En bloc resection Dotaz Zobrazit nápovědu
Cieľ: Vazoproliferatívny tumor sietnice patrí medzi benígne vaskulárne tumory, ktoré v pokročilom štádiu vedú k exsudatívnemu odlúpeniu sietnice s tvorbou epiretinálnych a subretinálnych membrán. V takto pokročilých štádiách je jednou z terapeutických možností pars plana vitrektómia. V článku prezentujeme prípad pacienta, u ktorého sme vykonali 23G pars plana fakovitrektómiu s en bloc resekciou tumoru s následným histologickým potvrdením. Kazuistika: 70 ročný pacient s ročnou anamnézou jednostranného poklesu zraku na ľavom oku bol prijatý vo februári 2018 na Očnú kliniku Fakultnej nemocnice v Nitre za účelom vyšetrenia. Pri príjme bola najlepšie korigovaná centrálna zraková ostrosť na pravom oku 1,0 a na ľavom oku bol sporný svetlocit. Na základe klinického obrazu, sonografického vyšetrenia oka a fluoresceínovej angiografii sme stav uzatvorili ako vazoproliferatívny tumor sietnice. Vzhľadom k pokročilosti nálezu sme pristúpili k chirurgickej intervencii. Vykonali sme 23G fakovitrektómiu s en bloc resekciou tumoru. Následné histologické vyšetrenie potvrdilo prítomnosť predpokladaného tumoru. Aj niekoľko mesiacov po operácii bola sietnica kompletne priložená pod silikónovým olejom, bez exsudatívneho nadvihnutia, avšak najlepšie korigovaná centrálna zraková ostrosť sa zlepšila len mierne na úroveň počítania prstov na 1 meter. Záver: Pars plana vitrektómia s en bloc resekciou je jednou z terapeutických modalít liečby pokročilých štádií vazoproliferatívneho tumoru sietnice.
Purpose: Retinal vasoproliferative tumor is one of the benign vascular tumors which in advanced stages leads to exudative retinal detachment with the formation of epiretinal and subretinal membranes. In such advanced stages, one of the therapeutic options is pars plana vitrectomy. This article presents the case of a patient on whom was performed 23-gauge pars plana phacovitrectomy with en bloc resection of the tumor followed by histological confirmation. Case report: A 70-year-old patient with a one-year history of unilateral loss of vision in his left eye was admitted to our clinic for examination in February 2018. At admission, the best corrected visual acuity in the right eye was 1.0, and in the left eye was light perception. Based on the clinical picture, sonographic examination of the eye, and fluorescein angiography, the patient was diagnosed with a retinal vasoproliferative tumor. Due to the advanced stage of disease, we proceeded with surgical intervention. We performed 23-gauge phacovitrectomy with a bloc resection of the tumor. Subsequent histological examination confirmed the presence of the presumed tumor. The follow-up exam a few months later showed a completely attached retina with silicone oil tamponade, without exudative retinopathy. However, the best corrected visual acuity improved only slightly to the ability to count fingers at one meter. Conclusion: Pars plana vitrectomy with en bloc resection of retinal vasoproliferative tumor is one of the therapeutic modalities in advanced stages.
