Navigation systems and 3D imaging in percutaneous nephrolithotripsy: improving outcomes and safety

PURPOSE OF REVIEW

Percutaneous nephrolithotripsy (PCNL) is the first-line management option for large kidney stones (>2 cm). It remains, however, a demanding procedure with considerable morbidity. The present narrative review summarizes recent knowledge from original research studies investigating navigation systems/three-dimensional (3D) imaging in PCNL, particularly on publications during the past 12-18 months.

RECENT FINDINGS

Navigation systems and 3D imaging are primarily used for preoperative planning, with few intra-operative applications. Patient management and residents' training could benefit from their use.

SUMMARY

Navigation systems and 3D imaging technology have emerged as a potential game-changer in PCNL. Even though available evidence is currently scarce/inconclusive, the safety/efficacy of navigation systems and 3D dimensional imaging use in PCNL appears promising. This advanced technology offers precise anatomical mapping, improved visualization, and surgical accuracy. Enabling a comprehensive preoperative evaluation and improving guidance, navigation systems, and 3D imaging technology may improve the safety and efficacy of PCNL. With continuous technological evolution, it is expected that improvements/innovations will offer further aid in such demanding procedures. Familiarization and cost reduction are necessary for widespread application, while larger-scale prospective studies and well designed randomized controlled trials are still needed.

Severity of precapillary pulmonary hypertension: Predictive factor

BACKGROUND AND OBJECTIVES

Patients with pulmonary arterial hypertension (PAH) require risk assessments for prognosis and appropriate therapy. These assessments need to be improved by incorporating clinical and laboratory data such as the analysis of the right ventricle. We aim to establish echocardiographic morphometric data of the right ventricle and its relationship with the left ventricle, to estimate the hemodynamic severity of precapillary pulmonary hypertension (PHprecapillary).

METHODS

This cohort, prospective, observational, and cross-sectional study included 41 consecutive patients with PHprecapillary using echocardiographic study and cardiac catheterization.

RESULTS

Patients' mean age was 44.0±16.4 years, and 37 were women (90.2%). Idiopathic PAH was diagnosed in 18 patients (43.9%). The World Health Organization/New York Association functional class was III or IV in 31 patients (75.6%). The ratio of the right to left ventricles (RV/LV) echocardiographic diastolic diameters was associated with pulmonary arterial pressures in cardiac catheterization, with the best cutoff per receiver operating characteristic curve being 0.8 for systolic pressure (sensitivity 90.0%, specificity 78.3%, area under the curve [AUC] 0.882) and mean pressure (sensitivity 60.0%, specificity 95.7%, AUC 0.823). Spearman's correlation (R) of RV/LV echocardiographic ratio and the hemodynamic variables was significant for systolic pressure (R = 0.7015, p < 0.0001), mean pressure (R = 0.6332, p < 0.0001), transpulmonary pressure gradient (R = 0.6524, p < 0.0001), pulmonary vascular resistance (R = 0.6076, p = 0.0021), and pulmonary vascular resistance index (R = 0.6229, p = 0.0014).

CONCLUSION

The ratio of RV/LV echocardiographic diastolic diameters contribute to the estimates the hemodynamic severity of precapillary pulmonary hypertension. The best cutoff for this assessment was RV/LV of 0.8.

CycleGAN-Based Image to Image Translation for Realistic Surgical Training Phantoms

Training in surgery is essential for surgeons to develop skill and dexterity. Physical training phantoms provide excellent haptic feedback and tissue properties for stitching and operating with authentic instruments and are easily available. However, they lack realistic traits and fail to reflect the complex environment of a surgical scene. Generative Adversarial Networks can be used for image-to-image translation, addressing the lack of realism in physical phantoms, by mapping patterns from the intraoperative domain onto the video stream captured during training with these surgical simulators. This work aims to achieve a successful I2I translation, from intra-operatory mitral valve surgery images onto a surgical simulator, using the CycleGAN model. Different experiments are performed - comparing the Mean Square Error Loss with the Binary Cross Entropy Loss; validating the Fréchet Inception Distance as a training and image quality metric; and studying the impact of input variability on the model performance. Differences between MSE and BCE are modest, with MSE being marginally more robust. The FID score proves to be very useful in identifying the best training epochs for the CycleGAN I2I translation architecture. Carefully selecting the input images can have a great impact in the end results. Using less style variability and input images with good feature details and clearly defined characteristics enables the network to achieve better results.Clinical Relevance- This work further contributes for the domain of realistic surgical training, successfully generating fake intra operatory images from a surgical simulator of the cardiac mitral valve.

A Comparative Study of Deep Learning Methods for Multi-Class Semantic Segmentation of 2D Kidney Ultrasound Images

Ultrasound (US) imaging is a widely used medical imaging modality for the diagnosis, monitoring, and surgical planning for kidney conditions. Thus, accurate segmentation of the kidney and internal structures in US images is essential for the assessment of kidney function and the detection of pathological conditions, such as cysts, tumors, and kidney stones. Therefore, there is a need for automated methods that can accurately segment the kidney and internal structures in US images. Over the years, automatic strategies were proposed for such purpose, with deep learning methods achieving the current state-of-the-art results. However, these strategies typically ignore the segmentation of the internal structures of the kidney. Moreover, they were evaluated in different private datasets, hampering the direct comparison of results, and making it difficult to determination the optimal strategy for this task. In this study, we perform a comparative analysis of 7 deep learning networks for the segmentation of the kidney and internal structures (Capsule, Central Echogenic Complex (CEC), Cortex and Medulla) in 2D US images in an open access multi-class kidney US dataset. The dataset includes 514 images, acquired in multiple clinical centers using different US machines and protocols. The dataset contains the annotation of two experts, but 321 images with complete segmentation of all 4 classes were used. Overall, the results demonstrate that the DeepLabV3+ network outperformed the inter-rater variability with a Dice score of 78.0% compared to 75.6% for inter-rater variability. Specifically, DeepLabV3Plus achieved mean Dice scores of 94.2% for the Capsule, 85.8% for the CEC, 62.4% for the Cortex, and 69.6% for the Medulla. These findings suggest the potential of deep learning-based methods in improving the accuracy of kidney segmentation in US images.Clinical Relevance- This study shows the potential of DL for improving accuracy of kidney segmentation in US, leading to increased diagnostic efficiency, and enabling new applications such as computer-aided diagnosis and treatment, ultimately resulting in improved patient outcomes and reduced healthcare costs.1.

