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ZusammenfassungDie Implantation spannungsfreier Bänder („tension free vaginal tape“ [TVT]) ist eine minimalinvasive Technik zur Behandlung der Belastungsinkontinenz. Um den Stellenwert und die Besonderheiten der Methode bei älteren Menschen zu evaluieren, wurde eine selektive Literaturrecherche in PubMed mit den Stichworten „urinary incontinence“/„tension free vaginal tape“/„stress incontinence“ AND „elderly“ durchgeführt. Angesichts der demografischen Entwicklung weltweit erweist sich die Harninkontinenz im Alter als zunehmendes medizinisches und sozioökonomisches Problem. Ein TVT kann selbst bei Hochaltrigen unter folgenden Bedingungen ins Auge gefasst werden: grundsätzlich fehlende Kontraindikation gegen einen chirurgischen Eingriff; Vorliegen einer Belastungs- oder Mischinkontinenz (mit hohem Belastungsanteil); Versagen der konservativen Therapie. Unter der Voraussetzung von Operationswunsch und gegebener Operabilität zeigen die Langzeitergebnisse des TVT über 11 Jahre eine persistierende Kontinenzrate von mehr als 80 %. Die Operation ist sicher und effektiv, geht allerdings mit einer erhöhten Rate von postoperativen Harnwegsinfekten und De-Novo-Dranginkontinenz einher.

Purpose On January 1st, 2018, the ÖGZ (Austrian Society of Cytology) revised its cytological nomenclature to make it more similar to the 2015 Bethesda system. Following these changes, the Austrian Society of Gynecology and Obstetrics felt it necessary to revise the approach currently used in Austria to diagnose and treat CIN and to review the procedures to be followed when the quality of cytological specimens is unsatisfactory. It was not possible to adopt the German S3 guideline “Prevention of Cervical Cancer” in its entirety, because the Munich III gynecological cytology nomenclature used in Germany is not used in Austria. This made it necessary to compile a separate scientific opinion for Austria. Methodology The OEGGG worked together with the ÖGZ (Austrian Society for Cytology), AGO Austria (Austrian Working Group for Gynecological Oncology), the AGK (Colposcopy Working Group), and physicians representing gynecologists in private practice. The different scientific associations nominated representatives, who attended the various meetings. After an in-depth analysis of the recent literature, three meetings and numerous votes by telephone, we were able to achieve a consensus about the contents of this guideline. Recommendations The guideline provides recommendations for the diagnosis and treatment of CIN which take account of the gynecological cytology nomenclature used in Austria.

The decades-long global obesity epidemic has resulted in steady increase in the incidence of obesity-related malignancies. The associated diagnostic and therapeutic implications present a clinical challenge for gynecologic oncology treatment strategies. Recent studies have provided solid evidence for an independent, linear, positive correlation between a pathologically increased body mass index and the probability of developing endometrial or postmenopausal breast cancer. The pathogenesis is complex and the subject of current research. Proposed causes include pathologically increased serum levels of sexual steroids and adiponectin, obesity-induced insulin resistance, and systemic inflammatory processes. The scientific evidence for an association between obesity and other gynecological malignancies is, however, less solid. The clinical relevance of obesity as a risk factor for epithelial ovarian cancer, cervical cancer and vulvar cancer appears to be negligible. Nevertheless, obesity appears to have a negative impact on prognosis and oncologic outcomes for all gynecological cancers. Whether or not this effect can be interpreted as correlative or causal is still a subject of ongoing debate.

Objective Aim of the study was to investigate the expression of transforming growth factor-β1 (TGF-β1), a key regulator of the extracellular matrix composition, in the uterosacral ligaments (USLs) of women with pelvic organ prolapse (POP) compared with controls. We hypothesized that the expression pattern of TGF-β1 differs between postmenopausal women with or without POP. Methods Under ethical approval, USL samples were obtained from postmenopausal women undergoing vaginal hysterectomy for stage two or greater pelvic organ prolapse (cases, n = 70) and from postmenopausal women without pelvic organ prolapse undergoing vaginal hysterectomy for benign indications (controls, n = 30). Immunohistochemical staining was performed from paraffin embedded tissue using anti-TGF-β1 antibodies. The expression of TGF-β1 was evaluated by the pathologist, who was blinded to all clinical data. Results The expression of TGF-s1 was similar in patients with symptomatic POP (89 % positive) and in controls (90 % positive) without any signs of prolapse (p = 0.091). Age-adjusted analysis did not significantly alter these results. Regarding POP-Q stages, TGF-s1 was significantly more frequently expressed in severe prolapse cases compared to moderate/mild cases (POP-Q stage IV versus POP-Q stage II and III; p = 0.001). No significant association could be detected between TGF-s1 expression and age, BMI and parity in cases with POP (p > 0.05). As published previously, advanced patients’ age as well as early menopausal age remained independent risk factors associated with POP in multiple logistic regression analysis (p = 0.001; p = 0.02). Conclusion Although our study detected POP-Q stage related alterations in USL composition and TGF-s1 expression, there was no significant difference in the expression of TGF-β1 in cases with or without prolapse.

Lung cancer during pregnancy represents a rare disease. In this case report, we present a patient at advanced and metastasized stage of signet ring cell carcinoma who presented in the22ndweek of gestation.

