Solitary castrate-resistant prostate cancer metastasis to adrenal gland with concordant intense avidity on PSMA and FDG PET.

Isolated prostate cancer metastasis to the adrenal gland is rare. We report a case of concordant high uptake in a solitary adrenal metastasis on both prostate-specific membrane antigen and fluorodeoxyglucose positron-emission tomography in a patient with castrate-resistant prostate cancer. Good initial biochemical response was achieved with laparoscopic adrenalectomy. The patient developed lymph node recurrence 12 months later, although remains asymptomatic on hormonal treatment 22 months post-operatively, in keeping with prior results for metastasis-directed therapy which can delay time to additional treatment. Application of dual tracer PET can be valuable for prostate cancer staging and guidance of metastasis-directed treatment.

3D Printing Improved Testicular Prostheses: Using Lattice Infill Structure to Modify Mechanical Properties.

Patients often opt for implantation of testicular prostheses following orchidectomy for cancer or torsion. Recipients of testicular prostheses report issues regarding firmness, shape, size, and position, aspects of which relate to current limitations of silicone materials used and manufacturing methods for soft prostheses. We aim to create a 3D printable testicular prosthesis which mimics the natural shape and stiffness of a human testicle using a lattice infill structure. Porous testicular prostheses were engineered with relative densities from 0.1 to 0.9 using a repeating cubic unit cell lattice inside an anatomically accurate testicle 3D model. These models were printed using a multi-jetting process with an elastomeric material and compared with current market prostheses using shore hardness tests. Additionally, standard sized porous specimens were printed for compression testing to verify and match the stiffness to human testicle elastic modulus (E-modulus) values from literature. The resulting 3D printed testicular prosthesis of relative density between 0.3 and 0.4 successfully achieved a reduction of its bulk compressive E-modulus from 360 KPa to a human testicle at 28 Kpa. Additionally, this is the first study to quantitatively show that current commercial testicular prostheses are too firm compared to native tissue. 3D printing allows us to create metamaterials that match the properties of human tissue to create customisable patient specific prostheses. This method expands the use cases for existing biomaterials by tuning their properties and could be applied to other implants mimicking native tissues.

Rapid Segmentation of Renal Tumours to Calculate Volume Using 3D Interpolation.

Small renal masses are commonly diagnosed with modern medical imaging. Renal tumour volume has been explored as a prognostic tool to help decide when intervention is needed and appears to provide additional prognostic information for smaller tumours compared with tumour diameter. However, the current method of calculating tumour volume in clinical practice uses the ellipsoid equation (π/6 × length × width × height) which is an oversimplified approach. Some research groups trace the contour of the tumour in every image slice which is impractical for clinical use. In this study, we demonstrate a method of using 3D segmentation software and the 3D interpolation method to rapidly calculate renal tumour volume in under a minute. Using this method in 27 patients that underwent radical or partial nephrectomy, we found a 10.07% mean absolute difference compared with the traditional ellipsoid method. Our segmentation volume was closer to the calculated histopathological tumour volume than the traditional method (p = 0.03) with higher Lin's concordance correlation coefficient (0.79 vs 0.72). 3D segmentation has many uses related to 3D printing and modelling and is becoming increasingly common. Calculation of tumour volume is one additional benefit it provides. Further studies on the association between segmented tumour volume and prognosis are needed.

Variability in accuracy of prostate cancer segmentation among radiologists, urologists, and scientists.

BACKGROUND: There is increasing research in using segmentation of prostate cancer to create a digital 3D model from magnetic resonance imaging (MRI) scans for purposes of education or surgical planning. However, the variation in segmentation of prostate cancer among users and potential inaccuracy has not been studied. METHODS: Four consultant radiologists, four consultant urologists, four urology trainees, and four nonclinician segmentation scientists were asked to segment a single slice of a lateral T3 prostate tumor on MRI ("Prostate 1"), an anterior zone prostate tumor MRI ("Prostate 2"), and a kidney tumor computed tomography (CT) scan ("Kidney"). Time taken and self-rated subjective accuracy out of a maximum score of 10 were recorded. Root mean square error, Dice coefficient, Matthews correlation coefficient, Jaccard index, specificity, and sensitivity were calculated using the radiologists as the ground truth. RESULTS: There was high variance among the radiologists in segmentation of Prostate 1 and 2 tumors with mean Dice coefficients of 0.81 and 0.58, respectively, compared to 0.96 for the kidney tumor. Urologists and urology trainees had similar accuracy, while nonclinicians had the lowest accuracy scores for Prostate 1 and 2 tumors (0.60 and 0.47) but similar for kidney tumor (0.95). Mean sensitivity in Prostate 1 (0.63) and Prostate 2 (0.61) was lower than specificity (0.92 and 0.93) suggesting under-segmentation of tumors in the non-radiologist groups. Participants spent less time on the kidney tumor segmentation and self-rated accuracy was higher than both prostate tumors. CONCLUSION: Segmentation of prostate cancers is more difficult than other anatomy such as kidney tumors. Less experienced participants appear to under-segment models and underestimate the size of prostate tumors. Segmentation of prostate cancer is highly variable even among radiologists, and 3D modeling for clinical use must be performed with caution. Further work to develop a methodology to maximize segmentation accuracy is needed.

