False-negative findings of malignant breast lesions on preoperative magnetic resonance mammography.

The aim of this study was to evaluate causes and percentages of false negative diagnoses of malignant breast lesions on preoperative dynamic magnetic resonance mammography (MRM). MRM was performed in 223 patients with 234 histopathologically proven malignant breast lesions (193 invasive carcinoma, 41 CIS) which were analyzed prospectively by routine analysis prior to surgery and re-analyzed by specialists, retrospectively. False negative findings were re-evaluated with respect to contrast enhancement, size and shape of lesions, reading errors, and technical problems. Preoperative analysis missed 27 of 234 malignant breast lesions (sensitivity 88.5%) including 15 of 193 invasive cancers (sensitivity 92%) and 12 of 41 CIS (sensitivity 71%). Five of 193 invasive cancers (four invasive lobular, one invasive tubular carcinoma) and five of 41 CIS lesions were missed due to delayed or no contrast enhancement. The remaining 17 false negative diagnoses were due to reading errors (n=8), previous core biopsies (n=3), metal induced artefacts (n=3), localization outside the field of view (n=1), incorrect injection (n=1) or movement artefacts (n=1). Using dynamic MR mammography, there were 4.3% slow contrast enhancing malignant breast lesions and a maximum sensitivity of 95.7% for detection of all malignant breast lesions (97.4% for invasive breast cancer, 87.8% for carcinoma in situ) can be achieved in a preselected preoperative population.

Endoscopic axillary lymphadenectomy without prior liposuction. Development of a technique and initial experience.

BACKGROUND: A new technique of endoscopic axillary lymphadenectomy without prior liposuction was developed by our group. METHOD: A total of 33 patients with early stage breast cancer were treated by breast-conserving therapy and endoscopic axillary lymphadenectomy. RESULTS: The median duration of the operation was 74.9 min (range, 30-130). Operation time was significantly shorter for the last 17 patients (p < 0.05) than for the first 16 patients. There were no intraoperative complications. The median number of removed lymph nodes was 14.5 (range, 2-28). Postoperatively three patients developed a seroma, one of which required evacuation. At postoperative day 5, arm mobility was unrestricted in 26 patients (78.7%); nine patients (27.2%) reported a loss of sensation in the outer side of the upper arm related to dermatome C5. One patient developed a temporary alar scapula, and one patient developed an axillary abscess 9 weeks after axillary lymphadenectomy during radiation therapy. After a median follow-up of 4.6 months seven patients reported persistent impairment of sensation, but all patients had regained full shoulder mobility. CONCLUSION: Endoscopic axillary lymphadenectomy can be done safely without prior liposuction.

Laparoscopic adnexal preservation in a patient with complete torsion--a case report.

OBJECTIVE: Laparoscopic adnexal preservation in a patient with complete torsion. STUDY DESIGN: Laparoscopy was performed in a 20-year-old nulliparous patient with a 24-h history of lower abdominal pain. RESULTS: Torsion of the left adnexa was diagnosed and detorsion was performed. After detorsion the patient reported complete resolution of pain. At second look laparoscopy blood supply of the left adnexa was completely normalized and a cystadenofibroma was excised with preservation of the ovary. CONCLUSIONS: Complete torsion of adnexa associated with edema and ischemia can be treated by laparoscopic detorsion.

Description of a laparoscopic technique for treating patients with ovarian remnant syndrome.

OBJECTIVE: A retroperitoneal approach for laparoscopic treatment of ovarian remnant syndrome was developed. DESIGN: Clinical study. SETTING: Department of Gynecology, Friedrich-Schiller-University Jena. PATIENT(S): During a 29-month period, seven consecutive patients with ovarian remnant syndrome were treated by laparoscopy. Patients were not preselected and preoperative, intraoperative, and postoperative data were registered prospectively. INTERVENTION(S): For removal of remnant ovaries we used a laparoscopic retroperitoneal approach that included complete dissection of the pelvic course of the ureter and coagulation and dissection of the infundibulopelvic ligament and of the uterine vessels. RESULT(S): In the first patient's case, the right ureter was injured during dissection, which was initiated too far distally between ovary and external iliac vessels. Thereafter, we changed our technique to start the dissection of the ureter at the pelvic brim. No subsequent patient had an intraoperative or postoperative complication. All patients reported fewer preoperative complaints and were free of recurrence by sonographic examination. CONCLUSION(S): Using a retroperitoneal approach laparoscopic resection of a remnant ovary may be a safe and effective technique.

[Abdominal actinomycosis with IUD]. / Abdominale Aktinomykose bei IUD.

We report a case of abdominal actinomycosis in a 54 year old woman using an intrauterine device for a period of 8 years. The most important finding was a tuboovarialabscess at the left pelvic side with involvement of the serosa of the jejunum, ileum, sigma, and omentum majus. Intraoperative exploration showed a solid retroperitoneal infiltration between the pelvic side wall and sigma. Another infiltration was found on the left side of the abdominal wall. The diagnosis was confirmed by histopathological examination and the patient was treated by a combination of Aminopenicillin and Metronidazol. After a period of three months we observed a complete regression of the clinical and the MRI findings.

[Value of laparoscopic pelvic lymph node excision in inguinal vulvar carcinoma metastasis]. / Wertigkeit der laparoskopischen pelvinen Lymphonodektomie beim inguinal metastasierten Vulvakarzinom.

