Turbo-gracilis myocutaneous flap for perineal reconstruction

The turbo-gracilis flap, which has been described previously for the purpose of extending the unreliable gracilis skin island, and previously applied in forearm reanimation surgery, is now adapted for reconstruction in the perineal region. We present a case report of a patient with previous vulvar carcinoma treated with resection and radiation who presented with a very large defect of the perineal region. Reconstruction was carried out using a turbo-gracilis flap. The advantages of the flap are well demonstrated in the successful reconstruction, in that it provides an extensive amount of well-vascularized tissue due to an extended gracilis skin island which is vascularized by way of a vein graft from the proximal pedicle blood supply to a distal gracilis pedicle which, in turn, supplies the extended skin island. This allows an extensive amount of tissue to be harvested from a single donor site and ensures the viability of the skin island. A review of the advantages and disadvantages of various types of perineal reconstruction is also presented and contrasted with the turbo-gracilis method.

Surgical resection of endometriosis after prior hysterectomy

Twenty-seven patients who underwent laparotomy after a prior hysterectomy for endometriosis were studied. The mean interval from index surgery to repeat surgery was 7.8 years. Abdominal/pelvic pain was the most common presenting complaint, followed by the objective finding of a pelvic mass. Six patients were taking estrogen replacement therapy. Physical findings suggested a pelvic mass or nodularity in 15 patients. Extensive pelvic adhesions with dense involvement of the ovaries was common. Surgery in 2 patients was complicated by an enterotomy, with 4 patients requiring a bowel resection and anastomosis. Postoperatively, 5 patients developed fever, 3 a postoperative ileus, 1 a wound breakdown, and 1 a small bowel obstruction. The mean hospital stay was 5 days. We conclude that in patients who have undergone a hysterectomy as treatment for endometriosis, subsequent surgery to remove the ovaries involved with recurrent endometriosis carries considerable morbidity. In light of readily available estrogen replacement therapy, conservation of the ovaries in patients who are undergoing a hysterectomy for endometriosis should be applied with caution.

Sacrospinous colpopexy: management of postoperative pudendal nerve entrapment

BACKGROUND

Sacrospinous colpopexy requires the placement of a suture through the sacrospinous ligament, under which lies the pudendal nerve. Entrapment of this nerve may result in perineal or buttock pain. This report analyzes a case of pudendal nerve entrapment and studies the management of the resultant neuropathy.

CASE

A 62-year-old patient experienced a chronic pudendal neuropathy with perineal and buttock pain following a sacrospinous colpopexy. Removal of the suture, 2 years after it was originally placed, resulted in immediate relief of her pain. She has been asymptomatic for 1 year following surgery.

CONCLUSION

Pudendal nerve entrapment should be considered in the differential diagnosis of perineal or buttock pain after sacrospinous colpopexy. Relief of pain can be achieved even 2 years after initial surgery.

Massive pelvic hemorrhage during gynecologic cancer surgery: "pack and go back"

Over a 13-year period, intraabdominal packing has been used to control massive hemorrhage during surgery for gynecologic malignancy in six patients. Five patients had undergone total pelvic exenteration and one total abdominal hysterectomy with bilateral salpingo-oophorectomy for endometrial cancer. Massive hemorrhage was defined as infusion of more than 10 units of blood and replacement of more than one total blood volume. Tamponade was performed using continuous Kerlex rolls (Kendall Co., Boston, MA) in a bowel bag with directed pressure over the hemorrhaging site with abdominal closure. The packs were removed in 48 to 72 hr in the operating room, transabdominally in five patients and transvaginally in one. One postoperative death occurred within 8 hr of surgery. The packing was ultimately successful in the five remaining patients. In five of six patients, tumors were removed before the packing, whereas in one, the tumor was removed concurrently with the pack. In one patient, immediate repacking was required after pack removal, with ultimate hemostasis. Morbidity included "empty pelvis syndrome" in four patients, neuropathy in three (obturator in 1, sciatic in 2), and small bowel obstruction in one. In patients with severe intraoperative hemorrhage, intraabdominal packing has been successful as a mode of treatment.

Radical hysterectomy for stage IB1 vs IB2 carcinoma of the cervix: does the new staging system predict morbidity and survival?

Two hundred twenty-nine patients with Stage IB cervical cancer treated with radical hysterectomy were assigned to the new FIGO substages IB1 (n = 181) and IB2 (n = 48) based on clinical tumor diameter. Our purpose was to determine the impact of the new staging system for IB1 and IB2 cervical cancer on nodal status and survival. Additionally, we analyzed the morbidity of radical hysterectomy in light of the new staging system. The complications were similar between the two groups. Para-aortic lymphadenectomy was the only independent predictor of complications (P = 0.00026). Stage IB2 patients did have a significantly worse 5-year survival (72.8%) when compared with IB1 (90.0%) (P = 0.0265). Multivariate stepwise logistical regression analysis indicated that the new staging system did not have an independent impact on survival. Stage acts through nodal status in its impact on survival. Positive lymph nodes, tumor diameter, and Ponderal Index are all independent predictors of survival (P = 0.0001). Patients with Stage IB2 carcinoma of the cervix undergoing radical hysterectomy showed no significant increase in morbidity when compared with patients with Stage IB1 disease treated with the same procedure.

