Presentation of Posterior Urethral Valves in Saudi Arabia in the 90's.

To evaluate the age and mode of presentation of patients with posterior urethral valves (PVU) in the antenatal and postnatal periods, we analyzed the files of 108 patients with the diagnosis of PUV in four referral hospitals in Riyadh, Saudi Arabia from 1989 to 1999. Of the study patients, 29 (27%) were antenatally discovered, 41 (38%) in the first year of life and 38 (35%) after the first year of life. The mode of presentation was by antenatal ultrasound in 29 (27%) patients, urinary tract infection in 33 (30.4%) patients, poor urinary stream in 35 (32.4%) patients, retention of urine in neonatal life in eight (7.4%) patients and symptoms of renal impairment in three (2.8%) patients. We conclude that the antenatal detection rate of PUV in our study patients is less than the international one (70%), despite the fact that most of the antenatal follow-ups were done in centers where ultrasound was available for routine antenatal work up. This calls for more vigilance by the radiologists and obstetricians to enhance the rate of detection of PUV.

Granulosa cell tumor of the adult type: a case report and review of the literature of a very rare testicular tumor.

We report a case of testicular granulosa cell tumor of the adult type in a 48-year-old man. Microscopically, the tumor consisted of round to ovoid cells with grooved nuclei that were arranged in several patterns, including microfollicular, macrofollicular, insular, trabecular, gyriform, solid, and pseudosarcomatous. These cells demonstrated strong immunopositivity with MIC2 (O13) antibody, vimentin, and smooth muscle actin and focal positivity with cytokeratin. Although this type of sex cord-stromal tumor is relatively common in the ovaries, it is still extremely unusual in the testis, and it probably represents the rarest type of testicular sex cord-stromal tumor.

Prospective randomized study of transurethral vaporization resection of the prostate using the thick loop and standard transurethral prostatectomy.

OBJECTIVES: Transurethral vaporization resection of the prostate (TUVRP) is a recent modification of the standard transurethral prostatectomy (TURP). The procedure uses one of the novel, thick resection loops coupled to augmented electrocutting energy. We evaluated the safety and efficacy of TUVRP in comparison with TURP. METHODS: Sixty-eight patients with prostatic outflow obstruction were prospectively randomized between equal TUVRP and TURP treatment groups. Safety parameters evaluated included changes in serum hemoglobin, hematocrit, and sodium 1 and 24 hours after resection. Operative time, catheterization time, and incidence of complications were noted. Efficacy parameters included evaluation by the International Prostate Symptom Score and maximum flow rate. RESULTS: Patients of both groups were balanced for the different baseline variables. One hour after TURP, patients had significantly lower levels of hemoglobin, hematocrit, and sodium (P = 0.03, 0.03, and 0. 01, respectively). The prostate resection weight was similar in both groups; however, the difference in the mean operative time was significant (TUVRP group 42.4 minutes and TURP group 35.9 minutes, P = 0.02). The postoperative catheterization time was significantly shorter for the TUVRP group (23.1 +/- 10.3 versus 36 +/- 17.3 hours, P <0.0001). All patients were followed up for an average of 9 months. The International Prostate Symptom Score was 4 +/- 3.4 and 5.6 +/- 3.1 and the maximum flow rate was 19 +/- 6.5 and 15.2 +/- 10 mL/s for the TUVRP and TURP groups, respectively; these differences were statistically significant (P = 0.03 and 0.01, respectively). Complications included urethral strictures (6 patients) and delayed hemorrhage with clot retention (2 patients); no differences in the incidence of complications were noted between the two groups. CONCLUSIONS: The results of the present study have demonstrated that TUVRP is as safe and efficacious as TURP in the treatment of men with prostatic outflow obstruction. The shorter catheterization time observed after TUVRP may be clinically significant, considering the demand for lower morbidity profiles by patients. The longer operative time in TUVRP was related to the slower motion of the Wing electrode needed to add the advantages of electrovaporization.

Extracorporeal shockwave lithotripsy for ureterolithiasis in patients with urinary bilharziasis: efficacy and variables that influence treatment outcome.

