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   Table of Contents - Current issue
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April-June 2021
Volume 13 | Issue 2
Page Nos. 89-198

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ORIGINAL ARTICLES  

“Tele-urology“: Is the COVID-19 pandemic a wake-up call? p. 89
Raed Almannie, Mana Almuhaideb, Meshari Alzahrani, Saleh Binsaleh, Fahad Alyami
DOI:10.4103/UA.UA_133_20  
Background: The purpose of this research is to measure the current use of telemedicine technologies among urologists, their readiness to adopt the same, and to assess the barriers preventing such usage. Methods: Two hundred and twenty eight board-certified urologists completed our self-designed survey. An analysis was done to assess the increase in the use of telemedicine and the urologists' telemedicine experience responses. Data analysis was done using SPSS software. Results: There has been a tremendous increase in the use of telemedicine among urologists during the coronavirus disease (COVID-19) pandemic. Most of the respondents of this study performed general urology as part of their daily practice (59.6%). Prior to the pandemic, 53.9% of the participants had never used any means of telemedicine. However, during the pandemic, 72.4% of urologists who had never used telemedicine began using the same. Almost all of the respondents agreed that physical examination is difficult when using telemedicine, which resulted in the highest mean value among the questionnaire items. Urologists below 35-year-old agreed, to a larger extent, that telemedicine saves them more time and is simple to use than urologists from other age groups. Conclusion: During the COVID-19 pandemic, most urologists adopted telemedicine technology rapidly. Adopting telemedicine in the future could have multiple advantages. However, the limitations of telemedicine should be respected in order to avoid compromising patient safety.
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Current surgical procedures for benign prostatic hyperplasia and impression of new surgical modalities p. 95
Abdullah M Al Khayal, Faisal K Balaraj, Turki A Alferayan, Khalid A Alrabeeah, Saad M Abumelha
DOI:10.4103/UA.UA_75_20  
Background : Surgery is considered the most effective treatment for Benign prostatic hyperplasia (BPH) and Transurethral resection of prostat (TURP) is considered the gold standard. The goal of this study is to assess the surgical interventions used in Saudi Arabia, the difference in surgical procedures done depending on age and years of experience and the participant's impression on the new modalities in the management of BPH. Methodology : An online survey using Google Forms was sent to the participants. The data were collected during Saudi Urological Association Annual Meeting February 2019. Additional data were gathered 2 months later. The study was closed in May 2019. No incentives were provided to participants. Results : A total of 65 (54.1% response rate) urologist participated in the survey, of whom 41.5% of respondents were aged <40 years, while 40% of them aged between 40 and 60 years. Forty-seven (72.3%) out of 65 were consultants. The essential investigations used by most participants prior to surgical interventions are prostate specific antigen, urine culture, urinalysis, and abdominal ultrasound. The most used surgical interventions are unipolar transurethral resection (TURP), Bipolar TURP, and open prostatectomy. About 50% of respondents preferred open prostatectomy for prostate size above 100 g. In general, 40%–50% of participants believe that urethral lift, Rezum, Aquablation, prostate artery embolization, and robotic simple prostatectomy are useful options. Conclusion : TURP continues to be the main intervention for prostate sizes <100 g. Open prostatectomy is widely used intervention for prostate sizes more than 100 g. New modalities gained little acceptance among urologist practicing in Saudi Arabia. Hands on workshops may help in educating urologists and introduce these new modalities for the future use.
