A step by step guide for conducting a systematic review and meta-analysis with simulation data

We read with interest the systematic review and meta-analysis (SR/MA) by Saracoglu et al regarding the efficacy of adding pain neuroscience education (PNE) to a multimodal treatment in fibromyalgia.1 Fibromyalgia can cause widespread musculoskeletal pain, fatigue, sleep disturbance, cognitive dysfunction, and psychiatric symptoms. Moreover, a lack of consensus on etiopathogenesis, classification criteria, and diagnostic criteria leads to inconsistency of treatment.2 PNE is a cognitive therapy among the various fibromyalgia treatment options, and the authors made a great effort to analyze the related randomized controlled trials (RCTs) in order to demonstrate the efficacy of PNE. We recognize the authors' contribution to validate the effectiveness of PNE; however, there are a few points we would like to further discuss. First, the authors selected only 4 studies in their SR/MA, which they admitted as a limitation; nevertheless, we found an SR/MA with a similar topic which includes 8 studies.3 After comparing the searching strategies, Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagrams, and the selected RCTs of the 2 SR/MAs, we consider that the authors of the former SR/MA excluded some RCTs not because their selection was rather strict, but because their searching strategy did not include enough synonyms for fibromyalgia and PNE. For example, 2 RCTs selected in the latter SR/MA titled “How Much Is Needed? Comparison of the Effectiveness of Different Pain Education Dosages in Patients with Fibromyalgia” and “Pain physiology education improves health status and endogenous pain inhibition in fibromyalgia: a double-blind randomized controlled trial” respectively,4, 5 might have been excluded by the former SR/MA because the titles do not include the keywords in the searching strategy of the authors. Although the searching strategy of the former SR/MA is reasonable and well-defined, we suppose that adding a few more synonyms in the searching strategy might be beneficial for collecting more RCTs concerning the topic. Second, the title “Efficacy of adding pain neuroscience education to a multimodal treatment in fibromyalgia: A systematic review and meta-analysis” of this SR/MA implies that the control group should be treated with a multimodal approach; on the other hand, the intervention group should be treated with a multimodal approach added with PNE. However, the second study in table 1 of the paper does not match the inference mentioned above,6 since its control group was treated with therapeutic exercise alone, which seems different from multimodal treatment. We suggest that the word “multimodal treatment” should be clearly defined in the context, and the RCTs should be strictly selected according to the meaning of the title. An alternative solution is to broaden the scope of the SR/MA, that is, to contain studies which can demonstrate PNE's efficacy without restricting the type of control group. In that way, the SR/MA could include more studies, and the results would be more universal. Third, we suggest that the authors could analyze the follow-up results of PNE on fibromyalgia patients. The SR/MA by Suso-Martí et al extracted the follow-up results from 8 RCTs and discovered a noteworthy phenomenon.3 Although the patients with fibromyalgia showed a short-term improvement on some aspects of the Fibromyalgia Impact Questionnaire, some of the results manifest no improvement after a follow-up assessment a few months later. In other words, PNE might benefit fibromyalgia patients in the short term, but not in the long term. The outcome mentioned above is still open to discussion; therefore, the addition of a follow-up analysis could be valuable. Above all, the authors made a great attempt on validating the efficacy of PNE. The study also shows that the promising PNE treatment still lacks sufficient studies to demonstrate the optimum dosage and duration. Further discussions and analyses of PNE could take a place in revealing the whole picture of fibromyalgia treatment and contribute to helping patients. None to declare.

