text:
External Genitalia
. External Genitalia. Urol Ann 2015;7, Suppl S2:107-23
. External Genitalia. Urol Ann [serial online] 2015 [cited 2020 Jan 23];7, Suppl S2:107-23. Available from: http://www.urologyannals.com/text.asp?2015/7/6/107/160674
Torsion of the appendix testis
Baher A. Kamal, Saud A. Taha
Urology Division, King Fahd Hospital of the University, King Faisal University, Dammam, Saudi Arabia
Between 1982 and 1988, twenty one patients with suspected testicular torsion were seen and explored in our hospital. Testicular torsion (torsion of the spermatic cord) was found in twelve patients, three patients had torsion and nine patients were found to have torsion of the testicular appendix. All patients with torsion of the testicular appendix were prepubertal, except one patient aged 34 years.
The aim of this presentation is to emphasize both the high incidence and the clinical features of torsion of testicular appendix as a cause of scrotal pain in children as well as in adults.
Presented at the: 5 th Saudi Urological Conference
King Fahd Military Medical Complex
The influence of the weather on testicular torsion in Saudi Arabia
V.C. Onoura, El-Bialy, G. Emad, M.G. Patil,
S. Kattan, A. Al Jasser, A.M. Youssef
Department of Urology, Riyadh Central Hospital, Riyadh, Saudi Arabia
Fifty nine patients with testicular torsion managed in Riyadh Central Hospital were studied retrospectively to investigate the association of torsion with air temperature and relative humidity. There was an even distribution of cases of torsion between the cold and hot months and between periods of low and high relative humidity. Statistical analysis showed no correlation between torsion of the testis and the weather. Unlike the findings from other places, no seasonal trend was apparent in the occurence of testicular torsion in Riyadh between 1985 and 1990.
Riyadh Armed Forces Hospital
Acute scrotum and the role of nuclear testicular scan diagnosis
Faris M. Ayya
Dhahran Health Centre, Saudi Aramco, Dhahran, Saudi Arabia
Objectives: To study the accuracy of nuclear testicular scan in differentiating the etiology of acute scrotal pain and swelling.
A retrospective study which was conducted at Dhahran Health Centre between 1989 and 1993. 85 patients were included in this study, 5 of those new born (NB). Age ranged between newborn up to 72 years old with a mean of 20.2 years. A follow up of minimum of 6 months. All patients who were explored for testicular torsion with no pre-operative testicular scans were excluded from the study, as well as straight forward cases of epididymo-orchitis. Only cases of indeterminate diagnosis were entered. 5 of these patients were evaluated after a direct scrotal trauma. 2 patients had previous orchiopexies.
Methods: All patients were evaluated clinically on presentation and all underwent testicular nuclear scan and some of them had a doppler ultrasound to substantiate their diagnosis. The scan was carried out within one hour time period. It was interpreted by a Urologist and a Nuclear Scan Specialist separately.
Results: All 5 newborn patients underwent orchiectomies because of a neonatal torsion and all had absent testicular function. 5 patients with direct testicular trauma were followed up with nuclear scan. 2 of them were explored for evacuation of hematoma and the findings were consistent with hematoma. None of these patients has lost a testicle on long term follow up with a minimum of six months and a maximum of 5 years. 26 patients had a diagnosis of testicular torsion with a mean age of 19.5 years and the age ranged between 3 months up to 39 years. 7 patients showed inconclusive diagnosis on testicular scan and were explored and found to have epididymo-orchitis, with no apparent torsion. 9 testicles were necrotic, 5 of NB.
Conclusions: Nuclear scan of the testicle is one of the most accurate methods currently available for diagnosis of testicular torsion, especially when it is supported by doppler ultrasound examination. 54 patients were spared unnecessary exploration of the testicle and were treated safely for epididymo-orchitis with no patients losing a testicle on further follow up.
Spermatic cord torsion in adults
Said A. Kattan
Department of Surgery, King Khalid University Hospital, Riyadh, Saudi Arabia
A five year retrospective review of 15 cases of spermatic cord torsion in male patients 18 years or older was performed. Eighty percent of patients were correctly diagnosed at time of initial presentation while 20% of patients were misdiagnosed as epididymitis. Fifty three percent of cases has history of similar previous attacks. The average delay prior to presentation was 7 hours. Absence of fever was the rule occurring in all patients.
Leucocytosis and significant pyuria were commonly encountered occurring in 33% and 27% of patients respectively. Our orchidectomy rate was 20%. We believe that leucocytosis and pyuria in adult patients presenting with acute unilateral scrotal pain does not establish the diagnosis of urinary tract infection and further studies with Doppler examination and Radionuclide Scans are necessary to establish the diagnosis.
Epididymo-orchitis: 10 years review
S.A. Orkubi, A. Al Ghamdi, M.T. Said,
A.A. Shaaban, K.E. Al Otaibi, M.S. Abomelha
Department of Urology, Riyadh Armed Forces Hospital, Riyadh, Saudi Arabia
From January 1983 till July 1993, 146 patients with epididymo-orchitis were treated in Riyadh Armed Forces Hospital. The affected age group were 50% between 20 and 45 years old, 31% age above 45 years old and 19% younger age below 20 years old. In older age, it is associated with transurethral manipulation in 54% of cases. In younger group, the question of testicular torsion was raised in only 14% of cases. The common associated organism was E.coli (58%) which was found in urine and blood cultures at the acute phase. Brucella was an important causative organism (9%), and showed increase presence in the last 5 years. Brucellosis was detected by serology and blood culture. All our patients were admitted to the hospital. Empirical antibiotic started and only changed according to sensitivity or if there was no clinical response. The common antibiotic combination used was tetracycline plus cephalosporin group (in 48 cases). Brucella epididymo-orchitis was treated more aggressively. All patients were given oral antibiotics to continue at home and were followed in the Outpatient Department till resolution occur.
Our results were as follows: 94 cases had a complete resolution (84%), 7 patients had formed testicular abscess, and 5 of them needed exploration and orchidectomy.
Conclusion: Epididymo-orchitis is a persistent disease affecting active age group. Hospitalization is needed. Empirical antibiotics combination found to be effective in most of the cases (only 9% showed no response). Long term oral antibiotics is needed until resolution occur. With improved facilities in serology and culture as in Brucella group, the causative organism could be detected efficiently and treated accordingly.
Aetiology of acute epididymitis in riyadh
V.C. Onoura, Imtiaz Shah and Nasser Al Jawini
Epididymitis is a major cause of loss of work among our population and constitutes a sizeable proportion of our inpatient admissions. If mismanaged, it could result in orchidectomy or infertility. The aetiology of epididymitis is controversial and treatment is unsatisfactory.
Thirty men with acute epididymitis were studied prospectively to determine the aetiology of this disease in Riyadh. Positive urine cultures were obtained from 27% of the patients, most of them in the younger age groups. There was no facility for chlamydia isolation in our hospital during this study. Pyrexia, leucocytosis or pyuria did not predict a concomitant urinary tract infection.
Our results do not support the reports from other places that acute epididymitis in young men is largely on non-bacterial origin. The need for a wider availability of facilities for chlamydia identification is stressed. This would identify the patients whose sexual partners need to receive treatment as well.
Fracture penis
A. Fallatah, Al Sowaigh, M. Al Jabry, A. Sirwi,
A. Bayoumi
King Fahad Hospital, Jeddah, Saudi Arabia
Twelve patients with fracture of the penis have been treated in the department during the last 18 years. Their mean age was 41.5 years (range 25-55) and two thirds of the injuries resulted from coitus. Eleven patients underwent immediate exploration and repair of the tunica albuginea and only 1 still has sexual dysfunction. One patient was treated conservatively and remains impotent. Immediate surgical treatment is recommended, since it avoids the formation of penile plaque, penile fibrosis, angulation and it accelerates restoration of normal penile function.
Presented at the: 9 th Saudi Urology Conference
King Fahad Hospital - Jeddah
The erect penis: An organ prone to injury
Mahmoud Tarsin, Abdul Muniem Koko
Riyadh Medical Complex, Riyadh, Saudi Arabia
No doubt erection, converts the safe, flaccid penis into an assailable organ to injury. Penile injury may be prevalent than has previously been reported and the literature concerning such injury suggestive of recent increase in the reported cases.
Fracture penis occurs only during erection by rupture of the rigid corporal body. The lesion consist of a tear in the tunica albuginea of the corpus cavernous. The thinning that occurs in the tunica from 2mm in thickness in flaccid state to 0.5mm when it is erected, makes the erect penis more vulnerable to injury.
The cause is usually secondary to direct trauma during violent sexual intercourse, forcible manipulation, impact on the partner's symphysis pubis or perineum, impaling penis into a mattress, or self-mutilation the factor possibly significant in the social aetiology of this injury is that most of our patients were expatriates unaccompanied by their wives. Fracture penis is an under reported urologic injury, with only about 300 cases reported in the world literature. We report on 63 cases treated between 1985-1995 at Riyadh Medical Complex, all treated surgically except 6 cases were treated conservatively. Partial urethral injury was found in approximately 10% of our cases.
Only 3 cases with complete urethral transection were reported in English literature. We present our experience in the management of 63 patients and conclude that the surgical repair of the corpora is quite safe and effective and all retained erectile potency.
Stricture of the urethra - role of int. Urethrotomy
Abdullah Fallatah
One hundred and twenty six patients were included in this retrospective study that included all the patients with stricture urethra in K.F.H. during the period from June 1984 to December 1991. The incidence was studied meticulously in relation to nationality, age and causative agents. Each stricture was analyzed in relation to its site, length, and management with special reference to recurrence. The patients were grouped in three groups namely: inflammatory (54.4%), traumatic (27.7%) and the post operative group (15.9%). Internal urethrotomy was the major mode of treatment used (83.3%) in all patients proving feasibility and effectiveness with even less recurrence rates than other modalities of treatment of stricture urethra.
KEY WORDS: Stricture urethra, Internal urethrotomy
Management of rupture of posterior urethra by delayed primary transpubic repair
Jeychandran Rajasekaran
Al Fanateer Hospital, Jubail Industrial City, Saudi Arabia
Delayed primary transpubic repair of traumatic rupture of the urethra is advocated as the treatment of choice in comparison to other methods of repair.
Eight male patients seen over a period of 7 years with a mean age of 22.5 years who were involved in motor vehicle accidents and sustained complete rupture of the posterior urethra secondary to fracture of the pelvis are reviewed.
Urinary diversion by stab suprapubic cystostomy was performed in all the patients after resuscitation. The diagnosis was confirmed by urethroscopy alone.
Delayed primary repair was performed between the 2nd and the 9th day after injury. Transpubic approach provided adequate exposure. It is essential to perform meticulous end to end anastomosis to achieve the best results.
Due to migrant population of the Jubail Industrial City, the average follow was less than a year. The two main complications were urethral stricture and impotence.
Delayed primary transpubic repair resulted in less severe complications than in other reported methods of repair. The urethral strictures were short and responded well to simple dilatation. Incontinence of urine was not present in any of the patients. Impotence was temporary-lasting up to a year in those followed.
New trials for managing urethral syndrome
M. Abdulmannan
Al Hada Military Hospital, Taif, Saudi Arabia
Urethral syndrome was always the question of doubt, our study describes the possible aetiology of this syndrome.
Total number of 20 patients in our study who were treated with calcium tablets were assisted by uroflowmetry study, serum calcium, 24 hours urine collection for calcium, bone densogram.
These patients showed an encouraging results.
Kin Fahad Hospital - Jeddah
Tetradecyl sulphate sclerotherapy for hydroceles
M.T. Said, M.S. Abomelha, M.A. Kourah,
K.E. Al Otaibi, A. Adnan
Recent reports of the efficacy of new and safe agents for injection sclerotherapy in hydroceles have promoted this study of tetradecyl sulphate sclerotherapy for hydroceles at the Riyadh Armed Forces Hospital. 18 patients (one with bilateral hydroceles) aged between 15-85 years (mean 50.3) were included in the study between January 1991 and June 1992. The follow up was 3-14 months. 3 patients did not attend for follow up. 15 hydroceles out of 16 (93.7%) who were followed up were cured after one or two sessions of treatment. Only one patient had undergone hydrocele surgery as he wished not to continue with sclerotherapy. Complications were minimal to moderate pain, mild scrotal oedema and mild inflammation in about 10% of cases. It is concluded that tetradecyl sulphate sclerotherapy for hydroceles is safe, effective and could save many patients especially the elderly from hydrocele.
Sclerotherapy for hydrocele
M.T. Said, M.S. Abomelha, K. Al Otaibi, S. Orkubi, A. Shaaban, A. Al Jutaili, A. Al Elaiwai
Riyadh Armed Forces Hospital, Riyadh, Saudi Arabia
In a five year prospective study at the Riyadh Armed Forces Hospital from January 1991 to December 1995, 3% sodium tetradecyl sulphate on an outpatient basis was applied to 74 hydroceles in 68 patients aged 20-85 years (mean 47 years).
The overall cure rate was 86% with a follow up range of 3 months to 5 years. Of the hydroceles, 75% were cured after one or two sclerosant instillations.
A post-sclerotherapy operation was required in 12% of the patients. Pain of a moderate degree and mild inflammation, each occurred after sclerotherapy in about 13% of the cases.
Sclerotherapy appears to be safe, economical and an effective form of outpatient therapy for hydroceles; and a valid alternative to surgery in older patients.
Presented at the: 10 th Saudi Urology Conference
King Fahad National Guard Hospital
Peyronie's disease
Charles E. Horton
Virginia, U.S.A.
A brief history of treatment and diagnosis of this problem will be presented.
Current considerations will be discussed, including the psychological involvement of the patient who has surgery on the genitalia.
A review of the surgical technique will be described with illustrative slides. Since most patients with Peyronie's disease complain of shortening of the phallus, techniques for enlarging the girth and length of the penis will be included.
Diphallia - case report and review of literature
Saad Abdulkader Sheer
Prince Saud Bin Jalawi Hospital, Hofuf, Al Ahsa, Saudi Arabia
This is a report on a rare case of diphallia, 40 days old boy having complete double penis without any of the commonly associated other congenital anomalies, neither in urinary organs nor other systems apart from cleft scrotum. The stream from the left side is more powerful and with wider calibre than from the right. The verumontanum is shown both cystoscopically and radiologically in the left urethra. Both urethrae open into a normally developed urinary bladder.
This rare anomaly is only reported less than 75 times in literature. It is estimated to occur once in each 5-6 million births.
Polyorchidism and bilateral polyorchidism: Case report
H. Sijani
Division of Urology, Department of Surgery, Iranian Hospital, Dubai, United Arab Emirates
Polyorchidism is a rare congenital anomaly and only three cases of bilateral polyorchidism had only been reported as yet in english literature, this will be the forth reported case in the world.
The embryological, anatomical and its tendency to malignancy with its effect on semen quality, fertility and potency are left for further discussion.
Urethroplasty versus urethrotomy in management of post-traumatic stricture of posterior urethra
A. El Tahawy, E. El Tahawy, A. Zein El Abidin,
R. Sayed, A. Hussein
Department of Urology, King Fahad Hospital - Hofuf. Al Hassa, Saudi Arabia
Aim: To evaluate the results of management of post-traumatic stricture of the posterior urethra by urethrotomy and urethroplasty.
Materials: 60 male patients, 20-40 years old, presented with post-traumatic stricture of the posterior urethra between 1987-1997.
Methods: Optic urethrotomy in 25 cases. Transperineal urethroplasty in 30 cases. Transpubic urethroplasty in 5 cases.
Results: All patients are continent. Stream: Fair; Qmax 15 ml./sec. Urethral caliber: Good. Potency: 1/2 the patients are potent.
Conclusion: O ptic urethrotomy is recommended for short passable strictures. Transperineal urethroplasty for impassable strictures 2-3cm; and Transpubic urethroplasty for recurrent and complicated strictures.
(7-9 Dhu Al Qa'dah 1419)
Al Hada and Taif Armed Forces
Hospitals Program
New trends in medical management of urethral syndrome in females
Mahmoud S. Abdul Mannan
Department of Urology, Al Hada Armed Forces Hospital, Taif, Saudi Arabia
Management of urethral syndrome has mostly been difficult and controversial. A total number of 50 female patients from different age groups (15-45 years) have undergone a selection criteria for our study:
1. Serum Ca-phosphorous.
2. Uroflowmetry and ultrasound of the kidneys pre and post void.
3. Bone Desmometry.
We found lower normal to normal serum Ca in all the patients and poor uroflow. Bladder residual values were variable among the patients.
Bone desmometry revealed a decrease in Ca content in the bones of the patients.
The patients were divided into two groups. Group A was given Ca 1 gm daily with one Alpha and Vitamin C. Group B were given placebo and observed for control results. After two weeks of therapy, serum Ca returned to normal. Uroflowmetry revealed improved uroflow in group A and no improvement in group B.
Ca therapy twice daily continued until the bone desmometry returned back to normal. After that, Ca maintenance was continued.
Traumatic complete amputation of penis
A. H. Kardar, F. Hashem 1 , E. Lindstedt, K. Hanash
Departments of Urology and 1 Surger, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
Complete penile amputation is a rare genital injury. This may result from self-mutilation in psychotic individuals, homicidal injury or circumcision. We report our experience of managing four such patients.
Materials and Methods: Between 1994 and 1998 four patients, two adults 28 and 34 years of age and 2 children, a 2-month old baby and a 4-year old child were seen with complete amputation of the penis. The cause of the amputation in adults included homicidal due to social reasons in one and suicidal in the other psychotic patient. The baby had his penis amputated by his mother at home and one day post operatively at King Faisal Specialist Hospital. The other child got his penile shaft completely amputated during circumcision by his father at home.
Results: One adult patient presented several months after the trauma with meatal stenosis and meatoplasty was performed. The baby underwent two reimplantations within 48 hours with skin flap coverage. The other two patients presented on the same day along with the amputated penis. Microsurgical replantation of penis was performed 18 hours (child) and 19 hours after the trauma. This patient was lost to follow up.
Replantation was successful and sensation came back in both patients. One patient required skin cover with split skin graft for partial necrosis at site of the anastomosis. No urethral complications were noted.
Conclusion: Complete amputation of penis is a rare injury. Penis can stand ischemia up to 19 hours; therefore replantation should be done using operating microscope
Presented at the: 13 th Saudi Urological Conference
(09-12 Dhu Al Qa'dah 1420)
