Two-trocar laparoscopic varicocelectomy: cost-reduction surgical technique

OBJECTIVES

To describe the technique of two-trocar laparoscopic varicocelectomy and compare it with the standard three-trocar laparoscopic technique in terms of effectiveness, morbidity, and cosmesis.

METHODS

Two matched groups of patients with left varicocele were recruited. Each group included 30 patients. One group underwent three-trocar and the other two-trocar laparoscopic varicocelectomy. The results of the two approaches were compared.

RESULTS

No significant differences were found in terms of mean hospital stay or morbidity between the two-trocar and three-trocar techniques. A significant difference was found in the operative time and proportion of patients needing postoperative parenteral narcotic analgesia in favor of the two-trocar technique. In both approaches, the previously infertile patients had a significant improvement in sperm count and motility (P <0.05). Cosmetically, the trocar wound scars were aesthetically superior using the two-trocar technique.

CONCLUSIONS

No significant difference was found between two-trocar and three-trocar laparoscopic varicocelectomy in terms of effectiveness and morbidity. The cost of an extra 5-mm disposable trocar in the three-trocar technique and the improved cosmesis after the two-trocar technique have made us prefer the latter technique.

Relationship between Serum Prostate Specific Antigen and the Pattern of Inflammation in Both Benign and Malignant Prostatic Disease in Middle Eastern Men

To determine the effect of prostatitis on serum prostate specific antigen in the diagnosis of prostate cancer in Middle Eastern men, H&E-stained sections of all consecutive prostate specimens were reviewed for diagnosis (malignant or benign) and pattern of inflammation. Inflammation was categorized into acute, active chronic and chronic inactive and graded semi-quantitatively according to previously published criteria. Results were correlated with serum PSA obtained from patients' records. Of 513 prostate specimens reviewed; 435 (84.8%) were benign and 78 (15.2%) were malignant. Chronic inactive prostatitis was present in 259 (204 benign, 55 malignant) and active chronic prostatitis in 221 (204 benign, 17 malignant). Acute prostatitis alone was not observed and prostatitis was absent in 33 (27 benign, 6 malignant). There was no significant difference in the prevalence of inactive chronic prostatitis between benign and malignant specimens (p < 0.071), but active chronic prostatitis was more prevalent in benign specimens (p < 0.001). Increasing serum PSA was observed for increasing grades of both inactive and active chronic prostatitis in both benign and malignant disease. Prostate cancer showed higher serum PSA levels than benign, at different cut-off points (4 ng/ml = p < 0.0001; 8 ng/ml = p < 0.0001; 12 ng/ml = p < 0.0001). However, significant numbers of patients with benign prostate biopsies presented with PSA above 12 ng/ml (82/260 = 32%). We conclude that active chronic prostatitis is common in Middle Eastern men with benign prostatic disease and a significant number of these present with very high PSA levels, some over 300 ng/ml.

Prostate Cancer Risk: The Significance of Differences in Age Related Changes in Serum Conjugated and Unconjugated Steroid Hormone Concentrations Between Arab and Caucasian Men

INTRODUCTION

Factors responsible for the low incidence of clinical prostate cancer (3-8/100,000 men/year) in the Arab population remain unclear, but may be related to changes in steroid hormone metabolism. We compared the levels of serum conjugated and unconjugated steroids between Arab and Caucasian populations, to determine if these can provide a rational explanation for differences in incidence of prostate cancer between the two populations.

PATIENTS/METHOD

Venous blood samples were obtained from 329 unselected apparently healthy indigenous Arab men (Kuwaitis and Omanis) aged 15-80 years. Samples were also obtained from similar Arab men with newly diagnosed prostate cancer or benign prostatic hyperplasia (BPH). The samples were taken between 8:00 am and 12:00 noon. Serum levels of total testosterone, (TT), sex hormone binding globulin (SHBG), free androgen index (FAI); adrenal C19-steroids, dehydroepiandrosterone sulphate (DHEAS) and androstenedione (ADT) were determined using Immulite kits (Diagnostic Systems Laboratories Inc, Webster Texas, USA). The results obtained in Arab men were compared with those reported for similarly aged Chinese, German and White USA men.

RESULTS

In all four ethnic groups, median TT and FAI declined with age, while SHBG increased with age. However, the mean TT and SHBG was significantly lower (p < 0.01) and the FAI significantly higher in Arab men (p < 0.01) compared to German men only in 21-30 years age group. In the other age groups the levels of TT and SHBG were higher in the Germans but the differences were not statistically significant. In all the racial groups serum levels of DHEAS and ADT reached a peak by about 20 years of life, and then declined progressively. The mean DHEAS in American Caucasians aged 20-29 years was 11.4 micromol/l compared to 6.22 micromol/l in the Arabs (p < 0.001). The mean DHEAS in USA Caucasians aged 70-79 years was 2.5 micromol/l compared to 1.8 micromol/l (p < 0.03) in the Arabs. There was no significant difference in mean serum levels of DHEAS between German and USA men. Similarly, there was no significant difference in the level of the hormones between Arab and Chinese men. Arab men with newly diagnosed prostate cancer had high serum TT, SHBG and DHEAS compared to those without the disease.

