Urodynamic evaluation: can it prevent the need for surgical intervention in women with apparent pure stress urinary incontinence?

OBJECTIVES: To identify how many patients with symptoms of pure stress urinary incontinence (SUI) do not require any surgical treatment on the basis of urodynamics (UDS) and how many patients still do not require surgery 1 year after UDS. To assess the outcomes of these patients at 12-month follow-up. PATIENTS AND METHODS: Women with pure SUI received UDS and were prospectively divided into four groups, comprising women with: urodynamic stress incontinence (USI); detrusor overactivity (DO); USI + DO; and inconclusive UDS. Women with USI underwent a Tension Free Vaginal Tape (Obturator) (TVT-O) procedure (Gynecare; Ethicon Inc., Somerville, NJ, USA), whereas women with DO ±/- USI were recommended 24-week antimuscarinic therapy. Follow-up was scheduled at 3 and 12 months. To define subjective outcomes, all patients completed the International Consultation on Incontinence Questionnaire - short form, the Patient Global Impression - Improvement and the Urinary Distress Inventory. Patients were considered cured if they presented a negative stress test, a score reduction of at least 80% on the Urinary Distress Inventory and a response of 'much better' or 'very much better' on the Patient Global Impression - Improvement. RESULTS: Of the 263 women with pure SUI, 74.5% had a urodynamic diagnosis of USI, 10.6% had DO, 8% had USI + DO and 6.8% had inconclusive UDS. At 12-month follow-up, 165/181 (91.6%) women in group 1 were considered cured post-TVT-O; in the other groups, 33/67 (49.2%) patients were considered cured simply as a result of taking antimuscarinics; 13 of these 67 patients required TVT-O. CONCLUSIONS: UDS is able to show that several patients with symptoms of pure SUI present an underlying DO and do not require surgery, even 1 year after UDS. In these patients, antimuscarinic treatment appears to ensure a good rate of cure; thus, UDS could lead to the avoidance of several surgical procedures.

Nerve-sparing minilaparoscopic versus conventional laparoscopic radical hysterectomy plus systematic pelvic lymphadenectomy in cervical cancer patients.

AIM: To present our preliminary experience with nerve-sparing minilaparoscopic radical hysterectomy plus pelvic lymphadenectomy for the surgical treatment of cervical cancer and to compare outcomes with those of the conventional laparoscopic approach. METHODS: Data of 87 consecutive women who underwent minimally invasive surgery for early and locally advanced stage cervical cancer were prospectively collected. Ten women who underwent laparoscopic surgery using a nerve-sparing technique performed through 3-mm ancillary ports were compared with the 77 patients who had standard laparoscopic surgery previously with 3 sovrapubic 5-mm trocars. RESULTS: Minilaparoscopic radical hysterectomy was successfully accomplished in every case with no conversion to standard laparoscopy or open surgery. Two (2.6%) conversions to open surgery occurred in the conventional laparoscopy group. Surgical characteristics (operative time, estimated blood loss, and length of stay) and complication rate were similar between the 2 groups. No differences in the amount of parametrial and vaginal tissue removed were observed. The number of lymph nodes retrieved through minilaparoscopy was higher than conventional laparoscopy (30 [range = 26-38] vs 22 [range = 8-49]; P = .002). However, no difference was observed when the analysis was restricted to the last 10 conventional procedures (30 [range = 26-38] vs 29 [range = 24-49]; P = .81). CONCLUSIONS: Our data show that minilaparoscopic radical hysterectomy with pelvic lymphadenectomy is a feasible procedure if performed by skilled surgeons.

Perioperative allogenic blood transfusions and the risk of endometrial cancer recurrence.

