Khaleel A. Al-Awadi

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.

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.

Do differences in age specific androgenic steroid hormone levels account for differing prostate cancer rates between Arabs and Caucasians

Objective:  Factors responsible for the low incidence of clinical prostate cancer in the Arab population remain unclear, but may be related to differences in androgenic steroid hormone metabolism between Arabs and other populations, especially as prostate cancer is believed to be androgen dependent. We therefore measured the levels of serum androgenic steroids and their binding proteins in Arab men and compared results obtained with values reported for Caucasian populations to determine if any differences could at least partially account for differences in incidence of prostate cancer rates between the two populations.

Extracorporeal Shockwave Therapy for Urolithiasis with Renal Insufficiency

Management of urolithiasis with renal insufficiency poses a multidimensional nephrourological situation. Sixty-two patients of potentially reversible calculus obstructive nephropathy and azotemia were treated with extracorporeal shockwave lithotripsy (ESWL) on the Siemans Lithostar. These patients were treated under sedoanalgesia after the initial therapeutic ureteral stenting. Satisfactory fragmentation was achieved in all the patients. The incidence of major complications was 3.2% with an 85% stone-free rate at 6 months. Pre- and post-ESWL hemodialysis was required in 14 and 3 patients, respectively. All patients had variable levels of improvement in the renal function. Proper selection of cases is mandatory for satisfactory outcome. The combination of ureteral stenting followed by phased ESWL represents an attractive alternative to traditional surgical management of stones with renal insufficiency.

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.

Sectorial Technetium-99m-Dimercaptosuccinic Acid Scintigraphy for Monitoring the Effect of Extracorporeal Piezoelectric Lithotripsy for Calyceal Calculi on Regional Renal Function

Objective: To apply a semiquantitative method for analysis of technetium-99m-dimercaptosuccinic acid (99mTc-DMSA) renal scintigraphy for monitoring the effect of extracorporeal piezoelectric lithotripsy (EPL) in patients with calyceal stones on regional kidney function and to check whether EPL had caused any deleterious effect on the target calyceal renal parenchymal function. Patients and Methods: Forty patients (mean age 35 years) suffering from calyceal stones documented by abdominal plain radiography, intravenous urogram or abdominal ultrasound were studied. All patients were treated by EPL. 99mTc-DMSA scan was performed before and 4 weeks after EPL. Sector analysis involved calculation of the relative function of the target calyx to the function of the ipsilateral kidney and the relative function of the treated kidney to global renal function. Results: The stone sizes were 6–11 mm in diameter and 11 were located in the upper, 13 in the middle and 16 in the lower calyx. After EPL, the overall stone clearance rate was 85% (100% for calculi in the upper and middle calyces, 62% for lower calyces). The sector analysis did not show statistically significant change of the relative regional (calyceal) or whole kidney function between the pre- and post-EPL 99mTc-DMSA scans. Using sector analysis, EPL appeared to be a safe modality and its usage was not associated with any untoward effect on calyceal or whole kidney function. Conclusion: Sector analysis of 99mTc-DMSA renal scan is a simple semiquantitative method for monitoring regional changes of kidney function after EPL for treatment of calyceal stone.

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 µmol/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.

Blind-ending ureteral duplication with calculi.

or reflux. 3 Because of non-filling of the blind ureter on intravenous urography (IVU), the diagnosis of blind-ending ureteral duplication is best made with the help of retrograde pyelography. However, a blind-ending bifid ureter can be opacified on IVU if uretero-ureteral reflux is present. The anomaly can also be seen on computerized tomography. 4 We report a case featuring a long, blind-ending ureteral duplication complicated by stone formation. Case Report A 45-year old male was admitted with right loin pain, dysuria and frequency of micturition of 3 months duration. He reported passing stones in urine in the past, but had no history of fever or recurrent urinary tract infection (UTI). The patient had presented to another hospital with the same complaints 6 weeks before reporting to our unit. Cystoscopy at that hospital showed a normal bladder with no calculus in the bladder or the ureters. He came to our unit because of persistent pain. Laboratory investigations showed normal renal function. Urine microscopy and culture showed red blood cells in the urine, but no bacterial growth. Plain radiograph of the kidneys, ureters and bladder (KUB) revealed two radio-opaque shadows in the region of the lower third of the right ureter (Figure 1). However, IVU showed patent ureters with no calculus seen in either ureter (Figure 2). A pre-operative CT scan showed grossly normal kidneys and ureters with 2 extravesical masses in the pelvis. Cystoscopy in our unit revealed an edematous mass just caudal and medial to the right ureteric orifice. A guide wire introduced into the right ureter under fluoroscopic control showed that the radio-opaque shadows seen on KUB were extraureteral and extravesical. Right retrograde pyelography showed a patent ureter with opacification of a normal pelvicalyceal system. Transurethral resection of the bullous, edematous mass revealed another ureteric orifice. Retrograde pyelography through the other ureteric orifice revealed multiple filling defects and a long blind-ending ureter, with no opacification of the pelvi-calyceal system (Figure 3). Ureteroscopy through the second ureteric orifice confirmed the presence of 2 calculi, which were removed using a Dormia basket. Post-operatively the patient became pain free. Postoperative micturating cystourethrogram (MCUG) performed 3 months after calculus extraction from the duplicated ureter, showed no vesicoureteric reflux (VUR).

Extracorporeal shock wave lithotripsy as monotherapy for staghorn calculi--is reduced renal function a relative contraindication?

Extracorporeal shock wave lithotripsy as monotherapy for staghorn calculus is not without complications. We describe a case in which, due to markedly reduced renal function following lithotripsy for a staghorn calculus, broken fragments of calculi forming steinstrasse became cemented together to form a solid calcified tube extending from the renal pelvis to the ureteric orifice. This resulted in further loss of kidney function. The patient eventually required nephro-ureterectomy. Extreme care should be taken when using extracorporeal shock wave lithotripsy to treat staghorn calculi in kidneys with markedly diminished function to prevent further loss of function due to treatment.