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Histopathological diagnoses and patterns in transrectal ultrasound-guided prostatic biopsy series from a large tertiary care center in Saudi Arabia Highly accessed article p. 101
Ali A Alsulihem, Muaiqel Al-Muaiqel, Abdulrahman Alsunbul, Abdulrahman Bin Jawhar, Abdullah Al-Dughaiman, Khalid K Bedaiwi, Sami Al-Rashidi, Faris Al-Harbi, Hosam S El-Tholoth, Mohammad Al-Hagbani, Bader Milibary, Abdullah M Alghamdi
DOI:10.4103/UA.UA_78_20  
Aim: The aim of the study was to report our transrectal ultrasound (TRUS)-guided prostatic biopsy histopathological diagnoses and clinical findings in our prostate cancer patients in a tertiary care center. Methods: We have reviewed our TRUS biopsy series done in our department from January 2011 to December 2016. We reviewed our patient's prebiopsy prostate-specific antigen (PSA) findings and the histopathological diagnoses and determined the clinical and pathological features of prostate cancer patients in our series. Results: A total of 398 patients underwent 12 core TRUS biopsies. Benign prostatatic hyperplasia was found in 48.5% of the patients and prostate cancer was found in 113 patients (28.4%). Among them, metastatic prostate cancer was found in 51.7% of them. High Gleason score (8–10) was found in 56.6% and a PSA of more than 20 was found in 63.3% of the patients. Conclusion: We recommend a mass public awareness program to encourage our patients to seek early prostate cancer screening and to alert the medical community to encourage more awareness of prostate cancer screening.
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The impact of the pelvicalyceal anatomy characteristics on the prediction of flexible ureteroscopy outcomes p. 105
Sinan Levent Kirecci, Musab Ilgi, Cumhur Yesildal, Abdullah Hizir Yavuzsan, Ahmet Tevfik Albayrak, Kemal Sarica
DOI:10.4103/UA.UA_19_20  
Background: The anatomical architecture is a prominent factor in the outcomes of flexible ureteroscopy (FURS). Aims and Objectives: The aim to regard the success of procedures based on Pelvicalyceal body that called Sampaio classification system. Materials and Methods: A total of 125 FURS procedures were reviewed between December 2012 and December 2016 in our department. Seven patients were excluded from the study due to the horseshoe kidney in two cases and recurrent cystine stone configuration in five patients. The patient's renal collecting system anatomy characteristics are regarded, and they are classified into four main groups based on the mid-renal-zone anatomy assessed according to Sampaio Classification. Results: Total stone-free rate (SFR) during the postoperative 1st-month evaluation was noncontrast computerized tomography 75 (63.6%). The evaluation of the SFR in all subgroup of cases based on Sampaio classification noticed easily, SFR was significantly lower in subgroup A2 (30.4%) (P = 0.00), significantly higher in subgroup B2 (P = 0.008). The comparative analysis of the operative duration defined that it was the shortest (75.3 ± 18.1 min) in Type B1 subgroup cases, and the longest (84.7 ± 25.7 min) in the Type A2 subgroup cases. Even though this duration was found to be relatively higher in Type A2 subgroup cases than the others, this difference was not statistically significant (P = 0.271). Fluoroscopy time was noted to be the shortest (11.9 ± 13.4 s) in B1 subgroup and the longest in A2 subgroup with a statistically significant different (median: 21.3 ± 30.4) (P = 0.04). While 6 (5.1%) cases had Clavien 2 and 3 (2.5%) cases, demonstrated Clavien 3a complications. Conclusion: The calyceal structure of the kidney affects the SFR; therefore, a detailed classification of pelvicalyceal could improve the outcomes, decrease the rate of auxiliary procedures and prevent the complications.
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Trends in the surgical management of renal cell carcinoma in a contemporary tertiary care setting p. 111
Noor Nabi Junejo, Sultan Saud Alkhateeb, Majed Faisal Alrumayyan, Khalid Yusuf Alkhatib, Hassan Messfer Alzahrani, Mohammed Faihan Alotaibi, Khalid Ibrahim Alothman, Turki Omar Al-Hussain, Waleed Mohamed Altaweel
DOI:10.4103/UA.UA_151_20  
Background: In the last three eras, the incidence of renal cell carcinoma (RCC) has increased, due to increased radiological studies. The expected 5-year survival rate has become better, associated with the identification of small size renal masses. However, this survival improvement may be secondary to improved surgical techniques and medical therapies for these malignancies. Objectives: The objective was to report the trends of clinical presentation, peri-operative, oncological outcomes, and surgical management trends for RCCs over the period. Methods: After Institutional Review Board approval, a retrospective study for adult patients was conducted, who presented with renal mass and were managed between 2008 and 2019. Variables, including demographics, perioperative and pathological outcomes analyzed using descriptive statistics for continuous variables reported as mean ± standard deviation and categorical variables values compared by Chi-square test. Survival Analysis calculated using the Kaplan-Meier method. The level of significance is set at P-value < 0.05. Results: A total of 588 patients underwent surgical treatment for kidney cancer from January 2008 to January 2019. 237 (40.30%) were females and 351 (59.69%) males. The clinical presentation was higher as an incidental diagnosis of 58.67%. 71.25% of patients were from outside Riyadh city. Pathology was mostly clear cell RCC 61.22% and grade 2 (57.48%). Tumor size, surgery time, and length of hospital stay showed a significant difference between the three periods (both P > 0.05). Robotic surgery performed more than open (P < 0.0001). There was no significant difference in the survival time, when compared to patients by the regions and when compared by the primary tumors (Log-Rank P = 0.4821). Patients from the Riyadh region (median = 54.0) had a significantly higher recurrence time (Log-Rank P < 0.0001). Conclusion: There was a rising trend in the incidence of RCC associated with comorbidities and incidental diagnosis. In our study period we found increase in the trend of minimal invasive approach. The size of the tumor, blood loss and operative time decreases over the period of time. The Robotic assisted nephrectomy approach has become increased over the period of time duration in present study.
