Luis E. Mendez

Guidelines of how to manage vesicovaginal fistula.

Vesicovaginal fistulas are among the most distressing complications of gynecologic and obstetric procedures. The risk of developing vesicovaginal fistula is more than 1% after radical surgery and radiotherapy for gynecologic malignancies. Management of these fistulas has been better defined and standardized over the last decade. We describe in this paper the success rate reported in the literature by treatment modality and the guidelines used at our teaching hospitals, University of Rome Campus Biomedico and University of Miami School of Medicine. In general, our preferred approach is a trans-vaginal repair. To the performance of the surgical treatment, we recommend a minimum of a 4-6 weeks wait from the onset of the fistula. The vaginal repair techniques can be categorized as to those that are modifications of the Latzko procedure or a layered closure with or without a Martius flap. The most frequently used abdominal approaches are the bivalve technique or the fistula excision. Radiated fistulas usually require a more individualized management and complex surgical procedures. The rate of successful fistula repair reported in the literature varies between 70 and 100% in non-radiated patients, with similar results when a vaginal or abdominal approach is performed, the mean success rates being 91 and 97%, respectively. Fistulas in radiated patients are less frequently repaired and the success rate varies between 40 and 100%. In this setting many institutions prefer to perform a urinary diversion. In conclusion, the vaginal approach of vesicovaginal fistulas repair should be the preferred one. Transvaginal repairs achieve comparable success rates, while minimizing operative complications, hospital stay, blood loss, and post surgical pain. We recommend waiting at least 4-6 weeks prior to attempting repair of a vesicovaginal fistula. It is acceptable to repeat the repair through a vaginal approach even after a first vaginal approach failure. In the more individualized management of fistulas associated with radiation, the vaginal approach should still be considered.

The safety of incidental appendectomy at the time of abdominal hysterectomy

OBJECTIVE The purpose of this study was to assess the complication rates of incidental appendectomies in women who undergo benign gynecologic procedures. STUDY DESIGN This was a retrospective case-controlled study of patients who did (n=100 women) or did not (n=100 women) undergo incidental appendectomies at the time of an abdominal hysterectomy between June 1995 and January 2001. Information was abstracted from hospital and clinic records and a gynecologic oncology database. Data were obtained about age, body mass index, hypertension, diabetes mellitus, the number of days with nothing by mouth, the length of hospital stay, and postoperative complications (cellulitis, fever, ileus, pneumonia, thromboembolic disease). Data were analyzed with the use of two-sample t tests, Wilcoxon Rank sum tests, chi(2) tests, and multiple logistic regressions. RESULTS There was no difference in preoperative diagnosis or operative procedure for either group. The number of patients in the group that did have incidental appendectomy versus the group that did not have incidental appendectomy with additional procedures at the time of abdominal hysterectomy was bilateral salpingo-oophorectomy (66 vs 61 women), unilateral oophorectomy (19 vs 19 women), lysis of adhesions (9 vs 8 women), and others (12 vs 8 women). Compared with the group that did not have incidental appendectomy, the group that did have incidental appendectomy was younger (mean age+/-SD: 44+/-9.6 years vs 48+/-13.6 years, P=.02) and had a lower mean body mass index (26.1+/-6.0 kg/m(2) vs 29.8+/-8.9 kg/m(2), P=.0009). No significant differences were found between the two groups (the group that did have incidental appendectomy vs the group that did not have incidental appendectomy, respectively) with respect to the following postoperative complications: fever (40 vs 27 women), cellulitis (1 vs 2 women), wound collection (4 vs 6 women), wound dehiscence (1 vs 5 women), wound abscess (7 vs 6 women), ileus (3 vs 2 women), and urinary tract infection (4 vs 10 women). The mean length of hospital stay was significantly longer in the group that did have incidental appendectomy than in the group that did not have incidental appendectomy (3.6+/-1.52 days vs 3.1+/-1.1 days, P=.006). However, the difference was no longer significant when patients who were fed electively on the postoperative day 2 were excluded from the analysis (3.16+/-1.13 days vs 3.04+/-1.13 days, P=.507). Thirty-one percent of the histologic specimens were abnormal, with fibrous obliteration being most common, and there was one case of acute appendicitis. CONCLUSION An incidental appendectomy at the time of benign gynecologic procedures does not increase postoperative complication rates or length of hospital stay. The inclusion of incidental appendectomies in all abdominal hysterectomies could potentially decrease the morbidity and mortality rates because of appendicitis in elderly women.

