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Computerized Medical Imaging and... Jun 2024Bio-medical image segmentation models typically attempt to predict one segmentation that resembles a ground-truth structure as closely as possible. However, as medical...
BACKGROUND AND OBJECTIVES
Bio-medical image segmentation models typically attempt to predict one segmentation that resembles a ground-truth structure as closely as possible. However, as medical images are not perfect representations of anatomy, obtaining this ground truth is not possible. A surrogate commonly used is to have multiple expert observers define the same structure for a dataset. When multiple observers define the same structure on the same image there can be significant differences depending on the structure, image quality/modality and the region being defined. It is often desirable to estimate this type of aleatoric uncertainty in a segmentation model to help understand the region in which the true structure is likely to be positioned. Furthermore, obtaining these datasets is resource intensive so training such models using limited data may be required. With a small dataset size, differing patient anatomy is likely not well represented causing epistemic uncertainty which should also be estimated so it can be determined for which cases the model is effective or not.
METHODS
We use a 3D probabilistic U-Net to train a model from which several segmentations can be sampled to estimate the range of uncertainty seen between multiple observers. To ensure that regions where observers disagree most are emphasised in model training, we expand the Generalised Evidence Lower Bound (ELBO) with a Constrained Optimisation (GECO) loss function with an additional contour loss term to give attention to this region. Ensemble and Monte-Carlo dropout (MCDO) uncertainty quantification methods are used during inference to estimate model confidence on an unseen case. We apply our methodology to two radiotherapy clinical trial datasets, a gastric cancer trial (TOPGEAR, TROG 08.08) and a post-prostatectomy prostate cancer trial (RAVES, TROG 08.03). Each dataset contains only 10 cases each for model development to segment the clinical target volume (CTV) which was defined by multiple observers on each case. An additional 50 cases are available as a hold-out dataset for each trial which had only one observer define the CTV structure on each case. Up to 50 samples were generated using the probabilistic model for each case in the hold-out dataset. To assess performance, each manually defined structure was matched to the closest matching sampled segmentation based on commonly used metrics.
RESULTS
The TOPGEAR CTV model achieved a Dice Similarity Coefficient (DSC) and Surface DSC (sDSC) of 0.7 and 0.43 respectively with the RAVES model achieving 0.75 and 0.71 respectively. Segmentation quality across cases in the hold-out datasets was variable however both the ensemble and MCDO uncertainty estimation approaches were able to accurately estimate model confidence with a p-value < 0.001 for both TOPGEAR and RAVES when comparing the DSC using the Pearson correlation coefficient.
CONCLUSIONS
We demonstrated that training auto-segmentation models which can estimate aleatoric and epistemic uncertainty using limited datasets is possible. Having the model estimate prediction confidence is important to understand for which unseen cases a model is likely to be useful.
PubMed: 38878632
DOI: 10.1016/j.compmedimag.2024.102403 -
JAMA Network Open Jun 2024Although tissue-based gene expression testing has become widely used for prostate cancer risk stratification, its prognostic performance in the setting of clinical care...
IMPORTANCE
Although tissue-based gene expression testing has become widely used for prostate cancer risk stratification, its prognostic performance in the setting of clinical care is not well understood.
OBJECTIVE
To develop a linkage between a prostate genomic classifier (GC) and clinical data across payers and sites of care in the US.
DESIGN, SETTING, AND PARTICIPANTS
In this cohort study, clinical and transcriptomic data from clinical use of a prostate GC between 2016 and 2022 were linked with data aggregated from insurance claims, pharmacy records, and electronic health record (EHR) data. Participants were anonymously linked between datasets by deterministic methods through a deidentification engine using encrypted tokens. Algorithms were developed and refined for identifying prostate cancer diagnoses, treatment timing, and clinical outcomes using diagnosis codes, Common Procedural Terminology codes, pharmacy codes, Systematized Medical Nomenclature for Medicine clinical terms, and unstructured text in the EHR. Data analysis was performed from January 2023 to January 2024.
EXPOSURE
Diagnosis of prostate cancer.
MAIN OUTCOMES AND MEASURES
The primary outcomes were biochemical recurrence and development of prostate cancer metastases after diagnosis or radical prostatectomy (RP). The sensitivity of the linkage and identification algorithms for clinical and administrative data were calculated relative to clinical and pathological information obtained during the GC testing process as the reference standard.
