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BACKGROUND: Incomplete surgical staging of patients with early-stage epithelial ovarian cancer (EOC) has been reported in up to 98% of cases, when based on the International Federation of Obstetrics and Gynecology (FIGO) staging procedure. The aim of the present retrospective study was to clarify the reasons for incomplete staging. METHODS: The PRISMA (Prevention Recovery Information System for Monitoring and Analysis) technique was used to evaluate cases with FIGO I-IIa EOC based on incomplete staging from five gynecologic oncologic center hospitals in the Netherlands in the period 2010-2014. RESULTS: Fifty cases with an incomplete surgical staging of EOC according to national guidelines were included. The most common reasons for incomplete staging were insufficient random biopsies of the peritoneum (n = 34, 68%), and less than ten lymph nodes being resected and/or found at pathology (n = 16, 32%). The most mentioned reason for not performing biopsies was, besides forgetting to do so, believing that after careful inspection and palpation, taking biopsies is irrelevant and/or already are being taken while performing a hysterectomy (peritoneum of cul-de-sac, bladder). The value of contralateral pelvic lymph node dissection in case of a unilateral ovarian malignancy was also doubted, influencing the number of lymph nodes resected. CONCLUSIONS: The most important reasons for incomplete staging in EOC are, besides omitting elements by accident, questioning the importance of obligatory elements of the staging procedure. A structured list of staging steps during surgery and more evidence-based consensus concerning these obligatory elements might increase the number of complete staging procedures in EOC. ispartof: Surgery open science vol:7 pages:6-11 ispartof: location:United States status: published

This retrospective observational study was designed to assess patients’ satisfaction after anterior rectopexy, with or without sacropexy, for treatment of symptomatic rectocele in a group of women with anterior rectoceles. Between February 1995 and March 2011, all female patients who underwent an anterior rectopexy for large (>grade 2) anterior rectocele were included in the study. Preoperatively, the rectocele was assessed at rectovaginal examination and a defecography was performed. Rectovaginal examination was repeated in all patients 6 weeks postoperatively and a control defecography was performed 6 months after surgery. Follow-up included a standard telephone questionnaire and chart review. The surgical techniques used were anterior rectopexy (ARP; n = 21) and ARP + sacropexy (ARP + SP; n = 20). Mean age of the study group was 60 years (range = 36–77) and median parity was 2.6 (range = 0–8). Median follow-up from anterior ARP ± SP to functional assessment was 40 months (range = 4–83). In both groups, two of the initial main clinical symptoms (discomfort due to feeling of prolapse and outlet obstruction) improved significantly (p grade 2) anterior rectocele.

Objective To assess the value and limitations of aspiration cytology in the diagnosis of cystic lesions of the ovary which were predicted sonographically as benign. Design A prospective study. All patients, pre- and postmenopausal, who were going to have a laparoscopic cystectomy or oophorectomy had a laparoscopic aspiration of the cyst. Without knowledge of the patient's clinical history or the histology of the lesion, cytological evaluation was performed. Cytomorphological evaluation and prediction of the subsequent histological diagnosis was made. Results Between July 1994 and August 1996 60 aspirates were evaluated. Of the aspirates, 16 (27%) were not evaluable, according to our cytological criteria. The predictive value for discrimination between functional or neoplastic cysts was 65% (95% CI, 52–77%). Sensitivity and specificity were 91% (95% CI, 80–97%) and 67% (95% CI, 22–96%), respectively. The predictive value for the correct histological diagnosis was 42% (95% CI, 29–55%). The size of the cyst had no significant predictive value for the histological diagnosis. Conclusion Cytological evaluation of aspirates of ultrasonographically benign ovarian cysts gives no additional information regarding the histology of the lesion. Because the therapeutic significance of this method is also low, aspiration of ovarian cysts should be abandoned.

The focus of this study was to document postoperative complications after vulvectomy and inguinofemoral lymphadenectomy using separate incisions. Data from 172 consecutive patients with newly diagnosed carcinoma of the vulva were studied. One hundred and one patients primarily treated with modified radical vulvectomy and complete inguinofemoral lymphadenectomy using separate groin incisions (n = 187) were included in this study. One or more complications were documented in 77 of the 101 (76%) patients. Complications after groin dissection were observed in 66% of the patients. The main complications were wound breakdown (17%) and/or infection (39%) of the groin, lymphocyst formation (40%), and lymphedema (28%). In 98 of 187 (52%) groin dissections, one or more complications were documented. The presence of lymph node metastases, postoperative radiation, age older than 65 years, and removal of the vena saphena magna were not significant risk factors for the occurrence of complications. The occurrence of early complications after groin dissection was significantly related to the late-complication lymphedema (P = 0.002). Our results confirm relatively high rates of wound breakdown, infection, lymphocyst formation, and lymphedema even with separate groin incisions. The occurrence of early complications was related to lymphedema. No other risk factors could be identified.

Purpose : Our goal was to compare fast SE (FSE) with T2-weighted conventional SE (CSE) MRI of cervical carcinoma and to evaluate the potential advantage of fat suppression technique. Methods : We compared the tissue contrasts between cervical carcinoma and the surrounding tissues in 24 patients. The following MR sequences were obtained at 0.5 T : T1-weighted CSE (450/20 ms), T2-weighted CSE (2,500/45, 90), and T2-weighted FSE (4,800/120), the latter with and without fat suppression using fat-selective prepulses. Results : T2-weighted FSE MRI provided significantly better contrasts between tumor and normal cervical stroma (p < 0.001) and between tumor and rectum wall (p < 0.05) than T2-weighted CSE MRI. T1-weighted SE MRI gave the highest tissue contrast between tumor and parametrial tissue (p < 0.001). Fat suppression did not further improve tissue contrasts. Conclusion : MR staging of cervical carcinoma is best done with the combination of T1-weighted SE and T2-weighted FSE images, without additional fat suppression.

