Correlation between anatomical findings and symptoms in women with pelvic organ prolapse using an artificial neural network analysis

INTRODUCTION AND HYPOTHESIS

The aim of the present study was to assess the relationship between lower urinary tract symptoms, anatomical findings, and baseline characteristics in women with pelvic organ prolapse (POP).

METHODS

A cross-sectional observational study was performed, enrolling consecutive women seeking cares for lower urinary tract symptoms (LUTS) with evidence of POP. Data regarding baseline characteristics, LUTS, and physical examination were gathered for each patient. Multivariate analysis (multiple linear regression (MLR)) and artificial neural networks (ANNs) were performed to design predicting models.

RESULTS

A total of 1,344 women were included. Age, BMI, pelvic organ prolapse quantification (POP-Q) stage I, and previous surgery for urinary incontinence resulted predictors of urgency and stress incontinence. POP-Q stages III-IV were related to voiding dysfunction and POP symptoms. Age, BMI, and menopausal status resulted predictors for sexual dysfunction. Receiver operating characteristic comparison confirmed that ANNs were more accurate than MLRs in identifying predictors of LUTS.

CONCLUSIONS

LUTS result from a fine interaction between baseline characteristics and anatomical findings. ANNs are valuable instrument for better understanding complex biological models.

Surgical and survival outcomes in older women with endometrial cancer treated by laparoscopy

OBJECTIVE

The aim of this study was to evaluate the feasibility and safety of laparoscopic surgical management of apparently early-stage endometrial cancer in older women and to compare clinical outcomes between older and younger women.

METHODS

Our prospective oncological database was retrospectively reviewed to identify all consecutive women who underwent surgery for endometrial cancer from 2002. Data available included information about demography, comorbidities, surgical outcomes, histology, adjuvant therapies, and follow-up. Women were divided in two groups according to age (older, >65 y, and younger, < or =65 y). Univariate and multivariate analyses were performed to identify factors that negatively impact disease-free and overall survival.

RESULTS

A total of 48 (44.4%) older and 60 (55.6%) younger women were included. Groups were comparable in operative time, blood loss, need for blood transfusions, nodal count, and intraoperative and postoperative complications. Cancer in older women was more frequently upstaged than that in younger women (17 [35.4%] vs 8 [13.3%], respectively; P = 0.01). The 2- and 5-year disease-free survival rates were 82% versus 96% (P = 0.003) and 74% versus 93% (P = 0.0005) and the overall 2- and 5-year survival rates were 87% versus 98% (P = 0.006) and 83% versus 95% (P = 0.01) for older and younger women, respectively. Multivariate analysis showed that advanced surgical stage, unfavorable histology, high-grade tumors (grade 3), and deep myometrial invasion (>50%) are independent risk factors for recurrence.

CONCLUSIONS

In the absence of absolute anesthesia contraindications, laparoscopy seems to be feasible and safe in older women with endometrial cancer. Comprehensive surgical staging should be offered, regardless of age, to avoid understaging and to optimize treatment strategies.

Postoperative pain after laparoscopic and vaginal hysterectomy for benign gynecologic disease: a randomized trial

OBJECTIVE

To compare postoperative pain after laparoscopic and vaginal hysterectomy for benign disease.

STUDY DESIGN

A prospective randomized trial was designed to compare laparoscopic hysterectomy and vaginal hysterectomy in patients with uterine volume <or=14 weeks of gestation. Postoperative pain was measured using the visual analog scale (VAS) at 1, 3, 8, and 24 hours postoperatively. Intra- and postoperative outcomes were carefully recorded, including the need for postoperative rescue doses of analgesia.

RESULTS

A total of 82 patients were enrolled. Patients who underwent vaginal hysterectomy complained of higher postoperative pain at each VAS evaluation (VAS-1 hour, P < .0001; VAS-3 hour, P < .0001; VAS-8 hour, P < .0001; VAS-24 hour, P = .0003) with a higher need for rescue analgesia (P < .0001) and a longer hospitalization (P = .001). The other perioperative characteristics were comparable between the 2 groups.

