Ibrahim Alkatout

Background: Preterm birth (PTB) remains a leading cause of neonatal morbidity and mortality worldwide. Although transvaginal cervical length (CL) is an established predictor, its discriminatory performance is limited. The uterocervical angle (UCA) has been proposed as an additional sonographic parameter reflecting biomechanical properties of the cervix and lower uterine segment, but evidence regarding its clinical utility remains limited. This study aimed to evaluate the predictive value of UCA and CL for PTB and to assess whether their combined use improves risk stratification. Methods: This retrospective cohort study included 548 pregnancies at the University Hospital for Gynecology and Obstetrics Innsbruck (2013–2023). Transvaginal ultrasound measurements of CL and UCA were analyzed. Associations with PTB were assessed using multivariable logistic regression, and discriminatory performance was evaluated via receiver operating characteristic (ROC) curve analysis. Optimal cut-off values were determined using Youden index. In a predefined subgroup of 366 pregnancies, models incorporating CL, UCA, and PartoSure were analyzed. Results: PTB occurred in 278 (50.7%) pregnancies, while 270 (49.3%) delivered at term. No significant differences were observed for measurements taken between 24 + 0 and 27 + 6 weeks. In contrast, between 28 + 0 and 34 + 0 weeks, CL was significantly shorter and UCA significantly wider in pregnancies resulting in PTB. Both parameters remained independently associated with PTB in multivariable analysis. ROC analysis demonstrated moderate discriminatory ability for CL (AUC = 0.614) and weaker performance for UCA (AUC = 0.561), while their combination improved discrimination (AUC 0.644). Using Youden index–derived cut-offs (CL < 15.5 mm; UCA ≥ 101°), the observed proportion of PTB was highest when both markers were present. In the PartoSure subgroup ( n = 366), short CL (OR 2.54, 95% CI 1.52–4.25, p < 0.001) and wide UCA (OR 2.10, 95% CI 1.21–3.64, p = 0.009) remained independently associated with PTB, whereas PartoSure positivity was not (OR 1.66, 95% CI 0.74–3.70, p = 0.217). The model integrating CL, UCA, and PartoSure yielded the numerically highest discriminatory performance among the models evaluated in this subgroup (AUC = 0.609). Conclusions: CL and UCA measured between 28 + 0 and 34 + 0 weeks are independently associated with PTB and provide complementary information for risk stratification. While overall predictive performance remains moderate, combining ultrasound parameters with PartoSure improves discrimination and may enhance clinical decision-making. Trial registration: Retrospectively registered.

Background: The rise in robotic surgical procedures underscores the need for effective training in minimally invasive surgery, particularly the interactions between robotic and conventional techniques. Aim of this experimental study was to examine whether conventional and robotic laparoscopy require different neuropsychological skills and to evaluate the role of individual experience and expertise. Study design: A single center, randomized crossover training trial was conducted at a university hospital surgical training center. Participants were 86 postgraduates (residents and experts) from general surgery, urology and gynecology who were enrolled in surgical training courses, and 237 fifth-year medical students participated within their gynecology curriculum. Participants underwent neuropsychological testing, followed by surgical training in both conventional and robot-assisted laparoscopy, performing identical tasks six times in a randomized crossover setting. Results: For conventional laparoscopy, 57 participants were “slow learners,” while 212 were “fast learners”. For robotic laparoscopy, 193 participants were “slow learners” and 76 “fast learners”. Among students, conventional training success was significantly associated with neuropsychological factors such as personality, motivation, psychomotor skills, while robotic training was predominantly associated with personality factors. Among physicians, both personality and psychomotor skills were critical for learning surgical skills in both techniques. Conclusion: Surgical training outcomes differ significantly between conventional and robotic laparoscopy. Conventional laparoscopy supports faster learning, with a good start performance strongly influencing training success, whereas good robotic start performance correlated with slower learning. Different individual factors influenced effective training of surgical skills according to the surgical method and prior experience and skills level, suggesting tailored training curricula. Trial registration: The study is registered in The UK´s Clinical Study Registry (ISRCTN79269632).

