Characterization of renal masses with MRI-based radiomics: assessment of inter-package and inter-observer reproducibility in a prospective pilot study.

OBJECTIVES: To evaluate radiomics features' reproducibility using inter-package/inter-observer measurement analysis in renal masses (RMs) based on MRI and to employ machine learning (ML) models for RM characterization. METHODS: 32 Patients (23M/9F; age 61.8 ± 10.6 years) with RMs (25 renal cell carcinomas (RCC)/7 benign masses; mean size, 3.43 ± 1.73 cm) undergoing resection were prospectively recruited. All patients underwent 1.5 T MRI with T2-weighted (T2-WI), diffusion-weighted (DWI)/apparent diffusion coefficient (ADC), and pre-/post-contrast-enhanced T1-weighted imaging (T1-WI). RMs were manually segmented using volume of interest (VOI) on T2-WI, DWI/ADC, and T1-WI pre-/post-contrast imaging (1-min, 3-min post-injection) by two independent observers using two radiomics software packages for inter-package and inter-observer assessments of shape/histogram/texture features common to both packages (104 features; n = 26 patients). Intra-class correlation coefficients (ICCs) were calculated to assess inter-observer and inter-package reproducibility of radiomics measurements [good (ICC ≥ 0.8)/moderate (ICC = 0.5-0.8)/poor (ICC < 0.5)]. ML models were employed using reproducible features (between observers and packages, ICC > 0.8) to distinguish RCC from benign RM. RESULTS: Inter-package comparisons demonstrated that radiomics features from T1-WI-post-contrast had the highest proportion of good/moderate ICCs (54.8-58.6% for T1-WI-1 min), while most features extracted from T2-WI, T1-WI-pre-contrast, and ADC exhibited poor ICCs. Inter-observer comparisons found that radiomics measurements from T1-WI pre/post-contrast and T2-WI had the greatest proportion of features with good/moderate ICCs (95.3-99.1% T1-WI-post-contrast 1-min), while ADC measurements yielded mostly poor ICCs. ML models generated an AUC of 0.71 [95% confidence interval = 0.67-0.75] for diagnosis of RCC vs. benign RM. CONCLUSION: Radiomics features extracted from T1-WI-post-contrast demonstrated greater inter-package and inter-observer reproducibility compared to ADC, with fair accuracy for distinguishing RCC from benign RM. CLINICAL RELEVANCE: Knowledge of reproducibility of MRI radiomics features obtained on renal masses will aid in future study design and may enhance the diagnostic utility of radiomics models for renal mass characterization.

The Effect of Multilayered Electrospun PLLA Nanofibers Coated with Human Amnion or Bladder ECM Proteins on Epithelialization and Smooth Muscle Regeneration in the Rabbit Bladder.

Nanofibrous scaffolds have attracted much attention in bladder reconstruction approaches due to their excellent mechanical properties. In addition, their biological properties can be improved by combination with biological materials. Taking into account the advantages of nanofibrous scaffolds and decellularized extracellular matrix (dECM) in tissue engineering, scaffolds of poly-L-lactic acid (PLLA) coated with decellularized human amnion membrane (hAM) or sheep bladder (SB)-derived ECM proteins are developed (amECM-coated PLLA and sbECM-coated PLLA, respectively). The bladder regenerative potential of modified electrospun PLLA scaffolds is investigated in rabbits. The presence of ECM proteins is confirmed on the nanofibers' surface. Coating the surface of the PLLA nanofibers improves cell adhesion and proliferation. Histological and immunohistochemical evaluations show that rabbits subjected to cystoplasty with a multilayered PLLA scaffold show de novo formation and maturation of the multilayered urothelial layer. However, smooth muscle bundles (myosin heavy chain [MHC] and α-smooth muscle actin [α-SMA] positive) are detected only in ECM-coated PLLA groups. All groups show no evidence of a diverticulumor fistula in the urinary bladder. These results suggest that the biofunctionalization of electrospun PLLA nanofibers with ECM proteins can be a promising option for bladder tissue engineering. Furthermore, hAM can also replace animal-sourced ECM proteins in bladder tissue regeneration approaches.

