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Laparoscopic bipolar coagulation of uterine vessels: a new method for treating symptomatic fibroids.

OBJECTIVE To evaluate the effects of laparoscopic bipolar coagulation of uterine vessels in treating symptomatic fibroids. DESIGN Prospective clinical study. SETTING University-affiliated tertiary referral center. PATIENT(S) Eighty-seven women with symptomatic fibroids warranting surgical treatment and wanting to retain their uteri. INTERVENTION(S) Laparoscopic bipolar coagulation of uterine arteries and anastomotic sites of uterine arteries with ovarian arteries. MAIN OUTCOME MEASURE(S) Percentage reduction in the dominant fibroid size and clinical response evaluation. RESULT(S) Eighty-five (97.7%) of 87 patients underwent technically successful laparoscopic coagulation of uterine vessels without intraoperative complications. The mean follow-up time was 10.2 months. Symptomatic improvement was reported in 76 (89.4%) of 85 patients, including 18 (21.2%) with complete resolution of symptoms. Significant reductions in the dominant fibroid size (average, 76%) and the uterine volume (average, 46%) were sonographically demonstrated. Two patients conceived 4 and 9 months, respectively, after treatment. Three (3.5%) premenopausal women became postmenopausal postoperatively. CONCLUSION(S) Laparoscopic bipolar coagulation of uterine vessels appears to be a promising new method for treating fibroid-related menorrhagia and pelvic pain.

Intraperitoneal cisplatin‐based chemotherapy vs. intravenous cisplatin‐based chemotherapy for stage III optimally cytoreduced epithelial ovarian cancer

Objective: To compare the survival between intraperitoneal cisplatin‐based chemotherapy (IPCT) and intravenous cisplatin‐based chemotherapy (IVCT) in stage III epithelial ovarian cancer with minimal residual disease (<1 cm) after primary debulking surgery. Method: One hundred and thirty‐two patients with stage III epithelial ovarian cancer after optimal primary debulking surgery with minimal residual disease between April 1990 and March 1995 were entered into a randomized clinical trial in which IPCT or IVCT was administered at 3‐week intervals. Patients in the IPCT arm received cisplatin‐based (100 mg/m2) intraperitoneal chemotherapy. Patients in the IVCT arm received cisplatin‐based (50 mg/m2) intravenous chemotherapy. The tumor response was assessed every 3 months. The hematological toxicity using the South West Oncology Group (SWOG) toxicity criteria was assessed. Catheter complications associated with intraperitoneal chemotherapy were also analyzed. Result: The estimated median survival in the IPCT group was 43 months (95% confidence interval, 34–54) and IVCT group was 48 months (95% confidence interval, 37–59). The hazard ratio of death was not statistically significant between IPCT and IVCT (hazard ratio, 1.13; 95% CI, 0.69–1.86; P=0.317). The frequencies of hematological toxic effects were significantly lower in the IPCT group than in the IVCT group. Conclusion: Intravenous and intraperitoneal chemotherapy are associated with equivalent survival in patients with minimal residual stage III epithelial ovarian cancer after optimal cytoreductive surgery.

Successful treatment of symptomatic arteriovenous malformation of the uterus using laparoscopic bipolar coagulation of uterine vessels.

OBJECTIVE To report a case of symptomatic arteriovenous malformation (AVM) of the uterus that was successfully treated with laparoscopic bipolar coagulation of uterine vessels. DESIGN Case report. SETTING University-affiliated tertiary referral center. PATIENT(S) A 66-year-old woman with symptomatic AVM of the uterus. INTERVENTION(S) Laparoscopic bipolar coagulation of uterine vessels. MAIN OUTCOME MEASURE(S) Clinical symptoms, color Doppler sonographic examination, and pelvic magnetic resonance imaging. RESULT(S) Remarkable shrinkage of the lesion size, obvious decrease in all of the impedance measurements (pulsatility, resistance, velocity indexes [systolic/diastolic]), and freedom from symptoms. CONCLUSION(S) This modality is a new alternative method for the management of patients with symptomatic AVM of the uterus who do not respond to conservative treatment.

