The Feasibility of Practical Training in Minimally Invasive Surgery at Medical School-A Prospective Study on the Pelvitrainer

Background and Objectives: The acquisition of practical skills at medical school is an important part of the multidimensional education program of future physicians. However, medical schools throughout the world have been slow in incorporating practical skills in their curriculum. Therefore, the aims of the present prospective study were (a) to demonstrate the feasibility of such surgical training, (b) to objectify its benefit in medical education, and (c) to investigate the impact of such training on subsequent career choices. Material and Methods: We introduced a two-day laparoscopy course on the pelvitrainer as part of the curriculum of the gynecological internship of fifth year medical students from 2019 to 2020. The results of the students' training were matched to those of surgeons who completed the same curriculum in a professional postgraduate laparoscopy course from 2017 to 2020 in a comparative study design. Additionally, we performed a questionnaire-based evaluation of the impact of the course on medical education and subsequent career choices directly before and after completing the course. Results: A total of 261 medical students and 206 physicians completed the training program. At baseline, the students performed significantly more poorly than physicians in a median of three of four exercises (p < 0.001). However, this evened out in the final runs, during which students performed more poorly than physicians only in one exercise and even better than physicians in one. The general integration of surgical training in medical school curricula was rated very low (12.4% on the VAS, IQR 3-16%) despite the high demand for such training. In the survey, the course was deemed very beneficial for medical education (median VAS 80.7%, IQR 73-98%), but did not appear to influence the students' subsequent career preferences. Conclusions: The acquisition of practical surgical skills during medical school is significantly under-represented in many medical faculties. The benefits of such training, as demonstrated in our study, would improve the education of future physicians.

Factors influencing surgical performance and learning progress in minimally invasive surgery - results of an interdisciplinary multicenter study

BACKGROUND

Advancing surgical techniques require a high level of adaptation and learning skills on the part of surgeons. The authors need selection procedures and decision support systems for the recruitment of medical students and young surgeons. The authors aimed to investigate factors influencing the surgical performance and learning abilities of surgeons and medical students.

MATERIALS AND METHODS

The training scores of persons attending 16 standardized training courses (at three training centers) of the German Working Group for Gynecological Endoscopy (AGE e.V.) from 2017 to 2020, individual characteristics, and the results of psychomotor tests of three-dimensional imagination and hand-eye coordination were correlated. Similar analyses were performed for medical students in their final clinical year from 2019 to 2020. The training concept was evaluated in a prospective, multicenter, interdisciplinary, multinational setting.

RESULTS

In all, 180 of 206 physicians (response rate 87.4%) and 261 medical students (response rate 100%) completed the multistage training concept successfully. Of personal characteristics, the strongest correlation was noted for good surgical performance and learning success, and the absolute number of performed laparoscopic surgeries ( r =0.28-0.45, P <0.001/ r =0.1-0.28, P <0.05). A high score on the spatial visualization ability test was also correlated with good surgical performance ( r =0.18-0.27, P <0.01). Among medical students with no surgical experience, however, age was negatively correlated with surgical performance, that is the higher the age, the lower the surgical performance ( r =0.13/ r =0.22, P <0.05/ P <0.001).

CONCLUSION

Individual factors (e.g. surgical experience, self-assessment, spatial visualization ability, eye-hand coordination, age) influence surgical performance and learning. Further research will be needed to create better decision support systems and selection procedures for prospective physicians. The possibilities of surgical training should be improved, promoted, and made accessible to a maximum number of surgical trainees because individual learning curves can be overcome even by less talented surgeons. Training options should be institutionalized for those attending medical school.

Preclinical safety testing and initial experience of a morcellation bag with four sealable ports

Electromechanical morcellation-so called power morcellation-is a minimally invasive approach to remove bulky lesions such as uterine fibroids. The spread of benign and malignant tissue due to morcellation is a major concern that might limit the use of laparoscopic interventions. We present an in vitro evaluation of the safety characteristics of a four-port endobag with closable trocar sleeves, and describe physical properties of the bag that may or may not allow passage through the hole. In addition, we report our preliminary experience of this tool when used for laparoscopic supracervical hysterectomies. The behavior of the endobag during the extraction process was analyzed by extracting opened and re-sealed bags filled with 20 ml blue dye solution through a wooden template, with incisions measuring 10 to 24 mm. The endobag was used in 50 subtotal hysterectomies during the morcellation procedure. In the in vitro test, no dye loss was recorded for incisions measuring 11-24 mm. The mean force required to pull the bag through the template was inversely proportional to incision size. No bag rupture occurred during the surgical procedures. The mean time taken to prepare the bag for morcellation was 7.1 min (range, 4-14 min), the mean duration of subtotal hysterectomy was 53.4 min (range, 20-194 min). The mean weight of the removed body of the uterus was 113.8 g (range, 13-896 g), the mean weight of tissue and fluid remaining in the bag after morcellation 7.9 g (range, 0-39 g). In the in vitro setting, the improved endobag signifies greater patient safety during bag extraction, along with less tissue traumatization due to a smaller incision in the abdominal wall. The improved ergonomic features of the bag permit the insertion of three trocars in the lower abdomen and avoid closure of unused access ports. Our preliminary experience has shown that the device can be used under routine conditions. Failure rates will be evaluated in future studies.

