Z Krstić

University Children's Hospital, Belgrade, Serbia, Beograd, Central Serbia, Serbia

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Publications (39)29.75 Total impact

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    ABSTRACT: To review our experience with severe penile trauma, mechanism of injury, and their treatment modalities in 16 children younger than 18 years. Management of penile trauma poses diverse challenges to the reconstructive urologist, as injuries vary from abrasions to total emasculation. Analysis of 16 patients with severe penile injuries referred to us between 2002 and 2011 was undertaken. The median age at surgery was 13 years (range, 5-17). Etiology of penile trauma and choice of treatment were evaluated. The management included a wide variety of surgical techniques that were tailored to the individual patient. Results were analyzed to define etiology, that is, mechanism of penile injury and to estimate modalities of surgical management and postoperative outcomes. Also, postoperative questionnaire was used, which included questions on functioning and esthetical appearance of participating patients and overall satisfaction. The causes of penile injury in these series were traffic accidents (2), iatrogenic trauma (5), self-amputation (1), electrocution (1), burns (3), dog bite (2), zipper injury (1), and mother's hair strangulation (1). The mean follow-up was 46 months (range, 14-122), and examinations were uneventful, except for 2 fistulae formation after neophallic urethral reconstruction. The main goal of reconstructive surgery is to have a penis with normal appearance and functions. Severe penile injuries should be treated on a case-by-case basis using the most propitious techniques.
    Urology 11/2013; · 2.42 Impact Factor
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    ABSTRACT: PURPOSE: To establish the importance of shunt surgery combined with partial resection of the spleen for selected pediatric patients with extra-hepatic portal vein obstruction (EHPVO), enormous splenomegaly and severe hypersplenism. Severe hypersplenism is often refractory to treatment with endoscopic sclerotherapy or band ligation and shunt surgery; however, to our knowledge, this is the first such study to be published. METHODS: Distal splenorenal shunt with partial resection of the spleen was performed in 16 of 60 children treated for EHPVO in the Gastroenterology Department of our hospital. Upper gastrointestinal endoscopy had shown esophageal varices of varying grade in all patients and band ligation or endoscopic sclerotherapy had been done for children with a history of bleeding. The indications for surgery were pain and discomfort caused by a large spleen (5-15 cm below the costal margin) and symptomatic hypersplenism with leucopenia, thrombocytopenia, and anemia. Partial resection of the spleen was performed, starting with ligation of the branches and tributaries of the caudal two-thirds. When an ischemic line demarcated the splenic parenchyma, it was transected using electrocautery or LigaSure, leaving 20-30 % of splenic tissue. After the spleen resection, a Warren shunt was performed. Platelet and white blood cell counts and liver function tests were performed before and after the operation. Growth was assessed using SD scores (z scores) for height, weight, and body mass index at the time of surgery and 1 year later. RESULTS: Postoperative recovery was uneventful and the leukocyte and platelet counts normalized. The shunt patency rate was 100 %. Two cases of shunt stenosis were treated successfully with percutaneous angioplasty. There was no postoperative mortality. During the follow-up period, from 1 to 7 years, all 16 children were asymptomatic, with improved quality of life, growth, and nutrition. No episodes of variceal bleeding, sepsis or encephalopathy occurred. CONCLUSION: Our results demonstrate that shunt surgery with partial resection of the spleen is effective and safe for pediatric patients with massive splenomegaly and severe hypersplenism secondary to EHPVO.
    Surgery Today 02/2013; · 0.96 Impact Factor
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    ABSTRACT: Intrapericardial teratomas are extremely rare and most often benign tumours. In this paper, we have described a case of intrapericardial teratoma diagnosed prenatally and successfully operated. The presented case is noteworthy as an example of potentially catastrophic cardiorespiratory distress caused by the space-occupying nature of the tumour. A multi-disciplinary approach is mandatory because the tumour most often arises from the ascending aorta and in some cases may require the use of cardiopulmonary bypass.
