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Introduction: The aim of this study was to assess toxicity and response in the sequential administration of gemcitabine followed by cisplatin in unresectable or metastatic non-small cell lung cancer., Materials and Methods: Twenty-three patients were enrolled in this study. Gemcitabine was given at 1,250 mg/m2 on days 1 and 8, for four 21-day cycles., Results: There were 4 patients with partial responses. 5 patients with stable disease and 10 patients with progressive disease, giving a response rate of 21%. The median time to disease progression was 3.3 months. The median overall survival was 14.6 months. Toxicities graded 3 or 4 included anaemia (13.0%), neutropaenia (13.0%), supraventricular tachycardia (4.3%), and nausea and vomiting (4.3%)., Conclusion: Although these results show similar efficacy to single-agent treatment regimens, the low toxicity profile and promising survival outcome with this regimen are important points for consideration.

Introduction: Data on combined modality treatment for locally advanced squamous cell carcinoma of the oesophagus involving Asian patients are limited., Materials and Methods: A retrospective study of 56 consecutive patients with this condition treated with concurrent chemoradiotherapy followed by surgery in a single tertiary institution in Singapore was performed., Results: The median overall survival of the entire cohort was 14.1 months [95% confidence interval (CI); range, 8.6 to 19.6 months]. In patients who underwent successful oesophagectomy after chemoradiotherapy (n = 17), the median survival was 27.8 months compared to 9.8 months for those who did not have surgery (n = 39) (P = 0.046, log-rank test). The median time to first relapse for the entire cohort was 16.1 months (95% CI, 7.7 to 24.5 months). The time to first relapse was 23.9 months in the subgroup of patients with successful surgery and 12.1 months in the group which did not (P = 0.147, log-rank test). The high proportion of patients who were medically unfit for surgery or declined surgery may have conferred a selection bias., Conclusion: Concurrent chemoradiotherapy followed by surgery is feasible in selected patients. The benefit of adding of surgery to chemoradiotherapy is still controversial and we await the results of randomised controlled trials comparing chemoradiotherapy with surgery versus chemoradiotherapy alone.

Introduction: This study was conducted to evaluate the results and complications of transurethral resection of prostate (TURP) over the last 30 years in our institution., Materials and Methods: This retrospective study encompasses 3 different eras: 168 patients in the late 70s, 175 patients in the late 80s and 283 patients in the late 90s. All the patients had at least 18 months of follow-up., Results: The mean age from the 1970s, the 1980s and 1999 were 68.8 years, 69.2 years and 69.4 years respectively. The proportion of patients operated on for acute retention fell from 78.6% (132) in the 1970s, to 54% (96) in the 1980s, and 43% (122) in 1999. The mean resection time was 44.8 minutes in 1989 and 41.8 minutes in 1999. The mean weight of prostate resected was 22.1 g in the 1970s, 24.2 g in 1989 and 22.2 g in 1999. 44% (74) required blood transfusion in the 1970s, with 11% (19) in 1989 and 4% (11) in 1999. There were 2 deaths (acute myocardial infarction and pneumonia) in the 1970s, 1 (pneumonia) in 1989 and no mortality in 1999. There were 4 patients with TURP syndrome in the 1970s, 3 in 1989 and 1 in 1999. The incidence of postoperative urinary tract infection (UTI) was 25% (42) in the 1970s, 16% (29) in 1989 and 6% (17) in 1999., Conclusions: As expertise and experience in TURP progress, the complication rates fall, as evidenced by the lower rates of transfusion, TURP syndrome and postoperative UTI in the later series.

Introduction: We report a patient with bowel infarction due to invasive Aspergillus infection as a result of prolonged chemotherapy-induced neutropenia., Clinical Picture: The patient was given neoadjuvant chemotherapy with doxorubicin, docetaxel, and capecitabine for a breast tumour. She developed prolonged neutropenia, Escherichia coli and Candida krusei sepsis, acute arterial thrombosis of the left lower limb, and invasive aspergillus infection., Treatment: She underwent a subtotal colectomy, small intestine resection and an above-knee amputation., Outcome: The hospitalisation was complicated with methicillin-resistant Staphylococcus aureus pneumonia and short gut syndrome. She subsequently underwent simple mastectomy with axillary clearance and received adjuvant chemotherapy and radiation without complication., Conclusion: Chemotherapy should be protocol-directed. In a non-trial situation, protocol must have a sound basis, proven safety, and efficacy. Aspergillus infection is uncommon in patients with solid tumours; prompt treatment must be started on high suspicion.

