[Closure of persisting rectourethral fistula after suprasymphyseal adenoma enucleation of the prostate by combining the Bressel-Naujox and gracilis flap procedure]. / Verschluss einer persistierenden urethrorektalen Fistel nach suprasymphysärer Adenomenukleation der Prostata durch kombiniertes Bressel-Naujox- mit einem Gracilisflapverfahren.

When taking into consideration the basic principles of fistula surgery, numerous options are available for the surgical repair of rectourethral fistulas. However, there is no standard regarding which surgical method should be used under which circumstances-due to the heterogeneity of this disease. This case report describes the individual adaptation of a surgical technique that is used for the treatment of vesicovaginal fistulas to treat a rectourethral fistula in a patient who had already undergone an unsuccessful fistula closure attempt. Successful closure of the fistula was achieved on the basis of an established method using tissue interposition.

[Oncologic follow-up in head and neck cancer patients]. / Onkologische Nachsorge von Kopf-Hals-Tumor-Patienten.

Despite medical treatment according to evidence-based guidelines, approximately 25-30% of all head and neck tumor patients suffer a disease relapse, depending on tumor stage and entity. The primary goal of systematic follow-up examinations is early detection and treatment of recurrent tumors or metachronous secondary tumors, but it also serves to rule out distant metastasis. Secondary goals are the diagnosis and management of treatment-associated side effects to optimize quality of life. Because of an especially high relapse risk in the first 2 years after treatment, close-knit clinical controls are recommended, e.g., quarterly. Later on, the clinical control interval can be extended to 6 months. Cross-sectional diagnostic imaging of the primary tumor region is performed annually and when screening for possible distant metastases, or upon clinical suspicion of recurrence. After 5 years without tumor recurrence, the structured clinical follow-up is usually completed.

Performance of microvascular anastomosis with a new robotic visualization system: proof of concept.

Microvascular procedures require visual magnification of the surgical field, e.g. by a microscope. This can be accompanied by an unergonomic posture with musculoskeletal pain or long-term degenerative changes as the eye is bound to the ocular throughout the whole procedure. The presented study describes the advantages and drawbacks of a 3D exoscope camera system. The RoboticScope®-system (BHS Technologies®, Innsbruck, Austria) features a high-resolution 3D-camera that is placed over the surgical field and a head-mounted-display (HMD) that the camera pictures are transferred to. A motion sensor in the HMD allows for hands-free change of the exoscope position via head movements. For general evaluation of the system functions coronary artery anastomoses of ex-vivo pig hearts were performed. Second, the system was evaluated for anastomosis of a radial-forearm-free-flap in a clinical setting/in vivo. The system positioning was possible entirely hands-free using head movements. Camera control was intuitive; visualization of the operation site was adequate and independent from head or body position. Besides technical instructions of the providing company, there was no special surgical training of the surgeons or involved staff upfront performing the procedures necessary. An ergonomic assessment questionnaire showed a favorable ergonomic position in comparison to surgery with a microscope. The outcome of the operated patient was good. There were no intra- or postoperative complications. The exoscope facilitates a change of head and body position without losing focus of the operation site and an ergonomic working position. Repeated applications have to clarify if the system benefits in clinical routine.

Changes in circulating exosome molecular profiles following surgery/(chemo)radiotherapy: early detection of response in head and neck cancer patients.

BACKGROUND: Head and neck cancers (HNSCC) are highly immunosuppressive. Plasma-derived exosomes of HNSCC patients carry immunomodulatory molecules, and their cargo correlates with clinical parameters. Here, we evaluated the exosomal molecular profile for early detection of treatment failure in locally advanced HNSCC patients treated with conventional therapy. METHODS: Plasma from 17 HNSCC patients was collected before, during, and after treatment by surgery with adjuvant (chemo)radiation and at recurrence. Exosomes were isolated by size-exclusion chromatography. Total exosomal protein (TEP) was used to estimate exosome load and on-bead flow cytometry to evaluate relative fluorescence intensity (RFI) of tumour-associated and immunoregulatory proteins on exosomes. Exosomal effects on the activity of and adenosine production by T cells was assessed by flow cytometry and mass spectrometry. RESULTS: TEP and the ratio of tumour-/immune-cell-derived exosomes varied during and after therapy with an overall decrease in the tumour-free follow-up but an increase at recurrence. RFI values of immunoregulatory proteins on exosomes, their ability for T cell inhibition and adenosine production changed during and after therapy. PD-L1 was the earliest discriminator for treatment failure and disease-free survival. CONCLUSIONS: Monitoring of plasma exosomes during therapy represents a promising opportunity for early detection of treatment failure and risk stratification to delay/avoid recurrence.

