The impact of rehabilitation sport on breast cancer-related lymphoedema and quality of life.

PURPOSE: Surgery and radiotherapy as part of breast cancer treatment can lead to lymphoedema of the upper extremities (breast cancer-related lymphoedema = BCRL) and reduce the quality of life (health-related quality of life = HRQoL). The aim of the present study was to investigate the influence of paddling in a dragon boat (PP) on HRQoL and BCRL in breast cancer survivors (BCS). METHODS: Between April and October 2017, a prospective case-control study evaluated the effects of PP compared to a control group. In the paddle group (n = 28), weekly arm circumference measurements were taken at four defined anatomic areas of the arm before and after training; in the control group (n = 70), the measurements were taken once a month. At the beginning and end of the study, questionnaires from both groups (SF 36, EORTC QLQ C30) were evaluated to understand the differences in HRQoL. RESULTS: The paddle group started with a higher HRQoL compared to the control group. Most interesting, whether the affected or unaffected arm, whether before or after training-the arm circumference decreased over time in the paddling group. A pre-existing lymphoedema was not negatively influenced by paddling. In the paddle group, the physical health was constant over the season, while the physical health of the control group decreased significantly over time. CONCLUSION: PP in a dragon boat does not lead to the development or worsening of pre-existing lymphoedema due to breast cancer therapy, and seems to have a positive effect on the quality of life.

Absorbable versus non-absorbable sutures for vaginal mesh attachment during sacrocolpopexy: a randomized controlled trial.

INTRODUCTION AND HYPOTHESIS: The purpose of the study was to analyze anatomical and functional outcomes after sacrocolpopexy (SCP) for vaginal vault prolapse pelvic organ prolapse quantification (POPQ) II-III by random use of absorbable (Vicryl) and non-absorbable sutures (Ethibond) for vaginal mesh fixation. METHODS: This study was designed as a two-center randomized controlled study (RCT). The primary objective was to evaluate the anatomical outcome. Success was defined when the vaginal apex (point C; POPQ) did not descend more than 50% of the total vaginal length (tvl) during Valsalva. Patients completed a pelvic examination incorporating the POPQ and questionnaires (the German pelvic floor questionnaire and the PISQ-12 questionnaire) at baseline and 6 months postsurgery. Perioperative adverse events (AE) were recorded. Sample size calculations, based on a 10% non-inferiority limit required 100 participants per group, with power = 90%. RESULTS: In 190 out of 195 women (ETH group n = 96; VIC group n = 94) anatomical success was achieved. The relative risk of anatomical success failure in the VIC group versus the ETH group was 0.69, with a 95% confidence interval 0.12-4.02. The change in the symptom scores did not differ significantly between the ETH and the VIC group. In the ETH group, three suture penetrations into the vagina were observed, and none in the VIC group 6 months postoperatively. CONCLUSIONS: Anatomical success after SCP for vaginal vault prolapse POPQ II-III is not affected by suture type for vaginal monofilament mesh attachment. Moreover, we did not see any differences in functional outcomes between the two groups. Three suture penetrations into the vagina were observed in the ETH group, and none in the VIC group 6 months postoperatively.

A retrospective analysis of perioperative complications associated with retropubic tension-free vaginal tape in 960 women.

PURPOSE: The purpose is to analyse perioperative complications associated with the retropubic tension-free vaginal tape (TVT) procedure and their management. METHODS: This retrospective, monocentric cohort study included 960 women after retropubic TVT procedure performed by one surgeon from 2011 to 2016. Complications were identified up to 6 weeks after the procedure, divided into specific and general complications and classified based on the Clavien-Dindo (CD) Classification. A visit 6 weeks after the surgical procedure was attended by all patients. RESULTS: 77 complications, of which 74 occurred postoperatively and 3 intraoperatively, affecting 72 (7.5%) out of 960 women. Urinary retention and voiding problems were the most common complication. The mean age of women suffering complications was 3.4 years higher in comparison to the mean age of women without complications (p = 0.036). The Body Mass Index (BMI) of the group of women with perioperative complications had an average BMI which was 0.5 kg/m2 lower than the average BMI of the women without complications. 22 (12.8%) out of 172 women with recurrent stress incontinence had postoperative complications, of which 21 were related to the TVT. CONCLUSION: The retropubic TVT is a surgical procedure associated with a low number of perioperative complications, even in the group of elderly and overweight women, as well as in cases of recurrent stress incontinence.

