MRI-Based Radiomics in Bladder Cancer: A Systematic Review and Radiomics Quality Score Assessment.

(1): Background: With the recent introduction of vesical imaging reporting and data system (VI-RADS), magnetic resonance imaging (MRI) has become the main imaging method used for the preoperative local staging of bladder cancer (BCa). However, the VI-RADS score is subject to interobserver variability and cannot provide information about tumor cellularity. These limitations may be overcome by using a quantitative approach, such as the new emerging domain of radiomics. (2) Aim: To systematically review published studies on the use of MRI-based radiomics in bladder cancer. (3) Materials and Methods: We performed literature research using the PubMed MEDLINE, Scopus, and Web of Science databases using PRISMA principles. A total of 1092 papers that addressed the use of radiomics for BC staging, grading, and treatment response were retrieved using the keywords "bladder cancer", "magnetic resonance imaging", "radiomics", and "textural analysis". (4) Results: 26 papers met the eligibility criteria and were included in the final review. The principal applications of radiomics were preoperative tumor staging (n = 13), preoperative prediction of tumor grade or molecular correlates (n = 9), and prediction of prognosis/response to neoadjuvant therapy (n = 4). Most of the developed radiomics models included second-order features mainly derived from filtered images. These models were validated in 16 studies. The average radiomics quality score was 11.7, ranging between 8.33% and 52.77%. (5) Conclusions: MRI-based radiomics holds promise as a quantitative imaging biomarker of BCa characterization and prognosis. However, there is still need for improving the standardization of image preprocessing, feature extraction, and external validation before applying radiomics models in the clinical setting.

A Light, 3D UNet-based Architecture for Fully Automatic Segmentation of Prostate Lesions from T2-MRI Images.

INTRODUCTION: Prostate magnetic resonance imaging (MRI) has been recently integrated into the pathway of diagnosis of prostate cancer (PCa). However, the lack of an optimal contrast-to-noise ratio hinders automatic recognition of suspicious lesions, thus developing a solution for proper delimitation of the tumour and its separation from the healthy parenchyma, which is of primordial importance. METHOD: As a solution to this unmet medical need, we aimed to develop a decision support system based on artificial intelligence, which automatically segments the prostate and any suspect area from the 3D MRI images. We assessed retrospective data from all patients diagnosed with PCa by MRI-US fusion prostate biopsy, who underwent prostate MRI in our department due to a clinical or biochemical suspicion of PCa (n=33). All examinations were performed using a 1.5 Tesla MRI scanner. All images were reviewed by two radiologists, who performed manual segmentation of the prostate and all lesions. A total of 145 augmented datasets were generated. The performance of our fully automated end-to-end segmentation model based on a 3D UNet architecture and trained in two learning scenarios (on 14 or 28 patient datasets) was evaluated by two loss functions. RESULTS: Our model had an accuracy of over 90% for automatic segmentation of prostate and PCa nodules, as compared to manual segmentation. We have shown low complexity networks, UNet architecture with less than five layers, as feasible and to show good performance for automatic 3D MRI image segmentation. A larger training dataset could further improve the results. CONCLUSION: Therefore, herein, we propose a less complex network, a slim 3D UNet with superior performance, being faster than the original five-layer UNet architecture.

Robotic Radical Cystectomy with Intracorporeal Urinary Diversion - Tips and Tricks.

Radical cystectomy represents the standard surgical treatment in case of muscle invasive bladder cancer. During the last two decades a change in the surgical approach of the MIBC has been observed, from open surgery to minimal invasive surgery. Nowadays, in the majority of tertiary urologic centers, robotic radical cystectomy with intracorporeal urinary diversion represents the standard surgical approach. The aim of the current study is to describe in detail the surgical steps of the robotic radical cystectomy and the reconstruction of the urinary diversion and to present our experience. From the surgical point of view, the most important principles which should guide the surgeon when performing this procedure are: 1. Good working place and access both to the pelvis and abdomen and use of the "technique of spaces" 2. Respect the oncological principles of the surgery with attention to the margin resection and limitation of the risk of tumour spillage; 3. Attention to both the ureter and bowel manipulation in order to avoid grasping lesions; 4. High care in realisation of the uretero-ileal anastomosis so that good long term functional results are achieved. We analyzed our database of 213 patients diagnosed with muscle invasive bladder cancer who underwent minimally invasive radical cystectomy (laparoscopic and robotic approaches) between January 2010 and December 2022. We identified 25 patients for whom the robotic approach was used to perform the surgery. Despite being one of the most challenging urologic surgical procedures, with careful preparation and training, the surgeon is able to achieve the maximum oncological and functional results by performing robotic radical cystectomy with intracorporeal urinary.

