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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 (p75%, including OPD visits and elective endourology procedures. Most hospitals have changed their strategic preventive measures by increasing the rate of teleclinics and day surgeries.

Objectives: With an increasing number of patients undergoing ureteroscopic surgery worldwide for stone disease, and the concomitant pressures on health care resources, we aimed to review global patterns for ureteric stenting following ureteroscopy. With a centralized electronic database, a longitudinal cohort study was designed to help define the indications for stenting, type of drainage, and methods of stent removal. Methods: This multicenter study was conducted prospectively, with centralized data acquisition by uCARE (research arm of the Société Internationale d'Urologie), and registered at ClinicalTrials.gov (NCT03567421). Along with baseline demographic data, details were entered for stone imaging characteristics, intraoperative information, including urine culture, and exit strategy for stent removal. An independent audit was undertaken to sample the accuracy of data entered across the sites. Results: In total, 2544 patients were included from 50 centers in 15 countries. There were 1969 patients with ureteric stones, and 942 with renal stones. While 41% ureteric stones were distal (median length 10mm), 52% renal stones were in the lower pole (median diameter 11 mm). The majority of patients (68.8%) were given antibiotics at induction; 20.6% were “pre-stented” before the ureteroscopy, and a high percentage were stented following ureteroscopy (91%). The majority of the stents (85.1%) were polyurethane, mean duration of stent after surgery was 27 days, and 80% of stent removals were undertaken in the operating room. Conclusion: This is one of the largest prospective global cohort studies, reflecting widespread usage of stenting, despite emerging evidence to the contrary. Stent removals may also be modified with time, as the pressure on health care resources mounts.

Purpose: The Société Internationale d’Urologie (SIU) conducted a survey to determine whether the pandemic has harmed the mental health of practicing urologists worldwide. Methods: Members of the Executive Board of the SIU designed a self-selected survey consisting of multiple-choice questions about the safety and mental health of urologists during the COVID-19 pandemic. The survey was disseminated by email to SIU members worldwide. Results: A total of 3448 SIU members from 109 countries responded to the survey, which sought to determine the extent of mental health symptoms, including depression, anxiety, insomnia, and distress—experienced during the COVID-19 pandemic. Overall, 21% of urologists who responded reported that their mental health was very challenged, with 58% indicating increased stress levels, and 15% indicating greatly increased stress levels. Older urologists were less likely to report any of the negative mental health symptom queried (ie, delirium [rs = −0.06, P = 0.001], psychosis [rs = −0.04, P = 0.019], anxiety [rs = −0.09, P < 0.001], depression [rs = −0.08, P 0.20). Furthermore, 29% of urologists indicated they were afraid to go to work, while 53% reported being afraid to go home to their families after work. Conclusion: In this worldwide survey of practicing urologists, more than half of the participants reported an increase in insomnia, distress, and other psychological symptoms as they managed patients during the COVID-19 pandemic, although half of respondents did not experience any mental health symptoms. Institutions should provide psychological coping resources to all health care staff, not only for the front-line workers during the pandemic.

INTRODUCTION: We sought to determine the possible predictors for effective insertion of the ureteral access sheath (UAS) during flexible ureteroscopy (fURS) in virgin ureters and their impact on postoperative ureteral wall injury and the procedural outcome. METHODS: A retrospective review of prospectively collected data was performed for all consecutive patients scheduled for fURS of virgin ureters at two tertiary care centers between 2018 and 2020. Demographics, stone characteristics, and perioperative data, including the configuration of the ureteral orifice (UO) over introductory guidewire insertion, were collected. Multivariate logistic regression was used to detect possible predictors of successful UAS insertion. RESULTS: In total, 128 patients who underwent primary fURS were included, with a mean age of 43.3±12.3 years and a stone burden of 12.3±6.9 mm. One hundred and ten patients (85.9%) achieved successful ureteral access insertion, including 81 (63.3%) without ureteral dilatation and 35 with dilation, of which 29 (22.7%) had a successful UAS afterward, while six failed. Total patients who underwent ureteral orifice dilatation were 35. 29 had a successful UAS afterward, while 6 failed. Patients who underwent successful UAS placement into virgin ureters were significantly older and had a lower body mass index (BMI). A tent-shaped UO over the guidewire led to successful UAS insertion. In multivariate regression analysis, cases with BMI

