The role of intravesical prostatic protrusion (IPP) in the evaluation and treatment of bladder outlet obstruction (BOO).

AIMS: Intravesical prostatic protrusion (IPP) may be an underutilized modality for the assessment of bladder outlet obstruction (BOO). Pressure flow studies or urodynamics have long been the gold standard for the evaluation of lower urinary tract symptoms (LUTS) in men but are invasive, time-consuming and costly. Potentially, IPP may be a useful adjunct prior to performing urodynamics. METHODS: Measurement of IPP is taken in the sagittal view, using the transabdominal ultrasound. It is the vertical height from the tip of the protrusion to the base of the prostate. This technique was previously described. We reviewed previous publications that studied the accuracy, positive predictive value and clinical use of IPP. In addition, we noted the comments regarding the challenges of using this technique. RESULTS: IPP has been shown to have a positive predictive value of 72% for BOO. It has been calculated to have an area under curve (AUC) value of 0.71 and 0.84 in some stuies. Clinically, it may be used to predict the outcome of a trial without catheter following acute retention of urine. Patients with higher IPP grade were noted to have a higher risk of clinical progression. Studies have also shown that men with higher IPP are poorer responders to medical treatment such as α-blockers. CONCLUSIONS: Compared to other modalities, the advantage of IPP in assessing BOO may be its easy applicability and non-invasive nature. Therefore, there is a consideration for a larger role of IPP in bedside assessment and management of BOO in daily practice. Neurourol. Urodynam. 35:535-537, 2016. © 2015 Wiley Periodicals, Inc.

Bipolar transurethral resection of prostate in saline: preliminary report on clinical efficacy and safety at 1 year.

PURPOSE: To determine the clinical efficacy and safety profile of the bipolar transurethral resection in saline (TURIS) system (Olympus Japan) in the treatment of men with benign prostate hyperplasia (BPH). PATIENTS AND METHODS: We prospectively evaluated 45 patients with a mean age of 66 years (range 50-87 years) who had clinically significant BPH and were treated with transurethral resection of prostate using the TURIS system beginning December 2003. Acute retention of urine was the indication in 49% of the patients. Patients had outpatient follow-ups at 1, 3, 6, and 12 months. RESULTS: A mean weight of 25.3 g of prostatic tissue was resected in a mean time of 42 minutes (range 15-75 minutes). The mean decrease in hemoglobin and sodium was 1.4 g/dL and 2.2 mmol/L, respectively. The mean follow-up period was 10 months. The mean International Prostate Symptom Score decreased from 22.6 preoperatively to 6.5 at 12 months and the mean Q(max) increased from 6.5 to 18.3 mL/sec at 12 months. Postoperative hemorrhage was seen in 6.6% of the patients, including 2 primary hemorrhages that necessitated blood transfusion (4.4%). Other complications were prolonged catheterization (11.1%), urinary-tract infection (8.9%), and bulbar urethral stricture (4.4%). CONCLUSIONS: This pilot study indicates that TURIS is a safe and efficacious treatment for BPH at 1 year.

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.

A case report on vesico-uterine fistula: a very rare complication of the lower caesarean section.

Vesico-uterine fistula is a very rare complication of lower caesarean section. There has only been two cases seen at the Department of Urology in the past 2 decades. Patients usually present in the early post operative period with the problem of continuous urinary incontinence. On the rare occasion, recurrent urinary tract infection, recurrent gross painless haematuria, or secondary infertility associated with secondary amenorrhoea would be the presenting complaint.

Transrectal ultrasound of the prostate: the early Singapore experience.

During a four-month-period 40 patients presenting to the Department of Urology with mainly retention of urine had their prostates scanned ultrasonically. Eight nodules were detected on the ultrasound of which five were not detected on digital rectal examination. Of the five non-palpable nodules two were diagnosed on ultrasound guided transperineal Tru-cut biopsy to be carcinomas. Of the three nodules detected both on ultrasound and digital rectal examination, two were proven to be carcinomas while the other was benign. The transrectal ultrasound was not only found to be easy to use but was also found to be a useful complement to the urologist's index finger with the added advantage of obtaining good quality biopsy material from suspicious lesions.

