Search Results (655)

Objective: To evaluate current and emerging perioperative optimization strategies in genitourinary surgery and assess their potential to improve surgical outcomes, particularly in patients with modifiable risk factors. Methods: A literature review was conducted using PubMed databases examining perioperative interventions relevant to patients undergoing surgery for genitourinary cancers. Areas of focus included enhanced recovery after surgery protocols, nutritional optimization, exercise prehabilitation, smoking cessation, glucagon-like peptide-1 receptor agonists, and gut microbiome modulation. Evidence from clinical trials, observational studies, systematic reviews, and current clinical guidelines was reviewed and synthesized. Results: Current evidence supports the use of enhanced recovery after surgery protocols to reduce acute complications, shorten length of stay and decrease recovery time. Nutritional optimization and exercise prehabilitation demonstrated improved functional and metabolic capacity. Smoking cessation improved wound healing and decreased pulmonary and infectious complications. Emerging evidence suggests GLP-1 RAs offer metabolic benefits, and microbiome-targeted interventions may improve postoperative recovery through gut microbiome diversity preservation, although clinical data remains limited. Conclusions: Perioperative strategies demonstrate promising potential to improve outcomes in patients undergoing genitourinary surgeries by addressing modifiable risk factors. Further prospective studies are needed to guide clinical implementation. Full article

Background: Postoperative bleeding and prolonged drainage after head and neck surgery may delay drainage tube removal and hospital discharge, increasing complication risk and resource utilization. Optimizing intra and postoperative hemostasis is essential to facilitate early recovery and support enhanced recovery after surgery (ERAS) pathways. This study aimed to identify factors associated with postoperative drainage and length of hospital stay, with particular focus on energy-based device and fibrin sealant use. Methods: Adult patients who underwent neck surgery under general anesthesia with inpatient admission at a tertiary medical center between January 2024 and December 2025 were retrospectively analyzed. Surgical procedures included thyroidectomy (n = 99), parotidectomy (n = 43), submandibular gland excision (n = 25), neck dissection (n = 27) and other procedures (n = 22). Clinical variables, surgical factors, use of energy-based device, hemostatic agents, postoperative drainage volume, and length of hospital stay were collected. Logistic regression analysis was performed to evaluate predictors of early discharge (defined as discharge on postoperative day 1). Results: A total of 216 patients were included. Surgical procedure type was strongly associated with operative duration, postoperative day 1 drainage volume, and length of hospital stay. Neck dissection and total thyroidectomy were associated with increased drainage and prolonged hospitalization. The use of fibrin sealants was independently associated with lower postoperative drainage volume, shorter hospital stay, and a significantly higher likelihood of early discharge (adjusted odds ratio: 4.43, 95% CI 1.92–10.23, p < 0.001). Energy-based device use and patient-controlled analgesia were not associated with early discharge. Conclusions: Incorporating fibrin sealant into perioperative management may facilitate safer and earlier discharge, improve patient turnover, and optimize resource utilization within ERAS-based care pathways. Full article

Background: Secondary lymphedema is a chronic complication of oncologic surgery and radiotherapy for which effective disease-modifying therapies remain lacking. While mesenchymal stem cells (MSCs) have shown partial benefit in experimental models, direct functional comparison with lineage-committed lymphatic endothelial progenitor cells (LEPCs) remains limited. Methods: Secondary lymphedema was induced in C57BL/6J mice by circumferential tail skin excision with disruption of superficial lymphatics. Animals received intradermal phosphate-buffered saline (PBS), MSCs, or adipose-derived LEPCs on postoperative days 1 and 7. Lymphatic function was longitudinally quantified using IVIS-based near-infrared indocyanine green (ICG) imaging with standardized region-of-interest analysis. Tail diameter was measured serially throughout follow-up as a complementary morphometric parameter. Tissue remodeling was assessed by Picrosirius Red staining and qualitative LYVE-1 immunofluorescence. Statistical analysis incorporated mixed-effects modeling to evaluate treatment group, sex, time, and their interaction terms, with estimation of effect sizes and 95% confidence intervals. Results: LEPC-treated mice demonstrated higher IVIS signal intensity than MSC- and PBS-treated animals, consistent with improved lymphatic transport at the injury site. Longitudinal tail diameter analysis showed a more favorable temporal profile in the LEPC group relative to controls, with exploratory analysis suggesting potential variations in temporal profiles between sexes that warrant further investigation in larger cohorts. Histologic analysis showed reduced non-tissue/void area and a more favorable qualitative pattern of LYVE-1 staining in LEPC-treated tissue. Conclusions: LEPC administration enhanced functional and structural recovery in a murine model of secondary lymphedema. These findings support further translational evaluation of LEPC-based approaches as a regenerative strategy for secondary lymphedema. Full article

