Metastatic uterine leiomyosarcoma presenting as a primary sarcoma of the parotid gland.

BACKGROUND: Leiomyosarcoma of the uterus has a high metastatic potential to distant sites due to its tendency for hematogenous spread. CASE: A 49-year-old woman presented with an enlarging parotid mass, diagnosed originally as a primary fibrosarcoma. Six years later, she developed pulmonary metastases and heavy, abnormal uterine bleeding. At hysterectomy, a uterine leiomyosarcoma, identical morphologically to the previous lesions, was identified. All tumors showed similar immunohistochemical staining, suggesting the metastatic nature of the original parotid tumor. CONCLUSION: This rare case of uterine leiomyosarcoma, presenting as a primary parotid sarcoma, underscores the importance of considering the possibility of a uterine primary tumor when a sarcoma arises in an organ in which these tumors are unusual.

Wide-band transabdominal cerclage for a foreshortened, incompetent cervix.

BACKGROUND: The role of cervical cerclage in the prevention of fetal wastage due to cervical incompetence is well established. The transvaginal approach and, failing that, the transabdominal approach, provide sufficient treatment in most cases. However, the traditional techniques require adequate cervical length for placement and maintenance of the suture. CASE: We report a new technique used for a patient with a markedly foreshortened cervix and a history of multiple second-trimester pregnancy losses despite placement of McDonald cerclages. To improve the performance of the cervix, we included the lower portion of the uterus in a 3-cm-wide Prolene mesh cerclage. During the patient's subsequent pregnancy, the mesh band funneled the lower uterine segment, creating a functionally longer cervix. The patient successfully carried the pregnancy to term and was delivered by cesarean. CONCLUSION: This variation on the transabdominal approach is useful in the management of patients with cervical incompetence who demonstrate a foreshortened cervix incapable of maintaining a traditional cervical suture.

Potential for bias in studies of the influence of human immunodeficiency virus infection on the recognition, incidence, clinical course, and microbiology of pelvic inflammatory disease.

As the human immunodeficiency virus (HIV) epidemic affects more women, clinicians are increasingly observing pelvic inflammatory disease (PID) in HIV-infected women. The extent to which PID is a factor in the recognition of HIV or HIV is a factor in the recognition of PID is unknown. Even less is known about how HIV infection influences the development, clinical course, and microbiology of PID. The paucity of existing data largely results from difficulties in designing studies that are free of bias. Several biases may distort studies of the effect of HIV on the recognition, incidence, clinical presentation and course, and microbiology of PID. Selection bias, diagnostic bias, and confounding bias are the most likely causes of invalid conclusions in studies of the influence of HIV infection on these aspects of PID, for three major reasons: Factors that determine patients' health care seeking behavior may be related to HIV status; the diagnosis of PID tends to be imprecise; and extraneous factors that cause or prevent PID may be distributed differently in HIV-infected and HIV-uninfected women. Appropriate study design and analytic techniques can eliminate, reduce, or estimate the magnitude and direction of these biases, thereby yielding more valid conclusions. To interpret properly existing and future studies of the influence of HIV infection on PID, clinicians must consider several biases that may distort results.

The concept of uterine preservation with ovarian malignancies.

A 30-year-old woman with bilateral, recurrent, borderline papillary serous cystadenocarcinoma of the ovary was treated with bilateral oophorocystectomy and omentectomy with uterine preservation. Ten years later, through induction of an artificial endometrial cycle and ovum donation, she conceived twins and delivered two healthy infants. Staging exploratory laparotomy at the time of cesarean delivery was negative for malignancy. This case illustrates the value of uterine preservation for cases in which classical teaching has indicated hysterectomy with bilateral salpingoophorectomy.

Operating room personnel morbidity from carbon dioxide laser use during preceptored surgery.

OBJECTIVE: To determine the extent of laser-induced morbidity away from the operative site during the preceptor phase of laser credentialing in our institution. METHODS: All laser surgeries performed from June 1, 1990 through May 31, 1991 and preceptored by one of the authors (MB) were included in the study. All of the surgeries were performed by a resident or attending physician seeking laser privileges in our institution. During that time, 141 such cases were performed. RESULTS: In 13 of 141 cases (9%), there were injuries unrelated to the surgical procedure itself to either the patient or operating personnel. There were nine accidents associated with laser use during 42 laparotomy procedures (21%) and four accidents at the time of 44 vulvar surgeries (9%). There were no accidents during laparoscopic or colposcopic surgery of the vagina or cervix. CONCLUSIONS: Despite extensive training requirements before use of the CO2 laser, accidents did occur. Operating room safety requirements should be a high priority to minimize morbidity. We report our experience with intraoperative morbidity caused by surgeons' errors and present recommendations to limit further complications.