Analysis of Current Deep Learning Networks for Semantic Segmentation of Anatomical Structures in Laparoscopic Surgery

Semantic segmentation of anatomical structures in laparoscopic videos is a crucial task to enable the development of new computer-assisted systems that can assist surgeons during surgery. However, this is a difficult task due to artifacts and similar visual characteristics of anatomical structures on the laparoscopic videos. Recently, deep learning algorithms have been showed promising results on the segmentation of laparoscopic instruments. However, due to the lack of large public datasets for semantic segmentation of anatomical structures, there are only a few studies on this task. In this work, we evaluate the performance of five networks, namely U-Net, U-Net++, DynUNet, UNETR and DeepLabV3+, for segmentation of laparoscopic cholecystectomy images from the recently released CholecSeg8k dataset. To the best of our knowledge, this is the first benchmark performed on this dataset. Training was performed with dice loss. The networks were evaluated on segmentation of 8 anatomical structures and instruments, performance was quantified through the dice coefficient, intersection over union, recall, and precision. Apart from the U-Net, all networks obtained scores similar to each other, with the U-Net++ being the network with the best overall score with a mean Dice value of 0.62. Overall, the results show that there is still room for improvement in the segmentation of anatomical structures from laparoscopic videos. Clinical Relevance- The results of this study show the potential of deep neural networks for the segmentation of anatomical structures in laparoscopic images which can later be incorporated into computer-aided systems for surgeons.

A deep learning method for kidney segmentation in 2D ultrasound images

Ultrasound (US) is a medical imaging modality widely used for diagnosis, monitoring, and guidance of surgical procedures. However, the accurate interpretation of US images is a challenging task. Recently, portable 2D US devices enhanced with Artificial intelligence (AI) methods to identify, in real-time, specific organs are widely spreading worldwide. Nevertheless, the number of available methods that effectively work in such devices is still limited. In this work, we evaluate the performance of the U-NET architecture to segment the kidney in 2D US images. To accomplish this task, we studied the possibility of using multiple sliced images extracted from 3D US volumes to achieve a large, variable, and multi-view dataset of 2D images. The proposed methodology was tested with a dataset of 66 3D US volumes, divided in 51 for training, 5 for validation, and 10 for testing. From the volumes, 3792 2D sliced images were extracted. Two experiments were conducted, namely: (i) using the entire database (WWKD); and (ii) using images where the kidney area is > 500 mm2 (500KD). As a proof-of-concept, the potential of our strategy was tested in real 2D images (acquired with 2D probes). An average error of 2.88 ± 2.63 mm in the testing dataset was registered. Moreover, satisfactory results were obtained in our initial proof-of-concept using pure 2D images. In short, the proposed method proved, in this preliminary study, its potential interest for clinical practice. Further studies are required to evaluate the real performance of the proposed methodology. Clinical Relevance- In this work a deep learning methodology to segment the kidney in 2D US images is presented. It may be a relevant feature to be included in the recent portable US ecosystems easing the interpretation of image and consequently the clinical analysis.

Urethra-sparing minimally invasive simple prostatectomy: an old technique revisited

PURPOSE OF REVIEW

The aim of this study was to review recent development in urethra and ejaculation preserving laparoscopic and robotic simple prostatectomy.

RECENT FINDINGS

Since Madigan prostatectomy original description in 1990, to recent reports of robotic-assisted surgery using this urethra-sparing technique, many studies have suggested the advantages of the preservation of urethra, bladder neck and ejaculatory ducts, when removing adenomatous tissue in benign prostatic obstruction (BPO) surgery. Allying anatomical preservation of this structure with the well known benefits of minimally invasive procedures seems to reduce postoperative haematuria, obviating the need for bladder irrigation, with shorter catheterization and hospitalization times, less risk of urethral stricture and, of utmost importance, reducing rates of retrograde ejaculation.

SUMMARY

Urethra and bladder neck sparing techniques, especially in minimally invasive simple prostatectomy procedures, seem to provide real benefits, not only in the maintenance of preoperative potency and antegrade ejaculation but also accomplishing better perioperative outcomes, with faster patient recovery, and less complications. These techniques might well be the future standard techniques for sexually active men with large benign prostatic hyperplasia (BPH) requiring surgery.

Kidney Segmentation in 3-D Ultrasound Images Using a Fast Phase-Based Approach

Renal ultrasound (US) imaging is the primary imaging modality for the assessment of the kidney's condition and is essential for diagnosis, treatment and surgical intervention planning, and follow-up. In this regard, kidney delineation in 3-D US images represents a relevant and challenging task in clinical practice. In this article, a novel framework is proposed to accurately segment the kidney in 3-D US images. The proposed framework can be divided into two stages: 1) initialization of the segmentation method and 2) kidney segmentation. Within the initialization stage, a phase-based feature detection method is used to detect edge points at kidney boundaries, from which the segmentation is automatically initialized. In the segmentation stage, the B-spline explicit active surface framework is adapted to obtain the final kidney contour. Here, a novel hybrid energy functional that combines localized region- and edge-based terms is used during segmentation. For the edge term, a fast-signed phase-based detection approach is applied. The proposed framework was validated in two distinct data sets: 1) 15 3-D challenging poor-quality US images used for experimental development, parameters assessment, and evaluation and 2) 42 3-D US images (both healthy and pathologic kidneys) used to unbiasedly assess its accuracy. Overall, the proposed method achieved a Dice overlap around 81% and an average point-to-surface error of ~2.8 mm. These results demonstrate the potential of the proposed method for clinical usage.

