Protecting Prostate Cancer Classification From Rectal Artifacts via Targeted Adversarial Training.

Magnetic resonance imaging (MRI)-based deep neural networks (DNN) have been widely developed to perform prostate cancer (PCa) classification. However, in real-world clinical situations, prostate MRIs can be easily impacted by rectal artifacts, which have been found to lead to incorrect PCa classification. Existing DNN-based methods typically do not consider the interference of rectal artifacts on PCa classification, and do not design specific strategy to address this problem. In this study, we proposed a novel Targeted adversarial training with Proprietary Adversarial Samples (TPAS) strategy to defend the PCa classification model against the influence of rectal artifacts. Specifically, based on clinical prior knowledge, we generated proprietary adversarial samples with rectal artifact-pattern adversarial noise, which can severely mislead PCa classification models optimized by the ordinary training strategy. We then jointly exploited the generated proprietary adversarial samples and original samples to train the models. To demonstrate the effectiveness of our strategy, we conducted analytical experiments on multiple PCa classification models. Compared with ordinary training strategy, TPAS can effectively improve the single- and multi-parametric PCa classification at patient, slice and lesion level, and bring substantial gains to recent advanced models. In conclusion, TPAS strategy can be identified as a valuable way to mitigate the influence of rectal artifacts on deep learning models for PCa classification.

Peri-operative, oncological and functional outcomes of robotic versus transanal total mesorectal excision in patients with rectal cancer: A systematic review and meta-analysis.

BACKGROUND: Comparative outcomes of robotic low anterior resection (rTME) and trans-anal total mesorectal excision (TaTME) in patients with low rectal cancer were evaluated. METHODS: A systematic online search was conducted using the following databases: PubMed, Scopus, Cochrane database, The Virtual Health Library, Clinical trials.gov and Science Direct. Comparative studies of rTME versus TaTME for low rectal cancer were included. Primary outcomes were postoperative complications, including anastomotic leak, surgical site infection, and Clavien-Dindo complication rate. Total operative time, conversion to open surgery, intra-operative blood loss, intensive therapy unit (ITU) and total hospital length of stay (LOS), oncological outcomes and functional outcomes were the other evaluated outcome parameters. RESULTS: A total of 12 studies with a total number of 3025 patients divided between rTME (n = 1881) and TaTME (n = 1144) groups were included. There was no significant difference between the two groups for total operative time (P = 0.39), conversion to open surgery (P = 0.29) and intra-operative blood loss (P = 0.62). Clavien-Dindo ≥ 3 complication rate (P = 0.47), anastomotic leak (P = 0.89), rates of re-operation (P = 0.62) and re-admission (P = 0.92), R0 resections (P = 0.52), ITU LOS (P = 0.63) and total hospital LOS (P = 0.30) also showed similar results between the two groups. However, the rTME group had higher rates of total harvested lymph nodes (P = 0.04) and complete total mesorectal excision (TME) resections (P = 0.05). Albeit with a limited dataset, the Wexner and low anterior resection syndrome (LARS) scores showed better functional results in the rTME group compared with the TaTME group (P = 0.0009 and P = 0.00001, respectively). CONCLUSION: Compared with TaTME, rTME seems to provide better functional outcomes, higher lymph node yield and more complete TME resections with a similar post-operative complications profile.

The postoperative renal function of persistent cloaca patients treated by posterior sagittal anorecto-urethro-vaginopalsty: results of a nationwide survey in Japan.

PURPOSE: We investigated the postoperative renal function in persistent cloaca (PC) patients who underwent posterior sagittal anorecto-urethro-vaginopalsty (PSARUVP) and factors influencing the renal functional outcomes. METHODS: A questionnaire survey was distributed to 244 university and children's hospitals across Japan. Of the 169 patients underwent PSARUVP, 103 patients were enrolled in the present study. Exclusion criteria was patients without data of renal prognosis. RESULTS: The present study showed that renal anomalies (p = 0.09), vesicoureteral reflux (VUR) (p = 0.01), and hydrocolpos (p = 0.07) were potential factors influencing a decline in the renal function. Approximately half of the patients had a normal kidney function, but 45.6% had a reduced renal function (Stage ≥ 2 chronic kidney disease: CKD). The incidence of VUR was significantly higher in the renal function decline (RFD) group than those in the preservation (RFP) group (p = 0.01). Vesicostomy was significantly more frequent in the RFD group than in the RFP group (p = 0.04). Urinary tract infections (p < 0.01) and bladder dysfunction (p = 0.04) were significantly more common in patients with VUR than in patients without VUR. There was no association between the VUR status and the bowel function. CONCLUSIONS: Prompt assessment and treatment of VUR along with bladder management may minimize the decline in the renal function.

