Mid-term clinical and sonographic outcomes of minimally invasive acromioclavicular joint reconstruction: mini-open versus arthroscopically assisted.

INTRODUCTION: The current literature describes various operative stabilization strategies which achieve good clinical outcomes after acute acromioclavicular joint (ACJ) dislocation. The aim of this study was to compare the mid-term clinical and sonographic treatment outcomes after minimally invasive mini-open and arthroscopic reconstruction. MATERIALS AND METHODS: We conducted a retrospective two-center study of patients with acute ACJ dislocation. Surgical treatment was performed using either a mini-open approach (MIOP) or an arthroscopic technique (AR). The primary outcome parameters of this study were the sonographically measured acromioclavicular (ACD) and coracoclavicular distances (CCD). Secondary outcome parameters included the Constant-Murley score (CS), range of motion (ROM), postoperative pain scale (VAS), return to daily routine, return to sports, complications, as well as operative revisions. RESULTS: After a mean follow-up of 29 months, 30 patients were included in this study with an average age of 41.3 ± 14.8 years (MIOP) and 41.2 ± 15.4 years (AR). The sonographic ACD (MIOP 9.11 mm vs. AR 8.93 mm, p = 0.41) and CCD (MIOP 25.08 mm vs. AR 24.36 mm, p = 0.29) distances showed no statistically significant differences. Furthermore, there was no statistically significant difference when compared to the contralateral side (p = 0.42). With both techniques, patients achieved excellent clinical outcome parameters without statistically significant differences in CS (MIOP 95 vs. AR 97, p = 0.11) and VAS (MIOP 1.76 vs. AR 1.14, p = 0.18). The return to daily activity and return to sport rates did not differ. There were neither complications nor revisions in both groups. CONCLUSION: Both minimally invasive techniques for acute ACJ stabilization achieved excellent clinical and sonographic outcomes without one technique being statistically superior to the other.

Acromioclavicular joint suture button repair leads to coracoclavicular tunnel widening.

PURPOSE: Biomechanical evaluation of three different suture button devices used in acromioclavicular joint repair and analysis of their effect on post-testing tunnel widening. METHODS: Eighteen human shoulder girdles were assigned into three groups with a similar mean bone mineral density. Three different single-tunnel acromioclavicular repair devices were tested: (1) AC TightRope® with FiberWire; (2) AC Dog Bone™ Button with FiberTape; (3) Low Profile AC Repair System. Biomechanical testing was performed simulating the complex movement of the distal clavicle as follows. A vertical load of 80 N was applied continuously. The rotation of the clavicle about its long axis was set at 10° anterior and 30° posterior for 2500 cycles at 0.25 Hz. The horizontal translation of the clavicle was set at 6 mm medial and 6 mm lateral for 10,000 cycles at 1 Hz. The coracoclavicular distance was measured before and after testing. After testing, each sample underwent micro-CT analysis. Following 3D reconstruction, the area of the bone tunnels was measured at five defined cross sections. RESULTS: In TightRope® and Dog Bone™ groups, all samples completed testing, whereas in the Low Profile group, three out of six samples showed system failure. The mean absolute difference of coracoclavicular distance after testing was significantly greater in the Low Profile group compared to TightRope® and Dog Bone™ groups (4.3 ± 1.3 mm vs 1.9 ± 0.7 mm vs 1.9 ± 0.8 mm; p = 0.001). Micro-CT analysis of the specimens demonstrated significant tunnel widening in the inferior clavicular and superior coracoid regions in all three groups (p < 0.05). CONCLUSION: Significant tunnel widening can be observed for all devices and is primarily found in the inferior parts of the clavicle and superior parts of the coracoid. The Low Profile AC Repair System showed inferior biomechanical properties compared to the AC TightRope® and AC Dog Bone™ devices. Therefore, clinicians should carefully select the type of acromioclavicular repair device used and need to consider tunnel widening as a complication.

All-suture anchor pullout results in decreased bone damage and depends on cortical thickness.