Axillary lymph node staging remains a cornerstone of the surgical management of breast cancer. Conventional axillary lymph node dissection (ALND) has historically been the standard procedure for evaluating nodal involvement; however, it is associated with significant morbidity, including lymphedema, sensory disturbances, and reduced shoulder mobility. Over the past few decades, minimally invasive surgery has demonstrated clear benefits in multiple surgical fields, particularly in reducing postoperative morbidity, improving recovery, and enhancing cosmetic outcomes. In breast surgery, these principles have been progressively incorporated into clinical practice. Endoscopic techniques were first introduced in the late 1990s as a minimally invasive alternative to axillary lymph node dissection. Early studies have demonstrated the technical feasibility of endoscopic axillary lymphadenectomy (EALND), reporting adequate lymph node retrieval and acceptable perioperative outcomes. Although the widespread adoption of sentinel lymph node biopsy and the progressive de-escalation of axillary surgery have limited the diffusion of this approach, the potential advantages of minimally invasive techniques appear to be applicable to axillary surgery. In recent years, minimally invasive approaches, including endoscopic and robot-assisted procedures, have been expanded in breast surgery and are now being explored for axillary management. Advances in instrumentation, optics, and imaging technologies, such as fluorescence, have improved surgical visualization and may facilitate safer and more precise dissection of axillary structures. This review summarizes the historical development, technical evolution, and current evidence regarding endoscopic axillary lymphadenectomy for breast cancer. Furthermore, we discuss the potential role of this approach in the modern era of axillary de-escalation and highlight the emerging technologies that may contribute to the future development of minimally invasive axillary surgery. Full article

The treatment of osteoarthritis (OA), a leading cause of disability worldwide, is increasingly integrating nutritional strategies that appear to offer the opportunity to significantly improve the quality of care. Patients are also aware of this and often seek clarification and advice from OA professionals. However, it is still too early to formulate definitive recommendations, as the scientific evidence is still heterogeneous. This can create a gap between patients’ need for clear guidance and the necessarily prudent communication of professionals. As a result, some patients may make decisions on their own, forgoing the opportunity to receive nutritional care personalised according to their dietary habits and disease severity. This commentary presents an expert interpretation of the currently available evidence and proposes a practical framework to support clinical discussions with patients. It is not intended as a formal clinical practice guideline but aims to help OA professionals navigate conversations about the role that nutritional strategies may play in disease management. Full article

Total knee arthroplasty (TKA) is increasingly performed in older adults, a population with a growing prevalence of frailty and sarcopenia. Analgesic strategies focused mainly on pain reduction may overlook mobility, functional independence, fall prevention, and delirium risk, making motor preservation a central goal of perioperative care. This narrative review examines the anatomical basis, clinical evidence, and practical application of motor-sparing regional analgesia for older adults undergoing TKA, with emphasis on frailty, sarcopenia, and mobility-centred recovery, synthesising current evidence on established, emerging, and experimental techniques. Evidence was classified as geriatric-specific, older-enriched mixed-age, or mixed-age adult. Most technique-specific evidence derives from cohorts that included younger adults; only two small randomised trials reported cohorts composed exclusively of patients aged ≥65 years, and no regional-analgesia trial stratified outcomes by frailty or sarcopenia. A pragmatic clinical decision framework was developed to support individualised strategy selection in frail and sarcopenic patients. Current evidence supports adductor canal block combined with local infiltration analgesia as the foundation of motor-sparing analgesia after TKA; supplementary techniques such as iPACK, popliteal plexus block, genicular nerve block, and anterior femoral cutaneous nerve block may further optimise sensory coverage while preserving quadricep strength, whereas femoral nerve block produces predictable motor impairment and appears less suitable for this population. The existing literature remains largely focused on pain scores and opioid consumption, while mobility-related outcomes are infrequently reported. Direct evidence for falls, near-falls, delirium, discharge destination, functional independence, and long-term mobility remains sparse or absent. Successful analgesia after TKA should be defined not only by pain relief but by preservation of mobility and functional recovery, and future research should prioritise frailty-specific, mobility-centred outcomes. Full article

