摘要:

ObjectiveTo compare intraoperative and postoperative outcomes between laparoscopically assisted vaginal hysterectomy and abdominal hysterectomy among patients who are not eligible for vaginal hysterectomy.MethodsStudy subjects were randomly assigned to undergo laparoscopically assisted vaginal hysterectomy or standard abdominal hysterectomy. Intraoperative and post-operative management was similar for each group. Surgical characteristics, complications, length of hospital stay, charges, and convalescence were analyzed.ResultsSixty-five women at three institutions underwent laparoscopically assisted vaginal hysterectomy (n= 34) or abdominal hysterectomy (n= 31). Three patients in the laparoscopic group required conversion to abdominal hysterectomy. Mean operating time was significantly longer for laparoscopically assisted vaginal hysterectomy (179.8 versus 146.0 minutes). There were no differences in blood loss or incidence of intraoperative complications. There was a higher incidence of wound complications in the abdominal hysterectomy group, but no significant difference in the frequency of postoperative complications. Laparoscopically assisted vaginal hysterectomy required a significantly shorter mean hospital stay (2.1 days) and convalescence (28.0 days) than abdominal hysterectomy (4.1 days and 38.0 days, respectively). There were no significant differences in mean hospital charges between the study groups (laparoscopic $8161, abdominal $6974).ConclusionExcept for operating time, there are no differences between laparoscopically assisted vaginal hysterectomy and abdominal hysterectomy regarding intraoperative characteristics among abdominal hysterectomy candidates. Postoperatively, laparoscopically assisted vaginal hysterectomy requires a shorter hospital stay and convalescence. Hospital charges are similar between the procedures. A larger number of cases will help determine the indications for laparoscopically assisted vaginal hysterectomy.

ISSN:0029-7844    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

ObjectiveTo determine the incidence and predictors of risk for operative complications, conversions to laparotomy, and postoperative admissions after laparoscopic procedures.MethodsWe obtained demographic information on and medical histories of a consecutive series of 843 women who underwent laparoscopic surgery for all procedures other than tubal ligation at Brigham and Women's Hospital during 1994. All major complications after surgery were recorded. Major operative complications were defined as bowel, bladder, ureter, or vascular injuries or significant abdominal wall or other internal bleeding. Categorical analysis was used to compare differences in the rates of operative complications, conversions to laparotomy, and postoperative admissions after laparoscopy. We also estimated the influence of medical history and specific laparoscopic procedures on the risk of adverse complications after surgery.ResultsOperative complications and conversion to laparotomy occurred in 1.9% and 4.7% of laparoscopic procedures, respectively. Complications included four bowel, two bladder, one ureteral, two vascular, and five abdominal wall injuries. There were 165 patients (19.6%) admitted postoperatively. Aside from the type of operative procedure, increasing age was the most important predictor of complications. Relative to all other operative procedures, women treated for endometriosis or ovarian cystectomy had generally low rates of operative complications, conversions to laparotomy, and postoperative admissions. In contrast, 12.5% of women undergoing laparoscopically assisted vaginal hysterectomy experienced operative injuries or abdominal bleeding and 90% were hospitalized postoperatively.ConclusionSerious operative complications after gynecologic laparoscopy were rare in this patient population. The more complex laparoscopic procedures resulted in proportionately greater rates of operative complications, conversions to laparotomy, and postoperative admissions to the hospital.

