Organ-preserving Surgery Research Articles

Transoral robotic surgery: does the ends justify the means?

Head and neck surgical science has developed dramatically during the past 20 years with a major focus on organ preservation surgery. Among these organ preserving surgeries are the selective neck dissections, supracricoid partial laryngectomies, transoral laser surgeries, and now a newcomer, transoral robotic surgery utilizing the da Vinci surgical system. Transoral robotic surgery is in its infancy, but, indeed, there have been some questions raised about the role of these innovative robotic surgical techniques. This article will review, point by point, the questions that have been raised concerning the feasibility; safety and efficacy; teachability; and cost effectiveness of transoral robotic surgery. Although the present literature reports early findings, without long-term oncologic outcomes, the results are consistently encouraging. Training programs have already yielded successes. Indeed, multiple institutions have shown that transoral robotic surgery programs can be successfully established yielding excellent clinical outcomes. In addition, early studies of swallowing function following transoral robotic surgery show swallowing outcomes that are superior to some of the reported chemoradiation results for equivalent lesions.

Radiotherapy after Partial Laryngectomy: An Analysis of 36 Cases and a Proposal to Optimize Radiotherapy

Laryngeal cancer treatment options include radical surgery, "organ preservation surgery", radiotherapy and chemotherapy. There is no proven evidence of a significant increase in late toxicity with adjuvant radiotherapy after conservative surgery. The aim of this retrospective study was to evaluate the toxicity, local-regional control and overall survival of adjuvant radiotherapy after conservative surgery. A total of 36 patients was treated with radiotherapy after partial laryngectomy at the Radiotherapy Department of the Institute for Cancer Treatment and Research (IRCC) of Candiolo and of the Mauriziano Hospital in Turin, between 1994 and 2007. The postoperative treatment doses ranged from 45 to 70.2 Gy with conventional fractionation. The Kaplan-Meier method was applied for statistical analysis. The RTOG-EORTC scale was used to evaluate late and acute toxicity. Overall 5- and 10-year survival was 93% and 47%, respectively. Local control was 93.5% at 5 and was unchanged at 10 years. Grade 2 acute cutaneous and mucous toxicity was 41% and 62%, and grade 3, 6.9% and 3.5%, respectively. Only one patient required percutaneous endoscopic gastrostomy due to severe dysphagia and one patient required temporary tracheostomy for severe acute laryngeal edema (grade 3). Two patients experienced late toxicity greater than grade 3. The median dose to the residual larynx was 59.5 Gy (range, 45-70.2), and the median dose to the neck was 50.4 Gy (range, 39.6 -55.8). The results of our study showed a dose-dependent increase in the late toxicity trend at doses over and above 60 Gy, which is higher than the cutoff dose reported in the literature. There was no indication from our data that adjuvant postoperative radiotherapy means additional toxicity. The use of highly conformal techniques can further reduce toxicity of the radiotherapy.

Important Aspects of Organ-Preserving Surgery for Renal Tumors

Organ-preserving surgery for renal tumors has become more common over the past two decades. At first, part of the kidney, rather than all of it, was resected only if there was an absolute indication for doing so, i.e., if the tumor was located in an anatomically or functionally solitary kidney or if renal failure was already present. Now that favorable oncological outcomes have been demonstrated, renal tumors are increasingly often removed with only partial resection of renal tissue even when the indications are less stringent, including when the other kidney is healthy. The indications for, and oncological outcomes of, partial renal resection are presented and discussed on the basis of a selective literature search of Medline as well as the guidelines of the European Association of Urologists (EAU). The EAU, in its new guidelines for renal cell carcinoma, recommends partial renal resection as the standard treatment for tumors less than 4 cm in size that are wholly contained within one kidney when the other kidney is healthy. This practice yields comparable outcomes to those of nephrectomy, with tumor-specific five-year survival rates exceeding 90%. In major urological centers, partial resection is favored even for tumors larger than 4 cm, as long as they are in a favorable location. Nonetheless, the estimated rate of nephrectomy for tumors less than 4 cm in size currently remains very high in Germany, as it does in American studies, even though the organ-preserving resection of such small tumors usually results in cure.