Ovarian metastasis from cervical carcinoma

Objective: To study the prognosis and metastatic route of cervical carcinoma with ovarian metastasis. Method: From 1980 to 1993, 10 of the 1507 patients with cervical carcinoma operated and who had ovarian metastasis were analyzed. Results: Six patients had squamous cell carcinomas and 4 patients had adenocarcinomas. Their mean age was 45 years. Six of 9 patients undergoing pelvic lymphadenectomy had nodal metastasis. One patient did not have nodal dissection in the treatment course. Five of 10 patients had involvement of corpus: 3 were accompanied with nodal metastasis, 1 was not and 1 other was unknown. None of our cases survived more than 5 years. Their mean survival time was 20.8 months for squamous cell carcinomas and 29 months for adenocarcinomas. Conclusions: (1) Ovarian metastasis is histologically one of the ominous signs of cervical carcinomas regardless of stage. The prognosis of patients with ovarian metastasis from cervical squamous cell carcinoma from our data is not different from those from cervical adenocarcinoma. (2) Lymphatic spread and transtubal implantation are possible pathways of cervical cancer metastasizing to ovary, and involvement of the corpus may potentiate this mechanism.

Laparoscopic Bipolar Coagulation of Uterine Vessels to Treat Symptomatic Myomas in Women with Elevated CA 125

STUDY OBJECTIVE To assess laparoscopic bipolar coagulation of uterine vessels (LBCUV) for symptomatic myomas in women with elevated CA 125 (>35 U/ml). DESIGN Prospective, longitudinal study (Canadian Task Force classification II-1). SETTING Private practice, university-affiliated hospital. PATIENTS Forty-six women (age 30-50 yrs) with symptomatic myomas and elevated CA 125 level. INTERVENTION Laparoscopic bipolar coagulation of uterine vessels performed over 10 months. MEASUREMENTS AND MAIN RESULTS All patients underwent successful LBCUV and coagulation of anastomotic site of uterine arteries with ovarian arteries without intraoperative complication. One, 3, and 6 months after treatment, respectively, 52.2%, 65.2%, and 71.7% of women reported improvement in menorrhagia, 19.6%, 45.7%, and 56.5% noted improvement in dysmenorrhea, and 6.5%, 16.1%, and 38.7% had improvement in bulk-related symptoms. Average reduction in uterine volume was 9.1%, 16.9%, and 38.3% and average reduction in dominant myoma was 12.1%, 23.9%, and 59.1% at those times; the average reduction of CA 125 in all patients was 39.8, 75.4, and 126.1U/ml. CONCLUSION Symptoms were improved and uterine volume and dominant myoma were reduced by LBCUV. The CA 125 level fell during follow-up in 40 patients (87.0%). Improvement in symptoms, especially menorrhagia, and shrinkage of uterine volume and dominant myoma seemed to be more pronounced in women with decreased than in those without decreased CA 125 after treatment (p = 0.045). The CA 125 level may be a valuable indicator for monitoring the efficacy of LBCUV.

Vaginal Expulsion of Submucous Myomas after Laparoscopic-Assisted Uterine Depletion of the Myomas

STUDY OBJECTIVE To determine the safety and side effects that may be caused by laparoscopic-assisted uterine depletion (LAUD) of submucous myomas. DESIGN Retrospective chart review and follow-up (Canadian Task Force classification II-2). SETTING University-affiliated tertiary referral center. PATIENTS Five hundred twenty women with symptomatic myomas warranting surgical treatment, who wished to retain their uteri. INTERVENTION Laparoscopic bipolar coagulation of uterine arteries and anastomotic sites of uterine arteries with ovarian arteries. MEASUREMENTS AND MAIN RESULTS Postoperative sonographs showed submucous myomas in 53 (10.2%) women. During follow-up for a mean of 8.6 months very few complications occurred; however, nine women (1.7%) experienced vaginal expulsion of myomas from 2 weeks to 5 months postoperatively. Four of them were readmitted within 43 days with high fever and fetid discharge, and cervical cultures revealed heavy growth of Escherichia coli in three. Vaginal myomectomy was performed in six patients, and one woman passed the myoma spontaneously. Histopathologic studies of these nine specimens showed that two had infarction, three had coagulative necrosis, and four had degeneration. After treatment, all nine women had normal menstruation and their symptoms resolved during follow-up of at least 3 months. CONCLUSION In our experience LAUD led to satisfactory symptomatic improvement and reduction in myoma volume and few complications. If vaginal expulsion of submucous fibroids can be viewed as a side effect, we should pay close attention to women with submucous myomas, especially within 2 months of LAUD. Otherwise, more dangerous complications could occur.