[Robotics in otorhinolaryngology, head and neck surgery]. / Roboterassistierte Chirurgie in der Hals­Nasen-Ohren-Heilkunde.

In many surgical specialities, e.g., visceral surgery or urology, the use of robotic assistance is widely regarded as standard for many interventions. By contrast, in European otorhinolaryngology, robotic-assisted surgery (RAS) is rarely conducted. This is because currently available robotic systems are not adequately adapted to the restricted space and partially difficult access to surgical fields in the head and neck area. Furthermore, RAS is associated with high costs at present. In some Anglo-American regions, robot-assisted surgery is already used regularly for different indications, particularly in transoral surgery of oropharyngeal tumors. Several feasibility studies demonstrate multiple fields of application for RAS in head and neck surgery. For standard use, the robotic systems and surgical instruments need to be reduced in size and adapted to application in the head and neck area.

Evaluation of a curved surgical prototype in a human larynx.

PURPOSE: It is not always possible to create linear access to the larynx using a rigid operating laryngoscope for microlaryngoscopy. In this study, we evaluate the usability of a novel curved surgical prototype with flexible instruments for the larynx (sMAC) in a simulation dummy and human body donor. METHODS: In a user study (n = 6), head and neck surgeons as well as medical students tested the system for visualization quality and accessibility of laryngeal landmarks on an intubation dummy and human cadaver. A biopsy of the epiglottis was taken from the body donor. Photographic and time documentation was carried out. RESULTS: The sMAC system demonstrated general feasibility for laryngeal surgery. Unlike conventional microlaryngoscopy, all landmarks could be visualized and manipulated in both setups. Biopsy removal was possible. Visibility of the surgical field remained largely unobstructed even with an endotracheal tube in place. Overall handling of the sMAC prototype was satisfactorily feasible at all times. CONCLUSION: The sMAC system could offer an alternative for patients, where microlaryngoscopy is not applicable. A clinical trial has to clarify if the system benefits in clinical routine.

Influence of travel burden on tumor classification and survival of head and neck cancer patients.

PURPOSE: Cancer patients have to overcome various barriers to obtain diagnostics and treatment at head and neck cancer centers. Travel distance to a specialized hospital may result in psychosocial and financial distress, thus interfering with diagnostics, treatment, and follow-up care. In this study, we have aimed to analyze the association of travel distance with cTNM status, UICC stage at primary diagnosis, and survival outcomes of head and neck cancer (HNC) patients. METHODS: We have analyzed data of 1921 consecutive HNC patients diagnosed between 2014 and 2019 at the head and neck cancer center of the Comprehensive Cancer Center Ulm (CCCU), Germany. Postal code-based travel distance calculation in kilometers, TNM status, and UICC stage were recorded at initial diagnosis. The assembly of travel distance-related groups (short, intermediate, long-distance) has been investigated. Moreover, group-related survival and recurrence analysis have been performed. RESULTS: In contrast to observations from overseas, no association of travel distance and higher cTNM status or UICC stage at primary diagnosis has been observed. Furthermore, no significant differences for recurrence-free survival and overall survival by travel distance were detected. CONCLUSION: In southern Germany, travel distance to head and neck cancer centers seems to be tolerable. Travel burden is not synonymous with travel distance alone but also involves sociodemographic, monetary, and disease-specific aspects as well as accessibility to proper infrastructure of transport and health care system.

An evaluation of semidistributed-pipe-network and distributed-finite-difference models to simulate karst systems.

