Non-Surgical Treatment Options for Peyronie s Disease

Introduction Currently, there is no consensus regarding the management of intermittent exotropia (IXT), which includes both surgical and non-surgical treatment options. Nonsurgical management of IXT has been suggested and includes watchful observation, patching, overminus lenses, prism, and vision therapy/orthoptics. While a significant portion of IXT patients are treated by surgery, it is reported that there is a substantial tendency for reoperation or recurrence of IXT. This paper provides a comprehensive review of non-surgical and surgical treatment options for the IXT. Methods Search strategies involving combination of keywords including intermittent exotropia, divergence excess, basic exotropia, refractive error, glasses, spectacles, natural history, untreated, observe, occlusion, patch, overminus, overcorrecting minus, prism, vision therapy, orthoptic, anti-suppression, fusion exercise, and surgery were used in Medline. All English articles from 01/01/1900 to 01/09/2020were reviewed. The reference list of the identified articles was also checked for additional relevant articles. Studies focused on animal models or strabismus associated with neurologic disorders or injury were excluded. The following filters were used for surgical management due to the abundance of reports: full text, randomized controlled trial, review, in the last 5 years. Results Appropriate optical correction of refractive error is generally the starting point for all management approaches, but there is a lack of randomized clinical trial data regarding this treatment modality. Randomized clinical trial data indicate that both observation and occlusion are reasonable management options for children 3–10 years old, and there were insufficient data to recommend occlusion for children 12–35 months old. While overminus lenses were found to improve the control of IXT when assessed wearing overminus spectacles, this improvement did not persist after the treatment ended. The result of the only randomized clinical trial on the effectiveness of base-in prism indicated that this treatment is no more effective than nonprism spectacles for improving control. A recent randomized clinical trial showed that vision therapy/orthoptics is effective in improving the control of IXT when compared to observation alone. Surgery was found to alter a number of clinical characteristics of IXT, including reducing the distance and near angle of deviation, reducing photophobia, improving health-related quality of life, stereopsis, and the Newcastle Control Score. However, there are no randomized clinical trial data comparing surgery with a control group such as placebo or a no treatment observation group. Discussion Rigorously designed clinical trials to investigate the effectiveness of non-surgical and surgical treatments for intermittent exotropia are needed.

Introduction The current treatment algorithm for Peyronie’s Disease (PD) was updated in 2015 to exclude oral therapies. Non-surgical pharmacological management is now limited to intralesional therapy with Collagenase Clostridium Histolyticum (CCh), Interferon, or Verapamil. Surgical options include tunical plication, plaque incision/excision with or without grafting, and penile prosthesis surgery with or without adjunctive procedures. An understanding of trends in management of PD since the updated guidelines is limited. Objective Our objective is to assess treatment utilization and temporal trends in PD with the change in guidelines. Methods We conducted a retrospective review of men with PD using data in the IBM MarketScan insurance claims database. Patients were identified using ICD 9/10 codes and treatments were identified using J and CPT codes. Only patients aged ≥18 years with at least 1 year before and after a PD diagnosis were included in the analysis. Descriptive statistics were used to describe non-surgical and surgical treatment groups. Linear regressions were also performed to assess the trends of each year based on initial PD treatment. Results Between 2011-2019, we identified a total of 45,114 patients with a diagnosis of PD. Overall, while the majority (91.9%) chose conservative management with no intervention, 1,041 (2.3%) pursued intralesional therapy and 2,594 (5.8%) pursued surgical intervention as an initial treatment option. Among the patients who initially opted for intralesional therapy, 67 (6.4%) sought subsequent surgical treatment whereas 974 (93.6%) did not pursue additional treatment. In comparison, 116 (4.5%) patients who initially underwent surgical intervention sought subsequent treatment with the remaining 2,478 (95.5%) not pursuing additional treatment. Annual overall treatment rates increased from 7.2% to 8.1%. There was a statistically significant increase in the utilization of intralesional therapies from 0.3% in 2011 to 4.1% in 2019 (p=0). Surgical interventions significantly declined from 6.8% to 3.9% over the same time period (p=0.004). Conclusions The present study demonstrates that PD treatment trends have changed over time. With overall low secondary treatment rates for patients initially pursuing either non-surgical or surgical treatment options, a greater proportion of patients are initially pursuing less invasive, non-surgical treatment options with intralesional therapy over time. These findings emphasize the dynamic nature of treatment decisions and contribute to a deeper understanding of the treatment landscape that can be incorporated into patient counseling. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Paterna bio, Firmtech, Turtle health, Maximus, Carrot, Contraline, endo pharmaceuticals, inherent biosciences, techfields inc, macro trials, alto neurosciences, curebase, vivify medical.

