The effect of chemotherapy or radiotherapy on thymidine phosphorylase and dihydropyrimidine dehydrogenase expression in cancer of the uterine cervix

Objective

To evaluate the feasibility in everyday practice and the advantages of salpingectomy for ectopic pregnancy by single-incision laparoscopic surgery with the SILS^® system.

Study design

This single-center prospective observational study included 37 women requiring salpingectomy for ectopic pregnancy who underwent single-incision laparoscopic salpingectomy with the SILS^® system. Information about feasibility and intra- and post-operative data were collected. The data for these patients were compared with those of a control group of 40 women treated by standard laparoscopy.

Results

Thirty-six (97%) patients were treated successfully with the SILS^® system. After laparoscopic confirmation of the ectopic pregnancy, salpingectomy was performed with bipolar forceps and scissors. In one case, conversion to classic laparoscopy was performed because SILS was not feasible. Compared with the control group, operative time was longer (50 ± 35 vs 35 ± 30 min, p = 0.001) but duration of hospitalization shorter with single-site laparoscopy (1.5 ± 1.5 vs 2.3 ± 1.5 days, p = 0.02).

Conclusions

Laparoscopic salpingectomy for ectopic pregnancy appears to be feasible in everyday practice by single-incision laparoscopic surgery with the SILS^® system and appears to reduce the duration of hospitalization. Larger series are necessary to confirm this conclusion.     

Tratamiento del embarazo ectópico cervical con metotrexato y rescate con leucovorina

Objective

To present two cases of cervical ectopic pregnancy successfully treated with systemic methotrexate.

Subjects and methods

Two women with a cervical ectopic pregnancy. Interventions: alternative day regime of methotrexate 1 mg/kg (days 1,3,5 and 7) with folinic acid rescue (days 2, 4, 6, and 8). End points: successful treatment.

Results

Two cases of ectopic cervical pregnancy were successfully treated and preserved their reproductive capability.

Conclusions

Conservative medical treatment of cervical ectopic pregnancy with systemic methotrexate is safe and effective.     

Análisis del valor del misoprostol en el tratamiento del aborto diferido

Objective

To study the use of misoprostol as an alternative management for early pregnancy loss.

Materials and methods

Patients (n = 109) diagnosed with early pregnancy loss between December 2009 and December 2010 were offered medical treatment with 600 μg intravaginal misoprostol or surgical curettage.

Results

Ninety-two patients (84.40%) received medical treatment and 17 (15.60%) were treated surgically. Medical treatment was successful in 78 patients (84.8%). Compared with surgery, medical treatment was more painful (visual analog scale 1-10) (6.29 [2.46] vs. 4.24 [3.35]; P = .026), required fewer days of absence from work (3.0 [1.3-7.0) vs. 6.5 [4.0-14.8]; P = .007), and increased the need for painkillers (P = .014). Overall satisfaction (scale 1-10) was higher with surgery 9.33 (1.32) vs. 8.26 (1.64) P = .024. The cost of medical treatment was 123,04 euros lower per procedure.

Conclusion

Medical treatment with misoprostol was successful in almost 90% of patients, with few adverse effects, a good satisfaction rate and lower cost than surgical curettage.     

Fertility outcomes subsequent to treatment of tubal ectopic pregnancy in younger Turkish women

Study Objective

The assessment of future fertility in patients that were hospitalized with diagnosis of tubal ectopic pregnancy.

Design

Between January 1998 and September 2008, we retrospectively reviewed 219 tubal ectopic pregnancy patients who were hospitalized. The patients using contraceptive methods, underwent previous pelvic or tubal surgery, pregnancy after in vitro fertilization, over the age of 28, and extratubal ectopic pregnancies were excluded. Patients who actively attempted to conceive were included. We called all the patients to see whether they had pregnancy in 24 months, and how long they had waited for this after the operation. Overall, we could not reach 14 patients who were treated surgically (n = 9) or medically (n = 5).

Setting

Department of Obstetrics and Gynecology, Ege University, Izmir, Turkey.