Systematic review and meta-analysis (SRMA) are the supreme collective scientific evidence available in our literature. Conducting a SRMA is a time consuming, relatively expensive team work. There are many funding options for a relevant SRMA. Hence it is advisable to check whether our proposed SRMA is unique or whether someone else is currently doing it. One can do it by searching PROSPERO maintained by University of York, Cochrane library, PubMed and Google Scholar. It is mandatory to register SRMA; PROSPERO is a major registration option. PROSPERO doesn’t allow multiple registrations of the same topic unless a valid justification can be given. PROSPERO requires a registration which is free of coast. Registration can be done by visiting https:// www.crd.york.ac.uk/prospero/ . After login, we can either register our SRMA or we can search ongoing SRMA. Having a protocol as per PRISMA-P guidelines is mandatory for a smooth registration process. Registration increases the credibility of the SRMA and eliminates the chance of unnecessary duplication of the work. Protocol helps to plan and anticipate problems associated with SRMA. There are different methods for preparing the protocol; Cochrane protocols and PRISMA-P protocols. This editorial will deal with PRISMA-P protocols. Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) was published in 2015 ( Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, Shekelle P, Stewart LA. Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) 2015 statement. Syst Rev. 2015;4(1):1. doi: 10.1186/2046-4053-4-1). PRISMA-P specifically talks about protocols, PRISMA about manuscript writing and PRISMA-S about reporting search strategies. PRISMA-P statement (http://www.prisma-statement. org/Extensions/Protocols ) contains some very important items. Administrative information includes identification (Title, original or updated SRMA), registration details, author information (primary and contributors), amendments (indicate ONLY if the protocol is a modification of the earlier one) and support (information regarding funding). Introduction includes rationale and objectives. Methods include eligibility criteria (study characters like PICO, study design and setting, time frame etc.), information sources (all intended digital and other sources), search strategy (MESH terms, Boolean operators, synonyms etc.), study records (data management methods like Rayyan, selection process like who screens the data and data collection process like MS excel / spread sheet), data (define al variables), role of bias in individual studies (describe methods for assessing risk of bias at study level or outcome level or both), data synthesis (describe the statistical aspects), meta bias (publication bias among studies, possibility of selective reporting) and confidence in cumulative evidence.

To the Editor: I read with interest the systematic review of Posadzki and Ernst regarding randomized controlled trials of osteopathy for musculoskeletal pain (MSP) patients [1]. The authors are correct in asserting that there is no compelling evidence for the effectiveness of osteopathic manipulative treatment (OMT) in managing musculoskeletal pain generally. However, a valid assessment of OMT in the management of patients with low back pain (LBP) was precluded by several methodological shortcomings of their review. Consequently, their results were discrepant from those of our previous systematic review and meta-analysis (SRMA) [2]. Posadzki and Ernst claim that our SRMA is burdened with a high risk of bias for two reasons: (1) four of the six included studies showed no difference between OMT and control treatments, and (2) it lacked a critical assessment of the methodology and validity of the included studies. With regard to the first criticism, the North Texas trial found significant differences between OMT and the nointervention control treatment at all three reported followup intervals [(Fig. 3) 3]. Other studies in our SRMA also found significant differences between OMT and the control treatments at one or more time intervals [4, 5]. Thus, the complexity of such clinical trials is too great to be adequately captured with a simple binary measure. For this reason, the vote-counting method invoked in this criticism has been largely abandoned since the earliest days of metaanalysis because it yields an unacceptably large risk of drawing erroneous conclusions [6]. Alternatively, metaanalysis is most useful in summarizing research studies that are too small to yield valid conclusions individually [7]. The second criticism, regarding the methodology and validity of included studies in our SRMA, can be dismissed by simply accepting the Jadad scores reported by Posadzki and Ernst in Table 1. Four of our six SRMA studies (references 9, 13, 22, and 24 in Table 1) were assigned Jadad scores of 3, 4, 4, and 2, respectively (mean Jadad score, 3.25). By contrast, the 16 included studies in Table 1 of the Posadzki and Ernst review achieved a mean Jadad score of only 2.63. Another shortcoming of their review was that they did not include the two remaining studies of OMT for LBP, which were previously identified in our SRMA [4, 8]. Even under adverse assumptions regarding the quality of these two additional studies [4, 8], the resulting mean Jadad score for our six SRMA studies would be comparable or superior to the mean Jadad score for the 16 included studies in Table 1 of the Posadzki and Ernst review. Finally, their review states, “to date no definitive conclusions about the effectiveness of osteopathy in the management ofMSP has [sic] been drawn, and the usefulness of OMT in treating MSP is unclear.” However, our SRMA [2] is now the basis for an evidence-based clinical practice guideline that promotes the use of OMT in patients with LBP [9]. Further, this guideline has been accepted by the National Guideline Clearinghouse (NCG:007504), which is sponsored by the Agency for Healthcare Research and Quality. J. C. Licciardone The Osteopathic Research Center, University of North Texas Health Science Center, Fort Worth, TX, USA

