Laparoscopic Fertility-Sparing Surgery for Early Ovarian Malignancies

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

The 3q Oncogene SEC62 Predicts Response to Neoadjuvant Chemotherapy and Regulates Tumor Cell Migration in Triple Negative Breast Cancer

In the absence of targeted treatment options, neoadjuvant chemotherapy (NACT) is applied widely for triple-negative breast cancer (TNBC). Response to NACT is an important parameter predictive of oncological outcomes (progression-free and overall survival). An approach to the evaluation of predictive markers enabling therapy individualization is the identification of tumor driver genetic mutations. This study was conducted to investigate the role of SEC62, harbored at 3q26 and identified as a driver of breast cancer pathogenesis, in TNBC. We analyzed SEC62 expression in The Cancer Genome Atlas database, and immunohistologically investigated SEC62 expression in pre- and post-NACT tissue samples from 64 patients with TNBC treated at the Department of Gynecology and Obstetrics/Saarland University Hospital/Homburg between January 2010 and December 2018 and compared the effect of SEC62 on tumor cell migration and proliferation in functional assays. SEC62 expression dynamics correlated positively with the response to NACT (p ≤ 0.01) and oncological outcomes (p ≤ 0.01). SEC62 expression stimulated tumor cell migration (p ≤ 0.01). The study findings indicate that SEC62 is overexpressed in TNBC and serves as a predictive marker for the response to NACT, a prognostic marker for oncological outcomes, and a migration-stimulating oncogene in TNBC.

Abstract P6-14-18: Effect of 3q oncogene SEC62 on migration and proliferation of triple-negative breast cancer cells

Background Chromosome 3q26 amplifications represent a frequent alteration in various cancer entities including breast cancer. SEC62 – a 3q26 encoded gene – was identified as a potential onco- and tumor-driver gene for the pathogenesis of breast cancer. Although the precise physiological function of the respective protein Sec62 is not completely understood, Sec62 seems to induce an increased stress tolerance, enhanced cell migration and invasive potential in SEC62 overexpressing cells. SEC62 overexpressing breast cancer patients have been shown to have a higher rate of lymph node metastasis and poorer overall prognosis. Hence, we aimed to further evaluate the effect of Sec62 for triple-negative breast cancer by targeting cell migration and proliferation of triple-negative cell lines altered in their SEC62 expression. Objectives The aim of this study was to investigate the role of Sec62 for triple-negative breast cancer in cell culture using functional analyzes comparing cell migration and cell proliferation in triple-negative cell lines using the effects of siRNA-mediated Sec62 depletion in vitro. Material& Methods In this study, three SEC62 gene silencing experiments each with two different siRNAs directed against the SEC62 mRNA were carried out in comparison to a control siRNA in combination with cell proliferation and cell migration tests plus Western blots for the triple-negative breast cancer cell line CAL120 in order to determine the suspected causal relationship between SEC62- overexpression and an increased cell migration and thus an enhanced invasion potential of the cancer cells. The cell proliferation was examined in real time in the 96 well xCELLigence system and the cell migration using Fluoroblock without matrigel using fluorescence microscopy. Results In cell migration assays, the median migrated cell number in the control siRNA group was 263 (241-279), the cell number in the groups of the two siRNAs directed against the Sec62 mRNA was 72 (70-149) and 178 (96-276) (p < 0.01). In cell proliferation assays, the median cell index in the control siRNA group was 7.5 (7.4-7.6), while it was 7.4 (7.3-7 .5) and 7.6 (7.5-7.7) (p=0.37). In the first analyzes of the medians of the three gene silencing experiments of the cell line CAL120, the expected negative effect of the SEC62-siRNA on cell migration is confirmed, while, as expected, the effect on cell proliferation remains unchanged with decreasing Sec62 content. Conclusion In this in vitro study using cell migration and cell proliferation assays we found a correlation between SEC62 overexpression and increased cell migration. This implies a potential association between Sec62 and an increased tumor cell invasion in triple-negative breast cancer.

Citation Format: Julia SM Zimmermann, Annika Cullmann, Askin Kaya, Merle Doerk, Maximilian Linxweiler, Marc P Radosa, Sven Lang, Martin Jung, Erich F Solomayer, Julia C Radosa. Effect of 3q oncogene SEC62 on migration and proliferation of triple-negative breast cancer cells [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-14-18.

Quality of life and sexual function in patients aged 35 years or younger undergoing hysterectomy for benign gynecologic conditions: A prospective cohort study

OBJECTIVE

To evaluate how hysterectomy performed for benign gynecologic pathologies affects the quality of life and sexual function of patients aged 35 years or younger, and if outcomes differ according to the surgical technique.

