Adel Al Dayel
Department Urology and Nephrology, King Fahd Military Medical Complex, Dhahran, Saudi Arabia
Introduction: Urinary stones is a well-known disease in the Middle East since long time ago, although no definite description was mentioned in the pre-historic Egyptian writings. Stones were discovered in the urinary bladder of a mummified child by Elliot Smith in 1901 in a tomb at El-Amrah, near Abydos. This was clear proof of the existence of the disease in this region.
Islamic scholars such as Abulcasis (Abu Al Kasim) Al Zahrawi and Al Razi and others who lived during the period 600–1200 AD gave full description of urinary stones in the kidney and ureter and urinary bladder with details of its presentation and management including surgical procedures on urinary bladder stones.
The Arab Peninsula is a large are of the Middle East extending from Syria in the North to Yemen in the South with diversity of cultures and difference in climate and temperature ranging from 0° in the North in winter and reaching 50° in some parts of the region in the summer. Most of the regions are desert. Saudi Arabia, which constitutes the major part of the Arab Peninsula, experienced rapid cultural changes with the effect of Western Civilisation developing large multicultural cities, thus creating wide migrations from the South and North mostly to the Western, Middle and Eastern regions.
Since about five decades Saudi Arabia introduced western medicine in most of the regions with modern hospitals and advanced management facilities, creating a good opportunity and accessibility for all the citizens to enjoy medical treatment free of change. Since about two decades many physicians have interested themselves in the urolithiasis problem and run clinical studies on the different aspects of that diseases.
Clinical Studies: We are intending in this review to present analysis of the available studies on this disease, which are mostly from the Middle and Western region Abdulhalim reported on a clinical study of 512 stones patients followed in the stone clinic. All of his was done in the Western Province of Saudi Arabia and a control group of 170 subjects and will be referred to as Study 1. Data collection and analysis of 1257 patients treated for stone diseases from the eastern region were reported for the first time, of which 200 patients had extensive dietary and biochemical analysis. We also included a review of urine analysis from 1060 non-stone former Military Cadets. This will be referred to as Study 2.
The review also included edited abstracts from the Saudi Urological Conferences (1983–1996) by Abomelha and Fallatah, as well as comparisons of results with the reported data from different international studies.
Study 1: Dr. Abdel-Halim et al. has reviewed the data sheets in stone clinics of 512 patients, which included bio-data and diet as well as biochemistry and stone analysis. The patient age range was from 1 to 80 with a mean of 39.15. The male to female ratio was 3:9:1. Loin pain was the commonest presenting symptoms, whilst burning micturition was the second, with haematuria the commonest presenting symptom in the age group below 15 years. Fresh urine samples were examined from 140 patients showing calcium oxalate crystalluria in 9.3%. No uric acid crystals were detected. A 24-hour urine analysis was studied in 115 patients. The total volume of urea was <200 ml/24 hours in 63.5% with a mean total volume of 1888.30 ml. 38% had acidic urine with pH range (5–5.4) with mean value of 5.2 while in control group 26.9% had acidic urine with a mean of 5.2 also. Hyperuicosurea was found in 12.7% which was less than in control group where with a value of less than 100 mg/24 hours was noted in 18.2%, which is much higher than the control were only 3 cases out of 23 subject had marked hypocitrate urea. Serum uric acid was elevated in 12.5% of the stone former and the entire control group was within the normal hospital range. Stone analysis was performed on stones from 512 patients. 112 stones (21.8%) was pure or high content of uric acid or urate. Oxalate was identified in 305 (59.5%) of the stones, and 95 (18.6%) was phosphate stones.
