Renal cell carcinoma (RCC) accounts for approximately 3% of all malignancies, with its incidence steadily increasing due to the widespread use of abdominal imaging techniques and the improved detection of asymptomatic renal masses. Traditionally, radical nephrectomy (RN) was considered the gold standard for the surgical treatment of renal tumors. However, over the past decades, advancements in minimally invasive surgical techniques have led to a paradigm shift in favor of nephron-sparing approaches, particularly partial nephrectomy (PN). The introduction of robot-assisted partial nephrectomy (RAPN) has further refined this approach by enhancing surgical precision, reducing invasiveness, and improving outcomes in terms of renal function preservation. This manuscript describes a standardized and reproducible technique for retroperitoneal robot-assisted partial nephrectomy (rRAPN) using the da Vinci Xi system, illustrated through two representative cases involving right- and left-sided posterior renal tumors. Key steps in the procedure included the creation of a retroperitoneal space, identification of crucial anatomical structures, excision of the tumor using a clamp-less technique, the suture of the resection bed and the application of hemostatic agents to control bleeding. Postoperative care focused on monitoring renal function, detecting complications, and ensuring optimal recovery. Both patients had successful outcomes, with minimal blood loss, stable renal function, and negative surgical margins. Furthermore, there were no postoperative complications, and both patients were discharged within 4 or 5 days of the procedure. Retroperitoneal access offers distinct advantages, particularly for patients with previous abdominal surgeries or for those with tumors located in the posterior renal region. This approach provides oncological and functional outcomes that are comparable to transperitoneal techniques while reducing perioperative morbidity. The detailed steps outlined in this study aim to facilitate the broader adoption of rRAPN, emphasizing its potential to improve the management of select renal neoplasms. By standardizing this technique, we aim to further refine the role of retroperitoneal robot-assisted surgery in treating RCC and promote its integration into routine clinical practice.
BACKGROUND: The prognostic assessment of metabolic dysfunction-associated steatotic liver disease (MASLD) is of critical importance. Although previous international studies have suggested an association between the cholesterol, high-density lipoprotein, and glucose (CHG) index and mortality in MASLD patients, its generalizability in the Chinese population remains unclear, and there is a lack of predictive tools directly applicable for individual risk stratification. METHODS: A total of 6936 participants with MASLD were sourced from the China Health and Retirement Longitudinal Study (CHARLS) database from 2011 to 2020. Survival differences were visualized using the Kaplan-Meier method. Multivariate Cox regression was employed to assess the association between the CHG index and mortality risk. Smooth curve fitting analysis was conducted to examine the nonlinear relationship between them. Mediation analysis was performed to explore the mediating roles of C-reactive protein (CRP) and triglyceride glucose-weight-adjusted waist index (TyG-WWI). To evaluate the predictive value of the CHG index, we implemented a set of eight distinct machine learning (ML) models. Subgroup and sensitivity analyses were conducted to verify the robustness of the results. Concurrently, the National Health and Nutrition Examination Survey (NHANES) database (1999–2018) was utilized for external validation. RESULTS: The median follow-up duration was 7.44 years. A total of 615 mortality events were recorded. After adjusting for multiple confounding factors, an elevated CHG index was significantly associated with an increased risk of mortality (highest vs. lowest tertile, HR = 1.49, 95% CI [1.21–1.84], P = 0.0002). Kaplan-Meier curves demonstrated that higher CHG index levels were significantly associated with reduced survival (P < 0.0001). Smooth curve fitting and threshold effect analysis revealed a nonlinear relationship between them. Mediation analysis indicated that CRP and TyG-WWI mediated 13.36% and 45.33% of the effect of CHG index on mortality, respectively (all P < 0.05). Logistic Regression model showed superior discrimination. Decision curve analysis confirmed that the Logistic Regression model provided significant clinical net benefit across a wide range of risk thresholds. The primary analyses were replicated using data from the representative NHANES cohort, revealing a significant positive association between CHG index and mortality. CONCLUSIONS: Elevated CHG index is significantly associated with an increased risk of mortality in the Chinese MASLD population, demonstrating a nonlinear relationship. Furthermore, indicators related to inflammation and insulin resistance (IR) significantly mediate these associations. The CHG index serves as an important tool for predicting long-term adverse outcomes in this population. RESEARCH INSIGHTS: What is currently known about this topic? 1. International studies have suggested that the CHG index is associated with mortality in patients with MASLD. 2. However, its generalizability in Chinese populations remains unclear, and there is a lack of prediction tools that can be directly applied for individual risk stratification. What is the key research question? 1. How does the CHG index influence mortality risk in Chinese MASLD individuals? What is new? 1. This is the first Chinese cohort study to investigate the relationship between CHG index and mortality risk in MASLD individuals. 2. A prediction model was constructed using ML. 3. Mediation analysis revealed the mediating role of inflammatory and IR-related indicators for the first time. How might this study influence clinical practice? 1. This research may promote the integration of the CHG index into routine risk assessment for MASLD patients. By providing a low-cost risk-stratification tool, it could facilitate early intervention. The identified threshold effect may offer evidence-based support for establishing personalized management cut-off values.
