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Purpose: Intraoperative ultrasound was used to assess the flow velocity in the marginal vessel arch adjacent to the anastomosis, critical for evaluating the anastomotic blood supply. This technique also enabled us to investigate the potential effects of preserving the left colonic artery on the perfusion of the anastomosis., Methods: This prospective study included 40 rectal cancer patients who underwent laparoscopic anterior resection between January 2021 and January 2023. The length of the inferior mesenteric artery (IMA) was measured from its origin to the first branch, and the diameters of the mesenteric vessel IMA, left colonic artery (LCA), and marginal mesenteric artery (MMA) were recorded. Blood flow velocity and Doppler ultrasound waveforms of the MMA near the anastomosis were collected. Measurements were taken both before and after clamping the IMA using atraumatic forceps. The tardus parvus pattern of the MMA ultrasound waveforms was recorded to evaluate the hypoperfusion status of the anastomosis., Results: The mean velocities of MMA were 47.9 cm/s before clamping and 34.9 cm/s after atraumatic clamping, indicating significant differences (p < 0.05). Thirteen patients (32.5%) exhibited a Tardus parvus pattern after IMA atraumatic clamping. Multivariate analysis revealed older age and LCA diameter as independent clinical predictors of the hypoperfusion status after IMA clamping., Conclusions: Preservation of the LCA may improve perfusion near the anastomosis during rectal cancer surgery. Older age and LCA diameter can be considered useful predictors of the mesenteric hypoperfusion status after IMA ligation. Intraoperative ultrasound can evaluate the perfusion of the MMA near the anastomosis. Chinese Clinical Trial Registry-Registration number: ChiCTR2000041475., Competing Interests: Declarations Conflict of interest I declare that the authors have no competing interests that might be perceived to influence the results and discussion reported in this paper. Ethical approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent Informed consent was obtained from all participants., (© 2024. The Author(s).)

Objective: To evaluate the benefits of volumetric modulated arc therapy (VMAT) based on multicriteria optimization (MCO) for gastric cancer patients, particularly the protection of serial organs at risk (OARs) that overlap with the target volume., Methods: MCO and single-criterion optimization (SCO) VMAT plans were conducted among 30 gastric cancer patients, with a prescription dose of 50.4 Gy delivered in 28 fractions. All treatment plans underwent review, and a comparison was made between the active planning time and different dose-volume parameters., Results: Both the MCO and SCO VMAT plans achieved the target dose coverage, with no significant difference in the conformity index (CI) for the planning target volume (PTV), at median CI values of 0.887 and 0.891, respectively (P = 0.417). The MCO plans showed a slight but significant increase in the homogeneity index of the PTV, with a median increase of 0.029 (P < 0.001). Additionally, the MCO plans resulted in a lower D 2% to the small intestine and duodenum, with reductions of 3.43 Gy and 0.3 Gy, respectively (P < 0.05). Furthermore, the D max to the small intestine correlated moderately with the overlapping volume between the small intestine and the target volume (ρ = 0.42, P = 0.023). Except for the mean dose to the liver, the MCO plans performed better in terms of dose indicators for other OARs. Moreover, compared to the SCO plans, the median active planning time in the MCO plans was significantly reduced by 53.2 min (P < 0.0001)., Conclusions: MCO can effectively help the physicians to quickly select an optimal treatment plan for patients with gastric cancer. It has been shown that MCO VMAT plans can significantly reduce the dose to OARs and shorten the active planning time, with acceptable target coverage. In addition, these plans take less dosimetric time, thereby streamlining the treatment planning process., Competing Interests: Declarations Ethics approval and consent to participate This study, conducted in accordance with the Declaration of Helsinki, received approval from the ethics committee of West China Hospital, confirming that informed consent was obtained from all subjects and/or their legal guardians. Consent for publication Not applicable. Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Background: Mastectomy is performed prior to or concurrently with deep inferior epigastric perforator (DIEP) flap breast reconstruction. However, the complication rates of nipple-sparing mastectomy (NSM) versus skin-sparing mastectomy (SSM) with DIEP are not well-characterized., Methods: This retrospective study included patients who underwent SSM or NSM with DIEP reconstruction between January 2019 and July 2022 at an academic institution. The primary outcome was 30-day postoperative complication rate. Variables were compared using Student's t-tests/Wilcoxon rank-sum and Chi-square/Fisher's exact tests., Results: Of 535 patients, 195 (36%) underwent NSM and 340 (64%) underwent SSM. The 30-day postoperative complication rates did not differ between cohorts (16.4% in NSM vs. 16.8% in SSM, p > 0.9). The NSM cohort had a higher rate of any flap necrosis (9.2% vs. 3.5%, p = 0.01) compared to the SSM cohort, though rates of total DIEP flap loss rate did not differ (4.1% vs. 1.5% respectively). Site-wide total DIEP flap loss was 2.4%. The NSM cohort had smaller preoperative sternal notch-to-nipple distances (25.0 vs. 26.5 cm, p < 0.001) and had lower rates of preoperative radiation therapy (28.2% vs. 42.9%, p < 0.002) compared to the SSM cohort. The cohorts did not differ in demographic or operative variables including reconstruction timing (delayed vs. immediate interval), readmission, and reoperation., Conclusions: Individuals who received an NSM prior to DIEP reconstruction had more flap complications compared to the SSM cohort. Both cohorts had comparable overall 30-day postoperative complication rates and demographic variables, and rate of total DIEP flap loss was 2.4%. Patient preference can further guide surgical decision-making., (© 2024 The Author(s). Microsurgery published by Wiley Periodicals LLC.)

Background: Potential differences in organ preservation between total neoadjuvant therapy (TNT) regimens integrating long-course chemoradiotherapy (LCCRT) and short-course radiotherapy (SCRT) in rectal cancer remain undefined., Patients and Methods: This natural experiment arose from a policy change in response to the COVID-19 pandemic during which our institution switched from uniformly treating patients with LCCRT to mandating that all patients be treated with SCRT. Our study includes 323 locally advanced rectal adenocarcinoma patients treated with LCCRT-based or SCRT-based TNT from January 2018 to January 2021. Patients who achieved clinical complete response were offered organ preservation with watch-and-wait (WW) management. The primary outcome was 2-year organ preservation. Additional outcomes included local regrowth, distant recurrence, disease-free survival (DFS), and overall survival (OS)., Results: Patient and tumor characteristics were similar between LCCRT (n = 247) and SCRT (n = 76) cohorts. Median follow-up was 31 months. Similar clinical complete response rates were observed following LCCRT and SCRT (44.5% versus 43.4%). Two-year organ preservation was 40% [95% confidence interval (CI) 34% to 46%] and 31% (95% CI 22% to 44%) among all patients treated with LCCRT and SCRT, respectively. In patients managed with WW, LCCRT resulted in higher 2-year organ preservation (89% LCCRT, 95% CI 83% to 95% versus 70% SCRT, 95% CI 55% to 90%; P = 0.005) and lower 2-year local regrowth (19% LCCRT, 95% CI 11% to 26% versus 36% SCRT, 95% CI 16% to 52%; P = 0.072) compared with SCRT. The 2-year distant recurrence (10% versus 6%), DFS (90% versus 90%), and OS (99% versus 100%) were similar between WW patients treated with LCCRT and SCRT, respectively., Conclusions: While WW eligibility was similar between cohorts, WW patients treated with LCCRT had higher 2-year organ preservation and lower local regrowth than those treated with SCRT, yet similar DFS and OS. These data support induction LCCRT followed by consolidation chemotherapy as the preferred TNT regimen for patients with locally advanced rectal cancer pursuing organ preservation., (Copyright © 2024 European Society for Medical Oncology. Published by Elsevier Ltd. All rights reserved.)