Introduction: Serum prostate specific antigen (PSA) testing has contributed to a dramatic rise in the incidence of prostate cancer diagnosed in the last decade in the West as well as in Singapore. Now prostate cancer is ranked as the sixth commonest cancer among men in Singapore. To form the basis for comparisons and to assess the trends and impact of these changes, we analysed the presentation, disease characteristics and outcome of treatment of patients with prostate cancer diagnosed in the pre-PSA era at the Singapore General Hospital (SGH)., Materials and Methods: Of the 149 patients (1980 to 1985) registered in the database, 134 (90%) records with full follow-up data were available for the analysis. All patients were diagnosed and managed at SGH. Follow-up and death data were collected through clinic visit, phone interviews of the patients, relatives, family physicians and the death registry. Survival analysis was carried out using the Kaplan-Meier product limit method., Results: The mean age at diagnosis was 69.8 years. There were no significant changes with reference to each year during 1980 to 1985 and the mean number of diagnoses per year was 22.3. Of the 134 patients, 86% had either retention of urine or severe lower urinary tract symptoms and 14% had metastatic disease at presentation. Most histological diagnosis was made during prostatectomy; wherein 82% was found with transurethral resection of the prostate (TURP) and 12% in open prostatectomy, respectively. Pathological analysis during diagnosis revealed that 72.4% patients had metastatic disease. Of which, 57.5% had high-grade (Gleason > 7) tumours. Among these, 82% underwent TURP to relieve urinary obstruction, while 26.1% received local irradiation to the prostate. Majority had hormone therapy shortly after diagnosis in the form of orchidectomy or oral diethylstilbestrol (76.1%). The median crude survival (26 months) was minimal for metastatic patients., Conclusion: The spectrum of prostate cancer in the pre-PSA era was characterised by high stages of high-grade disease, with very limited opportunity for successful treatment and hence survival.

Introduction: Reduced instrument size, increased flexibility, coupled with improved optics and larger working channels have enhanced the capabilities of the ureterorenoscope., Materials and Methods: We present our initial experience with the new 7.5F flexible ureterorenoscope. A total of 29 flexible ureterorenoscopies were performed from July 1995 to December 1997 by a single surgeon. The indications for flexible ureterorenoscopy was therapeutic in 10 (34.5%) patients (all had urolithiasis) whilst it was diagnostic in 19 patients (65.5%). For the diagnostic cohort, 9 (31.0%) patients had haematuria with radiological upper tract filling defect, 8 (27.6%) had radiological upper tract filling defect alone and 2 (6.9%) had ureteropelvic junction narrowing for evaluation., Results: Of the therapeutic cases, all 10 (100%) were stone free at 3 months. Of the diagnostic cases, 12 (63.2%) had normal findings, 4 (21.1%) had urolithiasis and 3 (15.8%) had transitional cell carcinoma (TCC). Of the 3 cases of TCC, one was managed endoscopically., Conclusions: The smaller calibre and actively deflectable 7.5F flexible ureterorenoscopes facilitate various endoscopic procedures thus broadening the diagnostic and therapeutic scope of the ureterorenoscope.

Introduction: A case of alpha-fetoprotein (AFP)-producing gastric cancer is described in a 57-year-old Chinese woman., Clinical Picture: She presented with bleeding tendency and bone pain, and was found to have haematological evidence of disseminated intravascular coagulation and spinal metastasis. Her tumour markers, including AFP, Ca 19-9 and carcinoembryonic antigen (CEA) were elevated. In view of the elevated tumour markers, there was an exhaustive search for a primary lesion in the gastrointestinal tract, liver and ovaries. There was no radiological evidence to suggest any lesion in the chest, liver or pelvis. Lectin affinity electrophoresis of the AFP showed AFP-L2 and AFP-L3 bands, which are suggestive of a non-hepatoma malignancy., Management: Gastroscopy showed a gastric ulcer and she developed bleeding after the gastric biopsy which required urgent surgery. Intraoperatively she was found to have carcinomatous peritone and a malignant ulcer in the greater curve of the stomach. Histology confirmed a linitis plastica like adenocarcinoma which stains for AFP., Outcome: She died from multi-organ failure 3 days after surgery., Conclusion: AFP-producing adenocarcinoma of the stomach is not uncommon. Lectin affinity electrophoresis of AFP is helpful in the differentiation between hepatoma and non-hepatoma malignancies.