Fully automated bladder tumor segmentation from T2 MRI images using 3D U-Net algorithm.

Introduction: Bladder magnetic resonance imaging (MRI) has been recently integrated in the diagnosis pathway of bladder cancer. However, automatic recognition of suspicious lesions is still challenging. Thus, development of a solution for proper delimitation of the tumor and its separation from the healthy tissue is of primordial importance. As a solution to this unmet medical need, we aimed to develop an artificial intelligence-based decision support system, which automatically segments the bladder wall and the tumor as well as any suspect area from the 3D MRI images. Materials: We retrospectively assessed all patients diagnosed with bladder cancer, who underwent MRI at our department (n=33). All examinations were performed using a 1.5 Tesla MRI scanner. All images were reviewed by two radiologists, who performed manual segmentation of the bladder wall and all lesions. First, the performance of our fully automated end-to-end segmentation model based on a 3D U-Net architecture (by considering various depths of 4, 5 or 6 blocks) trained in two data augmentation scenarios (on 5 and 10 augmentation datasets per original data, respectively) was tested. Second, two learning setups were analyzed by training the segmentation algorithm with 7 and 14 MRI original volumes, respectively. Results: We obtained a Dice-based performance over 0.878 for automatic segmentation of bladder wall and tumors, as compared to manual segmentation. A larger training dataset using 10 augmentations for 7 patients could further improve the results of the U-Net-5 model (0.902 Dice coefficient at image level). This model performed best in terms of automated segmentation of bladder, as compared to U-Net-4 and U-Net-6. However, in this case increased time for learning was needed as compared to U-Net-4. We observed that an extended dataset for training led to significantly improved segmentation of the bladder wall, but not of the tumor. Conclusion: We developed an intelligent system for bladder tumors automated diagnostic, that uses a deep learning model to segment both the bladder wall and the tumor. As a conclusion, low complexity networks, with less than five-layers U-Net architecture are feasible and show good performance for automatic 3D MRI image segmentation in patients with bladder tumors.

Systematic review of techniques and devices used to avoid warm ischemia time injury during kidney transplantation.

PURPOSE: The lack of a reliable and reproducible technique to ensure a constantly low temperature of the graft during kidney transplantation (KT) may be a cause of renal nonfunction. The aim of this review was to assess all the methods and devices available to ensure hypothermia during vascular anastomosis in KT. METHODS: A literature search was conducted through May 2022 using PubMed/Medline, Cochrane Library, Embase and Web of Science databases. Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed to identify eligible studies. The review protocol was registered on PROSPERO (CRD42022326550). RESULTS: A total of 20 studies reporting on four hypothermia techniques met our inclusion criteria. Simple instillation of cold serum is not sufficient, the graft reaching up to 33 ℃ at the end of warm ischemia time (WIT). Plastic bags filled with ice slush have questionable efficiency. The use of a gauze jacket filled with ice-slush was reported in 12/20 studies. It ensures a graft temperature up to 20.3 ℃ at the end of WIT. Some concerns have been linked to potentially inhomogeneous parenchymal cooling and secondary ileus. Novel devices with continuous flow of ice-cold solution around the graft might overcome these limitations, showing a renal temperature below 20 ℃ at all times during KT. CONCLUSION: The gauze filled with ice slush is the most common technique, but several aspects can be improved. Novel devices in the form of cold-ischemia jackets can ensure a lower and more stable temperature of the graft during KT, leading to higher efficiency and reproducibility.

