Lymph node dissection in endometrial cancer and clinical outcome: A population-based study in 5546 patients.

BACKGROUND: According to current treatment guidelines, comprehensive surgical staging procedures in endometrial cancer confined to the uterus depend on uterine risk factors: a systematic lymph node dissection (LND) is recommended in high risk patients and should be omitted in low risk patients. Its role in intermediate and high intermediate risk patients is inconclusive. The aim of this analysis was to review the implementation of this risk-adopted strategy. MATERIALS AND METHODS: Data were provided by the population-based Munich Cancer Registry. Patients with endometrial cancer diagnosed between 1998 and 2016 were included. RESULTS: Of 5446 eligible patients, 58.5%, 30.1% and 11.4% belonged to the low risk, intermediate/high-intermediate and high risk group, respectively. Lymph node dissection was performed in 20.2%, 53.0% and 63.7% within these groups. Lymph node involvement was diagnosed in 1.7%, 9.6% and 19.3%, respectively. Within these risk groups, there was no significant difference in the time to local recurrence, lymph node recurrence or distant metastases between patients with and without LND. After adjusting for age and comorbidity-status, no significant difference in overall survival was found. CONCLUSIONS: The application of a risk-adopted management of LND in early endometrial cancer in real-life is associated with a high rate of surgical under- and overtreatment. Corresponding survival data do not show a significant benefit of a systematic lymph node dissection. In order to improve the management and outcome of early endometrial cancer in the future, prospective trials, new surgical concepts and prognostic markers will be primary and necessary.

Cancer of the ovary, fallopian tube, and peritoneum: a population-based comparison of the prognostic factors and outcomes.

PURPOSE: The objective was to compare the prognostic factors and outcomes among primary ovarian cancer (OC), fallopian tube cancer (FC), and peritoneal cancer (PC) patients in a population-based setting. METHODS: We analysed 5399 OC, 327 FC, and 416 PC patients diagnosed between 1998 and 2014 in the catchment area of the Munich Cancer Registry (meanwhile 4.8 million inhabitants). Tumour site differences were examined by comparing prognostic factors, treatments, the time to progression, and survival. The effect of the tumour site was additionally analysed by a Cox regression model. RESULTS: The median age at diagnosis, histology, and FIGO stage significantly differed among the tumour sites (p < 0.001); PC patients were older, more often diagnosed with a serous subtype, and in FIGO stage III or IV. The time to progression and survival significantly differed among the tumour sites. When stratified by FIGO stage, the differences in time to progression disappeared, and the differences in survival considerably weakened. The differences in the multivariate survival analysis showed an almost identical outcome in PC patients (HR 1.07 [0.91-1.25]) and an improved survival of FC patients (HR 0.63 [0.49-0.81]) compared to that of OC patients. CONCLUSION: The comparison of OC, FC, and PC patients in this large-scale population-based study showed differences in the prognostic factors. These differences primarily account for the inferior outcome of PC patients, and for the improved survival of FC compared to OC patients.

Diagnosis and Therapy of Female Pelvic Organ Prolapse. Guideline of the DGGG, SGGG and OEGGG (S2e-Level, AWMF Registry Number 015/006, April 2016).

