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The demand for fertility-sparing surgery (FSS) has increased in the last decade due to increased maternal age, increased incidence of ovarian malignancies in younger patients, and technical advances in surgery. Data on oncological safety and fertility outcomes of patients with ovarian cancer after laparoscopic FSS are sparse, but some retrospective studies have shown that open FSS may be offered to selected patients. We assessed the role of minimally invasive FSS in comparison with radical surgery (RS) in terms of oncological safety and reproductive outcomes after FSS in this multicenter study. Eighty patients with FIGO stage I/II ovarian cancer treated with laparoscopic FSS or RS between 01/2000 and 10/2018 at the participating centers (comprehensive gynecological cancer centers with minimally invasive surgical expertise) were included in this retrospective analysis of prospectively kept data. Case-control ( n = 40 each) matching according to the FIGO stage was performed. Progression-free survival [150 (3-150) and 150 (5-150) months; p = 0.61] and overall survival [36 (3-150) and 50 (1-275) months; p = 0.65] did not differ between the FSS and RS groups. Eight (25.8%) women became pregnant after FSS, resulting in seven (22.5%) deliveries; three (37.5%) patients conceived after in vitro fertilization, and five (62.5%) conceived spontaneously. Laparoscopic FSS seems to be applicable and oncologically safe for patients with early-stage ovarian cancer, with adequate fertility outcomes.

Incentivized experiments in which individuals receive monetary rewards according to the outcomes of their decisions are regarded as the gold standard for preference elicitation in experimental economics. These task-related real payments are considered necessary to reveal subjects' "true preferences." Using a systematic, large-sample approach with three subject pools of private investors, professional investors, and students, we test the effect of task-related monetary incentives on risk preferences in four standard experimental tasks. We find no significant differences in behavior between and within subjects in the incentivized and non-incentivized regimes. We discuss implications for academic research and forions in the field., Supplementary Information: The online version contains supplementary material available at 10.1007/s11166-022-09377-w., Competing Interests: Conflict of interestThere exist no conflicts of interest of any of the authors involved in this project. , (© The Author(s) 2022.)

Background: Live surgery events serve as a valuable tool for surgical education, but also raise ethical concerns about patient safety and professional performance. In the present study, we evaluate the technical feasibility and didactic benefits of live surgery on body donors compared to real patients., Methods: A live surgery session performed on a body donor's cadaver embalmed in ethanol-glycerol-lysoformin was integrated into the live surgery program presented at a major gynecological convention of minimally invasive surgery. Surgical procedures carried out in real patients were paralleled in the body donor, including the dissection and illustration of surgically relevant anatomical landmarks. A standardized questionnaire was filled by the participants ( n = 208) to evaluate the appropriateness, effectiveness, and benefits of this novel concept., Results: The live surgery event was appreciated as a useful educational tool. With regard to the use of body donors, authenticity was rated high (85.5%), and the overall value of body donors for surgical education and training was rated very high (95.0%). The didactic benefit of simultaneous operations performed on body donors and real patients was considered particularly useful (95.5%), whereas complete replacement of real patients by body donors was not favored (14.5%)., Conclusions: The study demonstrated both the technical feasibility and didactic benefits of performing minimally invasive surgery in body donors as part of live surgery events. This novel concept has the potential to enhance anatomical knowledge, providing insights into complex surgical procedures, and may serve to overcome yet unresolved ethical concerns related to live surgery events.

Purpose: This study was performed to assess the practical laparoscopic training in Gynecological Endoscopy Working Group (AGE) certified Training Centers (TC) and evaluate the possible implementation for a manual dexterity skills-training within the Minimal Invasive Surgery (MIC) certification process., Material and Methods: An online questionnaire was developed and the link provided for the heads of the AGE TC. The questionnaire comprised topics on TC organization, practical training performance and perspectives for future training and demographic data., Results: Response rate was 78.9% (15/19) of AGE TC. Grasping for the basic and suturing exercises for the advanced curricula, respectively, are thought to be of highest value (each 1.0 ± 0, on a scale from 1 = very valuable to 6 = not at all valuable). Most valuable parameter in assessing training was thought to be pressure/tension with 1.80 ± 1.08 The most valuable training capacity was considered for box training under supervision (1.27 ± 0.59) and feed-back box training with direct evaluation of various surgical skills (1.40 ± 0.63). Supervised box training was also thought to have the most positive influence on surgical performance (1.33 ± 0.49). The majority of respondents (86.7%) were qualified with the highest MIC certification and additional 66.7% were sub-specialized Gynecological Oncologists., Conclusion: The AGE certified TC offer a structured curriculum with emphasis on practical training. The results of this questionnaire and the additional respondents comments on value and future perspectives/changes of practical training support the concept and the implementation of a skills-training to the AGE MIC concept.

Modern surgical strategies aim to reduce trauma by using functional imaging to improve surgical outcomes. This reviews considers and evaluates the importance of the fluorescent dye indocyanine green (ICG) to visualize lymph nodes, lymphatic pathways and vessels and tissue borders in an interdisciplinary setting. The work is based on a selective search of the literature in PubMed, Scopus, and Google Scholar and the authors' own clinical experience. Because of its simple, radiation-free and uncomplicated application, ICG has become an important clinical indicator in recent years. In oncologic surgery ICG is used extensively to identify sentinel lymph nodes with promising results. In some studies, the detection rates with ICG have been better than the rates obtained with established procedures. When ICG is used for visualization and the quantification of tissue perfusion, it can lead to fewer cases of anastomotic insufficiency or transplant necrosis. The use of ICG for the imaging of organ borders, flap plasty borders and postoperative vascularization has also been scientifically evaluated. Combining the easily applied ICG dye with technical options for intraoperative and interventional visualization has the potential to create new functional imaging procedures which, in future, could expand or even replace existing established surgical techniques, particularly the techniques used for sentinel lymph node and anastomosis imaging.

Clusterin (CLU) is expressed in tissues and body fluids and is altered in some pathologies. In endometriosis, a noninvasive test is still lacking, thus, we analyzed CLU in mucus samples of patients. Additionally, we investigated localization of CLU and the putative CLU receptors (apolipoprotein E receptor 2 [ApoER2], megalin, very low-density lipoprotein receptor [VLDLR], and transforming growth factor β receptor type I and II [TβR1/TβR2]). In mucus samples, CLU levels are modestly, but not significantly, higher in cases with endometriosis compared to cases without endometriosis, however, CLU levels are significantly (P = .02) reduced in patients with endometriosis receiving contraception compared to cases with endometriosis without contraception. Analysis of CLU and CLU receptors showed CLU mainly in the uterine epithelial cells in the majority of glands, but also in endothelial cells. Similarly, ApoER2 and TβR1 could also be found preferentially in the endometrial glands. Whereas ApoER2 staining was strong in the vessels, TβR1 was modestly expressed in vessels and muscle cells. In contrast, staining of VLDLR and TβR2 was modest in the glands but stronger in vessels and muscle cells. Megalin staining was faint in the glands. A similar pattern for these proteins could be observed in adenomyosis. We demonstrate for the first time high concentrations of CLU in mucus samples and significantly reduced CLU levels in cases with endometriosis receiving contraception compared to cases with endometriosis without contraception. Furthermore, we identified uterine epithelial and endothelial cells as the main source of CLU and found different preferential CLU receptor complexes on glands, vessels, and smooth muscle cells., (© The Author(s) 2016.)

