Indications and Route of Hysterectomy for Benign Diseases. Guideline of the DGGG, OEGGG and SGGG (S3 Level, AWMF Registry No. 015/070, April 2015)

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Official guideline “indications and

of hysterectomy ” to assign indications for the different methods published and coordi- nated by the German Society of Gynecology and Obstetrics (DGGG), the Austrian Society of Gyne- cology and Obstetrics (OEGGG) and the Swiss So- ciety of Gynecology and Obstetrics (SGGG). Be- sides vaginal and abdominal hysterectomy, three additional techniques have been implemented due to the introduction of laparoscopy. Organ- sparing alternatives were also integrated.

The guideline group consisted of 26 ex- perts from Germany, Austria and Switzerland. Recommendations were developed using a struc- tured consensus process and independent mod- eration. A systematic literature search and quality appraisal of benefits and harms of the therapeutic alternatives for symptomatic fibroids, dysfunc- tional bleeding and adenomyosis was done through MEDLINE up to 6/2014 focusing on sys- tematic reviews and meta-analysis.

All types of hysterectomy led in studies to high rates of patient satisfaction. If possible, vaginal instead of abdominal hysterectomy should preferably be done. If a vaginal hysterec- tomy is not feasible, the possibility of a laparo- scopic hysterectomy should be considered. An ab- dominal hysterectomy should only be done with a special indication. Organ-sparing interventions also led to high patient satisfaction rates, but con- tain the risk of symptom recurrence.

As an aim, patients should be en- abled to choose that therapeutic intervention for their benign disease of the uterus that convenes best to them and their personal life situation. Zusammenfassung ! Hintergrund: Offizielle Leitlinie, publiziert und koordiniert von der Deutschen Gesellschaft für Gynäkologie und Geburtshilfe (DGGG), der Öster- reichischen Gesellschaft für Gynäkologie und Ge- burtshilfe (OEGGG) und der Schweizerischen Gesellschaft für Gynäkologie und Geburtshilfe (SGGG). Durch die Einführung laparoskopischer Operationen wurde die vaginale und abdominale Hysterektomie um 3 weitere Techniken ergänzt. Um die Indikationsfelder abzugrenzen, wurde die Leitlinie „Indikation und Methodik der Hyster- ektomie bei benignen Erkrankungen“ initiiert. Or- ganerhaltende Therapiealternativen wurden ebenfalls integriert. Methode: Die Leitlinie wurde durch ein reprä- sentatives Gremium von 26 Experten aus Deutschland, Österreich und der Schweiz unter strukturierter unabhängiger Moderation im Kon- sens erstellt. Die systematische Literatursuche und ‑bewertung zu Nutzen und Schaden der The- rapiealternativen bei symptomatischem Uterus myomatosus, funktionellen Blutungsstörungen und Adenomyosis sowie ein Vergleich der Hyster- ektomieverfahren erfolgte bis 06/2014 in der Da- tenbank MEDLINE mit Fokus auf aggregierter Evi- denz. Ergebnisse: Alle Formen der Hysterektomie sind in Studien mit einer hohen Zufriedenheit der Pa- tientinnen verbunden. Der vaginalen Hysterekto- mie soll gegenüber der abdominellen, wenn mög- lich, der Vorzug gegeben werden. Ist die vaginale Hysterektomie nicht möglich, sollte die Möglich- keit einer laparoskopischen Hysterektomie ge- prüft werden. Die abdominale Hysterektomie sollte nur bei gesonderter Indikation durch- geführt werden. Für die organerhaltenden Alter- nativen wurde ebenfalls ein hoher Zufrieden- heitsgrad festgestellt, allerdings können bei Belas- sen des Uterus Rezidive auftreten. Indications and Route of Hysterectomy for Benign Diseases. Guideline of the DGGG, OEGGG and SGGG (S3 Level, AWMF Registry No. 015/070, April 2015) Indikation und Methodik der Hysterektomie bei benignen Erkrankungen. Leitlinie der DGGG, OEGGG und SGGG (S3-Level, AWMF-Registernummer 015/070, April 2015) Authors K. J. Neis 1, W. Zubke 2, T. Römer 3, K. Schwerdtfeger 4, T. Schollmeyer †5, S. Rimbach 6, B. Holthaus 7, E. Solomayer 1, B. Bojahr 8,F .N e i s9, C. Reisenauer 9, B. Gabriel 10, H. Dieterich 11, I. B. Runnenbaum 12, W. Kleine 13,A .S t r a u s s14, M. Menton 15, I. Mylonas 16, M. David 17, L-C. Horn 18,D .S c h m i d t19,P .G a ß20, A. T. Teichmann 21, P. Brandner22, W. Stummvoll †23, A. Kuhn 24, M. Müller 24, M. Fehr 25, K. Tamussino 26 Affiliations The affiliations are listed at the end of the article. Key words l" guideline l" hysterectomy l" uterine myomas l" bleeding disorders l" endometriosis Schlüsselwörter l" Leitlinie l" Hysterektomie l" Uterus myomatosus l" Blutungsstörungen l" Endometriose

DOI http://dx.doi.org/ 10.1055/s-0042-104288 Geburtsh Frauenheilk 2016; 76: 350–364 © Georg Thieme Verlag KG Stuttgart · New York · ISSN 0016‑5751 Correspondence Prof. Dr. Klaus Neis Department of Gynecology, Obstetrics and Reproductive Medicine of the University Hospital of the Saarland, Homburg/Saar Frauenärzte am Staden Bismarckstraße 39–41 66121 Saarbrücken [email protected] gynécologie suisse 350 Neis KJ et al. Indications and Route … Geburtsh Frauenheilk 2016; 76: 350 –364 GebFra Science Deutsche Version unter: www.thieme-connect.de/ ejournals/gebfra I Guideline Information Guidelines Program of the DGGG, OEGGG and SGGG. Information on this topic is provided at the end of the guideline. Citation format Indications and route of hysterectomy for benign diseases. Guideline of the DGGG, OEGGG and SGGG (S3 Level, AWMF Registry No. 015/070, April 2015). Geburtsh Frauenheilk 2016; 76: 350– 364 Guideline documents The complete long version and a summary of the conflicts of in- terest of all of the authors in the Guideline methods report are available on the AWMF website: http://www.awmf.org/leitlinien/detail/ll/015-070.html Authors See l" Table 1. Schlussfolgerung: Ziel der Aufklärung ist, die Patientin in die Lage zu versetzen, unter den Therapieoptionen für benigne Ute- ruserkrankungen diejenige herauszufinden, die am besten zu ihr und ihrer Lebenssituation passt. Table 1 Authors. Author Mandate holder DGGG working group/professional association/organization/society Coordinating lead authors: Prof. Dr. med. K. J. Neis1, 3 German Society of Gynecology and Obstetrics (Deutsche Gesellschaft für Gynäkologie und Geburtshilfe [DGGG]) Prof. Dr. med. K. Schwerdtfeger1 AWMF Guideline consultant Other participating authors contributing to the guideline: Dr. med. W. Zubke 2, 3 German Society of Gynecology and Obstetrics (Deutsche Gesellschaft für Gynäkologie und Geburtshilfe [DGGG]) Prof. Dr. med. K. Tamussino2, 3 Austrian Society of Gynecology and Obstetrics (Österreichische Gesellschaft für Gynäkologie und Geburtshilfe [OEGGG]) Prim. Dr. med. W. Stummvoll † Austrian Society of Gynecology and Obstetrics (Österreichische Gesellschaft für Gynäkologie und Geburtshilfe [OEGGG]) PD Dr. med. M. Fehr2 Swiss Society of Gynecology and Obstetrics (Schweizerische Gesellschaft für Gynäkologie und Geburtshilfe [SGGG]) Prof. Dr. med. A. Kuhn3 Swiss Society of Gynecology and Obstetrics (Schweizerische Gesellschaft für Gynäkologie und Geburtshilfe [SGGG]) Prof. Dr. med. M. Müller Swiss Society of Gynecology and Obstetrics (Schweizerische Gesellschaft für Gynäkologie und Geburtshilfe [SGGG]) Prof. Dr. med. B. Bojahr Working Group for Gynecological Endoscopy (Arbeitsgemeinschaft Gynäkologische Endoskopie [AGE]) PD Dr. med. S. Rimbach Working Group for Gynecological Endoscopy (Arbeitsgemeinschaft Gynäkologische Endoskopie [AGE]) Prof. Dr. med. T. Römer 2, 3 Working Group for Gynecological Endoscopy (Arbeitsgemeinschaft Gynäkologische Endoskopie [AGE]) Prof. Dr. med. E. Solomayer3 Working Group for Gynecological Endoscopy (Arbeitsgemeinschaft Gynäkologische Endoskopie [AGE]) Dr. med. T. Schollmeyer † Working Group for Gynecological Endoscopy (Arbeitsgemeinschaft Gynäkologische Endoskopie [AGE]) Dr. med. B. Holthaus Working Group for Gynecological Endoscopy (Arbeitsgemeinschaft Gynäkologische Endoskopie [AGE]) Dr. med. F. Neis 3 Working Group for Gynecological Endoscopy (Arbeitsgemeinschaft Gynäkologische Endoskopie [AGE]) Prof. Dr. med. B. Gabriel Working Group for Urogynecology and Reconstructive Pelvic Surgery (Arbeitsgemeinschaft für Urogynäkologie und plastische Beckenbodenrekonstruktion [AGUB]) Prof. Dr. med. C. Reisenauer3 Working Group for Urogynecology and Reconstructive Pelvic Surgery (Arbeitsgemeinschaft für Urogynäkologie und plastische Beckenbodenrekonstruktion [AGUB]) Dr. med. H. Dieterich Working Group for Esthetic, Plastic and Reconstructive Surgery in Gynecology (Arbeitsgemeinschaft für ästhetische, plastis che und wiederherstellende Operationsverfahren in der Gynäkologie [AWOGyn]) Prof. Dr. med. I. B. Runnenbaum3 Working Group Gynecologic Oncology (Arbeitsgemeinschaft Gynäkologische Onkologie [AGO]) Prof. Dr. med. W. Kleine Working Group Gynecologic Oncology (Arbeitsgemeinschaft Gynäkologische Onkologie [AGO]) Prof. Dr. med. A. Strauss3 Working Group for Ultrasound Diagnosis in Gynecology and Obstetrics (Arbeitsgemeinschaft für Ultraschalldiagnostik in Gynäkologie und Geburtshilfe [ARGUS]) Prof. Dr. med. M. Menton3 Committee on Cervical Pathology and Colposcopy (Arbeitsgemeinschaft Zervixpathologie & Kolposkopie [AGCPC]) Prof. Dr. med. I. Mylonas3 Working Group for Infectious Diseases and Infection Immunology (Arbeitsgemeinschaft Infektiologie und Infektions- immunologie ([AGII]) Prof. Dr. M. David3 German Society for Psychosomatic Gynecology and Obstetrics (Deutsche Gesellschaft für Psychosomatische Frauenheilkunde und Geburtshilfe [DGPFG]) Prof. Dr. med. L-C. Horn German Society of Pathology (Deutsche Gesellschaft für Pathologie [DGP]) Federal Association of Pathologists (Berufsverband Deutsche Pathologen [BDP]) Prof. Dr. med. D. Schmidt German Society of Pathology (Deutsche Gesellschaft für Pathologie [DGP]) Federal Association of Pathologists (Berufsverband Deutsche Pathologen [BDP]) Prof. Dr. med. A. T. Teichmann Association of Head Physicians of Gynecological and Obstetric Hospitals (Bundesarbeitsgemeinschaft Leitender Ärzt innen und Ärzte in der Frauenheilkunde und Geburtshilfe [BLFG]) Dr. med. P . Brandner3 Federal Association of Gynecologists (Bundesverband der Frauenärzte e. V. [BVF]) Dr. M. Nothacker4 AWMF Guideline consultant 1 methodological support, drafting of the guideline report, 2 member of the steering committee, 3 participant in the nominal group process entitled to vote, 4 drafting of the evidence report 351 Neis KJ et al. Indications and Route … Geburtsh Frauenheilk 2016; 76: 350 –364 Guideline Abbreviations AGCPC Committee on Cervical Pathology and Colposcopy AGE Working Group for Gynecological Endoscopy AGII Working Group for Infectious Diseases and Infection Immunology AGO Working Group Gynecologic Oncology AGUB Working Group for Urogynecology and Reconstructive Pelvic Surgery AIS adenocarcinoma in situ ARGUS Working Group for Ultrasound Diagnosis in Gynecology and Obstetrics AWMF Association of the Scientific Medical Societies in Germany BVF Federal Association of Gynecologists BLFG Association of Head Physicians of Gynecological and Obstetric Hospitals CIN cervical intraepithelial neoplasia DGPFG German Society for Psychosomatic Gynecology and Obstetrics DGGG German Society of Gynecology and Obstetrics DGP German Society of Pathology ETC European Training Centre for Gynecologic Endoscopy GnRH gonadotropin releasing hormone GR Grade of recommendation HE hysterectomy HPV human papilloma virus IUS intrauterine system LASH laparoscopically assisted supracervical hysterectomy LAVH laparoscopically assisted vaginal hysterectomy LoE Level of evidence OEGGG Austrian Society of Gynecology and Obstetrics SGGG Swiss Society of Gynecology and Obstetrics TLH total laparoscopic hysterectomy II Using this Guideline Purpose and objectives This guideline concerns hysterectomy performed in patients with benign diseases. It aims to examine the entire range of surgical procedures as well as the associated context in order to permit optimal treatment of women in each case. The guideline presents and evaluates the individual indication areas, describes the hys- terectomy routes, evaluates the advantages and disadvantages of individual surgical techniques and presents possible alternatives. The guideline aims to provide a basis that women can use to ob- tain in-depth information in order to make a decision about the treatment plan in consultation with their doctor based on their knowledge of the advantages and disadvantages of the specific procedure and of the effects of the operation on their quality of life. In these times of increasing cost pressure in the health care system, it is also essential to include this aspect in the considera- tions. Targeted patients Patients with an equivocal indication for hysterectomy and pa- tients who have undergone a hysterectomy. Target audience The guideline addresses members of the health care profession involved in performing this surgical procedure. A medical back- ground is required to understand this guideline. This guideline is aimed at the following groups of people: " gynecologists in private practice " gynecologists working in a clinical setting " nursing professionals " the cooperating partners of the medical profession (e.g. health care professionals, payers) " the patients concerned and their personal setting (partners, etc.) " the general public, in order to provide it with information about sound medical approaches Period of validity The validity of this guideline was confirmed by the chairpersons/ heads of the participating medical societies/organizations/asso- ciations and by the head of the DGGG and the DGGG Guideline Commission in April 2015, thereby also confirming the entire contents of the guideline. This guideline is valid until April 30, 2020. This period of validity was estimated based on the contents of the guideline. If need be, the guideline can be updated before it has expired; if the guideline is still considered to represent the current state of knowledge, its period of validity can be extended. III Guideline 1 Methodology 1.1 Principles The methodology for the compilation of this guideline is pre- scribed by the classification assigned to the guideline. The AWMF Guidance Manual and Rules for Guideline Development (Version 1.0) sets out the rules for classifying guidelines. Guidelines are differentiated into lowest (S1), moderate (S2) and highest (S3) class. The lowest class of guideline is defined as consisting of a set of recommendations for action compiled by a non-represen- tative group of experts. In 2004 the S2 class was divided into two subclasses: S2e (evidence-based) and S2k (consensus-based). The highest class (S3) combines both approaches. This guideline is classified as S3. 