Improved guideline compliance and textbook oncologic outcomes among patients undergoing multimodal treatment and minimally invasive surgery for locally advanced gastric cancer.

BACKGROUND: Although receipt of neoadjuvant chemotherapy has been identified to improve unfavorable survival outcomes among patients with locally advanced gastric cancer (LAGC), several randomized controlled trials have not demonstrated a difference in oncological outcomes/overall survival (OS) among patients undergoing minimally invasive surgery (MIS) versus open gastrectomy. This study aimed to investigate National Comprehensive Cancer Network (NCCN) guideline adherence and textbook oncological outcome (TOO) among patients undergoing MIS versus open surgery for LAGC. METHODS: In this cross-sectional study, patients with stage II/III LAGC (cT2-T4N0-3M0) who underwent curative-intent treatment between 2013 and 2019 were evaluated using the National Cancer Database. Multivariable analysis was performed to assess the association between surgical approach, NCCN guideline adherence, TOO, and OS. The study was registered on the International Standard Randomised Controlled Trial Number registry (registration number: ISRCTN53410429) and conducted according to the Strengthening The Reporting Of Cohort Studies in Surgery and Strengthening the Reporting of Observational Studies in Epidemiology guidelines. RESULTS: Among 13,885 patients, median age at diagnosis was 68 years (IQR, 59-76); most patients were male (n = 9887, 71.2%) and identified as White (n = 10,295, 74.1%). Patients who underwent MIS (n = 4692, 33.8%) had improved NCCN guideline adherence and TOO compared with patients who underwent open surgery (51.3% vs 43.5% and 36.7% vs 27.3%, respectively; both P < .001). Adherence to NCCN guidelines and likelihood to achieve TOO increased from 2013 to 2019 (35.6% vs 50.9% and 31.4% vs 46.4%, respectively; both P < .001). Moreover, improved median OS was observed among patients with NCCN guideline adherence and TOO undergoing MIS versus open surgery (57.3 vs 49.8 months [P = .041] and 68.4 vs 60.6 months [P = .025], respectively). CONCLUSIONS: An overall increase in guideline-adherent treatment and achievement of TOO among patients with LAGC undergoing multimodal and curative-intent treatment in the United States was observed. Adoption of minimally invasive gastrectomy may result in improved short- and long-term outcomes.

Comparing prostatic artery embolization to surgical and minimally invasive procedures for the treatment of benign prostatic hyperplasia: a systematic review and meta-analysis.

BACKGROUND: To summarize current evidence to report a comparative systematic review and meta-analysis of prostatic artery embolization (PAE) with transurethral resection of the prostate (TURP) and open simple prostatectomy (OSP) for the treatment of benign prostatic hyperplasia (BPH). METHODS: A systematic literature search was performed to identify studies published from inception until August 2021. The search terms used were (prostate embolization OR prostatic embolization) AND (prostatic hyperplasia OR prostatic obstruction) as well as the abbreviations of PAE and BPH. Risk of bias was assessed using the Cochrane Risk of Bias tool for randomized controlled trials (RCTs) and the Risk of Bias in Non-randomized Studies-of Interventions (ROBINS-I) tool for observational studies. Random-effects meta-analysis was performed using Revman 5.4. RESULTS: Seven studies were included with 810 patients: five RCTs and one observational study compared PAE with TURP, and one observational study compared PAE with OSP. The included studies had considerable risk of bias concerns. TURP and OSP were associated with more statistically significant improvements in urodynamic measures and BPH symptoms compared to PAE. However, PAE seems to significantly improve erectile dysfunction compared to OSP and improve other outcome measures compared to TURP, although not significantly. PAE appeared to reduce adverse events and report more minor complications compared with TURP and OSP, but it is unclear whether PAE is more effective in the long-term. CONCLUSION: PAE is an emerging treatment option for patients with symptomatic BPH who cannot undergo surgery or have undergone failed medical therapy. Overall, PAE groups reported fewer adverse events. Future ongoing and longer-term studies are needed to provide better insight into the benefit of PAE compared to other treatment options.

Minimally invasive techniques in quest of Holy Grail of surgical management of enlarged prostates: a narrative review.

PURPOSE: Past decade has seen a renewed interest in minimally invasive surgical techniques (MISTs) for management of enlarged prostate. This narrative review aims to explore newer MIST for benign prostatic hyperplasia (BPH) which are not yet integrated into established societal guidelines. METHODS: We conducted a literature search across PubMed, Google Scholar, and FDA ClinicalTrials.gov databases on June 1st, 2023, to identify studies published within the past decade exploring various MISTs for BPH. Additionally, we gathered insights from abstracts presented in meetings of professional associations and corporate websites. We broadly classified these procedures into three distinct categories: energy-based, balloon dilation, and implant/stent treatments. We collected detail information about the device, procedure details, its inclusion and exclusion criteria, and outcome. RESULTS: Our review reveals that newer energy-based MISTs include Transperineal Laser Ablation, Transurethral Ultrasound Ablation, and High-Intensity Focused Ultrasound. In the sphere of balloon dilation, Transurethral Columnar Balloon Dilation and the Optilume BPH Catheter System were gaining momentum. The noteworthy implants/stents that are on horizon include Butterfly Prostatic Retraction Device, Urocross Expander System, Zenflow Spring System, and ProVee Urethral Expander System. CONCLUSION: The exploration of various MISTs reflects ongoing efforts to enhance patient care and address limitations of existing treatments. This review provides a bird-eye view and valuable insights for urologists and researchers seeking to navigate the dynamic landscape of MISTs in the quest for effective and minimally invasive solutions for enlarged prostates.

