Adaptive variation in fall cold hardiness of aspen from northwestern Ontario.

We investigated adaptive variation in fall cold hardiness development based on the electrical conductivity of tissue diffusates (EC) among 20 aspen provenances from northwestern Ontario. Provenance accounted for over 40% of the total variation in cold injury for seven dates from September through November in three provenance trials. Principal component analysis was performed to summarize the combinations of results for all sampling sites, dates and temperatures (traits). Principal component (PC)-1 represented fully developed cold hardiness differences among provenances; PC-2 represented differences in the timing of the onset of cold hardiness development; and PC-3 represented a site-related difference in cold hardiness development. Heat sum in early summer and late summer precipitation together were the best predictors of absolute degree of cold hardiness (PC-1), whereas temperatures for mid- to late summer were best for predicting onset of cold hardiness development (PC-2). In a second study, we assessed the efficacy of chlorophyll fluorescence (CF) as a simpler technique for determining the cold hardiness of aspen stem samples. Fall cold hardiness of stem samples of 12 of the original 20 provenances was estimated by CF, and the results were evaluated by a visual scoring (VS) method. Correlations between EC and CF measurements from the two studies were moderately strong based on the extent of cold hardiness in October of each year, but were negative for September dates because of a later onset of cold hardiness in the EC study year. Although the EC and CF methods gave similar cold hardiness values for stem samples from 12 provenances, the CF method may be preferred to the EC or VS method for species with chlorophyllous stems because of its greater ease of use.

A classification system for laparoscopic hysterectomy.

The term "laparoscopic hysterectomy" has been applied to a variety of procedures, ranging from lysis of adhesions laparoscopically followed by vaginal hysterectomy, to removal of the entire uterus under endoscopic direction. These procedures vary in a number of ways, including cost, morbidity, operating time, and surgical skill required. To facilitate training, credentialing, and outcome evaluation, we present the following classification system: type I--division of one or both pedicles containing the ovarian arteries, type II--dissection including one or both uterine arteries, type III--type II plus separation of part of at least one cardinal-uterosacral ligament complex, and type IV--type II plus separation of the entire cardinal-uterosacral ligament complex on at least one side. Each of the types may be subclassified according to the degree of dissection of structures located anterior and posterior to the cervix. Supracervical hysterectomy has a separate system of classification. Operations are categorized by management of the ovarian and uterine arteries and subdivided according to treatment of the cervical canal.

Uterine sarcoma in patients operated on for presumed leiomyoma and rapidly growing leiomyoma.

OBJECTIVE: To determine the incidence of uterine sarcoma in patients operated on for symptomatic uterine leiomyomas or "rapidly growing" leiomyomas. METHODS: We reviewed the medical records of 1332 women admitted to either of two community hospitals between 1988-1992 for hysterectomy or myomectomy for uterine leiomyomas. The incidence of leiomyosarcoma, endometrial stromal sarcoma, and mixed mesodermal tumor was calculated. Patient ages, admitting symptoms, and operative and pathologic findings were analyzed. The study included 371 women (28%) operated on for rapidly growing leiomyomas. All patients operated on during the same interval and found to have a uterine sarcoma were reviewed. RESULTS: One of the 1332 patients operated on for presumed leiomyoma was found to have a leiomyosarcoma. This women was the only patient found to have a sarcoma among 371 women operated on for rapid growth of the uterus. None of 198 patients who met a published definition of rapid growth had a uterine sarcoma. Two women (0.15%) had endometrial stromal sarcoma, but none had a mixed mesodermal tumor. During the same interval, nine additional patients were found to have uterine sarcomas, and for these women, the preoperative diagnosis was sarcoma in four, endometrial cancer in three, ovarian cancer in one, and prolapsed uterus in one. CONCLUSIONS: The total incidence of uterine sarcoma (leiomyosarcoma, endometrial stromal sarcoma, and mixed mesodermal tumor) among patients operated on for uterine leiomyoma is extremely low (0.23%). The incidence of sarcoma among patients having surgery for "rapidly growing" leiomyoma (0.27%) or among those who met published criteria for rapid growth (0%) does not substantiate the concept of increased risk of sarcoma in these women.

A multicenter study of laparoscopic management of selected cystic adnexal masses in postmenopausal women.

