Postoperative pelvic intensity-modulated radiotherapy and concurrent chemotherapy in intermediate- and high-risk cervical cancer

ObjectiveAccording to national surveys, the use of intensity-modulated radiation therapy (IMRT) in gynecologic cancers is on the rise, yet there is still some reluctance to adopt adjuvant IMRT as standard practice. The purpose of this study is to report a single-institution experience using postoperative pelvic IMRT with concurrent chemotherapy in intermediate- and high-risk early stage cervical cancer.MethodsFrom 1/2004 to 12/2009, 34 patients underwent radical hysterectomy and pelvic lymph node dissection (28 median nodes were removed) for early stage cervical cancer. Median dose of postoperative pelvic IMRT was 50.4 Gy (range, 45–50.4). All patients received concurrent cisplatin.ResultsWith a median follow-up of 44 months, 3 patients have recurred; 1 vaginal recurrence, 1 regional and distant, and 1 distant. The 3- and 5-year disease-free survival (DFS) was 91.2% (95% CI, 81.4–100%) and overall survival (OS) was 91.1% (95% CI, 81.3–100%). All failures and all deaths were in the high-risk group (n = 3/26). There was 32.3% G3–4 hematologic toxicity, 2.9% acute G3 gastrointestinal toxicity, and no acute G3 or higher genitourinary toxicity. There were no chronic G3 or higher toxicities.ConclusionsOncologic outcomes with postoperative IMRT were very good, with DFS and OS rates of > 90% at median follow-up of 44 months, despite a preponderance (76.5%) of high-risk features. Toxicity was minimal even in the setting of an aggressive trimodality approach. Data from this study and emerging data from the Phase II RTOG study (0418) demonstrate the advantages of postoperative IMRT in early stage cervical cancer.     

Adjuvant radiation for early stage endometrial cancer with lymphovascular invasion

ObjectiveTo determine the impact of the decrease in use of postoperative pelvic external beam radiation (EBRT) in favor of intravaginal RT (IVRT) alone in patients with early stage endometrial cancer who had lymphovascular invasion (LVI).MethodsBetween 11/1988 and 5/2005, 126 patients treated with simple hysterectomy and postoperative RT had a final pathologic diagnosis of stage IB–IIB adenocarcinoma of endometrioid histology with documented LVI. The patients were divided into two groups based on the era of treatment, (early era: 1988–1996, vs. late era: 1997–2005), in order to best capture the shift away from the routine use of EBRT in favor of surgical staging and IVRT.ResultsOf the 126 patients, 35% (n = 44) were treated in the early era and 65% (n = 82) in the late era. The two groups were balanced in regards to age, race, depth of myometrial invasion, histologic grade, and cervical involvement. Significantly more patients had surgical staging and received IVRT alone in the late than early era (p = 0.0001, 0.004, respectively). The rate of pelvic control was 93% for the early era compared to 97% for latter era (p = 0.3). There was no significant impact of the treatment era on vaginal control, disease-free survival, or overall survival.ConclusionsThese data suggest that the mere presence of LVI need not trigger the use of pelvic EBRT. Instead, the decision on whether to omit EBRT in patients with LVI should be made in the context of a patient's competing risk factors and comorbid conditions.     

Postoperative pelvic intensity-modulated radiotherapy in high risk endometrial cancer

ObjectiveAccording to national surveys, the use of intensity-modulated radiation therapy (IMRT) in gynecologic cancers is on the rise, yet there is still some reluctance to adopt adjuvant IMRT as standard practice. The purpose of this study is to report a single-institution experience using postoperative pelvic IMRT with or without chemotherapy in high-risk endometrial cancer.MethodsFrom 11/2004 to 12/2009, 46 patients underwent hysterectomy/bilateral salpingo-oophorectomy for stage I-III (22% stage I/II and 78% stage III) endometrial cancer. Median IMRT dose was 50.4 Gy. Adjuvant chemotherapy was given to 30 (65%) patients.ResultsWith a median follow-up of 52 months, 4 patients recurred: 1 vaginal plus lung metastasis, 2 isolated para-aortic recurrences, and 1 lungs and liver metastasis. Five-year relapse rate was 9% (95% CI, 0–13.6%). Five-year disease-free survival (DFS) was 88% (95% CI, 77–98%) and overall survival (OS) was 97% (95% CI, 90–100%). There were 2 patients with non-hematological grade 3 toxicity: 1 (2%) acute and 1 (2%) chronic gastrointestinal toxicity. In patients treated with IMRT and chemotherapy (n = 30), 5 had grade 3 leukopenia, 8 grade 2 anemia, and 2 grade 2 thrombocytopenia.ConclusionsOncologic outcomes with postoperative IMRT were very good, with DFS and OS rates of > 88% at median follow-up of 52 months, despite a preponderance (78%) of stage III disease. Toxicity was minimal even in the setting of an aggressive trimodality (65% of patients) approach. Data from this study and emerging data from RTOG trial 0418 demonstrate the advantages of IMRT in high-risk endometrial cancer.     

