Case report: A fatal outcome from co-infection of COVID-19 and dengue in the western region of Jeddah, Saudi Arabia.

Introduction: Co-infection of coronavirus disease 2019 (COVID-19) and dengue may coexist, as both viruses share similar laboratory and clinical features, making diagnosis and treatment challenging for health care professionals to prescribe, negatively impacting patient prognosis, and outcomes. Results and discussions: Both cases were positive for PCR and X-ray laboratory investigation at clinical examination, confirming COVID-19 and dengue co-infection, admission, and better management in referral hospitals are presented and discussed. The timeline provides detailed cases of situational analysis and the medical actions taken, as well as the outcomes. Conclusion: Both co-infection cases' (patients) health conditions had a poor prognosis and diagnosis and ended with undesired outcomes. Scaling up dual mosquito-vector linked viral diseases surveillance in understanding the transmission dynamics, early diagnosis, and the timely and safe monitoring of case management in clinical and hospital settings nationwide is paramount in curbing preventable co-infections and mortality.

The influences of bariatric surgery on hemoglobin A1c in a sample of obese patients in Saudi Arabia.

BACKGROUND: Although the frequency of surgical weight loss interventions has increased in Saudi Arabia, literature describing the clinical outcomes of bariatric surgery in Saudi Arabia is limited. This study aimed to assess whether weight loss intervention improves hemoglobin A1c (HbA1c) in obese patients and to identify its associated factors. PATIENTS AND METHODS: A retrospective study was carried out on 318 patients with obesity class 1 or higher (body mass index [BMI] ≥ 30 kg/m2) who underwent laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass at King Abdulaziz Medical City in Riyadh, Saudi Arabia, between January 1, 2001 and March 31, 2017. Preoperatively and 12 months postoperatively, characteristics of patients were collected. BMI reduction was calculated, based on which patients were divided into three groups (0-9, 10-14, and >14 kg/m2). RESULTS: The postoperative HbA1c was 5.83±0.9, while the baseline level was 6.74±2.1 (P=0.001). Fifty-eight of the 318 patients had diabetes. We observed significantly higher HbA1c in diabetic than in non-diabetic patients preoperatively, whereas an insignificantly different HbA1c was observed postoperatively. Among those who had minimal reduction in BMI (0-9 kg/m2), we observed significantly higher HbA1c in diabetic than in non-diabetic patients, whereas among those who had large reduction in BMI (10-14 kg/m2) and (>14 kg/m2), we observed insignificant differences in HbA1c in diabetic than in non-diabetic patients. CONCLUSION: Being a diabetic patient was related to a significant reduction in HbA1c levels postoperatively. The study suggests that the reduction in HbA1c levels could be modified by BMI, wherein greater reduction in BMI leads to greater reduction in HbA1c levels.

Long-term patient satisfaction after retropubic and transobturator mid-urethral slings for female stress urinary incontinence.

AIM: The aim of this study was to report long-term patient outcomes after retropubic and transobturator mid-urethral slings for female stress urinary incontinence. METHODS: Women who underwent mid-urethral sling for stress urinary incontinence between 2000 and 2010 were invited to participate in a survey regarding their overall improvement. Patients' outcomes were assessed using the International Consultation on Incontinence Questionnaire - Short Form and the Global Response Assessment Scale. RESULTS: The questionnaires were completed by 330 patients. Their median age at the time of surgery was 54.8 years (±12.9) and the median follow-up period was 11.9 years (±6.4). Retropubic and transobturator approaches were performed in 128 (38.8%) and 202 (61.2%) patients, respectively. The International Consultation on Incontinence Questionnaire - Short Form score dropped from an average of 14 (±4.1) to 6.4 (±6) with no significant difference between the two groups. The Global Response Assessment Scale showed an 9% greater improvement in the retropubic (66.4%) over the transobturator (57.4%) approach. De novo overactive bladder was the commonest long-term reported adverse event, affecting 18/330 patients (5.5%). Voiding dysfunction that required surgical correction following the retropubic approach occurred in three patients (2.3%). CONCLUSION: Mid-urethral slings for the management of female stress urinary incontinence had good and durable long-term effects. Although the retropubic approach gave better results, they were not significantly different than those of the transobturator approach.

Iatrogenic submucosal tunnel in the ureter: a rare complication during advancement of the guide wire.

