Objective The objective of this revised official guideline, published by the German Society for Gynecology and Obstetrics (DGGG) and coordinated in the joint guidelines program of the DGGG, the Austrian Society for Gynecology and Obstetrics (OEGGG), and the Swiss Society for Gynecology and Obstetrics (SGGG), is to provide evidence-based and consensus-based recommendations for the diagnosis, treatment, care, and support of girls and women with confirmed or suspected endometriosis. Methods This S2k guideline was developed through a structured consensus process involving representative members of various professions (37 professional associations, organizations, and self-help groups) and includes 25 statements and 73 recommendations which are based on a systematic literature review (2019 - 2023) and expert consensus. Recommendations For the first time, the revised guideline has placed a greater focus on individualized, symptom-oriented diagnosis and treatment that combines hormonal, surgical, and multimodal approaches. A significant innovation is the use of transvaginal ultrasound as the central diagnostic procedure for detecting endometriosis. Therapeutically, primary hormone treatment is now recommended as the first choice approach, with surgical interventions and multimodal approaches supplemented on an individual and symptom-oriented basis.

Background and Objectives:The LevaLap 1.0 (Core Access Surgical Technologies, Atlanta, GA) was designed to promote safer, more stable, and more predictable abdominal access when using the Veress needle for insufflation. We report on the first postmarket clinical study (PMCF) assessing experience with the use of the LevaLap 1.0 during gynecologic laparoscopic surgery. Methods:Prospective multicenter study, including women ≥18 years old, excluding pregnancy, access site surgery in prior 10 days, abdominal hernia, contraindication to Veress needle or laparoscopy use, body mass index (BMI) >30 kg/m2, and inability/unwillingness to provide consent. Results:A total of 158 subjects were included, involving nine surgeons. Mean age was 43.6 ± 14.6 years and mean BMI: 24.7 ± 3.8 kg/m2. Access site was 83.5% transumbilical, 15.2% periumbilical, and 1.2% other. Using the device 96.8% (95% confidence interval [CI]: 92.8-99.0%, n = 152/157) of patients' access was successfully achieved at first attempt and 99.4% (95% CI: 96.5-100.0, n = 156/157) within the first 2 attempts. One minor device-related adverse event was reported: a circular redness on the skin at the site of device application, resolving spontaneously. Surgeons noted easier access in 59.5%, increased confidence in 68.3%, increased access control in 67.1%, and increased access efficiency in 66.4% of cases. Conclusion:This PMCF study indicates that the use of the LevaLap 1.0 resulted in easier, greater control and greater efficiency during abdominal access using the Veress needle. In 96.8% access was achieved at first attempt and in 99.4% within the first 2 attempts. The use of the LevaLap 1.0 may facilitate abdominal access when using the Veress needle for insufflation.

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.

Urogynäkologie und plastische Beckenbodenchirurgie beschäftigen sich mit der Diagnostik und konservativen sowie operativen Therapie von Erkrankungen des weiblichen Beckenbodens. Dabei spielt insbesondere die gestörte Sexualfunktion infolge von anatomischen Verletzungen nach vaginalen Entbindungen eine zentrale Rolle. Die chirurgische Rekonstruktion der Scheide, der Faszien und Sehnen sowie von Harnröhre, Vulva und Anus nach traumatischen Entbindungen ist eine Voraussetzung für die Funktionalität, und somit ist die Behandlung des Beckenbodens immer auch eine Sexualtherapie. Körperliche Defizite führen zu somatischen und psychosomatischen Störungen, die einem lustvollen Erleben des Sexuallebens entgegenstehen. Somatisch können Inkontinenz, Senkung- und Fremdkörpergefühl, Weitegefühl, Kontaktverlust zum Penis, Empfindungs- und Orgasmusverlust, Ein- und Austritt von Wasser oder Luft in und aus der Scheide, Harn- und Stuhlinkontinenz sowie Stuhlentleerungsstörungen bestehen. Hierdurch können Unsicherheit und das Gefühl von Unattraktivität erzeugt und die Libido reduziert werden, was tiefe Auswirkungen auf die Psyche der betroffenen Frau, aber auch auf deren soziales Umfeld und deren Paarbeziehung hat. Die häufig gewünschte sexuelle Aktivität im Senium kann durch gesundheitliche Beeinträchtigungen im Allgemeinen und Beckenbodenstörungen im Besonderen gestört sein. Ärztinnen und Ärzte müssen die Tabuisierung der Sexualität im Alter und von Sexualstörungen generell durch aktives Nachfragen durchbrechen. Sowohl konservative als auch operative Therapieansätze können hier Abhilfe schaffen, wobei insbesondere die breitflächige Netzchirurgie hohe Risiken für die Dyspareunie birgt.

