Tissue thermal effect during lithotripsy and tissue ablation in endourology: a systematic review of experimental studies comparing Holmium and Thulium lasers.

PURPOSE: We looked into the Thulium: yttrium-aluminum-garnet (TM:YAG), Thulium Fibre laser (TFL) and Holmium: yttrium-aluminum-garnet (Ho:YAG) thermal laser tissue effect during lithotripsy and tissue ablation. METHODS: We performed a PubMed, Scopus, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) search. RESULTS: During lithotripsy, the Ho:YAG generated temperatures from 24 to 68.7 °C at powers < 20 W, the Tm:YAG from 43.7 °C at 30 W to 68 °C at powers < 20 W, and the TFL from 33 to 40.46 °C. During ablation, the Ho:YAG and continuous wave (cw) Tm:YAG tissue incision depths ranged from 0.08 to 2.26 mm, and from 0.28 to 3.22 mm. The Ho:YAG and Tm:YAG vaporization areas ranged from 0.044 to 0.078 mm2 and from 0.050 to 0.078 mm3 and their coagulation zones were 0.075 mm2 and 0.125 mm3 respectively. Ho:YAG and Tm:YAG laser damage zones ranged from 0.093 to 2.6 mm3 and from 0.207 to 0.98 mm3 respectively. The TFL incision depth ranged from 0.04 to 5.7 mm. The cw and SuperPulsed (SP) vaporization volumes ranged from 8 to 28.2 mm3/s and from 4 to 11 mm3/s. TFL coagulation depth and coagulation zone ranged from zero to 1.1 mm, 2.2 to 5.1 mm3 in SP mode and from 7.7 to 18.1 mm3 in cw mode. CONCLUSION: During lithotripsy all lasers caused similar temperature changes and had a safe temperature profile at < 40 W. During tissue ablation, Ho:YAG has a deeper incision depth, while cwTm:YAG and cwTFL have broader coagulation and total laser areas.

Temperature change during laser upper-tract endourological procedures: current evidence and future perspective.

PURPOSE OF REVIEW: To examine the most recent data on temperatures produced during laser lithotripsy and to provide several strategies for maintaining lower values and reducing the risk of complications during endourological treatment. RECENT FINDINGS: Endourologists have access to a wide range of alternatives with the help of the holmium: yttrium-aluminum-garnet (Ho:YAG), thulium: yttrium-aluminum-garnet (TM:YAG), and thulium fiber laser (TFL) that compose a robust and adaptable laser lithotripsy armamentarium. Nevertheless, the threat of thermal damage increases as the local temperature rises with high total power. Most endourologists are not familiar with normal and pathological temperature ranges, how elevated temperatures affect perioperative problems, or how to avoid them. SUMMARY: Increased temperatures experienced during laser lithotripsy may affect the course of the healing process. All lasers display a safe temperature profile at energies below 40 W. At equal power settings, Ho:YAG, Tm:YAG, and TFL lasers change the temperature comparably. Shorter on/off laser activation intervals, chilled irrigation, open irrigation systems, and UASs all aid in maintaining acceptable temperatures.

Generated temperatures and thermal laser damage during upper tract endourological procedures using the holmium: yttrium-aluminum-garnet (Ho:YAG) laser: a systematic review of experimental studies.

PURPOSE: To perform a review on the latest evidence related to generated temperatures during Ho:YAG laser use, and present different tools to maintain decreased values, and minimize complication rates during endourological procedures. METHODS: We performed a literature search using PubMed, Scopus, EMBASE, and Cochrane Central Register of Controlled Trials-CENTRAL, restricted to original English-written articles, including animal, artificial model, and human studies. Different keywords were URS, RIRS, ureteroscopy, percutaneous, PCNL, and laser. RESULTS: Thermal dose (t43) is an acceptable tool to assess possible thermal damage using the generated temperature and the time of laser exposure. A t43 value of more than 120 min leads to a high risk of thermal tissue injury and at temperatures higher than 43 °C Ho:YAG laser use becomes hazardous due to an exponentially increased cytotoxic effect. Using open continuous flow, or chilled irrigation, temperatures remain lower than 45 °C. By utilizing high-power (> 40 W) or shorter laser pulse, temperatures rise above the accepted threshold, but adding a ureteral access sheath (UAS) helps to maintain acceptable values. CONCLUSIONS: Open irrigation systems, chilled irrigation, UASs, laser power < 40 W, and shorter on/off laser activation intervals help to keep intrarenal temperatures at accepted values during URS and PCNL.

