The findings, published in npj Digital Medicine, suggest this technology could help surgeons refine their techniques and improve patient outcomes.

The AI system, called Frame-to-Outcome (F2O), analyzes video recorded during the nerve-sparing portion of robot-assisted prostate surgery, when surgeons work to preserve the nerves responsible for sexual function. Rather than relying on experts to manually evaluate each procedure, the system automatically identifies patterns in a surgeon’s movements—called “surgical gestures”—and uses them to predict patient recovery.

Prior studies of these surgical gestures demonstrated a strong relationship between the gestures performed by the surgeon—such as the sequence of instruments used or the speed of stretching nerves to move them aside—and the patient’s outcome. By analyzing the gestures used during surgery, the AI system made determinations about whether the patient will be more or less likely to have a good outcome. Until now, this type of analysis required labor-intensive review by trained human observers.

“Our goal isn’t simply to predict who will recover,” said Andrew Hung, MD, corresponding author of the study and professor of Urology at Cedars-Sinai. “We want to identify the surgical techniques with the best outcomes so surgeons can learn, refine and improve care for our future patients.”

Investigators found that F2O matched expert human reviewers in predicting patient outcomes while dramatically reducing the time required to analyze surgical performance. The technology could eventually provide surgeons with objective feedback on the techniques most closely associated with successful patient recovery.

To develop the system, researchers trained the AI system using videos annotated by human analysts from 294 surgeries from 23 surgeons across four international centers. Then they tested it on an additional 29 surgeries and found its predictions closely matched those of expert human reviewers.

“By identifying and interpreting the gestures that result in positive patient outcomes, we can offer surgeons insights that can help improve surgical performance and patient care,” Hung said.

The study was a collaboration between the Department of Urology, the Department of Computational Biomedicine and the Center for Artificial Intelligence Research and Education (CAIRE) at Cedars-Sinai.

“This work highlights what we can achieve when surgeons and computational biomedicine experts work together toward a shared clinical goal," said Jason Moore, PhD, chair of the Cedars-Sinai Department of Computational Biomedicine and director of CAIRE. "Bringing together these disciplines allowed the team to build something that is technically rigorous and genuinely meaningful for surgeons—and their patients."

Additional Cedars-Sinai authors include Xi Li, Nicholas Matsumoto, Jay Moran, Miguel E. Hernandez, Cherine Yang, Jeanine Kim, Jasmine Lin, Peter Wager, Ujjwal Pasupulety and Atharva Deo.

Other authors include Alvin C. Goh, Christian Wagner and Geoffrey A. Sonn.

Funding: Research reported in this publication was supported by the National Cancer Institute of the National Institutes of Health under Award Number R01CA273031. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Cedars-Sinai Health Sciences University is advancing groundbreaking research and educating future leaders in medicine, biomedical sciences and allied health sciences. Learn more about the university.

“The annual AUA meeting is a pivotal event for urologists worldwide, providing a platform to discuss innovation and inspire future advancements,” said Hyung L. Kim, MD, professor of Urology and chair of the Department of Urology at Cedars-Sinai. “It is a great opportunity for our Cedars-Sinai team to collaborate with peers, sharing insights to advance research and elevate patient care across the field.” 

Cedars-Sinai Experts Available for Interviews

Michael Ahdoot, MD, assistant professor of Urology and director of the Minimally Invasive Urology Institute, will present research on the detection of bladder cancer using an advanced new urine test that measures multiple proteins and antibodies.

Timothy Daskivich, MD, associate professor of Urology and director of Urologic Oncology Research, can address the latest advances in prostate cancer treatment and patient care, including shared decision-making and life expectancy estimates in prostate cancer consultations.

Stephen Freedland, MD, professor of Urology and director of the Center for Integrated Research in Cancer and Lifestyle at Cedars-Sinai Cancer, is available to discuss the EMBARK Phase III international clinical trial, which tested a combination treatment option for men with recurrent prostate cancer. 

Andrew Hung, MD, professor of Urology and vice chair of Academic Development in the Department of Urology, can discuss artificial intelligence in surgical education and innovations in robotic surgery.

Aurash Naser-Tavakolian, MD, associate program director for the Urology Residency Training Program, can discuss treatment of male urinary incontinence and genitourinary reconstruction using minimally invasive surgical procedures.

Awards

Patrick Tamukong, MD, PhD, a urology resident in the Department of Urology at Cedars-Sinai, will receive the Humanism in Medicine Award for Residents and Fellows, presented by the Arnold P. Gold Foundation and the Urology Care Foundation. The award honors urology residents and fellows who exemplify humanism in their patient care and actively engage in humanitarian initiatives beyond their clinical responsibilities.

