A 10-year renaissance of en bloc resection of bladder tumors (ERBT): Are we approaching the peak or is it back to the trough?

BACKGROUND

The number of studies suggesting that en bloc resection of bladder tumor (ERBT) is superior to transurethral resection of bladder tumor (TURBT) for non-muscle-invasive bladder cancer (NMIBC) management is growing. The aim of this review is to discuss the features of these procedures and to determine the prospects of en bloc in NMIBC management.

MATERIALS AND METHODS

We conducted a literature search using two databases (Medline and Scopus) and included any research which reported ERBT outcomes.

RESULTS

The lasers with minimal tissue penetration depth are becoming the main tool for ERBT. Unfortunately, most of the systematic reviews continue to be characterized by high heterogeneity. However, recent studies indicate that ERBT may have the edge when it comes to the detrusor muscle rate and the quality of the histological specimen. ERBT may favor in terms of in-field relapse, but its rate in the studies varies greatly. As for out-field relapse-free survival, the data are still lacking. The strongest evidence supports that ERBT is superior to TURBT in complications rate (bladder perforation). ERBT is feasible irrespective to tumor size and location.

CONCLUSIONS

ERBT has gained in momentum with the increasingly widespread use of this kind of laser surgery. The introduction of novel sources (TFL and Thulium:YAG pulsed laser) will definitely affect how the field develops and will result in further improvements in safety and precision. The latest trials make us more certain in our belief that ERBT will be beneficial in terms of histological specimen quality, relapse rate and complications rate.

Gross total resection of spinal chondrosarcoma is associated with improved locoregional relapse-free survival and overall survival

BACKGROUND

Spinal chondrosarcomas are rare malignant osseous tumors. The low incidence of spinal chondrosarcomas and the complexity of spine anatomy have led to heterogeneous treatment strategies with varying curative and survival rates. The goal of this study is to investigate prognostic factors for locoregional recurrence-free survival (LRFS) and overall survival (OS) comparing en bloc vs. piecemeal resection for the management of spinal chondrosarcoma.

METHODS

We retrospectively identified patients who underwent curative-intent resection of primary and metastatic spinal chondrosarcoma over a 25-year period. Univariate and multivariate survival analyses were conducted with LRFS as primary endpoint and OS as secondary endpoint. LRFS and OS were modeled using the Kaplan-Meier method and assessed using Cox regression analysis.

RESULTS

For 72 patients who underwent first resection, the median follow-up time was 5.1 years (95% CI 2.2-7.0). Thirty-three patients (45.8%) had en bloc resection, and 39 (54.2%) had piecemeal resection. Of the 68 patients for whom extent of resection was known, 44 patients had gross total resection (GTR) and 24 patients had subtotal resection. In survival analyses, both LRFS and OS showed statistically significant difference based on the extent of resection (p = 0.001; p = 0.04, respectively). However, only LRFS showed statistically significant difference when assessing the type of resection (p = 0.02). In addition, higher tumor grade and more invasive disease were associated with worse LRFS and OS rates.

CONCLUSION

Although in our study en bloc and GTR were associated with improved survival, heterogenous and complex spinal presentations may limit total resection. Therefore, the surgical management should be tailored individually to ensure the best local control and maximum preservation of function.

Augmented Reality Neuronavigation for En Bloc Resection of Spinal Column Lesions

BACKGROUND

Primary tumors involving the spine are relatively rare but represent surgically challenging procedures with high patient morbidity. En bloc resection of these tumors necessitates large exposures, wide tumor margins, and poses risks to functionally relevant anatomical structures. Augmented reality neuronavigation (ARNV) represents a paradigm shift in neuronavigation, allowing on-demand visualization of 3D navigation data in real-time directly in line with the operative field.

METHODS

Here, we describe the first application of ARNV to perform distal sacrococcygectomies for the en bloc removal of sacral and retrorectal lesions involving the coccyx in 2 patients, as well as a thoracic 9-11 laminectomy with costotransversectomy for en bloc removal of a schwannoma in a third patient.

RESULTS

In our experience, ARNV allowed our teams to minimize the length of the incision, reduce the extent of bony resection, and enhanced visualization of critical adjacent anatomy. All tumors were resected en bloc, and the patients recovered well postoperatively, with no known complications. Pathologic analysis confirmed the en bloc removal of these lesions with negative margins.

CONCLUSIONS

We conclude that ARNV is an effective strategy for the precise, en bloc removal of spinal lesions including both sacrococcygeal tumors involving the retrorectal space and thoracic schwannomas.

Treatment of primary tracheal schwannoma with endoscopic resection: A case report

BACKGROUND

Schwannoma is a benign tumor originating from the peripheral nerve sheath. The clinical symptoms of tracheal schwannoma depend on the location of the tumor, and the most common clinical symptoms are cough and hemoptysis. The most effective treatment for benign tumors is complete resection of the primary lesion at an early stage. Our experience has demonstrated that primary tracheal schwannoma can be safely excised with a high-frequency electric knife in a minimally invasive manner.

CASE SUMMARY

We report a 61-year-old asymptomatic woman who underwent chest computed tomography (CT), which accidentally found an intraluminal tracheal mass without enlarged lymph nodes. Then, the patient underwent bronchoscopy, which found that the tracheal mass originated from the left wall of the upper trachea, was less than 1.5 cm in size, immovable, smooth and 4 cm away from the vocal cord, resulting in partial upper respiratory tract obstruction. Treatment was performed using an endoscopic resection for en bloc removal of the tracheal mass. The diagnosis was primary tracheal schwannoma. A follow-up was performed after endoscopic surgery, and bronchoscopy and thoracic CT were used to monitor whether there was a recurrence. At present, there is no evidence of recurrence, and the patient had a good quality of life. Endoscopic resection may be effective and safe in the treatment of primary tracheal schwannoma.

