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Background: In 2017, the Dutch cervical cancer screening program had replaced the primary cytology-based screening with primary high-risk human papillomavirus-based screening, including the opportunity to participate through self-sampling. Evaluation and balancing benefit (detection of high-grade cervical intraepithelial neoplasia) and burden of screening (unnecessary referrals, invasive diagnostics, and overtreatment) is needed., Objective: This study aimed to compare the referral rates, detection of high-grade cervical intraepithelial neoplasia, overdiagnosis, and overtreatment in the new high-risk human papillomavirus-based screening program, including physician-sampled and self-sampled material, with the previous cytology-based screening program in the Netherlands., Study Design: A retrospective cohort study was conducted within the Dutch population-based cervical cancer screening program. Screenees with referrals for colposcopy between 2014 and 2015 (cytology-based screening) and 2017 and 2018 (high-risk human papillomavirus-based screening) were included. Data were retrieved from the Dutch Pathology Registry (PALGA) and compared between the 2 screening programs. The main outcome measures were referral rate, detection of high-grade cervical intraepithelial neoplasia or worse, overdiagnosis (cervical intraepithelial neoplasia grade 1 or less in the histologic specimen), and overtreatment (cervical intraepithelial neoplasia grade 1 or less in the treatment specimen)., Results: Of the women included in the study, 19,109 received cytology-based screening, and 26,171 received high-risk human papillomavirus-based screening. Referral rates increased from 2.5% in cytology-based screening to 4.2% in high-risk human papillomavirus-based screening (+70.2%). Detection rates increased to 46.2% for cervical intraepithelial neoplasia grade 2 or worse, 32.2% for cervical intraepithelial neoplasia grade 3 or worse, and 31.0% for cervical cancer, and overdiagnosis increased to 143.4% with high-risk human papillomavirus-based screening. Overtreatment rates were similar in both screening periods. The positive predictive value of referral for detection of cervical intraepithelial neoplasia grade 2 or worse in high-risk human papillomavirus-based screening was 34.6% compared with 40.2% in cytology-based screening. Women screened through self-sampling were at higher risk of cervical intraepithelial neoplasia grade 2 or worse detection (odds ratio, 1.38; 95% confidence interval, 1.20-1.59) and receiving treatment (odds ratio, 1.31; 95% confidence interval, 1.16-1.48) than those screened through physician-sampling., Conclusion: Compared with cytology-based screening, high-risk human papillomavirus-based screening increases detection of high-grade cervical intraepithelial neoplasia, with 462 more cervical intraepithelial neoplasia grade 2 or worse cases per 100,000 women but at the expense of 850 more cases per 100,000 women with invasive diagnostics indicating cervical intraepithelial neoplasia grade 1 or less., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Surgical treatment for pediatric skin disorders is used for diagnostic and therapeutic reasons. We underline these procedures are usually easy and uncomplicated without the need for general anesthesia. Objective of this study was to share our experience in the field of pediatric dermatologic surgery., Methods: We retrospectively analysed records of all pediatric patients receiving surgical therapy at the Dermatology Department of Spedali Civili of Brescia. Demographic data and treatments characteristics were recorded and analyzed., Results: During the study period of one year, 670 surgical treatments concerning pediatric patients were collected. Number of procedures progressively grows with increasing age. All treatments were performed under local anesthesia except for a dermatofibrosarcoma protuberans for which general anesthesia was needed., Conclusions: Our data show that cryosurgery, electrodessication and excisional surgery constitute with equal proportion almost the whole of surgical procedures in dermatologic pediatric patients. Dermatologist's habit to perform surgery in local anesthesia avoids the risk of overtreatments, limits discomfort, anxiety, and pain perception linked to procedures performed.

Background: Only a few small studies have compared the 2-step method (biopsy followed by treatment) with a see-and-treat (immediate treatment) approach in women both low-grade or high-grade referral cytology. The clinical practice variation in the Netherlands has not been reviewed before., Objectives: To determine overtreatment rates in the 2-step versus see-and-treat approach in women referred for colposcopy because of abnormal cytology results, and to evaluate clinical practice variation in the Netherlands., Materials and Methods: This was a population-based retrospective cohort study including 36,581 women with a histologic result of the cervix identified from the Dutch Pathology Registry (PALGA) between 2016 and 2017. Odds ratios for overtreatment, defined primarily as cervical intraepithelial neoplasia grade 1 or less, were determined for the 2-step and see-and-treat approach in relation to age, high-risk human papillomavirus status, and referral cytology., Results: Of the included women 10,713 women (29.3%) received the 2-step method; 6,851 women (18.7%) underwent see-and-treat; and 19,017 women (52.0%) received conservative management after colposcopy with histologic assessment with cytologic follow-up or another type of treatment. Despite the existence of a national guideline advising see-and-treat only in case of suspected high-grade disease in women who have completed their childbearing, there is a wide practice variation between the 2 strategies in the Netherlands, with 7.0-88.3% of the women receiving see-and-treat per laboratory. The median time between cytology and treatment was 1-2 months (range, 0-12 months) in women receiving see-and-treat and the 2-step method, respectively. A total of 4119 women (23.5%) were overtreated, with older women, high-risk human papillomavirus-negative women, and women with low-grade cytology results being more likely to be overtreated. Women with low-grade cytology results and see-and-treat were associated with a higher overtreatment rate than women receiving the 2-step method (65.0% [1414 of 2174] versus 32.1% [1161 of 3613], respectively; odds ratio, 3.34; 95% confidence interval, 2.92-3.82). However, in women with high-grade cytology results, see-and-treat was inversely associated with overtreatment (11.3% [529 of 4677] versus 14.3% [1015 of 7100], respectively; odds ratio, 0.68; 95% confidence interval, 0.58-0.81)., Conclusion: A see-and-treat approach is justified only in women with high-grade cytology results who have completed their childbearing. There is a wide practice variation between the 2 strategies in the Netherlands, and gynecologists should adhere to the guideline to prevent overtreatment., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: The aim of the study was to determine which women require loop electrosurgical excision procedure (LEEP) or cervical conization (cone) to exclude cervical cancer after colposcopy for evaluation of abnormal cervical cancer screening tests yet before simple hysterectomy., Materials and Methods: Review of electronic medical records from colposcopy clinics followed by chart review of women with cervical cancer was conducted., Results: Of 18,537 cervical colposcopies for evaluation of abnormal cervical cancer screening tests, 0.6% (103/18,537) had cervical cancer; of 103 women with cervical cancer, 57 had neither cervical biopsy nor endocervical curettage (ECC) showing cancer or rule-out cancer (occult cancers) and were diagnosed by subsequent LEEP (n = 22), cone (n = 31), failed cone (n = 1), or hysterectomy (n = 3). The relative risk of occult cervical cancer at colposcopy for ECC of cervical intraepithelial neoplasia (CIN) 2 or CIN 3 versus ECC not CIN 2 or CIN 3 was 51.5 (5.0% vs 0.1%), for cervical biopsy of CIN 3 versus not CIN 3, was 34.5 (3.9% vs 0.1%), and for colposcopic impression of CIN 2, CIN 3, or cancer (CIN 2+) versus impression not CIN 2+, was 8.5 (1.9% vs 0.2%). If the 10.9% (2,018/18,537) of colposcopies with ECC of CIN 2 or CIN 3, cervical biopsy of CIN 3, or colposcopic impression of CIN 2+ had subsequent LEEP or cone, 96.5% (55/57) of occult cervical cancers would be detected before hysterectomy., Conclusions: After colposcopy, women with ECC of CIN 2 or CIN 3, cervical biopsy of CIN 3, or colposcopic impression of CIN 2+ require LEEP or cone before simple hysterectomy.

