Retrospective Evaluation of Bone Turnover Markers in Serum for the Prediction of Metastases Development in Breast Cancer Patients: A Cohort Study.

BACKGROUND: Serum bone turnover markers might play a role in the prediction of the development of bone metastases in breast cancer (BC) patients. We conducted a retrospective cohort study to address the association of serum bone turnover markers with oncologic outcomes. METHODS: We included 80 women with BC, who were operated on at the Department of Gynecology, Obstetrics and Reproductive Medicine, Homburg/Saar, Germany. Serum samples were obtained prior to surgery and were used for estimation of the concentration of tumor and bone turnover markers using enzyme-linked immunosorbent assay (ELISA) and radioimmunoassay (RIA). RESULTS: At baseline, pyridinoline cross-linked carboxy-terminal telopeptide of type-1 collagen (ICTP) concentrations were higher in nodal positive vs. negative tumors (Mann-Whitney test p = 0.04). After a median follow-up of 79.4 months, 17 patients developed metastases, with 9 demonstrating, among other organs, osseous metastases. ICTP demonstrated the best area under the curve in the predection of osseous metastases in our cohort (AUC = 0.740, DeLong Test p = 0.005). Univariable Cox proportional hazard models failed to demonstrate significant associations between serum bone turnover markers and oncologic outcomes (progression-free survival, overall survival). CONCLUSIONS: Serum bone turnover markers (e.g., ICTP) were able to predict the development of osseous metastases but were not associated with oncologic outcomes. Further investigation and validation are required for the use of such markers in clinical practice.

The Therapy of Vulvar Carcinoma-Evaluation of Surgical Options in a Retrospective Monocentric Study.

(1) Background: Surgical-oncological treatment methods are continuously put to the test in times of evidence-based medicine-notably, a constant reevaluation remains key, especially for tumor entities with increasing incidence such as vulvar carcinoma. (2) Methods: In order to determine the postoperative clinical course of different methods of vulvar excision (vulvectomy, hemivulvectomy) as well as inguinal lymph node removal (lymphadenectomy, sentinel lymph node biopsy) with regard to postoperative wound-healingprocess, perioperative hemorrhage, and re-resection rates, we retrospectively analyzed surgical, morphological and laboratory data of 76 patients with a pathological diagnosed vulvar cancer. (3) Results: Analysis of our data from a single center revealed a comparable perioperative clinical course regardless of the chosen method of vulvar excision and inguinal lymph node removal. (4) Conclusions: Thus, our results emphasize the current multimodality in surgical therapy of vulvar carcinoma, in which consideration of known prognostic factors together with the individual patient's clinical situation allow guideline-based therapy aimed at maximizing surgical safety.

Accuracy of Breast Ultrasonography and Mammography in Comparison with Postoperative Histopathology in Breast Cancer Patients after Neoadjuvant Chemotherapy.

INTRODUCTION: Nowadays chemotherapy in breast cancer patients is optionally applied neoadjuvant, which allows for testing of tumor response to the chemotherapeutical treatment in vivo, as well as allowing a greater number of patients to benefit from a subsequent breast-conserving surgery. MATERIAL AND METHODS: We compared breast ultrasonography, mammography, and clinical examination (palpation) results with postoperative histopathological findings after neoadjuvant chemotherapy, aiming to determine the most accurate prediction of complete remission and tumor-free resection margins. To this end, clinical and imaging data of 184 patients (193 tumors) with confirmed diagnosis of breast cancer and neoadjuvant therapy were analyzed. RESULTS: After chemotherapy, tumors could be assessed by palpation in 91.7%, by sonography in 99.5%, and by mammography in 84.5% (chi-square p < 0.0001) of cases. Although mammography proved more accurate in estimating the exact neoadjuvant tumor size than breast sonography in total numbers (136/163 (83.44%) vs. 142/192 (73.96%), n.s.), 29 tumors could be assessed solely by means of breast sonography. A sonographic measurement was feasible in 192 cases (99.48%) post-chemotherapy and in all cases prior to chemotherapy. CONCLUSIONS: We determined a superiority of mammography and breast sonography over clinical palpation in predicting neoadjuvant tumor size. However, neither examination method can predict either pCR or tumor margins with high confidence.

The Impact of the Microbiological Vaginal Swab on the Reproductive Outcome in Infertile Women.

