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Treatment of Kidney Stones

There are various treatment options for kidney stones and the treatment depends on a variety of factors, including the size and location of the stone in the kidney, symptoms and attendant complications of stones such as hydronephrosis (dilation of collecting system of the kidney).

The options range from observation, medical expulsion therapy (MET), extracorporeal shockwave lithotripsy (ESWL), percutaneous nephrolithotomy (PNL), ureteroscopy (URS) and retrograde intrarenal surgery (RIRS)

Observation

Small stones that are asymptomatic i.e. no pain, bleeding, infection, etc can be observed. Sometimes, these stones may be passed out spontaneously. Nevertheless, these stones should preferrably be monitored with serial imaging.

Should the stone increase in size, migrate to the ureter (tube that connect the kidney to the bladder) or become symptomatic, treatment should then be considered.

Spontaneous passage & medical expulsion therapy (MET)

Small stones in the lower ureter can pass out spontaneously. The likelihood of spontaneous passage can be increased with medication. The medication usually used is an alpha antagonist. It may take a few weeks for the stone to pass out.

Should the stone remain despite medical expulsion therapy or become symptomatic, then other treatment options should be considered.

Extracorporeal Shockwave Lithotripsy (ESWL)

This method uses shockwaves to break stones. Shockwaves are applied from outside the body (extracorporeal) and directed towards the kidney stones. Under x-ray or ultrasound guidance, these shockwaves target at the kidney stones and cause stone fragmentation. The stone fragments are then passed out spontaneously.

Shockwaves are delivered through a machine called lithotripter and effective for kidney stones up to 20 mm in size or 10 mm if the stone is in the lower pole (lower aspect of the kidney collecting system). It is also effective for stones in the upper portion of the ureter and this process can be performed as an outpatient procedure.

Percutaneous Nephrolithotomy (PNL)

This is a procedure where stones in the kidney are accessed via a channel that is created from the surface of skin to the kidney. This is accomplished using x-ray and / or ultrasound imaging and a variety of specialised instruments. Upon accessing the stone, it can then be broken into small pieces and the stone fragments retrieved.

It is a minimally invasive surgery requiring hospitalisation and is effectively for larger stones in the kidney.

Ureteroscopy (URS)

This involves direct visualistion of the ureter via a ureteroscope. A ureteroscope is an instrument that is passed from outside the body into the bladder and thence into the ureter. Through the scope, stones in the ureter can be seen and then fragmented using a variety of stone-fragmentation devices. This is usually performed as a day-case.

Retrograde intrarenal surgery (RIRS)

This is a special type of ureteroscope and it can reach not only the upper portion of the ureter but also the kidney. Thus it is useful for remnant stones in the kidney, following other procedures, or stones in the upper ureter. Again, this is usually performed as a day-case.

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Prevention of Kidney Stones

Urinary stones can be managed with non-invasive techniques such as extra-corporeal shockwave lithotripsy (ESWL) or minimally invasive surgeries. Endourology is the branch of urology that deals with minimally invasive surgical procedures. Using fine instruments, virtually all parts of the urinary tract is accessible and stone can be treated in this manner.

Prevention of kidney stones

A significant number of patients who have had kidney or urinary stones in the past form new stones again.  As high as 50% experience stone recurrence within 10 years.  The following dietary measures, among others, are helpful in preventing or decreasing the risks of kidney stone formation.

1) Increase fluid intake

The general recommendation of intake is at least 2 litres of fluids a day.  Increased fluid intake leads to increased urine production and it is the production of dilute urine that is important.

Water is adequate but fluids rich in citrate e.g. lemonade are also helpful

2) Adequate calcium intake

It is a common misconception that calcium intake should be restricted.  Calcium binds with oxalate in the intestines, thereby reducing absorption of oxalates.  This in turn reduces the risk of stone formation.  In fact low-calcium diet can lead to increased risk of stone formation and conversely, adequate calcium intake can lead to lower kidney stone formation rate.

3) Limit sodium intake

Sodium competes with calcium for reabsorption in the kidneys.  With high sodium content, less calcium is reabsorbed, leading to higher excretion of calcium in the urine and hence stone formation.

4) Limit foods with high oxalate content

Oxalate is excreted in the urine and its concentration is critical to stone formation.  Foods with high oxalate contents include nuts, spinach and rhubarb.

Vitamin is a precursor of oxalate produced in the body.  Increased intake of Vitamin C will lead to higher levels of oxalate.  It is recommended limiting to 1000 mg of Vitamin C per day.

5) Limit foods with high animal protein

Excess animal protein may lead to high uric acid levels resulting in formation of uric acid stones.  Furthermore, lower animal protein can result in lower excretion of calcium and increased excretion of citrate in the kidneys.

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Kidney Cancer

Traditionally, patients with kidney cancer presents with blood in the urine and / or flank pain. However, in recent years, many cases are detected during health screening and the patients do not have any symptoms. The diagnosis is then confirmed on radiologic imaging such as computerised tomography (CT scan).

As in the management of prostate and bladder cancers, it is necessary to stage the kidney cancer. In this regard, the CT scan is able to provide important information including the size of the kidney cancer, involvement of the renal vein (blood vessel that transport blood from the kidney to the heart), inferior vena cava (main blood vessel that transport blood from lower part of the body to the heart), surrounding lymph nodes and liver.