Percutaneous laser nephrolithotripsy: is it here to stay? Results of a systematic review.

PURPOSE OF REVIEW: PCNL (percutaneous nephrolithotomy) and its miniaturized variants are being widely employed in stone surgery, owing to their high-stone-free rates (SFRs) and efficacy for large (>20 mm) stones. With advances in laser technology, it has been readily utilized in PCNL, with the potential for lower complication rates at similar SFR. We aimed to perform a systematic literature review with a focus on recent prospective clinical data that compares laser PCNL to either nonlaser PCNL, different PCNL sizes or other current standards of care such as shockwave lithotripsy (ESWL) or flexible ureteroscopy (FURS). RECENT FINDINGS: Of the 294 studies initially identified through database searching, nine papers published between 2019 and 2021 were included which compared laser PCNL (Standard PCNL in three, mini-PCNL in four, ultra-mini PCNL in one, micro-PCNL in one study) to other nonlaser lithotripsy, ESWL, FURS, and different PCNL sizes. Complications for laser PCNL ranged from bleeding (4.4%), perirenal haematoma (1.1%), fever (4.6%), ureteric/renal pelvic injury (2.3%), haematuria (2.7%), and infection (2.6%). The mean SFR for laser PCNL was 91.5% at 3 months. SUMMARY: Percutaneous laser nephrolithotripsy is well tolerated and effective, with high-SFRs at 3 months and relatively low intraoperative and postoperative complication rates. Further research is required to assess the role of intraoperative techniques and suction to improve outcomes further.

Thulium Fiber Laser Behavior on Tissue During Upper- and Lower-Tract Endourology.

PURPOSE OF REVIEW: To present the latest evidence on thulium fiber laser (TFL) effects on tissue, during lithotripsy and ablation, emphasizing on generated temperatures, thermal damage thresholds, incision depths, areas of coagulation, and laser damage. RECENT FINDINGS: Lasers are frequently utilized during endoscopic treatment of different urological conditions. The holmium:yttrium-aluminum-garnet (Ho:YAG) is most frequently used for various types of stones and soft tissue. The TFL has been recently introduced, offering several advantages. However, its activity on tissue during upper and lower tract endourology is poorly understood. At equivalent power settings, TFL and Ho:YAG generate similar temperature changes during lithotripsy. TFL has a shallow incision depth during tissue ablation. Compared to SP TFL, (cw) TFL results in a broader coagulation zone, whereas SP TFL gives of Ho:YAG-similar incision, and (cw) TFL offers a quick, precise cut with more carbonization.

The Ascent of Artificial Intelligence in Endourology: a Systematic Review Over the Last 2 Decades.

PURPOSE OF REVIEW: To highlight and review the application of artificial intelligence (AI) in kidney stone disease (KSD) for diagnostics, predicting procedural outcomes, stone passage, and recurrence rates. The systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist. RECENT FINDINGS: This review discusses the newer advancements in AI-driven management strategies, which holds great promise to provide an essential step for personalized patient care and improved decision making. AI has been used in all areas of KSD including diagnosis, for predicting treatment suitability and success, basic science, quality of life (QOL), and recurrence of stone disease. However, it is still a research-based tool and is not used universally in clinical practice. This could be due to a lack of data infrastructure needed to train the algorithms, wider applicability in all groups of patients, complexity of its use and cost involved with it. The constantly evolving literature and future research should focus more on QOL and the cost of KSD treatment and develop evidence-based AI algorithms that can be used universally, to guide urologists in the management of stone disease.

