Novak Milovic

Short ileal segment for orthotopic neobladder: A feasibility study

Objectives:  The objective of this study was to present the construction of a neobladder with a modified pouch technique using 25–35 cm of terminal ileum.

[Extramedular plasmacytoma in the urinary bladder--unusual localization].

BACKGROUND Multiple myeloma is a plasmaproliferative disease characterized by the uncontrolled proliferation of a pathogenic plasma cell clone engaged in the production of monoclonal immunoglobulin. This condition affects the bone marrow, but it can be manifested in any other organ or tissue. The urinary bladder involvement is extremely rare. CASE REPORT We reported a 70-year-old male with the history of multiple myeloma, receiving chemotherapy containing melphalan and prednisone (MP). Two years after the treatment, there was a renal failure associated with oligoanuria, hematuria and bilateral hydronephrosis. The urine cytology tests revealed the atypical cells, so was suspected obstructive uropathy to be caused by urothelium cancer. However, only upon the cystoscopy and biopsy performed on the urinary bladder mass, plasmacytoid infiltration diagnosis was confirmed. This extremely rare variant was presented throughout the illness period and proved to be resistant to the administered chemotherapy. CONCLUSION When renal failure associated with hematuria and bilateral hydronephrosis is presented in a patient with multiple myeloma, this unusual and rare extramedular localization should be also considered.

[Extravesical diverticulectomy--a surgical technique for managing a giant bladder diverticulum].

BACKGROUND Bladder diverticulum may be congenital and acquired. Iatrogenic bladder diverticulum is classified in a special group. Indications for surgery are: persistant or recurrent urinary infection, the presence of a stone in a diverticulum, development of tumor in a diverticulum cavity, the lower urinary tract symptoms and voiding symptoms and vesicoureteral reflux due to diverticulum or ureteral obstruction. CASE REPORT We presented a patient with a giant bladder diverticulum. Transurethral bladder catheterisation was performed because of urine retention. Secondly, transurethral prostate resection solved subvesical obstruction. The third step was open, extravesical diverticulectomy. Post-operative course was without complications. Three months after the surgery, control intravenous urography revealed normal findings. CONCLUSION We believe that the three-steps treatment of a giant bladder diverticulum significatntly contributed to the decreasing of postoperative complications.

Five-year experience with ileal neobladder according to original and modified Hautmann method

INTRODUCTION Radical cystectomy is the method of treatment of muscle invasive tumor of the urinary bladder, T2-T4a, N0-Nx, M0, which is also performed in patients at high risk of superficial tumors G3, CIS (carcinoma in situ), which are resistant to BCG and diffuse papillary tumors which can not be controlled by conservative treatment. After radical cystectomy, an adequate derivation of the urine is needed, and in the best interest for patients comfort, is to make a new bladder from the parts of gastrointestinal tract and suture it to the rest of the urethra. In 1988, German surgeon Richard Hautmann published his method of creating a new bladder, for what he used 60cm of ileum. This method is in use at Department of Urology, Military Medical Academy, Belgrade, but, we introduced our modification of original operation because of early and late postoperative complications. OBJECTIVE The analysis of early and late complications after derivative surgery of orthotopic ileal bladder according to Hautmann. The patients operated according to original and modified method were analyzed. METHOD From 2000-2004, 117 radical cystectomies were performed due to malignant urinary bladder tumors as well as the same number of derivative surgeries at the Clinic for Urology, Military Medical Academy, Belgrade. During this five-year period, the orthotopic ileal neobladder surgery according to Hautmann was performed in 41 patients after radical cystectomy. Twenty three patients were operated on using the original method and 18 patients by our modification. RESULTS Metabolic disorders and problems of high capacity of neobladder were manifested in all patients operated on by original method, while the stenosis of the ureteroileal anastomosis was present in most of these patients. Metabolic disorders were less frequent and of lower degree in patients operated by our modification and there was no stenosis of the ureteroileal anastomosis. The problems with urination were not reported. CONCLUSION In our opinion and on the basis of our experience, Hautmann method is the method with fewer complications. However, our modifications are also acceptable because the number of complications is smaller and the value of operation is being kept.