Employing a mixed-methods approach, this study: (a) scoped the literature for desirable characteristics of online learning environments; (b) analyzed and compared the available online systematic review and meta-analysis (SR/MA) courses; and (c) proposed an outline for a model online systematic review SR/MA course that is aligned with PRISMA principles, and (d) charted learning outcomes, module contents, interactive elements, feedback and module assessment, and course evaluation of the proposed course. The findings highlight the many distinctive aspects and design of the proposed model course, including its comprehensiveness, alignment with PRISMA principles, self-pace and self-direction, with high interactivity levels, augmented by the expert trainer guidance (‘human’ factor), and individualized feedback, and its conclusion with the incorporation of the learners in virtual research teams undertaking real SR/MA. The proposed model course integrates principles of problem-based learning, where in addition to the provided resources (interactive assignments and video tutorials), trainees will be actively conducting their own real SR/MA as part of the course, while receiving expert feedback to enhance learning outcomes. Assignments’ scores will be used to evaluate the learners’ proficiency levels, and to pinpoint strengths and areas requiring enhancement. Overall, the proposed model course stands out as an innovative initiative in online SR/MA training, offering a valuable and comprehensive online learner-centered, expert-guided, ‘hands-on’ educational approach to SR/MA training. This sets a benchmark for future online courses in research synthesis methodology within health, medical, surgical and related fields.

In a systematic review and meta-analysis (SR/MA), Sanaie et al. concluded that open endotracheal suctioning (OES) increases the incidence of ventilator-associated pneumonia (VAP) compared with closed endotracheal suctioning (CES) [odds ratio (OR); 1.57, 95% confidence interval (CI); 1.06-2.32,p = 0.02]. 1We conducted a narrative review of the effects of OES vs CES on the incidence of VAP.The trials reviewed were included in the SR/MA published in your journal in 2022. 1 We found an error in data extracted from a trial included in the SR/MA paper by Sanaie et al., 1 which was also found in the SR/MA paper by Liang et al. 2 In the trial conducted by Ardehali et al., 60 patients were allocated to each group, and 10 and 12 VAP cases occurred in the CES and OES groups, respectively. 3 The authors concluded that the two suction methods did not significantly differ. 3 The OR calculated using the correct data was 1.25 (95% CI; 0.49-3.16).However, the results in the SR/MA paper by Sanaie et al. are inconsistent with this value, as they stated that, in the study by Ardehali et al., 22 VAP cases occurred in the OES group compared with 10 cases in the CES group (OR; 2.89, 95% CI; 1.23-6.83). 1 The trial by Ardehali et al. was assigned a weight of 10.9%. 1 Consequently, this data extraction error influences the conclusions of the SR/MA paper.The study of Sanaie et al. warrants reanalysis and correction using reliable data, and the rectification process should be made public, given the crucial role of SR/MA papers in evidence-based practice.

It is an honor and pleasure to be able to extend greetings as the Editor-in-Chief of Tropical Medicine and Health (TMH), a journal with a 56-year history of high-quality research and one of the most important publications in the field. When I was appointed to the position of Editor-in-Chief in 2014, I wrote in the editorial that “our greatest challenge is to continue to improve the journal in such a way as to provide essential and timely information regarding research in the field of tropical medicine and global health” [1]. To achieve this goal, we set up a target to shorten the submission/review/decision cycle to 21 days after the initial submission. I am delighted to report that this target was achieved in two consecutive years in 2014 and 2015: the average duration was 21.0 and 19.0 days, respectively. This achievement owes greatly to the efforts of our reviewers and editors. We believe that speedy publication will help to ensure that TMH papers are read and cited more often by experts in the related fields. TMH is attracting ever greater attention. The number of accesses and downloads of the papers on the journal website increased 3.9 and 2.6 times, respectively, in 2015, compared to the average in 2013. We also received 46 % more submissions to TMH in 2015 compared to 2013. While this is due in part to our promotion campaign as well as our recent decision to send e-mail announcements to society members right after a paper is published online, we are deeply indebted to all of our authors, reviewers, and readers for their enthusiastic cooperation. Now I am pleased to announce that BioMed Central is the new publisher of TMH. We have taken this opportunity to revise the aims and scope of the journal to incorporate, in addition to traditional tropical medicine, the issue of global health. Global health is health of populations in a global context which can be characterized by a “health issue that concerns many countries or is affected by transnational determinants” [2]. While traditional tropical medicine is still central to our scope, TMH welcomes clinical, epidemiological, laboratory, and policy research physically implemented in non-tropics when related to health issues in the tropics or in a global context. TMH will continue as an open-access publication as part of BioMed Central’s high-quality portfolio of open-access journals. Authors can expect accepted manuscripts to be published online in professionally copy-edited and typeset form within a few weeks of acceptance. Finally, I would like to convey my cordial request to all our contributors for their continued support of TMH. The TMH staff will continue to make their utmost efforts to achieve speedy publication and to provide essential and timely information on high-quality research in the field of tropical medicine and global health. On behalf of the Editorial Board and TMH staff, I look forward to working with you and serving the community.