With better understanding of the natural history of benign prostatic hyperplasia (BPH), the treatment can be tailored to the severity of the disease. The aims of this study were to determine the feasibility of staging BPH according to its severity and choose the optimal therapeutic tool for each category, and for comparing results of various modalities of treatment. Two hundred and twenty-five patients with clinical BPH were seen between October 1994 and July 1995. Initial assessment included the International Prostatic Symptom Score, and the quality of life index, digital rectal examination, urinalysis, prostate specific antigen, uroflow and residual urine estimation. Patients were then divided into: Stage 1, those with no bothersome symptoms and no significant obstruction, they can generally be watched. Stage 2, those with bothersome symptoms but without significant obstruction, they can be treated with pharmacotherapy/thermotherapy. Stage 3, those with significant obstruction defined as uroflow of less than 10 ml/s with persistent residual urine of > 100 ml, transurethral prostatic resection (TURP) would be recommended. Stage 4, those with complications of BPH such as chronic retention of urine and bladder stone, they would need TURP. One hundred and fifty-nine patients had complete follow up data of at least 2 years. Of the 70 patients who were originally in Stage 1, 59 (89%) remained in status quo, 6 patients developed acute retention of urine and only 1 required TURP. Of the 38 patients in Stage 2, 24 were down-staged to Stage 1 after medication and thermotherapy but 4 still remained in Stage 2 and the other 10 had worsening of symptoms requiring surgery. Of the 46 patients in Stage 3, 30 (65%) had TURP and all except 1 were down-staged to Stage 1. All patients in Stage 4 had TURP and improved. We conclude that staging of patients with clinical BPH is feasible. It serves as a useful guide for management and improves cost effectiveness.

The aim of this study was to analyse the outcome of trial off catheter for patients who were admitted to the Department of Urology, Singapore General Hospital (SGH) for acute retention of urine (ARU) due to benign prostatic hypertrophy (BPH). From 1 June to 15 October 1997, 150 patients were admitted for ARU. Seventy-one patients were excluded from our study due to our exclusion criteria such as chronic retention, patients with bladder stones and cancer of the prostate. Our results showed that 58% (n = 46) had a successful trial off catheter. The risk factors for failure were: high residual urine (more than 800 ml) and high prostatic specific antigen (PSA) value (10.9 versus 21.5). All patients with normal PSA value (< 4 ng/l) had successful trial off catheters. There was no difference between trial off catheter 24 hours versus 48 hours after admission.

A 3-year retrospective study (January 1995 to December 1997) of all treatment modalities for urinary stone disease done in the Department of Urology, Singapore General Hospital was documented, and open stone surgery identified. Patient's characteristics, stone burden, surgical factors, indications and outcome were reviewed for each patient. Of the 2651 procedures performed for urinary stone disease, the majority had extracorporeal shockwave lithotripsy [78% (n = 2075)], while 11% (n = 298) had percutaneous nephrostolithotomy and 9% (n = 228) ureteroscopy. Open stone surgery rate was 2% (n = 50) which included 16 anatrophic nephrolithotomies, 5 pyelolithotomies, 18 ureterolithotomies and 11 nephrectomies. There were 28 males and 22 females varying in age from 26 to 63 years (mean 48 years). The most common indications for open stone surgery were complex stone burden [38% (n = 19)], failure of minimally invasive modalities [16% (n = 8)], non-functioning kidneys [20% (n = 10)], concurrent open surgery [8% (n = 4)], co-morbid medical condition [4% (n = 2)], patient preference for open procedure [8% (n = 4)], anatomic abnormality [4% (n = 2)] and obesity [2% (n = 1)]. Stone free rate of 90% was achieved, morbidity of 8% (n = 4) mostly wound infections and a pneumothorax. Majority of patients with urinary tract calculi can be treated with less invasive modalities. Complex stone burden, failure of less invasive modalities, non-functioning kidney, concurrent open surgery, co-morbid medical problems, patients' preference, anatomic abnormality and obesity are factors to be considered in a small cohort of patients who may still benefit from treatment using open surgical technique.

Percutaneous nephrolithotomy (PCNL) and extracorporeal shockwave lithotripsy (ESWL) have largely replaced open surgical intervention for the management of upper urinary tract calculi. ESWL is the preferred treatment modality for calculi less than or equal to 2 cm in diameter as morbidity is lower than PCNL and success rates are comparable. However, the morbidity of ESWL rises substantially for stones greater than 2 cm in diameter while stone-free rate is less when compared to PCNL, suggesting that PCNL is the preferred treatment modality for most larger stones. PCNL was performed on 86 patients with 87 renal calculi. The indication for this approach was either high stone burden as in 72 patients (83%) or failed previous ESWL as in 15 patients (17%). The success rate was 74.7% and this was associated with minimal morbidity which included; symptomatic urinary tract infection (9.2%), pleural effusion (2.3%) and the formation of a pseudo-aneurysm (2.3%). Blood transfusion was required in one patient (1.1%) and we had one postoperative death due to massive pulmonary embolism (1.1%). PCNL is the preferred approach to patient with difficult renal calculi at our institution.

