Does the New National Cervical Screening Programme Guideline Detect Cases of High-Grade Squamous Intraepithelial Lesions That Previously Would Have Been Missed?

OBJECTIVE: The aim of this study was to determine the number of patients undergoing large loop excision of the transformation zone (LLETZ), for biopsy-confirmed high-grade squamous intraepithelial lesions (HSIL), where the original cervical screening test (CST) reported oncogenic human papillomavirus (HPV) and negative liquid-based cytology (LBC). This reflects the number of patients where a LLETZ procedure would not have occurred under the previous guideline. METHODS: Retrospective observational chart review of all patients (n = 477) who underwent LLETZ procedure in a single tertiary unit over a 36-month period. Prevalence of negative histopathology, positive margins, incidental cervical cancer, and accuracy of HSIL identification at colposcopy were measured. Diagnostic accuracy of HSIL diagnosis from initial colposcopic impression was calculated; factors influencing accuracy were evaluated using multivariable logistic regression analysis. There were no comparators. RESULTS: Of 477 LLETZs, 5.9% (n = 28) were for oncogenic HPV and normal LBC on referral CST. Demographics between the "study" (oncogenic HPV and normal LBC on referral CST) and the "standard" group were similar, except the study group was less likely to be using contraception (25% vs 47%, p = .023). In the study group, initial colposcopic cervical biopsy confirmed HSIL in 91.6% (n = 27) and low-grade squamous intraepithelial lesions in 3.6% (n = 1). Histopathological analysis of LLETZ specimens confirmed HSIL in 20 patients (71.4%) and low-grade squamous intraepithelial lesions in 2 (7.1%). No microinvasion was detected. CONCLUSIONS: The renewed National Cervical Screening Programme (NCSP), is detecting more "at risk" patients, predicted to lead to a further reduction in incidence of cervical cancer in adequately screened patients.

Association between pelvic pain bothersomeness and pain sensitivity: A community-based cross-sectional study of young adult females in the Raine Study.

OBJECTIVE: Pelvic pain has been associated with augmented nociceptive processing, but large studies controlling for multiple potential confounding factors are lacking. This study investigated the association between pelvic pain bothersomeness and pain sensitivity in young adult women, accounting for potential confounding factors. DESIGN: Cross-sectional study. SETTING: Community-dwelling sample. POPULATION: The Raine Study Gen2-22 year follow-up (n = 475). MAIN OUTCOME MEASURES: The experience of bothersomeness related to pelvic pain was determined from a question in the Urogenital Distress Inventory short form. Pain sensitivity was measured using pressure pain and cold pain thresholds. Potential confounding factors included ethnicity, marital status, highest level of education, income, waist-hip ratio, level of activity, sleep quality, smoking, comorbidity history, C-reactive protein level, musculoskeletal pain experience and psychological distress. RESULTS: Three hundred and sixty-two women (76.2%) reported no pelvic pain bothersomeness, 74 (15.6%) reported mild pelvic pain bothersomeness and 39 (8.2%) reported moderate-severe pelvic pain bothersomeness. After adjusting for marital status (and test site), moderate-severe pelvic pain bothersomeness was associated with a lower pressure pain threshold (i.e. greater pressure pain sensitivity) (coefficient -51.46, 95% CI -98.06 to -4.86, p = 0.030). After adjusting for smoking, moderate-severe pelvic pain bothersomeness was also associated with a higher cold pain threshold (i.e. greater cold pain sensitivity) (coefficient 4.35, 95% CI 0.90-7.79, p = 0.014). CONCLUSIONS: This study suggests augmented nociceptive processing as a contributing factor in pelvic pain bothersomeness for some women. Thorough assessment of women who present clinically with pelvic pain should consider pain sensitivity as a potential contributing factor to their presentation.

The effect of obesity on cost of total laparoscopic hysterectomy.