To evaluate the effectiveness of visualized reamer foraminoplasty in transforaminal endoscopic lumbar discectomy (TELD) for the treatment of lumbar disc herniation (LDH). A retrospective analysis was conducted on the clinical data of 100 LDH patients who met the selection criteria and underwent TELD between January 2022 and June 2024. According to the foraminoplasty technique, patients were divided into a visualized group and a transforaminal endoscopic spine system (TESSYS) group, with 50 patients in each group. There were no significant differences in baseline data between the two groups ( P>0.05), including gender, age, surgical level, disease duration, preoperative visual analogue scale (VAS) scores for low back and lower limb pain, and Oswestry disability index (ODI). The intraoperative fluoroscopy frequency, operation time, intraoperative blood loss, hospital stay, time from operation to discharge, and complications were recorded and compared between the two groups. Low back and lower limb pain were assessed using VAS scores, and function status was evaluated using ODI preoperatively and at 1 day, 1, 3, 6, and 12 months postoperatively. Surgical outcomes were evaluated at last follow-up using the modified MacNab criteria. All surgeries were completed successfully, with primary healing of the incisions. The visualized group showed significantly shorter operation time and fewer fluoroscopy frequencies than the TESSYS group ( P<0.05). No significant differences were found between the two groups in intraoperative blood loss, time from operation to discharge, or hospital stay ( P>0.05). One case of recurrence occurred in the visualized group, compared to 3 cases in the TESSYS group, with no significant difference between the groups ( P>0.05). Postoperative lower limb dysesthesia occurred in 4 cases in the TESSYS group, but was not observed in the visualized group, showing a significant difference ( P<0.05). No other complications, such as vascular injury, cerebrospinal fluid leakage, incisional hematoma, or infection occurred in either group. Both groups showed significant improvement in low back VAS score, lower limb VAS score, and ODI at all postoperative time points compared to preoperative values ( P<0.05). No significant difference was found in low back VAS score, lower limb VAS score, or ODI between the two groups at any postoperative time point ( P>0.05). According to the modified MacNab criteria at last follow-up, the excellent-good rates were 96% and 92% in the visualized and TESSYS groups, respectively, with no significant difference ( P>0.05). Both TESSYS and visualized reamer foraminoplasty techniques yield satisfactory outcomes in the treatment of LDH via TELD. The latter can significantly reduce intraoperative fluoroscopy frequency and operation time, but the effectiveness of the two groups is comparable. 探讨可视环锯椎间孔成形技术在脊柱内镜下经椎间孔入路脊柱内镜下腰椎间盘切除术（transforaminal endoscopic lumbar discectomy，TELD）治疗腰椎间盘突出症（lumbar disc herniation，LDH）中的临床疗效。. 回顾分析2022年1月—2024年6月收治且符合选择标准的100例LDH患者临床资料，均接受TELD治疗。根据椎间孔成形方式不同分为可视组与经椎间孔脊柱内镜系统（transforaminal endoscopic spine system，TESSYS）组，每组50例。两组患者性别、年龄、手术节段、病程、术前腰部和下肢疼痛视觉模拟评分（VAS）、Oswestry功能障碍指数（ODI）等基线资料比较差异均无统计学意义（ P>0.05）。记录并比较两组患者术中透视次数、手术时间、术中出血量、住院时间、术后至出院时间及并发症发生情况。术前及术后1 d，1、3、6、12个月采用VAS评分评估腰痛和下肢痛，ODI评估功能状态。末次随访时采用改良MacNab评分标准评估手术疗效。. 患者均顺利完成手术，切口均Ⅰ期愈合。可视组手术时间及透视次数均少于TESSYS组（ P<0.05）；两组术中出血量、术后至出院时间、住院时间比较，差异均无统计学意义（ P>0.05）。可视组术后复发1例，TESSYS组术后复发3例，两组比较差异无统计学意义（ P>0.05）。TESSYS组有4例出现术后下肢感觉异常，可视组未发生此类并发症，两组比较差异有统计学意义（ P<0.05）。两组均未出现血管损伤、脑脊液漏、切口血肿、感染等其他并发症。两组术后各时间点腰部VAS评分、下肢VAS评分和ODI均较术前显著改善（ P<0.05）。术后各时间点两组腰部VAS评分、下肢VAS评分、ODI比较，差异均无统计学意义（ P>0.05）。末次随访时采用改良MacNab评分标准评估临床疗效，两组优良率（96% vs 92%）比较差异无统计学意义（ P>0.05）。. TELD术中TESSYS技术和可视环锯成形技术治疗LDH均可获得良好疗效，后者可显著减少术中透视次数、缩短手术时间，但两组疗效相当。.
