Randomised trial of laparoscopic Burch colposuspension versus tension-free vaginal tape: long-term follow up.

OBJECTIVE: To compare the long-term efficacy of laparoscopic Burch colposuspension with tension-free vaginal tape (TVT) for the treatment of urodynamic stress urinary incontinence (SUI). DESIGN: Long-term follow up from a prospective randomised trial. SETTING: Academic tertiary referral centre. SAMPLE: Seventy-two women with urodynamic SUI from two institutions. METHODS: Subjects were randomised to either laparoscopic Burch or TVT from August 1999 to August 2002. Follow-up evaluations occurred 6 months, 1 year, 2 years, and 4-8 years after surgery. MAIN OUTCOME MEASURES: Subjects completed the Incontinence Severity Index, Urogenital Distress Inventory 6 (UDI-6), Incontinence Impact Questionnaire (IIQ-7), and Patient Global Impression of Improvement (PGI-I) scales. RESULTS: Median follow-up duration was 65 months (range 12-88 months) with 92% completing at least one follow-up visit. Seventy-four percent of subjects had long-term (4-8 years) follow up. Fifty-eight percent of subjects receiving laparoscopic Burch compared with 48% of TVT subjects reported any urinary incontinence 4-8 years after surgery (Relative Risk (RR):1.19; 95% CI: 0.71-2.0) with no significant difference between groups. Bothersome SUI symptoms were seen in 11 and 8%, respectively, 4-8 years after surgery (P = 0.26). There was significant improvement in the postoperative UDI-6 and IIQ-7 scores in both groups at 1-2 years that were maintained throughout follow up with no significant differences between the groups. CONCLUSIONS: TVT has similar long-term efficacy to laparoscopic Burch for the treatment of SUI. A substantial proportion of subjects have some degree of urinary incontinence 4-8 years after surgery; however, the majority of incontinence is not bothersome.

Obesity and retropubic surgery for stress incontinence: is there really an increased risk of intraoperative complications?

OBJECTIVE: The objective of the study was to evaluate the impact of obesity on length of surgery, blood loss, and intra- and postoperative complications in women who underwent retropubic surgery for stress urinary incontinence. STUDY DESIGN: Of 449 women participating in a multicenter, randomized trial evaluating antibiotic prophylaxis in women with suprapubic catheters, 250 women underwent retropubic anti-incontinence procedures. This is a prospective nested cohort study of these women, 79 (32%) of whom were obese (body mass index 30 or greater) and 171 (68%) overweight or normal weight (body mass index less than 30). Data collected included demographic variables, past medical history, physical examination, and intraoperative and postoperative complications. Data were analyzed with Fisher's exact for dichotomous variables, Student t tests for continuous variables, and analysis of variance for multivariate analysis. Significance was set at P < .05. RESULTS: Obese women undergoing stress urinary incontinence surgery were younger than nonobese women (48.7 versus 51.9 years, respectively, P < .019). The number and type of additional surgeries performed were similar between groups with the exception that obese women were less likely to undergo abdominal apical suspensions (P = .006) or abdominal paravaginal repairs (P = .001); therefore, estimated blood loss, change in hematocrit, length of stay, surgery, and suprapubic catheterization comparisons are adjusted for the performance of these procedures. Estimated surgical blood loss was greater for obese women (344 versus 284 P = .03); however, change in hematocrit was lower for obese than nonobese women (6.6 versus 7.3, P = .048). Mean length of surgery was 15 minutes longer in obese women (P = .02). Length of hospital stay did not vary between groups (P = NS). Major intraoperative complications were uncommon (14 [5.6%]), with no difference between weight groups. Incidence of postoperative urinary tract infection, wound infections, or postoperative major complications were likewise similar between groups (all P > .05). CONCLUSION: Surgery takes longer for obese patients, but blood loss as recorded by change in hematocrit is lower. Major complications were rare and similar between weight groups, as were infectious complications.

Cost effectiveness of expanded antenatal HIV testing in London.