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A second opinion pathology review improves the diagnostic concordance between prostate cancer biopsy and radical prostatectomy specimens p. 119
Takanori Maehara, Takuya Sadahira, Yuki Maruyama, Koichiro Wada, Motoo Araki, Masami Watanabe, Toyohiko Watanabe, Hiroyuki Yanai, Yasutomo Nasu
DOI:10.4103/UA.UA_81_20  
Objectives: The Gleason scoring system is an essential tool for determining the treatment strategy in prostate cancer (PCa). However, the Gleason grade group (GGG) often differs between needle-core biopsy (NCB) and radical prostatectomy (RP) specimens. We investigated the diagnostic value of a second opinion pathology review using NCB specimens in PCa. Materials and Methods: We retrospectively evaluated 882 patients who underwent robot-assisted RP from January 2012 to September 2019. Of these, patients whose original biopsy specimens were obtained from another hospital and reviewed by the urological pathology expert at our institution were included in the study. Patients who received neoadjuvant hormonal therapy were excluded from the study. Weighted kappa (k) coefficients were used to evaluate the diagnostic accuracy of each review. Results: A total of 497 patients were included in this study. Substantial agreement (weighted k = 0.783) in the GGG between initial- and second-opinion diagnoses based on NCB specimens was observed in 310 cases (62.4%). Although diagnoses based on a single opinion showed moderate agreement with the GGG of RP specimens (initial: 35.2%, weighted k = 0.522; second opinion; 38.8%, weighted k = 0.560), matching initial and second opinion diagnoses improved the concordance (42.9%, 133/310 cases) to substantial agreement (weighted k = 0.626). Conclusions: A second opinion of PCa pathology helps to improve the diagnostic accuracy of NCB specimens. However, over half of diagnoses that matched between the initial and second opinions differed from the diagnosis of RP specimens.
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Male sexual function after weight-loss surgeries in a group of Saudi population p. 125
Hossam S El-Tholoth, Abdalatiff K Bedaiwi, Abdulrahman Binjawhar, Ahmed A Almulhem, Khaled K Bedaiwi, Haider Alshurafa, Tarek Alzahrani, Ruyof K Alhussein, Abdulaziz K Alhussein, Mussa Alnumi
DOI:10.4103/UA.UA_144_19  
Introduction: Obesity is associated with erectile dysfunction in many studies. This study aims to inspect the impact of weight-loss surgery on the erectile function in the Saudi male population. Patients and Methods: Forty-two consecutive male patients who underwent weight-loss surgery during a period from February 2013 to July 2016 were included in the study. Unmarried patients were excluded from the study. A designed questionnaire includes the short version of the International Index of Erectile Function (IIEF), usage of phosphodiesterase inhibitors, overall satisfaction before and after the intervention, marriage duration, and fertility postsurgery. All the participants were contacted through phone in July 2018, and then the questionnaire was mailed to them. All the data were analyzed and compared to a control group of married obese patients, who were waiting for the bariatric surgeries, using specific statistical tests. Results: Thirty patients responded and completed the survey. Their mean age was 41.9 years (range 26–62), and the mean preoperative body mass index (BMI) was 46.3 ± 7.5, with a significant reduction in the BMI postoperatively to a mean of 30 ± 5.5. The IIEF score improved, and the overall satisfaction and feelings were better (76.7%). Only 16.7% of cases needed PDEI before and after the operation. Thirteen (43.3%) patients got children after the surgery. Univariate and multivariate analysis showed that age was a significant factor in association with both erectile function and fertility after bariatric surgeries (P = 0.02). Fertility was better in patients who underwent laparoscopic sleeve gastrectomy than gastric bypass surgery (P = 0.01). Conclusion: The weight-loss surgeries have a significant effect on erectile function, and they improve patient sexual satisfaction. Most of these patients feel better sexual function after bariatric surgeries. Fertility outcome seems to have a positive correlation with this type of surgery. However, a larger sample size and more elaborate studies are warranted to substantiate this claim.