Urogynecology and reconstructive pelvic floor surgery deal with the diagnosis, conservative and surgical treatment of female pelvic floor diseases. In particular, the disturbed sexual function as a consequence of anatomical injuries after vaginal childbirth plays a central role. Surgical reconstruction of the vagina, fascia and tendons as well as the urethra, vulva and anus after traumatic childbirth is a prerequisite for physical functioning and is always also a treatment for sexual function. Physical deficits, on the other hand, lead to somatic and psychosomatic disorders that prevent a lustful experience of the sex life. Somatically, it is about incontinence, lowering and foreign body feeling, feeling of vaginal width, loss of contact to the penis, loss of sensation and orgasm, entry and exit of water or air in and out of the vagina, urinary and stool incontinence as well as bowel emptying disorders. Physical deficits can create insecurity and a feeling of unattractiveness, reduce libido and have a profound effect on the psyche of the woman concerned as well as on her social environment and the partner relationship. The frequently desired sexual activity in old age may be disturbed by health impairments in general and pelvic floor disorders in particular. Urogynecologists must break the taboo of sexuality in old age and sexual disorders primarily through active questioning. Both conservative and surgical treatment approaches can remedy this situation, whereby in particular wide-area mesh surgery poses high risks for dyspareunia.

6067 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.

Background: Live surgery events serve as a valuable tool for surgical education, but also raise ethical concerns about patient safety and professional performance. In the present study, we evaluate the technical feasibility and didactic benefits of live surgery on body donors compared to real patients. Methods: A live surgery session performed on a body donor’s cadaver embalmed in ethanol–glycerol–lysoformin was integrated into the live surgery program presented at a major gynecological convention of minimally invasive surgery. Surgical procedures carried out in real patients were paralleled in the body donor, including the dissection and illustration of surgically relevant anatomical landmarks. A standardized questionnaire was filled by the participants (n = 208) to evaluate the appropriateness, effectiveness, and benefits of this novel concept. Results: The live surgery event was appreciated as a useful educational tool. With regard to the use of body donors, authenticity was rated high (85.5%), and the overall value of body donors for surgical education and training was rated very high (95.0%). The didactic benefit of simultaneous operations performed on body donors and real patients was considered particularly useful (95.5%), whereas complete replacement of real patients by body donors was not favored (14.5%). Conclusions: The study demonstrated both the technical feasibility and didactic benefits of performing minimally invasive surgery in body donors as part of live surgery events. This novel concept has the potential to enhance anatomical knowledge, providing insights into complex surgical procedures, and may serve to overcome yet unresolved ethical concerns related to live surgery events.

This study was performed to assess the practical laparoscopic training in Gynecological Endoscopy Working Group (AGE) certified Training Centers (TC) and evaluate the possible implementation for a manual dexterity skills-training within the Minimal Invasive Surgery (MIC) certification process. An online questionnaire was developed and the link provided for the heads of the AGE TC. The questionnaire comprised topics on TC organization, practical training performance and perspectives for future training and demographic data. Response rate was 78.9% (15/19) of AGE TC. Grasping for the basic and suturing exercises for the advanced curricula, respectively, are thought to be of highest value (each 1.0 ± 0, on a scale from 1 = very valuable to 6 = not at all valuable). Most valuable parameter in assessing training was thought to be pressure/tension with 1.80 ± 1.08 The most valuable training capacity was considered for box training under supervision (1.27 ± 0.59) and feed-back box training with direct evaluation of various surgical skills (1.40 ± 0.63). Supervised box training was also thought to have the most positive influence on surgical performance (1.33 ± 0.49). The majority of respondents (86.7%) were qualified with the highest MIC certification and additional 66.7% were sub-specialized Gynecological Oncologists. The AGE certified TC offer a structured curriculum with emphasis on practical training. The results of this questionnaire and the additional respondents comments on value and future perspectives/changes of practical training support the concept and the implementation of a skills-training to the AGE MIC concept.

