Characteristics of renal cell carcinoma in Saudi patients below the age of 50 years.

BACKGROUND: The incidence of renal cell carcinoma (RCC) in young adults has started to increase in recent years. OBJECTIVES: The objective of the study was to describe and compare the mode of presentation, incidence, risk factors, histopathological features, nephrectomy modalities used, and outcome in patients diagnosed with RCC below the age of 50. MATERIALS AND METHODS: A total of 139 confirmed RCC patients diagnosed below the age of 50 years who underwent nephrectomy from January 1990 to April 2019 were included in this retrospective review. We compared the characteristics of two age groups (≤40 years and 41-50 years) and evaluated incidentally discovered versus symptomatic tumors in patients below 50 years. RESULTS: Loin pain contributed to most symptomatic presentations in the older group (55%) (P = 0.014). Hypertension and diabetes were present in 24% of patients from 41 to 50 years of age versus 3.8% for hypertension and 5.7% for diabetes in the young group. (P = 0.001 and P = 0.004, respectively). Chromophobe was the second most common pathology (26.5%). Tumor size tended to be larger in the older group (P = 0.006). Fuhrman's grade was significantly lower in incidentally diagnosed patients (88.2%) (P = 0.006). The T stage was significantly lower in the incidental group (P = 0.005), but the mortality rate was higher in symptomatic patients (9.6%) (P = 0.013). CONCLUSION: RCC increases after the age of 40-50 years in the presence of other risk factors. Chromophobe represented almost a quarter percentage of the pathology, while partial nephrectomy yielded a better outcome.

Bilateral same session renal stone surgery tolerance and complications.

INTRODUCTION: The prevalence rate of upper urinary tract calculi in Saudi Arabia is one of the highest globally. Bilateral renal stone management is an option but is still controversial. METHODOLOGY: The study was a retrospective study, including 31 patients with bilateral renal or ureteric stones who underwent bilateral same-session ureterorenoscopy (BSS-URS). The data collected included age, gender, body mass index (BMI), stone burden bilaterally, operative time bilaterally, hospital stay, stone location, type of anesthesia, stone history, renal anomaly as well as pre- and postoperative JJ stenting. In addition, data related to complications (ureteric injury, renal failure, urinary tract infection, pain requiring an emergency department visit within 1 week of the procedure), the stone-free rate (defined as £ 3 mm asymptomatic stone fragment identified with computed tomography Kidney, Ureter and Bladder 3 months after surgery was also collected. The data were collected from the electronic patient record system, entered in an Excel spreadsheet, and descriptive analysis was done. RESULTS: In total, 31 patients were included, with the majority (80.6%, n = 25) male. The mean age was 41.6 years, the mean BMI 28.7 ± 5.59, the mean operative time for each renal unit 46.53 ± 25.69 min, and the mean hospital stay 17.87 ± 8.43 h. The majority (96.7%, n = 30) received general anesthesia. Less than half (40.3%, n = 25) of the renal units had stones in multiple calyces and the majority (90.3%, n = 56) of the renal units were stone free at the 3-month follow-up. A small proportion (3.2%, n = 2) of the renal units were polycystic. Prestenting was documented in 40.3% (n = 25) of the renal units and the majority (95.2%, n = 59) were stented postoperatively. CONCLUSION: BSS-URS is a safe and a highly effective management option for bilateral renal stones.

Effect of hormonal manipulation using clomiphene citrate prior to microdissection testicular sperm retrieval.

INTRODUCTION: Microdissection Testicular Sperm Extraction (micro-TESE) is a surgical method used for retrieving sperm from men with non-obstructive azoospermia. Clomiphene citrate (CC) is a selective estrogen receptor modulator (SERM) that stimulates luteinizing hormone (LH) and follicle-stimulating hormone (FSH) production. It is believed that treating patients with CC prior to micro-TESE increases the chance of sperm retrieval. METHODS: This retrospective study was conducted in a tertiary care center in Riyadh, Saudi Arabia and included all patients who underwent Micro-TESE from August 2015 to November 2018. Data related to the pre-surgery hormonal levels, testicular volume, and associated genetic abnormalities were collected. chi-square and t-test were used to compare variables. A p-value of less than 0.05 was considered significant. RESULTS: A total of 122 patients were included in this study, with 30.0% (n=37) treated with CC. The overall sperm retrieval rate was 44.3%. Micro-TESE results were not statistically affected by age, testosterone levels, Klinefelter syndrome, or taking CC. However, higher testicular volumes and lower LH and FSH levels had more positive micro-TESE results. CONCLUSION: In conclusion, Micro-TESE results were not affected by CC, age or testicular volume.