Continent urinary diversion and low colorectal anastomosis after pelvic exenteration. Quality of life and complication risk

INTRODUCTION Pelvic exenteration is one of the most destructive gynecologic operations performed on an elective basis, with consequent detrimental effects on the quality of life. The use of reconstructive surgery has significantly improved the quality of life of women undergoing this type of procedure. In this paper we review our experience with continent urinary diversion (Miami Pouch) and low colorectal anastomosis at the Division of Gynecologic Oncology of the University of Miami. METHODS Patients who underwent creation of the continent urinary diversion Miami Pouch from 1988 to 1997 and supralevator pelvic exenteration with low colorectal resection and primary anastomosis from 1990 to 1997 have been included in this study. Management of complications, with particular emphasis on the conservative treatment, has been reviewed in detail for each patient. Open surgery and conservative treatment have been compared. Analysis of complications in irradiated and nonirradiated patients was performed. RESULTS 77 patients who underwent creation of the Miami Pouch entered this study. Forty patients underwent total pelvic exenteration, and 37 patients underwent posterior exenteration. The most common urinary complications were ureteral stricture/obstruction (22.1%), difficult catheterisation (19.5%) and pyelonephritis (16.9%). Conservative management strategies were successfully used in 80% of the complications. Analysis of breakdown and fistula formation after low colorectal anastomosis was performed on 77 patients. Thirty-five percent of the irradiated patients developed anastomotic breakdown or fistulas, while the occurrence of this type of complications was only 7.5% in the nonirradiated group. CONCLUSIONS Reconstructive procedures after pelvic exenteration present a significant risk of complications, especially in irradiated patients. Most of the complications related to the creation of continent urinary diversion can safely be treated conservatively. Low colorectal anastomosis carries an acceptable risk of complications in nonirradiated patients, but the risk in irradiated patients is very high, therefore, detailed patient selection and extensive counselling in these groups of patients is mandatory.

URINARY DIVERSION IN GYNECOLOGIC ONCOLOGY

Urinary diversion in gynecology is performed primarily in conjunction with cancer surgery, but at times, it is required for women with intractable urinary fistulas or other urologic disorders. After 1950, ileal conduits replaced ureterosigmoidostomies as the most widely used form of urinary diversion. Transverse colon conduits have gained popularity because these nonirradiated bowel segments offer less risk for postoperative urinary leaks and small bowel complications associated with bowel and ureteral anastomoses. In 1978, Kock et al described the use of detubularized segments of ileum and the intussuscepted nipple valves to create a continent pouch that is still advocated by urologists in some centers. Ileocolonic continent pouches, originally suggested in 1908, have received considerable attention in the past 10 to 15 years because of ease of construction, lower revision rates, and higher continence rates compared with the Kock ileal pouches. At the Division of Gynecologic Oncology at the University of Miami, the authors have been using the Miami pouch as the preferred form of continent urinary diversion since 1988, with acceptable results. Women who need urinary diversion can be offered at least two major choices: (1) the traditional bowel (ileum or colon) conduit, which requires an external ostomy appliance, or (2) a continent pouch, such as the Miami ileocolonic reservoir. In choosing between non-continent and continent conduits, the patients must be made aware that the continent pouches are available in only a few centers in the United States and carry a slightly higher risk for complications because of the relatively higher complexity. Nonetheless, data strongly suggest that most of these complications can be managed noninvasively and that these patients retain a closer to normal quality of life. The age, disease status, and general health of the woman and the likelihood of her long-term survival after diversion weigh heavily in the final decision.

Abdominal pregnancy: to remove or not to remove the placenta.

