Osteitis pubis following holmium laser enucleation of the prostate.

Osteitis pubis is a rare, inflammatory condition involving the pubic symphysis. While osteitis pubis has been reported following many urological procedures, including those addressing bladder outlet obstruction such as transurethral resection of the prostate, it has never been reported after holmium laser enucleation of the prostate (HoLEP). Here, we detail the clinical course of a patient found to have osteitis pubis following HoLEP. This patient presented several weeks after surgery with non-specific, persistent symptoms of groin pain and difficulty ambulating, alerting our clinicians to consider osteitis pubis which was confirmed on MRI of the pelvis. While the majority of osteitis pubis cases are managed with locally invasive techniques, our patient's symptoms were successfully managed conservatively with Foley catheter placement, oral antibiotics and close follow-up. At 9 months postoperative, the patient has reported complete resolution of symptoms and continues to be followed closely.

Radiogenomic Associations Clear Cell Renal Cell Carcinoma: An Exploratory Study.

INTRODUCTION: This study investigates how quantitative texture analysis can be used to non-invasively identify novel radiogenomic correlations with clear cell renal cell carcinoma (ccRCC) biomarkers. METHODS: The Cancer Genome Atlas-Kidney Renal Clear Cell Carcinoma open-source database was used to identify 190 sets of patient genomic data that had corresponding multiphase contrast-enhanced CT images in The Cancer Imaging Archive. 2,824 radiomic features spanning fifteen texture families were extracted from CT images using a custom-built MATLAB software package. Robust radiomic features with strong inter-scanner reproducibility were selected. Random forest, AdaBoost, and elastic net machine learning (ML) algorithms evaluated the ability of the selected radiomic features to predict the presence of 12 clinically relevant molecular biomarkers identified from the literature. ML analysis was repeated with cases stratified by stage (I/II vs. III/IV) and grade (1/2 vs. 3/4). 10-fold cross validation was used to evaluate model performance. RESULTS: Before stratification by tumor grade and stage, radiomics predicted the presence of several biomarkers with weak discrimination (AUC 0.60-0.68). Once stratified, radiomics predicted KDM5C, SETD2, PBRM1, and mTOR mutation status with acceptable to excellent predictive discrimination (AUC ranges from 0.70 to 0.86). CONCLUSIONS: Radiomic texture analysis can potentially identify a variety of clinically relevant biomarkers in patients with ccRCC and may have a prognostic implication.

Stumpless ostial right coronary artery chronic total occlusion: Retrograde approach.

Percutaneous coronary interventions of the coronary total occlusions, especially of the aorto-ostial lesions, portray challenges. As the antegrade wiring is not feasible in aorto-ostial chronic total occlusions, the retrograde wiring remains the lone strategy. We present a successful case of stumpless ostial right coronary artery chronic total occlusion, which was successfully opened by retrograde wiring and externalization by snaring. Intravascular ultrasound was performed to comprehend the diffusely narrowed distal right coronary artery and posterior left ventricular branch (PLVB) to guide stenting strategy in percutaneous coronary intervention.

Long-term renal function in patients with chronic kidney disease following radical cystectomy and orthotopic neobladder.

OBJECTIVE: To evaluate long-term renal function in patients with chronic kidney disease (CKD) Stage IIIa who underwent radical cystectomy and orthotopic neobladder (RC/ONB) compared to matched controls. PATIENTS AND METHODS: Using our Institutional Review Board-approved institutional database, patients with a glomerular filtration rate (GFR) of 45-59.9 mL/min/1.73 m2 who underwent RC/ONB were identified. A control group of patients with a GFR of ≥60 mL/min/1.73 m2 was selected. Groups were matched based on age, baseline hypertension/diabetes mellitus, perioperative chemotherapy, and preoperative hydronephrosis. A decrease in GFR of >10 mL/min/1.73 m2 during the follow-up was considered significant. A multivariate Cox regression analysis was performed to identify predictors of GFR decline in each group. RESULTS: Of 1237 patients who underwent RC/ONB, 508 patients were included (254 per group). The mean preoperative GFR was 53.3 mL/min/1.73 m2 in the study group and 78.8 mL/min/1.73 m2 in controls. The median follow-up was 3.7 years. During follow-up, GFR stayed at or above baseline in 51% of the study patients compared to 46% of the controls (P = 0.5). The mean time to a significant GFR decline in the study patients was significantly longer compared to the controls (5.6 vs 2 years, respectively; P < 0.001). In multivariate analysis, neoadjuvant chemotherapy was found to be the strongest predictor of a significant GFR decline as well as GFR decline below baseline (hazard ratio [HR] 2.15, 95% confidence interval [CI] 1.4-3.29, P = 0.004; and HR 2.15, 95% CI 1.4-3.29, P < 0.001, respectively). CONCLUSION: Patients with CKD Stage IIIa who undergo ONB appear to have comparable long-term renal function to those with a GFR of ≥60 mL/min/1.73 m2 . An ONB reconstruction is a safe option for patients with CKD Stage IIIa desiring a continent diversion.

