Combined Mastectomy and Laparoscopic Hysterectomy with Salpingo-Oophorectomy in Transgender Men: a Cohort Study.

There are few data on complications with gender affirming surgery. The aim of this study was to assess peri- and postoperative complications of laparoscopic hysterectomy and mastectomy performed in a single sitting in transgender men. Assessment of intra- and postoperative complications in a series of 65 transgender men (mean age 27, range 18-47) undergoing concomitant mastectomy and laparoscopic hysterectomy with salpingo-oophorectomy. Mean operating time was 292 ± 47 min. Thirty-four (52%) patients experienced complications: 28 (41%) DINDO grade I, 0 DINDO grade 2, 6 (11%) DINDO grade III. The six grade 3 complications consisted of 5 hematomas requiring evacuation after mastectomy and 2 vaginal tears requiring transvaginal repair. Three patients were readmitted within 30 days, all for postoperative bleeding/hematoma. In transgender men, performing laparoscopic hysterectomy and mastectomy at a single sitting has a modest rate of perioperative complications, and may improve resource utilization.

How accurate is frozen section histology of pelvic lymph nodes in patients with endometrial cancer?

OBJECTIVE: Recent prospective data support the trend towards systematic retroperitoneal lymphadenectomy in patients with high-risk endometrial cancer. Because para-aortic node involvement in the absence of pelvic node involvement is uncommon, a reliable finding of negative pelvic lymph nodes (PLN) at intraoperative frozen section examination might allow omitting para-aortic dissection. We analyzed the diagnostic accuracy of frozen section examination of PLN in patients with endometrial cancer. METHODS: We reviewed 131 patients with endometrial cancer who underwent surgery including systematic pelvic lymphadenectomy (n=101) or pelvic and para-aortic lymphadenectomy (n=27). Intraoperative frozen section examination of PLN was performed in 72 (55%) patients. Results of frozen section examination were compared with those of final histopathology and the diagnostic accuracy of frozen section examination of PLN was calculated. One pathologist measured the diameters of PLN metastases retrospectively. RESULTS: A total of 1063 and 2666 PLN were analyzed by frozen section examination and by final histopathology, respectively. PLN metastases were found in 7 cases (10%) at frozen section examination, and in 17 cases (24%) at final histopathology (false negative rate, 59%). No false positive cases were noted. The mean diameter of all PLN metastases at final histopathology was 4.3 mm, as compared to 9.0 mm for the metastases detected at frozen section analyses. The mean diameter of PLN metastases missed at frozen section examination was 2.0 mm. CONCLUSION: In this review at a single institution, intraoperative frozen section histology missed nearly two of three endometrial cancer patients with positive nodes. These results do not support tailoring the extent of lymphadenectomy according to the results of frozen section examination.

Assessment of risk factors for survival of neonates born after second-trimester PPROM.

OBJECTIVE: Assess fetal risk factors which impact survival of infants delivered after second-trimester PPROM. STUDY DESIGN: Clinical records of 87 patients, who all had second-trimester rupture of membranes between 14+0 and 24+6 weeks of gestation treated January 1998 to July 2005 were reviewed regarding perinatal outcome. This study is based on 25 surviving infants. RESULTS: 13 of these 25 infants died in the hospital. Survivors had a higher birth weight (p=0.008) and higher Apgar scores after 5 min (p=0.005) than those infants dying. No differences in UA pH, the need of catecholamines and no association between histological verified chorioamnionitis and early onset sepsis were seen between survivors and nonsurvivors. CONCLUSION: Higher gestational age at birth, higher birth weight, the absence of histologically verified chorioamnionitis and 5 min Apgar scores of >or= than 6 have positive prognostic value for survival of neonates delivered preterm after second-trimester PPROM.

Neonatal outcome and two-year follow-up after expectant management of second trimester rupture of membranes.

