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To explore reoperation rates for different radical nephrectomy (RN) approaches that are experiencing a shift from open radical nephrectomy (ORN) toward minimally invasive surgery (MIS), we aimed to compare reoperation rates along with their culprit etiologies between the different types of surgical approaches for RN.The national surgical quality improvement program dataset was used to select patients who underwent RN between the years 2012-2019. A 1:1 propensity score matched analysis was used. Reoperation rates and causes were then compared between open and MIS approach.The propensity matched cohort included 15,294 patients. Reoperation rates due to large bowel injury (0.01 vs. 0.14%), vascular injury (0.07 vs. 0.22%), and other abdominal (0.5 vs. 0.77%) were more common in ORN as compared to MIS (MIS vs. ORN, respectively, p 0.034). Reoperation due to hernia (0.14 vs. 0.03%) was more common in MIS as compared to ORN (p = 0.027). No difference was seen for small bowel injury and incision/wound debridement. General reoperation (1.61 vs. 2.22%) and mortality (0.57 vs. 1.47%) were also more common in ORN as compared to MIS (p 0.008).Reoperation due to large bowel injury, vascular injury, and other abdominal was more likely to occur in ORN. Whereas reoperation due to hernia was more likely to occur in MIS. Surgical approach was an independent risk factor for immediate and early reoperation rates in RN patients. These results could be used to counsel patients pre-operatively on possible surgical approaches and complications.

The aim of this study is to evaluate the significance of the R.E.N.A.L nephrometry scoring system in predicting perioperative and oncological outcomes and determining the surgical approach of choice for kidney tumors.Patients and Methods: Our study retrospectively reviewed outcomes from the year 2002 to 2017. Mann-Whitney U test was used to compare continuous variables and chi-square test was used to compare categorical variables. Kaplan-Meier estimates and multivariable cox proportional hazard regression were performed to determine an association between the different R.E.N.A.L categories and disease recurrence or mortality.A total of 325 patients underwent kidney surgery The most common R.E.N.A.L score category in our cohort study was intermediate (41.2%), followed by low, (33.2%) and high (25.5%). Patients with a high R.E.N.A.L score had worse perioperative outcomes compared to those with a low R.E.N.A.L score. High R.E.N.A.L score patients were 3 times more likely to receive blood transfusions compared to those with a low R.E.N.A.L score (19.4% vs 6.3%, p = 0.018), and a statistically significant longer hospital length of stay was also observed between the two groups (median 4.5 vs 4 days, p = 0.0419). In addition, the only predictor of disease recurrence or mortality was a high R.E.N.A.L score (Hazard Ratio (HR) 3.65, 95% Confidence Interval (CI) 1.05-12.7, p = 0.041).Our study sheds light on the use of R.E.N.A.L nephrometry score in predicting perioperative, postoperative, and oncological outcomes. Such findings may play a role in optimizing surgical approaches and pre-operative patient counseling.

Introduction: Renal cell carcinoma (RCC) has various histopathological tumor subtypes which have a significant implication on the oncological outcome of these patients. We aimed to evaluate the distribution of RCC subtypes presenting at a tertiary care center in the Middle East, in comparison to the distribution reported in different geographic areas worldwide. Methods: A retrospective chart review was conducted on all patients who underwent partial or radical nephrectomy for RCC at the American University of Beirut Medical Center between January 2012 and January 2018. Data on histologic subtypes were compiled and compared to representative series from different continents. Results: One hundred and seventy-nine patients with RCC were identified, of whom 122 (68.2%) were classified as clear cell, 30 (16.8%) as papillary, 17 (9.5%) as chromophobe, and 10 (5.6%) as unclassified. When compared to other regions of the world, this Middle Eastern series demonstrated a higher prevalence of the chromophobe subtype compared to Western populations (9.5% in the Middle East vs. 5.3% in the US and 3.1% in Europe) and a lower prevalence of clear cell subtype (68.2% in the Middle East vs. 78.7% in the US and 85.8% in Europe). Conversely, there was a higher prevalence of papillary RCC in the Middle East (16.8%) compared to North America (13.1%, 95% confidence interval [CI]: 12.7–13.6), Europe (11.1%, 95% CI: 10.0–12.1), and Australia (10.2%). The prevalence of chromophobe and clear cell RCC in the Middle East was similar to that reported in South America. Conclusions: The distribution of RCC subtypes in this Middle Eastern cohort was significantly different from that reported in the Western hemisphere (Europe and the US) but similar to that reported in South America and Australia. These findings may point to a possible genetic predisposition underlying the global variation in distribution.