Exploratory analysis on the usage of Pi-score algorithm over endoscopic stone treatment step 1 protocol

BACKGROUND

The Performance Improvement score (Pi-score) has been proven to be reliable to measure performance improvement during E-BLUS hands-on training sessions. Our study is aimed to adapt and test the score to EST s1 (Endoscopic Stone Treatment step 1) protocol, in consideration of its worldwide adoption for practical training.

METHODS

The Pi-score algorithm considers time measurement and number of errors from two different repetitions (first and fifth) of the same training task and compares them to the relative task goals, to produce an objective score. Data were obtained from the first edition of 'ART in Flexible Course', during four courses in Barcelona and Milan. Collected data were independently analyzed by the experts for Pi assessment. Their scores were compared for inter-rater reliability. The average scores from all tutors were then compared to the PI-score provided by our algorithm for each participant, in order to verify their statistical correlation. Kappa statistics were used for comparison analysis.

RESULTS

Sixteen hands-on training expert tutors and 47 3^rd-year residents in Urology were involved. Concordance found between the 16 proctors' scores was the following: Task 1=0.30 ("fair"); Task 2=0.18 ("slight"); Task 3=0.10 ("slight"); Task 4=0.20, ("slight"). Concordance between Pi-score results and proctor average scores per-participant was the following: Task 1=0.74 ("substantial"); Task 2=0.71 ("substantial"); Task 3=0.46 ("moderate"); Task 4=0.49 ("moderate").

CONCLUSIONS

Our exploratory study demonstrates that Pi-score can be effectively adapted to EST s1. Our algorithm successfully provided an objective score that equals the average performance improvement scores assigned by of a cohort of experts, in relation to a small amount of training attempts.

Complications and quality of life of ileal conduit, orthotopic neobladder and ureterocutaneostomy: systematic review of reports using the Clavien-Dindo Classification

INTRODUCTION

Radical cystectomy (RC) and urinary diversion (UD) are two steps of the same surgical procedure involving likely complications and important impact on quality of life (QoL). The literature was reviewed to identify recent studies reporting UDs complications occurred 90 days after surgery and graded by Clavien-Dindo Classification System (CCS).

EVIDENCE ACQUISITION

A comprehensive systematic Medline search was performed in PubMed/Medline, Embase and Scopus databases to identify reports published in English starting from 2013 using key words related to review outcome (i.e. neobladder, ileal conduct, ureterocutaneostomy, cystectomy, QoL). Complications were defined as minor or major whether the CCS grade was ≤2 or ≥3, respectively. Then, manuscripts references were screened to identify unfounded studies. Only studies using CCS to report surgical complications were considered.

EVIDENCE SYNTHESIS

Retrieved studies were reported according to two main items of complications and QoL. About UDs complications, fourteen studies were identified incorporating overall 4436 patients. Up to 50% of patients experienced at least one low-grade complications (CCS≤2) requiring pharmacological treatment to be healed. On the other hand, high-grade complications (CCS≥3) occurred in 0.7-42% of cases and required surgical interventions (CCS 3a and 3b) or life support (CCS=4). Finally, mortality (CCS=5) rated between 0.4-7%. Regarding QoL, six studies were analyzed with overall 445 patients. Most of them were retrospective and showed conflicting results whether the external UDs were better than neobladder in term of impact on QoL.

CONCLUSIONS

The use of a standardized system such as CCS improves analyses of literature. However, rigorous patient selection for UD type makes unable a randomized comparison between UDs in terms of complications and QoL impact.

Trauma and work factors as predictors of firefighters' psychiatric distress

BACKGROUND

Studies into the mental health of firefighters have primarily focussed on individual factors (e.g. biological and psychological factors). Little is known about how exposure to traumatic events and psychosocial and organizational work factors influence firefighters' mental health despite the evidence that these are important for employee health.

AIMS

To study job demands, job control, social support and operational trauma as predictors of firefighters' psychiatric morbidity, and whether job control and social support moderate these relationships.

METHODS

Participants were drawn from a longitudinal cohort study of firefighters in Brazil. Portuguese-language variants of the Self-Report Questionnaire (SRQ-20) and Traumatic Events List for Emergency Professionals measured psychiatric morbidity and exposure to traumatic events. Job demands, job control and social support were measured by the Job Stress Scale. Hierarchical regressions were run controlling for socio-demographics and previous psychiatric morbidity. Subsequent regression steps first included the proposed predictors followed by their interactions.

RESULTS

Thirteen per cent of the sample (n = 40/312) met the caseness criteria indicating psychiatric morbidity. Operational trauma, job demands, job control and social support predicted psychiatric morbidity. Both job control and social support functioned as moderators and where these moderators were high, the job demands and psychiatric morbidity relationships were weaker.

CONCLUSIONS

These findings show that psychosocial factors and operational trauma predict firefighters' psychiatric morbidity. Crucially, the results that improving social support and job control could mitigate the detrimental influence of job demands highlight the need for more research and practice towards organizational-level interventions.

[Navigation systems for the percutaneous access to the kidney]

BACKGROUND

Percutaneous access to the renal pelvis still remains the most difficult step before nephrolitholapaxy (PCNL). New imaging techniques, such as 3D imaging and various navigation instruments such as electromagnetic, sonographic, CT-controlled and marker-based/iPAD try to simplify this step and reduce complications.

OBJECTIVES

In this review, various new techniques for puncturing the renal collecting system are presented and their advantages and disadvantages are evaluated.

MATERIALS AND METHODS

A systematic literature search was carried out in MEDLINE, whereby only puncture techniques that have already been evaluated in clinical studies were included.

RESULTS

Five different navigation methods for puncturing the renal pelvis before PCNL were found.

