Ricardo Estape

The impact of intraoperative autologous blood transfusion during type III radical hysterectomy for early-stage cervical cancer.

OBJECTIVE The aim of this study was to determine the effects on transfusion rates, perioperative complications, and survival of using intraoperative autologous blood transfusions for patients undergoing type III radical hysterectomy and lymphadenectomy. STUDY DESIGN A retrospective analysis was conducted on 156 patients treated with type III radical hysterectomy and lymphadenectomy at the University of Miami School of Medicine from 1990 to 1997. One group of patients (n = 50) had intraoperative autologous blood transfusions and the other (n = 106) did not. RESULTS The group that received intraoperative autologous blood transfusion had a significant reduction in homologous blood transfusions (12% vs 30%; P =.02). Patient demographic data, histologic parameters, and operative factors were similar between the 2 groups. There was a higher percentage of patients with positive pelvic lymph nodes in the group that did not receive intraoperative autologous blood transfusion (10% vs 30%; P =.02). Seven patients in the intraoperative autologous blood transfusion group (14%) died with disease present and all the recurrences in this group were local. CONCLUSION The use of intraoperative autologous blood transfusions during type III radical hysterectomy and lymphadenectomy appears to be safe and effective without compromising rates and patterns of recurrence.

Urinary complications of Miami pouch: Trend of conservative management

OBJECTIVE Continent urinary diversions have become popular among gynecologic oncologists. Much information has been gained concerning the complications and current management of patients with continent ileocolonic reservoirs. The high mortality rate associated with reoperation has led clinicians to adopt a trend toward conservative means of management. The purpose of this study was to evaluate the applicability of conservative management of complications related to the creation of the continent ileocolonic reservoir Miami pouch. STUDY DESIGN Patients who underwent creation of the Miami pouch at the Division of Gynecologic Oncology, University of Miami School of Medicine, since 1988 have been included in this study. Management of complications, with particular emphasis on the conservative treatment, has been reviewed in detail for each patient. Open surgery and conservative treatment have been compared. RESULTS Seventy-seven patients underwent creation of the Miami pouch from February 1988 to September 1997. Sixty (77.9%) patients were affected by recurrent cervical cancer; 72 (93.5%) were previously radiated. The perioperative mortality rate was 11.7% (9 patients). Six of these patients died as a result of sepsis; all of them underwent reoperation at least once. The most common urinary complications were ureteral stricture or obstruction (22.1%), difficult catheterization (19.5%), and pyelonephritis (13%). Conservative management strategies used for these complications included percutaneous nephrostomy, stent placement, balloon dilatation, radiologically (ultrasonography, fluoroscopy, computed tomography) guided placement of catheters, and antibiotic treatment. Eighty percent of the complications associated with the ileocolonic reservoir were resolved with conservative treatment, whereas 16.9% required surgical revision. CONCLUSION On the basis of these findings, conservative management of urinary reservoir complications should always be considered before surgical intervention is attempted. The exact time to engage in open revision should be individualized on the basis of the clinical condition of each patient. It is our belief that the conservative approach should be instituted whenever possible but surgical intervention not be delayed when absolutely indicated.

SURGICAL MANAGEMENT OF ADVANCED AND RECURRENT CERVICAL CANCER

Since the early 1940s, the incidence of cervical cancer has dramatically decreased due in large part to the work of Papanicolaou and Traut. Successful treatment can now be done using simple or radical surgical intervention for early invasive lesions and radiation therapy for more advanced lesions. However, despite current advances in screening and early treatment, local recurrences still happen and are difficult to treat. The natural history of cervical cancers is that of a slowly growing, locally invasive tumor. As such, it lends itself to radical surgical resection in selected patients prior to distant metastasis. Current advances in intraoperative and postoperative monitoring, as well as improved surgical techniques and devices, have decreased the morbidity and mortality of radical surgical procedures to acceptable levels. Current data associated with these procedures for advanced or recurrent cervical cancer are described.