Background: There is a paucity of data on outcomes of upper tract urothelial carcinoma (UTUC) arising from the renal pelvis (RPUC) versus UTUC arising from the ureter (UUC). The published literature is conflicting, and there is no consensus on patient prognosis based on disease location. The aim of this study is to compare clinical and survival outcomes based on location of primary tumor using a large national registry., Materials and Methods: The National Cancer Database was queried from 2010 to 2016 for patients with localized (cN0M0) UTUC. Patients were stratified based on location of tumor. Survival analysis was performed using Cox proportional hazard regression and inverse probability of treatment weighting (IPTW)-adjusted Kaplan-Meier curves. We also performed exploratory analyses based on tumor stage., Results: We identified 11,922 patients who underwent surgical treatment. The median follow-up was 32.1 months. Patients with RPUC presented with higher tumor stage and grade. Patients with UUC were treated with less radical nephroureterectomy (56.4% vs. 84.3%; P < .01). IPTW-adjusted Kaplan-Meier curves demonstrated higher median overall survival for RPUC versus UUC (71.1 vs. 66.8 months, respectively; P = .01). This benefit was consistent across tumor stage subgroups, reaching statistical significance in patients with T1 disease. On multivariable analysis, ureteral location of tumor was a predictor of worse survival., Conclusion: Patients with UUC were found to be treated with less radical surgery and to have worse survival than those with RPUC. These patients may suffer from poor initial staging and suboptimal treatments. Further studies are needed to evaluate potential biological differences of UTUC based on tumor location., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: To compare the healthcare utilisation and repeat surgical treatment rate amongst older men undergoing an electrosurgical-transurethral resection of the prostate (TURP) vs photoselective vaporisation of the prostate (PVP), as the real-world implementation and outcomes of laser-based treatment have not been well studied., Patients and Methods: We used administrative data from the province of Ontario, Canada, to identify all men aged >66 years who underwent their first electrosurgical-TURP/PVP between 2003 and 2016. Our primary exposure was type of procedure (PVP or electrosurgical-TURP). Our primary outcome was need for repeat surgical treatment. The primary analysis was an adjusted marginal Cox model approach, which accounted for clustering of patients within surgeons; adjusted hazard ratios (aHRs) or odds ratios (aORs) and 95% confidence intervals (CIs) are reported., Results: We identified 52 748 men: 6838 (13%) underwent PVP, and 45 910 (87%) underwent electrosurgical-TURP. The median age was similar, and PVP became more common with time. Compared to the PVP group, more patients in the electrosurgical-TURP group had prior gross haematuria or urinary retention, and fewer had used anticoagulants, α-blockers, or 5α-reductase inhibitors. The need for repeat surgical treatment was significantly higher amongst men who had PVP (aHR 1.57, 95% CI 1.38-1.78; absolute risk difference +2.3%). PVP was also associated with a slightly higher risk of return to the emergency room within 30 days (aOR 1.11, 95% CI 1.01-1.22) and a significantly lower risk of blood transfusion (aOR 0.24, CI 0.16-0.37); the majority of PVP cases were done with a <24 h stay (73%) vs electrosurgical-TURP (7%)., Conclusions: While some of the expected benefits of PVP (such as reduced transfusion risk and shorter length of stay) were observed, the significantly higher rate of repeat surgical treatment compared to electrosurgical-TURP may represent an important difference in implementation of this technology outside of clinical trials., (© 2019 The Authors BJU International © 2019 BJU International Published by John Wiley & Sons Ltd.)

Introduction: Our aim was to investigate whether cervical conization and/or loop electrosurgical excision procedure (LEEP) increases the risk of preterm delivery. Materials and Methods: We conducted a retrospective cohort study of singleton deliveries at our institution from 2010 to 2015. Women aged 16-49 years were included in our study. Univariate and logistic regression were used for statistical analyses. An interaction test was used to assess whether maternal human papillomavirus (HPV) positivity within the 3 years before delivery (referred to as maternal HPV status in this study) is an effect modifier. Results: Of 3933 women who delivered at our institution, 19.8% ( n  = 792) delivered prematurely. Of these women, 9.1% ( n  = 362) had a history of cervical surgery, including cervical conization and/or LEEP. Notably, a history of cervical surgery was not associated with current HPV status based on the most recent Pap smear results ( p  > 0.05). In univariate analysis, a history of cervical surgery was associated with preterm delivery (odds ratio [OR] = 1.54, 95% confidence interval [CI]: 1.26-1.88). This effect was the same among mothers positive (OR = 1.95, 95% CI: 1.16-3.28) and negative (OR = 1.91, 95% CI: 1.10-3.30) for HPV. Pregnancy-induced hypertension, preterm premature rupture of membranes, bacterial vaginosis infection, HPV infection, placenta previa, placental abruption, ethnicity, maternal body mass index, nulliparity, and smoking or drug use were also associated with preterm delivery ( p  < 0.05). In multivariable analysis, history of cervical surgery remained associated with preterm delivery (OR = 1.75, 95% CI: 1.31-2.33). There was no interaction ( p  = 0.91) between maternal HPV status and history of cervical conization or LEEP. Discussion and Conclusions: Maternal history of cervical conization and/or LEEP increases the risk of preterm delivery irrespective of concurrent maternal HPV positivity within the 3 years preceding delivery. Maternal HPV status does not modify the effect of history of cervical conization and/or LEEP on preterm delivery.

Introduction: Electrosurgery is used in 80% of surgical procedures. The technique allows surgeons to skilfully dissect tissues and achieve haemostasis. Since improper use of electrosurgery can lead to serious adverse events, training is required to potentially reduce the number and severity of these events. In this study we evaluate education and training in electrosurgery for surgical residents. Material and methods: Residents from six surgical subspecialties in the Netherlands were invited to anonymously complete a digital questionnaire about training, supervision and adverse events regarding electrosurgery. Results: Of the 197 respondents, 69% had received some form of training; mostly a single theoretical lecture. The feeling of competence in theory and practical skills was positively rated by 39% and 71%, respectively. Moreover, 35% judged the theoretical knowledge of their supervisors as insufficient and 65% changed their electrosurgical application technique to the preference of the supervisor. 30% of the residents had encountered a serious adverse event (e.g., burn wounds) related to the application of electrosurgery. Conclusions: The training of residents in theoretical aspects of electrosurgery is limited. Residents are not satisfied with the acquired theoretical knowledge of themselves and of their supervisors. Since adverse events related to electrosurgery occur frequently, more extensive education for both residents and their supervisors is needed to enhance patient safety.

Introduction: Radiofrequency tissue ablation (RFTA) and transoral robotic surgery (TORS) are the methods used in OSAS surgery. We also aimed to compare the advantages and disadvantages of RF and TORS as treatment methods applied in OSAS patients in terms of many parameters, especially apnea hypopnea index (AHI)., Materials and Methods: Patients were classified by performing a detailed examination and evaluation before surgery. 20 patients treated with anterior palatoplasty and uvulectomy -/+ tonsillectomy + RFTA (17 males, 3 females) and 20 patients treated with anterior palatoplasty and uvulectomy -/+  tonsillectomy + TORS (16 males, 4 females) were included in the study. PSG was performed preoperatively and postoperatively in all patients and Epworth sleepiness questionnaire was applied. All operations were performed by the same surgeon and these surgical methods -RF and TORS- were compared in terms of many parameters., Results: When the patients treated with RF and TORS were compared in operation time, length of hospitalization and duration of transition to oral feeding; all parameters were significantly greater in the patients treated with TORS., Conclusions: TORS technique was found to be more successful than RF in terms of reduction of AHI value, correcting minimum arterial oxygen saturation value and decreasing Epworth Sleepiness Scale score.

Objective: The aim of this article was to describe the outcome of women diagnosed with cervical intraepithelial neoplasia (CIN) grades 2 or 3 in pregnancy either observed or treated by loop electrosurgical excision procedure (LEEP) in the first 15 weeks of gestation., Methods: Loop electrosurgical excision procedure during the first 15 gestational weeks compared with observation of CIN2/3. This is a retrospective analysis of a nonrandomized study at tertiary, academic, and referring centers in Israel. Ninety-three pregnant women diagnosed with CIN2/3 between 2006 and 2016 were included in this study. Fifty patients with CIN2/3 on cervical biopsy were conservatively followed-up, and 43 patients have undergone LEEP during the first 15 gestational weeks. Main outcome measures were ultimate diagnosis of invasive cancer or CIN, pregnancy outcome, and complications., Results: In 5.4% of CIN2/3 during pregnancy, the final diagnosis was invasive cancer. The postpartum results of 50 women who were conservatively observed were as follows: 3 (6.0%) had cervical cancer and undergone radical hysterectomy, 33 (66.6%) had CIN2/3, and 14 (28%) had CIN1 or normal histology. The diagnoses of the 43 patients who have undergone LEEP were invasive cancer in 2 patients (4.6%) but did not undergo hysterectomy, CIN2/3 or adenocarcinoma in situ (AIS) in 38 patients (88.4%), and 3 women (7%) had CIN1 or normal histology. None of them suffered severe bleeding. Thirty-seven women continued their pregnancy, 34 (91.9%) had term deliveries, 2 (5.4%) gave birth at 34 and 36 weeks, and 1 patient had missed abortion (2.7%)., Conclusions: The LEEP procedure during the first 15 weeks of pregnancy is safe. A total of 5.4% of the women with CIN2/3 during pregnancy were diagnosed with invasive cancer. It is time to reconsider the recommendations about CIN2/3 in early gestation.