CONCLUSION

Primary tracheal schwannoma is a very rare benign tumor. In this case, we cured it by complete endoscopic resection.

Clinical utility of vesical imaging-reporting and data system (VI-RADS) in non-muscle invasive bladder cancer (NMIBC) patients candidate for en-bloc transurethral resection: A prospective study

OBJECTIVES

To assess accuracy of vesical imaging-reporting and data system (VI-RADS) 5-point score in detection of muscle invasive bladder cancer and avoiding second look transurethral resection of the tumors (TURBT). Additionally, to assess safety and efficacy of bipolar en-block transurethral urethral resection of bladder tumor.

METHODS

Patients with bladder mass up to 5 cm were included in the study. VI-RADS 5-point score was done preoperative for all cases and postoperatively before second look TURBT. Patients were followed up for 12 months.

RESULTS

In all, 80 cases were eligible for the study. Preoperative VI-RADS score at cutoff of 3 had sensitivity of 89.3 %, specificity 83.3 %, postive predective value (PPV) 92.6 %, negative predictive value (NPV) 76.9 %, accuracy of 87.5 %, while at cutoff 2 sensitivity was 82.1%, specificity 91.7%, PPV 95.8%, NPV 68.8%, accuracy of 85.0%. Operative time 28.8 ± 9.4 minutes, hemoglobin drop 0.3 ± 0.05 g/dl, catheterization time 2.8 ± 0.8 days, hospital stay 1.4 ± 0.4 days. No complications occurred. Recurrence in field of resection 3.75%. Detrusor muscle was available in 76 cases (95%). Postoperative VI-RADS score at cutoff of 3 had sensitivity of 78.6%, specificity 77.8%, PPV 84.6%, NPV 70.0%, accuracy of 78.3%. At cutoff 2 VI-RADS score sensitivity was 71.4%, specificity 77.8%, PPV 83.3%, NPV 63.6%, accuracy of 73.9%.

CONCLUSION

VI-RADS 5-point score showed high sensitivity and specificity in preoperative discrimination of non-muscle invasive bladder cancer (NMIBC) from muscle invasive bladder cancer cases and in avoiding unnecessary second look TURBT. Bipolar en-block TURBT technique is both safe and efficacious in resecting NMIBC cases with low recurrence rate.

Nerve Root Sparing En Bloc Resection of Sacral Chondrosarcoma: Technical Note and Review of the Literature

BACKGROUND

Total en bloc sacrectomy provides the best long-term local control for large primary bony sacral tumors, but often requires lumbosacral nerve root sacrifice leading to loss of ambulation and/or bowel, bladder, and/or sexual dysfunction. Nerve-sparing techniques may be an option for some patients that avoid these outcomes and accordingly improve postoperative quality of life.

OBJECTIVE

To describe the technique for a posterior-only en bloc hemisacrectomy with maximal nerve root preservation and to summarize the available literature.

METHODS

A 38-yr-old woman with a 7.7 × 5.4 × 4.5 cm biopsy-proven grade 2 chondrosarcoma involving the left L5-S2 posterior elements underwent a posterior-only left hemisacrectomy tri-rod L3-pelvis fusion. A systematic review of the English literature was also conducted to identify other descriptions of high sacrectomy with distal sacral nerve root preservation.

RESULTS

Computer-aided navigation facilitated an extracapsular resection that allowed preservation of the left-sided L5 and S3-Co roots. Negative margins were achieved and postoperatively the patient retained ambulation and good bowel/bladder function. Imaging at 9-mo follow-up showed no evidence of recurrence. The systematic review identified 4 prior publications describing 6 total patients who underwent nerve-sparing sacral resection. Enneking-appropriate resection was only obtained in 1 case though.

CONCLUSION

Here we describe a technique for distal sacral nerve root preservation during en bloc hemisacrectomy for a primary sacral tumor. Few prior descriptions exist, and the present technique may help to reduce the neurological morbidity of sacral tumor surgery.

Holmium laser en-bloc enucleation of the prostate: Bi-centric prospective evaluation of 109 consecutive cases

INTRODUCTION

Holmium laser enucleation of the prostate (HoLEP) is a validated alternative to transurethral resection of the prostate (TURP) and open prostatectomy (OP) for surgical treatment of bladder outlet obstruction (BOO) due to benign prostatic hyperplasia (BPH). The surgical technique may vary considerably from one surgeon to another. The three-lobe technique remains the reference procedure, but some surgeons claim "en bloc" enucleation could help to shorten enucleation time. Our objective was to prospectively assess the clinical results of "en bloc" HoLEP.

METHODS

Consecutive 109 patients presenting with lower urinary tract symptoms (LUTS) related to BPH and selected for surgical treatment were prospectively included in an observational clinical study. There were no exclusion criteria as long as the patient was operated on by one of the two participating surgeons. The surgeons involved had previous experience of more than 200 HoLEP cases, including more than 50 "en bloc" procedures, before starting the clinical study. Clinical data were prospectively collected in a common computerized database and analysed once the 3-month follow-up data were collected including complications, maximum urinary flow rate (Qmax), post-void residual urine volume (PVR), the International Prostate Symptom Score (IPSS) and the Quality of life score (QoL).