Vaginal and rectal microbiome contribute to genital inflammation in chronic pelvic pain.

BACKGROUND: Chronic pelvic pain (CPP) is a multifactorial syndrome that can substantially affect a patient's quality of life. Endometriosis is one cause of CPP, and alterations of the immune and microbiome profiles have been observed in patients with endometriosis. The objective of this pilot study was to investigate differences in the vaginal and gastrointestinal microbiomes and cervicovaginal immune microenvironment in patients with CPP and endometriosis diagnosis compared to those with CPP without endometriosis and no CPP. METHODS: Vaginal swabs, rectal swabs, and cervicovaginal lavages (CVL) were collected among individuals undergoing gynecologic laparoscopy. Participants were grouped based on patients seeking care for chronic pain and/or pathology results: CPP and endometriosis (CPP-Endo) (n = 35), CPP without endometriosis (n = 23), or patients without CPP or endometriosis (controls) (n = 15). Sensitivity analyses were performed on CPP with endometriosis location, stage, and co-occurring gynecologic conditions (abnormal uterine bleeding, fibroids). 16S rRNA sequencing was performed to profile the microbiome, and a panel of soluble immune mediators was quantified using a multiplex assay. Statistical analysis was conducted with SAS, R, MicrobiomeAnalyst, MetaboAnalyst, and QIIME 2. RESULTS: Significant differences were observed between participants with CPP alone, CPP-Endo, and surgical controls for body mass index, ethnicity, diagnosis of ovarian cysts, and diagnosis of fibroids. In rectal microbiome analysis, both CPP alone and CPP-Endo exhibited lower alpha diversity than controls, and both CPP groups revealed enrichment of irritable bowel syndrome-associated bacteria. CPP-Endo exhibited an increased abundance of vaginal Streptococcus anginosus and rectal Ruminococcus. Patients with CPP and endometrioma (s) demonstrated increased vaginal Streptococcus, Lactobacillus, and Prevotella compared to other endometriosis sites. Further, abnormal uterine bleeding was associated with an increased abundance of bacterial vaginosis-associated bacteria. Immunoproteomic profiles were distinctly clustered by CPP alone and CPP-Endo compared to controls. CPP-Endo was enriched in TNF⍺, MDC, and IL-1⍺. CONCLUSIONS: Vaginal and rectal microbiomes were observed to differ between patients with CPP alone and CPP with endometriosis, which may be useful in personalized treatment for individuals with CPP and endometriosis from those with other causes of CPP. Further investigation is warranted in patients with additional co-occurring conditions, such as AUB/fibroids, which add additional complexity to these conditions and reveal the enrichment of distinct pathogenic bacteria in both mucosal sites. This study provides foundational microbiome-immunoproteomic knowledge related to chronic pelvic pain, endometriosis, and co-occurring gynecologic conditions that can help improve the treatment of patients seeking care for pain.

Enrichment culture evaluation and characterization of Streptococcus agalactiae among pregnant women in Japan.