BACKGROUND: Inserting a guide wire is a common practice during endo-urological procedures. A rare complication in patients with ureteral stones where an iatrogenic submucosal tunnel (IST) is created during endoscopic guide wire placement. OBJECTIVE: Summarize data on IST. DESIGN: Retrospective descriptive study of patients treated from from October 2009 until January 2015. SETTING: King Fahd Hospital of the University, Al-Khobar, Saudi Arabia. PATIENTS AND METHODS: Patients with ureteral stones were divided to 2 groups. In group I (335 patients), the ureteral stones were removed by ureteroscopy in one stage. Group II (97 patients) had a 2-staged procedure starting with a double J-stent placement for kidney drainage followed within 3 weeks with ureteroscopic stone removal. MAIN OUTCOME MEASURE(S): Endoscopic visualization of ureteric submucosal tunneling by guide wire. RESULTS: IST occurred in 9/432 patients with ureteral stones (2.1%). The diagnosis in group I was made during ureteroscopy by direct visualization of a vanishing guide wire at the level of the stone (6 patients). In group II, IST was suspected when renal pain was not relieved after placement of the double J-stent or if imaging by ultrasound or intravenous urography showed persistent back pressure to the obstructed kidney (3 patients). The condition was subsequently confirmed by ureteroscopy. CONCLUSION: Forceful advancement of the guide wire in an inflamed and edematous ureteral segment impacted by a stone is probably the triggering factor for development of IST. Definitive diagnosis is possible only by direct visualization during ureteroscopy. Awareness of this potential complication is important to guard against its occurrence. LIMITATIONS: Relatively small numbers of subjects and the retrospective nature of the study.

Prostate extracellular vesicles in patient plasma as a liquid biopsy platform for prostate cancer using nanoscale flow cytometry.

BACKGROUND: Extracellular vesicles released by prostate cancer present in seminal fluid, urine, and blood may represent a non-invasive means to identify and prioritize patients with intermediate risk and high risk of prostate cancer. We hypothesize that enumeration of circulating prostate microparticles (PMPs), a type of extracellular vesicle (EV), can identify patients with Gleason Score≥4+4 prostate cancer (PCa) in a manner independent of PSA. PATIENTS AND METHODS: Plasmas from healthy volunteers, benign prostatic hyperplasia patients, and PCa patients with various Gleason score patterns were analyzed for PMPs. We used nanoscale flow cytometry to enumerate PMPs which were defined as submicron events (100-1000nm) immunoreactive to anti-PSMA mAb when compared to isotype control labeled samples. Levels of PMPs (counts/µL of plasma) were also compared to CellSearch CTC Subclasses in various PCa metastatic disease subtypes (treatment naïve, castration resistant prostate cancer) and in serially collected plasma sets from patients undergoing radical prostatectomy. RESULTS: PMP levels in plasma as enumerated by nanoscale flow cytometry are effective in distinguishing PCa patients with Gleason Score≥8 disease, a high-risk prognostic factor, from patients with Gleason Score≤7 PCa, which carries an intermediate risk of PCa recurrence. PMP levels were independent of PSA and significantly decreased after surgical resection of the prostate, demonstrating its prognostic potential for clinical follow-up. CTC subclasses did not decrease after prostatectomy and were not effective in distinguishing localized PCa patients from metastatic PCa patients. CONCLUSIONS: PMP enumeration was able to identify patients with Gleason Score ≥8 PCa but not patients with Gleason Score 4+3 PCa, but offers greater confidence than CTC counts in identifying patients with metastatic prostate cancer. CTC Subclass analysis was also not effective for post-prostatectomy follow up and for distinguishing metastatic PCa and localized PCa patients. Nanoscale flow cytometry of PMPs presents an emerging biomarker platform for various stages of prostate cancer.

Urodynamic findings in women with refractory overactive bladder symptoms.

OBJECTIVES: To assess: (i) the correlation between overactive bladder symptoms and urodynamic findings in female patients; and (ii) the association of urinary symptoms with the presence of detrusor overactivity and/or bladder outlet obstruction. METHODS: The present retrospective study included female patients with overactive bladder symptoms who underwent urodynamic evaluation by a single physician. Patients with previous anti-incontinence surgery or neurogenic bladder were excluded. Spearman's correlation coefficients were calculated to correlate overactive bladder symptoms with the urodynamic findings. Univariate and multivariate logistic regression analyses were used to determine the independent factors for detrusor overactivity and bladder outlet obstruction. RESULTS: Overall, 1737 reports were analyzed. All patients had urgency with or without urgency urinary incontinence. Urgency, urgency urinary incontinence and nocturia correlated with detrusor overactivity. The severity of frequency, nocturia and slow stream correlated with bladder outlet obstruction. In contrast, stress urinary incontinence showed an inverse, but weak, correlation with bladder outlet obstruction. Stress urinary incontinence correlated moderately with urine leak. Storage symptoms showed an inverse, but weak, correlation with maximum cystometric capacity. Multivariate analysis data showed that age, urgency, urgency urinary incontinence and nocturia were independent predictors of detrusor overactivity, whereas the severity of frequency was a predictor of bladder outlet obstruction. CONCLUSION: As overactive bladder symptoms increase in severity, female patients tend to have a smaller bladder capacity and a higher incidence of detrusor overactivity. A significant number of these patients have bladder outlet obstruction.

