Seminal vesicles in focus: An illustrated overview.

Seminal vesicles play a crucial role in the male reproductive system, as they are responsible for secreting a fluid that forms most of the ejaculate. Seminal vesicles' pathology can present with non-specific symptoms, making imaging diagnosis essential for proper patient management. Various imaging modalities can be used to evaluate these glands, with MRI beneficial in illustrating the spectrum of seminal vesicle disease. Typical seminal vesicles appear as elongated fluid-containing structures, but congenital anomalies, inflammatory conditions, and neoplastic disorders can alter their appearance. Furthermore, differentiating mimics from actual pathology can be challenging but crucial for proper management. This article aims to provide an overview of the typical imaging appearance of the seminal vesicles and illustrate the principal imaging characteristics of conditions involving these structures. It will review the imaging characteristics of common and uncommon lesions involving the seminal vesicles by exploring congenital, infectious, and neoplastic in detail. As the seminal vesicles are often evaluated incidentally during prostate imaging, radiologists should be aware of the variability of normal findings and recognize the principal pathologies affecting these structures to ensure proper patient management.

Clinical application of machine learning models in patients with prostate cancer before prostatectomy.

BACKGROUND: To build machine learning predictive models for surgical risk assessment of extracapsular extension (ECE) in patients with prostate cancer (PCa) before radical prostatectomy; and to compare the use of decision curve analysis (DCA) and receiver operating characteristic (ROC) metrics for selecting input feature combinations in models. METHODS: This retrospective observational study included two independent data sets: 139 participants from a single institution (training), and 55 from 15 other institutions (external validation), both treated with Robotic Assisted Radical Prostatectomy (RARP). Five ML models, based on different combinations of clinical, semantic (interpreted by a radiologist) and radiomics features computed from T2W-MRI images, were built to predict extracapsular extension in the prostatectomy specimen (pECE+). DCA plots were used to rank the models' net benefit when assigning patients to prostatectomy with non-nerve-sparing surgery (NNSS) or nerve-sparing surgery (NSS), depending on the predicted ECE status. DCA model rankings were compared with those drived from ROC area under the curve (AUC). RESULTS: In the training data, the model using clinical, semantic, and radiomics features gave the highest net benefit values across relevant threshold probabilities, and similar decision curve was observed in the external validation data. The model ranking using the AUC was different in the discovery group and favoured the model using clinical + semantic features only. CONCLUSIONS: The combined model based on clinical, semantic and radiomic features may be used to predict pECE + in patients with PCa and results in a positive net benefit when used to choose between prostatectomy with NNS or NNSS.

O-RADS MRI scoring system has the potential to reduce the frequency of avoidable adnexal surgery.

OBJECTIVE: To assess the potential impact of the O-RADS MRI score on the decision-making process for the management of adnexal masses. METHODS: EURAD database (prospective, European observational, multicenter study) was queried to identify asymptomatic women without history of infertility included between March 1st and March 31st 2018, with available surgical pathology or clinical findings at 2-year clinical follow-up. Blinded to final diagnosis, we stratified patients into five categories according to the O-RADS MRI score (absent i.e. non adnexal, benign, probably benign, indeterminate, probably malignant). Prospective management was compared to theoretical management according to the score established as following: those with presumed benign masses (scored O-RADS MRI 2 or 3) (follow-up recommended) and those with presumed malignant masses (scored O-RADS MRI 4 or 5) (surgery recommended). RESULTS: The accuracy of the score for assessing the origin of the mass was of 97.2 % (564/580, CI95% 0.96-0.98) and was of 92.0 % (484/526) for categorizing lesions with a negative predictive value of 98.1 % (415/423, CI95% 0.96-0.99). Theoretical management using the score would have spared surgery in 229 patients (87.1 %, 229/263) with benign lesions and malignancy would have been missed in 6 borderline and 2 invasive cases. In patients with a presumed benign mass using O-RADS MRI score, recommending surgery for lesions >= 100 mm would miss only 4/77 (4.8 %) malignant adnexal tumors instead of 8 (50 % decrease). CONCLUSION: The use of O-RADS MRI scoring system could drastically reduce the number of asymptomatic patients undergoing avoidable surgery.

