Search Results (764)

The posterior communicating artery (PComA) aneurysm is a challenging microsurgical problem due to multiple factors. These include the technical complexity of the surgery itself, potential injury to blood vessels during surgery, recovery of cranial nerve function, and overall neurological outcome after the operation. These are all related to the area where the PComA aneurysm is located, but they have fundamentally different biological determinants. Prior methods of describing aneurysms do not adequately describe how the relationships of the internal carotid artery (ICA) and PComA/P1 configuration influence the proximity of the aneurysm to other important structures such as the perforating arteries, the anterior choroidal artery (AChA), cranial nerve III (CN III), and the surgical corridor. We created PComA-CORE, an artificial intelligence-based framework designed to evaluate whether the elements of experienced microsurgeons’ thought processes can be measured individually while still maintaining temporally valid predictions, human interpretability, and explicit estimates of predictive uncertainty. Methods: Using a highly detailed database of clinical, radiographic, anatomical, intraoperative, and longitudinal data from 687 adult patients who underwent microsurgical clipping of PComA aneurysms over the period 1997–2026, we applied PComA-CORE to predict separately: Microsurgical Complexity (C); Oculomotor Recovery (O); Neurovascular Preservation Risk (R); and Expected 90-Day Functional Outcome (E). The models used cases from 1997–2020 (n = 564) for development and cases from 2021–2026 (n = 123) for temporal evaluation. Several architectures, including penalized regression, machine-learning techniques, interpretable machine learning, and ensembles, were compared using nested cross-validation, discrimination metrics, calibration metrics, decision-curve analysis, explainability measures, uncertainty-aware prediction, inter-observer reproducibility, and model-to-score distillation. Results: Four discrete predictive architectures were identified by PComA-CORE. PComA-C was found to be highly dependent upon anatomy because the specific geometric characteristics of individual vascular segments and the presence or incorporation of branches around the aneurysm strongly influenced temporal predictions. PComA-R was found to behave as a distributed susceptibility phenotype based on neurovascular attributes rather than a deterministic injury model and achieved a temporal AUC of 0.703. Among patients with preoperative CN III palsy, PComA-O identified that recovery primarily depended upon the time course of neurological dysfunction and structural deformation of the affected nerve. Temporal validation was not feasible given the small number of recent non-recovery events. Conversely, PComA-E showed that global functional outcome continued to depend predominantly upon clinical neurological severity, with a temporally evaluated penalized model achieving an AUC of 0.878. Uncertainty-aware predictions indicated that some cases would benefit from greater caution in interpretation. High-resolution anatomical phenotypes demonstrated good inter-observer reproducibility. Score distillation demonstrated that simplification preserved predictive information, but did so differently depending on the endpoint. Conclusions: The problem of predicting the consequences of clipping a PComA aneurysm is multidimensional and does not exist as a single “risk” prediction problem. Technical complexity, neurovascular vulnerability, neural recovery, and global disability each exist within distinct predictive spaces and require different levels of anatomical detail and/or computational complexity. PComA-CORE establishes a human-supervised framework to transform expert microsurgical thought processes into explicit, reproducible, uncertainty-aware, and clinically interpretable representations. While prospective multicenter validation will be needed prior to clinical use, it has the potential to establish a basis for explainable AI, precision cerebrovascular neurosurgery, anatomy-informed risk stratification, and clinically interpretable decision-support systems in complex aneurysm surgery. Full article

