Three-dimensional vs two-dimensional endoscopic approach in urogynecology: A retrospective cohort study of laparoscopic sacrocolpopexy.

AIM: The gold standard to treat an apical pelvic organ prolapse is the abdominal route via a sacrocolpopexy, which is also reproduced by laparoscopic route. A laparoscopic sacrocolpopexy however, requires surgical expertise. Three-dimensional (3D) laparoscopy has been developed to overcome the lack of depth perception, that is a known disadvantage of conventional two-dimensional (2D) laparoscopy. This procedure can accelerate the learning curve and optimize the intra-, peri-, and postoperative outcomes. This study aims to compare 3D laparoscopy to traditional 2D laparoscopy for sacrocolpopexy. METHODS: Data from 132 patients who underwent a sacrocolpopexy with 2D or 3D laparoscopy in Department of Obstetrics and Gynecology, University Medical Center of the Johannes Gutenberg University, between June 2012 and September 2021, were collected retrospectively. Seventy-one laparoscopic sacrocolpopexy operations in 2D (n = 23) and 3D (n = 48) group were reviewed and compared regarding the duration of surgery, blood loss and the length of hospital admission as primary objectives. RESULTS: There were no differences in the baseline demographics between the two groups. The estimated blood loss (1.0 (±0.6) g/dL vs 1.7 (±1.0) g/dL, p = 0.010), and duration of surgery (115.4 (±34.7) min. vs 134.7 (±26.2) min., p = 0.012) was significantly better in favor of 3D laparoscopy. The length of hospital stay was comparable in both groups (p = 0.833). Furthermore, no differences were observed between the groups regarding other surgical outcomes. CONCLUSION: 3D laparoscopy shows a significant benefit in terms of estimated blood loss and surgery duration among complex urogynecological surgeries compared to traditional 2D laparoscopy.

Safety of misoprostol for near-term and term induction in small-for-gestational-age pregnancies compared to dinoprostone and primary cesarean section: results of a retrospective cohort study.

OBJECTIVES: Small-for-gestational-age (SGA) pregnancy is a condition often leading to labor induction due to concerns about the possibility of an increased risk for fetal morbidity and mortality. In this retrospective cohort study, we try to evaluate the safety of oral misoprostol for labor induction in near-term and term pregnancies in SGA fetuses compared to dinoprostone as well as to planned primary cesarean section. MATERIALS AND METHODS: Retrospective analysis of labor indution and primary cesarean section in SGA pregnancies 37 weeks and beyond in a tertiary care centre. In total, 284 consecutive patients with SGA fetuses were included. 80 recieved oral misoprostol, 85 dinoprostone as vaginal Gel and 119 were delivered by means of primary cesarean section. Primary endpoints were umbilical aterial pH and APGAR 5'. Secondary endpoints were APGAR 1' and 10', rates of relevant acidosis with a pH < 7.11 and depressed children, NICU admissions and vaginal operative deliveries as well as cesarean sections after labor induction. RESULTS: No significant differences were found concerning the umbilical arterial pH. No significant differences were found concerning APGAR 5' after labor induction; however, APGAR 5' was significantly lower after primary cesarean section. Similar results were found concerning APGAR 1', 10-min APGAR values were not significantly different. Rates of relevant acidosis and depressed children did not differ; no significant differences were found concerning NICU admissions between all groups and vaginal operative deliveries and CS rates after labor induciton. CONCLUSION: Oral misoprosol is a safe method for labor induction in SGA near-term and term pregnancies and, concerning the neonatal outcome, comparable with other methods of labor induction or primary CS. Our study showed no adverse neonatal outcomes related to the use of oral misoprostol.

Birth experience from the perspective of the fathers.

