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A retrospective cohort study was set up to evaluate the effectiveness of conservative and radical surgery for tubal pregnancy towards subsequent fertility. Consecutive patients undergoing conservative or radical surgery for tubal pregnancy between January 1990 and August 1993 in two university hospitals were included in the study. Outcome measures were spontaneous intrauterine pregnancy (IUP) and repeat ectopic pregnancy (EP). Of the 135 patients analysed, 56 underwent conservative surgery and 79 underwent radical surgery. Patients treated with conservative surgery achieved a higher 3-year cumulative pregnancy rate than those treated radically (P < 0.001, log-rank test). In patients treated conservatively, there was only one spontaneous IUP in the period between 18 months and 3 years after the tubal pregnancy. In contrast, patients treated radically continued to conceive in this period. Multivariate analysis showed a fecundity rate ratio (FRR) of 1.9 [95% confidence interval (CI): 0.91 to 3.8] for IUP after conservative surgery in the first 18 months of follow-up. In patients with a history of bilateral tubal disease the FRR was 3.1 (95% CI: 0.76 to 12), whereas in patients without a history of bilateral tubal disease the FRR was 1.4 (95% CI: 0.13 to 16). The FRR for repeat EP was 2.4 (95% CI: 0.57 to 11). Our data indicate a beneficial effect of conservative surgery towards subsequent fertility that was not, however, statistically significant in the multivariate analysis. In view of these inconclusive data and the importance of this major health problem, randomized studies are required to assess whether conservative surgery really improves the fertility prospects of patients with tubal pregnancy. [ABSTRACT FROM AUTHOR]

The clinical impact of incontinence in pregnancy and after childbirth is growing because some studies report the efficacy of physiotherapy in pregnancy and because obstetric choices are supposed to have significant impact on post-reproductive urinary function (Goldberg et al. in Am J Obstet Gynecol 188:1447-1450, 2003). Thus, the need for objective measurement of urinary incontinence in pregnancy is growing. Data on pad testing in pregnancy are lacking. We assessed the clinical relevance of the 24-h pad test during pregnancy and after childbirth, compared with data on self-reported symptoms of urinary incontinence and visual analogue score. According to the receiver operating characteristic curve, the diagnostic value of pad testing for measuring (severity of) self-reported incontinence during pregnancy is not of clinical relevance. However, for the purposes of research, pad tests, combined with subjective/qualitative considerations, play a critical role in allowing comparisons across studies, quantifying the amount of urine loss and establishing a measure of severity.

Aims: (i) To describe the displacement and recovery of the vesical neck position during pregnancy and after childbirth and (ii) to discriminate between compliance of the vesical neck supporting structures with and without pelvic floor contraction., Methods: We focussed on the biomechanical properties of the vesical neck supporting structures during pregnancy and after childbirth by calculating the compliance and the hysteresis as a result from of abdominal pressure measurements and simultaneous perineal ultrasound., Results: This study shows that compliance of the supporting structures remains relatively constant during pregnancy and returns to normal values 6 months after childbirth. Hysteresis, however, showed an increase after childbirth, persisting at least until 6 months post partum., Conclusions: Vaginal delivery may stretch and or load beyond the physiological properties of the pelvic floor tissue and in this way may lead to irreversible changes in tissue properties which play an important role in the urethral support continence mechanism.