Ablative minimally invasive surgical therapies for benign prostatic hyperplasia: A review of Aquablation, Rezum, and transperineal laser prostate ablation.

INTRODUCTION: Benign prostatic hyperplasia (BPH) is one of the most common diseases affecting men and can present with bothersome lower urinary tract symptoms (LUTS). Historically, transurethral resection of the prostate (TURP) has been considered the gold standard in the treatment of LUTS due to BPH. However, TURP and other traditional options for the surgical management of LUTS secondary to BPH are associated with high rates of sexual dysfunction. In the past decade, several novel technologies, including Aquablation therapy, convective water vapor therapy (Rezum), and transperineal prostate laser ablation (TPLA), have demonstrated promising evidence to be safe and effective while preserving sexual function. METHODS: In this review, we discuss three ablative minimally invasive surgeries: Aquablation, Rezum, and TPLA. We review their techniques, safety, as well as perioperative and functional outcomes. We go into further detail regarding sexual function after these ablative minimally invasive surgical therapies. RESULTS: Aquablation is a surgeon-guided, robot-executed, heat-free ablative waterjet procedure with sustained functional outcomes at 5 years while having no effect on sexual activity. Rezum is an innovative office-based, minimally invasive surgical option for BPH that delivers convective water vapor energy into prostate adenoma to ablate obstructing tissue. Rezum leads to significant improvements in Qmax, IPSS while preserving sexual function. TPLA is another office-based technology which uses a diode laser source to produce thermoablation. It leads to improvement in Qmax, IPSS, and QoL while preserving ejaculatory function. CONCLUSIONS: Overall, ablative minimally invasive surgical therapies have demonstrated excellent safety and efficacy profiles while preserving sexual function. These modalities should be discussed with patients to ensure informed and shared decision-making. Ablative minimally invasive surgical therapies may be particularly interesting to patients who value the preservation of their sexual function.

Comparison of Minimally Invasive Procedures for Benign Prostatic Hyperplasia: A Cost-effectiveness Analysis.

Background Benign prostatic hyperplasia (BPH) is a disease that affects millions of U.S. men and is costly to treat. Purpose To compare the cost-effectiveness of four minimally invasive therapies (MITs) and medical management for the treatment of BPH. Materials and Methods A cost-effectiveness analysis from a payer's perspective with Markov modeling was performed, comparing prostatic artery embolization (PAE), prostatic urethral lift, aquablation, water vapor thermal therapy, and medical management for BPH spanning a time horizon of 5 years. The model incorporated the probability of procedural complications and recurrent symptoms necessitating retreatment, which were extracted from published studies with long-term follow-up. Costs were based on Medicare reimbursements using CPT codes for ambulatory surgery centers. Outcomes were measured using the quality-adjusted life year (QALY), incorporating both life quality and expectancy. Statistical analyses included a base case calculation (using the most probable value of each parameter) and probabilistic and deterministic sensitivity analyses. Results In the base case calculation, outcomes for the strategies were comparable, with a difference of 0.030 QALY (11 days of life in perfect health) between the most (PAE) and least (medical management) effective strategies. PAE was the most cost-effective strategy relative to medical management, with an incremental cost-effectiveness ratio of $64 842 per QALY. Probabilistic sensitivity analysis showed PAE was more cost-effective compared with prostatic urethral lift, aquablation, water vapor therapy, and medical management in pairwise comparisons. In sensitivity analysis of retreatment risk, PAE remained the most cost-effective strategy until its repeat treatment rates exceeded 2.30% per 6 months, at which point water vapor therapy became the optimal choice. PAE was the most cost-effective procedure when its procedural cost was lower than $4755. Aquablation and prostatic urethral lift became more cost-effective when their procedural costs were lower than $3015 and $1097, respectively. Conclusion This modeling-based study showed that PAE appears to be a cost-effective modality among medical management and MITs for patients with BPH, with comparable outcomes to prostatic urethral lift, water vapor therapy, and aquablation at a lower expected cost. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Gemmete in this issue.

Transanal minimally invasive surgery for benign and malignant rectal lesions: midterm outcomes from a tertiary center.