Importance: Little is known about the long-term yield of high-grade cervical intraepithelial neoplasia (CIN) and the influence on biopsy and treatment rates of human papillomavirus (HPV) triage of cytology showing atypical squamous cells of undetermined significance (hereafter ASC-US cytology)., Objective: To examine 5-year outcomes after ASC-US cytology with vs without HPV testing., Design, Setting, and Participants: In this observational study, all cervical cytology and HPV testing reports from January 1, 2007, to December 31, 2012, were obtained for women throughout New Mexico and linked to pathology reports. The dates of the analysis were May 4, 2015, to January 13, 2017., Main Outcomes and Measures: Influence of HPV testing on disease yield, time to histologically confirmed disease, and biopsy or loop electrosurgical excision procedure rates., Results: A total of 457 317 women (mean [SD] age, 39.8 [12.5] years) with a screening test were recorded between 2008 and 2012, and 20 677 (4.5%) of the first cytology results per woman were reported as ASC-US. CIN grade 3 or more severe (CIN3+) lesions were detected in 2.49% of women with HPV testing vs 2.15% of women without HPV testing (P = .23). Time to CIN3+ detection was much shorter in those with HPV testing vs those without testing (median, 103 vs 393 days; P < .001). CIN grade 1 was detected in 11.6% of women with HPV testing vs 6.6% without testing (relative risk, 1.76; 95% CI, 1.56-2.00; P < .001). Loop electrosurgical excision procedure rates within 5 years were 20.0% higher in those who underwent HPV testing, resulting in more CIN2+ and CIN3+ detection., Conclusions and Relevance: Human papillomavirus testing led to faster and more complete diagnosis of cervical disease, but 55.8% more biopsies and 20.0% more loop electrosurgical excision procedures were performed. In those tested, virtually all high-grade disease occurred in the 43.1% of women who were HPV positive, allowing clinical resources to be focused on women who need them most. These data provide essential information for cervical screening guidelines and public health policy.

OBJECTIVE: To compare the resection margin (RM) status and postoperative severe hemorrhage using different loop electrosurgical excision procedure (LEEP) techniques for cervical intraepithelial neoplasia (CIN) 2/3 treatment. STUDY DESIGN: We retrospectively reviewed 278 patients who underwent LEEPs for CIN 2/3 treatment at our institute between 2005–2014. In type A surgery (N=148), a ring-shaped loop was used. If the first pass failed to remove the entire lesion, separate loop excisions for the intracervical portion were performed. In type B surgery (N=130), a right-angled triangular loop in a single pass was used. Surgical outcomes and postoperative severe hemorrhage were compared between the two groups. Logistic regression analysis was performed to identify the independent predictors of RM status. RESULTS: The mean LEEP depth was larger after type A surgery (2.2 vs. 2.0 cm, respectively; p=0.04). Type B surgery showed lower rate of 30-day postoperative hemorrhage (13.8% vs. 26.4%, p<0.05) and higher rate of negative RM (68.9% vs. 82.3%, p<0.05). Multivariate analysis identified the surgery type (p=0.01, OR=0.45 [0.24–0.83]) and a postoperative pathological diagnosis of CIN3 (p=0.01, OR=2.53 [1.22–5.26]) as independent risk factors for positive RM. CONCLUSION: LEEPs using a right-angled triangular loop could reduce positive RMs.

Background: There is significant variability in the perioperative management of patients with cardiac implanted electronic devices (CIEDs) undergoing procedures requiring electrosurgery., Methods: We performed a multicenter registry from February 2014 to August 2015 at three suburban Chicago hospitals. Patients with transvenous CIEDs undergoing procedures requiring electrosurgery were assigned to one of three groups: (1) reprogram, (2) magnet, or (3) no change. Subjects with implantable cardioverter defibrillators (ICDs) or those pacemaker dependent having surgical procedures within 6 inches of their CIED were assigned to the reprogram group, whereby ICD therapies were programmed off with asynchronous pacing if pacemaker dependent. Subjects with ICDs ≥ 6 inches from their surgical site but above the iliac crest were assigned to the magnet group. All others were in the no change group. We evaluated electromagnetic interference (EMI) and postoperative device reset based on surgical location., Results: All patients (n = 331) had pectoral CIEDs with mean age 73 years, 65% male, ejection fraction 56% for pacemaker subjects, 35% for ICD subjects with 22% pacemaker dependent. Assignments were n = 52 (16%) reprogram group, n = 51 (15%) magnet group, and n = 228 (69%) no change. There was EMI in 45% of thoracic cases, 35% of head/neck, 15% of upper extremity, and 3% of abdominal cases above iliac crest. There was no EMI in procedures below the iliac crest. There were no inappropriate therapies or device reset., Conclusion: Results of the ICD-ON protocol demonstrate safe and efficient management of patients with CIEDs based on electrosurgery location, with 69% requiring no reprogramming or magnet application., (© 2016 The Authors. Pacing and Clinical Electrophysiology published by Wiley Periodicals, Inc.)

Background: In the USA, the number of people needing implantable cardioverter defibrillators (ICDs) has grown dramatically. Many ICD recipients will need to undergo a surgical procedure at some point following ICD implantation. Most surgeries involve the use of electrocautery. Currently, the effects of electrocautery-induced electromagnetic interference (EI-EMI) on ICDs are poorly understood. The aim of this study was to study EI-EMI using prospectively collected clinical data., Methods: We analyzed prospectively collected ICD data from patients undergoing a surgical procedure at Mayo Clinic between 2011 and 2012. Information on clinical, device history, device interrogation pre- and post-surgery, and surgical information were collected for all patients. ICDs were programmed with detections on and therapies off. The patients were then categorized into two groups: those with EI-EMI inappropriate arrhythmia detection and those without detection. The stored electrograms were reviewed. Clinical and device parameters were analyzed to identify predictors of EI-EMI., Results: Of 103 patients studied, bipolar cautery did not induce EI-EMI (0/11 cases), whereas monopolar cautery resulted in noise detection in 11/92 procedures. Among 11 inappropriate episodes of detection, 10 had surgery at chest, neck, and upper extremity sites with cautery current across the ICD lead tip; 1 had abdominal surgery; and none had back or low extremity surgery. On average, the near-field electrogram amplitude values were greater than the far-field amplitude values., Conclusions: EI-EMI does not occur when bipolar cautery or monopolar cautery is used below the hips with the dispersive ground pad applied to the lower extremities. In contrast to external EMI, EI-EMI may be larger on near-field than far-field electrograms.

This systematic review and meta-analysis compares hysteroscopic morcellation with electrosurgical resection to treat uterine cavitary lesions. A search of Ovid MEDLINE, Ovid Embase, Scopus, and Web of Science was conducted through August 18, 2015, for randomized controlled trials (RCTs) and prospective and retrospective studies, regardless of surgical indication and study language or sample size. Seven studies were eventually included (4 RCTs and 3 retrospective observational studies), enrolling 650 women. The meta-analysis showed that the total procedure time was significantly shorter for morcellation than for resection (weighted mean difference = 9.36 minutes; 95% confidence interval [CI], -15.08 to -3.64). When reviewing RCTs only, intrauterine morcellation was associated with a smaller fluid deficit and lower odds of incomplete lesion removal. This difference was not statistically significant in observational studies. There was no significant difference in the odds of surgical complications (odds ratio = 0.72; 95% CI, 0.20-2.57) or the number of insertions (weighted mean difference = -3.04; 95% CI, -7.86-1.78). In conclusion, compared with hysteroscopic resection, hysteroscopic morcellation is associated with a shorter operative time and possibly lower odds of incomplete lesion removal. The certainty in evidence was limited by heterogeneity and the small sample size., (Copyright © 2016 AAGL. Published by Elsevier Inc. All rights reserved.)