PURPOSE: To evaluate the effect of perioperative blood transfusions on the risk of recurrence of endometrial cancer. METHODS: This study is a retrospective analysis of 358 consecutive patients, without a history of other tumors, who underwent surgery for endometrial cancer between January 2000 and April 2010. RESULTS: Women who did not need any transfusion (N = 331) and patients who received allogenic blood donations (N = 27) were compared in terms of risk of cancer recurrence. The surgical standard procedure included peritoneal washing for cytologic examination, total hysterectomy + bilateral adnexectomy (N = 358), and pelvic lymphadenectomy (N = 227). The two groups were homogeneous in term of age, BMI, previous abdominal surgery, type of intervention, operative time, nodal count, and hospital stay. The median (range) estimated blood loss was higher in the transfusion group, 400 mL (100-2,000 mL), than in the non-transfusion group, 150 mL (10-1,000 mL). Median (range) follow-up was 67.5 months (6-132.4 months). Blood transfusions were associated with a higher relapse rate (P = 0.0021). At multivariate analysis, administration of packed red blood cells remained independently associated with recurrence (OR 4.64; CI 95 % 1.45-14.9), as well as myometrial invasion ≥50 % (OR 2.88; CI 95 % 1.18-7.07) and stage >1 (OR 4.24; CI 95 % 1.75-10.3). CONCLUSIONS: The use of allogenic blood transfusions is associated with a higher risk of recurrence. We hypothesize that this could be due to a transitory perioperative immunodepression that promotes the spread of neoplastic cells.

Transumbilical versus transvaginal retrieval of surgical specimens at laparoscopy: a randomized trial.

OBJECTIVE: We sought to compare transumbilical (TU) and transvaginal (TV) route for retrieval of surgical specimens at laparoscopy. STUDY DESIGN: Women scheduled for a laparoscopic resection of an adnexal mass were randomized to have their surgical specimen removed either through a posterior colpotomy (n = 34) or the umbilical port site (n = 32). Group allocation was concealed from patients and bedside clinicians. The primary outcome was postoperative incisional pain assessed by a 10-cm visual analog scale at 1, 3, and 24 hours after surgery. RESULTS: TV retrieval caused less postoperative pain than TU specimen extraction at each time point (visual analog scale score at 1 hour: 2.6 ± 2.9 vs 1.2 ± 2.0, P = .03; at 3 hours: 2.4 ± 2.0 vs 1.4 ± 2.0, P = .02; and at 24 hours: 1.1 ± 1.5 vs 0.5 ± 1.4, P = .02). A higher proportion of women in the TU group than in the TV group indicated the umbilicus as the most painful area at 1 and 3 hours postoperatively. Two months after surgery, the participants scored similarly as to their overall satisfaction, cosmetic outcome, and dyspareunia upon resumption of intercourse. CONCLUSION: A TV approach for specimen removal after laparoscopic resection of adnexal masses offers the advantage of less postoperative pain than TU retrieval.

A randomized trial of preinduction cervical ripening: dinoprostone vaginal insert versus double-balloon catheter.

OBJECTIVE: We sought to compare the efficacy of a double-balloon transcervical catheter to that of a prostaglandin (PG) vaginal insert among women undergoing labor induction. STUDY DESIGN: In all, 210 women with a Bishop score ≤6 were assigned randomly to cervical ripening with either a double-balloon device or a PGE2 sustained-release vaginal insert. Primary outcome was vaginal delivery within 24 hours. RESULTS: The proportion of women who achieved vaginal delivery in 24 hours was higher in the double-balloon group than in the PGE2 group (68.6% vs 49.5%; odds ratio, 2.22; 95% confidence interval, 1.26-3.91). There was no difference in cesarean delivery rates (23.8% vs 26.2%; odds ratio, 0.88; 95% confidence interval, 0.47-1.65). Oxytocin and epidural analgesia were administered more frequently when a double-balloon device was used. Uterine tachysystole or hypertonus occurred more frequently in the PGE2 arm (9.7% vs 0%, P = .0007). CONCLUSION: The use of a double-balloon catheter for cervical ripening is associated with a higher rate of vaginal birth within 24 hours compared with a PGE2 vaginal insert.

Lymphoceles, lymphorrhea, and lymphedema after laparoscopic and open endometrial cancer staging.

