The effects of loop excision of the transformation zone on cervical length: implications for pregnancy.

OBJECTIVE: This study was undertaken to determine whether previously described significant and quantitative cervical shortening caused by loop excision of the transformation zone persists after 3 months of healing. STUDY DESIGN: A prospective study was designed in which 20 patients were enrolled. Each underwent transvaginal ultrasonography for determination of cervical length before the loop excision of the transformation zone and >/=3 months after the loop excision of the transformation zone. Simple regression analysis and the Student paired t test was performed to determine whether the length of the cervix had changed significantly between the measurements. RESULTS: The mean cervical lengths as measured by transvaginal ultrasonography before and after loop excision of the transformation zone were 3.1 +/- 0.8 cm and 3.1 +/- 0.7 cm, respectively. The correlation between ultrasonographic measurements before and after loop excision of the transformation zone was r = 0.88 (P <.0001). A paired t test resulted in a P value of 1.0000, which indicates that the ultrasonographic measurement after loop excision of the transformation zone was not different from the ultrasonographic measurement before loop excision of the transformation zone. The mean difference between measurements was 0.0 +/- 0.4 cm. CONCLUSION: After adequate healing time after loop excision of the transformation zone, the length of the cervix, as measured by transvaginal ultrasonography, does not appear to remain shortened.

Endometrial carcinoma after endometrial ablation: high-risk factors predicting its occurrence.

Our purpose was to review reported cases of endometrial carcinoma after endometrial ablation and to evaluate high-risk factors predicting its occurrence. We present guidelines for the treatment of abnormal uterine bleeding unresponsive to medical therapy in this high-risk group of patients. Eight detailed reports on endometrial carcinoma after endometrial ablation were reviewed. The indications, methods of treatment, follow-up, and associated high-risk factors for endometrial carcinoma were analyzed. A focused list of high-risk factors for endometrial carcinoma was developed on the basis of the data collected. Guidelines were established to enable surgeons to minimize the risks of subsequent uterine cancer in women with abnormal uterine bleeding that is unresponsive to medical therapy (ie, candidates for ablation). Women who had endometrial carcinoma develop after ablation had predictive high-risk factors for subsequent neoplasia, and all eventually underwent a hysterectomy. Women with abnormal uterine bleeding and high-risk factors for endometrial carcinoma who did not respond to medical treatment may safely undergo endometrial ablation but must have a preablation biopsy indicating normal endometrium. Persistent hyperplasia unresponsive to hormonal therapy should influence the selection of a hysterectomy. Careful screening of patients before undergoing endometrial destructive procedures is prescient because minimally invasive, nonhysteroscopic ablative techniques are now emerging.

Urinary oxalate excretion and its role in vulvar pain syndrome.

OBJECTIVE: This study was undertaken to determine the urinary oxalate excretion patterns in patients with vulvodynia compared with controls and to evaluate antioxalate therapy in women with vulvar pain syndrome (vulvodynia). STUDY DESIGN: A total of 130 consecutive patients with vulvar pain syndrome and 23 volunteers without symptoms collected urine specimens for 24 hours; each voiding was saved in individual labeled containers and refrigerated. The specimens were analyzed individually for oxalate and calculated according to 24-hour concentration, volume, and peak oxalate by hour. A total of 59 patients were treated with low-oxalate diets and calcium citrate for 3 months and evaluated for objective relief of vulvar pain. RESULTS: The 24-hour excretion of oxalate was almost identical in controls and vulvodynia patients. The total 24-hour excretion was directly proportional to the volume of urine excreted (p < 0.001). No significant differences were found in peak oxalate excretion (95% confidence intervals). The number of voidings was higher in the vulvodynia cohort (p < 0.02). The 59 women with elevated oxalate concentrations (> 1 mg/40 dl) were treated with an antioxalate regimen. Fourteen (24%) demonstrated an objective response, but only 6 (10%) could have pain-free sexual intercourse. CONCLUSIONS: Urinary oxalates may be nonspecific irritants that aggravate vulvodynia; however, the role of oxalates as instigators is doubtful.

Endometrial ablation: a series of 568 patients treated over an 11-year period.