The effect of placenta previa on blood loss in second-trimester pregnancy termination.

OBJECTIVE: To determine whether placenta previa increases bleeding during second-trimester pregnancy termination. METHODS: The records of 131 consecutive women undergoing elective pregnancy termination at 13-24 weeks' gestation were reviewed and divided into those with and without placenta previa based on an ultrasound examination before the procedure. These two groups were then compared for differences in maternal characteristics, estimated blood loss, operative time, infection, and hospital admission. RESULTS: Twenty-three of 131 women (17.6%) had placenta previa. Sixty-seven percent of the previa patients smoked, versus 37% in the control group, a statistically significant difference. A statistical difference was noted with respect to placenta previa in intraoperative blood loss (P < .05), but not operative time, time to discharge, infection, hemorrhage, or other complications. CONCLUSION: Second-trimester pregnancy terminations in the presence of placenta previa are associated with a higher estimated blood loss, but no apparent increase in abortion-related infection, postoperative transfusion requirements, hysterectomy, or other complications.

Influence of human immunodeficiency virus infection on pelvic inflammatory disease.

OBJECTIVE: To examine the influence of human immunodeficiency virus (HIV) infection on clinical and microbiologic characteristics of pelvic inflammatory disease (PID). METHODS: Forty-four HIV-infected women and 163 HIV noninfected women diagnosed with PID by standard case definition were evaluated by using clinical severity scores, transabdominal sonograms, and endometrial biopsies. After testing for bacterial infections, patients were prescribed antibiotics as recommended by the Centers for Disease Control and Prevention (CDC). RESULTS: Symptoms of PID and analgesic use before enrollment did not differ by HIV serostatus. More HIV-infected women had received antibiotics before enrollment (40.9% versus 27.2%, P =.08), a factor associated with milder signs regardless of serostatus. More HIV-infected women had sonographically diagnosed adnexal masses at enrollment (45.8% versus 27.1%, P =.08), a difference that yielded higher median severity scores (17.5 of 42 points versus 15 of 42 points, P =.07). However, those differences were not significant at the P <.05 level. Mycoplasma (50% versus 22%, P <.05) and streptococcus species (34% versus 17%, P <.05) were isolated more commonly from biopsies of HIV-infected women. Within 30 days after enrollment, HIV-infected women generally responded as well to therapy as HIV-noninfected women did, regardless of initial CD4 T-lymphocyte percentage. CONCLUSION: Among women with acute PID, HIV infection was associated with more sonographically diagnosed adnexal masses. Clinical response to CDC-recommended antibiotics did not differ appreciably by serostatus. Mycoplasmas and streptococci were isolated more commonly from HIV-infected women, but those organisms also might be associated with PID in immunocompetent women.

Cystometric evaluation of vesical endometriosis before and after hormonal or surgical treatment.

Subjective patient complaints as they relate to bladder endometriosis have been well reported. Objective findings have been lacking. The case reported on demonstrates the cystometric finding of a small-capacity irritable bladder in a patient with vesical endometriosis. It further demonstrates the improvement of these findings following surgical resection of endometriosises and hormonal therapy using danazol.

Transvaginal small-bowel evisceration: a case report.

Transvaginal small-bowel evisceration is rare. Only 47 case reports appear in the literature in English. Review of this literature shows that vaginal evisceration occurs mainly in women who are older, multiparous, and have undergone vaginal surgery. The immediate cause of evisceration is either sudden, increased intraabdominal pressure, trauma, or a spontaneous event. The small bowel and omentum are most commonly involved. Surgical repair is performed vaginally, abdominally, or by both methods. We present a case of transvaginal small bowel evisceration caused by inadvertent self-induced trauma, a heretofore unreported cause of this complication, in a 79-year-old woman with known weakness of her pelvic structural support. She experienced sudden evisceration of small bowel following manual decompression of her cystocele during voiding. We used a combined abdominal and vaginal approach to examine the small and large intestines and mesentery for trauma, attach the vaginal vault to the shortened uterosacral ligament, obliterate the cul-de-sac using the Moschowitz procedure, and repair the defect in the levator plate. To limit risk, patients should be evaluated for predisposing conditions. We recommend a combined abdominal and vaginal surgical approach to adequately evaluate the involved tissues and to effect repair.

Morphometric and electron-microscopic analyses of the effects of gonadotropin-releasing hormone agonists on uterine leiomyomas.

