Diagnostic value of PET imaging in clinically unresponsive patients.

Rapid advancements in the critical care management of acute brain injuries have facilitated the survival of numerous patients who may have otherwise succumbed to their injuries. The probability of conscious recovery hinges on the extent of structural brain damage and the level of metabolic and functional cerebral impairment, which remain challenging to assess via laboratory, clinical, or functional tests. Current research settings and guidelines highlight the potential value of fluorodeoxyglucose-PET (FDG-PET) for diagnostic and prognostic purposes, emphasizing its capacity to consistently illustrate a metabolic reduction in cerebral glucose uptake across various disorders of consciousness. Crucially, FDG-PET might be a pivotal tool for differentiating between patients in the minimally conscious state and those in the unresponsive wakefulness syndrome, a persistent clinical challenge. In patients with disorders of consciousness, PET offers utility in evaluating the degree and spread of functional disruption, as well as identifying irreversible neural damage. Further, studies that capture responses to external stimuli can shed light on residual or revived brain functioning. Nevertheless, the validity of these findings in predicting clinical outcomes calls for additional long-term studies with larger patient cohorts suffering from consciousness impairment. Misdiagnosis of conscious illnesses during bedside clinical assessments remains a significant concern. Based on the clinical research settings, current clinical guidelines recommend PET for diagnostic and/or prognostic purposes. This review article discusses the clinical categories of conscious disorders and the diagnostic and prognostic value of PET imaging in clinically unresponsive patients, considering the known limitations of PET imaging in such contexts.

Functional MRI evaluation of blood oxygen dependent (BOLD) in renal allograft dysfunction: a prospective study.

BACKGROUND: Blood oxygen level dependent-magnetic resonance imaging (BOLD-MRI) is a non-invasive functional imaging technique that can be used to assess renal allograft dysfunction. PURPOSE: To evaluate the diagnostic performance of BOLD-MRI using a 3-T scanner in discriminating causes of renal allograft dysfunction in the post-transplant period. MATERIAL AND METHODS: This prospective study was conducted on 112 live donor-renal allograft recipients: 53 with normal graft function, as controls; 18 with biopsy-proven acute rejection (AR); and 41 with biopsy-proven acute tubular necrosis (ATN). Multiple fast-field echo sequences were performed to obtain T2*-weighted images. Cortical R2* (CR2*) level, medullary R2* (MR2*) level, and medullary over cortical R2* ratio (MCR) were measured in all participants. RESULTS: The mean MR2* level was significantly lower in the AR group (20.8 ± 2.8/s) compared to the normal group (24 ± 2.4/s, P <0.001) and ATN group (27.4 ± 1.7/s, P <0.001). The MCR was higher in ATN group (1.47 ± 0.18) compared to the AR group (1.18 ± 0.17) and normal functioning group (1.34 ± 0.2). Both MR2* (area under the curve [AUC] = 0.837, P <0.001) and MCR (AUC = 0.727, P = 0.003) can accurately discriminate ATN from AR, however CR2* (AUC = 0.590, P = 0.237) showed no significant difference between both groups. CONCLUSION: In early post-transplant renal dysfunction, BOLD-MRI is a valuable non-invasive diagnostic technique that can differentiate between AR and ATN by measuring changes in intra-renal tissue oxygenation.

Microscopic hematuria and pelvic ultrasonography could rule out flexible cystoscopy during surveillance for T1-low grade non-muscle invasive bladder cancer.

Purpose: Cystoscopy (rigid/flexible [FC]) is the standard surveillance tool for non-muscle invasive bladder cancer (NMIBC). Nevertheless, it has its drawbacks. The objective of this study is to evaluate the performance of microscopic hematuria (MH), abdominal ultrasonography (US), and urine cytology (UC) as potential substitutes for FC in patients with T1-low-grade (T1-LG) NMIBC. Methods: Over a 12-month period, patients attending our tertiary referral center for T1-LG NMIBC follow-up underwent urine analysis for MH and UC, and then US and FC were performed as outpatient surveillance procedures. Those with positive findings underwent inpatient rigid cystoscopy under anesthesia and biopsy. The negative predictive values (NPV) and sensitivity of different combinations of MH, UC, US, and FC were compared with the standard histopathology. Results: In 218 evaluated patients, FC had the highest NPV (97.9%). However, this figure showed no statistically significant difference if compared with the combination of negative MH and US (93.8%) (difference = 0.04, p = 0.1) or the combination of MH, US, and UC (94.9%) (difference = 0.03, p = 0.2). The reported sensitivity results were similarly comparable between FC (94.2%) and the aforementioned combinations (90.4% and 92.3%; differences: 0.038 and 0.019; p = 0.4 and 0.7, respectively). Conclusions: During the surveillance of NMIBC for patients diagnosed with T1-LG disease, the combination of MH/US has comparable sensitivity and NPV with FC. This non-invasive combination could be considered the first station that might preclude the need for FC in a considerable percentage of this group of patients.

