










































Key Words Competing Interests Article Information

Tuberculosis, urogenital tuberculosis, 
extrapulmonary tuberculosis, Sabah 
development of CRPC

None declared. Received on July 17, 2021 
Accepted on October 17, 2021 
This article has been peer reviewed.

Soc Int Urol J. 2022;3(2):69–76

DOI: 10.48083/ WHLL5336

69SIUJ.ORG SIUJ  •  Volume 3, Number 2  •  March 2022

This is an open access article under the terms of a license that permits non-commercial use, provided the original work is properly cited.  
© 2022 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada.

ORIGINAL RESEARCH

Epidemiology and Clinical Characteristics of 
Urogenital Tuberculosis in Sabah, Malaysia
Karthikayenee Ramasamy, Shankaran Thevarajah

Urology Unit, Hospital Queen Elizabeth, Sabah, Malaysia

Abstract

Objectives We aimed to describe the epidemiology and clinical characteristics of urogenital tuberculosis (UGTB) 
in Sabah, Malaysia.

Methods We performed a retrospective, descriptive study based on medical records of UGTB cases identified 
between January 1, 2014, and November 30, 2020.

Results We identified 131 cases of UGTB in Sabah. Patient gender was balanced except for a mild male 
predominance in the 35 to 44 age group. No cases were reported in children. The majority of the patients (96%) 
were diagnosed in the government facility. Among the UGTB cases, 72% of patients were from rural areas, and 29% 
were illiterate. The commonest presentation was frequency of micturition (28%), followed by abdominal pain (26%) 
and loss of appetite (26%). The common sites included renal (32%) and scrotal (25%). Diagnosis was achieved via 
histopathology in 39.7% of patients and smear microscopy in 35.9%. Anti-tubercular treatment duration was 8.6 
(±SD 4.0) months, and 81% of patients have completed treatment. A total of 50.4% of patients had received surgical 
intervention; 10.7% had undergone incision and drainage, 9.9% had cystoscopy, and 6.9% underwent orchidectomy.

Conclusion UGTB has varied non-specific symptoms, which poses a diagnostic challenge, leading to morbidity. 
Ensuring awareness via widespread education within government and private health care, along with rural outreach 
programs, will contribute to early recognition and treatment.

Introduction

Tuberculosis (TB) is an ancient disease that constitutes a global epidemic. It is caused by Mycobacterium tuberculosis, 
which was discovered by Robert Koch in 1882. Genomic analyses suggest that M. tuberculosis co-evolved with 
humans. Its early progenitor, Mycobacterium prototuberculosis, possibly infected early hominids more than 3 million 
years ago[1,2].

According to the WHO Global Report 2019, around 10 million people fall ill with TB each year. TB is one of the top 
10 causes of death, and the leading cause from a single infectious agent (Mycobacterium tuberculosis), ranking above 
HIV/AIDS. Of the 10 million annual cases, 5% to 45% have features of extrapulmonary TB[3].

In the early 1940s and 1950s, TB was the main cause of death in Malaysia. Realizing its significance, the Malaysian 
government launched its National TB Control Program in 1961. In 2014, 92.2% of TB cases were in Malaysian citi-
zens. The incidence of TB in Malaysia as of 2019 is 92 per 100 000, with various sources indicating that Sabah has the 
highest number of TB cases in Malaysia[1,4].

http://SIUJ.org
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Urogenital tuberculosis (UGTB) is the third most 
common form of extrapulmonary TB. It occurs in 2% 
to 20% of individuals with pulmonary TB. UGTB affects 
2 males for each female, with a mean patient age of 40 
years (range 5 to 90 years)[5–7].

Pathogenesis of UGTB is mainly from hematogenous 
spread and, rarely, venereal transmission.

UGTB is often overlooked because of its non-specific 
symptoms, lack of awareness, and lack of foolproof diag-
nostic tests. Delay in diagnosis often results in irrevers-
ible organ damage and renal failure. The most common 
symptom, found in more than 50% of patients, is irri-
tative voiding. The other symptoms of UGTB are fever, 
weight loss, anorexia, backache, and abdominal pain[8].

In this study, we aim to delineate the epidemiology 
and clinical characteristics of UGTB in Sabah, Malaysia.