Results of genital reconstruction in post-pubertal males
H.A. Mosli, A. Bazeem
King Abdulaziz University Hospital, Jeddah, Saudi Arabia
Objective: To evaluate and report the results of genital reconstruction in post-pubertal males in a trial to optimize the results since patients with neglected unrepaired congenital penile anomalies are still seen in later ages.
Methods: A retrospective analysis of the 25 patients with various penile congenital anomalies were seen and repaired at King Abdulaziz University Hospital (KAUH) in Jeddah. The nature and severity of the anomalies, the situation of the foreskin and the types of procedures were all studied. The overall results after dealing of the complications if any were evaluated.
Results: The overall results need to improve. Limiting factors for initial success include deficient penile skin following aggressive circumcision, frequent postoperative erections and postoperative infection.
Conclusions: The general medical awareness of contra-indication of circumcision of a penis with a congenital anomaly should be reinforced even publicly. New ideas to deal with the factors limiting the success of the reconstruction should be developed and applied to help improving the result of the repair in those patients.
7-9 May 2002 (24-26 Safar 1423)
King Fahd Hospital - Madinah Al Munawarah
Uro-alimentary fistula:
A report on 25 cases
I. Khalaf, A. A. El Saad, H. Amr, M. El Kholy, A. Garag
Department of Urology, Faculty of Medicine, Al Azhar University, Cairo, Egypt
Herein we report on 25 patients with uro-alimentary fistulae seen over a 10 year period. These included nephro-colic (8 patients), urethro-rectal (6 patients), poucho-colic (6 patients), vesico-colic (4 patients) and vesico-rectal (1 patient). The pathological types of fistula were mainly iatrogenic in 10 patients, post inflammatory in 9 patients, congenital in 1 patient, neoplastic in 3 patients and post traumatic in 2 patients. Associated metabolic alterations in the form of hyperchloremic acidosis were noticed in cases that followed continent intestinal pouch reconstruction. Our principles of treatment included appropriate urinary and faecal diversion before repair of the fistulae. Well-vascularized healthy tissue was utilized for repair. Closure was accomplished without tension and without overlapping suture lines. When possible, well vascularized non-involved tissue should be interposed between the suture lines to provide an additional buttress. We conclude that uro-alimentary fistulae are a rare entity in urologic practice, which usually requires innovative procedures for optimal treatment. In most of the cases it reveals a serious underlying disease. Preliminary diversion of the faecal or urinary stream is usually needed before definitive repair.
24-26 February 1998 (27-29 Shawwal 1418)
King Fahd Military Medical
Complex - Dhahran
Management of female genito-urinary fistulas
A. Tayeb, A. Al Malki, J. Shareef, W. Mainah
Nine (9) cases of genito-urinary fistulas reviewed in the period from 1996 to 2000.
The source of our patient is either from our hospital or other local area hospitals.
· 7 cases were vesico vaginal fistulas
· 1 case of uretero vaginal fistulas
· 1 case of vagino uterine fistula
All patients had IVP, cystogram and vaginal examination, methyline blue tests.
A. Vesico vaginal fistulas
· 3 cases with small fistulas (only 6F ureteric catheter can be passed), 2 of them treated successfully by fulguration of the fistulous tract and Foley catheter left for 4 weeks, 1 case have spontaneous closure after leaving the Foley catheter for 3 weeks.
· 4 cases required open surgical procedures O'Conor technique, all cases were successful.
1 case of uretero vaginal fistula treated by ureteral re-implantation and closure of the vaginal defect, successful.
1 case of vagino uterine fistula treated also by O'Conor technique successfully.
Conclusion: Conservative and open surgery techniques is successful in all cases that we had reviewed.
Complex - Dhahran
Challenge facing the urologist in saudi arabia in the future
K. E. Al Otaibi
Riyadh Armed Forces Hospital, Saudi Arabia
There are 72 government hospitals in the Kingdom with Urology Departments. The private sector is not included in this study. Approximately 257 Urologists are employed in these hospitals - 22% of these are Saudi.
The waiting list for out-patients is approximately 3 months for patients to be seen by a Urologist (RKH figures).
Out of these 72 hospitals, 6 centres are performing renal transplants by Urologists and 2 other centres are using surgeons to perform the transplants.
The current population stands at 17 million and the ratio of Urologists to the population is 1:66,000. The population is expected to increase more than 39 million by the year 2020, and we will discuss the challenge facing the Urologist to cope with the demand in the future.
The current status of urological training in Saudi Arabia
M. Abomelha, A. Fallatah, H. Mosli, N. Al Jawini,
W. Al Khudair, A. Al Dayel, S. El Faqih
The Supervisory Training Committee, Saudi Board in Urology, Saudi Council for Health Specialty (SCHS)
Introduction and Objective: Most of the practicing Urologists in the Kingdom have been trained abroad. The establishment of Saudi Board in Urology by the SCHS in 1994 had attracted many doctors to receive urological training locally. This paper present and discuss the current status of urology training in Saudi Arabia.
Methods: The structured training program in urology as well as the training facilities and training centers are presented and discussed.
Results: The Saudi Board in Urology (SBU) is a structured five years joint training program, which includes 15 months non-urological rotation. The remaining 45 months are allocated for pure urological training. The joint aspect of the program is fulfilled by spending one year in urological training in two other training centers outside the base hospital. The training objectives are to train and graduate competent knowledgeable Urologist capable of functioning independently. Trainees are required to complete the operative logbook, weekly tutorials and the three monthly evaluations and to pass the annual promotion examination. To enter the final board of examination, candidate should have passed the first board examination in addition to a successful training assessment.
Currently 54 trainees are enrolled at different levels in 17 training centers in the Kingdom. The ratio of trainee to trainers, beds and operative procedures are 1.8, 7, 365 respectively. The first batch of graduation of 5 Urologists was celebrated in January 2000.
Conclusion: In spite of the short experience in urology training in Saudi Arabia, the outcome so far is encouraging. We are going through an exciting transition period with a successful unique experience. This is attributed to the team spirit of participating training centers in addition to the managing role of the SCHS.
Features of saudi urology
M.S. Abomelha
Department of Urology, Riyadh Armed Forces Hospital,
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%). [1] 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% [2] 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. [3]
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. [4] 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. [5] 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. [6] 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.
1. The population estimation is based on 1992 census CDS.
2. Al Otaibi, Ketab E. Challenge facing the Urologist in Saudi Arabia in the future. 11 th Saudi Urology Conference, 24-26 February 1998, Dhahran.
3. Saudi Council for Health Specialities. Annual Report 1998.
4. Abomelha MS, al-Khader AA, Arnold J. Urolithiasis in Saudi Arabia. Urology 1990;35:31-4.
5. Cancer Incidence Report Saudi Arabia 1994-1996, National Cancer Registry.
6. Saudi Prostate Health Council Activities 1998.
Xanthogranulomatous pyelonephritis: A retrospective study of 10 cases and review of the literature
Fallatah A, Tarakji M, Amuesi J 1
Departments of Urology and 1 Pathology, King Fahd Hospital, Jeddah, Saudi Arabia
We herewith report 10 patients with Xanthogranulomatous pyelonephritis (XGP) who were treated in our department between the years 1988 and 2000. The patients' age ranged from 20 to 60 years (mean 45 years), there were seven males and three females giving a male-female ratio of 2.3:1. 60% of the patients were over 50 years old. The lesion was unilateral in all cases and pyonephrosis was found in seven patients. Nine cases had associated renal stones (90%), which led to non-functioning kidney in all these cases. Two cases had associated fistulae (one uretero-colonic fistula and one reno-cutaneous fistula). One case of focal XGP was found to be associated with renal cell carcinoma while a second patient with diffuse obstructive type of XGP and renal stone had associated transitional cell carcinoma of the renal pelvis. In all patients, the urine culture was negative. Pus culture revealed Escherechia Coli in four cases (40%), Salmonella Para B in one, and no organism could be grown in four other cases. One case did not have any pus formation. All patients were treated with nephrectomy.
Eosinophilic cystitis: A case report and review of literature
A. Ammari, A. Tayib, J. Al Maghrabi, A. Bazeem,
H. Mosli
Department of Urology, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
Eosinophilic cystitis is a rare inflammatory disorder of the urinary bladder. The clinical presentation and the radiological appearance may mimic bladder cancer.
A 55 years old female presented to us with painful gross hematuria and lower urinary tract irritative symptoms. Urethro-cystoscopy showed irregular polypoid mass with hyperemic mucosa. Biopsies were taken. Histopathological examination revealed polypoid eosinophilic cystitis. Patient responded well to bladder irrigation with steroids and oral antihistaminic. Review of the literature indicated that the disease may occur at different age groups, in children's it is short lived and self-limited. Many factors may predispose to eosinophilic cystitis. Medical treatment is sufficient in most of the case, but surgical intervention other than diagnostic TURBT may be indicated in rare reported cases.
Interstitial cystitis (I.C.) : Saudi experience
M.S. Tarsin, W. Al Dughiman
Department of Urology, Riyadh Central Hospital, Riyadh,
Introduction: Interstitial cystitis is a complex, chronic bladder disorder of unknown etiology. Severe progressive irritative symptoms, frequency, urgency, nocturia, severe dysuria and suprapubic pain characterize it. Symptoms may improve slightly after voiding. Although no strict definition of the disease exists, the etiology remains controversial and poses a diagnostic and therapeutic challenge to the urologists. Cystoscopic examination and hydrodialation under general anesthesia is part of the National Institute of Health diagnostic criteria. Interstitial cystitis has been widely regarded as wastebasket diagnosis, but there is extensive support in the literature for the validity of the entity, at least as a clinical condition.
Material: Nineteen patients diagnosed with I.C. at Riyadh Medical Complex between 1992 and 1998. All these patients met the National Institute of Health symptom criteria. Patient's evaluation included urine analysis, culture and sensitivity, culture for acid-fast bacilli and urine cytology. KUB, US and voiding cystouretherogram. Cystoscopic examination under GA, hydrodialation and bladder biopsy revealed no I.C. in two patients. Histopathologic examination revealed one case of eosinophylic cystitis.
Treatment: Sixteen patients their diagnosis with I.C. was confirmed cystoscopically and histologically. Our treatment is based on vesical hydrodialation, bladder training, instillation of Dimethyl sulfoxide (Rimso-50), or silver nitrate. Systemic medical treatments with sodium pentosanpolysulfate, amytryptiline and/or oxybutinin. Two failed all medical treatments and have severely contracted bladder-required surgery that was refused by the patients.
Results: One patient was excluded, found to have eosinophylic cystitis. 13/18 (72%) was treated with instillation of 50% Dimethyl sulfoxide (RIMSO-50), only 8 patients 68% showed significant improvement for over than 24 months. Three 23% were treated with silver nitrate and repeated hydrodilation their symptoms improved especially during night. Two 15.3% with severely contracted bladder refused surgery. 5/18 (27.7%) preferred medical treatment, two were treated only with Ditropan 5 mg, one responded well to Pentosanpolysulfate and two were placed on Amytriptiline.
Conclusion: Interstitial cystitis is not so uncommon in Saudi Arabia and so little is understood about this condition that patients may never get correctly diagnosed. About 2/3 of patients with classical symptomatic I.C. have achieved significant benefit from (Rimso-50) therapy. In few patients the lesions completely resolved.
Spectrum of cystoscopic and light microscopic changes in patients with persistant cystitis syndrome
Ammar A. Ghobish
Department of Urology, Al Amen Hospital, Taif, Saudi Arabia
Painful bladder syndrome or persistent cystitis syndrome is probably a complex group of disease manifested by bladder (SP) pain, irritative voiding symptoms with negative urine culture. In this work, cystoscopic and light microscopic spectrum of changes in those patients were studied.
Subject and Methods: All adult male and female who fulfilled the following criteria were included: Presence of symptom complex of suprapubic pain, dysuria frequency and nocturia for more than 3 months and repeated urinalysis and culture including specific media for tuberculosis and fungus were negative. Full investigations were done including cystoscopy with hydrodistention and multiple bladder biopsies that processed for light microscopy.
Results: This study included 51 patients (39 males and 12 females). The age ranged from 22 years to 64 years. Variable endoscopic finding were seen and in many cases only after bladder distention, cracked mucosa, some bilharzial lesions and small polypoid masses. In some males the only finding were in the posterior urethra e.g. adhesion between 2 prostatic lobes and villous growth from veru. Light microscopic changes were variable including hyperplastic/dysplastic transitional epithelium, chronic inflammatory cell infiltration, Brunn nest's, cystitis gladularis, squamous metaplasia, bilharzial reaction and some picture characteristic of interstitial cystitis. In situ carcinoma was found in 3 cases, inverted papilloma in one case and nephrogenic adenoma in one case.
Conclusion: Persistent cystitis syndrome was present in both males and female. They had very variable endoscopic and histopathologic findings including CIS, which mandates both routine endoscopy and bladder biopsies. The finding characteristics of interstitial cystitis were found in both males and females, which necessitates bladder distention to be done routinely in both males and females with this syndrome.
Post-pubertal undescended testis: Management and outcome, SFH experience
Samer Al Oraifi, Mohamed A. Gomha, A. Bin Saleh, M.S. Ragheb, A. Al Jasser
Security Forces Hospital, Riyadh, Saudi Arabia
Objective: The aim of this study is to review the management and outcome of post-pubertal patients presented with undescended testis to Security Forces Hospital.
Materials and Methods: Between March 1996 and July 2003, 56 patients with post-pubertal undescended testis were managed in Security Forces Hospital. The mean age was 24 + 8.3 years (range, 13-44). Patients were evaluated by history taking, clinical examination and ultrasonography and/or computerized tomography (CT) when clinically indicated. The undescended testis was on right side in 27 (48.2%), on left side in 25 (44.6%) and bilateral in 4 (7.1%). Among patients with unilateral undescended testis, orchiectomy was done in 34, orchiopexy in 15, no testis was found during exploration in 1 and 2 patients refused the operation. In patients with bilateral undescended testis, 1 had bilateral gonadal agenesis diagnosed by laparoscopy, one had bilateral inguinal testis (CT) and refused operation, one underwent right orchiectomy and left first stage orchiopexy and one underwent bilateral first stage orchiopexy. In patients with unilateral undescended testis, biopsy was taken from the other normally positioned testis in 3 cases with azoospermia.
Results: Post orchiectomy, one patient developed scrotal hematoma and another developed superficial wound infection that was treated conservatively. Among patients with unilateral undescended testis who underwent orchiectomy, histopathology showed seminoma in 2 (5.8%) specimen, atrophy in 4, Sertoli cell only in 24, normal testicular tissue in 1 and no testicular tissue in the specimen in 4. Size of the removed testes ranges from 15mm to 40mm in the longest diameter. Both testes that harbored seminoma were morphologically normal during operation and longest diameter were 35 mm and 28 mm respectively. Biopsy from both testes in the patient who underwent bilateral first stage orchiopexy showed maturation arrest, while histopathology showed Sertoli cell only in both testes in the patient who underwent orchiectomy for one side and orchiopexy for the other side. Biopsy from the normally positioned testis in patients with azoospermia showed normal spermatogenesis in one and Sertoli cell only in 2. Patients were followed up with a mean duration of 8.2 + 10.9 months (range, 0.1-56; median, 4). Most of the patients were not compliant for regular follow up. Among 14 patients who underwent one stage orchiopexy, testis was found in normal position in 10 and at neck of the scrotum in 1; the remaining 3 patients were lost for follow up. Among patients with bilateral undescended testis, testis was found in the normal position in the patient who underwent orchiopexy for one side and orchiectomy for the other side while patient who underwent bilateral one stage orchiopexy, both testes were not palpable during follow up.
Conclusions: Postpubertal undescended testis has high risk of malignancy. Intraoperatively, neither size nor macroscopic picture of the testis can predict presence of tumor or histologic picture. Orchiectomy should be the standard treatment in cases with unilateral presentation. This is to be overemphasized in our locality due to the poor compliance of patients to have regular follow-up after orchiopexy. Semen analysis is recommended in post-pubertal patients with undescended testis as presence of azoospermia is an indication for biopsy of the other normally positioned testis that may reveal sperms useful for ICSI.
(11-13 Muharram 1425)
King Faisal Specialist Hospital &
Correction of penile deformity with saphenous vein graft
Amr Jad 1 , Tom Lue
1 Riyadh Armed Forces Hospital/University of California,
Peyronie's disease often leads to penile curvature severe enough to hinder sexual intercourse. We demonstrate our technique for correction of a complex penile deformity using plaque incision and saphenous vein patch grafting. The region of the penile plaque is exposed and an H-shaped incision is performed through the plaque to release the shortened tunica albuginea. The tunical defect is then measured. An adequate segment of the saphenous vein is harvested from either the proximal or distal lower extremity. This vein segment is then detubularized, cut and reassembled into one patch graft. The graft is then sutured onto the tunical defect.
This technique reduces the problem of penile shortening associated with other approaches for repairing penile deformity. In addition, a low incidence of new-onset erectile dysfunction postoperatively, makes this procedure useful for the potent patient with a severe deformity. The saphenous vein graft serves as an excellent anatomical and functional coverage material for a tunical defect after plaque incision. Our experience and results are very encouraging.
Correction of penile deformity using the 16-dot plication technique
There are multiple procedures for correction of penile curvature due to congenital causes or Peyronie's disease. Penile plication is the least invasive procedure available today. We present our technique for plication of the penis to correct an abnormal curvature.