Role of MR imaging in surgical planning and prediction of successful surgical repair of pelvic organ prolapse

ObjectiveTo determine the role of magnetic resonance imaging (MRI) in surgical planning for females with pelvic organ prolapsed (POP) and to determine the clinical utility of MR imaging in predicting successful surgical repair.MethodsFifteen patients with different varieties of pelvic floor dysfunction and 15 nulliparous females as control subjects were studied by magnetic resonance imaging (static and dynamic). Intraoperative findings related to POP were correlated to MRI findings. In the symptomatic patients, magnetic resonance imaging was repeated within 6–12 months after surgery.ResultsPreoperative MRI and operative findings showed a significant correlation in all types of prolapse, except rectocele. On the other hand preoperative pelvic examination and operative findings were significantly correlated for cystocele, rectocele and vaginal cuff prolapse (r = 0.75, P < 0.008). Preoperative magnetic resonance imaging added information that changed the management in 40% of symptomatic women. Postoperative magnetic resonance imaging showed normal pelvic floor in asymptomatic patients (n = 13). Abnormal imaging findings were found in patients with persistent postoperative or de novo complaints (n = 2).ConclusionMagnetic resonance imaging can accurately localize pelvic floor defects, evaluate success or failure of surgical procedures, predict the need for more extensive reconstruction, and identify complications.     

Prediction of suboptimal primary cytoreduction in primary ovarian cancer with combined positron emission tomography/computed tomography--a prospective study

ObjectiveThe treatment of FIGO stage IB2 cervical cancer is controversial. Our aim was to assess treatment patterns, outcomes, and complications in patients with stage IB2 cervical cancer.MethodsA retrospective study of patients with stage IB2 cervical carcinoma at a single institution between January 1982 and September 2006 was performed. To adequately control treatment variables, we only included patients who underwent their entire treatment at our institution. Toxicity was assessed using NCI Common Toxicity Criteria (CTC).ResultsWe identified 82 patients, of whom 47 met the strict inclusion criteria. Of these, 27 patients (57%) underwent primary radical hysterectomy (RH) and 20 (43%) were treated with definitive radiation/chemoradiation therapy (RT/CRT). Patients selected for RT/CRT had a higher American Society of Anesthesiologist (ASA) score than those selected for surgery (P = 0.037). The 3-year progression free survival rate was 52% for the RH group and 55% for the RT/CRT group (P = 0.977). The 3-year overall survival rates were 72% and 55%, respectively (P = 0.161). Overall, 52% of patients in the RH group received postoperative radiation therapy as part of their adjuvant treatment. CTC grade 3, 4, and 5 complications affected 5 patients (19%) in the RH group and 3 (15%) in the RT/CRT group.ConclusionBoth RH and definitive RT/CRT are adequate management strategies for patients with FIGO stage IB2 cervical cancer. However, there was a subset of patients in whom RH as monotherapy was appropriate. Further studies are needed to evaluate the role of new preoperative models that will accurately identify these patients.     

