Syringe or mask? Loop electrosurgical excision procedure under local or general anesthesia: a randomized trial.

BACKGROUND: Loop electrosurgical excision procedure may be performed under local anesthesia or general anesthesia, and practice patterns differ worldwide. No randomized head-to-head comparison has been published to confirm or refute either practice. OBJECTIVE: This study aimed to compare loop electrosurgical excision procedure under local anesthesia vs general anesthesia regarding patient satisfaction and procedure-related outcomes such as rates of involved margins, complications, pain, and blood loss. STUDY DESIGN: Consecutive women referred to our colposcopy unit were recruited. Loop electrosurgical excision procedure was performed under local anesthesia with 4 intracervical injections of bupivacaine hydrochloride 0.5% or under general anesthesia with fentanyl, propofol, and a laryngeal mask with sevoflurane maintenance. The primary endpoint was patient satisfaction assessed on the day of surgery and 14 days thereafter using a Likert scale (score 0-100) and a questionnaire. Secondary endpoints included rates of involved margins, procedure-related complications, pain, blood loss, and surgeon preference. Results were compared using nonparametric and chi-square tests. RESULTS: Between July 2018 and February 2020, we randomized 208 women, 108 in the local anesthesia arm and 100 in the general anesthesia arm. In the intention-to-treat analysis, patient satisfaction did not differ between the study groups directly after surgery (Likert scale 100 [90-100] vs 100 [90-100]; P=.077) and 14 days thereafter (Likert scale 100 [80-100] vs 100 [90-100]; P=.079). In the per-protocol analysis, women in the local anesthesia arm had significantly smaller cone volumes (1.11 cm3 [0.70-1.83] vs 1.58 cm3 [1.08-2.69], respectively; P<.001), less intraoperative blood loss (Δhemoglobin, 0.2 g/dL [-0.1 to 0.4] vs 0.5 g/dL [0.2-0.9]; P<.001), and higher satisfaction after 14 days (100 [90-100] vs 100 [80-100]; P=.026), whereas surgeon preference favored general anesthesia (90 [79-100] vs 100 [90-100], respectively; P=.001). All other secondary outcomes did not differ between groups (resection margin status R1, 6.6% vs 2.1% [P=.26]; cone fragmentation, 12.1% vs 6.3% [P=.27]; procedure duration, 151.5 seconds [120-219.5] vs 180 seconds [117-241.5] [P=.34]; time to complete hemostasis, 60 seconds [34-97] vs 70 seconds [48.25-122.25] [P=.08]; complication rate, 3.3% vs 1.1% [P=.59]). In a multivariate analysis, parity (P=.03), type of transformation zone (P=.03), and cone volume (P=.02) and not study group assignment, age, body mass index, and degree of dysplasia independently influenced the primary endpoint. CONCLUSION: Loop electrosurgical excision procedure under local anesthesia is equally well tolerated and offers patient-reported and procedure-related benefits over general anesthesia, supporting the preferred practice in some institutions and refuting the preferred practice in others.

Acute colonic pseudoobstruction (Ogilvie's syndrome) in gynecologic and obstetric patients: case report and systematic review of the literature.

BACKGROUND: Acute colonic pseudo-obstruction or Ogilvie's syndrome (OS) is a rare form of postsurgical or posttraumatic complication. OS rarely occurs in the postoperative course of gynecologic and obstetric patients and is difficult to diagnose. CASE PRESENTATION: We present the case of an 83-years-old patient with carcinosarcoma of the uterus who developed OS with non-obstructive dilation of the right hemicolon and intraabdominal compression after total abdominal hysterectomy, omentectomy, and lymphadenectomy. Laparotomy with colonic decompression and abdominal dressing was performed. Subsequently, the patient developed pneumonia and peritonitis and died due to septic shock. SYSTEMATIC LITERATURE REVIEW: We identified 49 case reports and 10 case series describing 17 gynecologic (cervical cancer, n = 2; carcinosarcoma of the uterus, n = 1; benign gynecologic condition, n = 14) and 76 obstetric patients (cesarean section, n = 66; OS during pregnancy or after vaginal delivery, n = 10). Outcome data were available for 59 patients. First-line treatment was conservative in 22/59 (37%) cases, laparotomy with decompression or colon resection was performed in 20/59 (34%) cases, endoscopic decompression in 12/59 (20%) cases, and i.v. neostigmine in 4/59 (7%) cases. Resolution was achieved in 22/59 (37%) of patients. The most common second-line treatment was right hemicolectomy. Adverse events grade 3 and 4 were observed in 8/59 and 31/59 patients (together 66%), respectively, mortality was 3/59 (5%). CONCLUSION: OS is a rare postoperative complication of gynecologic and obstetric patients with a good prognosis, but a high morbidity. Pregnancy seems to be a predisposing factor for OS. Conservative treatment is a successful first-line approach.

