The Saudi urological association guidelines on urolithiasis.

Aims: The Saudi Urolithiasis Guidelines are a set of recommendations for diagnosing, evaluating, and treating urolithiasis in the Saudi population. These guidelines are based on the latest evidence and expert consensus to improve patient outcomes and optimize care delivery. They cover the various aspects of urolithiasis, including risk factors, diagnosis, medical and surgical treatments, and prevention strategies. By following these guidelines, health-care professionals can improve care quality for individuals with urolithiasis in Saudi Arabia. Panel: The Saudi Urolithiasis Guidelines Panel consists of urologists specialized in endourology with expertise in urolithiasis and consultation with a guideline methodologist. All panelists involved in this document have submitted statements disclosing any potential conflicts of interest. Methods: The Saudi Guidelines on Urolithiasis were developed by relying primarily on established international guidelines to adopt or adapt the most appropriate guidance for the Saudi context. When necessary, the panel modified the phrasing of recommendations from different sources to ensure consistency within the document. To address areas less well covered in existing guidelines, the panel conducted a directed literature search for high quality evidence published in English, including meta analyses, randomized controlled trials, and prospective nonrandomized comparative studies. The panel also searched for locally relevant studies containing information unique to the Saudi Arabian population. The recommendations are formulated with a direction and strength of recommendation based on GRADE terminology and interpretation while relying on existing summaries of evidence from the existing guidelines.

Water Vapor Thermal Therapy in Men With Prostate Volume ≥80 cm3: A Systematic Review and Meta-Analysis.

OBJECTIVE: To determine the safety and effectiveness of water vapor thermal therapy (Rezum) in men with large prostate volumes of at least 80cm3. METHODS: We performed systematic searches for studies of Rezum therapy in men with prostate volume of at least 80 cm3. Meta-analysis outcomes included the International Prostate Symptom Score (IPSS), IPSS Quality of Life (IPSS-QOL), Qmax, postvoid residual, International Index of Erectile Function-Erectile Function (IIEF-EF), and serious (Clavien-Dindo grade III-V) complications, surgical retreatments. Outcomes were analyzed using a random effects meta-analysis model. RESULTS: The review included 15 studies (11 retrospective) of 471 men with prostate volume at least 80 cm3 treated with Rezum therapy and followed for a median of 6months (range: 3-17months). Rezum therapy resulted in statistically significant improvements in IPSS (mean change: -11.0; 95% CI: -12.2, -9.7; P < .001), IPSS-QOL (mean change: -2.9; 95% CI: -3.5, -2.4; P < .001), Qmax (mean change: 6.5 mL/s; 95% CI: 4.8, 8.2 mL/s; P < .001), and postvoid residual (mean change: -101 mL; 95% CI: -145, -57; P < .001). No change in IIEF-EF was observed (mean change: 0.3; 95% CI: -1.1, 1.6; P = .71). Serious complications occurred in <0.1% (95% CI: 0.0%, 0.4%) and surgical retreatment in 1.2% (95% CI: 0.0%, 3.5%) of patients. CONCLUSION: Rezum therapy provides a statistically significant and clinically important short-term improvement in lower urinary tract symptoms with low complication rates in men with prostate volume of at least 80 cm3. Long-term outcomes with Rezum therapy in large prostates remain unclear.

Safety and efficacy of en bloc renal hilum control during laparoscopic nephrectomy and nephroureterectomy: A single-center experience in Saudi Arabia.