METHODS

Seventy-three patients who underwent total laparoscopic hysterectomy (TLH), supracervical laparoscopic hysterectomy (SLH), or vaginal hysterectomy (VH) for benign uterine disorders between April 2014 and June 2020 at the Department of Gynecology and Obstetrics, Saarland University Hospital, Homburg, Germany, were enrolled in this prospective observational cohort study. Quality of life and sexual function were assessed preoperatively and 6 months postoperatively using standardized validated questionnaires: the European Quality of Life Five-Dimension Scale (EQ-5D) and the Female Sexual Function Index (FSFI).

RESULTS

Thirty-three (45%) patients underwent TLH, 25 (34%) underwent SLH, and 15 (21%) patients underwent VH. The median preoperative EQ-5D score, FSFI score, and EQ-5D visual analog scale were 0.9 (range 0.62-1), 19.25 (range 2.4-27.4), and 50 (range 0-100); postoperative scores were 1 (range 0.61-1), 24.15 (range 3.9-29.3), and 90 (range 30-100), respectively (P ≤ 0.001). Postoperative scores were significantly higher than preoperative scores, with no significant difference according to the surgical technique.

CONCLUSION

Hysterectomy for benign indication in women aged 35 years or less significantly improved the patients' quality of life and sexual function with no differences regarding the surgical technique.

CLINICAL TRIAL REGISTRATION

The study was registered in the German trial registry (no. DRKS00005622).

Effect of the 3q26-coding oncogene SEC62 as a potential prognostic marker in patients with ovarian neoplasia

With approximately 220,000 newly diagnosed cases per year, ovarian cancer is among the most frequently occurring cancers among women and the second leading cause of death from gynecological malignancies worldwide. About 70% of these cancers are diagnosed in advanced stages (FIGO IIB-IV), with a 5-year survival rate of 20-30%. Due to the poor prognosis of this disease, research has focused on its pathogenesis and the identification of prognostic factors. One possible approach for the identification of biological markers is the identification of tumor entity-specific genetic "driver mutations". One such mutation is 3q26 amplification in the tumor driver SEC62, which has been identified as relevant to the pathogenesis of ovarian cancer. This study was conducted to investigate the role of SEC62 in ovarian malignancies. Patients with ovarian neoplasias (borderline tumors of the ovary and ovarian cancer) who were treated between January 2007 and April 2019 at the Department of Gynecology and Obstetrics, Saarland University Hospital, were included in this retrospective study. SEC62 expression in tumor tissue samples taken during clinical treatment was assessed immunohistochemically, with the calculation of immunoreactivity scores according to Remmele and Stegner, Pathologe, 1987, 8, 138-140. Correlations of SEC62 expression with the TNM stage, histological subtype, tumor entity, and oncological outcomes (progression-free and overall survival) were examined. The sample comprised 167 patients (123 with ovarian cancer and 44 with borderline tumors of the ovary) with a median age of 60 (range, 15-87) years. At the time of diagnosis, 77 (46%) cases were FIGO stage III. All tissue slides showed SEC62 overexpression in tumor cells and no SEC62 expression in other cells. Median immunoreactivity scores were 8 (range, 2-12) for ovarian cancer and 9 (range, 4-12) for borderline tumors of the ovary. Patients with borderline tumors of the ovary as well as patients with ovarian cancer and an immunoreactive score (IRS) ≤ 9 showed an improved overall survival compared to those presenting with an IRS score >9 (p = 0.03). SEC62 seems to be a prognostic biomarker for the overall survival of patients with ovarian malignancies.

Inverse correlation between urethral length and continence before and after native tissue pelvic floor reconstruction

Urethral length was evaluated retrospectively in patients with prolapse undergoing anterior native-tissue repair. Effects of age, prolapse stage, defect pattern, urodynamic and clinical stress test findings, and tension-free vaginal tape (TVT) surgery indication were analyzed using Mann-Whitney and Wilcoxon tests and linear and logistic regression. Of 394 patients, 61% had stage II/III and 39% had stage IV prolapse; 90% of defects were central (10% were lateral). Median pre- and postoperative urethral lengths were 14 and 22 mm (p < 0.01). Preoperative urethral length was greater with lateral defects [p < 0.01, B 6.38, 95% confidence interval (CI) 4.67-8.08] and increased stress incontinence risk (p < 0.01, odds ratio 1.07, 95% CI 1.03-1.12). Postoperative urethral length depended on prolapse stage (p < 0.01, B 1.61, 95% CI 0.85-2.38) and defect type (p = 0.02, B - 1.42, 95% CI - 2.65 to - 0.2). Postoperatively, TVT surgery was indicated in 5.1% of patients (median 9 months), who had longer urethras than those without this indication (p = 0.043). Native-tissue prolapse repair including Kelly plication increased urethral length, reflecting re-urethralization, particularly with central defects. The functional impact of urethral length in the context of connective tissue aging should be examined further.

Survey of current practices and opinions of German Society of Gynecologic Endoscopy members regarding the treatment of ovarian neoplasia by robotic surgery

PURPOSE

As data on this topic are sparse and contradictory, we aimed to ascertain the opinions of the members of the German Society of Gynecologic Endoscopy (AGE) regarding the use of robotic surgery in the treatment of ovarian malignancies.

