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BACKGROUND: Surgical decision making in the treatment of proximal humerus fractures (PHFx) is primarily based on fracture classification using standard radiographs. Due to the lack of objective criteria, this classification process is associated with high interobserver variation. In this study, we investigate the fluoroscopic analysis of humerus fractures through the surgical neck using a semi-quantitative determination of distinct angulation patterns of the proximal humerus as they appear in the image intensifier. METHODS: Using a saw bone model, defined subcapital 2-part fracture configurations were generated and assessed radiographically. Anatomical landmarks-including the greater and lesser tuberosity as well as anatomical neck-were identified using an image converter, and the exact degree of fracture displacement with 10° up to 70° (in 10° increments) of posterior, varus or combined posterior-varus angulation was compared to nondisplaced controls. From the resultant series of radiographs, the appearance of these angulations in anteroposterior (AP) and scapular Y-views were also visualized and defined. RESULTS: An angulation of 50° or more of any given 2-part fracture through the surgical neck is present when the greater tuberosity becomes the most proximal point in AP view (varus and combined posterior-varus angulation) or a bimodal form is found for the superior contour of the head with the lesser tuberosity being the most proximal point in the Y-view (posterior angulation). CONCLUSION: The radiological appearance of various PHFx constellations can be well visualized using the saw bone shoulder model. The presence of angulation in accordance with the Neer classification for group III fractures can be adequately determined by analyzing the relative position of the greater or lesser tuberosity to the humeral head calotte. This can assist the surgeon's decision on whether to operate or opt for a conservative approach. LEVEL OF EVIDENCE: Basic Science, Anatomy Study, Imaging.
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Fraturas do Úmero , Fraturas do Ombro , Tomada de Decisões , Fluoroscopia , Fixação Interna de Fraturas/métodos , Humanos , Fraturas do Úmero/diagnóstico por imagem , Fraturas do Úmero/cirurgia , Úmero/diagnóstico por imagem , Úmero/cirurgia , Fraturas do Ombro/diagnóstico por imagem , Fraturas do Ombro/cirurgiaRESUMO
BACKGROUND: Several surgical techniques have been reported for flexor tendon zone 1a-b lacerations without a clear consensus on the gold standard treatment. The purpose of this multicentre study was to measure the outcomes of zone 1a-b flexor tendon injuries treated with a pull-out suture (POS) versus direct suture (DS) technique. PATIENTS AND METHODS: Fifteen patients were treated with the pull-out technique and 22 patients with a direct suture technique between 2014 and 2020. The controlled active motion (CAM) regimen protocol and a standardised follow-up schedule were used in both groups. Data on the demographics, surgery, and treatment characteristics were collected at baseline as well as at week 6 and 13 post-operatively. The primary outcome measurement was the complication rate. Secondary outcome measurements were reoperation rate, finger range of motion (ROM), strength as well as patient satisfaction. RESULTS: The patient age ranged from 18 to 75 years in both groups with all patients having a complete FDP lesion after a clean-cut injury. The complication rate was 41% in the POS group and 16% in the DS group. The reoperation rate was 29% in the POS group and 8% in the DS group. Significant between-group differences in favour of the DS group were found in the passive DIP and passive PIP+DIP ROM at week 6 and week 13. Mean hand strength was 28.7 (11.6) kg in the POS group at week 13 and 21.3 (7.9) kg in the DS group. This difference was statistically significant (p=0.012) with a medium effect size (r=-0.41). Average patient satisfaction at week 13 was 7.5 (2.2) points in the POS and 7.7 (1.3) points in the DS group. The difference between groups was not significant (p=0.839). CONCLUSION: This register-based study demonstrates lower complication and reoperation rates with the direct suture approach compared with a pull-out button technique. Although clinical results were similar between the two surgery techniques at week 13 post-surgery, a direct suture approach should always be attempted whenever possible. If necessary, other local structures should be included to increase suture strength and allow for early active motion rehabilitation regimens.
