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Purpose: Evaluation of a kidney-adjusted enhanced recovery after surgery (ERAS ® ) protocol (kERAS) in patients undergoing nephron-sparing surgery (PN)., Methods: The kERAS protocol is a multidimensional protocol focusing on optimized perioperative fluid and nutrition management as well as strict intraoperative and postoperative blood pressure limits. It was applied in a prospective cohort (n = 147) of patients undergoing open or robotic PN. Patients were analyzed for the development of acute postoperative renal failure (AKI), achievement of TRIFECTA criteria, upstaging or new onset of chronic kidney disease (CKD) and length of hospital stay (LOS) and compared to a retrospective cohort (n = 162) without application of the protocol., Results: Cox regression analyses could not confirm a protective effect of kERAS on the development of AKI post-surgery. A positive effect was observed on TRIFECTA achievement (OR 2.2, 95% CI 1.0-4.5, p = 0.0374). Patients treated with the kERAS protocol showed less long-term CKD upstaging compared to those treated with the standard protocol (p = 0.0033). There was no significant effect on LOS and new onset of CKD., Conclusion: The implementation of a kERAS protocol can have a positive influence on long-term renal function in patients undergoing PN. It can be used safely without promoting AKI. Furthermore, it can be realized with a manageable amount of additional effort., (© 2024. The Author(s).)

Background: Currently, a standard, optimal surgical procedure is still lacking for gynecomastia. Despite the development of a variety of surgical interventions, these techniques were often limited to patients with Simon I and II. The present study aimed to introduce a novel technique for all types and grades of gynecomastia, and reported the preliminary results., Methods: Patients who received single axillary incision reverse sequence endoscopic nipple-sparing mastectomy (R-E-NSM) from March 2021 to March 2023 were enrolled at a single institution. The data from 3-month follow-up cut-off were collected prospectively and analyzed to determine the short-term esthetic and safety results of this technique, as well as the learning curve., Results: A total of 159 single axillary incision reverse sequence endoscopic nipple-sparing mastectomy procedures were performed in 81 gynecomastia patients. Among these 81 patients, 7 patients (8.6%) were classified as Simon grade I, 29 patients (35.8%) as grade IIa, 24 patients (29.6%) as grade IIb, and 21 patients (25.9%) as grade III. In the patient-reported cosmetic results, the overall satisfaction score was 8.4 ± 1.4. A total of 74.1% of patients were highly satisfied, and 25.9% were satisfied. The overall complication rate was 10.1%, and only 1 patient had a major complication. According to the cumulative sum plot analysis, approximately 12 cases were needed for surgeon B and 11 cases for surgeon C to decrease their operation time significantly., Conclusions: R-E-NSM is safe and effective for all Simon grade gynecomastia patients, with excellent cosmetic results and a short learning curve. However, a long-term follow-up assessment is still needed., Level of Evidence Iv: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 ., (© 2023. Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery.)