Oesophageal cancer is the sixth most common cause of cancer-related mortality in the world. Currently surgery is the recommended treatment modality when possible. However, it is unclear whether non-surgical treatment options is equivalent to oesophagectomy in terms of survival. To assess the benefits and harms of non-surgical treatment versus oesophagectomy for people with oesophageal cancer. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Science Citation Index, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) up to 4th March 2016. We also screened reference lists of included studies. Two review authors independently screened all titles and abstracts of articles obtained from the literature searches and selected references for further assessment. For these selected references, we based trial inclusion on assessment of the full-text articles. Two review authors independently extracted study data. We calculated the risk ratio (RR) with 95% confidence interval (CI) for binary outcomes, the mean difference (MD) or the standardised mean difference (SMD) with 95% CI for continuous outcomes, and the hazard ratio (HR) for time-to-event outcomes. We performed meta-analyses where it was meaningful. Eight trials, which included 1132 participants in total, met the inclusion criteria of this Cochrane review. These trials were at high risk of bias trials. One trial (which included five participants) did not contribute any data to this Cochrane review, and we excluded 13 participants in the remaining trials after randomisation; this left a total of 1114 participants, 510 randomised to non-surgical treatment and 604 to surgical treatment for analysis. The non-surgical treatment was definitive chemoradiotherapy in five trials and definitive radiotherapy in three trials. All participants were suitable for major surgery. Most of the data were from trials that compared chemoradiotherapy with surgery. There was no difference in long-term mortality between chemoradiotherapy and surgery (HR 0.88, 95% CI 0.76 to 1.03; 602 participants; four studies; low quality evidence). The long-term mortality was higher in radiotherapy than surgery (HR 1.39, 95% CI 1.18 to 1.64; 512 participants; three studies; very low quality evidence). There was no difference in long-term recurrence between non-surgical treatment and surgery (HR 0.96, 95% CI 0.80 to 1.16; 349 participants; two studies; low quality evidence). The difference between non-surgical and surgical treatments was imprecise for short-term mortality (RR 0.39, 95% CI 0.11 to 1.35; 689 participants; five studies; very low quality evidence), the proportion of participants with serious adverse in three months (RR 0.61, 95% CI 0.25 to 1.47; 80 participants; one study; very low quality evidence), and proportion of people with local recurrence at maximal follow-up (RR 0.89, 95% CI 0.70 to 1.12; 449 participants; three studies; very low quality evidence). The health-related quality of life was higher in non-surgical treatment between four weeks and three months after treatment (Spitzer Quality of Life Index; MD 0.93, 95% CI 0.24 to 1.62; 165 participants; one study; very low quality evidence). The difference between non-surgical and surgical treatments was imprecise for medium-term health-related quality of life (three months to two years after treatment) (Spitzer Quality of Life Index; MD -0.95, 95% CI -2.10 to 0.20; 62 participants; one study; very low quality of evidence). The proportion of people with dysphagia at the last follow-up visit prior to death was higher with definitive chemoradiotherapy compared to surgical treatment (RR 1.48, 95% CI 1.01 to 2.19; 139 participants; one study; very low quality evidence). Based on low quality evidence, chemoradiotherapy appears to be at least equivalent to surgery in terms of short-term and long-term survival in people with oesophageal cancer (squamous cell carcinoma type) who are fit for surgery and are responsive to induction chemoradiotherapy. However, there is uncertainty in the comparison of definitive chemoradiotherapy versus surgery for oesophageal cancer (adenocarcinoma type) and we cannot rule out significant benefits or harms of definitive chemoradiotherapy versus surgery. Based on very low quality evidence, the proportion of people with dysphagia at the last follow-up visit prior to death was higher with definitive chemoradiotherapy compared to surgery. Based on very low quality evidence, radiotherapy results in less long-term survival than surgery in people with oesophageal cancer who are fit for surgery. However, there is a risk of bias and random errors in these results, although the risk of bias in the studies included in this systematic review is likely to be lower than in non-randomised studies.Further trials at low risk of bias are necessary. Such trials need to compare endoscopic treatment with surgical treatment in early stage oesophageal cancer (carcinoma in situ and Stage Ia), and definitive chemoradiotherapy with surgical treatments in other stages of oesophageal cancer, and should measure and report patient-oriented outcomes. Early identification of responders to chemoradiotherapy and better second-line treatment for non-responders will also increase the need and acceptability of trials that compare definitive chemoradiotherapy with surgery.