Objective: To assess the incidence of urinary incontinence in pregnancy and after spontaneous vaginal delivery and its relation with changes in the static and dynamic function of the pelvic floor., Design: The second part of a prospective longitudinal study., Setting: University Hospital Groningen and Martini Hospital Groningen, the Netherlands., Population: A cohort of 62 women before and after spontaneous vaginal delivery at term and 27 nulliparous non-pregnant controls., Methods: Urinary incontinence was measured by a questionnaire and by a 24 hour pad test. The position and mobility of the urethrovesical junction were measured by perineal ultrasound and related to simultaneously measured abdominal pressure changes. Serial investigations were done at 38 weeks of gestation and at 6 weeks and 6 months after delivery., Main Outcome Measures: Urinary incontinence and its relation with the position of the urethrovesical junction at rest and with the mobility of the urethrovesical junction during Valsalva and during coughing, indicated by the displacement/pressure coefficient and with obstetric variables., Results: After delivery, reported urinary incontinence was reduced from 26% at 38 weeks of gestation to 16% and 15% at 6 weeks and 6 months after delivery, respectively. Even lower rates were measured by the 24 hour pad test, which revealed a decrease from 14% at 38 weeks to 10% and 5% at 6 weeks and 6 months postpartum, respectively. Six weeks and six months after delivery, the angle of the urethrovesical junction at rest was significantly increased compared with the non-pregnant control women. Compared with the antenatal measurements, the displacement/pressure coefficients during coughing and during the Valsalva manoeuvre were significantly increased six weeks after delivery. Six months after delivery, only the coefficient for coughing was still significantly greater than the antenatal value and the value in the non-pregnant control group. No relations were found between urethrovesical junction measurements and obstetric variables and subjective or objective urinary incontinence parameters., Conclusion: Although pregnancy and spontaneous vaginal delivery significantly increased the degree of bladder neck descent during coughing, urinary incontinence, quite common during pregnancy, occurs less frequently postpartum.

Objective: To assess the prevalence and the development of urinary incontinence in nulliparous pregnant women, both subjectively and objectively, and to investigate the relation of incontinence with the mobility of the urethro-vesical junction measured by perineal ultrasound., Design: A prospective longitudinal study., Setting: University Hospital and Martini Hospital Groningen, the Netherlands., Population: A cohort of 117 nulliparous pregnant women and 27 nulliparous non-pregnant controls., Methods: Urinary incontinence was measured by a questionnaire and by a 24-hour pad test. The position of the urethro-vesical junction and its mobility were measured by perineal ultrasound., Main Outcome Measure: Prevalence of urinary incontinence; mobility of the urethro-vesical junction, indicated by the displacement/pressure coefficient., Results: Up to 35% of the women reported urinary incontinence in pregnancy, and 20% of the women had a positive pad test. The angle of the urethro-vesical junction angle at rest and the displacement/pressure coefficient during coughing showed a significant increasing trend during pregnancy, but no changes were seen during the Valsalva manoeuvre. No relationship was found between subjective and objective incontinence data and the position and mobility of the urethro-vesical junction., Conclusion: The prevalence of incontinence in nulliparous women as found by the pad test was significantly higher in pregnancy (20%) than in the non-pregnant control group (4%). Perineal ultrasound of the urethrovesical junction showed lowering of the pelvic floor occurring as early as 12-16 weeks of pregnancy. Serial measurements of the displacement/pressure coefficient suggest that the dynamic characteristics of the connective tissues of the pelvic floor remain unaltered,whereas a significant decrease in pelvic floor muscle contraction occurs. Since no relation was found between measurements of the urethro-vesical junction and incontinence, urinary incontinence in pregnancy is most likely explained by other factors.

Hodgkin's disease was diagnosed in two girls aged 11 and 15 years, in stages IIIB and IIIA, respectively. Because of localizations in the para-aortic and para-iliac lymph nodes, irradiation of these lymph nodes was considered necessary; this would result in loss of the ovarian function. Transposition of the ovaries was performed by laparoscopy; in the first patient both ovaries were fixed behind the uterus to the midline, in the second the right ovary was fixed at the level of the right iliac crest and the left ovary to the pelvic wall in the cranial direction. Subsequently, the planned irradiation was carried out. In the first patient, the menarche started at the age of 13, in the second, the menstrual cycle returned to normal. In girls and young women needing irradiation of the pelvis, ovarian function may be preserved by transposition of the ovaries in a high-lateral direction, to the level of the iliac crest. If the irradiation has to include the region of para-iliac lymph nodes, as in patients with Hodgkin's disease in stage III, fixation of the adnexa in the midline at a low level behind the uterus may also be considered. Both interventions are possible by laparoscopy. The disadvantage of the midline oophoropexy is that relatively much scattered radiation can reach the ovary in spite of shielding of the median area; the advantage is that a natural form of conception remains possible (tubal function is preserved).

