AI-powered radiomics: revolutionizing detection of urologic malignancies.

PURPOSE OF REVIEW: This review aims to highlight the integration of artificial intelligence-powered radiomics in urologic oncology, focusing on the diagnostic and prognostic advancements in the realm of managing prostate, kidney, and bladder cancers. RECENT FINDINGS: As artificial intelligence continues to shape the medical imaging landscape, its integration into the field of urologic oncology has led to impressive results. For prostate cancer diagnostics, machine learning has shown promise in refining clinically-significant lesion detection, with some success in deciphering ambiguous lesions on multiparametric MRI. For kidney cancer, radiomics has emerged as a valuable tool for better distinguishing between benign and malignant renal masses and predicting tumor behavior from CT or MRI scans. Meanwhile, in the arena of bladder cancer, there is a burgeoning emphasis on prediction of muscle invasive cancer and forecasting disease trajectory. However, many studies showing promise in these areas face challenges due to limited sample sizes and the need for broader external validation. SUMMARY: Radiomics integrated with artificial intelligence offers a pioneering approach to urologic oncology, ushering in an era of enhanced diagnostic precision and reduced invasiveness, guiding patient-tailored treatment plans. Researchers must embrace broader, multicentered endeavors to harness the full potential of this field.

Factors Affecting Holmium Laser Efficiency: Comparison of Laryngeal Mask Airway and Endotracheal Intubation During Ureteroscopy for Renal Stones.

Introduction: Holmium laser lithotripsy is a standard energy source used for treatment of kidney stones during flexible ureteroscopy. Efficiency of laser surgery may be affected by patient and operator characteristics or perioperative management. Here, we sought to examine intraoperative data from patients undergoing high frequency dusting with high-powered holmium laser lithotripsy to evaluate surgical and demographic factors associated with lasing efficiency (LE). Methods: A total of 82 intraoperative reports were analyzed from an ongoing laser lithotripsy clinical trial evaluating the Lumenis Pulse™ 120H holmium laser with renal stones up to 20 mm in diameter with and without Moses 2.0 technology. For each case, the total pause time between lasing activations was corrected to remove lengthy pauses and divided by the total lasing time to calculate an efficiency percentage. This was then compared with patient demographics, anesthesia administration, stone burden, postoperative complications, and stone-free rates using both univariate and multivariate analyses. Results: Of the 82 included patients, 36 received endotracheal tube (ETT) intubation and 46 had a laryngeal mask airway (LMA). Patients with ETT had significantly higher LE (78.7%) compared to those with an LMA (73.3%) in our univariate analysis (p < 0.01) as well as in the multivariate model that adjusted for maximum stone size, number of stones, stone density, and patient body mass index (p < 0.05). There was also significantly higher mean LE in patients with no postoperative complications (76.3%) compared to those with any grade (I-V) Clavien-Dindo complication within 30 days after surgery (70.0%) (p < 0.05). Conclusions: Flexible ureteroscopy and laser lithotripsy cases with higher LE are associated with lower rates of postoperative complications. The data also support the use of ETT over LMA to improve overall LE; however, this remains one consideration among many for choosing anesthesia administration. Clinical Trial Registration number: NCT04505956.

Management of urachal anomalies in pediatric patients: A comparison of treatment strategies between pediatric urology and general surgery.