Is there a benefit for adjuvant radio(chemo)therapy in early cervical cancer? Results from a population-based study

PURPOSE

Due to insufficient and conflicting prospective evidence, the recommendations on when to apply adjuvant radiochemotherapy in early-stage cervical cancer vary between international guidelines. In this population-based study, we evaluated the outcome of patients with early-stage cervical cancer based on risk factors and the adjuvant therapy they received.

METHODS

The effect of primary therapy (surgery and radiochemotherapy RCT, surgery and radiotherapy RT, and surgery alone) on overall survival (OS) and recurrence-free survival (RFS) was evaluated in the complete cohort of 442 patients and in subgroups according to risk profile and nodal status.

RESULTS

In low-risk patients, there was no difference in OS (p = 0.276) depending on whether patients received adjuvant therapy or not. Concerning RFS, patients with RT (including one patient with RCT) exhibited a significantly worse outcome compared to the group with surgery alone (p = 0.015). In intermediate-risk patients, the administration of adjuvant RT significantly benefited RFS when compared to surgery only in multivariate analysis (p = 0.031). Concerning OS, no significant influence for adjuvant treatment could be seen (p = 0.354). Though trends towards better OS and RFS could be observed in patients of the high-risk group-both in RCT and RT groups compared to surgery alone-the effects did not prove to be significant.

CONCLUSION

Our study reaffirms the evidence against the use of adjuvant radio(chemo)therapy in low-risk early-stage cervical cancer. In intermediate-, and less pronounced in high-risk patients, however, it seems to be beneficial. The role of adjuvant radio(chemo)therapy in early cervical cancer should be further investigated in prospective randomized trials.

Prospective International Multicenter Pelvic Floor Study: Short-Term Follow-Up and Clinical Findings for Combined Pectopexy and Native Tissue Repair

Efforts to use traditional native tissue strategies and reduce the use of meshes have been made in several countries. Combining native tissue repair with sufficient mesh applied apical repair might provide a means of effective treatment. The study group did perform and publish a randomized trial focusing on the combination of traditional native tissue repair with pectopexy or sacrocolpopexy and observed no severe or hitherto unknown risks for patients (Noé G.K. J Endourol 2015;29(2):210–215). The short-term follow-up of this international multicenter study carried out now is presented in this article. Material and Methods: Eleven clinics and 13 surgeons in four European counties participated in the trial. In order to ensure a standardized approach and obtain comparable data, all surgeons were obliged to follow a standardized approach for pectopexy, focusing on the area of fixation and the use of a prefabricated mesh (PVDF PRP 3 × 15 Dynamesh). The mesh was solely used for apical repair. All other clinically relevant defects were treated with native tissue repair. Colposuspension or TVT were used for the treatment of incontinence. Data were collected independently for 14 months on a secured server; 501 surgeries were registered and evaluated. Two hundred and sixty-four patients out of 479 (55.1%) returned for the physical examination and interview after 12–18 months. Main Outcome and Results: The mean duration of follow-up was 15 months. The overall success of apical repair was rated positively by 96.9%, and the satisfaction score was rated positively by 95.5%. A positive general recommendation was expressed by 95.1% of patients. Pelvic pressure was reduced in 95.2%, pain in 98.0%, and urgency in 86.0% of patients. No major complications, mesh exposure, or mesh complication occurred during the follow-up period. Conclusion: In clinical routine, pectopexy and concomitant surgery, mainly using native tissue approaches, resulted in high satisfaction rates and favorable clinical findings. The procedure may also be recommended for use by general urogynecological practitioners with experience in laparoscopy.

