Medico Issue 15 by Esther Lim

Médico April to June 2013

A quarterly publication of GP Liaison Centre, National University Hospital.

MICA (P) No. 018/08/2012

The New NUH Medical Centre Urinary Incontinence

A/Prof Lim Thiam Chye

02-03 Medical Notes • 04-11 Treatment Room • 12-17 Insight • 18-19 Doctor’s Heartbeat

M EDIC AL N O TES

Scheduled to open later this year, the NUH Medical Centre is an integral part of the hospital’s redevelopment plan to meet the expanding and increasingly sophisticated healthcare needs of Singaporeans.

The New NUH Medical Centre

The 20-storey building, strategically located above the Kent Ridge MRT station, will bring greater convenience to both patients and visitors. With a total Gross Floor Area of 72,000sqm, the Centre will house primarily subsidised specialist outpatient clinics relocated from the hospital’s Main Building. This, in turn, will allow space at the 28-year-old Main Building to be upgraded and reconfigured for the expansion of existing and new patient care facilities. Ambulatory surgical facilities and clinical support services will also be available at the new facility to provide one-stop care for patients. The National University Cancer Institute, Singapore (NCIS) will also be housed at the new Centre. The NUH Medical Centre has incorporated design attributes like landscaping and the use of warm colours and natural lighting to create a conducive and healing environment for our patients.

NUH Medical Centre’s completed superstructure

Most patients will not have to make more than three turns to get to their destinations within the building. There are also barrier-free link bridges linking the new Centre to the Kent Ridge Wing, making it easy for patients who have to move between the buildings.

View from North Buona Vista Road

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Facilities and Services at the NUH Medical Centre: LEVELS

FACILITIES

LEVELS

FACILITIES

18 – 19

Future Clinical Space

Eye Surgery Centre

Colorectal Centre Urology Centre Anaesthetic Outpatient Consultation Clinic (AOCC)

National University Cancer Institute, Singapore • Stem Cell Therapy Centre • Viva-University Children’s Cancer Centre • Chemotherapy Centre • Pharmacy @ NCIS

ENT – Head and Neck Surgery Centre Fine Needle Aspiration (FNA) Clinic Surgical Specialists Centre

National University Cancer Institute, Singapore • Radiation Therapy Centre • Breast Care Centre

6-7A

Carpark

Digestive Centre Rehabilitation Centre

Food Court Carpark

Medicine Clinic Dietetics Medical Social Work

Diagnostic Imaging Amenities Linkways to Kent Ridge Wing

Laboratory Medicine

3 (Road Level)

Ambulatory Surgical Centre Ambulatory Surgical Ward

Main Lobby Outpatient Procedure Centre / OPAT Pharmacy Amenities

National University Cancer Institute, Singapore • Cancer Centre • Health Resource Centre @ NCIS

2 (Underground)

Amenities

1 (Underground)

Kent Ridge MRT Concourse Amenities

Department of Surgery’s Centennial Celebration In 1913, Dr. ED Whittle was appointed as a surgeon and also the first lecturer of Surgery in Singapore. Since then, many excellent doctors were educated for the nation. The emphasis on academic surgical excellence and research has been most rewarding. The Department of Surgery of the Yong Loo Lin School of Medicine, National University of Singapore (NUS), and the National University Hospital (NUH), will be commemorating a centennial history of this meaningful journey this year. A series of events have been planned to include you in this celebration. Please visit www.surgery100.sg for more information.

EVENTS • Walkathon, Jogathon & Cyclathon Tournament • Golf Fund Raiser • MedTech & Surgical Excellence Conference • Book Launches & more…

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T R EATMENT R OO M Dr Charles Tan

Consultant, Division of General Surgery (Thyroid & Endocrine Surgery), University Surgical Cluster

Dr Charles Tan is an Assistant Professor of Surgery at the NUS Yong Loo Lin School of Medicine. He received his surgical training at the National University Hospital, Singapore. His special interests are thyroid, parathyroid, adrenal and hernia surgeries, with a special interest in the minimally invasive access and approach to it. He spent a year of fellowship on endocrine surgery at Royal North Shore Hospital, University of Sydney in 2007. Dr Tan has a strong interest in undergraduate teaching and has been voted the best tutor in the department for multiple consecutive years. He has published in peer-reviewed scientific papers and has written a book for undergraduates and surgical trainees. Presently, his area of particular interest is in thyroid resections via the axilla. Email: charles_tan@nus.edu.sg

Lump in the Neck or Scar in the Neck? - New techniques in Thyroid Surgery Clinical case

Background

Ms X was a 23-year-old school teacher with a left thyroid nodule. It was increasing in size and she was concerned about the malignant potential of it. Pre-surgery needle biopsy of the nodule showed that it was a benign nodule.

90% of thyroid lumps are benign and up to 90% of the patients are female. Most of them want surgery as the goiter is aesthetically undesirable. When surgery is discussed, a dilemma is posed, “Should I have surgery? But what remains is a scar in the neck, which is equally undesirable!” Furthermore, Asian ethnic skin tends to form keloid more than the Caucasians.

Whenever she goes out on the street, she would often be met with curious glances and she would be asked about the lump in her neck. These encounters soon unnerved her further. When offered surgery for the benign thyroid, she then posed a question, “Which is worse? A lump in the neck or a scar in the neck?”

Left thyroid nodule

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In our tropical climate, 99% of our clothing exposes the neck, unlike those designed for the temperate climate. To address these concerns, thyroidectomies can be performed via the axilla with either endoscopic or robotic methods. The advantages are the absence of a scar in the neck and reduction of post-operative neck discomfort.

Conventional neck thyroidectomy scar

Scarless-in-the-neck Endoscopic Thyroidectomy (SET) This is a technique pioneered by the Japanese in 2001 and later by the Koreans in 2004. It involves the use of an endoscope and two or three working ports to dissect out the thyroid. The access can be via the axilla, breast or both. Surgeons from the NUH Division of General Surgery (Thyroid and Endocrine Surgery) started using this technique in 2005 and have operated on 80 patients to date. We have encountered minimal morbidity and no mortality. All patients had been pleased with the cosmesis in the neck as there is virtually no scar. Approximately 5% of patients had some discomfort in the chest area. Surgical times in most cases were longer than conventional surgery but the one-day average length of stay was similar in both groups.

is a very vascular organ and bleeding can be easily encountered. Lastly, there is the important recurrent laryngeal nerve to carefully isolate and preserve, which can be difficult. Robotic surgery The introduction of robotic technology has revolutionised the surgical management of prostate cancer and is increasingly popular in the other specialties such as gynaecology and colorectal surgery. The current system used is the da Vinci robotic system. It has several advantages over conventional endoscopic thyroid surgery, including a three (3-D) surgical view with the use of a stable camera platform, fine and free movement of the robotic arms in the surgical field. Features of the robotic arm include a tremor filtering system, motion scaling, dexterity and ambidexterity, and these allow surgeons to access deep and narrow spaces, which is ideal for thyroid surgery.