Transurethral resection of the prostate for benign prostatic hyperplasia--a local review.

There has been a recent resurgence of interest in the role of transurethral resection of the prostate for benign prostatic hyperplasia in view of the introduction of new modalities. We have conducted a retrospective analysis of 175 cases operated from October 1988 to June 1989 with an aim to ascertain the present mortality and morbidity rates associated with this procedure. The main presenting symptoms were acute retention of urine (54%) and bladder outlet obstruction (33%). The average weight of the prostate resected was 24.2 gm and 3% of specimens revealed malignant changes on histology. Seventy-five percent of the patients have post-operative stay of 5 days or less. Urinary tract infection was the commonest complication (16%). Clot retention requiring re-scope occurred in 2% of our patients. Twelve percent (12%) of our patients developed acute retention post-operatively but only 2% required re-scope as the rest resolved conservatively. We had one mortality in our series as a result of post-operative pneumonia. After 6 months follow-up, 4% complained of mild urinary incontinence and another 4% noted retrograde ejaculation. Six percent developed urethral strictures which required surgical treatment. Three years after the procedure, we retrieved the case notes of our cohort to analyse long-term results. We note that ninety-eight percent of our patients were discharged after nine months follow-up. This includes the 4% who complained of mild stress incontinence at 6 months follow-up. The remaining 2% was discharged after 24 months because of recurrent urethral stricture.(ABSTRACT TRUNCATED AT 250 WORDS)

Percutaneous ultrasonic lithotripsy--its role in the management of renal and upper ureteric stones.

Percutaneous ultrasonic lithotripsy (PUL), a new technique used in the treatment of renal stones has been shown to be safe and effective with low morbidity. 54 of the 57 patients (95%) were successfully treated by this method and all were done as a single stage procedure. 39 patients (68%) in this series were either unsuitable or had failed extracorporeal shock wave lithotripsy (ESWL). No mortality occurred in this series and one patient with staghorn stone required a nephrectomy due to severe secondary haemorrhage. Though PUL is technically more difficult to perform, it is a better alternative than open renal surgery and is complementary to ESWL especially in the treatment of the more complicated renal stones.

Intravesical chemotherapy for superficial carcinoma of the bladder.

Intravesical chemotherapy has been shown to be of value in the treatment of superficial transitional cell carcinoma of the bladder, not only in the prevention of recurrence but possibly progression of the disease to higher stage as well. At the Department of Surgery, National University of Singapore from 1980 to 1986 we had used intravesical chemotherapy for multiple or recurrent superficial carcinoma of bladder in 45 patients. Of these, 21 patients had associated carcinoma in situ. Initially, thiotepa was used as the main intravesical chemotherapeutic agent. Since 1984, mitomycin C was introduced. The schedule used is 30 mg in 30 mg of water, and left in the bladder for 2 hours weekly for 4 weeks. Intermittent courses were given when deemed necessary on follow-up cystoscopy at 3 to 6 months. Patients were deemed to have good response if there was no evidence of tumour on cytology and biopsy at follow-up cystoscopy. Eleven patients had thiotepa only, of these 4 had good response, 4 were stable and 3 had progression of disease to higher stage. Thirty-four patients had mitomycin therapy. Thirteen of them following thiotepa treatment. Twenty-one patients (64%) had good response to therapy. Three patients (9%) had progression of disease, requiring cystectomy. Of those who responded to therapy, none had developed muscle invasive disease so far with mean follow-up of 43 months. Of the group of patients treated with mitomycin, no patient developed myelosuppression.(ABSTRACT TRUNCATED AT 250 WORDS)

Extracorporeal shock wave lithotripsy monotherapy for selected staghorn stones.