Sexualité féminine après chirurgie pour endométriose pelvienne profonde

ObjectivesThe aim of this study is to assess the impact on sexuality of the surgical treatment in patients with symptomatic deep pelvic endometriosis.Patients and methodsThe design is a single-center cohort prospective study including all patients with symptomatic pelvic endometriosis and regular sexual activity who underwent surgery between October 2009 and September 2010. Sexual function was evaluated by the “Brief Index of Sexual Functioning for Women” (BISF-W) questionnaire translated and validated in French, including a global evaluation by the Composite Score (CS). Pain symptoms related to endometriosis were evaluated by the Visual Analog Scale (VAS) and the simple Verbal Rating Scale (VRS). Questionnaires were answered before surgery. A standardized mid and long-term postoperative follow-up was performed to compare sexuality and pain symptoms.ResultsTwenty women were included in the study. Mean follow-up was 23.3 months. When compared to a French reference population, global preoperative sexual function was significatively deteriorated (CS = 14.3 ± 10.8 vs 32.2 ± 12.6; P < 0.001), especially for arousal, frequency of sexual activity, pleasure and orgasm. Significant improvements in sex life were observed after surgery at the long-term follow-up (CS = 33.0 ± 11.7 vs 14.3 ± 10.8; P = 0.02). and sexual function was similar to the reference population (CS = 33.0 ± 11.7 vs 32.2 ± 12.6; P = 0.806). At the mid-follow-up, a significant improvement in the intensity of dysmenorrhoea, non-cyclic pelvic pain, dyspareunia and bowel symptoms were observed on the VAS. At the long-term follow-up, dysmenorrhoea and dyspareunia were significatively ameliorated. Pelvic pain recurrence related to endometriosis was 13.3%.Discussion and conclusionSurgical management of deep pelvic endometriosis in symptomatic patients improves sexual life at the long term follow-up. Deep dyspareunia pain decreases significantly, although other conditions are involved in the improvement of sexual function.     

Depressive symptoms,anxiety, and quality of life in women with pelvic endometriosis

ObjectiveTo assess depressive symptoms, anxiety and quality of life in women with pelvic endometriosis.Study designA prospective study of 104 women diagnosed with pelvic endometriosis. The Beck Depression Inventory (BDI) and the Hamilton Rating Scale for Depression (HAM-D) were used to evaluate depressive symptoms; the Spielberger State-Trait Anxiety Inventory (STAI) and the Hamilton Rating Scale for Anxiety (HAM-A) to evaluate anxiety symptoms; and the short (26-item) version of the World Health Organization Quality Of Life instrument (WHOQOL-BREF) to evaluate quality of life.ResultsOf the patients evaluated, 86.5% presented depressive symptoms (mild in 22.1%, moderate in 31.7%, and severe in 32.7%) and 87.5% presented anxiety (minor in 24% and major in 63.5%). Quality of life was found to be substandard. Age correlated positively with depressive symptoms, as determined using the BDI (P = 0.013) and HAM-D (P = 0.037). There was a positive correlation between current pain intensity and anxiety symptoms, as assessed using the STAI (state, P = 0.009; trait, P = 0.048) and HAM-A (P = 0.0001). The complaints related to physical limitations increased in parallel with the intensity of pain (P = 0.017). There was an inverse correlation between duration of treatment and quality of life (P = 0.017). There was no correlation between psychiatric symptoms and endometriosis stage.ConclusionsA rational approach to endometriosis should include an evaluation of the emotional profile and quality of life. That approach would certainly reduce the functional damage caused by the endometriosis.     

Prognostic value of responsiveness of neoadjuvant chemotherapy before surgery for patients with stage IB2/IIA2 cervical cancer

ObjectiveTo evaluate the factors that might affect the putative survival benefit from pre-operative neoadjuvant chemotherapy (NAC) in patients with early stage bulky cervical cancer.MethodsA retrospective review for 304 patients with stage IB₂/IIA₂ cervical cancer was performed. Two groups were made according to pre-operative NAC or not: NAC group (n = 154) and primary surgery group (PST, n = 150). Recurrence risks and survival were analyzed.ResultsThe total response rate was 72.1%. For those NAC-responders, NAC decreased the ratio of lymphovascular space invasion (0 vs. 4.7%, p = 0.022; 0 vs. 3.3%, p = 0.052), deep stromal invasion (19.8% vs. 53.5%, p = 0.000; 19.8% vs. 29.3%, p = 0.08), lymph node metastasis (8.1% vs. 25.6%, p = 0.004; 8.1% vs. 17.3%, p = 0.031), and the need of adjuvant radiotherapy (5.5% vs. 30.2%, p = 0.000; 5.4% vs. 15.3%, p = 0.012), whereas improve 5-year PFS rate (94% vs. 86%, p = 0.041; 94% vs. 80%, p = 0.089) and 5-year OS rate (96% vs. 86%, p = 0.015; 96% vs. 82%, p = 0.05), as compared with non-responders and PST. Multivariate analysis suggested that the response to NAC is an independent prognostic factor of PFS (HR 0.221, 95% CI 0.048–1.022, p = 0.053) and OS (HR 0.126, 95% CI 0.016–1.000, p = 0.05); as compared, stage IIA disease demonstrates negative impact upon PFS (HR 4.778, 95% CI 1.490–15.317, p = 0.009) and OS (HR 4.142, 95% CI 1.258–13.639, p = 0.019).ConclusionResponsiveness of NAC before surgery might be an independent prognostic factor for the patients with early stage bulky cervical cancer.     