1.2 Literature search The following literature databases were searched: " Cochrane Menstrual Disorders and Subfertility Group special- ized register of controlled trials " Central " MEDLINE " Embase " Biological Abstracts " The National Research Register The following keywords were used for the search: " hysterectomy CRT " hysterectomy " vaginal " abdominal " LA VH " LASH " TLH " myoma " endometriosis " adenomyosis " descensus " incontinence 352 Neis KJ et al. Indications and Route … Geburtsh Frauenheilk 2016; 76: 350 –364 GebFra Science " complications " quality of life The search encompassed the period from January 1990 to No- vember 2011. In addition, MEDLINE was specifically searched with regard to certain questions. In order to achieve a transparent and up-to-date evidence base, an updated literature search was performed in MEDLINE (via PubMed) in 2013– 2014 on the following topics: " comparison of hysterectomy routes " comparison of hysterectomy to uterine artery embolization or myomectomy for symptomatic uterine fibroids " comparison of hysterectomy and drug therapy for uterine fib- roids, dysfunctional menstrual disorders or adenomyosis. The results of the literature search were included in the current version of the guideline. 1.3 Evidence tables 1.3.1 Evidence grading based on the Oxford Centre for Evidence-Based Medicine levels of evidence To evaluate the evidence (levels 1 to 5), the Oxford Centre for Evi- dence-Based Medicine classification system was used in its most recent version published in 2009 as Level of Evidence (LoE). 1.4 Recommendation grading Pure evidence grading of a guideline at S2e/S3 level based on the Oxford classification can be translated into a grade of recommen- dation (GR) for a guideline. This symbolic recommendation level is divided into three gradations with various degrees of linguistic expression (l " Table 2). The classification of “Recommendations” presented above corre- sponds to both the evaluation of evidence and the clinical rele- vance of the studies on which they are based and their scope/fac- tors not listed in the grading of the evidence, such as the selection of patient cohort, intention-to-treat or per-protocol outcome analyses, medical or ethical action toward the patient, country- specific applicability, etc. Conversely, a strong, moderate or weak level of evidence can lead to strong, regular or open recommen- dations in a related linear fashion. The only level that permits both an upward and downward classification is the moderate evidence level, in which a translation into level A or level 0 is pos- sible. In special exceptional cases, converting the highest evi- dence level into the weakest/an open recommendation or vice versa must be explained in the background text. " Strong evidence level → Grade A or Grade B recommendation " Moderate evidence level → Grade A or Grade B or Grade 0 rec- ommendation " Weak evidence level → Grade B or Grade 0 recommendation 1.5 Statements If statements by specialists are included in this guideline that are not intended as recommendations for action, but rather simply for the purpose of presentation, these are referred to as “state- ments”. For these statements, it is not possible to indicate evi- dence levels. 1.6 Consensus strength As part of a structured consensus agreement process (S2k/S3 lev- el), the eligible participants at the meeting agree on the state- ments and recommendations that were drawn up. During this process, significant modifications to the wording may occur. Sub- sequently, the consensus strength is determined based on the number of participants ( l " Table 3). 1.7 Expert consensus As the name suggests, “expert consensus” refers to consensus de- cision specifically for recommendations/statements without a prior systematic literature search (S2k) or based on the missing evidence (S2e/S3). The term “expert consensus (EC) ” to be used is synonymous with terms from other guidelines such as “good clinical practice (GCP) ” or “clinical consensus point (CCP) ”. The recommendation strength is graded similarly to the aforemen- tioned classification without the use of the symbols and is ex- pressed in purely semantic terms ( “must”/“must not ” or “should”/“should not” or “may”/“does not need to ”). 2 Introduction All of the sections below are excerpts from the long version of the guideline and do not claim to be complete. Only the sections of the long version are mentioned that contain consensus- and/or evidence-based statements or recommendations. Sections with- out these particulars are described briefly at most. To obtain more information (background texts, additional litera- ture citations) on existing sections or sections not listed here, please download the long version (see Guideline documents). 3 Indications and contraindications 3.1 Indications Common indications for performing hysterectomy for benign diseases include the following: uterine fibroids, menstrual disor- ders, adenomyosis of the uterus, endometriosis, uterine prolapse and precancerous lesions of the endometrium and the cervix. The numbers in Germany were as follows in 2012: uterine fib- roids: 60.7 %, prolapse: 27.9 %, menstrual problems: 25.2 %, hy- perplasia and atypia of the endometrium or cervix: 2.9, and en- dometriosis: 15.1 % of cases [1]. Table 2 Grading of recommendations. Symbols Description of binding nature Expression A Strong recommendation with highly binding character must (soll)/ must not (soll nicht) B Regular recommendation with moderately binding character should (sollte)/ should not (sollte nicht) 0 Open recommendation with limited binding character may (kann)/ does not need to (kann nicht) Table 3 Classification of consensus strength. Symbol Consensus strength Agreement in percent +++ Strong consensus Agreement of > 95 % of the participants ++ Consensus Agreement of >7 5–95 % of the participants + Majority agreement Agreement of >5 0–75 % of the participants – No consensus Agreement of < 50 % of the participants 353 