What Is Different in Acute Hematologic Malignancy-Associated ARDS? An Overview of the Literature.

Background and Objectives: Acute hematologic malignancies are a group of heterogeneous blood diseases with a high mortality rate, mostly due to acute respiratory failure (ARF). Acute respiratory distress syndrome (ARDS) is one form of ARF which represents a challenging clinical condition. The paper aims to review current knowledge regarding the variable pathogenic mechanisms, as well as therapeutic options for ARDS in acute hematologic malignancy patients. Data collection: We provide an overview of ARDS in patients with acute hematologic malignancy, from an etiologic perspective. We searched databases such as PubMed or Google Scholar, including articles published until June 2022, using the following keywords: ARDS in hematologic malignancy, pneumonia in hematologic malignancy, drug-induced ARDS, leukostasis, pulmonary leukemic infiltration, pulmonary lysis syndrome, engraftment syndrome, diffuse alveolar hemorrhage, TRALI in hematologic malignancy, hematopoietic stem cell transplant ARDS, radiation pneumonitis. We included relevant research articles, case reports, and reviews published in the last 18 years. Results: The main causes of ARDS in acute hematologic malignancy are: pneumonia-associated ARDS, leukostasis, leukemic infiltration of the lung, pulmonary lysis syndrome, drug-induced ARDS, radiotherapy-induced ARDS, diffuse alveolar hemorrhage, peri-engraftment respiratory distress syndrome, hematopoietic stem cell transplantation-related ARDS, transfusion-related acute lung injury. Conclusions: The short-term prognosis of ARDS in acute hematologic malignancy relies on prompt diagnosis and treatment. Due to its etiological heterogeneity, precision-based strategies should be used to improve overall survival. Future studies should focus on identifying the relevance of such etiologic-based diagnostic strategies in ARDS secondary to acute hematologic malignancy.

More than Meets the Eye: Using Textural Analysis and Artificial Intelligence as Decision Support Tools in Prostate Cancer Diagnosis-A Systematic Review.

(1) Introduction: Multiparametric magnetic resonance imaging (mpMRI) is the main imagistic tool employed to assess patients suspected of harboring prostate cancer (PCa), setting the indication for targeted prostate biopsy. However, both mpMRI and targeted prostate biopsy are operator dependent. The past decade has been marked by the emerging domain of radiomics and artificial intelligence (AI), with extended application in medical diagnosis and treatment processes. (2) Aim: To present the current state of the art regarding decision support tools based on texture analysis and AI for the prediction of aggressiveness and biopsy assistance. (3) Materials and Methods: We performed literature research using PubMed MeSH, Scopus and WoS (Web of Science) databases and screened the retrieved papers using PRISMA principles. Articles that addressed PCa diagnosis and staging assisted by texture analysis and AI algorithms were included. (4) Results: 359 papers were retrieved using the keywords "prostate cancer", "MRI", "radiomics", "textural analysis", "artificial intelligence", "computer assisted diagnosis", out of which 35 were included in the final review. In total, 24 articles were presenting PCa diagnosis and prediction of aggressiveness, 7 addressed extracapsular extension assessment and 4 tackled computer-assisted targeted prostate biopsies. (5) Conclusions: The fusion of radiomics and AI has the potential of becoming an everyday tool in the process of diagnosis and staging of the prostate malignancies.

Adrenal Gland Primary Neuroblastoma in an Adult Patient: A Case Report and Literature Review.

