Search

Background: Complex atypical hyperplasia is a recognised precursor to endometrial cancer, the most common gynaecological cancer of the Western World, with hysterectomy being the first line of management. With the increasing elderly population size and BMI, optimal surgical management can be challenging in a sub-set of patients. Levonorgestrol releasing IUS system (Mirena coil) has been identified as a treatment for those unsuitable for surgical management., Aims: To assess the efficacy of Mirena coils in the treatment of endometrial cancers and complex atypical hyperplasia in our patient population., Method: Retrospective analysis of all type 1 endometrial cancers and CAH diagnosed in Tayside from April 2011 to March 2016 (duration 5 years) managed by a Mirena coil. Primary outcome was resolution of malignancy on biopsy. Secondary outcome was continuation of treatment., Results: Two hundred nineteen out of 245 eligible endometrial cancers and 38 of 41 CAH case notes were available for assessment. A Mirena coil was the primary mode of treatment in eight endometrial cancers (3.6%) and 18 cases of CAH (47.4%). Of the eight endometrial cancers treated, five (62%) continued with the Mirena coil as the primary mode of treatment. Two patients died during their follow-up due to unrelated illnesses and one patient proceeded to hysterectomy due to the absence of progestogenic effect on repeat Pipelle biopsy at six months (12.5%). Four patients have been followed for one year and of those; two showed no evidence of malignancy, one was unable to be biopsied and the last showed persistent disease but was too frail for intervention. At two-year follow-up, two patients remain with one showing disease recurrence. Thirteen patients (87%) have continued to use the Mirena as management of CAH out of 18 treatments. Of the five patients who did not continue with the IUS; two patients had progressive disease, despite the coil (11%), two patients lost enough weight to proceed to hysterectomy and one patient died unexpectedly. Medical co-morbidities and BMI were the main cited reasons for proceeding with the IUS as the primary treatment. Average BMI of endometrial cancer cases was 43.9 and 45.1 for CAH., Conclusions: Mirena coil is effective in treating or controlling the progression of endometrial malignancy in the subgroup of patients where there is an increased risk associated with definitive surgery. The treatment failure rate appears to be consistent at about one-tenth of the cohort of women with both endometrial cancers and complex atypical hyperplasia.

Background: Transverse abdominis plane (TAP) block is a peripheral nerve block designed to anaesthetise the nerves supplying the anterolateral abdominal wall (T6 to L1). We introduced laparoscopic TAP block at Ninewells Hospital in 2014 and present a retrospective study assessing its efficacy. To our knowledge, there is limited study done on laparoscopic-guided TAP block whilst there are abundant literatures available on ultrasound-guided TAP block., Aims: To evaluate the efficacy of laparoscopic-guided TAP block as postoperative analgesia following total laparoscopic hysterectomy (TLH)., Methodology: A retrospective study was done between November 2014 to October 2016 (24 months) comparing patients who had TLH with TAP block (Group 1; n = 45) and patients who had TLH without TAP block (Group 2; n = 31) in our gynaecology unit. Patients were identified from theatre database. Data was collected from clinical portal and medical notes. The data included demographic information, BMI, METS score, intra-operative opiates use, post-operative pain scores, opiate requirements and use of patient-controlled analgesia (PCA), total dose of opiates used and day of discharge. The outcomes were analysed using means, odds ratios (OR), Mann-Whitney U-test and Fisher's exact or Chi-square test with 95% confidence interval (CI)., Results: Patients in Group 1 were older (mean age of 64.4, range 38-87) when compared to Group 2 (mean age of 49.3, range 37-81). Group 1 and 2 had comparable mean BMI (30.34 vs. 30.02) and METS score (6.77 vs. 7.76). Mean post-operative pain scores were lower in Group 1 within 4 hours, in periods of 4-12 hours, 12-24 hours and 24-48 hours post-op. Smaller proportion of patients in Group 1 required opiates post-operatively in all periods as compared to Group 2. This was statistically significant in the periods of 12-24 hours post-op (OR 0.31, 95% CI 0.11-0.82; p = .01). PCA use was significantly lower in Group 1 (OR 0.02, 95% CI 0.0014-0.46; p = .01). Group 1 had lower mean total dose of opiates used (27.182 mg, range 0-102 mg) than Group 2 (59.452 mg, range 0-240 mg), which was statistically significant (p < .0001). Average post-op hospital stay was 1.3 and 1.8 days in Group 1 and 2, respectively., Conclusion: Laparoscopic-guided TAP block delivered as post-operative analgesia following TLH results in reduced opiate requirement at post-operative period 12-24 hours, reduced PCA use and lower total dose of opiates used.