OBJECTIVE: To define a subgroup of staghorn stones that is amenable to extracorporeal shockwave lithotripsy (ESWL) monotherapy and review the need for prophylactic ureteric stents. METHODS: Fifty-eight renal units with staghorn calculi in 56 patients (30 males and 26 females) were treated by ESWL monotherapy on the EDAP LT-01 lithotripter. The stones were grouped as complete staghorn (11, 19%), partial staghorn (34, 59%) and borderline staghorn (13, 22%). Results of treatment were analysed in relation to subgroup and calyceal dilatation. Post-treatment complications were studied and the influence of prophylactic ureteric stents examined. RESULTS: The average number of ESWL sessions was 3.1 (range: 1 to 8). The mean follow-up period was 13 months. Stone-free rate at 10 months was 52%. When clinically insignificant residual fragments less than 4mm were included, the overall clearance rate was 75%. Favourable factors influencing treatment outcome included smaller stone burden, peripheral distribution of stone mass and absence of pelvicalyceal dilatation. The overall complication rate was 39% with urosepsis being the commonest. Complications were related to stone burden. More than half of the renal units with complete staghorn stones developed one or more complications. Auxiliary procedures were required in 18% of the renal units. Twenty of 39 renal units with a stone burden (sum of length and width) greater than 50mm had pretreatment ureteric stenting using the double-J (DJ) siliastic stent. A urosepsis rate of 50% was noted in those with ureteric stents compared to 26% in those not stented. The stents did not offer any advantage in preventing post-treatment obstruction by fragments. Six of 7 renal units with post-treatment obstruction had in-situ stents. CONCLUSIONS: ESWL monotherapy is suitable for selected staghorn stones. Prophylactic ureteric stents do not offer any advantage and may predispose to urosepsis.

Idiopathic retroperitoneal fibrosis with bilateral lower ureteric obstruction--a case report with literature review.

Whilst prostatic enlargement remains the commonest cause of bilateral hydronephrosis in males greater than 50 years of age, other rarer conditions such as retroperitoneal fibrosis should be borne in mind. We report a case of bilateral hydronephrosis which was eventually diagnosed as idiopathic retroperitoneal fibrosis and treated with open surgical ureterolysis with omental wrapping.

Clinics in diagnostic imaging (38). Post-ESWL perinephric haematoma.

A 57-year-old man presented with urosepsis related to urinary calculi. He underwent multiple sessions of ESWL and developed a perinephric haematoma that was treated conservatively and monitored by serial imaging. However, the haematoma became infected, necessitating percutaneous drainage 2 months after the initial ESWL. The risk factors and sequelae of post-ESWL perinephric haematoma, as well as its diagnosis and imaging, are discussed.

Transurethral microwave thermotherapy (TUMT) for benign prostatic hyperplasia (BPH)--our first 100 cases.

One hundred consecutive cases treated by Transurethral Microwave Thermotherapy (TUMT) since October 1991 were analysed to assess its efficacy and safety. Out of these, 28 were in urinary retention. Patients were selected based on Madsen Symptom Score (MSS), Uroflowmetry, Transrectal Ultrasound Scanning (TRUS) plus biopsy and flexible cystoscopy. In the non-retention group, symptomatic improvement was 81%; mean MSS dropped from 13.6 to 2.6 at one year. Objective improvement was less marked: mean peak urine flowrate (PFR) (+45%), mean residual volume (-63%) and mean prostatic volume (-15%). 8.3% had failed TUMT requiring TURP. In the retention group, 79% was able to void freely after TUMT. Fourteen percent underwent TURP. Based on given criteria, the overall response rate for MSS and PFR averaged 71% at 3 months, 72% at 6 months and 84% at 1 year. Sixty-seven percent of patients who responded to a phone interview were satisfied with TUMT treatment. Minimal morbidity was encountered: temporary retention for non-retention group (24%), UTI (9%), haematuria (7%), impotence (2%) and fistula (1%). There was no treatment-related death. The results showed that TUMT is a viable alternative and safe treatment of BPH.

Current assessment and proposed staging of patients with benign prostatic hyperplasia.