Depth of Neuromuscular Block Is Not Associated with Abdominal Wall Distention or Surgical Conditions during Gynecologic Laparoscopic Operations. A Prospective Trial

The influence of the degree of a neuromuscular block (NMB) on surgical operating conditions during laparoscopic surgery is debated controversially. The extent of abdominal distension during the time course of the NMB was assessed as a new measurement tool. In 60 patients scheduled for gynecologic laparoscopic surgery, the increase of the abdominal wall length induced by the capnoperitoneum was measured at 5 degrees of the NMB: intense NMB—post-tetanic count (PTC) = 0; deep NMB—train-of-four count (TOF) = 0 and PTC = 1–5; medium NMB—PTC > 5 and TOF = 0–1; shallow NMB—TOF > 1; full recovery—train-of-four ratio TOFR > 90%. Simultaneously, the quality of operating conditions was assessed with a standardized rating scale (SRS) reaching from 1 (extremely poor conditions) to 5 (excellent conditions). Fifty patients could be included in the analysis. The abdominal wall length increased by 10–13 mm induced by the capnoperitoneum. SRS was higher during intense NMB (4.7 ± 0.5) vs. full recovery (4.5 ± 0.5) (mean ± SD; p = 0.025). Generally, an intense NMB did not increase abdominal wall length induced by capnoperitoneum. Additionally, its influence on the quality of surgical operating conditions seems to be of minor clinical relevance.

Value of indocyanine green pelvic lymph node mapping in the surgical approach of cervical cancer

PURPOSE

Lymph node metastasis is a significant predictive factor for disease recurrence and survival in cervical cancer patients and relevant for therapeutic strategies. We evaluated the clinical value of indocyanine green (ICG) by measuring the sensitivity and negative predictive value of sentinel lymph node mapping compared with the gold standard of complete lymphadenectomy in detecting lymph node metastases for cervical cancer.

METHODS

We utilized the near-infrared imaging agent ICG to detect tumor-infested lymph nodes in the pelvis analogue to a classical sentinel lymph node procedure by analyzing data from 20 patients who had undergone surgery for cervical cancer at our institution. A laparoscopic lymph node mapping procedure by means of ICG, followed by a complete pelvic lymphadenectomy with or without paraaortic lymphadenectomy was done in all patients.

RESULTS

Histological examination identified seven patients with tumor-positive pelvic nodes, whereas mapping with ICG identified only five of these patients. Detection rate of positive nodes by ICG mapping and false negative rate was 71.4% and 28.6%, respectively; bilateral detection rate was 83.3%. One of the two false negative patients additionally suffered from deep infiltrating endometriosis.

CONCLUSIONS

Our results indicate that ICG can identify the relevant pelvic nodes independent of tumor size, provided bilateral detection is achieved and additional, related diseases are excluded.

TRIAL REGISTRATION

This trial is registered within the German Clinical Trial Register (DRKS-ID: DRKS00014692).

Laparoscopic approaches to the retropubic space: three alternatives with anatomical considerations

INTRODUCTION

Many urogynecological and surgical laparoscopic interventions require access to the retropubic space, also known as the space of Retzius. Especially in patients with a history of previous surgery in this area or in general in the lower abdomen, the preparation may be complicated by adhesions and scar tissue. The necessity to combine several laparoscopic procedures in one surgical session may require consideration of the most appropriate way to approach the retropubic space.

MATERIAL AND METHODS

We describe and discuss three different options to access the space of Retzius via laparoscopy: the medial transperitoneal, the extraperitoneal and the lateral transperitoneal approach. For all approaches, we used one umbilical trocar and two trocars in the lower abdomen.

RESULTS

An algorithm was developed to select the most appropriate access route to the retropubic space, depending on the history of previous surgeries and accompanying interventions.

CONCLUSION

The knowledge of different access routes to the retropubic space offers the possibility of adjusting the surgical procedure to the individual constellation of the patient.

Prospective international multicenter pectopexy trial: Interim results and findings post surgery

The technique of laparoscopic pectopexy was published in 2010. A subsequent randomized trial focused on pectopexy versus sacropexy revealed no new risks for patients and significant advantages in terms of operating time and de novo defecation disorders compared to sacrocolpopexy. The present international multicenter trial was performed to evaluate the applicability of the technique in clinical routine.

MATERIAL AND METHOD

Eleven clinics and 13 surgeons in four European counties participated in the trial. To ensure a standardized approach and obtain comparable data, all surgeons followed the same rules in placing the apical tape, no further mesh was used. Data were collected for 14 months on a secured server; 501 surgeries were documented and evaluated.

RESULTS

Patients treated at the leading center (2 surgeons) contributed 44 % of the patient population. We made a distinction between high-volume (48-135 surgeries annually) (n = 4), intermediate-volume (28-37 surgeries annually) (n = 4), and low-volume (7-22 surgeries annually) (n = 5) surgeons. 97.3 % of the patients (n = 501) had delivered children; 5.6 % had had a Caesarian section. 29.7 % of the patients had undergone a hysterectomy. The operating time for pectopexy was less than 60 min in 79 % of cases. The procedures were completed in less than 159 min in 71 % of cases. Severe complications (n = 5) included four cases of organ damage (related to concomitant surgeries or adhesions) and one case of relevant bleeding. De novo incontinence was registered in two cases and voiding dysfunction in three. No intestinal obstruction or defecation disorder was observed. Two complicated infections were noted. Urinary infection occurred in 2 % of patients.