Study Objective To objectively enhance and add individual manual dexterity skills to the MIC certification of the german Gynecological Endoscopy Working group (AGE). Design Participants performance of a standardized skills-training was assessed. Setting The study was performed during four German gynecology and/or endoscopy meetings in 2017 and 2018. Patients or Participants MIC certified members of the AGE were randomly invited to participate in a laparoscopic skills-training. Interventions Participants performed two standardized tasks, maneuvering a needle through a parkour of eyelids and performing an interrupted suture, within a box trainer with automatic objective assessment of various parameters. These comprise time for task completion, force penalties, instrument path length i.e. and are summarized as an overall score. Measurements and Main Results Out of a total number of 190 participants, 160 completed results for passing the needle and 155 results for performing the interrupted suture were eligible for evaluation. The mean overall score for passing the needle was 1.89±1.14, 2.66±1.14 and 3.10±1.07 and for the interrupted suture 1.78±1.36, 2.38±1.31 and 3.04±1.37 for participants certified with MIC 1, MIC 2 MIC3, respectively. Conclusion This study validated the used box trainer and tasks with the graded accredited MIC certificate. The mean result value and half of the variance value was defined as minimal score for passing the manual dexterity training for all MIC certificates, hence passing score is 1.3, 2.1 and 2.6 for MIC I, MIC II and MIC III respectively. To objectively enhance and add individual manual dexterity skills to the MIC certification of the german Gynecological Endoscopy Working group (AGE). Participants performance of a standardized skills-training was assessed. The study was performed during four German gynecology and/or endoscopy meetings in 2017 and 2018. MIC certified members of the AGE were randomly invited to participate in a laparoscopic skills-training. Participants performed two standardized tasks, maneuvering a needle through a parkour of eyelids and performing an interrupted suture, within a box trainer with automatic objective assessment of various parameters. These comprise time for task completion, force penalties, instrument path length i.e. and are summarized as an overall score. Out of a total number of 190 participants, 160 completed results for passing the needle and 155 results for performing the interrupted suture were eligible for evaluation. The mean overall score for passing the needle was 1.89±1.14, 2.66±1.14 and 3.10±1.07 and for the interrupted suture 1.78±1.36, 2.38±1.31 and 3.04±1.37 for participants certified with MIC 1, MIC 2 MIC3, respectively. This study validated the used box trainer and tasks with the graded accredited MIC certificate. The mean result value and half of the variance value was defined as minimal score for passing the manual dexterity training for all MIC certificates, hence passing score is 1.3, 2.1 and 2.6 for MIC I, MIC II and MIC III respectively.

e17052 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.

Die fertilitätserhaltende chirurgische Therapie von Borderline-Tumoren des Ovars (BOT) und frühen Ovarialkarzinomen (eOC) wird international kritisch diskutiert. Sowohl im Hinblick auf die onkologische Sicherheit des fertilitätserhaltenden Vorgehens per se, als auch auf die verwendete chirurgische Radikalität (Zystenexstirpation vs. uni-/bilaterale Salpingo-Oophorektomie (SOE)) und auf das reproduktionsmedizinische Outcome ist die aktuelle Studienlage limitiert und teilweise widersprüchlich. Ziel dieser Studie ist daher die Untersuchung der fertilitätserhaltenden Therapie bei BOT und eOC im Hinblick auf onkologisches und reproduktionsmedizinisches Outcome.