In cases where the cancer is confined to the kidney, the main treatment modality is surgery. The surgery involves removing the whole kidney together with surrounding tissues. In selected cases, only the cancerous growth is removed and the rest of the kidney is preserved. This is possible only for some cases of kidney cancer and depends on factors such as the size and location of the cancer in the kidney. Surgery is done with general anaesthesia and requires hospitalisation, Besides the traditional method of open surgery (cutting through skin and muscles), the surgery can also be carried out via laparoscopy (key hole surgery).

In cases where the cancer has spread beyond the kidney, for example to the lungs, one option is combination therapy. This involves both surgery and immunotherapy. Surgery entails removing the kidney, as alluded to, whilst immunotherapy targets the kidney cancer cells that have spread to other organs. Immunotherapy is usually administered via oral medication. This is an area where, in the past decade, great advances have been made and it has radically changed the treatment of advanced stages of kidney cancer.

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Bladder Cancer

Bladder cancer is the 7th commonest cancer in Singapore and in the USA, it is 6th.

A common symptom of bladder cancer is blood in the urine. This may either be blood that is seen with the naked eye or blood that is detected through urine tests. Blood in the urine does not necessarily mean bladder cancer as there are other causes of blood in the urine such as urinary stones. Usually, further tests are needed for clarification.

These tests include radiologic imaging (X-rays and/or scans) and cystoscopy. Cystoscopy is direct visualisation of the bladder lining through an instrument, called cystoscope. The cystoscope is passed into the bladder and this procedure can be done in the clinic, under local anaesthesia. Through this procedure, the bladder lining can be seen and growth due to bladder cancer can thus be detected.

Following detection of bladder cancer, the next step is to remove the cancerous bladder growth. This can be accomplished by resecting the cancer using special instruments that, again, can be passed into the bladder. There is no need for open surgery (cutting through the skin, muscles, etc). This is generally done with either general or spinal anaesthesia and requires hospitalisation, usually for 1 day.

Once the bladder cancer is removed, the specimen is then sent for analysis by the pathologist – a specialist that studies the microscopic features of the bladder cancer. These features are important in confirming the diagnosis of bladder cancer as well as determining the stage, aggressiveness and type of the bladder cancer.

The commonest type of bladder cancers is papillary epithelial carcinoma. The aggressiveness of the bladder cancer is classified as either low grade or high grade. As for stage, the bladder cancer may either be non-muscle invasive, muscle-invasive or found within the bladder lining (carcinoma in-situ). Depending on the type, aggressiveness and stage, further assessment such as computed tomography (CT scan) may be necessary. Subsequent management of the bladder cancer also varies.

In cases of bladder cancer which are non-muscle invasive, low stage and low grade, no further treatment is needed. For others e.g. carcinoma in-situ, additional treatment with instillation of medication into the bladder will be beneficial. In both instances, bladder cancer can recur. Surveillance is thus necessary and this is done with regular checks using cystoscopy.

In cases where the bladder cancer is muscle-invasive, the treatment options include surgery to remove the bladder or radiation to the bladder. These options may be supplemented by chemotherapy. In situations where the bladder has spread beyond the bladder, the main treatment modality is chemotherapy.

The outcome (prognosis) for non-muscle invasive, low grade and low stage bladder cancer is excellent. The prognosis worsens with high grade and increasing stage. It is thus helpful to be evaluated early especially in cases of blood in the urine.

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Prostate Cancer

Prostate cancer is a form of cancer in the prostate gland, which is found only in males. In Singapore, more and more cases of prostate cancers are detected each year. This is probably due, in part, to increased health awareness among the public leading to more undergoing health screening. Most prostate cancers are detected through health screening.

In the early stages of prostate cancer, there are usually no symptoms. Many men confuse symptoms of benign prostatic hyperplasia with prostate cancer. Men with benign prostatic hyperplasia may have slow urinary flow, dribbling, frequent and night time urination, urge to pass urine, etc. On the other hand, these symptoms are usually not present in early stages of prostate cancer.

As such, early prostate cancer is usually diagnosed following health screening, which usually involves blood tests. One of the blood tests can detect a protein called Prostate Specific Antigen (PSA) and this protein is produced by prostate cells. Both normal or cancerous prostate cells produce this protein. An abnormal result for PSA may or may not mean the presence of prostate cancer. There is an ongoing debate as to the merits of screening for prostate cancer and it is best to discuss this with the attending doctor first.

Another way prostate cancer can be screened is by palpating the prostate, can be felt by a doctor inserting a finger into the anus / rectum. The prostate may feel hard or nodular in cases of prostate cancer. Oftentimes, the prostate feels normal even in the presence of prostate cancer.

Abnormal PSA or nodule in the prostate does not imply prostate cancer. A prostate biopsy is needed to confirm the diagnosis. Prostate biopsy involves retrieving some tissue from the prostate and it is a procedure that can be done in the clinic. Prostate tissue is retrieved from the rectum under ultrasound guidance. The tissue is then sent to the pathologist, a specialist who reviews tissues, for confirmation.

