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Patients are increasingly seeking uterus-preserving, minimally invasive treatments for symptomatic uterine fibroids. This has led to a greater use of nonresective treatments such as uterine artery embolization (UAE), focused ultrasound (FUS) and more recently, radiofrequency ablation (RFA) of fibroids. This systematic review, following PRISMA guidelines, examines the change in uterine and fibroid volumes associated with UAE, FUS, and RFA. Pubmed and MedlinePlus databases were searched from 1956 to 2016. The keywords used were ‘radiofrequency ablation,’ ‘magnetic resonance guided focused ultrasound,’ ‘ultrasound guided focused ultrasound’, ‘uterine artery embolization,’ ‘uterine fibroid embolization,’ and ‘leiomyoma’ or ‘fibroid’. Publications with at least 20 patients were included. Data were collected and analyzed using Microsoft Excel® (Microsoft Corporation, Redmond, WA) software. Eighty-one relevant papers were identified: 52 related to UAE, 11 to RFA, 17 to FUS, 1 compared UAE and FUS. We report the published uterine volume and fibroid volume changes seen in these studies at 1 to 36 months. The pooled fibroid volume reductions at six months seen with RFA were 70%, UAE 54% and FUS 32%. All three types of nonresective treatment result in fibroid volume reduction. However, fibroid volume reduction is most marked with RFA, with UAE resulting in the next most volume reduction. Additional larger cohort studies, including those that are randomized and/or comparative, would enable definitive conclusions. This is the first systematic review comparing uterine and fibroid volume reduction after RFA, UAE and MRgFUS.

Congenital absence of maxillary lateral incisors is a frequent clinical challenge which must be solved by a multidisciplinary approach in order to obtain an esthetic and functional restorative treatment. Noninvasive treatments, that are in accordance with the patients' expectations, should be the first therapeutic alternative. If the deciduous tooth is present, minimally invasive dental extraction followed by immediate dental implant placement and provisional restoration is indicated. In this restorative treatment, an adequate emergency profile can be achieved by peri‐implant soft‐tissue‐conditioning techniques. Moreover, the association of restorative materials, such as composite resins and dental ceramics, provides more predictable esthetic results. Clinical Considerations The present case report presents a rehabilitation of bilateral congenital absence of maxillary lateral incisors through a multidisciplinary approach. Dental implants, long‐term provisional restoration, tooth bleaching, minimally veneered high‐translucent monolithic zirconia crowns, feldspathic veneers, and composite restorations were used by the dental team to achieve the expected functional and esthetic outcomes. Conclusions Different treatment modalities are available for the rehabilitation of congenital absence of teeth. However, it is important that a dental team consider performing minimally invasive treatments, as many of these treatments are done on young patients. Clinical Significance Patient‐centered treatments involving minimally invasive approaches in a multidisciplinary environment would be appropriate in order to achieve predictable results.

Dupuytren disease (DD) is a fibroproliferative disorder that originates at the palmar fascia and results in flexion contracture of the digits. The gold standard treatment for DD has been surgery. Surgical treatment of DD can be done with various methods, from percutaneous needle fasciotomy to dermatofasciectomy. The most commonly used surgical treatment is limited fasciectomy (LF). The potential complications of limited fasciectomy include long recovery time, scarring, neurovascular injury, and tendon injury. Minimally invasive treatment for DD, which is simple and allows for rapid return of function, has gained popularity amongst both patients and surgeons. Currently, minimally invasive treatments for DD include percutaneous needle fasciotomy (PNF) and collagenase clostridium histolyticum (CCH). In this review, we provide an overview of the minimally invasive treatments for Dupuytren disease and summarize the current evidence regarding these minimally invasive treatments.

OBJECTIVE This abbreviated version of the American College of Occupational and Environmental Medicine's Low Back Disorders guideline reviews the evidence and recommendations developed for invasive treatments used to manage low back disorders. METHODS Comprehensive systematic literature reviews were accomplished with article abstraction, critiquing, grading, evidence table compilation, and guideline finalization by a multidisciplinary expert panel and extensive peer-review to develop evidence-based guidance. Consensus recommendations were formulated when evidence was lacking and often relied on analogy to other disorders for which evidence exists. A total of 47 high-quality and 321 moderate-quality trials were identified for invasive management of low back disorders. RESULTS Guidance has been developed for the invasive management of acute, subacute, and chronic low back disorders and rehabilitation. This includes 49 specific recommendations. CONCLUSION Quality evidence should guide invasive treatment for all phases of managing low back disorders.

In the last few years, image-guided minimally invasive treatments are been introduced in the treatment guidelines for thyroid benign nodules in order to spare thyroidectomy. Different ablative techniques are available. In this chapter, an overview of the different available ablative techniques will be provided, with a particular focus on indications to treatment and clinical results.

Scars vary from mature linear scars to abnormal excessive scars such as hypertrophic scars and keloid scars. Keloid scars are fibro-proliferative disease entities that reflect an abnormal process of wound healing. They can cause pain, itching, stiffness, and psychological distress, all of which can affect quality of life. Various treatment options have been advocated as ways to prevent and treat keloid scars. These include noninvasive treatments such as use of silicone gel sheeting and compression therapy, and invasive treatments such as intralesional corticosteroid injections, surgery, and radiotherapy. Novel treatments include chemotherapy, immunotherapy, and anti-inflammatory therapies. Unfortunately, keloids continue to pose a significant challenge due to the lack of efficacious treatments. Therefore, clinicians should be familiar with various therapeutic options and apply the most suitable treatment plan for patients. In this review, we introduce the current therapeutic options for the management of keloid scars.

