S.A.A Naqvi

Pediatric Urolithiasis: Developing Nation Perspectives

PURPOSEnWe evaluated epidemiology, etiology, dietary and urinary risk factors, and the composition of calculi in pediatric stone formers in Pakistan.nnnMATERIALS AND METHODSnThis retrospective study includes 1,440 children treated between 1987 and 2000. Case records were reviewed for demographics, etiology and clinical symptoms. Dietary and urinary risk factors were analyzed prospectively in idiopathic stone formers. Stone composition was analyzed by infrared spectroscopy.nnnRESULTSnThere were 1,075 males and 365 females for a male-to-female ratio of 3:1. The peak age for renal and bladder stones was 6 to 10 and 1 to 5 years, respectively. Overall 795 stones (55%) were renal, 198 (14%) were ureteral and 447 (31%) were vesical. Bladder stones were present in 60% of cases in the mid 1980s but decreased to 15% in the mid 1990s. The clinical symptoms were abdominal pain in 511 patients (51%) and fever in 193 (19.5%). There were anatomical abnormalities in 96 patients (12%), metabolic abnormalities in 206 (25%), infection stones in 60 (7%) and idiopathic stones in 444 (55%). Urinary analysis in idiopathic stone formers revealed hypercalciuria in 17 (11%), hyperoxaluria in 62 (40%), hyperuricosuria in 41 (27%) and hypocitruria in 97 (63%). Diet involved a low intake of protein in 60 cases (44%), calcium in 45 (33%), potassium in 105 (77%) and high oxalate in 75 (55%). The composition was calcium oxalate in 362 stones (47%), ammonium hydrogen urate in 210 (27%) and struvite in 49 (6.4%). Stones recurred in 30 patients (2%).nnnCONCLUSIONSnThe pattern of calculous disease changed from a predominantly lower tract site in the mid 1980s to the upper tract in the mid 1990s. Stone composition, urinary risk factors and dietary analysis suggest that diet, dehydration and poor nutrition are the main causative factors of stone disease.

Management of pediatric urolithiasis in Pakistan: Experience with 1,440 children

PURPOSEnWe evaluated the efficacy and safety of different modalities for pediatric urolithiasis in a developing country in 2 eras, namely before and after the advent of minimally invasive surgery.nnnMATERIALS AND METHODSnWe retrospectively reviewed the records of 1,440 children younger than 14 years treated with various modalities during a 14-year period. From 1987 to 1995, 486 and 50 patients were treated with open surgery, and extracorporeal shock wave lithotripsy (ESWL, Dornier Medical Systems, Inc., Marietta, Georgia) and minimally invasive methods, respectively. Between 1996 and 2000, 518 and 386 children were treated with surgery and minimally invasive methods, respectively.nnnRESULTSnOf the 1,440 children 795 (55.2%) had renal, 198 (13.8%) had ureteral and 447 (31%) had bladder calculi. Of the renal stones 556 (70%), 177 (22%) and 62 (7.8%) were treated with open surgery, ESWL and percutaneous nephrolithotomy, respectively. Of the ureteral calculi 85 (43%), 37 (18.6%) and 76 (38%) were managed by ESWL, ureterorenoscopy and open surgery, respectively. Of the bladder calculi 307 (68%), 77 (17.2%) and 63 (14%) were treated with open vesicolithotomy, transurethral pneumatic cystolithotripsy and ESWL, respectively. The renal stone clearance rate was 98% after open surgery, 84% after ESWL and 68% after percutaneous nephrolithotomy monotherapy at 3 months of followup. Similarly the ureteral stone-free rate was 54% after ESWL and 86.9% after ureterorenoscopy. Of the patients with bladder calculi 48% and 93% become stone-free after ESWL and transurethral pneumatic cystolithotripsy, respectively.nnnCONCLUSIONSnThe use of ESWL, percutaneous nephrolithotomy and ureterorenoscopy has resulted in treating a large number of children with a short hospital stay and early return to school. Open surgery is reserved only for complex stones.

