Publications by authors named "Nicolai Maass"

160 Publications

ADAM17-A Potential Blood-Based Biomarker for Detection of Early-Stage Ovarian Cancer.

Cancers (Basel) 2021 Nov 6;13(21). Epub 2021 Nov 6.

Department of Gynecology and Obstetrics, Christian-Albrechts-University Kiel and University Medical Center Schleswig-Holstein Campus Kiel, 24105 Kiel, Germany.

Ovarian cancer has the highest mortality rate among gynecological tumors. This is based on late diagnosis and the lack of early symptoms. To improve early detection, it is essential to find reliable biomarkers. The metalloprotease ADAM17 could be a potential marker, as it is highly expressed in many solid tumors, including ovarian and breast cancer. The aim of this work is to evaluate the relevance of ADAM17 as a potential diagnostic blood-based biomarker in ovarian cancer. Ovarian cancer cell lines IGROV-1 and A2780, as well as primary patient-derived tumor cells obtained from tumor tissue and ascitic fluid, were cultured to analyze ADAM17 abundance in the culture supernatant. In a translational approach, a cohort of 117 well-characterized ovarian cancer patients was assembled and ADAM17 levels in serum and corresponding ascitic fluid were determined at primary diagnosis. ADAM17 was quantified by enzyme-linked immunosorbent assay (ELISA). In the present study, ADAM17 was detected in the culture supernatant of ovarian cancer cell lines and primary cells. In addition, ADAM17 was found in serum and ascites of ovarian cancer patients. ADAM17 level was significantly increased in ovarian cancer patients compared to an age-matched control group ( < 0.0001). Importantly early FIGO I/II stages, which would not have been detected by CA-125, were associated with higher ADAM17 concentrations ( = 0.007). This is the first study proposing ADAM17 as a serum tumor marker in the setting of a gynecological tumor disease. Usage of ADAM17 in combination with CA-125 and other markers could help detect early stages of ovarian cancer.
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http://dx.doi.org/10.3390/cancers13215563DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8583642PMC
November 2021

Difficulties of Breast Reconstruction - Problems That No One Likes to Face.

Anticancer Res 2021 Nov;41(11):5365-5375

Department of Gynecology and Obstetrics, Christian-Albrechts-University Kiel and University Medical Center Schleswig-Holstein Campus Kiel, Kiel, Germany.

Reconstructive breast surgery following total or partial mastectomy can be performed using autologous tissues or breast implants, and each has its own set of complications. Most women do not experience significant complications and are highly satisfied but breast reconstruction must consider potential complications from surgical techniques, as well as additional complications that may arise from oncological treatment modalities such as radiation therapy and chemotherapy. The aim of this article is to provide a systemic overview of possible complications that may arise in the course of reconstructive breast surgery. Complications associated with flap-based or implant-based breast reconstruction can be classified as: i) Complications inherent to surgery and common to all, including seroma, bleeding, and hematoma; skin necrosis; and infection, among others. ii) Complications specifically related to reconstruction, such as flap ischemia/necrosis/loss; fat necrosis; implant capsular contracture; implant failure, exposure, or malposition. In conclusion, this overview of possible complications is intended to improve the decision-making process when considering breast reconstruction.
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http://dx.doi.org/10.21873/anticanres.15349DOI Listing
November 2021

Live Birth Rates after Active Immunization with Partner Lymphocytes.

Biomedicines 2021 Sep 29;9(10). Epub 2021 Sep 29.

Institute for Transfusion Medicine and Transplant Center, University Hospitals Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3 (House 17), 24105 Kiel, Germany.

Although many potential causes have been established for recurrent implantation failure (RIF) and recurrent miscarriage (RM), about 50% of these remain idiopathic. Scientific research is focused on immunological risk factors. In the present study, we aim to evaluate live birth rates after immunization with paternal lymphocytes (lymphocyte immunotherapy (LIT)). This retrospective study consisted of 148 couples with a history of RM and/or RIF. The women underwent immunization with lymphocytes of their respective partners from November 2017 to August 2019. Fifty-five patients (43%) had live births. Stratified by indication (RM, RIF, combined), live birth rates in the RM and the combined group were significantly higher than that in the RIF group (53%, 59% and 33%, respectively, = 0.02). The difference was especially noticeable during the first 90 days after immunization (conception rate leading to live births: 31%, 23% and 8% for RM, the combined group and RIF, respectively; = 0.005), while there was no difference between groups during the later follow-up. LIT was associated with high live birth rates, especially in women with recurrent miscarriage. In view of the limited data from randomized studies, LIT cannot be recommended as routine therapy. However, it may be considered in individual cases.
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http://dx.doi.org/10.3390/biomedicines9101350DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8533392PMC
September 2021

AGO Recommendations for the Surgical Therapy of the Axilla After Neoadjuvant Chemotherapy: 2021 Update.

Geburtshilfe Frauenheilkd 2021 Oct 6;81(10):1112-1120. Epub 2021 Oct 6.

Klinik für Gynäkologie und Geburtshilfe, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany.