A systematic review is a rigorous process that involves identifying, selecting, and synthesizing available evidence pertaining to an a priori-defined research question. The resulting evidence base may be summarized qualitatively or through a quantitative analytic approach known as meta-analysis. Systematic review and meta-analysis (SRMAs) have risen in popularity across the scientific realm including diabetes research. Although well-conducted SRMAs are an indispensable tool in informing evidence-based medicine, the proliferation of SRMAs has led to many reviews of questionable quality and misleading conclusions. The objective of this article is to provide up-to-date knowledge and a comprehensive understanding of strengths and limitations of SRMAs. We first provide an overview of the SRMA process and offer ways to identify common pitfalls at key steps. We then describe best practices as well as evolving approaches to mitigate biases, improve transparency, and enhance rigor. We discuss several recent developments in SRMAs including individual-level meta-analyses, network meta-analyses, umbrella reviews, and prospective meta-analyses. Additionally, we outline several strategies that can be used to enhance quality of SRMAs and present key questions that authors, editors, and readers should consider in preparing or critically reviewing SRMAs.

Effect of diabetes self-management education (DSME) on glycated hemoglobin (HbA1c) level among patients with T2DM: Systematic review and meta-analysis of randomized controlled trials

Typhoid fever, caused by Salmonellaentericaserovar Typhi (S. Typhi), can be transmitted via faecal-oral route. Although significant reduction in incidence from 11 million in 2017 to 7 million in 2021, typhoid fever remains a global health problem. The World Health Organization (WHO) recommended implementation of typhoid conjugate vaccine (TCV) in endemic countries. However, only ten countries have introduced TCV into their national immunisation programs to date. This study aims to estimate the real-world effectiveness of TCV to inform evidence-based decision making and support implementation in typhoid-endemic countries. In this systematic review and meta-analysis (SRMA), we searched MEDLINE (PubMed), EMBASE, Web of Science, and Cochrane Library. We included post-licensure observational and non-randomised studies evaluating vaccine effectiveness (VE) of TCV among children and adolescents published up to August 14th, 2025. Four TCV vaccines - Typbar TCV®, TYPHIBEV®, SKYTyphoid™, and ZyVac® TCV- had been WHO-prequalified at the time of review. The protocol is registered with PROSPERO (CRD42023456130). We identified 1337 records and included four studies in the meta-analysis, comprising 24,180 individuals from three countries (Pakistan, India, and Zimbabwe) comparing single-dose Typbar TCV® recipients with unvaccinated children. TCV prevented culture-confirmed typhoid with VE of 87% (95% CI, 57-94%). TCV also prevented combined suspected, probable, and culture-confirmed typhoid with VE of 55% (95% CI, 0.52-57%) and extensively drug-resistant (XDR) S. Typhi with VE of 97% (95% CI, 95-98%). Sensitivity analysis (eight studies, five countries; see Supplementary File) indicated a higher VE among older children (above 5years) and a significant decline in protection 4-5years after vaccination. Typhoid conjugate vaccines (TCV) demonstrate significant real-world effectiveness in preventing culture-confirmed, probable, suspected, and extensively drug-resistant (XDR) typhoid cases in endemic regions. This systematic review and meta-analysis support the implementation of TCV into national immunisation programs in typhoid-endemic countries. No previously published systematic review and meta-analysis evaluate the effectiveness of TCV. Evidence on real-world effectiveness is needed to support typhoid endemic countries considering the introduction of TCV into their national immunisation program.