The number of hip or knee arthroplasties, and internal fixations of the proximal and distal femur, is increasing in proportion to the growing and ageing population, whose life expectancy is lengthening. Thus, fractures of the femur between proximal and distal implants, although rare, are becoming more frequent. Women over the age of 70, with fragile bones and whose ends of the two implants are close to each other (“kissing implants”) are particularly vulnerable to them. Reliable and reproducible fracture classifications exist when it comes to 2 prostheses, but they are less well established in the presence of one, or even two, non-prosthetic implants. Their treatment is difficult and must consider the possibility of fracture consolidation while ensuring or restoring the stability and role of the implants. Whether it is the main element of treatment or a complement to prosthesis revision, locked plating forms the basis of the treatment but it must be rigorous, considering that failures are mainly the result of technical errors. Other more invasive treatments (total femoral arthroplasty, cortical sleeves) are offered more rarely if consolidation appears compromised.

Sepsis is a life-threatening condition that arises when the body's response to infection damages its own tissues and organs. Sepsis is caused by an inflammatory immune response triggered by an infection. Its risk factors include aging, weak immune system, major trauma, or burns. Treatment of sepsis is often based on fluid replacement and antibiotic therapy. In this study, an 83-year-old man is reported with two times of diagnosis of sepsis during three years. The first sepsis was due to an infection of the colostomy and the second one followed an infection at tracheostomy site. It seems that the disease and the underlying condition of the patient contribute to the occurrence of sepsis. The patient each time was discharged from the hospital after successful response to the treatment

INTRODUCTION: Conservative treatment for penile curvature in Peyronie’s disease (PD) by means of penile stretching is attractive compared to the available invasive treatments with risks for complications and failure. Therefore, penile stretching using penile traction therapy (PTT) or vacuum erection devices (VED) are used widely in the medical as well as in the commercial circuit. VED and PTT can be used in PD as stand-alone therapy and in combination with intralesional therapy. Many experimental and clinical studies have been conducted to assess the mechanism and effectivity of PTT and VED, however, clear guidelines are not yet available. METHODS: A PubMed search was performed of publications on PTT and VED in men with PD from inception through May 2019. RESULTS: PTT has been successful in primary penile lengthening and curvature correction in the acute phase of PD in vitro and in vivo studies. The duration and rhythm of its use appears to be of importance for optimal changes in penile curvature, length and girth. After surgical correction of PD, PTT has been shown to be effective in preserving penile length. The combination of PTT and intralesional injection therapies for PD treatment requires further investigation as the available clinical data are both contradictory and limited. There are fewer studies investigating VED and their role in PD management, but initial small trials suggest a role in curvature correction and penile lengthening as well. CONCLUSIONS: Penile stretching can be very effective in PD. Data suggest a role for PTT and VED in the management of PD as sole therapy, after surgery and during intralesional injection therapy. Further research is needed to be able to provide physicians with clarity about the optimal ways to deploy traction therapy in combination with other treatment options, and with guidelines for the most effective timing and duration of the use of the available traction devices.

Radiation therapy has long been established as an important modality in the management of prostate cancer, with about 25% of men electing this as their primary therapy [1]. Radiation therapy offers those patients who are unwilling or unable to undergo more invasive treatments a useful option for controlling their disease. However, it has also given rise to a particularly complex urologic issue: radiation-induced stricture disease. These strictures prove significantly more difficult to manage than other forms of urethral stricture, with significantly increased rates of recurrence and complications after treatment.

Today, there are a huge number of invasive treatments for choledocholithiasis, but there is no universal treatment that combines the advantages of mini- mally invasive endoscopic methods and laparotomy. With the accumulation of experience in laparoscopic operations, the advantages of an endovideoscopic method for the resolution of choledocholithiasis are increasingly convincing. The article contains descriptions of the currently available methods for resolving choledocholi- thiasis and the therapeutic algorithm for endovideososcopic treatment of choledocholithiasis developed by us.

The purpose of this review is to provide a description of the Aquabeam system, the technique more commonly known as aquablation, and review the literature to date including select results from the unpublished WATER study to assess the efficacy and safety of this novel technique for the treatment of male lower urinary tract symptoms (LUTS) due to bladder outlet obstruction (BOO). Promising outcomes from initial pilot studies and early clinical studies confirming safety and feasibility have led to the large international multi-centre randomised controlled study known as the WATER study. This compared the Aquabeam system to the current gold standard, transurethral resection of the prostate (TURP). This landmark trial has proven that aquablation equals TURP in clinical efficacy and has superior safety outcomes, particularly for larger prostates. Aquablation is not only a technically feasible and safe procedure for symptomatic male BOO, but has equivalent efficacy to TURP with a better safety profile. Ongoing trials are taking place to confirm aquablation’s role in the spectrum of minimally invasive treatments for male LUTS.