OBJECTIVES: Schistosomiasis affecting the ureter is commonly accompanied by ureteric dilatation with or without ureteric stricture and altered ureteric wall motility that can influence extracorporeal shockwave lithotripsy (ESWL) results. This study attempts to identify variables that may influence the outcome of ESWL in the treatment of ureterolithiasis in patients with urinary bilharziasis. PATIENTS AND METHODS: Forty-three patients with urinary schistosomiasis and ureterolithiasis treated with ESWL were reviewed. The study data include characteristics of patients, stones, urinary tract treated and details of ESWL treatment. RESULTS: Thirty-five patients (81.3%) were stone-free at 3 months. Multivariate analysis with logistic regression identified two significant variables that influenced treatment outcome, namely the presence of ureteric stricture (p = 0.004) and the ESWL voltage (p = 0.003). Ten ureteric strictures were encountered in 9 patients (21%), the majority of these were diagnosed post-ESWL when patients failed to pass well-fragmented stones in spite of pre-ESWL evaluation. CONCLUSIONS: In situ ESWL is a safe and effective first line of treatment for urinary stones in bilharzial ureters. The presence of concomitant bilharzial stricture is a significant variable which affects the treatment outcome. Every effort should be made to rule out and deal with possible complicating factors such as ureteric strictures in the pretreatment period.

Extracorporeal shock wave lithotripsy for lower pole nephrolithiasis: efficacy and variables that influence treatment outcome.

OBJECTIVES: Extracorporeal shock wave lithotripsy (ESWL) for the treatment of lower caliceal stones (LCS) tends to have a poor success rate, prompting many urologists to advocate alternative treatment modalities. This study attempts to identify variables that may influence the outcome of ESWL treatment for LCS to help in selecting patients that are likely to benefit from the treatment. METHODS: One hundred forty-two patients with isolated LCS treated with the Dornier HM3 lithotriptor were reviewed. The study data include characteristics of patients, stones, urinary tract treated, previous treatment of stones in the same kidney, and details of the ESWL treatment. RESULTS: Eighty patients (56%) were stone free 3 months after ESWL. Multivariate analysis with logistic regression identified six independent and significant variables that influenced treatment outcome: these included number of stones (P = 0.001), previous percutaneous nephrostolithotomy (PNL) treatment (P = 0.001), side of the stone (P = 0.002), presenting stone type (P = 0.004), number of ESWL sessions (P = 0.01), and maximum kilovoltage setting of ESWL at treatment (P = 0.02). Stone size did not influence the treatment outcome in this study. CONCLUSIONS: ESWL provides an acceptable first line treatment for patients with LCS. Patients who fail ESWL and have poor prognostic features (ie, multiple LCS, hard stones requiring high voltage and multiple ESWL sessions, lower caliceal stone formation secondary to ESWL treatment of stones in other locations of the renal unit, or previous treatment with PNL) should be counseled for alternative treatment modalities.

Extracorporeal shock wave lithotripsy for the rescue of post-endoscopic or surgically retained biliary duct stones: does saline irrigation affect the outcome?

Extracorporeal shock wave lithotripsy (ESWL) has been found valuable in situations where obstructing stones in the common bile or intrahepatic ducts are retained following surgery or attempted endoscopic removal. However, success rates are dependent on the type of ESWL system employed and upon a high frequency rate of repeated treatment sessions. We outline our experience with 23 cases of retained, obstructing bile duct stones, ranging in size from 10 to 40 mm diameter, treated with Dornier HM3 ESWL. In the initial 12 patients in the series, successful stone fragmentation occurred in 83% of cases with a median 1.6 treatment sessions. In the latter 11 cases in the series, patients were treated prone and the stone-bearing biliary duct was irrigated with saline solution during ESWL delivery. With this technique, successful stone break up was achieved in all patients (100%) with a single treatment session. Endoscopic sphincterotomy is, however, a prerequisite for extracorporeal lithotripsy and, despite the high success rates now available with new techniques, we believe the ESWL should continue to be employed in support of primary endoscopic methods of management for obstructing bile duct stones.