This study aimed to evaluate the modulated arc therapy (mARC) technique as a planning and treatment option for hippocampal sparing whole brain radiotherapy (HS-WBRT) following the Radiation Therapy Oncology Group (RTOG) 0933 dosimetric criteria. Computed tomography (CT) and magnetic resonance imaging (MRI) were selected retrospectively for 15 patients. Two types of plans were created for each patient, namely an intensity-modulated radiation therapy (IMRT) and a mARC plan. IMRT and mARC plans were compared in terms of plan quality indices, absorbed dose to organs at risk (OARs), number of monitor units (MUs), and treatment time. All plans in both techniques were considered clinically acceptable for treatment. However, IMRT plans presented a higher conformity (p = 0.01) as well as a higher homogeneity as compared to mARC plans, but this difference was not statistically significant (p > 0.05). In terms of the preservation of the hippocampus, it was observed that the IMRT plans achieved significantly lower doses for both 100% of its volume and for its maximum dose (p < 0.001). The evaluation of the remaining OARs showed that the IMRT technique resulted in lower doses, and significant differences were observed for the following organs: left cochlea (p < 0.001), left eye (p < 0.001), right eye (p = 0.03), both lenses of the eye (p < 0.001), and right optic nerve (p = 0.02). Despite these differences, the absolute differences in all dosimetric parameters were low enough to bear any clinical relevance. A drastic (close to 65%) and significant (p < 0.001) decrease was observed in the number of MUs for the mARC plans. This resulted in a substantial decrease in treatment time (60.45%, p < 0.001). It is concluded that the mARC technique is a feasible planning and treatment solution for HS-WBRT that meets the RTOG 0933 criteria. The main advantage of using mARC over IMRT for HS-WBRT is the considerable reduction in MUs and treatment time., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: Middle segment-preserving pancreatectomy (MSPP) is a relatively new parenchymal-sparing surgery that has been introduced as an alternative to total pancreatectomy (TP) for multicentric benign and borderline pancreatic diseases. To date, only 36 cases have been reported in English., Methods: We reviewed 22 published articles on MSPP and reported an additional case., Results: Our patient was a 49-year-old Japanese man diagnosed with Zollinger-Elison syndrome (ZES) caused by duodenal and pancreatic gastrinoma associated with multiple endocrine neoplasia syndrome type 1. We avoided TP and chose MSPP as the operative technique due to his relatively young age. The patient developed a grade B postoperative pancreatic fistula (POPF), which improved with conservative treatment. He was discharged without further treatment. To date, no tumor has recurred, and pancreatic function seems to be maintained. According to a literature review, the morbidity rate of MSPP is as high as 54%, mainly due to the high incidence of POPF (32%). In contrast, there was no perioperative mortality, and postoperative pancreatic function was comparable to that after conventional pancreatectomy., Conclusions: Despite the high incidence of POPF, MSPP appears to be safe, with low perioperative mortality and good postoperative pancreatic sufficiency., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Major surgical concerns associated with nipple-sparing mastectomy (NSM) are partial or total nipple-areola complex (NAC) loss, decreased sensation, and nipple malposition. Patient satisfaction and NAC outcomes including malposition in patients who have undergone unilateral expander-implant reconstruction after NSM as compared with skin-sparing mastectomy (SSM) remain unclear. Therefore, the aim of this study was to assess patient satisfaction and NAC outcomes of breast cancer patients who underwent spared or reconstructed NAC after unilateral NSM as compared with unilateral SSM., Methods: Patients who underwent immediate expander-implant breast reconstruction following unilateral NSM or SSM were included. Medical records of patients from April 2010 to February 2014 were retrospectively reviewed. Reconstruction-related complications such as infection, seroma, haematoma, delayed wound healing, and reconstruction failure were recorded. NAC outcome analysis was performed using preoperative and postoperative digital photographs for each patient. Patient satisfaction with the reconstructed breast and NAC was assessed using a study-specific questionnaire., Results: Delayed wound healing occurred in 18 of 55 NSM patients and 15 of 85 SSM patients (p = 0.040). Final reconstruction failure occurred in 0 NSM patients and 6 SSM patients (p = 0.043). The mean photography analysis score of total aesthetic outcome was 13.12 ± 2.39 in the NSM group and 14.06 ± 2.75 in the SSM group (p = 0.052). The mean questionnaire score of NAC position was 2.88 ± 0.85 in the NSM group and 3.80 ± 0.84 in the SSM group (p = 0.001). The mean questionnaire score of NAC sensitivity was 2.12 ± 0.58 in the NSM group and 1.84 ± 0.46 in the SSM group (p = 0.003). Satisfaction with the reconstructed breast was similar (p = 0.913) after NSM and SSM., Conclusions: We observed no significant difference in breast reconstruction satisfaction between the NSM and SSM groups. Although overall satisfaction with breast reconstruction is high, patients in the NSM group often report dissatisfaction with nipple position. With a favourable score for NAC position, skin-sparing mastectomy followed by NAC reconstruction can be considered as a balanced alternative to NSM for properly selected patients with breast cancer., Level of Evidence Iii: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Purpose: High thoracotomy allows access to the anterior cervicothoracic and upper thoracic vertebrae; however, traditional techniques transect shoulder girdle muscles, leading to postoperative shoulder dysfunction. Muscle-sparing techniques diminish this concern, but often sacrifice the quality of exposure. We describe a novel muscle-sparing, high thoracotomy approach for the treatment of ventral cervicothoracic and upper thoracic spine lesions., Methods: A novel muscle-sparing, high thoracotomy approach is described, utilizing a midline posterior incision with lateral extension from the lateral decubitus position. Five patients are presented to illustrate the application of this technique in thoracic tumors with intimate spinal involvement., Results: The muscle-sparing, high thoracotomy approach afforded gross total resection and spinal reconstruction in five consecutive patients, including stage IV lung carcinoma with invasion of the T5 and T6 vertebral bodies, two malignant fibrous histiocytomas causing thoracic cord compression, a metastatic T6 lesion of unknown primary with associated cord compression; and a Pancoast tumor. All patients seen at 6 months had full symmetric shoulder range of motion postoperatively., Conclusions: The described muscle-sparing, high thoracotomy approach provides excellent exposure of the ventral cervicothoracic and upper thoracic spine without the morbidity associated with the transection of shoulder girdle muscle bellies. This technique is particularly useful in patients with primary malignant bone tumors requiring en bloc excision and metastatic tumors with large soft tissue components.

Purpose: To present a novel posterior approach in multilevel cervical posterior decompression and fusion (PDF) using C2 pedicle screws that preserves the rectus capitis posterior major, oblique capitis inferior, and semispinalis cervicis., Methods: We analyzed 30 consecutive patients who underwent C2-T1 PDF using an approach that preserved these three muscles without resecting. We assessed O-C2 range of motion (ROM), cross-sectional area of the cervical posterior muscles, rotational ROM, visual analog scale (VAS) for axial pain, neck disability index (NDI), and limitations of activities of daily living (ADL) involving neck movements., Results: Mean preoperative O-C2 ROM (23.6°) was significantly increased postoperatively (33.0°). Mean atrophy rate of the cross-sectional area was 3.9%. Postoperatively, 69.8% of the preoperative rotational ROM (113.3°) was retained. The preoperative VAS for axial pain and the NDI did not increase postoperatively. The postoperative O-C2 ROM (33.9°) in 26 patients for whom extension ADL were possible was significantly larger than that in four patients for whom extension ADL were impossible (26.9°). The postoperative retained rate of rotational ROM (75.8%) in 18 patients for whom rotation ADL were possible was significantly larger than that in 12 patients for whom rotation ADL were impossible (62.3%)., Conclusions: This is potentially an effective approach for maintaining O-C2 ROM and rotational ROM, which enabled good levels of ADL after C2-T1 PDF. Axial pain and NDI were not worse after PDF.

Background: Due to the rising incidence of penile cancer and increasing life expectancy in western nations, the current international guidelines recommend a less aggressive surgical approach with reduced safety margins and preferably with organ preservation., Objectives: The goal of this review is to review the current data on stage-dependent reconstructive surgical techniques and their oncological and functional results., Materials and Methods: Five recently published reviews and several single studies and publications on the topic of organ-sparing surgical techniques and penile reconstruction were evaluated to draw conclusions for surgery in penile cancer., Results: Due to the rare incidence of penile cancer and the absence of comparative, prospective studies in the literature, evidence levels of the actual statements and conclusions are low., Conclusions: Organ-sparing techniques in penile cancer lead to slightly elevated local recurrence rates compared with traditional partial or total penile amputation. Thus, sufficient patient compliance is mandatory and an intensified follow-up for more than the usual 5 years postoperatively is required. On the other hand, these techniques enable the surgeon to offer improved functional and esthetic outcomes to the patient, maintaining erectile capacity and sensitivity. After extended partial or total penile amputation, penile reconstruction using free radial forearm flaps with later prosthetic implantation may be offered to younger and sexually active patients in cooperation with experienced plastic surgeons, even if the previously published case numbers do not permit standardization of these procedures.