Participants

Women aged between 18 and 28 years that were treated because of tubal ectopic pregnancy and have concerns about infertility.

Interventions

Medical treatment with methotrexate (n = 34), salpingectomy (n = 62) salpingostomy (n = 37).

Main Outcome Measures

Intrauterine pregnancy rates, ectopic pregnancy rates and mean time to pregnancy after interventions.

Results

After questionnaire: in the methotrexate group; six of 29 (20%) had no pregnancy; 23 (79%) of them conceived, but three (10%) of the pregnancies were extrauterine. Thirty-seven patients received salpingostomy and 62 patients composed the salpingectomy group. Intrauterine pregnancy rates up to 24 months were established as 65.2% in salpingectomy (n = 55) and 60.1% in the salpingostomy (n = 35) groups respectively. No significant difference was noticed when pregnancy rates were compared among three groups (P = 0.942). Mean time to pregnancy in methotrexate group was 7.8 ± 2.2 months, and in salpingostomy and salpingectomy groups was 8.7 ± 2.2 and 9.3 ± 3.1 months respectively (P = 0.841).

Conclusion

Since we found no difference in terms of pregnancy rates among three groups, medical treatment appears to be more favored with early and accurate diagnosis. After salpingectomy, patients may conceive later in life when compared with other groups so selected patients should be assessed according to their age for the decision of assisted reproductive techniques.     

Medical therapy (methotrexate and mifepristone) alone or in combination with another type of therapy for the management of cervical or interstitial ectopic pregnancy

Objective

To describe cases of cervical or interstitial ectopic pregnancy managed conservatively with combined medical treatment (methotrexate and mifepristone) alone or in association with other minimally invasive strategies.

Study design

We describe four cervical and two interstitial ectopic pregnancies at our hospital between 2006 and 2010. All received combined treatment with methotrexate and mifepristone. A search of MEDLINE is also described.

Results

The literature search identified only four previous cases of cervical ectopic pregnancies and no cases of interstitial ectopic pregnancy managed with combined therapy. In our study, all patients were successfully treated and had no adverse reactions with intramuscular methotrexate 50 mg/m² and oral mifepristone 600 mg, either alone or in association with minimally invasive treatment (uterine artery embolization and evacuation dilation and curettage). All patients remained asymptomatic with β-HCG levels that decreased and became negative within 14–49 days: the median hospital stay was 5.5 days. We also describe the first patient with a cervical ectopic pregnancy treated with methotrexate and mifepristone, followed by vaginal misoprostol 800 mcg for cervical evacuation.

Conclusion

Methotrexate–mifepristone, either alone or in combination with other minimally invasive strategies, could be considered an option for the treatment of both cervical and interstitial ectopic pregnancy. An individualized approach should be used in each patient, however, given the wide variety of possible clinical situations and the potential seriousness of ectopic pregnancy.     

Embarazo ectópico: de la cirugía de urgencia al tratamiento médico. Evolución de la terapéutica en nuestro centro

Objective

To analyze changing trends in the management of ectopic pregnancy in the previous 9 years.

Material and methods

We performed a retrospective study of 355 patients with ectopic pregnancy treated at the Virgen de las Nieves University Hospital from 1998 to 2006. We reviewed and analyzed changes in treatment trends over this 9-year period.

Results

Medical treatment was initiated in 139 patients (39.15%), with a failure rate of 10.07%. Surgery was performed in 230 women (60.85%). Of these, laparoscopy was performed in 121 and laparotomy in 109.

Conclusions

Laparoscopic surgery is currently the first-line therapeutic option in the management of tubal ectopic pregnancy. However, in the last few years, medical treatment has been shown to be safe and effective, allowing a less invasive approach.     

Abordaje laparoscópico del dolor abdominal agudo en mujeres en edad fértil

Objectives

To assess the effectiveness of the laparoscopic approach in acute abdominal pain in women of reproductive age presenting to the Emergency Department.

Material and methods

We performed an observational, prospective study of acute abdominal pain treated by gynecological laparoscopic procedures. The main variables evaluated were the cause of pain, type of surgery, complications, and conversions to open surgery.