Risk Biomarkers for Biochemical Recurrence after Radical Prostatectomy for Prostate Cancer Using Clinical and MRI-Derived Semantic Features.

OBJECTIVES: This study aimed to assess the impact of the covariates derived from a predictive model for detecting extracapsular extension on pathology (pECE+) on biochemical recurrence-free survival (BCRFS) within 4 years after robotic-assisted radical prostatectomy (RARP). METHODS: Retrospective data analysis was conducted from a single center between 2015 and 2022. Variables under consideration included prostate-specific antigen (PSA) levels, patient age, prostate volume, MRI semantic features, and Grade Group (GG). We also assessed the influence of pECE+ and positive surgical margins on BCRFS. To attain these goals, we used the Kaplan-Meier survival function and the multivariable Cox regression model. Additionally, we analyzed the MRI features on BCR (biochemical recurrence) in low/intermediate risk patients. RESULTS: A total of 177 participants with a follow-up exceeding 6 months post-RARP were included. The 1-year, 2-year, and 4-year risks of BCR after radical prostatectomy were 5%, 13%, and 21%, respectively. The non-parametric approach for the survival analysis showed that adverse MRI features such as macroscopic ECE on MRI (mECE+), capsular disruption, high tumor capsular contact length (TCCL), GG ≥ 4, positive surgical margins (PSM), and pECE+ on pathology were risk factors for BCR. In low/intermediate-risk patients (pECE- and GG < 4), the presence of adverse MRI features has been shown to increase the risk of BCR. CONCLUSIONS: The study highlights the importance of incorporating predictive MRI features for detecting extracapsular extension pre-surgery in influencing early outcomes and clinical decision making; mECE+, TCCL, capsular disruption, and GG ≥ 4 based on pre-surgical biopsy were independent prognostic factors for early BCR. The presence of adverse features on MRI can assist in identifying low/intermediate-risk patients who will benefit from closer monitoring.

Radiologic-pathologic correlation of prostatic cancer extracapsular extension (ECE).

Recent advancements on nerve-sparing robotic prostatectomy allow fewer side effects such as urinary incontinence and sexual dysfunction. To perform such techniques, it is essential for the surgeon to know if the neurovascular bundle is involved. Despite being the gold-standard imaging method for Prostate Cancer (PCa) staging, Magnetic Resonance Imaging (MRI) lacks high specificity for detecting extracapsular extension (ECE). Therefore, it is essential to understand the pathologic aspects of ECE to better evaluate the MRI findings of PCa. We reviewed the normal MRI appearance of the prostate gland and the periprostatic space and correlated them to prostatectomy specimens. The different findings of ECE and neurovascular bundle invasion are exemplified with images of both MRI and histologic specimens.

Early biomarkers of extracapsular extension of prostate cancer using MRI-derived semantic features.

BACKGROUND: To construct a model based on magnetic resonance imaging (MRI) features and histological and clinical variables for the prediction of pathology-detected extracapsular extension (pECE) in patients with prostate cancer (PCa). METHODS: We performed a prospective 3 T MRI study comparing the clinical and MRI data on pECE obtained from patients treated using robotic-assisted radical prostatectomy (RARP) at our institution. The covariates under consideration were prostate-specific antigen (PSA) levels, the patient's age, prostate volume, and MRI interpretative features for predicting pECE based on the Prostate Imaging-Reporting and Data System (PI-RADS) version 2.0 (v2), as well as tumor capsular contact length (TCCL), length of the index lesion, and prostate biopsy Gleason score (GS). Univariable and multivariable logistic regression models were applied to explore the statistical associations and construct the model. We also recruited an additional set of participants-which included 59 patients from external institutions-to validate the model. RESULTS: The study participants included 184 patients who had undergone RARP at our institution, 26% of whom were pECE+ (i.e., pECE positive). Significant predictors of pECE+ were TCCL, capsular disruption, measurable ECE on MRI, and a GS of ≥7(4 + 3) on a prostate biopsy. The strongest predictor of pECE+ is measurable ECE on MRI, and in its absence, a combination of TCCL and prostate biopsy GS was significantly effective for detecting the patient's risk of being pECE+. Our predictive model showed a satisfactory performance at distinguishing between patients with pECE+ and patients with pECE-, with an area under the ROC curve (AUC) of 0.90 (86.0-95.8%), high sensitivity (86%), and moderate specificity (70%). CONCLUSIONS: Our predictive model, based on consistent MRI features (i.e., measurable ECE and TCCL) and a prostate biopsy GS, has satisfactory performance and sufficiently high sensitivity for predicting pECE+. Hence, the model could be a valuable tool for surgeons planning preoperative nerve sparing, as it would reduce positive surgical margins.

