Abdominal or vaginal hysterectomy for enlarged uteri: a randomized clinical trial.

OBJECTIVE: The purpose of this study was to compare advantages, disadvantages, and outcomes in patients who undergo vaginal or abdominal hysterectomy for enlarged symptomatic uteri. STUDY DESIGN: In a prospective, randomized study, 60 vaginal hysterectomies (study group) were compared with 59 abdominal hysterectomies (control group); all of the hysterectomies were performed for symptomatic uterine fibroids from January 1997 through December 2000. We excluded from the study the other common causes of hysterectomy such as prolapse, bleeding, adenomyosis, and endometrial or cervical carcinoma. In both groups, uterine weights ranged from 200 g to 1300 g. For enlarged uteri, vaginal hysterectomies were performed with the use of volume reduction techniques: Intramyometrial coring, corporal bisection, and morcellation. The evaluated parameters included patient age, weight, parity, uterine weight, operative time, blood loss, demand for analgesics, eventual surgical complications, length of admission, and hospital charges. The Mann-Whitney U test and chi(2) tests were applied for statistical analysis. Probability values of <.05 were considered statistically significant. RESULTS: There were no major differences in patient age, weight, parity, and uterine weight between the two groups. Operative time was significantly lower for the vaginal route as compared with the abdominal route (86 minutes vs 102 minutes, P <.001). No intraoperative complications were noted both in the study and control groups or the control group. Surgical bleeding (expressed by hemoglobin loss) was not significantly different between the two groups. In the postoperative period, we found a higher incidence of fever (30.5% vs 16.6%, P <.05) and demand for analgesics (86% vs 66%, P <.05) in the abdominal group as compared with the vaginal group. Significant advantages of vaginal hysterectomy were a reduction in the hospital stay (3 days vs 4 days, P <.001) and cost. CONCLUSION: These results should lead to the choice of vaginal hysterectomy as a valid alternative to the abdominal hysterectomy, even for enlarged uteri.

Ultrasound assessment of biometric trends in a case of thanatophoric dysplasia.

We present a case of thanatophoric dysplasia diagnosed at the 21st week of gestation. Serial ultrasound was performed throughout pregnancy. The scans showed a distinctive pattern of development of the fetal long bones. Up to week 25, the fetal long bones appeared to grow steadily but slower compared to normal measurements (4-5 SD below the mean); then, between weeks 26 and 30, long bone growth was further and more severely hampered, until it almost stopped altogether approaching term, with measurements 9-12 SD below the mean at week 38.

[Sonographic characterization, Doppler ultrasonography and tumor markers in the diagnosis of malignancy of ovarian masses]. / Ecostructtura, eco Doppler e markers tumorali nella diagnosi di malignità delle masse ovariche.

BACKGROUND: The study analyses the diagnostic possibilities regarding ovarian neoplasms offered by different clinical approaches: B-mode morphological ultrasonographic examination, colour Doppler and Doppler pulsed ultrasonography, and lastly the assay of a number of tumour markers. METHODS: A prospective study was carried out in 125 selected patients attending the Ultrasonography unit of the Obstetrics and Gynecology Clinic at Parma University between June 1997 and June 1999 who presented an adnexal mass . All patients underwent transvaginal ultrasonography (multifrequency vaginal probe 5.0-6.5 MHz, Esaote Idea, Genova) to characterise the mass, applying 5 different ultrasonographic scores: Granberg, Sassone, Di Priest, Lerner, Ferrazzi. Colour Doppler imaging was then performed to analyse the vascularisation of the mass, also using pulsed Doppler to study a number of velocimetric parameters: pulsatility index, index of resistance, systolic and diastolic peak velocity, mean velocity. All the patients underwent surgery using laparotomy or video laparoscopy, accompanied by histological analysis. A number of different tumour markers were assayed prior to surgery: Cal25, CA19-9, CEA, beta-HCG, alpha-fetoprotein. RESULTS: Out of 127 pelvic masses examined, histological analysis showed that 19 were malignant and 108 benign. The diagnostic accuracy of malignancy was comparable for the 5 scores studied, with a minimum of 57.48% for Lerner and a maximum of 77.16% for Di Priest. The central importance of vascularisation was the only significant parameter among those analysed using colour Doppler which was useful for the diagnosis of a malignant neoplasm, with a diagnostic accuracy of 82.95%. No indicator obtained using pulsed Doppler was useful for diagnostic purposes. CA125 was the only tumour marker that revealed a statistically significant difference emerged between the benign (21.6 U/ml) and malignant (220.8 U/ml) masses. Its diagnostic accuracy was 75.58%. CONCLUSIONS: This study confirmed that the three methods analysed do not differentiate substantially in their overall diagnostic capacity of malignant ovarian neoplasms. The best performances for ecographic scores (Di Priest) did not exceed a sensitivity of 89.47% with a 21.25% incidence of false positives; this was comparable to CA125 with a sensitivity of 85.71% and false positives in 22.09%. In relation to the central importance of vascularisation, colour Doppler achieved a lower sensitivity (55.55%), but this was confirmed by a low incidence of false positives (7.95%). This revealed its importance as a useful method, especially for excluding the presence of malignant tumours.