Background: The number of obese and morbidly obese patients within the developed world is dramatically increasing within the last 20 years. Apart from demographical changes, obese patients are especially prone to have oestrogen-dependent morbidities and neoplasias, of which laparoscopic treatment should be the standard of care. The increasing number of patients with BMI >40 is concerning, making it necessary to summarise considerations for safe and effective Gynaecological Laparoscopic Surgery., Considerations: The sequel to successful laparoscopic surgery in obese patients comprises an interdisciplinary appreciation of laparoscopy. Preoperatively, anaesthetics and medical review are suggested to optimise treatment of comorbidities (i.e. infections and blood sugar levels). Positioning of the patient should consider anti-slip options and pannus fixation to ease laparoscopic access and decrease pressure to the chest. There is no standard port placement in obese patients and landmarks have to be the bony structures of the pelvis and ribs. Retraction of the bowel is essential and mobilisation of the sigmoid with fan retractors or endoloops can accomplish adequate vision. 30° scopes can be considered for vision "around the obstacle". An experienced assistant with anticipation of surgical steps is favourable for successful surgery completion. Intra-operatively, good surgical techniques are essential. Vessel sealing systems reduce the need for instrument changes and may be helpful in following visualised tissue planes. A transvaginal vault closure may be advantageous compared to laparoscopic closure and Endostiches may be preferred to close the fascia of large trocar sites under vision.

Background: The purpose of this study was to evaluate serum HE4 as a biomarker to detect recurrent disease during follow-up of patients with endometrial adenocarcinoma (EAC)., Methods: We performed a retrospective analysis of 98 EAC patients treated at Innsbruck Medical University, between 1999 and 2009. Twenty-six patients developed recurrent disease. Median follow-up was 5 years. Serum HE4 and CA125 levels were analyzed using the ARCHITECT assay (Abbott, Wiesbaden, Germany) pre-operatively (baseline), post-operative (interval) and after histological confirmation of recurrent disease or when patients returned for clinical review with no evidence of recurrent disease (recurrence/final)). Receiver operator curves (ROC), Spearman rank correlation coefficient, chi-squared and Mann-Whitney tests were used for statistical analysis., Results: HE4 levels decreased after initial treatment (p = 0.001) and increased again at recurrence (p = 0.002). HE4 was elevated (>70 pmol/L) in 21 of 26 (81%) and CA125 was elevated (>35 U/ml) in 12 of 26 (46%) patients at recurrence. In endometrioid histology (n = 69) serum HE4 measured during follow up (Area under the curve (AUC) = 0.87, 95%CI 0.79-0.95) was a better indicator of recurrence than CA125 (AUC = 0.67, 95%CI 0.52-0.83). A HE4 level of 70 pmol/L was associated with a sensitivity of 84%, a specificity of 74% and a negative predictive value of 93% when assessing for recurrent endometrioid EAC., Conclusion: This is a preliminary description of HE4 serum levels measured during routine follow up of EAC patients. Serum HE4 measured during clinical follow-up may identify recurrent disease particularly in patients with endometrioid histology. Further prospective validation of HE4 is warranted.

Background: Natural orifice transluminal endoscopic surgery (NOTES) in urology is becoming more and more interesting due to technical innovations. One of those innovations is the HybridKnife®, a multifunctional sonde that combines high-frequency electrosurgery and water jet surgery. The aim of this study was to establish a transrectal, flexible endoscopic retroperitoneoscopy in a porcine model by means of the HybridKnife® for further development of a transrectal retroperitoneal NOTES lymphadenectomy (NOTES-RLA)., Material and Methods: Five female pigs (25-30 kg body mass) were anesthetized and placed in a supine position. The rectal mucosa was opened 3-5 cm cranially of the linea dentata. After submucosal tunneling, the retrorectal space was opened. We performed a flexible endoscopic retroperitoneoscopy by means of a double-channel gastroscope 13.806 PKS (Karl Storz-Endoskope, Tuttlingen, Germany) and the HybridKnife® I-type (ERBE Elektromedizin, Tübingen, Germany)., Results: Transrectal access was safe and feasible without any difficulties. Using the HybridKnife® water jet technology, the retroperitoneal space could be distended which enabled safe access to the iliacal vessels, the bifurcation of the aorta/vena cava, and the pre- and paraaortal/-caval space up to the renal vessels. The water jet did not lacerate or injure blood vessels, nerves, or lymph vessels in any of the surgical procedures., Conclusions: By means of the HybridKnife®, transrectal access into the retrorectal space is safe and easily feasible. The water jet technology combined with electrosurgery prevented injuries of blood vessels, nerves, and lymph vessels and enabled transrectal flexible endoscopic retroperitoneoscopy as a precondition for further establishment of a transrectal NOTES-RLA.

Objective: The objective of this study was to evaluate the safety and efficacy of SprayShield™ Adhesion Barrier in preventing and/or reducing postoperative adhesion during gynecological surgery., Design: This was a prospective, controlled, blinded, and randomized study. Patient blinding was performed intraoperatively. Subjects were randomly assigned to the SprayShield™ or the control group in a 2:1 ratio., Setting: The study was conducted at the Clinic of Gynaecology and Obstetrics, at the University Hospital for Gynecology in Germany., Patients: Fifteen patients participated in this study; nine patients were assigned to the SprayShield™ and six patients to the control group., Interventions: During first operation (FLL) in the SprayShield™ group, the agent was applied to all myomectomy suture lines. Patients in the control group did not receive any anti-adhesion treatment, only good surgical practice. A second-look laparoscopy (SLL) was performed 8-12 weeks after myomectomy to evaluate adhesion formation., Main Outcome Measures: Main outcome measures were incidence, severity, and extent of uterine adhesions., Results: No significant differences were found between the two study groups., Conclusions: SprayShield™ is easy to use. No serious adverse event related to SprayShield™ was observed. Efficacy data are inconclusive regarding the performance of SprayShield™. Further studies are needed to better understand this performance.

The present survey was conducted among gynaecological surgeons from several European countries to assess the actual knowledge and practice related to post-surgical adhesions and measures for reduction. From September 1, 2012 to February 6, 2013, gynaecological surgeons were invited to answer an 18-item online questionnaire accessible through the ESGE website. This questionnaire contained eight questions on care settings and surgical practice and ten questions on adhesion formation and adhesion reduction. Four hundred fourteen surgeons participated; 70.8 % agreed that adhesions are a source of major morbidity. About half of them declared that adhesions represented an important part of their daily medical and surgical work. About two thirds informed their patients about the risk of adhesion. Most cited causes of adhesions were abdominal infections and extensive tissue trauma, and endometriosis and myomectomy surgery. Fewer surgeons expected adhesion formation after laparoscopy (18.9 %) than after laparotomy (40.8 %); 60 % knew the surgical techniques recommended to reduce adhesions; only 44.3 % used adhesion-reduction agents on a regular basis. This survey gives a broad picture of adhesion awareness amongst European gynaecological surgeons, mainly from Germany and the UK. The participants had a good knowledge of factors causing adhesions. Knowledge of surgical techniques recommended and use of anti-adhesion agents developed to reduce adhesions need to be improved.