Scheduling Interviews

To schedule an interview with a Cedars-Sinai expert, contact Jillian Scholten at 949-244-2561 or jillian.scholten@cshs.org.

As temperatures continue to soar in Southern California, the sweltering weather is associated with numerous health risks, including heat exhaustion and heatstroke. But while temperatures rise, so does the risk of another common and extremely painful issue: kidney stones.  

“Dehydration when you’re in drier, hotter climates is a big risk for the formation of stones. The more you sweat or lose fluids, the more concentrated your urine becomes,” said Cedars-Sinai urologist Arash Akhavein, MD. “When urine is too concentrated, it won’t dilute minerals effectively, and those are the conditions under which stones may form.”

What Are Kidney Stones?

Kidney stones are hard substances that form inside the kidneys, usually composed of minerals and salts, such as calcium, oxalate or uric acid. When these stones pass through the ureter, thereby obstructing the flow of urine, they are known to cause excruciating pain.

Who Is at Risk?

“What makes people form stones can be multifactorial,” said Akhavein, adding that diet and genetics also play significant roles.

Those with family history of kidney stones and patients with certain digestive disorders, such as inflammatory bowel disease or chronic diarrhea, are at a higher risk. Approximately 10% of people will develop a kidney stone in their lifetime, according to the National Kidney Foundation, with men at a slightly increased risk than women.

Treatment Options for Stones

While some stones may pass on their own, others may require intervention to remove. This is true especially when they are large and causing blockage, uncontrollable pain or vomiting. Many patients receive shock wave lithotripsy, a noninvasive procedure that focuses high-energy sound waves to break up stones in the urinary tract into smaller, passable fragments.

The most common surgical procedure Akhavein performs is ureteroscopy. This involves guiding a scope through the urethra, during which he can use a laser to break and remove the stone fragments, while placing a temporary ureteral stent to allow passage of urine until swelling resolves.

In more extreme cases, patients may require percutaneous nephrolithotomy, a surgical procedure that punctures through the back into the affected kidney to directly remove stones that are too large to break up or remove through the ureter.

Tips for Kidney Stone Prevention

If you are prone to kidney stones, Akhavein suggests:

1. Hydrate, hydrate, hydrate
   According to Akhavein, healthy adults should produce about 2 ½ liters of urine or more in a 24-hour period to prevent stone formation or reformation. He recommends drinking about 3 liters of water daily, spaced throughout the day for these patients.
    
2. Make lemonade
   The citric acid found in lemon and lime juice can help protect against stones forming or getting larger, so adding lime or lemon to your water or enjoying a glass of fresh-squeezed, sugar-free lemonade is a delicious prevention tactic.
    
3. Mindful eating
   Limiting foods that are high in oxalate, such as spinach, kale and nuts; avoiding excess animal proteins; consuming normal amounts of calcium; and reducing salt intake may help reduce stone production. 
   
   “You don’t need to avoid these things altogether,” Akhavein said. “Everything is fine in moderation.”

Read more on the Cedars-Sinai Blog: What You Need to Know About Kidney Stones

The research findings were published in the peer-reviewed journal JAMA Internal Medicine.

Prostate cancer is the second-most common cancer in the U.S., exceeded only by breast cancer. About one-eighth of U.S. men are diagnosed with prostate cancer at a median age of 67 according to the National Cancer Institute. Most patients have slow-growing, localized tumors, confined to the prostate gland, that are unlikely to threaten their lives. Instead of immediate treatment, these low-risk patients can be monitored through “active surveillance,” in which examinations and tests are performed on a regular schedule to make sure the disease is not progressing.

“Use of active surveillance has increased over the last 15 years for men with low-risk prostate cancer, and it is now the most common treatment for these men,” said Timothy Daskivich, MD, director of Urologic Oncology Research for the Cedars-Sinai Department of Urology and corresponding author of the new study. “This approach allows these patients to avoid the risks of urinary incontinence, erectile dysfunction and other potential side effects of surgery and radiation therapy.”

Conservative management, which includes active surveillance or watchful waiting, is also recommended for men with limited life expectancies who likely will not live long enough to benefit from aggressive local treatment, even for higher-risk cancers. However, for these men, the trend is going in the opposite direction, as measured by the investigators’ analysis of extensive data from the Veterans Affairs health system. They found that for men with limited life expectancies and intermediate- and high-risk cancers, conservative management was being employed less often and that more were receiving aggressive local treatment with surgery or radiation.

“We found this pattern surprising,” Daskivich said. “Prostate cancer patients with life expectancies of less than five or 10 years were being subjected to treatments that can take up to a decade to significantly improve their chances of surviving cancer, despite guidelines recommending against treatment.”

For their study, the investigators analyzed medical data on 243,928 men in the Veterans Affairs health system who were diagnosed with localized prostate cancer between 2000 and 2019.

