Bioinspired bi-phasic 3D nanoflowers of MgO/Mg(OH)2 coated melamine sponge as a novel bactericidal agent

By roughly mimicking the surface architectural design of dragonfly wings, novel bi-phasic 3D nanoflowers of MgO/Mg(OH)2 were successfully synthesized via the electrospinning technique. The 3D nanoflowers were coated over a commercial melamine sponge and extensively characterized by SEM, XRD, FTIR, and EDS. The formation of distinct dense 3D nano petals was revealed by SEM images whereby the mean petal thickness and mean distance between the adjacent petals were found to be 36 nm and 121 nm, respectively. The bactericidal activities of synthesized 3D nano-flowers coated melamine sponges were assessed against five different bacteria (Staphylococcus aureus, Enterococcus faecalis, Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa). This study demonstrated significant bactericidal activity of MgO/Mg(OH)2 3D nanoflowers coated MS against Gram-positive and Gram-negative bacteria. Plausible bactericidal mechanisms include envelope deformation, penetration, and induction of oxidative stress. This study introduces novel bioinspired biomaterial with the capacity to reduce the risk associated with pathogenic bacterial infections, especially in medical devices.

Technical insights to multivisceral resections using the da Vinci Xi

BACKGROUND

There have been few reports on the feasibility and safety of robotic multivisceral surgeries. The da Vinci Xi boasts significant upgrades that improve its applicability in combined resections. We report our early experience of multivisceral, multi-quadrant resections with the Xi system.

METHODS

Between May 2015 and August 2019, 13 multivisceral resections were performed. Patient demographics, procedural data, and perioperative outcomes were evaluated.

RESULTS

The procedures were completed at a median operative time of 290 (range, 210-535) minutes. The median postoperative length of hospital stay was 3.5 (range, 2-7) days. There was one case of readmission for anastomotic leak, but no positioning injuries, external robot arm collisions or issues arising from trocar position. There were no cases of perioperative mortality.

CONCLUSION

Multivisceral resections can be safely accomplished using the Xi. Further studies are necessary to ascertain whether there are benefits of the robotic approach over conventional laparoscopy in these complex cases.

Treatment of Primary Aldosteronism and Reversal of Renin Suppression Improves Left Ventricular Systolic Function

INTRODUCTION

Primary aldosteronism (PA) is associated with increased risk of cardiovascular events. However, treatment of PA has not been shown to improve left ventricular (LV) systolic function using the conventional assessment with LV ejection fraction (LVEF). We aim to use speckle-tracking echocardiography to assess for improvement in subclinical systolic function after treatment of PA.

METHODS

We prospectively recruited 57 patients with PA, who underwent 24-h ambulatory blood pressure (BP) measurements and echocardiography, including global longitudinal strain (GLS) assessment of left ventricle, at baseline and 12 months post-treatment.

RESULTS

At baseline, GLS was low in 14 of 50 (28.0%) patients. On multivariable analysis, GLS was associated with diastolic BP (P = 0.038) and glomerular filtration rate (P = 0.026). GLS improved post-surgery by -2.3, 95% CI: -3.9 to -0.6, P = 0.010, and post-medications by -1.3, 95% CI: -2.6 to 0.03, P = 0.089, whereas there were no changes in LVEF in either group. Improvement in GLS was independently correlated with baseline GLS (P < 0.001) and increase in plasma renin activity (P = 0.007). Patients with post-treatment plasma renin activity ≥1 ng/ml/h had improvements in GLS (P = 0.0019), whereas patients with persistently suppressed renin had no improvement. Post-adrenalectomy, there were also improvements in LV mass index (P = 0.012), left atrial volume index (P = 0.002), and mitral E/e' (P = 0.006), whereas it was not statistically significant in patients treated with medications.

CONCLUSION

Treatment of hyperaldosteronism is effective in improving subclinical LV systolic dysfunction. Elevation of renin levels after treatment, which reflects adequate reversal of sodium overload state, is associated with better systolic function after treatment.

CLINICAL TRIAL REGISTRATION

www.ClinicalTrials.gov, identifier: NCT03174847.

Improvement in quality of life and psychological symptoms after treatment for primary aldosteronism: Asian Cohort Study

BACKGROUND

In addition to increased cardiovascular risk, patients with primary aldosteronism (PA) also suffer from impaired health-related quality of life (HRQoL) and psychological symptoms. We assessed for changes in HRQoL and depressive symptoms in a cohort of Asian patients with PA, after surgical and medical therapy.

METHODS

Thirty-four patients with PA were prospectively recruited and completed questionnaires from 2017 to 2020. HRQoL was assessed using RAND-36 and EQ-5D-3L, and depressive symptoms were assessed using Beck Depression Inventory (BDI-II) at baseline, 6 months, and 1 year post-treatment.

RESULTS

At 1 year post-treatment, significant improvement was observed in both physical and mental summative scores of RAND-36, +3.65, P = 0.023, and +3.41, P = 0.033, respectively, as well as four subscale domains (physical functioning, bodily pain, role emotional, and mental health). Significant improvement was also seen in EQ-5D dimension of anxiety/depression at 1 year post-treatment. Patients treated with surgery (n = 21) had significant improvement in EQ-5D index score post-treatment and better EQ-5D outcomes compared to the medical group (n = 13) at 1 year post-treatment. 37.9, 41.6 and 58.6% of patients had symptoms in the cognitive, affective and somatic domains of BDI-II, respectively. There was a significant improvement in the affective domain of BDI-II at 1 year post-treatment.

CONCLUSION

Both surgical and medical therapy improve HRQoL and psychological symptoms in patients with PA, with surgery providing better outcomes. This highlights the importance of early diagnosis, accurate subtyping and appropriate treatment of PA.

Is there still a role of balloon dilatation of benign ureteric strictures in 2019?