METHODS

In 2015, an anonymous questionnaire was sent to AGE members to assess their views on the treatment of ovarian malignancies by robotic surgery according to T stage and the current treatment practices in their facilities.

RESULTS

Of the 228 respondents, 132 (58%) were fellows or attending physicians and 156 (68%) worked at university hospitals or tertiary referral centers. Most [n = 218 (96%)] respondents reported treating < 10% of their patients using robotic surgery. Respondents felt that T1 and borderline ovarian tumors, but not T2 (51%) or T3/4 (76%) tumors, should and could be treated by robot surgery. 162 (71%) respondents considered the currently available data on this subject to be insufficient, and 42% indicated their willingness to participate in clinical studies on the applicability of robotic surgery to the treatment of T1/2 ovarian tumors.

CONCLUSION

The majority of AGE members surveyed considered robotic surgery to be an option for the treatment of T1 ovarian malignancies and borderline ovarian tumors. However, prospective randomized studies are needed to determine the relevance of robotic surgery in this context.

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

Introduction

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

Materials and methods

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

Results

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

Conclusions

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

Laparoscopy compared with laparotomy for comprehensive surgical staging of early ovarian cancer: Results of a retrospective multicenter case-control study

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Background: The objective of this study was to compare laparoscopy and laparotomy for comprehensive surgical staging of early ovarian cancer in terms of efficacy and oncologic safety. Methods: Patients who had laparoscopic staging for early stage (I/II) ovarian cancer between 01/2000 and 10/2018 at the participating sites (Gynecologic comprehensive cancer centers with respective expertise in minimal invasive surgery) were included in this retrospective case-control study. The control group consisted of all patients treated via laparotomy during the study period. Clinical data were abstracted from medical record and recent follow up information were obtained. Comparisons were made between patients regarding surgical parameters and oncologic outcome and multivariate models were used to identify factors independently associated with disease recurrence. Results: Among 313 patients, staging was performed via laparoscopy in 208 (66 %) patients and via laparotomy in 105 (34 %) patients. Patients staged laparoscopically were younger (median 52 (15-86) vs. 59 (17-92) vears, p≤0.01) and had a lower BMI (24.4 (16.5-46.8) vs. 26 (15.5-53.8), p≤0.01). Regarding surgical parameters, duration of surgery was longer (291 (159-778) vs. 277 (159-690) minutes, p≤0.01), postoperative hospitalization was shorter (7 (0-27) vs. 9 (0-92) days, p≤0.01) and postoperative complications were lower in the laparoscopy group. On univariate analysis there were no differences in rates of tumor stage according to FIGO, intraoperative rupture of ovarian cysts (14 % vs. 13 %, p=0.87), number of lymph nodes removed (24 (0-89) vs. 22 (0-96), p=0.81) or any recurrence of disease (14 % vs. 16 %, p=0.52). At a median follow-up of 46 months (0-227), there were no differences in DFS and OS by surgical technique (5yr DFS 82 % (SE 0.04) vs. 83 % (SE 0.05), p=0.43; OS 91 % (SE 0.03) vs. 87 % (SE 0.04), p=0.87). On multivariate analysis route of surgery was not associated with an increased risk of recurrence. Conclusions: According to this preliminary analysis, laparoscopic surgical staging in patients with early ovarian cancer seems to be adequate and safe, but a longer follow-up and prospective data are needed to enhance evidence on oncologic outcomes.

Abstract P4-02-11: Can preoperative axillary staging replace sentinel node biopsy? Comparison of preoperative axillary and final histologic nodal findings in 2108 patients with primary breast cancer

Background Axillary staging is an integral part of the preoperative work-up in patients with breast cancer. Given the increasing number of patients treated with neoadjuvant chemotherapy (NC) and current guidelines to perform sentinel-node biopsy after the completion of neoadjuvant chemotherapy, axillary staging has gained more importance. Beside the prediction of nodal involvement, correct prediction of nodal stage is crucial in order to select respective treatment for the patients. Materials and Methods Patients treated for primary breast cancer from 01/2013 to 01/2018 and received preoperative sonografic axillary staging and surgery were identified from the breast databases of two large volume hospitals. In case of sonografic suspicion of nodal involvement an axillary biopsy was performed. Accuracy of axillary staging was examined regarding the concordance between prediction of nodal involvement and nodal (N) stage with final pathology. A multivariate model was used to identify factors associated with a high accuracy of axillary sonografic staging. Results Among 2220 patients, 112 were excluded due to incomplete clinical data or axillary surgery after completion of neoadjuvant chemotherapy leaving 2108 patients for final analysis. 1535 (73 %) showed a N0 stage on final pathology. Accuracy of axillary staging regarding prediction of nodal involvement was 92 % (1929/2108) with a sensitivity of 80 % and a specificity of 96 %, a positive predictive value of 88 % and a negative predictive of 93 %. Prediction of nodal stage was correct in 1894 of 2018 cases (90 %). Concordance between sonografic prediction of N stage and final pathology decreased with higher nodal stages (N0 - 91 %, N1 84 %, N2 81 %, N3 68 %) and was higher in node negative patients (91 %) compared to node positive patients (86 %; p ≤ 0.05). On multivariate analysis the presence of nodal involvement was the only factor associated with concordance of axillary staging and pathologic nodal stage (OR 0.11 (95 %CI 0.08 - 0.16) p ≤ 0.01). Conclusion In this large population of patients with primary breast cancer, we showed a high accuracy of preoperative axillary staging with respect to nodal involvement and prediction of respective N stage. With a negative predictive value of 93 % regarding node negativity, axillary staging showed accurate outcomes but improvements in sensitivity are necessary in oder to compete with sentinel node biopsy.