Several different approaches have been developed to model the specific characteristics of karst aquifers, taking account of their inherent complex spatial and temporal heterogeneities. This paper sets out the development of a semidistributed modelling approach for applications in an Irish karst context using urban drainage software. The models have proven to be very useful for different studies, with examples given for the ecohydrology of ephemeral karst lakes, extreme groundwater-flood alleviation, karst network investigation, submarine groundwater discharge, and quantification of different recharge and flow components. The limitations of the approach are also highlighted, in particular not being able to simulate diffuse infiltration and flow paths explicitly across the groundwater catchment. Hence, a more distributed, finite-difference modelling approach using MODFLOW Unstructured Grid (USG) with the newly developed Connected Linear Network (CLN) process is then compared against the semidistributed approach on the same karst catchment. Whilst it has proven difficult to achieve the same levels of model performance in simulating the spring flows in the distributed model compared to the semidistributed model, the ability to interrogate the flow paths at any point on the three-dimensional aquifer is demonstrated, which can give new insights into flows (and potential contaminant transport) through such complex systems. The influence of the proximity of highly transmissive conduits on the flow dynamics through the much-lower transmissive matrix cells in which the network is embedded has been particularly investigated.

Plusieurs approches différentes ont été développées pour modéliser les caractéristiques spécifiques des aquifères karstiques, prenant en compte leurs hétérogénéités spatiales et temporelles associées à leur complexité intrinsèque. Cet article présente le développement d'une approche de modélisation semi-distribuée appliquée à un contexte karstique irlandais en utilisant un logiciel de drainage urbain. Ces modèles se sont avérés très utiles pour différentes études, avec des exemples appliqués à l'écohydrologie de lacs karstiques éphémères, l'atténuation de crues extrêmes liées aux eaux souterraines, à l'étude du réseau karstique, à la décharge des sources sous-marines et à la quantification des différentes composantes aussi bien de la recharge que du débit. Les limites de cette approche sont aussi mises en évidence, avec en particulier l'incapacité de simuler l'infiltration diffuse et les voies d'écoulement de manière explicite au sein du bassin d'alimentation d'eaux souterraines. Par conséquent, une approche de modélisation plus distribuée aux différences finies utilisant le logiciel MODFLOW avec une grille non structurée (USG) intégrant le processus récemment développé de réseau linéaire connecté (CLN) est ensuite comparée à l'approche semi-distribuée appliquée au même bassin karstique. Alors qu'il s'est avéré difficile d'atteindre les mêmes niveaux de performance du modèle concernant la simulation du débit à la source à l'aide du modèle distribué en comparaison au modèle semi-distribué, la possibilité d'examiner les voies d'écoulement en tout point de l'aquifère en 3D est démontrée, ce qui peut donner de nouvelles connaissances sur les écoulements (et le transport potentiel de contaminants) au sein de tels systèmes complexes. L'influence de la proximité de conduits hautement transmissifs sur les écoulements dynamiques au travers des cellules de transmissivité plus faible de la matrice au sein de laquelle le réseau est intégré, a été particulièrement étudiée.

Se han elaborado varios enfoques diferentes para modelar las características específicas de los acuíferos kársticos, teniendo en cuenta sus complejas y propias heterogeneidades espaciales y temporales. En el presente documento se expone la elaboración de un enfoque de modelización semidistribuido para aplicaciones en un contexto kárstico de Irlanda utilizando programas informáticos de drenaje urbano. Los modelos han demostrado ser muy útiles para diferentes estudios, y se dan ejemplos para la ecohidrología de los lagos kársticos efímeros, la mitigación de las inundaciones extremas de aguas subterráneas, la investigación de redes kársticas, la descarga submarina de aguas subterráneas y la cuantificación de diferentes componentes de la recarga y el flujo. También se ponen de relieve las limitaciones del enfoque, en particular el hecho de no poder simular explícitamente la infiltración difusa y las trayectorias de flujo a través de la cuenca de captación de aguas subterráneas. Por lo tanto, un enfoque de modelización de diferencias finitas distribuidas utilizando la red no estructurada (USG) de MODFLOW con el proceso de la Red Lineal Conectada (CLN) recientemente desarrollado se compara entonces con el enfoque semidistribuido en la misma cuenca kárstica. Si bien se ha demostrado que es difícil lograr los mismos niveles de rendimiento del modelo en la simulación de los flujos de manantiales en el modelo distribuido en comparación con el modelo semidistribuido, se demuestra la capacidad de interrogar las trayectorias de los flujos en cualquier punto del acuífero tridimensional, lo que puede dar nuevos conocimientos sobre los flujos (y el transporte de contaminantes potenciales) a través de sistemas tan complejos. Se ha investigado en particular la influencia de la proximidad de conductos altamente transmisivos en la dinámica de los flujos a través de las células de la matriz transmisiva, mucho más bajas, en las que está incorporada la red.

