Interactive virtual 3D image reconstruction to assist renal surgery in patients with fusion anomalies of the kidney

Objective: Renal fusion anomalies are rare and usually present as horseshoe kidneys or crossed fusion ectopia. The complex renal anatomy seen in patients with these anomalies can present a challenge. Pre-operative planning is therefore paramount in the surgical management of these cases. Herein we report the use of interactive virtual three-dimensional (3D) reconstruction to aid renal surgery in patients with fusion anomalies of the kidney. Materials and Methods: A total of seven cases were performed between May 2016 and October 2020. 3D reconstruction was rendered by Innersight Labs using pre-operative computed tomography (CT) scans. Results: Five patients had malignant disease and two patients had benign pathology. Robotic and open operations were performed in four and three patients, respectively. Conclusion: The use of 3D reconstruction in the cases reported in this series allowed for the identification of variations in renal vasculature, and this informed the choice of operative approach. Oxford Centre for Evidence-Based Medicine Evidence Level: 4

A single centre service evaluation of the pre-biopsy mpMRI pathway for prostate cancer diagnosis

Aim: To study the efficacy and impact of the local pre-biopsy multiparametric magnetic resonance imaging (mpMRI) pathway for prostate cancer diagnosis. Methods: In this tertiary centre, 570 patients had prostate mpMRI across a 6-month period in 2019. A total of 511 patients met inclusion criteria for retrospective analysis. MRI reporting used the Prostate Imaging-Reporting and Data System (PI-RADS) v2.1. These were assessed alongside histological outcomes and diagnostic times. PI-RADS ⩾ 3 were recommended for biopsy consideration. Gleason scoring ⩾ 3 + 4 and 3 + 3 were used to define clinically and non-clinically significant prostate cancer (csPCa and nsPCa), respectively. Results: Overall prostate cancer prevalence was 40% (204/511, csPCa in 31.1%) with an overall biopsy avoidance of 32.1% (164/511). Around 69.7% (356/511) scored PI-RADS ⩾ 3 and 30.3% (155/511) scored PI-RADS 1–2. About 22.6% (35/155) of PI-RADS 1–2 patients proceeded to biopsy, demonstrating a negative predictive value of 91.43% for csPCa. For PI-RADS ⩾ 3 patients, 63.4% (197/312) of those biopsied had cancer (Gleason ⩾ 3 + 3), with 50% (156/312) demonstrating csPCa. Around 76.7% (102/133) of PI-RADS 5, 35.3% (48/136) of PI-RADS 4, 14.0% (6/43) of PI-RADS 3 and 8.6% (3/35) of PI-RADS 1–2 scores demonstrated csPCa. Overall median prostate-specific antigen (PSA) density was 0.15 ng/mL2 (IQR: 0.10–0.27/mL2). PSA density were significantly different across PI-RADS cohorts ( H = 118.8, p < 0.0001) and across all three biopsy outcomes ( H = 99.72, p < 0.0001). Only 34.3% (119/347) of biopsied patients met the NHS 28-day standard. MRI acquisition and reporting met the 14-day local standard in 96.1% (491/511). The biopsy was the most delayed component with a median of 20 days (IQR: 8–43). Conclusion: Pre-biopsy mpMRI with PI-RADS scoring safely avoided biopsy in almost one-third (32.1%) of patients. The use of PSA-density in risk stratifying PI-RADS 3 lesions has informed local practice in the period 2020–2021, with implementation of a PSA-density threshold of 0.12 ng/mL2. Biopsy scheduling issues and anaesthetic requirements need to be overcome to improve diagnostic waiting times. Level of evidence: 2

MRI-based nomogram for the prediction of prostate cancer diagnosis: A multi-centre validated patient–physician decision tool

Objective: To update and externally validate a magnetic resonance imaging (MRI)-based nomogram for predicting prostate biopsy outcomes with a multi-centre cohort. Materials and methods: Prospective data from five UK-based centres were analysed. All men were biopsy naïve. Those with missing data, no MRI, or prostate-specific antigen (PSA) > 30 ng/mL were excluded. Logistic regression analysis was used to confirm predictors of prostate cancer outcomes including MRI-PIRADS (Prostate Imaging Reporting and Data System) score, PSA density, and age. Clinically significant disease was defined as International Society of Urological Pathology (ISUP) Grade Group ⩾ 2 (Gleason grade ⩾ 7). Biopsy strategy included transrectal and transperineal approaches. Nomograms were produced using logistic regression analysis results. Results: A total of 506 men were included in the analysis with median age 66 (interquartile range (IQR) = 60–69). Median PSA was 6.6 ng/mL (IQR = 4.72–9.26). PIRADS ⩾ 3 was reported in 387 (76.4%). Grade Group ⩾ 2 detection was 227 (44.9%) and 318 (62.8%) for any cancer. Performance of the MRI-based nomogram was an area under curve (AUC) of 0.84 (95% confidence interval (CI) = 0.81–0.88) for Grade Group ⩾ 2% and 0.85 (95% CI = 0.82–0.88) for any prostate cancer. Conclusion: We present external validation of a novel MRI-based nomogram in a multi-centre UK-based cohort, showing good discrimination in identifying men at high risk of having clinically significant disease. These findings support this risk calculator use in the prostate biopsy decision-making process. Level of evidence: 2c