The modern sling procedures for treating female stress urinary incontinence encompass numerous methods, materials and manufacturers. On the basis of the current S2e guidelines, the methods used most frequently in the diagnosis of and therapy for stress urinary incontinence in women are critically illustrated. An individualised procedure is necessary for the choice of the surgical method, especially in the presence of accompanying pathologies. This article is intended to help the treating physician to carry out quality-assured diagnostics and therapy for the patient and to offer the best possible urogynaecological management. In addition to the complications and chances of success of the surgical options, the legal aspects of therapy planning are also taken into consideration.Die modernen Schlingenverfahren zur Behandlung der weiblichen Belastungsinkontinenz variieren heute zwischen zahlreichen Verfahren, Materialien und Herstellern. Basierend auf der aktuellen S2e-Leitlinie werden die am häufigsten angewendeten Verfahren bei der Diagnostik und Therapie der Belastungsinkontinenz der Frau kritisch beleuchtet. Bei der Wahl der Operationsmethode ist ein individualisiertes Vorgehen erforderlich, insbesondere, wenn Begleitpathologien vorliegen. Der Beitrag soll den behandelnden Ärzten helfen, die Diagnostik und Therapie der Patientinnen qualitätsgesichert durchzuführen und die bestmögliche urogynäkologische Versorgung anbieten zu können. Dabei werden neben den Komplikationen und Erfolgsaussichten der operativen Möglichkeiten auch juristische Aspekte bei der Therapieplanung berücksichtigt.

Lymph node ratio (LNR) can predict treatment outcome and prognosis in patients with solid tumors. Aim of the present analysis was to confirm the concept of using LNR for assessing outcome in patients with vulvar cancer after surgery with inguinal lymphadenectomy in a large multicenter project.The AGO-CaRE-1 study multicenter database was used for analysis. LNR was defined as ratio of number of positive lymph nodes (LN) to the number of resected. Previously established LNR risk groups were used to stratify patients. LNR was investigated with respect to clinical parameters. Univariate and multivariable survival analyses were performed to assess the value of LNR in order to predict overall (OS) and progression-free (PFS) survival.In total, 1047 patients treated with surgery including inguinal lymph node resection for squamous cell carcinoma of the vulva were identified from the database. Of these, 370 (35.3%) were found to have positive inguinal LN. In total, 677 (64.7%) had a LNR of 0% (N0), 255 (24.4%) a LNR of0% 20%, and 115 (11%) a LNR of ≥20%. Patients with higher LNR were found to have larger tumor size (P .001), advanced tumor stage (P .001), high tumor grade (P .001), and deep stromal invasion (P .001), more frequently. Three-year PFS rates were 75.7%, 44.2%, and 23.1% and three-year OS rates were 89.7%, 65.4%, and 41.9%, in patients with LNRs 0%,0% 20%, and ≥20%, respectively (P .001, P .001). On multivariable analyses LNR (HR 7.75, 95%-CI 4.01-14.98, P .001), FIGO stage (HR 1.41, 95%-CI 1.18-1.69, P .001), and patient's performance status (HR 1.59, 95%-CI 1.39-1.82, P .001), were associated with PFS. In addition, LNR (HR 12.74, 95%-CI 5.64-28.78, P .001), and performance status (HR 1.72, 95%-CI 1.44-2.07, P .001) were also the only two parameters independently associated with OS. LNR generally showed stronger correlation than number of affected LN when comparing the two different multivariable models.In women with vulvar cancer LNR appears to be a consistent, independent prognostic parameter for both PFS and OS and allows patient stratification into three distinct risk groups. In survival analyses, LNR outperformed nodal status and number of positive nodes.

The ethical behavior of authors, editors, and journals is increasingly placed in the spotlight, by both the public and the research community. Disclosures and conflict of interest (COI) statements of publishing authors represent one important aspect. We aimed to unravel the current management of disclosures, COI, and funding statements in the subspecialty urogynecology. A bibliometric study was carried out. We included six journals that published urogynecology articles between January and December 2013. All original articles, reviews, and opinion articles were assessed for the presence of disclosure/COI and funding statements. Information given on the official disclosure form was compared with information given in the final article (International Urogynecology Journal). All journals investigated require disclosure and funding statements in their instructions to authors. Of the 434 articles included, almost all contained a disclosure statement (98–100 %). Funding statements were present in 41–100 % of articles, indicating a difference in journal type (50 % on average among urogynecology journals; 75 % on average among general gynecology journals). The main source of funding was “grants” (58 %), followed by “none” (16 %), “industry” (16 %), and lastly “hospital/university” (10 %). Disclosure statements in the article were identical to the official disclosure form in 80 % (IUJ). Disclosure/COI statements were included in almost all urogynecology articles investigated. Their content, however, is sometimes incomplete and should possibly be monitored more closely by journals and authors. Despite universal requirements of journals, the reporting of funding seems inconsistent. This issue in addition to the completeness of disclosures should be given more attention.

