Urolithiasis in Saudi Arabia

Urolithiasis in Saudi Arabia


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UROLITHIASIS IN SAUDI ARABIA* MOHAMED SAID ABOMELHA, M.D. ABDULLAH AHMED AL-KHADER, M.R.C.P. TT~.,I aRNOLD e Department of Urology, Riyadh Armed [ospital, Riyadh, Saudi Arabia

~spective study, 760 Saudi patients with urolithiasis, were epidemiologically led (41% were # o m the Central region, 32 % South, 14 % West, 9 % North, ining 3 % were Saudi but of unknown region). The male to female ratio was patients were aged thirty to sixty years and 11 patients were under age clear relation of stone formation to occupation. Sixty-nine percent of calculi ureteric, and only 3 percent were bladder calculi. Two hundred seventytres were done (36.5 % of all patients), including pyelolithotomy, nephroforay, ESWL, cystolithotomy, and extractions by basket. Infection was a ! schistosomiasis was found in 33 patients (4.3 %), 24 of whom were from a gion. Raised serum calcium was found in only 5.7 percent and raised serum creased urinary excretion of urate was found in 60 percent and hypercal~nty-six percent of stones analyzed (239) were calcium oxalatG 20.5 percent phosphate.

g in Saudi Arabia knows non in this country--deare available2 -3 The exhiasis in Saudi Arabia is eetive study of the epideaspects of urinary stone ats, and report our five Lh urolithiasis on a large rots representing all the a. To our knowledge this eported in the literature. krabs and others) were :cluded from this report. netabolie and biochemigroup of Saudi male paand on control subjects ad will be presented in .nd Methods ,~d Forces Hospital 4,307 :he Department of Uro1:ted by Riyadh A1-Kharj Hospital

ogy between March 1, 1980, and February 28, 1985. We studied the files of 3,423 (80%) of those patients and have no reason to believe that the files not studied are significantly different. Of those studied, 960 patients had urolithiasis (i.e., 28 % of all urologic patients seen). Seven hundred sixty (79%) of these patients were Saudi. The remaining 200 non-Saudi patients were studied but are excluded from this report. All patients are considered to be stone formers and were admitted to the study if an excretory urogram proved the presence of stone or the patient passed a stone which on analysis proved to be a urinary stone, The parameters studied are: Nationality, region, sex, age, anatomic abnormalities, diagnosis Urine pH, infection, stone-analysis, operatire procedures, IVP Blood chemistry (SMAC): urea, creatinine, K, Na, C1, Ca, phosphate, bicarbonate, protein, bilirubin, alkaline phosphatase, transaminase, LDH 24-hour urine: creatinine, urate, calcium, phosphate, magnesium, amino acids.



No. o f

Patients 220 203


200 174

180 160 i40

FIcunE 1. Age distribution (n = 760).

~20 lO0



I i




40 23 9




20 0








Occupations Professional


Manual Indoor Manual Outdoor ] 27


Occupation o/ patients (n = 480). FIGUI{E








_ _ ] 52

Housewife Sedentary


Soldier I












Number of Patients

The patients' occupations were broadly divided into professional, sedentary, manual-indoor-outdoor, drivers, soldiers, officers, engineers, housewives, or students. Full biochemical profile was done using an autoanalyzer. Twenty-four-hour urine for creatinine, uric acid, phosphate, calcium, magnesium, and amino acids were measured in all patients. Urine pH using litmus paper was measured on a midstream urine (MSU) specimen (which was proved to be sterile) at outpatient attendances. Semiquantitative stone analysis was done on the 239 stones passed spontaneously or removed surgically.

Results Sex and age distribution (Fig. I) There were 635 male and 125 female (5:1 ratio) patients. The majority (87%) were aged thirty to sixty years, with only 11 patients aged fourteen years or under.


Occupation (Fig. 2) ~ Occupational details were available for on 480 patients. Twenty-four percent were m i ~ tary reflecting the fact that the hospital cate~ to the Ministry of Defense. In other respects there was no relevance to occupation. Urine pH and microbiology !~ Using litmus paper the urine pH was { o u ~ to be 5-6 in 80 percent of patients and 6 above in 13 percent of patients Only 6.3 pe,lr~ cent of patients had urinary tract infection: 9~ percent due to Escherichia coli and the rest t~!~ Streptococcus faecalis. Only 33 patients (4.3 ~!! had urinary schistosomiasis (three quarters ,~ these patients came from schistosoma-in{ecti! regions). Anatomic findings ~ Of the 760 patients 69 percent had renal, ~i percent ureterie, and 3 percent bladder c~cU!!,! UROLOGY





PUJ Obstruction 25

High Urate 25g

ctopic Kidney 2

Low Urate i4 perpsrathyroid 3


Horse-shoe Kidney l i


Causes of secondary stone formation (n

Calcium 39

FIGURE5. Twenty-four-hour urine chemistry (n = 445). Types of abnormalities.






Phosphate 18


carbonate i9 te 20 H~gh Calcium 44

Distribution of abnormal blood = 345)

Ureterolithotomy 43 FIGURE 6.

Basket 12 Cystolithotomy 23? Nephrolithotom¥ 35

Types of operative procedures (n =

27s). right kidneys were equally affected ;. Solitary calculi were found in 21 [tiple in 26 percent, staghorn in 7 t bilateral calculi in 25 percent. ) percent of patients had intrarenal :uation unlike that found in the :he majority have extrarenal pelvis. cent had anatomic abnormalities ve contributed to the stone forma-

cemla was found in only 5.7 percent dcemia in 13 percent (Fig. 4). No }hanges were found in serum phosiarbonate. The results of the twentyine from 445 patients showed a sigrease of urate excretion (>500 s) in 60 percent; on the other hand, !nt had hypercalciuria (>300 mg/24 5 ) . There were no changes noticed ie and]or magnesium excretion.



