18 F-DCFPyL positron emission tomography/magnetic resonance imaging-guided ultrasound fusion biopsy is an identical pathway in prostate cancer diagnosis.

BACKGROUND: Prostate biopsy is still unavoidable in patients with a rising prostate-specific antigen even though multiparametric magnetic resonance imaging (MRI) is widely used. 18 F-DCFPyL positron emission tomography (PET)/MRI was proved to be promising both in sensitivity and specificity. But its guiding fusion biopsy and the advantages in the diagnosis of prostate disease is seldom reported. This study aimed to verify the feasibility and advantage of 18 F-DCFPyL PET/MRI-guided fusion targeted biopsy (TB) over whole-mount histopathology (WMH) for prostate cancer diagnosis. METHODS: A prospective study of 94 biopsy-naïve patients were conducted using 18 F-DCFPyL PET/MRI scans and scored on a scale of 1-4. Systematic biopsy was performed for all patients. Patients with suspicious lesions also underwent PET/MRI/transrectal ultrasound-guided fusion biopsy. Patients with pathologically confirmed cancer underwent surgery and WMH sections. Systematic biopsy was compared with TB for the detection of index tumors (ITs). Significant cancer was defined as Grade group (GG) 2 or higher no matter the length of the cancer core. RESULTS: 18 F-DCFPyL PET/MRI detected 30/94 (32%) patients with a score of 4, all of whom were verified to have prostate cancer. While it detected 10 patients with a score of 1 (10.6%), they were shown to have no cancer. The sensitivity and specificity of 18 F-DCFPyL PET/MRI were 94.4% and 75%, respectively, if images with a score of 3 are defined as positive. Systematic biopsy detected 18% (203/1128) samples as prostate cancer; conversely, TB detected 113 samples out of 259 scores (43.6%). A statistically significant difference was seen between the PCa detection rates by TB and SB (p < 0.001). All targeted lesions were pathologically proven to be the IT on WMH. CONCLUSIONS: In biopsy-naïve patients, the ultrasound fusion biopsy targeted by 18 F-DCFPyL PET/MRI is an identical pathway for the detection of prostate cancer.

Mechanism of tumor-derived extracellular vesicles in prostatic cancer progression through the circFMN2/KLF2/RNF128 axis.

Circular RNAs (circRNAs) are a major type of cargos encapsulated in extracellular vesicles (EVs) and regulate the progression of prostatic cancer (PC). This study was conducted to explore the role of tumor-derived EVs in PC cell proliferation, invasion, and migration via shuttle of circRNA formin 2 (circFMN2). RT-qPCR or Western blot assay showed that circFMN2 was upregulated while KLF2 and RNF128 were downregulated in PC tissues and cells. EVs were separated from PC cells and characterized and its internalization in PC cells was examined, which suggested that PC-EVs mediated the shuttle of circFMN2 to upregulate circFMN2 expression in PC cells. PC cell functions were determined by cell counting kit-8, colony formation and Transwell assays, which suggested that PC-EVs fueled the proliferation, invasion, and migration of PC cells. At cellular level, PC-EVs mediated the shuttle of circFMN2 to upregulate circFMN2 expression in PC cells, and circFMN2 binding to HuR decreased the HuR-KLF2 interaction and repressed KLF2 expression, which further reduced the KLF2-RNF128 promoter binding and repressed RNF128 transcription. Overexpression of KLF2/RNF128 ablated the effects of PC-EVs on the proliferation, invasion, and migration of PC cells. The xenograft tumor models and lung/liver metastasis models were established and revealed that PC-EVs accelerated tumorigenesis and metastasis in vivo via delivery of circFMN2 and repression of KLF2/RNF128.

Robotic Level IV Inferior Vena Cava Thrombectomy Using an Intrapericardial Control Technique: Is It Safe Without Cardiopulmonary Bypass?