Intraoperative liver biopsy with the loop electrosurgical excision procedure in patients with gynecologic malignancies

When patients with gynecologic malignancies undergo exploratory surgery, hepatic lesions suggestive of malignancy are occasionally encountered. In 18 patients undergoing laparotomy for gynecologic cancer, visible liver lesions suggestive of malignancy were biopsied with the loop electrosurgical excision procedure (LEEP). Hemostatic suture placement was required in 3 of these 18 patients, and in 15, hemostasis was achieved with electrocautery only. Three of the 18 biopsies (16.7%) were positive for malignancy. No intraoperative or postoperative complications were attributed to the liver biopsy. One patient required postoperative transfusion of 2 units packed red blood cells. A new technique is described using the LEEP to remove suspicious lesions during exploratory laparotomy in patients with gynecologic malignancies.

Radical hysterectomy for stage IB cervical cancer: recurrence interval as a predictor of survival

Two hundred patients with stage IB carcinoma of the cervix were treated with radical hysterectomy. We evaluated the impact of recurrence interval on survival and determined its relationship to other prognostic factors. Thirty-one patients (15.5%) had recurrence, with a median follow-up of 2.8 years (range, 1 to 5 years). Multivariate analysis, using the Cox proportional hazard regression model, showed the impact of recurrence interval on survival and its relationship to other prognostic factors. Patients were 19 times more likely to die during follow-up if recurrence occurred shortly after the operation. However, the risk of death from recurrence decreased exponentially as recurrence interval increased, by a multiple of 0.93 m where m is recurrence interval in months. We conclude that in patients with stage IB carcinoma of the cervix treated initially with radical hysterectomy, the shorter the recurrence period after operation, the greater the likelihood the patient would die during 5-year follow-up. This information may help clinicians determine a patient's prognosis after confirmed recurrence.

Ability of visual tests to predict underlying cervical neoplasia. Colposcopy and speculoscopy

OBJECTIVE

To describe the attributes of colposcopy and a low-power, magnified examination that utilizes chemiluminescent illumination (speculoscopy) in the visualization of cervical epithelium in a predefined, high-risk population and to compare how the two tests predict cervical histology.

STUDY DESIGN

During this multicenter, prospective study, 395 women who were referred to our colposcopy clinic underwent a repeat cervical smear and speculoscopy followed immediately by colposcopy. Abnormal colposcopic lesions were biopsied and endocervical curettage performed when indicated. Histologic diagnoses were compared with cytology, speculoscopy and colposcopy results.

RESULTS

Colposcopy was more sensitive than speculoscopy in the detection of cervical neoplasia (97% vs. 82%) (P < .001) and was superior in visualizing focal lesions and vascular patterns. An antecedent acetowhite abnormality detected during speculoscopy was highly predictive of subsequent abnormal colposcopy (97% positive predictive value). The "overall" rate of acetowhite lesions during speculoscopy was nearly half the rate during colposcopy (P < .001).

CONCLUSION

Colposcopy is better suited than speculoscopy to the follow-up of patients with abnormal cervical cytology because it facilitates lesion grading and assists in directing biopsies. Speculoscopy is best utilized as a dichotomous screening test based on the presence or absence of at least one well-demarcated acetowhite lesion and may be more suitable than colposcopy as an adjunct to cervical cancer screening due to its lower overcall rate. The biophysical properties of blue-white chemiluminescent light as it relates to the diagnosis of cervical neoplasia are discussed.

Ileus following gynecologic surgery: management with water-soluble hyperosmolar radiocontrast material

Postoperative ileus following gynecologic surgery can prolong hospitalization and may predispose patients to mechanical obstruction. Our objective was to study the safety and efficacy of a water-soluble, hyperosmolar, radiocontrast material in the management of postoperative ileus in patients having gynecologic surgery. Of 115 cases, 57 were studied prospectively and received water-soluble radio-opaque contrast material via a nasogastric tube if bowel function had not returned by the third day. Fifty-eight well-matched control cases were managed without this material and received a suppository on the third day. The contrast material was well tolerated. Return of bowel function, day of oral intake, subsequent postoperative recovery, and duration of hospital stay were similar in the two groups. Water-soluble, hyperosmolar, radio-opaque contrast material given on the third postoperative day was safe, but of no apparent clinical benefit in resolving ileus following gynecologic surgery.

