Recent finding and new technologies in nephrolithiasis: a review of the recent literature

This review summarizes recent literature on advances regarding renal and ureteral calculi, with particular focus in areas of recent advances in the overall field of urolithiasis. Clinical management in everyday practice requires a complete understanding of the issues regarding metabolic evaluation and subgrouping of stone-forming patients, diagnostic procedures, effective treatment regime in acute stone colic, medical expulsive therapy, and active stone removal. In this review we focus on new perspectives in managing nephrolitihiasis and discuss recentadvances, including medical expulsive therapy, new technologies, and refinements of classical therapy such as shock wave lithotripsy, give a fundamental modification of nephrolithiasis management. Overall, this field appears to be the most promising, capable of new developments in ureterorenoscopy and percutaneous approaches. Further improvements are expected from robotic-assisted procedures, such as flexible robotics in ureterorenoscopy

Kidney Tomosynthesis Image Reconstruction Algorithms and Image Quality Evaluation

Kidney stone disease is one of the most common diseases that faces the American population. For proper diagnosis of kidney stones medical imaging must be performed. The current gold standard for kidney stone detection is computed tomography (CT) imaging. However, CT imaging exposes the patient to large amounts of x-ray radiation. Digital tomosynthesis is a novel technique in medical diagnosis due to its ability to generate high-resolution images while limiting the radiation dosage to patients. Tomosynthesis is a three-dimensional imaging technique that allows the reconstruction of an arbitrary set of planes from limited-angle series of projection images. Tomosynthesis has well-published success in the field of breast and chest imaging but has had limited studies performed in field of kidney imaging. In this study, C-arm geometry tomosynthesis was compared to traditional tomosynthesis using the shift and add reconstruction algorithm to evaluate the effectiveness of C-arm tomosynthesis for the application of kidney imaging. A simulation was created to generate projection images of each geometry and implement the shift and add algorithm. The results showed that when the images were reconstructed there was more blurring using C-arm tomosynthesis as compared to traditional tomosynthesis. This indicates that C-arm tomosynthesis geometry has the potential to be developed with other reconstruction algorithms to make it better suited for implementation in kidney imaging. Furthermore, the simulations developed in this study lay the groundwork for future development of C-arm tomosynthesis by providing a platform to test new reconstruction algorithms and optimize system parameters for clinical applications

Molecular Studies on Calcium Oxalate Kidney Stones: A Window into the Pathogenesis of Nephrolithiasis

Indiana University-Purdue University Indianapolis (IUPUI)Nephrolithiasis will affect one-in-eleven people, and more than half of those individuals will have stone recurrence within a decade of their first episode. Despite decades of biomedical research on nephrolithiasis and extraordinary advances in molecular and cell biology, the precise mechanisms of kidney stone formation are not fully understood. Currently, there are limited treatments or preventative measures for nephrolithiasis. Therefore, it is crucial to scrutinize kidney stones from a molecular and cell biology perspective to better understand its pathogenesis and pathophysiology; and to, hereafter, contribute to effective therapeutic targets and preventative strategies. Kidney stones are composed of an admixture of crystal aggregated material and an organic matrix. 80% of all kidney stones are composed of calcium oxalate (CaOx) and half of all CaOx patients grow their stones on to Randall’s plaques (RP). RP are interstitial calcium phosphate mineral deposits in the renal papilla. Thus, we developed and optimized methodologies to directly interrogate CaOx stones. CaOx stones were demineralized, sectioned, and imaged by microscopy, utilizing micro CT for precise orientation. Laser microdissection (LMD) of specific regions of stone matrix analyzed by proteomics revealed various proteins involved in inflammation and the immune response. Analyses on jackstone calculi, having arm protrusions that extend out from the body of the stone, revealed that they are a rare subtype of CaOx stone formation. Micro CT analyses on 98 jackstones showed a radiolucent, organic-rich core in the arm protrusions. Fluorescence imaging on RP stones showed consistent differences in autofluorescence patterns between RP and CaOx overgrowth regions. Moreover, cell nuclei were discovered with preserved morphology in RP regions, along with variable expressions of vimentin and CD45. In comparing spatial transcriptomic expression of reference and CaOx kidney papillae, CaOx patients differentially expressed genes associated with pathways of immune cell activation, reactive oxygen damage and injury, extracellular remodeling, and ossification. Our findings provide novel methodologies to better understand the role of molecules and cells in CaOx stone matrix. Several of the proteins and cells identified in these studies may serve as potential biomarkers, and future therapeutic targets in preventing kidney stone disease