Objective: HE4 has emerged as a promising biomarker in gynaecological oncology. The purpose of this study was to evaluate serum HE4 as a biomarker for high-risk phenotypes in a population-based endometrial cancer cohort., Methods: Peri-operative serum HE4 and CA125 were measured in 373 patients identified from the prospective Australian National Endometrial Cancer Study (ANECS). HE4 and CA125 were quantified on the ARCHITECT instrument in a clinically accredited laboratory. Receiver operator curves (ROC), Spearman rank correlation coefficient, and chi-squared and Mann-Whitney tests were used for statistical analysis. Survival analysis was performed using Kaplan-Meier and Cox multivariate regression analyses., Results: Median CA125 and HE4 levels were higher in stage III and IV tumours (p<0.001) and in tumours with outer-half myometrial invasion (p<0.001). ROC analysis demonstrated that HE4 (area under the curve (AUC)=0.76) was a better predictor of outer-half myometrial invasion than CA125 (AUC=0.65), particularly in patients with low-grade endometrioid tumours (AUC 0.77 vs 0.64 for CA125). Cox multivariate analysis demonstrated that elevated HE4 was an independent predictor of recurrence-free survival (HR=2.40, 95% CI 1.19-4.83, p=0.014) after adjusting for stage and grade of disease, particularly in the endometrioid subtype (HR=2.86, 95% CI 1.25-6.51, p=0.012)., Conclusion: These findings demonstrate the utility of serum HE4 as a prognostic biomarker in endometrial cancer in a large, population-based study. In particular they highlight the utility of HE4 for pre-operative risk stratification to identify high-risk patients within low-grade endometrioid endometrial cancer patients who might benefit from lymphadenectomy., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: We analysed the prevalence of the most common hereditary thrombophilia (hTP) - factor V Leiden (FVL) mutation, prothrombin 20210 G>A substitution (PT) - and the 677 C>T replacement in the 5,10-methylenetetrahydrofolate reductase (MTHFR) gene in Caucasian patients with a history of two and more consecutive recurrent miscarriages (RMs) as compared to healthy controls with an identical ethnic background and at least one live birth., Methods: A multicenter analysis of three hTP was performed in 641 RM patients identically screened at specialized university centres., Results: The study groups consisted of 240 patients with 2 (1) and 401 patients with >2 miscarriages (2) and were compared with 157 controls. There was no significant difference in the prevalence of the hTP between RM patients and controls nor within the two study groups. Subgroup analysis showed that the homozygous MTHFR polymorphism was significantly more prevalent in the study group 2 as compared to study group 1 (13.9 versus 7.9%, P = 0.02)., Conclusion: In Caucasians, maternal FVL or PT mutations do not seem to contribute to the pathophysiology of RM, irrespective of the number of miscarriages. However, the role of the homozygous MTHFR polymorphism merits further investigation., (© 2013 John Wiley & Sons Ltd.)

Objective: Abdominopelvic infiltrative disease may require aggressive surgical procedures. This study reports on our experience with distal ureterectomy, ureteroureterostomy, and extravesical ureteroneocystostomy as part of radical surgery for infiltrating gynecologic disease., Patients and Methods: Twenty-one women required surgery to the distal ureter at the Queensland Centre for Gynecological Cancer, Australia, from January 2006 to September 2012. Details of the patient's history, operation record, inpatient notes, and follow-up data were obtained through chart review., Results: Patients' median age was 57.8 ± 14.7 years (range, 30-80 years). Seventeen patients had gynecologic cancer. Mean operating time was 3.9 ± 0.9 hours (range, 2.5-5.5 hours). Restoration of continuity was achieved through extravesical ureteroneocystostomy and ureteroureterostomy in 18 and 3 patients, respectively. Boari flap was used in 3 patients, and psoas hitch was the technique chosen in 11 patients. Urinary tract infection was the most common clinical adverse event. Albeit clinically irrelevant, 38% of the patients showed structural renal tract changes postoperatively., Conclusions: To achieve maximal surgical radicalness, resection of the distal ureter with subsequent ureteroureterostomy or extravesical ureteroneocystostomy is feasible and safe. Radical surgery to the urinary tract should be considered as a legitimate part of a gynecologic oncologist's surgical armamentarium to increase a patient's probability of survival and its positive effect on kidney function.

Objective: Evaluating the presence of possible malignant disease in women with ovarian masses relies on medical imaging and serum marker findings. This study considers the role of serum Human Epididymal Protein 4 (HE4) antigen in combination with other serum markers to more effectively estimate the risk of malignancy in patients with isolated pelvic masses., Methods: We used prospectively collected biospecimens held by the Australian Ovarian Cancer Study (AOCS). Serum samples of patients with FIGO stage 1 epithelial ovarian cancer or with a benign condition were analysed for levels of circulating HE4 antigen, CA 125, and CEA, and test results were used to predict the presence of malignancy and to differentiate benign from malignant pelvic masses., Results: HE4 levels were significantly elevated amongst postmenopausal women and amongst patients with malignancy compared to premenopausal women and those with benign disease (p<0.001 for both). The combination of CA125 and age, achieved an area under the ROC curve of 0.677 (95% CI: 0.584 to 0.770, p=0.778), whilst HE4+CA125+CEA in combination with patient's age showed significantly higher AUC of 0.797 (95% CI: 0.721 to 0.874, p=0.0052). By adjusting the ROMA cut-off values the percentage of correctly classified premenopausal patients into low and high risk groups increased from 36.99% to 69.86%., Conclusions: In patients with isolated pelvic masses, the combination of HE4, CA 125 and age with or without CEA provides higher diagnostic value compared to CA125 and age alone. It may therefore be considered for continuous evaluation in patients with adnexal masses., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Introduction: Postpartum haemorrhage (PPH) remains to be the most common cause of maternal mortality and is responsible for 25 % of the maternal deaths worldwide. Although the absolute risk of maternal death is much lower, a recent increase of PPH and related maternal adverse outcomes has been noted in high-income countries as well. Generally, PPH requires early recognition of its cause, immediate control of the bleeding source by medical, mechanical, invasive-non-surgical and surgical procedures, rapid stabilization of the mother's condition, and a multidisciplinary approach. Second-line treatment of PPH remains challenging, since there is a lack of univocal recommendations from current guidelines and sufficient data from randomized controlled trials., Materials: For this review, electronic searches were performed in PubMed, Embase, and the Cochrane Central Register of Controlled Trials using the keywords "postpartum haemorrhage" in combination with 'uterine tamponade' and, especially with 'arterial embolisation', 'uterine compression sutures', and 'post(peri)partum hysterectomy' (from January 2000 to November 2011). Reference lists of identified articles were searched and article references to the keywords selected., Results: Treatment options such as uterine compression sutures, embolisation, arterial ligation and hysterectomy were evaluated with regard to their prerequisites, benefits, drawbacks and respective success rate. In addition, a treatment algorithm for the second-line treatment of PPH is presented.