Citation Format: Julia Caroline Radosa, Martin Deeken, Lisa Stotz, Sarah Huwer, Carolin Müller, Rosemarie Weinmann, Christoph G Radosa, Marc P Radosa, Stefan Wagenpfeil, Erich-Franz Solomayer. Can preoperative axillary staging replace sentinel node biopsy? Comparison of preoperative axillary and final histologic nodal findings in 2108 patients with primary breast cancer [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P4-02-11.

Abstract P1-10-28: Role of Sec62 in prediction of response to neoadjuvant chemotherapy in patients with primary breast cancer

Background Chromosome 3q26 amplifications have been shown to represent a frequent alteration in various cancer entities including breast cancer. SEC62 - a 3q26 encoded gene - was identified as a potential oncogene and tumor-driver-gene for the pathogenesis of breast cancer. Although the precise physiological function of the respective protein Sec62 is not completely understood, it is hypothesized, that Sec62 induces an increased stress tolerance and enhances cell migration in SEC62 overexpressing cells resulting in a high rate of lymphatic metastasis and poorer overall prognosis in tumor tissue with a high Sec62 expression. We sought to further elucidate the function of Sec62 in breast cancer with special focus on its predictive role on the response to neoadjuvant chemotherapy. Materials and Methods All patients treated for primary breast cancer with neoadjuvant chemotherapy at the Department of Gynaecology and Obstetrics, Saarland University Hospital, Homburg, Germany between 01/2007 and 12/2018 were enrolled in this study. The study was approved by the Saarland institutional review board. Sec62 protein levels were analyzed in tumor tissue samples using immunohistochemistry (IHC). Sec62 immunoreactivity was evaluated by three independent examiners using the immunoreactive score (IRS) according to Remmele and Stegner (0-12). For the assessment of Sec62 protein expression in tumor cells, we rated Sec62 “negative” 0-3, “low” for a score of 4-8 and “high” for 9-12 as described in previous publications. IHC was performed on initial breast core biopsy (CB) tissue (pre-treatment) and on definite pathology specimen (PS) obtained during breast surgery after completion of neoadjuvant chemotherapy. Sec62 expression in both samples were compared and correlated with response to neoadjuvant chemotherapy evaluated pathologically using the semi-quantitative response to neoadjuvant chemotherapy scoring system by Sinn et al. ranging from 0 (no effect) to 4 (no tumor detectable). Additionally, Sec62 expression in tumor tissue was compared with the histologically tumor-free tissue of the same patient. Sec62 expression levels and correlation with response to neoadjuvant chemotherapy were compared using Wilcoxon signed-rank, Mann-Whitney and Pearson`s chi square test. Results 203 patients were assessed for eligibility. Nine cases were excluded, due to incomplete clinical information or insufficient slide quality, leaving 194 patients for final analysis. Median patient age was 54 (22-86) years and median response to neoadjuvant chemotherapy score of 2 (0-4). 20 patients (10 %) had luminal A, 46 (24 %) luminal B, 60 (31 %) Her2/neu positive and 68 (35 %) triple negative breast cancer. All analyzed slides showed an over-expression of Sec62 in breast cancer cells but no positive staining of physiologic breast tissue cells. Median Sec62 expression in core biopsies (CB) (8 (2-12)) was significantly higher compared to expression in final specimen (PS) (4 (0-12); p ≤ 0.01). Median difference between Sec62 expression of CB and PS was 2 (0-4). Regarding response to neoadjuvant chemotherapy patients with a low Sec62 expression in PS and a difference ≥ 6 between CB and PS showed a significant higher median response score compared to other patients (2 (0-4) vs. 1 (0-2); p ≤ 0.01; 4 (1-4) vs. 1 (0-4); p ≤ 0.01). When looking at breast cancer subtypes these effects were strongest in Her2/positive and triple negative patients and median Sec62 expression showed the highest decrease between CB and PS in these two subgroups (6 (-3-12); 2 (-6-12)). Conclusion We identified Sec62 as a potential biomarker for prediction of response to neoadjuvant chemotherapy in patients with primary breast cancer. This effect was observed to be strongest in patients with Her2/positive and triple negative breast cancer.

