The Therapy of Vulvar Carcinoma-Evaluation of Surgical Options in a Retrospective Monocentric Study

(1) Background: Surgical-oncological treatment methods are continuously put to the test in times of evidence-based medicine-notably, a constant reevaluation remains key, especially for tumor entities with increasing incidence such as vulvar carcinoma. (2) Methods: In order to determine the postoperative clinical course of different methods of vulvar excision (vulvectomy, hemivulvectomy) as well as inguinal lymph node removal (lymphadenectomy, sentinel lymph node biopsy) with regard to postoperative wound-healingprocess, perioperative hemorrhage, and re-resection rates, we retrospectively analyzed surgical, morphological and laboratory data of 76 patients with a pathological diagnosed vulvar cancer. (3) Results: Analysis of our data from a single center revealed a comparable perioperative clinical course regardless of the chosen method of vulvar excision and inguinal lymph node removal. (4) Conclusions: Thus, our results emphasize the current multimodality in surgical therapy of vulvar carcinoma, in which consideration of known prognostic factors together with the individual patient's clinical situation allow guideline-based therapy aimed at maximizing surgical safety.

Accuracy of Breast Ultrasonography and Mammography in Comparison with Postoperative Histopathology in Breast Cancer Patients after Neoadjuvant Chemotherapy

INTRODUCTION

Nowadays chemotherapy in breast cancer patients is optionally applied neoadjuvant, which allows for testing of tumor response to the chemotherapeutical treatment in vivo, as well as allowing a greater number of patients to benefit from a subsequent breast-conserving surgery.

MATERIAL AND METHODS

We compared breast ultrasonography, mammography, and clinical examination (palpation) results with postoperative histopathological findings after neoadjuvant chemotherapy, aiming to determine the most accurate prediction of complete remission and tumor-free resection margins. To this end, clinical and imaging data of 184 patients (193 tumors) with confirmed diagnosis of breast cancer and neoadjuvant therapy were analyzed.

RESULTS

After chemotherapy, tumors could be assessed by palpation in 91.7%, by sonography in 99.5%, and by mammography in 84.5% (chi-square p < 0.0001) of cases. Although mammography proved more accurate in estimating the exact neoadjuvant tumor size than breast sonography in total numbers (136/163 (83.44%) vs. 142/192 (73.96%), n.s.), 29 tumors could be assessed solely by means of breast sonography. A sonographic measurement was feasible in 192 cases (99.48%) post-chemotherapy and in all cases prior to chemotherapy.

CONCLUSIONS

We determined a superiority of mammography and breast sonography over clinical palpation in predicting neoadjuvant tumor size. However, neither examination method can predict either pCR or tumor margins with high confidence.

The Impact of the Microbiological Vaginal Swab on the Reproductive Outcome in Infertile Women

BACKGROUND

The thesis on which this paper is based intended to investigate whether the result of the microbiological vaginal swab has an influence on the outcome of the fertility treatment.

METHODS

The microbiological vaginal swabs of patients who received fertility treatment at Saarland University Hospital were evaluated. Depending on the microorganisms detected, the swab result was classified as inconspicuous, intermediate, or conspicuous. The SPSS software was used to determine the correlation between the swab result and the outcome of the fertility treatment.

RESULTS

Dysbiosis was associated with a worse outcome of fertility treatment. The pregnancy rate with a conspicuous swab was 8.6%, whereas it was 13.4% with an inconspicuous swab. However, this association was not statistically significant. Furthermore, an association of endometriosis with dysbiosis was found. Endometriosis was more frequent with a conspicuous swab result than with an inconspicuous result (21.1% vs. 17.7%), yet the correlation was not statistically significant. However, the absence of lactobacilli was significantly associated with endometriosis (p = 0.021). The association between endometriosis and a lower pregnancy rate was also statistically significant (p = 0.006).

CONCLUSION

The microbiological vaginal and cervical swabs can be used as predictors for the success of fertility treatments. Further studies are needed to assess the impact of transforming a dysbiotic flora into a eubiotic environment on the success of fertility treatments.

Postpartum Assessment of the Correlation between Serum Hormone Levels of Estradiol, Progesterone, Prolactin and ß-HCG and Blood Pressure Measurements in Pre-Eclampsia Patients

Background: Preeclampsia is a pregnancy-related hypertensive disease. Aberrant hormone levels have been implicated in blood pressure disorders. This study investigated the association of postpartum maternal serum hormone levels of estradiol, progesterone, prolactin, and ß-HCG with poorer PE-related complications including arterial hypertension. Methods: Thirty patient women with preeclampsia, and twenty women with uncomplicated pregnancy were included in this study. Serum levels of estradiol, progesterone, prolactin, and ß-HCG were determined immediately after delivery, and on the first and third postpartum days by means of ECLIA. Results: Compared with normal pregnancy cases, preeclampsia cases had higher serum levels of ß-HCG levels on Day-0 (319%), of progesterone on Day-0 (207%) and Day-1 (178%), and of estradiol on Day-1 (187%) and Day-3 (185%). Increased prolactin levels were positively associated with disease severity and estradiol and progesterone levels were decreased in poorer preeclampsia features including disease onset and IUGR diagnosis. No significant correlation between different hormone levels and blood pressure measurements was reported. Conclusions: This study is the first that detected postpartum maternal serum hormone levels and their correlation with blood pressure measurements in preeclampsia. We believe that the persistent arterial hypertension in the puerperium in preeclampsia as well as poorer disease specifications are most likely not of hormonal origin. Larger, well-defined prospective studies are recommended.

