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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

About 5% of all ovarian-cancer cases are caused by a genetic predisposition, in particular as a component of the autosomal dominant hereditary breast-ovarian-cancer syndrome. This syndrome is usually due to germline mutations in the BRCA1- or BRCA2-gene. Ovarian and endometrial cancer also occur in families with hereditary non-polyposis colorectal cancer (HNPCC). This syndrome is caused by germline mutations in DNA mismatch-repair genes. Women at high risk of gynaecological cancer based upon familial clustering of disease or a demonstrated pathogenic germ-line mutation are candidates for surveillance: annual gynaecological examinations, including vaginal echoscopy and serum carcinoma antigen CA125 testing. Prophylactic surgery in the form of adnexectomy leads to a marked, but not complete, reduction of ovarian-cancer risk in high-risk cases. There is insufficient evidence to advise against the use of oral contraceptives or hormonal substitution after adnexectomy for healthy women with a genetic predisposition to breast cancer. Recommendations for surveillance and prevention should only be given after genetic-risk counselling, based on a detailed family study and DNA-based diagnosis

The Dutch College of General Practitioners' practice guideline 'Vaginal bleeding' is a useful instrument for general practitioners. The changes in the present version are based on recent developments in diagnostic and therapeutic possibilities, such as (hydro-)ultrasonography to diagnose intracavitary abnormalities, progesterone-containing 'intra-uterine devices' (IUDs) and endoscopic techniques for destroying the endometrium. The recommendation to prescribe cyclical progestogens in the case of hypermenorrhoea is not supported by randomised studies. On balance, this guideline provides clear and useful advice for the treatment of abnormal vaginal blood loss

OBJECTIVES: Our aim was to compare magnetic resonance imaging (MRI) with the current standard clinical practice (pelvic examination including general anesthesia in selected patients) with regard to treatment planning in invasive cervical carcinoma. It was of particular interest to compare the accuracy of both methods for allocating the patients to the appropriate treatment modality: surgery versus primary radiotherapy. METHODS: One hundred and three consecutive patients with primary invasive cervical carcinoma underwent both MRI at 1.5 T and pelvic examination. The gold standard for comparing treatment decisions was based on the surgico-pathologic data: tumor confined to the cervix (treatment decision for surgery) or extracervical tumor spread (treatment decision for primary radiotherapy). RESULTS: A gold standard was available in 91 patients. The pelvic examination made correct treatment decisions in 89% of patients. However, the sensitivity for extracervical spread was only 44% (8/18 patients). MRI was better at identifying extracervical tumor spread: 67 and 89% for observers 1 and 2, respectively. MRI, however, had more false positive results and correct treatment decisions were made in 69-84% of patients (observer 1, 76/91; observer 2, 63/91). CONCLUSION: Treatment decisions based on the pelvic examination were correct in 89%, with MRI not bringing improvement. MRI, however, is better in diagnosing extracervical spread, but at the cost of more false positives

OBJECTIVE: To analyse local tumour parameters of early cervical cancer that might be of prognostic significance for tumour relapse in the pelvis. DESIGN: Retrospective. METHOD: 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. RESULTS: 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 size > 30 mm (4.6) and depth of invasion > 10 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

A 73-year-old woman with minor intellectual skills had complaints which suggested a vulvar carcinoma. Despite her refusal she was examined and admitted to hospital, on the basis of good professional care. The psychiatrist examined her and judged her incompetent. For the operation of the diagnosed vulvar carcinoma a court ordered representative was obtained. Two months later she underwent radiotherapy to prevent local complications and pain and a few weeks thereafter she died. Because medical decision-making in a doctor-patient relationship is not always possible decision-making power should be assigned to a third party. That forms the basis of proper medical care

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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 involvement of human papillomavirus (HPV) in the development of carcinomas of the uterine cervix has been firmly established. However, other genetic alterations also play an important role in the pathogenesis of cervical cancer. Therefore, we have investigated the role of several (onco)genes in cervical carcinoma. In tumors from 136 patients with stage I and II cancer of the uterine cervix, the expression of epidermal growth factor receptor (EGFR), c-erbB-2/neu, p53, and murine double minute 2 (MDM-2) was studied using immunohistochemistry. In 32 cases, amplification of EGFR, c-erbB-2/neu, MDM-2, and c-myc was studied by Southern blot hybridization. The expression levels of these proteins were correlated with HPV positivity, International Federation of Gynecologists and Obstetricians stage, lymph node metastases, tumor diameter, vessel invasion, and disease-free and overall survival. Moderate/strong expression of EGFR was observed in 54% of tumors. c-erbB-2/neu was focally positive in 12 cases. p53 showed moderate/strong expression in 32% of the tumors. Thirteen % of tumors showed a moderate/strong expression of MDM-2, and this expression was correlated to p53 expression (P

OBJECTIVE: To determine the frequency of sexual difficulties and of sexual and physical abuse. DESIGN: Descriptive survey study. SETTING: Outpatient gynaecology clinic of the University Hospital of Leiden, the Netherlands. PATIENTS AND METHOD: During 3 months, December 1994-February 1995, all consecutive new female patients were questioned by the gynaecologist by means of a short standardised questionnaire. Oncology patients and non-Dutch-speaking patients were excluded. Data were analysed with descriptive statistical procedures; relationships among variables were tested with the chi 2 test with Yates' correction or Fisher's exact test. RESULTS: Of 325 patients 34.2% reported sexual difficulties, 15.4% reported sexual abuse and 7.4% physical molestation. Age of the patient and presence or absence of the partner during the consultation were not associated with differences in the patients' reports. 18.8% of the patients with these complaints answered affirmatively when asked if they needed specialised help. CONCLUSION: Sexual difficulties and sexual and physical abuse were common among gynaecology patients. Less than one-fifth of them required specialised help

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