Scrotal reconstruction using thigh pedicle flaps: long-term follow-up of 12 cases.

INTRODUCTION: Genital skin loss in men may be caused by avulsion injuries of the penis and scrotum or by gangrene of the male genitalia. Reconstruction of the scrotum after complete loss of the overlying skin is a challenging problem. We report our experience on the management of this problem. MATERIAL AND METHOD: Medical records of all male patients with massive scrotal skin loss and exposed testes treated at Ramathibodi Hospital and Noparat Rajthanee Hospital from 1990 to 1999 were reviewed. The etiologies of scrotal skin loss, technique of treatment, post-operative consequence as well as complications were noted. RESULTS: Twelve patients were described in this study. Nine patients had avulsion injuries of the penile and scrotal skin secondary to agricultural machinery accidents. Three patients were after extensive debridement of Fournierrís gangrene. The exposed testes had been placed in thigh pouches and scrotal reconstruction using thigh pedicle flaps was done 4-6 weeks later. No immediate and delayed complications were detected in all of the patients. They recovered without any sequelae and had a satisfactory cosmetic result. CONCLUSION: Extensive scrotal skin loss should be immediately treated surgically. Implantation of the exposed testes in the upper thigh pouch and delayed reconstruction of the scrotum using thigh pedicle flaps can provide excellent results

Hemospermia: review of the management with 5 years follow-up.

OBJECTIVE: To review our experience with hemospermia and a long term follow-up. MATERIAL AND METHOD: Medical records of patients with hemospermia treated at the Division of Urology, Ramathibodi Hospital between 1993 and 1995 were reviewed. Clinical presentation, investigation, diagnosis, treatment, outcomes and long term follow-up were noted. RESULTS: Sixty-eight patients were found and completed follow-up to 5 years. The mean age was 40 years (range 28-62). Physical examination including DRE and urine examinations were done in all of the cases. Special investigations such as PSA, TRUS, IVP and cystourethroscopy were performed in selected cases. Prostatitis was found in 27.9 per cent, tuberculosis in 4.4 per cent, sexually related causes in 5.8 per cent and idiopathic in 61 per cent No malignancy was found in this study. Hypertension was found in 7.3 per cent of the patients. Thirty-two per cent had recurrent episodes of hemospermia. Specific treatment was used only for prostatitis and tuberculosis. No specific treatment was used for the idiopathic group. CONCLUSIONS: Hemospermia is a benign condition. Most of the causes were from idiopathic and inflammation. Only simple investigation was needed and treatment was recommended depending on the diagnosis and no specific treatment was needed for idiopathic cause.

Pubovaginal sling for the treatment of female stress urinary incontinence: experience of 100 cases at Ramathibodi Hospital.

OBJECTIVE: To evaluate the outcome of pubovaginal sling procedure for treatment of female stress urinary incontinence. MATERIAL AND METHOD: From September 1997 to January 2000, one hundred consecutive patients with urodynamically proven stress incontinence had a pubovaginal sling procedure performed. Operative technique, intraoperative and post-operative complications, voiding patterns, residual urine as well as the follow-up course were reviewed. RESULTS: Of one hundred cases, the mean patient age was 52.6 years old (range 34-73). The etiologies of stress incontinence were 85 cases of urethral hypermobility and 15 cases of intrinsic sphincter deficiency (ISD). Eighteen cases were after failure of prior continence procedures. No intraoperative and post-operative complications were found except one case of wound infection. Minimal bleeding was noted. Marked post-operative residual urine (>100 ml) was found in 39 cases and clean intermittent catheterization was used. The mean time for catheterization was 8.9 weeks (range 2-12 weeks). The mean time to follow-up was 12.1 months (range 4-36 months). Ninety-four cases had been completely dried in the follow-up period since the last visit and 5 cases had much improvement of incontinence using only 1-2 pads/day. Only one case was found to have failed the procedure. De novo instability was found in 5 cases. CONCLUSION: On the basis of these results, we propose that pubovaginal sling is an effective treatment for female stress incontinence with very few complications.

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.

Risk factors for stress urinary incontinence in middle aged and elderly Thai women.