Purpose of Review: This review critically evaluates the current state of bladder-sparing options in muscle-invasive bladder cancer (MIBC) and provides an overview of future directions in the field., Recent Findings: Bladder-sparing treatments have emerged as viable alternatives to radical cystectomy (RC) for selected patients with MIBC, especially in those who are unfit for RC or elect bladder preservation. Numerous studies have assessed the efficacy of trimodal therapy (TMT), with outcomes comparable to RC in a subgroup of well selected patients. Combining immunotherapy with conventional treatments in bladder-sparing approaches can yield promising outcomes. Current research is making significant progress in optimizing treatment protocols by exploring new combinations of systemic therapy agents, innovative drug delivery methods, and biomarker-based approaches. Furthermore, clinical markers of response are being tested to ensure adequate response assessment., Summary: Bladder preservation promise to offer a viable alternative to RC for selected patients with MIBC with the potential to improve patient quality of life. Careful patient selection and ongoing research are essential to optimize patient selection, response assessment, and salvage strategies. As evidence continues to evolve, the role of bladder preservation in MIBC is likely to expand, providing patients with more treatment options tailored to their needs and preferences., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Interstitial and/or intracavitary brachytherapy is an integral part of the treatment of vaginal cancer Brachytherapy (BT) has shown to improve local control, overall survival (OS) and disease-free survival (DFS). The aim of our study was to analyze the efficacy and safety of brachytherapy in patients with vaginal cancer., Materials and Methods: Between 2000 and 2023, 27 patients with vaginal cancer in stage FIGO I-III were treated with brachytherapy with or without external beam radiotherapy (EBRT) and simultaneous chemotherapy. Brachytherapy has been performed either as PDR-brachytherapy alone with a median cumulative dose up to 62.5 Gy (EQD2 = 63.9 Gy) or with PDR-BT boost with median dose of 30.9 Gy (EQD2 = 30.4 Gy). HDR-BT was administered solely as boost with a median dose of 25.5 Gy (EQD2 = 47.8 Gy). The median dose of EBRT was 48.7 Gy and 49.4 Gy for primary and for pelvic lymph nodes., Results: Median follow-up was 39 months (2-120). 5/27 patients developed local recurrences and the 5-year cumulative local recurrence rate for whole patient population was 18.5%. 5-year OS and DFS was 90% and 68%. 5-year DFS for Stage I-II was 72% and for Stage III 65% (p = 0.933). Grade 3 late side effects of brachytherapy were documented in 3/22 patients (13.6%), one patient experienced Grade 4 toxicity (4.5%)., Conclusion: Brachytherapy with or without EBRT and concomitant chemotherapy for vaginal cancer is a safe and effective treatment option with excellent local control and overall survival and acceptable toxicity., Competing Interests: Declaration of competing interest The authors declare no conflict of interest., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: While increasing evidence supports the safety and effectiveness of immunohistochemistry-assisted Mohs micrographic surgery (MMS) for superficially invasive melanoma, there is a paucity of the literature investigating its effect on final defect size., Objective: To evaluate the tissue sparing effect of MMS for melanoma., Materials and Methods: Three hundred and twenty-eight patients with early-stage (T1a/T1b) cutaneous melanomas treated with MMS from January 2008 to December 2018 were evaluated. Measured defect sizes after Mohs tumor extirpation were compared with anticipated defect size that would result from standard-margin wide local excision (WLE). Average actual versus anticipated defect areas were compared using a paired t -test (95% confidence intervals)., Results: The following groups demonstrated a significantly smaller defect area for MMS-treated tumors when compared with anticipated standard-margin WLE defect: All tumors combined (13.8 cm 2 vs 10.4 cm 2 , p < .001), tumors requiring 1 stage (13.6 cm 2 vs 10.1 cm 2,p < .001), and tumors requiring 2 stages (13.2 cm 2 vs 10.5 cm 2 , p = .004). The majority of patients (83.5%, n = 274) achieved clear margins with 1 stage., Conclusion: Immunohistochemistry-assisted MMS for early-stage invasive melanoma is associated with smaller final defect size and overall tissue sparing effect compared with standard WLE margins., (Copyright © 2024 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Synchronous rectal and prostate malignancies are rare and standard treatment guidelines have not yet been established. 1-3 Combined robotic rectal and prostate surgery represents a potentially excellent approach for managing synchronous rectal and prostate malignancies, offering the advantages of a minimally invasive procedure. 4 METHODS: A 78-year-old male with a history of hypertension and type 2 diabetes presented with 3 months of dyschezia and dysuria. Diagnostic colonoscopy revealed a submucosal mass 3 cm from the anal verge in the anterior wall of the rectum, with abnormal carcinoembryonic antigen and prostate-specific antigen levels. Pelvic computed tomography (CT) indicated indistinct boundaries between the rectal mass and the prostate, suggesting potential invasion. CT-guided biopsies confirmed a rectal gastrointestinal stromal tumor (GIST) and prostatic acinar adenocarcinoma. After 3 months of neoadjuvant therapy with imatinib mesylate and bicalutamide, significant tumor reduction was achieved. 5 Subsequently, the patient underwent simultaneous robotic sphincter-preserving rectal resection and prostatectomy, starting with the prostatectomy, followed by rectal tumor excision and ending with bowel reconstruction and vesicourethral anastomosis using a running suture technique., Results: The operation time was 220 min and the estimated blood loss was 50 mL. No surgical complications were encountered and all resected margins were free of tumor, indicating a complete excision. The patient recovered well and was discharged on the seventh postoperative day. Follow-up at 3 months showed no evidence of recurrence or functional impairments., Conclusion: Simultaneous robotic sphincter-preserving local rectal resection and prostatectomy can be feasibly and safely performed following neoadjuvant therapy in cases of synchronous rectal GIST and prostate cancer., (© 2024. Society of Surgical Oncology.)

