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Introduction Advancements in radiological imaging technology have increased the discovery of adrenal incidentalomas. Large adrenal tumors (LATs) are not common, and the likelihood of malignancy increases with tumor size. LATs were defined as tumors larger than four centimeters (cm) with various pathologic diagnoses. Traditionally, open adrenalectomy was considered the gold standard for LATs, but with recent advancements in minimally invasive surgery (MIS), optimum perioperative and long-term outcomes are achievable by the MIS approach. The findings presented in this paper show that even large adrenal masses measuring up to 21 centimeters can be safely removed using a minimally invasive approach. Methodology After Institutional Review Board (IRB) approval, we reviewed medical records of adult patients who had adrenalectomies at two Saudi Arabian centers from January 2013 to February 2023. Inclusion criteria were laparoscopic or robotic adrenalectomy and adrenal lesions ≥5cm. Pediatric patients and those with open adrenalectomies were excluded. Pre-surgery, patients had imaging studies to assess mass characteristics. Pheochromocytoma patients received a 2-week adrenergic blocker treatment. Perioperative data including demographics, comorbidities, mass characteristics, surgery details, and follow-up were analyzed using SPSS-23. Patients provided informed consent and had follow-up appointments and imaging. Results Our experience involved 35 patients, 29 of whom received laparoscopic treatment and six of whom underwent robotic surgery. Of the 35 patients, more than half were females (57.1%), with a mean age of 41.7±14.9 years, the youngest and oldest participants being 16 and 73 years of age, respectively. The mean body mass index (BMI) of the participants was in the overweight range (26±6.0 kg/m2). The most common mode of presentation was incidental (42.9%), followed by hypertension (17.1%). Most patients had right-sided adrenal gland involvement (48.6%), with only four patients showing bilateral involvement. Most of the patients were classified as American Society of Anesthesiology score (ASA) 2 (40.0%) or ASA 3 (40.0%). Most of the patients were diagnosed with myelolipoma or adenoma (22.9% each) followed by pheochromocytoma (17.1%). The average estimated blood loss (EBL) was 189.3±354.6 ml for patients who underwent laparoscopic surgery and 80.0 ±34.6 ml for patients who underwent robotic surgery. The average operative room time (ORT) was 220.1±98.7 minutes (min) for laparoscopic surgery and 188.3±10.3 min for robotic surgery. One patient had to be converted from laparoscopic to open surgery due to aortic injury. The average length of stay (LOS) was 9.5±6.7 days for laparoscopic treatment and 5.5±1.9 days for robotic surgery. The mean tumor size in the greatest dimension was 8.0±4.4 cm. Only one patient who underwent unilateral laparoscopy experienced perioperative complications and converted to open surgery; nine patients who underwent unilateral laparoscopy required blood transfusion, and none of the patients who underwent robotic surgery required transfusion. None of the 35 patients experienced a recurrence of their adrenal disease during the mean follow-up period which lasted around 58 months. Conclusion MIS in Saudi Arabia is growing and is a safe method for LATs, with satisfactory surgical results compared to the traditional open surgery approach. It offers advantages in terms of EBL, complications, and disease recurrence.