OBJECTIVE: To assess neonatal outcome and 2-year follow-up of pregnancies complicated by second trimester preterm premature rupture of membranes (PPROM). METHODS: A retrospective review of obstetric and neonatal records for 87 pregnancies (56 singletons, 6 twins, 1 triplet) with PPROM between 14+0 and 24+6 weeks of gestation. Patients received antibiotics and steroids for fetal lung maturity once they reached 24 weeks of gestation. Placentas were examined histopathologically. Surviving infants were followed-up at 2 years of age. RESULTS: Median latency from PPROM to delivery was 4 days. Survival rate of 56 singletons was 45% (25/56); and 13 died in hospital. Survival rate of infants discharged from hospital was 23% (12/56). Chorioamnionitis was seen histologically in 42% (5/12) of surviving infants compared with 92% (12/13) of those that died in hospital. Of the 12 surviving infants, 50% had a normal neurological and developmental outcome at 2 years of age. CONCLUSION: Gestational age, birth weight, and histologic chorioamnionitis have prognostic importance in pregnancies complicated by PPROM. Surviving infants have a 50% chance of achieving an adequate health status at 2 years of age.

Where to look for the sentinel lymph node in cervical cancer.

OBJECTIVE: The aim of this study was to analyze lymphatic spread to pelvic, parametrial, and paraaortic lymph nodes in patients with cervical cancer. STUDY DESIGN: We reviewed 619 patients with invasive cervical cancer treated by radical abdominal hysterectomy and systematic pelvic or pelvic and paraaortic lymphadenectomy between 1971 and 2005. The present study included 61 patients with one positive lymph node (10%) and 59 patients with two positive lymph nodes (10%) at any location. RESULTS: The external iliac (43%) and obturator (26%) regions and the parametrium (21%) were the most commonly involved pelvic lymph node sites with solitary metastases. Isolated metastases to common iliac, presacral (internal iliac), and paraaortic nodes were found in 7%, 1%, and 1% of patients, respectively. Patients with 2 positive nodes had 1 parametrial and 1 pelvic node involved (32%), 2 ipsilateral positive nodes (31%), 1 positive lymph node on both sides of the pelvis (27%), and 2 positive nodes within the parametrium (10%). CONCLUSIONS: In cervical cancer patients with only 1 positive lymph node, this node is most frequently located within the external iliac and obturator regions and the parametrium. Sentinel node identification should primarily address these lymph node sites. If 1 positive lymph node is found, further metastases are unpredictable within pelvic and parametrial lymph node sites. Paraaortic spread without pelvic node involvement is rare.

Neonatal outcome of second twins depending on presentation and mode of delivery.

Our objective was to examine the neonatal outcome of second twins depending on presentation and mode of delivery. Using a database we analyzed the short-term neonatal outcome in twin pregnancies offered a trial of labor with special emphasis on the second twin depending on presentation and mode of delivery. Neonatal outcome was evaluated by Apgar scores, umbilical cord blood pH values, and perinatal or neonatal morbidity and mortality. Overall, in 219 (78%) of 281 pregnancies successful vaginal birth (VB) of both twins (VB-VB) was possible, 48 (17%) women had to be delivered by cesarean section (CS) of both twins (CS-CS), and in 14 (5%) women the second twin had to be delivered by CS after VB of the first twin (VB-CS). Successful VB was most common for vertex-vertex (V/V; n=171, 82%) and vertex-nonvertex (n=48, 75%) presentation (V/NV). Twins delivered by VB-CS had the lowest values for pHart (p=.006) and pHven (p=.010). pHart less than or equal to 7.00 values occurred only in second twins delivered VB-VB or VB-CS. Lower Apgar scores of the second twin occurred more frequently in the VB-CS and in the VB-VB than in the CS-CS groups (ps<.05). Lower levels of pHart (p=.002) and frequency of pHart less than or equal to 7.00 occurred more often in nonvertex second twins than in vertex second twins (p<.022). The high CS rate in V/NV presentation and the significantly worse perinatal short-term outcome of NV second twins after VB of the first twin underline that randomized studies are necessary to evaluate the best delivery mode for V/NV twins.

Long-term follow-up after neoadjuvant chemotherapy for high-risk cervical cancer during pregnancy.