BACKGROUND: Recently the Department of Health announced the introduction in England of voluntary universal HIV screening in early pregnancy to prevent vertical transmission. New data have shown the importance of HIV infection in infants born to mothers who were HIV-negative in early pregnancy and who acquired HIV later in pregnancy or during lactation. This requires consideration of repeat testing in late pregnancy and testing of partners of pregnant women (expanded antenatal HIV testing). OBJECTIVE: To estimate cost effectiveness of expanded antenatal HIV testing in London (England) within the framework of universal voluntary HIV screening in early pregnancy. DESIGN: Incremental cost-effectiveness analysis. METHODS: Cost estimates of service provision for HIV-positive children and adults by stage of HIV infection were combined with estimates of health benefits for infants and parents and with costs of counselling and testing (testing costs). In a pharmacoeconomic model cost effectiveness was estimated for expanded antenatal HIV testing in London for universal and selective strategies. RESULTS: Testing costs in the plausible range of pounds sterling 4 to pounds sterling 40 translate into favourable incremental cost-effectiveness estimates for expanded antenatal HIV testing in London which is already at low numbers of vertical transmissions averted per 100000 pregnant women who test HIV-negative in early pregnancy. Favourable cost effectiveness for universal expanded testing would require testing costs in the lower range, whereas selective expanded testing may produce favourable cost effectiveness at testing costs close to pounds sterling 40. CONCLUSION: Based on pharmaco-economic considerations, the authors believe that implementation of expanded HIV testing in London should be considered.

Transvaginal mobilization and removal of ovaries and fallopian tubes after vaginal hysterectomy.

OBJECTIVE: To describe a technique of transvaginal mobilization and removal of ovaries and tubes, and to assess its use in older women undergoing vaginal hysterectomy. METHODS: Charts of 151 women age 50 and older who underwent vaginal hysterectomy by one senior gynecologic surgeon during 1991-1993 were reviewed. RESULTS: Ninety of 138 women (65%) who chose ovarian removal had their ovaries successfully removed vaginally. In 48 women, one or both ovaries were examined and noted to be normal, and they were not removed or could not be removed vaginally. Operating time, estimated blood loss, length of hospital stay, and rates of intraoperative complications and postoperative morbidity did not differ significantly in the bilateral salpingo-oophorectomy and ovarian conservation groups. CONCLUSION: Transvaginal removal of ovaries and tubes can be achieved in about two-thirds of women undergoing vaginal hysterectomy with minimal or no increases in operating time and surgical morbidity.

Combination of pessary and periurethral collagen injections for nonsurgical treatment of uterovaginal prolapse and genuine stress urinary incontinence.

BACKGROUND: The combination of severe uterovaginal prolapse and stress urinary incontinence in medically compromised patients in whom surgery is contraindicated is a difficult treatment dilemma. CASE: A 75-year-old woman with severe cardiac compromise and a history of pulmonary embolus presented with severe uterovaginal prolapse and stress urinary incontinence. The combination of a vaginal pessary and three periurethral collagen injections resulted in successful management of her prolapse and resolution of her stress urinary incontinence. CONCLUSION: Although pessaries are frequently a satisfactory treatment option for women with severe uterovaginal prolapse, the appearance or worsening of urinary incontinence may make the option of pessary use less attractive. The addition of periurethral collagen injections will improve or cure urinary incontinence symptoms.

Anterior vaginal prolapse: review of anatomy and techniques of surgical repair.

OBJECTIVE: To summarize the literature on anterior vaginal prolapse, focusing on vaginal anatomy, etiologic theories, and comparison of anterior colporrhaphy and paravaginal repair. DATA SOURCES: We identified articles related to anterior vaginal prolapse through a MEDLINE search of English-language literature published from January 1966 through December 1995 and in bibliographies in gynecologic textbooks. METHODS OF STUDY SELECTION: We reviewed 80 articles published in peer-reviewed journals or textbooks and related to anterior vaginal prolapse. In addition, ten articles on operative procedures for urinary incontinence were studied. TABULATION, INTEGRATION, AND RESULTS: We abstracted and synthesized information from 31 papers that contained descriptions of and opinions on vaginal anatomy and etiology of vaginal prolapse. The vagina has three layers-mucosa, muscularis, and adventitia; there is no vaginal "fascia." Vaginal support is provided by the underlying levator ani muscles and by lateral connective-tissue attachments at the arcus tendineus fasciae pelvis or "white line." Anterior vaginal prolapse results from direct or indirect damage to the pelvic muscles or connective tissue or both. Forty-nine articles described surgical techniques for the correction of anterior vaginal prolapse, and 24 of them reported postoperative outcomes. Reported failure rates ranged from 0-20% for anterior colporrhaphy and 3-14% for paravaginal repair. No controlled studies compared different procedures performed primarily for correction of anterior vaginal prolapse. CONCLUSIONS: Dissection during anterior colporrhaphy splits vaginal muscularis, and repair involves plication of the muscularis and adventitia (not vaginal "fascia") in the midline, which may pull the lateral attachments further from the pelvic sidewall. Paravaginal repair restores the lateral attachments to the pelvic sidewall at the white line. Controlled studies that compare directly these two procedures for anterior vaginal prolapse repair are necessary to determine their relative effectiveness.