Endoscopic thyroidectomy scar

However, this technique is technically challenging, and it is why it has not been as popular as expected. Firstly, the current image is a two-dimensional visual representation – which leads to difficulty in visualisation of the surgical field. Secondly, the current endoscopic instruments are non-flexible and this translates to sub-optimal manipulation. Thirdly, unlike laparoscopic surgery in the abdominal cavity, the working space is limited; and furthermore, the thyroid

That said, there are a few major drawbacks of the robotic system. Firstly, there is the lack of both tactile sensation and tensile feedback to the surgeon. Secondly, prompt, open conversion to arrest any bleeding is impossible as it takes a while for the entire robotic system to be withdrawn from the patient. Thirdly, the cost for the use of the robot is high. Most of these surgeries are for benign disease, but the Korean surgeons have also pushed boundaries by using the robot for surgery on thyroid cancers and lymph node dissections. We experienced initial reluctance in using the robot for thyroid surgery as the “older” model had 3 arms (one for the camera and 2 working arms) and the endoscopic thyroidectomies (SET) were working for our patients. Using the robot was also much more expensive for our patients than conventional or endoscopic surgery. However, since the acquisition of an upgraded da Vinci robot model by the NUH University Surgical Cluster, we had performed 6 cases since August 2012. The surgeries with the robot were of shorter duration (2 hours), all patients stayed for only one day in hospital, there was no morbidity or mortality encountered, and all of them were very satisfied with the aesthetic outcome. Conclusion

Robotic thyroidectomy - Axillary scar

Gone are the days where patients would be petrified with the thought of a hideous scar in the neck after thyroid surgery. We can now tailor our choice of access to remove the thyroid gland to the patient’s needs and concerns without compromising on patient safety. A feasible option now is to move the scar away from the neck in the form of endoscopic or robotic thyroidectomy.

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T R EATMENT R OO M Dr David Consigliere

Senior Consultant, Department of Urology, University Surgical Cluster

Dr David Consigliere studied Medicine at the University of Singapore and is a Fellow of the Royal College of Surgeons (Glasgow). He started training in Urology in late 1989. He worked in the Department of Urology in Stepping Hill Hospital, Stockport, UK in 1992. Upon his return to Singapore he helped to set up & administer the section of Urology in Tan Tock Seng Hospital in April 1993. The unit subsequently gained accreditation for Specialist Training in Urology. In August 2001, he moved over to the Department of Urology, National University Hospital, as a Senior Consultant and was appointed Chief of Urology from January 2004 until June 2010. In 2008, he was appointed Chairman of the Subgroup on Prostate Cancer Screening, for the Ministry of Healthʼs Clinical Practice Guidelines Cancer Screening Workgroup. He was also a member of the Prostate Health Workgroup, under the auspices of the GSK Urology Advisory Board. He served as President of the Singapore Urological Association as well as Chairman of the Chapter of Urologists, College of Surgeons, under the Academy of Medicine, Singapore. He is engaged in undergraduate medical training as well as postgraduate urological training. He is presently the Chairman of the Urology Residentsʼ Advisory Committee / Specialist Training Committee and also the immediate past President of the Society for Continence, Singapore. Dr Consigliere is involved in the Departmentʼs neuro-urology and incontinence programme. Email: david_consigliere@nuhs.edu.sg

Urinary Incontinence Definition Urinary incontinence is defined by the International Continence Society as “the involuntary loss of urine that represents a hygienic or social problem to the individual”. Urinary incontinence can be thought of as a symptom as reported by the patient, as a sign that is demonstrable on examination, and as a disorder. Ureters

Mixed urinary incontinence is a combination of stress and urge incontinence; it is marked by involuntary leakage associated with urgency and also with exertion, effort, sneezing or coughing.

Bladder Urine External Bladder Sphincter Urethra

Muscle Contraction Sphincter Release

Normal micturition

Types of Urinary Incontinence Four types of urinary incontinence are defined in Clinical Practice Guidelines: stress, urge, mixed, and overflow. Some authors include functional incontinence as a fifth type of incontinence. Stress urinary incontinence is characterised by urine leakage associated with increased abdominal pressure from laughing, sneezing, coughing, climbing stairs, or other physical stressors on the abdominal cavity and, thus, the bladder. Urge urinary incontinence is involuntary leakage accompanied by or immediately preceded by urgency.

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Overﬂow incontinence is the leakage of urine due to obstruction and a full bladder Functional incontinence is urine loss associated with difficulty reaching a toilet when needed in an otherwise continent person. It can result from impaired mobility caused by conditions such as severe arthritis, muscle weakness, stroke, cognitive impairment, dementia, confusion, or sedation. Prevalence ◘ Up to 30% of people aged ≥ 65 years ◘ Highest prevalence is in older women ◘ 5-15% in the community, 20-30% in acute general hospital and up to 50% in nursing homes ◘ Severe or socially disabling incontinence: almost 3% of the adult population, or 1 out of every 35 people.

Consequences of Incontinence ◘ Medical: perineal rashes, skin breakdown, UTIs, falls and fractures ◘ Psychosocial: embarrassment, rejection by carers, social isolation, depression ◘ Economic: heavy financial burden incurred from coping with the problem Clinical Assessment History Basic assessment includes a detailed history. Patient complaints may be minor and situational or severe, constant, and debilitating. Determine whether the problem is a social and/or hygienic problem and the degree of disability attributable to the incontinence. In addition, the following points in clinical presentation should be sought when obtaining the history: ◘ Severity and quantity of urine lost and frequency of incontinence episodes ◘ Duration of the complaint worsening ◘ Triggering factors (e.g. cough, sneeze, lifting, bending, sound of running water, sexual activity/orgasm) ◘ Constant versus intermittent urine loss and provocation by minimal increases in intra-abdominal pressure, such as movement, changes in position, and incontinence with an empty bladder ◘ Associated frequency, urgency, dysuria, pain with a full bladder, and history of UTIs ◘ Coexistent complicating medical problems ◘ Obstetrical history, including difficult deliveries, grand

multiparity, forceps use, obstetrical lacerations, and large babies ◘ History of pelvic surgery, especially prior incontinence procedures, hysterectomy, etc. ◘ Other urologic procedures; Spinal and CNS surgery ◘ Lifestyle issues: smoking, alcohol or caffeine abuse, and occupational and recreational factors A key aspect to history-taking in incontinence patients is medication-use. It is important to collate an exhaustive list of medications, including those available over-the-counter. A large number of medications may potentially influence continence in a variety of ways. GPs should also consult the product information for each drug to establish whether drug interactions are likely. List of medications that can cause or contribute to urinary incontinence.

Medications that affect sphincter strength ◘ ACE inhibitors ◘ Medications for depression like Remeron ◘ Antihypertensives like Doxazosin and Prazosin ◘ Diuretics used in Hypertension and Cardiac Failure Medications that increase urine production ◘ Diuretics used in Hypertension and Cardiac Failure Voiding (Bladder) diary A 3-day voiding diary is a useful supplement to the medical history of the patient. Voiding diaries should record the daily volume and type of fluid intake and the frequency and volume of voids. Episodes of nocturia and incontinence are recorded.

