Complications of vaginal myomectomy by posterior colpotomy.

OBJECTIVE: To evaluate the morbidity of vaginal myomectomy by posterior colpotomy. STUDY DESIGN: From January 1, 1994, through December 31, 2003, 108 patients in our department underwent a vaginal myomectomy procedure by posterior colpotomy. This study assessed the intra-operative (conversion to laparotomy, organ injury, hemorrhage) and post-operative (hematoma, abscess) complications as well as the risk factors for conversion to laparotomy. RESULTS: There were 27 intra- or post-operative complications (25%), 17 (15.7%) of which concerned conversion to laparotomy necessary for successful myomectomy. One case involved rectal injury (0.9%), three hemorrhages (2.8%), one hematoma (0.9%) and five abscesses (4.7%). The mean weight of fibromas was significantly higher in the group of patients undergoing laparotomy (19 cases) than in the vaginal-myomectomy-only group (89 cases) (270+/-197 g versus 181+/-143 g, p=0.02). Similarly, the fibroma size measured by ultrasound was higher in the laparotomy group than in the vaginal-myomectomy-only group, but this difference was not significant (82.6+/-27.1 mm versus 73.7+/-21.8 mm, p=0.13). CONCLUSIONS: The principal risk of vaginal myomectomy is that it will require conversion to laparotomy. The risk of pelvic abscess also appears greater in myomectomy than in other procedures. However, apart from the risk of conversion to laparotomy, vaginal morbidity is lower with this procedure. Vaginal myomectomy is a useful alternative to laparotomy for specific indications.

Prognostic value of human chorionic gonadotropin changes after methotrexate injection for ectopic pregnancy.

Because early prediction of clinical outcome (one or more injections or surgery) of methotrexate treatment of ectopic pregnancy could ease the intensity of follow-up and patient compliance required, we studied the relationship between the change in hCG levels after methotrexate injection and outcome in 129 consecutive patients. A 20% decline in hCG levels between days 1 and 4 during methotrexate treatment has a positive predictive value of 97%.

Breast cancer guidelines--Physicians' intentions and behaviors.

Guidelines are written to define what a physician should do, and networks set up to provide every patient with good practice. However, is willingness to treat according norms enough to actually implement it? Between 1997 and 2003, 4,533 women with invasive, noninflammatory, nonmetastatic breast cancer have been treated within the framework of a regional network (R2C). The rate of implementation of 5 consensual norms was assessed. The rate of "abnormal" management regarding surgical re-excision for inadequate margin was found to be 12.6%. The main explanatory variable was patient age >70 years (OR = 4.05). For nodal exploration, the sampling quality threshold was set at 10. Mean rate of lack of compliance was 25.2%. The 2 main explicative factors were surgeon's experience and women's age. The observed rate of "insufficient" irradiation dose was 18.2%. The main explanatory variables were age (with a gradient) and a negative nodal status. Concerning adjuvant chemotherapy, the rate of no treatment (despite consensual indication) was 16.0%. Again, the main explicative factor was age (with a gradient). Women's age appears to be a major explanatory variable predicting lack of physician's compliance with consensual norms. Besides the age of the women, a "better" prognosis (negative nodal status and pT < or = 20 mn) is often associated with lack of compliance. It is not clear, however, if it's the rules that do not fit the clinical situation of aging patients or the physicians who are not aware of the benefit of consensual disease management for aging patients.

Influence of clinical and ultrasound factors on the efficacy of misoprostol in first trimester pregnancy failure.

An observational study including 276 patients with early pregnancy failure was performed to evaluate the clinical and ultrasound factors influencing the efficacy of misoprostol in the treatment of first trimester pregnancy failure. Gestational age did not influence the efficacy of this treatment and the success rate was inversely proportional to parity.

Laparoscopic removal of a remaining myoma after vaginal hysterectomy: a case report.

We report on an uncommon postoperative complication of vaginal hysterectomy--a remaining myoma--diagnosed and treated by laparoscopy. This procedure was performed for a remaining myoma 3 months after vaginal hysterectomy for fibroid uterus. Laparoscopy may be helpful to diagnose and treat this complication.

Oxytocin during myomectomy: a randomized study.

