Barry Sanders

Carcinoma in situ of the vagina

A review was made of 136 cases of carcinoma in situ of the vagina seen over a 30-year period, 1953 to 1982. The patients ranged in age from 17 to 77 years, with a mean age of 55 years. One hundred sixteen patients (85%) presented with an abnormal Papanicolaou smear. Colposcopically directed biopsies were used for diagnosis in 62% of the patients. The upper one third of the vagina was the most common site of disease, with 54% of patients having unifocal lesions. A previous hysterectomy had been performed in 71% of patients, 35% of whom had undergone operation for benign disease. A concomitant, subsequent, or prior neoplasm of the lower genital tract or pelvis was noted in 109 patients. Surgical intervention in the form of either wide local excision or partial or total vaginectomy was the most frequently used method of treatment. Radiotherapy, usually in the form of a vaginal mold, was the second most commonly used method of treatment, and it was used in 27 patients. Radiotherapy and more extensive surgical treatment methods gave the best results. Four patients subsequently developed invasive carcinoma of the vagina.

Clinical trial of the uterine thermal balloon for treatment of menorrhagia.

STUDY OBJECTIVES To evaluate the safety and efficacy of thermal balloon endometrial ablation in women with menorrhagia, and to identify factors influencing outcome. DESIGN Prospective, observational study (Canadian Task Force classification II-2). SETTING Three Canadian university-affiliated teaching hospitals. PATIENTS One hundred twenty-one women suffering from menorrhagia serious enough to make them candidates for endometrial ablation or hysterectomy. Patients without obvious structural or (pre)malignant abnormalities were included if their uterine cavities sounded to less than 12 cm, they were in good health, and had undergone hysteroscopy or pelvic ultrasound and endometrial biopsy within 6 months and had a normal Papanicolaou smear within 1 year. INTERVENTIONS A balloon catheter was placed through the cervix and after inflation in the endometrial cavity with 5% dextrose in water, was heated to 87 +/- 5 degrees C. Two-thirds of patients avoided general anesthesia and very few required cervical dilatation to admit the 4.5-mm diameter catheter. Balloon pressures were 90 to 140 mm Hg in 13 patients; pressures between 140 and 190 mm Hg were well tolerated by the rest. Nineteen women underwent 12 minutes of therapy, and the rest had 8-minute sessions. MEASUREMENTS AND MAIN RESULTS No intraoperative complications occurred, and minor postoperative morbidity occurred in 4% of patients. Preoperative and postoperative bleeding was assessed by pad counts and patient self-reports. The degree of dysmenorrhea was recorded similarly. A paired t test was used to compare pretreatment with posttreatment pad counts. A Wilcoxon signed rank test was employed to evaluate the effect of treatment on dysmenorrhea. The effects on outcome of several independent variables were analyzed by multiple and logistic regression. Success of the procedure was constant over the year (range 86-90%). Treatment led to significant decreases in menstrual flow, duration, and pain (p <0.0001). No significant effects of parity, uterine position or cavity depth, timing, or various endometrial-thinning regimens were found. Increasing age was significantly associated with increased odds of success (p < 0.05). Excluding the 19 women who underwent 12 minutes of therapy did not change statistical results, whereas excluding the 13 treated with balloon pressures less than 140 mm Hg improved the results. Conclusion. The facts that bleeding and dysmenorrhea were significantly reduced by thermal balloon endometrial ablation, that no intraoperative complication occurred, and that postoperative morbidity was minimal, lead us to conclude that this is potentially a safe and effective technique. Larger studies and longer follow-up are required to substantiate this impression.

Prevention and Management of Laparoscopic Complications

Abstract Complications of laparoscope may occur during both diagnostic and surgical procedures. The insertion of the Verres needle and trocars into the peritoneal cavity poses risks, as does the use of mechanical instruments and energy sources including electricity and laser for the performance of surgical procedures. The vascular structures in the abdominal wall, peritoneal cavity, and retro-peritoneal space may be injured as may the gastro-intestinal and urinary tracts. Prevention of complications is best, but when they occur, early recognition and prompt and appropriate management are required. The surgeon undertaking laparoscopy should be familiar with the equipment being used, potential problems that may be encountered, and should be able to manage complications. Furthermore, no surgeon should hesitate to call for assistance with managing a complication if necessary. With the development of increased laparoscopic expertise, many complications may be managed via the laparoscope.

Diagnosis of adverse events after hysterectomy with postoperative self-care web applications: A pilot study:

Increased pressures from multiple sources are leading to earlier patient discharge following surgery. Our objective was to test the feasibility of self-care web applications to inform women if, when, and where to seek help for symptoms after hysterectomy. We asked 31 women recovering at home after hysterectomy at two centers to sign into a website on a schedule. For each session, the website informed them about normal postoperative symptoms and prompted them to complete an interactive symptom questionnaire that provided detailed information on flagged responses. We interviewed eight women who experienced an adverse event. Six of these women had used the web application regularly, each indicating they used the information to guide them in seeking care for their complications. These data support that self-care applications may empower patients to manage their own care and present to appropriate health care providers and venues when they experience abnormal symptoms.