Background Renal artery aneurysm (RAA) is a rare condition, traditionally managed with endovascular or open surgical techniques. Objective To report our experience with robotic RAA repair. Design, setting, and participants Nine consecutive patients underwent intracorporeal robotic surgery for 10 RAAs. Surgical procedure Two patients underwent concomitant robotic partial nephrectomy. One patient had RAA in a solitary kidney. Median RAA diameter was 2.2 (1.8–3)cm. Intracorporeal transarterial hypothermic renal perfusion was performed in five patients. Robotic techniques included tailored aneurysmectomy and repair (n=5), excision with end-to-end anastomosis (n=2), aneurysmectomy with branch reimplantation (n=1), prosthetic interposition graft repair (n=1), and simple nephrectomy (n=1; this patient's data were excluded from analysis). Measurements Demographics, RAA characteristics, intraoperative techniques, perioperative outcomes, and follow up data were analyzed. Aneurysms were diagnosed by computed tomography, angiography, or incidentally during the performance of a partial nephrectomy. Results and limitations All cases were performed robotically, without conversion to open surgery. Median (range) operative time was 3.8 (3–6)h, warm ischemia time 26 (19–32)min, hypothermic renal perfusion time 34 (29–69)min, and estimated blood loss 100 (25–400)ml. No intraoperative blood transfusion was required. Median hospital stay was 3 (2–6)d. One patient had a Clavien-Dindo grade II complication. At median follow-up of 16 (2–67)mo, all patients had preserved renal function. Follow-up imaging confirmed normal caliber reconstructed renal arteries with globally perfused kidneys, except for two kidneys with small segmental infarcts due to an intentionally ligated small polar vessel. Limitations include the small number of patients and the retrospective nature of the study. Conclusions Robotic repair of complex RAAs is feasible. Surgical expertise, patient selection, and RAA-specific vascular reconstruction are critical for success. Greater experience is needed to evaluate the proper place of robotic repair of RAAs. Patient summary We report intracorporeal robotic repair for complex renal artery aneurysms. This robotic operation is feasible and safe, and replicates open principles. However, it requires considerable experience and expertise.

Objectives To compare the outcomes of bladder preservation therapy with early or deferred radical cystectomy (RC) in high-grade non-muscle invasive bladder cancer. Methods Prospectively collected data were obtained for patients undergoing transurethral resection of bladder tumor (TURBT) at a tertiary care center between 2007 and 2018. Patients with a high-grade tumor (HGT1) were divided into three groups, depending on the treatment plan: conservative (GI), early RC (GII), or deferred RC (GIII). Kaplan-Meier analysis was performed to assess the cancer-specific survival (CSS). Results Seventy-one patients were included, and the patients had a median (range) age of 49 (32-72) years. The GI, GII, and GIII groups included 34 (47.9%), 14 (19.7%), and 23 (32.4%) patients, respectively. A significantly lower number of GII patients underwent >2 TURBTs (14.3% vs. 100%, p

Objectives: To evaluate the general knowledge among primary health care (PHC) physicians regarding the management of common urological problems in Saudi Arabia. Methods : This is an observational prospective study, where a self-administered questionnaire was distributed to practicing PHC physicians in the western region of Saudi Arabia on January 2017. The questionnaire consisted of 21-item questions, inquiring about demographics and general urological knowledge and skills. The management of common urological problems was assessed by case scenarios for specific urological condition, including urethral catheterization, definition and evaluation of hematuria, recognition of age-specific increase in prostatic specific antigen (PSA), and management of lower urinary tract symptoms. Results : A total of 148 questionnaires were distributed, with a response rate of 75.7%, where 112 respondents completed the questionnaires, including 54.3% residents, 39% general practitioners, and 5.4% specialists. Fifty-seven percent of respondents were males and 68% were Saudi practitioners. A higher number of respondents expressed that they were able to catheterize a male than female patient (56.5% versus 34.3%). Only 6.4% of respondents defined microscopic hematuria accurately. Knowledge about hematuria, serum prostate specific antigen and overactive bladder was low in all groups. Apart from hematuria, seeking urological consultations was less than 35% for all other disease entities. Conclusion : Urological knowledge among PHC physicians seems to be insufficient. Significant percentages of the participants were unable to catheterize a female patient, did not know the definition of hematuria; and whether to ask for urological consultations in cases of hematuria, increased PSA, and overactive bladder. Saudi Med J 2019; Vol. 40 (5): 483-489 doi: 10.15537/smj.2019.5.24080 How to cite this article: Nassir AM, Baazeem A, Saada H, Elkoushy MA, Badr H, Bahuwyrith M, Melebari HA, Nasser J, Azhar RA. Urological knowledge among primary health care physicians in Saudi Arabia. Saudi Med J . 2019 May;40(5):483-489. doi: 10.15537/smj.2019.5.24080.

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.

