Ejaculatory duct obstruction in the infertile male: experience of 7 cases at Ramathibodi Hospital.

OBJECTIVE: To study the clinical presentations, management, outcomes as well as pregnancy rate of ejaculatory duct obstruction treated at the Division of Urology, Ramathibodi Hospital. MATERIAL AND METHOD: This retrospective study was done from 1980 to 1999 and information from the medical records of the patients of ejaculatory duct obstruction was obtained. Phone and mail were used for long-term follow-up. RESULTS: Seven male patients with ejaculatory duct obstruction were identified. The age ranged from 32-45 years old (mean 34.5). All of the patients had azoospermia without other symptoms related to ejaculatory duct obstruction such as painful ejaculation, perineal or testicular pain. Normal testicles and secondary sex characteristics were noted in all. Seventy-one per cent had normal hormonal profiles and twenty-nine per cent had a slight increase of FSH, LH but not more than one fold of normal range. Vasography was used as the diagnosis tool in all of the cases and 71 per cent of seminal vesicles were >1.5 cm in diameter and all the rest were 1 cm in diameter. Transurethral resection of ejaculatory duct (TURED) was done in 6 cases and transurethral incision of ejaculatory duct (TUIED) was done in 1 case. Semen analysis was done in the third month after operation and 4 of 7 (57%) showed improvement of semen analysis but another 3 cases (43%) still had azoospermia. Six months after operation 6 of 7 (86%) showed improvement of semen analysis. Up to one year, 6 of 7 (86%) have normal semen analysis and another one still had azoospermia. In the long-term follow-up, 4 of 7 (57%) were able to impregnate their wives. CONCLUSIONS: Ejaculatory duct obstruction is a treatable cause of male infertility. In an infertile male with oligospermia or azoospermia with low ejaculate volume, normal secondary sex characteristics, testes and normal hormonal profiles, ejaculatory duct obstruction is suggested. Transrectal ultrasonography (TRUS) and/or vasography can be done to confirm the dilatation of seminal vesicles and obstruction of the ejaculatory duct. Transurethral resection of the ejaculatory duct (TURED) has resulted in marked improvement in semen parameters, and pregnancies have been achieved.

Interstitial laser coagulation for the treatment of benign prostatic hyperplasia: a 3 year-follow-up of 30 cases.

OBJECTIVE: To report the results and 3 year-follow-up of treatment of benign prostatic hyperplasia (BPH) using interstitial laser coagulation. MATERIAL AND METHOD: Thirty men with BPH underwent treatment with interstitial laser coagulation between December 1996 and April 1997. Their average age was 68 years old. All of them were assessed prior to the treatment and post treatment for symptoms score, uroflowmetry and postvoid residual urine. Any complication and consequence were evaluated at each follow-up visit. RESULTS: Up to 36 months follow-up, all parameters showed marked improvement. The symptom score decreased from 20 to 5. Peak flow rate increased from 4 ml/sec to 17 ml/sec. Residual urine decreased from 115 ml to 8 ml. No major complication was detected. Urethral catheter or intermittent catheterization were used for the mean of 9.1 days. All of the patients who were potent prior to the treatment remained potent and 75 per cent still had prograde ejaculation. No re-treatment was needed in the 3 year-follow-up. CONCLUSION: On the basis of these results, we propose that interstitial laser coagulation appears to be a minimally invasive treatment for BPH, with substantial improvement of both objective and subjective parameters.

Mitrofanoff procedure incombination with enterocystoplasty for detrusor hyperreflexia with external sphincter dyssynergia: one-year experience of 12 cases.

Twelve patients with the mean age of 35 years who had undergone Mitrofanoff procedure incombination with enterocystoplasty between 1998-1999 were interviewed. All of the patients had suprasacral spinal cord injuries for the mean of 3.5 years from the accident to the operation and failure of medical treatment to suppress hyperreflexic bladder. The vermiform appendix was used to implant as continent stoma in 10 cases and ileal segment was used in 2 cases due to prior appendectomy. The bladder capacity was increased from the mean of 180 ml before the operation to 300 ml intraoperation and 800 ml at 1 year post-operation. Up to 1 year, no immediate and late complication was detected except one case who had orchitis at eleven months post-operation. All of them still have continence and self-intermittent catheterization can easily be performed via continent stoma at the abdominal wall.

Risk factors of urethral involvement of bladder cancer after radical cystectomy with orthotopic neobladder in females.

