Transurethral retrieval of a proximally dislodged ureteral stent.

A proximally migrated ureteral stent into the renal pelvis is an uncommon problem that poses a difficult technical challenge. A 32-year-old woman had her ureteral stent inadvertently dislodged into the renal pelvis at the time of stent exchange. The stent was successfully retrieved and repositioned transurethrally with a snare fed through the left ureter and into the renal pelvis. This is a relatively noninvasive method of retrograde retrieval of a proximally dislodged ureteral stent.

What is the role of interval blood testing in the management of chemotherapy for gynecologic malignancies.

PURPOSE: To determine the safety of omitting routine interval laboratory assessments, dietary restrictions, and isolation precautions between cycles of chemotherapy for gynecologic malignancies. METHODS: Data were retrospectively obtained from the records of women receiving chemotherapy for gynecologic cancer from July 1999-June 2000. Routine nadir determinations were not performed between treatment cycles; social interaction was encouraged, and pathogen-free diet recommendations were not provided. RESULTS: Eighty women received 449 cycles of chemotherapy. Four (5%) patients developed neutropenic fevers, and one of these women succumbed to sepsis. Eighteen (22.5%) women had 29 cycles delayed due to persistent myelosuppression when the ensuing chemotherapy infusion was to be administered. Hematopoietic growth factors overcame these delays during subsequent cycles in all but two patients. CONCLUSION: Omitting scheduled interval laboratory monitoring, dietary restrictions, and isolation precautions between chemotherapy cycles is convenient for patients, likely cost-effective, and does not increase morbidity in the gynecologic oncology population.

Stamm gastrostomy for postoperative gastric decompression in gynecologic oncology patients.

OBJECTIVE: The aim of this study was to report our experience with Stamm gastrostomy for postoperative gastric decompression on a gynecologic oncology service. METHODS: This was an observational study over the 9-year period ending in October 2000. A 24 French MIC gastrostomy with the Stamm technique was used. Criteria for a gastrostomy are outlined in the text and tubes placed for palliation were excluded. Patients were followed to determine length of open drainage, time to removal, related complications, and those who may have benefited. RESULTS: A total of 167 patients had 174 nonpalliative gastrostomy tubes placed. Nine percent of the patients had related complications with a major complication rate of 2%. Overall, approximately one-third of the patients appeared to benefit from the gastrostomy tube. CONCLUSION: The results support the safety and efficacy of the MIC gastric tube in patients undergoing extensive gynecologic cancer surgery which is likely to impact the function of the gastrointestinal tract.

Bartholin's gland carcinoma: a 15-year experience.

OBJECTIVE: Our objective was to review our experience with carcinoma of Bartholin's gland relative to treatment and oncologic outcome. METHODS: Patient names were collected from our vulvar cancer database for the period September 1985 to September 2000. The medical records were retrospectively reviewed, and data were abstracted relative to demographics, presenting symptoms, treatment, and oncologic outcome. RESULTS: We treated 12 women with Bartholin's gland carcinoma, and 11 patients are reported. Seven women presented with a painless vulvar mass, and 8 of 11 had initially been treated for an infectious process before referral to our institution. Squamous histology was most common, and the right gland was more frequently involved. Ten patients were treated with primary surgery, followed by adjuvant radiation in 7 for inadequate resection margins or lymphatic metastases. One patient was treated with primary chemoradiation. Stage I, II, III, IVA, and IVB disease was present in 3, 1, 4, 2, and 1 patient, respectively. Recurrence was suffered by 54.5% during a mean follow-up time of 73.5 months (median, 60; range, 8-180 months). Overall survival is 58.3% to date. CONCLUSIONS: Conventional therapy for Bartholin's gland carcinoma yielded a 67% 5-year survival. Seventy-one percent of women receiving adjuvant radiotherapy recurred despite this precaution. Work is needed to identify an effective systemic therapy and to better determine which patients may benefit from pelvic radiotherapy.

Diagnosis and management of vulvar and vaginal intraepithelial neoplasia.

Vulvar intraepithelial neoplasia and VAIN present unique challenges to the practicing gynecologist. VIN may produce distressing symptoms and undergo malignant conversion. A high index of suspicion and liberal use of biopsy are required to make the diagnosis. The approach to therapy for VIN has been reviewed. Treatment should be tailored to each individual patient and may include a period of expectant observation. Variations and combinations are used whenever necessary to preserve normal function and anatomy. Frequent surveillance is a must because recurrence rates are high, especially with multifocal disease in young women. Although VAIN accounts for less than 0.5% of lower genital tract neoplasia, the frequency of its detection is increasing, especially in younger patients. These lesions are most commonly found in the upper third of the vagina and are often multifocal in nature. The close proximity of the upper vagina to the rectum, bladder, and ureters makes treatment difficult. The occult invasion rate may be as high as 28%, and a wide variety of therapies are available. As is true for VIN, recurrence is not uncommon.

Surveillance of the endometrium in tamoxifen treated women.

