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Item Multicenter Multireader Evaluation of an Artificial Intelligence-Based Attention Mapping System for the Detection of Prostate Cancer With Multiparametric MRI(AMER ROENTGEN RAY SOC, 2020-01-01) Mehralivand, Sherif; Harmon, Stephanie A.; Shih, Joanna H.; Smith, Clayton P.; Lay, Nathan; Argun, Burak; Bednarova, Sandra; Baroni, Ronaldo Hueb; Canda, Abdullah Erdem; Ercan, Karabekir; Girometti, Rossano; Karaarslan, Ercan; Kural, Ali Riza; Pursyko, Andrei S.; Rais-Bahrami, Soroush; Tonso, Victor Martins; Magi-Galluzzi, Cristina; Gordetsky, Jennifer B.; Silvestre e Silva Macarenco, Ricardo; Merino, Maria J.; Gumuskaya, Berrak; Saglican, Yesim; Sioletic, Stefano; Warren, Anne Y.; Barrett, Tristan; Bittencourt, Leonardo; Coskun, Mehmet; Knauss, Chris; Law, Yan Mee; Malayeri, Ashkan A.; Margolis, Daniel J.; Marko, Jamie; Yakar, Derya; Wood, Bradford J.; Pinto, Peter A.; Choyke, Peter L.; Summers, Ronald M.; Turkbey, BarisOBJECTIVE. The purpose of this study was to evaluate in a multicenter dataset the performance of an artificial intelligence (AI) detection system with attention mapping compared with multiparametric MRI (mpMRI) interpretation in the detection of prostate cancer. MATERIALS AND METHODS. MRI examinations from five institutions were included in this study and were evaluated by nine readers. In the first round, readers evaluated mpMRI studies using the Prostate Imaging Reporting and Data System version 2. After 4 weeks, images were again presented to readers along with the AI-based detection system output. Readers accepted or rejected lesions within four AI-generated attention map boxes. Additional lesions outside of boxes were excluded from detection and categorization. The performances of readers using the mpMRI-only and AI-assisted approaches were compared. RESULTS. The study population included 152 case patients and 84 control patients with 274 pathologically proven cancer lesions. The lesion-based AUC was 74.9\% for MRI and 77.5\% for AI with no significant difference (p = 0.095). The sensitivity for overall detection of cancer lesions was higher for AI than for mpMRI but did not reach statistical significance (57.4\% vs 53.6\%, p = 0.073). However, for transition zone lesions, sensitivity was higher for AI than for MRI (61.8\% vs 50.8\%, p = 0.001). Reading time was longer for AI than for MRI (4.66 vs 4.03 minutes, p < 0.001). There was moderate interreader agreement for AI and MRI with no significant difference (58.7\% vs 58.5\%, p = 0.966). CONCLUSION. Overall sensitivity was only minimally improved by use of the AI system. Significant improvement was achieved, however, in the detection of transition zone lesions with use of the AI system at the cost of a mean of 40 seconds of additional reading time.Item Impact of Refractive Errors on Da Vinci SI Robotic System(SOC LAPAROENDOSCOPIC SURGEONS, 2020-01-01) Tuna, Mustafa Bilal; Kilavuzoglu, Ayse Ebru; Mourmouris, Panogiotis; Argun, Omer Burak; Doganca, Tunkut; Obek, Can; Ozisik, Ozan; Kural, Ali RizaObjective: To investigate the impact of refractive errors on binocular visual acuity while using the Da Vinci SI robotic system console. Methods: Eighty volunteers were examined on the Da Vinci SI robotic system console by using a near vision chart. Refractive errors, anisometropia status, and Fly Stereo Acuity Test scores were recorded. Spherical equivalent (SE) were calculated for all volunteers' right and left eyes. Visual acuity was assessed by the logarithm of the minimal angle of resolution (LogMAR) method. Binocular uncorrected and best corrected (with proper contact lens or glasses) LogMAR values of the subjects were recorded. The difference between these values (DiffLogMAR) are affected by different refractive errors. Results: In the myopia and/or astigmatism group, uncorrected SE was found to have significant impact on the DiffLogMAR (P < 0.001) and myopia greater than 1.75 diopter had significantly higher DiffLogMAR values (p < 0.05). Subjects with presbyopia had significantly higher DiffLogMAR values (p < 0.01), and we observed positive correlation between presbyopia and DiffLogMAR values (p = 0.33, p < 0.01). The cut off value of presbyopia that correlated the most with DiffLogMAR differences was found to be 1.25 diopter (P< 0.001). In 13 hypermetropic volunteers, we found significant correlation between hypermetropia value and DiffLogMAR (p > 0.7, p < 0.01). The statistical analysis between Fly test and SE revealed a significant impact of presbyopia and hypermetropia to the stereotactic view of the subject (p = -0.734, p < 0.05). Conclusion: Surgeons suffering from myopia greater than 1.75 diopter, presbyopia greater than 1.25 diopter (D), and hypermetropia regardless of grade must always perform robotic surgeries with the proper correction.Item Ischemia modified albumin: does it change during pneumoperitoneum in robotic prostatectomies?