Materials and Methods
We conducted a retrospective, descriptive, sub-state 
analysis of all notified cases of UGTB disease in Sabah 
State, Malaysia between January 1, 2014, and November 
30, 2020. All confirmed TB cases in Sabah are recorded 
in “myTB,” a secure electronic database.

Using national notification data, we calculated the 
proportion of all cases in Malaysia occurring in Sabah 
State. Descriptive analysis of demographic, epidemio-
logical, and clinical data was done using SPSS software 
(version 26). The categorical variables were analyzed 
through the study of frequencies. Maps were produced 
using Paintmaps.

This study was conducted in compliance with ethical 
principles outlined in the Declaration of Helsinki and 
Malaysian Good Clinical Practice Guideline.

Results
In the relevant time period, 35 157 TB cases were reported 
to the Sabah State TB surveillance database (myTB). 
Out of this number, 31 070 were pulmonar y TB 
and the remining 4087 cases were extrapulmonary  
TB (EPTB). UGTB accounted for 131 cases, which 
represents 3.2% of EPTB cases (January 1, 2014, to 
November 30, 2020).

Patient Demographics
The patient demographics are summarized in Table 1. 
The number of patients remained fairly constant over 
time, with a minor peak in 2019. The mean patient age 
at diagnosis was 48.6 (SD: 15.0) years and patient gender 
was balanced except for a mild male predominance in 
the 35 to 44 age group (Figure 1).

The highest number of cases was reported in Kota 
Kinabalu (14.0%), the state capital, which has the largest 
population, and the lowest number was reported from 
Kudat and Kinabatangan, which are both remote rural 

Abbreviations
DOTS directly observed treatment short course
EPTB extrapulmonary TB
FDC fixed-dosanation
TB tuberculosis
UGTB urogenital tuberculosis

TABLE 1. 

Patient demographics 

Variable
n (%)

n = 131

Incidence of GUTB/year

2014
2015
2016
2017
2018
2019
2020

20 (15.3)
20 (15.3)
14 (10.7)
19 (14.5)
17 (13.0)
28 (21.4)
13 (9.9)

Source of notification

Government hospital
Local health clinic
Health office
Private sector
Age (mean±SD)

107 (81.7)
14 (10.7)
5 (3.8)
5 (3.8)

48.64 (14.99)

Gender

Male
Female
kg/m2 (mean±SD)

71 (54.2)
60 (45.8)

22.52 (5.32)

Nationality

Citizen
Peribumi Sabah
Chinese
Others
Peribumi Sarawak
Non-Citizen
Indonesia
Philippines
Pakistan

118 (90.1)
108 (91.5)

6 (5.1)
3 (2.5)
1 (0.8)
13 (9.9)
8 (6.1)
4 (3.1)
1 (0.8)

a3 missing; b6 missing; c8 missing.

continued on page 71

70 SIUJ  •  Volume 3, Number 2  •  March 2022 SIUJ.ORG

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regions (Figure 2). The majority (81.7%) of patients were 
seen in government hospitals. Patients were Malaysian 
citizens in 90.1% of cases, Indonesian in 6.1%, and 
Filipino in 3.1%.

Clinical Characteristics of Patients
The clinical characteristics of the patient cohort are 
summarized in Table 2. The majority of the 131 cases 

(89.3%) were classified as new diagnoses. The most 
common sites of infection were renal (32.1%) and scrotal 
(25.2%), followed by endometrial and cervical (8.4% 
each) (Figure 3).

FIGURE 1.

Number of GUTB cases by age group and  
sex, 2014 to 2020

10

19

13
15 14

3

13

12

12
12

8

0

5

10

15

20

25

30

35

15-24 25-34 35-44 45-54 55-64 ≥65

Male Female

FIGURE 2.

Distribution of UGTB in Sabah, 2014 to 2020

15 - 20

10 - 15

5 - 10

1 - 5

0 - 1

0 - 0

Be
au

fo
rt

Beluran

Ke
ni

ng
au

Kinabatangan

Kota Belud

Kota Kinabalu

Kota Marudu

Kuala
Penyu

Kudat

Kunak

Lahad Datu

Nabawan

Papar

Pena.