Background and Objectives: Left-sided intracardiac masses (infected vegetations and non-infected thrombotic/tumor lesions) are traditionally managed with surgery in many cases, but procedural risk can be prohibitive. We systematically reviewed published experience with the AngioVac system for percutaneous debulking of left-sided cardiac masses. Methods: PubMed, Scopus, and Web of Science were searched for reports through November 2025, supplemented by hand-searching of congress abstract supplements; records were screened and assessed independently by two reviewers. Adult patients undergoing AngioVac removal of infected or non-infected left-sided cardiac masses were included. The primary effectiveness endpoint was technical success (≥70% debulking without conversion to open surgery). Safety outcomes included procedure-related complications. Data were synthesized descriptively due to heterogeneous designs and reporting. Patient-level and study-level data were distinguished a priori, pooled means were weighted by the number of patients contributed by each report, and pre-specified sensitivity analyses addressed possible patient overlap between reports from the same institution and exclusion of a non-intracardiac (aortic arch) target. Results: A total of 30 studies were included (predominantly single-patient reports, 90.0%). The pooled cohort comprised 42 patients; 23/42 (54.8%) had infective endocarditis (IE) and 45.2% had non-infected masses. Mean age was 62.9 years (range 30.0–86.0); sex distribution was female 47.6%, male 42.9%, and not reported 9.5%. All 42 patients were deemed to be at a prohibitively high risk of surgery. Access was mainly transseptal (29/42, 69.0%) or transapical (8/42, 19.0%). Mass size was reported in 23/42 (54.8%), with mean 23.3 mm, median 20.0 mm, and range 11.0–57.0 mm. Technical success was achieved in 35/42 (83.3%); residual mass occurred in 6/42 (14.3%) and one patient had cardiac perforation requiring conversion to open heart surgery (1/42, 2.4%). Procedure-related complications included valvular dysfunction (paravalvular leak or progressive mitral regurgitation), cardiac perforation, and cerebral infarctions (4/42, 9.5%). There were two deaths (2/42, 4.8%) after successful debulking, one in-hospital with recurrent embolic events and septic shock, and the other 4 months after the procedure following procedure-related progressive mitral regurgitation. Complications clustered in transapical procedures (3/8, 37.5% vs. 0/29 transseptal; p = 0.007) and in fungal endocarditis (2/2; p = 0.012). New clinically apparent embolic events occurred in 2/42 (4.8%), both in patients without documented cerebral protection, the choice of which to apply in the total population was unrelated to mass size (mean 23.5 vs. 23.2 mm). Estimates were stable in sensitivity analyses (technical success 32/38, 84.2% after maximal-overlap de-duplication; 31/37, 83.8% restricted to strictly intracardiac targets). Length of stay was reported in 8/42 (19.0%) with a median of 3.5 days (range 1.0–30.0). Conclusions: In published, highly selected non-surgical candidates, left-sided AngioVac debulking achieved ≥70% mass reduction in 83% of the 42 patients, with 4.8% mortality and one patient (2.4%) converting to emergency surgery. Because the evidence consists almost entirely of single-patient reports subject to publication bias, and because technical success is operator-reported and did not preclude death, these data do not support substituting debulking for a guideline-indicated operation. The technique is best positioned as a bridge or palliative strategy, with transapical access and fungal aetiology identified as signals warranting particular caution. Full article

Endometrial cancer is increasingly diagnosed in patients who have not yet completed childbearing. For carefully selected patients with grade 1 endometrioid endometrial carcinoma confined to the endometrium, fertility-sparing treatment (FST) can preserve reproductive potential but requires rigorous histologic surveillance. In eligible patients, oral progestins and/or the levonorgestrel-releasing intrauterine system (LNG-IUS) remain the mainstay of fertility-sparing treatment, with hysteroscopic lesion resection incorporated in selected cases. Obesity, polycystic ovary syndrome, abnormalities in glucose metabolism, molecular subtype, and primary or acquired progestin resistance collectively contribute to heterogeneity in treatment response and the risk of recurrence. This narrative review critically integrates current guidelines, randomized controlled trials, prospective studies, retrospective cohorts, and early exploratory evidence to evaluate the biological rationale, clinical positioning, efficacy, safety, and maturity of evidence for progestin-based therapy, metabolic interventions, combined endocrine approaches, molecularly guided strategies, and exploratory immunotherapeutic approaches. We further propose an integrated clinical pathway encompassing candidate selection, molecular assessment, response evaluation, transition to pregnancy, retreatment after recurrence, and timely conversion to definitive surgery. Importantly, this review distinguishes guideline-supported approaches from adjunctive, investigational, and exploratory strategies. Major evidence gaps include inconsistent definitions of treatment response, limited prospective molecularly stratified data, uncertain reproductive safety of emerging systemic therapies, and insufficient long-term data on pregnancy outcomes and offspring. Full article

Robotic-assisted cholecystectomy (RAC) is increasingly presented as the next step in minimally invasive biliary surgery, but its added value over laparoscopic cholecystectomy (LC) remains uncertain. Comparative evidence suggests that RAC may reduce conversion to open surgery in some settings, yet it has not demonstrated consistent improvement in postoperative outcomes and is generally associated with longer operative time, higher costs, and unresolved safety concerns during dissemination and learning. RAC may offer value in selected complex cases and within structured robotic training programs, but these roles require subgroup-specific evaluation. For an established, safe, and efficient procedure such as LC, noninferiority is not enough; routine adoption should depend on demonstrable clinical, educational, or operational added value. Full article

