Are there predictors for failed expectant management of cervical intraepithelial neoplasia 1?

OBJECTIVE: To identify the short-term natural history of cervical intraepithelial neoplasia (CIN) 1 and the potential risk factors for its progression, regression and persistence and to identify any characteristics of patients who were lost to follow-up. STUDY DESIGN: All colposcopic specimens from July 2001 through December 2004 were evaluated for the presence of CIN 1. Adequate follow-up was defined as 24 months of surveillance with Pap smears every 4-6 months. The chi2 and Student t test were performed for analysis. RESULTS: Three hundred sixty women who had colposcopic specimens with the presence of CIN 1 were evaluated. Persistence of CIN 1 and progression to CIN 2 and 3 were associated with pregnancy at the time of colposcopy (p = 0.04), history of sexually transmitted diseases (p = 0.007) and age at first intercourse (p = 0.04). Age (p = 0.001) and no prior history of abnormal Pap smears (p = 0.001) were associated with the rate of loss to follow-up. CONCLUSION: Expectant management for the majority of patients with biopsy-proven CIN 1 is appropriate, but some risk factors might influence that decision. In this study, age at first intercourse was the only independent predictor of failure to resolve CIN 1 on multivariate analysis.

Absent endocervical cells on Pap smears after loop electrosurgical excision procedure.

OBJECTIVE: To evaluate the absence of endocervical cells on Pap smear after loop electrosurgical excision procedure (LEEP) as a possible marker for cervical stenosis. MATERIALS AND METHODS: All LEEPs performed at a public health teaching hospital caring for the indigent between July 1, 1999, and September 30, 2002, were reviewed; 1,190 eligible charts of patients were reviewed, and extracted data included the following: age, parity, ethnicity, histology obtained during colposcopy, volume of loop specimen taken, and follow-up Pap smear results. RESULTS: One thousand four hundred twenty-one patients had LEEPs during this period. One thousand one hundred ninety first follow-up Pap smears were evaluated; 200 patients had no follow-up Pap smears. The baseline background rate for absent endocervical cells was 7% for the general population. The study showed that the rate of absent endocervical cells on first follow-up Pap smears was 13.64% (173/1,193) (p = .03). The mean age of patients was 33.6 years; 11% (20/1,193) were aged older than 50 years. There was no significant difference with age and parity in the stenosis versus nonstenosis group. CONCLUSION: The LEEP was significantly associated with absent endocervical cells on follow-up Pap smears, which may be indicative of cervical stenosis.

Pelvic actinomycosis: a case report.

BACKGROUND: Pelvic actinomycosis is rare but can manifest with multiple presentations. CASE: A 28-year-old woman, gravida 4, para 2, conceived with a Paraguard intrauterine device (IUD) (FEI Products LLC, North Tonawanda, New York) in place. The IUD had been present for 2 years. The patient presented with an incomplete abortion at 6 weeks' gestation, and the IUD was removed. Two and one-half months later the patient presented with signs and symptoms of pelvic inflammatory disease and underwent hospitalization and exploratory laparotomy. The pathology specimen revealed diffuse actinomycosis involving the tube and ovary, appendix, and bowel mucosa. A Pap smear 3 months earlier had revealed Actinomyces. CONCLUSION: Actinomyces has been associated with IUD use and may present even after removal of the IUD. Pelvic actinomycosis is rare, and removal of the IUD may not be adequate treatment. If a patient presents with symptoms of infection, early diagnosis and aggressive antibiotics may prevent further complications.

Vaginal hysterectomies performed in a residency program: can we increase the number?