The Prevalence, Management and Impact of Dysmenorrhea on Medical Students' Lives-A Multicenter Study

Introduction: Dysmenorrhea is defined as the presence of painful menstruation, and it affects daily activities in different ways. The aims of this study were to assess the prevalence and management of dysmenorrhea and to determine the impact of dysmenorrhea on the quality of life of medical students. Material and methods: The study conducted was prospective, analytical and observational and was performed between 7 November 2019 and 30 January 2020 in five university centers from Romania. The data was collected using an original questionnaire regarding menstrual cycles and dysmenorrhea. The information about relationships with family or friends, couples’ relationships and university activity helped to assess the effects of dysmenorrhea on quality of life. The level of significance was set at p < 0.05. Results: The study comprised 1720 students in total. The prevalence of dysmenorrhea was 78.4%. During their menstrual period, most female students felt more agitated or nervous (72.7%), more tired (66.9%), as if they had less energy for daily activities (75.9%) and highly stressed (57.9%), with a normal diet being difficult to achieve (30.0%). University courses (49.4%), social life (34.5%), couples’ relationships (29.6%), as well as relationships with family (21.4%) and friends (15.4%) were also affected, depending on the duration and intensity of the pain. Conclusion: Dysmenorrhea has a high prevalence among medical students and could affect the quality of life of students in several ways. During their menstrual period, most female students feel as if they have less energy for daily activities and exhibit a higher level of stress. The intensity of the symptoms varies considerably and, with it, the degree of discomfort it creates. Most student use both pharmacological and non-pharmacological methods to reduce pain (75.7%). University courses, social life, couples’ relationships, as well as relationships with family and friends are affected, depending on the duration and intensity of the pain.

Students' attitudes toward digital learning during the COVID-19 pandemic: a survey conducted following an online course in gynecology and obstetrics

PURPOSE

The purpose of this survey was to assess medical students' opinions about online learning programs and their preferences for specific teaching formats during COVID 19 pandemic.

METHODS

Between May and July 2020, medical students who took an online gynecology and obstetrics course were asked to fill in a questionnaire anonymously. The questionnaire solicited their opinions about the course, the teaching formats used (online lectures, video tutorials featuring real patient scenarios, and online practical skills training), and digital learning in general.

RESULTS

Of 103 students, 98 (95%) submitted questionnaires that were included in the analysis. 84 (86%) students had no problem with the online course and 70 (72%) desired more online teaching in the future. 37 (38%) respondents preferred online to traditional lectures. 72 (74%) students missed learning with real patients. All digital teaching formats received good and excellent ratings from > 80% of the students.

CONCLUSION

The survey results show medical students' broad acceptance of the online course during COVID 19 pandemic and indicates that digital learning options can partially replace conventional face-to-face teaching. For content taught by lecture, online teaching might be an alternative or complement to traditional education. However, bedside-teaching remains a key pillar of medical education.

Comparison of maternal third trimester hemodynamics between singleton pregnancy and twin pregnancy

OBJECTIVES

The impedance cardiography (ICG) technique measures the variation of impedance in the thorax due to the physical contractile activity of the heart. Twin pregnancy is characterized by greater maternal hemodynamic changes than a singleton pregnancy.

METHODS

In a study on 121 pregnant women in the last trimester we performed ICG, evaluating the following hemodynamic parameters: stroke volume, heart rate, cardiac output, ventricular ejection time, left ventricular ejection time, thoracic impedance, and systemic vascular resistance.

RESULTS

The study included singleton and twin pregnancies. Heart rate values in women with single fetus was lower than in those carrying twins (85 vs. 100 beats/min, p=0.021) as were the stroke volume values (64 vs. 83 mL, p=0.010) and the cardiac output (p<0.0001). Systemic vascular resistance decreased in twin pregnancies compared to singleton pregnancy (p=0.023).

CONCLUSIONS

ICG studies are rare, and the validation of their results is an ongoing process. However, the ICG technique is applicable in the third trimester of pregnancy and can yield important information regarding the hemodynamic profile of singleton and twin pregnancies, revealing maternal heart changes specific to twin pregnancies.

Incidence of and risk factors for vaginal cuff dehiscence following total laparoscopic hysterectomy: a monocentric hospital analysis

PURPOSE

Vaginal cuff dehiscence (VCD) is one of the major surgical complications following hysterectomy with data on incidence rates varying largely and studies assessing risk factors being sparse with contradictive results. The aim of this study was to assess the incidence rate of and risk factors for VCD in a homogenous cohort of women treated for benign uterine pathologies via total laparoscopic hysterectomy (TLH) with standardized follow-up.