PURPOSE: We introduce an intrapericardial control technique using a robotic approach in the surgical treatment of renal tumor with level IV inferior vena cava thrombus to decrease the severe complications associated with cardiopulmonary bypass and deep hypothermic circulatory arrest. MATERIALS AND METHODS: Eight patients with level IV inferior vena cava thrombi not extending into the atrium underwent transabdominal-transdiaphragmatic robot-assisted inferior vena cava thrombectomy obviating cardiopulmonary bypass/deep hypothermic circulatory arrest (cardiopulmonary bypass-free group) by an expert team comprising urological, hepatobiliary, and cardiovascular surgeons. The central diaphragm tendon and pericardium were transabdominally dissected until the intrapericardial inferior vena cava were exposed and looped proximal to the cranial end of the thrombi under intraoperative ultrasound guidance. As controls, 14 patients who underwent robot-assisted inferior vena cava thrombectomy with cardiopulmonary bypass (cardiopulmonary bypass group) and 25 patients who underwent open thrombectomy with cardiopulmonary bypass/deep hypothermic circulatory arrest (cardiopulmonary bypass/deep hypothermic circulatory arrest group) were included. Clinicopathological, operative, and survival outcomes were retrospectively analyzed. RESULTS: Eight robot-assisted inferior vena cava thrombectomies were successfully performed without cardiopulmonary bypass, with 1 open conversion. The median operation time and first porta hepatis occlusion time were shorter, and estimated blood loss was lower in the cardiopulmonary bypass-free group as compared to the cardiopulmonary bypass group (540 vs 586.5 minutes, 16.5 vs 38.5. minutes, and 2,050 vs 3,500 mL, respectively). Severe complications (level IV-V) were also lower in the cardiopulmonary bypass-free group than in cardiopulmonary bypass and cardiopulmonary bypass/deep hypothermic circulatory arrest groups (25% vs 50% vs 40%). Oncologic outcomes were comparable among the 3 groups in short-term follow-up. CONCLUSIONS: Pure transabdominal-transdiaphragmatic robot-assisted inferior vena cava thrombectomy without cardiopulmonary bypass/deep hypothermic circulatory arrest represents as an alternative minimally invasive approach for selected level IV inferior vena cava thrombi.

Transurethral Hem-o-lok Clip Ligation of the Distal Ureter in Retroperitoneal Laparoscopic Radical Nephroureterectomy.

BACKGROUND AND OBJECTIVE: Distal ureter management is an essential part of radical nephroureterectomy (RNU). However, there is no agreement on the optimal surgical treatment for ureter and bladder cuff excision. The classical "pluck" technique following transurethral resection of the intramural ureter increases the risk of extravesical and intravesical tumor cell spillage. We aimed to provide a simple transurethral technique with the Hem-o-lok clip ligation for the management of the distal ureter during retroperitoneal laparoscopic RNU. METHODS: Transurethral resection of the bladder cuff was performed using a bipolar ß electrode mounted on resectoscope. Subsequently, a Super Scope (S-scope) with a 5.6-mm diameter working channel was used with a clip applier to deliver the 5-mm Hem-o-lok clips, which consequently ligated the ureteral stump and avoided urine spillage from the upper tract. Traditional retroperitoneal laparoscopic surgery was used to treat the renal and upper ureter. The resected distal ureter and the Hem-o-lok clip were gently pulled out of the bladder by the "pluck" technique. RESULTS: A total of 14 upper tract urothelial carcinoma patients were analyzed, including 10 men and 4 women. The Hem-o-lok clip ligation took less than 20 s. In each patient, the clip was clearly visible and attached tightly to the ureter, and a clear distal ureter was observed in all patients. Histopathology results showed pT2 in 8 and pT3 in 6 patients. A median follow-up of 15 months revealed no extravesicular or intravesicular recurrences. CONCLUSIONS: Transurethral Hem-o-lok clip ligation technique provides a simple and safe option for distal ureter management in retroperitoneal laparoscopic RNU. This novel approach enables construction of a watertight system of the upper urinary tract, preventing the spread of tumor cells effectively and minimizing local tumor implantation risk.

Role of intraoperative ultrasound in robotic-assisted radical nephrectomy with inferior vena cava thrombectomy in renal cell carcinoma.

