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Flexible cystoscopy under local anaesthesia is standard for the surveillance of bladder cancer. Frequently, several reusable cystoscopes fail to reprocess. With the new grasper incorporated single-use cystoscope for retrieval of ureteric stents, we explored the feasibility of using it off-label for diagnosis and the detection of bladder cancer. Consecutive diagnostic flexible cystoscopies between Mar 2016 and Nov 2018 were reviewed comparing the reusable versus the disposable cystoscopes. A total of 390 patients underwent 1211 cystoscopies. Median age was 61.5 years (SD 14.2, 18.8–91.4), males 331 (84.9%) and females 59 (15.1%). Indication for cystoscopy was prior malignancy in 1183 procedures (97.7%), haematuria 19 (1.6%) or bladder mass 7 (0.6%). There were 608 reusable and 603 disposable cystoscopies. There was no significant difference between groups at baseline in age, sex, BMI, smoking status, or prior tumor risk category. There was no significant difference in positive findings (123/608, 20.2% vs 111/603, 18.4%, p = 0.425) or cancer detection rates (95/608, 15.6% vs 88/603, 14.4%, p 0.574) among the two groups, respectively. We conclude that the disposable grasper integrated cystoscope is comparable to reusable cystoscope in the detection of bladder cancer.

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. Saudi Med J 2019; 40 (1): 33-40 doi: 10.15537/smj.2019.1.22782 How to cite this article: Seyam RM, Alalawi MM, Alkhudair WK, Alzahrani HM, Azhar RA, Alothman KI, Al-Hussain TO, Alotaibi MF. Operative outcomes of robotic partial nephrectomy: A report of the first 101 cases from a single center in Saudi Arabia. Saudi Med J 2019; 40; 33-40.

Introduction: Constipation is a common complaint. The elderly are five times more prone to constipation than young people because of the effects of medication, immobility, and a blunted urge to defecate. Many of these patients are demented, have cognitive deficits, or suffer from a psychiatric disorder. Colonic perforation caused by hydrostatic pressure is rare, and this typically occurs during fluoroscopic studies resulting when there is excessive intraluminal colonic pressure. Self-induced colonic perforation is even rarer. Case report: We report the case of a 95-year-old man who presented to the emergency department with an acute surgical abdomen and symptoms of sepsis. He had a history of longstanding constipation. He gave a history of frequent insertion of a rubber hose into his anal canal to relieve his constipation while rinsing his anus after defecation. After resuscitation, an emergency operation was performed, and sigmoid colon perforation was found in addition to pre-existing diverticular disease. Hartmann’s procedure was performed after abdominal washout. Unfortunately, the patient died of multi-organ failure two days after surgery. Conclusion: Self-induced hydrostatic colonic perforation is rare. The consequence is fatal, especially in the elderly or in cases of delayed presentation.

Tubulocystic renal cell carcinoma (RCC) is one of the newly recognized subtypes of RCC. It has a unique cystic morphology and indolent behavior. During the last decade, few studies have been published describing tubulocystic RCC with poorly differentiated foci. A subset of these cases are associated with loss of fumarate hydratase which is a characteristic feature of hereditary leiomyomatosis and renal cell carcinoma-associated RCC. However, these two entities represent two distinct subtypes of RCC in the recent WHO Classification of kidney tumors. Herein, we are describing a rare case of tubulocystic renal cell carcinoma with poorly differentiated foci and loss of fumarate hydratase.

The Mashreq region and, in particular, the countries of Iraq, Jordan, and Lebanon are facing major policy and fiscal challenges to growth and job creation. The Maximizing Finance for Development (MFD) approach aims to optimize the relationship between the public and the private sector.It would achieve this in two major ways: (i) maximizing the volume of investment and commercial finance that can be crowded in by effective reforms coupled with targeted deployment of scarce domestic and international public funds; and (ii) efficiency gains with extensive involvementof the private sector to expand and improve public services while minimizing the burden on the national budget and tax resources. The World Bank Group seeks, for the first time, todevelop and implement the MFD agenda based on a standardized subregional framework. This note describes the prerequisites recently put in place in Jordan for effective MFD implementation through a combined public investment management (PIM) and public-private partnership (PPP)policy framework.

