[Interdisciplinary Diagnosis and Treatment of Deep Infiltrating Endometriosis]. / Interdisziplinäre Diagnostik und Therapie der tief infiltrierenden Endometriose.

Endometriosis is the second most common benign female genital disease after uterine myoma. This review discusses the interdisciplinary approach to the treatment of deep infiltrating endometriosis. Endometriosis has been defined as the presence of endometrial glands and stroma outside the internal epithelial lining of the cavum uteri. As a consequence, endometriosis can cause a wide range of symptoms such as chronic pelvic pain, subfertility, dysmenorrhea, deep dyspareunia, cyclical bowel or bladder symptoms (e.g., dyschezia, bloating, constipation, rectal bleeding, diarrhoea and hematuria), abnormal menstrual bleeding, chronic fatigue or low back pain. Approx. 50 % of teenagers and up to 32 % of women of reproductive age, operated for chronic pelvic pain or dysmenorrhoea, suffer from endometriosis. The time interval between the first unspecific symptoms and the medical diagnosis of endometriosis is about 7 years. This is caused not only by the non-specific nature of the symptoms but also by the frequent lack of awareness on the part of the cooperating disciplines with which the patients have first contact. As the pathogenesis of endometriosis is not clearly understood, a causal treatment is still impossible. Treatment options include expectant management, analgesia, hormonal medical therapy, surgical intervention and the combination of medical treatment before and/or after surgery. The correct treatment for each patient should take into account the severity of the disease and whether the patient desires to have children. The treatment should be as radical as necessary and as minimal as possible. The recurrence rate among treated patients lies between 5 and > 60 % and is very much dependent on the integrated management and surgical skills of the respective hospital. Consequently, to optimise the individual patient's treatment, a high degree of interdisciplinary cooperation in diagnosis and treatment is crucial and should, especially in the case of deep infiltrating endometriosis, be undertaken in appropriate centres.

[Endometriosis]. / Endometriose.

The major symptom is dysmenorrhea. Chronic, sometimes non-cyclic pain due to pelvic adhesions is often seen in the long course of the disease. Infiltration into the blader or bowel is a rare but serious complication. A group of patients presents with sterility. Endometriosis histologically resembles endometrium. There can be ovarian cysts and foci either on the peritoneum or in the muscularis of the uterus. The etiology is unknown. There are a number of existing theories. A rare condition is an endometriosis caused iatrogen during a caesarean section. It can develop between uterus and bladder or within the suture or scar tissue. Since we know so little, the treatment options are unsatisfying. Operative resection followed by endocrine medication is the standard therapy. Alternative medicine can be an useful additional factor in the treatment concept.

Indications and Route of Hysterectomy for Benign Diseases. Guideline of the DGGG, OEGGG and SGGG (S3 Level, AWMF Registry No. 015/070, April 2015)

Background: Official guideline "indications and methods of hysterectomy" to assign indications for the different methods published and coordinated by the German Society of Gynecology and Obstetrics (DGGG), the Austrian Society of Gynecology and Obstetrics (OEGGG) and the Swiss Society of Gynecology and Obstetrics (SGGG). Besides vaginal and abdominal hysterectomy, three additional techniques have been implemented due to the introduction of laparoscopy. Organ-sparing alternatives were also integrated. Methods: The guideline group consisted of 26 experts from Germany, Austria and Switzerland. Recommendations were developed using a structured consensus process and independent moderation. A systematic literature search and quality appraisal of benefits and harms of the therapeutic alternatives for symptomatic fibroids, dysfunctional bleeding and adenomyosis was done through MEDLINE up to 6/2014 focusing on systematic reviews and meta-analysis. Results: All types of hysterectomy led in studies to high rates of patient satisfaction. If possible, vaginal instead of abdominal hysterectomy should preferably be done. If a vaginal hysterectomy is not feasible, the possibility of a laparoscopic hysterectomy should be considered. An abdominal hysterectomy should only be done with a special indication. Organ-sparing interventions also led to high patient satisfaction rates, but contain the risk of symptom recurrence. Conclusion: As an aim, patients should be enabled to choose that therapeutic intervention for their benign disease of the uterus that convenes best to them and their personal life situation.

Hysteroscopy: an analysis of 2-years' experience.

