Automated surgical step recognition in transurethral bladder tumor resection using artificial intelligence: transfer learning across surgical modalities.

Objective: Automated surgical step recognition (SSR) using AI has been a catalyst in the "digitization" of surgery. However, progress has been limited to laparoscopy, with relatively few SSR tools in endoscopic surgery. This study aimed to create a SSR model for transurethral resection of bladder tumors (TURBT), leveraging a novel application of transfer learning to reduce video dataset requirements. Materials and methods: Retrospective surgical videos of TURBT were manually annotated with the following steps of surgery: primary endoscopic evaluation, resection of bladder tumor, and surface coagulation. Manually annotated videos were then utilized to train a novel AI computer vision algorithm to perform automated video annotation of TURBT surgical video, utilizing a transfer-learning technique to pre-train on laparoscopic procedures. Accuracy of AI SSR was determined by comparison to human annotations as the reference standard. Results: A total of 300 full-length TURBT videos (median 23.96 min; IQR 14.13-41.31 min) were manually annotated with sequential steps of surgery. One hundred and seventy-nine videos served as a training dataset for algorithm development, 44 for internal validation, and 77 as a separate test cohort for evaluating algorithm accuracy. Overall accuracy of AI video analysis was 89.6%. Model accuracy was highest for the primary endoscopic evaluation step (98.2%) and lowest for the surface coagulation step (82.7%). Conclusion: We developed a fully automated computer vision algorithm for high-accuracy annotation of TURBT surgical videos. This represents the first application of transfer-learning from laparoscopy-based computer vision models into surgical endoscopy, demonstrating the promise of this approach in adapting to new procedure types.

Incidence of Venous Thromboembolism and Safety of Perioperative Subcutaneous Heparin During Inflatable Penile Prosthesis Surgery.

OBJECTIVE: To identify the incidence of venous thromboembolism (VTE) risk factors, postoperative VTE, and to assess the morbidity of perioperative pharmacologic VTE prophylaxis in men undergoing inflatable penile prosthesis (IPP) surgery. METHODS: We retrospectively reviewed 215 patients undergoing IPP surgery between July 2017 and June 2019. Univariate and multivariate statistical analyzes were performed to assess pre-operative Caprini risk score and compare post-operative day 0 scrotal drain output, scrotal hematoma formation, and VTE in men who received subcutaneous heparin (SqH) vs those who did not receive SqH. RESULTS: Of 215 IPP patients, 84% were classified as high or highest risk for VTE utilizing the Caprini risk score. A total of 119 (55%) received perioperative SqH with or without additional anti-thrombotics. Post-operative day 0 scrotal drain output was higher in those who received SqH compared to those who did not receive SqH, 99.9 mL vs 75.6 mL, respectively (P = .001). Minor scrotal hematomas occurred in similar rates in patients who received perioperative SqH vs those who did not, 3.8% vs 6.3%, respectively (P = .38). Similar results were found on subgroup analysis when eliminating patients who received SqH concurrently with other anti-thrombotics. The overall rate of postoperative VTE was 0.9%. No post-operative infections occurred. CONCLUSION: Patients undergoing IPP surgery are at elevated risk for VTE. To our knowledge, this is the first study showing SqH use in the perioperative IPP surgery setting is safe when used in conjunction with a scrotal drain. Preoperative VTE risk stratification may be performed and can be used to guide clinical decision making regarding pharmacologic prophylaxis.

Pubectomy and urinary reconstruction provides definitive treatment of urosymphyseal fistula following prostate cancer treatment.

OBJECTIVE: To describe the natural history, reconstructive solutions, and functional outcomes of those men undergoing pubectomy and urinary reconstruction after prostate cancer treatment. PATIENTS AND METHODS: This study retrospectively identified 25 patients with a diagnosis of urosymphyseal fistula (UF) following prostate cancer therapy who were treated with urinary reconstruction with pubectomy. This study describes the natural history, reconstructive solutions, and functional outcomes of this cohort. RESULTS: All 25 patients had a history of pelvic radiotherapy for prostate cancer. The median (interquartile range [IQR]) time from prostate cancer treatment to diagnosis of UF was 11 (6, 16.5) years. The vast majority of men (24/25; 96%) presented with debilitating groin pain during ambulation. Posterior urethral stenosis was common (20/25; 80%), with 60% having repetitive endoscopic treatments. Culture of pubic bone specimens demonstrated active infection in 80%. Discordance between preoperative urine and intraoperative bone cultures was common, 21/22 (95.5%). After surgery, major 90-day complications (Clavien-Dindo Grade III and IV) occurred in eight (32%) patients. Pain was significantly improved, with resolution of pain (24/25; 96%) and restoration of function, the median (IQR) preoperative Eastern Cooperative Oncology Group Performance Status (ECOG PS) was 3 (2, 3) vs median postoperative ECOG PS score of 0 (0, 1). CONCLUSION: Endoscopic urethral manipulation after radiation for prostate cancer is a risk factor for UF. Conservative management will not provide symptom resolution. Fistula decompression, bone resection, and urinary reconstruction effectively treats chronic infection, improves pain and ECOG PS scores.

