Lack of improvement after audit assessing the management of voiding dysfunction in patients with spinal cord injury: necessity for institutional guidelines.

INTRODUCTION: Standard management guidelines for voiding dysfunction in patients with spinal cord injury (SCI) do not exist and these patients are managed on the basis of institutional protocols or individual judgment of managing physicians. OBJECTIVES: To notice general trends and improvements over a five-year period, in the institutional practices related to management of voiding dysfunction in SCI patients. METHODOLOGY: A retrospective cross-sectional study was conducted by Neurosurgery and Urology services together. A nine years (June 1995-June 2004) internal clinical audit of urological management of SCI patients was compared with a similar audit conducted five years later (January 2008-June 2010). Comparisons were made using chi-square test. A p-value of <0.05 was considered statistically significant. RESULTS: A total of 146 patients were compared (89-pre-audit, 57-post-audit). The quality of documentation of examination findings worsened over the two study periods (p = 0.002). Although determination of baseline serum creatinine improved to statistically significant levels (p = 0.019), no imaging for the kidneys was performed as baseline in the post-audit period (p = 0.000). Similarly the number of urodynamic studies performed decreased from 11% to 1.75% (p = 0.045). The number of urological consultations, however, increased from 26% to 31.58% (p = 0.452). During follow-up, only 17 (19.1%) patients in the pre-audit study period and 6 (10.5%) in the post-audit study period were voiding spontaneously. CONCLUSION: Our study of two eras clearly demonstrated a worsening trend in quality of patient management, which can be corrected by agreeing upon and implementing standard guidelines for management of SCI patients.

Preliminary study of efficacy of doxazosin as a medical expulsive therapy of distal ureteric stones in a randomized clinical trial.

OBJECTIVES: To assess the clinical efficacy of doxazosin as the medical-expulsive therapy for distal ureterolithiasis. METHODS: A total of 65 patients with a symptomatic 4-7 mm distal ureteral stone were included in the study. Patients were randomized to 1 of the 2 treatment groups. Group 1 (n=32 patients) was the control group and received diclofenac sodium 50 mg for their pain and group 2 (n=33 patients) received doxazosin (2 mg daily at the night) along with diclofenac sodium 50 mg. The treatment duration was until stone expulsion or 28 days, whichever come first. The primary endpoint of the study was the stone expulsion rate. The secondary endpoints included time to stone expulsion, use of analgesics, and number of emergency room visits, hospitalizations, and drug side effects. Statistical analyses were performed using chi-square test and Fisher exact test. RESULTS: Both groups were comparable in terms of demographic, clinical, and stone-related parameters. Stone expulsion rate was significantly higher in the treatment group (38% for group 1 and 70% for group 2, P=.009) while the expulsion time was significantly lesser in group 2 patients (P=.005). During the treatment period, we observed significant differences between the 2 groups in the number of pain episodes and analgesic used (P=.0001). None of the patients in either groups reported adverse drug-related events. CONCLUSIONS: Doxazosin significantly improves stone expulsion and is associated with decreased colic frequency and use of analgesia. It is also well tolerated with no adverse drug-related events.

Surgical ligation of scrotal varicocele for male factor infertility is a valid option of treatment.

OBJECTIVE: To evaluate the role of surgical ligation of scrotal varicocele for treatment of male factor infertility. METHODS: We studied 60 patients who presented with infertility and were also found to have scrotal varicocele. Patients with other probable causes contributing to infertility were excluded. Diagnosis was made by clinical examination and scrotal ultrasonography. All the patients underwent either laparoscopic varicocelectomy or open retroperitoneal high ligation of the testicular veins. Operative time and hospital stay was recorded. All patients were evaluated for postoperative improvement of semen parameters and development of any postoperative complication. The results were analyzed by commercially available software. RESULTS: During the study period 5 patients were lost to follow up and were excluded. The rest of patients (n=55) were young, with age ranging from 20-35 years (Mean age 27.8 years, SD +/- 4.38). All patients had unilateral left sided varicocele; two patients (3.6%) had grade I varicocele, 21 patients (38.2%) had grade II varicocele and 32 patients (58.2%) had grade III varicocele. Statistically significant improvement in sperm density (p value < 0.05), sperm activity (p value < 0.05) and sperm morphology (p value < 0.05) was observed after the surgical ligation. The mean operative time was 54.88 minutes (SD + 13). The mean hospital stay in laparoscopic procedure was 33.4 (SD + 15.3). Minor complications were noted in 13 patients and included superficial wound infection in 3 patients, 6 patients exhibited testicular pain and persistence of varicocele in 4 patients. CONCLUSION: Surgical ligation of scrotal varicocele is asafe and effective mode of treatment of male factor infertility in selected population.