Introduction. Maternal screening tests and prophylactic antibiotics are important to prevent neonatal and infant group B streptococcal (GBS) infections.Hypothesis/Gap Statement. The performance of enrichment broth media for GBS screening that are available in Japan is unclear. Whole-genome data of GBS isolates from pregnant women in Japan is lacking.Aim. The aim of this study was to compare the protocol performance of six enrichment broths and two subculture agar plates, which were all available in Japan, for GBS detection. In addition, we showed whole-genome data of GBS isolates from pregnant women in Japan.Methodology. We collected 133 vaginal-rectal swabs from pregnant women visiting clinics and hospitals in Nagasaki Prefecture, Japan, and compared the protocol performance of 6 enrichment broths and 2 subculture agar plates. All GBS isolates collected in this study were subjected to whole-genome sequencing analysis.Results. We obtained 133 vaginal-rectal swabs from pregnant women at 35-37 weeks of gestation from 8 private clinics and 2 local municipal hospitals within Nagasaki Prefecture, Japan. The detection rate of the protocol involving the six enrichment broths and subsequent subcultures varied between 95.5 and 100 %, depending on the specific choice of enrichment broth. The GBS carriage rate among pregnant women in this region was 18.8 %. All 25 isolates derived from the swabs were susceptible to penicillin, whereas 48 and 36 % of the isolates demonstrated resistance to erythromycin and clindamycin, respectively. The distribution of serotypes was highly diverse, encompassing seven distinct serotypes among the isolates, with the predominant serotype being serotype V (n = 8). Serotype V isolates displayed a tendency towards increased resistance to erythromycin and clindamycin, with all resistant isolates containing the ermB gene.Conclusion. There was no difference in performance among the culture protocols evaluated in this study. GBS strains isolated from pregnant women appeared to have greater genomic diversity than GBS strains detected in neonates/infants with invasive GBS infections. To confirm this result, further studies with larger sample sizes are needed.

Simple, Rapid, Safe, and Cost-Effective Technique for Rectal Washout During Laparoscopic Surgery for Rectal Cancer.

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[A case in which endoscopic ultrasound-guided transrectal drainage was effective for pelvic abscess].

The patient, a 33-year-old female, presented to her local doctor with lower abdominal pain. She was referred to our hospital for a plain CT scan, which revealed signs of ileitis. Because acute appendicitis could not be ruled out, the patient was hospitalized. On the third day of hospitalization, she underwent laparoscopic appendicectomy for perforated appendicitis. However, the inflammatory response persisted despite continued antibacterial treatment; we diagnosed this to be due to the formation of a postoperative residual abscess. Since drainage of the abscess was deemed necessary, the patient underwent EUS-guided transrectal drainage on the 26th day of hospitalization. The patient had a favorable postoperative course and was discharged on the 31st day of hospitalization. Along with some literature review, this report details a case in which transrectal drainage under ultrasound endoscopy was effective in treating a pelvic abscess. We report a case of a pelvic abscess that was drained through the rectum under EUS guidance and an internal and external fistula tube was placed. The abscess resolved without complications.

Developing an Animal Model for Swenson Transanal Endorectal Pull-Through: A New Possibility for Training and Research Purposes.

As far as we know, no report uses the Swenson transanal endorectal pull-through technique in an animal model. Our objective is to describe the use of this technique as an experimental model for training and research purposes. Ten Norfolk hybrid rabbits were randomly selected from our experimental laboratory, with a mean weight of 3539.3 (± 678.4) g. Neither colon preparation nor fast were used before the procedures. The surgical technique was based on the description performed by Levitt et al. (2013, J Pediatr Surg. 2013;48(11):2289-2295). Information related to the surgical procedures and the clinical evolution in the postoperative period were recorded and analyzed. There were no deaths or severe complications. The anesthetic and the surgical times were significantly higher for the first three animals of the experiment. Our animal model proved adequate to perform the transanal endorectal Swenson pull-through technique, allowing the training of surgical skills through a model similar to the human, with few anesthetic complications and good postoperative evolution, including postoperative follow-up. We believe that it will serve as a learning tool in many institutions that are continuously searching for improved new techniques and will support new researches in this area.

Colonoscopic removal of an intrauterine device with rectal perforation: A case report.

