Saudi Urological Association consensus guidelines on the use of robotic surgery in urology.

Over the past three decades, minimally invasive robotic technology has evolved substantially in urological practice, replacing many open procedures and becoming part of routine clinical practice. The Health Sector Transformation Program for the Kingdom's Vision 2030 aims to restructure the health sector and optimize its status and prospects as an effective and integrated ecosystem centered on the patient's health. Therefore, this consensus seeks to endorse the clinical practice guidelines for robotic surgery (RS) in the KSA, highlighting its effectiveness, safety, and favorable outcomes compared to open and laparoscopic surgeries in certain procedures when used by trained surgeons in well-structured RS programs.

Clinical behavior and survival outcome of urothelial bladder cancer in young adults.

Background: Bladder cancer (BC) is rare in young adults and therefore natural history of BC is still debatable. This study aimed to determine clinical behavior and prognosis of BC in patients <40 years. Materials and Methods: We reviewed patients (<40 years) managed with urothelial BC from 2003 to 2019. Patients with nonurothelial histology were excluded. Clinical behavior and prognosis such as recurrence, progression, and survival were assessed. The recurrence is defined as a newly diagnosed occurrence of BC at previous or new site(s). Cancer progression is defined as an increase in staging or grade. Results: Fifty-five patients inclusive of 45 males and 10 females with a median age of 30.0 (interquartile range [IQR] 25.0-33.0) years were included. The median follow-up was 3.5 (IQR: 1.5-7.0) years. Fifty-one (92.72%) patients were diagnosed with nonmuscle-invasive BC while four (7.27%) patients were diagnosed with muscle-invasive disease. Three out of four patients with muscle-invasive BC died of metastatic disease. According to stage and grade, there were 42 (76.36%) Ta, 9 (16.36%) T1 and 4 (7.27%) having T2 stage while 41 (74.54%) low grade and 14 (25.45%) were having high grade disease. Thirty-six (65.45%) patients remained stable, 13 (26.63%) patients progressed, and 6 (10.90%) patients regressed to lower stage and grade. Higher stage and grade (P = 0.0431) and tumor size >3 cm (P = 0.0454) were significant for recurrence, and higher stage and grade (P = 0.0012) and tumor size >3 cm (P = 0.0055) were associated with tumor progression. Conclusion: BC in younger adults is mostly low stage and low grade. We should be vigilant in patients with higher stage and grade as it is related with recurrence, progression, and metastatic disease.

SARS-CoV-2 Clinical Characteristics and Viral Shedding in Kuwait.

OBJECTIVES: We aimed to describe the clinical characteristics of SARS-CoV-2 infection and estimate viral shedding duration in respiratory specimens. METHODS: A retrospective cohort study was performed from February 25 to March 25, 2020. In Kuwait, all suspected coronavirus disease 2019 (COVID-19) cases, contacts of cases, and returning travelers were systematically tested for SARS-CoV-2 by RT-PCR. All infected persons, regardless of symptoms, were hospitalized and serially tested until they had two negative results. Descriptive statistics and regression analyses were performed. RESULTS: Two hundred seven cases of SARS-CoV-2 infection were included in this study. About half of the cases were asymptomatic and 1.9% died. The median time to negative RT-PCR was 22 days. Increasing age, ARDS, and low peripheral white blood cell count were associated with prolonged PCR positivity. CONCLUSION: Predictors for prolonged RT-PCR positivity included increasing age, ARDS, and low white blood cell count. The findings of this study may aid in better understanding of the epidemiology of SARS-CoV-2 infection and molecular testing dynamics.

Trends in the surgical management of renal cell carcinoma in a contemporary tertiary care setting.