Color Doppler ultrasound, pregnancy-induced hypertension and small-for-gestational-age fetuses

Objective: The nomogram of blood velocity flow resistance of the spiral arteries was built at 13–25 gestational weeks. Thereafter, by using the nomogram we tried to assess the results of the color Doppler examination of the uteroplacental circulation at the second trimester to predict pregnancy‐induced hypertension (PIH) and small‐for‐gestational‐age (SGA). Methods: Two groups of patients were studied. Group 1, for the establishment of the nomogram, included 175 uncomplicated pregnancies with gestational ages ranging from 13–25 weeks. The Doppler flow waveforms of the spiral arteries were measured once for each pregnancy in the studies. Group 2 consisted of 305 singletons selected consecutively for prospective study to confirm the occurrence of PIH or SGA. They were scanned twice for the measurements of the spiral artery waveforms at 13–19 and 20–25 weeks, respectively to test which gestational weeks interval in the nomogram is most sensitive in predicting PIH and SGA. Results: The 5th, 50th and 95th percentiles of the pulsatility index (PI) values of the nomogram at the second trimester were used as the cut‐off points to predict pregnancies complicated with SGA or PIH at delivery. Using the receiver operator curve, the 50th percentiles of the PI values of the nomograms were chosen as predictives for the development of PIH and SGA. At 13–19 gestational weeks, the specificities in predicting PIH and SGA were 50.71% and 49.82%, respectively, and the sensitivities were 52.00% and 50.00%, respectively. The calculated Cohens Kappa statistics were 0.008 and 0.001, respectively in predicting PIH and SGA. At 20–25 gestational weeks, the specificities in predicting PIH and SGA were 49.64% and 49.46%, respectively, and the sensitivities were 56.00% and 57.14%, respectively. The calculated Cohens Kappa statistics were 0.017 and 0.022, respectively in predicting PIH and SGA. Conclusion: The measurements of uteroplacental blood flow velocity waveforms at the second trimester are not sensitive enough to be an early screening tool for PIH and SGA in the low risk, non‐selected pregnancy population. The fact suggests that in most gravidas complicated with PIH and SGA, the physiological process of trophoblastic invasion in the spiral artery was not prevented before the 25th gestational week.

Comparison of Two Procedures for Laparoscopic-Assisted Vaginal Hysterectomy of Large Myomatous Uteri

STUDY OBJECTIVE To evaluate whether laparoscopic bipolar coagulation of uterine vessels (LBCUV) and supracervical amputation improve laparoscopic-assisted vaginal hysterectomy (LAVH). DESIGN Prospective, randomized, longitudinal study (Canadian Task Force classification II-1). SETTING Private practice, university-affiliated hospital. PATIENTS Sixty-four women (age 31-52 yrs) with symptomatic myomatous uteri larger than 12 weeks on bimanual examination. INTERVENTIONS LAVH with or without LBCUV and laparoscopic supracervical amputation followed by trachelectomy. MEASUREMENTS AND MAIN RESULTS LBCUV and laparoscopic supracervical amputation followed by trachelectomy and removal of the specimen vaginally were performed successfully in 29 women (group A). Hysterectomy was performed successfully in 32 comparable patients (group B) with severing of the round ligament, ovarian ligament, or infundibulopelvic ligament, and preparation of the bladder flap in the laparoscopic phase, and severing of uterine vessels and cardinal-uterosacral ligament complex through the vagina. Average blood loss was 169.8 and 308.7 ml in groups A and B, respectively (p <0.05); average operating time was 126.4 and 152.8 minutes, respectively (p <0.05); hemoglobin decreased on average 0.9 and 1.7 g/100 ml, respectively (p <0.05). Conclusion. LBCUV and laparoscopic supracervical amputation followed by trachelectomy reduce operating time and blood loss in LAVH, and allow conversion of many abdominal procedures to laparoscopy.

