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A proximally migrated ureteral stent into the renal pelvis is an uncommon problem that poses a difficult technical challenge. A 32-year-old woman had her ureteral stent inadvertently dislodged into the renal pelvis at the time of stent exchange. The stent was successfully retrieved and repositioned transurethrally with a snare fed through the left ureter and into the renal pelvis. This is a relatively noninvasive method of retrograde retrieval of a proximally dislodged ureteral stent.

Vulvar intraepithelial neoplasia and VAIN present unique challenges to the practicing gynecologist. VIN may produce distressing symptoms and undergo malignant conversion. A high index of suspicion and liberal use of biopsy are required to make the diagnosis. The approach to therapy for VIN has been reviewed. Treatment should be tailored to each individual patient and may include a period of expectant observation. Variations and combinations are used whenever necessary to preserve normal function and anatomy. Frequent surveillance is a must because recurrence rates are high, especially with multifocal disease in young women. Although VAIN accounts for less than 0.5% of lower genital tract neoplasia, the frequency of its detection is increasing, especially in younger patients. These lesions are most commonly found in the upper third of the vagina and are often multifocal in nature. The close proximity of the upper vagina to the rectum, bladder, and ureters makes treatment difficult. The occult invasion rate may be as high as 28%, and a wide variety of therapies are available. As is true for VIN, recurrence is not uncommon.

Objective: The aim of this study was to report our experience with Stamm gastrostomy for postoperative gastric decompression on a gynecologic oncology service., Methods: This was an observational study over the 9-year period ending in October 2000. A 24 French MIC gastrostomy with the Stamm technique was used. Criteria for a gastrostomy are outlined in the text and tubes placed for palliation were excluded. Patients were followed to determine length of open drainage, time to removal, related complications, and those who may have benefited., Results: A total of 167 patients had 174 nonpalliative gastrostomy tubes placed. Nine percent of the patients had related complications with a major complication rate of 2%. Overall, approximately one-third of the patients appeared to benefit from the gastrostomy tube., Conclusion: The results support the safety and efficacy of the MIC gastric tube in patients undergoing extensive gynecologic cancer surgery which is likely to impact the function of the gastrointestinal tract., (Copyright 2001 Academic Press.)

Objective: Our objective was to review our experience with carcinoma of Bartholin's gland relative to treatment and oncologic outcome., Methods: Patient names were collected from our vulvar cancer database for the period September 1985 to September 2000. The medical records were retrospectively reviewed, and data were abstracted relative to demographics, presenting symptoms, treatment, and oncologic outcome., Results: We treated 12 women with Bartholin's gland carcinoma, and 11 patients are reported. Seven women presented with a painless vulvar mass, and 8 of 11 had initially been treated for an infectious process before referral to our institution. Squamous histology was most common, and the right gland was more frequently involved. Ten patients were treated with primary surgery, followed by adjuvant radiation in 7 for inadequate resection margins or lymphatic metastases. One patient was treated with primary chemoradiation. Stage I, II, III, IVA, and IVB disease was present in 3, 1, 4, 2, and 1 patient, respectively. Recurrence was suffered by 54.5% during a mean follow-up time of 73.5 months (median, 60; range, 8-180 months). Overall survival is 58.3% to date., Conclusions: Conventional therapy for Bartholin's gland carcinoma yielded a 67% 5-year survival. Seventy-one percent of women receiving adjuvant radiotherapy recurred despite this precaution. Work is needed to identify an effective systemic therapy and to better determine which patients may benefit from pelvic radiotherapy., (Copyright 2001 Academic Press.)

Objective: We report our experience with a technique for planning the final vaginal caliber and location of the vaginal apex in patients with severe vaginal prolapse., Study Design: During the 2-year period ending April 1998, the technique was used in all 27 patients who were undergoing vaginal repair of prolapse performed by Mitchel S. Hoffman, MD, and who desired to retain the vagina but required at least partial excision. The major steps included determination of sites for lateral apical support, definition of the desired introital caliber, marking of the measured lateral vaginal flaps, excision of the intervening epithelium (and uterus if present, n = 14), high peritoneal closure, closure of the anterior vaginal wall, placement of apical supporting sutures, and completion of closure with tying of supporting sutures. Small flaps were designed for the 8 patients who did not anticipate further sexual intercourse., Results: The only intraoperative complication was hemorrhage >1000 mL in 3 patients. Immediate anatomic results were considered excellent for 26 patients. The only early postoperative complication was hemorrhage in a patient being treated with an anticoagulant; she responded to conservative management. Follow-up was available for 24 patients (21-42 months of follow-up; mean, 29 months). All patients had complete relief of prolapse symptoms. Anatomic results remained excellent for 21 of the 24 patients; in the remaining 3 patients asymptomatic grade 2 cystoceles developed at 6 to 12 months. Three patients had new urinary symptoms that persisted. Nine patients resumed sexual intercourse, with no difficulties noted., Conclusion: Defining the vaginal apex and designing lateral vaginal flaps facilitate the precise creation of an anatomically and functionally appropriate vagina, with reasonable morbidity, good symptomatic relief, and mild alteration of surrounding organ function.

