Bladder substitution by ileal neobladder for women with interstitial cystitis

OBJECTIVE: To report our experience with cystectomy and ileal neobladder for women with interstitial cystitis (IC). MATERIALS AND METHODS: Thirty-five female patients treated during 2000-2005 with the mean age of 45.9 ± 4.4 years were included in this study. All of them had experience suprapubic pain with irritative voiding symptoms and were diagnosed as having IC based on NIDDK criteria for at least 2 years. Conservative treatments had failed to relieve their symptoms; and therefore all of them agreed to undergo a bladder removal. For cystectomy, the urethra was cut 0.5 cm below the bladder neck, proximal to the pubourethral ligament, leaving the endopelvic fascia intact. An ileal segment of 65 cm was used to create the neobladder with the Studer's technique. RESULTS: All patients presented good treatment outcome with regard to both diurnal and nocturnal urinary control without any pain. Quality of life using the SF-36 questionnaire showed significant improvement of both physical health and mental health. Spontaneous voiding with minimal residual urine was found in 33 cases (94.3 percent), and the remaining 2 cases (5.7 percent) had spontaneous voiding with residual urine and were placed on clean intermittent catheterization (CIC). Twelve out of 30 cases with sexually active ability had a mild degree of dyspareunia but without disturbance to sexual life. CONCLUSION: Bladder substitution by ileal neobladder for women who suffer from IC can be a satisfactory option after failure of conservative treatment. Resection of the urethra distal to the bladder neck can preserve continence and allow spontaneous voiding in almost all patients.

Diagnostic accuracy of MRI/MRSI for patients with persistently high PSA levels and negative TRUS-guided biopsy results.

OBJECTIVE: To prospectively evaluate the accuracy of transrectal ultrasonographic (TRUS)-guided biopsies by using combined magnetic resonance imaging (MRI) and magnetic resonance spectroscopic imaging (MRSI) in patients with persistently high prostate-specific antigen (PSA) levels and negative TRUS-guided biopsy results. MATERIAL AND METHOD: Twenty-one patients (age range 50-77 years, average 61.4 years) with negative TRUS biopsy were enrolled Suspicious areas were identified by discrete low signal intensity in T2 on standard MRI. MRSI was interpreted by using spectral approach and given score of I (benign) to 5 (malignant). Suspicious voxels were localized for guided TRUS biopsy. All patients underwent sextant TRUS biopsies with up to four additional biopsies targeted at suspicious sites. Diagnostic accuracy of MRI/MRSI in patient-by-patient and voxel-by-core were analyzed. RESULTS: Prostate cancer was detected in 2 of 21 patients (9.5%). The sensitivity, specificity, PPV, NPV and accuracy of combined MRI/MRSI for detection of prostate cancer were 100%, 84%, 40%, 100%, and 86%, respectively. The site of positive biopsy correlated correctly with voxels were 80%, 85%, 21%, 99% and 85% on sensitivity, specificity, PPV, NPV and accuracy, respectively. CONCLUSION: MRI/MRSI have the potential to guide biopsy to cancer foci in patients with persistently high PSA levels and prior negative TRUS biopsy results.

Urinary risk factors for recurrent calcium stone formation in Thai stone formers.