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Comparative analysis of histopathological subtypes of renal cell carcinoma in the Middle East compared to other world regions p. 130
Mark Khauli, Nassib Abou Heidar, Jad A Degheili, Nizar Hakam, Mouhamad Al-Moussawy, Mohammed Shahait, Jose El-Asmar, Gerges Bustros, Ali Merhe, Rami Nasr, Muhammad Bulbul, Wassim Wazzan, Albert El-Hajj, Ali Shamseddine, Hala Kfoury, Deborah Mukherji, Raja Khauli
DOI:10.4103/UA.UA_172_20  
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.
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Adjustment of tension applied in transobturator tapes in females with intrinsic sphincteric deficiency: Two centers' prospective, comparative, randomized surgical trial Highly accessed article p. 134
Wally Mahfouz, Ahmed Moussa, Mohamed Elbadry
DOI:10.4103/UA.UA_73_20  
Objectives: Stress incontinence is the most common type of urinary incontinence in females. Recently, the gold standard treatment is mid-urethral tapes, however their efficacy is questioned in intrinsic sphincter deficiency (ISD). In our study, we try to adjust the tension applied during transobturator tapes (TOT) to evaluate its effectiveness in ISD, in order to prevent obstruction or failure and persistence of stress urinary incontinence. Materials and Methods: This study was prospectively conducted on eighty female patients having ISD, presenting at the Urology Departments in Alexandria and Minia University Hospitals. The patients were randomly assigned to two groups, with Group I including forty patients, who underwent TOT using tension-free technique, and Group II including forty patients using our new tension adjustment technique under saddle anesthesia. Patients filled the International Continence Questionnaire and Urinary Distress Inventory and did pressure flow study pre- and postoperatively. Postoperatively, the patients filled Patient Global Impression of Improvement and underwent translabial ultrasound (U/S) to estimate the distance between the tape and the urethra. Results: In Group I, 70% of the patients were cured with mean Valsalva leak point pressure (VLPP) of 51.43 ± 3.39 preoperatively, 20% were not improved, and 10% were improved with a mean VLPP of 44.5 ± 3.54 preoperatively, which increased to 86 ± 4.24 postoperatively. In Group II, 95% of the patients were cured with a mean VLPP of 50.74 cmH2O ± 6.56 preoperatively and 5% improved but not cured with a mean VLPP of 31 cmH2O preoperatively, which increased to 127 cmH2O at a bladder capacity of 400 ml. All patients in both groups underwent translabial U/S 6 months postoperatively. The distance between the mid-tape and the outer urethra measured by translabial US showed no significant difference between the two studied groups. Conclusion: Performing TOT using our tensioned proposed technique in ISD seems to be effective and with low morbidity. Intraoperative adjustment of tension using Valsalva maneuver under saddle anesthesia gives better outcomes than the conventional tension-free technique. The concept of tension-free vaginal tape should be challenged.
