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Year : 2016  |  Volume : 8  |  Issue : 6  |  Page : 198-207  

Benchmark urological presentations

Date of Web Publication26-Apr-2016

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How to cite this article:
. Benchmark urological presentations. Urol Ann 2016;8, Suppl S2:198-207

How to cite this URL:
. Benchmark urological presentations. Urol Ann [serial online] 2016 [cited 2020 Aug 9];8, Suppl S2:198-207. Available from: http://www.urologyannals.com/text.asp?2016/8/6/198/181214

Urological practice: The need for ethical and culture rooting

Abdulmoniem Bellah Mohamed Elamin

Department of Urology, Medical Services Armed Forces, Abu Dhabi, United Arab Emirates

Urological practice is the art of examining, investigating and treating kidneys, ureters, bladder, internal and external genital organs. The field of fertility is of common interest to the urologist, andrologist, and gynaecologist. Sexual organs are most important organs in social life next only to the brain. In many societies most taboos are webbed around sexuality and thought. Moral codes, Ethical values, and religion in a broader sense present formulae and guide lines of how to deal with the relationship between thought and sexuality. Islam provides a regulatory system of life that effects balance between sex and thought. A muslim patients, and a muslim urologist are expected to follow the teachings and the guide lines of Islam to characterize their behaviour, attitude, treatment, and acceptance of its outcome as part of the divine will. In disputable questions such as organ transplantation, operative change of sex, treatment of homosexuality, treatment and prevention of S.T. disease moral guidance based on practical exhaulted values is offered and answers can be found for even more complex moral medical issues.

A look in the daily urological practice in the Muslim world shows that it is far from being Islamic. The practice in Muslim countries follows Western schools of ethics and, philosophies. This is a contradiction that needs to be resolved. The correction of this situation is important, essential and urgent. It must inevitably follow reconstruction of identity, reconsideration of history and assessment of realities and practice of medicine in general urology in particular. Examples should be architectured to suit every day clinical, surgical, and medical counselling. Patients, doctors and legislators should have their contributions. This paper attempts to consider some of these complex moral issues and provide some suggestions.

Presented at the: 5 th Saudi Urological Conference

King Fahd Military Medical Complex

22-23 March 1989

The role of urodynamics in current urological practice and it's benefit in diagnosis and treatment of some pediatric urodynamic findings in relation to urological pathology

Mohamed Lotfi Mahrousseh, Adel Youssef, Saleh Al Mohalhel

Department of Urology, Riyadh Central Hospital, Riyadh, Saudi Arabia

Urodynamic study is becoming an important part of the evaluation of patients with voiding dysfunctions. This is a review of some aspects concerning methodology findings and current principles in urodynamics as well as summarizes the experience gained by us regarding urodynamic assessment based on the concepts that dysfunction is common and clinically important in the most frequent urological pathologies affecting patients, perhaps no other urological disorder has undergone such dramatic evolution in management during the recent past as that for neurogenic dysfunction of the bladder.

Nowadays urodynamic tests have greatest clinical validity when their interpretation is left to the treating physicians, who should either supervise the study or be responsible for correlating all of the findings with personal clinical observations.

Our study was interested in children having the following common urological problems:

Urological Incontinence: 42 children with refractory incontinence were examined. Detrusor instability was present in 72% of them. Anticholinergic treatment has improved or suppressed the symptoms. The bladder capacity was generally lower than normal

Recurrent Urinary Tract Infections: 66 girls were urodynamically examined because previous treatments had failed to control infection. 69.5% of them were having Detrusor instability. Although the uroflow was normal the cystometrical finding has proven the diagnosis. Anti-bacterial chemoprophylaxis plus anti-cholinergic and antiphligistics were instituted by this group

Primary Vesico Ureteral Reflux: From the 82 children with primary VUR, 55% in girls and 21% in boys were having Detrusor instability, the incidence of refluxing units was almost identical in stable and unstable bladders

Infravesical Obstruction : This group comprises 28 boys and 4 girls. Most of the boys were having a mechanical infravesical obstruction. In 3 of the girls Detrusor Sphincter Dyssynergia was diagnosed, and treated successfully.

In our opinion, we are getting nearer to a new definitive concept of Medicine and that is: "Medicine" is not only to save the life of the patient; it is also to make his life more useful and much more enjoyable.

Presented at the: 6 th Saudi Urological Conference

National Guard King Khalid Hospital - Jeddah

27-28 November 1991

Maldescended testis: Experience with 568 cases

A. Al Jutaili, M. S. Abomelha, S. Orkubi, M. Said, K. Al Otaibi, A. Shaaban

Department of Urology, Riyadh Armed Forces Hospital, Riyadh, Saudi Arabia

In a retrospective study, the case notes of 568 patients with maldescended testis treated at Riyadh Armed forces Hospital between January 1983 and July 1995 were reviewed. We found retractile testis in 29 cases and 539 cases with undescended testicles. The age of patients at correction were less than 2 years in 13%, between 2-5 years in 37%, 5-13 years in 27% and post pubertal in 23%. There were 21% with bilateral, 79% unilateral with left to right ratio of 1:1. The total number of testicles operated were 589. The intraoperative location of the testicles were inguinal in most of the cases 487 (83%), intra-abdominal in 18%, ectopic in 5 testicles (0.8%) while 28 testicles diagnosed as agenesis. The operative procedure was one stage in the majority of patients 85%, two stages in 3% and orchidectomy was necessary in 25%. The re-do operation was necessary only in 16 testicles (3%). 424 of operated testicles were followed up. 31 testicles found to be atrophied.