For many decades, the standard procedure to treat breast cancer included complete dissection of the axillary lymph nodes. The aim was to determine histological node status, which was then used as the basis for adjuvant therapy, and to ensure locoregional tumour control. In addition to the debate on how to optimise the therapeutic strategies of systemic treatment and radiotherapy, the current discussion focuses on improving surgical procedures to treat breast cancer. As neoadjuvant chemotherapy is becoming increasingly important, the surgical procedures used to treat breast cancer, whether they are breast surgery or axillary dissection, are changing. Based on the currently available data, carrying out SLNE prior to neoadjuvant chemotherapy is not recommended. In contrast, surgical axillary management after neoadjuvant chemotherapy is considered the procedure of choice for axillary staging and can range from SLNE to TAD and ALND. To reduce the rate of false negatives during surgical staging of the axilla in pN+ stage before NACT and ycN0 after NACT, targeted axillary dissection (TAD), the removal of > 2 SLNs (SLNE, no untargeted axillary sampling), immunohistochemistry to detect isolated tumour cells and micro-metastases, and marking positive lymph nodes before NACT should be the standard approach. This most recent update on surgical axillary management describes the significance of isolated tumour cells and micro-metastasis after neoadjuvant chemotherapy and the clinical consequences of low volume residual disease diagnosed using SLNE and TAD and provides an overview of this year's AGO recommendations for surgical management of the axilla during primary surgery and in relation to neoadjuvant chemotherapy.
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http://dx.doi.org/10.1055/a-1499-8431DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8494519PMC
October 2021

Challenges and Controversies in the Surgical Treatment of Cervical Cancer: Open Radical Hysterectomy versus Minimally Invasive Radical Hysterectomy.

J Clin Med 2021 Aug 24;10(17). Epub 2021 Aug 24.

Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein, Campus Kiel, 24105 Kiel, Germany.

Objective: The aim of the study was to perform a systematic assessment of disease-free survival (DFS), overall survival, and morbidity rates after open radical hysterectomy (ORH) and minimally invasive surgery (MIS) for early-stage cervical cancer and discuss with experts the consequences of the LACC trial (published by Ramirez et al. in 2018) on clinical routine.

Methods: A total of 5428 records were retrieved. After exclusion based on text screening, four records were identified for inclusion. Five experts from three independent large-volume medical centers in Europe were interviewed for their interpretation of the LACC trial.

Results: The LACC trial showed a significantly higher risk of disease progression with MIS compared to ORH (HR 3.74, 95% CI 1.63 to 8.58). This was not seen in one epidemiological study and was contradicted by one prospective cohort study reported by Greggi et al. A systematic review by Zhang et al. mentioned a similar DFS for robot-assisted radical hysterectomy (RRH) and LRH. Recurrence rates were significantly higher with MIS compared to ORH in the LACC trial (HR 4.26, 95% CI 1.44 to 12.60). In contrast, four studies presented by Greggi reported no significant difference in recurrence rates between LRH/RRH and ORH, which concurred with the systematic reviews of Zhang and Zhao. The experts mentioned various limitations of the LACC trial and stated that clinicians were obliged to provide patients with detailed information and ensure a shared decision-making process.

Conclusions: The surgical treatment of early-stage cervical cancer remains a debated issue. More randomized controlled trials (RCT) will be needed to establish the most suitable treatment for this condition.
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http://dx.doi.org/10.3390/jcm10173761DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8432133PMC
August 2021

Uterine Fibroids and Infertility.

Diagnostics (Basel) 2021 Aug 12;11(8). Epub 2021 Aug 12.

Department of Obstetrics and Gynecology, University Hospital of Schleswig-Holstein, Campus Kiel, Arnold-Heller-Strasse 3, 24105 Kiel, Germany.

Infertility is a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse. Uterine fibroids are the most common tumor in women, and their prevalence is high in patients with infertility. Fibroids may be the sole cause of infertility in 2-3% of women. Depending on their location in the uterus, fibroids have been implicated in recurrent pregnancy loss as well as infertility. Pregnancy and live birth rates appear to be low in women with submucosal fibroids; their resection has been shown to improve pregnancy rates. In contrast, subserosal fibroids do not affect fertility outcomes and their removal does not confer any benefit. Intramural fibroids appear to reduce fertility, but recommendations concerning their treatment remain unclear. Myomectomy should be discussed individually with the patient; other potential symptoms such as dysmenorrhea or bleeding disorders should be included in the indication for surgery.
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http://dx.doi.org/10.3390/diagnostics11081455DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8391505PMC
August 2021

Perioperative considerations in the treatment of endometriosis.

J Turk Ger Gynecol Assoc 2021 Jun 10. Epub 2021 Jun 10.

Department of Obstetrics and Gynecology, University Hospital of Schleswig-Holstein, Kiel, Germany.