Objective To investigate a possible correlation between the volume of the tubal ectopic pregnancy (EP) measured by vaginal-ultrasound (VUS) and methotrexate (MTX) therapy outcome. Study design Data of EP volume measured by one expert-sonographer, viability, clinical symptoms, previous IVF/insemination, follow-up of β-hCG and progesterone levels, and treatment of EP was collected of 100 patients with sonographically diagnosed EP, who attended the Department of Obstetrics and Gynecology of the Medical University Vienna between March 2008 and September 2011. Results The mean volume of EP (mVol.) in the group with successful MTX therapy ( n = 38) was 5.11 ml, 95%CI [2.4; 7.8] with a median 3.2 ml, IQR [5.0], in the group with unsuccessful MTX treatment ( n = 11) it was 15.24 ml, 95%CI [−2.6; 33.1], with a median 4.4 ml, IQR [11.4]. We could observe a trend towards a lower mVol. in the successful MTX group (5.11 ml vs. 15.24 ml). We could not show a significant correlation ( u -test p = 0.208). Conclusion A clear tendency was observed towards a lower mVol. in the successful MTX therapy group, but we could not verify a statistically significant correlation of volume of EP and MTX therapy outcome most likely due to the small sample size. This was the first study investigating the correlation of volume of EP and MTX therapy outcome as principal question.

To determine the optimal serum β-hCG cut-off level to predict MTX treatment success in tubal ectopic pregnancy (EP).Data of 240 women, who presented between 2003 and 2011 at the Department of Gynecology and Obstetrics, Medical University of Vienna, with tubal EP and who received MTX as primary treatment, were retrieved from the hospital information system (KIS). 198 patients could be included for final evaluation. Statistical analysis included area under the ROC curve, maximal Euclidean and Youden index, chi-squared and a five-fold cross validation.The serum β-hCG level cut-off value was calculated at 2121mlU/ml with a specificity of 76.54% and sensitivity of 80.56% (AUC 0.789; p0.001). Patients with an initial serum β-hCG level below 2121mlU/ml (n=131) experienced MTX treatment failure in 5.3% (n=7), compared to 43.3% (n=29) of patients with an initial serum β-hCG level equal to or above 2121mlU/ml (n=67). There was no statistically significant correlation between clinical symptoms and the MTX therapy outcome (p=0.580; likelihood quotient p=0.716).The correct decision of therapy in patients with tubal ectopic pregnancy still represents a challenge. In this study we can conclude that, according to our results there is no endpoint of initial serum β-hCG levels, which can be clearly used as cut-off value for the optimal management of tubal EP. However, an initial serum β-hCG level of less than 2121mlU/ml seems to be a good value to expect a successful MTX treatment. Limitations are the retrospective study design and the inability of classifying clinical symptoms like pain as an objective parameter. Wider implications of the findings may include more detailed patient information and more accurate selection of suitable patients for MTX therapy.

Objectives The aim of this study is to evaluate the activity and toxicity of fulvestrant, a pure estrogen receptor antagonist in patients with advanced or recurrent endometrial cancer, expressing estrogen and/or progesterone receptors (ER/PR). Methods Eligible patients with advanced or recurrent endometrial cancer not amenable to curative surgery and/or radiotherapy were treated with fulvestrant at a dose of 250mg by IM injection every 4weeks for at least 12weeks. Therapy was continued until disease progression, death, intolerable side effects or end of study. Response was assessed in patients with at least one target lesion according to WHO-criteria. Results Thirty-five patients were enrolled in this study and received at least one injection of fulvestrant (intention to treat-population, ITT). Twenty six patients received the intended 3 injections of fulvestrant (per protocol population, PP). There was no complete response but 4 partial responses (11.4% ITT) and 8 stable diseases. The median time to progression was 2.3months (ITT). Overall survival was 13.2months (ITT). Treatment was well tolerated. Conclusions Fulvestrant at a dose of 250mg IM every 4weeks has marginal activity and good tolerability in patients with ER and/or PR positive advanced or recurrent endometrial cancer. A loading dose strategy and the use of 500mg/4weeks might improve the efficacy of this treatment.

The association between an increased uptake of isoflavones and a reduced frequency of menopausal hot flushes was first described in 1992, based on a lower incidence of hot flushes in countries with a high consumption of soy. Since then, numerous clinical trials with various sources of isoflavones including soy and red clover have been presented, with practically all of the studies with adequate design delivering an outcome in favour of isoflavone supplementation. An in-depth risk assessment (EFSA 2015) concludes that the amply available human data does not indicate any suspected harmful effects from a potential interaction of isoflavones with hormone-sensitive tissues in the mammary gland, the uterus and the thyroid gland. Safety was ascertained with long-term intake of up to 150 mg isoflavones per day ingested for the duration of at least 3 years. Moreover, high isoflavone intake was found to have preventive effects with respect to breast cancer. Clinical findings indicate potential benefits of isoflavone exposure even during breast cancer treatment with tamoxifen or anastrozole.