CONCLUSION

Laparoscopic hysterectomy provides an advantage over vaginal hysterectomy in terms of postoperative pain, need for rescue analgesia and hospital stay, with similar perioperative outcomes.

Laparoscopy staging of early ovarian cancer: our experience and review of the literature

We report our experience with laparoscopic staging of apparent early ovarian cancer, and we critically review the current literature on this issue. Potential limits of laparoscopic technique and theoretical concerns of using pneumoperitoneum-based surgery in this setting are addressed.

METHODS

Surgical, pathological, and oncological outcome data of consecutive patients undergoing comprehensive laparoscopic staging for presumed early ovarian cancer at our institution were prospectively collected.

RESULTS

The median operative time was 348 minutes (range, 255-450 minutes). The median estimated blood loss was 250 mL (range, 50-3000 mL). The mean number of pelvic and paraaortic lymph nodes harvested was 24.5 (SD, 6.3) and 9.8 (SD, 7.1), respectively. The disease was upstaged in 6 women (23.1%). No conversion to laparotomy and no intraoperative complication occurred. One patient had a retroperitoneal hematoma recognized in the postoperative period, and this required laparotomy and ligature of the hypogastric arteries to achieve hemostasis. The median follow-up period was 26.7 months (range, 2-83 months). Recurrence-free survival was 96.1%.

CONCLUSIONS

Our results suggest that laparoscopic comprehensive surgical staging is a valuable treatment option for ovarian cancer patients with apparent early disease. Evidence is beginning to accumulate suggesting that minimally invasive surgery is at least equivalent in surgicopathological outcomes and middle-range oncological results to the conventional treatment approach, and early concerns are proving largely unfounded.

Laparoscopic versus open surgery for endometrial cancer: a minimum 3-year follow-up study

BACKGROUND

The paucity of long-term oncologic results published in the literature still prevents the scientific community from cementing the place of laparoscopy as the procedure of choice for managing endometrial cancer. We present the outcomes of consecutive patients with endometrial cancer managed laparoscopically with >3-year follow-up.

METHODS

Data from 117 consecutive women undergoing surgery for treatment of a clinical stage I endometrial cancer and who achieved at least 3-year follow-up were prospectively analyzed. These cases were compared with a historical cohort of 122 consecutive patients with endometrial cancer who had undergone surgery through laparotomy.

RESULTS

The laparoscopy and laparotomy groups were similar with regard to baseline patient characteristics, surgical stage, proportion of tumors with unfavorable histology and high grade, as well as patterns of adjuvant therapy. The median (range) follow-up of surviving patients was 52 (36-84) months in the laparoscopic cohort and 80 (36-151) months in the laparotomy cohort. Women who underwent laparoscopy and those who underwent laparotomy had similar 3-year recurrence-free survival rates (91.4% vs. 88.5%, P = 0.52), as well as similar 3-year overall survival rates (94.0% vs. 93.4%, P = 1.0). Multivariate analysis showed that advanced surgical stage, unfavorable histology, and patient age >65 years significantly affect survival, regardless of the surgical approach used.

CONCLUSIONS

Cancer control in women with endometrial cancer does not appear to be worsened by laparoscopic surgery. In the absence of level I evidence to establish long-term recurrence and survival equivalence, analysis of series as they mature is crucial to fully evaluate disease control afforded by laparoscopy.

Comparison between lidocaine-prilocaine cream (EMLA) and mepivacaine infiltration for pain relief during perineal repair after childbirth: a randomized trial

OBJECTIVE

The purpose of this study was to compare the effectiveness of topically applied lidocaine-prilocaine (EMLA) cream with local anesthetic infiltration in the reduction of pain during perineal suturing after childbirth.

