Customized treatment of recurrent gynaecological cancer--the need for intraoperative radiation therapy.

OBJECTIVE: The objective of this retrospective study was to analyze the experience with intraoperative radiation therapy (IORT) at the present institution and to evaluate its contribution to the management of patients with recurrent gynecological cancer. Materials and METHODS: Retrospectively this study reviewed data of patients with a gynecological malignancy considered for treatment with IORT at Freiburg University Medical Center between 2005 and 2012. For this purpose, an analysis of medical records, radiation oncology records, operation reports, and follow-up data was conducted. RESULTS: During the period of this study, 31 women with gynecological cancer underwent tumor resection in combination with IORT. The median age of the patients at the time of IORT was 62 years (range 38-85). Most patients had undergone surgery at the time of initial diagnosis (87%). More than one-third of the patients received prior radiation therapy. In addition to that, 52% of the patients had already received chemotherapy. The majority of patients suffered from the first relapse of their disease. The local recurrence was predominantly located at the pelvic side wall (32%) or in intra-abdominal lymph nodes (32%). In 12 patients the authors did not apply the planned IORT. Intraoperative complications were rare and IORT was tolerated without severe side-effects. Follow-up was 14 months (range 1-65), progression free survival (PFS) was five months (range 3-31). CONCLUSIONS: In carefully selected patients, IORT and cytoreductive surgery contributed to local control and disease palliation. The authors therefore consider IORT an important aspect of modern cancer treatment.

Mechanical properties of pelvic soft tissue of young women and impact of aging.

INTRODUCTION AND HYPOTHESIS: The female pelvic floor is a complex network of ligaments and muscles whose mechanical properties have not been completely understood. The goal of this study is to understand the biomechanical properties of the pelvic floor tissues of young women and the impact of aging. METHODS: Biomechanical uniaxial tension tests were performed on pelvic floor tissues (ligaments and organs) of six young female cadavers (average 29 years old). Results have been analyzed in order to define the characteristics of the mechanical properties of young pelvic soft tissues. Results have been compared with those in the literature in order to understand the similarities and discrepancies between young and old patients. RESULTS: Damageable, nonlinear elastic biomechanical behavior is observed. The variation in stiffness among the pelvic floor organs could be shown. Ligaments and the vaginal wall are the most rigid organs, whereas the rectum and bladder tend to be less rigid (approximately two times less rigid for small deformations and three times less rigid for large deformations). This study shows that ligaments and the vaginal wall of young women have similar mechanical behavior while those of older women differ. Furthermore, young women's tissues differ slightly from older women's tissues. CONCLUSIONS: Results show that aging and possibly diverse "trauma" have an impact on modifying the mechanical behavior of pelvic floor tissues. Over time pelvic floor ligaments and vaginal tissues will differentiate and acquire different mechanical behavior, as seen within the literature in older cadavers.

Lower exposure rates of partially absorbable mesh compared to nonabsorbable mesh for cystocele treatment: 3-year follow-up of a prospective randomized trial.

INTRODUCTION AND HYPOTHESIS: In surgery for pelvic organ prolapse (POP) the use of alloplastic meshes has become common. Among possible complications, mesh exposure is the most frequent problem. It is hypothesized that exposure rates are correlated to mesh weight and the amount of foreign material. Therefore, we conducted a prospective open-label randomized multicenter trial comparing a conventional polypropylene mesh (PP) with a partially absorbable polypropylene mesh (PA) for cystocele treatment. METHODS: A total of 200 patients with POP > stage I were randomized either to a conventional or a partially absorbable mesh. Exposure rates were observed after 3, 12, and 36 months and correlated to mesh material, patient characteristics, intraoperative data, and treatment centers. Furthermore, management of mesh exposure, satisfaction with surgery, and postoperative pain were evaluated. RESULTS: At all follow-up intervals mesh exposure rate was smaller in the group of the partially absorbable mesh (3 months PP 11.3 % vs PA 3.2 %, p=0.0492; 12 months 6.6 % vs 6.3 %; 36 months 7.5 % vs 3.4 %). Over the course of time, mesh exposure was observed in 27 patients, with surgical intervention necessary in 11 patients. The rate of recurrent POP was higher (p>0.05) in patients with the partially absorbable mesh. The majority of patients were fully satisfied with the operation (52.8 %) and had no pelvic floor pain (67.5 %). CONCLUSION: In this prospective, randomized trial with a long-term follow-up there was a low exposure rate in both treatment groups with a trend toward fewer exposures in the group of the partially absorbable mesh.

