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Background There is concern but no solid evidence that morcellation during laparoscopic or vaginal hysterectomy may cause abdominal spread and thereby impaired prognosis of incidental uterine sarcomas. Objective Our purpose was to compare survival among patients with uterine sarcomas who underwent hysterectomy with or without morcellation to test the hypothesis that morcellation impairs prognosis. Study design We identified all women in Norway diagnosed with uterine sarcoma between 1953 and 2012 through national registries and retrieved data on surgical technique and morcellation by evaluation of patient files. Patients were categorised into abdominal, laparoscopic or vaginal hysterectomy with or without morcellation. Vaginal and laparoscopic hysterectomies were introduced in 1991; our main comparison is from 1991 to 2012. We compared age-adjusted disease-specific survival of sarcoma patients treated with or without morcellation and calculated age-adjusted hazard ratios (HRs) and subdistribution HR (accounting for competing risk) with 95% confidence intervals (CIs). Results Among 1367 patients with uterine sarcoma between 1953 and 2012 in Norway, 653 were diagnosed after 1991, and 23 of these patients (3.5%) underwent morcellation. Uterine sarcoma prevalence was 3.6 per 1000 laparoscopic hysterectomies. Mean follow-up was 6.0 years in the morcellated group and 6.9 years in the non-morcellated group. The risk of dying from uterine sarcoma after morcellation was 1.5 per 1000 procedures. Sarcoma mortality was higher in the morcellated group than in the non-morcellated group (age-adjusted HR 1.90, CI 1.05–3.44; multivariate HR, 2.50, 95% CI 0.57–10.9). Age-adjusted 10-year uterine sarcoma survival was 32.2% for women treated with morcellation compared with 57.2% for non-morcellated group (difference 25.5%; CI −55.7 to 18.1). All-cause 10-year survival was 32.2% in the morcellated group and 44.1% in the non-morcellated group (difference 11.9%; CI −40.9 to 32.7). Conclusion Our results strengthen the evidence that morcellation during hysterectomy in patients with incidental uterine sarcoma may cause impaired survival. These results can guide shared decision-making in clinical practice.

Objectives: To develop and validate a scoring system for laparoscopic skills for five specific tasks on a virtual reality simulator. Study design: A longitudinal, experimental, non-randomised study including 30 gynecologists and gynecological trainees at three hospitals. The participants were categorized as inexperienced (Group 1), moderately experienced (Group 2), and experienced (Group 3).The study participants performed ten repetitions of three basic skill tasks, a salpingectomy and a laparoscopic supracervical hysterectomy on a virtual reality simulator. Assessment of skills was based on time, error parameters and economy of movements measured by the simulator. We used the results (mean and SD for each parameter in all tasks) of the four last repetitions performed by the experienced gynecologists as the basic for the scoring system. Performance equal to, and higher than, this mean score gave 2 points. A decrease of 1 SD from the mean gave 1 point. Every score below gave 0 points. The mean score for the inexperienced, moderately experienced and experienced study participants was compared. Results: The mean scores in Task 1 were 3.4 (SD 0.6) in Group 1, 3.4 (SD 0.6) in Group 2 and 5.1 (SD 1.1) in Group 3, respectively. There was a statistically significant difference in score between Group 1 and 3 (p = 0.01), and group 2 and 3 (p = 0.01). In Task 2 no statistical significant differences were found. In Task 3, the total mean scores were 1.7 (SD 0.7) in Group 1, 1.9 (SD 0.9) in Group 2 and 2.8 (SD 0.5) in Group 3, respectively. The difference in score between study groups was statistically significant when comparing Group 1 and Group 3 (p

Objectives To develop and validate a scoring system for laparoscopic skills for five specific tasks on a virtual reality simulator. Study design A longitudinal, experimental, non-randomised study including 30 gynecologists and gynecological trainees at three hospitals. The participants were categorized as inexperienced (Group 1), moderately experienced (Group 2), and experienced (Group 3). The study participants performed ten repetitions of three basic skill tasks, a salpingectomy and a laparoscopic supracervical hysterectomy on a virtual reality simulator. Assessment of skills was based on time, error parameters and economy of movements measured by the simulator. We used the results (mean and SD for each parameter in all tasks) of the four last repetitions performed by the experienced gynecologists as the basic for the scoring system. Performance equal to, and higher than, this mean score gave 2 points. A decrease of 1 SD from the mean gave 1 point. Every score below gave 0 points. The mean score for the inexperienced, moderately experienced and experienced study participants was compared. Results The mean scores in Task 1 were 3.4 (SD 0.6) in Group 1, 3.4 (SD 0.6) in Group 2 and 5.1 (SD 1.1) in Group 3, respectively. There was a statistically significant difference in score between Group 1 and 3 (p = 0.01), and group 2 and 3 (p = 0.01). In Task 2 no statistical significant differences were found. In Task 3, the total mean scores were 1.7 (SD 0.7) in Group 1, 1.9 (SD 0.9) in Group 2 and 2.8 (SD 0.5) in Group 3, respectively. The difference in score between study groups was statistically significant when comparing Group 1 and Group 3 (p