A solitary fibrous tumor (SFT) is a rare mesenchymal tumor with a high risk of local recurrence and a metastatic potential.1 Because of the rarity of the disease, the data regarding possible nonsurgical treatment options are limited. Until recently, most extensive reports regarding nonsurgical SFT treatment were based on case reports.2 Surgery remains the leading treatment option, and currently, the disease is being surgically managed similarly to soft-tissue sarcomas.3 Sadly, although a combination therapy has been already applied in clinical practice to soft-tissue sarcomas,4 additional therapies such as immunotherapy, have gained only minimal interest in SFTs. In the past few years, however, several new principles concerning the therapy of SFTs have evolved. We read with a great interest the recent study by Haas et al,5 who revealed the major potential of perioperative radiotherapy in the local control of the disease. The authors performed a retrospective analysis across 7 sarcoma centers by collecting data on 549 patients with SFTs who underwent either surgery alone or surgery together with peri/postoperative radiotherapy. To date, this is the largest study regarding the nonsurgical treatment of SFTs. The authors concluded that perioperative radiotherapy should be considered as a treatment option for this rare disease and thus broke the frequently cited claim of the inefficacy of radiotherapy for SFTs. Although the effectivity of standard cytotoxic chemotherapeutic regimens still remains questionable,6 an effort has been made through the past few years to discover different approaches in the treatment of SFTs. Some of these promising approaches, however, have not yet been tested in clinical trials. This is presumably due to the rarity of the disease. Only a small number of targeted therapies have been tested and further occasionally applied in clinical practice.3 The approved targeted therapies selectively target specific molecular pathways that may be involved in angiogenesis or tumorigenesis.3 So far, the most promising targeted therapy for malignant SFTs seems to be bevacizumab, a humanized recombinant antibody against vascular endothelial growth factor (VEGF), together with temozolomide, an alkylating chemotherapeutic. This therapy shows a partial response in 79% of patients.7 Pazopanib has been tested as an anti-VEGF receptor agent in the treatment of SFTs, however, it showed mild antitumor activity only in nondedifferentiated cases.8 On the other hand, sunitinib, a tyrosine kinase inhibitor, showed activity and long-lasting responses in the treatment of SFTs.9 Moreover, the pretreatment status of PDGFRB and/or VEGFR2, evaluated by immunostaining, was not predictive of a response. This suggests that sunitinib may be a promising treatment option for all patients with SFTs.9 Although different immunotherapeutic approaches, such as adoptive cell transfer, checkpoint inhibition, and chimeric antigen receptor T-cell therapy, have already been tested in soft-tissue sarcomas,4 only an anti–PD-L1 checkpoint inhibitor has been used in SFT therapy.10 A single case report by Boothe et al10 illustrates a major effect of anti–PD-L1 therapy in a patient with chemo-refractory and radiation-refractory SFT. The patient had a low PD-L1 expression status (5%) but presented a prompt and nearly complete response to an anti–PD-L1 antibody. The study itself reveals the large potential of checkpoint immunotherapy in SFT treatment. Although SFTs present rare diseases and may have a benign biological nature, local recurrence and metastatic behavior are also highly prevalent. Based on the limited data, we aim to highlight that similarly to soft-tissue sarcomas, radiotherapy, targeted therapy, and immunotherapy should become part of therapeutic algorithms in SFTs. Moreover, clinical testing of other immune checkpoint inhibitors is urgently needed, and only close interdisciplinary cooperation between surgical and nonsurgical institutions can introduce patients with SFTs to novel immunotherapeutic approaches, such as adoptive T-cell transfer and chimeric antigen receptor T-cell immunotherapy. No specific funding was disclosed. The authors made no disclosures.