BACKGROUND: The thesis on which this paper is based intended to investigate whether the result of the microbiological vaginal swab has an influence on the outcome of the fertility treatment. METHODS: The microbiological vaginal swabs of patients who received fertility treatment at Saarland University Hospital were evaluated. Depending on the microorganisms detected, the swab result was classified as inconspicuous, intermediate, or conspicuous. The SPSS software was used to determine the correlation between the swab result and the outcome of the fertility treatment. RESULTS: Dysbiosis was associated with a worse outcome of fertility treatment. The pregnancy rate with a conspicuous swab was 8.6%, whereas it was 13.4% with an inconspicuous swab. However, this association was not statistically significant. Furthermore, an association of endometriosis with dysbiosis was found. Endometriosis was more frequent with a conspicuous swab result than with an inconspicuous result (21.1% vs. 17.7%), yet the correlation was not statistically significant. However, the absence of lactobacilli was significantly associated with endometriosis (p = 0.021). The association between endometriosis and a lower pregnancy rate was also statistically significant (p = 0.006). CONCLUSION: The microbiological vaginal and cervical swabs can be used as predictors for the success of fertility treatments. Further studies are needed to assess the impact of transforming a dysbiotic flora into a eubiotic environment on the success of fertility treatments.

Cetrorelix in reproductive medicine.

This book chapter presents the most important clinical aspects concerning the gonadotropin-releasing hormone antagonist cetrorelix and its importance in reproductive medicine. After an overview of the historical milestones in the development and establishment of cetrorelix in the context of ovarian stimulation treatment, its dosage, effects, and side effects are evaluated. The chapter terminates with a conclusion emphasizing the ease of use and the increase in patient safety because of a significantly reduced risk of ovarian hyperstimulation syndrome with cetrorelix compared with the agonist protocol.

Postpartum Assessment of the Correlation between Serum Hormone Levels of Estradiol, Progesterone, Prolactin and ß-HCG and Blood Pressure Measurements in Pre-Eclampsia Patients.

Background: Preeclampsia is a pregnancy-related hypertensive disease. Aberrant hormone levels have been implicated in blood pressure disorders. This study investigated the association of postpartum maternal serum hormone levels of estradiol, progesterone, prolactin, and ß-HCG with poorer PE-related complications including arterial hypertension. Methods: Thirty patient women with preeclampsia, and twenty women with uncomplicated pregnancy were included in this study. Serum levels of estradiol, progesterone, prolactin, and ß-HCG were determined immediately after delivery, and on the first and third postpartum days by means of ECLIA. Results: Compared with normal pregnancy cases, preeclampsia cases had higher serum levels of ß-HCG levels on Day-0 (319%), of progesterone on Day-0 (207%) and Day-1 (178%), and of estradiol on Day-1 (187%) and Day-3 (185%). Increased prolactin levels were positively associated with disease severity and estradiol and progesterone levels were decreased in poorer preeclampsia features including disease onset and IUGR diagnosis. No significant correlation between different hormone levels and blood pressure measurements was reported. Conclusions: This study is the first that detected postpartum maternal serum hormone levels and their correlation with blood pressure measurements in preeclampsia. We believe that the persistent arterial hypertension in the puerperium in preeclampsia as well as poorer disease specifications are most likely not of hormonal origin. Larger, well-defined prospective studies are recommended.

The Prevalence, Management and Impact of Dysmenorrhea on Medical Students' Lives-A Multicenter Study.

INTRODUCTION: Dysmenorrhea is defined as the presence of painful menstruation, and it affects daily activities in different ways. The aims of this study were to assess the prevalence and management of dysmenorrhea and to determine the impact of dysmenorrhea on the quality of life of medical students. MATERIAL AND METHODS: The study conducted was prospective, analytical and observational and was performed between 7 November 2019 and 30 January 2020 in five university centers from Romania. The data was collected using an original questionnaire regarding menstrual cycles and dysmenorrhea. The information about relationships with family or friends, couples' relationships and university activity helped to assess the effects of dysmenorrhea on quality of life. The level of significance was set at p < 0.05. RESULTS: The study comprised 1720 students in total. The prevalence of dysmenorrhea was 78.4%. During their menstrual period, most female students felt more agitated or nervous (72.7%), more tired (66.9%), as if they had less energy for daily activities (75.9%) and highly stressed (57.9%), with a normal diet being difficult to achieve (30.0%). University courses (49.4%), social life (34.5%), couples' relationships (29.6%), as well as relationships with family (21.4%) and friends (15.4%) were also affected, depending on the duration and intensity of the pain. CONCLUSION: Dysmenorrhea has a high prevalence among medical students and could affect the quality of life of students in several ways. During their menstrual period, most female students feel as if they have less energy for daily activities and exhibit a higher level of stress. The intensity of the symptoms varies considerably and, with it, the degree of discomfort it creates. Most student use both pharmacological and non-pharmacological methods to reduce pain (75.7%). University courses, social life, couples' relationships, as well as relationships with family and friends are affected, depending on the duration and intensity of the pain.

