Management of early ectopic pregnancy.

OBJECTIVE: Management of early ectopic pregnancy was investigated in a multicenter, prospective study. METHODS: Serum beta-hCG levels were monitored after therapy and correlated to the type of management, gestational age, and initial serum beta-hCG levels in 119 patients with ectopic pregnancies detected at 5-7 postmenstrual weeks. RESULTS: Salpingectomy was performed in 16 patients. No post-operative complications were reported. After conservative laparoscopic surgery of 51 ectopic pregnancies, 9 (18%) had delayed decrease or an increase of serum beta-hCG levels. Re-operations were performed in 4 (7%) patients. Similar findings were noted in 2/6 patients after conservative operations performed by laparotomy. Intrachorionic injection treatment was successful in 17/18 ectopic pregnancies, and expectant management in 7/8 patients with initial serum beta-hCG levels below 250 mIU/ml. CONCLUSIONS: Persistence of trophoblastic activity is a potential complication of conservative surgical treatment of ectopic pregnancy. A detailed diagnosis as early as 6-7 post-menstrual weeks may be the key for future non-surgical management of ectopic pregnancy.

Diagnosis of intrauterine and ectopic pregnancy at 5-7 postmenstrual weeks.

OBJECTIVES: The potential of the combined use of vaginosonography and serum beta-hCG levels for early diagnosis of intrauterine and ectopic pregnancies (5-7 weeks postmenstrual) was investigated in a multicentric study. METHODS: Three hundred and forty-nine patients underwent vaginosonographic examination and determination of serum beta-hCG. When the first examination failed in establishing a precise diagnosis, repeat examinations were performed on alternate days. RESULTS: During the first 3 weeks after the missed menses, vaginosonography can detect practically all viable intrauterine pregnancies, half of the nonviable intrauterine and viable ectopic pregnancies, and one quarter of nonviable ectopic pregnancies, respectively. It was not possible to differentiate intrauterine and ectopic pregnancies by serum beta-hCG levels. CONCLUSIONS: Vaginosonographic screening, ideally at 2 weeks after the missed menses, permits detection, localization, and dating in 80%-90% of suspected pregnancies.

[Endoscopic hernioplasty. Transcutaneous aqua dissection of the hernia sack and pre-peritoneal prosthetic coverage of the abdominal wall defect]. / Endoskopische Hernioplastik. Transcutane Aquadissektion des Bruchsackes und präperitoneale prothetische Deckung des Bauchwanddefektes.

A new endoscopic procedure for hernioplasty is described. Operative pelviscopy technique according to Semm was used.

The Mayer-von Rokitansky-Küster-Hauser syndrome (uterus bipartitus solidus rudimentarius cum vagina solida): the development of gynecology through the history of a name.

A summary of the original descriptions of the Authors who gave the name to the syndrome characterized by absence of uterus and vagina is presented. Through these original descriptions a complete view of the development in gynecology over the last 150 years is offered.

A rabbit model for the evaluation of minimal access treatment of ectopic pregnancy in humans, using intrachorionic injection and local hyperthermia.

Rabbits at mid pregnancy were used as experimental models for investigating the feasibility of intrachorionic injection therapy in human ectopic pregnancy. Also, exposure of rabbit pregnancy to hyperthermia of 45 degrees C was studied. The experiments were followed by serial serum progesterone levels and by light as well as electron microscopy. Intrachorionic injection of different drugs led to demise in 92% of gestations. Application of hyperthermia to the pregnant rabbit uterus led in 94% to demise of gestations. Impairment of the reproductive functions after exposure did not occur. Injection was more effective up to day 15 of pregnancy, while hyperthermia had better results in older gestations. Morphological reactions to injection of different drugs and to hyperthermia were similar. Irreversible damage to the uterine wall was not observed. Intrachorionic injection of drugs may be a suitable treatment of human ectopic pregnancy. Application of hyperthermia may be a promising future therapy.

Improvement in endoscopic hernioplasty: transcutaneous aquadissection of the musculofascial defect and preperitoneal endoscopic patch repair.

Since abdominal wall herniae derive from the abdominal cavity, they are accessible to laparoscopic diagnosis and treatment. This may be more appropriate than the conventional external approach. In five gynecological patients, scheduled for pelviscopic surgery, a coexisting inguinal hernia was endoscopically repaired. Transcutaneous aquadissection of the musculofascial defect using physiological saline solution in a syringe was easy to perform and very helpful in the endoscopic dissection of the peritoneal space. The method is described in specific detail, and recommended for application.

Hernioscopic stuffing of direct inguinal hernia in female patients using resorbable mesh.

Since 1989 we have performed 21 endoscopic hernia repairs in 19 female patients. One recurrent hernia occurred 3 months after laparoscopic preperitoneal patch repair using a single layer of resorbable mesh. Hernioscopy was developed as the transcutaneous endoscopic CO2-gas dissection and subsequent inspection of the preperitoneal hernial sac. Hernioscopic stuffing of the preperitoneal hernial sac using resorbable patch material was performed in seven direct inguinal hernias and in one femoral hernia. Postoperative pain was minimal and convalescence was short. No recurrent hernia occurred during a 1-9-month follow-up.