PURPOSE: To evaluate the influence of cortical and cancellous bone structure on the biomechanical properties of all-suture and conventional anchors and compare the morphological bone damage after their failure. The hypothesis of the study is that all-suture anchor pullout is less invasive and that the pullout force is influenced by the cortical thickness. METHODS: Thirty human humeri were biomechanically tested as follows: starting with a load cycle from 20 to 50 N, a stepwise increase of the upper peak force by 0.05 N for each cycle at a rate of 1 Hz was performed. Analysis included maximum pullout strength for three different anchor implantation angles (45°, 90°, 110°) of the two anchor types. After anchor pullout, every sample underwent micro-CT analysis. Bone mineral density (BMD) and cortical thickness were determined at the anchor implantation site. Furthermore, the diameter of the cortical defect and the volume of the bone cavity were identified. RESULTS: The maximum pullout strength of all-suture anchors demonstrates a strong correlation to the adjacent cortical thickness (r = 0.82, p ≤ 0.05) with at least 0.4 mm needed to withstand 200 N. No correlation could be seen in conventional anchors. Moreover, no correlation could be detected for local BMD in both anchors. All-suture anchors show a significantly narrower cortical defect as well as a smaller bone cavity following pullout (4.3 ± 1.3 mm vs. 5.3 ± 0.9 mm, p = 0.037; 141 mm3 vs. 212 mm3; p = 0.009). The cortical defect is largest if the anchors are placed at a 45° angle. CONCLUSION: In contrast to conventional anchors, the pullout force of all-suture anchors depends on the thickness of the humeral cortex. Furthermore, all-suture anchors show a significantly smaller cortical defect as well as decreased bone damage in the case of pullout. Therefore, the clinical implication of this study is that all-suture anchors are advantageous due to their bone preserving ability. Also, intraoperative decortication should not be performed and cortical thickness should be preoperatively evaluated to decrease the risk of anchor failure.

Implementation of a multidisciplinary infections conference affects the treatment plan in prosthetic joint infections of the hip: a retrospective study.

INTRODUCTION: Establishing a systematic multidisciplinary approach in the treatment of prosthetic joint infections (PJI) of the hip and analyzing its effect on clinical decision-making. PATIENTS AND METHODS: Forty-six patients diagnosed with PJI of the hip were included in the retrospective study. The treatment plan was either established by a single-discipline approach (n = 20) or by a weekly multidisciplinary infections conference (n = 26) consisting of at least an orthopedic surgeon, microbiologist and pathologist. Recorded data included the length of hospital stay, number and type of surgeries, medical complications, recovered organisms as well as the number of applied antibiotics. RESULTS: Patients discussed in the multidisciplinary infections conference showed a significantly shorter in-hospital stay (29 vs 62 days; p < 0.05), a significant reduction in surgeries (1.8 vs 5.1; p < 0.05) and a smaller number of antibiotics required (2.8 vs 4.2; p < 0.05). No significant difference could be found comparing inpatient complications between the two groups. Staphylococcus aureus and coagulase-negative staphylococci were the most frequently recovered organisms in both patient groups. CONCLUSION: This study demonstrates the successful implementation of a weekly infections conference as an instrument to introduce a multidisciplinary approach to PJI of the hip. Implementation of these conferences significantly improves the treatment plan compared to a single-discipline approach, which we therefore highly recommend for other institutions. Multidiscipline may even affect clinical outcome which needs to be further investigated.

Androgen receptor expression is associated with adverse pathological features in ureteral but not in pelvicalyceal urothelial carcinomas of the upper urinary tract.

PURPOSE: This study aims to determine the significance of androgen receptor (AR) expression in urothelial carcinoma of the upper urinary tract (UTUC). METHODS: AR expression was assessed on tissue microarrays containing specimens of 737 patients with UTUC who underwent radical nephroureterectomy with curative intent. AR expression was correlated with clinical and pathological tumor features as well as recurrence-free survival (RFS), cancer-specific survival (CSS) and overall survival (OS). RESULTS: Overall, AR was expressed in 11 % of tumors. AR expression was significantly associated with tumor necrosis as well as sessile and multifocal tumor growth but not with RFS, CSS or OS. AR was detected nearly twice as often in tumors of the ureter than of the pelvicalyceal system (p = 0.005). Subgroup analyses showed that the significant associations of AR with unfavorable pathologic features were exclusively attributable to tumors located in the ureter. However, in both ureteral and pelvicalyceal tumors, AR status was independent of RFS, CSS and OS. CONCLUSIONS: In this cohort of patients treated with RNU, AR expression was found in approximately 10 % of UTUCs, twice as often in ureteral than in pelvicalyceal tumors. While AR expression had no impact on postoperative prognosis, it was significantly associated with unfavorable pathologic features in ureteral tumors. Steroid hormone signaling might be relevant for future investigations of differences between ureteral and pelvicalyceal tumors.

