Uterine Artery–sparing Minimally Invasive Radical Trachelectomy: A Case Report and Review of the Literature

Radical trachelectomy is considered in patients with early-stage cervical cancer who desire future fertility. This article is accompanied by a video that provides step-by-step demonstration of a uterine artery–sparing robotic-assisted radical trachelectomy in a patient with stage IB1 squamous cell carcinoma of the cervix, a 2-cm mass, and a desire for future fertility. We also conducted a review of the literature examining the use of uterine artery–sparing techniques among minimally invasive radical trachelectomies. Using PubMed, Google Scholar, and Ovid search tools, 28 total publications were reviewed, of which 16 were eligible for use in our comparison. With the addition of our case report, a total of 154 cases sparing the uterine artery and 40 cases sacrificing the uterine artery were examined, including both conventional laparoscopic and robotic-assisted approaches. Data describing patient demographics as well as surgical, oncologic, and fertility outcomes were collected. The mean age was 30 years for the spared group and 32 years for the sacrificed group. At least 42% of the women in the spared and 53% of the uterine artery–sacrificed group were nulliparous. The majority of cases in both the spared and sacrificed groups represented squamous cell histology (71% for spared and 51% for sacrificed) followed by adenocarcinoma (24% vs 43%). The majority of the patients in both groups had stage IB1 disease (79% for spared vs 65% for sacrificed). The operative times among the 2 groups were similar, with a mean time of 314 minutes (range, 170–420 minutes) in the spared group and 283 minutes (range, 172–345 minutes) in the sacrificed group. The mean estimated blood loss was 173 mL (range, 23–300 mL) in the spared group and 77 mL (range, 50–250 mL) in the sacrificed group. The recurrence rates for the uterine artery–sparing and –sacrificing groups were equal at 2.6% after a mean follow-up of 42 months and 26 months, respectively. The methods of reporting fertility outcomes were varied among the different publications, with 41 patients achieving pregnancy in the spared group and 2 patients achieving pregnancy in the sacrificed group. Among patients who were not trying to conceive or had not conceived, 15 patients in the spared group and 6 patients in the sacrificed group were reported to have normal menses. The successful preservation of uterine arteries supports the maintenance of uterine arterial blood flow and is used by many gynecologic surgeons performing minimally invasive radical trachelectomy, with promising oncologic and obstetric outcomes.     

Laparoscopic Hysterectomy in Case of Uteri Weighing ≥1 Kilogram: A Series of 71 Cases and Review of the Literature

Study ObjectiveTo present our experience with laparoscopic hysterectomy (LH) for uteri weighing 1 kilogram or more and to provide a systematic review of the available English literature.DesignRetrospective analysis and review of the literature (Canadian Task Force Classification II-2).SettingDepartment of Obstetrics and Gynecology, University of Insubria, Varese, Italy.PatientsAll women in whom LH was attempted at the Department of Obstetrics and Gynecology, University of Insubria for uteri weighing ≥1 kg were included in the present study. Demographic characteristics and perioperative details of patients were prospectively recorded in our institutional surgical database. We also performed a systematic review of the English literature to identify studies including at least 1 case of LH for uteri weighing ≥1 kg.InterventionsHysterectomy for uteri ≥1 kg was performed through a total laparoscopic approach with vaginal morcellation of the uterus in the majority of patients and transvaginal closure of the vaginal vault in all cases.Measurements and Main ResultsLH was attempted in a total of 71 women. The median uterine weight was 1120 g (1000–2860 g). Three (4.2%) conversions to open surgery were needed. The median operative time and blood loss were 120 minutes (55–360 minutes) and 200 mL (10–1000 mL), respectively. No intraoperative and 2 (2.8%) postoperative complications occurred. Our review identified 6 studies reporting details of LH for uteri weighing ≥1 kg for a total of 62 patients; conversion to open surgery was necessary in 6 (9.7%) patients, and an additional 13 (21%) received a minilaparotomic incision to extract the uterus. The overall complication rate reported in the literature was 11.4%.ConclusionLH represents a possibility even in cases of uteri weighing ≥1 kg. In a dedicated setting with high endoscopic experience, conversion and complication rates appear acceptable.     

