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Background Autosomal dominant polycystic kidney disease (ADPKD) is the most common renal monogenic disease, characterized by bilateral accumulation of renal fluid-filled cysts leading to progressive renal volume enlargement and gradual impairment of kidney function, often resulting in end-stage renal disease. Kuwait could provide valuable genetic insights about ADPKD, including intrafamilial phenotypic variation, given its large household size. This study aims to provide a comprehensive description of the pathogenic variants linked to ADPKD in the Kuwaiti population using multiple genetic analysis modalities and to describe and analyse the ADPKD phenotypic spectrum in terms of kidney function, kidney volume and renal survival. Methods A total of 126 ADPKD patients from 11 multiplex families and 25 singletons were recruited into the study. A combination of targeted next-generation sequencing (tNGS), long-range polymerase chain reaction, Sanger sequencing and multiplex ligation-dependent probe amplification were utilized for genetic diagnosis. Clinical evaluation was conducted through renal function testing and ultrasonographic kidney volume analysis. Results We identified 29 ADPKD pathogenic mutations from 36 families achieving an overall molecular genetic diagnostic rate of 112/126 (88.9%), including 29/36 (80.6%) in families. A total of 28/36 (77.8%) families had pathogenic mutations in PKD1, of which 17/28 (60.7%) were truncating, and 1/36 (2.8%) had a pathogenic variant in the IFT140 gene. A total of 20/29 (69%) of the identified ADPKD mutations were novel and described for the first time, including a TSC2-PKD1 contiguous syndrome. Clinical analysis indicated that genetically unresolved ADPKD cases had no apparent association between kidney volume and age. Conclusion We describe for the first time the genetic landscape of ADPKD in Kuwait. The observed genetic heterogeneity underlining ADPKD along with the wide phenotypic spectrum reveal the level of complexity in disease pathophysiology. ADPKD genetic testing could improve the care of patients through improved disease prognostication, guided treatment and genetic counselling. However, to fulfil the potential of genetic testing, it is important to overcome the hurdle of genetically unresolved ADPKD cases.

By December 2019, humanity was challenged by a new infectious respiratory disease named coronavirus disease of 2019 or COVID-19. This is a viral infection based on the presence of the previously non-problematic coronavirus with assigned number 2. This virus causes severe acute respiratory distress and is known now as SARS-CoV2. Since SARS-CoV2 is an RNA virus, remdesivir and favipiravir, both broad-spectrum RNA polymerase inhibitors, were repurposed for treating COVID-19 patients. Remdesivir and favipiravir are antimetabolites, and they are structurally related to the naturally occurring structural elements of RNA. Both agents are prodrugs and must be activated intracellularly to exert their effects through numerous and different mechanisms of action. Efforts have been exerted to determine their efficacy and safety against COVID-19 through clinical trials. Clinical trials have shown an association of remdesivir with increased frequency of adverse effects (in comparison to favipiravir). Nevertheless, the data obtained with remdesivir resulted in its approval by the FDA on the 22nd of October 2020 for COVID-19 treatment. At present, remdesivir is being recommended by several treatment guidelines for the treatment of COVID-19 patients. The evidence in favor of favipiravir is compromised by the small number and low-quality of trials conducted. Favipiravir has shown various benefits when administered in mild and moderate cases of COVID-19, while remdesivir was more beneficial in more severe cases of the disease. Since the two agents are suitable for different groups of patients, both drugs can play a significant role in fighting this pandemic. The goal of this work is to summarize the information available on two antimetabolites - remdesivir and favipiravir - and to compare clinical experience obtained so far with these two agents in COVID-19 patients.

