The study was performed to establish a level of practice needed for newly-trained residents to maintain robotic surgical skills during periods of robotic inactivity. Ten surgical residents were trained to a standardized level of robotic surgery proficiency with inanimate models. At the end of two, four and six weeks, the residents practiced with the models for a total of one hour. Each resident performed a timed tissue closure task immediately after reaching the proficiency standards and twice in succession at eight weeks. Time to completion was compared between the three trials with a repeated measures ANOVA and a post-hoc test. Average time to complete the tissue closure task decreased by more than 25% over the period between reaching the proficiency standards and the trials at eight weeks, with the difference significant ( P  < 0.004). Biweekly practice for one hour was sufficient to maintain robotic surgical skills. Copyright © 2013 John Wiley & Sons, Ltd.

Periodic practice is needed for newly trained robotic surgeons to maintain skills during periods of robotic inactivity. The current study was performed to determine whether virtual robotic skill maintenance can serve as an adequate substitute for practice on a surgical robot. Eleven surgical residents with no prior robotic training were trained to a level of robotic proficiency with inanimate models, including a needle driving pad, a running suture pad, and ring placement on a rocking peg board. After reaching proficiency, each resident was tested on a complex tissue closure task. For the next 8 weeks, the only robotic activity was biweekly virtual robotic skills maintenance. After 8 weeks, the residents performed the tissue closure task twice with the robot, followed by evaluation on the inanimate models used to reach proficiency. Repeated-measures statistical analyses were used to compare between the three tissue closure trials and between the final test at week 0 and the evaluation at week 8 for the other inanimate models. Time to complete the tissue closure task was more than 20 % lower for the second evaluation at 8 weeks than for the other two trials (p < 0.05). Residents maintained their skills for needle driving, but times for suture running and rocking peg board increased by more than 20 % at 8 weeks (p < 0.01). Virtual practice shows promise for maintaining robotic skills. Following a warm-up period, some skills may actually improve with biweekly virtual practice, but skill retention is selective, so further improvements are needed.

Background and Objectives: The degradation in robotic skills that occurs during periods of robotic surgical inactivity in newly trained surgeons was measured. The role of animate training in robotic skill was also assessed.Methods: Robotically naive resident and attending surgeons underwent training with the da Vinci (R) robot on needle passage (DN), rocking ring transfer peg board (RPB), and running suture pod tasks (SP). Errors were established to convert actual time to adjusted time. Participants were deemed "proficient" once their adjusted times were within 80% of those set by experienced surgeons through repeated trials. Participants did not use the robot except for repeating the tasks once at 4, 8, and 12 weeks (tests). Participants then underwent animate training and completed a final test within 7 days.Results: Twenty-five attending and 29 resident surgeons enrolled; 3 withdrew. There were significant increases in time to complete each of the tasks, and in errors, by 4 weeks (Adjusted times: DN: 122.9 +/- 2.2 to 204.2 +/- 11.7, t=6.9, P<.001; RPB: 262.4 +/- 2.5 to 364.7 +/- 8.0, t=12.4, P<.001; SP: 91.4 +/- 1:4 to 169.9 +/- 6.8, t=11.3, P<.001). Times decreased following animate training, but not to levels observed after proficiency training for the RPB and SP modules.Conclusions: Robotic surgical skills degrade significantly within 4 weeks of inactivity in newly trained surgeons. Animate training may provide different skills than those acquired in the dry lab.

► Fallopian tube carcinosarcomas may present emergently with hemoperitoneum. ► Fallopian tube carcinosarcomas may be detected better with MR than with CT. ► Heterologous fallopian tube carcinosarcomas have been reported more often than the homologous type.

