Michael David Mueller

Background/Objectives: Pelvic organ prolapse (POP) is a common condition, affecting approximately 3–6% of women symptomatically and up to 50% when assessed objectively, with a lifetime surgical risk of about 13%. Sacrocolpopexy is widely regarded as the gold standard for surgical management of apical prolapse, and minimally invasive techniques have increasingly supplanted open surgery due to reduced perioperative morbidity. Although laparoscopic sacrocolpopexy (LSC) is effective, it is technically challenging and associated with a substantial learning curve. Robot-assisted sacrocolpopexy (RASC) provides enhanced three-dimensional visualization and instrument dexterity, albeit at increased costs. This study aimed to compare the efficacy, safety, perioperative outcomes, and costs of these two surgical approaches. Methods: We searched MEDLINE, Embase, Scopus, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov from inception to 2 June 2025, with an updated search performed on 19 October 2026, for comparative studies of LSC and RASC in women with apical pelvic organ prolapse. Randomized and comparative observational studies were eligible. The primary outcome was operative time; secondary outcomes included total costs, objective cure rate, complication rate, reoperation rate, total blood loss, length of stay, and mesh-related outcomes. Continuous outcomes were synthesized as mean differences and dichotomous outcomes as odds ratios with 95% confidence intervals using random-effects meta-analysis; heterogeneity was assessed using I². Results: A total of 31 studies involving 15,783 patients (5417 LSC and 10,366 RASC) were included, comprising three randomized controlled trials and 28 non-randomized studies. RASC was associated with significantly longer operative time (MD 20.81 min, 95% CI 10.61–31.01; p < 0.001; I² = 96%) and higher costs (USD 5583.05, 95% CI 1449.91–9716.2; p = 0.008; I² = 94%). RASC was associated with a significantly lower intraoperative blood loss (MD −30.27 mL, 95% CI −44.12 to −16.42; p < 0.0001; I² = 97%), although the clinical relevance of this difference is questionable. No statistically significant differences were observed in postoperative POP-Q point C (MD −0.05 cm, 95% CI −0.45 − 0.35; p = 0.32; I² = 74%), objective cure rates (OR 0.97, 95% CI 0.28–3.39; p = 0.97; I² = 69%), overall complications (OR 1.19, 95% CI 0.83–1.69; p = 0.71; I² = 0%), or reoperation rates (OR 2.0, 95% CI 0.61–6.55; p = 0.25; I² = 51%). Conclusions: No statistically significant differences in effectiveness or safety outcomes were identified between LSC and RASC. RASC was associated with longer operative time and higher costs, while the reduction in intraoperative blood loss, although statistically significant, is of uncertain clinical significance. Further high-quality studies with extended follow-up are needed to determine whether these differences translate into meaningful clinical benefits.

BACKGROUND: Peritoneal adhesions are a major and often under-recognized cause of morbidity following abdominopelvic inflammation and surgery, contributing to chronic pelvic pain, infertility, bowel obstruction, and surgical complications. Endometriosis, affecting 10–11% of reproductive-age women, is strongly associated with adhesions; however, whether adhesion formation in endometriosis reflects general peritoneal injury or disease-specific mechanisms remains unclear. OBJECTIVE AND RATIONALE: This narrative review examines (i) physiological peritoneal healing and mechanisms of adhesion formation, (ii) how the altered peritoneal microenvironment in endometriosis may modify adhesiogenesis, and (iii) current and theoretical therapeutic and preventative strategies for adhesions in endometriosis. This will improve current understanding of adhesiogenesis and the implications of adhesions in women with endometriosis, and will identify areas for future research to reduce morbidity in this patient population. SEARCH METHODS: Literature searches were performed in PubMed, Embase and Cochrane Library using combinations of the terms ‘endometriosis’, ‘adhesions’, ‘pelvic’, ‘abdominal’, ‘peritoneal’ between January 2000 and February 2026. Randomized-controlled trials, observational studies, systematic reviews, and relevant experimental studies were included. Case reports and non-English publications were excluded. A total of 124 studies were included in this literature review. OUTCOMES: Adhesion formation results from dysregulated peritoneal repair involving inflammation, coagulation-fibrinolysis imbalance, and fibroproliferative remodelling. Evidence suggests that endometriosis creates a peritoneal environment characterized by chronic inflammation, altered immune responses, repeated tissue injury, and exposure to menstrual debris and iron, which may promote adhesiogenesis. However, much mechanistic understanding is derived from experimental models, and direct evidence from patients remains limited. Prevention of adhesiogenesis in endometriosis currently focuses on intra-operative interventions to limit adhesion development following endometriosis-related surgery, rather than preventing disease-related adhesiogenesis in the absence of surgery. We discuss potential pharmacotherapies, including hormonal treatments, identified by experimental studies, which may perturb endometriosis-related adhesiogenesis. WIDER IMPLICATIONS: Current data support a model in which adhesion biology in endometriosis largely reflects conserved wound-healing pathways but develop within a chronically altered peritoneal microenvironment that lowers the threshold for adhesiogenesis and promotes persistence and recurrence. Clarifying endometriosis-specific drivers and generating robust human data are essential to develop targeted adhesion-prevention strategies and improve long-term outcomes for affected patients. Notably, there are currently no effective pharmacological therapies to prevent or treat adhesions, representing a major unmet clinical need in endometriosis care. REGISTRATION NUMBER: N/A.