CONCLUSION

Intraoperative navigation can be useful when puncturing the collecting system. The combination of ultrasound and fluoroscopy currently remains the gold standard. However, there is still a need for further, primarily clinical, prospective studies to determine which new imaging technology and navigation systems will prevail and thus facilitate the access route to the kidney, especially in the case of special anatomical conditions.

Type 2 diabetes mellitus predicts worse outcomes in patients with high-grade T1 bladder cancer receiving bacillus Calmette-Guérin after transurethral resection of the bladder tumor

OBJECTIVES

The aim of this multicenter study was to investigate the prognostic role of type 2 diabetes mellitus (T2DM) comorbidity in a large multi-institutional cohort of patients with primary T1HG/G3 non-muscle-invasive bladder cancer (NMIBC) treated with transurethral resection of the bladder (TURB).

MATERIALS AND METHODS

A total of 1,172 patients with primary T1 HG/G3 who had NMIBC on re-TURB and who received adjuvant intravesical bacillus Calmette-Guérin therapy with maintenance were included. Endpoints were recurrence-free survival and progression-free survival.

RESULTS

A total of 231 (19.7%) of patients had T2DM prior to TURB. Five-year recurrence-free survival estimates were 12.5% in patients with T2DM compared to 36% in patients without T2DM, P < 0.0001. Five-year PFS estimates were 60.5% in patients with T2DM compared to 70.2% in patients without T2DM, P = 0.003. T2DM was independently associated with disease recurrence (hazard ratio = 1.41; 95% confidence interval = 1.20-1.66, P < 0.001) and progression (hazard ratio = 1.27; 95% confidence interval = 0.99-1.63, P < 0.001), after adjusting for other known predictive factors such as tumor size, multifocality, T1G3 on re-TURB, body mass index, lymphovascular invasion, and neutrophil-to-lymphocytes ratio.

CONCLUSIONS

Given the potential implications for management, prospective validation of this finding along with translational studies designed to investigate the underlying biology of such an association are warranted.

Using lamb sales data to investigate associations between implementation of disease preventive practices and sheep flock performance

Although the UK is the largest lamb meat producer in Europe, there are limited data available on sheep flock performance and on how sheep farmers manage their flocks. The aims of this study were to gather evidence on the types of disease control practices implemented in sheep flocks, and to explore husbandry factors associated with flock productivity. A questionnaire focusing on farm characteristics, general husbandry and flock health management was carried out in 648 farms located in the UK over summer 2016. Abattoir sales data (lamb sales over 12 months) was compared with the number of breeding ewes on farm to estimate flock productivity (number of lambs sold for meat per 100 ewes per farm per year). Results of a multivariable linear regression model, conducted on 615 farms with complete data, indicated that farms vaccinating ewes against abortion and clostridial agents and administering a group 4/5 anthelmintic to ewes (as recommended by the Sustainable Control of Parasites in Sheep Initiative) during quarantining had a greater flock productivity than farms not implementing these actions (P<0.01 and 0.02, respectively). Flocks with maternal breed types had higher productivity indexes compared with flocks with either pure hill or terminal breeds (P<0.01). Farms weighing lambs during lactation had greater productivity than those not weighing (P<0.01). Importantly, these actions were associated with other disease control practices, for example, treating individual lame ewes with an antibiotic injection, weaning lambs between 13 and 15 weeks of age and carrying out faecal egg counts, suggesting that an increase in productivity may be associated with the combined effect of these factors. This study provides new evidence on the positive relationship between sheep flock performance and disease control measures and demonstrates that lamb sales data can be used as a baseline source of information on flock performance and for farm benchmarking. Further research is needed to explore additional drivers of flock performance.

B-43 Adolescent Recovery Following TBI: Moderators of Change Over Time

Objective

The study aimed to assess (1) whether the severity of a TBI affects performance on a measure of memory, and (2) whether FSIQ, VIQ, and PIQ moderate recovery following TBI, over time, after controlling for severity of injury.

Method

TBI patients (n = 60) were recruited from admissions to the Loma Linda University Children’s Hospital (LLUCH). Indicators of memory and learning were assessed with the CMS for all the children (ages 6 to 16), while overall cognitive abilities were assessed with the WASI-II. These data are a component of a larger neuropsychology assessment battery collected at 3 and 12 months post-injury.

Results

Simple Linear Regression was conducted in SPSS. Results indicated that severity of injury explained a significant amount of the variance in participant’s performance on overall memory at the initial evaluation (R2 = .154). As severity of injury increased by one-point, general memory declined by .392 points, 95%CI [.820, 3.233] (p < .001). Three moderation analyses using model one of the PROCESS macro for SPSS were conducted to assess whether FSIQ, VIQ, or PIQ moderated recovery from TBI over time. We controlled for the severity of injury. FSIQ, VIQ, and PIQ did not significantly moderate verbal, nonverbal, or general memory recovery of moderate-to-severe TBI over time (ps > .05).

Conclusions

Results of the study suggest that, after controlling for severity of injury, FSIQ, VIQ, and PIQ did not significantly moderate recovery following a TBI. Given that research suggests that higher premorbid IQ is associated with more favorable outcomes, further investigation is warranted.

Absolute basophil count is associated with time to recurrence in patients with high-grade T1 bladder cancer receiving bacillus Calmette-Guérin after transurethral resection of the bladder tumor

BACKGROUND

Basophils, eosinophils and monocytes may be involved in BCG-induced immune responses and be associated with outcomes of bladder cancer patients receiving intravesical BCG. Our objective was to explore the association of baseline counts of basophils, eosinophils and monocytes with outcomes of patients with high-grade T1 bladder cancer receiving a standard course of intravesical BCG.