ISSN:0029-7844    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

ObjectiveTo assess the short-term efficacy of transurethral injection of silicone microimplants in women with intrinsic sphincter deficiency.MethodsDuring January 1995 and December 1996, 32 women (mean age 64.3 years, range 39-85 years) with type III stress incontinence (intrinsic sphincter deficiency) underwent transurethral injection of silicone microimplants under general anesthesia. Twenty-eight had undergone previous continence surgery. Subjective and urodynamic assessments were made at 6 and 12 months after injection to evaluate success and short-term effects.ResultsObjective and subjective success rates were 75% and 59% at 6 and 12 months, respectively. Injections of silicone microimplants significantly increased maximum urethral closure pressure (maximum urethral pressure at rest: 34.40 ± 16.46 cm H2O, 95% confidence interval [CI] 28.55, 40.25 versus 25.35 ± 10.78 cm H2O, 95% CI 21.52, 29.18;P= .027). There were no complications after surgery up to 1 year.ConclusionTransurethral silicone injections were effective in 60% of cases of intrinsic sphincter deficiency, although there was a time-dependent decrease.

ISSN:0029-7844    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

ObjectiveTo measure effectiveness, adverse event experience, and acceptability of the Food and Drug Administration-approved variant of levonorgestrel capsule implants in the United States through 5 years and to examine determinants of these outcomes.MethodsIn a prospective, multicenter study, 511 sexually active women selecting contraceptive implants were monitored four times in the 1st year, then semiannually through 5 years. Adverse events were elicited by query and physical examination, and their incidence was measured. Lifetable analyses computed pregnancy and other discontinuation rates. Cox regression models examined effects of age, parity, and preadmission desire for more children on continuation. Removal times were analyzed by analysis of variance.ResultsThree pregnancies occurred, yielding a 5-year cumulative rate of 1.3 ± 0.8 per 100 users, an average annual rate of three per 1000 women, and an ectopic pregnancy rate of 0.6 per 1000 woman years. No pregnancies occurred to women weighing less than 79 kg. Prolonged or irregular menstrual bleeding, followed distantly by headache, weight gain, and mood changes, was the most frequent medical conditions leading to removal. Weight gain averaged 1 kg per year. Each annual continuation rate was above 80 per 100, for a cumulative 5-year rate of 39 per 100. Continuation was age-dependent, with younger women (younger than 25 years at entry) having lower 5-year continuation rates than older subjects (P< .01). Tissue trauma from deeply placed or poorly aligned implants or severe reactions to local anesthetic affected subjects in 3.1% of removals (nine cases).ConclusionAs measured by annual continuation rates of 80 per 100 or higher and annual pregnancy rates below one per 100, implant contraception in the United States was found to be highly acceptable and effective, year after year, regardless of the woman's age or family formation status. The cumulative 5-year pregnancy rate, 1.3 per 100, is comparable to that of tubal ligation.

ISSN:0029-7844    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

ObjectiveTo assess subsequent pregnancy rates and recurrence of breech, as well as interpregnancy interval after a breech presentation.MethodsWe conducted a national population registry-based study using data from 1967 to 1994, with maternal record linkage of sibships, comprising the first to the fourth birth of a mother.ResultsThe subsequent pregnancy rate after a surviving breech birth was lower than after a surviving nonbreech birth. Women with two births, of which one was a perinatal loss, had a higher subsequent pregnancy rate, compared with those who had surviving infants. The subsequent pregnancy rate was lower after a cesarean delivery irrespective of presentation. The interpregnancy interval was shorter if the previous infant died, whereas presentation did not influence the interval. The adjusted odds ratio of recurrence of breech increased from 4.32 (95% confidence interval [CI] 4.08, 4.59) after one previous breech delivery to 28.1 (95% CI 12.2, 64.8) after three.ConclusionBreech and cesarean delivery lowered the subsequent pregnancy rate, probably because of the women's decision not to reproduce. Thus, preconceptional counseling with information, support, and reassurance regarding future pregnancies and deliveries might reduce the discouraging effect. A high odds ratio of recurrence of breech suggests effects of recurring specific causal factors of either genetic or more permanent environmental origin.