Disseminated tumour cells from the bone marrow of early breast cancer patients: Results from an international pooled analysis.

PURPOSE: Presence of disseminated tumour cells (DTCs) in the bone marrow (BM) has been described as a surrogate of residual disease in patients with early breast cancer (EBC). PADDY (Pooled Analysis of DTC Detection in Early Breast Cancer) is a large international analysis of pooled data that aimed to assess the prognostic impact of DTCs in patients with EBC. EXPERIMENTAL DESIGN: Individual patient data were collected from 11 centres. Patients with EBC and available follow-up data in whom BM sampling was performed at the time of primary diagnosis before receiving any anticancer treatment were eligible. DTCs were identified by antibody staining against epithelial cytokeratins. Multivariate Cox regression was used to compare the survival of DTC-positive versus DTC-negative patients. RESULTS: In total, 10,307 patients were included. Of these, 2814 (27.3%) were DTC-positive. DTC detection was associated with higher tumour grade, larger tumour size, nodal positivity, oestrogen receptor and progesterone receptor negativity, and HER2 positivity (all p < 0.001). Multivariate analyses showed that DTC detection was an independent prognostic marker for overall survival, disease-free survival and distant disease-free survival with hazard ratios (HR) and 95% confidence intervals (CI) of 1.23 (95% CI: 1.06-1.43, p = 0.006), 1.30 (95% CI: 1.12-1.52, p < 0.001) and 1.30 (95% CI: 1.08-1.56, p = 0.006), respectively. There was no association between locoregional relapse-free survival and DTC detection (HR 1.21; 95% CI 0.68-2.16; p = 0.512). CONCLUSIONS: DTCs in the BM represent an independent prognostic marker in patients with EBC. The heterogeneous metastasis-initiating potential of DTCs is consistent with the concept of cancer dormancy.

Anatomical and functional outcomes after hysterectomy and bilateral sacrospinous ligament fixation for stage IV uterovaginal prolapse: a prospective case series.

BACKGROUND: Aim of this study is to examine pelvic floor symptoms, anatomical results and patients' satisfaction after sacrospinous vaginal fixation for stage 4 pelvic organ prolapse. METHODS: All patients with stage 4 pelvic organ prolapse were treated with vaginal hysterectomy, native tissue cystocele and rectocele repair and bilateral sacrospinous vaginal fixation. Anatomical and functional outcomes according to the POPq classification system and the German version of the Australian pelvic floor questionnaire were assessed. Changes between baseline, first follow-up and second follow-up were assessed by the paired Wilcoxon rank test using R, version 3.5.1. RESULTS: 20 patients were included in the study. Scores in all four domains of the pelvic floor symptom questionnaire (bladder, bowel, prolapse, sexual function) were significantly improved at 6 and 12-months follow-up. One patient presented with a symptomatic stage 3 cystocele that needed a second surgical intervention and two patients needed surgery due to a de novo stress urinary incontinence. There were no perioperative adverse events and all patients reported full satisfaction after surgery. CONCLUSIONS: The vaginal approach with hysterectomy, native tissue repair and bilateral sacrospinous vaginal fixation seems to be a safe and effective method for the treatment of advanced stage POP, offering excellent relief in all pelvic floor symptoms. TRIAL REGISTRATION: ClinicalTrials.gov ( NCT02998216 ), December 20th, 2016. Prospectively registered.

Vaginal therapy of mild and moderate stress urinary incontinence using Er:YAG laser: a real treatment option.