Introduction and Objectives: Reconstructive surgery for benign ureteric strictures and long term nephrostomy are often invasive and lead to poor quality of life. Balloon dilatation has the potential to bridge this gap. We present the outcome of our series and examine the risk factors of stricture recurrence.Materials and Methods: There were 109 strictures in our series from August 2012 to July 2018 in our single center retrospective cohort analysis. All strictures were dilated retrogradely or antegradely and followed by stenting. Follow-up imaging was done to assess stricture recurrence.Results: Mean patient age was 57.7-years-old (SD ± 12.6). Mean follow-up was 20.2 months (SE ± 1.8). All strictures were successfully dilated and stented. Overall, mean patency rate was 63.7% at mean follow-up of 20.2 months (SE ± 1.8). Strictures caused by stone/inflammation had 28.0% (21/75) risk of recurrence compared to iatrogenic causes, 63.6% (7/11), and radiotherapy, 100.0% (5/5) (p = 0.001). Non-incidental strictures also had significantly higher risk of recurrence at 57.4% (27/47) vs. incidental strictures at 13.6% (6/44) (p = 0.000). The mean length of strictures was 12.5 mm (SE ± 1.7) in the recurrence group vs. 9.6 mm (SE ± 0.7) in those without recurrence (p = 0.001). The presence of ipsilateral atrophic kidney was associated with 72.2% (13/18) risk of recurrence vs. non-atrophic kidney 27.4% (20/73) (p = 0.000). The mean age of stricture was 14.5 months (SE ± 4.6) and 5.2 months (SE ± 2.1) in the recurrence and non-recurrence groups, respectively (p = 0.013).Conclusions: Balloon dilatation of benign ureteric stricture is a feasible option. Its effect can be long-lasting in selected patients, that is, non-irradiated, incidental, short strictures with normal kidneys. This will benefit patients unfit for reconstructive surgery.

Is excision necessary in the management of adult urachal remnants?: a 12-year experience at a single institution

OBJECTIVES

To determine the ideal management of uncomplicated adult urachal remnants and to confirm if conservative management with repeated imaging is acceptable.

PATIENTS AND METHODS

This is a retrospective review of clinical notes and imaging of 45 patients with a mean age of 54.6 years who had been diagnosed with urachal anomalies at a single urology tertiary centre from January 2005 to December 2016. Patients who underwent surgical intervention and findings from patients managed non-operatively, with a mean follow up of 31 months, were evaluated.

RESULTS

Thirty (66.7%) patients had incidental findings, while 15 (33.3%) were symptomatic. Eight underwent excision, one underwent an incision and drainage of abscess, while 34 of the 36 remaining patients elected to undergo surveillance with repeated ultrasound imaging. Two were lost to follow-up. Malignancy was confirmed in three patients. There was interval stability of the urachal remnant in all the patients in the non-operative cohort. The small sample size, limited follow-up, and retrospective nature of the study are recognised limitations.

CONCLUSIONS

It was found that simple and asymptomatic lesions can be monitored with ultrasound, but effort must be made on initial diagnosis to ensure that malignancy is excluded using CT imaging and flexible cystoscopy where possible. Long-term follow-up of this cohort is required to assess the natural history of observed urachal anomalies.

Urinary incontinence in female outpatients in Singapore

INTRODUCTION AND HYPOTHESIS

The aims of this study were to determine the prevalence, symptom characteristics, risk factors and impact on quality of life (QoL) of urinary incontinence (UI) in female outpatients in Singapore, to describe the attitudes of these women towards UI, and to investigate the barriers to healthcare-seeking behaviour in symptomatic women.

METHODS

This was a cross-sectional study in a convenience sample and 249 women enrolled from outpatient clinics. A modified self-administered questionnaire which included two validated instruments (the International Consultation on Incontinence Questionnaire-Urinary Incontinence short form and the Incontinence Impact Questionnaire-7) was used.

RESULTS

Questionnaires from 230 women were included in the analysis. The overall prevalence of UI was 41.74% (95% CI 35.49-48.26%). Most of the symptomatic women suffered from mild UI and the most common subtype was stress UI. Age (OR 1.03, 95% CI 1.00-1.05), vaginal delivery (OR 2.67, 95% CI 1.43-4.97) and being sexually active (OR 2.41, 95% CI 1.31-4.43) were associated with UI. Among symptomatic women, only 41.25% (95% CI 30.82-52.53%) had sought medical attention before. The most common barrier to healthcare-seeking behaviour was embarrassment. The median QoL score was 33.33, indicating a mild impact of UI on QoL. QoL score was associated with UI severity (p < 0.001).

CONCLUSIONS

Despite the high prevalence of UI, only about 41% of UI sufferers had sought medical attention before. Common barriers included embarrassment, fear of surgery and misconceptions. This study emphasizes the need for policy development for UI prevention and management in Singapore.

Ultrasound-guided percutaneous nephrolithotomy: Advantages and limitations

PURPOSE

The use of ultrasound in percutaneous nephrolithotomy (PCNL) has not been shown to translate to better clinical and stone outcomes. To compare the operative outcomes, postoperative outcomes and complication rates of ultrasound-guided access PCNL (USGA-PCNL) versus fluoroscopy-guided access PCNL (FGA-PCNL).

MATERIALS AND METHODS

A total of 184 consecutive patients who underwent PCNL from July 2008 to September 2014 were identified from our PCNL database. Seventy-two patients underwent USGA-PCNL and 112 FGA-PCNL.

RESULTS

The patients were similar in age, sex, race, American Society of Anesthesiologists physical status classification, mean largest stone diameters, side of PCNL, number of stones and the degree of hydronephrosis between both groups. There were higher rates of upper pole (5.6% vs. 3.6%), mid pole (8.3% vs. 2.7%) and multiple pole punctures (4.2% vs. 0%) in USGA-PCNL compared to FGA-PCNL (p=0.027). There was no difference in the stone free rates of both groups in univariate analysis. Those who had FGA-PCNL were 2.26 (95% confidence interval, 1.09-4.75; p=0.029) times more likely to require a second-look procedure compared to USGA-PCNL on univariate analysis but not on multivariate analysis. There were no differences in Clavien-Dindo complications. No patient in the USGA-PCNL group experienced organ injuries during puncture compared to 1 patient in the FGA-PCNL group who had pneumothorax requiring urgent chest tube insertion.

CONCLUSIONS

The use of ultrasonography to guide access puncture during PCNL eliminates the risk of inadvertent organ injuries. Similar operative and stone outcomes show that the learning curve for USGA is minimal compared to conventional FGA.

