Pitfalls in the differential diagnosis of a pelvic cyst: lessons from a post-menopausal woman with bladder diverticulum.

We present a case of non-obstructive bladder diverticulum in a 75-year-old post-menopausal woman. An ovarian cyst was previously suspected, which resulted in a futile exploratory laparotomy without making any definite diagnosis, 1 year earlier. During this admission, transvaginal ultrasound-guided cyst aspiration was arranged to determine the nature of the presumed 'recurrent' cyst and to relieve the symptoms. Prior to cyst aspiration, up to 700 ml of urine through urinary catheterisation and the gradual disappearance of the 'cyst' alerted us to the possibility of a bladder diverticulum, which was later confirmed by retrograde cystography. This case illustrates the lessons that despite considerable researches having been done on enhancing sonographic accuracy, diagnosis based on imaging alone is likely to be associated with multiple pitfalls. Recognising the common pitfalls and integrating clinical information and alertness with ultrasonic features remains the mainstay of sonographic differential diagnosis.

Negative predictive value of human papillomavirus test following conization of the cervix uteri.

OBJECTIVE: The goal of this study was to determine/evaluate the negative predictive value of human papillomavirus (HPV) testing following conization of cervix uteri. METHODS: A prospective analysis was undertaken on 79 cone biopsies of women with high-grade lesions (cervical intraepithelial neoplasia (CIN) III). HPV testing was performed on cervical smears before and after conization. We correlated the margin status (defined as positive cone margin or endocervical curettage status) and positive conization HPV status with the residual disease in a hysterectomy specimen. A Digene II kit was used to perform HPV testing. HPV detection was done by Hybrid Capture assay. RESULTS: Of the 79 patients, 47(59.5%) had positive margins after conization. HPV testing was positive in 37 cases (78.7%) and negative in 10 cases (21.3%). Residual disease was found in 31 of 47 (66%) postconization hysterectomy specimens. No residual lesions were found in HPV-negative cases. Of the 32 cases with negative margins following conization, HPV testing was negative in 25 cases (78%) and was positive in 7 cases (22%). Among these 25 cases with negative HPV tests, no residual lesion was detected, and in 7 HPV-positive cases, only one residual lesion was found. CONCLUSION: HPV testing is potentially an effective tool in predicting residual dysplasia after conization and could potentially assist in the decision between hysterectomy and conservative follow-up in women with CIN III.

Applications of the telomerase assay in peritoneal washing fluids.

OBJECTIVE: The aim of this study was to detect telomerase activity in peritoneal ascites and to assess whether it can be used as an assistant tool for the early detection of ovarian cancer. METHODS: Telomerase activity was measured by TRAP assay in 47 patients with ovarian malignancies and 50 patients with benign uterine leiomyomas (control group). RESULTS: All 26 peritoneal washing cytology positive cases were telomerase positive. Of the 21 peritoneal washing cytology negative cases, 3 were telomerase positive. When these 3 were reevaluated for peritoneal cytology, malignant ascitis was identified in 1. All telomerase negative cases were negative for peritoneal washing cytology. The sensitivity and specificity of peritoneal cytology and telomerase testing in correlation with true malignant cells were 96 (26/27) and 100% (20/20) versus 100 (27/27) and 90% (18/20), respectively. The false negative rate of peritoneal cytology was 4.7% (1/21). The false positive rate of the telomerase test in relation to malignant ascites was 6.9% (2/29). CONCLUSION: Our preliminary results reveal a high sensitivity and specificity of both telomerase testing and conventional cytology in peritoneal fluids. Our data suggest that the telomerase test in peritoneal fluids can be used as an adjuvant to cytopathological methods in the diagnosis of malignant peritoneal ascites, particularly in cases of negative cytology. In these cases, a review of peritoneal histocytology is advised.

Ultrasonographic and urodynamic evaluation after tension free vagina tape procedure (TVT).

