Ultrasonic surgical aspiration for vaginal intraepithelial neoplasia

Objective

To determine the safety and efficacy of ultrasonic surgical aspiration (USA) in the treatment of vaginal intraepithelial neoplasia (VAIN).

Methods

Using the ICD code for VAIN, all patients who underwent USA were evaluated. Patient demographics, clinicopathologic data, and follow-up outcomes were abstracted from the medical records.

Results

Ninety-two patients underwent USA for VAIN. No surgical complications or postoperative scarring were recorded, and all patients were followed without further therapy after the procedure. Pathologic evaluation of the degree of VAIN in the aspirate obtained at the time of USA correlated with the preoperative biopsy results in all cases. With a median follow-up period of 4.5 years, the overall recurrence rate was 19.6%. The recurrence rate for high grade VAIN was significantly greater than that for low grade VAIN (32.3% vs 13.1%, P = 0.044).

Conclusion

Ultrasonic surgical aspiration is a safe and effective surgical option for VAIN, providing a histologic sample with minimal invasiveness.     

20 year experience of postoperative radiotherapy in IB-IIA cervical cancer patients with intermediate risk factors: impact of treatment period and concurrent chemotherapy

Objective

To compare the long-term clinical outcomes of adjuvant radiotherapy (RT) versus concurrent chemoradiotherapy (CCRT) in cervical cancer patients with intermediate risk factors.

Methods

Between 1990 and 2010, 110 cervical cancer patients with 2 or more intermediate risk factors (deep stromal invasion, lymphovascular space invasion, and large tumor size) underwent adjuvant RT (n = 56) or CCRT (n = 54) following radical surgery. Because CCRT had been performed since 2000, patients were divided into 3 groups regarding treatment period and the addition of chemotherapy, RT 1990-1999 (n = 39), RT 2000-2010 (n = 17) and CCRT 2000-2010 (n = 54). Majority of concurrent chemotherapeutic regimens were carboplatin and paclitaxel (n = 48).

Results

Five-year relapse-free survival (RFS) rates for RT 1990-1999, RT 2000-2010 and CCRT 2000-2010 were 83.5%, 85.6% and 93.8%, respectively. CCRT 2000-2010 had a significant decrease in pelvic recurrence (p = 0.012) and distant metastasis (p = 0.027). There were no significant differences in overall survival and RFS between RT 1990-1999 and RT 2000-2010. Acute grade 3 and 4 hematologic toxicities were more frequently observed in CCRT 2000-2010 (p < 0.001). However, acute grade 3 and 4 gastrointestinal (GI) and chronic toxicities did not differ between the groups.

Conclusions

This study shows that the addition of concurrent chemotherapy to postoperative RT in cervical cancer patients with intermediate risk factors may improve RFS without increasing acute GI and chronic toxicities, although hematologic toxicities increased significantly.     

Phase II trial of cetuximab in the treatment of persistent or recurrent squamous or non-squamous cell carcinoma of the cervix: a Gynecologic Oncology Group study

Purpose

The Gynecologic Oncology Group (GOG) conducted a phase II trial to assess the efficacy and tolerability of the anti-EGFR antibody cetuximab, in persistent or recurrent carcinoma of the cervix.

Patients and methods

Eligible patients had cervical cancer, measurable disease, and GOG performance status ≤ 2. Treatment consisted of cetuximab 400 mg/m² initial dose followed by 250 mg/m² weekly until disease progression or prohibitive toxicity. The primary endpoints were progression-free survival (PFS) at 6 months and response. The study used a 2-stage group sequential design.

