Analysis of 114 Pedigrees of Renal Stone Patients: A Retrospective Review.

BACKGROUND:  Renal and ureteric stones (RS) can form due to genetic, metabolic, environmental, and diet-hydration related factors. Studies have shown that patients with family history (FH) of RS have higher likelihood of recurrence. MATERIALS AND METHODS:  We conducted a retrospective cross-sectional study on 114 pedigrees to investigate the impact of FH on recurrence of RS and examine patterns of inheritance.  Results: Family history of renal stone disease was found in 42% of all patients. There was a significant increase of stone recurrence in RS patients with a positive FH (p=0.001). Seventy-one percent of patients with recurrent stones had at least one family member with RS. Interestingly, male penetrance was higher in RS recurrence, where a greater proportion of males had no FH of RS, indicating that there may be other factors involved as well.  Conclusion: Family history in RS patients should be continuously explored for the possible underlying genetic influence, whilst keeping in mind the dietary habits of the family.

Foreign Body in Kidney Presenting as Renal Stone.

Retained foreign bodies in the urinary system are commonly found in the urinary bladder but are a rare finding in the renal pelvis. Foreign objects can reach the renal pelvis via different pathways. The presence of a foreign body could be iatrogenic, or via direct penetration from the gastrointestinal tract. Presentation could mimic tumor, abscess, hematoma, or even renal stone. We report an unusual case of intrarenal foreign body presenting as renal stone. The patient presented with flank pain and symptoms suggestive of renal stone and a non-contrast CT scan was also indicative of stone, however on endoscopy a foreign body was identified and retrieved.

Assessing clinical reasoning skills using Script Concordance Test (SCT) and extended matching questions (EMQs): A pilot for urology trainees.

INTRODUCTION: Clinical reasoning skill is the core of medical competence. Commonly used assessment methods for medical competence have limited ability to evaluate critical thinking and reasoning skills. Script Concordance Test (SCT) and Extended Matching Questions (EMQs) are the evolving tests which are considered to be valid and reliable tools for assessing clinical reasoning and judgment. We performed this pilot study to determine whether SCT and EMQs can differentiate clinical reasoning ability among urology residents, interns and medical students. METHODS: This was a cross-sectional study in which an examination with 48 SCT-based items on eleven clinical scenarios and four themed EMQs with 21 items were administered to a total of 27 learners at three differing levels of experience i.e. 9 urology residents, 6 interns and 12 fifth year medical students. A non-probability convenience sampling was done. The SCTs and EMQs were developed from clinical situations representative of urological practice by 5 content experts (urologists) and assessed by a medical education expert. Learners' responses were scored using the standard and the graduated key. A one way analysis of variance (ANOVA) was conducted to compare the mean scores across the level of experience. A p-value of < 0.05 was considered statistically significant. Test reliability was estimated by Cronbach α. A focused group discussion with candidates was done to assess their perception of test. RESULTS: Both SCT and EMQs successfully differentiated residents from interns and students. Statistically significant difference in mean score was found for both SCT and EMQs among the 3 groups using both the standard and the graduated key. The mean scores were higher for all groups as measured by the graduated key compared to the standard key. The internal consistency (Cronbach's α) was 0.53 and 0.6 for EMQs and SCT, respectively. Majority of the participants were satisfied with regard to time, environment, instructions provided and the content covered and nearly all felt that the test helped them in thinking process particularly clinical reasoning. CONCLUSIONS: Our data suggest that both SCT and EMQs are capable of discriminating between learners according to their clinical experience in urology. As there is a wide acceptability by all candidates, these tests could be used to assess and enhance clinical reasoning skills. More research is needed to prove validity of these tests.

Is laparoscopic pyeloplasty a comparable option to treat Ureteropelvic junction obstruction (UPJO)? A comparative study.