Endometriosis is one of the most common benign diseases in women of reproductive age. Nearly all gynecological offices and clinics are confronted with endometriosis; the frequency and severity of the disease vary from one setting to another. Adjoining specialties such as internal medicine, general medicine, surgery, urology, orthopedics, neurology and psychosomatic medicine are directly or indirectly confronted with various forms of endometriosis and its sequelae. The disease is marked by pelvic pain, dysmenorrhea, dyspareunia and sterility. Even in current times, several years elapse between the onset of the disease and its diagnosis. The diagnosis of endometriosis is rendered difficult by the fact that the symptoms may be very diverse. A precise documentation of the patient's medical history and thorough diagnostic procedures are essential to establish the disease. These will be described in the following.
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http://dx.doi.org/10.4274/jtgga.galenos.2021.2021.0017DOI Listing
June 2021

Ectopic pregnancy in noncommunicating horn of unicornuate uterus: 3D-ultrasound and primary laparoscopic management.

Clin Case Rep 2021 May 24;9(5):e04261. Epub 2021 May 24.

Department of Gynecology and Obstetrics University Hospitals Schleswig-Holstein Kiel Germany.

Unicornuate uterus with pregnancy in the noncommunicating rudimentary horn is extremely rare. Diagnosis requires awareness, high suspicion index, 3D ultrasound, and MRI. If missed, it can be catastrophic. Treatment varies across literature. We present a case where detection was done by 3D ultrasound and primary laparoscopic surgery done for treatment.
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http://dx.doi.org/10.1002/ccr3.4261DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8142796PMC
May 2021

Mucinous Cystic Neoplasm of Pancreas in a Pregnant Woman Presenting with Severe Anemia and Gastric Bleeding: Case Report and Review of the Literature.

Healthcare (Basel) 2021 May 6;9(5). Epub 2021 May 6.

Department of Gynecology and Obstetrics, Campus Kiel, University Medical Center UKSH, Arnold-Heller-Straße 3, Haus C, 24105 Kiel, Germany.

Mucinous cystic neoplasms of the pancreas are uncommon and especially their occurrence during pregnancy is an extremely rare event which necessitates an individualized and interdisciplinary management. A 33-year old woman was referred to our department during her third trimester of pregnancy (34th week of gestation) with severe anemia and tarry stools. Based on gastroscopic findings, our interdisciplinary team suspected a gastrointestinal stromal tumor and therefore indicated a prompt delivery via cesarean section completed with an oncological resection of the neoplasm. Histological examination subsequently showed a mucinous cystic neoplasm of the pancreas with no evidence of malignancy. To review the prevalence of mucinous cystic neoplasms and to discuss diagnosis and treatment during pregnancy. Moreover, we critically value the indication of preterm delivery and the oncological procedure in the perspective of outcome for mother and infant. A bleeding gastrointestinal tumor during pregnancy represents a life-threatening risk for mother and infant and requires an immediate interdisciplinary treatment. The urgency and radicality of the therapy should be adapted according to individual findings. As our patient's tumor was suspected of having a malignant progression, an extensive surgical intervention was necessary.
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http://dx.doi.org/10.3390/healthcare9050540DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8148137PMC
May 2021

[Focus on breast cancer].

Gynakologe 2021 6;54(5):307-308. Epub 2021 May 6.

Frauenheilkunde und Geburtshilfe, Universitätsklinikum Ulm, Prittwitzstr. 43, 89075 Ulm, Deutschland.

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http://dx.doi.org/10.1007/s00129-021-04797-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8101343PMC
May 2021

ADAM17 Inhibition Increases the Impact of Cisplatin Treatment in Ovarian Cancer Spheroids.

Cancers (Basel) 2021 Apr 23;13(9). Epub 2021 Apr 23.

Department of Gynecology and Obstetrics, Kiel University and University Medical Center Schleswig-Holstein Campus Kiel, 24105 Kiel, Germany.

Chemotherapy resistance is a major challenge in ovarian cancer (OvCa). Thus, novel treatment combinations are highly warranted. However, many promising drug candidates tested in two-dimensional (2D) cell culture have not proved successful in the clinic. For this reason, we analyzed our drug combination not only in monolayers but also in three-dimensional (3D) tumor spheroids. One potential therapeutic target for OvCa is A disintegrin and metalloprotease 17 (ADAM17). ADAM17 can be activated by chemotherapeutics, which leads to enhanced tumor growth due to concomitant substrate cleavage. Therefore, blocking ADAM17 during chemotherapy may overcome resistance. Here, we tested the effect of the ADAM17 inhibitor GW280264X in combination with cisplatin on ovarian cancer cells in 2D and 3D. In 2D, the effect on five cell lines was analyzed with two readouts. Three of these cell lines formed dense aggregates or spheroids (HEY, SKOV-3, and OVCAR-8) in 3D and the treatment effect was analyzed with a multicontent readout (cytotoxicity, viability, and caspase3/7 activation). We tested the combined therapy on tumor spheroids derived from primary patient cells. In 2D, we found a significant reduction in the half minimal (50%) inhibitory concentration (IC) value of the combined treatment (GW280264X plus cisplatin) in comparison with cisplatin monotherapy in all five cell lines with both 2D readout assays (viability and caspase activation). In contrast, the combined treatment only showed an IC reduction in HEY and OVCAR-8 3D tumor spheroid models using caspase3/7 activity or Celltox Green as the readout. Finally, we found an improved effect of GW280264X with cisplatin in tumor spheroids derived from patient samples. In summary, we demonstrate that ADAM17 inhibition is a promising treatment strategy in ovarian cancer.
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http://dx.doi.org/10.3390/cancers13092039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8122950PMC
April 2021

Metastases-directed Radiotherapy in Addition to Standard Systemic Therapy in Patients with Oligometastatic Breast Cancer: Study protocol for a randomized controlled multi-national and multi-center clinical trial (OLIGOMA).