Three-dimensional printing versus conventional machining in the creation of a meatal urethral dilator: development and mechanical testing.

BACKGROUND: Three-dimensional (3D) printing is a promising technology, but the limitations are often poorly understood. We compare different 3D printing methods with conventional machining techniques in manufacturing meatal urethral dilators which were recently removed from the Australian market. METHODS: A prototype dilator was 3D printed vertically orientated on a low-cost fused deposition modelling (FDM) 3D printer in polylactic acid (PLA) and acrylonitrile butadiene styrene (ABS). It was also 3D printed horizontally orientated in ABS on a high-end FDM 3D printer with soluble support material, as well as on an SLS 3D printer in medical nylon. The dilator was also machined in stainless steel using a lathe. All dilators were tested mechanically in a custom rig by hanging calibrated weights from the handle until the dilator snapped. RESULTS: The horizontally printed ABS dilator experienced failure at a greater load than the vertically printed PLA and ABS dilators, respectively (503 g vs 283 g vs 163 g, p < 0.001). The SLS nylon dilator and machined steel dilator did not fail. The steel dilator is the most expensive with a quantity of five at 98 USD each, but this decreases to 30 USD each for a quantity of 1000. In contrast, the cost for the SLS dilator is 33 USD each for five and 27 USD each for 1000. CONCLUSIONS: Low-cost FDM 3D printing is not a replacement for conventional manufacturing. 3D printing is best used for patient-specific parts, prototyping or manufacturing complex parts that have additional functionality that cannot otherwise be achieved.

Multi-colour extrusion fused deposition modelling: a low-cost 3D printing method for anatomical prostate cancer models.

Three-dimensional (3D) printed prostate cancer models are an emerging adjunct for urological surgical planning and patient education, however published methods are costly which limits their translation into clinical practice. Multi-colour extrusion fused deposition modelling (FDM) can be used to create 3D prostate cancer models of a quality comparable to more expensive techniques at a fraction of the cost. Three different 3D printing methods were used to create the same 3D prostate model: FDM, colour jet printing (CJP) and material jetting (MJ), with a calculated cost per model of USD 20, USD 200 and USD 250 respectively. When taking into account the cost, the FDM prostate models are the most preferred 3D printing method by surgeons. This method could be used to manufacture low-cost 3D printed models across other medical disciplines.

Current applications of three-dimensional printing in urology.

Three-dimensional (3D) printing or additive manufacturing is a new technology that has seen rapid development in recent years with decreasing costs. 3D printing allows the creation of customised, finely detailed constructs. Technological improvements, increased printer availability, decreasing costs, improved cell culture techniques, and biomaterials have enabled complex, novel and individualised medical treatments to be developed. Although the long-term goal of printing biocompatible organs has not yet been achieved, major advances have been made utilising 3D printing in biomedical engineering. In this literature review, we discuss the role of 3D printing in relation to urological surgery. We highlight the common printing methods employed and show examples of clinical urological uses. Currently, 3D printing can be used in urology for education of trainees and patients, surgical planning, creation of urological equipment, and bioprinting. In this review, we summarise the current applications of 3D-printing technology in these areas of urology.

Trends in Upper Tract Stone Disease in England: Evidence from the Hospital Episodes Statistics Database.

AIMS: The study aimed to determine the current trends in urolithiasis-related admissions and associated interventions in England between 2006/2007 and 2013/2014 utilizing Hospital Episode Statistics (HES) online data. MATERIAL AND METHODS: Data was extracted from the online HES data set for each year from 2006/2007 to 2013/2014 inclusive. Admissions and procedural interventions were identified from their corresponding OPCS-4 and ICD-10 codes. RESULTS: Finished consultant episodes (FCEs) for urolithiasis have increased by 20% over the last 7 years, with 93,039 FCEs in the year 2013/2014. Based on English population statistics, the lifetime prevalence of urolithiasis based on hospital-related admission/intervention data for 2013/2014 is 14%. The biggest increases were seen in those aged ≥75 years (up by 51%, n = 2,853). Total interventions have increased from 28,624 to 42,068, with increased rates of shock wave lithotripsy (26%), ureteroscopy (URS; 86%) and percutaneous nephrolithotomy (149%). Emergency URS procedures have increased by 38%. Day-case rates for ureteric and renal URS, in 2013/2014, were 22 and 21%, respectively. CONCLUSIONS: Over the last 7 years, there is a rising prevalence of kidney stone disease with associated increase in the number of interventions related to it. Both elective and emergency URS procedures are increasing, with a rising trend for day-case URS. Similar trends are seen worldwide and future resource planning for urolithiasis is needed to match the increase in demand.