OBJECTIVE: Our purpose was to retrospectively review the intraoperative and long-term outcomes of 568 patients with abnormal uterine bleeding who were treated by endometrial ablation over an 11-year period. STUDY DESIGN: From 1893 to 1994, 401 endometrial ablations were performed with the neodymium-yttrium-aluminum-garnet laser and another 167 patients were treated by electrosurgery. The majority of the patients were treated for irregular, heavy menses. Fifty-seven had ablation because of abnormal bleeding associated with a serious medical disorder, 12 with a bleeding diathesis, and 50 with morbid obesity. All patients had preoperative endometrial sampling that demonstrated benign histology. Nineteen patients had submucous myomas that were resected at the time of hysteroscopic ablation. All patients received preoperative and postoperative suppression. The minimum follow-up period was 1 year. RESULTS: The average operative time was 32.5 minutes. The mean hospital stay was 8 hours. Four patients who received 32% dextran 70 in dextrose (Hyskon) as the distending medium had pulmonary edema postoperatively. One case of endometritis was also detected. No uterine perforations were observed. Amenorrhea developed in 58% of the patients, 34% reported light or normal menstrual flow, and 8% did not respond (continued heavy flow). CONCLUSION: This study represents one of the largest published series of endometrial ablation, with a mean follow-up of 4.5 years. It demonstrates that hysteroscopic endometrial ablation is a reliable, safe alternative to hysterectomy for the surgical management of abnormal uterine bleeding.

Vulvar pain syndrome: a review.

Vulvar pain syndrome (vulvar vestibulitis, vulvodynia, burning vulvar syndrome) was first described at the end of the last century. Although more than 100 years have passed, the cause(s) of the disorder remains elusive. This review of the literature endeavors to collate the known facts relating to vulvar pain syndrome and to expose those hypothetical etiologies which fall short of establishing any scientific foundation. The diagnosis of vulvar pain syndrome is established on the basis of historical data which detail a rather abrupt onset of vestibular itching, burning, dryness which may be intermittent or continuous. Commonly, patients present with a history of chronic treatment for recurrent fungal infections. Sexual relations become uncomfortable or intolerable. Unanimously, the patients describe a panorama of topical creams and ointments which fail to alleviate the symptoms. Physical examination typically verifies hyperesthesia of the vestibular skin when touched lightly with a cotton-tipped applicator. Similarly, the vestibular skin shows varying degrees of redness. The treatment programs for vulvar pain syndrome are as diverse as the multitude of etiological hypotheses. This review includes data pointing out those therapeutic measures that appear valueless and that may add to the patient's chronic discomfort.

Tissue actions of bipolar scissors compared with monopolar devices.

OBJECTIVES: To establish whether bipolar scissors offer equivalent cutting performance compared with monopolar scissors and to compare extent of thermal coagulation injury using two electrosurgical generators. DESIGN: Eighteen female rabbits' uterine horns were cut using controlled velocity at several different wattages with either bipolar or monopolar scissors. The specimens were examined microscopically and zones of thermal necrosis were measured using a stage micrometer against a 1 mm standard. RESULTS: Bipolar scissors cut equally well compared with monopolar scissors and showed significantly less thermal injury. When coupled to a constant voltage generator both the bipolar and monopolar scissors performed better. CONCLUSION: Bipolar scissors offer the surgeon significant safety advantages and equivalent or better performance compared with monopolar scissors when used for laparoscopic surgery.

Comparison of thermal injury zones in loop electrical and laser cervical excisional conization.

Thirty cervical conization specimens obtained by thin-loop electric excision were compared with 30 carbon dioxide laser excisional cone specimens. Zones of thermal artifact were measured with a precise stage micrometer technique calibrated to a Zeiss standard. The mean depth of coagulation at the ectocervical margin measured 0.187 and 0.164 mm for thin loop and laser, respectively. Thermal artifact at the endocervical margin was greater with electric loop (0.295 mm) than with superpulsed carbon dioxide laser (0.137 mm). The zones of thermal injury induced by both electric loop and laser made no significant impact on the interpretation of margin adequacy.

Hysteroscopic treatment of septate uterus with Neodymium-YAG laser.