Navigation system based in motion tracking sensor for percutaneous renal access

Tese de Doutoramento em Engenharia BiomédicaMinimally-invasive kidney interventions are daily performed to diagnose and treat several renal diseases. Percutaneous renal access (PRA) is an essential but challenging stage for most of these procedures, since its outcome is directly linked to the physician’s ability to precisely visualize and reach the anatomical target. Nowadays, PRA is always guided with medical imaging assistance, most frequently using X-ray based imaging (e.g. fluoroscopy). Thus, radiation on the surgical theater represents a major risk to the medical team, where its exclusion from PRA has a direct impact diminishing the dose exposure on both patients and physicians. To solve the referred problems this thesis aims to develop a new hardware/software framework to intuitively and safely guide the surgeon during PRA planning and puncturing. In terms of surgical planning, a set of methodologies were developed to increase the certainty of reaching a specific target inside the kidney. The most relevant abdominal structures for PRA were automatically clustered into different 3D volumes. For that, primitive volumes were merged as a local optimization problem using the minimum description length principle and image statistical properties. A multi-volume Ray Cast method was then used to highlight each segmented volume. Results show that it is possible to detect all abdominal structures surrounding the kidney, with the ability to correctly estimate a virtual trajectory. Concerning the percutaneous puncturing stage, either an electromagnetic or optical solution were developed and tested in multiple in vitro, in vivo and ex vivo trials. The optical tracking solution aids in establishing the desired puncture site and choosing the best virtual puncture trajectory. However, this system required a line of sight to different optical markers placed at the needle base, limiting the accuracy when tracking inside the human body. Results show that the needle tip can deflect from its initial straight line trajectory with an error higher than 3 mm. Moreover, a complex registration procedure and initial setup is needed. On the other hand, a real-time electromagnetic tracking was developed. Hereto, a catheter was inserted trans-urethrally towards the renal target. This catheter has a position and orientation electromagnetic sensor on its tip that function as a real-time target locator. Then, a needle integrating a similar sensor is used. From the data provided by both sensors, one computes a virtual puncture trajectory, which is displayed in a 3D visualization software. In vivo tests showed a median renal and ureteral puncture times of 19 and 51 seconds, respectively (range 14 to 45 and 45 to 67 seconds). Such results represent a puncture time improvement between 75% and 85% when comparing to state of the art methods. 3D sound and vibrotactile feedback were also developed to provide additional information about the needle orientation. By using these kind of feedback, it was verified that the surgeon tends to follow a virtual puncture trajectory with a reduced amount of deviations from the ideal trajectory, being able to anticipate any movement even without looking to a monitor. Best results show that 3D sound sources were correctly identified 79.2 ± 8.1% of times with an average angulation error of 10.4º degrees. Vibration sources were accurately identified 91.1 ± 3.6% of times with an average angulation error of 8.0º degrees. Additionally to the EMT framework, three circular ultrasound transducers were built with a needle working channel. One explored different manufacture fabrication setups in terms of the piezoelectric materials, transducer construction, single vs. multi array configurations, backing and matching material design. The A-scan signals retrieved from each transducer were filtered and processed to automatically detect reflected echoes and to alert the surgeon when undesirable anatomical structures are in between the puncture path. The transducers were mapped in a water tank and tested in a study involving 45 phantoms. Results showed that the beam cross-sectional area oscillates around the ceramics radius and it was possible to automatically detect echo signals in phantoms with length higher than 80 mm. Hereupon, it is expected that the introduction of the proposed system on the PRA procedure, will allow to guide the surgeon through the optimal path towards the precise kidney target, increasing surgeon’s confidence and reducing complications (e.g. organ perforation) during PRA. Moreover, the developed framework has the potential to make the PRA free of radiation for both patient and surgeon and to broad the use of PRA to less specialized surgeons.Intervenções renais minimamente invasivas são realizadas diariamente para o tratamento e diagnóstico de