BACKGROUND: The objective of this study was to investigate the prognostic significance of serum antibodies to human papillomavirus (HPV)-16 peptides in patients with squamous cell cervical cancer. METHODS: Pretreatment sera from 78 patients and 198 control women were tested by an enzyme-linked immunosorbent assay technique for reactivity with HPV-16 E4 (E401p) and E7 (E701p) synthetic peptides. The presence and serum level of these antibodies were correlated with tumor stage, histologic features, and prognostic parameters. RESULTS: The median follow-up was 65 months (range, 6-97 months). Antibodies to E401p peptide were found in 5 of the 198 (3%) control subjects, 4 of the 43 (9%) patients with low tumor stage (International Federation of Gynecology and Obstetrics [FIGO] Ia, Ib, IIa), and 7 of the 35 (20%) patients with advanced tumor stage (FIGO IIb, III, IVa). Antibodies to E701p were found in 25 (13%), 11 (26%), and 11 (31%) women, respectively. The differences between patients and control subjects were significant (P

This article presents the state of the art of immunoscintigraphy (IS) of ovarian cancer. We will review the monoclonal antibodies (MoAbs) used in clinical trials: (HMFG1/2, OC125, H317, H17E2, NDOG2 and 791T/36). We conclude that none of the afore mentioned MoAbs are clearly superior and that IS cannot yet replace laparotomy for the diagnosis of ovarian cancer but may have a role in the follow-up of ovarian cancer, in timing second-look surgery and assessing the response/TD treatment.

Besides commercially available serological assays that detect antibodies to major outer membrane protein (MOMP)1 and lipopolysaccharide (LPS) “in-house” chlamydial heat shock protein 60 (cHSP60) assays are extensively used in assessing serological responses to urogenital Chlamydia trachomatis infection. Although comparison of the different “in-house” assays is difficult owing to a lack of standardisation, there is a consensus among the users of these assays that the anti-cHSP60 responses in women increase with the severity of C trachomatis associated disease, leading to the suggestion that the high amino acid sequence homology between chlamydial and human HSP60 results in autoimmune mediated fallopian tube damage. Owing to the significance of the possible association of the response to cHSP60 and progressive disease, a commercially produced assay that employs defined cHSP60 epitopes should allow for the comparison of results obtained in different laboratories, as well as forward the use of cHSP60 as a diagnostic tool if the assay proves to be relevant in predicting pathology or clinical outcome of a …

The desirability of adjuvant chemotherapy in patients with early ovarian carcinoma, i.e. a carcinoma limited to the internal genitalia (FIGO stage I-IIA), has long been controversial. Until recently, the few randomised studies that had been performed showed no improvement in survival after adjuvant chemotherapy, but the numbers of patients were too low to yield convincing proof. Complete surgical staging in patients with early ovarian carcinoma is of utmost importance to define the stage of the disease. In case of inadequate staging, there is a 24% risk (range 16-46%) that undetected tumour deposits will remain in the abdominal cavity following surgery, so that the estimated stage will be too low. The combined results of the two largest randomised clinical trials on early ovarian carcinoma to date have recently been published: the 'Adjuvant chemotherapy in ovarian neoplasm' (ACTION) trial, coordinated by the European Organisation for Research and Treatment of Cancer (EORTC), and the 'International collaboration in ovarian neoplasm' (ICON-1) trial; they showed a significant benefit from adjuvant chemotherapy on overall and progression-free survival in early ovarian cancer. The ACTION trial (448 patients), however, also showed that adjuvant chemotherapy only improved the overall and disease-free survival significantly in inadequately staged patients. In the patients who had undergone optimal surgical staging, adjuvant chemotherapy had no effect on the prognosis. In the ICON-1 study (477 patients) there was a favourable effect of adjuvant chemotherapy in the whole population. Analysis of this trial, however, shows that most probably only a very small percentage of these patients had undergone optimal surgical staging. Based on the published results, the best policy for the treatment of patients with early ovarian cancer is felt to be to make every effort to achieve optimal surgical staging and to reserve the burdensome adjuvant chemotherapy for those patients in whom optimal (re)staging is not feasible.

Diagnostic hysteroscopy is the standard investigation performed in the case of abnormal vaginal blood loss. More recently there has been increasing interest for minimal invasive saline contrast hysterosonography (SCHS) as this technique is less painful and less expensive. SCHS is indicated in case of abnormal uterine bleeding (premenopausal and postmenopausal), bleeding while using tamoxifen, suspicion of a congenital uterine abnormality and Asherman's syndrome. As well as intracavity abnormalities (polyps and myomas) SCHS can also be used to evaluate the intramural extension of myomas, which is necessary to assess whether hysteroscopic resection is possible. The sensitivity and specificity of SCHS for demonstrating intracavity abnormalities (with a prevalence of 54%) are 94% (95%-CI; 91-97) and 89% (95%-CI: 85-94) respectively. The positive and negative predictive values are 91% (95%-CI: 87-95) and 92% (95%-CI: 89-97) respectively. SCHS has a short learning curve and can be performed in an outpatient setting. SCHS fails more frequently in postmenopausal women than premenopausal women (12.5% vs. 4.7%; p = 0.03). The chance of a non-conclusive SCHS is 7.6% and is higher if the uterine volume is greater than 600 cm3 (relative risk: 2.63; 95%-CI: 1.05-6.60) and if two or more myomas are present: (RR 2.65; 95%-CI: 1.16-6.10). SCHS is 2 to 9 times cheaper than diagnostic hysteroscopy. It can replace 84% of the diagnostic hysteroscopies. SCHS, in combination with endometrial sampling, whenever indicated, might be able to replace diagnostic hysteroscopy as gold standard in the evaluation of the uterine cavity.

Autonomous pelvic nerves are essential for bladder and rectum function as well as sexuality. These nerves are usually permanent damaged during radical oncological surgery and this results in urological, sexual and proctological morbidity. Japanese surgeons have paved the way for surgical approaches to dissect these nerves during surgery and leave them intact. At the Department of Gynaecology of the Leiden University Medical Center, the Netherlands, a new surgical technique has been developed to spare the autonomous pelvic nerves during radical hysterectomy. In this procedure the lateral parts of the sacro-uterine ligament, through which the N. hypogastricus passes bilaterally, are left intact. The initial results of this nerve-sparing surgical technique during radical hysterectomy seem to be promising. The operation was easy to perform, with almost no extra blood loss and an extra operating time of just 10-15 minutes. Postoperative recovery of the bladder function occurred after a mean period of 9 days.

