A machine-learning-based combination of criteria to detect bladder cancer lymph node metastasis on [18F]FDG PET/CT: a pathology-controlled study.

OBJECTIVES: Initial pelvic lymph node (LN) staging is pivotal for treatment planification in patients with muscle-invasive bladder cancer (MIBC), but [18F]FDG PET/CT provides insufficient and variable diagnostic performance. We aimed to develop and validate a machine-learning-based combination of criteria on [18F]FDG PET/CT to accurately identify pelvic LN involvement in bladder cancer patients. METHODS: Consecutive patients with localized MIBC who performed preoperative [18F]FDG PET/CT between 2010 and 2017 were retrospectively assigned to training (n = 129) and validation (n = 44) sets. The reference standard was the pathological status after extended pelvic LN dissection. In the training set, a random forest algorithm identified the combination of criteria that best predicted LN status. The diagnostic performances (AUC) and interrater agreement of this combination of criteria were compared to a consensus of experts. RESULTS: The overall prevalence of pelvic LN involvement was 24% (n = 41/173). In the training set, the top 3 features were derived from pelvic LNs (SUVmax of the most intense LN, and product of diameters of the largest LN) and primary bladder tumor (product of diameters). In the validation set, diagnostic performance did not differ significantly between the combination of criteria (AUC = 0.59 95%CI [0.43-0.73]) and the consensus of experts (AUC = 0.64 95%CI [0.48-0.78], p = 0.54). The interrater agreement was equally good with Κ = 0.66 for both. CONCLUSION: The developed machine-learning-based combination of criteria performs as well as a consensus of experts to detect pelvic LN involvement on [18F]FDG PET/CT in patients with MIBC. KEY POINTS: • The developed machine-learning-based combination of criteria performs as well as experts to detect pelvic LN involvement on [18F]FDG PET/CT in patients with muscle-invasive bladder cancer. • The top 3 features to predict LN involvement were the SUVmax of the most intense LN, the product of diameters of the largest LN, and the product of diameters of the primary bladder tumor.

The Role of Cost-Effectiveness Analysis in Patient-Centered Cancer Care in the Era of Precision Medicine.

Over the last few decades, changes in diagnostic and treatment paradigms have greatly advanced cancer care and improved outcomes [...].

The Role of 18F-FDG PET/CT in Guiding Precision Medicine for Invasive Bladder Carcinoma.

Bladder cancer (BC) is the 10th most common cancer worldwide. Approximately one quarter of patients with BC have muscle-invasive disease (MIBC). Muscle-invasive disease carries a poor prognosis and choosing the optimal treatment option is critical to improve patients' outcomes. Ongoing research supports the role of 2-deoxy-2-(18F)fluoro-D-glucose positron emission tomography (18F-FDG PET) in guiding patient-specific management decisions throughout the course of MIBC. As an imaging modality, 18F-FDG PET is acquired simultaneously with either computed tomography (CT) or MRI to offer a hybrid approach combining anatomical and metabolic information that complement each other. At initial staging, 18F-FDG PET/CT enhances the detection of extravesical disease, particularly in patients classified as oligometastatic by conventional imaging. 18F-FDG PET/CT has value in monitoring response to neoadjuvant and systemic chemotherapy, as well as in localizing relapse after treatment. In the new era of immunotherapy, 18F-FDG PET/CT may also be useful to monitor treatment efficacy as well as to detect immune-related adverse events. With the advent of artificial intelligence techniques such as radiomics and deep learning, these hybrid medical images can be mined for quantitative data, providing incremental value over current standard-of-care clinical and biological data. This approach has the potential to produce a major paradigm shift toward data-driven precision medicine with the ultimate goal of personalized medicine. In this review, we highlight current literature reporting the role of 18F-FDG PET in supporting personalized management decisions for patients with MIBC. Specific topics reviewed include the incremental value of 18F-FDG PET in prognostication, pre-operative planning, response assessment, prediction of recurrence, and diagnosing drug toxicity.

Adjuvant Single-Dose Upper Urinary Tract Instillation of Mitomycin C After Therapeutic Ureteroscopy for Upper Tract Urothelial Carcinoma: A Single-Centre Prospective Non-Randomized Trial.

