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Background Robotic surgery has gained popularity for the reconstruction of pelvic floor defects. Nonetheless, there is no evidence that robot-assisted reconstructive surgery is either appropriate or superior to standard laparoscopy for the performance of pelvic floor reconstructive procedures or that it is sustainable. The aim of this project was to address the proper role of robotic pelvic floor reconstructive procedures using expert opinion. Methods We set up an international, multidisciplinary group of 26 experts to participate in a Delphi process on robotics as applied to pelvic floor reconstructive surgery. The group comprised urogynecologists, urologists, and colorectal surgeons with long-term experience in the performance of pelvic floor reconstructive procedures and with the use of the robot, who were identified primarily based on peer-reviewed publications. Two rounds of the Delphi process were conducted. The first included 63 statements pertaining to surgeons’ characteristics, general questions, indications, surgical technique, and future-oriented questions. A second round including 20 statements was used to reassess those statements where borderline agreement was obtained during the first round. The final step consisted of a face-to-face meeting with all participants to present and discuss the results of the analysis. Results The 26 experts agreed that robotics is a suitable indication for pelvic floor reconstructive surgery because of the significant technical advantages that it confers relative to standard laparoscopy. Experts considered these advantages particularly important for the execution of complex reconstructive procedures, although the benefits can be found also during less challenging cases. The experts considered the robot safe and effective for pelvic floor reconstruction and generally thought that the additional costs are offset by the increased surgical efficacy. Conclusion Robotics is a suitable choice for pelvic reconstruction, but this Delphi initiative calls for more research to objectively assess the specific settings where robotic surgery would provide the most benefit.

Purpose The purpose is to analyse perioperative complications associated with the retropubic tension-free vaginal tape (TVT) procedure and their management. Methods This retrospective, monocentric cohort study included 960 women after retropubic TVT procedure performed by one surgeon from 2011 to 2016. Complications were identified up to 6 weeks after the procedure, divided into specific and general complications and classified based on the Clavien–Dindo (CD) Classification. A visit 6 weeks after the surgical procedure was attended by all patients. Results 77 complications, of which 74 occurred postoperatively and 3 intraoperatively, affecting 72 (7.5%) out of 960 women. Urinary retention and voiding problems were the most common complication. The mean age of women suffering complications was 3.4 years higher in comparison to the mean age of women without complications (p = 0.036). The Body Mass Index (BMI) of the group of women with perioperative complications had an average BMI which was 0.5 kg/m2 lower than the average BMI of the women without complications. 22 (12.8%) out of 172 women with recurrent stress incontinence had postoperative complications, of which 21 were related to the TVT. Conclusion The retropubic TVT is a surgical procedure associated with a low number of perioperative complications, even in the group of elderly and overweight women, as well as in cases of recurrent stress incontinence.

Purpose The rates of hysterectomy are falling worldwide, and the surgical approach is undergoing a major change. To avoid abdominal hysterectomy, a minimally invasive approach has been implemented. Due to the increasing rates of subtotal hysterectomy, we are faced with the following questions: how often does the cervical stump have to be removed secondarily, and what are the indications? Methods This was a retrospective, single-centre analysis of secondary resection of the cervical stump conducted from 2004 to 2018. Results Secondary resection of the cervical stump was performed in 137 women. Seventy-four percent of the previous subtotal hysterectomy procedures were performed in our hospital, and 26% were performed in an external hospital. During the study period, 5209 subtotal hysterectomy procedures were performed at our hospital. The three main indications for secondary resection of the cervical stump were prolapse (31.4%), spotting (19.0%) and cervical dysplasia (18.2%). Unexpected histological findings (premalignant and malignant) after subtotal hysterectomy resulted in immediate (median time, 1 month) secondary resection of the cervical stump in 11 cases. In four patients, the indication was a secondary malignant gynaecological disease that occurred more than 5 years after subtotal hysterectomy. The median time between subtotal hysterectomy and secondary resection of the cervical stump was 40 months. Secondary resection of the cervical stump was performed vaginally in 75.2% of cases, laparoscopically in 20.4% of cases and abdominally in 4.4% of cases. The overall complication rate was 5%. Conclusion Secondary resection of the cervical stump is a rare surgery with a low complication rate and can be performed via the vaginal or laparoscopic approach in most cases. The most common indications are prolapse, spotting and cervical dysplasia. If a secondary resection of the cervical stump is necessary due to symptoms, 66.6% will be performed within the first 6 years after subtotal hysterectomy.

Purpose Conventional laparoscopic surgery (CLS) imposes an increased risk of work-related musculoskeletal disorders. Technical innovations, such as robotic-assisted laparoscopic surgery (RALS), may provide ergonomic benefits. We compare the surgeon`s work-related demands of CLS vs RALS for benign hysterectomies. Methods Five specialists (3 females, 2 males) each performed four RALS and four CLS as part of their daily clinical routine. During the surgical procedures, muscular demands were assessed by bipolar surface electromyograms of the descendent trapezius, extensor digitorum and flexor carpi radialis muscles as well as cardio-vascular demands by electrocardiography, and neck, arm and torso posture by gravimetrical position sensors. Additionally, the subjects rated their level of perceived workload (NASA TLX questionnaire with 6 dimension) and musculoskeletal discomfort (11-point Likert-scale, 0–10). Results Muscular demands of the trapezius and flexor carpi radialis muscles were lower with RALS but extensor digitorum demands increased. Cardiovascular demands were about 9 heart beats per minute (bpm) lower for RALS compared to CLS with a rather low median level for both surgical techniques (RALS = 84 bpm; CLS 90 bpm). The posture changed in RALS with an increase in neck and torso flexion, and a reduction in abduction and anteversion position of the right arm. The perceived workload was lower in the physical demands dimension but higher in the mental demands dimension during RALS. Subjective musculoskeletal discomfort was rare during both surgical techniques. Conclusions This explorative study identified several potential ergonomic benefits related to RALS which now can be verified by studies using hypothesis testing designs. However, potential effects on muscular demands in the lower arm extensor muscles also have to be addressed in such studies.

