[Caesarean section in german hospitals: validity of hospital quality report data for monitoring C-section rates]. / Kaiserschnitte in deutschen Krankenhäusern: Wie zuverlässig sind Routinedaten aus dem strukturierten Qualitätsbericht für die Bestimmung der Kaiserschnittraten?

OBJECTIVE: It is not known if "hospital quality reports" (HQR) document Caesarean (C-) section rates at the hospital level accurately enough for use as a reliable data source when it comes to explaining regional variations of C-sections in Germany by factors at the hospital level. We aimed to answer this question using HQR from hospitals in Baden-Württemberg as data source. METHOD: Diagnostic and procedure codes from HQR for the year 2008 (HQRdata), were used to calculate numbers of births, numbers of C-sections, and rates of births by C-section (CSR) for 94 of 97 hospitals in Baden-Württemberg. These numbers were compared to internal hospital (IH) data delivered upon request by 80 of 97 hospitals and stemming from vital statistics, birth registry forms, or external quality assurance datasets. RESULTS: There was no difference in the number of births between HQR data and IH data, but the number of C-sections and the CSR differed significantly (p<0.05; Wilcoxon rank sum test). CSR calculated using HQR data was 4.9 ± 17.9% higher than CSR from IH data (absolute difference 1.5 ± 5.8%). The correlation between the 2 data sources was moderate (r=0.73). Only 55% of the variance in IH data-based CSR was explained by HQR data. The proportion between highest and lowest CSR in hospitals in Baden-Württemberg was 4.9 for HQR data and 3.6 for IH data. CONCLUSION: There are significant and relevant differences between C-section rates based on ei-ther HQR or IH data. This questions routine data from HQR for 2008 as a reliable data source for research work.

Gynaecological laparoscopic surgery for benign conditions: do women care about incisions?

OBJECTIVE: To determine the relevance of the number and location of incisions in women undergoing gynaecologic laparoscopy due to benign conditions. STUDY DESIGN: This study included 141 women, who underwent gynaecologic laparoscopic surgery with 4 incisions due to benign conditions between November 2010 and November 2011 at the University Medical Centre Mannheim, Germany. Women with malign histology were excluded. Demographic parameters, type and duration of surgery, perioperative complications and duration of hospital stay were analysed. Women were contacted using a standardized telephone survey with an interval of at least 22 weeks after surgery. Patients were interviewed regarding the number, postoperative pain and their preferences for omission of incisions. RESULTS: Eighty-seven women (61.7%) responded to the standardized questionnaire. 38 (43.7%) remembered the number of incisions correctly. 45 of the women (51.7%) thought they had less, 4 (4.6%) thought, they had more incisions as they actually did have. If one of the incisions had to be discarded 28 (32.2%) patients did not have any preferences with regard to the localisation. Of the other 59 patients, 44 (74.6%) would prefer to eliminate the umbilical one. CONCLUSION: The majority of the women remembered fewer incisions than actually used. Most of the patients interviewed would, if possible, eliminate the umbilical incision. Therefore from the patient's perspective the skin scars after conventional laparoscopic surgery seem to be of limited importance and the alleged advantage of omission of additional incision using single site surgery remains debatable.

Prevalence, Trend and Determining Factors of Gestational Diabetes in Germany.

Purpose: The true prevalence of gestational diabetes in Germany is unknown. Thus, the study's purposes were to estimate the prevalence of gestational diabetes as well as to describe the temporal prevalence trend and to identify determinants. Material and Methods: We calculated prevalence estimates based on two datasets: the register-based German perinatal statistic (n = 650 232) and the maternal self-reports from the German children and youth health survey (KiGGS; n = 15 429). Differences between prevalence estimates were analysed using χ2 and trend tests, and determinants were identified using logistic regression. Results: According to the perinatal statistic, gestational diabetes was present in 3.7 % of pregnant women in Germany in 2010. The prevalence across the years 2001 to 2006 was estimated at 1.9 % which differed significantly from the prevalence estimate derived from the KiGGS dataset for the same period of time (5.3 %; 95 % confidence interval: 4.6-6.1 %). Both datasets show an increasing trend of gestational diabetes (p < 0.001). The risk for gestational diabetes was mainly associated with age, BMI and social class of pregnant women as well as with multiple pregnancies. Conclusion: The lack of significant screening studies among representative samples hampers a sound estimation of the true prevalence of gestational diabetes in Germany. The increasing trend in gestational diabetes might continue due to the projected increase of important risk factors (e.g., maternal age, obesity). Our analyses support the current consensus recommendations regarding standardised gestational diabetes screening.