Kuwait Vision 2035 is an initiative that was launched in 2017 by His Highness the Emir of the State of Kuwait Sheikh Sabah Al-Ahmad Al-Jaber Al-Sabah. This initiative includes the implementation of a detailed development plan aimed at transforming the state of Kuwait into a regional leader in science, technology, and innovation. Health research will arguably prove to be one of the most impactful research arenas when it comes to accomplishing the goals set forth by the Kuwait Vision 2035 Development Plan. The high impact of health research is derived from its capacity to aid in the establishment of a knowledge-based health industry. The state of Kuwait lacks a system for promoting and managing national R&D efforts. At present, the research and development (R&D) expenditure in the state of Kuwait is far below the international standards that have been shown to lead to innovation and the subsequent development of a knowledge-based economy. Improvement of the weak and unstructured existing R&D apparatus in the State of Kuwait is among the most urgent challenges facing the nation as it strives toward innovation and development of a knowledge-based economy. Developing health research capacities in the State of Kuwait can significantly contribute toward improving public health, health promotion, disease prevention and treatment, and overall human welfare. Importantly, the positive impacts of such extensive benefits will not be restricted to the state of Kuwait and its citizens, but may in fact reap benefits for the global society as a whole. This article first analyzes the current status of healthcare services and health science research in the State of Kuwait, and then summarizes some essential R&D design principles that Kuwait needs to implement in order to achieve the milestones set forth in the Kuwait Vision 2035 Development Plan.

Most public health issues in Kuwait are related to unhealthy behaviours. Research shows that behaviours are the result not only exclusively of personal choices but also of myriads of other social and environmental factors. Kuwait is one of the leading countries in obesity and tobacco use in the world. Cardiovascular diseases stemming from complications related to these and other risk factors are important health issues based on their morbidity and mortality implications. These risks are spread across society and affect the old as well as young boys. The serious gaps between Kuwait’s health-related needs and the existing policies to reduce public health risks in Kuwait create a significant obstacle to healthy behaviour change. Kuwait requires adequate laws, policies, regulations, activities, and programs to promote people’s health. The Socio-Ecological Model (SEM) has been used successfully in health promotion in various behavioural settings, including obesity, physical inactivity, and smoking. We propose the use of SEM as a planning framework in building sustainable health promotion programs in Kuwait while paying attention to other concepts such as systems thinking, authentic community participation, community capacity, policy development, public health infrastructure enhancement, health coaching, and equity.

Abstract objective To compare our novel loupe-assisted varicocelectomy (LV) technique to the ‘gold standard’ demanding microscopic varicocelectomy (MV) technique for the management of varicoceles. Patient and methods Our LV technique, featuring testicular delivery and proximal spermatic cord occlusion using a tourniquet, has not been used before nor to our knowledge has it been reported in the literature. In the LV group, inguinal incision was done prior to testicular delivery and spermatic cord occlusion. Pampiniform and gubernacular veins were identified then tackled. Proximal spermatic cord occlusion helped in identifying those veins, and not confusing them with other cord structures that should be preserved. In all, 95 infertile men were included in this prospective, comparative study; and divided into LV and MV groups. They were followed-up for 1 year, pregnancy achievement, improvements in semen parameters, and complication rates were assessed. Results Both groups had statistically significant pregnancy rates and negligible complication rates. However, LV cost 33% less than MV and was quicker to perform. We did not find that the MV technique was better than our simple, more cost-effective, less time-consuming LV technique. Conclusion Our novel LV technique has similar success and complication rates as the ‘gold standard’ MV technique for the management of varicoceles, and is more cost-effective and less time consuming.

At the beginning of 2020, the world was swept with a wave of a new coronavirus disease, named COVID-19 by the World Health Organization (WHO 2). The causative agent of this infection is the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The data available on one of the promising therapeutic agents—nucleotide analog remdesivir (Gilead Sciences number GS-5734)—were evaluated. These data were concerned with remdesivir activation from the prodrug to the active molecule—triphosphate containing 1′-cyano group and modified nucleobase. This triphosphate competes with the natural substrate adenosine triphosphate. Additionally, its mechanisms of action based on RNA and proofreading exonuclease inhibition, leading to the delayed RNA chain termination of infected cells, and basic pharmacological data were assessed. Additionally, the analytical determination of remdesivir and its metabolites in cells and body liquids and also some data from remdesivir use in other RNA infections—such as Ebola, Nipah virus infection, and Middle East Respiratory Syndrome (MERS)—were summarized. More recent and more detailed data on the clinical use of remdesivir in COVID-19 were reported, showing the intensive efforts of clinicians and scientists to develop a cure for this new disease. Remdesivir as such represents one of the more promising alternatives for COVID-19 therapy, however the current understanding of this disease and the possible ways of dealing with it requires further investigation.