BACKGROUND: The objective of this study was to determine the ability to predict benign adnexal masses in postmenopausal women and to evaluate the effectiveness of laparoscopic management in selected patients. STUDY DESIGN: Postmenopausal women found to have an adnexal mass were prospectively evaluated with clinical examination, sonography, and serum CA-125 levels. Women with cystic masses greater than 3 cm but less than 10 cm, with distinct borders, without solid parts or septations greater than 2 mm, without ascites or matted bowel, and with serum CA-125 levels less than 35 IU per mL were operated upon by laparoscopy. RESULTS: Sixty-one women gave consent for the study. Cyst size ranged from 3 to 10 cm. All masses were accurately predicted to be benign. Fifty-eight (95 percent) women were successfully managed by operative laparoscopy and three required laparotomy. For the patients managed by laparoscopy, the mean operative time was 63 minutes, the mean postoperative hospitalization period was 12 hours, and the mean return to normal activity was 5.6 days. CONCLUSIONS: The combination of clinical examination, sonographic appearance and serum CA-125 levels can accurately predict benign masses in postmenopausal women. Operative laparoscopy is acceptable for these patients and provides for a short period of hospitalization and a rapid recovery.

Total laparoscopic hysterectomy.

Alternatives to hysterectomy can provide excellent treatment outcomes for many women. In general, these alternatives are underused. For some women, however, alternative treatments fail and hysterectomy provides the best approach. The goal of future research should be to define better this group of women. For women who require hysterectomy, the laparoscopic approach affords the benefit of less postoperative discomfort, shorter hospital stay, and quicker recovery. The surgical techniques and instruments for laparoscopically directed hysterectomy are still in development. Few randomized, prospective studies that involve large numbers of patients have compared the risks and benefits of this approach with standard hysterectomy. In addition, data on the effectiveness of the operation, as performed by large numbers of gynecologists, are still not clear. Although the potential for real benefit exists, it is hoped that further study will clarify the place of laparoscopic-assisted hysterectomy in the nonsurgical and surgical treatment offered to patients.

Laparoscopic management of the adnexal mass.

Careful preoperative evaluation of women found to have an adnexal mass may select patients for whom operative laparoscopy is appropriate. The role of ultrasonography and serum tumor markers in patient selection is discussed. Operative techniques for the laparoscopic management of the adnexal mass are also presented.

Management of adnexal masses by operative laparoscopy. Selection criteria.

The management of adnexal masses by operative laparoscopy is controversial. The application of strict criteria for preoperative patient selection and careful intraoperative assessment and management are critical to the appropriate use of this approach. Clinical examination, ultrasound imaging of the pelvis and the addition of the CA-125 tumor marker in postmenopausal women can aid in the selection of a population at low risk for malignancy that may be appropriate for operative laparoscopic adnexal surgery. Recommended procedures include careful intraoperative inspection of the pelvis and abdomen, liberal use of frozen sections, and conversion to immediate-staging laparotomy when malignancy is found.

Management of ovarian masses. AAGL 1990 survey.

The American Association of Gynecologic Laparoscopists (AAGL) membership was surveyed on the use of laparoscopy in the management of persistent ovarian masses in 1990. A total of 13,739 laparoscopies were performed for this indication. Ninety-six percent of the respondents performed laparoscopy for this indication on premenopausal women only. Among respondents performing laparoscopy for suspected cancer, there was a 14% conversion rate to laparotomy, compared to 9% among those who performed direct laparotomies when cancer was suspected. An overall incidence of 4 per 1,000 cases of stage I ovarian cancer was found, and about 70% of women with persistent adnexal masses were managed by laparoscopy alone. The risks to women with cancer, as well as the benefits to those without, are discussed.

The case for laparoscopic management of the adnexal mass.

Careful patient selection criteria can be used to identify patients who are appropriate for management of an adnexal masses via operative laparoscopy. Proper intraoperative assessment and liberal use of rapid frozen section are also important for optimal clinical outcome. Reported studies show that laparoscopic management of adnexal masses can be safely done. The short hospital stay and rapid return to normal activity combine to potentially reduce the overall cost of patient care. When cancer is unexpectedly found at the time of laparoscopic surgery for an adnexal mass, the surgeon should be prepared to proceed with staging laparotomy for appropriate treatment.

Management of selected cystic adnexal masses in postmenopausal women by operative laparoscopy: a pilot study.

Twenty-five postmenopausal patients were predicted to have benign masses by screening criteria that included ultrasonographic findings of a cystic adnexal mass less than 10 cm with distinct borders and no evidence of irregular solid parts, thick septa, ascites, or matted bowel, and a normal serum CA 125 value (less than 35 U/ml). All 25 masses were accurately predicted to be benign. The size of the cysts on ultrasonography ranged from 3 to 9 cm with a mean of 5 cm. Twenty-two patients (88%) were successfully managed by operative laparoscopy and adnexectomy. Mean operative time was 70 minutes and mean postoperative hospital stay was 12 hours. Mean time of return to normal activity was 5 days. Three patients required laparotomy. We conclude that removal of these cystic adnexal masses by operative laparoscopy is an acceptable alternative in carefully selected postmenopausal women.