Chronic ectopic pregnancy: case report and systematic review of the literature.

BACKGROUND: Chronic ectopic pregnancy (CEP) is a variant of ectopic pregnancy (EP) characterized by low or absent serum human chorionic gonadotropin (hCG) levels, resistance to methotrexate (MTX), and an adnexal mass with fibrosis, necrosis, and blood clots due to repeated and gradual fallopian tube wall disintegration. CEP may complicate the course of patients with EP and is difficult to diagnose. CASE PRESENTATION: The case of a 36-year-old woman with EP, low serum hCG levels, a small echogenic adnexal mass, and resistance to MTX is presented. Salpingectomy was performed and histology demonstrated CEP with fibrosis, necrosis, and a hematocele within degenerated chorionic villi. SYSTEMATIC LITERATURE REVIEW: In a database search, 19 case reports, 3 case-control studies, and 3 case series describing 399 patients with CEP were identified. Serum hCG was negative in 40/124 cases (32%) with reported levels of serum hCG. The most common presenting symptom was abdominal pain (284/399 [71%]), followed by irregular vaginal bleeding (219/399 [55%]), and fever (20/399 [5%]). 73/399 (18%) women were asymptomatic. An adnexal mass was seen in 144/298 (48%) cases with perioperative ultrasound examination and with a mean largest diameter of 6.8 cm. Data on treatment modalities and outcomes were available for 297 women. Of these, 89% underwent surgery as first-line therapy. Laparoscopy was performed in most cases. MTX was the first-line therapy in a minority of cases. Complete resolution was achieved by first-line therapy in 287/297 (97%) cases. Adverse events were reported in 218 patients with CEP. Among those, adverse events ≥ grade 3 were seen in 186/218 (85%) cases. There was no case of treatment-related mortality. CONCLUSION: CEP is a variant of EP with low or absent trophoblast activity. A prolonged clinical course is typical and surgery is the mainstay of treatment.

Radiogenic angiosarcoma of the breast: case report and systematic review of the literature.

BACKGROUND: Radiogenic angiosarcoma of the breast (RASB) is a rare late sequela of local irradiation of the breast or chest wall after breast cancer. The prognosis of women with RASB is poor and there is no standardized therapy for this type of malignancy. CASE PRESENTATION: We present the case of a 54 year old woman with RASB (poorly differentiated angiosarcoma of the left breast; pT1, pNX, M0, L0, V0) and a history of invasive-ductal cancer of the left breast (pT1b, G2, pN0, ER positive, PR positive, HER-2/neu negative) treated in July 2012 with breast-conserving surgery, adjuvant chemotherapy with 6 cycles of epirubicin and cyclophosphamide, adjuvant irradiation of the left breast with 50 Gray, and adjuvant endocrine therapy with an aromatase inhibitor. In August 2016, a bilateral salpingo-oophorectomy was performed to remove a tumor of the left ovary, which was diagnosed as breast cancer recurrence. At the same time, a small, purple skin lesion of 1.2 cm in diameter was noted in the inner upper quadrant of the right breast. RASB was diagnosed by punch biopsy and the tumor was excised with clear margins. Imaging studies showed no evidence of further metastases. A systemic chemotherapy with 6 cycles of liposomal doxorubicin was initiated. Five months later, a local recurrence of RASB was diagnosed and mastectomy was performed. Six months later, the patient is alive with no evidence of disease. Three hundred seven cases of RASB were identified. The pooled incidence rate of RASB was 1/3754 women. The most common treatment of RASB was mastectomy in 83% of cases. Adjuvant radiotherapy or chemotherapy were rarely used with 6 and 4%, respectively, whereas in case of recurrence, chemotherapy was the mainstay of treatment, used in 58% of cases. Radiotherapy and repeated surgery were also common with 30 and 33% of cases, respectively. Overall, the prognosis of women with RASB was poor and the recurrence-free survival was short with a mean of 15.9 months. Mean overall survival was 27.4 months. CONCLUSION: RASB is a rare late complication of breast irradiation. The prognosis of women with RASB is poor. Surgery is the mainstay of treatment for localized disease while systemic chemotherapy and re-irradiation are appropriate for women with disseminated or recurrent RASB.

Neuroendocrine carcinoma of the cervix: a systematic review of the literature.