Purpose Data regarding patients' perception and satisfaction about physicians providing the medical care based on their attires in Southern Region of Saudi Arabia are scarce and even lacking. The aim of this study was to assess the patients' opinion regarding the suitable attires of physicians. Materials and methods A descriptive cross-sectional survey was performed on a random sample of patients from Aseer Central Hospital, Southern Military Hospital and Abha Maternity Hospital. The questionnaire collected data on their perception of physicians' attire as well as reflection of dress on trust and willingness to discuss personal issues. Results The study included 248 patients. The majority (81.9%) of the participants agreed on the importance for physicians to wear their medical attires. Also 84.3% of them confirmed that physician's appearance is important source of their confidence. Skirt plus lab coat was the most favored for female physicians (39.3%). As for male physicians, scrub plus lab coat was the most preferred (33.6%) attire. Conclusion Patients attending hospitals in southwestern Saudi Arabia preferred for their physicians to wear formal attire with white coats, rather than the Saudi national dress. Skirt plus lab coat was the most preferred for female physicians. As for male physicians, scrub plus lab coat was the most preferred attire. Patients approved the importance for physicians to wear their medical attires and confirmed that physician's appearance is important source for their confidence. The study recommends that physicians should adopt formal attire and the institutional dress code policy should be modified to fit these preferences.

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. Saudi Med J 2020; Vol. 41 (1): 25-33 doi: 10.15537/smj.2020.1.24780 How to cite this article: Alothman KI, Mehmood S, Alzahrani HM, Alotaibi MF, Alkhudair WK, Eldali AM. Surgical and oncological outcome after laparoscopic versus open nephroureterectomy for non-metastatic, upper-tract urothelial carcinoma. A single-centre experience. Saudi Med J . 2020 Jan;41(1):25-33. doi: 10.15537/smj.2020.1.24780.

Background: Earlier, medical literature replicated that diet was not a proven cause of acne. Nonetheless, studies in recent years have demonstrated a relation between certain dietary factors and acne. It is uncertain whether patients are aware of recent research findings. Purposes: Acne patients were surveyed to explore beliefs concerning the relationship between diet and acne, to determine whether these beliefs translated into behavior change and to recognize health information sources. Materials and Methods: Surveys were managed to 104 acne patients at King Abdulaziz Hospital from March2016 till February 2017, with 98 completed in full and included in this analysis. Results: of the 104 questionnaires administered, 98 were completed in full and were included in the analysis. The mean age of patients was 29 years (range, 15 to 45 years); 76 were female and 22 were male. Six respondents had an under-weight BMI of less than 18; 62 respondents had a normal BMI between 18–25; 26 respondents were overweight with BMI 25–30; and 4 respondents were qualified as obese with BMI greater than 30. A majority,( 90 of 98 ) of respondents, was educated at the college level . Conclusion: In this exploratory study, patients reported utilizing a diversity of information sources, a majority from the Internet. In those surveyed, there was a persistence of long-held belief that fried/greasy foods and chocolate may serve as acne triggers, and less belief in trigger foods supported by recent research, including refined carbohydrates and sugar. Given the multiplicity of beliefs and utilized sources among acne patients in our survey, there is a need to establish an up-to-date and reliable methods to educate patients the relationship between diet and occurrence of acne.

Background: the female pattern hair loss is the most common cause of hair loss in female, which is androgenic pattern, medical treatment such as anti-androgenic therapy and topical preparation may simply arrest progression of female pattern hair loss or in some women stimulate partial growth of hair, but the response is slow. This study aimed to determine the most common causes of hair loss among female with regard to the age, the effect of some drugs, balanced diet, average amount of hair loss per day. Objectives: this study aimed to determine the most common causes of hair loss among Saudi females. Materials and method: this was a cross sectional study of the women aged 20-50 years designed in a questionnaire form involved series of questions with multiple choices answers. It was conducted in Saudi Arabia in October 2017. The data entry was done by using Microsoft Excel, while the analysis was done by using SPSS version 23 and we used it in test correlation coefficient Spearman with measuring the mean value for all questions. Results: data were analyzed via using SPSS program, version 23 and we used it in test correlation Coefficient Spearman between Q1 AND Q9=0.146 week positive and p-value=.087 >0.05 we didn’t reject the null hypothesis. Correlation Coefficient Spearman Q23 and Q29=.008 no relation and p-value=0.927>0.05 we didn’t reject the null hypothesis. In Q3 the mean was =6.83 and Q7; the mean was =2.50. Conclusion: in KSA we found the unbalanced diet to be the most effective factor that leads to hair loss among out sample size. In the present study we need to educate the population about the importance of balanced diet for maintaining of healthy hair and skin.

