Metabolic and bariatric surgery remains one of the most effective interventions in the management of obesity and its associated medical conditions. The field has continuously grown to now encompass newer procedures that include one-anastomosis gastric bypass, single anastomosis duodeno-ileal bypass with sleeve gastrectomy, sleeve gastrectomy with transit bipartition, and single anastomosis sleeve ileal bypass. These procedures were developed with an aim to tackle current weight loss challenges and safety concerns that tend to present with the more common procedures. Taken together, they have been shown to induce excess weight loss ranging from 64% to 93% over 5 to 10 years, contribute to near-complete resolution of obesity-associated medical conditions, and simultaneously achieve lower rates of complications. However, as most of the current literature reports short-term outcomes, this review aims to identify and discuss their long-term efficacy and safety profiles, emphasizing the need for standardized guidelines that would encourage wider adoption and optimize patient outcomes.
Aim: Robotic-assisted surgery has been successfully introduced in hiatal hernia repair; however, clear advantages over laparoscopy remain limited, with small series and contradictory results. This study aims to evaluate the outcomes of robotic hiatal hernia repair in non-selected patients.
Methods: All patients presenting with symptomatic hiatal hernia were included. The DaVinci® robotic platform was used, and a strict standardized operative technique was performed. Preoperative and postoperative data were prospectively collected and retrospectively analyzed.
Results: A total of 103 consecutive, unselected patients underwent surgery. Median total operating time was 72 min [range 46-168 min]. The 30-day complication rate was 12% (12/103). After a median follow-up of 29 months [range 1-64 months], the late complication rate was 5% and the recurrence rate was 5%.
Conclusion: Robotic surgery is a valuable option for hiatal hernia repair, especially in difficult cases or emergency operations. Whether this translates to better long-term outcomes needs to be further investigated in series with longer follow-up.
The endoluminal functional lumen imaging probe (EndoFLIP) has emerged as a transformative tool in the operative and perioperative management of foregut disorders, including achalasia, gastroesophageal reflux disease (GERD), and esophagogastric junction outflow obstruction. Unlike traditional modalities such as high-resolution manometry and barium swallow studies, EndoFLIP provides real-time, intraoperative assessment of distensibility, compliance, and luminal geometry at the esophagogastric junction. As such, EndoFLIP may augment surgical precision in procedures such as Heller myotomy, fundoplication, and peroral endoscopic myotomy (POEM) by enabling physiologic calibration rather than reliance on static anatomical correction. We further discuss its evolving role in risk stratification, postoperative surveillance, and personalized foregut surgical planning. As the field moves toward functional and minimally invasive solutions, EndoFLIP may offer a data-driven framework to optimize patient outcomes through physiology-informed decision-making in real time.
Aim: Combined ablation and resection (CARe) is a recognized approach for managing multiple colorectal liver metastases (CRLM). Perioperative and long-term results of laparoscopic versus open CARe were evaluated in this study.
Methods: This retrospective multicenter cohort study included CRLM patients who underwent CARe at three hospitals between January 2018 and December 2023. Laparoscopic and open approaches were compared for perioperative and oncological results, with propensity score matching (PSM) applied to reduce baseline imbalance-related bias.
Results: Of the 107 CARe procedures, 65 (60.7%) were performed laparoscopically and 42 (39.3%) via open approach. After PSM, patients who underwent laparoscopic CARe had significantly lower intraoperative blood loss (55 vs. 100 mL, P = 0.028) and shorter postoperative hospital stays (6 vs. 8 days, P = 0.005) compared to those who underwent open surgery. However, the complication rates were comparable (P = 0.415). No differences in median recurrence-free survival (14.9 vs. 13.5 months, P = 0.781) or overall survival (70.9 vs. 48.7 months, P = 0.183) were observed. Notably, laparoscopic CARe group had a higher repeat resection rate following intrahepatic recurrence (52.94% vs. 20.00%, P = 0.036).
Conclusion: Laparoscopic CARe is a safe and effective approach for multiple CRLM, offering reduced perioperative morbidity and enhanced feasibility of repeat hepatic resection compared with the open approach.