Chlamydia trachomatis infections (CTI) are the most common sexually transmitted infections.1 CTI in women may cause pelvic inflammatory disease (PID) and subsequently result in tubal factor infertility and ectopic pregnancy.2 Finally, CTI in pregnancy may cause neonatal conjunctivitis and pneumonia.3 Approximately 70% of the CTI in women are asymptomatic. The prevalence in asymptomatic obstetric and gynaecological patients in Europe ranges from 0.8 to 4.8%.4,5 Intrauterine manipulations such as curettage and a hysterosalpingogram in women with a CTI may cause PID as well.6 In the Netherlands there are no general policies for intrauterine manipulations. We would like to establish general policies to prevent intra-abdominal CTI. Therefore, information about the clinical aspects of CTI, patient characteristics, and data on the prevalence of CTI in an outpatient department of obstetrics and gynaecology are needed. From June 1996 to September 1997, new patients attending the outpatient department of obstetrics and gynaecology of the Westeinde Hospital were requested to participate in the study. Approval was obtained by the ethics committee. The Westeinde Hospital is an inner city hospital, with a high percentage of patients of different ethnic origin. After informed consent a questionnaire was completed and a gynaecological examination was performed. For detection of CTI two methods were used: 1. A probe hybridisation assay from a urethral, an endocervical and an anorectal swab (PACE 2 assay) (Gen-Probe). Swabs were analysed within 24 hours according to Gen-Probe’s packet insert instructions. 2. Amplification of CT-rRNA by transcription mediated amplification (TMA) in urine samples with the …

To analyse local tumour parameters of early cervical cancer that might be of prognostic significance for tumour relapse in the pelvis.Retrospective.Data were collected from 308 patients who underwent radical hysterectomy and pelvic lymphadenectomy in the years 1984-1996 in the Leiden University Medical Centre, the Netherlands. Treatment policies and operating staff were the same during the study period. The existence of relapse was studied by physical, gynaecological, laboratory and, if indicated, radiological examination.Data on 294 patients were available for analysis. Their mean age was 45 years (range: 21-82). Postoperative radiation treatment was given to 119 patients (40%). Mean follow-up duration was 36 months (range: 1-136). Recurrences had developed in 46 patients (15.6%), 29 of whom had died. The calculated overall 5-year survival rate was 83%; 91% for those with negative and 53% for those with positive pelvic nodes. The calculated recurrence-free-5-year survival rate was 75% for the entire group, 83% for the patients without and 47% for those with lymph node metastases. When more than one lymph node region was affected, 5-year disease free survival was 19% and when lymph node metastasis occurred bilaterally, it was 22%. Multivariate analysis revealed that lymph node involvement (hazard ratio: 4.4), parametrial involvement (5.5), tumour size30 mm (4.6) and depth of invasion10 mm (5.1) were independent factors of prognostic significance for disease free survival. The current indications for adjuvant treatment might be extended with infiltration depth. The number and the bilaterality, if any, of affected lymph node stations might be indication for additional adjuvant therapy.

Urinary and sexual dysfunction are common problems after rectal cancer surgery, and the likely cause is damage to the pelvic autonomic nerves during surgery. In recent years, attention has been focused on preserving the autonomic nerves through a technique which is usually combined with total mesorectal excision or radical pelvic lymphadenectomy. The autonomic nerves consist of the paired sympathetic hypogastric nerve, sacral splanchnic nerves, and the pelvic autonomic nerve plexus. We will demonstrate the anatomy of the pelvic autonomic nerves and the relation of these nerves to the mesorectal fascial planes, and review the medical literature on sexual and urinary dysfunction after rectal cancer surgery with and without autonomic nerve preservation.

In the present study we report on the results of a retrospective study on the effect on survival of the pelvic lymphadenectomy in a group of 294 patients with stage Ia2-IIa cervical carcinoma treated by radical hysterectomy from 1984 through 1996 at the Leiden University Medical Center.Lymphadenectomy was called 'complete' when lymph node bearing tissue had been removed from 5 or 6 lymph node stations and 'not-complete' when this was the case in 1-4 stations.A radical hysterectomy was carried out in 294 patients. In 63 patients positive lymph nodes were found. Patients with positive nodes showed poorer 5 year survival: 64.5% compared to 90% in patients with negative nodes. In the univariate analysis the following factors were found to affect the presence of node metastases in a statistically significant way: age, tumor size, depth of infiltration, vaso-invasion, surgical margins, parametrial infiltration, stage and place of referral. In 63 patients with positive nodes, a complete lymphadenectomy was carried out in 23 patients, and in 40 patients the procedure was incomplete. All 63 patients were treated by adjuvant radiation therapy; those with complete lymphadenectomy had significantly less recurrences (25%) compared to those with incomplete lymphadenectomy (56%): the relative risk (RR) was 2.9 (95% ci: 1.3-6.7), p=0.012. After adjustment for other prognostic factors including tumor size, depth of infiltration and parametrial involvement, the complete lymphadenectomy showed an independent effect on disease free survival: RR= 3.2 (95% ci: 1.3-7.7), p=0.011. Prognostic factors were not significantly different for patients with complete or incomplete lymphadenectomy.From the results of this study, although retrospective and non randomized, it can be concluded that to complete removal of lymph nodes in combination with radical hysterectomy seems to have a beneficial effect on prognosis in case of positive nodes. The policy of aborting the procedure when lymph node metastases are found in frozen section should be questioned.

