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.

Prevalence of prostate cancer in aging males receiving PSA (prostate specific antigen) screening test (A campaign for celebration of Siriraj Established Day).

Prostate cancer is a potential men's health problem. The prevalence of prostate cancer continues to rise. Serum PSA (Prostate Specific Antigen) can be used as a screening tool for detection of early prostate cancer However, a screening program for prostate cancer has not yet been accepted as cost-effective and long term survival benefits have not been shown. Nevertheless, some doctors request PSA testing in men who present with lower urinary tract symptoms (LUTS) to detect prostate cancer OBJECTIVE: To study for prevalence of prostate cancer in healthy men seeking medical check-up for prostate cancer. MATERIAL AND METHOD: During the anniversary celebration of Siriraj established day (26/07/1888), a cohort study of Prevalence of prostate cancer in aging males using PSA Screening Test was carried out, 200 men over 45 years of age were invited to PSA testing and prostate glands check-up including, IPSS (international prostatic symptoms score), QOL (quality of life score) and DRE (digital rectal examination). Patients with elevated PSA were advised to undergo transrectal-ultrasound-guided-biopsy of the prostate (TRUS-biopsy). Cancer detection rate was calculated according to symptoms described by patients, IPSS and age groups. Data was compared using Chi-Square test. RESULTS: Median values from data of men's ages, IPSS, QOL and PSA were 63 years, 11, 2, and 1.23 ng/ml, respectively. 9 of 200 patients (4.5%) were found to have prostate adenocarcinoma on biopsy. Most of the cancer cases showed a localized lesion. Prostate cancer was found more common in patients who described themselves as having abnormal urination. There was no prostate cancer found in patients with a mild degree of LUTS (IPSS less than 8). Prostate cancer tended to be more common in men with high IPSS. CONCLUSION: Screening prostate cancer by PSA testing detected the cancer in 4.5%. Most cancers were found on symptomatic patients. Patients with LUTS should be made aware of prostate cancer and PSA testing may be offered in such patients. However screening of prostate cancer in all men regardless of symptoms must wait for a larger study looking at long term survival benefit, cost-effectiveness of screening, and lastly, quality of life of patients on a screening program.

The efficacy and safety of oral sildenafil in Thai men with erectile dysfunction: a randomized, double-blind, placebo controlled, flexible-dose study.

OBJECTIVE: To evaluate the efficacy and safety of sildenafil citrate (Viagra) in a randomized, double-blind, placebo-controlled, flexible-dose study in Thai men with erectile dysfunction of broad-spectrum etiology and more than 6 months' duration. MATERIAL AND METHOD: 125 patients aged 26 to 77 years were randomized at 4 centers in Thailand to receive either sildenafil citrate (50 mg initially, increased if necessary up to 100 mg or decreased to 25 mg depending on efficacy and/or tolerability) (n = 63) or a matching placebo (n = 62) taken on an 'as needed' basis approximately 1 hour prior to anticipated sexual activity for a period of 12 weeks. Efficacy was assessed by the patients' responses to the 15-question International Index of Erectile Function (IIEF), to questions on the event log of sexual activity, and to the global efficacy assessment question concerning improvement in erections. RESULTS: At the conclusion of the study, both the primary efficacy variables relating to the achievement and maintenance of erections sufficient for sexual intercourse and the secondary efficacy variables, which included the 5 separate domains of sexual functioning of the IIEF, the percentage of successful attempts at sexual intercourse, and the global efficacy assessment question concerning improvement in erections, were all significantly improved statistically by sildenafil in comparison with placebo except in the sexual desire domain which showed no difference. The percentage of successful attempts at sexual intercourse in the sildenafil group was 66.16 per cent while in the placebo group it was 33.05 per cent. The percentage of global efficacy assessment was improved in the sildenafil group by 82.5 per cent compared to 36.1 per cent in the placebo group. Adverse events considered treatment-related occurred in 19 patients (30.2%) receiving sildenafil and 7 (11.3%) receiving placebo. The most common adverse events with sildenafil were vasodilatation (flushing), headache, and dizziness, which occurred in 14.3 per cent, 6.3 per cent, and 6.3 per cent of patients respectively. All events were mild in nature. CONCLUSIONS: Sildenafil is a safe and effective treatment for erectile dysfunction of broad-spectrum etiology in Thai men. Its efficacy appears similar to that reported in other studies in Western populations.

The risk and effectiveness of transurethral resection of prostate.

