, the analysed springs will be subject to climate change consequences, with more extreme changes and intense variations. The WEI for average conditions indicates little risk of unmet future water demand. Considering seasonal variability, the future CWEIs indicates strong risk for most future water demand scenarios and overexploitation for water demand increases over 20%. The 2012 drought, more extreme than any considered future scenario, was also examined

Mini percutaneous nephrolithotripsy as treatment modality for kidney stones

Cilj: Prikazati naše rezultate u liječenju pacijenata s bubrežnim kamencima metodom miniperkutane nefrolitotripsije (miniPCNL). Pacijenti i metode: Retrospektivnim istraživanjem obuhvatili smo pacijente Klinike za urologiju, Kliničkog bolničkog centra u Rijeci koji su između 1. kolovoza 2015. i 31. prosinca 2016. godine zbog bubrežnih kamenaca liječeni metodom miniPCNL-a. Rezultati: U promatranom razdoblju u našem centru operirano je 6 pacijenata ovom metodom, od kojih je jedan bio s transplantiranim bubregom. U svih pacijenata uspješno je učinjena litotripsija s holmium-laserom. Na kontrolnom RTG-u nije bilo ostatnih fragmenata. U četvoro pacijenata poslijeoperativno je došlo do razvoja febriliteta koji je uspješno liječen antibiotskom terapijom. Niti u jednog pacijenta nije bila potrebna reoperacija, dodatne procedure niti potreba za davanjem krvi. Zaključak: Miniperkutana nefrolitotripsija je minimalno invazivna metoda koja se pokazala uspješnom i sigurnom u liječenju nefrolitijaze.Aim: To present our results in the treatment of nephrolithiasis using mini percutaneous nephrolithotripsy (miniPCNL). Patients and methods: We retrospectively analyzed all patients with nephrolithiasis treated with miniPCNL in Department of Urology, University Hospital Rijeka from August 1st 2015 to December 31st 2016. Results: In observed period 6 patients were operated with this novel method and one has transplanted kidney. In allpatients lithotripsy was successfully performed with holmium laser. On the control x-ray the residual fragments were not found in any patients. Postoperatively, in four patients febrility was noticed and successfully treated with antibiotics. Neither the one patient need reoperation, auxiliary procedures or blood transfusion. Conclusion: Mini percutaneous nephrolithotripsy is a minimally-invasive method which is successfull and safe method in the treatment of kidney stones

Urodynamics in clinical practice

Urodinamika je metoda kojom se procjenjuje funkcija mokraćnoga sustava, najčešće njegovog donjeg dijela. Donji dio urinarnog sustava je funkcionalna cjelina koja se sastoji od mokraćnoga mjehura, sfinkterskoga mehanizma i mokraćne cijevi. Osnovna funkcija mu je punjenje i pražnjenje mjehura uz kontinenciju. Urodinamikom se mogu adekvatno evaluirati sve te funkcije. Urodinamika je indicirana kao nadopuna standardnim pretragama. Najčešće korištene metode su mikciometrija, cistometrija i profilometrija uretre. Mikciometrijom se određuje protok urina u jedinici vremena tijekom akta mikcije. Cistometrijom mjerimo tlakove u mjehuru tijekom njegova punjenja i pražnjenja. Profilometrijom uretre određujemo tlakove u uretri, a dobiveni podaci govore nam o kontinenciji ispitanika. U preglednom radu prikazat ćemo osnove urodinamskog ispitivanja s kliničkim primjerima.Urodynamics is a method for evaluation of urinary tract function, specially lower urinary tract. Lower urinary tract is a unique functional entity consisted of urinary bladder, sphincteric mechanism and urethra. Their main function is storage of urine, voiding and continence. Urodynamics is used for evaluation of all this functions. Urodynamics is performed as adjunct to the basic clinical evaluation. The most frequently used methods are uroflow, cistometry, and urethral profilometry. Uroflow represent urinary flow during micturation. Cistometry is used for measurement of pressures during storage and expulsion of the urine. Urethral profilometry measured urethral pressure and show data about patient’s continency. In this review article we present basic information about urodynamic tests with clinical examples