The yield of microscopic varicocelectomy in men with severe oligospermia.

INTRODUCTION: Varicocele is detected in 35%-50% of men with primary infertility and up to 81% with secondary infertility. Various studies have shown that varicocele is related to testicular hypotrophy and impaired spermatogenesis. The effect of varicocelectomy in mild-to-moderate male factor infertility has been well reported. However, only a few studies addressed the impact of varicocelectomy in severe oligospermia. METHODS: We included 45 patients with severe oligospermia (<5 million/mL) who underwent microsurgical varicocelectomy between May 2014 and November 2017. Results of semen analysis taken at 6 months after varicocelectomy were compared and patients were divided into responders and nonresponders. Chi-square was used to compare the preoperative and postoperative sperm count, motility, and volume. RESULTS: After 6 months only one patient was found to be a responder with a pre- to post-operative motility of 45%-74% and a sperm concentration of 1 million/mL to 28.1 million/mL. There was a significant improvement in the mean sperm concentration after varicocelectomy which improved from 1.31 million/mL to 5.32 million/mL. However, a significant decrease in sperm motility was noted which decreased from 35.62% to 28.64% postoperatively. Postoperative semen volume increased from 2.56 mL to 3.19 mL, but this difference was not found to be statistically significant (P > 0.05). Four patients (8.9%) were found to have azoospermia after a 6-month follow-up. In these four patients who turned azoospermic had count <50,000 sperm/mL, two of them had a history of cryptospermia before varicocelectomy. Ejaculate sperm returned in two of these four patients in long-term follow-up (>6 months). CONCLUSION: The magnitude of improvement after microsurgical varicocelectomy for severely oligospermic patients is less profound than reported in mild male factor infertility.

Partial Nephrectomy, a Comparison between Different Modalities: A Tertiary Care Center Experience.

Kidney cancer, with 4% of all malignancies, is one of the most common malignancies occurring among in adults. In Saudi Arabia, kidney cancer comprises 2.3% of all cancers, and its incidence has increased by 33%. Partial nephrectomy (PN) is considered as the gold standard for T1 renal masses. In this retrospective study, we did a chart review for all patients who underwent PNs between April 2013 and February 2019. Data comprised presentation, tumor size, type of procedure (open vs. laparoscopic vs. robotic), and intra- and post-operative complications. Chi-square, ANOVA, and cross-tabulation were done using SPSS software. P > 0.05 was considered significant. Approval was obtained from the institutional review board of King Abdullah International Medical Research Center. In all, 69 patients were identified: 26 (37.7%) males and 43 (62.3%) females, with mean age = 54.53 ± 13.21 years; mean body mass index = 32.36 ± 7.03, and mean tumor size = 3.7 ± 1.72 cm. In terms of presentation, most patients (50, 72.4%) presented incidentally as opposed to symptomatic presentation. Of these patients, 18 (26.1%) underwent open partial nephrectomy (OPN), 29 (42%) laparoscopic partial nephrectomy (LPN), and 22 (31.9%) robotic partial nephrectomy (RPN). On comparing minimally invasive surgery (MIS) PN with OPN, we found that OPN had more blood loss and a longer hospital stay but a shorter operating room (OR) time. Results of PN irrespective of the procedure type, whether it was OPN, LPN, or RPN, were similar if performed by experienced surgeons. However, open procedures involved a higher blood loss, more operative time, and longer hospital stay when compared with minimally invasive techniques.

Priapism for 10 days in a patient with SARS-CoV-2 pneumonia: a case report.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been linked to thromboembolic complications. Priapism has been reported only once in link to SARS-CoV2. Here we report the second case of priapism in a patient with SARS-CoV2; our case is unique in being that the patient had priapism for 10 days while being hospitalized. We discuss potential causes and possible prevention strategies. The patient was managed by aspiration and Phenylephrine injection and achieved detumescence and reported normal erection at 2 weeks follow-up.