Prognostic significance of Fuhrman grade and age for cancer-specific and overall survival in patients with papillary renal cell carcinoma: results of an international multi-institutional study on 2189 patients.

PURPOSE: Because the prognostic impact of the clinical and pathological features on cancer-specific survival (CSS) and overall survival (OS) in patients with papillary renal cell carcinoma (papRCC) is still controversial, we want to assess the impact of clinicopathological features, including Fuhrman grade and age, on survival in surgically treated papRCC patients in a large multi-institutional series. METHODS: We established a comprehensive multi-institutional database of surgically treated papRCC patients. Histopathological data collected from 2189 patients with papRCC after radical nephrectomy or nephron-sparing surgery were pooled from 18 centres in Europe and North America. OS and CSS probabilities were estimated using the Kaplan-Meier method. Multivariable competing risks analyses were used to assess the impact of Fuhrman grade (FG1-FG4) and age groups (<50 years, 50-75 years, >75 years) on cancer-specific mortality (CSM). RESULTS: CSS and OS rates for patients were 89 and 81% at 3 years, 86 and 75% at 5 years and 78 and 41% at 10 years after surgery, respectively. CSM differed significantly between FG 3 (hazard ratio [HR] 4.22, 95% confidence interval [CI] 2.17-8.22; p < 0.001) and FG 4 (HR 8.93, 95% CI 4.25-18.79; p < 0.001) in comparison to FG 1. CSM was significantly worse in patients aged >75 (HR 2.85, 95% CI 2.06-3.95; p < 0.001) compared to <50 years. CONCLUSIONS: FG is a strong prognostic factor for CSS in papRCC patients. In addition, patients older than 75 have worse CSM than patients younger than 50 years. These findings should be considered for clinical decision making.

[Salmonella osteomyelitis - a rare differential diagnosis of bone tumors]. / Salmonellenosteomyelitis ­ eine seltene Differenzialdiagnose eines Knochentumors.

This case describes a rare salmonella infection suspected to be an osseous lymphoma. A 27-year-old female presented herself with painful swelling of her knee, with prednisolone-treated Crohn's disease as her only pre-existing condition. Salmonella species group C were detected in the osseous material derived from an extraction. The disease was treated with intravenous ceftriaxone, oral cotrimoxazole as well as multiple debridements. The working diagnosis should thus always be questioned and bone pain in patients who are immunosuppressed should be further investigated.

The Singh Index does not correlate with bone mineral density (BMD) measured with dual energy X-ray absorptiometry (DXA) or peripheral quantitative computed tomography (pQCT).

The Singh Index (SI), a classification system by which the severity of osteoporosis is assessed based on plain radiographs, is a renowned, simple and inexpensive form of evaluating osteoporosis. The aim of this study was to evaluate the correlation between the SI and bone mineral density (BMD) as measured by dual energy X-ray absorptiometry (DXA) and peripheral quantitative computed tomography (pQCT). The SI was evaluated in 128 cadaveric femora (64 patients, mean age 66.7 years, range 24-89 years) by three independent observers, all blinded to plain radiographs. BMD was also analysed by means of DXA and pQCT in the cadaveric femora. The mean interrater correlation was found to be 0.629. The correlation of the mean BMD measured by DXA (DXA-BMD) and SI was found to be poor, with r = 0.49. The corresponding sensitivity of 45.2 % and specificity of 92.3 % were even poor. The BMD measured by pQCT (pQCT-BMD) also revealed a poor correlation with SI, such that r = 0.337 and r = 0.428 for the trochanteric and neck regions, respectively. Due to the poor correlation of the SI with BMD and the poorer interrater correlation, the SI should be rejected as a tool for evaluating osteoporosis. The SI was found to be too imprecise and is therefore unsuitable for diagnosing osteoporosis and osteopenia.

[Primary meningococcal infection of the knee. A rare cause of septic arthritis]. / Primäre Meningokokkeninfektion des Kniegelenks. Eine seltene Ursache einer septischen Arthritis.

