Summary:Immediate breast reconstruction has advanced significantly, yet optimal implant placement remains debated. Prepectoral implant-based breast reconstruction (IBR) offers aesthetic benefits but risks implant exposure and ptosis. Although acellular dermal matrices mitigate these risks, they pose complications such as infection, red breast syndrome, and high costs. Here, we aim to describe and evaluate our technique using the serratus anterior fascia as an autologous alternative for lower pole and lateral support in prepectoral IBR. All patients undergoing prophylactic or curative nipple-sparing mastectomy with immediate prepectoral direct-to-implant reconstruction between October 2023 and December 2024 received the hybrid plane technique and were included. In total, 10 patients received this technique (19 breasts). The mean age was 40.9 years, and the mean body mass index was 22.6 kg/m². All patients had pathogenic mutations, most commonly BRCA1. Three (30%) patients experienced complications, but no reconstruction failures occurred. Mean follow-up was 12.8 months. The absence of implant exposure despite postoperative complications, including wound dehiscence, highlights the safety and protection from the serratus anterior fascia. Similar to its use in subpectoral reconstruction, the serratus anterior fascia can improve prepectoral IBR, offering a safe and cost-free solution for total skin- and nipple-sparing mastectomies.

IntroductionPrimary hyperparathyroidism is usually caused by parathyroid adenomas, however atypical tumors are rare. Brown tumors can occur from excessive parathyroid hormone release, which increases osteoclastic bone resorption. Although rare, atypical parathyroid tumors can cause such lesions. An unusual parathyroid tumor with a brown tumor is shown here.Clinical CaseA 57-year-old woman presented to the orthopedics clinic with complaints of left hip pain. Imaging revealed a mass in the left acetabulum. Laboratory tests suggested primary hyperparathyroidism, and she was referred to endocrinology with a suspected brown tumor.Left hip pain had been present for 1.5 years, with recent worsening, causing difficulty in walking. Her medical history included percutaneous nephrolithotripsy for nephrolithiasis. Physical examination revealed painful and restricted movements of the left hip. Laboratory investigations demonstrated: calcium 13.2 mg/dL (8.8–10.6), phosphorus 2.2 mg/dL (2.5–4.5), PTH 883 ng/L (15–65), 25-OH vitamin D 35.2 μg/L, creatinine 1.05 mg/dL (0–1.2), TSH 0.8 mUI/L (0.48–4.81), and 24-hour urinary calcium 312 mg/day (0–300).Neck ultrasonography showed a 30x15 mm hypoechoic solid nodule posterior to the left thyroid lobe, suggestive of a parathyroid adenoma, along with additional hypoechoic solid nodules measuring 25 x 10 mm at the left lobe–isthmus junction and 17x10 mm within the left lobe, which were evaluated as thyroid nodules. Parathyroid scintigraphy confirmed the suspected parathyroid lesion. Thyroid scintigraphy showed that the nodules in the left lobe had a hyperfunctioning pattern. Pelvic MRI revealed a heterogeneous mass measuring 8x5 cm, eroding almost the entire acetabulum. Bone mineral densitometry indicated severe osteoporosis (L1–L4 T-score: –3.9; femoral neck T-score: –4.2). Ultrasound showed multiple calculi in the lower pole of the left kidney, the largest 5 mm.The patient was hospitalized, started on intravenous hydration, and given zoledronic acid. She then underwent left hemithyroidectomy and left inferior parathyroidectomy. Histopathological examination of the thyroid specimen revealed follicular nodular disease. The parathyroid specimen showed irregular parathyroid parenchyma with nodular hyperplasia, and the differential diagnosis included atypical parathyroid tumor and prior biopsy tract changes. However, the patient had no history of invasive neck procedures.Postoperatively, serum calcium and PTH normalized. The patient was closely monitored for atypical parathyroid tumor, and orthopedic follow-up was planned for the brown tumor.ConclusionThis case shows a rare presentation of an atypical parathyroid tumor with a destructive brown tumor in the acetabulum. Clinicians should strongly suspect primary hyperparathyroidism in patients with unexplained osteolytic lesions, especially if labs show hypercalcemia and high PTH.