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Objectives: Double J (DJ) stent is widely used in cases of ureteric strictures as a temporary solution; however, it has certain limitations, such as the need for frequent exchange. Alternatively, a long-lasting thermoexpandable stent (Memokath™ 051) has been used to relieve ureteral obstructions in comorbid patients with multiple reported advantages, such as longer durability which avoids the need of frequent exchanges. In addition, it can be used in certain cases of urethral strictures. Our study is the first in the region to report the experience and outcome of Memokath stent with ureteral and urethral strictures. Materials and Methods: After local IRB approval, we retrospectively reviewed records of 21 patients who underwent insertion of Memokath 051 stent in the ureter and Memokath 045 in the urethra between 2013 and 2021. Indications of insertion, indwelling duration, and causes of removal were collected and analyzed by SPSS. Results: Twenty-one patients received 21 Memokath stents for 11 ureteral strictures and 10 urethral strictures. Fifty-five percent of ureteral strictures were malignant, and 27.3% of the benign ureteric strictures were transplant ureters. Ureteric memokath stents remained functioning for a mean of 16.1 months. Mean indwelling time for transplant ureteric memokath stents was 24.3 months. Total 4 ureteric stents had migrated, 4 stents blocked, and 2 stents were removed as planned and 1 stent removed due to febrile urinary tract infection (UTI). Ten urethral stents remained in place for mean of 14 months. Three stents were removed as planned with resolution of stricture, two were removed due to blockage, three stents had UTI, one was removed due to pain, and one stent remained functioning until the patient expired. Conclusion: Our outcome is comparable to other published studies, suggesting that ureteric Memokath stent is a better option with adequate indwelling time, especially in transplant ureters, in comparison with DJ stents. In addition, Memokath stents can be used in selected recurrent urethral strictures where surgical reconstruction is not feasible.
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Background: In men under the age of 35 years, testicular cancer is the most prevalent solid tumor. Additional treatment is necessary for many people with nonseminomatus germ cell tumors (NSGCTs). Whether in conjunction with chemotherapy or as a stand-alone procedure, retroperitoneal lymph node dissection (RPLND) continues to play a critical role in the treatment of these patients. There is a lack of information in Saudi Arabian literature about the long-term oncologic outcome of NSGCT following RPLND surgery. Objective: The study's goals were to identify clinical and pathological characteristics related with long-term survival following NSGCT for RPLND, as well as to assess the surgical and oncological results of this treatment. Methodology: From January 2010 to April 2021, nine adults who had had orchidectomy for testicular cancer and RPLND following treatment for the evidence of persistent NSGCT disease at our hospital were included in this retrospective research. Demographic information, laboratory results, radiological findings, staging, chemotherapy and radiotherapy status, surgical procedure details, perioperative problems, morbidity, and mortality were all acquired from patients' medical records. Rates of disease return and overall survival. SPSS was utilized for the data analysis. Results: During the study period, nine patients with NSGCT underwent RPLND, with a mean age of 28 years (5.4: standard deviation). The most common diseases were yolk sac and embryonal cell cancer. In addition to receiving neoadjuvant chemotherapy, all patients had a Clavien-Dindo score of 2, and there was no mortality after RPLND. Overall median survival time was 26, and disease-free survival time was 21 months. Overall survival at 1 year was 86%, and at 5 years, it was 66%. The prognosis of embryonal cell cancer was more optimistic than that of a tumor of the yolk sac. Conclusion: We have shown that RPLND has an extremely low rate of morbidity and postoperative problems. In terms of oncology, it results in adequate overall and disease-free survival rates, with low morbidity and postoperative complications.
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Chylous ascites is a form of peritoneal fluid accumulation that can arise from trauma or lymphatic obstruction. In this report, we present the first case of chylous ascites following laparoscopic donor nephrectomy in our high-volume kidney transplant center. The patient presented to the emergency department three weeks post-procedure with complaints of abdominal distention and discomfort, accompanied by constipation and nausea. Radiological confirmation of ascites was followed by paracentesis, which yielded 20 mL of milky fluid that was analyzed and confirmed as chylous ascites. A subsequent pigtail drain was inserted, resulting in a total drainage of 4 L of fluid. Chylous ascites is a rare complication of abdominal surgeries, with higher body mass index and the American Society of Anesthesiologists physical status score system being significant risk factors. Conservative management involving diet modification is the initial therapy, with percutaneous drainage or more aggressive surgical interventions considered if conservative measures are not effective, with high success rates reported for these interventions. Here, we report a case of chylous ascites following donor nephrectomy as the first case reported from our region.