Background and Purpose: Chemoradiotherapy (CRT) for locally-advanced non-small cell lung cancer (LA-NSCLC) has undergone advances, including increased overall survival (OS) when combined with immune checkpoint blockade (ICB), and using cardiac-sparing techniques to reduce the radiotoxicity. This research investigated 1) how radiotherapy schedules can be optimised with CRT-ICB schemes, and 2) how cardiac-sparing might change the OS for concurrent CRT (cCRT)., Methods and Materials: Survival data and dosimetric indices were sourced from published studies, with 2-year OS standardised and the hazard ratio of mean heart dose (MHD) against radiotoxicity tabulated in purpose. A published CRT dose-response model was selected, then modified with ICB and cardiac-sparing hypotheses. Models were maximum likelihood fitted, then visualised the prediction outcomes after bootstrapping., Results: The modelled 2-year OS rate of cCRT-ICB reached 71 % (95 % confidence intervals, CI 62 %, 84 %) and 66 % (95 % CI: 53 %, 81 %) for stage IIIA and IIIB/C, respectively, given 60 Gy in 2 Gy-per-fraction. 60 Gy in 30 fractions remained the best schedule for cCRT-ICB, whereas modest dose de-escalation to 55 Gy only reduced the OS in 2 %. Sequential CRT (sCRT)-ICB provided 6 % OS increases versus the best OS rate achieved by sCRT alone. Photon MHD-sparing achieved a 5-10 % increase in modelled 2-year OS, with protons providing a further roughly 5-10 % increase., Conclusion: Neither dose-escalation nor de-escalation relative to 60 Gy in 30 fractions influenced the survival with cCRT-ICB, while 5 Gy dose de-escalation might benefit patients with heavily irradiated organs at risk. Cardiac-sparing improved OS, and protons provided advantages for tumours anatomically overlapped or lay below the heart., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Aims: To assess in patients with 1-10 brain metastases, each of which has been treated by neurosurgery or stereotactic radiosurgery, whether hippocampal sparing whole brain radiotherapy (HS-WBRT) better spares neurocognitive function (NCF) than standard WBRT. Further, to assess whether a phase III randomised trial of HS-WBRT would be feasible in the UK., Materials and Methods: A multicentre, randomised, open label phase II trial was undertaken, randomising patients to 30Gy in 10 fractions of WBRT or HS-WBRT. The primary endpoint was decline in Total recall using Hopkins Verbal Learning Test Revised (HVLT-R) at 4 months post treatment. To assess this, we aimed to recruit 84 patients over 3 years. Secondary endpoints included further measures of NCF, quality of life, duration of functional independence, local control of treated metastases, development of new metastases, disease control within the hippocampal regions, overall survival, steroid and antiepileptic medication requirements, and toxicity., Results: The trial closed prematurely due to slower than anticipated recruitment. From April 2016 to January 2018, 23 patients were randomised. Follow up was a median of 25 months. Fifteen patients (6 WBRT, 9 HS-WBRT) were assessed for the primary endpoint; of these, 1 in each arm experienced significant decline in the 4-month HVLT-R Total recall score (p = 0.8). Patients in the HS-WBRT arm experienced less insomnia (p < 0.01) and drowsiness (p < 0.01). There were no differences in other secondary endpoints., Conclusion: A phase III randomised trial of HS-WBRT was shown not to be feasible at this time in the UK. As most randomised trials of HS-WBRT reported to date share common endpoints, including NCF, an individual patient data meta-analysis should be undertaken., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Purpose of Review: Several novel therapies approved by the Food and Drug Administration (FDA) and explosion of clinical trials have changed the landscape Bacillus Calmette-Guérin (BCG)-unresponsive nonmuscle invasive bladder cancer (NMIBC). Given the recent advancements in bladder sparing options, the role of radical cystectomy (RC) in BCG-unresponsive NMIBC remains a subject of debate., Recent Findings: All three novel agents currently approved by the FDA for BCG-unresponsive NMIBC have strict indication [carcinoma in situ (CIS)], low response rate, and short response duration. Some promising new agents are awaiting results and/or FDA approval. RC still provides the best oncologic control and acceptable quality of life, and potentially represents the most cost-effective option., Summary: It is an exciting time for the urologic oncology community to see the FDA approvals of some of the novel bladder sparing therapies and expansion of ongoing clinical trials. Yet, RC should still be considered as the gold standard of BCG-unresponsive NMIBC. We also must be cautious and selective in recommending bladder sparing options for patients with BCG-unresponsive NMIBC., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Pancreaticoduodenectomy has been the standard of care for managing duodenal neoplasms, but recent studies show similar overall and disease-specific survival after pancreas-preserving duodenectomy (PPrD) with potentially less morbidity., Methods: Retrospective cohort of all adult (age >18) patients who underwent PPrD with curative intent of a neoplasm in or invading into the duodenum at our institution from 2011 to 2022 (n ​= ​29), excluding tumors involving the Ampulla of Vater or the pancreas. Statistical analyses were performed using STATA., Results: R0 resection was achieved in 93 ​% patients. Ten (34.4 ​%) experienced postoperative complications (13.7 ​% within Clavien-Dindo III-V). PPrD patients had lower rates of pancreatic leak, delayed gastric emptying, and deep surgical site infection., Conclusions: In this case series, we demonstrate PPrD is safe and effective, with a high rate of complete resection and lower complication rate than that seen in pancreaticoduodenectomy., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Partial funding (in the form of salary support) for Dr. Christine Chung came from the foundation of fellowships., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: In invasive breast cancer, there are no differences among the mid- and long-term oncological safety results of nipple-sparing mastectomy (NSM), skin-sparing mastectomy (SSM), and simple mastectomy (SM). There are several reports comparing NSM and SSM with SM in the context of ductal carcinoma in situ (DCIS); however, the eligibility criteria vary among institutions, and there are no reports that compare all three surgical methods simultaneously within the same institution. This study aimed to compare the local recurrence and survival rates of the three techniques (NSM, SSM, and SM) in Japanese patients undergoing mastectomy for DCIS., Methods: Patients undergoing NSM, SSM, or SM at our institution between 2006 and 2015 were identified, and their outcomes were analyzed., Results: The mean follow-up period was 80.4 months (standard deviation [SD]: 37.1 months). NSM was performed in 152 cases, SSM in 49, and SM in 44. Five of 245 patients developed local recurrences. Four of these patients had invasive cancer. The primary endpoints of 5-year cumulative local recurrence were 2.4% (95% confidence interval [CI]: 0.0-5.0) for NSM, 2.2% (95% CI: 0.0-6.3) for SSM, and 0% (95% CI: 0.0-0.0) for SM. There were no significant differences among the 5-year local recurrence rates., Conclusions: In this single-center, retrospective study, the oncological safety of SSM and NSM for DCIS was comparable to that of conventional SM., (© 2024. The Author(s), under exclusive licence to The Japanese Breast Cancer Society.)

Study Objective: The main objective is to evaluate the feasibility of laparoscopic fertility-sparing surgery in women with growing teratoma syndrome., Design: Retrospective cohort study., Setting: Chinese tertiary university hospital., Patients: Patients with growing teratoma syndrome who underwent fertility-sparing surgery between January 2015 and August 2023., Interventions: Baseline characteristics and surgical outcomes were evaluated, including clinical information, surgical procedures, operative time, intraoperative blood loss, complications, length of hospital stay, and follow-up information., Measurement and Main Results: Twenty-six patients with ovarian growing teratoma syndrome underwent fertility-sparing surgery: 12 had laparoscopic surgery and 14 underwent laparotomic surgery. In the laparoscopic group, the median age of the patients during initial management of immature teratoma or mixed malignant ovarian germ cell tumor was 14.0 years (interquartile range, 13.0-24.5 years). Eleven patients were nulliparous. The primary ovarian tumor was pure immature teratoma in 10 patients and mixed ovarian germ cell tumor in 2 patients. Complete laparoscopic tumor resection was achieved in 11 patients. Patients in the laparoscopic group had shorter median operative time (76.5 vs 180.0 minutes, p = .001), lower estimated blood loss (20.0 vs 400.0 mL, p <.001), and decreased postoperative hospital stay (2.0 vs 7.0 days, p <.001) compared with laparotomic surgery. There was no conversion to laparotomy and no perioperative complications. Histologic examination confirmed mature teratoma in all cases. During a median follow-up of 21.9 months (interquartile range, 7.6-44.9 months), 11 patients were alive without disease and 1 was alive with disease. One pregnancy was achieved postoperatively., Conclusion: Laparoscopic fertility-sparing surgery may represent a feasible option in well-selected patients with ovarian growing teratoma syndrome. Surgery should be performed in gynecologic oncology centers by experienced staff trained in endoscopic procedures. More research and long-time follow-up are needed to determine the oncologic outcomes and safety of laparoscopic surgery in this population., (Copyright © 2024 AAGL. Published by Elsevier Inc. All rights reserved.)

Background: Valve-sparing root replacement (VSRR) has been associated with good survival and low rates of valve-related complications (VRCs). Whether these advantages are present irrespective of patient comorbidity or age is unclear. The aim of this study was to analyze survival and frequency of VRCs in relation to patient comorbidity and age., Methods: Between October 1995 and December 2021, 1156 patients with a bicuspid or tricuspid aortic valve were treated by root remodeling. The mean patient age was 53.3 ± 14 years, and 973 (84%) were male. The mean duration of follow-up was 6.7 ± 5.5 years (median, 5.9 years), and follow-up was 95% complete (7746 patient-years). We analyzed the population according to comorbidity and age at surgery. A discriminating cutoff for the effect of age was determined using receiver operating characteristic curve (ROC) analysis., Results: Mean survival at 15 years was 74.7 ± 2.5%. Deceased patients were older (mean, 65.3 ± 12 years vs 51.6 ± 14.1 years; P < .001) at the time of surgery and had more comorbidities (coronary artery disease [CAD], 28.4% vs 9.8%; P < .001). The sole significant adjusted predictor was age (P < .001). By ROC analysis (area under the curve, 0.780), the optimal cutoff for age was 61 years. Survival was 87.1 ± 2.8% at 15 years in patients age <61 years, compared to 55.3 ± 4.3% in patients age >61 years (P < .0001). Using competing risk analysis, VRC-free survival at 15 years was 66.8% at 15 years, including 76.7% in patients age <61 years and 52.4% in those age >61 years (P < .0001)., Conclusions: VSRR is associated with a low incidence of VRC and excellent durability. Survival is decreased in the presence of comorbidities, mainly CAD, and patient age >61 years. Despite lower survival, freedom from VRC is good., Competing Interests: Conflict of Interest Statement The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Maintaining erectile function is an important quality of life issue for patients with localized prostate cancer treated with robotic-assisted radical prostatectomy (RARP). However, most existing studies are retrospective and inherently weak and cannot conclude which NS approach is most effective in restoring function in patients. We therefore performed a consistent and objective assessment of sexual function outcomes in RARP using different nerve-sparing methods to optimize postoperative outcomes. A systematic review and meta-analysis was performed based on PRISMA and STROBE statement criteria. Statistical analysis was performed using StataMP software version 14. The Newcastle-Ottawa scale was used to assess the risk of bias. This single-arm meta-analysis included 3 randomized controlled trials and 14 cohort studies with a total of 3756 patients. Our meta-analysis found that patients had the highest efficiency rate of 0.86 (0.78, 0.93) after the NS technique using the retrograde method. Overall, there are significant differences between RARP NS techniques and outcomes, and the ideal technical strategy to optimize outcomes remains controversial. However, there is consensus on the importance of careful separation, dissection of the NVB, reduction of traction and thermal injury, and preservation of the fascia around the prostate. We still need more well-designed randomized controlled trials with videos describing the details of the different surgical techniques before they can be replicated.