The cystectomy and urethrectomy specimens of 20 females with invasive bladder cancer were studied for evidence of urethral involvement. The bladder showed transitional cell carcinoma in 18 cases (90%) and squamous cell carcinoma in 2 cases (10%). Urethral involvement was found in 5 cases (25%). The trigone was the most common site of tumor (50%) which had 33 per cent chance of urethral involvement. Bladder neck was the next common site of tumor (15%) and had 66 per cent chance of urethral involvement. High stage (T3b, T4) and high grade (III) at trigone also correlated with urethral involvement. The tumor bearing node showed only 20 per cent correlation with urethral involvement. Female patients with high stage/high grade at trigone and any stage/grade at bladder neck are at high risk of urethral recurrence after radical cystectomy and orthotopic neobladder procedure.

Stricture of the male urethra: 29 years experience of 323 cases.

The authors reported 323 cases of male urethral stricture managed at Ramathibodi Hospital from 1969 to 1998 (29 years period). Etiology included traumatic causes 237 (73%) and post infection 54 cases (16%). The managements were urethroplasties 281 cases (87%), urethrotomy 21 cases (6%) and dilatation 21 cases (6%). The over all successful rate of urethroplasty was 89 per cent. The mean follow-up time was 2.5 years (0.5-15 years).

Urethral diverticulum in females: 25 years experience at Ramathibodi Hospital.

We retrospectively reviewed the urethral diverticulum in females from 1972 to 1997. Sixty seven patients were found in this study. Nine per cent were nulliparous and the rest were multiparous with the mean of 2.2 births (range 1-6). Voiding cystourethrography and intravenous pyelography were the main diagnostic investigations (92.4%). Stones in the diverticulum were found in 4.4 per cent. The treatment included marsupialization for the diverticulum at distal urethra in 14 per cent and diverticulectomy for the diverticulum at middle and proximal urethra in 86 per cent. The complications included 1.4 per cent of stress incontinence and 4.4 per cent of recurrent infection.

Vesico-vaginal fistula: experience of 230 cases.

We reviewed 230 cases of vesico-vaginal fistula in Ramathibodi Hospital from 1969 to 1997. The cases of fistula included 164 cases after transabdominal hysterectomies, 5 cases after anterior colporrhaphies, 8 cases after radical hysterectomy, 23 cases after vaginal hysterectomy, 10 cases after prolonged or traumatic birth, 9 cases after radiation for cervical carcinoma, 7 cases of cervical cancer invasion, 2 cases after suprapubic cystolithotomy and 2 cases after pelvic fracture. Most of them were referred from other hospitals. In 7 cases, the fistula closed spontaneously after indwelling urethral catheters for 4-6 weeks. Five cases were cured after transurethral fulgurations. The rest were treated with different surgical procedures i.e. transvaginal, transvesical and retrovesical repairs. Ten cases were treated by urinary diversions, usually after failure using other surgical procedures.

Traumatic testicular dislocation a review of 36 cases.

We retrospectively reviewed 36 patients who were treated in our institutes with traumatic testicular dislocation from 1975 to 1997. The mean patient age was 25 years old (18-38). Average time to present at the emergency room was 1 hour (0.5-6). Bilateral dislocation was found in thirty cases and unilateral dislocation was found in six cases. The sites of dislocation included: 34 cases (64 testes) at superficial inguinal area, one case (one testis) at acetabular area, and one case (one testis) at the perineal area. Closed reduction under general anesthesia was successful in 14 cases, open reduction after failed closed reduction in 10 cases, open exploration and repaired testis with reposition in 11 cases and orchiectomy only in one case. The overall results after treatment showed the normal size and position of the testis.

The urological complications of renal transplantation: an 11-year-experience at Ramathibodi Hospital.

From February 1986 to December 1996, renal transplantation was performed on 344 patients at Ramathibodi Hospital. The urological complications were retrospectively analyzed in 335 patients (338 renal transplants), 9 patients were lost to follow-up. There were 227 males and 108 females with age ranging from 15 to 62 years (mean age 40.28 years). There were 207 cadaveric and 131 living-related graft donors. The ureteroneocystostomy was performed either by modified Politano-Leadbetter (93 cases) or extravesical technique (245 cases). There were 23 cases of urological complications: ureterovesical anastomotic leakage 6, ureteric obstruction 6, vesicoureteric reflux 4, significant bleeding from ureterovesical anastomosis 3, renal infarction with fistulas 2, hydronephrosis due to blood clot retention and swelling of the anastomosis, requiring temporary double J stenting 2. The analysis was done by dividing the patients into 3 groups, the first and second groups consisted of 100 cases each and the third group consisted of 138 cases. The urological complications in the groups were 10 per cent, 9 per cent and 2.89 per cent respectively. There was a statistically significant difference between the first two groups combined and the third group in terms of complications (p < 0.025). The urological complications of living-related cases were 9 (6.87%), and of cadaveric cases were 14 (6.76%). There was no significant difference of the complications between living-related and cadaveric transplants (p < 0.05). The comparative results of the ureteric complications of the extravesical technique were significantly less than the modified Politano-Leadbetter technique (4.49% vs 10.75%), (p < 0.05). In conclusion, the extravesical technique of ureterovesical anastomosis was superior than the modified Leadbetter-Politano technique in terms of post-operative ureteral complications.