OBJECTIVE: To determine the effectiveness of Neodymium-YAG (Nd-YAG) laser for hysteroscopic transection of the septate uterus to improve pregnancy outcome. DESIGN: Patients treated for recurrent pregnancy loss and/or infertility were evaluated for before versus after treatment pregnancy outcomes. SETTING: All patients were referred to a University Reproductive Endocrine and Infertility practice from 1986 through 1990. PATIENTS, PARTICIPANTS: Nineteen patients underwent hysteroscopic transection of uterine septa after exclusion of other factors that may cause recurrent fetal wastages and/or infertility. They were allowed to conceive 8 weeks after surgery after a postoperative hysterosalpingogram. Fourteen women attempted conception during a time span of 11 to 42 months; 3 patients declined to conceive, and 2 were lost to follow-up. INTERVENTIONS: Hysteroscopic transection of the uterine septum with a Nd-YAG laser was performed in all patients. The Nd-YAG laser delivered via a 600-microns bare fiber or an 800-microns sculpted fiber through operative hysteroscopy. MAIN OUTCOME MEASURES: To evaluate the success and complications of this new laser technique. RESULTS: (1) Thirteen patients conceived; 10 delivered a live infant at term; (2) 87% of the postoperative pregnancies were considered successful as compared with 11% preoperative; (3) complications included a small perforation of the uterus (no treatment needed) and development of uterine adhesions (1 case only). CONCLUSIONS: Hysteroscopic metroplasty with the Nd-YAG laser is a valuable alternative new technique for the treatment of uterine septum.

Serum levels of Hyskon during hysteroscopic procedures.

Hyskon hysteroscopy fluid is used with the hysteroscope as an aid in distending the uterine cavity and in visualizing its surfaces. We correlated the amount of Hyskon used during hysteroscopy with both the instillation pressures generated within the uterine cavity and with serum levels of Hyskon in 11 healthy subjects. Serum levels in excess of 1000 mg% were measured at 30 min when an amount of Hyskon greater than 300 mL was used. Intrauterine Hyskon absorption and/or injection during hysteroscopy were found even after volumes of Hyskon as small as 50-100 mL were used. Serum levels were significantly higher with the larger amounts of Hyskon used in ablative procedures (P less than 0.01), as compared with serum levels seen with the smaller amounts of Hyskon used for diagnostic procedures. The injection pressures should be low to minimize the amount of intravascular injection. In cases in which extensive ablative procedures are necessary, we suggest that a two-stage procedure be considered. Because of the hypertonicity of Hyskon, intravascular volume expansion that may be larger than that seen during transurethral prostatectomy occurs.

Presence of human immunodeficiency virus DNA in laser smoke.

Concentrated tissue culture pellets infected with human immunodeficiency virus (HIV) containing 1 x 10(7) cells/ml were vaporized by means of a carbon dioxide laser. The vaporous debris resulting from the laser's impact were evacuated through sterile silastic tubing, then bubbled through sterile culture medium (RPMI) positioned in series with a commercial smoke evacuator. No HIV DNA was detected in the culture medium flask. Tissue culture studies of the silastic collection tubing revealed p24 HIV gag antigen in 3 of 12 tube segments at the end of 1 week and in 1 of 12 tube segments at 2 weeks. No sustained infection of HIV cultured cells was observed at the 28th day. Polymerase chain reaction (PCR) analysis of particulate debris obtained from the silastic collection tubing was positive from proviral HIV DNA in both immediately sampled and day 14 cultured material.

Electrosurgical thin loop conization by selective double excision.

Thin loop electrosurgical conization of the cervix was performed in 30 women, using a selective double excision (SDE) technique in order to conserve cervical tissue. The entire excisional cone was completed within 4 minutes, and blood loss was estimated at 5 ml or less. All cervices healed in patterns identical to CO 2 laser conizations. Critical tissue margins were easily identified by the pathologist. Compared to simple loop excisional cones, SDE saved greater than 2 cm3 of cervical stroma.

Laser vaporization of genital condylomata in pregnancy.

Sixteen pregnant women with genital condylomata acuminata were treated with laser vaporization to assess effectiveness, complication rate, and impact on recurrence. Patients were treated at a gestational age of 13-35 weeks. No recurrences occurred before delivery. Five patients experienced uterine contractions before 37 weeks. Only one delivery before 37 weeks may have been attributed to the laser therapy. Four recurrences were detected during postpartum follow-up. Laser vaporization is a safe and effective treatment for condyloma during pregnancy. It is effective in maintaining a lesion-free state during pregnancy, but postpartum recurrences are not rare.