Results

Thirty-eight patients were entered with 3 exclusions, leaving 35 evaluable for analysis. Thirty-one patients (88.6%) received prior radiation as well as either 1 (n = 25, 71.4%) or 2 (n = 10) prior cytotoxic regimens. Twenty-four patients (68.6%) had a squamous cell carcinoma. Grade 3 adverse events possibly related to cetuximab included dermatologic (n = 5), GI (n = 4), anemia (n = 2), constitutional (n = 3), infection (n = 2), vascular (n = 2), pain (n = 2), and pulmonary, neurological, vomiting and metabolic (n = 1 each). No clinical responses were detected. Five patients (14.3%; two-sided 90% CI, 5.8% to 30%) survived without progression for at least 6 months. The median PFS and overall survival (OS) times were 1.97 and 6.7 months, respectively. In this study, all patients with PFS at 6 months harbored tumors with squamous cell histology.

Conclusion

Cetuximab is well tolerated but has limited activity in this population. Cetuximab activity may be limited to patients with squamous cell histology.     

A comparison of vaginal, laparoscopic-assisted vaginal, and minilaparotomy hysterectomies for enlarged myomatous uteri

Objective

To compare the operative data and early postoperative outcome of vaginal hysterectomy (VH), laparoscopic-assisted vaginal hysterectomy (LAVH), and minilaparotomy hysterectomy (MiniLPT).

Methods

A total of 150 women who required hysterectomy for enlarged myomatous uteri were randomly allocated into 3 treatment groups: VH (n = 50), LAVH (n = 50), and MiniLPT (n = 50). The primary outcome was hospital discharge time. The secondary outcomes were operative time, blood loss, paralytic ileus, postoperative pain, and intraoperative and early postoperative complications.

Results

Mean hospital discharge time was longest with MiniLPT, and shortest with VH (P < 0.01). VH was the fastest operating technique, was associated with less blood loss, and resulted in shortest duration of paralytic ileus (P < 0.01). No intraoperative complications occurred.

Conclusion

VH should be the preferred surgical approach in patients with enlarged myomatous uteri. When VH is not feasible, LAVH should be considered an alternative to MiniLPT. Further controlled prospective studies are required to confirm these results.     

Uterosacral-cardinal ligament stretching prior to vaginal hysterectomy increases uterine descent: a novel technique

Objective

To examine the effect of uterosacral-cardinal ligament complex stretching prior to vaginal hysterectomy on uterine descent.

Study design

A prospective trial of 25 consecutive women undergoing vaginal hysterectomy. Pre-operative, apical, anterior and posterior wall POP-Q measurements were recorded for each patient before and after uterosacral-cardinal ligament complex stretching during general anesthesia.

Results

Uterosacral-cardinal ligament complex stretching yielded a significant increase in mean stage of uterine and anterior wall descent (2.6 ± 0.6 vs. 3.2 ± 0.6 cm, p < 0.001, and 2.5 ± 0.8 vs. 2.9 ± 0.8 cm, respectively, p < 0.004). There was no significant change in posterior wall prolapse measurements (1.3 ± 0.7 vs. 1.4 ± 0.8 cm, p = 0.05).

Conclusion

Uterosacral-cardinal ligament complex stretching prior to vaginal hysterectomy increase uterine descent.     

Initial experience with repetitive transarterial chemoembolization (TACE) as a third line treatment of ovarian cancer metastasis to the liver: indications, outcomes and role in patient's management

Objective

To evaluate local tumor control and survival data after transarterial chemoembolization (TACE) with different drug combinations in the palliative third-line treatment of patients with ovarian cancer liver metastases.

Methods

Sixty-five patients (mean age: 51.5 year) with unresectable hematogenous hepatic metastases of ovarian cancer who did not respond to systemic chemotherapy were repeatedly treated with TACE in 4-week intervals. The local chemotherapy protocol consisted of Mitomycin (group 1) (n = 14; 21.5%), Mitomycin with Gemcitabine (group 2) (n = 26; 40%), or Mitomycin with Gemcitabine and Cisplatin (group 3) (n = 25; 38.5%). Embolization was performed with Lipiodol and starch microspheres. Local tumor response was evaluated by MRI according to RECIST criteria. Survival data were calculated according to the Kaplan-Meier method.

