Image Registration of In Vivo Micro-Ultrasound and Ex Vivo Pseudo-Whole Mount Histopathology Images of the Prostate: A Proof-of-Concept Study

Early diagnosis of prostate cancer significantly improves a patient's 5-year survival rate. Biopsy of small prostate cancers is improved with image-guided biopsy. MRI-ultrasound fusion-guided biopsy is sensitive to smaller tumors but is underutilized due to the high cost of MRI and fusion equipment. Micro-ultrasound (micro-US), a novel high-resolution ultrasound technology, provides a cost-effective alternative to MRI while delivering comparable diagnostic accuracy. However, the interpretation of micro-US is challenging due to subtle gray scale changes indicating cancer vs normal tissue. This challenge can be addressed by training urologists with a large dataset of micro-US images containing the ground truth cancer outlines. Such a dataset can be mapped from surgical specimens (histopathology) onto micro-US images via image registration. In this paper, we present a semi-automated pipeline for registering in vivo micro-US images with ex vivo whole-mount histopathology images. Our pipeline begins with the reconstruction of pseudo-whole-mount histopathology images and a 3-dimensional (3D) micro-US volume. Each pseudo-whole-mount histopathology image is then registered with the corresponding axial micro-US slice using a two-stage approach that estimates an affine transformation followed by a deformable transformation. We evaluated our registration pipeline using micro-US and histopathology images from 18 patients who underwent radical prostatectomy. The results showed a Dice coefficient of 0.94 and a landmark error of 2.7 mm, indicating the accuracy of our registration pipeline. This proof-of-concept study demonstrates the feasibility of accurately aligning micro-US and histopathology images. To promote transparency and collaboration in research, we will make our code and dataset publicly available

Bladder clot and prostate mass morcellation and enucleation

Objective: Advanced age, anticoagulation, and frailty are common risk factors for gross hematuria with clot obstruction [1,2]. Conservative management is preferred, however, patients with refractory bleeding frequently require invasive interventions. We present a case of endoscopic clot evacuation assisted by morcellation after failed conservative management. We aim to demonstrate the safety and efficacy of this technique as an alternative to open cystotomy. Patients and surgical procedure: Our patient is a 90-year-old male with a history of atrial fibrillation (on anticoagulation), metastatic prostate cancer on androgen deprivation therapy, recurrent hematuria, and urinary retention managed with suprapubic tube. He presented to the emergency department with gross hematuria and clot retention (Fig. 1) Initial management with cessation of anticoagulation, cystoscopy, and clot evacuation failed due to the size and density of blood products. The patient declined open clot evacuation due to concern about morbidity and opted for repeat endoscopic intervention. We used a 550-micron holmium laser fiber to release the prostate and adherent clot. Next, the clot was morcellated with Wolf® Piranha™ system at 2500 RPM (Fig. 2). Morcellation time was 35 min due to a lack of engagement and suction leading to divots which decreased efficiency. Care must be taken to optimize visualization during clot morcellation as poor visualization is a common cause of bladder injury during morcellation. After evacuation, excellent hemostasis was achieved. Results: Postoperatively, continuous bladder irrigation was weaned on day 1, and catheter was removed on day 2. The patient was discharged without any notable complications. Final pathology of morcellated tissue was 446 mL of poorly differentiated prostatic adenocarcinoma admixed with clot. Conclusion: Large volume clot removal assisted by morcellation represents a safe endoscopic alternative to open clot evacuation when other techniques fail. Care must be taken to ensure good visibility, distended bladder, and anticipation of differing tissue characteristics while morcellating

Metabolic Syndrome and Nephrolithiasis Risk: Should the Medical Management of Nephrolithiasis Include the Treatment of Metabolic Syndrome?

This article reviews the relationship between metabolic syndrome (MetS) and nephrolithiasis, as well as the clinical implications for patients with this dual diagnosis. MetS, estimated to affect 25% of adults in the United States, is associated with a fivefold increase in the risk of developing diabetes, a doubling of the risk of acquiring cardiovascular disease, and an increase in overall mortality. Defined as a syndrome, MetS is recognized clinically by numerous constitutive traits, including abdominal obesity, hypertension, dyslipidemia (elevated triglycerides, low high-density lipoprotein cholesterol), and hyperglycemia. Urologic complications of MetS include a 30% higher risk of nephrolithiasis, with an increased percentage of uric acid nephrolithiasis in the setting of hyperuricemia, hyperuricosuria, low urine pH, and low urinary volume. Current American Urological Association and European Association of Urology guidelines suggest investigating the etiology of nephrolithiasis in affected individuals; however, there is no specific goal of treating MetS as part of the medical management. Weight loss and exercise, the main lifestyle treatments of MetS, counter abdominal obesity and insulin resistance and reduce the incidence of cardiovascular events and the development of diabetes. These recommendations may offer a beneficial adjunctive treatment option for nephrolithiasis complicated by MetS. Although definitive therapeutic recommendations must await further studies, it seems both reasonable and justifiable for the urologist, as part of a multidisciplinary team, to recommend these important lifestyle changes to patients with both conditions. These recommendations should accompany the currently accepted management of nephrolithiasis

Blind loop: rare but important surgical complication

BACKGROUND: Surgical complications worldwide are dreaded by both patients and physicians alike. They represent significant and serious morbidity and mortality, and contribute substantially to increased costs of healthcare. CASE PRESENTATION: Our Case Report describes a 65yo Caucasian man with an extensive operative history for Crohn’s disease, including 4 laparotomies with small bowel resections to ameliorate small bowel obstructions. He presented with signs and symptoms of a chronic draining sinus, but was found to have a Blind Loop of bowel. This finding is believed to be the result of a surgical complication. CONCLUSION: While the Case Reports discusses this particular patient presentation, the paper defines, describes and offers treatment strategies for Enterocutaneous Fistulas (ECF). We offer aim to add Blind Loop to the differential diagnosis when presented with a patient with signs and symptoms of ECF