Background/Objectives: Adenomyosis is a chronic gynecological disorder characterized by the presence of endometrial tissue within the myometrium, causing pelvic pain, abnormal uterine bleeding, and infertility. Despite its high prevalence, the molecular mechanisms underlying disease initiation and progression remain incompletely understood. Current evidence implicates disruption of the endometrial–myometrial interface, epithelial–mesenchymal transition, and progesterone resistance in driving tissue invasion and remodeling. Diagnosis relies mainly on imaging modalities, while reliable non-invasive biomarkers are lacking. MicroRNAs, as stable post-transcriptional regulators of gene expression, have emerged as key modulators of proliferation, inflammation, and hormonal signaling, and represent promising candidates for novel diagnostic strategies. Methods: A systematic review was conducted in accordance with PRISMA guidelines and registered with PROSPERO (CRD42025637752). A comprehensive search of the Medline, Embase, Scopus, and Cochrane databases was performed in April 2025. Studies investigating miRNA expression in patients with adenomyosis compared with controls were included. The quality of the studies and the risk of bias were assessed using the Newcastle–Ottawa scale. Two reviewers independently performed study selection, data extraction, and quality assessment. Results: Twenty-seven studies published between 2015 and 2025 met the inclusion criteria. Thirty-nine distinct miRNAs were reported as significantly dysregulated in adenomyosis. Recurrently altered miRNAs included let-7a, miR-145, miR-10b, miR-30c-5p, miR-141-3p, miR-143, and miR-191. Functional analyses have consistently implicated miRNAs in key pathogenic pathways, including Hippo-YAP, PI3K/AKT, MAPK/ERK, JAK/STAT, and Wnt/β-catenin signaling. These alterations were associated with enhanced epithelial–mesenchymal transition, increased cellular proliferation and migration, progesterone resistance, chronic inflammation, and immune modulation. Emerging evidence highlights exosomal and circulating miRNAs as promising non-invasive biomarkers, with a few studies already demonstrating diagnostic potential using serum, plasma, or urine samples. However, substantial heterogeneity in tissue types, sampling timing, and analytical methods precluded meta-analysis. Conclusions: MiRNAs play a central role in the molecular pathogenesis of adenomyosis and show strong potential as non-invasive diagnostic biomarkers. However, large-scale validation studies and standardized methodologies are required before clinical implementation.

Endometriosis, affecting 1 in 9 women, presents treatment and diagnostic challenges. To address these issues, we generated a comprehensive single-cell atlas of endometrial tissue, comprising 466,371 cells from 35 endometriosis and 25 non-endometriosis donors without exogenous hormonal treatment. Detailed analysis reveals significant gene expression changes and altered receptor-ligand interactions present in the endometrium of endometriosis patients, including increased inflammation, adhesion, proliferation, cell survival, and angiogenesis in various cell types. These alterations may enhance endometriosis lesion formation and identify potential therapeutic targets. Using ScaiVision, we trained neural network models to predict endometriosis of varying disease severity (median AUC = 0.83), including one model based solely on a set of 11 genes confirmed as dysregulated in endometriosis patients through differential expression analysis. In conclusion, our findings reveal numerous pathway and ligand-receptor changes in the endometrium of endometriosis patients, offering insights into pathophysiology, potential targets for improved treatments, and predictive models for enhanced outcomes in endometriosis management. Our models, while not yet externally validated, can serve as a tool for hypothesis generation and starting point for further clinical development.