- MeSH
- lidé MeSH
- nádory sítnice * chirurgie MeSH
- odchlípení sítnice etiologie MeSH
- senioři MeSH
- vitrektomie MeSH
- výsledek terapie MeSH
- Check Tag
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- Publikační typ
- kazuistiky MeSH
PURPOSE OF THE STUDY: Radical resection of a vertebra is reserved only for specific tumors that invade the surrounding tissues and recur when not removed completely. The vertebra may be removed using a piecemeal technique or en bloc, using only two (in thoracolumbar spine) or more osteotomies (in cervical spine). We present our technique of en bloc resection of subaxial cervical vertebra for Ewing's sarcoma of C3, with preservation of all nerve roots and both vertebral arteries. To our knowledge, this surgical technique has not been reported in the English literature. The aim of this study is to describe the new technique of radical resection of subaxial cervical vertebra. MATERIAL AND METHODS: A transoral biopsy of tumor tissue anterior to C2-C3 was performed in 8-year old boy, revealing a diagnosis of Ewing's sarcoma. The patient was started on neoadjuvant chemotherapy. After 6 chemotherapy cycles with the VIDE regimen, the soft-tissue component completely regressed, with the only a residual deposit in C3 vertebral body. Based on further multidisciplinary meeting, an en bloc spondylectomy of C3 was recommended, preferably with preservation of nerve roots and vertebral arteries. In August 2014, prior to the planned surgery, we performed another thorough examination of the patient using plain films, CT and MRI. Neither angiography nor embolization was performed. DESCRIPTION OF SURGICAL TECHNIQUE: The first stage of the operation consisted of resection of the posterior structures. We exposed the posterior elements of C2 to C4 by the mid-line incision. The C3 arch was without pathological changes. After partial resection of the C2 inferior and C4 superior articular processes we performed bilateral osteotomy in the region of the pedicle adjacent to the arch with a chisel and removed the whole of the C3 posterior arch. Subsequently we perforated the transverse foramina close to the pedicle, using fine Kerrison rongeurs. The lateral parts around vertebral arteries were left in situ. In the next step we used instrumentation with polyaxial screws to stabilize the C2-C4 section. After 19 days we performed the second stage surgery from an anterior approach with the removal of the anterior and lateral parts of the vertebra. We made a transverse incision anterior to the sternocleidomastoid between the internal carotid artery and the trachea on the right side at the level of C3 to expose the spine. We resected C2-C3 and C3-C4 intervertebral discs and then performed osteotomy with fine Kerrison rongeurs on both sides, again, close to the vertebral body. Subsequently, the vertebral body was released and extracted en bloc. In the next step, both vertebral arteries were mobilized and shifted medially and the lateral portions of the transverse processes were released and removed en bloc. The empty space was filled with solid allograft and the C2-C4 levels were bridged by the cervical plate in 2+1+2 configuration. RESULTS: There were no complications during both surgeries. The follow-up CT examination 4 months after the operation revealed a clear bone fusion of C2-C4, both anteriorly between vertebral bodies and posteriorly between the arches. Clinically the patient has reached 8 month follow up and had no complaints, both he and his parents were satisfied. Physiotherapy is proceeding according to plan. The patient remains under supervision at our centre. DISCUSSION: Total en bloc resection of a subaxial cervical vertebra with preservation of neural and vascular structures has been described in the English literature only once. In 2007 was published a total en bloc resection of C5 for chordoma, preserving the above mentioned structures. Authors removed the lamina en bloc after bilateral osteotomy. Transverse foramina were perforated by the Gigli saw and removed in piecemeal fashion, including the posterior tubercle. In the next step, they removed the vertebral body and the anterior tubercle from the anterior approach. However, their treatment differs from the technique described here and does not correspond fully to the principle of en bloc resection. Our surgical technique is based on a similar principle of performing several osteotomies without the use of high speed burr, while preserving all neural and vascular structures. The difference can be particularly seen in the approach to remove lateral parts of the transverse foramen, which are surrounding the vertebral arteries. We consider it as ideal to split the cervical vertebra by smooth cuts into four parts and remove them en bloc. CONCLUSION: Total en bloc spondylectomy of a subaxial cervical vertebra with preservation of vertebral arteries and nerve roots is a radical surgery that should be used to treat only the most serious conditions. The risk of neurological deficit is outweighed by the benefits of oncological radicality. This new surgical technique has not yet been described and it is clear, that a larger cohort of patients is necessary to assess and potentially modify this technique so that it can be used more frequently in the future.