CONCLUSION

In clinical routine severe complications occurred in 1 %. The latter were unrelated to pectopexy, but occurred due to concomitant procedures or adhesions. The overall operating time as well as the operating time for pectopexy were similar to those reported in published studies on sacrocolpopexy.

Laparoscopic anterior and posterior native tissue repair: a new pelvic floor approach

Introduction: Traditionally, a cystocele caused by a midline defect of the pelvic fascia is treated by vaginal fascia duplication, also known as anterior colporraphy. The rectocele is managed by suturing the posterior fascia and, frequently, the levator ani muscles. We developed the approach of laparoscopic anterior and posterior fascia repair by native tissue. Material and methods: The methods were based on anterior and posterior exposure of pelvic fascia similar to the preparation of an extended sacral colpopexy. The fascia was compressed and narrowed by absorbable woven sutures, size 1. Twenty-seven patients were followed up for 6-13 months. All patients received additional apical fixation by pectopexy. Results: In the examination group, 13 patients underwent anterior laparoscopic fascia repair and 23 had posterior repair. We detected one apical and one posterior relapse, and also one in the anterior repair group. The patient with the apical relapse reported pain and de novo urgency. Anatomical reconstruction was achieved in all other patients. Summary: Laparoscopic anterior and posterior native tissue repair appears to be a feasible method for the treatment of midline cystocele and rectocele. No new risks were observed. The technique leaves no scar in the vagina and is well accepted. Abbreviations: POPQ: Pelvic Organ Prolapse Quantification System; FDA: Food and Drug Association; US: United States; Fig: Figure; ICIQ: International Consultation on Incontinence Questionnaire.

[Comparison of International Guidelines For the Application of Cardiotocography]

OBJECTIVE

This study examines the recommendations of international guidelines on the use of antepartum and intrapartum cardiotocography.

MATERIAL AND METHODS

The guidelines of Germany, Canada, UK, USA, Sri Lanka, Australia as well as FIGO have been compared. The recommendations on the use of cardiotocography were separately evaluated for antepartum and intrapartum use.

RESULTS

Antepartum: In risk-free pregnancies the use of cardiotocography is not recommended in all countries. On the other hand the use of cardiotocography is indicated in the presence of a defined maternal and fetal risk factors. While the NICE guidelines recommend cardiotocography in the case of maternal hypertension, as well as preeclampsia, the German guidelines as well as SOGC list considerably more risk factors. Intrapartually, the recommendations vary greatly from country to country. While German guidelines suggest the use of cardiotocography from late 1st stage of labor, the other countries strongly recommend the auscultation of the fetal heart rate of non-risk pregnancies. This is due to the current study situation, which does not show any advantage of cardiotocography as opposed to intermittent auscultation. Furthermore studies have indicated that the use of cardiotocography caused an increase in iatrogenic induced cesarean sections. In high risk pregnancies the use of cardiotocography is strongly recommended in the compared countries, however there are major differences in the definition of high risk pregnancy and therefore the indication for cardiotocographic monitoring.

CONCLUSION

Intermittent auscultation is a more cost-effective alternative compared to cardiotocography. However, in the case of legal litigation intermittent auscultation is harder to reconstruct the well-being of the newborn during birth. On the other hand cardiotocography might result in a higher cesarean section rate, but can be more helpful to prove fetal well-being during birth for a legal litigation process. Despite the lack of evidence only German guidelines recommend cardiotocographic monitoring from the late 1st stage of labor for risk-free pregnancies.

Comparison of the trapezius and the adductor pollicis muscle as predictor of good intubating conditions: a randomized controlled trial

Background

Adequate muscle relaxation is important for ensuring optimal conditions for intubation. Although acceleromyography of the adductor pollicis muscle is commonly used to assess conditions for intubation, we hypothesized that acceleromyography of the trapezius is more indicative of optimal intubating conditions. The primary outcome was the difference between both measurement sites with regard to prediction of good or acceptable intubating conditions.