Results

The local tumor control was: partial response (PR) in 16.9% (n = 11), stable disease (SD) in 58.5% (n = 38) and progressive disease (PD) in 24.6% (n = 16) of patients. In group 1, we observed SD in 78.6% (11/14), and PD in 21.4% (3/14) of patients. In group 2, PR in 7.7% (2/26), SD in 57.7% (15/26), and PD in 34.6% (9/26) of patients. In group 3, PR in 36% (9/25), SD in 48% (12/25), and PD in 16% (4/25) of patients. Survival rate from the start of TACE was 58% after 1-year, 19% after 2-years, and 13% after 3-years. The median and mean survival times were 14 and 18.5 months without statistically significant difference for the 3 groups of patients (p = 0.502).

Conclusion

Transarterial chemoembolization is effective palliative treatment in achieving local control in selected patients with liver metastases from ovarian cancer.     

A simple procedure to prevent chronic vaginal colpotomy wound bleeding after laparoscopically assisted vaginal hysterectomy

Objective

To determine whether injecting the colpotomy wound with diluted vasopressin decreases vaginal bleeding after laparoscopically assisted vaginal hysterectomy (LAVH).

Methods

In this prospective controlled study 100 patients who underwent LAVH from July 1, 2005 to June 30, 2007, were randomized to receive an injection of vasopressin (n = 50) or normal saline (n = 50) solution in the colpotomy wound.

Results

In the vasopressin group, bleeding from the colpotomy wound occurred for more than 7 days in 9 patients (18%), and none was bleeding after 1 month; in the control group, the corresponding values were 29 (58%) and 2 (4%). Compared with the study group, the control group had a significantly higher rate of chronic bleeding from the colpotomy wound for more than 7 days and for more than 14 days after LAVH (P < 0.001 for both).

Conclusion

Infiltrating the colpotomy wound with diluted vasopressin was found to prevent chronic vaginal bleeding, which frequently occurs following LAVH.     

A phase II trial of radiation therapy and weekly cisplatin chemotherapy for the treatment of locally-advanced squamous cell carcinoma of the vulva: a gynecologic oncology group study

Objectives

To determine the efficacy and toxicity of radiation therapy and concurrent weekly cisplatin chemotherapy in achieving a complete clinical and pathologic response when used for the primary treatment of locally-advanced vulvar carcinoma.

Methods

Patients with locally-advanced (T3 or T4 tumors not amenable to surgical resection via radical vulvectomy), previously untreated squamous cell carcinoma of the vulva were treated with radiation (1.8 Gy daily × 32 fractions = 57.6 Gy) plus weekly cisplatin (40 mg/m²) followed by surgical resection of residual tumor (or biopsy to confirm complete clinical response). Management of the groin lymph nodes was standardized and was not a statistical endpoint. Primary endpoints were complete clinical and pathologic response rates of the primary vulvar tumor.

Results

A planned interim analysis indicated sufficient activity to reopen the study to a second stage of accrual. Among 58 evaluable patients, there were 40 (69%) who completed study treatment. Reasons for prematurely discontinuing treatment included: patient refusal (N = 4), toxicity (N = 9), death (N = 2), other (N = 3). There were 37 patients with a complete clinical response (37/58; 64%). Among these women there were 34 who underwent surgical biopsy and 29 (78%) who also had a complete pathological response. Common adverse effects included leukopenia, pain, radiation dermatitis, pain, or metabolic changes.

Conclusions

This combination of radiation therapy plus weekly cisplatin successfully yielded high complete clinical and pathologic response rates with acceptable toxicity.     

Pelvic exenteration in the age of modern chemoradiation

Background

To examine outcomes after pelvic exenteration in women treated with modern chemoradiation and surgical techniques.