Surgical treatment of intractable postpartum hemorrhage and changing trends in modern obstetric perspective

To update the prevalence and risk factors of intractable postpartum hemorrhage (IPH) and evaluate the effectiveness of surgical treatment modalities. Between January 2002 and January 2008, IPH diagnosis was made in 86 cases. They were evaluated retrospectively. Placental implantation abnormalities were the leading cause, responsible for 45.6% of cases. Organ preserving surgery (OPS) methods were utilized in 47 cases, with a success rate of 76.6%. Among these cases, 11 were proceeded to hysterectomy. Hysterectomy was performed in 45 cases as definitive treatment. Compression sutures were quite effective in controlling hemorrhage due to placenta accreta and previa. For women who are hemodynamically stable and desirous for future fertility, OPS modalities should be applied first. Shorter operating time, hospital stay and less blood transfusion were seen with subtotal type hysterectomy, so in case of nonbleeding lower uterine segment, subtotal type should be performed first.

Horizontal partial laryngectomy in mucoepidermoid carcinoma of the larynx after failure of laser surgery followed by radiotherapy: a case report

IntroductionTumors of the minor salivary glands in the larynx are rare and represent <1%. They usually appear between the 4th and 7th decades of life. The most common site of occurrence is the supraglottis; however, these neoplasms can appear at any location in the larynx. Pulmonary metastases are the most frequent site for distant disease.Case presentationWe present the case of a 34-year-old Hispanic male with a history of cigarette smoking. He was admitted to our Institution in 2002 with a 1-year evolution of odynophagia, initially to solids and then to liquids. The patient was referred to our Institution for an undifferentiated carcinoma of the epiglottis treated one week earlier with laser surgery and positive surgical margins. Upon admittance, the patient did not demonstrate any tumor activity. A review of the slides confirmed undifferentiated carcinoma. Chemo-radiotherapy was proposed to the patient, but he accepted only radiotherapy and received a total dose of 70 Gy. The patient was followed-up every 3 months. Two years later, follow-up nasofibrolaryngoscopy demonstrated clear evidence of tumor activity at the site of the primary tumor (supraglottis). No cervical adenopathies were found either clinically or radiologically. Biopsy of the lesion was inconclusive; hence, the patient was scheduled for a suspension microlaryngoscopy with transoperative study, performing afterwards a supraglottic horizontal laryngectomy. Histological diagnosis reported ulcerated, high-grade supraglottic mucoepidermoid carcinoma with lymphatic permeation and invasion to the striate muscle and adipose tissue. The borders and surgical bed were free of neoplasm. The patient evolved satisfactorily. At 4 years following treatment, the patient is disease free.ConclusionRecurrence must be considered when planning treatment, and organ preservation surgery is justified, especially in young patients.

Ovarian Reconstitution Following Laparoscopic Decapsulation of Congenital Cyst

Laparoscopic management of congenital ovarian cysts is widely practiced but there is a dearth of information on the performance of the gonad where organ-preserving surgery is undertaken. Presented is a radiological diary documenting the progress of a complex congenital ovarian cyst from the antenatal period to a year post-laparoscopic decapsulation.

POD-2.06: Organ-Preserving Surgery for Penile Cancer

POD-2.06: Organ-Preserving Surgery for Penile Cancer

Therapiemöglichkeiten beim Uterus myomatosus - Neue Aspekte 2008

Due to the high incidence of uterine leiomyomas, various aspects involved in the treatment of the condition are extremely important. Many treatment methods are already long established, but there are important new findings that are of relevance for everyday practice - particularly with regard to myoma embolization, various hysterectomy procedures, and the issue of myoma enucleation in patients wishing to have children. Prospective and randomized studies have shown that 1 year after hysterectomy, patients have fewer symptoms compared to women who undergo myoma embolization, and that after 2 years there are no differences between the two methods. Two years after embolization, 20 - 25 % of the women having received this form of treatment had also undergone a hysterectomy. After myoma embolization, fertility was found to be reduced compared to a control group undergoing organ-preserving surgery, and the rate of miscarriages was markedly increased. It has been shown in randomized studies that supracervical hysterectomy offers no advantages over total hysterectomy with regard to sexuality, incontinence, or bowel function. Laparoscopic hysterectomy techniques are associated with an increased risk of injury to the urinary tract, but reduce the postoperative morbidity for patients.