The correlation between human papillomavirus (HPV) infection and tumor prognosis in 159 Russian women with cervical carcinoma was investigated. The presence of various HPV types was correlated with the histologic parameters of the carcinomas and with their immunoreactivity with antibodies to p53, Ki-67-Ag, and bcl-2.Formalin fixed, paraffin embedded tissue specimens representing 159 cases of International Federation of Gynecology and Obstetrics Stage I and II were used. HPV DNA was detected by polymerase chain reaction (PCR) using a general primer set that targets the L1 region and synthesizes a product of only 65 base pairs. The HPV types were determined by direct sequencing and compared with known HPV types.All 159 carcinomas were positive for HPV. HPV 16 (64.8%) was most frequently found, followed by HPV 18 (10.7%) and HPV 45 (8.2%). In 6 patients (3.8%), HPV types could not been further classified, and these cases were therefore categorized as HPV X. Although a trend was noted toward poorer prognosis for women with carcinomas harboring HPV types 16, 18, and 45 than for patients with carcinomas harboring HPV types 31, 33, 35, 52, 56, 58, and 68, the differences were not statistically significant. The prevalence of adenocarcinoma and adenosquamous carcinoma was higher among HPV 18 positive patients than among patients with the other known HPV types (P=0.0002).The rate of HPV positivity in these 159 cervical carcinomas was 100%. These findings challenge the assumption that HPV negative cervical carcinomas exist. This high rate might be attributed to the use of a new broad-spectrum HPV PCR test. HPV typing in cervical carcinoma was not significantly related to clinical outcome. HPV 18 was significantly more frequently found in adenocarcinoma and adenosquamous carcinoma. The possibility of classifying HPV 45 as an oncogenic high risk type should be considered.

Human papillomavirus (HPV) infection and p53 abnormalities might both play a role in the carcinogenesis of subtypes of squamous cell carcinoma of the vulva. In this study, the authors investigated the prevalence of and the relationship between p53 overexpression and HPV infection in patients with vulvar carcinoma.Immunohistochemical methods for the detection of p53 protein and consensus primer polymerase chain reaction (PCR) were used, followed by direct sequencing of the PCR product for the evaluation of HPV subtype infection. Sixty-six patients with squamous cell carcinoma of the vulva were available for this study.DO7, an anti-p53 monoclonal antibody, showed p53 overexpression in 35 carcinomas (53%). Consensus primer PCR showed HPV infection in 12 carcinomas (18%). No significant association was observed between p53 overexpression or HPV infection and tumor subtype. Approximately 57% of the HPV negative carcinomas and 33% of the HPV positive carcinomas had p53 overexpression. With regard to the patients with DO7 positivity inor =50% of the nuclei only, significantly more HPV negative carcinomas were DO7 positive compared with HPV positive carcinomas (41% vs. 0%, respectively; P = 0.018). No relation was found between either HPV infection or p53 overexpression and disease free survival.p53 overexpression is common in both HPV positive and HPV negative carcinomas of the vulva. These findings indicate that these two both play a role in the pathogenesis of vulvar carcinoma, but do not influence disease free survival.

Wound dehiscence after midline laparotomy is a life threatening complication, most frequently caused by sutures cutting through the fascia. Increasing the strength of the sutured wound could prevent wound rupture.In an experimental study in the rat, the simple continuous suture (SCS), loop suture (LS), interrupted double loop closure and continuous double loop closure (CDLC) techniques were evaluated. Dehiscence pressure and volume were measured after closing a standard laparotomy.Laparotomies closed with the newly developed CDLC technique could withstand by far the highest intra-abdominal pressure before dehiscence (P0.0002). Wounds closed with this technique remained well approximated regardless of the intra-abdominal pressure, unlike wounds closed with the frequently used SCS and LS methods.In all animals sutured with the CDLC technique the intact abdominal wall ruptured lateral to the wound at dehiscence pressure, indicating that the bursting strength of the sutured wound was higher than that of the intact abdominal wall.

To compare the analgetic efficacy and side-effects of Naproxen and Tramadol following the outpatient VABRA aspiration or hysterosalpingography.Ninety-one patients from the gynaecology clinics of two university hospitals and one municipal-teaching hospital.Multicentre double blind randomized clinical trial. Computerised randomisation, stratification per-centre.Semiquantitative assessment of the two drugs was performed by the patient and the gynaecologist using a 1- to 6-point scale. Pain, stress and well-being was scored by the patient using the visual analog scale (VAS) and the verbal description scale (VDS), ranging from 0 (good) to 100 (bad). Side-effects during the first 24 h postoperatively were recorded by the patient in a diary.The analgetic efficacy (pain, stress and well-being) of Naproxen and Tramadol was identical. Subjective assessment by the patient and the doctor also revealed no differences between Naproxen and Tramadol. Side-effects of Tramadol, however, were significantly more severe than those of Naproxen and this phenomenon was responsible for a lower ability to proceed with normal activities in the Tramadol group.Tramadol is a good alternative for Naproxen at outpatient VABRA or HSG procedures when Naproxen is contra-indicated.

The clinical value of pretreatment serum concentrations of cytokeratin 19 fragments, measured by Cyfra 21-1, was compared with tissue polypeptide antigen (TPA) and squamous cell carcinoma antigen (SCC-Ag) in 78 patients with squamous cell cervical cancer.Serum levels were compared with tumor stage, size, lymph node status, parametrial involvement, and prognostic data. The clinical performance of the different tests was evaluated by their receiver operating characteristic (ROC) curves.Serum levels of all markers were related significantly to tumor stage and size. Elevated serum levels of these markers were not found to be predictive for the presence of lymph node metastases. In contrast, a positive relation was found between quantitative serum Cyfra 21-1, TPA, and SCC-Ag levels and the presence of either lymph node metastases or parametrial involvement (i.e., extracervical disease). An elevated, i.e. positive, serum Cyfra 21-1 level was related significantly to the presence of extracervical disease (P = 0.020). The clinical performance of each serum marker in predicting lymph node metastases or parametrial involvement appeared to be similar as expressed by their ROC curves. In the univariate analysis, Cyfra 21-1, TPA, and SCC-Ag showed prognostic value with respect to disease free interval and survival. Elevated serum levels were associated with a poor prognosis. However, after adjusting for tumor stage and size, none of these markers remained statistically significant.Cyfra 21-1 may be of additional value in assessing stage of disease, tumor size, and the presence of extracervical disease in patients with cervical cancer. Determining its value during follow-up warrants further study.