BACKGROUND: Neuroendocrine carcinoma of the cervix (NECC) is a rare variant of cervical cancer. The prognosis of women with NECC is poor and there is no standardized therapy for this type of malignancy based on controlled trials. METHODS: We performed a systematic literature search of the databases PubMed and Cochrane Central Register of Controlled Trials to identify clinical trials describing the management and outcome of women with NECC. RESULTS: Three thousand five hundred thirty-eight cases of NECC in 112 studies were identified. The pooled proportion of NECC among women with cervical cancer was 2303/163470 (1.41%). Small cell NECC, large cell NECC, and other histological subtypes were identified in 80.4, 12.0, and 7.6% of cases, respectively. Early and late stage disease presentation were evenly distributed with 1463 (50.6%) and 1428 (49.4%) cases, respectively. Tumors expressed synaptophysin (424/538 cases; 79%), neuron-specific enolase (196/285 cases; 69%), chromogranin (323/486 cases; 66%), and CD56 (162/267; 61%). The most common primary treatment was radical surgery combined with chemotherapy either as neoadjuvant or adjuvant chemotherapy, described in 42/48 studies. Radiotherapy-based primary treatment schemes in the form of radiotherapy, radiochemotherapy, or radiotherapy with concomitant or followed by chemotherapy were also commonly used (15/48 studies). There is no standard chemotherapy regimen for NECC, but cisplatin/carboplatin and etoposide (EP) was the most commonly used treatment scheme (24/40 studies). Overall, the prognosis of women with NECC was poor with a mean recurrence-free survival of 16 months and a mean overall survival of 40 months. Immune checkpoint inhibitors and targeted agents were reported as being active in three case reports. CONCLUSION: NECC is a rare variant of cervical cancer with a poor prognosis. Multimodality treatment with radical surgery and neoadjuvant/adjuvant chemotherapy with cisplatin and etoposide with or without radiotherapy is the mainstay of treatment for early stage disease while chemotherapy with cisplatin and etoposide or topotecan, paclitaxel, and bevacizumab is appropriate for women with locally advanced or recurrent NECC. Immune checkpoint inhibitors may be beneficial, but controlled evidence for their efficacy is lacking.

A phase I, single-arm, open-label, dose escalation study of intraperitoneal cisplatin and doxorubicin in patients with recurrent ovarian cancer and peritoneal carcinomatosis.

OBJECTIVE: We performed a phase I, single-arm, non-randomized, open-label, dose-escalation trial to determine the dose-limiting toxicity of intraperitoneal cisplatin and doxorubicin applied as pressurized intraperitoneal aerosol chemotherapy (PIPAC) in women with recurrent ovarian cancer. METHODS: We used a standard 3 + 3 dose-escalation design with doxorubicin 1.5 mg/m2, cisplatin 7.5 mg/m2 q 4 to 6 weeks for 3 cycles and subsequent dose escalation steps (20% increment per step) in patients with recurrent ovarian cancer and peritoneal carcinomatosis. Toxicity and clinical efficacy were monitored. The primary endpoint was the maximum-tolerable dose. Secondary endpoints included histologic tumor regression and serum parameters. RESULTS: 15 evaluable patients (3, 7, and 5 in cohorts 1, 2, and 3, respectively) on average received 2.3 PIPAC cycles. No dose limiting toxicities were found. Adverse side effects were 1 grade 3 event (colon perforation) and 85 grade 1/2 events including fatigue (n = 19), abdominal pain (n = 18), nausea/vomiting (n = 14), sleep disorder (n = 8), diarrhea (n = 5), and fever (n = 2). Liver and renal toxicity was not observed in any of the 3 cohorts (AST 19.1 ±â€¯3.2, 25.8 ±â€¯6.5, and 22.1 ±â€¯4.5 IU/L, respectively; ALT 14.7 ±â€¯3.5, 18.5 ±â€¯5.6, and 23.3 ±â€¯13.0 IU/L, respectively; GGT 45.7 ±â€¯35.1, 25.2 ±â€¯10.3, and 43.9 ±â€¯26.4 IU/L, respectively; serum creatinine 1.06 ±â€¯0.23, 0.80 ±â€¯0.17, and 0.89 ±â€¯0.35 mg/dL, respectively). No systemic hematologic toxicity, alopecia, or neurotoxicity was noted. The maximum tolerable dose was not reached. Histologic tumor regression was observed in 7/11 (64%) patients who underwent ≥2 PIPAC cycles. CONCLUSIONS: PIPAC with cisplatin and doxorubicin may be safely used at an intraperitoneal dose of 10.5 mg/m2 and 2.1 mg/m2, respectively. Systemic toxicity of this therapy is low.

Loop electrosurgical excision procedure with or without intraoperative colposcopy: a randomized trial.