Operative Techniques and Indications for Organ Preserving Surgery in Kidney Tumors

Operative Techniques and Indications for Organ Preserving Surgery in Kidney Tumors

Organ-preservation surgery following failed radiotherapy for laryngeal cancer. Evaluation, patient selection, functional outcome and survival

Although radiotherapy is a well codified treatment for laryngeal carcinomas, the management of local recurrence after failed radiotherapy remains controversial. Total laryngectomy is the classical salvage surgical approach. Recent evidence showed that selected laryngeal recurrences may be successfully treated with partial laryngectomies with comparable survival rates, acceptable morbidity, tracheostomy closure, effective swallowing, and satisfactory voice intelligibility. Recurrent laryngeal carcinoma after radiotherapy failure requires a comprehensive clinical, radiological and pathological restaging. Strict selection criteria are mandatory for the identification of radiotherapy failure cases amenable to conservative laryngeal surgery. Although larger series confirmation is necessary, conservative salvage surgery seems definitely promising. Salvage endolaryngeal laser surgery after irradiation failure allows in selected cases a mean local control rate of 65%. Selectively, supracricoid laryngectomy can be a flexible alternative to salvage total laryngectomy being conservative of laryngeal functions (mean local control rate of 85%). Selected laryngeal recurrences can be correctly treated also with vertical or horizontal supraglottic laryngectomies. In partial laryngectomies, intraoperative frozen sections are mandatory: postoperatively permanent sections have to confirm all margins. When proper selection criteria for conservative salvage laryngeal surgery are used, laryngeal function can be preserved with oncological efficacy also after radiotherapy failure.

Swing of the pendulum: Optimizing functional outcomes in larynx cancer

For years, total laryngectomy was the only treatment option for patients with intermediate to advanced laryngeal cancer. Over the past two decades, great progress has been made in the management of this disease, with multimodality approaches aimed at laryngeal preservation reshaping the treatment landscape. In the era of chemoradiation, greater focus and attention are now directed toward functional laryngeal preservation--not simply "organ preservation." The continued development and integration of new treatment approaches, including organ preservation surgery (eg, transoral minimally invasive surgery of the head and neck, supracricoid partial laryngectomy), intensity-modulated radiotherapy, and targeted molecular therapies, offer the potential to improve clinical outcomes, function, and quality of life. Incorporation of these new approaches advances the concept of personalized medicine, with treatment strategies tailored to the circumstances and future of each patient.

Organ Preservation Surgery for Advanced Unilateral Glottic and Subglottic Cancer

Organ Preservation Surgery for Advanced Unilateral Glottic and Subglottic Cancer

Organ-Preserving Surgery for Penile Carcinoma

Introduction. Penile carcinoma has traditionally been treated by either surgical amputation or radical radiotherapy, both associated with devastating anatomical, functional, and psychological impact on the patient's life. Innovative surgical techniques have focused on penile preservation in well-selected patients to minimize physical disfigurement and consequently maximize quality of life. The objective of this article is to define the current status of these organ-preserving surgical options for penile carcinoma. Materials and Methods. An extensive review of the Pubmed literature was performed to find articles discussing only reconstructive surgery which have contributed significantly to change traditional, frequently mutilating treatments, to develop less disfiguring surgery, and to improve patients' quality of life over the last two decades. Results. Several articles were included in this analysis in which a major contribution to the change in therapy was thought to have occurred and was documented as beneficial. Some articles reported novel techniques of less-mutilating surgery involving different forms of glans reconstruction with the use of flaps or grafts. The issue of safe surgical margins was also addressed. Conclusion. The development of less-disfiguring techniques allowing phallus preservation has reduced the negative impact on functional and cosmetic outcomes of amputation without sacrificing oncological objectives in appropriately selected patients based on stage, grade, and location of the tumour. Until more prospective studies are available and solid evidence is documented, organ preservation should be offered with caution.

