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Improved Surgical Visibility and Navigation during Endoscopic Treatment of Upper Tract Urothelial Carcinoma
Project Summary The importance of localizing and treating all upper tract urothelial cancer (UTUC) tumors during a renal sparing, endoscopic treatment is emphasized by the high risk of cancer progression from inadequate tumor treatment. Insufficient treatment necessitates kidney and ureteral removal (i.e., nephroureterectomy). Nephroureterectomy permanently compromises renal function, and increases morbidity and mortality, while negatively impacting a patient’s quality of life. In contrast, endoscopic treatment (i.e., using a laser to ablate only the tumors) improves long-term outcomes by sparing healthy kidney tissue. However, endoscopic treatment is underutilized compared to nephroureterectomy because it is difficult to accomplish. Successful endoscopic treatment is dependent on the surgeon’s ability to create a mental 3D map of the branched, intrarenal endoscopic anatomy intraoperatively from preoperative 2D imaging, which is extremely difficult. Since mental mapping relies on hand-eye coordination, memory, and spatial reasoning, it is inherently imprecise and its impact on accuracy and tumor treatment is dependent on the surgeon’s experience. To make matters worse, even when tumors are successfully visualized, the surgeon often cannot accurately assess the location of tumor margins or infer pathologic grade due to the limited field of view and depth of field (10mm and 6mm on average, respectively) of current scopes. The scopes only provide visualization of a small part of the surgical field at any instant. These inherent challenges prevent many surgeons from attempting endoscopic tumor treatment since incomplete treatment leads to a devastating, oncologic outcome. Our overall goal is to create an enhanced visualization and navigational system that makes endoscopic UTUC tumor treatment easier and more accurate for all surgeons, enabling wider utilization. Toward this goal, our specific objective in this proposal is to test the hypothesis that our system can make endoscopic UTUC surgery more accurate and efficient. To test this hypothesis, we propose three Specific Aims: Aim 1 involves the development of an automatic, real-time segmentation and grading system of UTUC tumors during endoscopic treatment. Aim 2 integrates a 3D navigational map of collecting system anatomy, which includes tumor and endoscope location, during endoscopic surgery. Aim 3 evaluates the system in patients, with zero risk to the human subjects. The endpoint of this R01 will be a fully validated enhanced visualization and navigational system for endoscopic UTUC surgery, which would provide the necessary experimental data towards a large-scale, multi-center clinical trial and future FDA approval. As our system would require only software integration to current endoscopic surgical cameras, all existing endoscopic surgical systems could in principle immediately benefit from the results of this project. In this way, we believe the success of our project will facilitate improved UTUC treatment and mitigate progression to a higher risk extirpative surgery.
Locally-ordered representation of 3D space in the entorhinal cortex
When animals navigate on a two-dimensional (2D) surface, many neurons in the medial entorhinal cortex (MEC) are activated as the animal passes through multiple locations (‘firing fields’) arranged in a hexagonal lattice that tiles the locomotion-surface; these neurons are known as grid cells. However, although our world is three-dimensional (3D), the 3D volumetric representation in MEC remains unknown. Here we recorded MEC cells in freely-flying bats and found several classes of spatial neurons, including 3D border cells, 3D head-direction cells, and neurons with multiple 3D firing-fields. Many of these multifield neurons were 3D grid cells, whose neighboring fields were separated by a characteristic distance – forming a local order – but these cells lacked any global lattice arrangement of their fields. Thus, while 2D grid cells form a global lattice – characterized by both local and global order – 3D grid cells exhibited only local order, thus creating a locally ordered metric for space. We modeled grid cells as emerging from pairwise interactions between fields, which yielded a hexagonal lattice in 2D and local order in 3D – thus describing both 2D and 3D grid cells using one unifying model. Together, these data and model illuminate the fundamental differences and similarities between neural codes for 3D and 2D space in the mammalian brain.
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