Q-tip test: a study of continent and incontinent women.

Urethral axis position and mobility, as determined by the "Q-tip test," were measured in subjectively continent women (N = 26), women with genuine stress incontinence (N = 28), and women with other types of urinary incontinence and voiding dysfunction (N = 20). Diagnostic urodynamic evaluation in symptomatic women included standard history, physical examination, urine culture, Q-tip test, uroflowmetry, standing "stress test," resting and stress urethral pressure profiles, and subtracted medium-fill water cystometry with provocation. Multiple regression analysis was used to determine the existence of significant clinical predictors of the dependent variables (stress angle, urethral mobility). These factors were used as covariates to identify differences between the adjusted group means. The results indicate a wide range of values for each Q-tip test measurement in all groups. Age, parity, resting Q-tip angle, and the presence of anterior vaginal relaxation were associated with maximum stress Q-tip measurement. Significant differences in maximum stress Q-tip angle and urethral mobility were noted only between the continent controls and women with genuine stress incontinence. No differences were found between the two incontinent study groups. We conclude that urethral position and mobility as measured by the Q-tip test are related to defects in anterior vaginal support, but not to specific urologic diagnosis.

A randomized comparison of gentamicin-clindamycin and cefoxitin-doxycycline in the treatment of acute pelvic inflammatory disease.

In this prospective trial, 130 hospitalized patients with acute pelvic inflammatory disease based on clinical criteria were randomly treated with intravenous gentamicin plus clindamycin (N = 63) or cefoxitin plus doxycycline (N = 67) for at least 4 days, followed by oral clindamycin or doxycycline, respectively, for a total of 14 days. Pre-treatment cultures were obtained for endocervical Neisseria gonorrhoeae and Chlamydia trachomatis, and for endometrial C trachomatis and aerobic and anaerobic bacteria. Overall, 46 subjects (35%) had endocervical cultures positive for N gonorrhoeae. Endocervical and endometrial cultures were positive for C trachomatis in 16 and 6%, respectively. Ninety-five percent of patients had at least one aerobic bacterium, 38% had at least one anaerobic bacterium, and only 2% had no organisms isolated from their endometrium. Fifty-seven subjects taking gentamicin-clindamycin (90.5%) and 64 subjects taking cefoxitin-doxycycline (95.5%) were clinically cured, a nonsignificant difference. Three subjects treated with gentamicin-clindamycin and one treated with cefoxitin-doxycycline required hysterectomy or salpingectomy for cure. Follow-up examinations and cultures were performed in 84% of the subjects. Post-treatment cultures for N gonorrhoeae were negative in all cases tested. Post-treatment endocervical and endometrial C trachomatis cultures were negative in ten of 11 subjects treated with gentamicin-clindamycin and in eight of nine treated with cefoxitin-doxycycline, a nonsignificant difference. We conclude that gentamicin-clindamycin and cefoxitin-doxycycline have similar clinical cure rates for acute pelvic inflammatory disease and are equivalent in eradicating genital N gonorrhoeae and C trachomatis.

Burch procedure compared with sling for stress urinary incontinence: a decision analysis.

