Expectations for Endoscopic Training During Gynaecological Specialty Training - Results of a Germany-wide Survey.

Question: Endoscopy is an integral part of surgical gynaecology and is playing an increasingly important role in ensuring adequate gynaecological training in the context of specialty training in general. At present, little is known about the expectations and notions of young junior doctors with respect to endoscopic training. For this reason, junior doctors throughout Germany were surveyed on this topic and asked to share their opinions. Methods: Using an anonymized standardized survey, the following information was elicited: importance of endoscopic training, willingness to take courses, expectations for instructors and the hospital, ideas about the number of required operations, both as a surgical assistant and as a surgeon, as well as satisfaction with the current status of training. The questionnaires were sent via the Young Forum (Junges Forum) of the German Society of Gynaecology and Obstetrics (DGGG) and the newsletter of the Working Group for Gynaecological Endoscopy (AGE). Results: The evaluation of the study was based on 109 completed questionnaires. The resident junior doctors were 31 years old on average and were in their third to fourth year of their specialty training on average. The majority of the participants (87 %) considered the learning of endoscopic techniques to be very important and advocated regular participation in endoscopy training courses. Among the participants, 48 % were prepared to invest up to €1500 of their own funds to attend courses up to twice a year during the entire specialty training period. The expectations of the instructors and institutions focused on technical expertise, the willingness and time for teaching and on the number and range of surgical procedures, followed by being granted leave for the courses and having costs covered for the courses. Thirty-eight per cent stated that their expectations had been completely or mostly met and 62 % said they had been met in part or inadequately. Eighty-three per cent of the respondents reported that they would change specialty training institutions in order to achieve their own goals in the context of specialty training. Conclusions: This study presents data for the first time on the satisfaction of young junior doctors and their expectations for endoscopic specialty training. The residents exhibited a high level of interest in endoscopy and a high level of willingness to actively shape the specialty training, including course participation. However, there appears to be a great deal of room for improvement for endoscopic specialty training, independent of the current training institution, training year or sex of the junior doctors.

Indications and Route of Hysterectomy for Benign Diseases. Guideline of the DGGG, OEGGG and SGGG (S3 Level, AWMF Registry No. 015/070, April 2015)

Background: Official guideline "indications and methods of hysterectomy" to assign indications for the different methods published and coordinated by the German Society of Gynecology and Obstetrics (DGGG), the Austrian Society of Gynecology and Obstetrics (OEGGG) and the Swiss Society of Gynecology and Obstetrics (SGGG). Besides vaginal and abdominal hysterectomy, three additional techniques have been implemented due to the introduction of laparoscopy. Organ-sparing alternatives were also integrated. Methods: The guideline group consisted of 26 experts from Germany, Austria and Switzerland. Recommendations were developed using a structured consensus process and independent moderation. A systematic literature search and quality appraisal of benefits and harms of the therapeutic alternatives for symptomatic fibroids, dysfunctional bleeding and adenomyosis was done through MEDLINE up to 6/2014 focusing on systematic reviews and meta-analysis. Results: All types of hysterectomy led in studies to high rates of patient satisfaction. If possible, vaginal instead of abdominal hysterectomy should preferably be done. If a vaginal hysterectomy is not feasible, the possibility of a laparoscopic hysterectomy should be considered. An abdominal hysterectomy should only be done with a special indication. Organ-sparing interventions also led to high patient satisfaction rates, but contain the risk of symptom recurrence. Conclusion: As an aim, patients should be enabled to choose that therapeutic intervention for their benign disease of the uterus that convenes best to them and their personal life situation.

[CAMIC Recommendations for Surgical Laparoscopy in Non-Obstetric Indications during Pregnancy]. / CAMIC-Empfehlungen zur chirurgischen Laparoskopie aus nicht geburtshilflicher Indikation während der Schwangerschaft.

In the operative surgical primary care, the laparoscopic surgical technique has firmly established itself in recent years. Meanwhile, in the normal population over 90 % of all cholecystectomies and over 80 % of all appendectomies are performed in a minimally invasive manner. The proven benefits of the laparoscopic surgical technique, compared with conventional open surgery, are a comparatively rapid early postoperative recovery with early resumption of the general physical and occupational activity. As these benefits are equally applicable for necessary interventions during pregnancy, in recent years laparoscopy has become the preferred treatment for non-obstetric indications in the gravid patient. Overall, it can be assumed that such interventions have to be performed in approximately 2 % of all pregnant patients. Numerous studies have proven here that the use of laparoscopic techniques, in particular for the expectant mother, is safe and not associated with an increased risk. On the other hand, the current pregnancy makes necessary an adapted approach to the solution of surgical problems to ensure the protection of the unborn child. On the basis of currently available data situation, recommendations are formulated which can be used as a decision-making support for a variety of clinical situations.

