Incidence of complications after transrectal ultrasonography-guided biopsy of the prostate in a local tertiary institution.

INTRODUCTION: This study aimed to evaluate the risk of complications for patients who received periprosthetic nerve block (PPNB) with one percent lignocaine before transrectal ultrasonography (TRUS) biopsy of the prostate. METHODS: From 2008 to 2009, data on 526 consecutive patients who underwent prostate biopsy was prospectively recorded and analysed. 475 (90.3 percent) patients received PPNB with 10 ml of one percent lignocaine (Group 1), which was carried out under TRUS-guidance and prior to biopsy. 51 (9.7 percent) patients received diclofenac (100 mg) intramuscular injections or no analgesia (Group 2). Complications were defined as any adverse effects after biopsy. Serious complications were defined as those requiring hospitalisation or invasive/operative procedures for treatment. RESULTS: At baseline, both groups were comparable. The mean prostate-specific antigen level in Group 1 was higher than that in Group 2 (48.6 +/- 13.8 versus 19.0 +/- 4.3 ng/ml; p-value is 0.04). There was no perioperative mortality. Post-procedural complications were reported in 23.4 percent (n is 111) of patients in Group 1 and 25.5 percent (n is 13) in Group 2 (p-value is 0.27). Serious complications were reported in 2.5 percent (n is 12) and 7.1 percent (n is 3) of Group 1 and 2 patients (p-value is 0.10), respectively. Both univariable and logistic regression revealed age below 65 years and pre-procedure complaints of lower urinary tract symptoms as independent predictors for complications (p-values are 0.02 and 0.006, respectively). CONCLUSION: PPNB with one percent lignocaine is a safe analgesic procedure to perform in patients undergoing TRUS biopsy.

Ministry of health clinical practice guidelines: cancer screening.

The Ministry of Health publishes national clinical practice guidelines to provide doctors and patients in Singapore with evidence-based guidance on managing important medical conditions. This article reproduces the introduction and executive summary (with key recommendations from the guidelines) from the Ministry of Health clinical practice guidelines on cancer screening, for the information of readers of the Singapore Medical Journal. 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/mohcorp/publications.aspx?id=24018). 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.

Alfuzosin 10 mg once daily increases the chances of successful trial without catheter after acute urinary retention secondary to benign prostate hyperplasia.

OBJECTIVE: To compare the efficacy of Alfuzosin XL 10 mg once daily for the acute management of acute urinary retention (AUR) with placebo in patients with benign prostatic hyperplasia (BPH) and to determine the predictors that impact this. METHODS: 67 patients presenting with an initial episode of spontaneous AUR secondary to BPH were catheterized and were then prospectively randomized to receiving placebo or 10 mg Alfuzosin XL once daily for 2 days. The allocation and administration of treatment were double-blinded. The primary outcome measure was the rate of successful trial off catheter (TWOC) after 2 days. Clinical characteristics including intravesical prostatic protrusion (IPP) by transabdominal ultrasound were also assessed using uni- and multivariate analysis for their impact on successful TWOC. RESULTS: Three patients withdrew from the study, 2 due to adverse effects of the trial medication. Analysis on an intention-to-treat basis showed a significantly greater proportion of patients in the Alfuzosin XL group (21 of 35 or 60%) had a successful TWOC compared with patients in the placebo group (11 of 32 or 34%) (p = 0.036). Patients with grade 3 IPP (>10 mm) had a significantly lower chance of successful TWOC (p = 0.04) compared to grade 1 (10 mm are more likely to fail TWOC on Alfuzosin XL.

Control of pain during transrectal ultrasound-guided prostate biopsy: a prospective study comparing two methods.