Objective: To assess the accuracy of intraoperative lymph node palpation for identifying lymph node metastasis in gynecologic malignancies., Methods: We prospectively evaluated 126 women who had lymphadenectomies for staging of various gynecologic malignancies from August 1995 to June 1997. Surgeries were done by obstetrician-gynecologists with subspecialty certification in gynecologic oncology from the American Board of Obstetrics and Gynecology, who had practiced gynecologic oncology for at least 5 years. Data were collected on gynecologic oncologists' opinions of lymph node status by palpation. Nodes believed to be positive were sent separately. We recorded operating time for lymphadenectomies, and intraoperative and postoperative complications., Results: Mean (range) patient age was 55 (18-83) years. Mean (range) operating time was 188 (85-435) minutes. The mean (range) lymphadenectomy time was 46 (5-150) minutes. The total number of lymph nodes dissected was 2138. One hundred seven of 2138 (5%) nodes were positive for malignancy. Thirty-eight of 107 (36%) positive lymph nodes were missed by palpation. Fifty-six of 2031 (3%) negative lymph nodes were selected as positive. Sixty-nine of 107 (64%) positive lymph nodes were identified correctly. Sensitivity and specificity of palpation were 72% and 81%, respectively. The positive and negative predictive values of lymph node palpation were 56% and 89%, respectively., Conclusion: Intraoperative lymph node palpation has low sensitivity and positive predictive value even when done by experienced board-certified gynecologic oncologists.

Objective: To evaluate the utility of the deep circumflex iliac vein as a landmark for the caudal limit of external iliac lymphadenectomy for early cervical cancer., Methods: During dissection of the distal (caudal), anterior (ventral) aspect of the external iliac vessels in conjunction with radical hysterectomy for carcinoma of the cervix, a careful search was made for the deep circumflex iliac vein. Lymph nodes immediately above this vein were sent as adjacent and lymph nodes caudal to the vein were sent as distal. The distance from the vein to the femoral canal was measured., Results: Seventy-one women were studied over 40 months. Fifty-five had squamous cell carcinoma, 15 had adenocarcinoma, and one had adenosquamous carcinoma. The mean distance from the deep circumflex iliac vein to the femoral canal was 16 mm. Sixty-three patients had dissections distal to identified deep circumflex iliac veins and 49 (77%) of these had distal lymph nodes removed. The median number of pelvic lymph nodes removed was 24 (range nine to 68), and the median number of distal lymph nodes removed was 1.0 from each side. Lymph node metastases were found in 13 women (18%). One subject with multiple macroscopically positive nodes had a single positive distal lymph node. Thus, a small number of distal lymph nodes were found in most women with early invasive cervical cancer, and 8% of those with positive nodes had involvement of this nodal group., Conclusion: The deep circumflex iliac vein was an appropriate landmark for the caudal limit of external iliac lymphadenectomy.

Objective: We sought to report our experience with injury of the rectum during vaginal surgery., Study Design: A retrospective chart review of a vaginal surgery database was performed., Results: Nine injuries were identified. Four patients with posthysterectomy vault prolapse incurred a rectal laceration just above the perineum during an attempt to develop the rectovaginal space. Another rectal laceration occurred just above the perineum during an attempt to develop the rectovaginal space during vaginectomy-hysterectomy for gender dysphoria. Three other injuries occurred between the vaginal cuff and peritoneum while posterior culdotomy for vaginal hysterectomy was attempted. The remaining injury was in a Schuchardt incision. All 9 injuries were recognized, repaired, and healed without complication., Conclusions: Laceration of the rectum is an uncommon complication of vaginal surgery. Prompt recognition and repair result in uncomplicated primary healing.

BACKGROUND: Many oncologists regard endometrial cancer as a relatively benign and easily treatable gynecologic tumor. Inadequate care can result in poor outcomes. METHODS: The authors review the epidemiology and pathology of the disease, and they compare disease characteristics and outcomes of FIGO staging with their own 11-year experience at a tertiary referral center. RESULTS: Patients referred to tertiary referral centers tend to present with more advanced stages of disease than those reported by FIGO, although the profile of histologic types is similar. CONCLUSIONS: Prevention and early detection of endometrial cancer can minimize the impact of this disease. Complete staging and tumor removal including extrafascial hysterectomy with bilateral salpingo-oophorectomy, pelvic lymphadenectomy, and selective paraaortic lymphadenectomy are the cornerstones of surgical therapy.

Purpose: The aim of this study was to measure the radial occult microscopic spread of tumor in patients with invasive squamous cell carcinoma of the vulva., Materials and Methods: In the operating room the gross tumor border was marked. The pathologist took a radial section in each quadrant and measured the distance of occult lateral spread of the tumor., Results: From 7/01/93 to 6/30/96, 24 tumors from 21 patients were studied. The mean maximum tumor diameter was 3. 2 cm (0.5-7.0) and the mean depth of invasion was 9.1 mm (1.1-28.0). The gross and microscopic extent correlated in 20 tumors. Maximum lateral microscopic extent of the other 4 tumors was 3.5, 5 (to the margin), 10, and 16 mm. These 4 tumors were ulcerative and infiltrative and arose from or involved mucosa., Conclusion: The gross and microscopic periphery of most invasive squamous vulvar cancers are approximately the same. Ulcerative tumors with an infiltrative pattern of invasion which involve mucosal epithelium may be more likely to extend beyond what is grossly apparent. Measurement of the tumor-free margin should be included in future studies., (Copyright 1999 Academic Press.)

A prospective, randomized study of patients undergoing radical hysterectomy for gynecologic malignancies was undertaken from 10/95 to 11/96 to determine if ligation of the hypogastric arteries at the time of radical hysterectomy decreases blood loss. Patients were randomized to either ligation of the hypogastric artery (Group 1) or no ligation (Group 2) prior to a standard Piver type III radical hysterectomy. Surgeries were performed by Board certified gynecologic oncologists with gynecologic oncology fellows and/or OB/GYN residents. Patients were analyzed for demographic characteristics and intraoperative and postoperative parameters. Statistical analysis was performed with independent samples t-test, Mann-Whitney rank sum test, Chi square and Fisher exact test. Twenty-one patients were randomized to group 1 and 22 to group 2. Groups were similar with respect to demographics and preoperative parameters except for age. There were no differences among the groups with respect to intraoperative and postoperative parameters. The mean estimated blood loss for group 1 was 600 ml and 550 ml for group 2 (P = NS). Hypogastric artery ligation (HAL) at the time of radical hysterectomy for gynecologic malignancy does not reduce blood loss.

