Mannitol-induced diuretic renal ultrasonography: a new technique.

We herein describe a new technique to improve the ultrasonic imaging of nonobstructed stone-bearing kidneys. Mannitol-induced diuresis opens up the collapsed renal collecting system and yields better ultrasonographic imaging by increasing the amount of fluid surrounding the calculi. The potential usages of this technique include ultrasound localization for percutaneous stone extraction and during ultrasonographic monitoring of stones treated by extracorporeal shock-wave lithotripsy (ESWL).

In situ extracorporeal shock wave lithotripsy for primary ureteric calculi.

OBJECTIVE: To determine the efficacy of the Lithostar lithotriptor for the in situ treatment of primary ureteric stones. METHODS: We reviewed, retrospectively, our experience with 283 patients with primary ureteric stones treated with extracorporeal shock wave lithotripsy (ESWL) using the Lithostar lithotriptor. No attempts were made to manipulate the stones. The majority of the patients were treated using only intravenous analgesia. Auxiliary measures were used in 84 patients (29.6%). There were 112 patients (39.6%) with upper, 53 (18.7%) with middle, and 118 (41.7%) with lower ureteric stones. RESULTS: A single ESWL session was needed for 200 patients (70.6%), two for 49 patients (17.3%), and more than two sessions for 34 patients (12%). Of the 248 patients who had adequate follow-up, 220 (88.7%) were stone free, 14 (5.65%) had some residual stone, while 14 (5.65%) patients failed to respond to the treatment. Patients' gender and body weight influenced the treatment and the clearance rate numerically without any statistical significance. The stone site was the most significant factor influencing the final result. Stones larger than 10 mm and the presence of hydronephrosis adversely affected the treatment. CONCLUSIONS: In situ ESWL of ureteral stones with the Lithostar device is a convenient and efficient method of treating calculi within the whole length of the ureter without the need for any manipulation.

Endourethrotomy of posterior urethral obliterations and severe strictures: improved outcome with urethral self-dilatation.

Eighteen male patients underwent endoscopic management of urethral obliterations and severe strictures of the subprostatic urethra. Thirteen patients who performed clean urethral self-dilatation after endoscopic repair had a lower incidence of recurrent strictures (P = 0.03) and required fewer visual internal urethrotomies than the initial five patients, who did not self-dilate (P = 0.01). All patients had minimal morbidity and required short hospitalization to achieve adequate urine flow and a stable urethral neolumen during the follow-up period.

Bacteriuria and colonization of double-pigtail ureteral stents: long-term experience with 237 patients.

We prospectively studied 266 patients with indwelling double-pigtail ureteral stents to determine the incidence of stent colonization and associated bacteriuria. A urine culture was obtained just prior to stent insertion and was repeated at the time of its removal. The stent itself was also cultured. Of the 237 evaluable patients, 71 (29.9%) developed bacteriuria. Of the 237 stents, 161 (67.9%) became colonized with microorganisms. Pseudomonas aeruginosa was the most common pathogen isolated from the urine and the stents. Stents in female patients had a higher rate of colonization than those used in males (74.4% v 66.5%). The longer the duration of stenting, the higher was the rate of colonization (58.6% for stents left for < 1 month v 75.1% for those left for > 3 months). The rate of colonization according to catheter type was as follows: C-flex 55.5%, silicone 62.6%, urethane 100%, and Urosoft 56%. Long-term ureteric stenting is associated with a high rate of bacteriuria and stent colonization. The duration of stenting and the type of stent influence the results. We recommend that patients with double-J ureteral stents who could be at risk from bacteremia be covered by appropriate antibiotics, and the stents should be kept indwelling for the shortest possible time. If a patient with a stent develops symptomatic infection, an antibiotic should be started that covers the Pseudomonas species.

In situ extracorporeal shock wave lithotripsy (ESWL) for the management of primary ureteric calculi in children.

Lithotripsy was used to treat 19 children (3 to 16 years of age) with primary ureteric calculi. No attempts were made to mobilize the stones to the kidney. Stones were located in the upper ureter in seven patients, middle ureter in three, and lower ureter in nine. Stone size ranged from 5 to 25 mm (average, 10.4 mm). All treatments were performed in the outpatient unit. Two children required general anesthesia, and 17 received intravenous sedation. The mean amount of energy used was 17.8 kV, and the average number of shock waves was 5,489. Before commencement of lithotripsy, two patients needed ureteric catheterization, and two had placement of double pigtail catheters. Of the 18 children who had adequate follow-up, 17 (94.4%) were completely stone-free, without any complication. The authors conclude that in situ extracorporeal shock wave lithotripsy is a safe and effective method for the treatment of primary ureteric calculi in children.

Retention of urine in females: causes and management.

Retention of urine in the female results from various medical, surgical and gynaecological causes, but is often thought to be due to psychological disturbances. In order to find out the causes of urinary retention in females in our own population and the results of its management, we conducted a retrospective study on 30 female patients with retention of urine, seen at King Abdulaziz University Hospital, Jeddah, over a five year period. Only six (20%) patients were found to have psychological disturbances. Out of the 30 patients, 27 were available for follow-up. In those patients followed up, a success rate of over 85% was achieved through using clean intermittent catheterization with or without pharmacological treatment, either in regaining complete bladder function or in overcoming this clinical problem.

