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BACKGROUND: The aim of this study was to evaluate genomic risk of patients with persistent prostate specific antigen (PSA) using mRNA expression analysis and a validated prognostic genomic-risk classifier. METHODS: Monocentric retrospective study including all patients who underwent radical prostatectomy (RP) by one surgeon and Decipher Test from October 2013 to December 2018. PSA persistent population was defined as all patients with two consecutive PSA>0.1 ng/mL at follow-up after the surgery. Neurovascular Structure-adjacent Frozen-section Examination (NeuroSAFE) was performed intraoperatively for research of positive surgical margins. Multivariate analysis was performed for persistent PSA (pPSA) predictors. A specific localized, organ-confined, and negative margins sub-population with PSA persistence was compared to a similar sub-population without PSA persistence for genomic differential expression analyses. RESULTS: A total of 564 patients were included and 61 of them had pPSA. Preoperative PSA was higher in the PSA persistent group (11.6 [6.4, 21.2] vs. 6.2 [4.7, 9.2] P=0.00010), as well as PSA density (PSAd) (0.3 [0.2, 0.5] vs. 0.2 [0.1, 0.3] P=0.0001). Postoperative characteristics, Gleason Score, and positive surgical margins were significantly higher in the PSA persistent population. 31 patients had pPSA in our specific subpopulation and were compared to 217 patients with no pPSA. On multivariate analysis, only Decipher Score (OR=5.64 [1.28; 24.89], P=0.022) and preoperative PSA (OR=1.06, [1.02; 1.09], P=0.001) were significant predictors for PSA persistence. We found two genes to be significantly upregulated with a 2.5-fold change in our specific subpopulation (SERPINB11 and PDE11A). CONCLUSIONS: We found unique genomic features of patients with pPSA, whilst confirming previous clinical findings that this condition behaves to a worse prognosis. Given this high genomic risk, further imaging studies should be performed to select patients for early treatment intensification.
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Antígeno Prostático Específico , Serpinas , Masculino , Humanos , Antígeno Prostático Específico/genética , Márgenes de Escisión , Estudios Retrospectivos , Prostatectomía , Secciones por CongelaciónRESUMEN
INTRODUCTION: We evaluated for differences in post-procedure 30-day encounters or infections following office cystoscopy using disposable vs reusable cystoscopes. METHODS: Cystoscopies performed from June to September 2020 and from February to May 2021 in our outpatient practice were retrospectively reviewed. The 2020 cystoscopies were performed with reusable cystoscopes, and the 2021 cystoscopies were performed with disposable cystoscopes. The primary outcome was the number of post-procedural 30-day encounters defined as phone calls, patient portal messages, emergency department visits, hospitalizations, or clinic appointments related to post-procedural complications such as dysuria, hematuria, or fever. Culture-proven urinary tract infection within 30 days of cystoscopy was evaluated as a secondary outcome. RESULTS: We identified 1,000 cystoscopies, including 494 with disposable cystoscopes and 506 with reusable cystoscopes. Demographics were similar between groups. The most common indication for cystoscopy in both groups was suspicion of bladder cancer (disposable: 153 [30.2%] and reusable: 143 [28.9%]). Reusable cystoscopes were associated with a higher number of 30-day encounters (35 [7.1%] vs 11 [2.2%], P < .001), urine cultures (73 [14.8%] vs 3 [0.6%], P = .005), and hospitalizations attributable to cystoscopy (1 [0.2%] vs 0 [0%], P < .001) than the disposable scope group. Positive urine cultures were also significantly more likely after cystoscopy with a reusable cystoscope (17 [3.4%] vs 1 [0.2%], P < .001). CONCLUSIONS: Disposable cystoscopes were associated with a lower number of post-procedure encounters and positive urine cultures compared to reusable cystoscopes.