BACKGROUND: In the last three eras, the incidence of renal cell carcinoma (RCC) has increased, due to increased radiological studies. The expected 5-year survival rate has become better, associated with the identification of small size renal masses. However, this survival improvement may be secondary to improved surgical techniques and medical therapies for these malignancies. OBJECTIVES: The objective was to report the trends of clinical presentation, peri-operative, oncological outcomes, and surgical management trends for RCCs over the period. METHODS: After Institutional Review Board approval, a retrospective study for adult patients was conducted, who presented with renal mass and were managed between 2008 and 2019. Variables, including demographics, perioperative and pathological outcomes analyzed using descriptive statistics for continuous variables reported as mean ± standard deviation and categorical variables values compared by Chi-square test. Survival Analysis calculated using the Kaplan-Meier method. The level of significance is set at P-value < 0.05. RESULTS: A total of 588 patients underwent surgical treatment for kidney cancer from January 2008 to January 2019. 237 (40.30%) were females and 351 (59.69%) males. The clinical presentation was higher as an incidental diagnosis of 58.67%. 71.25% of patients were from outside Riyadh city. Pathology was mostly clear cell RCC 61.22% and grade 2 (57.48%). Tumor size, surgery time, and length of hospital stay showed a significant difference between the three periods (both P > 0.05). Robotic surgery performed more than open (P < 0.0001). There was no significant difference in the survival time, when compared to patients by the regions and when compared by the primary tumors (Log-Rank P = 0.4821). Patients from the Riyadh region (median = 54.0) had a significantly higher recurrence time (Log-Rank P < 0.0001). CONCLUSION: There was a rising trend in the incidence of RCC associated with comorbidities and incidental diagnosis. In our study period we found increase in the trend of minimal invasive approach. The size of the tumor, blood loss and operative time decreases over the period of time. The Robotic assisted nephrectomy approach has become increased over the period of time duration in present study.

Diagnostic efficacy and safety of transperineal prostate targeted and systematic biopsy: The preliminary experience of first 100 cases.

BACKGROUND: Post-biopsy urosepsis is a major concern for patient morbidity and cost. Trasperineal biopsy is reported to have less complications and higher detection rate of clinically significant prostate cancer (csPCa). OBJECTIVES: To determine the diagnostic efficacy and safety of transperineal prostate biopsy in patients with elevated prostatic specific antigen (PSA). MATERIAL AND METHODS: A prospective study included men with elevated PSA > 3 ng/ml and previous negative biopsy from January 2018 to April 2019. All patients had multiparametric magnetic resonance imaging (mpMRI) and suspicious lesions reported as Prostate Imaging Reporting and Data System (PIRADS) score version 2. Average twelve systematic and two targeted cores were biopsied under general anaesthesia. Patients received single dose of antibiotic prebiopsy. RESULTS: 100 Consecutive patients having median age 64.0 years and median PSA of 6.1ng/ml were included for mpMRI-US fusion transperineal biopsies. Cancer detection rate was 45% (targeted 38% and systematic 22%) and csPCa were detected in 75.55% (targeted 86.84% and systematic 59.09%). MRI-US fusion targeted biopsies detected 63.88% csPCa in PIRADS 5, 33.33% in PIRADS 4 and 5.88% in PIRADS 3 lesions. PSA > 10 (p = 0.012), PSA density > 0.15 (p = 0.0002), and PIRADS 5 (0.0001) were significantly associated with PCa. Factors like Age (0.0001), initial PSA (0.022) and PSA density (0.006) were significant on univariate analysis while age (0.0001) was significant on multivariate analysis. There was no case of urinary tract infection. CONCLUSIONS: Transperineal prostate biopsy is safe and effective in diagnosing csPCa. There is no risk of sepsis and major complications.

Surgical and oncological outcome after laparoscopic versus open nephroureterectomy for non-metastatic, upper-tract urothelial carcinoma. A single-centre experience.

OBJECTIVES: We determined the surgical and oncological outcomes of laparoscopic nephroureterectomy (LNU) in comparison to open nephroureterectomy (ONU) and factors predicting bladder recurrence after nephroureterectomy. Methods: We retrospectively reviewed and compared the data of patients who underwent ONU or LNU for non-metastatic, upper-tract urothelial carcinoma from 2000 to 2016. The primary endpoint was to determine bladder cancer recurrence-free survival (BCRFS), cancer-specific survival (CSS), and overall survival (OS). The data were analysed using Student's t-test, Chi-square test, and Kaplan-Meier curve. Results: Total of 50 patients, of which 24 had LNU and 26 had ONU, met the inclusion criteria. Median durations of follow-up were 4.2 and 6.5 years (p=0.1070) in LNU and ONU, respectively. Operative time, blood loss and hospital stay were significantly lower in the LNU group than in the ONU group (p=0.0001, p=0.0001, p=0.0018). Cancer-specific survival rate in the LNU was 75% and ONU was 73.3% (p=0.1902), whereas BCRFS and CSS were not significantly different in both groups (log-rank test; BCRFS: p=0.809 and CSS: p=0.802). Patients who underwent ureteroscopy with biopsy (p=0.001), had multifocality (p=0.001) and previous history of (H/O) bladder cancer (p=0.020) were at significant risk for developing bladder cancer recurrence after nephroureterectomy.  Conclusion: Laparoscopic nephroureterectomy can benefit patients because of its minimal invasiveness, and oncologic outcomes are comparable to ONU. Preoperative ureteroscopy with biopsy, multifocality and previous H/O bladder cancer might be risk factors for bladder cancer recurrence.

