Use of metallic ureteric stents for chronic ureteric obstruction and its association with value-based care.

Introduction: We aimed to compare the real-world data and our clinical experience with metallic stents (MSs) and conventional polymeric stents (PSs) in the management of both malignant and benign chronic ureteric obstruction (CUO), in terms of clinical outcomes and costs. Methods: Clinical data from our institution, including outcomes for all ureteric stents inserted for long-term management of CUO from all causes from 2014 to 2017, were retrospectively reviewed and compared between the MS and PS episodes. Results: A total of 247 stents were placed in 63 patients with CUO over the 4-year study period. Of these, 45 stents were MSs. There was no significant difference in all baseline characteristics between the MS and PS groups, except for the aetiology of obstructive cause. Mean indwelling stent duration was significantly greater for MS than for PS (228.6 ± 147.0 vs. 146.1 ± 66.0 days, P < 0.001), thereby leading to lower average number of stent changes per year in the MS group compared to the PS group (1.4 vs. 6.3 times, respectively). Despite the higher unit cost of MS compared to PS, there was no significant mean cost difference overall (cost per dwelling day SGD 7.82 ± SGD 10.44 vs. SGD 8.23 ± SGD 20.50, P = 0.888). Conclusion: Resonance MS is a better option than PS to manage CUO from malignant and benign causes because its significantly longer indwelling time mitigates the higher unit cost of the stent. It potentially reduces the number of procedures and operations in patients. Thus, it should be considered for all patients with CUO requiring long-term ureteric drainage.

Symptom prevalence, bother, and treatment satisfaction in men with lower urinary tract symptoms in Southeast Asia: a multinational, cross-sectional survey.

PURPOSE: The overall objective of the survey was to systematically examine patients' perspectives on lower urinary tract symptoms (LUTS) and their treatment in Southeast Asia. METHODS: A multinational cross-sectional survey involving adult men seeking consultation at urology outpatient clinics because of LUTS in Southeast Asia was conducted using convenience sampling. Self-reported prevalence, bother, treatment and treatment satisfaction of selected LUTS including urgency, nocturia, slow stream, and post-micturition dribble were evaluated. RESULTS: In total, 1535 eligible patients were enrolled in the survey. A majority of respondents were aged 56-75 years, not employed, and had not undergone prostate operation before. Overall, the self-reported prevalence of nocturia was 88% (95% CI 86-90%), slow stream 61% (95% CI 59-63%), post micturition dribble 55% (95% CI 52-58%), and urgency 52% (95% CI 49-55%). There were marked differences in the country specific prevalence of LUTS complaints. Frequently, symptoms coexisted and were combined with nocturia. More than half of patients felt at least some degree of bother from their symptoms: 61% for urgency, 57% for nocturia, 58% for slow stream, and 60% for post-micturition dribble. Before seeing the present urologists, nearly half of patients have received some form of prescribed treatment and more than 80% of patients indicated they would like to receive treatment. CONCLUSION: Men who sought urologist care for LUTS often presented with multiple symptoms. Nocturia emerged as the most common symptom amongst the four core symptoms studied.

Synchronous nephrectomy with unilateral dual kidney transplantation: feasibility in patients with adult polycystic kidney disease.

Adult polycystic kidney disease (APKD) accounts for 2% of end-stage renal disease in Singapore and is a major indication for kidney transplantation. We report synchronous nephrectomy with unilateral cadaveric dual kidney transplantation (DKT) in a patient with APKD. Simple nephrectomy of the right native 27-cm polycystic kidney was performed to provide adequate space for unilateral DKT. Right donor kidney transplantation was performed at the site of native nephrectomy. End-to-side anastomosis of the right donor renal vein to the distal inferior vena cava and the right donor artery to the common iliac artery were performed. Left donor kidney was transplanted below the right kidney, with its vessels anastomosed to the right external iliac vessels. Ureter anastomosis was performed after perfusion of both kidneys. Lich-Gregoir anastomosis of the left donor ureter to the bladder and direct right donor ureter to native ureter anastomosis was established. This case illustrates that synchronous nephrectomy with DKT is feasible to facilitate implantation on the same side.

Renal autotransplantation following long segment iatrogenic ureteric injury.

The authors describe a case of iatrogenic right ureteric injury post duodenectomy and right hemi-colectomy. Renal autotransplantation was chosen as the treatment for the upper ureteric injury. This was successfully performed and the renal function of the transplanted kidney was subsequently preserved. The advantages and disadvantages of this approach are discussed.

Impact of Kidney Disease Outcomes Quality Initiative guidelines on the prevalence of chronic kidney disease after living donor nephrectomy.

