Risk of development of diabetes mellitus in Chinese women with persistently impaired glucose tolerance after gestational diabetes.

OBJECTIVES: To estimate the cumulative incidence for the development of diabetes mellitus in Chinese women with persistently impaired glucose tolerance after gestational diabetes, and evaluate putative risk factors. DESIGN: Historical cohort study. SETTING: A regional hospital in Hong Kong. PATIENTS: Women with postpartum impaired glucose tolerance (as confirmed by a 75-gram oral glucose tolerance test 6 weeks after delivery) seen between January 2000 and December 2006. RESULTS: After a mean follow-up period of 52 (standard deviation, 22; range, 12-106) months, 47 (20%) of the 238 women converted to diabetes mellitus. Concomitant postpartum impaired fasting plasma glucose levels increased the risk of future diabetes mellitus by 3.5-fold (95% confidence interval, 1.7-7.0; P=0.001) when compared to those with postpartum impaired glucose tolerance only. Based on multivariate analysis, only antepartum and postpartum fasting plasma glucose levels predicted future development of diabetes mellitus. At 1 year after delivery in 95/159 (60%) of the women, glucose tolerance regressed to normal, while in only 9/159 (6%) it progressed to diabetes mellitus. At this stage, 29% of those with impaired glucose regulation (impaired glucose tolerance, impaired fasting glucose or both) compared to 2% of those whose glucose tolerance reverted to normal developed diabetes mellitus upon subsequent follow-up (P<0.001). In all, 24/159 (15%) fulfilled the definition of metabolic syndrome and its presence was associated with 4.7-fold increased risk of future diabetes mellitus (95% confidence interval, 1.7-13.4; P=0.004). CONCLUSIONS: Women with persistent postpartum impaired glucose tolerance after gestational diabetes have a high risk of developing diabetes mellitus. However, a significant proportion of these women regress to normal glucose tolerance 1 year after delivery, and their risk of progression to diabetes mellitus is lower than those with persistent impaired glucose regulation. Therefore, women with a history of gestational diabetes, particularly those with persistent glucose intolerance 6 weeks and 1 year after delivery, should have regular surveillance for the development of diabetes mellitus.

Urological complications in renal transplantation.

INTRODUCTION: Renal transplantation has gained much wider acceptance as a treatment option for local patients with end-stage renal failure in the last three decades. However, there are no local reports regarding the associated urological complications and their management. This paper aims to explore these complications in the local setting. METHODS: This is a retrospective review of 440 consecutive renal transplantations performed in Singapore General Hospital over a ten-year period. From the retrieved clinical records of transplant recipients, the occurrence of various urological complications and their management were studied. RESULTS: The overall incidence of urological complications among transplant recipients was 7.7 percent. Urological complications included urinary leakage, ureteric strictures, symptomatic lymphocoeles, malignancies, urolithiasis, double-J stent fragmentation as well as haemorrhagic cystitis, and their incidences were 1.4 percent, 2.0 percent, 1.8 percent, 2.3 percent, 0.2 percent, 0.2 percent and 0.2 percent, respectively. Among the malignancies, 70 percent were renal cell carcinomas in the native kidneys. CONCLUSION: The incidence of urological complications in our series was comparable to those in the various major centres. However, there was a significantly higher incidence of native renal cell carcinoma in our series, which was likely to be secondary to the prolonged period of dialysis prior to renal transplantation.

Long-term follow-up of transurethral microwave thermotherapy.

OBJECTIVES: To evaluate the long-term results of transurethral microwave thermotherapy (TUMT) for benign prostatic hyperplasia (BPH) with up to 5 years of follow-up at our institution. METHODS: From October 1991 to November 1993, 106 patients were treated for BPH with TUMT using the Prostatron 2.0. Of the 106 patients, 64 were available for evaluation of symptoms (Madsen-Iverson score), uroflow, residual urine, and retreatment rate at a mean follow-up of 50+/-5.4 months (mean+/-SD). RESULTS: The mean age of the patients was 65.2+/-9.8 years. Thirty-two patients (50.0%) were treated with one session of TUMT. Additional treatments were required for 32 patients (50.0%). Three patients had two sessions of TUMT, 14 underwent transurethral resection of prostate, and 3 had laser prostatectomy. Twelve patients received medical therapy. The mean symptom score decreased significantly from 12.9+/-2.5 to 5.7+/-3.6 (P = 0.001). The mean peak flow rates and postvoid residual volume showed little difference before and after TUMT. On the basis of the criteria described by Poincelet and Cathaud the overall clinical efficacy rate was 39.1% (15.6% complete response and 23.5% partial response). No obvious clinical parameter was useful to predict favorable outcome after TUMT. CONCLUSIONS: The present study showed that the efficacy rate of TUMT with the Prostatron 2.0 at 50 months was 39.1 %. None of the preoperative clinical factors was predictive of a favorable outcome.

Clinical evaluation of impotence.