The therapy of choice for breast cancer patients requiring adjuvant chemo- or radiotherapy is increasingly guided by the principle of weighing the individual effectiveness of the therapy against the associated side effects. This has only been made possible by the discovery and validation of modern biomarkers. In the last decades and in the last few years some biomarkers have been integrated in clinical practice and a number have been included in modern study concepts. The importance of biomarkers lies not merely in their prognostic value indicating the future course of disease but also in their use to predict patient response to therapy. Due to the many subgroups, mathematical models and computer-assisted analysis are increasingly being used to assess the prognostic information obtained from established clinical and histopathological factors. In addition to describing some recent computer programmes this overview will focus on established molecular markers which have already been extensively validated in clinical practice and on new molecular markers identified by genome-wide studies.Die Therapiewahl für die Mammakarzinompatientin in der adjuvanten Situation folgt immer mehr dem Prinzip, die individuelle Therapieeffektivität und die Nebenwirkungen gegeneinander abzuwägen. Die Entdeckung und Validierung moderner Biomarker ermöglicht erst dieses Vorgehen. In den letzten Jahrzehnten und insbesondere in den letzten Jahren konnten einige Biomarker in die klinische Praxis und in moderne Studienkonzepte integriert werden. Nicht nur der Vorhersage der Prognose kommt hierbei eine besondere Bedeutung zu, sondern auch der Vorhersage des Therapieansprechens durch Prädiktivfaktoren. Die Nutzung der prognostischen Information aus etablierten, klinischen und histopathologischen Faktoren erfolgt aufgrund der Vielzahl von Untergruppen mehr und mehr in Form von mathematischen Modellen und computergestützter Auswertung. Neben der Darstellung aktueller Programme soll in dieser Übersichtsarbeit des Weiteren der Fokus auf etablierten, molekularen Markern, die bereits eine umfassende klinische Validierung vorweisen können, und neuen molekularen Markern liegen, die durch genomweite Ansätze identifiziert wurden.

Background: We present a series of skin-sparing mastectomies (SSMs) with skin reduction and immediate breast reconstruction to treat large and ptotic breasts. The technique combines oncological mastectomy with immediate subpectoral implant placement as a single-step procedure. Methods: Data was collected from a prospective database from February 2009 to April 2011. A total of 24 patients with macromastia or pronounced ptosis fulfilled the criteria for skin-saving mastectomy. All operations were carried out as a single-step procedure with adaptation of the contralateral breast by reduction mastopexy. Results: A total of 27 SSMs were performed in 24 patients. The mean implant volume was 265 cm3. Immediate reconstruction of the nipple-areola complex was done in 22 patients. The cosmetic and functional results were assessed in all patients 6 months postoperatively; mean follow-up time was 13 months. Mean patient age was 49 years. The cosmetic result was assessed as “very good” or “good” by 22 patients; 2 patients graded the result as “unsatisfactory”. There was one local recurrence. Conclusion: Our results support the use of this technique as a safe oncoplastic procedure which is well tolerated by patients.

Objective P53 tumor suppressor gene plays a role in endometrial carcinogenesis. Former studies described correlations between p53 protein overexpression in endometrial cancer and prognostic factors, measured by immunohistochemistry. But data is still controversial. The aim of this study was to measure p53 and phospho-p53 overexpression by Western blot and evaluate correlations between overexpression and prognostic and clinical factors. Phospho-p53 seems to be the functional p53 protein and was examined for the first time in endometrial cancer. Methods 40 patients with endometrial cancer were included in the study. A control group of 20 patients with normal endometrial tissue samples was used. Western blot was performed for detection of p53 and phospho-p53. Clinical and pathological parameters were obtained from medical records. Statistical analysis was performed using the log-rank test, the Mann–Whitney test for two independent groups and the Fisher's exact test for dichotomous groupings. Results In 17.5% of the patients with endometrial cancer a p53 overexpression could be evaluated. There was a correlation between a p53 overexpression and recurring disease (p: 0.014), a negative progesterone receptor status (p: 0.021) and a low BMI (p: 0.022). Only one of 40 patients had a phospho-p53 expression. Conclusion Western blot is a valid method for the detection of p53 overexpression. As other authors described before, p53 overexpression seems to correlate with negative prognostic factors. The correlation between p53 overexpression and a low BMI may underline the relationship between p53 alterations and biological aggressive endometrial carcinomas.

Hypoactive Sexual Desire Disorder (HSDD) is the most common form of FSD (Female Sexual Dysfunction) and the most common sexual disorder in women in clinical practice. HSDD is defined as a deficiency or absence of sexual fantasies and of the desire for sexual activity with a great impact on interpersonal relationships which cannot be attributed to other causes such as psychiatric or medical illnesses or the effect of particular drugs. Both pre- and postmenopausal women may be affected by HSDD. The pathophysiology of HSDD is not known in any detail; the current scientific opinion is that it may be due to a neurobiological imbalance in the inhibitory and excitatory factors which control sexual desire in the brain. HSDD leads to reduced sexual and interpersonal satisfaction and is associated with high emotional psychological strain. Gynecologists should be first persons to whom women affected with HSDD should be able to turn, but due to the lack of specialist training, time, and effective therapy many doctors shy away from broaching the topic. The Decreased Sexual Desire Screener (DSDS®) is a short and simple diagnostic tool for the detection of HSDD by non-specialist colleagues. As the range of therapies currently available to women with HSDD is limited, multidimensional treatments should be offered to women with HSDD.

Since suburethral vaginal slings introduced a new era for the treatment of genuine stress urinary incontinence, new surgical techniques with alloplastic meshes have begun to be used in pelvic reconstructive surgery for vaginal prolapse. Thus established procedures without artificial materials are competing directly against new techniques using modern meshes. Controlled clinical trials will be necessary to allow a direct comparison in terms of evidence-based medicine. There are a variety of different vaginal and abdominal approaches available to treat prolapse. We describe the classic procedures and the new techniques using alloplastic material. The currently available data are presented and discussed. Standard operations such as colporrhaphy, abdominal sacral colpopexy and vaginal sacrospinous fixation still offer high success rates with only few complications. Although the abdominal route may offer some advantages with respect to the recurrence of prolapse, especially in the anterior compartment, and sexual function, vaginal sacrospinous colpopexy is characterized by a lower postoperative morbidity and comparable cure rates. The problem of the simultaneous correction of accompanying stress urinary incontinence versus correction following reconstructive surgery alone is discussed. Following the widespread use of new techniques and meshes, a new spectrum of postoperative complications ranging from erosions to infections has emerged, requiring an adequate management. As the current data only covers relatively small numbers and long-term follow-up is lacking, a final statement on the use of mesh material in reconstructive pelvic surgery cannot be made so far. While classic procedures without a mesh should be preferred for primary operations, mesh enforcement offers a promising alternative for relapse cases and in high-risk situations.