BACKGROUND: We report on a patient with a high-risk cervical cancer during pregnancy treated with neoadjuvant chemotherapy (NACT) followed by radical surgery. CASE: A 38-year-old woman was diagnosed with FIGO stage IIA cervical cancer at 19 weeks' gestation. She received four cycles of cisplatin (50 mg/m2) and vincristine (1 mg/m2) at 3-week intervals starting at 23 weeks' gestation. A cesarean section with radical hysterectomy and pelvic lymphadenectomy was performed at 33 weeks, delivering a 1920 g male newborn. Histology showed a poorly differentiated squamous cell carcinoma with lymph vascular invasion and pelvic lymph node metastases. The patient received three further cycles of chemotherapy. Both mother and child are healthy at 80 months after the primary diagnosis. CONCLUSION: NACT followed by radical surgery may be effective in selected patients with invasive cervical cancer during pregnancy.

Is intraoperative frozen section analysis of pelvic lymph nodes accurate after neoadjuvant chemotherapy in patients with cervical cancer?

OBJECTIVE: Intraoperative frozen section examination of pelvic lymph nodes is frequently used in patients with cervical cancer, some of whom have received neoadjuvant chemotherapy (NACT). However, NACT can cause necrosis, fibrosis, or keratinization of tumor deposits in extirpated lymph nodes, and it is unclear whether intraoperative frozen section analysis of extirpated nodes is accurate after NACT. We analyzed the accuracy of frozen section examination of pelvic lymph nodes in patients after NACT for cervical cancer. METHODS: We reviewed 134 patients with invasive cervical cancer who underwent surgery including systematic pelvic lymphadenectomy with intraoperative frozen section examination of pelvic lymph nodes. Results of frozen section examination were related to definitive histology and compared between patient groups of NACT and primary surgery. RESULTS: A total of 1670 pelvic lymph nodes were evaluated intraoperatively by frozen section examination, and 6689 pelvic lymph nodes were analyzed by final histopathology. Overall frozen section analysis had nine false negative results among 53 patients with positive lymph nodes (false negative rate, 16.9%). After NACT, there were two false negative diagnoses in twelve patients with node metastases (false negative rate, 16.7%). No false positive cases were noted. The sensitivity and negative predictive value of frozen section examination were 83% and 82%, respectively, in patients after NACT, and 83% and 91% at primary surgery. CONCLUSION: NACT does not appear to compromise the diagnostic accuracy of intraoperative frozen section examination of pelvic lymph nodes in patients with cervical cancer.

Bleeding complications with the tension-free vaginal tape operation.

OBJECTIVE: This study was undertaken to analyze bleeding problems with tension-free vaginal tape (TVT) operations in a national registry. STUDY DESIGN: We studied patients for whom increased intraoperative bleeding or reoperation for bleeding/hematoma with TVT operation were reported to the registry. RESULTS: Bleeding problems were reported for 151 of 5578 (2.7%) TVT operations. Increased intraoperative bleeding was reported for 106 (1.9%) and reoperation (or conversion) in 45 (0.8%) patients (both in 5 patients). Increased intraoperative bleeding was managed conservatively in 103 patients (95%). Overall, 45 (0.8%) patients required reintervention for bleeding or hematoma. The reinterventions comprised 34 laparotomies, 4 transvaginal evacuations of hematomas, 3 revisions for bleeding from a suprapubic catheter site, and 2 revisions of the vaginal incision (details unclear in 1 patient). Bleeding was considered arterial in 12% (including 1 external iliac artery injury and 1 obturator artery injury) and venous or unknown in 88%. Of reoperated patients, 39% were reoperated within 24 hours, 20% within 2 to 10 days, and 41% within 11 to 56 days after TVT placement. Overall, 19 patients received blood transfusions (range, 1-10 units). There were no deaths from bleeding complications. CONCLUSION: Bleeding complications were reported with less than 3% of 5578 TVT operations. Most cases of increased intraoperative bleeding were managed conservatively; 0.8% of patients required conversion or reoperation.

Isolated recurrence at the residual uterine cervix after abdominal radical trachelectomy for early cervical cancer.