Surgical Methods for the Treatment of Uterine Fibroids - Risk of Uterine Sarcoma and Problems of Morcellation: Position Paper of the DGGG.

The appropriate surgical technique to treat patients with uterine fibroids is still a matter of debate as is the potential risk of incorrect treatment if histological examination detects a uterine sarcoma instead of uterine fibroids. The published epidemiology for uterine sarcoma is set against the incidence of accidental findings during surgery for uterine fibroids. International comments on this topic are discussed and are incorporated into the assessment by the German Society for Gynecology and Obstetrics (DGGG). The ICD-O-3 version of 2003 was used for the anatomical and topographical coding of uterine sarcomas, and the "Operations- und Prozedurenschlüssel" (OPS) 2014, the German standard for process codes and interventions, was used to determine surgical extirpation methods. Categorical qualifiers were defined to analyze the data provided by the Robert Koch Institute (RKI), the German Federal Bureau of Statistics (DESTATIS; Hospital and Causes of Death Statistics), the population-based Cancer Register of Bavaria. A systematic search was done of the MEDLINE database and the Cochrane collaboration, covering the period from 1966 until November 2014. The incidence of uterine sarcoma and uterine fibroids in uterine surgery was compared to the literature and with the different registries. The incidence of uterine sarcoma in 2010, standardized for age, was 1.53 for Bavaria, or 1.30 for every 100 000 women, respectively, averaged for the years 2002-2011, and 1.30 for every 100 000 women in Germany. The mean incidence collated from various surveys was 2.02 for every 100 000 women (0.35-7.02; standard deviation 2.01). The numbers of inpatient surgical procedures such as myoma enucleation, morcellation, hysterectomy or cervical stump removal to treat the indication "uterine myoma" have steadily declined in Germany across all age groups (an absolute decrease of 17 % in 2012 compared to 2007). There has been a shift in the preferred method of surgical access from an abdominal/vaginal approach to endoscopic or endoscopically assisted procedures to treat uterine fibroids, with the use of morcellation increasing by almost 11 000 coded procedures in 2012. Based on international statements (AAGL, ACOG, ESGE, FDA, SGO) on the risk of uterine sarcoma as an coincidental finding during uterine fibroid surgery and the associated risk of a deterioration of prognosis (in the case of morcellation procedures), this overview presents the opinion of the DGGG in the form of four Statements, five Recommendation and four Demands.

Current and Future Status of Laparoscopy in Gynecologic Oncology.

Laparoscopy is playing an increasingly important role in gynecologic oncology. The benefits of minimally invasive surgery for oncology patients and the quality of this treatment are well documented. Outcomes and quality of minimally invasive surgical procedures to treat cervical cancer were evaluated based on retrospective and case-control studies; outcomes and quality after minimally invasive treatment für early-stage low-risk endometrial cancer were also assessed in prospective randomized studies. If indicated, laparoscopic lymphadenectomy is both technically feasible and oncologically safe. Adipose patients in particular benefit from minimally invasive procedures, where feasible. The potential role of laparoscopy in neoadjuvant therapy for ovarian cancer and in surgery for early-stage ovarian carcinoma is still controversially discussed and is currently being assessed in further studies. Using a minimally invasive approach in gynecologic oncology procedures demands strict adherence to oncological principles and requires considerable surgical skill.

Surgical Therapy of Endometriosis: Challenges and Controversies.

Endometriosis is one of the most common disorders encountered in surgical gynaecology. The laparoscopic technique, the planning of the surgical intervention, the extent of information provided to patients and the interdisciplinary coordination make it a challenging intervention. Complete resection of all visible foci of disease offers the best control of symptoms. However, the possibility of achieving this goal is limited by the difficulty of detecting all foci and the risks associated with radical surgical strategies. Thus, the excision of ovarian endometrioma can result in a significant impairment of ovarian function, while damage to nerve structures during resection of the uterosacral ligaments, the parametrium, the rectovaginal septum or the vaginal cuff to treat deep infiltrating endometriosis can lead to serious functional impairments such as voiding disorders. A detailed risk-benefit analysis is therefore necessary, and patients must be treated using an individual approach.