Clin Transl Radiat Oncol 2021 May 5;28:90-96. Epub 2021 Apr 5.

Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Kiel, Deutschland.

Background: Several recent randomized therapeutic exploratory trials demonstrated improvement of progression-free survival and in some even overall survival using stereotactic body radiotherapy in patients with oligometastatic disease. However, only very few patients enrolled in these trials had breast cancer, and results from confirmatory trials are lacking.

Methods/design: The OLIGOMA-trial is a randomized controlled multi-national multi-center therapeutic confirmatory trial studying the role of local ablative radiotherapy as an additive treatment in patients with oligometastatic breast cancer receiving standard systemic therapy. Patients will be randomized 1:1 to standard systemic therapy according to national guidelines with or without radiotherapy to all metastatic sites. Randomization will be stratified according to type and line of systemic therapy, which has to be determined by a multidisciplinary tumor board before enrollment. Patients with up to five metastatic lesions are eligible, including patients with up to three brain metastases (only in case of extracranial disease) and with locoregional recurrence (only in case of additional metastatic lesions). In the standard arm, palliative radiotherapy to symptomatic metastases is permitted if at least one lesion remains untreated. The co-primary endpoints are progression-free survival and quality of life. The primary hypothesis is that progression-free survival in the experimental arm will be superior to the standard arm while simultaneously demonstrating non-inferiority of quality of life at 12 weeks after randomization. Secondary endpoints are feasibility, overall survival, toxicity, quality of life and patient satisfaction. A translational sub-study with collection of ctDNA will be conducted.

Discussion: The OLIGOMA-trial will provide high level evidence on the use of and benefit from local ablative radiotherapy for patients with oligometastatic breast cancer.

Trial Registration: The OLIGOMA-trial is registered at clinicialtrials.gov under the identification NCT04495309. The related information was first posted on July 31st 2020.
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http://dx.doi.org/10.1016/j.ctro.2021.03.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8065185PMC
May 2021

A Giant Mammary Hamartoma in a Young Breast Cancer Patient.

Breast Care (Basel) 2021 Feb 24;16(1):85-88. Epub 2020 Jun 24.

Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany.

Background: Hamartomas of the breast are rare benign tumors. Pre- and also postoperative differentiation from other benign or even malignant tumors is challenging.

Case Presentation: A 36-year-old female presented with a giant tumor of the left breast. The patient had suffered from an early breast cancer of the contralateral right breast the year before, which was treated with breast-conserving therapy, radiation, and endocrine therapy ever since. The hamartoma was classified as BI-RADS 2 in mammography and BI-RADS 4 in ultrasound. On clinical examination, a tumor of nearly 15 cm in size led to an abstruse deformity of the breast and the nipple-areola complex. We found an indolent, grand bulging tumor with an elastic texture directly beneath the skin. A biopsy that had been performed before was compatible with the suspected hamartoma. Because of the remaining diagnostic uncertainties after contralateral breast cancer and the progressive malformation of the left breast, a tumor extirpation utilizing a reduction mammaplasty was performed without complications. Subsequent genetic analyses excluded a loss of PTEN in this patient.

Conclusion: We presented the rare case of a 36-year-old woman with a history of breast cancer and a 700-g breast hamartoma. The preoperative and even the postoperative specification of a hamartoma remains challenging, and associations with genetic alterations should be considered.
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http://dx.doi.org/10.1159/000507604DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7923926PMC
February 2021

Impact of nicotine and maternal BMI on fetal birth weight.

BMC Pregnancy Childbirth 2021 Feb 12;21(1):127. Epub 2021 Feb 12.

Department of Gynecology, University Hospital Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany.

Background: According to the World Health Organization, smoking is the most important risk factor for adverse pregnancy outcomes in industrialized nations. As the individual factors (body mass index - BMI (kg/m) - and cigarette consumption) have been extensively investigated in pregnancy, we aimed to establish how maternal BMI and nicotine interact with regard to perinatal outcomes and birth weight.

Methods: Data from 110.047 singleton pregnancies, achieved from the German Perinatal Survey in Schleswig-Holstein and registered between 2010 and 2017 were analyzed in August 2018 concerning maternal BMI and smoking. The BMI was taken from the maternity log. Information concerning the smoking status were self-reported and further subdivided into the following four categories: a) non-smokers; b) 1-7 cigarettes/day; c) 8-14 cigarettes/ day; and d) ≥ 15 cigarettes/ day. Furthermore, we classified women by their BMI into underweight, normal weight, overweight and obese. Comparisons between non-smokers and the respective smoking group, and their relationship with maternal BMI were performed by the t-test (birth weight). A P-value ≤0.05 was considered to indicate statistical significance.