Objective: The deleterious effect of abdominal pregnancy on the mother and fetus is in part related to the morbidity of the surgical interventions utilized in its treatment. The purpose of this study is to review outcome in abdominal pregnancy after surgical intervention.Study Design: Charts of patients diagnosed with abdominal pregnancy at our institution between 1984 and 1997 were reviewed. The identified cases were categorized as group I, placenta removed at surgery (n = 10), and group II, placenta left in situ (n = 4). Gestational age, maternal death, duration of hospital stay, blood transfusions, organ excisions, and postoperative readmissions were recorded. Student t test was used for statistical analysis with a P <.05 being significant.Results: Fourteen cases were identified ranging from 7 to 36 weeks of gestation. The diagnosis was made before laparotomy in 6 patients by imaging studies. There were no maternal deaths. Among the 9 in whom placenta was removed, 2 had salpingo-oophorectomy (S-O), 4 had total abdominal hysterectomy and bilateral S-O, and 5 received blood transfusions. One developed DIC requiring massive transfusion after a 7-week placenta was excised from the mesentery. This patient was hospitalized postoperatively for 5 months. In contrast, the 4 patients in whom the placenta was left in situ had neither blood transfusions nor removal of pelvic organs. Their hospital stay was shorter, group II, mean 9 +/- 6 days versus group I, 34 +/- 64 days, P =.0007. This difference was accounted for by the one prolonged hospitalization in group I. No patients in either group were readmitted.Conclusion: The diagnosis of abdominal pregnancy is often not made until laparotomy. Regardless of gestational age, placental excision can cause hemorrhage. Leaving the placenta in situ is potentially less costly and less morbid, and appears to shorten operative time and hospital stay while lowering risk of blood transfusion and of surgical menopause.

Detection of Carcinogenic Human Papillomavirus in Specimens Collected with a Novel Self-Sampling Device

ABSTRACT We compared the detection of carcinogenic human papillomavirus DNA in cervicovaginal specimens self-collected using a novel device to the detection in physician-collected cervical specimens from 137 women. The kappa value was 0.66 (95% confidence interval, 0.53 to 0.78), with an 83% overall test agreement and a 68% positive test agreement.

A phase I study of docetaxel as a radio-sensitizer for locally advanced squamous cell cervical cancer

OBJECTIVES This study was designed to determine the maximum tolerated dose (MTD) and dose-limiting toxicity (DLT) of weekly docetaxel with concurrent radiotherapy (RT) for the primary treatment of locally advanced squamous cell carcinoma of the cervix. METHODS Eligible patients included those with locally advanced squamous cell cervical cancer without para-aortic lymph node involvement. Docetaxel dose levels were 20 mg/m(2), 30 mg/m(2) and 40 mg/m(2) given intravenously weekly for 6 cycles. Three patients were to be treated at each dose level and 6 to receive the MTD. RESULTS Fifteen patients completed 4-6 cycles of chemotherapy. One of three patients experienced 2 delayed grade 3 severe adverse events (SAE) at the 20 mg/m(2) dose level consisting of colonic and ureteral obstruction. At the 30 mg/m(2) dose level, 1/4 patients had a probable treatment-related celiotomy due to obstipation and a necrotic tumor. Of the 8 patients treated at the 40 mg/m(2) dose level, 1 experienced grade 3 pneumonitis, likely treatment related. Overall, 10/15 (67%) experienced grade 1 or 2 diarrhea, 6 had grade 2 hematologic toxicity, and 2 had grade 2 hypersensitivity. 10 of 16 patients (67%) had no evidence of disease with follow-up ranging from 10-33 months (average 23 months). CONCLUSIONS The recommended phase II dose of docetaxel administered weekly with concurrent radiotherapy for locally advanced squamous cell carcinoma of the cervix is 40 mg/m(2).

Should Leiomyoma Morcellation Be Banned?: Risk of Sarcoma in 2,248 Patients Referred to a Gynecologic Oncologist [129]

INTRODUCTION: To determine the incidence of uterine leiomyosarcoma in patients undergoing total abdominal hysterectomy (TAH) and total robotic and laparoscopic hysterectomies for benign uterine leiomyomas. METHODS: We reviewed the medical records of 2,248 patients referred to a gynecologic oncology practice who underwent hysterectomies for symptomatic leiomyomas between 1995 and 2014. The patients ages, admitting diagnosis, operative, and pathologic findings were analyzed. The incidence of leiomyosarcomas, endometrial stromal sarcomas, and mixed mesodermal tumors were calculated. All myomectomies and all known sarcomas preoperatively were excluded from the study. RESULTS: Nearly half of the 2,248 patients underwent a laparoscopic and robotic hysterectomy (51%). A total of four (0.17%) patients with presumed benign disease were found to have a uterine leiomyosarcomas. The TAH group had a high rate—0.26% (3/1,136) compared with only 0.08% (1/1,112) in the total robotic and laparoscopic hysterectomy group. Eighty percent were postmenopausal women with an average age of 60 years. One (0.04%) patient in the TAH group was found to have endometrial stromal sarcoma. CONCLUSION: The incidence of all leiomyosarcomas in patients undergoing surgery for uterine leiomyomas is extremely rare (0.17%), more so in minimally invasive surgery (1/1,112) with more than 80% of patients being postmenopausal. Based on our study, the probability of morcellating an unknown sarcoma in a premenopausal woman not accounting for other high-risk factors would be 1 in 2,500–5,000. Based on the low incidence of leiomyosarcomas in our study, which is similar to others, banning morcellation would lead to increased morbidity and mortality as a result of laparotomy.

