Comparison of the impact of single-port laparoscopic and conventional laparoscopic ovarian cystectomy on the ovarian reserve in adult patients with benign ovarian cysts.

Objective: The surgical approach, hemostatic approach, histologic findings, and cyst size and location may have a role in reducing the ovarian reserve. The aim of this study was to investigate the impact of single-port laparoscopic cystectomy (SLC) and conventional laparoscopic cystectomy (CLC) on the ovarian reserve based on serum anti-Mullerian hormone (AMH) concentrations.Material and methods: This non-randomized concurrent control trial enrolled 79 female patients aged 18-45 years with benign ovarian cysts, including 47 patients in the SLC group and 32 patients in the CLC group. Outcome measures, including hospital stay, operative time, blood loss, analgesic use, body temperature, hospitalization cost, and serum AMH concentration, were evaluated preoperatively, two to three days postoperatively, and four to six weeks postoperatively.Results: The reduction in the AMH concentration after cystectomy was significantly different preoperatively, two to three days postoperatively (p < .001), and four weeks postoperatively (p < .001) regardless of the surgical approach (SLC or CLC) [F (1.00,31.00) = 0.026, p = .873]. Moreover, the hemostatic approach and histologic findings yielded significant differences in the serum AMH concentration regardless of the surgical approach (p < .05). The serum AMH concentration was higher in unilateral cysts (2.70 ± 1.80 ng/mL) than in bilateral cysts (1.73 ± 1.11 ng/mL) postoperatively (p < .05). In the SLC group, the serum AMH concentration in the patients with ovarian endometriomas (1.58 ± 1.39 ng/mL) was significantly lower than that in the patients with other cysts (3.22 ± 1.68 ng/mL) postoperatively (p < .05).Conclusion: The serum AMH concentration decreased over time postoperatively but did not significantly differ between SLC and CLC.

Construct Validity of a Simple Laparoscopic Ovarian Cystectomy Model Using a Validated Objective Structured Assessment of Technical Skills.

STUDY OBJECTIVE: To determine the construct validity and interrater reliability of a laparoscopic ovarian cystectomy simulator using a global rating scale. DESIGN: Prospective blinded observational study (Canadian Task Force classification II.3). SETTING: Academic teaching hospital. PARTICIPANTS: A total of 26 postgraduate year (PGY) 1 to 4 gynecology and obstetrics residents were recruited (15 junior residents, postgraduate year PGY 1-2 and 11 senior residents, PGY 3-4). INTERVENTION: We developed a simple, low-cost laparoscopic ovarian cystectomy simulator and incorporated it into our simulation curriculum. The simulation was directed at junior residents with instruction and immediate feedback in a scheduled simulation session once during the academic year. At the end of the year resident skills assessment, all levels were recorded with video using this model to assess the construct validity between junior and senior residents. Resident performance was later evaluated and scored by 2 blinded, experienced laparoscopists using a validated Objective Structured Assessment of Technical Skills (OSATS). MEASUREMENT AND MAIN RESULTS: Each resident received a unique identification number and the simulated laparoscopic ovarian cystectomy procedure was filmed during the end of the year assessment. Two blinded raters evaluated the video of each resident with the modified Global Rating Scale (OSATS), using 5 of the 7 domains (respect for tissue, time and motion, instrument handling, flow of operation and knowledge of specific procedure). An average of the 2 ratings was computed for each domain, and comparisons were made using the Mann-Whitney U test. Interrater reliability was calculated using the Kendall tau ß correlation coefficient. Construct validity was determined by comparing the rank scores of the junior to senior residents in each domain. Construct validity and interrater reliability was demonstrated in all of the measured domains except for respect for tissue. CONCLUSION: This simple, low-cost model can be used to teach important laparoscopic ovarian cystectomy skills. Construct validity discriminating between junior and senior residents was demonstrated using this model.

Enlarged uterine corpus volume in women with endometriosis: Assessment using three-dimensional reconstruction of pelvic magnetic resonance images.