ISSN:0029-7844    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

ObjectiveTo determine the efficacy of combined repeat Papanicolaou test and cervicography for identification of high-grade squamous lesions among patients who previously have had atypical squamous cells of undetermined significance (ASCUS) or low-grade squamous intraepithelial lesion (LSIL) diagnosed by the Bethesda System.MethodsAll patients who presented to a charity hospital gynecology clinic between July 1, 1994, and December 31, 1995, with a Papanicolaou test result of ASCUS or LSIL underwent repeat Papanicolaou test, cervicography, colposcopy with colposcopic-directed biopsy when appropriate, and an endocervical curettage. Pregnant patients and those who had undergone hysterectomy were excluded. The mean and median time from abnormal Papanicolaou test to clinical investigation was 61 and 58 days, respectively (range 6-162 days).ResultsOne hundred eighty-seven of the patients had an initial ASCUS Papanicolaou test. Of these 187, 24 (13%) were found to have cervical intraepithelial neoplasia (CIN) grades II-III. The second Papanicolaou test would have resulted in the detection of 11 of 24 lesions (sensitivity 46%), whereas the cervigram would have detected 22 of 24 (sensitivity 92%). The combined Papanicolaou test and cervigram sensitivity for ASCUS was 91%. One hundred forty-one of the patients had an initial LSIL Papanicolaou test. Of these 141, 37 (26%) patients were found to have CIN II-III. The repeat Papanicolaou test would have detected 29 of 37 lesions (sensitivity 78%), whereas the cervigram would have detected 33 of 37 (sensitivity 89%). The combined Papanicolaou test and cervigram sensitivity for LSIL was 97%.ConclusionCervicography is a helpful adjunctive technique for detection of CIN II-III lesions in patients with previous ASCUS or LSIL Papanicolaou tests.

ISSN:0029-7844    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

ObjectiveTo estimate the incidence of dysplasia in patients with Papanicolaou smears showing atypical squamous cells of undetermined significance (ASCUS) and low-grade squamous intraepithelial lesions (SIL) and to identify clinical predictors of dysplasia in these patients.MethodsPatients referred for ASCUS and low-grade SIL were reviewed retrospectively. All patients were evaluated with immediate colposcopy. A multivariate logistic regression analysis was performed to identify clinical predictors of histologic SIL and histologic high-grade SIL.ResultsOne hundred thirty-seven (34%) of 406 consecutive patients had histologic SIL. Regression analysis identified age (under 35 versus 35 years or above) and initial smear (low-grade SIL versus ASCUS) as statistically significant predictors of histologic SIL and high-grade SIL (P< .001). When patient outcomes were analyzed by age and initial Papanicolaou smear results, the subgroup of patients 35 years or older with ASCUS had low incidences of histologic SIL (14%) and high-grade SIL (1%). The other subgroups (under 35 years with ASCUS, under 35 years with low-grade SIL, and 35 years or older with low-grade SIL) had incidences of histologic SIL and histologic high-grade SIL of at least 28% and 14%, respectively.ConclusionThe high incidence of dysplasia in patients with minimally abnormal Papanicolaou smears suggests that immediate colposcopy might be appropriate for many of these patients. Age and initial Papanicolaou smear are predictive of dysplasia and might be used to select patients who have low incidence of dysplasia and might not require immediate colposcopy.

ISSN:0029-7844    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

ObjectiveTo determine whether serum vascular endothelial growth factor is an independent prognostic factor in ovarian cancer patients.MethodsWe measured vascular endothelial growth factor in pretreatment serum samples of 60 women with International Federation of Gynecology and Obstetrics stages I to IV epithelial ovarian cancer, using an enzyme-linked immunosorbent assay. The results were correlated to clinical data.ResultsThe median vascular endothelial growth factor serum level in ovarian cancer patients was 466.1 pg/mL (range 69.7-2835 pg/mL). The 75% quartile was defined as a cut-off level. Elevated vascular endothelial growth factor serum levels before therapy correlated significantly with a poorer disease-free (log-rank-test,P= .003) and overall survival (log-rank-test,P= .007). Multivariate analysis revealed serum vascular endothelial growth factor to be an independent prognostic factor of overall and disease-free survival. When median pretreatment levels of vascular endothelial growth factor were grouped by tumor stage, histologic grade of tumor cells, histologic type of the tumor, lymph node involvement, age of patient, and residual tumor mass, we found a statistically significant correlation between serum levels of vascular endothelial growth factor and histologic grade (Mann-WhitneyUtest,P= .03).ConclusionVascular endothelial growth factor appears to be an additional factor for predicting the outcome of patients with epithelial ovarian cancer. Owing to its independence from established prognostic factors, vascular endothelial growth factor could be used for prognostic information in clinically relevant subsets such as early-stage or lymph node-negative ovarian cancers.