The use of antimuscarinics, phosphodiesterase type V inhibitors and phytotherapy for lower urinary tract symptoms in men

Besides the mainstay of α-blockers and 5α-reductase inhibitors, other forms of medical therapy complete the armamentarium in the treatment of lower urinary tract symptoms (LUTS) in men. These treatments can target specific symptoms as well as associated symptoms that would affect the quality of life of the patients. Many patients are bothered by storage symptoms, more so than the voiding symptoms. Antimuscarinics are efficacious and safe, provided the patients do not have high post void residual urine. Many patients with LUTS also have erectile dysfunction, and phosphodiesterase type V inhibitors are effective in relieving both LUTS as well as erectile dysfunction for such patients. Phytotherapy provides a popular and safe treatment for LUTS, however, the efficacy of the treatment has not been proven in well conducted prospective randomized controlled studies.

Spermatic cord abscess: a rare complication of epididymo-orchitis, the diagnosis and management

We present a case of a 54-year-old man who had a history of poorly controlled diabetes and end-stage renal failure on haemodialysis. He presented with an acute left groin swelling that was diagnosed to be a rare occurrence of spermatic cord abscess. Two months prior to this, he had had an episode of bacterial epididymo-orchitis that was treated with oral antibiotics. An urgent CT of the abdomen and pelvis was performed to rule out incarcerated inguinal hernia. The spermatic cord abscess was initially managed with appropriate intravenous antibiotics and ultrasound-guided percutaneous drainage. When the pus eventually accumulated in the scrotum, an open incision and drainage of the scrotum was also performed. He achieved complete resolution after 2 months.

Detection rate of prostate cancer on the basis of the vienna nomogram: a singapore study

Purpose

The purpose of this study was to determine the efficacy of the Vienna nomogram prostate biopsy model in the detection of prostate cancer in our local population. We also assessed the incidence of complications from using such a template.

Materials and Methods

From January 2006 to June 2007, 120 men with either elevated prostate-specific antigen (PSA) scores (>4 ng/mL) and/or abnormal digital rectal examination were enrolled prospectively to undergo extraction of 6 to 18 cores for transrectal ultrasound-guided prostate biopsy, as indicated by the Vienna nomogram.

Results

The mean age was 62.6±8.3 years (range, 40-86 years). The mean PSA score was 13.42 ng/mL. The mean number of cores obtained was 9.68±3.1. According to the Vienna nomogram, 27 out of a total of 120 patients had prostate cancer, for a detection rate of 22.5%. In the group of patients with PSA scores <10 ng/mL, the detection rate was 14.9% (14 of 94 patients). The group of patients with PSA scores >10 ng/mL had a detection rate of 50% (13 of 26). The complication rate in our study was 7.5%.

Conclusions

With the use of the Vienna nomogram, our prostate cancer detection rate is comparable to previously published data for Asian patients. This nomogram offers an easy tool with which to select the optimal number of prostate biopsy cores to be taken on the basis of patient age and total prostate volume. With this biopsy strategy, we also have found that the complication rate from prostate biopsy is low.

Acute Pyelonephritis and Renal Abscesses in Adults—Correlating Clinical Parameters with Radiological (Computer Tomography) Severity

Introduction: The aim of this study is to evaluate the correlations between clinical and biochemical parameters with radiological severity of CT diagnosed acute pyelonephritis (APN) and renal abscesses, thereafter defining clinical predictors to identify patients with severe APN or renal abscesses. Materials and Methods: The inpatient medical records of all patients diagnosed with APN or renal abscesses admitted over one year were reviewed. Patients with CT imaging performed were classified into 3 groups—mild APN, severe APN and renal abscesses. Clinical and biochemical parameters were correlated with radiological severity. Results: One hundred and thirty patients were included in the study. Male gender, older age, presence of diabetes mellitus and unobstructing renal stones were significantly associated with severe APN or renal abscesses. Clinical and biochemical parameters that were associated with more severe disease include a higher leucocyte count and C-reactive proteins, left neutrophil shift, thrombocytosis or thrombocytopenia, low serum albumin, acute renal impairment and bacteremia. The percentage of patients had positive urine and blood cultures were 40.8% and 30.7% respectively. Of these patients, 97.9% had severe APN or renal abscesses on CT imaging had diabetes mellitus (DM), hypotension, acute renal failure or leucocyte count of >20K. Conclusion: Our study showed a good correlation between clinical and radiological severity in adult patients with APN and renal abscesses. Patients with severe APN or renal abscesses were likely to be diabetics presenting with hypotension, acute renal impairment and a leucocyte count of greater than 20K. Key words: Computer topography (CT), Pyelonephritis, Renal abscess, Severity

Acute pyelonephritis and renal abscesses in adults--correlating clinical parameters with radiological (computer tomography) severity

INTRODUCTION

The aim of this study is to evaluate the correlations between clinical and biochemical parameters with radiological severity of CT diagnosed acute pyelonephritis (APN) and renal abscesses, thereafter defining clinical predictors to identify patients with severe APN or renal abscesses.

MATERIALS AND METHODS

The inpatient medical records of all patients diagnosed with APN or renal abscesses admitted over one year were reviewed. Patients with CT imaging performed were classified into 3 groups--mild APN, severe APN and renal abscesses. Clinical and biochemical parameters were correlated with radiological severity.

RESULTS

One hundred and thirty patients were included in the study. Male gender, older age, presence of diabetes mellitus and unobstructing renal stones were significantly associated with severe APN or renal abscesses. Clinical and biochemical parameters that were associated with more severe disease include a higher leucocyte count and C-reactive proteins, left neutrophil shift, thrombocytosis or thrombocytopenia, low serum albumin, acute renal impairment and bacteremia. The percentage of patients had positive urine and blood cultures were 40.8% and 30.7% respectively. Of these patients, 97.9% had severe APN or renal abscesses on CT imaging had diabetes mellitus (DM), hypotension, acute renal failure or leucocyte count of >20K.

CONCLUSION

Our study showed a good correlation between clinical and radiological severity in adult patients with APN and renal abscesses. Patients with severe APN or renal abscesses were likely to be diabetics presenting with hypotension, acute renal impairment and a leucocyte count of greater than 20K.