Transcatheter mitral valve replacement (TMVR) has emerged as a transformative intervention for patients with severe mitral valve disease who are at high or prohibitive surgical risk. Among the various access routes, the transseptal approach has gained prominence due to its minimally invasive nature and favorable hemodynamic profile. The transseptal route offers direct access to the mitral valve while avoiding thoracotomy and cardiopulmonary bypass, making it particularly suitable for frail and comorbid patients. However, it poses unique technical challenges, including precise transseptal puncture, complex valve anchoring in the dynamic mitral annulus, and management of left ventricular outflow tract obstruction risk. Multimodal imaging, especially real-time 3D transesophageal echocardiography and cardiac computed tomography, plays a pivotal role in procedural planning and execution. This review underscores the transseptal TMVR approach as a rapidly advancing frontier in structural heart disease treatment, emphasizing the need for further randomized trials and long-term data to fully define its role in the therapeutic landscape of mitral valve disease.
Aim: Indocyanine green (ICG) fluorescence is not routinely used in acute small bowel obstruction (SBO), and standardized methods for its use in assessing intestinal perfusion, particularly via laparoscopy, remain lacking. Therefore, we aimed to explore its role in acute SBO in elderly and frail patients undergoing operative management.
Methods: In this single-center, prospective, non-randomized study, we included a case series of patients who underwent emergency laparoscopic surgery for SBO from January 2024 to January 2025 at an Italian community hospital. Patients included were those with acute SBO confirmed by computed tomography scan, who provided signed informed consent, had no allergy to ICG, and were ≥ 18 years old. In borderline cases of intestinal ischemia, we standardized the application of ICG fluorescence to help determine the need for intestinal resection: ICG dosage, timing of injection, timing of fluorescence imaging capture and assessment of the intestinal segment. The postoperative course and the need for re-intervention were evaluated.
Results: ICG fluorescence was applied in 16 patients. Half of the cases were male, the median age was 72 years old, 63% presented an American Society of Anesthesiologists (ASA) Physical Status score of 3-4, and the median Charlson Comorbidity Index was 3. Conversion rate was 37%. Main causes of SBO were strangulated hernia, adhesive bands, adhesions and vascular ischemia. In 6 patients, ICG fluorescence showed a non-fluorescent or perivascular pattern, prompting an intestinal resection. Two patients needed re-intervention. Postoperative complications occurred in 43% of the patients.
Conclusion: SBO often affects elderly and frail patients. ICG fluorescence serves as a useful and feasible tool in emergency laparoscopic surgery. It facilitates the surgical assessment in borderline cases of intestinal ischemia, thereby preventing unnecessary bowel resections.
Aim: To establish and describe a standardized single-position workflow for robot-assisted radical nephroureterectomy with bladder cuff excision (RANU + BCE) using the da Vinci Xi platform. This approach features a dual-rotation reconfiguration, allowing a seamless transition from the renal to the pelvic field without repositioning the patient.
Methods: A retrospective, single-center series of 37 patients with upper tract urothelial carcinoma (UTUC) undergoing transperitoneal Xi RANU + BCE. The rotational reconfiguration commenced with a 90° axial rotation of the multichannel single-site platform - clockwise for left-sided and counterclockwise for right-sided UTUC (as observed externally on the platform). This was followed by coordinated patient-cart axis rotation and overhead-boom adjustment to achieve a pelvic suturing view (12 → 3 for left-sided; 12 → 9 for right-sided), without altering port sites or patient position.
Results: All procedures were completed without repositioning; there were no conversions or reoperations. The median docking time was 15.00 min [interquartile range (IQR) 13.0-19.5], and the median console time was 150.0 min (IQR 121.50-175.50). Estimated blood loss was 50 mL (IQR 20.00-50.00). Hemoglobin reduction was 11.48% on postoperative day (POD) 1 and 10.20% on POD 3. Serum creatinine increased by 8.09% on POD 1 and 18.80% on POD 3. Postoperative complications occurred in 2/37 patients (5.41%), with no complications graded Clavien–Dindo ≥ III.
Conclusion: This integrated Xi workflow may enable a reproducible renal-to-pelvic transition and may help maintain continuous exposure for bladder cuff management without patient repositioning. The straightforward disengage–rotate–re-engage arm choreography allows flexible traction under surgeon discretion and facilitates team adoption and process standardization.