Background:Palmar hyperhidrosis (PH), a condition characterized by excess sweating of the palms, is a common concern that presents to the plastic surgeon, which can have major impacts on patient confidence and quality of life. While several studies summarize treatment options for hyperhidrosis in general, few outline the therapeutic options available specifically for PH.Method:The authors reviewed the current literature specific to the diagnostic workup and treatment of PH.Results:In this article, we show a practical approach to managing patients presenting with PH, summarize its main nonsurgical and surgical treatment options, provide a suggested treatment ladder, and outline emerging therapeutic approaches. We suggest that, after diagnosing PH and classifying its severity, nonsurgical treatments (ie, topical antiperspirants, iontophoresis, botulinum toxin A injection, and topical/oral anticholinergics) should be utilized in a stepwise manner. In patients with severe palmar hyperhidrosis who do not respond to nonsurgical treatments, surgical intervention may be warranted, generally in the form of sympathetic denervation.Conclusion:This article provides a clear overview of PH treatment options, stepwise guidelines for physicians, and educational video resources demonstrating botulinum toxin A injections with cryotherapy and nerve blocks.

Background:Symptomatic femoroacetabular impingement (FAI) is currently corrected by surgery. However, it is possible that nonsurgical treatment could resolve symptomatic FAI in some patients; thus, uncertainty about the necessity of surgical treatment exists. The current equipoise concerning FAI treatment presents an opportunity to conduct a randomized controlled trial (RCT) of surgical and nonsurgical treatment options. Given the unique challenge of adequate patient enrollment in RCTs, it is important that a preliminary study is done to appraise the feasibility of conducting an RCT.Purpose:To estimate enrollment rates of a planned future RCT to compare surgical and nonsurgical treatments for symptomatic FAI and to identify factors associated with patients’ willingness to participate in the randomized trial.Study Design:Cross-sectional study; Level of evidence, 4.Methods:Patients diagnosed with FAI at 2 orthopaedic centers were presented with a hypothetical randomized trial comparing 2 treatment options for FAI. All patients completed forms providing information regarding their willingness to participate and treatment preferences.Results:A total of 75 patients participated in the study: 53 and 22 from 2 centers, respectively. Twenty-eight percent indicated absolute willingness to participate in the trial, 40% were probably willing or unsure, and 32% were definitely not willing; 18.7% had a strong preference for surgery while 2.7% strongly preferred nonsurgical treatment. The majority (78.6%) had no strong preference for either treatment arm. There were correlations between treatment preferences and willingness to participate. Patients with a strong treatment preference and/or a preference for surgery were less likely to be willing to participate.Conclusion:The study findings suggest that sufficient patient accrual for a randomized trial of FAI treatment is currently feasible while equipoise still exists among patients and surgeons.

Background:Extracranial compression of peripheral sensory nerves is one of many origins of chronic headaches. Identifying these patients can be difficult, and they are often diagnosed with neuralgia or cervicogenic headache. The recent literature provides the outcomes of surgical decompression in patients with these headaches. This study aimed to give an overview of the current literature on the nonsurgical treatment options and to evaluate the effectiveness of these treatments in patients with neuralgia and cervicogenic headache.Methods:Databases were searched to identify all published clinical studies investigating nonsurgical treatment outcomes in patients with neuralgia or cervicogenic headaches. Studies that reported numerical pain scores, nonnumerical pain scores, headache-free days, or the number of adverse events after nonsurgical treatment were included.Results:A total of 22 articles were included in qualitative analysis. The majority of studies included patients who received injection therapy. Treatment with oral analgesics achieved good results in only 2.5% of the patients. Better outcomes were reported in patients who received local anesthetics injection (79%) and corticosteroid injection (87%). Treatment with botulinum toxin injection yielded the highest percentage of good results (97%; 95% CI, 0.81–1.00). The duration of headache relief after injection therapy varied from 30 minutes to 5 months.Conclusions:The nonsurgical treatment of patients with neuralgia or cervicogenic headache is challenging. Injection therapy in patients with these types of headaches achieved good pain relief but only for a limited time. Surgical decompression may result in long-lasting pain relief and might be a more sustainable treatment option.