Laparoscopic Internal Marsupializaton for Large Nonparasitic Splenic Cysts: Effective Organ‐Preserving Technique

Primary splenic cyst is a rare disease, and therefore there is no information regarding its optimal management. Most such cysts are classified as epithelial cysts. During the last few years, the laparoscopic approach has gained increasing acceptance in splenic surgery. We present our experience with the laparoscopic (organ-preserving) management of splenic cysts. We managed 11 patients with large symptomatic nonparasitic splenic cysts from 1996 to 2006. All the patients had fullness in the left upper abdomen and a palpable mass. Preoperative diagnosis was established with ultrasonography and computed tomography. All patients were treated with either laparoscopic partial cystectomy or marsupialization. Seven patients had mesothelial cysts, two had epidermoid cysts, and two had pseudocysts. Nine patients did not have any problems or recurrence during an average follow-up of 29.5 months. Two patients had cyst recurrence after 14 months. Laparoscopic organ-preserving surgery should be the goal of therapy in most cases. Total splenectomy is reserved for cases in which cyst excision cannot be done or most of the splenic tissue is replaced by the cyst. Plication of the cyst wall edges prevents the cyst walls from adhering and causing recurrence, as well as helping to control hemorrhage. Laparoscopic partial cystectomy/marsupialization is an acceptable procedure for the treatment of splenic cysts; and after short to mid-term follow-up, it seems that a reasonable rate of success is possible.

Organ Preservation Surgery for Advanced Unilateral Glottic and Subglottic Cancer

Functional surgery of unilateral T(2b) to T3 glottic cancer and cricoid chondrosarcoma is possible using the technique of tracheal autotransplantation. The objective of this paper is to report the functional and oncologic outcome of 24 consecutive patients treated with this technique between 2001 and 2007. Seventeen patients, of whom nine were previously irradiated, had unilateral glottic cancer with impaired mobility of the vocal fold. Clinical staging was T(2b) to (3)N(0). Seven patients had a chondrosarcoma of the cricoid cartilage. In a first operation, an extended hemilaryngectomy was performed, and a radial forearm flap, comprising a distal fascial and a proximal skin component, was transferred to the neck. The fascial paddle was wrapped around the upper 4-cm segment of cervical trachea, and the skin paddle was used for temporary closure of the extended hemilaryngectomy defect. The definitive reconstruction was performed after 2 to 3 months and consisted of removal of the skin paddle from the laryngeal defect and a transplantation of a patch of revascularized cervical trachea to reconstruct the laryngeal defect. Swallowing and speech were restored after the first operation. The glottic and subglottic airway lumen was restored during the second operation. The tracheostomy could be closed in 20 patients. After a median follow-up period of 33 (range, 1-66) months or almost 3 years, 23 patients remained free of tumor recurrence. Tracheal autotransplantation can be recommended as a functional treatment for selected T(2b) to T(3) glottic cancers and for unilateral chondrosarcomas of the cricoid cartilage. The technique is oncologically robust while resulting in good postoperative function.

Supracricoid laryngectomy with cricohyoidoepiglotto-pexy or cricohyoido-pexy: Experience on 32 patients

Objective Supracricoid laryngectomy (SCL) with Cricohyoidoepiglotto-pexy (CHEP) or Cricohyoido-pexy (CHP) is an organ preservation surgery indicated for early and selected advanced laryngeal cancers. To verify the clinical usefulness of supracricoid laryngectomy versus total laryngectomy, a retrospective review was conducted. Methods We summarized the clinical and postoperative data of 32 patients who received SCL over the past 9 years (1997–2005). Five-year survival rate of the SCL patient group (29 cases) was compared with that of the patient group receiving total laryngectomy (35 cases) within the same period. Results Wound infection was detected in 12 patients (38%). Those with severe infection, which required surgical intervention, included two cases of ruptured pexis and two cases showing cricoid cartilage necrosis induced by Forestier disease. There were two T4 cases that resulted in extensive excision. In one case, excision involved the posterior part of the cricoid cartilage resulting in insufficient closure of the neoglottis; the patient received total laryngectomy 30 months after SCL–CHEP because of persistent aspiration of liquid diet. In the other T4 case, the tumor invaded the thyroid and arytenoid cartilages but not the cricoid cartilage. Reposition of the remaining corniculate cartilage resulted in sufficient closure of the neoglottis; this patient subsequently acquired satisfactory laryngeal function. The 5-year overall survival rate was 86% for SCL group and 61% for the total laryngectomy group (limited to Stages III and IV glottic cancers). The causes of the four deaths were distant metastasis, neck metastasis, and intercurrent disease, respectively. Two patients are alive with distant disease. Conclusion Through our experience in this series, the functional and oncological results of SCL showed certain advantages over those of total laryngectomy. Particularly, the clinical impact of SCL–CHEP was impressive; this technique needs is recommended to both head and neck surgeons and patients.