We can conclude that the majority of children with maldescended testis do present after the age of 2 years (87%). Post pubertal presentation (23%) is still a major problem and need more public education.

Presented at the: 9 th Saudi Urology Conference

King Fahad Hospital - Jeddah

14-16 November 1995

Features of Saudi urology

M. S. Abomelha

Department of Urology, Riyadh Armed Forces Hospital, Riyadh, Saudi Arabia

Introduction: Saudi Urology had practically commenced in the 1980s, wherein schistosomiasis, tuberculosis, urinary tract infection and urolithiasis were the main presentations. At the same time, the new renaissance in Urology worldwide started with the advanced technology in the form of Endo-Urology, ESWL, minimal invasive procedures and laparoscopy. It was a big challenge for the Saudi Urology to provide the basic urological service and at the same time introduce the new advances in urological technology. Establishing secondary and tertiary medical care in the field of Urology absorbed this challenge. Moreover, the teaching and training program was launched to end with a well structural residency training program.

In this paper, some features of Saudi Urology will be covered outlining the population, urology service, education and training, and some aspects of urolithiasis, GU-tumour and BPH, which are the main topics of our conference.

Population: Saudi Arabia is a big country with an area of 2.4 million square kilometers. It has 14 million native inhabitants in addition to 7 million expatriates. The growth rate is very high (4.0%) and 50% of the population is below the age of 15 years. The percentage of population above the age of 65 years is only 2.6% (Europe and USA 13-16%). Due to the high growth rate, we expect a population of 40 million by the year of 2020. At that time, the percentage of population above 60 years of age will increase by 195%.

Urology Services: In most hospitals in the country, Urology Services does exist. Well-trained urologists are covering this service to deliver the most appropriate health care. There are 135 urological departments all over the country in which 257 urologist working. The ratio of urologists to individuals is 1:66000 (USA 19500, UK 228000). Most of the practicing urologists in the country are expatriates. The Saudi Urologist is making 22% at present time. By the year 2020, the coverage by Saudi Urologists will be 80%.

Education and Training: Since the beginning of the eighties, regular postgraduate educational activities were launched. A monthly urology club meeting exists in most big cities, in addition to the interdepartmental weekly teaching activities. The annual Saudi urological conference started its activities in 1983 and continued to grow in number of attendance and scientific level over the past 15 years. We are honoured to host the first and the present conference, which we are enjoying now. The need to start a residency training program in urology is obvious. A well-structured program was launched in 1994, where the first batch of Saudi trained urologists has graduated in January 2000. At the moment, 46 Residents were enrolled in the program at different levels of their training.

Urolithiasis: Urolithiasis is a common presentation in this region. Before the era of Endo-Urology and ESWL, urologists were confronted with big number of patients with large stone burden. The surgical stone removal or even kidney removal was the only option available to the urologists. In mid-eighties, PCNL and URS started. ESWL was introduced in the Middle East, in Riyadh by January 1985. The HM3 lithotripter was installed at the Riyadh Armed Forces Hospital (RAFH) before it crossed the Atlantic. The incidence of urolithiasis is not known, but urologists working in this country knew that 30% of their patients are stone former and 28% of the urological hospital admissions were patients with urolithiasis. In a clinical study conducted at RAFH in 1990, 760 Saudi patients with urolithiasis were analysed. The main features of the study showed a male to female ratio of 4:1, mean age 41 years. The study confirmed that infection and paediatric stone former were rare (4.3% and 1.4%). Moreover, the study showed no significant hypercalcaemia or hyperuricaemia, but very significant hyperuriuria (60%). The stone analysis showed 76% calcium oxalate, 20.5% urate and 3.3% phosphate stones.

GU-Tumour: GU-Tumours are seen frequently, but due to young age population and other unclear reasons, the incidence of malignant diseases in the country is less than North America. The crude incidence rate (CIR) of all cancer in Saudi population is 39/100,000. According to the National Cancer Registry, the GU cancer is 9.5% of all cancers. The most common GU cancer is bladder 3.6% of all cancers. It ranked 7 th in male and 18 th in females and with incidence of 2.9/100,000 population. The second cancer is prostate with incidence rate of 2.9% and rank of 8 th in male population and with an incidence of 4/100,000 population (The incidence of prostate cancer in the States is 200/100,000 population).

Cancer of the kidney and testes are of no difference as compared to Europe or the States, but it is worth to notice the rare incidence of penile cancer, which is mostly related to the routine circumcision done.

