Davor Librenjak

Results of long-term follow-up of patients with superficial bladder carcinoma treated with intravesically applied bacillus Calmette-Guerin vaccine according to the schedule of 6 weekly + 6 monthly instillations

BACKGROUND The efficacy of bacillus Calmette-Guerin (BCG) immunotherapy in the prevention of local recurrence and disease progression in patients with superficial bladder cancer is very well documented. This study reports the effect of BCG on disease-specific and overall survival. PATIENTS AND METHODS In this retrospective trial, we have analyzed 170 patients with stage Ta and T1 superficial bladder cancer. Patients in the control group (87 patients) we followed-up only (median follow-up of 119 months) and treated surgically or with other oncologic modalities when progression of disease was diagnosed. The BCG group consisted of 83 patients treated with 6 weekly followed by 6 monthly instillations, and they have been followed-up of median 124 months. RESULTS Patients receiving BCG had statistically significant better 10-year disease specific survival (83% vs. 69%, P = 0.03). At the same time point, the local recurrence rate was 48 % and the progression rate 19% for patients treated with BCG, while 77% (P < 0.001) and 38% (P = 0.007) were results in control group. Despite numerically better in the BCG group, overall survival is not significantly different in the 2 groups (P = 0.14). CONCLUSION BCG immunotherapy significantly increases the disease-specific survival in patients with superficial bladder carcinoma.

A rare cause of urosepsis: clinical quiz

An 81-year-old female presented to the emergency department. She had been unwell for three weeks, with increasing malaise, fever, chills, right flank pain and urinary symptoms. Antibiotics had produced no improvement. At admission: WBC 17 10/L, serum creatinine 142 mmol/L and C-reactive protein 200 mg/L. Urine had a murky appearance, with cellular debris, and white blood cells. Renal ultrasound showed two 7-mm mineral shadows and marked hydronephrosis of the right kidney. The following day, percutaneous nephrostomy was arranged for relief of urinary obstruction, and an anterograde pyelography was performed (Figure 1). Findings prompted a subsequent CT scan of abdomen (Figure 2).

A rare cause of urosepsis – answers

1. The anterograde pyelogram shows a fistulous tract between the right ureter and the sigmoid colon, with leakage of contrast into the colon. A linear filling defect can just be made out within the tract. 2. CT scan confirms the presence of a fistula connecting the right ureter and sigmoid colon at level of the iliac vessels. Gas locules – ‘air pockets’ are seen in the right ureter and fistula. Contrast from the pyelogram is seen in the sigmoid colon. 3. The filling defect in Figure 1 is seen as a hyperdense lesion on the CT. A foreign body? In Figure 1(b), it is measured as 2.2 cm in length. It looks like a toothpick . . .

Only a minority of patients in the urological emergency unit need urgent urology care

OBJECTIVE To present patients who were examined, monitored and admitted at the urological emergency unit (UEU) at the University Hospital, Split during the summer and winter of 2010 and to establish who of them were really in need of immediate urological care. METHODS A retrospective study of patients and diagnoses of patients examined at the UEU was undertaken during two winter and two summer months 2010. We compared the total number of patients, the number of patients with urological issues, patients with urological emergencies, patients with non-urological issues, patients who were briefly monitored at the UEU, and patients admitted to the urology department, within these two periods. Descriptive statistic and chi squared tests were used. RESULTS During the winter period 465 patients were examined at the UEU and during the summer 733 patients. During the summer period there were statistically more urological issues (χ²=12.3; p=0.005) and urological emergencies (χ²=4.14; p=0.042) while in the winter period there were more non-urological issues and more patients were monitored at the UEU (χ²=33.9; p<0.001). The most common diagnoses are: renal colic and urine retention, in both periods. Only 8% of patients in both the winter and summer periods were admitted to hospital after examination at the UEU, which represents the actual number of patients who needed immediate urological care. CONCLUSION Of all the patients examined at the UEU, only a fraction constituted real, life-threatening urological emergencies. Primary care physicians and general emergency departments should be more educated in urological emergencies so that they can resolve more nonemergency patients themselves.

Ureterorenoscopic treatment of ureteral stones – influence of operator’s experience and skill on the procedure outcome

Aim To observe the influence of operating urologist’s education and adopted skills on the outcome of ureterorenoscopy treatment of ureteral stones. Methods The study included 422 patients (234 men, 55.4%) who underwent ureterorenoscopy to treat ureteral stones at the Urology Department of Clinical Hospital Center Split, Croatia, between 2001 and 2009. All interventions were carried out with a semi-rigid Wolf ureteroscope and an electropneumatic generator used for lithotripsy. The operating specialists were divided into two groups. The first group included 4 urologists who had started learning and performing endoscopic procedures at the beginning of their specialization and the second group included 4 urologists who had started performing endoscopic procedures later in their careers, on average more than 5 years after specialization. Results Radiology tests confirmed that 87% (208/238) of stones were completely removed from the distal ureter, 54% (66/123) from the middle ureter, and 46% (28/61) from the proximal ureter. The first group of urologists completed significantly more procedures successfully, especially for the stones in the distal (95% vs 74%; P = 0.001) and middle ureter (66% vs 38%; P = 0.002), and their patients spent less time in the hospital postoperatively. Conclusion Urologists who started learning and performing endoscopic procedures at the beginning of their specialization are more successful in performing ureteroscopy. It is important that young specialists receive timely and systematic education and cooperate with more experienced colleagues.