METHODS

We retrospectively reviewed medical records of patients with primary T1 HG/G3 bladder cancer. After re-TURBT, patients were treated with a 6-week course of intravesical BCG induction followed by intravesical BCG every week for 3 weeks given at 3, 6, 12, 18, 24, 30 and 36 months from initiation of therapy The analysis of potential risk factors for recurrence, muscle invasion and cancer-specific and overall survival was performed using univariable Cox regression models. Those factors that presented, at univariate analysis, an association with the event at a liberal p < 0.1, have been selected for the development of a multivariable model.

RESULTS

A total of 1045 patients with primary T1 HG/G3 were included. A total of 678 (64.9%) recurrences, 303 (29.0%) progressions and 150 (14.3%) deaths were observed during follow-up. Multivariate analysis showed that logarithmic transformation of basophils count was associated with a 30% increment in the hazard of recurrence per unit increase of logarithmic basophils count (HR 1.30; 95% confidence interval 1.09-1.54; p = 0.0026). Basophil count modeled by quartiles was also significantly associated with time to recurrence [second vs. lower quartile HR 1.42 (1.12-1.79); p = 0.003, third vs. lower quartile HR 1.26 (1.01-1.57); p = 0.041; upper vs. lower quartile HR 1.36 (1.1-1.68); p = 0.005]. The limitations of a retrospective study are applicable.

CONCLUSION

Baseline basophil count may predict recurrence in BCG-treated HG/G3 T1 bladder cancer patients. External validation is warranted.

Atorvastatin prevents lipopolysaccharide-induced depressive-like behaviour in mice

Clinical and pre-clinical evidences indicate an association between inflammation and depression since increased levels of pro-inflammatory cytokines are associated with depression-related symptoms. Atorvastatin is a cholesterol-lowering statin that possesses pleiotropic effects including neuroprotective and antidepressant actions. However, the putative neuroprotective effect of atorvastatin treatment in the acute inflammation mice model of depressive-like behaviour has not been investigated. In the present study, we aimed to investigate the effect of atorvastatin treatment on lipopolysaccharide (LPS) induced depressive-like behaviour in mice. Mice were treated with atorvastatin (1 or 10 mg/kg, v.o.) or fluoxetine (30 mg/kg, positive control, v.o.) for 7 days before LPS (0.5 mg/kg, i.p.) injection. Twenty four hours after LPS infusion, mice were submitted to the forced swim test, tail suspension test or open field test. After the behavioural tests, mice were sacrificed and the levels of tumour necrosis factor-α (TNF-α), brain-derived neurotrophic factor (BDNF), glutathione and malondialdehyde were measured. Atorvastatin (1 or 10 mg/kg/day) or fluoxetine treatment prevented LPS-induced increase in the immobility time in the forced swim and tail suspension tests with no alterations in the locomotor activity evaluated in the open field test. Atorvastatin (1 or 10 mg/kg/day) or fluoxetine treatment also prevented LPS-induced increase in TNF-α and reduction of BDNF levels in the hippocampus and prefrontal cortex. Treatment with atorvastatin (1 or 10 mg/kg/day) or fluoxetine prevented LPS-induced increase in lipid peroxidation and the reduction of glutathione levels in the hippocampus and prefrontal cortex. The present study suggests that atorvastatin treatment exerted neuroprotective effects against LPS-induced depressive-like behaviour which may be related to reduction of TNF-α release, oxidative stress and modulation of BDNF expression.

Predictors of Residual T1 High Grade on Re-Transurethral Resection in a Large Multi-Institutional Cohort of Patients with Primary T1 High-Grade/Grade 3 Bladder Cancer

The aim of this multi-institutional study was to identify predictors of residual high-grade (HG) disease at re-transurethral resection (reTUR) in a large cohort of primary T1 HG/Grade 3 (G3) bladder cancer patients. A total of 1155 patients with primary T1 HG/G3 bladder cancer from 13 academic institutions that underwent a reTUR within 6 weeks after first TUR were evaluated. Logistic regression analysis was performed to assess the association of predictive factors with residual HG at reTUR. Residual HG cancer was found in 288 (24.9%) of patients at reTUR. Patients presenting residual HG cancer were more likely to have carcinoma in situ (CIS) at first resection (p<0.001), multiple tumors (p=0.02), and tumor size larger than 3 cm (p=0.02). Residual HG disease at reTUR was associated with increased preoperative neutrophil-to-lymphocytes ratio (NLR) (p=0.006) and body mass index (BMI)>=25 kg/m². On multivariable analysis, independent predictors for HG residual disease at reTUR were tumor size >3cm (OR = 1.37; 95% CI: 1.02-1.84, p=0.03), concomitant CIS (OR 1.92; 95% CI: 1.32-2.78, p=0.001), being overweight (OR= 2.08; 95% CI: 1.44-3.01, p<0.001) and obesity (OR 2.48; 95% CI: 1.64-3.77, p<0.001). A reTUR in high grade T1 bladder cancer is mandatory as about 25% of patients, presents residual high grade disease. Independent predictors to identify patients at risk of residual high grade disease after a complete TUR include tumor size, presence of carcinoma in situ, and BMI >=25 kg/m².

Systemic Inflammatory Markers and Oncologic Outcomes in Patients with High-risk Non-muscle-invasive Urothelial Bladder Cancer

BACKGROUND

Serum levels of neutrophils, platelets, and lymphocytes have been recognized as factors related to poor prognosis for many solid tumors, including bladder cancer (BC).

OBJECTIVE

To evaluate the prognostic role of the combination of the neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), and lymphocyte/monocyte ratio (LMR) in patients with high-risk non-muscle-invasive urothelial BC (NIMBC).

DESIGN, SETTING, AND PARTICIPANTS

A total of 1151 NMIBC patients who underwent first transurethral resection of the bladder tumor (TURBT) at 13 academic institutions between January 1, 2002 and December 31, 2012 were included in this analysis. The median follow-up was 48 mo.

INTERVENTION

TURBT with intravesical chemotherapy or immunotherapy.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Multivariable Cox regression analysis was performed to identify factors predictive of recurrence, progression, cancer-specific mortality, and overall mortality. A systemic inflammatory marker (SIM) score was calculated based on cutoffs for NLR, PLR, and LMR.

