Richard E. Symmonds

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.

Sarcoma of the uterus. A clinical and pathologic study of 177 cases.

Abstract Clinical and pathologic features of 177 cases of sarcoma of the uterus have been reviewed. Twenty-five of 60 patients with leiomyosarcoma and 17 of 53 patients with endometrial sarcoma who received their primary definitive therapy at the Mayo Clinic were known to be living at least 5 years later. Clinical features were not diagnostic, but suggested other more common neoplasms. Treatment of choice was total abdominal hysterectomy. Radiation therapy was of questionable value. The grade and extent of the sarcomas were the most significant prognostic factors.

Carcinoma of the vulva: Analysis of treatment failures

Continuous follow-up of 224 patients treated for primary invasive squamous cell carcinoma of the vulva in a 20-year period (1955 to 1975) at the Mayo Clinic resulted in the detection of recurrent (or persistent) neoplasia in 59 (26%). Rates of treatment failure increased with advancing stage of disease-from 14% for Stage I to 71% for Stage IV. The rate of local vulvar recurrence was 18%, which was about three times greater than the recurrence rates for the groin, pelvis, and distant sites. However, the 1- and 5-year survival rates of 73% and 50%, respectively, after vulvar recurrence were in sharp contrast to the corresponding rates of 34% and 10% for regional or distant recurrence. When 35 patients with central vulvar extension of disease were evaluated, groups at excessive risk for treatment failure (lesions 4 cm or larger inguinal node involvement, or both) were identified and modifications in conventional therapy applicable to these groups were considered.

Exenterative operations: Experience with 198 patients

Abstract In a series of 198 exenterative operations performed at the Mayo Clinic for various pelvic malignant lesions, a 5 year survival rate of 33 per cent was obtained. This rate is commendable, since almost 80 per cent of the operations were accomplished for recurrent malignancy. The diminished over-all operative mortality rate of 8.1 per cent, a reduction from 13.5 per cent (1950 through 1962) to 3 per cent (1963 through 1971), is attributed to better methods of urinary diversion and to better management of fluid replacement and of infectious complications. Major complications, excepting bowel fistula and obstruction, now can be controlled reasonably well. When more conservative and equally curative methods of therapy have been exhausted, all patients with pelvic malignancy (whether primary in cervix, vagina, bladder, urethra, rectum, or vulva) should be considered potential candidates for exenteration.

Melanoma of the vulva: An update

During the time interval 1950 through 1980, 48 patients having a mean age of 60.2 years were treated primarily for melanoma of the vulva. In all but one patient, a surgical therapeutic approach was selected, including 40 modified Basset procedures and 23 pelvic lymphadenectomies. The 5-year survival rate of the eligible population was 54%. Although surgical staging according to the classification established by the International Federation of Gynecology and Obstetrics (FIGO) was of minimal value, microstaging, using Clarks and Breslows stratifications for assessing dermal penetration, was of prognostic significance. Ten-year survival rates associated with Clarks level II, III, IV, and V tumors were 100, 83, 65, and 23%, respectively. Histologic growth patterns (5-year survival rates of 71 and 38% for superficial spreading and nodular melanomas, respectively) and groin nodal metastasis were cogent prognostic factors and indirectly were related to depth of local tumor invasion. Likewise, assessment of treatment failures demonstrated a positive correlation between recurrences (specifically at distant sites) and Clarks level of melanocytic penetration. Because of the unacceptably high (32%) local treatment failure rate despite radical vulvar resection, treatment modifications for vulvar melanoma are imperative.

Stage I squamous cell cancer of the vulva

A review of 106 patients with Stage I squamous cell cancer of the vulva treated at the Mayo Clinic from 1950 through 1975 is presented. Microinvasive lesions (5 mm penetration or less) were present in 96 patients (91%); invasive lesions (more than 5 mm penetration) were diagnosed in 10 (9%). Inguinal node involvement was present in nine patients (8.4%); one of these also had pelvic node involvement. Recurrence developed in 13 patients (12%). Four patients experienced inguinal node metastasis after initial surgical therapy. The incidence of positive nodes among patients with lesions invading the stroma for 3 mm or less was 3%. Thus, individualization for inguinal lymphadenectomy may be possible according to the age and condition of the patient when the depth of invasion is 3 mm or less.

Site of recurrence of cervical cancer after radical hysterectomy

Of 564 patients who underwent radical hysterectomies for cervical cancer. 104 had recurrences. Twenty (3.5%) had recurrence in the central pelvis, and in nine (1.6%), this was the only site of recurrence. Of the patients who had lymph node metastases at the time of radical hysterectomy, 40% subsequently had recurrence compared with 14% who had negative nodes and recurrence. The site of recurrence, however, had no relationship to lymph node involvement, size of the lesion, stage of disease, cell type or grade, or previous pelvic irradiation.

Vaginal prolapse following hysterectomy

Abstract The results of operations performed at the Mayo Clinic for posthysterectomy vaginal prolapse on 69 patients are reviewed. On follow-up 1 to 10 years or more after operation it was found that in 52 patients satisfactory support had been obtained, and in 11 it was unsatisfactory. Six patients could not be traced. The repair was attempted abdominally in 15 patients. In 10 of the 11 patients in whom the primary abdominal approach was utilized successfully, it was necessary also to repair the vaginal walls from below or to support the vault with a fascial sling to ensure a satisfactory result. The repair of the vault was attempted vaginally in 54 patients; 6 were untraced, but 41 (85.4 per cent) of the 48 traced patients had a satisfactory result. Among the patients in whom the vagina was preserved and who have attempted to have coitus, vaginal function was satisfactory in 9 of 13 treated abdominally although 2 of the 9 have recurrent prolapse), and in 12 of 21 treated vaginally. A technique for vaginal repair of vault prolapse is presented.

Endometrioid sarcoma, “stromal endometriosis”

Abstract “Endometrioid sarcoma” is the proposed designation of a rare neoplasm of the endometrial stroma commonly called “stromal endometriosis.” It occurs most frequently in the fifth decade of life but its onset may be earlier or later. The clinical features are not diagnostic; rather they suggest other commoner pelvic neoplasms. The lesion has a readily identifiable and diagnostic gross and histologic appearance, which, once seen and identified, can scarcely be confused with any other lesion of the pelvic organs. The initial treatment should be surgical, preferably total abdominal hysterectomy with bilateral salpingo-oophorectomy. Intravascular extensions should be sought and removed if found. The concept that this condition is benign is erroneous. This malignant neoplasm is directly responsible for death in perhaps 25 per cent of cases, usually after a protracted course.

Palliative exenteration—What, when, and why?

Between 1955 and 1981, 323 pelvic exenterations were performed at the Mayo Clinic. Fifty-nine (18%) were considered retrospectively to be palliative because of pelvic or aortic nodal metastasis, pelvic peritoneal involvement, pelvic wall involvement, bone involvement, or, in two cases, distant metastasis. The survivals were 47% at 2 years and 17% at 5 years. When metastatic nodal disease was found after irradiated pelvic recurrence, the 2- and 5-year survivals were 46% and 23%, respectively. Although exenteration procedures are designed to be curative, the palliative benefits obtained in this group of patients appear to be worthwhile and comparable to those achieved in advanced epithelial ovarian carcinoma for which aggressive surgical management is now strongly advocated.