Treatment for prostate cancer depends on the stage of the disease, which can be broadly divided into prostate cancer that’s still confined to the prostate or cancer that has spread outside the prostate or to another part of the body, commonly the bones. Treatment for organ-confined prostate cancer include surgery, to remove the prostate gland, or radiation therapy or a combination of both or observation. Treatment for cancer that has spread usually involves the use of hormones, which can be administered via injection therapy. There are other ways to treat prostate cancer and it is best to discuss the options with the doctor.

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About Dr Toh

Dr Toh Khai Lee
MBBS, FRCSEd, FRCSG, FAMS
 
Dr Toh obtained his medical degree at the National University of Singapore and post-graduate surgical diplomas at the Royal College of Surgeons of Edinburgh, UK as well as Royal College of Physicians & Surgeons of Glasgow, UK. He received his specialist urological training in Singapore and underwent further subspecialty training in the United States where he completed 2 fellowships – one at Duke University, North Carolina under the tutelage of Dr George Webster and the other at William Beaumont Hospital, Michigan with Dr Ananias Diokno. He is a certified specialist in Urology and is a Fellow of the Academy of Medicine, Singapore (Urology).

Dr Toh’s areas of interests in Urology include Reconstructive urology, Urodynamics and Voiding dysfunction / urinary leakage. He was the first in the region to use botulinum (Botox®, Irvine, California) to control urinary leakage in patients with spinal cord injuries. He also treats females with urinary leakage including stress incontinence and/or urge incontinence. In addition, he has directed courses and instructed in Urodynamics, which deals with the functions of the bladder and urethra. He is recognized by his peers as an expert in surgery involving the urethra as well as reconstructive surgery of the bladder and ureters affected by trauma or disease.

Dr Toh also treats urinary stone diseases and urological cancers including kidney, bladder and prostate cancers using minimally invasive surgical techniques – Endourology, Laparoscopy & Robotic Surgery. In addition, Dr Toh is a gazetted Kidney Transplant surgeon in Singapore.

On the research front, besides publishing scientific papers, Dr Toh was the institutional principal investigator in 3 global multi-centre clinical research trials. He is a reviewer for 5 urological journals and is a member of the Editorial Board of International Nephrology & Urology.

Dr Toh has been invited to speak and demonstrate surgery in Beijing, Hong Kong, Taipei, Dhaka, Ho Chi Minh City, Yogjarkarta, Kuala Lumpur, Sibu and Johor. He won the Best Video Presentation at the 2002 National Healthcare Group Annual Scientific Meeting and the Best Paper Presentation at the 1998 Singapore Urological Association Annual Scientific Meeting.

Dr Toh was the President of the Singapore Urological Association from 2012-2014 and also served as Vice-President from 2009-2012 and Honorary Secretary from 2004-2007. He was the Scientific Chairman of Urofair 2004 and Organising Chairman of Urofair 2010. Dr Toh also served as the Honorary Treasurer from 2014-2018 and has been appointed Adjunct Secretary-General (2018-2022) of the Urological Association of Asia.

Despite his busy schedule, Dr Toh found time to serve in humanitarian medical missions. He volunteered his services in Indonesia – both in Aceh following the tsunami and Yogjarkarta after the earthquake – as well as in Pakistan. In recognition of his efforts, he was awarded the ‘Unsung Heros Award’ by the Rotary Club.

Prior to his current practice, he was the Senior Consultant and Head of the Department of Urology in Tan Tock Seng Hospital, Singapore.