OBJECTIVE: To compare the relative risks and benefits of Burch colposuspension and sling procedure for primary genuine stress urinary incontinence in women. METHODS: We developed a decision analytic model to compare Burch procedure and sling for primary surgical treatment of genuine stress incontinence with urethral hypermobility in women. Risks and benefits were estimated from published literature. The main outcome measure was effectiveness of treatment, defined as cure of incontinence after initial and secondary treatments. We considered four outcomes of primary surgical treatment: cure, persistent incontinence (either caused by intrinsic sphincter deficiency without urethral hypermobility or genuine stress incontinence with hypermobility), de novo detrusor instability, and permanent urinary retention. Secondary treatment included repeated surgery for genuine stress incontinence, collagen injection for intrinsic sphincter deficiency, medical treatment for detrusor instability, and urethrolysis for retention. One-way sensitivity analyses were used to estimate the effect of varying each characteristic through its range; all other characteristics were fixed at their baseline values. RESULTS: The overall effectiveness of Burch and sling operations (percentages of women cured after initial and secondary treatments) was similar (94.8% and 95.3%, respectively). In sensitivity analyses, the Burch arm of the model was more effective than sling when the risk of retention after sling was higher than 9.0% or when the risk of de novo detrusor instability after sling was higher than 10.3%. Conversely, when the risk of de novo detrusor instability after Burch was higher than 6.8%, the sling arm of the model was more effective. CONCLUSION: The Burch and sling procedures are similarly effective for primary surgical treatment of genuine stress incontinence in women. Overall effectiveness is substantially influenced by relative rates of complications.

The contralateral corpus luteum and tubal pregnancy.

One hundred fourteen cases of tubal pregnancy were examined for evidence of active or chronic salpingitis, other anatomic and functional etiologies, and the side of the corpus luteum relative to the pregnancy. A corpus luteum was found ipsilateral to the tubal pregnancy in 80 cases (70%) and contralateral in 18 (16%). In 16 cases (14%), the position of the corpus luteum could not be identified by inspection. No differences were noted among the groups in days from last normal menstrual period or the incidence of irregular bleeding. Of the 98 cases in which a corpus luteum was identified, 53 women (54%) had at least one condition that could be considered etiologic for tubal pregnancy, including 38 (39%) who had microscopic evidence of chronic salpingitis. No association was found between the laterality of the corpus luteum and the presence of risk factors, including mechanical factors. Possible explanations for absent corpora lutea in association with tubal pregnancies are discussed.

Psychosexual study of women with detrusor instability.

Clinical impression suggests that many cases of detrusor instability are psychosomatic. We evaluated 63 women with urinary incontinence and 27 continent controls using the Minnesota Multiphasic Personality Inventory, Uplift and Hassle Scales, and a structured questionnaire screening sexual dysfunction. All incontinent women underwent diagnostic urodynamic studies including uroflowmetry, subtracted water cystometry with provocation, and urethral closure pressure profilometry. Thirty-five women had genuine stress incontinence and 28 had detrusor instability, including nine with mixed incontinence. No differences in psychological test results were noted between the detrusor-instability and genuine-stress-incontinence groups. On the Minnesota Multiphasic Personality Inventory, subjects with detrusor instability scored significantly higher than controls on the hypochondriasis (P = .006), depression (P = .01), and hysteria (P = .0009) scales. Compared with continent controls, the detrusor-instability group reported a lower frequency of uplifts (P less than .05) and a greater intensity of hassles (P less than .05). Both incontinent groups reported more sexual dysfunction than did controls. We conclude that many women with urinary incontinence have abnormal psychological and sexual test results reflecting moodiness, feelings of helplessness and sadness, pessimism, general hypochondriasis/somatization, and sexual dysfunction. These abnormalities appear to be associated with urinary incontinence in general rather than with specific diseases of the urinary tract.

Sexual function in women with uterovaginal prolapse and urinary incontinence.

OBJECTIVE: To compare sexual function in women with and without uterovaginal prolapse and urinary incontinence. METHODS: Eighty women with prolapse and with or without incontinence and 30 continent women without prolapse completed questionnaires assessing sexual function and underwent a physical examination. RESULTS: Women with prolapse were older than those without prolapse (mean age +/- standard deviation 58.2 +/- 13.0 versus 49.2 +/- 8.4 years, respectively; P < .001). The proportions of sexually active women were similar in both groups (56 and 57% for those with and those without prolapse, respectively). Measures of sexual function were not significantly different between the two groups. The mean global sexual function score was 0.58 +/- 0.15 in the prolapse group and 0.55 +/- 0.14 in the comparison group, a nonsignificant difference. The proportion of women with vaginal dryness or dyspareunia did not differ significantly between the two groups. Interest in sexual activity was unchanged in 70% of sexually active women with prolapse and incontinence, and 84% reported satisfaction with their sexual relationship. Twenty of 45 (44%) sexually active women with prolapse reported incontinence during sexual activity, and 14 (31%) reported that incontinence or prolapse interfered with sexual activity. After multivariate analysis, increasing age was the only significant factor predictive of a higher global sexual function score (P = .02), indicating worse sexual function. Increasing grade of prolapse predicted interference with sexual activity (P = .05), although this did not affect frequency of intercourse or description of satisfaction with the sexual relationship. CONCLUSION: Women with prolapse and urinary incontinence do not differ from continent women without prolapse in measures of sexual function; age is the most important predictor of sexual function.

