Gynecology and Obstetrics

Uterus transplantation: advantages and disadvantages of a deceased donor

Analysis of the reproductive outcomes and the size of the unicornuate uterus measured by magnetic resonance imaging and their relationship Abstract Purpose To evaluate the relationship between the uterine size measured by pelvic magnetic resonance and reproductive outcome in women with a unicornuate uterus. Methods This was a retrospective study including 140 patients affiliated with unicornuate uterus diagnosed by the pelvic MR prior to their first pregnancy in the Obstetrics and Gynecology Hospital of Fudan University from April 2010 to December 2017. All the length of the unicornuate uterus were re-measured and recorded by skilled radiologists during the study period. We divided all the 140 participants with complete pelvic MR imaging into four groups by the best reproductive outcomes, which refers to Group 1 (primary infertility, n = 21), Group 2 ( < 24 weeks' gestation, n = 34), Group 3 (preterm delivery, 24–35 weeks' gestation, n = 13), Group 4 ( ≥ 35 weeks' gestation, n = 72), followed them up and then analyzed the data. Results Measurements of 140 patients with hemi-uteri were retrieved for analysis. The mean length of the uterine was 4.90  ± 0.56 cm. There were no significant differences in the uterine cavity length, cervical length, endometrial thickness and uterine wall thickness between the four groups while the uterine length (P = 0.001) was statistically significant. Women with uterine lengths  ≥  4.5 cm were more likely to experience full-term delivery compared with the other group (P = 0.001). Ordinal multiple logistic regression analysis showed that the uterine length [OR = 9.03 (95% CI: 2.90–28.13)] and uterine cavity length [OR = 0.32 (95% CI: 0.06–2.04)] were independent protective factors for better obstetric outcomes Conclusion The uterine length is a reliable prognostic factor for the gestational week of delivery and an appropriate antenatal surveillance factor of women with unicornuate uterus.

Compare two different usages of FRD for detecting high-grade cervical lesions and invasive cancer Abstract Objective To evaluate two usages of the folate receptor-mediated staining solution (FRD) for detecting high-grade cervical lesions and invasive cancer, and compared with cytology test (TCT) and human papillomavirus (HPV) testing. Methods FRD sampling and FRD direct staining methods were used for detecting high-grade cervical lesions and invasive cancer. As a comparison, TCT and HPV testing were also applied for screening high-grade cervical lesions and invasive cancer. The sensitivity and specificity of TCT, HPV testing, and staining results of FRD were analyzed by the SPSS software. Results In this study, 317 patients with biopsy were collected. The positive rate of FRD sampling method was 35.33% (112/317), and positive rate of FRD direct staining was 48.90% (155/317). Area under the curve (AUC) of TCT, HPV testing, FRD sampling and FRD direct staining were 0.53, 0.55, 0.58, and 0.75, respectively. The sensitivity of TCT, HPV, FRD sampling and FRD direct staining was 69.72%, 97.25%, 64.22% and 81.65%, respectively, and the specificity was 37.98%, 12.98%, 79.81% and 68.27%, respectively. Conclusion Compared with TCT and HPV testing, two usages of FRD methods have compatible sensitivity and high specificity to detect high-grade cervical lesions and invasive cancer. FRD direct staining may be comfortable for routine cervical cancer screening

Incisional hernias following open gynecological surgery: a population-based study Abstract Introduction Incisional hernia is a common and costly complication following abdominal surgery. The incidence of incisional hernia after gynecological surgery is not as well studied as that after general surgery. Materials and methods The Swedish National Quality Register for Gynecological Surgery (GynOp) collects preoperative, intraoperative, and postoperative information regarding gynecological surgery. Data were extracted from 2006 to 2014. The National Patient Register (NPR) contains physicians' data from both public and private hospitals. Univariate and multivariate Cox proportional hazard analyzes were performed on risk factors. Results Between 2006 and 2014, 39,312 women undergoing open surgery were registered in GynOp. The NPR recorded 526 patients who were diagnosed with or had undergone surgery for incisional hernia. The mean follow-up was 2.8 years. Five years after surgery the cumulative incidence of incisional hernias was 2.0% (95% confidence interval 1.8–2.2%). In multivariate Cox proportional hazard analysis obesity (BMI > 30), age > 60 years, midline incision, smoking, kidney, liver, and pulmonary disease were found to predict an increased risk for incisional hernias (all p < 0.05). Conclusions There is much to be gained if the patient can cease smoking and lose weight before undergoing abdominal surgery. The Pfannenstiel incision results in fewer incisional hernias and should be considered whenever possible.