Objectives: The purpose of this study was to compare unenhanced computed tomography (UECT) to intravenous urography (IVU) for detecting urinary tract calculi, signs of obstruction and non-renal causes in the assessment of acute flank pain, and in their interobserver agreement. Patients and Methods: In this prospective study, carried out at a university hospital over a period of 1 year, 36 patients (27 males and 9 females) participated. Mean age was 44 ± 15 years (range: 14–73 years). The patients presented with acute flank pain and underwent UECT and IVU. The images were blindly evaluated by 2 experienced radiologists and the two techniques compared using the two-tailed McNemar’s test for matched pairs; p values Results: UECT detected stones in 11 (30.6%) patients, while IVU found them in only 8 (22.2%). The increased detection by UECT was due to its ability to detect smaller stones (Conclusion: UECT showed better detectability and interobserver agreement tan IVU, suggesting that UECT could replace IVU as the first imaging modality in the evaluation of acute renal colic.

Objectives: To compare the outcome of laparoscopic pyelolithotomy (LP) using the transperitoneal and the retroperitoneal routes. Methods: Demographics, intraoperative and postoperative clinical parameters were evaluated in 48 laparoscopic pyelolithotomies performed in patients with renal pelvic calculi of diameter >30 mm. The differences between the transperitoneal and retroperitoneal routes were analyzed. Results: Twenty-seven LP were performed using the transperitoneal approach (TLP), and 21 using the retroperitoneal approach (RLP). Apart from weight, the patients' demographics and stone size were similar in the two groups. Between the RLP and the TLP routes, the operative time was 112.1 versus 93.2 min (P = 0.01), mean time for oral intake was 1.9 versus 1.2 days (P

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).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.Patients given antioxidants had significantly reduced mean serum concentration of ALP (p0.001) 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 (p0.001) and ALP (p0.001) levels (from 24 hours to day 28) compared with patients who were not given antioxidants.These findings suggest that oral antioxidant therapy prior to lithotripsy may reduce the severity of long term renal injury caused by the shock waves.

Pain control in outpatient rigid cystoscopy is often achieved via the application of intraurethral lidocaine jelly. This clinical trial was designed to test the effectiveness and safety of a new method to provide local anesthesia, transperineal urethrosphincteric block (TUSB), prior to rigid cystoscopy.Male patients posted for outpatient rigid cystoscopy were randomized to receive TUSB (group A) using 10-20 ml of 1% lidocaine, intraurethral 30 ml of 2% lidocaine jelly (group B) or intraurethral 30 ml of neutral jelly (group C) as a method of pain control. Following the procedure, plasma concentrations of lidocaine were measured in group A patients. Outcome assessments included mean urethral and sphincteric numerated pain scores (0-10), overall discomfort level (0-4) and plasma lidocaine levels.One hundred and fifty patients were recruited, 50 in each group. When the three groups were compared, the ratio of group A patients with sphincteric pain scoreor=2 was significantly the least. Also, the ratio of group A patients with discomfort levelor=2 was significantly less than the same ratio in either group B or C. Plasma lidocaine concentrations were within nontoxic levels and never exceeded 2.83 microg/ml in 39 subjects.This study demonstrates that TUSB is an effective and safe method in significantly relieving the pain associated with outpatient rigid cystoscopy. TUSB may offer urologists and anesthetists an alternative way to achieve pain control besides intraurethral lidocaine jelly during rigid cystoscopy.