// Wei Yu 1,2 , Jian Zhu 1,2 , Yitian Wang 1,2 , Junjie Wang 1,2 , Weijing Fang 1,2 , Kaishun Xia 1,2 , Jianlin Shao 3 , Minzu Wu 4 , Bing Liu 1,2 , Chengzhen Liang 1,2 , Chengyi Ye 1,2 and Huimin Tao 1,2 1 Department of Orthopedics, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, PR China 2 Orthopedics Research Institute of Zhejiang University, Hangzhou, Zhejiang, PR China 3 La Jolla Institute for Allergy and Immunology, La Jolla, CA, USA 4 Salk Institute for Biological Studies, La Jolla, CA, USA Correspondence to: Huimin Tao, email: // Keywords : osteosarcoma; photodynamic; target therapy; nanotechnology; immunotherapy Received : November 16, 2016 Accepted : February 07, 2017 Published : March 15, 2017 Abstract Photodynamic therapy, one of the most promising minimally invasive treatments, has received increasing focus in tumor therapy research, which has been widely applied in treating superficial tumors. Three basic factors - photosensitizer, the light source, and oxidative stress - are responsible for tumor cell cytotoxicity. However, due to insufficient luminous flux and peripheral tissue damage, the utilization of photodynamic therapy is facing a huge limitation in deep tumor therapy. Osteosarcoma is the typical deep tumor, which is the most commonly occurring malignancy in children and adolescents. Despite developments in surgery, high risks of the amputation still threatens the health of osteosarcoma patients. In this review, we summarize recent developments in the field of photodynamic therapy and specifically PDT research in OS treatment modalities. In addition, we also provide some novel suggestions, which could potentially be a breakthrough in PDT-induced OS therapies. PDT has the potential to become an effective therapy while the its limitations still present when applied on the treatment of OS or other types of deep tumors. Thus, more researches and studies in the field are required.

Incompetent superficial veins are the most common cause of lower extremity superficial venous reflux and varicose veins; however, incompetent or insufficient perforator veins are the most common cause of recurrent varicose veins after treatment, often unrecognized. Perforator vein insufficiency can result in pain, skin changes, and skin ulcers, and often merit intervention. Minimally invasive treatments have replaced traditional surgical treatments for incompetent perforator veins. Current minimally invasive treatment options include ultrasound guided sclerotherapy (USGS) and endovascular thermal ablation (EVTA) with either laser or radiofrequency energy sources. Advantages and disadvantages of each modality and knowledge on these treatments are required to adequately address perforator venous disease.

Background Balloon pulmonary angioplasty (BPA) improves hemodynamics, symptoms and exercise capacity in patients with chronic thromboembolic pulmonary hypertension (CTEPH) who are ineligible for pulmonary endarterectomy (PEA). However, certain patients still have hypoxemia after BPA or PEA despite normalization of hemodynamics. In CTEPH, hypoxemia is related increased dead space ventilation caused by vascular obstruction. Purpose This study was aimed to clarify whether additional BPA can improve hypoxemia of CTEPH patients after normalization of hemodynamics. Methods A total of 335 patients who underwent initial series of BPA in our institute were followed up. Sixty-four patients with mean pulmonary artery pressure (mPAP) Results Thirty-three of 64 patients underwent additional BPA procedures. Patients' age was older in BPA group than those in non-BPA group (71.3±10.4 vs. 66.5±9.4 years old, p=0.02). mPAP and pulmonary vascular resistance (PVR) was significantly higher in BPA group (mPAP: 23.9±3.2 vs. 20.7±3.8 mmHg, p=0.001, PVR: 4.2±1.2 vs. 3.5±1.4 wood unit, p=0.03, respectively). Among the 1.8±1.4 BPA procedures per person, total 6.6±3.8 segmental pulmonary arteries per person were treated. While no obvious improvements were observed in non-BPA group, PVR and SpO2 in BPA group were significantly improved (4.2±1.2 to 3.7±1.3 wood unit, p=0.002, 90.7±3.1% to 94.1±3.6%, p Conclusions Additional BPA procedure was associated with improvement of hypoxemia in CTEPH patients after normalization of hemodynamics. Treating as many lesions as possible in BPA might relieve the patients' residual dyspnea.

The famous quotation of Winston Churchill, made in his radio broadcast of 1939 regarding Russia's next move, specifically "A riddle wrapped up in a mystery, inside an enigma," perfectly fits the current understanding of unusual accessory atrioventricular pathways, including the variants producing ventricular pre-excitation. It was many decades after their original descriptions that we came better to begin to understand most of their structure-function relationships. Their mysterious pathophysiology was sometimes unveiled after invasive treatments, such as surgical ablation of the atrioventricular conduction axis instead of the accessory pathway itself. Speculations made on this basis have largely been validated by subsequent clinical experience. Most of the names suggested for description of the pathways have stood well the test of time. For some of them, however, this is not the case, with the initial names becoming confusing. In a series of reviews, we re-visit those accessory pathways producing ventricular pre-excitation other than classical Wolff-Parkinson-White syndrome. To set the scene, in this initial review, we describe the development and anatomy of the normal atrioventricular conduction axis, along with the insulating tissues of the atrioventricular junctions. We have sought to illustrate our explanations by using virtual dissection of computerized tomographic datasets, since they retain the intact heart within the setting of the body. These images illustrate well the value of attitudinally appropriate terminology. Thereafter, we discuss the electrophysiological manifestations of the abnormal anatomical pathways which provide the potential for both accessory atrioventricular and intraventricular conduction.

Ureteral obstruction caused by extrinsic compression from advanced pelvic malignancies are not unusual in urology, with gynecological origin being the most common. As minimally invasive treatments for malignant ureteral obstruction (MUO), metallic ureteral stents have been promoted to provide long-lasting urinary patency and overcome the inherent limits of traditional double-J stents. In this review, we demonstrated three types of frequently used metal stents, including coiled stents, self-expendable stents and thermo-expendable stents. The Wallstent presented discrepant patency rates ranging from 6% to 100%, along with a high occlusion rate. The Memokath 051 stent showed satisfactory patency rates, often > 90%, but also a specific higher migration rate. The Resonance stent provided overall promising results with published success rates ranging from 20% to 100%, which on the whole remains relatively high. The long-term effectiveness rendered metal stents as viable options for managing MUO.