The objective of this case series was to describe different uterus-preserving surgical approaches and outcomes in patients with complex obstructive Müllerian duct malformation caused by cervical and/or vaginal anomalies. A retrospective analysis was performed including patients undergoing uterovaginal anastomosis (n = 6) or presenting for follow-up (n = 2) at the Department for Gynecology at the University of Tuebingen between 2017 and 2022. Uterovaginal anastomosis was performed with a one-step combined vaginal and laparoscopic approach (method A), a two-step/primary open abdominal approach with primary vaginal reconstruction followed by abdominal uterovaginal anastomosis after vaginal epithelization (method B) or an attempted one-step approach followed by secondary open abdominal uterovaginal anastomosis due to reobstruction (method A/B). Patients presented at a mean age of 15 years. Two patients were treated by method A, four by method B and two by method A/B. Functional anastomosis was established in seven of eight patients, with normal vaginal length in all patients. Concerning uterovaginal anastomosis, the primary open abdominal approach with or without previous vaginal reconstruction seems to have a higher success rate with fewer procedures and should be implemented as standard surgical therapy for complex obstructive genital malformations including the cervix.

Pelvic organ prolapse (POP) presents a common benign condition in women associated with reduced quality of life (QoL). The use of pessaries is considered a first-line treatment of POP. However, pessaries can cause perforations into adjacent organs resulting in fistulas. We present a series of three cases of rectovaginal fistulas (RVF) due to pessary perforation. Three consecutive cases of pessary-induced RVF in patients with POP stage IV were assessed between September 2016 and September 2019. Consensus for therapeutic strategy was reached by an interdisciplinary board. The RVF were located in the posterior vaginal wall and had a diameter of up to 60 mm. In one of three patients, a two-step approach was chosen with the ostomy being performed at the same time as fistula closure and modified LeFort colpocleisis. It was followed by ostomy closure 3 months later. In two patients, a three-step approach was chosen with the ostomy performed separately due to a local tissue inflammation around RVF. Neither fistula nor POP recurrences have occurred so far. Combined temporary gastrointestinal diversion, RVF closure and POP therapy can be performed as a two- or three-stage approach. Lack of evidence and standardized algorithms in RVF therapy make further clinical studies essential. We encourage the preoperative assessment of any case of complex rectovaginal fistula by an interdisciplinary board for determining an individualized treatment.

Noninvasive epithelial tissue treatment with cold atmospheric plasma (CAP) is a promising option for local treatment of chronic inflammatory and precancerous lesions as well as various mucosal cancer diseases. Atmospheric pressure plasma jets (APPJ) are well-characterized and medically approved plasma sources. There are numbers of medically approved plasma sources for the treatment of epithelial diseases; however, little is known about the biochemical effects of CAP at the plasma-tissue interface. Furthermore, the actual penetration depth of CAP into tissue is currently unclear. Noninvasive and marker-independent Raman microspectroscopy was employed to assess the molecular effects of CAP on single cells and primary human cervical tissue samples. CAP treatment showed immediate and persisting changes of specific molecular tissue components determined by multivariate analysis. Raman imaging identified CAP-dependent changes in the morphology of the tissue, as well as molecular tissue components. The expression of the different components was not significantly altered within 24 h of incubation. DNA and lipids showed the strongest changes upon CAP treatment, which were traced to the basal cell layer of cervical epithelium, corresponding to an average functional plasma penetration depth of roughly 270 μm. In this study, Raman microspectroscopy is shown to be a promising method for molecular single-cell and solid tissue characterization. Regarding CAP treatment of tissues, Raman microspectroscopy could be suitable for the screening of biological mechanisms as well as for future contact- and marker-independent monitoring of plasma tissue effects.

To evaluate the effectiveness of vaginal Er:YAG laser as treatment in patients with mild or moderate stress urinary incontinence. The study was a prospective, non-randomised, single center study of 33 women treated with two Er:YAG laser applications on an interval of four weeks. Follow-up evaluations were performed 4 and 8 weeks and 6 months after the first vaginal Er:YAG laser application (4 weeks and 5 months after the second vaginal Er:YAG laser application, respectively). The subjective outcomes were assessed using the International Consultation of Incontinence Modular Questionnaire Short Form (ICIQ-SF) and medical history. Patients rated their quality of life on a scale from 0 to 10. The average quality of life (QoL) showed a significant improvement 5 months after both Er:YAG laser applications. The mean QoL score was 6.0 (SD 2.4) and improved to a mean of 7.6 (SD 1.8) (p = 0.004). The mean ICIQ-SF score changed significantly from 12.3 (SD 3.2, median 13, range 8-18) before treatment to 6.8 (SD 4.0, median 7, range 0–15) 6 months after treatment (p

ZusammenfassungSelten können Geburtsverletzungen rektovaginale Fistelbildungen (RVF) zur Folge haben. Ziel dieser retrospektiven Studie war es, Ursachen und Management geburtshilflicher rektovaginaler Fisteln bei Patientinnen, die in der Universitäts-Frauenklinik Tübingen im Zeitraum Januar 2015 bis April 2019 operiert wurden, zu evaluieren. Fünf der 12 operativ versorgten rektovaginalen Fisteln waren Primärfisteln, in 7 Fällen lag ein Fistelrezidiv vor. Die operative Versorgung erfolgte über einen transvaginalen Zugang im Anschluss an die Geburt oder im Rahmen einer darauffolgenden Geburt. Die letztgenannte Vorgehensweise wählten wir bei Patientinnen mit hohem Rezidivrisiko bzw. bei denen, die ein hohes Risiko für postoperative funktionelle Beschwerden aufwiesen. Erstmalig wurden die schwangerschaftsbedingten Veränderungen der Vagina genutzt, um die Erfolgsraten eines Fistelverschlusses zu optimieren. 11 der 12 postpartalen rektovaginalen Fisteln konnten in unserem Patientenkollektiv verschlossen werden. Die Therapie einer geburtshilflich bedingten rektovaginalen Fistel hängt von dem Lokalbefund, den Voroperationen, den Wünschen der Patientinnen und der Erfahrung des Operateurs ab. Die Versorgung der Fisteln in Zentren ist eindeutig von Vorteil.

