Mitchel S. Hoffman

Abdominal wall metastases from ovarian cancer after laparoscopy.

We report three cases of abdominal wall metastases from ovarian cancer after laparoscopy. The implants occurred at the site of insertion of laparoscopy trocars. One patient had an implant of serous papillary carcinoma of low malignant potential at the trocar sites after laparoscopic oophorectomy. Laparoscopic surgery is inappropriate in patients with malignant ascites or when preoperative or intraoperative findings are suggestive of ovarian cancer.

Postoperative Neuropathies After Major Pelvic Surgery

OBJECTIVE To estimate the incidence, etiology, and outcome of neuropathies after major gynecologic surgery and to recommend management and prevention strategies for these complications. METHODS The medical records of women who suffered neuropathy after major pelvic surgery between July 1995 and June 2001 were reviewed. Mechanism of injury, treatment, and outcome were determined from the patient charts. RESULTS Twenty‐three of 1210 patients undergoing major pelvic surgery during the defined period suffered a postoperative neuropathy for an incidence of 1.9%. Neurologic injury involved the obturator (n = 9), ilioinguinal/iliohypogastric (n = 5), genitofemoral (n = 4), femoral (n = 3), and lumbosacral nerve plexus (n = 2) in these women. Etiologies were a result of direct surgical trauma, stretch injury, suture entrapment, or were retractor related. All patients with motor deficits were treated with physiotherapy, and pharmacologic or surgical management was used in women with sensory deficits or pain. Seventy‐three percent of the women experienced full recovery; the only patients with persistent symptoms were those with unrepaired nerve transection or injury to the lumbosacral plexus. Both time to diagnosis and time to resolution varied widely. CONCLUSION Neuropathies are infrequently associated with major pelvic surgery. We observed a 73% complete recovery rate, and time to resolution varied depending on the severity of injury. Physical therapy plays a valuable role in managing these patients, but some may require surgery for relief of their symptoms.

Invasive carcinoma of the vulva

Four hundred fifteen patients who had invasive carcinoma of the vulva were treated with primary surgery from July 1, 1955, through June 30, 1989. Three hundred seventy-six (90%) of the patients had squamous carcinoma. Two hundred fourteen patients (52%) had radical vulvectomy with inguinofemoral lymphadenectomy. Twenty-four patients (6%) underwent radical vulvectomy with pelvic exenteration for advanced disease, and 55 patients (13%) had nonradical operations. The remaining 122 patients (29%) underwent radical vulvectomy, inguinofemoral lymphadenectomy, and pelvic lymphadenectomy. The primary morbidity was associated with lymphedema (8.6%) and groin wound breakdown (54%). No intraoperative deaths occurred among the 415 patients treated surgically, but there were 17 deaths (4%) within 28 days of operation. The absolute 5-year survival rate was 85% in patients with negative inguinofemoral lymph nodes and 39% when these lymph nodes were positive for metastatic carcinoma. The overall absolute 5-year survival rate was 67%.

Morbidity and survival patterns in patients after radical hysterectomy and postoperative adjuvant pelvic radiotherapy

Morbidity and survival patterns were reviewed in 50 patients who underwent radical hysterectomy, pelvic lymphadenectomy, and adjuvant postoperative pelvic radiotherapy for invasive cervical cancer. Ninety percent of the patients were FIGO stage IB, and 10% were clinical stage IIA or IIB. Indications for adjuvant radiotherapy included pelvic lymph node metastasis, large volume, deep stromal penetration, lower uterine segment involvement, or capillary space involvement. Seventy-two percent of the patients had multiple high-risk factors. An average of 4700 cGy of whole-pelvis radiotherapy was administered. Ten percent of the patients suffered major gastrointestinal complications, 14% minor gastrointestinal morbidity, 12% minor genitourinary complications, one patient a lymphocyst, and one patient lymphedema. Of the five patients with major gastrointestinal morbidity, all occurred within 12 months of treatment. Three patients required intestinal bypass surgery for distal ileal obstructions and all are currently doing well and free of disease. All of the patients who developed recurrent disease had multiple, high-risk factors. The median time of recurrence was 12 months. All patients recurred within the radiated field. Actuarial survival was 90% and disease-free survival 87% at 70 months. It is our opinion that the morbidity of postoperative pelvic radiotherapy is acceptable, and benefit may be gained in such a high-risk patient population.