To develop a procedure-specific rating scale for laparoscopic supracervical hysterectomy (LSH), and to compare the construct validity and reliability with a general rating scale in laparoscopic surgery, global operative assessment of laparoscopic skills (GOALS).Prospective interobserver study. In collaboration with an expert group, we developed the procedure-specific rating scale, competence assessment tool for laparoscopic supracervical hysterectomy (CAT-LSH). LSH was performed by gynecologists with different levels of surgical competence levels (13 procedures were performed by inexperienced trainees, 13 by intermediate experienced, and 15 by laparoscopic experts). All procedures were video-recorded. Surgical performance was evaluated in all procedures using both CAT-LSH and GOALS by the surgical assistant, as well as by 2 blinded observers evaluating the video recordings.University teaching hospital.Laparoscopic experts, consultants and gynecological registrars from the Department of Gynecology.There were significant differences between the 3 proficiency groups in both the rating scales. Mean GOALS score evaluated by the operating assistant and the 2 observers were for inexperienced surgeons 16.4 vs. 13.6 (p0.01), for surgeons with intermediate experienced 22.6 vs. 19.5 (p0.05) and for expert surgeons 26.1 vs. 22.4 (p0.01), respectively. Corresponding results for the CAT-LSH scores were 41.0/34.6 (p0.01), 49.2/43.1 (p0.01), and 58.7/51.1 (p0.01), respectively. The interrater reliability measured by the interclass correlation coefficient between the surgical assistant and the 2 blinded observers for GOALS and CAT-LSH were 0.71 and 0.75, respectively.The GOALS and CAT-LSH appear to have construct validity and high interrater reliability. Assessment of surgical competence during LSH is feasible in daily practice with objective rating scales like CAT-LSH and GOALS.

BACKGROUND All of Norway's inhabitants are entitled to health services of a good and equal quality. The aim of this study was to evaluate whether women with benign gynaecological disorder are treated according to this principle. Guidelines recommend that the laparoscopic technique should be used to operate ectopic pregnancies and ovarian cysts. Vaginal or laparoscopic technique should be used for hysterectomies. MATERIAL AND METHODS Recording of surgical modality used in gynaecological departments in Norway to treat ectopic pregnancies, ovarian cysts and hysterectomies on the indication bleeding disorders and/or fibroids. Data were retrieved from the National Patient Register for the years 2003 - 06. RESULTS The proportion of operations performed with laparotomy was gradually reduced for the conditions assessed during the period of observation. 24 % of women with ectopic pregnancies were operated with laparotomy in 2003 and 14 % in 2006; 50 % of women with ovarian cysts were operated with the technique in 2003 and 41 % in 2006. For hysterectomies due to bleeding disorders and/or fibroids, the frequency of laparotomies decreased from 75 % in 2003 to 62 % in 2006. Adherence to guidelines is best in departments that perform many operations. INTERPRETATION Different surgical approaches are used to treat the same benign gynecological disorders in Norway. The reason for this difference has not been evaluated, but it may be explained by tradition, lack of competence and inadequate training of gynecologists.

Objective . Data regarding signal transduction pathways in human tumors are largely confined to cell line studies to date. We have recently reported on the activation and prognostic role of mitogen-activated protein kinases (MAPK) in ovarian carcinoma in effusions. The objective of the present study was to investigate the expression and clinical role of dual-specificity phosphatases (DUSP), inhibitors of MAPK signaling, in ovarian cancer cells at this site. Methods . Thirty-nine fresh frozen malignant effusions from patients diagnosed with serous ovarian carcinoma were studied for mRNA expression of the DUSP MKP-1, MKP-4, MKP-5, and PAC-1 using RT-PCR. DUSP expression was analyzed for possible correlation with patient age, disease stage, tumor grade, histological grade, chemotherapy status, and survival. Results . MKP-1 and PAC-1 mRNA were found in 36 and 37 effusions, respectively, with expression levels showing considerable variation. MKP-4 and MKP-5 were uniformly absent. MKP-1 showed no association with clinicopathologic parameters. However, PAC-1 expression was significantly higher in effusions obtained before the institution of treatment with both platinum compounds ( P = 0.029) and paclitaxel ( P = 0.036). In univariate survival analysis, high level of expression of PAC-1 mRNA predicted significantly worse overall survival compared to low expression (mean = 30 vs. 52 months, median=25 vs. 46 months) ( P = 0.007). Conclusions . Despite the limited size of this cohort, our results present the first evidence supporting a clinical role for PAC-1 in ovarian carcinoma. In view of the improved outcome associated with activation of all three MAPK families, as well as their elevated expression and activation in post-chemotherapy specimens presented in our previous work, they also suggest that PAC-1 is a true negative regulator of MAPK in ovarian carcinoma cells in effusions.

