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Objective: To document the frequency of genital herpes recurrences in men and women with histories of recurrent genital herpes during 1 year of continuous, suppressive therapy with valacyclovir hydrochloride (HCl)., Methods: In an open-label clinical trial conducted at 11 centers, 127 subjects (46 women and 81 men) with histories of recurrent genital herpes (at least 6 recurrences per year) were treated with valacyclovir HCl (500 mg once daily), and their clinical status was followed up for 1 year. Genital herpes recurrences were documented in diaries, and quarterly clinic visits were made for evaluating lesion recurrences and drug safety. In cases of recurrence, subjects self-treated with valacyclovir HCl 500 mg twice daily for 5 days, then resumed once-daily treatment., Results: After the first 3 months of suppressive therapy, 81% of subjects were free of recurrence. Recurrence-free rates remained undiminished during the second, third, and fourth quarters (84%, 84%, and 91%, respectively) and were similar for men and women. Thirty of 46 women (65%) and 56 of 81 men (69%) remained recurrence free during the study and therapy was well tolerated. Adverse events were mild, infrequent, and not considered related to the study drug., Conclusion: Valacyclovir HCl was highly effective and well tolerated as continuous suppressive therapy in men and women with recurrent genital herpes. Potential benefits of the once-daily regimen of valacyclovir HCl include improved patient compliance.

A 31-year-old G1 P0 patient with a history of infertility presented with light spotting and cramping at the end of her first trimester. An ultrasonogram at 19 weeks gestation revealed an intrauterine gestation of 21 weeks, a large leiomyoma, and a 8.9 x 6.8 cm complex left ovarian mass. At 35 weeks gestation she had an emergency cesarean section and left salpingo-oophorectomy due to a presumed ruptured ovarian mass. The ovarian mass was diagnosed as a serous cystadenocarcinoma. An exploratory laparotomy with a total abdominal hysterectomy, a right salpingo-oophorectomy, omental biopsy, and periaortic node sampling at 9 weeks postpartum revealed a diagnosis of stage IC ovarian serous cystadenocarcinoma and a stage IA secretory endometrial adenocarcinoma. Adjunctive 32P therapy was successfully administered and at this time the patient has had no recurrence., (Copyright 1999 Academic Press.)

Objectives: The purpose of this study was to combine the relative strengths of two screening tests - the Papanicolaou smear and cervicography - and to determine whether their combination is more efficient at evaluating the cervix than is the traditional method of cytological assessment alone., Methods: Two hundred eighty-five non-pregnant patients qualified for the study. Age range was 17 to 50 years, with an average age of 28.2 years. Papanicolaou smears were followed by cervicography., Results: Of all patients in whom cervical abnormalities were diagnosed via the combination of cervicography and cytology, 90 patients had cervical abnormalities. Ten patients would have been missed by this combined approach, four of the ten underwent colposcopy, and only one revealed findings significant enough for biopsy., Conclusions: Our results show that a dual procedure appears to be superior to either method individually for diagnostic capability.

Objectives: Paraaortic lymph node biopsy is a controversial but proved technique to determine the extent of spread of cancers from the uterine cervix or endometrium. This article explores the following questions. Does the presence of positive paraaortic lymph nodes result in modification of the patient's therapy? Does the evidence gained from a paraaortic lymph note biopsy improve patient survival?, Study Design: Five hundred sixty-eight patients had paraaortic lymph node sampling in conjunction with another operative procedure between 1976 and 1995. Five hundred seven (89.3%) of these patients had either endometrial or cervical cancer., Results: Paraaortic lymph node biopsies led to a survival rate of 9.1% for cervical carcinoma and 46.6% for endometrial carcinoma and were associated with acceptable morbidity., Conclusions: We believe that paraaortic lymph node biopsies should be part of the routine evaluation of patients with gynecologic cancers. The knowledge gained by this procedure along with appropriately administered radiation therapy can save lives.

Objective: The purpose of cold knife conization is to ligate the descending cervical branch of the uterine artery and thus to decrease bleeding. The aim of this study was to investigate the actual frequency of ligation., Study Design: Two lateral sutures were placed in the cervix at the 3 and 9 o'clock positions in 97 patients (194 sutures) as part of vaginal hysterectomy. The position of each suture was determined during evaluation of the surgical specimen., Results: Because the specimens from 10 patients contained only single sutures, only 184 sutures were actually evaluated. Upon microscopic examination, 50 of the 184 (27%) appeared to contain no artery. Of the remaining 134 sutures, 95 (71%) enclosed an artery, and 9 (7%) lay within a 10 x field of a branch. Only 30 sutures (22%) missed the artery entirely. Thus, in the 73% of cases where an artery of significant size could be identified, the artery lay within a lateral stitch 71% of the time., Conclusion: If the descending cervical branch of the uterine artery supplies most of the blood to the cervix, advance placement of lateral sutures would be expected to reduce blood loss during conization.