Background/Objectives: Chronic low back pain (CLBP) is the leading global cause of years lived with disability, but long-term real-world evidence for non-surgical management remains scarce, particularly in low- and middle-income countries. This study aimed to describe 5-year trajectories of pain, disability, healthcare utilization, patient satisfaction, and surgical conversion among patients with non-specific CLBP initially managed non-surgically at a tertiary spine center in Northwest China. We also compared long-term outcomes between unimodal therapy and multidisciplinary biopsychosocial care and examined baseline demographic, clinical, and psychosocial predictors of treatment success and conversion to surgery. Methods: We conducted a 5-year retrospective cohort study of consecutive patients with non-specific CLBP at a tertiary spine center in Northwest China. Of 485 consecutive patients screened for eligibility, 420 were enrolled and were compared on the basis of unimodal therapy with multidisciplinary biopsychosocial care. Primary outcomes were pain (Numerical Pain Rating Scale, NPRS) and disability (Oswestry Disability Index, ODI), analyzed using linear mixed-effects models; predictors of surgical conversion were identified via multivariable Cox regression. Results: Of the 420 patients, 352 (83.8% retention) completed the 5-year follow-up. Both pain and disability improved substantially during the first 12 months. Thereafter, pain intensity increased slightly (NPRS from 4.8 to 5.4), whereas functional disability continued to improve (ODI from 31.7 to 26.5). Early multidisciplinary care was associated with sustained superior outcomes (adjusted functional disability (ODI) difference: −8.2 points at 5 years) and a 42% lower observed risk of surgery (HR = 0.58). The cumulative 5-year surgical rate was 14.2%, with high pain catastrophizing as the strongest independent predictor (HR = 3.10). Conclusions: In patients with non-specific CLBP, non-surgical management yields substantial 12-month gains; function continues to improve through 5 years, while pain shows partial recurrence. Early multidisciplinary biopsychosocial care was associated with more durable outcomes and lower surgical conversion; because treatment was not randomized, these associations warrant confirmation in pragmatic trials and support routine psychosocial screening and stratified care. Full article

Background: Intersphincteric resection (ISR) is a technically demanding sphincter-preserving procedure for low rectal cancer. While robotic surgery may offer technical advantages, evidence comparing robotic ISR (R-ISR) and laparoscopic ISR (L-ISR) remains limited. This study aimed to compare perioperative, oncologic, and functional outcomes between R-ISR and L-ISR. Methods: A systematic review and meta-analysis was conducted in accordance with PRISMA 2020. PubMed, Scopus, and Cochrane Library were searched up to 1 March 2026. Comparative studies evaluating R-ISR versus L-ISR in adult patients with low rectal cancer were included. Random-effects models were used to calculate mean differences (MDs) and odds ratios (ORs) with 95% confidence intervals (CIs). Heterogeneity was assessed using I². Subgroup and sensitivity analyses were performed. Results: Seven studies were included. R-ISR was associated with a significantly longer operative duration (MD 34.53 min, 95% CI 7.48 to 61.59; p = 0.02; I² = 81%), a lower rate of overall complications (OR 0.78, 95% CI 0.61 to 0.99; p = 0.04; I² = 0%), a statistically lower Wexner score at 12 months, although the magnitude of the difference was small and its clinical significance uncertain (MD −1.53, 95% CI −2.54 to −0.51; p = 0.02; I² = 0%), and a slightly lower lymph node yield (MD −1.06, 95% CI −2.05 to −0.08; p = 0.04; I² = 65%). No significant differences were observed in blood loss (MD −8.15, 95% CI −23.03 to 6.73; p = 0.20; I² = 37%), conversion to open surgery (OR 0.35, 95% CI 0.02 to 6.02; p = 0.13; I² = 0%), anastomotic leakage (OR 0.92, 95% CI 0.61 to 1.37; p = 0.60; I² = 0%), length of hospital stay (MD −0.48, 95% CI −1.16 to 0.21; p = 0.12; I² = 0%), and CRM positivity (OR 0.93, 95% CI 0.01 to 69.04; p = 0.87; I² = 0%). Subgroup analyses in experienced surgeons and high-volume centers demonstrated no statistically significant differences across outcomes. Sensitivity analyses showed that several results were not robust. Conclusions: Evidence to date does not show superiority of robotic or laparoscopic ISR. Robotic ISR was associated with longer operative time and lower overall complication rates but most perioperative and oncologic outcomes were comparable. After robotic ISR, the 12-month Wexner scores were statistically lower, although the magnitude of this difference was small and the clinical significance uncertain. These results should be interpreted with caution given the limited non-randomized evidence base. PROSPERO Registration: CRD420261359130. Full article