Aim: We propose a novel pre-operative planning approach based on Deep-Learning techniques in the context of minimally invasive mitral valve surgery (MIMVS), for the identification of the mitral valve and optimal thoracic working port positioning in a patient-specific fashion.
Methods: We used supervised Deep-Learning for the processing of contrast-enhanced computed tomography (CT) scans. Our algorithm consisted of four steps: segmentation on CT scans, localization of the mitral valve, creation of maps under three criteria (distance/angle between the mitral valve plane and candidate working port spots, absence/presence of ribs), and selection of optimal working port.
Results: We compared the performance of the Deep-Learning-based approach vs. the previously described semiautomatic method and conventional user’s planning (Dice mean value: 93.59). The Deep-Learning method outperformed the semiautomatic method [intraclass correlation coefficient (ICC) = 0.206]. We defined two interfaces to navigate among candidate working ports.
Conclusion: We suggest that the Deep-Learning-based approach may help the surgeon in identifying the most appropriate working port (thoracic access) for MIMVS, and to comparatively predict the features of different candidate thoracic accesses in individual patients, and help address individual anatomic issues. It may also help standardize the pre-operative planning and obtain a faster learning curve for trainee surgeons.
Since the first laparoscopic liver resection (LLR) was reported in 1991, both surgical techniques and conceptual frameworks have developed rapidly worldwide. Progress in hepatic anatomy - from the classical Couinaud segmentation to refined subsegmental and dynamic portal territory systems - has provided a stronger foundation for precision liver surgery. The “gate theory” and its application in LLR have further enhanced the safety and reproducibility of anatomic dissections. Technically, indications for LLR continue to expand, preoperative evaluation has become more precise, and there has been rapid development in multimodal intraoperative navigation, vascular reconstruction techniques, and robot-assisted surgery. Conceptually, emerging strategies such as anatomic resection based on portal territory and limited anatomic resection are becoming key directions for precision liver surgery. Overall, LLR is advancing toward standardization, precision, and individualization, and is increasingly recognized as a mainstream approach for hepatic resection.
Aim: The optimal surgical technique for pilonidal sinus disease (PSD) remains controversial. This propensity score-matched study compared trephination with wide local excision to minimize selection bias.
Methods: We retrospectively analyzed 317 patients undergoing surgical treatment for PSD (2010-2022). Propensity score matching (1:1, caliper 0.05) using age, sex, body mass index (BMI), occupation, smoking, previous surgery, and symptom duration yielded 78 matched pairs. Primary outcome was recurrence; secondary outcomes included pain [Visual Analog Scale (VAS)], healing time, hospital stay, and return to work. Multivariate logistic regression identified recurrence predictors.
Results: After matching, groups were well-balanced [all standardized mean differences (SMDs) < 0.2]. Recurrence occurred in 15.4% of excision versus 7.7% of trephination patients (P = 0.20). Trephination demonstrated significantly lower pain scores at all timepoints: day 1 (5.2 ± 0.6 vs. 6.3 ± 1.7), day 7 (1.5 ± 1.1 vs. 2.8 ± 1.2), and month 1 (0.1 ± 0.2 vs. 0.5 ± 0.5; all P < 0.001). Hospital stay (1.0 ± 0.7 vs. 2.3 ± 1.2 days) and return to work (10.5 ± 2.2 vs. 12.7 ± 6.4 days) were shorter with trephination (both P < 0.001). Multivariate analysis identified younger age [odds ratio (OR) 0.46 per standard deviation (SD) increase of ~ 10-11 years; P = 0.005] and higher BMI (OR 1.60 per 1 kg/m2 increase; P = 0.03) as independent predictors of recurrence.
Conclusions: Trephination offers significant advantages in postoperative pain, hospital stay, and return to work compared to wide local excision, with a favorable but non-significant difference in recurrence. These findings support trephination when rapid recovery is prioritized. Larger trials are needed to establish long-term recurrence equivalence.
Aim: To assess whether the surgical approach - open pancreatoduodenectomy (OPD) vs. minimally invasive pancreatoduodenectomy (MIPD) - affects short-term postoperative complications in elderly patients, and to determine whether body mass index (BMI) and age-adjusted Charlson Comorbidity Index (aCCI) modify this effect.
