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Abstract: Background: Low morbidity has been advocated for cryoablation of small renal masses. Objectives: To assess negative perioperative outcomes of laparoscopic renal cryoablation (LRC) with ultrathin cryoprobes and patient, tumour, and operative risk factors for their development. Design, setting, and participants: Prospective collection of data on LRC in five centres. Intervention: LRC. Measurements: Preoperative morbidity was assessed clinically and the American Society of Anaesthesiologists (ASA) score was assigned prospectively. Charlson Comorbidity Index (CCI) and Charlson-Age Comorbidity Index (CACI) scores were retrospectively assigned. Negative outcomes were prospectively recorded and defined as any undesired event during the perioperative period, including complications, with the latter classed according to the Clavien system. Patient, tumour, and operative variables were tested in univariate analysis as risk factors for occurrence of negative outcomes. Significant variables (p <0.05) were entered in a step-forward multivariate logistic regression model to identify independent risk factors for one or more perioperative negative outcomes. The confidence interval was settled at 95%. Results and limitations: There were 148 procedures in 144 patients. Median age and tumour size were 70.5 yr (range: 32–87) and 2.6cm (range: 1.0–5.6), respectively. A laparoscopic approach was used in 145 cases (98%). Median ASA, CCI, and CACI scores were 2 (range: 1–3), 2 (range: 0–7), and 4 (range: 0–11), respectively. Comorbidities were present in 79% of patients. Thirty negative outcomes and 28 complications occurred in 25 (17%) and 23 (15.5%) cases, respectively. Only 20% of all complications were Clavien grade ≥3. Multivariate analysis showed that tumour size in centimetres, the presence of cardiac conditions, and female gender were independent predictors of negative perioperative outcomes occurrence. Receiver operator characteristic curve confirmed the tumour size cut-off of 3.4cm as an adequate predictor of negative outcomes. Conclusions: Perioperative negative outcomes and complications occur in 17 % and 15.5%, respectively, of cases treated by LRC with multiple ultrathin needles. Most of the complications are Clavien grade 1 or 2. The presence of cardiac conditions, female gender, and tumour size are independent prognostic factors for the occurrence of a perioperative negative outcome. [Copyright &y& Elsevier]

Purpose: To compare prostate shrinkage after transurethral microwave thermotherapy (TUMT) with calculated cell-kill.Materials and Methods: The calculated cell-kill from 33 males with benign prostatic hyperplasia (BPH) treated with TUMT according to the ProstaLund Feedback Treatment™ (PLFT) method was compared to the post-treatment prostate volume change. The prostate volume was estimated with three-dimensional transrectal ultrasound (3D-TRUS) planimetry at baseline, 3, 6, and 12 months follow-up. A paired t-test was used to test the statistical significance of differences between the cell-kill volume and the prostate volume change. Linear regression was used to infer a relationship between the cell-kill and the 3D-TRUS data. The reproducibility of the 3D-TRUS method was assessed in repeated measurements.Results: The mean prostate volume at baseline (N=33) was 56.1 cm3. After 3 (N=25), 6 (N=29) and 12 months (N=23), it was 45.5 cm3, 39.7 cm3, and 45.1 cm3, respectively. The corresponding average cell-kill volume was 16.4 cm3, 17.1 cm3, and 17.2 cm3, respectively. Predicted cell-kill volume was significantly larger than prostate shrinkage at 3 (p<0.0001), 6 (p=0.0002), and 12 months (p<0.0001), and showed a strong correlation at 3 and 6 months (r=0.74, p<0.0001). Correlation at 12 months was moderate (r=0.57, p=0.0041). Examination and investigation variability both averaged 2.5%.Conclusions: Cell-kill calculations of the PLFT method are proportional to the 3D-TRUS prostate shrinkage by a factor of 0.5 and have a precision of approximately ±10 cm3 for 90% of the patients during the first year after treatment. [Copyright &y& Elsevier]