CONCLUSIONS

The mean TT and SHBG was significantly lower in Arab men compared to Caucasian men especially in early adulthood. Caucasians have significantly higher serum levels of the precursor androgens DHEAS and ADT especially in early adulthood compared to Arab men. These observations of low circulating androgens and their adrenal precursors in Arab men may partially account for the decreased risk for prostate cancer among Arab men.

Epididymo-orchitis and testicular abscess caused by Salmonella enteritidis in immunocompromised patients in Kuwait

OBJECTIVE

To report relatively uncommon presentations of epididymo-orchitis and testicular abscess caused by Salmonella spp. in 2 immunocompromised patients.

CLINICAL PRESENTATION AND INTERVENTION

A 56-year-old man, a known case of systemic lupus erythematosus on azathioprine and prednisolone therapy, developed urinary tract infection followed by bacteremia and epididymo-orchitis. Both urine and blood cultures yielded Salmonella enteritidis strains, which were demonstrated by pulsed-field gel electrophoresis typing method to be genotypically identical. The second patient, a 55-year-old diabetic (type II), presented with a testicular abscess from which a pure culture of S. enteritidis was obtained. Both were treated with intravenous piperacillin and amikacin followed by oral ciprofloxacin, responded well to the therapeutic regimen and were discharged home well. Their follow-ups were uneventful.

CONCLUSION

This report shows that it is important to consider Salmonella infection in the differential diagnosis of inflamed and tender testis in immunocompromised patients and to include blood, urine and stool cultures in all cases.

Severe emphysematous pyelonephritis in diabetic patients: diagnosis and aspects of surgical management

PURPOSE

Emphysematous pyelonephritis (EPN) is a rare, severe gas-forming infection of renal parenchyma and surrounding tissues seen mostly in diabetic patients. Diagnosis and adequate therapeutic regimen are controversial. We reviewed the clinical presentation, diagnosis and aspects of surgical management of patients presenting with severe EPN.

PATIENTS AND METHODS

Patients with EPN managed in our unit between 1996 and 2004 were reviewed. Diagnosis was confirmed by CT scan appearance of gas in the renal or perirenal area in a very ill patient. We compared the outcome of immediate nephrectomy with drainage of perinephric abscesses in patients presenting with severe EPN.

RESULTS

Seven patients were managed in our unit during the 8-year period. All patients were diabetic and women outnumbered men (6:1). Renogram in all 7 patients showed renal function of affected kidney to be less than 15% in 6 patients. Escherichia coli was isolated in all patients from either urine, blood or perinephric pus. Management consisted of intensive resuscitation, control of blood glucose and use of intravenous antibiotics. Emergency nephrectomy was performed in 3 patients, delayed nephrectomy after an initial period of percutaneous drainage in 2 patients, incision and drainage in one patient and immediate percutaneous drainage was performed in one patient. One patient died 5 days post-nephrectomy of myocardial infarction. Patients who had immediate nephrectomy recovered quicker (18-21 days) and had no postoperative complications. Patients who had incision and drainage, or percutaneous drainage presented with recurrent discharging sinuses or perinephric abscesses requiring further surgical interventions and spent longer time in hospital (28-37 days).

CONCLUSION

Patients with severe EPN often present in extremis and require intensive medical treatment. The diagnosis must be entertained in diabetic women presenting with flank pain and septicemia. The function of the affected kidney is often very poor and early nephrectomy offers the best outcome. Percutaneous drainage or incision and drainage of the abscess may be performed in patients too ill for immediate formal nephrectomy.

Patients' tolerance and early complications of transrectal sonographically guided prostate biopsy: prospective study of 300 patients

PURPOSE

To determine the degree of pain and discomfort associated with transrectal sonography (TRS)-guided biopsy of the prostate and to analyze the complications associated with this procedure.

METHODS

Three hundred men referred as part of an investigation to exclude prostate cancer were studied. The reasons for referral were suspected prostate cancer due to increased serum prostate-specific antigen level (>4 ng/ml), the finding of a palpable nodule or greater firmness of one prostatic lobe than the other on digital rectal examination, or the finding of a suspicious area of neoplasm of the prostate on TRS biopsy. All TRS-guided biopsies were performed as outpatient procedures without anesthesia. Ciprofloxacin prophylaxis was used in all patients before biopsy. Tolerance of the procedure was recorded immediately after the examination and graded on a scale of 0-4 as follows: 0, no pain; 1, very mild pain; 2, moderate pain; 3, severe pain; 4, intolerable pain. Complications recorded in the first week after the procedure were analyzed. They included mild pain, self-limiting hematuria, hematospermia, rectal bleeding, severe hematuria, septicemia, severe hemorrhage of the anus, and vasovagal attack.

RESULTS

Out of 300 TRS-guided biopsies, 10 early complications were recorded. The most frequent was septicemia, which was seen in 5 cases (1.7%). Hematuria occurred in 29 patients, 3 of which were severe. Rectal bleeding and vasovagal attack occurred in 1 patient each. All patients made a full recovery with appropriate conservative management. Ten cases (3.33%) of severe pain (grade 3) and intolerable pain (grade 4) were observed. Three out of these 10 patients completed the procedure. The procedure was terminated in 1 patient, and 6 patients required local anesthetic due to perianal disease.