This article presents a case of primary septic arthritis of the knee due to serogroup C Neisseria meningitidis. A 19-year-old female presented to the emergency department with a painless but swollen knee joint which had started 2 days previously and fever (38 °C). The patient reported that she suddenly felt unwell 3 days ago and developed a rush at the same time which had almost disappeared when arrived at the emergency department. The patient was admitted to hospital and an antibiotic therapy was started with sulbactam and ampicillin. Initially, incubation of synovial fluid over the next 3 days did not result in detection of any pathogens; therefore, a reactive arthritis was assumed until Neisseria meningitidis was detected in cultures of the synovial fluid. Therapy was then switched to antibiotic therapy with ceftriaxon and arthroscopic irrigation was performed. The patient quickly recovered and was discharged from hospital after 14 days. This case example shows the difficulties of the clinical and microbiological diagnostics of a primary septic meningococcal arthritis; however, the treatment is relatively easy and mostly successful compared to other forms of bacterial joint infection.

Pretherapeutic gamma-glutamyltransferase is an independent prognostic factor for patients with renal cell carcinoma.

BACKGROUND: Gamma-glutamyltransferase (GGT) regulates apoptotic balance and promotes cancer progression and invasion. Higher pretherapeutic GGT serum levels have been associated with worse outcomes in various malignancies, but there are no data for renal cell carcinoma (RCC). METHODS: Pretherapeutic GGT serum levels and clinicopathological parameters were retrospectively evaluated in 921 consecutive RCC patients treated with nephrectomy at a single institution between 1998 and 2013. Gamma-glutamyltransferase was analysed as continuous and categorical variable. Associations with RCC-specific survival were assessed with Cox proportional hazards models. Discrimination was measured with the C-index. Decision-curve analysis was used to evaluate the clinical net benefit. The median postoperative follow-up was 45 months. RESULTS: Median pretherapeutic serum GGT level was 25 U l(-1). Gamma-glutamyltransferase levels increased with advancing T (P<0.001), N (P=0.006) and M stages (P<0.001), higher grades (P<0.001), and presence of tumour necrosis (P<0.001). An increase of GGT by 10 U l(-1) was associated with an increase in the risk of death from RCC by 4% (HR 1.04, P<0.001). Based on recursive partitioning-based survival tree analysis, we defined four prognostic categories of GGT: normal low (<17.5 U l(-1)), normal high (17.5 to <34.5 U l(-1)), elevated (34.5 to <181.5 U l(-1)), and highly elevated (⩾181.5 U l(-1)). In multivariable analyses that adjusted for the effect of standard features, both continuously and categorically coded GGT were independent prognostic factors. Adding GGT to a model that included standard features increased the discrimination by 0.9% to 1.8% and improved the clinical net benefit. CONCLUSIONS: Pretherapeutic serum GGT is a novel and independent prognostic factor for patients with RCC. Stratifying patients into prognostic subgroups according to GGT may be used for patient counselling, tailoring surveillance, individualised treatment planning, and clinical trial design.

Late-onset palsy of the recurrent laryngeal nerve after thyroid surgery.

BACKGROUND: A small subset of patients may develop late-onset palsy of the recurrent laryngeal nerve (RLN) after thyroid surgery. However, no conclusive data have been published regarding the incidence of, and possible risk factors for, this complication. METHODS: Preoperative, intraoperative and postoperative data from consecutive patients who underwent thyroid surgery at a single centre between 1999 and 2012 were analysed. Late-onset palsy of the RLN was defined as deterioration of RLN function after normal vocal cord function as investigated by routine preoperative and postoperative laryngoscopy. RESULTS: The cohort included 16 692 patients with 28 757 nerves at risk. Early postoperative palsy of the RLN was diagnosed in 1183 nerves at risk (4·1 per cent), whereas late-onset RLN palsy was found in 41 (0·1 per cent). Late-onset palsy of the RLN was diagnosed after a median interval of 2·5 (range 0·5-12) weeks and nerve function recovered completely in 28 patients after a median interval of 3 months. This recovery rate was significantly lower than that for early-onset RLN palsy: 1068 (90·3 per cent) of 1183 nerves (P < 0·001). No particular risk factor for late-onset RLN palsy was identified. CONCLUSION: Late-onset palsy of the RLN was diagnosed in a small subset of patients after thyroid surgery, and recovery of nerve function occurred less frequently than in patients with early-onset RLN palsy.