INTRODUCTION: Persistence of embryonic urachal structures due to a failure of the urachus to involute into the median umbilical ligament is known as a urachal anomaly (UA). UAs may remain asymptomatic or lead to abdominal pain and recurrent infections. Management of UAs in pediatric patients has historically lacked a clear consensus between conservative and surgical management. While both urologists and general surgeons manage this pathology, a comparison of management style and outcomes between these specialties has not been published to our knowledge. OBJECTIVE: To (1) evaluate trends in management of UAs among pediatric urologists and general surgeons across three tertiary care children's hospitals and (2) identify factors that place patients at higher risk for requiring surgery. STUDY DESIGN: All patients diagnosed with a UA from 2016 to 2020 at our multi-site institution were identified by ICD-10 code Q64.4 "malformation of the urachus" and retrospectively reviewed. Patient demographics, treatment specialty, remnant subtype, and management strategy were recorded. Data was dichotomized between both urology and general surgery as well as between surgical and nonsurgical intervention to identify and compare management strategies. RESULTS: Overall, 143 patients diagnosed with UAs were identified. Of these patients, 74 were treated by urology and 69 were treated by general surgery. Patients who were treated by urology were significantly more likely to receive conservative treatment (66.2% treated conservatively vs. 33.8% treated surgically), while patients treated by general surgery were significantly more likely to undergo surgery (84.1% treated surgically vs. 15.9% treated conservatively, p < .0001). Though, urology was more likely to treat patients who presented incidentally (p < .01), and general surgery was more likely to treat patients who presented with an infected remnant (p < .01). Patients of male sex were more likely overall to receive surgery compared to female patients (p < .01). DISCUSSION: Management of UAs by urologists was more conservative than general surgeons. However, both specialties treat distinctly different patient presentations, with urology managing more incidental remnants and general surgery operating on more emergent, infected urachi. Limitations of the study included its retrospective nature and the insufficient reporting of urachal remnant subtypes and presence of infection among patients. CONCLUSIONS: Management strategies of UAs differ among urology and general surgery, but surgical and conservative treatments are necessary to appropriately treat their distinct patient populations. This study provides valuable insight into current practices of UA management and may help to inform future treatment.

Exploring the Feasibility of GPT-4 as a Data Extraction Tool for Renal Surgery Operative Notes.

INTRODUCTION: GPT-4 is a large language model with potential for multiple applications in urology. Our study sought to evaluate GPT-4's performance in data extraction from renal surgery operative notes. METHODS: GPT-4 was queried to extract information on laterality, surgery, approach, estimated blood loss, and ischemia time from deidentified operative notes. Match rates were determined by the number of "matched" data points between GPT-4 and human-curated extraction. Accuracy rates were calculated after manually reviewing "not matched" data points. Cohen's kappa and the intraclass coefficient were used to evaluate interrater agreement/reliability. RESULTS: Our cohort consisted of 1498 renal surgeries from 2003 to 2023. Match rates were high for laterality (94.4%), surgery (92.5%), and approach (89.4%), but lower for estimated blood loss (77.1%) and ischemia time (25.6%). GPT-4 was more accurate for estimated blood loss (90.3% vs 85.5% human curated) and similarly accurate for laterality (95.2% vs 95.3% human curated). Human-curated accuracy rates were higher for surgery (99.3% vs 93% GPT-4), approach (97.9% vs 90.8% GPT-4), and ischemia time (95.6% vs 30.7% GPT-4). Cohen's kappa was 0.96 for laterality, 0.83 for approach, and 0.71 for surgery. The intraclass coefficient was 0.62 for estimated blood loss and 0.09 for ischemia time. CONCLUSIONS: Match and accuracy rates were higher for categorical variables. GPT-4 data extraction was particularly error prone for variables with heterogenous documentation styles. The role of a standard operative template to aid data extraction will be explored in the future. GPT-4 can be utilized as a helpful and efficient data extraction tool with manual feedback.

Reducing False-Positives Due to Urinary Stagnation in the Prostatic Urethra on 18 F-DCFPyL PSMA PET/CT With MRI.

PURPOSE: Prostate-specific membrane antigen (PSMA)-targeting PET radiotracers reveal physiologic uptake in the urinary system, potentially misrepresenting activity in the prostatic urethra as an intraprostatic lesion. This study examined the correlation between midline 18 F-DCFPyL activity in the prostate and hyperintensity on T2-weighted (T2W) MRI as an indication of retained urine in the prostatic urethra. PATIENTS AND METHODS: Eighty-five patients who underwent both 18 F-DCFPyL PSMA PET/CT and prostate MRI between July 2017 and September 2023 were retrospectively analyzed for midline radiotracer activity and retained urine on postvoid T2W MRIs. Fisher's exact tests and unpaired t tests were used to compare residual urine presence and prostatic urethra measurements between patients with and without midline radiotracer activity. The influence of anatomical factors including prostate volume and urethral curvature on urinary stagnation was also explored. RESULTS: Midline activity on PSMA PET imaging was seen in 14 patients included in the case group, whereas the remaining 71 with no midline activity constituted the control group. A total of 71.4% (10/14) and 29.6% (21/71) of patients in the case and control groups had urethral hyperintensity on T2W MRI, respectively ( P < 0.01). Patients in the case group had significantly larger mean urethral dimensions, larger prostate volumes, and higher incidence of severe urethral curvature compared with the controls. CONCLUSIONS: Stagnated urine within the prostatic urethra is a potential confounding factor on PSMA PET scans. Integrating PET imaging with T2W MRI can mitigate false-positive calls, especially as PSMA PET/CT continues to gain traction in diagnosing localized prostate cancer.

