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A new instrument originally designed for hysteroscopy can also be used for cystourethroscopy. The advantages of the instrument are: 1) it uses available room light; 2) it does not require any viewing medium such as water or gas; 3) it gives an excellent direct view of the urethra, bladder neck, and trigone; 4) it is easily included on the instrument table to be used as an adjunct to surgery; and 5) cystourethroscopy with the contact endoscope is an easy office procedure. Although this instrument does not give a panoramic view, limitations are readily recognized by the experienced operator; thus, errors resulting from its use can be avoided.

Fifteen women diagnosed with cervical stenosis were treated by vaporization of scar tissue using the carbon dioxide laser. Ninety-three percent of the cases demonstrated binding constriction of the cervical os to a 2-mm diameter or less and 40% of the cases had either a pinpoint opening or total endocervical obliteration. The technique for laser treatment and the success of the method depend on precise variations of mode, power, beam diameter, and "buttoning" the endocervical mucosal remnant. Twelve of the 15 patients were relieved of stenosis and 9 achieved pregnancy within 2 years of the operative procedure. Critical analysis of possible causative factors in this study revealed that virtually every case of stenosis had been iatrogenic.

Acute inversion of the uterus is a rare emergency that occurs during the third stage of labor. Three cases of this complication are reported. General anesthesia, fundal pressure on a soft uterus, fundal implantation of the placenta, and adherent placenta were identified as the possible causes. Prompt recognition and replacement are essential in the management to preempt morbidities and mortality. The prevention, etiology, and management of this serious complication are discussed.

Two series of patients with genital warts were compared for effectiveness of treatment by means of the carbon dioxide laser. In the earlier series (1977 to 1981) laser vaporization was used to remove overt warts while surrounding normal skin was spared. Examination of anal, urethral, and other extragenital sites for possible involvement was done only when warts persisted or recurred. In the later series (1983 to 1985), patients were similarly treated by carbon dioxide laser techniques; however, two additional measures supplemented laser vaporization of gross condyloma acuminatum. The brush technique superficially coagulated skin and mucosal surfaces contiguous to warts. This methodology was hypothesized to eliminate subclinical human papillomavirus infection within normal-appearing epithelium. Compulsive examination and treatment of extragenital sites at the time of the initial laser surgical procedure eliminated the most likely locations for persistence or recurrence. The primary cure rate for the earlier series was 65.8% compared to 91% for the later series. This difference was highly significant (p less than 0.005).

The carbon dioxide (CO2) laser was used to perform microsurgical excision of obstructed tubal segments in rabbit and human subjects. Approximation of the freshly severed tubes by means of laser "welding" was evaluated in both groups investigated. More important, the laser beam cuts accurately and atraumatically while sealing small vascular channels. Scanning electron microscopic studies of the human fallopian tube following laser surgery were done to determine the extent of tissue injury. At a distance of 1 mm distal to the vaporization and necrotic impact zone, normal tubal anatomy was observed. Follow-up data are presented for 7 women who underwent laser beam tuboplasty between 1979 and 1980. The principle advantages of the CO2 laser are its precise control, minimal tissue injury, and hemostatic properties.

Fourteen women underwent endometrial ablation by use of the Nd:YAG laser. All patients had significant risk factors that precluded safe hysterectomy for intractable bleeding. All patients had demonstrated anemia, menorrhagia, and metrorrhagia uncontrolled by hormonal therapy or curettage. Specifically, seven (50%) women in this group had proved major clotting abnormalities as their principal diagnosis. Three new techniques are described as modifications of the original Nd:YAG ablation methodology and include: (1) the use of Hyskon as the uterine distending medium; (2) the attachment of a high-resolution endoscopic television camera to the eyepiece of the hysteroscope, which permits the surgeon to view the endometrial cavity and operate via a video monitor; and (3) the application of a specially designed dual-channel operating hysteroscope that allows simultaneous laser ablation and aspiration of debris. Although this operation is a valuable alternative to hysterectomy in selected clinical situations, its major deficiencies are the lack of long-term follow-up data and the absence of a surgical specimen for pathologic analysis.

Fifty cases of vulvar carcinoma in situ comprising over 1000 histologic sections were studied. Each case was evaluated to determine the thickness of the neoplastic epidermis and the depth of involved skin appendages. Two precise techniques were used to perform the microscopic measurements. The areas most frequently afflicted with neoplasia were: one or both labia (45%), interlabial folds (27%), perineum-fourchette (15%), and perianal skin (10%). Multicentric disease was observed in 68% of the cases. The epidermal thickness ranged between 0.35-1.66 mm. The mean depth (+/- SD) of the epidermis was 0.93 +/- 0.37 mm. Eighteen of the 50 patients demonstrated involvement of the skin appendages to a mean depth of 1.53 +/- 0.77 mm, suggesting that laser vaporization to a depth of 2.5 mm will, with the anticipated additional thermal necrosis, eliminate appendages involved with carcinoma in situ in 95% of instances. The most common sites of skin appendage involvement were the labia majora or minora and the interlabial folds.