Gynaecological endoscopic evaluation of 4% icodextrin solution: a European, multicentre, double-blind, randomized study of the efficacy and safety in the reduction of de novo adhesions after laparoscopic gynaecological surgery.

BACKGROUND: Gynaecological laparoscopic surgery outcomes can be compromised by the formation of de novo adhesions. This randomized, double-blind study was designed to assess the efficacy and safety of 4% icodextrin solution (Adept(®)) in the reduction of de novo adhesion incidence compared to lactated Ringer's solution (LRS). METHODS: Patients undergoing laparoscopic surgery for removal of myomas or endometriotic cysts were treated with randomized solution as an intra-operative irrigant and 1l post-operative instillate. De novo adhesion incidence (number of sites with adhesions), severity and extent were independently scored at a second-look procedure and the efficacy of the two solutions compared. The effect of surgical covariates on adhesion formation was also investigated. Initial exploratory analysis of individual anatomical sites of clinical importance was progressed. RESULTS Of 498 patients randomized, 330 were evaluable (160 LRS--75% myomectomy/25% endometriotic cysts; 170 Adept--79% myomectomy/21% endometriotic cysts). At study completion, 76.2% LRS and 77.6% Adept had ≥ 1 de novo adhesion. The mean (SD) number of de novo adhesions was 2.58 (2.11) for Adept and 2.58 (2.38) for LRS. The treatment effect difference was not significant (P = 0.909). Assessment of surgical covariates identified significant influences on the mean number of de novo adhesions regardless of treatment, including surgery duration (P = 0.048), blood loss in myomectomy patients (P = 0.019), length of uterine incision in myomectomy patients (P < 0.001) and number of suture knots (P < 0.001). There were 15 adverse events considered treatment-related in the LRS patients (7.2%) and 18 in the Adept group (8.3%). Of 17 reported serious adverse events (9 LRS; 8 Adept) none were considered treatment-related. CONCLUSIONS: The study confirmed the safety of Adept in laparoscopic surgery. The proportion of patients with de novo adhesion formation was considerably higher than previous literature suggested. Overall there was no evidence of a clinical effect but various surgical covariates including surgery duration, blood loss, number and size of incisions, suturing and number of knots were found to influence de novo adhesion formation. The study provides direction for future research into adhesion reduction strategies in site specific surgery.

[Clinical 3-year follow-up of uterine fibroid embolization]. / Klinische 3-Jahres-Ergebnisse nach Uterusmyomembolisation.

PURPOSE: The purpose of this study was to evaluate the clinical long-term success of uterine artery embolization (UAE) in patients with symptomatic fibroids using spherical particles (Embosphere). MATERIALS AND METHODS: 34 consecutive patients treated with UAE were initially enrolled in the study which had the following study goals 1) 1-year follow-up MRI evaluation of the fibroid behavior and 2) clinical long-term success due to standardized assessment of the main fibroid-related symptoms (hypermenorrhoea, dysmenorrhoea and dysuria) of the patients' individual overall health status and their therapy satisfaction at 1-year, 2- year and 3-year intervals after UAE. RESULTS: Technical success was achieved in all procedures. Four patients had to be excluded from the long-term evaluation schedule: one because of a hysterectomy due to bleeding after 6 weeks, 3 patients were not available for the designated minimum follow-up interval. The preinterventional severe hypermenorrhoea (n = 27) with a score of 4.4 +/- 0.7 (5 = extreme menstrual bleeding) decreased after one year to 2.1 +/- 0.5 (p = 0.0001), after two years to 1.7 +/- 0.5 (p = 0.0042) and after three years to 1.3 +/- 0.6 (p = 0.0001). The preinterventional dysmenorrhoea (n = 15) with a score of 3.1 +/- 1.5 (3 = distinctly increased dysmenorrhoea) decreased after one year to 1.1 +/- 0.3 (p = 0.0001), after two years to 1.2 +/- 0.2 and after three years to 1.2 +/- 0.4 (p = 0.148). The pretreatment dysuria (n = 12) with a preinterventional score of 3.1 +/- 1.5 (3 = distinctly increased dysuria) decreased after one year to 1.1 +/- 0.3 (p = 0.0069) and remained after two years at 1.1 +/- 0.2 and after three years at 1.2 +/- 0.4 (p = 0.905). The initial overall health status was 54.7 +/- 20.1 (maximal value 100). After one year it rised to 90.5 +/- 15.4 (p = 0.0001), was 91.8 +/- 5.6 after two years and was 91.3 +/- 8.5 (p = 0.8578) after three years. The satisfaction with the therapy was 2.9 +/- 0.2 after one year, 2.6 +/- 0.3 after two years and 2.7 +/- 0.5 (3 = extremely satisfied) after three years. We observed 12 minor and 3 major complications (one hysterectomy, one fibroid expulsion associated with a short bleeding episode and one transient amenorrhoea for three months). All patients benefited clinically from the procedure and a clinical benefit was achieved in all cases. CONCLUSION: Under controlled study conditions, flow-guided UAE with spherical embolization particles achieves high clinical success for all relevant clinical symptoms without negative changes during follow-up after at least 3 years. Accordingly, patient therapy satisfaction remained extraordinarily high even 3 years after UAE.