BACKGROUND: Although transanal minimally invasive surgery (TAMIS) for rectal neoplasia has gained wide acceptance, the mid-term and long-term outcomes are not widely reported in the literature. OBJECTIVE: Describe the mid-term outcomes of patients who underwent TAMIS for benign and malignant rectal lesions in a single center. DESIGN: Retrospective cohort study. SETTINGS: Tertiary referral center. PATIENTS AND METHODS: Demographic, clinical, and oncological outcomes of patients who underwent TAMIS between January 2015 and December 2022 were prospectively collected. The indication for TAMIS was based on the National Comprehensive Cancer Network guidelines. The follow up for the cancer patients included clinical examination, tumor markers every 6 months and MRI rectum at the end of one year. In addition, colonoscopy and CT scan at years one and three and a final CT scan and colonoscopy at year five. MAIN OUTCOME MEASURES: Mid-term oncological and clinical outcome. RESULTS: Thirty elective TAMIS procedures included adenocarcinoma for 33.3% (n=10) of the patients, 20% (n=6) neuroendocrine tumor and the 40% (n=12) were adenomatous lesions. Negative resection margins were achieved in all malignant lesions. Perioperative complications occurred in 2 patients (6.6%), one patient had breaching into the peritoneal cavity, and postoperative hypotension occurred in another patient. The median follow-up time was 23 months (range: 5-72 months). Two patients with adenoma and positive margins developed recurrent adenoma (6.6%) and one patient with initial polypectomy biopsy of adenocarcinoma, had TAMIS with histopathology of adenoma and distant metastasis had developed. CONCLUSIONS: TAMIS for local excision of rectal neoplasia is a valid option with favorable mid-term outcomes provided there is adherence to careful selection criteria. LIMITATIONS: Retrospective nature and small number of the patients.

Comparison of post-operative pain and quality of life between total thoracoscopic surgery and conventional full-sternotomy for aortic valve replacement.

BACKGROUND: To compare the post-operative pain and quality of life of patients who underwent total thoracoscopic surgery (TTS) or conventional full-sternotomy (CFS) for aortic valve replacement (AVR). METHODS: We reviewed the records of 223 consecutive AVR patients with either TTS or CFS from January 2018 to December 2022. We used a visual analogue scale (VAS) and the Short Form-36 Health Survey (SF-36) to measure the post-operative pain and quality of life, respectively. We also compared the operative data and clinical outcomes between the two groups. RESULTS: The TTS group had lower adjusted mean VAS scores than the CFS group at all time points after surgery (at 1 to 3 days and at 3 and 6 months, p < .001 for all comparisons), indicating less pain. The TTS group also had higher mean SF-36 scores than the CFS group up to 6 months after surgery (p < .001 for all comparisons), indicating better quality of life. The operative time was similar between the two groups (p = .224), but the TTS group had longer cardiopulmonary bypass time and aortic cross-clamp time than the CFS group (p < .001). The TTS group had more pulmonary complications than the CFS group (p = .023). However, there were no significant differences in other major complications or mortality between the two groups. CONCLUSIONS: TTS is a safe and effective alternative to CFS for AVR. TTS resulted in less pain and better quality of life, especially in the early recovery period. However, further prospective randomized controlled studies are needed to confirm our findings.

Cost-effectiveness of alternative first- and second-line treatments for benign prostatic hyperplasia in Singapore.

BACKGROUND: Minimally invasive surgical therapies, such as water vapor thermal therapy (WVTT) and prostatic urethral lift (PUL), are typically second-line options for patients in whom medical management (MM) failed but who are unwilling or unsuitable to undergo invasive transurethral resection of the prostate (TURP). However, the incremental cost-effectiveness of WVTT or PUL as first- or second-line therapy is unknown. We evaluated the incremental cost-effectiveness of alternative first- and second-line treatments for patients with moderate-to-severe benign prostatic hyperplasia (BPH) in Singapore to help policymakers make subsidy decisions based on value for money. METHODS: We considered six stepped-up treatment strategies, beginning with MM, WVTT, PUL or TURP. In each strategy, patients requiring retreatment advance to a more invasive treatment until TURP, which may be undergone twice. A Markov cohort model was used to simulate transitions between BPH severity states and retreatment, accruing costs and quality-adjusted life-years (QALYs) over a lifetime horizon. RESULTS: In moderate patients, strategies beginning with MM had similar cost and effectiveness, and first-line WVTT was incrementally cost-effective to first-line MM (33,307 SGD/QALY). First-line TURP was not incrementally cost-effective to first-line WVTT (159,361 SGD/QALY). For severe patients, WVTT was incrementally cost-effective to MM as a first-line treatment (30,133 SGD/QALY) and to TURP as a second-line treatment following MM (6877 SGD/QALY). TURP was incrementally cost-effective to WVTT as a first-line treatment (48,209 SGD/QALY) in severe patients only. All pathways involving PUL were dominated (higher costs and lower QALYs). CONCLUSION: Based on the common willingness-to-pay threshold of SGD 50,000/QALY, this study demonstrates the cost-effectiveness of WVTT over MM as first-line treatment for patients with moderate or severe BPH, suggesting it represents good value for money and should be considered for subsidy. PUL is not cost-effective as a first- nor second-line treatment. For patients with severe BPH, TURP as first-line is also cost-effective.