Objective: The objective of the study is to evaluate the safety, efficacy, and long-term outcome of en bloc renal pedicle control during laparoscopic nephrectomy and nephroureterectomy. Patients and Methods: A total of 126 nephrectomies and nephroureterectomies that underwent en bloc renal pedicle control using the endovascular stapler (45 or 60 mm vascular reload) were retrospectively analyzed. Perioperative outcomes, including the risk of arteriovenous fistula (AVF), hospital stay, and estimated blood loss, were recorded. Complications were reported using Clavien classification. Results: En bloc pedicle control was employed in 126 laparoscopic nephrectomies and nephroureterectomies on 126 patients with a mean age of 55.7 years (range: 18-94) and a mean body mass index of 29.2 kg/m2 (range: 17-42). All laparoscopic nephrectomies were performed or supervised by one of three minimally invasive surgeons using identical surgical techniques, even in cases of multiple hilar vessels. During follow-up with a mean 23.3 months (range: 12-48), no patients presented with radiological or clinical signs of AVF (91 patients where followed up with either Doppler ultrasound, computed tomography with contrast, or magnetic resonance imaging for different indications). The mean operative time was 91.8 min (range: 45-215). Intraoperative blood transfusion was required in two cases. Diaphragmatic injury occurred in one case but was repaired laparoscopically. Open conversion occurred in two cases with severe colonic adhesions and injury, with one requiring primary repair, and the other managed with a colostomy. One patient developed fever; two patients developed paralytic ileus. Hospital stay mode was 5 days, ranging from 3 to 10 days. Conclusion: En bloc renal pedicle control during laparoscopic nephrectomies is safe with reasonable operative time, and there were no indications of AVF with this technique over the long term.

Urolithiasis and water intake in Saudi Arabia, is it a matter of quality or quantity?

Introduction: Urolithiasis is a significant problem with an increasing incidence and prevalence worldwide. Multiple factors such as water intake, climate change, dietary habit, and genetic factors can affect stone formation. Our aim is to clarify the relationship between water intake and urolithiasis in Saudi Arabia as a hot climate area. Methods: This cross-sectional internet-based survey was conducted in November 2017. Our study was performed using a standard web-based questionnaire using social media open to all internet users. We excluded the incomplete responses. Analysis of the data was then carried out using Chi-square test and SPSS package version 20. Results: We found a great response to our survey, where 9100 participants responded. Among the participants, 76.6% were females and 23.4% were males. The largest age group was between 18 and 30 years (60.8%). Of the participants, 842 (9.3%) had history of urinary tract stones. About 74.3% of the participants with a history of urinary tract stones were drinking <1 L/day of water in comparison with those who had no history of urinary tract stones who were drinking a minimum of 1.25 L/day in 55.1%. Regarding the type of water intake, there was no significant relationship between the type of water and the incidence of stones formation (P =0.096). The amount of water was significantly correlated with the urolithiasis (P = 0.000). Conclusion: We concluded that the amount of water intake per day significantly correlated with urolithiasis, and according to our study, the minimally accepted intake was ≥1.25 L/day. However, the type of water consumed has no statistically significant impact on stone formation.

Saudi patient knowledge and awareness regarding smoking as a risk factor for urological diseases.

AIM: Our aim was to evaluate Saudi patient knowledge and awareness regarding smoking as a risk factor for bladder cancer, kidney cancer, and erectile dysfunction (ED). SETTINGS AND DESIGN: This quantitative cross-sectional study was conducted across three major tertiary hospitals in Riyadh, the capital city of Saudi Arabia. MATERIAL AND METHODS: A self-administered questionnaire was distributed to 539 patients in the urology outpatient clinic. STATISTICAL ANALYSIS: Data were analyzed using the Statistical Package for the Social Studies 21.0. For descriptive statistics, the frequency was calculated for all study variables. Chi-squared test was used for categorical variables. P < 0.05 was considered statistically significant. RESULTS: A total of 539 urological patients completed the questionnaire. There were 460 (85.4%) male and 79 (14.6%) female respondents. Only 60.9%, 41.2%, and 36.9% of participants were aware that smoking was a risk factor for ED, kidney cancer, and bladder cancer, respectively. CONCLUSIONS: The knowledge and awareness were low among urological patients regarding smoking as a risk factor for urological diseases.

Impact of COVID-19 on endourology surgical practice in Saudi Arabia: A national multicenter study.