In recent decades, the local treatment of penile cancer has focused primary on the removal of the primary tumor. Due to the significant psycho-oncological effects of treating the primary tumor, the guidelines on penile cancer now contain a clear recommendation for preserving the target organ and prior to each surgical procedure histological examination should be performed to confirm the penile cancer. For more advanced tumors, reconstructive plastic surgery should also be considered. The treatment of the primary tumor should be based on the stage and the local extent and size of the tumor. The aim of this article is to highlight current standards in the local treatment of penile cancer.

Introduction: Scarpa fascia preservation might be a promising approach to reduce seroma and other complications after abdominoplasty. However, the results remained controversial. We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of scarpa fascia preservation in patients with abdominoplasty., Methods: PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases were systematically searched. Randomized controlled trials and clinical controlled trials assessing the effect of scarpa fascia preservation versus control (without scarpa fascia) during abdominoplasty were included. Two investigators independently searched articles, extracted data, and assessed the quality of included studies. The primary outcomes were seroma and hematoma/bleeding. Meta-analysis was performed using random-effect model., Results: Four studies involving 630 patients were included in the meta-analysis. Overall, compared with the control group, scarpa fascia preservation was associated with a significant reduced seroma (OR 0.16; 95% CI 0.06-0.43; P = 0.0004), time until drain removal (std. mean difference = -0.92; 95% CI -1.31 to -0.54; P<0.00001;), drain output (std. mean difference = -0.92; 95% CI -1.38 to -0.45; P = 0.0001), and hospital stay (std. mean difference = -0.93; 95% CI -1.48 to -0.39; P = 0.0008), but it failed to alter hematoma/bleeding (OR 0.46; 95% CI 0.09-2.38; P = 0.36), infection (OR 0.38; 95% CI 0.11-1.25; P = 0.11), and suture rupture (OR 0.67; 95% CI 0.12-3.73; P = 0.65) in patients with abdominoplasty., Conclusions: Scarpa fascia preservation was associated with a significant decreased seroma, time until drain removal, drain output, and hospital stay, but could not change hematoma/bleeding, infection and suture rupture following abdominoplasty. Scarpa fascia preservation should be recommended during abdominoplasty., Level of Evidence Ii: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Reconstruction of the limbal stem cell niche in patients with limbal stem cell insufficiency remains one of the most challenging tasks in the treatment of ocular surface diseases. Ex vivo expansion of limbal stem cells still has potential for optimization despite positive reports in centers worldwide. New biomaterials as well as alternative cell sources for the reconstruction of the limbal stem cell niche have been published in recent years. The aim of this review is to provide insight into new biomaterials and cell sources which may find their way into clinical routine in the upcoming decades.

Limbal stem cells reside in a highly specialized complex microenvironment that is known as the stem cell niche, an anatomically protected region at the bottom of the Palisades of Vogt, where the stem cells are located and where their quiescence, proliferation and differentiation are maintained in balance. Besides the epithelial stem and progenitor cell clusters, the limbal niche comprises several types of supporting niche cells and a specific extracellular matrix mediating biochemical and biophysical signals. Stem cell-based tissue engineering aims to mimic the native stem cell niche and to present appropriate microenvironmental cues in a controlled and reproducible fashion in order to maintain stem cell function within the graft. Current therapeutic approaches for ex vivo expansion of limbal stem cells only take advantage of surrogate niches. However, new insights into the molecular composition of the limbal niche and innovative biosynthetic scaffolds have stimulated novel strategies for niche-driven stem cell cultivation. Promising experimental approaches include collagen-based organotypic coculture systems of limbal epithelial stem cells with their niche cells and biomimetic hydrogel platforms prefunctionalized with appropriate biomolecular and biophysical signals. Future translation of these novel regenerative strategies into clinical application is expected to improve long-term outcomes of limbal stem cell transplantation for ocular surface reconstruction.

Homeostasis of the corneal surface is maintained by epithelial stem cells localized in the limbus. Multiple intrinsic factors or external injuries can destroy the delicate microenvironment of limbal epithelial stem cells causing a state which is termed limbal stem cell deficiency (LSCD). In such cases, re-epithelialization of the cornea is drastically impeded and conjunctival epithelium starts to extend beyond the limbus and to invade the corneal surface. In partial LSCD, a superficial keratectomy combined with an amniotic membrane is advised and helpful to restore an intact, healthy ocular surface. In complete LSCD, stem cell transplantation is the only curative option. Before any reconstruction, causative factors and comorbidities should be eliminated or at least optimized. In cases of unilateral LSCD, stem cells can be obtained from the contralateral eye. Advanced surgical and cultivation techniques pursue a gentle, tissue-saving procedure of harvesting a limbal biopsy from the only healthy functioning eye. Patients with bilateral involvement can be treated with allogeneic tissue, but will require long-term systemic immunosuppressive therapy. Another newer option is the use of autologous, but noncorneal epithelial cells as a tissue source, e.g., buccal mucosa. Future studies will focus on the further development of cellular expansion and/or the establishment of new alternative sources for replacing limbal epithelial stem cells.

Ureteral strictures are uncommon complications of radiotherapy which are often recognized late. Their consequences range from harmless dilatation of the ureter to loss of renal function and potential life-threatening urosepsis.Therapy of radiogenic ureteral stricture is a challenging task for every urologist. Several surgical strategies including minimally invasive procedures, reconstruction and partial or complete replacement of the ureter are available.This article provides an overview of the various options in the treatment of radiogenic stricture of the ureter, focusing on the use of ileum and colon segments for ureteral substitution.