Zusammenfassung Hintergrund Die chirurgische Therapie der rektovaginalen Fistel stellt trotz vielfältiger Operationsverfahren weiterhin eine Herausforderung dar. Es war Ziel dieser prospektiven Studie, die Ergebnisse einer innovativen Operationstechnik zu evaluieren. Material und Methoden Es erfolgte eine transperineale Ligatur des Fisteltrakts ohne Fistulektomie oder Sphinkterplastik. Es wurden ausschließlich tiefe rektovaginale Fisteln für die Operationsmethode ausgewählt. Standardisierte Ein- und Ausschlusskriterien wurden definiert. Ergebnisse Innerhalb eines 16-Monate-Zeitraums wurden an 2 Zentren 7 Patientinnen mit einer tiefen rektovaginalen Fistel über einen transperinealen Zugang operiert. Die Genese der rektovaginalen Fisteln war postpartal, operativ-iatrogen, bei Z. n. Bartholin-Abszess sowie bei Morbus Crohn. In allen Fällen konnte die Fistel identifiziert werden und zwischen einer Ligatur durchtrennt werden. Intra- und postoperative Komplikationen traten nicht auf. Nur eine Operation erfolgte unter Stomaschutz. Nach einem mittleren Follow-up von 9 Monaten kam es zu einer Heilung bei 4 von 7 Patientinnen (Erfolgsrate 57%). Schlussfolgerung Die ersten Ergebnisse einer transperinealen Ligatur des Fisteltrakts bei der rektovaginalen Fistel scheinen vielversprechend. Um den objektiven Stellenwert zu beurteilen, müssen weitere Erfahrungen, Studien mit größerer Fallzahl und Langzeitdaten abgewartet werden.

Die Pravalenz der uberaktiven Blase betragt bei Erwachsenen 16–17 %, ein Drittel der Betroffenen leidet zugleich unter einer Dranginkontinenz. Die Symptome der uberaktiven Blase (Pollakisurie, Nykturie und imperativer Harndrang mit oder ohne Inkontinenz) treten ohne pathologische Veranderungen des Harntraktes auf. Die Basisdiagnostik umfasst: eine ausfuhrliche Anamnese, eine klinische sowie urogynakologische Untersuchung, eine Urinuntersuchung und das Fuhren eines Miktionstagebuchs. Zur weiterfuhrenden Diagnostik gehoren: die Urodynamik, die Urethrozystoskopie und die bildgebenden Verfahren. Neurologische und internistische Untersuchungen konnen differenzialdiagnostisch hilfreich sein. Die Therapie erfolgt individualisiert. Zusammengefasst stehen folgende konservative Behandlungsoptionen zur Verfugung: Lifestyle-Anderungen, Verhaltenstherapie, Beckenbodentraining und die medikamentose Therapie. Bei therapierefraktarer Dranginkontinenz werden sowohl die Injektion von Onabotulinumtoxin A (100 Einheiten) als auch die sakrale Neuromodulation gleichrangig empfohlen. Die Patientenpraferenz und der Allgemeinzustand sind hierfur entscheidend. Die Blasenaugmentation stellt die Ultima Ratio der operativen Behandlung dar. Die Zufriedenheit mit der Behandlung korreliert mit den an die Therapie gestellten Erwartungen. Demzufolge sind die Aufklarung, die Motivation und die Begleitung der Patientinnen wahrend der Therapie essenziell.

Midurethral slings are a well-established treatment option in women suffering stress urinary incontinence. Various different products and methods are used, therefore, the aim of our study was to compare two inside-out retropubic slings (TVT exact® vs. RetroArc®) inserted in two different ways regarding perioperative and mid-term outcomes. In this prospective randomized controlled non-inferiority multicentre trial, primary endpoint was postoperative cure rate, both objective (negative cough test) and subjective (absence of leakage during physical activity using the UDI-6 questionnaire). Secondary endpoints were patients’ satisfaction (Likert scale; ICIQ-UI-SF questionnaires). In addition, intra-and postoperative complications were evaluated. The TVT®-group was operated with an empty bladder, a 18 CH catheter was used with a straight inserter as instructed. Patients randomized into the RetroArc®-group were operated without inserter leading to a reduced catheter size (14 CH), bladder was filled (200 ml) during the procedure. Of the 303 women, 152 were randomized to the TVT® and 151 to the RetroArc® operation. At 3 months, n = 288 (95.0%) and at 12 months n = 229 (75.6%) were assessed. In postoperative objective cure the RetroArc®-procedure was not inferior to TVT® (p = 0.144). In subjective cure, however, the TVT exact® procedure achieved significant better results (TVT® 76.1%, RetroArc® 54.3%, p = 0.002). Perioperative complications were in majority voiding difficulties and lower after the TVT exact®-procedure. Retropubic sling procedures are safe and successful to treat female stress urinary incontinence. However, different materials and techniques result in differences between outcomes also experienced surgeons should be aware of.