AIM: To evaluate the efficacy of intramuscular injection of 75 mg diclofenac sodium and periprostatic nerve block (PPNB) with 1% lignocaine in controlling pain during transrectal ultrasound (TRUS)-guided prostate biopsy. MATERIALS AND METHODS: A total of 120 patients undergoing TRUS-guided prostate biopsies were prospectively enrolled in the study. First, 20 patients did not get any form of analgesia/anesthesia and served as control; next, 20 patients received an intramuscular injection of diclofenac sodium. PPNB with 1% lignocaine was performed in the remaining 80 patients. Pain was assessed using Wong-Baker Faces Pain-Rating Scale (0-10). RESULTS: All three groups of patients were comparable at baseline in terms of age, prostate-specific antigen and final histological diagnosis. The mean pain scores (+/-SD) for control, diclofenac and PPNB groups were 5.10 +/- 3.14, 3.70 +/- 2.36 and 2.24 +/- 1.63, respectively. The difference was statistically significant between control and PPNB (p = 0.001), and diclofenac and PPNB (p = 0.002), but not between the control and diclofenac group (p = 0.120). In addition, the proportion of patients having mild or no pain (defined as pain score

Seminal vesicle calculus after transurethral resection of ejaculatory duct.

We report a case of symptomatic seminal vesicle calculus following transurethral resection of ejaculatory duct. A 37-year-old male, who had previously undergone transurethral resection of ejaculatory duct, presented with perineal discomfort and graveluria. Computed tomography revealed a calculus situated within a dilated left seminal vesicle. The patient was treated with cystoscopy and litholapaxy of the seminal vesicle calculus. Although rare, our case demonstrates that seminal vesicle calculi formation can occur following treatment of ejaculatory duct obstruction, possibly secondary to urinary reflux and stasis.

A meta-analysis of local anesthesia for transrectal ultrasound-guided biopsy of the prostate.

This meta-analysis evaluated the efficacy and safety of periprostatic nerve block (PPNB) and intrarectal local anesthestic (IRLA) gel in alleviating pain during prostate biopsy. Electronic databases MEDLINE, Cochrane Central Register of Controlled Trials and EMBASE were searched to identify all randomized controlled trials comparing PPNB with periprostatic placebo injection, no injection or with IRLA. Studies for inclusion were identified and extracted by two authors independently. The main outcome measure was patients' assessment of mean pain scores on a 10-point scale at the end of the biopsy procedure. Secondary outcomes were complications and adverse events. Continuous data from the trials were combined by calculating the weighted mean difference (WMD) with its 95% confidence interval. In total, 25 studies met the inclusion criteria. Twenty studies involving 1685 patients compared PPNB with either no anesthesia or with placebo injection controls, showing a significant reduction in pain score in the anesthetic group (WMD -2.09, 95% CI -2.44 to -1.75, P<0.00001). Five studies with 466 patients compared IRLA and control. Although IRLA was associated with pain reduction, the effect size was not statistically significant (WMD -0.22, 95% CI -0.56 to 0.12). Six studies with 872 patients compared PPNB with IRLA, showing a significant pain reduction in the former group (WMD -1.53, 95% CI -2.67 to -0.39, P=0.008). No trials reported an increase in complications in the treatment arms. In conclusion, the evidence from randomized controlled trials shows that local anesthetic given as a PPNB, but not as an intrarectal instillation, is effective and safe in alleviating pain from transrectal ultrasound biopsy of the prostate.

Surgical complications of Tenckhoff catheters used in continuous ambulatory peritoneal dialysis.

INTRODUCTION: The objective of this study was to audit the early and late complications of open Tenckhoff catheter insertion under local anaesthesia in a single institution. METHODS: A review was carried out on 164 insertions in 139 patients over a three-year period. All patient records were retrospectively analysed until the time of transfer to haemodialysis, death, or to current time if alive and receiving continuous ambulatory peritoneal dialysis (CAPD). Patient characteristics, operative factors, early and late complications were recorded. RESULTS: Early complications were reported in 31 percent of catheter insertions, predominantly wound infections and catheter malfunctions. The factors that were significantly associated with early complications were diabetes mellitus, glomerulonephritis, ongoing sepsis, previous abdominal surgery and prolonged surgical time. Late complications were seen in 26 percent of catheter insertions, mainly CAPD peritonitis. Poor nutritional status had a significant negative impact on late complications. The overall median catheter survival time was 41.9 months (95 percent confidence interval, 25.8-58.0 months). In addition, no significant difference in catheter survival time was detected between those patients with and those without diabetes mellitus. CONCLUSION: Tenckhoff catheter insertion for CAPD is a procedure associated with significant surgical morbidity. Patients with diabetes mellitus, glomerulonephritis and ongoing sepsis are at greater risk of early complications, and hence, must have their conditions stabilised or treated before surgery. In addition, prolonged surgical time and patients with previous abdominal surgery are at increased risk. The rate of complications may be improved by early consideration of patients with poor tolerance of local anaesthetic surgery or with previous abdominal surgery for laparoscopic insertion under general anaesthesia. To prevent late complications dominated by CAPD peritonitis, patients' nutritional status and care of the catheter should both be optimised.