Objective. A multicenter non-randomized phase II study was initiated to evaluate tolerability and efficacy of pegylated liposomal doxorubicin (PLD) in combination with carboplatin in gynecologic malignancies. Methods. One hundred forty women with recurrent or advanced endometrial ( n =31), cervical or vaginal cancer ( n =31), uterine sarcomas ( n =11), or recurrent platinum-sensitive ovarian cancer ( n =67) received six courses of PLD 40 mg/m 2 and carboplatin (AUC 6) every 28 days. Results. Hematological toxicities with NCI-CTC grade 3/4 were anemia in 8%, thrombocytopenia in 14%, neutropenia in 24%, and febrile neutropenia in 2% of 652 cycles. Grade 3/4 non-hematological toxicities included fatigue (14% of patients), pain (10%), dyspnea (9%), palmar–plantar erythrodysesthesia (7%), and nausea/vomiting (7%). Dose intensity reached 87.2% for PLD and 88.2% for carboplatin. Seventy-four percent of all non-progressive patients received at least 5 cycles. Overall response rates were (116 patients evaluable for response): ovarian cancer ( n =54) 68%, endometrial cancer ( n =27) 44%, uterine sarcomas ( n =9) 33%, and cervical/vaginal cancer ( n =26) 12%. Median progression-free survival was 11.6 months (95%CI 9.6–14.1) for ovarian cancer and 9.5 months (95%CI 6.6–12.6) for endometrial cancer. Median overall survival was 23.8 months (95%CI 19.0–30.2) and 21.4 months (95%CI 11.9–), respectively. Conclusions. The combination of PLD and carboplatin was well tolerated and feasible in patients with gynecologic malignancies. Efficacy was low in cervical/vaginal cancer, but promising in patients with endometrial cancer. Efficacy was within the expected range in recurrent platinum-sensitive ovarian cancer and is currently under further investigation in a prospective randomized phase III trial comparing PLD/carboplatin with paclitaxel/carboplatin (CALYPSO-trial; AGO-OVAR 2.9).

Die gegenwärtige Entwicklung unterschiedlicher Mesh-Materialien hat zu einer Verbesserung der individuellen operativen Sanierung des Genitalprolapses geführt. Makroporöse monofilamentäre synthetische Netze scheinen geeignet zur Verwendung beim Rezidivprolaps oder bei ausgeprägten Beckenbodeninsuffizienzen zu sein. Die Verwendung von biologischen Netzen zeigt eine deutlich bessere Verträglichkeit mit weniger Infektionen oder Erosionen, bislang ist jedoch nicht das Problem der langfristigen Haltbarkeit geklärt. Die operative Korrektur des Genitalprolapses muss alle Risiken und Nutzen zur Verbesserung der Lebensqualität abwägen, hier können Mesh- Materialien deutliche Vorteile gerade in der Rezidivsituation erbringen.