Benign prostatic hyperplasia (BPH) is a non-cancerous enlargement of the prostate, common among older men. Its symptoms include difficulties with starting and completing urination, incontinence, frequent and urgent need to urinate. Minimally invasive procedures, such as water vapor thermal therapy (WVTT) and prostatic urethral lift (PUL), are typically offered as second-line options to patients for whom medication has failed but who are unwilling or unsuitable to undergo invasive surgery (transurethral resection of the prostate, TURP). However, whether offering these procedures as first-line options represents good value for money (i.e. cost-effectiveness) is an open question. To address this question and inform subsidy decisions in Singapore, we investigated six stepped-up treatment strategies which differ in first- and second-line treatments. For each strategy, we simulated healthcare costs and quality of life for a cohort of moderate and severe BPH patients over their lifetime, considering the possibility of treatment-related adverse effects and multiple rounds of retreatment. The incremental cost of a unit improvement in quality of life for a strategy relative to the next most expensive one was compared against a willingness-to-pay threshold to determine cost-effectiveness. We found that WVTT was cost-effective relative to medication as a first-line treatment for patients with moderate or severe BPH, suggesting it represents good value for money and should be considered for subsidy. PUL was not cost-effective as first- nor second-line treatment. TURP is cost-effective as first-line for severe BPH patients only.

Efficacy of preoperative Shugan Sanjie decoction combined with mammotome-assisted minimally invasive surgery in the treatment of idiopathic granulomatous mastitis: A retrospective cohort study.

The management of idiopathic granulomatous mastitis (IGM) poses a significant challenge because of its ambiguous etiology. This study aimed to investigate the efficacy of traditional Chinese medicine (TCM) combined with mammotome-assisted minimally invasive surgery (MAMIS) for the treatment of IGM. This retrospective cohort study included patients with IGM who underwent treatment at our hospital between January 2017 and June 2022. Patients treated with Shugan Sanjie decoction alone and preoperative Shugan Sanjie decoction combined with MAMIS were included in Groups A and B, respectively. We focused on the demographics, clinical characteristics, and outcomes of the patients in the 2 groups. A total of 124 female patients with an average age of 33.9 ± 3.6 years were included in the study. The demographic and clinical characteristics of patients in Groups A (n = 55) and B (n = 69) were similar (P > .05). However, there were significant differences between the 2 groups in terms of treatment duration, 1-year complete remission (CR), and recurrence. Group B showed shorter treatment time (11.7 ± 5.1 vs 15.3 ± 6.4 months, P = .001), higher 1-year CR (72.5% vs 45.5%, P = .002), and lower recurrence (7.2% vs 21.8%, P = .019) in comparison to Group A. Shugan Sanjie decoction promoted the shrinkage of breast lesions in patients with IGM. Combined with MAMIS, this treatment regimen shortened the treatment duration, accelerated the recovery process, and reduced the recurrence rate.

Clinical Study of Percutaneous Endoscopic Large-channel Fusion and Transforaminal Lumbar Interbody Fusion in the Treatment of Degenerative Lumbar Spinal Stenosis.