Background: Endoscopic sphincterotomy has a higher risk of bleeding in patients with cirrhosis. Advanced Child stage and coagulopathy are well-known risk factors. We aimed to determine the role of electrosurgical currents in the development of endoscopic sphincterotomy bleeding in cirrhotic patients., Methods: The study was a retrospective observational study and included 19,642 patients who underwent endoscopic retrograde cholangiopancreatography between 2004 and 2013. The incidence of endoscopic sphincterotomy bleeding in cirrhotic patients who underwent sphincterotomy after 2009 with an electrosurgical generator applying alternating current in the pulse cut mode (Group 2) was compared with a historical control group who underwent endoscopic sphincterotomy between 2004 and 2009 via blended current (Group 1)., Results: Group 1 included 15 patients (six women, nine men, mean age: 62.2 ± 12.9 years). Group 2 included 14 patients (six women, eight men, mean age: 63.6 ± 16.9 years). There was no statistically significant difference between the demographic and clinical characteristics of the two groups. Endoscopic sphincterotomy bleeding was observed in three patients in Group 1 (two endoscopic bleeding and one clinically significant bleeding) and none of the patients in Group 2 (p = 0.77). There were no cases of perforation or pancreatitis in both groups. One patient in Group 2 developed cholangitis., Conclusions: Endoscopic sphincterotomy bleeding is less frequently observed in patients with cirrhosis who underwent sphincterotomy with alternating mixed current in the pulse cut mode compared with those with blended current.

Objective: Loop electrosurgical excision procedures (LEEPs) are negative for high-grade cervical intraepithelial neoplasia (CIN 2+) after a hematoxylin and eosin-based CIN 2+ colposcopic biopsy diagnosis in 14% to 24% of cases. This may be due to diagnostic errors or biopsy-related regression of the dysplasia. Because p16 immunohistochemical staining of cervical biopsies improves diagnostic accuracy, we hypothesized that p16-based cervical biopsy diagnoses may reduce the frequency of negative LEEPs., Materials and Methods: We performed a retrospective cross-sectional study of all cervical LEEPs completed at our institution from 2002 to 2012. We recorded patient age, sexual history, smoking history, pathologic diagnoses (including whether the diagnosis was p16 based), the number of days from biopsy to follow-up LEEP, and clinical follow-up. This yielded 593 study subjects meeting inclusion criteria of CIN 2+ colposcopic diagnoses with follow-up LEEP and 2 years of clinical follow-up. Colposcopic biopsies and follow-up LEEPs were reviewed and p16 immunostaining was performed on all samples to provide criterion standard results. Data were analyzed by χ and regression modeling., Results: Our practice employed p16 to aid cervical biopsy diagnoses by 2006. The frequency of negative LEEPs before 2006 was 12 (10%) of 126. The frequency dropped during the p16 era (2006-2012) to 23 (5%) of 467. Overall, we observed an inverse relationship between the frequency of p16 employment and the frequency of negative LEEP outcomes (R = 0.71; p < .001), independent of potential covariates., Conclusions: Our data suggest that more accurate p16-based diagnoses may reduce the frequency of unnecessary LEEPs.

Objectives: To report the overtreatment rate for see-and-treat versus 3-step conventional strategy (cervical cytology, colposcopic biopsies, then LEEP) for patients with high-grade squamous intraepithelial lesion (HSIL) cytology. Our second aim was to identify risk factors for overtreatment., Methods: We included 178 women with HSIL cytology from our university-based colposcopy clinic who underwent LEEP between 2007 and 2014. Overtreatment was defined as cervical intraepithelial neoplasia (CIN) 1 or less on LEEP specimen. Differences between treatment groups were compared using chi-square test, 2-sample t test, or Mann-Whitney rank-sum test as appropriate., Results: CIN2+ was found in 69 (80%) of women in the see-and-treat group and 69 (75%) of the conventional management group (P = 0.093), with overtreatment in 17 (20%) and 23 (25%, P = 0.403), respectively. Women who underwent see-and-treat (n = 86) were older (mean age, 36 vs 31 years; P = 0.007), and a greater proportion completed childbearing (30% vs 13%, P = 0.024). There were no differences in top hat excision; however, a higher proportion of the see-and-treat group had CIN2+ in endocervical samples (54% vs 27%, P = 0.047). Overtreatment, regardless of management strategy, was associated with age at time of LEEP, where older women were more likely to be overtreated (median age, 37 vs 32 years, respectively; OR, 1.04; 95% CI, 1.01-1.08; P = 0.011)., Conclusions: A see-and-treat strategy minimizes risk of loss to follow-up with a similar overtreatment rate compared with conventional management. With CIN2+ in some three-fourths of women with HSIL, a see-and-treat should be favored especially when adherence to follow-up is questionable.

Background: The recent evolution of surgical techniques, anesthesia and treatment strategies has led to a decrease in the number of cervical conization procedures performed in ordinary hospitalization or with anesthetics other than local infiltration anesthesia of the cervix. Conization should be as least invasive as possible, favor women's compliance and resumption of normal daily activities after surgery. We evaluated various aspects of patient care revolving around conization (technical, healthcare, and administrative aspects) in the clinical practice of 26 Italian colposcopy units., Methods: A standard multiple-choice questionnaire was used. The retrospective study covered a period of 10 years., Results: The overall number of conization procedures performed over the 10 years' observation period ranged from 20,000 to 37,500. The techniques used were the loop electrosurgical excision procedure in 79.9% of cases, CO2 laser in 16.7%, and the cold-knife biopsy in 3.4%. An outpatient regimen was reported in 62.1% of cases, a day-surgery regimen in 35.2% and an ordinary hospitalization in 2.7%. Local anesthesia, deep sedation and general anesthesia were usually performed in 86.7%, 11.9% and in 1.4% of cases, respectively. The use of prophylactic antibiotics was common only in 8% of cases. The rate of major adverse events recorded over the observed period varied between 0.04% and 0.02% (15,000-29,000 conizations)., Conclusions: The administrative regimen in which conizations are performed is an expression of behaviors of different health authorities and hospitals in relation to the costs that this procedure entails.

Objective: We sought to determine whether cervical dysplasia in the absence of an excisional procedure is associated with an increased risk of preterm birth (PTB) and whether that risk is independent of the presence of a short cervix., Study Design: This is a cohort study including women with a singleton pregnancy who underwent routine cervical length assessment between 18-23 6/7 weeks of gestation, stratified by cervical dysplasia (ie, no prior dysplasia, prior dysplasia but no excisional procedure, or prior excisional procedure). The frequency of a short cervix (≤2.5 cm) and PTB were compared between groups and multivariable analyses were performed to identify whether: (1) dysplasia alone or a prior excisional procedure was associated with PTB; and (2) whether these factors remained independently associated with PTB after adjusting for the presence of a short cervix., Results: Of the 18,528 women who met inclusion criteria, 3023 (16.3%) had prior dysplasia alone and 1356 (7.3%) had a prior excisional procedure. The frequency of a short cervix for women without dysplasia, with prior dysplasia alone, or with a prior excisional procedure was 0.8%, 1.0%, and 2.2%, respectively (P < .001). The frequency of PTB, respectively, was 6.4%, 6.5%, and 8.4% (P < .001). After adjusting for potential confounding factors, prior excisional procedure but not prior dysplasia alone was associated with PTB., Conclusion: Having a prior cervical excisional procedure but not dysplasia alone is associated with an increased risk of PTB. This association is independent of the presence of a short cervix., (Copyright © 2015 Elsevier Inc. All rights reserved.)