OBJECTIVE: Reports on the histologic effects of gonadotropin-releasing hormone agonists on uterine leiomyomas provide conflicting results. Most previous studies used qualitative methods of analysis. Using quantitative and semiquantitative stereologic methods of analysis, we assessed volume density of hyalinized areas, cell density, nuclear volume, and cytoplasmic cross-sectional areas of smooth muscle cells in histologic sections and also measured diameters of collagen fibrils in electron micrographs of uterine leiomyomas. DESIGN: Thirty leiomyomas from patients treated with gonadotropin-releasing hormone agonists (10 different patient samples), age-matched control patients (10 different patient samples), and postmenopausal women (10 different patient samples) were used. Hyalinization was assessed using a microscope with a projection head and affixed morphometric grid. Cell size and density were evaluated using a video-based, computerized system attached to the microscope, for which morphometric ad hoc programs were written. Diameters of collagen fibrils were measured from electron micrographs. SETTING: The study was conducted in the Department of Pathology, Mount Sinai Medical Center, New York, NY. PATIENTS: A total of 30 patient samples were studied, with three groups comprising 10 samples each, including patients treated with gonadotropin-releasing hormone agonists, age-matched control patients, and postmenopausal women. RESULTS: Myomas from patients treated with gonadotropin-releasing hormone agonists exhibited more hyalinization, greater cell density, slightly smaller cell sizes, and larger collagen fibrils than those of age-matched control patients and postmenopausal women. CONCLUSIONS: Shrinkage after treatment with gonadotropin-releasing hormone agonists is attributed to smaller cell size and increased collagenization in myomas.

Seroprevalence of human immunodeficiency virus in women admitted to the hospital with pelvic inflammatory disease.

To assess the association of the human immunodeficiency virus (HIV) with other sexually transmitted diseases we undertook an anonymous HIV antibody serosurvey of all women admitted to the hospital with pelvic inflammatory disease. All the patients were given HIV risk reduction information and offered voluntary antibody testing. Thirty-one consecutive patients were evaluated; 30 specimens were suitable for anonymous testing. Five of the 30 (16.7%) were seropositive on both an enzyme-linked immunosorbent assay and Western blot test. The majority of the patients expressed concern about their HIV risk; 23 (74%) requested confidential testing. Of those tested, five (21.7%) were seropositive; three had traditional risk factors (intravenous drug abuse and/or sexual contacts at risk), and two denied traditional risk factors but reported nonintravenous cocaine use and multiple sexual partners. Of the seronegative women, 33% reported nonintravenous cocaine use (many with multiple sexual partners). Preventing the heterosexual spread of HIV into this vulnerable population is a formidable public health challenge.

Human papillomavirus-associated lesions of the vagina and cervix. Treatment with a laser and topical 5-fluorouracil.

Twenty women with cervical and vaginal human papillomavirus-associated lesions were treated with CO2 laser ablation followed by eight weekly applications of 5-fluorouracil. Viral subtyping in a majority of patients and histology were obtained before and after treatment. After treatment 88% (15 of 17) had normal vaginal biopsies, and 59% (10 of 17) had normal cervical biopsies. There were no treatment failures with subtype 6/11 infection of the cervix or vagina. All the failures were with viral subtypes 16/18 and 31/35/51. The protocol was effective in treating patients with cervical and vaginal human papillomavirus-associated lesions.

Manchester procedure vs. vaginal hysterectomy for uterine prolapse. A comparison.

The Manchester procedure (MP) was compared with vaginal hysterectomy (VH) to determine whether any differences regarding patient demographics or operative or postoperative outcome could be found between the two techniques. A retrospective chart analysis was done comparing data from 88 consecutive MP to 105 randomly selected VH patients. All the operations were performed for uterine prolapse at Mount Sinai Hospital between 1984 and 1988. MP patients, when compared to VH patients, were more likely to be older and postmenopausal at the time of surgery and to have a private physician. MP patients were less likely to have significant medical illnesses than were VH patients. Statistically significant differences between MP and VH were found for operative time (100 vs 130 minutes, respectively) and blood loss (200 vs. 300 mL, respectively) (P < .001). This difference was not dependent on the performance of anterior or posterior repair. MP was associated with shorter operative time and less blood loss when compared to VH. This, coupled with apparently similar operative outcomes, suggests the use of MP as an alternative to VH in the absence of uterine pathology in appropriate candidates with uterine prolapse. Prospective, controlled, long-term studies comparing the operative results of these two procedures are needed.

Perinatal outcome after embryo transfer in ovum recipients. A comparison with standard in vitro fertilization.