Vaginal anatomy and sexual function.

OBJECTIVE: To describe vaginal anatomy related to sexual function in women. METHODS: One hundred four women presenting for gynecologic care (mean age 55.8 years) completed questionnaires assessing sexual function and underwent measurements of vaginal caliber and length, and grading of vulvovaginal atrophy. RESULTS: Women who were not currently sexually active had a higher mean body mass index. Current sexual activity was not associated with differences in vaginal length or introital caliber. Among 73 sexually active women, 30 had one or both symptoms of dyspareunia and vaginal dryness, and 43 had neither symptom. Menopausal status, current use of estrogen, introital caliber, and vaginal length were not different in women with dyspareunia, vaginal dryness, or both when compared to women having neither symptom. Premenopausal women with dyspareunia, vaginal dryness, or both had significantly higher global sexual function scores, reflecting worse sexual function, when compared with premenopausal women without these symptoms (0.61 +/- 0.16 versus 0.46 +/- 0.15, respectively; P = .02); however, there was no significant difference in postmenopausal women (0.60 +/- 0.12 versus 0.61 +/- 0.12). CONCLUSION: Vaginal anatomy, measured by introital caliber, length, and vulvovaginal atrophy, does not correlate well with sexual function, particularly symptoms of dyspareunia and vaginal dryness.

Vascular injury during tension-free vaginal tape procedure for stress urinary incontinence.

BACKGROUND: Tension-free vaginal tape procedure is a popular surgical treatment of genuine stress urinary incontinence. CASES: Two cases of retropubic hematoma after tension-free vaginal tape procedure are reported. One woman with an 8 x 10 cm hematoma localized to the retropubic space required transfusion of two units of packed red blood cells for symptomatic relief. Neither case required reoperation, and both patients' hematomas resolved over 6 months without treatment. Both patients were continent 9-12 months after surgery. CONCLUSION: Although the tension-free vaginal tape procedure is a minimally invasive operation for stress urinary incontinence and appears to be effective, significant vascular complications can result.

Determinants of voiding after three types of incontinence surgery: a multivariable analysis.

OBJECTIVE: To determine the time to normal voiding in women after various surgical procedures for genuine stress urinary incontinence (GSUI) or urethral hypermobility. METHODS: One hundred one women had bladder neck suspensions. Suprapubic catheters were used in 94 women and intermittent self-catheterization in seven to manage urinary retention after surgery. We used a standardized protocol to record days to adequate postoperative voiding. Univariable and multivariable regression analyses were used to determine clinical, urodynamic, and surgical factors that independently influenced time to adequate postoperative voiding. RESULTS: Women met the criteria for adequate voiding a mean of 7.1 days after modified open Burch procedures (n = 43), 9.5 days after anterior colporrhaphies with suburethral plication (n = 24), and 19.1 days after vaginal wall sling procedures (n = 34). The type of bladder neck suspension was independently associated with increasing time to void (P =.001). Multivariable regression analysis determined other factors significantly associated with longer time to adequate postoperative voiding: advancing age, previous vaginal bladder neck suspension, increasing volume at first sensation on bladder filling, higher postvoid residual urine volume (preoperative), and postoperative cystitis. Detrusor pressure, abdominal straining on pressure flow voiding study, and other concurrent surgeries were not significantly associated with postoperative voiding time in this model. CONCLUSIONS: Time to adequate voiding after bladder neck suspension was influenced by type of surgical procedure, postoperative cystitis, and several demographic and urodynamic factors. This study does not support using pressure flow studies to predict women at risk of voiding dysfunction.

Postabortal hemorrhage due to placenta increta: a case report.