Purpose: The aim of this study is to analyze the impact of different surgical techniques used to preserve the inferior mesenteric artery on patient outcomes following left colonic resection., Methods: A search was conducted in PubMed, Embase and Web of Science, founding 4795 articles. The review was registered on PROSPERO (registration number: CRD42024572291)., Results: Eleven articles published between 2001 and 2023, including 989 patients were the object of the present systematic review. Two hundred sixty-two patients (26.5%) underwent Valdoni's technique (Group A), which involves the skeletonization of the IMA, 272 (27.5%) underwent tubular resection (Group B), and 455 (46%) underwent peripheral dissection on sigmoid vessels (Group C). Laparoscopic surgery was predominant in Groups B (100%) and C (94.7%), while Group A had fewer laparoscopic procedures (44.6%). Patients in Group A experienced longer operative times (174.5 ± 27.4 min) and hospital stays (11.4 ± 3.6 days) compared to Groups B and C (165.9 min and 152.35 ± 46.9 min; 8.4 ± 5.7 days and 8.3 ± 3.6 days, respectively). Group A exhibited higher rates of anastomotic leakage (5%) compared to Group C (1.1%) and a higher incidence of bleeding (13%) compared to Group B (1.8%)., Conclusion: Valdoni's technique is less favourable for IMA preservation in left colon resection for diverticular disease. Peripheral dissection of sigmoid vessels or tubular resection is recommended for IMA preservation in this context., (© 2024. The Author(s).)

Objective: In this study, we compared indications and outcomes of 115 young (< 40 years) versus 40 elderly (> 60 years) patients undergoing nipple-sparing mastectomy (NSM) as risk-reducing surgery or for breast cancer (BC) treatment., Methods: Between January 2004 and December 2018, young and elderly patients undergoing NSM with complete data from at least 6 months of follow-up were included., Results: BC treatment was the main indication for NSM, observed in 85(73.9%) young versus 33(82.5%) elderly patients, followed by risk-reducing surgery in 30(26.1%) young versus 7(17.5%) elderly patients. Complication rates did not differ between the age groups. At a median follow-up of 43 months, the overall recurrence rate was higher in the younger cohort (p = 0.04). However, when stratified into local, locoregional, contralateral, and distant metastasis, no statistical difference was observed. During the follow-up, only 2(1.7%) young patients died., Conclusion: Our findings elucidate a higher recurrence rate of breast cancer in younger patients undergoing NSM, which may correlate with the fact that age is an independent prognostic factor. High overall survival and low complication rates were evidenced in the two groups showing the safety of NSM for young and elderly patients., Competing Interests: Conflicts to interest: none to declare., (© 2024. Federação Brasileira de Ginecologia e Obstetrícia. All rights reserved.)

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).)

Purpose: This is a retrospective study of one-stage anterior sagittal sphincter saving anorectoplasty (ASSSARP) for repairing rectovestibular fistula (RVF) including operative details and postoperative complications, functional and cosmetic outcome., Patients and Methods: Records of 41 cases of RVF, managed between April 2010 and September 2019 by one-stage ASSSARP, were reviewed. Preoperative preparation, both early and late postoperative care & complications, hospital stay, and functional & cosmetic outcomes were reported., Results: The mean age was 6.6 months. Vaginal tear occurred in 5/41 cases, and distal rectal tears in 4/41 cases. Thirteen patients suffered mild superficial wound inflammation; while Skin dehiscence; occurred in five patients. No colostomy or redo was needed. The mean hospital stay was 6.1 days. Mean follow-up was 43.13 months; (Range; 24-100 months). Subclinical anal stricture was detected in six patients. Constipation occurred in 14 cases. Soiling grade I occurred in five patients. Thirty-two patients reached past the age of three years; two of whom showed cough/diarrhea incontinence., Conclusion: One-stage ASSSARP is safe and gives functional and cosmetic results comparable to other techniques. It provides better access during RVF repair. The avoidance of muscle incision protects against muscle breakdown, if infection sets in, and thus against incontinence. It avoids the morbidity, cost and psychological burden of performing a three-stage repair., (© 2024. The Author(s).)

Bladder cancer is one of the common malignant tumors in urology. According to statistics, there will be 613 791 new cases of bladder cancer in the world in 2022, and the number of new cases of bladder cancer in China will be approximately 92 900, accounting for approximately 15% of new cases of bladder cancer in the world, ranking 11th in the spectrum of malignant tumors in China, among which there are approximately 73 200 new cases in males, ranking 8th in the spectrum of male malignant tumors. Bladder urothelial cancer accounts for approximately 90% of all bladder malignant tumors. It can be divided into non-muscle-invasive bladder cancer and muscle-invasive bladder cancer according to whether it invades the bladder muscle layer. Radical cystectomy is the standard treatment for muscle invasive bladder cancer patients and bacillus calmette-guerin (BCG) unresponsive high-risk non-muscle invasive bladder cancer patients. Nevertheless, due to the patient's underlying diseases and the deterioration of the quality of life caused by surgery, many patients refused or are not suitable for radical cystectomy. Therefore, it is vital to find a bladder-preserving treatment that can achieve cure other than radical cystectomy. Bladder-preserving therapy that balances tumor control and quality of life serves as an alternative and supplement to radical cystectomy. This consensus is based on contemporary evidence-based medicine, combined with native clinical practice and experiences of bladder preservation in a multidisciplinary treatment manner. To some extent, this consensus serves as a guidance for bladder preservation of bladder cancer in China. The consensus aims to discuss issues including organizational structure and workflow of multidisciplinary treatment, the selection of patients for bladder-preserving therapy, treatment options and regimens, efficacy evaluation, follow-up, as well as regimen choices of recurrence after bladder-preserving therapy.

Background: Using dose-painted intensity-modulated radiation therapy, specific dose volume constraints or implantation of tissue expanders prior to radiotherapy are validated options for reducing radiation dose on the bowel and therefore minimizing acute gastrointestinal toxicity during chemoradiation for anorectal malignancies. We describe the rare case of a female patient with a locally advanced anal carcinoma where a large myomatous uterus served as a natural spacer to protect the bowel during radiation therapy., Case Presentation: Initially the patient presented with anal pain, proctoscopy followed by an excisional biopsy confirmed the diagnosis of a squamous cell carcinoma of the anus. Imaging examination showed a locally advanced tumor and in addition a large uterus with typical leiomyomas up to 11.5 cm in diameter. The patient underwent chemoradiation; because of the large leiomyomas there was almost no dose burden for the small intestine and therefore practically no gastrointestinal toxicity., Conclusion: As we know, this report describes the situation that a large myomatous uterus served as a natural spacer during radiation therapy in a way that is unique to date., (© 2024. The Author(s).)

Introduction: Benign prostatic hyperplasia (BPH) is a common urological condition, particularly among middle-aged and elderly men. Trans urethral resection of prostate (TURP) has some drawbacks, particularly concerning ejaculatory function. Ejaculation preserving TURP (Ep-TURP) is one such technique that aims at preserving the tissues that are primarily responsible for antegrade ejaculation., Methods and Material: In this prospective study, patients with bothersome LUTS were randomized into Ep-TURP and standard TURP groups. Supramontal tissue was preserved in Ep-TURP while standard TURP group had resection of the entire prostatic tissue up to the verumontanum. The outcomes with regard to IPSS, Qmax, IIEF(Q9), Ejaculation and PVR were studied. Ejaculation projection score was separately calculated and assessed., Results: About 60 patients were studied, with 30 in each group. At 6 months' follow-up, complication rates were the same in both groups. The IPSS, Qmax, IIEF were similar and comparable. There was no change in erection in all patients (P = 0.559). The ejaculation was well preserved in Ep-TURP (p<0.001). Ejaculation projection score was maintained at 3.77 in the Ep-TURP group while in the standard group it was 0 (P<0.001)., Conclusions: Ep-TURP is a safe and a cost-effective method of preserving ejaculation in patients undergoing TURP. This procedure adds a better quality of life that greatly aids in enhancing the improving his psychological outlook towards life. Ep-TURP has now emerged as the standard procedure of choice in sexually active young males needing TURP, as the degree of ejaculation is largely well preserved in patients undergoing this procedure., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Extra-skeletal Ewing sarcoma (EWS) occurs in about 12% of EWS patients; at the same time, primary involvement of the kidneys remains extremely rare. Since it was first described in 1975, only a small case series have been reported worldwide. About 95% of surgically treated patients with EWS of the kidney described in the literature underwent nephrectomy, and the remaining patients only had a tumor biopsy. Nephron-sparing surgery (NSS) has not been sufficiently investigated as an alternative in the local surgical treatment of localized disease, mostly as a result of technically unfeasible provisions of negative surgical margins. In this report, we present a unique case of primary EWS of the kidney with an asymptomatic course without radiographic signs that suggest a highly aggressive disease, successfully locally treated with robotic-assisted NSS. This report showcases that robotic-assisted NSS could be a feasible alternative in treatment of localized disease yielding equally good oncological results while, at the same time, creating better prerequisites for necessary adjuvant chemotherapy.