Renal arterial embolization: Indications, angiographic findings, and outcomes in a series of 170 patients.

Background: The lack of overall experience and reporting on angiographic findings in previously published studies of renal arterial embolization (RAE) compelled us to report our overall experience on a series of patients. Materials and methods: A retrospective study was performed analyzing data of patients enrolled for RAE between 2010 and 2019. History, physical examination, and laboratory data were reviewed for all patients. Abdominal ultrasound was the initial imaging study, and all patients underwent subsequent computed tomography or magnetic resonance imaging. The outcome of RAE was determined based on radiographic and clinical findings. Results: Data from 202 patients were analyzed, with a mean age of 45 ± 15 years, and 71.3% of patients were male. Iatrogenic injury was the most common indication for RAE (54%), followed by renal tumors, trauma, and spontaneous, in 27.7%, 10.4%, and 8.4% of patients, respectively. Renal angiography revealing pseudoaneurysm alone or with other pathology in the lower pole of the kidney was the most common finding (40.6%), whereas no lesions were identified on angiography in 32 patients (15.8%), after which RAE was subsequently aborted. Renal arterial embolization was successful in 158 of 170 patients (92.9%) after 1 or more trials (maximum of 4). Microcoil alone or with other embolic materials was the most commonly used material for embolization (85%). Conclusions: Iatrogenic injury was the most common indication for RAE. Pseudoaneurysm alone or with other lesions was the most common lesion on renal angiography; however, angiography showed a negative result in 16% of patients, even those with symptoms. When lesions are present on angiography, the overall success of repeated trials of RAE reached 92.9%.

Predictors of renal angioembolization outcome: A retrospective analysis with 148 patients at a tertiary urology institute.

Objective: The aim of this study was to evaluate the predictor of unsuccessful outcome of renal angioembolization (RAE). Knowing those predictors may help in avoiding unnecessary RAE procedures and their associated side effects, while helping to prepare for an alternate procedure and improving patient's overall satisfaction. Methods: A retrospective analysis between January 2006 and December 2018 was performed, and the indications for RAE were classified into post-traumatic, iatrogenic, renal tumors, and spontaneous. Patients who underwent RAE prior to nephrectomy were eliminated. Computed tomography angiography was performed in patients with normal renal function and those who had no contrast allergy, otherwise magnetic resonance angiography was performed. For the purpose of statistical analysis, we stratified patients into two main categories based on the final outcome-successful or failed. Results: Of 180 patients, 32 with negative angiography were eliminated, leaving 148 patients; 136 (91%) had successful outcomes after one or more trials and 12 had unsuccessful outcomes. The mean age was 45±15 years, and 105 (71%) were male. Neither gender, side of the lesion, presence of hematuria, indication for RAE, nor the type of lesion affected the outcome. On the other hand, renal anatomy with presence of accessory artery was the only predictor to failed RAE (p=0.001). Failed RAE trial was a predictor for nephrectomy as a secondary procedure (p=0.03). Conclusion: No pre-procedural predictors could anticipate the RAE outcome, and different indications can be scheduled to RAE, which is equally effective. The presence of accessory renal artery on diagnostic angiography is the only factor that may predict the failure of the procedure.

CT and MRI in Urinary Tract Infections: A Spectrum of Different Imaging Findings.