94 months follow-up after laparoscopic assisted vaginal resection of septum rectovaginale and rectosigmoid in women with deep infiltrating endometriosis.

BACKGROUND: Endometriosis with bowel involvement is the most invasive form and can cause infertility, chronic pelvic pain and bowel symptoms. Effective surgical treatment of endometriosis requires complete excision of endometriosis and in same case may require segmental rectosigmoid resection. METHODS: Between December 1997 and October 2003, 55 patients with rectovaginal endometriosis underwent a combined laparoscopic vaginal technique. 30 patients were found at a follow-up and underwent a telephone interview. The questionnaire covered questions about symptoms related to recurrences of intestinal endometriosis, dyspareunia, dysmenorrhea and pregnancy. RESULTS: Twenty-seven of 30 (90%) women have no clinical symptoms of reported recurrence of endometriosis. Two patients (6.6%) had evidence of recurrence of bowel endometriosis. Dysmenorrhoea disappeared in 28 (93.3%), dyspareunia in 26 (86.7%) and pelvic pain in 27 (90%) patients. 17 patients (31%) tried to become pregnant and 11 of these patients (65%) became pregnant: 9 patients delivered healthy newborns, 18 pregnancies occurred and 19 healthy children were born. CONCLUSIONS: Despite the small number of follow-up patients, our 94-month follow-up data demonstrated that endometriosis with bowel involvement and radical resection was associated with significant reductions in painful and dysfunctional symptoms, a low recurrence rate (6.6%) and high pregnancy rate (36.6%).

Total laparoscopic hysterectomy without uterine manipulator: description of a new technique and its outcome.

INTRODUCTION: Hysterectomy remains the most common major gynecological operation. This is the first study that describes a new technique of TLH without using any kind of uterine manipulator or vaginal tube (TLHwM) and analyzes the intra- and postoperative surgical outcome of the first 67 cases. PATIENTS AND METHODS: Between October 2008 and December 2009, 67 patients underwent TLH without uterine manipulator or vaginal tube. We analyzed the differences in the outcome by using three different kinds of surgical instruments: in 21 cases the TLHwM was performed using conventional 5 mm bipolar and scissors, in 22 cases using Sonosurgical, and in 24 cases using PKS cutting forceps. RESULTS: There was no intra- or postoperative complications. The overall mean operating time was by TLHwM with salpingo-oophorectomy 98 min and without salpingo-oophorectomy, 80 min. The mean operating time using cutting forceps was significantly lower. The mean uterine weight was 263 g. DISCUSSION: Uterine manipulator seems to be a safe and practical surgical method, especially for patients with vaginal stenosis and in cases of enlarged uterus. With its short operation time and no complication rate, we believe that this method is an enrichment of the laparoscopic hysterectomy techniques.

Laparoscopic nerve-sparing surgery of deep infiltrating endometriosis: description of the technique and patients' outcome.

INTRODUCTION: The radical surgery of the deep infiltrating endometriosis of the rectovaginal septum and the uterosacral ligaments with or without bowel resection can cause a serious damage of the pelvic autonomic nerves with urinary retention and the need of self-catheterization. PATIENTS AND METHODS: We introduce a case series report of 16 patients with laparoscopic nerve-sparing surgery of deep infiltrating endometriosis. We describe the technique step by step and compare the patients' outcome with patients who had undergone a non-nerve-sparing surgical technique. In 12 patients, a double-sided and in four patients, a single-sided identification of the inferior hypogastric nerve and plexus were performed. RESULTS: In all patients at least single-sided resection of the uterosacral ligaments were performed. Postoperatively dysmenorrhoea, pelvic pain, and dyspareunia disappeared in all patients. The average operating time was 82 min (range 45-185). Postoperatively, the overall time to resume voiding function was 2 days. The residual urine volume was in all patients <50 ml at two ultrasound measurements. DISCUSSION: Identification of the inferior hypogastric nerve and plexus was feasible. In comparison with non-nerve-sparing surgical technique, no cases of bladder self-catheterization for a long or even life time was observed, confirming the importance of the nerve-sparing surgical procedure.

Teenage deliveries in Northern Germany: always a risk factor for higher surgical delivery rates?