Background: Radiotherapy plays a substantial role in the treatment of malignancies. More than 2/3 of all oncologic patients undergo radiotherapy during their specific treatment. Besides manifold side effects of radiotherapy, radiogenic fistulas of the urogenital tract are a potential severe complication. These fistulas might affect the female genital tract and the urinary tract., Therapy: Potential manifold variety of radiogenic urogenital fistulas requires a specific therapy. Radiation tissue damage includes severely disturbed local blood supply. Consequently, in some cases extremely complex reconstructive techniques are necessary to restore the functionality of the urinary tract., Conclusion: The treatment of radiogenic urogenital fistulas is challenging. A successful therapy can only be achieved by local improvement of the blood supply in the damaged area.

Background: Radiotherapy in the treatment of prostate cancer is well established. Intestinal complications following radiotherapy are divided into acute and chronic toxicity. Chronic complications like perforation and fistula formation to the rectum are rare and difficult to treat., Materials and Methods: In case of chronic radiotherapy complications and particularly chronic fistula formation to the rectum, evidence is low. Therefore, an overview of the available literature of surgical therapy strategies is given., Results: Options for the treatment of acute intestinal toxicity are established and therapy algorithms exist. Therapy of acute rectal perforation covers primary suture repair with or without diversion stoma as well as primary rectal resection with or without primary restoring bowel continuity. In chronic rectal lesions and particularly in fistula formation to the rectum, abdominal treatment strategies are preferred with additional interposition of an omental flap or vascularized muscle flap., Conclusion: Although evidence for surgical therapy strategies of the rare chronic rectourethral and rectovesical fistula is low, treatment is a real interdisciplinary challenge and should be provided in a specialized center.

Radiation-induced urethral stricture occurs most often due to radiation for prostate cancer. It is one of the most common side effects of radiotherapy. Stricture rates are lowest in patients undergoing external beam radiation therapy, occur more frequently in those who require brachytherapy and show highest stricture rates in patients receiving a combination of external beam radiation and brachytherapy. Strictures are mostly located at the bulbomembranous part of the urethra. Diagnostic work-up should include basic urologic work-up, ultrasound, uroflowmetric assessment, urethroscopy, retrograde urethrogram and voiding cystourethrography. Endoscopic management such as dilatation and internal urethrotomy has been proposed in short strictures. However these therapies have a high risk for recurrence. The success rate of urethroplasty is higher. Success rates of primary end-to-end anastomosis (EPA) have been reported to be 70-95 %; rates of incontinence are 7-40 %. While success rates of buccal mucosa graft urethroplasty (BMGU) range from 71-78 %, postoperative incontinence occurs in 10.5-44 %. Usually, postoperative incontinence can successfully be treated with an artificial urinary sphincter. It seems like EPA is the treatment of choice for short urethral strictures, whereas BMGU is indicated in longer, more complex strictures. Patients should be counselled with regard to length and location of strictures as well as with regard to postoperative incontinence.

The direct anterior approach to the hip allows good exposure of acetabulum and periacetabular bones. For simple acetabular revisions it can be chosen to be small (minimally invasive); in the case of extensive periacetabular bone loss exposure of the entire ilium cranial of the acetabulum may be achieved, and the pubic bone as well as inner-pelvic structures adjacent to the acetabulum can be exposed. The internerval plane of the approach between muscles innervated by the femoral nerve and the gluteal nerves allows exposure of the ilium without endangering the nerve supply of gluteal muscles.

Background: Intertrochanteric osteotomies are part of joint-preserving hip surgery. Indications involve not only the mature but also the growing skeleton. After identification of the causative pathologies multidimensional corrections with the aim of a better joint situation and prevention of early osteoarthritis are possible., Methods: The surgical technique of intertrochanteric osteotomies is presented. Potential indications are discussed on the basis of results in the literature., Results: In the surgical treatment of developmental dysplasia of the hip intertrochanteric osteotomies are used as additional surgery. In Perthes disease the containment is improved while the onset of osteoarthritis in epiphysis capitis femoris can be decelerated. Treatment of torsion pathologies is reliable. Avascular necrosis of the femoral head and beginning osteoarthritis are critical indications., Conclusion: For appropriate indications intertrochanteric osteotomies are a valuable element in joint-preserving surgery with very good long-term results.

Bilateral oncocytosis along with multiple tumours in both kidneys represents a very rare pathology that is accompanied by diagnostic and therapeutic challenges. We report the case of a 60-year old male patient who underwent computer tomography with incidental detection of multiple bilateral and contrast enhancing renal tumours of different size. Subsequently the patient underwent nephron-sparing tumor resection, first on the right side and 4 weeks later on the left side. The histology of all removed tumors showed evidence of pure oncocytoma. There were no postoperative complications and renal function reached a stable state within 6 months follow-up. The major challenge regarding diagnostic process and therapy of this pathology is to distinguish benign oncocytoma from chromophobe renal cell carcinoma and hybrid tumours, which can all be associated with renal oncocytosis. Because of limitations concerning imaging processes and biopsy, all patients should undergo nephron-sparing surgery as far as possible. On the other hand alternative therapies should - regarding to therapy-associated morbidity and the basically benign prognosis of oncocytoma - be well discussed to obtain informed consent. In this case report different therapy options and the international literature concerning renal oncocytosis will be discussed.

Background: Muscle invasive bladder cancer is a frequent disease in Germany. The accepted therapy of choice is radical cystectomy. Due to comorbidities, radical removal of the bladder is often associated with increased perioperative morbidity; therefore alternatives to a radical procedure should be offered., Objectives: Overview and description of focal therapeutic concepts in muscle invasive bladder cancer to provide therapeutic alternatives for radical organ removal., Materials and Methods: Database research, analysis and discussion of clinical trials presenting therapeutic concepts for focal therapy in muscle invasive bladder cancer., Results: High-energy shock waves, high-intensity focused ultrasound and laser therapy are experimental concepts for muscle invasive bladder cancer. Transurethral resection and radiotherapy in combination with chemotherapy, where appropriate, are available as focal therapy in bladder cancer., Conclusions: Cystectomy is the accepted therapy for muscle invasive bladder cancer. Several therapeutic procedures are available as focal therapy. In selected cases, focal therapy can offer an alternative therapy in muscle invasive bladder cancer.

