Stricture of the male urethra: 29 years experience of 323 cases.

The authors reported 323 cases of male urethral stricture managed at Ramathibodi Hospital from 1969 to 1998 (29 years period). Etiology included traumatic causes 237 (73%) and post infection 54 cases (16%). The managements were urethroplasties 281 cases (87%), urethrotomy 21 cases (6%) and dilatation 21 cases (6%). The over all successful rate of urethroplasty was 89 per cent. The mean follow-up time was 2.5 years (0.5-15 years).

The current therapy of urinary calculi in Thailand.

The paper analyses the impact of modern therapy of urinary calculi in Thailand since the introduction of ESWL and endourology (PCNL and URS) in 1988. Up to then, conservative and open surgical measures had been the standard procedures. The study covers 12 medical centres in the north, northeast, south and central parts of the country between 1988 and 1997. Approximately 40 ESWL machines have been in use. ESWL was used in 66.1 per cent and 20.8 per cent of patients with renal and ureteric calculi respectively. Only 1.1 per cent of the patients had PCNL. URS was used in 20.8 per cent of patients with ureteric calculi. Open operations were required in 32.6 per cent and 53.6 per cent of patients with renal and ureteric calculi respectively. Nephrectomy was required in 4.8 per cent--16.0 per cent of patients with renal calculi. Certain considerations have been put forward to appraise the situation concerning urinary stone therapy in Thailand.

The organization of Kidney Transplantation Services at Ramathibodi Hospital: fourteen years experience on waiting list, kidney donors and kidney transplantation.

The Kidney Transplantation Program at Ramathibodi Hospital was established in 1985. By the end of 1998, there were 1,614 patients on the cumulative waiting list. The first kidney transplantation (KT) was started in 1986 by using kidney from living-related donor (LD) while cadaveric KT (CD-KT) was started in 1987. A total of 528 KT were done, 278 cases (52.7%) were CD-KT and 250 cases (47.3%) were LD-KT. Six patients had two kidney transplants. 278 kidneys were donated from 189 cadaveric donors. Fifty cadaveric donors (26.4%) were from Ramathibodi Hospital while the rest were from other hospitals and the Organ Donation Center, Thai Red Cross Society. For LD, 233 out of 250 (93.2%) were from living-related, more than 50 per cent of these donors were from siblings. 17 spousal donors have been accepted for KT at Ramathibodi Hospital since 1997. Concerning the recipient pools, 522 patients (32.3%) were transplanted, 123 patients (7.6%) died without KT, 111 patients (6.9%) underwent KT at other hospitals, and 78 patients (4.8%) changed to waiting lists at other hospitals. The rest were lost to follow-up. At present, only 265 patients are still actively waiting (send serum every month). The number of KT and living donors has gradually increased, whereas, the number of cadaveric donors has decreased. However, cooperation with the "Organ Donation Center" has improved the number of cadaveric donation in the last two years. Sufficient organ donations and an active working team will provide a good kidney transplant service for the patients.

The urological complications of renal transplantation: an 11-year-experience at Ramathibodi Hospital.

From February 1986 to December 1996, renal transplantation was performed on 344 patients at Ramathibodi Hospital. The urological complications were retrospectively analyzed in 335 patients (338 renal transplants), 9 patients were lost to follow-up. There were 227 males and 108 females with age ranging from 15 to 62 years (mean age 40.28 years). There were 207 cadaveric and 131 living-related graft donors. The ureteroneocystostomy was performed either by modified Politano-Leadbetter (93 cases) or extravesical technique (245 cases). There were 23 cases of urological complications: ureterovesical anastomotic leakage 6, ureteric obstruction 6, vesicoureteric reflux 4, significant bleeding from ureterovesical anastomosis 3, renal infarction with fistulas 2, hydronephrosis due to blood clot retention and swelling of the anastomosis, requiring temporary double J stenting 2. The analysis was done by dividing the patients into 3 groups, the first and second groups consisted of 100 cases each and the third group consisted of 138 cases. The urological complications in the groups were 10 per cent, 9 per cent and 2.89 per cent respectively. There was a statistically significant difference between the first two groups combined and the third group in terms of complications (p < 0.025). The urological complications of living-related cases were 9 (6.87%), and of cadaveric cases were 14 (6.76%). There was no significant difference of the complications between living-related and cadaveric transplants (p < 0.05). The comparative results of the ureteric complications of the extravesical technique were significantly less than the modified Politano-Leadbetter technique (4.49% vs 10.75%), (p < 0.05). In conclusion, the extravesical technique of ureterovesical anastomosis was superior than the modified Leadbetter-Politano technique in terms of post-operative ureteral complications.