[Uterine fibroid embolization with spheric micro-particles using flow guiding: safety, technical success and clinical results]. / Uterusmyomembolisation mit sphärischen Mikropartikeln unter Flusssteuerung: Sicherheit, technischer Erfolg und klinische Ergebnisse.

PURPOSE: To evaluate safety and mid term efficacy (> or = 1 year follow-up) of uterine fibroid embolization (UFE) using spherical particles (Embosphere) in a study applying criteria identical to those submitted to the FDA for initial material approval. MATERIALS AND METHODS: Twenty of the first 26 consecutive patients referred for potential UFE were enrolled in the study. Pre-interventional MRI was used to assess morphologic contraindication to UFE. The embolization procedures were performed from a unilateral femoral approach using 4F selective catheters in straight vessels, > 2 mm in diameter, and micro-catheters in smaller and tortuous arteries. The endpoint of the "flow guided" embolization was defined by reaching the angiographic "pruned tree" appearance and sluggish flow in the main stem of the uterine artery. Assessment of morphologic mid term success was done by MRI 10 days, 3 months, 6 months, 9 months and 1 year after UFE. The clinical mid term success was assessed by having questionnaires completed for menstrual bleeding, retention of clinical (symptomatic) benefit and quality of life. RESULTS: Technical success was 100 %, with 8 minor (2 post-interventional collapses, 2 hematomas, 4 relevant post-embolizations syndromes, 1 spontaneous expulsion of a submucous myoma) and 3 major complications (1 hysterectomy because of vaginal bleeding for 5 weeks, 1 transient amenorrhea and 1 spontaneous expulsion of myoma with transient bleeding requiring admission). In 17 of 19 patients, MRI showed total fibroid devascularization throughout the entire follow-up. The average shrinkage of the dominant fibroid was 71.3 % at one year. The menstrual bleeding record in the cohort group fell from an average of 501.6 before treatment to 76.2 points at one year. At the same time, the clinical symptoms significantly improved. The patient satisfaction with the applied therapy was > 95 % at 1 year. One patient with residual fibroid perfusion underwent a second procedure, which achieved complete devascularization and adequate clinical success at one year. The second patient with incomplete devascularization had a persistent clinical benefit. CONCLUSION: Under controlled study conditions, flow guided UFE with spherical particles achieves high overall success and patient satisfaction. MRI provides exact morphologic description of the fibroid for the initial evaluation and for post-procedural follow-up.

[Risk and complication rate of uterine fibroid embolization (UFE)]. / Risiken und Komplikationen der Embolisationstherapie von Uterusmyomen.

AIM: Our goal was to evaluate risks and complication rate of uterine fibroid embolization (UFE). RESULTS: The most frequent complications reported in the literature are associated with angiography procedure, serious complications are extremely infrequent. CONCLUSION: The embolization of fibroids is a safe angiographic intervention. Nevertheless, the interventional radiologist must be aware of the common risks and complication and the strategies to avoid them.

Technical results of falloposcopy for infertility diagnosis in a large multicentre study.

