Soft cup vacuum extraction: a comparison of outlet delivery.

One hundred eighteen nulliparous patients delivered under conduction anesthesia who met the standard criteria for low forceps delivery were randomly assigned to one of three groups to be delivered by low Tucker-McLane forceps, Silastic vacuum extraction system, or Mityvac vacuum extractor. Significant maternal soft tissue trauma was identified in 48.9% of the forceps group, 36.1% of the Silastic group, and 21.6% of the Mityvac group. Superficial fetal scalp changes were found in 71% of the forceps group, 44% of the Silastic group, and 46% of the Mityvac group. Of these, cephalhematomatas were noted in 2.2% of the forceps group, 13.9% of the Silastic group, and 16.2% of the Mityvac group. All three instruments were considered effective outlet delivery instruments.

Ovarian cancer in women with prior hysterectomy: a 14-year experience at the University of Miami.

Between 1977-1990, 755 women were evaluated and treated for ovarian cancer at the University of Miami/Jackson Memorial Medical Center. Ninety-five of them (12.6%) had previously undergone hysterectomy with preservation of one or both ovaries. Sixty women (7.9%) had undergone hysterectomies after the age of 40. Review of the literature reveals a 4.5-14.1% incidence of prior hysterectomy in women developing ovarian cancer. Prophylactic oophorectomy in women undergoing hysterectomy at age 40 or older would have prevented 138 of 2632 cases (5.2%) of ovarian cancer in a combined literature series. Applied nationally, such an approach could be expected to prevent over 1000 cases of ovarian cancer annually. We recommend routine prophylactic oophorectomy in all women undergoing hysterectomy after the age of 40. This strategy would have prevented 60 cases of ovarian cancer treated at the University of Miami during the past 14 years.

Treatment of small intestinal fistulas with octreotide, a somatostatin analog.

Three patients with external small bowel fistulas were successfully treated with bowel rest, total parenteral nutrition, and the somatostatin analog, octreotide. Two of the patients had received prior multimodality therapy, including radiation, for gynecologic cancer. The time intervals to fistula closure were 2 days, 10 days, and 5 weeks after initiation of octreotide therapy. The efficacy of octreotide combined with total parenteral nutrition in the treatment of external enteric fistulas supports its routine use, especially in previously irradiated patients.

The prognostic significance of surgical staging for carcinoma of the endometrium.

This study is based on a retrospective review of 156 patients with endometrial carcinoma from 1978 through 1984 who underwent primary surgical evaluation. All cases were retrospectively restaged using the newly adopted FIGO surgical staging. The preoperative FIGO clinical stage distribution for this study was as follows: 121 (77.6%) Stage I, 22 (14.1%) Stage II, 5 (3.2%) Stage III, 2 (1.3%) Stage IV, and 6 (3.8%) unstaged patients. Most patients had TAH-BSO with a collection of peritoneal washings and retroperitoneal lymph node sampling. Surgical staging revealed 122 (78.2%) Stage I, 9 (5.8%) Stage II, 12 (7.7%) Stage III, and 13 (8.3%) Stage IV patients. Surgery upstaged 12.4% of clinical Stage I. In clinical stage II, 59.0% were downstaged while 27.3% were upstaged. For clinical Stage III, 60.6% were upstaged, but no downstaging occurred. No change in stage occurred for clinical Stage IV patients. Ninety-seven surgically staged patients received no adjuvant therapy. The remaining 59 patients had adjunctive treatment which consisted of radiotherapy (59.3%), hormonal therapy (25.4%), chemotherapy (5.1%), or combined modality treatment (10.2%). All patients were followed until death or a minimum of 5 years (60-139 months; median, 82 months) with the exception of 13 patients who were lost to follow-up (2-58 months; median, 34 months). Five-year survival by clinical staging was as follows: 86.2% for Stage I, 85.9% for Stage II, and 0% for Stage III and IV. Five-year survival by surgical staging was 90.6% for Stage I, 85.7% for Stage II, 58.3% for Stage III, and 0% for Stage IV. The 13 patients who were lost to follow-up were censored in all survival analyses at the time of last contact. Stepwise regression analysis using a parametric proportional hazards model identified surgical stage as the most significant prognostic factor (P = 0.02). Univariate analysis showed that patients with surgical Stage IC had significantly worse prognosis (75.0%, 5 years) than those in surgical Stage IA (93.8% 5 YS) or IB (95.4% 5 years). In summary, this study demonstrates that surgical staging as recommended by FIGO is indicated to accurately determine the initial extent of disease in endometrial carcinoma. In addition, surgical staging is the strongest predictor of survival. Deep myometrial invasion appears to be a significant independent prognostic factor within surgical Stage I. The role of adjunctive radiotherapy in Stage I disease awaits the results from an ongoing multi-institutional, prospectively randomized trial.