In the field of minimally invasive mitral valve surgery (MVS), recent technical and technological advances have made endoscopic approaches increasingly popular. However, enthusiasm for endoscopic cardiac surgery has not translated into routine clinical usage likely due to the perceived complexity of the technique and the lack of robust supporting evidence. This study aims to evaluate operative results, and assess the overall effectiveness of endoscopic approaches in current surgical practice using data from the Mini-Mitral International Registry (MMIR). This is a retrospective multicenter cohort study based on data from the MMIR, a collaborative effort including 7,957 patients who underwent minimally invasive mitral procedures. For this analysis, patients who did not receive a full endoscopic approach were excluded. Clinical and procedural outcomes were defined according to Mitral Valve Academic Research Consortium (MVARC) standards. Primary outcome measures included the rate of valve repair, in-hospital mortality, and the incidence of postoperative complications. Logistic regression was applied to assess the multivariable association between covariates and in-hospital mortality. Between 2015 and 2022, 2,563 patients underwent full endoscopic mitral surgery [median age 64 years; interquartile range (IQR), 53-73 years]. The etiology of mitral disease was degenerative in 70.5% of patients, functional in 13.7%, rheumatic in 6.6%, endocarditis in 3.3%, failure of previous mitral surgery in 3.8% and failure of previous transcatheter procedure in 1.2%. Mitral valve repair was performed in 2,107 cases (82.2%) and valve replacement in 439 (17.1%). A conversion to full sternotomy was required in 1.7% of cases. The overall in-hospital mortality rate was 2.5% (n=63), with a stroke rate of 1.1% (n=27). These were 1.7% and 0.8%, respectively, in patient who underwent isolated MVS. Risk analysis revealed that patient comorbidities and clinical status, rather than the technical aspects of the endoscopic approach, predominantly determined operative outcomes. Subgroup analysis of patients with degenerative mitral valve disease (n=1,800) revealed a younger cohort (62 years) with a low-risk profile (EuroSCORE II 1.1%). The valve repair rate was 94.9%. Overall, in-hospital mortality and stroke rates were 1.4% and 0.6%, respectively. Among patients who underwent valve repair, 98.8% had no or mild regurgitation at discharge. Endoscopic MVS is an effective technique for managing a broad range of mitral valve diseases, with excellent valve repair outcomes. The technique demonstrated satisfactory operative mortality and morbidity, even in high-risk patients and complex valve anatomies. Future studies should focus on long-term outcomes and the development of training programs to facilitate wider implementation.
Superior sulcus tumors invading the chest wall and major mediastinal vessels present significant surgical challenges. The transmanubrial approach (TMA) has been widely adopted for such tumors. However, the exposure of the dorsal side, particularly of the apex of the lung, can be limited when performing a TMA alone. This hybrid approach of TMA with robotic thoracic surgery improves visualization and resection safely. The clinical significance of this hybrid approach has received little attention. Here, we report a case of post-immunochemotherapy surgery using combined robotic-assisted thoracic surgery (RATS) and a TMA to achieve safe resection and vascular reconstruction of a tumor invading the right brachiocephalic vein. A 59-year-old man was diagnosed with right upper lobe squamous cell carcinoma (cT4N0M0, stage IIIA) invading the anterior apex and mediastinal structures, including the right brachiocephalic vein. Following four cycles of immunochemotherapy (carboplatin, nab-paclitaxel, and pembrolizumab), significant tumor regression was observed, and post-immunochemotherapy surgery was planned. A RATS lobectomy was first performed, in the left lateral decubitus position, using the da Vinci Xi system with a five-port setup using port placement only, without mini-thoracotomy, which allowed detailed hilar and apical dorsal dissection. Subsequently, the patient was placed in a supine position, and the TMA was used to resect and reconstruct the invaded right brachiocephalic vein using a synthetic graft. The total operative time was 12 h and 8 min, and the total blood loss was 1,120 mL. The postoperative course was uneventful. The chest tube was removed on postoperative day 4, and no major complications such as prolonged air leak, pneumonia, or recurrent laryngeal nerve palsy were observed. And the patient was discharged on postoperative day 12. The pathological examination findings revealed that the staging was ypT2bN0M0 stage IIA. The patient has remained recurrence-free for 6 months following the surgery. This case demonstrates that a hybrid approach combining RATS and the TMA is a safe and effective strategy for the resection of superior sulcus tumors with vascular invasion. RATS enhances surgical visualization and facilitates apical dissection, thereby optimizing safety and surgical outcomes when followed with the TMA.