Tips and tricks of ureteroscopy: consensus statement. Part II. Advanced ureteroscopy.

Our "tips and tricks" focuses on all aspects of upper tract endourology and we hope these will be of use to all trainees and consultants who perform ureteroscopy. We report an "expert consensus view" from experienced endourological surgeons, on all aspects of advanced ureteroscopic techniques, with a particular focus on avoiding and getting out of trouble while performing ureteroscopy. In this paper we provide a summary of placing ureteric access sheath, flexible ureteroscopy, intra renal stone fragmentation and retrieval, maintaining visual clarity and biopsy of ureteric and pelvicalyceal tumours.

Outcomes of open partial nephrectomies performed by Australian trainees.

BACKGROUND: Partial nephrectomy (PN) has become the standard of care for small renal tumours, with open partial nephrectomy (OPN) being superseded by minimally invasive PN. Advances in minimal access surgery have resulted in fewer relative contraindications, with subsequently fewer OPN being performed. Consequentially, trainees have less opportunity to gain skills and experience in open renal surgery. The aims of this study were to assess the standard of OPN performed by Australian urological trainees and to define whether OPN is a safe and suitable training opportunity. METHOD: A retrospective review was undertaken on patients who underwent OPN performed by urology trainees from 2010 to 2014 at two training hospitals in Western Australia. Data collected included patient demographics, surgical and oncological outcomes and morbidity. RESULTS: Sixty patients underwent OPN, with a mean age of 56 years. Most tumours were single, with mean size 31 mm. Mean operative time was 157 min, with a mean cold ischaemic time of 27 min. Mean pre- and post-operative creatinine levels were equivalent (77 µmol/L). The overall complication rate was 18%, with no documented urinary leaks, and 1.7% blood transfusion rate. Median length of stay was 4 days. There were no oncological positive margins or recurrence after a median follow-up of 2 years. CONCLUSION: Our data support the notion that Australian urological trainees can perform the majority of OPN cases, with equivalent oncological outcomes. We would advocate that when an OPN is being performed, the supervising consultant should use the case as an adjuvant for open renal surgery training.

Erratum to: The effectiveness of varicocele embolisation for the treatment of varicocele related orchalgia.

[This corrects the article DOI: 10.1186/s40064-015-1177-2.].

The effectiveness of varicocele embolisation for the treatment of varicocele related orchalgia.

PURPOSE: Orchalgia is a common problem with varicoceles however the association between varicocele embolisation for the treatment of varicocele related pain has not been widely investigated. We aim to investigate the effectiveness of varicocele embolisation for the treatment of orchalgia secondary to varicoceles; and to see if pre-embolisation pain scores can be used to predict treatment outcomes. METHODS: A prospectively collected database of patients undergoing varicocele embolisation for pain was analysed over a 10-year period. Pain scores were assessed with a 10-point visual analogue score. Analgesia requirements and satisfaction scores were assessed with questionnaires. RESULTS: Total of 96 cases. Median age was 34 years old. Median pain scores reduced significantly following embolisation (p < 0.001). 74% had reduced pain (30% of these had resolution of pain), 24% had no change in symptoms and 1% had worsening pain. Those with moderate or severe pain had a reduction of pain in 81 and 79% of cases respectively, however 64% of cases with mild pain did not experience any benefit. We also noted a reduction in analgesia requirements and a median satisfaction score of 8/10. CONCLUSION: Primary varicocele embolisation can successfully reduce varicocele related orchalgia. It works best in those with moderate or severe pain. The majority of patients with mild pain may not experience any benefit so should be counseled appropriately. The classification of patients into those with mild, moderate or severe symptoms prior to embolisation should be done, so robust consenting can be performed.

Evidence for Ureterorenoscopy and Laser Fragmentation (URSL) for Large Renal Stones in the Modern Era.