AIM: To assess and compare the uterine volume and endometrium length between women with and without endometriosis, using pelvic magnetic resonance imaging scans. METHODS: In this case-control study, a total of 75 nulligravid women (aged 20-45 years) with regular menstrual cycles whose uterus were free of any surgically confirmed lesions were enrolled. The endometriosis group underwent surgery for endometrioma (n = 39), and the control group underwent surgery for non-endometrioma ovarian cysts (n = 36). The primary outcome was uterine corpus volume, which was assessed using three-dimensional reconstructions of preoperative pelvic magnetic resonance imaging scans. RESULTS: The mean uterine volume was significantly larger in the endometriosis group than in the control group (mean ± standard deviation, 50.9 ± 14.4 cm3 vs 41.7 ± 14.3 cm3 ; P < 0.01). The longitudinal length and transverse diameter of the corpus and the longitudinal length of the endometrium were also significantly greater in the endometriosis group (all, P < 0.01). CONCLUSIONS: An increase in uterine volume and endometrium length was observed in women with endometriosis.

Retrospective Cohort Study to Assess Outcomes, Cost-Effectiveness, and Patient Satisfaction in Primary Vaginal Ovarian Cystectomy versus the Laparoscopic Approach.

STUDY OBJECTIVE: To compare surgical outcomes, cost-effectiveness, and patient satisfaction in women undergoing primary vaginal or laparoscopic ovarian cystectomy for benign ovarian cysts. DESIGN: Retrospective cohort control study (Canadian Task Force classification II-3). SETTING: Gynecologic unit at a university-affiliated hospital. PATIENTS: Fifty patients who underwent primary ovarian cystectomy either through the vaginal route via posterior colpotomy (n = 29) or laparoscopic route (n = 21). INTERVENTIONS: Nonmalignant ovarian cysts were initially determined by transvaginal ultrasonography and serum tumor markers. The index group of women (n = 29) underwent vaginal ovarian cystectomy via a posterior colpotomy incision, whereas the control group (n = 21) comprised women who had laparoscopic ovarian cystectomy using the traditional "grasp and peel" technique. The following outcomes were evaluated: duration of surgery, intraoperative complications, estimated blood loss, length of inpatient stay, and postoperative pain (visual analogue scale). The average cost of both surgical methods was calculated by factoring in theater time, equipment required, and the length of hospital stay. Patients were then surveyed to compare postoperative pain and satisfaction scores as well as the time taken to return to work (in days). MEASUREMENTS AND MAIN RESULTS: The 2 groups had similar mean ages (35.79 vs 36.72 years) and cyst diameter (6.8 vs 6.6 cm) (p > .05 in both cases). Vaginal ovarian cystectomy took a mean of 13.7 minutes longer (91.7 vs 78.0 minutes, p < .001) to perform and resulted in a greater mean estimated blood loss (116.1 vs 95 mL, p < .001). The spillage rate in the index group was 6-fold less compared with control cases (6% ± 2.4% vs 35% ± 4.6, p < .01). Although patients from the index group spent a mean of 2 hours longer as inpatients (10.9 vs 8.9 hours, p < .001), they reported a lower mean visual analogue pain score (2.01/10 vs 3.95/10, p < .05) and higher patient satisfaction scores (8.2/10 vs 6.5/10, p < .001). Mean perioperative cost of women who underwent vaginal ovarian cystectomy was lower (£1690.13 vs 1761.67) and they returned to work quicker compared with the laparoscopic group (13.6 vs 39.2 days, p < .001). CONCLUSION: Vaginal ovarian cystectomies took longer to perform and led to longer inpatient stay. However, these women had less postoperative pain and reported higher satisfaction scores compared with laparoscopic ovarian cystectomy, with a quicker return to work. The vaginal approach is a viable and cost-effective alternative to the laparoscopic approach in carefully selected patients.

Natural orifice transluminal endoscopic surgery-assisted versus laparoscopic ovarian cystectomy (NAOC vs. LOC): a case-matched study.