RATIONALE: The intrauterine device is one of the effective, safe, convenient, economical, and reversible contraceptive methods. Although its contraceptive effect is definite, some female patients may experience complications such as expulsion, bleeding, and pregnancy with the device in place. Rectal perforation is one of the rare and serious complications, which can lead to complications such as abdominal infection and intestinal adhesions, severely affecting the quality of life of patients. PATIENT CONCERNS: A 34-year-old female was sent to the Department of Gastroenterology with noticeable left lower quadrant abdominal pain. She had presented with abdominal discomfort and anal tenesmus 1 year earlier. Two months ago, her abdominal pain had gradually worsened and she was presented to our hospital. DIAGNOSES: Investigations, including colonoscopy and computed tomography scan, had revealed an intrauterine device migrated and perforated into the rectum. INTERVENTIONS AND OUTCOMES: The patient underwent successful colonoscopic removal of the intrauterine device. She recovered well after the treatment. LESSONS: This case proves that endoscopic therapy can be considered the preferred method for removing intrauterine devices displaced into the digestive tract lumen.

Robotic-assisted pull-through procedures for anorectal malformation: a systematic review.

AIM: To study the published literature on robotic-assisted pull-through procedures for anorectal malformation. METHOD: A PubMed search was done on 10th April 2024, with the words "robotic AND Anorectal malformation". The articles were screened for relevance and the data were compiled on the safety, feasibility, technical details, and limitations of robotic-assisted procedures in children for anorectal malformation. RESULTS: The search robotic and anorectal malformation gave ten articles. Two were excluded as they were not relevant. Two articles were added from cross-reference. Ten publications on robotic-assisted procedures for anorectal malformation were studied, describing procedures in thirty-three cases. The youngest child operated was 3 months old. All except one case were done in males. Most articles were from the US and the Kingdom of Saudi Arabia (KSA). The principles involved in robotic-assisted anorectoplasty (RAARP) were the same as that of laparoscopic procedures. Complications reported included pelvic abscess, epididymo-orchitis, and stricture of pelvic tunnel or conversion to open. The magnification and endo-wrist technology of robotics facilitated the sharp dissection and ligation at origin of fistula. The mean operating time was 228.7 min (docking and console time), shortest being 86 min and mean hospital stay was 7 days. The number of ports used varied from 3 to 4 with 8.5 mm being the most commonly used umbilical port and 8 mm as working ports, although in one article, a 12 mm port was used for telescope. The prolonged operating time and cost are the two factors to be addressed in RAARP. CONCLUSION: Robotic surgery is feasible in infants with ARM and safe in expert hands. Robotics is a very effective tool with its better ergonomics, tremor filtration, 3D magnification, and dexterity. Increasing awareness and referral to high-volume centers can tide over the cost factor, and good training of the surgeons can reduce the operative time.

[Transperineal versus transrectal ultrasound-guided prostate biopsy in detection of clinically significant and insignificant prostate cancer: A prospective randomized controlled trial].

OBJECTIVE: To compare transperineal prostate biopsy (TPB) with transrectal ultrasound-guided prostate biopsy (TRUSB) in detection of clinically significant prostate cancer (csPCa) and insignificant PCa (insPCa). METHODS: We conducted a prospective randomized clinical study on 279 patients receiving TPB (n = 144) or TRUSB (n = 135) from January 2022 to January 2023, and compared the detection rates of csPCa and insPCa between the two groups. RESULTS: The detection rate of PCa was significantly higher in the TPB than in the TRUSB group (37.50% vs 28.15%, P = 0.026). There were no statistically significant differences between the TPB and TRUSB groups in the detection rates of insPCa (6.94% ï¼»n = 10ï¼½ vs 4.45% ï¼»n = 6ï¼½, P > 0.05) and csPCa (30.56% ï¼»n = 44ï¼½ vs 23.70% ï¼»n = 32ï¼½, P > 0.05), nor in the detection rate of csPCa between different groups of age, PSA concentration and prostate volume (P > 0.05). No statistically significant differences were observed between the TPB and TRUSB groups either in the positive rate of biopsy punctures (ï¼»16.44 ± 2.86ï¼½% vs ï¼»12.48 ± 2.39ï¼½%, P > 0.05) or in the biopsy-related complications of urinary retention, urinary tract infection, hematuria and rectal bleeding (P > 0.05). CONCLUSION: TPB is more effective than TRUSB in detection of PCa, but there is no statistically significant difference between the two approaches in the detection rates of csPCa and insPCa.

Enough is enough: how many rectal suction biopsies do you need to diagnose Hirschsprung's disease?