Extracorporeal shock wave lithotripsy

Izvantjelesno mrvljenje kamenaca (ESWL) je novija terapijska metoda u liječenju urolitjaze. Temelji se na uporabi šok-valova koji se stvaraju u generatoru, fokusiraju i usmjeruju na kamenac u tijelu pacijenta. Razbijanje kamenca je posljedica nekoliko različith efekata tih valova na sam konkrement. Razbijanjem nastaju manji fragmenti koji se moraju izmokriti. ESWL se korist u liječenju bubrežnih kao i kamenaca u mokraćovodu. Metoda je izbora za liječenje bubrežnih kamenaca manjih od 2 cm te onih u proksimalnom dijelu mokraćovoda veličine do 1 cm. Komplikacije su rijetke i najčešće klinički beznačajne. Efkasnost ove metode ovisi o veličini kamenca, njegovom sastavu, kanalnom sustavu bubrega te o iskustvu i vještni urologa. Velika prednost ove metode je da nije potrebna anestezija, za razliku od drugih minimalno invazivnih metoda. Tretman ESWL-a može se ponavljati više puta. Do sada nije dokazan štetan učinak na bubrežnu funkciju, a može se koristiti i u dječjoj populaciji.Extracorporeal shock wave lithotripsy (ESWL) is a novel method for the treatment of urolithiasis. It is based on the use of shock waves that are generated in the generator, focused and directed to the stone in the body of the patent. Cracking of the stone is the result of several different effects of these waves. It results with stone fragmentation and spontaneous elimination of fragments. ESWL is used in the treatment of kidney stones and stones in the ureter. These method is the method of choice for treating kidney stones smaller than 2 cm, and those in the proximal part of the ureter up to 1 cm. Complicatons are rare and usually clinically insignificant. The effectiveness of this method depends on the stone size, its compositon, the renal system morphology and the experience and skill of the urologist. The great advantage of this method is that anesthesia is not needed, unlike other minimally-invasive treatements. Also, the ESWL treatment can be repeated several times. There is no proven damaging effect on the renal function and can be used for treatment of stones in the children

Inferior vena cava thrombosis due to polycystic kidney disease

Cilj: Adultna policistična bolest bubrega je najčešća nasljedna bolest bubrega.Tijekom godina dolazi do povećanja cisti, smanjenja funkcionalne nefronske mase i kompresije uvećanih bubrega na okolne strukture. U ovom radu prikazujemo pacijenticu s policističnom bolesti bubrega, kod koje se nakon presađivanja bubrega razvila tromboza donje šuplje vene. Prikaz pacijenta: Tri mjeseca nakon transplantacije kadaveričnoga bubrega u lijevu ilijačnu jamu 67-godišnja pacijentica hospitalizirana je zbog otoka desne noge. Kliničkim i ultrazvučnim pregledom ustanovljena je duboka venska tromboza desne noge i uvedena je terapija heparinom. S obzirom na to da nije dolazilo do poboljšanja, učinjen je pregled kompjutoriziranom tomografijom kojim je potvrđena duboka venska tromboza desne noge, ilijačnih vena desno i parcijalna tromboza distalnog dijela donje šuplje vene. Nalazi radiološke obrade ukazali su na pritisak desnog policističnog bubrega na donju šuplju venu te smo, zbog sprječavanja kompletnog venskog zastoja na razini donje šuplje vene, učinili nefrektomiju policističnog bubrega. Poslijeoperacijski tijek bio je uredan, otok noge se smanjio i funkcija bubrežnog presatka je ostala stabilna. Rasprava i zaključak: U pacijenata s velikim policističnim bubrezima kompresija donje šuplje vene može dovesti i do njezine tromboze. Indicirana je pravovremena nefrektomija.Aim: Autosomal dominant polycystic kidney disease is the most common renal hereditary disease. During many years renal cysts become larger, the functional nephron mass decreases and enlarged kidneys compress the surrounding structures. We present the case of a patient with polycystic kidney disease and inferior vena cava thrombosis after kidney transplantation. Case report: Three months after kidney transplantation into the left iliac fossa, the 67 year-old woman was admitted to our hospital due to swelling oft the right leg. Clinical and ultrasound examination revealed deep vein thrombosis of right leg and therapy with heparine was introduced. Since there was no improvement, a computerized tomography examination was performed that confirmed deep vein thrombosis of the right leg, thrombosis of iliac veins on the right side and partial thrombosis of the distal part of the inferior vena cava. As radiologic imaging revealed compression of the right polycystic kidney onto the inferior vena cava, we performed nephrectomy of the polycystic kidney to prevent complete thrombosis. The postoperative course was uneventful, with a regression of the right leg edema and stable graft function. Discussion and conclusion: In patients with large polycystic kidneys, compression of the inferior vena cava may lead to its thrombosis. A nephrectomy should be performed in time

