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Objectives: To compare recurrence rates between patients with mismatch repair proficient (pMMR) and MMR deficient (dMMR) high intermediate risk (HIR) endometrial cancer Methods: Adult women with HIR endometrial cancer diagnosed between January 1, 2016, and December 31, 2018, were identified from UC San Diego and Kaiser Southern California. Patient and disease characteristics were collected by chart review. Cases were limited to those who underwent hysterectomy with endometrioid histology and stage 1 disease. HIR disease was defined as the presence of three risk factors if age Results: Two hundred forty-four patients with HIR endometrial cancer were identified during the study period. One hundred fifty-eight patients (65%) were pMMR by immunohistochemical staining, and 86 patients (35%) were dMMR. There were no differences in mean age, mean body mass index (BMI), race, grade, mean follow-up time, or type of adjuvant treatment received between the pMMR versus dMMR cohorts. In total, 40 (16%) patients experienced cancer recurrence, and there were 11 (4.5%) cancer-related deaths during the study period. There was no statistically significant difference in recurrence rates between the pMMR and dMMR cohorts (15% versus 19%, p=0.49). The lack of association between MMR status and recurrence persisted after controlling for depth of myometrial invasion and LVSI in logistic regression multivariable analysis. pMMR tumors were more likely to exhibit ≥50% myometrial invasion than patients with dMMR tumors (p=0.03). dMMR tumors were significantly more likely to exhibit LVSI than pMMR tumors (p Download : Download high-res image (225KB) Download : Download full-size image Conclusions: Our analysis represents one of the largest recurrence rate analyses of HIR endometrial cancer as stratified by MMR status. Although our pMMR and dMMR patient cohorts with HIR did not differ with respect to patient characteristics, dMMR tumors were significantly more likely to have

Objective: Our purpose was to demonstrate that propylthiouracil and methimazole are equally effective and safe in the treatment of hyperthyroidism during pregnancy. Study Design: Between 1974 and 1990 records were available on 185 pregnant patients with a history or diagnosis of hyperthyroidism. Ninety-nine patients were treated with propylthiouracil and 36 with methimazole. The response to therapy was compared with respect to the time to normalization of the free thyroxine index and the incidences of congenital anomalies and hypothyroidism. Results: The time to normalization of the free thyroxine index was compared in the two groups by means of survival analysis. The median time to normalization of the free thyroxine index on propylthiouracil and methimazole was 7 and 8 weeks, respectively ( p = 0.34, log-rank test). The incidence of major congenital malformations in mothers treated with propylthiouracil and methimazole was 3.0% and 2.7%, respectively. No neonatal scalp defects were seen. One infant was overtly hypothyroid at delivery. Conclusion: Propylthiouracil and methimazole are equally effective and safe in the treatment of hyperthyroidism in pregnancy.

To review the clinical and urodynamic outcome of treatment by the modified Pereyra procedure in 93 women with genuine stress incontinence.Retrospective review.Harbor/UCLA Medical Center and Los Angeles County Women's Hospital, Los Angeles, California, USA.Clinical and urodynamic assessment one year after modified Pereyra procedure.Overall 82% of patients were subjectively cured while only 63% were objectively cured. Women with failed surgery had significantly lower pre-operative maximum urethral closure pressures. The procedure had a low operative and postoperative morbidity with no significant disturbance of voiding function noted at one year follow-up.Our results with the modified Pereyra procedure for stress incontinence showed a significantly lower success rate than has been reported from many previous studies.

Cervical intraepithelial neoplasia (CIN) after cryotherapy can pose both diagnostic and therapeutic problems. To clarify these issues, 27 consecutive patients who underwent cone biopsy for CIN after cryotherapy over a 10-year period at Women's Hospital LAC + USC Medical Center were reviewed. Although the initial features of the cervical intraepithelial neoplasia allowed for out-patient cryotherapy, the features of these failures did not (unsatisfactory colposcopy or CIN in the endocervical curettings). Eleven percent of these patients had stromal invasion on cone biopsy that was not suspected clinically. Patients presenting with cervical intraepithelial neoplasia following cryotherapy may, in fact, have progressive disease (i.e., stromal invasion) that is inapparent clinically. Hence, surgical excision should be considered in these circumstances.