PlasmaKinetic™ (bipolar) transurethral resection of prostate: a prospective trial to study pathological artefacts, surgical parameters and clinical outcomes

INTRODUCTION

The aims of the study were to compare the degree of cautery artefacts in prostatic chips between monopolar and PlasmaKinetic™ transurethral resection of prostate (TURP), and to determine if there is any difference in the intraoperative and post surgical parameters between them.

METHODS

After institutional review board approval, patients were prospectively enrolled to undergo PlasmaKinetic™ TURP. Their parameters were compared with those of the historical monopolar TURP controls. All histological specimens were reviewed by a single senior pathologist.

RESULTS

46 patients were recruited to undergo PlasmaKinetic™ TURP. The resection time was significantly longer for the bipolar group compared to the monopolar group (50.2 versus 36.7 min, p-value is 0.001). The speed of resection (resection weight/time) was lower for the bipolar group (0.45 versus 0.56 g/min, p-value is 0.017). More irrigant was used for the bipolar group (21.2 versus 15.6 litres, p-value is 0.001) intraoperatively. There was no statistically significant difference in terms of intraoperative drop in haemoglobin and serum sodium change between the two groups. There seems to be a lesser degree of cautery artefacts in the PlasmaKinetic™ group than the monopolar group (42.17 versus 45.07 microns); however, this was not statistically significant (p-value is 0.452).

CONCLUSION

Bipolar TURP seems to result in a lesser degree of cautery artefacts when compared to conventional monopolar TURP, albeit statistically insignificant, compared to monopolar TURP. TURP also resulted in a longer resection time and increased irrigant use, but no difference in blood loss and serum sodium levels.

Ureteral diverticulosis

Ureteric pseudo-diverticulosis is an uncommon urological finding, with fewer than 150 cases reported in the literature. These are usually seen as incidental findings on retrograde pyelography. We report a case of ureteric pseudo-diverticulosis that was incidentally detected on performing ureteroscopy for an upper ureteric stone.

Presentation and progression of benign prostatic hyperplasia: a Singapore experience profiling ethnic differences in a multiracial study cohort

INTRODUCTION

While benign prostatic hyperplasia (BPH) incidence has been shown to vary by race and ethnicity, data is lacking among Asians. This study aimed to describe the baseline symptom profile and response to medical therapy in a multiracial Singaporean cohort with BPH.

MATERIALS AND METHODS

International Prostate Symptom Score (IPSS), uroflowmetry and prostate specific antigen (PSA) levels were retrospectively analysed for 887 men at presentation and on follow-up 1 year later. Following diagnosis, 150 men were managed conservatively and 586 men with drugs; 151 received surgery.

RESULTS

Overall median IPSS scores were 9.0 at baseline. Malay men most often had severe symptoms (17.3%), compared to other groups (Chinese 11.7%, Others 11.1%, Indians 10.7%). Indians most frequently showed improvement in the Quality of Life (QOL) score following intervention (64.3%). Malays had the poorest initial mean peak-flow rates (9.6 mL/s) and Chinese, the highest (12.0 mL/s). Initial post-void residual urine volume was highest in Malays (100.1 mL) but showed greatest reduction with medical treatment. Median IPSS scores decreased from 10.5 below 50 years old to 7.0 above 80 years old. Peak-flow rates were 12.6 to 7.2 mL/s respectively, with a corresponding upward trend in RU. Treatment with a combination of 5-alpha-reductase inhibitor and alpha-blocker yielded the greatest improvement in IPSS and QOL scores, and residual urine volume (71.4%, 60% and 68.8%, respectively). Indians had the lowest initial and follow-up PSA (1.5 and 1.2, P = 0.8 and 0.6, respectively).

CONCLUSIONS

Inter-ethnic differences in symptom perception and quantitative assessment of BPH were evident among our multiracial urban study cohort, as well as varied degrees of response to the medical treatments instituted.

Computer-assisted navigational surgery enhances safety in dental implantology

INTRODUCTION

Dental implants are increasingly used to restore missing dentition. These titanium implants are surgically installed in the edentulous alveolar ridge and allowed to osteointegrate with the bone during the healing phase. After osseo-integration, the implant is loaded with a prosthesis to replace the missing tooth. Conventional implant treatment planning uses study models, wax-ups and panoramic x-rays to prefabricate surgical stent to guide the preparation of the implant site. The drilling into the alveolar ridge is invariably a "blind" procedure as the part of the drill in bone is not visible. Stereotactic systems were first introduced into neurosurgery in 1986. Since then, computer-assisted navigational technology has brought major advances to neuro-, midface and orthopaedic surgeries, and more recently, to implant placement.

CLINICAL FEATURE

This paper illustrates the use of real-time computer-guided navigational technology in enhancing safety in implant surgical procedures.

OUTCOME AND CONCLUSION

Real-time computer-guided navigational technology enhances accuracy and precision of the surgical procedure, minimises complications and facilitates surgery in challenging anatomical locations.

Lower pole ratio: A new and accurate predictor of lower pole stone clearance after shockwave lithotripsy?

BACKGROUND

Lower pole spatial anatomy is an important determinant of success after extracorporeal shockwave lithotripsy. In the present study, we determine whether there is a significant relationship between lower pole ratio (infundibular length : infundibular width) on preoperative intravenous urograms and stone fragment clearances after shockwave lithotripsy.

METHODS

A total of 42 patients with isolated lower pole stones were retrospectively reviewed. Anatomical factors, such as infundibular length, width and infundibulopelvic angle were measured and the lower pole ratio was calculated on pretreatment intravenous urogram. Stone fragment clearance was assessed at three months with a plain abdominal X-ray.

RESULTS

The overall three-month stone-free rate was 62%. Mean stone size +/- SD was 10 +/- 4.8 mm, mean infundibular length was 21.7 +/- 6.9 mm, mean infundibular width was 6.1 +/- 2.3 mm, mean infundibulopelvic angle was 62.1 +/- 30.1 degrees and mean lower pole ratio was 4.3 +/- 2.8. Stone-free status after shockwave lithotripsy was significantly related to infundibular length and width as well as to lower pole ratio, but not to infundibulo-pelvic angle. Infundibular length less than 30 mm, width greater than 5 mm and lower pole ratio less than 3.5 were noted to have an improved three-month stone-free rate (P = 0.049, 0.01 and <0.01, respectively).