Results: A number of 97.092 women (88.2%) were non-smokers and 12.955 (11.8%) were smokers. Furthermore 10.3% of women of normal weight smoked during pregnancy, but both high and low BMI were associated with a high prevalence of smoking. The proportion of smokers was highest (18.1%) among underweight women (BMI ≤ 18.5 kg/m). A large number of smokers (15.5%) were registered in the obesity group (BMI ≥ 30 kg/m). Mean birth weight (≥ 37 + 0 gestational age) increased with increasing maternal BMI, and was reduced by smoking for every BMI category. The differences between smokers and non-smokers were always highly significant (p < 0.001). Mean birth weight varied between 2995 g in underweight frequent smokers and 3607 g in obese non-smokers.

Conclusion: Both maternal BMI and smoking during pregnancy influences the birth weight and therefore pregnancy outcome. Smoking during pregnancy was significantly associated with low birth weight. Pregnant women should be advised to cease or at least reduce smoking in order to improve the birth weight of the newborn and to minimize child morbidities.
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http://dx.doi.org/10.1186/s12884-021-03593-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7881635PMC
February 2021

Evaluation of Laparoscopy Virtual Reality Training on the Improvement of Trainees' Surgical Skills.

Medicina (Kaunas) 2021 Feb 2;57(2). Epub 2021 Feb 2.

Alexandria Endoscopy Association (ALEXEA), 21529 Alexandria, Egypt.

: The primary objective was to evaluate the benefit of training with virtual reality simulation. The secondary objective was to describe the short-term skill acquisition obtained by simulation training and to determine the factors affecting its magnitude. : We prospectively performed a three-stage evaluation: face, constructive, and predictive to evaluate the training with a laparoscopic simulator with haptic feedback. The participants ( = 63) were divided according to their level of experience into three groups: 16% residents; 46% specialists and 38% were consultants. : Face evaluation demonstrates the acceptance of the design and realism of the tasks; it showed a median score of eight (IQR 3) on a Likert scale and 54% of participants ( = 34) gave the tissue feedback a moderate rating. Constructive evaluation demonstrates the improvement of the participants in the training session and the ability of the designed task to distinguish the experienced from the inexperienced surgeon based on the performance score, at task I (transfer of pegs) and II (laparoscopic salpingectomy). There was an improvement in both tasks with a significant increase in score and reduction in time. The study showed that those with a high score at the pre-test recorded a high score post-test, showing a significant pair-wise comparison () and correlation () showing a significant statistical significance ( < 0.001). The predictive evaluation demonstrates the beneficiary effect of training four weeks afterward on the practice of surgeons addressed with five questions. It showed an improvement regarding implementation into daily routine, performance of procedure, suturing, shortening of the operative time, and complication management. : Virtual reality simulation established high ratings for both realism and training capacity, including clinical relevance, critical relevance, and maintaining training enthusiasm.
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http://dx.doi.org/10.3390/medicina57020130DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7913105PMC
February 2021

Recurrent implantation failure - an overview of current research.

Gynecol Endocrinol 2021 Jul 29;37(7):584-590. Epub 2021 Jan 29.

Department of Obstetrics and Gynecology, University Hospitals Schleswig-Holstein, Kiel, Germany.

Background: Recurrent implantation failure (RIF) can be defined as a failure to achieve a clinical pregnancy after transfer of at least four embryos of good quality in a minimum of three fresh or frozen cycles in women under the age of 40. RIF is often a complex problem with a wide variety of etiologies and mechanisms as well as treatment options.

Summary: Anatomical conditions of the uterus, thrombophilia, genetic abnormalities, or immunological factors are only a few examples which could be responsible for RIF. The recommendations for women with RIF vary depending on the source of their problem. There is not just one treatment option, but many depending on the etiology and the severity of the problem.

Key Message: However, it would help to establish a set of standardized examinations and tests to use, in order to do a preliminary evaluation on each patient, which would then hopefully direct the approach of treatment for each individual couple.
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http://dx.doi.org/10.1080/09513590.2021.1878136DOI Listing
July 2021

Video Feedback and Video Modeling in Teaching Laparoscopic Surgery: A Visionary Concept from Kiel.

J Clin Med 2021 Jan 5;10(1). Epub 2021 Jan 5.

Department of Gynecology and Obstetrics, University Hospitals Schleswig-Holstein, Campus Kiel, Arnold-Heller Str. 3, Building 24, 24105 Kiel, Germany.

Learning curves for endoscopic surgery are long and flat. Various techniques and methods are now available for surgical endoscopic training, such as pelvitrainers, virtual trainers, and body donor surgery. Video modeling and video feedback are commonly used in professional training. We report, for the first time, the application of video modeling and video feedback for endoscopic training in gynecology. The purpose is to present an innovative method of training. Attendees (residents and specialists) of minimally invasive surgery courses were asked to perform specific tasks, which were video recorded in a multimodular concept. Feedback was given later by an expert at a joint meeting. The attendees were asked to fill a questionnaire in order to assess video feedback given by the expert. The advantages of video feedback and video modeling for the development of surgical skills were given a high rating (median 84%, interquartile ranges (IQR) 72.5-97.5%, = 37). The question as to whether the attendees would recommend such training was also answered very positively (median 100%, IQR 89.5-100%, = 37). We noted a clear difference between subjective perception and objective feedback (58%, IQR 40.5-76%, = 37). Video feedback and video modeling are easy to implement in surgical training setups, and help trainees at all levels of education.
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http://dx.doi.org/10.3390/jcm10010163DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7796509PMC
January 2021

Involvement of medical students in a surgery congress: impact on learning motivation, decision-making for a career in surgery, and educational curriculum.