Among patients with average life expectancies of less than 10 years, the proportion who underwent treatments such as surgery or radiation for low-risk prostate cancer rather than receiving active surveillance decreased from 37.4% to 14.7%; but treatment for intermediate-risk disease increased from 37.6% to 59.8%. Among patients with average life expectancies of less than five years, treatment for high-risk disease increased from 17.3% to 46.5%. Among men who were overtreated, roughly 80% were treated with radiation therapy.

Solving the issue of overtreatment in higher-risk prostate cancer patients with limited longevity requires a multifaceted approach involving better estimation, communication, and integration of life expectancy into decision-making, Daskivich said. He and his team have proposed a “trifecta” method for communicating cancer prognosis to the patient. This method involves the physician discussing the likelihood of dying from the cancer with treatment versus without treatment at the endpoint of the patient’s life expectancy. This approach personalizes the risk of the cancer that is relevant to each patient.

“Our goal is to encourage clinicians to make longevity part of the discussion about the best treatment options so that prostate cancer patients with limited life expectancies can make educated choices,” Daskivich said. “A patient may be given this data and choose to pursue surgery or radiation treatments regardless of a limited probability of benefit.  Another patient may take a different course.”

“Every individual is different, and statistical averages for lifespan, treatment effectiveness and cancer risk cannot predict outcomes with certainty,” Daskivich added. “But patients should be given the opportunity to make informed decisions with the best possible information.”

Hyung L. Kim, MD, chair of the Department of Urology at Cedars-Sinai, said the JAMA Internal Medicine study reflects a signature strength of Cedars-Sinai: the close cooperation among researchers and clinicians. “Many of our investigators are themselves clinicians, which ensures that their research addresses real-life problems in healthcare with an emphasis on finding solutions,” he said.

Other Cedars-Sinai authors include Michael Luu and John R. Heard. Other authors include I-Chun Thomas from Stanford University and senior author John T. Leppert from Stanford University in Stanford, California, and the VA Palo Alto Health Care System in Palo Alto, California.

This work was supported in part by VA Merit Review (I01 HX0021261 to JL). The Department of Veterans Affairs Health Services Research and Development Service work was supported using resources and facilities at the VA Informatics and Computing Infrastructure (VINCI), VA HSR RES 13-457. The contents do not represent the views of the U.S. Department of Veterans Affairs or the U.S. Government.

Follow Cedars-Sinai Academic Medicine on LinkedIn for more on the latest basic science and clinical research from Cedars-Sinai.

The prostate, a small gland that helps make semen, also produces a protein called prostate-specific antigen, or PSA. Blood levels of PSA tend to be elevated in people who have prostate cancer, and the PSA test, which measures those levels, is a common prostate cancer screening tool.

“Many transgender women take estrogen as part of their gender-affirming care,” said Stephen Freedland, MD, the Warschaw, Robertson, Law Families Chair in Prostate Cancer at Cedars-Sinai and senior author of the study. “This drastically lowers PSA levels, which could mean the threshold we are using as ‘normal’ is too high to detect early-stage cancer in these patients. We undertook this study to determine typical PSA values for this population so that we can screen them more appropriately.”

According to current guidelines, PSA levels above 4.0 nanograms per milliliter of blood (ng/mL) suggest cancer could be present, and that additional investigation, such as a prostate biopsy, is needed.

"In the study, we used Veterans Health Administration records to identify 210 transgender women without known prostate cancer who were taking estrogen,” said Farnoosh Nik-Ahd, MD, a urology resident at the University of California, San Francisco, and first author of the study. “We found that the median PSA value, the midpoint in the range of participants, was 0.02 ng/mL, which is fiftyfold lower than PSA values reported in similar-aged cisgender men.”

This suggests that if they are taking estrogen, transgender women who develop prostate cancer wouldn’t see their PSA rise to levels that trigger additional screening until their cancer was at a later stage, making it more difficult to treat. Nik-Ahd said that patients and clinicians should be aware of this and interpret results with caution.

“Cedars-Sinai Cancer serves one of the most diverse patient populations in the country,” said Dan Theodorescu, MD, PhD, director of Cedars-Sinai Cancer and the PHASE ONE Foundation Distinguished Chair. “This work is part of our mission to conduct research that helps us understand the unique needs of our patients, then translate our findings into practices that improve patient outcomes.”

Additional research is needed to pinpoint a specific PSA level that indicates a transgender woman taking estrogen is at high risk for developing prostate cancer. And Freedland, who is also a professor of Urology at Cedars-Sinai and staff physician at the Durham VA Medical Center in North Carolina, said this study is not a call for transgender women to be screened.