Urinary bladder paragangliomas are rare with a reported incidence of

Radical prostatectomy is the gold standard in patients that are surgical candidates with localized prostate cancer. While most postoperative urine leaks are from vesico-urethral anastomosis, urologists must be aware that a small percentage of patients may have a urine leak from other sites that may have been inadvertently injured during the procedure. We propose a systematic workup to evaluate the source of the urinary leak as well as appropriate management of such injuries. The mid-ureter can be injured during lymph node dissection. The distal ureter is at risk of injury when performing the Montsouris approach. The posterior bladder neck dissection can at times be challenging. If not careful, one can easily cause an injury to the trigone and/or ureteral orifices. The most common site of leak is at the vesico-urethral anastomosis due to a non-watertight closure. The management of intraoperatively detected ureteral injuries require placement of a ureteral stent. The location, severity and type of injury determine the reconstruction required to fix it. Postoperatively urine leak can be frequently detected when assessing the pelvic drain, and imaging such as CT Urogram with a cystogram phase may be helpful in the diagnosis. Urine leak after robotic-assisted laparoscopic radical prostatectomy remains a rare complication, sometimes the diagnosis can be challenging, and management varies depending on the site and severity of injury.

Iatrogenic bladder injuries with intraperitoneal extravasations are standardly managed surgically. However, we are presenting a case of iatrogenic intraperitoneal bladder injury developing after a cesarean section that was managed successfully by conservative therapy after tapping and pigtail drainage of 14 days. On the next follow up, which was 14 days later, there was a complete resolution with no signs of injury. Therefore, the trial of conservative approach may prove beneficial to minimize the chances of any invasive interventions in such cases.

Purpose: To present multinational experience in robot-assisted radical prostatectomy (RARP) by fellowship-trained expertise in low-volume regions in Gulf Cooperation Council (GCC) countries and to ...

Objectives Tocreate and validate a translated Arabic version of the Expanded Prostate Cancer Index Composite for Clinical Practice (EPIC-CP), a validated patient-reported outcome (PRO) widely used for assessing the quality of life in patients with prostate cancer (PCa). Patients and Methods Using the established protocol as defined by the Professional Society for the Health Economics and Outcomes Research (ISPOR) for translating patient care questionnaires, a harmonised translated Arabic version of EPIC-CP was created. The questionnaire was tested in native Arabic speakers from four different Arabic countries (Saudi Arabia, United Arab Emirates, Jordan, and Kuwait). Cronbach’s alpha and interclass coefficient correlation (ICC) analyses were used to test the internal consistency and test–retest reliability, respectively. In addition, PCa characteristics were collected for participants. Results In total, 168 patients with PCa participated in the study (39 from Saudi Arabia, 23 from United Arab Emirates, 65 from Jordan, and 41 from Kuwait). In all, 52 (31%) participants repeated the questionnaire for test–retest reliability analysis. The median (interquartile range [IQR]) age of patients included in the study was 66 (61–71) years. The median (IQR) PSA level was 9.8 (6–19) ng/mL. Most patients had Grade Group 2 PCa at diagnosis (31%), clinical stage cT1 (42%), managed primarily by urology (79%), and the primary treatment was radical prostatectomy (71%). The total Cronbach’s alpha coefficient was 0.84 demonstrating an acceptable internal consistency. The total ICC was also acceptable at 0.64. Conclusion The Arabic version of the EPIC-CP is a reliable and valid tool for assessing health-related quality of life for Arabic patients with PCa.

PURPOSE OF REVIEW The current data on complications reporting related to robot-assisted procedures (RAPs) in the urology literature are not comparable and do not use a validated classification. In this review, findings from various studies reporting positive and negative outcomes will be outlined. RECENT FINDINGS Robotic procedures have outcomes similar to open and laparoscopic techniques but generally cause fewer adverse events. However, the lack of standards for presenting surgical morbidity related to RAP leads to underreporting of surgical complications, makes comparisons of surgical outcomes difficult and prevents adequate knowledge about the outcomes of procedures. SUMMARY Although a reasonable number of positive outcomes of RAP have been reported in the literature, the extent of underreporting with this process is unknown. Further research and the development of a validated classification for reporting surgical complications will facilitate a better understanding of the actual outcomes.

Objectives: To evaluate robot-assisted surgery (RAS) in Urology in the Middle East, and its status and future perspectives. Methods: A Medical Literature Analysis and Retrieval System Online (MEDLINE) search was performed using the following keywords: ‘robotics’, ‘robot-assisted surgery’, ‘laparoscopy’, at first with each specific procedure name, such as radical cystectomy, followed by ‘Middle East’ and country names. All abstracts and articles in English that adhered to the scope of the current issue were selected, giving special consideration to relevant landmark articles and those describing trends and the future of RAS in Urology. Results: Only a few index case reports characterised RAS in the Middle East. The Middle East possess only 1% of the da Vinci® Surgical Systems (Intuitive Surgical Inc., Sunnyvale, CA, USA) installed worldwide, including 19 in Saudi Arabia; six in Qatar; two in each of Kuwait and Lebanon; three in the United Arab Emirates; and only one in Egypt. The total number of RAS performed in the Middle East is low compared to Europe and the USA. Many countries in the Middle East still lack surgical robots despite having the expertise and appropriate caseload, whilst others seem not to utilise the surgical robot at a suitable rate, as reflected by the sparse number of operated cases and outgoing publications. There are major differences in RAS availability, usage, and perception according to the geographical place of practice and acceptance of robots by surgeons and patients. Conclusion: RAS in Urology continues to grow in the Middle East, with increasing caseloads and diversity of operated cases. Acceptance of robots by Middle East surgeons is significantly increasing. Abbreviations: 3D: three-dimensional; KSA: Kingdom Saudi Arabia;MIS: minimally invasive surgery; RAA: robot-assisted adrenalectomy; RAP: robot-assisted pyeloplasty; (O)(RA)PN: (open) (robot-assisted) partial nephrectomy; RAS: robot-assisted surgery; (O)(RA)RC: (open) (robot-assisted) radical cystectomy; (RA)RP: (robot-assisted) radical prostatectomy; SAUC: Sabah Al-Ahmad Urology Center