- MeSH
- artrodéza metody MeSH
- axis chirurgie MeSH
- bederní obratle chirurgie MeSH
- biopsie MeSH
- dítě MeSH
- Ewingův sarkom patologie chirurgie MeSH
- krční obratle chirurgie MeSH
- lidé MeSH
- magnetická rezonanční tomografie metody MeSH
- nádory páteře patologie chirurgie MeSH
- následné studie MeSH
- osteotomie metody MeSH
- pooperační péče MeSH
- zákroky plastické chirurgie MeSH
- Check Tag
- dítě MeSH
- lidé MeSH
- mužské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- kazuistiky MeSH
OBJECTIVES: To assess the clinical significance of repeat transurethral resection (reTUR) and surgical margin status after en bloc resection of bladder tumour (ERBT) for pathological T1 (pT1) bladder cancer. PATIENTS AND METHODS: We retrospectively analysed the record of 106 patients with pT1 high-grade bladder cancer who underwent ERBT between April 2013 and February 2021 at multiple institutions. All specimens were reviewed by a genitourinary pathologist. The primary outcome measures were recurrence-free survival (RFS) and progression-free survival (PFS) between patients with and those without reTUR. We also analysed the predictive value of surgical margin on the likelihood of residual tumour on reTUR. RESULTS: A reTUR was performed in 50 of the 106 patients. The 2-year RFS and 3-year PFS were comparable between patients who underwent reTUR and those who did not (55.1% vs 59.9%, P = 0.6, 80.6% vs 82.6%, P = 0.6, respectively). No patient was upstaged to pT2 on reTUR. Regarding the surgical margin status, there were no recurrences at the original site in 51 patients with negative horizontal margins. Cox proportional hazard analysis revealed that a positive vertical margin was an independent prognostic factor of worse PFS. On reTUR, six pTa/is residues were detected in patients with a positive horizontal margin, and three pT1 residues were detected in one patient with a positive vertical margin or other adverse pathological features. CONCLUSIONS: A reTUR after ERBT for pT1 bladder cancer appears not to improve either recurrence or progression. Surgical margin status affects prognosis and reTUR outcomes. A reTUR can be omitted after ERBT in patients with pT1 bladder cancer and negative margins; for those with positive horizontal or vertical margins, reTUR should remain the standard until proven otherwise.
PURPOSE OF REVIEW: To discuss the most recent surgical lasers that have been made available to us and to evaluate their potential in performing en bloc resection of nonmuscle invasive bladder cancer. RECENT FINDINGS: Laser en bloc resection of bladder tumors (ERBT) can be performed with a number of laser systems including Ho:YAG, GreenLight, diode, Tm:YAG and thulium fiber lasers (TFL). The data that is currently available suggests that the water-targeting devices (utilizing water as a primary chromophore - Ho:YAG, Tm:YAG, TFL) may have a number of advantages over hemoglobin-targeting systems (potassium titanyl phosphate:YAG, lithium triborate:YAG). One recent addition to the surgical armamentarium Moses effect enhanced Ho:YAG and the TFL (being able to work both in quasi-continuous and SuperPulsed modes) necessitates careful discussion and comparison with the other available devices. SUMMARY: The majority of available lasers have proven to be safe to use and compared to electrocautery allow for lower rates of obturator nerve reflex and result in fewer bleeding complications. The minimal penetration depth and decreased peak power of Tm:YAG and TFLs render them the devices of choice when it comes to ERBT. Unfortunately, more studies on ERBT with TFL are needed in order for us to make a sound assessment of the respective pros and cons.