Profile, outcome and predictors of mortality of abdomino-pelvic trauma patients in a tertiary intensive care unit in Saudi Arabia.

INTRODUCTION: The Kingdom of Saudi Arabia (KSA) is one of countries with the world's highest number of deaths per 100,000 populations from road traffic accidents (RTAs). Numerous trauma victims sustain abdomino-pelvic injuries, which are associated with considerable morbidity and mortality. The purpose of this study was to describe profile, outcomes and predictors of mortality of patients with abdomino-pelvic trauma admitted to the intensive care unit (ICU) in a tertiary care trauma centre in Riyadh, KSA. METHODS: This was a retrospective analysis of prospectively collected ICU database. All consecutive patients older than 14 years with abdomino-pelvic trauma from March 1999 to June 2013 were included. The followings were extracted: demographics, injury severity, mechanism and type of injury, associated injuries, use of vasopressors and mechanical ventilation, and worst laboratory results in the first 24h. The primary outcome was hospital mortality. We compared profile and outcomes between survivors and non-survivors and reported predictors of mortality. RESULTS: Of the 11,374 trauma patients who were admitted to the hospital during the study period, 2120 (18.6%) patients had abdomino-pelvic injuries, out of which 702 (33.1%) patients were admitted to the ICU. The mean age was 30.7 (SD 14.4) years and the majority was male (89.5%). RTA was the most common cause of abdomino-pelvic trauma (70.4%). Pelvis (46.2%), liver (25.8%), and spleen (23.1%) were the most frequently injured organs; and chest (55.6%), head (41.9%), and lower extremities (27.5%) were the most commonly associated injuries. Mechanical ventilation was required in 89.6% with a mean duration of 9.1 (SD 9.2) days and emergency surgery was performed in 45.0% of the patients with prolonged ICU and hospital length of stay (10.8 [SD 10.8], 56.9 [SD 96.7] days; respectively). Of the 702 patients with abdomino-pelvic trauma, 115 (16.4%) patients did not survive. Associated head trauma and retroperitoneal haematoma, higher level of lactic acid on admission and ISS, and advanced age were potential risk factors for hospital mortality. CONCLUSIONS: Abdomino-pelvic injuries are common in trauma patients, affecting mainly young male victims, and are associated with significant morbidity and mortality, and resource utilisation.

Association of symptoms with urodynamic findings in men with overactive bladder syndrome.

UNLABELLED: Study Type--Therapy (review) Level of Evidence 4. What's known on the subject? and What does the study add? It is known that overactive bladder (OAB) symptoms correlate weakly with urodynamic findings, especially in female patients. The study shows that OAB symptoms also correlate weakly with urodynamic findings in male patients. More than third of male patients with OAB symptoms had evidence of BOO. The study finds that a pressure flow study is of benefit in the evaluation of this group of patients. OBJECTIVE: • To assess the correlation between overactive bladder (OAB) symptoms with urodynamic (UD) findings in men. PATIENTS AND METHODS: • We conducted a retrospective study of all UD studies involving men with OAB symptoms. • All UD studies were carried out at a single centre from 1994 to 2009 and were reported by one urology specialist. RESULTS: • There were 668 UD reports included in the final analysis. All patients had symptoms of urgency with or without urgency incontinence (UI). • There was a weak correlation between OAB symptoms and UD findings. • All storage symptoms, except frequency, correlated with a finding of detrusor overactivity (DO). • Severity of urgency correlated inversely with a finding of bladder outlet obstruction (BOO). • Both nocturia and frequency correlated inversely with maximum cystometric capacity. • More than 75% of patients had concomitant voiding symptoms. Severity of voiding symptoms (slow stream and incomplete emptying) correlated inversely with documentation of DO. Voiding symptoms were predictors of BOO, while severe urgency was a negative predictor for BOO. CONCLUSIONS: • There were weak correlations between OAB symptoms and UD findings. Most men with OAB symptoms had concomitant voiding symptoms and more than a third (43%) of these had evidence of BOO. • A pressure flow study is of benefit in the evaluation of patients with OAB symptoms.