The use of sildenafil in patients with erectile dysfunction in relation to diabetes mellitus--a study of 1,511 patients.

Erectile dysfunction (ED) seriously impairs the quality of life. Patients with diabetes mellitus (DM) are prone to ED due to various factors, including vasculopathy, neuropathy and sex hormone abnormalities. This is a retrospective study involving 1,511 patients taking sildenafil. Patients with DM have significantly more comorbidities like hypertension and ischaemic heart disease. They are also more likely to be on medications which may affect erectile function, including various antihypertensive drugs. 77.9% of patients with DM reported success with sildenafil, as compared to 86.5% of patients without DM. A significant number of patients with DM require a higher dose of sildenafil as compared to those without DM.

Transurethral alprostadil for the treatment of erectile dysfunction: results of a multicentre trial.

INTRODUCTION: The incidence of erectile dysfunction (ED) has been shown to increase significantly in Singaporean male population. Thus, this prospective study (no controls) assessed the clinical efficacy and safety of a medicated urethral system for erection (MUSE) in Singaporean male patients with a known history of ED. SUBJECTS AND METHOD: Eighty-six men with a mean age of 55.7 years with differential causes of ED were administered with MUSE in the clinic with a titration adjustment of 4 possible dose regimes (125, 250, 500 and 1000 mcg) till efficacy is achieved. Subsequently, patients were subjected to home treatment for a duration of 3 months. RESULTS: Sixty per cent of inclinic patients exhibited good responses and were given MUSE for home treatment. The efficacy rate for home treatment was 86%. Overall, the patients (n = 86) had a 51.2% success rate in achieving satisfactory sexual intercourse. Diabetic and psychogenic patients were noted to respond well to MUSE. No severe adverse events were found in this study. CONCLUSION: MUSE showed to be a safe, less invasive, well-tolerated and efficient alternative treatment for ED in Singaporean men.

Ureteroscopic lithoclast lithotripsy: a cost-effective option.

Seventy-four consecutive cases of ureteral stones listed for ureteroscopic lithotripsy were studied prospectively. In all cases, the Wolf 7.5F or 9F ureteroscope was used in conjunction with the Swiss Lithoclast system. Dormia baskets were employed on four occasions to prevent forward propulsion of fragments. Ureteroscopic access to the stones was successful in 70 patients (95%). Lithoclast lithotripsy was successfully applied in 68 patients (92%), with complete fragmentation noted in 62 patients (91%), one requiring two sessions. The 6-week stone-free rate was 96% for these patients. Five patients with partial fragmentation had successful adjuvant SWL. The overall successful fragmentation rate was thus 84% (62 of 74) and 91% (67 of 74) in combination with adjuvant SWL. Cost analysis indicated a three-fold advantage for the Lithoclast over Candela lasertripsy. Ureteroscopic Lithoclast lithotripsy is a cost-effective treatment modality for ureteral stones.

Bacillus Calmette-Guerin (BCG) in the treatment of superficial bladder cancer.

We evaluated the efficacy of immune and scarification Bacillus Calmette-Guerin (BCG) in the treatment of carcinoma in situ and prophylaxis against recurrence in patients with superficial transitional carcinoma of the bladder. A single-blind, randomised, comparative trial involving 43 patients with a median follow-up of 39 months was analysed. The end points were progression to muscle invasive disease or recurrence. The overall response rate was 93% after one to two courses. There was no difference between the two preparations and no statistically significant difference between the response or progression rates of the carcinoma in-situ or prophylactic groups. However, the response to BCG was found to be a significant prognostic indicator in a multivariate analysis.