Background: Identification of sentinel lymph nodes may allow prediction of metastatic disease in cancer patients. We did a prospective study to determine whether lymphazurin dye could identify sentinel lymph nodes in patients with cervical, uterine, and vulvar cancer., Methods: In 33 patients having surgery for either uterine, cervical, or vulvar carcinoma, lymphazurin dye was injected into the respective organs before the tumor and node dissection began. Sentinel lymph nodes were identified and dissected in situ., Results: The identification rate of sentinel lymph nodes was 0/8 (0%) for uterine cancer patients, 2/13 (15.4%) for cervical cancer patients, and 9/12 for vulvar cancer patients (75%)., Conclusions: In a limited number of patients, lymphazurin day may be useful in identifying or assessing the sentinel nodes draining vulvar and cervical cancers. The role of this procedure in treatment planning for patients with gynecologic malignancies is yet to be determined.

Objective: This article reports our experience with minilaparotomy hysterectomy., Study Design: Minilaparotomy was defined as a skin incision < or = 6 cm in length. From January 1, 1996, to June 30, 1997, data were collected on all patients who underwent hysterectomy by means of a minilaparotomy., Results: During the study a total of 250 hysterectomies were performed. Twenty-six of those were performed by means of a minilaparotomy. The mean age of the patients was 54 years. Seven had endometrial cancer and 8 had an adnexal mass. In 1 patient the incision was extended for staging of an ovarian cancer. The only intraoperative complication was rupture of a 6-cm ovarian tumor. After operation, 2 patients had febrile morbidity, 1 had a prolonged ileus, and in 1 atrial fibrillation developed. The mean uterine weight was 123 g. Median day of Foley catheter removal and mean day of ambulation, regular diet, and discharge were 1 day, 1.2 days, 2.4 days, and 3.4 days, respectively., Conclusion: Minilaparotomy is a safe and feasible route of hysterectomy for a selected group of patients.

Objective: We evaluated the effects of coliform endotoxin on the circulating levels of atrial natriuretic factor and renal function. To understand the direct effects of endotoxin in the release of atrial natriuretic factor by cardiac tissue, studies in isolated rat atria were performed., Study Design: In vivo studies were used. Anesthetized dogs were studied, with one group receiving isotonic saline solution (n = 6) and the other group receiving 50 microg/kg of coliform endotoxin (n = 7) as a continuous infusion over a 4-hour period. Cardiovascular parameters, renal function, and circulating levels of atrial natriuretic factor were measured at specified time intervals. In another set of experiments with in vitro studies left atria from Sprague-Dawley rats were isolated and perfused. In the control group (n = 9) the standard Krebs perfusate was used. In the endotoxin group (n = 9) coliform endotoxin was added at a concentration of 250 microg/mL to the standard perfusate. Atrial pressure was used as an index of stretch, and atrial natriuretic factor was measured from the perfusate., Results: Administration of endotoxin resulted in decreased blood pressure (P < .05) with a concomitant increase in heart rate. Renal artery flow, however, showed an increase (P < .05) initially followed by a return to its baseline value, with a sustained increase occurring in the saline solution control group. A significant (P < .05) and sustained increase in the circulating levels of atrial natriuretic factor after endotoxin infusion did not prevent the decrease in fractional sodium excretion (P < .05) and creatinine clearance despite an increase in the urinary output. Serum sodium, serum potassium, and osmolalities, however, remained relatively stable. The study pertaining to isolated atria showed that in the presence of low atrial pressures, addition of endotoxin had no significant effect on the release of atrial natriuretic factor. With the increase in atrial pressure atrial natriuretic factor release was significantly higher in the group directly exposed to endotoxin compared with the control group., Conclusions: These studies demonstrate that the slow infusion of coliform endotoxin results in increased circulating levels of atrial natriuretic factor. This increase is in part due to the direct effect of endotoxin on the heart as indicated by studies in isolated atria. Our data suggest that atrial natriuretic factor in endotoxemia acts in an integrative manner with other hormones on a variety of target organs to modulate cardiovascular function and fluid balance.

Background: The authors evaluated the impact of body mass on survival and morbidity of patients with new International Federation of Gynecology and Obstetrics (FIGO) Stage IB1 and IB2 cervical carcinoma managed with radical hysterectomy., Methods: Two hundred twenty-nine patients with Stage IB1 or IB2 cervical carcinoma treated with radical hysterectomy were studied in a multivariate logistic regression analysis. The body mass index (BMI) and the ponderal index (PI) were used as measures of body mass and were analyzed as predictors of recurrence, survival, and complications in light of the new staging system., Results: Twenty-seven of 229 patients died of recurrent disease. A low BMI or a high PI were predictive of poor survival. Tumor greatest dimension, lymph node involvement, BMI, and PI were all independent predictors of survival (P=0.0006). The only independent predictor of complications was para-aortic lymph node dissection (P=0.0026)., Conclusions: Cervical carcinoma patients with a low body mass, as indicated by a low BMI or a high PI, were found to have poor survival after undergoing radical hysterectomy. Additional predictors of poor survival included lymph node metastases and increased tumor size. BMI and PI are more important predictors of survival than the new FIGO Stages IB1 and IB2. Body mass is not predictive of complications.