'Negative Ureteroscopy' for Stone Disease: Evidence from a Systematic Review.

PURPOSE OF REVIEW: While ureteroscopy (URS) is a common procedure for ureteric stones, this window between diagnosis and treatment leaves the possibility for a 'negative', 'stoneless' or 'diagnostic' URS. We perform a systematic review to look at the rate of 'negative ureteroscopy' and risk factors associated with it. RECENT FINDINGS: From a total of 3599 articles and 68 abstracts, 4 studies (1336 patients) were selected. The negative URS rate varied from 4 to 14%. Common predictors seem to be female gender, small stones, radiolucent stones and distal ureteric stones. Although infrequent, negative ureteroscopy should be avoided in patients with ureteric stones by performing a low-dose CT scan on the day of surgery. This should especially be performed for females and those with smaller, radiolucent or distal ureteric stones.

Predictors and Results of Negative Ureteroscopy for Treatment of Consecutive Ureteric Stones Done as a Primary Procedure: Prospective Outcomes from a University Hospital.

INTRODUCTION: While negative ureteroscopy (URS) can be considered as an unnecessary procedure with medico-legal consequences, this avoids radiation from repeat CT scan and sometimes may be the only way to reassure patients with ongoing symptoms. We wanted to analyze our predictors and results of negative URS for treatment of ureteric stones. METHODS AND MATERIALS: Between March 2012 and August 2018, data on consecutive patients with ureteric stones undergoing a primary URS (without a pre-operative stent) were prospectively collected for patient demographics and outcomes. Comparison was done for patients with diagnostic and therapeutic primary URS for ureteric stones. Patients with renal stones were excluded from the study. RESULTS: A total of 270 patients underwent URS for ureteric stones during the study period of which 35 (13%) had a negative diagnostic URS. The patients who had negative URS were younger (p = 0.001), had smaller stones (p < 0.001), and more stones located in the distal ureter or vesico-ureteric junction (VUJ; p= 0.036). None of the patients who underwent negative URS had a postoperative stent inserted or any complications. CONCLUSION: Although the rates of negative URS should be as low as possible, it seems to be safe and reassures patients with on-going symptoms. Based on our data, patients with small distal ureteric or VUJ stones should undergo a repeat imaging to avoid this unnecessary procedure. Informed consent, patient counseling, and appropriate up-to-date imaging seem to be key to minimizing negative diagnostic URS.

Patient perception and barriers with fluid hydration: a prospective face-to-face interview and counselling from a university hospital stone clinic.

Introduction: Kidney stone disease (KSD) has a lifetime prevalence of up to 14% in the United Kingdom. Primary and secondary prevention of KSD via dietary intervention is a low-cost public health intervention and remains the best preventative strategy against urolithiasis. Material and methods: This prospective study was conducted on kidney stone patients attending a stone clinic at our tertiary endourology centre. Patients were taken through a questionnaire, which was completed in the clinic by a trained specialist endourology nurse. Results: A total of 259 patients completed the questionnaire. 141 (54.4%) had an active stone during the clinic visit with the remaining 118 (45.6%) with a history of stone treatment. Regarding barriers to fluid intake, 43 (16.6%) patients did not have a habit of drinking water or felt too bloated, 36 (13.9%) did not like the taste, 17 (6.6%) were not thirsty, 10 (3.9%) of patients were too busy. Of those who answered, 108 (46.8%) patients did not believe there was a link between fluid intake and stone formation. A belief of a link between fluid intake and stone formation significantly predicted fluid intake (p = 0.024) with people who did believe in this drinking less water. Conclusions: There are numerous perceived barriers to adequate fluid intake, with almost half of all patients not believing that there is a link between fluid intake and stone formation. This misunderstanding may predict a lower fluid intake. More attention should therefore be focussed on patient education and primary prevention aspects to avoid kidney stone recurrence.

The role of music in outpatient prostate biopsy: A comprehensive literature review.

