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Introduction/Objective. Infertility is the inability to achieve pregnancy after a year or more of unprotected sexual intercourse. It is a clinical and social issue affecting both sexes. Infertility can cause anxiety, depression, and personal distress with long-lasting consequences. Men and women tend to cope with infertility in different ways and reliance on certain coping mechanisms can be harmful. This study aims to examine the correlative effects of infertility, distress and depression among couples, and investigate sex disparities in levels of suffering. Methods. The research is a cross-sectional study that included 168 participants (84 couples) divided into two groups, control and infertility group. Beck Depression Inventory Second Edition (BDI-II) and the Brief Symptom Inventory (BSI) were used to identify and assess psychological symptoms. Statistical analysis was performed using SPSS at the 0.05 level of significance. Results. The results showed that there was a significant difference in the scores on BDI and BSI scales between the infertile and fertile groups, with participants in the infertile group reporting higher levels of depression and distress (t = -2.724, df = 166, p < 0.01; t = -3.609, df = 166, p < 0.01). Women had significantly higher scores on the depression scale than men (t = -2.079, df = 166, p < 0.05). Conclusion. In summary, the study found that couples dealing with infertility experience higher levels of distress and depression compared to the control group. Women in these couples are particularly vulnerable to depression. The study highlights the importance of addressing the mental health needs of individuals and couples dealing with infertility, in addition to treating the underlying medical issues.

Background/Aim. The incidence of postoperative delirium (POD) after non-cardiac surgery is a problem not often recognized by many anesthesiologists. The objective of our study was to detect POD and its possible cause, in patients undergoing radical retropubic prostatectomy (RRP) under general anesthesia. Methods. After Ethical Committee approval, we enrolled 80 patients, ASA (the American Society of Anestesiology) status II, scheduled to undergo RRP un-der general anesthesia, in a prospective study. All patients completed MMSE tests (the Folstein Mini Mental State Ex-am) the evening before, and 48 hours after the surgery. Assessment for the presence and severity of delirium was per-formed using CAM (the Confusion Assessment Method), and an assessment of the degree of agitation and sedation using RASS (the Richmond Agitation and Sedation Scale). Results. The average preoperative MMSE score (28.59 ± 1.04) significantly decreased following the surgery (27.74 ± 1.52) (p < 0.0001). The average postoperative MMSE score trend descended in correlation to intraoperative bleeding (p = 0.036). The patients with higher pain scores had significant decline in MMSE after the surgery (28.75 vs. 26.25; p < 0.001). Five patients were considered positive for delirium, and four of them reported regular alcoholic drinks intake (> 1 drink per day) preoperatively (p < 0.0001). Based on RASS score, 13 patients (16.3%) were agitated or sedated, and they had statistically significantly higher intraoperative bleeding (p < 0.001). Conclusion. Results of this study emphasize the importance of proper preoperative evaluation; especially regarding the alcohol consumption since all the patients that developed POD reported moderate alcohol consumption. Further-more, greater intraoperative bleeding and postoperative pain scores did not influence the occurrence of delirium, but resulted in lower postoperative MMSE scores, which high-lights the importance of adequate intraoperative treatment of patients during surgery and anesthesia in order to reduce the risk of developing POD.

Introduction/Objective. Nuclear Medicine Section of IAEA has developed the software for dynamic renal scintigraphy, which allows calculation of advanced parameters of drainage: renal output efficiency (OE) and normalized residual activity (NORA). The aim of this study was to validate IAEA software by comparing results of parameters of renal drainage in normal subjects against their established reference values and to assess diagnostic accuracy of OE and NORA in distinguishing between obstruction/unobstruction. Methods. Fifty-five patients with suspected obstruction and 36 kidney donors were investigated. Group A consisted of 24 obstructed kidneys, Group B of 37 kidneys with dilated urinary tract, and Group C of 72 normal kidneys. Forty-minute acquisition was applied. Furosemide was administered after 20 minutes. Post-micturition image was acquired at 50 minutes. The analyzed parameters were as follows: OE at 20 minutes (OE20) and at the end of the furosemide test (OE40), NORA at 20 minutes (NORA20) and after micturition (NORAPM). One-way ANOVA was used for evaluating the differences between the groups. Ability of OE40 and NORAPM to distinguish between obstruction/unobstruction was determined by ROC curve analysis. The sensitivity, specificity, area under the curve, and cut-off values were analyzed. Results. Excellent agreement of our results with established OE and NORA values was found. The difference between the groups was significant for OE20, OE40, NORA20, and NORAPM (p < 0.001). Cut-off values for obstruction were 82% and 0.11 for OE40 and NORAPM, respectively. Conclusion. IAEA software gives reliable analysis of diuretic renography and helps to better diagnose obstruction. IAEA should be encouraged to produce final version of the software and to release it online.