Despite increasing evidence of its potential clinical value, falloposcopy has not yet found widespread use. In a large prospective international multicentre study we investigated the hypothesis that limited technical reproducibility may be of crucial significance in this regard. From 1994 to 1998, data on 367 patients with 639 tubes were recorded from 18 centres (median number of falloposcopies 22). Falloposcopy was performed using hysteroscopic ostium access, coaxial tubal cannulation and retrograde visualization under laparoscopic control. The procedure was successful in 69.6% of the tubes. Failures occurred in 6.1% during hysteroscopy, in 10.6% during the cannulation step and in 16.4% during visualization. While predominantly intracavitary pathology or thick endometrium were found to interfere with hysteroscopic ostium access, technical insufficiencies resulting in catheter damage or vision disturbing light reflexions were identified to be responsible for most cannulation and visualization failures, confirming the importance of these factors. The number of patients who received a complete falloposcopic evaluation did not exceed 57%. Additionally, 23.7% of patients may have profited from unilateral success depending on the individual indication. As a consequence of these technically limited results it was concluded that the method currently qualifies for selected indications rather than for routine clinical application.

Intraluminal ultrasound imaging of the fallopian tube wall: results of standardized in vitro investigations of pig and human tubal specimens.

OBJECTIVE: To investigate to what extent anatomic structures of the tubal wall can be identified reproducibly and whether altered areas can be detected and delimited by intraluminal ultrasound. DESIGN: Standardized in vitro experiment with descriptive evaluation of findings, comparative analysis of apparative and morphologic data, and determination of interobserver variability (video documentation, blinded reviewer). SETTING: Department of Gynecology and Obstetrics, University of Heidelberg, Germany. SPECIMEN(S): Seventy-two human and pig fallopian tubes. INTERVENTION(S): Catheterization with a 2.9F or 3.2F ultrasound catheter and sonographic depiction of the fallopian tube, with either simultaneous manual and sonographic wall-thickness measurement or coagulation of the tubal wall. MAIN OUTCOME MEASURE(S): A correlation coefficient of r = 0.76 for manual and sonographic tubal wall measurements and K = 0.88 (with 95% confidence interval of 0.74-1.0) for interobserver variability in recognizing coagulated areas. RESULT(S): Tubal wall anatomy and artificially altered (coagulated) areas were displayed reproducibly with intraluminal ultrasound, thus giving a characteristic, recognizable pattern of the tubal wall. CONCLUSION(S): These in vitro experiments provide evidence that intraluminal ultrasound may expand the current diagnostic possibilities in cases of tubal pathology, providing nonsurgical access to the tubal wall.

Alternative splicing and cycling kinetics of myosin change during hypertrophy of human smooth muscle cells.

We investigated in vivo expression of myosin heavy chain (MHC) isoforms, 17 kDa myosin light chain (MLC17), and phosphorylation of the 20 kDa MLC (MLC20) as well as mechanical performance of chemically skinned fibers of normal and hypertrophied smooth muscle (SM) of human myometrium. According to their immunological reactivity, we identified three MHC isoenzymes in the human myometrium: two SM-MHC (SM1 with 204 kDa and SM2 with 200 kDa), and one non-muscle specific MHC (NM with 196 kDa). No cross-reactivity was detected with an antibody raised against a peptide corresponding to a seven amino acid insert at the 25K/50K junction of the myosin head (a-25K/50K) in both normal and hypertrophied myometrium. In contrast, SM-MHC of human myomatous tissue strongly reacted with a-25K/50K. Expression of SM1/SM2/NM (%) in normal myometrium was 31.7/34.7/33.6 and 35.1/40.9/24 in hypertrophied myometrium. The increased SM2 and decreased NM expression in the hypertrophied state was statistically significant (P < 0.05). MHC isoform distribution in myomatous tissue was similar to normal myometrium (36.3/35.3/29.4). In vivo expression of MLC17a increased from 25.5% in normal to 44.2% in hypertrophied (P < 0.001) myometrium. Phosphorylation levels of MLC20 upon maximal Ca(2+)-calmodulin activation of skinned myometrial fibers were the same in normal and hypertrophied myometrial fibers. Maximal force of isometric contraction of skinned fibers (pCa 4.5, slack-length) was 2.85 mN/mm2 and 5.6 mN/mm2 in the normal and hypertrophied state, respectively (P < 0.001). Apparent maximal shortening velocity (Vmax(appt), extrapolated from the force-velocity relation) of myometrium rose from 0.13 muscle length s-1 (ML/s) in normal to 0.24 ML/s in hypertrophied fibers (P < 0.001).