Methods

All patients at our institution with a diagnosis of gynecologic malignancy who underwent pelvic exenteration after treatment with chemoradiation between 1/90 and 6/08 were evaluated with a retrospective chart review.

Results

44 women were identified, of whom 29 (66%) had cervical, 6 (14%) had uterine, 5 (11%) had vaginal, and 4 (9%) had vulvar cancer. The majority of patients (82%) were initially treated with external beam whole-pelvic radiation with concurrent cisplatin. 38 patients (86%) underwent exenteration for a central pelvic recurrence, and the remaining 6 patients (14%) for radiation necrosis. The most common surgical complication was transfusion requirement in 36 patients (82%), followed by wound infection in 15 (34%), small bowel obstruction in 8 (18%), and sepsis in 6 (14%). The median time spent in the ICU post-operatively was 2 days. One patient (2%) died during her post-operative hospital stay. The mean EBL overall was 2497 cc and the mean operative time was 544 min. Use of electrothermal bipolar coagulation, which was used in 64% of the exenterations, significantly reduced blood loss (3679 cc vs. 1836 cc, p = 0.014). After exenteration, 21 patients (48%) were diagnosed with a recurrence of cancer, and the mean progression free survival was 31 months. Patients who received exenteration less than 2 years after their initial chemoradiation had a significantly shorter overall survival time (8 months vs. 33 months, p = 0.016).

Conclusions

Approximately 50% of women develop recurrence following exenterations done after chemoradiation. Survival is significantly longer in patients who necessitate exenteration greater than 2 years out from initial treatment. Electrothermal bipolar coagulation appears to significantly reduce blood loss during these surgeries.     

Smoking cessation counseling in women with genital intraepithelial neoplasia

Objective

Cigarette smoking is a risk factor for cervical, vaginal, vulvar, and anal dysplasia. We will study the prevalence of cigarette smoking in patients with genital dysplasia and effect of counseling on smoking cessation.

Methods

All patients with genital dysplasia were screened for smoking history. One clinician provided smoking cessation counseling using the US Department of Health 5 A's technique: ask patients about their smoking status, advise smokers to quit, assess their readiness to quit, assist with their smoking cessation effort, and arrange for follow-up visits. Patients were informed on how smoking may cause worsening of genital dysplasia and increased risk of progression to cancer. Each patient received 2 counseling sessions, but no pharmacological or psychological interventions. Smoking cessation was evaluated by patient self-report via phone or during clinic visits.

Results

From January 2007 to December 2010, 344 patients were referred to our gynecologic oncology clinic for evaluation of genital dysplasia. Patients who were smokers (n = 125, 36%) were counseled to cease smoking in 2 counseling sessions, with 100% compliance for attendance. At study analysis (July 2011), 83 patients still smoke and 40 patients quit smoking (smoking cessation rate of 32%). Caucasian patients (P = .0013) and patients with vulvar dyplasia (P = .411) seemed to smoke more than other races and patients with cervical/vaginal dysplasia respectively.

Conclusion

Smoking cessation counseling for the genital dysplasia patients who smoked was associated with smoking cessation in 32% of the patients.     

The importance of chemotherapy and radiation in uterine papillary serous carcinoma

Purpose

To identify prognostic and predictive factors of overall survival (OS), relapse-free survival (RFS) and toxicity for patients with uterine papillary serous carcinoma (UPSC).

Materials and methods

Patient, tumor, treatment and relapse characteristics of 135 women with Stages I-IVA UPSC treated between 1980 and 2006 at Dana-Farber/Brigham and Women's Cancer Center (DF/BWCC) were analyzed using Cox regression models to determine prognostic and predictive factors for OS, RFS and toxicity.