Gynecologically indicated single-endoloop laparoscopic appendectomy.

A prospective, observational study was performed to define the laparoscopic appearance of chronic or recurrent appendicitis, and to evaluate a new, simplified technique for laparoscopic appendectomy. Chronic appendicitis was assumed in 42 women with long-term or recurrent lower abdominal pain, and appendectomy was performed when two or all three of the following pathologic changes, which were highly predictive of the diagnosis, were present: vascular injection of appendiceal peritoneum, periappendiceal adhesions, and induration of the appendix. After thorough periappendiceal adhesiolysis, a catgut no. 2 endoloop was placed around the base of the appendix and mesoappendix. The appendix was skeletonized, crushed distal to the ligature, regrasped further distally while simultaneously closing the appendiceal lumen, and cut in the crushed area. It was removed retrograde through the left suprapubic 10-mm port. Iodine was applied to the stump. No major intraoperative or postoperative complications occurred. During mean observation of 12.6 months, 74% of women were free of abdominal pain, 12% had partial relief in a mean of 15.4 months' observation, and 12% experienced no change in abdominal pain. This technique is safe, simple, and effective when chronic or recurrent appendicitis is assumed during diagnostic laparoscopy for chronic lower abdominal pain.

Endoscopic patch repair of inguinal hernia in a female patient.

This is a photographically well documented case report of endoscopic patch repair of an inguinal hernia in a female patient. The surgical steps as well as the repair materials are described in detail. Patch repair of abdominal hernias is a promising new application of minimally invasive endoscopic surgery.

Is differentiation of benign and malignant cystic adnexal masses possible by evaluation of cysts fluids with respect to color, cytology, steroid hormones, and tumor markers?

OBJECTIVE: Differentiation of benign and malignant cystic adnexal masses by analysis of cyst fluid was investigated. STUDY DESIGN: Eighty-one cystic adnexal lesions of 80 patients were punctured intraoperatively or after surgical removal. Color of the cyst fluid, cytology, concentrations of steroid hormones (estradiol, progesterone, testosterone), and tumor markers (CEA, CA 125, CA 15-3) were correlated to histology. RESULTS: Color of cyst fluid was not reliable in the differential diagnosis of cystic adnexal masses. Cytology missed four out of seven malignant tumors. One mucinous cystadenoma was cytologically suspicious for malignancy. The combination of negative cytology, low tumor marker levels, and estradiol levels higher than 1000 pg/ml may support the diagnosis of a 'functional' cyst. Elevated CEA levels may be suspicious for all mucinous and malignant lesions. CONCLUSION: Analysis of cyst fluid could not accurately discriminate between benign or malignant tumors.

Creation of a neovagina by pelviscopy.

A pelviscopic method for the creation of a neovagina in a case of Mayer-von Rokitansky-Kuester-Hauser syndrome is described. Only one procedure for endoscopic diagnosis and minimal access operative therapy is required. The operative trauma of the Vecchietti procedure is greatly reduced by replacing the Pfannenstiel incision by pelviscopy.

The role of transvaginal sonography in chorionic villi sampling.

Vaginosonography has the potential of improving not only accurate diagnosis preceeding chorionic villus sampling but also the sampling procedure itself. The vaginosonographic diagnostic landmarks of early pregnancies are the contact area between the amnion and the chorion, the insertion of the umbilical cord, the yolk sac and the decidua-trophoblast complex. The occurrence of a "Swiss-cheese-pattern" in the latter structure is a strong hint for an unfavourable outcome of early pregnancy. Vaginosonographically guided puncture is a promising approach for chorionic villus biopsy. The punturing facilities are firmly attached to the high resolution vaginal ultrasound probe. Thus, precise ultrasound-guided puncture penetrating the vaginal skin and the uterine wall in the shortest possible distance has become possible.

Accuracy of bimanual palpation versus vaginosonography in determination of the measurements of pelvic tumors.

In a prospective study the size of 157 pelvic tumors in 101 patients was measured preoperatively by bimanual palpation and vaginosonography, and the results were compared with measurements made at operation. In 72 uterine and 85 ovarian lesions the Spearman correlation coefficients (rs) between the three maximum diameters at right angles to each other measured at operation and by bimanual palpation ranged from 0.48 to 0.78. The correlation coefficients (rs) between measurements at operation and preoperative vaginosonography ranged from 0.91 to 0.97. The size of small lesions was overestimated by bimanual palpation; 44% of tumors smaller than 5 cm in diameter were only detected by vaginosonography.

[Peri- and postoperative quality of life in pelviscopy and laparotomy]. / Peri- und postoperative Lebensqualität bei Pelviskopien und Laparotomien.