Patient selection for laparoscopic myomectomy.

STUDY OBJECTIVE: To determine if preoperative criteria could select patients who were likely to be managed successfully by laparoscopic myomectomy. DESIGN: Prospective. SETTING: Two community hospitals. PATIENTS: Premenopausal women who had symptomatic uterine myomata and met the following criteria underwent laparoscopic myomectomy: uterine size less than or equal to 14 weeks after 12 weeks of gonadotropin-releasing hormone (GnRH) agonist therapy; no individual myoma larger than 7 cm; no leiomyoma near the uterine artery, or near the tubal cornua if fertility was desired; and at least 50% of the leiomyoma subserosal, to be accessible and to allow adequate repair of the myometrium through the laparoscope. INTERVENTIONS: Laparoscopic assessment of the pelvis and laparoscopic myomectomy. MEASUREMENTS AND MAIN RESULTS: Forty-one patients entered the study: 23 met the selection criteria and were accepted for laparoscopic myomectomy, but 4 were excluded during laparoscopic assessment of the pelvis. Clinical examination or initial sonogram correctly predicted successful laparoscopic myomectomy in 13 of 19 women. After 3 months of GnRH agonist therapy, clinical examination or sonogram identified four additional candidates. In six patients in whom the optimum approach was still uncertain, laparoscopic assessment found two additional appropriate candidates for laparoscopic myomectomy. Nineteen patients underwent the procedure without the need to convert to laparotomy. None experienced any complications. CONCLUSIONS: Careful patient selection can decrease the likelihood of inappropriate performance of laparoscopic myomectomy and avoid the need to convert to laparotomy.

Genecological variation corresponding to Forest Ecosystem Classification vegetation and soil types for jack pine and black spruce from northwestern Ontario.

A preliminary study was undertaken to reveal ecotypic differentiation in jack pine and black spruce corresponding to ecological land classification groups. Seed sources of jack pine (64) and black spruce (68) from northwestern Ontario were classified according to Vegetation Types (V-Types) and Soil Types (S-Types) defined by the Forest Ecosystem Classification (FEC) developed by the Ontario Ministry of Natural Resources and Forestry Canada for northwestern Ontario. Two short-term common garden field trials and a greenhouse trial were established for each species. Significant differences were present among ecological groupings of seed sources for both species. These differences were expressed according to V-Types and S-Types based on first, second, and third year heights as well as needle flushing dates for jack pine and second year growth increments for black spruce. Rank differences among the groups based on FEC V-Types and S-Types were generally consistent for each of the two species although certain groups showed rank reversals at the two field trials. Apparently, selection pressures corresponding to different FEC V-Types and S-Types have resulted in a detectable pattern of adaptive variation for both jack pine and black spruce in northwestern Ontario. However, the management implications for these two species are uncertain since additional tests are required to verify these results.

Laparoscopic-assisted vaginal hysterectomy: American Association of Gynecologic Laparoscopists' 1995 membership survey.

A questionnaire was mailed to all members of the AAGL to determine the current performance of laparoscopic-assisted vaginal hysterectomy (LAVH), and to assess the relative frequencies of techniques and complications. Answers of the 1092 members who responded were entered into a database computer program and analyzed. The analysis revealed 14,911 LAVHs performed by 767 members. Complication rates appeared to be in the same range as those reported for vaginal hysterectomy and total abdominal hysterectomy. Inferior epigastric injury was the most common complication. Physicians showed a shift in their practices away from abdominal hysterectomy after they learned LAVH.

Laparoscopic management of benign cystic teratomas during pregnancy.

OBJECTIVE: Our purpose was to evaluate the surgical management and outcome of laparoscopic removal of benign cystic teratomas during pregnancy. STUDY DESIGN: The records of women with benign cystic teratomas who were managed with operative laparoscopy during pregnancy were reviewed. RESULTS: Twelve women had laparoscopic removal of a benign cystic teratoma during pregnancy. Gestational ages at surgery ranged from 9 to 17 weeks, with a mean of 14 weeks. Cyst size ranged from 5 to 13 cm, with a mean of 8.5 cm. Intraoperative rupture of the cyst occurred in 10 of 12 (93%) women. No patient had evidence of chemical peritonitis. The mean operating time was 87 minutes and the mean postoperative hospital stay was 44 hours. No intraoperative or postoperative maternal or fetal complications occurred. CONCLUSIONS: Laparoscopic removal of a benign cystic teratoma of the ovary may be safely accomplished during pregnancy. In spite of a significant risk of cyst rupture, careful operative technique followed by copious irrigation of the pelvis may avoid chemical peritonitis and potential adverse sequelae.