The surgical management of rectal cancer has evolved from open resection to laparoscopic and, more recently, robotic minimally invasive approaches. Laparoscopy established the short-term benefits of minimally invasive rectal surgery but is limited within the confines of the bony pelvis, prompting adoption of the robotic platform with its three-dimensional visualization, wristed instruments, and tremor filtration. Whether these refinements translate into measurable clinical benefit remains debated. This narrative review compares the two approaches across oncologic, perioperative, functional, and economic domains. Pathologic outcomes are broadly equivalent, though contemporary evidence—most notably the REAL trial—suggests a possible emerging robotic advantage, although further study is necessary in this regard. Robotic surgery offers potential advantages in conversion rates, blood loss, and postoperative urinary and sexual function, while laparoscopy retains advantages in operative time and cost. At present, platform choice should be guided by patient anatomy, tumor characteristics, and surgical expertise, with robotic surgery likely most valuable in anatomically challenging cases where laparoscopy is most limited. Full article

Anastomotic leakage (AL) and pelvic sepsis remain important causes of morbidity after restorative rectal cancer surgery, affecting mortality, stoma-free survival, bowel function, and oncologic treatment. Reported rates after low anterior resection are approximately 5–20%. We conducted a structured narrative review of PubMed/MEDLINE and the Cochrane Library through 20 July 2026, focusing on prevention, recognition, source control, and long-term recovery after low pelvic reconstruction. Most biological requirements for healing and principles of source control are approach-agnostic, whereas open, laparoscopic, and robotic surgeries create different technical conditions for pelvic exposure, stapler trajectory, articulation, tactile feedback, conversion, and fluorescence imaging. This review therefore integrates approach-specific technical constraints with post-discharge recognition, anatomy-based source control, and patient-centered long-term outcomes rather than treating these domains separately. Among preventive measures, combined mechanical bowel preparation and oral antibiotics has the strongest support in elective, non-obstructed patients; indocyanine green fluorescence is a useful adjunct when perfusion is uncertain but does not replace assessment of tension or mechanical integrity. C-reactive protein is mainly useful for ruling out major complications, whereas contrast-enhanced computed tomography remains first-line imaging and pelvic magnetic resonance imaging is best reserved for selected small defects, chronic sinuses, or complex pelvic sepsis. Management should be driven first by physiology and then by leak timing and location, defect size, conduit viability, diversion status, and cavity drainability. Durable success includes sepsis control, anatomical healing, stoma reversal when feasible, and acceptable long-term function. Full article

Gastrointestinal (GI) cancers represent a diverse group of malignancies that remain a major cause of cancer-related morbidity and mortality worldwide. Their management is increasingly complex, reflecting differences in tumor biology, anatomical location, stage, and molecular profile. In recent years, advances in molecular diagnostics, immunotherapy, and targeted treatment have moved clinical decision-making beyond a purely organ- and stage-based approach toward more individualized, biomarker-guided care. This narrative review summarizes established and emerging biological and targeted therapies used in esophageal, gastric and gastroesophageal junction, colorectal, pancreatic, hepatocellular, and biliary tract cancers. It focuses on immune checkpoint inhibitors targeting PD-1, PD-L1, and CTLA-4; HER2-directed monoclonal antibodies and antibody–drug conjugates; antiangiogenic and anti-EGFR therapies; and newer strategies involving CLDN18.2, FGFR2b, and tumor-agnostic alterations such as NTRK fusions. The review also considers the predictive biomarkers used to guide treatment selection and the growing integration of systemic therapy with surgery in neoadjuvant, perioperative, adjuvant, and conversion settings. However, clinical efficacy alone does not determine whether new treatments become part of routine practice. Regulatory approval, reimbursement, access to molecular testing, and the availability of specialized multidisciplinary care are equally important. The rapidly evolving treatment landscape for GI cancers therefore requires clinical decisions that account for tumor biology, anatomical resectability, molecular eligibility, expected benefit, treatment-related toxicity, and local access to therapy. Expanding access to comprehensive biomarker testing and effective molecularly guided treatments will be essential to translate progress in precision oncology into more personalized and equitable care for patients with GI cancers. Full article

