Pediatric urology surgical practice in the time of COVID-19: Results from tertiary Saudi Arabia hospitals.

PURPOSE: Our study aimed to evaluate the effect of COVID-19 on pediatric urology practice in the Kingdom of Saudi Arabia (KSA). METHODS: Data of 10 tertiary hospitals in KSA were retrospectively analyzed. Data of outpatient department (OPD) visits and pediatric urology surgical procedures from January 1, 2019, to April 30, 2019, and from January 1, 2020, to April 30, 2020, were extracted. The primary outcome was to compare OPD visits and pediatric urology workload in the first third of 2020 versus 2019, where there was no curfew. The secondary outcome was to compare the same variables during the full curfew time, i.e., April 2020 versus April 2019. RESULTS: The number of OPD visits was lower in the first third of 2020 (7390 vs. 10,379 in 2019 P < 0.001). OPD visits in April 2020 were 78.6% lower than in April 2019, and teleclinics represented 850 (94.3%). Elective procedures in the first third of 2020 were 688, with a reduction rate of 34.3% compared to the same period of 2019 (P < 0.001). In April 2020, there were 18 elective surgeries, with a 91.4% decrease than in April 2019. Ureteric reimplantation, hypospadias, cryptorchidism, and circumcision stopped, while pyeloplasty (n = 14) and urolithiasis (n = 4) procedures had declined by 50% and 76.5%, respectively. Most of the procedures (71.8%) were day surgery. Emergency procedures were similar in the first third of 2020 (65 vs. 64 in 2019, P = 0.994) and declined in April 2020 by 6.7% versus April 2019. During the full curfew, the most common emergency intervention were cases with obstructive uropathy (42.8%), followed by torsion testis (28.6%), posterior urethral valve (14.3%), and urological trauma (14.3%). CONCLUSIONS: In KSA, the number of elective pediatric surgical procedures were reduced by >90%, while the number of emergency pediatric surgical procdures were similar during COVID-19 pandemic compared with non-COVID-19 time. Ureteric reimplantation, hypospadias repair, cryptorchidism, and circumcision procedures were postponed. Pyeloplasty and urolithiasis-related procedures were performed to prevent irreversible disease progression or organ damage. There was an increase in rate of teleclinic and day surgery to reduce the risk of COVID-19 infection.

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.

Concurrent bilateral emphysematous pyelonephritis and secondary iliopsoas abscess extending to thigh muscles with profuse rectal bleeding. A rare case scenario.

INTRODUCTION: Bilateral emphysematous pyelonephritis is exceedingly rare. CASE PRESENTATION: A 56 year old diabetic male presented with high grade fever 40o c, chills, and bilateral loin pain since two weeks a picture of septic shock. CT showed bilateral emphysematous pyelonephritis, the left kidney was smaller in size, the right renal unit showed marked hydronephrosis, right iliopsoas abscess extending to the thigh. The patient was managed by bilateral nephrostomy tubes and two retroperitoneal drains. Initially, the patient recovered, but the general condition deteriorated and profuse rectal bleeding occurred. Colonoscopy showed bleeding colonic mucosa. CONCLUSION: Bilateral emphysematous pyelonephritis is devastating disease that should be managed promptly to avoid septic shock.

A large renal bullet that resembles a large renal stone. A rare case scenario.

INTRODUCTION: Genitourinary trauma secondary to a gunshot wound is uncommon as it only occurs in about 10% of cases. We present a case of a gentleman who suffered a gunshot wound to the kidney. PRESENTATION OF CASE: A 28 year old man presented with irritative lower urinary tract symptoms (LUTs) since three months. The medical history was irrelevant. He is known case of neurogenic bladder maintained on regular clean intermittent catheterization (CIC). He has history of gunshot to the back since few years that resulted in spinal injury. CTUT showed retained bullet inside the right kidney that look alike hyperdense renal stone, Moreover, multiple vesical stones. The vesical stones were treated with cystolitholapaxy. Given that the patient is asymptomatic, conservative management for the retained right renal bullet is the feasible option. DISCUSSION: Based on the ASST classification, renal gunshot injury results in a grade IV injury. Abdominal exploration was reserved only in selected scenarios. Gunshot injuries to the kidney are commonly associated with thoracic and abdominal injuries. Gunshot injuries may be caused by low-velocity or high-velocity bullets. Given the paucity of cases reported in the literature, it is not obvious what is the optimum management of such patients with a retained renal bullet? We present the radiological findings and a clinical case summary as well for those who have Grade IV kidney injury and retained bullet managed conservatively. CONCLUSION: Retained renal bullet post gunshot injury to the back is unusual presentation. A characteristic star-like pattern produced by lead shots and not by "stone," consisting of plastic detonating cap will aid the urologist to differentiate retained renal bullet from renal stone. In such scenario, asymptomatic renal bullet look alike renal stone doesn't necessitate treatment.