Purpose: To address the safety and feasibility of adjuvant single-dose upper urinary tract instillation of mitomycin (ASDM) immediately after therapeutic ureteroscopy for upper tract urothelial carcinoma (UTUC) and to compare urothelial (ipsilateral or bladder) recurrence rates in the ASDM group and controls. Materials and Methods: Between April 2015 and August 2018, 52 patients affected by UTUC were treated by endoscopic ablation, of whom 26 were selected for ASDM. Clinical and perioperative data and 30-day complications were recorded. Urothelial recurrence-free survival (URFS) was evaluated with second-look ureteroscopy (URS) and CT scan/URS every 6 months. Results: ASDM was administered through a Single-J (19/25, 76%) or a Double-J (6/25, 24%) in 25/26 (96%) patients. Median follow-up was 18 months (IQR 10-29). The urothelial recurrence rate was 23.5% and 55.5% in the ASDM group and controls, respectively (p = 0.086). Mean URFS was 28.8 months in the ASDM group vs 18.8 months in controls (log-rank p = 0.067). On multivariate Cox regression, ASDM was associated with a 7.7-fold lower risk of urothelial recurrence (HR = 0.13; 95% CI 0.03-0.65; p = 0.01). Clavien grade ≤II complications occurred in 32% (8/25) and 30.7% (8/26) of the ASDM and control group, respectively (p = 0.9). Two Clavien III complications occurred in the ASDM group: bladder hematuria after concomitant transurethral resection of bladder and obstructive kidney failure in a single-kidney patient. Conclusions: ASDM was well tolerated after therapeutic URS. It appears to reduce the risk of urothelial recurrence in patients affected by low-grade UTUC without bladder tumor. Therefore, its use should be evaluated.

Carcinoma In Situ of the Urinary Bladder: A Systematic Review of Current Knowledge Regarding Detection, Treatment, and Outcomes.

CONTEXT: Carcinoma in situ (CIS) of the bladder is defined as a high-grade flat lesion confined to the mucosa. Intravesical treatment with bacillus Calmette-Guérin (BCG) is commonly used to reduce the risk of recurrence and progression; however, CIS of the bladder exhibits a heterogeneous clinical behavior and a significant proportion of patients do not show a primary response. OBJECTIVE: To evaluate the available evidence concerning diagnosis, treatment strategies, follow-up, prognosis, and oncological outcomes in patients with CIS of the bladder. EVIDENCE ACQUISITION: A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search was conducted using the databases PubMed/MEDLINE and Embase. We included randomized controlled trials, systematic reviews, meta-analyses, and observational studies. Outcomes of interest were: (1) diagnostic strategies, (2) first- and second-line treatments, (3) follow-up strategies, and (4) prognosis and oncological outcomes. EVIDENCE SYNTHESIS: Overall 62 articles met the inclusion criteria. Most articles concerned retrospective studies and presented mixed data with other non-muscle-invasive bladder cancer categories. The evidence shows that new optical imaging modalities significantly increase the detection rate of CIS. BCG immunotherapy remains the first-line therapy in patients with CIS of the bladder; however, after treatment, adequate follow-up is necessary. Clinicopathological factors remain the main indicators of response to BCG, recurrence, and progression. CONCLUSIONS: New optical imaging modalities are superior to white light cystoscopy in the detection of CIS of the bladder. There are no robust data that justify consideration of other agents as an alternative to BCG immunotherapy. Despite efforts to identify relevant biomarkers, clinicopathological factors remain the most important prognostic factors. PATIENT SUMMARY: New optical techniques have improved the detection of carcinoma in situ (CIS) of the bladder. Bladder preservation using bacillus Calmette-Guérin immunotherapy remains the cornerstone of the treatment of CIS of the bladder.

Robotic radical cystectomy.

OBJECTIVES: Radical cystectomy (RC) is one of the most complex and morbid surgical procedures in Urology. Several retrospective and prospective studies have demonstrated that robotic-assisted RC (RARC) represents a minimally invasive alternative to open surgery, showing non-inferiority in mid-term oncological outcomes. Moreover, important advantages related with  perioperative complications have also been published. The aim of this article is to describe RARC surgical steps and to review the most relevant ndings in the eld of RARC, focusing on its strengths and weaknesses when compared with open RC. METHODS: We performed a detailed step-by-step description of the RARC surgical technique, paying particular attention to its specific surgical details and adding our tips and tricks for an out standing performance. We also conducted a review of the most relevant articles in literature in terms of oncological, pathological and perioperative results. All these findings have been compared with the classical open radical cystectomy (ORC) technique. RESULTS: None of the studies published have demonstrated RARC to have worse oncological outcomes (PSM,RFS, CSS, OS) compared to ORC. RARC shows a decrease in blood loss and transfusion rates. No differences have been observed in complications rate, length of hospital stay, quality of life, and time to bowel movement between both approaches. The two disadvantages of RARC compared to ORC are a longer operative time and increased cost. Operating time can be reduced with surgeons gaining experience and technique standardization. The cost disparities and operative time between ORC and RARC at high-volume academic centers are less pronounced than in the general medical community. CONCLUSIONS: RARC is a technically feasible and safe approach, with oncological, pathological and perioperative results, at least, equivalent to ORC.