PURPOSE: To determine the impact of intraoperative ultrasound on robotic-assisted radical nephrectomy with inferior vena cava (IVC) tumor thrombectomy in renal cell carcinoma (RCC). METHODS: We retrospectively analyzed intraoperative records of 27 patients with RCC and invasion of the IVC who underwent robotic-assisted nephrectomy with tumor thrombectomy at our center between December 2017 and July 2018. Diagnostic utility and impact of intraoperative transesophageal echocardiography (TEE), intraoperative robotic-assisted ultrasonography, and intraoperative contrast-enhanced ultrasound (CEUS) on surgical management were extracted from the surgical notes and intraoperative ultrasound reports. RESULTS: Twenty-seven patients with thrombus had intraoperative ultrasound. Complete tumor removal was achieved in 22 patients, IVC transection in 5 patients, and no residual tumor was observed in all patients. Intraoperative TEE changed the robotic surgical strategy in three patients by monitoring thrombus-level regression. Downstaging of the thrombus level occurred in three patients: Levels IV to III in one and Levels III to II in two. Intraoperative robotic-assisted ultrasonography has facilitated safe VC clamp placement and identification and protection of collateral vessels during IVC transection in five patients. Intraoperative CEUS helped to differentiate the boundary between tumor thrombus (enhancement and small vessel pulsation) and bland thrombus (hypoechoic or no enhancement) in eight (29.6%) patients with bland thrombus. CONCLUSIONS: Intraoperative ultrasound is a safe, minimally invasive technique that can provide accurate real-time information regarding the presence and extent of IVC involvement and guidance for placement of a vena cava clamp, confirming the character of the thrombus to plan an optimal surgical approach.

Automated lesion detection on MRI scans using combined unsupervised and supervised methods.

BACKGROUND: Accurate and precise detection of brain lesions on MR images (MRI) is paramount for accurately relating lesion location to impaired behavior. In this paper, we present a novel method to automatically detect brain lesions from a T1-weighted 3D MRI. The proposed method combines the advantages of both unsupervised and supervised methods. METHODS: First, unsupervised methods perform a unified segmentation normalization to warp images from the native space into a standard space and to generate probability maps for different tissue types, e.g., gray matter, white matter and fluid. This allows us to construct an initial lesion probability map by comparing the normalized MRI to healthy control subjects. Then, we perform non-rigid and reversible atlas-based registration to refine the probability maps of gray matter, white matter, external CSF, ventricle, and lesions. These probability maps are combined with the normalized MRI to construct three types of features, with which we use supervised methods to train three support vector machine (SVM) classifiers for a combined classifier. Finally, the combined classifier is used to accomplish lesion detection. RESULTS: We tested this method using T1-weighted MRIs from 60 in-house stroke patients. Using leave-one-out cross validation, the proposed method can achieve an average Dice coefficient of 73.1% when compared to lesion maps hand-delineated by trained neurologists. Furthermore, we tested the proposed method on the T1-weighted MRIs in the MICCAI BRATS 2012 dataset. The proposed method can achieve an average Dice coefficient of 66.5% in comparison to the expert annotated tumor maps provided in MICCAI BRATS 2012 dataset. In addition, on these two test datasets, the proposed method shows competitive performance to three state-of-the-art methods, including Stamatakis et al., Seghier et al., and Sanjuan et al. CONCLUSIONS: In this paper, we introduced a novel automated procedure for lesion detection from T1-weighted MRIs by combining both an unsupervised and a supervised component. In the unsupervised component, we proposed a method to identify lesioned hemisphere to help normalize the patient MRI with lesions and initialize/refine a lesion probability map. In the supervised component, we extracted three different-order statistical features from both the tissue/lesion probability maps obtained from the unsupervised component and the original MRI intensity. Three support vector machine classifiers are then trained for the three features respectively and combined for final voxel-based lesion classification.

Short-term and long-term outcomes of intracorporeal "V-O manner" ureter-ileal anastomosis in robotic-assisted laparoscopic radical cystectomy with urinary diversion: a retrospective cohort study.