Prostate biopsy is a standard urological procedure and a valuable tool for identifying prostate cancer. To assess the effect of music on outpatient prostate biopsy, we aimed to conduct a systematic review of literature to understand if music reduced the use of analgesics and anxiolytics. The systematic review was performed in line with the Cochrane guidelines and Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. The databases searched included MEDLINE, Scopus, CINAHL, Clinicaltrials.gov, EMBASE, Cochrane library, and Google Scholar, from inception of databases to February 2021. The primary outcome measures were the effect of music on pain and anxiety from the procedure. The initial search yielded 212 articles and after going through titles and abstracts, and six studies (570 patients) were included for the final review. It included five randomized-controlled trials and one case-control study. These studies were done in Korea, USA, Taiwan, and Turkey. Patients had a combination of either local anesthetic gel or periprostatic nerve block or intravenous pethidine. The choice of music was varied and most offered a choice of music to patients. Four of the six studies showed significantly reduced pain and anxiety with the use of music, and the willingness for repeat procedures was higher in two studies. This review has demonstrated that listening to music is associated with reduced anxiety and pain during prostate biopsy. It is likely to, therefore, increase procedural satisfaction, and willingness to undergo the procedure again considering repeated biopsy is sometimes needed in these patients. As music is simple, inexpensive, and easily accessible, it should be routinely offered to patients for outpatient and office-based urological procedures.

Electrocorticography to Investigate Age-Related Brain Lateralization on Pediatric Motor Inhibition.

Response inhibition refers to the ability to suppress inappropriate actions that interfere with goal-driven behavior. The inferior frontal gyrus (IFG) is known to be associated with inhibition of a motor response by assuming executive control over motor cortex outputs. This study aimed to evaluate the pediatric development of response inhibition through subdural electrocorticography (ECoG) recording. Subdural ECoG recorded neural activities simultaneously during a Go/No-Go task, which was optimized for children. Different frequency power [theta: 4-8 Hz; beta: 12-40 Hz; high-gamma (HG): 70-200 Hz] was estimated within the IFG and motor cortex. Age-related analysis was computed by each bandpass power ratio between Go and No-Go conditions, and phase-amplitude coupling (PAC) over IFG by using the modulating index metric in two conditions. For all the eight pediatric patients, HG power was more activated in No-Go trials than in Go trials, in either right- or left-side IFG when available. In the IFG region, the power over theta and HG in No-Go conditions was higher than those in Go conditions, with significance over the right side (p < 0.05). The age-related lateralization from both sides to the right side was observed from the ratio of HG power and PAC value between the No-Go and Go trials. In the pediatric population, the role of motor inhibition was observed in both IFG, with age-related lateralization to the right side, which was proved in the previous functional magnetic resonance imaging studies. In this study, the evidence correlation of age and response inhibition was observed directly by the evidence of cortical recordings.

Current Applications of Artificial Intelligence in Benign Prostatic Hyperplasia.

Artificial intelligence is used in predicting the clinical outcomes before minimally invasive treatments for benign prostatic hyperplasia, to address the insufficient reliability despite multiple assessment parameters, such as flow rates and symptom scores. Various models of artificial intelligence and its contemporary applications in benign prostatic hyperplasia are reviewed and discussed. A search strategy adapted to identify and review the literature on the application of artificial intelligence with a dedicated search string with the following keywords: "Machine Learning," "Artificial Intelligence," AND "Benign Prostate Enlargement" OR "BPH" OR "Benign Prostatic Hyperplasia" was included and categorized. Review articles, editorial comments, and non-urologic studies were excluded. In the present review, 1600 patients were included from 4 studies that used different classifiers such as fuzzy systems, computer-based vision systems, and clinical data mining to study the applications of artificial intelligence in diagnoses and severity prediction and determine clinical factors responsible for treatment response in benign prostatic hyperplasia. The accuracy to correctly diagnose benign prostatic hyperplasia by Fuzzy systems was 90%, while that of computer-based vision system was 96.3%. Data mining achieved sensitivity and specificity of 70% and 50%, respectively, in correctly predicting the clinical response to medical treatment in benign prostatic hyperplasia. Artificial intelligence is gaining attraction in urology, with the potential to improve diagnostics and patient care. The results of artificial intelligence-based applications in benign prostatic hyperplasia are promising but lack generalizability of results. However, in the future, we will see a shift in the clinical paradigm as artificial intelligence applications will find their place in the guidelines and revolutionize the decision-making process.