Nonsurgical Treatment of Nonmelanoma Skin Cancer

Concurrent Chemo-Proton Therapy Using 5-fluorouracil and Cisplatin for Esophageal Cancer

The efficacy of non-surgical and non-pharmacological treatment options in the management of adults with osteoarthritis of the foot and ankle. a systematic review

Chapter 7 - Nonsurgical treatment options: Laser, radiation and iontophoresis therapy for Peyronie’s disease

Treatment of Functional Popliteal Artery Entrapment Syndrome with Ultrasound-Guided Botox Injection

Proximal humerus fractures (PHF) are common in adults above 50years, often following low-energy trauma and underlying osteoporosis. Randomized trials in patients 60years and older have found no clinically important difference in 1- and 2-year outcomes between surgical and non-surgical treatments. There is limited evidence for the 50-65 age group, who may have different functional demands and even a different overall health status. There is limited knowledge to guide treatment decisions for this age group. A multicenter, parallel-group, randomized, superiority trial comparing osteosynthesis with non-surgical treatment in patients aged 50-65years with displaced PHF. A total of 60 patients will be randomized equally to surgical treatment (primary osteosynthesis) or non-surgical treatment. Follow-up visits are arranged at 6weeks and 6months for all patients, with an additional 12-week visit mandatory for the surgical group and optional for the non-surgical group. The primary outcome is the between-group difference in Oxford Shoulder Score at 12months. Sample size was calculated assuming a clinically relevant difference of 9.6 points on the OSS (SD 12), corresponding to 80% power at a 5% significance level. In case of treatment failure (persistent pain or a failed osteosynthesis), a salvage procedure will be offered. Patients not consenting to randomization will be asked to participate in a non-randomized cohort. They will have baseline data and preferences recorded, and they will receive the same follow-up and outcome assessments. Young shoulder CARE trial aims to provide insights into the treatment of displaced proximal humerus fractures in patients aged 50-65years, and to understand the benefits and harms of both surgical and non-surgical treatment options. The trial results will be published in an open-access peer-reviewed journal. Clinicaltrials.gov, NCT06416618, registered 14 May 2024.

Achilles tendon ruptures significantly impair long-term patient function, with two-thirds of patients experiencing persistent functional deficits. Although nonsurgical treatment has gained popularity due to its perceived lower risk of complications, the specific effects of this approach on tendon healing, muscle function, and overall performance remain poorly understood. Directly comparing surgical and nonsurgical treatment options in a clinical population is challenging given the diverse nature of the patient population. Preclinical models are essential to isolate the mechanisms underlying these treatments, enabling a detailed examination of the structural and functional outcomes that are difficult to assess in human studies. Here, we surgically induced Achilles tendon ruptures in 20 adult male Sprague Dawley rats and repaired the rupture in half of these animals. Then, functional outcomes were assessed by measuring plantar flexor torque across the ankle's range of motion using a custom-developed small animal dynamometer, and structural changes were evaluated through measurements of Achilles tendon elongation and plantar flexor muscle mass. We found that surgical treatment led to 11%-35% increased functional plantar flexor torque outcomes compared to nonsurgical treatment. Additionally, plantar flexor muscle mass decreased by 21% in nonsurgically treated animals compared to only 12% in the surgically treated group. Our results suggest that surgically repairing a tendon rupture restores plantar flexor function more effectively than nonsurgical treatment; however, persistent functional deficits in both groups indicate that enhanced rehabilitation strategies are necessary for full functional restoration.

Pediatric strabismus is a progressive condition that, in the early stages, presents as either esotropia or intermittent or constant exotropia when both eyes focus on the same target. If not promptly addressed, the child’s ocular accommodative convergence and fusion abilities will gradually weaken, ultimately affecting visual function and causing various inconveniences in daily life and learning. For children with mild strabismus, those who are young, have poor cooperation, or are awaiting surgery for a long time, non-surgical treatment is a good option. It offers high safety, ease of use, and has certain effects in alleviating strabismus symptoms and improving visual function. However, there are multiple non-surgical treatment options, and currently, clinical practice lacks clear consensus on which approach is best. The choice and implementation of treatment methods still need to be determined based on the specific situation, such as the child’s age and type of strabismus. In recent years, with the deepening of ophthalmological research, non-surgical treatment methods have been enriched, including a combination of visual training, occlusion therapy, and corrective glasses, which have shown certain clinical effects. This article will review the non-surgical treatment options for pediatric strabismus, explore current research progress, and discuss future development directions.