Blind ending branch of duplicate ureter associated with urolithiasis of contra-lateral kidney: case report and review of literature.

We report a case of a blind-ending branch of a duplicated ureter associated with obstruction and urolithiasis of the contra-lateral kidney. To our knowledge, this is the first report of such association. Review of the literature indicated that the former part of the association has been reported previously, although infrequently.

Benign prostatic hyperplasia. The Saudi perspective in the year 2000.

All published data on benign prostatic hyperplasia in Saudi Arabia was reviewed. The age of presentation of the benign prostatic hyperplasia Saudi patient is between 60 and 70 years. Until the introduction of medical therapy for benign prostatic hyperplasia, presentation by complication was common, mainly by retention of urine in 40-50% of the cases. Diagnostic modalities are improving and both biochemical and imaging techniques are now available. Medical therapy for benign prostatic hyperplasia is widely used but studies on only 2 alpha adrenergic blocking agents out the 5 pharmacological preparations currently in the field were reported. Those are Prazosin and Terazosin. Several studies on the use of the 5-alpha reductase enzyme inhibitor Finastride were also reported. Minimally invasive surgery, other recent techniques including laser technology and standard surgical techniques such as open prostatectomy and Trans-urethral Resection of the Prostate are reported to be efficiently utilized. The workload due to benign prostatic hyperplasia is increasing and estimated currently to be 20-40% of the whole urological workload. Late and complicated presentations still pose a serious medical problem. Screening programs and enhancement of awareness are required to ensure early presentation. The diagnostic modalities have improved and need to further improve by making both PSA testing and ultrasonography as standard procedures. Most advanced methods of medical and surgical treatment are available. More studies researching all aspects of benign prostatic hyperplasia are needed to improve patient care.

Prostate cancer: Experience at King Abdulaziz University Hospital, Jeddah.

This paper presents the experience of King Abdulaziz University Hospital (KAUH) in Jeddah, Saudi Arabia, with prostatic cancer patients seen over a period of more than ten years (1986-1997). Fifty-five patients with confirmed diagnosis of prostate cancer were identified at KAUH during this period. Forty-seven presented primarily to KAUH and eight were referred from other centers for management and/or follow-up. Data analyzed included age at presentation, ethnic origin, mode of presentation, result of digital rectal examination (DRE), results of serum tumor markers, prostatic acid phosphatase, or prostatic specific antigen (PSA), results of transrectal ultrasonographic scan of the prostate (TRUS), methods and results of prostate biopsy, pathological grade of the cancer tissues, the clinical staging, and finally the type of treatment used. The average age at presentation was 68.8 years. Forty-one patients were white, six were black and the ethnic origin was not determined in eight patients. The main clinical presentation was by symptoms of prostatism in 36 patients (65%). DRE revealed benign prostatic hyperplasia (BPH) in 31 patients (56%) and suspicion of cancer in 24 (44%). Of the patients with adenocarcinoma of the prostate, 27 had PSA measurements, elevated above 20 ng/mL in 17 (63%). The tissues were obtained from the prostate by needle biopsy in 30 patients (transperineal approach in 17 and TRUS-guided in 13 patients), prostatectomy in 17 patients (open in one, and transurethral prostatic resection in 16 patients), and unspecified method in eight patients. TRUS performed on 18 patients showed hypoechoic nodules indicative of cancer in 11 patients and BPH or normal in seven patients. Clinical staging revealed 15 (27%) in stage A, 5 (9%) in stage B, 5 (9%) in stage C and 30 (55%) in stage D. During this period no retropubic radical prostatectomy operation aimed at curing localized prostate cancer was performed at KAUH, while bilateral orchiectomy for control of metastatic disease was done for 12 patients, and 18 patients received endocrine therapy.

Prostate cancer in Saudi Arabia: A review of the literature (1975-1996).

This paper presents the current available information on prostate cancer in Saudi Arabia. This review of the literature includes most epidemiological studies on cancer in Saudi Arabia that were published in the Saudi medical literature. The reviewed papers presented the experience of medical centers in the Central, Eastern, Western and Southern regions of Saudi Arabia. Papers on prostate cancer that were presented during the annual Saudi Urological Meetings were also analyzed. There was no single paper previously published on this specific cancer in the Saudi medical literature. Four papers related to local experience of prostate cancer were presented in the annual Saudi Urological Conferences, and all reported infrequent encounters with this disease. The data gathered from multiple medical centers in the different regions of the Kingdom indicates that the reported incidence of prostate cancer has been steadily falling in Saudi Arabia over the past 20 years. The information presented here sheds some light on this cancer, and calls for the close observation of any future changes in the frequency of this disease and its related morbidity and mortality.

Visual laser ablation of the prostate (VLAP) with bare fiber in conjunction with laser bladder neck incision in the treatment of patients with benign prostatic hyperplasia (BPH).