To compare laparotomy closure with interrupted polyglactin 910 (Vicryl) and continuous polydioxanone (PDS II), and assess the mechanical and other factors that influenced the incidence of burst abdomen.Retrospective study.University hospital, The Netherlands.A random sample of 346 patients who did not burst their abdomens, taken from the total of 3768 patients who underwent primary midline laparotomy from 1986-1990, together with the 45 (1%) from the total series who did burst their abdomens.Incidence of burst abdomen, and the association with mechanical and others risk factors.There were no differences in the incidence of burst abdomen between those sutured with interrupted polyglactin 910 and those sutured with continuous polydioxanone (p = 0.12). Layered closure resulted in significantly more burst abdomens than any other method of closure (p0.001 in each case). Postoperative wound infection (14/43, 33%, compared with 33/343 10%) and pulmonary complications (25/43, 58%, compared with 44/344, 13%) were also significantly associated with the development of burst abdomens (p0.001).A continuous, monofilament, absorbable suture should be used to close a laparotomy incision. Elastic suture material, loop sutures, an the continuous figure-of-eight technique should be investigated.

To study the mechanical knotting abilities of the new synthetic absorbable monofilament suture poliglecaprone 25 (Monocryl) compared with other absorbable suture materials.Experimental laboratory study.Knotted loops (3/0 USP) of five synthetic absorbable sutures: Monocryl (poliglecaprone 25), PDS-2 (polydioxanone), Maxon (polyglyconate), Vicryl (polyglactin-910) and Dexon-Plus (polyglycolic acid). Three different knots were tested in a total of 150 experiments.Mean loop holding capacity (LHC) of 10 experiments, expressed in Newtons (N).Monofilament Maxon tied significantly more secure knots than the other sutures. Sliding knots of Monocryl (poliglecaprone 25) were similar to, and three-throw square knots were less secure than those tied with monofilament PDS-2. Braided Dexon-Plus was superior to Monocryl for sliding knots but comparable for square knots. Braided Vicryl did not differ significantly from Monocryl.The mechanical knot performance of Monocryl is identical to that of Vicryl, less than that of one other synthetic absorbable monofilament suture (Maxon) and comparable to or somewhat less than the other alternative (PDS-2). These findings, together with other characteristics such as degradation rate, should be used to define the application of Monocryl.

Although the omentum is extensively used in general, reconstructive and thoracic surgery as a pedicled omentoplasty, little information exists about the utility of such a procedure in general and radical gynecologic surgery. In this paper we review the properties of the omentum which may be useful in gynecologic surgery. The omentum is highly vasculated and rich in thromboplastin, an excellent property for treating difficult to handle abdominal or pelvic abscesses and for inducing hemostasis. Furthermore, it appears that the omentum has a trophical effect on the surrounding tissue, making it very useful in reconstruction procedures. Moreover, elevating the small intestines out of the true pelvis paves the way for high dose (brachy)radiotherapy with less radiation enteritis. The technique of the pedicled omentoplasty is straightforward and takes 20-30 min extra operating time. We use pedicled omentoplasty for covering large operating fields instead of reperitonealization, to prevent radiation enteritis, as a matrix for grafting, to treat serious intraperitoneal infections and to facilitate hemostasis. Our experience of 48 omentoplasty procedures in gynecology is described.

The objective of this study was to investigate the prognostic significance of serum antibodies to human papillomavirus (HPV)-16 peptides in patients with squamous cell cervical cancer.Pretreatment sera from 78 patients and 198 control women were tested by an enzyme-linked immunosorbent assay technique for reactivity with HPV-16 E4 (E401p) and E7 (E701p) synthetic peptides. The presence and serum level of these antibodies were correlated with tumor stage, histologic features, and prognostic parameters.The median follow-up was 65 months (range, 6-97 months). Antibodies to E401p peptide were found in 5 of the 198 (3%) control subjects, 4 of the 43 (9%) patients with low tumor stage (International Federation of Gynecology and Obstetrics [FIGO] Ia, Ib, IIa), and 7 of the 35 (20%) patients with advanced tumor stage (FIGO IIb, III, IVa). Antibodies to E701p were found in 25 (13%), 11 (26%), and 11 (31%) women, respectively. The differences between patients and control subjects were significant (P0.002). Seropositivity against these peptides showed no correlation with tumor stage. Antibody levels to both peptides were significantly higher in patients compared with control subjects (P0.05). Furthermore, antibody levels to E401p were higher in patients with advanced tumor stage versus patients with low tumor stage (P = 0.0097). Such a relation was not found for anti-E701p antibodies. In the univariate analysis, a high level of anti-E701p antibodies was associated with a shorter disease free interval (P = 0.012) and poor survival (P = 0.049). However, this variable possessed no prognostic value after adjusting for FIGO stage and tumor size.The authors' findings indicate that the prognostic significance of serum antibodies to the HPV-16 E4 and E7 peptides used in this study of patients with cervical cancer is limited.

In a group of 316 conizations performed from January 1984 to July 1991, 68 patients (22%) revealed no free margins of cervical intraepithelial neoplasia (CIN). They were divided into two groups with: 'negative follow-up' [normal cytology or less than two smears suggesting CIN I (class IIIa)] and 'positive follow-up' [at least two smears suggesting CIN I or one smear suggesting CIN II (class IIIb) or worse]. Forty-five patients (66%) fulfilled the criteria of negative follow-up. All patients with CIN I at the cone margin (18) were found in this group. The other 23 patients were in the positive follow-up group. Patients with positive follow-up were significantly younger (p = 0.04). Intervention after incomplete cone biopsy was necessary in approximately 10% (7/68) of cases. Cytology was thereby a reliable indicator for residual disease. Higher grade of CIN involved at the cone margin predicted a higher chance of positive follow-up. Semiquantitative measurement of CIN in the cone specimen showed a severe involvement of CIN II and CIN III in the positive follow-up group. In sum, our study showed that CIN I at the margin of the cone biopsy has no clinical significance. However, CIN II or III at the margin needs a careful cytologic follow-up, and appropriate action should be taken in case of cytologic abnormalities.