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Introduction: Robotic-assisted transperineal MRI-US-fusion guided biopsy of the prostate is a novel and highly accurate procedure. The aim of this study was to evaluate the MonaLisa prostate biopsy system in terms of safety, tolerability, and patient-related outcomes. Methods: This prospective study included 228 patients, who had undergone Robotic-assisted transperineal MRI-US-fusion guided biopsy of the prostate at the University Hospital Basel between January 2020 and June 2022. Peri-operative side effects, functional outcomes and patient satisfaction were assessed. Results: Mean pain score on the day of biopsy was 1.3 points on VAS, which remained constant on the day after biopsy. Overall, 32 of 228 patients (14%) developed grade I complications according to Clavien-Dindo classification. No higher-grade complications occurred. Gross haematuria, hematospermia and acute urinary retention occurred in 145/228 (63.6%), 98/228 (43%) and 32/228 (14%) patients, respectively. One patient (0.4%) developed urinary tract infection. Conclusions: Robotic-assisted transperineal MRI-US-fusion guided biopsy of the prostate performed under general anesthesia is a safe and well tolerated procedure. This technique allows to omit perioperative prophylaxis and at the same time minimizes the risk of infectious complications. We attribute the favorable risk profile and tolerability to the minimal invasive approach via two entry points.
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The surgical treatment of parastomal hernias is considered complex and is known to be prone to complications. Traditionally, this condition was treated using relocation techniques or local suture repairs. Since then, several mesh-based techniques have been proposed and are nowadays used in minimally invasive surgery. Since the introduction of robot-assisted surgery to the field of abdominal wall surgery, several adaptations to these techniques have been made, which may significantly improve patient outcomes. In this contribution, we provide an overview of available techniques in robot-assisted parastomal hernia repair. Technical considerations and preliminary results of robot-assisted modified Sugarbaker repair, robot-assisted Pauli technique, and minimally invasive use of a funnel-shaped mesh in the treatment of parastomal hernias are presented. Furthermore, challenges in robot-assisted ileal conduit parastomal hernia repair are discussed. These techniques are illustrated by photographic and video material. Besides providing a comprehensive overview of robot-assisted parastomal hernia repair, this article focuses on the specific advantages of robot-assisted techniques in the treatment of this condition.
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Hérnia Incisional , Procedimentos Cirúrgicos Robóticos , Robótica , Humanos , Herniorrafia/métodos , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Telas Cirúrgicas , Hérnia Incisional/etiologia , HérniaRESUMO
The surgical treatment of parastomal hernias is considered complex and is known to be prone to complications. Traditionally, this condition was treated using relocation techniques or local suture repairs. Since then, several mesh-based techniques have been proposed and are nowadays used in minimally invasive surgery. Since the introduction of robot-assisted surgery to the field of abdominal wall surgery, several adaptations to these techniques have been made, which may significantly improve patient outcomes. In this contribution, we provide an overview of available techniques in robot-assisted parastomal hernia repair. Technical considerations and preliminary results of robot-assisted modified Sugarbaker repair, robot-assisted Pauli technique, and minimally invasive use of a funnel-shaped mesh in the treatment of parastomal hernias are presented. Furthermore, challenges in robot-assisted ileal conduit parastomal hernia repair are discussed. These techniques are illustrated by photographic and video material. Besides providing a comprehensive overview of robot-assisted parastomal hernia repair, this article focuses on the specific advantages of robot-assisted techniques in the treatment of this condition.
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Hérnia Incisional , Procedimentos Cirúrgicos Robóticos , Robótica , Humanos , Herniorrafia/métodos , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Telas Cirúrgicas , Hérnia Incisional/etiologia , HérniaRESUMO
The treatment of inguinal hernias with open and minimally invasive procedures has reached a high standard in terms of outcome over the past 30 years. However, there is still need for further improvement, mainly in terms of reduction of postoperative seroma, chronic pain, and recurrence. This video article presents the endoscopic anatomy of the groin with regard to robotic transabdominal preperitoneal patch plasty (rTAPP) and illustrates the surgical steps of rTAPP with respective video sequences. The results of a cohort study of 302 consecutive hernias operated by rTAPP are presented and discussed in light of the added value of the robotic technique, including advantages for surgical training. rTAPP is the natural evolution of conventional TAPP and has the potential to become a new standard as equipment availability increases and material costs decrease. Future studies will also have to refine the multifaceted added value of rTAPP with new parameters.