Mirabegron versus Solifenacin in Children with Overactive Bladder: Prospective Randomized Single-Blind Controlled Trial.

PURPOSE: The purpose of this study is to investigate the efficacy and safety of mirabegron versus solifenacin in the treatment of newly diagnosed overactive bladder (OAB) in children. METHODS: We conducted a prospective randomized controlled study on pediatric patients with newly diagnosed OAB. Patients were randomized into 3 groups: mirabegron (50 mg once daily) in group I, solifenacin (5 mg) in group II, and placebo in group III. Before starting our treatment and at the end of the 3 months course, we obtained a 3-day voiding diary. This diary included incontinence episode per day, mean voided volume per micturition, mean number of micturition per day, and post-void residual urine. Moreover, the parents/patients were asked to rate symptom relief, and the adverse events were recorded throughout the study period. RESULTS: A total of 190 patients aged from 5 to 14 years completed this study. At the end of this trial, both groups I and II showed significant improvement versus placebo regarding our efficacy parameters with no significant difference between group I and II. The overall success rate based on assessment of symptom relief was significantly higher in the treated groups (87.5% in I and 90.2% in II) versus placebo (55.8%). Dry mouth was reported in 2.8, 10, and 0% and constipation in 2.8, 11.4, and 1.4% in group I, II, and III, respectively, without statistically significant difference between group I and placebo. However, there was a significant difference between group II and placebo regarding these side effects. CONCLUSION: Both mirabegron and solifenacin have comparable efficacy regarding the control of OAB symptoms in the newly diagnosed children, but mirabegrone seems to have less side effects.

A rare case of emphysematous pyelonephritis associated with pneumatosis intestinalis and bowel ischemia.

Emphysematous pyelonephritis (EPN) is a rare life-threatening gas producing kidney infection, commonly affects uncontrolled diabetic patients with underlying urinary tract obstruction. Presence of pneumoperitoneum and involvement of the bowels are uncommon presentation of EPN. In the present report, we present a 59-year-old African male who had extensive EPN with pneumoperitoneum, pneumatosis intestinalis and extension to the bowel causing ischemia. Successful surgical exploration was done, with resection anastomosis of the ischemic bowel segment and drainage of the kidney.

Outcomes of minimally invasive partial nephrectomy among very elderly patients: report from the RESURGE collaborative international database.

The aim of the study was to perform a comprehensive investigation of clinical outcomes of robot-assisted partial nephrectomy (RAPN) or laparoscopic partial nephrectomy (LPN) in elderly patients presenting with a renal mass. The REnal SURGery in Elderly (RESURGE) collaborative database was queried to identify patients aged 75 or older diagnosed with cT1-2 renal mass and treated with RAPN or LPN. Study outcomes were: overall complications (OC); warm ischemia time (WIT) and 6-month estimated glomerular filtration rate (eGFR); positive surgical margins (PSM), disease recurrence (REC), cancer-specific mortality (CSM) and other-cause mortality (OCM). Descriptive statistics, Kaplan-Meier, smoothed Poisson plots and logistic and linear regression models (MVA) were used. Overall, 216 patients were included in this analysis. OC rate was 34%, most of them being of low Clavien grade. Median WIT was 17 minutes and median 6-month eGFR was 54 ml/min/1.73 m2. PSM rate was 5%. After a median follow-up of 20 months, the 5-year rates of REC, CSM and OCM were 4, 4 and 5%, respectively. At MVA predicting perioperative morbidity, RAPN relative to LPN (odds ratio [OR] 0.33; p <0.0001) was associated with lower OC rate. At MVA predicting functional outcomes, RAPN relative to LPN was associated with shorter WIT (estimate [EST] -4.09; p <0.0001), and with higher 6-month eGFR (EST 6.03; p = 0.01). In appropriately selected patients with small renal masses, minimally-invasive PN is associated with acceptable perioperative outcomes. The use of a robotic approach over a standard laparoscopic approach can be advantageous with respect to clinically relevant outcomes, and it should be preferred when available.