Background: Prehabilitation has become an essential component of perioperative care in colorectal surgery, aiming to improve postoperative outcomes through multimodal interventions. However, its real-world implementation remains heterogeneous. This study aimed to evaluate the degree of implementation and variability of prehabilitation programs across colorectal surgery units in Spain. Methods: A national multicenter cross-sectional survey (VAPPER Survey) was conducted among colorectal surgery units. The questionnaire included 83 items addressing organizational structure, nutritional assessment, frailty screening, and multidisciplinary collaboration. Data were analyzed descriptively and expressed as frequencies and percentages. Results: A total of 104 hospitals participated. Prehabilitation programs were present in 79% (n = 82) of centers, while 21% (n = 22) reported no program. Nutritional screening was not performed in 21% (n = 22) of hospitals. Among those performing screening, MUST was the most frequently used tool (68%, n = 56), although considerable variability existed. Systematic use of GLIM criteria was reported in only 24% (n = 20), whereas 35% (n = 28) did not use GLIM and 41% (n = 34) applied it selectively. Frailty screening in patients ≥70 years was absent in 54% (n = 44) of centers, and geriatric involvement was limited and non-standardized. Conclusions: Prehabilitation is widely implemented in Spain but remains highly heterogeneous across all dimensions. The most relevant deficits are concentrated in systematic nutritional assessment, malnutrition diagnosis using standardized criteria, geriatric integration, and psychological support. Standardization of protocols, strengthening of multidisciplinary teams, and enhanced training in perioperative nutrition are priorities for optimizing outcomes in colorectal surgery. Full article

Background: Minimally invasive cardiac valve surgery has emerged as a preferred approach in selected patients, yet optimal postoperative extubation timing remains debated. This systematic review and meta-analysis examined clinical outcomes associated with extubation in the operating room (OR) versus the intensive care unit (ICU) among adult patients undergoing minimally invasive cardiac valve surgery. Methods: The study was conducted according to PRISMA guidelines. A single unit of analysis was applied throughout. Pooled odds ratios were computed with the Mantel–Haenszel random-effects method; where a study reported only a matched or covariate-adjusted estimate, that estimate was reserved for a prespecified sensitivity analysis using the generic inverse-variance method. Results: Five observational studies (2023–2025) including 1101 OR-extubated and 899 ICU-extubated patients from high-volume centers with fast-track or enhanced recovery pathways were included. OR extubation was associated with lower odds of reintubation (OR 0.40; 95% CI 0.24–0.69; I² = 0%), postoperative delirium (OR 0.47; 95% CI 0.31–0.72; I² = 0%), and pneumonia (OR 0.30; 95% CI 0.16–0.53; I² = 0%). No significant differences were observed for new-onset atrial fibrillation, stroke, or reoperation for bleeding. Thirty-day mortality was reported by four of the five studies and comprised few events (5 of 1043 ORE versus 17 of 645 ICE across the four studies reporting this outcome); given the small number of events, the concentration of deaths in the higher-risk ICU-extubated patients, and the reliance of the pooled estimate on two confounded cohorts, this difference is not interpretable as a treatment effect, and no pooled odds ratio is reported here. Length of stay was consistently shorter after OR extubation but was not pooled because of extreme heterogeneity (I² = 96–100%). Sensitivity analyses using adjusted estimates attenuated the associations for reintubation and pneumonia, consistent with substantial confounding by indication. Conclusions: In appropriately selected patients undergoing minimally invasive valve surgery, OR extubation is feasible and is associated with a recovery profile at least comparable to that of ICU extubation. Because extubation location was determined largely by intraoperative and early postoperative stability, these associations should be read as reflecting patient selection rather than a causal benefit of the strategy. The findings support the feasibility of OR extubation in appropriately selected patients at experienced centers and motivate prospective, ideally randomized, evaluation. Full article