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Cistoscopios , Infecciones Urinarias , Humanos , Estudios Retrospectivos , Cistoscopía/métodos , Pacientes Ambulatorios , Infecciones Urinarias/diagnósticoRESUMEN
To find an association between genomic features of connective tissue and pejorative clinical outcomes on radical prostatectomy specimens. We performed a retrospective analysis of patients who underwent radical prostatectomy and underwent a Decipher transcriptomic test for localized prostate cancer in our institution (n = 695). The expression results of selected connective tissue genes were analyzed after multiple t tests, revealing significant differences in the transcriptomic expression (over- or under-expression). We investigated the association between transcript results and clinical features such as extra-capsular extension (ECE), clinically significant cancer, lymph node (LN) invasion and early biochemical recurrence (eBCR), defined as earlier than 3 years after surgery). The Cancer Genome Atlas (TCGA) was used to evaluate the prognostic role of genes on progression-free survival (PFS) and overall survival (OS). Out of 528 patients, we found that 189 had ECE and 27 had LN invasion. The Decipher score was higher in patients with ECE, LN invasion, and eBCR. Our gene selection microarray analysis showed an overexpression in both ECE and LN invasion, and in clinically significant cancer for COL1A1, COL1A2, COL3A1, LUM, VCAN, FN1, AEBP1, ASPN, TIMP1, TIMP3, BGN, and underexpression in FMOD and FLNA. In the TCGA population, overexpression of these genes was correlated with worse PFS. Significant co-occurrence of these genes was observed. When presenting overexpression of our gene selection, the 5-year PFS rate was 53% vs. 68% (p = 0.0315). Transcriptomic overexpression of connective tissue genes correlated to worse clinical features, such as ECE, clinically significant cancer and BCR, identifying the potential prognostic value of the gene signature of the connective tissue in prostate cancer. TCGAp cohort analysis showed a worse PFS in case of overexpression of the connective tissue genes.
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Neoplasias de la Próstata , Masculino , Humanos , Estudios Retrospectivos , Estadificación de Neoplasias , Neoplasias de la Próstata/patología , Colágeno Tipo I , Antígeno Prostático Específico , Prostatectomía/métodos , Carboxipeptidasas , Proteínas RepresorasRESUMEN
Bladder leiomyomas are rare, benign tumors with a variety of clinical presentations. Surgical approach is typically based on symptomatology and leiomyoma location. Literature on robotic excision is limited. We present our case of a unique transvesical approach. The patient had rapid convalescence with no complications, suggesting robotic transvesical excision is a safe, effective treatment for bladder leiomyoma for suitable candidates.
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BACKGROUND: Intracavernosal injections (ICI) are a well-established treatment option for men with erectile dysfunction (ED); however, the anticipation of pain with injection remains a significant barrier to the use of ICI. AIM: To evaluate the patient-anticipated degree of pain versus the experienced degree of pain pre- and post-ICI in men undergoing their first injection with an erectile agent. METHODS: We studied 51 patients who underwent their first ICI in our men's health clinic. Anticipated needle-associated pain was judged with a pre-injection score, and pain experienced during the injection was judged with a post-injection score. All patients graded their pre- and post-ICI pain using a standard 10-point scale (0-10). OUTCOMES: Pre- and post-ICI pain was defined with the visual analogue scale (0-10) in men undergoing their first penile injection. RESULTS: Medians and interquartile ranges (IQRs) of the patients' age [65 years (54.5-68.0)], pre-injection pain [5 (4-7)], and post-injection pain [1 (1-2)] were recorded. Most men in the study had erectile dysfunction (68.6%) and/or Peyronie's Disease (64.7%). The average pre-injection prediction pain score was 5.45 ± 2.15; the average post-injection perceived pain score was 1.20 ± 0.73. Thus, there was an average discrepancy of over 4 points in predicted pain vs perceived pain. A paired t-test was performed which showed a statistically significant difference between pre- and post-injection scores (P < .05). A Wilcoxson Signed Rank Test showed statistical significance in the difference between pre- and post-injection pain scores (P < .05). CLINICAL IMPLICATIONS: ICI is a safe, effective treatment for patients with ED and is associated with significantly less pain than is anticipated by patients. STRENGTHS & LIMITATIONS: This is the first report to describe the discrepancy between pre-ICI anticipated pain and post-ICI experienced pain. Limitations include an overall small sample size. CONCLUSION: Patients experience significantly less pain with ICI than they anticipate having. This represents an important factor to consider when counseling patients about available ED treatments. Baird B, Wajswol E, Ericson C et al. Pre- and Post-Injection Needle Pain in Patients Undergoing First Intracavernosal Injection. J Sex Med 2022;19:590-593.