“We know that PSA screening reduces the risk that cisgender men ages 55 to 69 will die of prostate cancer, but we don’t know that it does the same thing for transgender women taking estrogen,” Freedland said. “However, because some of these women are being screened, we want to raise awareness that their typical PSA levels are different.”

Along with increased awareness, Freedland hopes to eventually see updated PSA screening guidelines. In the meantime, he advises transgender women who are taking estrogen to consult with their healthcare providers.

“Don't forget that you have a prostate and that prostates can become cancerous,” Freedland said. “The best way we know to find those cancers early and reduce the risk of death is a PSA test. And if you choose to do that, keep in mind that the test values are not calibrated for you. Bring your results—and possibly this study—to your urologist so that your results will be interpreted by someone who understands what to do with that information.”

Funding: Research reported in this publication was supported by NIA grant number R38AG07017, the 2023 Urology Care Foundation Residency Research Award Program, and the Robert J. Krane, MD, Urology Research Fund.

Additional authors include: Amanda M. De Hoedt, MS; Christi Butler, MD; Jennifer T. Anger, MD; Peter R. Carroll, MD, MPH; and Matthew R. Cooperberg, MD, MPH.

Read more on the Cedars-Sinai Blog: More Options to Treat Prostate Cancer

Neither option was appealing.

Luckily, Gold’s urologist recommended a different treatment option: prostate artery embolization. The urologist referred Gold to H. Gabriel Lipshutz, MD, a Cedars-Sinai interventional radiologist who specializes in the minimally invasive, low-risk procedure that uses tiny beads to block blood flow to the prostate, allowing it to shrink.

“Prostate artery embolization offers a dramatic improvement in quality of life for men whose symptoms are severe enough to affect their lives and the medication they’ve been using is not effective or causes unwanted side effects, or surgery is not an option for them,” Lipshutz said.

Gold was a good candidate for the outpatient procedure, which took about two hours and left him “exuberant” about being free of symptoms, side effects—and the catheter.

“Ten days after the procedure, there was definite improvement,” Gold said. “Three weeks later, I was a very happy camper. And today, my symptoms are completely gone.”

A Common Health Concern

June is Men’s Health Month, a time to raise awareness about men's health concerns and ways they can be proactive about their health.

Enlarged prostate, or benign prostatic hyperplasia (BPH), is common in men as they get older. About 50% of men have the condition at age 50, and the percentage increases with age. Most men have an enlarged prostate by the time they’re 80, according to the National Institutes of Health.

As the prostate gland grows, it presses on the urethra—the tube that carries urine from the bladder and out of the body. The result is often a weak urine stream, difficulty emptying the bladder completely, and difficulty urinating despite feeling an urgent need. Some men do not experience symptoms bothersome enough to seek treatment. But for others, like Gold, the symptoms become detrimental to their quality of life.

“You can either live with your symptoms, or you can’t,” Lipshutz said. “Men who can’t live with their symptoms seek treatment.”

It had been more than two decades since Gold, 68, had a normal urine flow. Medication helped for a while, but over time it became less effective.

Then one day late last year, Gold rushed to the hospital.

“My symptoms were as extreme as you can get—I was not able to urinate at all,” Gold said. “The suffering was unreal.”

Imaging revealed that his prostate was extremely large—too large, in fact, for some treatments. So a catheter was inserted, which Gold lived with for three months until the successful prostate artery embolization.

A Dramatically Improved Quality of Life

Prostate artery embolization is a complex procedure performed by highly trained specialists like Lipshutz. He makes a small incision in the wrist and a mini-catheter is inserted into the radial artery and then guided, using X-ray technology, through the body to the arteries that feed blood to the prostate. Microscopic beads are then injected into those arteries from the catheter to block the flow of blood.  

Because prostate artery embolization is a relatively new treatment for BPH, long-term research data is not yet available. However, clinical trials have shown the procedure to be highly effective. Patients’ urinary symptoms can continue to improve for up to six months afterward.

Complications are rare, there is virtually no risk of the incontinence or impotence that can accompany traditional surgery, and recovery time is minimal, Lipshutz said.

“Some of my patients are almost in tears because they are so happy with the results,” Lipshutz said. “These are people who were severely affected by their symptoms—not being able to sleep at night because they wake up several times to go to the bathroom, for example.

“They can’t believe how their lives have changed. Many ask, ‘Why didn’t I do this sooner?’ or [say], ‘I wish I had been aware of this procedure sooner.’”

Lipshutz partners with urologists to ensure that patients with enlarged prostate are informed of all treatment options and are treated optimally, based on each person’s individual needs.

Gold is grateful his urologist referred him to Lipshutz.

“This procedure was a godsend,” he said. “I’m back to where I was over 20 years ago. It’s changed my life.”

Read more on the Cedars-Sinai Blog: Why You May Have Trouble Peeing, Plus Solutions to Help