Ultrasound (US) guided supine percutaneous nephrolithotomy (PCNL) is increasingly being adopted. The aim of this study is to assess the safety and efficacy of lower versus non-lower pole access in supine US-guided PCNL. This study is a retrospective cohort analysis of 228 patients who underwent single access US-guided supine PCNL between March 2023 and June 2024 and were categorized into lower (n=162), interpolar (n=42) and upper pole (n=21) access categories. Baseline demographics, stone characteristics and intraoperative details were analyzed and compared between the groups. Safety outcomes, including 30-day postoperative total and major complications (based on Clavien-Dindo classification), as well as pain scores, were compared between lower pole access (LPa) and non-LPa access. Baseline clinical and stone characteristics were comparable between the groups. Non-LPa was more frequently performed on the right side (p=0.04), above 12th rib (p<0.001), into a posterior calyx (p=0.004), and more often followed by stent placement (p=0.01). Major complications occurred in 14% of the patients with upper pole access compared to 2% with LPa (p=0.03) and 5% with interpolar. Additionally, the LPa group had lower rates of total complications compared to upper pole and interpolar (11% vs 19% and 22% respectively, p=0.05). There were two visceral injuries in the interpolar group. VAS pain scores at the recovery room were not different between the groups. When performing US-guided supine PCNL, LPa has a superior safety profile, resulting in fewer major and total complications compared to non-LPa.

To correlate the spleen's shear wave elastography (SWE) with the severity of acute pancreatitis (AP) and the outcome. In this IRB-approved prospective study, 38 patients with a diagnosis of AP were enrolled. Patients were taken up for 2D-SWE of the spleen, which was measured in kPa. Mean SWE values of the spleen were compared with the severity of AP according to the Modified Marshall score and intervention using the Kruskal-Wallis test. Splenic stiffness increased progressively with the severity of acute pancreatitis. Among the three splenic regions, the lower pole showed the most consistent association with disease severity, demonstrating significantly higher stiffness in patients with severe forms of pancreatitis (p = 0.042). Higher overall splenic SWE values were also observed in patients who required more invasive management, such as necrosectomy or surgical drainage, compared with those managed conservatively or with percutaneous drainage. No significant relationship was noted between splenic SWE and demographic factors, etiology of pancreatitis, or splenic vascular changes. A significant positive association was seen between SWE values of the lower pole of the spleen and the severity of the Modified Marshall severity score. There was a significant positive association between the overall SWE values of the spleen and the nature of the intervention, which was highest in patients who underwent necrosectomy or surgical drainage.

BackgroundTo characterize volume reduction in benign solid and predominantly solid thyroid nodules during long‐term ultrasound surveillance, and to describe distinct absorption patterns over time.MethodsThis retrospective study included 34 solid or predominantly solid thyroid nodules from 32 patients (median age, 46 years; 78.1% female), who underwent longitudinal ultrasound surveillance for a median of 28 months (interquartile range, 47–120 months). Volumetric measurements were obtained at multiple time points. Generalized additive mixed models (GAMMs) were employed to model nonlinear trends in volume over time. Unsupervised clustering was applied to identify representative regression trajectories based on individual volume curves. Clinical and ultrasound features were compared between trajectory‐defined groups.ResultsAll nodules exhibited measurable volume decrease over time (median reduction: 85.6%). Two representative volume change patterns were identified: a rapid‐absorption group with early shrinkage and a slow‐absorption group with gradual decline. Nodules in the latter were more frequently located in the lower pole and lacked Doppler flow at baseline (p < 0.05). Some nodules developed hypoechoic or stiff appearances over time, leading to higher TIRADS categories despite continuous shrinkage and no clinical signs of malignancy.ConclusionSolid and predominantly solid thyroid nodules can undergo significant volume reduction during long‐term surveillance, resembling the well‐documented absorption phenomenon of cystic nodules. This phenomenon may be underrecognized in clinical practice. Describing the diversity of volume change patterns may improve the understanding and interpretation of nodule evolution during follow‐up.

