Amadeus Hornemann

HIV-infection and modern antiretroviral therapy impair sperm quality

PurposeSerodiscordant couples with a human immunodeficiency virus type 1 (HIV-1)-infected man request assisted reproductive technology (ART) in order to achieve safe conception. Most of these men are on highly active antiretroviral therapy (HAART). HIV-1 infection and the antiretroviral drugs are blamed for semen alterations. The aim of our study was to investigate the semen parameters in HIV-1-infected patients with and without HAART and to compare their sperm characteristics with those of healthy men.Materials and methodsA prospective study of 226 men attended the university fertility center of Mannheim between May 1996 and July 2003. The patients were divided into three groups: HIV-infected men taking antiretroviral therapy, HIV-infected patients who did not take antiretroviral therapy until now and a control group with 93 men consulting our fertility center together with their wives because of tubal sterility. Semen samples were examined with regard to ejaculate volume, sperm concentration, motility, and morphology.ResultsThe study showed significant differences between the ejaculate of HIV-infected and non-infected men. The HIV-infected men as a whole group and the subgroup of men with HAART had a lower ejaculate volume, less slow progressive and more abnormally shaped spermatozoa compared with the control group. The HIV-infected men without an antiretroviral therapy had a significant lower ejaculate volume compared with the control group; the other parameters were not altered significantly. Differences between the subgroups with and without HAART were not significant.ConclusionThe spermiogram in HIV-1-infected men in comparison to a control group of healthy men is negatively altered. Especially in men with HAART, ejaculate volume as well as sperm morphology and motility changed significantly.

Advanced age is a risk factor for higher grade perineal lacerations during delivery in nulliparous women

PurposeTo identify risk factors for the development of severe perineal lacerations and to give recommendations for their prevention in nulliparous women.MethodsA retrospective case–control analysis of deliveries at our University Hospital was performed. Multiparae, Caesarean sections, twin pregnancies, fetal breech position and preterm deliveries were excluded. Univariate and multivariate step forward regression analyses were performed; correlations between contributors were further analyzed by Spearman Rank Correlation. Differences between the degree of lacerations and maternal age were further analyzed with Friedman ANOVA followed by Dunn’s Multiple Comparison Test.ResultsA total of 2,967 deliveries fitted our inclusion criteria, 50 (1.7%) mothers had higher-grade lacerations. Mediolateral and median episiotomy, advanced maternal age, vaginal operative delivery, higher fetal birth weight and abnormal cephalic presentation were associated with severe lacerations.ConclusionsAdvanced maternal age plays an important role in the development of anal sphincter tears in nulliparous women. Episiotomy and operative vaginal deliveries should be restrictively performed when possible. To identify further preventive approaches in patients with accumulated risk factors prospective randomized studies are needed.

Expression of vitamin D receptor (VDR), cyclooxygenase-2 (COX-2) and 15-hydroxyprostaglandin dehydrogenase (15-PGDH) in benign and malignant ovarian tissue and 25-hydroxycholecalciferol (25(OH2)D3) and prostaglandin E2 (PGE2) serum level in ovarian cancer patients.

Ovarian carcinomas are associated with increased inflammation which is based upon an up-regulation of inducible cyclooxygenase-2 (COX-2). Moreover, based on our previous published data, the extra-renal vitamin D metabolism seems to be dysregulated in comparison to healthy tissue. In order to gain further insight into the prostaglandin (PG)- and vitamin D-metabolism in ovarian carcinomas, the study aimed to evaluate the expression of the PG metabolising enzymes COX-2 and 15-hydroxyprostaglandin dehydrogenase (15-PGDH) compared to the vitamin D receptor (VDR) in benign and malignant ovarian tissues. Additionally, we determined the 25-hydroxycholecalciferol (25(OH2)D3) serum levels. Expression of VDR, COX-2 and 15-PGDH was determined by Western blot analysis. Serum levels of 25(OH2)D3 and PGE2 were measured by chemiluminescence-based and colorimetric immunoassay. We detected significantly higher expressions of the PG metabolising enzymes 15-PGDH and COX-2 in malignant tissue and PGE2 serum levels were 2-fold higher in tumour patients. Furthermore, we found an inverse correlation to the VDR-expression which was 62.1% lower in malignant tissues compared to that in benign tissues. Surprisingly, we could not detect any differences between the 25(OH2)D3 serum levels in either group (n=20). These data suggest a correlation between PG- and vitamin D-metabolism in ovarian carcinomas.