PURPOSE: To evaluate the incidence of lymphoceles, lymphorrhea, and lymphedema after systematic pelvic lymphadenectomy in patients who underwent laparoscopic or open abdominal staging for endometrial cancer. METHODS: A total of 138 consecutive women who underwent systematic laparoscopic pelvic lymphadenectomy for endometrial cancer staging were compared to 123 historical control subjects staged via an open approach. Postoperative screening for lymphadenectomy-related complications by ultrasound was consistently performed. RESULTS: The incidence of perioperative complications was lower in cases than in control subjects. Overall, lymphoceles were diagnosed in 19 (15.4%) and 2 (1.4%) patients who had open and laparoscopic staging, respectively (odds ratio 12.42; 95% confidence interval 2.82-54.55; P < 0.0001). Symptomatic lymphoceles were more frequent after open staging than after laparoscopy (P = 0.028). Lymphorrhea occurred in 1 and 4 patients after laparoscopic and open surgery (P = 0.19). No difference in the incidence of lymphedema was observed. CONCLUSIONS: Our findings suggest that laparoscopic endometrial cancer staging is associated with a lower occurrence of both asymptomatic and symptomatic lymphoceles compared to open surgery.

Use of an antispasmodic (rociverine) to shorten the length of labor: a randomized, placebo-controlled trial.

OBJECTIVE: To determine the effectiveness of rociverine, an antispasmodic drug, for reducing the duration of labor among nulliparous women managed according to a standard intrapartum protocol. DESIGN: Randomized controlled trial. SETTING: An academic tertiary care hospital. POPULATION: Nulliparae in spontaneous active labor, with cervical dilatation between 3 and 5 cm. METHODS: Participants were randomly assigned to receive either an intramuscular injection of 20mg rociverine (n=55) or the same volume of saline (n=56). MAIN OUTCOME MEASURE: Cervical dilatation rate (from administration of study drug to full dilatation). RESULTS: Laboring women who received rociverine had faster cervical dilatation than those assigned to placebo (2.43 ± 1.84 vs. 1.85 ± 1.38 cm/hour, p=0.03). The time interval from treatment administration to full cervical dilatation was shorter in the rociverine group than in the placebo group (220 ± 125 vs. 278 ± 129 min, p=0.04). No difference was found in any other obstetric outcome. No adverse effects have been recorded from rociverine administration. CONCLUSIONS: Intrapartum administration of rociverine to nulliparous women may help to reduce the duration of the first stage of labor in a context of uniform labor management.

Minilaparoscopic versus conventional laparoscopic hysterectomy: results of a randomized trial.

STUDY OBJECTIVE: To compare operative outcomes and postoperative pain of laparoscopic hysterectomy (LH) versus minilaparoscopic hysterectomy (MLH). DESIGN: Randomized controlled trial (Canadian Task Force Classification I). SETTING: Tertiary care center. PATIENTS: Seventy-six women scheduled to undergo a hysterectomy for a supposed benign gynecologic condition. INTERVENTIONS: Participants were randomly assigned to LH (n = 38) or MLH (n = 38). MLH was performed with use of 3-mm ports. Both patients and assessors of the postoperative outcomes were blinded to the size of port used, and patients' wounds were concealed by standard-size nontransparent dressings. MEASUREMENTS: Primary outcome was postoperative pain (both rest and incident on coughing and abdominal pain, as well as shoulder pain) by use of a 100-mm visual analogue scale. MAIN RESULTS: The two groups were similar in terms of operative outcomes. No intraoperative conversion from MLH to both LH and open surgery occurred. No significant difference in pain scores at 1, 3, 8, and 24 hours after surgery between groups was found. Rescue analgesic requirement was similar in the MLH and LH groups (21.1% vs 13.2%, p =.54). CONCLUSIONS: Ports can safely be reduced in size without a negative impact on the surgeon's ability to perform LH. MLH appears to have no advantage over LH in terms of postoperative pain.

Vaginal cuff closure after minimally invasive hysterectomy: our experience and systematic review of the literature.