METHODS

All patients undergoing TLH at the Department of Gynecology and Obstetrics, Saarland University Hospital between November 2010 and February 2019 were retrospectively identified from a prospectively maintained service database.

RESULTS

VCD occurred in 18 (2.9%) of 617 patients included. In univariate and multivariate analyses, a lower level of surgeon laparoscopic expertise (odds ratio 3.19, 95% confidence interval (CI) 1.0-9.38; p = 0.03) and lower weight of removed uterus (odds ratio 0.99, 95% CI 0.98-0.99; p = 0.02) were associated positively with the risk of VCD.

CONCLUSION

In this homogenous cohort undergoing TLH, laparoscopic expertise and uterine weight influenced the risk of postoperative VCD. These findings might help to further reduce the rate of this complication.

In vitro Maturation of Oocytes with Consecutive Clinical Pregnancy after Accidental Premature Ovulation Induction-A Rescue Strategy in Art

BACKGROUND

The implementation of assisted reproductive techniques (ART) is a complex treatment requiring both a good cooperation between various professional groups in the fertility centre, and the patient's and her partner's cooperation. Accordingly, there are many sources of failure, such as using the wrong medication or not considering optimal times. If there is an artificial application of the ovulation induction injection, the success of the treatment is endangered and in some cases the cycle is discontinued, if the patient failed to administer the drug correctly. An alternative to cycle cancellation might be the maturation of the oocytes in vitro.

WE REPORT

on a 31-year-old patient in whom we performed an oocyte retrieval procedure 24 hours after triggering ovulation followed by in vitro maturation of the immature oocytes over a period of more than 12 h. The treatment resulted in a healthy, ongoing pregnancy.

WOMEN AND MEN WITH CANCER AND A FUTURE DESIRE FOR CHILDREN - WHAT SHOULD CLINICIANS CONSIDER IN COVID-19 PANDEMIC TIMES?

The topic of fertility preservation has been gaining increasing importance since the beginning of this century. The reasons for this development are the advances in oncological therapy over the past few decades, with cure rates of approximately over 90%, and the fact that starting families is increasingly postponed in later periods of life in industrialized countries. Since March 2020 the whole medical and non-medical world experiences a pandemic due to Covid-19 (coronavirus disease 2019) which has never been seen before. This created a plenty of challenges for both, the patients and healthcare providers. This review article presents the fertility-protective methods currently available for women and men suffering from cancer with their clinical approach, value, advantages and disadvantages. Besides, it focuses on the changes and special considerations which have to be taken into account during pandemic times including preventive measures as well as the patient's access to the fertility preserving options. In conclusion every premenopausal woman and every man with incomplete family planning suffering from cancer should be counselled about the existing fertility preserving techniques before commencing cancer therapy.

Teaching breast ultrasound skills including core-needle biopsies on a phantom enhances undergraduate student's knowledge and learning satisfaction

Purpose

To investigate whether a training program on breast ultrasound skills including core-needle biopsies to undergraduate students can improve medical knowledge and learning satisfaction.

Methods

Medical students attending mandatory classes at the Medical School of the University of Saarland received a supplemental theoretical and hands-on training program on ultrasound (US) breast screening and on US-guided core-needle biopsy using an agar–agar phantom. Experienced breast specialists and ultrasound examiners served as trainers applying Peyton’s 4-step training approach. The students’ theoretical knowledge and hands-on skills were tested before and after the training program, using a multiple-choice questionnaire (MCQ), the Objective Structured Clinical Examination (OSCE) and a student curriculum evaluation.

Results

The MCQ results showed a significant increase of the student’s theoretical knowledge (50.2–75.2%, p < 0.001). After the course, the OSCE showed a mean total of 17.3/20 points (86.5%), confirming the practical implementation of the new skills. The student curriculum evaluation in general was very positive. A total of 16/20 questions were rated between 1.2 and 1.7 (very good) and 3 questions were rated as 2.1 (good).

Conclusion

Undergraduate student’s medical education can be enhanced by teaching breast US skills.

Long-term effectiveness of an online decision aid for female cancer patients regarding fertility preservation: Knowledge, attitude, and decisional regret

INTRODUCTION

The decision, whether to undergo fertility preservation or not is highly demanding for cancer patients. Decision aids may act as an additional source of support. So far, only a limited number of decision aids regarding fertility preservation for female cancer patients exist and have been evaluated systematically. This paper presents the results of secondary analyses of the first randomized controlled trial evaluating an online decision aid for female cancer patients affected by different types of cancer. It focuses on fertility-related knowledge, attitude toward fertility preservation, and long-term effectiveness regarding decisional regret.

MATERIAL AND METHODS

Young female cancer patients between 18 and 40 years of age were recruited after fertility counseling with a reproductive specialist. They were assigned to either the control group (counseling only) or the intervention group (counseling followed by the additional use of the decision aid). Both groups had to complete a questionnaire after counseling as well as 1 and 12 months later, covering topics such as fertility-related knowledge, attitude towards fertility preservation, decisional conflict and regret. Recruitment was ongoing during 18 months in eight fertility centers located in Switzerland and Germany.