Purpose To evaluate the feasibility of telementoring for aquablation by comparing the outcomes of onsite versus telemetry proctoring. Methods The telemetry device of choice was Proximie, an innovative digital platform that uses live video stream with an augmented reality technology. Our study retrospectively reviewed outcomes from our IRB approved prospective Aquablation database from March 2018 till October 2019. Procedures were guided by a proctor either onsite or remotely through telemetry. One-way ANOVA or Chi-square was used to compare perioperative parameters and mixed model ANOVA was used to compare functional outcomes. Results Our data included 59 patients who underwent a proctored-based Aquablation of which 21 were telementor guided and 38 were onsite guided. The initial ten procedures were done with the latter approach. There was no statistical difference in age, comorbidities, prostate size, and baseline serum markers amongst the two groups. In contrast, telementor guidance was associated with increased general anaesthesia use (76.2% vs. 21.1%) and haemostatic cauterization (81.0% versus 47.4%) with a p value 0.05). Conclusion Following an initial phase of onsite proctoring, telementoring can be safely used in the adoption phase of a new robotic technology. This approach allowed more flexibility in patient scheduling and reduced travel costs with similar surgical outcomes.

Objectives We aim to compare the outcomes of a 3-arm versus a 4-arm robotic assisted partial nephrectomy (RAPN) using the da Vinci Si model; as well as, illustrate the deployment of long ports to decrease arm collision during the 4-arm approach. Patients and Methods Results of RAPN in a Middle Eastern tertiary referral center from August 2013 to December 2017 are reported. Comparison between 3 versus 4-arm robotic approaches was done in regards to patient and tumor characteristics, operative parameters, and postoperative outcomes. Statistical analysis was performed with the Student's t-test and chi-squared test. Results Forty consecutive 3-arm RAPNs and 40 consecutive 4-arm RAPNs were retrospectively evaluated. Differences in tumor complexity between the two groups were statistically insignificant. Similarly, surgical margin positivity, mean ischemia time, estimated blood loss, length of hospital stay, and mean change in serum creatinine were statistically insignificant between the two groups. Mean operative time was significantly shorter by 42 minutes in the 4-arm vs 3-arm group (p=0.01). Conclusions The addition of a 4th arm in RAPN can be of benefit in centers that still rely on the da Vinci Si model. The ease of hilar dissection, retraction, and surgeon independence instigated a statistically significant decrease in operative time with 4-arm use.

Bladder lesions are almost always malignant where only 5% turn out to be benign. Among the benign lesions, bladder lipomas are rarely reported in the literature. Typically, they are incidentally discovered, after endoscopic resection, during an investigation for hematuria or other urinary tract symptoms. This submucosal lesion must be differentiated from its malignant counterparts, such as liposarcoma or pelvic lipomatosis both of which have higher chance of recurrence and invasion when inadequately resected. We hereby report another rare case of an incidentally discovered bladder wall lipoma in a patient presenting with microscopic hematuria.

Giant multilocular cystadenomas of the prostate or seminal vesicles are rarely reported in literature. We present a case of a 76-year-old male presenting with lower urinary tract symptoms initially perceived as symptoms of benign prostatic hyperplasia. The patient was investigated by employing a multimodality imaging approach of the prostate that included ultrasound, computed tomography, and magnetic resonance imaging, which resulted in an incidental finding of large multiloculated benign cysts originating from the prostate, confirmed by pathological study. This case report highlights the multimodality imaging approach in the detection and diagnosis of this rare disease. Keywords: Multilocular cystadenoma, Prostate, Seminal vesicles, Pelvis, Benign prostate hypertrophy