Objective To determine whether the use of 3-dimensional (3D) imaging translates into a better surgical performance of naïve urologic laparoscopic surgeons during pyeloplasty (PY) and partial nephrectomy (PN) procedures. Materials and Methods Eighteen surgeons without any previous laparoscopic experience were randomly assigned to perform PY and PN in a porcine model using initially 2-dimensional (2D) and 3D laparoscopy. A surgical performance score was rated by an “expert” tutor through a modified 5-item global rating scale contemplating operative field view, bimanual dexterity, efficiency, tissue handling, and autonomy. Overall surgical time, complications, subjective perception of participating surgeons, and inconveniences related to the 3D vision were recorded. Results No difference in terms if operative time was found between 2D or 3D laparoscopy for both the PY ( P = .51) and the PN ( P = .28) procedures. A better rate in terms of surgical performance score was noted by the tutors when the study participants were using 3D vs 2D, for both PY (3.6 [0.8] vs 3.0 [0.4]; P = .034) and PN (3.6 [0.51] vs 3.15 [0.63]; P = .001). No complications occurred in any of the procedures. Most (77.2%) of the participating naïve laparoscopic surgeons had the perception that 3D laparoscopy was overall easier than 2D. Headache (18.1%), nausea (18.1%), and visual disturbance (18.1%) were the most common issues reported by the surgeons during 3D procedures. Conclusion Despite the absence of translation in a shorter operative time, the use of 3D technology seems to facilitate the surgical performance of naïve surgeons during laparoscopic kidney procedures on a porcine model. [ABSTRACT FROM AUTHOR]

Automatic diagnosis systems capable of handling multiple pathologies are essential in clinical practice. This study focuses on enhancing precise lesion localization, classification and delineation in transurethral resection of bladder tumor (TURBT) to reduce cancer recurrence. Despite deep learning models success, medical applications face challenges like small and limited datasets and poor image characterization, including the absence lack of color/texture modeling. To address these issues, three solutions are proposed: (1) an improved texture-constrained version of the pix2pixHD cGAN for data augmentation, addressing the tradeoff of generating high-quality images with enough stochasticity using the Fréchet Inception Distance (FID) measure. (2) Introducing the Multiple Mask and Boundary Scoring R-CNN (MM&BS R-CNN), a new mask sub-net scheme where multiple masks are generated from the different levels of the mask sub-net pipeline, improving segmentation accuracy by including a new scoring module to refine object boundaries. (3) A novel accelerated training strategy based on the SGD optimizer with the second momentum. Experimental results show significant mAP improvements: the data generation scheme improves by more than 12 %; MM&BS R-CNN proposed architecture is responsible for an improvement of about 1.25 %, and the training algorithm based on the second-order momentum increases mAP by 2–3 %. The simultaneous use of all three proposals improved the state-of-the-art mAP by 17.44 %. • Improved instance segmentation network for bladder cancer addressing multi-pathology classification and the critical aspect of bad cancer resection that leads to cancer recurrence. • Data augmentation using an texture-constrained version of the pix2pixHD cGAN, generating high-quality images with enough stochasticity to promote generalization capability in limited datasets. • Increase of about 2-3% in mAP by training with the proposed second-order momentum optimizer. • Increase of 17.44% in mAP compared with BMask R-CNN. [ABSTRACT FROM AUTHOR]