We performed penile plication under local anesthesia on patients with congenital or acquired curvature of the penis using the 16-dot and 24-dot techniques. First, pharmacological erection is induced with intracavernosal papaverine. A penile block is performed with local anesthetic. If the curvature is dorsal then a longitudinal midline incision is made on the ventral skin of the penis. If the curvature is ventral then we make a circumcising incision with a degloving dissection. The cavernosal tunical surface is exposed while avoiding dissection of the neurovascular bundles and the urethra. Sets of 4 dots each are marked in parallel fashion to represent entry and exit points for non-absorbable 2-0 Ticron plicating sutures. We will use either 16 dots or 24 dots depending on the degree of curvature and length of the curvature. Once the sutures are placed, they are tied down loosely so that fine adjustments can be made to assess how straight the penis will be in its erect state. Once satisfactory correction is achieved, closure of Buck's fascia and skin is performed and dressings are placed. There is no need for a urethral catheter. The preoperative angle of curvature ranged from 30 to 120 degrees. In our experience, 93% of patients reported straight erections and 7% reported almost straight but acceptable erections. The most common complaints were penile shortening and palpable suture knots. Worsened erectile function after surgery was rare. There were very few complaints regarding changes in penile sensation. Penile plication is a safe, simple and time expedient method for correction of congenital or acquired curvature of the penis. Durable results are obtained with our 16-dot or 24-dot minimal tension parallel plication technique which also avoids tunical incision and neurovascular bundle or urethral trauma. There are minimal to no changes in erectile function.
Patients should be counseled pre-operatively regarding the most common complaints which are penile shortening and palpable subcutaneous bumps (suture knots).
2 - 4 March 2004 (11-13 Muharram 1425)
Urolume urethral wall stent for the treatment of urethral stricture: Long term follow up results
Muhammad Aslam, Said Kattan, Irfan Ahmed, Hassan Al Zahrani, Kamal Hanash
Department of Urology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
Objective: To evaluate the long term outcome of self expanding urethral UroLume TM wall stent in recurrent urethral stricture.
Methods: The charts of patients who underwent UroLume stent insertion were reviewed retrospectively. Parameters studied included patient's demographics, aetiology of stricture, post deployment stent related complications and patient satisfaction.
Results: The case notes of 10 consecut6ive men who underwent UroLume stent insertion to treat recurrent bulbar urethral stricture were reviewed retrospectively. The mean age was 38 (18-58) years and mean follow up 28 (12-60) months. All underwent UroLume deployment under general anaesthesia taking great care to identify relevant land marks to avoid encroachment on sphincter mechanism. Aetiology: Traumatic catheterization (3), infection (3), unknown (4). All had several visual urethrotomies and urethral dilatations prior to stent insertion. Preoperative average Q was 6 ml/sec and mean residual volume was 66 ml. They all received antibiotics pre and post operatively. Post deployment average Q was 20 ml/sec. The most frequent post surgical complaint was post void dribbling (70%), 2 (20%) developed severe irritative voiding symptoms, 3 (30%) developed pain at the site of stent, 2 (20%) developed mild stress incontinence. Ejaculatory discomfort noted in 1 (10%) and 3 (30%) developed urosepsis. Surgical complications: Recurrent stricture and urethral stone in 1 (10%), treated successfully with Holmium laser, stent migrated in 1 (10%), explanted and inserted. None underwent endoluminal intrastent fibrous resection. 70% (7) were satisfied and 30% (3) were not satisfied.
Conclusion: UroLume wall stent to treat recurrent bulbar urethral stricture is a viable option, however, our study concludes that it may be associated with both surgical and non surgical complications. Post void dribbling was the most common post operative complaint among our patients. We suggest careful patient selection and UroLume stent deployment by an experienced urologist.
King Abdulaziz University Hospital
Post traumatic urethral stricture in yemeni patients
Tawfik Al Ba'adani, Mohammed Al Husseini, Mansour Al Towaity, Abdulelah Al Adimi, Ibraheim Al Nono
Thawra Hospital, Sana'a, Yemen
Objective: Urethral stricture is frustrating problem and our aim is to discuss different etiology in our society, sites and our experience in managing these strictures.
Patients and Method: In the last two years period, twenty three (23) patients with non passable urethral stricture presented to us with suprapubic cystostomy as a result of post traumatic urethral injury. Their ages ranged between 3-60 years (mean 21.7). The length of the stricture was 1-5cm (mean 2.07cm). The site was anterior (penile) in 6 patients while it was bulbomembranous in 17 patients. As regard the etiology, it was post car accidents in 9 patients, post gun shots in 8 patients, full astride in 3 patients, post pump explosion in one, post TURP in one and one was iatrogenic after cystoscopy. Combined ascending and micturating urethrocystogram followed by diagnostic cystoscopy were done. Urethral reconst5ruction through perennial approach using an inverted U shaped incision and cutting into the tip of a palpable dilator inserted through the suprapubic cystostomy into the perineum.
Results: Urethral reconstruction using excision and end to end anastomosis was done in 14 patients, VIU through antegrade and retrograde manner (cut to the light or to the bogie) in 6 patients, buccal mucosal tube graft in 2, while Orandi Island flap was done in 1 patient. Operative time was ranged between 1-4 hours (mean 2.33) and hospital stay was 1-6 days (mean 3.57 days). Success was achieved in 19 patients out of 23 (82.6%), while those 4 considered failure needed VIU and infrequent dilatation. Blood transfusion was needed in one case and two patients developed fistula.
Conclusion: Good result could be achieved if diagnosis is made properly and the different option of treating urethral stricture is known with fine and meticulous manipulation of the tissues.
Salvage urethroplasty for challenging cases
Abdulwahab El Kassaby
Department of Urology, Ain Shams University, Secretary General of Egyptian Urological Association, Cairo, Egypt
The last two decades has witnessed a revulsion in urethral reconstruction both for congenital and acquired deformities. Despite the fact that, the techniques available in the literatures are capable of solving most of the deformities, yet there are still some cases that need specific solutions tailored for each case. Of course this will require high experience in this subspeciality.
To achieve this goal the surgeon may choose a technique that has been designed for another anomaly or combining some techniques together to create a non-classic procedure.
For the occasional surgeon this may seem to be a rare situation, but actually for referral centers the number of such like cases is actually increasing.
The lecture will demonstrate examples of such situations.
Contemporary management of urethral stricture
Christopher R Chapple
Consultant Urological Surgeon, Royal Hallamshire Hospital, Sheffield, UK
The contemporary management of urethral strictures is discussed with reference to the current therapeutic algorithm. Whilst urethrotomy is one of the most commonly used surgical treatments, urethroplasty is the most effective surgical procedure for a urethral stricture. The appropriate use of these techniques is discussed with reference to early management of anterior urethral stricture disease. Posterior urethral strictures are uncommon and are usually associated with a pelvic fracture injury. The preferred surgical management of these is reviewed.
A comparative study of early to intermediate outcome of the different varicocelectomy techniques: Open inguinal, laparoscopic and subinguinal microscopic varicocelectomies: A single surgeon perspective
Ahmed Al Kandari
Department of Surgery, Faculty of Medicine, Kuwait University, Kuwait
Introduction: Varicocele treatment when indicated can be done by different surgical approaches and interventional radiologic approach. We reviewed our experience with three surgical approaches: open inguinal, laparoscopic and subinguinal microscopic varicocelectomies.
Materials and Methods: 60 patients with clinical varicoceles with different indications for surgery were included in this study. Age ranged from 14-38 years mean of 26 years. They underwent three different surgical approaches non randomly by a single surgeon divided into three groups as following:
Group a: open inguinal varicocelectomy,
Group b: laparoscopic varicocelectomy, and
Group c: subinguinal microscopic varicocelectomy.
Each group included 20 cases. Early outcome including hospitalization period, narcotic analgesic usage and return to normal activity was evaluated. At 3-6 months the occurrence of varicocele recurrence and hydrocele were recorded. Semen evaluation post operatively for the infertility cases was done at 3 months and every 3 months until pregnancy develops or up to 24 months postoperatively.
Results: Postoperative pain, narcotic analgesic usage and return to normal activity was not statistically different in the different groups, although a trend of less pain and analgesia requirement with early return to normal activity were observed in the bilateral laparoscopic varicocelectomy and bilateral microsurgical approach in correlation to the bilateral open inguinal approach which was more.
Conclusion: Comparing the three different surgical approaches of varicocelectomy, it was noted that microscopic subinguinal varicocelectomy had the least complications of varicocele recurrence and hydrocele development although it took longer operative time due to its meticulous nature. In regards to postoperative pain and return to normal activity microscopic varicocelectomy compared similarly to laparoscopic cases although no significance noted. A larger study will be conducted to evaluate these results.
20 - 23 February 2006 (21-24 Muharram 1427)
Varicocelectomy is associated with increased seminal antioxidant in infertile men
E.M. Al Barky, A. Al Shazly, O. Abdelwahab,
O. Al Shaer, M. Al Shafee
Departments of Urology and Clinical Pathology, Banha Faculty of Medicine, Egypt
Objective: To explore the impact of surgical correction of varicocele on antioxidant defense system, we assessed spermatozoal reactive oxygen species (ROS) and total antioxidant capacity of seminal plasma from infertile men with varicocele pre and post varicocelectomy.
Materials and Methods: A total of 58 patients with varicocele who presented for evaluation of infertility were studied, the duration of infertility was 12 months. All patients were subjected preoperatively to seminal fluid analysis, seminal plasma levels of two ROS; malondialdehyde (MDA) and hydrogen peroxide (H 2 O 2 ) and one ROS radical; nitric oxide (NO) were estimated as well as 4 antioxidants namely: superoxide dismutase (SOD), glutathione perioxide (GPX), Vit. E and C. Varicocelectomy was done in all patients by the laparoscopic methods. Semen analysis and seminal fluid level of MDA, H 2 O 2 , NO, SOD, GPX, Vit. E and Vit. C, were measured 3 and 6 months post varicocelectomy.
Results: A statistically significant improvement was noticed in all seminal parameters 3 and 6 months after varicocelectomy. There was also a significant reduction in the level of MDA, H 2 O 2 and NO when comparing with the pre-operative values. A further significant reduction in the three ROS levels took place after 6 months. Three of the four antioxidants tested (SOD, GPX and Vit. C) showed a significant increase in seminal plasma at 3 and 6 months after varicocelectomy when compared with the pre-operative values. Alternatively, seminal plasma level of Vit. E showed a significant decrease at 3 and 6 months postoperatively.
Conclusion: These results suggest that varicocele is associated with elevated seminal reactive oxygen species, decrease seminal total antioxidant agents and sperm dysfunction. Our data propose that varicocelectomy reduced seminal ROS levels and increased total antioxidant capacity levels. However, the use of antioxidants in infertile men with or without varicocele demands further controlled clinical trials.
Key Words: infertility, varicocele, reactive oxygen species, antioxidants
Inguinal optic loupe varicocelectomy
Abdou Khair Chamsuddin, Ismail Al Othman
Department of Surgery, Section Urology, College of Medicine, University of Damascus, Damascus, Syria
Objective: Microsurgical inguinal varicocelectomy has been associated with extremely high success rates and minimal postoperative complications. The aim of this study is to analyze the results of a group of patients who underwent inguinal microsurgical varicocelectomy using loupe magnification.
Patients and Methods: From April 2000 to April 2004, 72 patients underwent loupe-assisted inguinal varicocelectomy. In 68 patients the varicocele was on the left side, in 1 patient on the right side and in 3 patients bilateral. The mean age was 26.9 years (range: 16-42). 18 patients (25%) had painful scrotal sensation, in 6 of them oligoasthenospermie could be detected, and 54 patients (75%) were infertile. The diagnosis was based on clinical features (testicular pain or scrotal sensation), physical examination and color duplex ultrasonography (CDUS) in recurrent cases, the majority of varicocele were stage II and III, 5 of them were recurrent cases. The loupe-assisted microsurgical inguinal "artery- and lymphatic-sparing" technique of dissection was performed in general anesthesia.
Results: All operations were performed on an outpatient basis (post-operative stay: 3-7 hours) and the operating time was 30 to 55 minutes. Follow up was performed by physical examination, and semen analysis. CDUS was done only if recurrence was suspected. Immediate and long-term complications were 1 (1.3%) hydroceles, 2 (2.6%) palpable recurrence and 1 (1.3%) wound abscess. 46/60 (77%) patients showed an improvement of semen analysis and 6/18 (33%) have their scrotal pain disappeared.
Conclusion: Loupe-assisted inguinal varicocelectomy is a safe and effective method. It preserves spermatic artery, lymphatic and vas deferens and in our experience showed an improvement of semen analysis. The procedure is easy to perform and to master; also the results are comparable to those obtained by the standard microsurgical technique using microscope.
Genital and perineal fournier's gangrene: Experience with 12 patients
Tala H Al Afraa, Mohammed S Abomelha
Department of Urology, Riyadh Armed Forces Hospital, Saudi Arabia
Objective: Fournier's gangrene is an infective necrotizing fasciitis of the perineal, genital or perianal regions. We report our experience with the diagnosis and treatment of this extensive fulminant infection.
Patients and Methods: A retrospective review of 12 patients admitted with the diagnosis of Fournier's gangrene between 1990 and 2003. The data were collected on patient demographics, symptom, predisposing factor, comorbidities, physical examination including extent of disease using role of nine. The outcome includes complications, hospital stay and mortality assessed.
Result: Twelve patients were included in this review, age ranging between 1 and 88 years (mean 58 years). Most common presenting symptoms are scrotal swelling, pain and fever. Nine patients had predisposing factors where the most common source of infection is dermatological. All patients had at least one comorbid disease where diabetes mellitus (66.7%) was the commonest. The percentage of skin involved according to role of nine was statistically significant. Seven patients (58.3%) had electrolyte imbalance in form of hyponatremia ranges between 125mmol/L and 128mmol/L. All patients had at least one pathogen growth in tissue culture. Management was in the form of fluid resuscitation, broad spectrum antibiotics and aggressive surgical debridement. Reconstructive surgery was done in six patients. Eight patients survived (67%), with a mortality rate of 33%. Hospital stays ranging from 7 to 91 days (mean 47.8 days).
Conclusion: Fournier's gangrene is an infective disease within wide age range. Predisposing factor can be found always. It is usually affecting the comorbid patients. Broad spectrum antibiotic and timed aggressive surgical debridement is the corner stone of management. Simple, frequent daily wound care is sufficient. The length of hospital stays and mortality rate are still high.
Tunica albuginea free graft for corporoplasty in the baboon: A comparison between 6 months and 1 year effects
Raouf M. SeyamΈ Alaa A. Mokhtar, Muhammad A. Chishti, Maqbool Ahmed, Walid Mourad, Abdelraof Alagha, Raafat El Sayed, Kamal Hanash
King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
Autologous free tunica albuginea (TA) graft probably provides the most natural material for surgical correction of Peyronie's disease. We set out to evaluate this procedure in the baboon and compare its hemodynamic, histologic and molecular effects after 6 months and 1 year.
Under general anesthesia, 8 adult sexually active Baboons weighing 14.7 ΁ 1.6 kg were subjected to pharmacological cavernosometry and cavernosography (PCC). Harvesting of a 3.5 x 1 cm free TA graft from the right crus was carried out and grafted on the left side of the distal shaft of the penis. Samples from crural TA and corpus cavernosum (CC) were preserved. After 6 months 6 animals were subjected to PCC and 2 were sacrificed and penis excised.
After 1y the remaining 6 animals were similarly evaluated and sacrificed. The graft site was sectioned and stained for histology. Snap frozen TA graft and underlying CC were evaluated for protein expression by western blot analysis for neuronal NOS (nNOS), inducible NOS (iNOS) and transforming growth factor (TGF)- 1.
All animals resumed normal sexual activity after one month from surgery. At 1y cavernous pressure (CP) response to 15 mg papaverine (55.4 ΁ 20.1) was comparable to pre-surgery values (52 ΁ 9.7, p=0.79). There was no significant difference in CP during saline 96 ml/hour before (140.8 ΁ 126.2) and 1y after surgery (92.3 ΁ 102.7, p=0.13). However, new venous leakage could be documented in 4 of 6 animals at 6 months 2 of which ceased to leak at 1y.
A total of 4 animals had venous leakage at 1y. Various moderate degrees of penile angulation (<20 o ) were seen at the site of grafting in 3 animals at 6 months with additional 2 at 1 y. Histologically the graft was indistinguishable from the adjacent TA in structure and thickness. No fibrosis was seen in adjacent tissues. We observed a significant decrease in nNOS levels in CC under the graft after 1y whereas there was no change in iNOS and TGF-β levels. In the TA graft there was no significant change in TGF-β level but a decrease in iNOS at 1 y.
Conclusions: Autologous free TA graft is associated with normal sexual activity, minimal hemodynamic changes and an excellent histological outcome. iNOS and TGF-β associated with inflammation are not elevated. Venous leakage in some animals, a decrease in nNOS underneath the graft and penile deformity are persistent after 1 y.
Update on peyronie's disease
Ridwan Shabsigh
Department of Urology, Columbia University, New York Center for Human Sexuality, New York, USA
Peyronies Disease (or Indurato Penis Plastica) is characterized by the formation of plaque within the tunica albuginea of the penile corpora cavernosa. This plaque buildup results in a painful curved erection that makes intercourse difficult, if not impossible. The cause of Peyronie's is uncertain, and a cure is not available at this time. Many papers have been written about Peyronie's, including speculation about its etiology and the "best" methods for its treatment. In light of recent advancements in this area and the continuing lack of well-controlled prospective studies, the time has come for a consensus on an algorithm for the most effective treatment of Peyronie's disease. A Medline review of the history, pathophysiology, medical, and surgical treatments for Peyronie's was assimilated. The current standard is to treat Peyronie's in an conservative fashion, with expectant medical management, until the process has stabilized for 12-18 months. Besides pain relief, few patients will experience any significant disease regression as a result of medical management. During the chronic phase of Peyronie's disease, those with disabling curvature may require surgical intervention. Preoperatively, it is imperative to involve both the patient and his partner in conversations regarding surgical expectations. With a reasonable understanding of the risks and expected outcomes, men with Peyronie's can have their self-esteem restored and achieve significantly improved quality of life. We hope that a consensus conference will recommend a standardized treatment protocol, or at least consider a multi-institution, randomized prospective study, to help define the best treatment option(s) for men with Peyronie's.
King Abdulaziz University Hospitalaa