Large renal stones (>2 cm) are managed with percutaneous nephrolithotomy (PCNL), which has a good stone-free rate (SFR) but a relatively high incidence of complications graded Clavien ≥ 3. We wanted to review the literature for the use of ureterorenoscopy and laser fragmentation (URSL) for the management of these stones. A systematic review was done from 1990 to April 2014 for all English language articles reporting on a minimum of 10 patients for stones >2 cm in size (done by 2 reviewers independently) in accordance with the PRISMA and Cochrane review guidelines. A total of 379 articles were identified and after screening for the titles (54) and abstracts (29), 12 papers (651 patients) were included. The male to female ratio was 356:232 with a mean age of 54 years (range 16-86 years). With a mean stone size of 2.7 cm (2-3.15 cm) and the mean operating time of 96 min (28-238 min); the SFR was 91 % (1.45 procedures/patient). The overall number of complications was 58 (8.6 %) of which 26 (4.5 %) were complications classed Clavien ≥ 3 (haematuria with subcapsular haematoma/clot retention-7; ureteral perforation-7; steinstrasse-5; sepsis/pyelonephritis-5; prostatitis-1; cerebrovascular accident-1). Ureterorenoscopy for large renal stones in the modern era has good SFR with a small risk of major complications.

What effect do different 200 µm laser fibres have on deflection and irrigation flow rates in a flexible ureterorenoscope?

The objective of the study is to evaluate the reduction in flow and scope deflection of four leading 200-µm marketed laser fibres (Boston Scientific Flexiva™ 200, Boston Scientific Flexiva™ Trac Tip 200, Lumenis SlimLine™ EZ200 and Optical Integrity ScopeSafe™) via a flexible ureterorenoscope. A laboratory-based bench test was performed using a Flex X2™ flexible ureterorenoscope. Mean upward/downward deflection angles and flow rates (ml/min) for each fibre were calculated and compared to a control. The Optical Integrity ScopeSafe™ fibre has the least loss of deflection, losing only 8 % upward and 6 % downward deflection. Deflection loss was significantly less with this fibre compared to all other fibres (p < 0.0001). Mean flow rates were significantly greater with the Optical Integrity ScopeSafe™ laser fibre at 23 ml/min (p < 0.0001). Despite all fibres marketed as 200 µm, the deflection and flow properties show marked variations. The Optical Integrity ScopeSafe™ 200-µm laser fibre offers the best overall performance with significantly improved flow rates and the least loss of scope deflection.

Tips and tricks of ureteroscopy: consensus statement Part I. Basic ureteroscopy.

Ureteroscopy is fast becoming the first line treatment option for the majority of urinary tract stones. Ureteroscopy training can be performed in a variety of ways including simulation, hands on ureteroscopy courses and supervised operative experience. We report an "expert consensus view" from experienced endourological surgeons, on all aspects of basic ureteroscopic techniques, with a particular focus on avoiding and getting out of trouble while performing ureteroscopy. In this paper we provide a summary of treatment planning, positioning, cannulation of ureteric orifice, guidewire placement, rigid ureteroscopy and stone fragmentation.

Retrograde ureteric stent insertion in the management of infected obstructed kidneys.

OBJECTIVES: To quantify the outcomes of retrograde ureteric stenting in the setting of infected hydronephrosis secondary to ureteric calculi. PATIENTS AND METHODS: Prospective analysis of all patients over a 15-month period admitted with infected obstructed kidneys secondary to ureteric calculi. Inclusion criteria were based on clinical evidence of systemic inflammatory response syndrome (SIRS) and radiological evidence of obstructing ureteric calculi. Outcome measures included success of procedure, admission to intensive care unit (ICU), length of hospital stay, morbidity, and all-cause mortality during hospital admission. RESULTS: In all, 52 patients were included. Success of retrograde ureteric stenting was 98%. In all, 17% of patients required an ICU admission, with a post ureteric instrumentation ICU admissions rate of 6%. The mean white cell count and serum creatinine improved significantly after the procedure. Major complication rate included septic shock 6%, but there were no episodes of major haemorrhage and no deaths. CONCLUSION: Retrograde ureteric stenting is safe and effective in infected obstructed kidneys with results comparable to percutaneous nephrostomy tube insertion. Post instrumentation ICU admissions occur in 6% of retrograde stentings.

Ureteroscopy and stones: Current status and future expectations.

Urolithaisis is becoming an ever increasing urological, nephrological and primary care problem. With a lifetime prevalence approaching 10% and increasing morbidity due to stone disease, the role of ureteroscopy and stone removal is becoming more important. We discuss the current status of stone disease and review the ever increasing role that ureteroscopy has to play in its management. We discuss technological advances that have been made in stone management and give you an overview of when, how and why ureteroscopy is the most common treatment option for stone management. We touch on the role of robotic ureteroscopy and the future of ureteroscopy in the next 10 years.