Ovarian cancer prevention by opportunistic salpingectomy is a new de facto standard in Germany.

PURPOSE: The most prevalent and aggressive subtype of epithelial ovarian carcinoma (EOC), high-grade serous carcinoma (HGSC), originates in many cases from the fallopian tubes. Because of poor prognosis and lack of effective screening for early detection, opportunistic salpingectomy (OS) for prevention of EOC is being implemented into clinical routine in several countries worldwide. Taking the opportunity of a gynecological surgery in women at average cancer risk, extramural fallopian tubes are completely resected preserving the ovaries with their infundibulopelvic blood supply. Until recently, only 13 of the 130 national partner societies of the International Federation of Obstetrics and Gynecology (FIGO) have published a statement on OS. This study aimed to analyze the acceptance of OS in Germany. METHODS: (1) Survey of German gynecologists in 2015 and 2022 by the Department of Gynecology of the Jena University Hospital in co-operation with the Department of Gynecology at Charité-University Medicine Berlin with support of NOGGO e. V. and AGO e. V. (2) Salpingectomy numbers in Germany for years 2005-2020 as retrieved from the Federal Statistical Office of Germany (Destatis). RESULTS: (1) Survey: Number of participants was 203 in 2015 and 166 in 2022, respectively. Nearly all respondents (2015: 92%, 2022: 98%) have already performed bilateral salpingectomy without oophorectomy in combination with benign hysterectomy with the intention to reduce the risk for malignant (2015: 96%, 2022: 97%) and benign (2015: 47%, 2022: 38%) disorders. Compared to 2015 (56.6%), considerably more survey participants performed OS in > 50% or in all cases in 2022 (89.0%). Recommendation of OS for all women with completed family planning at benign pelvic surgery was approved by 68% in 2015 and 74% in 2022. (2) Case number analysis: In 2020, four times more cases of salpingectomy were reported by German public hospitals compared to 2005 (n = 50,398 vs. n = 12,286). Of all inpatient hysterectomies in German hospitals in 2020, 45% were combined with salpingectomy, and more than 65% in women at the age of 35 to 49 years. CONCLUSION: Mounting scientific plausibility regarding involvement of fallopian tubes in the pathogenesis of EOC led to change of clinical acceptance of OS in many countries including in Germany. Case number data and widespread expert judgment demonstrate that OS has become a routine procedure in Germany and a de facto standard for primary prevention of EOC.

"Locus minoris resistentiae" and connective tissue weakness in older women: a case report and literature review on pelvic organ prolapse with inguinal bladder hernia.

BACKGROUND: Conditions such as genital prolapse and hernia are known to be related to connective tissue dysfunction. In this report on cases of the rare simultaneous finding of large genital prolapse and post-prolapse repair female inguinal bladder hernia, we aim to contribute to the discussion of a possible clinical definition of connective tissue weakness, for its clinical assessment and preoperative patient counselling. CASE PRESENTATION: Three cases of medial third-grade (MIII, Aachen classification) inguinal bladder hernia developing or enlarging after successful stage-IV pelvic organ prolapse (POP) repair at a university pelvic floor centre are presented. All patients were aged ≥ 80 years with long-standing postmenopausal status. One patient was followed for 5 years and two patients were followed for 6 months. In all patients, ultrasound revealed that the hernia sac contained the urinary bladder, which had herniated through the inguinal hernia orifice. A literature search revealed only one case report of direct female inguinal bladder hernia and few investigations of the simultaneous occurrence of POP and hernia in general. CONCLUSION: The simultaneous occurrence of inguinal hernia and female POP can lead to bladder herniation following prolapse surgery in the sense of a "locus minoris resistentiae". Clinical examination for simultaneous signs of connective tissue weakness and counselling prior to pelvic reconstructive surgery could help to increase patients' compliance with further surgical treatment for hernia.

Inverse correlation between urethral length and continence before and after native tissue pelvic floor reconstruction.