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Disfunción Eréctil , Induración Peniana , Anciano , Disfunción Eréctil/tratamiento farmacológico , Humanos , Inyecciones , Masculino , Dolor/tratamiento farmacológico , Dolor/etiología , Erección Peniana , Induración Peniana/complicaciones , Induración Peniana/tratamiento farmacológico , PeneRESUMEN
OBJECTIVE: To compare transperineal (TP-TBx) and transrectal (TR-TBx) targeted prostate biopsy in a prospective non randomized single surgeon series of MR/US fusion-guided targeted biopsy performed using an electromagnetic tracking platform (NCT04026763). MATERIALS AND METHODS: In this single-institution prospective study, 168 patients who underwent transperineal systematic 12-core biopsy and TP-TBx with electromagnetic tracking (UroNav, Invivo, Gainesville, FL) were compared to 211 patients who underwent a similar procedure by a transrectal approach. Univariate and multivariate analyses were used to assess if biopsy technique impacted all cancer detection rates or clinically significant (Gleason score >3+4) cancer detection rates. RESULTS: Patients who underwent TP-TBx were older (68 vs 65 y, Pâ¯=â¯.014), with a slightly higher rate of PI-RADSv2.0 score (39% vs 28%, Pâ¯=â¯.039) and higher lesion volume on mpMRI (0.54 vs 0.41 cc, Pâ¯=â¯.039). The rates of CS disease detection by TP-TBx and TR-TBx were 59% and 54%, respectively. In a multivariate analysis adjusting for PSA, previous biopsy status, prostate volume, PI-RADS score, lesion volume, and lesion location, there was no statistically significant difference in likelihood to detect any PCa (OR, 0.98; 95% CI, 0.56-1.71; Pâ¯=â¯.940) or CS PCa (OR, 0.94, 95% CI, 0.58-1.51; Pâ¯=â¯.791). CONCLUSION: Transperineal targeted biopsy with electromagnetic-tracking is comparable to the transrectal fusion-guided approach in the detection of any PCa and csPCa cancer.
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Biopsia Guiada por Imagen/métodos , Próstata/patología , Neoplasias de la Próstata/diagnóstico , Anciano , Biopsia con Aguja Gruesa/efectos adversos , Biopsia con Aguja Gruesa/métodos , Fenómenos Electromagnéticos , Humanos , Procesamiento de Imagen Asistido por Computador , Biopsia Guiada por Imagen/efectos adversos , Masculino , Persona de Mediana Edad , Imagen Multimodal , Imágenes de Resonancia Magnética Multiparamétrica , Perineo , Estudios Prospectivos , Neoplasias de la Próstata/patología , Recto , UltrasonografíaRESUMEN
Idiopathic intracranial hypertension (IIH) is a rare, ill-understood disease of significant morbidity. Because the pathophysiology is poorly understood, treatment protocols are not uniform and are directed towards alleviating the most common symptoms: headache and visual loss. In this review, we analyze 25 case series, all of which included IIH patients (n = 408) who were treated with placement of a venous sinus stent. Among 342 patients who had headache, 240 patients (70.2%) had improvement or resolution of headache after the stent insertion. Of the 217 patients documented to have visual problems, visual acuity was improved or stabilized in 161 patients (74.2%). Of the 304 patients with papilledema, 257 showed resolution or improved (84.5%). Of the 124 patients who presented with pulsatile tinnitus, it was resolved in 110 patients (88.7%) after stent placement. Endovascular management of dural sinus stenosis is therefore clinically efficacious in patients with IIH who have failed medical and surgical therapy.
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Importance: Prostate cancer is the most common malignant neoplasm among men and is the one with the highest positive surgical margin (PSM) rate. This high rate is due to the difficulty in balancing the risk of extraprostatic disease and excising periprostatic structures, which ultimately affects patients' quality of life. In the case of a PSM, the appropriateness of adjuvant radiation therapy (aRT) should be discussed. The financial burden of PSMs on health systems has not been investigated. Objective: To estimate the financial costs associated with a PSM during radical prostatectomy on the basis of the odds of undergoing aRT. Design, Setting, and Participants: This cohort study used data on men with prostate cancer from the US National Cancer Database (January 1, 2010, through December 31, 2015). Data were requested in March 2019, accessed in April 2019, and analyzed in August 2019. Exposure: Treatment with radical prostatectomy followed by aRT, if indicated. Main Outcomes and Measures: The attributable risk fraction of PSMs on undergoing aRT was estimated from a logistic regression with aRT administration as the outcome. The analysis was adjusted for patients' socioeconomic and demographic characteristics and tumor characteristics. The aRT cost for the year 2019 was calculated using the Medicare Physician Fee Schedule and the Hospital Outpatient Prospective Payment System. The fraction of this cost attributable to a