Hamdy Abdul-Halim

Factors predisposing to urinary tract infection after J ureteral stent insertion

PURPOSE We determined the group of patients most likely to have bacterial infection or colonization of J stents inserted to relieve ureteral obstruction. MATERIALS AND METHODS Midstream urine from 250 consecutive patients who required indwelling J stent insertion obtained before stent insertion and on the day of stent removal was analyzed by microbiological testing. At stent removal 3 to 5 cm. of the stent tip located inside the bladder was also sent for culture. Patient sex, duration of stent insertion and systemic disease, such as diabetes mellitus, chronic renal failure or diabetic nephropathy, were recorded. Patients without systemic disease were classified as normal. The rates of bacteriuria, stent colonization and symptomatic urinary tract infection were compared in patients with and without systemic disease. RESULTS Of the 250 patients studied 180 (72%) were men and 70 (28%) were women, while 152 (60.8%) had no systemic disease, 27 (10.8%) had diabetes mellitus, 53 (21.1%) had chronic renal failure and 18 (7.2%) had diabetic nephropathy. The bacteriuria rate was 4.2% for stents removed within 30 days and 34% for stents removed after 90 days (p <0.001). Overall the bacteriuria rate in women was 24.3% compared with 13.9% in men (p <0.06). The rate of bacteriuria in normal patients was significantly lower (3.3%) than in patients with diabetes mellitus, chronic renal failure and diabetic nephropathy (33.3%, 39.6% and 44.4%, respectively, p <0.001). The colonization rate of the tip of the stent was higher in women (64.3%) than in men (34.7%). The stent was removed prematurely in 9 of the 250 patients (3.6%) because of septicemia, including 7 women (77.8%) with systemic disease. CONCLUSIONS The risk of bacteriuria and colonization of the J stent tip is significantly enhanced by the duration of stent retention, patient sex and the systemic disease, such as diabetes mellitus, chronic renal failure and diabetic nephropathy. These categories of patients should undergo shorter stent retention, antimicrobial prophylaxis and careful followup to minimize infectious complications.

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.

Management of Solitary Renal Pelvic Stone: Laparoscopic Retroperitoneal Pyelolithotomy Versus Percutaneous Nephrolithotomy

BACKGROUND AND PURPOSE Percutaneous nephrolithotomy (PCNL) is considered the main management option for large single renal pelvic stones; however, laparoscopic retroperitoneal pyelolithotomy (LRP) can be used as an alternative management procedure. We compare both procedures in the management of solitary large renal pelvic stones. PATIENTS AND METHODS Between June 2002 and July 2010, 105 patients with solitary large renal pelvic stones were selected and randomly divided into two groups; group 1 included 55 patients who were treated by LRP and group 2 included 50 patients who were treated by PCNL. The differences between the two procedures were compared and analyzed. RESULTS There was no difference between the two groups regarding patient demographics and stone size. There was no statistically significant difference between LRP and PCNL regarding mean estimated blood loss (166.4±98.3  mL vs 178±102.4  mL), mean hospital stay (4.5±1.9 d, vs 4.4±1.4 d), mean time of postoperative analgesia (2.2±0.9 d vs 2.4±0.9 d), rate of postoperative blood transfusion (5.5% vs 6%), and stone-free rate (100% vs 96%). The mean operative time was significantly longer in the LRP group (130.6±38.7  min vs 108.5±18.7  min), respectively. There was only one (1.8%) case from the laparoscopy group converted to open surgery because of uncontrolled bleeding. CONCLUSION RLP is a suitable surgical technique for patients with large renal pelvic stones but with good selection of cases; however, PCNL remains the standard treatment in most cases.

Laparoscopic pyelolithotomy: Is the retroperitoneal route a better approach?

Objectives:  To compare the outcome of laparoscopic pyelolithotomy (LP) using the transperitoneal and the retroperitoneal routes.

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.

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.

Prognostic significance of P27 (Kip 1) and MUC1 in papillary transitional cell carcinoma of the urinary bladder.

