Resection of hypertrophic papillary muscles and mitral valve replacement in a patient with midventricular hypertrophic obstructive cardiomyopathy

Midventricular hypertrophic obstructive cardiomyopathy (HOCM) is characterized by hypertrophy of the interventricular septum (IVS) and - in rare cases - of the papillary muscles (PM), which subsequently can cause dynamic left ventricular outflow tract obstruction (LVOTO) and severe heart failure symptoms. We report on a rare case of a 44-year-old patient suffering from midventricular HOCM with hypertrophic anterolateral PM and an additional chorda between the PM and the IVS. We describe a new surgical approach via right anterolateral thoracotomy in 3-dimensional (3D) video-assisted minimal-invasive technique with resection of hypertrophic PMs as well as the entire mitral valve-apparatus and valve replacement avoiding septal myectomy and potentially associated complications. After an uneventful procedure clinical symptoms improved from NYHA III-IV at baseline to NYHA 0-I postoperatively and remained stable over a follow-up period of 24 months. Therefore, the presented technique may be considered as a new and alternative approach in patients with hypertrophic PMs and hypertrophic IVS as subtype of midventricular HOCM

Institutional adoption and apprenticeship of fusion targeted prostate biopsy

$\textit {Introduction:}$ There are limited data on the learning curve of magnetic resonance imaging/transrectal ultrasound (MRI/TRUS)-fusion targeted prostate biopsies (tBx). $\textit {Objective:}$ The aim of this study was to investigate the difference in prostate cancer (PCa) detection rate between an experienced urologist and novice resident performing tBx. $\textit {Methods:}$ A total of 183 patients underwent tBx from 2012 to 2016 for a total of 518 tBx cores. Biopsies in this study were performed by an experienced urologist (investigator A) or a novice resident (investigator B). The outcome was the detection of PCa on tBx. Using a multivariable logistic regression model, we estimated odds ratios for the detection of PCa. Inverse probability treatment weighting (IPTW) was used to balance patients' baseline characteristics and compare detection rates of PCa. Before performance of tBx, all patients underwent MRI. $\textit {Results:}$ On multivariable logistic regression analysis, investigator experience was associated with a higher odds of detection of PCa (OR = 1.003; 95% confidence interval 1.002–1.006, $\it p$ = 0.037). After IPTW adjustment, there was no significant difference between the detection rate of investigator A (23%) and investigator B (32%; $\it p$ = 0.457). $\textit {Conclusions:}$ Data revealed a positive association between investigator experience and the odds of PCa detection, although there was no difference in the detection rates of the investigators

Psychosocial distress in the early recovery period after radical prostatectomy

$\bf Purpose:$ This study aimed to evaluate psychosocial distress in the context of continence and oncological outcome during the early recovery period after radical prostatectomy (RP) for prostate cancer. $\bf Patients and Methods:$ Retrospectively collected data from 587 patients who underwent inpatient rehabilitation after RP in 2016 and 2017 were analyzed. Psychosocial distress (measured by using a Questionnaire on Stress in Cancer Patients [QSC-R10]) and continence status (urine loss on a 24-h pad test and urine volume on uroflowmetry) were evaluated at the beginning (T1) and end (T2) of a 3-week inpatient rehabilitation. Multivariate logistic regression was performed to identify predictors for high distress (QSC-R10 score $\geq$15). $\bf Results:$ The median patient age was 65 years. At the start of rehabilitation, 204 patients (34.8%) demonstrated high distress. Psychosocial distress decreased significantly ($\it p$ < 0.001) from a median of 11.0 at T1 (median 16 days after surgery) to a median of 6.0 at T2 (median 37 days after surgery). Complete continence increased significantly ($\it p$ < 0.001) from 39.0% at T1 to 58.9% at T2. The median urine volume increased significantly ($\it p$ < 0.001) from 161 mL at T1 to 230 mL at T2. Often, distress is higher in younger patients, whereas incontinence is higher in older patients. Multivariate logistic regression analysis identified age $\leq$69 years ($\it p$ = 0.001) and tumor stage $\geq$pT3 ($\it p$ = 0.006) as independent predictors of high distress. $\bf Conclusions:$ Distress and incontinence decreased significantly during the 3 weeks of inpatient rehabilitation after RP. Patient age $\leq$69 years and tumor stage $\geq$pT3 are independent predictors of high psychosocial distress

Probability of prostate cancer diagnosis following negative systematic and targeted MRI: transrectal ultrasound fusion biopsy