Sporadic giant renal angiomyolipoma: A case report and literature review of clinical presentation, diagnosis, and treatment options.

Giant angiomyolipoma (AML) is uncommon benign renal neoplasm that occurs sporadic or in association with tuberous sclerosis syndrome. There is no specific cutoff tumor size and/or weight to define giant AMLs. Ovarian stimulation hormones might cause a marked increase in its size and subsequent bleeding risk. Incidental findings are not common in those patients as mass-associated symptoms always present. Computed tomography scan is the standard diagnostic imaging study except for tumors with poor fat content. According to the clinical presentation, site and side of renal involvement giant sporadic AMLs have different treatment options, for example, active surveillance, selective renal artery embolization, nephron-sparing surgery, and/or radical nephrectomy. In the present case report, we present a 22-year-old female with huge right renal mass (29 cm × 23 cm × 21 cm) and treated with right radical nephrectomy which proved to be renal AML on pathology examination.

An update of a former FIGO Working Group Report on Management of Posterior Compartment Prolapse.

BACKGROUND: The FIGO Working Group (FWG) in Pelvic Floor Medicine and Reconstructive Surgery (2012-2015) established a consensus among international opinion leaders in evaluating current evidence and providing practice recommendations. OBJECTIVES: To provide an update of the previous clinical opinion report on conservative and surgical treatment of posterior compartment prolapse. SEARCH STRATEGY: Search of evidence was performed using Pubmed, Embase, and Cochrane Library databases up to August 2018. SELECTION CRITERIA: Controlled trials on posterior colporrhaphy, site-specific defect, transanal, abdominal, laparoscopic, and mesh repair. DATA COLLECTION AND ANALYSIS: Collective consensus on surgical outcomes was based on a decision-making process during meetings and multiple group consultations. MAIN RESULTS: Basic evaluation and conservative treatment precede surgical management. Surgical techniques are performed by vaginal, transperineal, transanal, abdominal, or laparoscopic approach. The transvaginal surgical route without mesh appears superior to the transanal route. No conclusions can be drawn based on clinical studies or randomized controlled trials of posterior colporrhaphy and laparoscopic rectopexy. CONCLUSIONS: Management of rectocele should include patients' history, quality of life questionnaires, and, in case of complex anorectal symptoms, imaging and functional studies. Evidence on the best type of posterior vaginal wall repair is still scarce. Randomized controlled trials are needed to determine the best approach to achieve safe, effective, and long-term anatomical and functional outcomes.

New era of robotic surgical systems.

INTRODUCTION: To provide an update on the current status of robotic systems for surgery and the companies that produce these systems. METHODS: A non-systematic literature review was performed by using the PubMED/MEDLINE electronic search engines. Existing patents for robotic companies and devices were researched by using the Google search engine. RESULTS: Since the da Vinci Surgical System's patent expired, we have been able to predict the future of robotic companies based on the various robotic systems being developed. Currently, various attempts are being made to create consoles, robotic arms, cameras, handles, and instruments and to implement specific functions (e.g. haptic feedback, eye tracking). Herein, the benefits and limitations of each technology are identified, and likely future developments are described. CONCLUSIONS: The robotic surgical systems are continually being developed by various companies around the world. New technologies have been increasingly implemented to improve on the capabilities of previously established systems and surgical ergonomics. Future studies may need to evaluate the strengths and weaknesses of each robotic surgical system.

Novel robotic systems and future directions.

Robot-assistance is increasingly used in surgical practice. We performed a nonsystematic literature review using PubMed/MEDLINE and Google for robotic surgical systems and compiled information on their current status. We also used this information to predict future about the direction of robotic systems based on various robotic systems currently being developed. Currently, various modifications are being made in the consoles, robotic arms, cameras, handles and instruments, and other specific functions (haptic feedback and eye tracking) that make up the robotic surgery system. In addition, research for automated surgery is actively being carried out. The development of future robots will be directed to decrease the number of incisions and improve precision. With the advent of artificial intelligence, a more practical form of robotic surgery system can be introduced and will ultimately lead to the development of automated robotic surgery system.

Feasibility of Robot - assisted Segmental Ureterectomy and Ureteroureterostomy in Patient with High Medical Comorbidity.