Urethral length was evaluated retrospectively in patients with prolapse undergoing anterior native-tissue repair. Effects of age, prolapse stage, defect pattern, urodynamic and clinical stress test findings, and tension-free vaginal tape (TVT) surgery indication were analyzed using Mann-Whitney and Wilcoxon tests and linear and logistic regression. Of 394 patients, 61% had stage II/III and 39% had stage IV prolapse; 90% of defects were central (10% were lateral). Median pre- and postoperative urethral lengths were 14 and 22 mm (p < 0.01). Preoperative urethral length was greater with lateral defects [p < 0.01, B 6.38, 95% confidence interval (CI) 4.67-8.08] and increased stress incontinence risk (p < 0.01, odds ratio 1.07, 95% CI 1.03-1.12). Postoperative urethral length depended on prolapse stage (p < 0.01, B 1.61, 95% CI 0.85-2.38) and defect type (p = 0.02, B - 1.42, 95% CI - 2.65 to - 0.2). Postoperatively, TVT surgery was indicated in 5.1% of patients (median 9 months), who had longer urethras than those without this indication (p = 0.043). Native-tissue prolapse repair including Kelly plication increased urethral length, reflecting re-urethralization, particularly with central defects. The functional impact of urethral length in the context of connective tissue aging should be examined further.

Ablative dual-phase Erbium:YAG laser treatment of atrophy-related vaginal symptoms in post-menopausal breast cancer survivors omitting hormonal treatment.

PURPOSE: First evaluation of dual-phase vaginal Er:YAG laser to omit hormonal treatment for atrophy-related symptoms in post-menopausal breast cancer survivors following prolapse surgery. METHODS: Patients with a history of breast cancer at the time of surgery for pelvic organ prolapse were offered non-hormonal vaginal Er:YAG laser treatment when complaining of atrophy-related genitourinary syndrome of menopause. A single 10-min course of dual-phase protocol of pulsed Er:YAG laser (2940 nm, fractional ablative and thermal mode, fluence according to tissue thickness). Follow-up included subjective satisfaction, vaginal pH, vaginal health index (VHI), and complications after 6 weeks. RESULTS: A total of 16 breast cancer survivors (age 71 years, SD 7) had been seeking treatment for pelvic floor symptoms related to vaginal atrophy at follow-up visits after prolapse surgery. All ablative vaginal Er:YAG laser outpatient procedures were successfully completed, all patients returned to daily activities without a need for analgetic medication. Evaluation was performed after 8.3 (SD 2.5) weeks. Pre-laser VHI scored 16 (SD 4.6) and post-laser VHI 20 (SD 3) with p = 0.01. Patients were satisfied in 94% (n = 15) regarding symptom relief. CONCLUSIONS: Breast cancer survivors with atrophy-related complaints after pelvic floor surgery may benefit from vaginal application of this innovative dual protocol of Er:YAG laser technology as a non-hormonal treatment approach.

Gynaecological Prolapse Surgery in Very Old Female Patients: A Case-Control Study on Co-Morbidity and Surgical Complications.

BACKGROUND: The aim of this study is to compare very elderly female patients with a younger control group after prolapse surgery with regard to co-morbidity and complications. METHOD: In a case-control design, the consecutive data of patients after prolapse surgery at the age of over 80 years and those of a control group were analysed by means of the Clavien-Dindo (CD) classification of surgical complications, the Charlson Comorbidity Index and the Cumulative Illness Rating Scale Geriatrics (CIRS-G). Statistics: Student's t, Fisher's exact and Mann-Whitney U tests. RESULTS: The analysis comprised n = 57 vs. n = 60 operations. In the very elderly patients there was often a grade IV prolapse (p < 0.001), apical fixations were more frequent (p < 0.001), but the operating times were not different. In the very elderly patients 21 % CD II+III complications were observed, in the control group 6.6 % (p = 0.031). No CD IV and V complications occurred in either group, the duration of inpatient stay amounted to 5 (± 1) vs. 4.1 (± 0.8; p < 0.001) days, the very elderly patients needed an inpatient follow-up more frequently (p < 0.001). The co-morbidities of the very elderly patients differed from those of the control group in number (median 2.0 vs. 1.5; p < 0.001), in CIRS-G (4.1 ± 2.2 vs. 2.4 ± 1.7; p < 0.01) and in Charlson Index (1.6 ± 1.6 vs. 0.5 ± 0.7; p < 0.001). CONCLUSIONS: A prolapse in very elderly women can be safely managed by surgery. In no case did the complications require intensive care treatment nor were they life-threatening, but they did lead to a longer duration of hospital stay and more frequently to further treatment geriatric or inpatient internal medicine facilities.