Neis KJ et al. Indications and Route … Geburtsh Frauenheilk 2016; 76: 350 –364 Guideline Due to the comorbidities, a total of nearly 130 % is reached. This also reflects clinical reality, in which the histologically ascertain- able findings of uterine fibroids, adenomyosis and endometriosis often coincide. The clinical picture of “menstrual problems” as an umbrella term encompasses hypermenorrhea, dysmenorrhea and dyspareunia. For this reason, it is often difficult to list and code a single diagnosis as the indication for hysterectomy. This overlapping also means that experts may disagree about the treatment plan to be used in a particular case. Thus, when indi- cating surgery for these conditions, personal experience, espe- cially the mastery of a certain surgical technique or with the use of alternatives, plays a significantly greater role than for cancer, for example, for which treatment is based on a single hard diag- nosis. Due to this special situation, it is particular important to inform the patient about the range of treatment options, about the rec- ommended procedure, the associated risks and to clearly point out the advantages and disadvantages of each surgical technique that can be expected and if the merits of techniques “compete with” each other. Ultimately, the decision as to whether hysterectomy is indicated, as well as on using alternative methods, must be made by an in- formed patient along with her attending physician. For this rea- son, the term “informed consent and shared decision-making ” has become established. 3.2 Hysterectomy for uterine fibroids Consensus-based recommendation 3.E1 For suspected symptomatic uterine fibroids, the first step is to clarify whether the symptoms are actually caused by uterine fibroids. (expert consensus) Consensus strength (+++) Consensus-based recommendation 3.E2 If the symptoms are caused by fibroids, depending on the pa- tientʼs life circumstances, the treatment decision must be made together with the patient. (expert consensus) Consensus strength (+++) Consensus-based recommendation 3.E3 Hysterectomy may be performed in the case of symptomatic uterine fibroids, if fertility is no longer desired, if treatment alter- natives have failed and/or as requested by the patient. (expert consensus) Consensus strength (+++) Evidence-based statement 3.S1 For preoperatively anemic patients with uterine fibroids, drug therapy with GnRH analogues or Ulipristal may be indicated prior to hysterectomy. (LoE Oxford 2009 1a [GnRH analogues], 1b [Ulipristal]) Consensus strength (+++) Literature: GnRH analogues [2, 3] and Ulipristal [4, 5] 3.3 Dysfunctional uterine bleeding Consensus-based recommendation 3.E4 For abnormal uterine bleeding, premalignant or malignant le- sions must be excluded prior to further treatment. (expert con- sensus) Consensus strength (+++) Evidence-based statement 3.S2 If hormone therapy has failed and fertility is no longer desired, endometrial ablation and hysterectomy is a treatment option. (LoE Oxford 2009 1a) Consensus strength (+++) Literature: [6] Consensus-based recommendation 3.E5 If endometrial ablation has failed, a hysterectomy must be per- formed. (expert consensus) Consensus strength (+++) 3.4 Endometriosis/adenomyosis Evidence-based recommendation 3.E6 To confirm the diagnosis of adenomyosis/endometriosis, a de- tailed history and an ultrasound examination should be per- formed. (LoE Oxford 2009 1b, GR A) Consensus strength (+++) Literature: [7] Consensus-based recommendation 3.E7 For suspected endometriosis, laparoscopy should also be per- formed. (expert consensus) Consensus strength (+++) Literature: Expert consensus based on S2k Guideline for the Diag- nosis and Treatment of Endometriosis [8] Consensus-based recommendation 3.E8 If the primary desire to have a hysterectomy stems from the pa- tient herself, she must receive detailed information about treat- ment alternatives and their side effects and success rates. (expert consensus) Consensus strength (+++) Consensus-based recommendation 3.E9 If hormone therapy has failed and fertility is no longer desired, a hysterectomy should be performed. (expert consensus) Consensus strength (+++) Consensus-based statement 3.S3 For deep infiltrating endometriosis, a hysterectomy may be indi- cated in the overall concept of complete resection. (expert con- sensus) Consensus strength (+++) Literature: Expert consensus based on S2k Guideline for the Diag- nosis and Treatment of Endometriosis [8] 3.5 and 3.6 Cytological suspicion of endometrial and glandular precancers Consensus-based recommendation 3.E10 Microscopically confirmed CIN alone, regardless of severity, is not an indication for hysterectomy. In the case of persistent HPV detection after conization alone, hysterectomy must not be performed. If there is a cytological or microscopic diagnosis of an adenocarci- noma in situ (AIS) of the cervix, conization with endocervical cu- rettage of the high cervical canal must be performed (not a pri- mary hysterectomy) in order to rule out an invasive adenocarci- noma. 354 Neis KJ et al. Indications and Route … Geburtsh Frauenheilk 2016; 76: 350 –364 GebFra Science If there is a cytological or microscopic diagnosis of an adenocarci- noma in situ (AIS) of the cervix, a primary hysterectomy must not be performed in order to rule out an invasive adenocarcinoma. Instead, conization with endocervical curettage of the high cervi- cal canal must be performed. Hysterectomy may be performed after conization in the case of residual recurrent CIN 2/3 or glandular neoplasia located in the low cervical canal. (expert consensus) Consensus strength (+++) Literature: These recommendations were adopted in the expert consensus based on the S2 Guidelines for HPV infection/pre-inva- sive lesions of the female genitals: Prevention, Diagnosis and Treatment [9]. 3.7 Atypical endometrial hyperplasia in the histology of the aspiration or of the curettage material Consensus-based recommendation 3.E11 For atypical endometrial hyperplasia in women no longer desir- ing fertility, hysterectomy must be performed. (expert consen- sus) Consensus strength (+++) 3.8 Prolapse Consensus-based statement 3.S4 The uterus may be retained during surgery for uterine prolapse. (expert consensus) Consensus strength (+++) Literature: Expert consensus based on the Guidelines for diag- nosing and treating uterine prolapse [10] Consensus-based recommendation 3.E12 If the uterus is retained, the presence of a malignant tumor should be excluded. (expert consensus) Consensus strength (+++) 3.9 Urinary incontinence and hysterectomy Evidence-based recommendation 3.E13 Hysterectomy for incontinence problems must be separately in- dicated. (LoE Oxford 2009 2–3, GR A) Consensus strength (+++) Literature: [11] 3.10 Infections Consensus-based statement 3.S5 To treat an infectious disease of the internal genitals, hysterec- tomy may be