Methods: This retrospective cohort study included 156 elderly patients (≥ 65 years) undergoing pancreatoduodenectomy (PD) between 2020 and 2025. Multivariable logistic regression with interaction terms evaluated effect modification by BMI and aCCI on 30-day postoperative complications. Predicted probability-based scenario analyses were used for risk stratification. Exploratory computed tomography (CT) analyses were performed in a representative subgroup (n = 80).
Results: Overall complication rates were comparable between OPD and MIPD, and surgical approach alone was not an independent predictor of complications. Significant interactions were identified between surgical approach and BMI [odds ratio (OR) = 1.28, P = 0.032] and aCCI (OR = 4.18, P < 0.001). Scenario analyses showed that MIPD was associated with lower predicted complication risk in patients with aCCI ≤ 6 and BMI < 23.43 kg/m2, whereas OPD was safer in patients with aCCI > 6. CT analysis demonstrated fewer complications after MIPD in patients with low subcutaneous adipose tissue.
Conclusion: A combined BMI–aCCI–based risk stratification framework supports individualized surgical approach selection in elderly patients undergoing PD.
Aim: Temporary diverting ileostomy protects low colorectal/rectal anastomoses but adds stoma morbidity and a planned reversal. We evaluated an Interrupted Ileostomy Tube as a stoma-sparing diversion strategy.
Methods: We retrospectively analyzed 122 patients undergoing radical resection for low rectal cancer with prophylactic diversion (April 2020 - November 2022): traditional diverting ileostomy (n = 90) vs. Interrupted Ileostomy Tube (n = 32). Outcomes were compared before and after 1:1 propensity-score matching.
Results: The Tube group had shorter diversion-creation time (21.38 ± 4.53 vs. 32.03 ±
Conclusion: In this retrospective analysis, the Interrupted Ileostomy Tube was associated with faster recovery and lower index costs and avoided planned stoma reversal and late stoma morbidity without an apparent increase in early complications.
Aim: Robotic-assisted surgery has emerged as a minimally invasive alternative to open gastrectomy for gastric cancer, offering potential advantages in visualization, instrument precision, surgeon posture, and decreased length of stay (LOS). This study compares peri-operative and oncologic outcomes between robotic and open gastrectomy during an institutional transition to robotic-assisted gastric surgery.
Methods: A retrospective cohort study was conducted of 56 patients who underwent curative-intent gastrectomy for gastric adenocarcinoma between February 2016 and December 2024. Twenty-seven patients underwent robotic-assisted gastrectomy and 29 underwent open surgery. Demographic, operative, pathologic, and postoperative outcomes were compared using Fisher’s exact and Wilcoxon rank-sum tests, with overall survival analyzed by Kaplan–Meier methods.
Results: Baseline characteristics were comparable between groups. Operative time was significantly longer for robotic surgery (median 320 vs. 255 minutes, P = 0.012), but estimated blood loss was lower (100 vs. 175 mL, P = 0.025). Operative complications were significantly fewer in the robotic group (7.4% vs. 31.0%, P = 0.042), and postoperative LOS was significantly shorter (7 vs. 9 days, P = 0.025). While lymph-node yield, R0 resection rate, and 5-year overall survival were numerically higher in the robotic group, these differences did not reach statistical significance.
Conclusion: Robotic gastrectomy demonstrated reduced blood loss, fewer complications, and shorter hospitalization compared with open surgery, with equivalent oncologic outcomes. These findings support the safety and feasibility of robotic gastrectomy during program implementation with significant benefits to the patients.
Aim: To retrospectively analyze the clinical effectiveness of complete thoracoscopy vs. thoracoscopy-assisted surgery in the treatment of multiple rib fractures in non-flail chest.
Methods: A total of 86 patients with multiple rib fractures were divided into a “Complete Thoracoscopy group” (n = 40) and a “Thoracoscopy-Assisted group” (n = 46). Perioperative clinical data, Visual Analog Scale (VAS) pain scores, and 3-month postoperative clinical effectiveness were compared between the two groups.
