Staging for low malignant potential ovarian tumors: a global perspective.

OBJECTIVE: We describe current evidence for staging low malignant potential ovarian tumors and their conformity to current consensus guidelines and practice from an international perspective. DATA SOURCES: A search of MEDLINE, EMBASE, and SCOPUS databases was conducted for articles published between January 1990 and April 2015. STUDY ELIGIBILITY CRITERIA: Studies on low malignant potential ovarian tumors that evaluated the prognostic value of disease stage, staging vs no staging, complete vs incomplete staging, or discrete components of staging were eligible. Studies that described only crude survival rates were excluded. STUDY APPRAISAL AND SYNTHESIS METHODS: Eligible studies were categorized according to their outcome (disease stage, staging procedure, or discrete staging elements). Data were abstracted using a standard form. Inconsistencies on data abstraction were resolved by consensus among the authors. Risk of bias was assessed using the Newcastle-Ottawa Scale. RESULTS: Of 1116 studies, 702 were excluded for irrelevance and 364 for not meeting inclusion criteria. Nine studies were excluded for describing crude survival rates without a comparative conclusion. We found that studies supporting the value of defining disease stage or staging procedures (mostly conducted in northern Europe) included more patients than studies that did not find disease stage or staging useful (predominantly from North America, 4072 vs 3951). Disease stage correlated with survival in 13 of 25 studies, whereas none of the studies that evaluated the value of staging found it beneficial (9 studies, 1979 patients). Studies that evaluated isolated components of staging found no benefit to these procedures. Regional guidelines and consensus reviews drew conclusions based on a limited number of studies that generally originated from the same region. CONCLUSIONS: Although the correlation of stage with survival was mixed, performing staging procedures for low malignant potential ovarian tumors is not supported by the best available evidence. Guidelines in support of staging based their recommendations on a few regional studies and conflict with better-quality data that do not support staging procedures. An international consensus statement is needed to standardize the surgical management of low malignant potential ovarian tumors.

Intraoperative Predictors of Long-term Outcomes After Radiofrequency Endometrial Ablation.

STUDY OBJECTIVE: To identify intraoperative predictors of radiofrequency ablation (RFA) failure after adjusting for clinical risk factors. DESIGN: A cohort study (Canadian Task Force II-2). SETTING: An academic institution in the Upper Midwest. PATIENTS: Data were retrospectively collected from medical records of women who underwent RFA and who had a postprocedure gynecologic assessment between April 1998 and December 2011. INTERVENTIONS: RFA. MEASUREMENTS AND MAIN RESULTS: The primary outcome was RFA failure, which was defined as hysterectomy, repeat ablation, synechiolysis, or treatment with gonadotropin-releasing hormone analogue for postablation pain or bleeding. Cox proportional hazards regression was used to test the predictability of intraoperative variables on RFA failure with adjustment for baseline predictors. We created an RFA index to capture the procedure duration divided by the uterine surface area. One thousand one hundred seventy-eight women were eligible. The median age at ablation was 44 years (interquartile range, 40-48 years), and the median parity was 2 (interquartile range, 2-3). Dysmenorrhea and prior tubal ligation were reported in 37.1% and 37.2% of women, respectively. After adjustment for baseline characteristics, intraoperative predictors of failure were uterine sounding length >10.5 cm (adjusted hazard ratio [HR] = 2.58; 95% confidence interval [CI], 1.31-5.05), uterine cavity length >6 cm (adjusted HR = 2.06; 95% CI, 1.30-3.27), uterine width >4.5 cm (adjusted HR = 2.06; 95% CI, 1.29-3.28), surface area >25 cm(2) (adjusted HR = 2.02; 95% CI, 1.26-3.23), procedure time <93 seconds (adjusted HR = 2.61; 95% CI, 1.25-5.47), and RFA index <3.6 (adjusted HR = 3.14; 95% CI, 1.70-5.77). CONCLUSION: Intraoperative parameters are predictive of long-term adverse outcomes of RFA independent of patient clinical characteristics. Uterine length, procedure duration, and RFA index are associated with unfavorable outcomes and thus could be used to optimize postprocedure patient counseling.