OBJECTIVE: To determine the incidence of vaginal cuff dehiscence after minimally invasive hysterectomy, we reported our series of total laparoscopic hysterectomies with transvaginal colporraphy. STUDY DESIGN: We then conducted a systematic search of PubMed to retrieve published series of laparoscopic and robotic hysterectomies, in which different techniques for vaginal cuff closure were used. RESULTS: In our study group, vaginal cuff dehiscence occurred in 2 of 665 (0.3%) patients. Our literature search identified 57 articles, for a total of 13,030 endoscopic hysterectomies. Ninety-one postoperative vaginal separations were reported (0.66%). The pooled incidence of vaginal dehiscence was lower for transvaginal cuff closure (0.18%) than for both laparoscopic (0.64%; odds ratio [OR], 0.28; 95% confidence interval [CI], 0.12-0.65) and robotic (1.64%; OR, 0.11; 95% CI, 0.04-0.26) colporraphy. Laparoscopic cuff closure was associated with a lower risk of dehiscence than robotic closure (OR, 0.38; 95% CI, 0.28-0.6). CONCLUSION: Current evidence indicates that transvaginal colporraphy after total laparoscopic hysterectomy is associated with a 3- and 9-fold reduction in risk of vaginal cuff dehiscence compared with laparoscopic and robotic suture, respectively.

Female urinary incontinence at orgasm: a possible marker of a more severe form of detrusor overactivity. Can ultrasound measurement of bladder wall thickness explain it?

INTRODUCTION: Coital incontinence (CI) during orgasm is a form of urinary incontinence possibly because of detrusor overactivity (DO), as the underlying pathophysiological condition. Women with this symptom usually show a pharmacological lower cure rate than those with DO alone. The ultrasound measurement of the bladder wall thickness (BWT) allows an indirect evaluation of detrusor muscle thickness, giving a potential index of detrusor activity. AIM: We wanted to understand if CI at orgasm could be a marker of severity of DO by comparing BWT in women with both DO and CI at orgasm vs. women with DO alone. In addition we aimed to confirm if CI during orgasm is related to antimuscarinics treatment failure. METHODS: This is a prospective cohort study performed in two tertiary urogynecological referral departments, recruiting consecutive patients seeking treatment for symptomatic DO. MAIN OUTCOME MEASURES: All patients were thoroughly assessed including physical examination, urodynamic evaluation, and BWT measurement according to the International Continence Society/International Urogynecological Association and ICI recommendations. Solifenacine 5 mg once daily was then prescribed and follow-up was scheduled to evaluate treatment. Multiple logistic regression (MLR) was performed to identify risk factors for treatment failure. RESULTS: Between September 2007 and March 2010, 31 (22.6%) and 106 (77.4%) women with DO with and without CI at orgasm were enrolled. Women complaining of CI at orgasm had significantly higher BWT than the control group (5.8 ± 0.6 mm vs. 5.2 ± 1.2 mm [P=0.007]). In patients with CI at orgasm, the nonresponder rate to antimuscarinics was significantly higher than controls (P=0.01). After MLR, CI at orgasm was the only independent predictor decreasing antimuscarinics efficacy (odds ratio [OR] 3.16 [95% CI 1.22-8.18], P=0.02). CONCLUSIONS: Women with DO and CI at orgasm showed a significantly higher BWT values and worse cure rates than women with DO alone. CI at orgasm could be a marker of a more severe form of DO.

Urinary symptoms and urodynamic findings in women with pelvic organ prolapse: is there a correlation? Results of an artificial neural network analysis.

BACKGROUND: International official guidelines recommend urodynamic (UDS) evaluation in patients with pelvic organ prolapse (POP). However, the real benefit of this examination is still the subject of heated and controversial debate. Therefore, we aimed to assess the correlation between urinary symptoms and UDS findings in women with POP through the implementation of a sophisticated computer-based technology in the outpatient workup. DESIGN, SETTING, AND PARTICIPANTS: A prospective cohort study was performed in a single, tertiary, urogynaecologic referral department, enrolling consecutive women seeking care for pelvic floor dysfunctions. INTERVENTION: Patients underwent clinical and urodynamic evaluation. Data regarding baseline characteristics, symptoms, anatomic, and urodynamic findings were gathered for each patient. Multiple linear regression (MLR) and artificial neural networks (ANNs) were performed to design predicting models. RESULTS AND LIMITATIONS: A total of 802 women with POP were included. POP quantification stages and baseline data poorly correlated to final UDS findings. Stress urinary incontinence and overactive bladder were both independently associated to each UDS diagnosis, including detrusor overactivity (DO), urodynamic stress incontinence (USI), and mixed urinary incontinence (USI plus DO). Receiver operating characteristic comparison confirmed that ANNs were more accurate than MLR in identifying predictors of UDS diagnosis, but none of these methods could successfully overcome UDS. Case-control studies are needed to confirm our findings. CONCLUSIONS: Despite the current debate based on the actual value of UDS in women with POP, even the implementation of ANN, a sophisticated computer-based technology, does not permit an accurate diagnosis just on the basis of symptoms or avoiding UDS. Therefore, in women with POP, especially if scheduled for surgery, UDS should be considered as mandatory, since misleading counselling could result in unpleasant unexpected events.