Medications and substances that irritate or make the bladder overactive: ◘ Cyclophosphamide ◘ Ketamine ◘ Glue sniffing ◘ Caffeine ◘ Nicotine Medications that weaken bladder contraction: ◘ Medications for nasal congestion e.g. Pseudoephedrine ◘ Medications for depression like Remeron ◘ Medications for Alzheimer’s like Donezipil ◘ Certain antihistamines and asthma medications ◘ Painkillers containing opiods like Codeine ◘ Certain anxiolytics and hypnotics like Benzodiazepines, Imipramine

Bladder Diary

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Physical Examination The key points in the detailed physical examination for patients presenting with symptoms of incontinence should include pelvic, abdominal, rectal, neurological, and cardiac examinations. Table 1: Physical examination finding and implications

ORGAN SYSTEM

EXAM FINDINGS

IMPLICATIONS

Pelvic

Pelvic organ prolapse

Overflow incontinence (from bladder outlet obstruction) or voiding dysfunction

Vulvar/vaginal atrophy

Urge incontinence or voiding dysfunction

Weak pelvic floor muscle assessment

Stress incontinence

Anterior vaginal wall palpation for urethral tenderness or discharge

Irritative symptoms (frequency, urgency, burning) from urethral infection or inflammation

Bimanual exam for pelvic masses

Voiding dysfunction from pelvic masses

Fullness, bloating, masses, ascites

Voiding dysfunction from abdominal pressure

Palpable bladder

Overflow incontinence

Rectal

Reduced or absent anal sphincter tone Fissures may indicate chronic constipation or fecal impaction

Overflow incontinence Overflow incontinence (from bladder outlet obstruction) or voiding dysfunction

Neurologic

Mental status Abnormal perineum and lower extremity exam (motor/sensory)

Functional or mixed incontinence due to decreased awareness of need to void Overflow incontinence

Volume overload

Nocturia or nocturnal incontinence

Abdominal

Cardiac

Diagnostic Evaluation ◘ Clinical testing 1. Cough stress test The patient coughs with a full bladder, standing. A pad is held underneath the perineum or on the floor and the clinician observes directly whether there is urine leakage. 2. Laboratory tests

Urine cytology is indicated if there is hematuria or pelvic pain or if bladder cancer is suspected. ◘ Specialised Testing 1. Postvoid residual (PVR) measurement

4. Cystoscopy In general, a PVR < 50 mL is considered adequate emptying, and a PVR > 200 mL is considered abnormal & suggestive of detrusor weakness or obstruction.

Urinalysis should be performed in all patients, with urine culture if infection is suspected.

2. Urine ﬂow rate is useful in men with bladder outflow obstruction; not routine in women with U.I.

Renal panel, serum calcium and glucose testing may be done.

3. Urodynamic studies: Cystometry, Pressure Flow studies, EMG, Videurodyamics

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Urodynamics is the diagnostic "gold standard", but is invasive, expensive, requires special equipment and training. It is not recommended for routine evaluation but is useful if invasive treatment is planned.

Cystoscopy is only indicated in patients with suspected urinary tract neoplasm (persistent hematuria, or persistent irritative voiding symptoms in the absence of a UTI). 5. Other imaging MRI, CT, etc. are not recommended for routine assessment.

Treatment of Urinary Incontinence Treatment is directed to the type and cause of incontinence. At the start, search for conditions that cause temporary incontinence. Transient (Reversible) Conditions That Cause Urinary Incontinence The ‘DIAPPERS’ mnemonic This is a useful way to recall factors to be considered when evaluating a patient with urinary incontinence. These conditions may be detected by history, physical examination, or urinalysis D I A P P E R S

Delirium [or Diabetes] Infection (urinary tract) Atrophic urethritis/vaginitis Pharmaceuticals Psychological Excess urine Reduced mobility Stool impaction

These reversible conditions are common; identifying them can help avoid more complicated evaluations and treatments and often results in amelioration or elimination of symptoms. Treatment options are listed below in the order in which they are usually tried, from least-to-most invasive: ◘ Behavioral techniques and physical interventions ◘ Medications are tried next ◘ Surgery is the last resort ◘ Lifestyle techniques to improve quality of life and improve hygiene are part of all treatments Behavioural and Physical Interventions 1. Weight loss In women, pelvic floor muscle tone weakens with significant weight gain, Weight loss can help reduce the frequency of urinary incontinence episodes in overweight women.

Table 2: Indications for Referral of Patients with Incontinence for Specialist Evaluation

Conditions detected by history • Recent onset (within two months) of urge incontinence or irritative bladder symptoms • Previous anti-incontinence surgery • Previous radical pelvic surgery or irradiation • Incontinence associated with recurrent symptomatic urinary infections Conditions detected by physical examination • Prostate nodule or asymmetry • Gross pelvic prolapse (beyond hymen) • Neurologic abnormality suggesting systemic disorder or spinal cord lesion • Suspected fistula Conditions detected by urinalysis • Hematuria without infection • Significant persistent proteinuria Others situations that arise or are detected during or after the basic evaluation • Abnormal PVRU • Inability to arrive at a presumptive diagnosis or treatment plan • Failure to respond to initial primary care treatment • Consideration of surgical intervention

2. Fluid Intake A common misconception is that drinking less water will prevent accidents. In reality, limiting fluid intake may irritate the lining of the bladder and urethra and may actually increase leakage. Concentrated urine also has a stronger pungency and odour. Incontinent patients, however, should stop drinking beverages 2 - 4 hours before going to bed, particularly if they experience leakage during the night. 3. Physical activity Older persons in the community who perform regular physical activities report a lower frequency of urinary incontinence episodes. 4. Prompted voiding Prompted voiding is a behavioural therapy in which caregivers regularly ask about the need to go to the toilet (usually every 2-3 hours). It aims to improve bladder control for people with or without dementia using verbal prompts and positive reinforcement.

5. Pelvic Floor Muscle Training (PFMT) PFMT (also called Kegel exercises) is an effective treatment for women with stress and mixed incontinence and may also be effective in treating urge incontinence when used in combination with bladder training. 6. Bladder training Bladder training is a widely used and very helpful behavioural approach. Patients are put on a scheduled voiding programme with gradual increases in the duration between voids, and uses urge suppression techniques with distraction or relaxation. 7. Electrical Stimulation of the Pelvic Floor Electrical stimulation of the pelvic floor muscles uses a probe inserted into the anus or vagina, which produces a contraction in the pelvic floor muscles. Studies, however, show mixed results.

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8. Devices Tampons and pessaries are sometimes used to treat stress incontinence. These intra-vaginal devices support the pelvic organs. Pessaries need to be removed and cleaned regularly.