A retrospective assessment of outcomes of chemotherapy-based versus radiation-only adjuvant treatment for completely resected stage I-IV uterine carcinosarcoma

PurposeTo determine the progression-free survival (PFS) and overall survival (OS) in a cohort of patients who received either platinum-based chemotherapy with or without radiation therapy (pelvic or WAI), or RT alone.MethodsMemorial Sloan-Kettering Cancer Center (MSKCC) electronic medical records from 8/1/1995 to 10/3/2007 were reviewed for patient age, diagnosis date, type of primary surgery, residual disease at the completion of primary surgery, FIGO stage, treatment details, dates of progression and death, and site(s) of first recurrence. PFS and OS by stage (I/II v III/IV) and by treatment type (chemotherapy with or without RT v RT alone) were determined using landmark analyses 8 weeks after surgery. Patients who received chemotherapy with or without RT (pelvic or abdominal) or RT alone (pelvic or abdominal) were included in the analysis. Both groups were allowed to have received intravaginal radiation therapy (IVRT).ResultsForty-nine patients met study criteria. Thirty-eight/49 patients received chemotherapy: 23/38 (60.5%) received paclitaxel-carboplatin; 7/38 (18.4%) received ifosfamide-platinum; 8/38 (21.0%) received other chemotherapy. FIGO stage was: I = 15 (31%); II = 5 (10%); III = 21 (43%); IV = 8 (16%). Three-year PFS for the entire cohort was 24%. Three-year OS for the entire cohort was 60%. Three-year median PFS time for the entire cohort was 15 months (95% CI: 11–25 months). Three-year median OS time for the entire cohort was 67 months (95% CI: 23–89 months). Three-year PFS for stages I–II was 43% v 14% for stages III–IV (HR = 1.98 [0.9–4.33]); P = 0.082. Three-year OS for stages I–II was 68% v 55% for stages III–IV (HR = 1.26 [0.47–3.41]); P = 0.648. Three-year PFS for chemotherapy with or without RT was 35% v 9% for RT alone (HR = 1.74 [0.79–3.85]); P = 0.164. Three-year OS for chemotherapy with or without RT was 66% v 34% for RT alone (HR = 2.02 [0.77–5.33]); P = 0.146.ConclusionsOur study corroborates GOG 150 results, and shows that paclitaxel-carboplatin appears to be an efficacious adjuvant chemotherapy regimen for completely resected uterine carcinosarcoma. The role of adjuvant RT in addition to chemotherapy warrants further investigation.     

Effect of body mass index on clinical outcomes of patients undergoing total laparoscopic hysterectomy

ObjectiveTo evaluate the effect of normal body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters) and obesity on clinical results among patients who underwent total laparoscopic hysterectomy (TLH).MethodsIn a prospective study at the Civil Hospital of Culiacan in Sinaloa State, Mexico, data were compared from 209 patients who underwent TLH between July 6, 2009, and December 30, 2011. The following primary variables were analyzed for 77 normal BMI patients, 82 overweight patients, and 50 obese patients: procedure duration, operative bleeding, major and minor trans-operative complications, length of hospital stay, and postoperative pain.ResultsThe mean duration of surgical procedure (P < 0.001) and operative bleeding (P = 0.002) were lower for patients with normal BMI compared with the other 2 groups. The rate of conversion to laparotomy was similar among the 3 groups. Overall, the frequency of complications was 6.2% (n = 13/209); the frequency of complications by study group was 2.6%, 4.8%, and 14% for the normal BMI, overweight and obesity groups, respectively (P < 0.05). Major complications were more frequent among patients with obesity (P = 0.010).ConclusionThe duration of surgical procedure and operative morbidity were found to increase, mainly owing to major complications, among patients with obesity (BMI ≥ 30).     