Is transcervical Foley catheter actually slower than prostaglandins in ripening the cervix? A randomized study.

OBJECTIVE: The purpose of this study was to determine whether the maximum time for cervical ripening (from 24-12 hours) would influence the efficacy of a transcervical Foley catheter and to compare efficacy to that of a prostaglandin E(2) vaginal insert. STUDY DESIGN: Three hundred ninety-seven women were assigned randomly to (1) Foley catheter left in place for a maximum of 24 hours, (2) Foley catheter left in place for a maximum of 12 hours, or (3) prostaglandin E(2) controlled-release vaginal insert. Primary outcome was vaginal delivery within 24 hours. RESULTS: There were no differences in vaginal delivery rates. The proportion of women who achieved vaginal delivery in 24 hours was lower in the 24-hour Foley catheter group than in the other 2 groups (24-hour Foley catheter, 21.0%; 12-hour Foley catheter, 59.8%; vaginal prostaglandin E(2), 48.5%; P < .0001). CONCLUSION: Cutting the ripening time with a Foley catheter by one-half increases the proportion of women who deliver vaginally within 24 hours and yields efficacy similar to that of prostaglandin E(2) vaginal insert.

Surgical treatment for pelvic floor disorders in women 75 years or older: a single-center experience.

OBJECTIVE: Older patients are usually regarded as suboptimal candidates for surgical operations, particularly in cases of reparative, non-life-saving procedures. The aim of this study was to analyze the feasibility and safety of surgical treatment for pelvic floor dysfunction in advanced-age women. METHODS: A single-center descriptive study was performed through a retrospective medical records review. Women 75 years or older who underwent a surgical operation for urogynecological dysfunction (pelvic organ prolapse, urinary incontinence, or both) between January 2000 and December 2009 were considered. RESULTS: Overall, 138 women were included. Median age was 77 years (range, 75-95 y). Women underwent different types of surgical correction. The following procedures (alone or in combination) were performed: 102 (73.9%) vaginal hysterectomies, 106 (76.8%) anterior repairs, 36 (26%) posterior repairs, 9 (6.5%) colpocleisis, 4 vaginal vault ileococcygeus suspensions (2.9%), and 22 (15.9%) tension-free vaginal tape procedures. One (0.7%) intraoperative and five (3.6%) postoperative complications occurred. Urinary retention rate after surgical operation was 5.8%. Only one (0.7%) woman was discharged with a Foley catheter because of voiding difficulty. Clinical follow-up showed 87.6% anatomical success in women with genital prolapse and a subjective success rate of 86.4% in women undergoing anti-incontinence procedures. CONCLUSIONS: Our study shows that reconstructive surgical operation is a viable treatment option for pelvic floor dysfunction in older patients.

Female sexual function during pregnancy and after childbirth.

INTRODUCTION: Healthy sexual function during pregnancy and after childbirth is one of the cornerstones for couples to evolve from partners to parents. AIM: The aim of our review is to evaluate the available evidence and define present knowledge about female sexual function during pregnancy and after childbirth. METHODS: PubMed was searched for articles on sexual function during pregnancy and after childbirth, published from 1960 up to date. The most relevant articles have been reviewed and included. MAIN OUTCOME MEASURES: The main outcome is the review of the effect of pregnancy, delivery, and postpartum on female sexuality. RESULTS: A total of 48 articles which specifically addressed this topic were included. Sexual function was found to have a significant global decline during pregnancy, particularly in the third trimester and this persisted for 3-6 months following delivery. The lack of adequate information about sex in pregnancy and concerns about the possible adverse obstetric outcomes are the most relevant factors responsible for the avoidance of sexual activity during pregnancy. Breast-feeding, dyspareunia, and postpartum pelvic floor dysfunction were reported as possible causes for the delay in resuming sexual intercourses after childbirth. CONCLUSIONS: Couples should be informed about the decline of libido, desire and orgasm, commonly encountered during pregnancy, particularly in the last trimester, and puerperium which may lead to reduction in sexual intercourse frequency.