PURPOSE: As men nowadays often attend the delivery of their own child, they also have to go through the labor period. In this study, the condition of the expectant fathers attending labor was evaluated. METHODS: In 2016, fathers who went through labor with their partners in the University medical center of Mainz were interviewed within the first days after delivery and 6 months later. They received a "Fathers questionnaire" concerning their motivation, the valuation of their attendance, their emotions during labor, and concerning the service in the labor ward. Six months later, they also received the validated Impact of Event Scale questionnaire (IES-R). In total, 318 participants answered the "Fathers' Questionnaire", 226 the IES-R. RESULTS: Father's attendance during labor was considered to be beneficial for fathers themselves (254, 79.8%), for the mother (272, 85.5%), for the newborn child (187, 58.8%), for the relationship (234, 73.6%). Only four could not see a purpose in their attendance. 73 men (23%) felt helpless, 47 (14.8%) were overwhelmed by the situation, 116 (36.5%) felt fear, 299 (94%) were happy to be present at birth, 27 (8.5%) felt traumatized by experiencing their partners in labor. According to the IES-R, none of the 226 men surveyed showed all symptoms of post-traumatic stress disorder. CONCLUSION: Childbirth is related to positive and negative emotions. Positive emotions are predominant, but come along with negative feelings. In this survey, posttraumatic stress disorder did not occur among men after delivery. Nevertheless, fathers' needs should be kept in view.

Assessment of pelvic floor muscle contractility: digital palpation versus 2D and 3D perineal ultrasound.

PURPOSE: The aim of our study was to investigate 2D and 3D ultrasound assessment of pelvic floor muscle contractility as an objective non-invasive diagnostic tool in urogynecologic patients. METHODS: Patients from our urogynecological outpatient clinic were examined clinically by a single investigator including digital palpation as well as 2D and 3D perineal ultrasound. Muscle contractility was graded according to the modified Oxford Score and ultrasound images were saved for later analysis. Stored images were evaluated offline by another investigator blinded to all clinical data at a later stage. Bladder neck distance from pubic symphysis and symphysis-levator distance were measured in 2D at rest and during maximal pelvic floor muscle contraction. Hiatal area at the level of minimal hiatal dimensions as a 3D ultrasound parameter was measured at rest and during maximal pelvic floor muscle contraction, too. Spearman's rho was used to calculate statistical correlation between ultrasound parameters and digital assessment. RESULTS: A total of 114 patients were examined in our study. We found a significant correlation between modified Oxford Score and 2D ultrasound parameters of elongation of bladder neck length (Spearman's rho 0.292, p = 0.002) and reduction of symphysis-levator distance (Spearman's rho 0.0.301, p = 0.001), respectively. In addition, we detected a statistical significant correlation of modified Oxford Score and reduction of hiatal area in 3D ultrasound (Spearman's rho 0.458, p < 0.001), too. CONCLUSIONS: In this study, we found a significant correlation of subjective digital assessment of pelvic floor muscle strength with 2D and 3D ultrasound parameters as an objective diagnostic tool.

The effect of ovarian stimulation on the outcome of intrauterine insemination.

PURPOSE: Although intrauterine insemination is one of the oldest techniques in reproductive medicine, its significance is still controversially discussed. Many factors have been reported as influencing pregnancy rates after IUI. The aim of this retrospective analysis is to evaluate the success rate of repeated inseminations depending on the type of ovarian stimulation. METHODS: Patients who underwent intrauterine insemination in Wiesbaden Kinderwunschzentrum between 1998 and 2010, not older than 45 years of age, with male subfertility were included in this study. On the whole, 5,346 inseminations on 2,180 patients were analyzed retrospectively. RESULTS: Females' mean age was 34.1, ranging from 19-45 years. In 433 cycles an insemination was performed during a natural cycle. 4,020 cycles were stimulated with recombinant FSH, 596 cycles with clomiphene, 194 with urinary FSH, 103 with HMG. The pregnancy rates range from 7.4% in the clomiphene group to 14.4% in the urinary FSH group. Clomiphene stimulation seems to offer the significantly lowest pregnancy rate (p = 0.03). The other types of stimulation do not differ significantly from each other concerning the pregnancy rate. Patients under 39 years of age do not profit from any ovarian stimulation. In 40 and more years of old patients, pregnancy rates are higher, if any stimulation was performed. CONCLUSION: To sum up, clomiphene stimulation showed to offer significantly lower pregnancy rates in comparison to the natural cycle, FSH stimulation and HMG stimulation in IUI treatment. While women younger than 40 seem not to profit from any ovarian stimulation, women over 40 do profit.

Nationwide analysis on surgical staging procedures and systemic treatment for patients with endometrial cancer in Germany.