Pitas

Putatan
Ranau Sandakan

Semporna

Si
pi

ta
ng

Ta
m

bu
na

n

Tawau

Te
no

m

Tongod

Tuaran

TABLE 1. 

Patient demographics 

Variable
n (%)

n = 131

Years in Malaysia

0–5 years
6–15 years
16–20 years
21–25 years
> 25 years

2 (15.4)
3 (23.1)
3 (23.1)
3 (23.1)
2 (15.4)

Number of dependents

0
1–3
> 3

16 (12.2)
48 (36.6)
54 (41.2)

Location

Urban
Rural

37 (28.2)
94 (71.8)

Highest level of patient educationa

Illiterate/ No formal education
Higher secondary (Form 4/5)
Lower secondary (up to Form 3)
Primary school
Form 6/ Certificate/ Diploma course
Tertiary education

37 (28.2)
37 (28.2)
24 (18.3)
11 (8.4)
6 (4.6)
2 (1.5)

Employment and incomeb

Employed/Income
Unemployed

48 (36.6)
77 (58.8)

Occupationc

Professionals (including health care)
Skilled
Semi-skilled
Unskilled/ Labourers
Self-employed (unstated)
Retired

4 (3.1)
1 (0.8)

17 (13.0)
15 (11.5)
6 (4.6)
5 (3.8)

a3 missing; b6 missing; c8 missing.

, Cont’d 

71SIUJ.ORG SIUJ  •  Volume 3, Number 2  •  March 2022

Epidemiology and Clinical Characteristics of Urogenital Tuberculosis in Sabah, Malaysia

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Clinical Presentation
The clinical features at the time of presentation are 
summarized in Table 3 and Figure 4. Urinary frequency 
was the commonest symptom (28.2%), followed by 
abdominal pain and loss of appetite (each 26.0%). 
Overall, 45.8% of patients were found to have fever 
upon examination, and 3.1% presented with peripheral 
lymphadenopathy.

Method of Diagnosis
The means used to diagnose UGTB in the patient cohort 
are summarized in Table 4. Diagnosis was made by 
histopathological examination in 39.7%, microbial 
tests in 35.9%, urine for MTB culture in 3.8%, and 
radiological imaging in 0.8%. Information was missing 
for the remaining 20.6%

Of patients tested for HIV, 87.0% were negative 
and 2.3% were positive at the time of diagnosis (6.1% 
declined testing and data were missing for the remain-
ing 4.6%). The common risk factors were chronic kidney 
disease (17.6%), family history of tuberculosis(16.0%), 
and diabetes mellitus (9.9%). Smokers made up of 20.6% 
of the cases.

Treatment Outcomes
Treatment outcomes are summarized in Table 5. The 
mean duration of treatment was 8.6 (SD: 4.0) months 
and the average hospital stay was 1.0 (SD: 1.7) month. 

TABLE 2. 

Clinical characteristics of study participants 

Variable
n (%)

n = 131

Case statusa

New
Relapse

117 (89.3)
8 (6.1)

Sputum sample

Earlyb

Positive
Negative
Not done

4 (3.1)
81 (61.8)
13 (9.9)

Chest X-ray upon diagnosisa

No lesions
Minimal
Not done
Moderately advanced
Far advanced

59 (45.0)
32 (24.4)
19 (14.5)
11 (8.4)
4 (3.1)

Presence of HIV during diagnosisa

Positive with HIV
Negative with HIV
Test not done
On HAART
Not on HAART/ New HIV

3 (2.3)
114 (87.0)

8 (6.1)
2 (66.7)
1 (33.3)

Risk factorsc

Diabetes mellitus
Chronic kidney disease
Prior history of TB
Family history of TB
Malignancy
On immunosuppressive drugs

13 (9.9)
23 (17.6)
7 (5.3)

21 (16.0)
7 (3.0)

4 (3.05)

Working with cattlea

Yes
No

1 (0.8)
124 (94.7)

Smoking status

Smoker
Non-smoker

27 (20.6)
104 (79.4)

a6 missing; b9 missing; c60 missing.

FIGURE 3.