Citation Format: Julia Caroline Radosa, Mariz Kasoha, Merle Doerk, Barbara Linxweiler, Maximilian Linxweiler, Florian Bochen, Rainer M Bohle, Matthias Wagner, Marc P Radosa, Erich-Franz Solomayer, Zoltan Ferenc Takacs. Role of Sec62 in prediction of response to neoadjuvant chemotherapy in patients with primary breast cancer [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P1-10-28.

Impact of different intraoperative CO2 pressure levels (8 and 15 mmHg) during laparoscopic hysterectomy performed due to benign uterine pathologies on postoperative pain and arterial pCO2 : a prospective randomised controlled clinical trial

OBJECTIVE

To compare the effects of two different intraoperative CO₂ pressures (8 and 15 mmHg) during laparoscopic hysterectomy for benign uterine pathologies in terms of postoperative abdominal and shoulder pain, laparoscopy-mediated vegetative alterations, pain medication requirement, arterial CO₂ pressure (pCO₂ ), surgical parameters, and safety.

DESIGN

Prospective randomised controlled study.

SETTING

German university hospital.

POPULATION

Female patients undergoing laparoscopic hysterectomy for benign uterine pathologies.

METHODS

Patients were randomised to a standard pressure (SP; 15 mmHg, control) or low-pressure (LP; 8 mmHg, experimental) group.

MAIN OUTCOME MEASURES

Primary outcomes were postoperative abdominal and shoulder pain intensities, measured via numeric rating scale (NRS) and vegetative parameters (fatigue, nausea, vomiting, bloating) at 3, 24, and 48 hours postoperatively. Secondary outcomes were pain medication requirement (mg) and arterial pCO₂ (mmHg). Surgical parameters and intra- and postoperative complications were also recorded.

RESULTS

In total, 178 patients were included. Patients in the LP group (n = 91) showed significantly lower postoperative abdominal and shoulder pain scores, fewer vegetative alterations, lower pain medication requirements, a shorter postoperative hospitalization, and lower intra- and postoperative arterial pCO₂ values compared with the SP group (n = 87; P ≤ 0.01). No differences in intra- and postoperative complications were observed between groups.

CONCLUSIONS

Low-pressure laparoscopy seems to be an effective and safe technique for the reduction of postoperative pain and laparoscopy-induced metabolic and vegetative alterations following laparoscopic hysterectomy for benign indications.

TWEETABLE ABSTRACT

Low-pressure laparoscopy seems to be an effective and safe technique for reduction of pain following laparoscopic hysterectomy.

Accuracy of primary laparoscopic staging in patients with early ovarian malignancies: A retrospective multicenter study

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Background: Early ovarian malignancies (eOM) are often diagnosed incidentally in the course of diagnostic minimal invasive surgery or laparoscopy for preoperative suspected benign indications. To what extent initial minimal-invasive staging matches final FIGO stage following definite surgery is controversially discussed and current literature on this question is sparse. The aim of this study was to assess accuracy of laparoscopic staging of eOM with regard to final FIGO stage. Methods: We retrospectively identified all patients treated for eOM between 01/2000 and 10/2018. Participating sites were Gynecologic comprehensive cancer centers with great expertise in minimal invasive surgery. Inclusion criteria were no preoperative suspicion of advanced malignancy, initial staging laparoscopy, completion of surgical treatment via laparotomy and complete follow-up data. Clinical data and outcomes were abstracted from the medical record. Rate of upstaging and distinct causes were assessed and initial and definite FIGO stage and 3-year disease free (DFS) and overall survival (OS) were compared with regard to the incidence of upstaging. Results: 107 patients with eOM were included in the final analysis. In 72 (67 %) patients primary laparoscopic staging was concordant with final staging. 35 (33 %) cases were upstaged after the second operation. Regarding the cause for upstaging 4 (11 %) were upstaged because of infiltration of the contralateral ovarian capsule, 16 (46 %) because of peritoneal infiltrates and in 15 (43 %) patients an iatrogenic rupture of the ovarian tumor occurred during laparotomy. 21 (60 %) cases were upstaged within FIGO stage I and 14 (40 %) cases from stage I to II. Comparison of 3-year DFS and OS showed no differences regarding upstaging. Conclusions: In this population of patients with eOM, staging laparoscopy performed by specialized laparoscopic oncologic surgeons showed a sufficient accuracy with no case of upstaging to advanced FIGO stages. Regarding oncologic safety laparoscopic staging showed no impact on 3-year DFS and OS.

LAVH superior to TVH when concomitant salpingo-oophorectomy is intended in prolapse hysterectomy: a comparative cohort study

PURPOSE

This comparative cohort study evaluated the influence of surgical route for prolapse hysterectomy (vaginal or laparoscopically assisted) on the achievement of intended elective salpingo-oophorectomy, which was a procedural goal planned with the patient before primary vaginal native-tissue prolapse surgery.