Incidence and risk factors for peritoneal carcinomatosis following open radical cystectomy.

OBJECTIVE: To characterize the frequency and risk factors of peritoneal carcinomatosis (PC) in patients undergoing open radical cystectomy (RC). METHODS: We identified 3,285 patients with urothelial carcinoma treated with RC for curative intent between 1980 and 2016. At last follow-up, 72.1% (2,370/3,285) of patients had died, with a median follow-up of 8.6 years (Interquartile Range, (IQR) 3.7, 14.1). PC was defined as any recurrence involving the omentum, small bowel, and mesentery. Overall-specific survival (OSS) and cancer-specific survival (CSS) was evaluated using Kaplan-Meier methodology and log-rank test. Risk factors for mortality and recurrence were performed using Cox proportional hazards regression models. RESULTS: One hundred and twenty nine (3.9%) patients were diagnosed with PC, while a total of 1,148 (34.9%) patients experienced recurrence at other sites. Median time to PC vs. other-site recurrence was 1.3 (IQR 1.3, 2.3) and 0.9 (IQR 0.5, 2.1) years, respectively (P= 0.04). Only increasing pathologic stage on multivariable analysis was associated with developing PC (pT1 HR 2.51, 95CI 1.14-5.55, P= 0.02; pT2 OR 2.82, 95CI 1.47-5.43, P= 0.002; pT3+ 2.40, 95CI 1.31-4.42, P= 0.005) over other recurrence patterns. Nodal status and tumor margin status were not associated. Patients with PC experienced worse OSS and CSS than other types of recurrence (P< 0.001). CONCLUSION: PC was identified in almost 4% of patients undergoing open RC. PC is a rare occurrence after RC and primarily impacts patients with locally advanced disease.

Bacterial Cultures at the Time of Artificial Urinary Sphincter Revision Surgery in Clinically Uninfected Devices: A Contemporary Series.

PURPOSE: We evaluated the rate of bacterial colonization in artificial urinary sphincters during revision surgery for noninfectious etiologies. MATERIALS AND METHODS: We evaluated bacterial culture swab data on all explanted artificial urinary sphincter components (cuff, pump and reservoir) in patients who underwent revision surgery between February 2016 and July 2018. Those treated with revision for infection or erosion were excluded from study. Patient demographic variables were assessed to identify factors associated with colonization. RESULTS: Cultures were obtained from 200 components, including 86 cuffs, 56 pumps and 58 reservoirs among the total of 80 patients. The etiology of revision included urethral atrophy in 31 cases (39%) and mechanical failure in 49 (52%). Median time after prior artificial urinary sphincter placement was 4.3 years (IQR 2-9). Median operative time was 37.5 minutes (IQR 32-46). All components were explanted and replaced in 55 patients (69%) and a single component was replaced in 23 (28%). Positive culture swabs were identified in 37 of the 200 components (19%), including 25 of 86 cuffs (29%), 7 of 56 pumps (13%) and 5 of 58 reservoirs (9%). Of the 80 patients 31 (39%) had at least 1 positive component culture and were more likely to have a history of radiation (65% vs 33%, p = 0.006). Identified organisms included Staphylococcus species in 57% of cases, Propionibacterium in 10% and Aerococcus in 5%. CONCLUSIONS: Positive artificial urinary sphincter component bacterial swab cultures were found in 39% of patients undergoing artificial urinary sphincter revision in the absence of clinical infection. Those with positive cultures were more likely to have a history of pelvic radiation. These results suggest that bacterial colonization of organisms with low virulence may not lead to device infection.

Penile Traction Therapy and Vacuum Erection Devices in Peyronie's Disease.

