Total Robotic Myomectomy in a Complex Case: Extending the Limits.

We present the case of a 30-year-old female with primary infertility who had multiple large myomas up to 22 weeks uterine size. She had a body mass index of 42 kg/m2 and also concurrent endometriosis, for which she was on medical management. After meticulous preoperative planning, total robotic myomectomy and endometriosis clearance was done. Four large myomas weighing a total of 750 g were removed after morcellation. Console time was 160 min, and she made an uneventful recovery with only 0.1 g/dL drop in hemoglobin. Robotic myomectomy is considered as an improvement over laparotomy for patients with up to three myomas and when the surgical time does not exceed 4 hours. We were successful in our attempt at total robotic myomectomy to extend these limits and had a positive surgical outcome.

Cervical cancer: Can it be prevented?

Cervical cancer prevention requires a multipronged approach involving primary, secondary and tertiary prevention. The key element under primary prevention is human papilloma virus (HPV) vaccination. So far, only prophylactic HPV vaccines which prevent HPV infection by one or more subtypes are commercially available. Therapeutic HPV vaccines which aid in clearing established infection are still under trial. Secondary prevention entails early detection of precancerous lesions and its success is determined by the population coverage and the efficacy of the screening technique. A number of techniques are in use, including cytology, visual inspection (using the naked eye, magnivisualizer, acetic acid and Lugol's iodine), HPV testing and a combination of these methods. Updated screening guidelines have been advocated by the American Cancer Society in light of the role of HPV on cervical carcinogenesis. Recent research has also focussed on novel biomarkers that can predict progression to cancer in screen positive women and help to differentiate those who need treatment from those who can be left for follow-up. Last but not the least, effective treatment of precancerous lesions can help to reduce the incidence of invasive cervical cancer and this constitutes tertiary prevention. A combination of these approaches can help to prevent the burden of cervical cancer and its antecedent morbidity and mortality, but all of these are not feasible in all settings due to resource and allocation constraints. Thus, all countries, especially low and middle income ones, have to determine their own cocktail of approaches that work before we can say with certainty that yes, cervical cancer can be prevented.

Ovarian tumours in pregnancy: a literature review.

Ovarian tumours in pregnancy are a diagnostic and management challenge that is increasingly being faced by the clinician. While most masses are benign and resolve spontaneously, there are others that persist and indicate the need for surgical management. Ultrasound not only detects asymptomatic masses but also helps to guide their management based on presence or absence of features suspicious of malignancy. The role of tumour markers in pregnancy is limited due to their non-specific nature. Most masses treated in pregnancy are benign (most commonly dermoids), and most malignancies are either of low malignant potential or germ cell tumours, usually early stage disease. Surgical management is indicated for symptomatic masses or those with increasing size or complexity indicating possible malignancy. Both laparoscopy and laparotomy have similar results with regard to obstetric outcome. Conservative management is preferred in the remainder. MRI may help in better characterization of doubtful masses. National tumour registries can help to establish guidelines.

Can visual inspection with acetic acid under magnification substitute colposcopy in detecting cervical intraepithelial neoplasia in low-resource settings?

PURPOSE: To compare the sensitivity, specificity, positive and negative predictive values and accuracy of visual inspection with acetic acid under magnification (VIAM) and colposcopy for detecting cervical intraepithelial neoplasia (CIN) to determine if VIAM can substitute colposcopy in identifying the biopsy site in screen-positive cases. METHODS: A prospective cross-sectional study was carried out on 408 symptomatic multiparous women in the reproductive age group (15-49 years) at a tertiary care teaching hospital. VIAM and colposcopy were used to screen for cervical precancerous lesions. Screen-positive women underwent guided biopsy and endocervical curettage. The site of biopsy was recorded as VIAM guided or colposcopy guided. Histopathology was taken as the gold standard. RESULTS: The mean age was 32.3 ± 6.8 years (range 15-49), whilst the mean parity was 2.9 ± 1.2 (range 1-9). A total of 113 women screened positive. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of VIAM and colposcopy were 95, 78, 19, 99 and 79%, and 86, 79, 18, 99 and 79%, respectively for high-grade lesions. CONCLUSIONS: VIAM can be a useful alternative to colposcopy when the latter is not available, as it has better sensitivity and equivalent specificity for detecting high-grade CIN.

Comparison of Papanicolaou test with visual detection tests in screening for cervical cancer and developing the optimal strategy for low resource settings.