RESULTS AND LIMITATIONS

The 48-mo recurrence-free survival was 80.8%, 47.35%, 20.67%, and 17.06% for patients with an SIM score of 0, 1, 2, and 3, respectively (p<0.01, log-rank test) while the corresponding 48-mo progression free-survival was 92.0%, 75.67%, 72.85%, and 63.1% (p<0.01, log-rank test). SIM scores of 1, 2, and 3 were associated with recurrence (hazard ratio [HR] 3.73, 7.06, and 7.88) and progression (HR 3.15, 4.41, and 5.83). Limitations include the lack of external validation and comparison to other clinical risk models.

CONCLUSIONS

Patients with high-grade T1 stage NMIBC with high SIM scores have worse oncologic outcomes in terms of recurrence and progression. Further studies should be conducted to stratify patients according to SIM scores to identify individuals who might benefit from early cystectomy.

PATIENT SUMMARY

In this study, we defined a risk score (the SIM score) based on the measurement of routine systemic inflammatory markers. This score can identify patients with high-grade bladder cancer not invading the muscular layer who are more likely to suffer from tumor recurrence and progression. Therefore, the score could be used to select patients who might benefit from early bladder removal.

High-Grade T1 on Re-Transurethral Resection after Initial High-Grade T1 Confers Worse Oncological Outcomes: Results of a Multi-Institutional Study

INTRODUCTION

The aim of this multicenter study was to investigate the prognostic impact of residual T1 high-grade (HG)/G3 tumors at re-transurethral resection (TUR of bladder tumor) in a large multi-institutional cohort of patients with primary T1 HG/G3 bladder cancer (BC).

PATIENTS AND METHODS

The study period was from January 2002 to -December 2012. A total of 1,046 patients with primary T1 HG/G3 and who had non-muscle invasive BC (NMIBC) on re-TUR followed by adjuvant intravesical Bacillus Calmette-Guerin (BCG) therapy with maintenance were included. Endpoints were time to disease recurrence, progression, and overall and cancer-specific death.

RESULTS

A total of 257 (24.6%) patients had residual T1 HG/G3 tumors. The presence of concomitant carcinoma in situ, multiple and large tumors (> 3 cm) at first TUR were associated with residual T1 HG/G3. Five-year recurrence-free survival (RFS), progression-free survival (PFS), overall survival (OS), and cancer-specific survival (CSS) were 17% (CI 11.8-23); 58.2% (CI 50.7-65); 73.7% (CI 66.3-79.7); and 84.5% (CI 77.8-89.3), respectively, in patients with residual T1 HG/G3, compared to 36.7% (CI 32.8-40.6); 71.4% (CI 67.3-75.2); 89.8% (CI 86.6-92.3); and 95.7% (CI 93.4-97.3), respectively, in patients with NMIBC other than T1 HG/G3 or T0 tumors. Residual T1 HG/G3 was independently associated with RFS, PFS, OS, and CSS in multivariable analyses.

CONCLUSIONS

Residual T1 HG/G3 tumor at re-TUR confers worse prognosis in patients with primary T1 HG/G3 treated with maintenance BCG. Patients with residual T1 HG/G3 for primary T1 HG/G3 are very likely to fail BCG therapy alone.

Abscess originating from osteomyelitis as a cause of lower urinary tract symptoms (LUTS) and acute urinary retention

Lower urinary tract symptoms (LUTS) are a common complaint in the general population with great impact on the quality of life. Besides the classical pathologies, there are less common causes that must be considered in the treatment approach for patients with LUTS. We present the case of a 30-year-old patient with multiple emergency department episodes with dysuria, urinary frequency, suprapubic pain and an episode of acute urinary retention. The blood and urine tests only revealed increased systemic inflammatory parameters. The ultrasound examination showed thickening of the bladder wall, and the CT scan revealed a retropubic abscess originating from a pubic symphysis osteomyelitis. A percutaneous drainage was performed and, after empirical antibiotic therapy, there was complete resolution of the clinical picture.

Using cystoscopy to segment bladder tumors with a multivariate approach in different color spaces

Nowadays the diagnosis of bladder lesions relies upon cystoscopy examination and depends on the interpreter's experience. State of the art of bladder tumor identification are based on 3D reconstruction, using CT images (Virtual Cystoscopy) or images where the structures are exalted with the use of pigmentation, but none uses white light cystoscopy images. An initial attempt to automatically identify tumoral tissue was already developed by the authors and this paper will develop this idea. Traditional cystoscopy images processing has a huge potential to improve early tumor detection and allows a more effective treatment. In this paper is described a multivariate approach to do segmentation of bladder cystoscopy images, that will be used to automatically detect and improve physician diagnose. Each region can be assumed as a normal distribution with specific parameters, leading to the assumption that the distribution of intensities is a Gaussian Mixture Model (GMM). Region of high grade and low grade tumors, usually appears with higher intensity than normal regions. This paper proposes a Maximum a Posteriori (MAP) approach based on pixel intensities read simultaneously in different color channels from RGB, HSV and CIELab color spaces. The Expectation-Maximization (EM) algorithm is used to estimate the best multivariate GMM parameters. Experimental results show that the proposed method does bladder tumor segmentation into two classes in a more efficient way in RGB even in cases where the tumor shape is not well defined. Results also show that the elimination of component L from CIELab color space does not allow definition of the tumor shape.

An update on prostate biopsy in the era of magnetic resonance imaging

INTRODUCTION

Prostate cancer (PCa) is a singular disease owing to absence of imaging technique able to detect suspicious glandular area at higher risk of disease. Nowadays, magnetic resonance imaging (MRI) has been used as a way to detect PCa and simplify targeting prostate biopsy (PB). The aim of this study is to review the most recent data regarding standard BP and MRI-guided PB.