Results

Mean follow-up was 5.5 years (range, 0.01-25.2). Median 5-year OS was 52%, and RFS was 42% for all patients. On Cox regression analysis, increasing age, stage, and myometrial invasion were prognostic factors associated with shorter OS and RFS. A paclitaxel-platinum chemotherapy regimen was significantly associated with longer OS (hazard ratio [HR] = 0.34, 95% confidence interval [CI] 0.15-0.74, p = 0.007) and RFS (HR = 0.45, 95% CI 0.22-0.92, p = 0.03). RFS was improved for patients treated with RT (HR = 0.44, 95% CI 0.25-0.77, p = 0.004). The 5-year grade 3+ toxicity rate was 3.5% for those who received RT and was 2.9% for those who did not (p = NS).

Conclusion

Uterine papillary serous cancer can be an aggressive tumor type with a poor prognosis. RFS was improved by radiation and chemotherapy with few grade 3 or higher complications. Using radiation and paclitaxel-platinum chemotherapy should be attempted whenever feasible for patients with UPSC who do not have distant metastases at diagnosis.     

Completed versus aborted radical hysterectomy for node-positive stage IB cervical cancer in the modern era of chemoradiation therapy

Objective

Debate continues about optimal management of patients with node-positive stage I cervical cancer. Our objective was to determine if patient outcomes are affected by radical hysterectomy in the modern era of adjuvant chemoradiation.

Methods

Cervical cancer patients diagnosed from 2000 to 2008 were identified. Demographics, therapy, clinicopathologic data, progression free survival (PFS), overall survival (OS), total radiation exposure, and grade 3-4 complications were analyzed by student t, Mann-Whitney, Fisher's exact, Kaplan-Meier, and log rank tests.

Results

This single-institution review evaluated forty-one of 334 (13.4%) patients scheduled to undergo radical hysterectomy that had gross nodal disease diagnosed intraoperatively. 15 underwent aborted radical hysterectomy following lymphadenectomy; the remaining 26 underwent radical hysterectomy and lymphadenectomy. Eleven patients undergoing radical hysterectomy underwent whole pelvic radiation therapy (WPRT) while 8 (30.7%) patients underwent WPRT and postoperative vaginal brachytherapy (BT) for local treatment secondary to close margins. All patients undergoing aborted radical hysterectomy underwent WPRT and BT. With mean follow-up of 42.3 months, there were no significant differences in urinary, gastrointestinal, or hematologic complications between groups. When comparing those undergoing radical hysterectomy to aborted radical hysterectomy, there were no significant differences in local recurrence (11.5% vs 26.7%, p = 0.39) or distant recurrence (19.2% vs. 33.3%, p = 0.45), PFS (74.9 months vs 46.8 months, p = 0.106), or OS (91.8 months vs 69.4 months, p = 0.886).

Conclusions

Treatment of patients with early stage cervical cancer and nodal metastasis may be tailored intraoperatively. Completion of radical hysterectomy and lymphadenectomy decreases radiation exposure without apparently compromising safety or outcome in the era of adjuvant chemoradiation.     

Factors associated with operative hysteroscopy outcome in patients with uterine adhesions or submucosal myomas

Objective

To determine the factors associated with hysteroscopic surgery long-term outcome in patients with intrauterine adhesions or submucosal myomas.

Methods

Factors thought to be associated with outcome were retrospectively evaluated from the records of 591 patients who were followed up for at least 5 years after undergoing hysteroscopic adhesiolysis (n = 203) or myomectomy (n = 388).

Results

The major factors affecting outcome were degree of adhesion (OR, 1.91; P = 0.03) in the former group and parity (OR, 0.55; P = 0.005) and depth of intramural penetration of the myoma (OR, 30.74; P < 0.001) in the latter. Severe intrauterine adhesion, low parity, and deep intramural penetration of submucosal myoma had an associated increase risk of poor outcome. The overall complication rate was 1.35% and, respectively, 12.8% and 9.3% of the patients who underwent hysteroscopic adhesiolysis or myomectomy needed a second intervention.

Conclusion

Hysteroscopic surgery is a safe and effective procedure. Degree of adhesion or parity and depth of intramural penetration of myomas are the major factors affecting outcome in patients with these lesions.     