Hyperhomocysteinemia (HHcy) is associated with cardiovascular disease such as coronary arteriosclerosis and stroke. However, its role in the development of vasculogenic erectile dysfunction (ED) is still putative. In this study, we evaluated the relationship between plasma total homocysteine (tHcy) and the presence of vasculogenic ED in men with adult-onset diabetes mellitus.This was a case-control study of 97 adult-onset diabetics with vasculogenic ED and 97 concurrently sampled control diabetics, who were free from ED. We obtained risk estimates of odds ratios (ORs), both crude and adjusted, using logistic regression models. We then determined cardiovascular risk factors and HbA1c levels in both groups of patients.Plasma tHcy was significantly higher in cases compared with controls. The mean +/- standard deviation plasma tHcy in cases was 11.2 +/- 3.5 micromol/L versus 8.8 +/- 2.6 micromol/L in controls (P0.001). Moreover, those with HHcy had 5.2 times the odds of vasculogenic ED compared with men without HHcy (OR 5.2, 95% confidence interval, 1.4 to 18.9). Although the risk of ED did not vary significantly according to body mass index, serum cholesterol, triglycerides, C-reactive protein, and blood HbA1c levels, it was significantly affected by smoking status and hypertension.High plasma tHcy appears to be associated with ED in patient with adult-onset diabetes mellitus.

OBJECTIVE To determine the prevalence of and risk factors for erectile dysfunction (ED) in men newly diagnosed with type 2 diabetes mellitus (DM). PATIENTS AND METHODS All consecutive samples of men newly diagnosed with type 2 DM attending the diabetes centre in the capital of Kuwait were included in the study. Face-to-face interviews with the men were conducted using the International Index of Erectile Function (IIEF)-5 questionnaire. A threshold IIEF-5 score of

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. Methods: Venous blood samples were obtained from 327 unselected apparently healthy indigenous Arab men (Kuwaitis and Omanis) aged 15–79 years. Samples were also obtained from 30 Arab men with newly diagnosed prostate cancer. Serum levels of total testosterone (TT), sex hormone binding globulin (SHBG), derived free androgen index (FAI); adrenal C19-steroids, dehydroepiandrosterone sulfate (DHEAS) and androstenedione (ADT) were determined by chemiluminescent immunoassay. Age specific reference intervals, mean and median for each analyte were determined. Frequency distribution pattern for each hormone was plotted. The reference range for hormones with normal distribution was mean ± 2SD and 2.5–97.5% for those with non-normal distribution. The mean serum levels of the hormones in Arab men with prostate cancer were compared with values in healthy age-matched Arab men. Results: There was a significant decrease between the 21–29 years age group and the 70–79 years age group for TT (−38.77%), DHEAS (−70%), ADT (−36%) and FAI (−63.25%), and an increase for SHBG (+64%). The calculated reference ranges are TT (2.73–30.45 nmol/L), SHBG (6.45–65.67 nmol/L), FAI (14.51–180.34), DHEAS (0.9–11.0 µmol/L) and ADT (0.54–4.26 ng/mL). The mean TT, SHBG, DHEAS and ADT in Arab men were significantly lower than those reported for Caucasians especially in the 21–29 years age group. Arab men with newly diagnosed prostate cancer had higher serum TT (P

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

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.

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.

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.

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.

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.

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.

We determined the time course of malondialdehyde, a measure of free radical damage, in patients undergoing standard surgical treatment for testicular torsion.Patients presenting with testicular torsion were studied prospectively. Blood samples were obtained after administering general anesthesia but before surgical incision, and 10 minutes, 30 minutes and 24 hours after detorsion. Orchiopexy was performed in patients with viable testes (group 1) and orchiectomy was performed in those with nonviable testes (group 2). Further blood samples were obtained 1 and 3 months after surgery. Similar blood samples were taken from controls, including patients younger than 40 years undergoing other operations involving manipulation of the testis, such as hydrocelectomy or orchiopexy (group 3). The level of malondialdehyde in each serum sample was determined by the thiobarbituric acid reaction.A total of 65 patients were studied, including 56 with testicular torsion and 9 controls (group 3). Of the 56 patients 11 (19.6%) with testicular torsion underwent ipsilateral orchiectomy and contralateral orchiopexy (group 2). The remaining 45 patients (80.4%) underwent bilateral orchiopexy (group 1). However serum malondialdehyde was estimated in only 34 of the 56 patients with torsion. Mean malondialdehyde at 0, 10 and 30 minutes, 24 hours, and 3 and 6 months was 3.3, 3.69, 3.69, 2.9, 2.65 and 2.39 nmol./ml. on the 24 group 1 patients, 3.53, 4.56, 3.87, 2.87, 2.82 and 2.64 nmol./ml. in the 10 group 2 patients, and 3.6, 3.08, 3.18, 2.95, 2.88 and 2.65 nmol./ml. in the 9 group 3 controls, respectively. The highest serum malondialdehyde was at 10 minutes after detorsion in groups 1 and 2. There was a statistically significant difference in malondialdehyde between groups 1 and 2 compared with group 3 at 10 minutes (p0.04). Serum malondialdehyde returned to baseline at 24 hours in all patients.The results of this study indicate that testicular torsion and its treatment with detorsion is an example of ischemia-reperfusion injury, producing measurable changes in malondialdehyde in humans. Thus, serum malondialdehyde could be used to determine the extent of injury.