Tuberous sclerosis is a rare autosomal dominant genetic disorder caused by mutations in tumor suppressor genes (TSC1/2), leading to hamartomas in multiple organs. Renal angiomyolipomas are often asymptomatic but can cause mass effects or bleeding if they enlarge, requiring treatment. A 29-year-old woman presented with severe left flank pain, an abdominal mass, and facial papules. Imaging revealed a large, 18.3 × 13 × 11.5 cm mass in the lower pole of the left kidney, which was fat-poor, a smaller lesion on the opposite kidney, pulmonary cysts, and osteoblastic bone lesions, all indicating tuberous sclerosis-associated lymphangioleiomyomatosis. A left nephrectomy was performed, and she recovered well. Histology confirmed a renal angiomyolipoma with chronic inflammation. This case underscores the importance of nephrectomy for managing large angiomyolipomas to alleviate symptoms and improve quality of life. Managing such patients requires a multidisciplinary approach, including imaging and genetic testing, with ongoing care and surveillance to achieve better outcomes.

Background: Percutaneous nephrolithotomy (PCNL) is the preferred minimally invasive intervention for managing large renal calculi. The choice of calyceal access route has a significant influence on stone-free rates and perioperative complications. Although upper-pole puncture provides favorable instrumentation angles and improved access to the collecting system, concerns about thoracic complications persist. This study evaluates and compares the clinical outcomes of upper-pole and lower-pole access in pediatric PCNL. Objectives: To compare the residual stone rate between upper- and lower-pole access and to determine the frequency of chest complications associated with each approach. Methodology: A randomized controlled trial was conducted in the Department of Urology, Khyber Teaching Hospital from June 2025 to September 2025 involving 388 children under 12 years with a single renal pelvic stone. Participants were randomized to upper-pole (n=194) or lower-pole (n=194) puncture. Postoperative residual stones (day 1 imaging) and chest complications (within 48 hours) were assessed. Statistical significance was defined as p ≤ 0.05. Results: Upper-pole PCNL showed a significantly lower residual stone rate (20.1%) than lower-pole access (23.2%; p &gt; 0.05). Chest complications were higher in the upper-pole group (11.3%) as compared to the lower-pole group (4.6%; p=0.025). Age, sex, and laterality showed no association with residual stones, while obesity and larger stone size increased risk. Conclusion: Upper-pole calyceal access provides better stone-free outcomes and higher chest complications than lower-pole access in pediatric PCNL.

Abstract Background Unilateral breast reconstruction in patients with grade 2 ptosis presents significant challenges in achieving long-term symmetry. Traditional approaches require contralateral symmetrization, increasing operative time, costs, and the risk of postoperative asymmetry due to progressive changes in the contralateral breast. Objectives This study evaluates the effectiveness of the SIMPLE technique (Symmetry in Moderate Ptosis for Long-Lasting Effectiveness) in pre-pectoral direct-to-implant (DTI) breast reconstruction for patients with grade 2 ptosis. The goal is to restore the breast’s original shape and volume, avoiding contralateral procedures. Methods A retrospective review of 23 patients undergoing nipple-sparing mastectomy (NSM) followed by DTI pre-pectoral reconstruction using polyurethane-coated implants (Polytech Microthane® Sublime Line) was conducted. The median follow-up was 603 days (range 349-826). Inclusion criteria included a body mass index (BMI) &amp;lt;35,5 and no prior radiotherapy. Intraoperative confirmation of skin flap viability was assessed via indocyanine green angiography. Implants were strategically positioned to maintain symmetry, with special attention to alignment and preserving natural contours. Results All patients reported high satisfaction without the need for secondary procedures. Four minor complications, were observed, along with two infections that required implant removal. No significant post-operative complications, such as implant exposure in the lower pole, implant displacement or significant breast asymmetry requiring implants changes, were observed during the follow-up period, highlighting the technique's safety and effectiveness. Conclusions The SIMPLE technique may represent a reliable option for breast reconstruction in selected patients with grade 2 ptosis, reducing the need for contralateral symmetrization, surgical complexity, and potentially supporting more durable symmetry, favorable aesthetics, and patient satisfaction.

