Does transition from standard to Retzius-sparing technique in robot-assisted radical prostatectomy affect the functional and oncological outcomes?

Objective: To appraise the outcomes on the Retzius-sparing robot-assisted radical prostatectomy (Rs-RARP) learning curve of a surgeon with previous experience of anterior (standard) RARP. Materials and methods: The first 50 cases during the Rs-RARP learning curve (group 1) and 50 cases after the second 100 cases with the standard approach (group 2) were comprised in the study. Patients who used zero or one safety pads were considered continent. Erectile function recuperation was characterized as the competence to achieve penetrative intercourse without receiving any medication. All patients were reevaluated at two weeks, first, third, sixth, and 12th months after surgery using IIEF-5, PSA level, and continence status. Results: Immediate continence rates following catheter removal were 32/50 (64%) in Rs-RARP group and 26/50 (52%) in S-RARP group (p = 0.224). The continence recovery rate was 48/50 (96%) in Rs-RARP group and 46/50 (92%) in the S-RARP group at 12 months follow-up (p = 0.400). Total nerve-sparing surgery was enforced in 36/50 (72%) patients for group 1 and 35/50 (70%) patients for group 2. Potency recovery was 27/43 (62.8%) in Rs-RARP and 30/44 (68.2%) for S-RARP at 12 months follow up (p = 0.597). Surgical margin positivity was detected in 6/50 (12%) cases in the Rs-RARP group and in 4/50 (8%) cases in the S-RARP (p = 0.444). Conclusions: Functional and oncological results are not negatively affected in the first 50 cases for a surgeon who is experienced in S-RARP before transition to the Rs-RARP method.

Augmented Reality and Image-Guided Robotic Liver Surgery

Artificial intelligence makes surgical resection easier and safer, and, at the same time, can improve oncological results. The robotic system fits perfectly with these more or less diffused technologies, and it seems that this benefit is mutual. In liver surgery, robotic systems help surgeons to localize tumors and improve surgical results with well-defined preoperative planning or increased intraoperative detection. Furthermore, they can balance the absence of tactile feedback and help recognize intrahepatic biliary or vascular structures during parenchymal transection. Some of these systems are well known and are already widely diffused in open and laparoscopic hepatectomies, such as indocyanine green fluorescence or ultrasound-guided resections, whereas other tools, such as Augmented Reality, are far from being standardized because of the high complexity and elevated costs. In this paper, we review all the experiences in the literature on the use of artificial intelligence systems in robotic liver resections, describing all their practical applications and their weaknesses.

Left upper lobectomy with pulmonary artery reconstruction after neoadjuvant therapy in re-VATS

Video-assisted thoracoscopic surgery (VATS) is considered the gold standard for the treatment of early stage non-small-cell lung cancer. Many studies have demonstrated reduced postoperative pain, hospital stay, and morbidity, while achieving the same oncological results. Indeed, it has become a widespread technique in many countries around the world. VATS can be applied also to challenging surgical procedures, such as plasty of the pulmonary artery, to obtain an oncologically radical resection of the tumor, and in the context of an N2 disease even after a previous operation on the thorax. In this case report, we demonstrate how to carry out this procedure safely to achieve radical resection of the diseased tissue.

Impact of Prostate Size on the Outcomes of Radical Prostatectomy: A Systematic Review and Meta-Analysis

Background: The impact of prostate size on the radical prostatectomy outcome is not clear. Several published reports have shown conflicting results. Objectives: To investigate the effect of prostate size on the surgical, functional and oncological results of radical prostatectomy. Methods: A systematic review and meta-analysis were carried out in accordance with the PRISMA criteria. Finally, we investigated the research that reported on the impact of prostate size on radical prostatectomy outcome. The Review Manager (RevMan) software version 5.4 was utilized for statistical analysis. Results: Eighteen studies including 12,242 patients were included. Estimated blood loss was significantly less with smaller prostates (Z = 3.01; p = 0.003). The complications rate was 17% with larger prostates, compared to 10% for smaller prostates (Z = 5.73; p < 0.00001). Seventy-three percent of patients with a smaller prostate were continent within one month, compared to 64% with a larger prostate (Z = 1.59; p = 0.11). The rate of positive surgical margins was significantly higher with smaller prostates (20.2% vs. 17.8%). (Z = 2.52; p = 0.01). The incidence of biochemical recurrence was higher with smaller prostates (7.8% vs. 4.9%) (Z = 1.87; p = 0.06). Conclusion: Larger prostate size is associated with more blood loss and a higher rate of complications. However, the oncological outcome is better, compared to that in patients with smaller prostates. The impact of the size on the functional outcome is not clear.