Hysteroscopic Morcellation Versus Resection for the Treatment of Uterine Cavitary Lesions: A Systematic Review and Meta-analysis.

This systematic review and meta-analysis compares hysteroscopic morcellation with electrosurgical resection to treat uterine cavitary lesions. A search of Ovid MEDLINE, Ovid Embase, Scopus, and Web of Science was conducted through August 18, 2015, for randomized controlled trials (RCTs) and prospective and retrospective studies, regardless of surgical indication and study language or sample size. Seven studies were eventually included (4 RCTs and 3 retrospective observational studies), enrolling 650 women. The meta-analysis showed that the total procedure time was significantly shorter for morcellation than for resection (weighted mean difference = 9.36 minutes; 95% confidence interval [CI], -15.08 to -3.64). When reviewing RCTs only, intrauterine morcellation was associated with a smaller fluid deficit and lower odds of incomplete lesion removal. This difference was not statistically significant in observational studies. There was no significant difference in the odds of surgical complications (odds ratio = 0.72; 95% CI, 0.20-2.57) or the number of insertions (weighted mean difference = -3.04; 95% CI, -7.86-1.78). In conclusion, compared with hysteroscopic resection, hysteroscopic morcellation is associated with a shorter operative time and possibly lower odds of incomplete lesion removal. The certainty in evidence was limited by heterogeneity and the small sample size.

Fetal cerebro-placental ratio and adverse perinatal outcome: systematic review and meta-analysis of the association and diagnostic performance.

OBJECTIVE: The objective of this meta-analysis is to assess the value of fetal cerebro-placental Doppler ratio (CPR) in predicting adverse perinatal outcome in pregnancies with fetal growth restriction (FGR). METHODS: Three databases were used: MEDLINE, EMBASE (with online Ovid interface) and SCOPUS and studies from inception to April 2015 were included. Studies that reported perinatal outcomes of fetuses at risk of FGR or sonographically diagnosed FGR that were evaluated with CPR were considered eligible. Perinatal outcomes include cesarean section (CS) for fetal distress, APGAR scores at 5 min, neonatal complications and admission to neonatal intensive care unit (NICU). Pooled data were expressed as odds ratio (OR) and confidence intervals (CI), and the summary receiver operating characteristic (SROC) curve was used to illustrate the diagnostic accuracy of CPR. RESULTS: Seven studies were eligible (1428 fetuses). Fetuses with abnormal CPR were at higher risk of CS for fetal distress (OR=4.49, 95% CI [1.63, 12.42]), lower APGAR scores (OR=4.01, 95% CI [2.65, 6.08]), admission to NICU (OR=9.65, 95% CI [3.02, 30.85]), and neonatal complications (OR=11.00, 95% [3.64, 15.37]) than fetuses who had normal CPR. These risks were higher among studies that included fetuses diagnosed with FGR than fetuses at risk of FGR. Abnormal CPR had higher diagnostic accuracy for adverse perinatal outcomes among "sonographically diagnosed FGR" studies than "at risk of FGR" studies. CONCLUSION: Abnormal CPR is associated with substantial risk of adverse perinatal outcomes. The test seems to be particularly useful for follow up of fetuses with sonographically diagnosed FGR.

Robotic radical hysterectomy in early stage cervical cancer: A systematic review and meta-analysis.