RESULTS
A total of 92 976 of 95 578 (97.2%) participants who underwent prostate GC testing were successfully linked to administrative and clinical data, including 53 871 who underwent biopsy testing and 39 105 who underwent RP testing. The median (IQR) age at GC testing was 66.4 (61.0-71.0) years. The sensitivity of the EHR linkage data for prostate cancer diagnoses was 85.0% (95% CI, 84.7%-85.2%), including 80.8% (95% CI, 80.4%-81.1%) for biopsy-tested participants and 90.8% (95% CI, 90.5%-91.0%) for RP-tested participants. Year of treatment was concordant in 97.9% (95% CI, 97.7%-98.1%) of those undergoing GC testing at RP, and 86.0% (95% CI, 85.6%-86.4%) among participants undergoing biopsy testing. The sensitivity of the linkage was 48.6% (95% CI, 48.1%-49.1%) for identifying RP and 50.1% (95% CI, 49.7%-50.5%) for identifying prostate biopsy.
CONCLUSIONS AND RELEVANCE
This study established a national-scale linkage of transcriptomic and longitudinal clinical data yielding high accuracy for identifying key clinical junctures, including diagnosis, treatment, and early cancer outcome. This resource can be leveraged to enhance understandings of disease biology, patterns of care, and treatment effectiveness.
Topics: Humans; Male; Prostatic Neoplasms; Middle Aged; Aged; Transcriptome; Electronic Health Records; Cohort Studies; Longitudinal Studies; Prostatectomy; Information Storage and Retrieval; Algorithms
PubMed: 38874922
DOI: 10.1001/jamanetworkopen.2024.17274 -
BJUI Compass Jun 2024To investigate the racial and socioeconomic (income) differences in receipt of and time to surgical care for urinary incontinence (UI) and erectile dysfunction (ED)...
OBJECTIVES
To investigate the racial and socioeconomic (income) differences in receipt of and time to surgical care for urinary incontinence (UI) and erectile dysfunction (ED) occurring post-radical prostatectomy (RP) and/or radiation therapy (RT).
MATERIALS AND METHODS
Utilizing the Medicare Standard Analytical Files (SAF), a retrospective cohort study was performed on data of patients diagnosed with prostate cancer (PCa) from 2015 to 2021. Patients who underwent RP and/or RT and who subsequently developed UI and/or ED were grouped into four cohorts: RP-ED, RP-UI, RT-ED and RT-UI. County-level median household income was cross-referenced with SAF county codes, classified into income quartiles, and used as a proxy for patient income status. The rate of surgical care was compared between groups using two-sample t-test and log-rank test. Cox proportional hazards modelling was used to determine covariate-adjusted impact of race on time to surgical care.
RESULTS
The rate of surgical care was 6.8, 3.61 3.07, and 1.54 per 100 person-years for the RP-UI, RT-UI, RP-ED, and RT-ED cohorts, respectively. Cox proportional regression analysis revealed that Black men were statistically more likely to receive ED surgical care (RP-ED AHR:1.79, 95% CI:1.49-2.17; RT-ED AHR:1.50, 95% CI:1.11-2.01), but less likely to receive UI surgical care (RP-UI AHR:0.80, 95% CI:0.67-0.96) than White men, in all cohorts except RT-UI. Surgical care was highest among Q1 (lowest income quartile) patients in all cohorts except RT-UI.
CONCLUSIONS
Surgical care for post-PCa treatment complications is low, and significantly impacted by racial and socioeconomic (income) differences. Prospective studies investigating the basis of these results would be insightful.
PubMed: 38873355
DOI: 10.1002/bco2.342 -
Cancer Treatment and Research... Jun 2024Recently, some evidence emphasized the value of MSH2 and MSH6 inactivation and their hypermutation in predicting different cancers. The present consideration is to...
BACKGROUND
Recently, some evidence emphasized the value of MSH2 and MSH6 inactivation and their hypermutation in predicting different cancers. The present consideration is to evaluate the value of MSH2 and MSH6 protein deficient studied by the immunohistochemistry (IHC) method and the tumor behaviors and aggressiveness in prostatic carcinoma.
METHODS
This cross-sectional study was performed on 80 examples extricated from patients who endured prostate cancer and were planned for radical prostatectomy surgery. The expression levels of the genes were studied by IHC staining.
RESULTS
The deficiency in MSH2 and MSH6 expression was revealed in 10.0 % and 11.3 % of patients respectively, while the reduction of simultaneous expression in two genes was found in 6.2 % of patients. In the two subgroups with and without MSH2 and/or MSH6 staining, there was no difference in patients' mean age and history of prostate cancer. There was also no difference in tumor-related behaviors including combined Gleason grade group, tumor stage, vascular invasion, perineural invasion, and prostatic capsular invasion between the groups with and without gene loss.