    Cardiology in the Young 02/2013; · 0.95 Impact Factor
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    ABSTRACT: PURPOSE: We evaluated the results of one-stage and multi-stage penile reconstruction in adults with complications following multiple failed epispadias repairs. MATERIALS AND METHODS: From February 2006 to June 2011, a total of 23 adults underwent penile disassembly for redo epispadias repair. The median age of surgery was 27 (range 17-41). Surgical treatment included penile disassembly with complete straightening and lengthening of the penis, followed by urethral reconstruction. Corpora cavernosa was completely separated from the glans cap with neurovascular bundles as well from urethra. Urethra was short in all cases and divided at the glans level. Penile straightening and lengthening was achieved by tunica albuginea incision and grafting. Reconstruction of urethra was performed three to six months later, using combined buccal mucosa graft and genital skin flaps. Success was defined by achieving a functional penis without urethral fistula or stricture, or residual chordee, and an aesthetically acceptable penile appearance. RESULTS: Follow-up ranged from 14 to 78 months (mean 33 months). Nineteen patients have completely straightened and lengthened penis. Improved length of the erect penis ranged from 2.7 to 6.6 cm. Four patients developed mild curvature without requirement for additional correction. Urethral fistula occurred in three cases and repaired six months after urethroplasty in two patients, while in one was spontaneously closed. All 21 sexually active patients reported good erectile function. CONCLUSIONS: Adults with complications following childhood epispadias repair are still a difficult population to treat. Radical surgical approach must be used to achieve successful outcome.
    The Journal of urology 01/2013; · 3.75 Impact Factor
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    ABSTRACT: To investigate the possibility of fast-track surgery concepts in pediatric urology department as a single center study model of a developing country. The study included 1620 patients surgically treated at the pediatric urology department, from 2009 to 2011. According to the congenital anomalies, all patients were classified in one of four groups: I - testicular anomalies (197 patients); II - external genital anomalies (453); III - upper urinary tract anomalies (801) and IV - associated anomalies (169). We analyzed the total duration of stay in the hospital of all patients among all treating doctors concerning the anomaly. Statistically significant difference in total length of hospitalization of all patients in Group I was noted in Doctors 1 and 5 (F=10.36** for F0.05;5;12=3.11 and F0.01;5;12=5.06), as well as in the Group II (F=17.01** for F0.05;5;12=3.11 and F0.01;5;12=5.06). Statistical analysis was not possible to be performed in groups III and IV because of lack of the patients. Analyzing the length of hospitalization of the patients treated at the urology department, all doctors showed the tendency to shorten the total length of hospitalization in patients of all groups. Majority of the studies carried out on pediatric urology departments in developed countries, showed that over 50% of children were successfully treated using fast-track surgery concept. Modern methods of surgical management and anesthesia allow decrease of hospitalization length, financial savings to the healthcare system and better comfort for patients. KEY WORDS: Children, Fast-track surgery, Hospitalization, Urogenital anomalies.
    Annali italiani di chirurgia 01/2013; 84(1):61-6. · 0.29 Impact Factor
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    ABSTRACT: Introduction Redo surgery in failed epispadias presents a great challenge. Our aim was to present a radical approach for correction of penile deformities as well as urethral reconstruction in patients after failed epispadias repair.Materials and Methods Between January 2006 and January 2011, 13 patients, aged 13 to 22 years, underwent redo surgery due to failed epispadias repair in childhood. All patients presented with severe dorsal curvature and short urethra. First stage included penile disassembly technique with complete separation of corporal bodies, urethral dissection, and transposition and subtotal glans mobilization. Residual dorsal curvature was corrected by tunical incision and grafting of the defect. Short urethra was dissected and transposed ventrally with opening at the base of the penis. Penile entities were reassembled in normal anatomical relationship. Penile body was covered using available vascularized skin flaps. After 6 months, second stage was performed and included reconstruction of the penile urethra using buccal mucosa graft and scrotal hairless skin flap.Results Follow-up ranged from 12 to 60 months (mean 33 months). Acceptable outcome is achieved in all the patients. Complete penile lengthening and straightening is obtained in 10 out of 13 patients. Mild curvature is noted in three patients without consequences. Satisfactory sexual activity was reported from nine patients. One patient developed fistula that was closed after 4 months, whereas all other patients reported normal voiding with no difficulties.Conclusions Redo surgery of failed epispadias is very demanding procedure. Radical approach in these cases is necessary for complete repair of all penile deformities with satisfactory postoperative outcome.
