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Is there still a need for laparotomy in case of postmenopausal adnexal tumors?
LETTERS TO THE EDITORS Is there still a need for laparotomy in case of postmenopausal adnexal tumors? To the Editors: Although the number of minimally invasive surgical interventions increases rapidly, no malignant ovarian tumor should be operated on laparoscopically to avoid tumor tissue spilling into the abdomen. ' The following prospective study was performed to assess the possible undertreatment of an ovarian maligbenign by laparoscopy of a the overtreatment or nancy ovarian tumor by laparotomy. From January 1990 to August 1992 the study included 169 consecutive postmenopausal patients with a (48 62.6 The years mean age was clinical adnexal mass. to 89, SD 10.3). When the vaginal ultrasonographic examination showed a clear pelvic cyst without solid A); (group laparoscopy other was performed areas a lesions were treated by laparotomy (group BY In case of during the surface ovarian suspect proliferations on diagnostic laparoscopy, the planned endosurgical adnexectomy' (group Aa) was omitted, and a secondary laparotomy took place (group Ab). Malignancy, including borderline tumors, was found in 1.0% (1/96) of group Aa (primary diagnostic operative laparoscopy), 40.0% (4/10) of group Ab (diagnostic laparoscopy and laparotomy), and 52.4% (33/63) of group B (primary laparotomy). Evidence of solid and cystic areas in the preoperative vaginal ultrasonography or suspect proliferations on the ovarian surface during diagnostic laparoscopy make in laparotomy method the still needed as a surgical in (43.2%); all other postmenopausal adnexal tumors laparoscopy diagnostic (56.8%) the operative patients with adnexectomy proved to be a safe and efficient treatment.
Rudy Leon De Wilde, MD, PhD, and Mathias Hesseling, MD Department of Obstetricsand Gynecology,Pius Clinic, University of Göttingen, W-2900 Oldenburg, Germany REFERENCES 1. Hurwitz A. Yagel S, Zion I, et al. The management of by diagnosed ultrasonography. persistent clear pelvic cysts Obstet Gynecol 1988; 72: 320-22. 2. Herrmann UJ, Locher GW, Goldhirsch A. Sonographic 7771987; 69: Gynecol Obstet patterns of ovarian tumours. 781. 3. Semm K. Operationslehre für endoskopische Abdominalchirurgie. Stuttgart: Schattauer, 1984.
Why not begin "active management" of prolonged pregnancy sooner?
To the Editors: In regard to the article by Votta and Cibils (Votta RA, Cibils LA. Active management of prolonged if 557-63), 168: 1993; GYNECOL OBSrer pregnancy. AM J is in 294-day signifipregnancies the perinatal mortality cantly higher than that of the general obstetric popula"active manage2500 fetuses start not why > gm, tion of days? 294 days 280 than at rather ment" at desire to Most could agree that all obstetricians deliver a mature, healthy baby. Starting "active man-
agement" earlier should accomplish this goal. Current obstetric care, including early pregnancy tests or ultrasonography for dating, careful care to identify babies with stress even before 280 days' gestation, and timely induction with careful prostaglandin and oxytocin protocols should help realize the goal of a mature, healthy baby. William T. Yates,MD Ma: n St., East Wilton, ME 04234
Reply To the Editors: I thank Yates for his interest in the material we reported. It is not clear to me whether he suggests an "active management" from 280 days of gestation onward or whether the first paragraph is a sarcastic opening salvo. Be that as it may, in the last sentence "current obstetric care .. ." implies that it is possible to avoid induction with "careful care to identify.... " If it were possible to identify all postterm fetuses at risk of severe or lethal perinatal complications, the whole concept of "active management" would have to be applied to a very small number of cases.The unfortunate circumstance is that some of these fetuses (2% to 5%) do not express their asphyctic state in the manner we are used to seeing: late decelerations with tachycardia and fixed baseline, lack of reactivity and positive contraction stress tests during gestation, low biophysical profiles, etc. This fact is described in the last paragraph of the article, before the conclusions (page 562, lines 41 to 48). These points are elaborated in detail in a paper recently published. ' Clearly, past day 290 of gestation the behavior of these fetuses is different, and until we find a way to correctly interpret their changes, they will be better served by induction of labor (or even a "cold" cesarean section). Luis A. Cibils, MD Departmentof Obstetricsand Gynecology,ChicagoLying-In Hospital, 5841 Maryland Ave., Chicago, IL 60637 REFERENCE
1. Cibils LA, Votta R. Clinical significance of FHR patterns during labor. IX. Prolonged pregnancy. J Perinat Med 1993; 21: 107-16.