The objective of this paper was to assess the effectiveness of visual laser ablation of the prostate (VLAP) using a bare fiber with simultaneous laser incision of the bladder neck for patients with symptomatic benign prostatic hyperplasia. Sixty-seven patients with symptomatic bladder outlet obstruction due to benign prostatic hyperplasia were entered into a prospective trial where VLAP was done with neodymium:YAG laser, while the bladder neck incision was done with KTP laser. The laser was delivered using a bare fiber. There was marked improvement demonstrated at three months post-lasing in symptom score and flow rate. No significant changes were noticed in the subsequent follow-up. However, the addition of the bladder neck incision increased the rate of retrograde ejaculation without appreciable improvement in symptom score or flow rate when compared to other published data. None of the patients developed bladder neck contracture. VLAP, using a bare fiber, in conjunction with laser bladder neck incision, produces durable improvement in urine flow rate and symptom score in patients with symptomatic benign prostatic hyperplasia without the development of bladder neck contracture. This method will reduce the costs of laser prostatectomy.

Urinary tract infection in pregnancy.

During the period January 1987 until January 1988, midstream urine specimens were collected during the first antenatal visit of 2,642 pregnant patients. The specimens were obtained for the purpose of microbiological study. Significant bacteriuria was found in 15.8% (N = 419); 188 of the patients were asymptomatic and 231 were symptomatic, yielding an incidence of 7.1% and 8.7%, respectively. Two hundred females with negative urine cultures were selected as a control group, and matched by age, gravidity, and gestational age. The frequency of occurrence of premature birth was found to be higher only in the symptomatic group (P<0.05), while the frequency of anemia, hypertension, and diabetes was found to be higher in both symptomatic and asymptomatic patients, compared with the control group (P<0.04).

Genital infection in males with idiopathic infertility.

We investigated a group of male patients with idiopathic infertility to determine the presence of genital infection and to identify the pattern of this infection using a specially designed protocol. A prospective study was carried out on 63 patients and 23 controls. We cultured the first voided urine, semen and swabs taken from the anterior urethra of these patients and controls for bacteria, chlamydia. Ureaplasma urealyticum and Mycoplasma hominis. Two techniques were used for chlamydial isolation and identification. These involved the use of chlamydial culture on McCoy cells with culture confirmation test and the direct fluorescent identification of Chlamydiatrachomatis. The all-liquid media (MYCOFAST ALL-IN) kits were used for the identification of mycoplasma. Our results indicate that there is a significantly higher incidence of genital infection among male patients with idiopathic infertility than in normal fertile controls (P=0.0004). Extensive microbial investigations are indicated when genital infection is suspected to be the cause of the fertile state or cannot be ruled out as a possible cause in case of idiopathic infertility.

Caliceal diverticula developing into simple renal cyst.

Although common in adults simple cortical renal cysts are rare in children. Caliceal diverticula are rare in adults and children. A case of a caliceal diverticulum apparently sealing off and becoming an isolated simple cyst in the renal parenchyma has been reported as an unusual complication of caliceal diverticula. There have been 2 other cases of caliceal diverticula becoming sealed off reported in the literature, although neither progressed to frank cysts. We report 2 cases of definite caliceal diverticula progressing to simple renal cortical cysts.

Teratoma of the testis in a pubertal child.

We report an adult benign teratoma of the testis in a 12-year-old boy, which, to our knowledge, is the first reported instance of such a tumor developing during puberty. After radical inguinal orchiectomy all pathological sections proved to be consistent with a benign adult teratoma. This child is being followed closely.

Unusual clinical presentation of a patient with absent inferior vena cava.

We report a case of an absent inferior vena cava that presented clinically in an unusual manner. We believe this condition was caused by a combination of congenital and acquired factors. With the advent of modern imaging techniques such cases are being found with increasing frequency.

Inverted Y duplication of the ureter.

We report a case of inverted Y duplication of the ureter associated with an ectopic ureterocele.

Vesicoureteral reflux in patients with double pigtail stents.

A prospective study of 30 renal units in 27 patients with double pigtail ureteral stents seen at our hospital was done. The aim of the study was to confirm or rule out the occurrence of vesicoureteral reflux radiologically, and to define its degree in stented patients. During the filling phase of the cystourethrogram, reflux occurred in 19 of the 30 renal units (63%). Of those 19 renal units the reflux was grade 1/4 in 15 (79%), while in 4 (21%) it was of higher grades (2 to 3/4). During the voiding phase of the cystourethrogram reflux was observed in 24 of 30 renal units (80%). Of those 24 renal units reflux was of high grade (2 to 4/4) in 20 (83%), while it was low grade (1/4) in 4 (17%). In the presence of a double pigtail stent the ureteral peristaltic waves were sluggish and averaged 1 to 2 waves per minute in the 15 patients observed fluoroscopically for 1 minute after voiding. We conclude that in the majority of patients with double pigtail ureteral stents vesicoureteral reflux occurs at a low grade during vesical filling and at a high grade during voiding. Also, the stents adversely affect the ureteral peristaltic activities.