Diversas abordagens diferentes foram desenvolvidas para modelar as características específicas dos aquíferos cársticos, levando em consideração suas complexas heterogeneidades espaciais e temporais inerentes. Este artigo apresenta o desenvolvimento de uma abordagem de modelagem semidistribuída para aplicações em um contexto cárstico irlandês usando software de drenagem urbana. Os modelos provaram ser muito úteis para diferentes estudos, com exemplos dados para a ecohidrologia de lagos cársticos efêmeros, alívio de inundações subterrâneas extremas, investigação de rede cárstica, descarga de água subterrânea submarina e quantificação de diferentes componentes de recarga e fluxo. As limitações da abordagem também são destacadas, em particular não ser capaz de simular infiltração difusa e caminhos de fluxo explicitamente através da captação de água subterrânea. Portanto, uma abordagem de modelagem de diferenças finitas, mais distribuída, usando MODFLOW Unstructured Grid (USG) com o processo de Rede Linear Conectada (RLC) recém-desenvolvido é então comparada com a abordagem semidistribuída na mesma bacia cárstica. Embora tenha se mostrado difícil alcançar os mesmos níveis de desempenho do modelo na simulação dos fluxos de nascente no modelo distribuído em comparação com o modelo semidistribuído, a capacidade de interrogar os caminhos de fluxo em qualquer ponto do aquífero tridimensional é demonstrada, o que pode dar novas percepções sobre os fluxos (e o transporte potencial de contaminantes) por meio de tais sistemas complexos. A influência da proximidade de condutos altamente transmissivos na dinâmica do fluxo através das células da matriz transmissiva muito inferior nas quais a rede está inserida foi investigada particularmente.

[Effects of the SARS-CoV­2 pandemic on the otolaryngology university hospitals in the field of research, student teaching and specialist training]. / Auswirkungen der SARS-CoV­2-Pandemie auf die universitäre Hals-Nasen-Ohren-Heilkunde im Bereich der Forschung, Lehre und Weiterbildung.

BACKGROUND: From spring 2020, SARS-CoV­2 began to spread worldwide, with what is now known as the first wave of the pandemic, starting in March 2020. This resulted in restructuring and shift of resources at many hospitals. The aim of our work was to detect the effects of the pandemic on the german Oto-Rhino-Laryngology (ORL) university hospitals in terms of research, student teaching and further specialist training. MATERIAL AND METHODS: The chairmen of the 39 ORL university hospitals in Germany were asked about the effects of the pandemic on research, student teaching and ORL specialist training (residency) in the period from March to April 2020 using a structured online survey. RESULTS: All 39 chairmen took part in the survey. Of these, 74.4% (29/39) stated that their research activities had deteriorated as a result of the pandemic. In 61.5% (24/39) pandemic-related research issues were addressed. All hospitals reported a restriction for in-house teaching and 97.5% (38/39) introduced new digital teaching methods. During the observation period, 74.4% of the chairmen did not see ORL specialist training (residency)at risk. CONCLUSION: Our results provide an insight into the heterogeneous effects of the pandemic. The fast processing of pandemic-related research topics and the introduction of innovative digital concepts for student teaching impressively demonstrates the great innovative potential and the ability of the ORL university hospitals to react quickly in order to maintain their tasks in research, student teaching and ORL specialist training in the best possible way even during the pandemic.

Preclinical Performance Evaluation of a Robotic Endoscope for Non-Contact Laser Surgery.