The World Health Organization guidelines for screening and management of cervical precancerous lesions updated in 2013 made an emphasis on the use of the 'screen-and-treat' approach for cervical cancer prevention. In order to facilitate scaling-up in low income settings, most of these screen-and-treat strategies do not involve confirmatory biopsy. This yields a certain rate of overtreatment. In other words, a majority of people undergoing screen-and-treat intervention who are treated does not necessarily benefit from the treatment. Therefore, the issue of potential short term and long term complications of the recommended treatment procedures (cryotherapy and Loop Electrosurgical Excision Procedure) arises. This question has seldom been studied in resource poor countries, particularly in Sub-Saharan Africa where Human Immunodeficiency Virus infection is rampant in an epidemic fashion and where the procreative capacities are socially rewarding for women. We draw the attention of the scientific community and policy makers to the fact that the lack of evidence supporting the safety of these treatment procedures in African populations may have an impact on the acceptability of these strategies and therefore on the effectiveness of screening programs., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: To describe the impact of previous cervical surgery on preterm birth prior to 34 weeks in twins., Methods: A retrospective review of twin pregnancies delivered between January 1998 and December 2005 at two institutions was performed. Women with a prior cold knife cone (CKC), loop electrosurgical excision procedure (LEEP), or ablative procedure were compared to a control group of women who had not undergone a previous treatment for cervical dysplasia. The primary outcome was delivery before 34 weeks of gestation., Results: A total of 876 women met inclusion criteria. Of these, 110 (12.6%) had previous surgical procedures for cervical dysplasia, including CKC (n = 10), LEEP (n = 36), cryotherapy (n = 59) and CO2 laser treatment (n = 5). Delivery prior to 34 weeks was more common in women with a previous CKC compared to women with no prior treatment (40% versus 11.3%; odds ratio [OR], 3.6; 95% confidence interval [CI], 1.7-8.0). Delivery prior to 34 weeks was not more common in women with a previous LEEP (8.3%; OR, 0.8; 95% CI, 0.3-2.3) or ablative procedure (9.4%; OR, 0.9; 95% CI, 0.4-1.9) in comparison to the untreated group. Adjusting for the potential confounders of age, tobacco use, infertility treatments and previous preterm birth did not change the results., Conclusions: Previous CKC is associated with delivery prior to 34 weeks while LEEP and ablative procedures are not. CKC should be carefully considered and avoided when possible in reproductive age women.

Study Objective: To compare operative time with use of THUNDERBEAT (TB) vs standard electrosurgery (SES) during laparoscopic radical hysterectomy and pelvic lymphadenectomy to treat gynecologic tumors., Design: Evidence obtained from a properly designed, randomized, controlled trial (Canadian Task Force classification I)., Setting: Gynecologic Oncology Unit of the Catholic University of the Sacred Heart in Rome, Italy., Patients: Fifty patients with early cervical cancer (FIGO stages IA2, IB1, IIA <2 cm) or locally advanced cervical cancer (FIGO stages IB2, IIA >2cm, IIB) who received neoadjuvant treatment (chemotherapy or radiochemotherapy) and demonstrated a complete or partial clinical response and early stage endometrioid endometrial cancer (FIGO stages IB, II) were randomly assigned to undergo TB (arm A) or SES (arm B)., Intervention: Laparoscopic radical hysterectomy with bilateral pelvic lymphadenectomy, using an easily reproducible technique was performed., Measurements and Main Results: Fifty patients were available for analysis, with 25 women randomly assigned to TB (arm A) and 25 to SES (arm B). The median operative time was 85 minutes for TB vs 115 minutes for SES (p = .001). At multivariate analysis, endometrial cancer (p = .001) and TB (p = .001) were independently associated with shorter operating time. No differences in perioperative outcomes and postoperative complications were observed between the 2 arms. Patients who underwent TB reported less postoperative pain, both at rest (p = .005) and after the Valsalva maneuver (p = .008), with less additional analgesic therapy other than standard therapy required in patients who underwent SES (p = .02)., Conclusion: TB is associated with shorter operative time and less postoperative pain than is the standard technique (SES) in patients with uterine cancer., (Copyright © 2014 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: Assessment of cytology and biopsy results preceding cervical excisional treatment and their association with excisional histology, to evaluate compliance with treatment recommendations and the potential effect of revisions in cervical histology terminology and usage., Method: Data from a unique statewide population-based screening registry was used to describe the use and histologic outcomes of cervical excisional procedures in the year following an abnormal cervical screening cytology., Results: From 2007 to 2011, LEEP rates decreased 87%, 45%, and 16% for women aged 15-20, 21-24, and 25-29 years, respectively. Reductions were attributable to an overall decline in cervical screening and colposcopy, and a decrease in LEEP following a diagnosis of less than cervical intraepithelial neoplasia grade 2 (0.7) for women aged 30-39 years. Irrespective of age, CIN2 was the most common histologic antecedent of excisional treatment (42%), with most (80%) preceded by

Background: To investigate the indications of loop electrosurgical excision procedure (LEEP) and its overtreatment rates for the see and treat and three step strategies in cases of atypical squamous cells of undetermined cytology (ASC-US) and low grade intraepithelial neoplasia (LGSIL) cytology., Materials and Methods: We retrospectively analyzed colposcopy directed biopsy (CDB) and LEEP results of 176 paients with ASC-US or LGSIL cytologies who underwent colposcopic examination., Results: Initial cytologies were ASCUS in 120 women and LGSIL in 56. According to the see and treat approach immediate LEEP was performed for38 women. Among the remaining 138 women, LEEP was performed for 32 whose CDB results revealed CIN2/3 lesions. In the see and treat group the recognition of CIN2/3 was found to be 39.4%. The overtreatment rate was 60% as compared to 25% in the three step group. In CDB group detection of CIN 2 or greater lesions increased with 3 or more biopsies., Conclusions: In patients with ASC-US/LGSIL cytologies CDB should be performed before LEEP to prevent overtreatment, with attention to all suspected areas and more than 2 biopsies taken.

Recent epidemiological data suggest an increase of the incidence and prevalence of CIN as well as a decrease of the mean age of the patients presenting these lesions. Large loop electrosurgical procedure (LEEP) is the most commonly used treatment method. According to recent studies LEEP provides a 1.4 to 7.0 fold increase of preterm delivery. Cervical cerclage does not show efficiency in reducing this risk, even if cervical shortening is measured by transvaginal ultrasound. Considering histological severity of lesions and the age of patients, number of currently conducted conizations in France could be avoided and so their obstetrical consequences prevented, just because no treatment is necessary or could be done by ablative procedures., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

This is a retrospective observational study to compare outcomes in patients with cervical intraepithelial neoplasia (CIN) treated with loop electrosurgical excision procedure (LEEP) using combined ectocervical/endocervical resection vs ectocervical resection alone. We demonstrated that additional endocervical resection during loop electrosurgical excision procedure did not significantly lower the risk of subsequent recurrence compared with ectocervical resection alone, in the treatment of CIN. With current published data supporting subsequent increased adverse effects of LEEP on future obstetrical outcomes, endocervical excision should be applied selectively. We recommend that additional endocervical excision should be reserved only for patients with a strong suspicion of underlying endocervical canal involvement based on colposcopic assessment or in patients with unsatisfactory colposcopy, where it is essential to evaluate the endocervical canal.

The objective of our study was to evaluate surgical outcome of minimally invasive vaginal hysterectomy (MIVH), using the bipolar vessel sealing system (BVSS; BiClamp®). The design was a retrospective analysis (Canadian Task-force Classification II-3). The setting was a secondary care hospital. Records of patients who underwent vaginal hysterectomy for benign indications in our centre between November 2005 and March 2011 were reviewed. The demographic patients' data, indications for surgery, patient history with regard to previous surgery, duration of surgery, blood loss (postoperative hemoglobin drop '∆Hb'), perioperative complications, and length of inpatient stay were collected from the medical records. The intervention was vaginal hysterectomy using BVSS (BiClamp®). Results showed that the mean duration of surgery was 48.9 ± 15.3 min (95% CI, 49.2-52.5). The mean duration of hospital stay was 3.2 ± 1.2 days (95% CI, 2.8-3.2). The mean ∆Hb was 1.4 ± 1.8 g/dl. Overall, conversion to laparotomy was required in three cases (0.6%). Only one haemoperitoneum occurred (0.2%) and this is the only case who required blood transfusion. The main indication for VH was uterine prolapse in 52.0% (n = 260) of cases; uterine fibroids in 37.4% (n = 187); adenomyosis uteri in 4.2% (n = 21); cervical dysplasia in 22 patients (4.4%) and in 2% (n = 10) of patients, endometrial hyperplasia and other pathologies were the indications for VH. It was concluded that electrosurgical bipolar vessel sealing by (BiClamp®) can provide a safe and feasible alternative to sutures in vaginal hysterectomy, resulting in reduced operative time and blood loss, with acceptable surgical outcomes.