Ifosfamide is an active chemotherapeutic agent in a wide range of gynecologic tumors; favorable response rates have been reported in ovarian (epithelial and germ cell), uterine, and cervical neoplasms. Central neurotoxicity is a known, but poorly described side effect. We report 23 patients who received a total of 75 cycles of ifosfamide, either as a single agent or in combination with other chemotherapeutic agents. Six of twenty-three (26%) experienced grade 4 neurotoxicity; clinical presentation included confusion, aphasia, hallucinations, and coma. All patients exhibited the first evidence of neurotoxicity by the end of the 24-hr infusion. Three of six patients with grade 4 neurotoxicity expired within 14 days of receiving ifosfamide. The neurotoxicity resolved over 2 to 4 days in the remaining patients. Serum albumin was normal (greater than 3.5 g/dl) in 63 cycles of ifosfamide not associated with neurotoxicity. When serum albumin was less than 3.5 g/dl, 6 of 12 cycles were associated with severe neurotoxicity (P less than 0.001). Low serum albumin (less than 3.5 g/dl) appears to be associated with a high risk of severe neurotoxicity in patients receiving single-dose ifosfamide therapy.

OBJECTIVE: Our purpose was to assess the ability of fluorescein to intraoperatively detect viable fallopian and ovarian tissues involved in adnexal torsion. STUDY DESIGN: This prospective study was performed at Los Angeles County + University of Southern California Women's Hospital. Participants were female patients 18 to 45 years old with adnexal torsion confirmed at exploratory celiotomy. Five milliliters of 10% fluorescein were injected intravenously, and the involved untwisted adnexa was observed under ultraviolet light. Nonfluorescent tissue was resected and histologically evaluated. RESULTS: Eleven patients were entered into the study. Mean age was 25 years (range 15 to 42). Eight patients (72%) had preservation of involved ovarian tissue. No complications were associated with this procedure. Only three patients (28%) underwent oophorectomy. CONCLUSION: The use of intravenous fluorescein appears to be a valuable adjunct in the management of adnexal torsion. Application of this technique in reproductive-aged patients resulted in a three-quarter reduction in oophorectomy procedures.

Renal artery hemorrhage secondary to placement of percutaneous nephrostomy catheters can lead to major operations and even nephrectomy. We recently treated a woman who suffered a renal artery laceration during percutaneous nephrostomy catheter placement using interventional radiographic techniques. The perforation site was identified using angiography and treated using selective embolization. The patient was able to avoid a surgical procedure with its inherent risks.

The objective was to determine whether CA-125 levels have any clinical utility in gestational trophoblastic disease. Fifty-one patients with a pathologically confirmed diagnosis of complete hydatidiform mole had a CA-125 level obtained prior to suction molar evacuation. Data were analyzed using χ 2 and Mann-Whitney U test. CA-125 levels were twice as high in persistent gestational trophoblastic disease than those in complete hydatidiform molar patients (85.9 vs 48.3 U/ml; P = 0.004). CA-125 levels were independent of age, gravidity, weeks of amenorrhea, or presence of thecal-luteal cysts. CA-125 levels appear to be of value in predicting which molar patients will develop persistent disease.

One hundred and fourteen female patients had clinical and urodynamic diagnosis of detrusor instability. They all received oxybutynin chloride (Ditropan) 5 mg t.i.d. for four weeks and evaluation repeated. Sixty-six of the 114 patients (58%) responded favorably to anticholinergic treatment while 48 patients (42%) did not. Based on urethrocystometry, two groups of patients were identified: Group I consisted of 73 women with bladder contraction that preceded any change in urethral pressure. Group II consisted of 41 patients with urethral pressure drop that preceded the detrusor contraction by a few seconds. Sixty-one of the 73 women (84%) in Group I responded favorably to four weeks of anticholinergic therapy while 88 percent (36 of 41) of women in Group II did not (P less than 0.01). Our results suggest that women with bladder contraction that is preceded by urethral relaxation represent a different pathologic entity than women with "classic detrusor instability".

Endometrial ablation has been proposed as an alternative to hysterectomy for the treatment of dysfunctional uterine bleeding. We describe what we believe to be the first reported case of an endometrial adenocarcinoma that may have developed shortly after endometrial ablation.

Both EST and Mayer-Rokitansky-Kuster-Hauser syndrome are uncommon disorders. This report illustrates a case of these two rare conditions occurring in the same patient. Patients with Mayer-Rokitansky-Kuster-Hauser syndrome, although not appearing to be at increased risk for germ cell tumors, unlike testicular feminization patients, are not immune to ovarian cancer. Therefore, individuals with Mayer-Rokitansky-Kuster-Hauser syndrome should still be followed gynecologically because they are at least at the normal risk of developing ovarian as well as other gynecological neoplasms.