BACKGROUND: Natural orifice transluminal endoscopic surgery (NOTES) has shown its prospection as a minimally invasive endoscopic surgery. This study aimed to examine the safety and efficacy of combined NOTES and vaginal approach, natural orifice transluminal endoscopic surgery-assisted ovarian cystectomy (NAOC), in the conservative management of benign ovarian tumors. METHODS: Records were reviewed for the 34 consecutive NAOC procedures between May 2011 and March 2014. Age, body mass index, parity, size of the mass, and bilaterality of the mass were used to select comparable patient who had undergone laparoscopic ovarian cystectomy (LOC). RESULTS: A total of 277 patients were recruited in this study (243 LOCs and 34 NAOCs, respectively). There was no incidence of switching to abdominal laparotomy. Length of operation and length of postoperative stay were significantly greater in the LOC group than in the NAOC group, but total hospital charges were similar in both groups. There was no difference in febrile morbidity between the two groups but more estimated blood loss (EBL) in NAOC group, although EBL was <50 mL in the two groups. Linear correlations of mass size with operating time and EBL existed in LOC group, but not in NAOC group. CONCLUSION: NAOC can be safely performed for benign and large ovarian tumors. Besides, NAOC offers a superior operative efficiency compared with LOC.

Comprehensive Assessment of the Impact of Laparoscopic Ovarian Cystectomy on Ovarian Reserve.

STUDY OBJECTIVE: To evaluate the effects of laparoscopic cystectomy of endometrioma and nonendometrioma ovarian cyst on ovarian reserve. DESIGN: Prospective follow-up study of patients after laparoscopic ovarian cystectomy (Canadian Task Force II-2). SETTING: Academic hospital. PATIENTS: Seventy patients underwent laparoscopic ovarian cystectomy, with bilateral endometrioma (n = 21), unilateral endometrioma (n = 29), and unilateral other benign ovarian cyst (n = 20) from February 2011 and May 2012. The control group (n = 20) comprised patients treated with laparoscopic myomectomy or laparoscopic hydrotubation and fimbrioplasty at the same time period. INTERVENTIONS: All laparoscopic operations were applied by suture homeostasis. Ovarian reserve was assessed by serum levels of anti-Müllerian hormone (AMH) and follicle-stimulating hormone (FSH) and by antral follicle count (AFC), ovarian volume, ovarian stromal pulsatility index, and resistance index on the third day of menstruation preoperatively and in postoperative months 1.6 and 12. MEASUREMENTS AND MAIN RESULTS: FSH levels increased significantly but the AMH and AFC levels declined significantly in the bilateral endometrioma group at 1 month postoperatively compared with preoperative levels (p < .05) but did not differ significantly at 6 and 12 months postoperatively. The ovarian stromal pulsatility and resistance indices in the ipsilateral ovaries decreased significantly in all patients with unilateral ovarian cysts at 6 and 12 months postoperatively compared with preoperative levels (p < .05), although the mean ipsilateral ovarian volume was significant smaller than the unaffected side. CONCLUSION: There was no detectable difference on ovarian reserve marker levels between 4 groups and from baseline values at 6 and 12 months after laparoscopic ovarian cystectomy of endometrioma, although these levels significantly declined in the first month postoperatively.

The utility of the emergency department observation unit for children with abdominal pain.

OBJECTIVE: This study aimed to determine the outcome of children with unclear etiology for acute abdominal pain admitted to the emergency department observation unit (EDOU). METHODS: This is a retrospective cohort study of children 18 years or younger who presented with acute abdominal pain to a tertiary pediatric ED and were observed in the EDOU. Children with alternative explanations for abdominal pain were excluded. Patients were classified based on disposition, and data were analyzed using χ tests. RESULTS: There were 237 patients included in the study (median age, 9 years; 46% male). Mean length of stay in EDOU was 14.4 hours. Fifty-four percent were evaluated by surgery. Two hundred (84%) were discharged; 37 (16%) were admitted, of whom 22 (9%) underwent surgical intervention (13 appendectomies, 6 ovarian cystectomies, 2 small-bowel obstructions, 1 cholecystectomy). Eight had acute appendicitis on pathology reports. The duration of symptoms, the presence of fever, nausea/vomiting, right-lower-quadrant pain, rebound tenderness, or leukocytosis greater than 10,000 cells/µL did not predict admission. Patients with diarrhea were more likely to be discharged home (P = 0.02). Intravenous hydration (86%) and pain control (63%) were the most common interventions in the EDOU. Abdominal pain not otherwise specified and acute gastroenteritis were the 2 most common discharge diagnoses. Eight (4%) of the 200 discharged patients returned to the ED within 48 hours, and all were discharged home from the ED. CONCLUSIONS: The majority of children admitted to the EDOU with abdominal pain have nonsurgical causes of abdominal pain. The EDOU provides a reasonable alternative for monitoring these patients pending disposition.