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Media & Publications

Media

1) TV interview on “Living the Golden Age” < click here >

Publications

1. Gracilis transposition in prostato-rectal fistula.
Choen-Seow F, Toh KL. Tech Coloproctol; in press
2. Coexisting metastatic choriocarcinoma and bladder adenocarcinoma of common germ cell origin.
Jain A, Liew N, Chia WK, Chew SH, Chia YN, Lim TH, Lim A, Lim SL, Wong CF, Toh KL, Tan MH. Ann Acad Med Sing; in press
3. Life threatening intraperitoneal hemorrhage with abdominal compartment syndrome: Unusual presentation of renal angiomyolipoma.
Tan BW, Toh KL. Int J Urol 2010; 17(9): 820-1
4. Sustained clinical efficacy after repeat intradetrusor botulinum toxin type A in the treatment of neurogenic detrusor overactivity.
KS Png, KL Toh. Acad Med Singapore 2010; 39(2): 152-3
5. Renojejunal fistula: an exremely rare form of renoenteric fistula.
KS Png, KL Toh. Acad Med Singapore 2010; 39(5): 417-8
6. YL Chong, KL Toh.  Bulbar Urethroplastsy using combined dorsal cum ventral onlay buccal mucosal graft: A novel technique.
Acad Med Singapore 2009; 38(3): 275-6
7. ASC Wong, KT Chong, CT Heng, DT Consigliere, K Esuvaranathan, KL Toh, B Chuah, R Lim, J Tan.  Debulking Nephrectomy Followed By A “Watch And Wait” Approach In Metastatic Renal CellCarcinoma.  Urologic Oncology: Seminars and Original Investigations: 2009; 27:149-154
8. KL Toh. Ten-year follow-up of urethral stent for detrusor-sphincter dyssynergia.  Incont Pelvic Floor Dysfunct 2007; 1(3): 99-100
9. YL Chong, KL Toh.  Urethroplasty for anterior urethral strictures in a community-based practice.
Int Urol Nephrol 2007; 39: 505-9
10. Tow AM, Toh KL, Pang SP, Consigliere D.  Botulinum toxin type A for refractory detrusor overactivity in spinal cord injured patients in Singapore.
Ann Acad Med Singapore 2007; 36: 11-7
11. Toh KL, Ng CK.  Urodynamic studies in the evaluation of young men presenting with lower urinary tract symptoms.
Int J Urol 2006; 13: 518-21.
12. Raj GV, Peterson AC, Toh KL, Webster GD.  Outcomes following revisions and secondary implantation of the artificial urinary sphincter.
J Urol. 2005; 173(4): 1242-5
13. Toh KL, Tan JKN.  Artificial Urinary Sphincter in Adult Male with Neurogenic Stress Urinary Incontinence: A Rare Indication.
Ann Acad Med Singapore 2005; 34: 389-90
14. Diokno AC, Toh KL.  Urinary Incontinence in the Elderly.  In EA Bourcier, EJ McGuire, P Abrams (eds): Pelvic Floor Disorders, Philadelphia, Elsevier Saunders, 2004
15. Chong YL, Green JA, Toh KL, Tan JK.   Laparoscopic drainage of nocardial adrenal abscess in an HIV positive patient.
Int J Urol 2004; 11(7): 547-549
16. Miller EA, Amundsen CL, Toh KL, Flynn BJ, Webster GD.  Preoperative urodynamic evaluation may predict voiding dysfunction in women undergoing pubovaginal sling.
J Urol 2003; 169(6): 2234-7
17. Toh KL, Diokno AC.  Management of intrinsic sphincter deficiency in adolescent females with normal bladder emptying function.
J Urol 2002; 168(3): 1150-3
18. Guralnick ML, Miller EA , Toh KL, Webster GD.  Transcorporal artificial urinary sphincter (AUS) cuff placement in cases requiring revision for erosion and urethral atrophy.
J Urol 2002; 167(5): 2075-8
19. Toh KL, PH Tan, WS Cheng. Six-year follow-up of untreated T1 carcinoma of prostate.
Ann Acad Med Singapore 2000; 29: 201-6
20. Toh KL, Tan PH, Cheng WS.  Primary Extraskeletal Ewing’s Sarcoma of the External Genitalia.
J Urol 1999; 162: 159-60
21. Toh KL, Yip SKH, Li MK, Htoo MM.  Computed Tomography (CT) of a 70-year-old male presenting with sepsis and right renal mass.
Tech Urol 1999; 5: 119-122
22. Toh KL, Cheng WS.  Chronic left flank pain: Ureteral fibroepithelial polyp.
Tech Urol 1999; 5(1): 59-60
23. Li MK, Wong MYC, Toh KL, Ho GH, Foo KT.  Percutaneous Nephrolithotomy – Results and Clinical Experience.
Ann Acad Med Singapore 1995; 25: 683-6
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RESEARCH GRANTS
1. A multicenter, long-term follow-up study of the safety and efficacy two dose levels of Botox (botulinum toxin type A) purified neurotoxin complex in patients with urinary incontinence due to neurogenic detrusor overactivity.
Allergan protocol 191622-094
Institutional principal investigator
2. A Randomized, Double-Blind, Placebo-Controlled Study to Evaluate the Efficacy and Safety of Fesoterodine as an “Add-On” Therapy in Men with Persistent Overactive Bladder Symptoms Under Monotherapy of Alpha Blocker for Lower Urinary Tract Symptoms.
Protocol No. A0221009
Institutional principal investigator
3. Metabolic profile of patients with urolithiasis at risk of stone formation.
NHG Research Grant SIG09-01
4. A multicenter, double-blind, randomised, placebo-controlled parallel-group study of the safety and efficacy of a single treatment with two dose levels of Botox (botulinum toxin type A) purified neurotoxin complex followed by a treatment with Botox in patients with urinary incontinence due to neurogenic detrusor overactivity.
Allergan protocol 191622-516
Institutional principal investigator
5. Botulinum toxin for detrusor hyperflexia in spinal injuried patients: Preliminary results.
NHG Research Grant RPR/02078
6. Botulinum toxin A for treating Detrusor Hyperreflexia in spinal cord injured patients in Singapore.
NHG Research Grant NHG-SIG/05025
Co-investigator
7. The role of empirical treatment with antibiotics in patients with elevated PSA-a prospective cohort study.
NHG Research Grant NHG-RPR/02069
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SCIENTIFIC PRESENTATIONS (selected recent presentations)
1. Can the pattern of pelvic fracture ascertain the presence of concomitant urethral distraction defect?