OBJECTIVE: To determine risk factors of stress urinary incontinence in middle aged and elderly Thai women. MATERIAL AND METHOD: Between March 1999 and January 2000, 46 women with stress urinary incontinence (SUI) with the mean age of 49.05 years old and 168 continent women with the mean age of 49.05 years old were interviewed. The risk factors (e.g. cigarette smoking, childbirth, menopausal status, family history, previous abdominal hysterectomy, transvaginal surgery and body mass index) were studied. The Chi Square or Fisher exact test were used for statistical analysis and p<0.05 was considered as a level of statistical significance. Odds Ratio (O.R.) and its 95 per cent confidence of interval was calculated. RESULTS: The study suggested that menopausal status, childbirth, previous abdominal hysterectomy, transvaginal surgery and family history had no correlation with SUI. The risk factor of body mass index (BMI) > or = Kg/m2 had statistical correlation with SUI. (p=0.000, O.R.=3.570, 95% C.I. of O.R.=1.779 to 7.163). No smokers were found among the studied group so this factor could not be evaluated. CONCLUSIONS: Body mass index was the only identified risk factor of SUI in middle aged and elderly Thai women.

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.

Squamous cell carcinoma of the eviscerated bladder: a case report.

This is a report of a squamous cell carcinoma of the eviscerated bladder in a 52-year-old-Thai man. He had a history of pelvic fracture and failed urethroplasty. The bladder mucosa was eviscerated out from cystostomy tract after the spontaneous dislodging of the cystostomy tube. Squamous cell carcinoma developed at the eviscerated bladder 5 years later. The treatment consisted of radical cystectomy and ileal conduit with combination of radiotherapy. The patient died 7 months after operation due to liver metastasis. Correction or excision of the eviscerated bladder can prevent this kind of cancer.

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.

The organization of Kidney Transplantation Services at Ramathibodi Hospital: fourteen years experience on waiting list, kidney donors and kidney transplantation.

The Kidney Transplantation Program at Ramathibodi Hospital was established in 1985. By the end of 1998, there were 1,614 patients on the cumulative waiting list. The first kidney transplantation (KT) was started in 1986 by using kidney from living-related donor (LD) while cadaveric KT (CD-KT) was started in 1987. A total of 528 KT were done, 278 cases (52.7%) were CD-KT and 250 cases (47.3%) were LD-KT. Six patients had two kidney transplants. 278 kidneys were donated from 189 cadaveric donors. Fifty cadaveric donors (26.4%) were from Ramathibodi Hospital while the rest were from other hospitals and the Organ Donation Center, Thai Red Cross Society. For LD, 233 out of 250 (93.2%) were from living-related, more than 50 per cent of these donors were from siblings. 17 spousal donors have been accepted for KT at Ramathibodi Hospital since 1997. Concerning the recipient pools, 522 patients (32.3%) were transplanted, 123 patients (7.6%) died without KT, 111 patients (6.9%) underwent KT at other hospitals, and 78 patients (4.8%) changed to waiting lists at other hospitals. The rest were lost to follow-up. At present, only 265 patients are still actively waiting (send serum every month). The number of KT and living donors has gradually increased, whereas, the number of cadaveric donors has decreased. However, cooperation with the "Organ Donation Center" has improved the number of cadaveric donation in the last two years. Sufficient organ donations and an active working team will provide a good kidney transplant service for the patients.

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.

Ileal interposition for the treatment of a long gap ureteral loss.

We retrospectively reviewed 10 patients (7 males and 3 females) who were treated with ileal interposition for long gap ureteral loss between 1989-1995. The mean patient age was 42 years old (35-52), mean ureteral gap was 18 cms (10-25). The etiology of ureteral loss included: 4 retroperitoneal fibrosis, 2 recurrent stone, 2 after pancreatitis and its complication and 2 after ureteral injury. The mean follow-up was 4 years (2-7). The post operative course was uneventful with no immediate and long term complications detected and there was no metabolic problem. Only asymptomatic bacteriuria in 5 cases (50%) was noted but it was not clinically significant.

Urinoma, a case report with unusual presentation.

A case of urinoma in a 28-year-old man who had received blunt abdominal injury was reported. This urinoma developed from the detached but still functioned upper pole of the right kidney. The misdiagnosis from the previous surgical exploration and subsequent investigations thus delayed the proper management.