PCR detection rates of high risk human papillomavirus DNA in paired self-collected urine and cervical scrapes after laser CO2 conization for high-grade cervical intraepithelial neoplasia.

OBJECTIVE: To compare the PCR detection rates of high risk human papillomavirus DNA in self-collected urine and cervical scrapes during follow-up of patients treated for HG-CIN by laser CO2 conization. PATIENTS AND METHODS: 52 women who submitted to laser conization for HG-CIN were enrolled into this prospective follow-up study receiving liquid-based cytology and HR-HPV testing by PCR assay on self-collected urine and cervical scrapes before and at 3, 6 and 12 months after treatment. Diagnostic accuracy and predictive values for treatment failure were evaluated for both urinary and cervical HPV testing and follow-up cytology. RESULTS: 3 cases (5.8%) of recurrent HG-CIN occurred during follow-up. Positive margins and HR-HPV persistence resulted to significant risk factors for recurrence (p=0.01). The overall concordance on HR-HPV detection between paired urine and cervical samples was 96.6% and discord trend between agreement rates during follow-up were excluded by overall fixed-effect index (OR 1.03; 95% CI 0.62-1.70). No difference was observed comparing the three- and six-month cumulative sensitivity and NPV for recurrent disease of urinary and cervical HPV detections, with an increase of 5.6% in specificity associated with urinary testing. CONCLUSIONS: PCR detection of HR-HPV in paired urine and cervical samples during follow-up revealed an excellent concordance, suggesting a potential equivalent role of the two methods within post-treatment follow-up. In our experience HPV testing on self-collected urine was more sensitive than cytology and more specific than cervical HPV detection to predict treatment failure. Larger studies are needed to definitively establish the role of urine-based HPV testing during follow-up.

CO2 laser cylindrical excision or standard re-conization for persistent-recurrent high-grade cervical intraepithelial neoplasia (HG-CIN) in women of fertile age.

AIM: To investigate the therapeutic efficacy of cylindrical or cone-shaped excision performed by laser CO2 in the conservative management of persistent-recurrent high-grade cervical intraepithelial neoplasia (HG-CIN) in women of fertile age. PATIENTS AND METHODS: Ninety-four premenopausal patients with persistent-recurrent HG-CIN had undergone re-conization or cylindrical excision according to the time of reappearance of the disease. The length of the procedures, intra- and postoperative complications, height of the excised specimens, final histological findings and follow-up data were retrospectively evaluated. RESULTS: Fifty-five (58.5%) persistent and 39 (41.5%) recurrent cases had undergone cylindrical excision and standard re-conization respectively. All the treatments were successfully performed in an out-patient setting under local anesthesia with no differences in term of operative time, height of removed specimens, intra- and postoperative complications between the two groups. Definitive histology confirmed HG-CIN in 95.7% of the cases and FIGO Stage Ia1 cervical cancer (negative lymph vascular space involvement, LVSI) in 4.3% of the cases. The endocervical margins were involved in 3.6% of the cylindrical (persistent) and in 17.9% of the cone-shaped (recurrent) specimens (p = 0.03). The overall cure rate after a median follow-up time of 54 months (range 10-196) was 91.5%. A third excisional procedure was performed in 8 cases of persistent-recurrent HG-CIN with a disease-free subsequent follow-up of 38 months (range 6-108). CONCLUSION: Cylindrical or conical re-excision performed by CO2 laser according to the time of reappearance of the disease seems to be a promising conservative approach for persistent-recurrent HG-CIN even though further randomised prospective studies are needed to confirm the long-term efficacy and reproductive outcomes.

An epidemiological survey of vulvovaginal candidiasis in Italy.

Eight Italian hospital or University gynecology clinics participated in a prospective survey of patients with culture-confirmed symptomatic vulvovaginal candidiasis (VVC) (October 1999 to March 2001). Of 1138 patients recruited in the study, 931 were evaluable. A recent history of VVC was documented in 43.5% patients (358/823) with a mean number of 2.9+/-2.7 episodes per patient (N=302). A total of 77 patients (10.0%) had a history of recurrent VVC (four and more episodes in a 12-month period). The most frequent associated factors were related to life style: synthetic fabric underwear, vaginal douching and bike, training bike and motorbike (about 1/3 each). Oral contraception was found in 20.8% patients, recent antibiotic use in 15.9% patients, current pregnancy concerned 10.3% patients while 3.4% patients were taking hormonal replacement therapy. Diabetes, corticosteroids or HIV were rarely encountered. Yeast was documented by direct microscopy in 78.3% patients (448/572). A positive culture was obtained in 98.3% patients (909/925). Candida albicans was the predominant species (77.1%), followed by Candida glabrata (14.6%) and Candida krusei (4.0%). With the exception of one center with a lower proportion of C. albicans, this latter represented between 75 and 85% of the isolates. Overall, this study confirmed the preponderant role played by C. albicans in either sporadic and recurrent VVC.