Wien Med Wochenschr 2021 May 14;171(7-8):182-193. Epub 2021 Jan 14.

Center for Clinical Anatomy, Institute of Anatomy, Christian-Albrechts-Universität zu Kiel, Otto-Hahn-Platz 8, 24118, Kiel, Germany.

During the preclinical period of medical school, the clinical relevance of theoretical knowledge is given little attention. Medical students of the second year were invited to participate in an interdisciplinary congress for robot-assisted and digital surgery. The students had to evaluate the impact of the congress on their learning motivation, decision-making for a career in surgery, and relevance for their educational curriculum. Participation in the congress increased their learning motivation for preclinical subjects, and significantly increased their interest in a surgical career. Most students considered active involvement in medical congresses a valuable supplement to the medical curriculum. Congress participation during the preclinical period was ranked positively by medical students. Greater learning motivation and enthusiasm for the pilot teaching project as well as for surgical disciplines were registered. Thus, early involvement of medical students in scientific congresses should be an integral part of their educational curriculum.
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http://dx.doi.org/10.1007/s10354-020-00802-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8057979PMC
May 2021

Lymphadenectomy in endometrial cancer - achieving more with less?

Minim Invasive Ther Allied Technol 2021 Jan 13:1-9. Epub 2021 Jan 13.

Department of Obstetrics and Gynecology, University Hospital of Schleswig Holstein, Kiel, Germany.

The lymph node status of patients with endometrial cancer is known to be a crucial determinant for the prognosis of the disease. It also provides the indication for further adjuvant treatment. The staging of endometrial cancer by surgery has been a controversial issue for more than 30 years. The significant complication rate after lymphadenectomy and the development of minimally invasive surgery have led to the use of sentinel lymph node (SLN) mapping. In the present review, we present the development of surgical staging procedures in patients with endometrial cancer and summarize the recently expanding body of published literature on the subject. SLN mapping is a safe and accurate technique, especially when indocyanine green is used as a tracer. SLN mapping appears to reduce complication rates as well as costs without affecting the oncologic outcome. Large prospective studies are needed to establish the effects of SLN mapping on the outcome of disease, especially in high-risk patients with endometrial cancer. Furthermore, the need for additional systematic lymphadenectomy prior to adjuvant radio-chemotherapy in patients diagnosed with isolated lymph node metastasis during SLN biopsy must be investigated further. This might pave the way for a new surgical approach in patients with endometrial cancer.
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http://dx.doi.org/10.1080/13645706.2020.1868009DOI Listing
January 2021

Challenges Posed by Embryonic and Anatomical Factors in Systematic Lymphadenectomy for Endometrial Cancer.

J Clin Med 2020 Dec 19;9(12). Epub 2020 Dec 19.

Department of Obstetrics and Gynecology, University Hospital of Schleswig-Holstein, Campus Kiel, Arnold-Heller-Strasse 3, 24105 Kiel, Germany.

Lymph node involvement has been shown to be one of the most relevant prognostic factors in a variety of malignancies; this is also true of endometrial cancer. The determination of the lymph node status is crucial in order to establish the tumor stage, and to consider adjuvant treatment. A wide range of surgical staging practices are currently used for the treatment of endometrial cancer. The necessity and extent of lymph node dissection is an ongoing controversial issue in gynecological oncology. Lymph node surgery in endometrial cancer is technically challenging, and can be time consuming because of the topographic complexity of lymphatic drainage as such, and the fact that the lymph nodes are directly adjacent to both blood vessels and nerves. Therefore, profound and exact knowledge of the anatomy is essential. Sentinel lymph node mapping was recently introduced in surgical staging with the aim of reducing morbidity, whilst also obtaining useful prognostic information from a patient's lymph node status. The present review summarizes the current evidence on the role of lymph node surgery in endometrial cancer, focusing on the embryological, anatomical, and technical aspects.
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http://dx.doi.org/10.3390/jcm9124107DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7766017PMC
December 2020

Impact of Multiparametric MRI (mMRI) on the Therapeutic Management of Adnexal Masses Detected with Transvaginal Ultrasound (TVUS): An Interdisciplinary Management Approach.

Acad Radiol 2020 Dec 5. Epub 2020 Dec 5.

Department of Diagnostic and Interventional Radiology, RWTH Aachen University Hospital, Pauwelsstr. 30, Aachen, Germany.

Rationale And Objectives: Adnexal masses detected incidentally at transvaginal ultrasound (TVUS) are a common and still challenging diagnostic problem. The primary goal of further imaging is an accurate tissue characterization so an optimal treatment plan can be devised including surgery only for lesions that are indeterminate or malignant. The aim of this prospective study was to evaluate the diagnostic utility of complementary multiparametric magnetic resonance imaging (mMRI) for treatment planning in patients with adnexal masses, and to assess how it ultimately correlates with subsequent histopathologic findings.

