M Goldenberg

Emergency laparoscopy for suspected ovarian torsion: are we too hasty to operate?

OBJECTIVEnTo reevaluate the rate of correct diagnosis of ovarian torsion (OT) in our department.nnnDESIGNnRetrospective computerized chart review.nnnSETTINGnTertiary referral center.nnnPATIENT(S)nSeventy-eight women who underwent laparoscopy for suspected OT.nnnINTERVENTION(S)nLaparoscopy.nnnMAIN OUTCOME MEASURE(S)nRate of true diagnosis of torsion, correlation with Doppler studies.nnnRESULT(S)nThe preoperative diagnosis of OT was confirmed in only 36 (46.1%) of the patients. Immediate operation (<10 hours) after admission (n = 48) was associated with a statistically significantly higher likelihood of operatively confirming OT (56.2% vs. 28.6%). We found that the lack of ovarian blood flow on Doppler sonography was a good predictor of OT; women with pathologic flow were statistically significantly more likely to have OT (77% vs. 29%). The sensitivity and specificity of abnormal ovarian flow for OT were 43.8% and 91.7%, respectively, with a positive and negative predictive value of 78% and 71%, respectively.nnnCONCLUSION(S)nDespite 20 years of research, the accuracy of the preoperative diagnosis of OT remains low. The urge to operate can be attributed to the importance of preserving ovarian function in young women as well as to the availability and the low associated complication rate of laparoscopy.

A randomized, prospective study of endometrial resection to prevent recurrent endometrial polyps in women with breast cancer receiving tamoxifen**

STUDY OBJECTIVEnTo assess the role of endometrial resection in preventing recurrence of tamoxifen-associated endometrial polyps in women with breast cancer.nnnDESIGNnRandomized, prospective study (Canadian Task Force classification I).nnnSETTINGnTertiary university-affiliated medical center.nnnPATIENTSnTwenty consecutive women (age range 43-61 yrs).nnnINTERVENTIONSnHysteroscopic removal of tamoxifen-associated endometrial polyps with or without simultaneous resection of the endometrium.nnnMEASUREMENTS AND MAIN RESULTSnPatients were randomized to undergo (10 women) or not undergo (10) concomitant endometrial resection. They were followed for at least 18 months (range 18-24 mo), including transvaginal ultrasonography every 6 months and hysteroscopy when endometrial irregularity was noted. The main outcome variable was recurrence of endometrial polyps; occurrence of uterine bleeding was also noted. In women who underwent endometrial resection, only one had a 1 x 1-cm endometrial polyp diagnosed and removed during follow-up. Seven women remained amenorrheic, and three experienced spotting for a few days every month. In the control group, six women had recurrent endometrial polyps requiring hysteroscopic removal (two-tail Fishers exact test p <0.06).nnnCONCLUSIONnRecurrence of endometrial polyps, one of the most common problems in patients with breast cancer receiving long-term treatment with tamoxifen, may be reduced by performing endometrial resection at the time of hysteroscopic removal of polyps. The possible risk of occult endometrial cancer is yet to be determined. (J Am Assoc Gynecol Laparosc 6(3):285-288, 1999)

Sudden/nocturnal onset of acute abdominal pain, lasting less than a day and accompanied by vomiting: a tell-tale sign of ovarian torsion

The purpose of the study was to construct a clinical profile of a patient more likely to have ovarian torsion (OT). The study design was a retrospective chart review (Canadian Task Force Classification II-3). The study was done in a tertiary referral center setting. Patients were 78 women who underwent laparoscopy for suspected ovarian torsion. Intervention done was urgent laparoscopic surgery. The main outcome measure was a comparison of demographic data and the presenting signs and symptoms of the women with and without laparoscopically proven OT. Multivariable analysis was performed with a logistic regression model in order to determine the independent risk predictors for OT. The following factors were found to be predictive of OT: vomiting (ORu2009=u20095.67, 95% CI 1.69–19.0, pu2009=u20090.005); duration of pain less than a day (ORu2009=u20093.74, 95% CI 1.24–11.3, pu2009=u20090.02), and sudden/nocturnal onset of pain (ORu2009=u20094.13, 95% CI 1.19–14.3, pu2009=u20090.02). The model was found to be adequate, with a c value of 0.798. A patient presenting with an episode of pain lasting less than a day that started suddenly and or at night, accompanied by vomiting is more likely to have OT on urgent laparoscopy.

Is operative laparascopy contraindicated in women with ectopic pregnancy and hypovolemic shock

We evaluated the safety of operative laparoscopy for the management of ectopic pregnancy in 119 women with hypovolemic shock. In 19 (16.0%) of these women hypovolemic shock was based on a combination of signs and symptoms including hypotension, tachycardia, anxiety, thirst, tachypnea, and slow capillary refill. The table below presents the results (mean ± SEM; ap <0.01). One case in each group was converted to laparotomy, and all patients made full recovery. Laparoscopy allows rapid diagnosis and control of the source of bleeding, making it highly suitable for the surgical management of a ruptured ectopic pregnancy. The availability of appropriate anesthesia and advanced cardiovascular monitoring, and ability to convert rapidly to a laparotomy if necessary, allow safe performance of operative laparoscopic surgery in women with hypovolemic shock.

Long-term outcome of MR-guided focused ultrasound treatment and laparoscopic myomectomy for symptomatic uterine fibroid tumors

BACKGROUND: Fibroid tumors are the most common benign tumors in women of reproductive age. Treatment is usually indicated for those who are symptomatic, with different techniques being used. OBJECTIVE: The purpose of this study was to compare the long‐term outcome of laparoscopic myomectomy with magnetic resonance–guided focused ultrasound for symptomatic uterine fibroid tumors. STUDY DESIGN: A cohort study was conducted on all patients with symptomatic uterine fibroid tumors who were admitted to a single tertiary care center and treated operatively with laparoscopic myomectomy or treated conservatively with magnetic resonance–guided focused ultrasound from January 2012 until January 2017. Assessment for further interventions and sustained fibroid‐associated symptoms was performed, with the use of the Uterine Fibroid Symptom and Quality of Life symptom severity score. RESULTS: One hundred fifty‐four women met the inclusion criteria. Complete follow‐up evaluation was achieved for 64 women who underwent laparoscopic myomectomy and for 68 women who were treated by magnetic resonance–guided focused ultrasound. Follow‐up time was similar for the 2 groups (median, 31 months [interquartile range, 17–51 months] vs 36 months [interquartile range, 24–41]; P=.95). The rate of additional interventions was 5 (7.8%) and 9 (13.2%), respectively (P=0.312). Similarly, the Uterine Fibroid Symptom and Quality of Life symptom severity score questionnaire score at follow‐up interviews revealed comparable median scores of 17 (interquartile range, 12–21) vs 17 (interquartile range, 13–22) for laparoscopic myomectomy and magnetic resonance–guided focused ultrasound, respectively (P=.439). Analysis of each of the symptoms separately (bleeding, changes in menstruation, abdominal pain, bladder activity, nocturia, fatigue) did not change these findings, nor did a multivariate analysis. CONCLUSION: Satisfaction with long‐term outcome and rate of reinterventions after magnetic resonance–guided focused ultrasound treatment or laparoscopic myomectomy for uterine fibroid tumors was comparable. Further larger randomized trials are needed to confirm these findings.