Background: Assisted reproductive technology (ART) is increasingly utilized worldwide, and approximately 30% of ART pregnancies result in twin gestations. Chorionicity strongly influences perinatal risk, yet its specific impact on ART-conceived twins has not been systematically clarified. Objective: To compare obstetrical and neonatal outcomes in assisted ART-conceived monochorionic (MC) versus dichorionic (DC) twin pregnancies and evaluate the impact of chorionicity on maternal and perinatal outcomes. Methods: This systematic review was conducted according to PRISMA guidelines and registered in PROSPERO (CRD42024600292). PubMed, Scopus, and Web of Science were searched through October 2024 for studies comparing obstetrical and neonatal outcomes in ART-conceived monochorionic and dichorionic twin pregnancies. Eligible studies were qualitatively synthesized. Results: Thirty-five studies comprising 15,648 ART-conceived twin pregnancies were included, including 371 monochorionic and 15,277 dichorionic pregnancies. MC pregnancies consistently demonstrated less favorable perinatal outcomes compared with DC pregnancies, including an earlier gestational age at delivery, increased prematurity, lower birth weight, and higher rates of perinatal mortality. By contrast, maternal complications, such as hypertensive disorders, gestational diabetes mellitus, PROM, and cesarean delivery, varied considerably across the studies without a consistent association with chorionicity. The baseline maternal characteristics were generally comparable between the groups. Conclusions: Monochorionicity in ART-conceived twin pregnancies is associated with increased adverse neonatal and perinatal outcomes, particularly prematurity and perinatal mortality, while maternal outcomes appear less clearly influenced by chorionicity. Standardized prospective studies are needed to further clarify the chorionicity-specific risks in ART twin pregnancies.

The Dexter robotic surgery system is a novel approach combining conventional laparoscopic and robotic surgery through an on-demand hybrid concept. Following its clinical approval in 2022, it has been used in a variety of surgical fields, but data on routine gynecological application remain limited. This study reports the first consecutive case series evaluating technical feasibility and early outcomes of the Dexter system in routine gynecological surgery. This retrospective consecutive case series included all gynecological procedures performed with the Dexter system at a single academic center between November 2022 and March 2024. Primary outcome was operative time (skin-to-skin). A total of 47 patients underwent nine different types of gynecological procedures. Benign hysterectomies were the most common ( n = 28/47, 59.6%). Mean operative times varied between procedures, with the longest duration observed for hysterectomy combined with cervicosacropexy (161.0 min ± 26.0 min), followed by total hysterectomy (139.8 min ± 33.1 min) and myomectomy (131.0 ± 42.7 min). Blood loss was < 50 ml in all cases. No intraoperative complications were observed and no conversions to laparotomy or conventional laparoscopy occurred. This study demonstrates the technical feasibility of the Dexter robotic system for routine minimally invasive procedures in gynecological procedures. The on-demand hybrid concept was successfully integrated into clinical workflow. These findings provide foundational data for future comparative studies evaluating the Dexter system in gynecological surgery.

Background: The individual and social burden of endometriosis is high, and the diagnosis is usually delayed by 7–10 years. Menstrual effluent (ME) represents an accessible and uniquely informative biofluid. This systematic review evaluated the pathophysiological relevance and diagnostic potential of ME in endometriosis. Methods: Following PRISMA 2020 guidelines, we systematically searched PubMed/MEDLINE, EBSCOhost (Academic Search Premier, APA PsycArticles, APA PsycInfo, CINAHL, and MEDLINE), Semantic Scholar, and Google Scholar from inception to 30 November 2025. Original studies analyzing human ME or ME-derived cells in women with endometriosis versus controls were eligible. We extracted study design, analytic methods, diagnostic accuracy metrics (AUC, sensitivity, and specificity), mechanistic pathways, and risk of bias (QUADAS-2 for diagnostic, and NIH tools for mechanistic studies). Results: Thirty-five studies were included. ME consistently captured key pathophysiological mechanisms of endometriosis, including impaired decidualization and progesterone resistance, immune dysregulation with diminished cytotoxic clearance, pro-angiogenic and invasive phenotypes, heightened stem/progenitor cell survival, cellular senescence and DNA damage, and altered extracellular-vesicle signaling. Diagnostic accuracy was reported in nine studies. Aromatase mRNA showed the highest performance (AUC 0.977), followed by TGF-β1 (AUC 0.973) and IGFBP1 (AUC 0.92). A lipidomic two-marker model achieved an AUC of 0.87. All diagnostic assessments were based on case–control studies; none conducted prospective validation. Conclusions: ME is a biologically relevant, non-invasive, and patient-acceptable biospecimen reflecting core endometriosis mechanisms and yielding promising diagnostic accuracy. The highest diagnostic performance was achieved for assays reflecting steroidogenic and growth-factor pathways (e.g., aromatase and TGF-β1). Standardization and prospective validation are needed before clinical adoption.