Material And Methods: A total of 126 women (mean age: 54.6 years) with indeterminate adnexal masses underwent mMRI at 3T in addition to TVUS and testing to determine their CA-125 levels. The mMRI protocol consisted of a high-resolution T2-TSE in three planes, diffusion weighted images and dynamic contrast enhanced. First the character of the adnexal mass and the associated management decision (follow-up, laparoscopy or laparotomy) were assessed independently for each diagnostic method (TVUS + CA-125 and mMRI). All methods were then assessed in synopsis. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of each diagnostic method alone and in combination were calculated. The standard of reference was either final histology in women who underwent surgery or follow-up of at least 24 months in women who underwent follow-up.

Results: In 67.5% (85/126) of all patients, the adnexal mass was benign; a malignant tumor was diagnosed in 28.6% (36/126) and a borderline tumor in the remaining 4% (5/126) of patients. The diagnostic indices were as follows for TVUS + CA 125 alone, mMRI alone and all three methods combined: sensitivity 86% (31/36), 97% (35/36), and 100% (36/36); specificity 32% (29/90), 83% (75/90), and 80% (68/90); PPV 34% (31/91), 70% (35/50), and 74% (40/54); and NPV 65% (29/44), 98% (75/76), and 100% (72/72). Complementary use of mMRI changed the therapeutic management decision in 34% (41/126) of all patients. In 40.7% (37/91) of patients for whom surgery had been recommended based on TVUS + CA-125, MRI revealed a typical benign finding such that those patients underwent follow-up instead of surgery. None of the examined masses exhibited (tumor) progression or malignancy during the follow-up period. A laparotomy was performed instead of a laparoscopy in 8.7% (11/126) based on the mMRI result.

Conclusion: MRI helps significantly improve sensitivity and specificity of diagnosis in patients with indeterminate adnexal masses detected at TVUS. Its diagnostic information revised the planned treatment in more than one-third of women.
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http://dx.doi.org/10.1016/j.acra.2020.11.016DOI Listing
December 2020

Ovariopexy-Before and after Endometriosis Surgery.

Biomedicines 2020 Nov 25;8(12). Epub 2020 Nov 25.

Department of Gynecology and Obstetrics, University Hospitals Schleswig-Holstein, Campus Kiel, Arnold-Heller Str. 3, Building 24, 24105 Kiel, Germany.

Endometriosis surgery is often very challenging. Key to complete resection of endometriosis is access to the retroperitoneum. Endometriosis can involve the ureter and uterine vessels, and ovary on the lateral pelvic wall makes retroperitoneal access difficult. Primary and post-surgical adhesions prevalence in endometriosis is very high. Ovariopexy, transposition of ovaries temporarily, is done for better surgical access and to reduce postoperative adhesions. We concluded that although limited evidence, ovariopexy is an excellent tool to aid endometriosis surgery and prevent postoperative adhesions. It is cost effective, simple and complication rate almost nil. More robust trials are required to substantiate evidence for its impact on preventing postoperative adhesions and its effect on fertility. In this review, we describe our technique of ovariopexy supplemented with a video, with the aim to put light on this useful and important technique, which is beneficial both for surgeons and patients.
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http://dx.doi.org/10.3390/biomedicines8120533DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7759852PMC
November 2020

Impact of smoking and fetal gender on preterm delivery.

J Dev Orig Health Dis 2021 08 13;12(4):632-637. Epub 2020 Nov 13.

Department of Gynecology, University Hospital Freiburg, Hugstetter Str. 55, Freiburg79106, Germany.

According to the World Health Organization, smoking is the most important risk factor for adverse pregnancy outcomes in industrialized nations. We aimed to establish how fetal gender and smoking interact with regard to perinatal outcomes, especially preterm delivery. Data from 220,339 singleton pregnancies, obtained from the German Perinatal Survey in Schleswig-Holstein and registered between 2004 and 2017 were analyzed in regard to smoking behavior, fetal gender, and preterm delivery. The rate of preterm births was directly proportional to the women's consumption of nicotine. The rate of preterm deliveries was 6.8% among nonsmokers, and 13.2% in women who were very heavy smokers (≥22 cigarettes/day). Very heavy smoking (≥22 cigarettes/day) had a marked impact on extremely preterm births (<28 weeks of gestation) and very preterm births (28-31 weeks of gestation). Preterm births increased by 1.2% from heavy smokers to very heavy smokers; the differences between the other groups ranged between 0.1% and 0.4%. Fetal gender also had an impact on preterm birth: male infants were predominant in nearly all groups of women who delivered preterm infants. Smoking during pregnancy and male gender are both risk factors for preterm delivery. Fetal gender should be given greater attention as one of the several risk factors of preterm birth. Due to the high rate of morbidity among preterm infants and enormous costs for the healthcare system, women should be encouraged to cease or at least reduce smoking during pregnancy.
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http://dx.doi.org/10.1017/S2040174420000999DOI Listing
August 2021

Impact of Acoustic and Interactive Disruptive Factors during Robot-Assisted Surgery-A Virtual Surgical Training Model.