PURPOSE: To evaluate the impact of young maternal age on labour, intrapartum assessment and delivery mode. METHODS: A retrospective cohort analysis was conducted of 13,941 deliveries at a tertiary delivery unit between 2000 and 2009. Patients aged less than 18 years were compared with patients aged 18 years or older. The main outcome was defined as mode of delivery. Frequencies and odds ratios for adverse maternal-foetal outcomes were calculated for primiparous women. RESULTS: Of the deliveries occurring during the study period, 6,863 (49.2%) met the inclusion criteria. A total of 156 deliveries (2.3%) occurred among teenagers less than 18 years and 6,707 among patients 18 years and older. Compared with patients 18 years of age and older, younger maternal age was associated with a higher chance of spontaneous delivery [adjusted odds ratio (OR) 2.07, 95% confidence interval (CI) 1.45-2.93] than via operation (vaginal operative delivery: OR 0.98, 95% CI 0.48-2.03; secondary caesarean delivery: adjusted OR 0.51, 95% CI 0.32-0.82). CONCLUSION: Young maternal age at delivery does not represent a risk factor for high surgical delivery rates.

Laparoscopic nerve-sparing radical hysterectomy: description of the technique and patients' outcome.

OBJECTIVE: The radical hysterectomy type three can be accompanied by postoperative morbidity, such as dysfunction of the lower urinary tract with loss of bladder or rectum sensation. We describe the technique of laparoscopic nerve-sparing radical hysterectomy and patient's outcome. METHODS: Thirty-two patients underwent laparoscopic nerve-sparing radical hysterectomy with pelvic lymphadenectomy. Both the hypogastric and the splanchnic nerves were identified bilaterally during pelvic lymphadenectomy. RESULTS: The median age of the patients was 52 years, and the average operating time was 221 min. There were no intraoperative or postoperative complications considering the nerve-spring radical hysterectomy. Postoperatively, in all patients spontaneous voiding was possible on the third postoperative day with a median residual urine volume of <50 ml. CONCLUSIONS: Laparoscopic identification (neurolysis) of the inferior hypogastric nerve and inferior hypogastric plexus is a feasible procedure for trained laparoscopic surgeons who have a good knowledge not only of the retroperitoneal anatomy but also of the pelvic neuro-anatomy as this qualification could prohibit long-term bladder and voiding dysfunction during nerve-sparing radical hysterectomy.

Successful laser therapy of a papular acantholytic dyskeratosis of the vulva: case report and review of literature.

BACKGROUND: The papular acantholytic dyskeratosis summarizes a collection of papular skin lesions which occur in intertriginous areas and in the genital area. They show a very characteristic histology without the connection to a syndrome such as the Hailey-Hailey disease or the Darier disease. METHODS: We present the case of an affected 45-year-old woman and evaluate the laser therapy as therapeutic option. RESULTS: A long lasting reduction of the symptoms was achieved by paying special attention to involving the deep tissue layers while performing the laser therapy. Despite causing a long and painful healing process, this was the only way to achieve a lasting reduction of the symptoms. CONCLUSIONS: Laser therapy in afflicted areas can improve the symptoms of the papular acantholytic dyskeratosis. The deep tissue laser therapy showed more success than the superficial laser therapy.

[Impact of assisted reproduction on obstetrics and neonatology]. / Einfluss der assistierten Reproduktion auf Geburtshilfe und Neonatologie.

BACKGROUND: In industrialised countries, 1-4% of all children are born as a result of assisted reproductive therapies (ART), such as IVF and ICSI. Possible associations of these ARTs with obstetric and neonatal risk constellations are analysed critically in the context of this review. METHODS: A selective literature search was conducted to examine the influence of ART on obstetric and neonatal aspects. RESULTS: Multiple gestations, occurring more frequently after ART, are of special significance with regard to their associated risks. In comparison to spontaneous pregnancies, singleton gestations after ART are associated with higher rates of complications, such as preeclampsia, prematurity, low birth weight, foetal malformations and a higher rate of Caesarean sections. Although causal associations between extracorporeal fertilisation methods and health risks for mothers and infants in singleton pregnancies cannot be ruled out, these complications are rather attributed to the underlying causes of infertility than to the methods of assisted reproduction themselves. CONCLUSIONS: Pregnancies after ART are to be regarded as risk constellations with a need for closer surveillance during gestation - irrespective of the number of developing foetuses. Couples seeking advice about infertility should be informed in detail before the onset of ART.

[Prevention of complications in twin gestations and pregnancies after assisted reproduction]. / Risikoprävention bei Geminigraviditäten und Schwangerschaften nach assistierter Reproduktion.

