Endobag extractor to remove masses during laparoscopy.

BACKGROUND: Intra-abdominal masses are removed during laparoscopy using different types of endobags. However, in many cases the specimens are larger than the trocar or the incision in the abdomen, with a potential risk of endobag rupture. INSTRUMENT: We developed an instrument to facilitate extraction of an endobag during laparoscopy without the need for a conventional minilaparotomy. The endobag extractor has three removable diverging blades that symmetrically enlarge the operative canal in the abdominal wall if spread after sharp extension of the skin incision. The full endobag can be drawn through the canal without the risk of endobag rupture because the size of the canal can be individualized, building a funnel. EXPERIENCE: We removed various kinds of ovarian tumors, specimens from salpingo-oophorectomies, and other specimens in 22 cases. CONCLUSION: This new instrument allows easy removal of surgical specimens during laparoscopy without conventional minilaparotomy, regardless of the type of endobag used. We believe this instrument lessens the risk of endobag rupture.

m-THPC-mediated photodynamic therapy (PDT) does not induce resistance to chemotherapy, radiotherapy or PDT on human breast cancer cells in vitro.

Photodynamic therapy (PDT) uses laser light to activate a photosensitizer that has been absorbed preferentially by cancer cells after systemic administration. A phototoxic reaction ensues resulting in cell death and tissue necrosis. Some cells, however, may survive PDT. This study was performed to determine if surviving human breast cancer cells (MCF-7) can become resistant to PDT, chemotherapy or radiotherapy. The MCF-7 cells were cultured under standard conditions prior to being exposed to the photosensitizer, 5,10,15,20-meta-tetra(hydroxyphenyl)chlorin (m-THPC), for 24 h and then irradiated with laser light (652 nm). Surviving cells were allowed to regrow by allowing a 2 week interval between each additional PDT. After the third and final treatment, colony formation assays were used to evaluate the sensitivity of cultured cells to ionizing radiation and PDT and the ATP cell viability assay tested in vitro chemosensitivity. Flow cytometry was used to analyze the cell cycle. No alterations in the cell cycle were observed after three cycles of PDT with m-THPC. Similar responses to chemotherapy and ionizing radiation were seen in control and treatment groups. The m-THPC-sensitized PDT did not induce resistance to subsequent cycles of PDT, chemo- or radiotherapy. Photodynamic therapy with m-THPC may represent a novel adjunctive treatment of breast cancer that may be combined with surgery, chemotherapy or ionizing radiation.

[Bladder and rectal infiltration by uterine carcinomas: the accuracy of CT and MRI compared to endoscopic procedures]. / Blasen- und Rektuminfiltration durch Uteruskarzinome: Treffsicherheit der CT und der MRT im Vergleich zu endoskopischen Verfahren.

PURPOSE: To establish the value of computed tomography (CT) and magnetic resonance imaging (MRI) in predicting bladder and rectum involvement in uterine carcinoma. MATERIAL AND METHODS: 6 different imaging signs (focal obliteration of perivesical or perirectal fat planes, area and angle of contact between uterus and bladder or rectum, asymmetric bladder or rectum wall thickening, evidence of intraluminal masses, and signal intensity of bladder or rectum wall on T2-weighted or contrast-enhanced MR images) were analysed retrospectively in 129 patients who underwent 92 CT and/or 64 MRI examinations. The data were correlated with intraoperative findings and the results of cystoscopy and rectoscopy. RESULTS: Asymmetric wall thickening, evidence of intraluminal masses and increased signal intensities of the bladder wall or rectum wall were valuable signs of infiltration (sensitivity 71-100%, specificity 91-96% and accuracy 89-97%). In 27 patients submitted to both imaging examinations MRI was somewhat superior compared to CT (p > 0.1) and yielded similar results as endoscopic procedures (accuracy of cystoscopy and rectoscopy of 90% and 94%, respectively). CONCLUSION: CT and MRI allow to predict involvement of bladder or rectum wall in carcinoma of the uterus with a similar accuracy as endoscopic procedures.

[Developments in minimally invasive breast surgery - overview and our own experience: new diagnostic and therapeutic challenges in breast cancer]. / Entwicklung der minimal-invasiven Mammachirurgie - Ubersicht und eigene Erfahrungen. Neue chirurgische Herausforderungen in der Diagnostik und Therapie des Brustkrebses.