BACKGROUND: To advise a patient to have transurethral resection of prostate (TURP) needs information on the benefit and complications of the procedure. Quality assurance also needs present results to be compared with future ones. OBJECTIVES: The authors wanted to know: 1. Whether TURP can decrease theInternational prostate symptom score (IPSS) and improve the Quality of Life (QOL) scores concerning urination at 1.5 months post-operatively for at least 25 per cent of the pre-operative scores?; 2. What are the common medical diseases in this type of patient?; and 3. What are the mortality and immediate complications of TURPF? METHOD: This was a prospective, before-after design trial. All patients who came to have TURP at a tertiary care hospital were studied. IPSS and QOL scores were recorded before surgery and again when the patients came back to follow up at 1.5 months after discharge. Patients were evaluated for cardiopulmonary reserve and congestive heart failure. Anesthetic technique of choice was spinal anesthesia with 0.5 per cent bupivacaine. Anesthetic and surgical complications were recorded if the definitions were met. ANALYSIS: Pre-operative and 1.5 months post-operative scores were compared using paired t-test and 95 per cent confidence interval. RESULTS: During the 13 months there were 269 consecutive males who received TURP. The mean +/- SD age was 70.4 +/- 8.8 years (range 35-97). The mean difference between pre- and post-operative IPSS was 6.7 +/- 9.1 (95% CI 5.2-7.8). Quality of Life also improved, the mean difference between pre- and post-operative QOL was 3.2 +/- 1.6 (95% CI 2.9-3.5). Most patients had ASA class 2. Common pre-operative existing diseases were hypertension (31.6%), ischemic heart disease (18.2%), diabetes (15.6%), and COPD (7.1%). Anesthetic techniques were spinal block (77.3%), epidural block (5.9%), continuous epidural (11.2%), and general anesthesia (5.6%). Intra-operative complications were reported and T URsyndrome occurred in 1 patient (0.37%). There was one surgical death 3 days post-operation, due to septic shock probably from bowel perforation. CONCLUSION: The patients' symptoms and quality of life significantly improved, but there was 1 surgical death and 1 TUR syndrome among 269.

The prevalence of prostate cancer screening in Thai elderly.

PROBLEM: Prostate cancer is the most common cancer in elderly men in Western countries. In the future, it may be an important problem in Thailand. At present, there is no evidence about the prevalence and the outcome of screening in this disease. OBJECTIVES: To determine the prevalence of prostate cancer in elderly Thai men and to identify the most appropriate screening method for detection of prostate cancer in Thailand. MATERIAL AND METHOD: 928 elderly men from communities around Siriraj Hospital were evaluated for prostate cancer by Digital Rectal Examination (DRE) and/or Prostate Specific Antigen (PSA). Transrectal ultrasound guided biopsy (TRUS-Bx) which is the gold standard for definitive diagnosis was performed in cases with an abnormal DRE and/or PSA. If biopsy could not be performed, intermittent follow-up with DRE and/or PSA were recommended. RESULT: The prevalence of prostate cancer in Thai elderly men in the urban community was more than 0.75 per cent and the prevalence of abnormal DRE and PSA was 8.7 and 17.3 per cent respectively. The Positive Predictive Value (PPV) of both tests was 60 per cent and higher than the PPV of an individual test. A screening program for prostate cancer starting with DRE may be more cost effective. CONCLUSION: The prevalence of prostate cancer, abnormal DRE and abnormal PSA in Thai elderly men were more than 0.75, 8.7 and 17.3 per cent respectively which are comparable to the prevalence in Western countries. It is important that we take an interest in this disease.

Benign prostatic hyperplasia in elderly Thai men in an urban community: the prevalence, natural history and health related behavior.

PROBLEM: Although benign prostatic hyperplasia (BPH) is a common disease in elderly Thai men the prevalence in the community and its natural history is unknown. OBJECTIVES: To determine the prevalence of symptomatic BPH and its natural history. To determine the health related behaviors which have an impact on the voiding symptoms. MATERIAL AND METHOD: 879 elderly men aged > or = 60 years from communities around Siriraj Hospital were studied. The International Prostate Symptom Scores (IPSS) and Quality of Life (QOL) scores were evaluated in the participants at the beginning of the study and 1 year later. The overall assessment, complications and health related behaviors were also evaluated. RESULT: The prevalence of symptomatic BPH in the community was 41.3 per cent. In terms of overall assessment at 1 year follow-up, symptomatic BPH patients (IPSS 8-35), the rate of "improved", "same" and "worse" was 10.6, 70.2 and 19.2 per cent respectively. The complication rate was about 10 per cent. Three quarters of the elderly men had health related behavior at risk. CONCLUSION: The prevalence of symptomatic BPH was high. Its natural history was unpredictable and some BPH symptoms may be influenced by their behaviors.

Management of high-flow priapism: A case report and review.

A case of high-flow priapism was presented. Diagnosis was based on the history of painless and persistent erection for 20 days. Cavernous blood gas showed arterial type. The arteriocavernous fistula was detected by either a perineal duplex Doppler ultrasonography or an internal pudendal arteriography. The treatment of choice was selective embolization with a good result and no immediate complication. Detumescence was noticed within 10 days. Follow up of perineal and penile duplex Doppler ultrasonographies showed no turbulent flow and low inflow of cavernous blood. Erectile function partially recovered at 2 months after the treatment.

