A Rare Case of Acute Urinary Bladder Diverticulitis Mimicking Acute Appendicitis.

BACKGROUND Urinary bladder diverticula are common. They are typically asymptomatic and usually discovered incidentally. Urinary bladder diverticulitis, in contrast to colonic diverticulitis, is an extremely rare occurrence. CASE REPORT We describe a case of a 52-year-old man who presented with isolated urinary bladder diverticulitis mimicking acute appendicitis. Focal inflammation of a urinary bladder diverticulum along the right lateral urinary bladder wall caused right iliac fossa pain. Predominant findings of red blood cells in the urine were not dissimilar to per rectal bleeding seen with colonic diverticulitis. Cystoscopy and uroflow dynamic study revealed features of chronic urinary bladder outlet obstruction despite a computed tomography scan showing a minimally enlarged prostate gland and the patient reporting no lower urinary tract symptoms. CONCLUSIONS Urinary bladder diverticulitis is a very rare condition with poorly understood underlying etiology. Hematuria is possibly an important presentation correlating with the per rectal bleeding seen with colonic diverticulitis. Depending on its position relative to the urinary bladder wall, it can mimic other more common presentations. Follow-up investigations using cystoscopy and uroflow studies are useful to evaluate for findings associated with chronic urinary bladder outlet obstruction.

Tailoring the mechanical and biodegradable properties of binary blends of biomedical thermoplastic elastomer.

Blending polymers with complementary properties capitalizes on the inherent advantages of both components, making it possible to tailor the behaviour of the resultant material. A polymer blend consisting of an elastomer and thermoplastic can help to improve the mechanical integrity of the system without compromising on its processibility. A series of blends of biodegradable Poly(L-lactide-co-ɛ-caprolactone) (PLC) and Poly-(l,l-lactide-co-glycolic acid) (PLLGA), and PLC with Poly-(d,l-lactide-co-glycolic acid) (PDLLGA) were evaluated as a potential material for a biodegradable vesicourethral connector device. Based on the Tg of the blends, PLC/PLLGA formed an immiscible mixture while PLC/PDLLGA resulted in a compatible blend. The results showed that with the blending of PLC, the failure mode of PLLGA and PDLLGA changed from brittle to ductile fracture, with an significant decreas in tensile modulus and strength. SEM images demonstrated the different blend morphologies of different compositions during degradation. Gel Permeation Chromatography (GPC) and mechanical characterization revealed the degradation behaviour of the blends in this order (fastest to slowest): PDLLGA and PLC/PDLLGA blends > PLLGA and PLC/PLLGA blends > PLC. The PLC/PLLGA (70:30) blend was recommended as a suitable for the vesicourethral connector device application, highlighting the tailoring of blends to achieve a desired mechanical performance.

Management of penile cancer in a Singapore tertiary hospital.

OBJECTIVES: To present our experience of managing penile squamous cell carcinoma (SCC) in a tertiary hospital in Singapore and to evaluate the prognostic value of the inflammatory markers neutrophil-lymphocyte ratio (NLR) and lymphocyte-monocyte ratio (LMR). PATIENTS AND METHODS: We reviewed our prospectively maintained Institutional Review Board-approved urological cancer database to identify men treated for penile SCC at our centre between January 2007 and December 2015. For all the patients identified, we collected epidemiological and clinical data. RESULTS: In all, 39 patients were identified who were treated for penile SCC in our centre. The median [interquartile range (IQR)] follow-up was 34 (16.5-66) months. Although very few (23%) of our patients with high-risk clinical node-negative underwent prophylactic inguinal lymph node dissection (ILND), they still had excellent 5-year recurrence-free survival (RFS; 90%) and cancer-specific survival (CSS; 90%). At multivariate analysis, higher N stage was significantly associated with worse RFS and CSS. Patients with a high NLR (≥2.8) had significantly higher T-stage (P = 0.006) and worse CSS (P < 0.001) than those with a low NLR. Patients with a low LMR (<3.3) had significantly higher T-stage (P = 0.013) and worse RFS (P = 0.009) and CSS (P < 0.022) than those with a high LMR. CONCLUSIONS: Although very few of our patients with intermediate- and high-risk clinical node-negative SCC underwent prophylactic ILND, they still had excellent 5-year RFS and CSS. However, survival was poor in patients with node-positive disease. The pre-treatment NLR and LMR could serve as biomarkers to predict the prognosis of patients with penile cancer.