(BRAZILIAN SOC UROL, 2016-01-01) Ozgen, Serpil Ustalar; Ozveren, Bora; Kilercik, Meltem; Aksu, Ugur; Ay, Binnaz; Tufek, Ilter; Kural, Ali Riza; Turkeri, Levent N.; Toraman, FevziBackground: The unique positioning of the patient at steep Trendelenburg with prolonged and increased intra-abdominal pressure (IAP) during robotic radical prostatectomy may increase the risk of splanchnic ischemia. We aimed to investigate the acute effects of IAP and steep Trendelenburg position on the level of ischemia modified albumin (IMA) and to test if serum IMA levels might be used as a surrogate marker for possible covert ischemia during robotic radical prostatectomies. Patients and Methods: Fifty ASA I-II patients scheduled for elective robotic radical prostatectomy were included in this investigation. Exclusion criteria: The patients were excluded from the study when an arterial cannulation could not be accomplished, if the case had to be converted to open surgery or if the calculated intraoperative bleeding exceeded 300ml. All the patients were placed in steep (45 degrees) Trendelenburg position following trocar placement. Throughout the operation the IAP was maintained between 11-14mmHg. Mean arterial blood pressure (MAP), cardiac output (CO) were continuously monitored before the induction and throughout the surgery. Blood gases, electrolytes, urea, creatinine, alanine transferase (ALT), aspartate transferase (AST) were recorded. Additionally, IMA levels were measured before, during and after surgery. Results: (1) MAP, CO, lactate and hemoglobin (Hb) did not significantly change in any period of surgery (p>0.05)Item Non-muscle invasive bladder cancer tissues have increased base excision repair capacity(NATURE PORTFOLIO, 2020-01-01) Somuncu, Berna; Keskin, Selcuk; Antmen, Fatma Merve; Saglican, Yesim; Ekmekcioglu, Aysegul; Ertuzun, Tugce; Tuna, Mustafa Bilal; Obek, Can; Wilson, David M.; Ince, Umit; Kural, Ali Riza; Muftuoglu, MeltemThe molecular mechanisms underlying the development and progression of bladder cancer (BC) are complex and have not been fully elucidated. Alterations in base excision repair (BER) capacity, one of several DNA repair mechanisms assigned to preserving genome integrity, have been reported to influence cancer susceptibility, recurrence, and progression, as well as responses to chemotherapy and radiotherapy. We report herein that non-muscle invasive BC (NMIBC) tissues exhibit increased uracil incision, abasic endonuclease and gap-filling activities, as well as total BER capacity in comparison to normal bladder tissue from the same patient (p<0.05). No significant difference was detected in 8-oxoG incision activity between cancer and normal tissues. NMIBC tissues have elevated protein levels of uracil DNA glycosylase, 8-oxoguanine DNA glycosylase, AP endonuclease 1 and DNA polymerase beta protein. Moreover, the fold increase in total BER and the individual BER enzyme activities were greater in high-grade tissues than in low-grade NMIBC tissues. These findings suggest that enhanced BER activity may play a role in the etiology of NMIBC and that BER proteins could serve as biomarkers in disease prognosis, progression or response to genotoxic therapeutics, such as Bacillus Calmette-Guerin.Item Water Vapor Thermal Therapy (RezumTM) for Benign Prostate Hyperplasia: Initial Experience from Turkiye(GALENOS PUBL HOUSE, 2022-01-01) Tuna, Mustafa Bilal; Doganca, Tunkut; Argun, Omer Burak; Pirdal, Betul Zehra; Tufek, Ilter; Obek, Can; Kural, Ali RizaObjective: Rezumn{''} system is a safe minimal invasive treatment modality for benign prostate hyperplasia (BPH) treatment. The aim of this study was to evaluate the short-term results of Rezumn{''} therapy in our center.Materials and Methods: We retrospectively collected the data of 28 patients with symptomatic BPH who underwent RezumTM therapy in our center. All patients' pre-operative and post-operativeItem Distal ureterectomy techniques in laparoscopic and robot-assisted nephroureterectomy: Updated review(WOLTERS KLUWER MEDKNOW PUBLICATIONS, 2015-01-01) Stravodimos, Konstantinos G.; Komninos, Christos; Kural, Ali