BLADDER CONTROL SYSTEM

Anticholinergic medications are the drugs of choice for the management of over-active bladder and urge incontinence. Clinical usefulness in the elderly may be limited by adverse effects including overflow or functional incontinence. • Topical estrogens

Urine

Urethra

Bladder muscle

Sphincter

Pelvic ﬂoor muscles

muscles Pelvic Floor Muscles

Medications

Intra-vaginal estrogens may be useful for the treatment of overactive bladder and urge incontinence in postmenopausal women with atrophic vaginitis or severe vaginal atrophy. 2. Stress Urinary Incontinence Drug treatment of stress urinary incontinence is aimed at increasing the tone of the striated muscle in the urethra and pelvic floor.

3. Overﬂow incontinence • Alpha adrenergic antagonists Terazosin (Hytrin), doxazosin (Cardura), alfuzosin (Xatral), tamsulosin (Harnal) • 5-alpha reductase inhibitors Dutatsteride (Avodart), finasteride (Proscar) • Bethanecol (Generics, Urecholine) has been used to increase the strength of bladder contractions. Symptom Management • Containment products (diapers, pads, sanitary napkins) • Catheters Catheterisation (intermittent or indwelling; urethral or suprapubic)

1. OAB and urge incontinence • Duloxetine • Anticholinergics Oxybutynin (Ditropan), solifenacin (Vesicare), tolterodine (Detrusitol), propiverine (Mictonorm), trospium (Spasmolyt) and fesoterodine (Toviaz) Actions: ◘ Inhibit the involuntary contractions of the bladder ◘ Increase capacity of the bladder ◘ Delay the initial urge to void Side effects: dry mouth, dry eyes, headache, constipation, etc.

Duloxetine is a selective serotonin and noradrenaline reuptake inhibitor (SNRI) antidepressant. Its action is thought to increase urethral sphincter contraction. • Alpha adrenergic agonists Pseudoephedrine has been used to increase outflow resistance but is not selective for urethral receptors. Its usefulness is limited by adverse effects.

In-dwelling Foley Catheter

• Systemic estrogen therapy for urge, mixed and SUI Systemic estrogens, with or without progestins, can cause or worsen incontinence. Their use for the treatment of incontinence in postmenopausal women is not recommended.

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Chronic indwelling catheters can be a source of infection and should be used only after all alternative management strategies have been exhausted.

Surgery Surgery should be considered in patients who fail non-surgical treatment and in those with a major anatomic abnormality, or in men with incontinence from documented outflow obstruction. Table 3: Factors to consider when deciding on surgery for the treatment of incontinence. Factors relating to the patient

Factors relating to the surgeon and procedure

• Age • Type and severity of incontinence • Previous treatment • Medical comorbidities • Lifestyle/patient preference • Need for associated prolapse surgery • Overactive bladder symptoms

Surgery involves procedures that increase urethral outlet resistance. Operations include:

• Mid-urethral tape procedures: Tension-free vaginal tape (TVT); and transobturator tape (TOT) • Transobturator male sling: Used with good results for some men who have prostatectomy-induced incontinence • Bulking Material Injections Animal or human collagen; synthetic: carbon-coated beads • Artiﬁcial Sphincter Used in cases of sphincter incompetence, or complete lack of sphincter function.

Urethra

Sling

TRANSOBTURATOR

Pubic bone

• Bladder Neck Suspension: Retropubic (Burch) Colposuspension using standard "open" surgery

◘ sacral nerve neuromodulation ◘ open surgical procedures such as detrusor myomectomy, augmentation cystoplasty, and urinary diversion

RETROPUBIC

1. Surgery for Stress Urinary Incontinence

• Surgeon’s experience • Cure rates and outcome data • Complication rates • National and institutional guidelines

Pubic bone

Sling

Obturator foramen

Sling Procedures

2. Surgical Treatments for Urge Incontinence The aim of procedures is to improve bladder compliance or capacity. Surgical treatments are only indicated in refractory cases of urge incontinence. Treatment options for refractory urge incontinence include: ◘ intradetrusor injections of botulinum toxin

Summary and Recommendations • Incontinence is not a normal part of aging. Screen for it in all older patients. • Use basic office assessments including a medication review to assist in diagnosis. • Have the patient keep a bladder diary and complete a severity/quality of life questionnaire. • Recommend behavioural and physical therapies when indicated. • Consider a time-limited trial of medication if appropriate. Monitor for side effects and discontinue if no improvement. • Refer appropriately for specialist evaluation and treatment.

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I NSIGHT Dr Tiong Ho Yee

Consultant, Department of Urology, University Surgical Cluster Dr Tiong Ho Yee is currently a Consultant at the Department of Urology and the Director of Kidney Surgery and Transplantation at the National University Hospital (NUH). He graduated with Honours from the University of Nottingham, UK in 1997 and received his membership of the Royal College of Surgeons of England in 2001 after completing his General Surgical Residency at the University of Leicester Hospital Systems, UK. After completing his Urology residency at NUH in 2006, he was awarded the Singapore Urological Association-European Board of Urology Book Prize in 2005 and 2007. He has been a Fellow of the Academy of Medicine, Singapore since 2007. As a recipient of the Ministry of Healthʼs Human Manpower Development Plan (HMDP) scholarship, Dr Tiong completed a two-year clinical fellowship training in Kidney and Pancreas Transplantation at the Cleveland Clinic, Ohio, USA. He worked under the mentorship of the Glickman Urological and Kidney Institute faculty, ranked No.2 in the United States, to gain expertise in his current areas of interest as the Director of Kidney Surgery and Transplantation at NUH. In 2009, he was certified and became a full member of the American Society of Transplant Surgeons. He currently is licensed to practise in Singapore, United Kingdom and the state of Ohio, United States. With research and dedication, Dr Tiong believes in delivering patient-centric care and holistic management of his cancer and transplant patients.

Small Renal Mass: The Epidemic, Conundrum and Management Renal cell carcinoma (RCC) accounts for only about 3% of all cancer incidences. However, worldwide incidence is increasing by about 2 to 3% per year and in the United States, 39,000 new cases were diagnosed in 2006 alone. The rising incidence of renal cancer in the United States and other countries has been attributed to the increased detection and treatment of small tumours ≤ 4cm in size. This is, in turn, due to the widespread use of cross-sectional imaging such as CT scans. In Singapore, the incidence is 5.4 per 100,000 per year, according to the Singapore Cancer Registry1. The rates locally have also approximately doubled over the last 35 years. To counter this trend, significant medical advances have been made in the management of localised RCC in the form of the small renal mass. These advances are now applicable in our local population as part of our urological armamentarium to treat RCC.