indicated in certain circumstances. (expert consen- sus) Consensus strength (+++) 3.11 Chronic pelvic pain Consensus-based recommendation 3.E14 Laparoscopy should be performed before performing a hysterec- tomy for chronic pelvic pain. (expert consensus) Consensus strength (++) Literature: Expert consensus based on the Guidelines for diag- nosing chronic pelvic pain in women [12] Evidence-based recommendation 3.E15 When indicating hysterectomy for chronic pelvic pain, the deci- sion must be made in cooperation with the patient based on in- terdisciplinary findings and the patient must be informed about the high failure rate. (LoE Oxford 2009 2a−,G RA ) Consensus strength (++) Literature: [13, 14] 3.12 Elective hysterectomy Consensus-based recommendation 3.E16 A hysterectomy that is not medically indicated to be undertaken only at the patient ʼs request should not be performed. (expert consensus) Consensus strength (+++) 3.13 Emergency hysterectomy (nonpuerperal) Consensus-based statement 3.S6 In rare cases, a nonpuerperal emergency hysterectomy is indi- cated (trauma, coagulation disorder, bleeding, infection). (expert consensus) Consensus strength (++) 4 Alternatives to hysterectomy 4.1 Uterine fibroids When choosing an alternative to hysterectomy, the effectiveness and safety of the selected treatment method and the risk of fi- broid recurrence should be weighed against the (potential) ad- vantages of retaining the uterus (lower morbidity and retained fertility). In the end, rare complications may necessitate the ac- tually unwanted hysterectomy [15]. Consensus-based recommendation 4.E17 Patients must be informed about the individual success and fail- ure rates related to the various methods of fibroid treatment. (ex- pert consensus) Consensus strength (+++) 4.2 Menstrual disorders A number of reasons are responsible for menstrual disorders. Around 50 % of menstrual disorders have organic causes. These cases require causal treatment such as hysteroscopic polyp and fibroid resection (see also Uterine fibroids) or treatment of ad- enomyosis or endometrial hyperplasia. If organic causes have been ruled out, intermenstrual and dysfunctional bleeding can generally be treated with hormones, primarily progestogens, and in some cases, also estrogens. The primary indications for hysterectomy are refractory hypermenorrhea and menorrhagia. Before resorting to hysterectomy, the patient should receive in- depth information about the wide range of proven alternatives. Evidence-based recommendation 4.E18 Patients must be informed about the individual success and fail- ure rates related to the various methods of menstrual disorder treatment. (LoE Oxford 2009 1b [LNG-IUS], 1a [endometrial ablation], GR A) Consensus strength (+++) Literature: LNG‑IUS [16, 17] and endometrial ablation [18] 355 Neis KJ et al. Indications and Route … Geburtsh Frauenheilk 2016; 76: 350 –364 Guideline 5 Information and consent Preoperative information and consent includes the following: " the indication and objective of the procedure including an as- sessment of the probability of success " presentation of options for treatment/methods, including non- surgical alternatives " explanation of the preferred method " description of procedure-related risks and typical complica- tions, including their sequelae " information about patient behavior before and after the proce- dure. Consensus-based statement 5.S7 The nature, scope, time and form of information and consent are based on the patient ʼs individual situation, the legal provisions and current case rulings. Treatment options, side effects and probability of success must be presented. (expert consensus) Consensus strength (+++) 6 Perioperative management Hysterectomy is a procedure that generally involves the same steps regardless of the indication. For this reason, for quality-re- lated (and forensic) reasons, every hospital is advised to develop standards for perioperative management based on the current evidence. Perioperative checklists are recommended to prevent errors and ensure patient safety [19 – 24]. 6.1 Preoperative management Consensus-based recommendation 5.E19 For patients with known or suspected organic or systemic disor- ders, the relevant laboratory parameters (e.g. for patients with bleeding disorders) must be determined. (expert consensus) Consensus strength (+++) 6.2 Intraoperative management Evidence-based recommendation 6.E20 Prophylactic antibiotics must be administered prior to hysterec- tomy. (LoE Oxford 2009 1a, GR A) Consensus strength (+++) Literature: [25] 6.3 Postoperative management Evidence-based recommendation 6.E21 Perioperatively, risk-adapted thromboembolic prophylaxis must be administered. (LoE Oxford 2009 1a, GR A) Consensus strength (+++) Literature: [26] 7 Surgical techniques 7.1 Vaginal hysterectomy In addition to the general indication for a hysterectomy, the use of a vaginal approach involves the following special aspects: " To ensure that the approach is reliable, the uterus must be suf- ficiently mobile. In general, with the patient under anesthesia, it should be possible to pull the portio to at least the mid-vagi- na. The vagina must be sufficiently broad and elastic for the surgery to be performed safely. In case of doubt, it may be help- ful to perform the pelvic examination under anesthesia by pulling on the portio using bullet forceps. " In the case of suspected extrauterine pathology prior to sur- gery, for instance, in the adnexa, a laparoscopically assisted or abdominal approach should be favored. " A vaginal approach is therefore particularly suitable for benign uterine diseases such as uterine prolapse. For nulliparous women and postmenopausal patients with atrophied vaginas and patients with long, narrow vaginas (obese patients) and patients with massively enlarged uteruses, the vaginal ap- proach has its limits. " However, the size of the uterus can be overcome by using mor- cellation or hemisection. As a rule of thumb, again depending on the sufficient breadth of access and the mobility of the or- gan, vaginal hysterectomy can be performed for a uterine size of around a 12-week pregnancy or a uterine weight of around 250 to 300 g. This corresponds to an average diameter of the uterine body of around 8 to 10 cm [27]. On the other hand, much larger uteruses can also be delivered safely using a vagi- nal approach [28]. " If a patient has already had a Cesarean section or undergone other pelvic surgery, vaginal hysterectomy can be much more difficult and the risk of injuring the bladder is increased. In this case, the situation must be taken into consideration when indi- cating vaginal hysterectomy. " In the case of suspected or confirmed uterine or ovarian malig- nancy, a purely vaginal procedure should not be the primary choice. Selected patients with microinvasive cervical cancer or endometrial cancer are exceptions [29]. 