Prolonged survival after episiotomy recurrence of cervical cancer complicating pregnancy.

BACKGROUND: We report a case of recurrent cervical cancer in an episiotomy scar and the late treatment-related sequelae. CASE: Cervical cancer was diagnosed following a vaginal delivery, and was treated with surgery and radiotherapy. The patient developed a recurrence in her episiotomy scar, and was treated with chemoradiation. She remains without evidence of disease ten years later. CONCLUSION: Successful treatment of recurrent cervical cancer with chemoradiation is possible, but may be associated with significant normal tissue toxicity.

The utility of presurgical CA125 to predict optimal tumor cytoreduction of epithelial ovarian cancer.

The objective of this study was to evaluate the ability of a preoperative serum CA125 to predict whether optimal debulking (OD) could be achieved for patients with stage III and IV epithelial ovarian cancer (EOC). The records of consecutive patients who underwent primary surgery for EOC at Indiana University Hospital between January 1997 and January 2003 were reviewed. Eligibility criteria included FIGO stage III/IV disease, surgery by gynecologic oncology faculty, preoperative CA125, and an operative note clearly defining volume of residual disease. The Medcalc software statistical package was used to generate a receiver-operating characteristic (ROC) curve. Two hundred and eighty-nine cases of stage III/IV EOC were identified, of which 164 met the eligibility criteria. Serum CA125 /=75% of the time. Conversely, OD was achieved in /=4500. The area under the ROC curve for CA125 was .670. The OD rate for those with and without ascites was 49% and 79%, respectively (P < 0.001). In a multivariate analysis using CA125, age, and ascites, the area under the curve was 0.686. We conclude that preoperative serum CA125 did not reliably predict OD in patients with stage III-IV EOC.

Hematometra after thermal balloon endometrial ablation in a patient with cervical incompetence.

BACKGROUND: Thermal balloon endometrial ablation is a relatively safe nonsurgical treatment for menorrhagia. Hematometra follows this procedure in <3 % of patients, but risk factors for this complication are unclear. CASE: A woman with a history of cervical incompetence during pregnancy later developed cervical occlusion and hematometra after thermal balloon endometrial ablation. Cervical occlusion did not recur after cervical dilatation and temporary placement of a catheter as a stent. CONCLUSION: The normal resistance of the internal cervical os may be an important factor in avoiding thermal damage to the cervix during thermal balloon endometrial ablation. This case suggests that a history of cervical incompetence may be a clinical indicator of decreased cervical resistance.

Laparoscopic secondary port conversion using a reusable blunt conical trocar.

BACKGROUND: During operative laparoscopy, large (10 mm or more) ancillary ports are often used for instrumentation and tissue removal. Although sharp pyramidal trocars can be used to place these ports, their use appears to increase the risk of vessel injury and herniation. We describe a simple and cost-effective technique for converting a 5-mm port to a 10- or 12-mm port using a blunt conical trocar. TECHNIQUE: When a larger port is required, a previously placed 5-mm port is removed, and the skin incision is lengthened. A reusable 10- or 12-mm blunt conical trocar with a threaded sleeve is placed through the incision. The fascial defect is located by probing and is dilated gently with the blunt tip. Once the tip is through the fascia, it is advanced through the peritoneal defect with a clockwise, twisting motion. Afterwards, the fascial defect is closed with a single, interrupted absorbable suture. EXPERIENCE: We have had no complications or difficulty when using this technique in 26 cases, either during or after surgery. CONCLUSION: A reusable blunt conical trocar is a simple, safe, and cost-effective instrument for converting a 5-mm laparoscopic port into a 10- or 12-mm port.

Occult bladder injury during laparoscopy: report of two cases.

Bladder injuries occur in approximately 1.6% of all laparoscopic procedures. Most often, these injuries are recognized intraoperatively or immediately postoperatively because of gross hematuria. We report two cases of bladder injury related to placement of suprapubic laparoscopic trocars that were not recognized at the time of surgery and in which no gross hematuria was evident. In each case, the patient had a history of abdominal surgery, and the diagnosis was difficult to make. The treatment was prolonged catheterization in one patient and laparotomy through a midline incision in the other. Strategies are discussed for minimizing the risk of bladder injury during laparoscopic trocar placement and for diagnosing and treating injuries.

Concurrent chemotherapy and radiation therapy in primary cancer of the cervix.

Radiation therapy has been the most active agent for the treatment of patients with locally advanced cervical cancer for many years. Chemotherapy has shown some activity, but data has been lacking to support its routine use. Recently, data from five prospective, randomized trials evaluating this difficult population have matured. Reports from these trials are startlingly similar, leading to the common conclusion that concurrent cisplatin chemotherapy and radiation therapy substantially decrease the risk of relapse and increase the overall survival. These results are compelling evidence for the inclusion of cisplatin with irradiation as a new standard of care for patients with locally advanced cervical cancer.

