Synchronous nephrectomy with unilateral dual kidney transplantation: feasibility in patients with adult polycystic kidney disease

Adult polycystic kidney disease (APKD) accounts for 2% of end-stage renal disease in Singapore and is a major indication for kidney transplantation. We report synchronous nephrectomy with unilateral cadaveric dual kidney transplantation (DKT) in a patient with APKD. Simple nephrectomy of the right native 27-cm polycystic kidney was performed to provide adequate space for unilateral DKT. Right donor kidney transplantation was performed at the site of native nephrectomy. End-to-side anastomosis of the right donor renal vein to the distal inferior vena cava and the right donor artery to the common iliac artery were performed. Left donor kidney was transplanted below the right kidney, with its vessels anastomosed to the right external iliac vessels. Ureter anastomosis was performed after perfusion of both kidneys. Lich-Gregoir anastomosis of the left donor ureter to the bladder and direct right donor ureter to native ureter anastomosis was established. This case illustrates that synchronous nephrectomy with DKT is feasible to facilitate implantation on the same side.

Renal autotransplantation following long segment iatrogenic ureteric injury

The authors describe a case of iatrogenic right ureteric injury post duodenectomy and right hemi-colectomy. Renal autotransplantation was chosen as the treatment for the upper ureteric injury. This was successfully performed and the renal function of the transplanted kidney was subsequently preserved. The advantages and disadvantages of this approach are discussed.

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

INTRODUCTION

This study aimed to evaluate the risk of complications for patients who received periprosthetic nerve block (PPNB) with one percent lignocaine before transrectal ultrasonography (TRUS) biopsy of the prostate.

METHODS

From 2008 to 2009, data on 526 consecutive patients who underwent prostate biopsy was prospectively recorded and analysed. 475 (90.3 percent) patients received PPNB with 10 ml of one percent lignocaine (Group 1), which was carried out under TRUS-guidance and prior to biopsy. 51 (9.7 percent) patients received diclofenac (100 mg) intramuscular injections or no analgesia (Group 2). Complications were defined as any adverse effects after biopsy. Serious complications were defined as those requiring hospitalisation or invasive/operative procedures for treatment.

RESULTS

At baseline, both groups were comparable. The mean prostate-specific antigen level in Group 1 was higher than that in Group 2 (48.6 +/- 13.8 versus 19.0 +/- 4.3 ng/ml; p-value is 0.04). There was no perioperative mortality. Post-procedural complications were reported in 23.4 percent (n is 111) of patients in Group 1 and 25.5 percent (n is 13) in Group 2 (p-value is 0.27). Serious complications were reported in 2.5 percent (n is 12) and 7.1 percent (n is 3) of Group 1 and 2 patients (p-value is 0.10), respectively. Both univariable and logistic regression revealed age below 65 years and pre-procedure complaints of lower urinary tract symptoms as independent predictors for complications (p-values are 0.02 and 0.006, respectively).

CONCLUSION

PPNB with one percent lignocaine is a safe analgesic procedure to perform in patients undergoing TRUS biopsy.

Impact of Kidney Disease Outcomes Quality Initiative guidelines on the prevalence of chronic kidney disease after living donor nephrectomy

PURPOSE

We evaluated the prevalence of chronic kidney disease stage 3 or worse based on the National Kidney Foundation Kidney Disease Outcomes Quality Initiative guidelines after living kidney donation at a single institution.

MATERIALS AND METHODS

The collected data of 86 consecutive patients who underwent uneventful donor nephrectomy between 1987 and 2008 were evaluated retrospectively. Estimated glomerular filtration rate was determined using the Modification of Diet in Renal Disease from serum creatinine levels collected before and after surgery in kidney donor followup clinics. Chronic kidney disease was defined as an estimated glomerular filtration rate of less than 60 ml/minute/1.73 m(2) according to the Kidney Disease Outcomes Quality Initiative guidelines. Cox regression analyses were then used to determine the impact of predictors on the development of chronic kidney disease.

RESULTS

All donors (mean age 41.2, SD 9.9 years) had a mean preoperative estimated glomerular filtration rate of 88.7 ml/min/1.73 m(2) (SD 16.3). Median followup was 6.4 years (range 0.9 to 21.0). Progression to stage 3 or worse chronic kidney disease was seen in 24.4% (95% CI 15.2-33.7) of patients. There were 2 patient deaths secondary to cancer and none required dialysis. Multivariable analysis showed that preoperative estimated glomerular filtration rate less than 82 ml/minute/1.73 m(2) was an independent risk factor for post-donation chronic kidney disease. For every 1 ml/minute/1.73 m(2) increase in baseline estimated glomerular filtration rate, the hazard of postoperative chronic kidney disease was reduced by 7% (HR 0.93, 95% CI 0.89-0.97, p = 0.001).