7.2 Laparoscopically assisted vaginal hysterectomy (LAVH) Laparoscopically assisted vaginal hysterectomy (LAVH) combines laparoscopic and vaginal surgical techniques. The use of laparos- copy intends to avoid abdominal hysterectomy and enable vagi- nal hysterectomy. The laparoscopic part of the procedure in- cludes all of the steps that cannot be performed vaginally or that can only be performed with a great deal of difficulty or increased risk (adhesiolysis, excision of endometriotic nodules, adenec- tomy, detachment of the adnexa from the uterus). During LAVH, dissection in the area of the broad ligament of the uterus and the parametria ends above the uterine artery, which is detached from the vaginal side. The uterus is extracted through the vagina and if needed, hemi- otomy or morcellation is carried out. No specific contraindications applying only to LAVH are known. If laparoscopy is contraindicated in general, a purely vaginal or ab- dominal approach must be considered. 7.3 Total laparoscopic hysterectomy (TLH) With total laparoscopic hysterectomy (TLH), all steps of the pro- cedure are performed laparoscopically. In contrast to LAVH, the dissection of the uterine artery is performed laparoscopically, as is the paracervical dissection up to the vagina, the detachment of the uterus from the vagina and the closure of the vagina by means of laparoscopic suturing. There is no switch from an ab- dominal to a vaginal approach. Due to the dissection, in particular in the area of the cervix, TLH must be learned as a separate surgi- cal procedure, even by surgeons with laparoscopic experience [30]. For this reason, systematic reviews [31] report about ele- vated rates of complications, especially in the area of the urogen- ital tract, as well as increased risk of bleeding and relatively long operation times and recommend that this surgical procedure should be considered as a secondary choice. However, at centers with extensive TLH experience these problems have largely been resolved [30, 32]. Therefore, if there is sufficient experience with the technique, its complication rate is similar to that of other lap- 356 Neis KJ et al. Indications and Route … Geburtsh Frauenheilk 2016; 76: 350 –364 GebFra Science aroscopic surgical procedures. It appears that the operating time is longer than the operating time for vaginal hysterectomy and LAVH [31]. This is confirmed by the metaanalysis conducted by Gendy et al. [33]. However, the metaanalysis also confirmed that with the inclusion of 5 randomized controlled trials (RCTs) there were no differences with respect to complication rates (LoE 2a, level decreased due to high heterogeneity of the study results and signs of publication bias). Several publications report postoperative dehiscences of the vaginal cuff in contrast to other modes of hysterectomy [34 – 36]. This is attributed to the high frequency surgical detachment of the uterus from the vagina, whereby the endoscopic suturing technique is also discussed. A randomized study of vaginal stump suturing techniques comparing vaginal and laparoscopic ap- proaches by an experienced surgeon did not yield any differences [37]. 7.4 Laparoscopic supracervical hysterectomy (LASH) LASH constitutes an alternative to abdominal, total vaginal and total laparoscopic hysterectomy. In 2010, supracervical hysterec- tomy was performed in 13.5 % of cases in Germany, most of them using a laparoscopic approach [1]. In the United States, 2 % of all hysterectomies are performed supracervically, while in Scandi- navia, around 36 % of all hysterectomies are performed as supra- cervical hysterectomies [38]. With LASH, the first steps are performed similar to the procedure for LAVH and TLH and involve exposure of the site and dissection of possible associated pathologies (adhesions, endometriosis, ad- nexal abnormalities). Laparoscopic dissection ends at the level of the uterovesical fold. The uterus is detached supracervically and after intraabdominal morcellation is removed via the trocar. LASH is a procedure with a low complication rate [39 – 41]. De- taching the uterine body from the cervix at the level of the isth- mus means that surgery in the area of the parametria and dissec- tion of the bladder is required to only a limited extent, if at all. The complications reported for TLH, such as urinary tract lesions or dissection-related bleeding, are therefore rare for LASH. 7.5 Abdominal hysterectomy In addition to the general indication for a hysterectomy, the use of the abdominal approach involves the following special aspects: " In addition to oncological indications, the size of the uterus and associated disorders such as endometriosis or extensive adhe- sions resulting from previous surgery are indications for ab- dominal hysterectomy. " An abdominal approach is also indicated depending on the in- dividual situation in patients with a long, narrow vagina, for nulliparous women and patients with comorbidities and in pa- tients for whom a vaginal or laparoscopic approach does not appear to be possible or would be associated with an increased complication risk. In case of doubt, when deciding whether ab- dominal hysterectomy is indicated, it may be helpful to per- form the pelvic examination under anesthesia by pulling on the portio using bullet forceps. 7.6 Robot-assisted hysterectomy Robot-assisted surgical procedures are used to a limited extent for treating gynecological and obstetrics patients. They are often indicated in patients with cancer. Robot-assisted hysterectomy can be implemented and can be performed quickly by a surgeon with laparoscopic experience [42, 43]. Since the expenses and the operating time are far greater than those for conventional lapa- roscopy, in view of the limited resources, the use of robot-assis- ted hysterectomy must be decided on a case-by-case basis [44 – 47]. Systematic overview articles on robot-assisted hysterectomy (Tapper et al. 2014 [48], Liu et al. 2012 [49], Liu et al. 2014 [50]) identified the same 2 RCTs (Paraiso et al. 2013 [51], Sarlos et al. 2010 [46] [LoE 1b]). The interpretation of both RCTs showed dif- ferences in operating times. No differences were observed with regard to complications (blood loss, “minor” or “major” compli- cations or postoperative use of pain medication). With regard to quality of life, Sarlos et al. – without blinding – ob- served improvements in some aspects of quality of life after 3 weeks and after 6 to 8 weeks, while Paraiso et al. did not observe any differences after 6 months. In both studies, the operating time for robot-assisted hysterectomy was significantly longer than for laparoscopic surgery, with Paraiso observing an average longer time of 70 minutes and Sarlos reporting 20 minutes lon- ger. The length of hospital stay did not differ. A systematic review of robot-assisted hysterectomy with a single site port [52] found only retrospective series or case studies with a median operating time of 109 minutes. No information on transfusions was reported (LoE 3). No information on complica- tions or follow-up was reported. The procedure must still be con- sidered to be experimental. 