Pelvic Floor Tenderness in the Etiology of Superficial Dyspareunia

ObjectiveTo calculate the prevalence of pelvic floor tenderness in the population of women with pelvic pain and to determine its implications for symptoms of pelvic pain.MethodsWe conducted a retrospective review of patients with pelvic pain at a tertiary referral centre. Pelvic floor tenderness was defined as levator ani tenderness on at least one side during single digit pelvic examination. The prevalence of pelvic floor tenderness in this cohort of women with pelvic pain was compared with the prevalence in a cohort of women without pain attending a gynaecology clinic. In the women with pelvic pain, multiple regression was performed to determine which variables were independently associated with pelvic floor tenderness.ResultsThe prevalence of pelvic floor tenderness was 40% (75/189) in the cohort with pelvic pain, significantly greater than the prevalence of 13% (4/32) in the cohort without pain (OR 4.61; 95% CI 1.55 to 13.7, P = 0.005). On multiple logistic regression, superficial dyspareunia (OR 4.45; 95% CI 1.86 to 10.7, P = 0.001), abdominal wall pain (OR 4.04; 95% CI 1.44 to 11.3, P = 0.005), and bladder base tenderness (OR 4.65; 95% CI 1.87 to 11.6, P = 0.001) were independently associated with pelvic floor tenderness. Pelvic floor tenderness was similarly present in women with or without underlying endometriosis.ConclusionPelvic floor tenderness is common in women with pelvic pain, with or without endometriosis, and is a contributor to superficial dyspareunia. Pelvic floor tenderness was also associated with abdominal wall pain and bladder base tenderness, suggesting that nervous system sensitization is involved in the etiology of pelvic floor tenderness.     

Pelvic node removal and disease-free survival in cervical cancer patients treated with radical hysterectomy and pelvic lymphadenectomy

ObjectiveTo examine the relationship between the number of pelvic nodes removed and 5-year disease-free survival in early-stage cervical cancer patients who underwent radical hysterectomy and pelvic lymphadenectomy (RHPL).MethodsThe medical records of 826 cervical cancer patients who underwent RHPL and who had at least 11 pelvic nodes removed at Chiang Mai University Hospital between January 2002 and December 2008 were reviewed. The patients were divided into 4 groups according to the number of nodes removed: 11–20 nodes (n = 243); 21–30 nodes (n = 344); 31–40 nodes (n = 171); and ≥ 41 nodes (n = 68). The 5-year disease-free survival of patients in each group was compared. The clinicopathological factors were analyzed using Cox regression to identify independent prognostic factors.ResultFive-year disease-free survival was not significantly different among the 4 groups. When patients with and without nodal involvement were considered separately, the 5-year disease-free survival in all groups was not significantly different. At multivariate analysis, the number of pelvic nodes removed was not an independent prognostic factor.ConclusionThe number of pelvic nodes removed was not associated with 5-year disease-free survival or number of positive pelvic nodes.     

Analysis of disease recurrence and survival for women with uterine malignancies undergoing robotic surgery

