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Cilj: U prikazu slučaja željeli smo pokazati rijedak slučaj bolesnika s Fournierovom gangrenom te njegovo kirurško liječenje, zbog velike edukacijske vrijednosti u kliničkoj, urološkoj praksi. Prikaz slučaja: Muškarac star 53 godine prezentirao se s uznapredovalim gangrenoznim promjenama skrotuma i penisa kao i eritemom i otokom suprapubične regije prednje trbušne stijenke, ingvinalne regije, perineuma i unutarnje strane bedara. U bolesnika smo hitno pristupili operacijskom liječenju, pri čemu je učinjena bilateralna orhidektomija i ekstenzivna ekscizija nekrotičnih masa do u zdravu, dobro prokrvljenu kožu i potkožno tkivo. Postavljena je i suprapubična cistostoma za derivaciju urina. Rana je ostavljena da cijeli per secundam intentionem. Tijekom boravka bolesnika na našem odjelu rana je svakodnevno previjana uz dodatnu eksciziju nekrotičnog tkiva. Uz kirurško liječenje bolesnik je primao i parenteralnu antibiotsku terapiju. Na kraju liječenja rana je pokrivena kožnim režnjem, čime su postignuti zadovoljavajući kozmetički rezultati. Rasprava: Fournierova gangrena po život je opasan poremećaj u kojem se infekcija širi duž fascije, uzrokujući nekrozu kože i mekog tkiva. Ova bolest pogađa uglavnom bolesnike s konkomitantnim bolestima kao što su: dijabetes, alkoholizam i bubrežna insuficijencija. Unatoč liječenju, Fournierova gangrena povezana je s visokom stopom smrtnosti, a vremenski interval od nastanka kliničkih simptoma do početka kirurške intervencije najvažniji je prognostički čimbenik. Zaključak: Naš slučaj pokazuje kako je Fournierova gangrena prava urološka hitnoća, te zahtijeva promtno kirurško liječenje., Aim: In our case report we wanted to show a rare case of Fournier’s gangrene and his surgical treatment with high educational value in clinical practice. Case report: A 53- year old men presented with advanced gangrenous changes of the scrotum and penis as well as the erythematous and swollen areas on the anterior abdominal wall, inguinal regions, perineum and inner side of thighs. The patient was rapidly taken to the operating room and underwent bilateral orchiectomy and radical excision of the necrotic masses until the normal skin and fascia were found. Suprapubic urinary diversion was also performed and the wound was left open. During his stay at our Department surgical toilette and banding were performed daily. Along with the surgical treatment all the conservative measures were taken, including proper intravenous hydration and antibiotic therapy. Once a wound properly healed, plastic surgery and grafting was successfully performed giving satisfactory cosmetic results. Discussion: Fournier’s gangrene is a life-threatening disorder in which infection spreads along fascial planes, causing soft tissue necrosis. This disease affects mostly patients with predisposing factors including diabetes, alcohol abuse, paraplegia and renal insufficiency. Despite antibiotics and aggressive surgical debridement, Fournier’s gangrene is associated with a high mortality rate and the interval from the onset of clinical symptoms to the initial surgical intervention seems to be the most important prognostic factor. Conclusions: Our case shows that Fournier’s gangrene remains a true urologic emergency, which mandates aggressive initial surgical treatment.