Objective: To evaluate the effects of different suture materials and techniques on soft tissue in relation to defined tensions and time points., Materials and Methods: Two bovine intestine samples, 4 × 4 cm size and ~3 mm thickness, were adapted with interrupted and continuous techniques using three types of suture materials: Vicryl (polyglactin 910), PDS II (polydioxanone), and V-Loc 180 (knotless, barbed polyglyconate). Four stitches or loops 9 mm apart with three knots, and 10 mm end length were performed by one gynecologist. Forces were applied from 6 newtons (N) to 14 N continuously. Outcome measures included breakage of tissue, tearing of thread, and shortening of the end length of thread. They were evaluated immediately and then at first, third, and fifth minute., Results: Tissue breakage using No. 3/0 suture materials appears in the applied force from 10 N. polydioxanone causes more tissue tearing than polyglactin 910. The least to withstand tension is knotless polyglyconate. Interrupted stitches hold the sutured sites better than continuous stitches in all groups of threads. Shortening of the knotless polyglyconate end length by half took place with 6 N force., Conclusion: Simulating reparation of colpotomy, the ex vivo study supports that polyglactin 910 appears better in holding soft tissue than polydioxanone and knotless polyglyconate.

Objectives: Obesity is associated with the incidence of endometrial cancer. At present it is unclear whether it is also associated with cancer recurrence. This analysis evaluated the consequences of weight changes after diagnosis of endometrial cancer during the follow-up., Methods: Records of patients with endometrial cancer (n = 705) were reviewed for body weight after the diagnosis of cancer during the follow-up and related to recurrence-free survival., Results: About two-thirds of all endometrial patients gained more or less weight after the diagnosis of endometrial cancer. Patients with moderate weight gain (≤ 1 kg/m(2)) 6 months after the diagnosis had the best prognosis, followed by patients with greater weight gain (>1 kg/m(2)) and those with moderate weight loss (≤ 1 kg/m(2)). The fact that weight loss was associated with poor prognosis also persisted when the analysis was restricted to recurrences which occurred more than 18 months later., Conclusions: Weight loss after the diagnosis and treatment of cancer may be an adverse prognostic factor. Although it was impossible to distinguish between intentional and non-intentional weight loss, these results argue against weight loss for risk reduction in patients with confirmed endometrial cancer. However, it may be reasonable regarding the risk reduction of non-cancer related morbidity and mortality. Detailed, prospective randomised trials are warranted.

Background: Adhesions lead to considerable patient morbidity and are a mounting burden on surgeons and the health care system alike. Although adhesion formation is the most frequent complication in abdominal and pelvic surgery, many surgeons are still not aware of the extent of the problem. To provide the best care for their patients, surgeons should consistently inform themselves of anti-adhesion strategies and include these methods in their daily routine., Methods: Searches were conducted in PubMed and The Cochrane Library to identify relevant literature., Findings: Various complications are associated with adhesion formation, including small bowel obstruction, infertility and chronic pelvic pain. Increasingly, an understanding of adhesion formation as a complex process influenced by many different factors has led to various conceivable anti-adhesion strategies. At present, a number of different anti-adhesion agents are available. Although some agents have proved effective in reducing adhesion formation in randomised controlled trials, none of them can completely prevent adhesion formation., Conclusion: To fulfil our duty to provide best possible care for our patients, it is now time to regard adhesions as the most common complication in surgery. Further research is needed to fully understand adhesion formation and to develop new strategies for adhesion prevention. Large clinical efficacy trials of anti-adhesion agents will make it easier for surgeons to decide which agent to use in daily routine.

Background: Over the past decades, our knowledge and understanding of adhesions and adhesion-related complications has increasingly grown and it has become evident that adhesions have significant implications for patients, physicians and the healthcare system. The question arises whether this has resulted in greater awareness of adhesion-related problems among practicing physicians and appropriate patient education on this topic in daily practice. The following article provides a brief overview of the important subject of adhesions, discusses current awareness of adhesions among patients and doctors and addresses the consequences of failure to provide patient education and consent from a medical perspective. Methods: Selective literature searches were conducted in PubMed and the Cochrane Library. A patient information and consent form was developed based on several years' experience and expertise in the field of adhesions. Results: Adhesions are the most common type of complication in abdominopelvic surgery today, with devastating consequences for some patients. Surveys investigating the awareness of adhesions among physicians and patients clearly showed that even well-informed physicians fail to educate their patients adequately. Such failure could potentially lead to successful medical malpractice lawsuits against doctors. Conclusion: Considering their clear clinical impact, adhesions and related consequences should always be discussed with patients preoperatively. A newly developed consent form that specifically addresses adhesion formation may serve to thoroughly educate patients preoperatively and to adequately document the process of doing so.

Although myomectomy is widely accepted in women of childbearing age who wish to retain their fertility, the extent to which myomas affect fertility and whether their removal improves this remain unclear. This study aimed to elucidate the favourable surgical approach in women with uterine myomas and infertility. This retrospective, follow-up study was carried out in three centres in Germany. Data on women who had undergone myomectomy via laparoscopy, laparotomy or conversion to laparotomy in 2000-04 were collected and analysed. Fertility outcome after myomectomy was assessed by follow-up postal questionnaire in a subgroup of women with myoma-associated infertility. Data on 159 women with otherwise unexplained infertility were included (mean age 35 years (range 17-47), mean number of myomas 2.4 (range 1-8) and mean myoma size 6.1 cm (range 0.5-20)). Women who underwent laparoscopy had fewer complications. 39.6% (63/159) of women completed the questionnaire, which showed that the pregnancy rate after myomectomy was 46% in this group. No uterine rupture occurred. Laparoscopy is associated with fewer postoperative complications and since no preoperative or intraoperative factors seem to influence the fertility outcome in women with uterine myomas, it is the treatment of choice in these patients.

Purpose: Ovarian small cell carcinoma of the hypercalcaemic type is a very rare and highly aggressive malignant disease, mainly affecting young women. Due to the rarity of this tumour entity, prospective randomised trials are unlikely to be conducted, and the only retrospective analysis based on a large case series is from 1994. Since diagnostic and treatment modalities may have changed, we initiated this analysis., Methods: The aim of our study was to review and analyse cases published since 1975 to validate former findings and to gather more information about therapy options, diagnostic and prognostic factors. A systematic literature search of the PubMed/Medline database was performed assessing all articles until September 2010. All retrieved articles were evaluated and cross-checked for references on the topic. In total, 135 cases were included, selected from 62 case reports and smaller case studies., Results: Small cell carcinoma mostly affects women with a mean age of 23.4 years. They present with unspecific symptoms like abdominal pain or palpable mass, sometimes accompanied by an elevated calcium or CA-125 serum concentration. The tumour appears nearly almost unilaterally, mostly affecting the right ovary. Tumour stage is a clearly prognostic factor. Adjuvant chemotherapy consisting of etoposide, cisplatinum/carboplatinum or vinca alkaloids has shown improved survival, whereas radiotherapy has not., Conclusions: In spite of limitations this analysis provides new insights especially with respect to therapeutic aspects. This review underlines the importance of case reports in rare tumour entities in order to answer open questions.