Urosepsis is defined as sepsis caused by urinary tract infection (UTI). Urosepsis represents a quarter of all cases of sepsis in adults. Complications of UTIs are the most common risk factor for urosepsis development. These infections, especially pyelonephritis, often occur in patients with structural or functional malformations that interfere with normal urine flow. The problem of a significant increase in UTIs with multiresistant bacteria should be emphasized, especially in patients with recurrent UTI and their frequent treatments. As the urogenital tract is one of the most common sources of infection in sepsis in general, a detailed assessment of the tract should be carried out in all septic patients. Even though urosepsis is associated with a relatively good prognosis and lower mortality than sepsis of another etiology, it occurs rapidly and progresses at a significant speed. Since urosepsis is mainly the result of obstruction of the urinary tract, the development of septic shock can most often be prevented by implementing early deobstruction. Knowledge of the most common causes of urosepsis and the category of high-risk patients will provide clinicians with the tools with which to prevent its occurrence.

Ana Mimic,1 Carsten Bantel,2,3 Jelena Jovicic,1 Branko Mimic,4 Darija Kisic-Tepavcevic,5 Otas Durutovic,6,7 Nebojsa Ladjevic1,7 1Department of Anaesthesia, Urology Clinic, Clinical Centre of Serbia, Belgrade, Serbia; 2Department of Anaesthetics, Klinikum Oldenburg AöR, Oldenburg, Germany; 3Section of Anaesthetics, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK; 4East Midlands Congenital Heart Centre, University Hospital Leicester, Leicester, UK; 5Institute of Epidemiology, School of Medicine, University of Belgrade, Belgrade, Serbia; 6Department of Urology, Urology Clinic, Clinical Centre of Serbia, Belgrade, Serbia; 7Department of Surgery and Anaesthesiology, School of Medicine, University of Belgrade, Belgrade, Serbia Purpose: There is an increasing interest in the identification of predictors for individual responses to analgesics and surgical pain. In this study, we aimed to determine psychological factors that might contribute to this response. We hence investigated patients undergoing a standardized surgical intervention (open nephrectomy). Patients and methods: Between May 2014 and April 2015, we conducted a prospective observational cohort study. The following psychological tests were administered preoperatively: Mini-Mental State Examination, Amsterdam Preoperative Anxiety and Information Scale (APAIS), Hamilton Anxiety Rating Scale, Hamilton Depression Rating Scale, and Pain Catastrophizing Scale. The primary outcome, postoperative pain intensity (11-point numerical rating scale, [NRS]), was assessed in the “immediate early” (first 8 hours), “early” (12 and 24 hours), and “late early” periods (48 and 72 hours).Results: A total of 196 patients were assessed, and 150 were finally included in the study. NRS scores improved from 4.9 (95% confidence interval [CI]: 4.7–5.1) in the “immediate early” to 3.1 (95% CI: 2.9–3.3) in the “early” and 2.3 (95% CI: 2.1–2.5) in the “late early” postoperative period. Most (87%) patients received intravenous opioids, while 13% received analgesics epidurally. Repeated measures analysis of variance indicated better pain management with epidural analgesia in the first two postoperative periods (F=15.01, p

Nutritional support of surgical patients is a necessary part of the treatment. It alone cannot cure the disease but it significantly affects the recovery of patients and supports surgical interventions. Patients in malnutrition have shown to have significantly more postoperative infectious and non-infectious complications. This significantly prolongs treatment time and increases costs. However, there is one fact that cannot be expressed in money, which is the patient's impression of the surgical intervention. Adequate preoperative patient support, based on the intake of liquid nutritive solutions, reduces preoperative stress and deflects the metabolic response. Now, it is recommended for adults and children older than one year to drink clear liquid up to 2 hours before induction in anesthesia. Appropriate enteral nutrition has a significant place in the postoperative recovery of patients. Enteral nutrition is reducing complications, mainly infectious complications because the function of the digestive system as one large immune system is preserved. Perioperative enteral nutrition is a necessary part of the modern treatment of surgical patients. In addition to the significant effect on the occurrence of postoperative complications, it is also important that this type of diet improves the psychological status of patients.