e20553 Background: Endometrial cancer patients remain at risk for other obesity related cancers and illnesses. Patients should be counseled to increase their physical activity, however, their belief concerning potential outcomes of exercise will affect how they are counseled. Methods: Patients treated for Stage I endometrial cancer with no other cancer diagnoses were asked if they had been exercising regularly for more than 6 months using the CDC definition of exercise (exercisers), how likely they thought regular exercise would result in health related outcomes (see Table ) and how important these outcomes are to them using Likert-like scales ranging from 1 to 5. A weighed calculation of how likely regular exercise would result in an outcome of importance to them was obtained by multiplying the two scores. Chi-square and t-tests were used to analyze data with SPSS V15. Results: 76 of 90 women approached completed the questionnaire (84%), mean age was 59.5 ± 1.1 (SEM). 45% were exercisers, their mean BMI was lower (31.2 ± 1.2 vs. 38.0 ± 1.4, p=0.001) and a non significantly lower proportion reported having diabetes (15% vs 26%) or hypertension (26% vs 43%). The majority of all women believed regular exercise would result in positive outcomes; a lower proportion of exercisers reported it very to extremely likely that regular exercise would reduce the risk of developing cancer (27% vs 54%, p=0.023) or osteoporosis (46% vs 73%, p=0.019). The majority reported these outcomes were very to extremely important to them; a lower proportion of exercisers reported reducing the risk of developing a new cancer or diabetes were (cancer 79% vs 98%, p=0.013; diabetes 78% vs 100%, p=0.003). Both groups believed feeling better physically and emotionally were important and likely consequences of exercise; exercisers were less likely to believe several other outcomes were important and likely consequences ( Table ). Conclusions: Women who exercise regularly and develop cancer may become disillusioned with the potential health benefits of exercise despite having improved health. [Table: see text] No significant financial relationships to disclose.

Over 22,000 cases of ovarian cancer were diagnosed in 2007 in the United States, but only a fraction of them can be attributed to mutations in highly penetrant genes such as BRCA1. To determine whether low-penetrance genetic variants contribute to ovarian cancer risk, we genotyped 1,536 single nucleotide polymorphisms (SNP) in several candidate gene pathways in 848 epithelial ovarian cancer cases and 798 controls in the North Carolina Ovarian Cancer Study (NCO) using a customized Illumina array. The inflammation gene interleukin-18 (IL18) showed the strongest evidence for association with epithelial ovarian cancer in a gene-by-gene analysis (P = 0.002) with a <25% chance of being a false-positive finding (q value = 0.240). Using a multivariate model search algorithm over 11 IL18 tagging SNPs, we found that the association was best modeled by rs1834481. Further, this SNP uniquely tagged a significantly associated IL18 haplotype and there was an increased risk of epithelial ovarian cancer per rs1834481 allele (odds ratio, 1.24; 95% confidence interval, 1.06-1.45). In a replication stage, 12 independent studies from the Ovarian Cancer Association Consortium (OCAC) genotyped rs1834481 in an additional 5,877 cases and 7,791 controls. The fixed effects estimate per rs1834481 allele was null (odds ratio, 0.99; 95% confidence interval, 0.94-1.05) when data from the 12 OCAC studies were combined. The effect estimate remained unchanged with the addition of the initial North Carolina Ovarian Cancer Study data. This analysis shows the importance of consortia, like the OCAC, in either confirming or refuting the validity of putative findings in studies with smaller sample sizes. (Cancer Epidemiol Biomarkers Prev 2008;17(12):3567-72).

OBJECTIVE:To compare pain, adverse effects and recurrence of dysplasia in patients with vaginal intraepithelial neoplasia or vulvar intraepithelial neoplasia prospectively treated by carbon dioxide laser or ultrasonic surgical aspiration. METHODS:Patients were randomly assigned to receive treatment by laser or ultrasonic surgical aspiration from 2000-2005. Preoperative biopsy was done to confirm presence of dysplasia. Patients completed a visual analog scale regarding pain and were evaluated at 2-4 weeks to assess scarring, wound healing, and adverse effects. Patients returned every 3 months for 1 year for pelvic examination and cytology to assess recurrence. Follow-up colposcopy and biopsy were used at the discretion of the treating physician. Student t test, chi2, analysis of variance and multiple logistic regression were used for analysis. RESULTS:One hundred ten patients were randomly assigned. Ninety-six (87.3%) patients completed 1 year follow-up. Mean age of patients was 48.5 years. Mean visual analog scale score was significantly lower in patients treated by ultrasonic surgical aspiration (20.7 compared with 35.1; P=.032). For patients with vulvar lesions, there was less scarring with ultrasonic surgical aspiration (P<.01). Recurrence overall was 25% and was similar for ultrasonic surgical aspiration compared with laser (relative risk 0.96, 95% confidence interval 0.64-1.50, number needed to treat 95.6). Recurrence was associated with younger age (P<.01). CONCLUSION:Patients treated with ultrasonic surgical aspiration for vulvar and vaginal dysplasia reported less postoperative pain. Vulvar scarring was more common in patients treated by the laser. There was no difference in recurrence of dysplasia during a 1-year follow-up period between the two surgical modalities. CLINICAL TRIAL REGISTRATION:ClinicalTrials.gov, www.clinicaltrials.gov, NCT00394758 LEVEL OF EVIDENCE:I.

