Frits B. Lammes

Long-term results of hysteroscopic myomectomy for abnormal uterine bleeding

OBJECTIVE To analyze the efficacy of transcervical resection of submucous myomas and to identify prognostic factors for long-term results. METHODS Two-hundred eighty-five women were treated with transcervical resection of submucous myomas without endometrial ablation. In case of incomplete resection a repeat procedure was offered. Long-term follow-up was obtained. Recurrence was defined as the need for further surgery. The relation of several variables with the outcome was analyzed using Cox proportional hazard regression analysis. RESULTS Seventeen cases (6%) were lost to follow-up. The median follow-up was 46 months (range 1-104 months); for cases without recurrence median follow-up was 42 months (range 16-104 months). Forty-one (14.5%) patients had repeat surgery. An independent prognostic value of uterine size (P < .001) and number of submucous myomas (P < .001) for recurrence was noted. Twenty of 41 patients who had repeat surgery subsequently had a hysterectomy. None of the variables investigated predicted the need for hysterectomy. The surgery-free percentage of 165 patients with normal sized uteri and not more than two myomas was 94.3% (standard error +/- 1.8%) at 2 years and 90.3% (+/- 3.0%) at 5 years. CONCLUSION Transcervical resection of submucous myomas is a safe and effective treatment for patients with a normal sized uterus and not more than two myomas. It is an acceptable alternative for selected other patients. The need for a combined endometrial ablation is questionable. Transcervical resection of submucous myomas will give patients a high chance of averting further surgery and should modify the way patients are counseled.

A prospective comparison of transvaginal ultrasonography and diagnostic hysteroscopy in the evaluation of patients with abnormal uterine bleeding: Clinical implications

OBJECTIVE We determined the diagnostic value of transvaginal ultrasonography for endometrial and intrauterine abnormalities in patients with abnormal uterine bleeding. STUDY DESIGN Between June 1, 1992, and June 1, 1993, 279 consecutive patients underwent transvaginal ultrasonography. Findings were compared with the final diagnosis established by diagnostic hysteroscopy and histologic examination. RESULTS Transvaginal ultrasonography demonstrated a sensitivity of 0.96 and a specificity of 0.89. With a pretest probability (prevalence) of 0.42, this resulted in posttest probabilities of 0.03 in the case of a normal sonogram and 0.87 for an abnormal sonogram. The corresponding likelihood ratios were 0.04 and 9.09, respectively. CONCLUSION Transvaginal ultrasonography seems to be an effective procedure to exclude endometrial and intrauterine abnormalities. Its use could be implemented as a routine first-step procedure in patients with abnormal uterine bleeding, and it selects those in need of further diagnostic evaluation in the case of an abnormal or inconclusive sonogram.

Multifocal vulvar intraepithelial neoplasia grade III and multicentric lower genital tract neoplasia is associated with transcriptionally active human papillomavirus

Background. The incidence of vulvar intraepithelial neoplasia Grade III (VIN III) is increasing and is diagnosed at a younger age than previously. VIN III is often multifocal and frequently coexists with multicentric dysplastic lesions in the cervix and vagina. Warty‐type VIN III more often has been found to contain human papillomavirus (HPV) DNA than basaloid‐type VIN III. The authors performed HPV DNA polymerase chain reaction (PCR) analysis in 48 VIN III biopsies and reverse transcriptase (RT)‐PCR in 8 HPV‐16 DNA‐positive multifocal VIN III biopsies to detect E6/E7 transcripts.

The prognosis of cervical cancer associated with pregnancy: A matched cohort study