Objective: To evaluate the strategy of "see and treat" by loop electrosurgical excision procedure (LEEP) for cytologic high-grade precancerous cervical lesions (squamous intraepithelial lesions; HSIL) and post-LEEP recurrence among low-income Brazilian women., Methods: In a retrospective survey of women who underwent LEEP for cytologic HSIL without prior cervical biopsy between January 2004 and March 2008 at CISVALI, União da Vitória, Paraná, Brazil, LEEP sample histology and patient follow-up by Papanicolaou smear were assessed., Results: Among 117 women treated, 24% had no lesions, 67.5% had cervical intraepithelial neoplasia (CIN) grade 2/3, and 5.2% had squamous cell carcinoma or adenocarcinoma on LEEP histology. Among patients with follow-up, recurrences occurred in those with no lesions (16.7%) and CIN 2/3 (25%) (P>0.05). HSIL was the most frequent type of recurrence (87%) (P<0.001). In total, 6.3% of patients had positive ectocervical (ecto-positive) and endocervical (endo-positive) margins, 3.8% had ecto-positive, and 33.0% had endo-positive margins. Recurrences occurred in women with endo-positive (26.3%), no margin (17.4%), and cautery artifact margin (25.0%) involvement (P>0.05)., Conclusion: For cytologic HSIL, the benefits of the strategy of "see and treat" by LEEP outweighed the risk of overtreatment. Patients with both positive and negative margins on LEEP should be followed carefully., (Copyright © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.)

Objective: To evaluate the efficacy and security of ERBE BiClamp(®) forceps in radical abdominal hysterectomy for managing those cervical cancers, extending to other gynecologic cancers such as endometrial cancer and ovarian cancer as well., Methods: A retrospective cohort study was made in 391 cases from 450 FIGO IA2-IIB cervical cancers between November 2005 and September 2010. After baseline character analysis, the conventional group (n = 195) was compared with the BiClamp group (n = 196) on the basis of surgical outcome and complications. Data analysis was based on intention to treat with statistics software SPSS17.0., Results: Comparison between conventional suture ligation and BiClamp(®) forceps is as follows: the operation time was 247.7 ± 47.7 min for the conventional suture ligation versus 224.1 ± 36.2 min (P < 0.001) for BiClamp(®) forceps, estimated blood loss was 769.2 ± 310.4 ml versus 534.8 ± 232.5 ml (P < 0.001), gauze consumption was 35.3 ± 10.6 sheets versus 28.2 ± 7.4 sheets (P < 0.001), intra-operative blood transfusion rate was 75.9 versus 28.1% (P < 0.001), hemoglobin decline was 29.2 ± 10.1 g/L versus 26.5 ± 9.2 g/L (P = 0.085), postoperative blood transfusion rate was 17.0 versus 15.6% (P = 0.818), closed suction drainage was 268.8 ± 162.0 ml versus 208.3 ± 141.7 ml (P < 0.001), hospital stay was 8.8 ± 2.5 days versus 7.1 ± 2.2 days (P < 0.001), postoperative complications was 23.6 versus 14.8% (P = 0.027)., Conclusion: With obvious decrease of operation time, blood loss, postoperative complications, hospital stay and particularly, intra-operative blood transfusion rate, BiClamp(®) forceps has been proved more efficient and controllable in radical abdominal hysterectomies of cervical cancers than conventional suture ligations, extending to endometrial cancers and ovarian cancers, hence deserves to be popularized.

Objective: To investigate whether the 2006 American Society for Colposcopy and Cervical Pathology guidelines for conservative management of minimally abnormal Pap test results (atypical squamous cells of undetermined significance, human papillomavirus-positive, and low-grade squamous intraepithelial lesions) and moderate dysplasia (cervical intraepithelial neoplasia 2) in adolescents 1) resulted in fewer colposcopies and loop electrosurgical excision procedures (LEEPs) in adolescents or 2) resulted in unintended treatment changes in older age groups., Methods: We analyzed data from 1,806 women aged 18 years and older attending one of six community health centers who were diagnosed with abnormal Pap test results between January 1, 2004, and December 31, 2008. We used multivariable logistic regression to examine treatment differences in women with minimally abnormal Pap test results before and after guideline changes. Variables included date of abnormality, site of care, race or ethnicity, language, and insurance type. We used Fisher exact tests to examine rates of LEEP in patients with moderate dysplasia before and after guideline publication., Results: Among 206 women aged 18-20 years, rates of colposcopy after a minimally abnormal Pap test result decreased from 78% (n=102) to 45% (n=34) after guideline changes (P<.001). Colposcopy among women over age 21 (n=1,542) remained unchanged (greater than 90%). Multivariable logistic regression indicated that both date of abnormality and site of care were associated with colposcopy referral. After guideline changes, management of moderate dysplasia with LEEP in women aged 18-23 decreased from 55% to 18% (P=.04); rates remained stable in women ages 24 and older (70% compared with 74%; P=.72)., Conclusion: Health care providers quickly adopted new conservative management guidelines for low-income, minority adolescents, which may reduce preterm deliveries in these high-risk populations., Level of Evidence: II.

Objective: To examine the prevalence and histology of loop electrosurgical excision procedures (LEEPs) done on women who are outside the age limits of the updated guidelines for cervical cytologic screening., Materials and Methods: A database of all LEEPs performed between October 2004 and November 2009 was created. All data on age, human immunodeficiency virus status, cytology and histology before the procedure, and histology of the LEEP specimen were collected., Results: There were 939 LEEPs performed during the study period, and data on 64 cases were excluded because of inadequate information. Fifty-four LEEPs were performed on women who were either younger than 21 years and those 65 years or older. All LEEPs were performed under traditionally accepted indications, except for 1 LEEP, which was excluded. None of the women gave a history of human immunodeficiency virus infection, and none of the older women had a history of abnormal cervical cytologic result before the index case. Of the procedures performed on the adolescents, 24 demonstrated high-grade lesions on LEEP (51.1%). Of the 6 procedures performed on older women, 4 LEEP specimens demonstrated high-grade lesions (66.7%). There were no cancers., Conclusions: We treated many women with LEEP excision who would not have been screened using current 2009 guidelines. Most of these women had high-grade lesions. The new guidelines may not be applicable to all population groups.

Aim: To summarize data for cervical loop electrosurgical excision procedures (LEEP) in Israel from 2001 to 2007 inclusive., Methods: 16 colposcopy specialists in Israel completed yearly questionnaires that assessed their LEEP., Results: Of the 2,681 LEEP reported, cervical intraepithelial neoplasia 2/3 (CIN 2/3) and CIN 1 were the main indications, with 63.2 and 20.5%, respectively. CIN 2/3 was detected in 111 (20.4%) of those for whom CIN 1 was the indication for LEEP. Of those diagnosed with CIN 2/3 following LEEP, 34.8% (426/1,225) were in the 18- to 34-year age range. The agreement between punch and LEEP biopsies was 80.15% and the κ value was 0.536 (moderate agreement). Complications included severe bleeding in 3.02% during the procedure(s) and 2.99% in the 3 weeks following LEEP., Conclusions: In one-fifth of the women for whom CIN 1 was the indication for LEEP, CIN 2/3 was the final diagnosis. More than one-third of the cases of CIN 2/3 and carcinoma were diagnosed in women under the age of 35, the age at which Pap screening is offered in Israel. Based on these findings, the Israeli Society of Cervical Pathology and Colposcopy prepared guidelines for the treatment of CIN., (Copyright © 2011 S. Karger AG, Basel.)

