STEREOSCOPIC AUGMENTED REALITY FOR INTRAOPERATIVE GUIDANCE IN ROBOTIC SURGERY

Augmented reality (AR) technology is increasingly adopted in the surgical field and recently it has been also introduced in robotic-assisted urologic surgery. This work describes the design and development of an AR intraoperative guide system with stereoscopic visualization (SAR, stereoscopic augmented reality) for the Da Vinci surgical robot. As a major novelty, the developed SAR system allows the surgeon to have the virtual 3D model of patient anatomy superimposed on the real field, without losing the stereoscopic view of the operative field. The workflow starts with the 3D model generation of the anatomical district of interest for surgery, from patient diagnostic imaging. Then, the 3D model is uploaded in the developed SAR application, navigated using a 3D space mouse, and superimposed to the operative field using computer vision algorithms. The SAR system was tested during 30 robot-assisted surgeries, including 20 partial nephrectomies, 1 kidney explant, and 9 radical prostatectomies. The SAR guidance system received overall great appreciation from surgeons and helped in localizing hidden structures, such as arteries or tumoral masses, increasing the understanding of surgical anatomy with depth perception, and facilitating intraoperative navigation. Future efforts will be addressed to improve the automatic superimposition of digital 3D models on the intraoperative view

The role of MRI in the detection of local recurrence: Added value of multiparametric approach and Signal Intensity/Time Curve analysis

Objective: The aim of the study was to evaluate the accuracy of multiparametric Magnetic Resonance Imaging (mpMRI) in the detection of local recurrence of prostate cancer (PCa) with the evaluation of the added value of signal Intensity/Time (UT) curves.Materials and methods: A retrospective analysis of 22 patients undergoing mpMRI from 2015 to 2020 was carried out, with the following inclusion criteria: performing trans rectal ultrasound guided biopsy within 3 months in the case of positive or doubtful findings and undergoing biopsy and/or clinical follow-up for 24 months in the case of negative results. The images were reviewed, and the lesions were catalogued according to morphological, diffusion-weighted imaging (DWI) and dynamic contrast-enhanced (DCE) features.Results: The presence of local recurrence was detected in 11/22 patients (50%). Greater diameter, hyperintensity on DWI, positive contrast enhancement and type 2/3 signal UT curves were more frequently observed in patients with local recurrence (all p < 0.05). Of all the sequences, DCE was the most accurate; however, the combination of DCE and DWI showed the best results, with a sensitivity of 100%, a specificity of 82%, a negative predictive value of 100% and a positive predictive value of 85%.Conclusions: The utility of MRI in the detection of local recurrence is tied to the multiparametric approach, with all sequences providing useful information. A combination of DCE and DWI is particularly effective. Moreover, specificity could be additionally improved using analysis of the signal UT curves

Multiparametric magnetic resonance imaging for the differential diagnosis between granulomatous prostatitis and prostate cancer: a literature review to an intriguing diagnostic challenge

Multiparametric magnetic resonance imaging (mpMRI) is currently the most effective diagnostic tool for detecting prostate cancer (PCa) and evaluating adenocarcinoma-mimicking lesions of the prostate gland, among which granulomatous prostatitis (GP) represents the most interesting diagnostic challenge. GP consists of a heterogeneous group of chronic inflammatory lesions that can be differentiated into four types: idiopathic, infective, iatrogenic, and associated with systemic granulomatous disease. The incidence of GP is growing due to the increase in endourological surgical interventions and the adoption of intravesical instillation of Bacillus Calmette-Guerin in patients with non-muscle invasive bladder cancer; therefore, the difficulty lies in identifying specific features of GP on mpMRI to avoid the use of transrectal prostate biopsy as much as possible

Clinical Application of the New Prostate Imaging for Recurrence Reporting (PI-RR) Score Proposed to Evaluate the Local Recurrence of Prostate Cancer after Radical Prostatectomy