Trends in the Management of Pelvic Abscesses

Tuboovarian abscess (TOA) is an important and common cause of inflammatory pelvic masses in women of reproductive age. It is responsible for approximately 100,000 hospital admissions annually. TOA is a known complication of pelvic inflammatory disease (PID), and its incidence is expected to increase with the current epidemic of STDs. TOAs are especially prevalent in patients infected with HIV. TOA is a polymicrobial process with a preponderance of anaerobic organisms, including the resistant gram-negative anaerobes such as Bacteroides bivius and Bacteroides fragilis. Patients with a TOA frequently present as a diagnostic dilemma for the surgeon. The symptoms commonly mimic those of a perforated appendiceal abscess, and at laparotomy or laparoscopy, the inflammatory process may involve all three organs (ie, ovary, tube, and appendix), making it difficult to assess where the initial insult originated. Patients with TOA usually present with lower abdominal pain and adnexal mass(es). Fever and leukocytosis are usually present, but their absence does not rule out TOA, especially in immunocompromised individuals. This article reviews the causes, diagnosis, treatments, and outcomes of TOA.

URINARY DIVERSION IN GYNECOLOGIC ONCOLOGY

Urinary diversion in gynecology is performed primarily in conjunction with cancer surgery, but at times, it is required for women with intractable urinary fistulas or other urologic disorders. After 1950, ileal conduits replaced ureterosigmoidostomies as the most widely used form of urinary diversion. Transverse colon conduits have gained popularity because these nonirradiated bowel segments offer less risk for postoperative urinary leaks and small bowel complications associated with bowel and ureteral anastomoses. In 1978, Kock et al described the use of detubularized segments of ileum and the intussuscepted nipple valves to create a continent pouch that is still advocated by urologists in some centers. Ileocolonic continent pouches, originally suggested in 1908, have received considerable attention in the past 10 to 15 years because of ease of construction, lower revision rates, and higher continence rates compared with the Kock ileal pouches. At the Division of Gynecologic Oncology at the University of Miami, the authors have been using the Miami pouch as the preferred form of continent urinary diversion since 1988, with acceptable results. Women who need urinary diversion can be offered at least two major choices: (1) the traditional bowel (ileum or colon) conduit, which requires an external ostomy appliance, or (2) a continent pouch, such as the Miami ileocolonic reservoir. In choosing between non-continent and continent conduits, the patients must be made aware that the continent pouches are available in only a few centers in the United States and carry a slightly higher risk for complications because of the relatively higher complexity. Nonetheless, data strongly suggest that most of these complications can be managed noninvasively and that these patients retain a closer to normal quality of life. The age, disease status, and general health of the woman and the likelihood of her long-term survival after diversion weigh heavily in the final decision.

Robotic and Open Cytoreductive Surgery With Hyperthermic Intraperitoneal Chemotherapy in the Management of Recurrent Ovarian Cancer

INTRODUCTION: We aimed to evaluate the feasibility and tolerability of hyperthermic intraperitoneal chemotherapy after cytoreduction surgery for recurrent ovarian cancer. METHODS: In a single-institution, pilot study, patients underwent optimal cytoreductive surgery in combination with hyperthermic intraperitoneal chemotherapy followed by consolidation chemotherapy from September 2011 to May 2013. Optimal cytoreduction was defined as no lesion greater than 1 cm. Adverse and oncologic outcomes were measured. Standard statistical analysis was used. RESULTS: Thirteen patients with a median age of 52 years (range 20–86 years) were identified. The median number of chemotherapy regimens before hyperthermic intraperitoneal chemotherapy was three (range one to 12 prior regimens). A median of two platinum-containing regimens was administered before hyperthermic intraperitoneal chemotherapy (range zero to five regimens). Median CA-125 at time of hyperthermic intraperitoneal chemotherapy was 256 U/mL (range 13–8,543 U/mL). Seven (54%) of patients were platinum-sensitive at the time of hyperthermic intraperitoneal chemotherapy. Six (46%) patients underwent a robotic optimal cytoreductive surgery. The following cytotoxic agents were used during hyperthermic intraperitoneal chemotherapy: mitomycin, six (46%); cisplatin and paclitaxel, four (31%); carboplatin, two (15%); and paclitaxel, one (8%). There were no intraoperative complications or adverse events attributable to hyperthermic intraperitoneal chemotherapy therapy. Hospital stay was a median of 8 days (range 1–25 days). At a median follow-up of 4 months (range 1–7 months), the progression-free survival and overall survivals have not been reached. CONCLUSIONS: In select patients, robotic and open cytoreductive surgery in combination with hyperthermic intraperitoneal chemotherapy is feasible and safe. The optimal candidate and chemotherapy regimen have yet to be defined. Preliminary survival data suggest efficacy.