    European Journal of Pediatric Surgery 11/2012; · 0.84 Impact Factor
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    ABSTRACT: Urogenital congenital anomalies are among the most common congenital anomalies and very frequent pathology in paediatric urology. Health care systems strive to shorten the duration and reduce the costs of hospitalization, while maintaining treatment effectiveness. To evaluate the duration of hospital stay of surgically treated patients with congenital urogenital anomalies and estimate the possibility of using fast track surgery principles in paediatric urology in the local settings of a developing country. Retrospective non-randomized study included 552 patients who had been surgically treated at the Urology Department of the University Children's Hospital, during 2010. In line with their congenital anomalies, all patients were classified in one of four groups: I--upper urinary tract anomalies (252 patients); II--genital anomalies (164 patients); III--testicular anomalies (76 patients) and IV--associated anomalies (60 patients). We analyzed the total duration of stay as well as pre- and post-operative stay in the hospital. The average duration of hospitalization was 4.7 +/- 4.0 days. Patients with testicular anomalies stayed for the shortest period (2.3 +/- 1.9 days) (p < 0.01) and patients with associated anomalies stayed in the hospital the longest (6.5 +/- 4.7 days) (p < 0.01). Modern methods of surgical treatment allow reduction of hospitalization, financial savings to the healthcare system and greater comfort for patients. Our results showed that this is also possible to apply in our environment.
    Srpski arhiv za celokupno lekarstvo 01/2012; 140(5-6):326-31. · 0.23 Impact Factor
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    ABSTRACT: Hypospadias represents the most frequent penile anomaly. The most challenging part of hypospadias surgery is urethral reconstruction. Many various tissues are used (local skin flaps, bladder mucosa grafts, buccal mucosa grafts etc.) for the reconstruction of the neourethra. Our aim was to evaluate advantages and disadvantages of combined buccal mucosa graft and penile skin flap in urethral reconstruction in severe hypospadias repair. Between December 2005 and August 2009, 48 patients with severe hypospadias, aged from nine months to 12 years (mean age 23 months) underwent surgery. Thirty-four (71%) had penoscrotal and 14 (29%) scrotal hypospadias. Ventral penile curvature was present in all cases, and was corrected by incision of the short urethral plate. Urethroplasty was performed a buccal mucosa graft combined with dorsal penile skin flap. Mean follow-up was 22 months (range from 9 months to 3 years). Satisfactory functional and aesthetic results were achieved in 40 (83%) patients. Fistula was noted in six cases and was solved by minor revision. Urethral stenosis in two cases was resolved by simple dilatation. Urethral reconstruction using the buccal mucosa graft and dorsal penile skin flap in severe hypospadias repair could be the method of choice. Using this technique, single stage urethral reconstruction is possible with satisfactory esthetical and functional results.
    Srpski arhiv za celokupno lekarstvo 01/2011; 139(9-10):631-7. · 0.23 Impact Factor
  • Journal of Pediatric Urology 04/2010; 6. · 1.37 Impact Factor
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    ABSTRACT: Infantile choledochal cyst (CC) usually presents as jaundice, vomiting, acholic stools, and hepatomegaly, and it can resemble biliary atresia. Although bleeding tendency is a rare clinical presentation of CC, it can be the first symptom, especially in infants less than 12 months of age. We report a case of a two-month-old infant with choledochal cyst presenting as late vitamin K deficiency bleeding (VKDB). Early recognition of diseases predisposing to VKDB and immediate investigation and treatment of warning bleeds help to prevent the worst consequences. Late VKDB is often the presenting feature of a serious underlying disease that may be recognized early. The sudden onset of bleeding tendency in infants with congenital liver or biliary tract disease may suggest not only biliary atresia but also, although extremely rare, CC. Early vitamin K administration leads to rapid normalization of hemostatic parameters, which enables major liver surgery.
    The Turkish journal of pediatrics 01/2010; 52(6):652-4. · 0.56 Impact Factor
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    ABSTRACT: Congenital anomalies of the kidney and urinary tract (CAKUT) are common causes of chronic renal failure in children. The angiotensin II receptor type 2 (AT2R) is one of proposed candidate genes for CAKUT, but the expression was never explored in humans. The aim was to establish the AT2R gene expression in human CAKUT concerning -1332A/G polymorphism, which might affect alternative splicing. Forty-eight patients with CAKUT constitute the basis of this study. Genotyping for -1332A/G, RT-PCR for AT2R gene expression and confirmation sequencing were performed. The expression of Ex 1/2/3 and Ex 1/3 transcript splice variants of the AT2R mRNA were detected in human CAKUT tissue. The pattern was observed independently of A to G transition. The expression of AT2R mRNA in human CAKUT was established for the first time and was not affected by -1332A/G polymorphism in children with CAKUT.
    Clinical biochemistry 09/2009; 43(1-2):71-5. · 2.02 Impact Factor
  • Pediatric Anesthesia 03/2009; 19(2):177-9. · 2.44 Impact Factor
  • European Urology Supplements - EUR UROL SUPPL. 01/2009; 8(8):649-650.