Radical Robotic and Abdominal Hysterectomy: Perioperative and Oncologic Outcomes of 175 Cases of Cervical Cancer [238].

INTRODUCTION: The purpose of this study was to investigate the perioperative, postoperative, and oncologic outcomes regarding radical robot laparoscopic-assisted, and radical abdominal hysterectomy±pelvic or paraaortic lymphadenectomies in early-stage cervical carcinoma. METHODS: A total of 175 patients underwent radical hysterectomy for early-stage cervical carcinoma management between January 2005 and July 2014. All cases were retrospectively reviewed to compare demographics, perioperative and postoperative, such as mean operative time, estimated blood loss, lymph node counts, intraoperative and postoperative complications, and follow-up results. RESULTS: A total of 175 patients were divided equally between radical robot laparoscopic-assisted (53.8%) and radical abdominal hysterectomy (46.2%) groups. The groups did not differ in age, body mass index, and combined medical problems. The mean operating times were similar for both groups: radical robot laparoscopic-assisted 189±65.6 compared with radical abdominal hysterectomy 184±48.9 minutes, respectively. Estimated blood loss was significantly reduced in the radical robot laparoscopic-assisted group compared with radical abdominal hysterectomy (100±125 compared with 400±475 mL, P<.001) as well as length of stay radical robot laparoscopic-assisted=1 day compared with radical abdominal hysterectomy=3 days (P<.001). There was no difference in average paraaortic lymph nodes (3.7 compared with 3.9), pelvic lymph node count (18 compared with 14), intraoperative complications (4.7 compared with 4.3), postoperative complications (24.1 compared with 23.9) between radical robot laparoscopic-assisted compared with radical abdominal hysterectomy, respectively. Intraoperative complications included venotomy (n=2, one in each group), colostomy (radical robot laparoscopic-assisted=1), and cystotomy (radical abdominal hysterectomy=1). No cases of wound infections or incisional hernias in the radical robot laparoscopic-assisted group compared 4.0% and 1.3% among the radical abdominal hysterectomy group, respectively. Vaginal dehiscence was 3.5% in the radical robot laparoscopic-assisted and none in the radical abdominal hysterectomy group. There was no statistically significant difference in rates of readmission, postoperative fever, vaginal cuff complications overall, pelvic collections, and ileus or small bowel obstruction between the two groups. Recurrence rates were also similar 11% (radical robot laparoscopic-assisted) compared with 7.5% (radical abdominal hysterectomy). CONCLUSION: Minimally invasive surgery is associated with decreased hospital length stay, less blood loss, and postoperative complications in the treatment of early-stage cervical carcinoma patients compared with radical abdominal hysterectomy, making it a safe alternative with fewer complications.

Radical vaginal trachelectomy after supracervical hysterectomy

BACKGROUND Radical vaginal trachelectomy (RVT) is an acceptable approach when applied toward a select group of patients with early stage cervical carcinoma. It is less invasive, can maintain fertility, and can be ideal in patients with significant comorbid factors compared to abdominal approaches. A small subset of patients with a previous supracervical hysterectomy can pose a surgical dilemma. CASE An 81-year-old woman with a history of severe cardiac disease on routine gynecological examination was found to have adenocarcinoma in situ with a focus suspicious for invasion of the cervical stump diagnosed by cone biopsy. She previously had a supracervical hysterectomy for benign disease of the uterus. A RVT was performed as definitive treatment and the patient recovered without complications. CONCLUSION In the rare case that presents with a history of supracervical hysterectomy, RVT with some technical modifications can still be considered as a therapeutic option for early stage cervical carcinoma.