Background: Conservative treatment of chronic pancreatitis has only a limited effect in most patients. Surgery offers very good long-term results, even in the early stages of the disease. Unfortunately, only a minority of patients undergo surgical treatment. The aim of this work was to summarise the current treatment options for patients with an inflammatory mass of the pancreatic head. Data from patients in our study demonstrates that the surgery is a safe method, and here we compare the perioperative and early postoperative outcomes of patients who underwent a pancreatoduodenectomy and duodenum-preserving pancreatic head resection for chronic pancreatitis., Methods: All patients who underwent a pancreaticoduodenectomy or a duodenum-preserving pancreatic head resection in our department between 2014 and 2022 were included in this study. Perioperative and early postoperative results were statistically analysed and compared., Results: Thirty-eight pancreaticoduodenectomies and 23 duodenum-preserving pancreatic head resections were performed. The overall mortality was 3%, whereas the in-hospital mortality after pancreaticoduodenectomy was 5%. The mortality after duodenum-preserving pancreatic head resection was 0%. No statistically significant differences in the hospital stay, blood loss, and serious morbidity were found in either surgery. Operative time was significantly shorter in the duodenum-preserving pancreatic head resection group., Conclusions: Both pancreatoduodenectomy and duodenum-preserving pancreatic head resection are safe treatment options. Duodenum-preserving pancreatic head resection showed a statistically significant superiority in the operative time compared to pancreaticoduodenectomy. Although other monitored parameters did not show a statistically significant difference, the high risk of complications after pancreaticoduodenectomy with a mortality of 5%; maintenance of the duodenum and upper loop of jejunum, and lower risk of metabolic dysfunctions after duodenum-preserving pancreatic head resection may favour duodenum-preserving pancreatic head resection in recommended diagnoses. Attending physicians should be more encouraged to use a multidisciplinary approach to assess the suitability of surgical treatment in patients with chronic pancreatitis., (© 2024. The Author(s).)

Objective: To evaluate the better radiotherapy plan for pelvic tumours that may achieve a high target coverage dose and low normal tissue tolerance dose using simultaneous integrated boost-intensity-modulated radiation therapy technique., Methods: The analytical, cross-sectional, descriptive study was conducted from October 2020 to March 2021 at Al- Amal National Hospital for Cancer Treatment, Baghdad, Iraq, and comprised male pelvic cancer patients aged 50-80 years. Computed tomography scans were randomly selected. For each patient, 4 treatment plans (phases Ι and Π) were generated using the simultaneous integrated boost-intensity-modulated radiation therapy technique while keeping all parameters constant except the number of beams, which were 5, 7, 9 and 11. The optimal and safe dose was defined as the one to cover 95% planning target volume. Homogeneity and conformity indices were used to assess the uniformity of dose distribution in the target volume, and various treatment plans in the same patient were compared. Data was analysed using SPSS 24., Results: There were 15 males with mean age 67.12±2.84 years. There was a significant variance in the target volume dose and organ at risk in the 4 different plans generated using the simultaneous integrated boost-intensitymodulated radiation therapy technique (p<0.05). The 9-beam treatment plan was the best for coverage of tumours and protection of healthy organs assessed through homogeneity and conformity indices (p<0.05)., Conclusions: The 9-beam treatment plan showed significant tumour coverage, homogeneity and conformity values, and sparing dose for organs at risk.

Purpose: We investigated the relationship between the resected stomach measurements, the incidence of delayed gastric emptying (DGE), and food residue 1 year after surgery in patients who underwent laparoscopic pylorus-preserving gastrectomy (PPG)., Materials and Methods: The DGE group included 10 patients fasting due to nausea, vomiting, abdominal distension, or remnant stomach distension on radiographs; the control group included 36 patients without these symptoms. We compared the size and length of lesser and greater curvatures of the resected stomach and endoscopic findings after 1 year., Results: No significant differences were observed between groups in terms of sex, body mass index, gross type, histology, tumor progression, number of dissected lymph nodes, operating time, or blood loss. The DGE group was older, had a longer postoperative stay, and showed a smaller size and shorter greater curvature of the resected stomach than the control group (p < 0.01 for all). No difference was observed in the length of the lesser curvature of the resected stomach. In addition, there were no disparities in residual food, degree and extent of gastritis, or bile reflux 1 year after gastrectomy., Conclusions: Measurements of the resected stomach suggest that preventing DGE may be achievable by removing a larger area of the greater curvature and/or stomach during laparoscopic PPG. This implies potential surgical strategy improvements for better outcomes. Further multicenter trials are needed to validate and refine techniques., (© 2024 Asia Endosurgery Task Force and Japan Society of Endoscopic Surgery and John Wiley & Sons Australia, Ltd.)

Competing Interests: Declaration of competing interest The authors declare that there are no conflicts of interest.

Over the last 2 decades, the paradigm of laryngeal cancer management has pivoted toward preserving laryngeal function without sacrificing oncologic outcomes. Transoral laser microsurgery has diminished the role of open laryngeal surgery. For early-stage laryngeal cancer, the common primary modalities are endoscopic laryngeal surgery and narrow field radiation. Total laryngectomy followed by either radiation or chemoradiation is option for advanced laryngeal cancer. In experienced hands and following meticulous patient selection, supracricoid laryngectomy may serve as a viable alternative to total laryngectomy to preserve laryngeal function. Total laryngectomy is still the recommended treatment in those with airway compromise and/or laryngeal dysfunction., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Frozen section examination (FSE) of the tumor resection margins is important during penile-preserving surgery (PPS) in penile cancer. The margin status will impact on how much penile or urethral tissue is excised. We aim to evaluate the outcomes of intraoperative FSE of resection margins in PPS., Patients and Methods: A retrospective analysis of patients with penile squamous cell carcinoma (SCC) who underwent a FSE of resection margins between 2010 and 2022 was conducted. FSEs were compared with the final histopathological analysis and the Diagnostic Testing Accuracy (DTA): sensitivity, specificity, positive (PPV) and negative predictive values (NPV) were calculated., Results: Overall, 137 FSE were performed. The median (IQR) age was 65 (53-75) years. 118 (86.1%) patients had negative FSE margins, 16 (11.7%) had positive FSE margins and 3 (2.2%) had equivocal (atypical cells) results. The sensitivity, specificity, PPV, NPV and diagnostic accuracy of penile FSE were 66.7%, 100%, 100%, 93.2% and 94% respectively. 18 patients underwent further resection in the same episode due to a positive or equivocal FSE and 12 (66.7%) achieved negative margins. Limitations include the retrospective nature of the study and lack of control arm to compare with., Conclusions: Intraoperative FSE performed at our center for the assessment of penile SCC margins is 66.7% sensitive and 100% specific. FSE should be considered in PPS, as it's an essential and a reliable diagnostic tool in minimizing over-treatment., Competing Interests: Disclosure The authors have stated that they have no conflicts of interest., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Advanced gastric cancer that has not invaded the greater curvature is a good indication for total gastrectomy (TG) with spleen-preserving suprapancreatic and splenic hilar lymph node dissection (LND). However, the suprapancreatic and splenic hilar LND increases the area of dissection of the pancreas, and prolonged pressure drainage of the pancreas is required to maintain a clear operative view. This can lead to an increased risk of postoperative pancreatic complications. To report the efficacy of our novel preemptive retropancreatic approach (PRA) for the suprapancreatic and splenic hilar LND in robotic TG (RTG). We report our experience with nine patients with gastric cancer who underwent spleen-preserving splenic hilar LND using PRA during RTG at Hokkaido University from October 2018 to November 2021. The PRA involves initial dissection of the left side of the retropancreatic space, followed by the release of the adherence between the retroperitoneum surface and the pancreas (fusion fascia), which provides a good operative field and prevents contact with the pancreas during the suprapancreatic and splenic hilar LND in RTG. The median operating time was 488 min (254-564 min). The median intraoperative bleeding was 55 mL (0-115 mL). One patient had postoperative complications (above grade II of the Clavien-Dindo classification), but there were no postoperative pancreatic complications. The spleen-preserving suprapancreatic and splenic hilar LND using PRA could help to reduce the postoperative pancreatic complications associated with RTG.Trial registration number and date of registration The Hokkaido University Hospital institutional review board approved the data collection and analysis. The trial registration number and date of registration are No. 021-0022 and July 26, retrospectively registered., (© 2024. Italian Society of Surgery (SIC).)