Minimally invasive surgery (MIS) is the standard approach for early-stage lung cancer, offering benefits such as reduced recovery time, shorter hospital stays, and minimized postoperative pain. However, these techniques require advanced motor skills and a deep understanding of thoracic anatomy. Recent technological advancements, specialized surgical instruments, and energy devices, have further improved MIS capabilities. Despite these advancements, the steep learning curve of video-assisted thoracic surgery (VATS) and robotic-assisted thoracic surgery (RATS) highlights the need for structured simulation-based education to ensure patient safety and optimize skill acquisition. Simulation training provides a risk-free environment for developing technical proficiency before operating on real patients. Virtual simulators, such as LapSim and V-Trainer, are widely used to familiarize trainees with endoscopic instruments and procedural techniques. However, real analog models remain essential for refining motor skills, depth perception, and tactile feedback, which are crucial for complex thoracic procedures. Traditional training methods using wet labs or cadaveric models pose limitations in cost, availability, and ethical concerns. The integration of high-realistic physical anatomical models, including 3D printed anatomical components, represents a promising alternative, offering high-fidelity surgical simulations that mimic real-life operative conditions. At the University of Pisa's EndoCAS Interdipartimental Center for Computer Assisted Surgery, a structured training program incorporating lung phantoms in a 3D-printed thoracic cage, virtual simulation, and stepwise lobectomy simulations have been developed to enhance thoracic surgery education. This study presents our experience with a hybrid simulation approach, based on the combination of virtual and physical simulation, in lobectomy training, emphasizing its role in bridging theoretical learning with hands-on surgical practice, ultimately improving technical skills and clinical confidence among thoracic surgery residents.
While the role of surgery in intracerebral hemorrhage (ICH) remains controversial, endoscopic surgery (ES) has demonstrated efficacy for lobar ICH in clinical trials. However, a key limitation of ES is the requisite centimeter-scale injury to normal cortical tissue. In contrast, our previously proposed robot-assisted visualized minimally invasive aspiration (RAVMIA) technique enables efficient evacuation of elliptical hematomas while causing minimal collateral tissue injury (approximately 5 mm). This study aims to evaluate the efficacy of RAVMIA for lobar ICH. The RAVMIA procedure entails robot-guided insertion of a 5-mm trocar along the hematoma's long axis, coupled with real-time contact-visible endoscopic monitoring of aspiration. Its efficacy was assessed by comparing 15 patients treated with RAVMIA to 16 historical ES controls. No significant differences were observed in baseline characteristics between the two groups. RAVMIA achieved similar hematoma evacuation rates (86.0%[79.0%, 95.3%] vs. 92.3%[86.0%, 94.7%]; P = 0.189) but with a smaller scalp incision (1.33±0.46 cm vs. 6.59±1.30 cm; P < 0.001), smaller craniotomy (0.50 cm vs. 4.47±0.68 cm; P < 0.001), and shorter surgery time (25.0 [20.0, 30.0] min vs. 65.5 [58.5, 72.5] min; P < 0.001). This was associated with shorter ICU stay (3.0[2.0,4.0] days vs. 4.5[3.75,5.0] days; P = 0.002) and total hospital stay (11.0 [10.0,13.0] days vs. 13.0 [10.75,14.0] days; P = 0.010). While GCS and mRS improvements were similar, RAVMIA led to a superior reduction in NIHSS score (5 [4,6] vs. 4 [3, 5]; P = 0.006). No infections or deaths occurred in either group. For lobar ICH, RAVMIA demonstrates comparable hematoma evacuation rates to ES while offering enhanced minimally invasive benefits. The observed functional outcomes, including mRS, were similar between groups, though these findings require confirmation in larger, adequately powered studies. The potential for improved cost-effectiveness, as suggested by shorter operative time and hospital stay, warrants formal evaluation.
Minimally invasive segmentectomy/lobectomy is an alternative to traditional thoracotomy for the treating lung cancer, offering benefits such as reduced postoperative pain, shorter recovery times and improved cosmetic outcomes. However, its feasibility in patients with a history of prior thoracotomy remains debated due to potential pleuro-parenchymal adhesions, scarring and hilar fibrosis with altered anatomy, which may increase the complication rate. This paper addresses some technical considerations about redo video-assisted thoracoscopic surgery (VATS) major lung resection in patients with a history of thoracotomy. We describe the preoperative planning, anesthetic preparation for these cases, and a step-by-step description of the surgical strategy used in our center. Moreover, we discuss principles for postoperative care and follow-up, with specific attention to managing complications. The main concerns in redo cases are about the higher rates of postoperative bleeding and prolonged air-leaks, often associated with mobilizing dense adhesions and scar tissue during surgery. Redo VATS major lung resections following a prior thoracotomy offer substantial advantages in terms of reduced morbidity and faster recovery, but also present challenges related to adhesions, compromised anatomy and patient-specific factors. The decision to pursue this approach is made on a case-by-case basis, weighing the patient's overall performance status, challenges posed by the prior surgery and the surgeon's expertise.