Aims: The aim was to establish an official interdisciplinary guideline, published and coordinated by the German Society of Gynecology and Obstetrics (DGGG). The guideline was developed for use in German-speaking countries. In addition to the Germany Society of Gynecology and Obstetrics, the guideline has also been approved by the Swiss Society of Gynecology and Obstetrics (SGGG) and the Austrian Society of Gynecology and Obstetrics (OEGGG). This is a guideline published and coordinated by the DGGG. The aim is to provide evidence-based recommendations obtained by evaluating the relevant literature for the diagnostic, conservative and surgical treatment of women with female pelvic organ prolapse with or without stress incontinence. Methods: We conducted a systematic review together with a synthesis of data and meta-analyses, where feasible. MEDLINE, Embase, Cinahl, Pedro and the Cochrane Register were searched for relevant articles. Reference lists were hand-searched, as were the abstracts of the Annual Meetings of the International Continence Society and the International Urogynecological Association. We included only abstracts of randomized controlled trials that were presented and discussed in podium sessions. We assessed original data on surgical procedures published since 2008 with a minimum follow-up time of at least 12 months. If the studies included descriptions of perioperative complications, this minimum follow-up period did not apply. Recommendations: The guideline encompasses recommendations for the diagnosis and treatment of female pelvic organ prolapse. Recommendations for anterior, posterior and apical pelvic organ prolapse with or without concomitant stress urinary incontinence, uterine preservation options, and the pros and cons of mesh placements during surgery for pelvic organ prolapse are presented. The recommendations are based on an extensive and systematic review and evaluation of the current literature and include the experiences and specific conditions in Germany, Austria and Switzerland.

[Perioperative patient management. Evaluation of subjective stress and demands of patients undergoing elective gynaecological surgery]. / Perioperatives Patientenmanagement. Evaluation von subjektiver Beanspruchung bei Patientinnen mit elektiven gynäkologischen Operationen.

BACKGROUND: The aim of this investigation was to assess the extent of stress and demands in patients during preparation for general anesthesia for elective surgical procedures. PATIENTS AND METHODS: A total of 52 female patients scheduled for elective gynecological surgery under general anesthesia were included in this prospective study. The extent and time course of actual demands describing perceived emotional stress was assessed at close intervals using the German version of the Questionnaire for Actual Demands (KAB). Pre-operative and postoperative anxiety was assessed using part one of Spielberger's state-trait-anxiety inventory (STAI-X1). This was compared to hemodynamic (heart rate und blood pressure) and endocrinal stress parameters [cortisol concentration in serum and saliva, prolactin and dehydroepiandrosteronesulfate (DHEA-S) in serum]. Postoperatively, all patients were asked to rate the quality of care during preparation for general anesthesia. RESULTS: The extent of patients' demands and stress during preparation for general anesthesia could be quantified by the short questionnaire for the actual demands (KAB). So-called objective stress parameters like hemodynamic and endocrinal data alone did not correlate with perceived stress. However, the subjective information correlated with the nature of the underlying diagnosis. The postoperative assessment of quality of care during preparation for general anesthesia did not correlate with the course of actual demands and stress. CONCLUSION: In future studies assessing the perioperative management of patients and quality of care, standardized testing questionnaires should be preferred, instead of vegetative parameters alone, to reliably evaluate perioperative demands and stress in surgical patients.

[Functional MRI of the pelvic floor: postpartum changes of primiparous women after spontaneous vaginal delivery]. / Funktionelle Magnetresonanztomographie (MRT) des Beckenbodens: Postpartale Veränderungen bei Erstgebärenden nach vaginaler Spontangeburt.

PURPOSE: Detection of morphological and functional changes of the pelvic floor with functional MRI in primiparous women after spontaneous vaginal delivery. METHODS AND MATERIALS: The study comprises 26 primiparous women after vaginal delivery and a control group of 41 healthy asymptomatic nulliparous volunteers. MRI was performed on a 1.5 T system in supine position with vagina and rectum opacified with Sonogel. The static images consisted of sagittal and axial T 2 -weighted SE sequences and functional images of true FISP sequences in midsagittal and axial planes acquired with the patient at rest, straining and during defecation. Evaluation of morphometric parameters included pelvimetry, thickness of the puborectal muscle and width of the urogenital hiatus as well as position and movement of the pelvic organs relative to the pubococcygeal reference line. RESULTS: The configuration of the bony pelvis did not differ for both groups. The puborectal muscle was significantly thinner in the study group (0.8 cm vs 0.6 cm). The functional images showed no significant differences between both groups at rest but a significantly increased incidence in the descent of the bladder neck, vaginal fornix and anorectal junction in the study group during straining. In addition, the primiparous women had more prominent rectoceles (0.6 cm vs 1.5 cm). CONCLUSION: Static imaging alone fails to demonstrate relevant pelvic floor changes and a functional method is necessary to evaluate the interactions of the pelvic organs regarding organ descent. Functional MRI of the pelvic floor is an excellent method to reveal the significant changes of the pelvic floor after vaginal birth without exposing the uterus to radiation.