Results

Between January 2009 and December 2011, we performed 110 urgent laparoscopic interventions. The reasons for surgery were rupture of an ovarian cyst in 40 interventions (36.7%), an ectopic pregnancy in 24 (21.8%), a pelvic inflammatory disease in 23 (20.9%), adnexal torsion in 12 (10.9%), and other reasons in 11 (10%). In these 110 interventions, there was one case of postoperative bleeding requiring reintervention and one case of conversion.

Conclusions

The laparoscopic approach is safe and effective in urgent gynecological surgery.     

Twin ectopic pregnancy after ipsilateral salpingectomy: A report of cases

Background

Ectopic pregnancy continues to be a significant cause of maternal morbidity and mortality. Recurrent ectopic pregnancy in the remnant portion of the tube after a previous ipsilateral salpingectomy has only rarely been reported. We present unusual cases of ipsilateral ectopic pregnancy occurring in the stump of an ectopic site.

Prevención del aborto

Objectives

To assess various social factors related to therapeutic abortion (voluntary pregnancy interruption [VPI], since the term therapeutic was traditionally used for abortions due to medical indication) with the aim of obtaining information in the context of the couple, the family and society.

Subjects and methods

Data were gathered through a personal interview performed in 1,600 patients who underwent VPI.

Results

A total of 26.9% of the patients were visiting a gynecologist for the first time. Most of the patients (84.3%) had said nothing to their parents and 12.9% had said nothing to their partners either. Three-quarters (76%) agreed with the possibility of having a VPI and with its legality; 18.3% were against.

Conclusions

Reducing the number and rate of abortions requires a more open understanding of both sex and sexuality, promoting a dialogue within the family and at school, as well as the design of complete education programs.     

Hysteroscopic hydrosalpinx occlusion with Essure device in IVF patients when salpingectomy or laparoscopy is contraindicated

Objective

To evaluate, in patients with hydrosalpinges, the effect on in vitro fertilization (IVF) outcome of the insertion by hysteroscopy of an intratubal blocking device, in cases where laparoscopic salpingectomy or laparoscopy was contraindicated.

Study design

A prospective interventional case series study was conducted in fifteen women with unilateral (N = 6) or bilateral hydrosalpinges (N = 9) submitted for IVF. In all of them, laparoscopic salpingectomy was contraindicated. Hysteroscopic insertion of the Essure intratubal device in a consultation room setting was performed. IVF results were compared with those of women where hydrosalpinx was treated by laparoscopic salpingectomy (48 women, 76 cycles).

Results

There were no complications during or immediately after the procedure in any of the patients. There were four pregnancies from 16 embryo-transfers with own oocytes, one spontaneous pregnancy after unilateral Essure insertion, and one pregnancy after oocyte donation. In one case the hydrosalpinx grew and pelvic inflammatory disease developed 6 months after the insertion, requiring bilateral adnexectomy. Although not of statistical significance, IVF pregnancy rates were somewhat lower than in the laparoscopic salpingectomy group, which was attributed to the lower ovarian reserve before Essure insertion.

Conclusion

The hysteroscopic insertion of the Essure intratubal device prior to IVF is a reasonable option in cases where laparoscopic salpingectomy is contraindicated. Larger series are required to assess pregnancy outcome.     

Low-dose methotrexate treatment in ectopic pregnancy: a retrospective analysis of 164 ectopic pregnancies treated between 2000 and 2008

Purpose

Ectopic pregnancy is an acute, potentially life-threatening condition. The aim of this study was to compare the results of surgery and methotrexate treatment in women with ectopic pregnancy, along with a review of the literature.

Methods

164 women with ectopic pregnancy, treated from 2000 to 2008 at the university gynecology department, were examined in a retrospective analysis. Patients with diagnosed ectopic pregnancy underwent one of the following treatments: Salpingotomy, salpingectomy or administration of a single dose of 30 mg methotrexate. The main outcome measures were treatment success rate, rate of patients wishing to have children after the ectopic pregnancy, and rates of pregnancy, live births, recurrent ectopic pregnancy, miscarriage, use of assisted reproduction and side effects.