Renal angiomyolipoma (RAML), though a rare benign tumor, may impose a significant morbidity or even mortality due to its unique characteristics and the complications subsequent to its treatment. The classic tumor variant is composed of smooth muscular, vascular, and fatty components. The most straightforward diagnosis is when the fat component is abundant and gives a characteristic appearance on different imaging studies. In fat-poor lesions, however, the diagnosis is difficult and presumed a renal cell carcinoma. Yet, some variants of RAML, though rare, express an aggressive behavior leading to metastasis and mortality. The challenge lies in the early detection of benign variants and identifying aggressive lesions for proper management. Another challenge is when the vascular tissue component predominates and poses a risk of hemorrhage that may extend to the retroperitoneum in a massive life-threatening condition. The predicament here is to identify the characteristics of tumors at risk of bleeding and provide a prophylactic treatment. According to the clinical presentation, different treatment modalities, prophylactic or therapeutic, are available that span the spectrum of observation, embolization, or surgery. Renal impairment may result from extensive tumor burden or as a complication of the management itself. Improvement of diagnostic techniques, super-selective embolization, nephron-sparing surgery, and late treatment with the mammalian target of rapamycin inhibitors have provided more effective and safe management strategies. In this review, we examine the evidence pertaining to the risks imposed by RAML to the patients and identify merits and hazards associated with different treatment modalities.

Background: Two oral antifungal agents, griseofulvin and terbinafine, have regulatory approval but it is unknown whether one has superior overall efficacy. Genus-specific differences in efficacy are believed to exist for the two agents. It is not clear at what doses and durations of treatment these differences apply. Purpose: The purposes of this meta-analysis were to determine whether a statistically significant difference in efficacy exists between these agents at a given dose and duration of each in tinea capitis infections overall and to determine whether a genus-specific difference in efficacy exists for these two treatments at a given dose and duration of each. We performed a literature search for clinically and methodologically similar randomized controlled trials comparing 8 weeks of griseofulvin (6.25–12.5 mg⁄kg⁄day) to 4 weeks of terbinafine (3.125–6.25 mg⁄kg⁄day) in the treatment of tinea capitis. A meta-analysis was performed using the Mantel–Haenszel method and random effects model; results were expressed as odds ratios with 95%. Results: Meta-analysis of randomized controlled trials did not show a significant difference in the overall efficacy of the two drugs at the doses specified, but specific efficacy differences were observed based on the infectious species. For tinea capitis caused by Microsporumspp., griseofulvin is superior (p = 0.04), whereas terbinafine is superior for Trichophyton spp. infection (p = 0.04). Conclusion:Our results support species-specific differences in treatment efficacy between griseofulvin and terbinafine and provide a clinical context in which this knowledge may be applied.

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.

Highlights • Neuroendocrine tumor of the appendix inside an incarcerated Amyand’s hernia is extremely rare. • The diagnosis of Neuroendocrine tumor in a such emergency situation is a real challenge. • Treatment of the hernia defect in a such condition is interesting., Amyand’s hernia is a rare type of hernia where the vermiform appendix is within an inguinal hernia sac. Tumors of the appendix are quite uncommon. The coincidence of an Amyand’s hernia with neuroendocrine tumor of the appendix, as in our case, is even more rarely reported. We report the case of an 81-year-old male who presented with an incarcerated right inguinal hernia. After resuscitation, the clinical diagnosis was confirmed by computed tomography. It showed an incarcerated right inguinal hernia which contained the distal ileum, cecum, thickened appendix, as well as a small amount of fluid. Subsequently, the patient was prepared for emergency surgery. During the operation, the hernia sac was found and opened. The appendix was swollen. Therefore, appendectomy was performed. The inguinal defect was repaired using the Modified Bassini Technique. The patient had an uneventful postoperative recovery and surprisingly the histopathology of the appendix revealed a 1.5 cm well-differentiated low grade neuroendocrine tumor (carcinoid) of the appendix tip. An incidental finding of neuroendocrine tumor of the appendix in a patient with s hernia is extremely rare. A high index of suspicion is the key to diagnose such a coincidence in order to safely and optimally treat such a condition.

Cervical thymic cysts (CTCs) are unusual lesions, representing only 1% of cystic cervical masses. Diagnosis of this condition in adults is even rarer. We report a 34-year-old female who presented with asymptomatic progressively growing left-sided neck swelling. Neck ultrasound (US) showed a large cystic lesion with septation, compressing the ipsilateral vessels. Magnetic resonance imaging (MRI) confirmed the US findings. Surgical excision was performed which subsequently showed findings consistent with CTC. CTC in adult is extremely rare, with few reported cases identified in the literature. Thymic gland anomalies in the neck are the consequences of an arrest in the descent of the gland, sequestration of the thymic tissue, or failure of involution. The diagnosis of this condition is rarely done prior to surgical excision. The clinical presentation, radiologic imaging, surgical findings, and histologic appearance are all essential components to make the correct diagnosis of this very rare differential diagnosis of cystic lateral neck swelling.