Objective: To compare the effectiveness of the Cytobrush plus plastic spatula with that of the Cervex Brush for obtaining acceptable yields of endocervical cells in Papanicolaou smears., Methods: We collected 309 smears over a 6-month period, 132 with the Cytobrush plus spatula and 177 with the Cervex Brush. About one-third of the patients in each group were pregnant. Numbers of endocervical cells in the smears were described as none, few, moderate, or many., Results: Moderate or large numbers of endocervical cells were collected from 60.5% of the women in the Cervex Brush group and 65.2% of those in the Cytobrush-spatula group. The percentages were not statistically different., Conclusion: The Cytobrush plus spatula and the Cervex Brush sampling methods were equally effective in obtaining endocervical cells in routine Papanicolaou smears.

The efficacy of continuous postoperative epidural analgesia (CPEA) was assessed in 193 patients who collectively underwent 254 gynecologic oncology procedures. Seventy-five patients elected to receive CPEA; 118 did not. The CPEA patients received an epidural catheter the morning of surgery. Postoperatively, a bolus of meperidine was placed in each catheter. An IVAC pump continued to deliver meperidine at the rate of 14 to 20 mg per hour. The 193 patients also received a total of 655 postoperative intramuscular narcotic injections. CPEA patients were three times less likely to request injections, and those who did required an average of 6.58 compared with 12.42 for non-CPEA patients. The presence or absence of CPEA was the only significant variable. The use of CPEA led to no secondary complications, and it greatly enhanced mood and ability to participate in postoperative care. We conclude that CPEA provides excellent postoperative analgesia for such high-risk patients.

Cervicography is a photographic method to document abnormal cervical lesions. Screening for abnormal cervical lesions, one of the seven proposed purposes for cervicography, was investigated in this study. We evaluated 578 cervigrams obtained from patients with normal cervical cytologic tests. The evaluated cervigrams were placed in one of four categories. Seventy-nine (13.7%) of the patients had normal cervigrams; in 152 (26.4%) the result was unsatisfactory; in 159 (27.5%) the cervigram was technically defective; and in 188 (32.5%) the result was suspicious. One hundred one of the patients with suspicious cervigrams had colposcopic evaluations. In 69 patients colposcopically directed biopsies were done; 14 patients had koilocytotic atypia, seven had grade 1 cervical intraepithelial neoplasia, three had grade 2 cervical intraepithelial neoplasia, and one patient had an invasive cervical carcinoma. Although cervicography has not been proved to be cost effective, it is a method worthy of further evaluation.

Two cases of vaginal clear-cell adenocarcinoma occurred as a result of maternal ingestion of diethylstilbestrol during pregnancy. The first case was diagnosed during the patient's first office visit. The second patient was first seen by the authors in 1976 and was followed at six-month intervals during the ensuing six years; the adenocarcinoma developed during this interval. Colposcopy and cytology were important in the diagnosis of both cases.

Radiation-induced fistulas of the vagina are rare, occurring in only 1 of 3% of patients treated for cancer of the uterine cervix. Primary surgical repair of these fistulas is usually unsuccessful because the defect is a result of devascularization. This type of radiation injury results from endarteritis obliterans, and successful repair requires an accessory blood supply. From 1971 to 1980, the authors performed 14 Martius procedures on 12 patients with radiation-induced rectovaginal fistulas. Eleven patients had successful closure of their fistulas using this procedure, and no operative complications occurred. The Martius procedure is effective for most radiation-induced vaginal fistulas, and the operation is well tolerated by most patients.

The diagnostic value of colposcopy for primary gynecologic malignancies is well accepted. This study was conducted to determine the value of colposcopy in follow-up examinations of treated gynecologic oncology patients. The original gynecologic malignancies included carcinomas of the cervix, endometrium, ovary, vulva, vagina, fallopian tubes, and uterine sarcomas. Distinct colposcopic changes could be identified secondary to radiation therapy, granulation tissue, surgery, and recurrent disease. One-hundred eight treated gynecologic oncology patients were colposcopically examined. Twenty-four of the one-hundred eight patients developed recurrent disease. Thirteen of twenty-four patients had recurrent disease in the vagina, on the cervix, or the vulva. The recurrent disease in these 13 patients was colposcopically diagnosed.