RESULTS

Overall, 109 consecutive patients were included with median IPSS and QoL score of 20/35 and 5/6 respectively. At inclusion median prostatic size was 70mL, Qmax was 8mL/s, and PVR was160mL. The median length of the complete procedure, the enucleation and the morcellation were, respectively, 41min, 30min and 10min. The mean enucleation efficiency was 1.5g/min, and the mean morcellation efficiency was 4.5g/min. The median bladder catheterization and hospitalization length were of 18hours and 1 day respectively and 41% of patients had day-case procedure. Early post-operative complications were reported in 17 cases (16%) including 3 Clavien IIIb (bladder clot removal in the operating room). At 3-month, the IPSS and QoL decreased to 3/35 and 1/6 while Qmax and PVR improved to 26mL/s and 40mL.

CONCLUSION

In this bi-centric study evaluating short-term outcomes of the "en bloc" technique, the operating time was very short (41min) with excellent functional outcomes. A prospective clinical trial is necessary to confirm these results are due to the surgical technique itself and not only to the skills of the surgeons.

The Skin-Sparing Debridement Technique in Necrotizing Soft-Tissue Infections: A Systematic Review

BACKGROUND

Skin-sparing debridement (SSd) was introduced as an alternative to en bloc debridement (EBd) to decrease morbidity caused by scars in patients surviving Necrotizing soft-tissue infections (NSTI). An overview of potential advantages and disadvantages is needed. The aim of this review was to assess (1) whether SSd is noninferior to EBd regarding general outcomes, that is, mortality, length of stay (LOS), complications, and (2) if SSd does indeed result in decreased skin defects.

METHODS

A systematic literature search was performed according to the PRISMA guidelines. All human studies describing patients treated with SSd were included, when at least of evidence level consecutive case series. Studies describing up to 20 patients were pooled to improve readability and prevent overemphasis of findings from single small studies.

RESULTS

Ten studies, one cohort study and nine case series, all classified as poor based on Chambers criteria for case series, were included. Compared to patients treated with EBd, patients treated with SSd had no increased mortality rate, LOS or complication rate. SSd-treated patients had a high rate (75%) of total delayed primary closure (DPC) in the pooled case series.

CONCLUSION

The current available evidence is of insufficient quality to conclude whether SSd is noninferior to EBd for all assessed outcomes. There are suggestions that SSd may result in a decreased need for skin transplants, which could potentially improve the (health related) quality of life in survivors. Experienced surgical teams could cautiously implement SSd under close monitoring, ideally with uniform outcome registry.

Preliminary Results of a 3D-Printed Modular Vertebral Prosthesis for Anterior Column Reconstruction after Multilevel Thoracolumbar Total En Bloc Spondylectomy

OBJECTIVE

To evaluate preliminary results of a 3D-printed modular prosthesis for spinal reconstruction after multilevel thoracolumbar total en bloc spondylectomy (TES).

METHODS

Patients with thoracolumbar spinal tumors treated surgically between January 2016 and April 2019 were included in this retrospective study. A total of 17 male and 10 female patients with a mean age of 42 (range, 15-72) years comprised the sample. The pathological diagnoses included six chondrosarcomas (one of them was mesenchymal chondrosarcoma), six giant cell tumors, three malignant peripheral nerve sheath tumors, two osteosarcomas, two undifferentiated high-grade pleomorphic sarcomas (UPS), two solitary fibrous tumors, one Ewing's sarcoma, one liposarcoma, and four metastatic tumors. Tumors involved 2 levels in 14 patients, 3 levels in seven patients, 4 levels in four patients, 5 levels in one patient, and 6 levels in one patient. A 3D-printed modular prosthesis was used for anterior column reconstruction after TES. All analyses were performed using SPSS version 18.0 (SPSS, Inc., Chicago, IL). Descriptive statistics were used to analyze the demographic data and clinical outcomes. Data forms included mean, standard deviation and range.

RESULTS

Under general anesthesia, all patients received TES with an average operative time of 639 (range, 210-1650) min, and the mean blood loss during operation was 4.1 (range, 0.8-13.3) L. Twenty-two patients have been transferred to ICU for a mean time of 3.2 (range, 0-6) d. All patients had follow-up procedures except for one, who died of perioperative complications. Mean time of follow-up was 22 (range, 12-41) months. Local recurrence (19.2%) occurred in two patients with intralesional margin and three patients with marginal margin, respectively. At the end of follow-up, three patients died of disease, eight patients were alive with disease, and 15 patients had no evidence of disease. Average lengths of resected vertebrae and modular prostheses were 71.4 ± 26.5 mm (range, 40-142 mm) and 68.4 ± 23.9 mm (range, 40-132 mm), respectively. In 26 patients with minimum follow-up of more than 1 year, no evidence of internal fixation failure or dislocation of vertebral prosthesis was found. Asymptomatic prosthetic subsidence into adjacent vertebral bodies occurred in 10 patients with a mean length of 1.8 ± 1.0 mm (range, 1-4 mm). The subsidence was seen at proximal end in two patients, distal end in four patients, and both ends in four patients. Eighteen major complications and 14 minor complications were found in 15 patients. All patients fully recovered at 3 or 6 months after operation. At the latest follow-up, in 23 alive patients, 19 can walk independently and two can achieve outdoor activities by walking aid.

CONCLUSION

For spinal reconstruction after multilevel thoracolumbar TES, 3D-printed modular vertebral prosthesis is suitable for different length of anterior column reconstruction with less mechanical complications, and can provide a stable environment to maintain or rehabilitate patients' neurological function in short-term follow-up.

