Karl Tamussino

Tension-free vaginal tape operation: results of the Austrian registry.

OBJECTIVE To assess the use of and perioperative complications associated with the tension‐free vaginal tape operation with a central registry. METHODS Fifty‐five gynecology units completed questionnaires on patients undergoing the tension‐free vaginal tape operation. Information was collected on patient, surgical, and postoperative data. RESULTS A total of 2795 patients were entered. Overall, 773 patients (28%) had undergone previous surgery for incontinence or prolapse; 1640 (59%) tension‐free vaginal tapes were performed as isolated operations, and 1155 (41%) were done in combination with other procedures. The median operating time for tension‐free vaginal tapes alone was 30 minutes (range 10–120). Of the isolated tension‐free vaginal tapes, 727 (44%) were performed with local, 711 (43%) with regional, and 193 (12%) with general anesthesia. In patients undergoing tension‐free vaginal tape only, postoperative bladder drainage was obtained with intermittent catheterization in 389 (24%) patients, an indwelling urethral catheter in 1032 (63%), and a suprapubic catheter in 143 (9%). The bladder perforation rate was 2.7% overall (n = 75) and higher in patients with than in those without previous surgery (4.4% compared with 2.0%, P = .01). There were four bladder perforations (3.3%) among the 120 patients with previous colposuspension. Most patients undergoing tension‐free vaginal tape only were able to void the next day (range 0 to over 64). A total of 68 patients (2.4%) required reoperation for reasons related to the tape (39 to loosen, remove, or cut the tape, or to place a suprapubic catheter, 19 for hematoma, one for bowel injury). CONCLUSION The tension‐free vaginal tape has become a frequently performed operation in Austria. There are considerable variations in clinical practice. The risk of bladder perforation was increased in patients with previous surgery. Severe complications were rare.

Evaluation and outcome measures in the treatment of female urinary stress incontinence: International Urogynecological Association (IUGA) guidelines for research and clinical practice.

Millions of women are afflicted with stress urinary incontinence (SUI) and pelvic organ prolapse (POP) around the globe, and the literature is abundant with different types of surgery to correct these problems. Only recently have outcome measures been applied to research in these areas. There are great variations in types of surgery performed, secondary to many factors such as surgeon’s training and socioeconomic factors. As the population of aging women increases worldwide, it is inevitable that these women’s disorders will become more prevalent. This will pose a major challenge to the health care systems.

Nongenital cancers metastatic to the ovary

Abstract We review our experience with 82 patients with nongenital cancers metastatic to the ovary. All patients were referred for evaluation of an ovarian mass. The patients had primary carcinoma of the breast ( n = 28), colon ( n = 23), stomach ( n = 22), pancreas ( n = 7), or gallbladder ( n = 2). The overall actuarial 5-year survival rate was 10%. Five-year survival in patients with metastatic colon cancer was significantly higher (23%) than that in patients with metastatic cancer of the breast, stomach, gallbladder, or pancreas, all of whom died within 58 months ( P p = 0.003). Five-year survival in patients with disease limited to the pelvis was significantly higher than that in those with abdominal spread (22% vs 6%; P 2 cm in diameter was 18% or 4%, respectively ( P = 0.002). This pattern applied mainly to differences in patients with primary cancer of the breast or colon ( P

The importance of parametrial lymph nodes in the treatment of cervical cancer

This study aimed to determine the presence, distribution, and metastatic involvement of lymph nodes in the parametria of patients undergoing radical hysterectomy for cervical cancer. Parametrial nodes were present in the giant sections of 280 (78%) of 359 surgical specimens, and metastatically involved nodes were found in 63 (22.5%) of these 280. Both positive and negative nodes were distributed through the entire parametrium. The frequency of positive nodes was linearly associated with both the clinical stage and with the tumor volume. The recurrence rate was higher when the parametrial nodes were positive than when they were negative. Survival dropped when the parametrial nodes were positive, regardless of the clinical stage.

Microinvasive carcinoma of the uterine cervix (International Federation of Gynecology and Obstetrics Stage IA).