Deep learning-based image quality assessment: impact on detection accuracy of prostate cancer extraprostatic extension on MRI.

OBJECTIVE: To assess impact of image quality on prostate cancer extraprostatic extension (EPE) detection on MRI using a deep learning-based AI algorithm. MATERIALS AND METHODS: This retrospective, single institution study included patients who were imaged with mpMRI and subsequently underwent radical prostatectomy from June 2007 to August 2022. One genitourinary radiologist prospectively evaluated each patient using the NCI EPE grading system. Each T2WI was classified as low- or high-quality by a previously developed AI algorithm. Fisher's exact tests were performed to compare EPE detection metrics between low- and high-quality images. Univariable and multivariable analyses were conducted to assess the predictive value of image quality for pathological EPE. RESULTS: A total of 773 consecutive patients (median age 61 [IQR 56-67] years) were evaluated. At radical prostatectomy, 23% (180/773) of patients had EPE at pathology, and 41% (131/318) of positive EPE calls on mpMRI were confirmed to have EPE. The AI algorithm classified 36% (280/773) of T2WIs as low-quality and 64% (493/773) as high-quality. For EPE grade ≥ 1, high-quality T2WI significantly improved specificity for EPE detection (72% [95% CI 67-76%] vs. 63% [95% CI 56-69%], P = 0.03), but did not significantly affect sensitivity (72% [95% CI 62-80%] vs. 75% [95% CI 63-85%]), positive predictive value (44% [95% CI 39-49%] vs. 38% [95% CI 32-43%]), or negative predictive value (89% [95% CI 86-92%] vs. 89% [95% CI 85-93%]). Sensitivity, specificity, PPV, and NPV for EPE grades ≥ 2 and ≥ 3 did not show significant differences attributable to imaging quality. For NCI EPE grade 1, high-quality images (OR 3.05, 95% CI 1.54-5.86; P < 0.001) demonstrated a stronger association with pathologic EPE than low-quality images (OR 1.76, 95% CI 0.63-4.24; P = 0.24). CONCLUSION: Our study successfully employed a deep learning-based AI algorithm to classify image quality of prostate MRI and demonstrated that better quality T2WI was associated with more accurate prediction of EPE at final pathology.

Evaluating Diagnostic Accuracy and Inter-reader Agreement of the Prostate Imaging After Focal Ablation Scoring System.

Background and objective: Focal therapy (FT) is increasingly recognized as a promising approach for managing localized prostate cancer (PCa), notably reducing treatment-related morbidities. However, post-treatment anatomical changes present significant challenges for surveillance using current imaging techniques. This study aimed to evaluate the inter-reader agreement and efficacy of the Prostate Imaging after Focal Ablation (PI-FAB) scoring system in detecting clinically significant prostate cancer (csPCa) on post-FT multiparametric magnetic resonance imaging (mpMRI). Methods: A retrospective cohort study was conducted involving patients who underwent primary FT for localized csPCa between 2013 and 2023, followed by post-FT mpMRI and a prostate biopsy. Two expert genitourinary radiologists retrospectively evaluated post-FT mpMRI using PI-FAB. The key measures included inter-reader agreement of PI-FAB scores, assessed by quadratic weighted Cohen's kappa (κ), and the system's efficacy in predicting in-field recurrence of csPCa, with a PI-FAB score cutoff of 3. Additional diagnostic metrics including sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and overall accuracy were also evaluated. Key findings and limitations: Scans from 38 patients were analyzed, revealing a moderate level of agreement in PI-FAB scoring (κ = 0.56). Both radiologists achieved sensitivity of 93% in detecting csPCa, although specificity, PPVs, NPVs, and accuracy varied. Conclusions and clinical implications: The PI-FAB scoring system exhibited high sensitivity with moderate inter-reader agreement in detecting in-field recurrence of csPCa. Despite promising results, its low specificity and PPV necessitate further refinement. These findings underscore the need for larger studies to validate the clinical utility of PI-FAB, potentially aiding in standardizing post-treatment surveillance. Patient summary: Focal therapy has emerged as a promising approach for managing localized prostate cancer, but limitations in current imaging techniques present significant challenges for post-treatment surveillance. The Prostate Imaging after Focal Ablation (PI-FAB) scoring system showed high sensitivity for detecting in-field recurrence of clinically significant prostate cancer. However, its low specificity and positive predictive value necessitate further refinement. Larger, more comprehensive studies are needed to fully validate its clinical utility.