The perception and competency of undergraduates in urology: Is the clinical exposure necessary?

OBJECTIVE: The objective of this study is to investigate medical students' perception, choices of future career, and competency in urology. METHODS: A cross-sectional survey was distributed among 5th, 6th, and 7th(interns) year medical students at King Saud bin Abdulaziz University for Health Sciences using both hard copies and soft copies. Major outcomes were medical students' perception, future career decision, and core skills in urology. RESULTS: The overall response rate was 51.3%. A total number of 163 responses (122 were males and 41 females) were collected. Only 8% indicated that they would pursue a surgical career in urology and 42% thought that they had received a good clinical exposure to urology. Of the participants, 67.5% viewed urology as a male-dominated field. Only 17% of the respondents either agreed or strongly agreed that they were considering a future career in urology. Female students were less likely to consider a urological career (P < 0.01). About 32.5% were confident at urethral catheterization. About 66.9% felt that a workshop day to enhance urological skills and knowledge will be beneficial. Females were more confident at assessing a urological case in an acute setting (P < 0.05). CONCLUSION: Most of the students agreed that their urology exposure was inadequate and their confidence at urethral catheterization was low. As in many different global studies, urology is still regarded as a specialty with a male dominance. This report is consistent with the global decline in formal urological education.

Trends of upper urinary tract stone management in a high volume stone center in Saudi Arabia, 12 years analysis.

INTRODUCTION: Urolithiasis is a common urological problem globally with tremendous health and economic burden. In Saudi Arabia, an estimation has shown that the risk of developing a stone episode is 50% higher than that in Western countries. About 20% of males would experience at least one episode by 70 years of age. The introduction of minimally invasive and noninvasive methods such as shockwave lithotripsy (SWL), ureteroscopy (URS), and percutaneous nephrolithotripsy (PCNL) has driven the urologists to more complex decision-making with a noted variance in management options. OBJECTIVES AND METHODS: The objective of the study was to observe the trend of upper urinary tract stone management in our institution in the past 12 years. METHODS: Charts of patients who underwent upper urinary tract lithotripsy procedures of any kind were reviewed. The information obtained included, patient's age, surgeon, surgery type, stone size, stone location, and duration of surgery. ANALYSIS: The data obtained were from 2006 to 2016. Excel sheets used for the collection of data and SPSS software was used for analysis. RESULTS: The results showed that the majority of the patients were males accounting for 65%. ESWL was the predominant approach from 2006 to 2010. In 2006, ESWL accounted for 77.7% of the cases, 76% in 2007, 70% in 2008, 64% in 2009, and 62% in 2010. However, in 2011, the rates dropped to almost 18% and URS rates have increased from a few cases per year to 64%. The frequency of URS continued to rise through the years until 2015 where URS rates reached 75%. During the 12-year period, URS is the most common upper tract procedure conducted when compared to ESWL and PCNL, accounting for 63%, 16%, and 20%, respectively. CONCLUSION: In our institution, the frequency of URS rose over the years being the most abundant procedure done. ESWL rates have decreased over the years.

Failure of ureteral access sheath insertion in virgin ureters: A retrospective tertiary care center study.

OBJECTIVE: The objective of the study was to identify the failure rate of insertion of ureteral access sheath (UAS) during primary flexible ureteroscopy (FURS). MATERIALS AND METHODS: This was a single-surgeon, single-tertiary care center retrospective study. All patients who underwent primary FURS for proximal ureteric or renal stones from November 2014 to May 2018 were included in the study. Patients with a stone burden of more than 20 mm were excluded from the study. A 10/12-Fr coaxial UAS (Bi-Flex, Rocamed) was used. Data collection included age, sex, body mass index (BMI), stone burden and location, previous spontaneous passage of stones, type of anesthesia, and preexisting congenital anomalies. The Chi-square test and t-test were used for the statistical analyses. RESULTS: One hundred and twelve patients were included in the study. All patients underwent primary FURS. The failure rate of primary UAS insertion was 10.7% (n = 12). No statistically significant difference was found in age, BMI, type of anesthesia, previous history of spontaneous stone passage, and stone burden between the success and failure groups (P > 0.05). CONCLUSIONS: We believe that our study opens the door for a multicentric prospective trial. Identifying factors leading to a failed primary FURS and UAS insertion is crucial to properly counsel patients preoperatively about the number of procedures that they might need and to prevent the financial loss associated with failed UAS insertion.