Colonoscopy is routinely performed with conscious sedation. We wanted to determine if colonoscopy can be successfully completed without sedation and to assess patient tolerance and acceptance. One hundred nine consecutive patients undergoing colonoscopy were examined. The risks and benefits of colonoscopy with or without sedation were explained in a standard format. Patients were then given the option of having colonoscopy without premedication. After the procedure, as well as 2 to 5 days later, patients rated on an analog scale (0, no pain; 5, severe) the severity of pain and willingness to undergo colonoscopy in the future without sedation. Eighty patients underwent colonoscopy without prior sedation. Only 6% (n=5) required sedation to complete the examination. When questioned, 5% experienced no pain, 41% slight or mild pain, 34% moderate pain, and 20% severe pain. Seventy-three percent (n=58) were willing to undergo repeat colonoscopy without sedation, 10% (n=8) were undecided, and 18% (n=14) would request sedation. Pain severity was a strong predictor (p=0.001) of future sedation preference. Colonoscopy without sedation may be completed successfully in most patients and does not undermine many patients' willingness to undergo a similar procedure in the future. Sedation by choice is more cost-effective, may be safer, and should be offered as an alternative to routine intravenous sedation.

Congenital duplication of the tricuspid valve is a rare condition. We present a case of a 32-year-old man with an increase in intensity of a long-standing heart murmur and intermittent palpitations. The murmur was evaluated by transthoracic and transesophageal echocardiography that identified a mass in the right ventricle and right ventricular outflow tract resulting in partial obstruction of the right ventricular outflow tract. This mass was determined to be congenital duplication of the tricuspid valve by histologic examination after surgical excision.

Primary esophageal lymphomas are extremely rare. We report a primary esophageal T cell lymphoma of the diffuse large cell type in a patient with AIDS and review other published data. Although rare, the diagnosis should be considered in patients with dysphagia, weight loss (with or without hematemesis), and endoscopic findings of masses, polyps, or ulcerations that are especially unresponsive to antifungal therapy or antiviral therapy or both. Repeat endoscopy with biopsy may be needed to establish the diagnosis properly.

Objective: To identify sentinel lymph nodes using intraoperative lymphoscintigraphy., Methods: Technetium-99-labeled sulfur colloid was injected at the site of primary vulvar carcinoma. An intraoperative gamma counter was used to identify one or more sentinel lymph nodes., Results: Ten patients underwent bilateral inguinal and femoral lymphadenectomy. The clinical stages are as follows: T1 in 6, T2 in 2, and T3 in 2. A total of four groins (3 patients) were positive for metastases. In one patient only the sentinel node was positive for disease. In a second patient, two unilateral nodes were positive for disease and both were identified with the gamma counter as sentinel nodes. In the third patient, a single sentinel node was positive for malignancy in each groin. Multiple nonsentinel lymph nodes were positive in each groin in this patient. In no case was the sentinel node negative when other nonsentinel nodes were positive., Conclusion: Intraoperative lymphoscintigraphy quantitatively identifies one or more sentinel lymph nodes. Since sentinel lymph nodes can be localized transcutaneously, this technique may be useful for selective lymphadenectomy. Larger patient accrual is necessary to verify this technique., (Copyright 1997 Academic Press.)

Our experience with gynecologic oncology patients presenting preoperatively with a deep vein femoral thrombosis is reported. Over a 3-year period data were collected on all patients at the University of South Florida (USF) requiring surgery for a known or suspected gynecologic cancer and having a concomitant active femoral venous thrombosis. Twelve such patients were managed. Management was divided among three options: heparinization, preoperative inferior vena cava (IVC) filter, and intraoperative IVC ligation. For two patients a filter could not be placed preoperatively due to tumor compression of the IVC. Both underwent IVC ligation intraoperatively. One of the two died intraoperatively, possibly related to pulmonary embolism. One of eight with a preoperative IVC filter had obvious clot propagation postoperatively, managed with heparin. One of two managed with heparin only had severe bleeding and heparin-associated thrombocytopenia (HAT) preoperatively. Based on our experience and a review of the literature, we recommend therapeutic heparinization and a preoperatively placed IVC filter for most preoperative gynecologic oncology patients with femoral deep venous thrombosis.

Measurement of creatinine clearance remains in convenient because of the need for 24-hour urine collection. Our study compared creatinine clearance calculated from serum creatinine (CC alpha) to measured creatinine clearance (MC alpha) using an unsupervised 8-hour urine collection at home. Forty-two women admitted to our gynecologic oncology service participated in this study. Twenty-six of these patients had cancer originating from the ovaries, 8 from the uterus, 7 from the cervix, and 1 from the fallopian tube. There were adequate data for 61 collections. MC alpha using unsupervised 8-hour urine collection at home correlated well with CC alpha. This calculated value may be sufficient to be used as a guide in evaluating renal function in patients with gynecologic malignancy. However, if it becomes necessary to measure creatinine clearance, our data suggest that an 8-hour collection may be used.

Over a 13-year period, intraabdominal packing has been used to control massive hemorrhage during surgery for gynecologic malignancy in six patients. Five patients had undergone total pelvic exenteration and one total abdominal hysterectomy with bilateral salpingo-oophorectomy for endometrial cancer. Massive hemorrhage was defined as infusion of more than 10 units of blood and replacement of more than one total blood volume. Tamponade was performed using continuous Kerlex rolls (Kendall Co., Boston, MA) in a bowel bag with directed pressure over the hemorrhaging site with abdominal closure. The packs were removed in 48 to 72 hr in the operating room, transabdominally in five patients and transvaginally in one. One postoperative death occurred within 8 hr of surgery. The packing was ultimately successful in the five remaining patients. In five of six patients, tumors were removed before the packing, whereas in one, the tumor was removed concurrently with the pack. In one patient, immediate repacking was required after pack removal, with ultimate hemostasis. Morbidity included "empty pelvis syndrome" in four patients, neuropathy in three (obturator in 1, sciatic in 2), and small bowel obstruction in one. In patients with severe intraoperative hemorrhage, intraabdominal packing has been successful as a mode of treatment.

