QS ENDO Pilot - A Study by the Stiftung Endometrioseforschung (SEF) on the Quality of Care Provided to Patients with Endometriosis in Certified Endometriosis Centers in the DACH Region.

Introduction Endometriosis significantly reduces patients' quality of life and is additionally a burden on healthcare and social security systems. There are currently no quality indicators for the treatment of endometriosis. The care of patients with endometriosis must be considered inadequate. QS ENDO aims to record the quality of care available in the DACH region and to introduce quality indicators for the diagnosis and treatment of endometriosis as part of providing quality assurance in endometriosis care. The first phase, QS ENDO Real, recorded the reality of current care using a questionnaire. The second phase, QS ENDO Pilot, investigated the treatment of 435 patients who underwent surgical treatment within a defined one month period in certified endometriosis centers. Material and Methods An online tool was used to gather information about 9 points which covered both prior patient history and the process of clinical diagnosis. Surgery reports were reviewed to obtain information about the surgical approach, the investigated sites, findings of any histological examinations, the use of classification systems, and information about resection status. Results 85.3% of patients were asked all 4 questions about their prior medical history. All 5 diagnostic steps were carried out in 34.5% of patients. The 3 areas needed to describe potential sites of disease were recorded in 67.1% of patients. Samples for histological examination were taken in 84.1% of patients. The endometriosis stage was classified in 94.7% of surgeries. A combination of the rASRM and the ENZIAN classifications, which is needed for complex cases, was used in 46.1% of patients. Complete resection was achieved in 81.6% of surgical procedures. Conclusion For the first time, the quality of care in certified endometriosis centers has been recorded using QS ENDO Pilot. Despite the high certification standards, a substantial number of required indicators were omitted.

Learning laparoscopic hysterectomy: analysis of different surgeons' individual learning curves.

OBJECTIVE: The aim of this study was to examine the development of surgical skills among surgeons learning total laparoscopic hysterectomy (TLH), using differences in complication rates between surgeons with different levels of experience and analyzing the development of individual operating times. STUDY DESIGN: This retrospective, single-center cohort study included 576 total laparoscopic hysterectomy procedures conducted between January 2015 and December 2019 at the municipal hospital in Karlsruhe, Germany. All TLHs were performed by eight surgeons, two of whom were experienced and six inexperienced. Complications were graded using the Clavien-Dindo classification. RESULTS: No differences in complication rates were seen between experienced and inexperienced surgeons. With growing numbers of procedures, most surgeons quickly became faster, leading to reduced operating times. However, experienced surgeons who had performed more than 100 procedures also became faster, not reaching a time plateau after adjustment for weight of the uterus, presurgery score, and adnexal score. CONCLUSIONS: Learning laparoscopic hysterectomy in routine practice is safe for patients, and surgeons rapidly become faster as growing numbers of procedures are performed. Operating times for experienced surgeons who have carried out more than 100 operations also improve, and a time plateau is not reached.

Detection rate with routine postoperative renal ultrasound to identify urinary tract injury after gynecological surgery.

PURPOSE: The aim of this study was to establish the rate at which routine postoperative renal ultrasonography is able to detect urinary tract injury following gynecological surgery. METHODS: A retrospective analysis was carried out for the study period 2015-2019 of all patients who had undergone subtotal or total hysterectomy, or radical hysterectomy or salpingectomy, salpingo-oophorectomy, or oophorectomy, and subsequently had a urinary tract injury. RESULTS: In a total of 2068 patients, 25 urinary tract injuries occurred (1.21%), including 21 urinary bladder lesions (1.02%) and four ureteral injuries (0.19%). The incidence of urinary tract injuries was 3% in oncologic procedures and 0.86% in procedures for benign disease. Nineteen injuries (76%) were diagnosed intraoperatively, and six injuries (24%) were clinically diagnosed after surgery. All of the patients had uneventful postoperative renal ultrasound examinations. CONCLUSION: Routine postoperative renal ultrasonography was not capable of diagnosing urinary tract injuries after gynecologic surgery. Routine postoperative renal ultrasound examinations should, therefore, not be performed after gynecologic operations.