Results: There was no statistical difference between two groups of patients in basic information (P > 0.05). There was no significant difference between two groups in terms of number of rib fixation fractures during surgery, postoperative chest tube drainage volume, extubating time, postoperative hospital stays, as well as the incidence of common postoperative complications(P > 0.05). Compared with the Thoracoscopy-Assisted group, the Complete Thoracoscopy group had shorter incision length and longer surgical time (P < 0.05). On the 3rd and 7th day after surgery, the VAS scores of the Complete Thoracoscopy group were lower than those of the Thoracoscopy-Assisted group (P < 0.05). The clinical effectiveness of the Complete Thoracoscopy group was better than that of the Thoracoscopy-Assisted group at 3 months after surgery (P < 0.05).
Conclusions: Both complete thoracoscopy and thoracoscopy-assisted surgery have good surgical effects on multiple rib fractures. The complete thoracoscopy procedure has shorter incision length and less trauma, significantly reduces postoperative pain and improves clinical effectiveness. It is worth promoting and applying in clinical practice.
Transcatheter aortic valve replacement (TAVR) has rapidly evolved from a therapy reserved for high-risk surgical candidates to a preferred treatment option across a broad range of patients with severe aortic stenosis. Contemporary randomized trials have demonstrated comparable or superior early outcomes to surgical aortic valve replacement (SAVR), leading to expanded indications in intermediate- and low-risk populations, as well as select patients with bicuspid anatomy. Recent guideline updates, including the 2025 European Society of Cardiology recommendations, unify the age threshold for TAVR to ≥ 70 years in appropriately selected patients and support consideration of early intervention in asymptomatic severe aortic stenosis based on emerging evidence. As younger patients increasingly undergo TAVR, several key uncertainties have become central to clinical decision-making. Long-term valve durability beyond the first decade remains insufficiently defined, emphasizing the need for structured lifetime management strategies that account for anticipated reinterventions, prosthesis-patient mismatch, and coronary access preservation. The rise in valve-in-valve and redo-TAVR procedures introduces complex anatomical challenges, including coronary obstruction and sinus sequestration, which has driven the development of advanced leaflet-modification techniques. In parallel, the role of cerebral embolic protection (CEP) remains uncertain, as randomized trials have demonstrated neutral results, leading to ongoing investigation into which patients may benefit and which technologies may offer meaningful protection. This review synthesizes current evidence and unresolved questions in three domains essential to contemporary TAVR practice: lifetime management, leaflet modification strategies, and CEP.
Aim: Upper tract urothelial carcinoma (UTUC) is an aggressive malignancy historically managed with radical nephroureterectomy (NU). While multiport robot-assisted NU (MP-RANU) offers advantages over open surgery, data on single-port RANU (SP-RANU) remains limited. We aim to describe a single-institution’s experience with SP-RANU and evaluate its feasibility, safety, and early outcomes.
Methods: A retrospective review of SP-RANU procedures completed at a tertiary academic center was conducted. Demographic information, clinical data, tumor characteristics, operative details, and postoperative outcomes were recorded.
Results: Between July 2022 and March 2025, six patients underwent SP-RANU [median age 75 years, interquartile range (IQR) 68-77]. Median operative time was 297 min (IQR 248-368), median estimated blood loss was 325 mL (IQR 213-625), and no intraoperative complications were reported. Median hospital length of stay (LOS) was 1.5 days (IQR 1-5). Two patients experienced Clavien-Dindo grade II complications. Five patients achieved negative oncologic margins, one patient underwent SP-RANU for non-oncologic indications, and one patient developed distant nodal metastasis noted after surgery. There was a median reduction of 9 mL/min/1.73 m2 in estimated glomerular filtration rate (eGFR) between pre-op and discharge levels. Post-operatively, patients required a median of 77 morphine milligram equivalents (MMEs) for pain control, and two patients were discharged without narcotics.
Conclusion: SP-RANU offers regionalization of surgery, low intraoperative morbidity, decreased opioid requirements, short LOS, and promising early perioperative outcomes in carefully selected patients. This data supports SP-RANU as a viable minimally invasive surgical option, with need for further evaluation in a larger comparative cohort.
Aim: Transanal endoscopic microsurgery (TEM) and transanal endoscopic operation (TEO) are enabling platforms for tailored full-thickness or submucosal rectal excision. We evaluated outcomes of patients with rare rectal indications managed using these platforms.