Pulmonary embolism after major abdominal surgery in gynecologic oncology

OBJECTIVE: To estimate the incidence and prognostic significance of postoperative pulmonary embolism after gynecologic oncology surgery. METHODS: All patients who underwent gynecologic oncology surgery from June 2001 to June 2003 and received venous thromboembolism prophylaxis with only intermittent pneumatic compression and early ambulation were identified from our database. Patients were grouped by procedure (major/minor abdominal or nonabdominal surgery), diagnosis (malignant/nonmalignant), and cancer subtype. Groups were compared by &khgr;2 analysis and logistic regression. Survival was studied with the Kaplan-Meier method and Mantel-Byar test. RESULTS: A total of 1,373 surgical patients were identified over the 2-year period, including 839 major abdominal surgery cases and 534 minor abdominal surgery or nonabdominal surgery cases. Of the 839 patients, 507 had a diagnosis of cancer, and 332 were benign. The incidence of pulmonary embolism among cancer patients undergoing major abdominal surgery was 4.1% (21/507) compared with 0.3% (1/332) among patients undergoing major abdominal surgery with benign findings (P < .001, odds ratio [OR] 13.8, 95% confidence interval [CI] 1.9–102.1). The incidence of pulmonary embolism among patients undergoing minor/nonabdominal surgery was 0.4% (2/536). Cancer diagnosis and age more than 60 years were identified as risk factors for pulmonary embolism (P = .009, OR 0.31, 95% CI 0.13–0.74). One-year survival for patients with and those without pulmonary embolism were 48.0% ± 12% and 77.0% ± 2%, respectively. CONCLUSION: Patients with cancer undergoing major abdominal surgery and using pneumatic compression for thromboembolic prophylaxis had a 14-fold greater odds of developing a pulmonary embolism compared with patients with benign disease. Randomized studies are needed to determine whether additional prophylactic measures may benefit this high-risk group of patients. LEVEL OF EVIDENCE: II-3

Paget's disease of the vulva

Abstract Objective: Our goal was to review our experience with Pagets disease of the vulva relative to initial examination, treatment, and oncologic outcome. Study Design: Patients who were treated for extramammary Pagets disease of the vulva at the University of South Florida were identified in our vulvar cancer database for the period 1988 through 2000. The charts were reviewed, and the data were collected regarding patient demographics, previous Pagets treatment, symptoms, surgical margin status, associated malignancies, and time to recurrence. Results: Twenty-three women with extramammary Pagets disease of the vulva were treated by the Division of Gynecologic Oncology during the 12-year period. The average patient was postmenopausal and white and had symptoms for 21 months before the diagnosis was made. A pruritic lesion was the most common symptom. Treatment included wide local excision or vulvectomy, depending on the extent of disease. Six of the 23 patients displayed invasive disease and, consequently, underwent radical resection. There were 8 recurrences that were found, on average, 30 months after the surgical procedure. Two of the 8 patients had invasive disease at their primary operation, and 1 patient had underlying invasive disease at the time of recurrence. The average follow-up time was 39 months (median, 13.5 months; range, 1-216 months). Conclusion: Delay in diagnosis did not correlate with size or extent of disease. Margin status did not change the natural course of disease. Recurrence is relatively common, and long-term monitoring is recommended, with repeat excision of symptomatic lesions. (Am J Obstet Gynecol 2002;187:281-4.)