In 1985 the International Federation of Gynecology and Obstetrics (FIGO) subdivided Stage IA cervical cancer and specified metric criteria to demarcate Stage IA from Stage IB. Early stromal invasion (Stage IA1) denotes the first invasive protrusions of a carcinoma in situ into the stroma. Microcarcinomas (Stage IA2) are small cancers a number of orders of magnitude larger than Stage IA1 lesions and with a maximum depth of invasion of 5 mm and a maximum horizontal spread of 7 mm; larger lesions are classified as Stage IB. This study reviews 486 patients previously classified as having Stage IA disease. This yielded 344 Stage IA1 and 101 Stage IA2 lesions; 41 cancers were reclassified as Stage IB. Three hundred nine, 89, and 38 patients were followed for ± 5 years. One (0.3%) patient with Stage IA1 disease re‐presented with Stage IIB disease 12 years after conization. Five (5.6%) patients with Stage IA2 lesions developed invasive recurrences; three died. None of the 38 patients reclassified as having a Stage IB lesion, including 16 who were treated conservatively, developed a recurrence. The FIGO classification is not a guideline for treatment. Stage IA1 lesions can be treated conservatively, but treatment in Stage IA2 must be individualized. Risk factors such as vascular space involvement and confluency are of high sensitivity but low specificity.

Magnetic resonance imaging in cervical cancer: A basis for objective classification

Conventional clinical staging of cervical cancer is subjective because it is based on palpatory findings and inadequate because it cannot assess the single most important prognostic factor--tumor size. To determine the exactitude of in vivo MRI measurements of tumor volume, 22 patients with invasive cervical cancer were studied before surgery. The volumes obtained by MRI correlated well (r = 0.983) with those obtained by histomorphometric analysis of the surgical specimens, but only weakly with clinical stage. MRI may provide a basis for precise classification of cervical cancer and for objective comparison of surgery and radiotherapy.

Anhydramnios associated with administration of trastuzumab and paclitaxel for metastatic breast cancer during pregnancy

A 38-year-old women in her second pregnancy presented with symptomatic metastatic spinal-cord compression 7 years after undergoing lumpectomy and axillary dissection for stage I primary breast cancer. Immunohistochemistry analysis of the tumour had shown that it was oestrogen-receptor negative, progesterone-receptor positive, and overexpressed ERBB2. The patient had received six cycles of cyclophosphamide, methotrexate, and fl uorouracil followed by radiotherapy and then tamoxifen, which she had taken for 5 years. 86 months after primary diagnosis the patient developed paresthesia and hypoesthesia of the left arm and pain in the cervical vertebrae. MRI showed diff use metastatic infi ltration of the corpus of the second cervical vertebra (fi gure 1) with spinal-cord compression. Additional lesions in the fourth thoracic vertebra and the left femur were also seen with bone scintigraphy, but no other signs of metastatic disease were identifi ed by clinical examination, chest radiograph, or abdominal ultrasound. At this time the patient was 17 weeks pregnant with normal fetal development. After counselling the patient decided to continue pregnancy and was started on hydromorphone hydrochloride. Palliative radiotherapy of 46 Gy given in 23 fractions was administered to the cervical vertebra, which resulted in clinically improved neurological symptoms and pain. Cervical radiotherapy was undertaken with lead shielding of the uterus to protect the fetus. At 25+6 weeks’ gestation the patient received trastuzumab (8 mg/kg loading dose) combined with 175 mg/m of paclitaxel, followed by another cycle at 28+5 weeks with the dose of trastuzumab reduced to 6 mg/kg and the dose of paclitaxel kept the same. Close fetal surveillance was undertaken. Between 26 weeks’ gestation and 32 weeks’ gestation, during two cycles of trastuzumab and paclitaxel, fetal abdominal circumference stopped increasing and the volume of amniotic fl uid decreased to almost anhydramnios (fi gure 2). The mother was of normal constitutional size with normal weight gain of 11 kg during pregnancy and no other risk factors for restriction of intrauterine growth. Tests for premature rupture of the membranes were negative. At 31+6 weeks the volume of both fetal kidneys was decreased below the fi fth percentile. Additionally, the urinary bladder was barely visible, suggesting reduced renal function, and doppler sonography showed increased resistance indices of both the renal arteries (fi gure 3). Doppler sonography of the fetal umbilical and maternal uterine arteries was normal, which suggested healthy placental function. Serial ultrasound measurements of femur length, biparietal diameter, and head circumference were all within normal limits. As a result of the evidence of fetal renal failure and cessation of abdominal growth, fetal lung maturation was induced with corticosteroids after two cycles of trastuzumab and paclitaxel, and a caesarean section was done at 32+1 weeks’ gestation. The male newborn infant weighed 1460 g (tenth percentile), had a body length of 39 cm, and had a head circumference of 29.5 cm. The pH value of the umbilical artery was 7.31. The placenta weighed 290 g and placental histology was normal. The newborn infant showed signs of bacterial sepsis with hypotension, transient renal failure, respiratory failure necessitating mechanical ventilation, and positive laboratory fi ndings (C-reactive protein 30 mg/dL). With antibiotic treatment blood pressure normalised after 2 days and mechanical ventilation was ended on day 6. Diuresis was adequate with serum creatinine slightly increased (1.6 mg/dL) until day 14. Ultrasonography of the fetal kidneys showed transient hyperechodensities in the renal parenchyma that resolved by day 28. These transient hyperechodensities are often noted in newborn infants with transient renal failure as a result of decreased renal perfusion. Echocardiography and cranial ultrasound examinations were normal. The infant was discharged at age 6 weeks weighing 2335 g and in healthy condition. Development at 12 weeks was normal. Lancet Oncol 2007; 8: 79–81