Background: Long-term survivors (LTS) after gynecological cancer may be cured but still face physical and psychological challenges. This multicenter study aimed to assess the long-term side effects, the received follow-up care, and the personal perspectives of survivors. Methods: Between 2019 and 2025, LTS from four European countries within the ENGOT (European Network of Gynecological Oncological Trial Groups) and GCIG (Gynecologic Cancer InterGroup) networks were recruited. Long-term survival was defined as surviving at least five years after the first diagnosis. LTS completed a questionnaire with 81 questions (patient’s characteristics, oncological history, current health status, lifestyle factors). Analyses were mainly descriptive. Results: A total of 677 LTS were enrolled, with a median age of 64.0 years (range: 26–92) and a median survival time of 7 years (range: 5–38). A total of 46.6% were diagnosed with cervical cancer, 32.9% with endometrial cancer, 4.4% with ovarian cancer, and 16.1% with other types of gynecological cancer. Moreover, 36.9% still suffer from physical and psychological symptoms, most frequently being lymphedema (36.2%), hot flashes (22.4%), difficulties with concentration (21.1%), fatigue (20.9%), vaginal dryness (20.1%), and urinary incontinence (18.9%). Median overall health status was ranked (scale 1–5; 1 = very good, 5 = very poor) as 2, while 13.5% rated their health as poor/very poor. Current symptoms were associated with poorer health status (p < 0.001) and a history of recurrent disease (p = 0.001). In addition, 13.6% reported not receiving follow-up care. CA-125 was determined in 80.8% of ovarian LTS, as well as in 30.7% of cervical and 28.9% of endometrial LTS. Pap smear follow-up was reported by 50.5% of endometrial LTS. A total of 33.7% did not exercise at all or exercised less than an hour per week, 13.4% smoke tobacco, and 51.2% drink alcohol more often than once a month. Conclusions: Our findings highlight the need for patient-centered follow-up care, addressing both long-term side effects and education on lifestyle and prevention. Follow-up procedures that do not follow guidelines should be avoided.

Introduction: The outbreak of SARS-CoV-2 in 2020 and the resulting lockdowns had a major impact on general healthcare provision. This study aimed to investigate whether the COVID-19 pandemic affected diagnosis, treatment, and survival of ovarian cancer patients at our institution. Methods: This retrospective cohort study included patients diagnosed with primary ovarian cancer and borderline ovarian tumor (BOT) at Bern University Hospital between January 2019 and December 2022. Clinical data were collected in a standardized database. Results: A total of 218 patients were included. Annual distribution of primary ovarian cancer diagnoses was 52 (2019), 32 (2020), 39 (2021), and 57 (2022), while borderline ovarian tumor diagnoses remained stable: 10 (2019, 2020, 2022) and 8 (2021). FIGO stage distribution remained unchanged during the study period (p= .520). Among 131 patients with advanced-stage ovarian cancer, 84% underwent cytoreductive surgery without significant changes over time (p= .838). However, a shift in surgical strategy was observed with interval debulking surgery increasing significantly during the COVID-19 pandemic years (2020 – 2021) (p= .030). Complete cytoreduction was achieved in 89% of cases, remaining constant (p= .355). Chemotherapy was administered to 94% of advanced-stage patients, with no changes during the COVID-19 pandemic years (p= .139). Cox regression analysis revealed no increased risk of recurrence (p= .142) or death (p= .587) for patients diagnosed during the COVID-19 pandemic years (2020–2021) compared to those in 2019 and 2022. Conclusion: While BOT diagnoses remained stable throughout the COVID-19 pandemic years, primary ovarian cancer diagnoses decreased in 2020 and 2021. No shift in disease stage was observed. However, more patients received interval debulking surgery during the pandemic. Overall, the SARS-CoV-2 outbreak did not negatively affect the oncological outcomes of patients with advanced-stage ovarian cancer at our institution.

Background: Deep infiltrating endometriosis (DIE) and, in particular, bowel endometriosis stand out for their complexity. While surgery for bowel endometriosis has proven to be effective, there is a lack of standardization concerning the technique used and the reported outcomes. Objectives: The objective is to perform a review aiming to summarize the state of the art of bowel endometriosis and to point out the gaps to be addressed by future research. We also propose a novel classification of surgical procedures to fill these gaps and improve management. Methods: A literature search was performed on PubMed from inception to October 2025. Results: The following three major procedures for the excision of bowel endometriosis have been proposed: the nodule shaving, the discoid excision, and the segmental intestinal resection. One further technique, NOSE (natural orifice specimen extraction), can be applied for the removal of the specimen in cases of discoid or segmental resection. To reduce surgical morbidity, current data support the choice of most conservative surgical options, namely nodule dissection and discoid resection, as well as the use of nerve-sparing techniques in case of segmental resection. Nonetheless, there is little evidence concerning the indication and the most appropriate technique to be used, including their relative risks and benefits in terms of pain control, urinary and gastrointestinal function, risk of future relapse, and fertility outcomes. Conclusions: Significant barriers in comparing surgical outcomes due to unclear definitions, lack of standardization, and incomplete reporting are some of the most relevant issues frequently encountered. To fill these gaps, we propose a new classification system for bowel surgery that describes the dimension and the number of the lesions, as well as the type of surgical technique used, supplemented by the information if vaginal opening was necessary for complete lesion resection. This proposition aims to open a discussion on this topic and boost focused research to evaluate the utility of a new classification in clinical practice.

Robotic-assisted hysterectomy using DEXTER®: the first prospective multicentre study - Facts, Views and Vision in ObGyn