In to order to investigate the prevalence of HPV related parameters in sexually non-active women, smears of 75 virgins were microscopically reviewed for alterations caused by HPV i.e. koilocytosis, parakeratosis and multinucleinization. In none of these smears were the mentioned parameters seen together, so the diagnosis of HPV infection could not be assessed. In an age-matched control population consisting of 75 sexually active women smears were reviewed. In this group 10 smears (13%) were found positive for HPV infection, well in accordance with literature.

The results of a prospective study of laparoscopic management of ovarian cysts are discussed. This technique of minimally invasive surgery was introduced at the department of Gynaecology of the Leiden University Medical Centre in 1991. Only premenopausal women with unilocular ovarian cysts smaller than 10 cm in diameter and with sonographically benign characteristics were included in this study. In a period of one year, 25 cystectomies and one ovariectomy were performed. 88% of the cysts were initially treated with hormone therapy. Mean age of the patients was 30 years (range: 21-54), average size of the cysts was 6 cm (range: 4-10) and mean operating time was 80 minutes (range: 35-120), there were no complications during operation or in the postoperative period. No laparotomies had to be performed. Three times (11.5%) pathological specimen examination revealed a corpus luteum cyst. The other 23 were non-functional cysts. No carcinoma was detected. The results of this minimally invasive surgery for removal of ovarian cysts are encouraging. Morbidity compared with the conventional cystectomy by laparotomy is low as appears from a shorter hospital stay and quicker recovery. Cystectomy of the ovary, compared with laparoscopic aspiration and fenestration, has a better therapeutic effect and the histological evaluation is more reliable. Persistent, unilocular ovarian cysts, which fulfill the criteria used in our study, are best treated by laparoscopic removal instead of laparotomy.

To compare the cosmetic outcome of lower midline laparotomy scars using either nylon or polybutester suture for skin closure.A randomized clinical trial compared polybutester skin suture with nylon for lower midline laparotomy wounds in 50 women undergoing gynecologic surgery. Scar hypertrophy, scar width, scar color, the presence of cross-hatching marks, and a total score were assessed in all patients at 18 months following surgery and compared by nonparametric statistical tests.The wounds closed with polybutester suture were significantly less hypertrophic than those closed with nylon. Regardless of the suture material used, the lower part of the laparotomy scar showed an inferior cosmetic result compared with the upper part underneath the umbilicus for scar hypertrophy, scar width, and the total scar score.Polybutester skin suture diminishes the risk of hypertrophic scarring because of its special properties allowing it to adapt to changing tensions in the wound. Increased closure tension of the skin in the midline region above the pubic bone may be caused by a relative immobility of the skin. Scar cosmetics in this area may be improved by extra subcuticular suture support.

The serum vitamin B12 levels were determined in 44 asymptomatic patients at least one year after completion of pelvic irradiation for a gynaecological tumour. Ten patients (23%) were found to have decreased levels of serum vitamin B12, of which six (14%) were assumed to be caused by malabsorption due to radiation damage to the terminal ileum as no other reason for a lower vitamin B12 level could be detected. Neither the radiation dose or volume nor the manifestation of acute or late radiation side effects appeared to be correlated with the finding of decreased levels of vitamin B12. It is concluded that even in asymptomatic patients who received pelvic irradiation, serum vitamin B12 levels can serve as a marker for radiation enteropathy. It is advocated to check vitamin B12 levels prior to the radiation treatment as well as during the follow-up of these patients.

Developments in ultrasonographic technology have increased the possibilities of ovarian cyst aspiration. The risk of an extension of indications for ovarian cyst aspiration, however, is iatrogenic spread of malignant cells.In this article, the diagnostic accuracy and therapeutic effectiveness of ovarian cyst aspiration are discussed, and the potential risk from different forms of tumor spill are considered.Two cases are presented in which a laparoscopic puncture and aspiration of a malignant ovarian cyst were performed. In both cases, there were diagnostic problems with the cytologic assessment. In one case, aspiration of an apparently benign cyst, based on ultrasonographic and laparoscopic findings, yielded cytologically negative fluid, but 8 weeks later an extensively disseminated ovarian carcinoma was found at laparotomy. It is postulated that the time interval between first tumor spill and eventual removal of the diseased ovary is the most important determinant of prognosis.The conclusion of these case reports is that aspiration of ovarian cysts, except for the purposes of oocyte retrieval, is potentially dangerous and should not be regarded as routinely acceptable clinical practice.

To design an experimental model by which it would be possible to measure exactly the total amount of suture material required for interrupted and continuous closure of the abdominal fascia.Laboratory study.160 Patches of 1 mm thick synthetic material (silicone) 25 x 8 cm in which a midline incision had been made and sutured with absorbable sutures, either braided polyglycolic acid or monofilament polyglyconate, using a standard knot under standard tension.Length of suture material used when sutures placed either 2 or 1.5 cm from the cut edge and with 1 or 1.5 cm left between sutures. Each series of measurements was made 10 times.When the distance from the cut edge, the distance between sutures, and the suture material were standardised continuous suturing used less material than interrupted. Slightly less polyglycolic acid was needed than polyglyconate. More suture material (9-15%) was required for continuous sutures 1 cm apart compared with interrupted sutures 1.5 apart, when both were inserted 1.5 cm from the cut edge, but the difference was smaller when polyglyconate was used than when polyglycolic acid was used.The differences in lengths of suture material required do not outweigh the mechanical advantages of continuous closure of the fascia.