Hormonal treatment of an endometrial stromal nodule followed by local excision.

BACKGROUND: Endometrial stromal nodule is a rare subtype of endometrial stromal tumor. Although such nodules are benign, hysterectomy has been considered the treatment of choice, because evaluation of the margin is required for diagnosis. The similarity between low-grade stromal sarcoma and stromal nodule suggests that stromal nodules might respond to hormonal management. CASE: Twenty-one-year-old nulligravida, diagnosed with endometrial stromal nodule, which decreased in size with leuprolide acetate treatment, underwent local excision of the tumor with preservation of reproductive function. CONCLUSION: Hormonal therapy was successful in decreasing the size of this stromal nodule which allowed for conservative management.

Location of the transverse colon in relationship to the umbilicus: implications for laparoscopic techniques.

STUDY OBJECTIVE: To establish the location of the transverse colon in relationship to the umbilicus, and determine if it varies as a function of patient height or weight. DESIGN: Retrospective review of computed tomograms (CT) of the abdomen (Canadian Task Force classification II-2). SETTING: University hospital. PATIENTS: Sixty-seven women with normal abdominal anatomy. INTERVENTION: Review of abdominal CT scans. MEASUREMENTS AND MAIN RESULTS: The relative relationships of the transverse colon and umbilicus were compared with age, height, weight, and body mass index (BMI = kg/m2) using multiple regression analysis. Average location of the superior margin of the transverse colon was 4.6 cm (95% CI 3.5-5.7 cm) above the umbilicus. In nine (13%) women it was below the umbilicus. The colon was below the umbilicus in 25% of nonobese women (BMI <25 kg/m2). CONCLUSION: Because the transverse colon lies below the umbilicus in more than 10% of women, injury to it may be an uncommon yet unavoidable complication of laparoscopy.

Complete hydatidiform mole coexisting with a twin live fetus: clinical course.

A 33-year-old G4P0 white female presented for a pregnancy ultrasound at 9 weeks gestation and was found to have a complete hydatidiform mole coexisting with a live twin fetus (CHTF). The beta-hCG level was 600,000 mIU/ml and the chest X ray was negative. The pregnancy was uneventfully terminated by suction curettage and oral contraceptives were prescribed. The initial beta-hCG declined appropriately; however, it subsequently rose. The metastatic workup was negative and the patient was treated with weekly intramuscular methotrexate at 30 mg/m2. The hCG levels declined appropriately and then plateaued. Salvage chemotherapy with intravenous actinomycin D at 1.25 mg/m2 every 14 days was started. The hCG level normalized after 3 cycles and the patient was free of disease at 1 year follow-up.

A prospective controlled trial of early postoperative oral intake following major abdominal gynecologic surgery.

OBJECTIVE: The objective was to determine whether, when compared with traditional dietary advancement, early oral intake following major gynecologic surgery leads to a reduction in the length of hospitalization. METHODS: Patients undergoing major abdominal gynecologic surgery were invited to participate in this study. After informed consent was obtained, they were randomized to one of two groups. The control group (group 1) was treated traditionally. Oral intake was initiated only after documentation of bowel function, which was defined by two of the following three criteria: (1) bowel sounds; (2) flatus or bowel movement; and (3) subjective hunger. Those assigned to the study group (group 2) were given a clear liquid diet on postoperative day 1. Once 500 cc was tolerated, a regular diet was given. Patients were evaluated on a daily basis for bowel sounds, flatus, bowel movement, hunger, nausea, vomiting, and need for nasogastric tube decompression. The groups were compared with regard to length of hospital stay, length of postoperative ileus, and incidence of adverse effects including nausea, vomiting, and postoperative complications. Statistical analyses were performed with the Student t and chi 2 tests. RESULTS: The demographic characteristics of the control (N = 47) and study groups (N = 49) were similar, with no significant differences in underlying medical conditions, prior abdominal surgery, or diagnosis of a malignancy. The groups did not vary statistically in the number of subjects who required postoperative antiemetics or postoperative biscodyl suppository. There was a statistically significant reduction in the length of hospitalization for those patients on the early feeding regimen. The average length of stay for group 1 was 4.02 days +/- 0.30 (SEM), while that for group 2 was 3.12 days +/- 0.16 (P = 0.008). While there was a significantly higher incidence of emesis in the study population, this was not associated with any untoward outcome, and this group actually tolerated a solid diet nearly one full day earlier (2.72 days +/- 0.14 vs 1.88 days +/- 0.14, P < 0.0001). CONCLUSIONS: Early postoperative oral intake results in a decreased length of hospitalization and is well tolerated when compared with traditional dietary management in patients undergoing abdominal surgery on a university gynecologic oncology service.