OBJECTIVE: To evaluate the influence of oxytocin on peroperative blood loss during myomectomy. STUDY DESIGN: From October 1998 to May 2002, 94 patients requiring surgical myomectomy by laparotomy or by the vaginal approach were enrolled in a randomized double blind study. Patients were randomized to two groups. In the first group (47 patients) oxytocin was administered during myomectomy and in the second group (47 patients) a placebo was used. The main outcome measures were peroperative blood loss and rates of blood transfusion and autotransfusion. RESULTS: Peroperative blood loss was no different between the oxytocin group and the placebo group (508 +/- 558 ml versus 451 +/- 336 ml; P=0.55). Rates of autotransfusion and blood transfusion were also similar in both groups. CONCLUSION: Administration of oxytocin during myomectomy did not reduce peroperative blood loss in our study. The benefits of using oxytocin to prevent hemorrhage during myomectomy seem to be limited.

Vaginal myomectomy using posterior colpotomy: feasibility in normal practice.

BACKGROUND: Myomectomy is classically performed via laparotomy. Endoscopic surgery is limited for some indications. Vaginal myomectomy is a surgical procedure that has recently been evaluated. The aim of this study was to evaluate the feasibility, reproducibility and complication rate of vaginal myomectomy via posterior colpotomy. METHODS: A retrospective study was performed from November 1998 to February 2001 in three departments of gynaecology. RESULTS: Forty-five patients were involved, 17 (37.8%) of whom underwent laparoscopy before vaginal myomectomy for evaluation or treatment of a second pelvic disorder. Myomectomy was performed vaginally in 40 (89%) of the 45 patients. Peroperative laparotomy was required in five patients (11%), either because vaginal myomectomy proved impossible (four cases) or because of rectal injury (one case). One patient needed supplementary laparotomy on day 8 for the treatment of a pelvic abscess. CONCLUSION: Posterior vaginal myomectomy seems to be a feasible and reproducible surgical procedure. The success rate of vaginal myomectomy in this study was over 80%. Further randomised studies are needed to compare this procedure with laparotomy and laparoscopy.

Risk of vasovagal syndrome during outpatient hysteroscopy.

STUDY OBJECTIVE: To evaluate influence of hysteroscope type and media used during outpatient hysteroscopy on vasovagal syndrome risk. STUDY DESIGN: Prospective observational study (Canadian Task Force classification II-1). SETTING: University hospital. PATIENTS: Two thousand seventy-nine women undergoing outpatient hysteroscopy without analgesia. INTERVENTION: Office hysteroscopy with a flexible or rigid hysteroscope and normal saline or CO(2). MEASUREMENTS AND MAIN RESULTS: Fifteen cases of vasovagal syndrome were reported. The rate of vasovagal syndrome was higher with use of a rigid hysteroscope (12/647 [1.85%]) vs. a flexible hysteroscope (3/1432 [0.21%]), p =.00013; p =.009 after adjustment for medium used; and with the use of CO2 (10/426 [2.34%]) vs. saline solution (5/1653 [0.30%]), p <.0001; p =.014 after adjustment for hysteroscope type. CONCLUSION: Risk of vasovagal syndrome is higher with the use of a rigid hysteroscope and CO2, regardless of the indication for hysteroscopy or the parity and menopausal status of the patient.

Postoperative infection and surgical hysteroscopy.

OBJECTIVE: To evaluate the risk of infection after surgical hysteroscopy. DESIGN: Prospective observational study. SETTING: University hospital. PATIENT(S): One thousand nine hundred fifty-two patients requiring operative hysteroscopy during a 10-year period from January 1990 to January 2000. INTERVENTION(S): Two thousand one hundred sixteen operative hysteroscopies were performed: 782 fibroma resections, 422 polyp resections, 623 endometrectomies, 90 uterine septa sections, and 199 lyses of synechiae. MAIN OUTCOME MEASURE(S): Postoperative infectious complications. RESULT(S): Thirty (1.42%) infections occurred. There were 18 (0.85%) cases of endometritis and 12 urinary tract infections. No other severe infectious complications were reported. The risk for early-onset endometritis was higher after lysis of synechiae compared with endometrectomy, fibroma, or polyp resections. However, the risk for early-onset endometritis was similar for endometrectomy, septa, fibroma, or polyp resections. CONCLUSION(S): Infectious risk following surgical hysteroscopy is low. No major infectious complications occurred. Risk for early-onset endometritis was higher after lysis of synechiae compared with other procedures.