OBJECTIVE: In 2009 and 2006, the Arbeitsgemeinschaft Gynäkologische Onkologie evaluated therapeutic approaches for endometrial carcinoma (EC) in Germany. METHODS AND MATERIALS: A questionnaire was developed and sent to 775 German gynecologic departments in 2009 (500 in 2006). The results of the questionnaires were compared with each other and with the recommendations of the Arbeitsgemeinschaft Gynäkologische Onkologie's guideline. Subgroup analyses were performed, dividing the participating centers into small and large centers and into centers with less and more experience with EC. RESULTS: Responses were available in 33.3% in 2009 and 35.8% in 2006. Comparing 2009 with 2006, it became apparent that peritoneal washing cytology was performed in 94.6% versus 86.9% (P = 0.008), pelvic lymphadenectomy (LAN) in 98.3% versus 95.3%, and paraaortic LAN in 90.2% versus 73.8% (P < 0.001) for endometrioid EC, and LAN for histologic high-risk subtypes of EC in 99.6% versus 94.2% (P = 0.001), respectively. In 2009, all these criteria met the recommendation of the guidelines. Reoperation for LAN after postoperative upstaging was performed in 66.1% versus 50.6% (P = 0.002), and adjuvant systemic treatment with chemotherapy and endocrine therapy was performed in 63.7% versus 48.8% (P = 0.003) and 25.7% versus 15.4% (P = 0.014), respectively. This showed nonadherence to the guidelines. Laparoscopic approach was performed in 30.4% versus 19.7% (P = 0.014) of the participating centers, respectively. In subgroup analysis, laparoscopic approach showed a significant difference between small centers (11.5%) and large centers (27.3%) in 2006 (P = 0.012). CONCLUSIONS: German hospitals increasingly follow the guidelines concerning LAN and peritoneal washing cytology. However, recommendations concerning reoperating in upstaged patients and adjuvant treatment decisions do not meet the guidelines, thus underlining great uncertainties in this field of gynecologic oncology.

Sexual function and quality of life following retropubic TVT and single-incision sling in women with stress urinary incontinence: results of a prospective study.

PURPOSE: The objective of this prospective cohort study was to compare effectiveness, morbidity, quality of life (QoL) and sexual function in women treated with tension-free vaginal tape (TVT) versus single-incision sling (SIS) in the treatment of female stress urinary incontinence (SUI). METHODS: Retropubic TVT sling or SIS was implanted in local anesthesia and patients were followed post-operatively for 6 months. Evaluation was performed to assess post-operative rate of continence, complications, changes in sexual function and patient reported quality of life. Female sexual function was evaluated before and after sling procedure using Female Sexual Function Index (FSFI) in sexually active patients. RESULTS: From January 2009 to December 2011, 150 patients were enrolled and underwent a procedure to implant the retropubic TVT (n = 75) or the MiniArc(®) and Ajust(®) SIS (n = 75). Overall, 93.3 % of the patients who successfully received SIS demonstrated total restoration (84 %) or improvement of continence (9.3 %) at the 6 month post-operative study visit. In TVT group we found 88 % total continence and 6.7 % improvement, respectively. Improvements were seen in the QoL scores related to global bladder feeling (89.3 %) in SIS group and 96 % for TVT. Post-operative FSFI score improves significantly and were comparable in both groups (SIS pre-operative 24.30 ± 4.56 to 27.22 ± 4.66 (P < 0.001) post-operative; TVT 24.63 ± 6.62 to 28.47 ± 4.41, respectively). CONCLUSIONS: The SIS procedure appears to be as effective in improving incontinence-related quality of life and sexual function as the TVT through 6 months of post-operative follow-up. No differences in complications and sexual function were demonstrated between the groups.

Vasa previa: A rare obstetric complication-A case series and a literature review.

Vasa previa is a rare condition. However, since the increase in assisted reproductive technologies (ARTs), clinicians are more frequently confronted with this complication. In this study, we present five cases of vasa previa prenatally diagnosed from a tertiary referral hospital with approximately 2000 births yearly.

A 29-gauge atraumatic needle for amniocentesis.