Chemically assisted dissection of tissues: an interesting support in abdominal myomectomy.

BACKGROUND: The aim of this study was to verify the efficacy of sodium-2-mercaptoethanesulfonate (mesna) in the chemical separation of tissues in abdominal myomectomies when used with the traditional mechanical separation techniques. STUDY DESIGN: In a prospective, randomized study, 58 women underwent abdominal myomectomy. In 29 of these, we used mesna for highlighting and separating tissues, and in the other 29 we used saline solution for the same purposes. The variables evaluated included the number of myomas removed, the volume of the biggest myoma, and the total volume of the myomas removed in every intervention. We also recorded operating time, the length of hospital stay, the degree of procedure difficulty, perioperative blood loss, operative complications, and cost. RESULTS: The operation was significantly shorter in the mesna group (p < 0.05) even though the volume and the number of myomas were larger. The degree of difficulty evaluated by the surgeon at the end of every operation was not significantly different in the two groups. The reduction in hemoglobin 24 hours after operation was significantly less in the patients treated with mesna (p = 0.006), but this difference was probably altered by the increase in hematocrit levels. CONCLUSIONS: Because of its ability as a chemical dissector, mesna may be a useful aid in this type of benign gynecologic operation. Larger studies to confirm this are needed.

Intravesicular prostaglandin E2 for the prophylaxis of urinary retention after colpohysterectomy.

The aim of this study was to assess the efficacy of PGE2 in enhancing bladder function after vaginal hysterectomy. A total of 110 women with or without urinary incontinence underwent vaginal hysterectomy and cystourethropexy surgery because of grade II or III genital prolapse. Preoperatively the patients were randomly assigned to two groups: group 1 (n = 50) received on the fourth post-operative day, before removal of the bladder catheter, an intravesicular solution of 1.50 mg PGE2 (2 x 0.75 mg); group 2 (n = 60) did not receive any prophylaxis for urinary retention. In the PGE2-treated group significantly fewer patients had urinary retention for 3 days or more (10%, P < 0.05) than in the control group (27%). The use of intravesicular PGE2 reduced the time taken to restore detrusor function.

First-trimester chromosome diagnosis by lavage of the uterine cavity.

Fetal karyotyping of trophoblast cells obtained by lavage of the uterine cavity was evaluated on 86 first-trimester irrigation fluid samples. Villus fragments were observed in 72 fluid samples indicating an 83.7 per cent sampling success rate. The amount of villi in these samples ranged from 1 to 32 mg. In most cases, villus fragments showed degeneration of the external syncytiotrophoblast layer and absence of blood vessels. In the first phase of this study (15 samples), a high degree of maternal cell contamination was observed after long-term cultures. In the following phase (71 samples), this obstacle was overcome by the application of a semi-direct method. Chromosome preparations were set up after 24 h incubation of villus fragments and QFQ-banded metaphase spreads were scored for chromosome number and sex. Sixty samples showed the presence of villus fragments and the fetal karyotype was established in 40. Male and female chromosome complements were observed in 16 and 24 cases, respectively. In four cases, an abnormal fetal karyotype was diagnosed. These included trisomy of chromosomes 13, 15, and 16, and one mosaic with trisomy 12. Our results indicate that first-trimester fetal karyotyping might be feasible by a semi-direct method using chorionic villus fragments obtained at intrauterine lavage.

[Term pregnancy: the review and development of fetal surveillance protocols]. / La gravidanza a termine: revisione ed evoluzione dei protocolli di sorveglianza fetale.

The authors have analyzed the reasons behind the changes in clinical and biophysical monitoring of term and post-term pregnancies. In particular, there is an assessment of the results of NST monitoring over a one-year period. Furthermore, the importance of the introduction of new methods of labour induction by means of intracervical PGE2 is also discussed and there is a reference to the results. It is clinically evident that these methods have contributed to modify the problem of term-pregnancy management. Finally, there is a presentation of the new version of up-to-date procedures based on more clinical experience and more recent statistics on the subject.

In vitro effects of histamine on human pregnant myometrium contractility.

The effects of histamine on pregnant human myometrium was examined by means of an in vitro technique. Samples of myometrium were taken from women delivered by elective caesarean section at various stages of gestation. Histamine (1 x 10(-6) to 1 x 10(-4) M) had good stimulant activity on all the strips examined. This contractile action was unaffected by H2 blockers but was competitively antagonised by H1-blockers. The H2-selective agonist, impromidine, was ineffective at molar concentrations between 1 x 10(-8) and 1 x 10(-3) while a specific full agonist of the H1 receptors, thiazole in the range of molar concentrations from 1 x 10(-6) to 3 x 10(-4), had an activity identical to that of histamine. The data obtained suggest that in the pregnant human myometrium the activation of H1-receptors is responsible for the contractile effect of histamine; a possible involvement of histamine in the pathophysiology of labour is discussed.

Relationship between epidermal growth factor receptor and other prognostic factors in gynecological cancers.