CONCLUSIONS

TRS-guided prostate biopsy can be performed without local anesthesia in 90% of patients. Prophylactic antibiotics are mandatory to minimize approximately infectious complications.

Morphological Responses of the Rabbit Testis to Ischemic/Reperfusion Injury due to Torsion

OBJECTIVE

To investigate the morphological effects of free radical injury on spermatogenic cells in both testes of the rabbit experimental model of testicular torsion.

MATERIALS AND METHODS

The left testes of 8 peripubertal NZW rabbits (3-6 months) were subjected to 0, 15, 30, 60, 90, 120, and 180 min of ischemia by applying a clamp to the spermatic cord, followed by reperfusion. Another set of 8 rabbits was subjected to 60 min of ischemia and administered antioxidants (acetylsalicylic acid, ascorbic acid, allopurinol, quercetin, superoxide dismutase) before reperfusion. Both testes of 4 animals per group were harvested at 24 h and the remaining 4 at 3 months. Johnsen scores for spermatogenic activity and other changes were assessed histologically and these were compared with testicular malondialdehyde (MDA), a measure of free radical damage, assayed on testicular homogenates using the thiobarbiturate method.

RESULTS

In the 24-hour reperfusion group, apoptotic bodies and giant cells were more prominent in the seminiferous tubules of the left testes compared to the right, and were maximal after 90 min. In the 3-month reperfusion group, giant cells were absent, and apoptotic bodies were reduced in both testes. Testicular MDA showed an increase only in the left testes in the 24-hour reperfusion group, while the 3-month group showed increased MDA levels in both testes, but more on the left. The Johnsen score fell only to 8.0 in the left testes in the 24-hour reperfusion group, but dropped to 2.3 in the 3-month reperfusion group. Only in the 3-month reperfusion group, did antioxidant-treated animals show a fall in Johnsen scores in the left testes, regardless of the type of antioxidant.

CONCLUSION

These findings confirm a role for reactive oxygen species (ROS) in damage to spermatogenic cells in both the ipsilateral and contralateral testes following torsion, with longer term effects in the torted testis. Currently available antioxidants do not provide any significant long-term protection against morphological damage to the testis by ROS generated in testicular torsion.

Age-specific reference levels of serum prostate-specific antigen and prostate volume in healthy Arab men

OBJECTIVE; To determine age-specific reference ranges for serum prostate-specific antigen (PSA) concentration and prostate volumes in a population of healthy Arab men.

SUBJECTS AND METHODS

Blood samples were taken from 396 healthy Arab men (from Kuwait and Oman) aged 15-79 years and from across the social spectrum. Men aged >40 years had a digital rectal examination and transrectal ultrasonography of the prostate to determine prostate volume. The serum PSA level was measured using commercial kits, and age-specific ranges for PSA levels and prostate volume determined.

RESULTS

The serum PSA ranges (ng/mL) for each age range in Arab men were: 40-49 years, 0-0.9; 60-69, 0-2.7; 70-79, 0-5.5 ng/mL; the respective prostate volumes were 8-22, 9-30 and 10-33 mL. The serum PSA level and prostate volume correlated with age (P < 0.001). Arab men had lower serum PSA levels and prostate volumes than those reported for Caucasians, but similar to those reported for Asians (Japanese and Chinese).

CONCLUSION

These results indicate that Arab men have lower PSA levels and prostate volumes than Caucasians. The levels are slightly lower than those reported in the Japanese and, as in the Japanese, low PSA levels and small prostate volumes might be related to the low incidence of clinical prostate cancer in Arab men.

Reference intervals for important serum sex steroid hormones, prostate-specific antigen, insulin-like growth factor-1 and IGF binding protein-3 concentration in a normal Kuwaiti adult male population

OBJECTIVES

The purpose of this study was to determine the age-specific reference ranges for some important male sex steroid hormones, prostate-specific antigen (PSA), insulin-like growth factor-1 (IGF-1), and IGF binding protein-3 (IGFBP-3), for the Kuwaiti population.

SUBJECTS AND METHODS

Blood samples were taken from 398 consenting, fasting, healthy Kuwaiti males aged 15-80 years between 8.00 a.m. and 12.00 noon. The serum concentrations of total testosterone (TT), dehydro-epiandrosterone sulfate (DHEAS), androstenedione (ADT), sex hormone binding globulin, luteinizing hormone (LH), follicle-stimulating hormone (FSH), prolactin, PSA, IGF-1 and IGFBP-3 were determined. A distribution curve was plotted and age-specific reference levels were determined for each analyte. The reference interval for parameters with a normal distribution (Gaussian) was mean +/- 2 SD, while for the non-normal distribution (non-Gaussian), it was 2.5-97.5 percentile. The reference intervals for the analytes obtained from this study were compared with those suggested by the kit manufacturers and currently used by the Ministry of Health, Kuwait Laboratories (MOHKL).