RESULTS

Mean age of participating women was 29.31 years (SD 4.57). Of the entire sample (n = 51) 53% were affected with breast cancer, 27.4% with lymphoma, and 19.6% with various other types of cancer. Knowledge regarding the most common fertility preservation methods was high and comparable in both groups. Positive attitude significantly exceeded negative attitude among all participants (p = 0.001). Although the altogether low scores for decisional regret were on a higher level in the control group (T2: mean = 19.00, SD = 13.24; T3: mean = 22.0, SD = 20.67) than in the intervention group (T2: mean = 14.12, SD = 11.07; T3: mean = 12.94, SD = 13.24), there were no statistically significant differences between and within both groups. There was a positive association between decisional conflict and decisional regret at T3 (p = 0.001, r = 0.510).

CONCLUSIONS

This decision aid was suitable as an additional source of knowledge and may positively impact decisional regret in the long term. Results suggest that the provision of an online decision aid as a complement to fertility counseling may facilitate decision-making.

Treatment algorithm for women with endometriosis in a certified Endometriosis Unit

INTRODUCTION

Endometriosis is a chronic hormone-dependent disease affecting approximately 25-30% of women in the third and fourth decade. Despite its frequency, it is often detected late. The aim of this overview article was to present a standardized treatment algorithm for an interdisciplinary endometriosis consultation considering conservative and surgical approaches.

EVIDENCE ACQUISITION

Despite the frequency of endometriosis and a high number of publications dealing with the disease there is a lack of evidence in literature for standardized treatment algorithms allowing a rational diagnostic and therapeutic approach. In May 2019 we did a literature search in Medline. While finding 26702 publications under the term "endometriosis" there was only one publication for the search term "endometriosis consultation treatment algorithm." After screening the abstracts 144 publications in English, French or German language had been assessed as relevant for the diagnosis and therapy of endometriosis (143 overview articles and one guideline).

EVIDENCE SYNTHESIS

Based on clinical evidence, we have developed a treatment algorithm for women with suspected endometriosis. The diagnosis includes a structured medical history with the identification of endometriosis-typical symptoms and a gynecological examination, if necessary additional examinations. The treatment algorithm is essentially divided into the phase of diagnosis and the phase of therapy as well as the prevention of recurrence or long-term treatment. A multi-professional team of visceral surgery, urology, nutritional medicine, physiotherapy and psychology can be consulted for support.

CONCLUSIONS

The treatment of endometriosis should be multiprofessional, standardized and reproducible during specialized consultations at certified centers. So far, there are few publications on a standardized and clinically proven treatment algorithm for women with suspected endometriosis. The presented treatment algorithm could be helpful in the diagnosis and treatment of endometriosis patients, even at other centers.

Fertility Preservation in Breast Cancer Patients Under Special Consideration of Ovarian Stimulation for Fertility Purposes

N/A

Significant improvement of laparoscopic knotting time in medical students through manual training with potential cost savings in laparoscopy - an observational study

Objective

Laparoscopy is a standard procedure in operative gynaecology, but laparoscopic simulator training for novices/junior surgeons is not currently well-established. The aims of this study were to demonstrate that a laparoscopic knot course for trainees can significantly shorten the knotting time and to perform a counter-value calculation for the clinic’s costs.

Material and Methods

An observational study was performed with exercises on a laparoscopic box trainer as part of the practical clerkship in gynaecology and obstetrics between 07.10.2019-31.01.2020. At the beginning and at the end of the exercises, the participants made a laparoscopic knot and the difference in knotting time, Δt in seconds (s) was measured.

Results

Eighty-eight medical students needed an average of 247.1 s for the first laparoscopic knot at the beginning of the course and an average of 45.43 s for the second at the end of the course. Mean shortening of the knotting time was 201.67 s or 81.6% (p=0.02). Calculating costs of an average of €40-50 for an operation minute would mean a cost saving of at least €120-150 for a partial node.

Conclusion

Trainees can significantly improve their operative skills in a short time with the aid of surgical simulation training. Such training can be beneficial for clinics by reducing the operating time if the basics, such as sewing and instrument guidance, are learned on a simulator. We therefore suggest that operative simulation training should be mandatory in medical education.

Teaching undergraduate students gynecological and obstetrical examination skills: the patient's opinion

Introduction

Our study assesses the patients’ opinion about gynecological examination performed by undergraduate students (UgSts). This assessment will be used in improving our undergraduate training program. A positive opinion would mean a lower chance of a patient refusing to be examined by a tutor or student, taking into account vaginal examination (VE).

Materials and methods

We performed a prospective cross-sectional survey on 1194 patients, consisting of outpatient and inpatient at the departments of obstetrics and gynecology from November 2015 to May 2016. The questionnaire consisted of 46 questions. Besides demographic data, we assessed the mindset of patients regarding the involvement of undergraduate student (UgSt) in gynecological and obstetrical examinations. We used SPSS version 23 for the statistical analysis. For reporting the data, we followed the STROBE statement of reporting observational studies.