Objective: To study 24-hour urine metabolic abnormalities in patients with obstructive sleep apnea syndrome (OSAS), diagnosed by polysomnography. The purpose was to identify whether OSAS is independently associated with a distinctive set of 24-hour urine studies in a cohort of stone formers. Patients and Methods: Using our institutional stone database (2013–2017), 1132 consecutive patients with 24-hour urine collections were identified. After applying our exclusion criteria, the final cohort consisted of 376 patients of which 45 patients had OSAS. Descriptive statistics were used to compare 24-hour urine parameters between patients with and without OSAS. Logistic regression models were used to assess the association between OSAS and 24-hour urine parameters. Results: On univariate analysis, patients with OSAS were older (57.7 versus 48.2, p < 0.001) with a higher body mass index (BMI) (35 versus 27.8, p < 0.001), and higher likelihood of diabetes mellitus (DM) (57.8 versus 10.6%, p < 0.001) and hypertension (HTN) (60% versus 23.9%, p < 0.001). Patients with OSAS had higher 24-hour total amount of urine volume (2018 versus 1818 ml, p = 0.03), calcium (279.7 versus 208 mg, p = 0.02), oxalate (41.6 versus 31.3 mg, p < 0.001), yet lower 24-hour urine pH (5.75 versus 6.03, p = 0.001). On multivariable linear regression analysis, OSAS did not affect any of the 24-hour urinary parameters. Conclusion: OSAS is a prevalent comorbidity among nephrolithiasis patients. We found no major differences in 24-hour urine parameters between nephrolithiasis patients with OSAS and those without OSAS. Further study is needed to determine whether the severity of OSAS and compliance with treatment play a role in the pathogenesis of stone formation. Level of evidence: 2b

Urothelial carcinoma (UC) is a unique entity with different histological variants: squamous, glandular, small cell, micropapillary, sarcomatoid, and plasmacytoid. Each of those subtypes behaves differently. As such, and in many scenarios, an accurate histological diagnosis is of paramount importance to dictate the therapeutic approach. We hereby present a unique case of urothelial carcinoma that differentiated into two distinct histological subtypes, squamous and glandular, in three different organs within the genitourinary tract. We also describe the pathological and clinical differences entailed between the two histological variants in bladder and upper urinary tract urothelial carcinoma.

While handedness questionnaires are widely used in adults, there is no comparable measure designed specifically for children. The current study developed the Home Handedness Questionnaire (HHQ), a new measure for preschoolers administered by parents using common household items. The HHQ has two scales that distinguish action types typically combined on other measures: actions performed with only the right or left hand (i.e., unimanual, such as holding a toothbrush), and actions performed with one hand holding the object for the other hand's action (i.e., role-differentiated bimanual manipulation or RDBM, such as unscrewing a lid from a jar). The HHQ was able to detect right preference, left preference, and no preference for unimanual and RDBM actions in a proof of concept study in 3-year-olds (N = 64). The HHQ identified a majority of children as right-handed, but was also sensitive to variability in direction across skill types. Approximately one-quarter of children in the sample had mixed preferences for the two types of manual skills, suggesting that for a subgroup of children, hand use patterns may still be undergoing change. Suggestions for refining the HHQ are discussed. Overall, the HHQ is a promising multidimensional parent-led tool for assessing preschool handedness.

We herein describe, for the first time, the fetal presentation of a case of ventricular inversion, restrictive ventricular septal defect, pulmonary stenosis, hypertensive left ventricle and double outlet right ventricle at 34 weeks of gestational age. Postnatal echocardiography confirmed the prenatal diagnosis. The patient was subsequently successfully palliated with a left ventricle to pulmonary artery conduit. This report illustrates the importance of detailed fetal echocardiography to ensure appropriate delivery and neonatal management, and to optimize outcome.

Human schistosomiasis or bilharzia is a parasitic disease that highly impacts a country’s health and economic systems specifically when it affects individuals residing in underdeveloped countries. Daughter eggs produced by colonized Schistosoma can lead to multisystem immune-mediated response, one of them is an intravesicular granulomatous reaction leading to intramural lesions. Such outcome is directly related to the incubation of adult worms within the perivesical urogenital venous plexus. We hereby report an incidental discovery of calcified bladder wall lesions in a female patient residing in the United States for the last 27 years who presented with lower urinary tract symptoms. Despite a negative past medical history of schistosomiasis, intraoperative biopsies confirmed the presence of a calcified Schistosoma haematobium ova. Following that, a brief literature review of the pathogenesis and urogenital manifestations of Schistosoma is highlighted.