Background: Prostate cancer (PCa) is the most common cancer in men, which is increasingly diagnosed at a localized stage due to the widespread use of PSA (prostate-specific antigen)-screening., Method: Traditionally, definite treatment options for PCa include radical prostatectomy, external beam radiotherapy, or brachytherapy. However, treatment-related side effects such as urinary incontinence and erectile dysfunction are common. Alternatively, national and international guidelines recommend active surveillance (AS) as a treatment option for low-risk PCa. Organ-preserving surgery is commonly used in other organs, such as organ-conserving surgery for breast cancer. Focal therapy (FT) for PCa may close the gap between radical treatment options and active surveillance while reducing side effects., Aim: This article highlights the current therapy options for FT in Germany including their limitations and perspectives. Currently, different therapy options are available for FT in PCa. However, the use of FT is still embedded in clinical trials and has not been approved for routine use yet. Initial results seem to be promising, but most studies are currently enrolling or have not been published yet.

Background: Focal therapies for superficial penile cancer are today important treatments since organ preservation in penile cancer has a much higher priority than it used to. Because a local recurrence does not substantially influence long-term tumour-specific survival, a slightly higher risk of local recurrence is accepted in favour of maximum organ sparing., Therapy: Topical chemotherapy and laser ablation can be used for carcinoma in situ, while laser ablation and surgical options are used for Ta/T1 tumours. Radiotherapeutic options can be used, but carry a much higher rate of local complications and lower local control rates.

Background: The rising incidence of renal cell carcinoma, its more frequent early detection (stage T1a) and the increasing prevalence of chronic renal failure with higher morbidity and shorter life expectancy underscore the need for multimodal focal nephron-sparing therapy., Discussion: During the past decade, the gold standard shifted from radical to partial nephrectomy. Depending on the surgeon's experience, the patient's constitution and the tumor's location, the intervention can be performed laparoscopically with the corresponding advantages of lower invasiveness. A treatment alternative can be advantageous for selected patients with high morbidity and/or an increased risk of complications associated with anesthesia or surgery. Corresponding risk stratification necessitates previous confirmation of the small renal mass (cT1a) by histological examination of biopsy samples. Active surveillance represents a controlled delay in the initiation of treatment., Results: Percutaneous radiofrequency ablation (RFA) and laparoscopic cryoablation are currently the most common treatment alternatives, although there are limitations particularly for renal tumors located centrally near the hilum. More recent ablation procedures such as high intensity focused ultrasound (HIFU), irreversible electroporation, microwave ablation, percutaneous stereotactic ablative radiotherapy and high-dose brachytherapy have high potential in some cases but are currently regarded as experimental for the treatment of renal cell carcinoma.

Background: Treatment results of Wilms tumors have been impressively improved over the past 50 years resulting in a stage-independent overall survival of greater than 90%. However, unsatisfying treatment results still remain in children with high-risk tumors and tumor relapses., Materials and Methods: This review highlights the current concepts of Wilms tumor surgery as a cornerstone of the treatment strategy for this malignancy. A selective literature review focusing on the past 5 years served as the basis for this article., Results: Nephron-sparing surgery is associated with an analogue outcome compared to tumor nephrectomy in unilateral Wilms tumors. The surgical panel of the International Society of Pediatric Oncology (SIOP) group has recently introduced a novel nomenclature for organ-preserving resection procedures in order to facilitate a prospective comparison of data. The minimally invasive approach represents an alternative technique with adequate outcome. In bilateral disease, nephron-sparing procedures are gold standard. Complete resection of lung and liver metastases has a significant impact on patients' survival., Conclusions: Surgical guidelines for nephron-sparing surgery and minimally invasive tumor nephrectomy need to be established and implemented within newly formulated treatment protocols of the different national and international treatment trials. Risk stratification of patients needs to be more individualized with the aim of reducing late effects while at least maintaining the same survival rates. The unsatisfying treatment results of tumor relapses-associated with low patient numbers within the different trials-emphasize the need for international collaboration.

Background: Robot-assisted laparoscopic radical prostatectomy (RALP) has been rapidly adopted as a standard approach for surgical treatment of organ-confined prostate cancer. Despite additional costs, RALP seems to provide better functional and oncological outcomes and less blood loss compared to open radical prostatectomy (ORP). However, prospective randomized studies are still missing., Purpose: Based on the current literature, this review reports about the role of RALP in prostate cancer treatment. Its functional and oncologic outcomes as well as complication rates are compared to ORP. Particularly, the role of RALP in nonorgan-confined tumors will be discussed., Results: Based on the current literature, RALP provides better continence and potency rates as compared to ORP. Moreover, the incidence of positive surgical margins seems to be reduced. However, there is conflicting data regarding the role of RALP in nonorgan-confined prostate cancer. Regarding long-term oncologic outcomes, RALP seems to be comparable to ORP.

Focal therapy is a treatment strategy for men with localized prostate cancer that may serve as an alternative option to radical therapy. A number of minimally invasive ablative technologies are available to deliver treatment, and the energies most commonly used include high-intensity focused ultrasound and cryotherapy. The benefit of a tissue-preserving approach is the limitation of damage to key structures such as the neurovascular bundles, external urinary sphincter, rectal mucosa and bladder neck. This in turn minimizes side effects typically associated with radical therapies whilst also aiming to maintain oncological control. Over 30 single-centre studies of focal therapy have been published to date reporting excellent continence rates, good potency rates and acceptable short-term oncological outcomes. However, there are a number of controversial aspects associated with focal therapy including the index lesion hypothesis, patient selection criteria, assessment of treatment effect and the lack of medium- and long-term oncological outcomes. In the process of the adoption of new technology, there is a limited window of opportunity to provide this evidence in well-designed prospective trials. Men should be allowed to benefit from the potential advantages of this novel treatment whilst under close surveillance. An English version of this article is available under dx.doi.org/10.1007/s00120-014-3734-7.