BACKGROUND: Over the years, hysteroscopy has been increasingly performed for various gynecological disorders. In this study, we present a review of hysteroscopic procedures performed over a 2-year period analyzing the complications associated with it. METHODS: Seven hundred twenty-six hysteroscopic procedures performed at the Department of Gynecology and Obstetrics, University of Kiel over a period of 2 years were reviewed retrospectively using the GynReg database in the department. Indications, intraoperative diagnoses, and complications were particularly highlighted. RESULTS: The most common indications for the procedure were abnormal vaginal bleeding, endometrial ablation, polypectomy, and myomectomy. The most common findings were uterine polyps, submucous myoma, and hyperplastic endometrium. The complication rate was 1.65% of total hysteroscopies. False passage and uterine perforation were the most common acute complications. No late complications occurred. CONCLUSIONS: Correlating our data with that found elsewhere, we find hysteroscopy to be a safe, minimally invasive procedure with a very low rate of complications.

Accuracy of laparoscopic diagnosis of endometriosis.

BACKGROUND AND OBJECTIVE: Laparoscopy is the standard method to visually identify endometriotic lesions under magnification within and outside the minor pelvis. The aim of this study was to analyze the accuracy of laparoscopic visualization in diagnosing the various endometriotic sites as confirmed histologically. METHOD: Presumed endometriotic sites were observed in 164 patients operated on under the clinical suspicion of endometriosis. Targeted biopsies were performed for histologic corroboration, comparing the laparoscopic findings and diagnosis to the histological results. RESULT: The histological reports of the biopsies confirmed the presence of endometriosis in 138 patients (84.1%), but in 26 patients (15.9%), no evidence of endometriosis was observed. 100% of "red" lesions, 92% of "black" lesions, and 31% of "white" lesions turned out to be endometriosis. Of the 264 various suspected endometriotic sites observed, 142 (53.8%) were confirmed histologically. The most accurate diagnosis was in lesions on the parietal peritoneum of the pelvis, confirmed in 9/9 cases (100%); the ovarian fossa, confirmed in 8/12 cases (66.7%); and the uterosacral ligaments and posterior surface of the broad ligament, confirmed in 83/138 cases (60.1%). As for the other sites, the histologic confirmation rates in the ovarian surface, bowel serosa, and vesicouterine fold of the peritoneum were 48%, 40%, and 13%, respectively. CONCLUSION: Endometriosis has a multiple appearance, and the lesions may be confused with nonendometriotic lesions. It is clear that a nonhistology-based diagnosis may lead to unnecessary prolonged medical treatment and operations and may delay the proper treatment measures from being applied. Therefore, a meticulous histological confirmation should still be the first step in the laparoscopic diagnosis and treatment of suspected endometriosis.

Correlation of endoscopic interpretation of endometriosis with histological verification.

INTRODUCTION: In this study we correlate the laparoscopic findings of endometriosis with the histological confirmation of the disease over a period of two years. MATERIALS AND METHODS: One hundred and sixty-four laparoscopies performed at the Department of Gynecology & Obstetrics, University of Kiel, over a two-year period were reviewed for laparoscopic findings and histological confirmation of endometriosis. RESULTS: The majority of patients suspected of endometriosis at laparoscopy were confirmed by histological examination, i.e. 138 out of 164 patients (84.1%). CONCLUSION: Laparoscopy is the easiest diagnostic tool for the diagnosis of endometriosis which can be confirmed by histological examination.

Comparison of c-DNA microarray analysis of gene expression between eutopic endometrium and ectopic endometrium (endometriosis).

PROBLEM: As recent studies have suggested abnormalities in the regulation of specific genes in the development of endometriosis, we investigated differentially expressed genes in endometriosis compared to endometrium. METHOD OF STUDY: Gene expression profiles using the Atlas microarray were performed in endometriotic tissue and endometrium. Nine of the 13 genes of endometriotic tissue showed an up-regulation in relation to endometrium and four of the 13 genes a down-regulation. RESULTS: Of the 1176 genes on the Atlas Human 1,2 array, only 13 differentially expressed identical genes were detected after repeating the gene analysis three times. CONCLUSION: According to our c-DNA analysis some differentially expressed genes may be involved in the pathogenesis of endometriosis. An imbalance in the genes responsible for the reproductive process may lead to a decrease in embryo implantation in patients with endometriosis.

Ectopic pregnancy treatment by laparoscopy, a short glimpse.

Ectopic pregnancy is a life-threatening emergency, the incidence of which is increasing globally. There are a number of factors predisposing to this condition; today, the most common of these is salpingitis. Due to advancements in diagnostic technology it is possible to diagnose this condition early and thus try to achieve a favourable outcome for the patient. Treatment options in the form of medical and surgical modalities are widely available. As minimally invasive therapy techniques are rapidly advancing, laparoscopic treatment has become the most popular and preferred method for treating ectopic pregnancy. Both salpingotomy as well as salpingectomy can be performed through the laparoscope. This paper gives a short glimpse at the predisposing factors and the diagnostic investigations available for ectopic pregnancy and an insight into its laparoscopic treatment. It also reviews the pregnancy outcome and laparoscopic treatment of cases at the Department of Obstetrics and Gynaecology, Campus Kiel, University Hospitals Schleswig-Holstein.