CO2 laser surgery for vulvar intraepithelial neoplasia. Excisional, destructive and combined techniques.

OBJECTIVE: To evaluate CO2 laser excision, vaporization and combined techniques for treatment of vulvar intraepithelial neoplasia (VIN). STUDY DESIGN: Thirty-nine cases of VIN 3, 15 cases of VIN 2 and 9 of VIN 1, for a total of 63 patients with histologically proven VIN, underwent laser excision or vaporization under colposcopic guidance, using local anesthesia, in an outpatient setting or after day-surgery admission. Clinical aspects, cervical intraepithelial neoplasia (CIN) and vaginal intraepithelial neoplasia (VaIN) association, types of CO2 laser treatment, follow-up, recurrences and second treatments were evaluated. RESULTS: Twenty-seven (41.3%) patients underwent laser vaporization, and 37 (58.7%) with VIN 3, underwent laser excision or the combined technique. Colposcopic and biopsy examinations of patients with VIN revealed three cases of CIN 3 and nine cases of VaIN 3; two patients had concomitant VIN 3, CIN 3 and VaIN 3. Local anesthesia, using 2% carbocaine, and outpatient or day-surgery treatments were possible in all cases. A small incidence of intraoperative complications (4.8%) and absence of postoperative complications were observed. A single session was curative in 76.9% of patients treated with laser vaporization and in 78.4% of those treated with laser excision. Eleven cases of recurrent VIN and two cases of invasive vulvar carcinoma were observed during follow-up. A second laser procedure was carred out in all cases of relapsed VIN, with an overall cure rate of 96.8% after two treatments. Radical vulvectomy associated with inguinal-femoral lymphadenectomy was performed in the two cases of invasive carcinoma. CONCLUSION: CO2 laser surgery permits treatment of VIN in an outpatient or day-surgery setting under local anesthesia with excellent cosmetic and functional results. The treatment can also be adjusted to the patient's specific needs, with the possibility of calibrating the depth of the vaporized and removed tissues. Excisional treatment is the preferred method because it permits histologic evaluation of the excised tissue and detection of possible occult early invasion.

Carbon-dioxide laser vaporization of the Bartholin gland cyst: a retrospective analysis on 200 cases.

STUDY OBJECTIVE: To evaluate the effectiveness of carbon-dioxide laser vaporization as definitive treatment for Bartholin gland cyst. DESIGN: Retrospective analysis (Canadian Task Force classification II-3). SETTING: University teaching hospital. PATIENTS: A consecutive series of 200 patients with monolateral or bilateral Bartholin gland cyst. INTERVENTIONS: A standardized technique of cyst vaporization performed by carbon-dioxide laser in outpatient setting and local anesthesia. MEASUREMENTS AND MAIN RESULTS: Records of all patients were reviewed for anamnestic information, anatomic parameters, intraoperative and postoperative outcomes, and follow-up data. Seven patients having bilateral cyst were treated in a single session; 207 procedures were performed. The cyst mean size was 6.3 +/- 2.3 cm (95% CI 5.93-6.67). All treatments were completed in outpatient regimen and local anesthesia with a median operative time of 17 minutes (range: 7-45). Three (1.5%) cases of intraoperative major bleeding were observed. The cure rate of a single laser treatment was 95.7%. The 9 patients with recurrent disease observed during follow-up underwent carbon-dioxide laser reintervention by the same therapeutic strategy with a 100% cure rate after 2 or 3 treatments. CONCLUSION: Carbon-dioxide laser vaporization of Bartholin gland cyst represents a safe and effective procedure with complete healing and positive follow-up outcomes. Further randomized trials should be conducted to confirm these findings and to establish the best surgical strategy.

Feasibility of myomectomy performed by minilaparotomy.

BACKGROUND: To evaluate feasibility and clinical outcomes of myomectomy performed through minilaparotomic access in a large series of consecutive patients. METHODS: All patients submitted to laparotomic conservative surgery for uterine myomas through an initial minilaparotomic approach (4-8-cm transverse skin incision) were retrospectively evaluated. Preoperative findings, surgical technique, rate of laparotomic enlargement, operative time, surgical complications and length of recovery were the main analyzed outcomes. RESULTS: One hundred and seventy out of 212 patients experienced minilaparotomic approach for uterine myomatosis. In 97 (57.1%) multiple myomas were present (maximum, 23). The size of the largest myoma ranged from 2 to 19 cm (median 5.6). In 161 (94.7%) patients myomectomy was ended through minilaparotomic access with a mean length of skin incision of 6.2 cm (4-7.8). The correlation between severe obesity and laparotomic enlargement was statistically significant (p<0.05). The mean operative time was 57 min (32-118). One bladder intraoperative injury was successfully managed through minilaparotomic incision. Bowel or vascular complications never occurred. Estimated blood loss was not significant except in three cases (1.9%) requiring transfusion. Febrile complications were observed in nine patients (5.6%). The median postoperative stay in uncomplicated patients was 2.5 days (2-4). CONCLUSIONS: Our report supports the wide application of minilaparotomic myomectomy and suggests that more than 85% of women with fit uterine myomatosis could be successfully managed in this way with a failure rate of 5.3% in eligible patients. The main criteria of minimal invasive surgery seem to be by minilaparotomic myomectomy, which should be considered a valid option for uterine myohas conservative treatment.