Objective: To estimate the risk of significant pathology from atypical glandular cell (AGC) Pap tests classified by the 2001 Bethesda system and to assess potential differences in AGC management practices between physician specialties., Methods: A chart study was conducted to assess outcomes from AGC Pap tests diagnosed during 2001-2005., Results: One hundred thirty-one AGC Pap tests were identified from 84,748 Pap tests. The incidence of AGC was 0.15%. Thirty-nine AGC Pap tests (30%) were excluded from analysis, leaving 92 AGC Pap tests from 82 patients available for review. Thirty-one of 82 women (38%) had significant pathology. Seventeen women (21%) had preinvasive disease: cervical intraepithelial neoplasia 2 or 3, adenocarcinoma in situ and endometrial hyperplasia, whereas 14 women (17%) had invasive adenocarcinomas of the endometrium, cervix, ovary, and rectum. Women who were aged 40 years or younger differed significantly from women aged older than 40 years with regard to final pathology (P = .002). Specifically, they were more likely to have preinvasive disease and less likely to have invasive carcinoma. Recommended management for AGC includes colposcopy with or without biopsy, endocervical curettage, and endometrial biopsy. Sixty-three of 82 (77%) women were managed by recommended guidelines, and there was a statistically significant difference in physician adherence when comparing gynecologists to primary care physicians (87% compared with 50%, P < .001)., Conclusion: Atypical glandular cell cytology confers a risk (38%) of either preinvasive disease or carcinoma, with the risk of carcinoma increasing significantly for women aged older than 40. Adherence to recommended AGC management guidelines is crucial to identify underlying malignancies., Level of Evidence: II-2.

Purpose of Investigation: To evaluate women with cytological high-grade squamous intraepithelial lesions (HGSIL) who received standard colposcopic evaluation and direct diagnostic large loop electric excision for the transformation zone (LLETZ) to determine the feasibility of using LLETZ alone (ie, skipping the colposcopic examination)., Methods: From May 1999 to May 2001, 70 women, with the mean age of 49.58 years (range, 20-82 years) and with cervical HGSIL categorized by the Bethesda system were all evaluated by colposcopic evaluation and LLETZ. Cases with a satisfactory colposcopy examination were classified as group A and those with an unsatisfactory colposcopy examination were classified as group B. "Over-treatment" was determined if the women did not need further LLETZ for evaluation or management. "Under-treatment" was determined if treatment might be potentially inadequate or invasive cancer could be ruled out during a satisfactory colposcopic evaluation., Results: Group A consisted of ten women who were evaluated satisfactorily by colposcopy and group B consisted of 30 women who were not evaluated satisfactorily by colposcopy. Overall 8.6% of the patients (6/70) were considered "over-treated". The rate of over-treatment was 10.0% (4/40) in group A compared with 6.7% (2/30) in group B. In contrast, overall 10% of the patients (7/70) were considered "under-treated". The rate of under-treatment was 10% (1/40) in group A compared with 10% (3/30), in group B. The positive predictive values of group A and B were 90.6% and 88.0%, respectively. The negative predictive values were 33.2% and 40%, respectively., Conclusion: Direct diagnostic and therapeutic LLETZ for the management of cervical HGSIL may be a better alternative to colposcopy. This method of treatment avoids the possibility of under-treatment and is associated with an acceptable over-treatment rate, especially for postmenopausal women with cytological HGSIL. LLETZ has a good diagnostic accuracy with minimal morbidity and, most importantly, may help reduce patient anxicty, although further studies are needed to directly examine this effect.

Objectives: To compare the long-term results of subjective changes, flowmetry, morbidity, and mortality after transurethral resection of the prostate, contact laser prostatectomy, and electrovaporization in men with lower urinary tract symptoms associated with benign prostatic hyperplasia., Methods: A prospective randomized controlled trial was conducted. Included in the study were men with lower urinary tract symptoms, who met the criteria of the International Scientific Committee on Benign Prostatic Hyperplasia, had a prostate volume between 20 and 65 cm(3), and a Schäfer obstruction grade of 2 or greater. The subjective changes were quantified using the International Prostate Symptom Score, Symptom Problem Index, quality-of-life question, and benign prostatic hyperplasia impact index. Morbidity was registered objectively and by patient questionnaire. Maximal flow was measured by free uroflowmetry. These parameters were measured at regular intervals for up to 1 year. At the end of 2002, all patients were invited for a long-term follow-up examination, including the aforementioned parameters., Results: Fifty men were randomized to undergo transurethral resection of the prostate, 45 laser treatment, and 46 electrovaporization. Of the 50 men, 70% were followed up for a maximum of 7 years. The values for the International Prostate Symptom Score, Symptom Problem Index, quality-of-life score, and benign prostatic hyperplasia impact index increased slightly after a mean follow-up of 4.3 years. The maximal uroflow decreased similarly in all treatment groups to about 150% of the preoperative values. Morbidity, reoperation rates, and mortality were also similar., Conclusions: This study, with up to 7 years of follow-up, demonstrated durable subjective and objective results for patients with lower urinary tract symptoms associated with benign prostatic hyperplasia after transurethral resection of the prostate, contact laser prostatectomy, or electrovaporization. No clinically relevant differences were found among these modalities.

Background and Purpose: We conducted a questionnaire survey concerning the prevalence and preference with regard to various types of surgical treatment for benign prostatic hypertrophy (BPH), in order to gather preliminary data that may be helpful for standardizing the surgical treatment of BPH., Method: A questionnaire survey was mailed to institutes in which a council member of the Japanese Endourology and ESWL Society was present. The questions dealt with the type and volume of surgical treatment experienced previously, and the treatments which had been performed in each institute during 2000. Preferences concerning cost effectiveness, safety, degree of invasion, efficacy, overall usefulness, and the possibility of prevalence from now on at general hospitals were also asked with regard to each surgical treatment., Results: Of the 155 institutes to which the questionnaire was sent, 70 responded (45% response rate). TUVP (transurethral vaporization of the prostate by thick-loop) was second to TURP (transurethral resection of the prostate) both regarding the volume of the surgical treatment that had been experienced previously, and the volume that had been performed during 2000. TURP was recognized as the most preferred treatment with regard to both cost effectiveness and overall usefulness, while TURF (transurethral radiofrequency thermotherapy) was preferred both for safety and reduced invasiveness, and open surgery for efficacy. Minimal invasive surgical treatment, such as TUVP, followed by ILCP (interstitial laser coagulation of the prostate) and TUMT (transurethral microwave thermotherapy) was recognized as the most preferable treatment for dealing with the prevalence from now on at general hospitals., Conclusion: Each minimal invasive surgical treatment was recognized as being safer and less invasive, but less effective and less useful compared to TURP. Among these surgical treatments, TUVP by thick-loop was recognized as being second choice to TURP with regard to efficacy and overall usefulness. As a matter of course, it would seem to be essential to evaluate long-term efficacy in addition to both safety and invasiveness when trying to standardize the surgical treatment for BPH.

Objective: To review the results of a policy decision to offer selected women with cervical high grade squamous intraepithelial lesions (HSILs) loop electrosurgical excision (LEEP) at the time of their initial colposcopic evaluation., Study Design: Sixty-one patients with newly diagnosed cytologic cervical HSIL were evaluated for inclusion in a "see-and-treat" protocol. Fifty of these patients met inclusion criteria and underwent immediate loop excision of the cervical transformation zone at their initial colposcopic visit., Results: Forty-eight of 50 patients that underwent see-and-treat management at their initial colposcopic evaluation had histologic evidence of cervical dysplasia/neoplasia. The positive predictive value of diagnostic colposcopy in this setting was 96%, with a 95% confidence interval (88-99%). Two patients had no pathologic abnormality, for an overtreatment incidence of 4%., Conclusion: The selected use of see-and-treat management of cytologic cervical HSIL is feasible, highly predictive and associated with an extremely low incidence of overtreatment. Such management has the potential to increase patient satisfaction and compliance while drastically reducing health care dollars currently directed toward the management of HSIL. Strong consideration should be given to accepting see-and-treat management as a viable alternative in the care of patients with documented cervical cytologic HSIL.