We are looking back on over 10 years of successful work and numerous milestones in the interdisciplinary center of minimally invasive surgery, robotic surgery in particular. The success is largely owing to the spirit of sharing and collaborating — rather than competing — across the surgical disciplines. The collaboration became particularly fruitful by including the Kiel Center of Clinical Anatomy of Kiel University where many surgical approaches and techniques have been developed or refined on body donors. Apart from the traditional and renowned “Kiel school” for training in gynecological endoscopy built on the heritage of Kurt Semm; a training center (Kurt-Semm-Academy) for robot-assisted surgery was founded in 2020. The Kurt-Semm-Center has always followed the credo of establishing the best surgical technology for the best possible patient treatment. The ambitious claim to offer not only state-of-the-art surgery, but also to advance it further through studies and research, both experimental and clinical. This is evidenced by the enormous output of innovative research and publication activity, some of which is presented in this article. The key to success has been co-working across the disciplines, with continuing tenacity and dedication to state-of-the-art minimally invasive surgery. We believe that many hospitals could profit from an interdisciplinary spirit, having realized that individual department-specific interests are eventually better met when people learn from each other and work as a team. This article is dedicated to the spiritus rector of the Kurt-Semm-Zentrum, Prof. Dr. med. Klaus-Peter Jünemann.

Background/Objectives: Chronic pelvic pain (CPP) is defined as pelvic pain lasting longer than six months and is a common yet often overlooked condition, affecting over 40% of women worldwide and accounting for about 10% of gynecological consultations. Despite extensive investigation, including laparoscopy, no cause is identified in up to half of cases. Pelvic congestion syndrome (PCS), also referred to as pelvic venous insufficiency (PVI), has been estimated to account for up to 30% of CPP cases, although it remains underdiagnosed. PCS is caused by venous reflux or obstruction in pelvic veins and is characterized by dull, aching pain worsened by standing, intercourse, post-orgasm, and the premenstrual period. It occurs predominantly in premenopausal women, often after pregnancy. This narrative review aims to improve understanding of PCS and provide practical guidance to support diagnosis and treatment in routine gynecologic practice. Methods: We performed a comprehensive review of the current literature focusing on the clinical presentation, pathophysiology and diagnostic and treatment performance of various modalities. Special emphasis was placed on identifying accessible, non-interventional tools suitable for primary gynecological care. Results: PCS, CPP and endometriosis exhibit significant clinical overlap, including dysmenorrhea, dyspareunia and chronic pain. However, pathognomonic features like post-coital pain and pain-exacerbation by prolonged standing, combined with specific ultrasound markers, allow for early differentiation. While laparoscopy is often used to investigate CPP, it has limited sensitivity for PCS due to CO₂-pneumoperitoneum-induced venous compression, and Trendelenburg position, compared to venography, the diagnostic gold standard. In contrast, transvaginal ultrasound (TVUS) serves as a potent first-line tool. Key diagnostic criteria include ovarian vein diameter (>7–8 mm), low flow velocity (5 mm). Furthermore, the frequent co-occurrence of endometriosis and PCS requires a multimodal diagnostic approach to avoid “diagnostic bias.” Conclusions: To improve patient outcomes and reduce diagnostic delay, office-based gynecologists should integrate specific vascular TVUS into the routine workup of CPP, not only to diagnose endometriosis but also to identify PCS. Future efforts should focus on standardized TVUS protocols and interdisciplinary care pathways involving gynecologists and interventional radiologists to enable integrated diagnostic and therapeutic approaches for patients with coexisting endometriosis and PCS, addressing both surgical and non-surgical options, as well as the bidirectional relationship and mutual pathophysiological influence between these entities.