Complementary and alternative medicine (CAM) in women with endometriosis.

OBJECTIVE: This study aimed to provide an overview of the extent to which women with endometriosis are informed about, interested in, and make use of CAM, and to evaluate which of the methods are most often applied. STUDY DESIGN: A retrospective, two-center cohort study was conducted using a validated questionnaire among women with laparoscopically confirmed endometriosis at two urban teaching hospitals, certified as endometriosis centres. RESULTS: A total of 592 patients were included in the study and received the questionnaire; 114 (19.3 %) were included in the data analysis. Most of the women were not receiving hormone therapy at the time of the study (n = 60, 52.6 %). Most (n = 75, 65.8 %) were interested in CAM, but only a minority (n = 12, 10.5 %) had detailed knowledge about it. A total of 81 patients (71.1 %) had used at least one CAM method for disease management; the five most frequently used CAM methods were exercise (n = 55, 48.2 %), vitamins (n = 40, 35.1 %), yoga (n = 38, 33.3 %), homeopathy (n = 32, 28.1 %), and trace elements (n = 27, 23.7 %). CONCLUSIONS: In our study population, women with endometriosis are strongly interested in using CAM, but have only limited information about it. Nevertheless, a majority of the patients had used at least one CAM method to relieve symptoms associated with the disease and the most often used was exercise.

QS ENDO Real - A Study by the German Endometriosis Research Foundation (SEF) on the Reality of Care for Patients with Endometriosis in Germany, Austria and Switzerland.

Endometriosis affects a significant number of young premenopausal women. Quite apart from the medical challenges, endometriosis is a relevant burden for healthcare and social security systems. Standardized quality indicators for the treatment of endometriosis have not previously been systematically verified. The three-stage study QS ENDO was initiated to record and improve the reality and quality of care. One of its aims is to create quality indicators for the diagnosis and treatment of endometriosis. For the first stage of QS ENDO Real, letters were sent to all 1014 gynecological departments in the German-speaking area of Europe (the DACH region) which included a questionnaire as a means of surveying the current state of care. A total of 296 (29.2%) of the centers which received the questionnaire participated in the survey. The subsequent evaluation of the completed questionnaires showed that the majority of patients with endometriosis (around 60%, based on estimates from the data) are not treated in hospitals which have been certified by the SEF. The guidelines recommend the use of specific classification systems (rASRM, ENZIAN) but, depending on the level of care offered by the hospital, only around 44.4 to 66.4% of departments used the rASRM score and only 27% of hospitals used the ENZIAN classification system to describe deep-infiltrating endometriosis. When taking patients' medical history, some centers (6.6 - 17.9%) considered questions about leading symptoms such as dyschezia, dysuria and dyspareunia to be unimportant. QS ENDO Real has made it possible, for the first time, to get an overview of the reality of care provided to patients with endometriosis in the German-speaking areas of Europe. The findings indicate that several of the measures recommended in international guidelines as the gold standard of care are only used to treat some of the patients. In this respect, more efforts will be needed to provide more advanced training. The approach used for treatment must be guideline-based, also in not-certified centers, to improve the quality of care in the treatment of patients with endometriosis.

Total laparoscopic hysterectomy: how does training for surgeons in a standardized operation affect hospitals and patients?