Survival and prognostic factors in renal cell carcinoma in Saudi patients: A ten year review.

Full text is available as a scanned copy of the original print version.

Rare association of unilateral renal oncocytoma and angiomyolipoma.

A 65-year-old woman presented to the hospital with left loin pain and haematuria, radiological diagnostic studies demonstrated left renal mass suggestive of renal cell carcinoma and radical nephrectomy was performed. Pathological examination demonstrated the very rare association of renal angiomyolipoma and oncocytoma.

Renal tumors in adult Saudi patients: A review of 43 cases.

Seventy-nine patients with renal tumors were seen at King Khalid University Hospital (KKUH) over a 10-year period from 1985 through November 1995. In a retrospective study, we analyzed the records of 43 Saudi patients from all over the Kingdom; they represented 54% of all patients encountered. Fourteen percent of the patients had benign renal tumors in the form of angiomyolipoma and oncocytoma. Eighty-six percent of the patients had malignant renal tumors.

The aetiological and clinical pattern of childhood urolithiasis in Saudi Arabia.

The clinical and aetiological pattern in 85 stone-forming children presenting to an integrated nephrourological service in Riyadh is reviewed. All patients were below the age of 15 years, the male to female ratio being 2:1. Only 2 children presented with bladder calculi. The remaining all had upper tract stones and, in 12 cases, these were bilateral. Of 34 calculi recovered for analysis, one-third was predominantly calcium oxalate and a further third was composed of uric acid or urate. Four patients had cysteine stones and the remaining 7 presented mixed calcium stones, 6 (17.6%) being struvite and infection-related. Of the 85 patients 55 were treated successfully with extracorporeal shock wave lithotripsy, 16 underwent surgery and 7 had their stones removed by endourological procedures. In the remaining 7 children, stones dissolved or were passed spontaneously during medical therapy. Nine children (10.6%) showed a primary metabolic defect leading to their stone formation, 10 (11.8%) had a predisposing anatomical anomaly and 15 (17.6%) presented with urinary tract infection. Of the remaining 51 patients (60%) with idiopathic disease, 6 showed hypercalciuria on investigation and 2 children may have formed their stones due to prolonged recumbency.

Primary extracorporeal shockwave lithotripsy in management of large bladder calculi.

Large bladder calculi are often outside the range of treatment with conventional endoscopic lithotrites because of either anatomic factors or the mechanical limits of available instruments. Alternative methods of cystolithotripsy: ultrasonic, electrohydraulic, or laser, can prove time-consuming or even hazardous, so that open surgery is often the most expeditious option. We report our experience using Dornier HM3 extracorporeal shockwave lithotripsy (SWL) for initial bladder stone reduction preparatory to transurethral litholapaxy and definitive treatment of any underlying obstructive pathology. Primary cystolitholapaxy was judged impractical in these 24 patients (21 adults and 3 children) presenting 31 large bladder stones (mean size 35.6 mm). In all patients, primary transpelvic SWL was followed immediately by endoscopic evacuation of stone debris or cystolitholapaxy. In addition, 10 of the 24 patients (42%) underwent a definitive endoscopic operation for treatment of an underlying obstructive lesion at either the same or a follow-on session. Morbidity was minimal, and the mean hospital stay after the initial SWL treatment was 3.5 days. In our experience, Dornier SWL has proved invaluable in enabling cystolitholapaxy of very large bladder calculi that would otherwise require protracted and difficult endoscopic manipulation or open surgery.

Incidence of bacteremia and bacteriuria in patients with non-infection-related urinary stones undergoing extracorporeal shock wave lithotripsy.