Students' attitudes toward digital learning during the COVID-19 pandemic: a survey conducted following an online course in gynecology and obstetrics.

PURPOSE: The purpose of this survey was to assess medical students' opinions about online learning programs and their preferences for specific teaching formats during COVID 19 pandemic. METHODS: Between May and July 2020, medical students who took an online gynecology and obstetrics course were asked to fill in a questionnaire anonymously. The questionnaire solicited their opinions about the course, the teaching formats used (online lectures, video tutorials featuring real patient scenarios, and online practical skills training), and digital learning in general. RESULTS: Of 103 students, 98 (95%) submitted questionnaires that were included in the analysis. 84 (86%) students had no problem with the online course and 70 (72%) desired more online teaching in the future. 37 (38%) respondents preferred online to traditional lectures. 72 (74%) students missed learning with real patients. All digital teaching formats received good and excellent ratings from > 80% of the students. CONCLUSION: The survey results show medical students' broad acceptance of the online course during COVID 19 pandemic and indicates that digital learning options can partially replace conventional face-to-face teaching. For content taught by lecture, online teaching might be an alternative or complement to traditional education. However, bedside-teaching remains a key pillar of medical education.

Incidence of and risk factors for vaginal cuff dehiscence following total laparoscopic hysterectomy: a monocentric hospital analysis.

PURPOSE: Vaginal cuff dehiscence (VCD) is one of the major surgical complications following hysterectomy with data on incidence rates varying largely and studies assessing risk factors being sparse with contradictive results. The aim of this study was to assess the incidence rate of and risk factors for VCD in a homogenous cohort of women treated for benign uterine pathologies via total laparoscopic hysterectomy (TLH) with standardized follow-up. METHODS: All patients undergoing TLH at the Department of Gynecology and Obstetrics, Saarland University Hospital between November 2010 and February 2019 were retrospectively identified from a prospectively maintained service database. RESULTS: VCD occurred in 18 (2.9%) of 617 patients included. In univariate and multivariate analyses, a lower level of surgeon laparoscopic expertise (odds ratio 3.19, 95% confidence interval (CI) 1.0-9.38; p = 0.03) and lower weight of removed uterus (odds ratio 0.99, 95% CI 0.98-0.99; p = 0.02) were associated positively with the risk of VCD. CONCLUSION: In this homogenous cohort undergoing TLH, laparoscopic expertise and uterine weight influenced the risk of postoperative VCD. These findings might help to further reduce the rate of this complication.

Teaching breast ultrasound skills including core-needle biopsies on a phantom enhances undergraduate student's knowledge and learning satisfaction.

PURPOSE: To investigate whether a training program on breast ultrasound skills including core-needle biopsies to undergraduate students can improve medical knowledge and learning satisfaction. METHODS: Medical students attending mandatory classes at the Medical School of the University of Saarland received a supplemental theoretical and hands-on training program on ultrasound (US) breast screening and on US-guided core-needle biopsy using an agar-agar phantom. Experienced breast specialists and ultrasound examiners served as trainers applying Peyton's 4-step training approach. The students' theoretical knowledge and hands-on skills were tested before and after the training program, using a multiple-choice questionnaire (MCQ), the Objective Structured Clinical Examination (OSCE) and a student curriculum evaluation. RESULTS: The MCQ results showed a significant increase of the student's theoretical knowledge (50.2-75.2%, p < 0.001). After the course, the OSCE showed a mean total of 17.3/20 points (86.5%), confirming the practical implementation of the new skills. The student curriculum evaluation in general was very positive. A total of 16/20 questions were rated between 1.2 and 1.7 (very good) and 3 questions were rated as 2.1 (good). CONCLUSION: Undergraduate student's medical education can be enhanced by teaching breast US skills.