A nomogram for prediction of prostate cancer on multi-core biopsy using age, serum prostate-specific antigen, prostate volume and digital rectal examination in Singapore.

AIM: To develop and internally validate two nomograms for predicting the probability of overall and clinically-significant prostate cancer on initial biopsy in a Singaporean population. METHODS: Data were collected from men undergoing initial prostate biopsy at a single center. The indications for biopsy were serum prostate-specific antigen (PSA) ≥4.0 ng/mL or suspicious digital rectal examination (DRE) findings. Men with PSA >30 ng/mL were excluded. Age, PSA, prostate volume (PV) and DRE were predictors included in our logistic regression model and used to construct two nomograms for overall prostate cancer and clinically-significant (Gleason sum ≥7) cancer detection. Predictive accuracies of our nomograms were assessed using area under curve (AUC) of their receiver-operator characteristic curves. Internal validation was performed using the bootstrap method. Our nomograms were compared to a model based on PSA alone using AUC and decision curve analysis (DCA). RESULTS: Out of 672 men analyzed, our positive biopsy rate was 26.2% (n = 176), of which 63.6% (n = 112) had clinically significant disease. Age, PSA, PV and DRE status were all independent risk factors for both overall prostate cancer detection as well as clinically-significant cancer detection (all P < 0.05). Our nomogram outperformed serum PSA for both overall and clinically-significant cancer detection (0.736 vs 0.642, P < 0.001 and 0.793 vs 0.696, P < 0.001, respectively). Using DCA, our nomograms had superior net benefit and net reduction in biopsy rate compared to PSA alone. CONCLUSIONS: Our nomograms have been shown to be superior to PSA alone, on both AUC and DCA. However, it warrants external validation.

Prostate cancer detection: The impact of obesity on Asian men.

OBJECTIVE: To evaluate the impact of body mass index (BMI) on prostate cancer detection in biopsy-naive men presenting to a single tertiary hospital in Singapore. MATERIALS AND METHODS: We retrospectively examined 458 men who underwent initial prostate biopsies between January 2012 and April 2014. Indications for biopsy were serum prostate-specific antigen level≥4.0ng/ml, or digital rectal examination findings suspicious for malignancy, or both. Only men with serum prostate-specific antigen level <20ng/ml were included. BMI categories were based on the World Health Organization recommendations (normal:<25.0, overweight: 25.0-29.9, and obese: ≥30). RESULTS: Of the 458 men included in our cohort, 125 (27.3%) men were positive for prostate cancer on biopsy, with 69 (15.1%) being clinically significant (Gleason≥7). Men with BMI≥25kg/m(2) (41.7%) were younger (67.2 vs. 68.8y, P = 0.030), had larger prostates (45.5 vs. 40.1g, P = 0.014), and were more likely to have a positive biopsy finding (34.6% vs. 22.1%, P = 0.003). On multivariate analysis, being overweight or obese was associated with increased risk of having prostate cancer on biopsy (odds ratio [OR] = 2.61, 95% CI: 1.58-4.30, P<0.001 and OR = 3.26, 95% CI: 1.37-7.73 P = 0.007, respectively). The same trend was observed for clinically significant cancers but not for clinically insignificant cancers (OR = 3.57, 95% CI: 1.87-6.82, P<0.001 and OR = 3.86, 95% CI: 1.33-11.21, P = 0.013 for being overweight and obese, respectively). CONCLUSION: Asian men with BMI≥25kg/m(2) are at greater risk of having a positive initial biopsy result. The BMI threshold (BMI≥25kg/m(2)) for Asian men to be at increased risk of prostate cancer detection on initial biopsy is lower than that of Western populations (BMI≥30kg/m(2)).

Contemporary outcomes in the detection of prostate cancer using transrectal ultrasound-guided 12-core biopsy in Singaporean men with elevated prostate specific antigen and/or abnormal digital rectal examination.