Introduction: Improvement in preoperative care for the ageing population has resulted in an increasing number of elderly patients to be considered for surgery. With an increased incidence of endometrial cancer, it is inevitable that a significant number of elderly patients are referred for surgery, despite the concerns over co-morbid conditions and diminished cardiopulmonary reserves., Aim: To evaluate the clinical outcomes of laparoscopic hysterectomy for elderly women operated on for endometrial cancer with comparison to younger patients., Methods: A retrospective study of women who had undergone total laparoscopic hysterectomy for endometrial cancer at Ninewells Hospital between January 2015 and January 2017 was conducted. Patients were identified from the gynaecology oncology multidisciplinary team e-case database and were categorised into younger and older group according to their age. Both groups were compared and analysed for demographics details, pre-existing comorbidity, METS score, perioperative and postoperative data., Results: There were 100 women meeting the study criteria. Of these, 79 patients were aged ≤75 (Group A) and 21 patients were aged >75 (Group B). The mean age was 62.9 (age range 37-75) and 80.6 (age range 76-90) in Group A and Group B, respectively. Group A presented with higher mean BMI (̄ = 33.8) compared to Group B (̄ = 28.8). With the increase in patient's age, reduced METS score was observed. No difference was found between the groups in the incidence of estimated blood loss and postoperative hospital stay. Fisher's exact test was used to evaluate the postoperative complication in both groups. The two-tailed p value (p = .1108) had illustrated that the observation was statistically insignificant between both groups. One patient in Group A (n = 79) was found to have pelvic haematoma after the procedure; while two patients in Group B (n = 21) developed port site haematoma. Otherwise, no other patients from both groups developed postoperative complication regardless of their pre-existing medical conditions. Only one patient in Group A (n = 79) required conversion to open surgery due to difficult access and large uterine fibroid., Conclusions: Total laparoscopic hysterectomy appears to be feasible and safe in elderly women with no significant difference between groups. Minimally invasive surgery has shown to extend considerable benefits to patient safety regardless of their age.

Vulval cancers are rare, but after primary treatment, known to recur with a high frequency (30%). Clinico-pathological predictors of recurrence have been established to a great extent. However, there is paucity of literature on predictors of early versus late recurrence. We sought to identify such predictors through a retrospective study of vulval cancer recurrences in a single cancer centre over 11 years. Age of women, depth of invasion/site of primary tumour and presence of background VIN/lichen sclerosus do not appear to affect timing of recurrence. However, vulval cancers that recur after 2 years of primary tumour recognition are more likely to be well-differentiated tumours, have undergone radical surgery and have had a closest disease-free margin >1 cm. Late recurrences are entirely local rather than distant metastases and this translates into a better survival as shown in our study (40 months median survival in the early group versus 112 in the late recurrence group).

Our study adds to the BRCAness theory that hereditary ovarian cancers with BRCA 1 or 2 mutations show better chemosensitivity when compared with sporadic ovarian cancers.

Continuous intrapartum cardiotocography (CTG) augmented by fetal ECG ST segment analysis (STAN) has the potential to reduce the rates of neonatal metabolic acidosis and obstetric interventions. STAN was introduced at Ninewells Hospital, Dundee in October 2007. Data were collected prospectively from all women who received continuous intrapartum CTG and STAN between 1 October 2007 and 31 March 2008. A total of 253 women had continuous CTG and STAN. The median number of ST events was one (range = 1-32). Most (556/719, 77%) ST events were associated with a normal CTG; 46/144 (32%) patients with an ST event required immediate action. Three of the 253 (1.2%) women were delivered based on an ST event with a normal CTG; four (1.5%) had severe neonatal metabolic acidosis and all four cases had intrapartum ST events and were not managed according to STAN guidelines. ST events are common but the majority of ST events require no action. The high incidence of false-positive ST events might have contributed to the failure to act when a significant ST event occurred.