PURPOSE: Surgical training usually means inexperienced physicians initially doing operations supervised by an experienced physician, to gain the experience and skills needed to conduct surgery independently. Various issues arise here for both hospitals and patients. Are training procedures associated with higher complication rates, blood losses, and transfusion rates? What does training in the operating room ultimately cost in terms of valuable surgical time? Do longer hospitalization periods potentially mean financial losses for the hospital under the diagnosis-related groups (DRG) system? METHODS: A retrospective analysis was carried out of data for 571 patients who underwent total laparoscopic hysterectomy (TLH) in the Department of Gynecology at the University of Erlangen from 2009 to 2012, with/without adnexectomy, due to benign indication; and of data for 255 patients who underwent the same procedures in Karlsruhe Municipal Hospital in 2013-2014. The patients were classified into two groups: those in whom surgery was carried out by experienced specialists who had carried out at least 40 independent operations; and those in whom it was carried out by a trainee resident who had personally done fewer than 40 operations. RESULTS: In the two groups, the patients had similar mean body mass indexes, uterus weights, and blood losses. Patients in the specialist group were slightly older. There were no differences in complication rates. Over two-thirds of complications occurred in patients with previous surgery. Procedures by residents took significantly longer. Hospitalization periods in both groups were still below the mean threshold length of stay under Germany's DRG system, so that no income losses occurred even with training procedures. CONCLUSIONS: Training and teaching operations supervised by experienced surgeons are just as safe as operations by experienced surgeons themselves. Interpretation of these data is of course limited by the retrospective study design; patients treated by specialists tended to have more prior operations and were older, with a trend toward larger uteri. Surgical training, as the example of TLH in benign indication shows here, involves an additional time of approximately 10-20 min per operation. With regard to the revenue situation, the hospitalization periods in both groups were within the profit zone for the hospital concerned.

Comparison of dienogest and progesterone effects on uterine contractility in the extracorporeal perfusion model of swine uteri.

INTRODUCTION: Endometriosis is associated with hyperperistalsis and dysperistalsis in the uterus, and it has been shown that progesterone leads to a decrease in uterine contractility. The synthetic gestagen dienogest is often administered in women who are receiving conservative treatment for endometriosis, and it may be the treatment of choice. The present study investigated the effects of dienogest on uterine contractility in comparison with the known inhibitory effect of progesterone. MATERIAL AND METHODS: Eighty swine uteri were examined using an established extracorporeal perfusion model. The uteri were perfused for at least 4 hours with progesterone, dienogest, or a modified Krebs-Ringer solution as the control group, with uterine contractions being measured using an intrauterine microchip catheter. The amplitude and frequency of contractions and the area under the curve (AUC), reflecting overall contractility, were measured at two separate locations (the isthmus and fundus). RESULTS: Progesterone led to a significant decrease in the amplitude of uterine contractions and to reduced overall pressure (AUC) at the isthmus and fundus. Dienogest led to a significant decrease in the amplitude of contractions and overall pressure (AUC) in the area of the isthmus, but the decrease near the fundus was not significant. The frequency of uterine contractions was not influenced by either progesterone or dienogest. CONCLUSIONS: These results confirm the known inhibitory effect of progesterone on uterine contractility (relative to amplitude of contractions and overall contractility), affecting the whole organ. Perfusion of the uterus with dienogest also led to a general decrease in uterine contractility similar to the effect of progesterone.

Comparison of reoperation rates, perioperative outcomes in women with endometrial cancer when the standard of care shifts from open surgery to laparoscopy.

PURPOSE: To analyze reoperation rates and perioperative outcomes after long-term follow-up of two surgical approaches in the treatment of endometrial cancer when the standard of care shifts from open surgery to laparoscopy at a university hospital. METHODS: In this retrospective monocenter study a total of 267 patients with endometrial cancer were included; 107 women underwent laparoscopy and 160 laparotomy. All of the patients received total hysterectomy, bilateral salpingo-oophorectomy, and pelvic and para-aortic lymphadenectomy, depending on individual pathological features (e.g. high risk for positive lymph nodes) and the expertise of the surgeon. RESULTS: Repeat surgery was needed significantly more often in the laparotomy group in comparison with the laparoscopy group (11.9 vs. 0.9 %, respectively; P < 0.001). Hospital stays were longer in the laparotomy group in comparison with laparoscopy (16.2 vs. 9.5 days; P < 0.000001). Postoperative complications were significantly more frequent in the laparotomy group in comparison with laparoscopy (25.0 vs. 10.3 %; P < 0.01). Operating times and preoperative and postoperative hemoglobin differences were similar in the two groups (193.9 vs. 190.6 min, 2.0 vs. 1.8 g/dl). Intraoperative complication rates were similar in the two groups (3.8 vs. 5.6 %). CONCLUSIONS: Laparoscopy is a safe alternative to laparotomy for low risk endometrial cancer patients and offers markedly improved perioperative outcomes with a lower reoperation rate and fewer postoperative complications when the standard of care shifts from open surgery to laparoscopy in a university hospital.