Context: Degenerative changes in the lumbar spine more commonly cause spinal stenosis and with the aging of society, its incidence is on the rise. Endoscopic spinal surgery is a minimally invasive technique for decompression. The efficacy of percutaneous, endoscopic, large-channel fusion and transforaminal lumbar interbody fusion (TLIF) need confirmation by more studies. Objective: The study intended to investigate the clinical efficacy of percutaneous endoscopic large-channel fusion and TLIF in the treatment of degenerative lumbar spinal stenosis, to find the best treatment plan. Design: The research team performed a retrospective study. Setting: The study took place at Nanjing Lishui People's Hospital in Nanjing, Jiangsu Province, PR China. Participants: Participants were 100 patients with degenerative, lumbar, spinal stenosis who had been admitted to the hospital between October 2018 and October 2022. Intervention: The research team randomly divided participants into an intervention group and a control group, with 50 participants in each group. The intervention group received percutaneous, endoscopic, large-channel fusion and internal fixation, and the control group received foraminal, lumbar, interbody fusion. Outcome Measures: The research team measured: (1) perioperative indexes, (2) clinical efficacy at a postoperative follow-up at 6 months postintervention, (3) indexes for inflammatory responses at baseline and postintervention, (4) postoperative pain at baseline and at months 3 and 6 postintervention using a visual analog scale (VAS), (6) lumbar function at baseline and months 3 and 6 postintervention using the Oswestry Disability Index (ODI) and the Japanese Orthopedic Association (JOA) scale, and (7) complications. Results: Compared with the control group, the intervention group's perioperatively related and inflammatory-response indexes were significantly better: (1) amount of bleeding- 112.67 ± 17.38 for the control group and 78.62 ± 10.52 for the intervention group (P = .002); (2) volume of drainage-79.63 ± 14.21 for the control group and 52.18 ± 8.21 for the intervention group (P = .001); (3) ESR at baseline and postintervention-22.41 ± 5.62 and 15.18 ± 5.26, respectively, for the control group and 22.58 ± 5.82 and 10.54 ± 3.18, respectively, for the intervention group, with P = .013 postintervention; and (4) CRP at baseline and postintervention-17.42 ± 3.52 and 13.98 ± 3.65 for the control group, respectively, and 18.65 ± 3.78 and 10.14 ± 2.78 for the intervention group, with P = .008 postintervention; Also, compared to the control group, the intervention group's: (1) total effective rate was significantly higher (P = .018); (2) incidence of postoperative complications was significantly lower (P = .006); (3) VAS pain score was significantly lower at months 3 and 6, with P = .028 and P = .021, respectively; (4) Oswestry Disability Index (ODI) function score was significantly lower at months 3 and 6, with P = .016 and P = .014, respectively; and (5) postoperative JOA function score was significantly higher at months 3 and 6, with P = .011 and P = .007, respectively. Conclusions: Both percutaneous, endoscopic, large-channel fusion and TLIF had good therapeutic effects in the treatment of degenerative lumbar spinal stenosis. However, compared with the latter, the former was more effective, with better comprehensive efficacy and more obvious benefits for patients, so it's worthy of clinical promotion and use.

Comparison of Minimally Invasive Valve Surgery: Hemi-Sternotomy vs. Right Anterolateral Thoracotomy Incision.

Objective: This study aims to compare patient data from two different surgical approaches for minimally invasive valve surgery: hemi-sternotomy and right anterolateral thoracotomy. The primary objective is to determine the safety and efficacy of both surgical incisions. Methods: Between December 2019 and December 2022, a total of 90 patients underwent minimally invasive valve surgery at our center. Among them, 36 patients received the hemi-sternotomy incision with an average age of 45.86 ± 14.83, and 54 patients received the right anterolateral thoracotomy with an average age of 56.77 ± 14.83 years. In the hemi-sternotomy group, 21 patients underwent aortic valve surgery, and 15 had mitral valve surgery, while in the right anterolateral thoracotomy group, 30 patients underwent aortic valve surgery, and 15 patients had mitral valve surgery. Results: No deaths or significant bleeding occurred in the hemi-sternotomy group. However, in the right anterolateral thoracotomy group, one patient died from continuous low cardiac output syndrome after surgery, and one patient suffered a femoral artery dissection. All other patients were discharged without complications. The aortic clamp time and the cardiopulmonary bypass time were significantly lower in the hemi-sternotomy group compared to the right anterolateral thoracotomy group. Conversely, the two groups had no significant differences in intubation time, 24-hour drainage, hospitalization time, and blood transfusion. On the second day after surgery, serum c-TNT and NT-PROBNP levels significantly increased in both groups, but they were significantly higher in the right anterolateral thoracotomy group than in the hemi-sternotomy group. However, on the fifth day after surgery, serum c-TNT and NT-PROBNP levels decreased significantly in both groups, with no significant differences between them. Conclusions: Minimally invasive valve surgery, whether performed with right anterolateral thoracotomy or hemi-sternotomy, is safe and effective after the learning curve. Patients can benefit from these advances in minimally invasive cardiac surgery, and surgeons can easily master these techniques.

Complications associated with minimally invasive surgical therapies (MIST) for surgical management of benign prostatic hyperplasia: a Manufacturer and User Facility Device Experience (MAUDE) database review.

PURPOSE: MAUDE database houses medical device reports of suspected device-related complications received by Food and Drug Administration. In the present study we aim to evaluate the MAUDE database for reported complications of MIST procedures. METHODS: The database was queried using keywords: rezum, urolift, prostate embolization (PAE), transurethral needle ablation (TUNA), transurethral microwave therapy (TUMT), prostate stent and Temporarily Implanted Nitinol Device (iTIND) on 10/1/22 to extract information regarding device problems and procedure-related complications. Gupta classification system was used to stratify complications. Statistical analysis was performed to compare frequency of complications among MIST procedures. RESULTS: We found a total of 692 reports (Rezum-358, urolift-226, PAE-53, TUNA-31, TUMT-19, prostatic stent-4, and iTIND-1). Most complications related to device or users were minor (level 1 and 2) and there was no significant difference among various MIST procedures. The screen/system error was responsible for 93% and 83% aborted cases in Rezum and TUNA, respectively, and PAE showed 40% of device component detachment/fracture. Overall Urolift and TUMT were associated with statistically significant higher incidence of major (level 3 and 4) complications (23% and 21%, respectively) as compared with Rezum (7%). Most major complications needing hospitalization after Urolift included hematoma and hematuria with clots and those after Rezum included urinary tract infection and sepsis. Thirteen deaths were reported, mostly due to cardiovascular events, which were classified as not associated with the proposed treatment. CONCLUSION: MIST for BPH can occasionally cause significant morbidity. Our data should assist urologists and patients in shared decision-making process.