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Perineal urethrostomy: A single-stage viable option for complex anterior urethral strictures p. 142
Mukesh Chandra Arya, Ankur Singhal, Vivek Vasudeo, Yogendra Shyoran, Ajay Gandhi, Rakesh Maan, Mahesh Sonwal
DOI:10.4103/UA.UA_111_20  
Introduction: Perineal urethrostomy (PU) is a valid single stage option with maximum success to manage complex anterior urethral strictures. Aims: To evaluate the functional outcome of permanent PU using the Blandy technique in older patients or PU with staged reconstruction in young patients with severely diseased distal urethra. Materials and Methods: This is a retrospective analysis of 124 patients. They underwent Blandy's PU with or without Johanson stage 1. Exclusion criteria included patients with posterior urethral strictures or bladder neck contractures. Results: Mean age of patients was 54 years. Strictures due to catheterisation or instrumentation were most common – 85 (68.54%). Out of 124 patients, 71(57.3%) of them were posted for PU with Johanson stage 1 and 53 for PU only (42.7%) according to patients' choice. In patients age below 50 years, PU (N=10), PU with Johanson stage 1 (N=40) and Johanson stage 2 (N= 8) patients had mean Qmax of 20.2ml/s (17-24), 20.7ml/s (16-26), 16.375ml/s (14-18) respectively. In patients age> 50 years, PU (N=43), PU with Johanson stage 1 (N=31) and Johanson stage 2 (N= 4) patients had mean Qmax of 16.41ml/s (11-24), 17.25ml/s (11-25) and14.75 ml/s (12-17) respectively.For patients with only PU, 8/53 patients (15.09%) required secondary intervention (stomal dilatation N=6 and TURP N=2) while in PU with Johanson stage 1 patients, 10/71(14.08%) required secondary intervention (Stomal dilatation N=6, 8.45% and TURP N= 4, 5.6%). 112/124 (90.32%) were considered successful. Conclusion: Since most of patients have suffered for years, PU provides results in one stage.
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Detection rate of prostate cancer following 12-core extended biopsy in a Semi-urban Nigerian Tertiary Hospital p. 150
Friday Emeakpor Ogbetere, Eshiobo Irekpita
DOI:10.4103/UA.UA_136_20  
Background: Transrectal prostate biopsy using the extended protocol has become the standard mode of obtaining tissue for histological diagnosis with cancer detection rate varying with race and geographical regions. This study is aimed at evaluating the cancer detection rate following a 12-core extended transrectal biopsy of the prostate in a semi-urban Nigerian tertiary hospital. Materials and Methods: This was a hospital-based prospective study. Patients who had one or combination of elevated prostate-specific antigen (PSA) levels, abnormal digital rectal examination (DRE), and suspicious ultrasound findings were recruited into this study. Each had 12-core extended biopsy done. Their clinical and histological information were recorded in a pro forma. Data analysis was performed using the statistical programming for social sciences (SPSS) version 21. For all statistical tests, P < 0.05 was regarded as significant. Results: Of the 120 patients, 78 (65%) had prostate cancer. The cancer detection rate in participants aged 50–59, 60–69, 70–79, 80–89, 90–100 were 75%, 46.7%, 72.3%, 85.7%, and 100%, respectively. Overall, the cancer detection rate at PSA levels 4.0–10.0 was 25%, 10.1–20.0 was 54.7%, 20.1–50.0 was 67.4%, 50.1–100.0 was 100%, and >100.0 was 100%. The cancer detection rate for men with suspicious DRE and prostatic ultrasound findings were comparatively higher than those with normal DRE and prostatic ultrasound findings at similar PSA levels. Conclusion: This study showed a higher cancer detection rate with a 12-core biopsy protocol when compared to similar studies from the Western world, the Middle East, and urban centers in Nigeria due to poor awareness and late presentation in our environment.