Methods: We performed a single-centre retrospective cohort study of consecutive patients treated with TEM or TEO between 1993 and 2024 for lesions with rare final rectal histology. Inclusion criteria were local excision by TEM/TEO, rare definitive histology, and available perioperative data; standard indications (adenoma/adenocarcinoma), non-rectal lesions, and incomplete records were excluded. Data included lesion characteristics, operative details, margins, complications, hospital stay, follow-up, and recurrence.
Results: Forty-eight patients across 11 histotype groups were included. Excision was full-thickness in 45/48 cases and submucosal in 3/48. Peritoneal entry occurred in 3/48 and was managed on-platform without conversion. R0 resection was achieved in 46/48 patients. Four postoperative complications occurred overall; only one bleeding episode required transfusion and reoperation. There was no mortality. Median length of stay was 3 days [interquartile range (IQR), 2-5], and median follow-up was 36 months (IQR, 22-49). Recurrence occurred in 4/48 patients.
Conclusions: TEM/TEO provided safe, organ-preserving local excision for rare rectal lesions, with high R0 rates, limited morbidity, no mortality, and short hospital stay. These data support the use of rigid transanal endoscopic platforms for selected uncommon rectal pathologies.
Mesh-based repair is the standard treatment for groin hernias. The HerniaSurge Group guidelines recommend both anterior open repair, such as the Lichtenstein repair, and minimally invasive posterior approaches including totally extraperitoneal repair (TEP) and transabdominal preperitoneal repair (TAPP). Over the past decades, several open preperitoneal techniques (OPPs) have been developed, combining posterior mesh placement with an open surgical approach. However, their role in contemporary hernia surgery remains underrecognized. This narrative review summarizes the historical development, anatomical rationale, and clinical evidence supporting OPPs, including transinguinal preperitoneal repair (TIPP), transrectus sheath preperitoneal repair (TREPP), open new simplified totally extraperitoneal repair (ONSTEP), and minimal open preperitoneal repair (MOPP). Preperitoneal mesh placement allows complete coverage of the myopectineal orifice, which represents the anatomical basis for modern posterior repairs. Registry analyses and comparative studies suggest that OPPs may be associated with lower rates of chronic postoperative pain compared with anterior repairs such as the Lichtenstein technique, while achieving outcomes comparable to those of endoscopic approaches. In addition, these techniques offer several practical advantages, including the possibility of performing the procedure under regional or local anesthesia, lower costs, and broad applicability across various clinical settings. OPPs represent a valuable intermediate option between anterior open and endoscopic repairs. By combining the anatomical advantages of posterior mesh placement with the simplicity of open surgery, they may be particularly useful in selected patients and in complex hernias. Greater recognition and further comparative studies are needed to better define their role in modern groin hernia surgery.
The WEO Capsule Endoscopy Global Summit (WEO-CEGS) 2026 was successfully held on March 21, 2026, in Chongqing, China. Jointly organized by the World Endoscopy Organization (WEO) and the Chinese Association of Gastroenterologists and Hepatologists (CAGH), the summit brought together leading experts, clinicians, and researchers in capsule endoscopy. Conducted in a hybrid format, the meeting attracted more than 1,000 participants from 72 countries, including over 500 onsite attendees and more than 500 online participants. The scientific program featured keynote lectures, abstract presentations, panel discussions, and poster sessions, fostering academic exchange and international collaboration. A total of 41 abstracts were submitted, with eight receiving awards in recognition of outstanding scientific contributions. In addition, 19 posters were presented, providing further opportunities for discussion and knowledge sharing. The summit served as an important global platform for advancing research, clinical practice, and technological innovation in capsule endoscopy. Key topics highlighted during the meeting included the integration of artificial intelligence into diagnostic workflows, the development of magnetic navigation technologies, the implementation of standardized quality measures, and the expansion of capsule endoscopy into large-scale, non-invasive screening programs. By bringing together a diverse international community, WEO-CEGS 2026 strengthened global cooperation and contributed to the continued advancement of capsule endoscopy worldwide.