We performed a laparoscopic pelvic lymphadenectomy in three patients with vulvar cancer FIGO stage II or III and positive inguinal lymph nodes. Computertomographical and lymphographical findings of pelvic lymph nodes did not correlate with the histological findings in two patients: Surgical staging up-graded the clinical stage in one patient. No intra- or postoperative complications were encountered. Laparoscopic pelvic lymphadenectomy in inguinal metastasizing vulvar cancer is a valuable method with low peri- and postoperative morbidity.

[The historical development of radical vaginal operation of cervix carcinoma]. / Die historische Entwicklung der vaginalen Radikaloperation des Zervixkarzinoms.

Reviewing the historical development of radical vaginal surgery for the treatment of cervical cancer the different variations of this technique are defined. In 1880 the first modified radical hysterectomy for cervical cancer was performed by Pawlik. Radical vaginal hysterectomy is associated with the name of Schauta who further developed and categorized the technique. The most important modifications were done by Stoeckel and Peham/Amreich. Extraperitoneal dissection of pelvic lymph nodes was combined with radical vaginal hysterectomy by Stoeckel in 1928.

Laparoscopy-assisted radical vaginal hysterectomy modified according to Schauta-Stoeckel.

In laparoscopy-assisted radical vaginal hysterectomy, laparoscopy is used to develop the paravesical and pararectal spaces. The cardinal ligament is isolated and cut after bipolar coagulation to the level of the deep uterine vein. By the vaginal approach, the ureters are identified before their entry into the bladder pillar. The uterine vessels are pulled down until their laparoscopically coagulated ends become visible. After incision of the vesicocervical reflection, the uterine fundus is grasped and developed (Döderlein maneuver). The lower cardinal and uterosacral ligaments are exposed by pulling the cervix and fundus uteri to the contralateral side. The cardinal and uterosacral ligaments are dissected and ligated, and the specimen is removed. We combined laparoscopic lymphadenectomy with radical vaginal hysterectomy in 33 women with cervical cancer. The mean operating time was 80 minutes for the vaginal phase and 215 minutes for the laparoscopic phase, including paraaortic and pelvic lymphadenectomy and preparation of the cardinal ligaments. Blood transfusions were necessary in four women. Three patients sustained injury to the bladder, one patient to the left ureter, and another patient to the left internal iliac vein. Repair was achieved at primary surgery for all intraoperative complications. No fistula was observed. The patients had fully recuperated after a mean of 28 days. The laparoscopy-assisted Schauta-Stoeckel approach may prove to be a safe alternative to conventional radical abdominal hysterectomy.

[Laparoscopic management of a ureteral lesions in Schauta-Stoeckel radical vaginal hysterectomy]. / Laparoskopische Versorgung einer Ureterläsion bei radikaler vaginaler Hysterektomie nach Schauta-Stoeckel.

We report on the laparoscopic repair of an ureteral injury during radical vaginal hysterectomy according to Schauta-Stoeckel combined with laparoscopic paraaortic and pelvic lymphadenectomy. A 0.5 cm long oval incision of the left ureter 4 cm from the bladder was noticed during laparoscopic inspection at the final stage of the operation. The injury was repaired through a transvesical ureteral stent under laparoscopic guidance with laparoscopic intracorporeal suturing. On postoperative day 10 the ureteral stent was removed. An intravenous urogram taken 4 weeks after the operation showed normal conditions. Therefore primary laparoscopic repair of an ureteral injury is possible and effective.

[Laparoscopic para-aortic and pelvic lymph node excision--initial experiences and development of a technique]. / Laparoskopische paraaortale und pelvine Lymphonodektomie--erste Erfahrungen und Entwicklung einer Technik.

It was the aim of this study to establish and analyze the laparoscopic technique of para-aortic and pelvic lymphadenectomy. During a one year period (from August 1994 till July 1995) 42 patients underwent pelvic and para-aortic laparoscopic lymphadenectomy. In 29 cases cervical cancer, in 11 cases endometrial cancer and in 2 cases tumors of low malignant potential of the ovary were the indication for lymphadenectomy which was combined with radical vaginal hysterectomy in 19 patients or simple vaginal hysterectomy in 13 patients. During the observation period the mean operating time for para-aortic and pelvic lymphadenectomy decreased and the efficiency of the lymphadenectomy increased significantly: the mean operating time for the first 10 para-aortic lymphadenectomies was 52 minutes and for the pelvic lymphadenectomies 141 minutes, respectively. For the last 10 procedures the para-aortic part took 35 minutes and the pelvic part 110 minutes. Whereas at the beginning of the study a mean of 25 lymph nodes were removed, a mean of 36 lymph nodes were sampled during the last 10 procedures. In 3 patients operative injuries to major vessels were encountered of which two were followed by laparotomy. In 3 other patients laparotomy due to postoperative hemorrhage was necessary. These 6 complications occurred during the first half of the study and were not encountered during the following operations by changing from monopolar to bipolar coagulation and by modifying the regimen for perioperative thrombosis prophylaxis. In the first half of the study in 9 women blood transfusions were necessary and in the second half only 4 patients had to be transfused. In the first 10 patients the mean intraoperative blood loss was 1300 cc, in the last 10 patients 300 cc. After a short learning curve laparoscopic para-aortic and pelvic lymphadenectomy is a safe and effective technique for staging cervical, endometrial, and early ovarian cancers. Though this technique is no standard procedure results of this pilot study warrant prospective studies comparing this technique with conventional procedures.