OBJECTIVE: To evaluate if a concerted effort to increase the number of vaginal hysterectomies performed in a residency program could be accomplished safely when a standard approach vs. a concerted effort was utilized. STUDY DESIGN: A retrospective case review was performed for all patients undergoing vaginal hysterectomy at 1 hospital in a residency program. At Denver Health Medical Center, the Gynecology Division made a concerted effort to increase the number of vaginal hysterectomies performed. All hysterectomies from July 1998 to December 2003 were reviewed retrospectively. Abstracted data included age, race, parity, primary diagnosis, past medical history, past surgical history, history of pelvic inflammatory disease/sexually transmitted disease, removal of ovaries, conversion to an abdominal procedure, complications, length of hospital stay, and change in hematocrit. RESULTS: Over 1,029 hysterectomies were performed during the study period. In the first 3 years, 190 vaginal hysterectomies were performed. During the second 3 years, 320 hysterectomies were performed vaginally; laparoscopic vaginal hysterectomies were excluded. The percentage of vaginal hysterectomies performed increased from 37% to 60%. Age, race, uterine weight, primary diagnosis and past medial history were not significantly different (p>0.05). A significant difference was noted during the second period with regard to parity, previous surgeries, history of sexually transmitted diseases, removal of ovaries, length of hospital stay and complication rate. CONCLUSION: When there is a concerted effort to perform vaginal hysterectomies in lieu of abdominal ones in a residency program, the number can increase without increasing the complication rate.

Papanicolaou screening in an urgent care setting.

OBJECTIVE: This study was undertaken to determine the efficacy of Papanicolaou (Pap) screening in an urgent care setting, and to compare the rates of cervical intraepithelial neoplasia (CIN), and follow-up in patients with and without established primary care. STUDY DESIGN: All patients presenting with a complaint warranting pelvic examination between December 2000 and September 2001 underwent Pap screening. All patients were scheduled an appointment or follow-up visit when an abnormal Pap test was found. Charts were reviewed for cytologic interpretation, age, chief complaint, ethnicity, history of prior Pap smear in the institution, total visit history (includes urgent care and primary care clinics). SAS 8.1 was used for statistical analysis with the use of the Fisher exact test. RESULTS: A total of 673 Pap smears were performed. Of those, 660 were analyzed and 13 were discarded because of inadequate slides. The mean age was 29.6 years; the ethnic distribution was 0.2% Native American, 1.2% Asian, 17% black, 62.4% Hispanic, 18.2% white, and 1.1% other. In the study population, only 40.6% of the patients had a prior Pap screen and 59.4% had not. There were 318 (48.2%) patients who had accessed care only through the urgent care clinic, and 342 (51.8%) patients who had established some kind of primary care in the past. The overall follow-up rate was 56% for any abnormal Pap smear, regardless of visit history. CONCLUSION: Patients accessing medical care through an urgent care clinic exclusively had identical rates of CIN and follow-up when compared with patients with established care. Therefore, when a system exists to centrally process and triage cervical cytology, it is efficacious to screen for CIN in an urgent care setting.

A comparison of outcomes of transurethral versus suprapubic catheterization after Burch cystourethropexy.

The objective of this study was to evaluate the outcomes of patients with transurethral vs suprapubic catheterization after Burch cystourethropexy. This is a retrospective cohort study of patients who had an anti-incontinence procedure primarily including Burch cystourethropexy with hysterectomy or Burch alone between July 1997 and June 2002 and comparing the outcomes of transurethral vs suprapubic catheters. The suprapubic and transurethral catheter placed were both 16-Fr Foley catheters. The variables analyzed were length of hospital stay, length of catheterization, postoperative fever, and urinary tract infection. The number of postoperative visits and complications within each group were also compared. Analysis was done utilizing Fisher's exact test and Wilcoxon's rank-sum analysis when indicated. We analyzed the charts of 217 patients. The outcomes of surgery (i.e., blood loss, postoperative morbidity, incidence of urinary tract infection, length of hospital stay) in each group did not statistically differ. There was a significant difference in length of cauterization: 7.1 days for the transurethral group and 9.61 days for the suprapubic group, a 1.79 day difference (p=0.001) and a difference in the number of visits for complaints of pain, 2.5 visits for the suprapubic group, 3.5 visits for the transurethral group (p=0.01). There were no differences in outcomes whether a transurethral or suprapubic catheter was used. There was a significant difference in duration of catheterization and extra visits to the clinic or hospital with a practitioner for the complaint of pain. Patients with a transurethral catheter had on the average one more visit than those with the suprapubic catheter.

Complications of outpatient LLETZ procedures.