BACKGROUND:Quality of life (QoL) measurements are important in evaluating cancer treatment outcomes. Factors other than cancer and its treatment may have significant effects on QoL and affect assessment of treatments. Baseline data from longitudinal studies of women with endometrial or ovarian cancer or adnexal mass determined at surgery to be benign were analyzed to determine the degree to which QoL is affected by baseline differences in demographic variables and health.METHODS:This study examined the effect of independent variables on domains of the Functional Assessment of Cancer Therapy (FACT-G) pre-operatively in gynecologic oncology patients undergoing surgery for pelvic mass suspected to be malignant or endometrial cancer. Patients also completed the Short Form Medical Outcomes Survey (SF-36) questionnaire (a generic health questionnaire that measures physical and mental health). Independent variables were surgical diagnosis (ovarian or endometrial cancer, benign mass), age, body mass index (BMI), educational level, marital status, smoking status, physical (PCS) and mental (MCS) summary scores of the SF-36. Multiple regression analysis was used to determine the influence of these variables on FACT-G domain scores (physical, functional, social and emotional well-being).RESULTS:Data were collected on 157 women at their pre-operative visit (33 ovarian cancer, 45 endometrial cancer, 79 determined at surgery to be benign). Mean scores on the FACT-G subscales and SF-36 summary scores did not differ as a function of surgical diagnosis. PCS, MCS, age, and educational level were positively correlated with physical well-being, while increasing BMI was negatively correlated. Functional well-being was positively correlated with PCS and MCS and negatively correlated with BMI. Social well-being was positively correlated with MCS and negatively correlated with BMI and educational level. PCS, MCS and age were positively correlated with emotional well-being. Models that included PCS and MCS accounted for 30 to 44% of the variability in baseline physical, emotional, and functional well-being on the FACT-G.CONCLUSION:At the time of diagnosis and treatment, patients' QoL is affected by inherent characteristics. Assessment of treatment outcome should take into account the effect of these independent variables. As treatment options become more complex, these variables are likely to be of increasing importance in evaluating treatment effects on QoL.

6132 Background: The Functional Assessment of Cancer Therapy general (FACT) questionnaire was developed to assess disease and treatment specific issues affecting patients’ quality of life (QoL). Factors other than cancer and its treatment, such as age, general physical and emotional health, and socio-economic status, may have significant effects on QoL and patients’ response to treatments. This study examined the effect of these variables on the domains of the FACT in gynecologic oncology patients undergoing surgery for pelvic mass suspected to be malignant or endometrial cancer. Methods: Demographic information and patient characteristics were obtained pre-operatively. Patients also completed the FACT and the SF-36, a general health questionnaire that measures physical and mental well-being but is not designed to be sensitive to the detection of small treatment effects. Correlation and multiple regression analysis were used to assess the effect of diagnosis, age, body mass index (BMI), educational level, marital status, smoking status, physical (PCS) and mental (MCS) summary scores of the SF-36 on FACT domain scores. Results: Data were collected on 157 women at their pre-operative visit (endometrial cancer, n=45; benign masses, n=79; ovarian cancer, n=33). PCS, MCS and age were positively correlated with scores on the FACT, while BMI and smoking were negatively correlated ( Table ). Educational level was negatively correlated with scores on the social domain but positively correlated with physical scores on the FACT. PCS and MCS accounted for a significant amount of the variance (R 2 ) in regression models for each of the FACT domains ( Table ). Conclusion: Patients’ QoL, as measured by a questionnaire that is sensitive to their disease and treatment, is affected by their baseline characteristics. As treatment options become more complex, these variables are likely to be of increasing importance in evaluating QoL. [Table: see text] No significant financial relationships to disclose.

Objective. To prospectively examine body weight changes in women with newly diagnosed ovarian cancer receiving surgery and adjuvant chemotherapy. Body composition was examined in a subset of these women.Methods. Body weight (BW) and body composition, using bioelectrical impedance (RJL Systems Inc.), were prospectively measured pre- and post-operatively, and at 3, 6, and 12 months.Results. Mean age of 42 women was 59 years and did not differ by stage of disease. Nine women with early stage disease did not receive adjuvant chemotherapy. Mean BW of 33 patients receiving chemotherapy decreased from the pre- to post-operative visit and then returned to baseline levels by 12 months (F = 8.70, P = 0.003). Nine patients who did not receive chemotherapy demonstrated a similar pattern (F = 7.0, P = 0.002). Women receiving chemotherapy with stage I/II cancer had a 2.8 +/- 2.0 kg weight gain over the year, and women with stage III/IV cancer had a 1.5 +/- 1.5 kg weight loss (t = 1.72, P = 0.096). A subset of women with stage I/II (n = 6) and stage III/IV (n = 6) ovarian cancer receiving chemotherapy had body composition measured at three time points. Absolute body fat changes paralleled changes in BW (F = 9.95, P = 0.002).Conclusions. Our study is the first prospective evaluation of body weight and composition in women undergoing surgery and chemotherapy for ovarian cancer. These results demonstrate that women undergoing surgery for ovarian cancer lost weight following surgery and regained it slowly over the following year. Further investigations of weight changes during adjuvant chemotherapy are indicated to assess potential changes in different stages of disease. (c) 2006 Elsevier Inc. All rights reserved.