Religious circumcision: a Muslim view

Muslim community (ijma) and argument from analogy Male circumcision (qiyas). All Muslims agree that these constitute the sources of Islamic law but diCer on their application. The origin of circumcision is shrouded in antiquity; mummies 6000 years old have been reported to show Muslims are divided into diCerent schools of thought, some of which are distinctive enough to be called sects. evidence of circumcision [1]. The tradition was prevalent among the Egyptians, Kalahari bushmen, Australian The most fundamental division is between the Sunnites and the Shiites. These diCerences have led to the emergaborigines and other African communities. The first definite account appears in Genesis (chap. 17), in which ence of six schools of law; the Hanafite, the Jafarite, the Malikite, the Hanbalite, the Shafiite and the Zaidite (of the covenant is made between God and Abraham, stating; Yemen), named after legal scholars. There are diCerences of opinion among these schools of law in Islam about ‘And he who is eight days old shall be circumcised the rules for circumcision. However, among the six among you, every male throughout your existing schools, only the Shafiite school considers it generations.’ obligatory (wajib) while the others regard it only as a sunnah and therefore recommended. Even those who Abraham himself was circumcised at the age of 99 years while his son Ishmael was circumcised when he was 13 consider it obligatory or rigidly practise it do not, legally speaking, consider it a condition for becoming a Muslim. years old. The Jews have continued to uphold the covenant by circumcising boys 8 days after birth, proIt is at most considered as an external symbol of being a Muslim. Again, if a person converts to Islam, it is not vided they are healthy. Circumcision was a common practice in pre-Islamic obligatory for him to be circumcised. Similarly, a person born of Muslim parents, if not circumcised, may remain Arabia and there are references in pre-Islamic and early Islamic poetry, such as the compilations of Hudhayl, a Muslim and will not be considered non-Muslim only because he is uncircumcised. About a third of the Farazdak and other poets. The Arabic words used for circumcision are ‘Khitan’ for males and ‘Khafd’ for Christian population in Pakistan is circumcised, while Hindus and Buddhists are not, except for medical indifemales. The syllables ‘Kh-t-n’ belong to the primitive Semitic language, as they occur in the same or cognate cations, e.g. phimosis, and prevailing bladder stone disease, where some patients erroneously believe that if forms in North-Semitic languages. It is therefore certain that circumcision is a primitive custom and an old they are not circumcised the prepuce will hinder the passage of stone. Some believe that circumcision will Arabian tradition, but was not introduced initially by Islam. This is evident from the fact that circumcision is increase their sexual power and virility. not mentioned in any form in the Holy Quran, and in Muslim societies the practice is attributed to the Prophet Female circumcision of Islam. For this reason, circumcision acquired the status of ‘Sunnah’ (Prophet’s tradition) although the Female circumcision dates to the time of the Pharoahs, long before the advent of Islam. It is commonly practised tradition is attributed to the Prophet Abraham [2]. It is further recognized in hadith (the sayings of the Prophet in Egypt and other African countries, where the prevalence ranges from 5 to 99% [5]; it is not performed in Mohammed) that circumcision belongs to pre-Islamic institutions [3]. In the traditions that enumerate the Islamic countries like Saudi Arabia, Iran and Turkey. It is also practised in the Egyptian Coptic Christian minfeatures of natural religion (al-Din al-fitra), circumcision is mentioned under the heading Tahara (cleanliness) [4], ority. According to a WHO report in 1994, 85–114 million women undergo this procedure worldwide. together with the clipping of nails, the use of toothpicks, the cutting of moustaches, etc. Whereas male circumcision has a precise anatomical definition, where the prepuce around the glans is excised, The Sharia is the divine law in Islam and encompasses every aspect of Muslim private life, social transactions, female circumcision lacks such precision. It may involve removal of a minute portion of the skin around the piety and rituals. The Sharia is rooted in the Quran, hadith and sunnah, argument from the consensus of the clitoris, part of the clitoris and even its total removal. In

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