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Predictors of post-percutaneous nephrolithotomy sepsis: The Northern Malaysian experience p. 156
Khai Yeong Teh, Teck Meng Tham
DOI:10.4103/UA.UA_28_20  
Objectives: Percutaneous nephrolithotomy (PCNL) carries a small risk of postoperative sepsis due to the liberation of bacteria into the patients' bloodstream during stone fragmentation. The study aims to identify the incidence of post-PCNL sepsis in our center, as well as to delineate perioperative characteristics associated with increased rates of sepsis. Materials and Methods: We performed a retrospective review on all PCNLs performed in our center between July 2012 and June 2017, with emphasis on preoperative urine results, intra-operative findings, and postoperative septic complications. Results: Among 425 cases of PCNL performed, 16 (3.76%) developed sepsis postoperatively. Patients with positive preoperative urine cultures were almost four times as likely to develop post-PCNL sepsis compared to those with negative cultures (8.41% vs. 2.2%, P = 0.004). Among patients with positive urine leukocytes and positive urine cultures, the presence of Staghorn calculi and multiple PCNL punctures both predicted significantly higher risks of postoperative sepsis. In contrast, diabetes mellitus and preoperative stenting were not found to be associated with a greater risk of post-PCNL sepsis. Conclusions: Patients who had positive preoperative urine leukocytes and/or cultures, and either harbor Staghorn calculi or are deemed to require more than one puncture on PCNL, were at an increased risk of developing post-PCNL sepsis. Such at-risk patients should be identified preoperatively, given aggressive perioperative antibiotic treatment, and monitored closely for septic complications during the convalescence period.
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Pain modulation by audiovisual distraction during cystoscopy p. 163
Amadadin R Alhlib, Mohamed Haffejee, Marietha J Nel
DOI:10.4103/UA.UA_104_20  
Introduction: Cystoscopy is one of the most common urological procedures used for either diagnostics, therapeutics, or for surveillance. It may be performed under local or general anesthesia. The procedure is associated with pain and discomfort. Aims: The aim of the study was to compare the levels of perceived pain during local cystoscopy with and without audiovisual distraction (AVD). Methodology: A randomized control study was performed at our academic hospital local cystoscopy theater of the urology division. Approximately half the patients already booked for the local rigid cystoscopy procedure were exposed to a distracting musical video during the procedure (study group), while the control group was not. Statistical Analysis: Descriptive statistics were used to determine percentage, mean, and standard deviation (SD) for categorical data. The Mann–Whitney U-test for nonparametric data was used for comparing pain levels. Results: A total of 91 patients participated in the study with 48 patients in the study group and 43 patients in the control group. The visual analog scale (VAS) ranged between 1 and 5/10 in the study group and 1–8/10 in the control group, while the mean VAS was 2.52 ± 1.2 SD in the study group and 4.97 ± 1.35 SD in the control group. The AVD intervention was statistically significant (P < 0.0001). Conclusion: AVD during local rigid cystoscopy is highly recommended, especially in patients undergoing the procedure for the first time.
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Susceptibility of hospital-acquired uropathogens to first-line antimicrobial agents at a tertiary health-care hospital, Saudi Arabia p. 166
Abdulaziz Alamri, Bahaeldin Hassan, Mohamed E Hamid
DOI:10.4103/UA.UA_109_20  
Context: Management of urinary tract infections (UTIs) is caused by antibiotic resistance uropathogens. Aim: This study aimed to determine the important uropathogens and their resistance to first-line urinary tract antimicrobial agents. Settings and Design: The region of Aseer, Southern Saudi Arabia, between 2013 and 2016. Materials and Methods: A total of 1506 isolates were recovered from the urine samples of patients that were identified and tested against nine first-line UTI antimicrobial agents. Laboratory analysis was done as per the standard methods. Confirmation of bacterial identity and antimicrobial susceptibility assay was achieved by the VITEK 2 automated system. Statistical Analysis Used: Statistical Package for the Social Sciences software version 21.0 was used for the statistical analysis. Results: The dominant uropathogens were Escherichia coli (E. coli) 507 (33.7%); Klebsiella pneumoniae (K. pneumoniae), 229 (15.21%); Pseudomonas aeruginosa, 153 (10.2%); Acinetobacter baumannii, 80 (5.3%); Enterococcus faecalis, 71 (4.7%); and Proteus mirabilis, 61 (4.1%). Of all culture-positive uropathogens, 51.5% were resistant to the 39 agents, whereas 48.5% were sensitive (P = 0.7969). Regarding the susceptibility to the first-line agent, the most effective against the dominant (in vitro) agents against E. coli were fosfomycin and nitrofurantoin (93.5%) and (85.4%), respectively. Whereas those worked well against K. pneumoniae were cefoxitin (57.1). Conclusions: The present study recommends the use of fosfomycin, cefoxitin, nitrofurantoin, and amoxicillin/clavulanate as the first choice UTIs treatment given their relatively high in vitro activity against major uropathogens. Knowledge of the bacterial species and their antimicrobial sensitivity patterns are always necessary to serve as a base for selecting the empirical treatment of UTIs as resistance rates vary geographically and with time.