RESULTS

Serum IGFBP-3 and ADT had normal distribution while other analytes had non-normal distribution. The reference intervals from this study, manufacturers kit and MOHKL were as follows: TT 3-31, 9-60, 8-35 nmol/l; DHEAS 0.9-11, 1.0-7.3, 2.2- 15.2 micromol/l; ADT 0.5-4.3, 0.8-2.8, 2.0-9.2 nmol/l; LH 1-11, 0.8-7.6, 0.4-5.7 mIU/l; FSH 0.5-11, 0.7-11.1, 1.1-13.5 mIU/l; prolactin 42-397, 53-360, 80-230 nmol/l; IGF-1 41-542, 78-956, 71-261 ng/ml; IGFBP-3 88- 2,090, 900-4,000, 900-4,000 ng/ml, and PSA 0-3.1, 0-4, 0-4 ng/ml, respectively.

CONCLUSION

These data indicate that for Kuwaitis lower reference ranges must be used for serum TT, DHEAS, ADT, IGFBP-3 and PSA. There is no need to change the currently used reference interval for FSH whereas higher values must be used for LH, prolactin, and IGF-1.

Allopurinol provides long-term protection for experimentally induced testicular torsion in a rabbit model

OBJECTIVE

To assess the effect of five antioxidants on exocrine function of rabbit testes retained in situ for 24 h and 3 months after experimental torsion.

MATERIALS AND METHODS

The left testes of peripubertal rabbits were clamped for 60 min, after which the clamps were removed and the testes allowed to reperfuse. The right testes served as internal controls. There were eight rabbits in each of the following experimental groups: (a) sham; (b) 60-min ischaemia followed by reperfusion; (c) 60-min ischaemia followed by left orchidectomy. In five further groups, rabbits were exposed to 60-min ischaemia followed by reperfusion, but received one of the following antioxidants before reperfusion: acetyl salicylic acid, ascorbic acid, allopurinol, quercetin or superoxide dismutase. Both testes were excised at 24 h or 3 months. The degree of lipid peroxidation, a measure of free radical damage, was assessed in testicular tissue homogenates by measuring the tissue levels of malondialdehyde (MDA). The Johnsen score was used to assess the morphological damage at 24 h and 3 months for each group.

RESULTS

At 3 months twisted viable testes allowed to reperfuse had higher MDA levels than controls; the left testes of rabbits treated with allopurinol had significantly lower MDA levels than untreated rabbits and rabbits given other antioxidants. Rabbits given quercetin, ascorbic acid or superoxide dismutase had lower (but not significantly) left testicular MDA levels than untreated rabbits, while rabbits given acetyl salicylic acid had even higher levels. Allopurinol-treated rabbits had a Johnsen score of > 7.6 and those given other antioxidants had scores of < 7.6 at 3 months.

CONCLUSION

The twisted viable testis treated by orchidopexy contains high free radical levels at 3 months. Of the antioxidants studied, only allopurinol had a beneficial long-term effect, by significantly reducing testicular MDA levels at 3 months.

Transurethral microwave thermotherapy for treatment of benign prostatic hyperplasia: a preliminary assessment of the Prostalund feedback treatment machine

OBJECTIVE

The aim of this preliminary study was to evaluate the efficacy of Prostalund feedback treatment (PLFT) using microwave thermotherapy equipment for benign prostate hyperplasia (BPH) in patients with urinary retention and an indwelling urethral catheter.

SUBJECTS AND METHODS

Four unselected patients, 51-68 years old (mean age 60 years), with urinary retention and an indwelling catheter were treated with PLFT under local anaesthesia and sedation. They were considered high-risk patients for treatment by transurethral resection of the prostate (TURP) under spinal or general anaesthesia. Initial assessment included prostate-specific antigen, determination of prostate volume and exclusion of prostate cancer using transrectal ultrasound (TRUS). The patients had the indwelling catheter for 1-2 weeks prior to treatment, the urethral catheters were removed 10-12 days after PLFT. Two patients who failed to void after transurethral microwave thermotherapy underwent urodynamic study to determine the reason for failure.

RESULT

The mean volume of the treated prostate gland was 75.50 cm3 (range 51-150 cm3). Two of the 4 patients were successfully relieved of their indwelling catheter with satisfactory peak flow, residual urine and symptom score, while treatment failed in the remaining 2. The reasons for the failure were identified as a small bladder capacity and neurogenic bladder in a diabetic patient and the presence of a middle lobe with large protruding lateral lobes into the bladder of the other patient. The latter patient had a prostate volume of 150 cm3. 'Salvage' TURP in both patients revealed that PLFT caused extensive necrosis of prostatic tissue and the TURP was then accomplished with minimal blood loss (<200 ml) even in the patient with 150-gram prostate. There were no serious complications such as bleeding, sepsis, rectoprostatic fistula or urine incontinence.

CONCLUSION

The result of this preliminary investigation appears to be satisfactory and indicates that PLFT could be a good, minimally invasive alternative to surgery for BPH patients with retention of urine and an indwelling catheter.