Background/Purpuse:To review the outcome oftubularized incised plate (TIP) urethroplastyin the primary treatment of penile hypospadiaswith minimal chordee and to describe ourexperience with the lateral flap used to coverthe urethroplasty.Methods: The charts of all patients withpenile hypospadias who underwent primary TIPrepair in our hospital between 1996 and 2001were examined and pre as well as postoperativebiodata were recorded. We used the lateral flapto cover the repair rather than a flapharvested from preputual skin as in theoriginal description.Results: 94 patients were identified butonly 83 were suitable for analysis. The meanage of the evaluable patients was 2.67 years(range 1–10). The mean of follow-up was 17.49months (range 1–54). The preoperative meatalposition was coronal in 50 (60.2%), distalshaft in 28 (33.7%) and mid shaft in 5 (6.1%)patients. The mean length of the urethral platewas 8 mm (range 5–15) while the mean width ofthe plate was 6 mm (range 4–8). In 30 patients(36.14%) chordee was present preoperatively.All patients were admitted to the hospitalfollowing the TIP urethroplasty with a urethralstent in place. The lateral flap was used tocover the repair in 70 patients. The stent wasleft for an average of 7.83 days (7–10). Theaverage hospital stay was 8.83 days (7–11). Acosmetically normal vertically orientedslit-like meatus was seen in 78 (94%)patients. The TIP repair revealed an apicalmeatus in 82 (98.8%) and a conical glanularconfiguration in 79 (95.20%) patients. Theparents observed that the urinary stream andthe penile shaft were straight in 75 (90.4%)and 82 (98.8%) patients respectively. Sevenpatients (8.4%) developed meatal stenosisrequiring repeated dilatations; four patients(4.8%) developed urethrocutaneous fistula andone (1.2%) had postoperative bleedingrequiring transfusion. Of the 70 patients whohad the lateral flap, 3 (4.28%) developedurethrocutaneous fistula.Conclusion: Our experience indicates thatthe TIP repair gives a good cosmetic andfunctional outcome with minimal complications.Urethroplasty coverage using the lateral flapis associated with a low incidence ofurethrocutaneous fistulae.

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.

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...

Background Adrenocortical carcinoma is a rare and aggressive malignancy. Patients usually present early with manifestation of abnormal hormone secretion. However, adrenocortical carcinoma can also be nonfunctioning, and such patients present late with a mass effect or distant metastases. Case presentation We herein report a case of a 30-year-old Sri-Lankan woman who presented with a 3-month history of left flank pain associated with nausea, vomiting, and weight loss. Imaging revealed a large left upper quadrant mass with a 1.8-cm left lung nodule. The differential diagnoses included a left adrenal mass, left upper pole renal mass, and retroperitoneal sarcoma. A functional adrenal work-up revealed no abnormal findings. Surgical excision of the mass was uneventful with no postoperative complications. Pathological analysis revealed a nonfunctioning adrenocortical carcinoma measuring 16 × 14 × 10 cm. To our knowledge, a mass of this size is among the largest nonfunctioning adrenocortical carcinomas reported in the published literature. The investigations and approach to treatment were consistent with those in the published literature. Conclusion Large nonfunctioning adrenocortical carcinomas pose a diagnostic and therapeutic challenge, and most are diagnosed at a late stage. Appropriate imaging and functional work-up of the mass are vital before treatment. Surgical excision is safe, even for large adrenocortical carcinomas; excision in patients with advanced disease has been shown to have the best outcomes.