Addition of laparoscopic uterine nerve ablation to laparoscopic bipolar coagulation of uterine vessels for women with uterine myomas and dysmenorrhea.

STUDY OBJECTIVE To assess the effectiveness of laparoscopic uterine nerve ablation (LUNA) in women with dysmenorrhea caused by uterine myomas treated by laparoscopic bipolar coagulation of uterine vessels (LBCUV). DESIGN Prospective, randomized, longitudinal study (Canadian Task Force classification II-1). SETTING Private practice, university-affiliated hospital. PATIENTS Eighty-five women with uterine leiomyomas and associated dysmenorrhea. INTERVENTION Laparoscopic bipolar coagulation of uterine vessels with or without LUNA. MEASUREMENTS AND MAIN RESULTS Of 85 patients who entered the study, 41 were assigned to undergo LBCUV-LUNA (group A), which was successful in 40 (97.6%). In 44 women assigned to have LBCUV only (group B), 43 (97.7%) underwent successful surgery. Eighty women completed 1-, 3-, and 6-month follow-up (38 group A, 42 group B). The groups did not differ significantly in age, history of abdominopelvic surgery, intraperitoneal adhesions, endometriosis, concomitant surgery, and operating time. Seven (18.4%) of 38 women in group A and 12 (28.6%) of 42 in group B experienced lower abdominal pain postoperatively. Acceptable pain was defined as a score of zero or 1: 31 and 30 women in groups A and B reported scores of zero; 3 and 2 reported scores of 1; 4 and 8 reported scores of 2; zero and 2 reported scores of 3; and no patients reported scores of 4. The frequency and severity of postoperative pain were less in group A than in group B (both p <0.05). The efficacy of both methods was almost equal in shrinking the uterus and dominant myoma, and in improving menorrhagia and bulk-related symptoms. Dysmenorrhea improvement was 84.2% and 61.9% in groups A and B at 3 months and 92.1% and 73.8% at 6 months, respectively. This was more significant in group A than in group B (p <0.05). CONCLUSION Our results suggest that LUNA may decrease postoperative ischemic pain and improve dysmenorrhea associated with uterine myomas treated by LBCUV.

Parametrial tumor spreading patterns in cervix cancer patients treated by radical hysterectomy

Objectives: To evaluate tumor‐spreading patterns in the parametrium. Methods: We conducted a prospective clinical trial between January 1998 and December 2000 to define a new method for parametrium evaluation. The parametrium was divided into three areas, paracorpus, paracervix, and paravagina. A total of 284 consecutive patients with FIGO stage IB to IIA cervical cancer who had undergone radical hysterectomy were considered for the study. Results: Of the 262 patients who were found eligible for evaluation, 135 had histopathologic analysis performed according to the new method and 127 with the traditional method. The detection of rate of parametrial invasion was 36 (26.7%) with the new and 13 (10.2%) with the traditional method (P=0.0014). The frequency of pelvic lymph node metastasis was 66.7% in patients who had tested positive for invasion of the paracorpus, 57.7% in those who had tested positive for invasion of the paracervix, and 71.4% in those who had tested positive for invasion of the paravagina. The frequency of pelvic lymph node metastasis in patients who had tested negative for invasion of the paracorpus, paracervix, or paravagina was 4.0%. Tumor cells tend to spread laterally and inferiorly in the parametrium. Conclusions: Using our classification of three parametrium areas for histologic examination can increase the detection rates of parametrial tumor invasion and help prevent failure of local treatment by allowing to implement appropriate adjuvant therapy.