Minimal Sedation (Anxiolysis) is a drug-induced state during which patients respond normally to verbal commands. Although cognitive function and physical coordination may be impaired, airway reflexes, and ventilatory and cardiovascular functions are unaffected. Moderate Sedation/Analgesia ('Conscious Sedation') is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. Dexmedetomidine is a new generation highly selective α2-adrenergic receptor (α2-AR) agonist that is associated with sedative and analgesic sparing effects, reduced delirium and agitation, perioperative sympatholysis, cardiovascular stabilizing effects, and preservation of respiratory function.

Background. The transurethral resection of the prostate (TURP) syndrome is reported after ureteroscopic procedures with irrigating solutions. TURP syndrome may occur quickly or up to 24 hours postoperatively. TURP syndrome affects many systems and manifests itself mainly through acute changes in intravascular volume and plasma solute concentrations. Case report. We reported a 72- year-old patient with benign prostatic hyperplasia, diabetes mellitus and angina pectoris who underwent TURP under spinal anesthesia. Unusual marked somnolence, bradycardia (38 beats/min), disorientation and face edema indicated a diagnosis of TURP syndrome only 15 minutes after the operation had started. The diagnosis confirmed by arterial gas analyses (metabolic acidosis, pH was 7.29) and hyponatremia (96 mmol/l). Aggressive and adequate therapy with diuretic and bicarbonates decreased symptoms and saved patient's life. Conclusion. Very fast development of TURP syndrome is possible. Continuous patient monitoring is necessary to provide fast recognition of TURP syndrome. Adequate therapy can prevent considerable complications.

Background. Ovarian tumors of low malignant potential (LMP) are also known as atypically proliferating tumors. Ovarian tumors of LPM account for approximately 15% of all epithelial ovarian cancers. Mean age of occurrence is 40 years and they are 15-20 cm in diameter. Case report. A 32-year-old female patient was hospitalized as an urgent case with a large tumor mass that filled the entire abdomen. Cyst was 100 × 70 cm dimensions belonging to the right ovary and filled with 18 liters of content. Right adnexectomy, resection of the second ovary, as well as biopsy of the omentum were performed. Lymphadenectomy of the right iliac and obturator area was also performed. After receiving definitive histopathological results it was decided to perform a radical reoperation. On the 10th postoperative day relaparotomy, total hysterectomy and left adnexectomy were performed. The patient was released on the 6th postoperative day. She used to come to regular examinations up to date. Conclusion. This case is a proof that LMP tumors have low malignant potential, they grow slowly and can reach great proportions.

Percutaneous nephrolithotomy (PCNL) is frequently used as the first-line treatment of large and complex stones. The key point for successful complex stone removal with minimal risk of complications is to establish the most appropriate access route. Understanding the three-dimensional (3D) relationship of kidney stones and renal collecting systems is crucial for planning and creating an optimal access route. By using a 3D volume segmentation tool a more accurate approach to the renal collecting system and stone treatment could be planned. The objective of this study was assessing the impact of 3D software in getting the desired access., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Durutović, Filipović, Milićević, Somani, Emiliani, Skolarikos and Janković.)

Objective: The aim of this study was to estimate interobserver reproducibility of Tc-99m mercaptoacetyltriglycine renography in children and adults by assessing the parameters of the International Atomic Energy Agency (IAEA) software for the analysis of dynamic renal studies., Methods: The renograms of 65 children and 65 adults covered a wide age range, different quality of drainage, overall function and differential renal function (DRF). Three observers were processing parameters of the IAEA software. Normalized residual activity at 20 min (NORA20), NORA on the postmicturition acquisition (NORApm), PM to maximum renal count ratio (PM/max), output efficiency at 20 min (OE20), OE 20 min after diuretic stimulation (OEF + 20), whole kidney mean transit time (MTT) and DRF by integral and Rutland-Patlak were calculated by observers., Results: The overall agreement between three observers was almost perfect [the average intraclass correlation coefficient (ICC) above 0.99] in children and adults, with no significant difference between the parameters of renal drainage, transit and DRF. ICCs for all parameters were higher than 0.980 in children under 12 months, even slightly greater for PM/max and OEF+20. In children with poor/incomplete drainage and DRF below 40%, ICCs were above 0.98. In the subgroup of adults with impaired overall tubular extraction rate, level of reproducibility was almost perfect. Slightly lower but still insignificant values of ICC were presented in adults with poor/incomplete drainage., Conclusion: Our results indicate an excellent interobserver reproducibility for all quantitative parameters of IAEA software in both pediatric and adult patients.

