Utility of routine cytology in detecting asymptomatic cervical cancer recurrence.

INTRODUCTION: The objective of this study was to examine the utility of routine cervical cytology after cervical cancer treatment. MATERIAL AND METHODS: We performed a retrospective study from 2004 to 2020, which identified 581 cervical cancer patients. Of the 581 patients, 233 were included in the analysis. The remaining 348 were excluded because of failure to enter the surveillance period, loss to follow-up, or treatment at an outside facility. The continuous data were summarized using the median and interquartile range for non-normally distributed data. The categorical data were summarized using frequencies and proportions. Comparisons between the categorical data were performed using the Fisher exact test. RESULTS: Of the 233 included patients, 78 (33.5%) had had ≥1 abnormal Papanicolaou (Pap) test during surveillance. Of these 78 patients, 22 (28.2%) underwent biopsy, with all biopsies negative for malignancy. Local recurrence was identified in 15 patients. Of these 15 patients, 14 (93.3%) were symptomatic at diagnosis, 7 (46.7%) had had visible disease on the physical examination, and 6 (40.0%) had normal cytology findings throughout surveillance. Only 1 case of local, asymptomatic cervical cancer recurrence was detected by Pap test alone. A subset analysis was performed to compare the rate of abnormal Pap tests between the radiation therapy and non-radiation therapy groups. Of the 233 patients, 154 (66.1%) underwent primary radiation therapy, 64 (41.6%) of whom had abnormal cytology during surveillance. Of 82 patients who did not undergo radiation therapy, only 14 (17.1%) had had abnormal cytology (P < 0.01). None of the patients in either group had underlying recurrent disease at the time of abnormal cytology. CONCLUSIONS: The results of our study show that routine Pap tests have limited clinical utility in the surveillance of cervical cancer recurrence. Consideration should be given to removing routine cytology from the surveillance recommendations.

Pelvic support and urinary function improve in women after surgically induced weight reduction.

OBJECTIVE: : The objective of this study was to assess pelvic organ support and symptoms in morbidly obese women before and after weight reductive surgery. METHODS: : Fifty-four women were enrolled in this institutional review board-approved protocol. Data collection at baseline and 6 months following surgery included a Pelvic Organ Prolapse Quantification examination, questionnaires including the Pelvic Floor Distress Inventory, the Pelvic Floor Impact Questionnaire, and the Pelvic Organ Prolapse-Urinary Incontinence Sexual Function Questionnaire short form, and a 3-day voiding diary. Before-surgery and after-surgery measures were compared using paired Student t tests for continuous, normally distributed data or the Wilcoxon signed rank test for ordinal data. RESULTS: : Baseline and 6-month data were available for 34 women. The mean body mass index was 46 ± 6 kg/m at baseline and 33 ± 6 kg/m after 6 months. Subjects with ≥stage 2 prolapse at baseline demonstrated an improvement of 0.5 cm (baseline, 0.9 ± 0.8 cm; after 6 months, -1.4 ± 0.9 cm) in the anterior vaginal compartment (points Aa/Ba) 6 months following weight reductive surgery (P = 0.05). Of 24 women who completed 3-day voiding diaries, 12 were incontinent at baseline with a median number of incontinent episodes of 6.5 per day (range, 3-34). After surgery, 6 incontinent women became continent. In the 6 women who remained incontinent after surgery, the number of incontinent episodes per day decreased by a median of 2.5 (range, 1-11). Pelvic Floor Distress Inventory scores improved following weight reduction (baseline, 115 ± 80; after 6 months, 58 ± 70; P < 0.01). DISCUSSION: : Obese women, after surgically induced weight loss, demonstrate an improvement in anterior vaginal support, urinary leakage and pelvic floor symptoms.

Adaptations of the rat vagina in pregnancy to accommodate delivery.

