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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.

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.

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.

More than 100 alkaloids have been found in periwinkle, of which vincristine and vinblastine are the most notable for the treatment of diseases such as leukaemia. In this study, characterization of naturally occurring Cucumber mosaic virus (CMV) infection showed mosaic, leaf deformation and stunting of plants. Viral identification was confirmed by double-antibody sandwich enzyme-linked immunosorbent assay (DAS-ELISA) with a specific CMV polyclonal antibody and reverse transcription PCR with a specific primer for the CMV-RdRp-gene, which yielded a 513 base pair DNA fragment. The effect of CMV infection on the antineoplastic alkaloids in periwinkle leaves was determined. We also studied the effect of using plant-growth-promoting rhizobacteria (PGPR) isolates against virus infection to stimulate resistance induction in host plants. Bacillus subtilis 281 and B. pumilus 293 were examined individually (B1 and B2) and in a mixture (B1&B2) for their effectiveness against infection with CMV. The results of greenhouse experiments were confirmed by artificial mechanical inoculation. The PGPR strain treatments and results were reinforced by analysing the protein patterns as well as determining the total phenol, total flavonoid and total alkaloid contents. PGPR treatment evidently lowered the virus concentrations, the percentage of infected plants and the disease severity compared with healthy and infected controls. Seedlings treated with the B1&B2 strain mixture yielded significantly lower levels of virus infection than B1 or B2 individually in all experiments compared to controls. Our findings demonstrate the possibility of using selected Bacillus spp. strains to induce systemic resistance for CMV infection control.

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.

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.