Različiti pristupi u liječenju urolitijaze u bolesnika s transplantiranim bubregom - prikaz slučaja

Urolithiasis is a rare urologic complication after kidney transplantation, and its diagnosis and treatment can be challenging for clinicians. In our 52-year-old male patient, graft hydronephrosis was found six months after transplantation. The patient had recurrent urinary tract infections followed by macrohematuria and an increase in creatinine levels. Computerized tomography revealed a 13-mm diameter stone in the ureter of the transplanted kidney as the cause of obstruction. Percutaneous nephrostomy was placed in the graft to solve the obstruction. Initial endoscopic treatment with a retrograde approach failed. An antegrade approach through a previously placed nephrostomy was not successful either. By a repeated retrograde approach, laser lithotripsy was performed successfully. The patient has been monitored for six months and has stable graft function without hydronephrosis or stones. As in our patient’s case, the diagnosis and treatment of urolithiasis in kidney transplant patients is challenging, and minimally invasive procedures are the treatment of choice.Urolitijaza je rijetka urološka komplikacija nakon transplantacije bubrega dijagnosticiranje i liječenje koje predstavlja izazov za kliničare. Kod našeg 52-godišnjeg bolesnika uočena je hidronefroza grafta šest mjeseci nakon transplantacije. Bolesnik je imao ponavljajuće uroinfekcije praćene makrohematurijom, a došlo je i do porasta vrijednosti kreatinina. Kompjutorizirana tomografija pokazala je kako je uzrok opstrukcije kamenac promjera 13 mm u distalnom dijelu uretera transplantiranoga bubrega. Za rješavanje opstrukcije bolesniku je postavljena perkutana nefrostomija u presadak. Inicijalno endoskopsko liječenje retrogradnim pristupom bilo je neuspješno. Anterogradni pristup preko ranije postavljene nefrostomije također nije bio uspješan. Ponovljenim retrogradnim pristupom uspjela se učiniti uspješna laserska litotripsija. Bolesnik se prati šest mjeseci i nema kamenaca niti hidronefroze, a funkcija grafta je stabilna. Dijagnosticiranje i liječenje urolitijaze u bolesnika s transplantiranim bubregom je, kao i u našeg bolesnika, izazovno, a minimalno invazivne metode predstavljaju metodu izbora u liječenju ovih bolesnika

MINI-PERCUTANEOUS NEPHROLITHOTRIPSY – OUR FIRST EXPERIENCE

Urolitijaza je važan problem u razvijenim zemljama svijeta jer se broj ljudi s konkrementima povećava. Prije nekoliko desetljeća kirurško liječenje urolitijaze provodilo se samo putem otvorene kirurgije, dok su danas dominantne minimalno-invazivne metode. Jedna od njih je i miniperkutana nefrolitotripsija. U ovom radu prikazana su četiri bolesnika u kojih je učinjena miniperkutana nefrolitotripsija. U svih bolesnika konkrement se nalazio u pijelonu desnoga bubrega. U troje bolesnika konkrement je bio u nativnom bubregu, a u jednoga u transplantiranome. U svih bolesnika uspješno je učinjena laserska litotripsija konkremenata. Na kontrolnom RDG pregledu nije bilo ostatnih fragmenata. Miniperkutana nefrolitotripsija jest minimalno-invazivna metoda koja se pokazala uspješnom u liječenju nefrolitijaze i u nativnim bubrezima i u transplantiranom bubreguUrolithiasis is a significant problem in the developed countries due to the increased number of patients with stones. Just a few decades ago open surgery was the only surgical treatment which is today, in most cases, replaced with minimally-invasive methods. One of these new methods is mini-percutaneous nephrolihotripsy. We present four patients in whom mini-percutaneous nephrolithotripsy was performed. In all patients the stone was located in the renal pelvis. In three patients the stone was in the native kidney and in one in the transplanted kidney. In all patients laser lithotripsy was successfully performed. On the control x-ray the residual fragments were not found in any patients. Mini-percutaneous nephrolithotripsy is a minimally-invasive method which is successfull in the treatment of nephfrolithiasis in native and transplanted kidneys