STUDY DESIGN

Sixty-one women with either an episiotomy or a perineal laceration after vaginal delivery were assigned randomly to receive either the application of EMLA cream (n = 31) or infiltration with mepivacaine (n = 30) before perineal suturing. Primary outcome was pain during perineal repair.

RESULTS

Women in the EMLA group had lower pain scores than those in the mepivacaine group (1.7 +/- 2.4 vs 3.9 +/- 2.4; P = .0002). The proportion of women who needed additional anesthesia was similar in the 2 groups (3/30 vs 5/31; P = .71). A significantly higher proportion of women expressed satisfaction with anesthesia method in the EMLA group, compared with the mepivacaine group (83.8% vs 53.3%; P = .01)

CONCLUSION

EMLA cream appears to be an effective and satisfactory alternative to local anesthetic infiltration for the relief of pain during perineal repair.

Ultrasonographic measurement of thymus size in IUGR fetuses: a marker of the fetal immunoendocrine response to malnutrition

OBJECTIVE

To test the hypothesis that intrauterine growth restriction (IUGR) is associated with decreased thymus size in the human fetus.

METHODS

The thymus perimeter was measured in 60 consecutive IUGR fetuses at prenatal ultrasound examination. IUGR was defined as an abdominal circumference (AC) <5(th) centile. Sixty controls were identified by selection of the next consecutive appropriately grown fetus of similar gestational age (+/-1 week). To exclude fetal size effects, ratios between thymus perimeter and fetal biometry measurements including biparietal diameter (BPD), AC and femur length (FL), as well as estimated fetal weight (EFW) were compared between IUGR fetuses and controls.

RESULTS

The proportion of fetuses with thymus perimeter <5(th) centile for gestation was significantly higher in IUGR fetuses than in controls (58/60 vs. 7/60, P < 0.0001). The mean thymus perimeter/BPD ratio (0.87 +/- 0.20 vs. 1.13 +/- 0.13, P < 0.0001), thymus perimeter/AC ratio (0.28 +/- 0.06 vs. 0.35 +/- 0.03, P < 0.0001), thymus perimeter/FL ratio (1.18 +/- 0.26 vs. 1.51 +/- 0.19, P < 0.001) and thymus perimeter/EFW ratio (0.05 +/- 0.01 vs. 0.06 +/- 0.01, P = 0.02) were significantly lower in IUGR fetuses than in controls. There was a significant positive correlation between the observed-to-expected mean for gestation thymus perimeter ratio and the enrollment-to-delivery interval (r = 0.44, P < 0.001).

CONCLUSION

IUGR is associated with a disproportionately small thymus. This supports the hypothesis that thymic involution may be part of the fetal neuroendocrine response to intrauterine starvation.

Should adnexal mass size influence surgical approach? A series of 186 laparoscopically managed large adnexal masses

OBJECTIVE

To evaluate the feasibility and safety of laparoscopic management of adnexal masses > or = 10 cm in size.

DESIGN

Prospective cohort study.

SETTING

Two Gynecology Departments of University Hospitals.

POPULATION

All women presenting with an adnexal mass > or = 10 cm in diameter were candidates for laparoscopic management. Women were excluded from laparoscopic approach if there was evidence of ascites or gross metastatic disease. Neither the sonographic features of the cyst nor elevated serum CA125 level was used to exclude women from having a laparoscopic approach.

METHODS

A single operative protocol was followed for all women. All removed specimens were sent for immediate pathological evaluation.

MAIN OUTCOME MEASURES

Rate of conversion to laparotomy, incidence of cancer encountered, and operative complications.