Ileal ureter formation has been found to be a suitable treatment option for long, chronic ureteral strictures not amendable to less invasive forms of repair. Minimally invasive surgical techniques for this condition have been investigated. We report the first series of robotic completely intracorporeal ileal ureter using a four-arm robotic technique. Three patients underwent this procedure, including one patient with a solitary kidney. All procedures were performed effectively with a median operative time of 450 minutes (range: 420–540) and median estimated blood loss of 100 mL (range: 50–200). Postoperatively, one patient suffered volvulus and subsequent necrosis of small bowel and ileal ureter, which required re-operation and small bowel resection, including the ileal ureter. The other two patients report no surgical complications to date. This early series represents preliminary technical procedure feasibility. Further experience is necessary.

Objectives: The objective of this study is to assess the current status of urologic robot-assisted surgery (RAS) in Saudi Arabia and evaluate perceptions of its importance and utility. Methods: A 59-item questionnaire was E-mailed to urologists and trainees in Saudi Arabia to assess the demographics and individual and institutional surgical practices of minimally invasive surgery (MIS) with a focus on RAS and urologic subtypes. Results: Ninety-five surveys were completed. Nearly 53%, 46%, and 21% of respondents were formally trained in laparoscopic surgery, MIS, and RAS, respectively. Forty percent had used a robot console during training. Nearly 72% of participants felt that RAS training should be included to accomplish their career goals and stated that it would strengthen the department academically and financially. The absence of a robotic system (45%) and administrative disinterest with lack of support (39%) were the most common deterrents. Robot-assisted radical prostatectomy (RARP), robot-assisted radical cystectomy (RARC), and robot-assisted radical nephrectomy (RARN) were regarded as the gold standard for 34%, 23%, and 17% of respondents, respectively. Respondents would recommend RARP (74%), RARC (50%), and RARN (57%) for themselves or their family. The greatest perceived benefits of RAS were its ease of use and improvement in the patient's quality of life. Conclusion: Urologists in Saudi Arabia recognize the superiority of RAS over traditional surgical methods but lack exposure, training, and access to RAS. This survey reveals increasing acceptance of RAS and willingness to incorporate the technology into practice.

Background. Oncocytomas are the second most common benign renal neoplasm but, unfortunately, they are difficult to differentiate from renal cell carcinoma. Renal oncocytomas are rare and have mostly been reported in adults. To our knowledge, this is only the sixth pediatric reported case of renal oncocytoma worldwide. Case Presentation. A 14-year-old Yemeni girl with a recurrent history of urinary tract infections came to our clinic complaining of left flank pain with a frontal headache. Ultrasound showed a 3 cm, well-defined echogenic lesion with mild vascularity. This lesion increased in size on her subsequent follow-ups. Computed tomography showed no intralesional fat, vessels invasion, or enlarged lymph nodes. The patient underwent laparoscopic radical nephrectomy, and a pathology report confirmed the diagnosis of renal oncocytoma. Conclusion and Recommendations. We present the rare occurrence of renal oncocytoma in a pediatric patient and highlight the importance of considering oncocytomas in the diagnosis of a renal mass.

Different patient positions are required during robotic surgery including supine, Trendelenburg, lithotomy, and lateral flank positions. However, each surgical position has its own implications for circulation, ventilation, and hemodynamics and may possibly expose patients to morbid adverse events particularly peripheral nerve and pressure-related injuries, including sciatic nerve injury, paresthesia, numbness, rhabdomyolysis of the thigh, and compartment syndrome. These positioning injuries are rare in robotic urological procedures but may be serious enough to cause severe morbidity. Therefore, it is crucial to consider the complications unique to different positions to avoid or minimize these possible risks and maintain patient safety. Exaggerated intraoperative lateral or Trendelenburg positions, prolonged operative time, male gender, high preoperative American Society of Anesthesiologists class, and increased body mass index, especially with large muscle mass, are well-documented risk factors for these positioning injuries. Therefore, thorough perioperative assessment and careful attention to appropriate patient positioning is crucial while considering the different risk factors which may predispose and aggravate these complications, especially in prolonged procedures and/or when extreme positioning is used.