Neuroblastoma (NB) is an undifferentiated malignant tumor of the sympathetic ganglia, occurring in children under 5 years of age. However, it is a rare histology in adult patients, occurring once per every 10 million patients per year. We present the case of a 68-year-old male patient presented to our department for right lumbar pain, asthenia, loss of weight and altered general status. The contrast-enhanced abdominal computer tomography revealed bilateral adrenal tumoral masses of 149 mm and 82 mm on the right and left sides, respectively, with invasion of the surrounding organs. The patient underwent right 3D laparoscopic adrenalectomy and right radical nephrectomy. The pathological result concluded that the excised tumor was a neuroblastoma of the adrenal gland. The patient followed adjuvant oncological treatment; however, due to disease progression, he passed away 22 months after the surgery. To our knowledge, less than 100 cases of adrenal NB in adult patients have been published, the eldest case being diagnosed at 75 years of age; meanwhile, the largest reported tumor measured 200 mm, and was excised through open surgery. Minimally invasive techniques have been limited so far to smaller, organ-confined diseases, thus making the present case the largest adrenal NB removed entirely laparoscopically. Neuroblastoma in the adult population is a rare finding, with worse prognosis compared to pediatric patients. The available literature does not provide enough data for standardized, multimodal management, as the patients are treated following adapted pediatric protocols, thus reinforcing the need for international, multidisciplinary boards for rare tumors.

Combined Systematic and MRI-US Fusion Prostate Biopsy Has the Highest Grading Accuracy When Compared to Final Pathology.

Background and objectives: Systematic prostate biopsy (SB) has a low Gleason group (GG) accuracy when compared to final pathology. This may negatively impact the inclusion of patients into specific risk groups and treatment choice. The aim of our study was to assess the GG accuracy of magnetic resonance imaging-ultrasound (MRI-US) fusion prostate biopsy. Materials and Methods: Of a cohort of minimally invasive radical prostatectomy (RP), we selected all patients who were diagnosed with prostate cancer (PCa) via MRI-US fusion biopsy (n = 115). Results: Combined biopsy had the highest rate for GG concordance (61.7% vs. 60.4% for SB vs. 45.3% for MRI-US fusion biopsy) and the lowest for upgrading (20.9% vs. 24.5% for SB vs. 34.9% for MRI-US fusion biopsy), p < 0.0001. No clinical data were predictive for upgrading or downgrading at final pathology. Locally advanced PCa was associated with a high Prostate Imaging-Reporting and Data System (PIRADS) score (p = 0.0014) and higher percentages of positive biopsy cores (PBC)/targeted (p = 0.0002) and PBC/total (p = 0.01). Positive surgical margins were correlated with higher percentages of PBC/systematic (p = 0.003) and PBC/total (p = 0.009). Conclusions: Pre-biopsy prostate MRI improves GG concordance between biopsy and RP. Combined biopsy provides the highest grading accuracy when compared to final pathology. Targeted and systematic biopsy data are predictive for adverse pathologic outcomes.

MRI-US fusion guided prostate biopsy: how I do it.

Multiparametric magnetic resonance imaging (MRI) and MRI-guided prostate biopsy have become the standard for pros-tate cancer diagnosis. As their implementation is relatively recent, experience is still limited in various centres. MRI-guided biopsy requires basic knowledge in prostate MRI and ultrasound (US), but also in the image processing protocol specific for each device. Standardization of the method is needed to ensure the best results in terms of diagnosis accuracy. We hereby pre-sent our technique for MRI-US fusion guided prostate biopsy and the outcomes after performing more than 600 procedures.

MRI-targeted prostate biopsy: the next step forward!

AIM: For decades, the gold standard technique for diagnosing prostate cancer was the 10 to 12 core systematic transrectal or transperineal biopsy, under ultrasound guidance. Over the past years, an increased rate of false negative results and detection of clinically insignificant prostate cancer has been noted, resulting into overdiagnosis and overtreatment. The purpose of the current study was to evaluate the changes in diagnosis and management of prostate cancer brought by MRI-targeted prostate biopsy. METHODS: A critical review of literature was carried out using the Medline database through a PubMed search, 37 studies meeting the inclusion criteria: prospective studies published in the past 8 years with at least 100 patients per study, which used multiparametric magnetic resonance imaging as guidance for targeted biopsies. RESULTS: In-Bore MRI targeted biopsy and Fusion targeted biopsy outperform standard systematic biopsy both in terms of overall and clinically significant prostate cancer detection, and ensure a lower detection rate of insignificant prostate cancer, with fewer cores needed. In-Bore MRI targeted biopsy performs better than Fusion biopsy especially in cases of apical lesions. CONCLUSION: Targeted biopsy is an emerging and developing technique which offers the needed improvements in diagnosing clinically significant prostate cancer and lowers the incidence of insignificant ones, providing a more accurate selection of the patients for active surveillance and focal therapies.