PURPOSE: To evaluate the effectiveness of vaginal Er:YAG laser as treatment in patients with mild or moderate stress urinary incontinence. METHODS: The study was a prospective, non-randomised, single center study of 33 women treated with two Er:YAG laser applications on an interval of four weeks. Follow-up evaluations were performed 4 and 8 weeks and 6 months after the first vaginal Er:YAG laser application (4 weeks and 5 months after the second vaginal Er:YAG laser application, respectively). The subjective outcomes were assessed using the International Consultation of Incontinence Modular Questionnaire Short Form (ICIQ-SF) and medical history. Patients rated their quality of life on a scale from 0 to 10. RESULTS: The average quality of life (QoL) showed a significant improvement 5 months after both Er:YAG laser applications. The mean QoL score was 6.0 (SD 2.4) and improved to a mean of 7.6 (SD 1.8) (p = 0.004). The mean ICIQ-SF score changed significantly from 12.3 (SD 3.2, median 13, range 8-18) before treatment to 6.8 (SD 4.0, median 7, range 0-15) 6 months after treatment (p <0.001). 24 patients out of 32 (75%) would again choose to have this therapy performed and 25 patients of 32 (78%) would recommend the vaginal Er:YAG laser therapy to a friend. The rate of side effects was low and none of the patients needed a medical treatment. CONCLUSIONS: This study confirms that vaginal Er:YAG therapy can improve clinical and quality of life outcomes in patients with SUI.

Correction to: Differences in the clinical phenotype of adenomyosis and leiomyomas: a retrospective, questionnaire-based study.

In the Original article publication, the name of the co-author Antje Ganz was not included. The Correct order of authors is as given above.

Demographic changes and effects on the mode of delivery: a retrospective analysis of a large birth registry containing 27,729 singleton deliveries in a level I center.

PURPOSE: To characterize and understand the demographics (age and body mass index, BMI) of a cohort of women who delivered at a single institution over an 11-year period. The purpose of this analysis is to look for effects over time of demographic characteristics on mode of delivery. METHODS: Retrospective analysis of singleton deliveries between 2004-2014, n = 27,729; level 1 perinatal center, university hospital setting. Data were extracted from the digital birth registry. All statistical analyses were done using R version 3.5.1. Variables analyzed were: age, BMI, and mode of delivery (in the current and any prior pregnancies). RESULTS: Mean age increased from 31.1 ± 5.2 years in 2004 to 31.5 ± 5.0 years in 2014 (p < 0.001, eta2 = 0.0006). Mean BMI before pregnancy increased from 23.7 ± 4.5 to 24.7 ± 5.2 kg/m2. Mean BMI at delivery increased from 28.5 ± 4.7 to 29.6 ± 5.2 kg/m2 (p < 0.001, eta2 = 0.0049). Regarding maternal age, patients with elective Cesarean section (CS) (32.5 ± 5.3 years), emergency CS (31.6 ± 5.6 years) and CS in labor (31.4 ± 5.3 years) were older compared to those with spontaneous (31.0 ± 5.2 years) or instrument-assisted vaginal delivery such as vacuum (31.0 ± 5.0 years) and forceps (30.2 ± 5.4 years). Among the multiparous patients, the mode of delivery in prior pregnancies is the variable with the greatest effect on the mode of delivery in any subsequent pregnancies. The mode of delivery was: spontaneous (55.5%), vaginal operative including vacuum and forceps (8.8%), and Cesarean section (35.7%). CONCLUSIONS: Increase of age and BMI over years is significant, but very small and in a range which seems not clinically relevant. Previous births have the strongest effects on mode of delivery in the current pregnancy.

Perioperative adverse events associated with pelvic organ prolapse repair by nerve-preserving sacropexy: an analysis of 768 cases over a 10-year period.