OBJECTIVE: To determine the rates and types of acute complications occurring within 14 days of large loop excision of the transformation zone of the cervix. STUDY DESIGN: A retrospective chart review was performed for patients who underwent a loop excision procedure between July 1999 and July 2001. Extracted information included age, parity, ethnicity, indication for the procedure, risk factors for cervical intraepithelial neoplasia, histologic classification of the specimen, and type and incidence of complications. Length of follow-up was also recorded. Statistical analysis was performed utilizing Wilcoxon sum analysis. RESULTS: Five hundred fifty-seven charts were re- viewed; 74.8% of the patients were < or = 40 years old. Ethnicity was 59% Hispanic. The most common indication for loop excision was high grade squamous intraepithelial lesions on a Pap smear. Of the patients, 40% used tobacco, and 30% had a sexually transmitted disease. The overall complication rate was 9.7%, with a major complication rate of 0.6% and minor complication rate of 9.1%. Minor complications included 14 cases of abdominal pain and 26 of vaginal bleeding, 7 of which required treatment with Monsel solution or placement of Surgicel (Ethicon, Albuquerque, New Mexico). There were 6 cases of vaginal discharge and 1 of bladder spasm. Major complications included 1 patient with a bowel injury who returned to the operating room, 1 who returned to the operating room for hemorrhage and 1 with prolonged observation for chest pain. There was no association between age, parity, risk factors for cervical dysplasia, indication for procedure or pathology of specimen with acute complications. CONCLUSION: Any surgical procedure may cause acute complications. While acute complications are not frequent with loop excision, the procedure is not entirely risk free.

Increasing recruitment of quality students to obstetrics and gynecology: impact of a structured clerkship.

OBJECTIVE: To evaluate the satisfaction of the third-year medical students with their basic third-year obstetrics and gynecology rotation before and after a concerted effort was made to improve the rotation with prompt feedback and problem-based case learning. METHODS: At the end of each rotation, third-year medical students were asked to anonymously fill out an "in-house" course evaluation. A 1-5 rating scale to evaluate quality of teaching, instructor's commitment and enthusiasm, and enhancement of professional development was used. Scores were compared over 4 years, and a Wilcoxon rank sum analysis was performed to determine significance. Evaluations were compared for 1999 and 2000, which were the 2 years before the initiation of the structured rotation, with 2001 and 2002, the first 2 years of the new approach's implementation. RESULTS: Sixty third-year students were evaluated. The students noted that the quality of teaching improved (P <.002), the instructors' commitment and enthusiasm increased (P <.001), instructors enhanced the student's professional development (P <.001), and students perceived faculty as positive role models (P <.001). It is noteworthy that between the years 1999 and 2000, the number of students interested in obstetrics and gynecology was 3 and 4, respectively, whereas in 2001 and 2002, the first 2 years after implementation of the new process, 6 and 7 students, respectively, were interested in this field. CONCLUSION: Students' satisfaction with their third-year clerkship improved with a structured program and increased faculty involvement. LEVEL OF EVIDENCE: II-2

Are in-dwelling catheters necessary for 24 hours after hysterectomy?

OBJECTIVE: In-dwelling catheters for 24 hours after operation are used routinely in gynecologic surgery. This study assesses whether the immediate removal of an in-dwelling catheter after the operation affects the rate of recatheterization, febrile morbidity, symptomatic urinary tract infections, or subjective pain assessments. STUDY DESIGN: This study was a prospective randomized controlled trial comprised of 250 women who underwent hysterectomy and who did not require bladder suspension or strict fluid treatment. The in-dwelling catheter was removed either immediately after the operation or on the first day after the operation. The association between clinical variables and the length of catheterization were assessed by chi-squared analysis. RESULTS: Patients were assigned randomly into 2 groups, with no significant differences in the outcomes, only in the perception of pain. Clinical events included fever (>/=38.5 degrees C) that occurred in 6 patients in the in-dwelling catheter group compared with 5 patients in the early removal group (P=.01), symptomatic urinary tract infections in 3 patients in both groups (P=.99), and recatheterization in 3 patients in the in-dwelling catheter group compared with 5 patients in the early removal group (P=.17). Subjectively, patients in the early removal group reported significantly less pain than did the in-dwelling group (P<.001). CONCLUSION: The early removal of in-dwelling catheters after operation was not associated with an increased rate of febrile events, urinary tract infections, or need for recatheterization. In addition, subjective pain assessment was significantly less in the early removal group. Early removal of an in-dwelling catheter immediately after operation is not associated with adverse events.