Objective To assess the effect of pregnancy on the prognosis of cervical cancer and the morbidity of standard treatment. Methods We analyzed 44 women with cervical carcinoma associated with pregnancy, who were matched with 44 controls. Matching criteria were age, stage of disease (according to the International Federation of Gynecology and Obstetrics classification), tumor type, treatment modality, and period of treatment. Results In 23 cases, cervical cancer was diagnosed during pregnancy and in the other 21 cases, within 6 months after delivery. Thirty-nine women had early-stage disease (eight IA, 25 IB, and six IIA), and five had advanced stages (four IIB and one IIIB). The overall 5-year survival rate was 80% among subjects and 82% among controls, whereas the relative risk (RR) of dying within 5 years was 1.12 (95% confidence interval [CI] 0.48–2.65). With regard to the 5-year survival rate (85% for both subjects and controls, the RR of dying was 1.00 [95% CI 0.35–2.83]); no differences were found between subjects and controls for early-stage cervical carcinoma. The size of the group with advanced-stage cervical carcinoma was too small to allow any statistical analysis. No statistically significant differences in survival were observed between cases diagnosed during pregnancy and cases diagnosed after delivery. In addition, the mode of delivery had no effect on survival. Early complications within 6 weeks after treatment were seen 33 times in 25 subjects and 29 times in 23 controls. No differences were observed in the prevalence and type of early complications in subjects versus controls. Late complications after 6 weeks of treatment were seen nine times in nine subjects and 11 times in ten controls. No significant differences were observed in the prevalence and type of late complications in subjects versus controls. Conclusion The prognosis of early-stage cervical cancer is similar in pregnant and nonpregnant patients when standard treatment is given. Because of the limited number of patients, no conclusions can be drawn about advanced-stage cervical cancer. The goal should be standard oncologic treatment, which does not lead to morbidity in pregant patient.

An analysis of fluid loss during transcervical resection of submucous myomas

OBJECTIVE To determine the contribution of several variables to fluid loss during transcervical resection of submucous myomas. DESIGN An observational study using multiple linear regression analyses. SETTING A university-affiliated training hospital and a university department of clinical epidemiology and biostatistics. PATIENT(S) Patients with submucous myomas. INTERVENTION(S) Transcervical resection of submucous myomas and monitoring of fluid loss. MAIN OUTCOME MEASURE(S) Patient age, uterine enlargement, treatment with GnRH analogues or 8-ornithine-vasopressin, type of anesthesia, number of myomas, intramural extension of the myoma (type of myoma), and operating time were tested as variables. RESULT(S) Only intramural extension of the myoma and operating time were obviously related to fluid loss. For the other variables, such a relation was weak at best. The relation between fluid loss and operating time was not modified by any of the other variables. CONCLUSION(S) Because fluid loss is an important limiting factor in the transcervical resection of submucous myomas, special attention should be paid to reduction of the operating time and preoperative assessment of the intramural extension of the myoma to guide appropriate patient selection.

Surgical Pathologic Factors That Predict Recurrence in Stage IB and IIA Cervical Carcinoma Patients with Negative Pelvic Lymph Nodes

The purpose of this analysis was to identify pathologic risk factors for recurrence and patterns of recurrence in patients with International Federation of Gynecology and Obstetrics Stage IB and IIA cervical carcinoma and negative pelvic lymph nodes after radical hysterectomy.

Human papillomavirus DNA after treatment of cervical dysplasia: Low prevalence in normal cytologic smears

The presence of human papillomavirus (HPV) DNA in relation to cervical cytology was evaluated after treatment of cervical dysplasia.

Is dilatation and curettage obsolete for diagnosing intrauterine disorders in premenopausal patients with persistent abnormal uterine bleeding

Background. To determine the predictive value of dilatation and curettage (D& C) for diagnosing intrauterine disorders in patients with persistent abnormal uterine bleeding.

Feasibility of central co-ordinated EMA/CO for gestational trophoblastic disease in the Netherlands

Objective  In the Netherlands, high risk gestational trophoblastic disease (GTD) patients are treated in different referral hospitals with a national working party on trophoblastic tumours having a co‐ordinating function. Our purpose was to evaluate whether this policy is a satisfactory alternative to complete centralisation.

Results of artificial insemination at home by the partner with cryopreserved donor semen: a randomized study

The use of cryopreserved semen offers the possibility of home insemination by the instructed partner. A comparative study was designed whereby participants were randomly allocated to use home or clinic insemination for six cycles. If no pregnancy had occurred after six cycles, the site of insemination was switched to the opposite location for a maximum of six further cycles. Fifty-three women with primary infertility fulfilling all entry criteria entered the study. In the first 6cycles out of 29 home starters, 13 pregnancies were conceived, whereas in 24 clinic starters 11 pregnancies occurred, yielding no statistical difference in pregnancy rate. Of 138 couples who did not meet the criteria in the same period, 45 opted for home insemination, resulting in 20 home-inseminated pregnancies. Again, for comparable subgroups no statistical difference in pregnancy rate between home and clinic insemination was found.