Combination intraperitoneal Carboplatin and intravenous and intraperitoneal Paclitaxel in the management of advanced-stage ovarian cancer.

INTRODUCTION: Intraperitoneal (IP) chemotherapy is known to be effective after optimal primary debulking surgery for ovarian cancer. We conducted a pilot study to investigate a regimen of combination IP carboplatin and intravenous (IV) and IP paclitaxel. METHODS: A prospectively maintained database was used to identify all patients who received IP and IV chemotherapy after an optimal cytoreductive surgery for advanced epithelial ovarian carcinoma from May 2007 to June 2013. The regimen consisted of day 1 administration of IP carboplatin AUC 6 and IV paclitaxel 175 mg/m2 over 3 hours and day 8 IP paclitaxel 60 mg/m2 over 1 hour. Common toxicity criteria for adverse events were used to classify toxicities. Protocol toxicities and oncologic outcomes were recorded. RESULTS: Twenty patients received the treatment protocol. The median age was 62 years (range 42–88 years). The median CA-125 at presentation was 296 units/mL (range 31–4,838 units/mL). Nineteen (95%) patients were stage IIIC. The median number of IP cycles completed was six (range five to six cycles). Grade 3 and 4 toxicities occurred in 11 (55%) and 10 (50%) patients, respectively. The following grade 3 and 4 toxicities occurred: neutropenia in 14 (70%) patients, thrombocytopenia in five (25%), anemia in four (20%), nausea in two (10%), and fatigue in one (5%). With a median follow-up of 20 months, the median progression-free survival has not yet been met. The 5-year overall survival rate was 80%. CONCLUSIONS: Combination day 1 IP carboplatin, IV paclitaxel, and day 8 IP paclitaxel after optimal cytoreductive surgery for advanced-stage epithelial ovarian cancer is effective and safe.

The treatment of fecal incontinence after traumatic vaginal delivery: overlapping sphincteroplasty, internal anal sphincter imbrication, levatorplasty, culdoplasty, and perineorrhaphy

Abstract Objective: To assess the operative procedure used in the treatment of fecal incontinence after traumatic vaginal delivery and the functional outcome after surgery. Methods: Between 1995 and 1998, a prospective nonrandomized study was conducted on 22 patients, all of whom had complete fecal incontinence of gaseous, liquid, and solid stool. Preoperatively, all patients were found to have anterior rupture of the external anal sphincter after vaginal deliveries. All patients underwent overlapping sphincteroplasty, culdoplasty, levator ani plication, and perineorrhaphy. Results: Incontinence to gas was found in only one woman (6%). Liquid incontinence was reported in 3 of 22 patients (13.7%). One patient (6%) experienced incontinence to solid stool. A total of four patients (18.2%) suffered constipation, but in only three patients (17%) did the constipation persist after 1 month. Ninety-five percent of the patients had no incontinence to solid stool. The mean follow-up period was 20 months. Conclusion: Ninety-five percent of patients are continent to solid stool. A total of 82% of patients suffer no fecal incontinence and experience excellent functional status, maintaining Grade III and IV continence.