Postoperative pain after laparoscopic and vaginal hysterectomy for benign gynecologic disease: a randomized trial.

OBJECTIVE: To compare postoperative pain after laparoscopic and vaginal hysterectomy for benign disease. STUDY DESIGN: A prospective randomized trial was designed to compare laparoscopic hysterectomy and vaginal hysterectomy in patients with uterine volume

The impact of the loop electrosurgical excisional procedure for cervical intraepithelial lesions on female sexual function.

INTRODUCTION: Very limited knowledge exists concerning the impact of Loop Electrosurgical Excisional Procedure (LEEP) on female sexual function in women with cervical intraepithelial neoplasia AIM: To investigate sexual function in women who underwent LEEP for the treatment of cervical intraepithelial lesions, using a validated questionnaire (Female Sexual Function Index [FSFI]). MAIN OUTCOME MEASURES: FSFI questionnaire on six domains of female sexuality (desire, arousal, lubrication, orgasm, satisfaction, and pain). METHODS: Consecutive sexually active women, who underwent LEEP for the treatment of cervical intraepithelial neoplasia were enrolled in this study. All women were asked to complete a copy of FSFI questionnaire, at the time of LEEP and after 6 months. We finally compared the results of the pre-LEEP questionnaire and the post-LEEP questionnaire for each patient. RESULTS: A total of 67 sexually active women undergoing LEEP for the treatment of cervical intraepithelial lesions were enrolled. Nine of these patients (13.4%) completed only the questionnaire regarding their sexual function before LEEP; thus we did not include them for final analysis. In our study population, data showed a sexual function overall unchanged after LEEP; only the variable "desire" (sexual interest) became significantly worse (P = 0.02). CONCLUSIONS: LEEP for the treatment of cervical intraepithelial lesions doesn't affect women's sexuality, when compared with sexual function before surgery. In our study, all FSFI sexual function domains but desire, did not show significant change after LEEP.

Use of laparoscopy in older women undergoing gynecologic procedures: is it time to overcome initial concerns?

OBJECTIVE: The aim of this study was to analyze temporal trends in adoption of laparoscopy in a cohort of older women (> or =70 y) undergoing gynecologic abdominal procedures and to assess operative outcomes compared with those of open procedures. METHODS: A prospective entered database was queried for all women aged 70 years or older undergoing surgery at our department during a 9-year period. Surgical outcomes were compared according to the type of surgical approach (laparoscopy vs open) and assessed over time. RESULTS: Two-hundred thirty-one women were identified. Of these, 116 underwent laparoscopic procedures, and 115 had open abdominal surgery. The study groups were similar with regard to demographics and preoperative variables. Conversion to laparotomy due to intervening complications occurred in one case (0.9%). Among women with early-stage gynecologic malignancies, overall and postoperative complications were lower in the laparoscopy group than in the open surgery group. Estimated blood loss and hospital stay were lower in the laparoscopy group than in the open surgery group, for both benign and malignant conditions. The annual proportion of laparoscopic cases has increased significantly during the study period from 12% in 2001 to 79.3% in 2007 (P for trend < 0.0001). No difference was found in operative time, number of lymph nodes harvested, and complication rates, when data of subsequent time periods were compared. CONCLUSIONS: Older women who undergo laparoscopy have a significantly shorter hospitalization and fewer complications compared with older women who undergo open surgery. Laparoscopy should be considered in all women in whom a gynecologic abdominal procedure is planned regardless of age.

Surgical and survival outcomes in older women with endometrial cancer treated by laparoscopy.