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Hérnia Inguinal , Laparoscopia , Procedimentos Cirúrgicos Robóticos , Amidinas , Estudos de Coortes , Hérnia Inguinal/cirurgia , Herniorrafia , Humanos , Telas Cirúrgicas , Resultado do TratamentoRESUMO
The treatment of inguinal hernias with open and minimally invasive procedures has reached a high standard in terms of outcome over the past 30 years. However, there is still need for further improvement, mainly in terms of reduction of postoperative seroma, chronic pain, and recurrence. This video article presents the endoscopic anatomy of the groin with regard to robotic transabdominal preperitoneal patch plasty (rTAPP) and illustrates the surgical steps of rTAPP with respective video sequences. The results of a cohort study of 302 consecutive hernias operated by rTAPP are presented and discussed in light of the added value of the robotic technique, including advantages for surgical training. rTAPP is the natural evolution of conventional TAPP and has the potential to become a new standard as equipment availability increases and material costs decrease. Future studies will also have to refine the multifaceted added value of rTAPP with new parameters.
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Hérnia Inguinal , Laparoscopia , Procedimentos Cirúrgicos Robóticos , Estudos de Coortes , Hérnia Inguinal/cirurgia , Herniorrafia , Humanos , Telas Cirúrgicas , Resultado do TratamentoRESUMO
Endoscopic management of umbilical and incisional hernias has adapted to the limitations of conventional laparoscopic instruments over the past 30 years. This includes the development of meshes for intraperitoneal placement (intraperitoneal onlay mesh, IPOM), with antiadhesive coatings; however, adhesions do occur in a significant proportion of these patients. Minimally invasive procedures result in fewer perioperative complications, but with a slightly higher recurrence rate. With the ergonomic resources of robotics, which offers angled instruments, it is now possible to implant meshes in a minimally invasively manner in different abdominal wall layers while achieving morphologic and functional reconstruction of the abdominal wall. This video article presents the treatment of ventral and incisional hernias with mesh implantation into the preperitoneal space (robot-assisted transabdominal preperitoneal ventral hernia repair, rventral TAPP) as well as into the retrorectus space (r-Rives and robotic transabdominal retromuscular umbilical prosthetic repair, rTARUP, respectively). The results of a cohort study of 118 consecutive patients are presented and discussed with regard to the added value of the robotic technique in extraperitoneal mesh implantation and in the training of residents.
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Hérnia Ventral , Hérnia Incisional , Laparoscopia , Robótica , Amidinas , Estudos de Coortes , Hérnia Ventral/cirurgia , Herniorrafia , Humanos , Hérnia Incisional/cirurgia , Telas CirúrgicasRESUMO
Endoscopic management of umbilical and incisional hernias has adapted to the limitations of conventional laparoscopic instruments over the past 30 years. This includes the development of meshes for intraperitoneal placement (intraperitoneal onlay mesh, IPOM), with antiadhesive coatings; however, adhesions do occur in a significant proportion of these patients. Minimally invasive procedures result in fewer perioperative complications, but with a slightly higher recurrence rate. With the ergonomic resources of robotics, which offers angled instruments, it is now possible to implant meshes in a minimally invasively manner in different abdominal wall layers while achieving morphologic and functional reconstruction of the abdominal wall. This video article presents the treatment of ventral and incisional hernias with mesh implantation into the preperitoneal space (robot-assisted transabdominal preperitoneal ventral hernia repair, rventral TAPP) as well as into the retrorectus space (r-Rives and robotic transabdominal retromuscular umbilical prosthetic repair, rTARUP, respectively). The results of a cohort study of 118 consecutive patients are presented and discussed with regard to the added value of the robotic technique in extraperitoneal mesh implantation and in the training of residents.