Number of UGTB cases by site of involvement

15

10

5

20

25

30

35

40

45

Re
na

l

Sc
ro

ta
l

En
do

m
et

riu
m

Ce
rv

ic
al

Bl
ad

de
r

A
dr

en
al

U
re

te
r

U
ro

ge
ni

ta
l

(n
on

-s
pe

ci
�e

d)

Pr
os

ta
te

Pe
ni

s

Fa
llo

pi
an

 tu
be

O
va

ria
n

La
bi

a
Fe

m
al

e 
G

en
ita

l
(n

on
-s

pe
ci

�e
d)

0

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During the intensive phase, 44.2% of patients received 
2 months of ethambutol, isoniazid, rifampicin, and 
pyrazinamide (2 EHRZ regimen) and 41.2% received the 
fixed-dose combination (FDC) regimen. The majority 
of patients (77.9%) received 4 months of isoniazid and 
rifampicin (4HR regimen) during the maintenance 
phase. The most common adverse event during the 
intensive phase was death (3.8%). The directly observed 
treatment short course (DOTS) was used in 89.3% of 
patients in the intensive phase, and in 76.3% during 
the maintenance phase. The majority of observers for 
the DOTS treatment were the patient’s family members 
(63.6%). At the point of data compilation, 81.0% of the 
patients had already completed their treatment, and 
6.1% were lost to follow-up.

We found that 50.4% of patients had received surgical 
intervention; 10.7% had undergone incision and drainage, 
9.9% had cystoscopy, and 6.9% underwent orchidectomy.

Discussion
Tuberculosis is a communicable disease that is a major 
cause of ill health, one of the top 10 causes of death 
worldwide, and the leading cause of death from a single 
infectious agent (ranking above HIV/AIDS). The disease 
typically affects the lungs (pulmonary TB) but can also 
affect other sites (extrapulmonary TB). About 90% of 
cases are in adults, and there are more cases among men 
than women. Globally, an estimated 10 million people 
fell ill with TB in 2019. The incidence of TB in Malaysia 
as of 2019 is 92 per 100 000 population[1].

Our study provides a sub-state analysis of UGTB in 
Sabah, Malaysia, from January 2014 to November 2020. 
Our findings highlight the burden of disease in Sabah; 
however, there are no data for comparison with other 
states in Malaysia. In 2019, the WHO Southeast Asia 
region had accounted for 44% of TB cases. Malaysia, 
which is within that region, has a population of 32.7 
million people, and Sabah, its second largest state, 
accounts for 3.9 million[9].

Geographically, Sabah is situated between Indonesia 
and the Philippines, and these countries are amongst the 
top 8 countries that account for two-thirds of the global 
total of TB cases. Indonesia, second to India, accounts 
for 8.5% and the Philippines accounts for 6.0%[3].  
In 2019, the Philippines had an estimated incidence of 
554 per 100 000 population, Indonesia 312 per 100 000 
population, and Malaysia <100 cases per 100 000 
population[1,10].

Following the formation of Malaysia in 1963, 
cross-border movement, which had previously been 
considered legal, became illegal. However, proximity to 
Indonesia and the Philippines, and a long and porous 
border have made it difficult to stop all movement, and 

FIGURE 4.

Common presentations of UGTB, 2014–2020

36

34

34

32

23

22

22

18

17

15

13

9

6

6

4

2

2

1

1

5 10 15 20 25 30 35 40

Frequency

Abdominal pain

Loss of appetite

Loss of weight

Pyrexia

Dysuria

Lethargy

Hematuria

Scrotal pain/swelling

Atypical/incidental

Pyuria

Nocturia

Per vaginal discharge

Costovertebral tenderness

Night sweats

Cough

Penile swelling

Labial swelling

Others

0

TABLE 3.

Presentation features of patients in the study 

Variable
n (%)

n = 131

BP statusa

Normotensive
Hypotensive
Shock

65 (49.6)
51 (38.9)

1 (0.8)

Temperaturea

Febrile
Afebrile

60 (45.8)
57 (43.5)

Peripheral lymphadenopathya

Yes
No
Radial pulse
Glucose on arrival

4 (3.1)
113 (86.2)

111.80 (11.09)
8.77 (2.77)

a14 missing.