Long-term effectiveness of an online decision aid for female cancer patients regarding fertility preservation: Knowledge, attitude, and decisional regret.

INTRODUCTION: The decision, whether to undergo fertility preservation or not is highly demanding for cancer patients. Decision aids may act as an additional source of support. So far, only a limited number of decision aids regarding fertility preservation for female cancer patients exist and have been evaluated systematically. This paper presents the results of secondary analyses of the first randomized controlled trial evaluating an online decision aid for female cancer patients affected by different types of cancer. It focuses on fertility-related knowledge, attitude toward fertility preservation, and long-term effectiveness regarding decisional regret. MATERIAL AND METHODS: Young female cancer patients between 18 and 40 years of age were recruited after fertility counseling with a reproductive specialist. They were assigned to either the control group (counseling only) or the intervention group (counseling followed by the additional use of the decision aid). Both groups had to complete a questionnaire after counseling as well as 1 and 12 months later, covering topics such as fertility-related knowledge, attitude towards fertility preservation, decisional conflict and regret. Recruitment was ongoing during 18 months in eight fertility centers located in Switzerland and Germany. RESULTS: Mean age of participating women was 29.31 years (SD 4.57). Of the entire sample (n = 51) 53% were affected with breast cancer, 27.4% with lymphoma, and 19.6% with various other types of cancer. Knowledge regarding the most common fertility preservation methods was high and comparable in both groups. Positive attitude significantly exceeded negative attitude among all participants (p = 0.001). Although the altogether low scores for decisional regret were on a higher level in the control group (T2: mean = 19.00, SD = 13.24; T3: mean = 22.0, SD = 20.67) than in the intervention group (T2: mean = 14.12, SD = 11.07; T3: mean = 12.94, SD = 13.24), there were no statistically significant differences between and within both groups. There was a positive association between decisional conflict and decisional regret at T3 (p = 0.001, r = 0.510). CONCLUSIONS: This decision aid was suitable as an additional source of knowledge and may positively impact decisional regret in the long term. Results suggest that the provision of an online decision aid as a complement to fertility counseling may facilitate decision-making.

Comparison of maternal third trimester hemodynamics between singleton pregnancy and twin pregnancy.

OBJECTIVES: The impedance cardiography (ICG) technique measures the variation of impedance in the thorax due to the physical contractile activity of the heart. Twin pregnancy is characterized by greater maternal hemodynamic changes than a singleton pregnancy. METHODS: In a study on 121 pregnant women in the last trimester we performed ICG, evaluating the following hemodynamic parameters: stroke volume, heart rate, cardiac output, ventricular ejection time, left ventricular ejection time, thoracic impedance, and systemic vascular resistance. RESULTS: The study included singleton and twin pregnancies. Heart rate values in women with single fetus was lower than in those carrying twins (85 vs. 100 beats/min, p=0.021) as were the stroke volume values (64 vs. 83 mL, p=0.010) and the cardiac output (p<0.0001). Systemic vascular resistance decreased in twin pregnancies compared to singleton pregnancy (p=0.023). CONCLUSIONS: ICG studies are rare, and the validation of their results is an ongoing process. However, the ICG technique is applicable in the third trimester of pregnancy and can yield important information regarding the hemodynamic profile of singleton and twin pregnancies, revealing maternal heart changes specific to twin pregnancies.

Significant improvement of laparoscopic knotting time in medical students through manual training with potential cost savings in laparoscopy - an observational study

Objective: Laparoscopy is a standard procedure in operative gynaecology, but laparoscopic simulator training for novices/junior surgeons is not currently well-established. The aims of this study were to demonstrate that a laparoscopic knot course for trainees can significantly shorten the knotting time and to perform a counter-value calculation for the clinic's costs. Material and Methods: An observational study was performed with exercises on a laparoscopic box trainer as part of the practical clerkship in gynaecology and obstetrics between 07.10.2019-31.01.2020. At the beginning and at the end of the exercises, the participants made a laparoscopic knot and the difference in knotting time, Δt in seconds (s) was measured. Results: Eighty-eight medical students needed an average of 247.1 s for the first laparoscopic knot at the beginning of the course and an average of 45.43 s for the second at the end of the course. Mean shortening of the knotting time was 201.67 s or 81.6% (p=0.02). Calculating costs of an average of €40-50 for an operation minute would mean a cost saving of at least €120-150 for a partial node. Conclusion: Trainees can significantly improve their operative skills in a short time with the aid of surgical simulation training. Such training can be beneficial for clinics by reducing the operating time if the basics, such as sewing and instrument guidance, are learned on a simulator. We therefore suggest that operative simulation training should be mandatory in medical education.