OBJECTIVE: Despite being the third commonest cancer in Singaporean men, there is a dearth of basic data on the detection rate of prostate cancer and post-procedure complication rates locally using systematic 12-core biopsy. Our objective is to evaluate prostate cancer detection rates using 12-core prostate biopsy based on serum prostate specific antigen (PSA) levels and digital rectal examination (DRE) findings in Singaporean men presenting to a single tertiary centre. The secondary objective is to evaluate the complication rates of transrectal prostate biopsies. METHODS: We retrospectively examined 804 men who underwent first transrectal-ultrasound (TRUS) guided 12-core prostate biopsies from January 2012 to April 2014. Prostate biopsies were performed on men presenting to a tertiary institution when their PSA levels were ≥4.0 ng/mL and/or when they had suspicious DRE findings. RESULTS: Overall prostate cancer detection rate was 35.1%. Regardless of DRE findings, patients were divided into four subgroups based on their serum PSA levels: 0-3.99 ng/mL, 4.00-9.99 ng/mL, 10.00-19.99 ng/mL and ≥20.00 ng/mL and their detection rates were 9.5%, 20.9%, 38.4% and 72.3%, respectively. The detection rate of cancer based on suspicious DRE findings alone was 59.2% compared to 36.5% based on serum PSA cut-off of 4.0 ng/mL alone. The post-biopsy admission rate for sepsis was 1.5%. CONCLUSION: In conclusion, using contemporary 12-core biopsy methods, the local prostate cancer detection rate based on serum PSA and DRE findings has increased over the past decade presumably due to multiple genetic and environmental factors. Post-biopsy sepsis remains an important complication worldwide.

Academy of Medicine-Ministry of Health Clinical Practice Guidelines: assessment and management of infertility at primary healthcare level.

The Academy of Medicine (AMS) and Ministry of Health (MOH) have developed the clinical practice guidelines on Assessment and Management of Infertility at Primary Healthcare Level to provide doctors and patients in Singapore with evidence-based treatment for infertility. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the AMS-MOH clinical practice guidelines on Assessment and Management of Infertility at Primary Healthcare Level, for the information of SMJ readers. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website: http://www.moh.gov.sg/content/moh_web/healthprofessionalsportal/doctors/guidelines/cpg_medical/2013/cpgmed_infertility.html. The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.

Outcome of a strategy to reduce surgical site infection in a tertiary-care hospital.

BACKGROUND: Surgical site infection (SSI) is a preventable complication. Achieving a zero SSI rate for all clean operations should be the goal of all surgeons. AIM: We aimed to reduce our SSI rate by 50% for patients undergoing elective gastrointestinal and hernia operations. METHODS: The study was conducted in a tertiary-care hospital department of surgery from January 2006 to December 2007 for all clean and clean-contaminated elective gastrointestinal and hernia operations. Four interventions targeted at reducing SSI were implemented in January 2006: Use of clippers instead of shavers for surgical site hair removal; standardized prophylactic antibiotic regimen and antibiotic administration within 30 min before incision; standardized glucose monitoring for diabetics; and maintenance of postoperative normothermia. Prospective data were collected and compared with historical data from January to December 2005. RESULTS: A total of 2,408 patients underwent elective gastrointestinal and hernia operations from January 2006 to December 2007. After implementation, we were able to achieve 91%, 87%, 89%, and 76% overall compliance with the respective interventions, but postoperative normothermia was achieved in only 44% of our patients. With the bundle of interventions, our overall SSI rate was reduced from 3.1% to 0.5% (p < 0.001), an 84% reduction within two years. The incidence of SSI was 1.7% in colorectal operations, 1.2% in upper gastrointestinal operations, 0.3% in hepatopancreaticobiliary operations, and zero in inguinal and ventral hernia operations. The estimated cost saving for both the patients and the hospital was S$208,562 (US$147,967). CONCLUSIONS: Surgical site infections could be reduced with the bundle of interventions. With these encouraging results, the good practices should be sustained and promulgated. Such a SSI prevention program must be embedded in the work processes for all surgical disciplines.

Increased expression of non-sulfated chondroitin correlates with adverse clinicopathological parameters in prostate cancer.

Chondroitin sulfate is a structurally diverse glycosaminoglycan, which contains a variable degree of sulfation that helps to determine its biological function. It is involved in the regulation of cellular activity and has been implicated in carcinogenesis. To determine if the non-sulfated chondroitin backbone has a functional role in prostate cancer, we analyzed its expression by immunohistochemistry using the 1B5 monoclonal antibody and a set of tissue microarrays constructed with 227 prostate specimen cores from 81 cases of benign prostate tissue and 77 cases of prostate cancer, of which 69 of these cases are matched. Non-sulfated chondroitin was found in the secretory epithelial cells and stromal regions of both prostatic adenocarcinoma and benign prostatic tissues, as well as in the basal cells of benign glands. A higher percentage of cancerous cells were stained positively for non-sulfated chondroitin as compared with benign secretory cells of the same patient. Cancerous cells stained more intensely for non-sulfated chondroitin. This increase in percentage of cells stained and increase in staining intensity were associated with higher pathological T stage and extraprostatic extension. Non-sulfated chondroitin expression (either staining intensity or percentage of cells stained) in adenocarcinoma and its peritumoral stroma correlated significantly with several clinicopathological parameters of unfavorable outcome, including higher pathological T stage and Gleason score, presence of tumor in both prostatic lobes, extraprostatic extension, seminal vesicle involvement and preoperative prostate-specific antigen levels. These data suggest that non-sulfated chondroitin is a potentially useful biomarker for prostate cancer, and may be involved in regulating prostate cancer behavior.