CT-based radiomics stratification of tumor grade and TNM stage of clear cell renal cell carcinoma.

OBJECTIVES: To evaluate the utility of CT-based radiomics signatures in discriminating low-grade (grades 1-2) clear cell renal cell carcinomas (ccRCC) from high-grade (grades 3-4) and low TNM stage (stages I-II) ccRCC from high TNM stage (stages III-IV). METHODS: A total of 587 subjects (mean age 60.2 years ± 12.2; range 22-88.7 years) with ccRCC were included. A total of 255 tumors were high grade and 153 were high stage. For each subject, one dominant tumor was delineated as the region of interest (ROI). Our institutional radiomics pipeline was then used to extract 2824 radiomics features across 12 texture families from the manually segmented volumes of interest. Separate iterations of the machine learning models using all extracted features (full model) as well as only a subset of previously identified robust metrics (robust model) were developed. Variable of importance (VOI) analysis was performed using the out-of-bag Gini index to identify the top 10 radiomics metrics driving each classifier. Model performance was reported using area under the receiver operating curve (AUC). RESULTS: The highest AUC to distinguish between low- and high-grade ccRCC was 0.70 (95% CI 0.62-0.78) and the highest AUC to distinguish between low- and high-stage ccRCC was 0.80 (95% CI 0.74-0.86). Comparable AUCs of 0.73 (95% CI 0.65-0.8) and 0.77 (95% CI 0.7-0.84) were reported using the robust model for grade and stage classification, respectively. VOI analysis revealed the importance of neighborhood operation-based methods, including GLCM, GLDM, and GLRLM, in driving the performance of the robust models for both grade and stage classification. CONCLUSION: Post-validation, CT-based radiomics signatures may prove to be useful tools to assess ccRCC grade and stage and could potentially add to current prognostic models. Multiphase CT-based radiomics signatures have potential to serve as a non-invasive stratification schema for distinguishing between low- and high-grade as well as low- and high-stage ccRCC. KEY POINTS: • Radiomics signatures derived from clinical multiphase CT images were able to stratify low- from high-grade ccRCC, with an AUC of 0.70 (95% CI 0.62-0.78). • Radiomics signatures derived from multiphase CT images yielded discriminative power to stratify low from high TNM stage in ccRCC, with an AUC of 0.80 (95% CI 0.74-0.86). • Models created using only robust radiomics features achieved comparable AUCs of 0.73 (95% CI 0.65-0.80) and 0.77 (95% CI 0.70-0.84) to the model with all radiomics features in classifying ccRCC grade and stage, respectively.

An Ultrastructural Study on the Effect of High Temperatures on Teeth and Restorative Materials That Aids in the Identification of Human Remains.

INTRODUCTION: In most disasters, teeth are the only means of positive identification of an otherwise unrecognizable body, as there has been tremendous increase in the use of dental restorations that have different resistance to prolonged high temperature which is an important aid in identifying burned victims. Application of SEM/EDS in forensics was found useful in areas where there is a need for good imaging with high magnification combined with elemental analysis. The objective of this study was to analyze incineration effects on teeth and restorative materials using SEM/EDS. Materials and Method. 128 extracted teeth were collected, 96 were restored with silver amalgam, composite, and GIC of 32 each, and crown preparation was done in 32 teeth for which metal ceramic crowns were prepared. These teeth were subjected to 4 different temperatures (500°C, 700°C, 900°C, and 1100°C) for 20 minutes, and they were analyzed macroscopically and by using SEM for the changes subsequent to their exposure to such high temperatures. RESULTS: All the restorations which were very difficult to identify by naked eye were identified with the help of SEM/EDS. CONCLUSION: Elemental analysis of the specific restorative material proves to be an essential tool for the forensic odontologist.

Virtual Reality vs Dry Laboratory Models: Comparing Automated Performance Metrics and Cognitive Workload During Robotic Simulation Training.