BACKGROUND: Loop electrosurgical excision procedure is the standard surgical treatment for cervical dysplasia. Loop electrosurgical excision procedure is advised to be performed under colposcopic guidance to minimize adverse pregnancy outcomes. To date, there is no evidence from randomized trials for this recommendation. OBJECTIVE: We sought to assess the benefits of performing loop electrosurgical excision procedure under colposcopic guidance in women with cervical dysplasia. STUDY DESIGN: In a prospective, randomized trial, we compared loop electrosurgical excision procedure with loop electrosurgical excision procedure performed under direct colposcopic vision in a 1:1 ratio. The primary endpoint was resected cone mass; the secondary endpoints were margin status, fragmentation of the surgical specimen, procedure time, time to complete hemostasis, blood loss, and intraoperative and postoperative complications. A sample size of 87 per group (n = 174) was planned (with an assumed type I error of 0.05 and drop-out rate of 5%) to achieve 90% power to detect a 25% reduction in cone mass (with an assumed cone mass of 2.5 ± 1.6 g in the control group) using a nonparametric test (Mann-Whitney U). RESULTS: From October 2016 through December 2017, we randomized 182 women: 93 in the loop electrosurgical excision procedure group and 89 in the loop electrosurgical excision procedure-direct colposcopic vision group. Women undergoing loop electrosurgical excision procedure-direct colposcopic vision had significantly smaller cone specimens than those undergoing loop electrosurgical excision procedure (weight: median 1.86 [interquartile range 1.20-2.72] vs median 2.37 [interquartile range 1.63-3.31] g, respectively, P = .006). Secondary outcome measures did not differ significantly between groups: resection margin status involved vs free margin: 12 (13%) vs 75 (82%) and 11 (12.4%) vs 75 (84.3%); fragmentation no vs yes: 85 (92.4%) vs 7 (7.6%) and 84 (94.4%) vs 5 (5.6%); procedure time: 190 (interquartile range 138-294) and 171 (interquartile range 133-290) seconds; time to complete hemostasis: 61 (interquartile range 31-108) and 51 (interquartile range 30-81) seconds; intraoperative blood loss (Δhemoglobin): 0.4 (interquartile range 0.2-1.0) and 0.5 (interquartile range 0.1-0.9); complication rate: 6 (6.5%) and 2 (2.2%). In a multivariate analysis, study group allocation (P = .021) and parity (P = .028), but not age, body mass index, type of transformation zone, and dysplasia degree independently influenced the amount of resected cone mass. CONCLUSION: Loop electrosurgical excision procedure with intraoperative colposcopy leads to significantly smaller cone specimens without compromising margin status.

Pressurized intraperitoneal aerosol chemotherapy (PIPAC) for peritoneal carcinomatosis: systematic review of clinical and experimental evidence with special emphasis on ovarian cancer.

BACKGROUND: Systemic chemotherapy is not effective in patients with peritoneal carcinomatosis (PC) and only a minority of affected patients is eligible for cytoreductive surgery. Intraperitoneal chemotherapy may provide a therapy alternative for these patients. METHODS: We performed a systematic review of clinical and experimental evidence on the safety and efficacy of pressurized intraperitoneal aerosol chemotherapy (PIPAC) in patients with PC and provide clinical recommendations based on the available evidence. RESULTS: Fifty-eight reports were identified, categorized as experimental (18 reports), clinical (28 reports), and other articles (14 reports). Experimental studies demonstrated improved tissue penetration and peritoneal coverage. The 28 clinical studies reported on 3515 procedures in 1547 patients with PC of various primary tumors with 16 of these studies reporting on patients with ovarian cancer. Toxicity was manageable. Based on 1197 patients in 22 studies, adverse events CTCAE grades 1, 2, 3, 4, and 5 were observed in 537 (45%), 167 (14%), 83 (7%), 10 (0.8%), and 19 (1.6%) cases, respectively. In a pooled analysis, the objective tumor response rate was 69% and the mean overall survival duration was 13.7 months. No significant hepatic, renal, or hematologic toxicity was described. PIPAC maintained and/or improved quality of life, as reported in 10 studies with 396 patients. CONCLUSIONS: Available evidence from controlled trials (phase I and phase II) and retrospective cohort studies in > 1500 patients unequivocally demonstrates that PIPAC is feasible, safe, and effective. PIPAC maintains quality of life in patients with recurrent cancer and PC. PIPAC is as evidence-based as any other treatment in women with ovarian cancer and PC beyond the third line of systemic chemotherapy and can be recommended in this indication.

Identification of preterm birth in women with threatened preterm labour between 34 and 37 weeks of gestation.

