The clinical presentation and diagnosis of ketamine-associated urinary tract dysfunction in Singapore

Ketamine is a short-acting anaesthetic agent that has gained popularity as a 'club drug' due to its hallucinogenic effects. Substance abuse should be considered in young adult patients who present with severe debilitating symptoms such as lower urinary tract symptoms, even though the use of controlled substances is rare in Singapore. Although the natural history of disease varies from person to person, a relationship between symptom severity and frequency/dosage of abuse has been established. It is important to be aware of this condition and have a high degree of clinical suspicion to enable early diagnosis and immediate initiation of multidisciplinary and holistic treatment. A delayed diagnosis can lead to irreversible pathological changes and increased morbidity among ketamine abusers.

Heart failure as the first manifestation of renal cell carcinoma

We report the rare case of a patient with advanced renal cell carcinoma (RCC) who initially presented to the hospital with symptoms of cardiac failure. Preoperative cardiac studies did not reveal any underlying ischemia. After resection of a large 14-cm left renal tumor, cardiac function was noted to improve dramatically. We discuss this case of concomitant RCC and nonischemic cardiomyopathy.

Occurrence of a lymphocele following renal transplantation

<p><b>INTRODUCTION</b>The incidence of lymphoceles - lymphatic collections around a transplanted kidney - can be as high as 20%. We aimed to review the presentation, treatment and outcome of patients with lymphoceles.</p><p><b>METHODS</b>We reviewed a prospective database of 154 patients who underwent renal transplantation at our hospital from January 2005 to November 2008.</p><p><b>RESULTS</b>The mean age of the patients in our cohort was 46 (range 34-58) years. The incidence of lymphoceles in our series was 5.8% (n = 9). The median onset was 19 (range 6-28) days post-transplantation, while the median size of the lymphoceles was 5 (range 1.5-8) cm. Lymphoceles were most commonly found at the lower pole of the transplanted kidney. Eight patients with lymphoceles had received cadaveric transplants. While a majority of these patients did not have hydronephrosis on presentation, four had markedly elevated creatinine. Of the nine patients with lymphoceles, six were on macrolides (tacrolimus, sirolimus or everolimus), two were successfully managed conservatively, three were managed percutaneously and four required surgical drainage via either laparoscopic marsupialisation (n = 1) or open drainage (n = 3). There was no graft loss.</p><p><b>CONCLUSION</b>It remains unknown whether the choice of immunosuppressants increases the risk of lymphocele formation. Intervention is necessary in the case of impaired drainage of the pelvicalyceal system in these patients. Minimally invasive intervention, while effective in treating lymphoceles, does not provide definitive treatment. Surgical intervention should be considered early for the treatment of post-transplantation patients with lymphoceles, so as to shorten hospital stay and prevent further complications.</p>

Botulinum toxin a for idiopathic detrusor overactivity

<p><b>INTRODUCTION</b>This prospective study aims to evaluate botulinum toxin type A (BTX-A, Botox ®) as a treatment for idiopathic detrusor overactivity (IDO) for patients with symptoms of overactive bladder (OAB).</p><p><b>MATERIALS AND METHODS</b>Nineteen patients with IDO were treated with intradetrusal injection of 200 units of BTX-A under cystoscopic guidance. There were 10 males and 9 females, with a mean age of 60 years (range, 38 to 87). Subjective responses were measured using the International Prostate Symptom Score and quality of life (QOL) score, as well as incontinent episodes, functional capacity and voiding intervals obtained from the voiding diary. They were recorded prior to, and at 6 weeks, 3, 6 and 9 months after BTX-A injections. Urodynamic studies were performed between 6 weeks to 3 months post-treatment.</p><p><b>RESULTS</b>There was statistically significant improvement in subjective parameters at 3 months post-treatment involving QOL (P = 0.002), incontinence episodes (P = 0.004), functional capacity (P = 0.01) and voiding interval (P <0.001). Reflex volume was significantly increased (P = 0.003), and maximal detrusal pressure (P = 0.001) as well as leak volume (P = 0.013) were significantly decreased during follow-up. Results of a gender-based subgroup analysis reveal that BTX-A may be more efficacious in females. Observed side effects included a patient who needed to perform CISC for about 3 months, a patient who had gross haematuria needed bladder washout and 3 patients who required treatments for urinary tract infection.</p><p><b>CONCLUSION</b>Overall BTX-A, which is well received by most patients, has become a very important part of the armamentarium for the treatment of IDO.</p>

Intramuscular gentamicin improves the efficacy of ciprofloxacin as an antibiotic prophylaxis for transrectal prostate biopsy

<p><b>INTRODUCTION</b>Infection-related complications after transrectal ultrasound guided prostatic biopsy (TRPB) could be life threatening. Our centre observed sepsis after TRPB despite prophylactic oral ciprofloxacin. We reviewed all cases of post-TRPB sepsis with their bacteriology and evaluated if the addition of intramuscular (I/M) gentamicin to standard prophylaxis before TRPB could reduce its incidence.</p><p><b>MATERIALS AND METHODS</b>In a single urological centre, we performed an interventional study that compared a prospective group with retrospective control. The latter is known as the "cipro-only" group included consecutive patients who underwent TRPB between 1 September 2003 and 31 August 2004. The addition of I/M gentamicin 80 mg half an hour before TRPB started on 1 September 2004. All subsequent patients who underwent TRPB until 31 August 2005 were included in the "cipro+genta" group. Patients who did not receive the studied antibiotics were excluded.</p><p><b>RESULTS</b>There were 374 patients in the "cipro+genta" group and 367 patients in the "cipro-only" group with comparable profiles. There were 12 cases of post-TRPB sepsis in the "cipro-only" group and 5 cases in the "cipro+genta" group. Ciprofloxacin-resistant Escherichia coli (E. coli) was the only pathogen isolated in both groups. In the "cipro-only" group, 9 patients had positive blood cultures and 8 were sensitive to gentamicin. In the "cipro+genta" group, the only positive E. coli was gentamicin-resistant. One patient in the "cipro+genta" group was admitted to the intensive care unit with septicaemia.</p><p><b>CONCLUSION</b>The addition of I/M gentamicin to oral ciprofloxacin is a safe and effective prophylactic antibiotic regime in reducing the incidence of post-TRPB sepsis.</p>