Email: cfsthy@nus.edu.sg

Traditionally, in a patient with a unilateral enhancing solid renal mass on computer tomography imaging, the diagnosis is a presumed RCC and if the contra-lateral kidney is normal, the treatment prescribed would be a radical (complete) nephrectomy (RN). With the advent of laparoscopic radical nephrectomy, patients with unilateral RCC have been increasingly advocated to take up this minimally invasive treatment. Two recent landmark papers have now changed this thinking of removing the entire kidney for small cancers. A paper

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by Paul Russo et al from Memorial Sloan Kettering Cancer Center, United States, followed up on 662 patients who underwent kidney cancer surgery (both radical and partial nephrectomy)2. These patients had normal pre-operative serum creatinine, bilateral healthy kidneys and a single RCC tumour less than 4 cm in size. Three years after surgery, it was found that a significantly greater proportion of patients from the radical nephrectomy group developed chronic kidney disease (CKD) compared to patients who had their cancers treated with partial nephrectomy (removing only part of the

kidney with the cancer) (80% vs. 35%, P<0.001). CKD was defined as an estimated glomerular filtration rate (eGFR) of less than 60 ml/min/1.73m2, according to the National Kidney Foundation K/DOQI guidelines. Although no patient from either group required dialysis, the implication of a greater proportion of CKD patients is derived from the paper by Go et al in NEJM3. This large community-based population study of 1.1 million noted that CKD was significantly correlated with a rise in the risk of death, cardiovascular event and hospitalisation.

At Mayo clinic, researchers have found using their kidney cancer database that this may indeed be the case because in their retrospective series, radical nephrectomy for small renal cell cancers (<4cm in size) was associated with decreased overall survival compared with partial nephrectomy4. Nation-wide databases in the United States also painted the same picture. Although the rates of kidney surgery have increased concurrently with the rising incidence of kidney cancer over the last two decades, all cause mortality rates from patients with kidney cancer have not decreased5. Such ‘treatment disconnect’5 may be due to the potential of surgical treatment by radical nephrectomy to increase post-operative CKD morbidity, which in turn, increases associated competing causes of death. For example, up to a third of patients older than 70 years who are treated for kidney tumours have been found to die of other causes6. There is therefore an increasing need to focus on improving the non-oncological outcomes of patients with renal cancer. For urologists, nephron-sparing surgery, such as partial nephrectomy, is coming to the forefront as the initial treatment for localised RCC. For these small renal masses/localised kidney cancer, partial nephrectomy has been shown to achieve oncologic outcomes equivalent to those produced by RN. My HMDP institution – the Cleveland Clinic – initially developed the technique of open partial nephrectomy and has since reported excellent five and ten year cancer-specific survival of 92% and 77% respectively for RCC masses less than 4cm7. Furthermore, it reduces the risk of CKD and possibly cardiovascular disease compared to RN2. Using the same technique pioneered by Dr Andrew Novick, open partial nephrectomy is now offered to all patients at the National University Hospital (NUH) as a first-line treatment

Kidney tumour with fat covering it Excision margin Normal kidney

Blood vessels to kidney

Figure 1(a)

Kidney defect repaired with biologics after tumour resection Figure 1(b)

option for localised RCCs less than 4 cm. Figure 1(a) shows how the lesion on the kidney was prepared before excision and after controlling its blood flow and Figure 1(b) shows the same kidney after excision and suture repair of the resulting defect using special biologics.

as a minimally invasive treatment option to facilitate post-operative recovery. The surgery is technically challenging with significantly greater post-operative complications even at major centres and long-term oncological outcomes are still pending.

In view of the large incision required for open partial nephrectomy, laparoscopic partial nephrectomy has been developed

At our academic medical centre, the laparoscopic option has been offered for appropriate cases. We aim to replicate

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References 1. Seow A, Koh WP, Chia KS, Shi LM, Lee HP, Shanmugaratnam K. Trends in Cancer Incidence in Singapore 1968 - 2002. Singapore Cancer Registry 2006;Report No. 6. Figure 2(a): Scar from an open partial nephrectomy

2. Huang WC, Levey AS, Serio AM, Snyder M, Vickers AJ, Raj GV et al. Chronic kidney disease after nephrectomy in patients with renal cortical tumours: a retrospective cohort study. Lancet Oncol 2006;7(9):735-740. 3. Go AS, Chertow GM, Fan D, McCulloch CE, Hsu CY. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. NEnglJMed 2004;351(13):1296. 4. Thompson RH, Boorjian SA, Lohse CM, Leibovich BC, Kwon ED, Cheville JC et al. Radical nephrectomy for pT1a renal masses may be associated with decreased overall survival compared with partial nephrectomy. J Urol 2008;179(2):468-471; discussion 472-463. 5. Hollingsworth JM, Miller DC, Daignault S, Hollenbeck BK. Rising incidence of small renal masses: a need to reassess treatment effect. J Natl Cancer Inst 2006;98(18):1331-1334.

Figure 2(b): Scars from a laparoscopic partial nephrectomy

6. Hollingsworth JM, Miller DC, Daignault S, Hollenbeck BK. Five-year survival after surgical treatment for kidney cancer: a population-based competing risk analysis. Cancer 2007;109(9):1763-1768. 7. Fergany AF, Hafez KS, Novick AC. Long-term results of nephron sparing surgery for localized renal cell carcinoma: 10-year followup. JUrol 2000;163(2):442. 8. Miller DC, Hollingsworth JM, Hafez KS, Daignault S, Hollenbeck BK. Partial nephrectomy for small renal masses: an emerging quality of care concern? J Urol 2006;175(3 Pt 1):853-857; discussion 858.

the open surgery with minimally invasive techniques. Figures 2(a) and 2(b) compares the scars of the open and laparoscopic partial nephrectomy. As with other major centres, Da vinci robot assisted laparoscopic partial nephrectomy has also been used to treat small renal masses at NUH with success. The Da vinci robot, with its 16 degrees of freedom in the endowrist technology, decreases the technical difficulty of suture repair of the renal parenchyma following tumour excision and possibly expands the indications of partial nephrectomy to complex and larger tumours. What are the implications of these studies for primary health care? We now know that patients who undergo unilateral radical nephrectomy are not the same as those who undergo

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unilateral donor nephrectomy (for transplantation). Compared to healthy kidney donors, they are older with comorbidities including hypertension and diabetes, with resultant kidneys that are more vulnerable and less able to adapt to hyper-filtration after the contra lateral side is removed. We recently presented data at the American Urological Association 2012, demonstrating that patients with no CKD before surgery are at higher risk of developing radical nephrectomy. These patients will need closer follow-up in the primary care setting for better blood pressure and sugar control with interval screening for kidney disease in the remaining precious kidney. In conclusion, at NUH, our attention for the treatment of renal cancers is now sharply focused on both the long-term

9. Dulabon LM, Lowrance WT, Russo P, Huang WC. Trends in renal tumor surgery delivery within the United States. Cancer 2010;116(10):2316-2321. 10. Segev DL, Muzaale AD, Caffo BS, Mehta SH, Singer AL, Taranto SE et al. Perioperative mortality and long-term survival following live kidney donation. Jama 2010;303(10):959-966. 11. Ibrahim HN, Foley R, Tan L, Rogers T, Bailey RF, Guo H et al. Long-term consequences of kidney donation. N Engl J Med 2009;360(5):459-469. 12. Goldfarb DA, Matin SF, Braun WE, Schreiber MJ, Mastroianni B, Papajcik D et al. Renal outcome 25 years after donor nephrectomy. J Urol 2001;166(6):2043-2047. 13. Scherr DS, Ng C, Munver R, Sosa RE, Vaughan ED, Jr., Del Pizzo J. Practice patterns among urologic surgeons treating localized renal cell carcinoma in the laparoscopic age: technology versus oncology. Urology 2003;62(6):1007-1011.

functional outcomes of RCC treatments in addition to the cancer treatment outcomes, incorporating the convalescent benefits of minimally invasive laparoscopic and robotic surgery.