There are many acute and chronic infections affecting the urinary tract including bacterial, fungal and viral infections. Urinary tract infections (UTIs) can present in many different patterns with variable degrees of severity varying from asymptomatic and uncomplicated forms to life threatening complicated infections. Cross-sectional imaging techniques-including both computed tomography (CT) and magnetic resonance imaging (MRI)-have become very important tools not only for evaluation of UTIs, but also for detection of associated complications. Selection of either CT or MRI in the UTI evaluation depends on several factors such as the presence of contraindication, experience, cost and availability. CT and MRI help in early detection and management of UTIs that reduce the prevalence and severity of complications. In this article we will present the radiologic findings at CT and MRI in different types of upper and lower UTIs including acute pyelonephritis, intrarenal and perinephric abscesses, pyonephrosis, chronic pyelonephritis, emphysematous UTIs, xanthogranulomatous pyelonephritis, tuberculosis (TB), bilharziasis, fungal infection, corynebacterium infection, ureteritis, cystitis, prostatitis, prostatic abscess and urethritis.

Evaluation of serum fatty acid binding protein-4 (FABP-4) as a novel biomarker to predict biopsy outcomes in prostate biopsy naïve patients.

OBJECTIVES: To investigate the role of serum fatty acid-binding protein-4 (FABP-4) as a surrogate of obesity and metabolic syndrome in the prediction of the outcome of prostate biopsy. METHODS: A prospective pilot study was conducted for patients undergoing prostate needle biopsy (PNB) for clinically suspected prostate cancer (PCa) between June 2016 and August 2017. Fifty consecutive patients with biopsy-proven PCa were included as study group and 50 consecutive patients with negative biopsy were included as a control group. Receiver Operating Characteristic (ROC) curve was used to calculate the area under the curve (AUC) to compare the accuracy of the different parameters in the diagnosis as well as the presence of high-grade PCa (Gleason score 8-9) at PNB. Predictors of the outcome were analyzed using univariate and multivariate logistic regression analysis. RESULTS: FABP-4 (AUC: 0.75; P < 0.001) and PSA-density (AUC: 0.84; P < 0.001) were the most accurate to detect PCa at PNB. On multivariate analysis, FABP-4 > 22.5 ng/ml (OR: 16.6; 95% CI 2.8-98; P = 0.002) and PSA-density > 0.38 ng/ml/ml OR: 17.7; 95% CI 5.3-59; P < 0.001) were independent predictors of PCa detection. Regarding high-grade PCa at PNB, FABP-4 (AUC: 0.79; P < 0.001) and %Free-PSA (AUC: 0.75; P < 0.001) were the most accurate. Independent predictors of high-grade PCa were FABP-4 > 32.3 ng/ml OR: 9.2; 95% CI 1.8-45; P = 0.006) and %Free-PSA ≤ 21.9 (OR: 5.5; 95% CI 1.1-27; P = 0.03). CONCLUSIONS: FABP-4 is an independent predictor for both the diagnosis and high-grade Gleason score at PNB. This novel biomarker might have a promising role in optimizing PNB outcomes.

Chemoprophylaxis during transrectal prostate needle biopsy: critical analysis through randomized clinical trial.

PURPOSE: To compare the efficacy of three chemoprophylaxis approaches in prevention of post-transrectal biopsy infectious complications (TBICs). METHODS: Patients were randomly assigned to receive ciprofloxacin 3 days 500 mg B.I.D 3 days starting the night prior to biopsy (standard prophylaxis), augmented prophylaxis using ciprofloxacin and single preprocedure shot of 160 mg gentamicin IM (augmented prophylaxis) and rectal swab culture-based prophylaxis (targeted prophylaxis). Patients were assessed 2 weeks prior to biopsy, at biopsy and 2 weeks after. Primary end point was occurrence of post-TBICs that included simple UTI, febrile UTI or sepsis. Secondary end points were post-biopsy change in the inflammatory markers (TLC, ESR and CRP), unplanned visits, hospitalization and occurrence of fluoroquinolones resistance (FQ-R; bacterial growth on MacConkey agar plate with 10 µg/ml ciprofloxacin) in the fecal carriage of screened men. RESULTS: Between April/2015 and January/2017, standard, augmented and targeted prophylaxes were given to 163, 166 and 167 patients, respectively. Post-TBICs were reported in 43 (26%), 13 (7.8%) and 34 (20.3%) patients following standard, augmented and targeted prophylaxes protocols, respectively (P = 0.000). Post-TBICs included UTI in 23 (4.6%), febrile UTI in 41 (8.2%) and sepsis in 26 (5.2%) patients. Significantly lower number of post-biopsy positive urine culture was depicted in the augmented group (P = 0.000). The number of biopsy cores was statistically different in the three groups (P = 0.004). On multivariate analysis, augmented prophylaxis had independently lower post-TBICs (OR 0.2, 95% CI 0.1-0.4, P = 0.000) when compared with the other two groups regardless of the number of biopsy cores taken (OR 1.07, 95% CI 0.95-1.17, P = 0.229). Post-biopsy hospitalization was needed in four (2%), one (0.6%) and ten (6%) patients following standard, augmented and targeted prophylaxes, respectively (P = 0.014). However, sepsis-related hospitalization was not statistically different. Post-biopsy changes in the inflammatory markers were significantly less in augmented prophylaxis (P < 0.05). FQ-R was depicted in 139 (83.2%) of the screened men. CONCLUSION: Augmented prophylaxis with single-dose gentamicin is an effective and practical approach. Targeted prophylaxis might be reserved for cases with contraindication to gentamicin.