CONCLUSION

Caliceal anatomy is an important consideration for lower pole stone clearance after shockwave lithotripsy. The present study suggests that a lower pole ratio of less than 3.5, which considers both infundibular length and width, is a promising predictor for stone-free status.

Interaction of dense breast patterns with other breast cancer risk factors in a case-control study

The question of interactions between breast density and other breast cancer risk factors is of interest, since it bears upon the use of density as a marker for changes in breast cancer risk. We studied breast parenchymal patterns and 13 other potential risk factors for breast cancer in 172 breast cancer cases and 338 age-matched controls in Singapore. Dense breast patterns were defined as having Tabar parenchymal pattern IV or V. We found significant interactions between dense patterns and ethnic group (P=0.046), and between dense patterns and number of deliveries (P=0.04). Among women with nondense breast patterns, the non-Chinese had lower risk than the Chinese with an odds ratio (OR) of 0.47 (95% CI 0.24, 0.88), whereas in those with dense patterns, the non-Chinese had considerably higher risks (OR=5.34, 95% CI 0.54, 52.51). Alternatively expressed, the increased risk with dense patterns was only observed in the non-Chinese (OR=13.99, 95% CI 1.33, 146.99). Among parous women, the protective effect of three or more deliveries was only observed in those with dense breast patterns (OR=0.21, 95% CI 0.06, 0.70). Suggestive but nonsignificant interactions with dense patterns were observed for ever having delivered, age at first delivery, breast feeding and body mass index. The results are consistent with dense breast patterns as a marker for hormonal modification of breast cancer risk.

Extracorporeal shockwave lithotripsy and intracorporeal lithotripsy for proximal ureteric calculi--a comparative assessment of efficacy and safety

INTRODUCTION

Extracorporeal shockwave lithotripsy (ESWL) is the treatment modality of choice of many urologists for proximal ureteric calculi. In this study, we compared the efficacy and safety of ESWL versus ureteroscopy with holmium laser lithotripsy for the treatment of this group of stones.

MATERIALS AND METHODS

Between May 1999 and October 2000, 50 patients had ESWL and another 51 patients underwent ureteroscopy with holmium laser lithotripsy for proximal ureteric calculi. The two groups were similar in age, sex ratio and stone size. ESWL was performed with the Dornier Compact lithotriptor whereas holmium laser lithotripsy was performed via retrograde ureteric access with a Wolf 7.5 Fr semirigid ureteroscope.

RESULTS

Ureteroscopy with holmium laser lithotripsy was significantly better in terms of the mean procedure time (56 min in ESWL; 25 min in ureteroscopy; P < 0.001) and the 1-month stone free rate (50% in ESWL; 80% in ureteroscopy; P = 0.001). The 3-month stone free rate was also higher for ureteroscopy (78% in ESWL; 90% in ureteroscopy) but this difference was not statistically significant (P = 0.09). Minor complications of steinstrasse (6%) occurred in ESWL and proximal stone migration (8%) occurred during ureteroscopy.

CONCLUSION

Ureteroscopy with holmium laser lithotripsy is a viable and safe alternative to ESWL for the management of proximal ureteric calculi.

Non-consensual double reading in the Singapore Breast Screening Project: benefits and limitations

INTRODUCTION

The aims of this study were to assess the efficacy of non-consensual double reading (against single reading) in the Singapore Breast Screening Project (SBSP) and to compare the benefits (increase in cancer detection) and limitations (increase in recall and biopsy) with published data.

MATERIALS AND METHODS

The data from the SBSP was retrospectively analysed and the recommendations of the first and second readers were evaluated separately with regards to rate of recall, biopsy and cancer detection. The mean second screener contribution (MSSC) was also calculated for double reading.

RESULTS

In the SBSP, double reading detected 7 additional cancers (5.2% of cancers detected) compared with single reading and the MSCC was 5.5%. Double reading also resulted in 632 additional recalls, with a decrease in the positive predictive value (PPV) of cancer in the recalled women from 8.2% for single reading to 6.1% for double reading. An additional 30 biopsies were performed with double reading which represented a small decrease in PPV (41% compared to 42.9% for single reading).

CONCLUSION

In the SBSP, non-consensual double reading (compared to single reading) resulted in a modest increase in cancer detection (MSSC, 5.5%) with a modest decrease in PPV of recall (2.1%) and biopsy (1.9%). These findings were consistent with that of published data and non-consensual double reading is thus recommended.

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.

Computerized detection of breast cancer with artificial intelligence and thermograms

This paper shows the concurrent use of thermography and artificial neural networks (ANN) for the diagnosis of breast cancer, a disease that is growing in prominence in women all over the world. It has been reported that breast thermography itself could detect breast cancer up to 10 years earlier than the conventional golden methods such as mammography, in particular in the younger patient. However, the accuracy of thermography is dependent on many factors such as the symmetry of the breasts' temperature and temperature stability. A woman's body temperature is known to be stable in certain periods after menstruation and it was found that the accuracy of thermography in women whose thermal images are taken in a suitable period (5th - 12th and 21st day of menstruation) is higher (80%) than the total population of patients (73%). The stability of the body temperature will depend on physiological state. This paper examines the use of ANN to complement the infrared heat radiating from the surface of the body with other physiological data. Four backpropagation neural networks were developed and trained using the results from the Singapore General Hospital patients' physiological data and thermographs. Owing to the inaccuracies found in thermography and the low population size gathered for this project, the networks developed could only accurately diagnose about 61.54% of the breast cancer cases. Nevertheless, the basic neural network framework has been established and it has great potential for future development of an intelligent breast cancer diagnosis system. This would be especially useful to the teenagers and young adults who are unsuitable for mammography at a young age. An intelligent breast thermography-neural network will be able to give an accurate diagnosis of breast cancer and can make a positive impact on breast disease detection.

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.

Penile colour duplex ultrasonography as a screening tool for venogenic erectile dysfunction

INTRODUCTION

Vasculogenic impotence is one of the major causes of erectile dysfunction. Cavernosometry and cavernosography is traditionally the gold standard for evaluation of venogenic impotence. However, it is invasive and there are potentially significant complications. Penile colour flow Doppler imaging (PCDI) is non-invasive and can be used to assess venous incompetence.