Results

The median age was 38 years having a median of one child. 34% presented due to obstetrical problems, 38% due to gynecological complaints, and 19% due to known gynecological malignancies. Generally, we retrieved a positive opinion of patients towards the involvement of students in gynecological and obstetrical examination under supervision in 2/3 of the cases.

Conclusions

There is no reason to exclude medical UgSts from gynecological and obstetrical examinations after obtaining a written or oral consent.

Clinical implications and economic effects of the Coronavirus pandemic on gynecology, obstetrics and reproductive medicine in Germany: learning from Italy

The infection with the novel SARS Cov-2 Coronavirus, the cause of severe acute respiratory distress syndrome, possessing its origin in the Chinese province Hubei, has reached the extent of a global pandemic within a few months. After aerosol infection, most people experience mild respiratory infection with cold symptoms such as cough and fever, and healing within two weeks. In about 5% of those infected, however, a severe course develops with the occurrence of multiple subpleural bronchopulmonary infiltrates and even death as a result of respiratory failure. The Coronavirus pandemic has multiple impacts on social life that have not been seen before. For example, the government adopted measures to curb the exponential spread of the virus, which included a significant reduction in social contacts. Furthermore, the specialist societies recommended that no elective treatments be carried out during the pandemic period. This review article considers epidemiological aspects of novel Coronavirus infection and presents both the clinical as well the possible economic effects of the pandemic on gynecology, obstetrics and reproductive medicine in Germany in the past, present and future. In addition, useful preventive measures for daily clinical work and the previously known scientific findings dealing with the impact of Coronavirus on pregnancy and birth are discussed.

Patient satisfaction with personal patient care (PPC) in the inpatient treatment of endometriosis

PURPOSE

The aim of this retrospective cohort study was to validate patient's satisfaction and surgical complication rate in patients treated at a certified endometriosis centre with personal patient care (PPC).

METHODS

The implementation of PPC at a gynaecologic treatment centre was retrospectively evaluated by analysing perioperative complications using the Clavien Dindo (CD) classification and patient satisfaction utilizing the Picker Patient Experience Questionnaire (PPE-15) for a total of 219 symptomatic endometriosis patients treated surgically at a certified endometriosis centre (Agaplesion Diakonie Hospital, Kassel, Germany) between November 2018 and April 2019. Data from our sample on complication rates and satisfaction were compared with those from reference samples published by Radosa et al. and Jenkinson et al. RESULTS: An overall complication rate of 10.96% (24 out of 219 patients) was observed. Four endometriosis patients (1.83%) had major complications with complications grade III according to the CD classification system. 155 patients out of 219 chose to answer the PPE-15 (return rate 70.78%). 92 patients (59.35%) reported about problems during their treatment in our hospital in their PPE-15. "Doctors sometimes talked as if I was not here" was the best rated item (1.2%) in our cohort. "Staff gave conflicting information" was the most mentioned item (33.55%) by patients during their hospital stay in relation to patient dissatisfaction.

CONCLUSION

Incorporation of PPC in the surgical inpatient treatment of endometriosis patients resulted in a low postoperative complication rate and a high patient satisfaction in our study cohort. Furthermore, nursing staff of endometriosis patients also needs particular attention.

Conisation course for medical students-experience from a German University Hospital

Objective:

Conisation of the cervix is one of the most common surgical procedures in gynaecology. Nevertheless, surgical expertise is required because if the cone is too small, the oncological risk increases and if the cone is too large, the obstetric risk increases. The aim of this prospective study was to investigate the suitability of an in-house conisation simulator for teaching medical students the practical performance of conisation.

Material and Methods:

Following a demonstration, students performed a loop conisation with a target depth of 8-10 mm using the simulator. Cone biopsy dimensions were analysed and a loop electrosurgical excision procedure (LEEP) score was calculated. The students were surveyed using a questionnaire of 12 items with five possible responses for each in order to investigate the suitability and realism of the teaching experience.

Results:

Eighty-nine students participated in the course. The median (range) cone depth was 8 (3-25) mm with a standard deviation of 3.3 mm. The observed LEEP score amounted to 1.5. The questionnaire was answered by 88 students and completed by 86. Survey results showed the course was consistently rated as positive, especially towards the increase in practical skills. The questionnaire item producing the highest score was “I enjoyed the course” while the statement “I have gained enough self-confidence for the application of high-frequency surgery” received the lowest approval score. Students considered the course to be realistic and a helpful teaching exercise.

Conclusion:

Practical surgery exercises on the surgical simulator were received positively. Simulation training could be extended to other gynaecological operations and to other medical subjects.