Comparison of treatment outcomes between squamous cell carcinoma and adenocarcinoma in locally advanced cervical cancer

Objective

To compare the treatment outcomes between squamous cell carcinoma (SCC) and adenocarcinoma (ACA) in locally advanced cervical cancer patients.

Methods

All medical records of stages IIB-IVA of cervical cancer patients who had completed treatment between 1995 and 2008 were reviewed. ACA 1 case was matched for SCC 2 cases with clinical stage, tumor size, treatment modalities (radiation therapy (RT) vs concurrent chemoradiation (CCRT)). Treatment outcomes including response to RT/CCRT, time to complete response (CR), patterns of treatment failure and survival outcomes were analyzed.

Results

A total of 423 patients with stages IIB-IVA (141 ACA: 282 SCC) were included. Most of the patients (about 60%) had stage IIB. The overall complete responses (CR) between ACA and SCC were 86.5% and 94.7%, respectively (p = 0.004). Median time to clinical CR from RT/CCRT of ACA were 2 months (0-5 months) compared with 1 month (0-4 months) for SCC (p = 0.001). Pelvic recurrence and distant failure were found in 2.1% and 14.9% in ACA, and corresponding with 3.9% and 15.6% in SCC. The 5-year overall survival rates of ACA compared to SCC were 59.9% and 61.7% (p = 0.191), respectively. When all prognostic factors are adjusted, clinical staging was the only factor that influenced overall survival.

Conclusion

ACA in locally advanced cervical cancer had poorer response rate from treatment and also used longer time to achieve CR than SCC. However, these effects were not determinants of survival outcomes.     

The prognostic significance of age in surgically staged patients with Type II endometrial carcinoma

Objective

Many studies have examined the impact of older age on tumor recurrence and survival after hysterectomy for patients with endometrioid carcinoma. However, there is paucity of data examining the prognostic significance of age in patients with Type II endometrial carcinoma. The study was conducted to determine the prognostic impact of age in this patient population.

Materials and methods

In this Institutional Review Board (IRB)-approved study, our prospectively-maintained database of 1305 patients with endometrial cancer was reviewed. Seventy-two consecutive patients with serous and clear carcinoma 2009 FIGO stages I-II were identified with at least one year follow-up after surgical staging. Patients with mixed histology and those who received preoperative therapy were excluded. All the patients underwent surgical staging from 1989 to 2009. Their medical records were reviewed. The study cohort was divided into two groups based on their age at hysterectomy (≤ 65 vs. > 65). Patient's demographics, pathologic features and treatment-related factors were compared. The impact of age on recurrence-free survival (RFS), disease-specific survival (DSS) and overall survival (OS) were calculated. Following univariate analysis, multivariate modeling was done using step-wise Cox proportional hazards analysis to assess the impact of age on clinical outcomes after adjusting for various clinical variables.

Results

Median follow-up for the study cohort was 45 months (range 13-246). Fifty percent of patients received adjuvant platinum-based chemotherapy and/or adjuvant radiation treatment (RT). Thirty-five patients were older than 65 years (49%) and 37 were ≤ 65 (51%). There were no significant differences between the two groups in regard to race (African American vs Caucasian), FIGO stage, number of lymph nodes dissected, lymphovascular space involvement (LVSI), or adjuvant therapy received. There were more clear cell histology in the younger age group (p = 0.035). Patients > 65 years old developed more recurrences with a 5-year RFS of 59% compared to 84% for younger patients (p = 0.036). The five-year DSS was not statistically different between the two groups (68% vs. 79%, respectively with p = 0.313). 5-year OS was significantly shorter in the elderly patients (58% vs. 78% with p = 0.014). On multivariate analysis, the presence of LVSI, not receiving RT and age > 65 were independent predictors of worse RFS (p = < 0.001, 0.005, and 0.040 respectively).