P16INK4A immunohistochemistry for detection of human papilloma virus-associated penile squamous cell carcinoma is superior to in-situ hybridization.

We evaluated p16INK4A as a reliable option to detect human papilloma virus (HPV) DNA in penile tumor specimens. Formalin-fixed paraffin embedded samples of 26 patients with penile cancer and another 18 cases with non-tumorigenic lesions were stained by three different widely used commercially available chromogenic in-situ hybridization assays high-risk HPV CISH Y1443 (Genpoint, DAKO), pan HPV CISH Y1404 (Genpoint, DAKO), INFORM HPV III (Ventana, Tucson, Arizona) and p16INK4A immunohistochemistry, then compared to the known gold standard polymerase chain reaction detecting HPV 16, 18, 31, and 33. Immunoreactivity for p16INK4A was evaluated by using a 4-tiered (0, 1, 2, and 3) pattern based system. 19 cases were positive for p16INK4A, 13 of which showed a continuous transepithelial staining (pattern 3). Pan HPV ISH showed positivity in 9 cases, high-risk HPV ISH in 7 cases and INFORM HPVIII ISH in 7 cases. p16INK4A IHC pattern 3 versus pattern 0, 1 and 2 exhibited a specificity and positive predictive value of 100 percent, with a sensitivity and negative predictive value of 72 and 62 percent, respectively, which was much better than all HPV in-situ hybridization methods referred to polymerase chain reaction. p16INK4A seems to be a superior marker for the detection of HPV-associated penile squamous cell carcinoma compared to CISH tests, but is not recommend for the detection of non-tumorigenic lesions, where PCR should be used for the initial assessment.

Serum 20S proteasome is elevated in patients with renal cell carcinoma and associated with poor prognosis.

BACKGROUND: To date, no reliable serum marker for clear cell renal cell carcinoma (CCRCC) is available. The aim of this study was to evaluate the putative significance of circulating 20S proteasome levels. METHODS: Preoperative 20S proteasome serum levels were determined in 113 CCRCC patients and 15 healthy controls by a sandwich enzyme-linked immunosorbent assay. Associations with CCRCC, pathological variables, disease-specific survival (DSS), and response to sunitinib were evaluated. RESULTS: Median 20S proteasome levels were higher in CCRCC patients than in healthy controls (4.66 vs 1.52 µg ml(-1), P<0.0001). The area under the receiver operating characteristics curve curve was 87.1%. The 20S proteasome levels were associated with symptoms (P=0.0008), distant metastases (P=0.0011), grade (P=0.0247), and necrosis (P=0.0462). The 20S proteasome levels were identified as a prognostic factor for DSS in both univariable (hazards ratio 1.21, P<0.001) and multivariable (hazards ratio 1.17, P=0.0015) survival analysis. In patients responding to sunitinib, 20S proteasome levels were lower than in patients with stable disease and progressive disease. CONCLUSION: This study demonstrates for the first time that increased 20S proteasome levels are associated with CCRCC, advanced disease, and poor prognosis. Routine use of this marker may allow better diagnosis, risk stratification, risk-adjusted follow-up, and identification of patients with a greater likelihood of response to targeted therapy.

Incidence and severity of malreduction of the tibiofibular syndesmosis following surgical treatement of displaced ankle fractures and impact on the function -Clinical study and MRI evaluation.

PURPOSE: To compare tibiofibular reduction quality in different types of operatively treated ankle fractures and the impact on clinical and functional outcome at mid-term follow-up. PATIENTS AND METHODS: One hundred patients with an acute ankle fracture who had undergone open reduction and internal fixation were included. Eighty-eight patients who suffered from ligamentous ankle injury with neither fracture nor syndesmotic lesions served as a control group. Tibiofibular alignment was measured on MR images in all 188 patients. In case of tibiofibular malreduction tibiotalar positioning was determined as well. Clinical and functional outcome was assessed using the AOFAS hindfoot score as well as the SF-36. RESULTS: No tibiofibular malreduction was found in type Weber B fractures, irrespective of syndesmotic instability followed by syndesmotic screw placement, as compared to the control group. A significant tibiofibular malreduction was detected in bimalleolar/trimalleolar/dislocated type Weber B fractures and in isolated type Weber C fractures with syndesmotic screw, in comparison to the control group. Tibiotalar displacement could not be detected. Clinical and functional outcome analysis revealed no significant differences between the treatment groups. CONCLUSION: Three-dimensional imaging may improve tibiofibular malreduction visualization in bimalleolar/trimalleolar/dislocated type Weber B fractures and in isolated type Weber C fractures with syndesmotic transfixation. The clinical impact of improving tibiofibular positioning remains highly questionable since there was no correlation between tibiofibular alignment and the clinical outcome at mid-term follow-up.