To characterize and understand the demographics (age and body mass index, BMI) of a cohort of women who delivered at a single institution over an 11-year period. The purpose of this analysis is to look for effects over time of demographic characteristics on mode of delivery. Retrospective analysis of singleton deliveries between 2004–2014, n = 27,729; level 1 perinatal center, university hospital setting. Data were extracted from the digital birth registry. All statistical analyses were done using R version 3.5.1. Variables analyzed were: age, BMI, and mode of delivery (in the current and any prior pregnancies). Mean age increased from 31.1 ± 5.2 years in 2004 to 31.5 ± 5.0 years in 2014 (p

It was the aim to evaluate the personal preference of mode of delivery and to analyze differences between medical professionals and non-medical professionals. Interest in participating in a risk stratification system was evaluated. We hypothesized that gaining information about risk stratification provided in the survey could potentially change participants’ decision regarding the preferred mode of delivery; therefore, subjects were asked twice (before and after providing information). Five cohorts [four professionals (MP) including participants of the German Urogynecology Congress 2017, employees of two major university hospitals in Germany, and members of the German Society of Gynecology and Obstetrics, and one non-professional group (NP) including pregnant women] were invited online to participate in this survey. Vaginal delivery was the preferred mode of delivery in both groups (MP 90.4% vs. NP 88.8%; p = 0.429). MP are more likely to opt for CS due to concerns regarding pelvic floor disorders (MP 56.6% vs. NP 9.1%; p

The purpose of the study was to analyze anatomical and functional outcomes after sacrocolpopexy (SCP) for vaginal vault prolapse pelvic organ prolapse quantification (POPQ) II–III by random use of absorbable (Vicryl) and non-absorbable sutures (Ethibond) for vaginal mesh fixation. This study was designed as a two-center randomized controlled study (RCT). The primary objective was to evaluate the anatomical outcome. Success was defined when the vaginal apex (point C; POPQ) did not descend more than 50% of the total vaginal length (tvl) during Valsalva. Patients completed a pelvic examination incorporating the POPQ and questionnaires (the German pelvic floor questionnaire and the PISQ-12 questionnaire) at baseline and 6 months postsurgery. Perioperative adverse events (AE) were recorded. Sample size calculations, based on a 10% non-inferiority limit required 100 participants per group, with power = 90%. In 190 out of 195 women (ETH group n = 96; VIC group n = 94) anatomical success was achieved. The relative risk of anatomical success failure in the VIC group versus the ETH group was 0.69, with a 95% confidence interval 0.12–4.02. The change in the symptom scores did not differ significantly between the ETH and the VIC group. In the ETH group, three suture penetrations into the vagina were observed, and none in the VIC group 6 months postoperatively. Anatomical success after SCP for vaginal vault prolapse POPQ II–III is not affected by suture type for vaginal monofilament mesh attachment. Moreover, we did not see any differences in functional outcomes between the two groups. Three suture penetrations into the vagina were observed in the ETH group, and none in the VIC group 6 months postoperatively.

Introduction and hypothesis Urinary incontinence (UI) has a potentially devastating effect on women’s quality of life (QoL). Conservative treatment by means of pelvic floor muscle training is the first-choice treatment modality. Nowadays, this can be supported by digital apps like pelvina©—a digital health companion pelvic floor course. Methods Using pelvina©, UI symptoms and QoL are regularly examined through the questionnaires QUID and SF-6D. Subsequently, we analyzed the incidence and degree of UI and its impact on QoL in 293 users in a real-world environment. Results The 293 patients included in this study had a median age of 36 years and a median of two children. Patients were slightly to moderately affected by UI with a QUID of 6 (2–11, maximum 24). Age and number of children were independently associated with the incidence of UI with an adjusted odds ratio (aOR) of 1.06 (95% CI 1.01–1.12) and aOR of 1.86 (95% CI 1.12–3.08). The severity of UI strongly correlated with impairment of QoL (ρ = 0.866, P Conclusions The use of real-world data generated by digital health solutions offers the opportunity to gain insight into the reality of patients’ lives. In this article, we corroborate the known associations between number of children and UI as well as the great influence UI has on QoL. This study shows that, in the future, the use of digital apps can make an important contribution to scientific data acquisition and, for example, therapy monitoring.

Introduction The complication of tape erosion in the urethra following placement of a retropubic (TVT) or transobturator (TOT) tension-free suburethral vaginal sling or an accidental iatrogenic transurethral tape position can result in the formation of a urethrovaginal or vesicovaginal fistula. The objective of the investigation is the evaluation of the management of such rare complications. Patients and Methods Retrospective analysis of 14 patients who were treated for a urethral lesion or urethrovaginal fistula formation status post TVT/TOT placement between June 2011 and February 2018 in the Tübingen University Department of Gynaecology. Results As surgical therapy, 57.1% (n = 8) cases underwent vaginal fistula closure using a Martius flap of the labium majus and in 21.4% (n = 3) using a vaginal rotation skin flap. In 21.4% (n = 3), exclusively vaginal suture reconstruction of the urethra following excision of the tape running transurethrally or tape erosion was performed. 50% (n = 7) of the patients had lasting continence postoperatively without any further need for therapy. In 28.6% (n = 4), there was ongoing stress urinary incontinence, in 21.4% (n = 3) mixed urinary incontinence. Six of the 7 patients with persistent incontinence underwent new placement of a tension-free suburethral retropubic sling (TVT) an average of 8.8 months (5 – 13 months) postoperatively which was uncomplicated in all patients and achieved satisfactory continence. The 3 patients with mixed urinary incontinence and persistent urgency components additionally received anticholinergic medication. During the time period investigated, there were no long-term complications, in particular no recurrent fistulas. Conclusion The rare but relevant complications of a urethral erosion, transurethral tape position or urethrovaginal fistula formation status post TVT/TOT placement can be successfully managed via vaginal surgery. Persistent postoperative urinary incontinence with the need for a two-phase repeat TVT placement following sufficient wound healing must be preoperatively clarified.