Two hundred twenty-nine patients with Stage IB cervical cancer treated with radical hysterectomy were assigned to the new FIGO substages IB1 (n = 181) and IB2 (n = 48) based on clinical tumor diameter. Our purpose was to determine the impact of the new staging system for IB1 and IB2 cervical cancer on nodal status and survival. Additionally, we analyzed the morbidity of radical hysterectomy in light of the new staging system. The complications were similar between the two groups. Para-aortic lymphadenectomy was the only independent predictor of complications (P = 0.00026). Stage IB2 patients did have a significantly worse 5-year survival (72.8%) when compared with IB1 (90.0%) (P = 0.0265). Multivariate stepwise logistical regression analysis indicated that the new staging system did not have an independent impact on survival. Stage acts through nodal status in its impact on survival. Positive lymph nodes, tumor diameter, and Ponderal Index are all independent predictors of survival (P = 0.0001). Patients with Stage IB2 carcinoma of the cervix undergoing radical hysterectomy showed no significant increase in morbidity when compared with patients with Stage IB1 disease treated with the same procedure.

When patients with gynecologic malignancies undergo exploratory surgery, hepatic lesions suggestive of malignancy are occasionally encountered. In 18 patients undergoing laparotomy for gynecologic cancer, visible liver lesions suggestive of malignancy were biopsied with the loop electrosurgical excision procedure (LEEP). Hemostatic suture placement was required in 3 of these 18 patients, and in 15, hemostasis was achieved with electrocautery only. Three of the 18 biopsies (16.7%) were positive for malignancy. No intraoperative or postoperative complications were attributed to the liver biopsy. One patient required postoperative transfusion of 2 units packed red blood cells. A new technique is described using the LEEP to remove suspicious lesions during exploratory laparotomy in patients with gynecologic malignancies.

Two hundred patients with stage IB carcinoma of the cervix were treated with radical hysterectomy. We evaluated the impact of recurrence interval on survival and determined its relationship to other prognostic factors. Thirty-one patients (15.5%) had recurrence, with a median follow-up of 2.8 years (range, 1 to 5 years). Multivariate analysis, using the Cox proportional hazard regression model, showed the impact of recurrence interval on survival and its relationship to other prognostic factors. Patients were 19 times more likely to die during follow-up if recurrence occurred shortly after the operation. However, the risk of death from recurrence decreased exponentially as recurrence interval increased, by a multiple of 0.93 m where m is recurrence interval in months. We conclude that in patients with stage IB carcinoma of the cervix treated initially with radical hysterectomy, the shorter the recurrence period after operation, the greater the likelihood the patient would die during 5-year follow-up. This information may help clinicians determine a patient's prognosis after confirmed recurrence.

Objective: To investigate the morbidity and results of vaginal hysterectomy with concomitant sacrospinous colpopexy for uterovaginal prolapse., Study Design: An observational study was carried out from June 17, 1986, to September 22, 1992. Patients were selected if it was thought that the cardinal-uterosacral ligaments could not be relied upon for vaginal vault support., Result: During the study period, 265 vaginal hysterectomies were performed. Forty-five (17%) were with concomitant sacrospinous colpopexy. The mean patient age was 54 years. There was one incidental cystotomy during hysterectomy, and two patients required transfusion. Postoperatively, eight patients were treated for soft tissue infection, one developed new-onset urinary incontinence, and no apparent nerve injuries were diagnosed. The mean day of discharge was 4.4. Six patients were lost to follow-up after the early postoperative period. The mean follow-up for the remaining patients was 29 months (12-66). One patient required subsequent vaginal repair for recurrent cystocele and enterocele. Four patients had persistent stress urinary incontinence., Conclusion: Sacrospinous colpopexy at the time of vaginal hysterectomy is reasonably safe and effective for reestablishing upper vaginal support.

We evaluated the therapeutic value of sequential cyclical hormonal therapy (megestrol acetate, and tamoxifen citrate) plus single-agent chemotherapy (carboplatin) in the outpatient management of advanced or recurrent endometrial cancer. Carboplatin (300 mg/m2) was administered every 4 weeks for six courses or until disease progression. In addition, patients alternated megestrol acetate (80 mg orally twice daily) with tamoxifen citrate (20 mg orally twice daily) every 3 weeks. Thirteen of 18 (72.2%) patients were considered evaluable. Four patients (30.8%) had a complete response, six (46.2%) had a partial response, one (7.7%) had stable disease, and two patients (15.4%) progressed. Six of seven patients with vaginal disease responded. The median progression-free interval was 14 months for complete responders. Two patients (15.4%) are alive with no evidence of disease at 41 and 59 months. Seven of 13 patients experienced a hematologic toxicity (six grade 2, one grade 3); all resolved within 2 weeks. Dose reduction of carboplatin to 200 mg/m2 was required in one patient. No other toxicities were encountered. The median survival for all patients is 11 months, and is 33 months for complete responders. We conclude that a regimen of carboplatin plus sequential hormonal therapy shows promise in this pilot study for the treatment of advanced or recurrent endometrial cancer.