RETROGRADE BALLOON DILATATION AS A MINIMALLY INVASIVE TREATMENT FOR URETERAL STRICTURE

Stenoza uretera nije česta patološka promjena u svakodnevnoj urološkoj praksi. Balonska dilatacija jedna je od najmanje invazivnih metoda u liječenju stenoza uretera. Retrospektivno smo analizirali 24 bolesnika sa stenozom uretera liječenih u našoj ustanovi retrogradnom balonskom dilatacijom. U 11 (45,8%) bolesnika radilo se o ijatrogenoj te u po jednoga (4,2%) o kongenitalnoj stenozi, odnosno o stenozama uzrokovanim urogenitalnom tuberkulozom ili retroperitonealnom fibrozom. U 10 (41,6%) bolesnika uzrok stenoze uretera bio je nepoznat. U 12 (50%) bolesnika bio je sužen pelvični dio, u njih 9 (37,5%) lumbalni dio te u preostala 3 (12,5%) terminalni dio uretera. Svim bolesnicima učinjena je balonska dilatacija uretera retrogradnim pristupom, a jedina komplikacija bila je povišena tjelesna temperatura u 4 (16,7%) bolesnika. U 12 (50%) bolesnika s recidivom bilo je nužno otvoreno operacijsko liječenje ili postavljanje ureteralne endoproteze. Zaključujemo da je u bolesnika s kratkom stenozom uretera, prije otvorenoga kirurškoga liječenja, svakako vrijedno učiniti balonsku dilataciju stenoze.Ureteral stricture is not a common urologic condition. Balloon dilatation represents one of the least invasive methods for treatment of ureteral strictures. We retrospectively analysed 24 patients with ureteral strictures treated with retrograde balloon dilatation in our department. The etiology of stricture was iatrogenic in 11 (45.8%) patients, post-TBC in one (4.2%), congenital in one (4.2%), retroperitoneal fibrosis in one (4.2%) and unknown in 10 (41.6%) patients. Twelve (50%) patients had a stricture of pelvic, 9 (37.5%) lumbar, and 3 (12.5%) of terminal ureter. In all patients retrograde balloon dilatation has been performed. Only complication related to the procedure was febrility in 4 patients (16.7%). Restrictures were noted in 12 (50%) patients, who consequently have been treated surgically, or had to be stented. Retrograde balloon dilatation, as a safe and relatively effective treatment, is proposed as the first choice in patients with short ureteral stricture

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

Transurethral Incision of the Bladder Neck in a Woman with Primary Bladder Neck Obstruction after Kidney Transplantation

Voiding dysfunction is frequently seen in the early posttransplant period. Among other causes, this condition can arise due to bladder outlet obstruction. Primary bladder neck obstruction (PBNO) is a possible but very rare cause of bladder outlet obstruction. We present the case of a 52-year-old woman who, after kidney transplantation, presented with PBNO. The diagnosis was established based on symptoms, uroflowmetry, and multichannel urodynamics with electromyography. The transurethral incision of the bladder neck was made at the 5- and 7-o’clock position. After the operation, the maximal flow rate was significantly increased, and postvoid residual urine was decreased compared to the preoperative findings. The patient was followed for 5 years, and her voiding improvement is persistent. This is the first reported case of PBNO treated with a transurethral incision of the bladder neck in a posttransplantation female patient