Results

There were no significant differences in success rates between the groups (methotrexate 83.9 %, salpingotomy 88.2 %, salpingectomy 96.8 %). Significantly more patients in the salpingotomy group wished to become pregnant afterward than in the salpingectomy group. No significant differences were observed between the groups in the rates of intrauterine pregnancy, live births, recurrences, miscarriages, or side effects.

Conclusions

With defined inclusion criteria, similar results can be achieved with low-dose single administration of 30 mg methotrexate in comparison with surgical treatment for ectopic pregnancy. On the basis of the data presented here, further research to establish optimal dosages for methotrexate is needed.     

Overall care cost comparison between robotic and laparoscopic surgery for endometrial and cervical cancer

Objective

The aim of our medico-economic study was to compare robotic surgery cost with conventional laparoscopic cost in endometrial and cervical cancer.

Study design

Our study included laparoscopic and robot-assisted procedures (radical hysterectomies and lymphadenectomies) for endometrial or cervical cancer ever since first using the Da Vinci^® in 2008 within a hospital setting. In the hospital perspective, direct costs were determined by examining the overall medical pathway for each type of intervention. Actual costs were calculated for 27 conventional laparoscopic procedures and for 30 robot-assisted procedures including initial cost of the robot and its maintenance. We estimated the complete medical “overall care” costs by adding the costs of consultations, surgery and post-operative hospital stay to the costs of any eventual emergency consultation and/or hospitalisation within the two months that followed surgery. A sensitivity analysis was performed to evaluate the effects of variable modulations.

Results

For endometrial cancer, surgical procedure cost for robotic-assisted surgery was €7402 compared to €2733 for conventional laparoscopic surgery. When considering overall medical care, the patient treatment average cost was €6666 for the laparoscopic group (with an average length of stay of 5.27 days) as compared to €10,816 for robotic group (with an average hospital stay of 4.60 days), p = 0.39. For cervical cancer, average surgical cost with robotic-assisted surgery was €8501 compared to conventional laparoscopic surgery at €3239. For cervical cancer, overall care average cost was €7803 for the laparoscopic group (with an average length of stay of 5.83 days) as compared to €12,211 for the robotic group (with an average hospital stay of 4.70 days) p = 0.07. Sensitivity analysis results confirmed the cost overrun with the use of robotic assisted surgery.

Conclusions

Conventional laparoscopy was less expensive in our institution than robotic-assisted surgery for the surgery of endometrial (1:2.7) and cervical (1:2.6) cancers. When considering overall medical care, the use of robotic-assisted surgery was found to be 1.6 times more expensive than conventional surgery.     

Interstitial and Cornual Ectopic Pregnancy: Conservative Surgical and Medical Management

Background

Interstitial and cornual ectopic pregnancy is rare, accounting for 2–4% of ectopic pregnancies and remains the most difficult type of ectopic pregnancy to diagnose due to low sensitivity and specificity of symptoms and imaging. The classic triad of ectopic pregnancy—abdominal pain, amenorrhea and vaginal bleeding—occurs in less than 40% of patients. The site of implantation in the intrauterine portion of fallopian tube and invasion through the uterine wall make this pregnancy difficult to differentiate from an intrauterine pregnancy on ultrasound. The high mortality in this type of pregnancy is partially due to delay in diagnosis as well as the speed of hemorrhage.

Methods

Three cases of interstitial pregnancy were retrospectively analyzed.

Result

Successful laparoscopic cornuostomy and removal of products of conception were performed in two cases, while one case was successfully managed by local injection with KCL and methotrexate followed by systemic methotrexate.

Conclusion

Early diagnosis and timely management are key to the management of interstitial and cornual ectopic pregnancy. With expertise in ultrasound imaging and advances in laparoscopic skills progressively, conservative medical and surgical measures are being used to treat interstitial and cornual ectopic pregnancy successfully.