Surgical intervention Thirty-seven percent of the patients were in need of intervention to remove the calculi (Fig. 6). The majority required pyelolithotomy (121 patients). Extracorporeal shock-wave lithotripsy (ESWL) was introduced in January, 1985, therefore only 44 patients were treated by ESWL. Stone analysis Semiquantitative stone analysis was done on 239 stones showing 76 percent calcium oxalate, 20.5 percent urate, and 3.3 percent phosphate. Comment There are few reports about urolithiasis in Saudi Arabia.l-a Although the disease is common, no information about its incidence is available. Previous studies from Saudi Arabia and the Arab countries were related to a small number of patients and included several nationalities in the analysis of the results. 4-9 Our study has the advantage of concentrating on a large



number of Saudi patients (760) who represented all the major regions of the country. Moreover, these patients were investigated and treated in one hospital and by one team. Our results confirm the high incidence of urolithiasis in Saudi Arabia. Over one quarter (28 %) of all urologic patients had urolithiasis. Similar to other reports from the West these patients were predominantly male (83.4 % ). Similarly, the age distribution (87 % between 30-60 years) is similar to the West including the rarity of stone formers in pediatric subgroup in our study. This may be a reflection of the high living standard and the dietary habits of the Saudi population, which has changed during the last twenty years. Hyperparathyroidism was found in only 3 patients. No significant hypercalcemia or hyperuricemia was revealed. Whereas idiopathic hypercaleiuria is an important cause of stone formation in the West, it was found to be rare in our patients. On the other hand increased excretion of uric acid in urine is a significant finding in our patients (60 % ). The cause of this increased incidence of uric acid excretion is not yet established. It may be dietary in origin, but a more basic metabolic cause (e.g., by increased tubular reaction or reduced reabsorption of urate by Saudi population) cannot be excluded. Further studies are needed to confirm this. Comparing our findings to studies related to stone formation in Saudi Arabia, ~,~ there are similarities in the incidence, composition of stones, and the biochemical findings. Our findings were similar to the results obtained from the United Arab Emirates(s).4,5.7 While the infection rate in our study was low (4.3%), Dajani, BjSrnesj6, and Shehabi 7 from Jordan reported a higher infection rate of 41 percent in males and 61 percent in females. In our study, bladder calculi were found to be rare (3 %), which was similar to reports from Jordan and United Arab Emirates. 5,7 In Iraq the incidence of bladder stones seems to be very high. Reports from Northern Iraq gave an incidence of bladder calculi of 40 percent, 4 while Southern Iraq reported a rate of 24 percent (unpublished data by A1-Naama et al.). It is clear from this study and similar studies in the region that urolithiasis is a common disease. It is recommended that all urologic departments should consider having a clinic for stone formers with investigating facilities similar to those outlined herein. The urology departments which service a large number of the


population should give consideration Lo e~ ploying ESWL which we have found to i successful and cost-effective even for eornp cated stones.~° i~ The high incidence of hyperuricemia is i triguing and has led us to treat our patiei with allopurinol very readily; Interestingly 2~ majority of patients have urine with low which encourages uric acid crystallization. }i too early to determine whether or not our pr~ rice of widespread use of allopurinol will red~ the incidence of recurrence of stone formatii although there are some reports indicati this. 6 In our view all Saudi patients with reii stones should have a trial of allopurinol blin~ if there is no facility for measuring urate in urine. !i During the last twenty years the standard!! living in Saudi Arabia has risen. With this s c i o e c o n o m i c c h a n g e t h e Saudi diet h changed. There is more consumption of hii protein and high carbohydrate in the forrn meat, milk products, and refined carbohydr~ and less fiber products. On the other hand i] oral fluid intake in such a hot climate is 1o~ especially in females. Twenty-four-hour uri~ output ranges between 200 and 1,500 mL, va~i a mean of 700 mL per day. These factors (di~ fluid) are important risk factors in stone form! tion in Saudi Arabia. :~

(DR. References 1. Taha S, Mitry NF, and Hiondi G: The t calculi in the eastern province of Saudi Arabia, i ical Conference Proceedings, National Guard, 2. Kassimi MA, Abdul-Halim R, and Hardy of urinary stones in the western region of Sm Med J 7:394 (1986). 3. Hanash KA, Bissada NK, and Woodhou~ calcium metabolism in normo- and hypercalci calcium urolitbiasis in Saudi Arabia, Urology i 4. A1 Dabbagh TQ, and Mustafa R: Calct urinary tract in Northern Iraq, Ann Coll Meal lk 5. Husain I: A survey of urinary stone dise~ Emirates Med J 1:17 (1979). 6. A1 All IH, et ah Metabolic aspects of cal lithiasis and the effect of allopurinol, Emira (1980). 7. Dajani AM, BjSrnesj6 KB, and Shehabi disease in Jordan, in Brockis JG, and Finlaysor Calculus, Littleton, PSG Publishing Co Ine, i! 8, Kambal A, Wahab EMA, and Khattab ~. Sudan, Trop Geograph Med 31:75 (1979). 9. Sj6rall A: Urinary tract disease in the U ates: a radiological study, Saudi Meal J 7:143 ¢,. . . . ~. 10. Abomelha MS, et ah Extracorporeal shock wa tripsy: the first experience in the Middle East, Saudi Mec (1986).