[Abnormalities of external and internal genitalia]. / Fehlbildungen des äusseren und inneren Genitales.

The gynecologic examination of the female genitalia of children and young adults belongs in the hands of specialists and should be performed in the appropriate environment. The most important task of such an examination is the distinction between true developmental anomalies and anatomical findings mimicking such anomalies. Even newborn females can be successfully examined without any large effort expenditure. In most cases, the external inspection of the vestibule is enough to reach a diagnosis. In other case scenarios, vaginoscopy and gynecological speculum examination may be necessary. Additional imaging studies include abdominal sonography and magnetic resonance imaging. Normal variations of a child's hymenal membrane, fusion of the labia minora, hymenal polyps and hypertrophy of the preputium of the clitoris are the entities most likely to be mistaken for real developmental malformations. The most important asymptomatic developmental anomaly of the vagina and the uterus is the Mayer-Rokitansky-Kuster-Hauser syndrome (uterine and vaginal agenesis). Developmental malformations, such as hymenal atresia, vaginal septum formation and Millerian anomalies in general, tend to be symptomatic, presenting with hematometra, hematocolpos or dysmenorrhea. The treatment of genital developmental anomalies is generally not difficult but requires the appropriate clinical and surgical expertise.

[Influence of abdominal sacrocolpopexy and vaginal sacrospinal fixation (according to Amreich-Richter) on the anterior compartment]. / Einfluss der abdominalen Sakrokolpopexie und der vaginalen sakrospinalen Fixation (nach Amreich-Richter) auf das vordere Kompartiment.

OBJECTIVE: The aim of the study was to investigate the postoperative effect of abdominal sacrocolpopexy (aSCP) versus vaginal sacrospinal fixation (vssF) on the anterior compartment. PATIENTS AND METHODS: In a retrospective study, 25 patients at 24 months following aSCP (group 1) and 28 patients at 60 months following vssF (group 2) were examined and data collected as to vaginal prolapse, recurrent cystocele or stress incontinence, de novo stress incontinence and urge symptoms. In addition, a review of the literature published from 1970 to 2002 was performed. RESULTS: Both methods achieved comparable results. We recorded no recurrent vaginal prolapse in either study group. Moderate to severe cystoceles were found postoperatively in 38 % of group 1 and 43 % of group 2. There was no difference in occurrence of urge symptoms. These results are comparable to those published; however, the published rate of occurring cystoceles is slightly lower (11.6 % following vssF, 21.6 % following aSCP). CONCLUSIONS: Both methods are equally successful at achieving a permanent fixation of the vaginal vault. We postulate that higher success rates can only be achieved by a more frequent combination with other operative techniques.

Functional cine magnetic resonance imaging in women after abdominal sacrocolpopexy.