Acute scrotal pain requires immediate medical attention to determine the underlying cause and to treat accordingly. The diagnosis may not be straightforward and in some patients, immediate surgery may be necessary in order to treat torsion of the testes early to achieve good results. The aim of this retrospective study is to evaluate the underlying causes and the outcome of acute scrotal pain. It includes a total of 116 patients over a period of 18 months who were admitted to the general urology ward. Seventy-six percent of the patients complained of pain only, 13% complained of pain with fever, 7% complained of urinary symptoms and 4% a combination of the three. After evaluation, 44 patients were diagnosed to have torsion of the testes and all of these patients were below 20 years old. Thirty-eight of the patients complained of pain only and 2 had pain with fever. Two patients were thought to have torsion and exploration was performed. They were found to have infection. The rest had orchidopexy done and only 2 had orchidectomy due to infarction. Fifty-two patients had acute epididymo-orchitis, 50 of these were above 20 years old and half (n = 25) of this group of patients admitted to having had exposure to sexually transmitted diseases, 11 patients had a history of instrumentation and 14 had no known causes. From this study, age appeared to be the main differentiating point between torsion and epididymo-orchitis. for equivocal cases, new technology such as the Doppler ultrasound and testicular scan may be useful in future to improve the diagnosis of this urogenital emergency.

Prostate specific antigen (PSA) and transrectal ultrasound (TRUS) are two new modalities added to improve our ability to diagnose prostate cancer at an early stage. We reviewed our own experience of 100 cancers among 579 men from August 1991 to October1994. The detection rate was 17.3%. Digital rectal examination (DRE) alone had a positive predictive value (PPV) of 39.9%. The PPV for PSA was 23%. The combination of PSA and DRE gave a PPV of 47.2%. TRUS had a PPV of 30.6%. Features of cancer on TRUS may be both hypoechoic or hyperechoic nodules which appeared to have almost equal proportions associated with cancer. The addition of age-specific ranges did not affect the PPV of PSA. The PPV of the combination of TRUS and DRE was 53%. With all 3 modalities combined, the PPV was 58.8%. An interesting finding from the study was the higher average PSA for benign and malignant disease in the local population and cases of acute retention of urine. There was a higher incidence of prostatitis and lower incidence of cancer in cases with retention of urine.

We evaluated the efficacy of immune and scarification Bacillus Calmette-Guerin (BCG) in the treatment of carcinoma in situ and prophylaxis against recurrence in patients with superficial transitional carcinoma of the bladder. A single-blind, randomised, comparative trial involving 43 patients with a median follow-up of 39 months was analysed. The end points were progression to muscle invasive disease or recurrence. The overall response rate was 93% after one to two courses. There was no difference between the two preparations and no statistically significant difference between the response or progression rates of the carcinoma in-situ or prophylactic groups. However, the response to BCG was found to be a significant prognostic indicator in a multivariate analysis.

Radical retropubic prostatectomy as a viable option for patients with localized prostate cancer hinges on the morbidity associated with the surgery. We assessed a group of 15 patients operated between February 1992 to September 1994 by a single surgeon to gauge the severity of short-term morbidity. Their mean age was 66.7 years (range, 40-76 years). While most of them had obstructive urinary symptoms, 4 were asymptomatic and were diagnosed by screening. Their median preoperative prostate specific antigen (PSA) was 25.9 ng/dl. The mean operative time was 110 minutes and the mean blood loss was 450 ml. One patient developed postoperative pulmonary embolism which delayed his discharge from the hospital despite routine prophylactic physical measures. The median length of hospital stay was 7 days. Eight patients had immediate total continence, while the remainder attained day-time and nocturnal continence within 1 to 3 months. Three patients had adjuvant orchidectomy. Most patients had high grade and margin positive (T3) disease but none were node positive. With a median follow-up of 7 months, none of the patients developed local or systemic recurrence. With the minimum surgical morbidity, short hospital stay and excellent continence achieved, the option of radical prostatectomy can be offered to suitable patients for curative treatment of localised prostate cancer.