Bacillus Calmette-Guérin (BCG) therapy is the standard of care in the treatment of high-risk non-muscle invasive bladder cancer (NMIBC). In the absence of a response to BCG and persistent high-grade disease, cystectomy is recommended depending on the clinical risk. A variety of targeted therapy approaches, which aim at immune- and gene-based molecular targets, such as PD-(L)1 and FGFR, are currently being investigated in randomized studies for BCG-unresponsive NMIBC. Furthermore, novel forms of application for instillation therapy, such as the TAR device, in combination with gemcitabine or erdafitinib are being investigated in clinical trials in order to extend the duration of action of the active substance on the urothelium. Thus, there are now many developments that could make bladder-preserving therapy with comparable survival data possible as an alternative to BCG or in the event of BCG failure. In the future, it will be necessary to clarify how BCG response can be predicted by using molecular markers and how to define risk groups that should primarily be given an alternative therapy to BCG., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Objective: To demonstrate the anatomical and technical highlights of nerve-sparing deep endometriosis (DE) surgery with rectal discoid resection using a newer single-port robotic system., Design: Step-by-step demonstration of this method was provided with narrated video footage., Setting: The surgery was performed at an urban general hospital. Single-port laparoscopic surgery is a useful surgical approach in gynecology because of the excellent cosmetic results but shows challenges including reduced intracorporeal triangulation and conflict with nonarticulating instruments. The range of indications is thus limited., Patient: A 46-year-old woman was referred with severe pelvic pain, dysmenorrhea, and pain on defecation. Magnetic resonance imaging revealed uterine adenomyosis, bilateral ovarian endometriomas, and 3 cm of rectal endometriosis. Computed tomography colonography confirmed 38% stenosis of the rectum., Intervention: A newer single-port robotic system was used., Main Outcome Measures: The main outcome measures were technical safety and feasibility of intrapelvic complex DE surgery using a newer single-port robotic platform., Results: The procedure was performed using nine steps with a da Vinci SP surgical system (Intuitive Surgical, Sunnyvale, California). Importantly, the surgical steps were completely identical to conventional multiport laparoscopic or robotic surgery. This suggests that conventional laparoscopic or robotic skills are highly transferrable to the newer system. The surgical steps are as follows: The newer single-port system offered several advantages, including high-resolution three-dimensional visualization, articulating instruments (intracorporeal instrument triangulation), and improved dexterity and range of motion. These advantages allow precise dissection even in difficult situations such as DE., Conclusions: This appears to be the first reported use of the da Vinci SP for nerve-sparing DE surgery or rectal discoid resection. The newer single-port robotic system can provide the same quality of surgery as conventional multiport laparoscopic and robotic platforms with cosmetic advantages for the treatment of complex pelvic pathologies., Competing Interests: Declaration of Interests K.K. has nothing to disclose. S.Y. has nothing to disclose. M.S. has nothing to disclose. S.S. has nothing to disclose.M.A. has nothing to disclose., (Copyright © 2024 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Muscle invasive bladder cancer is generally an aggressive disease. Radical cystectomy (RC) is traditionally the treatment of choice. Due to possible advantages in morbidity, peri-interventional mortality, and quality of life, bladder-preserving treatment strategies are of interest. Here, trimodal therapy (TMT) consisting of maximum transurethral resection and subsequent radiochemotherapy with subsequent cystoscopic follow-up plays an important role. Current cohort analyses indicate equivalent oncological results of TMT to RC in selected patients. However, the use of systemic therapy alone with combined chemo-/immunotherapy or cytotoxic combination therapy also shows promising efficacy both in early surrogate parameters and in oncological endpoints. Overall, studies to date suggest that bladder preservation is possible without compromising oncologic outcomes. Future developments aim to refine patient selection by combining different risk factors and biomarkers to further improve outcomes., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: Minimally invasive spleen-preserving distal pancreatectomy with Warshaw procedure (MI-WP), has gained widespread recognition for the treatment of benign and low-grade malignant tumors of the pancreatic body and tail. However, the comparative advantages of the robotic Warshaw procedure (R-WP) over the laparoscopic Warshaw procedure (L-WP) remain uncertain. This study aimed to compare the surgical outcomes between R-WP and L-WP., Materials and Methods: Among the 146 cases of MI-DP conducted between October 2020 and December 2023 (L-DP:115, R-DP:31), 33 cases of MI-WP were subjected to analysis, comprising the R-WP group (n=10) and the L-WP group (n=23)., Results: R-WP successfully completed all procedures under a purely laparoscopic approach, whereas L-WP necessitated conversion to open surgery in 2 cases (8.7%). Despite the significantly prolonged operative time in R-WP compared with L-WP (R-WP vs. L-WP: 421vs. 300 min), there was no significant difference in estimated blood loss between the 2 groups (R-WP vs. L-WP: 19 vs. 20 mL). Although the rate of major complications did not significantly differ between the 2 groups, 2 cases (8.7%) of L-WP required reoperation, including splenectomy in 1 instance. Furthermore, the incidence of postoperative splenic infarction was significantly higher in L-WP than in R-WP (R- vs. L-WP:0 vs. 43.5%, P =0.015). The length of hospital stay after surgery did not exhibit a significant difference between the 2 groups (R-WP vs. L-WP: 11 vs. 12 d)., Discussion: R-WP demonstrated superiority to L-WP for reducing the incidence of postoperative splenic infarction, potentially contributing to enhancing the spleen preservation rate., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Sentinel node navigation (SNN) has been known as the effective treatment for stomach-preserving surgery in early gastric cancer; however, SNN presents several technical difficulties in real practice., Objective: This study aimed to evaluate the feasibility of regional lymphadenectomy omitting SNN, using the post hoc analysis of a randomized controlled trial., Methods: Using data from the SENORITA trial that compared laparoscopic standard gastrectomy with lymphadenectomy and laparoscopic SNN, 237 patients who underwent SNN were included in this study. Tumor location was divided into longitudinal and circumferential directions. According to the location of the tumor, the presence or absence of lymph node (LN) metastases between sentinel and non-sentinel basins were analyzed. Proposed regional LN stations were defined as the closest area to the primary tumor. Sensitivities, specificities, positive predictive values, and negative predictive values (NPV) of SNN and regional lymphadenectomy were compared., Results: Metastasis to non-sentinel basins with tumor-free in sentinel basins was observed in one patient (0.4%). The rate of LN metastasis to non-regional LN stations without regional LN metastasis was 2.5% (6/237). The sensitivity and NPV of SNN were found to be significantly higher than those of regional lymphadenectomy (96.8% vs. 80.6% [p = 0.016] and 99.5% vs. 97.2% [p = 0.021], respectively)., Conclusions: This study showed that regional lymphadenectomy for stomach-preserving surgery, omitting SNN, was insufficient; therefore, SNN is required in stomach-preserving surgery., (© 2024. The Author(s).)

