University Alumni Reunions

Reunion Rendition

Every few years or so, we get together again,

An organizer is chosen and he starts the plan

'A reunion is coming; it'll be really grand,

Make plans to attend or you are not my friend! '.

The first reunion was somewhat bitter-sweet

After 20 years being apart, we decided to meet

The Mines was chosen as the place of retreat

We were anxious who would be there to greet

To our surprise the turn-out was not bad

After 20 years many of us have put on some fat

The lean boys once are now not so nice to look at! ,

The shapely girls before are now very much flat!

Three years later in Kucing we camped

Many were there too, the distance was pre-empt

Even for a weekend, its worthy to be cramped!

Friendship among us is definitely stamped

Ipoh, then Penang reunions were done

Each time we met, the evening was fun

Many bring spouses daughters and sons

The joy we have is second to none!

Do you think we can meet again and again?

Will our body be in sync with our brain?

How many more years you think to attain?

And shall we meet again and again?

By the fortieth year, I hope we will still be around,

Even if by then our knees are somewhat bound

Who cares if our waists and cheeks are somewhat round,

When we meet again as always it’s time to clown.

Are you eager to meet on the 50th year? ,

By then perhaps hearing aid is in our ear.

The crowd may be less as some may have fear

To travel far as the vision is no longer clear.

By 60th year do we dare to promise?

We will be around and not give this a miss?

Do we bother even if bladder is forever apiss!

To be with friends for an evening of bliss!

That night as we stand staring at that door,

Wondering, but not knowing what fate is in store…

Hands trembling, our hearts are beating fast…..

We will cross the threshold and step into our past…….

Lets say grace to the Almighty

For showering us with friendship till eternity………

Noor Othman

PUV posterior urethral valve

PUV, Posterior Urethral Valve

PUV, posterior urethral valve is the most important urological condition to diagnose in the neonatal male.  This is often suspected in the antenatal ultrasound of the mother.  The typical ultrasonic findings are: bilateral hydronephrosis, hydroureter and a distended bladder.  Occasionally, the posterior urethra would also be found to be distended.

Early surgery helps to reverse some of the obstructive uropathy. The patient can be catheterised with a feeding tube and a MCU, micturition cystourethrogram Xray done to confirm the diagnosis.  The urethral catheter should be left insitu after the MCU to drain the kidneys and also to allow the urethra to dilate to facilitate subsequent endoscopic treatment.

The definitive treatment of PUV is that of endoscopic fulgration in the operating theatre.

However, if there are noun paediatric instruments and the child is well (e.g. sepsis or renal failure), an emergency treatment is that of a vesicostomy.  The vesicostomy can be closed later on when the child is better, e.g. at the age of 4 years.

PROGNOSIS:

However, the PUV has already caused obstruction inuretro and more than 50% of patients have life long bladder dysfunction and some degree of kidney failure. 

Written by:

Dr Clarence Lei Chang Moh, Consultant Urologist.

Date: 20.9.2013

Enclosures: Xray (urethrogram)  of posterior urethral valve before and after treatment.

Dealing with Urolithiasis in Primary Care

DEALING WITH UROLITHIASIS IN PRIMARY CARE,

MIMS GP Workshop, Sandakan, 22 September 2013

by Dr Clarence Lei Chang Moh; email: clarencelei@gmail.com

Urinary stones affect 5 – 15% of populations (commoner in young men), with a 50% recurrence rate over 10 years. Ureteric colic is the most severe pain that men experience.  In addition, urinary stones cause a variety of symptoms including backache, suprapubic discomfort, dysuria and haematuria.

A basic investigation in any clinic is that of a urinalysis. I use a urinalysis machine with a print-out, charged at the  PHCSA rate of RM10. Metabolic investigations to establish the cause of the stone include the following: serum calcium, serum uric acid, serum creatinine, urinalysis and urine culture. About 1% of patients coming to a stone centre for lithotripsy are found to have hypercalcaemia due to primary hyperparathyroidism.  Urinary stones are confirmed by imaging. The initial imaging is usually that of an ultrasound of the urinary tract, which readily pick up stones in the kidneys and bladder.  Small stones in the ureter can be seen almost instantly with non-contrast CT urography, low dose radiation.  IVP is outdated unless CT is not available. I also ask for a KUB as baseline for follow-up. In older patients, bladder stones may be due to associated BPH, benign prostatic hyperplasia.

Medical therapy and stone prevention is mainstay of therapy in general practice. The preferred analgesia for ureteric colic is diclofenac rather than an opiate, which  causes sedation. Patients who are allergic to diclofenac may be given tramadol. Diclofenac is nephrotoxic, if used for more than a week.  For passage of ureteric stones the lower ureter may be relaxed  by  MET, medical expulsive therapy. This consists of alpha-blockers e.g. prazosin 1 mg bd, terazosin 2mg ON.  This is  taken at night to reduce postural hypotension.  Stones smaller than 6 mm do not usually require surgical intervention unless complicated by sepsis. Large untreated urinary stones will  eventually cause urosepsis.

The most important medical treatment for urinary stones is that of water therapy such that the patient produces 2 litres of urine per day.  The fluid intake of the patient depends on his environment.  There is no good evidence of advantages of specific juices or herbals.  A diet suitable for a recurrent stone former is one with less salt, less uric acid (red meat, nuts, protein), less oxalate (chocolate, spinach, concentrated tea) and normal calcium.