Is there a way to predict failure after direct vision internal urethrotomy for single and short bulbar urethral strictures?

OBJECTIVE: To identify patient and stricture characteristics predicting failure after direct vision internal urethrotomy (DVIU) for single and short (<2 cm) bulbar urethral strictures. PATIENTS AND METHODS: We retrospectively analysed the records of adult patients who underwent DVIU between January 2002 and 2013. The patients' demographics and stricture characteristics were analysed. The primary outcome was procedure failure, defined as the need for regular self-dilatation (RSD), redo DVIU or substitution urethroplasty. Predictors of failure were analysed. RESULTS: In all, 430 adult patients with a mean (SD) age of 50 (15) years were included. The main causes of stricture were idiopathic followed by iatrogenic in 51.6% and 26.3% of patients, respectively. Most patients presented with obstructive lower urinary tract symptoms (68.9%) and strictures were proximal bulbar, i.e. just close to the external urethral sphincter, in 35.3%. The median (range) follow-up duration was 29 (3-132) months. In all, 250 (58.1%) patients did not require any further instrumentation, while RSD was maintained in 116 (27%) patients, including 28 (6.5%) who required a redo DVIU or urethroplasty. In 64 (6.5%) patients, a redo DVIU or urethroplasty was performed. On multivariate analysis, older age at presentation [odds ratio (OR) 1.017; P = 0.03], obesity (OR 1.664; P = 0.015), and idiopathic strictures (OR 3.107; P = 0.035) were independent predictors of failure after DVIU. CONCLUSION: The failure rate after DVIU accounted for 41.8% of our present cohort with older age at presentation, obesity, and idiopathic strictures independent predictors of failure after DVIU. This information is important in counselling patients before surgery.

Cysts of the lower male genitourinary tract: embryologic and anatomic considerations and differential diagnosis.

Cysts of the lower male genitourinary tract are uncommon and usually benign. These cysts have different anatomic origins and may be associated with a variety of genitourinary abnormalities and symptoms. Various complications may be associated with these cysts, such as urinary tract infection, pain, postvoiding incontinence, recurrent epididymitis, prostatitis, and hematospermia, and they may cause infertility. Understanding the embryologic development and normal anatomy of the lower male genitourinary tract can be helpful in evaluating these cysts and in tailoring an approach for developing a differential diagnosis. There are two main groups of cysts of the lower male genitourinary tract: intraprostatic cysts and extraprostatic cysts. Intraprostatic cysts can be further classified into median cysts (prostatic utricle cysts, müllerian duct cysts), paramedian cysts (ejaculatory duct cysts), and lateral cysts (prostatic retention cysts, cystic degeneration of benign prostatic hypertrophy, cysts associated with tumors, prostatic abscess). Extraprostatic cysts include cysts of the seminal vesicle, vas deferens, and Cowper duct. A variety of pathologic conditions can mimic these types of cysts, including ureterocele, defect resulting from transurethral resection of the prostate gland, bladder diverticulum, and hydroureter and ectopic insertion of ureter. Accurate diagnosis depends mainly on the anatomic location of the cyst. Magnetic resonance imaging and transrectal ultrasonography (US) are excellent for detecting and characterizing the nature and exact anatomic origin of these cysts. In addition, transrectal US can play an important therapeutic role in the management of cyst drainage and aspiration, as in cases of prostatic abscess.