This paper confronts two approaches to classify bladder lesions shown in white light cystoscopy images when using small datasets: the classical one, where handcrafted-based features feed pattern recognition systems and the modern deep learning-based (DL) approach. In between, there are alternative DL models that had not received wide attention from the scientific community, even though they can be more appropriate for small datasets such as the human brain motivated capsule neural networks (CapsNets). However, CapsNets have not yet matured hence presenting lower performances than the most classic DL models. These models require higher computational resources, more computational skills from the physician and are more prone to overfitting, making them sometimes prohibitive in the routine of clinical practice. This paper shows that carefully handcrafted features used with more robust models can reach similar performances to the conventional DL-based models and deep CapsNets, making them more useful for clinical applications. Concerning feature extraction, it is proposed a new feature fusion approach for Ta and T1 bladder tumor detection by using decision fusion from multiple classifiers in a scheme known as stacking of classifiers. Three Neural Networks perform classification on three different feature sets, namely: Covariance of Color Histogram of Oriented Gradients, proposed in the ambit of this paper; Local Binary Patterns and Wavelet Coefficients taken from lower scales. Data diversity is ensured by a fourth Neural Network, which is used for decision fusion by combining the outputs of the ensemble elements to produce the classifier output. Both Feed Forward Neural Networks and Radial Basis Functions are used in the experiments. Contrarily, DL-based models extract automatically the best features at the cost of requiring huge amounts of training data, which in turn can be alleviated by using the Transfer Learning (TL) strategy. In this paper VGG16 and ResNet-34 pretrained in ImageNet were used for TL, slightly outperforming the proposed ensemble. CapsNets may overcome CNNs given their ability to deal with objects rotational invariance and spatial relationships. Therefore, they can be trained from scratch in applications using small amounts of data, which was beneficial for the current case, improving accuracy from 94.6% to 96.9%. [ABSTRACT FROM AUTHOR]

Abstract: Context: Thermal ablation of small renal tumours is an established treatment modality in selected cases. Many groups have published their experiences. However, a major drawback of most of the previously published reviews and meta-analyses is their retrospective nature, the heterogeneity of included studies, and the limitations of a short-term oncologic follow-up. For those reasons, firm conclusions are still lacking. Objective: To assess the best combination of ablation technique and approach in those renal tumours deemed suitable for ablation. Evidence acquisition: A PubMed search was performed (up to December 2010) of the world literature on thermal ablation of renal tumours. To assess oncologic outcomes, we selected reports with a minimum follow-up of 36 mo and with appropriately documented pathologic results specifying the number of biopsy-proven renal cell carcinomas (RCCs). To assess perioperative complications we selected series with substantial caseloads of at least 70 cases and comparative series among techniques. Evidence synthesis: All long-term series of thermal ablation for small renal masses show a recurrence-free survival (RFS) of 84–94% with a cancer-specific survival (CSS) of 89–100%. Some cases with previous (partial) nephrectomy for RCC are included in the series with lowest RFS and CSS. No distinct differences exist between radiofrequency ablation (RFA) and cryoablation (CA). Initial failure and overall complication rates are higher for the percutaneous approach compared with laparoscopy. The major complication rate is slightly lower, ultimate survival is comparable, and length of stay and patient convalescence are favourable for the percutaneous approach, regardless of the modality. Conclusions: Low-quality evidence shows that CA or RFA modalities have a low major-complication rate, preserve renal function, and provide acceptable, oncologic, long-term outcomes. The percutaneous approach has a high rate of initial failure, but seems to be less costly. [Copyright &y& Elsevier]

Abstract: Context: The increasing incidence of localised renal cell carcinoma (RCC) over the last 3 decades and controversy over mortality rates have prompted reassessment of current treatment. Objective: To critically review the recent data on the management of localised RCC to arrive at a general consensus. Evidence acquisition: A Medline search was performed from January 1, 2004, to May 3, 2011, using renal cell carcinoma, nephrectomy (Medical Subject Heading [MeSH] major topic), surgical procedures, minimally invasive (MeSH major topic), nephron-sparing surgery, cryoablation, radiofrequency ablation, surveillance, and watchful waiting. Evidence synthesis: Initial active surveillance (AS) should be a first treatment option for small renal masses (SRMs) <4cm in unfit patients or those with limited life expectancy. SRMs that show fast growth or reach 4cm in diameter while on AS should be considered for treatment. Partial nephrectomy (PN) is the established treatment for T1a tumours (<4cm) and an emerging standard treatment for T1b tumours (4–7cm) provided that the operation is technically feasible and the tumour can be completely removed. Radical nephrectomy (RN) should be limited to those cases where the tumour is not amenable to nephron-sparing surgery (NSS). Laparoscopic radical nephrectomy (LRN) has benefits over open RN in terms of morbidity and should be the standard of care for T1 and T2 tumours, provided that it is performed in an advanced laparoscopic centre and NSS is not applicable. Open PN, not LRN, should be performed if minimally invasive expertise is not available. At this time, there is insufficient long-term data available to adequately compare ablative techniques with surgical options. Therefore ablative therapies should be reserved for carefully selected high surgical risk patients with SRMs <4cm. Conclusions: The choice of treatment for the patient with localised RCC needs to be individualised. Preservation of renal function without compromising the oncologic outcome should be the most important goal in the decision-making process. [Copyright &y& Elsevier]