Frühe Ovarialkarzinome (FIGO I und II (EOC)) sowie Borderline-Tumoren des Ovars (BOT) sind häufig Zufallsbefunde im Rahmen von diagnostischen oder operativen Laparoskopien. Inwieweit das initiale Staging im Rahmen des minimal-invasiven Eingriffs mit dem finalen FIGO Stadium übereinstimmt, wird international kritisch diskutiert und ist auf Grundlage der aktuellen Studienlage nicht suffizient zu beantworten. Ziel dieser retrospektiven Analyse ist es daher, die Übereinstimmung eines primären, laparoskopischen Stagings von EOC und BOT mit dem endgültigen FIGO Stadium nach finaler stadiengerechter Operation zu untersuchen.

Clusterin (CLU) is expressed in tissues and body fluids and is altered in some pathologies. In endometriosis, a noninvasive test is still lacking, thus, we analyzed CLU in mucus samples of patients. Additionally, we investigated localization of CLU and the putative CLU receptors (apolipoprotein E receptor 2 [ApoER2], megalin, very low-density lipoprotein receptor [VLDLR], and transforming growth factor β receptor type I and II [TβR1/TβR2]). In mucus samples, CLU levels are modestly, but not significantly, higher in cases with endometriosis compared to cases without endometriosis, however, CLU levels are significantly (P =.02) reduced in patients with endometriosis receiving contraception compared to cases with endometriosis without contraception. Analysis of CLU and CLU receptors showed CLU mainly in the uterine epithelial cells in the majority of glands, but also in endothelial cells. Similarly, ApoER2 and TβR1 could also be found preferentially in the endometrial glands. Whereas ApoER2 staining was strong in the vessels, TβR1 was modestly expressed in vessels and muscle cells. In contrast, staining of VLDLR and TbR2 was modest in the glands but stronger in vessels and muscle cells. Megalin staining was faint in the glands. A similar pattern for these proteins could be observed in adenomyosis. We demonstrate for the first time high concentrations of CLU in mucus samples and significantly reduced CLU levels in cases with endometriosis receiving contraception compared to cases with endometriosis without contraception. Furthermore, we identified uterine epithelial and endothelial cells as the main source of CLU and found different preferential CLU receptor complexes on glands, vessels, and smooth muscle cells.

Laparoskopische ausgedehnte retroperitoneale Operationen an der Beckenwand und im kleinen Becken erfordern konsequente Aufmerksamkeit und ideale Einsehbarkeit des operativen Situs. Endometriosechirurgie ist annähernd immer mit organerhaltendem Vorgehen assoziiert, so dass die Adnexe häufig zur besseren Übersicht bei Beckenwandpräparationen mit einem Instrument eleviert werden müssen. Somit übernimmt ein Instrument, welches unterstützend für die Präparation genutzt werden könnte, lediglich passive Halteaufgaben. Durch eine transiente Ovariopexie können die Ovarien für die Phase der Operation und darüber hinaus zur Bauchdecke eleviert werden. Somit können alle Instrumente aktiv zur Unterstützung der Präparation genutzt werden.

There is some evidence that cervix sparing methods in hysterectomy have advantages in prophylaxis and therapy of POP.

Uterusmyome treten bei vielen Frauen im reproduktiven Alter auf.

The objective of this study was to evaluate the safety and efficacy of SprayShield™ Adhesion Barrier in preventing and/or reducing postoperative adhesion during gynecological surgery.

Since its introduction, morcellation has paved the way for laparoscopic management of myomas. In the hands of an experienced surgeon, it has enabled even bulky tumours to be removed using a minimally invasive approach, affording patients the advantages of laparoscopic surgery. Initial reports on intraoperative safety of morcellation appeared promising and its introduction subsequently gained momentum. Despite two decades passing since the initial introduction of mechanical morcellation, there are still significant gaps in our knowledge of the longer term outcomes and complications. Recently, the technique has come under scrutiny as cases of iatrogenic spread of uterine tissue secondary to morcellation have been reported. Even more concerning is the inadvertent spread of unsuspected malignancy, which led the FDA to articulate a safety communication and discourage the use of uterine morcellation. This article aims to summarise current evidence for the roles and risks of morcellation in the laparoscopic management of myomas.