Use of patient-controlled analgesia in extracorporeal shockwave lithotripsy.

OBJECTIVE: To assess the advantages of patient-controlled analgesia (PCA)-in patients undergoing extracorporeal shockwave lithotripsy (ESWL) for urinary stones. PATIENTS AND METHODS: Between December 1995 and May 1996, a prospective study was carried out on 100 patients who underwent ESWL for urinary stones. The patients were assigned to two equal groups, one receiving PCA and the other pethidine (control). Patients in the PCA group self-administered varying doses of intravenous alfentanil according to their pain tolerance, while those in the control group were given a single bolus dose of 1 mg/kg body weight intravenous pethidine by the attending urologist before the start of the procedure. The stone site, maximum energy level achieved, number of shock waves given, duration of procedure, pain scores, patient tolerance and acceptance were recorded to assess the efficacy of PCA compared with analgesia controlled by the physician. RESULTS: Both groups were matched for age, body weight, stone location and number of shocks given. The PCA group received a mean of 1.03 mg alfentanil while the control group received a mean of 62.5 mg pethidine. The maximum discharge voltage of 16 kV was achieved in all but one patient (98%) in the PCA group whereas only 21 patients (42%) in the control group attained this level. The mean treatment duration was less in the PCA group (32.8 min) than in the control group (44.5 min), the mean pain score lower (3.76 and 4.62, respectively) and the incidence of nausea and vomiting much less (22% and 60%, respectively). In addition, all 21 patients in the PCA group who had received intravenous pethidine during previous sessions of ESWL chose PCA as the better form of analgesia. There were no adverse effects in the PCA group except for one patient whose arterial oxygen saturation decreased transiently. CONCLUSION: PCA enables the urologist to achieve better patient compliance through better pain control; its application has maximized the use of lithotripsy and the patients' acceptability for this form of analgesia is confirmed. We recommend that this form of analgesia be used for ESWL.

Endoscopic injection of collagen for the treatment of female urinary stress incontinence.

BACKGROUND: The objective of our study was to assess the efficacy and safety of glutaraldehyde cross-linked collagen injection in the treatment of female urinary stress incontinence. METHODS: We conducted a retrospective analysis of the records of 105 women who underwent collagen injection for urinary stress incontinence between March 1991 and April 1995. Preoperative assessment included uroflowmetry, residual urine determination, and urodynamic studies. RESULTS: Of the 105 women in our series, 95 patients (90.5%) had initial successful results at 3 months (61.0% cured, 29.5% significantly improved) while 4 patients (3.8%) had slight improvement and 6 (5.7%) failed surgical correction. One year after the procedure, the success rate dropped to 81.9% (86 patients) with 46.7% cured and 35.2% significantly improved. Nine patients (8.6%) had slight improvement and 10 patients (9.5%) failed surgical correction. Eight patients (7.6%) with initial unsatisfactory results underwent additional sessions of collagen injection and were subsequently either cured or had significant improvement. Twenty-three patients (21.9%) suffered a relapse. The mean time to relapse was 13.3 months, and 6 of those who relapsed underwent repeated injections with favorable results. Complications were minimal; 6 patients had temporary retention of urine, and 2 patients had urinary tract infections. CONCLUSIONS: We conclude that glutaraldehyde cross-linked collagen injection is a simple and safe method of treatment for urinary stress incontinence. A longer follow-up period is necessary to assess the long-term efficacy of this treatment.

Laparoscopic bladder-neck suspension for urinary stress incontinence in women: our first twenty patients.

BACKGROUND: Laparoscopic bladder-neck suspension for women with urinary stress incontinence avoids the problems associated with a large abdominal incision. This study reviews the short-term outcome of this minimally invasive operation. METHODS: Between September 1993 and February 1995, 20 female patients with type II urinary stress incontinence underwent laparoscopic bladder-neck suspension at our institution (mean age, 46.6 years; mean weight, 59.5 kg; mean duration of symptoms, 3.75 years; mean follow-up, 7 months). The extraperitoneal space was created with a preperitoneal distention balloon system; dissection of the bladder and bladder neck was done via 3 working ports. In 16 patients, the paraurethral vagina on either side of the bladder neck was hitched up to the iliopectineal ligament by 2-0 sutures. In the remaining 4 patients, the bladder-neck suspension was performed using hernia mesh and staples. Four patients had intraperitoneal suspension. RESULTS: The operative time ranged from 75 to 205 minutes, with a mean of 111.5 minutes. The period of urethral catheterization ranged from 2 to 7 days, with a mean of 3.1 days. The hospitalization stay ranged from 5 to 15 days, with a mean of 6.35 days. Thirteen patients (65%) had complete resolution of symptoms, 5 patients (25%) reported significant improvement, and 2 patients (10%) did not benefit from the operation. CONCLUSION: Long-term follow-up is necessary to determine the efficacy of this laparoscopic technique. The success rate for any incontinence procedure is usually inversely proportional to the duration of follow-up.

Prostate screening--the Singapore experience.