The conservative and interventional treatment of fibroids.

BACKGROUND: Fibroids are the most common benign tumors in women. One-third of all women of reproductive age undergo treatment for symptomatic fibroids. In recent years, the spectrum of available treatments has been widened by the introduction of new drugs and interventional procedures. METHODS: Selective literature review on the treatment of uterine fibroids, including consideration of several Cochrane Reviews. RESULTS: Fibroids can be treated with drugs, interventional procedures (uterine artery embolization [UAE] and focused ultrasound treatment [FUS]), and surgery. The evidence regarding the various available treatments is mixed. All methods improve symptoms, but only a few comparative studies have been performed. A meta-analysis revealed that recovery within 15 days is more common after laparoscopic enucleation than after open surgery (odds ratio [OR], 3.2). A minimally invasive hysterectomy, or one performed by the vaginal route, is associated with a shorter hospital stay and a more rapid recovery than open transabdominal hysterectomy. UAE is an alternative to hysterectomy for selected patients. The re-intervention rates after fibroid enucleation, hysterectomy, and UAE are 8.9-9%, 1.8-10.7%, and 7-34.6%, respectively. The main drugs used to treat fibroids are gonadotropin-releasing hormone analogs and selective progesterone receptor modulators. CONCLUSION: Multiple treatment options are available and enable individualized therapy for symptomatic fibroids. The most important considerations in the choice of treatment are the question of family planning and, in some cases, the technical limitations of the treatments themselves.

Visual pain mapping in endometriosis.

PURPOSE: To construct pain maps in order to describe the distribution of pelvic pain in a group of endometriosis patients and endometriosis-free patients, to assess the feasibility of this method. METHODS: A total of 159 patients with pelvic pain who were scheduled for diagnostic laparoscopy. RESULTS: A total of 117 patients with and 42 patients without endometriosis were included. The pain distribution between these two patient groups appeared to differ in some peripheral anatomical structures. In the endometriosis patients, the pain was most frequently located in the rectouterine pouch. CONCLUSIONS: In endometriosis patients, pain mapping to assess preoperative pain sensations relative to the anatomic location of endometriotic lesions is feasible. The pain provoked by vaginal examination is frequently perceived as median relative to the actual anatomic location of the endometriotic lesions. Several anatomic and neurophysiological factors may explain this phenomenon.

The Hohl instrument for optimizing total laparoscopic hysterectomy: results of more than 500 procedures in a university training center.

PURPOSE: To evaluate complication rates associated with total laparoscopic hysterectomy (TLH) using the Hohl instrument in women with benign indications for hysterectomy, a prospective cohort study was conducted in a university teaching hospital. METHODS: A total of 567 women with benign indications for hysterectomy underwent the TLH procedure using the Hohl instrument between January 2005 and July 2009. The laparoscopic approach was used when the patient had undergone more than one previous pelvic abdominal operation, when an adnexal finding was present, and/or if the patient had reduced vaginal capacity. RESULTS: One ureteral injury (0.18%), four bladder injuries (0.71%), one small-bowel injury (0.18%), one vaginal injury (0.18%), and one conversion to abdominal hysterectomy (0.18%) occurred. The general complication rate during surgery was 1.42%, whereas in the postoperative period was 3.19%. The mean loss of hemoglobin was 1.47 g/dL (SD 1.06), the mean operating time was 103.87 min (SD 43.89), and the mean uterus weight was 241.41 g (SD 196.73). CONCLUSIONS: Total laparoscopic hysterectomy using the Hohl instrument simplifies the surgical procedure. The technique reported here is safe and effective in preventing ureteral complications during TLH, even in a university training program.