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Hérnia Ventral , Hérnia Incisional , Laparoscopia , Robótica , Estudos de Coortes , Hérnia Ventral/cirurgia , Herniorrafia , Humanos , Hérnia Incisional/cirurgia , Telas CirúrgicasRESUMO
The principle of targeted separation or weakening of individual components of the abdominal wall to relieve tension in the median line during major abdominal reconstruction has been known for over 30 years as anterior component separation (aCS) and is an established procedure. In search of alternatives with lower complication rates, posterior component separation (pCS) was developed; transversus abdominis release (TAR) is a nerve-sparing modification of pCS. With the ergonomic resources of robotics (e.g., angled instruments), TAR can be performed in a minimally invasive manner (r-TAR): hernia gaps of up to 14â¯cm can be closed and a large extraperitoneal mesh implanted. In this video article, the treatment of large incisional hernias using the rTAR technique is presented. Exemplary results of a cohort study in 13 consecutive patients are presented. The procedure is challenging, but our own results-as well as reports from the literature-are encouraging. The rTAR is becoming the pinnacle procedure for abdominal wall reconstruction.
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Parede Abdominal , Hérnia Ventral , Hérnia Incisional , Músculos Abdominais/cirurgia , Parede Abdominal/cirurgia , Estudos de Coortes , Hérnia Ventral/cirurgia , Herniorrafia , Humanos , Hérnia Incisional/cirurgia , Telas CirúrgicasRESUMO
The principle of targeted separation or weakening of individual components of the abdominal wall to relieve tension in the median line during major abdominal reconstruction has been known for over 30 years as anterior component separation (aKS) and is an established procedure. In search of alternatives with lower complication rates, posterior component separation (pKS) was developed; transversus abdominis release (TAR) is a nerve-sparing modification of pKS. With the ergonomic resources of robotics (e.g., angled instruments), TAR can be performed in a minimally invasive manner (r-TAR): hernia gaps of up to 14â¯cm can be closed and a large extraperitoneal mesh implanted. In this video article, the treatment of large incisional hernias using the rTAR technique is presented. Exemplary results of a cohort study in 13 consecutive patients are presented. The procedure is challenging, but our own results-as well as reports from the literature-are encouraging. The rTAR is becoming the pinnacle procedure for abdominal wall reconstruction.
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Parede Abdominal , Hérnia Ventral , Hérnia Incisional , Músculos Abdominais/cirurgia , Parede Abdominal/cirurgia , Estudos de Coortes , Hérnia Ventral/cirurgia , Herniorrafia , Humanos , Hérnia Incisional/cirurgia , Telas CirúrgicasRESUMO
MRI-targeted prostate biopsy improves detection of clinically significant prostate cancer (PCa). However, up to 70% of PCa lesions display intralesional tumor heterogeneity. Current target sampling strategies do not yet adequately account for this finding. This prospective study included 118 patients who underwent transperineal robotic assisted biopsy of the prostate. We identified a total of 58 PCa-positive PI-RADS lesions. We compared diagnostic accuracy of a target-saturation biopsy strategy to accuracy of single, two, or three randomly selected targeted biopsy cores and analysed potential clinical implications. Intralesional detection of clinically significant cancer (ISUP ≥ 2) was 78.3% for target-saturation biopsy and 39.1%, 52.2%, and 67.4% for one, two, and three targeted cores, respectively. Target-saturation biopsies led to a more accurate characterization of PCa in terms of Gleason score and reduced rates of significant cancer missed. Compared to one, two, and three targeted biopsy cores, target-saturation biopsies led to intensified staging procedures in 21.7%, 10.9, and 8.7% of patients, and ultimately to a potential change in therapy in 39.1%, 26.1%, and 10.9% of patients. This work presents the concept of robotic-assisted target saturation biopsy. This technique has the potential to improve diagnostic accuracy and thus individual staging procedures and treatment decisions.