Background: There are several ways to perform ureter-ileal anastomosis (UIA), but there is currently no universally recognized standard approach. Unfortunately, these approaches may increase the risk of urine leakage or stricture. The aim of this study is we to describe an intracorporeal "V-O manner" UIA in robotic-assisted laparoscopic radical cystectomy (RARC) with urinary diversion, and to evaluate the short- and long-term patient outcomes. Methods: Between May 2012 and September 2018, 28 patients of bladder urothelial carcinomas (clinical stage T2-4aN0M0) who underwent RARC with intracorporeal urinary diversion (IUD) were included. All the patients received regular postoperative follow-up for 6-76 months. During the procedure of intracorporeal diversion, a "V-O manner" of UIA imitating the pyeloplasty in ureteropelvic junction (UPJ) obstruction was used to perform a mucosa-to-mucosa anastomosis. We observed short-term outcomes (operative time, blood loss, transfusion rate, length of hospital stay, 90-day mortality, and surgical complications) as well as long-term outcomes including kidney function and urinary diversion. Results: Intracorporeal orthotopic ileal neobladder (OIN) was performed in 23 patients whereas intracorporeal ileal conduit (ICD) was performed in 5 patients. The "V-O manner" UIA was applied in all the cases. The average duration of bilateral UIA was about 40 min. The median pelvic lymph node yield was 26 (range, 14-43). All patients ambulated on postoperative 2 to 3 days, and bowel function recovered on postoperative day 3 to 4. The median length of hospital stay was 14 days [interquartile range (IQR), 9-18 days]. A total of 9 patients experienced complications. Postoperative images confirmed satisfying drainage of bilateral ureters without urine leakage or stricture. During the follow up (median 29 months), all participants showed normal renal functions with satisfactory urinary diversion without hydronephrosis. Conclusions: We describe a feasible intracorporeal "V-O manner" UIA in RARC with urinary diversion, which provides improved outcomes in avoiding urine leakage or stricture and preventing the occurrence of hydronephrosis. Larger randomized controlled trials and longer duration of follow-up needs to be required in the future.

Proof-of-Concept: A Hands-Free Interface for Robot-Assisted Self-Feeding.

Eating and drinking is an essential part of every-day life. And yet, there are many people in the world today who rely on others to feed them. In this work, we present a prototype robot-assisted self-feeding system for individuals with movement disorders. The system is capable of perceiving, localizing, grasping, and delivering non-compliant food items to an individual. We trained an object recognition network to detect specific food items, and we compute the grasp pose for each item. Human input is obtained through an interface consisting of an eye-tracker and a display screen. The human selects options on the monitor with their eye and head movements and triggers responses with mouth movements. We performed a pilot study with four able-bodied participants and one participant with a spinal cord injury (SCI) to evaluate the performance of our prototype system. Participants selected food items with their eye movements, which were then delivered by the robot. We observed an average overall feeding success rate of 89.1% and an average overall task time of $31.4 \pm 2.4$ seconds per food item. The SCI participant gave scores of 90.0 and 8.3 on the System Usability Scale and NASA Task Load Index, respectively. We also conducted a custom, post-study interview to gather participant feedback to drive future design decisions. The quantitative results and qualitative user feedback demonstrate the feasibility of robot-assisted self-feeding and justify continued research into mealtime-related assistive devices.

A Pilot Study of 18F-DCFPyL PET/CT or PET/MRI and Ultrasound Fusion Targeted Prostate Biopsy for Intra-Prostatic PET-Positive Lesions.

OBJECTIVES: The purpose of this study was to evaluate the feasibility and diagnostic performance of prostate-specific membrane antigen (PSMA) based 18F-DCFPyL PET/CT-ultrasound (PET/CT-US) or PET/MRI-ultrasound (PET/MRI-US) fusion targeted biopsy for intra-prostatic PET-positive lesions. METHODS: From April 2018 to November 2019, we prospectively enrolled 55 candidates to perform PET/CT-US or PET/MRI-US fusion targeted biopsies for solitary PET-positive prostate lesions (two to four cores/lesion). The positive rates of prostate cancer based on patients and biopsy cores were calculated respectively. With reference to the pathological results of biopsy cores, the MR signal characteristics in the area of the PET-positive lesion were analyzed for the patients who underwent PET/MRI. RESULTS: A total of 178 biopsy cores were taken on the 55 patients. One hundred forty-six biopsy cores (82.0%, 146/178) from 51 (92.7%, 51/55) patients were positive for prostate cancer; 47 (85.5%, 47/55) were clinically significant prostate cancer. It is noteworthy that nine patients underwent both 18F-DCFPyL PET/CT and PET/MRI examinations; the seven patients with prostate cancer showed abnormal MR signal in the area of the PET-positive lesion while the other two patients with prostatic hyperplasia and prostatitis showed normal MR signal in the area of the PET-positive lesion. CONCLUSION: This study indicated that 18F-DCFPyL PET/CT-US or PET/MRI-US fusion targeted prostate biopsies may be valuable for prostate cancer diagnosis and have a high detection rate of clinically significant prostate cancer for PET-positive lesions. PET/MR can rule out some false PET-positive lesions, which may potentially reduce unnecessary prostate biopsies.