With better understanding of the natural history of benign prostatic hyperplasia (BPH), and recent advances in ultrasound and the many new modalities of treatment, the assessment of BPH has undergone rapid changes in the past few years. A system of staging of patients with BPH, to assist in the tailoring of treatment to the severity of the disease is proposed. The initial assessment consists of the International Prostatic Symptoms Score (IPSS) and the Quality of Life Index, digital rectal examination (DRE), urinalysis, prostate specific antigen (PSA) estimation, and subsequently, assessment with ultrasound of the urinary system and estimation of residual urine and uroflow done at the same sitting. Patients with no bothersome symptoms and no significant obstruction are classified as stage one, and they can generally be watched. Stage 2 patients are those with bothersome symptoms but no significant obstruction and they can be treated with pharmacotherapy in the first instance, failing which other less invasive therapies such as thermotherapy are advised before considering transurethral resection of the prostate (TURP). Stage 3 patients are those with significant obstruction and defined as patients with significant residual urine of more than 100 ml, generally with a maximum flow rate of less than 10 ml. This group of patients would be advised TURP first, then thermotherapy, or pharmacotherapy in descending order, taking into account the age of the patients, their co-morbidity and preferences. Stage 4 patients are those with complications resulting from significant obstruction by BPH such as retention of urine, bladder stone and recurrent urinary infection; they would be strongly advised to have TURP. With proper assessment and staging, it is hoped that patients with BPH will not be over or undertreated, and treatment outcome will be improved.

We describe a case of localised amyloidosis of the distal ureter in a 66-year-old lady who presented with intermittent haematuria. Ureteric transitional cell carcinoma was strongly suspected from the clinical and radiological features, and subsequent nephroureterectomy was performed. Histology revealed nodular eosinophilic deposits in the ureteric wall, with the staining characteristics of amyloid. The literature is reviewed, and conservative surgery is advocated, based on a greater awareness together with improved intraoperative diagnosis of this rare lesion.

The use of laser is a relatively new modality of treatment in urology. With the advent of the pulse-dye laser lithotripter and a finer 7.2 ureteroscope (miniscope), we found that it was more effective for treating ureteric stones than the conventional ultrasound lithotripsy. Between May 1989 and December 1991, 239 patients (162 males, 77 females) with 259 ureteric stones were treated endoscopically by this modality. Their ages ranged from 19 to 81 years (mean 46.3). The stones were mostly of 5 to 10 mm in their transverse diameters. They were situated in the upper ureter in 59, middle ureter in 39, and lower ureter in 161 cases. The miniscope was inserted into the ureter without prior dilatation and under direct vision. Stone fragmentation was performed using the 504-nm pulse-dye laser of 30 to 60 mJ energy. Complete fragmentation of the stone using the Candela laser lithotripter was achieved in 202 patients (85%). The average hospital stay was two days. Of the 37 unsuccessful cases, 11 were due to failed ureteroscopy, ten due to poor visibility from bleeding, 14 due to stone migrating up to the kidneys and two were monohydrate calculi which did not fragment with laser lithotripsy. Open ureterolithotomies were necessary in 14 patients (5.9%). Significant morbidity was perforation of the ureters which occurred in three patients (1.3%). This was due to ureteroscopy rather than the laser lithotripsy itself. With the availability of the new shockwave lithotripter (ESWL) which can treat ureteric stones in even less invasive ways, without anaesthesia and as outpatient, we are now reserving laser lithotripsy for those who failed ESWL. Generally they are the stones which cause severe obstruction to the ureter.

The Storz Modulith SL20 is a third-generation lithotripter which was installed in our hospital in March 1991. The aim of this paper is to evaluate our results in the management of renal calculi using this machine. We report our experience in the treatment of the first 215 renal units (118 renal and 83 ureteric) in 190 patients with a minimum follow-up period of three months. Success for renal stones was defined as stone-free or with insignificant residual fragments of less than 4 mm in size post therapy. Success for ureteric stones was defined as stone-free after therapy. The success rate for renal calculi was 88% and for ureteric calculi 71%. The mean number of sessions to achieve these results for renal calculi was 1.6 and for ureteric calculi 1.4. Of the failures, only 1.9% required open surgery whilst the remainder were dealt with using minimally invasive procedures like intracorporeal laser lithotripsy. There was no mortality in our series. Complications occurred in four patients, who required hospitalisation for renal colic (n = 1), urinary tract infection (n = 1) and obstructive uropathy (n = 2).