En bloc excision of sacroiliac chondrosarcoma aided by 3D laser printed modeling and stereotactic navigation

The surgical management of sacro-iliac chondrosarcomas is challenging given their intimate relationship to the nerves and vessels of the pelvis. Osteotomies for en bloc excision can be challenging because of lack of visualization and high risk of injury to pelvic structures. The use of three-dimensional (3D) printed models helps conceptualize the tumor relative to the patient's anatomy. Coupled with stereotactic navigation, safe osteotomy planning and execution can be performed with avoidance of vital nerves and vessels. Very few cases have been reported demonstrating the successful use of these 2 modern technologies for en bloc excision of difficult tumors. We present our technique of using a 3D printed model and navigation for en bloc excision of a large sacro-iliac chondrosarcoma, supplemented with an intraoperative video.

A comparison of renal vascular control techniques during laparoscopic nephrectomy

Background:

We compared outcomes of en bloc stapler ligation of the renal hilum with separate Hem-o-lok polymer clip ligation of the renal vessels during laparoscopic nephrectomy (LN).

Materials and Methods:

Clinical data of patients who underwent LN for renal surgery from January 2009 to December 2015 were collected. Operation time, estimated blood loss, device malfunction rate, open conversion rate, complications and arteriovenous fistula (AVF) formation were evaluated.

Results:

En bloc stapler ligation and separate clip ligation were performed in 64 and 66 patients, respectively. The mean operative time was 106.8 ± 20.8 min (range: 70–165) in the en bloc stapler ligation group compared with 112.5 ± 24.1 min (range: 70–180) in the separate clip ligation group (P = 0.147). The mean estimated blood loss was 141.4 ± 124.1 ml (range: 25–600) in the en bloc stapler ligation group compared with 147.6 ± 112.4 ml (range: 25–450) in the separate clip ligation group (P = 0.767). The open conversion was required in 7/64 (10.9%) and 2/66 (3.0%) patients in the en bloc stapler ligation and separate clip ligation groups, respectively (P = 0.093). Stapler device malfunction occurred in 6 patients (9.3%). There were no statistically significant differences in overall complications (P = 0.726), minor (Grade 1–2) complications (P = 0.698) and major (Grade 3–5) complications (P = 0.716). No patient was diagnosed with AVF formation during overall median 33-month (interquartile range: 30, range: 24–96) follow-up.

Conclusions:

En bloc stapler ligation of the renal hilum during nephrectomy is an effective and safe technique. Although there is no reported AVF formation with en bloc stapler ligation of the renal hilum, longer follow-up is necessary.

Bicentric Retrospective Analysis of en Bloc Resection and Muscularis Mucosae Detection Rate in Non-Muscle Invasive Bladder Tumors: A Real-World Scenario

Introduction

For risk stratification of non-muscle invasive bladder cancer (NMIBC), the depth of stromal invasion can be further classified, where the lamina muscularis mucosae (MM) serves as a reference structure. While the overall identifiability of MM in standard transurethral specimens is low, en bloc resection may help in identification and overall orientation. The aims of this study were to report the detection rate of MM in en bloc resected bladder tumors (ERBT) and to provide real-world information on tissue stability and preservation of en bloc architecture during recovery and processing for histopathologic evaluation.

Methods

Thirty-four ERBT specimens were histologically re-evaluated with regard to MM detectability and structure as well as the presence of en bloc architecture and further histologic features. Associations with tumor size and energy source and within histologic parameters were assessed by standard Pearson's chi-squared analyses and Cramér’s V effect size testing (V).

Results

The first parameter assessed was MM detection rate. In 19 out of 34 samples (56%) MM was detectable: scattered in 9 cases (26%), interrupted in 8 cases (24%) and continuous in 2 cases (6%). The second parameter assessed was preservation of en bloc architecture. In 11 out of 34 samples (32%), en bloc architecture could not be confirmed, and these samples served as a reference group for the detection of MM. Preservation of en bloc architecture was associated with an increased MM detection rate (MM in en bloc preserved 16/23, 70% vs. non-preserved 3/11, 27%; p = 0.020; V = 0.398) and with tumor size (p = 0.005; V = 0.595). Medium-sized tumors (1.1–2 cm) were best preserved. The choice of energy source did not show relevant association with en bloc architecture (p = n.s.).

Conclusions

In line with recent publications, ERBT increases the MM detection rate considerably. However, a third of the ERBT specimens lost en bloc architecture during sample recovery and processing. Tumor size is a relevant factor, with optimal architecture preservation between 1 and 2 cm. Optimizing resection techniques, recovery, transport, and diagnostic processing of ERBT samples is warranted to verify the diagnostic value of MM-based substaging.

Transition from open to minimally invasive en bloc esophagectomy can be achieved without compromising surgical quality

BACKGROUND

En bloc esophagectomy results in higher lymph node (LN) retrieval than standard esophagectomy. Minimally invasive esophagectomy (MIE) has gained traction due to improved short-term outcomes, but many large series report LN yields well below the international benchmark of 23. We sought to determine if an established approach to open en bloc resection can be safely transferred to MIE using LN yield as a quality benchmark.