Background: This study compares surgical performance during analogous vesico-urethral anastomosis (VUA) tasks in two robotic training environments, virtual reality (VR) and dry laboratory (DL), to investigate transferability of skill assessment across the two platforms. Utilizing computer-generated performance metrics and pupillary data, we evaluated the two environments to distinguish surgical expertise and ultimately whether performance in the VR simulation correlates with performance in live robotic surgery in the DL. Materials and Methods: Experts (≥300 cases) and trainees (<300 cases) performed analogous VUAs during VR and DL sessions on a da Vinci robotic console following an Institutional Review Board (IRB) approved protocol (HS-16-00318). Twenty-two metrics were generated in each environment (kinematic metrics, tissue metrics, and biometrics). The DL included 18 previously validated automated performance metrics (APMs) (kinematics and event metrics) captured by an Intuitive system data recorder. In both settings, Tobii Pro Glasses 2 recorded the task-evoked pupillary response (reported as Index of Cognitive Activity [ICA]) to indicate cognitive workload, analyzed by EyeTracking cognitive workload software. Pearson correlation, Mann-Whitney, and independent t-tests were used for the comparative analyses. Results: Our study included six experts (median caseload 1300 [interquartile range 400-3000]) and 11 trainees (25 [0-250]). A total of 8/9 metrics directly comparable between VR and DL showed significant positive correlation (r ≥ 0.554, p ≤ 0.032); 5/22 VR metrics distinguished expertise, including task time (p = 0.031), clutch usage (p = 0.040), unnecessary needle piercing (p = 0.026), and suspected injury to the endopelvic fascia (p = 0.040). This contrasts with 14/22 APMs in DL (p ≤ 0.038), including linear velocities of all three instruments (p ≤ 0.038) and dominant-hand instrument wrist articulation (p = 0.013). Trainees experienced higher cognitive workload (ICA) in both environments when compared with experts (p < 0.036). Conclusions: Most performance metrics between VR and DL exhibited moderate to strong correlations, showing transferability of skills across the platforms. Comparing training environments, APMs during DL tasks are better able to distinguish expertise than VR-generated metrics.

Innovations in Urologic Surgical Training.

PURPOSE OF REVIEW: This review aims to summarize innovations in urologic surgical training in the past 5 years. RECENT FINDINGS: Many assessment tools have been developed to objectively evaluate surgical skills and provide structured feedback to urologic trainees. A variety of simulation modalities (i.e., virtual/augmented reality, dry-lab, animal, and cadaver) have been utilized to facilitate the acquisition of surgical skills outside the high-stakes operating room environment. Three-dimensional printing has been used to create high-fidelity, immersive dry-lab models at a reasonable cost. Non-technical skills such as teamwork and decision-making have gained more attention. Structured surgical video review has been shown to improve surgical skills not only for trainees but also for qualified surgeons. Research and development in urologic surgical training has been active in the past 5 years. Despite these advances, there is still an unfulfilled need for a standardized surgical training program covering both technical and non-technical skills.

An Objective Assessment of Performance during Robotic Partial Nephrectomy: Validation and Correlation of Automated Performance Metrics with Intraoperative Outcomes.

PURPOSE: Automated performance metrics provide a novel approach to the assessment of surgical performance. Herein, we present a construct validation of automated performance metrics during robotic assisted partial nephrectomy. MATERIALS AND METHODS: Automated performance metrics (instrument motion tracking/system events) and synchronized surgical videos from da Vinci® Si systems during robotic assisted partial nephrectomy were recorded using a system data recorder. Each case was segmented into 7 steps: colon mobilization, ureteral identification/dissection, hilar dissection, exposure of tumor within Gerota's fascia, intraoperative ultrasound/tumor scoring, tumor excision, and renorrhaphy. Automated performance metrics from each step were compared between expert (≥150 cases) and trainee (<150 cases) surgeons by Mann-Whitney U test (continuous variables) and Pearson's chi-squared test (categorical variables). Clinical outcomes were collected prospectively and correlated to automated performance metrics and R.E.N.A.L. (radius, exophytic/endophytic, nearness of tumor to collecting system, anterior/posterior, location relative to polar line) nephrometry score by Spearman's correlation coefficients (r). RESULTS: A total of 50 robotic assisted partial nephrectomy cases were included for analysis, performed by 7 expert and 10 trainee surgeons. Automated performance metric profiles significantly differed between experts and novices in the initial 5 steps (p <0.05). Specifically, experts exhibited faster dominant instrument movement and greater dominant instrument usage (bimanual dexterity) than trainees in select steps (p ≤0.045). Automated performance metrics during tumor excision and renorrhaphy were significantly correlated with R.E.N.A.L. score (r ≥0.364; p ≤0.041). These included metrics related to instrument efficiency, task duration, and dominant instrument use. CONCLUSIONS: Experts are more efficient and directed in their movement during robotic assisted partial nephrectomy. Automated performance metrics during key steps correlate with objective measures of tumor complexity and may serve as predictors of clinical outcomes. These data help establish a standardized metric for surgeon assessment and training during robotic assisted partial nephrectomy.