Histological assessment of impact of ovarian endometrioma and laparoscopic cystectomy on ovarian reserve.

AIM: The rate of oocyte decline follows a biphasic pattern, characterized by acceleration between 32 and 38 years old. Ovarian reserve is also affected by external factors, including ovarian disease and iatrogenic damage. The aim of this study was to histologically evaluate the impact of ovarian endometriomas, laparoscopic cystectomy, and age on follicle reserve in healthy ovarian tissues and in surgically resected cyst walls. MATERIAL AND METHODS: Sixty-one patients were found to have ovarian endometriomas and 42 patients non-endometriotic cysts. A small amount of normal ovarian tissue was obtained during ovarian cystectomy. The follicles in normal ovarian tissue and resected cyst walls were histologically evaluated. RESULTS: The density of follicles in ovarian tissues correlated with the age of the patients in both groups. In women aged <35 years, the relative density of follicles in healthy ovarian tissues was consistently lower in the endometriotic cyst group compared to the non-endometriotic cyst group, with the relative ratio at age 20, 30 and 35 years calculated to be 35.4%, 46.8% and 62.7%, respectively. There was no significant difference between the groups in patients over the age of 35. The resection rate of normal ovarian tissue in cystectomy specimen of the endometriosis group was significantly higher than in the non-endometriotic cyst group (P < 0.001). CONCLUSIONS: Our data suggest that ovarian endometriomas have a detrimental impact on follicle reserve in younger patients. Further, laparoscopic cystectomy for endometriomas may accelerate the rate of oocyte loss associated with aging.

[Assessment of ovarian volume reduction with three-dimensional ultrasonography after cystectomy for endometrioma]. / Évaluation par échographie tridimensionnelle de la réduction du volume des ovaires après kystectomie des endométriomes.

OBJECTIVE: The aim of our study was to assess ovarian tissue loss related to endometrioma cystectomy by 3D-ultrasonography. PATIENTS AND METHODS: We have retrospectively included 15 women with no previous ovarian surgery who benefited from cystectomy of an unilateral endometrioma the diameter of which was superior to 30mm. Cystectomy has been performed using an ovarian tissue-sparing procedure with no incision of the ovarian cortex. Patients underwent ultrasonography at least 9 months after the surgery. Several ovarian parameters, such as the area on longitudinal cross-section, the volume and the antral follicles count (AFC), were measured on both operated and contra lateral ovary, and then were compared using Mann and Whitney test. The relationship between the reduction of operated ovary volume and preoperative endometrioma diameter was evaluated by multiple regression. RESULTS: Operated ovary presented a significant reduction in area (mean reduction 229.8mm(2)±47.6; P<0.0001), volume (mean reduction 5.8cm(3)±1.16; P<0.0001) and AFC (mean reduction 5.1±3.8, P=0.002). No statistically significant correlation was found between operated ovary volume reduction and preoperative endometrioma diameter. DISCUSSION AND CONCLUSION: Endometrioma cystectomy leads to significant reduction in ovarian parenchyma volume and AFC, when compared to contra lateral ovary. This event must be taken into account in the choice of treatment strategy, especially in the case of enlarged, bilateral and recurrent endometriomas, recurrence, as well as in women presenting with other risk factor for ovarian failure.

[Laparoscopic approach of the ovarian cyst tumors]. / Abordarea laparoscopica a tumorilor chistice de ovar.