PSM was estimated according to its attributable risk fraction. Results: In total, 230â¯175 men were identified (median [interquartile range] age at diagnosis, 62.0 [56.0-67.0] years). Overall, 22.8% of the patients had a PSM. Patients with PSMs were more likely than those without PSMs to be older (median [interquartile range] age, 62.0 [56.0-66.0] years vs 62.0 [57.0-67.0] years) and nonwhite (9320 patients [17.8%] vs 29â¯872 patients [16.8%]), to have higher comorbidity scores (1604 patients [3.1%] vs 4884 patients [2.7%] with a Charlson-Deyo Comorbidity Index score ≥2) and worse tumor characteristics (category T3 and T4 disease, 26â¯394 patients [50.3%] vs 36â¯040 patients [20.3%]), and to have lower socioeconomic indicators (median annual income <$30â¯000, 5708 patients [10.9%] vs 17â¯874 patients [10.1%]; proportion of individuals without a high school degree in the area ≥29%, 6925 patients [13.2%] vs 22â¯648 patients [12.7%]). In addition, PSMs were documented more frequently at nonacademic institutions than academic ones (31â¯702 patients [60.5%] vs 20â¯714 patients [39.5%]). A total of 11â¯585 patients (5.0%) underwent aRT, and 7698 of them (3.3%) had a PSM at the final pathology examination. When controlling for patients' socioeconomic and demographic characteristics and tumor characteristics, men with PSMs were more likely than those with negative margins to undergo aRT, with an odds ratio of 3.79 (95% CI, 3.63-3.96; P < .001). The attributable risk fraction of the presence of a PSM on aRT was 44% (95% CI, 42%-45%). The attributable cost of a PSM was calculated as $17â¯356 (95% CI, $16â¯567-$17â¯751). Assuming 60â¯000 prostatectomies in 2019 and similar trends of PSM and aRT, the overall health burden attributable to PSMs was calculated to be $52â¯068â¯000 (95% CI, $49â¯701â¯000-$53â¯253â¯000). Conclusions and Relevance: The estimated aRT cost attributable to the presence of a PSM was $17â¯356, resulting in $52â¯068â¯000 in spending on aRT in 2019. Strategies to reduce PSMs could be associated with a reduction in the overall health costs of surgically treated PCa.
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Costos de la Atención en Salud/estadística & datos numéricos , Neoplasias de la Próstata/economía , Neoplasias de la Próstata/radioterapia , Radioterapia , Anciano , Estudios de Cohortes , Humanos , Masculino , Márgenes de Escisión , Persona de Mediana Edad , Próstata/cirugía , Neoplasias de la Próstata/epidemiología , Neoplasias de la Próstata/cirugía , Radioterapia/economía , Radioterapia/estadística & datos numéricos , Estados UnidosRESUMEN
BACKGROUND: Prediction of extra-prostatic extension (EPE) in men undergoing radical prostatectomy (RP) is of utmost importance. Great variability in the performance of multiparametric magnetic resonance imaging (mpMRI) has been reported for prediction of EPE. The present study aimed to determine the diagnostic performance of mpMRI for predicting EPE in different National Comprehensive Cancer Network (NCCN) risk categories. METHODS: Overall 664 patients who underwent radical prostatectomy with a staging mpMRI were enrolled in this single-center, retrospective study. Patients with mpMRI report non-compliant with PI-RADSv2.0, were excluded. Patients were stratified according to NCCN criteria: very low/low (VLR-LR) to High Risk (HR) in order to assess final pathology EPE rates (focal and established). Sensitivity, specificity, positive and negative predictive values of staging mpMRI were computed in each group. Univariable and multivariable analysis were used to evaluate predictors of positive surgical margins. RESULTS: Pathological evaluation demonstrated established and focal EPE in 60 (9%) and 106 (16%) patients, respectively, while mpMRI suspicion for EPE was present in 180 (27%) patients. Age, preoperative PSA, PSA density, number of positive cores, NCCN groups, prostate volume, mpMRI suspicion for EPE, PIRADSv2.0 and lesion size differed significantly between the patients with any EPE and without EPE (all P≤0.05). The sensitivity of mpMRI in detecting any EPE varied from 12% (95% CI: 0.6-53%) in VLR-LR to 83% (66-93%) in HR while the corresponding values for the specificity were 92% (85-96%) and 63% (45-78%), respectively. Patients with false-negative mpMRI EPE prediction were more likely to have positive surgical margins in univariable (OR: 2.14; CI: 1.18, 3.87) as well as multivariable analysis adjusting for NCCN risk categories (OR: 1.97; CI: 1.08, 3.60). CONCLUSIONS: The performance of mpMRI for prediction of EPE varies greatly between different NCCN risk categories with a low positive predicting value in patients at low to favorable intermediate risk and a low negative predictive value in patients at Unfavorable intermediate to high risk PCa. Given that mpMRI EPE misdiagnosis could have a negative impact on oncological and functional outcomes, NCCN risk categories should be considered when interpreting mpMRI findings in PCa patients.