The aim of this study was to assess whether serum markers would be useful as a new predictor of preterm birth in patients with spontaneous, late preterm labour. Patients diagnosed with late preterm labour were divided into preterm delivery (229 patients) and term delivery (178 patients) groups. The two groups were compared in terms of clinical characteristics and levels of serum markers (leukocyte subtypes, platelet, C-reactive protein [CRP], neutrophil to lymphocyte ratio [NLR] and platelet to lymphocyte ratio [PLR]), which were obtained at admission. The levels of leukocyte (p < .001), neutrophil (p < .001), CRP (p = .001), NLR (p < .001) and PLR (p = .003) were significantly higher, whereas lymphocytes (p = .012) were significantly lower in the preterm delivery group, compared to the term delivery group. On multivariate regression analysis, NLR positive was the most powerful predictive variable (OR = 1.41; 95%CI: 1.32-1.51; p = .005). NLR had the highest area under curve (0.711; 95%CI 0.662-0.760) in predicting preterm birth and a NLR >6.2 had the highest sensitivity (65.1%) and specificity (62.5%). High NLR at admission is an independent predictor of preterm birth in patients with spontaneous, late preterm labour. Impact statement What is already known on this subject: Preterm birth accounts for 5-12% of all births, and is a major factor associated with perinatal morbidity and mortality worldwide. However, more than 70% of preterm births occur at late preterm between 340/7 and 366/7 weeks of gestation. The central role of systemic and subclinical infections in preterm labour is well documented. Intrauterine infection leading to delivery can be measured by using a variety of laboratory parameters. What do the results of this study add: Neutrophil to lymphocyte ratio is an inexpensive, easily interpretable and promising haematologic parameter that is widely available. This study explored the association of high neutrophil to lymphocyte ratio with the risk of preterm birth in women with preterm labour between 34 and 37 weeks of gestation. What are the implications of these findings for clinical practice and/or further research: Neutrophil to lymphocyte ratio could be used in combination with existing markers to improve detection rates of preterm birth. Concomitant use of markers could be more powerful than measuring any of the individual markers alone.

Paget's Disease of the Vulva Treated with Imiquimod: Case Report and Systematic Review of the Literature.

BACKGROUND: Extramammary Paget's disease of the vulva (EPDV) is a rare adenocarcinoma in situ of the vulvar skin and is often resected with involved margins due to its reticular growth pattern. Adjuvant treatment with the immunomodulator imiquimod may be suitable to avoid repeated and mutilating surgery. CASE PRESENTATION: We present the case of a 73-year-old woman with EPDV, initially treated with surgical resection and re-resection for involved margins. Final histology revealed Paget's disease of the left vulva with 8 cm in the largest diameter and again involved margins. Subsequently, topical therapy with imiquimod 5% cream twice weekly was applied for 3 months. Vulvoscopy and local biopsies confirmed complete remission (CR). Based on a literature search using PubMed and the Cochrane Central Register of Controlled Trials, 21 reports on the therapeutic efficacy of imiquimod in 70 women with EPDV have been published. Pooled rates of CR and partial remission were 71% (50/70) and 16% (11/70), respectively. There were 4 cases of disease progression under imiquimod and the therapy was generally well tolerated with mild to moderate local reactions in >50% of cases. CONCLUSION: EPDV is a rare genital neoplasia and may be successfully treated with the topical immunomodulator imiquimod. Specifically, adjuvant imiquimod is a feasible and efficacious treatment option for women with involved resection margins after surgery.

Extra-abdominal removal of placenta during cesarean section: a prospective randomized controlled trial of a novel technique.

AIM: To evaluate intraoperative and early postoperative outcomes of a novel placenta delivery technique; extra-abdominal removal vs. intra-abdominal removal of the placenta during cesarean section (CS). METHODS: A total of 210 women delivering by CS at term in a tertiary university hospital between March 2014 and January 2015 were randomized to extra-abdominal removal vs. intra-abdominal removal of the placenta. The women were randomly allocated to the extra- (group 1) or intra-abdominal removal group (group 2) according to random sampling method, where women with even and odd numbers were allocated to intra- and extra-abdominal groups, respectively. The amount of intra-abdominal hemorrhagic fluid accumulation, the duration of operation and estimated blood loss during operation were the primary outcomes. The secondary outcomes included the mean difference between pre- and post-operative hemoglobin and hematocrit levels, the mean postoperative pain score, any additional need of analgesia, postoperative bowel function, postoperative endometritis and wound infections. RESULTS: The amount of aspirated hemorrhagic fluid was significantly higher in the intra-abdominal group compared to the extra-abdominal group (34.6±22.2 mL vs. 9.4±4.8 mL, P<0.001). Mean duration of the operation, intraoperative blood loss, postoperative requirement of additional analgesia, postoperative pain scores, postoperative endometritis or wound infection, and length of hospital stay were not significantly different between the intra- and extra-abdominal placental removal groups. CONCLUSION: By extra-abdominal removal of the placenta, the accumulation of bloody fluid in the abdominal cavity is significantly less compared to the intra-abdominal removal method, which, in turn, provides avoidance of excessive mounted-gauze use, intra-abdominal manipulations, or iatrogenic trauma.