INTRODUCTION AND OBJECTIVES: Nephroureterectomy remains the gold standard treatment option for upper tract tumors. However, segmental ureterectomy may be another option in patients with single kidney, borderline renal function or high medical comorbidities. The aim of this video is to assess the feasibility of robotic surgery as a minimally invasive technique in treatment of a high comorbid patient with ureteric tumor. MATERIALS AND METHODS: Eighty-year old male patient, with a medical history of chronic hypertensive and uncontrolled Diabetes Mellitus, was referred to our department for treatment of ureteric tumor. Patient underwent robot-assisted radical prostatectomy 5 years ago. Patient's Charlson comorbidity index score was 9. Computed tomography showed a 2.5cm right ureteral luminal filling enhancing lesion at lower part of upper 1/3 ureter. We performed diagnostic flexible cystoscopy under local anesthesia to exclude associated lower urinary tract carcinoma, and bladder wash was negative for malignancy. Under general anesthesia patient underwent diagnostic flexible ureteroscopy to confirm mass location, and a retrograde pyelography to rule out additional tumors on the right collecting system. Then, the patient was placed in the full lateral flank position without Table flexion. Ports placement were inserted as follow: a "12mm" optical trocar at pararectal line superior and lateral to umbilicus, two "8mm" robotic trocars cranial and caudal to optical trocar (8cm distance), a "8mm" robotic trocar towards anterior superior ischial spine, and a "12mm" assistant trocar was inserted between umbilicus and pubic bone. The surgical steps are shown in the video. RESULTS: The procedure was performed easily. The total operative time and consol time were 100 and 60 minutes, respectively. Blood loss was 50ml. No reported intraoperative or postoperative complications. Notably, we took full precautions in case of intraoperative failure to complete the procedure successfully, nephroureterectomy was our second option. Postoperative serum creatinine was 1.2mg/dL and length of hospital stay was 2 days. The frozen biopsy showed that the tumor was resected with safe proximal and distal surgical margins. Final histopathology revealed high grade (G3) urothelial carcinoma (pT3), measures (1.3x1.2x0.2cm), associated with carcinoma in situ. CONCLUSION: We affirm that robotic segmental ureterectomy and ureteroureterostomy could be offered safely as a minimally invasive treatment for patients with ureteric tumors and high-risk medical comorbidities. It provides excellent perioperative outcomes and early oncological safety with regard to surgical margins.

Proctorship and mentoring: Its backbone and application in robotic surgery.

In pursuit of continuing medical education in robotic surgery, several forms of training have been implemented. This variable application of curriculum has brought acquisition of skills in a heterogeneous and unstandardized fashion from different parts of the world. Recently, efforts have been made to provide cost effective and well-structured curricula with the aim of bridging the gap between formal fellowship training and short courses. Proctorship training has been implicated on some curriculum to provide excellent progression during the learning curve while ensuring patient safety.

Comparison of Trifecta and Pentafecta Outcomes between T1a and T1b Renal Masses following Robot-Assisted Partial Nephrectomy (RAPN) with Minimum One Year Follow Up: Can RAPN for T1b Renal Masses Be Feasible?

PURPOSE/OBJECTIVES: To investigate the feasibility of RAPN on T1b renal mass by assessment of Trifecta and Pentafecta rate between T1a and T1b renal mass. MATERIALS/METHODS: We retrospectively reviewed the medical records of 277 cases of RPN performed from 2006 to 2015. Sixty patients with clinically T1b renal masses (> 4 cm and ≤ 7 cm) were identified, and from 180 patients with clinically T1a renal mass, 60 patients were matched with T1b renal mass by propensity score. Tumor complexity was investigated according to R.E.N.A.L nephrometry score. "Pentafecta" was defined as achievement of Trifecta (negative surgical margin, no postoperative complications and warm ischemia time of ≤ 25 minutes) with addition of over 90% estimated GFR preservation and no chronic kidney disease stage upgrading at 1 year postoperative period. Propensity score matching was performed by OneToManyMTCH. Logistic regression models were used to identify the variables which predict the Trifecta, and Pentafecta ac. RESULTS: Preoperative variables (age, sex, body mass index, ASA score) were similar between T1a and T1b after propensity score matching. The median R.E.N.A.L. nephrometry score was 8 vs 9 for T1a and T1b respectively (p<0.001). The median warm ischemia time was 20.1 min vs 26.2 min (p<0.001). Positive surgical margin rate was 5% vs 6.6% (p = 0.729) and overall complication rate of 13.3%. vs 15% (p = 0.793). The rate of achievement of Trifecta rate were 65.3% vs 43.3% (p = 0.017) and Pentafecta rate were 38.3% vs 26.7% (p = 0.172). For achievement of Pentafecta, R.E.N.A.L nephrometry score (HR 0.80; 95% CI (0.67-0.97); p = 0.031) was significant predictor of achieving Pentafecta. Subanalyis to assess the component of R.E.N.A.L nephrometry score, L component (location relative to the polar lines, HR 0.63; 95% CI (0.38-1.03); P = 0.064) was relatively important component for Pentafecta achievement. CONCLUSIONS: The rate of Pentafecta after RAPN was comparable between T1a and T1b renal masses. RAPN is a feasible modality with excellent long term outcome for patients with larger renal mass (cT1b).