Comparison of 270-degree percutaneous transforaminal endoscopic decompression under local anesthesia and minimally invasive transforaminal lumbar interbody fusion in the treatment of geriatric lateral recess stenosis associated with degenerative lumbar spondylolisthesis.

PURPOSE: Various lumbar decompression techniques have been used for the treatment of degenerative lumbar spondylolisthesis (DLS). Few studies have compared the clinical efficacy of percutaneous transforaminal endoscopic decompression (PTED) and minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) in the treatment of lateral recess stenosis associated with DLS (LRS-DLS) in geriatric patients. The objective of the study was to compare the safety and short-term clinical efficacy of 270-degree PTED under local anesthesia and MIS-TLIF in the treatment of LRS-DLS in Chinese geriatric patients over 60 years old. MATERIALS AND METHODS: From January 2017 to August 2019, the data of 90 consecutive geriatric patients with single-level L4-5 LRS-DLS were retrospectively reviewed, including those in the PTED group (n = 44) and MIS-TLIF group (n = 46). The patients were followed up for at least 1 year. Patient demographics and perioperative outcomes were reviewed before and after surgery. The Oswestry Disability Index (ODI), visual analog scale (VAS) for leg pain, and modified MacNab criteria were used to evaluate the clinical outcomes. X-ray examinations were performed 1 year after surgery to assess the progression of spondylolisthesis in the PTED group and bone fusion in the MIS-TLIF group. RESULTS: The mean patient ages in the PTED and MIS-TLIF groups were 70.3 years and 68.6 years, respectively. Both the PTED and MIS-TLIF groups demonstrated significant improvements in the VAS score for leg pain and ODI score, and no significant differences were found between the groups at any time point (P > 0.05). Although the good-to-excellent rate of the modified MacNab criteria in the PTED group was similar to that in the MIS-TLIF group (90.9% vs. 91.3%, P > 0.05), PTED was advantageous in terms of the operative time, estimated blood loss, incision length, drainage time, drainage volume, length of hospital stay, and complications. CONCLUSIONS: Both PTED and MIS-TLIF led to favorable outcomes in geriatric patients with LRS-DLS. In addition, PTED caused less severe trauma and fewer complications. In terms of perioperative quality-of-life and clinical outcomes, PTED could supplement MIS-TLIF in geriatric patients with LRS-DLS.

[Minimally Invasive Treatment of Benign Prostate Enlargement]. / Minimalinvasive Therapie der gutartigen Prostatavergrösserung.

Minimally Invasive Treatment of Benign Prostate Enlargement Abstract: Minimally invasive techniques are becoming increasingly important treatment options for benign prostate enlargement. With regard to the available evidence, UroLift has a high level of evidence with two prospective randomized studies compared to sham surgery or TUR-P (Transurethral resection of the prostate). The technique is characterized by a significantly higher rate of ejaculation preservation compared to TUR-P, while the improvement in objective voiding parameters is inferior to TUR-P. With regard to Rezum water vapor ablation of the prostate, data from a randomized study compared to sham surgery and several cohort studies are available, which show a significant improvement in urinary symptoms with a high rate of sexual function preservation. The iTIND (temporary implantable nitinol device) procedure has the least amount of evidence, with only one randomized study versus sham surgery with a follow-up of one year. This technique also shows a significant improvement in urinary symptoms with a low rate of comorbidities. Prostatic stents have been on the market for many years, but data from randomized trials are still lacking. When selecting minimally invasive techniques, one should balance the wishes and expectations of the patient with respect to less comorbidities and impact on sexual function against potentially inferior improvement of symptoms and micturition parameters compared to standard techniques.

Minimally Invasive Surgery for the Treatment of Moderate to Critical Acute Pancreatitis: A Case-matched Comparison With the Traditional Open Approach Over 10 years.

