Paolo Ricci A

ATRAPAMIENTO DEL NERVIO PUDENDO: UN SÍNDROME POR CONOCER

RESUMENEl atrapamiento del nervio pudendo comprende un sindrome descrito por primera vez en 1987. Entrelos multiples motivos de consulta se encuentra principalmente el dolor perineal y/o pelviano, lo que puedeasociarse a disfuncion urinaria, anal e incluso sexual. Las tres ramas terminales poseen en diferenteproporcion fibras motoras, sensitivas y autonomicas. Por ello su atrapamiento puede causar signos ysintomas de expresion en cualquiera de los tres ambitos. En total se estima que el 30% es autonomico yel 70% es somatico (50% sensitivo y 20% motor). El dolor es la causa mas comun de consulta. Clasica-mente se describe como perineal, que se agrava al sentarse, disminuye o desaparece al estar de pie,habitualmente ausente al acostarse, y no compromete el sueno. Para su diagnostico se utiliza la certifica-cion de 2 criterios mayores o 1 criterio mayor asociado a 2 criterios menores. El mejor esquema detratamiento es secuencial y comprende las siguientes etapas: etapa 1 o de autocuidado, etapa 2 o deinyecciones perineurales y etapa 3 o cirugia de descompresion del nervio pudendo.PALABRAS CLAVES: Compresion del nervio pudendo, dolor perinealSUMMARYThe pudendal nerve entrapment syndrome was first described in 1987. The main complaint forconsultation is pain, mainly located at the perineal and/or pelvic area; which can be associated to urinary,anal and even sexual dysfunction. The three main pudendal terminal branches contain motor, sensitive andautonomic fibers; this explains the diversity of signs and symptoms. 70% of nervous fibers are somatic(sensitive 50% and 20% motor), and the rest autonomic (30%). The classic pain is described as perineal,worsens when seating, diminishes or disappears when standing, usually absent when lying down and it doesnot interfere with night rest. The diagnosis can be entertained when two major criteria or one major and twominor are present simultaneously according the punctuation score mentioned. The treatment should alwaysbe sequential and includes three main steps. The stage 1 is autoprotection (perineal, avoidance of sitting,climbing, etc), stage 2 is based in pudendal nerve perineural injections (anesthetics and corticosteroids) andstage 3 implies decompression surgery of the pudendal nerve.KEY WORDS: Pudendal nerve compression, perineal pain

EMBARAZO TRIPLE: COMPLICACIONES MATERNAS Y PERINATALES

SUMMARY Objective: To review the maternal and perinatal complications of the triplet pregnancies registered in our service. Patients and Method: We analyzed 11 triplet pregnancies with an incidence of 1 in 4,730 childbirths, between January 1996 to December 2004. Results: Two pregnancies were been from fertility treatments. There was only 1 stillbirth and 1 death to 35 days of birth (multiple malformations). The childbirth was resolved between the 29 +1 and 36 +3 weeks of gestation. The resolution was by caesarean section, in 55% for labor. Pulmonary surfactante was necessary to use in 8 of the 32 new born (25%), and mechanical ventilation in 5 (16%). The maternal complication of greater frequency was hypertensive syndrome of the pregnancy appearing in 50% of the cases, 2 preeclampsia and one Hellp syndrome. The use of bed-days by new born was 822 days for 32 cases, (median 28 days; rank: 6-64 days). The total bed-days used by the 11 pregnant were 270 days, with an average of 25 bed-days. Conclusion: Even though in our casuistry good perinatal results were registered, triplet pregnancies are associated to greater maternal and perinatal morbidity. In addition they produce a greater cost of neonatology resources especially due to prematurity.