Discogenic pain is a known cause of low back pain (LBP). There are several proposed minimally invasive treatments in the literature including: percutaneous laser disc decompression, multiple radiofrequency thermocoagulation/ablative techniques, and intradiscal injection of varying medications. The body of literature suffers significantly from patient heterogeneity due to a lack of stringent inclusion criteria. Additional concerns in the literature include random follow-up times, variability in reported results, and non-reproducibility of findings. Collectively, these flaws significantly limit the conclusions that can be made regarding treating those with suspected discogenic pain. Despite this, the article will review the published literature to date on the interventional procedures for patients with suspected discogenic LBP.

Background: During the past two decades, external-beam radiation technology has substantially changed from traditional two-dimensional to conformal three-dimensional to intensity-modulated planning and stereotactic body radiotherapy (SBRT). Summary: Modern techniques of radiotherapy (RT) are highly focused and capable of delivering an ablative dose to targeted hepatocellular carcinoma (HCC) tumors. SBRT is an option for selected patients with limited tumor volume and non-eligibility for other invasive treatments. Moreover, RT combined with a radiation sensitizer (RS) to increase the therapeutic ratio has shown promising results in select studies, prompting further investigation of this combination. With the undetermined role of RT in treatment guidelines and variation in patterns of treatment failure after RT in patient with HCC, useful biomarkers to guide RT decision-making and selection of patients are needed and emerging. Key Message: The objective of this review is to summarize the current RS with SBRT schemes and biomarkers for patient selection used to maximize the effect of RT on HCC.

Microwave thermal ablation is under investigation for minimally invasive treatments. In the cases of small targets, such as adrenal glands, microwave thermal ablation is a valuable alternative to the traditional and more invasive treatments (e.g. surgical procedures, pharmaceutical therapies). In this work, ablation treatments are carried out on ex-vivo liver samples using a custom developed microwave ablation applicator for ablation of small targets. Ablation zones achieved with different treatment settings are analysed. The power and time settings suitable to achieve a small and well controlled ablation zone, are evaluated. Moreover, the temperature increase in different regions of the area under treatment is assessed. The research leading to these results has received funding from the European Research Council under the European Union’s Horizon-2020 Programme (H2020)/ERC grant agreement n.637780 and ERC PoC Grant REALTA n.754308. peer-reviewed

Although the prevalence of Peyronie's disease (PD) is reported to be 3-9% in men, the true prevalence is likely higher due to under-reporting. Many treatment modalities have been described for PD with varying degrees of success. In this article, we review and summarize the current literature pertaining to all pharmacotherapies (oral, intralesional, iontophoresis, and topical) and minimally invasive treatments available for PD (vacuum, traction device, shock wave therapy, and radiation treatment). Additionally, we discuss emerging therapies for PD that are still in pre-clinical development, including stem cell therapy.

Minimally invasive surgery (MIS) is increasingly being used to treat uterine fibroids because of the significant patient and societal benefits of these techniques over traditional laparotomy. Morcellation affords the removal of large fibroids in MIS but carries the risk of disseminating occult malignant tissue. The benefits of MIS for treating fibroids must be carefully weighed against its risks of morcellation.

The incidence of thyroid nodules, either solitary or within a multinodular goiter, is steadily increasing during the last decades, and new therapeutic tools, besides the current options of simple surveillance or surgery, would be profitable to attain a personalized management. Most thyroid nodules are asymptomatic and benign at cytological assessment, remain stable over the years, and do not warrant treatment. In other cases, however, the nodules grow progressively, become visible, and eventually cause local symptoms. As in these cases, a protracted clinical observation is frequently followed by surgical consultation; a well-timed use of minimally invasive procedures could reshape the progression of these benign thyroid lesions toward surgery.

International audience; The role of the interventional radiology (IR) in the musculoskeletal system, and in particular in the bone, is a field of knowledge that is growing significantly in the last years with indications for treatment of both benign and malign lesions. In this paper, we review the state of the art of this application of the IR in the bone (bone metastasis and benign bone lesions) with discussion about all the techniques today used.

Technical challenges and increased morbidity of open reconstruction for uretero-ileal strictures have led to a search for minimal invasive treatments as an alternative solution. The insertion of a thermo-expandable ureteral Memokath 051 ® metal stent across benign uretero-ileal anastomotic stricture in orthotopic neobladder has not been described in the English literature. Herein, we describe a case of a woman with a Hautmann neobladder and a 3.5 cm benign stricture of the right uretero-ileal anastomosis that was treated with insertion of a thermo-expandable ureteral Memokath 051 ® metal stent.

Lower urinary tract symptoms (LUTS) may be a sign of aging rather than a consequence of benign prostatic enlargement (BPE) or benign prostatic obstruction (BPO). Medical or invasive treatments should address the bothersome symptoms and the quality of life of patients. Alpha blockers and 5-alpha reductase inhibitors are most frequently used in benign prostatic hyperplasia (BPH) medical treatments, whereas Transurethral Resection of the Prostate (TURP) remains the "gold standard" for surgical treatments. Several minimal invasive treatments are emerging with promising outcomes.

The diagnosis of twin twin transfusion syndrome is an emergency and is generally easily done by ultrasound. Once the diagnosis is established patients should be referred rapidly for counselling and treatment within a network that can offer fetoscopic laser surgery as first-line treatment. Invasive treatments should be proscribed until then since they may impair fetoscopic visualization and therefore the overall prognosis, should this treatment be required. Depending on the presentation, other options may be offered such as cord coagulation, expectant management or delivery. Other treatment modalities such as amnioreduction or septostomy have almost no indications. Post-operative follow-up will be oriented by secondary hemodynamical complications and fetal neurological damage. An MRI may be a useful adjunct for ischemic/haemorrhagic brain injuries. Moderate prematurity may be justified, regarding the incidence of severe delayed complications.