STUDY OBJECTIVE: To test for the association between increasing patient body mass index (BMI) and the cost of total laparoscopic hysterectomy (TLH). Secondary outcomes include the relationship between increasing BMI and both peri- and post-operative morbidity. MATERIALS AND METHODS: Retrospective cohort study of patients (N = 510) who underwent TLH between January 2017 and December 2018 at a single public tertiary teaching hospital. RESULTS: Morbid obesity (n = 63) was associated with significantly higher total admission costs ($19 654 vs $17 475 Australian dollars, P = 0.002), operative costs ($9447 vs $8630, P = 0.017) and total costs including readmissions ($20 476 vs $18 399, P = 0.016) when compared to patients with normal BMI (n = 103) and adjusting for age, indication for surgery, additional procedures and conversion to total abdominal hysterectomy. Costs for overweight (n = 134) and obese (n = 210) BMI groups did not differ from costs for the normal BMI group. Increased operative costs observed in the morbidly obese group, were largely driven by the time associated with set-up, transfer and anaesthetic time while surgical and recovery times were not statistically significant. CONCLUSION: The total cost of TLH is increased in the morbidly obese category of patients. The operative costs appear to be related to pre-operative measures such as theatre set-up and anaesthetic requirements. TLH in the obese and morbidly obese category group is not associated with increased intra-operative or post-operative complications. There may be a role for exploring improvements in managing morbidly obese patients in the pre-operative setting.

The interval transfer of a frozen-thawed embryo is more successful than a fresh embryo transfer for women undergoing IVF with recurrent implantation failure after cleavage stage embryo biopsy.

BACKGROUND: Recurrent implantation failure (RIF) is repeated unsuccessful embryo transfers (ETs). AIMS: To identify predictive embryonic markers of implantation in RIF, following pre-implantation genetic screening (PGS) of cleavage stage embryos, after accounting for male and female factors. MATERIALS AND METHODS: Retrospective analysis of RIF patients undergoing PGS after correction of modifiable causes. RESULTS: Eighty-four patients underwent 140 in vitro ferilisation cycles. Forty-one cycles were excluded: 12 (no embryo for transfer), four (double ETs) and 25 (no biopsy). Sixty-three patients underwent 99 single euploid ETs (48 fresh, 51 frozen) resulting in 11 biochemical pregnancies, 36 clinical pregnancies (CP), and six miscarriages and 30 live births (LB). Frozen ET was more successful than fresh; respective live birth rate (LBR) and clinical pregnancy rate (CPR), 39.2% versus 20.8%, (P = 0.02), 45.1% versus 27.1% (P = 0.04). LBR and CPR were lower when 5-6 blastomeres were present at embryo biopsy, compared to embryos with ≥7 blastomeres: 15.4% versus 32.6% (P = 0.185) and 15.4% versus 39.5% (P = 0.074) respectively. Serum ß human chorionic gonadotropin (ßhCG) concentration was greater when a more developed embryo was biopsied (r = 0.448, P = 0.017 and r = 0.476, P = 0.118, fresh and frozen transfers, respectively). Embryo morphokinetic analysis demonstrated faster development to blastocyst stage when more cells were present at biopsy: mean 103.3, 102.2 and 96.0 h for biopsy at the 5-6, 7-8 or ≥9 cell stage respectively (P = 0.040 for difference between 7-8 cells vs ≥9). CONCLUSIONS: After cleavage stage biopsy, frozen ET was more successful than fresh ET. Chance of conception and serum ßhCG concentration correlated with number of cells present at time of biopsy.

Case report and surgical video presentation: Combined laparoscopic and cystoscopic partial bladder cystectomy for excision of deeply infiltrating endometriosis.