Vesico-vaginal fistula: experience of 230 cases.

We reviewed 230 cases of vesico-vaginal fistula in Ramathibodi Hospital from 1969 to 1997. The cases of fistula included 164 cases after transabdominal hysterectomies, 5 cases after anterior colporrhaphies, 8 cases after radical hysterectomy, 23 cases after vaginal hysterectomy, 10 cases after prolonged or traumatic birth, 9 cases after radiation for cervical carcinoma, 7 cases of cervical cancer invasion, 2 cases after suprapubic cystolithotomy and 2 cases after pelvic fracture. Most of them were referred from other hospitals. In 7 cases, the fistula closed spontaneously after indwelling urethral catheters for 4-6 weeks. Five cases were cured after transurethral fulgurations. The rest were treated with different surgical procedures i.e. transvaginal, transvesical and retrovesical repairs. Ten cases were treated by urinary diversions, usually after failure using other surgical procedures.

Sterilization in Thailand.

Sterilization in Thailand began in the 40ies but the slow progress was due to lack of government support. In 1970 the government declared the population policy that resulted in the development of the tubal resection and vasectomy programs in the governmental hospitals and private sectors. The current total number of sterilizations reaches 200,000 cases annually with female to male ratio of 4:1. Contributions by the government and the private sectors are 80% and 20% respectively. The university hospitals have been involved in programme planning and various studies on sterilization acceptance and development of appropriate technology and delivery system. Sterilization service has been directed to the rural areas where 80% of the Thais live. All efforts are directed towards an objective to reduce the population growth to 1.2 by the end of 1990.

Vasectomy and vasectomy reversal the Thai way.

PIP: In 1972 the ratio of female sterilization acceptors to vasectomy acceptors in Thailand was 24.5:1; in 1978 the ratio was 2.8:1. Several factors are responsible for this change. First, a national family planning program to support voluntary family planning started in 1970 and lowered the population growth rate from 3.2% in 1973 to 2.1% in 1982. Second, the desired family size in Thailand is 3 and it is generally agreed that the solution is voluntary sterilization as a more cost effective fertility control method. Thirdly, misunderstandings about vasectomy were cleared up through media campaigns which cleared the way for greater acceptance. Fourth, in 1975 special clinics at big hospitals and a mobile unit were set up to perform vasectomies. Lastly, a group of nongovernment organizations has been set up, such as the Thai Association for Voluntary Sterilization, to provide the infrastructure for vasectomy campaigns. Requests for vasectomy reversals have, expectedly, increased as well, usually caused by marriage, child's death, improved finances, and psychosexual health. In a recent study of 32 cases, positive sperm reappearance after vas reanastomosis was found in 71.4% and the pregnancy rate was 52.3%.^ieng

Vasectomy reversal: experience in Ramathibodi Hospital, Thailand.