Aktueller Stellenwert der offenen Larynxteilresektion unter besonderer Berücksichtigung der suprakrikoidalen Teilresektionen

Open partial laryngectomies include a broad variety of vertical or horizontal partial or supracricoid laryngectomies. Especially in Germany the excellent results of the transoral approach in combination with the CO2 laser surgery radically have diminished the indications of the open surgical techniques for laryngeal cancer staged cT1-2. In patients with laryngeal cancer staged cT3 the role of open organ-preservation surgery remains to be defined in the context of extended treatment options for endolaryngeal CO2 laser surgery and conservative larynx-preservation approaches with concurrent chemoradiation or induction chemotherapy followed by radiation therapy. With regard to the reviewed literature this manuscript will discuss current indications and future roles of open partial laryngectomies with special emphasis given to the supracricoid laryngectomies.

Partial nephrectomy and autotransplantation with pyelovesicostomy for renal urothelial carcinoma in solitary kidneys: a clinical update

To evaluate the indications and outcomes after partial nephrectomy and renal autotransplantation for urothelial cancer in solitary kidneys, with special attention to the ease of endoscopic tumour control after pyelovesicostomy. In all, 978 records of three institutions were reviewed for patients undergoing partial nephrectomy between January 1990 and December 2000. Ex vivo organ-preserving surgery was used in selected patients with a solitary kidney and localized pelvic or calyceal tumour. Autotransplantation was established using a pyelovesicostomy. The follow-up included ultrasonography, pelvi-cystoscopy, urine cytology, computed tomography, renal functional evaluation and video-urodynamics. The study included four patients aged 52-56 years, with a follow-up of 6-14 years. The histopathological status was pT1G2R0 in two and pT1G1R0 in the other two patients. One of them had an additional papilloma in the upper ureter. All patients entered a protocol of mitomycin/bacille Calmette-Guérin instillation therapy after surgery. The patients are currently alive with no recurrences. There is stable kidney function despite vesico-renal reflux, and normal bladder function with no subvesical obstruction. Partial nephrectomy and renal autotransplantation for renal urothelial cancer in solitary kidneys is feasible, but should only be used in the rarest cases, and for the most selective indications. Dialysis and renal replacement can be avoided. Pyelovesicostomy allows effective chemotherapy instillation therapy, and easy and secure urothelial cancer control of the upper urinary tract.

Preoperative Embolization of a Tumor-Bearing Horseshoe Kidney Via Both Channels of a Concomitant Aortic Dissection

Renal cell carcinoma arising in a horseshoe kidney is a rare entity. Preoperative tumor embolization can be performed to prevent massive bleeding complications during organ-preserving surgery. We report the first case of a patient with a tumor-bearing horseshoe-kidney in whom the preoperative embolization, already complex because of the abnormal vascular supply, was additionally complicated by an aortic dissection. An aberrant, horseshoe-kidney-supplying artery originated from the false dissection channel of the aorta, and thus had to be catheterized separately while the other tumor-supplying vessels could be reached via the true aortic lumen. After devascularization of the tumor, organ-preserving surgery was performed without bleeding complications.

Resección conservadora de la región duodenopancreática en el tratamiento del tumor papilar mucinoso intraductal

The standard surgical procedure for intraductal papillary mucinous neoplasms of the main duct (IPMN-M) or side branch ducts (IPMN-Br) is pancreaticoduodenectomy. IPMN-BR is a more indolent disease with a lower incidence of malignancy. To evaluate the usefulness of organ-preserving pancreatic resections (OPPR) including duodenum-preserving pancreatic head resection (DPHR) and pancreatic head resection with segmental duodenectomy (PHRSD) in patients with IPMN-BR. Surgical outcomes were evaluated in eight IPMN-Br patients: DPHR was performed in 4 patients and PHRSD was performed in 4 patients. In addition, 13 IPMN patients with Whipple resections were included in the analysis. The incidence of postoperative complications was 38% after Whipple resection, 100% after DPHR and 25% after PHRSD. The mean length of hospital stay was 27 days after DPHR, 22 days after Whipple resection and 16 days after PHRSD. Invasive IPMN was found in 38% of the patients in the Whipple group, and noninvasive IPMN was found in 100% of patients who underwent organ-preserving surgery. Pancreaticoduodenectomy remains the treatment of choice in patients with invasive IPMN. PHRSD appears to be a useful procedure for IPMN-Br located in the head of the pancreas.