A discordant histological risk classification in preoperative and operative biopsy in endometrial cancer is reflected in metastatic risk and prognosis.

INTRODUCTION: In endometrial cancer, tissue for histological evaluation is obtained preoperatively (endometrial biopsy) and operatively (hysterectomy specimen). We investigated if a discordant risk classification based on preoperative and operative biopsy is reflected in metastatic risk and prognosis. PATIENTS AND METHODS: One thousand three hundred and seventy-four patients were prospectively included in a multicentre setting (Molecular Markers for Treatment of Endometrial Cancer (MoMaTEC) study). Preoperative and operative specimens were classified as high risk if non-endometrioid histology or endometrioid grade 3; otherwise low risk. Disease specific survival differences were calculated by means of Kaplan-Meier and Cox proportional hazard models. RESULTS: Discordant risk was found in 207 (16%) cases. Lymph node metastases were detected in 7% and 23% of patients with concordant low and high risk respectively versus 14% and 20% in the discordant groups (p<0.001). Five-year disease specific survival in the discordant groups proved intermediate (75-80%) to concordant low (94%) or high (58%) risk. Both operative and preoperative biopsy high-risk results have independent prognostic impact on disease specific survival with adjusted hazard ratios of 2.4 (95% confidence interval (95% CI) 1.5-3.9) and 2.1 (95% CI 1.3-3.2) respectively by Cox analysis. CONCLUSIONS: Discordant risk in preoperative biopsy and hysterectomy identifies an intermediate group with respect to disease spread and prognosis. Preoperative biopsy results remain important also with the hysterectomy histology available.

Validation of three-dimensional perineal ultrasound and magnetic resonance imaging measurements of the pubovisceral muscle at rest.

OBJECTIVE: To compare biometric measurements of the pubovisceral muscle during rest, measured using transperineal three-dimensional (3D) ultrasound and magnetic resonance imaging (MRI). METHODS: In this prospective study, 18 female volunteers underwent 3D perineal ultrasound examination and MRI. All women were examined at rest in the supine position and the following measurements were taken: area and anteroposterior and transverse diameters of the levator hiatus; thickness of the pubovisceral muscle, measured lateral to the vagina and to the rectum, on the right and left sides; length of the levator-urethra gap (LUG), measured from the center of the urethra to the insertion of the pubovisceral muscle on the pubic bone. Interclass correlation coefficients (ICC) between the measurements obtained with 3D ultrasound and with MRI were calculated. To quantify the intermeasurement agreement, the bias and SDs were calculated, and limits of agreement constructed. One investigator performed all the analyses. RESULTS: There was no significant difference between the mean values of the measurements by 3D perineal ultrasound and those by MRI. The ICC values showed very good agreement (range, 0.80-0.97). There was a significant positive bias for LUG on the left side and muscle thickness on the right side of the vagina. CONCLUSION: These results suggest that 3D ultrasound could be used instead of MRI when evaluating static pelvic floor anatomy in women without pelvic organ prolapse at rest.

Improving quality by introducing enhanced recovery after surgery in a gynaecological department: consequences for ward nursing practice.

INTRODUCTION: Enhanced Recovery After Surgery (ERAS) is a perioperative treatment protocol that can improve individual recovery. This allows patients to leave hospital earlier, implying a cost reduction. The programme seems to spread slowly. ERAS was introduced at the Department of Obstetrics and Gynaecology at Akershus University Hospital in 2005. The objective of this study was to monitor changes in the workload and work environment of the ward nursing staff when ERAS was introduced at the department. METHODS: A pre-postintervention prospective design was used. Triangulated data were collected immediately before introduction (Phase 1), soon after (Phase 2), and 1 year after introduction (Phase 3). Data sources in all phases were registrations of time spent caring for individual patients during their stay, personnel survey responses and verbal interviews with informants from different staff groups. Patients were included consecutively, the aim being to include a minimum of 40 per phase. RESULTS: Time registration showed that during the observation period, there was a 28% reduction in mean length of stay (-1.3 days, 95% CI -1.63 to -0.97, p<0.001) and 39% reduction in total time used in nursing activities per stay (-162 min, 95% CI -239.3 to -84.4, p<0.001). The personnel survey had a 100% response rate and presented few changes other than decreasing workload. The interview data from four informants described a successful change. CONCLUSION: The findings confirmed the successful introduction of ERAS in the gynaecological department of a large university hospital. The experiences we made indicate that the expected gains of implementing ERAS are achieved without compromising the workload or work environment of ward nursing staff.