Simultaneous Retzius-sparing robot-assisted radical prostatectomy and partial nephrectomy.

We present a 61-year-old man who was diagnosed with synchronous prostate cancer and suspicious renal cell carcinoma of the right kidney, treated with combined Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) and robot-assisted partial nephrectomy (RAPN). The combined approach using RS-RARP and RAPN is technically feasible and safe surgical option for treatment of concomitant prostate cancer and suspicious renal cell carcinoma.

Clinical significance of prostatic-urethral angulation on the treatment outcome of patients with symptomatic benign prostatic hyperplasia treated with tamsulosin hydrochloride.

OBJECTIVES: To evaluate the impact of the prostatic-urethral angulation (PUA) on the treatment efficacy of selective alpha-1A receptor blocker in male patients with lower urinary tract symptoms secondary to benign prostatic hyperplasia (LUTS/BPH). MATERIALS AND METHODS: A total of 80 patients with LUTS/BPH and with mean age 53.3 ± 6.3 (range 47-70) were included in our prospective comparative study. The patients were classified into 2 groups as a consecutive cases 40 in each one depending on the PUA either ≤ 35° (group A) or > 35° (group B). PUA and different prostatic parameters were measured using transrectal ultrasound. Prostate-specific antigen (PSA), the International Prostate Symptom Score and quality of life score (IPSS/QoL score), maximum flow rate (Qmax), and postvoid residual (PVR) volume were compared between the groups. The clinical significance of PUA was evaluated after 8 weeks of medical treatment with tamsulosin hydrochloride 0.4 mg daily. RESULTS: Baseline evaluation (pre-treatment) for both groups were comparable to each other with no clinically significant difference regarding age, PSA, IPSS/QoL score, Q(max) and PVR volume (P-value > 0.05). Comparison of parameters after 8 weeks showed that tamsulosin hydrochloride improved the total IPSS and all subscores (P < 0.001), QoL (P = 0.001), Q(max) (P = 0.002), and PVR (P = 0.04) in group A (Table 1). CONCLUSION: Tamsulosin hydrochloride appears to be less effective in improving IPSS/Qol score, Qmax and PVR in patients with lager PUA. The PUA might be a predictor for the treatment efficacy of α-blockers and more studies are warranted in the future before the final conclusion.

Urinary and sexual functions after surgical treatment of penile fracture concomitant with complete urethral disruption.

OBJECTIVES: Penile fracture with concomitant complete urethral disruption is an uncommon urologic disorder. Data about the treatment and outcome measurements of this condition are scarce in the literature. The aim of the present study is to evaluate the long term urinary and sexual functions of patients with penile fracture associated with complete urethral injury after immediate surgical reconstruction. PATIENTS AND METHODS: Twelve patients met our inclusion criteria and were included in this retrospective case series study; however, one was lost during follow-up. Patient's medical records were reviewed and all patients were interviewed for clinical evaluation. Urinary function was assessed by history, uroflometry and retrograde urethrography, while, sexual function was assessed by questionnaire (Sexual Health Inventory for Men) and penile Doppler for patients with erectile dysfunction. RESULTS: Patients' mean age was 32.3 ± 7.5 years (range 21-43) and the mean follow-up period was 72.6 ± 45.4 months (range 14-187). Vigorous sexual intercourse was the main cause in 91% of our patients. No serious long term complications was found. Only 1 patient (9%) suffered from anterior urethral stricture, 1 patient (9%) complained of weak erection, 3 patients (27%) had a palpable fibrosis and 2 patients (18%) reported a slight penile curvature during erection. Ninety one percent of all our patients maintained their normal urinary and sexual functions. CONCLUSION: On the long term follow-up, most of the patients maintained their normal erectile and voiding functions with no harmful long-term complications. We advocate immediate surgical intervention and reconstruction of both corpora cavernous and urethra as a first line treatment for those patients.