OBJECTIVE: To report the perioperative adverse events associated with nerve-preserving sacropexy for pelvic organ prolapse (POP) repair and to identify risk factors that could predict possible adverse events. MATERIALS AND METHODS: A total of 768 women who underwent sacropexy for POP repair performed by one surgeon using the same technique, beyond the learning curve, over a 10-year period, between January 1st 2007 and December 31st 2016. METHODS: The medical records of 768 women were reviewed for age, body mass index (BMI), tobacco use, previous surgeries (for POP and incontinence, abdominal surgeries in general), operating time, duration of hospitalization and perioperative events at time of surgery and 6 weeks postoperatively. Additionally, the complications were classified according to the Clavien-Dindo grading system and the Charlson Age Comorbidity Index (CACI) was evaluated for the patients. RESULTS: Between January 1st 2007 and December 31st 2016, 768 patients underwent sacropexy for POP. 27 (3.5%) adverse events occurred intra- and post-operative within 6 weeks after surgery. In univariate and multivariate analyses, only comorbidity and concomitant posterior colporrhaphy are significantly associated with complications. CONCLUSIONS: Surgeon's experience and a standardized technique minimize the risk of perioperative adverse events. The data on complications we found can be used to guide effective consent.

Hyperandrogenemia and ovarian reserve in patients with Mayer-Rokitansky-Küster-Hauser syndrome type 1 and 2: potential influences on ovarian stimulation.

PURPOSE: This study aimed to analyze the hormone profiles, to detect the rate of hyperandrogenemia and to investigate the potential effect of Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS) on ovarian reserve, as reflected by the serum Anti-Mullerian hormone (AMH) levels. Clinical implications were analyzed by including our own experiences with three patients after ovarian stimulation in preparation for uterus transplantation. METHODS: Serum samples of 100 patients with MRKHS (50 patients with MRKHS type 1 and 50 with type 2) were analyzed and compared to 50 individually age-matched healthy controls. Blood samples for hormone analyses were collected routinely during the clinical visit. RESULTS: The mean age was 20.0 years for MRKHS type 1, MRKHS type 2 and healthy controls. Compared to healthy controls, there was no significant difference in AMH values in the MRKH patients. As shown in previous studies, the proportion of hyperandrogenemia without clinical symptoms was significantly higher in MRKHS type 1 (52%; p < 0.001) and type 2 (56%; p < 0.001) patients when compared to age-matched controls. In preparation for uterus transplantation, three patients were stimulated with FSH/hMG for mean 14.2 days and the mean number of aspirated oocytes was 13.2 (3-22), while 8.3 (2-10) oocytes could be fertilized and cryopreserved. The mean fertilization rate was 51.2% (30-67%). CONCLUSION: The rate of hyperandrogenemia was significantly higher in MRKH patients compared to healthy age-matched controls. Though, ovarian reserve (AMH level) was not reduced compared to controls. Future studies are needed to identify optimal ovarian stimulation protocols as well as to implement a systematic multicenter reporting system.

Does applying postoperative suprapubic catheterisation in urogynecology benefit patients?

PURPOSE: The aim of this study was to define groups of women that are at particular risk for postoperative voiding dysfunction (PVD) after surgery for stress urinary incontinence (SUI) and/or pelvic organ prolapse (POP) and to focus on the question if these specific groups would benefit from suprapubic catheter (SPC) insertion. Complications associated with SPC were identified. METHODS: Between 06/2005 and 01/2013, the medical records of N = 4463 patients who underwent POP and/or SUI surgery were reviewed for suprapubic bladder drainage, duration of suprapubic catheterisation and SPC associated complications. 35 women suffering from vesicovaginal (28) and urethrovaginal (7) fistulas at the same time span were enrolled additionally. RESULTS: The results obtained revealed that patients after isolated anterior colporrhaphy, isolated anterior colporrhaphy and TVT, isolated cystocele repair using mesh and TVT, as well as patients with concomitant posterior and/or middle compartment prolapse surgery are at increased risk of developing PVD. Thus, postoperative suprapubic bladder drainage is beneficial. Complications occurred in 4.9 % of patients who received an SPC: urinary tract infection (UTI) (35), catheter dislocation (21), infection at the catheter insertion (2) and small bowel perforation (1). For the patients treated for fistulas we noticed a complication rate related to SPC of 11.4 %: UTI (2) and small bowel perforation (2). CONCLUSIONS: Patients should be counselled about the risk of developing PVD after POP and/or SUI surgery and should be informed about postoperative bladder drainage options related to their surgery.

Differences in the clinical phenotype of adenomyosis and leiomyomas: a retrospective, questionnaire-based study.