Background: Stage I renal cell carcinoma is a malignancy with a relatively good prognosis. The incidence of all renal cell carcinomas is approximately 9/100,000 persons. There are nearly 15,000 newly diagnosed patients every year (men twice as often as women)., Trend: In the last decade, a trend away from radical open resection towards nephron-sparing approaches has been observed. Currently, partial nephrectomy is the surgical gold standard for the treatment of small renal tumors. However, excellent clinical results are obtained using percutaneous radiofrequency ablation (RFA): low complication rates and preservation of the renal function., Results: Primary and secondary technical success rates are 69-100% and 90-100%, respectively. In large series, major complication rates of RFA of 0-14% are reported. A relevant deterioration of renal function after RFA is very rare. The 5-year local recurrence-free survival rates, metastasis-free survival rates, cancer-specific survival rates, and overall survival rates are 88-93, 95-100, 98-100, and 58.3-85%, respectively. In this context, the lack of appropriate long-term data is often cited as a limitation., Conclusion: Different meta-analyses come to the conclusion that in case of adequate tumor and patient selection RFA shows oncologic results comparable with surgical resection. Accepted indications for RFA are T1 renal tumors in patients with advanced age, significant comorbidities, reduced renal function, single kidney, and/or no wish for operation. Predictors for the success include tumor size and location as well as operator experience. To define the real efficacy of RFA in the treatment of renal tumors, randomized controlled clinical long-term studies are indicated.

Background: In recent years, small renal masses (SRM) have been increasingly detected as an incidental finding of radiological or ultrasound studies for other indications. Organ-sparing renal tumor resection as open partial nephrectomy (OPN) is the international standard for renal tumors <7 cm., Results: Due to technical developments, minimally invasive procedures have emerged as an alternative to OPN. In experienced hands, conventional laparoscopic partial nephrectomy (LPN) has achieved good functional and oncological results comparable to OPN. Robot-assisted laparoscopic partial nephrectomy (RAPN) has been performed since 2004. Compared to LPN, RAPN provides a faster learning curve, better visualization and more versatile instrumentation due to the degrees of freedom of the articulated instruments. After about 30 procedures, a level of experience is reached, which is characterized by good functional results, less blood loss, and shorter warm ischemia time of the kidney as compared to LPN. This can relate to a shorter hospital stay and faster recovery. Complications according to the Clavien classification are mostly grade I and II and are mainly treated conservatively., Conclusion: Oncological long-term results are not available yet; so that RAPN cannot be considered as an equivalent treatment to LPN and OPN. Until long-term evidence is available, decisions regarding the surgical technique for organ-sparing renal tumor resection will be determined by patient's wishes and surgeon's preference.

Background: Splenic preservation can be achieved through splenic vessel resection by Warshaw's technique (WT) or by preserving the splenic vessels. This meta-analysis aims to provide evidence-based comparison regarding the perioperative outcome and long-term benefits between patients with and without splenic vessel preservation (SVP) during spleen-preserving distal pancreatectomy., Method: A meta-analysis was performed to evaluate studies comparing splenic vessel preservation versus resection groups. Ten retrospective studies including 699 patients were eligible for an analysis of general, perioperative, and long-term outcomes. A further analysis composed of five subgroups was also conducted in terms of laparoscopic approach., Results: Warshaw's technique related to significant shorter operation time (P < 0.0001). There was no difference in blood loss (P = 0.45) as well as median tumor size (p = 0.1) between the two groups. The overall rate of complications indicated no difference between SVP and WT (P = 0.1), including pancreatic fistula rates, which were not statistically different among the treatment groups (P = 0.27). However, the occurrence of gastric varices and splenic infarction was significant higher in the WT group (P < 0.01). In laparoscopic subgroups, patients treated by WT had much lower blood loss (P = 0.002)., Conclusion: In spleen-preserving distal pancreatectomy, comparing with SVP, there is no evidence of significant benefit of WT. Nonetheless, surgeons should master both techniques and choose an appropriate one based on personal experience and a "case by case" situation. However, the current available evidence is weak, and further randomized controlled data are warranted.

Background: Primary urethral cancer in males is a rare entity with only approximately 800 cases described, which is why it is difficult to formulate evidence-based guidelines for treatment. For tumors in the pT2 stage with a localization distal to the membranous urethra, a penis-preserving operation can be carried out., Methods: In the period from November 2006 to February 2014 a total of 4 patients with primary urethral cancer underwent a penis-preserving urethral resection. The tumor characteristics and treatment results were collated retrospectively., Results: Of the four patients one had a transitional cell carcinoma of the mid-penile urethra in stage pT2 G2. In two out of the four patients a squamous cell carcinoma (PEC) was present in the mid-penile urethra in stages pT2 G2 and pT2 G3, respectively, with concomitant carcinoma in situ (CIS). The fourth patient had a PEC of the fossa terminalis in stage pT2 G2. Initially all patients underwent a penis-preserving resection. In one case, despite an initial R0 resection a local recurrence occurred and a complete penectomy was performed. Irradiation and lymphadenectomy were not carried out. At a mean follow-up of 37 months all patients are currently in complete remission., Conclusion: Primary penile urethral cancer can be treated by a penis-preserving operation. Close follow-up is essential because recurrence can arise despite an initial R0 resection.

