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Biomedical subjects

N Kadar

Publications and source records attributed to N Kadar.

At least 37 records · Page 2Linked to original sources
PubMed1995

Laparoscopic pelvic lymphadenectomy in obese women with gynecologic malignancies.

Laparoscopic pelvic lymphadenectomy was performed successfully in 10 women weighing over 180 pounds (mean 212 lbs) in conjunction with simple (7) or radical (3) hysterectomy for carcinoma of the endometrium or cervix. Four patients had extensive lysis of adhesions in addition, and one had a myomectomy to allow access to the cul-de-sac. Mean operating time was approximately 4 hours (range 2.5-7 hrs), mean blood loss 1030 ml (range 300-2000 ml), and median hospital stay 3.5 days. The average number of lymph nodes recovered was 33 (range 11-49 nodes). It is concluded that obesity, even in the presence of other pelvic pathology, does not significantly limit the feasibility of pelvic lymphadenectomy. This finding is important to the laparoscopic management of women with endometrial carcinoma.

Adult↗
PubMed1995

Dissecting the pelvic retroperitoneum and identifying the ureters. A laparoscopic technique.

A technique for dissecting the pelvic retroperitoneum and identifying the ureters and uterine arteries is described that makes use of the obliterated hypogastric arteries. The obliterated arteries are readily identified laparoscopically and, as relatively fixed structures, are easily dissected free of the bladder and surrounding areolar tissues. Once freed by blunt dissection, they are traced proximally to where they are joined by the uterine arteries to form the internal iliac arteries. Blunt dissection just proximal and medial to the uterine artery will open the pararectal space, the medial border of which is bounded by the ureter. The uterine arteries are then traced to where they cross the ureters and are freed from them by blunt dissection. The site at which the uterine arteries are divided and the extent to which the extraperitoneal spaces are developed and ureters mobilized off the medial leaf of the broad ligament are tailored to the operation performed.

Dissection↗
PubMed1994

The discriminatory human chorionic gonadotropin zone for endovaginal sonography: a prospective, randomized study.

OBJECTIVE: To determine the probability of detecting the gestational sac of a normal intrauterine pregnancy by vaginal ultrasound at different gestational ages and serum hCG concentrations. DESIGN: Prospective, randomized study. SETTING: Pregnant human volunteers in a university-based clinical research environment. PATIENTS: Women with viable pregnancies who conceived spontaneously or after ovulation induction. INTERVENTIONS: Vaginal ultrasound and serum hCG determinations were performed between 20 and 30 days after conception. The timing of the tests was determined randomly. MAIN OUTCOME MEASURE: Detection of gestational sac. RESULTS: The probability of detecting a gestational sac increased significantly with both gestational age and serum hCG concentration, but the regression on gestational age fitted the data much better than the regression on loge (hCG). The probability of detecting a sac was similar in multiple and singleton pregnancies of the same gestational age but, for a given hCG concentration, the probability of detecting a sac was lower for multiple than for singleton pregnancies because multiple gestations were associated with higher serum hCG concentrations than singleton pregnancies of the same gestational age. CONCLUSION: If it is known, gestational age rather than the serum hCG concentration should be used to determine whether the gestational sac of an intrauterine pregnancy should be detectable by vaginal ultrasound. Failure to image a gestational sac > or = 24 days after conception is presumptive evidence of an ectopic pregnancy. Reliance on serum hCG rather than gestational age may lead to an erroneous diagnosis of ectopic pregnancy in women with multiple pregnancies.

Chorionic Gonadotropin↗
PubMed1994

An operative technique for laparoscopic hysterectomy using a retroperitoneal approach.

The technique used for abdominal hysterectomy does not lend itself well to a laparoscopic approach because vital structures will be difficult to visualize and retroperitoneal spaces difficult to open. An entirely different approach is required. An operative technique for laparoscopic hysterectomy is based on a systematic dissection of the retroperitoneum in a very precise sequence of operative steps. It provides complete control of the operative field and allows visualization of all important retroperitoneal structures. The technique is simple to learn, and requires no special surgical skills beyond what is necessary for routine laparoscopic gynecologic procedures.

Female↗
PubMed1994

Laparoscopically assisted hysterectomy for uteri weighing 500 g or more.

We attempted to determine the feasibility and results of laparoscopically assisted vaginal hysterectomy (LAVH) for removing symptomatic fibroid uteri not suitable for vaginal hysterectomy. We retrospectively reviewed cases in which the uterus weighed 500 g or more and was considered not suitable for traditional vaginal hysterectomy after examination under anesthesia. Laparoscopically assisted hysterectomy with or without unilateral or bilateral adnexectomy was successfully completed in 20 (91%) of 22 cases. Thirteen patients had concurrent laparoscopic lysis of adhesions, and one a laparoscopic bladder neck suspension. Mean uterine weight was 837 g, mean operating time 167 +/- 42 minutes, mean blood loss 390 +/- 107 ml, and mean hospital stay 2.6 days. No febrile morbidity or surgical complications occurred among these patients. The only significant intraoperative complication was bleeding requiring blood transfusions, which occurred in one of the two women who required abdominal hysterectomy. Our results suggest that LAVH is a safe and effective alternative to total abdominal hysterectomy of the very large fibroid uterus, and that conversion to total abdominal hysterectomy could be expected to occur in less than 10% of cases.