PURPOSE: To compare women undergoing laparoscopic hysterectomy with adenomyosis and women with leiomyomas. MATERIALS AND METHODS: Retrospective and questionnaire-based study was conducted at the Department of Obstetrics and Gynecology, University Women's Clinic, Tuebingen, Germany. The study sample comprised a total of 454 women who underwent hysterectomy for adenomyosis or leiomyomas and responded to the questionnaire; 52 (11.4 %) women with a histologic diagnosis of adenomyosis and 452 (88.6 %) women with a histologic diagnosis of leiomyomas. RESULTS: Both groups of patients had enlarged uteri, but women with adenomyosis had a lower mean uterine weight as compared to women with leiomyomas (p < 0.001). Women with adenomyosis had significantly more pregnancies (p = 0.003), were more likely to have more than one pregnancy (p = 0.033) or more than one delivery (p = 0.025) as compared to women with leiomyomas. In addition, women with adenomyosis had a significantly higher surgical procedure score (p = 0.017), had more frequently a history of laparotomy (p = 0.042) and a history of Cesarean section as compared to women with leiomyomas only (p = 0.024). Significantly, more women with adenomyosis had pelvic pain or pressure as compared to women with leiomyomas (p = 0.045). We observed no differences between the two groups of patients regarding pelvic pain during the menstrual period, irregular menstrual periods, heavy bleeding, painful sexual intercourse and urination problems. Furthermore, we observed no differences in the therapeutic impact of the surgical procedure between the two patient groups. CONCLUSIONS: Women with a histologic diagnosis of adenomyosis differ from women who have only leiomyomas at the time of hysterectomy.

Clinical characteristics indicating adenomyosis coexisting with leiomyomas: a retrospective, questionnaire-based study.

OBJECTIVE: To elucidate the clinical profile of a concomitant diagnosis of adenomyosis in women with leiomyomas. DESIGN: Retrospective questionnaire-based study. SETTING: Academic medical center. PATIENT(S): The study sample comprised a total of 560 women: 159 women with adenomyosis and leiomyomas and 401 women with leiomyomas alone. INTERVENTION(S): Mailing of a symptom questionnaire. MAIN OUTCOME MEASURE(S): Comparison of women undergoing hysterectomy with adenomyosis and leiomyomas and women with leiomyomas alone. RESULT(S): Women with a concomitant diagnosis of adenomyosis and leiomyomas had significantly higher scores for disease burden during the menstrual period before surgery: heavy bleeding episodes and passing blood clots. Furthermore, women with adenomyosis and leiomyomas reported higher scores of distress regarding pelvic pain occurring during the menstrual period and pelvic pain not associated with the menstrual cycle. Moreover, in multivariate analysis, older age (odds ratio [OR] 1.10, 95% confidence interval [CI] 1.04-1.18), gravidity (OR 1.44, 95% CI 1.12-1.74), and pelvic pain occurring during the menstrual period (OR 1.27, 95% CI 1.06-1.54) increase the odds of having adenomyosis and not only leiomyomas. CONCLUSION(S): Adenomyosis contributes to symptomatology in women with concomitant adenomyosis and leiomyomas.

Modified LeFort colpocleisis: clinical outcome and patient satisfaction.

OBJECTIVES: The purpose of this study was to determine the anatomical and functional outcomes, as well as patients' satisfaction and morbidity associated with modified LeFort colpocleisis. STUDY DESIGN: Between 7/2007 and 6/2011 58 patients underwent a modified LeFort colpocleisis. Thirty-eight were available for follow-up visit. Records were reviewed for patients' characteristics, operative data and incidence of complications. The follow-up visit comprised a medical history and a gynecological examination. A visual-analog-scale to assess patients' quality of life after surgery was used. The patients were asked: "Would you again choose to have this surgery performed?" and "Do you regret choosing to have a vaginal closure procedure?" Statistical analysis was performed using R version 2.12.1, R Foundation for Statistical Computing, Vienna, Austria. RESULTS: There were no treatment failures within a mean follow-up of 14 months (range 3-41 months). 89% of patients reported an improved quality of life postoperatively. No complications occurred intraoperatively and none of the patients regretted the loss of sexual function. All patients stated that they would choose to have the colpocleisis procedure again. Postoperatively 8 urinary tract infections, 2 hematomas and 1 pyometra occurred. Two patients complained about stress urinary incontinence and another one about an overactive bladder. CONCLUSION: The study highlights an additional safe and effective option for an individualized treatment of pelvic organ prolapse.