In 298 patients we evaluated criteria of peri- and post-operative quality of life. 222 patients underwent pelviscopic surgery and 76 patients underwent laparotomy. The parameters of convalescence used were: the duration of hospital stay and disablement, the duration and intensity of post-operative discomfort, and the number of consultations in a physician's office after discharge from hospital. Our results show, that minimal access endoscopic surgery can reduce the impairment in the peri- and post-operative quality of life.

Myometrial biopsy in the diagnosis of adenomyosis uteri.

OBJECTIVE: Automatic cutting needle sampling was used for diagnosis of adenomyosis uteri. The purpose of this study was the establishment of myometrial biopsy as a clinically applicable method. STUDY DESIGN: Sensitivity and specificity of myometrial biopsy in diagnosis of uterine adenomyosis was estimated by examining 680 biopsy specimens from 68 surgically removed uteri. In 34 patients with clinical symptoms of adenomyosis uteri 70 myometrial biopsies were performed during laparoscopy, and vaginal ultrasonographically guided myometrial biopsy was performed in six patients (14 specimens) without complications. Prevention of myometrial bleeding was achieved by prophylactic injection of ornipressin into the biopsy cannula. RESULTS: The sensitivity of a single myometrial sample for diagnosing adenomyosis uteri ranged from 8% to 18.7%; specificity was 100%. CONCLUSION: Our results may encourage further investigation on the clinical use of myometrial biopsy.

Ectopic pregnancy treatment using pelviscopic or vaginosonographically-guided intrachorionic injection of methotrexate and POR 8.

It is believed by some that the basis of modern first-trimester pregnancy care should involve screening for ectopic pregnancy using vaginal ultrasonography. This has led to this condition being diagnosed in most cases at an earlier stage than has previously been possible. This advance in diagnostic ability has introduced the concept of conservative management for this condition. The authors describe the conservative management of nine cases of ectopic pregnancy using intrachorionic injection of either methotrexate alone or in combination with POR 8. In all cases less than 9 weeks had passed since the last menstrual period, and the ectopic pregnancies treated under ultrasound control were all thought to be viable. Five cases were treated using pelviscopy, whilst in another four the needle was guided using vaginal ultrasonography. There were no procedure-related complications. Following therapy, the women were followed up using serial levels of serum beta-hCG. In seven cases there was a gradual reduction to normal levels. There were two treatment 'failures'. In both these cases methotrexate alone, rather than in combination with POR 8, was used for injection. Although formal tests of tubal patency have not been performed in all cases, one woman in the series has since conceived and has a normal intrauterine pregnancy. It is concluded that vaginal instillation of methotrexate is an alternative treatment for early ectopic pregnancy. It should be limited to viable ectopic pregnancies whose chorionic cavities are less than 2.0 cm in diameter. A plan for the management of ectopic pregnancy is presented, involving selection for both ultrasound-guided injection and pelviscopic surgery. Laparotomy is not considered to be a treatment option in the majority of cases.

[Gynecologic endosonography: initial experiences]. / Gynäkologische Endosonographie: erste Erfahrungen.

Basing on our research work in hysteroscopy, we used recently developed small endosonographic sounds for intrauterine and later vaginal approach, for the first time in 1981. We call this method endosonography. The equipment used so far is described, the procedure explained, and the efficacy of this new technique demonstrated via several endosonograms. The advantage to transabdominal sonography is the close contact of the ultrasound transducer with the organ to be examined. This enables the use of high frequencies with correspondingly good resolution. Finally, our own experience is discussed.

[Amniocentesis under permanent ultrasonic control--advantages of a special procedure]. / Amniozentese unter permanenter Ultraschallsicht--Vorteile eines speziellen Verfahrens.

Advocates of the so-called "free hand technique" in amniocentesis argue against permanent sonographic control as follows: "Free hand technique" is the only method enabling vertical guiding of the puncture needle between abdominal wall and amniotic cavity, and hence to cover the shortest distance with the lowest risk of traumatisation. "Free hand technique" is the only method permitting sensitive guiding of the needle in amniocentesis, since the puncturing doctor can use both hands without requiring one hand for sonographic examination. Amniocentesis under permanent sonographic control is claimed to raise serious problems in guaranteeing the necessary sterility. The authors present a modification of the puncture method with permanent sonographic control. This does away with all of the above arguments against permanent sonographic control, whereas all of its obvious advantages are retained (greater safety, less risk of injury). The method employs a fixation scaffolding and an aiming groove for routine sector scanning (Figures 1 and 2). The entire system is covered in a sterile manner by a pasted-on foil sheeting after having introduced the sonographic contact gel. The only contact medium for the skin is a disinfecting agent enabling satisfactory imaging (Figure 4). This method offers the following advantages over the methods using conventional puncture soundheads: Better possibility of disinfection. No rigid guiding of needle, and hence correction can be effected even during puncture. Adjacent levels can be observed by free displacement of scanner and needle. Modifiable puncture angle in respect of skin and uterus. The fixation scaffolding does away with the need for an assistant, and enables tremor-free fixation of the scanner during puncture.(ABSTRACT TRUNCATED AT 250 WORDS)