Adult↗
PubMed1994

Laparoscopic-Vaginal Radical Hysterectomy

Eleven patients with stage IA2-IIA carcinoma of the cervix have been treated by combined laparoscopic-vaginal radical hysterectomy and bilateral pelvic lymphadenectomy (3-Stage IA2, 5-stage IB, 3-Stage IIA). The patients were unselected. Three patients had bulky (&gte; 5 cms) tumors, one of whom weighed 239 lbs; one had prior anterior-posterior repair, was apareunic and had significant vaginal narrowing; two patients had extensive pelvic adhesions, one of whom also had a 480 gram uterus. Pelvic lymph node metastases were present in one patient and paracervical lymph node metastases in one. The technique used has undergone significant modification. The laparoscopic phase of the procedure contributes much more to the operation than the lymphadenectomy for it allows a symbiotic partitioning of the operation into the laparoscopic and vaginal components. Only those steps of the operation are carried out vaginally that are easier to perform from below (division of the uterosacral and cardinal ligaments, unroofing of the ureter), and they are made much easier by the preceding laparoscopic phase of the operation. Laparoscopic development of the para-vesical and para-rectal spaces makes vaginal entry into these spaces very straightforward, and laparoscopic division of the uterine artery facilitates vaginal unroofing of the ureter. By allowing the proximal ureter to be freed from the medial leaf of the broad ligament, and the proximal attachments and blood supply of the uterus to be divided, the laparoscopic phase of the operation also permits the cervical ligaments to be divided before the ureters are freed from the vesico-cervical ligament, which helps to avoid a Schuchardt incision in most patients.

Journal Article↗
PubMed1994

Pelvic and Aortic Lymphadenectomy in Endometrial Cancer

Pelvic and aortic lymphadenectomy have been incorporated into the FIGO staging for endometrial carcinoma although the indications for lymphadenectomy were undefined. When lymphadenectomy is carried out, however, both the pelvic and para-aortic lymph nodes are usually removed. This policy has limited the ability to manage patients with endometrial carcinoma laparoscopically because many women who have endometrial cancer are obese, and aortic lymphadenectomy is frequently difficult to carry out in patients weighing 180 pounds or more. Data are presented to show that the presence of pelvic lymph node metastases provide a better criterion for aortic lymphadenectomy than deep myometrial invasion. If positive pelvic nodes rather than deep myometrial invasion were used as the criterion for aortic lymphadenectomy, 23% more women with aortic lymph node metastases would be identified, and 35% fewer aortic lymphadenectomies would need to be carried out, although these would need to be performed as a second operation. Data are also presented to show that pelvic lymphadenectomy can be carried out laparoscopically in women weighing 180 pounds or more. Our heaviest patient weighed 300 lbs. Because obese women tend to have more favorable lesions, few will be found to have pelvic lymph node metastases, and therefore few will require aortic lymphadenectomy. I conclude, therefore, that most women with endometrial carcinoma can be successfully managed laparoscopically if they are treated by laparoscopic hysterectomy and pelvic lymphadenectomy, and aortic lymphadenectomy is reserved for those who have positive pelvic nodes.

Journal Article↗
PubMed1994

Prognostic factors in surgical stage III and IV carcinoma of the endometrium.

OBJECTIVE: To identify prognostic factors in surgical stage III and IV endometrial carcinoma. METHODS: We performed a retrospective analysis of 58 cases of stage III and IV endometrial cancer using the Cox proportional hazards model. RESULTS: Extrapelvic peritoneal metastases and positive peritoneal cytology greatly affected survival. If either of these factors was present, the 2-year survival rate was only 25%, whereas if they were absent, it was 82%. All patients with extrapelvic metastases died of their disease despite systemic therapy, as did ten of 13 patients with positive peritoneal cytology. Although postoperative therapy in these patients varied, it had no obvious effect on survival or on the site of recurrence. In the absence of abdominal disease or positive peritoneal cytology, survival was not influenced significantly by the presence or absence of lymph node metastases. The difference in survival between women with aortic and pelvic lymph node metastases (24% at 5 years) was not significant, but the power to detect this difference was low (35%). Stage affected survival significantly (P < .05), but a two-category variable, indexing patients as having either positive peritoneal cytology or abdominal disease, provided a much better fit and a more parsimonious model for the data. CONCLUSION: Five-year survival rates exceeding 70% can be achieved in endometrial carcinoma even if extrauterine disease is present, provided that peritoneal cytology is negative and abdominal metastases are absent.

Aged↗
PubMed1993

Steroid receptor concentrations in endometrial carcinoma: effect on survival in surgically staged patients.