Ultrazvučna dijagnostika različitih, a poglavito hitnih uroloških bolesti, u današnje vrijeme dostigla je visoku razinu. Uz anamnezu i fizikalni pregled, ultrazvuk je postao nezaobilazan postupak prilikom obrade urološkog bolesnika te predstavlja moćno oružje za brzo i sigurno postavljanje točne dijagnoze. Osim neizmjerne pomoći pri dijagnostici uroloških bolesti, mnogi urolozi pridaju još veći značaj ultrazvuku kao najboljoj slikovnoj metodi za terapijske intervencijske postupke na mokraćnom sustavu. Ovakva važnost ultrazvuka zasnovana je na nizu prednosti u kojima će biti riječi u ovome članku. Intervencijski ultrazvuk u urologiji obuhvaća niz perkutanih zahvata kojima se prodire u mokraćni sustav pod kontrolom ultrazvuka, s primarnim ciljem brzog i efikasnog otklanjanja potencijalno smrtonosnih komplikacija podležećih bolesti. Naime, svaka bolest koja uzrokuje opstrukciju mokraćnog sustava s posljedičnom smetnjom normalnog otjecanja mokraće, bez obzira radi li se o zloćudnom ili dobroćudnom procesu, može dovesti do ozbiljnih stanja kao što su kompletna retencija mokraće, akutna bubrežna insuficijencija, hidronefroza i urosepsa. Takva stanja u pravilu zahtijevaju hitnu derivaciju mokraće retrogradnim ili perkutanim putem jer podležeću bolest, osim u rijetkim slučajevima, nije moguće u kratkom razdoblju u cijelosti otkloniti. Retrogradna derivacija mokraće često nije moguća radi neprolazne zapreke unutar mokraćnog sustava ili pritiska patološkog procesa izvana, pa perkutani intervencijski zahvat ostaje jedino rješenje. Perkutani zahvati najčešće se izvode na hidronefrotičnom bubregu. Hidronefroza označava proširenje kanalnog sustava bubrega koje, ako se adekvatno ne liječi, dovodi do atrofije bubrežnog parenhima. Naglašavamo kako u domenu urološkog interesa pripadaju i perkutani intervencijski zahvati na tkivima priležećim mokraćnom sustavu, npr. drenaže retroperitonejskih kolekcija., Ultrasound diagnostic of different urological diseases has reached a high level at the present time. Along with patient’s history and physical examination, ultrasound has become an unavoidable procedure when processing urological patients and represents a powerful tool to quickly and safely set the accurate diagnosis. Besides tremendous help in diagnostics of urological diseases, many urologists attach even greater importance to the ultrasound as the best imaging method for therapeutic interventional procedures on the urinary system. Interventional ultrasound in urology includes a number of percutaneous interventions which penetrate into the urinary system under ultrasound guidance, with a primary aim of fast and efficient removal of the potentially fatal complications of underlying diseases. Any obstruction of the urinary system with subsequent disturbance of normal urine flow can lead to serious conditions such as complete urinary retention, acute renal failure, hydronephrosis and urosepsis. Those conditions most often require urgent urinary diversion by retrograde or percutaneous way because the underlying disease, except in rare cases, cannot be entirely eliminated in a short period of time. Retrograde diversion of urine in often impossible due to impassable barrier within the urinary system or pressure of pathologic process from outside, so percutaneous interventional procedure remains the only solution. Hydronephrosis indicates a widening of the renal collecting system which, if mistreated, leads to the atrophy of renal parenchyma. We emphasize that percutaneous interventional procedures on the nearby urinary tract tissues also belong into a field of urologic interest, for example drainages of retroperitoneal collections.

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 strictures

Cilj: Polipi stražnje uretre u muške djece rijetke su i obično benigne kongenitalne lezije. U ovom radu prikazat ćemo slučaj osmogodišnjeg dječaka koji je po drugi put primljen u bolnicu zbog akutne retencije urina (ARU) uzrokovane polipom stražnje uretre. Prikaz slučaja: Kod prvog primitka dječaka u bolnicu, zbog ARU-a, učinjene su uretrocistoskopija i cistouretrografija. No, navedenim pretragama nije se uspio pronaći uzrok dječakovim tegobama. Njegovo mokrenje postupno se normaliziralo i dječak je otpušten kući. Dvije godine kasnije, kada je ponovno primljen zbog ARU-a, ultrazvukom (UZ) je uočena polipoidna tvorba na bazi mjehura i defekt punjenja na mikcijskoj cistouretrografiji (MCUG). Magnetskom rezonancijom (MR) točno se definiralo mjesto na kojem se nalazi polip; s ishodištem u verumontanumu i protruzijom u mokraćni mjehur, gdje slobodno prominira. Nakon transuretralne resekcije učinjena je patohistološka analiza kojom je potvrđen fibroepitelni polip koji je vrlo vjerojatno kongenitalan. Rasprava: Uretralni polipi izuzetno su rijetki, a njihova etiologija je stalna tema rasprave. Prezentirajući simptomi su intermitentna retencija urina, nepotpuno pražnjenje mjehura, hematurija i urinarna infekcija. Mogu biti i asimptomatski, ali rijetko. Dijagnoza se obično postavlja s UZ-om i MCUG-om. MR definira kirurški pristup polipoznoj tvorbi, dok se uretrocistoskopijom postavlja definitivna dijagnoza. Zaključci: Dijagnoza uretralnog polipa može se postaviti sa UZ, MCUG i MR, ali uretrocistoskopija ima važnu ulogu, kako dijagnostičku, tako i terapijsku., Aim: Polyps of the male posterior urethra are rare and usually benign congenital lesions. We report a case of an 8-year-old boy who presented with recurrent urine retention caused by urethral polyp. Case report: At his first admittance to the hospital, the 8-year-old boy presented with urine retention. The performed urethrocystoscopy and cystourethrography were not diagnostic. His condition spontaneously improved, micturition was normal and the boy was discharged. Two years later he presented with recurrent urine retention, and ultrasonography (US) revealed a polypoid mass at the bladder base while cystourethrogram showed a filling defect. Magnetic resonance imaging (MRI) revealed the localization of urethral polyp projecting from verumontanum into the bladder cavity. After successful transurethral resection, histological analysis showed fibroepithelial polyp indicating congenital origin. Discussion: Urethral polyps are very rare and their etiology is controversial. The presenting symptoms are intermittent urine retention, incomplete bladder emptying, hematuria and urinary infection. Rarely, they are asymptomatic. The diagnosis is usually made by US and voiding cystourethrogram (VCUG). Urethrocystoscopy is always diagnostic. The role of MRI is to define the surgical approach to the polypoid lesion. Conclusions: The diagnosis of urethral polyp can be made by US, VCUG or MRI but urethrocystoscopy still has a major diagnostic and therapeutic value, especially in boys presenting with urine retention.