  • European Urology Supplements - EUR UROL SUPPL. 01/2009; 8(8):650-650.
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    ABSTRACT: Urethral reconstruction in severe hypospadias presents a great challenge. We have designed a method of combining a longitudinal dorsal island skin flap and buccal mucosa graft to create a neourethra in most severe hypospadias. Between January 2003 and March 2007, 17 patients (aged from 9 to 23 months) underwent severe hypospadias repair (13 penoscrotal and 4 scrotal hypospadias). Short urethral plate was divided in all cases and remaining curvature repaired by dorsal plication. We harvested and fixed a buccal mucosa graft to the ventral side of corpora cavernosa to be the first half of a neourethra. A longitudinal dorsal island skin flap was created and buttonholed ventrally. We sutured it together with the buccal mucosa graft to form the neourethra. We fixed the abundant flap pedicle laterally to cover all suture lines of the neourethra. We performed penile skin reconstruction using available penile skin. The mean (range) follow-up was 25 (7 to 58) months. We achieved satisfactory, functional, and aesthetic results in 14 patients. In 3 cases urethral fistula (2) and distal stricture (1) required secondary treatment. Combined longitudinal island skin flap and buccal mucosa graft could be a good choice for urethral reconstruction in most severe hypospadias repairs.
    Urology 06/2008; 71(5):821-5. · 2.42 Impact Factor
  • Proceedings of the 16th European Congress of Physical and Rehabilitation Medicine; 06/2008
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    ABSTRACT: Gastroesophageal reflux disease (GERD) is the most common esophageal disorder and the most frequent reason why infants are referred to the pediatric gastroenterologist, affecting as much as 30% of the pediatric population. Presenting features of GERD in infants and children are quite variable and follow patterns of gastrointestinal and extra-esophageal manifestations that vary between individual patients and may change according to age. Patients may be minimally symptomatic, or may exhibit severe esophagitis, bleeding, nutritional failure, or severe respiratory problems. GERD is also complex for the diagnostic techniques required to assess its repercussions or explain its origin. Although different abnormalities in motility variables, such as lower eso-phageal sphincter (LES) function, esophageal peristalsis and gastric motor activity can contribute to the development of GERD, the degree of esophageal acid exposure represents the key factor in its pathogenesis. Esophageal pH monitoring, based on both the detection of acid reflux episodes and the measurement of their frequency and duration, has been regarded as the most sensitive and specific diagnostic tool for diagnosing reflux disease. The aim of this paper is to give a concise review for the clinicians encountering this specific disease in infants and children.
    Acta chirurgica iugoslavica 02/2008; 55(1):47-53.
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    ABSTRACT: Lymphangiomas are congenital malformations of the lymphatic system. We report a 10-year-old boy with lymphatic malformation of the scrotum, which presented as a multiloculated scrotal mass associated with edema of the left thigh and left cryptorchidism. Histopathologic examination showed scrotal lymphangioma cavernosum. Ultrasonography was of major importance for the preoperative diagnosis and to determine the extent of the scrotal lesion. Scrotal lymphangiomas are very rare. It is important to consider them in boys with a cystic scrotal mass in order to avoid misdiagnosis, improper treatment and recurrences.
    Pediatric Dermatology 11/2007; 24(6):654-6. · 1.04 Impact Factor
  • Haemophilia 08/2007; 13(4):447-9. · 3.17 Impact Factor
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    ABSTRACT: Renal artery stenosis (RAS) is one of the most common causes of severe arterial hypertension in infants. Its management is very difficult, especially when present in a single kidney. We report a case of severe hypertension caused by RAS of congenital single pelvic kidney in a 4-month-old boy. The patient presented with cardiorespiratory insufficiency that was first treated as acute fulminate myocarditis. Medical treatment of arterial hypertension was disappointing, as it had to be balanced between congestive cardiac failure and acute renal failure. Percutaneous transluminal angioplasty (PTA) done by coronary balloon dilatation catheters through the left axillary access was successful. Following dilatation of the renal artery, blood pressure decreased and its good control was possible by only one drug. With improved medical blood pressure control and normal growth development, the reassessment of clinical therapy options adjusted to a larger vessel size would be possible. Renovascular hypertension due to RAS in infants with a solitary kidney is difficult to control by medical treatment alone. PTA should be considered as a viable option in infants with refractory hypertension due to renal artery stenosis in a solitary kidney, since it has the potential of improving hypertension while preserving renal function.
    Pediatric Nephrology 04/2006; 21(3):437-40. · 2.94 Impact Factor