The prognosis of patients with early ovarian cancer is good as compared with that of patients with advanced disease. However, there are no methods for predicting prognosis of early ovarian cancer, on which treatment decisions can be based.The prognostic significance of DNA flow cytometric and morphometric analysis was evaluated in 64 surgically treated patients with well-differentiated early-stage (International Federation of Gynecology and Obstetrics [FIGO] Stage IA, IB, IC, and IIA) epithelial ovarian cancer. The extent of the well-defined staging procedure was assessed strictly in every patient.Only five patients died of recurrent ovarian cancer; all of these patients belonged to the inaccurately staged group. No significant relationship was found between clinicopathologic characteristics, such as menopausal status, FIGO stage, histologic cell type, and 5-year disease-free survival rate. Forty-two of the tumors had a mitotic activity index (MAI) of less than 30, and 43 of the tumors showed a volume percentage epithelium (VPE) of less than 65. Neither as a single parameter nor in combination did MAI and VPE correlate significantly with disease-free survival. Thirty-two tumors (50%) were DNA diploid, 15 were considered wide-CV-diploid, and 17 were aneuploid. Nearly 90% of the tumors showed DNA indices (DI) of 1.40 or less. The 5-year disease-free survival rate was significantly lower (61%) for patients with DI greater than 1.40 than for those with DI of 1.40 or less (96%) (P0.005). From the total number of five patients who died of their disease, three had tumors with DI in the tetraploid range.

Seventy-four patients presenting between 1978 and 1989 with carcinoma of the uterine cervix were analysed to compare our results with the published literature, especially with regard to the pelvic failure rate and radiation toxicity. Overall 5-year survival reached 41%. Overall 2-year survival rate for Stage IIB was 85% and Stage IIIB was 32%. For Stage IIB the results agreed with those reported in the literature. Pelvic control was related to total dose and the application of intracavitary irradiation. For Stage IIIB the results were disappointing, partly due to a large number of bulky tumours and also to a relatively low paracentral dose and dose to the pelvic side wall. Percentages of radiation side-effects were low compared with those reported in the literature, probably also due to the relatively low total dose.

• Three hundred forty women undergoing midline laparotomy were randomized into an interrupted suture (polyglactin 910, size 1) or a continuous suture (polyglyconate, size 0) closure group. The two groups were well balanced with respect to various risk factors for postoperative wound complications. Early evaluation revealed no differences between the continuous and interrupted suture groups with respect to wound infection (3% vs 1 %), superficial wound dehiscence (2% vs 4%), and deep wound dehiscence (0.6% vs 0%). Late evaluation showed no differences between the two groups either. Continuous polyglyconate and interrupted polyglactin 910 sutures had a similar incidence of suture fistula (0% vs 2%), wound pain (1% vs 2%), and incisional hernia (3% vs 4%). Continuous closure was done faster and resulted in less foreign-body suture material. Despite its smaller diameter, the polyglyconate suture also retains a higher tensile strength after surgery than does the quicker-degrading polyglactin 910 suture. Results of this study lead to the conclusion that a running polyglyconate suture is the better choice for closure of the abdominal-wall fascia following midline laparotomy. ( Arch Surg . 1992;127:1232-1234)

One hundred consecutive radical hysterectomies performed in a Dutch oncology centre during a five and a half year period between 1984 and 1990, were analysed. The operations were performed in a uniform manner by the same three surgeons. Surgical mortality was nil. Mean operating time was 4 hours and mean blood loss amounted to 1200 ml. One patient developed a vesicovaginal fistula. Long lasting urinary symptoms occurred in 32% of patients, sex problems in 13%. The latter situation was encountered significantly more frequently when surgery was combined with radiotherapy. Eighty-two of the 100 patients had a primary cervical carcinoma and were analysed further. Distribution according to stage was as follows: stage IA: 3, IB: 64, IIA: 13, IIB: 2. Postoperative external and intracavitary pelvic radiation was given in 34 patients (41%). Three-year survival of these patients amounted to 86%. One-third of patients had a large primary tumour (diameter greater than 4 cm). Three-year survival rate in this subgroup of patients was 78%. Lymph node metastases were found in 14 patients (17%). Three-year survival rates for patients with and without lymph node metastases were 64% and 94%, respectively (p less than 0.0001). Results and complications of this series were compared with the current literature data and found to be comparable and sometimes even better than recent literature data. These findings may serve to advocate further centralisation of this kind of surgery in oncological centres in the Netherlands.

Objective To see whether surgical adhesiolysis would improve pelvic pain in women with pelvic adhesions. Design Randomized clinical trial comparing surgery (adhesiolysis) with no surgery with final analysis of results after 9–12 months. Setting Department of Gynecology, Leiden University Medical Center, the Netherlands. Subjects 48 women known by laparoscopy to have stage II-IV pelvic adhesions. Interventions Midline laparotomy and surgical adhesiolysis. Main outcome results Pelvic pain assessed by the McGill pain score, subjective pain assessment and disturbance of daily activities. Results 24 women were randomly allocated to undergo surgical adhesiolysis and 24 to a control group who did not have surgery. After 9–12 months there were no significant differences between the two groups overall with regard to pelvic pain. A subgroup of women with severe, vascularized and dense adhesions involving bowel (stage IV) had significantly less pelvic pain after adhesiolysis for two of the three methods of assessment. Conclusions Adhesiolysis for the treatment of pelvic pain is not indicated in women with light or moderate degree pelvic adhesions. It may be beneficial in those with severe adhesions involving the intestinal tract.

A bispecific monoclonal antibody (bs-MAb) (OC/TR) was produced in large quantities for the intraperitoneal (i.p.) treatment of ovarian cancer. The bs-MAb recognizes the folate-binding protein on ovarian cancer cells on the one hand and the CD3 activation site on T lymphocytes on the other. T lymphocytes were expanded ex vivo, targeted with OC/TR in vitro and administered to the i.p. cavity in the presence of soluble OC/TR. All patients developed human anti-mouse-antibodies (HAMA). In the Dutch study, 2 complete remissions (CR) were seen, 2 partial regressions (PR), I stable disease (SD) and I progressive disease (PD). In the Italian study 3 CR, I PR, I SD and 2 PD were seen.