Morbidity associated with nonemergent hysterectomy for placenta accreta

OBJECTIVE The purpose of this study was to report the morbidity of nonemergent hysterectomy for suspected placenta accreta. STUDY DESIGN This was a retrospective study of all patients who underwent nonemergent hysterectomy for placenta accreta at Tampa General Hospital from June 1, 2003 to May 31, 2009. RESULTS Twenty-nine patients were identified. Diagnosis was suspected on ultrasound scanning in 26 women (6 women also underwent magnetic resonance imaging) and on direct vision at repeat cesarean section delivery in 3 women. All of the women were multiparous, and 18 women had undergone > or =2 cesarean section deliveries. Twenty-one women had a placenta previa, and 8 women had a low anterior placenta. Final pathologic findings revealed accreta (20 specimens), increta (6 women), and percreta (3 women). Mean total operative time was 216 minutes; blood loss was 4061 mL. Two women had ureteral transection (1 was bilateral); 3 women had cystotomy, and 3 women had partial cystectomy. Postoperative hemorrhage occurred in 5 women; 1 hemorrhage resolved after catheter embolization, and the other 4 hemorrhage required reoperation. CONCLUSION Nonemergent hysterectomy for placenta accreta is associated with significant morbidity in the forms of hemorrhage and urinary tract insult.

Abdominal hysterectomy versus transvaginal morcellation for the removal of enlarged uteri

OBJECTIVE The purpose of this study was to compare the intraoperative and postoperative complications of transvaginal morcellation and abdominal hysterectomy for the removal of moderately enlarged uteri. STUDY DESIGN An observational study was performed on all uteri weighing > 200 gm removed transvaginally from July 1, 1987, to June 30, 1993. An abdominal hysterectomy control group was selected. RESULTS There were 50 patients in the vaginal group and 112 in the abdominal group. At a p value < 0.05 there was no statistically significant difference between the two groups for age, parity, obesity, hypertension, insulin-dependent diabetes mellitus, or prior genitourinary surgery. The mean operative time in the vaginal hysterectomy group was 122 minutes and in the abdominal hysterectomy group 148 minutes (p < 0.05). The mean estimated blood loss was 527 and 586 ml, respectively (not significant). Twenty-two percent of the vaginal group and 70% of the abdominal group underwent bilateral oophorectomy (p < 0.05). The mean uterine weights were 335 and 336 gm, respectively (not significant). The mean day of starting a regular diet was 2.1 and 3.6, respectively (p < 0.05). The mean day of discharge was 3.6 and 5.1, respectively (p < 0.05). Complications were similar for the two groups. CONCLUSIONS In selected patients transvaginal morcellation is a safe and effective alternative to abdominal hysterectomy for the removal of moderately enlarged uteri. The two procedures are comparable in operative time, blood loss, and complications. Both ovaries are more likely to be removed with abdominal hysterectomy. Cosmesis and recuperation may be advantages of the vaginal approach.

Upper vaginectomy for in situ and occult, superficially invasive carcinoma of the vagina

Between Aug. 1, 1985, and July 31, 1990, 32 patients underwent upper vaginectomy for grade 3 vaginal intraepithelial neoplasia. Thirty-one of these patients had undergone hysterectomy, 25 because of cervical neoplasia. Fourteen patients had undergone treatment for vaginal intraepithelial neoplasia. Nine (28%) had invasive cancer on final pathologic examination. Among the remaining 23 patients, recurrence of vaginal neoplasia developed in four (17%), with a mean time to recurrence of 78 weeks, and one was found to have superficial invasion at the time of recurrence. The remaining 19 patients remain alive with no evidence of recurrent disease at a mean follow-up interval of 152 weeks. In our patients upper vaginectomy was efficacious for the diagnosis of occult invasive carcinoma of the vagina and for the treatment of in situ and superficially invasive carcinoma of the vagina.

Further experience with radiation therapy and concomitant intravenous chemotherapy in advanced carcinoma of the lower female genital tract.

Sixty-seven patients with advanced carcinoma of the lower female genital tract (cervix, vagina, and vulva) were treated with radiation and concomitant intravenous cisplatin and/or 5-fluorouracil. Fifty-seven patients (85%) responded completely clinically. Thirty-five (61%) complete responders recurred with a median time to recurrence of 6 months. Twenty-six of the thirty-five patients who recurred had some component of local failure. The 22 complete responders who have not recurred have been followed a median of 13 months. Acute toxicity was minimal, with only 6 patients requiring interruption of therapy. Nine (13%) patients developed severe late complications and eight required surgery. The actuarial 5-year survival is 22%. This treatment regimen is disappointing in terms of both survival and local control.