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A bit of an "out of right field" development in the coal market yesterday. With potentially big implications for global supply and pricing.
The news came from critical thermal coal supplier Colombia. Where it appears export shipments will be abruptly halted at any time.
That's because of labor unrest hitting major producer Cerrejon--operator of the largest open-pit coal mine in South America.
Reports suggest that those operations have been largely crippled by workers from local security firm Sepecol. Who have blocked the railway line leading from the Cerrejon mine to port export facilities.
The move is intended as a protest, after Cerrejon failed to renew a contract with Sepecol. Setting up the termination of several hundred security employees when the current contract expires at the end of June.
The shutdown of the railway means no coal is moving now. With Cerrejon officials saying that stocks at the port will likely be depleted today or tomorrow. Forcing the company to look at completely halting export shipments.
As the company's Vice President of Public Affairs, Juan Carlos Restrepo, told Reuters, "We're looking, together with our lawyers, at the possibility of declaring force majeure given the inability to adhere to our trading commitments, if the situation persists."
This would be an important loss of global supply. Given that Cerrejon was last year one of the world's largest producers--at 33 million tonnes of output.
If that supply is lost, it sets up some interesting dynamics. The majority of Colombian coal is currently shipped to Europe. A region that could now be forced to look for alternative supply.
One go-to source would be South Africa. One of the few suppliers globally that's positioned to sell into either European or Asian markets.
If more South African coal does flow to Europe, Asian customers like India might in turn be left with a shortfall. Prompting them to buy more aggressively from Asian producers like Indonesia or Australia.
We'll see how long the Cerrejon shutdown wears on. But any prolonged interruption here could be the shot in the arm that the bottoming coal market has been looking for.