OBJECTIVE: The aim of this study was to evaluate the feasibility and safety of laparoscopic surgical management of apparently early-stage endometrial cancer in older women and to compare clinical outcomes between older and younger women. METHODS: Our prospective oncological database was retrospectively reviewed to identify all consecutive women who underwent surgery for endometrial cancer from 2002. Data available included information about demography, comorbidities, surgical outcomes, histology, adjuvant therapies, and follow-up. Women were divided in two groups according to age (older, >65 y, and younger, < or =65 y). Univariate and multivariate analyses were performed to identify factors that negatively impact disease-free and overall survival. RESULTS: A total of 48 (44.4%) older and 60 (55.6%) younger women were included. Groups were comparable in operative time, blood loss, need for blood transfusions, nodal count, and intraoperative and postoperative complications. Cancer in older women was more frequently upstaged than that in younger women (17 [35.4%] vs 8 [13.3%], respectively; P = 0.01). The 2- and 5-year disease-free survival rates were 82% versus 96% (P = 0.003) and 74% versus 93% (P = 0.0005) and the overall 2- and 5-year survival rates were 87% versus 98% (P = 0.006) and 83% versus 95% (P = 0.01) for older and younger women, respectively. Multivariate analysis showed that advanced surgical stage, unfavorable histology, high-grade tumors (grade 3), and deep myometrial invasion (>50%) are independent risk factors for recurrence. CONCLUSIONS: In the absence of absolute anesthesia contraindications, laparoscopy seems to be feasible and safe in older women with endometrial cancer. Comprehensive surgical staging should be offered, regardless of age, to avoid understaging and to optimize treatment strategies.

Laparoscopy staging of early ovarian cancer: our experience and review of the literature.

UNLABELLED: We report our experience with laparoscopic staging of apparent early ovarian cancer, and we critically review the current literature on this issue. Potential limits of laparoscopic technique and theoretical concerns of using pneumoperitoneum-based surgery in this setting are addressed. METHODS: Surgical, pathological, and oncological outcome data of consecutive patients undergoing comprehensive laparoscopic staging for presumed early ovarian cancer at our institution were prospectively collected. RESULTS: The median operative time was 348 minutes (range, 255-450 minutes). The median estimated blood loss was 250 mL (range, 50-3000 mL). The mean number of pelvic and paraaortic lymph nodes harvested was 24.5 (SD, 6.3) and 9.8 (SD, 7.1), respectively. The disease was upstaged in 6 women (23.1%). No conversion to laparotomy and no intraoperative complication occurred. One patient had a retroperitoneal hematoma recognized in the postoperative period, and this required laparotomy and ligature of the hypogastric arteries to achieve hemostasis. The median follow-up period was 26.7 months (range, 2-83 months). Recurrence-free survival was 96.1%. CONCLUSIONS: Our results suggest that laparoscopic comprehensive surgical staging is a valuable treatment option for ovarian cancer patients with apparent early disease. Evidence is beginning to accumulate suggesting that minimally invasive surgery is at least equivalent in surgicopathological outcomes and middle-range oncological results to the conventional treatment approach, and early concerns are proving largely unfounded.

First-trimester maternal serum screening and the risk for fetal distress during labor.

OBJECTIVE: The purpose of this study was to assess whether low pregnancy-associated plasma protein-A (PAPP-A) levels in the first trimester are related to the risk of emergency cesarean section delivery (CS) for fetal distress during labor and fetal intrapartum acidemia. STUDY DESIGN: We prospectively studied patients who requested first-trimester biochemical screening for Down syndrome. RESULTS: Among the 1037 women who were enrolled, 152 women (14.7%) had a low first-trimester PAPP-A value, and 855 women (85.3%) had a normal first-trimester PAPP-A value. Excluding elective CS, 19 of 117 women (16.2%) with low PAPP-A values vs 59 of 749 women (7.9%) with normal PAPP-A values underwent CS for concerning fetal status during labor (P = .003; odds ratio, 2.27; 95% confidence interval, 1.30-3.97). This difference remained significant after correction for possible confounders (hypertension, preterm delivery, small for gestational age, labor induction). Among these 78 women, umbilical artery pH was significantly lower in fetuses from mothers with low vs normal PAPP-A values (pH = 7.19 [range, 6.95-7.39] vs pH = 7.26 [range, 7.02-7.39]; P = .022). CONCLUSION: Low PAPP-A levels at first-trimester screening are associated independently with higher rates of emergency CS for nonreassuring fetal status during labor and lower pH.