J.L. Muñoz

Conservative management of retained trophoblastic tissue and placental polyp with diagnostic ambulatory hysteroscopy

OBJECTIVE To analyse the results of our conservative management of retained trophoblastic tissue and placental polyp with diagnostic ambulatory hysteroscopy and to describe our experience and guidelines. STUDY DESIGN Descriptive retrospective study. Eighty-four women with suspected retained trophoblastic tissue after pregnancy underwent hysteroscopic examination and extraction of all residual tissue in the office under direct visualization of the uterine cavity, without anaesthesia or cervical dilatation. RESULTS Hysteroscopic examination was tolerated by all but one patient. In 82 cases (97.4%), the diagnosis after hysteroscopic examination was placental polyp or retained trophoblastic tissue. This diagnosis was histologically confirmed in 79 cases (94.7%). In 43.6% (36) of the cases, complete evacuation of the uterine cavity was achieved during a single hysteroscopic examination. The only complication after hysteroscopy was one case of major vaginal bleeding requiring curettage. CONCLUSIONS Diagnostic-operative ambulatory hysteroscopy is a suitable alternative to blind curettage in the management of retained trophoblastic tissue. This technique can be performed in the office without anaesthesia and with a low rate of complications.

Rectosigmoid deep infiltrating endometriosis and ureteral involvement with loss of renal function

UNLABELLED Endometriosis is a complex disease with unclear pathogenesis, defined as the presence of endometrial tissue (glands and stroma) outside its usual location in the uterine cavity. Ureteral involvement is rare, with an estimated frequency of 10-14% in cases of deep endometriosis with nodules of 3 cm or larger. An important complication of ureteral involvement is asymptomatic loss of renal function. In a patient with asymptomatic renal failure the relevance of extrinsic ureteral involvement by deep endometriosis has been taken to account. CASE REPORT A 32-year-old nulliparous woman presented with chronic pelvic pain associated with severe dysmenorrhea, dyspareunia and digestive problems including diarrhea, occasional constipation and rectal bleeding. She reported no urological symptoms. Magnetic resonance imaging (MRI) identified a 4 cm nodule in the recto-vaginal septum, compressing and infiltrating the rectal wall, and chronic left hydronephrosis. Isotope renogram revealed 91% function in the right kidney and 9% in the left kidney. A multidisciplinary surgical team including consultants from the departments of digestive surgery and urology assessed the patient. The treatment recommended was a joint approach of laparoscopic surgery to perform adhesiolysis, ureterolysis, freeing of the uterus and appendages, resection of the rectovaginal septum nodule, and left nephrectomy. COMMENT Diagnosis and treatment of deep endometriosis should be performed in specialized centers and in the context of multidisciplinary collaboration. We must be aware of the potential risk of ureteral involvement and the asymptomatic loss of renal function in any patient with endometriosis nodules of 3 cm or larger.

Severe menorrhagia due to Glanzmann thrombasthenia treated with hydrothermal ablation

Glanzmann thrombasthenia is a rare platelet disorder inherited as an autosomal recessive trait. Abnormal uterine bleeding is a common problem in women with the disease. Medical management may not always be effective and further treatment may be necessary. Two women underwent endometrial ablation with a continuous-flow circulating hydrothermal ablator. After follow-up of 12 and 18 months, both women remained without abnormal uterine bleeding.

Conservative management in ureteric hydronephrosis due to deep endometriosis: Could the levonorgestrel-intrauterine device be an option?

Abstract Endometriosis can affect up to 10% of women of reproductive age, in a wide range of clinical presentations that vary from mild to severe or deep endometriosis. Deep endometriosis can affect the urinary tract in 1–5% to 15–25% cases. Even though deep endometriosis’ surgeries are usually complex with higher rate of complications, conservative management is not always considered as an option because of its high failure rates. This paper describes two cases of deep endometriosis with ureteric involvement (hydronephrosis) treated conservatively with a double-pigtail stent plus a Levonorgestrel intrauterine device, after conservative surgery, who remained symptom free with no evidence of recurrence at 3 years follow-up, avoiding radical high-risk surgery. Impact statement Several treatments have been described for endometriosis. From a symptomatic perspective, conservative medical management has been proposed with a variable response. Concerning deep endometriosis (affecting the urinary or digestive tract), the definitive treatment has always been thought to be radical surgery. However, this can lead to several complications. To illustrate a possible more conservative approach this paper describes two cases of deep infiltrating endometriosis affecting the ureter, treated conservatively with a temporary pigtail ureter stent plus a Levonorgestrel intrauterine device. The management demonstrates that, in a selected population, conservative treatment solves the urinary disease avoiding the surgical complications and, what is more, improving patients’ symptoms in a permanent way. Further prospective studies are needed to confirm whether the introduction of this management in clinical practice would reduce the need for surgery thereby, avoiding high-risk surgery and improving the success rate of conservative management.

Laparoscopic location and extraction of abortion cannula lodged in the retroperitoneal space.

A 29-year-old patient was admitted into our emergency ynecologic area with hypogastric pain after undergoing uterne curettage because of an abortion. The results of the pelvic xamination were normal; ultrasound scanning and a simple adiograph of the abdomen revealed a tubular formation in the eft side of the abdomen (Fig. 1). Laparoscopic inspection of he pelvis revealed a perforation in uterus (Fig. 2A). An inammatory mass of the sigmoid and mesosigmoid was deected inside a 30-cm plastic cannula, which was draining carce quantities of pus-infected material (Fig. 3B). Liberation f adherences and endoscopy sutures of the uterine perforation re shown in Fig. 2A. Liberation and extraction of the foreign ody are shown in Figs. 2B and 3A. Evacuation of the inflamatory plastron is shown in Fig. 3B. Peritoneal washing was erformed. Jackson Pratt drains were left in the abdominal avity and removed in 2 days. Laparoscopic surgery should be onsidered the preferred technique for the extirpation and exloration of foreign bodies from the abdominal cavity [1–4].