Urology has been an evolving specialty since the time of Hippocrates. The itinerant surgeon was known to go from town to town to remove bladder stones in the early middle ages. In this century, urologists had been at the forefront in pioneering minimally invasive surgery with the introduction of transurethral resection of the prostate more than 50 years ago in the United States. This could be considered the first revolution in urology and this has influenced the evolution of urology in Singapore. Transurethral surgery had proved to be far superior to open surgery for most lesions of the lower urinary tract. This technique was introduced to Singapore in the early 1970s by Dr N E Wong. Because of the need for special instruments, skill and training, there was a need for a Department of Urology. This was not to be until after the second revolution in urology. The second revolution saw the introduction of endoscopic surgery of the upper urinary tract and Extra-corporeal Shockwave Lithotripsy in the early 1980s. This had truly revolutionised the treatment of urinary stones and today almost 95% of patients can be treated with these non to minimally invasive techniques. These new modalities of treatment were rapidly introduced in Singapore in the mid 1980s. The need for the establishment of urology as a specialty was more urgently felt. The Singapore Urological Association was formed in February 1986 and in March 1987, a Division of Urology was formed at the Singapore General Hospital.(ABSTRACT TRUNCATED AT 250 WORDS)

Carcinoma of the prostate has become one of the top ten malignancies in Singapore but to date, there has been little local clinical data available on the disease. This study aims to establish the clinical profile of Stage D carcinoma of the prostate in the local population. Forty-seven patients with Stage D disease treated by the department over a ten-year period, 1981-90, were studied. The majority (47.7%) fell in the age-group 66-75 years and the most common presenting symptom was bone pain (36.2%). Both acid and alkaline phosphatases were found to be poor diagnostic markers of the extent of the disease. Acid phosphatase was not elevated in 25.0% and alkaline phosphatase not elevated in 39.1% of our patients. Forty of these patients had orchidectomy and of these, ten were also treated with oral stilbesterol. Five-year survival for the orchidectomy group was 22.7% and that for the orchidectomy-plus-stilbesterol group was 23.0%. This compares well with other studies done in the West. Eight patients died within the first year of diagnosis but of those who survived, all remained symptom-free within this first year. The proportion of those who remained symptom-free fell to 25.0% of the survivors for subsequent years.

Chronic radiation cystitis complicating pelvic irradiation can occasionally result in massive bleeding difficult to control with conventional means. Between 1986 and 1989, we managed 42 cases of chronic radiation cystitis of which nine (21%) were of this severe type based on the necessity for repeated cystodiathermy, massive transfusions and open surgical intervention. We found early cystodiathermy and alum bladder irrigation beneficial in early cases, but six (67%) patients required emergency bilateral percutaneous nephrostomies for proximal urinary diversions to help stop the bleeding. Despite aggressive treatment, two patients (22%) died during their admissions and two others (22%) died shortly after discharge. Three patients eventually required elective ileal conduit diversion for their contracted defunctioned bladder. Thus this group of patients suffered relatively high morbidity and mortality for an essentially benign condition. Increased physician awareness and timely percutaneous nephrostomies may improve results.

In the treatment of transitional cell carcinoma of the bladder, the recent trend is towards radiation or chemotherapy which can be either regional or systemic. There have also been good results with giving Mitomycin or Bacillus Calmette Guerin instillation into the bladder for superficial tumours. There are occasions where patients present with large bulky tumours which cannot be controlled by endoscopic measures, invasion involving multiple sites and carcinoma in-situ which progresses to invasion. In these occasions, we have to resort to surgical clearance of the tumour. If it is possible, all patients would not like to wear a urinary bag for the rest of their lives. A bladder replacement if ever possible is always welcomed because the patient can pass urine from the natural passage. Due to the magnitude of a radical cystectomy and status of the urethra, it is not always technically possible to reconstruct the bladder. With improvement of operative techniques and suture materials, there has been a recent development of a method of bladder reconstruction that uses an ileal pouch. We report our early experience with this operation.

Papillary cystadenoma of the seminal vesicle is very rare. We describe such a case presenting in a 58 year old man with bladder outlet obstruction. Investigations included magnetic resonance imaging (MRI), the usefulness of which in pre-operative diagnosis is highlighted in this case. Seminal vesicle cysts can usually be identified by conventional radiological imaging techniques such as ultrasound and computed tomography; however, identification would be difficult if the cyst is very large, causing distortion of the adjacent anatomy. In such cases, MRI, through coronal and sagittal scanning, can be helpful in localising the lesion, as in this patient. The precise pathological nature of the cyst can only be confirmed by biopsy.

Two cases of malignant hyperthermia (MH) are presented. The first patient presented initially with tachyarrhythmia intraoperatively and rapid onset of MH crisis. Nasopharyngeal temperature of 43 degrees C was attained after 15-20 minutes of anaesthesia. The patient eventually died of myocardial failure despite external cardiac massage, inotropic support and ventricular pacing. The second patient presented with increasing endogenous hypercarbia following the administration of suxamethonium and isoflurane. The use of the end tidal carbon dioxide monitor led to an early diagnosis of MH. The early use of dantrolene may have contributed to the favourable outcome.