Laparoscopic hysterectomy: challenges and limitations.

Twenty years after the first description of vaginal hysterectomy with laparoscopic assistance by Kurt Semm in 1984 (1), and 16 years after the publication of the so-called laparoscopically assisted vaginal hysterectomy (LAVH) by Harry Reich in 1989 (2), it is time to review and evaluate the real benefits of laparoscopic hysterectomy. Although laparoscopic surgery is well accepted by gynaecologists worldwide for the treatment of certain gynaecological conditions, laparoscopic hysterectomy in Germany, and probably worldwide, is still only performed by a few specialists. Highly skilled surgical techniques, longer operating time and expensive technology are suggested to be the deterring factors. Laparoscopic hysterectomy, in its different forms, is an attractive and safe procedure for the management of benign gynaecological conditions and many authorities recommend its use on a larger extent. On the other hand, in our opinion, the use of laparoscopic hysterectomy for oncological indications is still controversial. Extensive experience of over 15 years, of the first author, in practising and teaching various forms laparoscopic hysterectomy, namely, laparoscopically assisted vaginal hysterectomy (LAVH), total laparoscopic hysterectomy (TLH), classic intrafascial supracervical hysterectomy (CISH) and laparoscopic supracervical hysterectomy (LSH), has led us to the firm conclusion that these techniques are advantageous to patients if performed for the appropriate indication. In particular, subtotal or supracervical hysterectomy, with the cervix remaining in its place, is associated with fewer complications and a very favourable outcome for the patient. Radical laparoscopic vaginal hysterectomy (RLVH), the last variant in our exposé, is only successful in an expert's hands. The surgical techniques of these varieties of laparoscopic hysterectomies will be described and illustrated in detail in this paper.

[Imitation of ovarian malignant tumor by malignant schwannoma]. / Imitation eines Ovarialmalignoms durch ein malignes Schwannom.

A case is reported of a 78-year old female with a malignant retroperitoneal schwannoma. The diagnosis of schwannoma is often delayed because of the absence of early clinical signs. Clinical examination and computed tomography indicated an ovarian tumour. IVP demonstrated retroperitoneal involvement. Biopsy of a pelvic wall tumour at laparotomy yielded a positive histology for malignant schwannoma. Due to the extensive size and infiltration of the tumour it was deemed inoperable and the patient recommended a trial of radiotherapy. The patient had no manifestation of von Recklinghausen's disease.

Morbidity and mortality of discordant twins up to 34 weeks of gestational age.

UNLABELLED: The combination of weight discordance and prematurity implies a high perinatal morbidity and mortality for the affected twins. Several pathomechanisms may be responsible for the weight difference in twins including a different genetic growth potential in dizygotic twins, placenta insufficiency in one twin, and chronic feto-fetal transfusion (CFFT). Little is known about neonatal morbidity and mortality of discordant twins. Therefore, a retrospective, case-controlled study on preterm discordant twins up to 34 weeks gestation was carried out. Twenty-seven (27,3%) of 99 twin pairs born in our clinic had a birth weight difference of more than 20%. The control group consisted of 27 non-discordant twins matched for gestational age. Discordant twins showed a significantly higher mortality (19%) than the control twins (2%). Severe intracranial haemorrhage (ICH) and persistent ductus arteriosus Botalli (PDA) were found more often in discordant twins than in the control group. The increased mortality and morbidity of discordant twins compared with concordant twins matched for gestational age indicates that the increased morbidity and mortality of preterm weight discordant twins is not only due to prematurity, but is also related to the discordance itself. Thirteen (48.1%) of the weight discordant twin pairs fulfilled the criteria for CFFT. Twins with CFFT differed significantly from controls with respect to the incidence of mortality and the rate of severe ICH, PDA, and the necessity of postnatal cardiopulmonary resuscitation. By contrast, no significant differences were found between discordant twins without CFFT and controls. Thus, CFFT appears to be a major contributing factor for increased mortality and morbidity of weight discordant twins. Intra-twin pair analysis revealed a higher rate of postnatal hypoglycaemia in the smaller twins only, probably caused by insufficient glycogen storage due to intra-uterine malnutrition. Mortality was the same for both the larger and the smaller twins. It may be concluded that neonatal outcome of smaller twins who have survived intra-uterine malnutrition is the same as in larger twins. Intra-twin pair analysis in twins with CFFT revealed no significant differences except for a higher rate of ICH grade 2-4 in the larger twins which might be explained by hypervolaemia of the recipient. CONCLUSION: Morbidity and mortality of weight discordant twins are increased. CFFT appears to be a major contributing factor for the increased mortality and morbidity. Postnatal mortality was the same in acceptor and donor; however, the acceptor had a higher postnatal morbidity.

