Michel E. Rivlin

Leuprolide acetate in the management of cesarean scar endometriosis

Background Progestin or estrogen-progestin combination therapy has not proven useful in the treatment of endometriosis of the abdominal scar after cesarean delivery. We report our experience in managing this condition with a gonadotropin agonist. Case A 22-year-old black woman with a history of two previous cesareans developed endometriosis of the abdominal scar. The extent of the lesion was estimated by computed tomographic (CT) scan, and a 6-month preoperative course of leuprolide acetate was administered. The patient exhibited prompt symptomatic response to the gonadotropin agonist, but the physical examination and CT scan findings were unchanged. Pathologic examination after surgical removal of the lesion confirmed the clinical diagnosis. Conclusion Leuprolide acetate administered to a patient with cesarean scar endometriosis was associated with an improvement in symptoms, but there was no change in lesion size.

Danazol in the management of ureteral obstruction secondary to endometriosis

Ureteral obstruction caused by endometriosis is uncommon. It is, however, an important complication that imposes a 25% chance for permanent loss of renal function on the affected side. The standard management is surgical; however, three cases have been reported in which regression of obstruction followed medical therapy. This case report concerns a patient with long-standing partial ureteric obstruction due to endometriosis who was treated for 2 months with danazol. Clinical response of the endometriosis was excellent, but the obstruction persisted, a retroperitoneal ureteroneocystotomy was therefore performed. The ureter was found to be obstructed by dense fibrous tissue that contained endometrial glands. It seems therefore that a trial of danazol may be attempted in selected cases, but that the drug is unlikely to relieve endometriotic ureteric obstruction once dense fibrosis has occurred.

Infectious necrosis with dehiscence of the uterine repair complicating cesarean delivery: a review.

The authors summarize current knowledge about infectious uterine incisional necrosis/dehiscence, an uncommon but serious complication of cesarean delivery. A MEDLINE search of the literature from 1966 to the present did not identify any previous review of this entity. From case reports, small case series, and textbook descriptions, the evidence regarding the definition of the disorder, its prevalence, etiology, pathogenesis, diagnosis, prognosis, and management is presented. The paucity of reports in the modern literature indicate the need for further studies to more precisely characterize this entity for cross-study comparisons and aggregation to provide clearer management guidelines, especially as it regards diagnosis, and the safety of conservative surgery in well-selected cases. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to define the condition infectious uterine incisional necrosis, and to outline potential management options.

Persistent trophoblastic tissue following salpingostomy for unruptured ectopic pregnancy

Radioimmunoassay of beta-hCG was used to diagnose an ectopic pregnancy in a 30 year old patient and the site of pregnancy was determined by ultrasonography. A salpingostomy was performed; the ectopic pregnancy and the residual trophoblastic tissue were removed. Six weeks later a right salpingectomy was performed to remove persistent trophoblastic tissue. Histologic examination of the surgical specimen demonstrated viable chorionic villi. Serial measurements of beta-hCG are recommended following conservative surgery for ectopic gestation to assure the patient and the surgeon that the tube contains no residual products of conception.

Tuboovarian abscess: a postoperative complication of endometrial ablation.

BACKGROUND: Global endometrial ablation may be associated with serious complications. CASE: We present a case of bilateral tuboovarian abscesses that developed 50 days postoperatively after a thermal ablation. The patient underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy. CONCLUSION: Infectious morbidity is known to occur after thermal endometrial ablation. Further investigation is required into ways of reducing the risks of endometrial ablation.

Surgical management of diffuse peritonitis complicating obstetric/gynecologic infections.