ISSN:0029-7844    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

ObjectiveTo determine the clinical utility of cystoscopy to rule out bladder invasion in cervical cancer patients who have had pelvic computed tomographic (CT) scan.MethodsWe reviewed charts of 49 patients at Walter Reed and Tripler Army Medical Centers who had International Federation of Gynecology and Obstetrics stage II or greater cervical cancer and who underwent both cystoscopy and CT scan before treatment. Data retrieved included diagnosis, race, age, cystoscopy results, and CT scan reports. These patients were evaluated and treated between January 1, 1991, and September 1997.ResultsThe mean age of the patients was 50 years. Seven of the women were Asian, five black, six white, one Hispanic, and 30 Pacific Islander. There were 40 squamous cell carcinomas and nine adenocarcinomas. There were 25 stage II, 20 stage III, three stage IV, and one recurrent stage II carcinomas. Three patients with bladder invasion were identified by cystoscopy and all also were identified with possible bladder invasion by CT scan. Two additional cases of possible invasion seen on CT scan proved not to be invasion with cystoscopy. The positive predictive valve of CT scan in predicting bladder invasion was 60% (three of five). The negative predictive valve of CT scan in predicting bladder invasion was 100%.ConclusionThe utility of performing cystoscopy to rule out bladder invasion in a patient with no evidence of bladder involvement on CT scan is low and might not be necessary.

ISSN:0029-7844    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

ObjectiveTo identify the effects of estrogen and simvastatin, individually and in combination, on the levels of low-density lipoprotein (LDL) subclasses in postmenopausal women with type IIa hypercholesterolemia.MethodsFifty-five postmenopausal women with type IIa hypercholesterolemia were assigned randomly to 0.625 mg of conjugated equine estrogen (n= 20), 5 mg of simvastatin (n= 18), or both (n= 17) daily for 3 months. Cholesterol, triglyceride, and apolipoprotein B levels in the plasma and in the LDL1 (density 1.019-1.045 g/mL) and LDL2 (density 1.045-1.063 g/mL) fractions were measured before and after treatment.ResultsEstrogen treatment significantly reduced LDL1 cholesterol and LDL1 apolipoprotein B levels by 18.4% and 20.8%, respectively; simvastatin treatment by 21.9% and 29.2%, respectively; and combination therapy by 38.5% and 34.4%, respectively. In contrast to estrogen or simvastatin treatment, the combination therapy also significantly lowered the levels of LDL2 cholesterol by 19.5% and LDL2 apolipoprotein B by 30.5%. Posttreatment levels of total cholesterol, LDL1 cholesterol, and LDL1 apolipoprotein B were significantly lower after combination treatment than after estrogen treatment. Estrogen treatment, but not combination therapy, significantly increased total plasma triglyceride levels (103.1 ± 26.0 mg/dL to 138.8 ± 75.6 mg/dL,P± .01). Significantly more patients receiving combination therapy than those receiving estrogen had total and LDL cholesterol concentrations reduced to target levels.ConclusionCombination therapy with estrogen and simvastatin favorably affected lipid metabolism by reducing large and small LDL particles and prevented the estrogen-induced increase in plasma triglyceride levels.

ISSN:0029-7844    

出版商:OVID    

年代:1998

数据来源: OVID