Machine learning in predicting extracapsular extension (ECE) of prostate cancer with MRI: a protocol for a systematic literature review.

INTRODUCTION: In patients with prostate cancer (PCa), the detection of extracapsular extension (ECE) and seminal vesicle invasion is not only important for selecting the appropriate therapy but also for preoperative planning and patient prognosis. It is of paramount importance to stage PCa correctly before surgery, in order to achieve better surgical and outcome results. Over the last years, MRI has been incorporated in the classical prostate staging nomograms with clinical improvement accuracy in detecting ECE, but with variability between studies and radiologist's experience. METHODS AND ANALYSIS: The research question, based on patient, index test, comparator, outcome and study design criteria, was the following: what is the diagnostic performance of artificial intelligence algorithms for predicting ECE in PCa patients, when compared with that of histopathological results after radical prostatectomy. To answer this question, we will use databases (EMBASE, PUBMED, Web of Science and CENTRAL) to search for the different studies published in the literature and we use the QUADA tool to evaluate the quality of the research selection. ETHICS AND DISSEMINATION: This systematic review does not require ethical approval. The results will be disseminated through publication in a peer-review journal, as a chapter of a doctoral thesis and through presentations at national and international conferences. PROSPERO REGISTRATION NUMBER: CRD42020215671.

Ovarian-Adnexal Reporting Data System Magnetic Resonance Imaging (O-RADS MRI) Score for Risk Stratification of Sonographically Indeterminate Adnexal Masses.

Importance: Approximately one-quarter of adnexal masses detected at ultrasonography are indeterminate for benignity or malignancy, posing a substantial clinical dilemma. Objective: To validate the accuracy of a 5-point Ovarian-Adnexal Reporting Data System Magnetic Resonance Imaging (O-RADS MRI) score for risk stratification of adnexal masses. Design, Setting, and Participants: This multicenter cohort study was conducted between March 1, 2013, and March 31, 2016. Among patients undergoing expectant management, 2-year follow-up data were completed by March 31, 2018. A routine pelvic MRI was performed among consecutive patients referred to characterize a sonographically indeterminate adnexal mass according to routine diagnostic practice at 15 referral centers. The MRI score was prospectively applied by 2 onsite readers and by 1 reader masked to clinical and ultrasonographic data. Data analysis was conducted between April and November 2018. Main Outcomes and Measures: The primary end point was the joint analysis of true-negative and false-negative rates according to the MRI score compared with the reference standard (ie, histology or 2-year follow-up). Results: A total of 1340 women (mean [range] age, 49 [18-96] years) were enrolled. Of 1194 evaluable women, 1130 (94.6%) had a pelvic mass on MRI with a reference standard (surgery, 768 [67.9%]; 2-year follow-up, 362 [32.1%]). A total of 203 patients (18.0%) had at least 1 malignant adnexal or nonadnexal pelvic mass. No invasive cancer was assigned a score of 2. Positive likelihood ratios were 0.01 for score 2, 0.27 for score 3, 4.42 for score 4, and 38.81 for score 5. Area under the receiver operating characteristic curve was 0.961 (95% CI, 0.948-0.971) among experienced readers, with a sensitivity of 0.93 (95% CI, 0.89-0.96; 189 of 203 patients) and a specificity of 0.91 (95% CI, 0.89-0.93; 848 of 927 patients). There was good interrater agreement among both experienced and junior readers (κ = 0.784; 95% CI, 0.743-0824). Of 580 of 1130 women (51.3%) with a mass on MRI and no specific gynecological symptoms, 362 (62.4%) underwent surgery. Of them, 244 (67.4%) had benign lesions and a score of 3 or less. The MRI score correctly reclassified the mass origin as nonadnexal with a sensitivity of 0.99 (95% CI, 0.98-0.99; 1360 of 1372 patients) and a specificity of 0.78 (95% CI, 0.71-0.85; 102 of 130 patients). Conclusions and Relevance: In this study, the O-RADS MRI score was accurate when stratifying the risk of malignancy in adnexal masses.