The purpose of this study is to report our experience with weekly intramuscular methotrexate for nonmetastatic gestational trophoblastic disease. Treatment was begun at a dose of 40 mg/m2 and escalated weekly by 5-10 mg/m2, depending upon response and tolerance, to a maximum dose of 60 mg/m2. Remission was induced with weekly intramuscular methotrexate alone in 12 (60%) of 20 patients in 2-12 (median 8) weeks. The remaining 7 patients had a complete response to alternate chemotherapy. There were no major toxicities. Although the results of the present study are less favorable in terms of response, the overall published results using weekly intramuscular methotrexate for nonmetastatic gestational trophoblastic disease indicate that it is comparable in efficacy to other first-line treatments while having the advantages of convenience, low cost, and low toxicity.

Invasion and metastasis require the destruction of the extracellular matrix and basement membranes to facilitate growth or migration of tumor cells into vascular and lymphatic spaces. These processes are mediated by proteolytic enzymes. Malignant cells produce urokinase which is a protease known to enhance the invasiveness of many tumor cells. The relationship between urokinase and various prognostic factors was investigated in 16 patients with epithelial ovarian cancer. Tissue concentrations of urokinase were measured in tumor cytosols using enzyme-linked immunoassays. Urokinase levels were lower in ovarian tumors of low malignant potential (median 9.5, range 3.5-18.3 pg/mg protein, n = 4) than invasive cancers (median 44.6, range 16.1-210.6 pg/mg protein, n = 12), p < 0.01. In the invasive carcinomas urokinase levels did not vary significantly with tumor stage or cell type. Grade 3 tumors had higher levels of urokinase (median 120.4, range 21.4-397.1 pg/mg protein, n = 6) than grade 1 and 2 tumors (median 29.2, range 16.1-51.8 pg/mg protein, n = 6), p < 0.05. Urokinase levels were higher in recurrent (median 120.4, range 51.8-210.6 pg/mg protein, n = 4) than in primary (median 29.2, range 16.1-97.1 pg/mg protein, n = 8) tumors, p < 0.05. These results support the hypothesis that urokinase plays a role in invasion and metastasis of ovarian epithelial cancers and suggest that tissue levels of urokinase may have prognostic value.

Cancer of the cervix is one of the leading causes of cancer-related deaths in women in the United States and accounts for more cancer deaths than any other cancer in third-world countries. Various screening procedures have been developed, but many issues need to be resolved for cervical cancer screening to be effective. Large segments of the population who do not undergo regular screening account for most of the patients with invasive cancers in the United States and worldwide. Allocation of resources and widespread educational programs for these target populations are needed to promote adequate cytologic screening programs and to reduce the death rate from squamous carcinoma of the cervix.

Objective: To determine whether plasma atrial natriuretic factor (ANF) levels are different in patients with gynecologic malignancy compared with those in healthy, nonpregnant women, and if differences do exist, whether chemotherapy plays a role., Methods: We compared the plasma levels of ANF in nonpregnant women free of malignancy (group 1, n = 25) and in patients with malignancy receiving at least one course of platinum-based chemotherapy (group 2, n = 32). To differentiate the contributory role of chemotherapy, another group of patients (group 3, n = 18) was studied before the initiation of chemotherapy., Results: The ANF values (mean +/- standard error [SE]) in groups 1, 2, and 3 were 7.3 +/- 0.3, 13.8 +/- 0.8, and 14.6 +/- 1.8 fmol/mL of plasma, respectively. Significant differences (P < or = .001) occurred between groups 1 and 2 and 1 and 3, but not between 2 and 3. In comparing groups 2 and 3 for a specific type of cancer, there were no significant differences. The respective values (mean +/- SE) for endometrial, ovarian, and cervical cancer before chemotherapy were 9.9 +/- 1.7, 15.05 +/- 2.6, and 18.5 +/- 4.3 fmol/mL. After chemotherapy, the values remained at 9.3 +/- 1.5, 15.03 +/- 1.06, and 14.6 +/- 2.2 fmol/mL, respectively., Conclusion: Plasma ANF levels in gynecologic cancer patients were significantly higher than those in healthy, nonpregnant women. Levels were higher before chemotherapy started, thus negating the idea that chemotherapy may initiate the production and release of ANF.

Postoperative ileus following gynecologic surgery can prolong hospitalization and may predispose patients to mechanical obstruction. Our objective was to study the safety and efficacy of a water-soluble, hyperosmolar, radiocontrast material in the management of postoperative ileus in patients having gynecologic surgery. Of 115 cases, 57 were studied prospectively and received water-soluble radio-opaque contrast material via a nasogastric tube if bowel function had not returned by the third day. Fifty-eight well-matched control cases were managed without this material and received a suppository on the third day. The contrast material was well tolerated. Return of bowel function, day of oral intake, subsequent postoperative recovery, and duration of hospital stay were similar in the two groups. Water-soluble, hyperosmolar, radio-opaque contrast material given on the third postoperative day was safe, but of no apparent clinical benefit in resolving ileus following gynecologic surgery.