PURPOSE: We evaluated the prevalence of chronic kidney disease stage 3 or worse based on the National Kidney Foundation Kidney Disease Outcomes Quality Initiative guidelines after living kidney donation at a single institution. MATERIALS AND METHODS: The collected data of 86 consecutive patients who underwent uneventful donor nephrectomy between 1987 and 2008 were evaluated retrospectively. Estimated glomerular filtration rate was determined using the Modification of Diet in Renal Disease from serum creatinine levels collected before and after surgery in kidney donor followup clinics. Chronic kidney disease was defined as an estimated glomerular filtration rate of less than 60 ml/minute/1.73 m(2) according to the Kidney Disease Outcomes Quality Initiative guidelines. Cox regression analyses were then used to determine the impact of predictors on the development of chronic kidney disease. RESULTS: All donors (mean age 41.2, SD 9.9 years) had a mean preoperative estimated glomerular filtration rate of 88.7 ml/min/1.73 m(2) (SD 16.3). Median followup was 6.4 years (range 0.9 to 21.0). Progression to stage 3 or worse chronic kidney disease was seen in 24.4% (95% CI 15.2-33.7) of patients. There were 2 patient deaths secondary to cancer and none required dialysis. Multivariable analysis showed that preoperative estimated glomerular filtration rate less than 82 ml/minute/1.73 m(2) was an independent risk factor for post-donation chronic kidney disease. For every 1 ml/minute/1.73 m(2) increase in baseline estimated glomerular filtration rate, the hazard of postoperative chronic kidney disease was reduced by 7% (HR 0.93, 95% CI 0.89-0.97, p = 0.001). CONCLUSIONS: Kidney Disease Outcomes Quality Initiative stage 3 chronic kidney disease or worse occurs in 24.4% of kidney donors. Long-term prospective studies and closer followup of donors are needed to identify its implications, given the associated risk of cardiovascular diseases with chronic kidney disease in the general population.

Treatment of a patient with post-TURP hemorrhage using bilateral SAPE.

BACKGROUND: A 74-year-old man developed severe, life-threatening bleeding refractory to endoscopic fulguration from a prostatic capsular perforation while undergoing transurethral resection of prostate (TURP) for complicated benign prostatic hyperplasia. At the time of the procedure the patient had several comorbidities, including hypertension and associated nephropathy, and erectile dysfunction. INVESTIGATIONS: CT angiography and pelvic arteriography. DIAGNOSIS: Post-TURP arterial hemorrhage refractory to conventional methods of hemostasis, complicated by TURP syndrome and disseminated intravascular coagulopathy. MANAGEMENT: Bilateral selective arterial prostatic embolization, after endoscopic hemostasis and continuous catheter balloon traction failed to stop the hemorrhage.

Debulking nephrectomy followed by a "watch and wait" approach in metastatic renal cell carcinoma.

OBJECTIVE: Debulking nephrectomy has been shown to improve survival in metastatic renal cell carcinoma and is now a standard procedure. However, it remains controversial if debulking nephrectomy should routinely be followed by interferon. We report on the clinical course of metastatic renal cell carcinoma patients after debulking nephrectomy who did not receive routine systemic anticancer therapy. PATIENTS AND METHODS: Fifteen consecutive metastatic renal cell carcinoma patients were put on a "watch and wait" protocol after debulking nephrectomy. This included regular computer tomographic scans done at 6 to 8 weeks after debulking nephrectomy, and subsequently 3 to 4 monthly. Systemic treatment was instituted only after disease progression. RESULTS: At a median follow-up of 18 months, 80% of patients had progressed. However, a third of the patients had at least 6 months of progression-free interval, and 3 of 15 patients had not progressed at prolonged follow-up durations of 18, 23, and 46 months. A third of the patients remained alive and the median survival for the cohort was 25 months. Preoperative predictive factors for nonprogression after debulking nephrectomy included absence of abnormal laboratory indices, single organ system metastases, and good performance status. CONCLUSIONS: There is a subset of metastatic renal cell carcinoma patients who will have an indolent course after debulking nephrectomy. Toxic systemic therapies may be avoided in such patients for a significant period of time.

Botulinum toxin type A for refractory neurogenic detrusor overactivity in spinal cord injured patients in Singapore.