Upper pole renal tumors, despite the unique surgical techniques and preparations necessitated by their anatomical location, are assigned the same numerical complexity as lower pole tumors by the RENAL nephrometry score. Consequently, this study aimed to compare the perioperative outcomes of robot-assisted partial nephrectomy (RAPN) for upper versus lower pole renal tumors. Out of 484 consecutive patients who underwent RAPN at our institution, this retrospective study included 186 patients with renal polar tumors. Upper and lower pole tumors were defined as those with a RENAL nephrometry score L component of 1, indicating polar tumors not overlapping the superior or inferior polar lines. RAPN procedures were performed using either the da Vinci Xi or the hinotori system, a newly developed robotic platform in Japan. For upper pole tumor excision in a transperitoneal approach, a 30° down-angle robotic camera was inserted via a camera port previously positioned approximately 3 cm more superolaterally than the standard placement, alongside two robotic arms, irrespective of the robotic platform. The study population was divided into lower (n = 109) and upper (n = 77) pole tumor groups; tumors located centrally, including hilar tumors, were entirely excluded. No significant differences were observed in baseline patient characteristics between the two groups. Following surgery, significant differences were found in operative time (165 vs. 179 min, p = 0.010) and robotic time (98 vs. 116 min, p = 0.004) between the lower and upper pole groups, respectively. However, other major perioperative outcomes, including the Trifecta achievement rate (94.5% vs. 98.7%, p = 0.24), showed no significant differences. Uni- and multivariate analyses identified sex, tumor size, and tumor polar location as independent factors for prolonged robotic time; however, robotic platform type was not. With proper technical preparation, RAPN for upper pole tumors can achieve comparable perioperative outcomes to that for lower pole tumors, despite requiring longer operative and robotic times.

Amaç: Çalışmamızın amacı 2 cm'den küçük tek taşlarda alt pol lokalizasyonunun diğer lokalizasyonlara kıyasla pediatrik retrograd intrarenal cerrahi (RIRS) sonuçları üzerindeki etkisini araştırmaktır. Gereç ve Yöntemler: Ocak 2021 ile Haziran 2024 arasında bir üniversite hastanesinde RIRS uygulanan hastaların verileri retrospektif olarak analiz edildi. Çalışmaya 2 cm'den küçük, tek taşı olan ve verilerine ulaşılabilen, 18 yaş altı 69 hasta dahil edildi. Hastalar böbrek taşı lokalizasyonuna göre iki gruba ayrıldı: alt pol (Grup 1) ve diğer lokalizasyonlar (Grup 2). Her iki grupta hastaların demografik verileri, klinik özellikleri, taşla ilgili verileri, perioperatif ve postoperatif verileri istatistiksel olarak karşılaştırıldı. Bulgular: Çalışmaya ortalama yaşı 7±4.4 (1-17) yıl ve ortalama taş boyutu 11±3.3 (5-20) mm olan 69 hasta dahil edildi. Grup 1'de 21 hasta ve Grup 2'de 48 hasta vardı. Her iki gruptaki hastaların demografik verileri ve klinik özellikleri benzerdi. Grupların taş boyutu, lokalizasyonu ve dansitesi benzerdi (sırasıyla p=0.58, 0.58 ve 0.63). Grup 1'de prestenting oranı Grup 2'ye göre istatistiksel olarak anlamlı derecede daha yüksekti (%76.2 vs %50, p=0.04). Gruplar arasında access sheath kullanımı, operasyon süresi, floroskopi süresi, 1. gün ve 3. aydaki taşsızlık oranı veya ek prosedürler açısından istatistiksel olarak anlamlı bir fark saptanmadı (sırasıyla p=0.69, 0.95, 0.60, 0.97, 0.27 ve 0.28). Komplikasyon oranları her iki grupta benzerdi (p=0.28). Hastaların hiçbirinde yüksek dereceli veya anesteziyle ilişkili komplikasyon gözlenmedi. Sonuç: Alt pol lokalizasyonu 2 cm'den küçük tek taşlarda prestenting oranı hariç cerrahi parametreleri etkilememektedir. Pediatrik popülasyonda prestenting uygulamasının genel anestezi altında yapıldığı göz önüne alındığında, alt pol taşları anestezi seanslarının sayısını, radyasyon maruziyetini ve hastane yatışlarını artırabilir.