Despite great efforts, transoral robotic laser surgery has not been established clinically. Patient benefits are yet to be proven to accept shortcomings of robotic systems. In particular, laryngeal reachability and transition from microscope to accurate endoscopic laser ablation have not been achieved. We have addressed those challenges with a highly integrated robotic endoscope for non-contact endolaryngeal laser surgery. The current performance status has been assessed in multi-level user studies. In addition, the system was deployed to an ex vivo porcine larynx. The robotic design comprises an extensible continuum manipulator with multifunctional tip. The latter features laser optics, stereo vision, and illumination. Vision-based performance assessment is derived from depth estimation and scene tracking. Novices and experts (n = 20) conducted teleoperated delineation tasks to mimic laser ablation of delicate anatomy. Delineation with motion-compensated and raw endoscopic visualisation was carried out on planar and non-planar nominal patterns. Root mean square tracing errors of less than 0.75 mm were feasible with task completion times below 45 s. Relevant anatomy in the porcine larynx was exposed successfully. Accuracy and usability of the integrated platform bear potential for dexterous laser manipulation in clinical settings. Cadaver and in vivo animal studies may translate ex vivo findings.

[Robot-assisted head and neck surgery]. / Robotik in der Kopf-Hals-Chirurgie.

Robot-assisted surgery (RAS) has already been approved for several clinical applications in head and neck surgery. In some Anglo-American regions, RAS is currently the common standard for treatment of oropharyngeal diseases. Systematic randomized studies comparing established surgical procedures with RAS in a large number of patients are unavailable so far. Experimental publications rather describe how to reach poorly accessible anatomical regions using RAS, or represent feasibility studies on the use of transoral robotic surgery (TORS) in established surgical operations. With general application of RAS in clinical practice, the question of financial reimbursement arises. Furthermore, the technical applications currently on the market still require some specific improvements for routine use in head and neck surgery.

Age-related changes in T lymphocytes of patients with head and neck squamous cell carcinoma.

INTRODUCTION: The number of aging cancer patients has increased continuously and will do so further in the future. The immune system of elderly people experiences critical changes over the time. Therefore, tumor-induced changes in the immune system are believed to differ in young and elderly cancer patients as well. METHODS: The effect of aging on the immune system was measured in peripheral blood lymphocytes (PBL) of healthy volunteers (n = 48, 21-84 yrs.) divided into three different age groups. Seventy years was set as a cut-off for defining subjects as elderly. Results were compared to two groups of adult cancer patients, which donated PBL and tumor infiltrating lymphocytes (TIL): young cancer patients (40-69 yrs.; blood: n = 13; TIL: n = 17) and elderly cancer patients (70-90 yrs.; blood: n = 20; TIL: n = 15) with head and neck squamous cell carcinoma (HNSCC). Frequencies and phenotypes of CD4+ and CD8+ T cells as well as regulatory T cells (Treg) were assessed by flow cytometry. RESULTS: We observed lower frequencies of CD8+ cytotoxic T cells during aging in both groups. Frequencies of tumor infiltrating regulatory T cells were significantly higher than in the peripheral blood but showed a significant decline in older tumor patients. With increasing age, expression of immunosuppressive CD73 and CCR7 was lower and expression of PD1 elevated on peripheral T cells in healthy volunteers and tumor patients. CONCLUSION: Immunosenescence takes place in healthy donors and cancer patients. Our results suggest that in elderly tumor patients, the immune system is impaired and the tumor-induced immune escape is less pronounced. The increased expression of PD1 implies the potential for effective immunotherapies in elderly, as treatment with checkpoint inhibitors could be more beneficial for elderly HNSCC patients.

Adenosine production in mesenchymal stromal cells in relation to their developmental status.

BACKGROUND: Mesenchymal stromal cells (MSC) are multipotent progenitor cells found in the tumor microenvironment. They have an innate and regulatory immune activity, and they are able to produce immunosuppressive adenosine (ADO) via their ectonucleotidases CD39 and CD73. The present study explores ADO metabolism of MSC in relation to their developmental status. METHODS: We analyzed MSC (n = 6), chondrogenic progenitor cells (CPC, n = 8), and chondrocytes (n = 8) for surface markers by flow cytometry. The ability to hydrolyze ATP and to produce ADO was tested by luminescence assays and mass spectrometry. RESULTS: Significant differences in the surface marker expression of MSC, CPC, and chondrocytes were seen. While the expression of CD73 was observed to be the same on all cell types, the expression of the ectonucleotidase CD39 was significantly increased on MSC. Consequently, production of ADO was most abundant in MSC as compared with chondrocytes and CPC. CONCLUSION: Mesenchymal stromal cells are potent producers of ADO and are, therefore, able to increase immunosuppression. As MSC differentiate into chondrocytes, they lose this ability and may take on other functions.