Advanced prostatic carcinomas with low serum levels of prostate-specific antigen

The serum levels of prostate-specific antigen (PSA) represent a significant diagnostic and monitoring parameter of prostatic carcinoma (PC). The aim of the study was to establish correlation of serum PSA level in addition to grade, histological type, and clinical stage of PC in patients with normal or intermediary PSA serum level. In 37 untreated PC patients with preoperative serum PSA levels ranging between 0.1 and 9.6 ng/ml, paraffin-embedded tissue and serum samples were immunohistological studied and immunoassay for PSA was done. The most representative was poorly differentiated PC with D stage In serum samples from PC patients 27 (73.7%) normal (≤ 4.0 ng/ml), and 10 (27.3%) intermediate (4.1-10 ng/ml) PSA levels were found Immunohistochemistry, in 36 PC (97.3%) had demonstrated the expression of PSA. Our study results had shown low serum PSA levels in some patients with advanced poorly differentiated PC.

Predijalizna transplantacija bubrega

Predijalizna transplantacija bubrega je sa medicinskog i socioekonomskog aspekta metoda izbora u lecenju terminalne bubrežne insuficijencije kod bolesnika koji imaju živog davaoca bubrega. Nase pocetno iskustvo sa ovom metodom lecenja vrlo je afirmativno. Predijalizna transplantacija bubrega je posebno prihvatljiva kod dece, dijabeticara i bolesnika sa losim pristupom za dijalizu. U nasoj zemlji postoje dodatni medicinski (los kvalitet dijalize, visok rizik od infekcije virusima hepatitisa, visok rizik od senzibilizacije na tkivne antigene transfuzijama krvi) i paramedicinski razlozi (prepunjenost dijaliznih centara, ograniceni zdravstveni ekonomski resursi) koji namecu potrebu daljeg razvijanja programa predijalizne transplantacije.

Tissue and urinary KIM-1 relate to tumor characteristics in patients with clear renal cell carcinoma

AbstractThe objective of this prospective follow-up trial was to ascertain whether the urinary kidney injury molecule-1 (uKIM-1) associates with tumor tissue (tKIM-1) expression and with the pathological characteristics of clear renal cell carcinoma (cRCC) in radically nephrectomized (RN) and/or in partially nephrectomized (PN) patients with cRCC, pre- and postoperatively. This clinical study included 40 patients subjected to RN/PN (cRCC group) and 30 healthy volunteers (control group). Urinary KIM-1 was determined by ELISA TIM-1/KIM-1 kit and normalized by urinary creatinine. Immunohistochemical staining (monoclonal anti-human anti-TIM-1/KIM-1/HAVCR antibody) was used for semiquantitative analysis of the tKIM-1 expression and expressed as a score (% KIM-1 positively stained tubules). Both markers were interpreted in terms of the tumor characteristics comprising tumor size, Fuhrman grade, pathological (pT) stage, tumor/nodes/metastasis (TNM) stage, lymphovascular invasion and type of surgery RN/PN. Preoperative uKIM-1 was significantly higher in the cRCC group compared to controls, such as uKIM-1 was statistically higher in RN than in PN patients. Postoperatively, uKIM-1 decreased to control values. Expression of tKIM-1 was documented in all nephrectomized patients. Significant associations were achieved between uKIM-1 and tKIM-1 and with considered tumor characteristics, especially with tumor size and grade. Based on the accomplished associations, we found uKIM-1 as a highly sensitive marker for cRCC diagnosis. The clinical trial registration number: 1110-2012.

The clinical course of non-muscle invasive bladder cancer after transurethral resection of the tumor with or without subsequent intravesical application of bacillus Calmette-Guérin: The influence of patients gender and age.

UNLABELLED BACGROUND/AIM: The therapy with intravesical instillation of bacillus Calmette-Guérin (BCG) after transurethral resection (TUR) of tumor is the gold standard of treatment of non-muscle invasive bladder cancer (NMIBC). The role and importance of BCG intravesical therapy in various shape of tumors, were confirmed by our previous investigation. The aim of this study was to examine whether incidence of recurrence and tumor regression differs depending on sex and age of patients. METHODS This study included a total of 899 patients suffering from NIMBC, treated at our institution from January 1, 2007 to March 1, 2013. Two groups of patients were formed: patients underwent TUR + BCG therapy (the group I) and the group II with patients in whom TUR was performed as only therapy. These two groups of patients were divided into subgroups of respondents male and female, age 60 years or younger and older than 60 years. Statistical analysis was performed using χ2 test and the Kolmogorov-Smirnov test. RESULTS This research suggests that if the frequency of recurrence is seen as the only parameter, considering all the subjects, the lowest recurrence rate was determined in the male subjects, aged 60 years and younger who had received BCG after TUR. A high statistical significance was found in the incidence of recurrence in patients younger than 60 years, depending on the response to the therapy, while in those older than 60 years, the difference was at the level of statistical significance. This can be attributed to a certain degree of infravesical obstruction in older men. CONCLUSIONS Sex and age of patients may have a significant influence on the course and outcome of NMIBC. The disease has the most malignant and most aggressive behavior when present in males older than 60 years.

