Maurice J. Webb

Posthysterectomy enterocele and vaginal vault prolapse

Of 421 patients with posthysterectomy enterocele and vault prolapse, 190 cases are reported for the first time. These 190 patients had 197 operations, 90% were vaginal procedures and 10% were abdominal-presacral suspension procedures; 88% of the operations provided good vaginal support and a satisfactory result. A vaginal repair is advocated for this condition because it provides an excellent result with minimal exposure of the frequently elderly patient to serious risk or disability. An abdominal-presacral suspension is advised only for those patients who are anxious to preserve vaginal function, in whom there is an inversion of an already much-operated-on, snug vagina.

Factors influencing survival in Stage I ovarian cancer

Abstract A total of 271 patients with Stage I epithelial cancer of the ovary were treated at the Mayo Clinic from 1950 through 1966. Data related to various forms of treatment show that many factors in addition to the stage of the lesion influence survival. Among these are cell type, grade of malignancy, and gross characteristics of the lesion. These factors should be considered in the selection of the proper treatment of the specific lesion. Such individualized treatment should give a highly satisfactory survival.

Exenterative operations: Experience with 198 patients

Abstract In a series of 198 exenterative operations performed at the Mayo Clinic for various pelvic malignant lesions, a 5 year survival rate of 33 per cent was obtained. This rate is commendable, since almost 80 per cent of the operations were accomplished for recurrent malignancy. The diminished over-all operative mortality rate of 8.1 per cent, a reduction from 13.5 per cent (1950 through 1962) to 3 per cent (1963 through 1971), is attributed to better methods of urinary diversion and to better management of fluid replacement and of infectious complications. Major complications, excepting bowel fistula and obstruction, now can be controlled reasonably well. When more conservative and equally curative methods of therapy have been exhausted, all patients with pelvic malignancy (whether primary in cervix, vagina, bladder, urethra, rectum, or vulva) should be considered potential candidates for exenteration.

Posthysterectomy vaginal vault prolapse: primary repair in 693 patients

Objective To examine the results of primary repair of posthysterectomy vaginal vault prolapse in a current, large series of patients with long-term follow-up. Methods From January 1976 to December 1987, 693 patients underwent primary repair of vault prolapse at the Mayo Clinic. The Mayo culdoplasty technique was used in 95% of these patients. Patients were followed up by reference to their Mayo Clinic medical records, a specifically designed questionnaire, and pelvic examination in a subgroup of patients. Results The median age at operation was 66 years. Abdominal hysterectomy had been performed on 49.5% of patients and vaginal hysterectomy on 43.4% (hysterectomy type was not documented on 7.1%). The median number of years to vault prolapse repair after hysterectomy was 15.8 (range 0.4-48.4). Information about prolapse after primary repair was available for 504 patients (72.7%) and 80 had evidence or complaint (bulge, protrusion) of recurrent prolapse. Thirty-six of 693 patients (5.2%) had subsequent prolapse repair. Eighty-two percent of patients indicated satisfaction with the result. Complications of operation included entry into the bladder or rectum (2.3% of patients), vault hematoma (1.3%), cuff infection (0.6%), and ureteral complications (0.6%). The number of patients presenting for vault prolapse repair increased during the study interval. Conclusion The Mayo culdoplasty can be performed with minimal morbidity. It achieved an anatomic restoration of upper vaginal support in a high percentage of patients with long-term follow-up.

Stage I squamous cell cancer of the vulva

A review of 106 patients with Stage I squamous cell cancer of the vulva treated at the Mayo Clinic from 1950 through 1975 is presented. Microinvasive lesions (5 mm penetration or less) were present in 96 patients (91%); invasive lesions (more than 5 mm penetration) were diagnosed in 10 (9%). Inguinal node involvement was present in nine patients (8.4%); one of these also had pelvic node involvement. Recurrence developed in 13 patients (12%). Four patients experienced inguinal node metastasis after initial surgical therapy. The incidence of positive nodes among patients with lesions invading the stroma for 3 mm or less was 3%. Thus, individualization for inguinal lymphadenectomy may be possible according to the age and condition of the patient when the depth of invasion is 3 mm or less.

Site of recurrence of cervical cancer after radical hysterectomy

Of 564 patients who underwent radical hysterectomies for cervical cancer. 104 had recurrences. Twenty (3.5%) had recurrence in the central pelvis, and in nine (1.6%), this was the only site of recurrence. Of the patients who had lymph node metastases at the time of radical hysterectomy, 40% subsequently had recurrence compared with 14% who had negative nodes and recurrence. The site of recurrence, however, had no relationship to lymph node involvement, size of the lesion, stage of disease, cell type or grade, or previous pelvic irradiation.

Surgical treatment for local control of female urethral carcinoma.