New diagnostic and therapeutic modalities in breast cancer are necessary because nowadays an increased number of suspicious breast lesions are referred to breast clinics for a histological diagnosis. In the future more than one quarter of patients might present with a preinvasive lesion and more than half of the patients will have tumors less than 2 cm. Mammography screening helps to find more preinvasive lesions. Therefore we need new tools for exact stereotactic breast biopsies in the outpatient setting, such as the advanced breast biopsy instrumentation (ABBI((R))) or the Mammotome((R)) system. For axillary clearance we need methods that lead to less morbidity. The detection of the sentinel lymph node is one of these new techniques. Endoscopic axillary clearance after liposuction also helps to reduce morbidity. Due to better visualization of the anatomic structures with axilloscopy less traumatic surgery is possible. We also combined these two new methods and described the endoscopic clearance of the sentinel lymph node in the axilla with the additional help of isosulfan blue. However, this combined method is not only time-consuming but also more expensive and shows no obvious advantage compared to the open sentinel technique. Therefore we stopped using the endoscopic sentinel technique and we now promote open sentinel lymph node biopsy without full axillary clearance when frozen section shows sentinel node-negative lymph nodes.

[Ovarian cancer. Screening, therapy and follow-up]. / Ovarialkarzinom. Screening, Therapie und Follow-up.

In April 1994, the National Cancer Institute, together with the Office of Medical Applications of Research of the National Institutes of Health, convened a Consensus Development Conference on Ovarian Cancer: Screening, Treatment and Follow-up. The panel weighted the scientific evidence and drafted answers to the following key questions: (1) What is the current status of screening and prevention of ovarian cancer? (2) What is the appropriate management of early-stage ovarian cancer? (3) What is the appropriate management of advanced epithelial ovarian cancer? (4) What is the appropriate follow-up after primary therapy? (5) What are important directions for future research?

[Staging of malignant trophoblast diseases: a dilemma]. / Staging der malignen Trophoblasterkrankungen: Ein Dilemma.

In the past, three different staging systems have been used for trophoblastic disease: The WHO scoring system, the NIH classification and the FIGO staging system. The NIH classification has been preferred by most oncologists in the United States of America and is currently still first choice. The Federation of Gynecology and Obstetrics (FIGO) published a new staging system in 1992 which includes both prognostic factors and the anatomic spread of the disease. Here we wish to present and evaluate these staging systems.

[Primary therapy of advanced ovarian carcinoma: current status and perspectives]. / Primärtherapie des fortgeschrittenen Ovarialkarzinoms: Standortbestimmung und Perspektiven.

Standard therapy of advanced ovarian cancer includes staging laparotomy with aggressive debulking, possibly pelvic and para-aortic lymphadenectomy, and postoperative chemotherapy. Until present, combination chemotherapy with cis-/carboplatin and cyclophosphamide has been standard. Due to the positive results emerging from recent clinical trials, paclitaxel in combination with platinum might soon emerge as a new standard for patients with advanced ovarian cancer. The role of high-dose chemotherapy is currently under investigation. Pretherapeutic chemosensitivity testing, using a third-generation assay, is studied in randomized trials. Since the cost/benefit ratio is increasingly playing an important role, a cost comparison of the six most commonly used chemotherapy protocols is presented.

[Surgical strategy in incontinence and prolapse]. / Operative Strategie bei Inkontinenz und Deszensus.

By means of 5 typical examples, repeated problems in the operative strategy of incontinence and descensus are discussed. Prior to each vaginal repair a urodynamic examination should be done to clarify the risk of incontinence. In the case of vaginal repair the periurethral structures should be preserved. In the case of abdominal colposuspension nonabsorbable suture material should be used. A wide elevation should be avoided. Continent patients with a cystocele and a urodynamically verified, hidden stress incontinence need, in addition, a vaginal colposuspension. In the case of vaginal stump prolapse the organ-saving operation (vaginal sacropexy) should be preferred to colpectomy. In the case of recurring stress incontinence, patients should preoperatively undergo an intensive local therapy, thus enabling a tension-free elevation.

[Determination of kidney function in patients with ovarian cancer treated with chemotherapy: calculation versus measurement of creatine clearance]. / Nierenfunktionsbestimmungen bei Patientinnen mit Ovarialkarzinom unter Chemotherapie: Berechnung versus Messung der Kreatinin-Clearance.

In patients with ovarian cancer receiving chemotherapy we compared the creatinine clearance measured in the usual way with the calculation of the creatinine clearance according to the formulas of Jelliffe and Cockroft. Regression analysis only showed a moderate correlation, whereas the analysis of the data by ROC curves allows the use of these formulas as screening tests with acceptable values of sensitivity and false-positive rate. Therefore, in the majority of these patients, collecting urine over 24 h before starting chemotherapy is no longer necessary.

[Persistent ductus omphaloentericus--a possible cause of bleeding umbilicus]. / Persistierender Ductus omphaloentericus--Eine mögliche Ursache des blutenden Nabels.