Use of the omentum flap as additional soft-tissue cover for abdominal wall defects reconstructed with Gore-Tex.

BACKGROUND: Use of alloplastic materials such as Gore-Tex and locoregional flaps for reconstruction of large abdominal wall defects has been well described. The purpose of this article is to present a novel technique of using the omentum as an interpositional flap to protect the Gore-Tex repair of the abdominal wall. METHODS: Four patients with large abdominal wall defects underwent reconstruction with Gore-Tex and omentum flap. These defects resulted from tumor resection and recurrent incisional hernia. Their dimensions ranged from 15 x 10 cm to 25 x 27 cm. The Gore-Tex patch was inset using an underlay technique. The omentum was tunneled through a separate opening in the abdominal wall into the subcutaneous plane and used to cover the Gore-Tex. Skin coverage was accomplished by direct closure or myocutaneous flaps. RESULTS: The mean follow-up was 17 months. All wounds healed, with no hernias. One patient developed a subcutaneous abscess 6 months postoperatively, and this was treated successfully by percutaneous drainage, as the omentum had walled-off the abscess. CONCLUSION: The omentum flap served as an additional soft-tissue cover over the Gore-Tex repair to prevent exposure in the event of infection or flap breakdown. This technique is useful in situations in which delayed wound healing is anticipated or when large quantities of prosthetic material are used.

Clinical application of prognostic factors for patients with organic causes of erectile dysfunction on 100 mg of sildenafil citrate.

OBJECTIVES: There are still no clinical predictive factors to determine the response rate of erectile dysfunction (ED) patients to sildenefil citrate. The aim of the present study is to evaluate and stratify the risk factors and attempted to determine the prognostic factors in clinical practice to predict the response rate. This is important in improving cost effectiveness and avoiding side-effects. MATERIAL AND METHODS: This is an open label prospective study including patients attending the andrology clinic in Tan Tock Seng Hospital, Singapore, over 2 years. The patients were evaluated and investigated for possible underlying causes and ED severity was assessed by five-items of the International Index of Erectile Function questionnaire (IIEF-5), together with the duration, degree and rigidity of erection. Psychogenic causes were excluded with a minimal follow up of 6 months. All patients were placed on 100 mg of sildenafil citrate and were reassessed at the end of 6 months. Logistic regression with univariate and multivariate was used as the method of statistical analysis. RESULTS: A total of 232 patients were in the cohort. The overall response rate was 43%, with the best response rate in veno-occlusive cases and the worst responses from neurogenic causes. Age, smoking, diabetes mellitus, hypertension, hyperlipidemia, pretreatment IIEF-5 score, interval to achieve erection and duration of erection were significant in univariate analysis, but only age, smoking and IIEF-5 score were significant in multivariate analysis. With a combination of these factors, a table was formed to determine the possible response rate in clinical practice. This will assist physicians in selecting patients with potentially favorable responses and avoid side-effects and an unnecessary wastage of time and cost. CONCLUSION: Possible factors could be determined and used clinically to predict the response rate to sildenafil citrate.

Use of the scrotal remnant as a tissue-expanding musculocutaneous flap for scrotal reconstruction in Paget's disease.

Wide excision of extramammary Paget's disease of the penoscrotal region may leave large defects that cannot be closed easily. The authors describe their experience with a series of 6 patients in whom reconstruction of the scrotal defect was undertaken using the scrotal remnant raised as a stretchable musculocutaneous flap. It was observed that as little as a third of the residual scrotum could be expanded to resurface the entire scrotum. All flaps survived completely. Severe scrotal edema and ecchymosis were observed in 1 patient but the symptoms resolved completely with Trendelenburg positioning. The penile defects were resurfaced individually with thick skin grafts. Good-quality take with no chordee was observed in all patients after initial reconstruction. One patient developed penile contracture after reexcision of recurrent disease. Mean follow-up was 22 months (range, 3-60 months). Large defects of as much as two thirds of the scrotum may be reconstructed successfully using the tissue-expanding scrotal musculocutaneous flap.