Community-acquired pneumonia and positive urinary antigen tests: Factors associated with targeted antibiotic therapy.

BACKGROUND: The use of rapid microbiological tests is supported by antimicrobial stewardship policies. Targeted antibiotic therapy (TAT) for community-acquired pneumonia (CAP) with positive urinary antigen test (UAT) has been associated with a favorable impact on outcome. We aimed to determine the factors associated with TAT prescription. PATIENTS AND METHODS: We conducted a retrospective multicenter study including all patients presenting with CAP and positive UAT for Streptococcus pneumoniae or Legionella pneumophila from January 2010 to December 2013. Patients presenting with aspiration pneumonia, coinfection, and neutropenia were excluded. CAP severity was assessed using the Pneumonia Severity Index (PSI). TAT was defined as the administration of amoxicillin for pneumococcal infection and either macrolides or fluoroquinolones (inactive against S. pneumoniae) for Legionella infection. RESULTS: A total of 861 patients were included, including 687 pneumococcal infections and 174 legionellosis from eight facilities and 37 medical departments. TAT was prescribed to 273 patients (32%). Four factors were found independently associated with a lower rate of TAT: a PSI score≥4 (OR 0.37), Hospital A (OR 0.41), hospitalization in the intensive care unit (OR 0.44), and cardiac comorbidities (OR 0.60). Four other factors were associated with a high rate of TAT: positive blood culture for S. pneumoniae (OR 2.32), Hospitals B (OR 2.34), E (OR 2.68), and H (OR 9.32). CONCLUSION: TAT in CAP with positive UAT was related to the hospitals as well as to patient characteristics.

Risk index for pelvic organ prolapse based on established individual risk factors.

PURPOSE: To identify known risk factors for pelvic organ prolapse (POP) in a hospital cohort and to develop a prolapse risk index (PRI). METHODS: Risk factors for POP were recorded in women who underwent surgery with symptomatic POP (n = 500) or non-POP gynaecological conditions (n = 236). Descriptive statistics were determined by Chi-squared and Mann-Whitney U tests. Stepwise multivariate regression analysis was performed for all patients and subgroups by age (<60 and ≥60 years). Primary outcome measures were variables with the strongest impact on prolapse and PRI development. Secondary: specificity, sensitivity, positive and negative predictive values (PPV and NPV, respectively), and Cohen's kappa statistic (κ). RESULTS: Stepwise multivariate regression analysis (n = 736) showed difficult obstetric history [odds ratio (OR) 10.04], family history of POP (OR 7.28), and ≥10 years since menopause (OR 4.53) were independent risk factors for prolapse (P < 0.001). When one of the three variables with the strongest influence on POP development was present, the PRI for all women showed a PPV of 82%, NPV of 68%, and κ of 0.47 for predicting symptomatic POP requiring treatment. In women under 60 years (n = 349), logistic regression revealed difficult obstetric history (OR 9.108), positive family history (OR 8.016), and body mass index (OR 2.274) as independent risk factors. CONCLUSIONS: Eighty-seven percent of our patient cohort with symptomatic POP requiring therapy could be identified by the PRI, which may be useful for counselling and education.