I NSIGHT Dr Asim Shabbir

Consultant, Division of General Surgery (Upper Gastrointestinal Surgery), University Surgical Cluster Dr Asim Shabbir is a Consultant at the National University Hospital, and an Assistant Professor at the National University of Singapore. He has an interest in upper gastrointestinal surgery. His clinical interests and research are focused on gastric cancer, bariatric and metabolic surgery. He is currently the Post-Graduate Education Director for the Department of Surgery and the Assistant Director of the Minimally Invasive Surgical Centre at NUH. Email: cfsasim@nus.edu.sg

Metabolic syndrome is a name of a group of risk factors that occur together and increase the risk for coronary artery disease, stroke and T2DM. Metabolic syndrome is present if patients display three or more of the following signs: • Blood pressure equal to or higher than 130/85 mmHg • Fasting blood sugar (glucose) equal to or higher than 100 mg/dL • Large waist circumference (length around the waist): ◘ Men - 40 inches or more ◘ Women - 35 inches or more • Low HDL cholesterol: ◘ Men - under 40 mg/dL ◘ Women - under 50 mg/dL • Triglycerides equal to or higher than 150 mg/dL Bariatric surgery was originally envisioned for the unhealthy, obese patients. Walter Pories’ publication, “Who would have thought it? An operation proves to be the most effective therapy for adult onset diabetes mellitus” in 1995 glorified

Sleeve Gastrectomy – An effective tool for obesity and metabolic syndrome The twin epidemic of obesity and type II diabetes (T2DM) continues to soar globally. Nationwide efforts geared towards primary prevention are underway, but it will be some time before a change is seen. However, for those who have been affected by these chronic diseases, a combination of lifestyle changes and medical therapy remains to be the mainstay of treatment. metabolic surgery1. Later, more evidence emerged and confirmed that the benefits of bariatric procedures were not limited to the staggering and sustained weight loss; but patients also had marked improvements in their metabolic syndrome.

outcomes boasts of its effectiveness and safety. The weight loss after sleeve gastrectomy results as a consequence of profound reduction in hunger, increased satiety from partial loss of ghrelin secretion, paradoxical increase in energy expenditure and also promotion of healthy food choices.

The threshold for bariatric and metabolic surgery for Asians has been 32.5kg/m2 with comorbidities; in the West, it has been set at 35kg/m2 with associated reversible comorbid conditions like type II diabetes, hypertension and dyslipidemia. Bariatric surgery in the clinical management of T2DM is now an option in the clinical practice algorithm and is recommended by the International Diabetic Federation2. The federation recommends surgery for obese patients whose targeted metabolic control could not be achieved by intensive glycemic control because of intolerance or inadequate responses to nutritional and pharmacologic treatment. Laparoscopic sleeve gastrectomy (LSG) as a primary procedure for weight loss is relatively new and emerging data on

Laparoscopic sleeve gastrectomy (LSG)

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The percentage excess weight loss (%EWL) after sleeve gastrectomy was reported by Himpens et al to be 77.5% and 57.3% at 3 and 6 years respectively3. A study of the super obese patients reported mean EWL to be 52%, 43%, 46% at 72, 84 and 96 months follow-up sessions respectively4. These two studies suggest that there is a tendency for LSG patients to regain weight like any other patients who undergo other bariatric procedure. Regular follow-up sessions and patients’ compliance to lifestyle changes thus remain keys to sustaining successful weight loss. Patients who undergo sleeve gastrectomy have better quality of life (QOL) and food tolerance in comparison to other bariatric procedures. Over’s SE et al compared the food tolerance and gastrointestinal quality of life at 2 to 4 years after LSG, gastric bypass and gastric banding. LSG is said to offer the best QOL and food tolerance followed by bypass5. After LSG, food tolerance continues to be good in the long run. D’Hondt M study reported that 95.2% of their patients described their food tolerance as acceptable to excellent as far out as 6 years after LSG6. Weight loss can modify major factors involved in the pathogenesis of metabolic syndrome like insulin resistance and beta cell function, and is considered a primary therapy for obese patients who have metabolic syndrome. The exact mechanisms that govern changes in glycemic control after LSG are still not well understood. However, several plausible hypotheses have been articulated, including calorie deprivation, changes in secretion of hormones like Ghrelin, PYY, leptin, GLP-1, unknown endogenous factors released from the gut, decrease in insulin resistance, long-term weight loss and perturbations of gut microbiota that cumulatively result in improved glucose homeostasis after surgery7,8.

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The controversy as to which is the best metabolic procedure remains hotly debated. This issue is far from being settled, as the choice of a procedure is dependent on the patient’s perception of each procedure’s risk, benefits and outcomes, financial considerations, the surgeon’s technical expertise and availability of operative instruments. Additional research is needed to advance our understanding of the physiological effects and possible weight loss, independent mechanisms that improve metabolic outcomes, so as to better advise patients. Nonetheless, as we discuss the effects of LSG on metabolic outcomes, LSG can certainly benefit patients either by achieving remission (i.e. having a normal glucose level without any medication), decreasing the amount of medications

they take on a daily basis, or by postponing the onset of metabolic syndrome in their lifetime. Choosing the best candidates for bariatric surgery to achieve optimal metabolic outcomes has been a challenge. Several predictors have been proposed to predict response to surgery and published data seems to suggest that patients who are young, obese, diagnosed with type II diabetics, had metabolic surgery early and able to maintain weight loss after surgery, have better results. Eid GM et al have reported the longest follow-up of LSG patients as a primary procedure and 77% of their diabetic patients showed improvement or remission of their disease 6 to 8 years