Between 1977 and 1987, the CO2 laser was used to treat 4024 women who were diagnosed by cytology studies, colposcopy, and biopsy examination to have cervical intraepithelial neoplasia. On the basis of specific indications, these women were treated by vaporization, excisional conization, or combination conization procedure. The evolution of methodology for each laser technique was based on specific pathophysiology and long-term observation of results. A total of 3070 patients underwent vaporization, 2881 of whom had no evidence of disease after one laser exposure (93.8%). Of the 954 patients who had laser excisional procedures, 925 (97%) had no evidence of disease. The most common complications observed were intraoperative and postoperative bleeding; however, sutures were required in only 1.34% of the latter. The risks of cervical stenosis (1.1%), incompetent cervix (0%), and pelvic infection (0.05%) were very low. This 10-year study demonstrated that the CO2 laser was a highly effective method for treating cervical epithelial neoplasia and had the added benefit of preserving reproductive function and anatomic integrity.

Forty-three rats underwent a series of operations with the CO2 laser to incise the uterine horn. Electronically pulsed laser light was compared with the continuous-wave (CW) mode on alternative horns, with each animal serving as its own control. Five variations of the superpulsed mode were compared with the same number of CW settings. Three experiments were performed: acute evaluation after partial uterine horn transection, acute observation after complete transection, and chronic studies after partial transection. The sectioned uterine horns were grossly observed and photographed, then sampled, histologically fixed, and studied by light and scanning electron microscopy. Zones of thermal necrosis were measured by an imaging tube and quantified by a computer-linked digitizing tablet. The results of this study demonstrated 2.5 times less thermal necrosis by electronically pulsed, versus the CW, laser beam. Four-and-one-half times less necrosis was also observed when the pulsed laser was employed for complete transection experiments. Adhesions were provoked in every animal that underwent chronic investigation. Inflammatory response, adhesion progression, and hydrosalpinx formation were significantly diminished in the pulsed-treated group. Qualitatively, wounds inflicted by pulsing showed different geometric patterns, compared with CW incisions. Electronic pulsing offers the surgeon the combined advantages of knife-like incisions and the precision and hemostatic properties of the CO2 laser.

A new conservative method for treating carcinoma in situ of the vulva is presented. The carbon dioxide laser offers the advantage of a microsurgical technique combined with the benefits of sharp local excision. As one third of the 35 patients treated in this series are under 30 years of age, preservation of the anatomic and functional integrity of the vulva is of paramount importance. Laser therapy has proved to be precise and has resulted in rapid healing without scar formation. The laser regimen conveniently unifies the therapeutic program directed against multicentric squamous neoplasia of the lower genital canal.

Although some physicians have the opportunity to participate in a journal club during residency, many infrequently receive formal instruction on how to critically evaluate a journal article. Systematic guidelines for appraising a clinical journal article are presented and illustrated with examples. Considering each guideline in its respective order may lead to a better understanding of what the literature may offer one's practice.

Extensive cervical intraepithelial neoplasia may simultaneously involve large areas of the ectocervix, even extending to the vaginal fornices, as well as the endocervical canal. In such instances conventional sharp knife conization would result in virtual removal of the cervix if the surgeon wished to completely circumscribe the entire lesion. By combining a narrow carbon dioxide laser excisional conization with ectocervical vaporization, cervical intraepithelial neoplasia may be eradicated by a virtually bloodless surgical procedure and fertility may be preserved. Sixty-one combination conizations with 6 months to 4 years of follow-up are reported. In 95% of the cases biopsy demonstrated cervical intraepithelial neoplasia in three or more ectocervical quadrants, and 16% had extension of disease into the vagina. The technique of combination conization uses 20 to 30 W of power and 1/2 to 1 mm spots for excision and 10 to 15 W and 1 to 1.5 mm spots for vaporization. The average time to complete the entire procedure was 21 minutes. In three of 61 cases endocervical margins were positive; there were no instances of persistence of neoplasia at either the ectocervical or the vaginal margins. Four complications were observed, all related to delayed bleeding; however, only two patients required the placement of a suture. The volume of tissue removed by a large excisional conization is more than two times greater than that of a laser combination conization.