The kidneys are organs with multiple functions and essential to maintain life. Ablative procedures, such as nephrectomy, diminish nephron mass and can have a potentially negative impact on renal function. We investigated renal function outcome in patients who underwent nephrectomy for renal cell cancer with special emphasize on elderly patients. Data from 104 patients who underwent nephrectomy for kidney cancer in the Department of Urology, University Hospital Rijeka from January 2005 to December 2010 were retrospectively analyzed. All patients had a normal concentration of serum creatinine and a normal contralateral kidney before surgery. Renal function, as estimated by the glomerular filtration rate (eGFR), was determined before and after nephrectomy using the abbreviated Modification of Diet in Renal Disease equation. We compared the eGFR before and after nephrectomy in the patients of different age. The mean preoperative eGFR was 75.2 mL/min, and the mean postoperative eGFR was 52.7 mL/min (p0.0001). In the group of patientsor = 65 years old, the mean preoperative GFR was 69.2 mL/min, and the mean postoperative eGFR was 47.4 mL/min (p0.0001). Our data indicate that the eGFR significantly decreased after nephrectomy for kidney cancer. In elderly patients, diminished renal function following nephrectomy was more prominent.

Cilj: Transplantacija bubrega metoda je izbora u liječenju bolesnika s terminalnim kroničnim bubrežnim zatajenjem. S obzirom na nesrazmjer između broja primatelja i darivatelja organa, kako bi se povećao broj darivatelja, počeli su se koristiti i bubrezi takozvanih marginalnih donora. U njih spada i korištenje obaju bubrega darivatelja u istog primatelja (dvostruka transplantacija bubrega). U ovom radu prikazujemo prvi slučaj bilateralne dvostruke transplantacije bubrega u KBC-u Rijeka i Republici Hrvatskoj. Prikaz slučaja: Primatelj je 75-godišnji muškarac koji je 15 godina bio na hemodijalizi zbog kroničnog bubrežnog zatajenja uzrokovanog kroničnim glomerulonefritisom. Darivatelj bubrega bila je 78-godišnja žena, čiji je uzrok smrti bilo intrakranijalno krvarenje. Bubrezi su transplantirani bilateralno, ekstraperitonealno, u ilijačne jame. Poslijeoperacijski tijek protekao je uredno, bez kirurških i imunoloških komplikacija. Korištena je trojna imunosupresivna terapija. Godinu nakon transplantacije oba presatka uredno funkcioniraju. Rasprava i zaključak: S obzirom na to da je preživljenje bolesnika s dvostrukom transplantacijom bubrega veće nego u bolesnika koji se liječe hemodijalizom, smatramo kako se korištenjem organa ove skupine donora može povećati broj transplantacija., Aim: Kidney transplantation is the method of choice for treatment of patients with end-stage renal disease. Because of disparity between donors and recipients, the use of marginal donors was established to increase the number of donors. Dual kidney transplantation represents using two kidneys from the same donor for one recipient. In this case report we present the first case of bilateral dual kidney transplantation in KBC Rijeka and Croatia. Case report: The recipient was a 75-year-old man who was on hemodialysis for 15 years. The cause of end-stage renal disease was chronic glomerulonephritis. The donor of kidneys was a 78-year-old woman with cerebral death caused by intracranial bleeding. The kidneys were transplanted bilaterally and placed extraperitoneally in the iliac fossa. Postoperative course was uneventful, without surgical and immunological complications. Triple immunosuppressive therapy was used. One year after transplantation both kidneys have good function. Discussion and conclusion: As survival of patients with dual kidney transplantation is better than on haemodialysis, we believe that using kidneys from expanded criteria donors can possibly increase the number of kidney transplantations.