There is much debate about the risks and benefits of tamoxifen, most specifically about the incidence of associated endometrial cancer. Nearly all of the published trials on the subject have been criticized for methodological flaws and various forms of bias, making resolution of this controversy difficult. There is a consensus, however, that tamoxifen results in an increased incidence of both premalignant and malignant lesions of the endometrium. As the indications for tamoxifen continue to broaden, a larger number of women will be subjected to the potential adverse effects of tamoxifen. Many techniques for screening patients on tamoxifen for the development of endometrial abnormalities have been suggested. None of these methods appears to be consistently clinically or cost effective. We have reviewed the literature on endometrial surveillance in tamoxifen treated women with a focus on the larger publications reported within the past year. From this, we have provided what we hope to be safe and cost-effective recommendations for the management of these patients.

Neuroendocrine signet ring cell adenocarcinoma of the endocervix.

Signet ring cell morphology in mixed carcinoma of the uterine cervix is not uncommon. It is rare for such morphology to predominate, however, and there are no reported cases of a signet ring cell adenocarcinoma (SRCA) of the endocervix with neuroendocrine differentiation. A 53-year-old woman presented with abnormal perimenopausal bleeding, and uterine curettings revealed a signet ring cell carcinoma. After clinical evaluation to eliminate a metastasis from an extra-uterine primary, the patient underwent surgical therapy and staging, and was treated with postoperative adjuvant chemoradiation. Pathologic evaluation found the tumor to arise from the endocervix and to be of predominant signet ring cell morphology. Immunohistochemical staining revealed that the tumor exhibited neuroendocrine differentiation and helped confirm its endocervical origin. The patient remains without evidence of disease 6 months after primary therapy. This is the first case report of endocervical SRCA with neuroendocrine differentiation (SRCA with features of carcinoid tumor). Discussion of this entity is provided.

Comparison of elective and empiric cerclage and the role of emergency cerclage.

We describe the maternal, obstetric, and neonatal outcomes of patients undergoing elective, empiric, and emergency cervical cerclage at our institution in an attempt to determine predictive factors for adverse perinatal and maternal outcomes. A retrospective chart review was conducted on patients who underwent cervical cerclage placement over a 7-year time span. Of 55 charts, 40 contained complete peripartum data satisfactory for review; 7 elective, 15 empiric, and 18 emergency cerclages were analyzed. There was no perinatal mortality in the elective group, and 5/7 patients delivered at term. The empiric population experienced a 20% neonatal mortality; 6/15 gestations progressed to term. The perinatal mortality was 44% in the emergency group and 2/18 patients delivered at term. Relative to neonatal outcome, elective cerclage was statistically significantly better than emergent cerclage; there was no statistically significant difference between the elective and empiric groups nor between the empiric and emergent groups. This relatively small series with a large number of variables appeared to favor an elective procedure rather than an empiric one. Although emergent cerclage was associated with only a 56% neonatal survival, it did have value in some patients.

Magnesium sulfate, maternal hypothermia, and fetal bradycardia with loss of heart rate variability.

BACKGROUND: Fetal bradycardia and decreased heart rate variability can indicate a nonreassuring fetal status. However, there can be iatrogenic, physiologic, or pathologic causes. CASE: A patient in premature labor received toxic levels of magnesium sulfate for tocolysis. Elevated maternal serum magnesium levels correlated inversely with maternal temperature and both fetal heart rate and fetal heart rate variability. There was also a relative decrease of the maternal heart rate from baseline. When the magnesium levels returned to normal, these vital signs returned to normal. CONCLUSION: Magnesium sulfate therapy can result in maternal hypothermia and a decrease in fetal heart rate and heart rate variability. Maternal hypothermia might be the cause of fetal bradycardia. A direct action of magnesium on the fetal heart might be the cause of heart rate variability.

Cesarean delivery of twins during maternal cardiopulmonary arrest.

BACKGROUND: In modern times, maternal death is rare. Timely cesarean delivery in the setting of maternal cardiopulmonary arrest may save both the infant and the mother. CASE: A 36-year-old white woman with a twin pregnancy suffered cardiopulmonary arrest at 28 weeks' gestation. Advanced cardiopulmonary resuscitative measures were unsuccessful, and the twins were delivered by cesarean at the bedside. Immediately after delivery, a maternal pulse was noted; both the mother and her infants are alive 15 months later. CONCLUSION: Relieving vena caval occlusion by perimortem cesarean delivery in a term gravida allows chest compressions to provide sufficient cardiac output in the unfortunate event of maternal cardiopulmonary arrest. When delivery occurs within 5 minutes of maternal insult, the neonatal outcome is favorable.

Reactive nonstress test despite severe congenital brain damage. What does the test measure?

BACKGROUND: Antenatal testing with the nonstress test is common in the evaluation of high-risk pregnancies. A reactive test gives the clinician reassurance of fetal well-being. CASE: A 19-year-old woman, gravida 1, para 0, delivered an infant with holoprosencephaly and multiple facial and limb abnormalities at 38 weeks' gestation. The fetal heart tracing was reassuring despite the infant's compromised neurologic status. CONCLUSION: The nonstress test is dependent only upon the fetal brainstem, and it predicts oxygenation at that site rather than normality of the entire central nervous system. This limitation of the nonstress test must be remembered when performing antenatal testing.