ABSTRACTIntroductionWe present a technique that combines a fluorescent ureteral catheter with Firefly near‐infrared fluorescence imaging to identify the ureter and avoid injury during robot‐assisted resection of a retroperitoneal cystic tumor.Case PresentationComputed tomography revealed a 6‐cm retroperitoneal cystic mass anterior to the abdominal aorta near the lower pole of the left kidney that adhered to the left ureter in a 53‐year‐old man. A fluorescent ureteral catheter was placed preoperatively, and robot‐assisted transperitoneal resection was performed. Firefly imaging enabled clear visualization of the ureter, allowing safe dissection and tumor identification. The tumor was excised without cyst rupture. The console time was 4 h 13 min, with minimal blood loss. Pathology confirmed schwannoma.ConclusionWe demonstrated the feasibility and clinical benefits of integrating a fluorescent ureteral catheter with Firefly fluorescence imaging for intraoperative ureteral identification during robot‐assisted surgery. This fluorescence‐guided approach improves dissection accuracy and helps prevent ureteral injury.

To compare the safety and diagnostic yield of two ultrasound (US)-guided percutaneous renal biopsy (PRB) approaches, lateral to medial and medial to lateral, which differ in access route, muscle groups traversed, and cortical targets. This retrospective study included 490 patients (mean age: 38.2 ± 21.2 years; 267 men, 223 women) who underwent US-guided PRB between 2019 and 2024 and had abdominal computed tomography (CT)/magnetic resonance imaging (MRI) within 1 year. At the left kidney lower pole level (L3-L4), anterior-posterior thicknesses of the traversed muscle groups were measured on CT/MRI. Complications were classified according to the Society of Interventional Radiology guidelines. Diagnostic yield was categorized as optimal (≥ 12 glomeruli), suboptimal (≥ 3 glomeruli), and pathologist based (diagnostic according to final pathology assessment). Group comparisons were performed using the chi-square test, Fisher's exact test, and t-test. In 490 PRBs (237 lateral to medial, 253 medial to lateral), the medial-to-lateral approach, despite traversing thicker muscles (35.7 vs. 11.5 mm, P = 0.001), produced smaller hematomas (8.6 vs. 17.3 mm, P = 0.001) with similar complication rates (major: 3.6% vs. 3.4%, P = 0.913; minor: 36% vs. 33.8%, P = 0.608). Diagnostic adequacy was comparable, but optimal yield was higher with the medial-to-lateral route (85.0% vs. 73.0%, P = 0.001). Both approaches demonstrated comparable safety. However, the medial-to-lateral route was associated with smaller hematomas and a higher proportion of optimal biopsies from the lateral cortex, but suboptimal and pathologist-based adequacy remained high in both techniques. When standard lower pole lateral cortex biopsy is not feasible due to cortical scarring, cysts, overlying skin lesions, or anatomic limitations-especially in patients for whom contralateral biopsy is not possible (e.g., solitary or ectopic pelvic kidney, severe unilateral hydronephrosis)-alternative cortical targets must be used. Understanding how different access routes and muscle pathways influence hemorrhage control and diagnostic yield helps operators choose the safest and most effective technique in these situations.

IntroductionFlexible ureteroscopy has advanced modern stone management; however, lower pole renal stones remain a challenge due to suboptimal ureteroscope deflection and navigation using conventional flexible and navigable suction ureteral access sheaths (FANS). The SCULPT trial is designed to assess whether the novel steerable FANS—which enables active controlled deflection—can improve the success rate of lower pole access during flexible ureteroscopy.Methods and analysisThis multicentre, prospective, single-blinded, randomised controlled superiority trial will recruit 400 adult patients (aged 18–75 years) with solitary lower pole renal stones ≤2 cm diagnosed by CT from 20 high-volume urological centres in China. Participants will be randomised 1:1 to undergo flexible ureteroscopy with either steerable or conventional FANS. The primary outcome is the success rate of navigating into the lower pole calyx (defined as successful direct stone visualisation, laser lithotripsy and aspiration without adjunct use). Secondary outcomes include immediate and 1 month stone-free rates, operative time, complication profiles (graded by Clavien–Dindo), instrument damage rates, quality-of-life assessments and cost analysis. Statistical analysis will be performed using appropriate tests for continuous and categorical data, with their significance set by prespecified superiority margins.Ethics and disseminationThe study protocol has been designed in accordance with the Declaration of Helsinki and ICH-GCP guidelines. Ethical approval was centrally granted by the Institutional Review Board of The First Affiliated Hospital of Guangzhou Medical University and adopted by all participating centres following local feasibility review. The trial results will be disseminated via peer-reviewed publication and presentation at international conferences.Trial registration numberNCT06898216.