Robotic-assisted simple prostatectomy has increased significantly in popularity in recent years as a treatment for benign prostatic hyperplasia. Compared to conventional techniques, the robotic-assisted technique allows greater tissue resection with less blood loss and shorter recovery time. However, urologists must be aware of the potential complications before, during, and after surgery, including vascular injury, infection, urinary complications, intestinal injuries, cardiovascular or thromboembolic events, and sexual dysfunction. Here we describe the prevention, risk factors, identification, and treatment of these complications.

To develop a robotic technique for exclusively transabdominal control of the suprahepatic, infradiaphragmatic inferior vena cava (IVC) to enable level 3 IVC tumor thrombectomy.Robotic technique was developed in three fresh, perfused-model cadavers. Preoperatively, inflow (right jugular vein) and outflow (left femoral vein) cannulae were inserted and connected to a centrifugal pump to establish a 10 mmHg pressure in the IVC for the water-perfused cadaver model. Using a five-port transperitoneal robotic approach, the falciform ligament was detached from the anterior abdominal wall toward its junction with the diaphragm and tautly retracted caudally; this adequately retracted the liver caudally as well. Triangular and coronary ligaments were incised, allowing ready visualization of suprahepatic/infradiaphragmatic IVC and right/left main hepatic veins. Under direct robotic visualization, IVC was circumferentially mobilized, vessel-looped, and controlled.All three robotic procedures were successfully completed transabdominally. Average robotic time to control the suprahepatic IVC was 37 minutes; in each case, the suprahepatic IVC was circumferentially controlled with a vessel-loop. There were no intraoperative complications. Length of the mobilized suprahepatic IVC measured between 2 and 3 cm. Right and left suprahepatic veins were clearly visualized in each case. Necropsy revealed no intra-abdominal/intrathoracic visceral or vascular injuries to the suprahepatic IVC, bilateral hepatic veins, or tributaries.We developed a novel robotic technique for transabdominal control of the suprahepatic infradiaphragmatic IVC in a perfused human cadaver model. This approach may extend the application of advanced robotic techniques for the performance of major vena caval, hepatic, and level 3 IVC renal tumor thrombus surgery.

PURPOSE: Multiparametric magnetic resonance imaging often underestimates or overestimates pathological cancer volume. We developed what is to our knowledge a novel method to estimate prostate cancer volume using magnetic resonance/ultrasound fusion, biopsy proven cancer core length. MATERIALS AND METHODS: We retrospectively analyzed the records of 81 consecutive patients with magnetic resonance/ultrasound fusion, targeted biopsy proven, clinically localized prostate cancer who underwent subsequent radical prostatectomy. As 7 patients each had 2 visible lesions on magnetic resonance imaging, 88 lesions were analyzed. The dimensions and estimated volume of visible lesions were calculated using apparent diffusion coefficient maps. The modified formula to estimate cancer volume was defined as the formula of vertical stretching in the anteroposterior dimension of the magnetic resonance based 3-dimensional model, in which the imaging estimated lesion anteroposterior dimension was replaced by magnetic resonance/ultrasound targeted, biopsy proven cancer core length. Agreement of pathological cancer volume with magnetic resonance estimated volume or the novel modified volume was assessed using a Bland-Altman plot. RESULTS: Magnetic resonance/ultrasound fusion, biopsy proven cancer core length was a stronger predictor of the actual pathological cancer anteroposterior dimension than magnetic resonance estimated lesion anteroposterior dimension (r = 0.824 vs 0.607, each p

Objectives To assess the feasibility of a novel percutaneous navigation system (Translucent Medical, Inc., Santa Cruz, CA, USA) that integrates position-tracking technology with a movable tablet display. Materials and Methods A total of 18 fiducial markers, which served as the target centres for the virtual tumours (target fiducials), were implanted in the prostate and kidney of a fresh cadaver, and preoperative computed tomography (CT) was performed to allow three-dimensional model reconstruction of the surgical regions, which were registered on the body intra-operatively. The position of the movable tablet's display could be selected to obtain the best recognition of the interior anatomy. The system was used to navigate the puncture needle (with position-tracking sensor attached) using a colour-coded, predictive puncture-line. When the operator punctured the target fiducial, another fiducial, serving as the centre of the ablative treatment (treatment fiducial), was placed. Postoperative CT was performed to assess the digitized distance (representing the real distance) between the target and treatment fiducials to evaluate the accuracy of the procedure. Results The movable tablet display, with position-tracking sensor attached, enabled the surgeon to visualize the three-dimensional anatomy of the internal organs with the help of an overlaid puncture line for the puncture needle, which also had a position-tracking sensor attached. The mean (virtual) distance from the needle tip to the target (calculated using the computer workstation), was 2.5 mm. In an analysis of each digitalized axial component, the errors were significantly greater along the z-axis (P < 0.01), suggesting that the errors were caused by organ shift or deformation. Conclusion This virtual navigation system, integrating a position-tracking sensor with a movable tablet display, is a promising advancement for facilitating percutaneous interventions. The movable display over the patient shows a preoperative three-dimensional image that is aligned to the patient. Moving the display moves the image, creating the feeling of looking through a window into the patient, resulting in instant perception and a direct, intuitive connection between the physician and the anatomy.