MATERIALS AND METHODS

One hundred and sixty-eight patients were referred for PCDI assessment from March 1998 to February 2001. Forty-three of these also had cavernosogram and cavernosometry done and were included in the study.

RESULTS

The sensitivity was 93.9%, the specificity was 90.0%, the accuracy was 93.0% with a negative predictive value of 81.8% and a positive predictive value of 96.9%. Kappa value of 0.81 was obtained, indicating excellent agreement between PCDI and cavernosogram and cavernometry.

CONCLUSIONS

Penile colour flow Doppler imaging is accurate in the assessment of venogenic erectile dysfunction. It can replace cavernometry and cavernosogram as a screening tool. Cavernometry and cavernosogram should only be done in cases when PCDI suggests venogenic impotence, and when surgery is contemplated.

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.

Adrenal myelolipoma presenting with spontaneous retroperitoneal haemorrhage demonstrated on computed tomography and angiogram--a case report

INTRODUCTION

A rare case of adrenal myelolipoma presenting with spontaneous rupture and retroperitoneal haemorrhage is described.

CLINICAL PICTURE

A 51-year-old Caucasian male presented with acute onset of right loin pain. Preliminary diagnosis of haemorrhagic adrenal tumour was made on computed tomography (CT) and angiography.

TREATMENT

Vascular embolisation was performed to stabilise the patient prior to definitive surgery. Tumour resection was subsequently performed. Histology confirmed ruptured adrenal myelolipoma.

OUTCOME

The patient made an uneventful recovery.

CONCLUSION

Ruptured adrenal myelolipoma should be considered in cases of spontaneous retroperitoneal haemorrhage. Vascular embolisation may be useful in stabilising the patient prior to definitive surgery.

Holmium laser lithotripsy in the management of ureteric calculi

INTRODUCTION

To evaluate the efficacy and safety of the holmium:YAG laser in retrograde ureteroscopic laser lithotripsy of ureteric calculi.

METHODS

Three hundred and twenty-five patients (256 males and 69 females) with mean age of 45 years underwent 328 retrograde ureteroscopic laser lithotripsy as the primary therapy for ureteric calculi using semirigid mini-ureteroscopes and the holmium:YAG laser (Coherent, Palo Alto, California, USA). Four consultants and three registrars performed the procedures over a period of 31 months.

RESULTS

The mean largest diameter of the calculi was 8.4 mm. The mean hospital stay was 1.8 days and the mean duration for the operation was 25 minutes. One hundred and twenty-two (37%) procedures were done as day surgery cases. Complete stone-free rates after single primary treatment using only the holmium:YAG laser were 75% and 91% at 4 weeks and 12 weeks of follow-up, respectively. Including 22 (7.6%) renal units which required additional procedures, the overall stone-free rate was 97%. Seventeen cases (5.2%) needed additional extracorporeal shock wave lithotripsy (ESWL) and 5 cases (1.5%) needed an additional repeat ureteroscopy and lithotripsy for complete stone clearance. Significant complications include 1 case of ureteric perforation.

CONCLUSIONS

The holmium:YAG is a safe and effective intracorporeal lithotripter when deployed in a retrograde manner in conjunction with a mini-ureteroscope.

Statistical analysis of healthy and malignant breast thermography

Analysis of thermograms has often been subjective and has resulted in inconsistency in the diagnosis of breast diseases by thermography. The aim of this paper is to study the problem of subjective interpretation of breast thermograms and hence using thermography as an adjunct tool for breast cancer diagnosis. It ws proposed that the thermograms should be taken within the recommended screening period, classified and analysed in conjunction with an artificial neural network (ANN). Qualitative interpretation of thermal images can be carried out using an active contours algorithm. The 256 x 200 pixel image can be segmented as one of the inputs to the ANN. To achieve quantitative analysis of the breast thermograms, firstly the inputs of the ANN should be determined, so that the thermograms could be successfuly classified and based on the suggested inputs.

Pathologic-radiologic correlations in screen-detected ductal carcinoma in situ of the breast: findings of the Singapore breast screening project

Mammography detected 34 (25%) cases of ductal carcinoma in situ (DCIS) of the breast out of a total of 135 cancers diagnosed in 28, 231 participating women during the Singapore breast screening project. Radiologic findings in these 34 women with DCIS were calcifications only in 25 (74%); mass only in 2 (6%); and mass with calcifications in the remaining 7 (20%) cases. Calcifications were classified mammographically as powderish in 2 (6%), crushed stone-like in 16 (50%) and casting in 14 (44%) cases. Pathologic assessment revealed 11 (32%) cases with pure comedo, 16 (47%) mixed, 3 (9%) cribriform, 2 (6%) papillary, 1 (3%) micropapillary and 1 (3%) solid patterns. Histologic nuclear grade was low in 6 (18%), intermediate in 9 (26%) and high in 19 (56%). Necrosis was observed in 26 (77%) cases and absent in the rest. Pathologic-radiologic correlations yielded a significant association between the mammographic and pathologic lesional size, with the degree of agreement improved when there was histologic necrosis. A trend for radiologic crushed stone-like and casting-type calcifications to be associated with DCIS with necrosis and of higher nuclear grade was noted. Int. J. Cancer (Radiat. Oncol. Invest.) 90, 231-236 (2000).

Spectrum of abnormal mammographic findings and their predictive value for malignancy in Singaporean women from a population screening trial

INTRODUCTION

The ability to categorise mammographic features according to their likelihood of malignancy would be valuable in the management of women with abnormal mammograms. The aim of our study was to correlate abnormal mammographic features in a screened population with their histology to identify those features which are predictive of malignancy. The study also examined the spectrum of mammographic features in an Asian population.

MATERIALS AND METHOD

This prospective study involved 28,231 women who were randomly selected from a population registry and underwent two-view screening mammography without physical examination. Women with suspicious lesions were recalled for further mammographic views or to a joint assessment clinic prior to biopsy. Mammographic abnormalities and their corresponding histology were assessed.

RESULTS

The spectrum of mammographic abnormalities was similar to that in Caucasian populations. The positive predictive value for malignancy was 44.1% of all biopsied cases. Mammographic features could be broadly classified into low-, moderate- and high-risk categories for malignancy. Those features which correspond to high malignancy rates (9.8% to 16.0%) include multiple abnormalities or parenchymal lesions with microcalcifications. The presence of microcalcifications was a good predictor of ductal carcinoma-in-situ (DCIS): 46% of lesions in which the microcalcifications were the sole abnormality were DCIS only. Further, 71% of cancers with any microcalcification on the mammogram had a focus of DCIS on histology.

