A 12-year experience in the surgical management of vesicovaginal fistulae.

INTRODUCTION: Vesicovaginal fistulae are largely iatrogenic and represent therapeutic dilemmas in surgical approach and timing of repairs. AIM: We have reviewed our surgical management of vesicovaginal fistulae over a 12-year period to determine whether the outcome is dependent on surgical approach and timing of repair. PATIENTS AND METHODS: From January 1990 to September 2001, 23 patients were referred to our department of whom 20 have retrievable records. Fourteen of these 20 patients had gynaecological operations as the primary cause for their fistulas whilst the remaining six had varied causes ranging from forceps delivery to recurrent pelvic malignancies. RESULTS: Of 20 patients, four underwent transvaginal repair, seven transvesical repair, eight supravesical repair and one required an ileal conduit diversion. There was an 85% success after first repair with only three fistula recurrences, two of whom underwent a successful second repair and one was treated conservatively and successfully with urethral catheterisation. There were no further recurrences at mean follow-up of 23 months for our cohort. Earlier repair seemed to be associated with a higher recurrence rate (33% of six patients within six weeks) compared with delayed operations (7% of remaining 14 operated after six weeks). CONCLUSION: Vesicovaginal fistulae can be successfully managed surgically. Although the type of approach did not affect outcome, the timing of the repair may affect the success of the operation.

Ureteroscopy as an out-patient procedure: the Singapore General Hospital Urology Centre experience.

OBJECTIVE: To study the safety and efficacy of ureteroscopy as an out-patient procedure. DESIGN: Retrospective study. SETTING: Teaching hospital, Singapore. SUBJECTS AND METHODS: Operating facilities for out-patient ureteroscopy were introduced in late 1998. A retrospective review of all patients undergoing ureteroscopy from March 1999 to December 2000 was conducted. Clinical records were reviewed for operating time, surgical outcome and complications, and length of hospital stay and re-admissions. RESULTS: Two hundred and ten patients underwent ureteroscopy for a variety of indications--115 patients were admitted to hospital as in-patients and 95 patients were treated as out-patients. Ureteroscopy and laser lithotripsy were performed using general or regional anaesthesia. Patients assessed to be American Society of Anesthesiology class I or II were eligible for an out-patient procedure. American Society of Anesthesiology class was found to be lower for those treated as out-patients compared with those undergoing in-patient procedures--63% versus 28% for class I and 36% versus 69% for class II. Mean operating time was 37 minutes for out-patient procedures and 57 minutes for in-patient procedures (P<0.01). Complications were low for out-patients, with six unplanned re-admissions, mostly for minor complications. All patients were discharged the following day. CONCLUSION: Ureteroscopy can be offered selectively as an out-patient procedure to patients with low surgical risk, especially American Society of Anesthesiology class I patients, and others expected to have an uncomplicated surgical procedure.

Clinical experience and results of ESWL treatment for 3,093 urinary calculi with the Storz Modulith SL 20 lithotripter at the Singapore general hospital.

We study the outcome of 2,700 patients treated for 3,093 urinary calculi over a period of 60 months. All patients underwent Extracorporeal Shock Wave Lithotripsy (ESWL) treatment using the Storz Modulith SL20, predominantly on an outpatient basis (99.9% using intravenous pethidine for analgesia). The treatment outcome of 1,666 renal calculi and 1,427 ureteric calculi were analysed and stratified according to size and site. Follow-up status at 3 months was available for 91.8% of patients. For renal calculi, the overall success rate was 81% (re-treatment rate 29.7%). The majority of failures were stones larger than 2 cm and those situated in the lower pole of the renal calyces. The overall success rate for ureteric calculi is 85% with similar clearance rates throughout the ureter (re-treatment rate 22.8%). Failures were predominantly with stones larger than 2 cm. For the entire series, the morbidity rate requiring hospital admission was 2.9%, there was no mortality. The commonest cause for admission was for pain control (1.8%). To our knowledge, our experience with this lithotriptor is the largest to date. We have demonstrated that ESWL with Storz Modulith SL20 is safe, well tolerated and highly effective for the treatment of urolithiasis.

Outcome of percutaneous nephrostomy for the management of pyonephrosis.