     

Laparoscopia frente a laparotomía para el tratamiento quirúrgico del cáncer de endometrio

Objective

To compare overall survival and disease-specific survival for endometrial cancer with the laparoscopic and laparotomy approaches.

Subjects and methods

We performed a retrospective cohort study that included 235 patients with a diagnosis of endometrial carcinoma who were surgically treated between 2001 and 2010 either by the laparoscopic approach (104 patients) or by laparotomy (131 patients) in our hospital.

Results

Overall survival, disease-specific survival and the disease-free interval were similar in the two groups. In the laparoscopic group, disease-free survival was 85.5% and survival was 80.2%, while in the laparotomy group, disease-free survival was 77.9% and survival was 82.3%, with no statistically significant differences. In the laparoscopy group, operating time was longer and hospital stay was shorter. Except for organ injury, surgical and postoperative complications were similar.

Conclusions

There were no differences in survival or the disease-free interval between the laparoscopy and laparotomy groups. Considering the risks of surgery, laparoscopy is a good alternative to traditional surgery.     

Cornual Suture at the Time of Laparoscopic Salpingectomy Reduces the Incidence of Interstitial Pregnancy after In Vitro Fertilization

Study Objective

To investigate the effect of cornual suture at the time of laparoscopic salpingectomy on the incidence of interstitial pregnancy (IP) after in vitro fertilization (IVF).

Early experience with isobaric laparoendoscopic single-site surgery using a wound retractor for the management of ectopic pregnancy

Objective

To report our initial experience with isobaric (gasless) transumbilical laparoendoscopic single-site (LESS) surgery using a wound retractor for the management of ectopic pregnancy.

Study design

Twelve consecutive cases of ectopic pregnancy were managed by isobaric LESS surgery with the subcutaneous abdominal wall-lift method. In each case, a wound retractor was used as a transumbilical working port with insertion into the peritoneal cavity through a 2.5-cm vertical umbilical incision. Subsequent surgical procedures were performed with multiple conventional laparoscopic instruments through single umbilical port.

Results

All cases of ectopic pregnancy were successfully managed by isobaric LESS surgery. Procedures included salpingectomy in eight cases of ampullary pregnancy and two cases of isthmic pregnancy, salpingectomy and local methotrexate injection in one case of isthmic pregnancy, and salpingo-oophorectomy for one case of ovarian pregnancy. Neither extraumbilical incisions nor conversion to laparotomy was required. In a case of ruptured ampullary pregnancy with massive hemoperitoneum, intraoperative autologous blood salvage and donation avoided the need for the transfusion of bank blood. Although postsurgical umbilical seroma was noted in one case and systemic methotrexate administration was required for persistent ectopic pregnancy in one case of isthmic pregnancy respectively, there were no major surgical complications in this series. The technique yielded excellent cosmetic results with minimum postoperative scar concealed within umbilicus. Retrospective comparison of surgical parameters including surgical duration, estimated blood loss, frequency of postoperative analgesic use, time of bowel recanalization, postoperative inflammatory response and postoperative hospital stay did not show any significant differences between isobaric LESS surgery group and conventional isobaric multiport laparoscopic surgery group.

Conclusions

Based on the satisfactory outcome achieved in these initial 12 cases of ectopic pregnancy treated by isobaric LESS surgery, the wound retraction system combined with the subcutaneous abdominal wall-lift method appears to contribute favorably to LESS surgery for the management of ectopic pregnancy because the device permits free circumferential access and retraction during procedures without the closed condition required during pneumoperitoneum.     

Éxito en el manejo conservador del acretismo placentario mediante embolización y metotrexato

Introduction

The incidence of placenta accreta has risen and this entity can cause postpartum hemorrhage, often requiring obstetric hysterectomy. There are, however, alternative conservative treatments to surgery.

Case report

A 38-year-old woman in her first pregnancy underwent manual removal of the placenta, with moderate hemorrhaging and subsequent curettage. The diagnosis was confirmed by ultrasound scan and magnetic resonance imaging. Selective embolization of the nutritional vessel was performed and methotrexate was administered. Three days after the embolization, the placental mass was expelled.

