A randomized controlled trial of pubovaginal sling versus vaginal wall sling for stress urinary incontinence.

PURPOSE: To compare the results of Pubovaginal sling and Vaginal wall sling for the treatment of stress urinary incontinence in females. MATERIAL AND METHOD: Between February 2001 and December 2001, a randomized controlled trial was done to compare safety and efficacy of pubovaginal sling versus vaginal wall sling in the management of women with urinary incontinence. Fifteen women 42-68 years old (mean age 51.3 years) were treated with fascial sling (group A) and 11 women 45-60 years old (mean age 50.4 years) with vaginal wall sling (group B). Twenty-one patients had type II SUI and 5 patients had type III SUI (ISD); none had pre-operative detrusor instability. Measures of outcome included efficacy based on SEAPI-QMN, post-operative presence of stress or urge incontinence, frequency of complications, operative time, post-operative pain, length of hospitalization, length of clean intermittent catheterization (CIC) time and mean global evaluation. RESULTS: All patients were followed for at least 3 months after surgery (median 7 months). A total of 20 and 6 women received spinal and general anesthesia, respectively. SEAPI-QMN decreased from a median of 6.3 to 0.8 for group A and from 6.1 to 0.9 for group B. No patient in either group had persistent stress incontinence. Urge incontinence was present in 2 of group A patients and 1 of group B patients. No serious post-operative complications were encountered in both groups. Post-operative pain and operative times for group B patients were significantly lower than for group A patients. Length of hospitalization, length of CIC time and mean global evaluation were not significantly different between the two groups. CONCLUSION: In the short-term, both pubovaginal sling and vaginal wall slings were effective in the treatment of women with SUI. However, the use of vaginal wall sling resulted in significantly shorter operative times and lower post-operative pain compared with pubovaginal sling. Therefore, the vaginal wall sling should be the prefered treatment for SUI.

Ureteral calculi during pregnancy: review of the management at Ramathibodi Hospital.

OBJECTIVE: To review our experiences with diagnosis and management of symptomatic ureteral calculi complicating pregnancy. MATERIAL AND METHOD: Medical records of all pregnant patients documented with symptomatic ureteral calculi treated at the Division of Urology, Department of Surgery, Faculty of Medicine, Ramathibodi Hospital from 1990 to 2000 were reviewed. Presenting symptoms, diagnostic studies and management of ureteral stone were evaluated. RESULTS: Twenty patients were found in this study with the mean age of 27.5 years (18-36). The mean gestational age at presentation was 18.5 weeks (12-33). Severe flank pain was the common presenting symptom (100%), 60 per cent were on the right side and 40 per cent were on the left side, 20 per cent had associated fever and 20 per cent had irritative voiding symptoms. All of the cases had micro or macroscopic hematuria. Ultrasonography was the initial test confirming the diagnosis and visualized stones were obtained in 60 per cent of the cases. Plain KUB film was done in 6 cases and stones could be seen in 5 cases (83%). Limited IVP was done in 3 cases and the diagnosis could be done in all of them (100%). Spontaneous passing of stones was noted in 14 cases (70%) and double J stents were placed in 6 cases. Ureterolithotomy was done in 2 cases and percutaneous nephrostomy with subsequent definite stone treatment in the post partum period was done in 2 cases. No abortion and no congenital anomalies of the infant were noted. Four cases had premature labor but there was no correlation with the procedures performed for treating the ureteral stone. CONCLUSION: This study provides evidence for effectiveness of diagnosis and treatment of ureteral stone during pregnancy. The appropriate management may be helpful to reduce morbidity of urinary calculi during pregnancy.

Ureterocalicostomy for reconstruction of complicated ureteropelvic junction obstruction.

OBJECTIVE: To review our experience with ureterocalicostomy using the treatment of complicated ureteropelvic junction (UPJ) obstruction. MATERIAL AND METHOD: Medical records of all patients with complicated ureteropelvic junction obstruction treated by ureterocalicostomy from 1985 to 2000 were reviewed. Causes of UPJ obstruction, surgical techniques, peri-operative course and outcome were noted. RESULTS: Fifteen patients were enrolled in this study (6 males and 9 females) with the mean age of 39 years old (28-45). Twelve patients were after stone surgery, 2 were after pyeloplasty for congenital UPJ obstruction and one patient was after blunt abdominal trauma. All the procedures were done by flank incision. After excision of the lower pole, the ureter was anastomosed to the lower caliceal mucosa without tension over an internal stent. Nephrostomy tubes were used in all of the patients. The mean hospital stay was 14 days (10-20). Twelve cases (80%) were found to be successful and are still doing well with the mean follow-up time of 2.5 years (0.5-12). Three patients (20%) were found to have failed, and subsequently nephrectomy was done in one case and permanent nephrostomy was used in 2 cases due to a solitary kidney. CONCLUSION: Ureterocalicostomy is one of the options for treatment of complicated UPJ obstruction that can provide good drainage as well as excellent long term results.