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Biópsia com Agulha de Grande Calibre/métodos , Biópsia Guiada por Imagem/métodos , Imagem por Ressonância Magnética Intervencionista/métodos , Neoplasias da Próstata/diagnóstico por imagem , Ultrassonografia de Intervenção/métodos , Idoso , Idoso de 80 Anos ou mais , Humanos , Masculino , Pessoa de Meia-Idade , Gradação de Tumores , Estudos Prospectivos , Neoplasias da Próstata/patologia , Procedimentos Cirúrgicos Robóticos , Sensibilidade e EspecificidadeRESUMO
Improved and cheaper molecular diagnostics allow the shift from "one size fits all" therapies to personalised treatments targeting the individual tumor. However, the wealth of potential targets based on comprehensive sequencing remains a yet unsolved challenge that prevents its routine use in clinical practice. Thus, we designed a workflow that selects the most promising treatment targets based on multi-omics sequencing and in silico drug prediction. In this study we demonstrate the workflow with focus on bladder cancer (BLCA), as there are, to date, no reliable diagnostics available to predict the potential benefit of a therapeutic approach. Within the TCGA-BLCA cohort, our workflow identified a panel of 21 genes and 72 drugs that suggested personalized treatment for 95% of patients-including five genes not yet reported as prognostic markers for clinical testing in BLCA. The automated predictions were complemented by manually curated data, thus allowing for accurate sensitivity- or resistance-directed drug response predictions. We discuss potential improvements of drug-gene interaction databases on the basis of pitfalls that were identified during manual curation.
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Antineoplásicos/uso terapêutico , Simulação por Computador , Músculos/patologia , Medicina de Precisão , Neoplasias da Bexiga Urinária/tratamento farmacológico , Neoplasias da Bexiga Urinária/genética , Antineoplásicos/farmacologia , Variações do Número de Cópias de DNA/genética , Regulação Neoplásica da Expressão Gênica , Humanos , Invasividade Neoplásica , Polimorfismo de Nucleotídeo Único/genética , Transcriptoma/genética , Neoplasias da Bexiga Urinária/patologiaRESUMO
BACKGROUND: Transrectal (TR) ultrasound-guided prostate biopsy is one of the most commonly performed urologic procedures worldwide. The major drawback of this approach is the associated risk for infectious complications. Sepsis rates are increasing due to rising antibiotic resistance, representing a global issue. The transperineal (TP) approach for prostate biopsy has recently been adopted at many centres as an alternative to the TR biopsy, and it was shown to be associated with a lower risk for sepsis. The aim of this study was to assess safety and tolerability of TP prostate biopsy performed in local anaesthesia. METHODS: We retrospectively analysed data of patients who had undergone office-based TP prostate biopsy in local anaesthesia, performed by a single surgeon between January 2015 and May 2019. We evaluated the patients' acceptance of the procedure by a pain score, as well as its safety and diagnostic performance. RESULTS: Four hundred patients were included. Median age was 66 years [range, 49-86]. Median prostate-specific antigen (PSA) concentration was 6.4 ng/ml [range, 0.3-1400], median PSA density was 0.15 ng/ml2 [range, 0-31.1] and median prostate volume was 40 ml [range, 6-150]. A total of 118 (29.5%) and 105 (26.2%) patients had orally received two and one doses of 500 mg fluoroquinolone, respectively, and 177 (44.3%) patients did not receive any antibiotic prophylaxis. No infectious complications occurred. Median pain score was 2.0 (range, 0-8). Overall cancer detection rate was 64.5% (258/400). CONCLUSIONS: Freehand TP prostate biopsy in local anaesthesia is a safe, effective and well-tolerated outpatient procedure with a high cancer detection rate. The elimination of infectious complications and its high accuracy make this technique a feasible alternative to the TR approach for the urological office. We assume that the single puncture and our trocar-like access sheath introduction technique diminish tissue trauma and bacterial exposition, and thus contribute to these promising results.