Iatrogenic Ureteric Injuries: Incidence, Aetiological Factors and the Effect of Early Management on Subsequent Outcome

OBJECTIVE

To investigate the changing pattern in incidence, aetiological factors and the effect of early diagnosis and surgical treatment on the outcome of iatrogenic ureteric injuries in our Urology Unit over a 5 year period.

PATIENTS/METHODS

All patients with ureteric injuries caused as a result of any surgical procedures (iatrogenic ureteric injuries) were studied during a 5 year period (1998-2002). Data collected and analysed included yearly incidence of injury, aetiological factors, modalities of treatment and the outcome of management of the injuries. During the study period, our general surgical colleagues had a policy of requesting "J" stent insertion prior to major abdominopelvic surgical procedures. During the same period, in nearly all difficult cases of ureteroscopy (URS) + lithoclast lithotripsy+/-Dormia basket, a ureteric catheter or "J" stent was prophylactically inserted by urological surgeons.

RESULTS

There were 82 iatrogenic ureteric injuries in 75 patients over the 5 year period. The total number of iatrogenic ureteric injuries declined from 26 (31.7%) in 1998 to 10 (11.8%) in 2002. Urological, obstetrics and gynaecological and general surgical procedures were involved in 69(84.1%), 7(8.7%), and 4(4.9%) of the injuries respectively. The commonest types of injuries encountered were; injury to ureteric mucosa post URS or lithoclast calculi disintegration 34 (41.5%), complete ureteric perforation 15 (18.3%) and false passage 15 (18.3%). The most severe complications encountered were complete ureteric avulsions 3 (3.75%) and loss of ureteral segment 2 (2.4%). The commonest treatment options used were "J" stent insertion or ureteric catheter placement (48, 59.4%), percutaneous nephrostomy (17, 20.7%), laparotomy and removal of suture on tied ureters (5, 6.1%). Two (2.4%) nephrectomies were performed because of poor renal function in one patient and severe damage to a functioning renal unit during a difficult retroperitoneal surgery in another patient. Recognition and treatment of ureteric injuries at the time of surgery was associated with less morbidity compared to those in whom the diagnosis was delayed. The overall successful resolution of ureteric injuries in this series was 77/82 (93.9%). There was no mortality attributable to these ureteric injuries.

CONCLUSION

In our Unit, the incidence of significant iatrogenic ureteric injuries has shown a decline over a 5-year period. We attribute this trend to the prophylactic use of "J" stents or ureteric catheter placement and good surgical technique during major abdomino-pelvic surgeries in our hospital. Endourological procedures are the commonest causes of ureteric injuries. Prompt diagnosis and institution of appropriate corrective surgical procedures often result in a very satisfactory outcome in about 94% of cases.

Tension Free Vaginal Tape Versus Burch Colposuspension for Treatment of Female Stress Urinary Incontinence

INTRODUCTION

Many surgical procedures have been proposed for treatment of stress urinary incontinence (SUI) but none of them has proved completely successful. The aim of this study is to compare the efficacy and safety of tension free vaginal tape (TVT) with Burch colposuspension in the treatment of SIU.

PATIENTS AND METHODS

Fifty female patients, presenting with SUI were randomly divided into two equal groups. SUI was confirmed using urodynamic study in all patients. Group 1 (n=25) patients underwent Burch colposuspension while Group 2 (n=25) underwent TVT. Patients with high grade cystocele, previous surgical failure for SUI, uninhibited detrusor contraction during bladder filling on urodynamic study and incompetent internal sphincters were excluded from this study. A patient was declared cured of SUI, if 3-6 months after surgery she had no SUI. The procedure was judged to be a failure if 3-6 months after surgery, patient had SUI.

RESULTS

In group 1 patients, 72% were completely cured, 16% improved and 12% showed no improvement. In group 2 patients, 72 were completely cured, 20% improved and only 8% showed no improvement. There was no difference between the two groups in terms of cure rates. Operative time for TVT was significantly less compared to Burch. Postoperative pain was less in TVT than Burch. Return to normal activity was earlier in TVT compared to Burch group. Intra operative perforation of the urinary bladder occurred in 8% of patients in group 2. Urine retention occurred in 12% of patients in group 1 compared to 20% in group 2. This was successfully managed conservatively. De novo urgency developed in 12% in group I and 8% in group II and was successfully managed by medical treatment.

CONCLUSION

The success rates of TVT and Burch colposuspension in the treatment of SUI in our experience are very similar. However, TVT is associated with less morbidity. We recommend TVT procedure for females with genuine SUI.

Mode of presentation and first line of management of non-recurrent urolithiasis in Kuwait

AIMS

To determine the incidence, mode of presentation, first line of management and composition of non-recurrent urolithiasis in Kuwait.

METHODS

Consecutive patients admitted between January 1999 and December 2002 with non-recurrent urolithiasis were prospectively analyzed.