Unenhanced ultrafast computerized tomography for the evaluation of patients with acute flank pain.

OBJECTIVE: To determine the value of unenhanced ultrafast computerized tomography (CT) in the diagnosis of acute flank pain in 43 patients evaluated for suspected stone disease. MATERIAL AND METHOD: Noncontrasted ultrafast CT was performed in 43 consecutive patients seen in the emergency department to evaluate acute flank pain. All CT studies were reviewed for the presence of ureteral and renal calculi, perinephric and periureteral stranding, presence and degree of pelvicalicectasis or other radiological findings. If necessary, an excretory urogram was performed to confirm the presence or absence of urinary stone. Patients were followed to determine clinical outcome including the need for urological intervention. RESULTS: Of the 28 patients determined to have stones 16 (57.14%) had spontaneous stone passage, 7 (25%) had improved symptoms without documented stone passage and 4 (14.29%) required surgical intervention. In 6 of 14 patients (42.86%) with negative CT readings for stone disease a diagnosis was established by other intra-abdominal findings. In 7 patients (50%) no clinical diagnosis could be established, and 1 scan in a patient with a ureteral calculus was interpreted as falsely negative. These findings yielded a sensitivity of 96.63 per cent, Specificity 92.85 per cent and overall accuracy 95.24 per cent for diagnosing ureteral stones. CONCLUSIONS: Unenhanced ultrafast CT is an accurate, safe and rapid imaging modality for the detection of urinary tract calculi and obstruction. The majority of patients required no further imaging to determine the need for urological intervention. Ultrafast CT could be used as the standard method to evaluate patients with acute flank pain.

Penile fracture: long-term outcome of treatment.

OBJECTIVE: Penile fracture is a rare injury, usually resulting from direct trauma to the erect penis during sexual intercourse. Immediate surgical treatment is the basis for the treatment of this injury due to the high rate of complications associated with delayed management. The aim of this study was to evaluate the clinical presentations, diagnostic methods, and outcomes of the treatment. MATERIAL AND METHOD: We retrospectively studied patients with penile fracture treated at Ramathibodi Hospital from 1975 to 2000. Clinical presentation, diagnostic methods, technique of treatment and outcomes of treatment were noted. RESULTS: Twelve patients were found in this study. The mean patient age was 32 years old (range 19-42). The interval from time of injury to presentation was 3-48 hours. Of these patients 10 had been injured during sexual intercourse (83%) while 2 had been injured during masturbation. All patients presented with a very suggestive clinical picture (pain, detumescence and hematoma). No further investigation was needed for confirming the diagnosis. One case had urethral bleeding, therefore, retrograde urethrogahpy was performed but no extravasation of contrast media was noted. All patients were treated by immediate surgery, through a circular subcoronal incision and degloving of the penis to allow a thorough exploration. All of the patients had a tunica albuginea tear that was promptly repaired. No associated urethral larceration was noted. All of the patients did very well after surgery and two had mild curvature, which had not hindered intercourse at follow-up (mean time of 24 months). CONCLUSIONS: Penile fracture has very typical clinical signs and no further investigation is usually needed. Early surgical treatment is associated with a low incidence of late complications.

Vesicourethral strictures after radical prostatectomy: review of treatment and outcome.

OBJECTIVE: Stricture of the vesicourethral anastomosis is a complication after radical prostatectomy. Urethral dilatation, internal urethrotomy, transurethral resection or laser therapy have been reported as the treatment for this complication. The objective of this study was to present our experience with the management of the vesicourethral stricture. MATERIAL AND METHOD: A retrospective study of 90 patients undergoing radical prostatectomy for localized prostatic carcinoma was done. The vesicourethral stricture was treated by dilatation, internal urethrotomy, and transurethral resection of scar tissue in all of the patients. Dilatation was done in less severe cases, internal urethrotomy was done in partial obliteration or after failure of dilatation. Transurethral resection was done in cases with long scar tissue. RESULTS: Ten patients (11%) had anastomotic stricture. The strictures were treated by dilatation in 5 cases, internal urethrotomy in 4 cases and transurethral resection in 1 case. Cure was achieved in all of the patients without incontinence. The median follow-up was 10 months (4-36 months) CONCLUSION: The dilatation and endoscopic procedures of the vesicourethral stricture showed a high cure rate and low incidence of incontinence.