INTRODUCTION: Peyronie's disease (PD) has historically been managed by at least 1 treatment, including oral supplements or medications, intralesional injections, or surgery. Adjunctive mechanical therapies also have been described, including penile traction therapy (PTT) and vacuum erection devices (VEDs), although relatively limited data are available on their use with PD. AIM: To review and summarize the published literature on the role and efficacy of PTT and VED in men with PD. METHODS: A PubMed search was performed of all publications on PTT and VED in men with PD from inception through September 2017. MAIN OUTCOME MEASURES: Changes in penile curvature, length, girth, erectile function, and adverse events with PTT or VED. RESULTS: PTT and VED exhibit mechanisms to improve aspects of PD, although clinical outcomes data are limited. Based on current data, PTT likely has a potential role as a primary lengthening therapy (modest improvements), in curvature correction (acute phase; unclear role in chronic phase), before penile prosthesis insertion, and after surgical correction of PD. The role of PTT as a combination therapy during collagenase Clostridium histolyticum injections is unclear. Fewer and lower level-of-evidence studies are available on VEDs and suggest potential roles in curvature correction, before penile prosthesis placement, or after PD surgery. Guideline statements from the American Urological Association and International Consultation on Sexual Medicine also support the potential role of PTT and VED in managing PD. CONCLUSIONS: PTT and VED represent viable therapeutic options for managing PD, with more data currently available on PTT. Because all PTT studies used a similar style of traction device, it is unclear whether results reflect outcomes of these particular devices or traction more broadly. Further studies are required to better delineate the benefits of PTT and VED, particularly in relation to other established treatments. Avant RA, Ziegelman M, Nehra A, et al. Penile Traction Therapy and Vacuum Erection Devices in Peyronie's Disease. Sex Med Rev 2019;7:338-348.

Impact of anabolic androgenic steroids on sexual function.

BACKGROUND: To describe the impact of supra-physiologic anabolic-androgenic steroid (AAS) use, including agent, dosage, and duration of therapy, on sexual function. METHODS: We reviewed data from an online survey of AAS users to evaluate their sexual function on and off AAS. The online survey consisted of questions addressing demographics, anabolic steroid use and patterns, ancillary medications, testosterone (T)-related symptoms while on and off of therapy, as well as sexual function which was assessed using the 5-item, International Index of Erectile Function (IIEF-5). RESULTS: A total of 321 men responded to the survey, of which 90 failed to meet inclusion criteria, for a final cohort of 231 AAS users. The majority of men were Caucasian (85%), employed (62%), and younger than 35 years (58%), while an equal mix were single (47%) or married (46%). The mean IIEF-5 was 22.5, with higher scores associated with increased T dosages (>600 mg/week), use of 17-alpha alkylated hormones and anti-estrogens, and absence of concurrent medical conditions. Lower mean IIEF scores were associated with current and pre-AAS low T symptoms, self-reported angry or violent tendencies, self-reported erectile dysfunction (ED), decreased libido, decreased energy, and depression. After controlling for age, low T symptoms and decreased energy remained significantly associated with lower IIEF scores. Among 127 men reporting de novo decreased libido when not taking AAS, several factors were significantly associated including frequency and duration of T and use of adjunctive therapies, while post-cycle therapies were protective. Men who reported any other de novo symptom (decreased energy, libido, muscle mass or depression) after discontinuing T were also more likely to report de novo ED, as well as those using >10 years or for >40 weeks per year. CONCLUSIONS: The long-term impact of high dose AAS use on sexual function remains poorly defined. Although high T dosages appeared to be protective of erectile function during use, de novo symptoms such as decreased libido and ED occurred more frequently after discontinuing T, particularly among those using more frequently and for longer durations. Given the importance of these findings, long-term studies evaluating the impacts of discontinuing T on sexual dysfunction are indicated.

Medication patterns and fertility rates in a cohort of anabolic steroid users.

BACKGROUND: To describe self-reported medication patterns and fertility rates in a population of anabolic steroid (AS) users. METHODS: We reviewed data from an online survey of AS users and identified a sub-group who had attempted to achieve a pregnancy with their partners while using AS. The online survey consisted of questions addressing demographics, AS use, ancillary medications, and fertility outcomes. RESULTS: A total of 97 men (of 231 total respondents) had attempted to achieve a pregnancy while taking AS and comprise the current cohort. The majority of men were 25-44 years old (63.9%), married (75.5%) and Caucasian (88.7%). Ancillary drug use was common with only 5.2% denying drug use other than ASs. The most common reported ancillary drugs were antiestrogens (89.7%) and sexual enhancement medications (SEMs) (68%). The fertility rate was 92.8%, with 82.4% achieving pregnancy within one year. Interestingly, only 13.5% sought fertility evaluation with treatment required in 8.3%. Age at initiation of AS use, maximum dosage utilized, yearly duration of supplementation, and number of years using steroids were not associated with a prolonged duration to pregnancy or decreased rate of pregnancy. CONCLUSIONS: Despite continued use of ASs, this cohort's self-reported fertility rates are unexpectedly high. This is presumably related to cycling of therapy and concomitant use of fertility preserving medications.

Clinical Experience With Penile Traction Therapy Among Men Undergoing Collagenase Clostridium histolyticum for Peyronie Disease.