A combination of transcriptome and methylation analyses reveals embryologically-relevant candidate genes in MRKH patients.

BACKGROUND: The Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is present in at least 1 out of 4,500 female live births and is the second most common cause for primary amenorrhea. It is characterized by vaginal and uterine aplasia in an XX individual with normal secondary characteristics. It has long been considered a sporadic anomaly, but familial clustering occurs. Several candidate genes have been studied although no single factor has yet been identified. Cases of discordant monozygotic twins suggest that the involvement of epigenetic factors is more likely. METHODS: Differences in gene expression and methylation patterns of uterine tissue between eight MRKH patients and eight controls were identified using whole-genome microarray analyses. Results obtained by expression and methylation arrays were confirmed by qRT-PCR and pyrosequencing. RESULTS: We delineated 293 differentially expressed and 194 differentially methylated genes of which nine overlap in both groups. These nine genes are mainly embryologically relevant for the development of the female genital tract. CONCLUSION: Our study used, for the first time, a combined whole-genome expression and methylation approach to reveal the etiology of the MRKH syndrome. The findings suggest that either deficient estrogen receptors or the ectopic expression of certain HOXA genes might lead to abnormal development of the female reproductive tract. In utero exposure to endocrine disruptors or abnormally high maternal hormone levels might cause ectopic expression or anterior transformation of HOXA genes. It is, however, also possible that different factors influence the anti-Mullerian hormone promoter activity during embryological development causing regression of the Müllerian ducts. Thus, our data stimulate new research directions to decipher the pathogenic basis of MRKH syndrome.

Assessment of vision-related quality of life in patients with homonymous visual field defects.

BACKGROUND AND PURPOSE: Homonymous visual field defects (HVFDs) are among the most common disorders that occur in the elderly after vascular brain damage and can have a major impact on quality of life (QOL). Aims of this study were to describe the vision-targeted, health-related QOL in patients with HVFDs after cerebrovascular lesion, and to determine the relationship between patients' self-reported difficulties and the characteristics of HVFDs in the binocular visual field. METHODS: The German version of the 25-item National Eye Institute Visual Functioning Questionnaire (NEI-VFQ-25) was used. NEI-VFQ-25 scores for patients were compared to reference values of healthy German subjects from Franke (Z Med Psychol 7:178-184, 1999). Extent and location of absolute HVFDs were assessed by binocular semi-automated kinetic perimetry (SKP) within the 90 degrees visual field. Correlations of the NEI-VFQ-25 scores of patients with the area of sparing within the affected hemifield (A-SPAR) were estimated by Spearman's r (s). RESULTS: The mean NEI-VFQ-25 composite score for 33 patients (time span after brain injury at least 6 months) was 77.1, which was significantly lower (p < 0.0001) than the reference value for 360 healthy subjects (composite score = 90.6), and this was also the case for general vision, near activities, vision specific mental health, driving, colour, and peripheral vision. The score for general health was also significantly lower in patients than in reference subjects (p < 0.0001). A weak correlation of the composite score with A-SPAR (r (s) = 0.38) was observed. CONCLUSIONS: Our findings indicate that detectable decrements in vision-targeted, health-related QOL are observed in patients with homonymous visual field loss. A relationship of the perceived visual functioning with objective parameters is by definition difficult; however, understanding what components of visual function affect certain visual tasks, would help in developing more efficient, clinical assessment strategies. The results reveal a tendency for increasing QOL with advancing size of the area of sparing within the affected hemifield (A-SPAR). The lack of a strong correlation between NEI-VFQ-25 subscales and A-SPAR suggests that an assessment of the visual field may not accurately reflect patients' perceived difficulty in visual tasks. Additional consideration of visual exploration via eye and head movements may improve the correlation between visual function and its perception.