PURPOSE: The purpose of this study is to compare short-term and midterm outcomes between patients with acute pancreatitis (AP) treated with minimally invasive surgery (MIS) and patients treated with open necrosectomy (ON). MATERIALS AND METHODS: We compared data of all patients who had undergone MIS for AP with a similar group of patients with ON patients between January 2012 and June 2021 using a case-matched methodology based on AP severity and patient characteristics. Inhospital and midterm follow-up variables, including quality-of-life assessment, were evaluated. RESULTS: Starting from a whole series of 79 patients with moderate to critical AP admitted to our referral center, the final study sample consisted of 24 patients (12 MIS and 12 ON). Postoperative (18.7±10.9 vs. 30.3±21.7 d; P =0.05) and overall hospitalization (56.3±17.4 vs. 76.9±39.4 d; P =0.05) were lower in the MIS group. Moreover, the Short-Form 36 scores in the ON group were statistically significantly lower in role limitations because of emotional problems ( P =0.002) and health changes ( P =0.03) at 3 and 6 months and because of emotional problems ( P =0.05), emotional well-being ( P =0.02), and general health ( P =0.007) at 1 year. CONCLUSIONS: MIS for the surgical management of moderate to critical AP seems to be a good option, as it could provide more chances for a better midterm quality of life compared with ON. Further studies are needed to confirm our findings.

Safety and feasibility of same-day discharge following minimally invasive hysterectomy in the morbidly obese patient population.

OBJECTIVES: To determine whether morbid obesity should serve as an independent factor in the decision for same day discharge following minimally invasive hysterectomy. METHODS: Retrospective review was performed of patients with BMI ≥ 40 who underwent minimally invasive hysterectomy within a single comprehensive cancer center between January 2018 - August 2020. Demographics, perioperative factors, post-operative monitoring, complications, and readmissions were compared between patients who underwent same day discharge and overnight observation using Fisher's exact tests and Wilcoxon rank-sum tests. RESULTS: 374 patients with BMI ≥ 40 were included. Eighty-three (22.2%) patients underwent same day discharge, and 291 (77.8%) patients underwent overnight observation. Factors associated with increased likelihood of same day discharge included younger age (median age 53 vs 58; p = 0.001), lower BMI (median BMI 45 vs 47; p = 0.005), and fewer medical co-morbidities (Charlson Co-Morbidity Index 2 vs 3; p < 0.001). On multivariate regression analysis, frailty (OR 2.16 [1.14-4.11], p = 0.019) and surgical completion time after 12 PM (OR 3.67 [2.16-6.24], p < 0.001) were associated with increased risk of overnight observation. Few patients admitted for routine overnight observation required medical intervention (n = 14, 4.8%); most of these patients were frail (64.3%). The overall hospital readmission rate within 30 days of discharge was 3.2% (n = 12), with no patients discharged on the day of surgery being readmitted. CONCLUSIONS: Morbid obesity alone should not serve as a contraindication to same day discharge following minimally invasive hysterectomy. Admission for observation was associated with low rates of clinically meaningful intervention, and patients who underwent same day discharge were not at increased risk of adverse outcome.

A triple minimally invasive surgery combination for subacute osteoporotic lower lumbar vertebral collapse with neurological compromise: a potential alternative to the vertebral corpectomy/expandable cage strategy.

OBJECTIVE: Acute/subacute osteoporotic vertebral collapses (OVCs) in the lower lumbar spine with neurological compromise, although far less well documented than those in the thoracolumbar junction, may often pose greater treatment challenges. The authors clarified the utility of 3 familiar combined techniques of minimally invasive surgery for this condition as an alternative to the corpectomy/expandable cage strategy. METHODS: This report included the authors' first 5 patients with more than 2 years (range 27-48 months) of follow-up. The patients were between 68 and 91 years of age, and had subacute painful L4 OVC with neurological compromise and preexisting lumbar spinal stenosis. The authors' single-stage minimally invasive surgery combination consisted of the following: step 1, balloon kyphoplasty for the L4 OVC to restore its strength, followed by L4-percutaneous pedicle screw (PPS) placement with patients in the prone position; step 2, tubular lateral lumbar interbody fusion (LLIF) at the adjacent disc space involved with endplate injury, with patients in the lateral position; and step 3, supplemental PPS-rod fixation with patients in the prone position. RESULTS: Estimated blood loss ranged from 20 to 72 mL. Neither balloon kyphoplasty-related nor LLIF-related potentially serious complications occurred. With CT measurements at the 9 LLIF levels, the postoperative increases averaged 3.5 mm in disc height and 3.7 mm in bilateral foraminal heights, which decreased by only 0.2 mm and 0 mm at the latest evaluation despite their low bone mineral densities, with a T-score of -3.8 to -2.6 SD. Canal compromise by fracture retropulsion decreased from 33% to 23% on average. As indicated by MRI measurements, the dural sac progressively enlarged and the ligamentum flavum increasingly shrank over time postoperatively, consistent with functional improvements assessed by the physician-based, patient-centered measures. CONCLUSIONS: The advantages of this method over the corpectomy/expandable cage strategy include the following: 1) better anterior column stability with a segmentally placed cage, which reduces stress concentration at the cage footplate-endplate interface as an important benefit for patients with low bone mineral density; 2) indirect decompression through ligamentotaxis caused by whole-segment spine lengthening with LLIF, pushing back both the retropulsed fragments and the disc bulge anteriorly and unbuckling the ligamentum flavum to diminish its volume posteriorly; and 3) eliminating the need for segmental vessel management and easily bleeding direct decompressions. The authors' recent procedural modification eliminated step 3 by performing loose PPS-rod connections in step 1 and their tight locking after LLIF in step 2, reducing to only once the number of times the patient was repositioned.