We report the case of a 23-year-old woman with a persistent omphalomesenteric duct. The diagnosis was verified by histology. Further differential diagnoses of bleeding umbilicus are the urachal fistula and endometriosis.

[Systemic methotrexate therapy of persistent trophoblast after tube saving surgery for extrauterine pregnancy]. / Systemische Methotrexattherapie bei Trophoblastpersistenz nach tubenerhaltender Operation wegen Extrauteringravidität.

Is single-drug methotrexate therapy for persistent trophoblastic tissue after conservative laparoscopic surgery an effective medical treatment? Here we report and discuss a case of apparent persistent trophoblastic tissue after salpingotomy and removal of an ectopic pregnancy treated with methotrexate and review the published cases. Single drug-therapy with methotrexate is an alternate approach to a persistent trophoblast after conservative surgery for ectopic pregnancy. Having recently undergone surgery, these women suffer when operated again due to anesthesiologic, surgical and psychological stress. The current case and the published data demonstrate that methotrexate is a simple, efficacious, successful and by now established therapy.

[Effectiveness of estriol depot vaginal suppositories in postmenopausal women with urogenital climacteric manifestations]. / Wirkung von Ostriol-Depot-Vaginalovula bei postmenopausalen Frauen mit urogenitalen Ausfallerscheinungen.

In this study, 43 postmenopausal patients with urogenital complaints such as vaginal dryness, incontinence, or bleeding with intercourse were treated with weekly applications of Orthogynest vaginal estriol suppositories in a new depot form. A marked increase in the vaginal epithelium (A. Schmitt score) and a significant decrease in symptoms due to vaginal atrophy were noted. The depot form allows for decreased dosing frequency, leading to improved compliance. Systemic symptoms, such as hot flashes and emotional lability, were also noted to respond to the Orthogynest suppositories.

[Quantitative determination of dose-response relations of taxol and cisplatin in ovarian cancer cells with a bioassay in comparison with cytomorphology]. / Quantitative Erfassung der Dosis-Wirkungs-Beziehungen der Zytostatika Taxol und Cisplatin an Ovarialkarzinomzellen mit einem Bioassay im Vergleich zur Zytomorphologie.

The dose-response relations of the cytotoxic drugs taxol and cisplatin and their combination were analyzed in an ovarian cancer cell line (BG-1). The chemosensitivity profiles were obtained with 5 concentrations using the ATP cell viability assay (ATP-CVA). Furthermore, the cytomorphologic changes were analyzed. Our findings demonstrate that the ATP-CVA is able to determine the fraction of surviving cells and has proved to be an effective tool to measure cytotoxicity. At the same time we were able to analyze the cytomorphologic changes. The implications of these results for the practice of gynecologic oncology are discussed.

[Transvaginal ultrasound of "placental-site trophoblastic tumor"]. / Transvaginalsonographie eines "Placental Site Trophoblastic Tumor".

The case of a placental-site trophoblastic tumor (PSTT) is described. Transvaginal sonography revealed a vascularized tumor mass with a deep invasion of the myometrium, partly with echogenic, solid parts and partly multiple echo-free cystic lesions. The maximum size of an echo-free cystic lesion was 4.4 cm. Doppler exploration indicated the presence of blood flow in all these cystic lesions. Distinctly abnormal low flow indices were prominent in the whole tumor area. According to the clinical results and the slightly positive levels of human chorionic beta-gonadotropin (100-1,000 IU/l postpartum), this tumor was classified as malignant trophoblastic disease, most likely PSTT. The authors conclude that, in the case of a patient with suspected trophoblastic disease and in view of the sonographic findings, PSTT may be a valid differential diagnosis, particularly if larger cystic lesions of more than 3 cm in diameter are found in the tumor bed together with evident blood flow at a low vascular resistance.

[Gynecological management of patients over 80 years old. Results of a prospective study]. / Die gynäkologische Behandlung von über 80jährigen Patientinnen. Resultate einer prospektiven Studie.

OBJECTIVE: Diagnosis and therapy of gynecologic inpatients who were over 80 years of age were analyzed with respect to the desired and the actual management. METHODS: A general assessment protocol for diagnostic and therapeutic steps which were not carried out in individual cases was drawn up and used for the 96 patients analyzed. The desired therapy corresponded to the ideal management of a 60-year-old patient. RESULTS: In two thirds of the cases, the desired therapy could be given. For 32 patients, there was a reduction of 5-50%; for only 2 patients one of > 50%. The most frequent deviation from the ideal therapy was for the oncologic patients. CONCLUSIONS: Our conclusions agree with those reported in the literature, namely that age alone can not be taken as an argument against standard treatment of a patient with a gynecologic disorder. For patients over 80 years of age, the individual risks and benefits of a particular therapy, especially when surgery is involved, should be carefully considered.