ObjectivesTo evaluate recurrence-free survival (RFS) and overall survival (OS) for patients who underwent robotic-assisted laparoscopic hysterectomy (RALH) for uterine malignancies.MethodsMedical records from 372 patients with uterine malignancies who underwent RALH from 3/06 to 3/09 at two institutions were reviewed for clinico-pathologic data, adjuvant therapies, disease recurrence, and survival. Median follow-up for survival analysis was 31 ± 14 months. Thirty (8.1%) patients were lost to follow-up before 12 months and censored from the recurrence analysis.ResultsMean age and BMI of 372 patients was 61.8 ± 9.8 years and 32.2 ± 8.4 kg/m² (range 19–70). Robotic procedures included RALH 16 (4.3%), RALH with pelvic lymphadenectomy (PL) 96 (25.8%), and RALH with pelvic-and-aortic lymphadenectomy (PAL) 252 (67.7%) cases. Histology included 319 (85.8%) endometrioid and 53 (12.6%) high-risk histologies. Mean pelvic and aortic lymph node counts were 16.8 ± 8.7 and 8.4 ± 4.5, respectively. Lymph node metastases were identified in 26 (7.3%) cases. Adjuvant therapies were prescribed for 108 (29.1%) of patients: 7.8% brachytherapy, 1.9% pelvic radiation + brachytherapy, 7.8% chemotherapy, 11.6% chemotherapy + radiation. Risk of recurrence for all patients was 8.3% and 17 (4.6%) patients died of disease. The estimated 3-year recurrence-free survival (RFS) for the entire study group was 89.3% and the estimated 5-year overall survival (OS) was 89.1%, compared to 92.5% and 93.4% for the endometrioid sub-set.ConclusionsPatients with endometrial cancer undergoing robotic hysterectomy with staging lymphadenectomies during our 3-years of robotic experience had low-risk for recurrence and excellent disease-specific survival at a median follow-up time of 31 months.     

Identifying risk factors for occult lower extremity lymphedema using computed tomography in patients undergoing lymphadenectomy for gynecologic cancers

ObjectiveTo identify risk factors for lower extremity lymphedema (LEL) using computed tomographic (CT) scan in patients undergoing lymphadenectomy for gynecologic cancers.MethodsWe retrospectively reviewed 511 consecutive gynecologic cancer patients undergoing lymphadenectomy. Mean difference (3.77 ± 3.14 mm) of subcutaneous layer thicknesses between preoperative and postoperative 1-year CT scans of 106 patients with clinical LEL was used as an objective criterion for regrouping all the patients into those with mean difference > 3.77 mm and ≤ 3.77 mm. Risk factors for clinical LEL and significant increase of subcutaneous layer thickness on CT were evaluated using a logistic regression model.ResultsA total of 106 (20.7%) patients were clinically diagnosed with LEL by a physician. Total number of lymph nodes (LNs) retrieved > 30 (Odds ratio [OR] 3.2; 95% Confidence interval [CI] 1.94–5.32; p < 0.001) and adjuvant pelvic radiotherapy (OR 3.1; 95% CI 1.75–5.52; p < 0.001) were risk factors for clinical LEL. One hundred-nineteen (23.3%) had subcutaneous layer thickness increase of > 3.77 mm. In addition to number of LNs retrieved > 30 (OR 2.3; 95% CI 1.40–3.74; p = 0.001) and adjuvant pelvic radiotherapy (OR 1.7; 95% CI 1.01–2.74; p = 0.046), open surgery (OR 1.8; 95% CI 1.01–3.11; p = 0.045), long operation time (OR 1.7; 95% CI 1.05–2.83; p = 0.032), and no use of intermittent pneumatic compression (IPC) (OR 2.1; 95% CI 1.06–4.16; p = 0.034) were risk factors for thick subcutaneous layer on postoperative CT.ConclusionsIn addition to high LN retrieval and adjuvant pelvic radiotherapy, open surgery, long operation time, and no IPC use could be risk factors for occult LEL after lymphadenectomy in gynecologic cancers.     

Pregnancy on long term follow up in endometriosis patients with evidence of altered peritoneal fluid oxidative stress status