A retrospective review of 176 women undergoing surgery for diffuse peritonitis secondary to pelvic infections from 1972 to 1976 was conducted. Mortality with septic abortion was 27.3% (12 of 44), with pelvic inflammatory disease 7.1% (eight of 113), and with puerperal sepsis 6.7% (one of 15). Overall mortality was 13.1% (23 of 176). Mortality was lower (P less than .05) with surgery within 24 hours (7.5%, six of 80) than after 24 hours (17.7%, 17 of 96). Mortality was lower (P less than .01) with specific antianaerobic antibiotics (zero of 36) than without (16.4%, 23 of 140). Mortality was 21.3% with hysterectomy (ten of 47) and 10.1% (13 of 129) with conservative surgery, however hysterectomy was usually performed in the more severe cases (septic abortion 75%, puerperal sepsis 66%, pelvic inflammatory disease 3%). Mortality declined from 17.6% in 1972 to 1974 (21 of 119) to 3.5% in 1975 to 1976 (two of 57). Significant differences between the two periods included an increased use of specific antianaerobic antibiotics (8.4%/45.5%) and an increased incidence of early surgery (35.3%/66.6%) in the latter years. This series emphasizes the overriding importance of early surgery and the need for the inclusion of specific antianaerobic antibiotic agents in the chemotherapeutic regimen.

Vulvar granular cell tumor

Granular cell tumors are rare, usually benign, soft tissue neoplasms of neural origin. They occur more often in females than males, the peak age incidence is in the fourth through fifth decades. They can occur anywhere in the body with up to 15% situated in the vulva. The commonest presentation is as an asymptomatic mass. Microscopic findings are usually sufficient, but immunohistochemistry can also be helpful in confirming the diagnosis. The vulvar tumors are benign in 98% of cases with 2% reported as malignant. In this case report we describe a woman with a granular cell tumor confirmed by biopsy who underwent excision of the mass but with focal extension to the resection margin on microscopy. Our recommendation of re-excision was declined. Since it is not uncommon with these tumors to find groups of tumor cells extending beyond the macroscopic limits of growth, we conclude that it is advisable to have margins assessed intraoperatively by frozen section such that further excision can be performed for positive margins. Our patient has been followed for 18 mo without recurrence, should the tumor recur, re-excision, with frozen section control, is indicated. Recurrence rates are reported as 2%-8% with clear margins and 20% with positive margins.

Conservative surgery for uterine incisional necrosis complicating cesarean delivery.

BACKGROUND: Hysterectomy is the usual management of uterine incisional necrosis with dehiscence as a complication of cesarean delivery. Debridement with resuture of the uterine wound as an alternative therapy would conserve fertility at the risk of continued necrosis and infection. Unfortunately the literature provides few guidelines in deciding when to select conservative surgery and whether it is a safe option. CASES: Three cases are presented with uterine incisional necrosis complicating cesarean delivery. In 2 instances, uterine conservation was considered an acceptable option and was successfully completed. The third patient underwent hysterectomy because of clinical features deemed to be contraindications to conservative surgery. CONCLUSION: In well-selected patients, debridement and resuture of the uterine incision is an acceptable alternative to hysterectomy for uterine incisional necrosis.

Retroperitoneal fibrosis associated with carcinoma of the cervix: Review of the literature☆

Microinvasive cervical cancer presented in a woman with retroperitoneal fibrosis in remission following steroid therapy. The cervical lesion was treated surgically with good outcome. Review of the literature documenting this association reveals three other cases, one following and two preceding the diagnosis of retroperitoneal fibrosis. The case reports are reviewed and potential difficulties in the management of these patients are discussed.

Intracystic hemorrhage in a non-endometriotic mullerian vaginal cyst.

The commonest type of simple vaginal cyst is the Mullerian cyst. These are typically lined by columnar epithelium and contain serous or mucinous fluid. If blood is found in the cyst, the source is usually due to the presence of endometrial elements in the cyst wall. The cyst is then termed an endometriotic cyst. In this case report, we have described a woman with a symptomatic 3 cm upper vaginal cyst who underwent surgical excision of the cyst. The cyst cavity was found to be full of old dark blood and mucous, however the wall contained no endometrial tissue and was lined by columnar epithelium which stained positive for mucous with mucicarmine. No cause for the intracystic hemorrhage was identified. We conclude that intracystic hemorrhage can occur in a simple Mullerian vaginal cyst in the absence of endometrial components.