Abstract: The diagnostic problems in the subtyping of renal tumors were evaluated by a panel of five pathologists studying a set of selected tumors. Five pathologists independently assessed a single hematoxylin-and-eosin (HE)-stained slide from 28 selected renal tumors. After this independent assessment, the pathologists reevaluated and discussed all discordant cases. Additional HE-stained sections and immunohistochemically (IHC) stained slides were available. The generalized kappa for interobserver agreement was calculated. After independent assessment of the HE-stained slides, the five pathologists unanimously reached an agreement in the decision between malignant and benign in 82% of the cases. Fifty percent of the cases were correctly subclassified. The overall generalized kappa value for the five pathologists was 0.320 (CI 95% 0.090–0.551), which is considered a moderate agreement. A 100% agreement was reached for all 28 cases after examination of more slides from different tumor areas and IHC-stained sections. An accurate histologic distinction between benign and malignant renal tumors is possible on one HE-stained section. Correct assignment of the subtype is difficult on one slide alone and relies on IHC-markers and additional slides. Tumors composed of an eosinophilic cell type and tumors with a papillary growth pattern were the major causes of an incorrect diagnosis on an HE-stained section alone. [Copyright &y& Elsevier]

Abstract: Background: Fine needle aspiration (FNA) cytology is under consideration as an auxiliary preoperative diagnostic technique in the diagnosis of renal masses. However, reports for FNA are contradictory with regard to diagnostic accuracy and applicability. Objective: To evaluate the diagnostic accuracy and reproducibility of FNA from renal masses. Design: FNAs performed in-bench (hematoxylin and eosin [H&E] stains) from 66 consecutive renal tumours (58 malignant and 8 benign tumours) were presented twice with a 6-mo interval to five pathologists with little experience in renal cytology. Pathologists were blinded for the results of the first round as well for the surgical specimen. The FNAs were stained for Papanicolaou and Giemsa. Measurements: Diagnostic accuracy, concordance between smears and surgical specimens, and the generalized kappa for interobserver/intraobserver agreement were calculated. Results and limitations: The number of nondiagnostic and nonconclusive cases ranged from 5–14% in the first and 3–8% in the second round. Overall accuracy varied between 73–89% and 71–91% for the first and second round, respectively. Sensitivity (72–97%) and positive predictive value (PPV) (93–100%) to classify a malignant tumour in both rounds was high. Sensitivity (25–100%) and PPV (28–100%) to classify a benign tumour was lower with a wide confidence interval. Overall concordance in subtyping ranged from 39–70% in the first, and from 52–74% in the second round. Interobserver agreement ranged from fair (κ =0.039) to substantial (κ = 0.540) for the different subtypes. The intraobserver agreement (mean κ = 0.357, CI 95%=0.304–0.411) was moderate for all pathologists. The low number of benign tumours in this study precludes sound statements regarding the diagnostic accuracy of FNA to classify benignity. Conclusion: Despite the lack of experience in renal cytology, all pathologists showed a high diagnostic yield and good overall accuracy in distinguishing between malignant and benign tumours. Concordance in subtyping varied widely among pathologists and was reliable only for clear cell renal cell carcinoma (ccRCC). These results suggest that FNA may have a potential role in the diagnosis of renal tumours although its value in subtyping was limited in our setting. [Copyright &y& Elsevier]