This study was designed to examine if interleukin-12 (IL-12) can induce cytolytic function of lymphocytes from ovarian cancer patients against either an ovarian cancer cell line or their own autologous tumor cells. Lymphocytes were obtained from the peripheral blood or ascites of ovarian cancer patients and activated with IL-12 alone or concomitantly with interleukin 2 (IL-2) for 2 to 3 days. Activation of lymphocytes and assessment of tumoricidal function by a chromium release assay were performed directly in a standard control medium (RPMI 1640 containing 2 mM glutamine, 100 micrograms/ml streptomycin, 100 units penicillin, 5% heat-inactivated human AB serum, and 5 mM 4-(2-hydroxyethyl)-1-piperazinesulfonic acid) and in 50% ascitic fluid (50% by volume filter-sterilized ascites with 50% of the above-mentioned control medium). Target cells were added directly into the medium in which the lymphocytes were activated in order to more closely mimic in vivo conditions. Lymphocytes, activated by IL-12 in 50% ascitic fluid, were able to lyse autologous tumor cells in 3 of 6 assays and were able to lyse SKOV3 cells (an ovarian cancer cell line) in 5 of 7 assays. The results were not significantly different in the control medium. When both IL-2 and IL-12 were used to activate lymphocytes in 50% ascitic fluid, significant cytotoxicity was generated in 6 of 6 autologous assays and in all 7 patient assays using SKOV3 as a target (P < 0.05). Synergy between the two cytokines was seen in all 13 patient assays in ascitic medium compared to only 5 of 13 assays in control medium. Additionally, when lymphocytes were stimulated with both IL-2 and IL-12, significantly greater cytotoxicity was seen in the ascitic fluid medium compared to the control medium in 13 of 14 assays (P < 0.05). No significant tumoricidal activity was seen by lymphocytes maintained in either medium without the addition of IL-2 or IL-12. Ascitic fluid consistently potentiates the synergy between IL-2 and IL-12 in generating cytotoxicity against ovarian cancer cells but does not increase cytotoxicity induced by IL-12 alone. IL-12 by itself activates tumoricidal activity of lymphocytes in ascitic fluid; however, the addition of IL-2 increases the degree and consistency of this effect. These data support the possibility that IL-12 may warrant further investigation as a potential therapeutic agent in the treatment of advanced ovarian cancer.

A pilot study was conducted assessing the operative feasibility, complications and results of a retropubic bladder neck suspension performed through a transvestibular approach. This study extended from July 1, 1990, to June 30, 1991, and included patients who planned to undergo primary surgical correction of stress urinary incontinence. Through a transvestibular incision, a bladder neck suspension was performed by suturing the adjacent area of the vagina to the back of the pubic symphysis or the puborectalis muscle near the pubic bone. Ten women were entered into the study. There was one notable complication, a hematoma in the space of Retzius. One patient described worsening of her incontinence and underwent a Marshall-Marchetti-Krantz procedure three months postoperatively. The mean follow-up for the remaining nine patients was 27 months (range, 13-31). At this writing, 6 patients were completely continent, 1 was improved, and 2 had some degree of bladder instability with associated incontinence. Overall, the transvestibular procedure was thought to be technically difficult. Based on very limited data, the results of the study have discouraged our continued use of this procedure. The transvestibular approach may be applicable occasionally on selected patients.

During 1993, four persistent groin lymphocysts were diagnosed following inguinal lymphadenectomy for the management of gynecologic cancer. All four were successfully managed by a scheme involving active drainage combined with compression. Patient details and specifics of the suggested management scheme are outlined in the text.

Eleven patients undergoing inguinofemoral lymphadenectomy for carcinoma of the vulva had the femoral vessels covered with Dura Film (Codman, Randolph, MA); a total of 21 groins were explored. The Dura Film was sutured to the inguinal ligament, sartorius muscle fascia, and adductor longus fascia. Nine of the 21 groins became infected with 3 of these breaking down; each of these 3 required removal of the Dura Film to achieve satisfactory healing. One patient developed a unilateral inflammatory groin mass requiring surgical removal of the Dura Film. One patient developed a chronic draining sinus that required surgical intervention. Seven groins developed lymphocysts. The morbidity was high with 9 of the 11 patients experiencing complications. Coverage of the femoral vessels with Dura Film after inguinofemoral lymphadenectomy is not an effective alternative to human dura mater or sartorius muscle transplant.

This is an evaluation of our experience with colorectal reanastomosis on a gynecologic oncology service. A retrospective review was carried out on all patients who underwent colorectal resection and reanastomosis on the gynecologic oncology service from October 1, 1987 to September 30, 1992. Thirty-nine procedures were performed: Nine patients underwent sigmoidectomy alone, 20 also underwent cytoreduction, and 10 also underwent exenteration. Thirty-eight percent of the patients had undergone prior radiotherapy. The level of anastomosis above the anal verge was 3-5 cm in 9 patients, 6-9 cm in 20 patients, and 10-14 cm in 10 patients. Sixteen had a protective colostomy which included 13 of the 15 patients with prior radiotherapy. Thirteen of the protective colostomies were taken down, although three of these required a second permanent colostomy. Three other patients required colostomy at a later date, one of whom developed a rectovaginal fistula 10 days following exenteration for postradiation recurrent carcinoma of the cervix. A total of 30 of the 37 evaluable patients (81%) had an ultimately functional colorectal reanastomosis. Problems related to colorectal function included stricture (4), fistula (4), chronic diarrhea (3), tenesmus (1), and fecal incontinence (1). Colorectal anastomosis is a worthwhile endeavor in selected patients with gynecologic cancer.

The pudendal thigh is a sensate fasciocutaneous flap supplied by the posterior labial artery. We report on the results of pudendal thigh flaps used for vaginal reconstruction in eight patients at the time of pelvic exenteration (6) and radical vaginectomy (2). Patients were interviewed and results were assessed 5 to 19 months after surgery. The flaps were raised in the thigh creases just lateral to the hair bearing area of the labia majora and included skin, subcutaneous tissues, deep fascia of the thigh, and the epimysium of the adductor muscles. Flap sizes varied from 9 x 4 cm to 15 x 6 cm. Bilateral flaps were used in seven patients. The flaps were technically easy to perform. Partial (apical) flap necrosis occurred in four patients. One patient developed complete necrosis of bilateral flaps, followed by an enterovaginal fistula. One patient whose flaps did not necrose developed a rectovaginal fistula at the site of rectal reanastomosis. The functional results are disappointing. The only patient having successful vaginal intercourse had a unilateral flap reconstruction following lower vaginectomy in a nonirradiated pelvis. No patient with bilateral flaps or prior pelvic irradiation has had successful coitus. Other long-term sequelae include vulvar pain (2), chronic vaginal discharge (2), hair growth (4), and protrusion of the flaps (2). These vulvovaginal symptoms discourage patients and their partners from genital contact. Breaching the integrity of the vulva to construct a neovagina that is likely to be unsuitable for sexual intercourse may deprive women of their only potential for normal genital sexual responsiveness. Techniques of vaginoplasty require continued assessment.