Role of the Laparoscopic Approach for Complex Urologic Surgery in the Era of Robotics.

(1) Introduction: The advent of robotic surgery led to the assumption that laparoscopic surgery would be replaced entirely. However, the high costs of robotic surgery limit its availability. The aim of the current study was to assess the feasibility of the 3D laparoscopic approach for the most complex urological procedures. (2) Materials and methods: We included in the current study all patients who had undergone complex 3D laparoscopic procedures in our department since January 2017, including radical nephrectomy (LRN) using a dual combined approach (19 patients), radical nephroureterectomy (LRNU) with bladder cuff excision (13 patients), and radical cystectomy (LRC) with intracorporeal urinary diversion (ICUD) (21 patients). (3) Results: The mean operative time was 345/230/478 min, the complications rate was 26%/30.76%/23.8% and positive surgical margins were encountered in 3/1/1 patients for the combined approach of LRN/LRNU/LRC with ICUD, respectively. A single patient was converted to open surgery during LRN due to extension of the vena cava thrombus above the hepatic veins. After LRC, sepsis was the most common complication and 8 patients were readmitted at a mean of 15.5 days after discharge. (4) Conclusions: In the era of robotic surgery, laparoscopy remains a plausible alternative for most complex oncological cases.

Different clinical significance of ASAP/HGPIN pattern in systematic vs. MRI-US fusion guided prostate biopsy.

Atypical small acinar proliferation (ASAP) and high grade intraepithelial neoplasia (HGPIN) patterns identified at prostate biopsy yield an important clinical significance, their presence signaling an increased likelihood of future oncological development or underdiagnosed PCa. MRI and MRI-TRUS fusion prostate biopsy have recently become the standard for the diagnosis of prostate cancer. Thus, we aimed to assess the role of ASAP/HGPIN pattern in the context of these recent developments as compared with the standard systematic biopsy. The present study included 400 patients who underwent MRI-TRUS fusion prostate biopsy. A subgroup of these patients had a history of prior systematic biopsy and their results were also included in the analysis. We observed that ASAP/HGPIN pattern diagnosed at systematic biopsy is suggestive of a high-volume clinically-significant disease, most probably located outside the standard sampling area. On the contrary, ASAP/HGPIN at MRI-TRUS fusion biopsy has clinical features more similar to benign prostate hyperplasia, thus suggesting a more incipient disease, if present. No relation between concurrent ASAP/HGPIN and PCa was observed in our study.

Leiomyosarcoma of the inferior vena cava. Our experience and a review of the literature.

Leiomyosarcoma (LMS) of the inferior vena cava (IVC) is a rare malignant tumor, accounting for 2% of all LMSs. Less than 400 cases have been reported in literature. Computed tomography (CT) is the most accurate imaging method in assessing the location of the tumor within the IVC and magnetic resonance imaging (MRI) accurately identifies its extent and the potential for surgical resection. We present the case of a patient with inferior vena cava leiomyosarcoma (IVCL), for whom the pathological diagnosis was different from the initially expected one, the tumor appearance on pre-operative imaging mimicking renal cell carcinoma. The intraoperative difficulty of approaching renal hilum and IVC was a factor suggesting the vascular origin of the tumor, which was confirmed at pathological analysis. The extensive defect in the IVC after tumor excision led to the decision of complete transverse suturing of IVC, as significant collateral venous circulation was already present. Because IVCL is a rare disease, there is scarce data regarding the prognosis and treatment options. Long-term survival depends on the extent of the surgery. The need of vascular reconstruction is not always mandatory. Despite high recurrence rates, no consensus regarding adjuvant treatment exists yet. A multidisciplinary approach including surgical oncologists and vascular surgeons is mandatory to achieve the best patient outcomes. Perioperative planning, coordination and adherence to oncological techniques are critical.