Fragestellung: Goserelin unterdruckt uber den Umweg der Blockierung der hypophysaren Gonadotropin-Synthese die ovarielle Steroidproduktion, ist aber nicht in der Lage, die periphere Steroidproduktion zu inhibieren. Der Aromatase-Inaktivator Exemestan fuhrt dagegen sowohl peripher als auch in den gonadalen Synthesestatten zu einem optimalen Abfall der Estrogen-Spiegel. Somit musste die Kombination von Goserelin und Exemestan in der adjuvanten Therapie des primaren Mammakarzinoms bei pramenopausalen Patientinnen zur Optimierung des Therapieergebnisses fuhren. Die zu erwartende klimakterische Symptomatik unter diesem Therapieregime kann moglicherweise durch Zusatz von Tibolon als Additivum gemildert werden. Ziel der vorliegenden Arbeit ist es, das Risiko und die Tolerabilitat einer solchen Medikamentenkombination aus Goserelin und Exemestan mit und ohne Tibolon zu uberprufen. Material und Methoden: Es handelt sich um eine offene, randomisierte, multizentrische ADAGIO (Adjuvante Aromasin-Goserelin Studie)-Pilotstudie, Dauer 24 Wochen. 48 pramenopausale Patientinnen (Alter 35 - 55 Jahre) mit histologisch gesichertem, rezeptorpositivem Mammakarzinom mit niedrigem Risiko (pT1, N0, M0 [Grading 1 - 2]) wurden in die Studie aufgenommen. Die Patientinnen wurden in vier Therapiearme randomisiert: Goserelin, 3,6 mg Depot, s.c. alle 28 Tage; Goserelin plus Exemestan oral, 25 mg taglich; Goserelin plus Tibolon 2,5 mg oral, taglich; Goserelin plus Exemestan plus Tibolon. Ergebnisse: In allen vier Therapiearmen kam es zu einem rapiden Abfall der Serumspiegel fur Estradiol, Estron und Estronsulfat auf postmenopausale Werte; LH und FSH wurden ebenfalls supprimiert. Die Differenzen zwischen den Therapiegruppen waren nicht signifikant. Die klimakterischen Symptome nahmen an Intensitat uber den Behandlungszeitraum zu. Die Patientinnen, die Tibolon als Zusatztherapie erhielten, wiesen signifikant weniger Hitzewallungen (p < 0,01), Schlafstorungen (p < 0,05), Libidoverlust (p < 0,01) und vaginale Trockenheit (p < 0,05) auf. Die Kombination Goserelin/Exemestan reduzierte die Knochendichte nicht mehr als Goserelin allein. Es wurde aber ein Trend hin zu einem protektiven Effekt auf die Knochendichte bei Zusatz von Tibolon beobachtet. Signifikante Differenzen hinsichtlich unerwunschter Nebenwirkungen im Vergleich aller vier Therapiearme waren nicht zu verifizieren. Schlussfolgerung: Die kombinierte Therapie von Goserelin und Exemestan ist so sicher und gut tolerabel wie die Standardtherapie mit Goserelin allein. Das Additivum Tibolon reduziert signifikant eine Reihe durch die Therapie induzierter klimakterischer Symptome und scheint positiven Einfluss auf die Knochendichte zu nehmen. Purpose: Goserelin suppresses ovarian function, but does not inhibit oestrogen production in peripheral tissues. Therefore addition of the aromatase inactivator exemestane may optimally decrease oestrogen levels. The combination of goserelin and exemestane may therefore be useful in the adjuvant treatment of primary breast cancer. The climacteric symptoms expected with this regimen may be relieved by tibolone. Material and Methods: The 24-week, open, randomised, multicentre ADAGIO (Adjuvant Aromasin combined with Goserelin) pilot study was conducted in 48 premenopausal women (aged 35 - 55 years) with histologically confirmed oestrogen and/or progesterone receptor-positive, node negative primary breast cancer (pT1, M0 [grade 1 - 2]) of low or intermediate risk. Patients were randomised to one of four groups: goserelin 3.6 mg depot implanted s.c. every 28 days; goserelin plus oral exemestane 25 mg/day; goserelin plus oral tibolone 2.5 mg/day; or goserelin plus exemestane and tibolone. Results: There was a rapid fall in serum oestradiol, oestrone and oestrone sulphate to postmenopausal levels in all four treatment groups; there were no significant differences between the groups. LH and FSH were also suppressed. Climacteric symptoms increased in intensity in all groups, although patients receiving tibolone had significantly fewer hot flushes (p < 0.01), sleep disorders (p < 0.05), loss of libido (p < 0.01) and vaginal dryness (p < 0.05). The combination of goserelin and exemestane did not reduce bone mineral density (BMD) more than goserelin alone. There was a trend towards a protective effect of tibolone on BMD. There were no significant differences in adverse events between the four groups and no serious adverse events were observed. Conclusions: Combination treatment with goserelin and exemestane is as safe and well tolerated as standard treatment with goserelin alone. The addition of tibolone reduces the severity of some climacteric symptoms and may also reduce bone loss.

Purpose: HER-2 blocking strategies, for instance with trastuzumab (Herceptin®), have been successfully used in therapy of breast cancer. To study molecular mechanisms and the efficiency of HER-2 blocking therapies we established a mouse tumor model that allows switching-off of HER-2 expression in tumor tissue. Material and Methods: NIH3T3 cells conditionally expressing HER-2 by the TET-OFF system (NIH3T3-HER-2 cells) were subcutaneously injected into the dorsal skin of nude mice. These cells allowed switching-off of HER-2 expression by exposure to anhydrotetracycline. We examined the influence of HER-2 down-regulation on tumor volume of subcutaneously growing tumors in nude mice. Tumor development was studied by magnetic resonance imaging. HER-2 expression was quantified by Western Blot analysis. Results: Eight to ten days after injection of 7 × 10 6 NIH3T3-HER-2 cells small subcutaneously growing tumors became visible. A surprisingly efficient tumor remission was observed already 7 days after switching-off of HER-2 expression: mice with initial tumor volumes of 0.8, 1.2, 3.9 and 14.9 cm 3 showed a decrease in tumor volumes to 1.9, 11.8, 11.3 and 25.8%, respectively, compared to the respective volumes before anhydrotetracycline administration. In contrast, a steady increase in tumor volume was observed for mice not exposed to anhydrotetracyclin. Conclusion: Switching-off of HER-2 expression causes a strong remission already after 7 days. Interestingly, the extent of tumor remission depends on initial tumor size, whereby a stronger remission can be achieved for smaller tumors. Our data support clinical studies testing HER-2 blocking strategies as adjuvant therapy for early breast cancer.