Urological fistulas are an underestimated problem worldwide and have devastating consequences for patients. Many urological fistulas result from surgical complications and/or inadequate perinatal obstetric healthcare. Surgical correction is the standard treatment. This article reviews minimally invasive surgical approaches to manage urological fistulas with a particular emphasis on the robotic techniques of fistula correction.In recent years, many surgeons have explored a minimally invasive approach for the management of urological fistulas. Several studies have demonstrated the feasibility of laparoscopic surgery and the reproducibility of reconstructive surgery techniques. Introduction of the robotic platform has provided significant advantages given the improved dexterity and exceptional vision that it confers.Fistulas are a concern worldwide. Laparoscopic surgery correction has been developed through the efforts of several authors, and difficulties such as the increased learning curve have been overcome with innovations, including the robotic platform. Although minimally invasive surgery offers numerous advantages, the most successful approach remains the one with the surgeon is most familiar.

Purpose of review Partial nephrectomy provides equivalent long-term oncologic and superior functional outcomes as radical nephrectomy for T1a renal masses. Herein, we review the various vascular clamping techniques employed during minimally invasive partial nephrectomy, describe the evolution of our partial nephrectomy technique and provide an update on contemporary thinking about the impact of ischemia on renal function. Recent findings Recently, partial nephrectomy surgical technique has shifted away from main artery clamping and towards minimizing/eliminating global renal ischemia during partial nephrectomy. Supported by high-fidelity three-dimensional imaging, novel anatomic-based partial nephrectomy techniques have recently been developed, wherein partial nephrectomy can now be performed with segmental, minimal or zero global ischemia to the renal remnant. Sequential innovations have included early unclamping, segmental clamping, super-selective clamping and now culminating in anatomic zero-ischemia surgery. By eliminating ‘under-the-gun’ time pressure of ischemia for the surgeon, these techniques allow an unhurried, tightly contoured tumour excision with point-specific sutured haemostasis. Recent data indicate that zero-ischemia partial nephrectomy may provide better functional outcomes by minimizing/eliminating global ischemia and preserving greater vascularized kidney volume. Summary Contemporary partial nephrectomy includes a spectrum of surgical techniques ranging from conventional-clamped to novel zero-ischemia approaches. Technique selection should be tailored to each individual case on the basis of tumour characteristics, surgical feasibility, surgeon experience, patient demographics and baseline renal function.

Background Conventional systematic biopsy has the shortcoming of sampling error and reveals “no evidence of cancer” with a rate of >50% on active surveillance (AS). The objective of this study is to report our initial experience of applying a 3D-documented biopsy-mapping technology to precisely re-visit geographically documented low-risk prostate cancer and to perform serial analysis of cell-cycle-progression (CCP) gene-panel. Methods Over a period of 40 months (1/2010–4/2013), the 3D-biopsy-mapping technique, in which the spatial location of biopsy-trajectory was digitally recorded (Koelis), was carried out. A pair of diagnostic (1st-look) and surveillance (2nd-look) biopsy were performed per subject (n = 25), with median interval of 12 months. The documented biopsy-trajectory was used as a target to guide the re-visiting biopsy from the documented cancer focus, as well as the targeted field-biopsy from the un-sampled prostatic field adjacent to negative diagnostic biopsies. The accuracy of re-visiting biopsy and biopsy-derived CCP signatures were evaluated in the pair of the serial biopsy-cores. Results The 1st-look-biopsy revealed a total of 43 cancer lesions (1.7 per patient). The accuracy of re-visiting cancer was 86% (37/43) per lesion, 76% (65/86) per core, and 80% (20/25) per patient. This technology also provided an opportunity for 3D-targeted field-biopsy in order to potentially minimize sampling errors. The CCP gene-panel of the 1st-look (−0.59) versus 2nd-look (−0.37) samples had no significant difference (P = 0.4); which suggested consistency in the molecular signature of the known cancer foci during the short-time interval of median 12 months. Any change in CCP of the same cancer foci would be likely due to change in sampling location from the less to more significant portion in the cancer foci rather than true molecular progression. The study limitations include a small number of the patients. Conclusion The 3D-documented biopsy-mapping technology achieved an encouraging re-sampling accuracy of 86% from the known prostate cancer foci, allowing the serial analysis of biopsy-derived CCP signatures. Prostate 75:863–871, 2015. © 2015 Wiley Periodicals, Inc.

