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Objective: This study was undertaken to determine whether previously described significant and quantitative cervical shortening caused by loop excision of the transformation zone persists after 3 months of healing.Study Design: A prospective study was designed in which 20 patients were enrolled. Each underwent transvaginal ultrasonography for determination of cervical length before the loop excision of the transformation zone and >/=3 months after the loop excision of the transformation zone. Simple regression analysis and the Student paired t test was performed to determine whether the length of the cervix had changed significantly between the measurements.Results: The mean cervical lengths as measured by transvaginal ultrasonography before and after loop excision of the transformation zone were 3.1 +/- 0.8 cm and 3.1 +/- 0.7 cm, respectively. The correlation between ultrasonographic measurements before and after loop excision of the transformation zone was r = 0.88 (P <.0001). A paired t test resulted in a P value of 1.0000, which indicates that the ultrasonographic measurement after loop excision of the transformation zone was not different from the ultrasonographic measurement before loop excision of the transformation zone. The mean difference between measurements was 0.0 +/- 0.4 cm.Conclusion: After adequate healing time after loop excision of the transformation zone, the length of the cervix, as measured by transvaginal ultrasonography, does not appear to remain shortened. [ABSTRACT FROM AUTHOR]

Our purpose was to review reported cases of endometrial carcinoma after endometrial ablation and to evaluate high-risk factors predicting its occurrence. We present guidelines for the treatment of abnormal uterine bleeding unresponsive to medical therapy in this high-risk group of patients. Eight detailed reports on endometrial carcinoma after endometrial ablation were reviewed. The indications, methods of treatment, follow-up, and associated high-risk factors for endometrial carcinoma were analyzed. A focused list of high-risk factors for endometrial carcinoma was developed on the basis of the data collected. Guidelines were established to enable surgeons to minimize the risks of subsequent uterine cancer in women with abnormal uterine bleeding that is unresponsive to medical therapy (ie, candidates for ablation). Women who had endometrial carcinoma develop after ablation had predictive high-risk factors for subsequent neoplasia, and all eventually underwent a hysterectomy. Women with abnormal uterine bleeding and high-risk factors for endometrial carcinoma who did not respond to medical treatment may safely undergo endometrial ablation but must have a preablation biopsy indicating normal endometrium. Persistent hyperplasia unresponsive to hormonal therapy should influence the selection of a hysterectomy. Careful screening of patients before undergoing endometrial destructive procedures is prescient because minimally invasive, nonhysteroscopic ablative techniques are now emerging.

Objective: This study was undertaken to determine the urinary oxalate excretion patterns in patients with vulvodynia compared with controls and to evaluate antioxalate therapy in women with vulvar pain syndrome (vulvodynia)., Study Design: A total of 130 consecutive patients with vulvar pain syndrome and 23 volunteers without symptoms collected urine specimens for 24 hours; each voiding was saved in individual labeled containers and refrigerated. The specimens were analyzed individually for oxalate and calculated according to 24-hour concentration, volume, and peak oxalate by hour. A total of 59 patients were treated with low-oxalate diets and calcium citrate for 3 months and evaluated for objective relief of vulvar pain., Results: The 24-hour excretion of oxalate was almost identical in controls and vulvodynia patients. The total 24-hour excretion was directly proportional to the volume of urine excreted (p < 0.001). No significant differences were found in peak oxalate excretion (95% confidence intervals). The number of voidings was higher in the vulvodynia cohort (p < 0.02). The 59 women with elevated oxalate concentrations (> 1 mg/40 dl) were treated with an antioxalate regimen. Fourteen (24%) demonstrated an objective response, but only 6 (10%) could have pain-free sexual intercourse., Conclusions: Urinary oxalates may be nonspecific irritants that aggravate vulvodynia; however, the role of oxalates as instigators is doubtful.