Abstract: Context: Laparoscopic retroperitoneal lymph node dissection (L-RPLND) is not recommended as standard tool in European Association of Urology (EAU) guidelines. Objective: To update the role of L-RPLND in patients with clinical stage I nonseminomatous germ cell tumour (NSGCT) compared to open retroperitoneal lymph node dissection (O-RPLND). Evidence acquisition: A systematic literature search from 1992 to 2008 was performed in Medline, EMBASE, and Cochrane. The largest series from each group was considered. Comparative analysis was based on raw data of series published in 2000 and later. Evidence synthesis: Results of >800 patients treated by L-RPLND reported in 34 articles were analyzed. Lymph node dissection (LND) was based on modified templates, removing an average of 16 (5–36) lymph nodes. At experienced centres, complication rates were 15.6% (9.4–25.7), including 2% (0–5) retrograde ejaculation and 1.7% (0–6) reintervention. Operating room times are longer compared to O-RPLND (204 vs 186min). Five publications with a follow-up of 63 (36–89) mo include 557 patients. One hundred twenty-six of 140 (90%) patients with positive nodes (25%, range: 17–38) received adjuvant chemotherapy, resulting in a local relapse rate of 1.4% (0.7–2.3) with no in-field recurrence; rate of distant relapses was 3.3% (1.8–4.6), including one port-site metastasis; and rate of biochemical failure was 0.9% (0.7–2.3). Two of 14 patients with positive nodes (pN1) who did not receive adjuvant chemotherapy relapsed, both 8 mo after surgery, and were salvaged by chemotherapy. Compared with O-RPLND, there was no difference in relapse rates, percentage of patients receiving chemotherapy (29% vs 31%), chemotherapy (CTx) cycles per cohort (0.6), rate of salvage surgery (1.2% vs 1.5%), and patients with no evidence of disease (NED; 100% vs 99.7%). Conclusions: L-RPLND offers similar staging accuracy and long-term outcome to O-RPLND. In a late series of experienced L-RPLND centres, there was a trend towards fewer complications. L-RPLND represents a valuable tool for experienced laparoscopic surgeons. Further studies must focus on the curative potential of the procedure in pathologic stage IIA. [Copyright &y& Elsevier]

Abstract: Objective: The diagnostic accuracy of in-bench core biopsies (CBs) from renal masses, and the interobserver and intraobserver variability in pathological subtyping of renal tumors were assessed. Methods: We performed two CBs in 62 consecutive renal masses suspected for renal cell carcinoma (RCC), obtained after radical or partial nephrectomy and, in one case, after autopsy. Routine hematoxylin-eosin (HE)–stained sections from each CB were evaluated by five pathologists on two occasions. The surgical specimen was the reference standard. Diagnostic accuracy and the generalized kappa for intraobserver and interobserver agreement were calculated. Results: Five tumors were benign and 57 malignant. Eight percent to 16% of the CBs were considered inadequate for diagnosis. In 0–8% of the cases, the pathologist could not discriminate between a benign or malignant tumor. Overall accuracy ranged from 77% to 90%. Sensitivity (79–100%) and positive predictive value (100%) were high with narrow 95% confidence interval (95%CI). Specificity (100%) was high but negative predictive value (29%–100%) varied, with wide 95% CI. Interobserver agreement was fair to almost perfect (κ=−0.010 to 0.830) for the different subtypes. In 64–81% of the CBs, the subtype was correctly classified. Intraobserver agreement was substantial (mean κ=0.628) for all pathologists. Conclusion: Diagnostic accuracy of CBs was high, with a diagnostic yield varying between 84% and 92%. Pathological subtyping of CBs was highly reproducible with the exception of the chromophobe renal cell carcinoma, which was problematic on HE-stained sections only. [Copyright &y& Elsevier]