357 Neis KJ et al. Indications and Route … Geburtsh Frauenheilk 2016; 76: 350 –364 Guideline 8 Intraoperative and postoperative complications (l" Table 4) 9 Documentation Every patient chart created for a patient undergoing a hysterec- tomy must include the indication, the symptoms and the findings of the patient. These comprise the general and specific history, especially previous illnesses and operations, as well as the gener- al and gynecological examination results including imaging re- sults. Checklists have proven helpful for perioperative documentation. The surgical report lists the date, diagnosis and summary of the treatment plan, along with the names of the physicians involved. The surgical report serves as a description of the surgical proce- dure and the findings observed during surgery. In the case of an uncomplicated hysterectomy, this description may be brief. A surgical report becomes particularly important, however, if com- plications occur. It is recommended to clearly describe in the pri- mary report any special anatomic circumstances and other con- ditions giving rise to complications. At critical points, such as in the case of parametric bleeding, the surgeon should state that he or she checked the ureter by means of inspection, palpation or exposure and acted properly and carefully. The postoperative course must also be documented. The scope and results of a physical examination should be listed in the form of notes accompanied by the time of day. The same procedure should be used for findings from other hospitals and institutes. The discharge summary is also very important. 10 Comparison of methods In recent years, numerous publications and two systematic re- views have compared methods. The recommendation of the Na- tional Institute for Health and Care Excellence (NICE) [54] was first drawn up in 2002 and was adapted in 2004 and 2006. Inde- pendent of this recommendation, a Cochrane Review was con- ducted and published in 2009 [31], LoE 1a. For the most part, the reviews examine the same studies. Nieboer et al. recently evaluated 34 studies with a total of 4495 women. The NICE pub- lication also evaluated a control study with 37 049 women and a control study with 10 100 women. The advantages of vaginal hysterectomy compared to abdominal hysterectomy involved the significantly shorter recovery time (mean difference [MD] 9.5 days), fewer febrile episodes and un- specific infections (OR 0.42) and shorter hospital stays (MD 1.1 Table 4 Incidence of intraoperative and postoperative complications. FINHYST 2011 (complication) n = 5 279 (%) AQUA 2012 (complication) n = 103 232 (%) Intraoperative blood loss ≥ 1 000 ml AH LH VH 5.7 3.0 1.6 Intraoperative blood loss ≥ 1 000 ml No comparative data Bladder injury AH LH VH 0.9 1.0 0.6 Bladder injury 0.59 Ureter injury AH LH VH 0.3 0.3 0.04 Ureter injury 0.09 Bowel injury AH LH VH 0.2 0.4 0.1 Bowel injury 0.23 Postoperative bleeding or hematoma AH LH VH 2.6 2.7 2.8 Postoperative bleeding or hematoma 0.94 Ileus AH LH VH 1.0 0.3 0.1 Ileus 0.09 Urinary retention AH LH VH 0.5 0.5 1.6 Urinary retention No comparable data Urinary tract infection AH LH VH 2.2 0.7 1.5 Urinary tract infection 1.0 Wound infection AH LH VH 2.4 1.5 0.9 Wound infection No comparable data Febrile events AH LH VH 2.5 1.4 0.9 Febrile events 0.28 Pelvic infection, hematoma or abscess 10 54 51 1.00 5.08 5.40 Pelvic infection, hematoma or ab- scess No comparable data FINHYST study: n = 5 279 with 1 255 abdominal, 1 679 laparoscopic and 2 345 vaginal hysterectomies in Finland in 2006 [53]; AQUA 2012: n = 103 232 independent of approach and distinction between endoscopically performed hysterectomies, only exact mention of 16 196 abdominal hysterectomies and 57 398 vaginal hysterecto mies. Abbreviations: AH = abdominal hysterectomy, LH = laparoscopic hysterectomy, VH = vaginal hysterectomy 358 Neis KJ et al. Indications and Route … Geburtsh Frauenheilk 2016; 76: 350 –364 GebFra Science days). When comparing vaginal hysterectomy with laparoscopic hysterectomy (LH), no significant differences were found in this respect. However the operating time was longer for LH (MD 39.3 minutes) and severe bleeding occurred more frequently (OR 2.76). The Cochrane Review concluded that owing to the same or significantly more favorable results across the board, vaginal hysterectomy should be preferred over abdominal hysterectomy whenever possible. If a vaginal hysterectomy is not possible, lap- aroscopic procedures can be used to avoid the disadvantages of a laparotomy due to the more favorable adverse effect profile [27]. The American College of Obstetricians and Gynecologists came up with the same recommendations [55]. Diverse comparative analyses have come up with identical re- sults for the procedure with the lowest costs, which is vaginal hysterectomy. In addition to the systematic review by Nieboer et al., after updat- ing the search to include publications up to June 2014, other sys- tematic overview articles were included on the following issues related to the comparison of methods ( l " Tables 5 und 6): Evidence-based recommendation 10.E22 If possible, vaginal hysterectomy must be favored over abdominal hysterectomy. (LoEOxford 2009 1a, GR A) Consensus strength (+++) Literature: [42, 56, 57] Evidence-based recommendation 10.E23 If vaginal hysterectomy is not possible, the possibility of laparo- scopic hysterectomy should be reviewed. (LoE Oxford 2009 1a, GR B) Consensus strength (+++) Literature: [42, 58] Evidence-based recommendation 10.E24 LASH may be performed as an alternative to abdominal hysterec- tomy and vaginal hysterectomy. (LoE Oxford 2009 1a, GR 0) Consensus strength (+++) Literature: [59] Consensus-based statement 10.S8 However, current data do not permit the different laparoscopic techniques to be exactly differentiated. (expert consensus) Consensus strength (+++) Consensus-based recommendation 10.E25 Abdominal hysterectomy should only be performed if it is specif- ically indicated. (expert consensus) Consensus strength (+++) Evidence-based statement 10.S9 In the available randomized studies, no confirmed patient- related benefits were found for the use of robot-assisted technol- ogy. (LoE Oxford 2009 1b) Literature: [45– 47] 11 Special situation – What do I do if …? 