Päivi Kannisto

Robot-assisted abdominal laparoscopic radical trachelectomy.

BACKGROUND Radical trachelectomy in conjunction with pelvic lymphadenectomy is an established method to preserve fertility in early cases of cervical cancer. The radical trachelectomy is usually performed vaginally despite the initial use of laparoscopy for the lymphadenectomy. The complexity of a laparoscopic abdominal trachelectomy may explain this dual approach. Here we describe the surgical technique of a robot-assisted laparoscopic radical trachelectomy with lymphatic mapping using a radiotracer and without a vaginal approach. CASES AND SURGICAL TECHNIQUE Two nulliparous women with early cervical cancer underwent a laparoscopic radical trachelectomy and pelvic lymphadenectomy with the assistance of the da Vinci robot (Intuitive Surgical Inc, Sunnyvale, CA). After the sentinel lymph nodes were found negative on frozen section, the parametria, paracolpia and sacrouterine ligaments were dissected sparing the main branches of the uterine arteries. Following ligation of the descending branches of the uterine arteries the cervix and the vagina were transsected using monopolar diathermia and the vagina was sutured to the remaining cervix. Finally, a permanent cerclage was placed. Time for surgery was 387 and 358 min respectively. No perioperative complications were noted and the postoperative period was uneventful in both cases. CONCLUSIONS Robot-assisted laparoscopic abdominal trachelectomy is a feasible alternative to a combined laparoscopic and vaginal approach.

Robot assisted laparoscopic radical hysterectomy and pelvic lymphadenectomy with short and long term morbidity data.

OBJECTIVE To evaluate feasibility and morbidity of robot assisted laparoscopic radical hysterectomy. METHODS From December 2005 to September 2008 robot assisted laparoscopic radical hysterectomy and pelvic lymphadenectomy was performed on 80 women. Using a prospective protocol, and an active investigation policy for defined adverse events, perioperative, short and long term data were obtained. RESULTS Time for surgery (skin to skin) reached 176 and 132 min after 9 and 34 procedures respectively. All tumours were radically removed. Median number of retrieved lymph nodes was 26 (range 15-55). All women had an early follow up (1-3 months) and 43 of eligible 46 women (93%) had a long term follow up (> or =12 months). In 33 of 80 women (41%) the peri/postoperative period was uneventful. The remainder had one or more mainly mild adverse events, most commonly from the vaginal cuff (n=17, 21%) or the lymphatic system (n=16, 20%). The proportion of uneventful cases increased significantly over time. Five women were resutured for dehiscence of the vaginal cuff, two women were reoperated for trocar site hernias and one woman had a ureter stricture that resolved following stent treatment. Eight women (14%) needed 60 days or more to resume spontaneous voiding. One 72-year old woman with disseminated endometrial cancer on autopsy died of pulmonary embolism 31 days after surgery. CONCLUSIONS Robot assisted laparoscopic radical hysterectomy is a feasible alternative to conventional laparoscopy and open surgery. Effort should be made to ensure proper closure of the vaginal cuff, trocar sites and to develop nerve sparing techniques.

The sentinel node concept in early cervical cancer performs well in tumors smaller than 2 cm.

OBJECTIVE The aim of the study was to evaluate the sentinel node (SLN) concept for lymphatic mapping in early stage cervical cancer. METHODS 105 women with early stage (1a1-2a) cervical cancer were scheduled for the sentinel node procedure in conjunction with a complete pelvic lymphadenectomy. The day before surgery, 1-1.5 mL 120MBq Tc(99) albumin nanocolloid was injected submucosally at four points around the tumor followed by a lymphoscintigram (LSG) to achieve an overview of the radiotracer uptake. RESULTS During surgery, the overall detection rate (gamma probe) of at least one SLN was 90% (94/105 women) whereas at least one SLN was identified in 94% (61/65 women) with a tumor <or=2 cm. Bilateral SLNs were identified in 62/105 (59%) of the women. Among 18 women with any metastatic lymph node 17 had a metastatic SLN (sensitivity 94%, 95% CI 73-100%). Among 61 women with a tumor <or=2 cm, all five women with any metastatic lymph node also had a metastatic SLN (sensitivity 100%). One woman with a 1.5-cm squamous epithelial carcinoma had metastatic positive SLNs on each side but also one metastatic bulky (>2 cm) node without radiotracer uptake. The negative predictive value for patients with cervical cancers <or=2 cm was 100%. CONCLUSIONS The SLN-technique seems to be an accurate method for identifying lymph node metastases in cervical cancer patients with tumors of 2 cm or smaller. In case of a unilateral SLN only, a complete lymphadenectomy should be performed on the radionegative side. All bulky nodes must be removed.

Early-stage cervical cancer: Tumor delineation by magnetic resonance imaging and ultrasound - A European multicenter trial

OBJECTIVE To compare the diagnostic accuracy of ultrasound (US) and magnetic resonance imaging (MRI) in the preoperative assessment of early-stage cervical cancer using pathologic findings as the reference standard. PATIENTS AND METHODS Prospective multi-center trial enrolling 209 consecutive women with early-stage cervical cancer (FIGO IA2-IIA) scheduled for surgery. The following parameters were assessed on US and MRI and compared to pathology: remaining tumor, size, tumor stromal invasion<2/3 (superficial) or ≥2/3 (deep), and parametrial invasion. RESULTS Complete data were available for 182 patients. The agreement between US and pathology was excellent for detecting tumors, correctly classifying bulky tumors (>4cm), and detecting deep stromal invasion (kappa values 0.84, 0.82, and 0.81 respectively); and good for classifying small tumors (<2cm) and detecting parametrial invasion (kappa values 0.78 and 0.75, respectively). The agreement between MRI and histology was good for classifying tumors as <2cm, or >4cm, and detecting deep stromal invasion (kappa values 0.71, 0.76, and 0.77, respectively). It was moderately accurate in tumor detection, and in assessing parametrial invasion (kappa values 0.52 and 0.45, respectively). The agreement between histology and US was significantly better in assessing residual tumor (p<0.001) and parametrial invasion (p<0.001) than the results obtained by MRI. Imaging methods were not significantly influenced by previous cone biopsy. CONCLUSION US and MRI are highly accurate for the preoperative assessment of women with early-stage cervical cancer, although US may be more accurate in detecting residual tumors and assessing parametrial invasion.