Simple Summary The aim of the new Prostate Imaging for Recurrence Reporting (PI-RR) is a standardization in reporting to assess the likelihood of relapse after radical prostatectomy. Our study documented an excellent inter-observer agreement in recurrence reporting when using the PI-RR score, demonstrating a wide reproducibility, thus supporting the wide use of the PI-RR score in the clinical practice. The diagnostic accuracy was 68.4%, with the detection rate influenced by the PSA values. Overall, the PI-RR score globally showed a higher detection rate than PET/CT scans for local recurrence. Background: We investigated the diagnostic accuracy of the new Prostate Imaging for Recurrence Reporting (PI-RR) score and its inter-observer variability. Secondly, we compared the detection rate of PI-RR and PET and analyzed the correlation between Prostate Specific Antigen (PSA) levels and the PI-RR score. Methods: We included in the analysis 134 patients submitted to multiparametric magnetic resonance imaging for suspected local recurrence. The images were independently reviewed by two radiologists, assigning a value from 1 to 5 to the PI-RR score. Inter-observer agreement and diagnostic accuracy of the PI-RR score (compared to histopathological data, available for 19 patients) were calculated. The detection rate was compared to those of choline PET/CT (46 patients) and PSMA PET/CT (22 patients). The distribution of the PSA values in relation to the PI-RR scores was also analyzed. Results: The accuracy of the PI-RR score was 68.4%. The reporting agreement was excellent (K = 0.884, p < 0.001). The PI-RR showed a higher detection rate than choline PET/CT (69.6% versus 19.6%) and PSMA PET-CT (59.1% versus 22.7%). The analysis of the PSA distribution documented an increase in the PI-RR score as the PSA value increased. Conclusion: The excellent reproducibility of the PI-RR score supports its wide use in the clinical practice to standardize recurrence reporting. The detection rate of PI-RR was superior to that of PET, but was linked to the PSA level

Preservation of the smooth muscular internal (vesical) sphincter and of the proximal urethra during retropubic radical prostatectomy: A technical modification to improve the early recovery of continence

Objective: We describe our technique for preservation of the smooth muscular internal (vesical) sphincter and proximal urethra during radical retropubic prostatectomy (RRP) and present our preliminary clinical results. Materials and methods: The first steps of the prostatectomy reflect the standard RRP, while for the final phases the procedure continues in an anterograde manner with incision of the fibers of the detrusor muscle at the insertion of the ventral surface of the base of the prostate. At this level, the inner circular muscle of the bladder neck forms a sphincteric ring of smooth muscle that covers the longitudinally oriented smooth muscle component of the urethral musculature that extends distally to the verumontanum. These two proximal structures represent the internal sphincter that envelops and locks the proximal urethra. A blunt dissection is continued until the ring shaped vesical sphincter is separated from the prostate and the longitudinally oriented smooth muscle component of the urethral musculature is identified. The base of the prostate is then gently separated from the urethra and from the bladder until the maximal length of the urethral musculature is isolated and preserved. Results: After 30 initial set-up procedures, 40 consecutive patients with organ confined prostate cancer were submitted to radical retropubic prostatectomy with the preservation of muscular internal sphincter and the proximal urethra and compared to 40 patients submitted to standard procedure who served as control group. The group of patients submitted to our technical modification had a faster recovery of early continence than control group at 3 and 7 days. Conclusions: The described technique is a feasible and safe method for preservation of the internal urethral sphincter and allows improving the early recovery of urinary continence. The technique does not increase the rate of positive margins and the duration of the procedure

A case report of myoid gonadal stromal tumor treated with testis sparing surgery

Background: Myoid gonadal stromal tumors (MGST) of the testis represent a very rare finding. They are an emerging clinicopathological entity with specific features and identity. Nowadays, pathological recognition and diagnosis of MGSTs still represents a difficult challenge in most cases and there are no data of specific radiological features of these tumors expect for what seen by ultrasound; besides a conservative surgical approach was never performed to treat these lesions.Case Description: We present the case of a 20-year-old young man patient with symptoms suspicious for left varicocele, who was incidentally diagnosed with right testicular nodule via scrotal doppler ultrasound powered with contrast enhancement infusion and subsequent multiparametric magnetic resonance imaging. Then, lesion was treated through a testis sparing surgical approach. Histopathology, which included an external revision by an experienced Center, revealed a MGST with benign features, so that no further treatment was considered. 3 and 12 months after surgery a contrast enhancement ultrasound was performed with no evidence of recurrence.Conclusions: Previous reported cases of MGST were all difficult to characterize as a specific pathological entity; treatment usually applied was radical orchiectomy and a subsequent total Body CT was performed for staging purpose. No metastatic spreading nor recurrence were ever reported. Considering the favorable behavior of this pathologic entity, testis-sparing surgery with no radiation exposure during follow-up is a safe and effective strategy