Purpose: To determine whether a structured questionnaire can improve preoperative assessment of patients with endometriosis., Methods: Hospital records for patients with endometriosis were evaluated retrospectively to determine the completeness of information. A structured electronic questionnaire was developed and used to assess preoperatively patients with suspected or proved endometriosis. Data from both assessments were compared., Results: Data analysed retrospectively showed that there were valid answers for 89.2% of questions on a standard patient history template, but information was available for only 46.3% of parameters considered specific to endometriosis. Data from 69 patients investigated by structured electronic questionnaire gave improved rates of 90.3% for standard patient history items and 88.5% for endometriosis-specific parameters. Significant improvement in valid answers was achieved in 66.7%., Conclusions: A structured questionnaire improved the documentation of endometriosis-specific parameters. Further studies are needed to ensure that it enhances the effectiveness of preoperative counselling and decisions about surgery.

Background: This pilot study aimed to evaluate the optical performance and clinical handling of a new variable-view rigid endoscope with angulation from 0 º to 120 º in gynecologic laparoscopic surgery., Methods: The EndoCAMeleon endoscope was assessed by experienced surgeons and assistants during a variety of advanced gynecologic laparoscopic procedures. After each procedure, both the surgeon and the assistant each completed questionnaires designed to assess the endoscope's ease of handling and optical performance., Results: The endoscope was assessed during 21 advanced procedures. Questionnaire responses confirmed surgeon and assistant satisfaction with the mechanical handling and vision provided by the endoscope. In particular, the ability to vary the viewing angles enabled the surgeon to visualize the surgical site without moving the endoscope shaft., Conclusions: The new endoscope performed well in the hands of experienced surgeons and assistants undertaking advanced procedures. The variable-view rigid endoscope allows the use of visual ports during primary port entry and enhances vision. Further study is required to evaluate its performance in routine practice.

Aim: The impact of postsurgical intra-abdominal adhesions, which represent a considerable burden for patients and health services, is often underestimated. Various factors influence adhesion formation, including the surgical approach. This study aimed to further understand the condition by investigating surgeons' perceptions of adhesion formation, particularly differences after laparoscopic and open surgery, and by performing a selective literature review., Materials and Methods: South Asian surgeons attending endoscopy symposia in India and in Germany completed Likert-scale-based questionnaires on awareness of adhesion formation and associated consequences in gynecology. MEDLINE and PubMed were searched for articles published in 2000-2010 comparing laparoscopy and laparotomy in relation to adhesion formation. The results of the questionnaire study were then considered in view of findings from this review., Results: In total, 43.1% (97/225) of questionnaires were completed. Respondents considered that laparoscopy caused fewer adhesions than laparotomy for all gynecological procedures. Although they believed their knowledge of adhesion formation was satisfactory, they widely underestimated the risk, giving estimated rates of 12.5% after laparoscopy and 36.3% after laparotomy. Twenty-eight studies were identified in the review. Most concluded that laparoscopy was less likely to cause adhesions than laparotomy but further statistical analysis was precluded because so many different definitions and classifications of adhesions had been used., Conclusions: The risk of adhesion formation was widely underestimated in the study group. Both the questionnaire study and the review concluded that laparoscopy results in less adhesion than laparotomy but further statistical comparison necessitates the development of standard definitions and classifications of adhesions., (© 2011 The Authors. Journal of Obstetrics and Gynaecology Research © 2011 Japan Society of Obstetrics and Gynecology.)

Objectives: This study was done to analyze the frequency of use of acupuncture and other complementary and alternative medicine (CAM) methods during labor and to investigate the different characteristics of women being treated with or without acupuncture and CAM methods, as well as try to analyze birth-related outcome measures., Study Design: Data were analyzed from 409,413 deliveries, registered between 2001 and 2008 by the agency for quality assurance in Hesse (the Hessian Perinatal Registry [HEPE] survey), which made up more than 95% of all deliveries in this German state during the given time period., Results: Interest in the use of CAM seems to have decreased within the given time period. On average, acupuncture was used in 3.7% (15,345/409,295) of all deliveries and other CAM methods in 4.8% (19,507/409,295). The most important determinant for the use of one or both methods was the type of hospital. It was also found that German women with higher job qualifications were more likely to receive CAM treatment during delivery. Interestingly, application of CAM methods was associated with a higher use of analgesics during labor. The risk status of the pregnancy or the delivery was of minor importance., Conclusions: This analysis shows that the determinants of CAM use are similar to those in the field of oncology. In order to assess the efficacy of acupuncture or other CAM methods in the field of obstetrics, it seems necessary to extend the HEPE survey to cover these areas.

Although it has been agreed that complementary and alternative medicine (CAM) should be included in the German medical curriculum, there is no consensus on which methods and how it should be taught. This study aimed to assess needs for CAM education by evaluating current knowledge, attitudes and interests of medical students, general physicians and gynecologists. Two instruments based on established and validated questionnaires were developed. One was given to seventh semester medical students and the other to office-based doctors. Data were analyzed by bivariate correlation and cross-tabulation. Altogether 550 questionnaires were distributed-280 to doctors and 270 to medical students. Completed questionnaires were returned by 80.4% of students and 78.2% of doctors. Although 73.8% (160/219) of doctors and 40% (87/217) of students had already informed themselves about CAM, neither group felt that they knew much about CAM. Doctors believed that CAM was most useful in general medicine, supportive oncology, pediatrics, dermatology and gynecology, while students believed that dermatology, general medicine, psychiatry and rheumatology offered opportunities; both recommended that CAM should be taught in these areas. Both groups believed that CAM should be included in medical education; however, they believed that CAM needed more investigation and should be taught "critically". German doctors and students would like to be better informed about CAM. An approach which teaches fundamental competences to students, chooses specific content based on evidence, demographics and medical conditions and provides students with the skills they need for future learning should be adopted.

Purpose: To evaluate semi-rigid and rigid endoscopes for transvaginal NOTES surgery., Methods: One rigid endoscope (EndoCAMeleon, KARL STORZ GmbH & Co. KG, Tuttlingen Germany) and one semi-rigid endoscope (EndoEYE LTF-VH, Olympus Deutschland GmbH, Hamburg, Germany) that allow adjustable viewing angles have been used during four transvaginal gynecological NOTES procedures for chronic pelvic pain and infertility., Results: Feasibility of transvaginal access to enter the abdominal cavity was shown. Posterior peritoneum, ovaries and tubal patency were evaluated. The evaluated endoscopes did not overcome the inability to explore the anterior pelvic structures., Conclusions: Rigid and semi-rigid endoscopes that allow adjustable viewing angles during transvaginal NOTES approaches cannot explore the whole pelvic anatomical structures.

Objective: To assess the advantages of a surgeon-controlled robotic endoscope holder in gynecologic minimally invasive solo-surgery as compared with conventional assistance with a second surgeon., Methods: One hundred gynecologic laparoscopies were consecutively allocated to surgery with either a robot as the surgical assistant or a conventional assistant surgeon. Total operation time, image stability, and frequency of corrective maneuvers of the camera, in addition to the surgeon's satisfaction regarding the ergonomics of the intervention, were recorded. All interventions were performed by the same surgeon. All laparoscopic surgery was classified as either easy or advanced surgery., Results: The image stability score was significantly higher (10 vs 7; P<0.001) and fewer corrective maneuvers of the robotic endoscope were necessary (1 vs 5; P<0.001) with the robotic laparoscope holder; in addition, the surgeon recorded a significantly higher satisfaction score for the ergonomics of the semi-active robot (10 vs 7; P<0.001)., Conclusion: The robot does not prolong total operation time and increases the surgeon's comfort by improving image stability and laparoscope handling. It could provide major benefit, especially in complex gynecologic laparoscopic surgery., (Copyright © 2010 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.)