Objectives: To evaluate the clinical accuracy and patient-reported outcomes (PROMs) of robotic-assisted full-arch implant rehabilitation performed with an autonomous robotic implant system. Materials and Methods: Six consecutive edentulous patients requiring implant-supported full-arch rehabilitation were treated using the Yakebot task-autonomous robotic implant system following a fully digital workflow. A total of 36 Straumann Bone Level Tapered implants were placed using a flapless approach. Implant placement accuracy was assessed by comparing planned and postoperative CBCT datasets. Coronal, apical, depth, and angular deviations were automatically calculated using dedicated robotic planning software. Patient-reported outcomes were prospectively evaluated through a structured questionnaire assessing preoperative perceptions, postoperative morbidity, and overall treatment satisfaction. Results: All implants were successfully placed according to the robotic-assisted workflow without intraoperative complications or conversion to conventional surgery. Mean three-dimensional coronal and apical deviations were 0.45 ± 0.18 mm and 0.47 ± 0.19 mm, respectively, while mean total angular deviation was 1.30 ± 0.63°. Patients reported low preoperative anxiety (0.5 ± 0.8/10), limited postoperative pain (2.2 ± 3.5/10), swelling (1.3 ± 2.2/10), and interference with daily activities (1.3 ± 2.2/10). Overall surgical experience was highly rated (9.7 ± 0.8/10). Final satisfaction scores were exceptionally high, with all patients indicating they would undergo robotic-assisted surgery again and recommend the procedure to others. Conclusions: Robotic-assisted full-arch implant rehabilitation demonstrated a high level of clinical accuracy, with submillimetric coronal and apical deviations and low angular discrepancies. In addition, treatment was associated with low postoperative morbidity, excellent patient acceptance, and very high satisfaction. These findings support the potential of autonomous robotic implant surgery as a predictable and patient-centered approach for full-arch rehabilitation, although larger controlled studies are required to confirm these results. Full article

Objective: The aim of this study was to evaluate the efficacy and safety of endovascular and hybrid treatment approaches in patients with aortic arch aneurysms. Materials and Methods. This retrospective study included 68 male and female patients with a confirmed diagnosis of either an aortic arch aneurysm or a descending thoracic aortic aneurysm with a short proximal landing zone (<1.5 cm) who underwent either hybrid or endovascular treatment at the Department of Vascular Surgery between January 2017 and December 2024. Study outcomes included a composite measure of technical success, a composite measure of in-hospital clinical success, and a composite measure of long-term treatment outcomes, including stroke, myocardial infarction, and aortic-related mortality. Results. All 68 patients were divided into two groups: Group I comprised patients who underwent endovascular treatment, whereas Group II included patients who underwent hybrid surgical treatment. The groups were comparable with regard to demographic and anatomical characteristics, clinical presentation, and comorbidities. The composite technical success rate (defined as successful target stent-graft deployment without conversion to open surgery and absence of type I or type III endoleaks) was comparable between the groups at the intraoperative stage (p = 1.000). The composite measure of in-hospital clinical success was achieved in 33 patients (94%) in Group I and 22 patients (67%) in Group II and was significantly higher in the endovascular group (adjusted p = 0.005). This difference was primarily attributable to a higher incidence of complications in the hybrid treatment group, including stroke (9%) and peripheral nerve injury (9%), associated with the open surgical component of the procedure. The mean follow-up duration was shorter in Group I (19.3 ± 10.4 months) than in Group II (63.9 ± 29.5 months), reflecting the fact that most patients in Group I underwent treatment during the later years of the study period. Although a difference in the composite long-term outcome measure was observed before adjustment (p = 0.031), this finding did not remain statistically significant after correction for multiple testing (adjusted p = 1.000). Conclusions. In this preliminary single-centre study, endovascular and hybrid approaches showed comparable technical efficacy in the early postoperative period. However, hybrid surgical treatment was associated with a less favourable safety profile during the early postoperative period, as reflected by the significantly lower in-hospital composite clinical success rate and longer hospital stay than in the endovascular group. These findings remained robust after correction for multiple testing. Long-term results should be interpreted with caution and require confirmation in larger prospective studies with longer and balanced follow-up periods. Full article