Telemedicine and Telehealth in Urology: Uptake, Impact and Barriers to Clinical Adoption.

Telemedicine has great potential in urology as a strong medium for providing patients with continuous high-quality urological care despite the hurdles involved in its implementation. Both clinicians and patients are crucial factors in determining the success of tele-consults in terms of simplicity of use and overall satisfaction. For it to be successfully incorporated into routine urological practice, rigorous training and evidence-based recommendations are lacking. If these issues are addressed, they can provide a significant impetus for future tele-consults in urology and their successful deployment, even beyond the pandemic, to assure safer and more environment-friendly patient management.

Is endoscopic combined intrarenal surgery ready for primetime in endourology? Outcomes from a systematic review and meta-analysis.

Introduction: We aimed to review the outcomes of endoscopic combined intrarenal surgery (ECIRS) as compared to conventional percutaneous nephrolithotomy (PCNL) for kidney stones. Material and methods: We performed a systematic literature review using MEDLINE, EMBASE, and Cochrane Central Controlled Register of Trials. We included all studies comparing ECIRS and conventional PCNL. Surgical time, hemoglobin drop, and postoperative stay were pooled using the inverse variance of the mean difference (MD) with a random effect, 95% confidence intervals (CI), and p-values. Complications, stone-free rate, and retreatment were assessed using Cochran-Mantel-Haenszel method with random effect model and expressed as odds ratio (OR), 95% CI, and p-values. Results: A total of 17 studies were included. Surgical time and mean postoperative length did not significantly differ between the groups (MD -8.39 minutes 95%CI -21.30, 4.53, p = 0.20; 5.09 days 95%CI -19.51, 29.69, p = 0.69). Mean hemoglobin drop was significantly lower in the ECIRS group (MD -0.56 g/dl 95%CI -1.08, -0.05, p = 0.03), while blood transfusion rate did not differ between the two groups (OR 0.88 95%CI 0.64, 1.23, p = 0.15). While the incidence of postoperative sepsis did not differ between the two groups (OR 0.52 95% CI 0.17, 1.59, p = 0.25), the incidence of postoperative fever was lower in the ECIRS group but the difference was not significant (OR 0.61 95%CI 0.35, 1.06, p = 0.08). The stone-free rate was significantly higher in the PCNL group (OR 2.52 95%CI 1.64, 3.90, p <0.0001) and the retreatment rate was lower in the ECIRS group (OR 0.34 95%CI 0.14, 0.87, p = 0.002). Conclusions: ECIRS showed shorter operative time, lower complication rate, and retreatment compared to PCNL. Conventional PCNL showed a higher stone-free rate.

A Systematic Review of Thulium Fiber Laser: Applications and Advantages of Laser Technology in the Field of Urology.