Given the continuous technical upgrade and increased surgical expertise, laparoscopy is replacing laparotomy in day-to-day gynecological surgical practice. Laparoscopic management offers many advantages for the patient: accurate diagnosis, minimal bleeding, reduced need for analgesia, less adhesion formation, fast recovery, better cosmetic results, shorter hospital stays (one day surgery in selected cases), and reduced costs for the patient and hospital.

Unexpected findings on laparoscopy for suspected acute appendicitis: a pro for laparoscopic appendectomy as the standard procedure for acute appendicitis.

PURPOSE: Evaluation of the feasibility, cost-effectiveness, time of surgery, morbidities, and other/additional findings during laparoscopy for suspected appendicitis. METHODS: Prospective evaluation of 148 laparoscopies for suspected acute appendicitis. RESULTS: Laparoscopic appendectomy was safe and cost-effective. No appendiceal stump leaks or wound infections occurred. Of the patients, 4.7% developed intra-abdominal abscesses. Mean time of all procedures was 47 min: 42 min for simple appendectomies (n = 126), 67 min for perforated appendicitis (n = 15), and 75 min for converted procedures (n = 7). Twenty-one of 148 (14.2%) patients had unexpected findings instead of appendicitis: inflamed epiploic appendices (three times), inflammatory disorders of intestine (five times), intestinal adhesions (two times), ovarian cysts (six times: one time with mesenteric lymphadenitis, one time ruptured), tubo-ovarian abscess (one time), tubal necrosis (one time), adnexitis with mesenteric lymphadenitis (one time), and acute cholecystitis (one time). These diagnoses might have been missed during conventional open appendectomy and were, if necessary, treated during laparoscopy. CONCLUSIONS: Laparoscopic appendectomy should be recommended as standard procedure for acute appendicitis.

[Assessment of the usefulness of ultrasound screening in fetal ovarian cysts]. / Ocena przydatnosci ultrasonografii u plodów z torbiela jajnika.

OBJECTIVES: The aim of the study was to assess the usefulness of ultrasound in management and prognosis in fetal ovarian cysts. MATERIAL AND METHODS: The study included 38 fetuses with cyst in abdominal cavity, who, between 1995 and 2006, underwent an ultrasound examination in our unit at the Polish Mother's Memorial Hospital in Lodz, The Department for Diagnosis and Prevention of Birth Defects. RESULTS: In all 38 fetuses with cyst in abdominal cavity we have diagnosed 27 (74%) cases of ovarian cyst. In 14 (74%) fetuses cysts regressed spontaneously, including all cysts < or = 40mm (n = 7). In 3 cases with cysts > 40mm needle aspiration has been successfully performed, without any further complications. Surgical neonatal treatment has been performed in 5 cases in prenatal cysts > 40mm without prenatal aspiration. In 3 cases cysts > 40mm regressed spontaneously. Ovarian cysts in 22 (87%) cases were an isolated malformation; in 5 (19%) cases other malformations were present CONCLUSIONS: 1. Fetal ovarian cysts < or = 40mm required only ultrasound assessment and, in majority of cases, revealed the tendency to spontaneous regression. 2. Cysts > 40mm in maximal diameter have signaled complications more often and required surgical procedure after birth. 3. In utero, aspiration of fetal ovarian cyst > 40mm may lead to cyst regression, making the surgery after birth unnecessary.

Health technology assessment of surgical therapies for benign gynaecological disease.