CIRUGÍA MÍNIMAMENTE INVASIVA EN EL TRATAMIENTO DE LA INCONTINENCIA URINARIA FEMENINA DE ESFUERZO: TVT-O

SUMMARY Objective: To review the results obtained in our experience in the application of TVT-O for surgical correction of stress urinary incontinence (SUI). Patient and Method: Prospective pursuit of 135 patients submissive TVT-O in Las Condes Clinic. Results: The median age was 55 years (R: 38 to 74 years), BMI 27.5 (R: 23 to 34) and vaginal parity 2 (R: 0 to 5). Media operating time was 7 minutes (R: 4 to 17 minutes). One intraoperative complication appeared corresponding to the passage of the tape through urethra. Seven patients developed complications in immediate operative time. Five cases presented urinary retention. In them the tape was readjusted to 48 hours by ambulatory procedure. Hematomas and infections of the wounds were not registered. The discharge at home occurred in the cases of TVT-O without other surgery association at 12 hours. In remote operative period a case of tape exposition in the anterior vaginal wall was registered. The average of pursuit for the series was 10 months, with a maximum of 16 months. The cure of the SUI was obtained in 128 (95%) patients, improvement in 5 (4%) and fails in 2 (1%). Conclusions: TVT-O is a surgical technique for the treatment of the SUI with very promissory results to the present date. Nevertheless, of the same form that the other types of TOT requires a long time to evaluate the real effectiveness.

CITOLOGÍA DE BASE LÍQUIDA: REVISIÓN DE LA HISTORIA Y LOS ESTUDIOS AL RESPECTO

RESUMENGeorge Nicolas Papanicolaou introdujo la citologia diagnostica de frotis vaginal en 1940, tecnica detamizaje de bajo costo y de aplicacion masiva. Donde se implemento, ha permitido aumentar la detecciondel cancer cervico uterino en etapas precoces y de lesiones premalignas, reduciendo significativamentela mortalidad por esta causa. El frotis tecnificado, de alto costo, en teoria resuelve los cinco problemasde la convencional: 1) captura de la totalidad de la muestra, 2) fijacion deficiente, 3) distribucion aleatoriade celulas anomalas, 4) existencia de elementos perturbadores, 5) calidad del frotis. Estudios en grandespoblaciones no evidencian diferencias significativas en su capacidad diagnostica comparados con lacitologia convencional que permitan sugerir su uso en el sistema publico de salud.PALABRAS CLAVES: Frotis de Papanicolaou, citologia de base liquida, cancer cervico-uterinoSUMMARYLiquid-based cytology and conventional cervical smears: a completed review of the literature isdiscussed. Evidence based on population studies still does not support it use for a public health system.KEY WORDS: Conventional cervical smears, liquid-based cytology, cervical cytology,cervical cancer

DESARROLLO DE LA CIRUGÍA LAPAROSCOPICA: PASADO, PRESENTE Y FUTURO: DESDE HIPÓCRATES HASTA LA INTRODUCCIÓN DE LA ROBÓTICA EN LAPAROSCOPIA GINECOLÓGICA

SUMMARY We understand by endoscope to those procedures that allow diagnosing and treated pathologies by means of instruments with which we observed in the interior of the human body. The first treatments by means of endoscope were made by Hipocrates. Soon through history the precursors, pioneers and so many others are multiple that gave inventions that allowed arriving until modern laparoscopy; becoming an indispensable tool in the present minimally invasive gynecological surgery. The new technologies have allowed developing the robotics technologies of which the laparoscopy procedures have not remained out. Thus the Da Vinci robot has born, who more than a technology of the future already constitutes a reality of the present in the gynecological laparoscopic surgery.

MIASTENIA GRAVIS: EMBARAZO E IMPACTO PERINATAL

SUMMARY A total of 19 pregnancies in 9 patients with myasthenia gravis are analyzed. Two exacerbations of myasthenia gravis were observed. One associated to the use of aminoglycosides to treat an acute pyelonephritis. A debut of myasthenia gravis occurred during the 24th week of gestation. There were three cases of neonatal myasthenia gravis that appeared in the same patient, two newborn died after 29 and 25 days respectively, in spite of treatment. One case of preterm childbirth was observed and six cases (35%) of intrauterine growth retardation.

SÍNDROME DE FITZ-HUGH-CURTIS COMO HALLAZGO DURANTE CIRUGÍA GINECOLÓGICA

violin SUMMARY The Fitz-Hugh-Curtis Syndrome is a perihepatitis secondary to peritonitis caused by ascending bacteria from a pelvic infl ammatory disease. During the chronic phase may be observe adherences between the abdominal wall and the liver surface characterized by a “violin string” similarity. This image is considered criterion for the diagnosis. A case of incidental Fitz-Hugh-Curtis syndrome observed during a routinely abdominopelvic cavity inspection at the end of a laparoscopic hysterectomy is presented.