24 patients with urethral strictures which were managed with the optical urethrotome are studied. These patients had developed strictures due to previous transurethral reaction of the prostate, and trauma or inflammation of the urethra. In some cases we have not been able to determine the aetiology of the problem. 58% of the patients responded satisfactorily to this mode of therapy. Although a high percentage develop recurrent stenosis, these can be treated by repeated urethrotomy under vision without much morbidity. Resistant cases would need urethroplasty.

A series of 178 urinary stones is analysed qualitatively during a three year period from 1980 to 1982. The majority (96%) of stones orginate from the upper tract. Calcium oxalate stones are the commonest entity seen in the western countries but less than 20% of such stones occur locally. A large proportion consists of mixed stones and one third are infective as triple phosphate is present. 20% contain urate as a constituent whereas relatively pure urate stones constitute 4%. The true incidence of pure urate stones is higher (about 10%) as we have been dissolving them with alkalinisation of urine without surgery. Idiopathic hypercalciura occurs in 11.8% and none has persistent hypercalcaemia. Hyperuricosuria which is commoner, occurs in 24% of patients. It is important to identify this group as it results in the formation of metabolically active stones, and they can be treated with allopurinol to prevent recurrence of stones.

Gross haematuria is one of the most important symptoms in urology, as one of its causes is neoplasm of the urinary tract. The other important causes are urinary stones, urinary tract infection, which may be acute or chronic, trauma, and chronic haemorrhagic radiation cystitis. The differential diagnosis of gross haematuria depends on the age and sex of the patient, and the associated symptoms. The most important associated symptom is pain.

Endoscopic Surgery of the lower urinary tract was popularised in Singapore about a decade ago. Since then it has been established as the treatment of choice not only for obstructing prostates, but also for stones, carcinoma of the urinary bladder and management of neurogenic bladder, haemorrhagic chronic radiation cystitis, ureteric obstruction and urethral strictures. The main advantages of endoscopic surgery are lack of post-operative pain and minimum morbidity and mortality. Patients' recovery is rapid thus saving much needed hospital beds. However, endoscopic surgery requires special training and special equipment to get good results. If not properly done serious complications including the death of patients can occur. A plea is made for the setting up of a special division or department of Urology in Singapore to carry out this work and to train our young surgeons in this field.

A review of 23 cases of renal cell carcinoma was undertaken. The sex distribution was 3.6 males to 1 female, the male preponderance being higher than in most reported series. The tumour was most common in the 6th and 7th decades of life. Haematuria was the commonest presenting symptom (52.2%); however, all the features of the classical triad of haematuria, loin pain and swelling were not present in any of our patients; 26% of patients presented with non-urological symptoms. At the time of diagnosis, four patients (17.3%) had evidence of metastasis. Another four developed secondaries after nephrectomy. Our approach to renal cell carcinoma has been aggressive and all 23 patients including those with metastasis were treated by nephrectomy.

This paper illustrates one of the more satisfying aspects of the treatment of urinary calculous disease. A small series of 8 patients is presented to emphasize the possibility of dissolving uric acid stones by conservative measures thereby saving the patients extensive and often destructive surgical procedures. Patient selection is important for successful therapy. The stone must not be calcified and there must be sufficient function in the kidney. The regime consists of allopurinol 100 mg and sodium bicarbonate 2 to 4 grams given orally three times a day. Treatment period lasted up to six months, with dissolution of stones.

Though the incidence of pulmonary tuberculosis has been on the decline, the incidence of genito-urinary tuberculosis has not decreased proportionately as the majority of patients have no associated pulmonary tuberculosis. Genito-urinary tuberculosis affects male and female equally and is commonest in the 4th decade of life. The most frequent presentation is that of persistent urinary tract infection in 2/3 of patients and gross haematuria in about 1/3 of our patients. A few may be relatively asymptomatic with loin ache. Though urine culture for acid-fast bacilli is important, diagnosis in most patients was established on histopathology and typical radiological features. The main stay of treatment is medical. The role of surgery is mainly reconstructive, to overcome strictures causing obstruction so as to preserve renal function. Close cooperation between physician and surgeon is important in the management of this disease.