Comparison of in-vitro falloposcopy with tubal histology in the diagnosis of fallopian tube pathology.

In order to assess the diagnostic quality of falloposcopy in relation to pathomorphology, a consecutive series of 30 Fallopian tubes obtained from surgical salpingectomy cases were prospectively examined by in-vitro falloposcopy and histology. Falloposcopy was performed using an over-the-wire catheterization system and a 0.5 mm falloposcope with 3000 pixels. Assessment of the specimens included the description of lumen geometry, intraluminal changes and status of the mucosal surface. Falloposcopy classified 14 tubes as normal and 16 pathological. Histology resulted in 17 normal versus 13 pathological tubes. Pathologies included lumen obstructions and dilatations, intraluminal synechiae and mucosal damage. Sensitivity and specificity of falloposcopy were calculated to be 0.85 and 0.71; positive and negative predictive values were 0.69 and 0.86. It was concluded that falloposcopic findings indeed reflect and successfully differentiate normal and pathological conditions allowing adequate and reproducible image interpretation. However, variations of the diagnostic accuracy with the type of pathology and the tubal segment have to be taken into account before clinical consequences are drawn from a falloposcopic investigation.

[Addition of ethanol to the distension medium in surgical hysteroscopy as screening to prevent "fluid overload". A prospective randomized comparative study of ablative versus non-ablative surgical hysteroscopy and different ethanol concentration]. / Ethanol-Beimengung im Distensionsmedium bei der operativen Hysteroskopie als Screening zur Vermeidung eines "Fluid overloads". Eine prospektiv-randomisierte Vergleichsstudie von ablativer versus nicht-ablativer operativer Hysteroskopie und unterschiedlichen Ethanol-Konzentrationen.

For answering the question at which hysteroscopical procedures an intraoperative screening method is necessary to avoid a fluid overload and whether a beginning fluid absorption can be diagnosed early by adding ethanol to the distension medium, a prospectively randomised comparative study of ablative versus non-ablative operative hysteroscopy with differing ethanol concentrations was performed (n = 120). Purisole (a mannit/sorbit solution) was used a distension medium. The measuring parameters (breath alcohol, amount of absorbed fluid, haematocrit and haemoglobin values, central venous pressure, heart frequency) were intraoperatively determined at 5-minute intervals. The results of the study show that with those hysteroscopical procedures during which the endometrium is not or only minimally injured (e.g. syneciolysis, hysteroscopic proximal tubal catheterisation). Intraoperative screening is not necessary due to the low absorbing amounts. With hysteroscopical procedures such as resection of myoma, endometrium ablation and septum resection, however, an addition of ethanol of 2% to the distension medium has proved useful, because with this method absorption amounts of 400 ml and more can be detected by positive values of breath alcohol. As the result of a further absorption of fluid, delayed in time compared to the first positive value of breath alcohol, there is an increase in central venous pressure and hyponatraemia. Intraoperative ethanol monitoring is a non-invasive procedure which can be performed during ablative-operative hysteroscopies and has no negative influence on the course of the intervention and the general condition of the patients.

[The value of laparoscopic and laser-assisted techniques in reconstruction of distal fallopian tube pathology]. / Die Wertigkeit laparoskopischer bzw. laser-assistierter Techniken zur Rekonstruktion bei distaler Tubenpathologie.

In an overall study population (3 different study designs) of n = 285 patients the role of laparoscopic resp. laser-assisted techniques was evaluated on the basis of the results of distal tubal reconstruction. An interventional comparison of a laparoscopic (n = 150) with a retrospective microsurgical (n = 135) group of patients with distal tubal pathology showed a significantly higher baby-take-home rate in the laparoscopically treated patients (38% vs. 22.2%, p < 0.05), but detailed critical analysis of indication revealed a certain selection effect in the laparoscopic group. A prospective study on laser (n = 100) and non-laser techniques for salpingostomy showed in no significant differences between the two groups, as results were concerned (delivery 35% in the laser, 44% in the non-laser cohort). In a prospective randomized subgroup laparoscopic fimbrial eversion with the laser was compared to suture eversion (n = 20). In both groups the reocclusion rate was of 20%. On may thus conclude, that the most important surgical approaches for treatment of a tuboperitoneal sterility: micro-surgery and endoscopy, resp. the various surgical techniques: laser and non-laser, should not be regarded as competing procedures, but as components of a multimodal strategy. The indication, however, must be critically viewed in every particular case. Of major importance being strict scientific evaluation criteria to prevent misinterpretations, e.g. based on indication-specific selection.