METHODS

An open approach to en bloc esophagectomy (OE) was established over 5 years (~ 300 cases) before en bloc MIE was introduced in 2010. Patients undergoing curative-intent en bloc Ivor-Lewis and McKeown esophagectomy for cancer from 2010 to 2019 by a single surgeon with formal minimally invasive surgery training were identified from a prospectively collected database. Mann-Whitney U and χ² tests and cumulative sum analysis were used for statistical analysis. "Failure" was defined as LN yield less than AJCC's 8th edition guidelines: 10 LNs for pT1 cancers, 20 for pT2 and 30 for pT3-4.

RESULTS

A total of 269 esophageal resections met inclusion criteria [193(72%) OE; 76(28%) MIE]. Age, sex, BMI and comorbidities were comparable between groups. Tumors were larger and more often locally advanced in OE. Median LN retrieval was sufficient by international standards in both groups [OE:34(27-46); MIE:28(22-39); p = 0.01]. "Failures" occurred in 33(17%) of OE and 12(16%) MIE cases (p = 0.63). No learning effect was observed for LN yield. R0 resection rate was comparable [OE:191(99%); MIE:73(96%); p = 0.90]. Operative time was longer for MIE [275(246-300)] than OE [240(210-270) minutes], p < 0.0001, while estimated blood loss (OE:350(250-500)mL; MIE:300(200-400)mL; p = 0.02] and length of stay [OE:8(6-13); MIE7(6-9) days; p = 0.02] were higher for OE. Morbidity and mortality were comparable between groups and LN yield did not impact survival.

CONCLUSIONS

Under appropriate conditions, an established approach to open en bloc esophagectomy can be safely transferred to MIE without compromising surgical quality.

En bloc and two-lobe techniques for laser endoscopic enucleation of the prostate: retrospective comparative analysis of peri- and postoperative outcomes

OBJECTIVES

Various techniques can be used for endoscopic enucleation of the prostate (EEP): removal of all nodes as a single unit (en bloc) or a step-by-step removal of adenomatous nodes (two- and three-lobe techniques). The objective of this study was to perform a comparative analysis of en bloc and two-lobe techniques for holmium laser enucleation of the prostate (HoLEP) and thulium fiber laser enucleation of the prostate (ThuFLEP).

METHODS

Retrospective assessment included patients with bladder outlet obstruction (IPSS > 20, Qmax < 10) secondary to BPH treated from January 2013 to December 2018. All the patients were assessed prior to surgery, as well as at 1, 3 and 6 months after surgery.

RESULTS

The data of 1115 patients who underwent HoLEP or ThuFLEP were analyzed. Two techniques were used: en bloc (406 patients) and two-lobe (709 patients). Mean prostate volumes were comparable between groups. Mean surgery times (68.8 ± 30.6 min vs 67.4 ± 30.1 min; p = 0.604) and enucleation rates (1.9 ± 0.74 g/min vs 1.9 ± 0.69 g/min; p = 0.217) were also comparable. Morcellation rate was lower in en bloc patients with prostate > 150 cc (2.8 ± 1.1 g/min vs 3.7 ± 2.3 g/min; p < 0.001). At 6 months, no differences in functional outcomes (IPSS, PVR, Qmax and QoL) were found.

CONCLUSIONS

Outcomes and complication rates of en bloc and two-lobe EEP techniques were comparable. En bloc technique was found to have less favorable outcomes in morcellation rate for prostates > 150 cc. The choice of the technique should depend on surgeon's preferences.

Reconstruction of the pelvic ring after total en bloc sacrectomy using a 3D-printed sacral endoprosthesis with re-establishment of spinopelvic stability: a retrospective comparative study

AIMS

The aim of this study was to describe the use of 3D-printed sacral endoprostheses to reconstruct the pelvic ring and re-establish spinopelvic stability after total en bloc sacrectomy (TES) and to review its outcome.

PATIENTS AND METHODS

We retrospectively reviewed 32 patients who underwent TES in our hospital between January 2015 and December 2017. We divided the patients into three groups on the basis of the method of reconstruction: an endoprosthesis group (n = 10); a combined reconstruction group (n = 14), who underwent non-endoprosthetic combined reconstruction, including anterior spinal column fixation; and a spinopelvic fixation (SPF) group (n = 8), who underwent only SPF. Spinopelvic stability, implant survival (IS), intraoperative haemorrhage rate, and perioperative complication rate in the endoprosthesis group were documented and compared with those of other two groups.

RESULTS

The mean overall follow-up was 22.1 months (9 to 44). In the endoprosthesis group, the mean intraoperative hemorrhage was 3530 ml (1600 to 8100). Perioperative complications occurred in two patients; both had problems with wound healing. After a mean follow-up of 17.7 months (12 to 38), 9/10 patients could walk without aids and 8/10 patients were not using analgesics. Imaging evidence of implant failure was found in three patients, all of whom had breakage of screws and/or rods. Only one of these, who had a local recurrence, underwent re-operation, at which solid bone-endoprosthetic osseointegration was found. The mean IS using re-operation as the endpoint was 32.5 months (95% confidence interval 23.2 to 41.8). Compared with the other two groups, the endoprosthesis group had significantly better spinopelvic stability and IS with no greater intraoperative haemorrhage or perioperative complications.

CONCLUSION

The use of 3D-printed endoprostheses for reconstruction after TES provides reliable spinopelvic stability and IS by facilitating osseointegration at the bone-implant interfaces, with acceptable levels of haemorrhage and complications. Cite this article: Bone Joint J 2019;101-B:880-888.

Extracorporeal radiation and reimplantation: a safe and viable option for reconstruction after sacral tumor resection?