Previous reports examining adnexal torsion suggested that benign ovarian neoplasms are more likely to undergo torsion than malignant ovarian neoplasms. To our knowledge, this clinical observation has not been quantified. To examine this hypothesis, we reviewed our experience with ovarian neoplasms found at the time of surgery over a 10-year period. Benign ovarian neoplasms had a 12.9-fold increased risk of undergoing adnexal torsion when compared with malignant ovarian neoplasms (95% confidence interval, 10.2 to 15.9). The histologic type of ovarian neoplasm does not appear to affect the rate of adnexal torsion. Adnexal torsion rarely involves cancer.

Objective To relate hypothyroidism to perinatal outcome. Methods A cohort of 68 hypothyroid patients with no other medical illnesses was divided into two groups according to the initial thyroid function tests. The first group had 23 women with overt hypothyroidism, and the second had 45 subjects with subclinical hypothyroidism. We sought to identify the pregnancy outcomes of gestational hypertension, low birth weight, fetal death, congenital anomalies, maternal anemia, and postpartum hemorrhage. Results Gestational hypertension--namely, eclampsia, preeclampsia, and pregnancy-induced hypertension--was significantly more common in the overt and subclinical hypothyroid patients than in the general population, with rates of 22, 15, and 7.6%, respectively. In addition, 36% of the overt and 25% of the subclinical hypothyroid subjects who remained hypothyroid at delivery developed gestational hypertension. Low birth weight in both overt and subclinical hypothyroid patients was secondary to premature delivery for gestational hypertension. Except for one stillbirth and one case of clubfeet, hypothyroidism was not associated with adverse fetal and neonatal outcomes. Conclusion Normalization of thyroid function tests may prevent gestational hypertension and its attendant complications in hypothyroid patients.

Bilateral ovarian neoplasms are believed more likely to be malignant than are unilateral neoplasms. To our knowledge, this clinical tenet has not been evaluated or quantified. To test this hypothesis, we conducted a 10-year review of ovarian neoplasms found at the time of celiotomy at the Women's Hospital, Los Angeles County-University of Southern California Medical Center. Overall, women with bilateral neoplasms had a 2.6-fold increased risk of malignancy when compared with women who had unilateral neoplasms (95% confidence interval, 2.0 to 3.4; p less than 0.001). The age-standardized relative risk was 1.8 (95% confidence interval 1.4 to 2.3). When standardized for the effect of menopausal status, the relative risk was 2.0 (95% confidence interval, 1.6 to 2.5). Bilaterality is associated with a doubling in the risk of cancer, a highly significant difference.

Sixty-nine women with a clinically and urodynamically proven diagnosis of genuine stress incontinence underwent urethropexy in the form of the revised Pereyra procedure (n = 28) or Burch colposuspension (n = 41). Postoperatively the patients were assigned randomly to one of three study groups. Group 1 received a daily saline injection to the bladder (control group, n = 24), group 2 received daily intravesical injections of 250 mg of prostaglandin F2 alpha (PGF2 alpha) (n =23), and group 3 received a daily 10-mg PGE2 (PGE2) vaginal suppository (n = 22). The patients' suprapubic catheter was removed once the postvoiding residual urine volume was less than or equal to 50 mL. Both PGE2 and PGF2 significantly reduced the length of time required for postoperative bladder drainage after both the Burch and Pereyra procedures as compared to that in the control group (P less than .05). Hospital stay and bacteriuria were reduced as well in women receiving postoperative prostaglandins as compared to the control group. Clinically there were no differences between PGE2 and PGF2 alpha. Both produced no side effects, were well tolerated by the patients and were effective in reducing both the number of days required for bladder catheterization and the incidence of significant bacteriuria when administered after the surgical procedures.