11.1 Hysterectomy for adenomyosis/endometriosis Consensus-based recommendation 11.E26 If the patient has the relevant symptoms, there is no desire for fertility and there are clinical signs of adenomyosis, a hysterec- tomy should be performed. (expert consensus) Consensus strength (+++) Consensus-based statement 11.S10 For deep infiltrating endometriosis, a hysterectomy may be indi- cated in the overall concept of complete resection. (expert con- sensus) Consensus strength (+++) Table 5 Comparison of hysterectomy methods Vaginal hysterectomy vs. abdominal hysterectomy Quicker return to normal activity Average difference 9.5 days Fewer febrile events, fewer febrile episodes and specific infections OR 0.42; CI 0.21–0.83 Shorter hospital stay Average difference 1.1 days LH vs. abdominal hysterectomy Return to normal activity Average difference 13.6 days Lower blood loss Average 45 cm 3 Lower drop in HB Average difference 0.55 g/dl Shorter hospital stay Average difference 2.0 days Less wound and abdominal infiltrates OR 0.31; CI 0.12 –0.77 More bladder and ureter injuries OR 2.41; CI 1.21 –4.82 Longer operating time Average 2.3 min LAVH vs. TLH Lower rate of infection OR 3.77; CI 1.05 –13.51 Shorting operating time Average 25.3 min VH vs. LH Shorter operating time Average 39.3 min Less intraoperative bleeding OR 2.76; CI 1.02 –7.42 Table 6 Comparison of different hysterectomy modalities. Operating time Blood loss Complications Admission period Return to work Costs Vaginal hysterectomy +++ +++ +++ +++ +++ +++ LAVH ++ +++ +++ +++ +++ ++ TLH ++ ++(+) ++(+) +++ +++ ++ LASH ++ +++ +++ +++ +++ ++ Abdominal HE ++ ++ ++ + + ++ Number of “+” means increasing advantage of the method. 359 Neis KJ et al. Indications and Route … Geburtsh Frauenheilk 2016; 76: 350 –364 Guideline 11.2 Hysterectomy and incontinence If a patient for whom a hysterectomy is indicated is to undergo surgery for stress incontinence at the same time, the hysterec- tomy may be performed using the most straightforward proce- dure. The stress incontinence surgery does not impact the meth- od used for hysterectomy. 11.3 Obstetric hysterectomy for postpartum hemorrhage Consensus-based recommendation 11.E27 For postpartum, life-threatening uterine bleeding and the failure of alternative treatment options, a hysterectomy is indicated as a last resort and in the event of a life-threatening situation. (expert consensus) Consensus strength (+++) 12 Quality of life Evidence-based recommendation 12.E28 Patients should be informed that after they have undergone an indicated hysterectomy, they can generally expect to experience improvement in quality of life and sexual functioning compared to their preoperative situation. (LoE Oxford 2009 1a, GR B) Literature: [60– 63] Evidence-based statement 12.S11 A prophylactic bilateral adnexectomy may be associated with un- desired long-term adverse effects and requires separate informa- tion and consent. (LoE Oxford 2009 1a) Consensus strength (++) Literature: [64, 65] 13 Algorithm: Alternatives to hysterectomy (l" Figs. 1 to 3) Uterine fibroids Discontinue treatment Symptoms? Fertility no longer desired? Patient would like… HysterectomyUterine artery embolization (UAE) Symptoms improved? Observe No NoNo Yes Yes No Yes Yes Symptoms improved and/or pregnancy planned? Myomectomy hysteroscopic and/or laparoscopic open surgery Fig. 1 Pathway: Uterine fibroids. 360 Neis KJ et al. Indications and Route … Geburtsh Frauenheilk 2016; 76: 350 –364 GebFra Science Menstrual disorder Discontinue treatment Symptoms improved? Symptoms improved? Symptoms improved? Fertility no longer desired? Oral contraceptives possibly long-term use Endometrial ablation Hysterectomy Plan a pregnancy Yes Yes Yes Yes No No No No Progestogens systemic local Fig. 2 Pathway: Menstrual disorder. Endometriosis/adenomyosis Discontinue treatment Symptoms improved? Symptoms improved? Symptoms improved? Patiend would like… Plan a pregnancy HysterectomyShort-term use of GnRH analogues (monitor for adverse effects!) Fertility no longer desired? Oral contraceptives Preferably long-term use Yes Yes Yes No No No YesNo Progestogens systemic local Fig. 3 Pathway: Endometriosis/adenomyosis. 361 Neis KJ et al. Indications and Route … Geburtsh Frauenheilk 2016; 76: 350 –364 Guideline Affiliations 1 Klinik für Frauenheilkunde, Geburtshilfe und Reproduktionsmedizin der Universitätsklinik des Saarlandes 2 Frauenklinik des Universitätsklinikum Tübingen 3 Evangelisches Krankenhaus Köln-Weyertal 4 Klinik für Neurochirurgie der Universitätsklinik des Saarlandes 5 Klinik für Gynäkologie und Geburtshilfe Universitätsklinikum Schleswig-Holstein 6 Klinik für Gynäkologie und Geburtshilfe Krankenhaus Agatharied GmbH 7 Klinik für Frauenheilkunde und Geburtshilfe St. Elisabeth Krankenhaus Damme 8 Klinik für MIC Minimal Invasive Chirurgie am Ev. Krankenhaus Hubertus in Berlin 9 Frauenklinik des Universitätsklinikum Tübingen 10 Klinik für Gynäkologie und Geburtshilfe St. Josefs-Hospital Wiesbaden 11 Privates Brustzentrum Rheinfelden 12 Universitätsklinikum Jena Klinik für Frauenheilkunde und Geburtshilfe 13 Universitätsklinikum Mannheim Klink für Frauenheilkunde und Geburtshilfe 14 Klinik für Gynäkologie und Geburtshilfe Christian-Albrechts-Universität zu Kiel 15 Dysplasiezentrum Reutlingen 16 Klinik und Poliklinik für Frauenheilkunde und Geburtshilfe Klinikum der Universität München 17 Campus Virchow-Klinikum Charité Klinik für Gynäkologie 18 Institut für Pathologie Universitätsklinikum Leipzig 19 Institut für Pathologie Mannheim 20 Universitätsklinikum Erlangen Frauenklinik 21 Frauenklinik Aschaffenburg 22 Frauenärzte-West Saarbrücken 23 Krankenhaus der Barmherzigen Schwestern Linz 24 Inselspital Bern 25 Kantonsspital Frauenfeld 26 Universitäts-Frauenklinik Graz

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Beckmann Universitätsklinikum Erlangen Frauenklinik Universitätsstraße 21– 23 DE-91054 Erlangen Guidelines Coordination Dr. med. Paul Gaß, Tobias Brodkorb, Marion Gebhardt Universitätsklinikum Erlangen Frauenklinik Universitätsstraße 21– 23 DE-91054 Erlangen [email protected] http://www.dggg.de/leitlinienstellungnahmen Austrian Society of Gynecology and Obstetrics (Österreichische Gesellschaft für Gynäkologie und Geburtshilfe [OEGGG]) Innrain 66A AT-6020 Innsbruck [email protected] http://www.oeggg.at President of OEGGG Prof. Dr. med. Uwe Lang Universitätsklinik für Frauenheilkunde und Geburtshilfe Graz Auenbruggerplatz 14 AT-8036 Graz OEGGG Guidelines Representative Prof. Dr. med. Karl Tamussino Universitätsklinik für Frauenheilkunde und Geburtshilfe Graz Auenbruggerplatz 14 AT-8036 Graz Swiss Society of Gynecology and Obstetrics (Schweizerische Gesellschaft für Gynäkologie und Geburtshilfe [SGGG]) Gynécologie Suisse SGGG Altenbergstraße 29 Postfach 6 CH-3000 Bern 8 [email protected] http://www.sggg.ch/ President of SGGG Dr. med. David Ehm FMH für Geburtshilfe und Gynäkologie Nägeligasse 13 CH-3011 Bern SGGG Guidelines Representative Prof. Dr. med. Daniel Surbek Universitätsklinik für Frauenheilkunde Geburtshilfe und feto-maternale Medizin Inselspital Bern Effingerstraße 102 CH-3010 Bern gynécologie suisse 364 Neis KJ et al. Indications and Route … Geburtsh Frauenheilk 2016; 76: 350 –364 GebFra Science