Carbon dioxide laser therapy for benign cervical tumors.

Eight patients underwent carbon dioxide (CO 2) laser excision of benign cervical tumors during a 5-year period. Six patients had symptoms of abnormal vaginal bleeding, and 2 had asymptomatic cervical masses. All but one procedure was performed as outpatient surgery. Blood loss was minimal in 7 patients and less than 50 ml in the other patient. There were no cases of morbidity, and long-term follow-up showed excellent results. The technique to perform CO 2 laser excision of large benign cervical tumors is described.

Death caused by air embolism associated with neodymium:yttrium-aluminum-garnet laser surgery and artificial sapphire tips.

Two women undergoing intrauterine surgery with the neodymium:yttrium-aluminum-garnet laser delivered by the artificial sapphire tip had catastrophic cardiovascular collapse during operation. In each case the evolution of clinical events was consistent with the diagnosis of air embolus. Investigation of causative factors links the use of the sapphire tip and the gaseous cooling of the tip to the calamitous outcomes. Both women died.

Quantitative evaluation of the skin and accessory appendages in vulvar carcinoma in situ.

Fifty cases of vulvar carcinoma in situ comprising over 1000 histologic sections were studied. Each case was evaluated to determine the thickness of the neoplastic epidermis and the depth of involved skin appendages. Two precise techniques were used to perform the microscopic measurements. The areas most frequently afflicted with neoplasia were: one or both labia (45%), interlabial folds (27%), perineum-fourchette (15%), and perianal skin (10%). Multicentric disease was observed in 68% of the cases. The epidermal thickness ranged between 0.35-1.66 mm. The mean depth (+/- SD) of the epidermis was 0.93 +/- 0.37 mm. Eighteen of the 50 patients demonstrated involvement of the skin appendages to a mean depth of 1.53 +/- 0.77 mm, suggesting that laser vaporization to a depth of 2.5 mm will, with the anticipated additional thermal necrosis, eliminate appendages involved with carcinoma in situ in 95% of instances. The most common sites of skin appendage involvement were the labia majora or minora and the interlabial folds.

A ten-year experience treating cervical intraepithelial neoplasia with the CO2 laser.

Between 1977 and 1987, the CO2 laser was used to treat 4024 women who were diagnosed by cytology studies, colposcopy, and biopsy examination to have cervical intraepithelial neoplasia. On the basis of specific indications, these women were treated by vaporization, excisional conization, or combination conization procedure. The evolution of methodology for each laser technique was based on specific pathophysiology and long-term observation of results. A total of 3070 patients underwent vaporization, 2881 of whom had no evidence of disease after one laser exposure (93.8%). Of the 954 patients who had laser excisional procedures, 925 (97%) had no evidence of disease. The most common complications observed were intraoperative and postoperative bleeding; however, sutures were required in only 1.34% of the latter. The risks of cervical stenosis (1.1%), incompetent cervix (0%), and pelvic infection (0.05%) were very low. This 10-year study demonstrated that the CO2 laser was a highly effective method for treating cervical epithelial neoplasia and had the added benefit of preserving reproductive function and anatomic integrity.

Evaluation of tissue healing and adhesion formation after an intraabdominal amniotic membrane graft in the rat.

The amniotic membrane was used as a graft intraabdominally in the rat to study the healing process and the graft's efficacy in preventing postoperative adhesions. We observed the gradual invasion of the graft with fibroblasts and plasma cells and increased vascularity. By the tenth postoperative day the graft had taken completely. There was no evidence of infection at the graft site or rejection of the graft. Application of the graft after lysis of adhesions was followed by adhesion formation at the graft site. The graft did not show evidence of necrosis but failed to prevent adhesion formation.

Catastrophic injury secondary to the use of coaxial gas-cooled fibers and artificial sapphire tips for intrauterine surgery: a report of five cases.

Five women undergoing endometrial ablation with the Nd-YAG laser developed sudden gas embolism. In each case laser intrauterine contact surgery was carried out utilizing coaxial fibers with (three cases) and without (two cases) artificial sapphire tips but commonly cooled by air or nitrogen. Four of the five women died in a sequence of sudden cardiovascular collapse followed by irreversible cardiac arrest. One woman was critically ill and following prolonged hospitalization survived with neurological deficits.