Is laparoscopic extirpation of the cervical stump after laparoscopic supracervical hysterectomy justified in women with incidentally found atypical endometrial hyperplasia?

OBJECTIVE: An incidental finding of atypical endometrial hyperplasia (AEH) in women who have undergone laparoscopic supracervical hysterectomy (LASH) is a rare phenomenon, and it is unclear whether laparoscopic extirpation of the cervical stump (LECS) is justified in these patients. METHODS: LECS due to AEH found incidentally in the morcellated uterus after LASH. RESULTS: A total of 332 women underwent LASH between January 2002 and September 2010. Five of the women (1.5%) underwent secondary LECS procedures due to histological evidence of AEH or focal atypical endometrial cells found incidentally in the morcellated uterus. No atypical endometrial cells were histologically diagnosed in the cervical stump in any of the cases, nor were any endometrial cells found in the cervical stumps in any of the 5 patients. There was no abdominal evidence at all of any disseminated endometrial cells. In all 5 cases, cytological examination of peritoneal fluid confirmed the absence of adenocarcinoma cells. CONCLUSIONS: No signs of AEH were found in the removed cervical stumps. However, women should receive counseling regarding the need for secondary LECS to minimize any risks in such cases.

Comparison of re-operation rates and complication rates after total laparoscopic hysterectomy (TLH) and laparoscopy-assisted supracervical hysterectomy (LASH).

OBJECTIVE: To compare re-operation rates and complication rates after total laparoscopic hysterectomy (TLH) and laparoscopy-assisted supracervical hysterectomy (LASH). STUDY DESIGN: Retrospective analysis of 867 women who underwent laparoscopic hysterectomy between January 2002 and December 2009 for benign gynaecological diseases. Total laparoscopic hysterectomy was performed in 567 women (TLH group) and laparoscopy-assisted supracervical hysterectomy was performed in 300 women (LASH group). RESULTS: The women in the LASH group were significantly younger (45.6 years) than those in the TLH group (47.9 years) and the uteri removed with LASH were significantly heavier (326.4 g) than those removed with TLH (242.7 g). The rate of salpingo-oophorectomy was significantly lower in the LASH group. The overall re-operation rates were equivalent in the two groups. Two method-specific reasons for re-operations were identified. A method-specific procedure after LASH was extirpation of the cervical stump, which was performed in 2.7% of the women. Vaginal cuff dehiscence was a method-specific problem leading to secondary operation after TLH and was observed in 0.7% of the patients. No differences between the intraoperative and postoperative complication rates were observed, although there was a trend toward lower complication rates after LASH. CONCLUSIONS: There seem to be equivalent overall re-operation rates and complication rates after both hysterectomy procedures, making the two laparoscopic approaches for hysterectomy equivalent.

Preoperative pain and recurrence risk in patients with peritoneal endometriosis.

OBJECTIVE: Pain symptoms in endometriosis patients do not necessarily correlate with the extent of the disease, and there is little evidence regarding the recurrence risk. Aim of this study was to assess the risk factors for the recurrence of endometriosis, with regard to preoperative and postoperative pain. DESIGN: Retrospective observational study. SETTING: Single institution study. POPULATION: A total of 150 patients were followed up for recurrence after surgical treatment for endometriosis. METHODS: The patients were interviewed retrospectively to obtain information about pain levels during the course of the disease. MAIN OUTCOME MEASURES: Disease free survival. RESULTS: High preoperative pain levels were associated with a higher risk of recurrence after 4 years of follow-up. The hazards ratio was 2.30 (95% CI, 1.22-4.31; p = 0.009). None of the other parameters assessed for medical history, reproductive history, or lifestyle was associated with the recurrence risk. CONCLUSIONS: The risk for recurrence after surgery for endometriosis may be substantially influenced by the patients' perception of pain. Risk classifications for the recurrence risk in endometriosis are nonexistent. Developing these is imperatively needed soon to improve further treatment and/or prophylaxis for patients after surgery. A classification might be improved by adding sensory testing before surgery.