OBJECTIVE: To survey the urinary risk factors associated with recurrent calcium stone and the contribution of renal tubular acidosis to the prevalence of recurrent calcium stone formation in Thai recurrent stone formers. MATERIAL AND METHOD: There were 86 consecutive recurrent calcium stone formers. Three-day dietary record, serum biochemical parameters, first morning urine pH, and two 24-hour urine collections were obtainedfrom each subject. Urinary risk factors for calcium stone formation were determined from the average of the 2-day urine collection. Normal controls were 34 subjects matched for aged, sex, and weight, and without a history of renal stone formation. RESULTS: Seven patients (8.1%) were diagnosed as incomplete renal tubular acidosis (iRTA). Among the 79 idiopathic calcium stone formers (ISF), 69.6%, 15.2%, 10.1%, 7.2% and 1.3% of patients were hypocitraturia, hypercalciuria, low urinary volume, hyperuricosuria and hyperoxaluria, respectively. The common combinations of risk factors were hypocitraturia plus low urine output (8.9%) or plus hypercalciuria (7.6%). There were significant differences between ISF and normal controls in urinary oxalate excretion (0.16 +/- 0.01 vs 0.12 +/- 0.01, p < 0.05), urinary calcium/citrate ratio (4.49 +/- 0.50 vs 2.83 +/- 0.34, p < 0.01) and ion activity product for calcium oxalate stone (0. 46 +/- 0.03 vs 0. 33 +/- 0.03, p < 0. 05). Urinary citrate in ISF varied directly with net alkaline absorption (r = 0.34, p < 0.005) and urinary potassium (r = 0.54, p < 0.001). There were significant correlations between urinary calcium excretion and both sodium excretion (r = 0.42, p < 0.001) and urea excretion (r = 0.41, p < 0.001) in ISE There were seven (8.1%) with incomplete renal tubular acidosis. Patients with iRTA tended to have less urinary citrate and higher calcium/citrate ratio than did ISF, but hypercalciuria was uncommon. CONCLUSIONS: Hypocitraturia was the most common urinary risk factor found in Thai recurrent idiopathic calcium stone formers followed by hypercalciuria and low urinary volume. Almost one-fourth of the stone formers had multiple risk factors. Hypocitraturia might result from low potassium and low alkaline intake. iRTA was common among recurrent calcium stone formers. Determination of morning urine pH should be a part of the investigations for urinary risk factors to avoid overlooking the diagnosis of iRTA.

Hand-assisted laparoscopic partial nephrectomy for renal cell carcinoma: the first case report in Thailand: case report.

The authors report their first experience on a hand-assisted laparoscopic partial nephrectomy surgical technique and the result after it was performed successfully in a 45-year-old woman who presented with an asymptomatic small renal mass. This is the first successful case report of this operation in Thailand.

Laparoscopic renal surgery: Ramathibodi Hospital experience.

OBJECTIVE: To report the authors' early experience of laparoscopic renal surgery for benign and malignant renal conditions. MATERIAL AND METHOD: Laparoscopic renal surgery was performed on 24 patients with benign and malignant renal conditions between July 2004 and February 2005. The patient characteristics and perioperative data including operative time, blood loss, analgesic requirement, complications, duration of postoperative drain removal, length of hospital stay, and duration to return to normal activity were all recorded. RESULTS: Laparoscopic simple nephrectomy was performed in 15 patients with nonfunctioning benign renal conditions. Three operations of hand-assisted laparoscopic radical nephrectomy and one of partial nephrectomy were performed for large and small renal cell carcinoma, respectively. Transitional cell carcinomas were managed by retroperitoneoscopic nephrectomy or hand-assisted approach in 3 cases. For a case of severe inflammatory renal condition, hand-assisted approach was used for treatment. Laparoscopic renal cyst decortication was performed in one case. In the laparoscopic simple nephrectomy group, the mean operative time was 126 +/- 38.3 minutes. The median (range) estimated blood loss was 100 (50-500) mL, and one patient required conversion to open surgery because of renal vein injury. In three cases of hand-assisted laparoscopic radical nephrectomy, the operation time was 315, 325 and 150 minutes and the operative blood loss was 500, 1000 and 200 ml, respectively. In cases of hand-assisted laparoscopic partial nephrectomy, the operation time and the operative blood loss were 220 minutes and 350 ml, respectively. In three cases of transitional cell carcinoma, the operation time was 120, 140 and 150 minutes and the operative blood loss was 100, 150 and 150 ml. The surgical margins of all resected specimens for malignant tumors were negative and no major complication was recorded Simple renal cyst decortication was successfully performed within 90 minutes of operation time and bleeding 50 ml. In cases of severe inflammatory renal condition performed by hand-assisted approach, the operative time was 250 minutes and the operative blood loss was 250 ml. CONCLUSION: Laparoscopic renal surgery is a safe and efficacious approach for resection of benign nonfunctioning kidneys and malignant renal tumors.

Reliability of a Thai version of King's Health Questionnaire in Thai females with overactive bladder symptoms.