Cervical intraepithelial neoplasia III: long-term follow-up after cold-knife conization with involved margins.

OBJECTIVE To evaluate the long‐term outcome of patients with severe cervical intraepithelial neoplasia (CIN) III or squamous carcinoma in situ after cold‐knife conization with involved margins. METHODS A total of 390 patients (median age 39 years, range 20–69) with positive margins after cold‐knife conization for CIN III were followed expectantly for a mean of 19 (range 6–30) years. Follow‐up consisted of colposcopy, cytology, histology, and pelvic examination. RESULTS Overall, 306 (78%) patients remained free of CIN III, and 84 (22%) had persisting or recurrent CIN III (n = 78) or developed invasive carcinoma (n = 6). Fifty‐three patients had persisting CIN III (diagnosed within 1 year of conization), 25 developed recurrent CIN III after a median of 3 (range 2–28) years, five developed microinvasive carcinomas (at 3, 6, 7, 12, and 23 years), and one developed a stage IB carcinoma at 8 years. Persisting or recurrent disease was more common in patients in whom both the endocervical and the ectocervical cone margins were involved than in those in whom only the ectocervical or the endocervical margin was positive (52% versus 17% and 21%, respectively, P < .001). CONCLUSION Expectant management is reasonable for patients with CIN III and positive margins after cold‐knife conization. However, these patients require careful follow‐up, particularly during the first year.

Pelvic and paraaortic lymphocysts after radical surgery because of cervical and ovarian cancer

To determine the incidence and clinical import of lymphocysts after radical gynecologic surgery including lymphadenectomy, we reviewed the records of 173 patients with cervical cancer and 135 patients with ovarian cancer who were followed up by computed tomography. Lymphocysts were found in 35 (20%) and 43 (32%) of the patients, respectively. Patients with cervical cancer and positive lymph nodes had a significantly higher rate of lymphocyst formation than did those with negative nodes (29% versus 14%, respectively, p less than 0.02). Age, type of lymphadenectomy, volume of fluid furthered by postoperative drains, disease stage, and tumor histology were not related to lymphocyst development. We saw no complications strictly attributable to lymphocysts. The clinical import and treatment possibilities are discussed.

Cervical pregnancy: case reports and current concepts in diagnosis and treatment.

SummaryCervical pregnancy produces profuse but painless vaginal bleeding. After ultrasound diagnosis early in pregnancy, preservation of the uterus is possible. After the 12th week, hysterectomy is almost always necessary. We review current concepts in the diagnosis and management of cervical pregnancy.