PURPOSE: Rectal suction biopsy (RSB) is the gold standard for diagnosing Hirschsprung's disease (HD) in infants. Despite being a common procedure, no standard exists on the number of biopsy specimens and their respective level within the rectum. METHODS: We conducted a retrospective review of epidemiological and pathological data of patients who underwent RSB at our institution between January 2011 and May 2022. During RSB we obtain 4 specimens: at 1 cm, 3 cm and 5 cm above the dentate line, besides one specimen at the dentate line. We used a logistic regression model for statistical analysis and included control variables (e.g. underlying disease, weight at first biopsy, gestational age). RESULTS: A total of 92 patients underwent 115 biopsies, with an average of 3.77 specimens per session. Of the specimens taken at 1 cm above the dentate line 73.9% were conclusive, at 3 cm 75.9% and at 5 cm 79.2%. Specimens taken at the dentate line were squamous or transitional epithelia in 31.5% and therefore of no use for HD diagnostics. The specimen at 3 cm shows the highest discriminative power whether the biopsy session was diagnostic (p-value < 1%). CONCLUSIONS: We propose that a total of three specimens, namely one at 1 cm, one at 3 cm and one at 5 cm above the dentate line, is enough to diagnose or exclude HD.

AI-driven automatic compression system for colorectal anastomosis.

Although circular staplers offer technical advancements over traditional hand-sewn techniques, their use remains challenging for unskilled users, necessitating substantial time and experience for mastery. In particular, it is challenging to apply a consistent pressure of an appropriate magnitude. We developed an automated circular anastomosis device using artificial intelligence (AI) to solve this problem. Automation through AI reduces experiential factors during the anastomosis process. We defined damage occurring during the anastomosis process, noting that a greater depth of damage indicated a more severe injury. For automated anastomosis, data at a tissue strain of 40% were used for the AI model, as this strain level showed optimal performance based on the accuracy and cost matrix. We compared the outcomes of automated anastomosis using a trained AI with those of unskilled users. The results were validated using the Shapiro-Wilk test and t tests. Compression damage was verified on collagen sheets. The AI-driven automatic compression system resulted in less damage compared to unskilled users. In particular, a more significant difference in damage was observed in poor-condition collagen than in good-condition collagen. Damage to the collagen under poor conditions was 54.8% when handled by unskilled users, while the AI-driven automatic compression system resulted in 38.9% damage. This study confirmed that novices' use of AI for automated anastomosis reduces the risk of damage, especially for tissues in poor condition.

Gestational diabetes as a risk factor for GBS maternal rectovaginal colonization: a systematic review and meta-analysis.

BACKGROUND: Maternal rectovaginal colonization by group B Streptococcus (GBS) increases the risk of perinatal GBS disease that can lead to death or long-term neurological impairment. Factors that increase the risk of rectovaginal GBS carriage are incompletely understood resulting in missed opportunities for detecting GBS in risk-based clinical approaches. There is a lacking consensus on whether gestational diabetes mellitus (GDM) is a risk factor for rectovaginal GBS. This systematic review and meta-analysis aims to address current conflicting findings and determine whether GDM should be clinically considered as a risk factor for maternal GBS colonization. METHODS: Peer-reviewed studies that provided GDM prevalence and documented GBS vaginal and/or rectal colonization in women with and without GDM were included in this analysis. From study inception to October 30, 2023, we identified 6,275 relevant studies from EMBASE and PUBMED of which 19 were eligible for inclusion. Eligible studies were analyzed and thoroughly assessed for risk of bias with a modified Newcastle-Ottawa Scale that interrogated representativeness and comparability of cohorts, quality of reporting for GDM and GBS status, and potential bias from other metabolic diseases. Results were synthesized using STATA 18 and analyzed using random-effects meta-analyses. RESULTS: Studies encompassed 266,706 women from 10 different countries, with study periods spanning from 1981 to 2020. Meta-analysis revealed that gestational diabetes is associated with a 16% increased risk of rectovaginal GBS carriage (OR 1.16, CI 1.07-1.26, P = 0.003). We also performed subgroup analyses to assess independent effects of pregestational vs. gestational diabetes on risk of maternal GBS carriage. Pregestational diabetes (Type 1 or Type 2 diabetes mellitus) was also associated with an increased risk of 76% (pooled OR 1.76, CI 1.27-2.45, P = 0.0008). CONCLUSIONS: This study achieved a consensus among previously discrepant observations and demonstrated that gestational diabetes and pregestational diabetes are significant risk factors for maternal rectovaginal carriage of GBS. Recognition of GDM as a risk factor during clinical decisions about GBS screening and intrapartum antibiotic prophylaxis may decrease the global burden of GBS on maternal-perinatal health.