Background: Acute appendicitis is the leading pediatric surgical emergency. Identifying drivers of disease severity and laparoscopic-to-open conversion remains critical for surgical planning. We evaluated the discriminative performance of clinical scores and inflammatory biomarkers for both peritonitis and surgical conversion, and explored combined clinical–laboratory models among children with acute appendicitis undergoing an initially attempted laparoscopic appendectomy. Methods: A retrospective study was conducted, including pediatric patients with acute appendicitis who underwent surgical treatment. Clinical scores (Alvarado score and Pediatric Appendicitis Score) and laboratory parameters (C-reactive protein, neutrophil count, and neutrophil-to-lymphocyte ratio) were analyzed. Receiver operating characteristic (ROC) curve analysis was used to assess discriminative ability, with calculation of the area under the curve (AUC). Combined models based on standardized variables were constructed and evaluated. Comparisons between AUCs were performed using DeLong’s test. Results: For prediction of peritonitis, clinical scores suggested good discriminative ability within the sample, with AUC values of 0.805 for the Alvarado score and 0.812 for the Pediatric Appendicitis Score, whereas C-reactive protein showed moderate performance (AUC = 0.735). Combined models achieved AUC values of 0.823 for both zPAS + zCRP and zAlvarado + zCRP, and 0.773 for zCRP + zNLR. For surgical conversion, higher within-sample AUC values were observed, reaching 0.879 for the Alvarado score and up to 0.932 for the combined models (zAlvarado + zCRP), followed by 0.926 for zPAS + zCRP and 0.874 for zCRP + zNLR. However, these results should be interpreted with caution due to the limited number of conversion events. Conclusions: Clinical scoring systems and inflammatory biomarkers suggested good ability to predict peritonitis in pediatric acute appendicitis, while their performance for predicting surgical conversion appeared higher but remains exploratory. Combined clinical–laboratory models showed promising within-sample discriminative ability; however, given the very small number of conversion events, these findings should be regarded as exploratory and hypothesis-generating only. Full article

Background/Objectives: Identifying geriatric hip fracture patients who will require postoperative intensive care unit (ICU) admission remains a clinical challenge. The American Society of Anesthesiologists Physical Status (ASA-PS) classification and the Clinical Frailty Scale (CFS) are both used in preoperative risk stratification, yet their comparative utility for this purpose has not been well characterized. Methods: This single-center, retrospectively designed study included 243 patients aged 65 years or older who underwent hip fracture surgery between January 2023 and December 2025. The primary outcome was determined as postoperative ICU admission, while the secondary outcomes were in-hospital mortality and postoperative complications. Discriminative performance was assessed by ROC analysis with DeLong pairwise comparison. Multivariable logistic regression analysis was performed to identify independent predictors of ICU admission. Results: Postoperative ICU admission occurred in 72.8% of patients. On multivariable analysis, neither ASA-PS nor CFS independently predicted ICU admission. Age (OR 1.052, 95% CI 1.009–1.096; p = 0.017), coronary artery disease (OR 3.992, 95% CI 1.581–10.083; p = 0.003), and spinal anesthesia (OR 0.363, 95% CI 0.161–0.823; p = 0.015) were found to be independent determinants. The addition of either scoring system to this clinical model did not improve discriminative performance (AUC 0.712 vs. 0.709 for both). For in-hospital mortality, CFS demonstrated a markedly superior discriminative ability compared to ASA-PS (AUC 0.801 vs. 0.623; DeLong p = 0.047). Conclusions: In this study, ASA-PS and CFS demonstrated comparable performance in predicting ICU admission; however, neither scale retained independent predictive value after adjustment for age, coronary artery disease, and type of anesthesia. Moreover, incorporating either score into the existing clinical risk model did not meaningfully improve discriminative performance (AUC: 0.709 vs. 0.712). Conversely, CFS exhibited superior discriminative ability compared to ASA-PS for in-hospital mortality. Given the low number of mortality events (n = 13), this finding should be interpreted cautiously as exploratory and warrants confirmation in larger, prospective, multicenter studies. Full article