Non-invasive physical plasma (NIPP) generated by non-thermally operated electrosurgical argon plasma sources is a promising treatment for local chronic inflammatory, precancerous and cancerous diseases. NIPP-enabling plasma sources are highly available and medically approved. The purpose of this study is the investigation of the effects of non-thermal NIPP on cancer cell proliferation, viability and apoptosis and the identification of the underlying biochemical and molecular modes of action. For this, cervical cancer (CC) single cells and healthy human cervical tissue were analyzed by cell counting, caspase activity assays, microscopic and flow-cytometric viability measurements and molecular tissue characterization using Raman imaging. NIPP treatment caused an immediate and persisting decrease in CC cell growth and cell viability associated with significant plasma-dependent effects on lipid structures. These effects could also be identified in primary cells from healthy cervical tissue and could be traced into the basal cell layer of superficially NIPP-treated cervical mucosa. This study shows that NIPP treatment with non-thermally operated electrosurgical argon plasma devices is a promising method for the treatment of human mucosa, inducing specific molecular changes in cells.

Introduction It is unclear how pelvic floor supporting structures might be affected by the absence of the vagina. It was the aim of this prospective study to analyze the magnetic resonance imaging morphology of pelvic support prior and after a Vecchietti procedure in women suffering Mullerian agenesis (Mayer-Rokitansky-Kuster-Hauser syndrome). Material and methods 26 women with a diagnosis of Mayer-Rokitansky-Kuster-Hauser syndrome associated vaginal agenesis were recruited prospectively prior to the laparoscopic creation of a neovagina according to the Vecchietti procedure. The primary outcome measure was the magnetic resonance imaging morphology of supporting structures. Secondary outcome measures were anatomical and functional vaginal length. Follow up was conducted six months after surgery. Results Twenty-six women were analyzed. Mean age was 19.8 ± 4.4 years (±SD) and mean body mass index was 23.7 ± 4.3 kg/m2 (±SD). All were Caucasian. Supporting structures consistent with cardinal and uterosacral ligaments were visible on magnetic resonance imaging in all cases (100%). There were no levator ani defects. The vaginal apex could be visualized postoperatively in 12 women (46.2%) reaching up to Level I. The vagina was visible in both Level II and III with normal relations to the pelvic walls in all cases. On gynecological examination, vaginal length was 8.8 ± 2.1 cm (mean ± SD) anatomically and 10.2 ± 2.2 cm (mean ± SD) functionally. Conclusions The preoperative presence of pelvic support structures into which the vagina is lengthened by the surgery likely explains the uncommon occurrence of vaginal prolapse in women who had the Vecchietti procedure.

To contribute to establishing donor selection criteria based on our experience with two successful living-donor human uterus transplantations (UTx) and an aborted attempt. This interventional study included three patients with uterine agenesis, aged 23, 34, and 23 years, scheduled for UTx, and their uterus-donating mothers, aged 46, 61, and 46 years, respectively. Interventions included preoperative investigations, donor surgery, back-table preparation, and recipient surgery. Preoperative imaging, surgical data, histopathology, menstrual pattern, and uterine blood flow were the main outcome measures. In the first case (46-year-old mother/23-year-old daughter), donor/recipient surgery took 12.12/5.95 h. Regular spontaneous menstruations started 6-week post-transplantation, continuing at 24–28-day intervals throughout the 6-month observation period. Repeated follow-up cervical biopsies showed no signs of rejection. In the second case (61-year-old donor), surgery lasted 13.10 h; attempts to flush the retrieved uterus failed due to extreme resistance of the left uterine artery (UA) and inability to perfuse the right UA. Transplantation was aborted to avoid graft vessel thrombosis or insufficient blood flow during potential pregnancy. Histopathology revealed intimal fibrosis and initial sclerosis (right UA), extensive intimal fibrosis (parametric arterial segments), and subtotal arterial stenosis (myometrial vascular network). In the third case (46-year-old mother/23-year-old daughter), donor/recipient surgery took 9.05/4.52 h. Menstruations started 6-week post-transplantation. Repeated cervical biopsies showed no signs of rejection during the initial 12-week follow-up period. Meticulous preoperative evaluation of potential living uterus donors is essential. This may include selective contrast-enhanced UA angiograms and limitation of donor age, at least in donors with risk factors for atherosclerosis. ClinicalTrials.gov Identifier: NCT03048396.

Proktologische Erkrankungen und Symptome werden haufig im Rahmen der gynakologischen Untersuchung erstmalig benannt; neben Hamorrhoiden als haufigster proktologischer Erkrankung sind dies prolabierende Erkrankungen (Anal- und Rektumprolaps), Perianalvenenthrombosen, Obstipation und Stuhlinkontinenz sowie malignen Erkrankungen, z. B das Analkarzinomen. Neben einer ausfuhrlichen Anamnese und klinischen Untersuchung umfasst die koloproktologische Diagnostik die Evakuationsproktographie, die dynamische Magnetresonanztomographie (MRT), die Rektoskopie und die Proktoskopie, die flexible Koloskopie, die Kolontransitzeit, die Endoanalsonographie und die Sphinktermanometrie. Die wichtigsten Krankheitsbilder aus dem koloproktologischen Bereich werden zusammengefasst, Blickdiagnosen und Diagnosen, die sich durch eine digital rektale Untersuchung abgrenzen lassen, stehen im Vordergrund. Des Weiteren werden weiterfuhrende diagnostische und therapeutische Masnahmen orientierend dargestellt.