OBJECTIVE: To compare laparoscopic with open pyeloplasty. METHODS: The retrospective study was conducted at Aga Khan University Hospital, Karachi, and comprised records of patients who underwent surgical correction of ureteropelvic junction obstruction between during January 2008 and December 2012. Patients with laparoscopic pyeloplasty were placed in group 1 and those with open pyeloplasty in group 2.The groups were compared for operative time, hospital stay, perioperative complications, blood loss, duration of surgery, outcome and follow-up. Data was analysed using SPSS 19. RESULTS: Of the 73 patients, 29(40%) were in group 1, and 44(60%) in group 2. A crossing vessel could be identified in 25(86.2%) in group 1 and in 33(75 %) in group 2. Laparoscopic procedures were associated with a longer mean operating time (p=0.04), median estimated blood loss (p<0.001) and a shorter mean hospital stay (p<0.001). Follow-up mercaptoacetyltriglycinescan was done in 21(74.5%) patients in group 1 and 23(52.2%) in group 2. Only 2(7%) patients in group 1 and 2(4.5%) in group 2 had poor response on mercaptoacetyltriglycine scan. Mean follow-up was 2.71±1.2 months. Postoperative complications were 5(13%) in group 1 and 9(20%) in group 2(p=0.141). CONCLUSIONS: Laparoscopic pyeloplasty was associated with shorter hospital stay, less pain and less blood loss. The efficacy in term of success rate and perioperative complications of laparoscopic pyeloplasty was comparable to that of open pyeloplasty.

Late presentation of posterior urethral valves.

Presence of posterior urethral valves (PUV) is the most common cause of urinary tract obstruction in the male neonate. Late presentation occurs in 10% of cases. We present a case of PUVs in an adult male who presented with history of obstructive lower urinary tract symptoms and hematuria. On evaluation, he was found to have raised serum creatinine level. A voiding cystourethrogram (VCUG) could not be completely performed because of narrowing in the posterior urethra. A rigid urethrocystoscopy was performed at which he was found to have type-I posterior urethral valve which were fulgurated. A repeat uroflowmetry revealed maximum flow rate of 12 ml/second. This case highlights that PUVs is not solely a disease of infancy but may also present late. VCUG is the radiological investigation of choice but the diagnosis may be missed. A urethrocystoscopy is advised if there is a high index of suspicion.

Renal failure: unusual clinical presentation of an isolated intrarenal hydatid cyst.

Cystic echinococcosis or hydatid disease is a zoonotic parasitic infection caused by larval stage of cestode Echinococcus spp. Humans are an accidental intermediate host and present with the involvement of different organs, the liver being the most common while kidney is the rarest site. Here, authors are reporting a case of a 55-year-old woman who presented with renal failure and was found to have a right-sided intrarenal hydatid cyst, diagnosed and treated with nephroscopy without sacrificing the kidney. She had an uneventful postoperative course and her renal function improved dramatically. She is now on oral albendazole therapy and doing well on follow-up. To the best of our knowledge, renal failure has never been reported in the literature as clinical manifestation of intrarenal hydatid cyst in adult population.

Triggers of blood transfusion in percutaneous nephrolithotomy.

OBJECTIVE: To determine the triggers of blood transfusion in patients undergoing percutaneous nephrolithotomy (PCNL). STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: The Aga Khan University Hospital, Karachi, from 1988 to 2007. METHODOLOGY: The percutaneous surgery database was retrospectively reviewed to identify patients with postoperative haemorrhage and need for blood transfusion. Blood loss was estimated by the postoperative drop in haemoglobin factored by the quantity of any blood transfusion. Various patients and procedure-related factors were assessed for association with total blood loss or blood transfusion requirement using stepwise univariate, forward multivariate regression analysis. RESULTS: A total of 326 procedures were performed in 316 patients. Two hundred and thirty two procedures were included in the study. There were 167 males and 65 females. The mean age was 41+14 years. The mean haemoglobin drop was 1.68 +1.3 gm/dL. The overall blood transfusion rate was 14.2%. Stepwise multivariate regression analysis showed that female gender (p = 0.003), staghorn stone (p = 0.023), stone fragmentation with ultrasound (p = 0.054) and chronic renal failure (p = 0.001) were significantly predictive of the need for blood transfusion. CONCLUSION: Chronic renal failure, female gender, presence of staghorn calculi and stone fragmentation using ultrasonic device were predictive of blood transfusion in this cohort of patients.

Mediastinal parathyroid adenoma causing primary hyperparathyroidism.

An ectopically placed parathyroid adenoma in the anterior mediastinum is a rare cause of persistent or recurrent primary hyperparathyroidism (PHPT) and is recognized as an important cause of failed primary neck exploration. We encountered 3 such cases amongst 70 surgically treated patients with PHPT (4.3%) over a 20-year period. In 2 cases, the offending adenoma could be removed at first exploration whereas in the 3rd case, it was successfully removed with mediastinal exploration after 2 failed neck explorations. In established cases of PHPT with equivocal preoperative localization studies or negative neck explorations, an ectopically placed parathyroid adenoma should be considered and once localized, should be surgically removed for cure.