Acute haemoperitoneum in patients with coagulation disorders or those under anticoagulation therapy is a diagnostic and therapeutic dilemma. Since radiological imaging is often insufficient for establishing the origin of the bleeding, a laparoscopic approach can be considered before a laparotomy is performed in haemodynamically unstable patients. A 32-year-old woman receiving coumadin therapy presented with acute lower abdominal complaints. Due to suspicion of a tubo-ovarian abscess after the initial ultrasound, a conservative treatment was administered. A routine blood count after 12 hours showed a significant reduction in haemoglobin. During the CT scan, the patient developed unstable haemodynamics. Based on deteriorating coagulation parameters, mass transfusion and stabilization of the coagulation were performed but were not successful. Therefore an interventional laparoscopy was performed and a ruptured ovarian cyst was found to be the cause of bleeding. A ruptured ovarian cyst might be the cause of an acute abdomen and haemoperitoneum in young women. Therefore cyclus anamnesis and the exclusion of other obvious reasons for acute mass bleeding, i.e. ectopic pregnancy, can justify the laparoscopic approach after stabilization of the coagulation parameters. Long-term combined oral contraceptive therapy is indispensable for the prevention of these sorts of bleeding complications.

Background: Intra-abdominal adhesions arise after more than 50% of all abdominal operations and are an important source of postoperative complications. They attach normally separated organs to each other and can cause major problems for the affected patients by giving rise to small bowel obstruction, chronic pelvic pain, dyspareunia, infertility, and higher complication rates in subsequent operations. They are also a frequent source of medicolegal conflict. Thus, every physician should be familiar with their mechanism of origin, their consequences, and the methods by which they can be prevented., Methods: A selective PubMed/Medline search from 1960 onward as well as articles to which these publications referred. The expert consensus position of the European Society for Gynaecological Surgery is also taken into consideration., Results: Adhesions arise through aberrant wound healing after peritoneal injury with further influence from a variety of other factors. Preventive measures include minimizing peritoneal injury intraoperatively through the meticulous observance of basic surgical principles, moistening the mesothelium to keep it from drying out, irrigating the peritoneal cavity to remove blood and clot, and keeping the use of intra-abdominal foreign material to a minimum., Conclusion: Adhesions are an inevitable consequence of intra-abdominal surgery. They can be prevented to some extent with meticulous surgical technique and certain other measures. For operations carrying a high risk of postoperative adhesions, e.g., surgery on the adnexa or bowel, commercially available peritoneal instillates or barrier methods can be used to limit adhesion formation.

Gynecologists have been performing transvaginal surgery for over a century and consequently the transvaginal approach was advocated for establishing natural orifice transluminal endoscopic surgery (NOTES) in gynecological and surgical practice. From 2008 the NOTES alternative has been offered to selected patients. Transvaginal cholecystectomies were intended in 13 patients and completed in 12. Various additional procedures were performed. All surgical procedures and postoperative courses were uneventful. The mean operating time for transvaginal cholecystectomy only was 88.4 minutes (standard deviation [SD] 17.3). A questionnaire was posted to the patients after a mean follow-up of 8.5 months. Patients primarily chose transvaginal NOTES because of the lack of scarring. Vaginal sensation was not affected. Patients perceived transgastric, transvesical, and transrectal surgery to be less acceptable approaches. The feasibility of transvaginal NOTES was proven for different indications. Patients' experiences and perceptions concerning transvaginal NOTES were excellent., (© Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: Granulocyte colony-stimulating factor (G-CSF) producing tumours were found associated with poor prognosis. Unfortunately, this finding is based on several case reports only. Thus, we investigated the expression of G-CSF in the tumour cells and the tumour stroma in a large collective of patients with ovarian cancer with long-term follow-up., Methods: Tissue and clinical records of 175 patients with histologically confirmed ovarian carcinoma were analysed for G-CSF expression in tumour cells and the surrounding stroma. The results were compared with peripheral blood counts and other prognostic factors in ovarian cancer., Results: No correlations were found between both G-CSF expression in tumour cells and the surrounding stroma and prognosis as well as peripheral blood counts. We only found a positive influence of granulocytes in the tumour stroma on prognosis, which however, was not significant in multifactorial analyses., Conclusions: In contrast to the many case reports from other entities, G-CSF expression in tumour cells and the surrounding stroma is not an adverse prognostic factor. To find out the safety of G-CSF administration for the prevention or treatment of febrile neutropenia, it is suggested for clinical trials to include long-term follow-up and immunohistochemical characterisation of the tumour.

Objective: Intra-abdominal adhesion formation after abdominal surgery is the most common postsurgical complication, and the consequences are a considerable burden for patients, surgeons and health systems. Since a wide variety of factors influence adhesion formation, it is difficult to define clear guidelines on how to reduce adhesion formation in daily practice. Given this dilemma, this study assessed the awareness and perception of adhesion formation among gynaecologists in Germany in order to define a baseline for further research and education., Study Design: The Clinical Adhesion Research and Evaluation (CARE) group of the University of Giessen designed a questionnaire that was sent to the heads of all gynaecological departments in Germany. The director or one of the surgical consultants was asked to complete the questionnaire and return it for evaluation., Results: The completed questionnaire was returned by 279 of 833 gynaecological departments. Interviewed surgeons expected adhesions to form in 15% of cases after laparoscopy and 40% after laparotomy. Before surgery, 83.1% of the respondents told their patients about the risk of prior adhesion formation. More than 60% believed that postsurgical adhesion accounts for major morbidity. Infections within the abdomen, previous surgery and extensive tissue trauma were thought to have the most influence on adhesion formation. Risk of adhesion formation was thought to be highest in endometriosis and adhesiolysis surgery. The respondents agreed on performing adhesiolysis in symptomatic but not in all patients. Only 38.4% used adhesion reduction agents regularly. A total of 65.1% of a repertoire of adhesion prevention agents were familiar to the interviewed surgeons. Only 22.0% of them used anti-adhesion products in clinical practice. In general, the respondents were uncertain whether these products play an important role in adhesion reduction, represented by a range of 1.97+/-0.98% on a scale from 0 to 4., Conclusions: Even though postoperative adhesions are recognized as a major cause for morbidity, and it is widely agreed that infections, extensive tissue trauma and surgery lead to adhesion formation, there is uncertainty about the treatment and prophylactic strategies for dealing with adhesions. This dilemma reflects the awareness and perception of gynaecologists in Germany and is an initial point for further research., (Copyright 2010 Elsevier Ireland Ltd. All rights reserved.)