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.

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.

A retrospective study of carcinoma of the prostate between 1993-1995 (phase 2).

In Thailand, carcinoma of the prostate gland is the tenth most common malignancy in males. Here we report the incidence of carcinoma of the prostate during 1993-1995, as the previous report in 1990-1992. The average number of patients was about 32 per year. The incidence was common at the age of 70-79 years. The common symptoms were difficulty in urination 51 per vent, hematuria 13 per cent, back and bone pain 9 per cent and urinary retention 18 per cant. Level of serum PSA (prostate specific antigen) is low in stage A, and high in stage C and D. Most patients were in stage C and D, and treatments were TUR (transurethral resection) and orchidectomy with or without hormonal adjuvant therapy. Radical prostatectomy was done in one patient with stage A and he is showing satisfactory recovery.

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.

Prostatic tumour markers in BPH and prostate cancer.

The blood levels of acid phosphatase (AP), prostatic acid phosphatase (PAP) and prostate specific antigen (PSA) in 80 cases of begin prostatic hypertrophy (BPH) patients and 22 cases of prostate cancer patients were studied. It was shown that the average levels of AP, PAP and PSA in BPH patients were 4.06 U/L, 1.27 U/L and 7.45 ng/ml. respectively, while those in prostate cancer patients were 5.09 U/L, 1.63 U/L and 62.63 ng/ml. respectively. In a comparison between the two groups of patients, the levels of AP and PAP were not found to be significantly different (p > 0.05), whereas in the case of PSA there was a significant difference (p < 0.005). Therefore, although AP and PAP cannot be used to differentiate between BPH and prostate cancer, PSA could be utilized However, no exact level of PSA was observed which would allow differentiation between the groups because although the PSA levels in 64 per cent of the BPH patients were higher than normal none were over 40 ng/ml.; those in 14 per cent of prostate cancer were normal. There was correlation between PSA level and adenoma tissue weight, from TUR-P, with an average value of 0.35 ng/ml. per 1 gram of tissue. It is import to note that in a patient who has a PSA level of over 40 ng/ml., or a PSA level that has no correlation to the weight of the prostate, there is a high possibility of prostate cancer. Therefore, a pathological tissue examination should be approved for this patient.

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.

Normal voiding function in elderly Thai females.

Voiding dysfunction is quite a common problem. Before we evaluate dysfunction, we should first know the normal function. This study was about voiding symptoms and normal uroflowmetry in 50 elderly Thai females whose ages ranged from 60-80 years. All of them had no voiding symptoms or problems. They were interviewed about their voiding habit and voided over a uroflowmeter with voided volumes of not less than 100 ml. They were ruled out if there were conditions that caused voiding dysfunction. The most common symptom was nocturia with 1-2 times a night. This symptom was found in 34 percent and 20 percent respectively. The average range of voided volume, peak flow rate, mean flow rate and residual urine were 250 (120-495) ml., 24.9 (15.4-46.5) ml/sec., 15.3 (7.6-31.8) ml/sec. And 21 (0-70) ml. Respectively. Superflow pattern was the most common voiding pattern and were found in 56 percent.

Pseudosarcomatous tumor of urinary bladder.

The first case in Thailand ofpseudosarcomatous tumor of the urinary bladder is reported. A 32-year-old female, presented with gross hematuria and dysuria. Cystoscopy showed large mass floating in the bladder and biopsy of the tumor showed to be leiomysarcoma. IVP was normal but CT scanning showed huge mass occupied the whole bladder and invasion outside the anterior wall was suspected. The bladder was explored and the tumor with part of the bladder around the tumor’s stalk was resected. A microscopic section revealed spindle cell proliferation exhibiting mitotic activity within myxoid stroma. The election microscopic finding showed myofibroblast. The final diagnosis was pseudosarcomatous fibromyxoid tumor. The patient was followed up for 5 years and no evidence of recurrence has been detected.

Adjuvant therapy with mitomycin C intravesically for superficial bladder cancer.

A retrospective study was carried out using the OPD cards of 25 cases (stage A, grade 2) with transitional cell carcinoma (superficial bladder cancer), to determine effects of Mitomycin C on preventing tumor recurrence. Of these patients, 13 had been managed by surgery (TUR/TUF) only (group 1). The remaining 12 cases (group 2) were given Mitomycin C (intravesically) administration at two weeks post surgery (4 cases/group 2 A) and after several tumor recurrence was found in eight cases (group 2 B). The study compared the mean recurrence rate per year of these three groups. The mean recurrence rate per year of group 1, group 2 A and group 2 B was 0.34, 0.68 and 1.22, respectively, and there was no statistical difference between them. The percentage of recurrence in group 1, group 2 A and group 2 B was 61.5, 50 and 75, respectively. In conclusion, Mitomycin C dose not significantly reduce the recurrence of tumors, but if used two weeks after surgery it dose reduce the percentage of recurrence.