Flexible ureterorenoscopy for upper urinary tract treatment using new 7.5 F 270 degree deflectable ureteroscope: Siriraj Hospital early experience.

Objective: To evaluate the efficacy and report our experience of using a flexible ureterorenoscopy in the diagnosis and therapy for upper urinary tract disease. Methods: Between September 2005 and June 2008, 21 upper urinary tract procedures were performed with 7.5 F actively deflectable, flexible ureteroscope. Of these 13 were for diagnostic reasons and eight for therapeutic purposes. A retrospective data of these procedures was collected. The indication, diagnostic or therapeutic procedure, operative time, success rate and postoperative course were analyzed. Results: The procedures were performed in 21 patients (mean age 66.71 years; range, 47-85 years; 11 procedures in males and 10 procedures in females). The indications were lateralizing essential hematuria (2), hematuria with upper tract radiolucent lesions (11), upper tract lesions without hematuria (3) and stones (5). In the diagnostic group, the mean operative time was 50 min (range 15-120). The procedure was completed successfully in all patients. The most common endoscopic finding was urothelial carcinoma in hematuria with upper tract lesions (9/11). In the therapeutic group (stone removal five, tumor fulguration three), the mean operative time was 83.12 min (range 30-160). The success rate of these therapeutic procedures was 62.5% (5/8). There was no intra and postoperative major complication. With an average follow up of 14 months (range 1-33), no patient had a late complication, such as ureteral stricture. The flexible ureteroscope did not need repair during this study. Conclusion: Flexible ureterorenoscopy is an effective and minimally invasive diagnostic and therapeutic tool for upper urinary tract disease.

Retroperitoneoscopic nephrectomy in dialysis dependent patients and comparison with open surgery.

OBJECTIVE: To evaluate the surgical outcomes and morbidity of retroperitoneoscopic nephrectomy compared with open nephrectomy for dialysis dependent patients. MATERIAL AND METHOD: Between November 2002 and August 2007, 14 hemo or peritoneal dialysis patients underwent nephrectomy or nephroureterectomy at Siriraj Hospital. Of the 14 patients, seven were treated with retroperitoneoscopic nephrectomy and seven with open nephrectomy. A retrospective review and data were carried out. The patient factors, type of surgery, perioperative outcomes and complications were analyzed. RESULTS: There was no conversion rate in the retroperitoneoscopic group. The mean estimated blood loss, analgesic requirement and time before starting oral intake were lower in the retroperitoneoscopic group (141.4 +/- 95 versus 292.8 +/- 226 ml, 5.0 +/- 4.5 versus 7.6 +/- 1.9 mg and 14.5 +/- 16.1 versus 23.1 +/- 23.3 hours, respectively). On the other hand, the mean operative time in the retroperitoneoscopic group was longer than the open group but with no significant difference (177.14 +/- 51 versus 160.71 +/- 84 min, p = 0.521). Two patients in the open group required intraoperative blood transfusion. There were two complications. One patient developed a large retroperitoneal hematoma after retroperitoneoscopic nephrectomy. Another had a perivesical collection in the open nephrectomy group. No mortality related to the procedures occurred. CONCLUSION: Retroperitoneoscopic nephrectomy should be considered as the procedure of choice for dialysis dependent patients. This has all the benefits of minimally invasive surgery such as reduced blood loss, minimal post operative pain leading to faster convalescence.

Intravesical knotting of a feeding tube used as a urinary catheter.

Urethral catheterization is a common procedure among pediatric patients. Intravesical knotting of a polyethylene feeding tube used as a urethral catheter is rare. This report described such a complication in an infant who had urethral catheterization with 5 Fr feeding tube. Removal of the catheter necessitated cystotomy. This complication is preventable if the feeding tube is inserted only as short as possible to retrieve urine.

Management of ureteral calculi with the use of transurethral ureteroscopy and electrohydraulic lithotripsy: 101 patients experience.

To evaluate the results of transurethral ureteroscopy and electrohydraulic lithotripsy for ureteral calculi needing surgical management. From 1993 to 1995, 101 patients with ureteral calculi were retrospectively analyzed. The locations and sizes of the calculi were examined and the success rate of the procedure was assessed. The overall success rate was 74%. The success rates of upper and lower ureteral calculi were 67% and 81%, respectively. The stone size did not affect the success rates. Among the failure patients, there were no serious complications and they could be subsequently treated with either ureterolithotomy or double J stent replacement. The median hospitalization was 4 days. Transurethral ureteroscopy and electrohydraulic lithotripsy is an effective and safe procedure for ureteral calculi treatment. This method is a minimally invasive procedure and involves a short hospital stay.

Postnatal management of fetal hydronephrosis.