In this video, we present the surgical technique and operative nuances of the zygomatic pretemporal skull base approach for resection of a large left sphenoid wing and middle cranial fossa radiation-induced meningioma (RIM) with invasion and encasement of the middle cerebral artery (MCA). RIMs represent a distinct and surgically challenging entity due to aggressive biological behavior, altered tissue planes, and frequent vascular involvement. In the present case, prior childhood cranial irradiation resulted in dense tumor adherence to the MCA within radiation-altered tissue, necessitating meticulous microsurgical technique. The zygomatic pretemporal approach effectively converts a deep skull base lesion into a convexity-like lesion, providing a wide basal surgical corridor, reducing working distance, and minimizing frontal and temporal lobe retraction. After zygomatic osteotomy and extradural skull base drilling, early devascularization was achieved through removal of the sphenoid ridge and division of the meningo-orbital band. Intradural microsurgical dissection focused on internal tumor debulking followed by sharp arachnoid dissection to circumferentially separate the tumor from the MCA and its branches. In areas of dense adherence, vessel-preserving strategy was prioritized. A Simpson Grade I resection was achieved without vascular injury. Zygomatic reconstruction using low-profile "dog-bone" plates allowed anatomical realignment of the osteotomized segment, preservation of temporalis muscle function, and excellent cosmetic outcome. Postoperative imaging confirmed gross total resection (GTR) and stable reconstruction. The patient recovered without new neurological deficits and demonstrated complete resolution of preoperative hemiparesis at follow-up. This case highlights the value of the zygomatic pretemporal skull base approach in achieving radical resection of complex sphenoid wing RIMs while facilitating safe dissection of critical neurovascular structures.
To investigate the factors influencing the occurrence of intermediate and long-term renal failure in patients with chronic kidney disease (CKD), to construct a risk prediction model, and to provide a reference for the timing of substitution therapy in these patients. A total of 354 patients who attended the Nephrology Department of Guizhou Medical University Hospital from January 2018 to July 2019 were used as the training set. The variables were screened using methods such as LASSO regression and the model was visualized using a nomogram. A total of 139 patients who attended the Department of Nephrology of the First People's Hospital of Bijie between November 2018 and June 2021 were used as an external validation cohort, and analyses were performed to verify the judgmental ability and clinical utility of the model. Multifactorial Cox regression analysis revealed that hypertension, mesangial proliferation, renal tubular atrophy, serum potassium, and estimated glomerular filtration rate were independent risk factors for renal failure. The 1-year AUC values of internal validation and external validation were 0.978 (0.970-0.984) and 0.919 (0.853-0.986), respectively. The 2-year AUCs were 0.945 (0.914-0.961) and 0.902 (0.822-0.982), respectively. The AUC values over three years were 0.933 (0.897-0.945) and 0.915 (0.846-0.985), respectively. The bias correction curves were close to the ideal curves and revealed a high degree of consistency between actual observations and predictions. We have developed a nomogram with excellent predictive power regarding the likelihood and time to progression to end-stage renal disease in CKD patients at 1, 2, and 3 years, which may help to classify patients and select the appropriate treatment plan in advance.
Double sleeve (DS) lobectomy is a specialised lung-sparing operation which can be offered to patients with centrally located tumours, which can avoid pneumonectomy. The technique is historically performed via thoracotomy, but video-assisted thoracic surgery (VATS) and robotic-assisted thoracic surgery (RATS) are gaining traction as minimally invasive alternatives. There are currently no reviews of these techniques. We aim to provide a narrative review of the techniques of DS lobectomy for lung cancer. We searched MEDLINE and PubMed for the following Medical Subject Headings (MeSH) terms: "sleeve", "lobectomy OR resection", "lung OR cancer OR NSCLC OR tumour", "VATS, RATS, thoracotomy, open OR minimally invasive", and limited the review to all English language studies published between 1946 and 23rd October 2024 only. In total, our automatic search criteria found 173 papers discussing sleeve lobectomies/resections. After manual sorting, 36 studies in total described DS operations using varied terminology, including "tangential sleeve resection with circumferential anastomosis, extended sleeve resection, sleeve resection with pulmonary angioplasty, complex sleeve resections", and most commonly "DS". Of these 36 studies, 12 (n=233) described DS resections exclusively, while the rest discussed both single and DS resections. Our review found that current literature reports little difference in long-term overall survival (OS) between single and DS operations. Surgical approach (particularly thoracotomy vs. VATS) does not appear to be a determinant of survival in DS operations. Thoracoscopic techniques may offer shorter postoperative hospital stays and less postoperative pain. In experienced units, the oncological outcomes of DS are at least equivalent to single sleeve resections and pneumonectomy, with preservation of more lung and less postoperative complications. Thoracotomy remains the most used approach in DS lobectomies; VATS may offer shorter post-operative stays than the thoracotomy approach. RATS is currently too infrequently performed to make overarching conclusions, but short-term perioperative outcomes in single-centre reports are promising. We hope that this review provides a novel and comprehensive review of evolving trends in current surgical practices of DS operations to assist clinical decision making for maximum patient benefit.