Introduction: With 60,000 cases per year, breast cancer is the most frequent type of cancer in France, and a quarter of these cases require mastectomy. Following the surgery, breast reconstruction can be indicated. Two of the available techniques are breast implants (BIs) and muscle-sparing latissimus dorsi (MSLD). The aim of this study was to compare postoperative complications of each approach and thus help the surgeon and the patient in making an informed decision before surgery., Materials and Methods: This descriptive, retrospective and single-centre study was conducted in the Croix Rousse hospital in Lyon (France) between 1 July 2018 and 1 July 2023. It included women aged ≥18 years who underwent mastectomy followed by (immediate or delayed) breast reconstruction with MSLD or BI. Complications were recorded and evaluated using the Clavien-Dindo classification., Results: Over the course of the study, 92 patients were managed with MSLD reconstruction and 63 patients with BI. We observed a complication rate of 62% in the BI group and 39% in the MSLD group (odds ratio [OR]=0.16; p < 0.005). Body mass index (BMI) significantly impacted this rate (OR=1.11; p = 0.01), whereas smoking status and diabetes did not. No complication occurred more predominantly than others. A second surgery was required more often in the BI group (p < 0.005). There were no severe complications (>Grade 4)., Conclusion: MSLD predicted fewer complications and was associated with a shorter hospital stay compared with implants, suggesting that it may be a preferable option for breast reconstruction., (Copyright © 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Benign ovarian lesions in the pediatric population have variable risk of recurrence or development of metachronous lesions, leading to variations in operative approach. Our study compares outcomes with differing surgical approaches to better elucidate risk of recurrent or metachronous lesions, time to development of these lesions, and hospital length of stay to determine if one operative approach has superior outcomes. Methods: We retrospectively examined data from Indiana University Health facilities from 2002 to 2020. Patients ≤18 years old who underwent surgical management of a benign ovarian lesion were included. Patients were categorized as undergoing oophorectomy versus ovarian sparing surgery (OSS), with open and laparoscopic approaches. Significance was defined as P < .05. Results: We identified 127 patients who underwent an open ( n = 65) versus laparoscopic ( n = 55) surgical approach. Patients undergoing open surgery had a greater mean size of lesion ( P = .05) and longer length of stay ( P < .01). Complication rates ( P = .1), rates of developing a metachronous or recurrent lesion postoperatively ( P = .47), and time to formation of additional lesions were similar between groups ( P = .25). The incidence of identifying an additional lesion after surgery was 14.2% ( n = 18) in the mean time of 29.5 ± 31.6 months [SEM 7.5]. Risk of developing a metachronous lesion was similar regardless of the operative approach. Surgery for recurrent ovarian lesions was rare and occurred in only 1 case. Conclusions: Laparoscopic surgery was performed for smaller lesions and was associated with a shorter length of hospital stay. Laparoscopic and OSS was found to have no increased risk of developing metachronous lesions nor increased reoperative risk compared with traditional open and oophorectomy techniques.

Background: Robot-assisted nipple sparing mastectomy (RANSM) is emerging because it offers hidden incisions and ergonomic movements. In this study, we report the learning curve and feasibility of RANSM., Methods: A retrospective study was conducted among women who underwent RANSM with immediate breast reconstruction from July 2019 to June 2022. All RANSM procedures were performed by a single surgeon. We divided all the cases into two phases: the early phase (cases 1 to 21) and the late phase (cases 22 to 46). The total operation time, breast operation time, docking time, and console time were analyzed, and the cumulative sum (CUSUM) method was used to evaluate the effects of case experience accumulation on the time required for RANSM. Postoperative complications were analyzed according to their Clavien-Dindo grade., Results: Overall, 42 women underwent 46 RANSM procedures. In the early and late phases, the mean console times were 78.1 min and 60.1 min (p = 0.011), respectively. In learning curve analysis, 21 RANSM procedures were required to reduce the breast operation time. Two cases of Clavien-Dindo grade III postoperative complications occurred (4.3 %). One case was an implant removal caused by infection, and the other was partial nipple ischemia; both occurred in the early phase, with none in the late phase., Conclusions: The breast operation time improved after the 21st RANSM procedure, and only two cases had Clavien-Dindo grade III or higher postoperative complications. RANSM is thus technically feasible and acceptable, with a short learning curve., Competing Interests: Declaration of competing interest The Authors declare that there is no conflict of interest., (Copyright © 2024. Published by Elsevier Ltd.)

Objective: One of the possible risks of sinonasal malignancy is its possible spread in the orbit. However, there is no clear consensus among the different departments as to whether it is necessary to exenterate the orbit in limited tumorous infiltration of periorbital fat. The purpose of the study was to demonstrate that periorbital infiltration and periorbital fat invasion without involvement of deeper orbital tissues are not the indication of orbital exenteration., Materials and Methods: Retrospective analysis was performed over a 17-year period of patients undergoing surgical treatment for sinonasal malignancy with histologically verified periorbital infiltration or deeper invasion into the orbit. A total of 32 patients were included in the study. For each group, the following data were analysed: sex, age, preoperative imaging studies, histological findings, site of origin, stage, surgical reconstruction, oncological treatment, survival, cause of death, number of recurrences in the orbit and functional status of preserved eyes., Results: Based on our criteria for orbital exenteration, orbital preservation was feasible in 18 patients. Orbital exenteration was performed in 14 patients with deeper tumor infiltration. There was a statistically insignificant difference in survival between the two groups. The 5-year overall survival (OS) was 44% for the orbital preservation group (only 2 patients died from local tumor recurrence) and 34% for the orbital exenteration group. The groups did not differ in other observed factors other than the extent of orbital infiltration. In 11 (61.1%) patients, vision was without significant change after radiation therapy. In 2 (11.1%) patients, visual function was impaired due to diplopia. 5 (27.8%) patients had severely impaired vision due to optic nerve atrophy after radiation therapy., Conclusions: Our results show a relatively high survival rate in the group of patients with orbital preservation with a high chance of vision preservation, which justifies our approach to orbital preservation even in some tumors with periorbital infiltration., (© 2024. The Author(s).)

Background: Spleen preservation during laparoscopic distal pancreatectomy (LSPDP) should be pursued if safe and oncologically justified. The aim of the presented study was to compare surgical outcomes and identify risk factors for unplanned splenectomy during laparoscopic distal pancreatectomy and evaluate short and long-terms outcomes., Methods: The following study is a retrospective cohort study of consecutive patients who underwent laparoscopic distal pancreatectomy, with the intention of preserving the spleen, for benign tumors of the body and tail of the pancreas between August 2012 and December 2022. Follow-up for patients' survival was completed in January 2023. In all, 106 patients were in total included in this study. Median age was 58 (41 to 67) years. The study population included 29 males (27.4%) and 77 females (72.6%)., Results: Spleen preservation was possible in 67 (63.2%) patients. The tumor size was larger in the splenectomy group (respectively, 30 (16.5 to 49) vs. 15 (11 to 25); P <0.001). Overall, serious postoperative morbidity was 13.4% in the LSPDP group and 20.5% in the second group ( P =0.494). There were no perioperative deaths. The postoperative pancreatic fistula rate was 18% in the splenectomy group and 14.9% in the LSPDP group, while B and C fistulas were diagnosed in 15.4% and 10.5% of patients, respectively. In the multivariate logistic regression model, tumor size >3 cm was found to independently increase odds for unplanned splenectomy (OR 8.41, 95%CI 2.89-24.46; standardized for BMI)., Conclusion: Unplanned splenectomy during the attempt of LSPDP does not increase the risk for postoperative morbidity and postoperative pancreatic fistula. The independent risk factor for unplanned splenectomy during LSPDP is tumor size above 3 cm., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction and Objective: Previous studies showed that extra blood supply can decrease testicular atrophy following laparoscopic orchiopexy. We evaluated the impact of preserving the gubernacular attachment (which contains blood supply from cremasteric artery and its anastomoses) on atrophy rates following open conventional orchiopexy., Study Design: This double-blinded randomized trial was implemented from March 2022 to September 2023. Included boys with non-palpable testis, even with examination under anesthesia, underwent diagnostic laparoscopy to evaluate the testis's location and size. Nubbin testes and those with > 2-cm distance from the internal inguinal ring. Participants were assigned into two groups (gubernaculum sparing (GS) and excision (GE)) by permuted block randomization. Overall success was defined as achieving both morphologic success (atrophy <20% of the intraoperative size) and anatomical success (scrotal or high-scrotal locations). Boys were followed at three- and six-month post-surgery via ultrasound. Independent t-test, repeated ANOVA, and Friedman's tests were used where appropriate., Results: Of 92 boys (105 UDTs overall), 75 testes (36 in GS, 39 in GE groups) were used in the analysis. The mean age of participants was 25 ± 17 months (range 6-84). The mean testis size of cases intraoperatively was 460 ± 226, 396 ± 166, and 520 ± 258 mm 3 among all participants, GS, and GE cases, respectively. Both groups showed a significant decrease in testicular volume on both follow-up checkpoints, but this decrement was significantly higher in the GE group (p < 0.001). The anatomical success rate was significantly higher among GS boys (97.2% versus 82.1%; p = 0.038). The overall success rate was significantly higher for the GS group (61.1% versus 25.6%; p = 0.002)., Conclusion: Although mean testicular volume decreased in both groups, we found superior morphologic and overall success rates among the GS group. The greatest size reduction was noted at the three-month post-surgery compared to the six-month checkpoint., Trial Registration: https://irct.ir/trial/58842., Competing Interests: Conflict of interests None to declare., (Copyright © 2024 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Background: We detail our approach and experience with a hybrid version of the endopelvic hood-sparing (HS) robot-assisted radical prostatectomy (RARP) using the da Vinci robotic platform. Materials and Methods: We retrospectively reviewed the records of 200 patients who underwent RARP by a single surgeon. Patients were propensity-matched into three cohorts depending on biopsy and prostatectomy Gleason Grade Groups: traditional retropubic (RP) ( n = 80), retzius-sparing (RS) ( n = 40), and HS ( n = 80). Patient characteristics and oncologic and functional outcomes were examined. Zero pads per day defined return of continence. Erections suitable for penetrative intercourse with/without medications defined return of sexual function. Results: Patient characteristics were similar between cohorts excluding prostate-specific antigen levels ( p = 0.014), which were significantly lower in the RS cohort (7.1 ± 5.3 ng/mL) compared with RP (9.2 ± 9.3 ng/mL) and HS (8.8 ± 8.9 ng/mL). Clinically significant positive margin rates were significantly higher ( p = 0.046) in the RS cohort (32.5%) compared with RP (17.5%) and HS (13.9%). Biochemical recurrence and metastasis rates were similar between all cohorts. Median time to continence was significantly lower for RS and HS-RARP ( p < 0.001) compared with RP-RARP at 1.3, 1.6, and 5.4 months, respectively. Median time to return of sexual function was significantly lower for RS and HS-RARP ( p < 0.001) compared with RP-RARP at 4.0, 7.7, and 15.1 months, respectively. Conclusions: Our hybrid HS-RARP approach provides functional outcomes similar to RS-RARP with the early oncologic control of traditional RP-RARP.