METHODS

Consecutive patients who underwent total vaginal hysterectomy (TVH; n = 163) or laparoscopically assisted vaginal hysterectomy (LAVH; n = 144) and vaginal native-tissue repair for pelvic organ prolapse at Jena University Hospital were enrolled.

RESULTS

Peri- and postoperative parameters, including Clavien-Dindo (CD) classification of surgical complications, were compared between groups using Student's t test, Fisher's exact test, and multivariable regression. Patient characteristics were similar, except that grade IV prolapse was more common in the LAVH group (p < 0.001). The following parameters differed between the TVH and LAVH groups: concomitant salpingectomy (1.2% vs. 34%) and salpingo-oophorectomy (45% vs. 66%), non-performance of intended salpingo-oophorectomy (36% vs. 0% OR 0.006, 95% CI < 0.001-0.083), adhesiolysis (0% vs. 44%), CD II-III complications (51% vs. 14.6% p < 0.001), operating time (153 ± 61 vs. 142 ± 27 min), and postoperative in-patient days (9.02 ± 4.9 vs. 4.99 ± 0.96; all p < 0.001).

CONCLUSIONS

LAVH enabled the safe performance of planned concomitant salpingo-oophorectomy in all cases. To achieve the procedural goal in such cases, laparoscopic assistance in prolapse hysterectomy should be considered.

Instrument usage in laparoscopic gynecologic surgery: a prospective clinical trial

PURPOSE

To evaluate instrumental usage in laparoscopic gynecological surgeries and to develop key timesets of a laparoscopic operation, which allows categorization of the operation time into different sections.

METHODS

In this prospective clinical observational study, frequency of instrument usage, time for instrument switches, and instrument utilization time were recorded in a standardized manner for laparoscopic surgeries in 103 endoscopic surgeries.

RESULTS

A standard equipment (including atraumatic grasping forceps, irrigation and suction device, bipolar clamp, and laparoscopic scissors) was used for nearly all interventions. Bipolar clamps and scissors were changed most frequently. The tool used for the longest amount of time was the atraumatic grasping forceps. Laparoscopic instruments were switched 51 times per surgery (range 2-250 times). One instrument switch lasted for a median of 0.13 min (0.08-1.2 min). Median time for instrument switch for a single surgery added up to 6.83 min. Instrument switches required 10.5% of the overall operation time.

CONCLUSION

We analyzed the current instrument usage in laparoscopic gynecological surgeries. The results of our standardized investigation suggest ways to reduce the time required for surgery and provide starting points for the standardization of the work routine.

Gynaecological Prolapse Surgery in Very Old Female Patients: A Case-Control Study on Co-Morbidity and Surgical Complications

BACKGROUND

The aim of this study is to compare very elderly female patients with a younger control group after prolapse surgery with regard to co-morbidity and complications.

METHOD

In a case-control design, the consecutive data of patients after prolapse surgery at the age of over 80 years and those of a control group were analysed by means of the Clavien-Dindo (CD) classification of surgical complications, the Charlson Comorbidity Index and the Cumulative Illness Rating Scale Geriatrics (CIRS-G). Statistics: Student's t, Fisher's exact and Mann-Whitney U tests.

RESULTS

The analysis comprised n = 57 vs. n = 60 operations. In the very elderly patients there was often a grade IV prolapse (p < 0.001), apical fixations were more frequent (p < 0.001), but the operating times were not different. In the very elderly patients 21 % CD II+III complications were observed, in the control group 6.6 % (p = 0.031). No CD IV and V complications occurred in either group, the duration of inpatient stay amounted to 5 (± 1) vs. 4.1 (± 0.8; p < 0.001) days, the very elderly patients needed an inpatient follow-up more frequently (p < 0.001). The co-morbidities of the very elderly patients differed from those of the control group in number (median 2.0 vs. 1.5; p < 0.001), in CIRS-G (4.1 ± 2.2 vs. 2.4 ± 1.7; p < 0.01) and in Charlson Index (1.6 ± 1.6 vs. 0.5 ± 0.7; p < 0.001).

CONCLUSIONS

A prolapse in very elderly women can be safely managed by surgery. In no case did the complications require intensive care treatment nor were they life-threatening, but they did lead to a longer duration of hospital stay and more frequently to further treatment geriatric or inpatient internal medicine facilities.