Clinical implications and economic effects of the Coronavirus pandemic on gynecology, obstetrics and reproductive medicine in Germany: learning from Italy.

The infection with the novel SARS Cov-2 Coronavirus, the cause of severe acute respiratory distress syndrome, possessing its origin in the Chinese province Hubei, has reached the extent of a global pandemic within a few months. After aerosol infection, most people experience mild respiratory infection with cold symptoms such as cough and fever, and healing within two weeks. In about 5% of those infected, however, a severe course develops with the occurrence of multiple subpleural bronchopulmonary infiltrates and even death as a result of respiratory failure. The Coronavirus pandemic has multiple impacts on social life that have not been seen before. For example, the government adopted measures to curb the exponential spread of the virus, which included a significant reduction in social contacts. Furthermore, the specialist societies recommended that no elective treatments be carried out during the pandemic period. This review article considers epidemiological aspects of novel Coronavirus infection and presents both the clinical as well the possible economic effects of the pandemic on gynecology, obstetrics and reproductive medicine in Germany in the past, present and future. In addition, useful preventive measures for daily clinical work and the previously known scientific findings dealing with the impact of Coronavirus on pregnancy and birth are discussed.

Correlation between total sperm count and sperm motility and pregnancy rate in couples undergoing intrauterine insemination.

The frequency and significance of sterility is increasing due to different socio-demographic factors in the industrialized countries. At the same time, the patients' demand for more natural and less invasive fertility treatments is increasing. The most common method used in subfertility is intrauterine insemination (IUI). Retrospectively, the data from the patients were analyzed, in which at least one insemination and a maximum of eight inseminations were performed in the last five years (observation period 01.01.2014-31.12.2018) at the Women's University Hospital Homburg. The primary endpoint was the onset of a clinical pregnancy. Clinical pregnancy was correlated with the partner's total sperm count (sperm density in millions), sperm concentration and motility during insemination. These three parameters were evaluated according the World Health Organization (WHO) 2010 guidelines. The results of the spermiograms were correlated with clinical pregnancy outcome. The data were examined for 138 women with sterility, in which a total of 345 inseminations were performed (median 2.5 per woman, range 8 inseminations). There was no correlation found between spermiogram parameters and pregnancy probability in any of the inseminations. After 5 inseminations no further pregnancy occurred. The present study showed no correlation between the conception probability of intrauterine insemination (IUI) and the total sperm count/concentration/motility. After the sixth IUI, we no longer found conceptions in our patient collective. Therefore, data from this study indicate that intrauterine inseminations can be performed at all severity levels of oligoasthenozoospermia. However, the treatment should be limited to five attempts.

Treatment algorithm for women with endometriosis in a certified Endometriosis Unit.

INTRODUCTION: Endometriosis is a chronic hormone-dependent disease affecting approximately 25-30% of women in the third and fourth decade. Despite its frequency, it is often detected late. The aim of this overview article was to present a standardized treatment algorithm for an interdisciplinary endometriosis consultation considering conservative and surgical approaches. EVIDENCE ACQUISITION: Despite the frequency of endometriosis and a high number of publications dealing with the disease there is a lack of evidence in literature for standardized treatment algorithms allowing a rational diagnostic and therapeutic approach. In May 2019 we did a literature search in Medline. While finding 26702 publications under the term "endometriosis" there was only one publication for the search term "endometriosis consultation treatment algorithm." After screening the abstracts 144 publications in English, French or German language had been assessed as relevant for the diagnosis and therapy of endometriosis (143 overview articles and one guideline). EVIDENCE SYNTHESIS: Based on clinical evidence, we have developed a treatment algorithm for women with suspected endometriosis. The diagnosis includes a structured medical history with the identification of endometriosis-typical symptoms and a gynecological examination, if necessary additional examinations. The treatment algorithm is essentially divided into the phase of diagnosis and the phase of therapy as well as the prevention of recurrence or long-term treatment. A multi-professional team of visceral surgery, urology, nutritional medicine, physiotherapy and psychology can be consulted for support. CONCLUSIONS: The treatment of endometriosis should be multiprofessional, standardized and reproducible during specialized consultations at certified centers. So far, there are few publications on a standardized and clinically proven treatment algorithm for women with suspected endometriosis. The presented treatment algorithm could be helpful in the diagnosis and treatment of endometriosis patients, even at other centers.