OBJECTIVE: To characterize ultrastructural changes in the rat vagina in pregnancy, delivery, and postpartum, focusing on collagen architecture and smooth muscle cell morphology. METHODS: The vagina of four virgin, four midpregnant, four late pregnant, four immediate, and four late post-vaginal-delivery rats were examined by transmission electron microscopy. Images were classified into one of four categories based on collagen fibril area fraction, with group 1 containing the highest number of collagen fibers per unit area and group 4 containing the lowest. Smooth muscle cells were characterized into three cell types ("synthetic," "intermediate," and "contractile") based on the volume fraction of cytoplasm occupied by organelles compared with myofibrils. RESULTS: Quantitative analysis demonstrated that 76% of collagen fibers in virgin rats were categorized as group 1 or 2 compared with 49% in midpregnant, 40% in late pregnant, and 23% in immediate postpartum animals (P=0.006). Late postpartum tissue seemed similar to virgin tissue (77%). Midpregnant (37%), late-pregnant (34%) and immediate postpartum animals (43%) contained a higher proportion of synthetic smooth muscle cells compared with virgins (20%) and late postpartum animals (21%) (P=.02). Contractile smooth muscle cells predominated in virgin (64%) and late postpartum animals (70%) compared with midpregnant (42%), late pregnant (50%) and immediate postpartum (50%, P=.05). CONCLUSION: In pregnancy, collagen fiber area decreased while smooth muscle cells transformed from a contractile to a synthetic phenotype. The late postpartum period returned to prepregnant levels for both collagen and smooth muscle cell morphologies. It is likely that these changes represent adaptations to minimize trauma to the vagina during passage of the fetus.

Humidified compared with dry, heated carbon dioxide at laparoscopy to reduce pain.

OBJECTIVE: To study whether using 95% humidified, heated carbon dioxide (CO(2)) at laparoscopy reduces pain compared with dry, heated CO(2). METHODS: Patients were randomly assigned to either heated, 95% humidified CO(2) (study group) or heated, dry CO(2) (control group) during laparoscopy. Pain control was achieved per standard protocols. Pain scales were administered the first 4 hours and 24 and 48 hours postoperatively. RESULTS: The 89 patients available in the intent-to-treat model revealed a decrease in total morphine equivalents and a decrease in pain scores at 1, 2, and 24 hours in the study group (directional P values < .05). Subgroup analysis in patients without chronic pelvic pain revealed lower mean pain scores at 1, 2, 24, and 48 hours and decreases in postoperative and total morphine equivalents (directional P values < .05) in the study group. CONCLUSION: At laparoscopy, heated, 95% humidified CO(2) effectively decreases postoperative pain and narcotics usage compared with heated, dry CO(2). LEVEL OF EVIDENCE: II-2.

Total laparoscopic hysterectomy utilizing a robotic surgical system.

OBJECTIVES: To describe the use of a robotic surgical system for total laparoscopic hysterectomy. METHODS: We report a series of laparoscopic hysterectomies performed using the da Vinci Robotic Surgical System. Participants were women eligible for hysterectomy by standard laparoscopy. Operative times and complications are reported. RESULTS: We completed 10 total laparoscopic hysterectomies between November 2001 and December 2002 with the use of the da Vinci Robotic Surgical System. Operative results were similar to those of standard laparoscopic hysterectomy. Operative time varied from 2 hours 28 minutes to 4 hours 37 minutes. Blood loss varied from 25 mL to 350 mL. Uterine weights varied from 49 g to 227 g. A cystotomy occurred in a patient with a history of a prior cystotomy unrelated to the robotic system. CONCLUSION: Total laparoscopic hysterectomy is a complex surgical procedure requiring advanced laparoscopic skills. Tasks like lysis of adhesions, suturing, and knot tying were enhanced with the robotic surgical system, thus providing unique advantages over existing standard laparoscopy. Total laparoscopic hysterectomy can be performed using robotic surgical systems.

Making the transition from standard gynecologic laparoscopy to robotic laparoscopy.

OBJECTIVES: To determine the feasibility of using a simple procedure, a bilateral tubal ligation, as a transition procedure when adopting robotic laparoscopy for gynecologic surgery. METHOD: To obtain robotic credentialing and gain experience with the robotic system, the surgeons first went through robotic training, then 4 women desiring permanent sterilization had robotically assisted laparoscopic bilateral tubal ligations performed, using the Parkland method. RESULTS: Total operating room time varied from 1 hour 25 minutes to 2 hours 31 minutes. Improvement in operating time for each surgeon was noted with each successive case. Best times in robotic cases were similar to those of standard laparoscopy. CONCLUSION: Robotically assisted laparoscopic tubal ligation using the Parkland method is a satisfactory procedure to provide transition for gynecologic surgeons and operating room personnel to gynecologic robotic surgery.