BW Tan, KL Toh.  Singapore Urological Association Annual Scientific Meeting.  March 2010.
2. Metabolic evaluation for patients at risk of recurrent urolithiasis.
KS Png, YL Chong, KL Toh.  Singapore Urological Association Annual Scientific Meeting.  March 2010.
3. Robotic Laparoscopic Assisted Prostatectomy (RALP) – Preliminary experience of a single institution.
Bang S, CK Ng, YM Lee, SJ Chia, KL Toh, YL Chong.   Singapore Urological Association Annual Scientific Meeting.  March 2010.
4. Anastomotic repair of pelvic fracture urethral distraction defect – experience in last 8 years.
SEK Yeo, KL Toh.  Singapore Urological Association Annual Scientific Meeting.  March 2010.
5. Tolterodine improves the compliance and cystometric capacity of adult neurogenic bladders secondary to spinal cord injury.
YK Tan, KL Toh.  39th International Continence Society Annual Meeting.  San Francisco, USA. Sep 09.
6. To evaluate the mid term efficacy of alpha-adrenergic antagonists in the treatment of men with detrusor smooth muscle dyssynergia.
KL Toh, SEK Yeo.  9th Asian Congress in Urology.  New Delhi, India. October 2008.
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INVITED SPEAKING ENGAGEMENTS
1. The Urinary System.
School of Chemical & Biomedical Engineering, Nayang Technological University. BG6005 Physiological Systems Course. September 2011
2. Kidney Transplantation.
Preah Kosomak Hospital. Phnom Penh, Cambodia. September 2011
3. Impact of Spinal Cord Injury on the Urinary System.
Kidney Foundation, Bangladesh & International Society of Nephrology. 6th Annual Convention & International Scientific Seminar. Dhaka, Bangladesh. December 2010
4. Starting a Urodynamic Programme.
The Vietnam Urology & Nephrology Association Annual Meeting. HaiPhong, Vietnam. November 2010
5. Impact of Spinal Cord Injury on Urinary System.
Bangladesh Kidney Foundation. Dhaka, Bangladesh. December 2010
6. Visiting Professor.
Department of Surgery, Chinese University of Hong Kong.  Hong Kong.  September 2009
7. Anterior urethral strictures: when to do what.
Chinese University of Hong Kong.  Hong Kong.  November 2008
8. The Professor Visit Program.
Binh Dan Hospital, Ho Chi Minh City, Vietnam.  August 2008
9. Neuro-urology.  Urology Advanced Course.
Singapore Urological Association.  August 2008
10. Management of Overactive bladder.
University Medical Center.  Ho Chi Minh City, Vietnam.  April 2008
11. Botulinum toxin therapy: Indications, Pros and Cons.
Singapore Urological Association Urofair 2008, February 2008.
12. Bipolar TURP for BPH.  Intravesical botulinum for refractory detrusor overactivity.  Cardiothoracic, Urology, Neurosurgery & ENT Symposium.
Sarawak Health Department, Sibu Hospital & Malaysian Medical Association (Sibu Sub-branch).  Sibu, Malaysia.  March 2007.
13. Starting a botulinum programme: practical considerations. 15th Malaysian Urological Conference.
Malaysian Urological Association.  Kuala Lumpur, Malaysia.  December 2006.
14. Urological management of spinal injured patients.  Urology Advanced Course.
Singapore Urological Association.  August 2006
15. Update on management of overactive bladder.  Urology Advanced Course.
Singapore Urological Association.  August 2006
16. Botulinum Toxin: Clinical issues related to neurogenic detrusor overactivity.
Taiwan Continence Society.  Taipei, Taiwan. June 2006.
17. Role of botulinum in neurogenic detrusor overactivity.
Singapore Urological Association Urofair 2006, February 2006. ‘Botulinum in Urology’ workshop, April 2006.
18. Emerging role of botulinum toxin in Urology.
14th Malaysian Urological Conference.  Malaysian Urological Association.  Johor Bahru, Malaysia.  December 2005.
19. Surgical Management of Urethral Strictures.  Urology Advanced Course.
Singapore Urological Association.  August 2005.
20. Botulinum toxin in Urology.
Singapore Urological Association Urofair 2005.  February 2005.
21. Urethroplasty for Anterior Urethral Strictures.
Singapore Urological Association Urofair 2004.  February 2004.
22. Stoma – urinary diversion.
Singapore Urological Association Nursing Forum 2003.
23. EMG and Video Urodynamic Studies.
Urodynamic Workshop.  Urofair 2003.  February 2003.
24. The Ageing Bladder.
Urofair 2002.  February 2002.
25. Intradetrusor botulinum for neurogenic detrusor overactivity. International Conference on Overactive Bladder.
Bangabandhu Sheikh Mujib Medical University. Dhaka, Bangladesh. June 2012.
26. Management of Males & Females with Overactive Bladder.
Singapore Urological Association. Urofair 2012. March 2012
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SCIENTIFIC APPOINTMENTS
1. Editorial Board member of International Urology & Nephrology Journal
2. Reviewer for
a) International Brazilian Journal of Urology
b) Current Urology
c) Singapore Medical Journal
d) Hong Kong Medical Journal
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AWARDS
1. 2002 1st National Healthcare Group Scientific Congress for Best Video.
Chong YL, KL Toh, JKN Tan.  Right colon pouch: An alternative method of urinary diversion.  August 2002.
2. 2001 Tan Tock Seng Hospital HMDP.
Neuro-urology, female urology & Urodynamics in William Beaumont Hospital, USA.
1999 Human Manpower Development Programme, Ministry of Health.
Reconstructive Urology in Duke University Medical Centre, USA.
3. 1998 Singapore Urological Association Book Prize for Best Paper.  SJ Chia, KL Toh, KS Chan, SW Seng, D Consigliere.  Do patients with acute urinary retention merit a trial without catheter?  1st Combined Meeting of Singapore Society of Nephrologists – Singapore Urological Association. January 1998.
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Services