BACKGROUND The granulin-epithelin precursor (GEP) was preferentially expressed in invasive ovarian tumor epithelium specimens compared with specimens of borderline ovarian tumors. The objective of the current study was to evaluate the anatomic site-related and cellular expression of GEP and its association with clinicopathologic parameters and survival in patients with advanced-stage ovarian carcinoma. METHODS Effusions (n = 190), corresponding primary tumor specimens (n = 64), and specimens of metastatic lesions (n = 125) were analyzed using immunohistochemistry with a specific polyclonal antipeptide antibody. In addition, 36 effusions were analyzed using immunoblotting. RESULTS GEP was detected in tumor cells in 171 of 190 (90%) effusions and demonstrated both focal membrane and cytoplasmic localization. Mesothelial cells were often GEP positive (81%). GEP was found in carcinoma cells in 180 of 189 (95%) tumor biopsy specimens, with stromal and endothelial cell expression in 93 of 180 (52%) and 124 of 185 (67%) specimens, respectively. Lower GEP expression in stromal cells was observed in metastases sampled during or after chemotherapy (P = 0.034). The presence of GEP-positive stromal cells in untreated primary tumor specimens correlated with worse overall survival (P = 0.014). Significantly more frequent GEP expression was observed in tumor cells of both primary (P = 0.002) and metastatic (P < 0.001) tissue specimens compared with malignant effusions. CONCLUSIONS GEP expression was observed in primary and metastatic epithelial ovarian carcinoma specimens, with down-regulated expression in tumor cells of malignant effusions. The poor outcome associated with stromal GEP expression suggests a prognostic role for this growth factor in ovarian carcinoma. Cancer 2004. Published 2004 American Cancer Society.

All of Norway's inhabitants are entitled to health services of a good and equal quality. The aim of this study was to evaluate whether women with benign gynaecological disorder are treated according to this principle. Guidelines recommend that the laparoscopic technique should be used to operate ectopic pregnancies and ovarian cysts. Vaginal or laparoscopic technique should be used for hysterectomies.Recording of surgical modality used in gynaecological departments in Norway to treat ectopic pregnancies, ovarian cysts and hysterectomies on the indication bleeding disorders and/or fibroids. Data were retrieved from the National Patient Register for the years 2003 - 06.The proportion of operations performed with laparotomy was gradually reduced for the conditions assessed during the period of observation. 24 % of women with ectopic pregnancies were operated with laparotomy in 2003 and 14 % in 2006; 50 % of women with ovarian cysts were operated with the technique in 2003 and 41 % in 2006. For hysterectomies due to bleeding disorders and/or fibroids, the frequency of laparotomies decreased from 75 % in 2003 to 62 % in 2006. Adherence to guidelines is best in departments that perform many operations.Different surgical approaches are used to treat the same benign gynecological disorders in Norway. The reason for this difference has not been evaluated, but it may be explained by tradition, lack of competence and inadequate training of gynecologists.

To analyze circumstances relating to severe anal sphincter tears occurring at spontaneous delivery, in view of reported differences in practice regarding manual perineal protection during delivery.Cohort study of midwife-conducted non-operative vaginal deliveries.Five Norwegian hospitals with 12,438 consecutive deliveries during a 12-month period.Data from 357 women sustaining third and fourth grade anal sphincter tears (2.9%) were analyzed.Different incidence of major perineal tears.Sphincter tear incidence varied significantly between the five hospitals, from 1.3 to 4.7% (p0.001, RR=3.14 (CI: 2.38-5.56)). There was no significant difference between the five hospitals when other risk variables were compared. Use of oxytocin in the second phase of labor and of epidural analgesia was significantly more often applied in the hospital with the lowest rate of sphincter tears. The midwives' perception of having applied perineal support was not significantly different between the two hospitals with the highest and the lowest incidence of sphincter tear.The observed difference in incidence of sphincter tear between the hospitals remains unexplained, but could be due to different perineal protection handling techniques.

The granulin-epithelin precursor (GEP) was preferentially expressed in invasive ovarian tumor epithelium specimens compared with specimens of borderline ovarian tumors. The objective of the current study was to evaluate the anatomic site-related and cellular expression of GEP and its association with clinicopathologic parameters and survival in patients with advanced-stage ovarian carcinoma.Effusions (n = 190), corresponding primary tumor specimens (n = 64), and specimens of metastatic lesions (n = 125) were analyzed using immunohistochemistry with a specific polyclonal antipeptide antibody. In addition, 36 effusions were analyzed using immunoblotting.GEP was detected in tumor cells in 171 of 190 (90%) effusions and demonstrated both focal membrane and cytoplasmic localization. Mesothelial cells were often GEP positive (81%). GEP was found in carcinoma cells in 180 of 189 (95%) tumor biopsy specimens, with stromal and endothelial cell expression in 93 of 180 (52%) and 124 of 185 (67%) specimens, respectively. Lower GEP expression in stromal cells was observed in metastases sampled during or after chemotherapy (P = 0.034). The presence of GEP-positive stromal cells in untreated primary tumor specimens correlated with worse overall survival (P = 0.014). Significantly more frequent GEP expression was observed in tumor cells of both primary (P = 0.002) and metastatic (P0.001) tissue specimens compared with malignant effusions.GEP expression was observed in primary and metastatic epithelial ovarian carcinoma specimens, with down-regulated expression in tumor cells of malignant effusions. The poor outcome associated with stromal GEP expression suggests a prognostic role for this growth factor in ovarian carcinoma.