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Ureteric strictures are a relatively uncommon complication following renal transplant, which may be managed endoscopically or surgically by repairing the stricture. Extra-anatomical bypass is a useful procedure in complex cases that bypasses the ureter by creating a subcutaneous route, although it is uncommonly used given its rare indication. We report a case of renal transplant ureteric stricture, in which we utilized a modified extra-anatomical stenting technique with a Detour® stent to avoid the fibrotic planes surrounding the lateral aspect of the kidney graft.
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Angiomyolipomas (AML), also known as hamartomas, are benign mesenchymal tumors of the kidneys which consist of vascular tissue, smooth muscles, and adipose tissue, with a higher prevalence in females than males. AML may be associated with tuberous sclerosis, and the growth of the mass may present as hematuria or flank pain. We present a case of a 14-year-old female patient who had a known case of tuberous sclerosis since early childhood. She has a history of numerous bilateral renal masses radiographically consistent with AML. A special and unique entity of our case is the age of presentation which is 14 years and the presence of TSC. In contrast to our case, which was invading the right renal vein and IVC at a young age, AML is well known for its benign nature. According to a recent literature review, the youngest patient reported was 16 years old. Typically, non-complicated AMLs less than 4 cm in size are managed by annual radiological imaging which is preferably a CT scan, while larger AMLs of more than 4 cm that present with perinephric hemorrhages or intralesional aneurysms are treated by partial nephrectomy or selective angioembolization. A radical nephrectomy and IVC thrombectomy are typically necessary due to the risks that the IVC thrombus carries as well as the AML itself and its unpredictable behavior. In cases like ours with the extension into the renal vein and IVC, the surgical approach is similar to the venous invasion of renal cell carcinomas.
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Objective: To determine the nature of adrenal pathology in patients undergoing adrenalectomy in Saudi Arabia over the last decade and compare it with the literature. We compared perioperative outcomes between minimally invasive adrenalectomy (MIA) and open adrenalectomy (OA). Methods: This retrospective study included patients who underwent adrenalectomy at five tertiary care centers in Saudi Arabia from 2010 to 2020. We collected patients' baseline and perioperative characteristics and detailed hormonal evaluation of adrenal masses. Results: Among 160 patients (mean age 44 ± 14.5 years; mean BMI 29.17 ± 5.96 kg/m2), 84 (51.5 %) were men and 51.5 % had left-sided adrenal masses. The mean tumor size was 6.1 ± 4.2 (1.0-19.5) cm, including 60 (37.5 %) incidentalomas and 65 (40.6 %) functioning masses. Histopathology revealed 74 (46.2 %) adenomas and 24 (15 %) cancers or metastases from other primary organs; 20 %, 8.8 %, and 2.5 % of patients had pheochromocytoma, myelolipoma, and 2.5 % ganglioneuroblastoma, respectively. MIA and OA were performed in 135 (84.4 %) and 21 (15.6 %) patients, respectively. Adrenalectomy was increasingly performed over three equal periods in the last decade (17.5 % vs 34.4 % vs 48.1 %), with increasing numbers of MIAs to replace OAs. OA patients had larger tumors and needed blood transfusion more frequently (47.6 % vs 10.8 %, p< 0.001). MIA was significantly associated with shorter operative time, shorter length of stay, and less blood loss. Postoperative complications occurred in 10 (6.2 %) patients and were significantly higher for OA (24 % vs 3.0 %, p< 0.001). Conclusions: The majority of adrenal masses are benign. Herein, the observed functional and perioperative outcomes were comparable to those of available meta-analyses.
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Inflammatory myofibroblastic tumor (IMT) is a rare type of tumor composed mainly of fibroblastic and myofibroblastic spindle cells, with an inflammatory infiltrate of lymphocytes, plasma cells, and eosinophils. IMT may arise from different organs and sites, but it is infrequent to arise from the urinary bladder and usually manifests as hematuria. We report a case of a 24-year-old pregnant woman who presented to our hospital with gross hematuria. After further workup, we concluded that she had this extremely rare tumor, which was resected eventually with a partial cystectomy. Although the diagnosis of these kinds of tumors is usually made by anaplastic lymphoma kinase (ALK) using immunohistochemistry and detecting ALK gene translocation using fluorescence in situ hybridization (FISH), they were negative in our study; hence, we relied mainly on the morphological features of the tumor for the diagnosis.