Mayer–Rokitansky–Küster–Hauser Syndrome and 16p11.2 Recurrent Microdeletion: A Case Report and Review of the Literature

Background

Mayer–Rokitansky–Küster–Hauser syndrome (MRKH; Online Mendelian Inheritance in Man #277000) is a rare disorder of the female reproductive tract. Its etiology is still unknown for most patients, although the genetic background of this condition has been intensively studied. Chromosome 16p11.2 deletion syndrome (Online Mendelian Inheritance in Man #611913) is a well known recurrent deletion syndrome that can present with various clinical phenotypes, including developmental delay, intellectual disability, autism spectrum disorder, obesity, and an increased frequency of congenital defects.

Is the Current Practice Providing an Integrated Approach to the Management of LUTS and ED in Primary Care? An Audit and Literature Review

IntroductionLower urinary tract symptoms (LUTS) and erectile dysfunction (ED) are highly prevalent in aging men. A common pathophysiology is hypothesized to explain causal link. However, prevalence of ED in patients with LUTS remains underdiagnosed, as we believe general practitioners (GPs) do not inquire about ED in men presenting with LUTS.AimOur goal to find out if LUTS and ED were dealt with in an integrated fashion in primary care.MethodsOne hundred consecutive patients with LUTS attending the prostate assessment clinic anonymously completed a locally developed, qualitatively validated questionnaire and sexual health inventory for men.Main Outcome Measures(i) Prevalence of concomitant ED in men presenting with LUTS; (ii) proportion of GPs enquiring about ED; (iii) patients with LUTS + ED who were offered treatment in primary care; and (iv) patients who sought treatment on review in secondary care.ResultsThe age of patients was 39–86 years. Fifty-four percent admitted to ED: 66% ≥60 years, and 28% ≤60 years had ED.Mean international prostate symptom score in both LUTS +/− ED groups was 16. There was a direct correlation between severity of LUTS and ED. Only 13/54 (24%) admitted ED to their GP. Of the patients, 15.4% received treatment, but 90.9% untreated patients were interested in therapy. Seventy-one percent stated definite reasons for inability to discuss their ED. GPs inquired about ED in only 9.2%. Overall, 66.6% wanted their ED addressed.ConclusionsFifty-four percent of the patients with LUTS also admitted to ED. Patients with more severe LUTS had more severe ED. More than 75% of patients did not report coexistent ED. GPs inquired about ED in only <10% of patients and offered no therapy to more than 80%. Sixty-seven percent of LUTS patients were interested in receiving treatment for ED when offered.Chitale S, Collins R, Hull S, Smith E, and Irving S. Is the current practice providing an integrated approach to the management of LUTS and ED in primary care? An audit and literature review.A more integrated approach is desired to address the prevalence of ED in patients presenting with LUTS in order to offer them a comprehensive management in primary care.     

“Habitual Adnexal Torsions”—Recurrence after Two Oophoropexies in a Prepubertal Girl: A Case Report and Review of the Literature

BackgroundRecurrent adnexal torsion rarely affects girls. Various surgical techniques for its prevention are available. We describe a case of recurrent asynchronous bilateral torsions in a prepubertal patient.CaseAn 8-year-old girl first presented with a right adnexal torsion and underwent a laparoscopic untwisting. During the following 3 years, 4 additional laparoscopies were required for treatment of left adnexal torsions. Although undergoing bilateral utero-ovarian ligament plication twice, torsion recurred. After examining the various options, we fixated the left ovary to the sidewall just below the pelvic brim.Summary and ConclusionIn the absence of clear evidence, treatment should be flexible and dependent on the individual case. Thorough patient education is imperative in order to prevent a delay in diagnosis and treatment of recurrent adnexal torsion.     

Ectopic Pregnancy in the Era of Medical Abortion: Are We Ready for It? Spectrum of Sonographic Findings and Our Experience in a Tertiary Care Service Hospital of India

Aim

The aim of this study was to share our experience of clinical presentation and ultrasonographic findings in cases of ectopic pregnancy especially in the context of usage of unsupervised medical abortifacients.