In a prospective pilot study, 26 patients with non-infection-related renal or ureteric stones and sterile urine were examined for evidence of bacteriuria and bacteremia following extracorporeal shock wave lithotripsy (SWL). Blood samples were obtained for aerobic and anaerobic bacterial culture at the end of, and 1 hour after, the SWL procedure. Urine cultures were performed 24 hours before and after treatment. Bacteremia was recorded in 7.7% of the patients immediately after SWL but in no patient at 1 hour after treatment. None of the patients manifested significant bacteriuria or post-SWL fever. These findings support the contention that, provided the urine is sterile and a negative history of urosepsis is available, antibiotic prophylaxis is unnecessary in patients with non-infected renal stones submitted to SWL treatment.

Polyurethane internal ureteral stents in treatment of stone patients: morbidity related to indwelling times.

The morbidity and complications associated with use of internal polyurethane ureteral stents in a series of 290 stone patients treated endourologically or with extracorporeal shock wave lithotripsy were retrospectively reviewed. Of the 299 stents retrieved 141 were also tested for patency to relate the rate of luminal blockage with stent caliber, indwelling time and clinical evidence of obstruction in the stented tract. Stent indwelling times ranged from a few days to 18 months: 11.3% were indwelling longer than 6 months and 1.9% were lost to followup. Incrustation occurred in 9.2% of the stents retrieved before 6 weeks, 47.5% indwelling 6 to 12 weeks and 76.3% thereafter. In 19 cases over-all (6.4%) an auxiliary procedure was required to decrease incrusted stone burden and enable stent retrieval. Other complications included stent migration (3.7%), infection (6.7%) and breakage (0.3%). Despite a 30% rate of luminal blockage in stents retrieved after indwelling times up to 3 months, the incidence of clinical obstruction in stented tracts up to 3 months was 4%, confirming other reports that significant urine flow occurs around rather than through hollow, vented stents. Our findings underline the importance of restricting the use of stents to stone patients who will be reliable at followup. Morbidity was minimal if stent indwelling times did not exceed 6 weeks.

Influence of Dornier HM3 system on respiration during extracorporeal shock-wave lithotripsy.

Patients undergoing extracorporeal shock-wave lithotripsy (ESWL) for renal stones in the Dornier HM3 apparatus are immersed to the clavicles in water and anchored by abdominal and leg restraining straps. The respiratory effects of this system and sedation with midazolam were studied in 70 awake patients anesthetized with epidural blockade. On immersion, surface abdominal pressure and respiratory frequency (f) increased. Tidal volume (VT) and arterial saturation (SaO2) decreased. After intravenous midazolam 0.045 mg/kg body weight, VT decreased further to 35% below pre-immersion values and stone excursions measured by fluoroscopy diminished by more than 50%; reduction of VT and stone excursions were linearly correlated (R = 0.45). SaO2 declined sharply to 6.1% (range -1.5-13.8%) below pre-immersion values, whereas end-tidal CO2 (PETCO2) increased more slowly and f remained above the pre-immersion rate. In three patients, SaO2 decreased to below 85% but was rapidly restored to 98-100% by oxygen administration. The respiratory effects of sedative drugs are exaggerated by the Dornier HM3 system, and continuous monitoring of gas exchange and appropriate oxygen administration are recommended in patients receiving regional anesthesia and sedation.

Primary choice of intervention for distal ureteric stone: ureteroscopy or ESWL?

Either transurethral ureteroscopy (URS) or extracorporeal shock wave lithotripsy (ESWL) was the primary method of intervention in two series of patients presenting consecutively with stones located in the ureter distal to the radiological marking of the sacroiliac joint. Of 65 patients treated by URS, successful evacuation of the major part of the stone was achieved in 97% in one or two sessions. Of those subsequently attending for review, 93% proved stone-free but 3% required surgery for serious complications. In the ESWL series of 53 patients, successful stone fragmentation was recorded in 94%, with 2 patients requiring a supplementary endourological or surgical procedure. No significant complications were related to ESWL and 90% of those followed up after successful ESWL proved stone-free at 6 weeks. In uncomplicated cases, the mean procedure time for ESWL was one-third of that required for URS and the hospital stay one-half. It is suggested that ESWL should be the primary method of intervention in patients with distal ureteric stone, with URS reserved for the small number that prove refractory to such treatment.