Conclusion

In this study for surgically staged FIGO I-II patients with Type II endometrial carcinoma, age more than 65 years is a significant adverse prognostic factor for tumor recurrence.     

Neoadjuvant chemotherapy and vaginal radical trachelectomy for fertility-sparing treatment in women affected by cervical cancer (FIGO stage IB-IIA1)

Objectives

The aim of the present report is to support the feasibility and the safety of a new fertility-sparing treatment in young women affected by bulky cervical cancer.

Methods

Between February 2007 and October 2010, seven patients presenting large IB-IIA1 tumors (30-45 mm) were scheduled for conservative treatment. All patients underwent neoadjuvant chemotherapy (NACT) followed by laparoscopic pelvic lymphadenectomy and vaginal radical trachelectomy (VRT).

Results

One patient presented hematological toxicity during NACT (grade 3). All patients showed complete disappearance of tumor (n = 4/7) or partial response (a 50% or more decrease in total tumor size, n = 3/7) to neoadjuvant treatment, and they were all treated with pelvic lymphadenectomy and VRT. Additional treatment (interstitial brachytherapy) was offered to only one woman because of a persistent parametrial tumoral lesion.After a mean follow up of 22 months (range 5-49), no relapse was observed. To date, only one woman in our study attempted to conceive and she is currently pregnant.

Conclusions

Neoadjuvant chemotherapy for fertility sparing treatment is an innovative approach which is potentially quite interesting for many young women affected by bulky cervical cancer. These women, i.e. those with tumors larger than 2 cm (2-5 cm), are traditionally not offered fertility sparing treatment, thus the preliminary data we report here might have a promising impact. Nevertheless, for these patients it may be suitable to use the more radical, and time-tested, conservative surgical approach to allow for a complete and conservative excision of the residual tumor after neoadjuvant treatment.Studies with a larger number of patients and adequate follow-up are required to validate this conservative approach and to define clearly the good indications for this treatment.     

Complications of mid-urethral slings for treatment of stress urinary incontinence

Objective

To compare the incidence of complications associated with the use of retropubic tension-free vaginal tape (TVT) and transobturator tension-free vaginal tape (TVT-O) for the management of stress urinary incontinence (SUI).

Methods

In a cross-sectional study, 1081 patients were treated for SUI via mid-urethral slings, and the outcomes of those treated via TVT and those treated via TVT-O were compared. Patients who suffered from recurrent or mixed urinary incontinence were excluded.

Results

Group 1 included patients treated via TVT (n = 207) and group 2 included those treated with TVT-O (n = 570). There was a higher incidence of bladder perforation (5.4% versus 0.6%; P = 0.001) and hematoma formation (9.1% versus 1.5%; P = 0.001) in group 1 than in group 2. Compared with group 1, there was higher incidence of vaginal wall perforation in group 2 (0.0% versus 3.8%, P = 0.044). The rate of intraoperative complications was not related to patient age, body mass index, or parity. Of the patients who did not leak urine during a cough test 1 month after surgery, 90.9% still had a negative cough test at the long-term follow-up.

Conclusion

TVT-O was superior to TVT with regard to the incidence of bladder perforation and hematoma formation, but it resulted in more vaginal wall injuries.     

Is time to recurrence after hysterectomy predictive of survival in patients with early stage endometrial carcinoma?

Purpose/objective(s)

To determine the prognostic significance of time to recurrence (TTR) on overall survival (OS) and disease-specific survival (DSS) following recurrence in patients with stage I-II uterine endometrioid carcinoma.

Materials/methods

After IRB approval, we retrospectively identified 57 patients with recurrent endometrioid carcinoma who were initially treated for FIGO 1988 stages I-II between 1987 and 2009. The Kaplan-Meier approach and Cox regression analysis were used to estimate OS and DSS following recurrence and identify factors impacting outcomes.