Genetic Analysis of SCN11A, SCN10A, and SCN9A in Familial Episodic Pain Syndrome (FEPS) in Japan and Proposal of Clinical Diagnostic Criteria.

Familial episodic pain syndrome (FEPS) is an early childhood onset disorder of severe episodic limb pain caused mainly by pathogenic variants of SCN11A, SCN10A, and SCN9A, which encode three voltage-gated sodium channels (VGSCs) expressed as key determinants of nociceptor excitability in primary sensory neurons. There may still be many undiagnosed patients with FEPS. A better understanding of the associated pathogenesis, epidemiology, and clinical characteristics is needed to provide appropriate diagnosis and care. For this study, nationwide recruitment of Japanese patients was conducted using provisional clinical diagnostic criteria, followed by genetic testing for SCN11A, SCN10A, and SCN9A. In the cohort of 212 recruited patients, genetic testing revealed that 64 patients (30.2%) harbored pathogenic or likely pathogenic variants of these genes, consisting of 42 (19.8%), 14 (6.60%), and 8 (3.77%) patients with variants of SCN11A, SCN10A, and SCN9A, respectively. Meanwhile, the proportions of patients meeting the tentative clinical criteria were 89.1%, 52.0%, and 54.5% among patients with pathogenic or likely pathogenic variants of each of the three genes, suggesting the validity of these clinical criteria, especially for patients with SCN11A variants. These clinical diagnostic criteria of FEPS will accelerate the recruitment of patients with underlying pathogenic variants who are unexpectedly prevalent in Japan.

Ligilactobacillus salivarius V4II-90 eradicates Group B Streptococcus colonisation during pregnancy: a randomised, double-blind, placebo-controlled trial.

Group B Streptococcus (GBS) is the leading cause of bacterial neonatal sepsis. This study aimed to confirm the effect of Ligilactobacillus salivarius V4II-90 on GBS colonisation during pregnancy. A randomised, multicentre, double-blind, placebo-controlled, parallel-group study was conducted in seven hospitals in Madrid, Spain. The sample was broken down into two groups with 20 participants each (n = 40) in order to show reduced GBS colonisation frequency in the probiotic versus the placebo group. Pregnant participants positive for vaginal-rectal colonisation before or during the 13th week of gestation were randomly assigned to either the placebo or the probiotic group. The probiotic, L. salivarius V4II-90 at 1 × 109 cfu/day was administered for 12 weeks, starting at week 21-23 of gestation. The primary outcome was the percentage of participants with vaginal and/or rectal GBS colonisation at the end of the intervention period (35 weeks of gestation). Secondary outcomes were changes in the microbial composition of vaginal and rectal exudates; premature delivery; premature rupture of membranes; intrapartum antibiotics; new-borns with early or late-onset GBS sepsis; adverse events (AEs); and GBS test results performed at the hospital at week 35 of gestation. Of the 481 participants included, 44 were vaginal-rectal colonised with GBS and randomised. 43 completed the study (20 in the probiotic group and 23 in the placebo group). After intervention, GBS was eradicated in six participants (27%) from the placebo group and in twelve participants (63%) from the probiotic group ( P = 0.030). None of the 185 AEs reported were identified as possibly, probably, or definitely related to the investigational product. In conclusion, oral administration of L. salivarius V4II-90 is a safe and successful strategy to significantly decrease the rates of GBS colonisation at the end of pregnancy and, therefore, to reduce the exposure of subjects and their infants to intrapartum antibiotic prophylaxis. Trial registered at ClinicalTrials.gov: number NCT03669094.