The Financial Burden of Nephrolithiasis and Predictors of Disease-specific Financial Toxicity.

OBJECTIVE: To characterize stone-related financial toxicity among US adults with kidney stones through validated questionnaires for financial toxicity and disease-specific health-related quality of life. MATERIALS AND METHODS: We performed a cross-sectional survey of adults with kidney stone disease from the general population ascertained through a national registry of volunteers (ResearchMatch). A computer-based survey queried stone event history and related costs for medical care, disease-specific quality of life (WISQOL), and an 11-item measure of stone-related financial toxicity (COST-11 score). Multivariable logistic regression was performed to evaluate predictors of financial toxicity, defined as having a COST-11 score ≤20. RESULTS: Of 942 responses, median COST-11 score was 29 (IQR 21-38), and 24.7% (N = 233) met criteria for disease-specific financial toxicity. Stone-formers with financial toxicity spent more out of pocket on stone-treatment in the previous year than patients with lower financial burden (P <.001) and were more likely to defer or delay recommended treatment due to anticipated cost (27% vs 3%; P <.001). Stone-specific financial toxicity was associated with poorer disease-specific health-related quality of life across all WISQOL domains (each P <.001). Multivariable logistic regression showed that female gender (OR 1.81; 95% CI 1.24-2.67), Medicaid compared to private insurance (OR 3.91; 95% CI 2.34-6.94), and stone passage in the previous year (OR 2.00; 95% CI 1.41-2.86) were independently associated with financial toxicity. CONCLUSION: Approximately 1 in 4 individuals with kidney stone disease report disease-specific financial toxicity. These data suggest the financial burden of the condition may influence decision-making and associates with poorer disease-specific quality of life.

Adnexal smooth muscle hyperplasia resulting in non-traumatic testicular dislocation: A case report.

Tumors of the para-testicular adnexa are very rare and are typically histologically diagnosed as adenomatoid neoplasms, leiomyomata, or smooth muscle hyperplasia. Though these masses are usually benign, the potential for malignancy and mass effect causing intrascrotal discomfort necessitate proper diagnosis and excision. Herein, we describe a unique case of gradual, atraumatic testicular dislocation in a 40-year-old male caused by smooth muscle hyperplasia of the testicular adnexa affecting the epididymis and vas deferens. This case highlights the diagnostic and surgical challenges associated with this presentation.

Patient-Reported Financial Toxicity Associated With Management of Nephrolithiasis.

OBJECTIVE: To characterize stone-related financial burden among adults with nephrolithiasis through validated questionnaires for financial toxicity. METHODS: We performed a cross-sectional survey of adults with history of nephrolithiasis at an outpatient clinic. The survey contained a measure of stone-related financial toxicity (COST score), and assessed demographics, stone event history, and burden of overall, ancillary, preventative, and insurance costs. A COST score ≤21 was classified as high financial toxicity. Multivariable logistic regression was used to evaluate associations with demographic variables and stone event history. RESULTS: One hundred patients completed the survey (median age 57, IQR, 48-64). The median COST score was 30 (IQR, 23-37), and 19% reported high financial toxicity. Insurance status, household income, stone surgeries during lifetime and within the last 3 years were associated with financial toxicity on univariable analysis (P <.05). Burden of costs was significantly higher in all categories within the high financial toxicity cohort (each P <.05). On multivariable logistic regression, only income >$75,000 remained significant within the second model (OR: 0.22, 95% CI, 0.05-0.77, P = .02), however, this relationship did not persist on the final model. When asked whether providers should be mindful of their financial situation prior to making treatment recommendations, 39% responded "quite a bit" or "very much." CONCLUSION: One in 5 patients seeking care for nephrolithiasis meet criteria for high financial toxicity. Financial toxicity was associated with household income, insurance, education, and frequency of stone events. Thirty-nine percent reported that their provider should be mindful of their financial situation when making recommendations.