after LSG4. The lipid profiles of patients after weight loss improve. Zhang F et al showed significant improvements in HDL and TG levels, TC/HDL and TG/HDL ratios after one year of follow-ups. However, patients’ TC and LDL levels remain unchanged9. During the weight loss phase, the lipid profile of patients change remarkably and patients are advised to continue their anti-lipid drugs and are monitored for complications like gall stone formation. Hypertension in an obese individual is multi-factorial and some common aberrations leading to hypertension include hyperinsulinemia, hyperlipidemia, enhanced sympathetic activity, altered renin-angiotensin activity, insulin resistance and changes in glucose intolerance. A systematic review of sleeve gastrectomy and hypertension looked at 33 studies with a total of 3,997 patients. After an average follow-up of 16.9 ± 9.8 months (12 to 48) after surgery, their mean pre-operative BMI of 49.1 ± 7.5 kg/m(2) had decreased to 36 ± 7.0 kg/m(2). LSG resulted in resolution of hypertension in 58% of patients. On average, 75% of patients experienced resolution or improvement of their hypertension10. A retrospective study of all the morbidly obese patients who underwent LSG procedure reported a mean excessive body mass index loss of 79.9% after 2 years. After surgery, 83.3% of patients with T2DM discontinued their hypoglycemic medication after 1 month. All patients with hypertension discontinued anti-hypertensive drugs after 6 months. 100% of patients with hypertriglyceridemia discontinued their hypolipidemic drugs after 3 months. Overall, the study supported a significant reduction in glucose and triglyceride levels and the cardiovascular risk predictor triglyceride/HDL ratio and

increased HDL levels after LSG and these changes were maintained in normal ranges for at least 2 years11. In the Cavarrette et al study, 16 obese patients underwent complete clinical evaluation, laboratory tests and color Doppler/tissue, Doppler imaging echocardiography pre-operatively and 12 to 20 months post-operatively. They reported significant decrease in systolic blood pressure, total cholesterol and triglycerides and increase in high-density lipoprotein. Diabetes remission rate was 83% and sleep apnea at 80%. Echocardiography showed significantly remodeling of the heart with reduced interventricular septum and posterior wall thickness and reduced left ventricular mass. They concluded that LSG is associated with marked improvement in terms of weight loss, lipid profile, type 2 diabetes, sleep apnea, hypertension and left ventricular hypertrophy12. The role of sleeve gastrectomy in patients of low BMI is controversial. It would suffice to say that the published results seem promising for the non-morbidly obese patients but the lower limit of BMI that would outweigh surgical risks is yet to be ascertained. An Asian study from Taiwan reported remission of poorly controlled T2DM in non-morbidly obese patients of up to 50%, 1 year after LSG13. The ease to perform LSG, low morbidity & mortality, access to a normal gastrointestinal tract for future endoscopies, absence of anastomoses, low or no nutritional deficiencies, good weight loss with satisfactory control of associated diseases and the flexibility to convert to other procedures at a later stage if results were not ideal, places LSG at an advantage as compared to all other bariatric procedures.

References 1. Pories WJ, Swanson MS, MacDonald KG, et al. Who would have thought it? An operation proves to be the most effective therapy for adult onset diabetes mellitus. Ann Surg. 1995;222:339–50. 2. IDF. Bariatric surgical and procedural interventions in the treatment of obese patients with type 2 diabetes. A position statement from the International Diabetes Federation Taskforce on Epidemiology and Prevention; 2011. 3. Himpen J , Dobbeleir J, Peeters G. Long-term results of laparoscopic sleeve gastrectomy for obesity. Ann Surg. 2010 Aug;252(2):319-24. 4. Eid GM, Brethauer S, Mattar SG, Titchner RL, Gourash W, Schauer PR. Laparoscopic sleeve gastrectomy for super obese patients: forty-eight percent excess weight loss after 6 to 8 years with 93% follow-up. Ann Surg. 2012 Aug;256(2):262-5. 5. Overs SE, Freeman RA, Zarshenas N, Walton KL, Jorgensen JO. Food tolerance and gastrointestinal quality of life following three bariatric procedures: adjustable gastric banding, Roux-en-Y gastric bypass, and sleeve gastrectomy. Obes Surg. 2012 Apr;22(4):536-43. 6. D'Hondt M, Vanneste S, Pottel H, Devriendt D, Van Rooy F, Vansteenkiste F. Laparoscopic sleeve gastrectomy as a single-stage procedure for the treatment of morbid obesity and the resulting quality of life, resolution of comorbidities, food tolerance, and 6-year weight loss. Surg Endosc. 2011 Aug;25(8):2498-504. 7. Thaler JP, Cummings DE. Minireview: hormonal and metabolic mechanism of diabetes remission after gastrointestinal surgery. Endocrinol. 2009;150:2518–25. 8. Rubino F, Forgione A, Cummings DE, et al. The mechanism of diabetes control after gastrointestinal bypass surgery reveals a role of the proximal small intestine in the pathophysiology of type 2 diabetes. Ann Surg. 2006;244:741–9. 9. Zhang F, Strain GW, Lei W, Dakin GF, Gagner M, Pomp A. Changes in lipid profiles in morbidly obese patients after laparoscopic sleeve gastrectomy (LSG). Obes Surg. 2011 Mar;21(3):305-9 10. Sarkhosh K, Birch DW, Shi X, Gill RS, Karmali S. The impact of sleeve gastrectomy on hypertension: a systematic review. Obes Surg. 2012 May;22(5):832-7. 11. Ruiz-Tovar J, Oller I, Tomas A, Llavero C, Arroyo A, Calero A, Martinez-Blasco A, Calpena R. Midterm impact of sleeve gastrectomy, calibrated with a 50-Fr bougie, on weight loss, glucose homeostasis, lipid profiles, and comorbidities in morbidly obese patients. Am Surg. 2012 Sep;78(9):969-74. 12. Cavarretta E, Casella G, Calì B, Dammaro C, Biondi-Zoccai G, Iossa A, Leonetti F, Frati G, Basso N. Cardiac Remodeling in Obese Patients After Laparoscopic Sleeve Gastrectomy. World J Surg. 2012 Dec 20. 13. Lee WJ, Ser KH, Chong K, Lee YC, Chen SC, Tsou JJ, Chen JC, Chen CM. Laparoscopic sleeve gastrectomy for diabetes treatment in nonmorbidly obese patients: efficacy and change of insulin secretion. Surgery. 2010 May;147(5):664-9.

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D OC T O R ʼ S H EAR TBEAT A/Prof Lim Thiam Chye is presently a Senior Consultant and Head of the Division of Plastic, Reconstructive and Aesthetic Surgery at the National University Hospital (Singapore), and an Associate Professor at the National University of Singapore. A/Prof Lim completed his advanced surgical training (JCAST) in 1994 and had his cranio-facial fellowship in Australia and Switzerland in 1992 – 1993. Since then, he has accumulated more than 20 years of surgical experience in the Division of Plastic, Reconstructive and Aesthetic Surgery in NUH. His clinical and research interest includes regenerative medicine for bone, skin and fat. He is also involved in the development and training of a navigational system for Craniomaxillofacial Surgery. Assoc Prof Lim has a wide range of publications, to date he has more than 66 publications in various medical Journals. He also holds membership of several professional societies in Plastic Surgery and is actively involved with the AO foundation as a past Chairman AO CMF Asia-Pacific board and is presently a member of the AO CMF Clinical programme research committee as well as the AO Academic Council.

MD (Mal), FRCS, AM (Mal), FAMS (Plastic Surgery)

Specialist in Focus

A/Prof Lim Thiam Chye

What was the driving force that made you decide to become a plastic surgeon? Did you have an alternate career choice? I wanted to take up dermatology but while serving as a house officer, a plastic surgeon did a surgical procedure on a young man’s knee. On outpatient follow up, I could not see any scarring at all. It was an enlightening moment that made me consider this career.