The usage of Andrographis paniculata following Extracorporeal Shock Wave Lithotripsy (ESWL).

One hundred consecutive cases with renal stones less than 3 cm in size and normal renal function underwent ESWL from January to March 1994. Out of these, 50 were given Andrographis paniculata tablets (250 mg), 4 tablests tid, 25 were given cotrimoxazole 2 tablets bid and 25 received norfloxacin 200 mg bid, started immediately after ESWL and continued for 5 days. All tolerated the treatment well and none had complications. At one month follow-up, pre- and post-ESWL pyuria, hematuria and proteinuria among the Andrographis paniculata group were 84, 58, 72, 40, 52, 22 per cent; the cotrimoxazole group 88, 64, 84, 64, 56, 44 per cent and the norfloxacin group 92, 56, 72, 40 per cent and 56, 28 per cent respectively. The results showed that post ESWL pyuria and hematuria in patients receiving Andrographis peniculata were reduced to 0.69 and 0.55 time of pre ESWL value. We think that this herbal medicine is beneficial in the treatment of post ESWL urinary tract infection. Besides the herbal drug given to eighteen previously sulfa sensitized patients resulted in no allergic reaction.

Effects of Folia orthosiphonis on urinary stone promoters and inhibitors.

Yaa-Knuatmaeo or Folia orthosiphonis showed both favourable and non favourable effects of stone prevention. Uric acid and uric acid containing stone may be prevented by the increased alkalinity of the urine after drinking Orthosiphon tea. The unfavourable effect of orthosiphon being the excretion of oxalate in the urine may result in higher risk of stone formation. However, this study may or may not apply to the stone patients since it has been done only on healthy persons and all parameters were within normal limits. We feel that Orthosiphon tea may be beneficial in prevention of uric acid stone formation. This study was supported by a grant from the Medicinal Herbs Development Fund, Mahidol University.

Rhabdomyosarcoma in Thai children.

Twenty-six cases of rhabdomyosarcoma diagnosed from a total of 845 Thai children with childhood malignancy who had been treated at the Department of Pediatrics Ramathibodi Hospital, from May 1970 to December 1982 were analyzed retrospectively. There were 16 boys and 10 girls, aged 3 months to 13 years old (mean age was 5.6 +/- 4.1 years old). The common type was the embryonal cell sarcoma (19 cases), 3 cases were undetermined, 2 cases of alveolar cell type and one each of the pleomorphic and undifferentiated cell type. Only 2 cases had stage II disease, 10 and 14 cases were stage III and IV respectively. The common locations were head and neck (10 cases), abdomen (8 cases including one in the uterus, scrotum and 3 in the urinary bladder), and in 7 cases in the extremities. One patient had small lesion at the buttock. The treatment consisted of surgery, radiation therapy, actinomycin, vincristine and cyclophosphamide. Eight cases were lost to follow-up, 10 cases were discharged in advanced stage after been treated for 6.2 +/- 4 months, 4 cases had no evidence of disease for 2 to 7.5 years, 4 cases died after 4 to 27 months of treatment. The poor result obtained was probably due to the late stages of the disease at diagnosis, and limitations in the use of effective medications.

Djenkol bean as a cause of urolithiasis.

An 8-year-old boy was admitted into the hospital with symptoms of anuria after consumption of 12 djenkol beans. Laparotomy showed a urethral calculus, size 2.0 x 0.4 cm, which was found to contain djenkolic acid 65 gm/100 gm stone with a small amount of protein, sodium, potassium and uric acid. This calculus contained no calcium, magnesium, phosphorus, ammonium salt, oxalate, carbonate, cystine and fibrin. The solubility of L-djenkolic acid in urine at 37 degrees C was found to be pH dependent, i.e., the higher the pH, the increase in solubility of djenkolic acid. D-pencillamine also showed similar effect, increasing the solubility of L-djenkolic acid in the urine at pH 5.7 in vitro. The cause and mechanism of formation of djenkolic acid crystals and calculi were discussed.