Objective: To our report our experience with the laparoscopic placement of peritoneal access ports and to compare it to our experience with placement at laparotomy., Methods: Patients with advanced ovarian carcinoma were enrolled in a study to receive intraperitoneal paclitaxel in combination with intravenous cisplatin and cyclophosphamide as first- or second-line chemotherapy. Patients had a PAP catheter placed at primary laparotomy or by a separate laparoscopic procedure under general anesthesia., Results: In 13 patients a PAP catheter was placed during primary laparotomy, without complications. Thirteen patients had laparoscopic catheter placing, using routine Veress needle insufflation. After a bowel perforation at insertion of the umbilical trocar had occurred in one patient, due to extensive adhesions, we decided to use only an open laparoscopic procedure. No other procedure or catheter-related complications occurred., Conclusion: Laparoscopic-assisted placement of PAP catheters is feasible, but should preferably be performed by an open laparoscopic procedure in this patient population at risk for intraabdominal adhesions.

Objective: Determination of the difference in percentages of ectopic pregnancies in patients with and without tubal pathology after in-vitro fertilisation and consequences for prevention., Setting: Thirteen IVF clinics in the Netherlands., Method: The clinics submitted data on clinical and ectopic pregnancies and the indication for IVF from the years 1990 and 1991., Results: The indication in 1075 cases of IVF-clinical pregnancies was a tubal factor and in 990 cases of IVF-clinical pregnancies another (non-tubal) factor. Percentages of ectopic pregnancies in these groups were 4.5 and 1.1 respectively (significant difference: relative risk: 4.02; 95% confidence interval: 2.10-7.69). One case of heterotopic pregnancy had occurred. No particular type of tubal pathology with high risk for ectopic pregnancy could be identified., Conclusion: Preventive salpingectomy before the IVF procedure in patients with a tubal factor is not justified.

In a group of 367 women treated for invasive carcinoma of the cervix tumor recurrence was discovered at an asymptomatic stage in 16 (23%) patients. The tumor recurrence was localized to the pelvis in 29 (41%) cases, in the vaginal wall in 3 (4%) cases, and 39 (55%) patients had distant metastases (with or without recurrent tumor in the pelvis). Curative treatment (surgery, n = 2; radiotherapy, n = 8) was applied in 5/29 (17%) patients whose recurrent disease was confined to the pelvis, in all 3 patients with vaginal recurrence and in 2/39 (5%) of the patients with distant metastases. Permanent remission (follow-up > 36 months) was observed in 2 patients with vaginal recurrence and in one with central recurrence. Temporary complete remission (mean 22 months, range 12-30 months) was observed in 3 patients (2 with central recurrence and one with vaginal recurrence). In 20 (69%) of the patients with central or locoregional recurrence, the primary treatment had been so radical (including adjuvant postoperative or full radiotherapy) that surgical treatment or radiotherapy of the recurrence was not considered possible or worthwhile; moreover, 4 of the patients were older than 80 years of age. In retrospect, exenterative treatment could have been considered in 14 patients (< 70 years) and based on 50% operability, could have led to a cure in 2 to 4 patients with tumor recurrence in the pelvis without distant metastases. Chemotherapy was applied to 10 patients, one of whom went into complete remission of lung metastases (follow-up 108 months).