EVIDENCE ACQUISITION

A comprehensive systematic MEDLINE search was performed in December 2017 for English-language reports by using the following terms: "prostate biopsy," "multiparametric magnetic resonance imaging," "prostate cancer," "transrectal and transperineal ultrasound," "target biopsy." Previous published reviews and recent published original articles were preferred in order to meet our study scope.

EVIDENCE SYNTHESIS

Retrieved studies of greater interest were reported in two main sections: standard PB and MRI-guided BP. Thus, the main items regarding PB were analyzed. Briefly, clinical suspicious of PCa is based on prostate specific antigen level and digital rectal examination findings although a PCa risk assessment through a nomogram risk calculator is nowadays advised. Ten-eighteen biopsy cores, depending on prostate volume, and peripheral sampling seem the suitable scheme for initial biopsy while a saturation template (>20 cores including transitional prostate area) is widely used in case of repeat PB. Performing a local anesthesia is now the standard of care with several available techniques. No difference exists in term of PCa detection rate between transperienal and transrectal approaches however the last one is mostly used. The use of MRI-guided biopsy seems to be a promising imaging technique able to identify an index lesion at higher suspicious of PCa. In particular, MRI shows a higher accuracy than standard PB in the detection of clinically significant PCa. No general consensus exists on which MRI-guided biopsy should be used with three different ways currently available to take biopsy core. However, the initial MRI cognitive PB has been replaced by fusion MRI technique to guide biopsy with reproducible results. Absence of standardization founded in initial MRI studies has been recently revised by introduction of common criteria to assess PCa presence on MRI.

CONCLUSIONS

PB is the cornerstone in diagnosis and management of PCa. Although ultrasound transrectal and transperineal PB are still considered as the standard, emerging data confirm the role of MRI-guided biopsy, particularly in patients with a previous negative biopsy. However, MRI costs and the moderate inter-reader reproducibility of the exam are still significant concerns requiring further studies to define the right role of MRI in the PCa diagnostic pathway.

Neuroprotective effect of melatonin against lipopolysaccharide-induced depressive-like behavior in mice

Accumulating evidence indicates an interaction between inflammation and depression since increased levels of pro-inflammatory cytokines are associated with depression-related symptoms. Melatonin is a hormone synthesized and secreted by the pineal gland with antioxidant, anti-inflammatory and antidepressant-like effects. In this way, it would be interesting to evaluate the putative antidepressant-like effect of melatonin treatment in an acute inflammation mice model of depression. The present study aimed to investigate the effect of melatonin treatment on lipopolysaccharide (LPS) induced depressive-like behavior, neuroinflammation, oxidative stress and alteration on brain-derived neurotrophic fator (BDNF) levels. Mice were treated with melatonin (10 mg/kg, i.p.) 30 min before LPS (0.5 mg/kg, i.p.) injection. Twenty-four hours after LPS infusion, mice were submitted to the behavioral tests and, thereafter, biochemical determinations were performed. Melatonin treatment prevented LPS-induced depressive-like behavior in the forced swim and tail suspension tests with no alterations in locomotor activity evaluated in the open field test. Melatonin attenuated LPS-induced increase in tumor necrosis factor-α (TNF-α) and reduction of BDNF levels in the hippocampus. Treatment with melatonin also prevented LPS-induced increase in lipid peroxidation and the reduction of glutathione levels in the hippocampus. In conclusion, the present study suggests that melatonin treatment exerted neuroprotective effects against LPS-induced depressive-like behavior which may be related to reduction of TNF-α release, oxidative stress and modulation of BDNF expression.

Bladder stone management: an update

INTRODUCTION

Bladder stone (BS) is a rare disease curable with several options. Herein, we reviewed the specific literature in order to update the current BS management.

EVIDENCE ACQUISITION

A comprehensive systematic MEDLINE search was performed for English language reports published before April 2017 using the BS related terms, i.e. bladder-vesical calculi, lithotripsy. Then manuscripts references were screened to identify unfounded studies. Studies regarding BS in children were excluded.

EVIDENCE SYNTHESIS

Retrieved studies were classified according to their main item as: etiology, diagnosis, treatment, treatment in specific illnesses and advances in BS management. Treatment option was mainly related to stone size and number as well as concomitant causative disease. However, stone nature was not analyzed in all the retrieved studies. Both trans-urethral and percutaneous lithotripsy were efficacy for stone fragmentation although the last one was suggested to avoid urethral injuries. Holmiun:Yag laser lithotripsy has made stone fragmentation feasible by using local anesthesia however in selected patients only. The urological dogma to perform concomitant prostate surgery in men with BS has been recently questioned by some observational case-series studies however, the lack of randomization and long follow up preserve that knowledge.

CONCLUSIONS

Bladder stone is a rare and ancient disease. Nowadays new technologies have been developed in the effort to make less invasive stone treatment. The retrieved studies show that stone fragmentation can be archived by using several surgical approaches and devices whereas comparative randomized studies are still unavailable to identify the best option.

Precision surgery and genitourinary cancers

The landscape of the surgical management of urologic malignancies has dramatically changed over the past 20 years. On one side, better diagnostic and prognostic tools allowed better patient selection and more reliable surgical planning. On the other hand, the implementation of minimally invasive techniques and technologies, such as robot-assisted laparoscopy surgery and image-guided surgery, allowed minimizing surgical morbidity. Ultimately, these advances have translated into a more tailored approach to the management of urologic cancer patients. Following the paradigm of "precision medicine", contemporary urologic surgery has entered a technology-driven era of "precision surgery", which entails a range of surgical procedures tailored to combine maximal treatment efficacy with minimal impact on patient function and health related quality of life. Aim of this non-systematic review is to provide a critical analysis of the most recent advances in the field of surgical uro-oncology, and to define the current and future role of "precision surgery" in the management of genitourinary cancers.