  1. Male Urinary Diseases
    Many males have urinary symptoms such as frequent visits to pass urine, needing to pass urine again soon after visiting the toilet and occasionally, sudden urge to pass urine, which may result in urine leakage before reaching the toilet. In addition, some may experience poor urinary flow, needing to strain and the urine tends to drip at the end of the flow. Read More >>
  2. Prostate Cancer
    Prostate cancer is a form of cancer in the prostate gland, which is found only in males. In Singapore, more and more cases of prostate cancers are detected each year. This is probably due, in part, to increased health awareness among the public leading to more undergoing health screening. Most prostate cancers are detected through health screening. Read More >>
  3. Blood in the urine
    Hematuria refers to the presence of blood in the urine. The blood can either be seen with the naked eye (also referred to as gross hematuria) or detected from urine tests (microscopic hematuria). Read More >>
  4. Reconstructive Urology
    Reconstructive urology re-establishes structure of the urinary tract that has been disrupted by disease, trauma, etc. Narrowing or strictures of the urethra or the ureter often require reconstructive surgery. Another procedure is the reconstruction of the urinary bladder using intestines following bladder cancer surgery.
  5. Urinary Incontinence / Urine Leak
    Urinary incontinence or Urine Leak is any involuntary leakage of urine and affects both men and women. Although it is common and negatively impacts the quality of life, it is often ignored as many patients believe it is related to ageing. Ironically, incontinence often results from underlying medical conditions which can be treated. Read More: Urine Leak
  6. Female Urology
    Female urology deals with urinary incontinence in women including overactive bladder, stress incontinence, etc. Depending on the cause, treatment can either be medicinal or surgery. Often, urodynamics aid in the diagnosis and treatment.
  7. Urodynamics
    Urodynamics refers to the study of the function, as opposed to the structure, of the bladder and urinary outlet. It assesses the storage and voiding functions of the lower urinary tract.
  8. Urinary/Kidney Stone Disease
    Urinary stones can be managed with non-invasive techniques such asextra-corporeal shockwave lithotripsy (ESWL) or minimally invasive surgeries. Endourology is the branch of urology that deals with minimally invasive surgical procedures. Using fine instruments, virtually all parts of the urinary tract is accessible and stone can be treated in this manner.
    Read More: Prevention of kidney stone, Treatment of kidney stone
  9. Urological Cancers
    Common urological malignancies include cancers of the prostate, kidney and bladder. Depending on the nature and stage of the cancer, management may include radiation therapy, medical oncology and/or surgery.
    Prostate Cancer, Bladder Cancer, Kidney Cancer
  10. Prostate Diseases
    A very common prostate disease is benign prostatic hyperplasia (BPH), which afflicts many men above the age of 50 and causes urinary frequency, urgency, poor flow, nocturia. It can be treated with medication or surgery.Another common condition is prostate cancer. Localised prostate cancer can be managed with watchful waiting, radiation therapy or surgery – either open or robotic.
  11. Neurourology
    Neurourology pertains to urinary problems in patients with neurological conditions, such as strokes, Parkinson’s disease, multiple sclerosis and spinal cord injury. Many experience inability to void, urinary leakage or urgency. Urodynamics play an important role in the assessment and management include intermittent catheterisation, oral medication, injection of botulinum and less commonly, surgery.
  12. Laparoscopic & Robotic Surgeries
    Laparoscopy is a branch of Urology utilising minimal access to remove kidney tumours, etc. Small incisions in the skin are made and the surgery is carried out using special instruments. Robotic assisted laparoscopic prostatectomy uses a robot to remove the prostate in cases of prostate cancer. A proven benefit of a robotic prostatectomy is less blood loss.
  13. Kidney Transplant
    Kidney transplant is one option of managing patients with kidney failure. The kidney can either be from a deceased donor or living donor. Living kidney transplants used to be restricted to donors being related to the recipient but nowadays, non-living related transplants renal transplants are also performed.
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Doctor’s Profile