A patient with combined pregnancy developed an acute condition in the abdomen 9 weeks after surgical removal of a tubal pregnancy. At laparotomy she was found to have bilateral theca-lutein cysts. After operation, the patient went into preterm labor and was delivered of a male fetus. Pathologic examination of the placenta revealed hydropic change and trophoblastic hyperplasia.

A flexible carbon dioxide laser fiber delivery system was used in conjunction with the laparoscope to treat 12 women. The 77 by 2 mm hollow fiber could subtend an arc of 90 degrees without significant loss of power or unfavorably affecting the delivery mode. As many as 20 W of power was transmitted through the fiber; however, carbon dioxide gas flow rates as high as 2000 cc/min reduced power by approximately 25%. Replaceable tips preserved fiber integrity to the extent that a single fiber could be reused repeatedly and gas sterilized without jeopardizing laser transmission. Of the 12 cases, endometriotic implants were vaporized in eight women, adhesiolysis was performed in four women, endometrial cysts were drained in two women, and vaporization of myomata was accomplished in two patients. The fiber was also used as a manipulating instrument and could be internally bent with a grasping forceps to better site the laser beam on a lesion. No complications related to the use of the carbon dioxide laser fiber were observed. The safety aspects of carbon dioxide laser fiber technology are not inconsiderable and could provide laser laparoscopy with an extra margin of security.

Continuous wave (CW) CO2 laser using a power of 20 W and a spot size of 0.2 mm was used to cut the left uterine horn in 15 rats. Pulsed CO2 laser using a power of 14 W, pulse repetition rate of 400 pps, and a spot size of 0.2 mm was used to cut the left uterine horn in 16 rats. The right uterine horn was sham-operated and used as a control in each group. Microsurgical anastomosis of the cut horn was performed. The effect on fertility showed a pregnancy rate of 66.6% and 81.25% for the CW and pulsed CO2 laser, respectively. Histopathology studies of the anastomotic site revealed thinning of muscularis with fibrosis of both muscularis and subserosal layers in the CW CO2 laser-treated group. There was no thinning, disruption, or fibrosis of muscularis in pulsed laser-treated group. Adhesion score was not different in the two groups.

The amniotic membrane was used as a graft intraabdominally in the rat to study the healing process and the graft's efficacy in preventing postoperative adhesions. We observed the gradual invasion of the graft with fibroblasts and plasma cells and increased vascularity. By the tenth postoperative day the graft had taken completely. There was no evidence of infection at the graft site or rejection of the graft. Application of the graft after lysis of adhesions was followed by adhesion formation at the graft site. The graft did not show evidence of necrosis but failed to prevent adhesion formation.

A total of 66 women with cervical intraepithelial neoplasia extending into the endocervical canal were investigated by endocervical curettage, contact endoscopy, and conization biopsy of the cervix. Although atypical epithelium was obtained in only 8 women by blind endocervical curettage, contact endoscopy identified 42 instances of disease of equal or greater magnitude than determined by the original ectocervical colposcopic evaluation. These findings were subsequently confirmed by conization biopsy. As the 6-mm contact hysteroscope may easily be inserted into the pregnant cervix, sufficient reassurance may be gained to avoid endocervical curettage or cone biopsy and thus to avoid the hazard of major hemorrhage and/or pregnancy interruption.

A total of 115 women with various grades of CIN were treated with high-power--density, continuous time mode CO2 laser beams. During the 2-year follow-up period, residual tumor was noted in 4.34% of the treated cases. Detailed observations of the rapid healing of tissues after laser exposure were carried out in 50 women who were colposcoped every other day for 4 weeks. The CO2 laser is an acceptable instrument for use in treating early gynecologic malignancy, with its principal advantage being the precision with which it destroys tissue.

A retrospective study of 5346 cases of laparoscopic sterilization with special reference to early and late complications was undertaken. In the 6-year period from 1972 to 1978, 846 patients were sterilized by the elasticized silicone-ring technique and 4500 patients were sterilized by the electrocautery method. The electrocautery method was complicated by electrical burns in 13 cases (0.29%); 3 of these patients required bowel resections. Mechanical complications occurred in 1.6% of the Silastic-ring cases, but none of the patients required additional surgery. The Silastic-ring patients had greater postoperative abdominal pain than the electrocautery patients, but it usually abated within 48 hours. There were 15 cases of postoperative pelvic infection in the electrocautery group, and none in the Silastic-ring group. Bleeding from the mesosalpinx occurred in both groups and occurred more often with coincident suction D&C. Technical failure to perform the sterilization procedure was principally related to previous abdominal surgery. A substantial number of patients complained of menstrual irregularity and/or dysmenorrhea following these sterilization procedures. The majority of women reported unchanged or improved sexual relations. Improvement in sexual relations was reported by significantly more patients in the Silastic-ring group than in the electrocautery group.