Primary tumors of the sacrum are difficult to manage, as they often require morbid resections and complex reconstructions. In the case of tumors such as chordoma or chondrosarcoma, aggressive resections are often required to achieve appropriate margins (extending disease-free survival), followed by complex reconstructions. These reconstructions are aimed at restoring the pelvic ring and have traditionally resulted in a lumbosacral construct that utilizes structural allograft/autograft bone (fibula most commonly used) and more recently, reconstruction with 3D-printed custom sacral prostheses. While there are no reports of anatomical reconstruction using sacral allografts, extracorporeal radiation therapy (ECRT) and reimplantation provides a size and shape-matched irradiated autograft which avoids the cultural stigma, structural strength and graft-host concerns associated with allografts, as well as the high costs and time to production associated with custom 3D-printed implants. Here we present an illustrative case with technical notes, outlining the steps used at our center for ECRT. While early results with ECRT in the sacrum are promising, future larger studies should be carried out to help detect differences that may exist in long-term complications.

Extracellular vesicles: Vehicles of en bloc viral transmission

En Bloc transmission of viruses allow multiple genomes to collectivelly penetrate and initiate infection in the same cell, often resulting in enhanced infectivity. Given the quasispecies (mutant cloud) nature of RNA viruses and many DNA viruses, en bloc transmission of multiple genomes provides different starting points in sequence space to initiate adaptive walks, and has implications for modulation of viral fitness and for the response of viral populations to lethal mutagenesis. Mechanisms that can enable multiple viral genomes to be transported en bloc among hosts has only recently been gaining attention. A growing body of research suggests that extracellular vesicles (EV) are highly prevalent and robust vehicles for en bloc delivery of viral particles and naked infectious genomes among organisms. Both RNA and DNA viruses appear to exploit these vesicles to increase their multiplicity of infection and enhance virulence.

To assemble or not to assemble: The changing rules of pneumovirus transmission

Pneumoviruses represent a major public health burden across the world. Respiratory syncytial virus (RSV) and human metapneumovirus (HMPV), two of the most recognizable pediatric infectious agents, belong to this family. These viruses are enveloped with a non-segmented negative-sense RNA genome, and their replication occurs in specialized cytosolic organelles named inclusion bodies (IB). The critical role of IBs in replication of pneumoviruses has begun to be elucidated, and our current understanding suggests they are highly dynamic structures. From IBs, newly synthesized nucleocapsids are transported to assembly sites, potentially via the actin cytoskeleton, to be incorporated into nascent virions. Released virions, which generally contain one genome, can then diffuse in the extracellular environment to target new cells and reinitiate the process of infection. This is a challenging business for virions, which must face several risks including the extracellular immune responses. In addition, several recent studies suggest that successful infection may be achieved more rapidly by multiple, rather than single, genomic copies being deposited into a target cell. Interestingly, recent data indicate that pneumoviruses have several mechanisms that permit their transmission en bloc, i.e. transmission of multiple genomes at the same time. These mechanisms include the well-studied syncytia formation as well as the newly described formation of long actin-based intercellular extensions. These not only permit en bloc viral transmission, but also bypass assembly of complete virions. In this review we describe several aspects of en bloc viral transmission and how these mechanisms are reshaping our understanding of pneumovirus replication, assembly and spread.

Symptomatic aneurysmal bone cysts of the spine: clinical features, surgical outcomes, and prognostic factors

PURPOSE

The aim of the study was to report the long-term outcomes and analyze the potential prognostic factors that may contribute to symptomatic patients with aneurysmal bone cyst (ABC) of the spine undergoing surgical treatments.

METHODS

A retrospective analysis of consecutive patients with ABCs of the spine was performed. The clinical features were reviewed, and the disease-free survival (DFS) and overall survival (OS) rates were estimated using the Kaplan-Meier method. Factors with p values ≤ 0.05 were subjected to multivariate analysis by Cox proportional hazards model to identify the independent prognostic contributors. p values < 0.05 were considered statistically significant.

RESULTS

A total of 42 patients with ABCs of the spine were included in the study. All patients received surgical treatments. The mean follow-up period was 41.3 months (median 39.5, range 24-64). Local recurrence was detected in eight patients after surgery in our center, whereas death occurred in three patients. The estimated 5-year DFS and OS rate was 54.1% and 76.8%, respectively. The statistical analyses indicated that both en bloc resection and primary/secondary tumor status were independent prognostic factors for DFS.

CONCLUSIONS

Secondary ABC status may be associated with worse prognosis, and en bloc resection remains the treatment of choice for ABCs with neurologic deficits or spinal instability of the spine, which is correlated with better prognosis for local tumor control. These slides can be retrieved under Electronic Supplementary Material.

Utilisation of small paediatric donor kidneys for transplantation

With the increasing need for kidney transplantation in the paediatric population and changing donor demographics, children without a living donor option will potentially be offered an adult deceased donor transplant of marginal quality. Given the importance of long-term graft survival for paediatric recipients, consideration is now being given to kidneys from small paediatric donors (SPDs). There exist a lack of consensus and a reluctance amongst some centres in transplanting SPDs due to high surgical complication rates, graft loss and concerns regarding low nephron mass and long-term function. The aim of this review is to examine and present the evidence base regarding the transplantation of these organs. The literature in both the paediatric and adult renal transplant fields, as well as recent relevant conference proceedings, is reviewed. We discuss the surgical techniques, long-term graft function and rates of complications following transplantation of SPDs. We compare graft survival of SPDs to adult deceased donors and consider the use of small paediatric donors after circulatory death (DCD) organs. In conclusion, evidence is presented that may refute historically held paradigms regarding the transplantation of SPDs in paediatric recipients, thereby potentially allowing significant expansion of the donor pool.