Sensors (Basel) 2020 Oct 17;20(20). Epub 2020 Oct 17.

Department of Obstetrics and Gynecology, University Hospitals Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3 (House C), 24105 Kiel, Germany.

The use of virtual reality trainers for teaching minimally invasive surgical techniques has been established for a long time in conventional laparoscopy as well as robotic surgery. The aim of the present study was to evaluate the impact of reproducible disruptive factors on the surgeon's work. In a cross-sectional investigation, surgeons were tested with regard to the impact of different disruptive factors when doing exercises on a robotic-surgery simulator (Mimic Flex VR). Additionally, we collected data about the participants' professional experience, gender, age, expertise in playing an instrument, and expertise in playing video games. The data were collected during DRUS 2019 (Symposium of the German Society for Robot-assisted Urology). Forty-two surgeons attending DRUS 2019 were asked to participate in a virtual robotic stress training unit. The surgeons worked in various specialties (visceral surgery, gynecology, and urology) and had different levels of expertise. The time taken to complete the exercise (TTCE), the final score (FSC), and blood loss (BL) were measured. In the basic exercise with an interactive disruption, TTCE was significantly longer ( < 0.01) and FSC significantly lower ( < 0.05). No significant difference in TTCE, FSC, or BL was noted in the advanced exercise with acoustic disruption. Performance during disruption was not dependent on the level of surgical experience, gender, age, expertise in playing an instrument, or playing video games. A positive correlation was registered between self-estimation and surgical experience. Interactive disruptions have a greater impact on the performance of a surgeon than acoustic ones. Disruption affects the performance of experienced as well as inexperienced surgeons. Disruption in daily surgery should be evaluated and minimized in the interest of the patient's safety.
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http://dx.doi.org/10.3390/s20205891DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7594064PMC
October 2020

Didactic Benefits of Surgery on Body Donors during Live Surgery Events in Minimally Invasive Surgery.

J Clin Med 2020 Sep 9;9(9). Epub 2020 Sep 9.

Department of Obstetrics and Gynecology, Kiel School of Gynaecological Endoscopy, University Hospitals Schleswig-Holstein, Campus Kiel, Arnold-Heller Str. 3, House C, 24105 Kiel, Germany.

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 ( = 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.
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http://dx.doi.org/10.3390/jcm9092912DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7563950PMC
September 2020

Postoperative Telephone-Based Questionnaire on Quality of Life after Robotic-Assisted Laparoscopic Hysterectomy versus Conventional Total Laparoscopic Hysterectomy.

J Clin Med 2020 Sep 2;9(9). Epub 2020 Sep 2.

Department of Gynecology and Obstetrics, University Hospitals Schleswig-Holstein, Campus Kiel, 24105 Kiel, Germany.

: The objective of the study was to evaluate the benefits of robotic-surgery for hysterectomy compared to conventional laparoscopy for benign indications. A specially prepared telephone-based questionnaire was used postoperatively. : All women ( = 155) undergoing total laparoscopic hysterectomy for benign indications either by the robotic-assisted procedure (RALH) or conventional laparoscopy (CL) between 1 January 2013 and 31 December 2017 at the Department of the Gynecology, University Hospitals, Campus Kiel, Germany, were eligible for analysis. Intra-operative and postoperative parameters affecting the patients' quality of life were assessed by a telephone-based questionnaire. The latter addressed postoperative pain, limitations of basic hygiene, daily activity, active pursuit of hobbies, sexual intercourse, and days of sick leave. All patients received the questionnaire by post at least three weeks prior to being contacted on the phone. : 78% of the contacted patients responded to the questionnaire; 96% ( = 115) of the patients said they would recommend the operation to other patients. Both groups needed 42 days to resume their regular hobbies. In whole 90.8% ( = 108) were total satisfied with the cosmetic result of the abdominal incision; the numbers in the respective groups were 80% (80% = 36) in RALH and 97.3% ( = 72) in CL. The difference was significant on the Chi-square test ( = 0.002). 5% ( = 7) were dissatisfied with the scar (13.3%; = 6) in the RALH group, and 1.4% ( = 1) in CL. In all 1.7 % of patients were dissatisfied with the position of the incisions; the respective numbers were 4.4 % ( = 2) in the RALH group and no patient in the CL group. 33% of patients experienced no limitations in regard of sexual intercourse after the operation. The median number of days taken to resume sexual intercourse after the operation was 56 days in the CL group, and 49 days in the RALH group. Nearly 30% ( = 25) were hesitant to resume intercourse. The median operating time was 145 min in the RALH group, which was significantly longer than the 117 min taken in the CL group ( < 0.001). : The RALH procedure was associated with some minor advantages for the patients according to the results, however it does not have major significant advantages, especially in regard of early restoration of sexual function, while the CL shows shorter operating times and similar limitation. Postoperative counseling of patients should be aligned to their fears and expectations in regard of sexual function.
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http://dx.doi.org/10.3390/jcm9092849DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7565397PMC
September 2020
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