text:
Ignition: What You Can Do to Fight Global Warming and Start a Movement
The evidence is irrefutable: global warming is real. While the debate continues about just how much damage spiking temperatures will wreak, we know the threat to our homes, health, and even way of life is dire. So why isn't America doing anything? Where is the national campaign to stop this catastrophe?
It may lie between the covers of this book. Ignition brings together some of the world's finest thinkers and advocates to jump start the ultimate green revolution. Including celebrated writers like Bill McKibben and renowned scholars like Gus Speth, as well as young activists, the authors draw on direct experience in grassroots organization, education, law, and social leadership. Their approaches are various, from building coalitions to win political battles to rallying shareholders to change corporate behavior. But they share a belief that private fears about deadly heat waves and disastrous hurricanes can translate into powerful public action.
For anyone who feels compelled to do more than change their light bulbs or occasionally carpool, Ignition is an essential guide. Combining incisive essays with success stories and web resources, the book helps readers answer the most important question we all face: "What can I do?"
NRCS Technical Resources
Factors to consider in Choosing Instruments to Promote Environmental Services
Stay up to date on the latest in environmental markets
© 2020 Ecosystem Marketplace. All Rights Reserved.


The cartoon classics that need to grow up.
Childhood is tragically one of those things you never can truly appreciate until it's gone. Early adulthood is rough and while we're witnessing our parents age, struggling to navigate the job market and drowning in debt, it is easy to become nostalgic for the simplicity of adolescence.
Luckily there are a plethora of cartoons for all 20 and 30-somethings to look back on with fondness. The 90s and 2000s were a golden age for cartoons aimed at children. Nickelodeon and Cartoon Network were never better, both producing programming that ranged from cult classics to international mega-franchises.
Many of these shows were great and it is sometimes best to leave well enough alone. Although most of those cartoons you remember should be left in your youth, there are some, with a little alteration, that could be adapted to an older audience.
Rocko's Modern Life ran for four seasons on Nickelodeon from 1993-96, producing over 50 episodes. The show followed the titular Rocko, a Wallaby as he navigated his, well, modern life.
The early 90s was a period in which the lines between adult and children's programming were somewhat blurry. Existing episodes are already filled with adult innuendo and hidden jokes, so the show should just drop some of the subtlety and make a return.
Rocko's Modern Life almost feels as if it is an early ancestor of BoJack Horseman. It may have lacked the complexity and character development BoJack offers (no surprise given it was meant for children), but it still offered a humorous and charming take on our mundane existence. Cynicism is in and maybe no children's show from its era is as capable of capturing it as Rocko's Modern Life.
Since the end of the show's original run, it has gained a bit of a cult following, as shows like Rocko's Modern Life often do. Who knows if the creators would be willing to return, given that many of them have had continued success in the realm of child programming. If they were, however, there is a dedicated following already in place for Rocko's return.