In 62 cases of gynecological malignancies, 16 of the ovarian, 31 of the endometrium and 15 of the cervix, the EGF-R status was evaluated in order to establish its prognostic value and its correlation with other classical prognostic factors. We have failed to demonstrate any correlation between EGF-R status and stage, grade and hormonal receptors, ER/PgR, in ovarian and cervical cancer. In contrast, in endometrial cancer, we observed significantly lower levels of EGF-R in poorly differentiated tumors. Moreover, a weak negative relationship between EGF-R and PgR status was found. Regarding survival, we noticed a better prognosis in patients with ovarian cancer EGF-R positive, but without statistical significance.

[Resectoscopic endometrial ablation in the treatment of recurrent, dysfunctional menometrorrhagia: our experience]. / L'ablazione di endometrio tramite resettoscopio nel trattamento delle menometrorragie recidivanti disfunzionali: nostra esperienza.

UNLABELLED: Advances in hysteroscopic surgery provide additional options to hysterectomy for the treatment of dysfunctional uterine bleeding resistant to medical therapy and multiple curettages. Two techniques are now available: (a) Resectoscopic endometrial ablation. (b) Electrocoagulation or laser photovaporisation of endometrium. 52 patients underwent resectoscopic endometrial ablation at the Gynaecology Department of Parma University from January 1991 to April 1993. All patients suffered from dysfunctional uterine bleeding without atypical histologic findings on endometrial biopsies and had a normal shaped uterine cavity. 41 patients were subsequently contacted for follow-up. Follow-up period ranged from a minimum of 3 months to a maximum of 24 months. 78.1% of the patients reported a satisfactory outcome (amenorrhea or decreased menstrual flow). No operative complication occurred. Post operative complications included one case of hematometra. CONCLUSIONS: resectoscopic endometrial ablation is an advantageous technique but our follow-up period is relatively short and long term sequelae have yet to be determined.

[Ultrasonic diagnosis of fetal ovarian cysts]. / Diagnosi ultrasonica di cisti ovarica fetale.

A clinical case of fetal ovarian cyst diagnosed at the 22nd week of pregnancy and disappearing at the 34th week is reported. The echographic and clinical criteria underlying diagnosis and obstetrical conduct in cases of fetal abdominal tumescence of probable ovarian origin are discussed.

[Gynecological celioscopy: indications and findings]. / Celioscopia ginecologica: indicazioni e reperti.

The Authors have critically reviewed 1000 consecutive laparoscopies, performed in the Department of Obstetrics and Gynecology, University of Parma. The most common diseases of the genital tract are represented into the population of the patients studied. Conclusions are the safety and the usefulness of the described technique, particularly in discrimination of pelvic pain, pelvic masses and sterility. Concerning the latest field, the importance of ovarian biopsy in distinguishing hypergonadotropic anovulations is confirmed.

Effect of anesthesia and surgical stress on prolactin levels in pregnancy.

The authors examine the variations of PRL plasma levels after the administration of sodium thiopentale 500 mg i.v. to ten patients undergoing voluntary pregnancy interruption between the 8th and the 14th gestational week; PRL levels which were already elevated due to estrogen action, as is physiological in pregnancy, further increased after the anaesthetic drug injection confirming the ability of sodium thiopentale to increase prolactin levels even in estrogen-induced hyperprolactinemic conditions; the possible ways through which the drug may act are then discussed.

Endometriosis of the colon and rectum: an indication for peroperative coloscopy.

Endometriosis in women is a frequent disease and not uncommon is the implant of ectopic endometrium in the colon and rectum. In the present study three cases are reported without intestinal symptoms related to endometriosis, in which the intraoperative findings of thickened and stricturing areas of the colon and rectum--generally attached to the posterior portion of the uterus and presenting the aspects of a cancer--caused serious differential diagnostic problems, and made the choice of treatment difficult. These problems were solved by peroperative coloscopy that, revealing an extrinsic compression of the colonic and rectal wall in the presence of an intact mucosa, indicated the conservative treatment of the lesions in all three cases.

[The preparation and characterization of steroid antisera (author's transl)]. / Preparazione e caratterizzazione di antisieri anti-steroide

The steroids, as compounds of low molecular weight, are not immunogenic; however, certain small molecules (haptens) when covalently linked to proteins become antigenic i.e., they provoke the production of unique antibody. If a steroid were covalently copuled to a protein, an artifical antigen would be produced capable of eliciting the formation of antibody with specificity not only for the protein carrier but also for the particular haptenic steroid. The results would be an in vivo production of a tailor made binding sites for any steroid that can be attached as a hapten to a protein by covalent bonds and thus become antigenic. This procedure allow the preparation of steroid specific antisera suitable for clinical use in radioimmunoassay, methods. The Authors report the techniques of preparation of steroid-derivative antigens of Androstenedion, Testosteron, and Progesteron. The three derivative steroid antigens have shown a good antigenic property by eliciting the formation of specifical antisera in 5 out of 6 rabbits used for the immunization. After 10 weeks from the beginning of immunization antisera useful in radioimmunoassay at the diluition 1/300; 1/1600; 1/2000 respectively for Progesteron, Testosteron and Androstenedion were obtained. The standard curves show a good sensitivity suitable for clinical use.