Management of premature ejaculation -- a comparison of treatment outcome in patients with and without erectile dysfunction.

This study evaluated the problem of premature ejaculation (PE) in patients treated for erectile dysfunction. The aim was to compare the efficacy of selective serotonin reuptake inhibitors (SSRIs) in the management of primary PE and PE associated with sildenefil treatment. Eighty-seven patients with PE seen over a period of 17 months were recruited into this prospective study. They were categorized into two groups: primary PE (GPI) and PE in sildenefil-treated patients (GPII). All patients recruited into GPII had erectile dysfunction (ED) that was successfully treated with sildenefil citrate for at least a year. Both groups of patients were given sertraline 50 mg 4 h before expected time of sex. The minimum follow-up was 6 months. The ejaculation latency before and after treatment of the two groups were compared. The sexual satisfaction scores of the patients in the two groups were also sought and analysed. Twenty-eight percent of patients with ED who were successfully treated with sildenefil developed PE. Subjects in group GPI were younger and have less comorbid factors than those in group GPII. There was no significant difference in the mean ejaculation latency for both groups (46 vs. 34.6 sec for GPI and GPII, respectively). However, there was highly significant difference in the ejaculation latency between the two groups after treatment with sertraline for 6 months (247.2 vs. 111.6 sec for GPI and GPII, respectively). There was also significant difference in the sexual satisfaction score for group GPI post-treatment, but not for GPII. No significant side-effect of sertraline was reported from patients in both groups. Successful treatment of ED could not assure sexual satisfaction. At least a quarter of sildenefil treated ED patients might develop PE which would continue to frustrate these patients sexually. While selective serotonin re-uptake inhibitors (SSRIs) was effective in the management of primary PE, they were not as effective in patients with sildenefil corrected ED.

Clinical efficacy and safety of sildenafil citrate (Viagra) in a multi-racial population in Singapore: A retrospective study of 1520 patients.

BACKGROUND: Sildenafil citrate (Viagra), a selective inhibitor of cGMP-specific phosphodiesterase type-5, has been used as an oral therapeutic drug for erectile dysfunction. The present paper is a clinical study of the success rate and side-effects of the use of sildenafil in a multi-racial population in Singapore. METHODS: From April 1999 to May 2000, 1520 patients were given sildenafil citrate. Of these, 912 patients (mean age, 54.6 years; age range, 22-99 years) were followed up and evaluated for clinical efficacy and safety of the drug. The mean duration of erectile dysfunction (ED) and follow-up periods were 31.5 and 3.0 months, respectively. RESULTS: Satisfactory erections assessed by single global efficacy question (GEQ) occurred in 83% of patients, major side-effects in the form of flushing (3.48%), headache (1.97%), blurred vision (1.25%), giddiness (1.18%), warmth (1.11%) and others (4.92%) were recorded in 127 patients (13.9%). Racially, Chinese men with ED had higher efficacy (85.7%), compared to Indian men (74.2%) and Malay men (72.8%). With respect to comorbid profiles, an efficacy of 77.8% (n = 271), 83.9% (n = 292), 86.4% (n = 44) and 83.3% (n = 199) was recorded in diabetic, hypertensive, ischemic heart disease patients and in benign prostatic hyperplasia patients, respectively. Patients who smoked (n = 135) and drank alcohol (n = 118) showed an efficacy of 80%. Baseline hormonal profiles of luteinizing hormone, follicle stimulating hormone, testosterone and prolactin did not affect the success rates of sildenafil citrate. Many patients had earlier received other forms of treatment (medicated urethral suppository for erection (MUSE; 84.9%); vacuum devices (86.8%), traditional medicines (100%) and other oral medications (89.2%)), but this did not influence the success rate of sildenafil citrate. But patients previously treated with prostaglandin-E intracavernosal injections were less successful on sildenafil citrate (77.3%). In the total cohort, 50 mg sildenafil citrate was an effective dose in 49% of patients and 46.5% patients needed 100 mg sildenafil citrate, while 4.1% of the total cohort needed only 25 mg sildenafil citrate. CONCLUSION: Oral sildenafil citrate has been shown to be an effective, safe and well tolerated drug in Singaporean men with ED, as in men from other parts of the world.