Infectious and Inflammatory Diseases of the Urinary Tract: Role of MR Imaging.

Urinary tract infection (UTI) is among the most common of bacterial infections. Imaging studies are only required in cases of complicated UTIs. Ultrasound remains the first-line imaging method; however, CT is the gold standard for evaluation of UTIs. MR imaging's improved contrast resolution and absence of ionizing radiation may recommend its use for assessment of lower UTIs. Furthermore, MR imaging performs with diagnostic accuracy at least similar to CT in complicated UTIs, except for the identification of calculi and emphysematous pyelonephritis. In this article, the role of MR imaging for the evaluation of infectious and inflammatory disease processes of the urinary tract is reviewed.

Obturator Internus Muscle Endometriosis with Nerve Involvement: a Rare Clinical Presentation.

STUDY OBJECTIVE: To describe our surgical approach in a rare case of deep infiltrating endometriosis of the obturator internus muscle with obturator nerve involvement. DESIGN: A step-by-step surgical explanation using video and literature review (Canadian Task Force Classification III). SETTING: Endometriosis can be pelvic or rarely extrapelvic and is classically defined as the presence of endometrial glands and stroma outside the uterine cavity [1,2]. Pain along the sensitive area of the obturator nerve, thigh adduction weakness and difficulty in ambulation are extremely rare presenting symptoms [2-4]. PATIENT: We report a case of a 32-year-old patient who presented with cyclic leg pain in the inner right thigh radiating to the knee caused by a cystic endometriotic mass in the obturator internus muscle with nerve retraction. The patient provided informed consent to use the surgical video. Institutional review board approval was obtained. INTERVENTIONS: Pelvic magnetic resonance imaging was performed and confirmed a nodular lesion of about 2.3 cm with high signal on T1WI and T2WI and without fat suppression on T2FS inside the right obturator internus muscle, suggesting an endometriotic lesion (Fig. 1). Surgical removal of the mass was performed using the laparoscopic approach. A normal pelvic cavity was found, and the retroperitoneal space was dissected. A mass located within the right obturator internus muscle, below the right iliac external vein, behind the corona mortis vein, and lateral to the right obturator nerve was identified. The whole region was inflamed, and the nerve was partially involved. Dissection was performed carefully with rupture of the tumor, releasing a chocolatelike fluid (Fig. 2), and the cyst was removed. Pathology examination was consistent with endometriosis. Patient improvement was observed, with pain relief and improved ability for right limb mobilization. No recurrence of endometriosis was found at the follow-up visit 6 months later. MEASUREMENTS AND MAIN RESULTS: The obturator nerve is responsible for motor and sensitive innervation of the joins and internal muscles of thigh and knee as well as the innervation of skin in the internal thigh. Pain along the sensitive area of the obturator nerve at the time of menstruation, thigh adduction weakness, difficulty ambulating, or paresthesia can be presenting symptoms with the involvement of the obturator nerve [5]. Besides paresthesia, our patient presented all the symptoms. The suspected diagnosis of obturator internus muscle endometriosis with retraction of the obturator nerve was confirmed by laparoscopic surgery and pathological examination of the excised tissue. To our knowledge, only 4 cases of endometriosis involving the obturator nerve have been described (according to MEDLINE searched in January 2017) [5-8]. The laparoscopic approach provided an excellent access to the retroperitoneal space, allowing fine dissection of the obturator nerve and the surrounding structures with complete removal of the cystic mass. CONCLUSION: We report a rare case of endometriosis with a single mass located inside the right obturator internus muscle with neuronal involvement of the obturator nerve. The fundamental role of laparoscopy was clearly demonstrated for the diagnosis and treatment of our patient.

Treatment for Uterine Isthmocele, A Pouchlike Defect at the Site of a Cesarean Section Scar.