Laparoscopic nerve-sparing radical hysterectomy: Description of the technique and patients’ outcome

OBJECTIVE The radical hysterectomy type three can be accompanied by postoperative morbidity, such as dysfunction of the lower urinary tract with loss of bladder or rectum sensation. We describe the technique of laparoscopic nerve-sparing radical hysterectomy and patients outcome. METHODS Thirty-two patients underwent laparoscopic nerve-sparing radical hysterectomy with pelvic lymphadenectomy. Both the hypogastric and the splanchnic nerves were identified bilaterally during pelvic lymphadenectomy. RESULTS The median age of the patients was 52 years, and the average operating time was 221 min. There were no intraoperative or postoperative complications considering the nerve-spring radical hysterectomy. Postoperatively, in all patients spontaneous voiding was possible on the third postoperative day with a median residual urine volume of <50 ml. CONCLUSIONS Laparoscopic identification (neurolysis) of the inferior hypogastric nerve and inferior hypogastric plexus is a feasible procedure for trained laparoscopic surgeons who have a good knowledge not only of the retroperitoneal anatomy but also of the pelvic neuro-anatomy as this qualification could prohibit long-term bladder and voiding dysfunction during nerve-sparing radical hysterectomy.

Successful laser therapy of a papular acantholytic dyskeratosis of the vulva: case report and review of literature

BackgroundThe papular acantholytic dyskeratosis summarizes a collection of papular skin lesions which occur in intertriginous areas and in the genital area. They show a very characteristic histology without the connection to a syndrome such as the Hailey–Hailey disease or the Darier disease.MethodsWe present the case of an affected 45-year-old woman and evaluate the laser therapy as therapeutic option.ResultsA long lasting reduction of the symptoms was achieved by paying special attention to involving the deep tissue layers while performing the laser therapy. Despite causing a long and painful healing process, this was the only way to achieve a lasting reduction of the symptoms.ConclusionsLaser therapy in afflicted areas can improve the symptoms of the papular acantholytic dyskeratosis. The deep tissue laser therapy showed more success than the superficial laser therapy.

94 months follow-up after laparoscopic assisted vaginal resection of septum rectovaginale and rectosigmoid in women with deep infiltrating endometriosis

BackgroundEndometriosis with bowel involvement is the most invasive form and can cause infertility, chronic pelvic pain and bowel symptoms. Effective surgical treatment of endometriosis requires complete excision of endometriosis and in same case may require segmental rectosigmoid resection.MethodsBetween December 1997 and October 2003, 55 patients with rectovaginal endometriosis underwent a combined laparoscopic vaginal technique. 30 patients were found at a follow-up and underwent a telephone interview. The questionnaire covered questions about symptoms related to recurrences of intestinal endometriosis, dyspareunia, dysmenorrhea and pregnancy.ResultsTwenty-seven of 30 (90%) women have no clinical symptoms of reported recurrence of endometriosis. Two patients (6.6%) had evidence of recurrence of bowel endometriosis. Dysmenorrhoea disappeared in 28 (93.3%), dyspareunia in 26 (86.7%) and pelvic pain in 27 (90%) patients. 17 patients (31%) tried to become pregnant and 11 of these patients (65%) became pregnant: 9 patients delivered healthy newborns, 18 pregnancies occurred and 19 healthy children were born.ConclusionsDespite the small number of follow-up patients, our 94-month follow-up data demonstrated that endometriosis with bowel involvement and radical resection was associated with significant reductions in painful and dysfunctional symptoms, a low recurrence rate (6.6%) and high pregnancy rate (36.6%).