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Objectives: The present study explores how young urologists in Saudi Arabia are adopting social media as a learning tool and how this new development is shaping as far as learning is concerned. Methods: A 18-item online survey via survemonkey.com was conducted. The survey was distributed through email in Saudi Arabia. The survey targeted young urologists and urology residents. The survey design and distribution was performed according to CHERRIES guidelines. Due to the quantitative nature of study data, SPSS software was used to analyze collected data. Results: A total of 104 young Saudi urologists responded to our survey. Participants were mostly familiar with the use of Twitter (86%), followed closely by YouTube (82%) and then Snapchat and Instagram (73% and 63%, respectively), a large portion (72%) of participants believe that social media has a moderate-to-high influence on their urology knowledge, YouTube was by far the most used source to watch and understand surgical skills, followed by reference books and websites, respectively. Conclusion: Social media has contributed to the spread of medical information among urology community and outside the urology community as well, with easier spread of medical knowledge to all involved by using social media, an extensive impact is achieved to both physicians and patients as well. For future work, this study should be conducted again, to monitor and compare the progression of usage among urologists.
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Double-J (DJ) stents are integral tools in the hands of urologists. Nonetheless, it might be associated with significant complications. Forgotten DJ stent is a commonly encountered problem. Herein, we present a case of a 42-year-old female patient who presented with extensively encrusted bilateral DJ stents, with bulky stones and encrustations at the entire course of the DJ stents on both sides. They were inserted 4 years ago with no follow-up. Multimodal endourological techniques were tailored to manage this difficult case. Cystolithotripsy, endoscopic combined intrarenal surgeries, and spontaneous bilateral endoscopic surgery were required to render her stone free.
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Introduction: Myxoma is a rare benign kidney tumor. Only 18 cases have been described in the literature. We report a new case of renal myxoma that arises from the renal parenchyma. Case presentation: A 56-year-old man, medically free, presented complaining of intermittent vague left-side abdominal pain for 1 year, otherwise no history of gross hematuria or lower urinary tract symptoms. Clinical examination revealed a soft, non-tender abdomen. All laboratory investigations were within normal. Abdominal and pelvic computed tomography scan with contrast revealed a large mass located in the upper pole of left kidney with the possibility of renal cell carcinoma. A laparoscopic-assisted left robotic radical nephrectomy was performed. Microscopic examination revealed renal myxoma. Conclusion: Renal myxoma is a very rare benign kidney tumor with excellent prognosis. Considering its rarity, it is important to recognize this entity to avoid diagnostic errors with other neoplasms with prominent myxoid features.
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Phaeochromocytoma (PHEO) is a neoplasm that arises from chromaffin cells present in the adrenal medulla. The counterpart of the PHEO extra-adrenal is termed paraganglioma (PGL). The urinary bladder PGL is a rare tumour, and it accounts for less than 0.06% of all bladder tumours. In this report, we discuss a case of a young female who presented with symptoms of headache, dizziness, palpitations, and high blood pressure. After workup, she was diagnosed with concurrent urinary bladder PGL and adrenal PHEO, and the genetic study of the whole exon sequence indicated the presence of succinate dehydrogenase-B (SDHB) mutation. Both tumours were treated surgically; however, the patient ultimately developed recurrence, rapid progression, and metastasis. All secondary modalities were unsuccessful, and the patient was referred for palliative treatment and eventually lost to follow-up. PGL should be included in the differential diagnosis of bladder tumours, and testing for SDHB gene mutations should be considered in all urinary PGLs. Therefore, these patients need follow-up and genetic counselling.