INFILTRACIÓN DEL NERVIO PUDENDO GUIADA POR TOMOGRAFÍA AXIAL COMPUTADA, POR VÍA TRANSGLÚTEA: TERAPIA FRENTE AL DOLOR OCASIONADO POR NEURALGIA DEL NERVIO PUDENDO

Antecedentes: La neuralgia del nervio pudendo pocas veces es sospechada y menos diagnosticada. Por esta razon, las pacientes que la padecen, consultan multiples veces antes de llegar a un diagnostico definitivo. Objetivo: Revisar la seguridad y eficacia de la infiltracion de nervio pudendo, en el tratamiento del dolor en pacientes con neuralgia del nervio pudendo. Metodo: Seguimiento prospectivo de cinco pacientes ingresadas bajo el diagnostico de sindrome de atrapamiento del nervio pudendo. La edad media de las pacientes fue 45 anos. Debian tener 2 criterios mayores o 1 criterio mayor asociado a 2 criterios menores. Dolor con al menos 6 meses de evolucion. Sin tratamientos previos. A todas se les realizo encuesta de sintomas y signos de atrapamiento del nervio pudendo. Todas fueron infiltradas con corticoides y anestesico, guiada por tomografia axial computada. Se comparo el dolor antes y despues de la infiltracion con escala de 0 a 10. Resultados: No hubo complicaciones durante el procedimiento. Todas disminuyeron el dolor despues de la infiltracion, y senalaron estar conformes con los resultados. Conclusion: La infiltracion del nervio pudendo guiada por tomografia axial computada, es una tecnica segura y eficaz, en el control o disminucion del dolor pelviano, ocasionado por neuralgia del nervio pudendo. Solo el seguimiento permitira evidenciar la mantencion de los buenos resultados, o la necesidad de repetir la infiltracion o de realizar cirugia de descompresion.

NEUROMODULACIÓN PERIFÉRICA EN EL TRATAMIENTO DE LA INCONTINENCIA DE ORINA: EFECTO DE LA ESTIMULACIÓN TRANSCUTÁNEA DEL NERVIO TIBIAL POSTERIOR SOBRE LA VEJIGA HIPERACTIVA

SUMMARY Objective: To demonstrate objectively the efficiency of the neuromodulation with the transcuteneous posterior tibial nerve stimulation in overactive bladder, in a patient with urge incontinence, refractory to traditional treatments. Patient: A case of urinary mixed incontinence is presented. The TVT-Secur was used for the stress urinary incontinence. The urge-incontinence due to overactive bladder was treated by transcutaneous tibial nerve neuromodulation when refractory appearing to the treatment with medicines and physiotherapy by thirty days. The action of the neuromodulation is demonstrated objectively by cystometry. Monochannel urodynamic equipment was used. The Biomed 2000 equipment was used for the transcutaneous neuromodulation, with stimuli in continuos way to 20 Hertz and 200 milliseconds. Results: The transcutaneous tibial

HISTERECTOMÍA MÍNIMAMENTE INVASIVA A TRAVÉS DE LAPAROSCOPIA CON BISTURÍ ULTRASÓNICO

SUMMARY Objective: To evaluate the security, effectiveness and reproducibility of the laparoscopic hysterectomy by ultrasonic scalpel. To discuss the comparatives advantages with the electro surgery technique. Method: A descriptive prospective study about 18 patients underwent laparoscopic hysterectomy with ultrasonic scalpel in Las Condes Clinic. The age fluctuated between 38 and 66 years old (median 47 years old). The median parity was 2 childbirths. The body mass index was 28. 5 total laparoscopic hysterectomies (TLH), 9 supracervical laparoscopic hysterectomies (SLH) and 4 total hysterectomies finished by vaginal route (TLHFV) were made. In 13 patients other surgery was associated. Results: The surgical time for SLH was between 23 and 45 minutes (mean 35 minutes), for LTH between 45 and 90 minutes (mean 65 minutes), for TLHFV between 60 and 90 minutes (mean 75 minutes). Complications were not registered during the intraoperative, immediate, early or late postoperative times. The visual analogue scale for pain at 12 hours was 2 to 5 for LTH, 0 to 2 for SLH, and 2 to 5 for TLHFV; at 24 hours was 2 to 4 for HTL, 0 to 2 for SLH and 2 to 5 for TLHFV. Conclusions: The laparoscopic hysterectomy with ultrasonic scalpel is a safe, effective and feasible surgery allows to cut and to coagulate with comparative advantages on electrosurgery. It allows