BPH: Patients with prostatic disease constitute 10% of the urologists' workload. BPH is the commonest presentation (70%), followed by prostatitis (23%) and cancer of the prostate only 7%. These figures are the result of study conducted by the Saudi Prostate Health Council in 1998. The presentations of BPH were acute retention of urine in 44%, bladder outlet obstruction in 40% and with irritative symptom in 10%. Most urological patients over 50 years of age have a routine DRE in addition to PSA testing and if indicated TRUS. The option of BPH treatment range from alpha-blocker, over Finasteride, to minimal invasive procedures. TUR-P is still the most practiced treatment option. The Saudi Prostate Health Council (SPHC) was introduced in 1994 and had achieved some important improvements. Arabic I-PSS system, National Prostate Registry, and awareness program were some of the SPHC activities over the past 5 years.

Presented at the: 13 th Saudi Urological Conference

Riyadh Armed Forces Hospital

14-17 February 2000 (09-12 Dhu Al Qa'dah 1420)

Incidence of pediatric urological anomalies

M. S. Abomelha, M. T. Said, S. A. Orkubi, A. A. Shaaban, K. E. Al Otaibi

Department of Urology, Riyadh Armed Forces Hospital, Riyadh, Saudi Arabia

In neonates, early diagnosis and management of congenital urological anomalies is essential to preserve the premature nephrons which are more susceptible to pressure and infection. Fetal congenital urological anomalies can be diagnosed by the routine use of antenatal ultrasound which thereby helps in early management. The incidence of congenital urological anomalies in Saudi Arabia is 1:302 live births as we have found by screening 21500 pregnant women attending the antenatal clinic between 1987-1990.

We have treated 220 pediatric patients with urological anomalies between 1987-1995. 142 (65%) were boys and 78 (35%) were girls. The most common urological anomalies were PUJ-obstruction 39%, followed by vesico-ureteral reflux in 18%. Renal dysplasia was found in 10% while posterior urethral valve and neurogenic bladder were seen in 9% and 8% respectively. The remaining anomalies which make 16% were as follows: ectopia vesicae, renal agenesis, megaureter and ureterocele. It is of interest that boys were more affected by the common anomalies (PUJ and reflux) than girls and that there was no difference of site affection.

It is concluded that the incidence of urological anomalies in Saudi Arabia is 1:302 live births. The most common anomalies were PUJ-obstruction and reflux. Antenatal ultrasound screening helps in early diagnosis and treatment, as well as contributing to better prognosis.

Presented at the: 11 th Saudi Urological Conference

King Fahd Military Medical Complex - Dhahran

24-26 February 1998 (27-29 Shawwal 1418)

Antenatally detected hydronephrosis: Diagnosis and treatment

Mohammed S. Abomelha

Department of Urology, Riyadh Armed Forces Hospital, Riyadh, Saudi Arabia

The use of routine antenatal ultrasound screening during pregnancy did help a lot in recognizing congenital anomalies of the fetus at an early state. Among these anomalies are those of the urinary tract. Around 80% of the urinary tract anomalies are associated with hydronephrosis. The incidence of urinary tract anomalies in Saudi Arabia was found to be 3.3/1000 birth and 86% of these were associated with hydronephrosis. The treatment of fetal hydronephrosis is controversial. The use of standard radiological investigation of the renal function in the first weeks of the neonate is not accurate. This makes the decision of medical or surgical treatment difficult for the treating physician. Recent studies in the nineties suggest close observation as the treatment of choice. Around 25% of the neonate may need surgical intervention, which can be picked up very easy without further damage to the kidney. Our experience with 220 infants with congenital urological problem showed 39% PUJ type hydronephrosis, 18% vesico-ureteric reflux, 10% cystic-dysplastic kidneys, 9% posterior urethral valve and 8% neurogenic bladder. The treatment of PUJ type hydronephrosis was close observation in 73% and surgical correction in 27%. Long-term follow up showed resolution and improvement in 70% and 30% of the observation group. The results of surgical correction were 66% and 34% with no significant difference between the two groups.

It is concluded that the incidence of urological anomalies in Saudi Arabia is 3.3 per 1000 birth. Neonatal hydronephrosis is often not associated with obstruction. Initial radiological tests for assisting hydronephrosis are not accurate and should not be used as indication for surgery. Hydronephrosis is a relatively benign condition, which improved by time. Close follow up is necessary to identify the sub-group, which need surgery. Non-surgical treatment with close observation is safe and recommended.

Presented at the: 14 th Saudi Urological Conference

King Fahad Military Medical Complex - Dhahran

13-15 February 2001 (19-21 Dhu Al Qa'dah 1421)

Urology contribution of ibn zuhr (avenzoar) to the progress of surgery and surgical subspecialties

Rabie Abdel Halim

Department of Urology, King Khalid University Hospital, Riyadh, Saudi Arabia

Ibn Zuhr, known in the West as Avenzoar or Abumeron, is the Muslim physician Abu-Marwan Abdel-Malik ibn Abi Alaa Zuhr ibn Abi Marwan Abdel-Malik ibn Abi Bakr Muhmad ibn Marwan ibn Zuhr Al-Eyadi Al Eshbeely who lived and practiced in Eshbeelia (modern day Seville, Andalucia, Spain) between 1093-1162 AD.