CONCLUSION
The evaluation of the deficient rate of two genes among patients with prostate cancer to predict the tumor grade and its aggressive behavior needs further study in every population.
PubMed: 38870667
DOI: 10.1016/j.ctarc.2024.100826 -
International Journal of Surgery Case... Jul 2024Iatrogenic injury to the cavernous nerve and its branches results in post-operative erectile dysfunction in up to 85 % of men undergoing a radical prostatectomy. Here,...
INTRODUCTION AND IMPORTANCE
Iatrogenic injury to the cavernous nerve and its branches results in post-operative erectile dysfunction in up to 85 % of men undergoing a radical prostatectomy. Here, we describe using a novel fluorescence-imaging system developed to detect nerve autofluorescence in a 66-year-old gentleman with prostate adenocarcinoma (Gleason Score 8 [4 + 4], prognostic group 4, indicating a highly-aggressive prostate cancer) who underwent laparotomic radical prostatectomy.
CASE PRESENTATION
Under general anesthesia, a laparotomic radical prostatectomy was performed using standard operative techniques. During surgery, a Dendrite imaging camera (Dendrite® Imaging, Germany) was employed to permit the surgical team to toggle freely between standard operating room (white) light and near-ultraviolet light (NUVL), with the specific purpose of enhancing visualization of the periprostatic nerve plexus, including the cavernous nerve and all its branches. Under white light, neither the cavernous nerve nor any of its branches were clearly visible. However, under NUVL, all fluoresced brightly and were easily avoided during prostate resection. Prostate resection proceeded with no intra-operative or post-operative complications. Moreover, upon one-month follow-up in the surgery clinic, the patient reported no erectile dysfunction, difficulties voiding, or other neurological or non-neurological complaints.
CLINICAL DISCUSSION
In this case, autofluorescence of the cavernous nerve and its branches during radical prostatectomy aided in their visualization and appeared to help prevent post-operative erectile dysfunction and all other potential neurological deficits.
CONCLUSION
Novel intra-operative technology enabling nerves to auto-fluoresce warrants larger series and comparative trials to assess its effectiveness reducing iatrogenic nerve injury during radical prostatectomies.
PubMed: 38870655
DOI: 10.1016/j.ijscr.2024.109820 -
European Urology Focus Jun 2024The introduction of the single-port (SP) robotic system has led to new approaches in robot-assisted radical prostatectomy (RARP), such as the transvesical (TV) approach,...
Preoperative Prostate Magnetic Resonance Imaging-based Anatomical Predictors of Early Urinary Continence Following Single-port Transvesical Robot-assisted Radical Prostatectomy.
BACKGROUND AND OBJECTIVE
The introduction of the single-port (SP) robotic system has led to new approaches in robot-assisted radical prostatectomy (RARP), such as the transvesical (TV) approach, offering high rates of early urinary continence. While previous studies of SP TV RARP have identified perioperative factors influencing continence outcomes, the impact of anatomical factors remains unexplored. This study aims to assess magnetic resonance imaging (MRI)-based anatomical predictors of urinary continence after SP TV RARP.
METHODS
A retrospective analysis of consecutive SP TV RARP cases (November 2020 to June 2023) with preoperative prostate MRI was performed. Two urogenital radiologists independently evaluated ten anatomical parameters to distinguish patients achieving urinary continence within 1 wk and 3 mo. Nonparametric methods estimated receiver operating characteristic curves (area under the curve [AUC]) and inter-reader agreement.
KEY FINDINGS AND LIMITATIONS
In 120 cases, 40% achieved continence within 1 wk, rising to 71.7% by 3 mo. Membranous urethra length (MUL) alone was significantly associated with continence at 3 mo (AUC: 0.67, p = 0.003). At 1 wk, several parameters, including anteroposterior diameter of the prostate, coronal membranous urethra length, prostate volume, and transverse diameter of the prostate, showed promise in predicting continence.
CONCLUSIONS AND CLINICAL IMPLICATIONS
A longer preoperative MUL was significantly associated with better odds of an early return to urinary continence after SP TV RARP. Each 1-mm increase in coronal MUL was associated with a 27% increase in the odds of continence at 3 mo. This information can aid in patient counseling and expectations preoperatively.
PATIENT SUMMARY
Urinary incontinence is a common outcome after prostate cancer surgery, particularly in the early months. Recently, the single-port (SP) robotic system has emerged, localizing surgery to the diseased area. With the SP robot, accessing the prostate via the bladder leads to high rates of early continence. Our study reveals that the longer the urethral portion beneath the prostate, the higher the likelihood of regaining continence within 3 mo after surgery.