[Invasive bladder cancer with lymphangiosis carcinomatosa and carcinoma in situ in a 19-year-old female. Case report with 21-year follow-up]. / Invasives Harnblasenkarzinom mit Lymphangiosis carcinomatosa und Carcinoma in situ bei einer 19-jährigen Patientin. Fallbericht mit Langzeitverlauf über 21 Jahre.

We report a 19-year-old female with a grade 2 transitional cell carcinoma of the bladder invading the lamina propria. In addition, lymphangiosis carcinomatosa and a carcinoma in situ were found. The presenting symptom was painless gross hematuria. The patient was treated with transurethral resection. No tumor recurrence occurred during the 21-year follow-up. The literature on bladder tumors in the first two decades of life is reviewed in this article.

Accuracy of Latarjet graft and screw position after using novel drill guide.

PURPOSE: For the success of Latarjet procedure a correct graft positioning is mandatory. Furthermore, the correct screw placement is important to avoid cartilage damage and soft tissue irritation. Due to a cadaveric experimental study, the accuracy of graft and screw positioning utilizing a novel drill guide for a minimal-invasive Latarjet procedure was analyzed. METHODS: Five human fresh-frozen shoulder specimens have been treated in accordance with the Congruent-Arc Latarjet technique using the glenoid bone loss set (Arthrex, Naples, FL, USA) with 3.75 mm cannulated screws throughout a 5 cm skin incision without detachment of the scapularis tendon. All procedures were performed by one single, experienced shoulder surgeon. The accuracy of graft and screw positioning was assessed due to a CT scan. RESULTS: A noticeable learning curve was noted during the study period as the first surgery took 45 min and the last 33 min. All grafts were correctly positioned with regard to the articular line of the glenoid surface. Impingement with the maximum head circumference was not encountered. The screw positions did not affect the suprascapular nerve. A damage of the graft was not noticed. CONCLUSIONS: The authors can recommend the usage of the new drill guide tested in this study. It seems to be beneficial in the Latarjet procedure and may ease correct graft positioning and prevent screw misplacement. Compared to fully arthroscopically performed Latarjet procedures it provides much steeper learning curve and seems technically easier and quicker to handle.

European temporal trends in the use of lymph node dissection in patients with renal cancer.

BACKGROUND: The role of lymph node dissection (LND) in renal cell carcinoma (RCC) is still under debate. We aimed to assess the utilization rates of LND over time in Europe. METHODS: A multi-institutional database of 13,581 RCC patients who underwent radical nephrectomy (RN) or nephron sparing surgery (NSS) between 1988 and 2014 was created within an European consortium. We analysed temporal trends in the frequency of LND by using Joinpoint regression. Logistic regression models were used to identify predictors of LND. RESULTS: Overall, 5114 patients (42.7%) underwent LND. Lymph node invasion was recorded in 566 cases (11% of LND patients) which represents 4.7% of the whole study cohort. A gradual decline in the use of LND started in the 1990s. After 2008 LND decreased significantly by 21.5% per year (95%CI -33.3 to -7.5, p < 0.01) until 2011 and stabilized thereafter (Annual Percentage Change 4.9%, 95%CI -3.4 to 13.8, p = 0.2). At multivariable analyses, patient age (OR 0.98, p < 0.0001), type of surgery (RN vs. NSS: OR 5.46, p < 0.0001), surgical approach (open vs. minimally invasive: OR 1.75, p < 0.0001), T stage (T2 vs. T1: OR 1.57; T3-4 vs. T1: OR 1.44, p < 0.0001), clinical tumour size (OR 1.14, p < 0.0001), and year of surgery (OR 0.95, p < 0.0001) were associated with higher probability of LND at nephrectomy. CONCLUSIONS: A trend towards lower LND was observed over time for RCC patients who underwent RN or NSS. LND is more frequently performed in younger patients, locally advanced diseases and in case of open surgery.