ObjectiveThe aim is to assess whether women with endometriosis, idiopathic infertility, and tubal ligation have different levels of reactive oxygen species (ROS), total antioxidant capacity (TAC), and ROS–TAC score in their peritoneal fluid, and to assess whether the ROS–TAC score is a better predictor of endometriosis and pregnancy than the ROS and TAC scores alone.Materials and methodsPeritoneal fluid from 108 women: 60 with endometriosis, 38 with tubal ligation/reanastomosis and 10 with unexplained infertility was obtained. ROS was measured by the chemiluminescence assay using luminol as the probe and TAC was measured using the colorimetric assay. We compared the three groups on their ROS, TAC, and ROS–TAC scores using Kruskal–Wallis test, and compared the ability of ROS, TAC and the ROS–TAC scores to predict endometriosis vs. idiopathic and tubal, and pregnancy using the DeLong non-parametric method of comparing two dependent ROC curves.ResultsEndometriosis patients had significantly higher ROS values compared with tubal ligation/reanastomosis patients (P = 0.005). Peritoneal fluid TAC levels were not different across the three groups. Significantly lower ROS–TAC score [indicative of higher oxidative stress (OS)] was observed in endometriosis and unexplained infertility patients compared to tubal ligation/reanastomosis patients (overall P = 0.003). There is no evidence that the ROS–TAC score (AUC = 0.71, 95%; CI = 0.60, 0.81) is significantly better at predicting endometriosis diagnosis than either TAC alone (AUC = 0.73, 95%; CI = 0.63, 0.82) or ROS alone (AUC = 0.73, 95%; CI = 0.63, 0.83). Fifty-four patients with endometriosis attempted to become pregnant. Those that became pregnant (20%, 11/54) had significantly lower levels of ROS values (P = 0.001), higher levels of TAC (P = 0.021), and higher ROS–TAC scores (P = 0.002) than endometriosis patients who did not get pregnant.ConclusionEndometriosis patients with lower peritoneal fluid ROS and higher TAC levels were more likely to get pregnant.     

Position-related injury is uncommon in robotic gynecologic surgery

ObjectiveTo assess the rate and risk factors for position-related injury in robotic gynecologic surgery.MethodsA prospective database from 12/2006 to 1/2014 of all planned robotic gynecologic procedures was retrospectively reviewed for patients who experienced neurologic injury, musculoskeletal injury, or vascular compromise related to patient positioning in the operating room. Analysis was performed to determine risk-factors and incidence for position-related injury.ResultsOf the 831 patients who underwent robotic surgery during the study time period, only 7 (0.8%) experienced positioning-related injury. The injuries included minor head contusions (n = 3), two lower extremity neuropathies (n = 2), brachial plexus injury (n = 1) and one large subcutaneous ecchymosis on the left flank and thigh (n = 1). There were no long term sequelae from the positioning-related injuries. The only statistically significant risk factor for positioning-related injury was prior abdominal surgery (P = 0.05). There were no significant associations between position-related injuries and operative time (P = 0.232), body mass index (P = 0.847), age (P = 0.152), smoking history (P = 0.161), or medical comorbidities (P = 0.229–0.999).ConclusionsThe incidence of position-related injury among women undergoing robotic surgery was extremely low (0.8%). Due to the low incidence we were unable to identify modifiable risk factors for position-related injury following robotic surgery. A standardized, team-oriented approach may significantly decrease position-related injuries following robotic gynecologic surgery.     

Complications after double-barreled wet colostomy compared to separate urinary and fecal diversion during pelvic exenteration: Time to change back?

ObjectiveTo assess complications associated with double-barreled wet colostomy (DBWC) in the first six months after pelvic exenteration as compared to separate urinary and fecal diversion (SUD).MethodsA single institution retrospective chart review was conducted of all patients who underwent a pelvic exenteration between 2000 and 2011. Patients were included if the procedure involved at least a urinary diversion and a perineal phase. Patient demographics and complications in the first 6 months after surgery were recorded.ResultsThirty-three patients met inclusion criteria (12 DBWC and 21 SUD). The majority of patients had recurrent cervical cancer (58%) followed by vaginal, vulva, and endometrial cancer. All patients had previously received radiation. 10/12 patients with a DBWC and 67% of SUD had pelvic reconstruction. Median length of stay (LOS) was shorter for DBWC (14.5 vs. 20 days, p = .01). Median operating times were shorter for DBWC (610 vs. 702 minutes, p = .04). No urinary conduit or anastomotic bowel leaks occurred in the DBWC group compared to 5 (24%) and 2 (9.5%), respectively, in the SUD group (p = .06 for any leak). 58% of the DBWC and 62% of the SUD group required re-operation, and there were no 30-day peri-operative deaths.ConclusionsDBWC can be performed safely at the time of pelvic exenteration. We found reduced operating times, shorter LOS, and a trend toward fewer urinary conduit and/or bowel anastomotic leaks in DBWC exenteration patients. DBWC may be favorable over more technically challenging SUD in this heavily radiated population that generally has a limited overall survival.     