The reputation which Ibn Zuhr enjoyed in Europe was founded on his book Al-Taisir Fi Al-Mudawat Wal Tadbeer which was translated into Latin and published in Venice in 1490 AD with 8 reprints up to the middle of the 16 th century. However, little is known whether Ibn Zuhr was primarily a physician like Al-Razi (Rhazes, 854-925 AD) and Ibn Sina (Avicenna, 980-1037 AD), his predecessors in the East Islamic Caliphate or primarily a surgeon like Al-Zahrawi (Albucasis, 936-1013 AD), his predecessor in Cortoba (Cordova).

It is for this reason that we studied Ibn Zuhr's book Al-Taisir utilizing the edition published in 1983 by the Arab Educational Scientific and Cultural Organization. Another aim of this study was to evaluate Ibn Zuhr's contributions to the advance and progress of surgery and surgical subspecialities particularly urology.

In addition to listing the major original contributions he made, the presentation will also include translations of relevant text. It will, also, highlight a remarkable connection that existed between his book Al-Taisir and the book Al-Kulliyat Fi Tibb (The Colliget) of Ibn Rushd (Averroes, 1125-1198 AD); a connection that clearly documents the first ever example of joint authorship of a medical text book.

Presented at the: 17 th Saudi Urological Conference

King Fahd Military Medical Complex

8-10 March 2005

Muhadhdhab al-deen al-baghdadi (515-610 h/1117-1213 ad): His contributions to the progress of medicine and urology

Rabie E. Abdel-Halim

Department of Surgery, Division of Urology, King Khalid University Hospital, Riyadh, Saudi Arabia

Little is known, in the contemporary medical literature, about the Muslim physician/scholar Muhadhdhab Al-Deen Al-Baghdadi (born in Baghdad in 515 H/1117 AD - died in Mosul in 610 H/1213 AD). This study of the original Arabic edition of his four volumes encyclopedic book Al-Mukhtar Fi Al-Tibb (The choice book on Medicine) aims at evaluating his contributions to the progress of medicine and urology together with providing an English translation of relevant excerpts. The introduction and first chapter of the book documented the author's emphasis on the morals of medical practice and the principles of medical education describing how to select medical students and how to evaluate graduates. Al Baghdadi stressed on the need for a long training program directly supervised by skilled expert doctors both in hospitals (Al-Bimaristanat) and during home visits.

In both the general and special sections of the book, same as all his predecessors in the Islamic era, he stressed the importance of clinical medicine and gave more details related to history taking (asking for the Aaradd) and physical examination (looking for the Dalalat). Like Al-Razi (Rhazes, 841-926 AD) and all the other Muslim scholars before him, he also emphasized that the doctor should be quite knowledgeable in anatomy to be able to identify the state of the organs and how they are related to each other. The detailed description of the functional anatomy of the uretero-vesical junction, the antireflux mechanism and the micturition mechanism given by Al-Baghdadi is contrary to that of Galen (130-200 AD) but conforms well with our contemporary understanding. This constitutes a continuation of the original observations made by Al-Razi, Al-Zahrawi (Albucasis, 930-1013 AD) and Ibn Sina (Avicenna, 980-1037 AD).

Furthermore, the presence of anatomical drawings in Kitab Al Mukhtar Fi Al-Tibb is a further step forward in illustrating medical text books; a trend that flourished in the Islamic era reflecting the role of direct observations and experience. Al-Baghdadi described a comprehensive classification of urological diseases based on etiology; discussing, in details, the pathological changes and the clinical picture of each disease highlighting the symptoms and signs of importance in diagnosis, prognosis and differential diagnosis. He distinguished between kidney stones and bladder stones with regard to their pathogenesis and clinical picture reporting his own experience both in pediatric and in various adult age groups. He also described the symptoms of the stone transit from the kidney to the bladder and how to diagnose impaction. In the conservative management of urinary stones, he described 70 simple and 13 compound drugs while those described by Paulus Aeginata (625-690 AD) were only 20 simple and 3 compound drugs. Furthermore, Al-Baghdadi's description of the instruments and techniques of urethral catheterization, perineal cystolithotomy and perineal cystolithotripsy using Al-Zahrawi's lithotrite is meticulous and reveals originality, dexterity and experience.

Presented at the: 18 th Saudi Urological Conference

King Abdulaziz University Hospital

20-23 February 2006 (21-24 Muharram 1427)

araburo.net: Websites for all Arab urologists

Adel Al Dayel

Department of Urology, King Fahd Military Medical Complex, Dhahran, Saudi Arabia

The araburo.net is a network of websites developed with the intention to promote the communication between the Arabic speaking urologists, and to promote the urology in the Arab countries, as well as to increase the awareness about the urological diseases in the Arab countries.

Since the start of the araburo.net on the internet for less than two years, more than five hundred urologist have placed there full address in the address book, and a social and scientific coverage was provided on the site for most of the major conferences held in the Arab countries. Dedicated sites were developed for The Arab Association of Urology, the Saudi Urological Association, the Syrian Society of Urology, The Kuwait Society of urology, The Sudanese Urological Society, The Tunisian Urological Society, and The Lebanese Urological Society. The sites with open space allocation and freedom of content posting, the aim is to joint all the efforts in the field of medical and patient education, and other professional aspects, while providing the individuality of the association for their specific issues.