BACKGROUND: This study was carried out to evaluate the urodynamic and ultrasonographic findings after tension-free vagina tape (TVT) procedure on stress urinary incontinent women. METHODS: Ninety women suffering from genuine stress incontinence without pelvic relaxation syndrome underwent surgery. Urodynamic measurement, one-hour pad test and introital ultrasonographic evaluation were performed preoperatively and one year after surgery. Additional ultrasonographic surveillance of the urethra was performed immediately after the operation. The position and mobility of the bladder neck was compared pre- and post-operatively in relation to the inferior edge of the pubic symphysis. RESULT: Eight women were excluded for various reasons. Among the 82 women who completed the study, 76 (93%) were cured, four were improved and two failed. No major intra- or post-operative complications occurred. The position and mobility of the bladder neck showed no significant difference before and after surgery. A urethral knee angle was noted ultrasonographically on cured and improved patients during maximum straining. Nine patients with immediate postoperative voiding difficulty were found to have a pronounced mid-urethra angulation. The symptom and sign were resolved by time after urethra depressing. Urodynamic assessment of the urethral pressure profile and other parameter showed no significant difference before and after the surgery except that a positive pressure transmission in the middle portion of the urethra was noted among 70 (87.5%) of cured and improved subjects. CONCLUSION: Tension-free vagina tape operation is an effective surgical procedure for the treatment of female urinary stress incontinence. The procedure seems neither to change hypermobility nor to elevate the position of bladder neck. Urinary continence after surgery is most probably achieved by creating a dynamic mid-urethral knee angulation by which the urethra is closed i.e. kinked at stress. Lifting of the mid-urethra resulted in postoperative voiding difficulty. It is the important that the tape is placed tension free under the urethra. Introital ultrasonographic surveillance is a suitable technique to visualize the result of the operation.

Isolated fetal ascites: five cases report.

Isolated fetal ascites is a rare abnormality that can be detected prenatally by sonography. Fetuses with transient or isolated ascites were reported to have a good outcome if the specific etiology is confirmed and the appropriate treatment is given. In this report, we present 5 cases of nonimmune fetal ascites of different etiologies and obstetric managements. Fetuses that presented with generalized hydrops, chromosomal abnormalities and viral etiologies were excluded. Four of the fetuses survived without major neonatal complications, which included one chyloperitoneum, one meconium peritonitis and 2 idiopathic causes. Spontaneous resolution occurred in three cases. The one treated with prenatal paracentesis did not experience respiratory distress after birth but the other who did not undergo the procedure showed neonatal respiratory distress. The only neonatal mortality was a case involving intestinal obstruction who developed necrotizing enterocolitis four days after the surgery. Nonimmune fetal ascites can have a good outcome by using ultrasound in establishing the specific prenatal diagnosis and surveillance.

Conservative conization for microinvasive carcinoma of the cervix.

OBJECTIVE: Our purpose was to examine conservative conization as treatment for microinvasive carcinoma of the cervix with depth of invasion < 3 mm. STUDY DESIGN: Twelve patients with microinvasive carcinoma of the cervix underwent cervical conization under colposcopic guidance followed by careful observation. RESULTS: The 12 patients were alive without evidence of disease after a mean follow-up of 6.7 years. Four pregnancies with term deliveries were identified. CONCLUSION: Microinvasive carcinoma with a depth of invasion < 3 mm without confluent invasion or lymph vascular involvement can be treated successfully with conservative conization and provided a good pregnancy outcome.

Conservative treatment for cervical cancer IA1: four cases report.

Cervical carcinoma IA1 is defined as invasive cervical cancer with measured invasion of the stroma no greater than 3 mm in depth and no wider than 7 mm in diameter. It has been managed by extrafascial or modified radical hysterectomy. For young female patients who want to preserve future fertility, conservative treatment using therapeutic conization should be considered. In Taiwan, there has been little information about conservative treatment for cervical carcinoma IA1. We present 4 cases of young women with cervical carcinoma IA1 treated by conization alone. Pathological reports of all specimens demonstrated squamous cell carcinoma with free margins, stroma invasion less than 3 mm and no evidence of lymphovascular space invasion (LVSI). After 5-year follow-up with pelvic examination, pap smear, and colposcopy, there was no evidence of disease recurrence. We believe that conservative treatment for cervical carcinoma IA1 without LVSI is appropriate for selected patients to preserve future fertility.