Separate vulvar and groin incisions have significantly reduced the morbidity of vulvar cancer surgery. We describe a patient with FIGO stage II squamous vulvar cancer, who developed an ipsilateral tumor recurrence in the skin bridge between the vulva and the groin within 7 months of modified radical vulvectomy and bilateral inguinofemoral lymphadenectomy, using triple incisions. The recurrence was treated by wide local excision alone and she remains free of disease 2 years later. Although rare, the potential for failing to excise tumor emboli in the lymphatics of the skin bridge must be recognized when the triple incision technique is used in the surgical treatment of vulvar cancer.

Objective: The purpose of this study was to compare the intraoperative and postoperative complications of transvaginal morcellation and abdominal hysterectomy for the removal of moderately enlarged uteri., Study Design: An observational study was performed on all uteri weighing > 200 gm removed transvaginally from July 1, 1987, to June 30, 1993. An abdominal hysterectomy control group was selected., Results: There were 50 patients in the vaginal group and 112 in the abdominal group. At a p value < 0.05 there was no statistically significant difference between the two groups for age, parity, obesity, hypertension, insulin-dependent diabetes mellitus, or prior genitourinary surgery. The mean operative time in the vaginal hysterectomy group was 122 minutes and in the abdominal hysterectomy group 148 minutes (p < 0.05). The mean estimated blood loss was 527 and 586 ml, respectively (not significant). Twenty-two percent of the vaginal group and 70% of the abdominal group underwent bilateral oophorectomy (p < 0.05). The mean uterine weights were 335 and 336 gm, respectively (not significant). The mean day of starting a regular diet was 2.1 and 3.6, respectively (p < 0.05). The mean day of discharge was 3.6 and 5.1, respectively (p < 0.05). Complications were similar for the two groups., Conclusions: In selected patients transvaginal morcellation is a safe and effective alternative to abdominal hysterectomy for the removal of moderately enlarged uteri. The two procedures are comparable in operative time, blood loss, and complications. Both ovaries are more likely to be removed with abdominal hysterectomy. Cosmesis and recuperation may be advantages of the vaginal approach.

In order to prevent the complications of long-term nasogastric suctioning and increase patient comfort, we have been using gastrostomy tubes (G-tubes) in gynecologic oncology patients who are deemed to be at risk for protracted postoperative bowel dysfunction. This study describes our patient selection criteria and evaluates the results with 35 MIC (Medical Innovation Corporation, Milpitas, CA) gastrostomy tubes inserted between September 1, 1992 and April 30, 1993. The procedure is technically easy and adds approximately 10 min to operating time. The tubes were well tolerated by the patients over periods ranging from 5 to 135 days. All tubes were used for postoperative gastric drainage and in addition, eight tubes were used for short-term enteral feeding. One patient with short bowel syndrome continued enteral nutritional supplementation at home. Twenty patients were discharged with their G-tubes in situ. Five of these patients required continuous gastric drainage because of obstruction of gastric emptying or small bowel by advanced tumor, and four of them were taking full liquids orally prior to discharge from the hospital. Gastrostomy tubes are convenient adjuncts to postoperative care of the gynecologic oncology patient and afford palliation with few complications to patients dying with bowel obstruction.

There have been five previous well-documented cases of metastatic vulvar basal cell cancer in the literature. We now present the sixth case-an 86-year-old patient with vulvar basal cell cancer metastatic to an ipsilateral groin node. She was treated with radical vulvectomy and bilateral inguinofemoral lymphadenectomy and remains free of disease 1 year later.

There is a demand on gynecologic oncology services for semipermanent cannulization of central veins to improve the quality of life in cancer patients by circumventing the need for frequent peripheral venous punctures. Central venous thrombosis and sepsis are the major complications with these lines. We reviewed our experience with the externalized Groshong catheters and subcutaneously implanted Hickman ports in 104 gynecologic oncology patients requiring either chemotherapy (56), hyperalimentation (5), or supportive care (43). All devices were inserted under the supervision of one primary gynecologic oncologist. Groshong catheters and Hickman ports remained in place for a median of 68.5 and 210 days, respectively (P < 0.001). Thrombosis occurred in association with 4.8% of catheters and was exclusive to the Groshong catheters. Line sepsis occurred in 32% of Groshong catheters and 16.2% of Hickman ports (P = 0.04). Infection rates were not higher in dual-lumen compared to single-lumen Groshong catheters. Staphylococcus epidermidis was the comments isolate in line infections. The majority of lines were salvaged despite infectious complications. Malfunction of the catheter was equally common in both groups (10.5-13.5%), but was complete, necessitating replacement of only 2.9% of lines. The Groshong catheters took less time to insert (P < 0.003). The externalized Groshong catheter remains a useful alternative to the subcutaneously implanted ports, especially when relatively short-term use is anticipated, but gynecologic oncologists should be aware that there is an increased frequency of complications with the externalized catheter.

From January 31, 1990 to November 15, 1991, I treated three patients by cesarean hysterectomy with cervical conization for cervical neoplasia. All three hysterectomies were facilitated by the use of a combined abdominal-vaginal technique, which is described in this report.