Surgical Techniques and Associated Outcomes of Primary Chondrosarcoma of the Spine

BACKGROUND

Only a few case reports and case series exist reporting on primary chondrosarcomas of the spine. The objective of this study was to gain a better understanding of this patient population and surgical techniques used for treatment.

METHODS

A systematic literature search was performed in January 2018 querying several scientific databases, per PRISMA guidelines. Surgery type was categorized into en bloc, piecemeal excision, or non-en bloc or piecemeal excision.

RESULTS

In total, 34 records and 3 patients were included in the systematic review, yielding 87 patients with primary chondrosarcoma of the spine. The mean age was 41.5 years, with the tumor most commonly arising in adult patients (90.8%, 79/87); most were male (66.7%, 58/87). Those who underwent piecemeal excision had the highest death rate (56.7%, P ≤ 0.001) and highest rate of recurrence (63.3%, P ≤ 0.001) compared with en bloc and non-en bloc or piecemeal excision. The calculated reduced relative risk (RR) comparing en bloc with the other surgical techniques for recurrence and mortality was 78.8% (RR, 0.21; P ≤ 0.001) and 80.7% (RR, 0.19; P≤ 0.001), respectively. Survival analysis showed patients with a piecemeal excision had 9.4 times hazards ratio for death compared with en bloc (P = 0.001).

CONCLUSIONS

CS is a rare lesion that most commonly presents in adult male patients. En bloc surgical resection was associated with a significant decrease in recurrence, mortality, and increased survival compared with the other surgical techniques. In addition, any surgical technique that involved entering the tumor capsule showed a significantly greater risk for recurrence and death.

Langerhans cell histiocytosis at L5 vertebra treated with en bloc vertebral resection: a case report

BACKGROUND

Langerhans cell histiocytosis (LCH) in adult lumbar spine is extremely rare, and optimal treatments remain unclear. In literature, only a few cases of lumbar spine LCH were treated using surgery but en bloc vertebral resection has not been used.

CASE PRESENTATION

A 50-year-old man presented with unbearable radiating pain at his right leg. Radiological studies revealed a solitary osteolytic lesion, which was moderately enhanced on contrast MR imaging and hyper-metabolic on PET/CT, at the right L5 vertebral body and arch. In biopsy, Langerhans cells were observed, but findings were insufficient to establish a diagnosis of LCH. A modified L5 en bloc vertebral resection via anterior and posterior approaches was performed to remove the right 2/3 portion of the L5 vertebra. The left 1/3 vertebral body and left pedicle of L5, which were not affected, were kept in situ to allow short instrumentation and reconstruction. His leg pain disappeared after the surgery, and a precise diagnosis of LCH was established after a throughout histological study of the removed vertebra. The patient further accepted 1 cycle of low-dose radiotherapy postoperatively. At 18-month follow-up, the lumbosacral spine was fused and no local reoccurrence was noticed.

CONCLUSIONS

For lumbar spine LCH, surgery should be considered if there are neurological symptoms or histological diagnosis is indefinite in biopsy. En bloc vertebral resection can be used to alleviate neurological symptoms and prevent local reoccurrence.

Transurethral en bloc resection with bipolar button electrode for non-muscle invasive bladder cancer

PURPOSE

Transurethral resection of bladder tumor (TURBT) using a wire loop is considered the gold standard for staging and treating non-muscle invasive bladder cancer (NMIBC). TURBT is associated with serious disadvantages that facilitate tumor recurrence. The present study evaluated the safety and efficacy of the bipolar button electrode for en bloc resection of NMIBC.

METHODS

From January 2013 to July 2016, 82 consecutive patients newly diagnosed with NMIBC received transurethral en bloc resection with bipolar button electrode. Operative details, pathological result, and intraoperative and postoperative complications regarded as safety outcomes were documented. Each patient was followed up for ≥ 18 months.

RESULTS

A total of 118 neoplasms were removed en bloc from 82 patients. The mean tumor diameter was 2.42 ± 1.34 cm. The average operation time was 35 ± 14 min. No complications such as bladder bleeding, vesicle perforation, and obturator nerve reflex occurred during the treatment. Pathological evaluations showed urothelial carcinoma with stage Ta low grade in 26 patients, T1 high grade in 51 patients, and T2 high grade in 5 patients. In addition, the bladder detrusor muscle layer was provided in all cases. The 18-month recurrence-free survival was 88.5% (23/26) and 74.5% (38/51) for Ta and T1 patients, respectively.

CONCLUSIONS

The current results demonstrated that transurethral en bloc resection with bipolar button electrode is an effective, feasible, and safe treatment for NMIBC.

Epithelial-myoepithelial carcinoma metastasis to the thoracic spine

Epithelial-myoepithelial carcinoma (EMC) is a very rare salivary gland malignancy accounting for less than 1% of salivary gland tumors, and classically arises from the parotid gland in females. Spinal cord compression caused by EMC metastasized from the parotid gland has only been described once in the literature to our knowledge. We report the first case of a patient with parotid EMC spinal metastasis undergoing a gross total resection with instrumented fusion. This case illustrates that an en bloc resection with a planned transgression through the spinal canal may be a reasonable option for EMC metastasized to the spine.

