Ketamine is a short-acting anaesthetic agent that has gained popularity as a 'club drug' due to its hallucinogenic effects. Substance abuse should be considered in young adult patients who present with severe debilitating symptoms such as lower urinary tract symptoms, even though the use of controlled substances is rare in Singapore. Although the natural history of disease varies from person to person, a relationship between symptom severity and frequency/dosage of abuse has been established. It is important to be aware of this condition and have a high degree of clinical suspicion to enable early diagnosis and immediate initiation of multidisciplinary and holistic treatment. A delayed diagnosis can lead to irreversible pathological changes and increased morbidity among ketamine abusers.

INTRODUCTIONRecurrent prostate adenoma is a long-term complication following transurethral resection of the prostate (TURP). Transurethral enucleation and resection of the prostate (TUERP) is more appealing, since the nodular adenoma can be completely removed through endoscopy. TUERP is also hypothesised to result in a lower frequency of recurrent adenoma. This study aimed to compare the early outcomes of TUERP and TURP, and assess the feasibility and safety of TUERP. METHODSWe compared the outcome of 81 patients who underwent TUERP with that of 85 patients who underwent TURP. International prostate symptom score, quality of life score, prostate volume, degree of intravesical prostatic protrusion, maximum flow rate, post-void residual volume and prostate-specific antigen (PSA) level were obtained pre-and postoperatively. Complications (e.g. transfusion rate, incontinence, infection and urethral stricture) were analysed. RESULTSOperative time was significantly longer in the TUERP group compared to the TURP group (85.3 minutes vs.51.6 minutes). After TUERP, the maximum flow rate was significantly higher (21.1 mL/s vs. 17.1 mL/s) and PSA level was significantly lower (1.2 ng/mL vs. 1.9 ng/mL) than after TURP. The rates of infection, transfusion and urethral stricture were similar for both groups, but the TUERP group had a higher rate of temporary incontinence (13.6% vs. 4.7%). CONCLUSIONThe lower PSA level and better maximum flow rate achieved following TUERP suggest that prostate adenoma removal was more complete with TUERP. Long-term follow-up is required to establish whether TUERP results in fewer resections for recurrent adenoma. Keywords: benign prostatic hyperplasia, transurethral enucleation and resection of prostate, transurethral resection of prostate

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ObjectiveDespite high-grade intravesical prostatic protrusion (IPP) being closely related to bladder outlet obstruction (BOO), up to 21% of patients with low IPP remain obstructed. This study evaluates the characteristics and urodynamic findings of men with small prostates and low IPP.MethodsOne hundred and fourteen men aged >50 years old with lower urinary tract symptoms (LUTS) were assessed with symptoms, uroflowmetry, serum prostate-specific antigen (PSA), transabdominal ultrasound measurement of prostate volume (PV), IPP and post-void residual urine (PVRU). All patients underwent pressure flow studies. Patients with PV < 30 mL and IPP ≤ 10 mm were examined for parameters correlating with BOO or impaired detrusor contractility.ResultsThirty-six patients had PV < 30 mL and IPP <10 mm. Nine patients (25.0%) had urodynamic BOO, all with normal bladder contractility. Fourteen patients (38.9%) had poor detrusor contractility and all had no BOO. PV, PVRU and IPP were significantly associated with BOO, with IPP showing greatest positive correlation. Both Qmax and IPP were significantly associated with detrusor contractility. At 5-year follow-up, most patients responded to medical therapy. Only three out of nine patients (33.3%) with BOO eventually underwent surgery, and all had a high bladder neck seen on the resectoscope. Only one patient (7.1%) with poor detrusor contractility eventually required surgery after repeat pressure flow study revealed BOO.ConclusionIn men with small prostates and low IPP, the presence of BOO is associated with higher PV, PVRU and IPP, and most respond well to medical management. BOO can possibly be explained by elevation of the bladder neck by a small subcervical adenoma.

Management of urinary calculi has changed from open pyelolithotomy and ureterolithotomy to predominantly non-invasive procedures such as extracorporeal shockwave lithotripsy (ESWL) as well as endourological such as ureterorenoscopy (URS) and percutaneous nephrolithotripsy (PCNL). Technology has advanced rapidly allowing stone disease to be treated with minimally invasive techniques that have lower morbidity than the open operations of the past. Newer semi-rigid ureteroscopes of size 7 to 9 F allow visualisation of the ureter without traumatic dilatation. There is the flexible ureteroscope developed with smaller fibre optics, the addition of the working channel that allows the use of laser fibres for stone fragmentation and a greater deflection of the tip that enables all parts of the pelvicalyceal system to be inspected for stones. New generation lithotripters for ESWL deliver shockwave to a smaller focal zone so as to minimise damage to surrounding soft tissue but as a result, there are higher failure rates. PCNL, though more invasive than ESWL and URS, is the procedure of choice for large renal stones. It is highly efficient in such situations as newer equipment to disintegrate stone and newer techniques for percutaneous access has been developed. In addition to all these minimally invasive surgical techniques, there is medical therapy available to allow the expulsion of distal ureteric stones as well as alkalinising agents to dissolve uric acid stones. Metabolic evaluation is necessary for patients with recurrent stones. Dietary adjustments may help prevent recurrent stone formation in selected patients depending on the results. With all these techniques currently available, management of urinary calculi has to be tailored according to the size, location of stone as well as patient preference.