Aim: To examine p27 (Kip 1) and MUC1 expression in specimens of papillary transitional cell carcinoma (PTCC) of the urinary bladder and to correlate their expression with the tumor grades,stages and outcome. Patients and Methods: Paraffin sections from previously diagnosed PTCC bladder were graded, staged and the patients were followed up for 5 years. Ten non-neoplastic urological lesions diagnosed as polypoid cystitis were taken as control. Three sections of 4 um thickness were obtained from every case. One was hematoxylin and eosin (H and E) stained for diagnosis, reviewing and confirmation. The other two sections were immunohistochemically stained for both p27and MUC1. The data of immunohistochemical results were correlated with the following conventional prognostic variables: tumor grade, stage, distant metastasis and 5 year survival. Results: The results showed a highly significant and an insignificant relationship between p27 expression and tumor grade and stage (P<0.01 and P>0.05), respectively. Correlating p27 expression with distant metastasis and overall survival showed a significant relationship with distant metastasis (P<0.05) and a highly significant one with overall survival (P<0.01). The results showed also a significant relationship between MUC1 expression and both tumor grade (P<0.01) and overall survival (P<0.05). Conclusion: p27 and MUC1 immunohistochemistry augment the classic histochemistry for the prognosis of PTCC of the bladder as well as improving the prediction of the patient outcome and survival.

Antioxidant Therapy Is Associated with a Reduction in the Serum Levels of Mediators of Renal Injury Following Lithotripsy for Renal Calculi

OBJECTIVE To investigate the effects of antioxidant therapy on the levels of mediators of shock wave induced renal injury in patients with renal calculi treated with extracorporeal shock wave lithotripsy (ESWL). PATIENTS AND METHODS One hundred and twenty patients with renal calculi were divided into three treatment groups: Group A patients (n = 39) served as a control group; Group B patients (n = 41) were given 2 capsules of Nature Made((R)) antioxidants 2 hours before, and 2 and 8 hours after ESWL and Group C patients (n = 40) were given 2 capsules of the antioxidants at 2 and 8 hours after ESWL. Blood and urine samples were obtained from all patients just before the start of treatment with ESWL, and at 2 and 24 hours and on day 7 and 28 after ESWL. Levels of mediators of renal injury such as serum alkaline phosphatase (ALP), C-reactive protein (CRP) and lactate dehydrogenase (LDH) were measured. Urinary levels of albumin and ALP were also determined as measures of renal tubular injury. RESULTS Patients given antioxidants had significantly reduced mean serum concentration of ALP (p < 0.001) at 24 hours, lower serum ALP and LDH on day 7 and 28, and lowest CRP on day 28 after ESWL. They also had higher urine albumin (p < 0.001) and ALP (p < 0.001) levels (from 24 hours to day 28) compared with patients who were not given antioxidants. CONCLUSION These findings suggest that oral antioxidant therapy prior to lithotripsy may reduce the severity of long term renal injury caused by the shock waves.

A Pilot Study of Transperineal Urethrosphincteric Block for Visual Internal Urethrotomy in Patients with Anterior Urethral Strictures

PURPOSE To evaluate the effectiveness of transperineal urethrosphincteric block (TUSB) in providing analgesia during visual internal urethrotomy for patients with anterior urethral strictures. PATIENTS AND METHODS A total of 26 consecutive patients scheduled for elective visual internal urethrotomy for symptomatic urethral stricture were considered for this prospective study. Twenty-four patients agreed to participate in the study. Their demographics and medical conditions were recorded. Twenty-five percent of the patients had comorbid conditions that would have put them at high risk for general anesthesia. All patients had TUSB as the primary method of analgesia, using 1% lidocaine. Postoperatively, patients were asked to score the severity of the pain experienced during TUSB and during the transurethral surgery on a scale from 0 to 10. Postoperative adverse effects and the need for sedation or additional analgesia were recorded. All patients rated their overall satisfaction with the analgesia. RESULTS Patient mean age was 43.5 years (range 26-71 years). The mean pain score during instillation of the transperineal block was 1.9 (range 0-3), and for visual internal urethrotomy was 1 (range 0-5). No sedation, narcotics, or additional analgesia were required and no postoperative adverse effects were encountered. Ninety-two percent of the patients were very satisfied with the method of analgesia. CONCLUSION TUSB is a safe and effective method of local analgesia for visual internal urethrotomy in patients with anterior urethral strictures, and is particularly suitable for those at high risk of general anesthesia.

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.