PURPOSE: En bloc resection of bladder tumors (ERBT) may improve staging quality and perioperative morbidity and influence tumor recurrence. This study was designed to evaluate the safety, efficacy, and recurrence rates of electrical versus laser en bloc resection of bladder tumors. METHODS: This European multicenter study included 221 patients at six academic hospitals. Transurethral ERBT was performed with monopolar/bipolar current or holmium/thulium laser energy. Staging quality measured by detrusor muscle involvement, various perioperative parameters, and 12-month follow-up data was analyzed. RESULTS: Electrical and laser ERBT were used to treat 156 and 65 patients, respectively. Median tumor size was 2.1 cm; largest tumor was 5 cm. Detrusor muscle was present in 97.3 %. A switch to conventional TURBT was significantly more frequent in the electrical ERBT group (26.3 vs. 1.5 %, p < 0.001). Median operation duration (25 min), postoperative irrigation (1 day), catheterization time (2 days), and hospitalization (3 days) were similar. Overall complication rate was low (Clavien ≥ 3, n = 6 [2.7 %]). Hemoglobin was significantly lower after electrical ERBT (p = 0.0013); however, overall hemoglobin loss was not clinically relevant (0.38 g/dl). Patients (n = 148) were followed for 12 months; 33 (22.3 %) had recurrences. In total, 63.6 % recurrences occurred outside the ERBT resection field. No difference was noted between ERBT groups. CONCLUSIONS: ERBT is safe and reliable regardless of the energy source and provides high-quality resections of tumors >1 cm. Recurrence rates did not differ between groups, and the majority of recurrences occurred outside the ERBT resection field.
- MeSH
- cystektomie * MeSH
- karcinom patologie chirurgie MeSH
- kohortové studie MeSH
- laserová terapie * MeSH
- lasery pevnolátkové terapeutické užití MeSH
- lidé středního věku MeSH
- lidé MeSH
- nádory močového měchýře patologie chirurgie MeSH
- senioři MeSH
- urotel * MeSH
- výsledek terapie MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- multicentrická studie MeSH
- srovnávací studie MeSH
PURPOSE OF REVIEW: Transurethral resection of bladder cancer (TURB) is the critical step in the management of nonmuscle invasive bladder cancer (NMIBC). This review presents new improvements in the strategy and technique of TURB as well as in technological developments used for tumour visualization and removal. RECENT FINDINGS: The goal of TURB is to perform complete resection of NMIBC. Tumor visualization during procedure can be improved by enhanced optical technologies. Fluorescence-guided photodynamic diagnosis (PDD) and narrow-band imaging (NBI) used during TURB can improve tumour detection and potentially reduce recurrence rate, their influence on progression, however, remains controversial. TURB can be performed using monopolar or bipolar electrocautery without significant differences in results or safety. To overcome limitations of traditional TURB, the technique of en-bloc resection was introduced to improve the quality of tumour removal. In selected cases, an early re-resection (re-TURB) within 2-6 weeks after initial procedure is recommended. SUMMARY: TURB is a fundamental step in diagnosis and treatment of NMIBC. Urologists should be aware of promising innovations including new imaging and surgical techniques and their potential benefits. Hopefully, new technologies and performance of TURB bring improved outcomes, which can alter the indication criteria for re-TURB.
- MeSH
- cystektomie metody normy trendy MeSH
- invazivní růst nádoru patologie MeSH
- lidé MeSH
- lokální recidiva nádoru prevence a kontrola MeSH
- močový měchýř diagnostické zobrazování patologie chirurgie MeSH
- nádory močového měchýře diagnostické zobrazování patologie chirurgie MeSH
- progrese nemoci MeSH
- reoperace metody normy trendy MeSH
- směrnice pro lékařskou praxi jako téma MeSH
- úzkopásmové zobrazení metody trendy MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- přehledy MeSH
PURPOSE: To learn about the history and development of en bloc resection of bladder tumour (ERBT), and to discuss its future directions in managing bladder cancer. METHODS: In this narrative review, we summarised the history and early development of ERBT, previous attempts in overcoming the tumour size limitation, consolidative effort in standardising the ERBT procedure, emerging evidence in ERBT, evolving concepts in treating large bladder tumours, and the future directions of ERBT. RESULTS: Since the first report on ERBT in 1980, there has been tremendous advancement in terms of its technique, energy modalities and tumour retrieval methods. In 2020, the international consensus statement on ERBT has been developed and it serves as a standard reference for urologists to practise ERBT. Recently, high-quality evidence on ERBT has been emerging. Of note, the EB-StaR study showed that ERBT led to a reduction in 1-year recurrence rate from 38.1 to 28.5%. An individual patient data meta-analysis is currently underway, and it will be instrumental in defining the true value of ERBT in treating non-muscle-invasive bladder cancer. For large bladder tumours, modified approaches of ERBT should be accepted, as the quality of resection is more important than a mere removal of tumour in one piece. The global ERBT registry has been launched to study the value of ERBT in a real-world setting. CONCLUSION: ERBT is a promising surgical technique in treating bladder cancer and it has gained increasing interest globally. It is about time for us to embrace this technique in our clinical practice.