Settings and Design

This is prospective study conducted over a period of 1 year extending from August 01, 2009 to July 31, 2010 in a tertiary care Armed Forces Hospital of India.

Materials and Methods

Clinically and or sonologically suspected cases of ectopic pregnancy formed the study group. Detailed clinical, menstrual, and treatment history was obtained for each patient. Ultrasonography (USG) was done with multifrequency convex (2.5–6 MHz) followed by transvaginal (6–10 MHz) probes. Operative findings were noted and recorded in each case.

Results

In the study period, a total of 1958 pregnant patients were admitted and treated, which included 1690 deliveries and 268 abortions. Based on USG findings, 16 cases (0.8 %) of ectopic pregnancy were diagnosed. While four patients were treated medically (with methotrexate), 12 cases underwent surgery. Out of 16 cases, 10 cases were suspected clinically as ectopic pregnancy. Features suggestive of menorrhagia, threatened abortion, and pelvic inflammatory disease were present in five, three, and three cases, respectively. History of intake of medical abortifacients (MA) (mifepristone followed by misoprostol) was present in 07 (43.75 %) cases. On USG, commonest abnormality was a complex adnexal mass seen in 12 (75 %) cases. Gestational sac with definite embryo within and surrounding echogenic rim was seen in five cases. Live ectopic pregnancy was diagnosed in two (12.5 %) cases. Endometrial thickness was less than 10 mm in all cases who had taken MA. Pseudo gestation sac was seen in 02 (12.5 %) cases. Significant hemoperitoneum was present in 10 out of 12 cases operated. Organized hematoma in pelvis masking the presence of adnexal mass was noted in three cases.

Conclusion

Over-the-counter availability, failure to strictly follow the guidelines, unsupervised usage of MA along with atypical clinical history have increased diagnostic dilemma in ectopic pregnancy. Sonographic findings are frequently atypical in such cases. Ectopic pregnancy may remain under-diagnosed with potentially serious consequences in patients who have taken MA without prior confirmation of intrauterine gestation.     

Intrauterine Inflated Foley’s Catheter Balloon in the Management of Abnormally Invasive Placenta Previa: A Case–Control Study

Objective

To describe the use of intrauterine inflated Foley’s catheter balloon for control of postpartum hemorrhage (PPH) during cesarean section (CS) in cases of abnormally invasive placenta previa aiming to preserve the uterus.

Methods

Retrospective case–control study of the data of women who underwent elective CS on abnormally adherent placenta previa was carried out. Women in whom inflated Foley’s catheter balloon was used for control of PPH during CS (n = 40) were compared with a control group of women who underwent elective CS by the same technique but without use of intrauterine catheter balloon (n = 38).

Results

Use of intrauterine inflated Foley’s catheter balloon significantly reduced the estimated amount of blood loss (P = 0.008), amounts of crystalloids, colloids and packed red blood cells transfusion (P = 0.025, 0.017 and 0.022, respectively), and the need for bilateral internal iliac artery (IIA) ligation (P = 0.016). No significant difference was observed between both groups regarding the use of massive transfusion protocol, performing cesarean hysterectomy, relaparotomy, and admission to the intensive care unit.

Conclusion

Application of an intrauterine inflated Foley’s catheter balloon during CS in cases of morbidly adherent placenta previa helps to control PPH with preservation of the uterus and decreases the need for the invasive IIA ligation.

     

Induction of apoptosis in cervical cancer cells by the duplex drug 5-FdU–ECyd,coupling 2′-deoxy-5-fluorouridine and 3′-C-ethinylcytidine

Objective

Therapeutic options are limited for patients with advanced cervical cancer, and more effective drugs with favorable side-effect profiles are needed. We developed a nucleoside analogue duplex drug (5-FdU–ECyd), in which the DNA synthesis inhibitor 5-fluorodeoxyuridine is coupled to the RNA synthesis inhibitor 3′-C-ethinylcytidine. We therefore aimed to test its efficacy in cervical carcinoma cells in vitro and to establish its mechanism of action.