Complete Mesogastric Excisions Involving Anatomically Based Concepts and Embryological-Based Surgeries: Current Knowledge and Future Challenges

Surgeries for gastrointestinal tract malignancies are based on the paradigm that we should remove the tumour together with its lymphatic drainage in one block. This concept was initially proposed in rectal surgery and called a total mesorectal excision. This procedure gained much interest and has improved oncological results in rectal cancer surgery. The same idea for mesogastric and complete mesogastric excisions was proposed but, because of the complexity of the gastric mesentery, it has not become a standard technique. In this review, we analysed anatomical and embryological factors, proposed technical aspects of this operation and incorporated the available initial results of this concept. We also discussed analogies to other gastrointestinal organs, as well as challenges to this concept.

Role of checkpoint inhibitors immunotherapy in non-muscle invasive bladder cancer: current methods and future perspectives

Immuno-therapy involvement in bladder urothelial malignancies is growing very fast. The use of Immuno-therapy with check-point inhibitor has greatly developed since it was first approved as a second-line treatment for cases who had formerly failed platinum-based chemotherapy. There are recognized applications for first-line metastatic illness in platinum-ineligible or cisplatin-ineligible PD-L1 diagnosed cases, as well as a label for BCG-refractory high-risky non-muscle invasive bladder cancer (NMIBC). It is now being studied in neo-adjuvant and adjuvant muscle invasive bladder cancer (MIBC) clinical trials. This review discusses the clinical trials that led to these FDA agreements, as well as prospective and ongoing trials. Current clinical guidelines support Bacillus Calmette-Guérin (BCG) as the primary treating option for intermediate to high-risk NMIBC. Despite the intra-vesical BCG-instillation, intra-vesical relapse occurs in a considerable number of individuals with intermediate to high risk NMIBC. Furthermore, treating BCG-nonresponsive NMIBC is still difficult. For these individuals with BCG-nonresponsive NMIBC, there are no viable therapy alternatives other than radical cystectomy, which has been shown to have excellent oncological results. In this regard, for the care of BCG-nonresponsive NMIBC, safe and reliable noninvasive or lesser-invasive therapeutic alternatives with adequate oncological results are needed. Regarding the latest introduction of immuno-therapeutic medications, the treatment of progressive or metastatic urothelial cancer has substantially advanced. These developments have sparked a surge in interest in immuno-therapeutic medications for NMIBC, particularly BCG-nonresponsive NMIBC. The goal of this literature review is to provide and debate the most up-to-date information on the function of Immuno-therapy in BCG-nonresponsive NMIBC and the presently accessible treatment options. Furthermore, this page highlights the current research in this topic. We wanted to convey the current state of Immuno-therapy in NMIBC and discuss future directions.

Amputation for Extremity Sarcoma: Indications and Outcomes

Background: Sarcomas are rare, malignant tumors of soft tissues or bone. Limb salvage surgery (LSS) is the standard treatment, but amputation is still an option, especially in local recurrence or complications after LSS. Methods: We retrospectively reviewed indications and oncological outcomes in patients who underwent an amputation. Two groups with either primary amputations (n = 120) or with secondary amputations after failed LSS with local recurrence or complications (n = 29) were compared with the main end points of LRFS and OS. Results: Five-year LRFS was 84% with 17 (16%) patients developing local recurrence, of which 16 (13%) occurred in group I. Forty-two (28%) patients developed metastatic disease and overall survival at five years was 44%. Overall survival (OS) was the same in both groups. In those group II patients who had a secondary amputation due to LR or insufficient margins after LSS (n = 12) the five-year OS was 33% compared to 48% in patients with amputation due to complications (n = 17) (n.s.). Conclusion: This study indicates the worse oncological outcomes with respect to OS of sarcoma patients requiring an amputation as compared to LSS. Patients with primary amputation or those who had a secondary amputation after failed LSS for whatever reason showed the same oncological results.