Symptomatic spinal metastases frequently complicate and often herald the diagnosis of cancer. Minimally invasive treatment options are particularly attractive in these patients as widespread malignant disease significantly increases the risks and potential complications of open spinal surgery. Moreo

Introduction: The evaluation of symptom association between gastroesophageal reflux and cardiorespiratory events in preterm infants remains unclear. This paper describes a conservative approach to decision-making of anti-reflux surgery through symptom association analysis. Methods: Forty-three neonates with potentially reflux-related cardiorespiratory symptoms underwent synchronized esophageal impedance-pH and cardiorespiratory monitoring. Three indices were considered to evaluate symptom association, the symptom index (SI), the symptom sensitivity index (SSI) and the symptom association probability (SAP). A conservative strategy was adopted regarding the decision of anti-reflux surgery, and therefore, patients were scheduled for laparoscopic Nissen fundoplication if the three indices showed a positive assessment of symptom association. Retrospectively, these indices and the binomial symptom index (BSI) were contrasted against the decision of anti-reflux surgery using different windows of association. Results: Thirteen patients showed positive symptom association but only two underwent anti-reflux surgery. The SI and the SSI showed an increasing trend with the width of the window of association. The SAP was affected randomly by slightly altering the windowing parameters. The BSI showed the best performance with the two-minute window (κ = 0.78). Conclusions: The pathology under study is known to improve with maturity. However, the severity of cardiorespiratory symptoms may threaten the neonate's life and therefore, on some occasions, invasive treatments must be considered to protect life. The BSI provides a good prediction of a combination of positive SI, SSI and SAP, which may improve clinical decisions. However, further clinical studies are required to prove the BSI as an optimal predictor of clinical outcomes. Resumen: Introducción: La evaluación de la asociación de síntomas entre el reflujo gastroesofágico y los eventos cardiorrespiratorios no está aún resuelta. Este artículo describe una aproximación conservadora para la decisión del tratamiento quirúrgico anti-reflujo mediante el análisis de la asociación de síntomas. Métodos: Cuarenta y tres neonatos con síntomas cardiorrespiratorios potencialmente asociados al reflujo se sometieron a una monitorización cardiorrespiratoria y de pH-impedancia esofágica. Se consideraron tres índices, el índice de síntomas (IS), el índice de sensibilidad de síntomas (ISS) y la probabilidad de asociación de síntomas (PAS). Asimismo, se adoptó una estrategia conservadora para la aplicación de cirugía anti-reflujo, de manera que solo se consideró el tratamiento quirúrgico en aquellos pacientes con valor significativo en los tres índices. Se contrastaron retrospectivamente estos índices y el índice de síntomas binomial (ISB) frente a la decisión de cirugía anti-reflujo utilizando diferentes ventanas de asociación. Resultados: Trece pacientes mostraron algún índice con valor significativo pero solo dos se sometieron al tratamiento quirúrgico. Tanto el IS como el ISS mostraron una tendencia creciente al aumentar el ancho de la ventana de asociación. El PAS sufrió fuertes variaciones aleatorias frente a pequeños cambios del enventanado. El ISB presentó el mejor resultado con la ventana de dos minutos (κ = 0.78). Conclusiones: La patología bajo estudio mejora con la madurez del individuo. Sin embargo, la severidad de los síntomas cardiorrespiratorios puede amenazar la vida del neonato y por lo tanto, en algunas ocasiones se deben considerar tratamientos invasivos para proteger la vida. El ISB proporciona una buena predicción de la combinación de valores positivos del IS, ISS y PAS, lo que puede ayudar a mejorar las decisiones clínicas. Sin embargo, son necesarios futuros estudios que prueben al ISB como un predictor óptimo de los eventos clínicos.

Objective To review the poor natural history of intracerebral hemorrhage (ICH), current treatment options for ICH, discuss ongoing trials evaluating minimally invasive techniques for clot evacuation, and offer future directions of investigation for the management of this devastating disease. Methods A selective review of recent trials regarding treatment of ICH was performed. Results Completed trials of medical and surgical management are reviewed. The supportive research for clot evacuation to limit secondary injury is surveyed. We also provide a comprehensive discussion of current data evaluating minimally invasive techniques to achieve clot removal, including Minimally Invasive Surgery plus tPA for ICH Evacuation (MISTIE), Clot Lysis: Evaluating Accelerated Resolution (CLEAR), and endoscopic evacuation. Conclusion We encourage the neurosurgical community to pursue improved therapies for ICH. Practice New minimally invasive treatments for ICH are being developed. Implications Treatment of ICH is an important area of research and should continue to be aggressively pursued because of the significant societal burden and poor outcomes associated with ICH.

In the treatment of locomotor pain, many conditions can be treated by manual methods alone, but invasive treatments are often used in combination with manual treatments, or are used on their own. T...

To present a summary of published estimates of the economic burden of uterine fibroids in the United States and identify areas for additional research.A search of three electronic databases, MEDLINE, EMBASE, and Current Contents, was conducted, along with a review of information on the Internet and abstraction of economic data.Only 10 papers and 1 Internet document met our inclusion criteria and were used to abstract data. Cost estimates for surgically invasive treatments of uterine fibroids included hysterectomy (USD 5,012-7,934), myomectomy (USD 5,425-11,839), and uterine artery embolization (UAE) (USD 5,425-7,645) (2004 USD). One cost-effectiveness study estimated lower costs and higher quality-adjusted life years with UAE compared with hysterectomy. A second study estimated potential savings of USD 4.2 million in hospital charges in the United States if higher rates of vaginal (vs. abdominal) hysterectomy would be achieved after pretreatment with gonadotropin hormone-releasing hormone (GnRH) agonists compared to without pretreatment with GnRH agonists (80% vs. 13%). There were no estimates of the total direct and indirect economic burden of uterine fibroids. Neither estimates of the costs for the ambulatory care of fibroids nor studies estimating the indirect costs associated with the management of fibroids and their symptoms were found.This summary of published U.S. economic estimates shows that despite the high prevalence of fibroids and their impact on clinical practice and women's lives, there is very little published information on their economic impact apart from data showing standard treatments for uterine fibroids are invasive and expensive. Reduction in the need for and cost of invasive procedures by the increased usage of noninvasive treatments could potentially achieve significant national cost savings, but further clinical and economic studies are needed.

