Lateral extension and attachment of mesh to the lateral vagina during laparoscopic sacrocolpopexy: a modified technique aimed at lowering recurrences in the anterior vaginal compartment. A surgical video.

PURPOSE/OBJECTIVE: Laparoscopic sacrocolpopexy has been demonstrated to be the gold standard of prolapse surgery in cases with apical defect. Most recurrences seem to occur in the anterior compartment, especially if a paravaginal defect is present. To reduce the incidence of anterior recurrence after laparoscopic sacrocolpopexy we modified our previous published technique by placing the anterior mesh not only deep under the bladder but also laterally and fixing it to the lateral edge of the vagina. With this video article, we would like to show and explain our modified technique and demonstrate how lateral mesh placement can be easily and safely performed using laparoscopy. METHODS: The video demonstrates our modified technique with lateral extension and fixation of the anterior mesh to the lateral vagina during laparoscopic sacrocolpopexy in a patient with severe uterine prolapse (grade III) and a large cystocele (grade III). Special emphasis is given to the topographical anatomy of the paravaginal space and the surgical technique of lateral fixation. RESULTS: This modified new technique shows excellent perioperative results in more than 100 cases without any occurrences of lesions of the ureters. Our initial experience also shows very good anatomical results in all three compartments. CONCLUSIONS: Paravaginal dissection and exposure of the ureters to extend the mesh placement and fixation to the lateral border of the vagina in the anterior compartment during laparoscopic sacrocolpopexy seem to be feasible and safe, helping to significantly reduce the risk of anterior recurrences. Prospective data are needed to evaluate this interesting technique.

Time trends (2006-2015) of quality indicators in EUSOMA-certified breast centres.

AIM OF THE STUDY: The European Society of Breast Cancer Specialists (EUSOMA) has fostered a voluntary certification process for breast centres to establish minimum standards and ensure specialist multidisciplinary care. Prospectively collected anonymous information on primary breast cancer cases diagnosed and treated in the units is transferred annually to a central EUSOMA data warehouse for continuous monitoring of quality indicators (QIs) to improve quality of care. Units have to comply with the EUSOMA Breast Centre guidelines and are audited by peers. The database was started in 2006 and includes over 110,000 cancers from breast centres located in Germany, Switzerland, Belgium, Austria, The Netherlands, Spain, Portugal and Italy. The aim of the present study is assessing time trends of QIs in EUSOMA-certified breast centres over the decade 2006-2015. MATERIALS AND METHODS: Previously defined QIs were calculated for 22 EUSOMA-certified breast centres (46122 patients) during 2006-2015. RESULTS: On the average of all units, the minimum standard of care was achieved in 8 of 13 main EUSOMA QIs in 2006 and in all in 2015. All QIs, except removal of at least 10 lymph nodes at axillary clearance and oestrogen receptor-negative tumours (T > 1 cm or N+) receiving adjuvant chemotherapy, improved significantly in this period. The desirable target was reached for two QIs in 2006 and for 7 of 13 QIs in 2015. CONCLUSION: The EUSOMA model of audit and monitoring QIs functions well in different European health systems and results in better performance of QIs over the last decade. QIs should be evaluated and adapted on a regular basis, as guidelines change over time.

The effect of EUSOMA certification on quality of breast cancer care.

AIM OF THE STUDY: The European Society of Breast Cancer Specialists (EUSOMA) has fostered a voluntary certification process for breast units to establish minimum standards and ensure specialist multidisciplinary care. In the present study we assess the impact of EUSOMA certification for all breast units for which sufficient information was available before and after certification. MATERIALS AND METHODS: For 22 EUSOMA certified breast units data of 30,444 patients could be extracted from the EUSOMA database on the evolution of QI's before and after certification. RESULTS: On the average of all units, the minimum standard of care was achieved for 12/13 QI's before and after EUSOMA certification (not met for DCIS receiving just one operation). There was a significant improvement of 5 QI's after certification. The proportion of patients with invasive cancer undergoing an axillary clearance containing >9 lymph nodes (91.5% vs 89.4%, p 0.003) and patients with invasive cancer having just 1 operation (83.1% vs 80.4%, p < 0.001) dropped, but remained above the minimum standard. The targeted standard of breast care was reached for the same 4/13 QI's before and after EUSOMA certification. CONCLUSION: Although the absolute effect of EUSOMA certification was modest it further increases standards of care and should be regarded as part of a process aiming for excellence. Dedicated units already provide a high level of care before certification, but continuous monitoring and audit remains of paramount importance as complete adherence to guidelines is difficult to achieve.

Radioguided occult lesion localization (ROLL) for treatment and diagnosis of malignant and premalignant breast lesions combined with sentinel node biopsy: a prospective clinical trial with 100 patients.

UNLABELLED: Advanced breast cancer screening techniques and their availability increased the number of non-palpable breast lesions requiring surgery. Consequently reliable and efficient therapeutic management permitting accurate localization and removal of these occult lesions is essential. AIMS: In our study we evaluated radioguided occult lesion localization (ROLL) for effectiveness of localization, oncological safety and feasibility of concomitant sentinel node biopsy. METHODS: Hundred patients (120 lesions) underwent ROLL and tumour excision with or without sentinel node biopsy after confirmed histopathological findings via intra-tumoral injection of Tc99m-labelled macro-aggregate albumin for ROLL and Tc99m-labelled nanocolloids with periareolar-subdermal injection for simultaneous sentinel node biopsy. RESULTS: Our detection rate for ROLL was 98.3%, respectively, 98.6% for sentinel nodes in cases of concomitant sentinel node biopsy. We had a radical excision rate of 55 out of 69 cases of invasive ductal cancer and 17 out of 26 cases of DCIS to achieve 1mm, respectively, 10 mm tumour-free margins. CONCLUSIONS: Intra-tumoral tracer injection of for ROLL and periareolar-subdermal tracer injection for simultaneous sentinel node biopsy seem to be a sensitive technique. According to our results ROLL is a safe, precise and simple technique permitting definitive therapeutic removal of malignant or premalignant breast lesions. The high detection rate of the sentinel node in cases with concomitant sentinel node biopsy shows that the combination of both procedures is possible and safe. In our opinion ROLL is an excellent therapeutic option after histological confirmation of malignancy or premalignant disease.

[Urinary incontinence in the woman--pathophysiology and diagnosis]. / Harninkontinenz der Frau--Pathophysiologie und Diagnostik.

Since urinary incontinence is one of the most frequent female health problems and may severely affect a woman's life quality, knowledge about its pathophysiology, evaluation and therapy is very important. Even basic diagnostic tests can determine the type of incontinence (stress or urge urinary incontinence) thus permitting appropriate therapy to be initiated. The patients history, micturition diary, clinical evaluation, perineal ultrasound and urinalysis are important parts of these basic diagnostic tests. The positive stress cough test and the typical symptoms such as urine loss during physical activity point to the diagnosis of stress urinary incontinence. Frequency, nocturia and urgency with or without urine loss as well as more objective criteria such as micturition diaries and urinalysis indicate urge incontinence. Questions to help determine how quality of life is affected by the incontinence symptoms aid in deciding how urgent the treatment is. An urodynamic evaluation together with perineal ultrasound and cystoscopy is performed in patients with complex or recurrent urinary incontinence after surgery or with micturition disorders.