várias doenças renais. O acesso renal percutâneo (ARP) é uma etapa essencial e desafiante na maior parte destes procedimentos. O seu resultado encontra-se diretamente relacionado com a capacidade do cirurgião visualizar e atingir com precisão o alvo anatómico. Hoje em dia, o ARP é sempre guiado com recurso a sistemas imagiológicos, na maior parte das vezes baseados em raios-X (p.e. a fluoroscopia). A radiação destes sistemas nas salas cirúrgicas representa um grande risco para a equipa médica, aonde a sua remoção levará a um impacto direto na diminuição da dose exposta aos pacientes e cirurgiões. De modo a resolver os problemas existentes, esta tese tem como objetivo o desenvolvimento de uma framework de hardware/software que permita, de forma intuitiva e segura, guiar o cirurgião durante o planeamento e punção do ARP. Em termos de planeamento, foi desenvolvido um conjunto de metodologias de modo a aumentar a eficácia com que o alvo anatómico é alcançado. As estruturas abdominais mais relevantes para o procedimento de ARP, foram automaticamente agrupadas em volumes 3D, através de um problema de optimização global com base no princípio de “minimum description length” e propriedades estatísticas da imagem. Por fim, um procedimento de Ray Cast, com múltiplas funções de transferência, foi utilizado para enfatizar as estruturas segmentadas. Os resultados mostram que é possível detetar todas as estruturas abdominais envolventes ao rim, com a capacidade para estimar corretamente uma trajetória virtual. No que diz respeito à fase de punção percutânea, foram testadas duas soluções de deteção de movimento (ótica e eletromagnética) em múltiplos ensaios in vitro, in vivo e ex vivo. A solução baseada em sensores óticos ajudou no cálculo do melhor ponto de punção e na definição da melhor trajetória a seguir. Contudo, este sistema necessita de uma linha de visão com diferentes marcadores óticos acoplados à base da agulha, limitando a precisão com que a agulha é detetada no interior do corpo humano. Os resultados indicam que a agulha pode sofrer deflexões à medida que vai sendo inserida, com erros superiores a 3 mm. Por outro lado, foi desenvolvida e testada uma solução com base em sensores eletromagnéticos. Para tal, um cateter que integra um sensor de posição e orientação na sua ponta, foi colocado por via trans-uretral junto do alvo renal. De seguida, uma agulha, integrando um sensor semelhante, é utilizada para a punção percutânea. A partir da diferença espacial de ambos os sensores, é possível gerar uma trajetória de punção virtual. A mediana do tempo necessário para puncionar o rim e ureter, segundo esta trajetória, foi de 19 e 51 segundos, respetivamente (variações de 14 a 45 e 45 a 67 segundos). Estes resultados representam uma melhoria do tempo de punção entre 75% e 85%, quando comparados com o estado da arte dos métodos atuais. Além do feedback visual, som 3D e feedback vibratório foram explorados de modo a fornecer informações complementares da posição da agulha. Verificou-se que com este tipo de feedback, o cirurgião tende a seguir uma trajetória de punção com desvios mínimos, sendo igualmente capaz de antecipar qualquer movimento, mesmo sem olhar para o monitor. Fontes de som e vibração podem ser corretamente detetadas em 79,2 ± 8,1% e 91,1 ± 3,6%, com erros médios de angulação de 10.4º e 8.0 graus, respetivamente. Adicionalmente ao sistema de navegação, foram também produzidos três transdutores de ultrassom circulares com um canal de trabalho para a agulha. Para tal, foram exploradas diferentes configurações de fabricação em termos de materiais piezoelétricos, transdutores multi-array ou singulares e espessura/material de layers de suporte. Os sinais originados em cada transdutor foram filtrados e processados de modo a detetar de forma automática os ecos refletidos, e assim, alertar o cirurgião quando existem variações anatómicas ao longo do caminho de punção. Os transdutores foram mapeados num tanque de água e testados em 45 phantoms. Os resultados mostraram que o feixe de área em corte transversal oscila em torno do raio de cerâmica, e que os ecos refletidos são detetados em phantoms com comprimentos superiores a 80 mm. Desta forma, é expectável que a introdução deste novo sistema a nível do ARP permitirá conduzir o cirurgião ao longo do caminho de punção ideal, aumentado a confiança do cirurgião e reduzindo possíveis complicações (p.e. a perfuração dos órgãos). Além disso, de realçar que este sistema apresenta o potencial de tornar o ARP livre de radiação e alarga-lo a cirurgiões menos especializados.The present work was only possible thanks to the support by the Portuguese Science and Technology Foundation through the PhD grant with reference SFRH/BD/74276/2010 funded by FCT/MEC (PIDDAC) and by Fundo Europeu de Desenvolvimento Regional (FEDER), Programa COMPETE - Programa Operacional Factores de Competitividade (POFC) do QREN