Artificial Dura Film for femoral vessel coverage after inguinofemoral lymphadenectomy

Eleven patients undergoing inguinofemoral lymphadenectomy for carcinoma of the vulva had the femoral vessels covered with Dura Film (Codman, Randolph, MA); a total of 21 groins were explored. The Dura Film was sutured to the inguinal ligament, sartorius muscle fascia, and adductor longus fascia. Nine of the 21 groins became infected with 3 of these breaking down; each of these 3 required removal of the Dura Film to achieve satisfactory healing. One patient developed a unilateral inflammatory groin mass requiring surgical removal of the Dura Film. One patient developed a chronic draining sinus that required surgical intervention. Seven groins developed lymphocysts. The morbidity was high with 9 of the 11 patients experiencing complications. Coverage of the femoral vessels with Dura Film after inguinofemoral lymphadenectomy is not an effective alternative to human dura mater or sartorius muscle transplant.

Pudendal thigh fasciocutaneous flaps for vaginal reconstruction in gynecologic oncology

The pudendal thigh is a sensate fasciocutaneous flap supplied by the posterior labial artery. We report on the results of pudendal thigh flaps used for vaginal reconstruction in eight patients at the time of pelvic exenteration (6) and radical vaginectomy (2). Patients were interviewed and results were assessed 5 to 19 months after surgery. The flaps were raised in the thigh creases just lateral to the hair bearing area of the labia majora and included skin, subcutaneous tissues, deep fascia of the thigh, and the epimysium of the adductor muscles. Flap sizes varied from 9 x 4 cm to 15 x 6 cm. Bilateral flaps were used in seven patients. The flaps were technically easy to perform. Partial (apical) flap necrosis occurred in four patients. One patient developed complete necrosis of bilateral flaps, followed by an enterovaginal fistula. One patient whose flaps did not necrose developed a rectovaginal fistula at the site of rectal reanastomosis. The functional results are disappointing. The only patient having successful vaginal intercourse had a unilateral flap reconstruction following lower vaginectomy in a nonirradiated pelvis. No patient with bilateral flaps or prior pelvic irradiation has had successful coitus. Other long-term sequelae include vulvar pain (2), chronic vaginal discharge (2), hair growth (4), and protrusion of the flaps (2). These vulvovaginal symptoms discourage patients and their partners from genital contact. Breaching the integrity of the vulva to construct a neovagina that is likely to be unsuitable for sexual intercourse may deprive women of their only potential for normal genital sexual responsiveness. Techniques of vaginoplasty require continued assessment.

Surgical management of groin node metastases from nonvulvar gynecologic malignancies

Metastatic disease from nonvulvar gynecologic malignancies involving the groin lymph nodes is uncommon. The purpose of this study is to analyze the morbidity, recurrence-free interval, and survival in this group of surgically managed patients. Twenty patients underwent surgical resection of metastatic disease involving the groin lymph nodes between January 1, 1984 and December 31, 1991. Individual factors which have an impact on morbidity, recurrence, and survival were analyzed. Two patients developed wound infection and 2 had wound breakdown. Both of the patients with postoperative wound infection had clinically fixed nodes. None of the patients developed deep venous thrombosis. Long-term complications included lymphocytes in 2 patients and lymphedema in 4 patients. The median local disease progression-free interval was 10 months, with 5 of 20 patients developing local recurrence. The overall median survival was 11 months, with an adjusted 5-year survival rate of 11.5%. Patients with clinically fixed lymph nodes had a shorter median survival (3.6 months) than those with clinically mobile (median, 22.6 months) nodes (P = 0.0032). Metastatic disease from carcinoma of the ovary, fallopian tube, uterus, and cervix involving the groin lymph nodes can be managed safely and effectively with surgical resection. The acute and long-term morbidity is acceptable. Local control can be achieved in the majority of patients.

Cervical cancer and tuboovarian abscesses. A report of three cases

Tuboovarian abscesses are rarely found in cervical cancer cases. In each of the three cases presented below, the diagnosis of adnexal disease was established at exploratory laparotomy. In one patient following surgery the cancer was downstaged from IIIb to IB. Another patient had undergone external radiotherapy with considerable morbidity prior to surgery. The third patient presented with ruptured tuboovarian abscesses. The cases illustrate the spectrum of problems when these diseases coexist. Exclusion of the presence of tuboovarian abscesses in selected cases by surgery is recommended to optimize treatment of the cancer.