Laser technology is widely used in urological surgery, from lithotripsy, prostate surgery to en-bloc resection of tumours. While Holmium:YAG has been widely employed over the last two decades, in recent years, there has been a surge of interest in Thulium Fiber Laser (TFL), which offers theoretical advantages of better water absorption and lower stone ablation thresholds. A systematic review was conducted to assess the evidence from clinical research on TFL's application for lithotripsy and prostate surgery. It identified 357 articles and 8 (1506 patients) were selected, of which 4 clinical studies each investigated TFL enucleation of prostate (ThuFLEP) and TFL lithotripsy. For flexible ureteroscopic lithotripsy (FURSL), stone ablation settings ranged from 0.1-4 J, and 7-300 Hz, mean operative time ranged from 23.4-39.8 minutes and lasing time ranged from 1.2-10 minutes. For stone dusting in percutaneous nephrolithotomy (PCNL), settings of 0.2 J and 125-200 Hz were found to be optimal. For ThuFLEP, all studies showed a significant improvement in IPSS (International Prostate Symptom Score), urinary flow rate (Qmax), quality of life measures, and post-void residual volume, with mean operative time ranging from 67-104.5 minutes. Our review shows that there is limited evidence on the use and clinical outcomes of TFL. ThuFLEP might suggest equivalence to the widely used HoLEP in the available evidence so far. TFL lithotripsy shows promising results but further prospective, randomized trials are required to properly assess its usability, clinical effectiveness and standardisation of the settings for successful adoption of the technology.

Evidence-based protocol-led management of renal angiomyolipoma: A review of literature.

Renal angiomyolipomas (R-AMLs) are rare benign tumors, which occur sporadically and in association with genetic conditions such as tuberous sclerosis complex (TSC) and lymphangioleiomyomatosis (LAM). The key clinical concern is life-threatening hemorrhage. There is uncertainty about the optimal management strategy for patients with R-AMLs. We aim to review the evidence and provide a protocolled approach for the management of R-AMLs. A literature search of R-AML was conducted using MEDLINE and EMBASE for articles published between January 1990 and March 2020. Patient with TSC and sporadic cases were included. Treatment strategies, including active surveillance, surgery, selective arterial embolization (SAE), ablation, and systemic therapies, were reviewed. Outcomes from contemporary case series of active surveillance, surgery, and SAE were collated. There were no randomized controlled trials on this topic. The retrospective case series reviewed showed that many R-AMLs can be managed safely with active surveillance. Tumor size is the most important predictor of bleeding, and other factors such as rate of growth, women of child-bearing age, aneurysm size, and symptoms should be considered when deciding on prophylactic treatment. There is limited evidence for the traditional 4-cm cutoff for treatment, which may lead to overtreatment. The primary intervention options are SAE and surgery; whereas SAE is a less invasive option, nephron sparing surgery offers a lower risk of recurrence. Both appear to have similar morbidity, and the current evidence does not recommend one over the other in most cases. Thermal ablation has promising results but has only been trialed in small case series. Patients with TSC can be offered mammalian target of rapamycin inhibitors of which everolimus appears to cause the greatest shrinkage of tumors with an acceptable side-effect profile. R-AMLs should be assessed for their risk of bleeding. Low-risk tumors should be treated with active surveillance. High-risk tumors should be treated with SAE or surgery. Systemic treatments are the first-line of treatment for patients with TSC to preserve renal parenchyma.

Machine Learning Models for Predicting Stone-Free Status after Shockwave Lithotripsy: A Systematic Review and Meta-Analysis.

We performed a systematic review and meta-analysis to investigate the use of machine learning techniques for predicting stone-free rates following Shockwave Lithotripsy (SWL). Eight papers (3264 patients) were included. Two studies used decision-tree approaches, five studies utilised Artificial Neural Networks (ANN), and one study combined a variety of approaches. The summary true positive rate was 79%, summary false positive rate was 14%, and Receiver Operator Characteristic (ROC) was 0.90 for machine learning approaches. Machine learning algorithms were at least as good as standard approaches. Further prospective evidence is needed to routinely apply machine learning algorithms in clinical practice.

Contemporary application of artificial intelligence in prostate cancer: an i-TRUE study.

Artificial intelligence (AI) involves technology that is able to emulate tasks previously carried out by humans. The growing incidence, novel diagnostic strategies and newer available therapeutic options have had resource and economic impacts on the healthcare organizations providing prostate cancer care. AI has the potential to be an adjunct to and, in certain cases, a replacement for human input in prostate cancer care delivery. Automation can also address issues such as inter- and intra-observer variability and has the ability to deliver analysis of large volume datasets quickly and accurately. The continuous training and testing of AI algorithms will facilitate development of futuristic AI models that will have integral roles to play in diagnostics, enhanced training and surgical outcomes and developments of prostate cancer predictive tools. These AI related innovations will enable clinicians to provide individualized care. Despite its potential benefits, it is vital that governance with AI related care is maintained and responsible adoption is achieved.