[Case report of 39-Year-Old Gravida III, Para III with Inverted Uterus after Breech Birth]. / Fallbericht 39-jährige III. Gravida, III. Para mit Inversio uteri nach Steißgeburt.

An inverted uterus is defined as the eversion of the uterus into the vagina. It is a very rare event but has to be treated as an emergency. A woman with an inverted uterus is in serious danger of developing atony with high blood loss in a short time. This can lead to hypovolemic shock and circulatory failure. Therapy includes urgent uterine repositioning under narcosis and curettage after manual abruption of the placenta. Afterwards, uterotonics such as prostaglandins should be administered. A disorder of the coagulation system is very common due to blood loss. Therefore, substitution of plasma components and antifibrinolytic drugs are recommended. If vaginal repositioning of the uterus cannot be achieved, laparotomy or hysterectomy are possible alternatives. We report the case of a 39 year-old gravida III, para III in the 36+3 gestational week who, after a spontaneous breech delivery with placenta accreta, experienced an inverted uterus, which was then repositioned.

A standardized simulation training program to type 1 loop electrosurgical excision of the transformation zone: a prospective observational study.

PURPOSE: To evaluate a simulation-based standardized training program for type 1 loop electrosurgical excision procedure (LEEP) under direct colposcopic vision in postgraduate teaching. METHODS: Seventeen participants (five experienced and 12 novice surgeons) performed 170 simulated cervical excisional procedures. Each participant performed 10 type 1 (cone length between 8 and 10 mm) excisional procedures under direct colposcopic vision on a low-fidelity simulator. Length of specimen was measured after each excision allowing the surgeons a subsequent resection to ensure a cone length of more than 8 mm. Main outcome measures were cone length, specimen fragmentation, and a self-developed score (LEEP score), which allowed the simultaneous evaluation of both measured parameters. RESULTS: The precision of the excision showed statistically significant improvement in the novice group during the training procedures after five procedures [LEEP score 1.61 (SD 1.34) vs. 0.46 (SD 0.58); p = 0.023], while experts showed consistently high performance. Inexperienced surgeons performed more frequently cuts that were too deep than experienced surgeons (33/120, 27.5% vs. 4/50, 8%; p = 0.003). CONCLUSIONS: Low-fidelity simulation training seems to be an effective method for learning the accurate cone length for a type 1 excision for novice surgeons. As excessive excisions are related with high risk for premature delivery in subsequent pregnancies, in our opinion, LEEP should be practiced in simulation training, especially before performing in woman of reproductive age.

Conisation course for medical students-experience from a German University Hospital

Objective: Conisation of the cervix is one of the most common surgical procedures in gynaecology. Nevertheless, surgical expertise is required because if the cone is too small, the oncological risk increases and if the cone is too large, the obstetric risk increases. The aim of this prospective study was to investigate the suitability of an in-house conisation simulator for teaching medical students the practical performance of conisation. Material and Methods: Following a demonstration, students performed a loop conisation with a target depth of 8-10 mm using the simulator. Cone biopsy dimensions were analysed and a loop electrosurgical excision procedure (LEEP) score was calculated. The students were surveyed using a questionnaire of 12 items with five possible responses for each in order to investigate the suitability and realism of the teaching experience. Results: Eighty-nine students participated in the course. The median (range) cone depth was 8 (3-25) mm with a standard deviation of 3.3 mm. The observed LEEP score amounted to 1.5. The questionnaire was answered by 88 students and completed by 86. Survey results showed the course was consistently rated as positive, especially towards the increase in practical skills. The questionnaire item producing the highest score was "I enjoyed the course" while the statement "I have gained enough self-confidence for the application of high-frequency surgery" received the lowest approval score. Students considered the course to be realistic and a helpful teaching exercise. Conclusion: Practical surgery exercises on the surgical simulator were received positively. Simulation training could be extended to other gynaecological operations and to other medical subjects.