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Imágenes de Resonancia Magnética Multiparamétrica , Neoplasias de la Próstata , Anciano , Humanos , Imagen por Resonancia Magnética/métodos , Masculino , Persona de Mediana Edad , Planificación de Atención al Paciente , Prostatectomía/métodos , Neoplasias de la Próstata/diagnóstico por imagen , Neoplasias de la Próstata/cirugía , Estudios RetrospectivosRESUMEN
PURPOSE: For transradial interventions, most published studies report an initial Terumo Radial (TR) band placement time of 60 minutes, with gradual deflation over 30 to 90 minutes. We aimed to determine, retrospectively, whether TR band removal time could be expedited to 45 to 60 minutes, without adverse effects via an expedited single-step deflation protocol. METHODS: A total of 115 consecutive noncoronary visceral interventions that utilized TR band from September 2017 till February 2019 were retrospectively reviewed. Alternative single-step deflation protocol was utilized where the nursing staff was instructed to deflate the TR band in 1 step between 45 and 60 minutes; 79 patients (43 men, 36 women, mean age of 55.3 ± 13.6 years) underwent 115 transradial interventions. Mean procedure time was 49.8 ± 22.1 minutes, and mean fluoroscopy time was 18.5 ± 10.6 minutes. Data collected included patient demographics, procedure details, and nursing notes on complications including bleeding and reinflation of the TR band. Univariate and Multivariate analyses of independent variables were performed using a binary logistic regression model. All patients were followed up postoperatively before discharge and in clinic upon follow-up. RESULTS: The TR band was deflated at 51.3 ± 14.5 minutes, with successful removal achieved on the first attempt in 103 cases (90.3% primary technical success rate). In 12 cases, bleeding was noted upon initial deflation, secondary technical success was achieved when the band was reinflated for an additional mean time of 37.0 ± 19.1 minutes. There was 1 incidence of radial artery occlusion (0.8%) and 1 incidence of a grade 1 hematoma (0.8%). The only variable predictive of technical outcome upon initial band deflation on univariate binomial logistic regression was initial TR band removal time (P = .019). CONCLUSIONS: A single-step deflation protocol for TR band placement may be safe for nonocclusive patent hemostasis and may translate to even further shorten postprocedural hospital times for patients and cost savings for hospitals.
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Cateterismo Periférico , Hemorragia/prevención & control , Técnicas Hemostáticas/instrumentación , Arteria Radial , Adulto , Anciano , Cateterismo Periférico/efectos adversos , Diseño de Equipo , Femenino , Hemorragia/etiología , Técnicas Hemostáticas/efectos adversos , Humanos , Masculino , Persona de Mediana Edad , Punciones , Arteria Radial/diagnóstico por imagen , Radiografía Intervencional , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE: To evaluate the ability to detect clinically significant prostate cancer (PCa) using a novel electromagnetically (EM) tracked transperineal magnetic resonance imaging (MRI)/ultrasonography (US) fusion-guided targeted biopsy (transperineal TBx) platform and the impact of inter-reader variability on cancer detection. MATERIALS AND METHODS: A total of 176 patients with suspicious lesions detected on multiparametric MRI (mpMRI) underwent a systematic modified Barzel template biopsy (12-core) transperineal biopsy (transperineal SBx) and transperineal TBx with EM tracking (UroNav; Philips Healthcare, Best, the Netherlands) in the same setting. Cancer detection rates (CDRs) were stratified by Prostate Imaging Reporting and Data System (PI-RADS) v2 scores and compared with Fisher's exact test. Area under the curve (AUC) was calculated for prostate-specific antigen (PSA), PSA density (PSAD), PI-RADS score, and subgroup analysis of individual readers' PI-RADS scores with respect to overall CDR and clinically significant CDR. RESULTS: The overall CDR was 76.7% (135/176), of which 76.3% (103/135) was clinically significant PCa. Among the 135 patients with PCa, transperineal TBx detected 90.4% of cases (122/135), either alone or in combination with transperineal SBx. The remaining 9.6% of cases (13/135) missed by transperineal TBx were diagnosed by transperineal SBx alone, of which three were clinically significant. Conversely, transperineal SBx missed 14% of cases (19/135), 14 of which were clinically significant PCa. Sensitivities for transperineal TBx and transperineal SBx were 90.4% and 85.9%, respectively. On a per-lesion basis, PI-RADS score (AUC 0.74) outperformed both PSA (AUC 0.59) and PSAD (AUC 0.63) in discriminating clinically significant from non-clinically significant PCa on transperineal TBx. Although not formally statistically tested, AUCs amongst different mpMRI readers appeared to display considerable variability. There were no adverse events, including sepsis. CONCLUSIONS: Electromagnetically tracked transperineal TBx of MRI-visible lesions enhanced the ability of transperineal SBx to detect PCa, with greater sensitivity for clinically significant disease. These findings suggest transperineal TBx is a safe, alternative fusion platform for patients with a suspicious lesion on prostate MRI. The assessment of inter-reader variability, in conjunction with prediction of clinically significant PCa and CDR, is an important first step for quality control in implementing an MRI-based screening programme.