Solitary Intrascrotal Plexiform Neurofibroma in a 10-Year-Old Male.

Intrascrotal neurofibromas are extensive tumors that grow from peripheral nerves within the scrotum and are exceedingly rare among the benign extratesticular tumors. Though the risk is low, potential for malignancy and patient discomfort make diagnosis and surgical evaluation imperative. Pediatric neurofibromas are typically only associated with neurofibromatosis type 1. However, herein, we describe a rare case of a benign, intrascrotal plexiform neurofibroma in a 10-year-old male who lacks any stigmata associated with this genetic disorder. Diagnostic and surgical challenges as well as histopathological findings are discussed.

Enteroendocrine Cell Formation Is an Early Event in Pancreatic Tumorigenesis.

Pancreatic ductal adenocarcinoma (PDAC) is a devastating disease with a 5-year survival rate of only 11%, due, in part, to late diagnosis, making the need to understand early events in tumorigenesis critical. Acinar-to-ductal metaplasia (ADM), when not resolved, is a PDAC precursor. Recently, we showed that ADM is constituted by a heterogenous population of cells, including hormone-producing enteroendocrine cells (EECs: gamma, delta, epsilon, and enterochromaffin cells). In this study, we employed histopathological techniques to identify and quantify the abundance of EEC subtypes throughout pancreatic tumorigenesis in mouse models and human disease. We found that EECs are most abundant in ADM and significantly decrease with lesion progression. Co-immunofluorescence identifies distinct lineages and bihormonal populations. Evaluation of EEC abundance in mice lacking Pou2f3 demonstrates that the tuft cell master regulator transcription factor is not required for EEC formation. We compared these data to human neoplasia and PDAC and observed similar trends. Lastly, we confirm that EECs are a normal cellular compartment within the murine and human pancreatic ductal trees. Altogether, these data identify EECs as a cellular compartment of the normal pancreas, which expands early in tumorigenesis and is largely lost with disease progression.

Systematic review on the application of 3D-bioprinting technology in orthoregeneration: current achievements and open challenges.

BACKGROUND: Joint degeneration and large or complex bone defects are a significant source of morbidity and diminished quality of life worldwide. There is an unmet need for a functional implant with near-native biomechanical properties. The potential for their generation using 3D bioprinting (3DBP)-based tissue engineering methods was assessed. We systematically reviewed the current state of 3DBP in orthoregeneration. METHODS: This review was performed using PubMed and Web of Science. Primary research articles reporting 3DBP of cartilage, bone, vasculature, and their osteochondral and vascular bone composites were considered. Full text English articles were analyzed. RESULTS: Over 1300 studies were retrieved, after removing duplicates, 1046 studies remained. After inclusion and exclusion criteria were applied, 114 articles were analyzed fully. Bioink material types and combinations were tallied. Cell types and testing methods were also analyzed. Nearly all papers determined the effect of 3DBP on cell survival. Bioink material physical characterization using gelation and rheology, and construct biomechanics were performed. In vitro testing methods assessed biochemistry, markers of extracellular matrix production and/or cell differentiation into respective lineages. In vivo proof-of-concept studies included full-thickness bone and joint defects as well as subcutaneous implantation in rodents followed by histological and µCT analyses to demonstrate implant growth and integration into surrounding native tissues. CONCLUSIONS: Despite its relative infancy, 3DBP is making an impact in joint and bone engineering. Several groups have demonstrated preclinical efficacy of mechanically robust constructs which integrate into articular joint defects in small animals. However, notable obstacles remain. Notably, researchers encountered pitfalls in scaling up constructs and establishing implant function and viability in long term animal models. Further, to translate from the laboratory to the clinic, standardized quality control metrics such as construct stiffness and graft integration metrics should be established with investigator consensus. While there is much work to be done, 3DBP implants have great potential to treat degenerative joint diseases and provide benefit to patients globally.