text:
Chris Woodhouse: MAAC Field Performer of the Week
by KATIE HENNEGEN, Asst. Features Editor Senior Pole Vaulter and Computer Science major Chris Woodhouse had a major win at last week's VCU meet. He was named MAAC Field Performer of the week and was selected for the MAAC All-Academic team. In [...]
Matt Centrowitz Returns Back to Where It All Started to Bolster Running Program
by John Jackson Sports Editor Manhattan College had a reunion this past August with a former Jasper student-athlete who has accomplished numerous things over the last 44 years since he attended college in Riverdale. That former Jasper, Matt [...]
Summer Break Sports Recap: New Coaches, Alumni Success and More
by JOHN JACKSON, Sports Editor A lot has happened around Manhattan College athletics since the Jaspers finished their finals to conclude the spring 2018 semester. Over the past few months, there have been teams that finished their 2018 seasons, [...]
Track and Field Standout and Resident Assistant Ire Bozovicar
by TAYLOR BRETHAUER & STEPHEN ZUBRYCKY, Editor in Chief & Managing Editor A senior kinesiology major from Slovenia, Irenej "Ire" Bozovicar has a lot on his plate. From being a model student-athlete on the track and field team to [...]
Chad Maier Shines in First Outdoor Race of 2018
Chad Maier, a standout member of the men's track and field team at Manhattan, was recently named the Metro Atlantic Athletic Conference (MAAC) Male Performer of the Week for his performance at the Shamrock Invitational in Myrtle Beach, South [...]
MAAC Record Falls, Individual Awards Abound at 2018 MAAC Championships
The Manhattan College men's and women's track and field teams took a trip down to 216 Fort Washington Avenue on Feb. 17-Feb. 18 to participate in the 2018 MAAC Indoor Championships held in the New Balance Armory Track and Field Center. [...]
Running Through the Line, Track and Field Looking Strong
by C. GARRETT KEIDEL, Asst. Editor On Thursday Feb. 1, the Men's and Women's Track and Field teams started two days of competition at the Metropolitan Championships. At the end of competition, the Men's team finished in second place while [...]
Sophomore Brenton Foster Jumping to New Heights
While most Jaspers spent the first weekend in December preparing for college finals, sophomore Brenton Foster spent it by breaking a college record. Foster is a member of the Manhattan College men's track and field team. The Townsville, Australia [...]
What's Up During Winter Break?
by RIKKILYNN SHIELDS, Editor During winter break, Jaspers are everywhere. Some study abroad, others travel with their L.O.V.E. Trips, some stay home and the athletes continue working hard and preparing for games, meets and upcoming seasons. The [...]
Manhattan Indoor Track and Field Teams Already Providing Much to Discuss
Manhattan College's track and field teams opened up their 2017-2018 indoor campaign with a bang on Dec. 1 and since then have already had a record-breaking jump, some qualifying marks, a couple of MAAC Performers of the Week, a lot of personal [...]