Background: Enhanced Recovery After Surgery (ERAS) pathways have become the standard of care in elective colorectal surgery. However, implementation remains heterogeneous across institutions, and the relative contribution of ERAS pathways and minimally invasive surgery to improved postoperative outcomes remains uncertain. This study evaluated the association between ERAS implementation and short-term outcomes in two university-affiliated colorectal units with different levels of ERAS adoption. Methods: A retrospective bi-centre observational study was conducted, and comprised 802 consecutive patients who underwent elective colorectal resection between January 2016 and December 2024. Patients managed according to a standardized ERAS pathway (Group 1, n = 406) were compared with patients who received conventional perioperative care (Group 2, n = 396). Primary endpoints included postoperative morbidity, anastomotic leakage, and length of hospital stay (LOS). Secondary endpoints included mortality, readmission, postoperative complications, and hospitalization-related costs. Multivariable logistic regression was performed, adjusting for age, sex, ASA score, tumour stage, and tumour location. Results: Baseline demographic characteristics were largely comparable between groups, although patients in the conventional care group had a higher proportion of ASA III–IV status. Overall postoperative morbidity was significantly lower in the ERAS cohort (8.6% vs. 20.9%, p < 0.001), together with a lower incidence of anastomotic leakage (1.2% vs. 4.5%, p < 0.001). Median LOS was reduced from 9 to 8 days overall and, among patients who underwent laparoscopic surgery, from 6 to 4 days (p = 0.010). After multivariable adjustment, conventional perioperative management remained independently associated with higher postoperative morbidity (OR 2.62, 95% CI 1.60–4.09; p < 0.001) and anastomotic leakage (OR 1.92, 95% CI 1.01–4.98; p = 0.048). Mortality, surgical site infections, intra-abdominal abscesses, and other postoperative complications were comparable between groups. Based on regional reimbursement tariffs, ERAS implementation was associated with an estimated annual reduction of 567 hospital bed-days. Conclusions: Implementation of a standardized ERAS pathway was associated with reduced postoperative morbidity, lower anastomotic leakage rates, and shorter hospital stay after elective colorectal surgery. These benefits persisted after adjustment for major clinical confounders, supporting the effectiveness of standardized perioperative care. The greatest reduction in hospital stay was observed when ERAS was combined with minimally invasive surgery, emphasizing the complementary role of these strategies in optimizing postoperative recovery. Full article

Background/Objectives: Surgical treatment of colorectal cancer (CRC) is associated with a substantial risk of postoperative complications and delayed recovery of functional capacity, particularly in older patients and those with multiple comorbidities. Preoperative prehabilitation has emerged as a strategy aimed at optimizing patients’ physical, nutritional, and psychological status prior to surgery; however, its clinical effectiveness and feasibility of implementation remain subjects of ongoing debate. The aim of this narrative review was to provide a clinically oriented synthesis of current evidence regarding multimodal prehabilitation in patients undergoing CRC surgery, with particular emphasis on perioperative outcomes, functional recovery, nutritional optimization, and implementation-related considerations. Methods: A targeted narrative review of the peer-reviewed literature indexed in PubMed (2015–2025) was conducted to identify contemporary review-type publications, including narrative reviews, systematic reviews, scoping reviews, and meta-analyses, addressing prehabilitation in CRC surgery. The findings were synthesized narratively and interpreted with emphasis on clinical applicability and translational relevance. Results: Twenty contemporary review publications were included in the analysis. Across the included publications, the most frequently reported favorable effects were observed for multimodal prehabilitation, incorporating physical exercise, nutritional support, and a psychological component. These interventions were associated with improvements in functional capacity and, in some meta-analyses, with a reduction in postoperative complication rates and shorter length of hospital stay, particularly in high-risk patients. Prehabilitation was assessed as safe and well tolerated. Conclusions: The current body of evidence indicates that multimodal prehabilitation may constitute a beneficial adjunct, particularly in improving functional capacity, while its impact on hard postoperative outcomes remains closely dependent on intervention quality, appropriate patient selection, and seamless integration with established perioperative care pathways. Future meta-analyses should address underexplored components of prehabilitation, including preparation for stoma formation and targeted educational and psychological support related to sexual health. Full article