Effect of antenatal betamethasone administration on Doppler velocimetry of fetal and uteroplacental vessels: a prospective study.

OBJECTIVES: To examine the effect of antenatal betamethasone administration on Doppler parameters of fetal and uteroplacental circulation. METHODS: Seventy-six singleton pregnancies that received betamethasone therapy were prospectively evaluated. Doppler measurements of pulsatility indices (PI) in fetal umbilical artery (UA), middle cerebral artery (MCA), ductus venosus and maternal uterine arteries were performed before (0 h) and 24, 48, 72 and 96 h after the first dose of betamethasone. Women with positive end-diastolic flow (EDF) in UA and those with absent or reversed EDF in UA were evaluated separately. RESULTS: Fifty-two women with EDF in UA and 24 women with absent or reversed flow in UA were examined. Administration of maternal betamethasone was followed by a significant decrease in the PI of the MCA at 24 h (P<0.05). Additionally, return of absent to positive, reversed to absent or from reversed to positive diastolic flow in UA was detected within 24 h in 19 (79.2%) fetuses with absent or reversed UA-EDF. All alterations were transient and maintained up to 72 h. CONCLUSIONS: Antenatal administration of betamethasone is associated with significant but transient changes in the fetal blood flow. Hence, intensive surveillance of fetuses with Doppler ultrasonography is warranted following betamethasone therapy.

Which uterine sparing technique should be used for uterine atony during cesarean section? The Bakri balloon or the B-Lynch suture?

PURPOSE: To evaluate various aspects of two popular uterine sparing techniques, the B-Lynch uterine compression suture and Bakri balloon tamponade, in severe postpartum hemorrhage (PPH). METHODS: 21 women who underwent the Bakri balloon procedure and 24 women who underwent the B-Lynch suture as primary uterus-sparing methods, due to PPH not responding to medical treatment, were retrospectively evaluated. RESULTS: The success rates of the B-Lynch procedure and the Bakri balloon were 79.1 and 80 %, respectively. The success rates of the B-Lynch + IIAL and the Bakri balloon + IIAL were 91.6 and 95 %, respectively. There was no significant difference in success rates, mean duration of time to stop bleeding, estimated blood loss, transfused packed red blood cells or mean duration of hospital stay between the B-Lynch and the Bakri balloon groups. The duration of operation was significantly longer in the Bakri balloon compared to the B-Lynch group (p = 0.01). CONCLUSION: In our study, the Bakri balloon and the B-Lynch suture had similar success rates in uterine atony during CS. The advantages of the B-Lynch suture include rapid application with no need for lithotomy position or extra material; whereas the Bakri balloon is less invasive and easier to learn, but more time consuming and expensive compared to the B-Lynch suture. We suggest that the B-Lynch suture may be preferred in uterine atony during CS in low resource settings; however, the less invasive Bakri balloon should be the first line in full resource settings. Further studies are needed to evaluate the advantages and disadvantages of the two methods.

A novel preoperative scoring system for predicting endometrial cancer in patients with complex atypical endometrial hyperplasia and accuracy of frozen section pathological examination in this context: a multicenter study.

OBJECTIVE: To estimate the accuracy of frozen pathological analysis in patients preoperatively diagnosed with endometrial atypical complex hyperplasia (ACH) and to develop a model predicting the probability of the presence of endometrial carcinoma in ACH. METHODS: Patients (n = 128) who underwent total hysterectomies because of diagnoses of ACH were evaluated at four tertiary centers. RESULTS: Diagnoses made using frozen sections and permanent sections were in good agreement (ĸ = 0.61, p < 0.0001). A useful scoring system combining weighted risk factors derived from a regression model is as follows: (2 × age ≥50 years) + (3 × BMI ≥30) + (2 × menopausal status) + (2 × diabetes comorbidity) + (3 × endometrial thickness >12 mm). The AUC of this score was 0.793, and the score afforded 80.9% sensitivity, 70.3% specificity, a 75.3% positive predictive value, and a 76.4% negative predictive value, when a score of 5 was used as a cutoff. CONCLUSIONS: Patients with ACH should be evaluated by gynecological oncologists and intraoperative frozen section analysis should be performed by pathologists specializing in the evaluation of gynecological malignancies, because ACH is closely associated with endometrial cancer (EC). Our novel preoperative scoring system may aid in the detection of patients at increased risk of EC and thus guide general gynecologists.

Predictors of severity in primary postpartum hemorrhage.