Influence of the Preoperative Decision-Making Process on the Postoperative Outcome after Hysterectomy for Benign Uterine Pathologies

Introduction: The aim of this study was to assess whether the preoperative decision-making process might influence treatment success in premenopausal women undergoing hysterectomy for benign uterine pathologies Materials and Methods: All premenopausal women treated with hysterectomy for benign uterine pathologies between April 2011 and June 2013 at a tertiary university center were enrolled in this prospective observational cohort study. Five parameters of the preoperative decision-making process were assessed upon their correlation with postoperative quality of life, sexual function and patients' satisfaction. These outcome measures were assessed for the pre- and postoperative (six months after surgery) status using two validated questionnaires (EQ-5D and "female sexual function index" (FSFI). Patients' satisfaction with the postoperative outcome was assessed with a self-developed questionnaire. Results: 255 of 402 (63 %) patients completed the study. A correlation between the co-variables "interval between first counseling and decision to surgery", "subjectively perceived quality of the preoperative counseling" and "certainty in the decision for the intervention" and postoperative outcomes were found. The co-variables "person mainly responsible for election of hysterectomy mode" and "discussion of decision for surgery with others" showed no influence on postoperative patients-reported outcomes. Conclusion: We found a correlation between certain parameters of the preoperative decision-making process and postoperative patient-reported sexual function, quality of life and patients' satisfaction in premenopausal women undergoing hysterectomy for benign uterine pathologies. An optimization of these factors could contribute to an improvement in treatment outcomes.

Systematic classification of uterine cervical elongation in patients with pelvic organ prolapse

OBJECTIVE

To define and classify cervical elongation, to compare uterine measurements after prolapse hysterectomy with a non-prolapse control group, and to associate stage of prolapse and degree of cervical elongation.

STUDY DESIGN

This was a single-centre retrospective case-control study conducted at the University Hospital, Urogynaecological Unit, with a certified urogynaecological surgeon. Data were collected from patients with and without pelvic organ prolapse (POP) who underwent laparoscopically assisted vaginal hysterectomy. Post-hysterectomy uterine cervical elongation was examined using the corpus/cervix ratio (CCR), calculated from measurements taken on photographs. Cervical elongation was classified as physiological (grade 0, CCR>1.5) grade I (CCR>1 and ≤1.5) grade II (CCR>0.5 and ≤1), and grade III (CCR≤0.5).

RESULTS

Cervical elongation was detected in 288/295 (97.6%) patients in the prolapse group (grade I, 44/288 [15.2%]; grade II, 212 [73.6%]; grade III, 32 [11.1%]). Mean CCR was greater among those with stage II/III than among those with stage IV prolapse (1.0±0.4 vs. 0.8±0.2; p<0.001). Grades of cervical elongation and prolapse stages were associated (p<0.001). Grade I cervical elongation was detected in 26/69 (37.6%), grade II in 5/69, and grade III in 0/69 patients of the control group. Cervical elongation was found more often in the prolapse group compared to the control group (p<0.001). Mean total uterine length did not differ between the prolapse and control groups (8.0±1.6 vs. 8.2±1.3cm), but mean calculated cervical length was greater in the prolapse group than in the control group (4.4±1.1 vs. 3.1+0.8cm; p<0.001).

CONCLUSIONS

Uterine cervical elongation is found in patients undergoing hysterectomy for pelvic organ prolapse. Cervical elongation grades and prolapse stages are correlated. Defining uterine cervical elongation based on corpus/cervix ratio with grades I-III could be a valuable basic tool for further research.

Bilateral minimal tension sacrospinous fixation in pelvic organ prolapse: an observational study

OBJECTIVE

To evaluate the safety and the subjective and objective outcomes of bilateral minimal tension sacrospinous fixation for pelvic organ prolapse.

STUDY DESIGN

This was a single-centre observational study conducted at the University Hospital, Urogynaecological Unit, with a certified urogynaecological surgeon. A cohort of 110 patients receiving modified bilateral sacrospinous fixation following a diagnosis of grade II-IV pelvic organ prolapse and defects of three pelvic compartments. Non-absorbable sutures were placed on each side of the sacrospinous ligament. The main aim was to achieve a minimal tension situation by intentionally leaving suture bridges on both sides of the suspension. The post-surgical follow-up period was 14±7 months. The three characteristics of cure in functional surgery - anatomy, function, and subjective patient's judgement - were evaluated in this study. Primary outcomes were anatomic, functional, and subjective cures, that were measured pre- and postoperatively using the POP-Q system values, a validated pelvic quality-of-life questionnaire (P-QoL/D), and interviews regarding expectations, goal-setting, goal achievement, and satisfaction. Secondary outcome measures included data on surgical complications. Data analysis was performed with descriptive statistics, Wilcoxon tests, and Mann-Whitney U-tests.

RESULTS

A total of 110 patients underwent anterior and posterior colporrhaphy and minimal tension bilateral sacrospinous fixation. An objective anatomic cure was reported for 94.5% of patients, and significant improvement of all prolapse symptoms was observed following surgery (p<0.001). Full or partial fulfilment of the criteria for a subjective cure was demonstrated in 96% of the patients. Only 5.5% of the patients experienced postoperative urinary tract infections. No other complications requiring medical or surgical interventions were reported.

CONCLUSION

Bilateral minimal tension sacrospinous fixation was associated with low morbidity, as well as excellent anatomic, functional, and subjective results at follow-up.