RESULTS

The average annual incidence of hospital admission for non-recurrent urolithiasis in Kuwait was 43.44 per 100,000 population, representing men and women (ratio, 9:1) with a median age of 41.91 years. Of the hospital admissions for non-recurrent urolithiasis, 57.2% of cases were acute. Overall, the most predominant symptom was flank pain, while the least common symptom was acute urinary retention. Ureteroscopic stone manipulation was the most common initial treatment modality in the present series, as it was utilized in 43.3% and 37.09% for patients admitted on elective and emergency basis, respectively. Of the calculi available for chemical analysis, 91% contained calcium, 73% contained calcium oxalate, 17% contained mixed calcium and 1% contained calcium phosphate. The composition of the rest of the stones were urate in 7%, struvite in 1% and cystine in 1%.

CONCLUSIONS

Urolithiasis is a common disease in the Kuwait region that mainly presents with flank pain. Ureteroscopic calculus removal is the most common modality of treatment. The majority of the calculi seen in Kuwait contained calcium.

Putative role of serum insulin-like growth factor–1 (IGF-1) and IGF binding protein-3 (IGFBP-3) levels in the development of prostate cancer in Arab men

INTRODUCTION

The incidence of clinical prostate cancer in the Arab population is among the lowest in the world. High serum IGF-1 level has been implicated as a possible risk factor for the development of prostate cancer in Caucasians. The purpose of this study was to determine serum IGF-1 and IGFBP-3 levels in healthy Arab men and in Arab men with newly diagnosed benign prostatic hyperplasia (BPH) and prostate cancer, and to compare these values with values reported in Caucasians.

PATIENTS AND METHODS

Subjects were recruited in two groups: (a) indigenous, healthy Arab men aged 15-90 y (n = 383); (b) Arab men with newly diagnosed prostate cancer (n = 30) or BPH (n = 40). Blood was obtained from fasting patients and volunteers, between 8:00 a.m. and 12:00 noon. The serum concentrations of IGF-1 and IGFBP-3 were determined using Immunoradiometric assay (IRMA) kits.

RESULTS

As in Caucasians, serum IGF-1 and IGFBP-3 levels declined with age in Arab men. The mean +/- s.d. of serum IGF-1 levels in healthy Arab men in the age group 15-20, 51-60, 61-70 y were lower (376.2 +/- 153.2, 134.9 +/- 105.7 and 89.6 +/- 48.4 ng/ml, respectively), compared to values reported for similarly aged Caucasians. Arab men with newly diagnosed prostate cancer had significantly higher serum IGF-1 level (P < 0.01) and lower IGFBP-3 levels (P < 0.01) compared to age-matched Arabs without the disease.

CONCLUSIONS

Arab men have lower serum IGF-1 levels compared to Caucasians and this may be an important factor in the explanation of the low incidence of prostate cancer in the Arab population.

Bacteriology of urinary tract infection associated with indwelling J ureteral stents

PURPOSE

To investigate the microorganisms responsible for urinary tract infection (UTI) and stent colonization in patients with indwelling J ureteral stents and to compare the antimicrobial susceptibility pattern of the isolates from urine and J stents in order to establish the etiologic agents of bacteriuria and colonized stents in such patients and provide baseline data on an antibiotic policy for the urology unit.

PATIENTS AND METHODS

Midstream urine from 250 patients requiring J stent insertion was investigated microbiologically prior to stent insertion and on the day of stent removal. After stent removal, 3 to 5 cm of the tip located in the bladder was also sent for culture. Patients' bio-data and underlying diseases were documented. Those with no known systemic diseases ("normal patients") were also studied as controls. Of the 250 patients studied, 152 (61%) were normal, while 27 (11%), 53 (21%), and 18 (7%) had diabetes mellitus (DM), chronic renal failure (CRF), and diabetic nephropathy (DN), respectively. The mean duration of stent retention was 27 days. All microbial isolates were tested for their susceptibility to a panel of 10 antibiotics.

RESULTS

Twelve patients (5%) before stent insertion and 42 patients (17%; P < 0.001) on the day of stent removal had positive urine cultures. One hundred four stents (42%) were culture positive. Of the 104 patients with positive stent cultures, in 62 patients (60%), urine culture was sterile. The commonest isolates were Escherichia coli, Enterococcus spp., Staphylococcus spp., Pseudomonas, and Candida spp. On the day of stent removal, urine culture was positive in 28% of the normal patients compared with 57% (P = 0.11), 78% (P < 0.001), and 62% (P < 0.001) of patients with CRF, DM, and DN, respectively. Stent isolates were more resistant to antibiotics than the organism isolated before stent insertion.

CONCLUSION

An indwelling J ureteral stent carries a significant risk of bacteriuria and stent colonization. The sensitivity of urine culture to stent colonization is low, and therefore, a negative culture does not rule out a colonized stent. Bacteria cultured from urine after stent insertion and from the stents are more resistant to antibiotics than are those cultured from urine before stent insertion. Norfloxacin or ciprofloxacin is recommended as prophylaxis prior to stent insertion, and an aminoglycoside can be added to treat symptomatic patients with severe infections.

Significance of determining the point of reperfusion failure in experimental torsion of testis

BACKGROUND

Experimental studies of the use of free radical scavengers in ischemic/reperfusion (I/R) injury following detorsion of the torted testis have yielded conflicting results due to differences in the period of ischemia used. The authors studied I/R injury in the rabbit model, to define the point beyond which there is reperfusion failure.