Objectives To evaluate the changing management of sporadic renal angiomyolipoma and renal angiomyolipoma associated with the tuberous sclerosis complex (TSC) during the past 16 years. Methods We retrospectively reviewed the charts of 60 patients with angiomyolipoma seen at our institutions. Results The median age at presentation was 45 years (range 7-78). The presentation was pain in 30 patients and hematuria in 13; it was incidentally discovered in 17 patients. Of the 60 patients, 43 were females. TSC was present in 14 patients. The median tumor size was 4 cm (range 0.3-40, mean 6.5 ± 1.1). Of the 60 patients, 31 were followed up expectantly. Surgery or intervention was needed for 29 patients to control hemorrhage or relieve pain or because of the suspicion of malignancy. Of these 29 patients, 12 underwent nephrectomy, 11 partial nephrectomy, and 6 embolization. The patients treated for hemorrhage had a median tumor diameter of 11 cm (range 2-21). Patients were followed up for a mean of 39.3 ± 5.4 months. The lesions grew an average of 4.7 ± 3.4 cm for TSC tumors and 0.6 ± 0.2 cm for sporadic angiomyolipoma tumors. None of the patients developed renal impairment. Patients with TSC presented at a younger age, had larger and bilateral lesions, and were more symptomatic during follow-up. In the past 6 years, a significant trend was seen toward finding tumors in asymptomatic patients and toward the use of conservative or interventional (embolization) treatment. Conclusions Renal angiomyolipoma has a slow growth rate. The preservation of renal function was noted in all our patients. A recent shift was noted toward finding smaller tumors in asymptomatic patients and the use of conservative and interventional treatment.

Patient Female, 68 FINAL DIAGNOSIS: Gallbladder agenesis with situs inversus totalis Symptoms: Epigastric pain • jaundice Medication - Clinical Procedure: - Specialty: Surgery. Objective Rare disease. Background Situs inversus totalis is an inherited condition characterized by the mirror-image transposition of thoracic and abdominal organs. Gallbladder agenesis, which has normal bile ducts, is a rare congenital condition that occurs in 13 to 65 people out of 100 000. A common bile duct (CBD) stone or choledocholithiasis in patients with gallbladder agenesis is even rarer. Case report We report the case of a 68-year-old woman who presented with epigastric pain and jaundice. She was not known to have situs inversus totalis. Abdominal ultrasound showed a large stone in the CBD, which could not be extracted by endoscopic retrograde cholangiopancreatography (ERCP), necessitating exploration. The gall-bladder and cystic duct were found to be absent. Incisional exploration of the CBD was performed, and a large stone was removed. A choledochoscope was used to identify the remnants and exclude the presence of ectopic gallbladder, and a T-tube was placed into the CBD. Conclusions Gallbladder agenesis in a patient with situs inversus totalis is extremely rare, with no single reported case identified in the literature. In addition, our case showed a rare complication of ERCP - a failure to extract the CBD stone - and illustrates a way to overcome this complication.

Background: Road traffic accidents (RTAs) are not frequently because of ignorance but are because of carelessness, thoughtlessness, and overconfidence, and it can lead to permanent disability. Hence, it is very important to determine the students’ attitude and knowledge toward the road traffic regulation in Saudi Arabia. Objectives: The objectives of this study were to assess the knowledge, attitudes, and practices of male students at the Health Science College in Taif University, Taif, KSA, toward road traffic regulations. Materials and Methods: This study was performed during the second semester of the academic year 2013 among the students studying at the Health Science College for Boys in Taif University, Taif, KSA. A questionnaire of 18 different questions was distributed to all available students and asked to respond under the direct supervision of the heads of the four departments of the college. The questionnaire consisted of three main parts: the first was about the sociodemographic and scientific data of the students; the second on the knowledge of road traffic regulations; and the third dealt with the attitudes of driving and the use of seat belts. Results: One hundred twenty students participated in this study. The mean age of the participants was 21 years; 30% lived in cities, and 60% and 100% had cars and driving licenses, respectively. More than half of the students had been involved in RTAs; 83.3% of these had been injured in these RTAs and 41.6% admitted to hospital for an average of 11 ± 1.3 days. High speed was the main cause of their RTAs. The percentage of knowledge of road traffic regulation was moderate in more than 90% of the students, while more than 85% of them believed in the importance of the use of seat belts. Conclusion: This study revealed that many students had been involved in RTAs as a result of driving at high speed. Most of the students had good attitude toward the use of seat belts.