One hundred six patients with chronic pelvic pain were randomly allocated to one of two treatment groups. In the standard-approach group, organic causes of pelvic pain were excluded first and diagnostic laparoscopy was routinely performed. If no somatic cause could be found, attention was given to other causes such as psychological disturbances. In the second group an integrated approach was chosen. From the beginning equal attention was devoted to somatic, psychological, dietary, environmental, and physiotherapeutic factors. In this group, laparoscopy was not routinely performed. Both groups were similar with respect to clinical characteristics of the patients and the severity of their pain as assessed by various pain parameters. Postcoital pain was reported by 27% of the patients. Twenty percent of the patients had had negative sexual experiences such as childhood sexual abuse or rape. Evaluation of the pain 1 year after the institution of treatment revealed that the integrated approach improved pelvic pain significantly more often than the standard approach for three out of four pain parameters (P less than .01). Laparoscopy played no important role in the treatment of pelvic pain. It is concluded that equal attention to both organic and other causative factors from the beginning of therapy is more likely to result in a reduction of pelvic pain than is a standard approach.

The first ten applications of an absorbable polyglycolic-acid mesh to keep small bowel from descending into the pelvis during postoperative radiation treatment, are described. Two of the ten patients developed mild symptoms of (sub)ileus that could be treated conservatively. In two patients GI tract series revealed that a small bowel loop had slipped outside the sling and had descended into the pelvis. To prevent this condition an interlocked running suture to adjust the mesh is recommended. It is concluded that this intestinal sling procedure is a feasible surgical method causing only mild postoperative complaints or no symptoms at all. The sling procedure is effective to keep the small bowel out of the pelvis following surgery in patients who may require postoperative radiation treatment for pelvic malignancy.

Patients with well-differentiated epithelial ovarian cancer Stages Ia, Ib, Ic, and IIa (FIGO 1976) were observed after surgical treatment without adjuvant therapy. Careful surgical staging was required, and the extent of the staging procedure was assessed in each individual patient. There were 107 patients entered in the study by nine Dutch oncology centers. Of these 107, 21 did not fulfill all of the inlet criteria of the study and were excluded. Central pathologic review was performed in the remaining 86 cases, revealing that there was borderline tumor in seven patients, moderately or poorly differentiated tumor in nine patients, and tumor of nonepithelial histologic cell type in one patient. In two cases, no material for histologic review was available. After exclusion of these 19 cases, 67 patients were further analyzed. None of these 67 patients was lost during the follow-up period that ranged from 19 to 99 months (mean, 50 months). Tumor recurrence was found in four patients after 11, 25, 34, and 34 months of follow-up, all of whom died shortly after diagnosis of the recurrence without satisfactory response to secondary treatment. For the patients who underwent the most extensive staging procedure, disease-free 5-year survival was 100%. For the patients who were inaccurately staged, disease-free 5-year survival was 88%. It was concluded that well-differentiated early stage (Ia-IIa) ovarian cancer carries an excellent prognosis after surgical treatment and complete surgical staging, with the possible exception of patients with Stage Ic disease with malignant peritoneal washings. Furthermore, it was considered that the application of more objective and consistent ways of assessing tumor grade should be encouraged. Surgical staging should be regarded as the golden standard in defining subsets of low-risk patients and should be included and clearly defined in future trials on early ovarian cancer.

Laparoscopic findings in 200 asymptomatic, healthy women having a sterilization were recorded; 148 patients (74%) had no abnormality and 52 patients had abnormalities comprising pelvic adhesions (14%), uterine fibromyomas (5%), endometriosis (3%) and ovarian or parovarian cysts (2%).To place diagnostic laparoscopy in perspective, laparoscopic findings in 200 consecutive healthy women having laparoscopic sterilization by clips or rings were recorded. The subjects all had regular menses and a normal pelvic exam. 148 had no pathology on laparoscopy. 52 remaining women had adhesions (28, 14%), hydrosalpinx (3), ovarian cyst (3), endometriosis (5), fibromyomas (10, 5%), parovarian cyst (1), benign bladder tumor (1), and carcinoid bowel tumor (1). 43% of the adhesions were moderate or severe; 26% were associated with history of appendectomy; 68% were located outside the small pelvis. These findings are comparable to those published in 2 other series. They are relevant to management to patients complaining of chronic pain or infertility.

Summary Eighty-five pairs of simultaneously recorded external and internal cardiotocograms (CTGs) were coded and evaluated with a ten-point scoring system routinely used for the assessment of antepartum CTG. The highest consistency in interpretation between the external ultrasound and the internal fetal scalp CTG was found for basal heart rate followed by decelerations. Oscillatory amplitude and frequency were interpreted differently in 14 per cent of CTGs and accelerations in 16 per cent. When differences in interpretation arose, there was certainly no tendency for the external CTG to present an optimistic image of the fetal heart rate variables. With the exception of oscillatory amplitude all variables, including oscillatory frequency and the total CTG score, were more frequently underestimated than overestimated on external CTGs. When accelerations were present on only one recording, there was an 85 per cent chance for these to be absent on the external CTG. The study abolishes fears that the routine clinical assessment of antepartum CTGs of adequate technical quality provides overrated and more optimistic data than would be achieved by direct fetal scalp monitoring.

Summary A ten-point scoring system was used to assess 2770 antepartum cardiotocograms (CTGs) obtained in 405 pregnancies at risk. There were 284 pregnancies with a last CTG within 24 hours before labour, Caesarean section or intrauterine death; these were analysed separately and their outcome correlated well with the last CTG score, better than with individual CTG criteria. The relationship between CTG score and fetal condition at birth was particularly close for pregnancies with growth retardation, rhesus isoimmunisation or hypertension. A score of 8 to 10 reliably predicted good condition at birth in 95 per cent of pregnancies which ended within 24 hours and in 88 per cent of those which ended after three or four days. A score of 5 points or less invariably indicated poor fetal condition with little chances of a normal outcome unless the cause could be effectively treated. The score provides a highly specific but moderately sensitive test for fetal well-being with virtually no false positive and only few false negative results. However, almost 15 per cent of CTGs, scoring 6 or 7 points, provide too little information on fetal well-being to be of clinical value.