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Biomedical subjects

N Kadar

Publications and source records attributed to N Kadar.

At least 19 recordsLinked to original sources
PubMed1996

Surgical anatomy and dissection techniques for laparoscopic surgery.

All anatomically important pelvic structures lie embedded in the fatty-fibrous connective tissue of the retroperitoneum from which they may be freed by blunt dissection in the correct tissue planes. By relying on fixed laparoscopic landmarks, the correct surgical planes of dissection can be found, and all vital structures freed and identified by a systematic dissection consisting of a precise sequence of operative steps. Once the retroperitoneal dissection has been completed and all vital structures identified, most gynecologic operations can be carried out safely and without much difficulty laparoscopically. A nonanatomical approach to laparoscopic pelvic surgery may be easier to learn, but it is neither very versatile nor very safe except in the simplest of cases.

Dissection↗
PubMed1995

Possible metaplastic origin of lymph node "metastases" in serous ovarian tumor of low malignant potential (borderline serous tumor).

A patient with a stage III serous ovarian carcinoma of low malignant potential (borderline serous tumor) is described who had extensive involvement of the pelvic and para-aortic lymph nodes by both borderline tumor and endosalpingiosis. Transition from endosalpingiosis to papillary serous borderline tumor was demonstrable in multiple intranodal sites, and in fully developed lesions, areas of metaplastic growth acquired a desmoplastic stroma. This finding suggests that the lymph node "metastases" may have arisen de novo by neoplastic transformation of preexistent metaplastic tubal-type epithelium (endosalpingiosis), and would lend further credence to the metaplastic (rather than metastatic) origin or extraovarian implants in serous ovarian carcinoma of low malignant potential.

Adult↗
PubMed1995

Laparoscopic pelvic and aortic lymphadenectomy.

A systematic approach to the laparoscopic management of gynaecological malignancies began about 5 years ago more or less simultaneously in a few centres in France and the USA. Mature data and long-term follow-up are not yet available. Despite the absence of comparative studies, evidence is, in this author's opinion, now compelling that pelvic and aortic lymphadenectomy can be carried out just as effectively laparoscopically as via a laparotomy. This conclusion is based on traditional surgical, anatomical and pathological considerations such as the way in which the operation is executed, photodocumentation of the extensiveness of the dissection, the lymph node harvest and the proportion of positive lymph nodes recovered. The benefits of a laparoscopic approach have yet to be demonstrated in comparative studies, but compared with historical controls, the reduction in morbidity is so dramatic as to leave little doubt that patients benefit from laparoscopic treatment in experienced hands.

Aorta↗
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

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↗
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↗
PubMed1992

Selective pelvic and periaortic lymphadenectomy does not increase morbidity in surgical staging of endometrial carcinoma.

OBJECTIVE: The objective of this study was to retrospectively assess whether there was increased morbidity associated with the addition of selective pelvic and periaortic lymphadenectomy to hysterectomy in patients with endometrial carcinoma. STUDY DESIGN: From 1977 through 1988, 196 patients undergoing selective pelvic and periaortic lymphadenectomy plus hysterectomy were compared with 104 patients who underwent hysterectomy alone for endometrial adenocarcinoma. RESULTS: Only after adjusting for covariates was selective pelvic and periaortic lymphadenectomy associated with a higher estimated blood loss, which increased linearly with weight and was higher for black than for white women. The transfusion rate was similar for the two groups (selective pelvic and periaortic lymphadenectomy 6%, hysterectomy 10%). The mean blood loss was significantly different among the four gynecologic oncology surgeons (range 343 to 652 ml). The operating time primarily depended on patient weight and race, surgeon, and estimated blood loss. Postoperative hospital stay increased significantly with age, surgeon, wound infections, thrombotic events, and serious complications. Selective pelvic and periaortic lymphadenectomy had no effect on wound infections, which were directly related to operating time. Seventy-five (38%) of the selective pelvic and periaortic lymphadenectomy group and 19 (18%) of the hysterectomy group (p < 0.01) received whole-pelvic radiation with no difference in bowel complications (selective pelvic and periaortic lymphadenectomy 2/75, hysterectomy 1/19). The risk of serious complications was associated only with increasing age. CONCLUSION: Selective pelvic and periaortic lymphadenectomy in patients with endometrial carcinoma does not significantly add to morbidity from hysterectomy, which is related primarily to other factors such as patient weight, age, and race; operating time; and surgeon.

Adenocarcinoma↗