Background: Similar to the re-appreciation of high tibial osteotomy (HTO), supracondylar distal femur varus osteotomy (SCO) for lateral compartment osteoarthritis (OA) of the knee has gained renewed interest as new knowledge has become available on the influence of malalignment on the development, progression and symptoms of OA. Furthermore, the less than optimal results of knee replacements (TKR) in younger patients have also led to renewed interest in joint-preserving treatment options., Purpose: Varus SCO has not had the same success or widespread use as valgus HTO. The goal in SCO is similar to HTO, to shift the load from the diseased to the healthy compartment, in order to reduce pain, improve function and delay placement of a TKR. Valgus OA however occurs much less frequently than varus OA and varus SCO is considered a technically more demanding procedure. In the past the surgical techniques for SCO were mainly dependent on difficult-to-use implants making the procedure more complex. Complication rates related to the failure of fixation up to 16% have been reported., Disussion: The new biplane osteotomy technique fixated with a locking compression plate is very stable; bone healing potential is optimal using this technique and takes 6-8 weeks. Full weight bearing before full bone healing is possible without loss of correction., Conclusion: In this article, patient selection, planning, surgical techniques, stability of fixation, and bone healing are discussed. Varus supracondylar osteotomy is a viable treatment option for a well-defined patient group suffering from valgus malalignment and lateral compartment osteoarthritis, and in addition may be considered in ligamentous imbalance and lateral patellofemoral maltracking.

Background: Isolated deviations in flexion and extension of the leg axis are rare. These deviations can be corrected if necessary by osteotomy and the range of motion (ROM) of the knee joint can be optimized. In addition to correction in the frontal plane, the tibial slope (i.e. inclination of the surface of the tibial joint) can also be influenced by osteotomy and therefore osteotomy can also be utilized to optimize the biomechanical stability of the knee joint., Method: Careful planning taking all three spatial planes and torsion into consideration is the foundation of a successful operation. A controlled surgical technique based on careful planning and some basic principles allows the alteration of the three dimensional alignment of the tibia.

Transitional cell carcinoma of the bladder can - in the majority of cases - be safely treated by transurethral resection and bladder preservation. In case of more aggressive and genetically instable tumors, the effect of radical cystectomy depends on tumor volume. If complete resection of invasive tumors is also possible, the additional effect of radical cystectomy seems to be marginal. In patients with favorable tumor location and acceptable prostate parameters, prostate-sparing surgery seems to be oncologically safe with good quality of life.

Primary urethral carcinomas are rare tumors that can occur both in men and women. Histological patterns of these tumors are mixed, urothelial tumors occur as well as squamous cell tumors or adenocarcinomas.There are different clinical factors that define clinical prognosis, and the 1- and 5-year cancer-free survival is 75% and 54%. Therapy of locally limited disease is surgical resection, and organ-preserving treatment is possible if negative frozen sections prove complete surgical resection. However, in men a perineal urethrostomy might be necessary, and in women there is a high risk of urinary incontinence if more than 2 cm of the distal urethra is resected.In case of locally advanced tumors or tumors of the proximal urethra, a radical urethrectomy with supravesical urinrary diversion is necessary. In some cases neoadjuvant (radio-)chemotherapy may be an option.

Background: Curative treatment for prostate cancer is associated with risks which may adversely influence quality of life. Furthermore, there is a considerable rate of overdiagnosis of tumors which would be non-life-threatening if left untreated. Efforts have been made to reduce overtreatment., Discussion: Beside the traditional conservative symptomatic management especially in elderly patients with meaningful comorbidity, several prostate-sparing or deferred treatment options are currently discussed. For all of them, insufficient data on efficacy and safety are available., Results: Because of the required long-term follow-up of large sample sizes, conclusive data will not become available in the near future. Therefore, these treatment options have to be considered experimental to a large degree. This applies both to focally ablative techniques and to active surveillance of prostate cancer in patients with a long further life expectancy. Only in carefully selected patients with favorable tumor-associated risk profiles and high risk of medium-term competing mortality may active surveillance be considered a valid and relatively safe treatment option.

Background: The therapy of malignant testicular neoplasms has always been characterized by a high degree of radicality. Thanks to a number of medical achievements the cure rate of testicular cancer has notably increased through the last decades. In the meanwhile the main focus is on reducing therapy load, scrutinizing radical orchiectomy as the only adequate therapy for the primary tumour., Objectives: This article discusses the question, if and under which conditions an organ-sparing approach can be used appropriately in clinical practice., Materials and Methods: A selective literature search was performed in PubMed., Results: A set of data suggest that endocrine and exocrine function of the testis can be preserved using an organ-sparing approach and many patients could benefit regarding their quality of life, e.g., preserving the ability to father a child at least temporarily and avoiding the need for hormone substitution. Different from kidney tumors, precancerous lesions (testicular intraepithelia neoplasia, TIN) can almost inevitably be found in the surrounding tissue of testicular tumors. This has to be considered when making a decision in favor of an organ-sparing approach, because radiation therapy on the affected testis has to be performed after tumor resection. Despite the absence of prospective data, organ-sparing surgical tumor resection can be recommended in carefully selected patients., Conclusion: After careful selection of patients, particularly young men can profit from an organ-sparing therapy regimen. Therefore, organ preservation should always be considered in the surgical treatment of testicular masses.

In recent years, a definite change towards organ-sparing, reconstructive local treatment of penile cancer has been observed. Surgical treatment aims to achieve margin-free resections with risk-adapted much smaller safety margins. Thus, the penile structures are preserved as far as possible or reconstructed in order to achieve a functionally and cosmetically satisfactory result. The oncological safety concerning tumor-free survival is not compromised. However, a higher rate of local recurrences has to be accepted.

With the technical innovations of smaller, flexible ureteroscopes, color-filtered imaging, and endoscopic laser technology, organ-preserving treatment for upper urinary tract transitional cell carcinoma has become feasible. While in the past, radical nephroureterectomy was the sole gold standard approach for the treatment of upper urinary tract tumors, the endoscopic approach is no longer restricted to only patients with the imperative indication of kidney preservation. Initial clinical results have demonstrated oncologic efficacy of endoscopic management or segmental ureteral resection. However, careful preoperative risk-assessment and close endoscopic follow-up are mandatory.