Laser CO2 conization in postmenopausal age: risk of cervical stenosis and unsatisfactory follow-up.

OBJECTIVE: To assess chances of adequate cyto-colposcopic follow-up after laser conization performed in postmenopausal screening population by the evaluation of postoperative cervical stenosis and unsatisfactory colposcopy rates. PATIENTS AND METHODS: One thousand two hundred eighteen patients were submitted to laser CO2 conization for cervical intraepithelial neoplasia (CIN). Incidence and risk factors for cervical stenosis and unsatisfactory follow-up were retrospectively evaluated comparing fertile with postmenopausal patients. RESULTS: Global incidences of postoperative unsatisfactory colposcopy and cervical stenosis were 46.2% and 7.1%. These rates were higher in postmenopausal patients compared with fertile ones, revealing a statistical correlation between unsatisfactory follow-up and postmenopausal status at the time of conization. Association between CIN relapse and cervical stenosis was significantly higher in postmenopausal group (66.7% vs. 8.6%; P <0.05), where two cases of recurrence were detected only after hysterectomy, because of an insurmountable cervical stenosis. Univariate and multivariate analysis revealed HRT use as the only significant factor in influencing postoperative cervical stenosis. CONCLUSION: Conization is still considered as the standard treatment for CIN at any woman's age, when excisional management is indicated, but all postmenopausal patients should be counseled about the possibility of postoperative stenosis that could exclude an adequate follow-up, configuring a failure of the conservative treatment. HRT use is associated with a low risk of stenotic complications; therefore, if possible, users should be encouraged to continue therapy at least 1 year after laser conization.

Laser CO2 vaporization for high-grade cervical intraepithelial neoplasia: a long-term follow-up series.

OBJECTIVE: The goal of this study was to evaluate the effectiveness of laser CO(2) vaporization for conservative treatment of ectocervical high-grade cervical intraepithelial neoplasia (CIN) particularly by the evaluation of the reappearance risk of disease in long-term follow-up. METHODS: One hundred fifty-nine patients were submitted to CO(2) laser vaporization for high-grade CIN and followed up for a minimum of 5 years. Selection of cases, depth of ablation, complications, and cure rate (percentage of treated patients in whom there was no recurrent/persistent high-grade CIN at the 5-year follow-up examination) were retrospectively evaluated. RESULTS: Selected cases for colposcopy were submitted to a 6-mm mean depth of vaporization without intra- or postoperative complications. The cure rate for a single treatment was 97.5% and a satisfactory colposcopic follow-up was possible in 99.4% of treated patients. No case of invasive carcinoma occurred after a mean follow-up of 7.1 years. Four cases (2.5%) were high-grade CIN persistence observed after a mean time of 3.75 months, suggesting incomplete destruction of the deepest part of the lesion involving the glandular crypt base. CONCLUSIONS: Long-term follow-up proves that laser CO(2) vaporization still has a place in the treatment of CIN. In selected cases it represents a safe alternative for conization in the treatment of high-grade CIN, but colposcopic expertise is essential for adequate preoperative selection of cases.

Type III female genital mutilation: clinical implications and treatment by carbon dioxide laser surgery.

OBJECTIVE: The purpose of this study was to examine clinical implications of type III female genital mutilation and to evaluate the use of carbon dioxide laser surgery to restore vulvar opening and to treat associated epithelial inclusion cysts. STUDY DESIGN: Twenty-five infibulated patients underwent carbon dioxide laser treatment. Seven of the women (28%) were pregnant, between 10 and 37 weeks of gestation. Vulvar examination revealed five cases of epidermal inclusion cysts. One pregnant patient, with a cyst that was 7 cm in diameter, was at 24 weeks of gestation. Deinfibulation was performed in an outpatient setting with local anesthesia. A colposcopy-guided laser beam was used to create an incision along the fusion midline of the labia majora. In case of vulvar epidermal inclusion cyst, the capsule was opened and emptied of sebaceous contents; the inner surface of the cyst was vaporized completely. RESULTS: The carbon dioxide laser procedure restored a complete vulvar opening in all 25 patients. The complete vaporization of cyst capsule was possible in all five cases. No case of intraoperative or postoperative complication occurred. The average duration of follow-up was 11 months. Four patients who underwent deinfibulation antenatally had labor with spontaneous vaginal delivery and no evidence of perineal trauma. CONCLUSION: On the basis of the advantages that were observed, deinfibulation treatment must be offered to all infibulated patients. The procedure is particularly appropriate during pregnancy to prevent childbirth complications. Laser carbon dioxide has been proved to be a suitable technique for the treatment of female genital mutilation when inclusion cysts are associated with it.