The expansion of the network is going on to include Medical Education activities and Patient Education sites.

The purpose of the presentation is to provide update to the members of the Saudi Urological Association, and seeking aspects of possible improvement to meet their expectations.

Presented at the: 16 th Saudi Urological Conference

King Faisal Specialist Hospital & Research Centre

2-4 March 2004 (11-13 Muharram 1425)

History of renal transplantation in Saudi Arabia

Mohammed S. Abomelha

Department of Urology, Riyadh Armed Forces Hospital, Riyadh, Saudi Arabia

Renal transplantation in Saudi Arabia started as early as 30 years ago. It was in 1972 when the first documented renal transplant was performed in a Saudi patient. That renal transplant was carried out in UK by the same team who helped later on to start the first renal transplant unit in Saudi Arabia in 1979. To establish such a tertiary care unit in a country with no previous existing facilities was a quite big challenge. The big achievement was to build up a complete local facility to carry out the whole work up, operative procedures and postoperative follow up for such demanding treatment. The first renal transplant in Saudi Arabia was done on 03 April 1979 at the Riyadh Armed Forces Hospital. Two years later, the renal transplant was managed by permanent local team.

Soon after the establishment of the first renal transplant unit in the Kingdom, the magnitude of patients with end-stage-renal disease was obvious. We were aware from the beginning that the already started living related donation program will cover only small number of patients, while the majority will not be able to produce any suitable living related donors.

To cover the shortage of kidneys, a cadaveric renal donation campaign was launched after religious approval was obtained in 1982. In the same time, surplus cadaveric kidneys were utilized and used successfully with the help and cooperation of the Eurotransplant in Leiden, The Netherlands. In 1984, the legalization of renal transplant program and set-up of the National Kidney Foundation was of great importance for the advancement of medical care offered to those patients with end-stage-renal disease (ESRD).

The National Kidney Foundation (NKF) was established in 1985 aiming to coordinate nationwide utmost care to patients with ESRD. The NKF was initiated and continuously supported by HRH Prince Salman, the Governor of Riyadh. At this stage, the services for patients with ESRD had improved. Several dialysis and renal transplant centers were established.

The renal transplant program opened the door for the transplantation of other organs. Starting with heart transplant in 1986, followed by liver transplant in 1990, other organs and tissue transplant (e.g. lung, pancreas, cornea and bone marrow) were performed in several centers in Saudi Arabia. The national transplant program reached its step incorporating transplantation of different organs and the need to change the goals as well as the name of the NKF became apparent. The change was achieved in 1993 and the NKF was renamed Saudi Center for Organ Transplantation (SCOT). With the SCOT, Saudi Arabia was the first country in the region with a functioning organ transplant program.

The successful Saudi experience in organ transplantation is the result of long-term planning and the support of all governmental and medical institutions in the country. This experience is unique and it is the best of its kind outside North America and Europe.

Presented at the: 17 th Saudi Urological Conference

King Fahd Military Medical Complex

8-10 March 2005

History of urology in Saudi Arabia

Mohammed S. Abomelha

Department of Urology, Central Hospital, Riyadh, KSA

Up to the seventh decade last century, urological care in Saudi Arabia was delivered by the general surgeons. With the opening of modern hospitals in mid-seventies, qualified urologists started to provide urological service with limited coverage. Pioneered urologists, mostly expatriates, delivered an outstanding service before the start of any organized urological community.

During the annually held Saudi Medical Conferences (1976-1983), we can document some urological presentations delivered by pioneered urologists mainly located in Riyadh, Jeddah and Dammam. The 7 th Saudi Medical Conference held in 1982 in Dammam was the birth of Saudi Urology. At this conference, 17 urologists met to commence the Saudi Urological Activities. One year later, the first Saudi Urological Conference was organized at Riyadh Armed Forces Hospital (1983). Now in year 2008, we are enjoying the 20 th Saudi Urological Conference at the King Faisal University, where the 3 rd Saudi Urological Conference was successfully held in 1985. Most of the founding members (Table 1) continued over the years to promote not only the annual urological meetings, but also to develop the standards of urological care, in addition to continuous medical education, training and research.

With time, the number of urologists and urological units increased and with that the goals and objectives of the Saudi Urology expanded. The Saudi Urological Conferences are not the only activities of the Saudi Urology. The residency training program started in 1989 with the Arab Board, followed by the Saudi Board in 1994 and the formation of the Residency Training and Scientific Board at the Saudi Commission for Health Specialties. On international level, the Societe Internationalle d'Urologie (SIU) Saudi Chapter, as well as the Saudi Prostate Health Council were activated in the early nineties. Sub-specialty working groups were initiated, some of which are very active (e.g. Pediatrics and Andrology). We have registry of urologists, which is updated regularly containing more than 330 urologists Kingdom-wide. All 18 conferences (1983-2006) were documented in three proceeding books, which were distributed to all urologists all over the country.

All these activities for 25 years were managed without official cover. It is only in year 2006, when the Saudi Urological Association (SUA) was announced under the umbrella of the King Abdulaziz University in Jeddah. We are thankful to the officers of our SUA, especially to the first SUA President Prof. Hisham A. Mosli, who worked hard to get our association recognized.