Influence of antimicrobial photodynamic therapy on the bond strength of endodontic sealers to intraradicular dentin: A systematic review and meta-analysis.

A Systematic Review and Meta-Analysis of the Effect of Iron Chelation Therapy on Survival in Patients with Lower Risk Myelodysplastic Syndrome

To date, findings from systematic reviews and meta-analyses on unintended pregnancies in low-income and middle-income countries (LMICs) are inconsistent, posing challenges for preventive efforts. Therefore, the aim of this study is to determine the magnitude, determinants, and adverse outcomes of unintended pregnancy among pregnant mothers in LMICs: an umbrella review of systematic review and meta-analysis. PubMed, Scopus, Science Direct, Web of Science, as well as databases specific to systematic reviews, such as the Cochrane Database, have investigated the magnitude, risk factors, and adverse outcomes of unintended pregnancy in LMICs. The methodological quality of the included studies was assessed using the Assessment of Multiple Systematic Reviews (AMSTAR) tool. The estimates from the included studies regarding the magnitude and predictors of unintended pregnancy were then pooled and summarised using random-effects meta-analysis models. We included 13 systematic review and meta-analysis (SRM) studies involving 1 446 122 women. The summary estimate for the magnitude of unintended pregnancy was 28.38% (95% CI = 23.06-33.7%, I2 = 100%). From the umbrella review, the reported factors and complications of statistical significance were as follows: maternal illiteracy (AOR = 3.79; 95% CI = 1.36-8.94), being unmarried (AOR = 12.98; 95% CI = 1.88-27.85), lack of communication with the husband about family planning (AOR = 3.43; 95% CI = 1.68-5.19), inability to attend antenatal care (AOR = 1.4; 95% CI = 0.62-2.17), never using family planning (AOR = 1.4; 95% CI = 0.62-2.17), maternal depression (AOR = 1.72; 95% CI = 0.81-2.64), stunting (AOR = 1.76; 95% CI = 1.25-2.48), and parity 3.83 (AOR = 1.3; 95% CI = 1.3-11.3). The pooled magnitude of unintended pregnancies in LMICs was high. Therefore, it is crucial to integrate family planning and maternal health care services to prevent unintended pregnancy. Additionally, interventions targeting rural, unmarried, less-educated, and adolescent women are important for preventing unintended pregnancies in LMICs.

India faces a growing burden of non-communicable diseases (NCDs), particularly diabetes, cardiovascular conditions, and cancer, straining the healthcare system. Given the urgent need for prevention and management, a systematic review and meta-analysis (SRMA) of health-seeking behaviors for NCDs is essential to guide targeted interventions to improve health outcomes. The SRMA protocol was registered in PROSPERO (CRD42023476381) and conducted adhering to the Preferred Reporting Items of Systematic reviews and Meta-Analysis (PRISMA) 2020 guidelines. PubMed-Medline and Scopus databases were searched from inception to October 27, 2023. Eligible studies focused on adults (>18 years) with NCDs covered under the National Programme for prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and stroke (NPCDCS). Data extraction and risk of bias assessment were conducted using predefined criteria. Meta-analysis of quantitative data was performed using DerSimonian and Laird random-effect model. From 2,917 identified studies, 64 were included in the SRMA, with 40 suitable for meta-analysis. The meta-analysis revealed that 72.72% (95% CI 59.48-85.97%, I 2 = 99.97%) of individuals sought treatment for existing health conditions, with 73.09% (95% CI 54.01-92.16%, I 2 = 99.18%) preferring allopathy, compared to 8.89% (95% CI 5.56-12.22%, I 2 = 86.73%) preferring Alternative medicine with a significant heterogeneity. Major barriers to seeking treatment included illness not considered serious [0.4785 (95% CI 0.4556-0.5013)] and financial constraints [0.3263 (95% CI 0.1457-0.5069)], with delays in cancer treatment attributed to lack of disease awareness [0.5091 (95% CI 0.0294-0.9888)] and painlessness [0.4502 (95% CI 0.3312-0.5692)]. Private healthcare facilities (51.26, 95% CI 42.85-59.67%) were preferred over government facilities (33.78, 95% CI 28.10-39.45%). This SRMA provide a comprehensive overview of health-seeking behavior for NCDs in India. The findings underscore the complex interplay of socioeconomic, cultural, and systemic factors influencing healthcare access and outcomes. Targeted interventions addressing barriers identified in this review are imperative for improving public health and reducing the burden of NCDs in India. https://www.crd.york.ac.uk/PROSPERO/view/CRD42023476381.

