Raymond A. Lee

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.

Characteristics of Patients With Vaginal Rupture and Evisceration

OBJECTIVE: To characterize vaginal rupture and evisceration. METHODS: We reviewed medical records (1970–2001) for use of the diagnostic terms “vaginal rupture,” “vaginal evisceration,” and “ruptured enterocele.” RESULTS: Twelve clinical cases were identified. Patients usually presented with pain, vaginal bleeding, and abdominal pressure. In 9 of 12 women, rupture was primarily associated with postmenopausal prolapse and a history of pelvic surgery. Women with a history of abdominal hysterectomy tended to rupture through the vaginal cuff, and those with a history of vaginal hysterectomy tended to rupture through a posterior enterocele. Premenopausal rupture in 1 woman occurred postcoitally and involved the posterior fornix. Prolapse recurrence after repair was limited to 1 woman. CONCLUSIONS: Vaginal rupture and evisceration should be considered in women presenting with acute vaginal bleeding and pelvic pain. Evaluation is especially important in postmenopausal women with a history of pelvic surgery. In some cases, surveillance after pelvic surgery may prevent rupture, evisceration, and incarceration. LEVEL OF EVIDENCE: II-3

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.

Recurrent disease after negative second-look laparotomy in stages III and IV ovarian carcinoma

Between 1977 and 1984, second-look laparotomy to evaluate disease status after adjuvant chemotherapy was performed in 134 patients originally presenting with advanced epithelial ovarian carcinoma. Surgical and histologic assessment did not detect persistent disease in 50 patients (37%). Recurrent carcinoma was subsequently documented in 15 patients (30%), all failures occurring within the abdominal cavity or the retroperitoneal space. Several patient subgroups at high risk for recurrence after negative second-look laparotomy are identified that might benefit from additional adjunctive therapy. Because of different treatment-associated morbidities, the corresponding sensitivities and specificities of the high-risk groups may assist subsequent treatment selection.

Endometriosis of ureter

Endometriosis, a common gynecologic problem, affects up to 15 per cent of menstruating women.’ The disorder occurs more frequently in nulliparous women or women of low parity than in those of higher parity. Its incidence appears to be increasing with the current trend toward smaller families.2,3 Urinary tract involvement occurs in 1.2 per cent of cases, the bladder, ureter, and kidney being affected in a ratio of 40:5:1.4.5 More than 100 cases of ureteral obstruction secondary to endometriosis have been recorded; however, this number probably is an underestimation because of the silent way in which obstructive uropathy can occur.6 A striking nephrectomy rate-as high as 43 per cent-has been reported;7 thus, compulsive surveillance of premenopausal women with endometriosis is mandatory. We present a case of endometriosis of the ureter that produced severe hydroureteronephrosis necessitating nephroureterectomy. The current literature is reviewed, and treatment recommendations are proposed.

Leiomyoma of the female urethra and bladder: Report of twenty-three patients and review of the literature☆☆☆★

OBJECTIVES Our purpose was to review what may be the largest experience of bladder and urethral leiomyomas from a single institution. STUDY DESIGN A retrospective review was done of 23 female patients with emphasis on presentation, symptoms, and operative approach for excision. RESULTS The majority of bladder and urethral leiomyomas in this series were asymptomatic, nonobstructive, or incidental (discovered at surgery for another entity). Ten patients had a palpable mass on physical examination. Two patients had pain as a presenting complaint. The route of operative excision was transvaginal (10 patients), transurethral (6 patients), or abdominal (6 patients). One patient had the leiomyoma removed elsewhere with a resultant vesicovaginal fistula. CONCLUSIONS Corollaries should be sought with the experience of uterine leiomyomas, which are histologically identical to bladder leiomyomas. Asymptomatic, nonobstructive, and nonproblematic leiomyomas should not serve as an indication for primary operation. Pedunculated endovesical lesions may be an exception because of the ease of transurethral removal and their tendency to cause future symptoms. Ultrasonographic imaging, cystoscopy, and biopsy should be considered to allow observation and follow-up of leiomyomas. Future investigative cytogenetic studies should be considered on these mesenchymal tumors.

McIndoe procedure for vaginal agenesis: Long-term outcome and effect on quality of life

OBJECTIVE The purpose of this study was to evaluate quality of life, sexual function, and long-term outcome in women after undergoing the McIndoe procedure for vaginal agenesis. STUDY DESIGN This was a retrospective descriptive study of patients who were treated with the McIndoe procedure for vaginal agenesis. Participants answered a structured questionnaire to describe self-reported outcomes in quality of life, sexual function and satisfaction, and body image after the McIndoe procedure. Patient characteristics along with short- and long-term findings were abstracted from the medical record. RESULTS Eighty-six patients responded to the questionnaire. Average age (+/-SD) at surgery was 21+/-6 years (range, 12-49 years). The mean number of years (+/-SD) since surgery was 23+/-12 (range, 2-50 years). Seventy-nine percent of the respondents stated that the McIndoe procedure improved their quality of life. Ninety-one percent of the respondents were sexually active, with 75% able to achieve orgasm. Reported self-image was improved in 55% of the women. CONCLUSION The McIndoe procedure improves quality of life and sexual satisfaction and provides a functional vagina with minimal complications.

Leiomyoma of the ovary: Report of five cases and review of the literature

Abstract Five cases of leiomyoma of the ovary are presented. The importance of special staining for a definitive diagnosis is stressed. The theories regarding the origin of leiomyoma of the ovary and also the literature have been reviewed.

Torsion of the uterine adnexa

Abstract Torsion of the uterine adnexa is an urgent surgical condition that usually occurs in women of reproductive age. In the present review of 135 women with surgically proved disease, sudden abdominal pain, a tender pelvic mass, and signs of moderate, pelvic, peritoneal irritation were the most specific helps to diagnosis. More than half of the patients recalled having had previous, similar attacks. Most patients with twisted uterine adnexa did not have malignancy. When possible, a conservative surgical approach should be used, and fertility should be preserved.

Anatomy of anal sphincters and related structures in continent women studied with magnetic resonance imaging

Five anally continent nulliparas of reproductive age were studied with magnetic resonance imaging. The internal and external anal sphincters could be easily delineated, as could the intervening longitudinal musculature, puborectalis muscle, anococcygeal raphe, anorectal lumen, vagina, uterus, bladder, urethra, coccyx, and pubis. The shape of the sphincters was nearly cylindrical, with an anterior component averaging 18.3 mm thick and 28.0 mm long. Fifty-four percent of this anterior thickness was attributable to the internal sphincter. The anorectal angle varied considerably, with a mean of 86.8 +/- 19.1 degrees (range 60-112). The angle between the portion of the rectal lumen supported by the anococcygeal raphe, or levator plate, and the plane of the puborectalis muscle was consistent at 149.0 +/- 6.3 degrees (138-154). The finding of anterior anal sphincters with substantial thickness and length contrasts markedly with a view often pictured in the literature of a female anal sphincter that narrows anteriorly to half its posterior length and forms a small bundle of muscle rather than a broad band. Knowledge of these relationships is important in primary repair of obstetric sphincter lacerations as well as in surgical correction of anal incontinence.