Methods

Neuromuscular blockade after injection of rocuronium 0.3 mg/kg IV was measured simultaneously with acceleromyography of the adductor pollicis muscle and the trapezius muscle in sixty female patients, American Society of Anesthesiologists physical status I to III, undergoing general anesthesia for gynecologic surgery. Exclusion criteria were: expected difficult tracheal intubation (e.g. history of difficult intubation, reduced mouth opening (< 2 cm) and/or Mallampati Score 4), increased risk of pulmonary aspiration (e.g. gastroesophageal reflux or delayed gastric emptying) allergies to drugs used during the study, pregnancy, neuromuscular diseases, medication with potential to influence neuromuscular function (e.g. furosemide, magnesium, cephalosporins) and hepatic or renal insufficiency (serum bilirubin >26 μmol/L, serum creatinine >90 μmol/l). Patients were randomized to 2 groups: group A (n = 30): endotracheal intubation after onset of the neuromuscular block at the adductor pollicis muscle. Group B (n = 30): endotracheal intubation after onset at the trapezius muscle. Intubating conditions were compared between both groups by means of a standardised score (the Copenhagen score) with Fisher’s exact test.

Results

Onset of the block after rocuronium injection was observed at the adductor pollicis muscle compared to the trapezius with 2.8 (1.1) versus 2.5 (1.1) min (mean ± SD; P = 0.006). Intubating conditions were poor in 2 patients (7%) of group A, and in 1 patient (3%) of group T. They were acceptable (either excellent or good) in 28 patients (93%) in group A, and in 1 patient (97%) in group T (P = 0.82).

Conclusions

Performing acceleromyography at the trapezius muscle reduced the time between injection of neuromuscular blocking agents and intubation by 18 s (11%). Thus, trapezius muscle acceleromyography is an acceptable alternative to adductor pollicis muscle acceleromyography in predicting acceptable intubating conditions, which allows for earlier indication of adequate intubating conditions.

Trial registration

ClinicalTrial.gov Identifier: NCT01849198. Registered April 29, 2013.

Monitoring recovery from rocuronium-induced neuromuscular block using acceleromyography at the trapezius versus the adductor pollicis muscle: an observational trial

PURPOSE

Positioning for surgery can restrict access to the patient's hand, thereby limiting assessment of the response at the adductor pollicis muscle to ulnar nerve stimulation. We evaluated a novel site to assess neuromuscular block by stimulating the accessory nerve and measuring the acceleromyographic response at the trapezius muscle.

METHODS

In this prospective non-blinded observational study, we assessed neuromuscular transmission in anesthetized adult female patients undergoing elective laparoscopic gynecological surgery. We performed the assessment by simultaneous recording acceleromyographic responses with the TOF-Watch(®) SX monitor at both the right adductor pollicis and left trapezius muscles. The neuromuscular block was achieved using rocuronium 0.3 mg·kg(-1), and the repeatability, time course, and limits of agreement (Bland-Altman) of responses were compared at the two recording sites. The primary endpoint was the 90% train-of-four (TOF) recovery time with other endpoints included the onset time of the block, maximum T1 depression, time to 25% T1 recovery, and recovery time course of the T1 response and TOF ratio.

RESULTS

Thirty-six patients were enrolled with responses obtained from 27 subjects. The variability of baseline responses recorded at the trapezius muscle was larger than that recorded at the adductor pollicis muscle, as determined by their mean (SD) repeatability coefficients [twitch height T1, 6.1 (1.9)% and 4.2 (1.6)%, respectively; P = 0.001; TOF ratio, 6.2 (2.1)% and 4.3 (1.7)%, respectively; P = 0.001]. The recorded responses showed relatively narrow limits of agreement. The onset time of the block was 0.3 min earlier at the trapezius muscle than at the adductor pollicis muscle [2.3 (0.8) min and 2.6 (0.7) min, respectively; P = 0.007], with limits of agreement ranging from 1.6 min earlier to 1.0 min later. The time to 25% T1 recovery was 1.8 min earlier at the trapezius muscle than at the adductor pollicis muscle [18.2 (5.7) min and 20.0 (5.2) min, respectively; P = 0.039], with limits of agreement ranging from 11.1 min earlier to 7.5 min later. Additionally, the time to achieve 90% TOF ratio was 4.4 min earlier at the trapezius muscle than at the adductor pollicis muscle [32.6 (7.9) min and 37 (9.1) min, respectively; P = 0.004], with limits of agreement ranging from 18.4 min earlier to 9.7 min later.

CONCLUSIONS

We conclude that recording evoked acceleromyographic responses at the trapezius muscle is an acceptable alternative when monitoring from the adductor pollicis muscle is compromised. Nevertheless, we caution that recording a 90% TOF response at the trapezius muscle may overestimate functional recovery from the neuromuscular blockade. This trial was registered at ClinicalTrials.gov identifier, NCT01849198.

Laparoscopic pectopexy: a prospective, randomized, comparative clinical trial of standard laparoscopic sacral colpocervicopexy with the new laparoscopic pectopexy-postoperative results and intermediate-term follow-up in a pilot study

PURPOSE

The purpose of the study was to compare the outcome of laparoscopic sacral colpocervicopexy with laparoscopic pectopexy. Our aim was to show that the safety and effectiveness of the new technique is similar to the traditional technique. We expected differences regarding defecation disorders.