Ureteric colic: value of initial investigations and the outcome.

During a one-year period (from April 1992 to April 1993), 294 patients with the complaint of ureteric colic seen at the Emergency Department of Tan Tock Seng Hospital were investigated with a plain X-ray of the kidney, ureter and bladder (KUB), urinary analysis (urine FEME) and subsequently intravenous urogram (IVU) at the outpatient clinic. The results showed that majority (73%) of the patients were male. Sixty percent of the cohort were in the age group 30-50 years. After evaluation, it was found that only 114 (39%) of the patients with ureteric colic had abnormal IVU. Among these patients, 99 were diagnosed to have calculus disease, 12 with urothelial tumours, 1 with renal cyst and 2 had no pathology detected. Nevertheless most (72%) of the patients did not require intervention. In addition, it was noted that if the KUB or urine FEME was positive, the chances that a urological pathology was present were 72% and 91% respectively. However, if both of them were negative, the chance that a pathology would not be present was 93%. This suggests that patient selection is very essential to avoid unnecessary investigations.

A case of localised ureteric amyloidosis.

We describe a case of localised amyloidosis of the distal ureter in a 66-year-old lady who presented with intermittent haematuria. Ureteric transitional cell carcinoma was strongly suspected from the clinical and radiological features, and subsequent nephroureterectomy was performed. Histology revealed nodular eosinophilic deposits in the ureteric wall, with the staining characteristics of amyloid. The literature is reviewed, and conservative surgery is advocated, based on a greater awareness together with improved intraoperative diagnosis of this rare lesion.

Four year experience with cholangiocarcinoma: a survey of patients, clinical presentation, management and prognosis in two hospitals.

Seventeen patients with cholangiocarcinoma diagnosed in Toa Payoh and Tan Tock Seng Hospitals from 1986-90 were studied retrospectively. There was a male preponderance (male:female = 12:5) with a mean age of 58 years (range 28-82 years). All presented with obstructive jaundice. Three had cholangitis. Biliary stones were associated in 3 (18%). Two patients (12%) had choledochal cysts. The level of obstruction was identified at the hilum in 12 (70.5%), lower third in 4 (23.5%) and at a choledochojejunostomy anastomosis in 1 (6%). Ultrasound and percutaneous cholangiography (PTC) were the commonest investigations used. Endoscopic retrograde cholangio-pancreatography (ERCP) was performed in 7 (41%) and computer tomography (CT) of abdomen in 6 (35%). Biochemically, a raised alkaline phosphatase (1.5-9 x normal) was typical. Biliary bypass surgery was performed in 7 (41%); Whipple's procedure in 2 (12%) and drainage only in 6 (35%). Nine operated upon survived an average of 6 months (range 2-11 months) and six by drainage survived an average of 62 days (range 13-155 days). Three (of which two declined treatment) were lost to follow up. Cholangiocarcinoma is an uncommon cancer occurring in the older age group. In younger patients, choledochal cyst seems to be an association. Survival is dismal with palliative treatment.

Computed tomography for oesophageal carcinoma: its value to the surgeon.

Between January 1988 and June 1991, 75 patients with carcinoma of the oesophagus or gastro-oesophageal junction were evaluated by computed tomography (CT). Fifty of these patients underwent operation, allowing 48 cases to have a detailed surgical and pathological verification of CT features. For thoracic oesophageal tumours the accuracy of CT was 59% for fat plane status, 86% for aortic contact, 81% for tracheobronchial tree compression and 66% for direct local invasion. CT was 69% accurate for identifying lymph nodes, of which only 38% contained metastatic deposits. For gastro-oesophageal junction tumours, CT was 74% accurate for fat plane status and 90% accurate for direct local invasion. Accuracy for detecting lymph node involvement was 63%, metastatic tumour being present in 91% of these nodes. By pathological staging, only 15% of all resections could be considered potentially curative. The value of CT was found to be in predicting a palliative or curative resection, and in warning the surgeon about possible infiltration of specific mediastinal or abdominal structures that would be encountered during operative dissection.