OBJECTIVE: To identify the impact of COVID-19 on endourology surgical practice in Saudi Arabia. METHODS: A retrospective study of seven tertiary hospitals from January 2019 to April 2019, and from January 2020 to April 2020 was performed. Records of urology outpatient department (OPD) visits and endourology procedures in the first third of 2020 were analyzed and compared with those in the first third of 2019, as well as, during the full curfew time, i.e. April 2020 versus April 2019. RESULTS: Number of OPD visits in the first third of 2020 and 2019 were 19 499 and 26 594, respectively (p<0.001). Number of OPD visits in April 2020 was 1512, with a 78.6% decrease compared to that in April 2019, and among them 1373 (90.8%) were teleclinics. Number of elective procedures in the first third of 2020 has decreased by 34.3% (from 3025 to 1988) compared to that in the first third of 2019 (p<0.001). There were 120 elective procedures in April 2020, 84.1% lower than that in April 2019. Percutaneous nephrolithotomy, shockwave lithotripsy, and transurethral resection of prostate procedures declined by 94.2%, 98.5%, and 93.8%, respectively. Most procedures were performed as day surgery (85.0%). Number of emergency procedures in 2020 have fallen by 9.3% compared to 2019 (p=0.286). Urolithiasis was the commonest pathology (52.6%) presented to the emergency room (52.6%). CONCLUSION: During COVID-19 pandemic, urology services slashed by >75%, including OPD visits and elective endourology procedures. Most hospitals have changed their strategic preventive measures by increasing the rate of teleclinics and day surgeries.

Male sexual function after weight-loss surgeries in a group of Saudi population.

INTRODUCTION: Obesity is associated with erectile dysfunction in many studies. This study aims to inspect the impact of weight-loss surgery on the erectile function in the Saudi male population. PATIENTS AND METHODS: Forty-two consecutive male patients who underwent weight-loss surgery during a period from February 2013 to July 2016 were included in the study. Unmarried patients were excluded from the study. A designed questionnaire includes the short version of the International Index of Erectile Function (IIEF), usage of phosphodiesterase inhibitors, overall satisfaction before and after the intervention, marriage duration, and fertility postsurgery. All the participants were contacted through phone in July 2018, and then the questionnaire was mailed to them. All the data were analyzed and compared to a control group of married obese patients, who were waiting for the bariatric surgeries, using specific statistical tests. RESULTS: Thirty patients responded and completed the survey. Their mean age was 41.9 years (range 26-62), and the mean preoperative body mass index (BMI) was 46.3 ± 7.5, with a significant reduction in the BMI postoperatively to a mean of 30 ± 5.5. The IIEF score improved, and the overall satisfaction and feelings were better (76.7%). Only 16.7% of cases needed PDEI before and after the operation. Thirteen (43.3%) patients got children after the surgery. Univariate and multivariate analysis showed that age was a significant factor in association with both erectile function and fertility after bariatric surgeries (P = 0.02). Fertility was better in patients who underwent laparoscopic sleeve gastrectomy than gastric bypass surgery (P = 0.01). CONCLUSION: The weight-loss surgeries have a significant effect on erectile function, and they improve patient sexual satisfaction. Most of these patients feel better sexual function after bariatric surgeries. Fertility outcome seems to have a positive correlation with this type of surgery. However, a larger sample size and more elaborate studies are warranted to substantiate this claim.

Giant hydronephrosis management in the Era of minimally invasive surgery: A case series.

INTRODUCTION: Giant hydronephrosis (GH) is a rare urological entity, described as more than 1 L of fluid contained in the renal collecting system. Ureteropelvic junction obstruction (UPJO) is the most common cause. GH if not discovered and managed early can result in long term complications. We present our experience in the late presentation of adult Giant hydornephrosis. PRESENTATION OF CASES: We reviewed all the cases of patients with giant hydronephrosis who presented to our institute from December 2017-December 2019 at our institute. Pre-operative renal ultrasound, computed tomography with contrast and MAG-3 were performed on all patients to establish their diagnoses. The patients' demographic data, clinical presentation, preparatory investigations, indications for intervention, type of intervention, pre- and post-operative complications and durations of hospital stay were reported. Laparoscopic transperitoneal nephrectomy was completed in three cases without open conversion. One case proceeded to open conversion owing to a lack of space and severe adhesions. The mean operating time was 79.7 min (range: 65-95 min), estimated blood loss was 75 mL and the mean hospital stay was 4 days (range: 2-6 days). DISCUSSION: The first case of GH was described in 1746. Since then, few cases have been described in the literature. A radiological definition, is the occupation of the hemi-abdomen by the kidney with a midline cross which is the height of five vertebral bodies. GH may be congenital or acquired. The most common presentation of GH is abdominal distention followed by fever and flank pain. CONCLUSION: When nephrectomy is indicated in giant hydronephrosis, the laparoscopic trans-peritoneal approach is feasible. Pre-operative decompression using a nephrostomy tube and suspension stitch use facilitate the surgery.