Objective: Our purpose was to retrospectively review the intraoperative and long-term outcomes of 568 patients with abnormal uterine bleeding who were treated by endometrial ablation over an 11-year period., Study Design: From 1893 to 1994, 401 endometrial ablations were performed with the neodymium-yttrium-aluminum-garnet laser and another 167 patients were treated by electrosurgery. The majority of the patients were treated for irregular, heavy menses. Fifty-seven had ablation because of abnormal bleeding associated with a serious medical disorder, 12 with a bleeding diathesis, and 50 with morbid obesity. All patients had preoperative endometrial sampling that demonstrated benign histology. Nineteen patients had submucous myomas that were resected at the time of hysteroscopic ablation. All patients received preoperative and postoperative suppression. The minimum follow-up period was 1 year., Results: The average operative time was 32.5 minutes. The mean hospital stay was 8 hours. Four patients who received 32% dextran 70 in dextrose (Hyskon) as the distending medium had pulmonary edema postoperatively. One case of endometritis was also detected. No uterine perforations were observed. Amenorrhea developed in 58% of the patients, 34% reported light or normal menstrual flow, and 8% did not respond (continued heavy flow)., Conclusion: This study represents one of the largest published series of endometrial ablation, with a mean follow-up of 4.5 years. It demonstrates that hysteroscopic endometrial ablation is a reliable, safe alternative to hysterectomy for the surgical management of abnormal uterine bleeding.

Objectives: To establish whether bipolar scissors offer equivalent cutting performance compared with monopolar scissors and to compare extent of thermal coagulation injury using two electrosurgical generators., Design: Eighteen female rabbits' uterine horns were cut using controlled velocity at several different wattages with either bipolar or monopolar scissors. The specimens were examined microscopically and zones of thermal necrosis were measured using a stage micrometer against a 1 mm standard., Results: Bipolar scissors cut equally well compared with monopolar scissors and showed significantly less thermal injury. When coupled to a constant voltage generator both the bipolar and monopolar scissors performed better., Conclusion: Bipolar scissors offer the surgeon significant safety advantages and equivalent or better performance compared with monopolar scissors when used for laparoscopic surgery.

Thirty cervical conization specimens obtained by thin-loop electric excision were compared with 30 carbon dioxide laser excisional cone specimens. Zones of thermal artifact were measured with a precise stage micrometer technique calibrated to a Zeiss standard. The mean depth of coagulation at the ectocervical margin measured 0.187 and 0.164 mm for thin loop and laser, respectively. Thermal artifact at the endocervical margin was greater with electric loop (0.295 mm) than with superpulsed carbon dioxide laser (0.137 mm). The zones of thermal injury induced by both electric loop and laser made no significant impact on the interpretation of margin adequacy.

Objective: To determine the effectiveness of Neodymium-YAG (Nd-YAG) laser for hysteroscopic transection of the septate uterus to improve pregnancy outcome., Design: Patients treated for recurrent pregnancy loss and/or infertility were evaluated for before versus after treatment pregnancy outcomes., Setting: All patients were referred to a University Reproductive Endocrine and Infertility practice from 1986 through 1990., Patients, Participants: Nineteen patients underwent hysteroscopic transection of uterine septa after exclusion of other factors that may cause recurrent fetal wastages and/or infertility. They were allowed to conceive 8 weeks after surgery after a postoperative hysterosalpingogram. Fourteen women attempted conception during a time span of 11 to 42 months; 3 patients declined to conceive, and 2 were lost to follow-up., Interventions: Hysteroscopic transection of the uterine septum with a Nd-YAG laser was performed in all patients. The Nd-YAG laser delivered via a 600-microns bare fiber or an 800-microns sculpted fiber through operative hysteroscopy., Main Outcome Measures: To evaluate the success and complications of this new laser technique., Results: (1) Thirteen patients conceived; 10 delivered a live infant at term; (2) 87% of the postoperative pregnancies were considered successful as compared with 11% preoperative; (3) complications included a small perforation of the uterus (no treatment needed) and development of uterine adhesions (1 case only)., Conclusions: Hysteroscopic metroplasty with the Nd-YAG laser is a valuable alternative new technique for the treatment of uterine septum.

Hyskon hysteroscopy fluid is used with the hysteroscope as an aid in distending the uterine cavity and in visualizing its surfaces. We correlated the amount of Hyskon used during hysteroscopy with both the instillation pressures generated within the uterine cavity and with serum levels of Hyskon in 11 healthy subjects. Serum levels in excess of 1000 mg% were measured at 30 min when an amount of Hyskon greater than 300 mL was used. Intrauterine Hyskon absorption and/or injection during hysteroscopy were found even after volumes of Hyskon as small as 50-100 mL were used. Serum levels were significantly higher with the larger amounts of Hyskon used in ablative procedures (P less than 0.01), as compared with serum levels seen with the smaller amounts of Hyskon used for diagnostic procedures. The injection pressures should be low to minimize the amount of intravascular injection. In cases in which extensive ablative procedures are necessary, we suggest that a two-stage procedure be considered. Because of the hypertonicity of Hyskon, intravascular volume expansion that may be larger than that seen during transurethral prostatectomy occurs.