Evaluating the use of Clavien-Dindo classification and Picker Patient Experience Questionnaire as quality indicators in gynecologic endoscopy

PURPOSE

Over the last few decades, laparoscopy has become a standard procedure within gynecological surgery. Validated quality indicators for the determination of the objective (perioperative complications) and subjective (patient satisfaction) quality of treatment as a surrogate parameter for the success of the treatment have so far found no regular application in the clinical routine. The purpose of this study was to evaluate the use of the Clavien-Dindo (CD) classification for postoperative complications and the Picker Patient Experience Questionnaire (PPE-15) as tools in the evaluation of endoscopic therapies in clinical routine.

METHODS

Retrospectively, perioperative complications using the CD classification and patient satisfaction utilizing the PPE-15 were reviewed for a total of 212 consecutive patients at a gynecologic endoscopic referral center (Agaplesion Diakonie Kliniken, Kassel, Germany) in September 2018.

RESULTS

An overall complication rate of 13.21% (28 out of 138 patients) was observed. Five patients (2.36%) had complications grade III and above according to the CD classification system. 138 patients out of 212 chose to answer the PPE-15 (return rate 65.01%). 112 patients (81.16%) reported about problems during their treatment in our hospital in their PPE-15. "Purpose of medicines not explained" was the most mentioned item (28.99%) by patients during their hospital stay.

CONCLUSION

CD classification and PPE-15 may be helpful instruments to evaluate the quality of care in gynecology. The application of both instruments for the assessment of treatment quality in clinical routine should be further investigated in prospective studies.

Fertility preservation in female cancer patients: current knowledge and future perspectives

INTRODUCTION

Protecting fertility in the presence of cancer has become highly significant, as the desire to give birth to a child is increasingly postponed to later in life, and long-term survival with cancer has increased. A variety of fertility-preserving methods have been developed.

EVIDENCE ACQUISITION

To find them, we performed a literature search in Medline using the key words "female fertility preservation in cancer" in December 2017. A total of 2381 different publications were found.

EVIDENCE SYNTHESIS

After screening the abstracts 78 publications in English, French, or German language had been assessed as relevant (17 dealing with medical approaches, six with surgical approaches, 15 with oocyte cryopreservation, 11 with ovarian tissue cryopreservation and 29 were review articles). In general, there are medical (non-surgical) and surgical approaches. Medical approaches comprise administration of GnRH-analogues during gonad toxic oncologic treatment, and cryopreservation of oocytes after ovarian stimulation. Surgical approaches comprise traditional methods of organ-saving surgery and ovarian transposition outside of the radiation portal as well as ovary cryopreservation as standard.

CONCLUSIONS

It is important to inquire about a prospective desire to have children with premenopausal women with cancer and comprehensively explain the fertility conserving methods available. Every premenopausal woman with cancer should be counseled about the methods of fertility protection currently available at a multiprofessional center.

Endoscopic surgery: talent or training?

PURPOSE

There are two groups of undergraduate students involved in endoscopic surgery with different degrees of experience: average and more experience. This study proves whether the subjective impression of the laparoscopic trainer is verifiable and which factors influence extreme talent.

METHODS

21 medical students of the eighth term of the University of Witten-Herdecke participated in the study. On their first course day, students got instructed in suturing and knot technique. They were then required to tie a maximum of five knots within 2 h. After a week, students repeated this procedure. Time used for tying knots was stopped.

RESULTS

Regarding the time students used for their first knots, great differences were provable (7-8 min, average 23 min). However, an adaption of the knotting time was noticed at the end of the first course day. This was confirmed during the second course day. Neither acquired factors (music, sport, etc.) nor individual factors (visual acuity, handedness, etc.) had any impact on the time used for knotting. Merely, one advantage was seen with the first knots with the factors of playing the guitar and having a more than 10-h surgical previous experience. Knotting times leveled off at 95% to less than 10 min, though.

DISCUSSION

Neither normally talented nor extremely talented junior surgeons could be noticed, and so could not the co-factors providing an advantage or disadvantage for surgery, respectively. All prospective surgeons can learn defined tasks (knots) by short interval training, and thus show similarly good results after a few repetitions.

[Case report of 39-Year-Old Gravida III, Para III with Inverted Uterus after Breech Birth]

An inverted uterus is defined as the eversion of the uterus into the vagina. It is a very rare event but has to be treated as an emergency. A woman with an inverted uterus is in serious danger of developing atony with high blood loss in a short time. This can lead to hypovolemic shock and circulatory failure. Therapy includes urgent uterine repositioning under narcosis and curettage after manual abruption of the placenta. Afterwards, uterotonics such as prostaglandins should be administered. A disorder of the coagulation system is very common due to blood loss. Therefore, substitution of plasma components and antifibrinolytic drugs are recommended. If vaginal repositioning of the uterus cannot be achieved, laparotomy or hysterectomy are possible alternatives. We report the case of a 39 year-old gravida III, para III in the 36+3 gestational week who, after a spontaneous breech delivery with placenta accreta, experienced an inverted uterus, which was then repositioned.

Introduction of a learning model for type 1 loop excision of the transformation zone of the uterine cervix in undergraduate medical students: a prospective cohort study

PURPOSE

We address the impact of applying loop electrosurgical excision procedure (LEEP) under direct colposcopic vision teaching to our undergraduates using a self-developed simulation model and a standardized assessment to evaluate the progress of learning.