The main reason for the restricted use of methotrexate in the treatment of ectopic pregnancy (EP) obviously is the fear of tubal rupture in patients with lower abdominal pain after the administration of methotrexate. Therefore, we wanted to find out if patient characteristics at first presentation, such as age, pretreatment β-hCG level, adnexal mass as visualized by transvaginal ultrasonography, or history of prior EP, would identify patients at risk for tubal rupture if they were hemodynamically stable and showed no signs of peritoneal irritation. We examined whether more patients could have been treated medically with methotrexate, because tubal rupture was unforeseeable at first presentation and inclusion criteria for methotrexate treatment were fulfilled. From January 1996 to August 1998, 122 patients diagnosed as having EP were treated at the Gynecologic Department of the University Hospital of Vienna. Inclusion criteria for medical treatment with intramuscular methotrexate (50 mg/ m2 body surface area) were (1) hemodynamic stability, (2) an unruptured ectopic mass ≤5 cm at the greatest dimension demonstrated at transvaginal ultrasonography; (3) β-hCG level ≤5,000 mIU/ml; (4) no cardiac activity of the extrauterine embryo; (5) wish of future fertility, and (6) informed consent. Patients with hemodynamic instability, severe abdominal pain, an ectopic mass ≥5 cm at the greatest dimension, β-hCG levels ≥5,000 mIU/ml, cardiac activity of the extrauterine embryo, and no wish of future fertility, or disagreement with methotrexate treatment, primarily underwent surgery. Despite the fact that none of the above patient characteristics at first presentation identified patients at risk for tubal rupture, only 60/122 patients (49%) actually underwent medical treatment whereas our inclusion criteria would have granted medical treatment in 101/122 patients (83%). We determined the actual and maximal possible percentages of patients with unruptured EP eligible for medical treatment of EP with intramuscular single-dose methotrexate 50 mg/m2 body surface area. Our data show that tubal rupture in hemodynamically stable patients is not foreseeable and should not lead to a restricted use of medical treatment in patients preferring methotrexate.

OBJECTIVE: The aim of the study was to compare the perinatal outcome of spontaneously conceived twins with those conceived after in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI). MATERIAL AND METHODS: A retrospective study was performed. Clinical data of 188 twin pregnancies was collected from the Department of Obstetrics and Gynecology, University Hospital of Mainz for the years 1996-2006. The twins were divided into 2 groups according to the manner of conception: spontaneously conceived twins (n = 142) and twins (n = 46) conceived after IVF and ICSI. In order to investigate the perinatal outcome of spontaneous twins and twins conceived by assisted reproductive technology (ART), we evaluated the following parameters: maternal age, fertility, nulliparity rate, gestational age, mode of delivery, fetal weight and Apgar score. RESULTS: No significant difference was found in maternal age, fertility and gestational age between spontaneous twins and IVF/ICSI twins. Maternal gestational age was 255 days in the spontaneous group and 254 days in IVF/ICSI group. Fetal weight and Apgar score were similar between the two groups. The nulliparity rate was higher in IVF/ICSI group. Obviously there were more cesarean sections in the IVF/ICSI group than in the spontaneous group (76.2 % and 42.5 %, respectively). CONCLUSIONS: Duration of gestation, neonatal birth weight and Apgar score were similar between IVF/ICSI twins and spontaneous twins. IVF/ICSI twins had a higher cesarean section rate.

Objective. To determine the present state of urogynecological diagnostics, therapy and follow-up in the Departments of Gynecology and Obstetrics in Austria. Design. We sent questionnaires to all Departments of Gynecology and Obstetrics in Austria. The anonymous questionnaire consisted of 25 multiple choice questions. It was possible to choose one ore more answers by ticking applicable boxes with the casual option to give some additional information in form of free text. Results. Fifty-eight departments (58%) returned their questionnaires completely answered indicating interest in quality management in medicine. The most remarkable discrepancy was found between the interrogated people's estimation of the expressiveness of examination techniques and the actual use of such techniques. Conclusion. We regard the results of this survey as a basis for further quality management strategies in the field of urogynecology in Austria.

Objective Rigid cystoscopy is a common diagnostic tool in the assessment of lower urinary tract symptoms, but it is an invasive procedure which can cause distress. Data exist about pain perception during cystoscopy in male patients but only a few data are available in women. The purpose of this study was to investigate pain perception in urogynecologic patients during cystoscopy and compare it with pain perception during urodynamics. We also investigated the difference between anticipated and actual pain perception. Study design A cooperative, non-randomized cohort study was performed including 109 women with pelvic floor dysfunction scheduled for outpatient cystoscopy or urodynamic testing. Patients completed a questionnaire and a visual analog scale (VAS, 0–10 cm) before and after examination. Patients were called one day after examination and asked about pain and their general state of health. According to power calculation, a sample size of 52 patients per group was needed to detect a 2 cm difference in pain scores on the VAS – judged as a clinically significant – with 95% power and a two-sided significance level of 0.05. Results In 57 patients undergoing cystoscopy versus 52 patients undergoing urodynamics, the main pain scores on VAS were 1.9 cm for cystoscopy and 1.2 cm for urodynamics (p = 0.03). Patients in both groups anticipated more pain than they actually experienced: 2.7 ± 2.4 before versus 1.9 ± 1.8 after cystoscopy (p Conclusion Patients experience cystoscopy as more painful than urodynamics. Patients anticipate both cystoscopy and urodynamics to be more painful than they actually are.