PURPOSE: To identify risk factors and etiologies leading to severe primary postpartum hemorrhage (PPH) in women with PPH. METHODS: Women who experienced PPH within the first 24 h after delivery over a 3-year period were retrospectively evaluated. Patients were divided into two groups on the basis of severe PPH (n = 125) or non-severe PPH (n = 411). Risk factors and etiologies for severe PPH were explored using univariate and multivariate logistic regression analyses. RESULTS: PPH and severe PPH complicated 2.1 and 0.49 % of all deliveries, respectively. Previous cesarean delivery (OR = 3.15, 95 % CI = 1.02-10.3; p = 0.001), prolonged labor (OR = 3.62, 95 % CI = 3.21-4.03; p < 0.001), oxytocin augmentation (OR = 3.32, 95 % CI 2.05-5.93; p < 0.001) and emergency cesarean delivery (OR = 4.75, 95 % CI 1.32-12.96; p < 0.001) were the factors independently associated with severe PPH. Etiologies significantly associated with severe PPH are uterine atony (OR = 2.72, 95 % CI 1.64-4.55; p < 0.001) and abnormal placentation (OR = 3.05, 95 % CI 1.56-6.27; p = 0.006). CONCLUSION: Previous cesarean delivery, prolonged labor, oxytocin augmentation and emergency cesarean delivery are strongest predictors of severe blood loss in women with PPH. In addition, uterine atony and abnormal placentation are the etiologies significantly associated with severe PPH.

B-Lynch uterine compression sutures in the conservative surgical management of uterine atony.

AIM: To evaluate the success rate and possible complications of the B-Lynch uterine compression sutures in women who suffered from postpartum uterine atony unresponsive to medical treatment. MATERIALS AND METHODS: A total of 36 women who were managed with the B-Lynch suture, with or without additional surgical procedures following uterine atony unresponsive to medical treatment, were evaluated retrospectively. RESULTS: Sixteen women were primarily managed with the B-Lynch compression sutures, and 11 women had the B-Lynch compression sutures following failure of achievement of hemostasis by ligation of uterine artery alone (n = 4), or uterine artery plus uterine branch of ovarian artery (n = 7). Eight women had bilateral internal iliac artery ligation (BIIAL) following failure of achievement of hemostasis by the B-Lynch compression sutures. Two women (5.5%) underwent post-cesarean hysterectomy. The overall success rate of B-Lynch was 75% (27/36), and the overall success rate of B-Lynch plus BIIAL was 94.4% (34/36). Three women were admitted to the intensive care unit. There was no death related to the hemorrhage in our series. No short-term complications such as uterine necrosis, hematometra, pyometra, or uterine erosion related to the uterine compression suture were observed. CONCLUSION: Overall success rate of the B-Lynch sutures and B-Lynch sutures plus BIIAL was 75 and 94.4%, respectively. The B-Lynch technique does not necessarily require specific suture material. Uterine devascularization or BIIAL did not increase the risk of the possible short-term complications such as uterine necrosis. In case of failure of the B-Lynch uterine compression sutures, BIIAL may be beneficial to save the uterus.

Lymphovascular space invasion and cervical stromal invasion are independent risk factors for nodal metastasis in endometrioid endometrial cancer.

AIMS: The purpose of this study was to investigate the potential roles of pathological variables in the prediction of nodal metastasis in women with endometrioid endometrial cancer (EC). MATERIALS AND METHODS: Women who underwent surgery for endometrioid EC between 1995 and 2012 were retrospectively reviewed. Those who underwent prior neoadjuvant chemotherapy or radiotherapy and inadequate lymphadenectomy as well as those with nonendometrioid histology, synchronous cancers, International Federation of Gynecology and Obstetrics stage IV disease, gross uterine serosal and/or gross adnexal involvement were excluded. Lymph node dissemination was defined as occurring in the following circumstances: (i) when nodal metastasis with pelvic and/or para-aortic (P/PA) lymph node dissection (LND) was performed or (ii) when there was recurrence in the P/PA lymph nodes after a negative LND or when LND was not performed. Univariate and multivariate logistic regression models were used to identify the pathological predictors of lymphatic dissemination. RESULTS: A total of 827 women with endometrioid EC were assessed; 516 (62.4%) of whom underwent P/PA LND and 205 (24.8%) underwent P LND. Sixty-seven (13%) women in the P/PA LND group and 5 (2.4%) in the P LND group had positive lymph nodes. Multivariate analysis confirmed cervical stromal invasion (OR 4.04, 95% CI 2.02-8.07 (P < 0.001)) and lymphovascular space invasion (LVSI) (OR 110.18, 95% CI 38.43-315.87 (P < 0.001)) as independent predictors of lymphatic dissemination. CONCLUSION: Cervical stromal invasion and LVSI are highly associated with LN metastasis. These markers may serve as a surrogate for nodal metastasis.

Does neoadjuvant chemotherapy plus cytoreductive surgery improve survival rates in patients with advanced epithelial ovarian cancer compared with cytoreductive surgery alone?