In boys with non-palpable testis (NPT), the affected side may present as a viable testis (VT) or a nonviable testis (NVT), the latter representing true monorchidism. This study evaluated the utility of ultrasonography (US) for predicting monorchidism and testicular location in unilateral NPT. We retrospectively reviewed boys with unilateral NPT who underwent preoperative US between 2009 and 2025. Testicular volumes were converted to age-adjusted standard deviation (SD) scores. A rule-based model classified NVT when the affected testis was visualized with an SD score ≤ cutoff A and the unaffected testis had an SD score ≥ cutoff B. If the affected testis was not visualized, an SD score ≥ cutoff C for the unaffected testis indicated NVT; remaining cases were classified as VT. Predictions were compared with intraoperative findings. Receiver operating characteristic analysis determined optimal cutoffs. Internal validation using repeated stratified five-fold cross-validation and bootstrap resampling assessed model performance and threshold stability. US-based localization was also compared with surgical findings. Sixty-nine boys were included; surgery identified 51 NVT and 18 VT. Optimal cutoffs were A = -2.60, B = +0.45, and C = +0.60. The model achieved an AUC of 96.1%, with 100% sensitivity, 92.2% specificity, 81.8% positive predictive value, and 100% negative predictive value. Internal validation showed median AUCs of 90.0% and 89.4%, with stable thresholds. Localization accuracy was 66.6%. A rulebased US model may predict monorchidism in unilateral NPT with a very low risk of misclassifying VT as NVT, despite its limited ability to determine testicular location.
Sensitive, point-of-care detection of salivary miRNA-31 holds considerable potential for the early, noninvasive screening and diagnosis of oral squamous cell carcinoma (OSCC). This study reports the first development of a sensitive, portable biosensor that integrates an autocycling primer extension reaction (ACPER) with a bioinspired photonic-crystal (PC) microchip for quantitative analysis of miRNA-31 in saliva. The high amplification efficiency of ACPER enables sensitive detection of miRNA-31 in saliva. Meanwhile, due to the fluorescence-enhancing properties of the PC microchip, the fluorescence signal generated by the ACPER on the PC microchip can be directly visualized and captured through a smartphone imaging system under ultraviolet-light illumination. The fluorescence intensity values are subsequently extracted via image processing software for quantification analysis. This approach obviates the need for bulky instrumentation and mitigates errors arising from subjective interpretation of color depth by the naked eyes, thereby significantly enhancing detection accuracy. Preliminary clinical feasibility assessment demonstrated that this newly developed biosensor can differentiate between cancer patients and healthy individuals in clinical samples with good accuracy (area under the curve = 1), providing a novel paradigm for the early, noninvasive, and sensitive diagnosis of OSCC.
As registries transition from the EQ-5D-3L to the EQ-5D-5L, maintaining continuity of patient-reported outcomes is critical. Crosswalk algorithms were developed to convert between versions, but their performance in spine surgery patients has not been validated. To externally validate the EuroQol crosswalk and reverse crosswalk algorithms in patients scheduled for lumbar spine surgery. Single-center, observational cohort study using prospectively collected registry data from a tertiary spine center in Denmark. A total of 766 adult patients with lumbar spine conditions who completed both EQ-5D-3L and EQ-5D-5L at baseline within 3 months (≤90 days). Agreement between observed EQ-5D index values and predicted values derived from EuroQol crosswalk algorithms. Paired EQ-5D-3L and EQ-5D-5L responses were compared with predicted crosswalk values. Mean absolute error (MAE), root mean square error (RMSE), Spearman's rho, mean difference, Wilcoxon signed-rank tests, and intraclass correlation coefficients (ICC(A,1)) were used. Agreement and bias were visualized with Bland-Altman plots, scatterplots, residual plots, and histograms. The mean age was 57.8±15.5 years; 53.4% were female. The mean EQ-5D-3L index value was 0.311±0.247. Prediction errors were moderate (MAE 0.23-0.26; RMSE 0.29-0.32) with weak-to-moderate correlations (rho 0.54-0.56). ICCs were low (0.51 for 3L predicted from 5L; 0.32 for 5L predicted from 3L). Visual analyses revealed systematic under- and over-prediction, distributional distortion, and nonlinear error patterns. EuroQol crosswalk algorithms showed only moderate predictive performance in lumbar spine patients. While they may be acceptable for broad group-level comparisons or retrospective harmonization, they are unsuitable for individual-level assessment or clinical decision-making. Direct use of the appropriate EQ-5D version is recommended.