Patients with squamous cell carcinoma of the cervix FIGO stages IB to IV (n = 306) were compared to patients with adeno(squamous) carcinoma (n = 70). There was no difference between the mean ages of the groups. In the patients who underwent radical surgical treatment, whether or not in combination with radiotherapy (n = 209), stepwise regression analysis showed that a positive lymph node status was the most unfavorable prognostic factor, followed by the histologic type (adeno(squamous) carcinoma) and the tumor diameter (> 3 cm). Vascular-space invasion had no additional prognostic value. Patient's age did not affect the prognosis. Distant metastases were not found to be more prevalent in the patients with adeno(squamous) carcinoma. In patients with adeno(squamous) carcinoma and positive lymph nodes, it is worth considering more intensive locoregional treatment than is usually prescribed for these patients and/or adjunctive chemotherapy, because there is a high risk of tumor recurrence.

The relationship between age and urodynamic parameters was studied cross-sectionally in a group of 28 women in whom clinically and urodynamically both stress incontinence and detrusor instability were excluded (no proven incontinence, NPI) and in a group, matched for age, with genuine stress incontinence (GSI). At all ages the maximal urethral closing pressure (MUCP) was higher in the NPI than in the GSI group; in both groups there was, however, a similar decrease in MUCP with age. The transmission rate increased significantly with age in the NPI group; this was not found in the women with GSI. These data indicate that in older women loss of MUCP is compensated by an increase in transmission rate (presumably because of active contraction of the pelvic floor muscles); this mechanism fails in women with GSI.

With a curved array real-time ultrasound scanning machine and the probe placed sagitally onto the vulva, symphysis, bladder, urethra and the pelvic floor can be visualized in one frame. With this technique we studied 10 women with stress incontinence and 10 control women. In both groups active contraction of the pelvic floor resulted in a similar elevation of the urethrovesical junction (UVJ). During Valsalva maneuver an equal descent of the UVJ was found in patients and controls. During coughing a significant descent of the UVJ only occurred in the patient group. This suggests that women with stress incontinence are capable of operating the pelvic floor muscles but do not use them adequately during a cough.

Between 1979-1986, 82 of 407 patients (20%) treated for infiltrative carcinoma of the cervix were asymptomatic at the time of diagnosis. Sixteen (20%) of these 82 patients had stage IA, 60 (73%) had stage IB, and six (7%) had stage IIA disease. Asymptomatic patients represented 16 of 23 (70%) of stage IA, 60 of 196 (31%) of stage IB, and six of 77 (8%) of stage IIA. In the Netherlands, population screening for cervical carcinoma is conducted on women aged 35-55 years. To examine the prevalence of asymptomatic cervical carcinoma and the way in which it was detected in different age groups, we studied the patients referred to our department. Among the patients younger than 35 years with cervical carcinoma, 20 of 70 (29%) were asymptomatic with disease detected by incidental screening, whereas eight of 177 (5%) in the group 55 years or older had been detected by incidental screening. In the age category 35-55 years, 54 of 160 (34%) were asymptomatic. Patients aged 35-55 years had undergone population screening or incidental screening. In the patients 55 years or older, asymptomatic disease was significantly less prevalent than in younger patients. Only one of the 66 asymptomatic patients in stage IB or higher suffered tumor recurrence. Among symptomatic patients, 25 of 136 (18%) with stage IB and 17 of 71 (24%) with stage IIA had tumor recurrence. Despite the favorable prognosis of patients with asymptomatic carcinoma, asymptomatic presentation could not be shown to be a significant prognostic factor, as were tumor diameter and lymph node status.

From January 1, 1970, to December 31, 1985, 51 patients with stage IB (FIGO) carcinoma of the cervix with lymph node metastases were treated at the University Hospital, Groningen, The Netherlands. The survival rate was 54% and the average duration of follow-up was 78 months (range 47-132). Important clinical variables for survival were investigated retrospectively: the survival rate in patients with a single lymph node metastasis (with tumor confined to the node itself) (n = 23) appeared to be much better than that of patients with multiple node involvement and/or single nodes with extranodular tumor infiltration (n = 28); survival was 85 and 24%, respectively (P less than 0.001). The same applied to patients with only occult lymph node involvement: the survival rate in patients with occult involvement of the hypogastric, external iliac, or obturator nodes was 87% in 19 patients with a single metastasis and 53% in 15 patients with multiple node involvement (P less than 0.02). The survival rate in 8 patients with adenomatous histological components was 42%. In 42 patients with squamous cell carcinoma, the survival rate was 56%. This difference was not statistically significant. Treatment complications and the effect of treatment on the site of recurrence were investigated.