Severe acute pancreatitis (SAP) is a heterogeneous and potentially fatal disease in which infected necrosis, persistent organ failure, and procedure-related morbidity remain major clinical challenges. Although minimally invasive intervention has largely replaced early open necrosectomy, important uncertainties persist regarding the optimal timing of intervention, the choice of initial access route, and the threshold for escalation beyond drainage alone. This review synthesizes current evidence on minimally invasive management of SAP with a particular focus on unresolved controversies and decision-making in real-world practice. Rather than viewing percutaneous, endoscopic, and minimally invasive surgical techniques as competing modalities, we propose that they should be understood as complementary tools within an individualized step-up strategy. In our view, the most meaningful clinical question is not whether minimally invasive treatment is preferable to open surgery, but how intervention should be tailored according to indication, urgency, collection maturity, anatomical distribution, solid necrotic burden, septic trajectory, and local multidisciplinary expertise. Based on these considerations, we present a practical decision-centered framework to guide route selection, timing, and escalation. Future research should move beyond broad modality comparisons toward anatomy-stratified studies, standardized escalation criteria, and long-term patient-centered outcomes.
Minimally invasive treatment for hepatocellular carcinoma (HCC) is evolving from isolated procedures into a longitudinal pathway linking local control, liver-function preservation, and future treatment options. This review synthesizes recent evidence on positioning these therapies according to treatment intent, technical feasibility, biologic selection, and integration with systemic therapy. The evidence is organized into five scenarios: curative-intent treatment, bridging or downstaging to transplantation, unresectable liver-dominant disease, post-recurrence salvage, and transition to systemic therapy. Randomized studies in mixed liver-tumor populations support faster recovery after laparoscopic resection, whereas HCC-specific randomized data have not demonstrated a survival advantage for surgery over radiofrequency ablation (RFA) for small tumors; this does not establish equivalence. Robotic platforms may extend minimally invasive surgery to selected complex cases. RFA remains the benchmark for small tumors, while microwave ablation and combined locoregional approaches extend the boundary of local radicality. Navigation, software-based margin assessment, and real-time imaging are also moving ablation toward a closed-loop quality-control model. In unresectable liver-dominant disease, selected transarterial chemoembolization (TACE)-based sequences and combinations have improved progression-free survival or disease control in trial-defined populations, but LEAP-012 and EMERALD-1 have not demonstrated an overall-survival benefit. Candidate selection extends beyond tumor geometry to tumor biology and host reserve, although artificial intelligence, biomarkers, histotripsy, and experimental platforms remain at different stages. The central challenge is no longer expansion of technical capability alone. It is disciplined sequencing: choosing the right local therapy for the right patient at the right point in the disease course without prematurely exhausting liver reserve.
Aim: To assess whether chronological age (≤ 35 years vs. > 35 years) is associated with technical performance during a standardized high-fidelity Rezūm simulation pathway.
Methods: This retrospective observational simulation-based study was conducted within a national itinerant Rezūm training program across 46 Italian institutions between June 2023 and July 2025. Board-certified urologists and senior residents (postgraduate years 4-5) who were Rezūm-naïve and had no prior simulator exposure were enrolled and stratified into Junior (≤ 35 years) and Senior (> 35 years) cohorts. After completing a standardized online theoretical module and qualification test, participants underwent a single-pass assessment without familiarization, repetition, or real-time feedback. Five fixed-order scenarios of increasing anatomical and cognitive complexity were completed. The primary outcome was the scenario-specific normalized simulator score (0-100).
Results: Overall, 460 participants were included (Junior, n = 120; Senior, n = 340). Mean scores were similar in Scenario 1 (93.38 vs. 93.30; P = 0.89) and Scenario 2 (89.59 vs. 89.21; P = 0.61). Junior participants scored higher in Scenario 3 (84.98 vs. 80.69; P < 0.01) and Scenario 4 (93.55 vs. 91.56; P < 0.01), whereas Senior participants showed higher scores in Scenario 5 (95.55 vs. 93.85; P = 0.02).
Conclusion: Chronological age was not consistently associated with simulator performance. Differences were modest and scenario-specific, supporting standardized high-fidelity simulation while underscoring the need for transfer-validity studies and Rezūm-specific proficiency benchmarks.