Hysteroscopic findings in women with two and with more than two first-trimester miscarriages are not significantly different

The purpose of this study was to analyse hysteroscopic results in patients with recurrent miscarriages and to compare the frequency of uterine anomalies in women with a history of exactly two and with more than two consecutive miscarriages. A retrospective analysis of 206 patients undergoing hysteroscopy for repeated early pregnancy losses was performed at two university centres. Late miscarriages were excluded, terminations of pregnancy were not counted. Eighty-seven patients had suffered from exactly two early miscarriages and 119 from more than two. Both groups were comparable with respect to age at admission (32.95+/-4.46 versus 34.06+/-5.02 years) and at first miscarriage (30.43+/-4.24 versus 29.08+/-5.38 years). The prevalence of acquired (adhesions, polyps, fibroids) and congenital uterine anomalies (septate or bicornuate uterus, etc.) did not differ significantly (acquired: 28.7 versus 27.7%; congenital: 9.2 versus 16.8%). The rates of uterine anomalies did not differ significantly overall (36.8 versus 42.9%). In conclusion, uterine anomalies are frequently found in patients with two and with more than two early miscarriages. Due to the high rate of anomalies, their risk for adverse pregnancy outcome and a possible therapeutic approach, hysteroscopy might be a diagnostic option even after two early miscarriages.

Immunohistochemical workup of sentinel nodes in endometrial cancer improves diagnostic accuracy

OBJECTIVE The purpose of this study was to examine the effect of immunohistochemical (IHC) staining of sentinel (SLN) and non sentinel lymph nodes (NSLN) on the detection of additional metastases in patients with endometrial cancer. PATIENTS AND METHODS Between April 2004 and March 2006, 25 patients with endometrial cancer were operated on. A new method for labelling SLNs with Patent Blue(R) was used. One additional slice was cut out of each lymph node and immunohistochemically stained (IHC). Sentinel and NSLN nodes were re-evaluated. RESULTS 673 lymph nodes from 21 patients were available for re-evaluation. With IHC staining significantly more metastases were detected compared to H&E staining. Though more patients with metastases were discovered this was not significant on the basis of affected SLNs or NSLNs. In the conventional evaluation 7 metastases were found in 3 patients. Applying re-evaluation and IHC 6 additional metastases in 5 patients were detected. These additional metastases were evenly distributed among the pelvic and para-aortic area, and among the SLNs or NSLNs. This had an impact on the diagnostic accuracy of the sentinel concept. Sensitivity reduced from 66.7% to 33.3% and the negative predictive value (NPV) fell from 94.7% to 79.0% only if the NSLNs were additionally IHC stained. On the contrary, if the SLNs were also IHC stained, the sensitivity rose to 83.3%, the NPV rose to 93.8%. CONCLUSION Our results indicate that additional immunohistochemistry staining of one additional block of SLNs improves the validity of sensitivity and the NPV in the sentinel concept.

Spontaneous uterine rupture at the 21st week of gestation caused by placenta percreta.

AbstractPurposeTo describe the management of a ruptured uterus caused by placenta percreta in the 21st week of gestation.Methods We present a case report of a 33-year-old patient with a ruptured uterus in the 21st week of gestation who presented at the Department of Gynecology and Obstetrics, University of Schleswig-Holstein, Campus Luebeck. Therapeutic management was performed by laparoscopy, and consecutive laparotomy and hysterectomy.Results A 33-year-old patient presented with severe abdominal pain in the 21st week of gestation at the department of abdominal surgery. A laparoscopy was performed to exclude appendicitis. There was about one liter of blood in the peritoneal cavity and a small, bleeding lesion in the fundus uteri was found which was coagulated. The blood was evacuated and the patient returned to department of gynecology. One hour after the first operation, the patient developed signs of hypovolemic shock and ultrasound showed absent fetal heart beat. An immediate laparotomy was performed and a ruptured uterus was detected. The fetus was removed and a hysterectomy performed. Pathology results showed a placenta percreta. After a few days in hospital and transfusion of 4 liters of blood the patient was discharged in a healthy condition.Conclusions In a pregnant woman with severe abdominal pain even in the 21st week of gestation a placenta percreta has to be considered as a differential diagnosis. If there is no evidence of other causes, laparoscopy may help to confirm the diagnosis and hysterectomy is a life saving intervention.

Laparoscopic management of ectopic pregnancy during a 9-year period

The present study analyzed the epidemiology and outcome of ectopic pregnancy during a 9-year period on a total of 473 women. Our follow-up shows that laparoscopic salpingostomy, performed in 84.9% of the patients, is a safe and effective treatment for ectopic pregnancy.