Forty-nine patients aged less than or equal to 45 years, with cervical carcinoma stage IB (less than or equal to 3 cm) were treated with either primary radical surgery (n = 26), or intracavitary irradiation followed by radical surgery (n = 23). With primary surgery, ovarian function had been preserved in 15 of the 25 patients, who were alive and well. Seven of the primary surgery patients were irradiated postoperatively and 2 others with a central recurrence were cured by irradiation. One other patient, who was not irradiated postoperatively, had an intestinal metastasis and died of the disease. If any of the adverse prognostic factors (as reported in the literature) had been considered as an indication for postoperative irradiation, 17 patients instead of 7 would have been irradiated after primary radical surgery. In the comparable group of 23 patients treated by intracavitary irradiation and radical surgery (and in 4 cases postoperative irradiation as well) there was no recurrence. There was no significant statistical difference between the treatment results in the cesium + surgery group and those who underwent primary radical surgery. Young patients with early cervical carcinoma without prognostic indicators for postoperative irradiation can benefit from primary radical surgery, because their ovarian function can be preserved.

In a group of 20 asymptomatic women at increased risk for ectopic pregnancy, serum analyses were conducted prospectively early in pregnancy (amenorrhea less than or equal to 45 days) at 2-4-day intervals, to examine the rate of increase in hCG values. The initial serum hCG level, which was determined at the time of the first transvaginal ultrasound examination, was below the discriminatory zone of 1000 IU/l (2nd International Standard). In 8 out of the 9 women who were ultimately diagnosed as having an ectopic pregnancy, the increase in hCG progressed only slowly, with a doubling time exceeding 2.2 days. This slow hCG increase occurred in 2 out of the 11 women who were ultimately diagnosed as having an intra-uterine pregnancy; both women subsequently had an early spontaneous abortion. When Lindblom's hCG score was applied retrospectively to distinguish between intra-uterine and ectopic pregnancies, the hCG increase in all the ectopic pregnancies was below 190 IU/l per day and in 10 of the 11 women with an intra-uterine pregnancy above 190 IU/l per day. A slower rate of increase was observed in only one woman with an intra-uterine pregnancy; she had a spontaneous abortion. The doubling time of hCG and the hCG score are useful diagnostic aids in cases where transvaginal ultrasound has not (yet) given a definite answer regarding the presence of an intra-uterine pregnancy.

Factors related to semen improvements and fertility after high ligation of the left internal spermatic vein were investigated in 97 men from infertile couples. Changes in some semen characteristics after operation suggest a relationship between varicocele size and semen improvements and an inverse relationship between preoperative semen values and semen improvements. An inverse relationship seemed to exist between varicocele grades and deterioration of semen values. Fertility after operation was related to age and to semen improvements. Preoperative semen characteristics had no prognostic value for postoperative fertility.

Twenty eight patients with bulky cervical carcinoma, who were treated by irradiation and simple hysterectomy, were studied. Eight of these patients had non-radical pre-operative irradiation. The patients had various FIGO-stages. The prognostic significance of morphologically intact tumor cells in the hysterectomy specimen and the relationship between pre-operative irradiation dosage, intact tumor cells and recurrences is discussed. Positive pelvic lymph-nodes obtained by sampling had more prognostic significance than intact tumor cells in the hysterectomy specimen. The role of adjunctive hysterectomy in local tumor control was not evident. Non-radical pre-operative irradiation proved to be inadequate.