- MeSH
- cystektomie metody MeSH
- lidé MeSH
- metaanalýza jako téma MeSH
- močový měchýř patologie MeSH
- nádory močového měchýře * chirurgie patologie MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- přehledy MeSH
PURPOSE OF REVIEW: Conventional transurethral resection of bladder tumor (cTURBT) is the standard approach to the diagnosis and treatment of nonmuscle invasive bladder cancer. However, it suffers from inherent limitations such as insufficient assessment of resection depth and the need for intravesical tumor fragmentation that hampers histopathological evaluation. We summarize recent clinical data on en bloc resection of bladder tumor (ERBT), a method that promises to overcome these limitations. RECENT FINDINGS: The PubMed/Medline databases were searched for reports on ERBT focusing on trends in the last 2 years. ERBT provides greater resection quality, making up to 95% of detrusor muscle available for pathological evaluation. ERBT also allows detection of the muscularis mucosae thus facilitating T1 substaging. Available data demonstrate no significant difference in perioperative morbidity. No conclusions can be drawn on the impact of either modality on tumor recurrence and progression, as the available data is too underpowered. SUMMARY: ERBT is gaining acceptances as there is increasing evidence that it improves the quality of resected specimens. There seems to be no difference in perioperative morbidity between ERBT and cTURBT. The impact of ERBT on important endpoints such as recurrence and progression remains to be fully elucidated in further studies.
- MeSH
- cystektomie * MeSH
- lidé MeSH
- lokální recidiva nádoru MeSH
- nádory močového měchýře patologie chirurgie MeSH
- progrese nemoci MeSH
- urologické chirurgické výkony MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- přehledy MeSH
PURPOSE: Detrusor muscle (DM) in the resected specimen of patients with pT1 bladder cancer (BCa) is a quality-of-care criteria. We aimed to assess whether obtaining adequate DM is dependent on surgeon's experience, whether is a surrogate for resection quality, and whether the degree of DM thickness is related to postoperative outcomes in en bloc resection for bladder tumors (ERBT). MATERIALS AND METHODS: We retrospectively analyzed the records of 106 pT1 high-grade BCa patients who underwent ERBT at several institutions. All specimens were reviewed by a single pathologist who assessed the presence or absence of DM and its thickness measured by a micrometer, when present. Early recurrence, defined as pathologically confirmed BCa on repeat resection or tumor recurrence at the first follow-up cystoscopy (within 3 months), was the endpoint reflective of the resection quality. RESULTS: Of 106 patients, DM was detected in 99 (93%), and the median DM thickness was 1.8 mm. Large tumor size (>30 mm) was associated with adequate DM sampling (>1.8mm) (odds ratio [OR]: 6.10, 95% confidence intervals [CIs]: 2.08-17.9, P = 0.001), while surgeon's experience was not. DM presence and DM thickness were both not associated with early recurrence, while positive surgical margin was an independent prognosticator for early recurrence (OR: 3.38, 95% CI: 1.12-10.2, P = 0.031). Excessive DM sampling (>2.1 mm) was associated with prolonged urethral catheterization (OR: 28.8, 95% CI: 3.36-248, P = 0.002). CONCLUSIONS: In ERBT, surgeon's experience seems irrelevant to obtain DM. Resection quality relies on surgical margin status, not the degree of DM. Obtaining excessive DM incurs adverse events/unnecessary medical care.
- MeSH
- cystektomie MeSH
- lidé MeSH
- lokální recidiva nádoru * patologie MeSH
- nádory močového měchýře * chirurgie patologie MeSH
- retrospektivní studie MeSH
- svaly patologie MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