OBJECTIVE: To compare perinatal outcome after embryo transfer vs. standard in vitro fertilization (IVF) in ovum recipients. STUDY DESIGN: We reviewed 22 consecutive ovum donor pregnancies delivered at Mount Sinai Hospital between July 1989 and November 1992 and matched them for age, parity and order of gestation to a control group who underwent standard IVF-embryo transfer (ET) during that period. RESULTS: The two groups showed similar rates of maternal complications, including hypertensive disorders, gestational diabetes and puerperal complications. When compared to patients undergoing autologous IVF-ET, ovum recipients had a lower rate of preterm labor (22.7% vs. 54.6%, P < .05), a higher mean gestational age at delivery (38.7 vs. 36.1 weeks, P < .01) and increased mean birth weight of neonates (2,924 vs. 2,374 g, P < .005). Though infants born through traditional IVF-ET were more likely to be preterm, Apgar scores were similar at one and five minutes. Our data support the generally favorable outcome seen in pregnancies conceived through ovum donation despite the fact that many of these patients had prior poor prenatal outcomes, long intervals until conception, and coexisting medical conditions. CONCLUSION: Ovum donation in women of comparable ages has obstetric outcomes equal to or better than patients undergoing traditional IVF-ET. Obstetric and perinatal outcome do not seem to be impaired in patients receiving donated oocytes.

Staging of cervical carcinoma: accuracy of magnetic resonance imaging and computed tomography.

A prospective study was undertaken to assess the ability of magnetic resonance imaging (MRI) to stage cervical carcinoma. Compared to computed tomography (CT), MRI showed a high degree of accuracy in correctly demonstrating involvement of the vagina, parametria and sidewalls, bladder, and lymph nodes but tended to overestimate disease in all of the categories studied. Large-scale studies comparing the two modalities are necessary because the most accurate staging of cervical carcinoma is crucial for selecting the best treatment protocols.

Ascending back pain and headache during attempted epidural placement.

A 30-year-old parturient requested epidural analgesia during labor. Immediately after the epidural space was presumably identified using the loss-of-resistance-to-air technique, she reported severe back pain, followed by neck pain, which progressed to severe unrelenting headache. An emergency computerized tomographic (CT) scan performed during labor showed air in the intracranial subarachnoid space.

Peribronchial electrical admittance measures lung edema and congestion in the dog.

A new method has been developed to detect interstitial pulmonary edema. This method utilizes the unique arrangement of air and interstitial fluid within the lung. A 1.3-mm-diam twin catheter electrode was wedged in a peripheral airway of the lung. The electrical impedance measured at 35 kHz between these catheter-tip electrodes was 1,540 +/- 240 omega (mean +/- SD; n = 10) in the anesthetized closed-chest dog. Intravenous infusion of 1-3 liters 0.154 M NaCl increased extravascular water per gram of dry lung from a control value of 3.54 +/- 0.27 to 4.1-5.14. Peribronchial electrical impedance decreased in proportion to the amount of saline infused reaching a minimum of 550 omega. No signs of alveolar flooding were present during the experiments. Linear regression performed on peribronchial electrical admittance (PEA) as a function of extravascular water per gram of dry lung (ELW) resulted in the following relationship: PEA = 0.72 ELW - 1.81; r = 0.95. It is concluded that this method is a sensitive quantitative measure of lung interstitial fluid and can detect pulmonary edema and congestion in the dog lung before alveolar flooding occurs.

Laparoscopic Pomeroy tubal ligation in a residency training program.

STUDY OBJECTIVE: To evaluate the efficacy of the laparoscopic Pomeroy method of tubal ligation as a teaching tool during the initial acquisition of advanced laparoscopic skills by 14 residents in a 28-person, 4-year program. DESIGN: A prospective, nonrandomized study. SETTING: A metropolitan teaching hospital. PATIENTS: Fifty-seven women who desired permanent sterilization, and 56 controls who underwent laparoscopic sterilization by standard coagulation. One refused entry and had standard sterilization by bipolar coagulation. In two women, both with several previous laparotomies, visualization of the pelvic organs was incomplete and the procedure was abandoned at the discretion of the surgeon. One had a minilaparotomy Pomeroy tubal ligation and the other was sterilized by standard two-puncture laparoscopic coagulation. One patient was excluded due to an incomplete data profile. INTERVENTIONS: Laparoscopic sterilizations using the Pomeroy technique and standard coagulation were performed by gynecology residents with an attending physician present. First-year residents performed 36 (68%) of the 53 procedures. MEASUREMENTS AND MAIN RESULTS: Operative times to teach this technique to house officers rotating on the gynecologic service were recorded by postgraduate year and stratified by the number of cases performed by each operator. The average operative times for residents in postgraduate years 1 through 4 were 18.6, 15.4, 21.7, and 14.8 minutes, respectively. These diminished with experience. A statistically longer time of 7.1 minutes was required to teach residents the Pomeroy technique compared with standard bipolar coagulation (p<0.0003). CONCLUSION: Laparoscopic Pomeroy tubal ligation as a method to begin educating residents in advanced operative video-laparoscopy appears to have great potential.