Presented at the: 20 th Saudi Urological Conference

King Fahad Hospital of the University - Tabuk

18-20 March 2008

Evolusion of urology training in Saudi Arabia

Mohammed S. Abomelha, Hassan M. Al Zahrani

Department of Urology, Advanced Medicine Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

The year 1992 was a milestone in urology training in Saudi Arabia. In that year, two important events accelerated the local urology training: the launching of the Arab Board in Urology by the Arab Board for Medical Specializations and the establishment of the Saudi Commission for Health Specialties (SCFHS). The preparation to set up the urology training was a joint effort of the different health care providing institutions in the country. At an earlier stage, the foundation, structure, and regulations were designed and implemented by the pioneer urologist heading the Urology Departments in Riyadh, Jeddah, and Al Khobar.

In 1994, the Saudi Board of Urology enrolled the first group of urological trainees and the first batch of graduation of five urologists was celebrated in 1999. The Saudi Board of Urology is a structured five-year joint training program. The training's objective is to train and graduate competent, knowledgeable urologists, who are capable of functioning independently. During the training, the residents are required to complete their operative log book, weekly tutorials and a 3-monthly evaluation. To move to a higher training level, the resident has to pass the annual promotion examination. The requirement to proceed to the final board examination, the candidates should have passed the Part-I exam, in addition to successful training assessment.

Currently, 75 trainees are enrolled at different levels in 18 training centers. The majority of the training slots were provided by the Ministry of Health (MOH) and Ministry of Defence and Aviation (MODA), 45% and 25% respectively, and for that reason 68% of the graduates were from these two sectors. The average intake of residents is 15 each year. The ratio of trainee to trainers, beds and operative procedures are 1:1.8, 1:8, and 1:365 respectively. 65 urologists were graduated during the past 15 years, with an average passing rate of the final written exam of 70% and oral of 87%. During the past 5 years, the average graduation rate was 6 urologists per year. This rate is not going to make much on the demand of urologists in a country where still 70% of urologists are expatriates. The present urology manpower in Saudi Arabia is operated by around 600 urologists (ratio 1:40000 urologist/population), of whom 66% are urologists at specialist level. Of the 196 consultant urologists working all over the country, 49% are Saudi nationals. It is also of interest to mention that the majority of graduated Saudi Board Urologists choose to go for subspecialty training abroad. The local subspecialty training in pediatric urology started in 2006 and the first graduation of trainee was achieved in December 2009 following successful passing the final examination.

The Saudi urology training is a challenging and dynamic program, which needs to be evaluated and improved on a regular basis to meet the required number of Saudi urologists in the future. The years to come will witness substantial reform in urology training as has been planned by the training committee of the SCFHS.

Presented at the: 22 nd Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

15-18 March 2010

The learning environment of urology training in Saudi Arabia

Abdulrahman Babaeer, Abdullah Alkhayal, Saleh Bin Saleh

Department of Urology, King Abdulaziz Medical City and King Khalid University Hospital, Riyadh, Saudi Arabia

There is a growing evidence that the environment in which residents learn influences the quality of learning outcome. Since the urology training in Saudi Arabia is a work-based learning, evaluation of this environment gives the training program insight into the educational functioning of clinical departments approved for the training. The Postgraduate Hospital Educational Environment Measure (PHEEM) is a validated questionnaire that evaluated the learning environment. It has 40 items that measure 3 subscales: perceptions of autonomy, perceptions of social support and perceptions of teaching.

Objectives: To assess the learning environment of urology residents in Saudi Arabia.

Methods: The PHEEM questionnaire was distributed hand-to-hand to urology residents attending the 22 nd Saudi Urology Conference in March 2010. It was sent afterwards as a link through e-mail to all the urology residents in Saudi Arabia in order to be completed online by those who did not attend the conference. All completed questionnaires were returned anonymous. Each item in the questionnaire is scored on a 5-point scale, where 1 = strongly disagree and 5 = strongly agree. A score more than 3 is considered satisfactory.

Results: Seventy-two residents were enrolled in the urology-training program in Saudi Arabia in the academic year 2010-2011. The response rate was 53% (38/72). Four of the responders were in their first year of training that consists of general surgery, so they were excluded from the analysis. The mean score for autonomy is 2.86. The mean score for the perception of social support is 2.99. The mean score for the perception of teaching is 2.98. The total mean score is 2.94.

Conclusion: The results of the survey show that urology residents in Saudi Arabia do not perceive their learning environment positively. Significant concerns should be addressed by the training program.

Presented at the: 23 rd Saudi Urological Conference

King Fahd Specialist Hospital - Dammam

21-24 February 2011

Knowledge about urology in the general population in Jeddah, Saudi Arabia

Ghassan Bayaran, Hassan Farsi, Hesham Saada, Rami Salawi, Anwar Nassir

Department of Urology, Umm Al-Qura University, Jeddah, Saudi Arabia

Introduction: The knowledge of general population about the medical specialties is not well studied before in our community. Our aim is to explore the amount of knowledge known in Urology by general population.

Methods: A questionnaire was completed by 154 respondents in Jeddah, Saudi Arabia. After measuring the amount of knowledge in our population, we looked forward to compare it with English as well as French speaking populations in the west. We translated in Arabic the same questionnaire used in their study. Two (2) extra questions added to further serve our aim.