Loop-cone cerclage in pregnancy: a 5-year review.

OBJECTIVE: The purpose of this study was to evaluate the efficacy and outcomes of patients undergoing conization utilizing a technique of loop-cone cerclage when a diagnostic cone biopsy was required in pregnancy. METHODS: All loop conizations between 1997 and 2001 were reviewed; 15 patients were identified who underwent cone- cerclage with 13 medical records completely available for review. Abstracted data included age, parity, pap smears prior to and during pregnancy, and histology obtained during colposcopy. The operative time for the procedure, estimated blood loss, complications, pathology of loop specimen, and pregnancy outcomes were recorded. RESULTS: Thirteen charts were available for complete review. The mean operating time was 22 min; 11 patients had less than 50 cc blood loss and two patients had a 250 cc blood loss. The median age was 26.5, average parity was 2, and mean gestational age was 24.1 weeks. Six patients had abnormal pap smears prior to pregnancy, one woman had previously undergone colposcopy, and there was no documentation of previous pap smears in six patients. During pregnancy, on pap smear, nine patients had HSIL, three patients had ASCUS/LSIL, and one patient had adenocarcinoma. Thirteen patients underwent colposcopy and biopsy; eight patients had the question of invasive disease, five patients had endocervical glandular involvement with carcinoma in situ, which were the indications for conization. There were no intraoperative or late postoperative complications. All patients delivered at term. CONCLUSIONS: While the need for conization during pregnancy is rare, there are indications when it is necessary. Loop-cone cerclage is a safe method for performing diagnostic and therapeutic conization during pregnancy.

Bowel injury occurring during an outpatient LLETZ procedure. A case report.

BACKGROUND: Large loop excision of the transformation zone (LLETZ) of the cervix has almost entirely replaced cold knife conization for the treatment of dysplasia. CASE: A 17-year-old woman, gravida 0, underwent LLETZ of the cervix for treatment of cervical intraepithelial neoplasia 2. A bowel injury occurred during the procedure. The bowel was repaired in the operating room, and no long-term complications resulted. CONCLUSION: While LLETZ is a minor outpatient procedure, serious complications can occur.

A "see and treat" management for high-grade squamous intraepithelial lesion pap smears.

OBJECTIVE.: This study evaluates a "see and treat" intervention for high-grade squamous intraepithelial lesions (HSIL) on Pap smears. This is a case control study comparing cost-effectiveness, patient compliance, and pathology obtained from immediate colposcopy and large loop excision of the transformation zone of the uterine cervix. (LLETZ) MATERIALS AND METHODS.: At our institution before the onset of the study, a chart review of 100 patients with HSIL Pap smears was performed. This was the control group. Ninety percent of the patients' in the control group who had HSIL on Pap eventually had LLETZ. The next consecutive 100 women presenting to the clinic who met the same inclusion criteria underwent colposcopy and LLETZ at the same visit and were compared with the control group. Demographics, pathology, compliance, and cost were analyzed. RESULTS.: One hundred patients were treated with one visit colposcopy/LLETZ intervention. Histologic diagnosis of cervical intraepithelial neoplasia (CIN) 2,3 was confirmed in 94% of patients. Two percent of the patients had CIN 1, 1% had no histologic evidence of CIN, and 3% had microinvasive cancer to a depth of 0.5-1.5mm. Cost analysis revealed savings of $35,000 for the institution. Patient compliance was improved with a kept appointment rate of 82%. CONCLUSIONS.: "See and treat" intervention for HSIL Paps was an effective tool. Treating HSIL Paps without a separate visit for colposcopy is a cost-effective management. This method was more convenient for patients with only one disruption of daily schedules.