To determine the efficacy of physiotherapy and behavior therapy and to find specific subgroups of women with overactive bladder syndrome that might gain increased benefit from this therapy. Women with ≥10 micturitions per 24-h period were included. Six to nine therapy sessions were held within a 14-day interval. Efficacy end point was a reduction in micturitions and in episodes of nocturia. Secondary outcomes included ICIQ-OAB, ICIQ-OABqol and visual analog scales. Follow-up was 6 months. Levene test, Student’s t test, Pearson´s and Spearman’s correlations were utilized as well as the Friedman test and a multivariable-multilevel model. 32 women were included. Mean age was 51 ± 15.9 (years ± standard deviation, sd). Mean body mass index (BMI) was 24.4 ± 4.8 (kg/m2 ± sd). There was a 22.9% reduction in the number of micturitions per 24 h (11.7 ± 1.6 vs. 9.0 ± 1.3 p

This study is aimed at presenting and discussing the device-related complication management during a 5-year period, of the sacral nerve modulation (SNM), in a tertiary-care university unit. This is a retrospective chart review of all women, who received SNM in our department between May 2011 and May 2016. All two-stage procedures were performed by the same experienced surgeon and according to our strict protocol of patients’ selection and follow-up. Data of perioperative and postoperative complications and their management were collected. The test stimulation was positive in 59 out of 64 patients (92%), who then received the permanent implantation after a mean test phase duration of 9 days. Mean overall follow-up was 16.5 (±10.9) months. We recorded 20 complications (31%) in 15 patients, after a mean follow-up time of 160 days. These comprise: lead migration (13.8%), infection (8.6%), pain (5.2%), wound healing disorders (5.2%) and lead fibrosis (10%). The event/patient ratio was significantly reduced from 0.6 in the beginning of our experience with SNM to 0.2 at the second period of the study (p = 0.005). All complications could be successfully resolved after surgical intervention without influence on the treatment effect. Complications after SNM are common and may require additional surgical intervention for full resolution but without affecting the treatment effect. Also, due to a learning curve, a lower events/patient ratio over time is to be expected.

Pelvic floor protection is an issue of increasing relevance. This article sought to summarize the session at last year's annual meeting of the German Society of Gynecology and Obstetrics (DGGG) in Stuttgart (10/2016) called "Urogynecology 2020-what is the optimal rate of cesarean section-does urogynecology have to deal with Obstetrics?". The main focus was set on the two important anatomical structures, the levator ani muscle and the anal sphincters. Operative vaginal delivery, epidural anesthesia, and episiotomy are subject to discussion.

Benign perivaginal masses (PVM) are relatively rare. The aim of this study is, to create a higher awareness for these entities and to point out reliable diagnostics and an accurate treatment.The medical records of the Department of Obstetrics and Gynecology Tuebingen were searched for number and type of urogynecological surgery in general, and a surgery, which took place particularly owing to benign PVM, over a period of 5 years. Diagnostics, treatment, histology and postoperative management were summarized and analyzed. Vaginal endometriosis manifestations were not considered.Between 2011 and 2015 a total number of 4.157 women underwent urogynecological surgery, 65 (1.6%) of these particularly because of benign PVM. The benign PVM in the patient cohort were composed as follows: urethral diverticula (UD), squamous epithelial inclusion cysts, periurethral cysts, Gartner's duct cysts, Müllerian cysts, pseudocysts, abscesses, epidermal inclusion cysts, angiofibromas, angiomyofibroblastomas, leiomyomas, solitary fibrous tumor and masses due to alloplastic materials. The PVM occurred singly or multiply. They were asymptomatic or accompanied by symptoms. Case history, clinical examination, pelvic floor sonography, urethrocystoscopy and MRI are essential tools for diagnostics. PVM simulated cystoceles and recto/enteroceles, were cause of an overactive bladder, dyspareunia, pain or were concomitants in women with stress urinary incontinence. The PVM were excised in 65 out of 66 cases, in one case an infected UD regressed completely under conservative antibiotic therapy.The awareness for benign PVM is helpful for their diagnostics and management. As secondary pathology, intradiverticular stones and malignancy have to be considered.

BACKGROUND Background: Many women experience urinary incontinence (UI) during andafter pregnancy due to pelvic floor weakness. First-line therapy is conservative treatment, which nowadays can be facilitated by using digitalsolutions. OBJECTIVE The aim ofthe present study was to investigate the efficacy and effectiveness of pelvinain patients with existing UI. METHODS Methods: In the present observational study we analyzed the effectivenessof pelvina, a certified digital pelvic floor training course, in reducing UI symptoms by regularly applying “The Questionnaire for Urinary Incontinence Diagnosis” (QUID) and furthermore examining quality of life (QoL) by conducting the SF-6D. RESULTS Results: In this prospective study, 373 patients with a median age of 36 years (IQR 33 - 47 years) were included. At baseline the patients had a median QUID of 11 (IQR 11 - 15). During the course, incontinence improved significantly to a QUID of 5 (IQR 2 – 11; p CONCLUSIONS Conclusion: Use of the certified digital pelvic floor course pelvinasignificantly reduces existing UI due to pelvic floor weakness over the timespan of the course. At the same time QoL is significantly improved. CLINICALTRIAL The present study was approved by the ethics committee of the Heidelberg University Hospital (S-392/2019)