OBJECTIVE: To compare perforation characteristics of standard 22 G (0.7 mm) to 29 G needle (0.34 mm) for amniocentesis. METHODS: Seventeen human chorio-amnion membranes were perforated immediately after cesarean section using 22 G needle for spinal anesthesia and 29 G "pencil-point" needles for amniocentesis under in-vitro conditions. Area of perforation was determined using a microscope and volume of fluid leakage was measured over a period of 5 min. RESULTS: Membrane perforation with the 22 G needle resulted in a mean damaged area of 225,147.4 µm(2), a hole with a mean area of 50,154 µm(2) and amniotic fluid volume passage of 17.5 mL/5 min, whereas the 29 G needle generated a mean damaged area of 114,812.4 µm(2), a hole with an average area of 1382.5 µm(2) and volume passage of 0.28 mL/5 min. These differences were significant. CONCLUSION: The hole formed by membrane perforation with 29 G "pencil-point" needle for amniocentesis is 36 times smaller, and the amniotic fluid loss is 61 times less than that measured with the 22 G standard needle for spinal anesthesia. Significant reduction of complications following amniocentesis is expected with the 29 G needle.

Neonatal outcome using ultrathin fetoscope for laser coagulation in twin-to-twin-transfusion syndrome.

OBJECTIVE: To improve neonatal outcome using ultrathin fetoscope for laser treatment of twin-to-twin transfusion syndrome. METHODS: Retrospective cohort study of a series of 80 cases of twin-to-twin-transfusion syndrome prior to 26-weeks' gestation subjected to laser coagulation by means of a 1.0/1.2 mm fiber fetoscope with a sheath sectional area 2.65 mm(2)/3.34 mm(2) (n=27) and a 2.0 mm classic lens fetoscope with a sheath sectional area: 6.63 mm(2)/11.27 mm(2) (n=53). RESULTS: The survival rates of at least one twin in the compared groups were 94.4% (classic optic) and 100% (ultrathin optic), for both twins: 75.5% and 83.3%, respectively. By decreasing sheath diameter a pregnancy was prolonged by an average of 21.3 days (P=0.0045), with a resulting increase in the recipient's weight of 389 g (P=0.0049) and an increase in the donor's Apgar score. However, the intervention with ultrathin optic took 11 min longer (P=0.031). CONCLUSION: The reduction of the iatrogenic damage of the amniotic membrane using ultrathin fetoscope with a small sheath, significantly improves the neonatal outcome after laser treatment of twin-to-twin-transfusion syndrome. The operator should only commence working with the 1 mm fetoscope after the learning curve has been accomplished.

Risk Factors for Chemotherapy-Associated Venous Thromboses in Gynaecological Oncology Patients.

Introduction Venous thromboses and their consequences are among the main causes of death in patients with tumour diseases. The objective of this study is the analysis of risk factors and the evaluation of the applicability of two risk scores in a purely gynaecological oncology patient collective. The identification of patients at high risk for the occurrence of venous thromboses could enable the implementation of targeted medication-based thrombosis prophylaxis which has a significant benefit and, simultaneously, a low risk. Materials and Methods A retrospective case-control study on 152 patients who were undergoing oncological treatment in the Department of Gynaecology of the Mainz University Medical Centre between 2006 and 2013 investigated the data from 104 patients with breast, 26 with ovarian and 22 with cervical cancer. A control was assigned to 76 subjects in the case group who suffered a venous thrombosis during chemotherapy and this control coincided in the points of tumour location, age, lymph node involvement, metastasis and time of initial diagnosis. The group differences were analysed using the χ 2 test, t test, Mann-Whitney-U test and a logistic regression analysis. Results There were clear group differences in the lack of inpatient thrombosis prophylaxis (p = 0.014), elevated leukocyte counts (p = 0.018) prior to the start of chemotherapy and port systems (p = 0.032). Surgical interventions were confirmed to be an independent risk factor (p ≤ 0.001). The Khorana and Protecht scores did not emerge from the analysis as independent predictors for a thrombosis. More patients died in the case group than in the control group (p = 0.028; OR: 8.1; CI: 1.254 - 52.162). Conclusion In this patient collective, surgeries represent an independent risk factor for venous thromboses. In addition, a correlation was seen between inpatient thrombosis prophylaxis, leukocytosis as well as port systems and an increased risk of thrombosis. Neither the Khorana nor the Protecht score were independent risk factors for venous thromboses. Significantly more thrombosis patients died during the observation period.