[Acute and chronic fetofetal transfusion syndrome]. / Akutes und chronisches fetofetales Transfusionssyndrom.

BACKGROUND: In the fetofetal transfusion syndrome we can discriminate between a chronic form with severe difference in weight and an acute form with a difference in haemoglobin between the twins. The aim of the retrospective study was to investigate the influence of both forms regarding infant morbidity and mortality. PATIENTS: Of the 135 twins treated from 1.1.1984 to 31.12.1993 in the Department of Pediatrics at the Christian-Albrechts-University Kiel, 27 (20%) showed evidence of fetofetal transfusion. RESULTS: Twelve (8.8%) fulfilled the criteria for an acute and 10 (7.4%) for a chronic transfusion. In 5 (3.9%) twins both forms were evident. Clear differences between twins with acute or chronic fetofetal transfusion syndrome could be seen in gestational age and birth weight. The twins with an acute fetofetal transfusion were significantly older (median: 31.5 vs. 29.0 weeks of gestation), and heavier (median: 1900 vs. 1020 g). Furthermore this group faired significantly better statistically when compared to the chronic form as regards the incidence of mortality (7 vs. 0), the Respiratory Distress Syndrome grades III and IV (7 vs. 2), persistent ductus arteriosus (13 vs 9), intraventricular haemorrhage (14 vs 6) and posthaemorrhagic hydrocephalus (4 vs 0). Similar significant differences could be seen as regards mortality, the Respiratory Distress Syndrome, and intraventricular haemorrhage when acute fetofetal transfusion was compared with the combined acute on chronic form. No significant difference regarding neonatal morbidity and mortality, however, could be shown between infants having undergone chronic fetofetal transfusion and infants with the combined acute on chronic form. CONCLUSIONS: It can be concluded that twins with chronic fetofetal transfusion show a higher rate of neonatal morbidity and mortality, whereas, the acute form does not significantly influence these factors. As both forms not only differ in onset of the disease, pathogenesis, and the actual course of the disease. It is important to always differentiate between the acute and chronic forms.

[Combination of Cantrell pentalogy and amniotic band syndrome: a case report]. / Kombination von Cantrellscher Pentalogie und Amnionbändersyndrom: Eine Falldarstellung.

A case is reported of sonographic diagnosis of ADAM-complex (amniotic band syndrome) in combination with Cantrell-syndrome in the 19th gestational week. The ultrasonic investigation also showed a large defect in the fetal skull with encepholocele as well as a marked defect of the abdominal wall and chest with dislocation of the intestines, liver, and heart. The pregnancy was interrupted because of the severe fetal malformations. Aetiology and pathogenesis of such rare abnormalities and possible correlations between ADAM-syndrome and Cantrell-syndrome are discussed with reference to the literature.

Complicaciones laparoscópicas en la cirugía ginecológica: experiencia de la escuela de endoscopiaginecológica de la Universidad de Kiel / Laparoscopic complications in gynaecological surgery: The experience of the Gynaecological Endoscopy School at the University of Kiel

La cirugía endoscópica ha demostrado ser una eficaz alternativa quirúrgica para distintas patologías obstétricas y ginecológicas; su principal virtud se basa en la disminución de la morbilidad y estancia hospitalaria que se afronta con la cirugía abdominal convencional. Sin embargo, no está exenta de riesgos y complicaciones, aun en manos expertas. Presentamos un estudio retrospectivo de un total de 1.774 intervenciones laparoscópicas realizadas en un período de un año, de las cuales el 90 por ciento fueron terapéuticas y el 10 por ciento diagnósticas; se evalúan los factores de riesgo como antecedentes quirúrgicos previos y localización de la patología intervenida (ovárica [52 por ciento], tubárica [25 por ciento] y uterina [23 por ciento]. Se produjeron un 0.68 por ciento de complicaciones (12/1.774), siendo un 42 por ciento por factores eléctricos. El diagnóstico inmediato de la complicación se realizó en el 58 por ciento de los casos tardíamente en un 17 por ciento; controlándose la complicación mediante laparoscopia (58 por ciento), laparotomía (33 por ciento) e histeroscopia (8 por ciento), respectivamente. Se concluye que el porcentaje de complicaciones de la cirugía endoscópica es mínimo; no obstante, para mantener o disminuir estos porcentajes, se requiere una estricta selección de casos, adecuado entrenamiento, prudente observación y diagnóstico inmediato de los accidentes o complicaciones que puedan acontecer (AU)