ARTICULO SOLO EN INGLES.OBJETIVO: La cistectomía radical (CR) esuno de los procedimientos quirúrgicos más complejosy con mayor morbilidad. Varios estudios retrospectivosy prospectivos han demostrado que la CR asistida porrobot (CRAR) representa una alternativa mínimamente invasivaa la cirugía abierta, mostrando no inferioridad enlos resultados oncológicos a medio plazo. Además, sehan publicado importantes ventajas en relación con lascomplicaciones peroperatorias. El objetivo de este artículoes describir los pasos quirúrgicos de la CRAR y revisarlos hallazgos más relevantes en el campo de la CRAR,focalizando en sus fortalezas y debilidades cuando secomparan con la CR abierta. MÉTODOS: Realizamos una descripción paso a paso,detallada, de la técnica quirúrgica de CRAR, poniendoparticular atención a sus detalles quirúrgicos específicos yañadiendo nuestros trucos y consejos para una ejecución excelente. También realizamos una revisión de los artículos más relevantes de la literatura en términos de resultadosoncológicos, patológicos y peroperatorios. Todosestos hallazgos se han comparado con los de la técnicaclásica de cistectomía radical abierta (CRA). RESULTADOS: Ninguno de los estudios publicados hademostrado que la CRAR tenga peores resultados oncológicos(márgenes quirúrgicos positivos, supervivencia librede recurrencia, cáncer específica y global) en comparación con la CRA. La CRAR muestra un descenso del sangradoy las tasas de transfusión. No se han observadodiferencias entre ambos abordajes en las tasas de complicaciones,estancias hospitalarias, calidad de vida y eltiempo hasta la deposición. Dos desventajas de la CRARen comparación con la CRA son el tiempo operatoriomás largo y el aumento del coste. El tiempo operatorio puede reducirse con el aumento de la experiencia de loscirujanos y la estandarización de la técnica. Las disparidadesen los costes y la duración de la cirugía son menospronunciadas en centros académicos de gran volumen que en los de la comunidad médica general. CONCLUSIONES: La CRAR es un abordaje técnicamentefactible y seguro, con resultados oncológicos, patológicosy peroperatorios, al menos, equivalentes a los dela CRA.

Obesity in percutaneous nephrolithotomy. Is body mass index really important?

OBJECTIVE: To evaluate the influence of obesity in the results of percutaneous nephrolithotomy (PCNL) in terms of efficacy and safety and to evaluate other aspects such as fluoroscopy time, radiation exposure, total operative time, hemoglobin loss, hospital stay, and the need of auxiliary procedures. MATERIALS AND METHODS: We evaluated prospectively all the PCNLs performed at our institution between 2011 and 2012. A series of perioperative and postoperative details were recorded in our database. The patients were distributed in 4 groups using World Health Organization's classification of body mass index (BMI): normal weight, ≤ 25 kg/m(2); overweight, 25-29.9 kg/m(2); obese, 30-39.9 kg/m(2); and morbidly obese, ≥ 40 kg/m(2). Modified Clavien classification was used for reporting the complications. Results were compared between the groups using the chi square and multivariate logistic regression tests. RESULTS: A total of 255 procedures were performed between January 2011 and December 2012. Overall stone clearance was 76.3% and complication rate using the modified Clavien grading system was 31.4%. No statistical differences in terms of complication rate and stone free rate were noted between the 4 groups. Total operative time and radiation doses increase along with BMI. No difference was found in fluoroscopy time, failure to gain access, hospital stay, or need for auxiliary procedures. CONCLUSION: Obesity does not increase complications in PCNL, and the efficacy of the technique is similar to normal weight patients with appropriate expertise. Total operative time and radiation exposure increase along with BMI, putting patients at risk.