Saline Hysteroscopy for Removal of Retained Intrauterine Contraceptive Devices in Early Pregnancy

OBJECTIVE Pregnancies complicated by a retained intrauterine device (IUD) are at increased risk for adverse outcomes such as miscarriage and preterm labour. There is limited evidence to guide the management of retained IUDs in pregnancy when the strings are not visible at the external cervical os. We describe a method for IUD retrieval in such cases. METHODS Twenty-six patients underwent saline hysteroscopy with or without concurrent ultrasound guidance for retrieval of a retained IUD in early pregnancy between 2002 and 2015. We retrospectively evaluated procedural and pregnancy-related outcomes in this case series. RESULTS The average gestational age at the time of the procedure was 11+0 weeks. Successful IUD retrieval occurred in 22 of 26 cases (84.6%). There were 23 live births, including 20 full term and three preterm deliveries. The average gestational age at delivery was 38+4 weeks. There was one miscarriage and one elective termination of pregnancy following the procedure. There were no complications directly related to the procedure. CONCLUSION Saline hysteroscopy is a safe and effective method for retrieval of a retained IUD in early pregnancy. It appears that concurrent ultrasound guidance can facilitate IUD localization, but more cases are needed to confirm this. Pregnancy outcomes after IUD retrieval were favourable, with a low rate of miscarriage and preterm labour.

Retained intrauterine devices in pregnancy

With typical use, unintended pregnancy rates in the first year after insertion are 0.8% for the copper-containing intrauterine device (IUD) and 0.2% for the levonorgestrel-releasing intrauterine system.[2][1] A systematic review in 2012 found increased rates of spontaneous abortion (48%–77%) and

Surgeons’ early experience with the Acessa™ procedure: gaining proficiency with new technology

Purpose Successful adoption of a new surgical procedure varies among practicing surgeons, and skill acquisition depends on the surgeon’s innate ability, the complexity of the technique, and training. We report intraoperative and near-term postoperative outcomes from the Acessa procedure conducted by minimally invasive gynecologic surgeons new to Acessa, and report the surgeons’ experiences during the training period. Patients and methods The study was designed as a postmarket, prospective, single-arm, multicenter analysis of operative and early postoperative outcomes after proctored surgical training with the Acessa device and procedure (laparoscopic ultrasound-guided radiofrequency volumetric thermal ablation of symptomatic fibroids) in premenopausal, menstruating women as conducted in community and university hospitals in the USA and Canada. Surgeons completed evaluation forms once they felt they could safely and comfortably conduct the operations. Results Ten gynecologic surgeons without prior Acessa experience completed 40 Acessa procedures – all on an outpatient basis. Mean procedure time was 1.9±1.0 hours and was similar to that reported in the pivotal premarket study (2.1±1.0 hours). Two intraoperative complications occurred: a 1 cm uterine serosal laceration due to uterine manipulation and blood loss from both the probe insertion site and the lysis of uterine-omental adhesions. No postoperative complications or reinterventions for fibroid symptoms were reported. The surgeons completed the evaluation forms after two to five cases, and none found any factors affecting procedure efficiency to be inferior or needing improvement. Conclusion Minimally invasive gynecologic surgeons new to Acessa can perform the procedure and provide acceptable outcomes after two to five proctored cases.

Pseudo-Meig's Syndrome in a Woman on Ulipristal Acetate

Ultrasound and MRI demonstrated persistent uterine enlargement with new onset of ascites. Paracentesis yielded 3.5 litres of benign serous fluid. Laparotomy revealed a 19 × 14 × 10 cm soft, deep-red oblong pedunculated fundal mass (Figure) and six intramural or subserosal fibroids from 2 to 7.5 cm in diameter. As the suspicion of malignancy was low, seven fibroids were removed by myomectomy, and histology confirmed benign leiomyomata. The patient did well postoperatively.

Pseudo-syndrome de Meigs chez une femme prenant de l’acétate d’ulipristal

La patiente a demande une myomectomie afin de preserver sa fertilite et a alors commence un traitement preoperatoire a l’acetate d’ulipristal. Un mois plus tard, son abdomen en etait venu a presenter une distension manifeste. Le traitement a l’acetate d’ulipristal a ete abandonne et la patiente a ete hospitalisee. Bien que son taux serique de CA 125 ait presente une nette hausse (810 kU/l), les taux des autres marqueurs tumoraux etaient normaux.