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CASE REPORTS Top

Testicular chondrosarcoma p. 171
Abdulaziz Alhussaini, Mohammed Al Mansour, Noura Al Oudah, Khalid Al Rabeeah, Abdullah Al Khayal, Saad Abumelha
DOI:10.4103/UA.UA_168_19  
Only 5% of all urological tumors are accounted as Testicular tumors. Furthermore, a well differentiated chondrosarcoma of the testis is extremely rare. Thus, we are representing a rare case of testicular chondrosarcoma. A 43-year-old male with right scrotal swelling did Doppler Ultrasonography demonstrating a large heterogenous hypervascular mass. Patient has had uneventful radical inguinal orchiectomy. The histopathology of the resected tumor reveled 50% seminoma – 50% teratoma with somatic type malignancy (well differentiated chondrosarcoma). Only few cases were reported in the medical literature for testicular chondrosarcoma. Thus, reporting such cases will add to the literature and shall help in establishing a management strategy.
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Recurrent renal cell carcinoma presenting as a cutaneous metastasis: A case report and review of the literature p. 174
Paulo Pe Leve, João Felício, Rui Carneiro, Carlos Zagalo
DOI:10.4103/UA.UA_2_20  
Renal cell carcinoma (RCC) is a common urological malignancy. Despite early detection and surgical treatment, some lesions recur late at distant sites. The most common dissemination sites are lung, bone, and liver. Skin metastases are not common, and the incidence and clinical manifestations are poorly established in the literature. We report here the case of a male patient with an isolated scalp cutaneous metastase of RCC, 7 years after radical nephrectomy. An excisional biopsy was performed and confirmed metastatic RCC.
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Arteriovenous malformation of ureter presenting without hematuria: An unusual presentation of a rare disease p. 177
AG Yadunandan, Narendra Pai, Suraj Hegde, TP Rajeev
DOI:10.4103/UA.UA_24_20  
Genitourinary tract arteriovenous malformations are extremely rare. Most of the lesions are found either in the kidney or urinary bladder. So far, to the best of our knowledge, only five cases of arteriovenous malformation of the ureter have been reported in the literature. Here, we present, a young male, clinically presented with pain in the left flank with no other significant history. On radiological evaluation found to have left hydroureteronephrosis with stricture of the left distal ureter at the level of iliac vessel crossing. Urine routine, cytology, and cystoscopy were unremarkable. Left retrograde pyelogram showed distal ureteric stricture. Patient underwent excision of left distal ureteric stricture segment and ureteric reimplantation with psoas hitch. Histopathological examination revealed the features of arteriovenous malformation of the left ureter. The patient is asymptomatic and has no recurrence on follow-up until 12 weeks after surgery.
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Mucinous tubular and spindle cell carcinoma: A difficult diagnosis p. 180
Jyotsna Naresh Bharti, Gautam Ram Choudhary, Vijay Kumar Sarma Madduri, Taruna Yadav
DOI:10.4103/UA.UA_44_20  
Mucinous Tubular and Spindle Cell Carcinoma (MTSCC) is infrequently seen renal malignancy with favorable outcome, when diagnosed in the early stage. Once out of kidney it is have lethal course. Radiologically MTSCC is heterogeneously hypo-enhancing renal mass in delayed phase, may mimic to papillary renal cell carcinoma and in histopathology showed these tumoral cells shows complex immunophenotype expression. As this does not show enhancement pattern of common renal cell carcinomas, radiological diagnosis may be challenging. Histopathological reporting is also tedious indeed necessary to reach definitive diagnosis, which help in tailoring follow up and prognosis. Metastatic disease has dismal outcome and responds poorly with adjuvant therapy and patient succumbs within short span of time.