We reviewed 53 patients (mean age 63 years) who underwent partial urethrectomy (n = 26) or radical extirpation (n = 27) for primary female urethral cancer from 1948 through 1999. Clinical stage, histology, high pathologic stage (3 or 4) and grade, tumor location, nodal status, surgery type, adjuvant therapy, and treatment decade were candidate outcome predictors. The predominant carcinomas were squamous cell (n = 21), transitional cell (TCC) (n = 15), and adenocarcinoma (n = 14). For adjuvant therapy, 20 patients had radiation (8 preoperatively), 2 had radiation + chemotherapy, and 1 had chemotherapy alone. During mean follow-up of 12.8 years, 27 patients had recurrence; 15 local only, 2 distant only and 10 local + distant. Of patients undergoing partial urethrectomy for pT1-3 tumors, 6/27 (22%) had urethral recurrence. Overall, there were no bladder recurrences. Recurrence-free survival +/- standard error (SE) at 10 years was 45 + 8%. Those who recurred had a cancer mortality rate of 71% at 5 years postrecurrence. The estimated 10-year cancer-specific survival (CSS) and crude survival (CS) rates were 60 +/- 8% and 42 +/- 7%, respectively. Pathologic stage was predictive for local recurrence (P = 0.02) and CSS (P = 0.01). Positive nodes on pathology were related to local and distant recurrence and CSS (P = 0.01). Upon review, partial urethrectomy resulted in a high urethral recurrence rate (22%) with no bladder recurrences. These patients may be better served with radical urethrectomy and creation of continent catheterizable stoma.

9 Radical hysterectomy

Radical hysterectomy for the treatment of cervical cancer was first performed just over 100 years ago. Refinements of surgical technique and improvements in supportive measures, such as transfusions and antibiotics, have brought about a marked decrease in morbidity and mortality from surgery and improvement in overall survival. The indications for operation, pre-operative investigations and preparation, surgical technique, post-operative complications and their management, and factors influencing prognosis are discussed.

Treatment of placental site trophoblastic tumor with hysterotomy and uterine reconstruction

Background Placental site trophoblastic tumor is an unusual variant of gestational trophoblastic neoplasia that is usually confined to the uterus, although 10% of patients have metastases. Because this tumor occurs in women of reproductive age, preservation of fertility may be relevant. Therefore, local excision of placental site trophoblastic tumor by hysterotomy may have a place in management. Case A 25-year-old woman, gravida 1, para 1, presented with irregular bleeding. Uterine curettage revealed intermediate trophoblasts that on immunostaining were positive for hCG and human placental lactogen, consistent with placental site trophoblastic tumor. Endovaginal ultrasonography and magnetic resonance imaging demonstrated tumor localized to the anterior fundal myometrium. The patient underwent local excision of the tumor by hysterotomy followed by uterine reconstruction. Pathologic examination confirmed that the surgical margins were free of tumor. The patient has had no recurrence. Two subsequent pregnancies resulted in two spontaneous abortions. A third pregnancy was carried to term. The patient was delivered by cesarean because of the hysterotomy. The hysterotomy scar was intact at cesarean. Conclusion Hysterectomy has been recommended by most authors for treatment for placental site trophoblastic tumor. In some patients with localized placental site trophoblastic tumor who desire preservation of fertility, more conservative surgical therapy may be considered.

Intraoperative radiation therapy in gynecologic cancer: update of the experience at a single institution.

PURPOSE To update the Mayo Clinic experience with intraoperative radiation therapy (IORT) in patients with gynecologic cancer. METHODS AND MATERIALS Between January 1983 and June 1991, 39 patients with recurrent or locally advanced gynecologic malignancies received intraoperative radiation therapy with electrons. The anatomical area treated was pelvis (side walls or presacrum) or periaortic nodes or a combination of both. In addition to intraoperative radiation therapy, 28 patients received external beam irradiation (median dose, 45 Gy; range, 0.9 to 65.7 Gy), and 13 received chemotherapy preoperatively. At the time of intraoperative radiation therapy and after maximum debulking operation, 23 patients had microscopic residual disease and 16 had gross residual disease up to 5 cm in thickness. Median follow-up for surviving patients was 43.4 months (range, 27.1 to 125.4 months). RESULTS The 5-year actuarial local control with or without central control was 67.4%, and the control within the IORT field (central control) was 81%. The risk of distant metastases at 5 years was 52% (82% in patients with gross residual disease and 33% in patients with only microscopic disease postoperatively). Actuarial 5-year overall survival and disease-free survival was 31.5 and 40.5%, respectively. Patients with microscopic disease had 5-year disease-free and overall survival of 55 and 50%, respectively. Grade 3 toxicity was directly associated with IORT in six patients (15%). CONCLUSION Patients with local, regionally recurrent gynecologic cancer may benefit from maximal surgical debulking and IORT with or without external beam irradiation, especially those with microscopic residual disease.