Tiffany J. Williams

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.

Endometriosis in 1,000 consecutive celiotomies: Incidence and management☆

A prospective study of the incidence of endometriosis encountered in consecutive pelvic explorations was carried out. When study cards were filled out immediately after operation, it was found that one half of the patients had endometriosis. The symptoms, indications for operation, and pelvic findings in patients with endometriosis were compared with those in patients not having endometriosis but with similar operative procedures. The location of the condition and the results of the operation were evaluated. Further comparisons were made as to subsequent symptoms, pregnancy, operations, and hormone requirements, and conclusions were drawn as to risks and benefits referable to the type of operation performed.

Factors influencing survival in Stage I ovarian cancer

Abstract A total of 271 patients with Stage I epithelial cancer of the ovary were treated at the Mayo Clinic from 1950 through 1966. Data related to various forms of treatment show that many factors in addition to the stage of the lesion influence survival. Among these are cell type, grade of malignancy, and gross characteristics of the lesion. These factors should be considered in the selection of the proper treatment of the specific lesion. Such individualized treatment should give a highly satisfactory survival.

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.

Pregnancy after metroplasty for uterine anomalies

OBJECTIVE To clarify the relation between metroplasty for correction of uterine anomalies and subsequent pregnancy, we reviewed the charts of all patients for whom a diagnosis of bicornuate, septate, or didelphic uterus had been made between 1972 and 1982 and analyzed their obstetric outcomes. DESIGN Of the 146 patients evaluated, 23 received a metroplasty procedure, and 123 patients did not have surgical intervention. Fifteen of the nonsurgical patients could be matched with 15 of the surgical patients by age, chief complaint, gravidity, and type of anomaly and therefore served as matched controls. RESULTS The percentage of patients with living children after the diagnosis of uterine anomaly was 67% for the matched nonsurgical group and 73% for the patients who underwent metroplasty. The difference was not statistically significant. Although marked improvement in fetal salvage rates was noted when reproductive outcomes before and after metroplasty were compared, the obstetric outcome was similar to that of the control groups after the diagnosis was made and surgery deferred. CONCLUSION The efficacy of metroplasty in the treatment of multiple pregnancy losses is thus being questioned.

Microsurgical reconstruction of the proximal oviduct

Since the successful advent of in vitro fertilization and embryo transfer (IVF-ET), reproductive surgeons have been forced to compare pregnancy outcomes of surgical procedures for tubal infertility with those of IVF-ET. The current study reports pregnancy outcomes, with extended follow-up, in patients who had proximal oviductal obstruction. Twenty-seven patients who had proximal oviductal disease with limited distal disease were evaluated after microsurgical repair. The conception rate at the end of 3 years of observation was 69.3%. The live birth rate was 53.2% at 3 1/2 years. The results indicate that microsurgical reconstruction of proximal oviductal occlusion is a workable option for patients with infertility.

Alveolar soft-part sarcoma of the vagina

A 26-year-old female with an alveolar soft-part sarcoma of the vagina, manifesting itself during and after pregnancy, is described. The presenting symptoms were pain and an increase in the size of the mass. Local excision, followed by radiotherapy and chemotherapy, was ineffective and the tumor reoccurred within 6 weeks. Reoperation with removal of a portion of the vagina, surrounding tissues, and adjacent periosteum of the pubic bone has resulted in a stabilization of the disease.

Primary microsurgery for postinflammatory tubal infertility

Pelvic inflammatory disease is a common cause of tubal infertility. The pregnancy outcomes in 161 patients who underwent primary microsurgical tuboplasty for postinflammatory tubal disease at the Mayo Clinic from 1977 through 1981 were evaluated. The outcome (3-year rate) was evaluated for each category of microsurgical procedures. The proximal anastomosis group had a conception rate of 71% (50% live births, 30% spontaneous abortions, 6% ectopic pregnancies). The terminal salpingoneostomy group, which accounted for the largest number of procedures, had a conception rate of 47% (32% live births, 12% spontaneous abortions, 11% ectopic pregnancies). Even after microsurgical tubal reconstruction, most women do not achieve a live birth. Pregnancy outcome is probably related to several factors reflecting the severity of pre-existing intrinsic damage. Prognostic factors that may better predict pregnancy outcome are discussed.

Results of microsurgical reconstruction in patients with combined proximal and distal tubal occlusion: double obstruction.

Thirty-one patients underwent microsurgery for correction of postinflammatory occlusion of both the proximal and the distal portions of the oviduct. Preoperative staging of tubo-ovarian adhesions, hydrosalpinges, and sites of oviductal occlusion was completed in each patient. Laparoscopic records were reviewed to correlate laparoscopic sites of occlusion with those found at the time of microsurgery. The conception rate at 2.5 years of observation was 12%, and there were no live births. The sensitivity of laparoscopy to predict proximal and distal disease was 65.6 and 55.2%, respectively. The poor surgical outcome in these patients suggests that IVF-ET should be strongly considered and that a careful preoperative laparoscopic examination is necessary for prospective counseling in these patients.

Management of unilateral and encapsulated ovarian cancer in young women

Abstract Unilateral encapsulated ovarian cancer of the epithelial variety may be safely managed by conservative operation in young women who are desirous of childbirth, provided the opposite ovary is normal and the tumor is not ruptured. The lesion must be a low-grade ovarian neoplasm (Grade 1 or 2). Whether the tumor is serous or mucinous probably is of little consequence, as suggested by our previous studies. 6 Bisection of the opposite ovary with wedge biopsy is recommended, and there must be frequent follow-up. The late recurrences (27 and 32 years after operation) noted in the opposite ovary of two patients in our series suggest that reoperation and definitive surgery should be considered after the patients childbearing is complete.