Uniportal video-assisted thoracoscopic surgery (VATS) is considered the optimal access method for pneumothorax surgery. Currently, uniportal VATS is used worldwide because it requires an incision in only one intercostal space, which simplifies postoperative pain control, due to reduced acute pain, and the incidence of chronic pain is also potentially lower. It is essential to tailor the surgical technique to each individual case, ensure reliable closure of air leaks, and minimize the risk of recurrence. This article introduces the practical aspects of uniportal VATS for pneumothorax, focusing on the pitfalls. Moreover, detailed methodologies for the lateral intercostal approach for uniportal lung wedge resection, and subxiphoid uniportal bilateral lung resection are provided. During lung resection (bullectomy) for primary spontaneous pneumothorax, the reinforcement-equipped cartridge is used to prevent recurrence, and an oxidized regenerated cellulose sheet is applied as a covering material. In the case of secondary spontaneous pneumothorax, in addition to the oxidized regenerated cellulose sheet, the most appropriate reinforcement material is applied after the surgical procedure. During lung resection, the planned resection line should be marked as needed to clearly define the resection area and ensure no residual lesions are left behind. When partial lung resection is challenging, or in cases of air leakage from a pedunculated bulla, suture closure or ligation may be required. The most common approaches include direct suturing of the damaged pleura or ligating the base of the bulla. Given the condition of the underlying lung, reinforcement with covering materials is essential in all cases. This article includes numerous visual materials, including figures and videos, to illustrate the uniportal VATS technique for pneumothorax. Irrespective of the technique used, it is necessary for clinicians to undergo training, refine their skills, and select the appropriate instruments.
Minimally invasive repair of inguinal hernias offers several advantages over the conventional open approach in the context of reduced postoperative pain and faster return to daily activities with a non-inferior recurrence rate. With the increasing adoption of robotic platforms in surgical units worldwide, robotic transabdominal pre-peritoneal (rTAPP) repair has become an increasingly popular option offered to the patients. Successful surgical outcomes for any minimally invasive inguinal hernia depend on thorough understanding of the internal landmarks of myopectineal orifice (MPO). A conceptual framework such as inverted Y or 5 triangles described by Furtado et al. is essential to be understood prior to embarking on any minimally invasive inguinal hernia repair. While complex inguinal hernia repairs have traditionally been relative contraindication for laparoscopic repair due to technical difficulties, the robotic approach may help overcome these challenges. What sets this technique apart is the integration of a structured teaching framework designed to standardise the dissection process. We present the case of an 82-year-old female who underwent rTAPP for bilateral inguinal hernias, classified per the European Hernia Society (EHS) as right (P L2M0F1) and left (P L1M0F1). Following Veress needle insufflation, a 12-mm visiport was inserted in the right pararectal space, with two 8-mm robotic ports placed in linear alignment. Instrumentation included a bipolar grasper, camera, and monopolar scissors. A self-adhesive mesh and barbed sutures were introduced intra-abdominally at the outset. Total operative time was 80 minutes. The urinary catheter was removed post-procedure, and the patient was discharged the same day following an uneventful recovery. In this surgical technique we visually overlay Furtado's concept onto the robotic intraoperative view to create a reproducible anatomical roadmap. By mapping these defined safety and danger zones during the robotic dissection, we translate theoretical anatomy into a practical, stepwise intraoperative guide. This educational overlay aims to enhance reproducibility, anatomical orientation during the surgical learning curve, and potentially reduce complications or recurrence by promoting consistent identification of key landmarks. Whilst further randomised studies comparing robotic and laparoscopic approaches are needed to fully assess the role of robotic approach in surgical treatment of inguinal hernias, this visual framework serves as a training tool for surgeons adapting rTAPP.
Redo mitral and tricuspid valve surgery presents considerable technical challenges due to dense adhesions, previous surgical alterations, and distortion of normal anatomical landmarks. Traditionally, these complex reoperative procedures have been approached through repeat median sternotomy, a strategy that, while familiar, carries heightened risks of cardiac or great vessel injury during re-entry, increased bleeding, longer operative times, and prolonged recovery. As minimally invasive cardiac surgery has evolved, endoscopic techniques have emerged as a viable and increasingly attractive alternative, offering surgeons enhanced visualization and patients a less traumatic operative experience. In this technical paper, we outline our institutional approach with endoscopic redo mitral and tricuspid valve surgery, emphasizing comprehensive preoperative planning, thoughtful patient selection, and meticulous intraoperative strategy. Critical components of preparation include detailed imaging assessment, analysis of previous operative notes, and formulation of a cannulation strategy tailored to each patient's anatomy and prior interventions. Myocardial protection remains a fundamental priority, and we describe the methods we have found most effective in achieving consistent and safe cardiac preservation in a reoperative setting. Our stepwise operative approach focuses on minimizing dissection, utilizing enhanced visualization, and employing targeted techniques to navigate scar tissue and restored anatomy while preserving procedural safety. In the experience of expert surgeons and teams, endoscopic access has translated into meaningful clinical benefits, including reduced transfusion requirements, shorter intensive care and hospital stays, and excellent early postoperative outcomes compared with traditional redo sternotomy as previously published. With proper preparation, a multidisciplinary team, and intraoperative vigilance, endoscopic redo mitral and tricuspid valve surgery represents a reliable, reproducible, and patient-centered option for complex valve reoperations.