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Biopsia Guiada por Imagen/métodos , Imagen por Resonancia Magnética , Neoplasias de la Próstata/diagnóstico por imagen , Neoplasias de la Próstata/patología , Ultrasonografía Intervencional , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Humanos , Masculino , Persona de Mediana Edad , Variaciones Dependientes del Observador , PerineoRESUMEN
The 2019 European Association of Urology guidelines recommend multiparametric magnetic resonance imaging (mpMRI) for biopsy-naïve patients with clinical suspicion of prostate cancer (PC) and avoiding biopsy in patients with negative mpMRI and low clinical suspicion. However, consensus on the optimal definition of low clinical suspicion is lacking. We evaluated 266 biopsy-naïve patients who underwent mpMRI, the 4Kscore test, and prostate biopsy to define the best strategy to avoid unnecessary testing and biopsies. The European Randomized Study of Screening for Prostate Cancer risk calculator (ERSPC-RC) and prostate-specific antigen density (PSAd) were also considered. For men with Prostate Imaging-Reporting and Data System v2.0 (PI-RADS) 1â¿¿2 lesions, the highest negative predictive value was observed for those with low or intermediate 4Kscore risk (96.9% and 97.1%), PSAd <0.10ng/ml/cm3 (98.7%), and ERSPC-RC <2% (98.7%). For men with PI-RADS 3â¿¿5 lesions the lowest positive predictive value was observed for those with low 4Kscore risk (0%), PSAd <0.10ng/ml/cm3 (13.2%), and ERSPC-RC <2% (12.3%). The best biopsy strategy was an initial 4Kscore followed by mpMRI if the 4Kscore was>7.5% and a subsequent biopsy if the mpMRI was positive (PI-RADS 3â¿¿5) or the 4Kscore was â¿¥18%. This would result in missing 2.7% (2/74) of clinically significant PCs (csPCs) and avoiding 34.2% of biopsies. Initial mpMRI followed by biopsy for negative mpMRI (PI-RADS 1â¿¿2) if the 4Kscore was â¿¥18% or PSAd was â¿¥0.10ng/ml/cm3 resulted in a similar percentage of csPC missed (2.7% [2/74] and 1.3% [1/74]) but slightly fewer biopsies avoided (25.2% and 28.1%). Physicians should consider clinical risk screening tools when ordering and interpreting mpMRI results to avoid unnecessary testing and diagnostic errors. PATIENT SUMMARY: Performing the 4Kscore test in conjunction with multiparametric magnetic resonance imaging for men with a clinical suspicion of prostate cancer may help to reduce unnecessary biopsies.
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Imágenes de Resonancia Magnética Multiparamétrica/estadística & datos numéricos , Antígeno Prostático Específico/sangre , Próstata/patología , Neoplasias de la Próstata/sangre , Neoplasias de la Próstata/diagnóstico , Procedimientos Innecesarios/estadística & datos numéricos , Biopsia/estadística & datos numéricos , Árboles de Decisión , Humanos , Masculino , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Medición de RiesgoRESUMEN
Objectives: To assess the incidence of postoperative arterial malformation (AM) and urine leak/urinoma (UL) after robotic partial nephrectomy (RPN) in a contemporary series and to evaluate risk factors for these complications. Materials and Methods: All RPNs were queried from Institutional Review Board-approved retrospective and prospective nephrectomy databases. Demographics, perioperative variables, and postoperative complications were collected. Differences between cohorts were analyzed using univariate analysis. Postoperative complications were graded using the Clavien-Dindo system. UL was defined in the context of signs and symptoms of a collection with supporting evidence of urine collection through drainage or aspiration. AM was identified based on postoperative imaging indicative of arteriovenous fistula or pseudoaneurysm and/or requirement for selective embolization. Predictors of AM and UL were assessed by univariate analysis. Results: A total of 395 RPNs were performed by four urologists between January 2014 and October 2018. Tumor complexity, defined by nephrometry score, was significantly greater in the prospective cohort (p = 0.01). Overall incidence of postoperative complications was 5.6% with cohort-specific incidences of 5.3% and 5.8%. The retrospective cohort had a greater percentage of complications classified as ≥IIIa: 8/13 (61.5%) vs 2/8 (25%). Overall incidence of AM was 2.3% with cohort-specific incidence of 3.1% (7/225) vs 1.1% (2/170). Overall incidence of UL was 0.25% with cohort-specific incidence of 0.55% (1/225) and 0.0% (0/170). The difference in incidence of both complications between cohorts was significant (p < 0.05). No significant predictors for AM were identified. Conclusions: The incidence of postoperative complications after RPN remains low (5.3% vs 5.8%, overall: 5.6%). UL and AM are becoming rarer with experience, despite increasing surgical complexity (0.55% vs 0%, 3.1% vs 1.1%).