PubMed: 38866663
DOI: 10.1016/j.euf.2024.05.025 -
American Journal of Men's Health 2024This study assesses the morphological effectiveness of benign prostatic hyperplasia (BPH) surgery using multislice spiral computed tomography three-dimensional imaging...
This study assesses the morphological effectiveness of benign prostatic hyperplasia (BPH) surgery using multislice spiral computed tomography three-dimensional imaging (CT3D) with urethral contrast. Twenty-five male patients with BPH and bladder outlet obstruction (BOO) who underwent bipolar transurethral resection of the prostate were selected. Preoperative and postoperative CT3D indicators of retrograde and voiding cystourethrography, including bladder neck diameter, length of the posterior urethra, and degree of prostate protrusion into the bladder and upper and lower diameter of the prostate were used to assess bladder neck and posterior urethra morphology and BOO severity. In addition, preoperative and postoperative International Prostate Symptom Scores and maximum urine flow rates were compared. Postoperative CT3D was used to evaluate changes following obstruction relief postsurgery. Preoperative CT3D indicated significant BOO, whereas postoperative imaging showed improved patency but with irregular posterior urethral lumens and varying degrees of residual glandular tissue. Comparative analysis of preoperative and postoperative bladder outlet metrics revealed significant changes ( < .05). Urethral contrast CT3D effectively visualizes the prostate, bladder neck, and prostatic urethra. It quantifies changes in the urethral lumen postsurgery, correlating the extent of posterior urethral lumen spaciousness with urinary flow rates.
Topics: Humans; Male; Prostatic Hyperplasia; Imaging, Three-Dimensional; Aged; Urinary Bladder Neck Obstruction; Urethra; Middle Aged; Transurethral Resection of Prostate; Contrast Media; Aged, 80 and over
PubMed: 38864148
DOI: 10.1177/15579883241258319 -
The World Journal of Men's Health May 2024To compare the perioperative and postoperative outcomes between traditional trans-vesical robot-assisted simple prostatectomy (TV-RASP) and the newly introduced...
PURPOSE
To compare the perioperative and postoperative outcomes between traditional trans-vesical robot-assisted simple prostatectomy (TV-RASP) and the newly introduced urethral-sparing (US) RASP.
MATERIALS AND METHODS
We retrospectively reviewed 42 patients who underwent TV-RASP (n=22) or US-RASP (n=20) performed by two experienced surgeons at two tertiary centers. Perioperative outcomes including operation time, estimated blood loss, length of hospital stay, and catheterization time were assessed. Postoperative outcomes were evaluated using the International Prostate Symptom Score (IPSS), quality of life (QoL), uroflowmetry parameters, Male Sexual Health Questionnaire-Ejaculation Dysfunction-Short Form (MSHQ-EjD-SF) scores, and maintenance of anterograde ejaculation.
RESULTS
This study analyzed 22 and 20 patients who underwent TV-RASP and US-RASP, respectively. Except for the TV-RASP group being older (70.0 years) than the US-RASP group (64.5 years) (p=0.028), no differences among other baseline characteristics existed. Perioperative outcomes indicated that hospital stay and catheterization time were significantly shorter in the US-RASP group than in the TV-RASP group (p<0.001). At postoperative month 1, the median IPSS and QoL scores were significantly better in the US-RASP group than in the TV-RASP group (p=0.001 and p=0.002, respectively). However, at months 6 and 12, no significant differences were noted in IPSS, QoL, maximum flow rate, and postvoid residual urine between the two groups. Sexually active patients in the US-RASP group maintained postoperative MSHQ-EjD functional and bother scores, whereas the TV-RASP group experienced a decline. Notably, 75.0% of patients in the US-RASP group preserved antegrade ejaculation, compared to only 20.0% in the TV-RASP group (p<0.001).
CONCLUSIONS
US-RASP is not inferior to TV-RASP in terms of functional outcomes. In addition, US-RASP yielded more rapid symptom improvements and preserved antegrade ejaculation than TV-RASP. However, larger prospective studies are required to confirm these findings and to further investigate the long-term efficacy and safety of US-RASP.
PubMed: 38863375
DOI: 10.5534/wjmh.240023 -
Ulusal Travma Ve Acil Cerrahi Dergisi =... Jun 2024Robot-Assisted Radical Prostatectomy (RARP) is increasingly becoming the standard surgical treatment for prostate cancer. While some risk factors for postoperative...
Efficiency of the estimation of physiologic ability and surgical stress (E-PASS) score in predicting postoperative complications after robot-assisted radical prostatectomy.
