Miodrag Acimovic

Vesico-vaginal fistula: report of 220 cases

ObjectiveTo present the major causes, diagnosis, indications, and basic principles of surgical treatment of vesico-vaginal fistulas (VVF).MethodsFrom 1978 to 2004, 235 surgical procedures in 220 women with vesico-vaginal fistulas were performed at the Clinical Center of Serbia, Urological Clinic, due to primary or recurrent VVF. There were 220 primary procedures: 129 transvesical approaches (TVES), 59 transvaginal repairs (TVAG), and 32 transperitoneal approaches with flap interposition (TPA). Transvesical approach was the most common procedure in the early period (1978–1993) and less frequent in the late period (1994–2004). The main causes of VVF were hysterectomy for benign conditions (62.7%), hysterectomy for malignant conditions (30.4%), cesarean section (5.9%), and obstetric injuries (0.9%).ResultsThere was no perioperative mortality. There were fifteen recurrent fistula formations: twelve after the first operation and three after the second. The recurrence rates between the procedures were comparable: TVES 6.6%, TVAG 6.4%, and TPA 5.4%.ConclusionsThe total recurrence rate of 6.4% did not differ significantly between various procedures. However, TVAG is less invasive and suitable for uncomplicated cases, whereas TPA should be recommended for great and recurrent VVF.

Uretère rétrocave : à propos de 16 cas☆

INTRODUCTION AND OBJECTIVES To analyse the postoperative results of surgical treatment for retrocaval ureter. MATERIAL AND METHODS The authors report a retrospective clinical study of a series of 16 patients (six women and 10 men) with a mean age of 38 years (range: 15-45 years) with retrocaval ureter treated between 1975 and 2005. The mean follow-up was 18 months (range: 12 to 34 months). All patients were evaluated by the standard diagnostic protocol for the time and were treated by one of the following surgical techniques: resection of the ureter and renal pelvis to renal pelvis anastomosis; resection of the ureter and pyelo-ureteric anastomosis; resection of the ureter and oblique end-to-end uretero-ureteric anastomosis; nephrectomy. RESULTS The mean operating time was 95 min. Late postoperative follow-up revealed two cases (13%) of ureteric stenosis at the site of the oblique end-to-end uretero-ureteric anastomosis. Surgical revision was performed in one patient with resection of the ureter and reanastomosis, while anterograde dilatation of the stenosis was performed in the other patient. The postoperative course was uneventful in both patients. All patients were reviewed at six months with a satisfactory result, corresponding to reduction of hydronephrosis and improvement of renal function. CONCLUSION Over the last 30 years, the diagnosis of retrocaval ureter has become more reliable and less invasive. Satisfactory results can be obtained with conventional surgical management.

Buccal mucosal graft interposition in the treatment of recurrent vesicovaginal fistula: A report on two cases

OBJECTIVE To present the use of autologous buccal mucosa graft (BMG) in the treatment of recurrent vesicovaginal fistula (VVF). CASE REPORTS In 2011, two women, aged 45 years and 56 years, were admitted due to recurrent VVF. Both women had previously undergone abdominal hysterectomies for benign conditions and, subsequently, vaginal VVF repair due to vaginal urine leakage. On admission, the younger woman had a round fistula, with a diameter of 1.5 cm, located on the left side, supratrigonally; the other woman had an ellipsoidal fistula measuring 2.5 cm × 1.5 cm, located medially and supratrigonally. Both women underwent suturing of the VVF with the interposition of BMG. After the last treatment, both women were cured. CONCLUSION Treatment of recurrent VVF with the interposition of BMG is a good alternative to the use of other tissue grafts. Larger series are needed to confirm the advantages of this method.

Vesicovaginal fistulas: transperitoneal surgical repair using omentum or peritoneal tissue interposition, a summary of 35 years of experience

SummaryObjectiveTo report the result of primary vesicovaginal fistula (VVF) repair using the transabdominal approach with omental or peritoneal flap interposition.MethodsThe study evaluated 38 patients who were treated with transabdominal approach with omental or peritoneal flap. The omental flap was used as the first choice if it was of sufficient length; otherwise, a peritoneal flap was created. Patients were followed postoperatively for 1 year and by telephone survey thereafter.ResultsThe age of patients ranged from 29 to 68 years, with a median of 52 years. The main causes of VVF in this study cohort were hysterectomy for benign conditions (60.5 %), hysterectomy for malignant conditions (34.2 %), and radiation therapy (5.3 %). Peritoneal flap interposition was used in 6 patients and omental flap was used in 32 patients. All patients were continent following catheter removal. Overall, 89.5 % (34 out of 38) of fistulae were successfully repaired at first attempt. The success with omental flap interposition was 100 %. Recurrence of the fistula was reported in four patients (all with primary peritoneal flap interposition). Two of them were successfully cured by peritoneal flap re-interposition. While in two patients, with a history of radiation therapy, sigma rectum pouch was performed.ConclusionTransperitoneal surgical repair using omentum or peritoneal tissue interposition should be considered in the first attempt of repair of supratrigonal VVFs. However, successful repair depends on the experience of the surgeon.