OBJECTIVES:To prospectively evaluate quality of life (QoL), use of complementary and alternative medicine (CAM), and diet/exercise changes in ovarian cancer patients during the first 6 months following diagnosis.METHODS:Patients with newly diagnosed ovarian cancer were enrolled pre- or post-operatively and surveyed at 3 and 6 months. The Functional Assessment of Cancer Therapy (FACT-G), Medical Outcomes Survey (SF-36), and CAM/diet/exercise questionnaires were used. Independent samples t test and repeated measures ANOVA were used.RESULTS:Forty-two patients underwent surgical debulking and staging prior to chemotherapy. Patients completing the initial surveys post-operatively had significantly lower physical FACT-G and SF-36 physical scores compared to patients completing the surveys pre-operatively. In patients completing the baseline survey pre-operatively, there was a decrease in physical scores at 3 months (after surgery and during chemotherapy). There was no change observed at 3 months relative to baseline when patients completed the baseline survey post-operatively. Increases in physical and functional well-being were seen at 6 months relative to 3 months. There were no changes in emotional or social scores over time. CAM use increased over time; main reasons were to improve QoL and relieve symptoms. Alterations in diet and exercise were not seen.CONCLUSIONS:These data highlight the need to conduct assessments before and after surgery to identify effects due to surgery and/or chemotherapy. Patients may be using CAM during chemotherapy to deal with symptoms and compensate for decreased QoL. Intervention trials should be implemented to increase QoL following surgery and during adjuvant chemotherapy.

Objective: This study was undertaken to prospectively evaluate the effect of early stage endometrial cancer, age, and obesity on quality of life (QOL).Study design: Women undergoing surgery for endometrial cancer or an adnexal mass determined at surgery to be benign (controls) were enrolled preoperatively and followed for 6 months.Results: Seventy-nine women completed the study. Functional Assessment of Cancer Therapy (FACT-G) scores increased significantly in all women; however, significant differences by patient weight and age were obtained. Obesity was associated with decreased physical FACT-G and SF-36 scores. Older women had lower SF-36 physical scores, higher emotional scores, and less change over time.Conclusion: Women with early endometrial cancer had similar changes in QOL as those who received surgery for benign disease. Obese and elderly women had domain alterations. Given the aging population and rising incidence of obesity, these results emphasize the need for QOL interventions in postoperative gynecologic care of these patients. (C) 2005 Mosby, Inc. All rights reserved.

Longitudinal assessments of quality of life are needed to measure changes over the course of a disease and treatment. Computer versions of quality of life instruments have increased the feasibility of obtaining longitudinal measurements. However, there remain occasions when patients are not able to complete these questionnaires. This study examined whether changes measured using a computer version of the Functional Assessment of Cancer Therapy – General (FACT-G) on two occasions would be obtained if patients completed a paper version on one of the two occasions.

8253 Background: Cancer specific questionnaires such as the Functional Assessment of Cancer Therapy (FACT) are sensitive to quality of life (qol) effects due to illness and treatment, but interpretation may be hampered by response shifts if women's perception of qol changes over the course of their illness. The SF-36 Health Survey is designed to measure health in a variety of disease states and may be more likely to measure a decline with severity of illness. Using the SF-36 would allow for interpretation of qol relative to defined populations as well as previously measured health status. Methods: Ninety women undergoing surgery for endometrial cancer, ovarian cancer or a benign adnexal mass completed the FACT-G and the SF-36 pre-operatively and 6 months following surgery. Spearman correlation coefficient was used to compare scores from similar scales obtained by the two questionnaires at baseline. Significance was set at .01 due to multiple tests performed. Results: Significant changes over 6 months were seen in the FACT emotional and functional scales and the bodily pain and mental health subscales of the SF-36. SF-36 data at baseline and 6 months were similar to age and gender specific national norms. The physical and functional scales of the FACT were significantly correlated with the physical scales of the SF-36 (p's<.01). The emotional scale of the FACT was significantly correlated with the mental health scales of the SF-36 (p's<.01), but the social scale of the FACT was only correlated with the SF-36 vitality subscale (p<.01). Conclusions: The FACT and SF-36 physical scales were highly correlated suggesting that women are responding similarly within the physical domain at the beginning of their illness. The FACT questionnaire appears more sensitive to changes resulting from cancer and treatment, but may benefit from being used with the SF-36 for malignancy that progresses. Under these conditions, SF-36 scores are likely to decrease but women may “compensate” by changing their definition of qol as measured with the FACT. Reported qol using the FACT can then be evaluated within the context of their general health status measured with the SF-36. No significant financial relationships to disclose.