Fear tries to drag us down, but Jesus is the lifter of our heads. When we give our lives to Christ, his Spirit lives within us, and within that Spirit lies no fear. Enjoy this beautiful printable from Sarah Dohman to remind yourself of the power that dwells in you through Christ.


text:
package org.newdawn.slick.util;

import java.io.BufferedInputStream;
import java.io.File;
import java.io.FileInputStream;
import java.io.IOException;
import java.io.InputStream;
import java.net.URL;

/**
 * A simple wrapper around resource loading should anyone decide to change
 * their minds how this is meant to work in the future.
 *
 * @author Kevin Glass
 */
public class ResourceLoader {

	/**
	 * Get a resource
	 *
	 * @param ref The reference to the resource to retrieve
	 * @return A stream from which the resource can be read
	 */
	public static InputStream getResourceAsStream(String ref) {
		String cpRef = ref.replace('\\', '/');
		InputStream in = ResourceLoader.class.getClassLoader().getResourceAsStream(cpRef);

		if (in == null) {
			File file = new File(ref);
			try {
				if (System.getProperty("jnlp.slick.webstart", "false").equals("false")) {
					in = new FileInputStream(file);
					return new BufferedInputStream(in);
				} else {
					Log.error("Resource not found: "+ref);
					throw new RuntimeException("Resource not found: "+ref);
				}
			} catch (IOException e) {
				Log.error("Resource not found: "+ref);
				throw new RuntimeException("Resource not found: "+ref);
			}
		}

		return new BufferedInputStream(in);
	}

	/**
	 * Get a resource as a URL
	 *
	 * @param ref The reference to the resource to retrieve
	 * @return A stream from which the resource can be read
	 */
	public static URL getResource(String ref) {
		String cpRef = ref.replace('\\', '/');
		URL url = ResourceLoader.class.getClassLoader().getResource(cpRef);

		if (url == null) {
			File file = new File(ref);
			try {
				if (System.getProperty("jnlp.slick.webstart", "false").equals("false")) {
					return file.toURL();
				} else {
					Log.error("Resource not found: "+ref);
					throw new RuntimeException("Resource not found: "+ref);
				}
			} catch (IOException e) {
				Log.error("Resource not found: "+ref);
				throw new RuntimeException("Resource not found: "+ref);
			}
		}

		return url;
	}
}

redpajama_set_name: RedPajamaGithub


text:
WYPR News
Who was Roger Taney?
WYPR - 88.1 FM Baltimore | By Rachel Baye
Any discussion of former Supreme Court Chief Justice Roger Taney inevitably begins with the opinion he published in 1857 in Dred Scott v. Sanford.
"It was an extremely polarizing ruling," said Tim Huebner, a history professor at Rhodes College and the author of a book about Taney's time on the court. "He was saying that African Americans had no rights under the U.S. Constitution, and arguably the most infamous words of the history of the court were those words spoken by Chief Justice Taney, that they had no 'rights that the white man was bound to respect.'"
The ruling overturned a federal law barring slavery in the west and helped set the country on a path toward civil war.
Taney's role in the case was a major reason behind the decisions by city and state officials last week to remove two statues of Taney from their pedestals — one on the front lawn of the State House in Annapolis, the other on Mount Vernon Place in Baltimore.
Dred Scott came in the latter half of Taney's 28 years on the court and toward the end of a long career in public service. A devoted Marylander, he served in the General Assembly and as state attorney general. He later served in President Andrew Jackson's cabinet, first as acting secretary of war, then attorney general.
"Jackson did not have a lot of elite supporters," said Mark Graber, a law professor at the University of Maryland who has written extensively about Dred Scott. "Taney was one of the first, and that's how he rose to power."
After the Dred Scott opinion, Graber said the second-most important thing Taney did was help Jackson destroy the Second Bank of the United States.
"He's the person who precipitated a crisis," Graber said. "When two secretary of the treasuries refused to remove federal deposits from the national bank, Taney became secretary of the treasury and he removed the deposits."
Taney's loyalty to Jackson in that episode likely led to his appointment to the Supreme Court. But the appointment was contentious.
"Taney's reputation kind of goes up and down throughout history, and actually at the time that he was nominated by President Andrew Jackson, he was a very, very controversial figure," Huebner said. "He was seen as a sort of political hack who had been put on the court basically to try to carry out Jackson's will."
Once on the court, Taney's opinions helped shape the relationship between the federal government and the states, said Martha Jones, a history professor at Johns Hopkins University.
But Taney's opinions, both as attorney general and on the court, often hinged on race.
"One of his earliest decisions as the attorney general of the United States … turns on whether or not free African Americans are citizens because there's a question about whether or not they can obtain federal licenses to pilot boats along the coastal waters of the United States," Jones said.
Taney didn't believe it would be possible for multiple races to coexist in a democracy, Jones said. He was a colonizationist, meaning he believed that free African Americans should be strongly encouraged or even paid to leave the United States.
"The reason that no black person can be a citizen of the United States in an operational sense for Taney is that that would mean that they would have a claim to stay and would not be subject to colonization or removal," Jones said.
She said Taney expressed regret about Dred Scott late in life, but not because he thought he had been wrong. Rather, he felt that his reasoning was misunderstood. He wrote a second Dred Scott opinion to explain that reasoning. It was published after his death.
WYPR News Roger TaneyConfederate monumentsPoliticsWYPR News
Rachel Baye
Rachel Baye is a reporter for WYPR's newsroom. @RachelBaye
See stories by Rachel Baye
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A statue of former Supreme Court Chief Justice Roger B. Taney was removed from the State House grounds early Friday morning, following a key state…
Baltimore wakes up to Confederate monuments gone
Baltimore quietly removed four Confederate monuments Tuesday night, responding to activists who called for them to be taken down after a white supremacist…
Confederate monuments come down
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Four Confederate monuments in Baltimore were torn down overnight at the order of Mayor Catherine Pugh. She said she was concerned about the "safety and…
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A Baltimore mayoral commission released Wednesday formalized recommendations to remove two city-owned Confederate monuments.The commission studied four…