Thin loop electrosurgical conization of the cervix was performed in 30 women, using a selective double excision (SDE) technique in order to conserve cervical tissue. The entire excisional cone was completed within 4 minutes, and blood loss was estimated at 5 ml or less. All cervices healed in patterns identical to CO 2 laser conizations. Critical tissue margins were easily identified by the pathologist. Compared to simple loop excisional cones, SDE saved greater than 2 cm3 of cervical stroma.

Sixteen pregnant women with genital condylomata acuminata were treated with laser vaporization to assess effectiveness, complication rate, and impact on recurrence. Patients were treated at a gestational age of 13-35 weeks. No recurrences occurred before delivery. Five patients experienced uterine contractions before 37 weeks. Only one delivery before 37 weeks may have been attributed to the laser therapy. Four recurrences were detected during postpartum follow-up. Laser vaporization is a safe and effective treatment for condyloma during pregnancy. It is effective in maintaining a lesion-free state during pregnancy, but postpartum recurrences are not rare.

Eight patients underwent carbon dioxide (CO 2) laser excision of benign cervical tumors during a 5-year period. Six patients had symptoms of abnormal vaginal bleeding, and 2 had asymptomatic cervical masses. All but one procedure was performed as outpatient surgery. Blood loss was minimal in 7 patients and less than 50 ml in the other patient. There were no cases of morbidity, and long-term follow-up showed excellent results. The technique to perform CO 2 laser excision of large benign cervical tumors is described.

Between 1976 and 1981, 412 women with biopsy-proven cervical intraepithelial neoplasia (CIN) were treated by means of the carbon dioxide laser. A previous publication reported the author's initial therapeutic results with laser surgery for CIN, carried out between 1976 and 1978. This report includes data on 297 patients who were followed for 6 months to 5 years after laser vaporization and on 55 women treated by laser excisional cone. Major improvements in the technique of carbon dioxide laser vaporization evolved as experience was gained, and related to elimination of the entire squamocolumnar junction, to destruction of neoplastic tissue to a depth of 5 to 7 mm, and to utilization of power densities greater than 1000 watts/cm2. Cures were achieved in 285 of the 297 patients treated by vaporization, ie, the failure rate was 4% (52 of 55 women treated by excisional cone). Complications during this study were minor and usually correlated with delayed bleeding. One patient developed cervical stenosis following laser excisional cone. No patient was found to have invasive carcinoma after laser surgery to the cervix. Because laser vaporization and laser excisional cone are best adapted for the outpatient setting, financial savings accruing to the patient are considerable. Rapid healing, minimal pain, and a general absence of noxious symptomatology also promote early return to work and daily routines.

The Cavitron ultrasonic surgical aspirator was used for cytoreduction in ten patients with intra-abdominal malignancy (nine ovarian and one fallopian tube). The mean age was 65 years, and eight patients had stage IIIC disease. Standard surgical techniques were used to resect the adnexa, uterus, and omentum. The Cavitron was used to remove disease from the diaphragm, spleen, stomach, and small bowel without resection or injury. These nongenital viscera would have required resection using surgical techniques for cytoreduction. The mean Cavitron surgical time was 49 minutes. Cytoreduction by the Cavitron facilitates tumor removal and reduces the requirement for nongenital visceral resection.

Complications associated with the use of the carbon dioxide laser in 624 gynecologic patients are presented. Bleeding and pain were the most common side effects of this new modality. Although bleeding occurred in 63 patients, it was considered minor, i.e., requiring no treatment in 56 women. Pain was rather mild and could be dealt with easily by allowing heat buildup to dissipate. Only one laser accident was observed in the entire series. Interestingly, scar formation, e.g., cervical stenosis, was essentially nonexistent. Similarly, no infections were reported. The carbon dioxide laser compares favorably to conventional treatment methods insofar as complications are concerned; however, if future complications are to be avoided, careful training in CO2 laser technology must precede clinical use of the instrument.