Testicular metastasis in prostate cancer: A rare case of testicular metastasis diagnosed with 68Ga-PSMA and review of the literature

Objective: Testicular metastasis in prostate cancer is a rare entity. We aimed to report the case where this rare condition was diagnosed with Gallium prostate-specific membrane antigen–positron emission tomography/computed tomography (68Ga-PSMA-PET/CT). Subjects/patients and methods: A 68-year-old male with a prostate adenocarcinoma presented with testicular metastasis. The patient was diagnosed with 68Ga-PSMA-PET/CT, and bilateral inguinal orchiectomy was performed. Herein, our case is presented, and a short review of the literature is carried out. Conclusion: 68Ga-PSMA-PET/CT is an effective imaging method for detecting rare metastases. Level of evidence: 4

Risk stratification for renal deterioration in the neurogenic bladder patient: Should it be a prerequisite for patient selection in video-urodynamic studies?

Objective: The aim of this retrospective review is to determine whether risk stratification for renal deterioration in neuro-urology patients is supported by urodynamic findings in terms of bladder safety and whether urodynamic findings affect bladder management in this patient group. The primary endpoints are to determine any statistically significant differences between the high and low risk for renal deterioration groups in terms of urodynamic findings regarding bladder safety, and the frequency of changes in bladder management following video-urodynamics (VUDs). Methods: VUDs, which were performed between March 2015 and March 2021 in view of neurogenic lower urinary tract dysfunction, were included in the study. These were divided into those performed in patients with high risk and those in patients with low risk for renal deterioration categories according to criteria specified in the National Institute of Clinical Excellence (NICE) Urinary Incontinence in Neurological Disease guidelines. The two groups were then statistically compared in terms of urodynamic parameters for bladder safety and changes in management thereafter. Results: In total, 69 VUDs were included, 49.3% were classified as having been performed in high risk for renal deterioration patients, and 50.7% as low risk. 50% of those in the former group were found to have an unsafe bladder versus 31.4% in the latter group ( p = 0.12). Meanwhile, 65.2% of VUDs resulted in a change in bladder management, with no difference in change in management frequency between the two risk stratification groups ( p = 0.36). Conclusion: The lack of statistically significant difference in urodynamic bladder safety findings and change in frequency of bladder management for the low and high risk for renal deterioration categories in this cohort bring into question the need for risk stratification in the clinical decision to perform VUDs in the neurogenic bladder patient. Level of evidence: 2c

A case report on penile duplication: A rare congenital anomaly

Introduction: Penile duplication or penile diphallia is a rare congenital anomaly that is mainly associated with renal, anorectal or vertebral anomalies, that is, spina bifida. This condition was first described by Johannes Jacob Wecker in 1609 in Italy. Problem: Its incidence is extremely rare, about one in millions. The aetiology of this condition is unknown up till now; however, it is considered that defect of genital tubercle leads to the formation of diphallia. Methods: The condition is diagnosed clinically, and management depends on the appearance of genitalia and the associated anomalies as well as after taking into account the social and ethical considerations. Most of the time, management involves surgical incision of the non-functioning penis. Results: In this case report, a child of age 10 years presented with double penis since childhood. The child was evaluated clinically and radiologically for any other associated abnormalities, and his non-functional urethra was surgically removed. Level of evidence: Level IV

Distal ureteral atresia – an embryological dilemma

Introduction: Distal ureteral atresia is a rare urinary tract anomaly generally associated with ipsilateral renal dysplasia and abnormalities such as multicystic dysplastic kidney, hydronephrosis and megaureter in the contralateral kidney. Despite burgeoning investigation modalities, definitive preoperative diagnosis of this condition is rarely feasible, also the embryological disarray of events that result in the development of this anomaly and the associated malformations is not clearly understood. Case presentation: We hereby report two cases of distal ureteral atresia and discuss the diversity in their presentations, diagnosis, atypical associations and management and review the possible embryological mal-development. Conclusion: Distal ureteral atresia with urogenital sinus as in Case 1 has not been documented so far and a plausible embryological explanation is deduced regarding its occurrence. The course of the affected kidney following timely and adequate relief of obstruction in Case 2 is depicted, highlighting the eventual management. Level of evidence: Not applicable