Riza; Constantinides, ConstantinosControversies exist about the best method for managing the distal ureter during the laparoscopic (LNU) and robot-assisted nephroureterectomy (RANU). Therefore, PubMed, Scopus and Web of Science databases were searched in order to identify articles describing the management of distal ureter during LNU or RANU in patients suffering from upper urinary tract urothelial cell carcinoma. Forty seven articles were selected for their relevance to the subject of this review. The approaches that are usually performed regarding the distal ureter management are open excision, transurethral resection of ureteral orifice (Pluck Technique), ureteric intussusception and pure LNU or pure RANU. Pure LNU and RANU with complete laparoscopic dissection and suture reconstruction of ureter and bladder cuff seems to be better tolerated than open nephroureterectomy providing equal efficacy, without deteriorating the oncological outcome, however evidence is poor. Transurethral resection of the ureteric orifice and the bladder cuff after occlusion of the ureter with a balloon catheter seems to be an attractive alternative option for low stage, low grade tumors of the renal pelvis and the proximal ureter, while stapling technique is correlated with the increased risk of positive surgical margins. The open resection of the distal ureter in continuity with the bladder cuff is considered the most reliable approach, preferred in our practice as well, however the existing data are based on retrospective and non-randomized studies.Item Is robotic radical nephroureterectomy a safe alternative to open approach: The first prospective analysis(PAGEPRESS PUBL, 2021-01-01) Mourmouris, Panagiotis; Argun, Omer Burak; Tzelves, Lazaros; Tuna, Mustafa Bilal; Gourtzelidou, Maria; Tziotis, Andreas; Kural, Ali Riza; Skolarikos, AndreasPurpose: To test the efficacy and safety profile of robotic radical nephroureterectomy compared to the open approach. Methods: We enrolled 45 consecutive patients who suffered from non-metastatic, upper urinary tract urothelial carcinoma from September 2019 to March 2021 and underwent radical nephroureterectomy. Patients were divided in two groups: group A consisted of 29 patients (open approach) and group B consisted of 16 patients (robotic approach). The factors which were taken into consideration were age, sex, body mass index, tumour size, side and grade, cancer stage, ASA score, operation time, drain removal time, foley time, hospitalization time, estimated blood loss, surgical margins, preoperative and postoperative creatinine, Hct and bladder recurrences. Statistical analysis was performed with the use of SPSS version 26 and p < 0.05 was the cut-off for reaching statistical significance. Results: The mean age in group 1 was 67.12 years and in group 2 68.12 years, whereas the mean body mass index (BMI) in group 1 was 26.54 kg/m(2) and in group 2 25.20 kg/m(2). Operative time was better in group A (124 vs 186 mins p < 0.001) and estimated blood loss were better in group B compared to group A (137 vs 316 ml p < 0.001). Length of stay (LOS) was significantly less in the robotic group (5.75 vs 4.3 days p = 0.003) and the same applied for time required for drain removal (4.5 vs 33 days p = 0.006). Conclusions: Robotic radical nephroureterectomy is a safe and efficient alternative to open approach. It provides a favorable perioperative profile in patients suffering from upper urinary tract carcinoma without metastasis.Item Magnetic resonance image-guided adaptive stereotactic body radiotherapy for prostate cancer: preliminary results of outcome and toxicity(BRITISH INST RADIOLOGY, 2021-01-01) Ugurluer, Gamze; Atalar, Banu; Mustafayev, Teuta Zoto; Gungor, Gorkem; Aydin, Gokhan; Sengoz, Meric; Abacioglu, Ufuk; Tuna, Mustafa Bilal; Kural, Ali Riza; Ozyar, EnisObjective: Using moderate or ultra-hypofractionation, which is also known as stereotactic body radiotherapy (SBRT) for treatment of localized prostate cancer patients has been increased. We present our preliminary results on the clinical utilization of MRI-guided adaptive radiotherapy (MRgRT) for prostate cancer patients with the workflow, dosimetric parameters, toxicities and prostate-specific antigen (PSA) response. Methods: 50 prostate cancer patients treated with ultrahypofractionation were included in the study. Treatment was performed with intensity-modulated radiation therapy (step and shoot) technique and daily plan adaptation using MRgRT. The SBRT consisted of 36.25 Gy in 5 fractions with a 7.25 Gy fraction size. The