You have a particular interest in facial reconstruction. What, or, who inspired you to specialise and build up your expertise in this ﬁeld? I did fellowships in Adelaide, Australia & Basel, Switzerland. The work they did in the reconstruction of congenital, cancer & traumatic deformities was quite amazing at that time. Prof. Joachim Prein, the Head of the Department of Plastic, Maxillofacial & Hand Surgery in Basel, was especially inspiring to me. He had a no-nonsense approach to patient management and would always be at the forefront of the latest treatment methods that would benefit patients. He was also thorough and a perfectionist – he refused to give

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anything less than the best possible for his patients. I was impacted deeply by his work ethic and how he treated patients under his care.

Share with us about your current practice. What responsibilities do you have? I am the Head of the Division of Plastic, Reconstructive & Aesthetic Surgery at the National University Hospital. Presently, my clinical practice concentrates on patients with problems related to the craniomaxillofacial region – be it congenital such as cleft lip / palate & craniofacial anomalies; traumatic deformities or defects after oncology resection. Another area of responsibility that I have is in teaching. I need to make sure that besides imparting skills and technical know-how, I also ground medical students in good, solid values of becoming a doctor; the dictum of achieving excellent clinical outcomes for patients through every decision and action. My department also focuses on undertaking research related to new technologies, which ultimately bring about better patient care and outcomes. We believe firmly in offering

appropriate, evidence-based treatments to every patient we treat.

What are the more recent developments in the ﬁeld of Craniomaxillofacial reconstruction? There are many new developments in this field. The advent of image-guided surgery and intra-operative navigation, virtual planning of complex surgical procedure with actualisation software, and printing of 3D medical models in the pre-operative phase to create patient-specific implants, all herald much better management modalities for patients. This platform of technologies has been assembled in NUH to deliver better care for our patients.

Tell us more about the facial reconstruction software currently used in your Division. How does this beneﬁt patients with facial injuries? We have a number of different management capabilities for the reconstruction of the craniomaxillofacial skeleton.

What are some most important lessons you've learned in your extensive career? I was a Medical Officer (MO) in NUH’s Accident & Emergency Department many years ago. And I remembered a case where a little girl was brought in to us. She was walking to school when she was knocked down by a car. Her injuries were severe, and we did not manage to save her despite our best efforts. Breaking the news to her devastated father was one of the hardest things I ever had to do… The fragility of life was etched deeply in my mind at that moment. It was a very humbling experience, and from then onwards, I do the best I possibly can for each person I treat.

Virtual planning of complex surgical procedure with actualisation software and printing of 3D models.

“Being in NUH my entire medical career, I’ve also learnt the importance of team-work. I am indeed very fortunate to be working with a multi-disciplinary team, which includes the Ophthalmologist, Ear Nose & Throat surgeons, Neurosurgeons and Physiotherapists. This is a team in which I have total confidence and trust that will do the best for each patient.”

We use a software called iPlan (Brainlab®, Munich, Germany) to assist us in the pre-operative planning. This software has many capabilities, one of which allows us to reflect the normal part of the facial skeleton onto the injured part to give a “map” of the optimal position for the recontruction of the displaced injured skeleton. This not only allows us to restore the facial symmetry, but also to do post-operative checks to ensure that the procedure was done correctly and appropriately. We also make use of another type of virtual software, which tells us how and where to place customised facial implants on a patient’s face. Most of the software that we use helps us to plan – a step as important as the actual surgery itself. Planning enables us to anticipate potential situations and issues, and this information is crucial in deciding the best method of treatment for each individual patient before surgery. In addition, we are currently working with Prof Ian Gibson (Associate Professor from the Faculty of Engineering, NUS) and his team on Materialise® software. An example is a visor incorporated with the software. It will allow us to view actual versus virtual images during surgery, in real-time.

Being in NUH my entire medical career, I’ve also learnt the importance of team-work. I am indeed very fortunate to be working with a multi-disciplinary team, which includes the Ophthalmologist, Ear Nose & Throat surgeons, Neurosurgeons and Physiotherapists. This is a team in which I have total confidence and trust that will do the best for each patient. Money can buy a lot of useful technologies and data; but the experience and commitment of the team is something that is accumulated over the many years of working together.

What do you enjoy doing when you’re not practicing medicine? I go diving. It makes one stop and consider the beautiful but fragile world we live in. Those moments alone in the sea make me thankful for the gift of having life on this earth, and secondly, the ability to help patients with the skills that I have.

Aside from your profession, are there any other things in life that you are passionate about? My team and I go to Myanmar every year to conduct a course for their local doctors, to impart our skills and share knowledge. We also participate in charitable medical missions in the regional countries too, like Vietnam, Cambodia. I was privileged to have had great mentors and seniors. Their work and investments of time and energy inspired and mould me to be who I am. I firmly believe in doing the same for younger doctors. This way, I hope to do all I can to leave this world in better shape for the next generation.

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UPCOMING

EVENTS

NUH GP CME Programme 2013 Please refer to our GPLC website for online registration.

April SATURDAY

The GP Guide to Infant Neuro-Development: What's New? What's Hot?

SATURDAY

Managing Opthalmic Cases in GP Clinics

GP Guide on Obstetrics: Managing Pregnant Women in your Clinic

SATURDAY Gynaecological Cancer Update for GPs 2013

May SATURDAY Update on Infectious Diseases Tuberculosis & HIV

SATURDAY Approach to Knee Problems

SATURDAY

June SATURDAY

Update on Common Emergencies

SATURDAY “Doctor, I have a breast lump” Common Breast Issues & the Patient’s Journey at NUH

SATURDAY Food, Diet, Lifestyle Controlling the Deadly Quartet

Event information listed is correct at time of print. While every attempt will be made to ensure that all events will take place as scheduled, the organisers reserve the rights to make appropriate changes should the need arises. Please refer to our events calendar at www.nuh.com.sg/nuh_gplc for more updates and information.

A Publication of NUH GP Liaison Centre (GPLC) Advisors A/Prof Goh Lee Gan Editor Esther Lim Editorial Member Lisa Ang We will love to hear your feedback on Médico. Please direct all feedback to: The Editor, Médico GP Liaison Centre, National University Hospital 1E Kent Ridge Road, NUHS Tower Block, Level 6, Singapore 119228 Tel: 6772 5079 Fax: 6777 8065 Email: gp@nuhs.edu.sg Website: www.nuh.com.sg/nuh_gplc Co. Reg. No. 198500843R The information in this publication is meant purely for educational purposes and may not be used as a substitute for medical diagnosis or treatment. You should seek the advice of your doctor or a qualified healthcare provider before starting any treatment, or, if you have any questions related to your health, physical fitness or medical condition(s). Copyright (2013). National University Hospital All rights reserved. No part of this publication may be reproduced without permission in writing from National University Hospital.

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