Non-intubated video-assisted thoracic surgery (VATS) is an option for the treatment of secondary spontaneous pneumothorax (SSP) in high-risk patients. Although persistent air leakage remains a major postoperative challenge, the efficacy of subsequent treatment to arrest such leakage has not been fully clarified. This study aimed to describe the surgical procedures and postoperative management of non-intubated VATS and to evaluate treatment outcomes. A single-center retrospective study was conducted on patients who underwent non-intubated VATS for intractable SSP between 2011 and 2021. All patients were considered intolerant to surgery under general anesthesia with endotracheal intubation. The air-leak sites were managed with ligation or pleural coverage. Postoperative pleurodesis was performed to terminate air leakage or to prevent pneumothorax recurrence. Twenty-one patients were included in the study. The mean age was 78.3±8.4 years. Air leakage was treated by ligation in 10 patients (48%). Postoperative air leakage occurred in 11 patients (52%). Twenty patients underwent pleurodesis. Air leakage was arrested by surgery alone or by surgery combined with pleurodesis in 16 patients (76%), and ultimately in 19 patients (90%), including three who required bronchial occlusion. Six patients (29%) died during hospitalization. Postoperative recurrence of pneumothorax was observed in two patients (11%). The 1- and 2-year overall survival rates were 47% and 35%, respectively. Postoperative air leakage was common after non-intubated VATS for SSP. However, non-surgical interventions effectively controlled air leakage in most cases. The high in-hospital mortality rate likely reflected the patients' poor physical condition and the severity of their underlying diseases. Non-intubated VATS combined with postoperative pleurodesis or bronchial occlusion is an alternative for patients with persistent air leakage who are poor candidates for surgery under general anesthesia. Further studies are required to assess the validity of this procedure.
Myocardial bridging (MB) is a congenital anomaly in which a segment of the coronary artery, most commonly the left anterior descending (LAD) artery, courses intramyocardially. While often asymptomatic, MB can cause myocardial ischemia, arrhythmias, and, in rare cases, sudden cardiac death. Surgical unroofing is the definitive treatment for symptomatic patients who are unresponsive to medical therapy, and it is considered superior to catheter-based interventions. The adoption of robotic techniques has enabled a totally endoscopic approach that minimizes surgical trauma, facilitates faster recovery, and improves cosmetic results. This manuscript details our technique for robotic myocardial bridge unroofing. Preoperative assessment besides standard workup for cardiac surgery, includes coronary computed tomography (CT) angiography, lung function tests, and invasive physiological testing to confirm the significance of MB. Using the da Vinci Xi robotic system, the procedure is performed through four 8-mm robotic ports with femoral cannulation and endoaortic balloon occlusion for endo-cardioplegia, ensuring a motionless field for precise unroofing of the LAD without compromising vessel integrity. Compared to traditional sternotomy-based techniques, the robotic totally endoscopic approach represents a version of the procedure with the least surgical trauma and offers improved visualization as well as enhanced dexterity and precision. Specialized robotic training is required and our experience demonstrates robotic unroofing is a promising evolution in the surgical management of a symptomatic LAD MB.
Minimally invasive thoracic surgery has evolved significantly over the past two decades, with robotic-assisted thoracic surgery (RATS) emerging as a leading approach due to its enhanced visualization, wristed instrumentation, and improved ergonomics. Traditional multiport RATS relies on three or four incisions, while uniportal RATS (U-RATS) offers a less invasive approach but presents technical challenges, including instrument crowding and limited stapler manoeuvrability. The development of biportal RATS (Bi-RATS) represents a balance between these techniques, offering improved ergonomics while reducing access-related trauma. This approach has been employed for diverse pulmonary resections-ranging from wedge resections in peripheral nodules to complex anatomic segmentectomies and lobectomies. This manuscript provides a comprehensive overview of Bi-RATS for lung segmentectomies, detailing patient positioning, port placement, intraoperative technique, and the role of advanced imaging adjuncts such as near-infrared fluorescence [indocyanine green (ICG)] and three-dimensional computed tomography (3D CT) reconstruction. By leveraging these advancements, thoracic surgeons can achieve improved outcomes and enhanced decision-making during complex resections. Compared to multiport RATS, U-RATS, and video-assisted thoracoscopic surgery (VATS), Bi-RATS offers improved instrument manoeuvrability, a more ergonomic stapler trajectory, and utilizes anterior port placement in such a way as to reducing intercostal nerve compression, which may lead to lower postoperative pain. It allows for a fully robotic stapling process, minimizing the need for manual staplers and excessive lung manipulation. The integration of ICG fluorescence further refines segmental plane identification, ensuring precise and safe parenchymal division. Postoperative management includes adherence to enhanced recovery after surgery (ERAS) protocols, early chest tube removal, and effective pain control, which contribute to shorter hospital stays and faster patient recovery. Despite a steep learning curve, Bi-RATS optimizes robotic thoracic surgery by enhancing surgical efficiency while minimizing access trauma. Future research should focus on long-term oncological outcomes, cost-effectiveness, and training standardization to establish Bi-RATS as a widely adopted technique in modern thoracic surgery.