OBJECTIVE: To evaluate whether functional cine magnetic resonance imaging (MRI) is a reliable method for verifying postoperative anatomy and function in women after abdominal sacrocolpopexy. METHODS: We did postoperative functional cine MRI in 25 women who had sacrocolpopexies. Visibility of grafts and vaginal and sacral fixation points were assessed and correlated with intraoperative results. Ranges of vaginal movement were calculated and compared with results of postoperative gynecologic examinations. RESULTS: Functional cine MRI achieved full view of vaginas in all cases. The mean vaginal axis was 142 degrees. Grafts were entirely visible in 13 women, partly visible in nine, and not visible in three. Functional cine MRI defined exactly the sacral fixation points in 22 women. Compared with intraoperative results, functional cine MRI showed a higher level of fixation in nine of 11 women. Functional cine MRI defined exact vaginal fixations point in 15 of 25 women. According to the pubococcygeal reference line, the postoperative range of movement of the vaginal apex was 1.8 cm. Recurrent vaginal vault prolapses in three women were detected equally by functional cine MRIs and gynecologic examinations. In those cases, no parts of patches were seen on the images. CONCLUSION: Functional cine MRI provided reliable abdominal sacrocolpopexy follow-up data. It might help with individual surgical planning and augment understanding of benefits and flaws of various surgical approaches to repair of vaginal vault prolapse.

The effects of childbirth on the pelvic-floor.

Basically, vaginal delivery is associated with the risk of pelvic floor damage. The pelvic floor sequelae of childbirth includes anal incontinence, urinary incontinence and pelvic organ prolapse. Pathophysiology, incidence and risk factors for the development of the respective problems are reviewed. Where possible, recommendations for reducing the risk of pelvic floor damage are given.

[Morphological and functional pelvic floor disorders from the gynecological viewpoint]. / Morphologische und funktionelle Beckenbodenstörungen aus gynäkologischer Sicht.

PURPOSE: The following article is designed to describe the diagnostics and therapy of morphological and functional defects in the female pelvic floor from a gynaecological point of view. Assessment of the relevance of imaging techniques is of particular importance. MATERIAL AND METHODS: The main diagnoses are: in the anterior compartment of the pelvic floor, urethro- cystocele; in the middle compartment, uterine descent/prolapse or enterocele; and in the posterior compartment, rectocele. They are clinically examined by means of a standardised gynaecological examination and classified according to recommendations from the International Continence Society (ICS) in order to obtain internationally comparable results. Comparison with the usual imaging procedures (introitus- and perineal sonography, colpocystorectography/defaecography and functional MRI of the pelvic floor) are described and critically discussed. The most important functions affected are storage and evacuation of the bladder and rectum. They are clinically examined by means of stress test and padweigh test and technically examined using urodynamics, sphincter-rectum manometry and EMG. Imaging procedures play a very important role here also. RESULTS: Comparison of clinical and imaging procedures shows that the two methods are at present limited in comparability, mainly because different points of reference are used to quantify results. The line of the hymen is a good point of reference in grading descent and prolapse. During the gynaecological examination, the three compartments can readily be assessed separately by use of split gynaecological specula. This is presently practically impossible using imaging procedures. The pubococcygeal line is generally used to describe findings. DISCUSSION: Scientific progress can only be expected if and when these problems are studied as a whole. Imaging procedures have securely established themselves in the diagnostic repertoire, but do not as yet influence therapy decisions. The indication and choice of operation depend on the severity of the patient's symptoms the clinical findings and the results of urodynamic investigations. Dynamic CTG is presently the most reliable method of showing all three compartments at rest and during function. It has largely replaced colpocystorectography. Sonography is found to be varied in ist results at the moment.

[Functional MRI of the pelvic floor: its normal anatomy and pathological findings]. / Funktionelle MRT des Beckenbodens: normale Anatomie und pathologische Befunde.

PURPOSE: Functional MRI of the pelvic floor allows mapping and definition of different forms of pelvic floor dysfunction. METHODS: We performed functional MRT of the pelvic floor in 39 healthy nulliparas and 324 patients. The diagnosis of a pathological organ descent was made if certain landmarks of the pelvic floor compartments descended below the pubococcygeal reference-line (PC-line). RESULTS: If there was no organ descent below the PC-line on straining and if the pelvic floor muscles hardly changed position, a normal finding was diagnosed. 70% of organ prolapses came in the combined form. The generally gradual development of an organ descent led to a change of the main finding in 21.6%. The masking of a cystocele (48.6%) or of an enterocele (34.3%) by a rectocele was most frequent in these cases. DISCUSSION: The use of functional MRI of the pelvic floor appears to be especially useful in young patients, in cases of divergent clinical and sonographic or radiological findings and if the presence of a predominant hernial sac with or without enterocele/rectocele is supposed.