Introduction: The positioning-related compartment syndrome of the lower leg after long-duration operations in the lithotomy position -represents a rare complication. The aim of this retrospective study was to draft recommendations to avoid this rare complication by reviewing the cases with positioning-related compartment syndromes in our own patient data. PATIENTS / MATERIAL AND METHODS: From January 1996 to February 2009, 3 women and 1 man with an average age of 38 years (24 to 55 years) were treated with a medial and lateral dermatofasciotomy with opening of lower leg loges due to a clinically manifested compartment syndrome of the -lower leg after long-duration operations in the -lithotomy position., Results: In all 4 patients a dermatofasciotomy with opening of the lower leg compartments could -avoid considerable secondary damage of the limb. A long-duration lithotomy position in connection with obesity, a low positioning of the head as well as nicotine abuse are only some of the risk factors contributing to the development of a positioning-related compartment syndrome. An epidural anaesthesia bears the risk of a protracted diagnosis., Conclusion: The positioning-related compartment syndrome represents a rare but considerable complication after long-duration operations in the -lithotomy position. It is a clinical complication and the inducing and exponentiation risk factors as well as the clinical symptoms should be known by the treating team. If the operation time is expected to be longer than 3 hours, we recommend written information to the patient concerning this complication. Consequent postoperative controls of risk patients are obligatory. An epidural anaesthesia bears the risk of a protracted diagnosis. In the case of suspected compartment syndrome we recommend early dermatofasciotomy in order to avoid -irreversible damage to the limb.

To perform hysterectomy in uterus myomatosus, there are several surgical techniques. For a uterine weight of >1000 g, after a caesarean section and in nullipara per vaginam, the most common surgical technique for hysterectomy in patients is hysterectomy per laparotomiam. A new endoscopical technique developed to treat such patients and to avoid laparotomy is described in this case report: the laparoscopic combined hysterectomy (LACH) using the change-over technique. Adhesiolysis, preparation of the ureters and the bladder and morcellation of the uterus of 2480 g were performed minimally-invasive in two steps, from one side of the patient with a change-over of the OP-team to the other side of the patient. The cervix was removed per vaginam.

Endometriosis affects 6-10% of women in reproductive age, 35-50% of whom experience pain, infertility or both. Mild cases are managed medically but surgery provides relief to women in pain. However, symptoms recur in 75% of cases within 2 years. We investigated the impact of endometriosis on quality of life among 65 women aged 18-60 years working at a city supermarket in Giessen, Germany. Of the 65 women, 12 had undergone surgeries, 22 had dysmenorrhoea, 24 dyspareunia and 3 were infertile. Of the 22 women with dysmenorrhoea, 10 had difficulties performing gardening, housework, sports and leisure activities. Five of these 10 women experienced social isolation, 6 professional setbacks; 6 declined efficiency at work and 3 had taken time off work. Of the 24 women with dyspareunia, 7 experienced minimal, 12 light and 5 moderate to strong pain. Only 16 of these 24 women discussed the problem with their partners. This study demonstrates that pain is a major cause of physical, psycho-social, emotional and professional or work related impairment among women with endometriosis. Because endometriosis is likely to impose emotional and financial burdens, we suggest that future studies should be extended to include interviews with family members.

Small studies have suggested that honey benefits patients with high cholesterol concentrations. The present study aimed to confirm this finding in a larger group of subjects. Sixty volunteers with high cholesterol, stratified according to gender and hydroxymethylglutaryl-coenzyme A reductase inhibitor (statin) treatment (yes/no), were randomized to receive 75 g of honey solution or a honey-comparable sugar solution once daily over a period of 14 days. Baseline measurements, including body mass index (BMI) and lipid profile, were obtained, and subjects also completed dietary questionnaires and the Inventory for the Assessment of Negative Bodily Affect-Trait form (INKA-h) questionnaire. Measurements were repeated 2 weeks later. BMI and high-density lipoprotein (HDL) cholesterol values were significantly correlated (r = -0.487; P < .001) as were BMI and a lower ratio of low-density lipoprotein (LDL) cholesterol to HDL cholesterol (r = 0.420; P < .001), meaning that subjects with a high BMI had a lower HDL cholesterol value. INKA-h scores and LDL cholesterol values were also significantly correlated (r = 0.273, P = .042). Neither solution influenced significantly cholesterol or triglyceride values in the total group; in women, however, the LDL cholesterol value increased in the sugar solution subgroup but not in the women taking honey. Although ingesting honey did not reduce LDL cholesterol values in general, women may benefit from substituting honey for sugar in their diet. Reducing the BMI lowers the LDL cholesterol value, and psychological interventions also seem important and merit further investigation.

Uterine atony accounts for the majority of primary postpartum hemorrhage. Timely recognition and intervention are fundamental in preventing serious maternal morbidity and mortality. Combinations of conservative manual and medical therapies are adequate and successful treatment options in most cases. However, when the hemorrhagic process continues and when either clotting abnormalities or hemodynamic instability develop, the next step must be an invasive intervention. Depending on the mode of delivery a vaginal approach (i.e. curettage and uterine packing) after spontaneous delivery or an abdominal surgical approach (i.e. compression sutures and systematic devascularization) after a Cesarean delivery can be performed. Uterine compression sutures are especially highly effective and a straightforward and easy emergency procedure which conserves fertility. The ultima ratio in all cases of persistent haemorrhage after conservative and uterus preserving surgical therapy is the emergent hysterectomy. It might be of advantage to perform a subtotal or supracervical hysterectomy compared to a total hysterectomy in an emergency setting.

Objective: To identify and evaluate surgical management of women with uterine fibroids., Design: Retrospective analysis of mandatory surgical data sent to the Institute for Quality Assurance., Setting: Data collection from 1998 to 2004 in Hesse, Germany., Patient(s): 34,814 women who underwent surgery for uterine fibroids., Intervention(s): Patients were treated with either myomectomy or hysterectomy., Main Outcome Measure(s): Statistical analysis of mandatory surgical parameters., Result(s): Altogether, 4975 (14.3%) women had myomectomies, and 29,839 (85.7%) had hysterectomies. Age was an important determinant of surgical procedure; hysterectomy was preferred for patients over 40 (odds ratio 4.3; 95% confidence interval: 4.1-4.5). Laparoscopic myomectomy rates increased from 25.9% in 1998 to 41.9% in 2004; during the same period, the proportion of conversion procedures and abdominal approaches fell from 15.6% to 2.9% and 38.9% to 30.9%, respectively. Intraoperative complication rates were similar for myomectomy (1.1%) and hysterectomy (1.0%), but postoperative complication rates were higher for hysterectomy (5.8%) than myomectomy (3.2%)., Conclusion(s): The increasing use of endoscopic procedures was an important feature in this series and appeared to be safe. The reduction of conversion rates and intraoperative complications might be related to improvements in surgical skill. Acceptance of the benefits of endoscopic approaches seems to have promoted its steady growth as a primary surgical approach.

SUMMARY: BACKGROUND: In the case of breast cancer, removal of the breast can not always be avoided. The use of external prostheses, however, can lead to discomfort for the patients through shoulder pain and muscle hardening. It can be assumed that this is caused by strain on the shoulder due to the weight of the prosthesis. This study was to identify the possibilities to objectively assess patients' complaints associated with this type of supportive treatment. SUBJECTS AND METHODS: In this pilot study, varying types and sizes of prostheses were tested on male subjects, quasi as if they were women amputated on both sides. The strain caused by the prostheses and distributed via the straps of the brassiere were measured by electronic pressure sensors and statistically evaluated. RESULTS: Weight-reduced prostheses significantly decreased the resulting average pressure amplitude (p < 0.01) compared to normal weight prostheses. Furthermore, heavy contact prostheses, which are attached to the chest wall, have a significant advantage (p < 0.01) compared to normal prostheses of the same size. Moreover, evidence was found that contact prostheses have advantages with respect to pressure on the shoulder during physical exercise, e.g. running. CONCLUSION: Currently, weight-reduced contact prostheses present optimal treatment after breast amputation.