Abstract: Objective: To up-date the 2001 version of the EAU testicular cancer guidelines. Methods: A non-structured literature review until January 2005 using the MEDLINE database has been performed. Literature has been classified according to evidence-based medicine levels. Results: Testicular cancer is a highly curable disease. Excellent cure rates have been achieved by standardization of treatment, interdisciplinary management, and tremendous success in performing clinical trials. Currently, the aims of testicular cancer treatment are as follows: for patients with low-stage disease, a reduction in treatment is proposed to improve long-term toxicity in these patients with unaltered life expectancy; for about 10% of patients with advanced disease and poor prognosis, intensification of treatment (including high-dose chemotherapy and new drugs as well as aggressive surgical approaches) is being investigated to improve long-term cure rates. Conclusion: Guidelines will improve clinical practice only if they are regularly updated. This update presents the state-of-the-art management of testicular cancer patients in 2005. [Copyright &y& Elsevier]

Objectives: To assess the efficacy and safety of the thermoexpandable hourglass-shaped nitinol prostatic stent in the treatment of patients with lower urinary tract symptoms due to bladder outlet obstruction.Methods: The stents were inserted in an outpatient setting under local anesthesia and direct vision. Five different stent lengths (2.0 to 4.0 cm) were used, depending on the length of the prostatic urethra. Assessment of voiding function and symptom scores was performed at baseline, directly after stent insertion, at 14 days, and 1, 3, 6, and 12 months after stent placement.Results: We enrolled 35 men in the trial. In 5 patients, insertion of the stent failed, mainly because of anatomical limitations. After all placement procedures, minimal temporary hematuria was observed. Spontaneous voiding was achieved in all patients, with immediate significant improvements in voiding parameters and symptom scores. The median indwelling time of the stent was 70 days. Kaplan-Meier survival analysis showed that at 14 days and at 3, 6, and 12 months, the stent was still in situ in 73%, 40%, 33%, and 23% of the patients, respectively. The main reason for removal of the stent was migration (93%), in most cases toward the bladder. Removal was uneventful in all but 1 case.Conclusions: The placement of the thermoexpandable hourglass-shaped nitinol stent results in relief of outflow obstruction and improvement of symptom scores. Because of the high migration rate, however, this stent design needs further improvement to be suitable for clinical practice. [ABSTRACT FROM AUTHOR]

Purpose: Longitudinal assessment of health-related quality of life (HRQoL) differences in patients with localized renal masses according to treatment strategy.Methods: Consecutive patients ≥ 18 years with localized renal masses treated with different approaches (open [O], laparoscopic [L], and percutaneous [P]) and modalities (radical nephrectomy [RN], nephron sparing surgery [NSS] and cryoablation [CA]). The SF-36, Functional Assessment of Cancer Therapy-Kidney Symptom Index-15 questionnaires and pain visual analog scale were completed pretreatment and at 1, 3, and 12 months posttreatment. Questionnaire results were stratified according to approach and treatment modality using a longitudinal multilevel linear regression model. Clinical patient and tumor characteristics, complications, and histopathology results were tested as confounders.Results: Ninety eight patients completed baseline and at least one follow-up questionnaires; 27.5%, 16.3%, 22.5%, 9.2%, 13.3%, and 11.2% patients received LNSS, ONSS, LRN, ORN, LCA, and PCA, respectively. Higher baseline SF-36 (3 domains) and Functional Assessment of Cancer Therapy-Kidney Symptom Index-15 scores were reported in L group compared with the O approach. Overall, HRQoL decreased at 1 month and gradually normalized to baseline level or higher at 1 year. For treatment modality at baseline, higher mean visual analog scale was observed in CA than RN group. A trend to decreased HRQoL was observed at 1 month for RN and NSS; thereafter, scores normalized to baseline levels or higher. Approach or treatment modality HRQoL did not change substantially when corrected for confounders.Conclusion: At short-term, HRQoL outcome favored minimally invasive treatment of RCC; at mid-term, these advantages were no longer apparent. This suggest that in selecting the best surgical treatment for the patient, oncological outcome should be the primary consideration as both approach and treatment modality result in similar HRQoL outcomes. [ABSTRACT FROM AUTHOR]