An isthmocele appears as a fluid pouchlike defect in the anterior uterine wall at the site of a prior cesarean section and ranges in prevalence from 19% to 84%, a direct relation to the increase in cesarean sections performed worldwide. Many definitions have been suggested for the dehiscence resulting from cesarean sections, and we propose standardization with a single term for all cases-isthmocele. Patients are not always symptomatic, but symptoms typically include intermittent abnormal bleeding, pain, and infertility. Pregnancy complications that result from an isthmocele include ectopic pregnancy, low implantation, and uterine rupture. Magnetic resonance imaging and transvaginal ultrasound are the gold standard imaging techniques for diagnosis. Surgical treatment of an isthmocele is still a controversial issue but should be offered to symptomatic women or the asymptomatic patient who desires future pregnancy. When surgery is the treatment choice, laparoscopy guided by hysteroscopy, hysteroscopy alone, or vaginal repair are the best options depending on the isthmocele's characteristics and surgeon expertise.

MRI for adenomyosis: a pictorial review.

Adenomyosis is defined as the presence of ectopic endometrial glands and stroma within the myometrium. It is a disease of the inner myometrium and results from infiltration of the basal endometrium into the underlying myometrium. Transvaginal ultrasonography (TVUS) and magnetic resonance imaging (MRI) are the main radiologic tools for this condition. A thickness of the junctional zone of at least 12 mm is the most frequent MRI criterion in establishing the presence of adenomyosis. Adenomyosis can appear as a diffuse or focal form. Adenomyosis is often associated with hormone-dependent lesions such as leiomyoma, deep pelvic endometriosis and endometrial hyperplasia/polyps. Herein, we illustrate the MRI findings of adenomyosis and associated conditions, focusing on their imaging pitfalls. TEACHING POINTS: • Adenomyosis is defined as the presence of ectopic endometrium within the myometrium. • MRI is an accurate tool for the diagnosis of adenomyosis and associated conditions. • Adenomyosis can be diffuse or focal. • The most established MRI finding is thickening of junctional zone exceeding 12 mm. • High-signal intensity myometrial foci on T2- or T1-weighted images are also characteristic.

Laparoscopic Psoas Hitch Double Ureteral Re-implantation in the Duplex Urinary System for Treatment of Ureterovaginal Fistula.

INTRODUCTION: Although laparoscopy is widely established for ablative urologic procedures, pelvic reconstructive procedures are still mostly performed by open-surgery. As urologists continue to introduce advanced laparoscopic skills to reconstructive urologic procedures, we present our experience with a laparoscopic psoas hitch double ureteral re-implantation in a patient with an ureterovaginal fistula and an ipsilateral duplex urinary system. MATERIALS AND METHODS: A 42-year-old patient presented with continuous involuntary urine loss from the vagina after an abdominal hysterectomy. A double modified Lich-Gregoir ureteral re-implantation with a psoas hitch was performed, using a 4-port laparoscopic approach. RESULTS: There were no post-operative complications and the cystography at post-operative day 14 revealed good positioning of the psoas hitch, with no leak or reflux. At three-months follow-up, the patient is completely dry and asymptomatic. CONCLUSION: Laparoscopic ureteroneocystostomy with psoas hitch for the treatment of lesions of the distal ureter is a possible, safe, and effective way to resolve a complex urologic situation with minimally invasive surgery. Laparoscopy is becoming the standard approach to urologic pelvic reconstructive procedures, even in the most complex cases.

[Aortic vascular anomalies and Kommerell's diverticulum, an imagiologic diagnosis]. / Anomalias vasculares aórticas e divertículo de Kommerell, um diagnóstico imagiológico.

Aortic vascular anomalies are complex anatomic entities requiring often complex and problematic surgical approaches. The authors report the clinical case of a Kommerell's diverticulum and right-sided aortic arch. Right-sided aortic arch is an uncommon congenital defect of the aorta and it is rare in the setting of an otherwise normal heart. A right-sided aortic arch was described more than two centuries ago. Several classifications of these anomalies have been proposed on the basis of the arrangement of the arch vessels, relationships with the esophagus, or the presence of congenital heart anomalies. In the adult population, a right-sided aortic arch is often asymptomatic, unless aneurismal disease develops. This usually occurs at the level of the take-off of an aberrant left subclavian artery and is known as a Kommerell's diverticulum. In spite of its rarity, this condition is clinically relevant due to the mortality associated with rupture, morbidity caused by compression of mediastinal structures, and complexity of surgery.