Pelvic fracture-related bladder injury: Characteristics and literature review

In a traumatic pelvic fracture, the forces of the trauma or pieces of the broken pelvic bones can lacerate or tear the urinary system. This type of trauma can range in its severity and some injuries can require immediate or delayed urinary reconstruction. In addition to direct trauma to the lower urinary system (bladder, prostate and urethra), pelvic trauma can disrupt nerves to the bladder and penis and lead to urinary problems like leakage and erectile dysfunction. Bladder rupture is rare and is often associated with other serious injuries and a high mortality rate. The bladder can also be torn or burst during a pelvic fracture. If these tears are large or urine spills into the abdomen around the intestine, they have to be fixed surgically.

Bilateral renal cell carcinoma with bilateral synchronous adrenal gland metastases – a case report

The authors reported a case of a 52-year-old patient with bilateral synchronous renal cell carcinoma synchronously disseminated in adrenal glands is presented. The patient underwent surgical treatment: radical nephrectomy on the right side, bilateral adrenectomie on the right and partial nephrectomy on the left side. Five years after surgery, patient is in complete remission.

Management of penile trauma caused by a dog bite.

Background: Dog bites to the external genitalia are extremely rare. The literature shows only sporadic cases of penile injuries due to dog bites, presenting mostly as children and adolescents. Case presentation: We report the case of a 45-year old patient with avulsion and traumatic degloving of the penile skin, with exposure of the tunica albuginea, which surrounds the cavernous bodies. Conclusion: Dog bite wounds pose a serious medical threat. An effective initial treatment of the wound, as well as adequate supportive treatments are essential for the efficient healing of the resulting infection.

Repeated endoscopic treatments of multiple recurrent ureteral tumors following 15-year-long history of bladder tumors in the patient from endemic nephropathy region

Ureteral urothelial tumors (UUT) are uncommon; their incidence is higher in areas affected by Balkan endemic nephropathy (BEN), with low–grade lesions prevalent. In these patients, the efficacy of conservative surgery is comparable to that of nephroureterectomy. Endoscopic treatment is indicated for single, small and low grade UUT, in older patients with significant comorbidity. The case of an 84–year–old lady from an area affected by BEN is presented. Over 20 years, the patient underwent five endoscopic interventions for multiple UUT, and numerous endoscopic interventions for recurrent bladder tumors. Among a highly select group of patients, endoscopic treatment of multiple small superficial low–grade ureteral tumors may prove successful.

Malignant disease in renal transplant recipients: Our experience

Kidney transplantation is a treatment of choice for patient with end stage renal disease. Chronic renal failure is characterized with weak cellular and humoral immunity. In our paper we present our experience with presence of malignancy in renal transplant patients. Urology clinic in Belgrade transplanted 411 patients over the period of 16 years. Living donor transplantation was performed for 272 and cadaveric kidney transplant for 139 patients. In the postoperative follow up, malignancies were diagnosed in 7 of the transplanted patients. Three patients developed basal cell skin carcinoma, one was diagnosed with adenocarcinoma of the transplanted kidney, one developed transitional cell carcinoma of the bladder and testicular tumors were diagnosed in two patients. Postoperative immunosuppressive therapy usually double or triple when patients are in the immunological high risk group. Incidence of malignancy according to big health centers is around 1 in every 1000 transplanted patients. It is also noted the rise of incidence of malignancies in transplanted patient in over 50%.

Tuberculous Bladder Contracture Treated by Augmentation Ileocystoplasty

Objective: To analyze the indications, diagnosis, and basic principles and aims of surgical reconstruction of tuberculous bladder contracture. Patients and Methods: From October 1993 to June 2006, 12 patients with severe bladder contracture due to tuberculous infection underwent augmentation cystoplasty in 3 urological institutions in Serbia. Results: All patients underwent subtotal cystectomy and bladder augmentation, using a segment of the ileum. Compliance increased from 2.72 ± 1.35 (range 0.92–4.85 ml/cm H2O) to 46.24 ± 35.44 ml/cm H2O (range 12.73–120.0 ml/cm H2O). Mean total bladder capacity increased from 180 ± 105 to 610 ± 192 ml (p < 0.001) and mean maximum detrusor pressure decreased from 79 ± 45 to 20 ± 14 cm HO. Average residual urine was 130 ml (50–220 ml). Conclusion: The presented surgical procedure is relatively easy, the compliance and the capacity of the augmented bladder are satisfactory and the complication rate is low.