OBJECTIVES: To compare the sensitivity, specificity, positive and negative predictive values, and accuracy of Papanicolaou test with visual inspection with acetic acid (VIA)/VIA using magnification devices (VIAM) and develop the best strategy for screening in low resource settings. MATERIALS AND METHODS: This is a prospective cross-sectional study on 408 symptomatic multiparous women in the reproductive age group, sequentially using the Papanicolaou test, the VIA, and the VIAM for screening. Women with a positive screening test underwent guided biopsy and endocervical curettage. The site of biopsy was recorded. Histopathological findings were taken as the "gold" standard in comparing the methods. RESULTS: The mean (SD) age was 32.3 (6.8) years (range, 15-49 years), whereas the mean (SD) parity was 2.9 (1.2) (range, 1-9). Abnormal cytological findings were detected in 2.9% patients, whereas the remaining smears were negative for any intraepithelial lesion or malignancy. A total of 113 cases were screened positive by one/all methods. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the Papanicolaou test, the VIA, and the VIAM were 24, 98, 42, 96, and 94%; 95, 78, 19, 99, and 79%; and 95, 78, 19, 99, and 79%, respectively, for high-grade lesions. CONCLUSIONS: The Papanicolaou test had low sensitivity but high specificity, whereas visual detection methods had a high sensitivity in addition to being cheaper. Alternative methods of screening such as VIA/VIAM can be a valuable alternative to the Papanicolaou test for cervical cancer screening in low resource settings. Visual inspection using magnification devices may be of benefit over VIA in doubtful cases.

Serum tumour markers in gynaecological cancers.

Serum tumour markers have had a role in screening, diagnosis and monitoring of some gynaecological cancers. Women with suspected ovarian malignancies have as routine a CA125 serum test, and in conjunction with scans, the risk of malignancy can be calculated. Equally, this CA125, if elevated pre-operatively can be used to predict chemotherapeutic responses, and even disease relapse prior to any symptoms or clinical findings. Other useful markers in ovarian cancer are betaHCG and AFP produced by germ cell tumours. betaHCG is also of extreme importance in both the diagnosis and management of choriocarcinomas. The level of betaHCG determines the need, and with other indicators, the type of chemotherapeutic intervention. Other serum markers are known in cervical cancer, and possibly endometrial and vulval cancer-but their clinical utility is very limited. Novel markers may help in managing patients, and in the future permit screening for certain diseases.

A survey of obstetricians' practice of using prophylactic antibiotics in vaginal deliveries and caesarean sections.

Antibiotics are prescribed in pregnancy but only few reports provide information about the actual practice of prophylactic antibiotics usage in various obstetrical conditions amongst obstetricians. The present study evaluates the practice of obstetricians of Delhi regarding prescription of antibiotics in vaginal deliveries and caesarean sections. The open-ended predesigned questionnaire study incorporated details of the obstetricians working in different hospitals of Delhi and their practice of prescribing antibiotics in vaginal deliveries, episiotomies and caesarean sections was filled by obstetricians. The data was analysed using Student's 't' test and Chi-square test. The mean age of obstetricians was 35.5 years; 90% were females and 48.9% were postgraduate students with 70% less than 5 years experience and 77.8% were working in a government hospital. In episiotomy, 18.9% obstetricians did not use antibiotics while 33.3%, 27.8% and 20% obstetricians used ampicillin, amoxicillin and cephalexin orally for 5 days respectively. Injection cefazolin was used intravenously, 1 g 12 hourly for 3 days by 34.4% and 33.3% obstetricians in elective and emergency caesarean sections respectively, while it was used for 5 days by 35.5% and 41.1% obstetricians respectively. A combination of ampicillin, gentamicin and metronidazole for 5 days was used by 30% and 25.5% obstetricians for elective and emergency caesarean sections respectively. In spite of clear evidence from Cochrane Database of Clinical Reviews that use of penicillin or first generation cephalosporins in single dose therapy is effective; the actual practice is contrary with use of multiagent antibiotics for long periods, being very rampant in actual clinical practice.

Role of hyoscine N-butyl bromide (HBB, buscopan) as labor analgesic.

BACKGROUND: Hyoscine N-butyl bromide (HBB) acts by inhibiting cholinergic transmission in the abdomino-pelvic parasympathetic ganglia, thus relieving spasm in the smooth muscles of gastrointestinal, biliary, urinary tract and female genital organs, especially the cervico-uterine plexus and aiding cervical dilatation. AIM: The study was undertaken to observe the effects of 40 mg intravenous HBB as a labor analgesic and labor accelerant. SETTINGS AND DESIGN: This prospective randomized control trial was carried out on 104 primigravidae with single live fetus in cephalic presentation, with spontaneous onset of labor, between 37-40 weeks of gestation. MATERIALS AND METHODS: Women were consecutively randomized into study (group I) and control (group II) groups, each with 52 patients after excluding high risk factors like preeclampsia, antepartum hemorrhage, previous uterine scar, and any contraindications to vaginal delivery. Group I received 40 mg HBB as a slow intravenous injection in the active phase of labor while Group II received 2 mL normal saline. Pain scores were assessed at baseline and two hours later. Secondary outcome measures compared were progress of labor based on injection delivery interval, mode of delivery and neonatal condition at birth. STATISTICAL ANALYSIS: Statistical significance was assessed by using Student's t-test and Chi-square test. P-value < 0.05 was taken as significant. RESULTS: Pain relief of 35.6% was noted on visual analog score with the use of HBB. Mean duration of labor was 3 hours 46 minutes in Group I compared to 8 hours 16 minutes in Group II (P value: < 0.001). Mode of delivery and neonatal outcome were comparable. No adverse maternal effects were noted. CONCLUSIONS: Intravenous Hyoscine N-Butyl Bromide causes pain relief of up to 36% and shortens the duration of active phase without any untoward short term fetal or maternal effects.