Nationwide analysis on surgical procedures for patients with endometrial cancer in Germany: results of the AGO pattern of care studies from the years 2013, 2009, and 2006.

PURPOSE: In 2013, 2009, and 2006, the Arbeitsgemeinschaft Gynäkologische Onkologie evaluated the therapeutic approaches and the adherence to their guidelines for endometrial carcinoma (EC) in Germany. Here, we present the results concerning the surgical procedures. METHODS: A questionnaire was developed and sent to 682 German gynecological departments in 2013 (775 in 2009 and 500 in 2006). The results were compared with the recommendations of the guideline and with each other. RESULTS: Responses were available in 40.0 % in 2013, 33.3 % in 2009, and 35.8 % in 2006, respectively. Pelvic lymphadenectomy (LAN) was performed in accordance with the guidelines with some exceptions in 2013, 2009, and 2006, whereas paraaortic LAN was performed in accordance with the guideline only in 2009. Histological high-risk subtypes of EC received pelvic and paraaortic LAN in 2013, 2009, and 2006 in accordance with the guidelines with small exceptions. LAN for Patients, who were postoperatively upstaged or upgraded, was not conducted in accordance with the guidelines in 2013, 2009, and 2006. In 2013, 84.6 % of the participants offered the laparoscopic approach (LSA) for hysterectomy and bilateral salpingo-oophorectomy, 63.3 % for pelvic LAN, and 49.1 % for paraaortic LAN, respectively. More participants offered the LSA in 2013 compared to 2009 and 2006 (p values <0.014). CONCLUSIONS: The paraaortic LAN, the LSA as well as the second operation on patients who had postoperatively been upstaged were not conducted in accordance with the guideline [CORRECTED]. Improvements concerning surgical treatment are possible and might lead to higher survival rates and a reduction of morbidity in patients with EC in Germany.

Overexpression of epithelial cell adhesion molecule protein is associated with favorable prognosis in an unselected cohort of ovarian cancer patients.

PURPOSE: The aim of this study was to evaluate the prognostic influence of epithelial cell adhesion molecule (EpCAM) in an unselected cohort of ovarian cancer (OC) patients. METHODS: Expression of EpCAM was determined by immunohistochemistry in an unselected cohort of 117 patients with OC. Univariable and multivariable Cox regression analyses adjusted for age, tumor stage, histological grading, histological subtype, postoperative tumor burden and completeness of chemotherapy were performed in order to determine the prognostic influence of EpCAM. The Kaplan-Meier method is used to estimate survival rates. RESULTS: Univariable Cox regression analysis showed that overexpression of EpCAM is associated with favorable prognosis in terms of progression-free survival (PFS) (p = 0.011) and disease-specific survival (DSS) (p = 0.003). In multivariable Cox regression analysis, overexpression of EpCAM retains its significance independent of established prognostic factors for longer PFS [hazard ratios (HR) 0.408, 95 % confidence interval (CI) 0.197-0.846, p = 0.003] but not for PFS (HR 0.666, 95 % CI 0.366-1.212, p = 0.183). Kaplan-Meier plots demonstrate an influence on 5-year PFS rates (0 vs. 27.6 %, p = 0.048) and DSS rates (11.8 vs. 54.0 %, p = 0.018). CONCLUSIONS: These findings support the hypothesis that the expression of EpCAM is associated with favorable prognosis in OC.

Changes in sexual function and quality of life after single-incision mid-urethral sling for treatment of female stress urinary incontinence.

OBJECTIVES: To evaluate the effectiveness and assess the changes in sexual function and quality of life after placement of a single-incision sling for the treatment of female stress urinary incontinence. STUDY DESIGN: A prospective study of women diagnosed with stress urinary incontinence. The single-incision sling was implanted and patients were followed postoperatively for 6 months. The postoperative rate of continence, complications, changes in sexual function, and patient-reported quality of life were evaluated. Female Sexual Function in sexually active patients was evaluated before and after the single-incision sling procedure using the Female Sexual Function Index. From January 2009 to November 2011, 73 patients were enrolled and underwent the procedure to implant the MiniArc® or Ajust® single-incision sling. RESULTS: Overall, 93.2% of the patients who successfully received a single-incision sling demonstrated total restoration of continence (83.6%) or improved continence (9.6%) at the 6-month postoperative visit. Improvements were seen in the quality of life scores related to global bladder feeling (87.7%) and the Female Sexual Function Index (preoperative score 23.86±5.67 vs postoperative score 27.25±4.66 [P<0.0001]). CONCLUSION: Single-incision sling treatment for stress urinary incontinence led to improvements in continence and sexual function at 6 months of postoperative follow-up.