Trends in the surgical management of kidney cancer by tumor stage, treatment modality, facility type, and location.

Partial nephrectomy (PN) is an alternative to radical nephrectomy (RN) in the appropriate localized renal tumor. The scope of PN has expanded over time and, since the advent and proliferation of minimally invasive surgery, more surgeons have access to and have been trained in laparoscopic and robotic technology. Amid the changing surgical landscape, we sought to characterize the trends in management by cancer stage, institution type, and geographic location using the National Cancer Database (NCDB). We queried the NCDB for patients with kidney cancer from 2004 to 2019. Overall, 241,311 patients who underwent PN or RN were included in the study. The nephrectomy approach was categorized as robotic partial (RPN), robotic radical (RRN), laparoscopic partial (LPN), laparoscopic radical (LRN), open or unspecified partial (OPN), and open or unspecified radical (ORN). The categorical variables were presented as frequency and percentages. Overall, there was an increase in the utilization of robotic approaches from 2010 to 2019. For cT1 tumors, the use of RPN and RRN increased from 14.27 to 33.06% and 5.24% to 19.63%, respectively. The use of ORN for cT2 and cT3 tumors declined, with rates dropping from 54.71 to 10.76% and 64.71 to 46.64%, respectively. Conversely, the utilization of RRN rose during this period. However, ORN remained the most common approach for cT3 tumors. The use of RPN increased across different facility types, with the highest utilization observed in academic/research programs. The use of ORN for cT2 and cT3 tumors declined across facility types, although it remained most prevalent in community cancer programs. The use of robot-assisted surgery to treat localized renal cancer increased in the US between 2010 and 2019 across all stages of disease. RPN became the most used approach for cT1 disease, while LRN was preferred for cT2 disease. ORN remained the approach of choice for cT3 disease throughout the study period. Trends in facility type and geographic location largely mirrored the overall trends.

Operative and oncological outcomes of salvage robotic radical and partial nephrectomy: a multicenter experience.

We aim to describe the perioperative and oncological outcomes for salvage robotic partial nephrectomy (sRPN) and salvage robotic radical nephrectomy (sRRN). Using a prospectively maintained multi-institutional database, we compared baseline clinical characteristics and perioperative and postoperative outcomes, including pathological stage, tumor histology, operative time, ischemia time, estimated blood loss (EBL), length of stay (LOS), postoperative complication rate, recurrence rate, and mortality. We identified a total of 58 patients who had undergone robotic salvage surgery for a recurrent renal mass, of which 22 (38%) had sRRN and 36 (62%) had sRPN. Ischemia time for sRPN was 14 min. The median EBL was 100 mL in both groups (p = 0.581). One intraoperative complication occurred during sRRN, while three occurred during sRPN cases (p = 1.000). The median LOS was 2 days for sRRN and 1 day for sRPN (p = 0.039). Postoperatively, one major complication occurred after sRRN and two after sRPN (p = 1.000). The recurrence reported after sRRN was 5% and 3% after sRPN. Among the patients who underwent sRRN, the two most prevalent stages were pT1a (27%) and pT3a (27%). Similarly, the two most prevalent stages in sRPN patients were pT1a (69%) and pT3a (6%). sRRN and sRPN have similar operative and perioperative outcomes. sRPN is a safe and feasible procedure when performed by experienced surgeons. Future studies on large cohorts are essential to better characterize the importance and benefit of salvage partial nephrectomies.

Retained needles during intracavernosal self-injection for erectile dysfunction treatment: a case report and systematic literature review.