Introduction: Several surgeons use electrocautery (Bovie) discreetly or avoid it completely with the fear of increasing the chances of postoperative infection and delaying wound healing. However, the experience of many other surgeons is different. The current authors have used Bovie extensively to perform a broad array of spinal surgeries. Their rate of infection in spinal surgery can be positively compared with the existing literature where Bovie has been used to variable extent. The purpose of this study is to project the authors' concept that the use of Bovie dissection in spinal surgery does not increase the chances of postoperative wound infection., Methods: A MEDLINE search was carried out to determine various aspects of Bovie, including historical perspectives, circuit design, tissue response, effect on wound healing, determination of wound infection, and role of surgical smoke. The search also included the rate of infection after various spinal surgeries in the existing literature (up to 15%)., Materials: In the span of 5 years (1996-2000), 322 spinal surgeries of various kinds were performed at Children's Hospital Medical Center (Cincinnati, Ohio). Most of them were performed by the senior author (A.H.C.). There were 102 cases of idiopathic scoliosis (two infected [2%]), 53 cases of neuromuscular scoliosis (two infected [4%]), and 167 cases of other spinal surgeries (three infected [1.8%]). Of these seven patients who developed wound infection in the postoperative period, one had superficial and six had deep infection. The overall rate of wound infection was 2%. Development of infection elsewhere in the body after surgery, such as respiratory, pleural, or urinary tract infections, has not been included in this analysis., Results: Despite the fact that the authors have extensively used Bovie in spinal surgery, their rate of postoperative wound infection is comparable with the rate of infection cited in the available literature where Bovie was used to a variable extent. It strongly suggests that the use of Bovie does not increase the chances of postoperative wound infection., Discussion: The role of Bovie for musculoskeletal surgery in general and spinal surgery in particular is not well defined. A review of the available literature indicates that Bovie delays the wound healing and increases the chances of infection. The authors' experience with the Bovie and this indirect method of analysis suggest that Bovie does not increase the chances of infection. A detailed search of the literature has been presented along with historical and analytical perspectives. More clinical and experimental studies are needed to further substantiate this claim. If future publications describe the exact surgical technique, extent of the use of Bovie, infection containment (antibiotic) method used before, during, and after surgery, length of the operative exposure, duration of the surgery, and rate of infection, then a meta-analysis of the published clinical material from different centers could be performed, which would provide more comprehensive information.

Objectives/hypothesis: Electrosurgical instruments are routinely used in many applications by otolaryngologist-head and neck surgeons; and a complete description of their historical development, physics of operation, histological effects, and technological advancements is necessary for our specialty to take full advantage of this instrumentation. Because of the electrical current, heat production, and common use associated with these instruments, compounded by the complex environments in which they are used, potential complications must be considered and are likely underreported in the literature. This thesis describes the important aspects of electrosurgery along with a study of complications so otolaryngologists can use these instruments to their fullest potential while limiting complications., Study Design: National survey of electrosurgical complications., Methods: A survey addressing potential complications of electrosurgery was developed based on a review of the electrosurgical and complications literature. The electrosurgical complications were organized in the following categories: 1) unanticipated direct burns as a result of the active electrode contacting some tissue unintentionally; 2) unintentional burns as a result of capacitive coupling where radiofrequency (RF) current passes through a metallic instrument (such as forceps) and burns tissue in contact with that metallic instrument; 3) fires occurring as a result of electrosurgical instruments; 4) electromagnetic interference with a pacemaker, defibrillator, or cardiac monitoring device; and 5) other complications not included in the previous categories. The survey was mailed to the 620 members of the Society of University of Otolaryngologists., Results: Of the 620 surveys mailed, 35 were returned by the post office for lack of a forwarding address and 296 were returned completed for a response rate of 49.7%. The respondents performed a total of 99,664 cases in the previous year. During that year, 324 complications related to electrosurgical instruments were reported. These included 219 unanticipated direct burns, 48 burns as a result current flow through a metallic retractor or instrument (capacitative coupling), 13 grounding pad burns, 11 fires, 32 cases of electromagnetic interference, and 1 hair loss at an incision site as a result of a cutting electrosurgical instrument. Information regarding the circumstances surrounding these complications and outcome are presented., Conclusions: Electrosurgery has proliferated since its original application by William T. Bovie and Harvey Cushing in the 1920s. Because surgeons use this technology frequently, a thorough understanding of these instruments and their potential complications is critical to their safe and successful use. Electrosurgical units operate on basic fundamental principles of physics and involve the passage of electrical current through tissue to create the desired tissue effect. With knowledge of the history, physics, techniques, histological effects, and safety issues of electrosurgery, the field will continue to proliferate and electrosurgery will continue to assist surgeons in alleviating human suffering.

Analysis of the results of various modes of treatment and follow-up of 160 patients with benign submucosal tumors (BST) was carried out. Most often histological type of BST was leiomyoma (43.7%). BST were mainly located in the stomach (68.7%). 22 patients underwent open operations, 37--endoscopical removal of BST, 101 patients were followed-up from 5 to 10 years. The analysis of the material makes it possible to come to the conclusions about advisability of endoscopical treatment. The results of which are not inferior to surgical method of treatment. In patients with absence or slow growth of BST endoscopic follow-up is valid.

Previous studies have suggested that electrodissection tonsillectomy is associated with increased pain and delayed healing in comparison with sharp techniques for tonsillectomy. To better define the clinical significance of this difference, a detailed study of the time course of recovery was undertaken in adults and children after tonsillectomy or adenotonsillectomy by the sharp or electrodissection method. For electrodissection tonsillectomy, electrocautery set to 20 W was used for dissection and hemostasis, and after sharp dissection the suction electrocautery was used only selectively at bleeding sites. Daily pain scores were recorded for 2 weeks, and return to normal diet and activities was monitored. In adults the electrodissection tonsillectomy (n = 26) resulted in an average delay of 2 days in recovery from pain (p < 0.05) and a 2-day delay in return to a normal diet (p < 0.05) compared with sharp tonsillectomy (n = 24). In children (aged 2 to 12 years) the electrodissection technique (n = 26) resulted in an average delay trend of 1 to 1.5 days (not significant) compared with the sharp method (n = 24). Electrodissection tonsillectomy results in an average delay in recovery of 2 days for adults and in a lesser delay in pediatric patients.

In a prospective randomized study using a canine model, we compared the use of monopolar electrosurgery (EC) (n = 23) and the Nd:YAG Contact Laser (CL) (n = 21) on intra- and postoperative morbidity in laparoscopic large-bowel resection. In EC, cutting was performed with scissors and coagulation was performed with electrosurgery. In CL, cutting and coagulation were carried out with the Nd:YAG Contact Laser. Laparoscopic oncologic right colectomy with intraperitoneal ileocolic stapled anastomosis was performed in all dogs. Intraoperative smoke development, difficulty of dissection, hemostasis, and postoperative adhesions were judged using a five-point score. Two weeks after surgery, all dogs were sacrificed and zoopsy was carried out. Three dogs died postoperatively from pneumonia and one from an anastomotic leak. There were no other postoperative complications. Operative time was 135 min (range 105-180) in the CL group and 145 min (range 60-210) in the EC group. Intraoperative smoke development, difficulty of dissection, and postoperative amount of adhesions were not different between groups (P > 0.05). Hemostasis in the CL group (median score of 1, range 1-2) was significantly better (P = 0.01) than in the EC group (median score of 2, range 1-5). Scissors and electrosurgery as well as Nd:YAG Contact Laser can be used successfully in intestinal laparoscopic surgery. Although the use of the Contact Laser did not cause less postoperative morbidity than the conventional method, there was significantly better hemostasis using the Nd: YAG Contact Laser.

Objective: To assess whether hemorrhoidectomy done with the Nd:YAG laser was associated with less pain or fewer complications and sequels than with conventional surgery., Design: A prospective comparative, randomized study., Patients: Over a period of six months, a total of 35 consecutive patients, 13 females and 22 males, with symptomatic hemorrhoidal disease requiring surgery, were alternatively randomized to either laser hemorrhoidectomy (17 patients) or surgery (18 patients). The type of disease and the number of affected and treated hemorrhoids were prospectively recorded in each patient. Patients were monitored prospectively for postoperative complications, pain (assessed daily for five days using a standard 10 mm. linear analogue scale), wound healing, time until full recovery and sequelae 6 moths later., Results: These two groups were well matched. No differences were seen between laser and non-laser groups for postoperative complications. Linear analogue pain scores were not significantly different between the two groups at any stage after operation. Healing time was longer in laser group. Two few patients returned at 6 months for rectoscopy for any meaningful conclusion to be drawn., Conclusions: This study has failed to confirm any reduction in postoperative pain, complications, or healing time laser when performing a hemorrhoidectomy.