A review of the current management of urinary tract stones as applied to the University Department of Surgery is presented. The use of allopurinol and alkalinisation of urine is effective in dissolution and prevention of uric acid stones. Cellulose phosphate and thiazide therapy for calcium stone formers have a limited place, as we are still unable to identify those who will benefit from such therapy in the local population. Antegrade pyelogram and percutaneous nephrostomy have useful roles to play in investigation and also management of patients with calculous anuria. The use of regional renal hypothermia has enabled us to operate with more confidence on branched or multiple renal calculi. With better visual lithotrite, more and bigger stones in the lower urinary tract can now be removed endoscopically.

Haemorrhagic chronic radiation cystitis is not an uncommon clinical entity, and should be suspected in patients with painless gross haematuria who have a past history of radiotherapy to the pelvic region. A series of 29 patients with haemorrhagic chronic radiation cystitis were managed in the University Department of Surgery, Singapore General Hospital over a 5 years period from 1979 to 1983. Cystodiathermy was the mainstay of treatment and was successful in controlling haematuria in 27 patients. Two patients developed uncontrolled haematuria, urinary tract infection, septicaemia and died giving mortality of 6.9%. Excellent control of haemorrhage can be obtained with cystodiathermy in the majority of patients. Intravesical instillation of steroid or silver nitrate is used for the more intractable cases, after cystodiathermy. Urinary diversion with or without cystectomy are desperate measures to salvage the severe case and mortality is high.

With the development of the operating uretero-renoscope, and high frequency ultrasound generator, ureteric stones which otherwise would require open operative procedure can now be removed transurethrally with minimum morbidity and rapid recovery of patient. After preliminary cystoscopy, the ureteric orifice is dilated with flexible metal dilator or ureteric balloon dilator to size 15F. The rigid operating uretero-renoscope of 11F is then introduced and passed up to the stone. A 5F ultrasound probe is then passed through the uretero-renoscope to make contact with the stone. Stone disintegration with ultrasound is done under direct vision, and the fragments aspirated or removed with the help of forceps or Dormia basket. Of the first 70 patients done within 2 years from July 1984 to August 1986, 66 (94%) had their stones successfully removed by this procedure. It can be performed without radiological control and routine stenting of the ureter is not necessary. Serious complications included two perforation of the ureter and late development of ureteric strictures in another two patients. One patient had occlusion of the lower ureter requiring reimplantation.

Carcinoma in situ of the urinary bladder has been described since 1952. However, it was not well recognised as a clinical entity until recently when we are more aware of its clinical significance, that a large proportion progresses to muscle invasive cancer and becomes life threatening, and therefore more aggressive management is needed. From 1980 to 1984 over a period of 5 years, we studied the records of 130 patients with transitional cell carcinoma of the urinary bladder. Eighty-two (63%) were staged as superficial carcinoma while 48 (37%) were diagnosed as muscle invasive cancer (Tables II, III & IV). Out of the 82 cases of superficial carcinoma, 12 (11%) were found to have associated carcinoma in situ of the bladder. Diagnosis depends on a high index of suspicion, urinary cytology and biopsies of not only the obvious papillary or solid tumours but also any abnormal bladder mucosa and random bladder biopsy. Management is a problem and controversial. We have been using intensive intravesical chemotherapy with thiotepa and mitomycin, and if there is evidence of deep muscle invasion, then more aggressive therapy such as cystectomy would be advised. Management of these 12 cases and the problems we encountered are discussed.

34 patients with difficult upper and middle ureteric stones were treated by antegrade ureteroscopy with ultrasonic lithotripsy over a 2-year period. 14 patients (41 percent) had failed extracorporeal wave lithotripsy and another 20 patients (59 percent) were considered unsuitable for extracorporeal shock wave lithotripsy due either to obstruction associated with urosepsis or renal failure. Thirty patients (88 percent) had large stones with a transverse diameter from 10 to 20mm in size. Thirty-three of the 34 patients (97 percent) were successfully treated by this method with minimal morbidity. Of the 7 patients with residual stones, only one needed transurethral ureteroscopic removal and another by piezoelectric extracorporeal shock wave lithotripsy. This technique is a safe and effective method in removing impacted upper and middle ureteric stones for patients who have failed or are unsuitable for extra-corporeal shock wave lithotripsy treatment.

A series of 62 cases of transurethral resection of large obstructing prostates above 40 grams is presented. The weight of resected prostates ranged from 41 to 84 grams with an average of 54.5 grams. The average rate of resection was 0.7 gm/min. Though 74.2% of patients were in clinical grade II and III categories, no mortality occurred and serious complications were minimum. 71% of patients were discharged within a week. On the whole, the results were satisfactory although clot retention (11.3%) was a more common complication following transurethral resection of large prostate. Transurethral resection is a safe and acceptable alternative to open prostatectomy even for large prostates.