$\bf Introduction:$ The risk of occult prostate carcinoma (PCa) after negative multiparametric MRI (mpMRI)-transrectal fusion biopsy (F-Bx) is unknown. To determine the false-negative predictive value, we examined PCa detection after prior negative F-Bx. $\bf Methods:$ Between December 2012 and November 2016, 491 patients with suspected PCa and suspicious mpMRI findings underwent transrectal F-Bx. Patients with benign pathology ($\it n$ = 191) were eligible for our follow-up (FU) survey. Patient characteristics and clinical parameters were correlated to subsequent findings of newly detected PCa. $\bf Results:$ Complete FU with a median of 31 (interquartile range: 17–39) months was available for 176/191 (92.2%) patients. Of those, 54 men had either surgical interventions on the prostate or re-Bxs. Newly detected PCa was evident in 14/176 (7.95%) patients stratified to ISUP $\leq$ 2 in 10 and $\geq$ 3 in 4 cases. The comparison of patients with newly detected PCa to those without cancerous findings in FU showed significant differences in prostate-specific antigen (PSA) density (0.16 vs. 0.13 ng/mL$^{2}$) and prostate volume (45 vs. 67 mL, both $\it p$ < 0.05). Both factors are significant predictors for newly detected cancer after initial negative F-Bx. $\bf Conclusion:$ Only PSA density (>0.13 ng/mL$^{2}$) and small prostate volume are significant predictors for newly detected PCa after initial negative F-Bx. Despite negative mpMRI/TRUS F-Bx results, patients should be further monitored due to a risk of developing PCa over time. Notwithstanding the limitation of our study that not all patients underwent another Bx, we assume that the false-negative rate is low but existing. Our data represent a real-world scenario

How many cores should be sampled during systematic prostate biopsy in case of negative multiparametric magnetic resonance imaging?

$\bf Introduction:$ This study aimed to investigate the number of cores needed in a systematic biopsy (SB) in men with clinical suspicion of prostate cancer (PCa) but negative prebiopsy multiparametric magnetic resonance imaging and to test prostate-specific antigen (PSA) density as an indicator for reduced SB. $\bf Methods:$ Two hundred and seventy-four patients were analyzed, extracted from an institutional database. Detection rates of any PCa and clinically significant (CS) PCa for different reduced biopsy protocols were compared by using Fisher’s exact test. $\bf Results:$ In total, 12-core SB revealed PCa in 103 (37.6%) men. Detection rates of reduced biopsy protocols were 74 (27%, 6-core) and 82 (29.9%, 8-core). Regarding CSPCa, 12-core SB revealed a detection rate of 26 (9.5%). Reduced biopsy protocols detected less CSPCa: 15 (5.5%) and 18 (6.6%), respectively. All differences were statistically significant, $\it p$ < 0.05. PSA density $\geq$0.15 did not help to filter out men in whom a reduced biopsy may be sufficient. $\bf Conclusions:$ Twelve-core SB still has the highest detection rate of any PCa and CSPCa compared to reduced biopsy protocols. If the investigator and patient agree – based on individual risk calculation – to perform a biopsy, this SB should contain at least 12 cores regardless of PSA density

Machine-learning-based diagnostics of cardiac sarcoidosis using multi-chamber wall motion analyses

Background: Hindered by its unspecific clinical and phenotypical presentation, cardiac sarcoidosis (CS) remains a challenging diagnosis. Objective: Utilizing cardiac magnetic resonance imaging (CMR), we acquired multi-chamber volumetrics and strain feature tracking for a support vector machine learning (SVM)-based diagnostic approach to CS. Method: Forty-five CMR-negative (CMR(−), 56.5(53.0;63.0)years), eighteen CMR-positive (CMR(+), 64.0(57.8;67.0)years) sarcoidosis patients and forty-four controls (CTRL, 56.5(53.0;63.0)years)) underwent CMR examination. Cardiac parameters were processed using the classifiers of logistic regression, KNN(K-nearest-neighbor), DT (decision tree), RF (random forest), SVM, GBoost, XGBoost, Voting and feature selection. Results: In a three-cluster analysis of CTRL versus vs. CMR(+) vs. CMR(−), RF and Voting classifier yielded the highest prediction rates (81.82%). The two-cluster analysis of CTRL vs. all sarcoidosis (All Sarc.) yielded high prediction rates with the classifiers logistic regression, RF and SVM (96.97%), and low prediction rates for the analysis of CMR(+) vs. CMR(−), which were augmented using feature selection with logistic regression (89.47%). Conclusion: Multi-chamber cardiac function and strain-based supervised machine learning provides a non-contrast approach to accurately differentiate between healthy individuals and sarcoidosis patients. Feature selection overcomes the algorithmically challenging discrimination between CMR(+) and CMR(−) patients, yielding high accuracy predictions. The study findings imply higher prevalence of cardiac involvement than previously anticipated, which may impact clinical disease management