During enucleative partial nephrectomy excision is performed adjacent to the tumor edge. To better determine the oncologic propriety of enucleative partial nephrectomy we histologically examined the tumor-parenchyma interface.Archived hematoxylin and eosin stained slides of 124 nephrectomy specimens were rereviewed. We evaluated representative sections of tumor abutting the renal parenchyma and overlying pseudocapsule/perirenal fat were selected at 4 mm(2) sectors apportioned 1, 2, 3 and 4 mm, respectively, from the tumor edge.Median tumor size was 3.5 cm. Of the tumors 111 were malignant (90%) and 119 (96%) had a pseudocapsule with a median thickness of 0.6 mm. Of malignant and benign tumors 82% and 31%, respectively, had an intrarenal pseudocapsule (p0.001). Pseudocapsule invasion was noted in 45% of cancers and 15% of benign tumors (p0.04). Of pT1a cancers 36% showed intrarenal pseudocapsule invasion. No patient had positive surgical margins. Intrarenal pseudocapsule invasion correlated with clear cell renal cell carcinoma histology but not with cancer size, grade, necrosis or margin width. Inflammation, nephrosclerosis, glomerulosclerosis and arteriosclerosis decreased with increasing distance from the tumor edge. At 1 mm changes were moderate to severe in 38%, 32%, 20% and 17% of tumors while at 5 mm changes were mild in 2.5%, 0.8%, 0.8% and 4%, respectively (p0.001). Mean arteriolar diameter decreased with tumor proximity (p0.0001).Most renal cancers have an intrarenal pseudocapsule. Partial nephrectomy excision adjacent to the tumor edge appears to be histologically safe. Because 18% of cancers lacked a discernible intrarenal pseudocapsule and 25% of pT1a cancers showed intrarenal pseudocapsule invasion, extreme care is needed to avoid positive margins during enucleative partial nephrectomy.

To determine the feasibility and develop a robotic technique for intracorporeal implantation of a biodegradable tubular scaffold seeded with adipose-sourced smooth muscle cells (Neo-Urinary-Conduit) that, when implanted as a conduit for urinary diversion, facilitates regeneration of native-like neourinary tissue.Robotic NUC implantation was performed in two fresh male cadavers. The greater omentum was widely detached from the greater curvature of the stomach, in preparation for final wrapping of the conduit. Bilateral ureters were mobilized for implantation. The NUC, with two precreated ureteral openings, was inserted into the abdomen. Bilateral, stented uretero-NUC anastomoses were created. The NUC was circumferentially wrapped with the predissected omentum, exteriorized through the abdominal wall, and maturated.Both procedures were successfully completed intracorporeally. Operative time for NUC implantation was 90 and 100 minutes, respectively. Examination of gross anatomy showed no injury to other organs. There was no omental kinking, rotation, eversion, or stripping from the NUC. Bilateral stents were confirmed to be in situ with the proximal coil in the kidney. Uretero-NUC anastomoses and omentum were tension free. The entire NUC, including its distal edge and posterior aspect, was circumferentially wrapped 360 degrees.We demonstrated the feasibility and developed a robotic technique for intracorporeal implantation of a biodegradable regenerative urinary conduit. This study serves as the foundation for the robotic surgical technique before the clinical application.

Surgical complications are related to the learning curve of the surgeon and, in particular, the first 30 surgical cases, in which the rate of major complications reaches 30%. However, this rate decreases to 20% in the first 50 cases and 6% once the surgeon has performed 200–250 cases. It has been noted that surgeons with experience in previous laparoscopic surgery have no such associated rate of complications.

In this chapter we provide an overview on strategies and techniques to manage hemorrhagic complications during and after laparoscopic urologic surgery. Preparing for these complications is crucial as accidents could occur at any time. Several tips are provided on the basis of evidence from the literature as well as authors’ own experience. Proper patient selection, the experience of the surgeon, meticulous attention to detail and knowledge of the potential complications that are associated with each procedure are the most important factors in minimizing vascular complications.

Objective: To study the effect of Saudi medicinal plant in stress-induced cystitis in experimental rats. Materials and Methods: Seventy-two female Sprague Dawley rats (200–250 g) were divided into eight groups of 9 rats each. Group 1 and 2 are controls assigned nonstressed and stressed, respectively. Other six groups received different treatments for 2 weeks. After the 14 days of treatment, each group was exposed to water-immersion restraint stress (WIRS) for 30 min. Blood samples were collected to measure the corticotropin-releasing hormone (CRH) and adrenocorticotropic hormone (ACTH) levels. The rats were sacrificed, and their urinary bladders were isolated immediately for a histological and immunohistochemical examination. Results: Rats exposed to WIRS had lesions in the urinary bladder, with a significant increase in plasma CRH and ACTH levels in comparison to the nonstressed controls. Bladder cut sections in stressed rats showed no gross structural abnormality in smooth muscle and connective tissue ratio. There were noticeable variations in mast cell (MC) infiltration and activity with a loss of more than 20% of cellular staining and a significant increase in the number of red blood cell-filled blood vessels. Our findings showed that supplementation of Olea europaea leaf extract (OEE) or Juniperus procera leaf extract (JPE) reduced the MC infiltration and significantly reduced stress hormones compared to the stressed controls. Conclusions: The present study demonstrated that OEE/JPE alone and their combination have a potential protective effect against stress-induced cystitis in rats. The underlying mechanism of the present study also resulted in a decrease in CRH and ACTH stress hormones.