[Functional MRI of the pelvic floor. The methods and reference values]. / Funktionelle MRT des Beckenbodens. Methodik und Referenzwerte.

PURPOSE: Functional cine MRI of the pelvic floor is a yet another modality in addition to various radiological fluoroscopic techniques. This article describes our own method in view of the recent literature and provides morphometric reference values. MATERIAL AND METHOD: We examined 20 nulliparous women (range of age: 25-51 years) with normal findings in the gynecological and urodynamic examination. Functional cine MRI was performed on a 1.5 Tesla equipment after opacification of the vagina and rectum. We used a T2-weighted gradient-echo sequence (Ture-FISP) to determine the position of the reference organs at rest and during straining/defecation. Two different reference lines were used. In addition 29 morphometric and functional parameters were measured, all of them being observer independent. RESULTS: Functional cine MRI was able to show the extent and interaction of the pelvic floor organs in all cases with the reference organs always remaining above the pubococcygeal reference line. The depth of the rectocele was 2 cm. With the exception of the diameter of urogenital hiatus the different parts of the levator ani muscle could not be determined. DISCUSSION: Functional cine MRI using an appropriate organ opacification and slice positioning is an objective, unifying diagnostic approach of the pelvic floor. The reference data given can be of help to distinguish normal from abnormal findings.

Diagnosing enteroceles using dynamic magnetic resonance imaging.

PURPOSE: Enteroceles are in part difficult to detect but a frequent finding in pelvic floor disorders. The aim of this study was to evaluate magnetic resonance colpocystorectography in the diagnosis of enteroceles. METHODS: In this prospective study 11 volunteers and 55 patients with pelvic floor descent were examined. In addition to magnetic resonance colpocystorectography, a dynamic cystoproctography was performed on 34 patients. Opacification of organs was used. An enterocele was assessed in relationship to the pubococcygeal reference line (magnetic resonance colpocystorectography) or the width of the rectovaginal space (dynamic cystoproctography). A clinical gynecologic examination served as reference. RESULTS: The clinical examination diagnosed an enterocele in 43, magnetic resonance colpocystorectography in 49, and dynamic cystoproctography in 14 cases. Magnetic resonance colpocystorectography further subdivided the enteroceles according to their contents (mesenteric fat or fluid, 12; small bowel, 32, large bowel, 3; and rectosigmoidocele, 2). Magnetic resonance colpocystorectography proved statistically significantly superior to dynamic cystoproctography (15 cases) and the reference. Sensitivity and specificity of magnetic resonance colpocystorectography were 100 percent each. It was able to reveal clinically missed enteroceles as being peritoneoceles associated with a rectocele or a uterovaginal prolapse (10 cases). CONCLUSION: Magnetic resonance colpocystorectography is a promising method for diagnosis of enteroceles, because hernial canal, sac, and contents are reliably identified.

Myogenic changes of the levator ani muscle in premenopausal women: the impact of vaginal delivery and age.