Validating pelvic stone angle as a substitute for infundibulopelvic angle in RIRS outcome prediction.

IntroductionRenal stone disease is common, affecting mainly working-age adults, with a lifetime prevalence of 10 percent across the world. Approximately 50 percent of people with renal stones will experience symptoms and 25 percent will require treatment. This study assessed the cost effectiveness of flexible ureterorenoscopy (FURS), compared with extracorporeal shockwave lithotripsy (ESWL) (PUrE-RCT1) and percutaneous nephrolithotomy (PCNL) (PUrE-RCT2) for treating stones in the lower pole of the kidney.MethodsThe UK PUrE studies were pragmatic, multicenter, open-label superiority randomized controlled trials recruiting participants with lower pole stones sized 10 mm or less (n=466; PUrE-RCT1), and more than 10 but less than 25 mm (n=159; PUrE-RCT2). Mean costs to the health service and quality-adjusted life years (QALYs) were estimated using generalized linear models by intention-to-treat 12 months after randomization. A Markov model used trial data, combined with longer term data from the literature, for a five-year extrapolation based on the expected recurrence due to residual fragments. Uncertainty around results was characterized by conducting probabilistic and deterministic sensitivity analyses.ResultsFor PUrE-RCT 1, FURS was, on average, more costly (GBP1,138 [USD1,536], 95% confidence interval [CI]: GBP646 [USD872], GBP1631 [USD2,202]) and produced 0.017 (95% CI: −0.008, 0.043) additional QALYs with an incremental cost-effectiveness ratio (ICER) of GBP65,163 (USD87,970) per QALY gained. However, ESWL had a 99 percent chance of being cost effective at a GBP20,000 (USD27,000) cost per QALY threshold. For PUrE-RCT2, FURS was, on average, more costly (GBP733 [USD990], 95% CI: −GBP508 [−USD686], GBP1,973 [USD2,664]) when a micro-costing approach was used and produced fewer QALYs (−0.001, 95% CI: −0.044, 0.042). PCNL had an 87 percent chance of being cost effective at a GBP20,000 (USD27,000) threshold value. However, FURS was cost effective when the Healthcare Resource Group (HRG) costing approach was used.ConclusionsPUrE-RCT1 found that ESWL was cost effective, compared with FURS, with no meaningful difference in QALYs gained, even though stone-free rates were higher after FURS. In PUrE-RCT2, PCNL was cost effective compared with FURS, but the results were sensitive to the costing approach used. Higher transparency in the methods used to derive HRG costing is needed.