Assessment of lower calyceal single-access percutaneous nephrolithotomy for staghorn stones: A single-surgeon and a single-center experience at KAMC, Riyadh.

INTRODUCTION: Percutaneous nephrolithotomy (PCNL) is still the mainstay and the treatment of choice for most complex renal stones. The success of PCNL is defined by achieving a stone-free rate (SFR). Lower calyceal access PCNL is established to be the safest percutaneous access to the renal system, but controversy is present when it comes to SFR in comparison to upper calyceal and middle calyceal accesses. AIM: We aim to prove that lower calyceal access PCNL is the safest PCNL access and has the same efficacy as upper calyceal access PCNL for staghorn stones. METHODOLOGY: All lower calyceal access PCNLs done from May 2012 to August 2017 were included in the study. Postoperative complications were reported using the modified Clavien Grading System. RESULTS: Sixty-seven patients were included in the study. The mean age was found to be 49.39 years; most (36 [53.73%]) patients were male. The prevalence of diabetes, hypertension, dyslipidemia, and chronic kidney disease was 40.91%, 47.76%, 37.31%, and 20.00%, respectively. The mean hospital stay was 7.9 days; mean operative time was 138.52 min. The mean staghorn stone burden was 476.34 mm2. About 80.59% (n = 54) of patients had complete stone resolution after the first session. Only 3 (4.47%) patients had complications and classified as Grade 2 on the modified Clavien Grading System and the remainder were classified as Grade 1, two patients needed postoperative blood transfusion, and one had a renal pelvis perforation. CONCLUSION: When it comes to safety and efficacy, the use of lower calyceal single-access PCNL has a very low complication rate compared to upper calyceal access PCNL, especially pneumothorax and bleeding.

Kidney cancer in Saudi Arabia. A 25-year analysis of epidemiology and risk factors in a tertiary center.

OBJECTIVES: To evaluate available epidemiological data and risk factors for kidney cancer in a tertiary care center in Riyadh, Saudi Arabia, over a period of 25 years. METHODS: This retrospective study conducted in a tertiary care center included all adult patients with primary kidney cancer who presented and were managed between 1990 and 2015. Based on this information, we forecast the incidence of the disease in our center over the next 5 years (2016 to 2020). RESULTS: In total, 371 patients were included in the study. The mean age of the patients was 56.3 years and the majority were male (61%). Among the patients, 55.8% were diagnosed incidentally. At the time of diagnosis, 53.2% were hypertensive, 46.2% were diabetic, 39.1% had dyslipidemia, and 25% were smokers. In addition, most patients were obese (42.3%) or overweight (30%). The most frequent histopathological variants were clear cell and chromophobe. Most patients presented with Stage 1. Minimally invasive surgery (laparoscopic, robotic) was performed in 55% of cases. Based on these data, we predicted that 172 new cases will present at our tertiary care center in 5 years from 2016 to 2020. CONCLUSION: The incidence in kidney cancer is increasing and is associated with an alarming increase in the prevalence of associated risk factors.

Prevalence of Dietary Supplements Use among Gymnasium Users.

Background. Several studies showed that regular gymnasium users use various dietary supplements without comprehension of their potential risks. Objective. To determine the prevalence and dietary supplement intake and assess the awareness of supplement use among regular gymnasium users in Riyadh, Saudi Arabia. Methods. A descriptive cross-sectional study was conducted among regular gymnasium users in Riyadh, Saudi Arabia, between April 2015 and June 2015. A validated structured questionnaire was used. Results. The study included 299 participants. Of these 113 (37.8%) were dietary supplements users and this was more common among males than females (44.7% versus 16.4%). Gender based analysis showed that males were exercising more frequently than females and the type of cardiovascular exercise was more among them. The most commonly used supplements were whey protein (22.1%), amino acids (16.8%), multivitamins (16.8%), creatine (11.5%), and omega 3 (11.5%). The reasons for taking dietary supplements were to improve body shape (47.7%), increase health (44.2%), and improve performance (41.5%). Conclusion. Most of the information about supplements was obtained from unreliable sources. More studies are needed to better understand supplements use and their impact on health in Saudi Arabia.