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Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Dor Processual/diagnóstico , Próstata/patologia , Neoplasias da Próstata/diagnóstico , Infecção da Ferida Cirúrgica/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Ambulatórios/métodos , Anestesia Local , Antibioticoprofilaxia , Estudos de Viabilidade , Humanos , Biópsia Guiada por Imagem/efeitos adversos , Biópsia Guiada por Imagem/métodos , Calicreínas/sangue , Imageamento por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Imagem Multimodal/métodos , Medição da Dor/estatística & dados numéricos , Dor Processual/etiologia , Dor Processual/prevenção & controle , Períneo/cirurgia , Próstata/diagnóstico por imagem , Antígeno Prostático Específico/sangue , Neoplasias da Próstata/sangue , Neoplasias da Próstata/patologia , Reto/microbiologia , Reto/cirurgia , Estudos Retrospectivos , Infecção da Ferida Cirúrgica/etiologia , Ultrassonografia de Intervenção/métodosRESUMO
PURPOSE: Information plays an important role in the management and treatment of chronic pain conditions. Often, however, delivered information does not address specific difficulties of consumers. The present study illustrates the design and implementation of the website ONESELF - run by the Institute of Communication and Health of the University of Lugano - which has been created to meet the ranging of informational needs of chronic low back pain sufferers. METHOD: ONESELF rests on an integrated idea of health literacy that highlights the kind of information consumers need to inform their decisions about back pain. This idea has been tested through a qualitative analysis of requests posted by users in the forum of ONESELF between July 2006 and December 2007. RESULTS: Users seek information to build their declarative (factual) and procedural knowledge, as well as to evaluate that knowledge and apply it to the context of their own life. CONCLUSION: Online interactional tools such as ONESELF are a promising source of health communication, provided that the content manager of the website and the health professionals collaborate in a rigorously structured manner. ONESELF can benefit traditional medical consultations in helping screen requests from patients that do not need to see a doctor, and in acting as a repository of background information that saves consultation time for more urgent matters.
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Informação de Saúde ao Consumidor , Internet , Dor Lombar/reabilitação , Educação de Pacientes como Assunto/métodos , Doença Crônica , Letramento em Saúde , Humanos , Internet/organização & administração , Desenvolvimento de Programas , Design de Software , Interface Usuário-ComputadorRESUMO
BACKGROUND: Mastopexy is one of the most performed cosmetic surgery procedures in the U.S. Numerous studies on mastopexy techniques have been published in the past decades, including case reports, retrospective reviews, and prospective studies. However, to date, no study has investigated the overall complications or satisfaction rates associated with the wide spectrum of techniques. OBJECTIVES: This review aims to assess the outcomes of the various mastopexy techniques, without the use of implants, thus focusing on associated complications, and to provide a simplified classification system. METHODS: This systematic review was performed in accordance with the PRISMA guidelines. PubMed database was queried in search of clinical studies describing nonprosthetic mastopexy techniques, which reported the technique, indication, and outcomes. RESULTS: Thirty-four studies, published from 1980 through 2016, were included and represented 1888 treated patients. Four main surgical technique categories were identified: dermal reshape, glandular reshape, glandular reshape associated with perforator flaps, and glandular reshape with mesh support. Despite varying techniques, mastopexy was generally found to be a reliable esthetic procedure with unsatisfactory breast shape, thus accounting for only 1.3% of the patients. The overall complication rate was 10.4%. The most represented complications were scar-related (3%, including hypertrophic or unesthetic appearance) and nipple-areola-related problems (2.9%; including distortion, asymmetry, and reduction in sensation). CONCLUSIONS: Mastopexy techniques achieve high patient satisfaction and can be tailored according to patient needs and clinical presentation. Complication rates and morbidity are relatively low. However, a significant number of issues related to scars, asymmetry, and potential ptosis recurrence should be highlighted in the information provided to patients.