This chapter summarises the evidence of the benefits and harm of surgical therapies for benign gynaecological disease. We have limited the discussion in this chapter to three gynaecological conditions - menorrhagia, endometriosis and benign ovarian tumours - with a further section on the different surgical approaches for performing a hysterectomy for menorrhagia due to dysfunctional uterine bleeding and pelvic masses such as fibroids and benign adnexal masses. The currently available evidence suggests that there is little to choose between the four first-generation endometrial destruction techniques - laser ablation, transcervical resection of endometrium, vaporisation ablation and rollerball ablation - in terms of clinical efficacy and patient satisfaction. There is a paucity of evidence with regards to the comparison of the different second-generation endometrial-destruction techniques but current evidence suggests that bipolar radiofrequency ablation is more effective than thermal balloon ablation for treating menorrhagia. Overall, the second-generation techniques are at least as effective as first-generation methods but are easier to perform and can be done under local rather than general anaesthesia in some circumstances. Hysteroscopic endometrial ablation is an alternative to hysterectomy and should be offered to women with menorrhagia because of its high satisfaction rates, shorter operation time, shorter hospital stay, earlier recovery and reduced postoperative complications; hysterectomy remains the surgical option of choice for women with intractable menorrhagia despite repeated endometrial ablations and for those who do not wish under any circumstances to continue to have menstrual bleeding. The combined use of laparoscopic laser ablation, adhesiolysis and uterine nerve ablation has been shown to have a beneficial effect on pelvic pain associated with mild to moderate endometriosis. Current evidence also supports the use of laparoscopic treatment of minimal and mild endometriosis to improve the on-going pregnancy and live birth rate in infertile patients. The current available evidence suggests that the laparoscopic approach is superior to laparotomy for the surgical management of benign ovarian cysts. It results in less postoperative pain and a shorter postoperative hospital stay; it also costs less. With regards to the surgical approach for performing a hysterectomy for menorrhagia and benign pelvic masses, vaginal hysterectomy should be performed over laparoscopic and abdominal hysterectomy when possible. Where it is not possible to perform the hysterectomy vaginally, then laparoscopic hysterectomy can be employed instead of abdominal hysterectomy to avoid a laparotomy scar. There appears to be no significant advantage in performing a subtotal hysterectomy instead of the total removal of the uterine corpus and cervix.

Ovarian cysts in tamoxifen-treated women with breast cancer.

OBJECTIVE: The objective of this study was to detect any ovarian changes in tamoxifen-treated breast cancer patients. METHODS: In all, 51 patients with breast cancer were enrolled in the study, which was conducted in the SSK (Social Security Agency) Aegean Maternity Hospital between January 1999 and December 2002. The patients' demographic and medical data were reviewed. All patients taking part in the study received tamoxifen therapy, but the duration was not uniform. Gynecological examination and transvaginal ultrasonography (TVU) were performed in each case. Any ovarian cysts or masses were identified, and serum Ca-125 levels were recorded. RESULTS: Of the 51 tamoxifen-treated patients enrolled in this study, 24 were still premenopausal and 27 were postmenopausal when they were monitored for breast cysts during the tamoxifen treatment started after the diagnosis of breast cancer. Their average age was 53.7 (range 31-64) years. The mean duration of tamoxifen therapy was 23.5 (range 8-49) months. Ovarian cysts were diagnosed in nine (17.6%) patients and required surgery in two of these; pathological examination revealed serous cysts of the ovary in both. CONCLUSION: : In cases with ovarian cyst formation during tamoxifen treatment of breast cancer, discontinuation of tamoxifen followed by monitoring is quite a reasonable way to proceed in most cases. Surgical intervention should be carried out when cysts are >5 cm in diameter.

Prospective randomized comparison of single-dose versus 1-day cefazolin for prophylaxis in gynecologic surgery.

BACKGROUND: The purpose of this prospective, randomized study was to compare the efficacy of single-dose versus 1-day cefazolin prophylaxis for the prevention of postoperative gynecologic infections. METHODS: From June 2001 to January 2003, 548 patients were randomized to receive either single-dose (1 g of cefazolin intravenously before surgery, 273 patients) or 1-day cefazolin (1 g intravenously before surgery and three more doses every 6 hr after surgery, 275 patients) prophylaxis. RESULTS: A total of 531 (267 patients in the single-dose group and 264 in the 1-day group) completed the study. Only one of 267 (0.37%) patients in the single-dose group developed a trocar wound infection and one of 264 (0.37%) patients in the 1-day group developed a vaginal cuff infection. Had a single dose of prophylactic antibiotics been administered to all patients, the antibiotic cost would have been reduced by 75-80%. CONCLUSIONS: The use of single-dose preoperative cefazolin prophylaxis was as effective as four doses of cefazolin for preventing serious infectious morbidity among our patients. Shortening the duration of antibiotics prophylaxis also reduced medical costs and microorganism resistance.