RESULTS

One hundred and eighty-six women underwent laparoscopic evaluation for an adnexal mass of 10 cm or larger in size. The average preoperative mass size was 12.1 +/- 4.9 cm. A benign pathological condition was found in 86.6% (161/186) of the women, primary ovarian cancer in 16 (8.6%) women, a metastatic tumour of gastrointestinal origin in 1 (0.5%) woman, and a low malignant potential ovarian tumour in 8 (4.3%) women. Laparoscopic management was successful for 174 (93.5%) women. Reasons for conversion to laparotomy included anticipated technical difficulty (n = 7) and malignancy (n = 5). No intraoperative complications occurred in the entire study group.

CONCLUSIONS

The vast majority of large adnexal masses can be safely resected laparoscopically, provided that there is expertise in laparoscopic surgery, immediate access to frozen section diagnosis, and preparation of patient to receive an adequate cancer surgery where indicated.

Blunt expansion of the low transverse uterine incision at cesarean delivery: a randomized comparison of 2 techniques

OBJECTIVE

The purpose of this study was to compare 2 methods of expansion of the uterine incision at the time of cesarean delivery.

STUDY DESIGN

Women who underwent a low-segment transverse cesarean delivery were assigned randomly to have the blunt expansion of the uterine incision by the physician separating the fingers either in a transversal direction or in a cephalad-caudad direction. The primary outcome measure was the incidence of unintended extensions.

RESULTS

The transversal (n = 406) and cephalad-caudad (n = 405) expansion groups were similar with regard to patient characteristics, indication to surgery, type of anesthesia, and proportion of emergency procedures. No difference in the need for transfusions (0.7% vs 0.7%; P = 1.0) or estimated blood loss (440 +/- 341 vs 398 +/- 242 mL; P = .09) was noted. The incidence of unintended extension (7.4% vs 3.7%; P = .03) and blood loss of >1500 mL (2.0% vs 0.2%; P = .04) was significantly higher in the transversal expansion group, compared with the cephalad-caudad group. Transversal expansion was an independent contributor to unintended extension and blood loss of >1500 mL.

CONCLUSION

Because it is associated with less risk of unintended extension and excessive blood loss, expansion of the uterine incision with a cephalad-caudad traction should be preferred to transversal expansion when a cesarean delivery is performed.

Large cross-sectional area of the umbilical cord as a predictor of fetal macrosomia

OBJECTIVE

To determine whether a large cross-sectional area of the umbilical cord is a predictor of fetal macrosomia.

METHODS

Consecutive patients of > 34 weeks' gestation, who presented for sonographic examination and who delivered within 4 weeks of the examination, were included in the study. The sonographic cross-sectional areas of the umbilical cord, the umbilical vessels and the Wharton's jelly were measured in a free loop of the umbilical cord. Logistic regression analysis was used to determine significant predictors of macrosomia (actual birth weight > 4000 g and > 4500 g). Fetal biometric parameters (biparietal diameter, abdominal circumference and femur length), sonographic estimated fetal weight and umbilical cord area > 95(th) centile for gestational age were used as covariates.

RESULTS

During the study period, 1026 patients were enrolled. Fifty-three (5.2%) newborns had a birth weight > 4000 g, and 22 (2.1%) weighed > 4500 g. The proportion of cases with a large umbilical cord was significantly higher in the group of macrosomic compared with non-macrosomic infants (54.7% vs. 8.7%, P < 0.0001). Multiple regression models demonstrated an independent contribution of the large cord in the prediction of birth weight > 4000 g and > 4500 g (odds ratio (95% CI), 20.6 (9.2-45.9) and 4.2 (1.2-17.7), respectively). The sensitivity, specificity and positive and negative predictive values of a sonographic large umbilical cord were 54.7%, 91.3%, 25.4%, and 97.4%, respectively. The combination of abdominal circumference > 95(th) centile and large cord predicted 100% of macrosomic infants. The proportion of umbilical cords with a Wharton's jelly area > 95(th) centile for gestation was significantly higher in macrosomic fetuses of diabetic compared with non-diabetic mothers.

CONCLUSIONS

Sonographic assessment of umbilical cord area may improve the prediction of fetal macrosomia.