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A case report of emphysematous cystitis with spontaneous intraperitoneal bladder perforation in an operated case of prolapsed intervertebral disc p. 183
Rishikesh C Velhal, Nikhilesh A Jibhakate, Sujata K Patwardhan, Bhushan P Patil
DOI:10.4103/UA.UA_60_20  
This is a case report of emphysematous cystitis with spontaneous intraperitoneal bladder perforation in postoperative period of pedicle fixation surgery for prolapse intervertebral disc (L3–L4). The patient developed urinary retention with overflow incontinence with abdominal tenderness and fever 3 days after orthopedic procedure which on computed tomography (CT) scan found to have abundant air in urinary bladder with multiple air foci in bladder wall with suspected leak into intraperitoneal pelvic cavity, proven only after CT cystogram.
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Combined ureterocalicostomy with buccal mucosa graft ureteroplasty in complex upper ureteral stricture: A rare case of reconstruction p. 186
Jaydeep Arun Date, Akshay Shyamlal Nathani, Subodh Ratnakar Shivde, Chetan Rajendra Kulkarni
DOI:10.4103/UA.UA_80_20  
The treatment of a major and complex ureteric stricture requires the use of a bowel interposition or autotransplantation of the kidney, which is a major undertaking and remains the traditional option. Buccal mucosa is an established tissue for urethral reconstruction and can be used safely for the repair of narrowing of the ureter. This technique has been well documented in the literature; however, a combined ureterocalicostomy with buccal mucosa graft ureteroplasty has not yet been reported in literature. We report the case of a 59-year-old female who was diabetic and hypertensive presented with a long-length, complex upper ureteric stricture with recurrent pyelonephritis. A long stricture in the upper ureter measuring approximately 8 cm was successfully repaired by free buccal mucosal onlay patch graft over a double J stent with ureterocalicostomy. This technique can be used in salvaging kidneys with complex ureteric strictures along with fibrotic pelvis.
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Transdiaphragmatic nephrectomy with synchronous pulmonary and anterior thoracic wall mass metastasectomy in a young male with metastatic renal cell carcinoma; a single-incision approach p. 190
Lazaros Lazarou, Marinos Berdempes, Angeliki Peninta, Maria Mitselou, Andreas Skolarikos, Achilleas G Lioulias
DOI:10.4103/UA.UA_96_20  
Renal cell carcinoma represents approximately 3% of all cancers, with the highest incidence occurring in the western world. Around 33% of the patients experience metastatic disease at diagnosis. Since the approval of the first targeted therapy, the treatment of metastatic renal cell carcinoma (mRCC) has positively changed, but the surgical treatment of the primary tumor, and metastases if possible, is sometimes crucial in selected patients controlling the burden of cancer sites with the intention to improve survival. We, herein, report on a case of a young male patient presented in the emergency room with gross hematuria which underwent transdiaphragmatic nephrectomy with synchronous pulmonary and anterior thoracic wall mass metastasectomy with a single thoracic incision due to mRCC. Achieving a full response in patients with mRCC is extremely rare only with medical treatment. The role of complete surgical metastasectomy is questioned, but there are several studies that support its efficacy in achieving metastases free status prolonged overall survival and better quality of life. The therapeutic treatment plan for these patients should be discussed within dedicated multidisciplinary cancer centers and focus on each patient individually and they should be offered a closed follow-up strategy.
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Urethral leiomyoma: A rare neoplasm p. 194
Sergey V Popov, Igor N Orlov, Daria Yu Chernysheva, Evgeniy A Grin'
DOI:10.4103/UA.UA_90_20  
Extrauterine leiomyoma is a rare benign tumor, originating from smooth muscle cells, most often localized in the uterus. Extrauterine localization of leiomyoma is extremely rare. The presence of a neoplasm near the urethra always poses a challenge for differential diagnosis. Variety of pathologies sharing similar clinical findings requires further diagnostic testing and doctor alertness. We present the clinical case of urethral leiomyoma in a female patient aged 42 years complaining of frequent urination and vulval mass. The patient underwent neoplasm removal with further histologic examination revealing urethral leiomyoma. The article features the diagnosis and treatment of this rare pathology.
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ERRATUM Top

Erratum: Comparison of magnetic resonance defecography with pelvic floor ultrasound and vaginal inspection in the urogynecological diagnosis of pelvic floor dysfunction p. 198

DOI:10.4103/0974-7796.313628  
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