Presence and severity of lower urinary tract symptoms are inversely correlated with the risk of prostate cancer on prostate biopsy

BACKGROUND

The assessment of lower urinary tract symptoms (LUTS) is common part of urological investigation. Furthermore, patients bother of prostate cancer (PCa) when they are affected of LUTS. This study was aimed to determine whether the presence and severity of LUTS, as assessed by the International Prostate Symptoms Score (IPSS), could help to identify patients at higher risk of prostate cancer (PCa) on prostate biopsy (PBx). In this effort, an initial PCa predictive model was calculated and IPSS was subsequently added. The diagnostic accuracy of both models was compared.

METHODS

The analysis of prospectively collected data of patients scheduled for PBx at four academic hospitals between January 2012 and June 2015 was performed. Univariate and multivariate analysis assessed the correlation between the IPSS and the risk of being diagnosed with PCa; Receiver operator characteristic curve (ROC) analysis evaluated the predictive models including or not the IPSS.

RESULTS

Of the 1366 enrolled patients, 706 (52%) were diagnosed with PCa. Patients with PCa had a significantly lower IPSS (10.6±7.4 vs. 12.7±8.1) than those with benign diagnosis. Multivariate logistic regression analysis showed that age, prostate-specific antigen (PSA), prostate volume and IPSS were the most significant predictors of PBx outcome, (OR 1.61, P=0.001; OR 1.20, P=0.001; OR 0.97, P=0.001; OR 0.74, P=0.004; respectively). ROC curve analysis showed that the addition of IPSS to the predictive model based on age, PSA, DRE and prostate volume significantly improved the model diagnostic accuracy (AUC: 0.776 vs. 0.652; P=0.001).

CONCLUSIONS

Presence and severity of LUTS are inversely correlated with the risk of being diagnosed with PCa at PBx. Incorporating the IPSS into predictive models may reduce the risk of unnecessary PBxs.

A novel hydrogel of poloxamer 407 and chitosan obtained by gamma irradiation exhibits physicochemical properties for wound management

Application of polymers cross-linked by gamma irradiation on cutaneous wounds has resulted in the improvement of healing. Chitosan (CH) and poloxamer 407 (P407)-based hydrogels confer different advantages in wound management. To combine the properties of both compounds, a gamma-irradiated mixture of 0.75/25% (w/w) CH and P407, respectively, was obtained (CH-P), and several physical, chemical, and biological analyses were performed. Notably, gamma radiation induced changes in the mixture's thermal behavior, viscosity, and swelling, and exhibited stability at neutral pH. The thermal reversibility provided by P407 and the bacteriostatic effect of CH were maintained. Mice full-thickness wounds treated with CH-P diminished the wound area during the first days. Consequently, with this treatment, increased levels of macrophages, α-SMA, and collagen deposition in wounds were observed, indicating a more mature scar tissue. In conclusion, the new hydrogel CH-P, at physiologic pH, combined the beneficial characteristics of both polymers and produced new properties for wound management.

Metabolic syndrome diagnosis and widespread high grade prostatic intraepithelial neoplasia significantly increase prostate cancer risk: results from a multicenter biopsy study

Background

To test in multicenter setting if patients affected of metabolic syndrome (MetS) and initial widespread high grade prostatic intraepithelial neoplasia (wHGPIN) diagnosis are at higher risk of prostate cancer (PCa) on repeat biopsy.

Methods

Patients clinical charts from three European Academic Hospital were reviewed in order to identify patients with initial diagnosis of HGPIN undergone to repeat biopsy. Inclusion and exclusion criteria were adopted to minimize patient heterogeneity. MetS was defined according to Word Heart Organization criteria while initial wHGPIN when ≥4 cores biopsy were involved. A multivariate logistic model was computed to assess the association between PCa and clinical-pathological variables.

Results

Overall 283 patients were scheduled. Median age was 67 years (IQR 62–72). MetS was diagnosed in 116/283 (41 %) patients and PCa was detected in 84/283 (29.7 %) patients.

In particular, PCa was more frequently diagnosed in patients affected of wHGPIN and MetS (45/86, 52.3 %) than in patients with wHGPIN and normal metabolic profile (28/95, 29.5 %), p = 0.002. The multivariate logistic model confirmed that wHGPIN and MetS are independent risk factors for following PCa diagnosis, respectively OR 2.4 (95 % CI 1.01–5.71, p = 0.04), OR 2.79 (95 % CI 1.49–5.22, p = 0.01) while total PSA and DRE findings are not able to predict PCa at repeat biopsy, OR 1.05 (95 % CI 0.98–1.03 p = 0.69) and OR 1.01 (95 % CI 0.55–1.84, p = 0.96) respectively.

Conclusions

wHGPIN is positively associated to PCa; assessing metabolic profile and repeat prostate biopsy is advisable in patients with initial diagnosis of wHGPIN.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-016-2085-8) contains supplementary material, which is available to authorized users.

Polymorphism of the CYP2D6 gene in women with breast cancer treated with tamoxifen

OBJECTIVE

To evaluate polymorphism frequency of the CYP2D6*4, *10, and * 17 alleles in women with breast cancer treated with tamoxifen.

MATERIALS AND METHODS

Ninety-five women with estrogen and progesterone receptor-positive breast carcinoma were investigated from September to December 2013. A three-ml sample of peripheral blood was collected from each patient to analyze the presence of CYP2D6 *4, *10, and *17 allele polymorphism by specific polymerase chain reaction technique (PCR) for analysis of haplotypes *1, *4, *10, and *17, determined by studies of different single-nucleotide polymorphism (SNP). The data obtained were compiled and analyzed with the aid of Excel software 2010.

RESULTS

The frequency of CYP2D6 alleles *4, *10, and *17 was 16%, 29%, and 2%, respectively, and haplotype * 1/*10 was shown in 22% of the women. The phenotype of intermediate metabolism occurred in 8% of women.

CONCLUSIONS

The present study showed a deficiency in tamoxifen metabolism, characterized by intermediate metabolism in 8% of Brazilian women.