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Neoplasias Renales/cirugía , Nefrectomía/efectos adversos , Nefrectomía/métodos , Complicaciones Posoperatorias/epidemiología , Procedimientos Quirúrgicos Robotizados/efectos adversos , Procedimientos Quirúrgicos Robotizados/métodos , Anciano , Bases de Datos Factuales , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Estudios Retrospectivos , Factores de Riesgo , Resultado del Tratamiento , Urinoma/epidemiología , Urinoma/etiologíaRESUMEN
PURPOSE: To evaluate the safety and efficacy of sacroplasty for the treatment of osteoporotic and malignant sacral fractures by performing a systematic review and meta-analysis of existing literature. MATERIALS AND METHODS: PubMed, Web of Science, and SCOPUS databases were searched from their inception until February 2018 for articles describing sacroplasty. Inclusion criteria were as follows: studies reporting > 5 patients, and pain assessment before and after the procedure recorded with visual analog scale (VAS). Demographic data, procedural details, technical success rates, VAS scores before and after the procedure, and procedural complications were recorded. A random-effects meta-analyses of the VAS pain score before the procedure, at 24-48 hours, at 6 months, and at 12 months were calculated. RESULTS: Nineteen studies (18 case series and 1 cohort study) were identified consisting of 861 total patients (682 women and 167 men; mean age 73.89 ± 9.73 years). Patients underwent sacroplasty for the following indications: sacral insufficiency fractures secondary to osteoporosis (n = 664), malignancy (n = 167), and nonspecified sacral insufficiency fractures (n = 30). Technical and clinical successes were achieved in 98.9% (852/861) and 95.7% (623/651) of patients undergoing sacroplasty, respectively. The pooled major complication rate was 0.3%, with 3 patients requiring surgical decompression for cement leakage. Random-effects meta-analyses demonstrated statistically significant differences in the VAS pain level at preprocedure, 24-48 hours, 6 months, and 12 months, with cumulative pain scores of 8.32 ± 0.01, 3.55 ± 0.01, 1.48 ± 0.01, and 0.923 ± 0.01, respectively. CONCLUSIONS: Sacroplasty appears safe and effective for pain relief in patients with osteoporotic or malignant sacral fractures, with statistically significant sustained improvement in VAS pain scores up to 12 months.
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Dolor de Espalda/terapia , Cementos para Huesos/uso terapéutico , Cementoplastia/métodos , Fracturas Osteoporóticas/terapia , Sacro/lesiones , Fracturas de la Columna Vertebral/terapia , Anciano , Anciano de 80 o más Años , Dolor de Espalda/diagnóstico , Dolor de Espalda/etiología , Cementos para Huesos/efectos adversos , Cementoplastia/efectos adversos , Femenino , Curación de Fractura , Humanos , Masculino , Persona de Mediana Edad , Fracturas Osteoporóticas/diagnóstico por imagen , Fracturas Osteoporóticas/etiología , Factores de Riesgo , Sacro/diagnóstico por imagen , Sacro/patología , Fracturas de la Columna Vertebral/diagnóstico por imagen , Fracturas de la Columna Vertebral/etiología , Neoplasias de la Columna Vertebral/complicaciones , Neoplasias de la Columna Vertebral/patología , Resultado del TratamientoRESUMEN
Biocompatible gold nanoparticles designed to absorb light at wavelengths of high tissue transparency have been of particular interest for biomedical applications. The ability of such nanoparticles to convert absorbed near-infrared light to heat and induce highly localized hyperthermia has been shown to be highly effective for photothermal cancer therapy, resulting in cell death and tumor remission in a multitude of preclinical animal models. Here we report the initial results of a clinical trial in which laser-excited gold-silica nanoshells (GSNs) were used in combination with magnetic resonance-ultrasound fusion imaging to focally ablate low-intermediate-grade tumors within the prostate. The overall goal is to provide highly localized regional control of prostate cancer that also results in greatly reduced patient morbidity and improved functional outcomes. This pilot device study reports feasibility and safety data from 16 cases of patients diagnosed with low- or intermediate-risk localized prostate cancer. After GSN infusion and high-precision laser ablation, patients underwent multiparametric MRI of the prostate at 48 to 72 h, followed by postprocedure mpMRI/ultrasound targeted fusion biopsies at 3 and 12 mo, as well as a standard 12-core systematic biopsy at 12 mo. GSN-mediated focal laser ablation was successfully achieved in 94% (15/16) of patients, with no significant difference in International Prostate Symptom Score or Sexual Health Inventory for Men observed after treatment. This treatment protocol appears to be feasible and safe in men with low- or intermediate-risk localized prostate cancer without serious complications or deleterious changes in genitourinary function.