Study 2: The 1257 patients included in this review were from the Eastern Province region who underwent treatment for renal stones and would be analysed and reported for the first time. The patients were referred from different medical centers to the King Fahd Military Medical Complex in Dhahran for treatment of Urolithiasis between 1988 and 1998 after confirming the diagnosis of urinary stones. Male to female ratio was 3:3:1 with age range from 3 to 82 years (mean 40.81:13.34). The clinical work up included urine analysis and culture, 24-hour urine analysis blood chemistry, radiological evaluation and wet chemical stone analysis. Ultrasond and IVU were performed on all patients and revealed no obstruction in 39.5%, while 139 patients (13.2%) had marked obstruction. 265 patients (25.2%) had moderate obstruction and 204 patients (19.4%) had mild obstruction. The stone position was identified from plain x-ray film as radiopaque, faint, or radioluscent. Accordingly, 873 patients (82.6%) were presented with radio-opaque stone, 127 patients (12%) had faint stones and only 57 patients (5.4%) had complete radioluscent stones. A total of 967 (76.93%) patients had acidic urine with urine pH <6 while 970/1063 controls, 91.25% had urine pH <6, and micro-organisms were isolated in 180 (14.32%) patients [Table 1].
Table 1.
Summary of the results of 24-h urine analysis
Hypercalcemia found in 51 (3.4%) patients, hyperuricemia in 136 (11.01%). Hyperparatyrodisim was reported in 42 (6.38%) patients; all of them had stone recurrence [Table 2].
Table 2.
The incidence in hypercalcemia, hypophosphatemia, hyperuricemia, hyperparathyroidism and hypomagnesemia
Stone analysis was performed on 896 stones, component analysis revealed 378 (42.2%0 were calcium oxalate stones, 203 (22.7%) were mixed calcium oxalate phosphate stones (with or without infection). Uric acid stones found in 171 (19.08%) patients and cysteine stones in 77 (8.59%) [Table 3].
Table 3.
The incidence of different types of stones
Conference Reports: National Saudi Urological meetings have been held on an annual basis since 1983. Abomelha and Fallatah have collected all the abstracts of the presentations at the Saudi Urological Conference held between 1983 and 1996. With reference to urolithiasis, many have reported certain aspects of their experience and management. Faqih et al. reported on the treatment of 444 complicated renal stone patients with non-surgical strategies. Out of those 264 patients treated with PCNL, only 8.7% had residual stones 3 mm or larger on discharge. 110 patients were treated with ESWL mono-therapy and showed a success rate with stone particles residue of not more than 3 mm in three months in 54 patients (49.1%).
Abomelha et al. reported on the changing pattern and sizes of the renal calculi through the analysis of the data of more than 3000 stone patients treated in their clinic between 1980 and 1989, it showed decrease of the bulky stones from 28% t 15% and increase of the solitary stone from 14% to 50%. Another review for the same group showed that 21% of their patients were with ureteric calculi. Data from many other centers was presented in reports over many years with reference to observations on special entities of management like management of stag horn uric acid stone, ESWL in renal pelvic ectopia, as well as experiences with modalities of management and generations of lithotripters. It showed beyond doubt that there is continuous interest in reviewing the stone management data and treatment options.
The above studies and reports represent the outline of most of the work conducted on stone diseases in Saudi Arabia, which is not only limited but also non randomized and lacking proper control groups. Abeulhalim study could be considered the only statistically significant epidemiological study. Still there are many important lessons that could be drawn. Above all the high incidence of cysteine and uric acid stone in comparison to reported data from western reports, Herring et al.; Murphy and Pyrah. Urine analysis showed that the mean of urine pH in study 1 showed a higher percentage of acidic urine that in control group with a mean urine pH of 5.76%. Robertson et al. has reported that the mean urine pH in their study was of less acidic urine and reflected patient communities from the Riyadh area. The mean urine pH was toward the acidic side in the entire patient groups. The observation of Abdulhaim of high fiber and calcium intake in the Saudi stone formers patient, is contrary to the previously reported observations by Griffith et al. The stone management in Saudi Arabia took an important leap within the last ten years, with the introduction of the new modalities of the stone management including the Endoscopic surgery as well as Extra Corporeal Shock Wave Lithotripsy (ESWL) which became widely available, with more than (30) ESWL devices distributed in all the regions of the Kingdom. The report of changes in size of the stones presented over the last 10 years confirm the availability of the stone management to the major part of the community. Further well constructed studies of the above variable could confirm or explain the differences between the disease characteristic in this community and previously reported data from different western communities.
Presented at the: 13th Saudi Urological Conference
Riyadh Armed Forces Hospital
14–17 February 2000 (09–12 Dhu Al Qa'dah 1420)