Placenta accreta is defined as a condition involving an abnormal adherence of the placenta to the myometrium. It is rare for placenta accreta to present before 20 weeks' gestation; only eight cases have been previously reported. This case report describes a first-trimester placenta accreta which presented during suction curettage for missed abortion. The major risk factors for placenta accreta are related to previous uterine trauma. Considering the rising rate of operative births in the United States, it is possible that the incidence of placenta accreta in early gestation will increase.

Intraoperative cystoscopy in conjunction with anti-incontinence surgery.

OBJECTIVE: To determine the frequency of lower urinary tract injury detected by routine intraoperative cystoscopy after anti-incontinence surgery. METHODS: We reviewed charts from women who had anti-incontinence surgery and routine intraoperative cystoscopy done by a single surgeon from June 1, 1995, to June 1, 1998, and assessed preoperative and intraoperative variables. RESULTS: We reviewed 351 patient records. Four records were incomplete and there were nine injuries in the other 347 cases (2.6%, 95% confidence interval [CI] 1.2, 4.9). Four cystotomies occurred during laparoscopic Burch procedures and were detected before cystoscopy. Five injuries were detected at cystoscopy, a rate of 1.5% (95% CI 0. 5, 3.4). Four injuries occurred during 161 pubovaginal sling procedures (2.5%, 95% CI 0.7, 6.2). One woman had sutures in her bladder from a prior procedure detected at cystoscopy. In 186 Burch procedures (48 laparoscopic, 138 open), there were no previously unrecognized injuries detected by cystoscopy. All injuries were repaired during original surgery. It was not possible to assess preoperative and intraoperative risk factors because of the low rate of injury. CONCLUSION: The rate of injury to the lower urinary tract during anti-incontinence surgery in this series was 2.6% (95% CI 1.2, 4.9). Injuries during Burch procedures were all detected before cystoscopy.

Prevalence of hydronephrosis in patients undergoing surgery for pelvic organ prolapse.

OBJECTIVE: To determine the prevalence of hydronephrosis in patients undergoing surgery for pelvic organ prolapse and to determine whether hydronephrosis is associated with the type and severity of prolapse. METHODS: The charts of 375 consecutive patients undergoing surgery for pelvic organ prolapse at the Cleveland Clinic Foundation between January 1, 1990, and December 31, 1993 were reviewed. Preoperative renal ultrasounds and intravenous pyelograms (IVP) were evaluated for hydronephrosis based on the final diagnosis established by the radiologists. The severity of prolapse was determined from the preoperative office examination or from the examination under anesthesia at the time of surgery. RESULTS: Of 375 patients, 323 had either a preoperative renal ultrasound or IVP. The mean age was 66.0 +/- 10.2 years (range 35-93) and median parity was 3.0 (range 0-10). Of the 323 patients, 25 (7.7%, 95% confidence interval 5, 11) had hydronephrosis. Thirteen patients (4.0%) had mild hydronephrosis, nine (2.8%) had moderate hydronephrosis, and three (0.9%) had severe hydronephrosis. The prevalence of hydronephrosis increased with increasing severity of prolapse. Two patients with hydronephrosis had evidence of renal insufficiency (creatinine > or = 1.6), and both had severe bilateral hydronephrosis and complete procidentia. The prevalence of hydronephrosis was lower in patients with vaginal vault prolapse versus uterine prolapse (3.9% compared with 12.6%, P < .01), CONCLUSION: The prevalence of hydronephrosis in patients undergoing surgery primarily for pelvic organ prolapse is low, increases with worsening pelvic organ prolapse, and is lower in patients with vaginal vault prolapse that in those with uterine prolapse.

Anatomy and pathology of tubal pregnancy.

The prevalence of tubal pregnancy has increased markedly during the past decade. The reasons for this are obscure. A systematic gross and histopathologic study of 25 consecutive ectopic pregnancies has been performed using a clearing method not used previously for this purpose. In addition, the presence of the corpus luteum and its location in reference to the tubal pregnancy are documented. Results indicate that trophoblastic spread was predominantly intraluminal in 67% of cases. Intratubal hemorrhage, generally in parallel to trophoblastic spread, often led to marked tubal destruction. Histologic evidence of salpingitis was noted in only seven of 24 specimens (29%). The corpus luteum was contralateral to the ectopic pregnancy in five of 21 cases (23.8%). Clinical correlates and areas of future research are discussed. Results indicate that segmental resection of the tubal pregnancy is appropriate in selected cases.