OBJECTIVE: The aim of this study was to evaluate the efficacy of percutaneous nephrostomy (PCN) drainage for the interim management of pyonephrosis. METHODS: Ninety-two consecutive patients [29 men, 63 women; mean age, 57 years; range, 23 to 88] who underwent PCN for the treatment of pyonephrosis from 1996 to 1999 were evaluated retrospectively. The clinical presentation, bacteriology and patient outcomes were analyzed. RESULTS: The majority [77%] of patients had underlying obstructing urinary calculi. Other causes of obstruction included strictures [9%], papillary necrosis [7%], pelvi-ureteric junction obstruction [4%] and malignant stricture [3%]. The microorganisms cultured were Escherichia coli [30%], Klebsiella [19%], Proteus [8%], Pseudomonas [5%], Enterococcus [5%], and Candida spp [5%]. The microorganisms were sensitive to gentamicin [79%], ceftriaxone [71%], cephalexin [54%], nitrofurantoin [40%], cotrimoxazole [35%], nalidixic acid [32%] and ampicillin [29%]. Only 30% of bladder urine cultures were positive for microorganisms; the addition of PCN cultures improved this yield to 58%. The antibiotic regimen was revised according to the PCN culture whenever there was a discrepancy. After PCN, 69% of patients underwent minimally invasive procedures as definitive treatment of the obstructing lesion. Only 14% of patients required open surgery. There was low procedure-related morbidity [14%] and low overall mortality [2%]. CONCLUSIONS: PCN cultures yield important bacteriological information. The procedure is associated with minimal morbidity, facilitates definitive treatment and provides therapeutic benefit.

Percutaneous nephrolithotomy in the management of complex upper urinary tract calculi: the Singapore General Hospital experience.

INTRODUCTION AND OBJECTIVES: Presently, percutaneous nephrolithotomy (PCNL) is a well-established and effective method of treating upper urinary tract stones at our institution. The aim of this paper was to evaluate a single surgeon's four-year experience of PCNL in the Singapore General Hospital. MATERIALS AND METHODS: Between January 1996 and December 2000, 300 PCNLs were performed on 280 renal units. The mean age was 53.7 years. PCNL was performed on 57 complete staghorn calculi (20.4%), 83 partial staghorn calculi (29.6%), 66 large pelvic calculi (23.6%), 60 impacted uretero-pelvic junction (UPJ) and upper ureteric stones (21.4%) that failed extracorporeal shock wave lithotripsy (ESWL) and 14 symptomatic lower pole calculi (5%). RESULTS: The stone-free rate on discharge was 88.2% (n = 247). At 3 months and 1-year post PCNL, the stone-free rate was 91.1% (n = 255) and 95.7% (n = 268), respectively. The average postoperative stay was 4.5 days. Complications included 1 urosepsis post-PCNL (0.4%) and 2 arterio-venous fistulae (0.7%). Only 1 patient (0.4%) required blood transfusion. Thirty-four patients (12.1%) required ESWL and 4 needed ureteroscopy (1.3%). CONCLUSION: In experienced hands, the use of PCNL for upper urinary tract calculi is safe and effective.

Clinical safety profile of sildenafil in Singaporean men with erectile dysfunction: pre-marketing experience (ASSESS-I evaluation).

Safety and tolerability of sildenafil citrate was assessed in a population subset of 60 Singaporean men with erectile dysfunction taken from the Asian Sildenafil Efficacy and Safety Study (ASSESS-I), a double-blind, placebo-controlled, flexible-dose study. The men, from two centres, with > or = 6 months' history of erectile dysfunction, were randomized to two treatment arms for 12 weeks. One group (30 patients) received sildenafil (initial dose 50 mg taken 1 h before sexual activity for the first 2 weeks, increased to 100 mg or decreased to 25 mg, according to efficacy and/or tolerability). The remaining 30 patients received a matching placebo. Incidence and type of adverse effects were evaluated at 2, 4, 8 and 12 weeks. Nine patients (30.0%) on sildenafil (33.1% in the full ASSESS-I study) and one patient (3.3%) on placebo (22.8% in the full ASSESS-I study) experienced treatment-related adverse events, the most frequent being headache in the sildenafil group (reported by five patients [16.7%]; 11.0% in the full ASSESS-I study). Flushing, visual disturbance, dizziness, insomnia, myalgia and back pain each occurred in one patient in the sildenafil group (3.3%); in the placebo group, one patient (3.3%) had headache. Importantly, the incidence of cardiovascular and respiratory system adverse events were relatively less than in the full ASSESS-I population (cardiovascular 3.3% in the present study versus 10.2% in the full ASSESS-I population; respiratory 3.3% versus 5.5%). All adverse events were transient and mild, and did not lead to treatment withdrawal. There was no effect on sitting blood pressure, heart rate or standard laboratory parameters; more importantly, there was no incidence of myocardial infarction, stroke or priapism. These results should reassure Singaporean patients and their physicians of the safety of sildenafil for erectile dysfunction.