Introduction: Although the breakage and entrapment of the needles inside the penis during intracavernosal self-injection for erectile dysfunction treatment is a rare complication, when it happens, it can cause significant distress and anxiety to the patients who experience it. Aims: Our work aims to report a case of retained penile needle and to compare it with similar cases in the literature to define the risk factors and the best practice to prevent and treat this complication. Methods: We are reporting successful surgical removal of a deeply retained penile needle with the aid of intraoperative fluoroscopy after an unsuccessful attempt of ultrasound-guided removal in the emergency room. We searched the PubMed and Embase databases for similar cases and compared the findings across all the cases. Results: In our case, the needle was initially superficial; however, excessive manipulation in the emergency room resulted in deep displacement into the corpus cavernosum. We were able to successfully localize the needle using intraoperative fluoroscopic guidance. The needle was then surgically removed via a small skin incision with minimal dissection of cavernosal tissue. We identified 15 reported cases of retained penile needles in the literature and performed a comprehensive comparison among all the cases. It is critical to search for specialized treatment with a urologist to avoid great damage due to erroneous manipulation of the corpora cavernosa. Conclusion: Selecting patients with good manual dexterity is essential to avoid breakage and entrapment of penile needles during intracavernosal self-injection for erectile dysfunction treatment. The management of retained penile needles should be individualized depending on the clinical picture at the time of presentation. It is critical to avoid excessive manipulation as it can push the needle deeper into the penis and make the extraction more demanding.

Urine supernatant reveals a signature that predicts survival in clear-cell renal cell carcinoma.

OBJECTIVE: To profile the cell-free urine supernatant and plasma of a small cohort of clear-cell renal cell carcinoma (ccRCC) patients by measuring the relative concentrations of 92 proteins related to inflammation. Using The Cancer Genome Atlas (TCGA), we then performed a targeted mRNA analysis of genes encoding the above proteins and defined their effects on overall survival (OS). SUBJECTS/PATIENTS AND METHODS: Samples were collected prospectively from ccRCC patients. A multiplex proximity extension assay was used to measure the concentrations of 92 inflammation-related proteins in cell-free urine supernatants and plasma. Transcriptomic and clinical information from ccRCC patients was obtained from TCGA. Unsupervised clustering and differential protein expression analyses were performed on protein concentration data. Targeted mRNA analysis on genes encoding significant differentially expressed proteins was performed using TCGA. Backward stepwise regression analyses were used to build a nomogram. The performance of the nomogram and clinical benefit was assessed by discrimination and calibration, and a decision curve analysis, respectively. RESULTS: Unsupervised clustering analysis revealed inflammatory signatures in the cell-free urine supernatant of ccRCC patients. Backward stepwise regressions using TCGA data identified transcriptomic risk factors and risk groups associated with OS. A nomogram to predict 2-year and 5-year OS was developed using these risk factors. The decision curve analysis showed that our model was associated with a net benefit improvement compared to the treat-all/none strategies. CONCLUSION: We defined four novel biomarkers using proteomic and transcriptomic data that distinguish severity of prognosis in ccRCC. We showed that these biomarkers can be used in a model to predict 2-year and 5-year OS in ccRCC across different tumour stages. This type of analysis, if validated in the future, provides non-invasive prognostic information that could inform either management or surveillance strategies for patients.

Recent innovations in renal replacement technology and potential applications to transplantation and dialysis patients: a review of current methods.

The current standard of care for patients with end-stage renal disease (ERSD) is a kidney transplant or dialysis when a donor organ isnot available. The growing gap between patients who require a kidney transplant and the availability of donor organs as well as thenegative effects of long-term dialysis, such as infection, limited mobility, and risk of cancer development, drive the impetus to developalternative renal replacement technology. The goal of this review is to assess the potential of two of the most recent innovations inkidney transplant technology-the implantable bioartificial kidney (BAK) and kidney regeneration technology-in addressing the aforementionedproblems related to kidney replacement for patients with ERSD. Both innovations are fully implantable, autologous, personalizedwith patient cells, and can replace all aspects of kidney function. Not only do these new innovations have the potential toimprove the possibility of transplantation for more patients, they also have potential to improve the outcome of transplantation or dialysis-related renal cancer diagnosis. A major limitation of the current technology is that both implantable BAK and kidney regenerationtechnology are still in preclinical stages, and thus their potential effects cannot be comprehensively generalized to human patients.