The aim of this study was to evaluate the impact of parity and age on histomorphology of the pelvic floor muscles in female cadavers of reproductive age and to find out whether there is evidence of myogenic or neurogenic muscle injury. In a cross-sectional study 45 premenopausal unfixed and fresh female cadavers were studied. Four groups were defined: nulliparous and parous women under the age of 40 and over 40 years of age. The pelvic floor was biopsied at six standardized locations. For evaluation of the quantitative parameters and fiber type identification, actomyosin ATPase at pH 9.4 was used. For histomorphological evaluation, sections were stained with hematoxylin/eosin, van Gieson, and Gomori trichrome. The circumference of type I fibers is significantly larger in nulliparous women younger than 40 years compared to nulliparae older than 40 years. Comparing these groups, the form factor of type II fibers also increases significantly, presenting a more circular cell form. Compared to nulliparae, vaginal delivery led to a significant difference regarding the presence of centrally located nuclei, fibrosis, and variation in fiber diameter. In nulliparous women, these significant changes were also found with increasing age. In women with a history of vaginal delivery, no further increase in these characteristics could be detected with increasing age. Comparing the three different biopsy sites, all three changes were more pronounced in the ventral part. There was no evidence of grouped fiber atrophy, small angulated fibers, or type grouping in any of the biopsy specimens. Aging and vaginal childbirth lead to histomorphological changes of the pelvic floor muscle that are consistent with changes of myogenic origin. Evidence of neurogenic damage could not be demonstrated.

Dynamic MR colpocystorectography assessing pelvic-floor descent.

Magnetic resonance colpocystorectography (MR-CCRG) is presented in the evaluation of patients with pelvic-floor disorders. Five healthy volunteers and 44 female patients with isolated or combined visceral descent underwent dynamic MRI and dynamic fluoroscopy (DF). MR-CCRG was performed with the patient in a supine position using a True FISP sequence (1 image/1.2 s; in-plane resolution 1.02 mm) during pelvic floor contraction, relaxation, and straining maneuvers. Relevant organs, such as urethra, bladder, vagina, and rectum, were opacified by using a saline solution, Magnevist (Schering AG, Berlin, Germany), and sonography gel, respectively. The clinical evaluation and the intraoperative results (30 cases) were used as reference. MR-CCRG and DF were non-diagnostic in 3 cases each. Most patients had a combined type of visceral prolapse, the most frequent combination being a vaginal vault prolapse and a cystocele. The points of reference were sufficiently outlined by DF and MR-CCRG. In comparison with the clinical and intraoperative results, MR-CCRG proved to be especially beneficial in the diagnosis of different types of enteroceles including a uterovaginal prolapse. MR-CCRG showed an equal or higher sensitivity and specificity for all individual sites when compared with DF. Also, predominant herniation obscuring other concomitant prolapse could be verified in 8 cases. MR-CCRG is superior to DF and accurately depicts pelvic-floor descent and prolapse in women. The possibility of dynamic presentation (see enclosed CD-ROM) allows for a better understanding of the organ movements within a given topographic reference setting.

Changes in vesical neck mobility following vaginal delivery.

OBJECTIVE: To assess changes in urethral movement during the Valsalva maneuver and pelvic floor muscle contraction following vaginal delivery. METHODS: In a prospective repeated-measures study, 25 primigravidas, 20 multiparas, and ten women who were to have elective cesarean delivery were examined sonographically at 36-42 weeks of pregnancy and 6-10 weeks after delivery. Vesical neck position at rest and excursion during Valsalva maneuver and maximum pelvic muscle contraction were measured with perineal ultrasound. Data about resting bladder neck position and bladder neck elevation at contraction were compared with findings in age-matched nulligravid volunteers. RESULTS: The bladder neck was significantly lower at rest in women after vaginal delivery than in those who had an elective cesarean delivery and in nulligravid controls. Bladder neck mobility had increased during the Valsalva maneuver in 16 of 25 primigravidas and 15 of 20 multiparas 6-10 weeks after vaginal delivery. The ability to elevate the vesical neck during pelvic muscle contraction was decreased in six of 25 primigravidas and in two of 20 multiparas 6-10 weeks after birth. Two women, one primigravid and one para 2 (with a previous elective cesarean delivery), both of whom had forceps delivery, completely lost the ability to contract voluntarily the pelvic floor muscles. CONCLUSION: Vaginal delivery alters vesical neck descent during the Valsalva maneuver, and the ability of the pelvic muscles to elevate the urethra in some women.