Rigid carbon dioxide wave guides measuring 300 to 500 mm in length and 3.0 mm in diameter were evaluated in rabbits and humans. The wave guide provided an effective laser delivery system for operative laparoscopy. The tested guide was introduced into the abdominal cavity alternatively via the operating channel of a 9-mm operating laparoscope, through the central channel of a smoke evacuation/irrigation cannula, or via a 3.25-mm second puncture trocar. In contrast to previously tested flexible guides, the rigid device transmitted a visible helium-neon aiming beam, power up to 50 watts, and a beam diameter of less than 1 mm. The hollow guide was kept free of smoke by-products by continuous purging with carbon dioxide gas flowing at 800 to 1000 cc per minute. All wave guides could be sterilized by ethylene oxide gas or Cidex (Surgikos, Arlington, TX) soaking. Fourteen women with a variety of reproductive disorders underwent laser laparoscopy. The rigid wave guide was fired at distances ranging from less than 1 mm to 30 mm from the target and performed with maximal impact at distances of 3 to 5 mm. Perhaps the greatest advantage of this system is its ability to focus-defocus while directly coupling to the handpiece of standard lasers and requiring no special alignment procedures.

A flexible, hollow fiber measuring 1.5 mm diameter was used in conjunction with the laparoscope to deliver a CO2 laser beam to the rabbit uterine horn. The fibers tested consistently transmitted 5 to 15 W of laser power without loss of input mode. Several fiber-to-target distances were evaluated from the standpoint of crater characteristics. Microscopic sections were studied, and crater heights and widths were quantified. All lesions produced by the CO2 laser fiber closely mimicked those delivered by the free-hand piece or micromanipulator. In two chronic experiments, rapid fibrosis and "filling in" of the craters was evident at 5 days. No adhesions were observed. The CO2 laser fiber has several advantages over current techniques for the performance of laser laparoscopy as well as over alternative systems, e.g., neodymium:yttrium-aluminum-garnet(ND:YAG) and argon-coupled fibers. The CO2 laser fiber will further increase the options available to the gynecologist for operative endoscopy.

The effect of pulsed CO2 laser treatment on tissue reaction and fertility was evaluated. The left uterine horn was cut with a pulsed CO2 laser in 16 rats. In eight other rats, the left uterine horn was cut with microscissors. The anastomosis in both groups was accomplished by microsurgical techniques. The adhesions were mostly filmy after laser treatment, as compared with thick adhesions in the conventional group. Absence of adhesions was found in 62.5% and 50% of the laser and conventional surgery group, respectively. Histologically, some degree of fibrosis in the muscularis layer of the uterine horn was seen in the conventional group, whereas proper muscle continuity was seen in the laser-treated group. The pregnancy rates were 81% and 87.5% in the laser and conventional groups, respectively.

A significant number of patients with severe pelvic endometriosis are at risk of developing pelvic adhesions and/or loss of ovarian function. Although numerous surgical techniques have been advocated, none has any clear advantage over the others. This article presents a new surgical method for conservative management of pelvic endometriosis. The CO2 laser, directed via the microscope or the freehand piece of the articulated arm, was utilized to vaporize focal endometrial implants, to excise endometrial cysts, and to lyse pelvic adhesions in 54 patients. Fourteen of 23 patients (60.8%) attempting pregnancy have conceived at the time of this report. The observed advantages of laser surgery for endometriosis are a bloodless field, precision destruction (vaporization), precision cutting, and the ability to treat poorly accessible areas.

One hundred twenty patients with cervical intraepithelial neoplasia who were treated by laser excisional conization were compared with a group of 100 women who had similar diagnoses and were treated by laser vaporization. Every operation in the series was performed in the outpatient surgical unit or in the office. In two thirds of the cases the procedures were carried out with the patients under local anesthesia. The parameters studied included time required to perform the procedure, immediate and delayed bleeding, postlaser stenosis, healing time, patient discomfort, persistence or recurrence of disease, and risk of invasion. The results of this study revealed few disadvantages to performing a laser excisional procedure. Immediate and delayed complications were less frequent with laser excisional conization. The time required to perform an excisional conization was on the average only 4 minutes longer than that for a vaporization. Most significantly, the laser excisional cone provides a large and excellent specimen for the pathologist to review.

Two women undergoing intrauterine surgery with the neodymium:yttrium-aluminum-garnet laser delivered by the artificial sapphire tip had catastrophic cardiovascular collapse during operation. In each case the evolution of clinical events was consistent with the diagnosis of air embolus. Investigation of causative factors links the use of the sapphire tip and the gaseous cooling of the tip to the calamitous outcomes. Both women died.