Shoulder dystocia and brachial plexus injury: a case–control study

Objective and background. To evaluate risk factors for shoulder dystocia and brachial plexus injury using a case–control study at the departments of obstetrics and gynecology at the four largest hospitals in southern Sweden. All cases of shoulder dystocia between 1987 and 1993 inclusive were identified. For each case, two control infants with similar birthweight (± 100 g) and identical year of birth were randomly selected.

Gray‐scale and color Doppler ultrasound characteristics of endometrial cancer in relation to stage, grade and tumor size

To describe the gray‐scale and vascular characteristics of endometrial cancer in relation to stage, grade and size using two‐dimensional (2D)/three‐dimensional (3D) transvaginal ultrasound.

Evidence for prejunctional GABAB receptors mediating inhibition of ovarian follicle contraction induced by nerve stimulation

The motor effects of gamma-aminobutyric acid (GABA) on the bovine ovarian follicle were studied in vitro using strips from follicle walls. Electrical field stimulation of nerves in the preparation, secured by tetrodotoxin blockade, caused a contraction that was almost totally abolished by phentolamine and only slightly affected by atropine. This mainly adrenergic neurogenic response was inhibited by GABA in a dose-dependent way. The GABAA-receptor antagonists, bicuculline and picrotoxin, did not affect the GABA action whereas the GABAB-receptor antagonist, homotaurine, significantly inhibited the GABA effect. The GABAA-receptor agonist, muscimol, did not affect the contractile response while the GABAB-receptor agonist, baclofen, imitated the action of GABA. On the other hand, GABA had no direct contractile or relaxing effect on the follicle strips nor did it interfere with the contractile response induced by noradrenaline or acetylcholine. The findings suggest that activation of prejunctional GABAB receptors inhibits transmitter release from mainly adrenergic nerves associated with the follicle, thereby affecting nerve-mediated tension in the follicle wall.

Vaginal self-sampling without preservative for human papillomavirus testing shows good sensitivity.

BACKGROUND Several strategies have been used to reach non-attending women in organized cervical-cancer-screening programs, with varying success. Self-sampling (SS) for HPV is effective for increasing coverage in screening programs, but requires expensive commercial sampling kits. OBJECTIVE We aimed to evaluate if vaginal SS, without commercial preservatives was adequate for HPV testing. STUDY DESIGN Women with abnormal cervical smears as determined from the organized screening program were invited to a colposcopy clinic. The 121 women were asked to insert a cotton swab into the vagina and rotate it, put the cotton swab into a sterile cryotube, break the upper part of the stick and put the cap on. Thereafter, the gynaecologist collected a liquid based cytology (LBC) sample. The presence of HPV-types in SS and LBC samples was analysed with PCR and luminex-based typing. RESULTS High-risk-HPV (hr-HPV) DNA was found in 65 of the tested 108 SS (60%; 95% CI 0.50-0.69), whereas LBC found hr-HPV in 64/108 samples (59%; 95% CI 0.49-0.69). The agreement between sampling with SS and LBC was good, kappa value 0.67 (95% CI; 0.53-0.81). The sensitivity for SS with hr-HPV to find HSIL was 77% (95% CI; 62-91%), specificity 47% (95% CI; 35-59%) [corrected] and the sensitivity for LBC with hr-HPV to find HSIL was 79% (95% CI 66-93%), specificity 50% (95% CI; 38-62%). [corrected] CONCLUSIONS This new vaginal self-sampling method detects hr-HPV-infections with similar sensitivity as a cervical smear taken by a gynaecologist. This self-sampling method is cost-effective and well tolerated, and the kit is suitable for regular mail transport.

Sonographic characteristics of squamous cell cancer and adenocarcinoma of the uterine cervix.

The objective of this study was to describe the sonographic characteristics of squamous cell cancer (SCC) and adenocarcinoma (AC) of the cervix using transvaginal ultrasound.

The influence of neuropeptide Y and norepinephrine on ovulation in the rat ovary

Neuropeptide Y (NPY) was measured in tissue extracts from ovaries of rats treated with pregnant mare serum gonadotropin (PMSG). The extracted NPY-immunoreactive material was identical to synthetic human NPY with regard to size and hydrophobicity as evaluated by gel filtration and high performance liquid chromatography. The concentration of NPY was related to the estrous cycle and a maximum was observed in relation to the endogenous luteinizing hormone (LH) peak. NPY immunoreactivity was demonstrated by immunohistochemistry to be localized within nerve fibers supplying blood vessels and follicles. The increase in the NPY content could not be related to accumulation around specific ovarian structures. Employing an in vitro set-up, NPY (10(-7) M) was unable to induce ovulation and did not increase the ovulation rate in LH-stimulated ovaries. The combination of NPY (10(-7) M) and NE (10(-7) M) did not significantly increase the number of ovulations compared to that induced by NE (10(-7) M) alone. In conclusion, NPY content in the ovary is related to the estrous cycle, but NPY does not seem to have any direct effect on the ovulatory process.