PATIENTS AND METHODS

We randomly assigned patients to two treatment groups: 44 in the pectopexy and 41 in the sacropexy group. If necessary, the operative procedures were planned in a so-called multicompartment setting regarding the different pelvic floor disorders. All defects were managed at the same time. Eighty-one patients were examined 12 to 37 months after treatment (mean follow-up 20.67 months).

RESULTS

The long-term follow-up (21.8 months for pectopexy and 19.5 months for sacropexy) showed a clear difference regarding de novo defecation disorders (0% in the pectopexy vs 19.5% in the sacropexy group). The incidence of de novo stress urinary incontinence was 4.8% (pectopexy) vs 4.9% (sacropexy). The incidence of rectoceles (9.5% vs 9.8%) was similar in both groups. No de novo lateral defect cystoceles were found after pectopexy, whereas 12.5% were found after sacropexy. The apical descensus relapse rates, 2.3% for pectopexy vs 9.8% for sacropexy, were not statistically significant. The occurrence of de novo anterior defect cystoceles and rectoceles revealed no significant differences.

CONCLUSION

Laparoscopic pectopexy is a novel method of vaginal prolapse therapy that offers clear practical advantages compared with laparoscopic sacropexy. Because laparoscopic pectopexy does not reduce the pelvic space, it results in a zero percentage of defecation disorders.

Pain medication requirements after sacropexy and combination interventions

BACKGROUND AND OBJECTIVES

Laparoscopic surgery is associated with reduced morbidity, and postoperative pain is reduced. The aim of this study was to assess postoperative pain intensity, analgesic requirements, and the influence of cofactors after laparoscopic sacral colpopexy.

METHODS

The study assessed 287 patients treated with laparoscopic sacropexy for genital prolapse with a Pelvic Organ Prolapse Quantification grade>1. Patients were asked to evaluate their pain postoperatively using a 4-point verbal pain rating scale. In addition, medical records were analyzed regarding the requirement for analgesic medication.

RESULTS

Patients distinguished between abdominal pain and shoulder pain after laparoscopy. Abdominal pain reached maximum severity on day 1 and showed a good response to nonsteroidal antiphlogistics, whereas shoulder pain was rarely found (6.27%). Of the patients, 38% required no pain treatment or required 1 dose at most. The need for pain medication reached its climax on day 1 and decreased during the 5 following days. Non-opioid analgesics provided a sufficient therapeutic effect.

CONCLUSION

Laparoscopic sacropexy is associated with a moderate degree of postoperative pain. Non-opioid analgesics should be preferred as first-line therapy. The typical shoulder-tip pain showed only a low prevalence in our study group. From our point of view, the low rate of shoulder-tip pain corresponded with the low intra-abdominal carbon dioxide pressure.

Value of clinical and laboratory inflammation factors in the postoperative period after laparoscopic urogynecological surgery

BACKGROUND/AIMS

Leukocytes and C-reactive protein (CRP) levels are often used to detect infections. The aim of this study was to evaluate the diagnostic and screening validity of leukocytes and CRP levels as well as body temperature >38° C to predict infections after laparoscopic sacrocolpopexy.

METHODS

The study included 287 patients suffering from genital prolapse higher than POP-Q I. In addition to the sacrocolpopexy, a laparoscopic supracervical hysterectomy was performed in cases of preexisting uterus (n = 171). Leukocytes and CRP levels were analyzed preoperatively and 4 days after surgery. Early and late onset of infections was documented.

RESULTS

Urinary tract infection was identified as the most frequent early postoperative complication (11.4%). Early wound infections were found in 2.8% of the patients (8/287). Late onset of infections was found in 1% of patients (3/287). Areas under ROC curves were low for both leukocytes (0.52, 95% CI: 0.37-0.66) and CRP levels (0.60, 95% CI: 0.44-0.77).

CONCLUSION

Our findings question the benefit of routine determination of leukocytes and CRP levels 4 days after surgery. The sensitivity and specificity of leukocytes and CRP levels are probably more significant after normalization of the initial tissue response (days 8-10).