With better understanding of the natural history of benign prostatic hyperplasia (BPH), and recent advances in ultrasound and the many new modalities of treatment, the assessment of BPH has undergone rapid changes in the past few years. A system of staging of patients with BPH, to assist in the tailoring of treatment to the severity of the disease is proposed. The initial assessment consists of the International Prostatic Symptoms Score (IPSS) and the Quality of Life Index, digital rectal examination (DRE), urinalysis, prostate specific antigen (PSA) estimation, and subsequently, assessment with ultrasound of the urinary system and estimation of residual urine and uroflow done at the same sitting. Patients with no bothersome symptoms and no significant obstruction are classified as stage one, and they can generally be watched. Stage 2 patients are those with bothersome symptoms but no significant obstruction and they can be treated with pharmacotherapy in the first instance, failing which other less invasive therapies such as thermotherapy are advised before considering transurethral resection of the prostate (TURP). Stage 3 patients are those with significant obstruction and defined as patients with significant residual urine of more than 100 ml, generally with a maximum flow rate of less than 10 ml. This group of patients would be advised TURP first, then thermotherapy, or pharmacotherapy in descending order, taking into account the age of the patients, their co-morbidity and preferences. Stage 4 patients are those with complications resulting from significant obstruction by BPH such as retention of urine, bladder stone and recurrent urinary infection; they would be strongly advised to have TURP. With proper assessment and staging, it is hoped that patients with BPH will not be over or undertreated, and treatment outcome will be improved.

Third chapter of surgeons lecture: revolution in urology and its evolution in Singapore.

Urology has been an evolving specialty since the time of Hippocrates. The itinerant surgeon was known to go from town to town to remove bladder stones in the early middle ages. In this century, urologists had been at the forefront in pioneering minimally invasive surgery with the introduction of transurethral resection of the prostate more than 50 years ago in the United States. This could be considered the first revolution in urology and this has influenced the evolution of urology in Singapore. Transurethral surgery had proved to be far superior to open surgery for most lesions of the lower urinary tract. This technique was introduced to Singapore in the early 1970s by Dr N E Wong. Because of the need for special instruments, skill and training, there was a need for a Department of Urology. This was not to be until after the second revolution in urology. The second revolution saw the introduction of endoscopic surgery of the upper urinary tract and Extra-corporeal Shockwave Lithotripsy in the early 1980s. This had truly revolutionised the treatment of urinary stones and today almost 95% of patients can be treated with these non to minimally invasive techniques. These new modalities of treatment were rapidly introduced in Singapore in the mid 1980s. The need for the establishment of urology as a specialty was more urgently felt. The Singapore Urological Association was formed in February 1986 and in March 1987, a Division of Urology was formed at the Singapore General Hospital.(ABSTRACT TRUNCATED AT 250 WORDS)

Current management of urinary tract stones.

A review of the current management of urinary tract stones as applied to the University Department of Surgery is presented. The use of allopurinol and alkalinisation of urine is effective in dissolution and prevention of uric acid stones. Cellulose phosphate and thiazide therapy for calcium stone formers have a limited place, as we are still unable to identify those who will benefit from such therapy in the local population. Antegrade pyelogram and percutaneous nephrostomy have useful roles to play in investigation and also management of patients with calculous anuria. The use of regional renal hypothermia has enabled us to operate with more confidence on branched or multiple renal calculi. With better visual lithotrite, more and bigger stones in the lower urinary tract can now be removed endoscopically.

Surgical causes of haematuria--the diagnostic approach.

Gross haematuria is one of the most important symptoms in urology, as one of its causes is neoplasm of the urinary tract. The other important causes are urinary stones, urinary tract infection, which may be acute or chronic, trauma, and chronic haemorrhagic radiation cystitis. The differential diagnosis of gross haematuria depends on the age and sex of the patient, and the associated symptoms. The most important associated symptom is pain.

Preliminary experience in ileal neobladder reconstruction.

