Influence of transvaginal ultrasound examination on quantitative vaginal fibronectin measurements: a prospective evaluation study.

OBJECTIVE: The most important parameter in prediction of preterm birth is the cervical length measured by transvaginal ultrasound. In cases with mid-range cervical length (10-30 mm), prediction of preterm birth is difficult. In these cases, testing for cervicovaginal fluid fetal fibronectin (fFN) can improve prediction. However, it is unclear whether transvaginal ultrasound itself influences the fFN result. The purpose of this study was to evaluate this issue independent of gestational age and cervical length. METHODS: A prospective evaluation study with 96 cases of pregnant women at 20-41 weeks of gestation was conducted in a tertiary perinatal center. A comparison of cervicovaginal fFN samples before and immediately after transvaginal ultrasound was performed. Fetal fibronectin was measured using the Hologic Rapid fFN 10Q system. It was analyzed quantitatively and qualitatively with ≥50 ng/mL as threshold for "positive". Changes in fFN values following transvaginal ultrasound were measured. RESULTS: Ninety-six percent (69/72) of women with a fFN concentration of <26 ng/mL before ultrasound had a corresponding fFN value <26 ng/mL after ultrasound. Ninety-three percent (13/14) of women with a fFN concentration of ≥100 ng/mL before ultrasound had a corresponding fFN value ≥100 ng/mL after ultrasound. In 80% (4/5) of women with a positive fFN sample but with a value <100 ng/mL, it turned negative (<50 ng/mL) after ultrasound. For fFN concentrations ≥100 ng/mL, there are high random fluctuations in the measurement results. CONCLUSIONS: Fetal fibronectin values of <26 ng/mL (for "negative") and ≥100 ng/mL (for "positive") from samples taken after ultrasound provide the same qualitative information as when sampled before ultrasound. For the correct interpretation however, quantitative analysis is necessary.

Cervical sonoelastography for improving prediction of preterm birth compared with cervical length measurement and fetal fibronectin test.

AIM: Accurate prediction of the risk of spontaneous preterm birth is crucial for the clinical management of patients with preterm labor. The aim of the study was to investigate whether cervical sonoelastography improves prediction of spontaneous preterm birth compared with cervical length measurement and a fetal fibronectin (fFN) test. METHODS: A prospective cohort study was conducted including 64 patients with preterm labor at 23-34 weeks of gestation. Patients had an fFN test and transvaginal cervical length measurement, followed by real-time cervical sonoelastography. The ratio of nondeformable tissue to the total area of a designed region of interest was analyzed and related to the gestational week of delivery. RESULTS: Cervical sonoelastography and fFN test show a significant correlation with spontaneous preterm delivery (P=0.007, P=0.001), resulting in 72.7%/36% sensitivity and 73%/95% specificity. The positive predictive value (PPV) was 61.5%/81.8% and the negative predictive value was 81.8%/70%. The cervical length was not different in cases with and without term delivery (P=0.165). CONCLUSIONS: Cervical sonoelastography is a promising technique that can complement routine diagnostic procedures to improve prediction of preterm birth. The PPV is improved by an fFN test.

Robotically assisted para-aortic lymphadenectomy: surgical results: a cohort study of 487 patients.

OBJECTIVES: The aim of this study was to evaluate perioperative outcomes of robotic-assisted laparoscopic para-aortic lymphadenectomy (PAL) in patients with gynecologic cancers during the learning phases of robotic surgery programs and to compare results of extraperitoneal versus transperitoneal approaches of PAL. MATERIALS AND METHODS: This study is a retrospective multicentric study of patients who underwent robotically assisted laparoscopic PAL (N = 487). Eleven European centers and 1 US center participated in the study. Abstracted data included age, body mass index, indication, type of surgical approach (transperitoneal or extraperitoneal), associated surgical procedures, operative time, estimated blood loss, lymph node count, hospital length of stay (LOS), and complications. Para-aortic lymphadenectomy was performed by an extraperitoneal approach in 58 cases (12%) and transperitoneal in 429 cases (88%). RESULTS: The mean (SD) para-aortic lymph node count was 12.6 (8.1), operative time was 217 (85) minutes, estimated blood loss was 105 (110) mL, and LOS was 2.8 (3.2) days. Four (0.8%) conversions to open and 2 (0.4%) conversions to laparoscopy were described. There were 32 lymphocysts (6.6%), 3 deep venous thromboses (0.6%), and 10 transfusions (2.1%). For transperitoneal approach, the average number of lymph nodes removed was higher in isolated PAL group than the hysterectomy combined group (report node counts 95% confidence interval, -7.29 to -3.52, P = 1.5 × 10⁻6). For isolated PAL, the LOS was shorter in the extraperitoneal group than in the transperitoneal group (report data 95% CI, -1.35 to -0.35, P = 0.001). CONCLUSIONS: Robotic-assisted PAL seems safe and feasible. More lymph nodes were removed during an isolated transperitoneal PAL dissection compared with a combined procedure with hysterectomy. Extraperitoneal approach seems attractive relative to transperitoneal dissection, but the superiority of one or the other way is not demonstrated by our study.