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Male Urinary Diseases

Many men have urinary symptoms such as frequent visits to pass urine, needing to pass urine again soon after visiting the toilet and occasionally, sudden urge to pass urine, which may result in urine leakage. In addition, some may experience poor urinary flow with dribbling, the need to strain to empty the bladder and sensation of incomplete bladder emptying.

These urinary problems can either be due to the bladder or bladder outlet (tube for urine to flow from the bladder and out of the body) or both. To distinguish between the two, urodynamic study – a specialised test to evaluate the functions of the bladder – is helpful. Research on urodyanmic studies in males has shown that for most men above 50 years old, the cause is usually due to the bladder outlet and specifically, the prostate.

The prostate is an organ found only in men and is located below the bladder, forming part of the bladder outlet. The prostate produces a liquid which mixes with sperms to form semen. For many men, with increasing age, the cells in the prostate increases in number and this may lead to a condition known as benign prostatic hyperplasia (BPH).

Benign prostatic hyperplasia is common and can result in poor urinary flow, dribbling of urine, the need to strain, sense of remnant urine in the bladder despite emptying the bladder, waking up in the middle of the night to void, needing to rush to the toilet, etc. A troublesome consequence is the inability to pass urine.

Treatment for benign prostate hyperplasia include medications and surgery. For surgery, it involves removing most part of the prostate and this can be accomplished via surgical instruments that are passed into the urine tube.

As for medications, there are many different types available. For example, one type causes the prostate to shrink and another relaxes the muscles around the neck of the bladder. The underlying treatment intent is to widen the urine tube, thereby facilitating urinary flow.

Younger men may experience similar symptoms but the cause may not be due to the benign prostatic hyperplasia. Other causes need to be considered and these include urethral strictures (narrowing of the urine tube) or primary bladder neck dysfunction. These require more specialised evaluation such as urethrogram and video urodynamic studies.

Whether young or old, many men are embarassed to talk about it, either with relatives or close friends or even with their spouses. Many incorrectly attribute their urinary symptoms to having a weak bladder or simply dismiss it as part of the ageing process. As a result, many suffer in silence for months or years. Medical therapy is available and it is beneficial for men with urinary problems to be properly evaluated and treated.

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Contact Details

3 Mount Elizabeth #05-05
Mount Elizabeth Medical Centre
Singapore 228510

Tel: +65 6836 4045

Fax: +65 6836 4046

Mail: enquiry@tohklurology.com

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Urological Cancer

Common urological malignancies include cancers of the prostate, kidney and bladder. Depending on the nature and stage of the cancer, management may include radiation therapy, medical oncology and/or surgery.

Prostate Cancer

Prostate cancer is a form of cancer in the prostate gland, which is found only in males. In Singapore, more and more cases of prostate cancers are detected each year.

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Bladder Cancer

Bladder cancer is the 7th commonest cancer in Singapore and in the USA, it is 6th.

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Kidney Cancer

Traditionally, patients with kidney cancer presents with blood in the urine and / or flank pain. However, in recent years, many...

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Blood in the urine

Hematuria refers to the presence of blood in the urine. The blood can either be seen with the naked eye (also referred to as gross hematuria) or detected from urine tests (microscopic hematuria).

A person may have microscopic hematuria without realising it. The urine may appear clear when there’s actually blood in the urine. In fact, blood in the urine is not uncommonly detected when a person undergoes urine tests during health screening.

Simple exercises or sexual activity usually do not result in blood in the urine. Hence, in the event of repeated microscopic hematuria or gross hematuria, further evaluation of the urinary tract, which comprises the kidneys, bladder and ureters (tubes that transport urine from kidneys to the bladder), is recommended.

Evaluation can be done in a variety of ways. For the kidneys and ureters, these are usually assessed with radiologic imaging such as X-rays (e.g. intravenous pyelogram) or scans (e.g. CT scans). The bladder is evaluated using cystoscopy, which is direct visualisation of the lining of the bladder. This is accomplished using a fine instrument that is passed from the urine tube opening into the bladder and can be performed in the clinic under local anaesthesia.

Following evaluation, the cause of blood in the urine can usually be ascertained. There are many causes of blood in the urine. The more common causes of hematuria include cancers (e.g. kidney or bladder), stones, infection, etc. Once the cause is determined, treatment can be instituted. For example, kidney cancer can be managed with surgery of whole or part of the kidney. If stones are the cause of hematuria, depending on the size and location of the stone, treatment options include observation, extracorporeal shockwave lithotripsy, intracorporeal laser lithotripsy, etc.

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Urinary Incontinence / Urine Leak

Urine Leak in woman

Many women suffer from involuntary urine leakage, which is also known as urinary incontinence. In addition to urinary incontinence, many also experience frequent urination, sudden urges to pass urine as well as night-time urination. The night time urination and urgency are troublesome occurences as the need to go to the toilet frequently comes unexpectedly, with some women suffering the embarassment of urine leakage even before reaching the toilet. Frequent night time urination can also cause deprivation of sleep, thus affecting the ability to concentrate during the day.

Some women experience urine leakage upon coughing, laughing, sneezing, brisk walking or climbing stairs. These women often have had many childbirths – vaginal (normal) deliveries, in the past. While many experience the occasional urine leak for many years, the leak worsens upon reaching menopause.

Oftentimes, urine leakage adversely affects the women’s lifestyles. Many end up having to change their lifestyles such as avoiding social functions or sports, preferring to stay at home instead.

There are different types of urine leakage with different treatment options, depending on the underlying cause. The more common types are urge incontinence and stress incontinence.

Urge incontinence

It is primarily a condition of the bladder. There are muscles and nerves within the bladder. Sometimes, these muscles develop unwanted contractions or the nerves send signals to the brain, resulting in frequent urges to pass urine. This causes frequent urination, night-time urination and possibly urine leakage.

Treatment is aimed at decreasing or abolishing these sensations / contractions. The usual treatment for such urine leak is behavioural change and oral medication. Behavioural change may include timed voiding i.e. setting a minimal time interval between urination. As for oral medication, there are different types of medication and a common one is anti-cholinergic medicine. Examples of anti-cholinergic medicine include oxybutynin, tolterodine, solifenacin and darifenacin. More recently, a new class of medicine has been developed. They are beta-3 agonists and the first to be available is mirabegron.

Sometimes, oral medication may not be effective. In such instances, other treatment options are available. One such alternative is the injection of botulinum A into the bladder, which has been shown to be effective in treating this type of urine leakage.