In the treatment of transitional cell carcinoma of the bladder, the recent trend is towards radiation or chemotherapy which can be either regional or systemic. There have also been good results with giving Mitomycin or Bacillus Calmette Guerin instillation into the bladder for superficial tumours. There are occasions where patients present with large bulky tumours which cannot be controlled by endoscopic measures, invasion involving multiple sites and carcinoma in-situ which progresses to invasion. In these occasions, we have to resort to surgical clearance of the tumour. If it is possible, all patients would not like to wear a urinary bag for the rest of their lives. A bladder replacement if ever possible is always welcomed because the patient can pass urine from the natural passage. Due to the magnitude of a radical cystectomy and status of the urethra, it is not always technically possible to reconstruct the bladder. With improvement of operative techniques and suture materials, there has been a recent development of a method of bladder reconstruction that uses an ileal pouch. We report our early experience with this operation.

Management of severe chronic radiation cystitis.

Chronic radiation cystitis complicating pelvic irradiation can occasionally result in massive bleeding difficult to control with conventional means. Between 1986 and 1989, we managed 42 cases of chronic radiation cystitis of which nine (21%) were of this severe type based on the necessity for repeated cystodiathermy, massive transfusions and open surgical intervention. We found early cystodiathermy and alum bladder irrigation beneficial in early cases, but six (67%) patients required emergency bilateral percutaneous nephrostomies for proximal urinary diversions to help stop the bleeding. Despite aggressive treatment, two patients (22%) died during their admissions and two others (22%) died shortly after discharge. Three patients eventually required elective ileal conduit diversion for their contracted defunctioned bladder. Thus this group of patients suffered relatively high morbidity and mortality for an essentially benign condition. Increased physician awareness and timely percutaneous nephrostomies may improve results.

Is staging of benign prostatic hyperplasia (BPH) feasible?

With better understanding of the natural history of benign prostatic hyperplasia (BPH), the treatment can be tailored to the severity of the disease. The aims of this study were to determine the feasibility of staging BPH according to its severity and choose the optimal therapeutic tool for each category, and for comparing results of various modalities of treatment. Two hundred and twenty-five patients with clinical BPH were seen between October 1994 and July 1995. Initial assessment included the International Prostatic Symptom Score, and the quality of life index, digital rectal examination, urinalysis, prostate specific antigen, uroflow and residual urine estimation. Patients were then divided into: Stage 1, those with no bothersome symptoms and no significant obstruction, they can generally be watched. Stage 2, those with bothersome symptoms but without significant obstruction, they can be treated with pharmacotherapy/thermotherapy. Stage 3, those with significant obstruction defined as uroflow of less than 10 ml/s with persistent residual urine of > 100 ml, transurethral prostatic resection (TURP) would be recommended. Stage 4, those with complications of BPH such as chronic retention of urine and bladder stone, they would need TURP. One hundred and fifty-nine patients had complete follow up data of at least 2 years. Of the 70 patients who were originally in Stage 1, 59 (89%) remained in status quo, 6 patients developed acute retention of urine and only 1 required TURP. Of the 38 patients in Stage 2, 24 were down-staged to Stage 1 after medication and thermotherapy but 4 still remained in Stage 2 and the other 10 had worsening of symptoms requiring surgery. Of the 46 patients in Stage 3, 30 (65%) had TURP and all except 1 were down-staged to Stage 1. All patients in Stage 4 had TURP and improved. We conclude that staging of patients with clinical BPH is feasible. It serves as a useful guide for management and improves cost effectiveness.

Haemorrhagic papillary cystadenoma of the seminal vesicle mimicking giant seminal vesicle cyst: MRI appearances.

Papillary cystadenoma of the seminal vesicle is very rare. We describe such a case presenting in a 58 year old man with bladder outlet obstruction. Investigations included magnetic resonance imaging (MRI), the usefulness of which in pre-operative diagnosis is highlighted in this case. Seminal vesicle cysts can usually be identified by conventional radiological imaging techniques such as ultrasound and computed tomography; however, identification would be difficult if the cyst is very large, causing distortion of the adjacent anatomy. In such cases, MRI, through coronal and sagittal scanning, can be helpful in localising the lesion, as in this patient. The precise pathological nature of the cyst can only be confirmed by biopsy.