BACKGROUND: The prevalence of benign prostatic hyperplasia (BPH) is believed to be highly significant in most communities. In our country, many elderly men are unaware that something can be done for their troublesome urinary symptoms. The main objective of our prostate health screening was to educate our elderly male population that this is an abnormality, for which treatment is readily available. At the same time, we attempted to determine the prevalence of BPH, to detect possible prostate cancer, and to derive normal prostate specific antigen (PSA) and uroflow values for our population. METHODS: Over an eight-day period in April 1994, 799 men above the age of 50 years volunteered to participate in a free prostate screening exercise held at our hospital. The parameters assessed were PSA level, American Urological Association (AUA) symptom score, uroflowmetry, and digital rectal examination (DRE) of the prostate. RESULTS: Elevated PSA levels of more than 4 micrograms/L were detected in 105 men (13.1%). Of these, 23 men (2.9%) had PSA values above 10 micrograms/L. Abnormal AUA symptom scores of more than eight (moderate and severe categories) were noted in 540 men (67.6%). Clinically enlarged prostate glands of more than 20 g on DRE were noted in 80 men (10.0%), and abnormal DRE findings were detected in 48 men (6.01%). Impaired maximal uroflow rates of less than 10 mL/s were recorded in 224 men (39%), while another 167 men (29.1%) had maximal uroflow values in the equivocal zone (between 10 to 15 mL/s). The reference PSA levels at the 5th percentile, 10th percentile, median, mean, 90th percentile and 95th percentile were 0.38, 0.47, 1.05, 1.57, 3.27 and 4.25 micrograms/L, respectively. The age-specific PSA values were 3.51, 3.78 and 6.02 micrograms/L in the 50 to 59, 60 to 69, and 70 to 79 years age groups, respectively, and the reference mean maximal uroflow rates was 14.8 mL/s. CONCLUSIONS: Although controversial, our experience with prostate screening was generally positive. As far as our population is concerned, the free prostate screening exercise generated publicity, and succeeded in enhancing public awareness for better prostate health.

Surgical management of stress urinary incontinence: Burch colposuspension, modified Pereyra and Stamey bladder neck suspension, and collagen injection--Toa Payoh Hospital experience.

A retrospective analysis was performed on 34 female patients who underwent corrective surgery for stress urinary incontinence over a 4-year period at the Toa Payoh Hospital. These patients were offered surgery only after an adequate trial of medical therapy, pelvic floor exercises and weight reduction. Bladder neck suspension operations were performed via the Burch, Stamey and modified Pereyra techniques. Towards the later part of this study, endoscopic injection of Collagen was performed as a salvage procedure in 2 patients. The Burch colposuspension gave uniformly good results, with all patients being completely dry. Seventy percent and sixty percent complete continence were achieved via the modified Pereyra and Stamey techniques respectively. Three patients required additional surgical procedures. Using these techniques, the overall results showed that 27 patients (79.4%) had complete urinary continence following surgery, while the remaining 7 patients (20.6%) experienced significant improvement of symptoms.

A prospective trial with vacuum-assisted erection devices.

The effectiveness of vacuum-assisted erection devices was evaluated in a prospective trial involving 18 men with erectile dysfunction. The patients were reviewed at 1, 3 and 6 monthly intervals by the same interviewer using a standard questionnaire. Sixteen patients (88.9%) were able to attain satisfactory erections. The overall satisfaction rate was 83.3%. Sixteen patients (88.9%) found the device easy to use. Thirteen patients (72.2%) were able to master using the device in less than one week, and 11 patients (61.1%) were able to get it working at the first attempt.

Corporeal plication for correction of penile curvature.

A retrospective analysis was done on 15 men who underwent corrective surgery for penile curvature between December 1989 to March 1993. The period of follow-up ranged from 3 months to 3 years, with a mean of 16 months. All patients underwent corporeal plication, with sutures placed on the convex side of the penile curvature to straighten the penis. Three patients (20%) developed recurrence of their penile curvatures between 3 months to 1 year after their surgery. All 3 patients underwent a repeat operation. Thirteen patients (86.6%) were satisfied with the operation, and had a straight erect penis which did not cause pain or discomfort during sexual intercourse. One patient (6.7%) was particularly upset with a shortened penis. The last patient (6.7%) developed venous leak impotence, and subsequently underwent ligation and stripping of the deep dorsal vein of his penis.

Penile implant surgery--local experience with the semi-rigid, single component inflatable and the multi-component inflatable penile prostheses.

A retrospective analysis was performed on 26 men who underwent penile implant surgery using semi-rigid, single component inflatable, and multi-component inflatable penile prostheses over a five-year period. No intraoperative complications were encountered in our series. Major complications following discharge from the hospital were encountered in 6 patients (23.1%). After revision surgery, 4 patients (15.4%) eventually required removal of their penile implants. Good sexual satisfaction was noted in 18 patients (69.2%), while another 2 patients (7.7%) reported fair sexual satisfaction. Six patients (23.1%) expressed dissatisfaction with the procedure.