Treatment of vulvar intraepithelial neoplasia with topical 5% imiquimod cream

ObjectiveTo assess the efficacy of 5% imiquimod cream for treating vulvar intraepithelial neoplasia (VIN).MethodsIn a retrospective study, data were analyzed from 62 patients with biopsy-diagnosed VIN stage I–III who were treated with 5% imiquimod cream at University Hospital of Freiburg, Germany, between 2004 and 2011. Several patient and lesion characteristics were evaluated, and follow-up was 3–72 months (median 21 months).ResultsAmong 62 women treated, 47 (76%) showed a complete response, 12 (19%) showed a partial response, 2 (3%) showed a weak partial response, and 1 did not respond. Disease recurrence occurred for 17 (27%) women. Recurrence rates were significantly lower among HPV-positive patients (P = 0.046), and among women younger than 65 years (P = 0.030). Patients without local inflammation during treatment were less likely to show a complete response (P = 0.049). Response rates did not depend on lesion size; however, women with large lesions required longer treatment and higher total dosages for a complete response.Conclusion5% imiquimod cream was found to be a favorable alternative to ablative treatment of VIN independently of lesion grading, appearance, and size. Patient age, HPV status, and occurrence of adverse effects significantly influenced treatment outcome.     

Circulating endothelial progenitor cells and placental abruption in women with preeclampsia

ObjectiveAbnormalities in circulating angiogenic factors and endothelial progenitor cells (EPCs) have been reported in patients with preeclampsia and placental abruption. The objective of this study was to determine whether the number of EPCs is altered in patients with placental abruption.DesignA case control study.SettingHiroshima University Hospital in Japan.SamplePregnant Japanese women with preeclampsia (n = 27) and those without any complications (n = 15).MethodThe EPC (CD45^lowCD34⁺CD133⁺ cells) counts were examined using flow cytometry in peripheral blood collected from 27 women with preeclampsia and 15 normal pregnant women. Among the 27 women with preeclampsia, five subsequently developed placental abruption. All subjects were divided into three groups: normal pregnancy (NP, n = 15), preeclampsia without placenta abruption (PE, n = 22) and preeclampsia with placental abruption (PA, n = 5).Main outcome measuresThe EPC counts were measured in pregnant women with preeclampsia who subsequently developed placental abruption.ResultsThe EPC count in the PE group significantly decreased in comparison to that observed in the NP group (620 cells/ml versus 1918 cells/ml, P < 0.01). In the PA group, the EPC count was found to markedly decrease in comparison to that observed in the PE group (221 cells/ml, P < 0.05).ConclusionsThe number of EPCs was found to significantly decrease in preeclamptic women who subsequently developed placental abruption.     

Bacterial vaginosis and Mycoplasma infections in reproductive-age women: Clarifying the association with risk factors

ObjectivesThis study seeks to examine the association between predisposing risk factors and the prevalence of bacterial vaginosis (BV) as well as Mycoplasma hominis (MH) and Ureaplasma urealyticum (UU) infections in reproductive age women and investigate its relationship with infertility.MethodsThis cross-sectional, prospective study was carried out using sexually active females who presented at the Gynaecology Clinic with complaints of vaginal discharge. Two cervical smear samples were taken from the endocervical canal using sterile cotton swabs for each patient. The patients were questioned to obtain their demographic data and potential risk factors for lower genital tract infections, and their responses were recorded.ResultsOf 348 patients, BV was detected in 46.3%, UU in 26.7%, MH in 3.7% and UU and MH co-infection in 13.2%. The prevalence of BV concomitant with UU and/or MH was significantly high (p = .001). The most prominent risk factors for BV were UU and MH infection (AOR = 6.79, 95% confidence interval (CI): [2.63–17.56]), vaginal douche use (AOR = 6.80, 95% CI: [03.60–12.83]), abortion history (AOR = 2.82, 95% CI: [1.55–5.12]) and high body mass indexes (BMI) (AOR = .81, 95% CI: [.74–.89]). The prevalence of BV, UU and MH was significantly higher in infertile patients than fertile patients (p = .002).ConclusionsBacterial vaginosis, MH, and UU co-infection were common in patients with vaginal discharge, and it was detected considerably higher in infertile patients than in fertile patients.