Procedimiento de malone videoasistido en pediatria: primeros dos casos en Uruguay / Laparoscopic malone procedure in pediatrics: first cases in Uruguay / Procedimento de malone videoassistido em pediatria: dois primeiros casos no Uruguai

El procedimiento de apendicostomía continente para la realización de enemas anterógrados ha sido publicado ya hace varios años para el tratamiento de la incontinencia fecal y del estreñimiento de muy difícil manejo. Otra indicación del mismo incluye el estreñimiento severo, en el cual se agotaron las medidas farmacológicas y el único tratamiento efectivo es la realización de enemas. El objetivo principal del procedimiento es ofrecer a los niños y sus familias una alternativa a la hora de realizar los enemas, logrando una mayor adherencia al tratamiento y buscando alcanzar una mejor calidad de vida que permita adecuarse a las actividades con sus pares. Por otra parte permite al niño ir logrando cierta independencia gradual a medida que crezca, preparándolos para el futuro y haciéndolos participes activos de su cuidado. Se describen los primeros casos en donde utilizamos en nuestro medio el abordaje laparoscópico, sus indicaciones, la técnica quirúrgica y los resultados iniciales. Hemos constatado como ventaja principal los beneficios del abordaje mínimamente invasivo, como la exploración completa de la cavidad abdominal, el menor dolor postoperatorio, cicatrices más pequeñas, menor creación de adherencias.

The appendicostomy procedure for performing antegrade enemas has been published several years ago for the treatment of fecal incontinence and constipation that are very difficult to manage. The Malone procedure is performed in our setting, especially in patients with fecal incontinence secondary to neurological disorders such as myelomeningocele using a conventional approach. Other indications of it is severe constipation, in which pharmacological measures have been exhausted and the only effective treatment is enemas. The main objective of the procedure is to offer children and their families an alternative when performing enemas, achieving greater adherence to treatment and seeking to achieve a better quality of life that allows them to adapt to the activities of their peers. On the other hand, it allows the child to achieve a certain gradual independence as they grow, preparing them for the future and making them active participants in their care. The first cases in which we use the laparoscopic approach, its indications, the surgical technique and the initial results are described. We think that its main advantage is the benefits of the minimally invasive approach, such as complete exploration of the abdominal cavity, less postoperative pain, smaller scars, and less creation of adhesions.

O procedimento de apendicostomia continente para a realização de enemas anterógrados foi publicado há vários anos para o tratamento de incontinência fecal e constipação de difícil manejo. Outra indicação inclui constipação grave, na qual as medidas farmacológicas foram esgotadas e o único tratamento eficaz são os enemas. O principal objetivo do procedimento é oferecer às crianças e seus familiares uma alternativa na realização dos enemas, alcançando maior adesão ao tratamento e buscando alcançar uma melhor qualidade de vida que lhes permita adaptar-se às atividades com seus pares. Por outro lado, permite que a criança alcance uma certa independência gradual à medida que cresce, preparando-a para o futuro e tornando-a participante ativa em seus cuidados. São descritos os primeiros casos em que utilizamos a via laparoscópica, suas indicações, a técnica cirúrgica e os resultados iniciais. Confirmamos os benefícios da abordagem minimamente invasiva como principal vantagem, como exploração completa da cavidade abdominal, menos dor pós-operatória, cicatrizes menores e menor formação de aderências.

Development of Injectable Calcium Sulfate and Self-Setting Calcium Phosphate Composite Bone Graft Materials for Minimally Invasive Surgery.

The demand of bone grafting is increasing as the population ages worldwide. Although bone graft materials have been extensively developed over the decades, only a few injectable bone grafts are clinically available and none of them can be extruded from 18G needles. To overcome the existing treatment limitations, the aim of this study is to develop ideal injectable implants from biomaterials for minimally invasive surgery. An injectable composite bone graft containing calcium sulfate hemihydrate, tetracalcium phosphate, and anhydrous calcium hydrogen phosphate (CSH/CaP paste) was prepared with different CSH/CaP ratios and different concentrations of additives. The setting time, injectability, mechanical properties, and biocompatibility were evaluated. The developed injectable CSH/CaP paste (CSH/CaP 1:1 supplemented with 6% citric acid and 2% HPMC) presented good handling properties, great biocompatibility, and adequate mechanical strength. Furthermore, the paste was demonstrated to be extruded from a syringe equipped with 18G needles and exerted a great potential for minimally invasive surgery. The developed injectable implants with tissue repairing potentials will provide an ideal therapeutic strategy for minimally invasive surgery to apply in the treatment of maxillofacial defects, certain indications in the spine, inferior turbinate for empty nose syndrome (ENS), or reconstructive rhinoplasty.