[Effect of resorption of Purisole (mannitol/sorbitol solution) as a distention medium in hysteroscopic operations on cardiovascular and laboratory parameters and energy metabolism--a prospective non-randomized observational study]. / Der Einfluss der Resorption von Purisole (Mannit/Sorbit-Lösung) als Distensionsmedium bei hysteroskopischen Operationen auf Kreislauf-und Laborparameter sowie Verstoffwechselung--Eine prospektive, nicht-randomisierte Beobachtungsstudie.

This paper reports on an open explorative study on the absorption of the electrolytfree distension medium Purisole (Mannitol-Sorbitol solution) during hysteroscopic procedures and its effects on laboratory and cardiovascular parameters. Intra- and postoperative levels of mannitol and sorbitol in urine were also measured to determine elimination of both components. The study population consisted of 84 patients aged 22-62 years. 54 women underwent ablative (resection of submucous fibroids, endometrial ablation, septum resection), 30 patients non-ablative operative hysteroscopic procedures (synechiolysis, hysteroscopic proximal tubal catheterisation). The duration of operations was between 23-48 minutes. Ethanol was added to the Purisole solution for determination of resorption. In 57 cases 1% ethanol in Purisole was used as irrigating fluid. In 27 cases 2% ethanol was added to the distension fluid. A median slight encrease of central venous pressure was noted during the procedures. 18 women had an intraoperative hyponatriaemia (only 4 patients < 130 mmmol/1). For the 15 patients, in which ethanol absorption was noted, fluid resorption was calculated on the basis of blood alcohol concentration (median 850 ml). Resorption was below the determination threshold in the other 69 women. Urine examination showed intra- and postoperatively increased concentrations of sorbitol and mannitol. Fluid overload and intraoperative cardiovascular complications did not occur in our patients.

[Micro-endoscopy, minimal access endoscopy--an overview of current status and future possibilities]. / Mikroendoskopie, Minimal-Access-Endoskopie--Ein Uberblick über den derzeitigen Stand und zukünftige Möglichkeiten.

Based on technical and clinical application research a new generation of so-called micro-endoscopes was developed, with a wide range of indications in gynaecology as well. The innovative potential of these new endoscopes is, however, still to be considered against the background of the risks of erroneous findings at laparoscopical and hysteroscopical diagnosis, so that here too, clear indications will have to be worked out.

[Tubal catheterization and fallopian tube endoscopy for expanded diagnosis in tubal sterility]. / Tubenkatheterisierung und Falloposkopie zur erweiterten Diagnostik bei tubarer Sterilität.

The present study reports first experiences with falloposcopy for extended diagnosis in tubal sterility. In a total of 38 patients, n = 62 tubes were to be examined falloposcopically. Catheterization was successful in 85.5%. After successful catheterization, optically interpretable images were obtained in 93.6%. The overall success rate was therefore 80%. Considering the anatomical segments of the tube, no differences were found neither for catheterization nor for visualization. The spectrum of intratubal findings extended from normal in 25% to partly obstructive, nodular or non-nodular pictures, together with various degrees of mucosal alteration with or without synechia formation.

[Abdominal colposuspension: a synopsis of various approaches and techniques including endoscopic modifications]. / Die abdominale Kolposuspension: Eine Synopsis der verschiedenen Zugangswege und Techniken incl. endoskopischer Modifikationen.

Though abdominal colposuspension is an established operative procedure in the therapeutic spectrum of female urinary stress incontinence, there is controversy concerning new access routes and fixation techniques. On the basis of a comparison between results of a "feasibility" study at our department concerning the trans- and extra-peritoneal endoscopic access as well as suspension techniques with alloplastic material and suturing vs. stapler application, and al literature survey, a synoptic concept is being evaluated. In case of critically made indication, first trends show that results of laparoscopically and retziusscopically assisted techniques are comparable to those of conventional procedures. However, the lack of long-term results as well as an initially prolonged operation time have to be considered. In the meantime an extraperitoneal transumbilical colposuspension was attempted in 2 patients, already unsuccessfully operated upon (conventional Burch) previously. Due to extensive perivesical adhesions a laparotomy had to be performed. The limits of the endoscopic approach seen to be reached in these cases.