PURPOSE OF REVIEW The purpose of this review is to appraise new developments and publications in the field of penile prosthetic surgery. Urologists dealing with erectile dysfunction need to recognize the value of penile prosthetic surgery as a very efficacious treatment for this common condition. This type of surgery is needed in a considerable proportion of patients with erectile dysfunction so this review is timely and relevant. RECENT FINDINGS The main themes in the literature covered include risk factors for infection of penile prostheses, its prevention with the use of hydrophilic and antibiotic-coated prostheses, particularly in re-operations, and its management with the new rescue procedures. Surgical tips for prosthetic surgery are also reviewed as well as clinical outcomes and factors influencing them. SUMMARY Of all the invasive treatments currently available, placement of a penile prosthesis is one of the most successful, giving high levels of satisfaction. With the aid of new technical advances, the risk of infection--the most feared complication--can be minimized so prosthetic surgery may play a major role in the treatment of erectile dysfunction.

Although many minimally invasive treatments of lumbar disc pathology have been developed over the years, until the introduction of the current generation of tubular retractor systems none have afforded the same elements of bony decompression and completeness of exploration of the disc space as open microdiscectomy. Accordingly, none have provided the same success rate and low complication rate as open discectomy. Current tubular retractor systems have overcome these difficulties and provide the benefits associated with traditional microdiscectomy through a minimally invasive approach. We review the use of these techniques with particular attention to surgical technique and anatomy.

Category: Hindfoot Introduction/Purpose: Plantar fasciitis is the most common cause of heel pain, resulting in an estimated 1 million visits to medical professionals annually. Conservative treatments for plantar fasciitis include rest, orthotics, night splint, stretching and non- steroidal anti-inflammatory drugs. Such treatments are successful in nearly 90% of patients, however, more invasive treatments are required for patients whose heel pain symptoms persist greater than six months. Fetal tissues, including the umbilical cord (UC) and amniotic membrane (AM) have been increasingly used to modulate healing in different parts of the body over the last two decades. These tissues have been demonstrated to possess anti-inflammatory and anti-scarring properties in addition to containing growth factors, cytokines, and matrix components to promote healing, and offer a potential therapy for plantar fasciitis. Methods: In this clinical series, we sought to evaluate the efficacy of cryopreserved, particulate UC/AM tissues as a treatment for plantar fasciitis as well as to determine if multiple injections provide an even greater benefit compared to a single injection. A multicenter prospective study was performed where patients were randomized to receive 25, 50, or 100 mg UC/AM tissue and either a single injection or two injections (at baseline and six weeks). All injections were administered under ultrasound guidance into the plantar fascia. At six, 12, and 18 weeks, patients returned and data on foot pain as well as the FAAM questionnaire were collected. Results: Last year, we presented interim data on 18 patients who had completed 18 weeks of follow-up. This year, we present the completed results of the study. Overall, patient foot pain was found to be significantly reduced in all treatment groups from baseline. FAAM scores for both activities of daily living and sports subscales also improved in all treatment groups, with overall improvement ranging from 60 – 150% compared to baseline. All patients showed variable degrees of improvement with no patients showing any deterioration. Conclusion: The results of this case series are similar to the results of an earlier study which found that injection of a particulate human amniotic membrane product for plantar fasciitis was safe and comparable to corticosteroids. While all treatments demonstrated improvement in both foot pain and FAAM scores, there was both a dose dependent as well as injection dependent effect of particulate UC/AM tissue on foot pain reduction (100 mg > 50 mg >25 mg; 2 injections > 1injection) suggesting a possible additive effect. Overall, these results are promising and highlight the potential effectiveness of UC/AM tissues as a treatment for plantar fasciitis.

Intractable or persistent hiccups require intensive or invasive treatments. The use of a phrenic nerve block or destructive treatment for intractable hiccups has been reported to be a useful and discrete method that might be valuable to patients with this distressing problem and for whom diverse management efforts have failed. We herein report a successful treatment using a removable and adjustable ligature for the phrenic nerve in a patient with recurrent and intractable hiccups, which was employed under the guidance of electromyography.

Review of a case of paraosseous extramedullary hematopoiesis (EMH) affecting the maxillary sinuses and retro-orbital spaces imitating bilateral orbital cellulitis. Maxillofacial EMH causes diagnostic/therapeutic challenges. This case report describes a 4-year-old African American male with sickle cell disease (HbSS) who presented with bilateral orbitofacial swelling. Diagnosis was made with imaging and confirmed with tissue sampling. Partial exchange transfusion was utilized to stop the progression of maxillofacial EMH and to treat the patient's chronic anemia. Follow-up MRI showed regression of orbital and retro-orbital involvement. Early treatment with conservative modalities and close observation may prevent need for more invasive treatments.

The AV node is a fascinating region, with particular and complex anatomy and physiology. It well illustrates the evolution of the rhythm disorders and their treatments; it was the first target when invasive electrophysiology started; from His recordings to DC ablation and from selective radiofrequency “slow pathway” modification to cryoablation, we have followed a long road of learning while burning; as our knowledge broadens, we can now very precisely target this region to invasive treatments. This chapter reviews the literature and discusses an approach regarding anatomic findings and physiology and its relationship to AVNRT ablation.