Introduction: Medical conferences are known to be a prime source of continued learning and knowledge sharing among the medical community. The quantity and importance of systematic review and meta-analysis (SRMA) has been reported to be increasing in the medical field, but has not been reviewed in the gastroenterology (GI) conference world. We aimed to assess the prevalence of SRMA from 2010 to 2016 at common GI conferences, their country of origin, and if there was an association between the United States News & World Report (USNWR) and increased abstract prevalence. Methods: We used the search term of “systematic review” (SR) and “meta-analysis” (MA) on the Digestive Disease Week (DDW), American College of Gastroenterology (ACG), American Association for the Study of Liver Disease (AASLD), and Advances in Inflammatory Bowel Disease (AIBD) databases for conference abstracts from 2010 to 2016. Two reviewers performed the search and assessed which abstracts were SR or MA or SRMA and extracted first and last author institution names and nationality from 2011 to 2016. We used the USNWR to tier institutions in categories of 25 for the top 150 GI/GI surgery scores to see if this predicted increased prevalence of conference abstracts. Results: Total SR, MA, SRMA per year was calculated for DDW (2010 - 2016: 53, 72, 84, 100, 90, 124, 170), ACG (2010 - 2016: 20, 10, 34, 45, 52, 72, 81), AASLD (2010 - 2016: 11, 14, 34, 22, 23, 18, 25), and AIBD (2015 - 2016: 5, 10). We found a linear increase in publication over the years (Figure 1). From 2011-2016, 69.4% (753/1085) of these had a first author and 66% (716/1085) had a senior author from the US. There was an increasing trend of US first authors when compared to international based first authors over time, accounting for the increase of abstracts (Figure 2). The top 150 institutions in the USNWR by first author contributed to 44.9% (333/741) of abstracts and 46.5% (328/706) by senior author. Contribution of abstracts by senior/first author tier were as follows: 1st tier: 201/185, 2nd tier: 56/60, 3rd tier: 28/33, 4th tier: 14/19, 5th tier: 17/22, 6th tier: 12/14.The top 25 senior author hospitals published 74 more abstracts than the remaining 125 hospitals.FigureFigureConclusion: Overall, there is an increasing trend of SRMA abstracts at GI conferences since 2010. US first authors have majorly contributed to the increasing prevalence. The USNWR can predict institutional representations of SRMA at GI conferences.

Concerns about the long-term toxicity of chemotherapy and radiotherapy in stage II seminoma have renewed the interest in the surgical management. Retroperitoneal lymph node dissection (RPLND) has emerged as a potential treatment alternative. This systematic review and meta-analysis (SRMA) evaluates the oncological, functional, and peri-operative outcomes of RPLND in stage II seminoma. A SRMA (systematic review and meta-analysis) of prospective studies was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Eligible studies included prospective trials assessing RPLND in stage II seminoma. Outcomes analyzed were relapse-free survival (RFS), recurrence patterns, functional outcomes, and peri-operative complications. Risk of bias was assessed using the Newcastle--Ottawa Scale. The review was registered in PROSPERO (CRD420250559629). Four prospective phase II studies with 216 patients were included. The pooled 2-year RFS was 85% (95% confidence interval [CI]: 77.8%--92.2%). In-field recurrence occurred in 5.5%, while the rate of out-of-field recurrence was 10.1%. Preservation of antegrade ejaculation was achieved in 92.8% (95% CI: 87.4%--98.1%). Major complications (Clavien-Dindo ≥ IIIA) were reported in 9.6% of the patients. Risk of bias was low to moderate across the studies. Primary RPLND is a feasible and safe treatment for carefully selected patients with stage II seminoma, providing favorable oncological control, high rates of functional preservation, and acceptable morbidity. While short-term outcomes are encouraging, long-term follow-up and randomized comparisons with conventional therapy are required to establish its definitive role.