INTRODUCTION: Managing neurogenic detrusor overactivity (NDO) successfully in spinal cord-injured patients is a challenge. The aims of preserving kidney function by achieving safe bladder pressures with anticholinergic medication often leave a significant proportion of patients with side effects. Botulinum toxin type A has been shown to be a promising alternative. MATERIALS AND METHODS: Spinal cord injury patients who had NDO, on clean intermittent self-catheterisation, and were refractory to oral medications, were recruited. Three hundred units of botulinum toxin type A (Botox) in 30 mL NaCl solution were injected under cystoscopic guidance into the bladder. RESULTS: Fifteen patients were recruited of whom 9 were tetraplegic and 6 were paraplegic. Eleven (73.3%) had complete injuries. There was a significant reduction in the mean number of leakages from 3.75 +/- 1.79 pre-injection to 0.67 +/- 1.31 and 1.5 +/- 1.5 at 6 and 26 weeks postinjection, respectively (P <0.05). Seventy-five per cent, 37.5% and 50% were completely dry at 6, 26 and 39 weeks post-injection, respectively. The mean maximal catheterisable volume increased from 312.3 +/- 145.6 mL pre-injection to 484.6 +/- 190 mL, 422.3 +/- 157.3 mL and 490.0 +/- 230.4 mL at 6, 26 and 39 weeks post-injection, respectively (P <0.005). Maximum detrusor pressure decreased significantly from 66.3 +/- 22.6 cmH2O to 21.2 +/- 23.1 cmH2O and 33.6 +/- 30.2 cmH2O at 6 and 26 weeks post-injection, respectively (P <0.05). The volume at which reflex detrusor contractions first occurred increased from 127.8 +/- 57.5 mL pre-injury to 305.7 +/- 130.8 mL at 6 weeks and 288.3 +/- 13.0 mL at 26 weeks post-injection (P <0.05). Mean cysometric bladder capacity increased from 187.8 +/- 69.2 mL to 305 +/- 136.4 mL and 288.3 +/- 13.0 mL at 6 and 26 weeks post-injury, respectively (P <0.05). Sixty per cent of patients were completely off medications at 6 and 26 weeks post-injection. One patient had urinary tract infection and 1 experienced autonomic dysreflexia during cystoscopy. Satisfaction levels increased from 4.3 +/- 2.3 pre-injury to 7.2 +/- 1.9 and 7.3 +/- 2.3 at 6 weeks and 26 weeks, respectively. This also correlated with fewer leakages. CONCLUSION: Botulinum toxin type A injected into the detrusor is safe and efficacious for spinal cord injured patients with refractory detrusor overactivity. This effect is maintained at 26 weeks post-injection.

Antegrade ureteral intussusception: a rare complication of percutaneous endopyelotomy.

Ureter intussusception is a rarely reported event and is usually secondary to a ureteral lesion. We report a case of a 15-year-old boy developing antegrade ureteral intussusception secondary to percutaneous endopyelotomy performed for pelvicaliceal junction obstruction. The most appropriate treatment is likely to be surgical excision coupled with pyeloplasty reconstruction or nephrectomy if renal function is beyond salvage. To our knowledge, this has never been reported, and we believe that awareness of this complication should be made known to urologists.

Clinical efficacy and safety of sildenafil citrate (Viagra) in a multi-racial population in Singapore: A retrospective study of 1520 patients.

BACKGROUND: Sildenafil citrate (Viagra), a selective inhibitor of cGMP-specific phosphodiesterase type-5, has been used as an oral therapeutic drug for erectile dysfunction. The present paper is a clinical study of the success rate and side-effects of the use of sildenafil in a multi-racial population in Singapore. METHODS: From April 1999 to May 2000, 1520 patients were given sildenafil citrate. Of these, 912 patients (mean age, 54.6 years; age range, 22-99 years) were followed up and evaluated for clinical efficacy and safety of the drug. The mean duration of erectile dysfunction (ED) and follow-up periods were 31.5 and 3.0 months, respectively. RESULTS: Satisfactory erections assessed by single global efficacy question (GEQ) occurred in 83% of patients, major side-effects in the form of flushing (3.48%), headache (1.97%), blurred vision (1.25%), giddiness (1.18%), warmth (1.11%) and others (4.92%) were recorded in 127 patients (13.9%). Racially, Chinese men with ED had higher efficacy (85.7%), compared to Indian men (74.2%) and Malay men (72.8%). With respect to comorbid profiles, an efficacy of 77.8% (n = 271), 83.9% (n = 292), 86.4% (n = 44) and 83.3% (n = 199) was recorded in diabetic, hypertensive, ischemic heart disease patients and in benign prostatic hyperplasia patients, respectively. Patients who smoked (n = 135) and drank alcohol (n = 118) showed an efficacy of 80%. Baseline hormonal profiles of luteinizing hormone, follicle stimulating hormone, testosterone and prolactin did not affect the success rates of sildenafil citrate. Many patients had earlier received other forms of treatment (medicated urethral suppository for erection (MUSE; 84.9%); vacuum devices (86.8%), traditional medicines (100%) and other oral medications (89.2%)), but this did not influence the success rate of sildenafil citrate. But patients previously treated with prostaglandin-E intracavernosal injections were less successful on sildenafil citrate (77.3%). In the total cohort, 50 mg sildenafil citrate was an effective dose in 49% of patients and 46.5% patients needed 100 mg sildenafil citrate, while 4.1% of the total cohort needed only 25 mg sildenafil citrate. CONCLUSION: Oral sildenafil citrate has been shown to be an effective, safe and well tolerated drug in Singaporean men with ED, as in men from other parts of the world.