Precision Postoperative Radiotherapy in Sinonasal Carcinomas after Endonasal Endoscopic Surgery

Radiotherapy plays an important role in the treatment of sinonasal cancer, mainly in the adjuvant setting after surgical resection. Many technological approaches have been described, including intensity-modulated radiotherapy, concomitant chemoradiotherapy, charged particle therapy or combined approaches. The choice is based on general criteria related to the oncological results and morbidity of each technique and their availability, as well as specific criteria related to the tumor (tumor extensions, pathology and quality of margins). The aims of this review are: (i) to provide an overview of the radiotherapy techniques available for the management of sinonasal malignant tumors and (ii) to describe the constraints and opportunities of radiotherapy owing to the recent developments of endonasal endoscopic surgery. The indication and morbidity of the different techniques will be discussed based on a critical literature review.

Radiomodifiers in the combined treatment of rectal cancer patients

Objective. To evaluate the effectiveness of the combined method of treatment of patients with rectal cancer using several variants of polyradiomodification (CT+PRM). Material and methods. To increase the effectiveness of the «short» course of neoadjuvant radiation therapy (RT) 5×5 Gy until total focal dose Gy, the concept of polyradiomodification proposed by S. P. Yarmonenko (1982) was used [1]. Three radiomodifiers were used: local intracavitary microwave hyperthermia (MWH), Metronidazole (MZ) as part of a polymer composition for intrarectal administration, and the chemotherapy drug Capecitabine (Cap). Four variants of the PRM have been created, divided into two-component and three-component. Two-component variants were used when the MWH was not possible in the case of stenosis or localization of cancer in the upper ampullary rectum. Initially, Capecitabine was used at a daily dose of 1.5 g/m2 on 1–5 days in combination with a double administration of Metronidazole («Cap5+MZ») and surgery 3 weeks after RT, and later the dose of Capecitabine was increased to 2.0 g/m2 on 1–14 days («Cap14+MZ») with surgery 4–6 weeks after RT. With three-component versions of PRM, 3 additional sessions of MWH were used: «Cap5+MZ+MWH» and «Cap14+MZ+MWH». A total of 241 patients were included in the study. Results. The total toxicity in CT+PRM was 33.4%, and the overall rate of postoperative complications was 14.9%. The 5-year relapse-free survival (RFS) rate of 80.5% was achieved due to pronounced local control: cancer recurrence was detected only in 1 (0.4%) of 241 patients. This made it possible to perform sphincter-sparing operations (SSO) without compromising oncological results in 211 (86.7%) patients out of 241. The most pronounced therapeutic pathomorphosis in the tumor was achieved with «Cap14+MZ» and «Cap14+MZ+MWH»: pathomorphosis of the III degree was achieved in 9 (30.0%) of 30 patients with «Cap14+MZ», and in 13 (25.0%) of 52 patients with «Cap14+MZ+MWH», a complete pathomorphological response was detected in 7 (23.4%) of 30 patients with «Cap14+MZ», and in 9 (17.3%) of 52 patients with «Cap14+MZ+MWH». When reaching the III–IV degree of pathomorphosis, distant metastases were detected in 6.3% of patients, at the II degree and below — in 19.7% (p=0.01). Conclusion. When using CT+PRM, 5-year RFS rate was increased to 80.5%, and the frequency of SSO was increased to 86.7%, with a low level of postoperative complications (14.9%) and acceptable toxicity (33.4%).