Sonographic assessment of non-malignant ovarian cysts: does sonohistology exist?

BACKGROUND: Transvaginal ultrasound (TVU) is feasible and accurate in the differentiation between non-malignant and malignant ovarian abnormalities. However, despite the clinical relevance, the accuracy of TVU in the differentiation between the many different non-malignant cysts is unknown. METHODS: Between 1992 and 2002, all women who had surgery at our centre because of a non-malignant ovarian cyst were included prospectively in this study. The sonographic characteristics as well as the expected histological diagnosis (the 'sonohistological diagnosis') were evaluated pre-operatively. This diagnosis was compared with the histopathological diagnosis, and diagnostic parameters [with 95% confidence interval (CI)] of the sonohistological diagnosis were calculated. Logistic models, with the sonographic characteristics as variables, were constructed for each histopathological diagnosis. RESULTS: A total of 406 women were included consecutively. The overall diagnostic accuracy of the sonohistological diagnosis was 60% (95% CI 0.56-0.65). Only in cases of simple ovarian cysts did the diagnostic accuracy of the respective logistic model exceed that of the sonohistological diagnosis (0.88 versus 0.81, P < 0.01). The diagnostic accuracy of the sonohistological diagnosis for endometriotic and dermoid ovarian cysts was significantly better compared with the respective logistic model (0.84 versus 0.71, P < 0.01 and 0.87 versus 0.82, P = 0.03, respectively). CONCLUSION: In approximately half of the non-malignant ovarian cysts, TVU is capable of distinguishing between the different histopathological diagnoses of non-malignant ovarian masses. Only in the diagnosis of simple ovarian cysts might use of the logistic models be helpful.

Preoperative assessment of unilocular adnexal cysts by transvaginal ultrasonography: a comparison between ultrasonographic morphologic imaging and histopathologic diagnosis.

OBJECTIVE: Our purpose was to evaluate the risk of malignancy in surgically removed ovarian cysts that were characterized before the operation as unilocular according to transvaginal ultrasonography. STUDY DESIGN: This prospective analysis included 927 premenopausal women and 377 postmenopausal women operated on at 2 European university hospitals between January 1992 and December 1997. On the basis of ultrasonographic findings the cysts were characterized either as echo-free, without solid parts or papillary formations (group 1), or as having echogenic cyst content, with solid parts or papillary formations (group 2). Ultrasonographic and macroscopic appearances of the cysts were compared with histopathologic diagnosis. RESULTS: In group 1, in premenopausal women 3 of 413 cysts (0.73%) proved to be borderline or malignant, and in postmenopausal women 4 of 247 cysts (1.6%) proved to be borderline or malignant. The figures for cysts in group 2 were 11 of 514 cysts (2.1%) and 13 of 130 cysts (10.0%), respectively. It was not possible to differentiate by transvaginal ultrasonography between benign, borderline, and malignant cysts when solid parts or papillary formations were visualized. CONCLUSIONS: This study confirmed that the risk of malignancy associated with unilocular echo-free cysts (group 1) was low. Serial ultrasonographic follow-up should therefore be the standard procedure with unilocular echo-free cysts <50 mm in diameter. In cysts with a mean diameter of >50 mm, papillary formations or solid parts may be missed by transvaginal ultrasonography. The risk for malignancy in cysts containing papillary formations or solid parts (group 2) was 3 to 6 times higher than that in unilocular echo-free cysts.

Outpatient minilaparotomy for ovarian cysts.