Our objective was to describe and compare the use of complementary and alternative medicine (CAM) in gynecology and gynecological oncology patients. Five hundred and twenty-nine gynecology and gynecological oncology patients completed a questionnaire regarding CAM use. Overall, 56.3% of gynecology and gynecological oncology patients reported current use of CAM. Therapies used included nutritional supplements (20%), prayer as medical therapy (17%), exercise as medical therapy (12%), megavitamins (10%), and green tea (10%). While 69.5% believed CAM to be beneficial, only 31.6% discussed these therapies with their physician. The women spent a mean of $656.22 on CAM (range $0–$7,000), with 31.7% receiving some insurance reimbursement. Gynecologic oncology patients (n =161) used CAM significantly more than gynecology patients (n =368) (66% vs. 52%, 95% CI=0.046–0.230, P =0.004). Gynecological oncology patients also spent more for CAM, with a mean expenditure of $711 versus $622 by gynecology patients. Within the gynecological oncology patient group, there were 69 patients currently receiving modern medical treatments for cancer; among these patients, 58% reported using CAM; of these, 39.3% communicated their use of CAM to their physician. Patients in this group spent an average of $1,178 on CAM during their illness, with only 6.3% receiving insurance reimbursement. Benefits from CAM were perceived by 54.5% in this group. We concluded that cancer patients have a higher usage rate and expenditure for CAM, particularly while they are receiving medical therapy, and are more likely to discuss the use of alternative therapies with their physicians. CAM was perceived as helpful by patients despite the lack of scientific data about its effect.

BACKGROUND: Hemolytic anemia associated with benign pelvic neoplasms is very rare. Sixteen cases have been reported in the English-language literature. CASE: A 27-year-old woman complained of dizziness, fatigue and headache. Physical Examination revealed jaundice and mild tachycardia. Laboratory evaluation indicated intravascular hemolysis, and workups for hematologic and infectious disease etiologies were negative. Multiple blood transfusions and steroids failed. Computed tomography showed a large, complex pelvic mass (10 x 10 x 6 cm). Exploratory laparotomy and excision of bilateral dermoid cysts were performed, and the anemia resolved. The patient was healthy, without recurrence, seven years later. CONCLUSION: It is important to seek to identify pelvic tumors in patients presenting with hemolytic anemia because this condition is often resistant to standard medical therapy and resolves only after removal of the neoplasm. (J Reprod Med 2001;46:401-404).

OBJECTIVE To examine the rate of utilization of complementary and alternative medicine (CAM) in Amish women, a population that traditionally uses non-mainstream medicine. METHODS & RESULTS Sixty-six Amish women completed a survey concerning their use of CAM. Thirty-six percent of the Amish women used at least one form of CAM, primarily reporting a use of diet and nutrition programs, herbal therapies, and chiropractic medicine. In addition, ten pregnant Amish women reported using echinacea, St. John's Wort, red clover, garlic and ginseng. CONCLUSION This survey highlights the need to address potential adverse effects of herbal therapies in young women who are a member of a group that may use non-mainstream medicine.

Rhabdomyosarcoma is a neoplasm of childhood which commonly arises in the genitourinary tract. Reported locations include the bladder, prostate, paratestis, vagina, uterus, cervix, and ovary. Rhabdomyosarcomas have been reported to occur in the fallopian tube only as a component of a malignant mixed müllerian tumor. We present a case of pure embryonal rhabdomyosarcoma of the fallopian tube in a 17-year-old. The diagnosis was confirmed by immunohistochemical stains. The strongest evidence for the primary location of this pure embryonal rhabdomyosarcoma was the gross appearance of the tumor at laparotomy. Additionally, rhabdomyosarcomas arising from adjacent organs have never been reported to grow into the fallopian tubes.