Adrenal cysts are rarely observed lesions. Adrenal cystic lymphangiomas are asymptomatic benign lesions of the lymphatic vessels with the vast majority occurring in women. We herein present a rare case of a middle-aged gentleman with labile blood pressure associated with an incidental finding of an adrenal mass of 4 x 3 x 3 cm. Following surgical resection, pathology revealed the diagnosis of adrenal cystic lymphangioma.

Background Management strategies for advanced testicular cancer published from a few, high-volume clinical centers may not be generalizable. Objective To discern treatment patterns for stage II nonseminomatous germ cell tumor (NSGCT) in a nationwide cancer registry. Design, setting, and participants The National Cancer Database was queried for patients with a stage II NSGCT from 2004 to 2014. Patients were stratified by clinical nodal status: cN1/stage IIA, cN2/stage IIB, and cN3/stage IIIC. Outcomes measurements and statistical analysis Logistic regression was performed to determine factors independently associated with primary retroperitoneal lymph node dissection (RPLND), primary chemotherapy, and postchemotherapy RPLND (PC-RPLND). Results and limitations A total of 2203 patients (stages IIA, n = 1060; IIB, n = 869; and IIC, n = 274) met the inclusion criteria. Overall, 83% of patients underwent primary chemotherapy, while 17% underwent primary RPLND. Stratified by stage, use of primary chemotherapy was 78%, 88%, and 86% for stages IIA, IIB, and IIC, respectively. Overall, 24% of patients underwent PC-RPLND. Factors independently associated with a lower likelihood of undergoing primary RPLND were a more recent diagnosis and a higher clinical nodal stage. Conversely, patients treated at high-volume facilities were more likely to receive primary RPLND. Factors associated with a higher likelihood of undergoing PC-RPLND included a higher clinical nodal stage, treatment at a high-volume center, and a greater distance of patient travel. Associations based on serum tumor markers could not be assessed. Conclusions For clinical stage II NSGCT, nationwide utilization of primary chemotherapy is increasing compared with RPLND and is the preferred therapy for more advanced nodal disease. Primary RPLND may be underutilized in stage IIA disease. Utilization of PC-RPLND is driven by nodal stage as well as accessibility of a high-volume center. Patient summary The use of primary retroperitoneal lymph node dissection (RPLND) in early nodal disease is declining, while upfront chemotherapy is increasingly utilized. Primary RPLND may identify patients who are actually pN0 and would not benefit from systemic chemotherapy. Primary RPLND and postchemotherapy RPLND are performed more frequently at centers of excellence.

Objective The available nomograms used to predict lymph node involvement (LNI) are not comprehensive. We sought to derive a novel nomogram incorporating the platelet to lymphocyte ratio (PLR) to predict LNI and compare its performance to validated preoperative risk nomograms in a cohort of men undergoing robotic-assisted radical prostatectomy at our institution. Methods Our electronic health record was queried for patients who underwent robotic-assisted radical prostatectomy with bilateral pelvic lymphadenectomy between 2013 and 2019. A bootstrapped multivariate logistic regression model was constructed for the predictors of LNI while adjusting for other covariates. Then, we used the derived logistic regression formula to estimate each patient's risk (%) for LNI. Individualized risks were also calculated using the following verified nomograms: Briganti-2012, Cagiannos, Godoy, and Memorial Sloan Kettering Cancer Center. Subsequently, we plotted the risks for our nomogram and the 4 verified nomograms into receiver operating characteristics curves. We reported the area under the curve (AUC) for each of the 5 nomograms and the corresponding 95% confidence interval (CI). Results The cohort included 173 patients, of which 13.9% demonstrated LNI. LNI was associated with higher preoperative prostate-specific antigen (PSA) ≥ 10 [odds ratio [OR] = 4.89; 95% confidence interval [CI] (1.42–16.83)], higher grade (WHO group ≥ 3)[19.21; (2.23–195.25)], and higher percentage of positive biopsy cores (≥60%) [3.38, (1.04–11.00)]. With every 30-unit increase in PLR the risk of LNI increased by 47%. The nomogram derived from our data had the highest AUC [(AUC 0.877; 95% CI (0.806–0.947)]. The Memorial Sloan Kettering Cancer Center and Briganti 2012 displayed almost congruent ability [0.836; 95% CI (0.758–0.915)] and [0.827; (0.752–0.902)] to identify patients with positive nodes in our cohort with perfect sensitivity and negative predictive value. Conclusion The nomogram incorporating PLR demonstrated 94.7% sensitivity to predict LNI and avoided pelvic lymphadenectomy in half of the patients at a cut-off between 6.5% and 8.5%. A prospective study with a larger sample is needed to validate our findings.