With better understanding of the pathophysiology of erectile dysfunction, various causes of impotence can be identified accurately with the help of different investigation modalities. However, it is controversial as to what extent investigations are considered as adequate because most of the time they do not influence patient management. The clinical evaluation of erectile dysfunction should include a thorough sexual and medical history and physical examination. Further special investigations such as nocturnal penile tumescence studies, duplex ultrasonography, dynamic infusion cavernosometry and cavernosography, and arteriography should only be ordered logically after careful consideration of whether they will affect patient outcome. Therefore in this review, we aim to evaluate critically these different special investigations with regards to their indications and pitfalls so that a logical approach to the evaluation of impotence can be obtained.

A case report--delayed vesicocutaneous fistula after radiation therapy for advanced vulvar cancer.

This is the first case report of a vesicocutaneous fistula related to prior radiation therapy for recurrent vulvar cancer. Urinary tract complications happen not infrequently after radiation therapy for various pelvic malignancy. It can occur as long as 30 years after cessation of such therapy. Urinary incontinence or obstructive uropathy is, by far, the most common complication. The authors report an unusual complication secondary to radiation therapy. The aetiology, presentation and management of this patient were discussed.

Preliminary results of heart-beating and non-heart-beating donor kidney transplants--the Singapore experience.

Renal transplantation is the ideal renal replacement therapy for treatment of end stage kidney failure but its limitation is the constant shortage of cadaveric donors. While the traditional source of cadaveric kidneys is procurement from heart-beating donors, organ procurement from non-heart-beating donors (NHBD) would help in coping with the rising demand for organs. However various important legal, logistic and technical constraints have limited the implementation of such a procurement programme. Nevertheless, prolonged warm ischaemic times in procuring kidneys from NHB donors may affect the viability of these organs and adversely affect overall outcome after transplant. Fifty-three consecutive patients who underwent renal allotransplantation (Tx) between January and December 1994 at the Singapore General Hospital were retrospectively reviewed. Outcomes after renal transplantation among 25 heart-beating donor (HBD) and 28 NHBD were compared. Despite significant differences in donor age (23.7 +/- 11.0 and 34.1 +/- 7.9, P = 0.001), first warm (0 and 22.2 +/- 9.0 minutes) and cold ischaemic times (12.8 +/- 6.7 and 5.2 +/- 5.0 hours, P = 0.001) between the HBD and NHBD groups, the two-year patient and graft survivals were very similar in both groups (100% versus 98% and 98% versus 96%). The incidence of delayed graft function (DF) was also comparable between the HBD (41%) and the NHBD (50%) Tx. These results suggest that NHBD is a viable source for kidney transplants and comparable patient and graft survivals can be achieved if the first warm and cold ischaemic times are kept to the minimum.

Outcome of obstructive uropathy after pelvic irradiation in patients with carcinoma of the uterine cervix.

The natural history and outcome of intervention for obstructive uropathy were studied retrospectively in 20 patients managed at the Department of Urology, Singapore General Hospital between 1991 and 1997. The diagnoses of these strictures were made between 10 months and 21 years after the initial treatment. There were 9 (45%) malignant and 11 (55%) benign strictures. The site of ureteric obstruction was in the lower ureter in 15 patients, in the middle ureter in 3 patients and in the upper ureter in 2 patients. Comparisons between malignant and benign strictures showed that patients with higher original stage of tumour were more likely to have malignant strictures. Besides latency period between primary treatment of the tumour and diagnosis of uropathy, bilaterality and site of strictures showed no discernible difference between benign and malignant strictures. Ureteric stenting provided good outcome in 5 patients with benign strictures and in 3 patients with malignant strictures. Open surgical reconstruction was performed on 2 patients with benign strictures and 2 patients with malignant strictures. All these four patients showed good outcome. Ureteric stenting is an acceptable treatment of benign ureteric stricture and for selected patients with malignant strictures. Open surgery is recommended in patients with benign strictures who could not be treated successfully on stenting.

Feasibility of early catheter removal after radical retropubic prostatectomy.

PURPOSE: This study was conducted to determine if early (1 week) removal of the urethral catheter after radical prostatectomy is feasible. MATERIAL AND METHODS: Eighty patients underwent surgery from 1992 to 1999. Of the 78 patients with analyzable results, 22 (28%) had the catheter removed after 3 weeks (group 1) and 56 (72%) after 1 week (group 2). RESULTS: Median follow-up of 49 months revealed no mortality or major morbidity in the two groups of patients. Urinary functions were satisfactory and similar in both groups of patients. Group 2 patients had an improved continence rate of 92%, achieving full continence at 3 months, compared to 59% for group 1. The mean duration of hospitalization of 8.2 days for group 2 was better than the 12.1 days for group 1. CONCLUSIONS: Early removal of the catheter after radical prostatectomy was feasible, did not impose any short- or long-term morbidity, and may offer some benefits.