Efficacy of a collagen-fibrin sealant patch (TachoSil®) as adjuvant treatment in the inguinofemoral lymphadenectomy for vulvar cancer: a double-blind randomized-controlled trial Abstract Purpose To evaluate the effect of a collagen-fibrin sealant patch (TachoSil®) in preventing postoperative complications after inguinofemoral lymphadenectomy for vulvar cancer. Methods Double-blind randomized-controlled trial on consecutive patients undergoing bilateral inguinofemoral lymphadenectomy for vulvar cancer. Intraoperatively, inguinofemoral areas were randomized: one was treated with TachoSil®, while the contralateral had standard closure without collagen-fibrin sealant patch. Surgical outcomes, amount of drainage volume, duration of drain placement, and any postoperative complication (vulvar wound dehiscence, inguinal wound dehiscence, cellulitis, lymphangitis, lymphoceles, and hematoma) were recorded. Leg measurements were taken preoperatively and during postoperative follow-up until 6 months to evaluate lymphedema. Results A total of 19 patients were enrolled and 38 inguinofemoral dissections were performed. There was no significant difference between the investigational and control arm in the amount of drainage volume (p = 0.976), and duration of drain placement (p = 0.793). The postoperative complications, excluding lymphedema, were 10/19 (53%) in investigational arm and 9/19 (47%) in control arm (p = 0.74). At the end of follow-up, the prevalence of grade 1 lymphedema was 44.4% and 50% in investigational and control arm, respectively (p = 0.744); grade 2 and 3 lymphedema had a prevalence of 33.3% in both arms (p = 1). Conclusion Application of TachoSil® does not seem to improve postoperative lymphorrhagia nor to reduce the incidence of postoperative complications in patients undergoing inguinofemoral lymphadenectomy for vulvar cancer. Considering this point, it would be useful to identify additional strategies in inguinofemoral dissection for the prevention of these complications.

The impact of EndoPredict ® on decision making with increasing oncological work experience: can overtreatment be avoided? Abstract Background Estimating distant recurrence risk in women with estrogen receptor-positive, human epidermal growth factor receptor 2 (HER2)-negative early breast cancer is still challenging. EndoPredict® is a gene expression-based test predicting the likelihood of recurrent disease. We analyzed the difference in oncological decision making with and without the knowledge of gene expression tests. Patients and methods This is a retrospective analysis including patients diagnosed with hormone-receptor positive, Her2 negative breast cancer between 2011 and 2015 at the Municipal Breast Cancer Centre Cologne, Germany. All patients received an evaluation by EndoPredict®. An oncological tumor board (TB) with knowledge of these results served as a baseline (control group). This baseline was compared to the treatment decision (adjuvant chemotherapy yes vs. no) made by oncologists with different experience levels (less than 5 years, between 5 and 15 years, and more than 15 years) who were not provided the EndoPredict® scores. All clinicians had access to clinical as well to histopathological data. Results There was no significant difference between control group and the oncologists with different experience levels concerning a chemotherapy indication. A trend could be shown in the subgroup of nodal negative patients between the treatment recommendation and physicians with more than 15 years of experience (p = 0.088). A further trend could be demonstrated in the subgroup of patients with a low Ki67 index (≤ 14%) (p = 0.063) between physician with 5–10 years of clinical experience and official treatment recommendation. Conclusion It seems that inexperienced physicians may profit from the use of EndoPredict® to avoid an overtreatment. In nodal negative patients and patients with a low Ki67 index, undertreatment can be avoided with the use of EndoPredict® (borderline significance). Further prospective studies with larger study cohorts are needed to further validate this tool.

Tumor cell-specific Serpin A1 expression in vulvar squamous cell carcinoma Abstract Purpose The two main etiological factors for vulvar squamous cell carcinoma (vSCC) are the vulvar dermatosis lichen sclerosus (LS) and high-risk human papillomavirus (hrHPV). Serpin A1 (α1-antitrypsin) is a serine protease inhibitor, which plays a role in the tumorigenesis of various cancer types. The aim of the study was to evaluate the expressions of Serpin A1 in LS, premalignant vulvar lesions, and vSCC using immunohistochemistry (IHC) and serum analysis, and to compare Serpin A1 stainings to the tumor markers p53 and p16. Methods In total, 120 samples from 74 patients were studied with IHC for Serpin A1, p53 and p16: 18 normal vulvar skin, 53 LS, 9 premalignant vulvar lesions (dVIN/HSIL) and 40 vSCC samples. Serum concentrations of Serpin A1 were analyzed from 30 LS, 44 vSCC and 10 control patients. Expressions were compared to clinical data. Results Tumor cell-specific Serpin A1 overexpression was detected in 88% of vSCC samples, independent of the etiology. The intensity of Serpin A1 expression was significantly higher in vSCC than in healthy vulvar skin, LS, or premalignant vulvar lesions. Serpin A1 showed an association with p53 positivity. No difference in overall survival was found between Serpin A1-, p53-, or p16-positive vSCC patients. Serum concentrations of Serpin A1 were equal in the LS, vSCC, and control groups. Conclusion Tumor cell-specific Serpin A1 overexpression is a potential biomarker in vSCC.