Objective To assess the awareness and attitudes of the general public in Lebanon regarding the interactions between physicians and pharmaceutical companies. Setting Primary healthcare clinics and shopping malls in the Greater Beirut Area. Participants 263 participants completed the questionnaire, of whom 62% were female and 38% were male. Eligible participants were Arabic-speaking or English-speaking adults (age≥18 years) residing in Lebanon for at least 5 years. Primary and secondary outcome measures Awareness, attitudes and beliefs of the general public. Results 263 out of 295 invited individuals (89% completion rate) completed the questionnaire. While the majority of participants were aware of pharmaceutical company presence (or absence) in physicians9 offices (range of 71–76% across questions), smaller percentages were aware of gift-related practices of physicians (range of 26–69% across questions). 40% thought that the acceptance of small gifts or meals by physicians is wrong/unethical. The percentage of participants reporting lower trust in physicians due to their participation in various pharmaceutical company-related activities ranged from 12% to 45% (the highest percentage being for large gifts). Participants who reported receiving free medication samples were significantly more likely to consider physicians9 acceptance of small gifts as ‘not a problem’ than ‘unethical’ (OR=1.53; p=0.044). Conclusions Participants in our survey were generally more aware of pharmaceutical company presence (or absence) in physicians9 offices than of gift-related practices of physicians. While the level of trust was not affected for the majority of participants for various types of interactions, it was affected the most for accepting large gifts.

Objectif L’aquablation est une technique mini-invasive innovante utilisant un jet d’eau a haute velocite delivre par une plateforme robotisee. Le traitement est guide par vision endoscopique et echographique transrectale simultanee. L’avantage par rapport a la RTUP est la rapidite de la resection prostatique ainsi que la preservation de l’ejaculation chez 80 a 90 % des patients. Methodes Un patient de 60 ans s’est presente pour HBP et retention urinaire malgre traitement medical. Apres rachianesthesie et position de lithotomie une sonde d’echographie endorectale est inseree. Un resectoscope robotique ou « piece a main » Ch24 est introduit dans l’uretre. En utilisant le logiciel robotique, la planification du traitement est faite delineant l’angle, la profondeur et les limites de la resection. Un jet d’eau de haute velocite est declenche par une pompe activee par la pedale. L’hemostase est realisee par sonde a 4 voies CH24. Les ballonnets vesical et prostatique sont gonfles a 30cc et 5cc. Un systeme de traction continu est fixe a la sonde. Resultats Le temps de resection etait de 4 min, avec saignement minimal. A J1, la traction est enlevee et le ballonnet prostatique est degonfle. Le lavage vesical est arrete et la sonde urinaire enlevee deux heures plus tard. Le patient est revu a 3 mois, son residu post-mictionnel est de 50cc, le score IPSS est de 5 et l’index de qualite de vie est de 1. Le debit urinaire maximal est a 17,5 ml/sec. La fonction sexuelle et l’ejaculation etaient preservees. Conclusion L’aquablation est une technique robotique innovante permettant un traitement chirurgical efficace de l’adenome prostatique. L’apport de la robotique permet une planification et execution precise du geste chirurgical en utilisant un jet d’eau a haute velocite.

Xanthogranulomatous pyelonephritis (XGP) is seldom seen nowadays due to the aggressive treatment of upper urinary tract infections as well as recent advances in the management of urolithiasis. It has been rarely reported in the peri-partum period. We present a case of XGP without any evidence of renal calculi, manifesting in a 26-year-old previously healthy woman immediately post-partum., Highlights • Xanthogranulomatous pyelonephritis is rare due to the aggressive treatment of upper urinary tract infections and urolithiasis. • It has been rarely reported in the peri-partum period. • A post-partum 26-year-old woman developed acute xanthogranulomatous pyelonephritis, without any evidence of renal calculi.