[Fetal renal failure after intrauterine exposure to inhibitors of the renin-angiotensin system]. / Fetale Niereninsuffizienz bei Therapie mit Hemmstoffen des Renin-Angiotensin-Systems in der Schwangerschaft.

UNLABELLED: HISTORY AND AIM: A 36-year-old woman (primigravida, nullipara) at 25 + 3 weeks of gestation and a 27-year-old (primigravida, nullipara) at 22 + 7 weeks of gestation presented with oligo-/anhydramnios at our department of obstetrics. Both patients suffered from diabetes type 1 and 2, respectively, complicated by diabetic nephropathy, renal hypertension and retinopathy. The first woman had received an AT1 receptor antagonist and a beta blocker, the other one an ACE inhibitor and a beta blocker. At initial clinical examination both patients were in a good general state of health. Respiration, pulse and blood pressure were within normal limits. INVESTIGATIONS: Sonography showed oligy-/anhydramnion with enlarged echogenic kidneys of both fetuses. Having ruled out premature rupture of the membranes the reduced amount of amniotic fluid was interpreted as a consequence of the antihypertensive medication. TREATMENT AND COURSE: The medication was changed to methyldopa which resulted in an adequate and moderate increase of amniotic fluid in both patients. At post partum examination renal failure was confirmed in both infants. The first infant, now a boy at the age of two years, still suffers from chronic renal failure, needing antihypertensive medication with an ACE blocker. Follow-up of the second baby has so far shown normal growth of the kidneys and normotensive blood pressure. CONCLUSION: When planning a pregnancy, a preexisting hypertension should be treated with either methyldopa (1st choice) or a beta blocker as a second choice (e. g. Metoprolol). In patients who are treated with ACE blockers or AT1 antagonists, medication should be changed as soon as the pregnancy is ascertained.

Video-assisted thoracic surgery (VATS) evaluation of intrathoracic disease in patients with FIGO III and IV stage ovarian cancer.

OBJECTIVES: The aim of this study was to assess the influence of video-assisted thoracic surgery (VATS) on our treatment decisions in FIGO III and IV ovarian cancer patients. METHODS: Patients with ovarian cancer and suspected supra-diaphragmatic involvement (pleural effusions, pleural carcinomatosis, lung metastasis, or enlarged supra-diaphragmatic lymph nodes) at chest computer tomography (CT) scan underwent VATS with or without laparoscopy (LSC) to decide for primary cytoreduction or neoadjuvant chemotherapy. Operation time, VATS complications (intrapleural hematoma, secondary hemorrhage with intervention, pneumonia and empyema) and shift in the therapeutic strategy due to VATS were evaluated. RESULTS: 17 patients were included into this study (1 patient with FIGO stage IIIb, 1 with IIIc and 15 with stage IV). The median operation time for VATS only was 46.5 min (range: 20-50 min, n=3). Perioperatively, no complications occurred. After surgical staging, the tumor was confined to the abdomen in four patients in whom primary cytoreduction was attempted. All other 13 patients underwent neoadjuvant chemotherapy. VATS altered the therapeutic management in 6/17 ovarian cancer patients (3 times upstaging, 3 times downstaging). Negative predictive values (NPV) for local and diffuse pleural carcinomatosis ranged between 0.5 and 0.71. CONCLUSION: In this case series, VATS in addition to LSC showed negligible morbidity related to surgery and a short operation time. We were able to improve the accuracy of the FIGO staging and assessed operability more reliably in these patients than through imaging techniques alone.

[Fractures in neonates as a result of birth trauma caused by caesarean section]. / Geburtstraumatische Frakturen nach Kaiserschnitt.

BACKGROUND: The occurrence of 4 bone fractures associated with birth by Caesarean section (CS) prompted us to examine the incidence and predisposing factors of bone injuries sustained during birth. CASE REPORT AND METHOD: The 4 cases with fractures were evaluated retrospectively and discussed in combination with a short review of the literature. CONCLUSIONS: With the increasing number of Caesarean sections the incidence of birth trauma has decreased. Nevertheless, when performing a CS there is still a risk of serious trauma to the neonate, including bone fractures. A Caesarean section for breech presentation constitutes a predisposition for femoral fractures. When diagnosed early and treated properly, the prognosis for these fractures is good without sequelae and one can expect a satisfactory clinical outcome for the child. We suggest that the possibility of this complication be mentioned when counselling the mother and getting informed consent.