Vertebroplasty and kyphoplasty are minimally invasive treatments for vertebral compression fractures. Although infrequent, both transitory and persistent adverse effects have been reported. They range from asymptomatic to severe neurological deficits that are caused directly by polymethylmethacrylate (PMMA) leakage or may be related to local or general reactions not due to PMMA leakage. Transitory hypotension after the procedure has been observed, but the characteristics and etiology of this phenomenon are not defined.To describe a case of prolonged hypotension after kyphoplasty and suggest a possible mechanism.Six months after L2 kyphoplasty, a 63-year-old woman with severe osteoporosis developed a new back pain due to compression fracture of L1 and compression deformity of the superior L3 endplate. The patient underwent bilateral kyphoplasty at the L1 and L3 levels. She developed persistent hypotension for approximately 46 hours immediately after the procedure. Common causes of hypotension were ruled out and the event resolved spontaneously.On the basis of needle placement, the temporal relationship between the procedure and blood pressure change, and the lack of other identifiable causes, thermal sympathectomy from heating of the PMMA adjacent to the paravertebral sympathetic chain is proposed as a potential mechanism.Single case report based on clinical observation.Prolonged hypotension can complicate kyphoplasty at upper lumbar levels. Two days of severe hypotension has not been described as a complication of kyphoplasty. Although the mechanism is unknown, a transient thermal sympathectomy may be the cause.

Given the widespread use of medical therapies and the introduction of a myriad of minimally invasive treatments, the patient population undergoing the most established surgical procedures for BPO has considerably changed over the last two decades. General indications for surgical intervention are well described in current guidelines. However, patients may seek surgery as primary treatment, and the decision for surgery should be always based on the patient’s risk/benefit assessment. TURP is still considered as the gold standard treatment, given its well-documented long-term efficacy. Moreover, its surgical-related morbidity has been considerably reduced with introduction of bipolar systems. Simple prostatectomy can have a role in certain instances as it also appears to be safe and effective in contemporary series, especially in settings where more recent (laser) technology is not available. TUIP can be regarded as a viable option in selected patient with a suitable gland. Other recently introduced electrosurgical options, such as TUERP and TURisV, seem promising and user-friendly, but they need to be further scrutinized.

The authors have successfully performed laparoscopic surgery for esophageal achalasia and reflux esophagitis. Five patients with esophageal achalasia who complained of severe dysphagia have been treated with laparoscopic long esophagomyotomy and esophagofundopexy. The postoperative course was uneventful for all patients. Dysphagia had disappeared immediately after surgery, and none of the patients have had any symptoms suggestive of gastric reflux or esophagitis. Two patients with reflux esophagitis, who had been reluctant to undergo concervative therapy, have been successfully treated with laparoscopic Nissen fundoplication. The postoperative course was uneventful for both patients. The symptoms of reflux esophagitis disappeared after surgery. If indications are selected properly, the procedures described are curative and minimally invasive treatments for esophageal achalasia and reflux esophagitis.

Available and improved options for the treatment of femoral-popliteal disease have increased over the last decade. Even though most patients suffering from claudication due to femoral-popliteal disease are treated with aggressive medical and noninvasive methods, patients with limb-threatening disease and severely lifestyle-limiting symptoms are treated with invasive treatments, which include endovascular treatment options. Unfortunately, the unique forces involved in this vascular segment have challenged the long-term patency and clinical effectiveness of these treatments. The purpose of this brief review is to discuss treatment strategies and options for patients with femoral-popliteal disease. Included in this discussion will be the review of data from recent published studies and late-breaking trials as it pertains to certain treatment strategies.

Female sexual pain disorders are prevalent and have a deleterious effect on women's well-being. Because there are psychological elements to this pain, cognitive–behavioral therapy (CBT) may be a viable treatment alternative, particularly when compared to more physically invasive treatments such as surgery or medication. This article provides a critical analysis of research studies in this area by evaluating each study in detail, identifying gaps in the research base, and providing directions for future study. For the most part, all of the studies reviewed in this article found CBT to be effective. However, CBT modalities with minimal therapist direction or interaction were found to be problematic. In addition, there may be other noninvasive treatment types that are equally or more effective, such as biofeedback or supportive psychotherapy.

X-ray fluoroscopy is a medical-imaging technique whereby low-dose high-acquisition-rate x-ray images are obtained [1, 2]. Fluoroscopy provides quantum-limited high-definition digital-television viewing of structures inside the body. It makes possible many minimally invasive treatments such as balloon angioplasty, neuroembolizations, and transjugular intrahepatic portosystemic shunts (TIPS). Despite many recent developments in MR and CT imaging, x-ray fluoroscopy remains the principal imaging method for image-guided therapy. Although the x-ray dose per acquisition is low, very long sessions of fluoroscopy are required during complex interventional procedures giving relatively large doses to patients and operators [3]. Procedures lasting 4 hours with fluoroscopy times over 100 minutes are documented [4, 5], and some interventional neuroangiography procedures last 8 to 12 hours with fluoroscopy times exceeding 75 min [6]. The FDA has documented reports of severe skin injury [7, 8]. In a public health advisory, the FDA warns of “… occasional, but sometimes severe radiation-induced skin injuries to patients resulting from prolonged, fluoroscopically-guided, invasive procedures.” The advisory points out that injury can occur after less than one hour of fluoroscopy at normal exposure rates of 2 to 5 rad/ˆ•min [9]. Such exposures are easily reached in complex procedures. Hence, on average fluoroscopy accounts for one half of the population diagnostic x-ray dose [10] and for exceptionally large doses to those patients getting the most intricate procedures.

