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Introduction Surgery for endometriosis is usually performed through minimally invasive surgery, either by experienced endometriosis surgeons or by supervised gynecology residents during their surgical training. This trial aimed to assess the influence of surgical experience on the efficiency and safety of minimally invasive surgery treatment for early-stage endometriosis. Material and Methods Post- and introperative complications rates and length of stay of patients with stage I and II (revised American Society of Reproductive Medicine stage (rASRM)) endometriosis undergoing laparoscopic surgery at the University Hospital Mainz, Germany, between 2018 and 2022 were evaluated in a propensity score-matched analysis based on the experience of the primary surgeon (resident/fellow vs. attending). Linear and logistic regression models were used on the matched data set to calculate the treatment effect on the treated. Results 580 patients were included in the final data set. Of those, 339 were operated on by 11 attending surgeons and 241 by 22 residents/fellows. The matched dataset showed a mean difference of 0.02 in propensity scores after full propensity score-matching. Compared to surgical procedures performed by experienced surgeons, prolonged operating times were found for surgeries performed by residents/fellows (5.27 min in the whole data set (SE 1.36), p  < 0.001), and 9.54 min (SE 3.57, p  = 0.007) when analyzing only rASRM stage II endometriosis. The need for revision surgery was reduced in the resident/fellow group, but did not reach statistical significance (0.56 (95%CI: 0.301-0.1.02), p  = 0.06). No significant differences were found for intra- or postoperative complications and length of hospital stay. Conclusions Gynecology residents and fellows trained on the patient can safely perform surgery for early-stage endometriosis at the cost of increased operative times. Additional training options, such as surgical simulation training, should be explored to shorten learning curves, reduce the financial burden on hospitals due to prolonged operative times and counter the impending reduction in intraoperative training possibilities for residents.

Background: Lymph node involvement is the most important prognostic factor for recurrence and survival in vulvar cancer. Sentinel node (SN) procedure can be offered in well-selected patients with early vulvar cancer. This study aimed to assess current management practices with respect to the sentinel node procedure in women with early vulvar cancer in Germany. Methods: A Web-based survey was conducted. Questionnaires were e-mailed to 612 gynecology departments. Data were summarized as frequencies and analyzed using the chi-square test. Results: A total of 222 hospitals (36.27%) responded to the invitation to participate. Among the responders, 9.5% did not offer the SN procedure. However, 79.5% evaluated SNs by ultrastaging. In vulvar cancer of the midline with unilateral localized positive SN, 49.1% and 48.6% of respondents, respectively, would perform ipsilateral or bilateral inguinal lymph node dissection. Repeat SN procedure was performed by 16.2% of respondents. For isolated tumor cells (ITCs) or micrometastases, 28.1% and 60.5% of respondents, respectively, would perform inguinal lymph node dissection, whereas 19.3% and 23.8%, respectively, would opt for radiation without further surgical intervention. Notably, 50.9% of respondents would not initiate any further therapy and 15.1% would opt for expectant management. Conclusions: The majority of German hospitals implement the SN procedure. However, only 79.5% of respondents performed ultrastaging and only 28.1% were aware that ITC may affect survival in vulvar cancer. There is a need to ensure that the management of vulvar cancer follows the latest recommendations and clinical evidence. Deviations from state-of-the-art management should only be after a detailed discussion with the concerned patient.

Gestationsbedingte Trophoblasterkrankungen (GTD) sind seltene, heterogene Erkrankungen mit Fehldifferenzierung und/oder pathologischer Proliferation des Trophoblastepithels. Die Inzidenz beträgt 1–2/1000 Geburten/Jahr. Die häufigsten benignen Trophoblasttumoren sind die Blasenmole und die Partialmole, welche mit einem veränderten Chromosomensatz (Disomie und Triploidie) aufgrund einer entarteten befruchteten Eizelle einhergehen. Klinisch können sich vaginale Blutungen mit massiv erhöhtem humanen Choriongonadotropin (hCG) zeigen. Neben der histologischen Diagnosesicherung durch die Saugkürettage ist die Bestimmung des hCG der wichtigste Parameter zur Therapieplanung. Gemäß FIGO-Score wird in Low- und High-risk-GTD eingeteilt, um die Chemotherapie mit hohen Heilungsraten festzulegen. Blasenmole und Partialmole werden mittels Saugkürettage therapiert, wohingegen beim aggressiven und früh metastasierenden Chorionkarzinom eine kurative Chemotherapie meist mit Methotrexat, Actinomycin D oder dem EMA-CO-Schema zum Einsatz kommt. Eine Hysterektomie wird nur in Ausnahmefällen bei unstillbarer uteriner Blutung durchgeführt.

The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45·6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84·5 (95% CI 84·1–84·9), which varied between HIC (88·5 [89·0–88·0]), MIC (81·8 [82·5–81·1]), and LIC (66·8 [64·9–68·7]) settings. In the third phase, 1217 (74·6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51·4%) were from HIC, 538 (44·2%) from MIC, and 54 (4·4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3·6% (95% CI 3·0–4·1; p<0·0001) increase in SVR. This was consistent in HIC (4·8% [4·1–5·5]; p<0·0001), MIC (2·8 [2·0–3·7]; p<0·0001), and LIC (3·8 [1·3–6·7%]; p<0·0001) settings. The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs. National Institute for Health Research (NIHR) Global Health Research Unit on Global Surgery, NIHR Academy, Association of Coloproctology of Great Britain and Ireland, Bowel Research UK, British Association of Surgical Oncology, British Gynaecological Cancer Society, and Medtronic.

Introduction Ventricular arrhythmias (VAs) in patients with chronic heart failure (CHF) are sometimes refractory to antiarrhythmic drugs and cardiac ablation. This study aimed to investigate catheter-based renal sympathetic denervation (RDN) as antiarrhythmic strategy in refractory VA. Methods These are the first data from a pooled analysis of 13 cases from five large international centers (age 59.2 ± 14.4 years, all male) with CHF (ejection fraction 25.8 ± 10.1 %, NYHA class 2.6 ± 1) presented with refractory VA who underwent RDN. Ventricular arrhythmias, ICD therapies, clinical status, and blood pressure (BP) were evaluated before and 1–12 months after RDN. Results Within 4 weeks prior RDN, a median of 21 (interquartile range 10–30) ventricular tachycardia (VT) or fibrillation (VF) episodes occurred despite antiarrhythmic drugs and prior cardiac ablation. RDN was performed bilaterally with a total number of 12.5 ± 3.5 ablations and without peri-procedural complications. One and 3 months after RDN, VT/VF episodes were reduced to 2 (0–7) ( p  = 0.004) and 0 ( p  = 0.006), respectively. Four (31 %) and 11 (85 %) patients of these 13 patients were free from VA at 1 and 3 months. Although BP was low at baseline (116 ± 18/73 ± 13 mmHg), no significant changes of BP or NYHA class were observed after RDN. During follow-up, three patients died from non-rhythm-related causes. Conclusions In patients with CHF and refractory VA, RDN appears to be safe concerning peri-procedural complications and blood pressure changes, and is associated with a reduced arrhythmic burden.