Stress incontinence

This refers to urine leakage on coughing, laughing, sneezing, etc. This is due to the inability to hold urine when pressure is applied to the outlet of bladder i.e. when the bladder is ‘stressed’. The bladder outlet consists of a tube through which urine is passed out of the bladder. The function of the bladder outlet is, among others, maintained by the health of the tissues around it as well as the strength of the pelvic floor muscles. After multiple childbirths and on reaching menopause, these pelvic floor muscles and surrounding tissues are weakened, resulting in stress incontinence.

Treatment is aimed at strengthening the outlet. This can be accomplished by pelvic floor exercise. Also known as Kegel exercise, this is effective but requires perseverance. For some, other forms of treatment are needed such as surgery. There are many types of surgery available for stress incontinence. One effective surgical option is mid-urethral sling. The sling surgery involves placing a synthetic material beneath the bladder outlet where it acts as a backstop during urination. This can be done as a day procedure i.e. without the need for overnight stay in the hospital and has been shown to be an effective way of treating stress incontinence.

Evaluation

A urodynamic study may be required in some instances. It is basically a test to evaluate the function of the bladder and outlet. It involves placing a tube (catheter) into the bladder and another tube (rectal probe) into the rectum. The 2 tubes are then connected to a computer.

The bladder is then filled with liquid. When the bladder is full, the patient will be asked to pass urine. During this process, information of the function of the bladder and outlet will be collected and stored in the computer. These can then be downloaded and printed.

The urodynamic study provides additional information on urinary incontinence which may aid in the management in many patients.

Should I seek medical attention?

Many women do not seek medical attention as urine leakage is often attributed to ageing where nothing much can be done. As such, many suffer in silence.

However, with better understanding of the condition and medical advances, much can be done to help those who suffer from urine leakage.

Summary

Urine leak is not uncommon among women and often affects their lifestyle negatively. There are different causes of urine leak and management depends on the underlying cause. While cure may not be possible in all cases, many can be improved with current medical options.

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Urinary / Kidney Stones Disease

Urinary stones can be managed with non-invasive techniques such as extra-corporeal shockwave lithotripsy (ESWL) or minimally invasive surgeries. Endourology is the branch of urology that deals with minimally invasive surgical procedures. Using fine instruments, virtually all parts of the urinary tract is accessible and stone can be treated in this manner.

Prevention of Kidney Stones

Urinary stones can be managed with non-invasive techniques such as extra-corporeal shockwave lithotripsy (ESWL) or minimally invasive surgeries.

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Treatment of Kidney Stones

There are various treatment options for kidney stones and the treatment depends on a variety of factors, including the size and location of the stone...

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Other Conditions

  1. Reconstructive Urology
    Reconstructive urology re-establishes structure of the urinary tract that has been disrupted by disease, trauma, etc. Narrowing or strictures of the urethra or the ureter often require reconstructive surgery. Another procedure is the reconstruction of the urinary bladder using intestines following bladder cancer surgery.
  2. Urodynamics
    Urodynamics refers to the study of the function, as opposed to the structure, of the bladder and urinary outlet. It assesses the storage and voiding functions of the lower urinary tract.
  3. Neurourology
    Neurourology pertains to urinary problems in patients with neurological conditions, such as strokes, Parkinson’s disease, multiple sclerosis and spinal cord injury. Many experience inability to void, urinary leakage or urgency. Urodynamics play an important role in the assessment and management include intermittent catheterisation, oral medication, injection of botulinum and less commonly, surgery.
  4. Laparoscopic & Robotic Surgeries
    Laparoscopy is a branch of Urology utilising minimal access to remove kidney tumours, etc. Small incisions in the skin are made and the surgery is carried out using special instruments. Robotic assisted laparoscopic prostatectomy uses a robot to remove the prostate in cases of prostate cancer. A proven benefit of a robotic prostatectomy is less blood loss.
  5. Kidney Transplant
    Kidney transplant is one option of managing patients with kidney failure. The kidney can either be from a deceased donor or living donor. Living kidney transplants used to be restricted to donors being related to the recipient but nowadays, non-living related transplants renal transplants are also performed.
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Laparoscopic & Robotic Surgeries

Laparoscopy is a branch of Urology utilising minimal access to remove kidney tumours,
etc. Small incisions in the skin are made and the surgery is carried out using special instruments.
Robotic assisted laparoscopic prostatectomy uses a robot to remove the prostate in cases of
prostate cancer. A proven benefit of a robotic prostatectomy is less blood loss.

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Kidney Transplant

Kidney transplant is one option of managing patients with kidney failure. The kidney can either
be from a deceased donor or living donor. Living kidney transplants used to be restricted to
donors being related to the recipient but nowadays, non-living related transplants renal
transplants are also performed.

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Neurourology

Neurourology pertains to urinary problems in patients with neurological conditions, such as
strokes, Parkinson’s disease, multiple sclerosis and spinal cord injury. Many experience inability
to void, urinary leakage or urgency. Urodynamics play an important role in the assessment and
management include intermittent catheterisation, oral medication, injection of botulinum and
less commonly, surgery.

Mount Elizabeth Medical Centre
3 Mount Elizabeth #05-05
Singapore 228510
t +65 6836 4045 f +65 6836 4046
e enquiry@tohklurology.com