Purpose: Optimal analgesia in ambulatory urology patients still remains a challenge. The aim of this study was to examine if the pre-emptive use of intravenous tramadol can reduce pain after ureteroscopic lithotripsy in patients diagnosed with unilateral ureteral stones., Materials and Methods: This prospective pilot cohort study included 74 patients diagnosed with unilateral ureteral stones who underwent ureteroscopic lithotripsy under general anesthesia in the Urology Clinic at the Clinical Center of Serbia from March to June 2012. All patients were randomly allocated to two groups: one group (38 patients) received intravenous infusion of tramadol 100 mg in 500 mL 0.9%NaCl one hour before the procedure, while the other group (36 patients) received 500 mL 0.9%NaCl at the same time. Visual analogue scale (VAS) scores were recorded once prior to surgery and two times after the surgery (1 h and 6 h, respectively). The patients were prescribed additional postoperative analgesia (diclofenac 75 mg i.m.) when required. Pre-emptive effects of tramadol were assessed measuring pain scores, VAS1 and VAS2, intraoperative fentanyl consumption, and postoperative analgesic requirement., Results: The average VAS1 score in the tramadol group was significantly lower than that in the non-tramadol group. The difference in average VAS2 score values between the two groups was not statistically significant; however, there were more patients who experienced severe pain in the non-tramadol group (p<0.01). The number of patients that required postoperative analgesia was not statistically different between the groups., Conclusion: Pre-emptive tramadol did reduce early postoperative pain. The patients who received pre-emptive tramadol were less likely to experience severe post-operative pain.

Background: PCNL is safe procedure which is well tolerated, but as with any other surgical procedure, it is associated with a specific set of complications. There is a marked heterogeneity in reporting complication rates in literature, and this problem was highlighted in Ad Hoc EAU guidelines panel who recommended urgent creation of uniform and reproducible quality system. Modified Dindo-Clavien grading system today is the most utilized classification for complications in urology, and standard in reporting complications for PCNL., Aim(s): To analyze the complication rate for PCNL using the modified Dindo-Clavien grading system in our patients and literature review., Methods: In our institution, with few breaks, PCNL was performed since mid 2010. Complication rate in 63 patients was analyzed retrospectively. Modified Dindo-Clavien grading system that is validated for PCNL has been accepted for classification of complication for PCNL, and literature review was performed. We have summarized the most significant factors which may affect the complication rate during and after PCNL., Results: Overall complication rate was 30% in our study population. The most common complications observed were: postoperative fever Grade 1-2 (9.52%) and bleeding Grade l (7.9%), Grade 2 (3.17%), Grade 3a (4.76%) and Grade 3b (1.58%). Nephrostomy tube leakage was not found in our sample, mostly due to specific postoperative utilizing of auxiliary procedures., Conclusion: Reporting of complication for PCNL should be uniform, and modified Dindo-Clavien grading system that is validated for PCNL should be accepted to be a standard in urology. Surgeons training and experience are the most important to ensure the efficacy of procedure, therefore we suggest that learning of percutaneous renal access should be mandatory in residents trainee program.

If patients with renal diseases had to undergo surgical intervention, they should be prepared in such a way to be in a stable phase of the underlying surgical disease, without any infection, euvolemic, with satisfactory blood pressure and corrected electrolyte balance. These patients need to be hydrated well before intervention, the fall of blood pressure during intervention should be avoided and adequate hydration after the intervention must be continued (taking into account the condition of the kidneys, heart and age of patient). It is assumed that nephrotoxic drugs are to be evaded in renal patients or, if they were necessary, the dosage and dosing interval should be adjusted and prolonged, respectively. The use of radiographic contrast is not advisable, but if required, plentiful hydration will be needed, the least workable contrast dose and, if possible, with lower ionic charge and lower osmolarity will be administered. If surgical intervention was urgent and if there was not enough time for conservative therapy, i.e., correction of electrolytes, volemia, blood pressure and higher values of nitrate substances, a renal patient would be temporarily dialyzed in the immediate preoperative and postoperative course. Any surgical intervention in these patients may aggravate the renal function and bring the patient closer to dialysis treatment. Nevertheless, sometimes the benefit of surgical treatment for the acute surgical disease is higher (especially if it was life-threatening) than the risk of renal function exacerbation and coming closer to dialysis.

Patients with end stage renal failure (ESRF) present a number of challenges to the anesthesiologist. They may be chronically ill and debilitated and have the potential for multisystem organ dysfunction. Patients with primary renal disease are likely younger and have good cardiopulmonary reserve. Older patients with renal failure secondary to diabetes mellitus or hypertension may suffer the ravages of diffuse atherosclerosis and heart disease. To safely manage these patients we need to understand the benefits and limitations of dialysis, problems related with primary disease, pathophysiological effects of ESRF, and the altered pharmacology of commonly used anesthetic agents and perioperative medications in ESRF. Problems encountered by anesthesiologist in ESRF patients include hypertension, ischemic heart disease, congestive heart failure, anemia, metabolic acidosis, hyperkaliemia, hyponatremia and circulatory collapse. All surgical procedure in patients with ESRF carries significant risk of peri- and postoperative complications (mostly cardiovascular) and even fatal outcome.