Introduction. Calyceal diverticular stones are uncommon findings that represent a challenge in their treatment, due to the technical difficulty in accessing the diverticulum, and the high risk of their recurrence. Current percutaneous technique for calyceal diverticular stones involves establishing a renal access, clearing the stone, and fulguration of the diverticular lining with a roller-ball cautery electrode using hypotonic irrigation solution such as sterile water or glycine solution which may be associated with the absorption of hypotonic fluids with its inherent electrolyte disturbances.Case Report. In this paper, we present for the first time percutaneous holmium laser fulguration of calyceal diverticula in 2 patients using normal saline. Their immediate postoperative sodium was unchanged and their follow-up imaging showed absence of stones. Both patients remain asymptomatic at 30 months post-operatively.Conclusion. This demonstrates that holmium laser is a safe alternative method to fulgurate the calyceal diverticulum after clearing the stone percutaneously.

Percutaneous nephrolithotomy (PCNL) in the prone position is associated with a 0.1% risk of colon injury, yet there have not been any reported cases of colon injury with supine PCNL. The aim of the present study was to prospectively compare CT scans of patients performed in both supine and prone positions on bolsters.Sixteen consecutive patients (mean age 55, 12 men) with 19 renal units (3 bilateral) who presented for PCNL underwent preoperative supine (without bolsters) and prone (with bolsters) noninfused CT scans. Axial images through lower pole calices containing stones necessitating percutaneous access were then analyzed. Percutaneous access was planned based on both supine and prone CT scans. Skin-to-stone distance (cm), angle of the percutaneous tract to the anterior-posterior axis (degrees), and visceral organ-to-tract distance (cm) were measured.Visceral organ-to-tract distance was significantly shorter in the prone position when compared with the supine position (2.8 cm vs 3.5 cm, P=0.04). In three renal units, visceral organ-to-tract distance in the prone position was less than 0.4 cm. Furthermore, the prone position was associated with significantly shorter skin-to-stone distance (7.6 cm vs 9.0 cm, P=0.0005) and significantly wider angles (40 degrees vs 35 degrees, P=0.02). Small sample size and simulation of the percutaneous access tract are two limitations of the present study.When prone PCNL is contemplated, preoperative planning CT scans that are performed in the prone position with bolsters provide better preoperative assessment of colon-to-percutaneous renal tract distance.

Enhanced Recovery after Surgery (ERAS) programs are multimodal care pathways that aim to decrease intra-operative blood loss, decrease postoperative complications, and reduce recovery times.To overview the use and key elements of ERAS pathways, and define needs for future clinical trials.A comprehensive systematic MEDLINE search was performed for English language reports published before May 2015 using the terms "postoperative period," "postoperative care," "enhanced recovery after surgery," "enhanced recovery," "accelerated recovery," "fast track recovery," "recovery program," "recovery pathway", "ERAS," and "urology" or "cystectomy" or "urologic surgery."We identified 18 eligible articles. Patient counseling, physical conditioning, avoiding excessive alcohol and smoking, and good nutrition appeared to protect against postoperative complications. Fasting from solid food for only 6h and perioperative liquid-carbohydrate loading up to 2h prior to surgery appeared to be safe and reduced recovery times. Restricted, balanced, and goal-directed fluid replacement is effective when individualized, depending on patient morbidity and surgical procedure. Decreased intraoperative blood loss may be achieved by several measures. Deep vein thrombosis prophylaxis, antibiotic prophylaxis, and thermoregulation were found to help reduce postsurgical complications, as was a multimodal approach to postoperative nausea, vomiting, and analgesia. Chewing gum, prokinetic agents, oral laxatives, and an early resumption to normal diet appear to aid faster return to normal bowel function. Further studies should compare anesthetic protocols, refine analgesia, and evaluate the importance of robot-assisted surgery and the need/timing for drains and catheters.ERAS regimens are multidisciplinary, multimodal pathways that optimize postoperative recovery.This review provides an overview of the use and key elements of Enhanced Recovery after Surgery programs, which are multimodal, multidisciplinary care pathways that aim to optimize postoperative recovery. Additional conclusions include identifying effective procedures within Enhanced Recovery after Surgery programs and defining needs for future clinical trials.