Surgical site infections and other healthcare related infections in cohort of urological patients, 2010-2013

Background: Surgical site infections (SSIs) and other healthcare related infections continues to be significant problem in surgical patients across the globe. Aim: To analyze and compare the surveillance data from large cohort of patients operated in Clinic for Urology, Military Medical Academy Methods: A prospective cohort study was performed to identify incidence rate and risk factors for surgical site infections (SSI) from 2010 to 2013. Infection control personal collected general and healthcare related data about patients. The microbiologic testing was performed at the Institute of Medical Microbiology by routine methods. Results: A total of 3823 surgical procedures (3288 patients) were included in the study. The lowest incidence rate was observed in kidney surgery (total nephrectomy - 2.4% and partial nephrectomy - 3.6%), and highest during bladder surgery (total cystectomy - 21.6% and partial cystectomy - 23.5%). The postoperative infections (RR: 2.018; 95%:1.111 -3.666; SE: 0.305; p: 0.021), dra inage (RR:10.417; 95%CI:4.339 - 25.011; SE: 0.447; p: 0.000), preoperative length of hospital stay (RR:0.909; 95%CI: 0.880 - 0.939; SE: 0.017; p: 0.000) and total length of hospitalization (RR:1.140; 95%CI:1.117-1.164; SE: 0.010; p:0.000), as well as contamination class (RR:1.633; CI95%:1.215 - 2.194; SE:0.151; p:0.001) are independent risk factors for SSI in this cohort of patients. Incidence rate of diarrhea caused by Clostridium difficile was 5.01 to 10 000 patient days. The most common cause of SSI and urinary tract infections was Klebsiella spp. Conclusion: The greater attention has been given to adherence to recommendations for the prevention and control of SSIs as well as management of multidrug resistant organisms in urology department.

Urodynamic characteristics of the modified orthotopic ileal neobladder

BACKGROUND/AIM Radical cystectomy is the method of choice in management of muscle invasive, organ-confined tumors of the bladder (T2-T4, N0-Nx). The most frequent continent orthotopic urinary diversion after radical cystectomy is the ileal neobladder. A modified technique consists of using a shorter segment of the terminal ileum than the standard technique, around 30 cm. The aim of this study was to determine the urodynamic characteristics of the orthotopic ileal neobladder created by a modified technique. METHODS In this prospective clinical study we analyzed the urodynamic parameters of 24 patients who had underwent radical cystectomy with orthotopic urinary diversion by ileal neobladder created using a modified technique. In all the patients we performed invasive and noninvasive urodynamic investigations 12 months after the operation. The urethral pressure profile parameters analyzed were maximal urethral pressure, maximal urethral closure pressure and the functional urethral profile length. RESULTS The average age of the patients was 63 (49-73) years, 90% were males and 10% were females. The median length of the shorter segment of the terminal ileum was 28 (range 22-35) cm. Prior to enterocystometry and uroflowmetry postvoid residual (PVR) urine was measured by a urethral catheter. The median PVR was 16.7 (0-140) mL. The median enterocystometric capacity was 396 (range 372-532) mL. The median end filling pouch pressure was 27.6 (range 20-70) cmH2O. The median maximal flow of urine was 22.1 (range 9.7-39.5) mL/s and the average flow of urine was 9.61 (range 3.6-17.6) mL/s. Flow time in the analyzed group was 47.5 (range 22-119) s. The median maximal urethral pressure was 54 (range 12-101) cmH2O, maximal urethral closure pressure 36.6 (range 6-91) cmH2O. Functional urethral profile length was 14.9 (range 4-37) mm. CONCLUSION An ileal orthotopic pouch created by a modified technique using a shorter segment of the terminal ileum after 12 months presents with urodynamic characteristics similar to the native bladder.