Standardised Registration of Surgical Complications in Laparoscopic-Gynaecological Therapeutic Procedures Using the Clavien-Dindo Classification

Introduction: The registration of complications represents an important component in the evaluation of surgical therapeutic procedures. The aim of the present study was to examine the frequency of occurrence as well as the severity of surgical complications after laparoscopic-gynaecological operations in a standardised manner using the Clavien-Dindo system. Material and Methods: Altogether 7438 treatment courses after laparoscopic-gynaecological interventions by 9 working groups were evaluated. Covariates recorded were the technical complexity of the operation, type of study cohort, study size, data acquisition as well as study centre. Target variables recorded were the surgical morbidity rate, subdivided into mild (Clavien-Dindo grade I-II) and severe complications (Clavien-Dindo grade III-V). In addition, a binary logistic regression analysis for the mentioned covariates and the occurrence of surgical complication was carried out. Results: 946 complications were recorded (overall complication rate: 13 %). These included 664 mild complications (8.9 %) and 305 severe complications (4.1 %). A correlation was found between the covariates technical complexity (relative risk [rR] 1.37; p < 0.01), study size (rR: 0.35; p < 0.01) and study centre (rR 0.19; p < 0.01) and the occurrence of surgical complications. Conclusion: By means of a standardised registration of complications using the Clavien-Dindo classification it appears to be possible to limit the methodologically caused underestimation of surgical morbidity in the retrospective evaluation of gynaecological-endoscopic therapeutic procedures. Factors decisively influencing the surgical morbidity of gynaecological-laparoscopic therapeutic procedures are the respective operative experience of the treating facility as well as the technical complexity of the intervention.

Sonographic discrimination between benign and malignant adnexal masses in premenopause

PURPOSE

The aim of this study was to assess the diagnostic value of sonographic pattern recognition by experts, a standardized morphological scoring system, the risk malignancy index (RMI) and CA 125 assay for the preoperative assessment of ovarian lesions in premenopausal patients.

MATERIAL AND METHODS

Diagnostic work-up of 1320 patients who underwent surgical exploration due to an adnexal mass at a tertiary referral center were included. We assessed the discriminative value of pattern recognition, a sonographic morphological scoring system, RMI and CA 125 by calculating sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and Cohen's kappa for each diagnostic approach while using histopathology as the reference standard.

RESULTS

Pattern recognition showed the highest discriminative power with an observed kappa of 0.53. Sensitivity and specificity yielded 0.76 and 0.97 respectively. Combining pattern recognition with CA 125 serum measurement in the context of a triage system diminished the diagnostic value (kappa: 0.24; sensitivity: 0.29 specificity: 0.97). For the RMI we observed a sensitivity of 0.54 and a specificity of 0.96 and estimated kappa value yielded 0.37. Omitting the CA 125 assay and using a morphological sonographic assessment system increased the kappa value to 0.45 with sensitivity and specificity observed at 0.61 and 0.97 respectively.

CONCLUSION

Expert pattern recognition was found to be the method with the highest discriminative power in assessing an adnexal mass during premenopause. Additional assessment of serum CA 125 diminished the diagnostic accuracy. Standardized morphological sonographic assessment resulted in a moderate diagnostic accuracy. Supplementing the morphological sonographic assessment with CA 125 by using the RMI algorithm did not improve the diagnostic value.

Long-term risk of fibroid recurrence after laparoscopic myomectomy

OBJECTIVE

The use of laparoscopic myomectomy as a surgical treatment for uterine leiomyoma is associated with low intraoperative morbidity and short hospitalization. Limited data about the long-term outcome of this surgical approach are available. The aims of this study were to estimate the risk of uterine fibroid recurrence after laparoscopic myomectomy and to identify factors contributing to the rate of fibroid relapse.

STUDY DESIGN

Between 1996 and 2003, 331 patients underwent laparoscopic myomectomy to treat uterine leiomyoma in our hospital; 224 of these patients consented to participate in our 2009 follow-up survey. Clinical symptomatic uterine leiomyoma recurrence was defined as relapse. Recurrence rates at 24 and 60 months post-operatively were calculated for the study population. Fisher's exact tests were used to examine the impacts of factors previously linked to an increased risk of fibroid recurrence, including (1) patient age at the time of initial surgery, (2) pre-operative body mass index, (3) number and localization of uterine leiomyoma removed, and (4) pregnancy and (5) delivery after laparoscopic myomectomy on fibroid recurrence in our study cohort.

RESULTS

We observed 75 recurrences in 224 patients. The cumulative risk of recurrence was 4.9% at 24 months and 21.4% at 60 months post-operatively. An age of 30-40 years and the presence of more than one fibroid at the time of initial laparoscopic myomectomy were identified as factors significantly increasing the risk of symptomatic recurrence after laparoscopic myomectomy (31.25% and 38.71%, respectively; both p<0.01).

CONCLUSION

Patients with multiple uterine leiomyoma and those in the third decade of life should be counselled thoroughly about the risk of recurrence prior to laparoscopic myomectomy. The low observed recurrence rate in peri- and postmenopausal patients in our study may support the use of laparoscopic myomectomy as a uterus-preserving surgical alternative beyond the reproductive period.