An unusual case report of pulmonary adenoid cystic carcinoma metastasis to the kidney. Case report and literature review.

Adenoid cystic carcinoma (ACC) is a malignant neoplasm, frequently affecting the salivary glands, and rarely occurring in other locations. ACC is characterized by slow growth, perineural invasion, local and late recurrence after original treatment. However, renal metastasis of ACC is very rare. To our best knowledge, only 11 cases of ACC metastasis to the kidney have been reported in the English literature to date. Herein, we presented a rare case of a 70-year-old man with renal metastasis from ACC of the right lung after 3 years of primary presentation. Our patient underwent right radical nephrectomy and histologically confirmed as Metastatic Adenoid Cystic Carcinoma.

Operative outcomes of robotic partial nephrectomy. A report of the first 101 cases from a single center in Saudi Arabia.

OBJECTIVES: To report robotic partial nephrectomy (RPN) outcomes from a single tertiary hospital in Saudi Arabia. Methods: We retrospectively reviewed consecutive cases of patients undergoing RPN at King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of  Saudi Arabia, between January 2008 and January 2018. The study reports patient's demographics, tumor characteristics, operative details, and perioperative outcomes, using descriptive statistics of median and range values. Results: One hundred and one patients underwent RPN during the study period. Average tumor size was 3 (1.3-6.4) cm and average radius exophytic nearness anterior/posterior location (RENAL) score was 6 (4-10). Perioperative parameters were blood loss 200 (5-1500) ml and warm ischemia time 17 (8-40) minutes, excluding off-clamp surgery in 12 (11.9%); operative time was 166 (66-381) minutes. Conversion to open partial nephrectomy occurred in 9 (8.9%) patients, major complications in 3 (3%) patients, positive surgical margins in 5 (5%) patients, and the hospital stay was 4 (2-14) days. A total of 73 (73%) patients achieved a trifecta of freedom from any complication, negative surgical margins, and ischemia time ≤25 minutes. Study limitations included the retrospective design and small cohort size. Conclusions: The initial experience of robotic partial nephrectomy was associated with a surgical outcome comparable to that reported by higher-volume centers.

Fracture risk following bilateral orchiectomy.

PURPOSE: Bone loss has been reported in patients with prostate cancer treated with androgen deprivation therapy. We assess fracture risk following bilateral orchiectomy. MATERIALS AND METHODS: Through the Rochester Epidemiology Project we identified 429 Olmsted County, Minnesota men who underwent bilateral orchiectomy in 1956 to 2000, almost all for prostate cancer. Fractures were ascertained from comprehensive medical records and compared with expected numbers based on local incidence rates (standardized incidence ratio, SIR). Potential risk factors were assessed with proportional hazards models. RESULTS: During 1961 person-years of followup 161 men experienced 267 fractures, for a cumulative incidence after 15 years of 40% compared to 19% expected (p <0.001). However, 42 were pathological fractures and 82 were found incidentally on radiological surveys for metastasis. Overall fracture risk was increased (SIR 3.42, 95% CI 2.91-3.99) but was reduced by excluding the pathological and incidental fractures (SIR 2.04, 95% CI 1.66-2.47). The increase was largely accounted for by the moderate trauma fractures of the hip, spine and distal forearm traditionally linked with osteoporosis (SIR 3.50, 95% CI 2.71-4.43). In multivariate analyses risk factors for fractures generally included patient age, inactivity, prior radiological diagnosis of osteoporosis, chemotherapy and use of nonsteroidal antiandrogens, while independent risk factors for the traditional osteoporotic fractures included age, inactivity and diagnosis of osteoporosis. CONCLUSIONS: Fractures are common in men with prostate cancer due to advanced age, occurrence of pathological fractures and enhanced skeletal surveillance but there remains a significant increase in osteoporotic fracture risk following bilateral orchiectomy.