Viral venereal infections caused by herpes simplex virus 2 and papillomavirus (wart) are epidemic diseases in the United States. Unfortunately, these two infections have eluded conventional therapy to date. Therefore, 306 women were treated for viral venereal diseases with the CO2 laser. Two hundred twenty-eight patients were treated for condyloma acuminatum and 78 for genital herpes. All the patients who underwent treatment for herpes were enrolled in an investigative protocol. Since the viral organisms of both diseases replicate in either the basal or prickle cell layers of the epithelium, deep laser treatment is not necessary; treatment to a depth of 1 to 2 mm is adequate. The average power densities ranged from 311 to 660 w/cm2. Herpes patients responded with relief of pain and elimination of viral infectivity for that cycle. Patients with primary herpes were "cured" in 83% of cases. C. acuminatum could be eliminated with the CO2 laser in virtually every woman.

Experiences with unselected intrapartum fetal monitoring in the 3-year period from 1972-1974 are compared with those of the 3 preceding years before monitoring was instituted. The effect of monitoring all laboring patients is correlated with a significant decrease in the perinatal mortality and a significant increase in the cesarean section rate. There were 16 intrapartum deaths during the period before monitors were used compared to only 1 intrapartum death in the period when monitors were used. The advantages and disadvantages of unselected electronic monitoring are discussed. The importance of education of medical and paramedical personnel necessary for intense intrapartum care is emphasized.

Condylomata acuminata virus accounts for a significant number of venereal infections in the western world and constitutes a major public health problem. Unfortunately, conventional therapeutic measures have given inconsistent and largely unsuccessful results for the elimination of genital warts. A 3.5-year experience with 110 women using the carbon dioxide (CO2) laser for evaporation of viral warts is presented. Six patients (5.5%) developed recurrent lesions and were retreated. Several patients were staged for 2 or 3 treatments because of extensive condylomata; this occurred especially during pregnancy and other altered states of immunity. The principal advantages of CO2 laser therapy are precision, which results in sparing of normal tissue; probable elimination of the infective agent; and rapid healing without scar formation. Sixty-three patients had atypical cytology associated with condylomata acuminata; this finding suggests an association with lower genital tract neoplasia.

Abdominal wound disruption occurred in 6 cases in a series of 2500 consecutive abdominal laparotomies. A prospective study of 900 laparotomies utilizing polyglycolic acid suture material and the Smead-Jones closure technic was carried out over a period of 1 year with a reduction in the incidence of wound disruption from 0.4 to 0.1%. Etiologic factors placing patients in a high-risk category for disruption are identified, and specific prophylactic measures are discussed. Prevention of catastrophic disruption is advocated because of its high mortality rate, averaging 20%.

The sequelae of long-term inhalation of carbon dioxide laser smoke on 10 white rats were studied in a three-phase experiment. The fine particulate matter resulting from tissue vaporization was deposited in the animals' alveoli, which produced congestive interstitial pneumonia, bronchiolitis, and emphysema. The pathologic findings induced by laser plume are not dissimilar to those resulting from the long-term inhalation of other types of particulate matter. Use of an efficient smoke evacuator should offer substantial protection against these normal effects.

The CO2 laser produces a highly directional and collimated light beam that may be precisely focused to a fine point. Because the laser beam physically removes tissue by vaporization, causes little damage to neighboring cells and seals small vessels, a minimum amount of suture material is required and scar formation is reduced. Although the laser has been utilized commonly in recent years to treat lower genital tract pathology, its application to intraabdominal surgery is in the early developmental phase. Special adaptations of the operative microscope and special accessory instruments are necessary before the laser can be used within the abdominal cavity. One hundred twenty-one cases are described to illustrate the technique and use of the laser for infertility surgery and for the treatment of pelvic endometriosis.

A method of laparoscopic sterilization using an elasticated silicone ring is described. It was used in 155 patients over a period of 13 months by 12 gynaecologists. There were 12 complications specifically related to the method and only one of them required laparotomy. One tubal patency was discovered, but no pregnancy occurred in a total follow-up period of 81-25 years. Many patients had pain in the first 24 hours after operation but only 3 per cent had pain after three months.

Contact hysteroscopy is a new endoscopic technique that allows direct examination of the uterine cavity. The procedure is performed using ambient room light, which is collected by a special light trap incorporated into the body of the instrument. The mechanism for gathering and transmitting light eliminates the need for any electric connections whatsoever. The optical design enables the examiner to see the endocervix and endometrium even in the presence of bleeding. Neither gas nor liquid media are required for observations since the uterine cavity is not distended. An initial appraisal of 80 women with the contact hysteroscope proved successful from the standpoint of technical simplicity, diagnostic accuracy, and absence of complications.