Estrogen and progesterone receptor concentrations were measured in the primary tumors of 137 surgically staged women with clinical stages I and II endometrial carcinoma. For each steroid, increasing receptor concentrations were associated with a decrease in hazard (increase in survival) and the effect was linear for each receptor. When expressed dichotomously, steroid receptor status was also significantly associated with a number of known risk factors, and the significance of the association was influenced by the receptor concentration used as the criterion for receptor positivity. In a multivariate analysis, only progesterone receptor concentration affected survival independently, but the effect disappeared when the analysis was restricted to women with disease confined to the uterus. We conclude that the estrogen and progesterone receptor status of the primary tumor is of limited prognostic significance in endometrial carcinoma unless extrauterine disease is present.

Adenocarcinoma↗
PubMed1993

The operative laparoscopy debate: technology assessment or statistical Jezebel?

Laparoscopic surgery has been severely criticized recently because few controlled studies have been performed to show that specific operations are better when carried out endoscopically rather than by using an open technique. Critics have also claimed that only randomized clinical trials can show these procedures to be effective, and they have not been carried out because surgical and medical therapy are held to different standards. These criticisms are examined and discussed in this paper, and many of the arguments are shown to be invalid. Although bias is an undeniable concern in retrospective studies, the scope of randomized clinical trials is limited by the inability to randomize or blind treatment, and their validity is restricted by the failure to select patients randomly for study. Therefore, whatever the limitations of retrospective studies, there is frequently no option but to adopt a research strategy other than a randomized trial, and some possibilities are discussed.

Bias↗
PubMed1993

Incisional hernias after major laparoscopic gynecologic procedures.

OBJECTIVE: Our purpose was to determine the incidence of incisional hernias after operative laparoscopy. STUDY DESIGN: A retrospective case review was performed. RESULTS: The frequency of incisional hernias at extraumbilical 10 and 12 mm trocar insertion sites was one in 429 (0.23%) cases and five in 161 (3.1%) cases, respectively; the difference is statistically significant (p = 0.007, Fisher's exact test). Incisional hernias were also significantly more common if the fascia was left open (p = 0.021), although three of the five hernias at 12 mm trocar sites occurred after attempted closure of the underlying fascia. CONCLUSION: The underlying fascia should be closed whenever a 10 mm or larger trocar is placed at an extraumbilical site during laparoscopy. The peritoneum may also require closure at 12 mm trocar sites if the trocar is placed through, rather than lateral to, the rectus sheath.

Adult↗
PubMed1993

A prospective, randomized study of the chorionic gonadotropin-time relationship in early gestation: clinical implications.

OBJECTIVE: To investigate the hCG-time relationship in early pregnancy. DESIGN: Prospective, randomized study. SETTING: Pregnant human volunteers in a university-based clinical research environment. PATIENTS: Normal pregnant women with viable singleton pregnancies, conceived spontaneously or after ovulation induction. INTERVENTIONS: Vaginal ultrasound was performed, and blood samples were obtained for hormone parameters between 20 and 30 days after conception. The timing of the tests was determined by random assignment using sealed envelopes. MAIN OUTCOME MEASURE: Serum hCG. RESULTS: The log hCG-time relationship was linear, both during the first 20 days and between 20 and 30 days after conception. The inclusion of a quadratic term in either regression was not statistically significant. The slopes of the two regression lines were also not statistically different. CONCLUSION: For practical purposes, the hCG-time relationship in early pregnancy can be treated as log-linear, but short sampling intervals should be used if doubling times are to be calculated from paired samples.

Chorionic Gonadotropin↗
PubMed1993

The electronic video operative laparoscope.

A new 14-mm electronic video operative laparoscope accommodates a 5-mm operative channel. The video image sensor is located at the distal end of the laparoscope. The image quality is far superior to that of the standard video camera systems that attach to rigid endoscopes. Additional advantages are improved maneuverability, elimination of focusing, superior illumination system, and the capability to interchange with conventional video equipment. This instrument marks the next generation of laparoscopes.

Electronics, Medical↗
PubMed1992

Positive peritoneal cytology is an adverse factor in endometrial carcinoma only if there is other evidence of extrauterine disease.

The prognostic significance of peritoneal cytology among 269 women with clinical stage I and II carcinoma of the endometrium was studied. All patients were surgically staged and had undergone selective pelvic and para-aortic lymphadenectomies. Patients with clear cell and papillary serous carcinomas were excluded from the analysis. Thirty-four (12.6%) patients had malignant cells in the peritoneal washings (positive peritoneal cytology). The effect of positive peritoneal cytology on survival depended upon the extent of disease present. If the disease was confined to the uterus, positive peritoneal cytology did not influence survival; if the disease had spread to the adnexa, lymph nodes, or peritoneum, positive peritoneal cytology had a significant adverse effect on survival, decreasing it at 5 years from 73 to 13%, all recurrences being at distant sites. These findings suggest that treatment specifically directed at positive peritoneal cytology is not warranted unless extrauterine disease is present, and when it is, systemic rather than intra-abdominal treatment will be required to affect survival.

Adenocarcinoma↗