Unlabelled: BACKGROUND; Ovarian tumors of low malignant potential (LMP) are also known as atypically proliferating tumors. Ovarian tumors of LPM account for approximately 15% of all epithelial ovarian cancers. Mean age of occurrence is 40 years and they are 15-20 cm in diameter., Case Report: A 32-year-old female patient was hospitalized as an urgent case with a large tumor mass that filled the entire abdomen. Cyst was 100 x 70 cm dimensions belonging to the right ovary and filled with 18 liters of content. Right adnexectomy, resection of the second ovary, as well as biopsy of the omentum were performed. Lymphadenectomy of the right iliac and obturator area was also performed. After receiving definitive histopathological results it was decided to perform a radical reoperation. On the 10th postoperative day relaparotomy, total hysterectomy and left adnexectomy were performed. The patient was released on the 6th postoperative day. She used to come to regular examinations up to date., Conclusion: This case is a proof that LMP tumors have low malignant potential, they grow slowly and can reach great proportions.

Background: The transurethral resection of the prostate (TURP) syndrome is reported after ureteroscopic procedures with irrigating solutions. TURP syndrome may occur quickly or up to 24 hours postoperatively. TURP syndrome affects many systems and manifests itself mainly through acute changes in intravascular volume and plasma solute concentrations., Case Report: We reported a 72-year-old patient with benign prostatic hyperplasia, diabetes mellitus and angina pectoris who underwent TURP under spinal anesthesia. Unusual marked somnolence, bradycardia (38 beats/min), disorientation and face edema indicated a diagnosis of TURP syndrome only 15 minutes after the operation had started. The diagnosis confirmed by arterial gas analyses (metabolic acidosis, pH was 7.29) and hyponatremia (96 mmol/l). Agressive and adequate therapy with diuretic and bicarbonates decreased symptoms and saved patient's life., Conclusion: Very fast development of TURP syndrome is possible. Continuous patient monitoring is necessary to provide fast recognition of TURP syndrome. Adequate therapy can prevent considerable complications.

The type of urinary derivation after radical cystectomy due to urinary bladder carcinoma does not influence survival substantially, but it may influence the quality of life of the patients very much. One of modifications of classical ureterosigmoidostomy that has been focused by urologist in recent years in the sigma rectum pouch (Mainy pouch II), for its substantially improved aspects of quality of life and earlier occupational rehabilitation of these patients. In the period August 1994 through March 1998 we made Meinz pouch II (the modification implies fixation of the pouch to the parietal peritoneum and implantation of the ureter into the pouch as suggested by Camey-Le-Duc). This surgical technique is associated with lots of advantages as the continent form of urinary derivation, and as a fairly simple surgical technique it is an improvement in this type of surgery. Intactness of the abdominal wall (no urostoma), frequency of defecation/urination in 3-4 hr intervals during the day and 4-5 hours during the night, absolutely volitonal control of these functions, rapid postoperative recovery with stabilization of renal function parameters, low percentage of ascending infections, higher degree of occupational rehabilitation, i.e. lower incidence of disability and good psychosocial status are all advantages of this method in the light of the quality of life of these otherwise very difficult patients.

Penile carcinoma is a rare disease with the annual incidence of 1-2 cases per 100,000 men. About 95% of all penile malignancies are squamous cell carcinoma. At the Clinic of Urology in the period 1988-1998 we treated 58 patients with penile carcinoma. Nine of these (15.5%) were subjected to total penectomy due to the extent of the lesion, while partial amputation of the penis was performed in 84.5% (49 cases). The aim of the therapy was to completely remove the primary lesion with adequate margins. Postoperative follow-up comprised, among other things, evaluation of the quality of life as reflected in pain, sexuality and emotional distress. Quality of life of patients subjected to partial penectomy where no cases of relapse were recorded, was satisfactory, while in cases of total penectomy about 24% (14 patients) suffered marked emotional distress induced by the loss of the mark of male sexuality and sexual impotence. In the light of the prominent problems related to the quality of life induced by severe psychological influence of penis amputation, local excision, Mohs's operation and laser therapy are increasingly used in the treatment of penile carcinoma.