Magnetic Induction Tomography (MIT) simulation study for renal screening using different system frequencies and sizes of calcium oxalate

Nephrolithiasis is the process of forming stone in the kidney by crystallization. Due to the increasing prevalence of nephrolithiasis from time to time, medical institutions look for more advanced technology of medical imaging which can tackle the disadvantages of current medical imaging devices for renal, which are non-invasive, free radiation and rapid use. The research encompassed the design simulation study of Magnetic Induction Tomography (MIT) system for renal screening by using COMSOL multiphysics. MIT is a soft field tomography and a non-contact imaging modality used to image the passive electromagnetic properties (conductivity, permittivity and permeability) by applying principle of electromagnetic induction. In this research, 8 copper trans-receiver coils were employed in the MIT system and fixed by the insulation belt. Meanwhile, geometric set-up of renal organ imitates the transverse section at renal level of human body. Sensor performance analysis of MIT system was done based on various frequency and radius of calcium oxalate inside kidneys. In conclusion, frequency and radius of calcium oxalate affect the sensitivity performance of MIT system and has inverse relationship with sensitivity performance

A study of Magnetic Induction Tomography (MIT) for calcium oxalate renal screening

Nephrolithiasis is a process of stone formation in the kidney by crystallization. The increasing prevalence of nephrolithiasis from time to time had sought an alternative from the conventional imaging techniques that is invasive, radiative, and non-rapid usage. This paper enclosed a design simulation study of Magnetic Induction Tomography (MIT) system using COMSOL Multiphysics for renal imaging. MIT is a soft field tomography and non-contact imaging modality which can project the passive electromagnetic properties (conductivity, permittivity and permeability) under the principle of electromagnetic induction. In this research, 8 copper transreceiver coils were employed in the MIT system and fixed by the insulation belt. Meanwhile, geometric set-up of renal organ was set to imitate the transverse section of human renal. In the methodology, sensor performance analyses were done using frequency ranging from 50 kHz to 2 MHz of the MIT system on radii of calcium oxalate in renal. The sensor response and pattern are discussed in this paper

Minimally Invasive Urological Procedures and Related Technological Developments

The landscape of minimally invasive urological intervention is changing. A lot of new innovations and technological developments have happened over the last 3 decades. Laparoscopy and robotic surgery have revolutionised kidney and prostate cancer treatment, with more minimally invasive procedures now being carried out than ever before. At the same time, technological advancements and the use of laser have changed the face of endourology. Several new innovative treatments are now commonplace for benign prostate enlargement (BPE). Management of prostate cancer now involves procedures such as robotic prostatectomy, brachytherapy, radiotherapy, cryotherapy and HIFU. Robotic partial nephrectomy and cryotherapy have changed the face of renal cancer. En-bloc resection of bladder cancer is challenging the traditional management of non-muscle invasive bladder cancer and becoming commonplace, while robotic cystectomy is also gaining popularity for muscle invasive bladder cancer. Newer surgical intervention related to BPE includes laser (holmium, thulium and green light), water-based treatment (Rezum, Aquablation) and other minimally invasive procedures such as prostate artery embolisation (PAE) and Urolift. Endourological procedures have incorporated newer laser types and settings such as moses technology, disposable ureteroscopes (URS) and minimisation of percutaneous nephrolithotomy (PCNL) instruments. All these technological innovations and improvements have led to shorter hospital stay, reduced cost, potential reduction in complications and improvement in the quality of life (QoL)