Fragestellung: Eine aberrante Expression von spezifischen Isoformen (Splice-Varianten) des Adhasionsmolekuls CD44 wurde in verschiedenen malignen Tumoren des Menschen nachgewiesen. Wir wollten abklare

The value of transvaginal ultrasound in gynaecological examinations is beyond dispute. But it is of particular forensic importance that the validity of this type of imaging with regard to the reliable detection of early-stage malignancy is properly understood. Vaginal ultrasound screening in asymptomatic patients for the early detection of endometrial carcinoma is not useful from a medical point of view, nor is it cost-efficient. However, even though the validity of transvaginal ultrasound for screening has currently not been proven, the method should still be an integral part of gynaecological examinations.Die Wertigkeit der transvaginalen Ultraschalluntersuchung im Rahmen der gynäkologischen Untersuchung ist unbestritten. Es ist aber von besonderer auch forensischer Bedeutung, dass die Aussagekraft dieses Untersuchungsverfahrens im Hinblick auf das sichere Erkennen einer Krebserkrankung im Frühstadium sinnvoll eingeordnet wird. Unter Kosten-Nutzen-Gesichtspunkten ist ein generelles Screening bei asymptomatischen Patientinnen nicht sinnvoll. Zwar kann die transvaginale Sonografie das Ziel als Screeninginstrument zum gegenwärtigen Zeitpunkt nicht erreichen kann, sie bleibt aber integraler Bestandteil der gynäkologischen Untersuchung.

The new development of single-incision slings (SIS) for the treatment of female stress urinary incontinence offers comparable results with only minimal side effects and will find wide acceptance in modern incontinence surgery. This mini-sling is inserted over a single vaginal incision and fixed on both sides to the pelvic wall tissue with special anchors, without passing through the groin and avoiding a blind tape passage. Compared with the established sub-urethral tapes, there are comparable success rates with fewer complications. Randomised prospective studies are needed to evaluate whether, in the long run, the benefits of the single incision technique can be correlated with satisfying continence results.Die Neuentwicklung von Single-Incision-Schlingen (SIS) bei der operativen Therapie der Belastungsinkontinenz der Frau ist mit vergleichbaren Kontinenzraten und nur geringsten Nebenwirkungen verbunden und kann in Zukunft breite Anwendung in der Inkontinenztherapie finden. Diese minimalinvasiven Schlingen werden über eine singuläre vaginale Inzision eingebracht und bds. an der Beckenwand über verschiedene Haltesysteme verankert. Bei gleicher Wirkung durch suburethralen Bandsupport wird hier jedoch eine Blindpassage wie bei den bekannten retropubischen oder transobturatorischen Systemen vermieden. Im Vergleich zu den etablierten suburethralen Schlingen zeigen sich in den ersten Untersuchungen äquivalente Erfolgsraten und deutlich geringere Nebenwirkungen. Hierzu müssen prospektive Studien die Wertigkeit im Vergleich zu den etablierten Verfahren noch belegen.

Illicit drug abuse, as well as smoking, are known risk factors in the development of intrauterine growth retardation. In an attempt to clarify the influence of these two aetiological factors, a retrospective analysis was carried out. 35 drug- and nicotine-addicted pregnant women were compared to 104 smokers and 101 non-smoking controls with regard to foetal outcome. Relative risk estimates for intrauterine growth retardation of the drug and nicotine group were 3.14 (95% confidence limits 1.88-5.25; p = 0.0001) whereas the smoking group had 1.39 (95% confidence limits 0.96-2.02; p = 0.0482) compared to non-smoking controls. The foetal outcome was best in the latter group: children of drug-addicted mothers had a considerably higher morbidity and mortality rate. This study shows an almost threefold risk for intrauterine growth retardation in drug-addicts who smoke, compared to nicotine abuse alone.

In a retrospective study, we analysed 26 CO2-laser vulvectomies within the observation period between 1982 and 1990. Indications for vulvectomies were invasive malignancies of the vulva, FIGO stage I to III. 91.7% were squamous cell carcinomas. The mean age of patients was 69.3% (43 to 87) years. Five radical local excisions, one modified radical vulvectomy and in all other cases radical vulvectomy was performed. Laser surgery of the vulva was combined with bilateral lymphadenectomy or radiotherapy of inguinal lymph nodes. If necessary, a gluteal rotation flap was built to achieve closure of the wound without tension. No serious intra- or postoperative complications were observed, wound breakdown with per secundam healing as the most common complication occurred in 29.1%. Functional and cosmetic results were examined in a detailed follow-up at least 12 months postoperatively, showing promising results (56.3% good, 37.5% satisfactory, 6.3% unsatisfactory). The surgical procedure, perioperative management, recurrence rate (3 patients, 12.5%), as well as functional and cosmetic results, are presented and discussed in detail. The use of CO2-laser in surgical treatment of vulvar malignancies improves cosmetic and functional results. This is important, particularly with regard to the increasing number of young women with vulvar neoplasia.

For creation of a neovagina in patients with congenital vaginal agenesis, a variety of operative procedures are recommended. Basically, two different procedures are described: (1) Application of pressure or traction to the perineum and (2) plastic-surgical operations. Since 1981, the 2nd Department of Obstetrics and Gynecology, Vienna, utilises the method described by Vecchietti. 9 Patients with congenital absence of the vagina and one with vaginal occlusion after radiotherapy underwent Vecchietti's procedure. Patients were seen after a follow-up period of at least 5 years. We evaluated morphological and functional long-term results using a detailed questionnaire as well as clinical investigations including cytological smears, screening for vaginal infections and determination of sexual hormone levels in peripheral blood. To evaluate distensibility and greatest cross-sectional diameter of the neovagina, a vaginal cast (vinyl-polysiloxan) was obtained. All patients treated for congenital malformations showed good to excellent functional results.