A Propensity-Matched Comparison of the Perioperative Outcomes Between Single-Port and Multi-Port Robotic Assisted Partial Nephrectomy: A Report from the Single Port Advanced Research Consortium (SPARC).

Purpose: Single-port (SP) robotic surgery is a new technology and early in its adoption curve. The goal of this study is to compare the perioperative outcomes of SP to multi-port (MP) robotic technology for partial nephrectomy. Materials and Methods: This is a prospective cohort study of patients who have undergone robot-assisted partial nephrectomy using SP and MP technology. Baseline demographic, clinical, and tumor-specific characteristics and perioperative outcomes were compared using χ2, t-test, and Mann-Whitney U test in the overall cohort and in a 1:1 propensity score-matched cohort, adjusting for baseline characteristics. Results: After propensity matching, 146 SP patients were matched with 146 MP patients. SP and MP groups had similar mean age (58 ± 12 years vs 59 ± 12 years; p = 0.606) and proportion of men (54.11% vs 52.05%; p = 0.725). The SP had a longer mean ischemia (18.29 ± 10.49 minutes vs 13.79 ± 6.29 minutes; p < 0.001). Estimated blood loss (EBL) and length of hospital stay (LOS), operative time, positive margin rate, and any complication rate were similar between the two groups. Conclusions: SP partial nephrectomy had a longer ischemia time, and a comparable LOS, EBL, operative time, positive margin rates, and complication rates to MP. These early data are encouraging. However, the role of SP requires further study and should evaluate safety and long-term data when compared with the standard MP technique.

Is YouTube a good resource for patients to better understand kidney cancer?

OBJECTIVE: To assesses the complexity, reliability, and quality of the most popular kidney cancer videos on YouTube. METHODS: We searched YouTube using phrases relevant to kidney cancer and grouped videos based on publishing channel type. Video parameters along with complexity, reliability, and quality scores were recorded. Video complexity was determined using the SMOG index. SMOG scores greater than 6.4 equate to content that is too complex for the general public. Video quality and reliability was scored by 5 reviewers using the Global Quality Scale and a modified DISCERN criteria. All categorical and numerical variables were analyzed via independent t-test and 1-way analysis of variance using SPSS. RESULTS: One hundred twenty-one videos were analyzed. The most popular publishing channel types are professional development (n = 65), medical institutions (n = 27), student education (n = 9), and nonprofit organization (n = 4). Professional development videos are significantly more complex than medical institution videos (mean SMOG score of 11.1 vs. 9.4, P = 0.004), and nonprofit organization videos (11.1 vs. 7.8, P = 0.003). Compared to medical institution videos, professional development videos have fewer mean total views (876 views vs. 17,554, P = 0.016), mean views per month (14.92 views vs. 351.7, P = 0.007), and mean comments (1 comment vs. 18, P = 0.038). Both professional development videos and medical institution videos are more reliable than student education videos (mean DISCERN score of 3.9 vs. 2.9, P < 0.001). CONCLUSION: There is a lack of understandable and reliable kidney cancer videos on YouTube. Moreover, the majority of kidney cancer videos are intended for medical professionals and may be too complex for the general public. The medical community has the opportunity to make an active effort to provide better resources for patients on YouTube.

Conversion to Open Radical or Partial Nephrectomy Associated with Unplanned Hospital Readmission After Attempted Minimally Invasive Approach.