To differentiate neonates with hydronephrosis who will benefit from early surgical treatment from those who will not. Patients and Methods: Twelve consecutive neonates with a history of fetal hydronephrosis in 19 renal units were treated conservatively. Investigations included urinalysis, serum creatinine, ultrasonography, diuretic radionuclide renography and intravenous pyelography. Surgery was indicated when there was evidence of recurrent urinary tract infection and deteriorating differential renal function of the involved kidneys. Results: Postnatal ultrasound confirmed hydronephrosis in 17 out of 19 renal units. Based on drainage curve obtained on diuretic radionuclide renography, patients were classified into obstructive (9 units), non-obstructive (5 units) and equivocal group (3 units). Diagnoses in the first group were uretero-pelvic junction obstruction in 8 and ectopic ureterocele in 1. Pyeloplasty was done in 7 renal units and heminephrectomy was performed for ectopic ureterocele. Average age at operation was 15 months. None of the non-obstructive group required surgery after an average of 24 months of follow up. There was one dropout in equivocal group. One neonate underwent ureteroneocystostomy for megaureter at 18 months of age, while the remaining neonate has been doing well on regular follow after 27 months. Conclusion: Approximately half of neonates with history of fetal hydronephrosis ultimately required surgery. Diuretic radionuclide renography was useful in differentiating between neonates whose hydronephrosis ultimately required surgery and those with a benign outcome.

Bladder cancer in Siriraj Hospital from 1991 to 1995.

A retrospective study was under taken of 284 patients with blander cancer seen at Siriraj Hospital from 1991 to 1995. Of the total 284 patients, new patients comprised 158 cases, while recurrent cases numbered 126. The average ages were 60-70 years. The male to female patients ratio was 235 to 59 (4:1), with the most common symptom being haematuria. Most of the patients (both new and recurrent cases) were in stage A, and the common histology was transitional cell carcinoma. A total of 39 patients in stages O and A were treated by TUR and adjuvant intravesical BCG therapy, while 62 patients with invasive bladder cancer underwent cystectomy.

Nerve-sparing clitoral reduction in congenital adrenal hyperplasia: Experience with 22 cases.

Clitoral hypertrophy in girls is commonly caused by excessive androgen production from congenital adrenal hyperplasia. While medical treatment of this clinical entity is well established, evolution of surgical is well established, evolution of surgical reconstruction is continuing to seek a perfect result. In the past, clitorectomy, clitoral recession/relocation and clitoral placation were undertaken with unfavourable cosmetic outcome. Cumulative experience has led us to develop an alternative procedure that preserves both the neurovascular bundle and ventral mucosal wall and creates the labia minora so that normal appearing external female genitalia are achieved. From February 1992 to May 1997, 22 cases of congenital adrenal hyperplasia afflicted from clitoromegaly underwent nerve-sparing clitoral reduction at the Division of Urology, Siriraj Hospital. Four of the cases had previously undergone recession/relocation with unacceptable outcomes. Age at operation ranged from 2 months to 18 years. The follow-up period was at least six months. Satisfactory cosmetic results were obtained in all instances except one who had clitoral atrophy at five months post-operatively.

Prostatic carcinoma at Siriraj Hospital.

In Thailand, carcinoma of the prostate gland ranks at the number tenth of the most common malignancy in male. Here we report the incidence of carcinoma of the prostate during 1990-1992. The average number of patients was about 30 per year. The incidence was common at the age of 70-79. The common symptoms were difficulty in urination 48%, hematuria 19%, back and bone pain 16%, urinary retention 14.4%,Most of them were in stage C and D and treatment of choice were TUR and orchidectomy. Only one patient, the histologic section was transitional cell carcinoma.

The pattern of lymph node metastasis of penile cancer in Thais.

The prognosis of penile cancer is dependent on ilioinguinal lymph node metastasis. However, some controversy still exists concerning the management of those lymph nodes because the pattern of lymph node metastasis, especially in Thai males, is questionable e. Hence a prospective study of the pattern of lymph node metastasis was undertaken in 26 penile cancer patients from 1992 to 1995. All patients had the same pattern of lymph node metastasis. From primary lesion, tumour metastasized first to the inguinal lymph node, and then to the ipsilateral pelvic lymph node. There was no skip pattern. There was no correlation between Jackson staging, degree of cell differentiation, extension of primary lesion, palpability of clinical inguinal lymph node and pathological staging of lymph node metastasis after bilateral ilioinguinal lymphadenectomy. The primary lesion with poor differentiation was highly related to lymph node metastasis at the initial diagnosis. In patients with a clinically negative inguinal lymph node, 50 percent had inguinal lymph node metastasis and 12.5 percent had inguinal lymph node metastasis. In patients with a clinically positive inguinal lymph nod, 83.3 percent had inguinal lymph node metastasis and 38.8 percent had pelvic lymph node metastasis. In conclusion, lymph node metastasis in penile cancer is unpredictable by clinical evidence. Therefore prophylactic bilateral inguinal lymphadenectomy is recommended in all patients, and especially in cases with poor differentiation of the primary lesion, low education or low compliance with follow up. If there is inguinal lymph node metastasis, ipsilateral pelvic lymphadenectomy is recommended.