Retroperitoneal abscesses are uncommon in obstetrics and gynecology. Recently, seven reported cases of retropsoas-subgluteal abscesses following paracervical-pudendal anesthesia have been reported, and we have seen two additional cases. The infrequent occurrence and diagnostic difficulties make these abscesses especially dangerous. They can result in substantial patient morbidity and mortality. They must be suspected in patients receiving paracervical-pudendal anesthesia prior to vaginal delivery in whom hip pain subsequently develops. Therapy consists of prompt surgical exploration and drainage and appropriate antibiotic therapy.

This project was designed to determine if the presence of fibrin degradation products (FDP) in the blood are of value in the preoperative evaluation of patients with pelvic masses. This study comprised 120 consecutive patients who were evaluated for a diagnosis of pelvic mass, ovarian cyst, or ovarian carcinoma. A blood sample was drawn from each patient and fibrin degradation products were determined utilizing the Thrombo-Wellcotest. Platelet counts and partial thromboplastin time (PTT) were also determined on each patient. Ovarian carcinoma was present in 17 (14.2%) of the patients. The FDP was found in the serum of 16 (94.1%) of the patients with ovarian carcinoma. One (5.9%) of 17 patients with ovarian carcinoma had a negative FDP (less than 10 mg/ml). Eleven of the 120 patients (9.2%) had a positive FDP with no demonstrable etiology. A sample of fluid was obtained from two cystic ovarian carcinomas and when analyzed for FDP both samples were strongly positive.

Although the first Brenner tumor was reported in 1898 by MacNaughton-Jones, it was not until 1907 that Fritz Brenner described the tumor that bears his name. Since then more than 500 cases have been reported with bilaterality ranging from 3.7 to 8.0 per cent. However, this percentage is probably high. The tumor was originally thought to arise from follicular epithelium. Several other etiologies of the Brenner tumor have been suggested, including celomic surface epithelium, Walthard rests, teratoma, urothelium, and rete ovarii. The majority of Brenner tumors are inert, but there have been reports suggesting endocrine activity. The question of malignant transformation of the Brenner tumor has gained attention since Von Numers described the first malignant Brenner tumor in 1945. The determination of malignancy of these tumors has been hampered by vague histologic criteria for malignancy. The confusion surrounding the histogenesis, hormonal capabilities, and malignant potential of the Brenner tumor has persisted. A case report of bilateral Brenner tumors of the ovaries is presented as well as a review of the literature with emphasis on the bilaterality of Brenner tumors.

A double-blind, placebo-controlled study was undertaken to evaluate the long-term efficacy and safety of oral acyclovir suppressive therapy over a 1-year period. Results from the multicenter trials, based on a total of 261 patients with frequently recurring genital herpes, were analyzed. Of the patients enrolled in the study, 131 received oral acyclovir capsules (800 mg) daily and 130 received placebo capsules. Medication was taken twice daily. Analysis of data from patients who completed a full year of therapy demonstrated that only 5% of patients receiving placebo were free from recurrences, as compared with 46% of acyclovir recipients. The mean number of recurrences for patients on acyclovir therapy was 1.8, as compared with a rate of 8.7 recurrences for the placebo group over the course of the year. The mean time to the first recurrent herpes outbreaks was 19 days for the placebo group and 274 days for the acyclovir-treated patients. There were no significant differences between the two groups in laboratory data or in the frequency or nature of side effects reported. Daily administration of acyclovir capsules for 1 year is a safe and effective therapy for control of frequent recurrences of genital herpes.

The healing of a midfibular fracture was studied in mature rats. The strength of the healing fracture was determined by a constant speed-driven tensiometer which measured the force required to separate the healing callus. The breaking strength of the healing experimental fracture was ascertained in control, estrogen-treated, and oophorectomized animals. The fracture strength was not significantly different in any of these groups.

Sixty patients had a radical abdominal hysterectomy with or without a bilateral salpingo-oophorectomy. The Ohkawa procedure was utilized in 26 (43.3%) of the patients and retroperitoneal ureteral placement with suction drainage in 34 (56.7%) of the patients. These two operative procedures were evaluated for complications such as fistula, obstruction, and hydronephrosis by comparing preoperative and postoperative intravenous pyelograms. Five of the 60 patients (8.3%) had surgical complications within one postoperative month. A ureteral obstruction occurred in two patients, and a uretrovaginal fistula occurred in two patients. Hydronephrosis was found in both sets of patients. All of these complications occurred in an additional two patients, both of whom had an Ohkawa procedure. The study led us to conclude that retroperitoneal ureteral placement is not only quicker to perform but also leads to fewer complications than the Ohkawa technique.