Should we treat cN+ prostate cancer patients with surgery as part of multimodal approach?

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Current Strategies and Novel Therapeutic Approaches for Metastatic Urothelial Carcinoma

Urothelial carcinoma (UC) is a frequent cause of cancer-related deaths worldwide. Metastatic UC has been historically associated with poor prognosis, with a median overall survival of approximately 15 months and a 5-year survival rate of 18%. Although platinum-based chemotherapy remains the mainstay of medical treatment for patients with metastatic UC, chemotherapy clinical trials produced modest benefit with short-lived, disappointing responses. In recent years, the better understanding of the role of immune system in cancer control has led to the development and approval of several immunotherapeutic approaches in UC therapy, where immune checkpoint inhibitors have been revolutionizing the treatment of metastatic UC. Because of a better tumor molecular profiling, FGFR inhibitors, PARP inhibitors, anti-HER2 agents, and antibody drug conjugates targeting Nectin-4 are also emerging as new therapeutic options. Moreover, a wide number of trials is ongoing with the aim to evaluate several other alterations and pathways as new potential targets in metastatic UC. In this review, we will discuss the recent advances and highlight future directions of the medical treatment of UC, with a particular focus on recently published data and ongoing active and recruiting trials

Tolterodine extended release in the treatment of male oab/storage luts: A systematic review

Overactive bladder (OAB)/ storage lower urinary tract symptoms (LUTS) have a high prevalence affecting up to 90\% of men over 80 years. The role of sufficient therapies appears crucial. In the present review, we analyzed the mechanism of action of tolterodine extended-release (ER) with the aim to clarify its efficacy and safety profile, as compared to other active treatments of OAB/storage LUTS.A wide Medline search was performed including the combination of following words: "LUTS", "BPH", "OAB", "antimuscarinic", "tolterodine", "tolterodine ER". IPSS, IPSS storage sub-score and IPSS QoL (International Prostate Symptom Score) were the validated efficacy outcomes. In addition, the numbers of urgency episodes/24 h, urgency incontinence episodes/24 h, incontinence episodes/24 h and pad use were considered. We also evaluated the most common adverse events (AEs) reported for tolterodine ER.Of 128 retrieved articles, 109 were excluded. The efficacy and tolerability of tolterodine ER Vs. tolterodine IR have been evaluated in a multicenter, double-blind, randomized placebo controlled study in 1529 patients with OAB. A 71\% mean reduction in urgency incontinence episodes was found in the tolterodine ER group compared to a 60\% reduction in the tolterodine IR (p 29 cc) only the combination therapy significantly reduced 24-h voiding frequency (2.8 vs. 1.7 with tamsulosin, 1.4 with tolterodine, or 1.6 with placebo). A recent meta-analysis evaluating tolterodine in comparison with other antimuscarinic drugs demonstrated that tolterodine ER was significantly more effective than placebo in reducing micturition/24 h, urinary leakage episodes/24 h, urgency episodes/24 h, and urgency incontinence episodes/24 h. With regard to adverse events, tolterodine ER was associated with a good adverse event profile resulting in the third most favorable antimuscarinic. Antimuscarinic drugs are the mainstay of pharmacological therapy for OAB / storage LUTS; several studies have demonstrated that tolterodine ER is an effective and well tolerated formulation of this class of treatment.Tolterodine ER resulted effective in reducing frequency urgency and nocturia and urinary leakage in male patients with OAB/storage LUTS. Dry mouth and constipation are the most frequently reported adverse events