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the presence of marginalized communities (sea-nomads) 
is of concern in eastern Sabah[10]. Most of the cases that 
we observed in migrants were reported in Sandakan 
and Lahad Datu, the coastal region through which 
cross-border movement commonly occurs.

Topographically, Sabah poses a challenge in term of 
gaining immediate health access, and delays in seek-
ing treatment were common. During our study, 71.8% 

of cases were noted to be from rural areas. We also 
observed that most of our cases were detected by the 
government facilities: 96.3%, compared with 3.8% by 
non-governmental facilities. Continuous health educa-
tion on TB, aimed at raising awareness and correcting 
misconceptions, is needed and should be extended to 
include those who use non-government facilities[11,12].

Economically, Sabah has been challenged more 
than the rest of Malaysia. In 2019, Sabah was one of the  
4 states with the lowest GDP per capita (RM 25 326). 
Sabah had an unemployment rate of 5.8% in 2019[9]. 
Our results have shown that 58.8% of UGTB patients 
were unemployed, with a high percentage of illiteracy  
(28.2%). This supports the view that poverty and  
poor education contribute to delays in access to diagno-
sis and care.

UGTB has insidious onset, with varied or atypical 
presentation, which poses difficulty in diagnosis and can 
delay treatment. Most patients present with local symp-
toms such as frequent voiding, dysuria, pyuria, or back, 
flank, or abdominal pain. The organs most commonly 
involved are kidney, bladder, fallopian tubes, and scro-
tum. It commonly affects middle aged subjects. The 
incidence is slightly higher in men, and it is uncommon 
in children[1,8,11–15]. Patients with UGTB have been 
reported as having more local than systemic symp-
toms. Our study concurs with common presentation of 
frequency of micturition (28.2%), followed by abdominal 
pain (26.0%). We also found that systemic symptoms, 
such loss of appetite (26.0%) and loss of weight (24.4%), 
were common. The sites most commonly seen in our 
study were kidney (32.1%) and scrotum (25.2%).

We note that during our study period, treatment 
duration was 8.6 (±SD 3.97) months. The most common 
intensive phase regimens in the first 2 months were 2 
EHRZ (ethambutol, isoniazid, rifampicin, pyrazin-
amide) 44.2% and fixed-dose combinations (FDC) 
consisting of 41.2%. The most common maintenance 
regimen was 4 months of HR (77.9%). A total of 89.3% 
have observed DOTs during intensive phase, DOTs was 
observed by family members in 63.6% of our subjects. 
76.3% observed DOTs during maintenance phase. 81.0% 
of patients have completed treatment at the time of this 
study. We note that 50.4% of patients received surgical 
intervention. In these patients, 10.7% had undergone 
incision and drainage, 9.9% had cystoscopy, 9.2% did 
not have surgical intervention, and orchidectomy was 
done for 6.9% of patients. However, limitation in terms 
of retrieving primary records and details led to difficulty 
in further description of interventions and outcome.

An understanding of the local epidemiology and clin-
ical characteristics of disease is essential to successful 
prevention measures and treatment implementation. 
No previous data collection has been done in Malaysia 

TABLE 4. 

Method of diagnosis 

Variable
n (%)

n = 131

Presence of BCG scara

Yes
No

92 (70.2)
34 (25.8)

Mode of diagnosisb

Histopathological diagnosis
HPE testis

HPE endometrium
HPE cervix

HPE Bladder biopsy
HPE kidney

HPE prostate
HPE fallopian tube

HPE ovary
HPE renal pelvis

FNA Adrenal

Smear microscopy for AFB
Urine for AFB

Pus from scrotum for AFB
Pus from kidney for AFB
Pus from penis for AFB
Pus from labia for AFB

Urine MTB C&S
Urine for Gene Xpert

Radiology

52 (39.7)
13 (9.9)
11 (8.4)
11 (8.4)
7 (5.3)
3 (2.3)
2 (1.5)
2 (1.5)
2 (1.5)
1 (0.8)
1 (0.8)

47 (35.9)
22 (16.7)
17 (13.0)
5 (3.8)
2 (1.5)
1 (0.8)

5 (3.8)
1 (0.8)

1 (0.8)

Case detectionc

Active
Passive
Incidental/ screening

12 (9.2)
115 (87.8)

2 (1.5)

Method of testing

Special test
Contact tracing

10 (7.6)
2 (1.5)

a6 missing; b10 missing; c3 missing.