CONCLUSION

Mammographic abnormalities can be segregated into three risk groups for malignancy, and this in turn can improve the selection criteria for breast biopsy, hence reducing unnecessary intervention. Furthermore, the presence of microcalcifications denotes the presence of DCIS, and would be an important determinant of the extent of surgical excision.

Mammographic parenchymal patterns and risk of breast cancer at and after a prevalence screen in Singaporean women

BACKGROUND

The objective of this study was to assess the effect of mammographic parenchymal patterns on risk of breast cancer detected at first screen or in the period following a negative screen.

METHODS

The study utilizes a nested case-control design with 132 breast cancer patients detected at first screen (from a total of 29 193 screened) and 42 breast cancer patients detected in the period following the first screen. These patients were matched to 348 screened-negative controls. The mammograms were classified according to Tabar's classification for parenchymal pattern and statistical analysis was done by conditional logistic regression.

RESULTS

The risk of breast cancer for women with Tabar pattern IV was significantly high when compared to the remaining patterns (odds ratio 2.59). Risk factors for Tabar pattern IV coincided largely with established risk factors for breast cancer.

CONCLUSION

The study confirms the increased risk of breast cancer associated with Tabar pattern IV (approximately Wolfe pattern P2), in an Asian population. This pattern is associated with nulliparity and high educational status and is strongly associated with grade 3 cancers.

Screen detected breast cancer in an Asian population: pathological findings of the Singapore breast screening project

We document the pathological characteristics of 135 cancers detected in 132 predominantly Chinese women in the Singapore breast screening project. Thirty-four (25%) screen detected tumours were in situ ductal cancers; 98 (73%) invasive, while three (2%) women with malignant fine needle aspirate smears refused further treatment. The median size of in situ cancers was 10 mm; the majority (56%) demonstrated a comedo pattern. Of the invasive tumours which had a median size of 15 mm, three (3%) were microinvasive, 75 (77%) infiltrative ductal, three (3%) invasive lobular, and the remaining 17 (17%) special types or others. Histologic grading revealed 23 (24%) grade I, 52 (53%) grade II, 19 (19%) grade III and four (4%) ungraded cases. Sixty-three (65%) of the invasive cancers were node negative, while 64% of all screen detected malignancies were Stages 0 (in situ) or I. From the pathological perspective, problems of borderline lesions, microinvasion, grade assessment and histological subtyping have to be addressed.

Results of intermediate measures from a population-based, randomized trial of mammographic screening prevalence and detection of breast carcinoma among Asian women: the Singapore Breast Screening Project

BACKGROUND

Although increasing rates of breast carcinoma incidence have been observed in Asian countries, appropriate strategies for detecting early stage breast carcinoma in such communities have been difficult to formulate, particularly because no large population screening trial specifically involving Asian women has been reported. The objective of this study was to evaluate the effectiveness and quality of mammography as a screening technique for Singaporean women, who are predominantly Chinese.

METHODS

In this prospective study, 166,600 women in Singapore ages 50-64 years were randomized to either 2-view mammography without physical examination (67,656) or observation (97,294, controls) over 2 years.

RESULTS

Of these women, 28,231 (41.7%) responded and were screened; they were more likely to be married, have more formal education, be working, be Chinese, and be in a higher socioeconomic group (P < 0.001 for all variables). To assess for response bias that could affect outcome, results were also evaluated for nonrespondents (n = 39,425). The incidence rate of cancers among nonrespondents (1 per 1000 woman-years) was less than the 1.3 in women not invited to have screening (P = 0.03, relative risk [RR], 1.3; 95% confidence interval [CI], 1.0-1.7). However, cancers arising from nonrespondents did not differ significantly in stage distribution when compared with cancers within the control group. For every 1000 women screened, 4.8 cancers were detected. The prevalence ratio (the number of cancers detected per 1000 women at first screening divided by the corresponding incidence rate in controls per year) was 3.6 for screened women and 2.4 for women invited to have screening. The majority of cancers detected through screening were early stage, with 64% as either ductal carcinoma in situ (26%) or Stage I disease (38%) and was significantly more than the corresponding 26% in women not invited to have screening (P < 0.001). When only invasive cancers were considered, screened women still had more early cancers, with 65% having no lymph node involvement, compared with 47% in the group not invited to have screening (P = 0.001; RR, 1.4; 95% CI, 1.2-1.7). Women who were screened had half the risk of having Stage II or later cancers (P < 0.0001; RR, 0.5; 95% CI, 0.4-0.7) when compared with women not invited to have screening. This higher detection rate of early cancers through screening was accomplished with acceptable recall rates of 8% for further mammographic films or physical examination and a biopsy rate of 1.0% (10 per 1000 women screened). The interval cancer rate was 2.1 per 10,000 women screened in the first year of follow-up.

CONCLUSIONS

These positive results of intermediate measures suggest that, in Asian communities, screening mammography could be an important modality for detecting early stage breast carcinoma. However, the low compliance rates suggest that health education efforts must focus on issues related to acceptability if such programs are to succeed.

Electrohydraulic lithotripsy: an effective and economical modality of endoscopic ureteric lithotripsy

BACKGROUND

Electrohydraulic lithotripsy (EHL) has been available for endoscopic treatment of urinary calculi since 1960, but the large probe size and concerns regarding safety had previously restricted its use to the treatment of bladder calculi. However, recent refinements have made it particularly suitable for the treatment of ureteric calculi.

METHODS

The authors report their initial experience using EHL in conjunction with mini-ureteroscopy in the treatment of 94 ureteric calculi in 89 patients. The size of the calculi ranged from 3 to 19 mm in diameter, with a mean of 8.2 mm. The mean operating time was 29 min, ranging from 10 to 120 min.

RESULTS

A complete fragmentation rate of 91.5% of the calculi was achieved. There were no major complications and a low incidence of minor complications: haematuria (2.2%), urinary tract infection (3.4%) and postoperative ureteric colic (2.2%). There were four cases of minor ureteric perforations (4.5%); all were successfully treated using conservative measures.