BACKGROUND: We report an isolated recurrence at the residual cervix shortly after abdominal radical trachelectomy for cervical cancer. CASE: A 34-year-old woman underwent radical abdominal trachelectomy and pelvic lymphadenectomy for FIGO stage IB1 squamous cell cervical cancer. The tumor measured 10 mm in maximum diameter with 4 mm of invasion. Histology showed lymph vascular space involvement with no infiltration of adjacent structures and no pelvic lymph node metastases. Tumor-free resection margins exceeded 15 mm. At the 6-month follow-up examination, cervical cytology showed cells suspicious for recurrent cervical cancer. Abdominal hysterectomy was performed and histology showed an isolated 3-mm recurrence in the residual cervix. The patient is free of disease 8 months after hysterectomy. CONCLUSION: Recurrence at the residual cervix is a potential risk of abdominal trachelectomy for early cervical cancer. Patients should be counseled accordingly and followed closely.

Ectopic (pelvic) kidney mimicking bulky lymph nodes at pelvic lymphadenectomy.

BACKGROUND: Ectopic (pelvic) kidney is the most common congenital renal anomaly with an incidence of 1 in 500 to 1 in 2000. A pelvic kidney can be encountered at pelvic or paraaortic lymphadenectomy. CASE REPORTS: In two patients undergoing pelvic lymphadenectomy, lobulated tumors near the pelvic brim were initially interpreted as bulky lymph node conglomerates. Further dissection showed the ureter to originate from the masses, leading to a diagnosis of pelvic kidney. CONCLUSION: Pelvic kidneys mistaken for bulky lymph nodes are a potential intraoperative pitfall in patients with gynecologic malignancies. Keys to recognition include an index of suspicion, identifying the course of the ureter and origin of the renal vessels, and confirming absence of a kidney at the normal location.

Placement of a retropubic drain with the tension-free vaginal tape operation.

Intraoperative bleeding and postoperative hematomas are recognized complications of the tension-free vaginal tape (TVT) operation. We devised a connector to attach a drain to the end of the TVT needle. The drain is pulled upward with the tape itself and is left in the space of Retzius in the tract created by the needle. The drain connector provides a simple method to place a drain in the space of Retzius during the TVT operation.

A prospective randomised trial of atosiban versus hexoprenaline for acute tocolysis and intrauterine resuscitation.

OBJECTIVE: The aim of this study was to compare the efficacy and side effect profile of atosiban with hexoprenaline when used for intrauterine resuscitation of intrapartum fetal distress. STUDY DESIGN: Women in labour with acute intrapartum fetal distress detected by cardiotocography were randomly assigned to receive intravenous atosiban or hexoprenaline. SETTING: Department of Obstetrics and Gynecology, Karl Franzens University of Graz and General Hospital Graz, Austria. POPULATION OR SAMPLE: One thousand and four hundred and thirty-one women with singleton pregnancy at term and cephalic presentation were enrolled in the study during October 2000 and May 2001. METHODS: A prospective, randomised, pilot study with no a priori sample size calculation. MAIN OUTCOME MEASURE: Efficacy of treatment for stopping uterine contractions and the resumption of contractions determined by fetal heart rate monitoring. RESULTS: Tocolysis was achieved in 92% (12/13) of the women receiving atosiban and 100% (13/13) of those receiving hexoprenaline. Maternal tachycardia developed in 1/13 women, receiving atosiban and 10/13 women hexoprenaline. Hypertension occurred in 1/13 on atosiban and 3/13 women on hexoprenaline. Palpitations were only reported by 10/13 women receiving hexoprenaline. Uterine contractions resumed after 8 minutes (+/-3) in the atosiban group and 14 minutes (+/-4) in the hexoprenaline group (P < 0.001). CONCLUSION: Atosiban and hexoprenaline were similarly effective for stopping uterine contractions. Women receiving atosiban had significantly fewer adverse events than those receiving hexoprenaline. Uterine contractions resumed more promptly in the atosiban group. Considering the low incidence of mild maternal adverse events, atosiban may be an option for acute intrapartum tocolysis for fetal distress.