Severe community-acquired pneumonia and positive urinary antigen test for S. pneumoniae: amoxicillin is associated with a favourable outcome.

Positive urinary antigen tests (UAT) for pneumococcal infection in community-acquired pneumonia (CAP) may lead to targeted antibiotic therapy. We report an audit aimed at defining the link between mortality and targeted therapy. We conducted a retrospective multicentre audit of patients with severe CAP for whom a UAT was positive for S. pneumoniae. Patients admitted from January 2010 to December 2013 to 8 medical centres (from A to H) were included. Co-morbidities were defined by the specific treatment administered before hospital care, or if the diagnosis was newly established during the hospital stay. We used the Pneumonia Severity Index (PSI) to assess disease severity. Only patients with PSI > 90 were included. Antibiotic treatments and the PSI were extracted from patients' charts. Amoxicillin had to be prescribed as a targeted antibiotic treatment or at the time of antibiotic reassessment. A total of 389 patients were included. The mean (±STD) PSI score was 128 ± 29; 38.9% of the patients had a class 5 PSI score. Intensive care was required for 36.6% of the patients. Amoxicillin was initially prescribed in 47 cases (12.1%) and in 34 cases after reassessment (8.7%). In logistic regression analysis, we found three parameters associated with mortality: being hospitalised in institution D, class 5 PSI score, and metastatic cancer. In contrast, three antibiotic regimens were protective factors, including targeted therapy: OR = 0.09, p < 0.001. In the context of severe CAP with positive UAT for S. pneumoniae, targeted therapy was associated with a reduction in mortality.

Standardised Registration of Surgical Complications in Laparoscopic-Gynaecological Therapeutic Procedures Using the Clavien-Dindo Classification.

Introduction: The registration of complications represents an important component in the evaluation of surgical therapeutic procedures. The aim of the present study was to examine the frequency of occurrence as well as the severity of surgical complications after laparoscopic-gynaecological operations in a standardised manner using the Clavien-Dindo system. Material and Methods: Altogether 7438 treatment courses after laparoscopic-gynaecological interventions by 9 working groups were evaluated. Covariates recorded were the technical complexity of the operation, type of study cohort, study size, data acquisition as well as study centre. Target variables recorded were the surgical morbidity rate, subdivided into mild (Clavien-Dindo grade I-II) and severe complications (Clavien-Dindo grade III-V). In addition, a binary logistic regression analysis for the mentioned covariates and the occurrence of surgical complication was carried out. Results: 946 complications were recorded (overall complication rate: 13 %). These included 664 mild complications (8.9 %) and 305 severe complications (4.1 %). A correlation was found between the covariates technical complexity (relative risk [rR] 1.37; p < 0.01), study size (rR: 0.35; p < 0.01) and study centre (rR 0.19; p < 0.01) and the occurrence of surgical complications. Conclusion: By means of a standardised registration of complications using the Clavien-Dindo classification it appears to be possible to limit the methodologically caused underestimation of surgical morbidity in the retrospective evaluation of gynaecological-endoscopic therapeutic procedures. Factors decisively influencing the surgical morbidity of gynaecological-laparoscopic therapeutic procedures are the respective operative experience of the treating facility as well as the technical complexity of the intervention.

Long-term risk of fibroid recurrence after laparoscopic myomectomy.