Effects of Putative Epididymal Osmolytes on Sperm Volume Regulation of Fertile and Infertile c-rosTransgenic Mice

Volume regulation by spermatozoa has been demonstrated to be crucial in both mice and men for transport in the female tract. In order to determine the nature of osmolytes used by spermatozoa, they were released from the cauda epididymis of fertile c-ros heterozygous mice into incubation medium of uterine osmolality (representing an osmotic challenge), containing increasing concentrations of compounds that are major epididymal fluid components and known osmolytes in somatic cells. This should nullify the concentration gradients for osmolytes that mediate volume regulation, prevent osmolyte efflux, and lead to swelling. Of the osmolytes tested, K(+) caused the most rapid and extensive volume increases; glutamate, taurine, L-carnitine, and myo-inositol also were effective, but glycerophosphocholine was not. Such effects were not observed in cauda sperm from the infertile knockout mice, demonstrating a defect in normal volume regulation. K(+) concentrations in cauda epididymal fluid were 21 mM higher in the knockout than the heterozygous mice, but no differences were found in caudal fluid glutamate, carnitine, or myo-inositol. The carnitine content of cauda sperm from knockout males was not different from that of fertile males, but lower amounts of glutamate and inositol were found that could explain the poor volume regulation. In heterozygous mice, cauda but not caput sperm responded to the K(+) channel blocker quinine by swelling, demonstrating development of volume regulation during epididymal transit, whereas knockout cauda sperm showed no response, as with the osmolytes. Major epididymal secretions could serve as osmolytes in murine spermatozoa for volume regulation in response to physiological osmotic challenge in the normal fertile mice; the reduced sperm content of inositol and glutamate in the c-ros knockout mice might reflect maturational abnormalities in volume regulation.

Laparoscopic pectopexy: a randomised comparative clinical trial of standard laparoscopic sacral colpo-cervicopexy to the new laparoscopic pectopexy. Short-term postoperative results

PURPOSE

Sacral colpopexy is a well established method of vaginal prolapse correction. Although it is capable of restoring the physiologic axis of the vagina, this method also bears some serious operative risks [1]. The aim of the study was to compare the laparoscopic sacral colpopexy with a laparoscopic bilateral fixation of the vagina/cervix to the iliopectineal ligaments via a PVDF-mesh (pectopexy).

METHODS

This part of a single-center randomized prospective clinical trial (Canadian Task Force Classification) compared the short-term operative outcome of laparoscopic sacropexy and pectopexy. We evaluated the operating time, blood loss, hospital stay duration, occurrence of major complications, episodes of constipation, urinary retention, de novo urinary incontinence, urinary tract infections, body mass index and postoperative Creactive protein values. The 1-year follow up examination will be carried out to evaluate the occurrence of relapse as well as late complications. Local symptoms and sexual activity will be evaluated using a German version of the ICIQ Vaginal Symptoms Questionnaire.

RESULTS

We carried out 43 pectopexies and 40 sacropexies in conjunction with other laparoscopic and/or vaginal procedures, as indicated. No major complications occurred in both groups during the hospital stay. There were no significant differences in the body mass index, average age, hospital stay duration and occurrence of constipation. The average operating time (43.1 vs. 52.1 min) and blood loss (4.6 vs. 15.3 ml) were significantly lower in the pectopexy group (p < 0.001).

CONCLUSION

Although laparoscopic pectopexy cannot yet be generally recommended as an alternative to sacropexy until the follow-up data is obtained, the new method can be considered in patients where the presacral preparation bears a higher risk of injury.

Volume regulation of mature and immature spermatozoa in a primate model, and possible ion channels involved

BACKGROUND

Human ejaculated sperm undergo volume regulation, and swollen cells fail to penetrate mucus. Study of an infertile mouse model indicates maturation of volume regulation mechanism in the epididymis.

METHODS

Sperm from the ejaculate and three regions of the epididymis of the cynomolgus monkey (Macaca fascicularis) were dispersed in BWW medium and changes in the cell volume and kinematics, and their responses to ion channel blockers, were monitored by flow cytometry and motion analysis.

RESULTS

Initially swollen cauda epididymidal spermatozoa regained their original volume within 20 min, but not in the presence of 0.25 mM quinine. Corpus epididymidal spermatozoa underwent such regulatory volume decrease (RVD) to a lesser extent, with a similar response to quinine. Caput sperm showed no swelling throughout incubation. The chloride channel inhibitor NPPB also caused swelling of cauda spermatozoa and both quinine and NPPB decreased the efficiency of forward progression. RVD of ejaculated spermatozoa was inhibited by the K+ channel blockers quinine and 4-aminopyridine (4-AP) but not by tetraethylammonium, Ba2+ or Gd3+, or the specific potassium channel blockers charybdotoxin, margatoxin, dendrotoxin, apamin, glybenclamide or clofilium. Quinine and 4-AP also altered ejaculated sperm kinematics as reported in human ejaculated spermatozoa.

CONCLUSIONS

Quinine- and 4-AP-sensitive (implying K+) and NPPB-sensitive (implying Cl-) channels are involved in RVD of primate sperm, which develop this volume regulatory ability in the epididymis.