Evaluation of the efficacy of Phyllanthus niruri standardized extract combined with magnesium and vitamin B6 for the treatment of patients with uncomplicated nephrolithiasis.

INTRODUCTION: The aim of our study was to assess the efficacy of Phyllanthus niruri standardized extract, combined with magnesium and B6 vitamin, used to treat uncomplicated nephrolithiasis. METHODS: We included in the present study 48 patients with uncomplicated nephrolithiasis, with the maximum calculi diameter of up to 15 mm, confirmed by non-contrast-enhanced computer tomography. Each patient followed a three-month therapeutic regimen with the above mentioned combination, with imaging assessment of the calculi after treatment. RESULTS: Per patient: The mean age of the patients was 48 years. The median number of calculi was 1 and the mean dimension was 5.5 mm. The stone-free status after treatment was not correlated with gender (p=0.7), side location (p=0.8) or with the number of calculi (p=0.3), but we found a correlation with the location in the upper or middle calyx (54.5% vs 13.8%, p=0.008) and with the maximum diameter (p=0.001).Per stone: 60 calculi were analyzed, 8.3% being located in the upper calyx, 36.7% in the middle and 55% in the lower one. After treatment, 40% were absent, 21.7% showed lower dimensions and 38.3% remained unchanged, with the mean reduction of 1.7 mm. We identified a cut-off value of ≤ 3 mm (AUC 0.9, CI:0.8-0.9, p<0.0001) for the prediction of stone-free status after treatment. CONCLUSIONS: The current treatment had the highest efficacy in achieving stone-free status for patients with calculi ≤ 3 mm, located in the middle or upper calyx. A higher duration of the treatment might show improved results.

Retroperitoneal laparoendoscopic single-site approach for renal cyst decortication - first experience and a review of literature.

Laparoendoscopic single-site (LESS) approach has been successfully employed for a number of urologic procedures. The retroperitoneal approach further limits the working space and instrument movement during LESS surgery, but has the advantage of a faster post-operative recovery and lower complications rate. We present our first experience using retroperitoneal LESS approach for a renal cyst decortication in a 40-year-old patient. The operative time was 40 minutes, the blood loss was minimal and we did not encounter significant conflicts between the instruments. The patient was discharged 2 days after the procedure and returned to full normal activity within one week. We consider that the retroperitoneal LESS approach is feasible for upper tract urologic surgery. Pre-bent instruments might further improve surgical gestures and extend the indications for more complex procedures. Nevertheless, the advent of reusable devices is expected to increase the cost-effectiveness of LESS and expand its use.

Dual Combined Laparoscopic Approach for Renal-Cell Carcinoma with Renal Vein and Level I-II Inferior Vena Cava Thrombus: Our Technique and Initial Results.

OBJECTIVE: To present our technique and initial results of dual combined retroperitoneal and transperitoneal laparoscopic approach for the treatment of renal-cell carcinoma (RCC) with level 0-II venous tumor thrombus. PATIENTS AND METHODS: We included nine consecutive patients with RCC and level 0-II inferior vena cava (IVC) thrombus who underwent laparoscopic radical nephrectomy and IVC thrombectomy using dual combined laparoscopic approach in our department between January 2016 and June 2017. RESULTS: The mean operative time was 150 minutes when cavotomy was not performed and 240 minutes when cavotomy with thrombectomy was required. The mean IVC clamping time was 24 minutes and the mean blood loss was 300 mL. We encountered no major intraoperative or postoperative complications (Clavien III-IV). The patients were discharged a mean of 7 days after the procedure. At the 6-month follow-up, all patients were alive. One patient presented a retroperitoneal enlarged lymph node and started systemic treatment. CONCLUSIONS: The dual combined laparoscopic approach for kidney tumors with level 0-II IVC thrombus is feasible, reproducible, and especially useful in patients with complex renal pedicle. The technique provides early arterial control by retroperitoneal approach, which reduces the blood flow through the renal vein and has the advantage of minimal mobilization of the thrombus-bearing renal vein; it therefore lowers the risk of tumor embolism and intraoperative hemorrhage.