METHODS

Ischemia/reperfusion injury of the testis was created in 3-6-month-old male New Zealand white rabbits by cross-clamping the left spermatic cord for periods of ischemia lasting 0, 15, 30, 60, 90, 120 and 180 min. There were eight animals per experimental group. The right testis served as internal control. Both testes were harvested after 24 h of reperfusion in four animals and after 3 months in the remaining four animals for each group. Testicular malondialdehyde (MDA), a measure of free radical damage, was determined by using the thiobarbituric acid reaction on testicular homogenates. Johnsen score was used to assess morphological damage caused by the ischemia.

RESULTS

After 24 h of reperfusion, the mean testicular MDA in the control right testes at 0, 15, 30, 60, 90, 120 and 180 min was 2.1, 2.5, 2.9, 2.4, 2.1 and 1.9 nmol/mg protein, respectively. The mean left testicular MDA at corresponding ischemic periods was 1.6, 2.0, 3.9, 10.0, 4.4, 6.1 and 1.0 nmol/mg protein, respectively. The maximum left testicular MDA was at 60 min (10.0 nmol/mg protein), following which the level dropped significantly to 1.0 nmol/mg protein at 180 min. At 3 months, the mean Johnsen scores for left testes subjected to 0, 60, 120 and 180 min ischemia were 9.4, 8.8, 2.3, 3.5, respectively.

CONCLUSION

The results suggest that following ischemia of up to 60 min in the rabbit testis, adequate reperfusion is possible, but ischemia lasting beyond 60 min results in inadequate reperfusion leading to irreversible damage. Thus, in experiments for assessing the effect of antioxidants on I/R injury of the testis in rabbits, periods up to 60 min of ischemia should be regarded as optimum to observe an effect.

Testicular torsion: a perspective from the Middle East

OBJECTIVE

To report our experience in the management of testicular torsion with emphasis on seasonal variation, salvage rate and the status of the torted testis 3-6 months after orchidopexy.

SUBJECTS AND METHODS

Seventy-five patients with a presumptive diagnosis of testicular torsion, who presented to our hospital between January 1999 and December 2002, were included in the study. Following scrotal exploration, 63 patients were found to have testicular torsion. Of these, 11 with nonviable testes had orchiectomy while 52 with viable testes had orchidopexy. Both groups of patients had simultaneous contralateral orchidopexy. Patients who had orchidopexy were followed up 3-monthly by testicular ultrasound to assess the volume of the affected testis.

RESULTS

Sixty-three patients were confirmed to have testicular torsion. The average number of new cases in the winter was 6.7 compared to 4 in the summer. Fifty-two patients underwent orchidopexy to give an operative salvage rate of 82.5%. Of 51 patients in whom the duration of torsion was less than 24 h, 1 (2.0%) had a nonviable testis, whereas of 12 patients in whom the duration of torsion was more than 24 h, 10 (83.3%) had a nonviable testis. After a minimum follow-up of 3 months for patients who had orchidopexy, 7 (13.5%) developed testicular atrophy. The incidence rate was estimated to be 7.9 cases per 100,000 population.

CONCLUSION

The highest incidence was during the cold season. The outcome of surgical management of testicular torsion was dependent on the duration of torsion.

Tubularized incised plate urethroplasty: modification and outcome

BACKGROUND/PURPOSE

To review the outcome of tubularized incised plate (TIP) urethroplasty in the primary treatment of penile hypospadias with minimal chordee and to describe our experience with the lateral flap used to cover the urethroplasty.

METHODS

The charts of all patients with penile hypospadias who underwent primary TIP repair in our hospital between 1996 and 2001 were examined and pre as well as postoperative biodata were recorded. We used the lateral flap to cover the repair rather than a flap harvested from preputual skin as in the original description.

RESULTS

94 patients were identified but only 83 were suitable for analysis. The mean age of the evaluable patients was 2.67 years (range 1-10). The mean of follow-up was 17.49 months (range 1-54). The preoperative meatal position was coronal in 50 (60.2%), distal shaft in 28 (33.7%) and mid shaft in 5 (6.1%) patients. The mean length of the urethral plate was 8 mm (range 5-15) while the mean width of the plate was 6 mm (range 4-8). In 30 patients (36.14%) chordee was present preoperatively. All patients were admitted to the hospital following the TIP urethroplasty with a urethral stent in place. The lateral flap was used to cover the repair in 70 patients. The stent was left for an average of 7.83 days (7-10). The average hospital stay was 8.83 days (7-11). A cosmetically normal vertically oriented slit-like meatus was seen in 78 (94%) patients. The TIP repair revealed an apical meatus in 82 (98.8%) and a conical glanular configuration in 79 (95.20%) patients. The parents observed that the urinary stream and the penile shaft were straight in 75 (90.4%) and 82 (98.8%) patients respectively. Seven patients (8.4%) developed meatal stenosis requiring repeated dilatations; four patients (4.8%) developed urethrocutaneous fistula and one (1.2%) had postoperative bleeding requiring transfusion. Of the 70 patients who had the lateral flap, 3 (4.28%) developed urethrocutaneous fistula.