Human sperm volume regulation. Response to physiological changes in osmolality, channel blockers and potential sperm osmolytes

BACKGROUND

Volume regulation is an important sperm function because defective sperm cannot negotiate the female tract in an infertile mouse model and swollen human sperm cannot penetrate and migrate through mucus.

METHODS AND RESULTS

The size of sperm from 52 donor ejaculates incubated in medium of female tract fluid osmolality (BWW290) was measured by flow cytometry to be identical to that in homologous semen osmolality (289-351 mosmol/kg), indicating effective volume regulation. Inhibition of anticipated regulatory volume decrease in BWW290 by the channel blocker quinine induced size increases and associated kinematic changes measured by computer-aided sperm analysis. Incubation in L-carnitine, myo-inositol and taurine did not change sperm volume or kinematics, but the presence of glutamate and K(+) decreased the efficiency of forward progression indicative of volume increase, suggesting them as potential osmolytes for human sperm. Linear regression suggested correlations of changes in cell volume and in kinematic parameters, and the association of faster forward progressive sperm with smaller cell size.

CONCLUSIONS

Sperm volume and its regulation may be crucial to natural fertility. The identification of sperm osmolytes, ion channels and mechanisms involved would contribute to the understanding of male infertility and offer a lead for male contraception.

Measurement of volume changes in mouse spermatozoa using an electronic sizing analyzer and a flow cytometer: validation and application to an infertile mouse model

The importance of sperm volume has recently been highlighted in a knockout mouse model in which infertility was caused by defects in volume reguiation, which led to sperm transport failure in the female tract. Inhibition of volume regulation by human sperm, resulting in failure of penetration of cervical mucus in vitro, has also been reported. The present work aims to establish a sensitive and convenient method for monitoring changes in sperm volume for functional studies. Mature murine sperm obtained from the cauda epididymidis were analyzed by flow cytometry for their forward and side (90 degrees C) scatter of a 488-nm excitation wavelength laser, and the data were compared with volumes measured by electronic sizing using a Coulter counter. Changes in cell volume were induced by releasing or diluting sperm into culture media of various osmolalities (208-520 mmol/kg). Forward scatter signal (FSS) intensity correlated well with volume measurement obtained by a Coulter counter (R =.83; P <.001), confirming that FSS reflects Coulter counter findings as for somatic cells. Sperm swelling was also induced by the presence of quinine, a wide-spectrum channel blocker, in a medium of 330 mmol/kg, which is similar to the osmolality of uterine fluid. The effect of quinine on sperm volume was more obvious when analyzed by flow cytometry than by electronic sizing. This effect was even more marked after dead sperm identified by fluorescent dye were eliminated from analysis using flow cytometry. Swelling was characterized by an increase in forward scatter and side scatter, generating a subpopulation of sperm that correlated well (R =.79; P <.0001) with the population of sperm exhibiting an angulation of the tail, which is a morphological manifestation of swollen murine sperm. Flow cytometric analysis revealed that infertile sperm released from the cauda epididymidis of c-ros knockout mice were significantly larger than those of fertile sperm from heterozygous mice. This finding directly substantiates the suggestion that infertile sperm are defective in their volume regulation. Laser scatter analysis of viable murine sperm by flow cytometry offers a convenient and sensitive method for the study of sperm volume regulation.

Sperm volume regulation: maturational changes in fertile and infertile transgenic mice and association with kinematics and tail angulation

Laser light scatter analyzed by flow cytometry was used to monitor the volume of viable maturing murine spermatozoa. Upon release, dispersion, and dilution, epididymal sperm from fertile heterozygous c-ros knockout mice were smallest in the cauda region and largest in the corpus region. Cauda sperm from both infertile homozygous c-ros knockout and GPX5-Tag2 transgenic mice were abnormally large. When incubated, corpus and cauda sperm from normal mice became slightly enlarged and later returned to a smaller size. This suggests an immediate swelling due to high intracellular osmolality, which triggers a regulatory volume decrease (RVD) that results in a net volume reduction. Normal caput sperm increased in size continuously and became larger than the more mature sperm, indicating a lack of RVD. The ion-channel blocker quinine induced dose-dependent size increases in normal cauda sperm but not in caput sperm. Dose-dependent quinine action on mature sperm also included induction of tail angulation, and suppression of straight-line velocity and linearity. The kinematic effects were more sensitive, with a quicker onset, but they diminished with time in contrast to tail angulation, which intensified. These results suggest that kinematic changes are an early phenomenon of swelling, which gradually accumulates at the cytoplasmic droplet to cause flagellar angulation. Disruption of the epididymal maturation of sperm volume regulation capacity would hinder the transport of sperm in the female tract, and may thereby explain infertility under certain conditions, but may also provide a novel approach to male contraception.