Background/Objectives: Robotic surgery offers an additional minimally invasive option for gastric gastrointestinal stromal tumor (GIST) resection, particularly in anatomically demanding locations. Evidence regarding its integration into routine surgical practice remains limited. This study evaluated the evolution of surgical approaches for primary localized gastric GIST following the introduction of an institutional robotic program. Methods: We retrospectively analyzed 44 consecutive patients who underwent curative-intent resection for primary localized gastric GIST at a tertiary referral center between July 2015 and June 2025. Surgical management and perioperative outcomes were described for an early era (2015–2021; n = 29) and a later era after the introduction of robotic surgery (2022–2025; n = 15). Results: Overall, 22 procedures were completed laparoscopically, six robotically, and 13 through a primary open approach; three laparoscopic procedures were converted to open surgery. In the later era, robotic surgery accounted for 40.0% of resections, and no conversions occurred. The proportion of completed minimally invasive resections was 62.1% in the early era and 66.7% in the later era. R0 resection was achieved in all patients, and no tumor rupture was documented. Median operative time was 73.5 min, median postoperative length of stay was 7.5 days, and major morbidity occurred in six patients (13.6%). One patient (2.3%) died from sepsis within 30 days after reoperation for a postoperative gastric suture-line leak. Conclusions: Following the introduction of robotic surgery, management of primary gastric GIST evolved toward a more diversified and individualized surgical strategy. Robotic surgery was incorporated as an additional minimally invasive option, while the overall proportion of completed minimally invasive resections remained stable. These findings represent an early institutional experience and do not establish equivalence or comparative superiority among surgical approaches. Full article

Objective: Our objective was to compare clinical safety and postoperative efficacy between transvesicoscopic Politano–Leadbetter (TPL) and laparoscopic Lich–Gregoir (LLG) ureteral reimplantation in infants and toddlers under 36 months diagnosed with primary obstructive megaureter (POM). Methods: This was a single-center retrospective cohort study of pediatric patients with POM who underwent ureteral reimplantation between January 2018 and April 2025. Patients were stratified into TPL and LLG groups by surgical approach. Baseline characteristics, perioperative outcomes, perioperative complications, imaging findings, renal functional outcomes, and long-term complications were collected and analyzed. Primary group comparisons were unadjusted, with additional multivariable linear regression performed for operative duration. Results: We enrolled 65 children: 30 in the TPL group and 35 in the LLG group. Baseline characteristics showed no statistically significant differences across the two study cohorts. There were no open conversions in either group. Total operative duration did not differ significantly between the TPL and LLG groups (145.8 ± 30.6 min vs. 136.9 ± 25.2 min; mean difference, 8.9 min; 95% CI, −4.9 to 22.7; p = 0.210). In multivariable linear regression, TPL showed a non-significant trend toward longer operative time after adjustment for age, preoperative ureteral diameter, and surgery year (B = 10.4 min; 95% CI, −3.7 to 24.4; p = 0.141). Time to postoperative oral intake was slightly shorter in the TPL group (6.1 ± 2.3 h vs. 8.2 ± 2.9 h; mean difference, −2.1 h; 95% CI, −3.4 to −0.8; p = 0.002). No statistically significant differences were detected in estimated blood loss, ureteral tapering rate, double-J stent placement rate, postoperative pain score, acetaminophen use, urinary catheterization duration, or length of hospital stay. Perioperative complications occurred in 3 patients in the TPL group and 5 patients in the LLG group (10.0% vs. 14.3%; risk difference, −4.3%; 95% CI, −20.1% to 11.5%; p = 0.716). No Clavien–Dindo grade III or higher complications occurred in either group. During follow-up, both groups showed reductions in anteroposterior pelvic diameter (APD) and ureteral diameter (UD), with preserved differential renal function (DRF). Low-grade postoperative vesicoureteral reflux (VUR) was detected in two LLG patients, including one grade I case at 4 months and one grade II case at 6 months after surgery; both were managed conservatively. Neither group experienced recurrent ureterovesical junction obstruction (UVJO) nor required reoperation during follow-up. Conclusions: In this single-center retrospective cohort of infants and toddlers with POM, no statistically significant differences were detected in the main perioperative and follow-up outcomes between TPL and LLG. TPL enables intravesical reconstruction and better preserves the natural anatomical course of the ureter and may serve as an alternative minimally invasive option for this patient population. Full article