BACKGROUND: Twin pregnancies and gestations after assisted reproductive therapy (ART) are of special obstetric significance with regard to their associated risks. However, little is known about preventive approaches specifically evaluated for these constellations. METHODS: A selective literature search was conducted to examine possible preventive approaches for complications such as hypertensive disorders, anaemia, gestational diabetes, prematurity, and others, seen significantly more often in twin gestations and pregnancies after ART. RESULTS: For both constellations, preventive approaches are not specifically evaluated for the majority of complications. For some preventive methods a possible detrimental effect cannot even be ruled out. CONCLUSIONS: The knowledge about specific preventive approaches against complications in twin pregnancies and gestations after ART is scarce. More prospective trials are urgently needed to assess the risks and benefits of prophylactic approaches for these risk constellations.

[Spontaneously conceived twins and twins after ART: are there any differences regarding direct financial costs of delivery]. / Gibt es einen Unterschied der direkten Entbindungskosten bei spontan eingetretener Zwillingsgravidität und Gemini nach Kinderwunschbehandlung?

BACKGROUND: Healthcare expenditures are rising steadily. There are no data on delivery expenses of twin pregnancies. This study aims to provide data on expenses of twin deliveries and to compare expenditures of deliveries after spontaneous conception with deliveries after infertility treatment. PATIENTS AND METHODS: Retrospective cohort-analysis on obstetrical data of twin deliveries at the Department of Obstetrics and Gynaecology of the University Hospital Schleswig-Holstein, Campus Luebeck between January 2000 and December 2008. A comparison of delivery expenses of spontaneous twin pregnancies and after infertility treatment. RESULTS: Patients delivering twins after infertility treatment stay 1.1 days longer at the hospital, are 2.5 years older and the number of previous pregnancies and deliveries are significantly lower compared to women after spontaneous conception of twins. In our setting fetal outcome (weeks of gestation, birthweight, APGAR, umbilical arterial pH, admission to neonatal intensive care unit etc.) and other maternal data (maternal height, maternal weight, length of surgery etc.) were not significantly different. The prolonged time spent in hospital leads to a 250 Euro higher expense per patient. DISCUSSION: Additional expenses of twin deliveries after assisted reproduction are due to a longer stay at the hospital. This prolonged stay of an average of 1.1 days was not obvious to medical reasons. Main delivery expenses for the substantial outcome-parameters are not significantly different between both groups.

[Seasonality of omphalocele in northern Germany]. / Saisonalität der Omphalozele in Norddeutschland.

PURPOSE: Omphalocele is a rare congenital abdominal wall defect that has been attributed to environmental factors such as increased levels of herbicides in surface water. We wanted to verify a seasonal variation of the incidence of Omphalocele and thus to identify possible environmental factors in an area in Northern Germany that is characterized by a predominantly agricultural setting. MATERIALS AND METHODS: A retrospective analysis of all pregnancies (n = 28 935) screened by ultrasound at our University Hospital between January 1, 1993 and December 31, 2007 was carried out. After identification of fetuses with persisting Omphalocele, analysis for additional structural defects and for chromosomal anomalies, such as trisomy 18, was carried out. We further categorized all patients with regard to the date of conception during summer (April-September) and winter months (October-March). Categorical variables were compared by the Mann-Whitney-U test and were considered statistically significant when two tailed analyses yielded p = 0.05. RESULTS: There was no significant difference in the seasonal distribution of conception neither for all fetuses (p = 0.70) nor for fetuses with Omphalocele (p = 0.94). The results were constant for fetuses with isolated Omphalocele and with additional malformation and for those with Omphalocele and associated chromosomal anomalies. The incidence of fetal Omphalocele has remained relatively stable within the last 15 years. No significant difference was found in the seasonal incidence of Omphalocele in patients from an urban or rural background. CONCLUSION: Since we were unable to demonstrate a relationship between the time of conception and the incidence of fetal Omphalocele in our cohort of pregnant women from a predominantly agricultural background, other factors should be investigated for possible associations with the onset of Omphalocele.

A new approach to label sentinel nodes in endometrial cancer.

PURPOSE: The objective of the study was to determine the feasibility of a new method of labeling sentinel lymph nodes in patients with endometrial cancer using blue dye. PATIENTS AND METHODS: 4 ml of blue dye was subserously administered in 25 patients with endometrial cancer at eight sites. After 8 min, sentinel lymph nodes were harvested. RESULTS: Detection rate was 92.0%, sensitivity was 62.5%, and negative predictive value was 92.5%. In two patients there was no detection of sentinel nodes and in addition in two patients only sentinel nodes were harvested due to minimal disease. No side effects occurred. CONCLUSIONS: This new and simple approach yielded a high pelvic detection rate. This new approach reveals a way to label sentinel nodes in endometrial cancer. Combining a different labeling agent with the proposed new method might overcome the lack of para-aortic sentinel detection.