Extended followup oncologic outcome of randomized trial between cryoablation and external beam therapy for locally advanced prostate cancer (T2c-T3b).

PURPOSE: We assessed and compared the survival outcomes between cryoablation and external beam radiation therapy in patients with locally advanced prostate cancer (cT2c-cT3b). MATERIALS AND METHODS: Patients with locally advanced prostate cancer, recruited from 1999 to 2002, were randomized to primary cryoablation or external beam radiotherapy. All patients received neoadjuvant hormonal therapy for 3 months before and 3 months after the procedures. Patients underwent followup transrectal ultrasound guided biopsy (at 3, 6, 12, 18 and 24 months for cryoablation, and at 18 and 24 months for external beam radiotherapy) and as clinically indicated thereafter. Biochemical failure was based on the Phoenix criterion (prostate specific antigen nadir +2 ng/dl). RESULTS: A total of 62 patients completed the trial. Median followup was 105.2 months (SD ±35.8). Accrual was limited due to newer data favoring longer neoadjuvant hormonal therapy and higher external beam radiotherapy dose for locally advanced prostate cancer. There was a greater reduction in prostate volume in the cryoablation group after intervention (-54% vs -34%, p ≤0.01). Disease specific survival and overall survival were comparable between the groups. However, the 8-year biochemical disease-free survival rate was significantly lower in the cryoablation group (17.4% vs 59.1%) (p = 0.01). CONCLUSIONS: This randomized trial with median followup approaching 9 years showed that cryoablation was inferior in attaining biochemical disease-free survival in patients with locally advanced prostate cancer (cT2c-T3). Cryoablation may be more suited for less bulky prostate cancer. Longer duration neoadjuvant hormonal therapy or a multimodal approach may provide optimal biochemical disease-free survival in this patient population.

Pelvic lymphadenectomy in the treatment of invasive bladder cancer: literature review.

The standard surgical treatment of invasive bladder cancer is the radical cystectomy and pelvic lymph node dissection (PLND). Up to one-third of patients with invasive bladder cancer have lymph node metastasis. Thus, PLND has important therapeutic and prognostic benefits. The number of lymph nodes that should be removed and the extent of the PLND are still a controversial issue. Recently, the trend of PLND increased toward more extended PLND. Several prognostic factors related to PLND were reported in the literature. In this paper, we will discuss the different PLND templates, number of lymph nodes that should be resected, lymph node density, lymphovascular invasion, tumor burden, extracapsular extension, and the aggregate lymph node metastasis diameter.

Long-term efficacy and tolerability of pentosan polysulphate sodium in the treatment of bladder pain syndrome.

OBJECTIVE: The primary objective of this study is to report on the long-term efficacy and tolerability of pentosan polysulphate sodium (PPS) in patients with bladder pain syndrome (BPS). The secondary objective is to find the predictors of the long-term outcome. METHODS: This is a single institution, retrospective study. The study period was from 1994 to 2008. All patients fulfilled the clinical criteria of BPS, as suggested by European Society for the Study of Interstitial Cystitis. We included only patients with de novo BPS diagnosis and no previous PPS or other treatment. The efficacy of PPS was measured with the global response assessment scale (GRA). Patients were stratified into 2 groups based on the duration of the treatment. Group 1 took the drug for less than 12 months. Group 2 took the drug for more than 12 months. RESULTS: There were 271 patients eligible for the study. Most of the patients were female (90%), with the mean age at presentation of 45.5 years. The average duration of symptoms was 28.5 months. The mean follow-up was 22 months (range 3-130). Out of all the patients, 147 patients (54.2%) reported over 50% improvement using the GRA. The reported efficacy was higher in Group 2 (60%). Ninety-three patients (34.3%) decided to stop taking the medication for various reasons. The most common reasons to stop the medication were poor outcome (16.6% of patients) and side effects (11.1% of patients). Poor outcome was associated with nocturia, smoking and detrusor overactivity. Good outcome was associated with longer PPS intake (>12 months) and severe cystoscopic findings of glomerulation. CONCLUSION: Pentosan polysulphate sodium is an effective oral therapy to control the symptoms of BPS with good long-term efficacy and tolerability.

Long-term outcome and surgical interventions after sacral neuromodulation implant for lower urinary tract symptoms: 14-year experience at 1 center.