Carcinoma neuroendocrino de cérvix uterino: descripción de 2 casos clínicos, uno de ellos asociado a gestación. Revisión de la bibliografía

Resumen El carcinoma neuroendocrino de cervix uterino (CNCU) es una entidad infrecuente asociada a un comportamiento agresivo. El tratamiento optimo no esta definido claramente. Rara vez se asocia a una gestacion. Se presentan 2 casos de CNCU tratados en nuestro departamento, el primero de ellos asociado a un embarazo.

Incidencia de adenocarcinoma de endometrio en la pieza de histerectomía tras diagnóstico de hiperplasia endometrial atípica

Resumen La hiperplasia endometrial atipica es un aumento del espesor endometrial con riesgo de progresion a carcinoma de endometrio. Asi, el riesgo de progresion a adenocarcinoma endometrial para la hiperplasia compleja atipica (HCA), segun diversos autores, varia entre el 29 y el 100%. Es muy importante realizar un diagnostico diferencial entre la HCA y el carcinoma de endometrio bien diferenciado, pues tras un diagnostico de HCA por biopsia o legrado, se ha encontrado una incidencia del 15-43% de adenocarcinoma endometrial en la pieza de histerectomia. Objetivos Analizar la coexistencia de HCA y adenocarcinoma de endometrio en la pieza quirurgica de histerectomia, y evaluar la conducta actual ante la HCA. Material y metodo Estudio retrospectivo de 15 HCA obtenidas tras una biopsia endometrial durante una histeroscopia, sometidas a histerectomia con doble anexectomia y lavado peritoneal, desde mayo de 2001 a marzo de 2004. Resultados Se obtuvieron 8 casos (53%), que mantuvieron el diagnostico prequirurgico de hiperplasia compleja atipica. En las otras 7 piezas quirurgicas (47%) se observo la existencia de un adenocarcinoma endometrioide de grado I de diferenciacion, en estadio I de la FIGO. En 3 de los 7 casos con adenocarcinoma (el 20% del total de HCA operadas) se comprobo la infiltracion miometrial en menos del 50% de su espesor (estadio IB de la FIGO). No hubo invasion miometrial en los otros 4 adenocarcinomas (estadio IA de la FIGO). Conclusiones Ante estos resultados, se deberian proponer estrategias encaminadas a resolver los casos de infraestadificacion, con un estudio de extension tras el diagnostico de HCA similar al realizado en el carcinoma de endometrio, y a evitar tratamientos incompletos, con biopsia intraoperatoria de la pieza de histerectomia para realizar la linfadenectomia pelviana en el mismo acto quirurgico si se confirmara la invasion miometrial.

Enfermedad de Mondor. Descripción de un caso clínico

Resumen La enfermedad de Mondor es una patologia infrecuente, caracterizada por la tromboflebitis de la venas toracicas subcutaneas. Presentamos el caso de una paciente de 85 anos de edad, que acudio por la aparicion de una tumoracion en la mama izquierda de aparicion espontanea, sin causa aparente. El cuadro mejoro tras la aplicacion de un tratamiento antiinflamatorio local, hasta su completa resolucion transcurridas unas semanas.

Cáncer de mama subclínico y edad

Resumen Objetivo Analizar retrospectivamente los carcinomas de mama subclinicos hallados en el grupo de estudio de 263 pacientes con lesiones radiologicas de mama no palpables. Material y metodo El grupo de estudio esta compuesto por 88 pacientes diagnosticadas mediante mamografia de lesion sospechosa no palpable con resultado histologico de malignidad. En todas ellas se realizo marcaje con arpon de la lesion mediante tecnica estereotaxica y biopsia diferida con comprobacion radiologica intraoperatoria de la pieza. Resultadoso De las 263 mujeres con mamografia sospechosa, en 88 (33,5%) casos el diagnostico anatomopatologico fue de cancer. En el grupo con edad inferior a 50 anos la incidencia de cancer fue de 25/98 (25%); en las edades comprendidas entre 50 y 65 anos, de 46/113 (47%), y en las mayores de 65 anos, de 17/34 (50%). Se diagnosticaron 27 carcinomas in situ , de los cuales 12 se presentaron en mujeres menores de 50 anos y los 15 restantes en el grupo con edades comprendidas entre 50 y 65 anos. La incidencia de carcinoma in situ en las mujeres jovenes fue de 12/25 (48%), y en el grupo de edades comprendidas entre 50 y 65 anos, de 15/47 (32%). Conclusiones Las imagenes mamograficas sospechosas corresponden en un elevado porcentaje de casos a lesiones malignas y la posibilidad es mas elevada cuanto mayor es la edad de la mujer. Los canceres no infiltrantes son mas frecuentes en las mujeres jovenes.

Cerclaje abdominal: nuestro primer caso

Resumen El cerclaje istmicocervical por via abdominal es una tecnica escasamente utilizada, de mayor riesgo que el cerclaje convencional, pero que puede constituir la unica opcion terapeutica en determinados casos de insuficiencia istmicocervical. En este trabajo presentamos nuestra primera experiencia con esta tecnica, realizada en la semana 11 a una paciente con mala historia obstetrica y que permitio una evolucion favorable del embarazo.