Richard J. Cardosi

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.

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.)

DIAGNOSIS AND MANAGEMENT OF VULVAR AND VAGINAL INTRAEPITHELIAL NEOPLASIA

Vulvar intraepithelial neoplasia and VAIN present unique challenges to the practicing gynecologist. VIN may produce distressing symptoms and undergo malignant conversion. A high index of suspicion and liberal use of biopsy are required to make the diagnosis. The approach to therapy for VIN has been reviewed. Treatment should be tailored to each individual patient and may include a period of expectant observation. Variations and combinations are used whenever necessary to preserve normal function and anatomy. Frequent surveillance is a must because recurrence rates are high, especially with multifocal disease in young women. Although VAIN accounts for less than 0.5% of lower genital tract neoplasia, the frequency of its detection is increasing, especially in younger patients. These lesions are most commonly found in the upper third of the vagina and are often multifocal in nature. The close proximity of the upper vagina to the rectum, bladder, and ureters makes treatment difficult. The occult invasion rate may be as high as 28%, and a wide variety of therapies are available. As is true for VIN, recurrence is not uncommon.

Vaginectomy with pelvic herniorrhaphy for prolapse

OBJECTIVE The study was undertaken to report our experience with vaginectomy and pelvic herniorrhaphy for vaginal prolapse. STUDY DESIGN This was an observational study of patients undergoing vaginectomy (n=41) or hysterovaginectomy (n=13) for stage III/IV vaginal prolapse. Morbidity was compared with cohorts who had undergone transvaginal repair of prolapse, by using the Mann-Whitney U test. RESULTS Morbidity did not differ significantly (estimated blood loss) between the vaginectomy and hysterovaginectomy groups. There were no recurrent hernias (6-56 months). Operative time, estimated blood loss, and day of discharge were significantly greater for the posthysterectomy prolapse group compared with the vaginectomy group. Operative time was significantly greater for the uterovaginal prolapse group versus the hysterovaginectomy group. CONCLUSIONS Vaginectomy with or without hysterectomy with pelvic herniorrhaphy is associated with a low rate of morbidity in a high-risk patient population. Hysterovaginectomy is not associated with a clinically significant difference in morbidity over vaginectomy alone. Vaginectomy with or without hysterectomy should be offered as a surgical option to selected patients with severe genital prolapse.

Magnesium sulfate, maternal hypothermia, and fetal bradycardia with loss of heart rate variability.

Background Fetal bradycardia and decreased heart rate variability can indicate a nonreassuring fetal status. However, there can be iatrogenic, physiologic, or pathologic causes. Case A patient in premature labor received toxic levels of magnesium sulfate for tocolysis. Elevated maternal serum magnesium levels correlated inversely with maternal temperature and both fetal heart rate and fetal heart rate variability. There was also a relative decrease of the maternal heart rate from baseline. When the magnesium levels returned to normal, these vital signs returned to normal. Conclusion Magnesium sulfate therapy can result in maternal hypothermia and a decrease in fetal heart rate and heart rate variability. Maternal hypothermia might be the cause of fetal bradycardia. A direct action of magnesium on the fetal heart might be the cause of heart rate variability.

Comparison of elective and empiric cerclage and the role of emergency cerclage

We describe the maternal, obstetric, and neonatal outcomes of patients undergoing elective, empiric, and emergency cervical cerclage at our institution in an attempt to determine predictive factors for adverse perinatal and maternal outcomes. A retrospective chart review was conducted on patients who underwent cervical cerclage placement over a 7-year time span. Of 55 charts, 40 contained complete peripartum data satisfactory for review; 7 elective, 15 empiric, and 18 emergency cerclages were analyzed. There was no perinatal mortality in the elective group, and 5/7 patients delivered at term. The empiric population experienced a 20% neonatal mortality; 6/15 gestations progressed to term. The perinatal mortality was 44% in the emergency group and 2/18 patients delivered at term. Relative to neonatal outcome, elective cerclage was statistically significantly better than emergent cerclage; there was no statistically significant difference between the elective and empiric groups nor between the empiric and emergent groups. This relatively small series with a large number of variables appeared to favor an elective procedure rather than an empiric one. Although emergent cerclage was associated with only a 56% neonatal survival, it did have value in some patients.

Risks of rigid dilation for a radiated vaginal cuff: two related rectovaginal fistulas.

BACKGROUND Dyspareunia secondary to significant radiation fibrosis of the vagina is a difficult clinical problem. The benefit of vaginal dilator therapy in such patients is unclear. CASES We report two patients who had attempted dilation and elongation of a small, fibrotic, heavily radiated vagina and subsequently developed a rectovaginal fistula. CONCLUSION Use of a rigid dilator in an attempt to lengthen a heavily radiated vaginal cuff may be hazardous.

Infectious urinary tract morbidity with prolonged bladder catheterization after radical hysterectomy

OBJECTIVE This study was undertaken to determine the incidence of catheter-associated infection after radical hysterectomy and to evaluate the role of prophylactic antibiotics in these patients. STUDY DESIGN A 4-year retrospective review of 102 women undergoing radical hysterectomy for cervical or endometrial cancer was performed. Clinical data were abstracted and analyzed with chi(2) and t tests. RESULTS Catheter-associated infection was observed in 11% (12 of 102) and was not altered by the administration of prophylactic antibiotics (11.1% vs 11.8%, P=.95). Of the 12 women who had infection, 11 were treated as outpatients, and 1 patient required admission for pyelonephritis. Patient age, comorbid medical conditions, class of radical hysterectomy, perioperative complications, operative time, blood loss, catheter type, duration of catheterization, and length of hospitalization had no effect on the development of catheter-associated infection. CONCLUSION The incidence of catheter-associated infection in women requiring prolonged catheterization after radical hysterectomy is relatively low. Withholding prophylactic antibiotics from these patients is a reasonable clinical option.

Surveillance of the endometrium in tamoxifen treated women.

There is much debate about the risks and benefits of tamoxifen, most specifically about the incidence of associated endometrial cancer. Nearly all of the published trials on the subject have been criticized for methodological flaws and various forms of bias, making resolution of this controversy difficult. There is a consensus, however, that tamoxifen results in an increased incidence of both premalignant and malignant lesions of the endometrium. As the indications for tamoxifen continue to broaden, a larger number of women will be subjected to the potential adverse effects of tamoxifen. Many techniques for screening patients on tamoxifen for the development of endometrial abnormalities have been suggested. None of these methods appears to be consistently clinically or cost effective. We have reviewed the literature on endometrial surveillance in tamoxifen treated women with a focus on the larger publications reported within the past year. From this, we have provided what we hope to be safe and cost-effective recommendations for the management of these patients.

Venous thromboembolic complications in obstetrics and gynecology with a focus on the role of low molecular weight heparin

Venous thromboembolism is a major cause of morbidity, mortality, and economic expense in the field of obstetrics and gynecology. Without prophylaxis, as many as 30% of at-risk patients will suffer deep vein thrombosis, and nearly 1% of these patients will succumb to a fatal pulmonary embolism. Both deep venous thrombosis and pulmonary embolism manifest few specific symptoms, and the presentation of these entities is often clinically silent. Therefore, a prophylactic approach is preferred. We review the pathophysiology, risk factors, prophylactic choices, and treatment of venous thromboembolic complications for the general obstetric and gynecology population. We focus on the role of low molecular weight heparin because of its convenient dosing and favorable risk/benefit profile.