Obstetric injuries can rarely lead to formation of rectovaginal fistula (RVF). The aim of this retrospective study was to evaluate the causes and management of obstetric rectovaginal fistulas in patients treated at the Department of Obstetrics and Gynecology, Tuebingen, from January 2015 to April 2019. Five of 12 surgically treated rectovaginal fistulas were primary fistulas, and 7 patients had recurrence of a fistula. The surgery was carried out by using a vaginal approach following birth or in the context of a subsequent delivery. The latter procedure was chosen in patients at high risk of recurrence or in those who had a high risk of postoperative functional discomfort. For the first time, pregnancy-related changes of the vaginal wall were used to optimise the success rates of a fistula closure. 11 of 12 obstetric rectovaginal fistulas could be closed successfully. The choice of rectovaginal fistula repair should be tailored to the underlying pathology, the type of repair performed previously, the patient's wishes and the surgeon's experience. The therapy of rectovaginal fistulas in special centres is clearly beneficial.Selten können Geburtsverletzungen rektovaginale Fistelbildungen (RVF) zur Folge haben. Ziel dieser retrospektiven Studie war es, Ursachen und Management geburtshilflicher rektovaginaler Fisteln bei Patientinnen, die in der Universitäts-Frauenklinik Tübingen im Zeitraum Januar 2015 bis April 2019 operiert wurden, zu evaluieren. Fünf der 12 operativ versorgten rektovaginalen Fisteln waren Primärfisteln, in 7 Fällen lag ein Fistelrezidiv vor. Die operative Versorgung erfolgte über einen transvaginalen Zugang im Anschluss an die Geburt oder im Rahmen einer darauffolgenden Geburt. Die letztgenannte Vorgehensweise wählten wir bei Patientinnen mit hohem Rezidivrisiko bzw. bei denen, die ein hohes Risiko für postoperative funktionelle Beschwerden aufwiesen. Erstmalig wurden die schwangerschaftsbedingten Veränderungen der Vagina genutzt, um die Erfolgsraten eines Fistelverschlusses zu optimieren. 11 der 12 postpartalen rektovaginalen Fisteln konnten in unserem Patientenkollektiv verschlossen werden. Die Therapie einer geburtshilflich bedingten rektovaginalen Fistel hängt von dem Lokalbefund, den Voroperationen, den Wünschen der Patientinnen und der Erfahrung des Operateurs ab. Die Versorgung der Fisteln in Zentren ist eindeutig von Vorteil.

Despite a variety of surgical procedures for rectovaginal fistulas, surgical therapy remains a considerable challenge. Therefore, it was the aim of this prospective study to evaluate preliminary results of an innovative technique.Surgical transperineal ligation of the fistula tract was performed without any fistulectomy or sphincter reconstruction. Only lower rectovaginal fistulas were selected for this technique. Standardised inclusion and exclusion criteria were defined.Within a 16-month period, 7 female patients with lower rectovaginal fistulas were treated by transperineal ligation of the fistula tract in two centres. Rectovaginal fistulas were associated with iatrogenic obstetric trauma, following Bartholin infection, and with Crohn's disease. In all cases, rectovaginal fistulas could be identified and treated by ligation of the fistula tract. Neither intra- nor postoperative complications were documented. Only one operation was performed under fecal diversion. After a mean follow-up of 9 months, fistula healing was observed in 4 of 7 patients (success rate 57%).Preliminary results of transperineal ligation of the fistula tract for rectovaginal fistulas seem to be promising. However, further experience, larger series and long-term follow-up have to be provided to objectively assess this innovative technique.Die chirurgische Therapie der rektovaginalen Fistel stellt trotz vielfältiger Operationsverfahren weiterhin eine Herausforderung dar. Es war Ziel dieser prospektiven Studie, die Ergebnisse einer innovativen Operationstechnik zu evaluieren.Es erfolgte eine transperineale Ligatur des Fisteltrakts ohne Fistulektomie oder Sphinkterplastik. Es wurden ausschließlich tiefe rektovaginale Fisteln für die Operationsmethode ausgewählt. Standardisierte Ein- und Ausschlusskriterien wurden definiert.Innerhalb eines 16-Monate-Zeitraums wurden an 2 Zentren 7 Patientinnen mit einer tiefen rektovaginalen Fistel über einen transperinealen Zugang operiert. Die Genese der rektovaginalen Fisteln war postpartal, operativ-iatrogen, bei Z. n. Bartholin-Abszess sowie bei Morbus Crohn. In allen Fällen konnte die Fistel identifiziert werden und zwischen einer Ligatur durchtrennt werden. Intra- und postoperative Komplikationen traten nicht auf. Nur eine Operation erfolgte unter Stomaschutz. Nach einem mittleren Follow-up von 9 Monaten kam es zu einer Heilung bei 4 von 7 Patientinnen (Erfolgsrate 57%).Die ersten Ergebnisse einer transperinealen Ligatur des Fisteltrakts bei der rektovaginalen Fistel scheinen vielversprechend. Um den objektiven Stellenwert zu beurteilen, müssen weitere Erfahrungen, Studien mit größerer Fallzahl und Langzeitdaten abgewartet werden.

BACKGROUND Urinary Incontinence (UI) can have a potentially devastating effect on women’s quality of life (QoL) in the physical, social, sexual, and psychological spheres. During pregnancy and after delivery, the strength of the pelvic floor muscle may decrease, resulting in a high rate of UI. Conservative treatment by means of pelvic floor muscle training is the first-choice treatment modality. Nowadays, this can be supported by digital apps. Those apps have the advantage of giving insights into real-world data on UI. OBJECTIVE The aim of the present study was to analyze the impact of UI on QoL using the app pelvina. METHODS We analyzed data from pelvina - a digital health companion pelvic floor course. This course regularly examines incontinence symptoms through “The Questionnaire for Urinary Incontinence Diagnosis” (QUID) and QoL through SF-6D. Subsequently, we analyzed the incidence and degree of incontinence in a real-world environment and determined the influence of different demographic factors. In addition, the impact of UI on the QoL was evaluated in more detail. RESULTS In all, 293 patients with a median age of 36 years and a median of 2 deliveries could be included in this study. Patients were slightly to moderately affected by UI with a QUID of 6 (2 - 11, max: 24). Age and parity were independently associated with the incidence of UI with an adjusted odds ratio (aOR) of 1.06 (95% CI 1.01 – 1.12) and aOR of 1.86 (95% CI 1.12 – 3.08), respectively. The severity of incontinence symptoms strongly correlated with impairment in QoL ( = 0.489, P < 0.001). CONCLUSIONS The use of real-world data, as generated by digital health solutions such as pelvina, gives us, for the first time, the opportunity to gain insight into the reality of patients' lives outside of classical clinical studies. In this paper we can corroborate the known associations between parity and UI known from the literature and the great influence UI has on QoL on a daily basis. This study shows that, in the future, the use of digital apps can make an important contribution to scientific data acquisition and, for example, therapy monitoring.