Knuckle wire technique in percutaneous coronary intervention of chronic total occlusion: Knuckle wire technique.

In percutaneous coronary intervention, the knuckle wire technique is one of the approaches to cross the long and ambiguous course of the occluded segment. However, this technique is generally used as a last alternative, when all other techniques fail. Although knuckle wiring expedites chronic total occlusion crossing, it can also complicate the percutaneous coronary intervention strategy irreversibly. Therefore, understanding the various aspects of the knuckle wire technique is a prerequisite in a chronic total occlusion setting. The authors herein intend to describe in detail the knuckle wire technique and its safe and effective approach in various chronic total occlusion wiring strategies, while befitting to the scope of a mainstream interventionist.

Evaluation of the Nature of Collagen Fibers in KCOT, Dentigerous Cyst and Ameloblastoma using Picrosirius Red Stain - A Comparative Study.

BACKGROUND: Reciprocal interaction between dental epithelium and mesenchyme is thought to be crucial for normal odontogenesis. Thus, the mesenchymal influence of the fibrous capsules may play an important role in the maintenance of epithelial expression. Collagen is the major component of the extracellular matrix and possibly there is an alteration in the nature and structure of collagen in various pathological conditions. Studies by polarizing microscopy have also shown that there is a difference in collagen and probably these differences may play a role in their biologic behaviour. AIM: The purpose of this study was to evaluate the nature of collagen fibers in keratocystic odontogenic tumour (KCOT), dentigerous cyst (DC), unicystic ameloblastoma (UA) and solid/multicystic ameloblastoma (SMA) and correlating this with their biological behaviour. MATERIALS AND METHODS: Five diagnosed cases each of UA, SMA, KCOT and DC were taken and stained using Picrosirius red stain kit and evaluated using a polarizing microscope. STATISTICAL ANALYSIS: Chi-square test was used to analyse the results. RESULTS AND CONCLUSION: Collagen fibers in dentigerous cysts showed predominant yellowish-red birefringence and fibers in KCOT and ameloblastomas showed a predominantly greenish-yellow birefringence. Hence, our study suggests that the nature and character of collagen fibers may influence the clinical behaviour of the lesion. Since ours is a pilot study, to corroborate our view, studies with larger sample size are required to substantiate the results.

Intercostal artery pseudoaneurysm complicating corrosive acid poisoning: Diagnosis with CT and treatment with transarterial embolisation.

Pseudoaneurysms of intercostal artery are very rare. All the published cases have been caused by trauma, either iatrogenic or otherwise. They can cause hemothorax, retroperitoneal hemorrhage or can present as pulsatile chest mass. Doppler ultrasound, contrast-enhanced CT and conventional angiogram can accurately diagnose this condition. All the reported cases have been treated by embolisation, stenting or surgery. We report an unusual case of intercostal artery pseudoaneurysm arising as a complication of corrosive poisoning presenting with hematemesis and treated by glue embolisation. The authors believe this to be the first case of intercostal artery pseudoaneurysm that is non-traumatic, complicating corrosive poisoning and presenting with hematemesis.

Calcipotriol delivery into the skin as emulgel for effective permeation.

The objective of this work is to formulate and evaluate an emulgel containing calcipotriol for treatment of psoriasis. Emulgels have emerged as a promising drug delivery system for the delivery of hydrophobic drugs. Isopropyl alcohol and polyethylene glycol have been employed as permeation enhancers. Formulation chart is made with seven formulations, evaluated for physical parameters, drug content, viscosity, thixotropy, spreadability, extrudability, mucoadhesion, diffusion studies, skin irritation test along with short term stability studies. Carbopolis is reported to have a direct influence on appearance and viscosity of final formulation. The photomicroscopic evaluations showed the presence of spherical globules in size range of 10-15 µm. Rheograms revealed that all the formulations exhibited pseudoplastic flow. Optimized formulation (F6) had shown 86.42 ± 2.0% drug release at the end of 8 h study. The release rate through dialysis membrane and rat skin is higher when compared to commercial calcipotriol ointment. Hence it is concluded that calcipotriol can be delivered topically with enhanced penetration properties when formulated as emulgel.