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TABLE 5.

Treatment of patients in the study 

Variable
n (%)

n = 131

Treatment length months (mean±SD) 8.60 (3.97)

Length of stay months (mean±SD) 1.00 (1.65)

Intensive phase regimena

2 EHRZ
2 HRZ
FDC
Others

58 (44.2)
1 (0.8)

54 (41.2)
12 (9.2)

Intensive phase adverse events

Deaths
MDR-TB
None

5 (3.8)
0

126 (96.2)

Maintenance phase regimena

4H 2R 2E
4 HR
FDC
Others

3 (2.3)
102 (77.9)

1 (0.8)
19 (14.5)

Current statusb

Still under treatment
Completed treatment
Lost to follow-up/ defaulted
Death
Change of diagnosis

5 (3.8)
106 (81.0)

8 (6.1)
7 (5.3)
2 (1.5)

a6 missing; b3 missing; c9 missing; d14 missing; e58 missing.

to evaluate UGTB. Malaysia has a complex system of 
data collection and TB reporting, involving both paper 
and electronic methods. The Sabah State TB notification 
system (myTB) database is the best data source avail-
able. It has been under regular audit and scrutiny of 
The Sabah State Department of Health. The economic 
challenges in Sabah, however, pose hurdles in terms of 
data collection which may have caused underreporting 
of UGTB. Furthermore, myTB has shortfalls in terms of 
the extent of information provided, especially for EPTB. 
Lack of primary records and missing documentation 
created a significant challenge to obtaining necessary 
information such as previous surgical interventions and 
outcome, which would further enhance our understand-
ing of this disease.

Conclusion
UGTB is a relatively uncommon manifestation of 
extrapulmonary TB, which is challenging to diagnose. 
Progression is insidious, symptoms are non-specific, 
awareness is poor, and bacteriological diagnosis is 
difficult. Therefore, high levels of vigilance and clinical 
suspicion are required if it is to be recognized. UGTB 
is a contagious infectious disease that necessitates early 
diagnosis and treatment to prevent morbidity. Patients 
from endemic areas need to be assessed with high 
suspicion and screened for UGTB for early diagnosis and 
treatment. Ensuring awareness via widespread education 
within health care, in both the government and the 
private sector, along with rural outreach programs, will 
contribute to early recognition and treatment.

TABLE 5.

Treatment of patients in the study 

Variable
n (%)

n = 131

Underwent

DOTS intensive phasec

DOTS maintenance phased
117 (89.3)
100 (76.3)

Main observer for intensive phase DOTSb

Family
Health care worker
Unobserved

84 (63.6)
43 (32.8)

1 (0.8)

Surgical interventione

I&D
Cystoscopy
Orchidectomy
Colposcopy
Pipelle
Stenting
Nephrostomy
Ovarian cystectomy
TRUS biopsy
Salpingectomy
Ureteroscopy
Nephrectomy
Renal biopsy
FNAC

14 (10.7)
13 (9.9)
9 (6.9)
8 (6.1)
4 (3.1)
4 (3.1)
3 (2.3)
3 (2.3)
2 (1.5)
2 (1.5)
1 (0.8)
1 (0.8)
1 (0.8)
1 (0.8)

a6 missing; b3 missing; c9 missing; d14 missing; e58 missing.

, Cont’d 

75SIUJ.ORG SIUJ  •  Volume 3, Number 2  •  March 2022

Epidemiology and Clinical Characteristics of Urogenital Tuberculosis in Sabah, Malaysia

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Acknowledgements

The aut hors wou ld li ke to t ha nk t he Director 
General of Health, Malaysia for his permission to 
publish this article. The authors are grateful to Dr 
Christina Rundi, Dr Roddy Teo, The Sabah State 
Department of Hea lth, a long with the involved 

district hospitals of Sabah for making data available. 
We acknowledge the generous support of Dr Sophia Lee 
Eu Wei, Dr Prabakaran Balakrishnan and the staff in 
Urology Clinic Hospital Queen Elizabeth Sabah.

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http://SIUJ.org