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Terapia por Láser/instrumentación , Nanopartículas del Metal/administración & dosificación , Neoplasias de la Próstata/cirugía , Anciano , Estudios de Factibilidad , Estudios de Seguimiento , Oro/administración & dosificación , Oro/efectos de la radiación , Humanos , Biopsia Guiada por Imagen/métodos , Rayos Infrarrojos , Terapia por Láser/efectos adversos , Terapia por Láser/métodos , Imagen por Resonancia Magnética Intervencional/efectos adversos , Imagen por Resonancia Magnética Intervencional/instrumentación , Imagen por Resonancia Magnética Intervencional/métodos , Masculino , Nanopartículas del Metal/efectos de la radiación , Persona de Mediana Edad , Imagen Multimodal/efectos adversos , Imagen Multimodal/instrumentación , Imagen Multimodal/métodos , Nanocáscaras/administración & dosificación , Nanocáscaras/efectos de la radiación , Oligopéptidos , Órganos en Riesgo/efectos de la radiación , Erección Peniana/efectos de la radiación , Proyectos Piloto , Próstata/diagnóstico por imagen , Próstata/patología , Próstata/cirugía , Neoplasias de la Próstata/diagnóstico por imagen , Neoplasias de la Próstata/patología , Salud Sexual , Ultrasonografía Intervencional/efectos adversos , Ultrasonografía Intervencional/instrumentación , Ultrasonografía Intervencional/métodos , Sistema Urogenital/efectos de la radiaciónRESUMEN
BACKGROUND: Neurocritical care combines the management of extremely complex disease states with the inherent limitations of clinically assessing patients with brain injury. As the management of neurocritical care patients can be immensely complicated, the automation of data-collection and basic management by artificial intelligence systems have garnered interest. METHODS: In this opinion article, we highlight the potential artificial intelligence has in monitoring and managing several aspects of neurocritical care, specifically intracranial pressure, seizure monitoring, blood pressure, and ventilation. RESULTS: The two major AI methods of analytical technique currently exist for analyzing critical care data: the model-based method and data driven method. Both of these methods have demonstrated an ability to analyze vast quantities of patient data, and we highlight the ways in which these modalities of artificial intelligence might one day play a role in neurocritical care. CONCLUSIONS: While none of these artificial intelligence systems are meant to replace the clinician's judgment, these systems have the potential to reduce healthcare costs and errors or delays in medical management.
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Inteligencia Artificial , Lesiones Encefálicas/terapia , Cuidados Críticos/métodos , Toma de Decisiones , HumanosRESUMEN
PURPOSE: To systematically review and perform a meta-analysis on the safety and efficacy of endovascular therapy in the treatment of the two most common etiologies of vasculogenic erectile dysfunction (ED): veno-occlusive dysfunction (VOD) and arterial insufficiency (AI). MATERIALS AND METHODS: PubMed, Web of Science, ScienceDirect, and Scopus databases were searched for published English literature regarding endovascular ED treatments. Case series (n ≥ 3) were included. Multiple data points were obtained, including demographic data, etiology, diagnosis method, imaging studies, treatment approach, technical success, clinical success, complications, and follow-up. RESULTS: Sixteen relevant articles were obtained and a total of 212 patients with VOD and 162 with AI were identified. The VOD cohort were treated either percutaneously (60.4%; n = 128) or after surgical exposure of the deep dorsal vein (33.5%, n = 71), or it was unspecified (6.1%; n = 13). The most common embolic used was n-butyl cyanoacrylate (51.9%; n = 109). Meta-analysis found an overall clinical success rate of 59.8% in VOD patients. Complications occurred in 5.2% of patients (n = 11), with 9 considered to be mild and 2 considered to be severe. The AI cohort contained 162 patients most commonly treated via stenting of the internal pudendal artery (40.1%; n = 65). Meta-analysis found an overall clinical success rate of 63.2% in AI patients. Complications occurred in 4.9% of patients (n = 8), with 4 considered to be mild and 4 considered to be severe. CONCLUSIONS: Endovascular therapy for medically refractory ED is safe and may provide a treatment alternative to more invasive surgical management; however, conclusions are limited by the heterogeneity of clinical success definitions among the included studies.