PURPOSE: The purpose of this study was to compare the outcomes of interval debulking surgery after neoadjuvant chemotherapy (NAC/IDS) with primary debulking surgery (PDS) in patients diagnosed with advanced epithelial ovarian cancer (EOC). METHODS: A total of 292 patients with IIIC and IV disease stages, who were treated with either NAC/IDS or PDS between 1995 and 2012 were retrospectively reviewed. The study population was divided into two groups: the NAC/IDS group (N=84) and the PDS group (N=208). Progression-free survival (PFS), overall survival (OS), and optimal cytoreduction were compared. RESULTS: The mean patient age was significantly higher in the NAC/IDS group (61.5±11.5 vs 57.8±11.1, p=0.01). Optimal cytoreduction was achieved in 34.5% (29/84) of the patients in the NAC/IDS group and in 32.2% (69/208) in the PDS group (p=0.825). The survival rates were comparable. The survival rate of patients who received optimal cytoreductive surgery in either the PDS or the NAC/IDS arm was significantly higher than that of patients who received suboptimal cytoreductive surgery (p<0.01 and p<0.01, respectively). Multivariate analysis confirmed the treatment method, amount of ascitic fluid, and optimal cytoreduction as independent factors for OS. CONCLUSIONS: There was no definitive evidence regarding whether NAC/IDS increases survival rates compared with PDS. NAC should be reserved for patients who cannot tolerate PDS or when optimal cytoreduction is not feasible.

Does neoadjuvant chemotherapy plus cytoreductive surgery improve survival rates in patients with advanced epithelial ovarian cancer compared with cytoreductive surgery alone?

PURPOSE: To compare the outcomes of interval debulking surgery (IDS) after neoadjuvant chemotherapy (NAC/IDS) with primary debulking surgery (PDS) in patients diagnosed with advanced epithelial ovarian cancer (EOC). METHODS: A total of 292 patients with stages IIIC and IV disease who were treated with either NAC/IDS or PDS between 1995 and 2012 were retrospectively reviewed. The study population was divided into two groups: the NAC/IDS group (N=84) and the PDS group (N=208). Progression-free survival (PFS), overall survival (OS), and optimal cytoreduction were compared. RESULTS: The mean age was significantly higher in the NAC/IDS group (61.5±11.5 vs 57.8±11.1 years, p=0.01). Optimal cytoreduction was achieved in 34.5% (29/84) of the patients in the NAC/IDS group and in 32.2% (69/208) in the PDS group (p=0.825). The survival rates were comparable. The mean survival rate of patients who achieved optimal cytoreductive surgery in either the PDS or the NAC/IDS arm was significantly higher than that of patients who achieved suboptimal cytoreductive surgery (p<0.001 and p<0.001, respectively). Multivariate analysis confirmed the treatment method, amount of ascitic fluid, and optimal cytoreduction as independent factors for OS. CONCLUSIONS: No definitive evidence was noticed regarding whether NAC/IDS increases survival compared with PDS. NAC should be reserved for patients who cannot tolerate PDS or when optimal cytoreduction is not feasible.

Pelvic tuberculosis, echinococcosis, and actinomycosis: great imitators of ovarian cancer.

AIMS: To evaluate the demographic, laboratory, clinical and imaging findings, surgical procedures and complications in women with final pathology results of pelvic tuberculosis (PT), pelvic echinococcosis (PE) or pelvic actinomycosis (PA) following exploratory surgery for suspicion of ovarian cancer. METHODS: Among 492 operations from January 2005 through January 2013, we retrospectively reviewed women with PT (n = 15), PE (n = 6), or PA (n = 5) mimicking ovarian cancer seen in an education and research hospital clinic. RESULTS: The mean ages of the women with PT, PE and PA were 34.2 ± 9.4, 39.1 ± 11 and 46.3 ± 3.6 years, respectively. The serum CA-125 was elevated in 14 (93%), four (67%) and four (80%) women, respectively. The average CA-125 levels were 242.8 ± 240, 104.3 ± 76.4 and 52.3 ± 18.6 IU/mL, respectively. The most common symptom was lower abdominal pain in 12 (87%), four (67%) and four (80%) women, respectively. The most common ultrasonography and computed tomography/magnetic resonance imaging finding was a pelvic mass in 11 (73%), six (100%) and five (100%) women, respectively. The most common surgical procedure was extensive adhesiolysis in 10 (67%), three (50%) and five (100%) women, respectively. CONCLUSIONS: Pelvic tuberculosis, echinococcosis and actinomycosis must be included in the differential diagnosis of women suspected to have ovarian cancer with or without ascites and elevated CA-125 levels, especially in those living in endemic countries. During surgical exploration, frozen section analysis is important to avoid unnecessarily prolonged surgical procedures and retroperitoneal lymphadenectomy, which increases morbidity in women with these curable pelvic infectious conditions.