Total-knee arthroplasty (TKA) is associated with substantial acute postoperative pain. While the adductor canal block (ACB) is widely used to provide motor-sparing anterior knee analgesia, effective management of posterior knee pain remains an important clinical challenge. The infiltration between the popliteal artery and the capsule of the posterior knee (IPACK) block was developed to address posterior capsular pain but may be associated with technical and ergonomic limitations. More recently, the popliteal plexus block (PPB) has emerged as a novel motor-sparing alternative. This narrative review summarizes the anatomical basis, current clinical evidence, and practical considerations of combining the ACB with the PPB, with particular emphasis on its potential role as an alternative to the IPACK block within Enhanced Recovery After Surgery (ERAS) pathways. Current anatomical and early clinical evidence suggests that the PPB selectively targets the terminal articular branches around the adductor hiatus while preserving the major motor nerve trunks. Available randomized clinical trials indicate that the PPB provides analgesia comparable to IPACK while maintaining motor function, with additional practical advantages including shorter procedural time and, in individual studies, reduced postoperative opioid consumption and postoperative nausea. Overall, the combined ACB and PPB approach appears to be a promising motor-sparing strategy for perioperative analgesia after TKA. However, the current evidence is derived predominantly from cadaveric studies, early-phase randomized trials, and single-center clinical investigations. Therefore, larger multicenter studies with longer follow-ups are needed to establish its long-term efficacy, safety, and role relative to the established IPACK technique. Full article

Background and Objectives: Over recent decades, germline genetic testing has become increasingly integrated into breast cancer care, yet its precise effect on the timing of surgical workflows remains incompletely defined. This study investigates the implementation of nationally reimbursed genetic testing programs and examines how the scheduling of multigene germline testing relates to surgical timing. Materials and Methods: In this retrospective cohort analysis, we examined 502 breast cancer cases from the institutional registry of the “Ion Chiricuță” Oncology Institute (IOCN), with a mean age of 52 years, a high rate of neoadjuvant therapy (82.3%) and a majority of them in T2 (52%) and N1 (43%), N2 (29%) clinical stage: 263 patients from an earlier private-practice pay testing era (pre-reimbursement) as a comparison sample and 239 patients from the period when reimbursement programs were in operation. We then evaluated the benefits of state-funded genetic testing initiatives, computing three intervals: diagnosis to genetic test, genetic test to surgery, and diagnosis to surgery. Patients were categorized by timing of multigene testing (preoperative vs. postoperative), receipt of neoadjuvant systemic therapy (NACT), mutation status, and funding source for testing (national PNS program funded by the Romanian Ministry of Health; PNRR European Recovery and Resilience Facility funds; or self-funded private testing). Nonparametric statistics (Mann–Whitney U, Spearman correlation) and effect-size metrics (Cliff’s delta, Theil–Sen slope) were employed. Results: The median diagnosis-to-surgery interval was 203 days (IQR 179–230). Patients tested preoperatively had longer intervals than those tested postoperatively (216 vs. 182.5 days; p = 0.000153; Cliff’s δ = −0.486), a pattern driven by shared pathways involving NACT rather than by testing-induced delays. NACT was the principal determinant of surgical timing (211 vs. 43 days; p = 302.55 × 10⁻¹¹). Within the preoperative subgroup, time to multigene testing correlated strongly with time to surgery (Spearman ρ = 0.54; p = 4.75 × 10⁻⁷; Theil–Sen slope = 0.37, 95% CI = 0.22–0.53). However, the no-NACT group included only four patients. The presence of a pathogenic variant did not significantly change surgical timing (p = 0.982). The PNS national reimbursement program achieved the highest preoperative integration rate for multigene genetic testing after adjustment for NACT confounder (76.7%), outperforming PNRR (61%) and private practice (56%). Conclusions: While genetic testing timing correlates with surgical workflow, neoadjuvant systemic therapy pathways and program structure exert greater influence than testing per se. Structured national programs enhance preoperative testing uptake without causing delays beyond those inherent to NACT pathways. Full article