Laparoscopic pelvic surgery: Better? Safer? To the Editors: I believe that the article by Grimes (Grimes DA. Frontiers of operative laparoscopy: A review and critique of the evidence. AM J Oasre-r GYNECOL 1992; 166: 1062-71) was a significant literature contribution and I can understand why the American Gynecological and Obstetrical Society requested him to carry out this review. I believe that Radar's implication (Kadar N. Laparoscopic surgery: Experiment or expedient? [Letter]. Am] OBSTFTGYNECoc1993; 168: 1333) that a randomized clinical trial was not useful or appropriate is incorrect.
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Rudy Leon De Wilde, MD, PhD, and Mathias Hesseling, MD Department of Obstetricsand Gynecology,Pius Clinic, University of Göttingen, W-2900 Oldenburg, Germany REFERENCES 1. Hurwitz A. Yagel S, Zion I, et al. The management of by diagnosed ultrasonography. persistent clear pelvic cysts Obstet Gynecol 1988; 72: 320-22. 2. Herrmann UJ, Locher GW, Goldhirsch A. Sonographic 7771987; 69: Gynecol Obstet patterns of ovarian tumours. 781. 3. Semm K. Operationslehre für endoskopische Abdominalchirurgie. Stuttgart: Schattauer, 1984.
Why not begin "active management" of prolonged pregnancy sooner?
To the Editors: In regard to the article by Votta and Cibils (Votta RA, Cibils LA. Active management of prolonged if 557-63), 168: 1993; GYNECOL OBSrer pregnancy. AM J is in 294-day signifipregnancies the perinatal mortality cantly higher than that of the general obstetric popula"active manage2500 fetuses start not why > gm, tion of days? 294 days 280 than at rather ment" at desire to Most could agree that all obstetricians deliver a mature, healthy baby. Starting "active man-
agement" earlier should accomplish this goal. Current obstetric care, including early pregnancy tests or ultrasonography for dating, careful care to identify babies with stress even before 280 days' gestation, and timely induction with careful prostaglandin and oxytocin protocols should help realize the goal of a mature, healthy baby. William T. Yates,MD Ma: n St., East Wilton, ME 04234
Reply To the Editors: I thank Yates for his interest in the material we reported. It is not clear to me whether he suggests an "active management" from 280 days of gestation onward or whether the first paragraph is a sarcastic opening salvo. Be that as it may, in the last sentence "current obstetric care .. ." implies that it is possible to avoid induction with "careful care to identify.... " If it were possible to identify all postterm fetuses at risk of severe or lethal perinatal complications, the whole concept of "active management" would have to be applied to a very small number of cases.The unfortunate circumstance is that some of these fetuses (2% to 5%) do not express their asphyctic state in the manner we are used to seeing: late decelerations with tachycardia and fixed baseline, lack of reactivity and positive contraction stress tests during gestation, low biophysical profiles, etc. This fact is described in the last paragraph of the article, before the conclusions (page 562, lines 41 to 48). These points are elaborated in detail in a paper recently published. ' Clearly, past day 290 of gestation the behavior of these fetuses is different, and until we find a way to correctly interpret their changes, they will be better served by induction of labor (or even a "cold" cesarean section). Luis A. Cibils, MD Departmentof Obstetricsand Gynecology,ChicagoLying-In Hospital, 5841 Maryland Ave., Chicago, IL 60637 REFERENCE
1. Cibils LA, Votta R. Clinical significance of FHR patterns during labor. IX. Prolonged pregnancy. J Perinat Med 1993; 21: 107-16.
Laparoscopic pelvic surgery: Better? Safer? To the Editors: I believe that the article by Grimes (Grimes DA. Frontiers of operative laparoscopy: A review and critique of the evidence. AM J Oasre-r GYNECOL 1992; 166: 1062-71) was a significant literature contribution and I can understand why the American Gynecological and Obstetrical Society requested him to carry out this review. I believe that Radar's implication (Kadar N. Laparoscopic surgery: Experiment or expedient? [Letter]. Am] OBSTFTGYNECoc1993; 168: 1333) that a randomized clinical trial was not useful or appropriate is incorrect.
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