Uric acid stones can be effectively dissolved by medical therapy through urinary alkalinisation, keeping the pH around 7.  Uric acid stones comprise of about 20% of stones and are radiolucent but readily seen on ultrasound and non-contrast CT.  Even staghorn calculi of uric acid can be dissolved over a period of 6 months.  However, the patient should have good renal function to avoid accumulation of  potassium in PotCit and sodium  in sodium citrate.  Citrate in the urine reduces crystallisation of the calcium and uric acid and increases the stone free rate following lithotripsy, from 45.5% recurrence to 12.5% compared to a controlled group, over a 12 month period.

Stones may also be associated with infection especially in ladies; infective stones are faintly radio-opaque.  Stone and infection should be cleared by surgery, vigorous antibiotic therapy and followed by prophylaxis e.g.  nitrofurantoin 50mg on night for 6 months. In Malaysia stones are also not uncommon during pregnancy.  Unfortunately, radiation and lithotripsy are contraindicated in pregnancy. Obstructed ureters during pregnancy can be drained  with a percutaneous nephrostomy or ureteric stent, until the baby is delivered.

Indications for referral to a urologist would include: persistent severe colic for more than 48 hours, fever above 38ºC indicating urosepsis, stones which are large or multiple. Most stones are removed by ESWL, extracorporeal shockwave lithotripsy or endoscopic lithotripsy viz ureteroscopy or percutaneous nephrolithotripsy.  Only 5% of stones require open surgery eg huge stones or bladder stones in children, the later to avoid injury to the small urethra.

Urinary Tract Stones

URINARY TRACT STONES

INTRODUCTION:

Malaysia lies in the “stone belt”.  This is probably related to chronic dehydration from the hot weather, as well as the diet.  The prevalence of stones in male is about 15% whereas it is only about 1/3 of this in female.  Again, this is probably related to the outdoor activities of men in general and possibly from the longer urinary tract in men.  Stones can form in any part of the urinary tract: kidney, ureter and bladder. The stones can occasionally get impacted in the urethra, causing urinary retention.

PRESENTATION:

Ureteric colic is the most severe pain a man can experience.  If the stone is in the kidney, there may be not much  symptoms.  If the patient has a bladder stone, he may present with intermittent gross haematuria and difficulty in urination. Stones can often cause infection giving rise to high fever. 

Pain relief is important for ureteric colic and the most efficacious is that of a NSAID e.g. Diclofenac.

One also has to consider the differential diagnosis of a ureteric colic: if in the right side, this may be an ectopic pregnancy or appendicitis.  In older persons, one has to consider perforated diverticulitis and aortic aneurysm.

INVESTIGATIONS FOR STONE DISEASE:

The following investigations need to be done:

(1)    Urinalysis, urine culture

(2)    KUB, this picks up about 80% of the radio opaque stones.  Uric acid stones are not radio opaque.

(3)    Ultrasound is a simple screening test which can pick up stones easily in the kidney upper ureter and the bladder.

(4)    CT, non-contrast: this is useful in acute setting to rapidly diagnose stones in the ureter to clarify the diagnosis of loin pain.  One has to be careful with the use of intravenous contrast as this may give rise to fatal anaphylaxis.  In patients with renal impairment, the intravenous contrast may be nephrotoxic and should be avoided if the eGFR is <35 min.="" ml="" nbsp="" o:p="">

NATURAL HISTORY OF STONES:

Large kidney stones will be associated with infection and formation of pus.  Stones in the ureter can cause obstruction, also giving rise to sepsis as well as kidney failure. 

METABOLIC INVESTIGATIONS FOR STONES:

To prevent stone formation, one would need to try to find out the underlying cause.  This may be infection.  The blood should be sent for analysis of serum calcium and uric acid.  A raised serum calcium may be due to a hyperactive parathyroid gland, which may need surgical treatment.  Stone formation is part of the presentation of hyperparathyroidism.

MEDICAL MANAGEMENT OF URINARY STONES:

(1)    The most important management is to drink liquids to produce 2 litres of urine a day.

(2)    The dietary management could involve taking low salt diet, normal calcium diet, low uric acid diet and a low oxalate diet (namely, less chocolate, less nuts).

MANAGEMENT OF URINARY STONES:

Stones which are less than 6 mm and not causing significant obstruction or infection may be treated conservatively. This involves taking sufficient fluids and analgesia.  If the patient has uric acid stones, such stones can be dissolve by taking urinary alkaliniser e.g. Potassium Citrate.

MET, MEDICAL EXPLUSIVE THERAPY:

MET is used if the stone is in the lower ureter.  An alpha adrenergic blocker (e.g. Terazosin) can be used to relax the lower ureteric orifice and the bladder neck to encourage the passage of stones.

SURGICAL INTERVENTION

Stones which are in the kidney and upper ureter and are less than 20 mm may be treated by ESWL, Extracorporeal Shockwave Lithotripsy.

Stones in the bladder and in the lower ureter may be treated by endoscopic means.  Treatment of the stone in the ureter is with ureteroscopic lithotripsy and that in the bladder, by vesicolithotripsy.  The stone may be fragmented by an energy source e.g. laser or mechanical Lithotrite. 

Big stones in the kidney may be treated by PCNL, Percutaneous Nephrolithotripsy.  It is important to cover PCNL with antibiotics as a percutaneous tract may be complicated by infection (and also by bleeding). 

SUMMARY:

Urinary stones are common, often a cause of severe loin pain in young men.  Smaller stones can often be treated by pain relief, ESWL, Extracorporeal Shockwave Lithotripsy and drinking sufficient fluids to prevent further formation. Bigger stones can be treated by endoscopic lithotripsy.

Written by:

Dr Clarence Lei Chang Moh, FRCS Urol, FEBU

Consultant Urologist

email: clarencelei@gmail.com

4 September 2013