Results: Of the 154 respondents, 66% (102) said that they know little or nothing about urology and 43% (66) did not know that urology involves surgery. When asked to mention 3 diseases within the field of urology, 37% (57) were able to do so. Fourteen percent (21) were unable even to mention one disease. When asked about the modality of treatment, only 33% (50) were unable to mention even one modality. Most of the wrong answers were related to mixing Urology with Nephrology, Gastroenterology, General Surgery and Obstetrics and Gynecology. Most of the results were better in comparison to the western study done in west.

Summary and Conclusion: Although significant proportion of our population know little about the field of urology, the overall result is better when compared to western population. The clarity of Arabic terminology related to the field may explain the difference.

Presented at the: 22 nd Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

15-18 March 2010

Do we have enough surgical volume to ensure better cancer outcome?

Mohammed S. Abomelha

Department of Urology, Advanced Medicine center For Subspecialties, Riyadh, Saudi Arabia

There is a strong evidence that high surgical volume is associated with improved short- and long-term patient outcomes. Patients treated by experience surgeon had 40% lower rate of cancer recurrence than inexperience one and will decrease surgical complication by 20%.

The low incidence of cancer among Saudis is reflected by a low Age Standardized Rate (ASR) of 83/100.000. This pattern of incidence is also apparent in the ASR of Genito-Urinary Cancer (GUC), which is 11.6 compared to the world rate of 38.8/100.000. Looking at the data of the Saudi Cancer Registry (SCR) over a five years period (2003-2007), the average yearly incidence rate of prostate, bladder, kidney and testicular cancer were 228, 204, 174 and 45 cases respectively. SEER summary stage data showed late presentation of GUC at time of diagnosis. Prostate and bladder cancer cases legible for radical treatment are more or less half of all reported cases, and those for radical surgery are much less than that. Unfortunately there are no national data on number of radical surgeries of patients with GUC and trail to collect such data failed. Due to the low incidence of cancer, the high staged disease and a dozen of treating centers, radical surgeries for cancer of Prostate and bladder are not frequently done and the numbers are not reaching the minimum operative threshold level required.

To ensure better cancer outcome centralization of care for radical cancer surgeries might be the best solution. That can be done through a national cancer control program. Such a program will introduce improvement of quality of life to all cancer patients in the country, through implementation of strategies for cancer prevention, early detection, diagnosis, treatment and palliation, making the best use of the country's available resources.

Presented at the:
24 nd Saudi Urological Conference

King Abdulaziz University Hospital - Jeddah

6-9 February 2012

25 th anniversary of Saudi urological conferences: The input and outcome

Mohammed S. Abomelha

Department of Urology, Advanced Medicine center For Subspecialties, Riyadh, Saudi Arabia

Up to the 7 th decade last century, urological care in Saudi Arabia was delivered by the general surgeons. With the opening of modern hospitals in mid-seventies, qualified urologists, started to provide urological service with limited coverage. Pioneered urologists, mostly expatriates, delivered an outstanding service before the start of any organized urological community. They also participated scientifically in the annually held Saudi Medical Conferences (1976-1983).

The 7 th Saudi Medical Conference held in 1982 in Dammam was the birth of Saudi Urology. At this conference, 17 urologists (10 expatriates, 7 Saudis) met and planed to commence the Saudi Urological Activities. One year later, the first Saudi Urological Conference (SUC) was organized on 12 May 1983 at the Riyadh Military Hospital. Now in year 2013 we enjoy the 25 th SUC held at this charming city Abha.

During the 25 SUCs, there were 1376 papers presented, 85 pre-conference courses organized in form of live moderated surgery, hands-on training, courses, and workshops. There were 182 distinguished guests invited and 387 CME hours accredited. The main topics discussed were: Uro-oncology, Ped. Urology, Urolithiasis, Prostate, and Robotic-Lap. Interventions. There is a registry of urologists, which is being updated regularly containing more than 330 urologists. All SUCs (1983-2011) were documented in four abstract proceeding hard copies and electronic on line at sua.org.sa. With time the number of urologists and urological units increased and with that the goals and objectives of the Saudi urology expanded.

The SUCs are not the only activities of the Saudi Urology. It started in 1981 with the creation of the monthly Riyadh Urology Club Meeting, which was followed in different cities e. g. Jeddah, AL-Khubar, and Abha.The residency training program started in 1989 with the Arab Board, followed by the Saudi Board in 1994 with first patch of graduation in 1999. The total number of graduation up to Dec. 2012 were 103 urologists. The formation of the urology Scientific Board at the the Saudi Commission for Health Specialties (SCFHS) was the actual recognition of the hard and successful work done. On international level, the Societe Internationalle dUrologie (SIU) Saudi Chapter, as well as the Saudi Prostate Health Council (SPHC) were activated in the early nineties. Sub-Specialty working Groups were initiated and each subspecialty started its own activity. The first graduation of the Subspecialty in Pediatric Urology was celebrated in 2009.