Does spontaneous renal hemorrhage mandate close surveillance for impending renal cell carcinoma? A case report and literature review.

INTRODUCTION: Renal cell carcinoma (RCC) classically presents as a triad of hematuria, loin pain, and a palpable mass. However, Renal cell carcinomas (RCCs) nowadays are more commonly present as incidental findings rather than symptomatic. Wunderlich syndrome is a rare first presentation of RCC. PRESENTATION OF CASE: We present a clinical case of spontaneous renal hemorrhage with unclear etiology that was treated with therapeutic embolization and was found to have renal mass after long follow up. DISCUSSION AND CONCLUSION: In regards to treating Wunderlich syndrome, some authors favor angioembolization and follow up. Others proposed radical nephrectomy in conditions with no apparent etiology and normal contralateral kidney because of the high incidence of small renal tumors. Spontaneous perinephric hematoma of unknown etiology should be followed up regularly with a CT image for concerning of impending renal tumor.

Renal Leiomyoma: Case Report and Literature Review.

Renal leiomyomas are rare benign tumors of the kidney originating from muscle cells. They are usually found by an autopsy, whether the patient is asymptomatic or has symptoms (i.e., abdominal/flank pain, hematuria, and palpable mass). Today the widespread use of ultrasonography and CT has increased the detection of clinically asymptomatic renal leiomyomas. The differential diagnosis between leiomyomas and other malignant lesions (above all renal cell carcinoma or leiomyosarcoma) is still possible by histologic examination. Radiologic examinations are not sufficient for the differential diagnosis. Renal leiomyomas have no aggressive behavior and they usually do not metastasize. The prognosis, after surgery, is excellent without recurrence. We report a case of leiomyoma in a 78-year-old man who presented with hematuria and flank pain. We also review the literature and provide a summary of clinical, radiologic, and histologic features of renal leiomyomas.

Paraganglioma of Urinary Bladder Managed by Laparoscopic Partial Cystectomy in Conjunction with Flexible Cystoscopy: A Case Report.

Background: Paraganglioma of the urinary bladder (PUB) is exceedingly rare, accounting for <0.1% of all urinary bladder tumors. Various challenging treatment options are available. Case Presentation: A 67-year-old female presented with malignant hypertension on four medications for which investigation was done. An observation of having functioning PUB was noted. She was admitted and laparoscopic partial cystectomy was done with the guidance of flexible cystoscopy. She had a smooth postoperative course and was discharged home, then catheter was removed after cystogram. Histopathology confirmed the diagnosis of a bladder paraganglioma. Finally, during the last follow-up, the patient was asymptomatic with controlled blood pressure and normalized catecholamine levels with no evidence of recurrence. Conclusion: PUB is an exceedingly rare tumor that can be managed with minimally invasive techniques such as laparoscopic partial cystectomy with cystoscopy guidance.

Changing Patient Position Can Eliminate Arrhythmias Developing During Extracorporeal Shockwave Lithotripsy.

INTRODUCTION: Extracorporeal shockwave lithotripsy (SWL) has a low complication rate. While serious complications are rare, cardiac arrhythmias, such as ventricular tachycardia, may occur. The etiology of these arrhythmias is poorly understood, but it appears to be due to stimulation of the heart by the shock waves. OBJECTIVE: This study examines the effect of rotating the patient 15° to 20° when an arrhythmia occurs. METHODS: Eight hundred nineteen patients were prospectively evaluated for arrhythmias during SWL. The initial patient position was dependent on the location of the stone and the body mass index (BMI) of the patient. If a sustained arrhythmia developed, treatment was withheld for 2 minutes and then recommenced. If the patient developed an arrhythmia again, the patient was rotated 15°-20° away from the original position and treatment recommenced. RESULTS: Twenty patients developed significant arrhythmias during SWL. Arrhythmias occurred more frequently in patients with a lower BMI (p < 0.01), of younger age (p = 0.01), and with right-sided stones (p = 0.035). After the first rotation, 11 patients had no further arrhythmias, and 4 patients had a reduction of their arrhythmia to unsustained minor arrhythmias that did not require cessation of the treatment. The remaining five patients required a second repositioning. Three of these patients required gated SWL to abolish the arrhythmia. CONCLUSION: Changing the position of the patient by rotating the patient by 15 to 20° can eliminate arrhythmias that develop during SWL.