CONCLUSIONS

Kidney Disease Outcomes Quality Initiative stage 3 chronic kidney disease or worse occurs in 24.4% of kidney donors. Long-term prospective studies and closer followup of donors are needed to identify its implications, given the associated risk of cardiovascular diseases with chronic kidney disease in the general population.

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

OBJECTIVE

To compare the efficacy of Alfuzosin XL 10 mg once daily for the acute management of acute urinary retention (AUR) with placebo in patients with benign prostatic hyperplasia (BPH) and to determine the predictors that impact this.

METHODS

67 patients presenting with an initial episode of spontaneous AUR secondary to BPH were catheterized and were then prospectively randomized to receiving placebo or 10 mg Alfuzosin XL once daily for 2 days. The allocation and administration of treatment were double-blinded. The primary outcome measure was the rate of successful trial off catheter (TWOC) after 2 days. Clinical characteristics including intravesical prostatic protrusion (IPP) by transabdominal ultrasound were also assessed using uni- and multivariate analysis for their impact on successful TWOC.

RESULTS

Three patients withdrew from the study, 2 due to adverse effects of the trial medication. Analysis on an intention-to-treat basis showed a significantly greater proportion of patients in the Alfuzosin XL group (21 of 35 or 60%) had a successful TWOC compared with patients in the placebo group (11 of 32 or 34%) (p = 0.036). Patients with grade 3 IPP (>10 mm) had a significantly lower chance of successful TWOC (p = 0.04) compared to grade 1 (<or=5 mm) and 2 (6-10 mm). It remained a significant independent predictor for failed TWOC after AUR (p = 0.034) on multivariate analysis.

CONCLUSION

The administration of Alfuzosin XL prior to TWOC following AUR secondary to BPH increases the chance of successful catheter removal. Patients with IPP >10 mm are more likely to fail TWOC on Alfuzosin XL.

Botulinum Toxin Type A for Refractory Neurogenic Detrusor Overactivity in Spinal Cord Injured Patients in Singapore

Introduction: Managing neurogenic detrusor overactivity (NDO) successfully in spinal cord-injured patients is a challenge. The aims of preserving kidney function by achieving safe bladder pressures with anticholinergic medication often leave a significant proportion of patients with side effects. Botulinum toxin type A has been shown to be a promising alternative. Materials and Methods: Spinal cord injury patients who had NDO, on clean intermittent self-catheterisation, and were refractory to oral medications, were recruited. Three hundred units of botulinum toxin type A (Botox) in 30 mL NaCl solution were injected under cystoscopic guidance into the bladder. Results: Fifteen patients were recruited of whom 9 were tetraplegic and 6 were paraplegic. Eleven (73.3%) had complete injuries. There was a significant reduction in the mean number of leakages from 3.75 ± 1.79 pre-injection to 0.67 ± 1.31 and 1.5 ± 1.5 at 6 and 26 weeks post-injection, respectively (P <0.05). Seventy-five per cent, 37.5% and 50% were completely dry at 6, 26 and 39 weeks post-injection, respectively. The mean maximal catheterisable volume increased from 312.3 ± 145.6 mL pre-injection to 484.6 ± 190 mL, 422.3 ± 157.3 mL and 490.0 ± 230.4 mL at 6, 26 and 39 weeks post-injection, respectively (P <0.005). Maximum detrusor pressure decreased significantly from 66.3 ± 22.6 cmH2O to 21.2 ± 23.1 cmH2O and 33.6 ± 30.2 cmH2O at 6 and 26 weeks post-injection, respectively (P <0.05). The volume at which reflex detrusor contractions first occurred increased from 127.8 ± 57.5 mL pre-injury to 305.7 ± 130.8 mL at 6 weeks and 288.3 ± 13.0 mL at 26 weeks post-injection (P <0.05). Mean cysometric bladder capacity increased from 187.8 ± 69.2 mL to 305 ± 136.4 mL and 288.3 ± 13.0 mL at 6 and 26 weeks post- injury, respectively (P <0.05). Sixty per cent of patients were completely off medications at 6 and 26 weeks post-injection. One patient had urinary tract infection and 1 experienced autonomic dysreflexia during cystoscopy. Satisfaction levels increased from 4.3 ± 2.3 pre-injury to 7.2 ± 1.9 and 7.3 ± 2.3 at 6 weeks and 26 weeks, respectively. This also correlated with fewer leakages. Conclusion: Botulinum toxin type A injected into the detrusor is safe and efficacious for spinal cord injured patients with refractory detrusor overactivity. This effect is maintained at 26 weeks post-injection. Key words: Anticholinergics, Spinal cord injury, Urodynamics, Voiding

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

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

Botulinum toxin type A for refractory neurogenic detrusor overactivity in spinal cord injured patients in Singapore

INTRODUCTION

Managing neurogenic detrusor overactivity (NDO) successfully in spinal cord-injured patients is a challenge. The aims of preserving kidney function by achieving safe bladder pressures with anticholinergic medication often leave a significant proportion of patients with side effects. Botulinum toxin type A has been shown to be a promising alternative.