PURPOSE: Few reports address the reoperation rate after sacral neuromodulation implants. We report our long-term results and reoperations during our 14-year experience with sacral neuromodulation at our center. MATERIALS AND METHODS: We retrospectively reviewed the patient database at our center to assess the long-term outcome, incidence and cause of surgical re-intervention after InterStim® sacral neuromodulation implantation for lower urinary tract dysfunction between 1994 and 2008. RESULTS: A total of 96 sacral neuromodulation devices were implanted in 88 women and 8 men. Indications for implantation were bladder pain syndrome in 47.9% of cases, urgency urinary incontinence in 35.4% and idiopathic urinary retention in 16.7%. The explantation rate was 20.8% and median time to removal was 18.5 months. Reasons for explantation in all subgroups were poor result in 12 patients, painful stimulation in 6 and radiation of stimulation to the leg in 2. Median long-term followup was 50.7 months. The long-term success rate was 87.5%, 84.8% and 73% in patients with idiopathic urinary retention, urgency urinary incontinence and bladder pain syndrome, respectively. Overall 39% of patients needed revision of the sacral neuromodulation implant. The main reason for revision was loss of stimulation in 58.5% of cases. The revision rate decreased with the introduction of the tined lead technique from 50% using lead Model 3092 to 31% using lead Model 3893 (Medtronic, Minneapolis, Minnesota). The battery was changed in 8 patients. Mean battery life was 101.8 months. CONCLUSIONS: Sacral neuromodulation is a minimally invasive procedure with a good long-term outcome. The reoperation rate has improved with advances in surgical technique and equipment.

The long-term efficacy of sacral neuromodulation in the management of intractable cases of bladder pain syndrome: 14 years of experience in one centre.

UNLABELLED: Study Type--Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? Bladder pain syndrome (BPS) is a chronic debilitating disease. A recently done survey estimates the prevalence of the BPS symptoms among adult females in the U.S. to be 7%. Conservative management is the first line of therapy but at least 10% of the patients show poor response. Sacral neuromodulation is a minimal invasive technique with good long-term outcomes in these patients. It should be considered before any invasive surgical intervention is planned. However, the revision rate is high and patients need lifelong follow-up. OBJECTIVE: • To evaluate the long-term success and tolerability of sacral neuromodulation (SNM) in the control of the symptoms of bladder pain syndrome (BPS). METHODS: • This was a retrospective study of all patients with BPS who underwent peripheral nerve evaluation and then SNM in our department of urology by a single surgeon from 1994 till 2008. The global response assessment scale was used to evaluate the outcome of the SNM. RESULTS: • A total of 78 patients fulfilled the International Consultation on Incontinence clinical criteria for BPS and showed cystoscopic evidence of glomerulation or ulcer as recommended by the European Society for the Study of Interstitial Cystitis/Painful Bladder Syndrome. All patients failed conservative management before considering SNM. • Permanent SNM implant was performed in patients who showed at least 50% improvement in their symptoms with a temporary peripheral nerve evaluation test. Median follow up was 61.5 months (SD ± 27.7). Good long-term success of the SNM was seen in 72% of the patients. • Presence of urgency was a positive predictor of the long-term success of the implant. The explantation rate was 28%. The commonest reason for explantation was poor outcome (54% of the failed patients). The revision rate was 50%. • The most common indication for revision was lack of stimulation sensation and worsening of symptoms. The average durability of the pulse generator battery was 93 months. CONCLUSION: • SNM is an effective treatment to control the symptoms of BPS. It should be considered before any major invasive surgical intervention if conservative measures have failed. It is a minimally invasive, safe procedure with good long-term outcome. However, the revision rate is high and patients require lifelong follow-up.

Recurrent urinary bladder paraganglioma.

A 39-year-old male presented with recurrent attacks of painless haematuria. The patient has a history of partial cystectomy for bladder paraganglioma 10 years prior to the presentation. Imaging study and cystoscopic examination revealed a small anterior wall bladder tumor. The histological examination of the lesion confirmed that it was a urinary paraganglioma. Partial cystectomy was performed to this recurrent lesion. This case report stresses the importance of life-long follow-up of these lesions.

Leiomyosarcoma of the bladder in a 16-year-old girl with a history of cyclophosphamide therapy for bilateral retinoblastoma during infancy.

A 16-year-old female with bladder leiomyosarcoma had a history of bilateral retinoblastoma at 6 months of life. She received cyclophosphamide chemotherapy after surgical enucleation. In this report, we discussed the possible role of retinoblastoma or cyclophosphamide as a target for the development of bladder leiomyosarcoma.

Renal dysplasia with extrarenal calyces.

We describe a case of simple renal dysplasia with extrarenal calyces of the left kidney in a 2-year-old boy. Other anomalies also included pelviureteral junction obstruction and ectopic ureterocele on the same side, as well as grade V vesico-ureteral reflux on the opposite side.