Can the Use of Serial Multiparametric Magnetic Resonance Imaging During Active Surveillance of Prostate Cancer Avoid the Need for Prostate Biopsies?-A Systematic Diagnostic Test Accuracy Review.

CONTEXT: The role of multiparametric magnetic resonance imaging (mp-MRI) during active surveillance (AS) of prostate cancer needs evaluation. It remains unclear whether mp-MRI can replace prostate biopsies completely during AS. OBJECTIVE: To evaluate the diagnostic performance of mp-MRI for disease progression in men on AS for prostate cancer. EVIDENCE ACQUISITION: This systematic review was performed in accordance with the Cochrane Handbook and the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). Cross-sectional studies that evaluate the diagnostic performance of mp-MRI (index test) for disease progression compared with systematic and targeted prostate/template biopsies or a composite of this (reference standard) were included. A meta-analysis was performed using STATA with "metandi" and "midas" commands. EVIDENCE SYNTHESIS: Seven studies with 800 patients were included in this systematic review. The pooled pathological progression rate was 27%. The pooled sensitivity and specificity of mp-MRI for disease progression were 0.61 (95% confidence interval [CI]: 0.46-0.74) and 0.78 (95% CI: 0.54-0.91), respectively. Adjusting for a prevalence of disease progression of 30% results in a positive predictive value of 0.43 (95% CI: 0.39-0.46) and a negative predictive value of 0.81 (95% CI: 0.78-0.84). Significant heterogeneity was observed. The meta-regression analysis did not demonstrate any significant outliers. CONCLUSIONS: It is not possible to supplant prostate biopsies with mp-MRI in AS protocols with the current level of evidence. There is significant institutional variation in the diagnostic performance of mp-MRI during AS. Institutions must internally audit the diagnostic performance of mp-MRI in the AS setting. AS protocols must be based on local diagnostic performance, rather than on international AS protocols that may have limited applicability at individual settings. PATIENT SUMMARY: In this review, we explored the accuracy of multiparametric magnetic resonance imaging in diagnosing disease progression for patients who were enrolled in active surveillance programmes for prostate cancer.

The Role of Dorsal Premotor Cortex in Resolving Abstract Motor Rules: Converging Evidence From Transcranial Magnetic Stimulation and Cognitive Modeling.

In this study, repetitive transcranial magnetic stimulation (rTMS) was applied over left dorsal premotor cortex (PMd) while participants performed a novel task paradigm that required planning of responses in accordance with both instructed rules and present stimuli. rTMS is a noninvasive form of neurostimulation that can interfere with ongoing processing of a targeted cortical region, resulting in a transient "virtual lesion" that can reveal the contribution of the region to ongoing behavior. Increased response times (RTs) were observed specifically when rTMS was applied over PMd while participants were preparing to execute a complex response to an uninstructed stimulus. To further delineate the effect of stimulation, condition-specific RT distributions were modeled as three-parameter Weibull distributions through hierarchical Bayesian modeling (HBM). Comparison of the estimated parameters to those of a paired control demonstrated that while PMd-rTMS slightly decreased nondecision time, it also greatly increased the variability in the RT distribution. This increased variability resulted in an overall increase in predicted mean RT and is consistent with a delay in cognitive processes. In conjunction, an ACT-R cognitive model of the task was developed in order to systematically test alternative hypotheses on the potential cognitive functions that may be affected by stimulation of PMd. ACT-R simulations suggested that participant's behavior was due to an effect of TMS on a "re-planning" process, indicating that PMd may be specifically involved in planning of complex motor responses to specific visual stimuli. In conjunction with the HBM modeling effort, these results suggest that PMd-rTMS is capable of pausing or slowing the execution of a motor response-planning process.