MATERIALS AND METHODS

Spinal cord injury patients who had NDO, on clean intermittent self-catheterisation, and were refractory to oral medications, were recruited. Three hundred units of botulinum toxin type A (Botox) in 30 mL NaCl solution were injected under cystoscopic guidance into the bladder.

RESULTS

Fifteen patients were recruited of whom 9 were tetraplegic and 6 were paraplegic. Eleven (73.3%) had complete injuries. There was a significant reduction in the mean number of leakages from 3.75 +/- 1.79 pre-injection to 0.67 +/- 1.31 and 1.5 +/- 1.5 at 6 and 26 weeks postinjection, respectively (P <0.05). Seventy-five per cent, 37.5% and 50% were completely dry at 6, 26 and 39 weeks post-injection, respectively. The mean maximal catheterisable volume increased from 312.3 +/- 145.6 mL pre-injection to 484.6 +/- 190 mL, 422.3 +/- 157.3 mL and 490.0 +/- 230.4 mL at 6, 26 and 39 weeks post-injection, respectively (P <0.005). Maximum detrusor pressure decreased significantly from 66.3 +/- 22.6 cmH2O to 21.2 +/- 23.1 cmH2O and 33.6 +/- 30.2 cmH2O at 6 and 26 weeks post-injection, respectively (P <0.05). The volume at which reflex detrusor contractions first occurred increased from 127.8 +/- 57.5 mL pre-injury to 305.7 +/- 130.8 mL at 6 weeks and 288.3 +/- 13.0 mL at 26 weeks post-injection (P <0.05). Mean cysometric bladder capacity increased from 187.8 +/- 69.2 mL to 305 +/- 136.4 mL and 288.3 +/- 13.0 mL at 6 and 26 weeks post-injury, respectively (P <0.05). Sixty per cent of patients were completely off medications at 6 and 26 weeks post-injection. One patient had urinary tract infection and 1 experienced autonomic dysreflexia during cystoscopy. Satisfaction levels increased from 4.3 +/- 2.3 pre-injury to 7.2 +/- 1.9 and 7.3 +/- 2.3 at 6 weeks and 26 weeks, respectively. This also correlated with fewer leakages.

CONCLUSION

Botulinum toxin type A injected into the detrusor is safe and efficacious for spinal cord injured patients with refractory detrusor overactivity. This effect is maintained at 26 weeks post-injection.

Antegrade ureteral intussusception: A rare complication of percutaneous endopyelotomy

Ureter intussusception is a rarely reported event and is usually secondary to a ureteral lesion. We report a case of a 15-year-old boy developing antegrade ureteral intussusception secondary to percutaneous endopyelotomy performed for pelvicaliceal junction obstruction. The most appropriate treatment is likely to be surgical excision coupled with pyeloplasty reconstruction or nephrectomy if renal function is beyond salvage. To our knowledge, this has never been reported, and we believe that awareness of this complication should be made known to urologists.

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.

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.

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

INTRODUCTION

The incidence of erectile dysfunction (ED) has been shown to increase significantly in Singaporean male population. Thus, this prospective study (no controls) assessed the clinical efficacy and safety of a medicated urethral system for erection (MUSE) in Singaporean male patients with a known history of ED.

SUBJECTS AND METHOD

Eighty-six men with a mean age of 55.7 years with differential causes of ED were administered with MUSE in the clinic with a titration adjustment of 4 possible dose regimes (125, 250, 500 and 1000 mcg) till efficacy is achieved. Subsequently, patients were subjected to home treatment for a duration of 3 months.

RESULTS

Sixty per cent of inclinic patients exhibited good responses and were given MUSE for home treatment. The efficacy rate for home treatment was 86%. Overall, the patients (n = 86) had a 51.2% success rate in achieving satisfactory sexual intercourse. Diabetic and psychogenic patients were noted to respond well to MUSE. No severe adverse events were found in this study.

CONCLUSION

MUSE showed to be a safe, less invasive, well-tolerated and efficient alternative treatment for ED in Singaporean men.

Ureteroscopic lithoclast lithotripsy: a cost-effective option

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

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

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

Ureteric colic: value of initial investigations and the outcome

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

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

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