OBJECTIVE: To evaluate the outcomes in men undergoing collagenase Clostridium histolyticum (CCH) with concurrent penile traction therapy (PTT) for the treatment of Peyronie disease (PD). MATERIALS AND METHODS: We identified patients treated with CCH between March 2014 and July 2016. Patients were recommended to perform modeling and PTT between injection series. A final curve assessment was performed after patients completed CCH. A prospective database was maintained, including patient-reported frequency and duration of PTT. Statistical analysis was performed to evaluate outcomes based on use and duration of PTT. RESULTS: A total of 51 patients completed CCH and had complete objective data available for analysis. Mean (standard deviation [SD]) baseline curvature was 66.7 (25.0) degrees, and mean (SD) improvement post CCH was 20.9 (17.3) degrees (P < .0001). Thirty-five (69%) men reported daily PTT for a mean (SD) of 9.8 (6.3) hours per week. No significant difference was identified in the degree of curve improvement based on frequency or duration of PTT (P = .40). Similarly, no associations between PTT and functional outcomes including intercourse restoration and surgery prevention were identified. Stretched penile length increased nonsignificantly by a mean (SD) of +0.4 (1.5) cm in the PTT group, compared with -0.35 (1.5) in the non-PTT group (P = .21). CONCLUSION: The current series represents a "true-to-life" experience, wherein utilization patterns, attrition, and compliance issues are relevant factors impacting efficacy. PTT use with the Andropenis declined in both frequency and duration with subsequent injection series, and there was no significant difference in curve improvement or stretched penile length with a mean 10 hours of weekly concurrent PTT.

Operant responding for sucrose by rats bred for high or low saccharin consumption.

The use of rats differing in the intake of sweet substances has highlighted some interesting parallels between taste preferences and drug self-administration. For example, rats selectively bred to consume high (HiS) or low (LoS) amounts of a 0.1% saccharin solution (when compared to water consumption), show corresponding differences across several measures of cocaine self-administration (HiS>LoS). In this study, we measured whether the two strains also differ when response requirements are imposed for obtaining a sucrose reinforcer. Male HiS and LoS rats were measured for operant responding for sucrose pellets under fixed-ratio (FR) schedules of 1, 3, 5 and 10 and under a progressive-ratio (PR) schedule, during which the response requirement for each successive pellet increased exponentially. The effect of systemic naltrexone (0.3, 1 and 3mg/kg) on PR responding for sucrose pellets was also tested. Under all FR and PR schedules, the number of pellets obtained by the LoS rats were significantly lower than those obtained by the HiS rats. Although the LoS weighed more than the HiS rats, this difference does not appear to explain differences in operant behavior. No strain differences in the effect of naltrexone were observed; the 3mg/kg dose reduced the number of pellets obtained in both strains. Measures of locomotor activity taken prior to operant trials suggest that the differences in responding were not due to differences in general activity levels. These studies provide further characterization of the HiS and LoS rat lines by demonstrating that motivation to consume sucrose is greater in HiS than in LoS rats.

Naturally occurring altered peptide ligands control Salmonella-specific CD4+ T cell proliferation, IFN-gamma production, and protective potency.

T cell activation required for host defense against infection is an intricately regulated and precisely controlled process. Although in vitro studies indicate that three distinct stimulatory signals are required for T cell activation, the precise contribution of each signal in regulating T cell proliferation and differentiation after in vivo infection is unknown. In this study, altered peptide ligands (APLs) derived from the protective Salmonella-specific FliC Ag and CD4+ T cells specific for the immune-dominant FliC(431-439) peptide within this Ag were used to determine how changes in TCR stimulation impact CD4+ T cell proliferation, differentiation, and protective potency. To explore the prevalence and potential use of altered TCR stimulation by bacterial pathogens, naturally occurring APLs containing single amino acid substitutions in putative TCR contact residues within the FliC(431-439) peptide were identified and used for stimulation under both noninfection and infection conditions. On the basis of this analysis, naturally-occurring APLs that prime proliferation of FliC-specific CD4+ T cells either more potently or less potently compared with the wild-type FliC(431-439) peptide were identified. Remarkably, despite these differences in proliferation, all of the APLs primed reduced IFN-gamma production by FliC(431-439)-specific CD4+ T cells after stimulation in vivo. Moreover, after expression of the parental FliC(431-439) peptide or each APL in recombinant Listeria monocytogenes, only CD4+ T cells stimulated with the wild-type FliC(431-439) peptide conferred significant protection against challenge with virulent Salmonella. These results reveal important and unanticipated roles for TCR stimulation in controlling pathogen-specific CD4+ T cell proliferation, differentiation, and protective potency.