Quantifying and Numerically Representing Recharge and Flow Components in a Karstified Carbonate Aquifer.

Karstified carbonate aquifers are highly heterogeneous systems characterized by multiple recharge, flow, and discharge components. The quantification of the relative contribution of these components, as well as their numerical representation, remains a challenge. This paper identifies three recharge components in the time and frequency domain. While the analysis in the time domain follows traditional approaches, the analysis of the power spectrum allows frequencies associated with specific spectral coefficients and noise types to be distinguished more objectively. The analysis follows the presented hypothesis that the different frequency-noise components are the result of aquifer heterogeneity transforming the random rainfall input into a sequence of non-Gaussian signals. The distinct signals are then numerically represented in the context of a semidistributed pipe network model in order to simulate recharge, flow, and discharge of an Irish karst catchment more realistically. By linking the power spectra of the modeled recharge components with the spectra of the spring discharge, the information usually gained by classical performance indicators is significantly widened. The modeled spring discharge is well matched in the time and frequency domain, yet the different recharge dynamics explain the signal of the aquifer outlet in different noise domains across the spectrum. This study demonstrates the conjunctive use of frequency analysis in conceptualization of a hydrological system together with modeling and evaluation.

[Oncoimmunology in old age]. / Onkoimmunologie im Alter.

Physiological aging processes of the immune system are associated with an increased susceptibility to infectious, autoimmune and tumor diseases. In accordance with the general demographic development the number of tumor patients in advanced age also increases. An end to this development is not yet foreseeable. In tumor treatment, immunotherapy with checkpoint inhibitors is becoming increasingly more important; however, only a few studies on the efficacy and side-effect profiles in older patients exist so far. In this review article the changes in the immune system in old age and the influence on carcinogenesis are discussed. In addition, the current state of research on the immunotherapy of patients in advanced age who suffer from head and neck cancer is presented.

[Laryngectomy-still state of the art?] / Die Laryngektomie ­ noch zeitgemäß?

Total laryngectomy provides a curative approach for patients with advanced laryngeal and hypopharyngeal cancer without distant metastasis. Especially in stage cT4a disease, laryngectomy is superior to primary radio(chemo)therapy in retrospective studies. Further relevant indications for the procedure are tumor-related laryngeal dysfunction such as dysphagia and aspiration, as well as cancer recurrence after primary radio(chemo)therapy. The surgical procedure is highly standardized, with an appropriate safety profile. The subsequent loss of voice must be compensated by voice rehabilitation (voice prosthesis, ructus). The current overview provides information about indications for laryngectomy, preoperative clinical diagnostics, the surgical procedure, complications, alternative treatment, rehabilitation, and prognosis. Total laryngectomy remains a standard procedure in modern head and neck oncology.

[Salivary gland malignancies-highlights of the 2019 ASCO Annual Meeting]. / Maligne Speicheldrüsentumoren ­ Highlights der ASCO-Jahrestagung 2019.

BACKGROUND: Due to their comparatively low incidence, salivary gland carcinomas have only been the subject of isolated clinical studies in recent years. In addition, surgery with/without adjuvant radiotherapy is considered standard treatment. Systemic therapies have received little attention and are only used for advanced and distantly metastasized salivary gland malignancies. OBJECTIVE: The contributions with the highest relevance for this year's meeting of the American Society of Clinical Oncology (ASCO) were to be reviewed. MATERIALS AND METHODS: A total of 12 contributions pertaining to clinical studies on salivary gland malignancies were identified, eight of which were classified as relevant for future changes to the therapeutic landscape. RESULTS: Three studies dealt with different combinations of a checkpoint blockade, and each showed a low response rate. In addition, studies on targeted therapies depending on the results of a mutation analysis and expression of HER2 or the androgen receptor were presented. CONCLUSION: A favorable response of HER2-positive salivary gland carcinomas to an antibody-drug conjugate could be shown. Furthermore, no convincing data regarding response to programmed cell death protein 1 (PD1)/programmed death ligand 1 (PD-L1) inhibitors in advanced salivary gland cancer were presented. Further studies and ideas for new treatment approaches will be needed to improve the therapeutic options for patients with salivary gland carcinoma.