CONCLUSIONS

It is concluded that EHL is a safe and effective method of treating ureteric calculi.

Venous ligation for cavernous leak impotence--a report on 30 cases

We report our experience with the surgical treatment of 30 patients with venous leak impotence seen at the Division of Urology, Toa Payoh Hospital, over a period from April 1991 to August 1993. The patients were assessed by history, clinical examination, hormonal evaluation and intracavernosal injection of papaverine. Confirmation of venous leak impotence was obtained by pharmaco-cavernosography in all patients; dynamic cavernosometry was performed in the later part of the series. Surgical treatment consisted of ligation and stripping of the deep dorsal vein, ligation of all its emissary and circumflex tributaries for all patients, with crural plication and suspensory ligament re-approximation in selected patients. Peroperative intracavernosal injection of papaverine was used to identify veins and to assess the adequacy of the extent of venous ligation. The mean age of the patients was 40 years. The average operative time was 2 hours. The usual period of hospitalisation was 3 days. Patients were followed up for an average period of 15.6 months. Success was defined as having adequate erections for normal coitus; the success rates at 1, 3, 6, 9 and 12 months were 76.2%, 61.9%, 52.4%, 42.9% and 38.1%, respectively.

Laparoscopic varicocelectomy: technique and results

OBJECTIVE

To determine the safety and efficacy of laparoscopic varicocelectomy in the treatment of symptomatic varicocele.

PATIENTS AND METHODS

Indications for surgery were subfertility in 98 patients and pain in nine. All varicoceles were confirmed on Doppler ultrasound. Seventy-two per cent of the patients had left-sided varicoceles and bilateral varicoceles were seen in 27%. A three-puncture technique was used with carbon dioxide insufflation. The spermatic vessels were individually identified and clips were used to ligate the veins. The spermatic artery was preserved in all cases. The operation was performed on a day surgery basis with an average operative time of 61.4 min (56.6 min for unilateral and 75.8 min for bilateral varicocelectomy).

RESULTS

Morbidity was low, with pneumoscrotum in two patients and wound infection in two others. Sixty-one patients for whom pre- and post-operative seminal analyses were available showed improvement in sperm count and motility, with a concomitant fall in the percentage of abnormal sperm forms.

CONCLUSION

Laparoscopic varicocelectomy is safe and effective, causing minimal discomfort and allowing patients an early return to activity.

Adenosquamous carcinoma of the ileum--a case report

Small bowel malignancies are very uncommon and adenosquamous carcinomas of the small intestine are extremely rare. We report the second case of an adenosquamous carcinoma of the ileum in a 77-year-old Chinese male.

Experience with laparoscopic cholecystectomy at the Toa Payoh Hospital

A retrospective analysis was done of 88 cases of laparoscopic cholecystectomy performed by the first author from November 1990 to March 1992 at the Toa Payoh Hospital. There were 61 female and 27 male patients; the average age was 47.1 years. The most common presenting symptom was biliary colic (85.3%), followed by acute cholecystitis (10.2%) and gallstone pancreatitis (4.5%). In the vast majority of patients, the diagnosis was established by ultrasound (96.6%) while the remainder was diagnosed by oral cholecystography (3.4%). The operation was performed using the usual 4 puncture approach with the single-handed technique of dissection. Antibiotic prophylaxis with a broad-spectrum agent was used in all patients and there was no incidence of wound infection. A low complication rate of 4.5% was experienced--consisting of 1 case each of subcutaneous emphysema, abdominal colic, fever and bile duct injury. There was no mortality in our series. The conversion rate was 9.1% and this was due to our policy of performing laparotomy whenever the safety of laparoscopic surgery was in doubt. The mean duration of postoperative hospitalisation was 3 days and 7 days after laparoscopic and converted cholecystectomies respectively. The majority of patients (61.4%) returned to work after 2 weeks.

Operative cholangiography

Retrospective analysis of 174 operative cholangiograms done over a 3-year period confirms its substantial benefit when used selectively in patients with clinical criteria for common bile duct exploration. A low incidental ductal stone rate of 1.6%, together with a 3.3% false positive cholangiogram rate and a case of bile duct injury resulting from the procedure makes its routine application appear superfluous.

Pulsed Dye Laser Lithotripsy-the Toa Payoh Hospital Experience

We report our experience with pulsed dye laser lithotripsy in the treatment of 100 ureteric stones in 95 patients over a 14-month period from July 1989 to September 1990. The overall rate of successful stone fragmentation was 97%. There was a low incidence of minor complications--mild haematuria, ureteric colic and urinary tract infection; ureteric perforation occurred in only 3 patients, all of whom were successfully treated conservatively. Pulsed dye laser lithotripsy is a safe and effective mode of treatment for ureteric stones. Current indications for laser fragmentation of stones are ureteric stones, impacted pelviureteric junction stones and Steinstrasse.

Erectile dysfunction in Singapore men: presentation, diagnosis, treatment and results

Three hundred and thirteen new cases were seen in more than two years at the Sexual Dysfunction Clinic at the Division of Urology, Toa Payoh Hospital (TPH). Patients were assessed by history, clinical examination, psychological evaluation, hormonal and biochemical tests; special investigations such as monitoring of nocturnal penile tumescence, cavernosography, selective pudendal arteriography and tests of neurological function were performed where indicated. Two hundred and twenty-seven patients (72.5%) had impotence due to organic causes while 86 patients (27.5%) were found to have psychogenic impotence. Diabetes mellitus and vascular disease account for the large proportion of organic impotence (81%). Patients with psychogenic impotence responded fairly well to psychosexual therapy and drug treatment in certain cases. Forty-four patients underwent medical therapy which consisted mainly of pharmacologically induced penile erections by the use of papaverine, phentolamine or prostaglandin E-1; 21 patients (48%) who were on self-injection therapy became non-compliant subsequently. One hundred and fourteen andropausal patients with low testosterone levels received hormonal replacement. Thirty-one patients underwent surgery--stripping and ligation of the deep dorsal vein of the penis (13 patients), microsurgical arterial revascularisation (two patients) and penile prosthetic implantation (16 patients). Our success rates for the operations were 54%, 100% and 88% respectively.