OBJECTIVE: To design an operative procedure for the ambulatory management of ovarian cysts using classical surgical techniques. STUDY DESIGN: One hundred consecutive patients 55 years old or younger with 115 persistent or complex ovarian cysts less than 10 cm in diameter were managed as outpatients by minilaparotomy. Minilaparotomy is defined as a transverse or vertical incision 3-5 cm in length. The procedure and anesthetic were dictated by each clinical situation. Bupivacaine HCl with epinephrine was injected in the wound preemptively, and ketorolac was administered systemically perioperatively. Operative times, complications and pathology were determined for each case. RESULTS: The procedures (unilateral cystectomy, 65; bilateral cystectomy, 9; unilateral salpingo-oophorectomy, 20; and bilateral salpingo-oophorectomy, 6) were performed under general endotracheal anesthesia in 89, laryngeal mask anesthesia in 5 and spinal block in 6. Mean operative time was 46 minutes. Estimated blood loss in 96% of cases was < 50 mL, and none was > 100 mL. Pathology in two cases revealed adenocarcinoma of borderline malignancy. Remaining histology included endometrioma, 40; dermoid, 25; serous cystadenomas, 14; hemorrhagic corpus luteum, 9; mucinous cystadenoma, 8; cystadenofibroma, 7; follicular cyst, 3; fibrothecoma, 2; and peritoneal inclusion cyst, 1. Ninety-six of 100 patients were discharged on the day of surgery. Two were admitted for urinary retention, one for severe nausea and vomiting, and one for diabetes control. CONCLUSION: Minilaparotomy is a safe, rapid procedure for the management of ovarian cysts on an ambulatory basis. It can be performed under regional anesthesia, avoids intraperitoneal spill and requires only basic operative techniques and instrumentation. Minilaparotomy is also a cost-effective technique for outpatient management of ovarian cysts.

A new sonomorphologic scoring system (Mainz Score) for the assessment of ovarian tumors using transvaginal ultrasonography. Part I: A comparison between the scoring-system and the assessment by an experienced sonographer.

OBJECTIVE: The problem of an accurate sonographic assessment of ovarian tumor status has not yet been solved. To what extent can the preoperative assessment of adnexal tumors be improved on the basis of a maximum number of sonographic tumor parameters included in the newly developed sonomorphologic Mainz Score? MATERIALS AND METHODS: In a prospective study 314 premenopausal patients with adnexal tumor underwent a transvaginal sonographic examination performed by an experienced sonographer. In parallel to the sonographic examination a new score including 10 different sonographic parameters was used to predict adnexal tumor status: 1. Total tumor structure, 2. tumor border, 3. wall thickness, 4. inner echos in cystic component, 5. septa, 6. shape of echo complex or of the completely solid tumor, 7. echogenicity of the echo complex or of the completely solid tumor, 8. acuostic phenomena behind tumor, 9. ascites, 10. detection of liver metastases/peritoneal carcinosis Depending on the respective degree of expression, the individual characteristics were rated on a scale from 0 to 2. The total score obtained following addition of the points recorded for each parameters served to confirm the validity of the sonographic tumor status assessment. The first sonographer assessed the tumor status based on his experience and in the knowledge of all clinical parameters. The second sonographer evaluated the tumor status based on the score. All preoperative ultrasonographic findings were compared with the postoperative histologic analysis. RESULTS: A maximum number of 20 points may be obtained using the Mainz Score. Tumors with a total score of below 9 were rated as benign and those with a score of above 9 as malignant. This resulted in a sensitivity of 96.4%, a specificity of 80.7%, a positive predictive value of 47.4%, and a negative predictive value of 99.6%. The predictive value of the scoring-system was diminished by the presence of 30 false-positive cases, which were identified as inflammatory conglomerate tumors, teratomas, endometrial cysts, cystadenomas and hemorrhagic cysts. The experienced sonographer assessed 233 cases as benign and 24 cases as malignant. The findings were confirmed by the histological examination in 252 of 257 cases. No conclusive prediction of tumor status could be made in 57 tumors. However, the application of the Mainz Score enabled an accurate prediction of the tumor status in 44 of the 57 cases. With the exception of septal thickness all assessment criteria of the score showed a statistically significant correlation between the assigned score and the histologic findings, (p < 0.05). CONCLUSIONS: The use of the Mainz Score enables even less experienced sonographers to assess the status of premenopausal adnexal tumors with a high degree of accuracy. The score provides the experienced sonographer with a refined and improved method for the prediction of tumor status, especially in the presence of not readily assessable findings.