METHODS

The undergraduate teaching module was composed of a theoretical course on cervical dysplasia, colposcopy, electrosurgery and excisional procedures of the uterine cervix. This was followed by hands-on practical rounds. During the hands-on practice the students performed five "type 1" LEEP under direct colposcopic vision on the self-developed simulator. Based on specimen fragmentation and excision accuracy a score system was established. The students were asked to answer a course evaluation questionnaire.

RESULTS

The accuracy of the excisions showed a statistically significant improvement during the five training procedures (excision depth 7.34 ± 1.60-8.54 ± 1.67 mm, p = 0.0041; deviation from target cone thickness 0.88 ± 1.16-0.13 ± 0.94 mm, p = 0.0116). The fragmentation of the conus decreased (2.57 ± 1.26-1.29 ± 0.60 pieces, p < 0.0001). All this led to a general improvement of the LEEP score (2.59 ± 1.93-0.84 ± 1.03, p = 0.001). The student's questionnaire revealed a subjective satisfaction and improvement of their knowledge in pathomechanism, diagnosis and therapy of cervical pathologies.

CONCLUSION

Undergraduate surgical training, in cervical excisional procedure, is a successful method in improving the students' perception and management of cervical pathologies.

[Case Report of Liver Rupture with Fulminant HELLP Syndrome in the 37th Gestational Week]

HELLP syndrome, characterized by the triad of hemolysis, elevated liver enzymes due to liver impairment, and low platelet count, is a hypertensive disorder in pregnancy. Although it is said to be caused by disturbed placentation in the first trimester, its clinical presentation can be seen mostly in the third trimester, but never before the completed 20^th gestational week. Predictive for its diagnosis is the reported upper abdominal pain that normally is localized under the right arc of ribs. With the aid of laboratory examination, the suspected diagnosis can be confirmed or excluded. Therapeutic options are observational treatment with the prophylaxis of respiratory distress syndrome and attempting to prolong pregnancy with the help of steroids like dexamethasone, or delivering the infant by inducing labor or performing a primary caesarian section, depending on the gestational week. Delivery is the unique causal therapy of HELLP syndrome. Clinical management is mainly influenced by the course of HELLP syndrome. There are mild forms that allow prolonging the pregnancy for several days or sometimes weeks, but also foudroyant courses with acute liver damage. We report the case of a 40-year-old, gravida 1 woman in gestational week 36+1 who was brought to our hospital in hemorrhagic shock caused by a rupture of the liver due to acute HELLP-syndrome.

Overview Tumour Disease and Oncologic Therapy During Pregnancy

Newly diagnosed cancer in pregnancy is an issue with increasing importance, because fulfilling the wish to have a child is shifted later in life. Tumour disease is diagnosed in around 0.1% of all pregnancies in Germany. Most common tumour entities involve the breast, the cervix and the hematopoietic system. As tumour prognosis is not negatively affected by pregnancy and gestation does not disclude oncologic therapy it is important to plan treatment immediately. Oncologic surgery preserving the uterus is not at all limited. Chemotherapy with anthracyclines, taxanes or platinum derivates is possible from the second trimenon on. Only radiotherapy should be avoided during pregnancy. Before initiating therapy, fertility preserving methods like cryopreservation of oocytes and/or ovarian tissue should be offered to the patient. Preterm birth is more common in women with a first diagnosis of cancer during pregnancy. Other negative effects on the child's future are not yet known. Treatment of pregnant cancer patients should be handled by experienced centres with a multi-professional team.

Fertility Preservation in Young Female Cancer Patients: Development and Pilot Testing of an Online Decision Aid

PURPOSE

Impairment of fertility is a common sequela of successful cancer treatment. Therefore, fertility preservation (FP) should be discussed with all young cancer patients. Decisions about FP are challenging. Patients wish more specific support and the first results concerning the helpfulness of decision aids (DA) were promising. Aside from describing the process of development and the content of an online DA in German, the objective of this study was to pilot test users' satisfaction with the DA and its effect on knowledge about FP and decisional conflict (DC).

METHODS

In this prospective consecutive study, a control group (n = 20, fertility counseling) was followed by and compared with an intervention group (n = 20, counseling and additional use of the DA, developed by an interdisciplinary team) of recently diagnosed female cancer patients between 18 and 40 years.

RESULTS

Nearly all participants who applied the DA considered it helpful for decision-making and recommendable. Knowledge about FP was high with regard to FP techniques women went for. DC was moderate according to the mean score (M = 27.92, standard deviation = 13.27) and only in 20%, the score was above the threshold for high DC. There was no difference between the control and intervention group for knowledge and DC.

CONCLUSION

The DA seems to serve as additional and well-accepted support tool in decision-making for patients and professionals. Referral to a reproductive specialist is crucial to warrant comprehensive information. These results need to be confirmed with the current ongoing randomized controlled study.