OBJECTIVES: To develop and test the reliability of a Thai version of the King's Health Questionnaire (KHQ). MATERIAL AND METHOD: Three Thai Urologists forward translated the original English KHQ into a Thai version. Back translations were performed by an independent group of physicians. A consensus was reached on a final Thai version after comparing the original KHQ and various translations. Fifty Thai female patients with symptoms of overactive bladder were tested and retested every two weeks using the Thai version (twice) as well as the English version (once) of the KHQ. Test-retest reliability of the Thai questionnaire was measured using the kappa statistic. RESULTS AND CONCLUSION: The Thai version of the KHQ was found to be reasonably reliable for use in Thai female patients with over active bladder symptoms.

Correlation between symptoms and urodynamic findings in Thai female patients with urinary incontinence.

OBJECTIVE: To determine the accuracy of a urinary incontinence questionnaire in the diagnosis of various types of urinary incontinence classified according to the results of multichannel urodynamic testing. MATERIAL AND METHOD: Between May 2000 and April 2004, 129 women with symptoms of urinary incontinence were interviewed using a urinary incontinence questionnaire consisting of 12 urinary symptoms questions. Various patient demographic and other descriptive data were also collected. All patients underwent multichannel urodynamic testing, and classified using the International Continence Society criteria. Descriptive data and patient symptoms were tested for statistical association with the types of urinary incontinence. Sensitivity and specificity were used to measure the accuracy of the symptoms in distinguishing between the various urodynamic conditions. RESULTS: Of the 12 questions, only three questions (two stress incontinence symptoms and one overactive bladder symptom) were significantly associated with the urodynamic diagnoses of genuine Stress Urinary Incontinence (SUI) and Detrusor Overactivity (DO). The sensitivity and specificity for distinguishing between genuine SUI and DO from other urodynamic diagnoses or between each other were relatively low. CONCLUSION: Symptoms of urinary incontinence were not sufficient to predict types of urinary incontinence. Therefore, the authors suggest that urodynamic testing is still essential in the diagnosis and management of female urinary incontinence.

Cystine urinary lithiasis in Thailand: a report of five cases.

Cystine urinary stone is an autosomal recessive hereditary disease, frequently recurring and resisting fragmentation by Shockwave lithotripsy. As cases have never been reported before in Thailand, five cases of renal cystine stones at Ramathibodi Hospital were reported. Two were in the same family. In all cases the stones were removed by open surgery or percutaneous nephrolithotomy. Postoperatively, all the stones were analyzed by infrared spectroscopy for cystine. In two cases, cystine stones were also identified by scanning electron microscopy. Urine was analyzed for cystine by sodium cyanide-nitroprusside test, its concentration by spectrophotometry and cystine crystals were identified by the new crystal induction technique under light microscopy. By high-performance liquid chromatography (HPLC) test, urinary dibasic amino acids (ornithine, lysine, arginine) in these cases were also found to be significantly elevated. Clinical findings, diagnosis, treatment and prevention of cystine stones are reviewed.

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.

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.

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.

Tension-free vaginal tape procedure for the treatment of stress urinary incontinence: the first experience in Thailand.

OBJECTIVE: Tension-free vaginal tape (TVT) is gaining popularity as an effective treatment for genuine stress urinary incontinence. To better understand this procedure including its results, a retrospective study was carried out to determine surgical technique, effectiveness, safety and early results of this new continence procedure. MATERIAL AND METHOD: From January 1999 to July 2000, twenty female patients with the mean age of 52 years old underwent the TVT procedure. All of them were done by a small incision at mid urethra and a special instrument was used to apply a polypropylene mesh supporting the urethra. Urethral catheter was used as urinary drainage which was removed the next day. Operative time, post-operative course, voiding patterns and residual urine were recorded. RESULTS: Mean operative time was 32 minutes (range 15-45 minutes). Up to 10 months, all of the patients were subjectively cured. There was no significant per- and post-operative complication including blood loss, wound infection and severe pain. Four patients (20%) had marked residual urine (>100 ml) and needed clean intermittent catheterization for the mean of 0.7 week. CONCLUSION: Although the follow-up period was short, the TVT procedure seems to be a safe and effective method for the treatment of stress urinary incontinence.

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.