An unknown number of patients who undergo thoracic surgery develop post-thoracotomy neuralgia (PTN). Many seek a cure. As with other chronic, benign pain conditions, a variety of treatment modalities may be offered by different specialists. Results of therapy in terms of patient satisfaction are not known. A record of 73 patients with PTN was made. It has been used to measure the incidence, the natural and therapeutic history and the success of the management of PTN. Over 70% of the cases received three or more of the treatment modalities and regimens that have been reputed to be of value. More than 50% were referred to three different types of specialist. No patient claimed to have become free of symptoms as a result of treatment and a significant proportion, not clearly defined, implied that therapy was either more disabling than PTN or made it worse. Side effects of drugs were blamed for the former, and invasive treatments, aimed at nociceptive pathways, were incriminated in the latter. It is reasoned that about 5% of patients undergoing thoracic surgery may require resources for the management of PTN. No patient studied thought that conventional treatments had brought about a cure. Some treatments, known to be deleterious, remain extant. This information reflects and corroborates that from other studies which suggests that multidisciplinary approaches are more appropriate for chronic benign pain conditions than management by isolated physicians using specific therapies.

El esfínter artificial (EA) es actualmente el tratamiento considerado como "gold standard" en el tratamiento de la incontinencia urinaria post prostatectomía radical. La incontinencia de orina post prostatectomía radical es una complicación que se presenta en un 5-25% de los pacientes sometidos a este tratamiento. Esta complicación genera en los pacientes un deterioro importante en cuanto a su calidad de vida. Tratamientos conservadores y mínimamente invasivos han sido utilizados sin éxito, como por ejemplo los ejercicios de Kegel, el uso de absorbentes, farmacoterapia y electroestimulación o cirugía menor como los inyectables. Esta revisión resume las ventajas y complicaciones del esfínter artificial y su efectividad en el manejo de la incontinencia urinaria tras una prostatectomía radical.

The increasingly common incidental diagnosis of small renal masses (SRMs)(measuring under 4 cm in size) has led to the consideration of applying minimally invasive techniques to deal with them - particularly in view of the high percentage of non-malignant conditions of this size that are radiologically indistinguishable from tumor lesions. Accordingly, laparos copic access has gained great importance in the management of these masses, in an attempt to lessen the morbidity asso ciated with lumbotomy. Laparoscopic partial nephrectomy (LPN) is an evolving technique in most centers; on one hand it competes with open partialnephrectomyasthetechniqueofchoice,andontheotheritwillcompeteinthefuturewiththenon-excisionalmana gement techniques. These latter procedures in turn have become more precise thanks to laparoscopy. Based on a standardized review of the abundant literature on the treatment of SRMs, the present study examines the technical innovations and improvements afforded by the laparoscopic approach, not only for excision purposes but also a vehicle for minimally invasive treatments. Likewise, the requirements of Services of Urology and the improvements that could be introduced in health systems for advancing the application of LPN in the management of SRMs are commented. Progressive fine-tuning of the technique, with improvement of the laparoscopic repertoire and availability of hemosta tic agents, will contribute to increase the indications for LPN in the future. The limited frequency of the disorder and the need to optimize the technique will require health care supervisors to centralize this type of pathology in centers with expe rience in laparoscopy and open partial nephrectomy.

As minimally invasive treatments for liver cancers, percutaneous ablation therapies represent a valid alternative to liver resections, especially in patients with poor liver function. Recently, image-guided surgical and interventional procedures using open magnetic resonance imaging (MRI) have been introduced.We performed percutaneous ablation therapy for 51 nodules of liver cancer in 34 patients using a navigation system based on open MRI. During the ablation therapy, the ultrasonography (US) probe, needle, and tumor were displayed on the MR image. Immediately after the procedure, the therapeutic effect was evaluated by open MRI.In all cases, percutaneous puncture into the tumors was successful, even in the case of tumor undetectable by US. Mean fiducial registration error was approximately 3 mm. MR images captured after the procedure clearly demonstrated the ablated area. No mortality or major complications occurred, except for mild hemorrhage, pyrexia, and ascites.We developed a novel navigation system integrating US and MR images using open MRI for percutaneous ablation therapy of liver cancers. The presented system allows a safe and accurate approach to liver cancers, especially certain tumors that cannot be adequately visualized by US, and an evaluation of therapeutic results immediately after the procedures.

Inflammation is a recognised risk factor for the vulnerable atherosclerotic plaque. The aim of this study was to explore whether there is a difference in the degree of magnetic resonance (MR) defined inflammation using ultra small superparamagnetic iron oxide (USPIO) particles within carotid atheroma in completely asymptomatic individuals and the asymptomatic carotid stenosis contralateral to the symptomatic side.20 symptomatic patients with contralateral disease and 20 completely asymptomatic patients underwent multi-sequence MR imaging before and 36 h after USPIO infusion. Images were manually segmented into quadrants and signal change in each quadrant was calculated following USPIO administration. Mean signal change was compared across all quadrants in the two groups.The mean percentage of quadrants showing signal loss was 53% in the contralateral group compared with 31% in completely asymptomatic individuals (p = 0.025). The mean percentages showing enhancement were 44% and 65%, respectively (p = 0.024). The mean signal difference between the two groups was 8.6% (95% CI 1.6% to 15.6%; p = 0.017).Truly asymptomatic plaques seem to demonstrate inflammation but not to the extent of the contralateral asymptomatic stenosis to the symptomatic side. Inflammatory activity may be a significant risk factor in asymptomatic disease.