Comparison of 18F-DCFPyL and 18F-FDG PET/computed tomography for the restaging of clear cell renal cell carcinoma: preliminary results of 15 patients.

OBJECTIVES: This study aimed to compare the diagnostic performance of F-DCFPyL and 2-deoxy-2-[F]fluoro-D-glucose (F-FDG PET/computed tomography in the restaging of clear cell renal cell carcinoma after nephrectomy. METHODS: In this retrospective study, a total of 15 patients with suspected local recurrence of clear cell renal cell carcinoma or metastasis after surgery underwent both F-DCFPyL and F-FDG PET/computed tomography. A systematic comparison of the maximum standardized uptake value and the target to background ratio was carried out between the lesions detected by the two tracers. RESULTS: A total of 42 lesions were detected either by F-DCFPyL PET/computed tomography or by F-FDG PET/computed tomography. F-DCFPyL PET/computed tomography, but not F-FDG PET/computed tomography, accurately distinguished the two local recurrence from four postoperative changes. The remaining 36 lesions were soft tissue (14) and bone lesions (22); all 36 lesions were detected by F-DCFPyL PET/computed tomography while only 10 (10/14) soft tissue lesions and 12 (12/22) bone lesions were detected by F-FDG PET/computed tomography. The higher detection rate of soft tissue lesions using F-DCFPyL PET/computed tomography was not statistically significant (P = 0.125); however, F-DCFPyL PET/computed tomography was statistically better (P = 0.002) at detecting bone lesions. The average maximum standardized uptake value and target to background ratio of F-DCFPyL were significantly higher than that of F-FDG for soft tissue lesions (maximum standardized uptake value P = 0.005; target to background ratio P = 0.028) and bone lesions (maximum standardized uptake value P = 0.001; target to background ratio P = 0.001). CONCLUSIONS: Our preliminary results indicated that F-DCFPyL PET/computed tomography is superior to F-FDG PET/computed tomography for the detection of local recurrence at both the surgical site and in bone metastasis while the tracers are comparable in the detection of soft tissue metastases.

Initial Series of Robotic Segmental Inferior Vena Cava Resection in Left Renal Cell Carcinoma With Caval Tumor Thrombus.

OBJECTIVE: To present our preliminary experience of robotic left radical nephrectomy (LRN) and segmental inferior vena cava (IVC) resection without caval replacement for left renal cell carcinoma (RCC) with inferior vena cava tumor thrombus. MATERIALS AND METHODS: Between 2017 and 2018, 7 patients underwent segmental IVC resection and LRN robotically. All patients underwent preoperative cavography, demonstrating complete IVC occlusion. Computed tomography-based 3-dimensional reconstruction revealed sufficient collateralization of the IVC and right renal vein (RRV). The cephalic IVC was circumferentially resected and ligated just below the second porta hepatis. The caudal IVC was circumferentially resected above the RRV with preservation of the major collaterals. The RRV was not dissected during the procedure to avoid compromising its neocollaterals. The IVC portion between the RRV and the second porta hepatis was removed en bloc with the tumor thrombus, and the LRN was performed. RESULTS: All cases were successfully performed by robotic surgery without conversion. Median operative time was 420 minutes. Median intensive care unit stay was 3 days. Four grade Ⅱ complications occurred in 2 patients. One patient had mild LEE postoperatively and recovered without special medication. Median preoperative and 3-6 months follow-up serum creatinine was 118.7 µmol/L and 135.2 µmol/L, respectively. No patient needed dialysis postoperatively. One case occurred disease progression. No patient died during the follow-up period. CONCLUSION: Robotic segmental IVC resection for left RCC with inferior vena cava tumor thrombus is feasible in well-selected cases. Three-dimensional reconstruction and cavography are helpful in the preoperative evaluation of neocollaterals in patients with suprarenal IVC occlusion.