BACKGROUND
Robot-Assisted Radical Prostatectomy (RARP) is increasingly becoming the standard surgical treatment for prostate cancer. While some risk factors for postoperative complications of RARP have been identified, no scoring model that incorporates both preoperative physical status of the patient and intraoperative risk factors has been developed. The Estimation of Physiologic Ability and Surgical Stress (E-PASS) score was initially described to predict postoperative complications after gastrointestinal surgical procedures. This study aims to assess the effectiveness of the E-PASS score in predicting postoperative complications of RARP.
METHODS
A retrospective evaluation was conducted on 204 patients who underwent RARP between 2019 and 2022. Demographic data, parameters indicating patients' preoperative physical condition, and intraoperative risk factors were analyzed. The E-PASS score and subscores were calculated for each patient.
RESULTS
Of the patients, 164 (80.4%) were discharged without any postoperative complications (Group 1), and 40 (19.6%) experienced various degrees of complications (Group 2). Patients in Group 2 had higher rates of previous abdominal surgery, elevated Eastern Cooperative Oncology Group (ECOG) performance scores, longer surgical durations, and higher E-PASS scores. To assess the effectiveness of the Comprehensive Risk Score (CRS) as a predictive factor for postoperative complications, a receiver operating characteristic (ROC) curve was constructed with a 95% confidence interval (CI), and a cut-off value was established. The cut-off value for CRS was determined to be -0.0345 (area under the curve [AUC]=0.783, CI: 0.713-0.853; p<0.001). Patients with a CRS higher than the cut-off value had a 16.4 times higher rate of postoperative complications after RARP (95% CI: 5.58-48.5).
CONCLUSION
The E-PASS scoring model successfully predicts postoperative complications in patients undergoing RARP by using preoperative data about the physical status of the patient and surgical risk factors. The E-PASS score and its subscores could be utilized as objective criteria to determine the risk of postoperative complications before and immediately after surgery.
Topics: Humans; Prostatectomy; Male; Postoperative Complications; Retrospective Studies; Middle Aged; Robotic Surgical Procedures; Aged; Prostatic Neoplasms; Risk Factors; Risk Assessment; Predictive Value of Tests; ROC Curve
PubMed: 38863296
DOI: 10.14744/tjtes.2024.36332 -
Ulusal Travma Ve Acil Cerrahi Dergisi =... Jun 2024This study aims to compare the effects of 8 mmHg and 12 mmHg pneumoperitoneum (PNP) pressures on operative, postoperative, and anesthesiological parameters in... (Randomized Controlled Trial)
Randomized Controlled Trial
Anesthesiological and surgical perspectives on using 8 mmHg versus 12 mmHg pneumoperitoneum pressures during robotic radical prostatectomy: Results of a prospective randomized study.
BACKGROUND
This study aims to compare the effects of 8 mmHg and 12 mmHg pneumoperitoneum (PNP) pressures on operative, postoperative, and anesthesiological parameters in robot-assisted laparoscopic radical prostatectomy (RARP).
METHODS
In this prospective study, 43 patients undergoing RARP performed by a single experienced surgeon were randomly assigned to either the low-pressure group (8 mmHg - Group I) or the standard-pressure group (12 mmHg - Group II). We evaluated the operative and postoperative parameters from both urological and anesthesiological perspectives. All patients were treated using the AirSeal® insufflation system.
RESULTS
No statistically significant differences were observed between the groups in terms of console time, estimated blood loss, time to first flatus, or hospital length of stay. PNP was increased due to bleeding in six patients in the 8 mmHg group and two patients in the 12 mmHg group. Except for the heart rate measured five minutes after the initial incision, there were no observed differences between the groups in terms of blood pressure, ventilation, and administered medications. The heart rate was significantly lower in Group I (54.4 vs. 68.8, p=0.006). Additionally, during the surgery, the number of manipulations performed by the anesthesiologists, including drug administrations and ventilator management, was significantly lower in Group I (6.1 vs. 9.6, p=0.041).
CONCLUSION
In RARP, while the 8 mmHg PNP pressure does not demonstrate differences in operative parameters compared to the 12 mmHg pressure, it offers the advantage of requiring fewer anesthetic interventions, thus minimizing the impact on cardiovascular and respiratory systems.
Topics: Humans; Prostatectomy; Male; Prospective Studies; Middle Aged; Pneumoperitoneum, Artificial; Robotic Surgical Procedures; Aged; Laparoscopy; Pressure; Prostatic Neoplasms
PubMed: 38863292
DOI: 10.14744/tjtes.2024.78617