Operative techniques and complications of extraction and transplantation of ovarian tissue: the Erlangen experience

PURPOSE

Extracting ovarian tissue before oncologic therapy and transplanting it afterwards are increasingly being used to preserve fertility in women. This study describes standardized and safe operative procedures, with few complications, and reports the resulting ovarian function and pregnancy rates.

METHODS

The standardized operative techniques for removing and transplanting ovarian tissue used at the Erlangen center are: for tissue removal, one-third to half of the tissue from one ovary is excised with scissors, without tissue coagulation; for subsequent transplantation, pieces of ovarian tissue are placed in a retroperitoneal pocket without closure of the pocket.

RESULTS

Between January 2007 and December 2015, ovarian tissue was extracted in 399 women and transplanted following cancer therapy in 38. No surgical complications were observed within 28 days. To date, there have been ten pregnancies and nine live births after transplantation in seven different women; 26 of the 38 women developed hormonal activity, confirmed by a menstrual cycle or raised serum estradiol levels.

CONCLUSIONS

The techniques for laparoscopic removal and transplantation of ovarian tissue described here provide a standardized method with a very low risk of complications. The pregnancy rate after ovarian tissue transplantation, currently 15-30%, can be expected to rise further in the near future.

Twenty-five-year-old Woman with Bilateral Borderline Ovarian Tumour Desiring to Preserve Fertility - Case Report and Literature Review on the Current State of Fertility Preservation in Women with Borderline Ovarian Tumours

Borderline ovarian tumours are semimalignant tumours occurring unilaterally or bilaterally with a peak incidence among women of reproductive age. Since the affected women often wish to preserve fertility, particular precautions must be taken when counselling the patient and obtaining consent prior to planning an individual treatment. Options for preserving fertility include an organ-sparing surgical procedure and cryopreservation of oocytes and/or ovarian tissue. In this article, we report on a 25-year-old patient with a bilateral seromucinous borderline tumour who desired all fertility-preserving options. In order to perform the procedure without delay, we opted to perform luteal phase stimulation prior to oocyte retrieval. We conclude by discussing the current literature on the state of fertility preservation in the treatment of borderline ovarian tumours.

Surgical Aspects of Ovarian Tissue Removal and Ovarian Tissue Transplantation for Fertility Preservation

Introduction: The removal of ovarian tissue prior to starting oncologic treatment and the subsequent transplantation of this tissue after completing therapy have become increasingly important surgical fertility-preserving techniques. The aim of this review was to investigate the different surgical techniques used for this method reported in the literature to date and to discuss the advantages and disadvantages of the respective techniques. Review: A search was done in MEDLINE using a defined algorithm to find studies published between January 2004 and December 2015. All study designs were included in our review if they contained statements on the surgical technique used. We found 16 publications (8 retrospective cohort studies, 6 case reports and 2 systematic reviews) with a total of 1898 female patients which reported on the surgical technique used for ovarian biopsy and 15 publications (7 retrospective cohort studies, 6 case reports and 2 systematic reviews) with a total of 455 women which mentioned the surgical technique used for ovarian transplantation. Different surgical techniques can be used both for ovarian biopsy and for the transplantation of ovarian tissue. A number of different surgical routes have been used, and the amount of tissue extracted, the instruments used, the treatment of the ovary, the transplantation site, the blood supply to the transplanted ovarian tissue and the procedure used for simultaneous surgical interventions vary. Conclusion: In future, one of the tasks will be to establish a standard surgical method for ovarian extraction and transplantation which will have a low rate of complications and a high pregnancy and birth rate while ensuring that the transplanted tissue is fully functional.

The International Endometriosis Evaluation Program (IEEP Study) - A Systematic Study for Physicians, Researchers and Patients

INTRODUCTION

Endometriosis is a heterogeneous disease characterized by a range of different presentations. It is usually diagnosed when patients present with pain and/or infertility, but it has also been diagnosed in asymptomatic patients. Because of the different diagnostic approaches and diverse therapies, time to diagnosis can vary considerably and the definitive diagnosis may be delayed, with some cases not being diagnosed for several years. Endometriosis patients have many unmet needs. A systematic registration and follow-up of endometriosis patients could be useful to obtain an insight into the course of the disease. The validation of biomarkers could contribute to the development of diagnostic and predictive tests which could help select patients for surgical assessment earlier and offer better predictions about patients who might benefit from medical, surgical or other interventions. The aim is also to obtain a better understanding of the etiology, pathogenesis and progression of the disease.

MATERIAL AND METHODS

To do this, an online multicenter documentation system was introduced to facilitate the establishment of a prospective multicenter case-control study, the IEEP (International Endometriosis Evaluation Program) study. We report here on the first 696 patients with endometriosis included in the program between June 2013 and June 2015.

RESULTS

A documentation system was created, and the structure and course of the study were mapped out with regard to data collection and the collection of biomaterials.

CONCLUSION

The documentation system permits the history and clinical data of patients with endometriosis to be recorded. The IEEP combines this information with biomaterials and uses it for scientific studies. The recorded data can also be used to evaluate clinical quality control measures such as the certification parameters used by the EEL (European Endometriosis League) to assess certified endometriosis centers.