INTRODUCTION: Whilst endometriosis is a relatively common condition, deeply infiltrating endometriosis (DIE) of the bladder is less so, and when medical treatment fails, surgical management is an effective option. We present a case report and surgical video of a patient undergoing combined laparoscopic and cystoscopic excision of deeply infiltrating endometriosis of the bladder. DESIGN: Case report (Canadian Task Force Classification III) and step-by-step explanation of the surgery using video. Exemption was granted from the local institutional review board. PRESENTATION OF CASE: We present a case report and surgical video of a 36-year-old nulliparous patient presenting with a 12-month history of sudden onset cyclical dysuria and haematuria. Imaging demonstrated a deeply infiltrating endometriotic nodule involving the bladder. The patient underwent a combined laparoscopic and cystoscopic excision of deeply infiltrating endometriosis of the bladder. The procedure was uneventful and the patient progressed to a full recovery. DISCUSSION: DIE is a highly invasive form of endometriosis which is defined arbitrarily as endometriosis infiltrating beneath the peritoneum by 5mm or greater. When medical therapy is declined or fails, surgical excision by partial cystectomy would appear to be the most effective management option. A combination of cystoscopy and laparoscopy has been shown to be a safe and feasible procedure, with a low rate of complications. It represents the ideal way by which to identify the resection limits for complete excision of the lesion, and allows for optimal repair of the bladder defect. CONCLUSION: Combined laparoscopic and cystoscopic partial cystectomy for excision of deeply infiltrating bladder endometriosis is a safe and feasible procedure in our institution.

Early intrauterine pregnancy during major surgery: the importance of preoperative assessment and advice.

We present a case of a live birth occurring post radical laparoscopic excision of endometriosis, hysteroscopy, curettage and test of tubal patency in the presence of an early intrauterine gestation.

Do Groin Drains Reduce Postoperative Morbidity in Women Undergoing Inguinofemoral Lymphadenectomy for Vulvar Cancer?

OBJECTIVE: Sentinel lymph node biopsy has been widely adopted in the surgical management of women with early-stage vulvar cancer, but many patients require inguinofemoral lymphadenectomy (IFL). Following IFL, many surgeons drain the groin to prevent lymphocyst formation despite a lack of evidence to support this practice. Our objective was to investigate whether groin drains after IFL are associated with reduced postoperative morbidity in women undergoing surgery for vulvar cancer. METHODS: A retrospective cohort study of women diagnosed as having primary vulvar cancer who underwent vulvectomy/radical local excision and unilateral or bilateral IFL was conducted. Cases were ascertained from the weekly outcome reports of a statewide tertiary gynecologic oncology tumor board. Data including postoperative outcomes were abstracted from medical records. Patients were stratified into 1 of 2 groups according to whether a groin drain had been used. RESULTS: Seventy-one patients were included. Inguinal drains were used in 48 patients (67.6%) and 23 patients (32.4%) did not have their groin wound(s) drained. The most common postoperative complications recorded were wound infection (59.2%), groin lymphocyst (32.4%), and cellulitis (25.4%). The mean length of hospital admission was 11.5 days (2-40 days). Compared with patients in whom inguinal drains were placed, those in the "no drain" group had a significantly lower incidence of postoperative groin cellulitis (8.7% vs 25.4% P = 0.039). No significant differences were observed between patients in the "drain" and "no drain" groups in lymphocyst formation, wound infection, return to the operating room, duration of hospital stay, readmission post-discharge, and lower-limb lymphedema. CONCLUSIONS: In this study of patients undergoing inguinofemoral dissection for primary vulvar cancer, postoperative cellulitis occurred less frequently in patients without an inguinal drain. The incidence of other postoperative complications was no different whether or not a groin drain was used. Prospective studies may be warranted.

Angiomatosis of the uterus, cervix and fallopian tubes: a rare and benign cause of intractable, heavy menstrual bleeding.

Angiomatosis of the uterus, cervix and fallopian tubes is a rare and benign entity that has not been reported in the literature previously. We present a case of a 27-year-old patient with severe and intractable heavy menstrual bleeding unresponsive to all conservative and conventional forms of treatment. Following a laparoscopic hysterectomy, the histopathological finding of angiomatosis, a vascular abnormality in the uterus, cervix and fallopian tubes, provided a plausible explanation in this situation.