Introduction: Bilateral mucinous cystadenoma of the ovary are extremely rare. These tumors are benign and might lead to abdominal distension, if no secondary symptoms occur and patient delay the consultation of physicians., Case: A 60-year-old patient was admitted to the internal medicine department for constipation and dyspnoea. Transabdominal punctions were performed because of suspected ascites. Finally the patient was transferred to the gynecological department after forced diuresis did not reduce the suspected ascites and a CT scan showed large intraabdominal masses. Tumor excision was initiated and final histology revealed bilateral mucinous cystadenoma of the ovaries., Discussion: Huge intraabdominal tumors that almost double a patient's body weight can hardly be malign. Total tumor excision is necessary because the heterogeneous composition requires careful examination by pathologists to rule out borderline tumors and non-invasive carcinomas. After tumor excision an abdominal wall reconstruction might be necessary because of the laxity and redundancy of the skin.

Up to a quarter of ovarian masses originate from germ cells, and many of these are mature cystic teratomas. The secondary development of malignancy is a rare but well-known phenomenon in patients with ovarian teratomas. Squamous-cell carcinoma accounts for 80% of secondary malignant transformations of ovarian teratomas. We aimed to do an up-to-date systematic review of this rare malignant transformation. 64 suitable studies provided information on 277 patients. Squamous-cell carcinoma in mature cystic teratoma was mainly found in women aged more than 50 years, with high concentrations of squamous-cell-carcinoma antigen and cancer antigen CA125, and with ovarian tumours more than 100 mm in size. Patients with FIGO stage Ia tumours had better survival than those with more advanced disease. Complete resection together with hysterectomy, bilateral salpingo-oophorectomy and lymphadenectomy for patients with advanced disease, followed by adjuvant chemotherapy with an alkylating drug was associated with higher survival, radiotherapy was not. We make proposals for investigation and treatment of this rare disorder.

Objective: To evaluate the effect of obesity on the presentation and course of disease in patients with gynecological cancers., Study Design: Records of patients with endometrial (n = 1180), cervical (n = 738), and ovarian cancer (n = 824) treated between 1986 and 2005 were reviewed. Body mass index (BMI) was analyzed in relation to tumor stage, tumor grading, and prognosis. Steroid hormone receptor status and growth fraction (MIB1; Ki-67-antigen) of tumors in relation to BMI were analyzed in subgroups with endometrial (n = 183) and advanced ovarian (n = 221) cancers. In the latter subgroup, tumor vascularization (CD31) and expression of bcl-2, c-erb-B2, fibronectin, and tumor markers (CA-125, CA15-3, CEA) were also evaluated. Statistical analyses included bivariate correlation, cross-tabulation, Kaplan-Meier-survival analyses, and multifactorial residual survival analyses., Results: Obese patients with endometrial carcinoma were significantly younger (p < 0.001) and their tumors were less advanced at diagnosis (p = 0.001) and were better differentiated (p = 0.010). In the subgroups, neither steroid hormone receptor status nor MIB1-determined growth fraction correlated with BMI. For both endometrial and cervical carcinomas, a high BMI influenced overall survival favorably (p (endometrial )= 0.004 and p (cervical )= 0.026). In ovarian cancer, there was a trend toward improved survival in more obese patients (p = 0.053). Immunohistochemistry revealed that c-erb-B2 expression was slightly lower in tumors of obese patients (r = -0.142; p = 0.039), but BMI did not influence any other factor., Conclusions: Although obesity increases the incidence of cancer, a high BMI does not seem to adversely influence the prognosis in patients with the mentioned gynecological malignancies.

Background: Transmural uterine compression suturing methods are a fertility-preserving alternative in patients with atonic primary postpartum hemorrhage (PPPH), which does not respond to manual compression or drugs. This study evaluated the effectiveness of a modified U-suturing technique in effecting uterine compression in patients with PPPH after Cesarean section., Methods: U-suture uterine compression was introduced at our hospital at the beginning of 2005. The medical records of patients with PPPH after Cesarean section who had undergone this treatment, and results of a follow-up and questionnaire were evaluated and our experience with this method was reviewed., Results: Between January 2005 and September 2007, seven patients underwent uterine compression with U-sutures after PPPH. In all cases, treatment was successful, the hemorrhage was controlled and the uterus preserved. Normal menstruation patterns returned in the five patients who returned the questionnaire and no surgery related morbidities were noted at the follow-up examinations of six patients. The technique was simple to perform in an emergency situation., Conclusions: Uterine compression with U-sutures is a highly effective and straightforward emergency procedure which conserves the uterus in these patients.

Background: Some toothpastes, cosmetics and ointments contain propolis, a bee product, and it is increasingly popular as a dietary supplement. Although propolis is known to cause contact allergy, there have been no studies of the prevalence of this., Objectives: This study aimed to determine the prevalence of contact allergy to propolis in beekeepers and any relationship between propolis allergy and environmental and physical and mental health characteristics in this group., Subjects and Methods: A specially developed instrument which included a validated questionnaire on emotional stability was included in the issues of three German beekeeping journals sent to subscribers in a number of regions (potential readership 35,000). A reference group also completed questionnaire., Results: 1051 questionnaires were returned and 37 cases of allergic reactions to propolis were reported (3.6%). Only 10 of the 37 (27%) beekeepers had recognised the allergy before participating in this study. Propolis contact allergy was significantly associated with lung diseases and other allergic reactions. Only some affected beekeepers protected their hands more while working with bees and showed significantly greater emotional instability than those not sensitised to propolis., Conclusions: Contact allergy to propolis is common among beekeepers, but they do not seem to recognise the problem or protect themselves properly.

Introduction: Although large randomized trials have not shown benefits for breast self-examination (BSE), many organizations still endorse the practice. This study aimed to determine whether an instruction video or palpation aid improved the effectiveness of BSE., Methods: A total of 100 volunteers (50 men and 50 women) with no previous experience of BSE and/or clinical breast palpation were randomly assigned to the following intervention: instruction video seen versus not seen and use of palpation aids versus aids not used. Participants completed psychological trait and previous knowledge questionnaires before the intervention and/or breast examination. Examination was carried out on 24 different sized silicone breast forms, into 20 of which had been inserted tumor equivalents measuring 0.8-3.0 cm in diameter. The dependent variable was the rate of accurate tumor detection--the mean sum of correct positive hits (CPH)--defined as tumors detected within 20 s. Mean CPH values were then analyzed in relation to the interventions and other variables including gender and psychological measures (ANOVA and COVAR)., Results: Neither the instruction video nor interaction effects between gender and the instruction video influenced the mean CPH value. Furthermore, the palpation aid was strongly and significantly associated with a reduced detection (p=0.00003)., Conclusion: Using an instruction video or palpation aid did not improve the effectiveness of breast examination in detecting tumors--a finding which supports results from large randomized studies. It is difficult to understand why BSE is still promoted by various groups.