OBJECTIVE: To compare intraoperative and short-term postoperative outcomes of robotic radical hysterectomy (RRH) to laparoscopic and open approaches in the treatment of early stage cervical cancer. METHODS: A search of MEDLINE, EMBASE (using Ovid interface) and SCOPUS databases was conducted from database inception through February 15, 2014. We included studies comparing surgical approaches to radical hysterectomy (robotic vs. laparoscopic or abdominal, or both) in women with stages IA1-IIA cervical cancer. Intraoperative outcomes included estimated blood loss (EBL), operative time, number of pelvic lymph nodes harvested and intraoperative complications. Postoperative outcomes were hospital stay and surgical morbidity. The random effects model was used to pool weighted mean differences (WMDs) and odds ratios (OR). RESULTS: Twenty six nonrandomized studies were included (10 RRH vs abdominal radical hysterectomy [ARH], 9 RRH vs laparoscopic radical hysterectomy [LRH] and 7 compared all 3 approaches) enrolling 4013 women (1013 RRH, 710 LRH and 2290 ARH). RRH was associated with less EBL (WMD=384.3, 95% CI=233.7, 534.8) and shorter hospital stay (WMD=3.55, 95% CI=2.10, 5.00) than ARH. RRH was also associated with lower odds of febrile morbidity (OR=0.43, 95% CI=0.20-0.89), blood transfusion (OR=0.12, 95% CI 0.06, 0.25) and wound-related complications (OR=0.31, 95% CI=0.13, 0.73) vs. ARH. RRH was comparable to LRH in all intra- and postoperative outcomes. CONCLUSION: Current evidence suggests that RRH may be superior to ARH with lower EBL, shorter hospital stay, less febrile morbidity and wound-related complications. RRH and LRH appear equivalent in intraoperative and short-term postoperative outcomes and thus the choice of approach can be tailored to the choice of patient and surgeon.

Combined Endometrial Ablation and Levonorgestrel Intrauterine System Use in Women With Dysmenorrhea and Heavy Menstrual Bleeding: Novel Approach for Challenging Cases.

STUDY OBJECTIVE: To evaluate the feasibility and impact of levonorgestrel intrauterine system (LNG-IUS) on treatment failure after endometrial ablation (EA) in women with heavy menstrual bleeding (HMB) and dysmenorrhea at 4 years. DESIGN: Cohort study (Canadian Task Force II-2). SETTING: An academic institution in the upper Midwest. PATIENTS: All women with HMB and dysmenorrhea who underwent EA with combined placement of LNG-IUS (EA/LNG-IUS cohort, 23 women) after 2005 and an historic reference group from women who had EA alone (EA cohort, 65 women) from 1998 through the end of 2005. INTERVENTION: Radiofrequency EA, thermal balloon ablation, and LNG-IUS. MEASUREMENTS AND MAIN RESULTS: The primary outcome was treatment failure defined as persistent pain, bleeding, and hysterectomy after EA at 4 years. The combined treatment failure outcome was documented in 2 patients (8.7%) in the EA/LNG-IUS group and 19 patients (29.2%) in the EA group with an unadjusted OR of .23 (95% CI, .05-1.08). After adjusting for known risk factors of failure, the adjusted OR was .19 (95% CI, .26-.88). None of the women who underwent EA/LNG-IUS had hysterectomy for treatment failure compared with 16 (24%) in the EA group (p = .009); postablation pelvic pain was documented in 1 woman (4.3%) in the EA/LNG-IUS group compared with 8 women (12.3%) in the EA group (p = .24). One woman in the EA/LNG-IUS group (4.3%) presented with persistent bleeding compared with 15 (23.1%) in the EA group (p = .059). Office removal of the intrauterine device was performed in 4 women with no complications. CONCLUSION: LNG-IUS insertion at the time of EA is feasible and can provide added benefit after EA in women with dysmenorrhea and HMB.

The labour scale--assessment of the validity of a novel labour chart: a pilot study.

BACKGROUND: Labour dystocia is the most common indication for caesarean section (CS). This study assessed the validity of the labour scale (WHO partograph modification) as an intrapartum management tool to minimise over-diagnosis of labour dystocia. MATERIALS AND METHODS: The study included 77 women in the early active phase of labour using the scale. This scale covers the same titles as the partograph with the cervico-graph modified using National Institute of Clinical Excellence (NICE) recommendations that adjust interference according to clinical circumstances. Labour progress was plotted on the labour scale then on the partograph to compare outcomes. Maternal and fetal outcomes were compared with international and local reports. RESULTS: Only 21 (27.3%) women crossed the 'membrane line', which promotes amniotomy, and 35 women (45.5%) crossed the 'augmentation line' and received oxytocin. Four women were delivered by CS for failure to progress. When the same data were re-plotted on the partograph, twenty-eight women were diagnosed with failure to progress. The outcome difference between the 'labour scale' and the partograph was significant (P < 0.0001). Maternal and neonatal outcomes were excellent. CONCLUSIONS: We suggest that the 'labour scale' is a promising tool for labour management that minimises labour dystocia without additional maternal or fetal risk.