Through the treatment of anaemia in dialysis patients part of the iron ions remain free in the serum which is at the bacterias disposal for growth and the strengthening of their virulence. The linear relation of the increased serum iron level and tissue iron stores in the body and the infection incidence in dialysed patients has become more emphasised. The need of a clearly defined upper threshold of the serum iron concentration limit has been mentioned in scientific journals intensely, and consequently the demand for more precise professional instructions for anaemia treatment. For the purpose of participating in these professional and scientific discussions, we have observed the relation between the iron overload of the organism and complication incidence in 120 of our haemodialysis uremic patients, with special emphasis on infections. It has been established that the sepses incidence is much higher in patients with a serum ferritin concentration above 500 microg/L, than in those patients with a ferritin level lower than the mentioned value (Chi2 = 7.857, p = 0.005). The incidence of vascular access infection is significantly higher in those patients with a serum ferritin level above 500 microg/L than in those patients with a ferritin level lower than the mentioned value (Chi2 = 23.186, p = 0.001). Furthermore, it has been determined that the incidence of total infection in patients is 3.8 episodes per 100 patients months, which is in accordance to the referral values of other authors. CONCLUSION--In the analysis of the achieved results, it has been determined that the infection incidence is significantly higher in dialysed patients with a serum iron level higher than 500 microg/L, than in those patients with lower values.

Limfocele su jedna od češćih kirurških komplikacija transplantacije bubrega. Retrospektivno smo analizirali bolesnike s transplantiranim bubregom u našem centru u kojih su dijagnosticirane limfocele. Tijekom 39 godina učinili smo 922 transplantacije bubrega, a limfocele su dijagnosticirane u 45 (4,9%) bolesnika. Limfocele smo liječili na sljedeći način: perkutana drenaža s instilacijom povidon-jodida u 36 (80%) bolesnika, perkutana drenaža s instilacijom tetraciklina u jednog (2,2%), perkutana aspiracija u četiri (8,9%) i kirurško liječenje u četiri (8,9%) bolesnika. U četiri (8,9%) bolesnika s recidivom sekundarni postupak bio je uspješan. Ukupno smo otvorenim kirurškim zahvatom liječili pet (11,1%) bolesnika, a laparoskopski četiri (8,9%) bolesnika. Perkutana drenaža limfocele, s instilacijom sklerozirajućeg sredstva ili bez instilacije, je metoda izbora u liječenju limfocele. Laparoskopska fenestracija limfocela je alternativa perkutanoj drenaži, posebno kod recidiva., Lymphoceles are a well-known surgical complication of kidney transplantation. We retrospectively analyzed patients with lymphoceles among our renal transplant recipients. During the last 39 years, we performed 922 renal transplantations. Lymphoceles were diagnosed and treated in 45 (4.9%) patients. We used the following methods: percutaneous drainage with instillation of povidone-iodide in 36 (80%), percutaneous drainage with instillation of tetracycline in one (2.2%), percutaneous aspiration in four (8.9%) and surgical treatment in four (8.9%) patients. In all four (8.9%) patients with relapse, secondary procedure was successful. In total, open surgery was done in five (11.1%) and laparoscopy in four (8.9%) patients. Percutaneous drainage of lymphoceles, with or without the instillation of a sclerosant, is the first-line treatment. Laparoscopic fenestration of lymphoceles has become an alternative to percutaneous drainage, especially in case of post-drainage relapse.