Risk factors for relapse of middle-stage squamous cell carcinoma of the submandibular region and floor of mouth: the importance of en bloc resection

Our aim was to investigate retrospectively the rate of recurrence in the intervening region for middle-stage squamous cell carcinoma (SCC) of the tongue and identify the factors that predict relapse and prognosis. A total of 204 patients were included, 96 in the en bloc group and 108 in the control group. The groups were comparable. Two patients in the en bloc group (2%) and 12 in the control group (11%) developed recurrences in the intervening region. Kaplan-Meier analysis showed a reduction in the 5-year disease-specific survival once a recurrence had developed after the primary operation (77% compared with 14%, p<0.001). The en bloc group developed significantly fewer recurrences (2%) than the control group (11%) during the five years; p=0.037), and also had better 5-year disease-specific survival (80% compared with 66%, p=0.04). Cox's multivariate regression indicated that the pathological nodal status (p=0.016) and surgical technique (p=0.037) were independent predictive factors for the 5-year recurrence rate, as well as of 5-year disease-specific survival (p=0.001 and p=0.050, respectively). Recurrence in the intervening region is a negative prognostic factor for these patients, and we recommend en bloc resection as the management of choice for middle-stage SCC of the tongue.

Quality of life after en bloc resection of tumors in the mobile spine

BACKGROUND CONTEXT

Little has been reported regarding the patient-centered quality-of-life (QOL) outcomes after en bloc spondylectomy (ES). Despite lower local recurrence rates, it is unknown whether outcomes justify the surgical morbidity.

PURPOSE

The purpose of this study was to report on patient QOL after ES as measured by validated instruments and to identify factors that may predict better postoperative QOL.

STUDY DESIGN

This is a retrospective case-control study (Level III).

PATIENT SAMPLE

Thirty-five consecutive patients with mobile spine tumors were included. Twenty-seven patients underwent en bloc resection, whereas 8 patients received definitive radiation and no surgery. Minimum follow-up was 6 months (median, 32 months).

OUTCOME MEASURES

The outcome measures were European Quality Group 5-Dimensional Questionnaire (EQ5D), four Patient-Reported Outcome Measurement Information System (PROMIS) short-form metrics, Neck Disability Index, and Oswestry Disability Index (ODI).

METHODS

We performed statistical comparisons between the surgery and radiation groups, of the general US population, and within the study group itself to identify predictors of higher QOL scores.

RESULTS

We identified a significant difference in QOL between the surgery and radiation groups in only one instrument, PROMIS pain interference, with surgery having more pain interference (15.7 vs. 10.1, p=.04). For most metrics, including EQ5D, pain interference, pain behavior, and ODI, scores were around one standard deviation worse than the US population mean. Multivariable linear regression for each instrument demonstrated that preoperative factors such as better performance status, tumor location in the cervical spine, lack of mechanical back or neck pain, and shorter fusion span were independently predictive of better QOL scores. Postoperative factors such as poor performance status, chronic narcotic use, and local recurrence were more dominant than preoperative factors in predicting worse QOL.

CONCLUSIONS

Patients may experience more pain interference after surgery as opposed to definitive radiotherapy, but we did not identify a difference for most metrics. Quality of life in our study group was significantly worse than the general population for most metrics. Cervical tumors, lack of mechanical pain, better baseline performance status, and less extensive surgery predict better QOL after surgery.

Epidemiologic, functional, and oncologic outcome analysis of spinal sarcomas treated surgically at a single institution over 10 years

BACKGROUND CONTEXT

Spinal sarcomas are aggressive tumors that originate from the cells of mesechymal origin, specifically fat, cartilage, bone, and muscle. They are high-grade lesions, and treatment of spinal sarcomas can involve chemotherapy, radiation therapy, and surgery. In the appendicular skeleton, sarcomas are often treated with amputation, however, in the spinal column, surgical resection poses a unique set of challenges.

PURPOSE

To better understand the optimal treatment regimens and the impact of en bloc or intralesional resection on patient outcome.

STUDY DESIGN

A cohort of 25 sarcoma patients treated at a single medical institution between 2002 and 2012 was reviewed.

PATIENT SAMPLE AND OUTCOME MEASURES

Patients were classified by tumor type for subgroup analysis, including chondrosarcoma, osteosarcoma, and other malignant spinal sarcomas. Demographic data for review included patient age, tumor type, tumor location, surgery type, exposure to chemotherapy, and radiation therapy.

METHODS

Survival statistics and Kaplan-Meier curves were calculated using GraphPad Prism 5.0. The threshold for statistical significance was set at p<.05. Unpaired, two-tailed, equal variance t tests were performed for statistical analyses in Microsoft Excel 2010.

RESULTS

Twenty-five patients with spinal sarcomas were treated over the 10-year period. Diagnosis included chondrosarcoma (n=9), osteosarcoma (n=4), and other sarcomas (n=12). Mean age at the time of diagnosis was 42 years. Pain was present at the time of diagnosis in 92% patients. Median survival after surgery was 59.5 months for chondrosarcoma, undefined for other sarcomas, and 16.8 months for osteosarcoma. Median survival after en bloc resection was undefined. Median survival after intralesional resection was 17.8 months. The difference in median survival between en bloc and intralesional resection was statistically significant (p=.049).

CONCLUSIONS

The authors report the largest cohort of patients with spinal sarcoma. Median survival in this cohort was the longest for patients with sarcomas of varying pathologies. Median survival was longer for chondrosarcoma. En bloc resection demonstrated a survival advantage over intralesional resection. Long-term follow-up is needed for patients with spinal sarcoma to establish definitive survival data.