All these activities over 25 years were managed by a group of pioneer Saudi Urologists without official identity. The official recognition of Saudi Urological Activities was declared by the announcement of the Saudi Urological Association (SUA) in 2006 under the umbrella of King Abdulaziz University (KAU) in Jeddah.

The SUA succeeded in establishing the SUA-Newsletter (Dr. H. Al- Zahrani) and the Journal Urology Annals (Prof. Fouda Neel). We recognize and appreciate the enormous and fruitful work done by the founding committee over the years, as we are also thankful to KAU Jeddah and to Prof. Mosli and Prof. Al-Tayib for the hard work done to get our association established.

Presented at the: 25 nd Saudi Urological Conference

Aseer Central Hospital - Abha

8-11 April 2013

Regionalization of urological cancer surgery in KSA: The challenging merit

Mohammed Abomelha

Department of Urology, Advanced Medicine Center for Subspecialties, Riyadh, Saudi Arabia

Do we have enough surgical volume to ensure better cancer outcome? This was the title of my presentation at the 24 th Saudi Urological Conference held in Feb. 2012. The paper analyzed a representative survey of 4 urology centers done in 2011, which showed a yearly hospital volume of 16, 5 and 3 for radical nephrectomy, cystectomy and prostatectomy respectively. The paper recommended centralization of surgical service. Due to low volume of urological centers, the existing care offered to patients requiring radical cancer surgery in our country is suboptimal. The reasons behind the very low hospital volume were multifactorial. Some of the crucial reasons in addition to young age population are as follows. First the incidence of cancer in general and the urological in particular among Saudis is low, Age Standardized Rate (ASR) 84/100.000 and 11.6/100.000 respectively, compared to worldwide data (ASR 182/100.000, 38.8/100.000). The average yearly incidence of all Genito-Urinary Cancers (GUCs) is less than 900 patients. The second reason is the late presentation of patients coming with advanced disease when they reach the urologist (40% to 60% of all GUC cases). So the number of cancer patients, who are suitable for radical surgery are relatively small. The 3rd reason is the absence of a national referral protocol or national cancer control center, which resulting in further delaying of patients care and reducing hospital volume. As a result of above mentioned reasons, all urological centers in the country do not reach the minimum threshold of the hospital or surgical volumes and that adversely affect the outcome.

Ever since the first report by Luft in 1979 about the relation between surgical volume and mortality, this issue was a matter of debate. Meanwhile current literature showed a strong evidence that high surgical volume is associated with improved short- and long-term patient outcome. Although variation among surgeons is a fact, nevertheless maintenance curve should apply to maintain surgeon skills level. The high surgical volume should be accepted as a proxy for quality curve, providing that a quality review program is ensured. The old adage "Practice makes perfect" ought to be replaced by "Perfect practice makes perfect". Nowadays there is no dispute about the positive effect of the hospital- and surgeon volume on the outcome of radical cancer surgery: perioperative complications, early and late morbidity, cancer control and mortality. The creation of high-volume centers through centralization or regionalization should go hand in hand with the implementation of a performance feedback program, which results not only in improving outcome, but also allowing faster individual improvement of surgeon skills. Several countries in Europe and North America even with higher cancer incidence rate already opted for centralization or regionalization of radical cancer surgery with significant improvement of outcome. Just recently 3 leading US-institutions launched the "Take the Volume Pledge" campaign asking hospitals to pledge to minimize surgical procedures, which not reaching the minimum volume threshold required. In case this move will be widely accepted, the existence of the low volume centers will be challenged.

Current literature is heavily loaded with articles on volume-effect, I will try to highlight only three reports. The volume effect on mortality for radical cystectomy was nicely demonstrated by Birkmeyer et al. 2002, where the mortality within 30 days of surgery dropped from 6.3% to 2.9% by increasing the yearly number of cystectomy from 3 to >11. The volume- and quality control-effect on continence and potency after radical prostatectomy was reported by Cathcart et al. 2015, where they demonstrated at 12 months after surgery an increase of urine continence from 57% to 67% and potency from 21% to 61%. A recent report from a high-volume prostate cancer center performing more than 2000 radical prostatectomy per year documented dramatic change in surgical management of prostate cancer. Huland and Graefen 2015 found that radical prostatectomy is rarely done in early cancer but is used more for aggressive tumors, which diminished overtreatment thanks the cancer- and patient-selection and a tight quality protocol.

Implementation of such program requires the involvement and authentic cooperation of all urologists and institutions in the kingdom, which provide radical surgical cancer care. The regionalization of cancer care results in reorganization of surgical care delivery. The process need to work in teams providing a hub- and spoke model of care, which should incorporate regular quality review meetings. An administrative body is to be created to introduce and oversee the integrated cancer system. Different cancer pathways are to be developed, which cover urologic cancers: kidney, bladder and prostate. The involved Onco-Urologists have to split their work between the base hospital and the regional center. To establish such a program in our country, we should concentrate initially on the Urologists to accept the concept first and then take it gradually higher up to the decisive authority.

We are ethically obliged to force the pace of creating high-volume urological centers. Our patients deserve nothing less.

Presented at the: 28 nd Saudi Urological Conference

King Faisal Convention Center, King Abdulaziz University - Jeddah

3-6 February 2016


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