Prostate cancer is a leading public health problem of male population in developed countries. Gold standard for prostate cancer diagnosis is true cut biopsy guided by transrectal ultrasound1–5. Aim of this study was to determine sensitivity, specificity, accuracy, positive and negative predictive value of transrectal sonography (TRUS) in prostate cancer detection. The analysis was made for two time periods, before and after routine implementation of prostate specific antigen (PSA) in prostate cancer diagnostics. From 1984 to 1993 TRUS guided prostate biopsy was performed in 564, and from 1994 to 2008 in 5678 patients. In the second period PSA was routinely used in prostate cancer diagnostics. In the first period by TRUS we have made an exact diagnosis of prostate cancer in 18.97% of patients what was confirmed by biopsy. 4.61% ware false positive and 11.34% ware false negative. In the second period prostate cancer was recognized in 30.34% of patients, confirmed by biopsy. False positive cases ware 6.11% and false negative 29.31%. Sensitivity of transrectal sonography in the first period was 62.57%, specificity 94.2%, accuracy 86.2%, positive predictive value 80.45% and negative predictive value 87.72%. In the second period sensitivity was 50.87%, specificity 91.93%, accuracy 73.84%, positive predictive value 83.24% and negative predictive value 70.39%. Based on our experience we can conclude that prostate cancer is mostly found in the peripheral zone. Smaller tumors are hipoechoic and bigger tumors are hiperechoic. Prostate cancer lesions are impossible to differentiate from chronic prostatitis only by TRUS. Implementation of PSA has significantly decrease sensitivity, accuracy and negative predictive value of TRUS in prostate cancer detection. TRUS guided true cut biopsy is a gold standard in prostate cancer diagnostics.

Transplantacija bubrega najučinkovitija je metoda nadomještanja bubrežne funkcije. Razvoj transplantacije bubrega u svijetu vezan je uz drugu polovicu 20. stoljeća. U bolnici na Sušaku prvi eksperimentalni kirurški postupci koji su prethodili zahvatima na ljudima počeli su 1966. godine. Prva transplantacija bubrega sa živog davatelja u bolnici na Sušaku učinjena je 31. Siječnja 1971., a godinu dana kasnije i prva transplantacija bubrega s umrlog davatelja. Posljednjih 40 godina napredak transplantacijske medicine u Rijeci i Hrvatskoj rezultirao je činjenicom da je Rijeka i danas jedan od vodećih transplantacijskih centara u Hrvatskoj. Od 2007. godine Klinika za urologiju je Referentni centar Ministarstva zdravstva za transplantaciju bubrega., Kidney transplantation is the most efficient method of renal replacement therapy. Development of kidney transplantation occurred in the second part of the 20th century. At Sušak hospital, the first experimental surgical acts on animal models started in 1996. The first kidney transplantation from living related donor at Sušak hospital was performed on January 31, 1971. One year later, first transplantation from cadaveric donor was performed. In the last 40 years, development of transplantation medicine in Rijeka and Croatia was successful and Rijeka has become one of the top transplantation centers in Croatia today. Since 2007, Department of Urology has become Referral Center for Kidney Transplantation of the Croatian Ministry of Health and Social Welfare.

The goal of our study was to present our long-standing experience of the treatment of prostate carcinoma in patients over the age of 70. During the 20 years period (from 1991 to 2010) we diagnosed the prostate carcinoma in 1998 patients. More than 58% of the patients were over 70 years old. The most frequent symptoms of the prostate carcinoma were frequent urination and backache. At the first examination 36% of the patients had both prostate lobes involved, and 27% of them had metastases. The most frequent ones (26%) were those in the bone system (pelvis and spine), while in only 1% metastases were found in solid organs (lungs and liver). According to the TNM classification, T1 and T2 were diagnosed in 818 (71%) patients. Histopathological examination discovered Gleason score 2 in 70% of patients and Gleason score 3 in 24% of them. Most often the combination of castration and antiandrogen therapy (in 68% of the patients) and the combination of castration and Estracyt therapy (in 19% of the patients) were applied. In conclusion, intensified efforts should be made in promoting preventive urological examinations because of the great number of patients (27%) with metastases at the first examination.

Transplantacija bubrega je najučinkovitiji način liječenja bolesnika s terminalnim kroničnim bubrežnim zatajenjem. Transplantacija u bolesnika s urinarnom diverzijom efikasan je način liječenja pacijenata koji imaju disfunkcionalan donji urinarni trakt. Preživljenje presatka, ali i bolesnika ne razlikuje se u odnosu na bolesnike s klasičnom ureterovezikalnom anastomozom. Predstavljamo jednog bolesnika s urinarnom diverzijom (ilealni konduit) koji je uspješno prije 2 godine transplantiran u našem centru., Kidney transplantation is the most efficient treatment in patients with end-stage renal disease. Transplantation in patients with urinary diversion is an effective treatment for patients with chronic renal insufficiency and abnormal lower urinary tract. Graft and patient survival is comparable to that with classical ureterovesical anastomosis. We present one patient with urinary diversion (ileum conduit) who was successfully transplanted in our center two years ago.