Intra-corporeal robotic renal auto-transplantation.

Renal auto-transplantation (RATx) is a suitable option for managing patients with long upper ureteric or pan-ureteric strictures. The current gold standard approach to RATx is a laparoscopic nephrectomy followed by open auto-transplantation. The advent of robotic-assisted laparoscopic surgery has allowed us to apply minimally-invasive techniques to ever-more complex surgical procedures. We present the case of a 38-year-old patient referred to our institution for management of a failed laparoscopic pyeloplasty resulting in a long upper ureteric stricture with complete ureteric obstruction. After complete evaluation, RATx was determined as a suitable management option. Completely intracorporeal right RATx was performed robotically with intraperitoneal cold perfusion. Total operative time was 6.5 hours, with total ischemia time of only 79 minutes (4 minutes warm ischemia, 48 minutes cold ischemia, 27 minutes re-warming time), comparable to the gold standard approach for RATx. To our knowledge, this is the first reported case of a completely intracorporeal robotic RATx in Canada.

Transfer of skills on LapSim virtual reality laparoscopic simulator into the operating room in urology.

OBJECTIVE: Assessing the predictive validity of the LapSim simulator within a urology residency program. MATERIALS AND METHODS: Twelve urology residents at McGill University were enrolled in the study between June 2008 and December 2011. The residents had weekly training on the LapSim that consisted of 3 tasks (cutting, clip-applying, and lifting and grasping). They underwent monthly assessment of their LapSim performance using total time, tissue damage and path length among other parameters as surrogates for their economy of movement and respect for tissue. The last residents' LapSim performance was compared with their first performance of radical nephrectomy on anesthetized porcine models in their 4(th) year of training. Two independent urologic surgeons rated the resident performance on the porcine models, and kappa test with standardized weight function was used to assess for inter-observer bias. Nonparametric spearman correlation test was used to compare each rater's cumulative score with the cumulative score obtained on the porcine models in order to test the predictive validity of the LapSim simulator. RESULTS: The kappa results demonstrated acceptable agreement between the two observers among all domains of the rating scale of performance except for confidence of movement and efficiency. In addition, poor predictive validity of the LapSim simulator was demonstrated. CONCLUSIONS: Predictive validity was not demonstrated for the LapSim simulator in the context of a urology residency training program.

Validation of the da Vinci Surgical Skill Simulator across three surgical disciplines: A pilot study.

OBJECTIVE: In this paper, we evaluate face, content and construct validity of the da Vinci Surgical Skills Simulator (dVSSS) across 3 surgical disciplines. METHODS: In total, 48 participants from urology, gynecology and general surgery participated in the study as novices (0 robotic cases performed), intermediates (1-74) or experts (≥75). Each participant completed 9 tasks (Peg board level 2, match board level 2, needle targeting, ring and rail level 2, dots and needles level 1, suture sponge level 2, energy dissection level 1, ring walk level 3 and tubes). The Mimic Technologies software scored each task from 0 (worst) to 100 (best) using several predetermined metrics. Face and content validity were evaluated by a questionnaire administered after task completion. Wilcoxon test was used to perform pair wise comparisons. RESULTS: The expert group comprised of 6 attending surgeons. The intermediate group included 4 attending surgeons, 3 fellows and 5 residents. The novices included 1 attending surgeon, 1 fellow, 13 residents, 13 medical students and 2 research assistants. The median number of robotic cases performed by experts and intermediates were 250 and 9, respectively. The median overall realistic score (face validity) was 8/10. Experts rated the usefulness of the simulator as a training tool for residents (content validity) as 8.5/10. For construct validity, experts outperformed novices in all 9 tasks (p < 0.05). Intermediates outperformed novices in 7 of 9 tasks (p < 0.05); there were no significant differences in the energy dissection and ring walk tasks. Finally, experts scored significantly better than intermediates in only 3 of 9 tasks (matchboard, dots and needles and energy dissection) (p < 0.05). CONCLUSIONS: This study confirms the face, content and construct validities of the dVSSS across urology, gynecology and general surgery. Larger sample size and more complex tasks are needed to further differentiate intermediates from experts.