To inform uro-gynecologists about the current standards and latest developments of sacral neuromodulation (SNM) in women with overactive bladder (OAB). Literature search in the PubMed database for articles published between 1988 and 2019 on SNM for OAB in women. In total, 361 articles were identified and 51 articles retrieved for the review. SNM shows an objective success rate of 70–80%, OAB cure rate of 17–47% and a subjective satisfaction rate of 80–90%. These benefits have to be weighed against an adverse event rate of approx. 40%. SNM is significantly more successful than switching to another antimuscarinic after failed antimuscarinic drug therapy. Efficacy of SNM is slightly lower compared to bladder wall injections with 200 U botulinum toxin in the first months but efficacy of both treatments appears to be similar after 24 months. MRI examinations of patients with a sacral neurostimulator should only be performed after radiologist consultation. Sacral neurostimulators in patients with another pacemaker system should only be implanted after interdisciplinary consultation. The sacral neuromodulator should be turned off during pregnancy and delivery. SNM for OAB in patients with concomitant female sexual dysfunction or fecal incontinence seems to be beneficial. SNM is a successful and recommended second-line treatment of OAB. Sacral neurostimulators should preferably be implanted in SNM-centers because complications and the frequency of revisions are significantly reduced with increasing experience of the surgeon.

In einer der weltweit grosten epidemiologischen Erhebungen im Rahmen der norwegischen EPICONT-Studie, in der 28.000 Frauen zur Harninkontinenz befragt wurden, gaben 25 % der Frauen unfreiwilligen Harnverlust an. Die Haufigkeit stieg mit wachsendem Alter. Die Altersstruktur der Bevolkerung in Deutschland andert sich dramatisch. In 2005 waren 19 % der Bevolkerung alter als 65 Jahre. In 2020 wird der Anteil der uber 65-Jahrigen bei 23 % erwartet. Durch die hohe Pravalenz von Kontinenz- und Beckenbodenproblemen bei Frauen ergeben sich daher ein enormer Versorgungsauftrag und eine vielversprechende Perspektive fur die Subspezialitat Urogynakologie vergleichbar mit der Onkologie. Vor diesem Hintergrund ist es unerlasslich, die Urogynakologie als vierte Saule in der Frauenheilkunde zu etablieren, wie dies bereits in der Schweiz und auf europaischer Ebene (EBCOG) vollzogen ist.

Uterus transplantation (UTx) can provide a route to motherhood for women with Mayer&ndash, Rokitansky&ndash, K&uuml, ster&ndash, Hauser syndrome (MRKHS), a congenital disorder characterized by uterovaginal aplasia, but with functional ovaries. Based on our four successful living-donor transplantations and two resulting births, this analysis presents parameters relevant to standardizing recipient/donor selection, UTx surgery, and postoperative treatment, and their implementation in routine settings. We descriptively analyzed prospectively collected observational data from our four uterus recipients, all with MRKHS, their living donors, and the two newborns born to two recipients, including 1-year postnatal follow-ups. Analysis included only living-donor/recipient pairs with completed donor/recipient surgery. Two recipients, both requiring ovarian restimulation under immunosuppression after missed pregnancy loss in one case and no pregnancy in the other, each delivered a healthy boy by cesarean section. We conclude that parameters crucial to successful transplantation, pregnancy, and childbirth include careful selection of donor/recipient pairs, donor organ quality, meticulous surgical technique, a multidisciplinary team approach, and comprehensive follow-up. Surgery duration and blood vessel selection await further optimization, as do the choice and duration of immunosuppression, which are crucial to timing the first embryo transfer. Data need to be collected in an international registry due to the low prevalence of MRKHS.

Objective To report our experience with the screening and selection of potential recipients and living donors of our uterus transplantation (UTx) program. Design Part of an observational program. Setting University hospital. Patient(s) Patients with absolute uterine factor infertility (AUFI). Intervention(s) Screening by e-mail and telephone, selection during surgical consultation, and preoperative investigations according to a multistep procedure for living donation. Main Outcome Measure(s) Age, cause of AUFI, exclusion reasons, and preoperative workup. Result(s) A total of 212 potential recipients expressed interest in participation. Among the 46 potential recipients and 49 directed donors were 4 potential recipients, each with 2 directed donors. Mean (range) age of potential recipients was 29.6 (19–41) years. Of the potential recipients, 39 (84.8%) had congenital AUFI and 7 (17.3%) had acquired AUFI. Ultimately, 15 potential recipients with 16 directed donors were selected for participation, with 1 potential recipient having 2 directed donors. Mean age of included potential recipients was 28.9 (22–35) years, and mean donor age was 51.3 (37–62) years. Fourteen potential recipients (93.3%) had congenital AUFI, and one potential recipient (6.7%) had undergone hysterectomy for obstetric complications. Conclusion(s) The number of potential candidates for UTx is not inconsiderable, with congenital AUFI being the leading cause of AUFI in our cohort. However, our findings highlight that large numbers of AUFI patients need to be screened, considering our exclusion rates were >50%, owing to ABO incompatibility, unavailability of a directed donor, and self-withdrawal. Moreover, meticulous preoperative screening, including in-depth psychological assessment, is mandatory to maximize living donor safety and UTx success.