Methods

The cytotoxic effects of 5-FdU–ECyd on cervical cancer cells were assessed using the MTT assay, clonality assays, FACScan analysis, and its effect on cancer cell spheroids. Mechanisms of cell death were analyzed by Western blotting for apoptosis and autophagy pathways and mitochondrial membrane potential.

Results

HeLa, CaSki, SiHa, and Me180 cervical cancer cells were highly sensitive to 5-FdU–ECyd in both 2- and 3-dimensional cancer models. The cell death induced by 5-FdU–ECyd was associated with characteristic morphological and biochemical signs of apoptosis, including nuclear chromatin condensation and fragmentation, PARP cleavage, and a breakdown in mitochondrial membrane potential. 5-FdU–ECyd treatment led to an early S-phase arrest and drastically reduced expression of the anti-apoptosis protein Mcl-1 and increased signaling via the JNK and p38 MAPK pathways.

Conclusions

5-FdU–ECyd is highly cytotoxic in cervical cancer cells and exploits apoptosis pathways that might be specific to cancer, but not normal cells. 5-FdU–ECyd might represent a new chemotherapeutic option for patients with advanced or treatment refractory cervical cancer.     

Oral Ibuprofen for Treatment of Patent Ductus Arteriosus: More than a Cheap Alternative?. Concerning the Article by R. Neumann et al.: Oral Ibuprofen versus Intravenous Ibuprofen or Intravenous Indomethacin for the Treatment of Patent Ductus Arteriosus in Preterm Infants: A Systematic Review and Meta-Analysis [Neonatology 2012;102:9-15

No abstract available.     

ORIGINAL RESEARCH–WOMEN'S SEXUAL HEALTH: Clinically Relevant Changes in Sexual Desire,Satisfying Sexual Activity and Personal Distress as Measured by the Profile of Female Sexual Function,Sexual Activity Log,and Personal Distress Scale in Postmenopausal Women with Hypoactive Sexual Desire Disorder

IntroductionTransdermal testosterone patch (TTP) treatment produced statistically significant improvements in a satisfying sexual activity (SSA), sexual desire, and personal distress in postmenopausal women suffering from hypoactive sexual desire disorder (HSDD), but clinical significance of these changes was not determined.AimTo quantify the magnitude of change in three principal outcomes measures determined by HSDD patients as associated with the perception of meaningful benefit with TTP therapy.MethodsThe criteria for defining responders were determined using anchoring methodology and receiver operating characteristics analysis to establish minimum important differences (MIDs) in a representative subsample of 132 patients in two randomized, controlled trials in surgically menopausal women with HSDD (N = 1,094). Perceived benefit was established based upon the question “Overall, would you say that you experienced a meaningful benefit from the study patches?”. These data defined responders and established MIDs for changes in sexual desire, SSA, and personal distress. The MIDs were applied to the two trials to establish responder rates in each treatment group.Main Outcome MeasuresChanges in score that correspond to the MID for sexual desire, SSA, and personal distress, and responder rates in each treatment group based upon these values.ResultsIncreases in frequency of SSA of greater than 1 activity/4 weeks, increases in sexual desire score of ≥8.9, and decreases in the personal distress score of ≥20.0 were identified as threshold improvements best able to differentiate responders and nonresponders. The responder rate was significantly higher (P < 0.001) in the testosterone group vs. placebo for all three outcomes measures (sexual desire, 50% vs. 34%; SSA, 44% vs. 30%; personal distress, 51% vs. 39%).ConclusionsChanges in sexual desire, SSA, and personal distress observed with TTP treatment in surgically menopausal women with HSDD were clinically significant and were associated with a meaningful treatment benefit. DeRogatis LR, Graziottin A, Bitzer J, Schmitt S, Koochaki PE, and Rodenberg C. Clinically relevant changes in sexual desire, satisfying sexual activity and personal distress as measured by the profile of female sexual function, sexual activity log, and personal distress scale in postmenopausal women with hypoactive sexual desire disorder. J Sex Med 2009;6:175–183.