Conclusions

Selective embolization of a nutritional vessel and adjuvant treatment with methotrexate are conservative techniques that allow preservation of both the uterus and fertility. According to previous reports in the literature, the time interval between delivery and definitive placental expulsion was lower in our case than in other conservatively managed cases.     

Epidemiología del aborto de repetición

Objective

To determine the possible causes of recurrent miscarriage in our environment and the pregnancy rate in these couples.

Material and methods

An observational retrospective study was carried out in 172 women who attended our unit for two or more recurrent miscarriages between 2002 and 2008.

Results

A total of 80.2% of the women became pregnant. Of these, 81.2% carried the fetus to term. The results of clinical study were normal in 70.9%. The alterations found were uterine in 48%, genetic in 2% and coagulation alterations in 44%. These alterations were associated in 6% of the patients.

Conclusions

Most of the couples consulting for recurrent miscarriage will not receive an etiologic diagnosis after clinical study. Reproductive prognosis worsens as the number of miscarriages increases. However, up to 80.2% of these women become pregnant again, of whom 81.1% will deliver a healthy neonate.     

La colposacropexia laparoscópica en el tratamiento del cistocele

Objective

To study the results of sacrocolpopexy in our hospital for the treatment of cystoceles.

Material and methods

A total of 77 patients were treated by laparoscopic sacrocolpopexy. With a minimum mean follow-up of 6 moths, a clinical examination was performed to detect symptoms of prolapse or urinary, sexual and rectal symptoms. Objective cure was defined as < grade 2 prolapse in the Baden-Walker classification.

Results

The mean age was 53.8 + 8.9 years. The mean operating time was 193.6 + 44 minutes. Intra-operative and post-operative complications rates were 11.6% and 19.4%, respectively. The mean length of hospital stay was 2.7 (1-8) days. With a mean follow-up of 15.3 + 12.8 months, the subjective cure rate was 89.6% and the improvement rate was 6.4%. The rate of anatomical recurrence of cystocele was 11.6%. Seventy-five patients reported they were satisfied or moderately satisfied (97.7%)

Conclusion

Laparoscopy sacrocolpopexy appears to be an effective method for the treatment of cystocele.     

An Updated Review of Ectopic Pregnancies Resulting from Assisted Reproduction

Purpose of Review

The purpose of this study was to review the most recent data regarding clinical risk factors for ectopic pregnancy (EP) among patients pursuing assisted reproduction, and the diagnosis and management of EP in this specific population.

Recent Findings

EP rates following assisted reproduction have fallen over time to 1–2%, identical to the general population. Clinical risk factors for EP following assisted reproduction include the transfer of autologous, fresh and cleavage-stage embryos. Use of a GnRH agonist trigger alone for fresh cycles is associated with a greater risk of EP than hCG trigger. Serial hCG measurements and transvaginal ultrasound remain the mainstay of EP diagnosis. The addition of endometrial sampling to exclude failing intrauterine pregnancy spares a majority of patients unnecessary methotrexate. Two recent meta-analyses confirm that methotrexate for EP does not diminish subsequent response to controlled ovarian hyperstimulation (COH), while data conflict regarding the effects of salpingectomy on subsequent ovarian response. A recent randomized controlled trial, primarily in a non-infertility population, showed similar rates of subsequent intrauterine pregnancy following salpingectomy or salpingostomy in the presence of normal contralateral fallopian tubes. A large population-based study confirmed this finding, but reported higher ongoing pregnancy rates following tubal preservation in patients with infertility or tubal disease attempting natural conception.

Summary

The risk of EP following IVF appears largely mediated by altered endometrial receptivity, shown to result from COH and GnRH agonist-only triggers. Transfer of frozen-thawed blastocysts confers the lowest rate of EP following IVF. Methotrexate does not impact subsequent ovarian response to stimulation, though the effects of salpingectomy remain to be determined. Salpingectomy and salpingostomy confer equitable subsequent ongoing pregnancy rates, though tubal preservation may confer an advantage in women with tubal disease or infertility planning natural conception.