PIP: Vasectomy, as a fertility control measure, is appropriate for developing countries which face the problem of increasing population growth, such as Thailand. Vasectomy would be a much more attractive procedure if it could be easily reversed. Outcomes of vasectomy reversals using both conventional techniques and microsurgical methods are reported. From April 1973-January 1980, 34 vasectomy reversals were performed in Ramathibodi Hospital using conventional methods. 21 cases are available for analysis. Patient ages ranged from 25-51 years, with an average of 36.8 years. Vasectomies had been performed up to 17 years prior to reversal; in 14 cases, the procedures had taken place within the previous 10 years. The conventional method involved placing intravasal splints of nylon or other material and stitching the muscularis with interrupted sutures. Of the 21 cases, sperm reappearance was positive in 15 patients (71.4%) and pregnancy occurred in 11 cases (52.3%). The interval from reversal to pregnancy ranged from 2 to 12 months, and averaged 5.1 months. Of these patients whose vasectomies had been within the past 10 years, pregnancy occurred in 64.3%. For patients whose vasectomies had been performed more than 10 years prior to the reversal, only 28.5% achieved pregnancy. 16 vasectomy reversals using microsurgical techniques were performed from August 1978-January 1980 and 13 cases were available for analysis. The patients' ages ranged from 28-50 years with a mean of 38.7 years. In 6 cases, the vasectomy had been performed within the previous 10 years. The microscopic technique involved 2 layered anastomosis with 6 sutures in the mucosa and muscularis sutures for reinforcement. 9 of the 13 cases had sperm in the ejaculate and 4 achieved pregnancy. Sperm reappearance was 100% for patients whose vasectomies had been done within the previous 10 years, and 43% in the other cases. The average interval from reversal to pregnancy was 6.2 months. 1 case had postoperative epididymo-orchitis. The results of the microsurgical methods are encouraging and with more experience, the overall results of vasectomy reversal should be highly satisfactory. Special centers in selected hospitals should be developed where reversal using microsurgical methods can be performed by trained surgeons.^ieng

How do we decide?

PIP: Examples of the types of questions presented by the population to the Thai Association for Voluntary Sterilization are examined. They indicate that the population has interests exemplified by the family planning slogan: "Delay the 1st, space the 2nd, and stop the 3rd." Statistics show that contraceptive pills are the most popular form of birth control in Thailand, with 62.2% of all contraceptive-using females using the pill. A discussion of sterilization methods, and possible side effects is presented, along with the questions couples should consider before submitting to sterilization. Restoration of fertility after sterilization is presented as being an unlikely possibility.^ieng

Vaso-vasostomy using microsurgical techniques. A preliminary report.

PIP: To respond to the many men on the waiting list for surgical recanalization at Ramathibodi Hospital in Bangkok, Thailand, a new service was established as part of the overall family planning service. From October 1978 to June 1979, 16 vasovasostomies were performed using microsurgery. A 2-layered anastomosis with 8-0 Dexon on an opthalmic needle was used for both mucosal and muscularis sutures. A 16X magnification on the microscope was found adequate. After mobilization of the vas through separate scrotal incision, the scar tissues or sperm granuloma, if any, were excised. The cut ends of the vas deferens were examined to determine if the lumens were patent. Hemostatis must be meticulous using a bipolar electrode, and care must be taken not to strip the adventitia of the vas too much for fear of endangering the blood supply. The mucosa could be easily seen under the microscope. A microscopic examination of the sperm fluid was routinely performed. 2 stay sutures were placed diametrically opposite to one another. The special clamps were applied. 3 anterior sutures were inserted first. Appropriate muscularis sutures were inserted only to reinforce the 1st mucosal layer. Of the 16 patients, follow-ups were possible in only 8 cases. There were 2 definite failures (12%). The 1st case in the series that was a failure was because of unfamiliarity with the technique. The 2nd failure was due to severe bilaterial intrascrotal infection with abscess formation. The patients ranged in age from 29-42 years. The duration postvasectomy ranged from 2-15 years. The reasons for requesting reversal were divorce (55%), death of the children (18.7%), wanting more children (13.8%), and psychological (12.5%). Only in 8 patients was it possible to perform sperm analysis after the 1st postoperative months. The ejaculates contained spermatozoa in all cases, excluding the 2 failures. The sperm reappearances occurred as early as 2 weeks postoperatively. The count increased to 20 million/ml at 4 weeks in 1 patient. 1 patient, on whom vasectomy was performed 15 years previously, showed negative smears intraoperatively and poor sperm count postoperatively. The volume of the ejaculates was 3-4 ml. The motility ranged from 40-60%. All patients except 1 had positive smears intraoperatively. Thus far there is no information on the pregnancy rate. In sum, initial results were encouraging.^ieng