Abdominal disimpaction with lower uterine segment support as a novel technique to minimize fetal and maternal morbidities during cesarean section for obstructed labor: a case series.

Cesarean section for obstructed labor remains a difficult procedure that may be associated with serious fetal and maternal injuries. In this case series, we evaluated the use of abdominal disimpaction with lower segment support as a novel technique to minimize morbidities. Eight patients who underwent cesarean section for obstructed labor were recruited. Impacted fetal head was delivered using this technique and uterine extensions, bladder injury, vaginal injury, and intraoperative bleeding were reported. Maternal and neonatal outcomes were observed postoperatively. No major morbidities were reported. Accordingly, we consider this technique as a promising step to minimize complications during cesarean section for obstructed labor.

Integrative mid-trimester anomaly (IMTA) chart: a novel sonographic approach for syndromatic challenges (pilot study).

OBJECTIVE: To validate the use of the integrative mid-trimester anomaly (IMTA) chart, a novel chart that aims to increase sonographers' ability to diagnose fetal syndromes and complex anomalies. METHODS: This study was conducted between September 2014 and January 2015. Pregnant women who attended our hospital for fetal medicine consultation during the second trimester were recruited. The diagnosis was assigned by a qualified consultant. The research coordinator randomized women between two groups (each consisted of two sonographers with comparable experience) and each was then examined twice (once with and once without the chart). Supposed diagnosis, patient and sonographer satisfactions were reported. RESULTS: Twenty five women were recruited. Their average age was 26.48 ± 4.49 years and gestational age at examination was 24.39 ± 6.39. There were 17 (68%) fetuses that had multiple anomalies. The duration of examination was comparable. However, patient and sonographer satisfactions were higher when the same women were examined with the chart (p < 0.0001). The accuracy of diagnosis was also significantly higher (p = 0.03). CONCLUSION: The IMTA chart seems to be a useful tool for novice sonographers that could increase their diagnostic accuracy and improve their patient and their own satisfaction.

Impact of Simple Ovarian Cysts on the Interpretation of Endometrial Thickness in Women with Postmenopausal Bleeding.

BACKGROUND: There is evidence that premenopausal hormones may persist for variable time after menopause. Histological specimens from postmenopausal women support the presence of follicular growth at that age. Residual ovarian function may explain postmenopausal bleeding (PMB), which is not associated with endometrial pathology. Our objective was to evaluate the effect of sonographic diagnosis of simple ovarian cysts on the association between thickened endometrium and endometrial pathology in women with PMB. MATERIALS AND METHODS: Data were retrospectively collected from medical records of women who underwent office hysteroscopy for PMB between January 2007 and October 2011. Women with sonographic reports within 3 months of presentation were included. Endometrial thickness and the presence of a simple ovarian cyst (≤5 cm) were documented by reviewing sonographic reports. Diagnosis of endometrial pathology was abstracted according to pathology reports or hysteroscopic impression. Endometria with hyperplasia, cancer, or polyps were considered pathological. RESULTS: Of 836 women with PMB, 356 had recent transvaginal sonography and were included in the analysis. Pathological endometrium was documented in 129 (36.2%) women, including 29 (8.2%) with endometrial cancer. In women with PMB and no evidence of a simple ovarian cyst, endometrial thickness was an independent predictor of endometrial pathology and endometrial cancer with adjusted OR = 1.13 (95% CI = 1.07-1.19) and 1.16 (95% CI = 1.07-1.25), respectively. In the presence of simple ovarian cysts, the adjusted ORs for endometrial thickness as a predictor of endometrial pathology were 1.06 (95% CI = 0.90-1.25) and 0.84 (95% CI = 0.62-1.14), respectively. CONCLUSION: The presence of simple ovarian cysts (≤5 cm) tempers the value of endometrial thickness in predicting endometrial pathology in women with PMB.