Neonatal outcome following long-distance air travel for fetoscopic laser coagulation treatment of twin-to-twin transfusion syndrome.

OBJECTIVE: To investigate the impact of undertaking long-distance air travel to a specialized medical center while pregnant in order to undergo fetoscopic laser coagulation (FLC) for twin-to-twin transfusion syndrome (TTTS). METHODS: A retrospective cohort study was conducted of women with TTTS who travelled by air (n=16) or land (n=61) to the Centre of Perinatal Diagnosis and Microinvasive Fetal Surgery, Mainz, Germany, between January 1, 2006, and December 31, 2010. All women underwent FLC on arrival at the study center. Neonatal outcome, postoperative neonatal survival rates, and rates of adverse effects were recorded. RESULTS: The postoperative survival rate for a single twin was 100.0% (n=16) in the flight group and 98.3% in the land transportation group (n=60). The postoperative survival rate for both twins was 81.3% in the flight group (n=13) and 75.4% (n=46) in the land transportation group. No differences in neonatal outcome or the rate of adverse effects were observed between the 2 groups. No flight-related pregnancy complications were recorded. CONCLUSION: Long-distance air travel to a specialized tertiary care medical center is sufficiently safe to warrant recommendation to pregnant women with TTTS who require FLC.

Long-term amnioinfusion through a subcutaneously implanted amniotic fluid replacement port system for treatment of PPROM in humans.

OBJECTIVES: To introduce a novel method for the treatment of PPROM (preterm premature rupture of membranes) using continuous amnioinfusion via a subcutaneously implanted port system. STUDY DESIGN: After development and testing since 2001 in a fetal sheep model, the port system has been successfully implanted in two humans with PPROM. In the first case, the subcutaneous port system was implanted during the 23rd week of gestation in a 39-year-old 5th-gravida with PPROM since the 18th week of gestation; in the second case, the port system was implanted during the 24th week of gestation in a 27-year-old 3rd gravida with PPROM since the 21st week of gestation. After port implantation, 100ml/h saline solution was infused intermittently into the amniotic cavity. The whole course of treatment was supported by tocolysis. RESULTS: In the cases presented, gestation was terminated by cesarean section, in one case in the 29th week of gestation, and in the other case in the 30th week. The newborns showed no signs of lung hypoplasia and were successfully extubated on the 1st or 2nd day after delivery. Six months later the children did not exhibit any deviation from the normal development. CONCLUSION: Long-term amnioinfusion via a subcutaneously implanted port system could be used in humans with PPROM for prolongation of pregnancy and to avoid lung hypoplasia. Prospective randomized studies are ongoing.

Two new approaches in intrauterine tracheal occlusion using an ultrathin fetoscope.

OBJECTIVES/HYPOTHESIS: To introduce and establish a new approach in minimal invasive fetoscopic surgery in order to reduce access trauma and the iatrogenic preterm premature rupture of the membranes (PPROM) as a major complication of intrauterine treatment of congenital diaphragmatic hernia. METHODS: In total, 27 pregnant sheep were operated on using fetoscopes with 1.2 and 1.0 mm optics. We used an elliptic sheath alone with a maximum diameter of 2.6/1.3 mm; in these cases the balloon was placed under ultrasound control. In comparison, we placed the balloon under fetoscopic control using the fetoscopic sheath and a 7F (2.3 mm) introducer. Therefore, the maximum access trauma was not bigger than the diameter of sheath of introducer. RESULTS: With this technique we successfully operated on 22 sheep. The use of real time three-dimensional ultrasound control distinctly facilitates the operation procedure. CONCLUSIONS: Our preliminary findings show that fetoscopic tracheal occlusion using ultrathin fetoscopes and reducing the access trauma on the level of 4.2 or even 2.65 mm(2) could be seen as a method of reducing the rate of PPROM.