There were 289 women with clinical and urodynamic diagnosis of primary stress urinary incontinence, stable bladder, and pelvic relaxation who underwent a single-stage surgical procedure because of incontinence and pelvic relaxation. Patients underwent one of three surgical procedures because of stress incontinence—anterior colporrhaphy, revised Pereyra procedure, or Burch retropubic urethropexy. Decisions with regard to the type of bladder neck suspension and the surgeon were made randomly with a randomization table. Each patient had a complete clinical and urodynamic evaluation before surgery and at 3 and 12 months after surgery. Cure rate as defined by strict clinical and urodynamic criteria was not significantly different among the three groups at the 3-month postsurgical evaluations; however, at the 12-month postsurgical evaluations, the cure rate among women who underwent Burch urethropexy ( n = 101) was significantly higher than that of either Pereyra or anterior colporrhaphy (cure rates were 87%, 70%, and 69%, respectively; p

One hundred seven consecutive patients with clinical and urodynamic findings of genuine stress incontinence not previously treated were prospectively allocated in a randomized manner to one of three surgical procedures: anterior colporrhaphy, revised Pereyra procedure, or Burch retropubic urethropexy. Randomization included the surgical procedure and choice of surgeon (one of the three authors). Clinical and urodynamic evaluations were repeated at 3 months and 1 year after surgery. Differences in cure rates among the three procedures at the 3-month postoperative evaluation were insignificant (82%, 84%, and 92% for the anterior colporrhaphy, Pereyra, and Burch respectively) but became statistically significant at the 1 year postoperative evaluation (cure rates of 65%, 72%, and 91% for the anterior colporrhaphy, Pereyra, and Burch respectively, p less than 0.05). In our hands the Burch procedure stabilized the urethrovesical junction and prevented its descent during straining (evaluated by a postoperative Q-tip test) more effectively than either the Pereyra or anterior colporrhaphy. No procedure resulted in severe postoperative voiding difficulties. The present prospective randomized study demonstrates that in our hands the abdominal retropubic operation for genuine stress incontinence in patients not previously operated on results in a higher cure rate when compared with anterior colporrhaphy or Pereyra procedure.

Thirty-nine patients (from a total of 307 women) with clinical and urodynamic diagnosis of stress urinary incontinence had cystometric findings consistent with detrusor instability. Detailed multichannel urethrocystometry of these 39 patients revealed that urethral relaxation preceded the bladder contraction by 2-5 s. These patients were randomly allocated to either medical treatment (n = 21) by Ditropan 5 mg t.i.d. for 6 weeks prior to the surgical procedure, or to surgical treatment (n = 18) with no attempt to treat the bladder instability prior to surgery. All patients had repeat clinical and urodynamic evaluation at 3-12 months postoperatively. Six of the 39 patients (15%) still had urethral relaxation and bladder contractions on postoperative urethrocystometry. Four of these 6 patients still had stress urinary incontinence and urethral funneling. These 4 were considered surgical failures. Two of the 39 (5%) had postoperative detrusor instability in spite of good surgical results. This series suggests that in women with combined stress urinary incontinence and bladder instability, where bladder contraction is preceded by urethral relaxation, there is a more than 90% chance that bladder instability will disappear after successful operation for stress urinary incontinence.

A total of 67 female patients with pelvic relaxation (cystocele beyond the vaginal orifice) and with no urinary incontinence were clinically and urodynamically evaluated before and after a reconstructive surgical procedure. Of these, 24 patients had a significant decrease in abdominal pressure transmission to the urethra once the cystocele was reduced by vaginal pessary (abdominal pressure transmission ratio to urethra: bladder of less than 1.0). All 24 had a revised Pereyra procedure in addition to the cystocele repair. The other 43 patients had adequate abdominal pressure transmission to the urethra once the cystocele was reduced by vaginal pessary (abdominal pressure transmission ratio to urethra: bladder of greater than or equal to 1.0). These 43 patients underwent cystocele repair only with no surgical repair to the urethra or urethrovesical junction. Evaluation was repeated at 3 to 6 months after the operation. No patient developed urinary incontinence after operation. All 67 patients had urodynamically good abdominal pressure transmission to the urethra while coughing. Women with significant genitourinary prolapse may be continent in spite of a weak urethral sphincter because of kinking of the poorly supported urethra. Urodynamic testing can identify those women at risk of developing postoperative urinary incontinence so that prophylactic measures can be undertaken.

One hundred and twenty-one patients with genuine stress urinary incontinence underwent urodynamic examination before and after Burch colposuspension. They were divided into two groups, one with preoperative urethral pressure of 20 cm water or less (n = 17), and the other with urethral pressure greater than 20 cm water (n = 104). Success rates at 12 months were significantly lower in women with low urethral pressure as compared with those with normal urethral pressure (65 vs. 88%; p less than 0.01). Starting in January 1987, all patients with low urethral pressure preoperatively underwent a surgical procedure which combined the techniques of the Ball and Burch procedures. Short-term cure rate (at 3 months postoperative follow-up) in women with low urethral pressure was 83% as opposed to 70% with the Burch urethropexy (p less than 0.05).