Background: In localized low-risk prostate cancer (PCa), there is a therapeutic dilemma between possible overtreatment by one of the standard therapies and potentially insufficient cancer control by active surveillance (AS). Focal therapy (FT) provides an alternative therapeutic option as it aims to preserve the organ and to eliminate the cancer focus at the same time., Methods: In this article the current state of FT for localized low-risk prostate carcinoma in Germany is described. In addition, criteria that should be used to select patients for FT are proposed., Results: Currently, the effectiveness of FT is under evaluation by two multicenter, prospective studies in Germany: TOOKAD and HEMI. However, localized low-risk prostate carcinoma remains a diagnostic challenge: Multiparametric MRI as well as histopathological second opinion are considered mandatory in addition to transrectal biospy., Conclusion: The oncological outcome of both the TOOKAD and HEMI study will be crucial for any form of FT for prostate carcinoma in Germany in the future. However, there is a remarkably high acceptance of FT among patients.

Background: Proximal femoral focal deficiency (PFFD) types II and III (Pappas) have no femoral or only abortive femoral head development. Winkelmann published a case of one patient treated with a modification of rotation plasty by creating a new articulation after 180° rotation of the lower leg and insertion of the lateral tibial plateau into the deficient acetabulum. This article reports on three consecutive patients treated with this technique to validate this procedure and to consider this operation in selected patients., Patients and Methods: At the time of rotation plasty the patients (2 boys and 1 girl) were aged between 5 and 10 years. The observation period is between 5 and 9 years after surgery. All patients used an orthoprosthesis with full contact in the foot region and a shaft connecting the thigh. A hip basket and any additional walking support were not necessary (e.g. canes). They were all highly satisfied and would choose the same treatment again., Conclusion: Rotation plasty is a technically highly demanding procedure, especially in situations such as PFFD where the anatomy is distorted and structures such as blood vessels and nerves are too short. However, it is an option to improve the orthoprosthetic fitting functionally and esthetically.

Aspergillus infections frequently affect immunocompromised patients and are associated with high mortality. We report the case of a renal aspergilloma in a bone marrow transplant recipient. Treatment is challenging and requires a combination of systemic antifungal therapy and surgery. In the present case, a minimally invasive retroperitoneoscopic resection of the aspergilloma was performed.

Testicular cancer currently shows excellent rates of curing and even in advanced stages of disease about 70% can be achieved. This was possible due to continuously carrying out studies. To reduce long-term toxicity the focus is now put on reduction of treatment. In nonseminomatous germ cell cancer this is discussed especially for stage I disease where different therapeutic strategies can be offered. Concerning advanced disease the aim is a further improvement of treatment results. Polychemotherapy and surgical procedures are equally important in this scenario. Concerning residual tumor resection it should always be considered that the procedure can be extended by adjuvant surgery, e.g. cava resection. Therefore, those resections should only be performed at centers where all possibly needed surgical disciplines are available.

Introduction: Using the intravoxel incoherent motion (IVIM) model, diffusion-related coefficient (D) and perfusion-related parameter (f) can be measured. Here, we used IVIM imaging to characterize squamous cell carcinomas of head and neck (HNSCC) and evaluated its application in follow-up after nonsurgical organ preserving therapy., Methods: Twenty-two patients with locally advanced HNSCC (clinical stage III to IVb) were examined before treatment using eight different b values (b = 0, 50, 100, 150, 200, 250, 700, 800 s/mm(2)). All patients were followed for at least 7.5 months after conclusion of therapy. In 16 of these patients, follow-up MRI was available. Using the IVIM approach, f and D were extracted using a bi-exponential fit. For comparison, ADC maps were calculated., Results: The initial values of f before therapy were located between 5.9 % and 12.9 % (mean: 9.4 ± 2.4 %) except for two outliers (f = 17.9 % and 18.2 %). These two patients exclusively displayed poor initial treatment response. Overall, high initial f (13.1 ± 4.1 % vs. 9.1 ± 2.4 %) and ADC (1.17 ± 0.08 × 10(-3) mm(2)/s vs. 0.98 ± 0.19 × 10(-3) mm(2)/s) were associated with poor short term outcome (n = 6) after 7.5 months follow-up. D values before treatment were 0.98 × 10(-3) ± 0.18 mm(2)/s and ADC values were 1.03 × 10(-3) ± 0.18 mm(2)/s. At follow-up, in all primary responders, D (69 ± 52 %), f (65 ± 46 %), and ADC (68 ± 49%) increased., Conclusions: Our preliminary evaluation indicates that an initial high f may predict poor prognosis in HNSCC. In responders, a significant increase of all IVIM parameters after therapy was demonstrated.

Deformity and malposition of the acetabulum can occur during the development of the hip. Developmental hip dysplasia and acetabular retroversion are possible causes of osteoarthritis in the young adult. Surgical management with reorientation of the acetabulum allows causal therapy of the deformity and preservation of the native hip joint. Established techniques are the Bernese periacetabular osteotomy (PAO) and the Tönnis and Kalchschmidt triple osteotomy of the pelvis. Both techniques permit three-dimensional correction of the position of the acetabulum. Advantages and disadvantages of each technique must be considered and are summarized in the present paper. If performed early (osteoarthritis grade Tönnis 0 and 1) with correct indication and proper technique, good results can be expected.

The rising incidence of renal cell cancer in recent decades has led to a revision in the therapy of this malignancy. For small renal masses, partial nephrectomy has become the standard surgical treatment instead of radical nephrectomy. This approach can lead to a higher overall survival due to preservation of renal function. Avoiding chronic kidney disease is mandatory for patients with benign or small non-aggressive tumors; however, partial nephrectomy correlates with higher complication rates and is conditioned by operator skills. The role of partial nephrectomy compared to radical nephrectomy is still to be established particularly for larger tumors. The results of studies so far are mostly based on non-randomized retrospective data. This article will present the pros and cons of partial nephrectomy and will focus on the steps required to promulgate the indications of nephron-sparing surgery.