text:
Night of the Golden Ghetto
Black Bucks Coffee
The Shape-up
Slurred
What Makes a Writer Like the TARDIS - Consider Amor Towles, Author of the RULES OF CIVILITY
If you look at the below clip of Amor Towles, you would never guess that he penned a novel that has both the glamor of F. Scott Fitzgerald and the inner depth of Henry David Thoreau. He looks like an investment banker, which is exactly what his resume says he is. He does not have Fitzgerald's flamboyance or any of the peculiarities one associates with the famous authors reviewers have compared him to.
In today's world of "make it rain" celebrity glitz, you would pass him on the streets of his beloved New York City without a second glance. He blends in like the blue phone booth (police box) that disguises Dr. Who's fabulous spaceship, the TARDIS. Looked at from the outside, all you see is a blue box. Open the door, and you find a vast time-traveling machine, complete with time-specific wardrobe changes, capable of moving freely through the space-time continuum.
It's the TARDIS' effortless freedom of movement that brings Towles to mind. For who would guess that the slender, mild-mannered investment banker interviewed below could so completely inhabit the persona of his narrator, Katey Kontent, as to make us love her the way so many of us do. And not only Katey, but Eve Ross, Ann Grandin, Bitsy, Dicky, Wallace Woolcott, and the Gatsby-like protagonist, Tinker Grey.
The main hoopla for The Rules of Civility came with its release in 2011 and continued into 2012. So I'm a bit late to the party on this. But isn't that what's wonderful about a novel? You can pick up The Scarlett Letter (which by the way, was published on this date in 1850) and still find something of value 164 years later. That is what Ezra Pound meant in 1934 when he said, "Literature is the news that STAYS news." Besides, if we were on the TARDIS, we could take all the time in the world to read a novel and still join in the buzz the first day it was published.
I pick up a novel or listen to a particular piece of music when something inside me says, Now would be a good time to experience this. I've been on the academic treadmill. I know what forced reading feels like. Just imagine if food or sex were that way.
With The Rules of Civility, Towles has succeeded in doing two important things:
1.) He has significantly restated F. Scott Fitzgerald's thematic premise in The Great Gatsby in a fresh, original way. With Katey Kontent acting as a female Nick Carraway, we witness one man's quest to capture the American Dream at any price. It's a story that can be told many times in many ways, but few have succeeded in doing so. That's why we keep going back to Fitzgerald almost ad nauseam.
Witness Baz Lurhman's recent Gatsby movie with Leo DiCaprio and that wooden version with Robert Redford and Mia Farrow back in the day. Here in metro Atlanta, there's even a stage version of the novel, which prolongs the love affair between Nick and Jordan Baker and completely misinterprets Gatsby's Plaza Hotel confrontation with Tom Buchanan by having Tom pull a knife on Gatsby instead of allowing Gatsby's own uncouth and possibly murderous impulses to reveal themselves. In this well-meaning community-theater version, he walks away from the fight like a hero with Daisy on his arm, instead of the jumped-up wannabe who has just lost everything but doesn't realize it. But no matter. It's what that audience wanted to see. As Ron Burgundy says in Anchorman 2, "Instead of giving people the news they need, why not give them the news they want?"
I'm not about to criticize anything that gets people out to see live theater. The point here is this: there is something in Gatsby, however you re-frame it, that speaks an essential truth about American life. Our fascination with this mythic story is understandable in times like our own when the gap between the very rich and the very poor is wider than ever and the middle class is diminishing like an anorexic waistline. Like trying to write a symphony after Beethoven "used up all the notes," it's daunting for a contemporary writer to attempt recapturing Gatsby's essence in a debut novel. But Amor Towles has done just that in The Rules of Civility.
2) Towles successfully managed to conceal his own boyhood dreams of becoming a writer by taking on the persona of a mild-mannered investment banker, becoming a sort of literary Clark Kent. He got his undergraduate degree from Yale and picked up a Master's in English at Stanford, where he was a Scowcroft Fellow. (I spent a couple of post-TV years writing for Stanford's News and Publications office, and believe me, they don't give Scowcrofts away to talentless hacks.)
Writer Peter Matthiessen encouraged Towles' early writing, and he eventually landed a story in The Paris Review - an extremely difficult nut to crack. Years went by, and instead of the take-em-by-storm bravado of other young writers from Stanford, Towles was silent. But he never lost his dream. Gustave Flaubert, who gave us the timeless masterpiece, Madame Bovaray, once had this advice for aspiring writers. "Live like a bourgeois, but be a revolutionary in your work." Over time, patience and a quiet devotion to the writer's craft won out. Thank you, Mr. Towles for hanging in there.
Of course, there's to be a movie of The Rules of Civility from Lionsgate, which is currently in development. We already know it will pale in comparison to the novel. Katey is a big reader with books stacked all over her working-class apartment, even under the bed. There's no way to get her trenchant literary insights onto the screen. But that's okay. It will be fun to see how close they can come to the original, especially since Towles himself may be on the writing team that now includes Scott Neustadter and Michael Weber of Spectacular Now.
Hooray for good stories, wherever they come from. And three cheers for movies, watered down they may be, for providing a jumping-off place for some very good reads.
TAGS: Writers & Writing
I always enjoy your blogs, Andrew, and this one is one of my favorites. You have certainly piqued my interest in reading Rules of Civility, which will happen when I finish the book I am reading now. It's fascinating how you manage to weave so many seemingly unrelated works into one beautiful tapestry of information for your readers. Now, I'm going to read it again...
Aw shucks, ma'am. Twaren't nothin' Thanks for reading it!
I'm just a bit dizzy with déjà vu…Ron Burgundy, hahaha! Thanks for putting together some really wonderful words about Gatsby and Towles.
Is the clip just a random teaser or does it really represent the movie-in-development? The trailer scares me with a vision of sugary dilution of the story. The Jazz Bar looks far classier than the rugged bar in the book. Is the movie going to gloss prettily over the cold poverty that demands creativity from Eve and Katey? They are sharply alert to the opportunity that appears in the form of Tinker; their conversation is an arsenal of gentle stings and fierce focus. This is directly because they are down to their last three dollars and then it's gone. If they started out blessed with cozy glamour, then they wouldn't be hungry to pursue the beauty of what Tinker represents. Hand wringing! Pearl clutching! Movie, don't mess up this book! But that's so often the case for us book purists. So it's best to just accept the "watered down" object as simply a different channel for similar material.
And now, I'm off to the laBORat'ry to cook up the next item on your reading list…bwahahaa!
Hi Julie, and thanks for commenting on my blog post. The movie is in development, and there's very little info available at this point beyond what I've mentioned. I'm with you on this. I love this novel, and even though the movie can't possibly measure up, let's hope they don't mess it up! Cheers to you, and thanks again for your comment.
Hi...
I like big books, and I cannot lie. My background includes talk radio, newspapers and TV news. I've hosted a morning-drive classical music program on the California coast and published nationally in Reader's Digest, the Christian Science Monitor, and Playboy. I've won awards for my journalism and my fiction. One of my essays even made it into an anthology for college English courses. For real? Yes, for real.
Muses-music
If you're reading this website, think of me as a troubadour standing on the street corner, strumming a guitar and singing a few songs. Not everyone who comes this way is able to make contribution. But if you're one of the passers-by who can, then feel free to drop a little spare change in my hat by clicking either the Donate or the Become a Patron button below.
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@2019 ANDREW HILL | ALL RIGHTS RESERVED | www.andrewhillbooks.com | CONTACT | PURCHASE BOOKS


text:
Excitement Abounds at the German Juniors
2008 has seen a whirlwind start to the year for the majority of badminton players and the same can be said for the junior badminton players with the recent German Junior event which took place in early March being the latest tournament featuring high drama and excitement.
The popularity of the event was shown with the fact that there were 94 competitors taking part in the Men's Singles tournament, with four young Scottish players helping to swell the ranks. The four Scots boys also doubled up to take part in the Doubles event so they were certainly getting plenty of opportunity to play.
Kieran Merrilees went the furthest of the Scots quartet as he reached the fourth round, defeating host nation player Tobia Wadenka along the way. This hard fought 21-15, 19-21, 21-14 victory was indicative of the tough matches that were facing the young Scots but Merrilees managed to follow on this victory with a triumph over Yohan Turlan by 21-11, 21-15 before Merrilees run was halted by Korea's Young Woo Choi.
Choi was ranked as the 9th seed going into the tournament and a convincing 21-15, 21-8 result emphasized the gulf in class between the two players although it had been a fine showing from the Scots youngster.
Angus Gilmour also managed to seal victory in his first match where a 21-10, 21-15 over Sweden's Mathias Lopez ensures the 17 year old Scot would gain at least one triumph at the tournament but this was followed by a three set match loss to Milan Ludik with a score line of 21-16, 19-21, 21-12 being enough to send Gilmour crashing out.
The two remaining Scots were both knocked out in their opening matches with Martin Campbell being defeated by Malaysian Iskander Zulkanain Zainuddin by a score of 21-18, 21-14 whereas Paul Van Rietvelde was quickly beaten 21-13, 21-11 by Emil Host from Denmark.
A similar fate fell on the players during the Doubles matches where Merrilees and Van Rietvelde managed to win their first match against home nation opposition before losing to Denmarks Host and Simon G Peterson. Given that Host managed to get the better of Van Rietvelde in the singles match up as well, it would be fair to say that the Scottish players would be delighted to see the back of him.
The mach against the Germans was another epic and the score of 25-23, 16-21, 21-12 indicated the thrilling and swinging nature of the match but it possible took a lot out of the Scottish players as they meekly surrendered 21-19, 21-15 to their Danish opposition in the following match.
Germany did get some measure of success over the Scottish team though as Martin Campbell and Angus Gilmour were defeated 21-18, 15-21, 21-18 in a close match by Julian Degiuili and Kevin Joss, which brought the Scottish male involvement in the tournament to a close.
The only way for young players to get better is through training and by playing against a better class of opposition and although there may be disappointment over the manner of the defeats, there is every chance the Scottish players will bounce back to better things in the future after the experience of this tournament.
Return from Excitement Abounds at the German Juniors to Badminton News & Videos
Return from Excitement Abounds at the German Juniors to Badminton Information


Lehigh Valley, PA – My name is Chazmichael Morales, and I represented Team Cycle Veloce at 2012 JR Track Nationals, in Lehigh Valley, PA.
I entered the JRM15-16 Omnium, which included 4 events. The first being the 16 km points race which I placed 7th. The 200m TT qualifier which lead to the match sprints, I took 1st. The 8 km Scratch Race, placed 3rd. The 500m TT, placed 2nd. This gave me a second place overall in the Omnium. The difference between first & second was a point.
When I began the qualifying heats, it was not much of a struggle to advance to the finals. But when finals came around, it was on another level to stay with the field. One of the biggest things I learned from nationals was you should never expect a race to play out how you plan it to, because it will always change, people will breakaway before sprints, and laps will be taken. The most important thing to do is to ride off of instinct and mark the riders who are in contention with the jersey. When it came down to the final day which was the 500 meter time trial, I knew that I had to get first if I wanted to win overall. I just missed the jersey by 3 one-hundredths of a second when James Mellen beats my time with a 36.1 second time trial! I was a bit disappointed at first, and then I realized that I just placed second at Jr. Nationals and realized the importance of embracing the second spot on the podium. I was the only 15 year old in the top 5. I had beaten second place by 5 points, and barely missed the jersey. In the end, Track Nationals taught me one thing, which is realizing that I can do anything if I put my mind to it!!!!!