Results

Median follow-up times were 54.8 months from hysterectomy and 19.8 months after recurrence. Median time to recurrence was 20.2 months. Twenty-eight (47%) patients had a recurrence < 18 months after hysterectomy and 29 (53%) had a recurrence ≥ 18 months. Both groups were evenly matched regarding initial pathological features and adjuvant treatments. The median OS and DSS in patients with TTR < 18 months was shorter than those with TTR ≥ 18 months, but not statistically significant (p = 0.216). TTR did not impact outcomes after loco-regional recurrence, but for extrapelvic recurrence, a shorter TTR resulted in worse OS and DSS (p = 0.03). On multivariate analysis, isolated loco-regional recurrence (HR 0.28, p = 0.001) and salvage radiation therapy (HR 0.47, p = 0.045) were statistically significant independent predictors of longer OS following recurrence. TTR as a continuous variable or dichotomized was not predictive of OS or DSS.

Conclusions

In our study, the prognostic impact of time to recurrence was less important than the site of recurrence. While not prognostic for the entire cohort or for patients with loco-regional recurrence, TTR < 18 months was associated with shorter OS and DSS after extrapelvic recurrence.     

Delivery route preferences of urban women of low socioeconomic status

Objective

To identify the main determinants of mode of delivery preference among urban dwelling women of lower socioeconomic status (SES).

Methods

Over a 12-month period, a self-completion 36-item questionnaire was administered to a convenience sample of 308 women within the first 3 postpartum days. Non-parametric tests were used for analysis.

Results

Study participants were mostly African American (> 85%), single mothers (> 75%), and unemployed (≥ 55%). Among the women, 85.7% had vaginal delivery (VD) and 14.3% had cesarean delivery (CD). Women who preferred CD (10%) were more likely to be concerned about a vaginal tear/episiotomy during VD, forceps, and a "big" baby compared with women who preferred VD, for whom “pushing the baby out myself” and “fear of cesarean” were the most important factors. In the final model of 7 factors, the 3 main factors found to positively impact maternal preference for CD were a vaginal cut during VD (P < 0.001), higher mean BMI (P = 0.001), and cesarean as the most recent delivery type (P < 0.001). The total explained variance by this model was 46%.

Conclusions

Short-term complications of a VD, higher BMI, and a previous cesarean delivery are the most significant factors that impact the preferences of women of lower SES for future mode of delivery.     

Vaginal length and incidence of dyspareunia after total abdominal versus vaginal hysterectomy

Objective

To evaluate the vaginal length and incidence of dyspareunia after total abdominal hysterectomy compared to vaginal hysterectomy.

Study design

This is a prospective observational study. Sixty-six patients were invited to participate in the study who were already planned to undergo abdominal or vaginal hysterectomy for different benign indications in the OB/GYN department, Sohag University Hospital, during the period from March 2007 till April 2009. Patients were classified into two groups. Thirty-six patients who were planned to undergo total abdominal hysterectomy (TAH) represented the first group, and 30 patients who were planned to undergo vaginal hysterectomy (VH) represented the second group. Vaginal length was obtained just before the operation and three times postoperatively. Pre- and post-operative dyspareunia was reported.

Results

The mean pre-operative and post-operative vaginal lengths in the TAH group were nearly the same (10.5 ± 2.1 cm vs. 10.2 ± 1.8 cm) without statistically significant difference. In the VH group, there was a statistically significant difference between pre- and post-operative vaginal length (10.1 ± 1.9 cm vs. 8.4 ± 1.6 cm). In the TAH group, 2 patients (5%) reported a newly developed post-operative dyspareunia. In VH group, 6 patients (20%) developed dyspareunia after surgery.

Conclusion

Postoperative dyspareunia is more common after vaginal hysterectomy compared to abdominal hysterectomy. This may be attributed to postoperative shortening of the vagina secondary to excessive trimming of the vaginal walls especially if VH was done for utero-vaginal prolapse.