Effects of clarithromycin on inflammatory markers and clinical manifestations in postsurgical follow-up of patients with endometriosis: a double-blinded randomized placebo-controlled clinical trial Abstract Purpose Studies showed anti-inflammatory and immunomodulatory effects of macrolide antibiotics such as clarithromycin in endometriosis. Therefore, the present study aims to investigate the therapeutic efficacy of clarithromycin in patients with endometriosis. Methods This was a double-blinded randomized placebo-controlled trial conducted on endometriotic women during March 2016–2017 in Dena Hospital, Shiraz, Iran. Immediately after surgery, the patients were randomly divided into clarithromycin (real) (n = 120) and placebo group (n = 169). The real group received 500 mg of clarithromycin everyday for 6 months and the placebo group received the placebo. The serum levels of tumor necrosis factor-alpha (TNF-α), interleukin-10 (IL-10), Erythrocyte sedimentation rate (ESR) and C-reactive protein as well as clinical symptoms at baseline and 3 and 6 months of post-surgery were compared within and between groups. Results The scores of dysmenorrhea, dyschezia, dyspareunia, and non-menstrual pain significantly decreased in both real and placebo groups compared with the baseline values. However, the real group showed greater reductions compared with the placebo group (p < 0.001). Similarly, the serum levels of CRP, TNF-α, and IL-10 decreased in both groups compared with the baseline values, but the real group showed greater reductions. Interestingly, the reductions in the clinical symptoms and serum levels did not significantly differ between the real and placebo groups. Moreover, the reductions in the studied variables showed no dependence on the time. Conclusion Clarithromycin may be an appropriate treatment in endometriotic patients. However, the non-significant differences between the real and placebo groups necessitate further studies on the therapeutic efficacy of clarithromycin.

Endoscopic surgery: talent or training? Abstract Purpose There are two groups of undergraduate students involved in endoscopic surgery with different degrees of experience: average and more experience. This study proves whether the subjective impression of the laparoscopic trainer is verifiable and which factors influence extreme talent. Methods 21 medical students of the eighth term of the University of Witten-Herdecke participated in the study. On their first course day, students got instructed in suturing and knot technique. They were then required to tie a maximum of five knots within 2 h. After a week, students repeated this procedure. Time used for tying knots was stopped. Results Regarding the time students used for their first knots, great differences were provable (7–8 min, average 23 min). However, an adaption of the knotting time was noticed at the end of the first course day. This was confirmed during the second course day. Neither acquired factors (music, sport, etc.) nor individual factors (visual acuity, handedness, etc.) had any impact on the time used for knotting. Merely, one advantage was seen with the first knots with the factors of playing the guitar and having a more than 10-h surgical previous experience. Knotting times leveled off at 95% to less than 10 min, though. Discussion Neither normally talented nor extremely talented junior surgeons could be noticed, and so could not the co-factors providing an advantage or disadvantage for surgery, respectively. All prospective surgeons can learn defined tasks (knots) by short interval training, and thus show similarly good results after a few repetitions.

Patients' perspectives towards malignant ascites: results of a prospective observational trial regarding expectations, characteristics and quality of life—a study of the North-Eastern-German Society of Gynecological Oncology Abstract Purpose Malignant ascites (MA) is a frequent and common symptom in (gyneco-) oncological patients. The present trial evaluated and assessed patients' characteristics, clinical features and the possible influence of MA on QoL measurements. Methods A prospective observational trial was conducted from Oct 2013 until Nov 2016. Therefore an interdisciplinary questionnaire was developed. Overall 250 patients with histological confirmed MA were included with different cancer entities (gynecological, gastrointestinal). The correlation of MA caused symptoms and QoL measurements was assessed using Kendall's tau b. Multivariable logistic regression models were applied to analyze the risks of symptoms or severe limitation in daily activities. Results 125 questionnaires could be analyzed. The majority of patients with MA had diagnosis of ovarian cancer (68.8%) and were under current cancer treatment (57.6%), mostly chemotherapy. Over 50% reported abdominal tension as major symptom, around 56% of the patients had MA when cancer was firstly diagnosed. Regression analysis showed that patients with MA above 2l were significantly more likely to be harmed in everyday activities. However, the age, gender, type of malignancy and the current treatment (chemotherapy vs. no chemotherapy) had no significant influence. Conclusion MA has a significantly impact on QoL measurements in cancer patients and might influence everyday activities including basic needs like eating, walking and body care. There is a high need for more information and education of patients with MA