Background: Mastectomy skin flap necrosis (SFN) is common following nipple-sparing mastectomy (NSM), but studies on its quality-of-life (QOL) impact are limited. We examined patient-reported QOL and satisfaction after NSM with/without SFN utilizing the BREAST-Q patient-reported outcome measure (PROM) survey., Patients and Methods: Patients undergoing NSM between April 2018 and July 2021 at our institution were examined; the BREAST-Q PROM was administered preoperatively, and at 6 months and 1 year postoperatively. SFN extent/severity was documented at 2-3 weeks postoperatively; QOL and satisfaction domains were compared between patients with/without SFN., Results: A total of 573 NSMs in 333 patients were included, and 135 breasts in 82 patients developed SFN (24% superficial, 56% partial thickness, 16% full thickness). Patients with SFN reported significantly lower scores in the satisfaction with breasts (p = 0.032) and psychosocial QOL domains (p = 0.009) at 6 months versus those without SFN, with scores returning to baseline at 1 year in both domains. In the "physical well-being-of-the-chest" domain, there was an overall decline in scores among all patients; however, there were no significant differences at any time point between patients with or without SFN. Sexual well-being scores declined for patients with SFN compared with those without at 6 months and also at 1 year, but this did not reach significance (p = 0.13, p = 0.2, respectively)., Conclusions: Patients undergoing NSM who developed SFN reported significantly lower satisfaction and psychosocial well-being scores at 6 months, which returned to baseline by 1 year. Physical well-being of the chest significantly declines after NSM regardless of SFN. Future studies with larger sample sizes and longer follow-up are needed to determine SFN's impact on long-term QOL., (© 2024. Society of Surgical Oncology.)

Objectives: Among the complications of parotid surgery, facial palsy is frequent and burdened by high functional and social impact for the patient. There are few data on the efficacy of facial neuromuscular retraining (FNR) in patients with facial palsy after parotid surgery, and no data exist on its impact in timing and extent of recovery., Material and Methods: A retrospective study was conducted on patients undergoing FN sparing parotid surgery and suffering from postoperative facial palsy. Among 400 patients undergoing surgery between July 2016 and May 2023, those with the preservation of the FN and onset of facial palsy were selected. Nerve function was evaluated during 2 years follow up using the House-Brackman (H&Bs) and Sunnybrook scales (SBs)., Results: A total of 46 patients undergoing partial or total parotidectomy were included. At discharge 18 patients (39,1%) had IV to VI grade paralysis according to the H&Bs and the mean SBs value was 54. At 2 and 6 months after surgery, the average value of Sunnybrook increased to 76.5 and 95.4 respectively. After 12 months no patients with IV to VI grade paralysis were represent in our cohort. Two years after surgery, only five patients (10.9%) had persistent grade II paralysis according to HBs., Conclusions: Our study supports the efficacy of FNR in the rehabilitation of facial paralysis after nerve-sparing parotidectomy. The greater functional improvement is achieved within the first 6 months of rehabilitation. A significant improvement is detected still after 18 months, supporting the importance of long rehabilitation for patients without complete recovery after the first year., (© 2024. The Author(s).)

Purpose: Radiation esophagitis is frequent and annoying toxicity in high dose thoracic radiation therapy. Contalateral esophagus sparing intensity modulated radiation therapy (CES-IMRT) has been proposed to mitigate this problem, and this is to report the impact of CES-IMRT in definitive concurrent chemoradiotherapy (dCCRT) for lung cancer patients., Materials and Methods: From January 2021 till May 2023, 183 stage III non-small cell lung cancer patients underwent dCCRT. Esophagus was located within 1 cm from internal target volume in 159 patients. We comparatively evaluated the frequency and severity of esophagitis by pain-killer usage, analgesic quantification algorithm (AQA) score, and failure patterns in 159 CES-necessary patients., Results: All patients underwent dCCRT (66 Gy in 30 fractions with concurrent chemotherapy). Actual CES-IMRT application was determined based on the discretion of responsible radiation oncologists: CES-applied in 41 patients; and CES-unapplied in 118. CES-applied patients experienced pain events less frequently (pain-killer usage: 53.7 % vs. 77.1 %, p = 0.008) and less severely (AQA score of 2-3: 39.0 % vs. 68.6 %, p = 0.002). On multivariate analyses, overlapping volume of esophagus and planning target (HR = 1.32, 95 % CI 1.12-1.55, p = 0.001) and CES-IMRT application (HR = 0.31, 95 % CI 0.13-0.76, p = 0.010) were associated with AQA score of 2-3 less frequently. There were no differences in failure pattern, progression-free survival, and overall survival., Conclusions: CES-IMRT application resulted in less frequent and less severe pain events without compromising oncologic outcomes. Further studies, preferably in a randomized fashion, would be desired., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: This study aimed to determine the postoperative intestinal functioning, quality of life (QoL), and psychological well-being of patients treated either with organ-preserving surgery (OPS) or organ-resection surgery (ORS) for high-grade intraepithelial neoplasia (HIN) or T1 colorectal cancer (CRC)., Methods: This cross-sectional study was conducted at a single tertiary care center. In total, 175 eligible individuals with T1 CRC or HIN were divided into the OPS (n = 103) or ORS (n = 72) group based on whether the relevant segment of the intestine was preserved or resected. Intestinal function was evaluated using low anterior resection syndrome (LARS) scores. QoL was evaluated using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ)-C30 and EORTC-QLQ-CR29. Psychological status was evaluated using the Fear of Progression Questionnaire-Short Form and the Self-rating Anxiety and Depression scales. Propensity score matching (PSM) was used to minimize the influence of potential confounders., Results: Overall, 130 of 175 patients (74.29%) responded to the questionnaires; 56 and 74 were in the ORS and OPS groups, respectively. Thirty-five patient pairs were successfully matched through PSM. The mild and severe LARS rates were significantly higher in the ORS group than in the OPS group (P < 0.001). The EORTC-QLQ-C30 and EORTC-QLQ-CR29 scores revealed significantly better physical, role, and emotional functioning and an overall improved state of health (with multiple reduced symptom scores) in the OPS group than in the ORS group (P < 0.05). Significantly more patients were depressed in the ORS group than in the OPS group (P = 0.034), whereas anxiety or fear of disease progression did not differ significantly between the groups., Conclusions: OPS for the treatment of HIN or T1 CRC was found to be more advantageous for patients in terms of improved intestinal function, QoL, and psychological status than was ORS., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)