BackgroundMidlife obesity and insulin resistance are established risk factors for Alzheimer's disease, but their impact on brain structure and amyloid and tau burden remains unclear. This study explored the associations of obesity (BMI ≥ 30 kg/m²) and insulin resistance (HOMA‐IR) with cortical thickness, brain volume, and PET‐derived amyloid and tau burdens in Alzheimer's‐related regions.MethodEighty cognitively normal, middle‐aged participants (mean age: 48.87 years; 32.5% male; 48.75% obese; mean BMI: 31.52 kg/m²) underwent 3T MRI, amyloid and tau PET scans, and metabolic assessments. Insulin resistance was defined as HOMA‐IR ≥ 1.9. Brain regions were segmented using FreeSurfer 7.1.1 with quality control. Amyloid PET imaging used ∼15 mCi [11C] PiB and computed whole‐brain amyloid Centiloid from the 30–60 minute scan window. Tau PET scans used AV‐1451 (7.2–10.8 mCi), analyzing standardized uptake value ratios (SUVRs) from the 50–70 minute window via the PET Unified Pipeline (PUP) Participants were categorized into four groups based on HOMA‐IR and obesity status: metabolically normal non‐obese (MNNO), metabolically abnormal non‐obese (MANO), metabolically normal obese (MNO), and metabolically abnormal obese (MAO). One‐way ANOVA, with age and sex as covariates, evaluated differences in Alzheimer's‐related cortical thickness and volume.ResultOne‐way ANOVA identified significant between‐group differences in the right posterior cingulate volume, right superior temporal volume, and total temporal lobe volume. Post‐hoc ANCOVA revealed significantly lower right posterior cingulate volume in the MAO group compared to the MNNO group. Cortical thickness analyses showed significant differences in the left superior temporal and left temporal pole regions, with post‐hoc results indicating significantly lower left temporal pole thickness in the MAO compared to the MNNO group. PET‐derived results showed significant between‐group differences in whole‐brain amyloid Centiloid and total inferior temporal cortex amyloid. Post‐hoc ANCOVA revealed significantly higher whole‐brain amyloid Centiloid and total inferior temporal cortex amyloid in the MAO group compared to the MNNO group. No significant between‐group differences in tau burden were observed in the ROIs.ConclusionMidlife obesity is associated with reduced volumes and higher amyloid burden in Alzheimer's disease‐associated region of the brain. The lack of significant tau burden differences reflects the cohort's subclinical stage of the disease.

Should the presence of ipsilateral lower pole vesicoureteral reflux impact the decision to offer a uretero-ureterostomy for children with duplication anomalies?

ABSTRACTWilms tumor, or nephroblastoma, is a malignant embryonal tumor originating from nephrogenic blastema, which imitates the histology of a developing kidney. Primarily, it occurs in children. Wilms tumor is exceedingly rare in adults, where the diagnosis is often delayed, and the prognosis tends to be worse compared to children. Owing to their rarity in the adult population, Wilms tumors do not have true treatment guidelines and are instead treated with regimens identical to those for pediatric tumors. Herein, we present a case of Wilms tumor in a middle‐aged adult and review the relevant literature. A 48‐year‐old female presented to our facility with a long‐standing history of left flank pain for more than 4 months. Upon examination, a huge palpable mass in the left lumbar region was noted. An abdominal‐pelvic CT scan revealed a large, complex, heterogeneous, enhancing cortical renal mass with cystic and solid components. The mass had an exophytic growth, surrounded by fat tissue, occupying the lower pole of the left kidney, compressing renal parenchyma with no infiltration of the renal vein or inferior vena cava. A clinical diagnosis of renal cell carcinoma was considered, and surgery was recommended. Pathology evaluation of the nephrectomy specimen confirmed it to be a Wilms tumor. She was discussed in a multidisciplinary team, and a consensual decision was made to be given palliative chemotherapy with a combination of vincristine, dactinomycin, doxorubicin, and cyclophosphamide after optimization. This case report highlights the rarity of Wilms tumor in adults, especially in middle age, and emphasizes the importance of considering it in the differential diagnosis of renal masses.