Primary cesarean sections were performed on 395 patients between January 1, and December 31, 1976. A retrospective review of 322 of these patients indicated that the incidence of postoperative intrauterine infection was the same in both monitored and nonmonitored patients. The incidence of postoperative intrauterine infections was not significantly related to ruptured membranes or the duration of ruptured membranes. The most significant factor associated with postoperative morbidity was the type of anesthesia.

The male partners of women diagnosed with human papilloma virus (HPV) or dysplasia were examined colposcopically. Anogenital infection was found in 82% of the men, and dysplasia in two of the partners of dysplastic women. Men may not be merely asymptomatic carriers of HPV.

Fifty-five patients treated for cervical carcinoma developed bony metastases between January 1, 1961 and December 31, 1973. Roentgenograms were diagnostic in all but 2 of the patients. In 15 patients, a combination of radioactive scans and roentgenograms was used to establish the diagnosis. The most common mechanism of bony involvement from carcinoma of the cervix was extension of the neoplasm from para-aortic nodes, with involvement of the adjacent vertebral bodies. The earliest metastases were discovered at the time of the primary diagnosis. Thirteen years was the longest interval from the primary diagnosis until the discovery of bony metastases. Sixty-nine percent of the patients were diagnosed within 30 months. Ninety-six percent of the patients died within 18 months. Seventy-six percent of the patients received some form of therapy for their metastases. Thirty-six of these patients were treated with radiation therapy. Four of these patients received complete relief of symptoms, 24 some relief, and 8 patients received no relief.

Spontaneous rupture of the esophagus is associated with continuous nausea and vomiting in the chronic alcoholic. The following is a case report of a similar occurrence in a young, healthy, primigravida with hyperemesis gravidarum. To our knowledge, this has not previously been reported in the obstetric literature.

Two hundred ten patients with endometrial and cervical carcinoma had para-aortic node biopsies. Nineteen of the 210 patients (9.0%) had positive para-aortic nodes. These 19 patients received pelvic irradiation, and 18 patients received para-aortic irradiation. The incidence of para-aortic nodal involvement in cervical carcinoma was directly related to the stage of the disease. Eleven of the 12 patients with cervical carcinoma and positive para-aortic nodes received both pelvic and para-aortic irradiation. Three of these patients are alive without disease, resulting in a survival rate of 25%. These patients are surviving for 16, 30, and 41 months. The incidence of positive para-aortic nodes in endometrial adenocarcinoma was related to the uterine length and the histologic grade. The survival rate for patients with endometrial adenocarcinoma and positive para-aortic nodes in this study was 57.1%. Four patients have survived for 1, 30, 60, and 71 months. There were no surgical deaths or radiation therapy complications directly attributable to para-aortic biopsy or irradiation.

Radiation and gynecologic oncologists agree that pelvic irradiation in the presence of pelvic inflammatory disease, parametritis, or pyometra can be catastrophic. A temperature elevation in a patient having intrauterine radiation is very perplexing. This study was designed to investigate one of the three reported etiologies for this condition. Some investigators have suggested an exacerbation of a quiescent infection as a possible etiology because of the necrotic condition of many cancerous cervices. Aerobic, anaerobic, and fungus cultures were performed on 32 patients prior to intrauterine administration of cesium. The organisms cultured were similar to those identified as the normal cervical flora. The frequency of the organisms seemed independent of the amount of irradiation. The number of organisms cultured did not vary with the use or nonuse of cleansing vaginal suppositories. This study indicated no increase in bacterial growth in these cancerous necrotic cervices; also it did not indicate the growth of any unusual pathologic bacteria.

Six hundred ambulatory women were screened with the Endo-pap cytology sampler in two medical centers. None of the women developed complications from the use of the instrument. Their smears were routinely processed together with cervical cytology smears. One hundred fifty-three of these women had a tissue diagnosis by endometrial biopsy, dilatation and curettage, or hysterectomy. Adequate cytology specimens were obtained in 93% of these patients. In these 153 patients, 32 (18%) had a tissue diagnosis of endometrial adenocarcinoma, and 31 patients had a tissue diagnosis of endometrial hyperplasia. The cytology samples obtained with this device were diagnostic of endometrial adenocarcinoma in 30 (94%) of these 32 patients and ten (32%) of the patients with endometrial hyperplasia. Two patients (1.6%) were diagnosed falsely positive. The Endo-pap cytology sampler is considered a safe and effective screening tool for endometrial adenocarcinoma. Its value in diagnosing endometrial hyperplasia remains to be determined.