CONCLUSION

Our experience indicates that the TIP repair gives a good cosmetic and functional outcome with minimal complications. Urethroplasty coverage using the lateral flap is associated with a low incidence of urethrocutaneous fistulae.

Morbidity associated with surgical treatment of ureteric calculi in a teaching hospital in Kuwait

BACKGROUND

Ureteric lithiasis is a common urological problem in Kuwait. Because of the different interventional approaches, we carried out an audit on the morbidity associated with the surgical management of the disorder.

PATIENTS AND METHODS

The surgical records were reviewed of all patients with the diagnosis of ureteric lithiasis that were managed surgically by ureteroscopy or ureterolithotomy in Mubarak Al-Kabeer Hospital in Kuwait between January 1996 and December 1999. Patients' bio-data, location of calculi, indications for surgical intervention, types of therapeutic interventions, operating surgeon and complications were analysed. Patients managed primarily and successfully by extracorporeal shockwave lithotripsy were excluded from this analysis.

RESULTS

A total of 1383 patients with ureteric calculus were managed in the period under review--775 (56%), 567 (41%), and 41 (3%) patients were managed by extracorporeal shockwave lithotripsy, ureteroscopy and ureterolithotomy, respectively. The 608 patients managed by ureteroscopy or ureterolithotomy had a total of 710 operations. The commonest surgical procedure performed was ureteroscopy with Dormia basket with or without double 'J' stenting and this accounted for 418 (58.9%) operations. The least common procedure was ureteric meatotomy with Dormia basket and with or without double 'J' stenting in 9 (1.3%) patients. The overall complication rate was 110 out of 710 (15.5%) operations. Of the complications, 101 (92%) were minor (e.g. haematuria, fever, and mucosal injury). Nine (8%) complications were major complications (e.g. ureteric perforation and ureteric avulsions). Ureterolithotomy and ureteroscopy with intracorporeal lithotripsy were associated with the highest complication rates.

CONCLUSIONS

This analysis has shown that with technological advances, the treatment of ureteric lithiasis has improved and major complications have decreased. However, with so many therapeutic options to choose from, there is a need to audit the various therapeutic options and select those associated with the least morbidity rates in each urology unit.

Interstitial cystitis: a review of current concepts of aetiology, diagnosis and therapy

Until recently, interstitial cystitis (IC) has been described as a chronic clinical syndrome of obscure aetiology and, consequently, specific treatment for the condition is lacking. IC has often been regarded as a diagnosis of exclusion in women complaining of chronic pelvic pains, frequency, dysuria, etc. and until recently most clinicians rarely considered this diagnosis in men. However, recent research efforts have begun to yield vital information on this underdiagnosed and distressing clinical condition regarding its aetiology and diagnosis and, consequently, more effective therapeutic options are now emerging. The aim of this review is to highlight these emerging concepts of the aetiology, diagnosis and innovative therapy of IC, in order to help clinicians confronted by patients with this disorder.

Anuria secondary to hot weather-induced hyperuricaemia: diagnosis and management

BACKGROUND

There is little information on the management of anuria secondary to severe volume depletion or as a rare manifestation of heat stroke in areas of the world with very hot summers. We present our experience with hot weather-induced hyperuricaemia in Kuwait.

PATIENTS AND METHODS

Patients presenting to our urology unit as an emergency during the hot summer months of April to October (average temperature 40-55 oC) were suspected of having hot weather-induced anuria secondary to hyperuricemia if they had a history of working in the sun for 6 to 8 hours per day and a progressive decrease in urine output to complete anuria. The diagnosis was confirmed by demonstration of elevated serum creatinine and uric acid, ultrasound findings of normal kidneys, ureters, and bladder (KUB) or mild to moderate hydronephrosis, but no features of chronic renal disease and little or no urine in the bladder. Management consisted of emergency cystoscopy, retrograde pyelogram, ureterorenoscopy (URS), and J stents followed by rehydration, oral allopurinol and urinary alkalinization.

RESULTS

Twenty-nine patients (27 males and 2 females, mean age, 44.52A +/- 8.3 years) satisfied the diagnostic criteria for anuria secondary to hot weather-induced hyperuricaemia. Twentyeight (97%) patients worked outdoors on construction sites. Six patients had small radiopaque calculi on plain KUB X-ray. During cytoscopy and URS, uric acid crystals were encountered in all patients in the ureters and bladder. Recovery of renal function was complete in 23/29 (79.3%) patients, while 4/29 (13.8%) had partial recovery and 2/29 (6.9%) had no renal recovery.

CONCLUSION

Hot weather-induced anuria secondary to hyperuricaemia is a complication of severe dehydration. Effective treatment will result in successful resolution of this rare but reversible cause of acute renal failure in about 80% of cases. Ancillary treatment methods like haemodialysis or the use of PCN can be safely avoided in the majority of the patients. However, rehydration alone may be insufficient treatment in these patients.