Introduction Extracorporeal Shockwave Lithotripsy (SWL) remains a pivotal, non-invasive treatment modality for urolithiasis, having revolutionized the management of stone disease since its introduction in the 1980s (Preminger et al., 2024; Long &amp; Matlaga, 2020). Despite its established role, the current clinical landscape sees SWL increasingly challenged by highly effective, though more invasive, endourological techniques such as Ureteroscopic Lithotripsy (URSL/RIRS) and Percutaneous Nephrolithotomy (PCNL). The enduring relevance of SWL hinges critically upon optimal patient selection and rigorous adherence to technical optimization protocols to maximize efficacy and minimize failure rates (Wang et al., 2020). Methods A systematic search compliant with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was performed, synthesizing outcomes from high-level evidence studies, including meta-analyses encompassing a minimum of 15 randomized controlled trials (RCTs) (Li et al., 2023; Mokhtari et al., 2023). Data were extracted for 12 clinical outcomes. The quality of comparative trials was assessed using the Cochrane Risk of Bias tool, version 2 (RoB 2) (Higgins et al., 2024; Minozzi et al., 2022). Results Efficacy and Logistics: Contemporary endourological treatments generally yield higher efficacy; URSL/PCNL result in significantly superior overall stone-free rates (SFRs) compared to SWL, especially for stones exceeding 10 mm and those located in the lower pole calyx (Wang et al., 2015). SWL is associated with a significantly greater need for retreatment procedures, with an Odds Ratio (OR) of 0.08 favoring URSL (Li et al., 2023). However, SWL maintains substantial logistical advantages, including a significantly shorter operating time (Standardized Mean Difference -29.314 minutes favoring SWL) and shorter hospital stay (Mean Difference 1.14 days longer for URSL) (Mohamed et al., 2023; Li et al., 2023). Safety and Predictors: While overall complication rates are statistically similar across methods (Li et al., 2023), URSL carries a higher specific risk of perforation (OR 0.13 favoring SWL) (Mohamed et al., 2023). Successful SWL is highly predictable based on pre-treatment imaging, with optimal success linked to stone density HU &lt; 1000 and SSD &lt; 10 cm (Siddiqui &amp; Ahmed, 2021; Türk et al., 2024; Ouzaid et al., 2014). Furthermore, technical refinement, such as decreasing the shock wave rate to 60 to 90 shocks per minute, substantially improves stone fragmentation efficacy (Long &amp; Matlaga, 2020). Long-Term Safety: A significant association exists between SWL performed for nephrolithiasis and the development of new-onset hypertension, evidenced by an overall Relative Risk (RR) of 1.21 (95% CI 1.11–1.31) (Seo et al., 2021). This risk increases with the number of SWL sessions required (Rudnick et al., 2018). Conclusion Extracorporeal Shockwave Lithotripsy remains the optimal non-invasive intervention for highly favorable calculi (≤ 10 mm, low HU, short SSD), provided technical optimization is rigorously applied. For stones predicted to be resistant, early treatment pivot toward URSL or PCNL is warranted to maximize definitive stone clearance and to mitigate the potentially dose-dependent long-term risk of hypertension and the requirement for multiple auxiliary procedures.

Birt-Hogg-Dubé (BHD) syndrome is a rare genetic condition characterized by pathogenic variation in the folliculin (FLCN) gene on chromosome 17p11.2. Individuals affected with BHD are at risk to develop renal cysts and masses (13-34% of cases); renal masses are mostly hybrid oncocytic/chromophobe tumors, chromophobe renal cell carcinoma, or oncocytomas. This study aims to investigate the computed tomography (CT) manifestations of renal masses associated with BHD syndrome. Multiphase CT imaging of patients with BHD syndrome who underwent renal surgery between March 2000 and December 2020 was evaluated. Imaging characteristics of the masses, including laterality, diameter, margin, tumor configuration, homogeneity, longitudinal location, percentage of tumor deepening into the kidney, location relative to the rim, presence of central scar, fat, calcification, pre-contrast density, and enhancing pattern, were recorded. This investigation included 169 renal masses from 30 adult patients with BHD syndrome (mean age 53 ± 12 years, 15 males). Surgical laterality was 36.7% left, 40.0% right, and 23.3% bilateral. The mean diameter of the examined masses was 2.71 ± 1.62cm. Growth rate analysis of 132 masses showed a growth rate of 0.04cm per year (95% CI: 0.01- 0.07). The majority of masses selected for analysis (94.1%) were hybrid tumors. In the hybrid masses, 98.8% were predominantly solid, 68.0% were homogeneous, and 73.4% had well-defined margins. Exophytic masses were predominant (79.9%), primarily located on the lateral rim (45.6%). Longitudinally, 32.6% were in the upper pole, 36.0% interpolar, and 30.5 in % lower pole. Central scar was present in 9.5%, calcification in 4.1%, and none contained fat. In the pre-contrast phase, the mean density of masses was 36.1 HU ± 8.9. Normalized enhancement based on the renal cortex was lower in the venous than the arterial phase (0.73 vs. 0.88). Our analysis confirmed that while BHD-associated renal masses demonstrate diversity in CT presentations, most are solid, homogeneous, exophytic, exhibit a pre-contrast density of 36.1 HU ± 8.9, and have well-defined margins in the lateral rim.