Isthmic-vaginal smear cytology in the follow-up after radical vaginal trachelectomy for early stage cervical cancer: is it safe?

BACKGROUND: Isthmic-vaginal cytology is a follow-up method in patients who have undergone radical vaginal trachelectomy (RVT) for early cervical cancer. However, to the authors' knowledge, little is known regarding its ability to monitor patients and diagnose disease recurrence. Herein, the authors report their experience with cytology after RVT compared with cytology in patients after cone biopsy and women undergoing screening. METHODS: A database of 563 specimens from 303 patients was analyzed retrospectively (RVT in 361 specimens, conization in 102 specimens, and screening in 100 specimens). The following criteria were applied: Bethesda system, the presence of endocervical and metaplasia cells, regeneration criteria, vaginal flora, and morphological signs of human papillomavirus. The analysis was performed by 2 cytopathologists. Differences between the groups and correlation between the cytopathologists were analyzed. RESULTS: Smears without endocervical and metaplasia cells were significantly less frequent among the patients who underwent RVT. There was no difference in regeneration signs, vaginal flora, and morphologic signs of human papillomavirus between the groups. After RVT, 26/23 smears (cytopathologist 1/cytopathologist 2) smears were diagnosed as abnormal. Biopsies revealed 7 cases of dysplasia and 1 case of disease recurrence. After conization, 1 patient was diagnosed with a low-grade lesion on cytology; follow-up cytology was normal. In the screening, 10/13 smears were diagnosed with lesions on cytology; biopsy revealed dysplasia in 2 cases. The correlation between both cytopathologists was high. CONCLUSIONS: After RVT, histological verification of cytology is frequently needed. The reasons might include alterations of anatomy, regeneration, and inflammation process after RVT. Cytopathologists should become familiar with the spectrum of changes in post-RVT cytology and communication between cytopathologists and clinicians should be improved. This might reduce false-positive results.

Vaginal-assisted laparoscopic radical hysterectomy (VALRH) versus laparoscopic-assisted radical vaginal hysterectomy (LARVH) in the treatment of cervical cancer: surgical results and oncologic outcome.

PURPOSE: The aim of this study was to compare the morbidity and survival rates of patients with early-stage cervical cancer treated by vaginal-assisted laparoscopic radical hysterectomy (VALRH) with pair-matched laparoscopic-assisted vaginal radical hysterectomy (LARVH) controls. METHODS: One hundred nine patients who underwent VALRH for cervical cancer stage FIGO Ia1, L1 to IIb between 2007 and 2009 and 200 patients who underwent LARVH between 1994 and 2002 were analysed in their entirety and in a group of matched pairs. RESULTS: In both groups, there was no conversion to laparotomy due to an intraoperative complication. Prevalence of blood transfusions was significantly lower in the VALRH group (2 vs. 39 patients; P < 0.001). Bladder function resumed sooner (P < 0.001), and patients were discharged earlier after VALRH (P < 0.001). There were no intraoperative injuries in the VALRH group. In the LARVH group, the most common intraoperative injury occurred to the bladder (7.0 %). Postoperatively, the most common complication in the VALRH group was ureterovaginal fistula (2.7 %) and fever (2.7 %) and in the LARVH ureterostenosis (3.5 %), uretero/bladder fistula (1 %), and fever (7 %). For patients with tumour stage Ib1 the 5-year recurrence-free survival was 92.8 % and 5-year overall survival 95.2 % following VALRH and 88.2 and 90.5 %, respectively, following LARVH. No significant difference in the survival rate was found (log rank, P = 0.740). CONCLUSION: VALRH is a feasible and oncologically safe surgical option for patients with early-stage cervical cancer. We believe the complication rate is lowered in VALRH by the combination of the laparoscopic and vaginal approach.