Introduction/Objectives: We endeavored to explore the rates of unplanned hospital readmission (UHR) in patients who underwent minimally invasive radical or partial nephrectomy who were subsequently converted to open surgery. Patients and Methods: The National Cancer Database (NCDB) was used for this study. Patients diagnosed with renal cancer and who had minimally invasive partial or radical nephrectomy from 2004 to 2016 were included in the study. Patients were categorized as converted or not converted to open surgery. UHR was the outcome of the study and was defined as UHR within 30 days of discharge. We conducted a one-to-one nearest-neighbor propensity-score matching using baseline clinical, tumor, and facility characteristics. To evaluate the relationship between conversion to open surgery and UHR, we conducted a multivariable logistic regression on the propensity-matched cohort, a propensity score-matched model without controlling for any covariate, and a propensity score-adjusted model, controlling for only the propensity score. Results: A total of 142,040 patients were identified, with a 2.98% conversion rate. There was an overall decrease in the rate of conversion to open surgery from 2010 (4.11%) to 2016 (2.43%). Laparoscopic radical nephrectomy remained a significant contributor to the rate of conversion (at least 50% per year). In the unmatched cohort, the UHR rate was higher among those who had a conversion to open surgery (n = 710, 0.52% versus n = 44, 1.04%; P < .001). Similarly, in the propensity score-matched cohort, the UHR rate was higher among those who had a conversion to open (n = 22, 0.52% versus n = 44, 1.04%; P = .007). After controlling for other factors, conversion to open remained independently associated with UHF. Conclusion: Conversion to open radical or partial nephrectomy from a minimally invasive approach is independently associated with an increased risk of 30-day UHR.

Association between chronic kidney disease and COVID-19-related mortality in New York.

PURPOSE: To evaluate mortality risk of CKD patients infected with COVID-19, and assess shared characteristics associated with health disparities in CKD outcome. METHODS: We extracted the data from a case series of 7624 patients presented at Mount Sinai Health System, in New York for testing between 3/28/2020 and 4/16/2020. De-identified patient data set is being produced by the Scientific Computing department and made available to the Mount Sinai research community at the following website: https://msdw.mountsinai.org/ . RESULTS: Of 7624 COVID-19 patients, 7.8% (n = 597) had CKD on hospital admission, and 11.2% (n = 856) died of COVID-19 infection. CKD patients were older, more likely to have diabetes, hypertension, and chronic obstructive pulmonary disease (COPD), were current or former smokers, had a longer time to discharge, and had worse survival compared to non-CKD patients (p < 0.05). COVID-19 mortality rate was significantly higher in CKD patients (23.1% vs 10.2%) with a 1.51 greater odds of dying (95% CI: 1.19-1.90). Controlling for demographic, behavioral, and clinical covariates, the logistic regression analysis showed significant and consistent effects of CKD, older age, male gender, and hypertension with mortality (p < 0.05). CONCLUSION: CKD was a significant independent predictor of COVID-19 mortality, along with older age, male gender, and hypertension. Future research will investigate the effects of COVID-19 on long-term renal function.

Should a Drain Be Routinely Required After Transperitoneal Robotic Partial Nephrectomy?

Introduction: Closed drains have traditionally been placed after partial nephrectomy because of risks of bleeding and urine leak. We sought to study the safety of a nonroutine drain (NRD) approach after transperitoneal robotic partial nephrectomy (RPN). Patients and Methods: From a multi-institutional database, we have analyzed the data of 904 patients who underwent RPN. Five hundred forty-six (60.40%) patients underwent RPN by a surgeon who routinely placed drains. Three hundred fifty-eight (39.60%) patients underwent RPN by a surgeon who did not routinely placed drains. Perioperative outcomes, length of stay (LOS), and readmission rates were compared between the two groups. Baseline characteristics, perioperative, and postoperative outcomes were compared using Mann-Whitney U test, chi-square test, and Fisher's exact test. Results: Patients in the NRD group were more likely to have higher body mass index (30.10 kg/m2vs 28.07 kg/m2; P < 0.001), higher tumor size (3.0 cm vs 2.5 cm; P = 0.001), and higher renal score (8 vs 7; P < 0.001). Rate of transfusion (0.00% NRD vs 0.56% RD; P = 0.157) and overall complication (7.33% NRD vs 7.82% RD; P = 0.782) were comparable. Median hospital stay is 1 day for both groups. Readmission rate was also similar (0.55% NRD vs 1.40% RD; P = 0.279). In a multivariable analysis, NRD approach was associated with shorter length of hospital stay (incidence rate ratio [IRR] - 0.72, P < 0.001). Conclusion: An NRD approach for RPN yielded a decreased LOS and similar perioperative outcomes. Placement of surgical drains should be based on individual circumstances, and not required on a routine basis.