OBJECTIVE: The use of laparoscopic myomectomy as a surgical treatment for uterine leiomyoma is associated with low intraoperative morbidity and short hospitalization. Limited data about the long-term outcome of this surgical approach are available. The aims of this study were to estimate the risk of uterine fibroid recurrence after laparoscopic myomectomy and to identify factors contributing to the rate of fibroid relapse. STUDY DESIGN: Between 1996 and 2003, 331 patients underwent laparoscopic myomectomy to treat uterine leiomyoma in our hospital; 224 of these patients consented to participate in our 2009 follow-up survey. Clinical symptomatic uterine leiomyoma recurrence was defined as relapse. Recurrence rates at 24 and 60 months post-operatively were calculated for the study population. Fisher's exact tests were used to examine the impacts of factors previously linked to an increased risk of fibroid recurrence, including (1) patient age at the time of initial surgery, (2) pre-operative body mass index, (3) number and localization of uterine leiomyoma removed, and (4) pregnancy and (5) delivery after laparoscopic myomectomy on fibroid recurrence in our study cohort. RESULTS: We observed 75 recurrences in 224 patients. The cumulative risk of recurrence was 4.9% at 24 months and 21.4% at 60 months post-operatively. An age of 30-40 years and the presence of more than one fibroid at the time of initial laparoscopic myomectomy were identified as factors significantly increasing the risk of symptomatic recurrence after laparoscopic myomectomy (31.25% and 38.71%, respectively; both p<0.01). CONCLUSION: Patients with multiple uterine leiomyoma and those in the third decade of life should be counselled thoroughly about the risk of recurrence prior to laparoscopic myomectomy. The low observed recurrence rate in peri- and postmenopausal patients in our study may support the use of laparoscopic myomectomy as a uterus-preserving surgical alternative beyond the reproductive period.

Contribution of systematic RT-PCR screening for influenza during the epidemic season.

OBJECTIVE: We assessed the systematic RT-PCR screening of patients admitted to an infectious diseases department (IDD), during the 2012-2013 influenza outbreak. METHODOLOGY: Patients admitted with cough and fever underwent a nasopharyngeal smear for RT-PCR screening. RESULTS: Ninety-eight patients were admitted in the IDD, from January 1st to February 22nd, 46 were screened; 11 male and 6 female patients (17.3%, mean age of 68 years) were positive. The diagnoses made in the emergency department, before RT-PCR screening, were most frequently lung infection and sepsis, but influenza in only 4 cases. The diagnosis of influenza led to stopping antibiotics (n=4), initiating curative (n=4) and preventive (n=4) treatments with oseltamivir, and isolating patients to prevent a hospital outbreak. CONCLUSION: Systematic RT-PCR screening allows a rapid therapeutic management and the prevention of hospital epidemic through appropriate isolation measures.

Laparoscopic lymphocele fenestration in gynaecological cancer patients after retroperitoneal lymph node dissection as a first-line treatment option.

OBJECTIVE: To evaluate laparoscopic lymphocele fenestration (LLF) as a first-line treatment in gynaecological cancer patients with a history of retroperitoneal lymph node dissection (LND). DESIGN: Retrospective cohort study. SETTING: A tertiary referral centre. POPULATION: Patients who underwent LLF between January 2001 and December 2010 for a symptomatic lymphocele following retroperitoneal LND. METHODS: Surgical outcomes of 102 patients who underwent LLF at our hospital between January 2001 and December 2010 were analysed. Patients were identified using hospital database search software, and hand-written and electronic charts were reviewed. MAIN OUTCOME MEASURES: Outcomes included operating time, blood loss, conversion rate, intra- and postoperative complication rates, hospital stay and relapse rate. RESULTS: A total of 132 lymphoceles were fenestrated in 102 patients. The mean duration of surgery was 115.6 minutes and the average intraoperative blood loss per patient was 146 ml. The overall conversion rate to laparotomy was 7.8%. Intra- and postoperative complication rates were estimated at 9.8 and 5.9%, respectively. The rate of intraoperative and postoperative complications was significantly higher in patients after pelvic plus paraaortic LND (23.8%), compared with those after pelvic LND only (3.6%; P > 0.01). The mean follow-up time was 60.4 months and a total of seven symptomatic recurrences of lymphoceles were observed (a recurrence rate of 6.9%). CONCLUSIONS: For the treatment of symptomatic lymphoceles, LLF has previously been established as an efficient first-line treatment option in a post-transplant context. Our data suggest that these favourable results for LLF may be transferable to gynaecological cancer patients.