time for workflow steps was documented. Patients were followed for the acute and late toxicities and PSA response. Results: The median follow-up for our cohort was 10 months (range between 3 and 29 months). The median age was 73.5 years (range between 50 and 84 years). MRgRT was well tolerated by all patients. Acute genitourinary (GU) toxicity rate of Grade 1 and Grade 2 was 28 and 36\%, respectively. Only 6\% of patients had acute Grade 1 gastrointestinal (GI) toxicity and there was no Grade 2G1 toxicity. To date, late Grade 1 GU toxicity was experienced by 24\% of patients, 2\% of patients experienced Grade 2 GU toxicity and 6\% of patients reported Grade 2 GI toxicity. Due to the short follow-up, PSA nadir has not been reached yet in our cohort. Conclusion: In conclusion, MRgRT represents a new method for delivering SBRT with markerless soft tissue visualization, online adaptive planning and real-time tracking. Our study suggests that ultra-hypofractionation has an acceptable acute and very low late toxicity profile. Advances in knowledge: MRgRT represents a new markerless method for delivering SBRT for localized prostate cancer providing online adaptive planning and real-time tracking and acute and late toxicity profile is acceptable.Item Minimizing Ports During Robotic Partial Nephrectomy(SOC LAPAROENDOSCOPIC SURGEONS, 2016-01-01) Argun, Omer Burak; Mourmouris, Panagiotis; Tufek, Ilter; Obek, Can; Tuna, Mustafa Bilal; Keskin, Selcuk; Kural, Ali RizaBackground and Objective: Robotic upper urinary tract surgery is in most of the cases performed utilizing a standard 5 port configuration. Fewer ports can potentially produce a less invasive operation. Taking in consideration the above we report a novel technique for robot assisted laparoscopic partial nephrectomy utilizing fewer ports and we test its feasibility and safety profile. Methods: Data on 11 robot-assisted laparoscopic partial nephrectomies performed by using our technique from February 2015 through June 2015 were retrospectively analyzed. The robotic platform used was DaVinci Xi (Intuitive Surgical, Inc., Sunnyvale, California, USA) with a 3-arm setup. The AirSeal system (SurgiQuest, Milford, Connecticut, USA) was used as a port allowing simultaneous introduction of 2 instruments for the bedside surgeon, obviating the need for an additional (fourth) robotic arm. A long suction-and-irrigation device and atraumatic grasping forceps were used. Both instruments were introduced through the trocar of the AirSeal system, making simultaneous introduction and use possible. We preferred the long suction-and-irrigation device, because it minimizes collision of the instruments. Results: Mean age and BMI of the patients were 55 +/- 14.6 y and 29.18 +/- 6.85, respectively. Seven tumors were on the right side and 4 were on the left. The mean size of the tumors was 32.45 mm (+/- 11.31). Surgical time was 132.2 minutes (+/- 37.17), with an estimated blood loss and ischemia time of 103.63 mL (+/- 65.92) and 16.72 minutes (+/- 9.52), respectively. One patient had postoperative bleeding that was resolved without transfusion. The median hospitalization period was 3.9 d (+/- 0.53). Loss of intra-abdominal pressure was not observed, and pressure was stable at 10 mm Hg. Conclusion: The AirSeal System and its valveless trocar eliminated the need for an additional port placement in our series. The technique is feasible, safe, and reproducibleItem Magnetic Resonance - Transrectal Ultrasound Fusion Guided Prostate Biopsy(GALENOS YAYINCILIK, 2016-01-01) Argun, Omer Burak; Obek, Can; Kural, Ali RizaProstate has remained as the single solid organ for which biopsy cannot be performed from a lesion for decades. Lately, the groundbreaking magnetic resonance imaging (MRI) techniques have emerged to scan prostate cancer and have become an important diagnostic tool in the diagnosis of prostate cancer. Efforts to improve the accuracy of the standard biopsy methods have led to the emergence of target-oriented biopsy methods. Today, MRI-transrectal ultrasound (TRUS) fusion guided biopsy methods are being used increasingly, especially for patients with an increasing prostate specific antigen level after a previous negative biopsy result and for patients under follow-up with active surveillance protocols. Even though it is not yet suggested in guidelines, our view and practice are in line with the fact that MRI-TRUS fusion guided biopsy is the most ideal biopsy method in any patient scheduled for a prostate biopsy with a significant lesion on MRI.