Vessel and Tension-Free Reconstruction During Robot-Assisted Partial Nephrectomy for Hilar Tumors: "Garland" Technique and Midterm Outcomes.

Purpose: Robot-assisted partial nephrectomy (RAPN) is increasingly applied to renal hilar tumors. The present study aims to introduce our vessel and tension-free reconstruction technique and discuss the perioperative, functional, and midterm oncologic outcomes of RAPN for hilar tumors in a large cohort. Materials and Methods: We retrospectively reviewed clinical data of 286 consecutive patients with hilar tumors who underwent RAPN from June 2013 to December 2016 in our center. Our anatomy-based "Garland" technique specialized in protecting the large hilar vessels and minimizing the tension of suturing the defect via trans/retroperitoneal approaches for anterior/posterior lip hilar tumors, respectively. Results: "Garland" technique was effectively applied in 286 patients, and the warm ischemia time was 18.2 ± 4.1 minutes. Median estimated blood loss for RAPN was 100 mL (interquartile range [IQR]: 50-200 mL). Median operative time was 120 minutes (IQR: 90-150 minutes). No patient was converted to open surgery. Postoperative stay was 4.0 days (IQR: 4.0-5.0 days). Three patients (1.1%) had positive surgical margin. Two patients (0.7%) received blood transfusion. Complications occurred in 20 patients (7.0%), in which 18 patients were Clavien 1 and 2. Three patients (1.1%) had local recurrence. All patients were alive at a 48-month median follow-up (range: 24-66 months). Conclusions: "Garland" technique is safe and feasible for hilar tumor resection and kidney reconstruction. The trans/retroperitoneal approaches are options for anterior/posterior hilar tumors. Longer follow-up involving more patients is required.

Degraded Image Semantic Segmentation with Dense-Gram Networks.

Degraded image semantic segmentation is of great importance in autonomous driving, highway navigation systems, and many other safety-related applications and it was not systematically studied before. In general, image degradations increase the difficulty of semantic segmentation, usually leading to decreased semantic segmentation accuracy. Therefore, performance on the underlying clean images can be treated as an upper bound of degraded image semantic segmentation. While the use of supervised deep learning has substantially improved the state of the art of semantic image segmentation, the gap between the feature distribution learned using the clean images and the feature distribution learned using the degraded images poses a major obstacle in improving the degraded image semantic segmentation performance. The conventional strategies for reducing the gap include: 1) Adding image-restoration based pre-processing modules; 2) Using both clean and the degraded images for training; 3) Fine-tuning the network pre-trained on the clean image. In this paper, we propose a novel Dense-Gram Network to more effectively reduce the gap than the conventional strategies and segment degraded images. Extensive experiments demonstrate that the proposed Dense-Gram Network yields stateof-the-art semantic segmentation performance on degraded images synthesized using PASCAL VOC 2012, SUNRGBD, CamVid, and CityScapes datasets.

Small Object Sensitive Segmentation of Urban Street Scene with Spatial Adjacency Between Object Classes.

Recent advancements in deep learning have shown exciting promise in the urban street scene segmentation. However, many objects, such as poles and sign symbols, are relatively small and they usually cannot be accurately segmented since the larger objects usually contribute more to the segmentation loss. In this paper, we propose a new boundary-based metric that measures the level of spatial adjacency between each pair of object classes and find that this metric is robust against object size induced biases. We develop a new method to enforce this metric into the segmentation loss. We propose a network, which starts with a segmentation network, followed by a new encoder to compute the proposed boundary-based metric, and then trains this network in an end-to-end fashion. In deployment, we only use the trained segmentation network, without the encoder, to segment new unseen images. Experimentally, we evaluate the proposed method using CamVid and CityScapes datasets and achieve a favorable overall performance improvement and a substantial improvement in segmenting small objects.