Background/Objectives: Total Knee Arthroplasty (TKA) is the gold-standard treatment for end-stage knee osteoarthritis. After surgery, the natural onset of edema and pain usually influences the early functional recovery. Manual Lymphatic Drainage (MLD) has been proposed as a possible adjunct rehabilitation strategy in the immediate management of the operated joint. This review aimed to assess the effectiveness of MLD during early rehabilitation after TKA. Methods: Searches were conducted in PubMed, Embase, CINAHL, and Google Scholar up to June 2025. Eligible studies were randomized controlled trials (RCTs) comparing MLD with non-MLD interventions (standard physiotherapy, Kinesiotaping, and negative-pressure devices). An exploratory meta-analysis using a random-effects model was performed. The primary outcome was postoperative edema reduction; secondary outcomes were the effects on pain and range of motion (ROM). Results: Eight RCTs (n = 463 participants) met the inclusion criteria. Edema data were insufficient for reliable quantitative synthesis (two poolable studies; SMD = −1.08 and +0.20; I² = 78.1%). MLD did not yield consistent improvements in AROM (SMD = 0.15; 95% CI: −0.08 to 0.37; I² = 0.0%) or pain. Two studies reported modest, short-lived benefits in the first postoperative days. No treatment-related adverse events were reported. Conclusions: Available evidence does not support the routine use of MLD as a primary intervention after TKA. Owing to its excellent safety profile, MLD may be considered selectively within a multimodal rehabilitation program as an adjunctive comfort-enhancing intervention, particularly for patients with low exercise tolerance. Further high-quality RCTs with standardized protocols are needed. Full article

The association of atrial fibrillation (AF) and neck of femur fractures (NOF) are common in old people, creating a complex clinical scenario with significant implications for morbidity, mortality, and healthcare systems. This narrative review explores the bidirectional relationship between AF and NOF, focusing on shared risk factors, pathophysiological links, and challenges in clinical management, and also reviews the benefit of an orthogeriatric model. Advanced age, frailty, osteoporosis, polypharmacy, and cardiovascular comorbidities predispose patients to both conditions, while AF itself increases fall risk through haemodynamic instability, syncope, and adverse effects of rate- or rhythm-controlling medications. Importantly, the physiological stress of hip fracture and subsequent surgery can precipitate new-onset or worsening AF via inflammatory, neurohormonal, and metabolic mechanisms. The main challenge for ortho-geriatricians lies in anticoagulation management and preoperative and postoperative management. While anticoagulation reduces thromboembolic risk in AF, it increases perioperative bleeding risk in patients with NOF, often leading to delays in surgery that are independently associated with poorer outcomes. This review examines the current evidence regarding perioperative anticoagulation strategies, timing of surgery, and postoperative resumption of therapy. In addition, the review examines important outcome parameters such as mortality, stroke, bleeding, length of hospital stay, and functional recovery. This highlights the importance of not only improving multidisciplinary care involving orthopaedics, cardiology, geriatrics, and anaesthesia to optimise outcomes, but also enhancing risk stratification. Standardised perioperative pathways and integrated geriatric–cardiac assessment may help mitigate complications. Therefore, understanding how AF and NOF interact is key to delivering holistic, patient-centred care for an increasingly elderly population in orthogeriatric wards. Full article

Background and Objectives: Laparoscopic adrenalectomy is the standard treatment for adrenal tumors, providing reduced postoperative pain, shorter recovery, and improved cosmetic outcomes compared with open surgery. Robotic adrenalectomy was developed to overcome issues resulting from its restricted instrument mobility and two-dimensional vision by providing three-dimensional visualization, tremor elimination, and enhanced dexterity. The single-port (SP) robotic system further reduces invasiveness and improves ergonomics. In this study, we aimed to compare perioperative outcomes between SP robotic and conventional laparoscopic adrenalectomies performed at a single institution. Materials and Methods: This retrospective study included data from 114 consecutive patients who underwent adrenalectomy at Korea University Ansan Hospital between January 2015 and July 2025. Among them, 33 patients underwent robotic adrenalectomy using the da Vinci SP system (SP group), whereas 81 underwent conventional laparoscopic adrenalectomy (laparoscopy group). The preoperative characteristics and perioperative outcomes were compared between the two groups. Results: There were no significant differences in the demographic or tumor characteristics between the groups. Operation time did not differ significantly between the groups; however, in patients undergoing right adrenalectomy, the mean operation time was significantly shorter in the SP group than in the laparoscopy group. Conclusions: SP robotic adrenalectomy demonstrated safety and perioperative outcomes comparable to those of conventional laparoscopic surgery. In right adrenalectomies, the da Vinci SP system achieved a significantly shorter operation time, suggesting that the enhanced instrument flexibility and stable three-dimensional visualization provide a technical advantage in anatomically challenging conditions. Full article