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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.

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.

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.

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.

Case reports are presented for 2 patients in whom copper-containing IUDs had penetrated through the uterine wall into the abdominal cavity. It is pointed out with reference to reports in the literature that laparoscopic removal is frequently impossible and may also be dangerous because of the marked peritoneal reaction surrounding the copper part of the IUD. The results could be adhesions and infiltration. A scheme is proposed for the treatment of patients who are suspected of perforation by a copper-containing IUD. Authors' modified)

A 24-year-old Vietnamese boat refugee went to a physician to have her IUD removed. There was no control thread, and X-rays showed an IUD of unknown type in situ. The IUD could not be removed with a Wilbaut hook, so curettage was performed to extract the IUD, which could not be identified. It is possible that other Vietnamese refugees are using the same type of IUD.