Elective cesarean hysterectomy for treatment of cervical neoplasia. An update

From January 1, 1979, to March 31, 1991, 37 patients underwent elective cesarean hysterectomy for early cervical neoplasia. Thirty-four patients had cervical intraepithelial neoplasia III, and three patients had stage IA-1 squamous cell carcinoma of the cervix. Twenty-eight were primary cesarean sections; nine had obstetric indications. The mean operative time was 128 minutes; mean estimated blood loss was 1,400 mL. One patient experienced an intraoperative hemorrhage (3,500 mL). There were no other recognized intraoperative complications. Four significant postoperative complications included a vaginal cuff abscess, a wound dehiscence and pelvic abscess, one patient with febrile morbidity and an ileus and ligation with partial transection of a ureter. Patients were discharged on a mean of postoperative day 5.7. Although significant complications occurred, we believe that the noncompliant nature of our patient population justifies elective cesarean hysterectomy for treatment of cervical neoplasia.

Use of speculoscopy in the evaluation of women with atypical Papanicolaou smears. Improved cost effectiveness by selective colposcopy

Since up to 45% of patients with atypical Papanicolaou smears have been shown to have significant pathology, women with persistent atypia are usually referred for colposcopy. This study evaluated the use of a new adjunctive screening test, speculoscopy, in selecting women with atypical Papanicolaou smears who would most benefit from referral for colposcopy. Both screening and referral patients were evaluated with the Papanicolaou smear, speculoscopy and colposcopy at 10 study centers. Biopsies were obtained from most women with positive colposcopy. The results in patients with atypical smears were used to perform a cost-benefit analysis of each of three management protocols. Using the results of speculoscopy to select women with atypical Papanicolaou smears for colposcopy provided a cost-effective alternative to performing colposcopy either on all women or on those with persistent atypia following treatment. Even when all women undergo speculoscopy at the time of screening, this protocol provides a cost savings of up to 24% and no significant loss of diagnostic accuracy. These data suggest that speculoscopy performed at the time of initial screening can accurately select women with atypical Papanicolaou smears who require colposcopy for diagnostic biopsy in a cost-effective manner.

Interstitial radiotherapy for early stage vaginal cancer. A new method of tumor localization

Carcinoma of the vagina is optimally treated primarily with teletherapy, followed by interstitial needle brachytherapy. Following teletherapy, identification of the original tumor site is frequently difficult. We describe a method of marking the tumor with an india ink "tattoo" at initial presentation, followed by placement of a purse-string suture and titanium hemoclips at the time of brachytherapy. A stable marker is created so that the location of the original vaginal tumor can be easily identified on dosimetric films.

The effects of cold therapy on postoperative pain in gynecologic patients: a prospective, randomized study

OBJECTIVE

The purpose of the study was to determine the effect of cold therapy on the subjective assessment of pain, analgesic requirements, and wound complications in female patients undergoing major abdominal surgery.

STUDY DESIGN

Twenty-seven patients were entered in the study in a prospective, randomized fashion. The Hot/Ice Thermal Blanket was applied to 13 patients, and 12 patients were in the control group. All patients underwent exploratory laparotomy and received postoperative pain relief with intravenously self-administered morphine sulfate through a patient-controlled analgesic pump.

RESULTS

Compared with the control group (0.363 +/- 0.118 mg/kg/day), the cold pack group used more morphine sulfate on the first postoperative day (0.529 +/- 0.236 mg/kg/day, p < 0.05). The mean amount of morphine sulfate used by both groups was similar on postoperative day 2.

CONCLUSION

We conclude that the cold pack does not improve postoperative pain control in gynecologic patients undergoing exploratory laparotomy.

Lymphoscintigraphy in vulvar cancer: a pilot study

This pilot study was undertaken to correlate the patterns of lymphatic drainage demonstrated by vulvar lymphoscintigraphy with the clinical and pathologic findings of the inguino-femoral lymph nodes in patients with vulvar cancer. Ten patients were studied with the radionuclide Technetium-antimony trisulfide colloid (Tc 99m ASC) using a perilesional technique. Images were obtained at 2-4 hr postinjection. Four of the six patients with central lesions or lesions that crossed the midline had bilateral groin uptake, and two had unilateral uptake to the side on which the lesion was predominantly located. Three of these patients, each with suspicious groin nodes bilaterally, had metastatic nodal disease, two unilateral and one bilateral, in whom the uptake was bilateral and unilateral, respectively. Three of the four patients with unilateral lesions had ipsilateral groin drainage only and one had no drainage. Three underwent a bilateral lymphadenectomy and none had metastasis. The pattern of Tc 99m ASC uptake was not predictive of metastatic nodal disease. In two of the three patients with unilateral groin recurrence the side of recurrence was the same as that demonstrated on lymphoscintigraphy, and in the third case there was bilateral drainage. Further data are needed to determine the role of lymphoscintigraphy in the management of vulvar cancer.

A comparative study of radical vulvectomy and modified radical vulvectomy for the treatment of invasive squamous cell carcinoma of the vulva

Forty-five patients who underwent a modified radical vulvectomy for invasive squamous cell carcinoma of the vulva were compared with forty-five patients who underwent radical vulvectomy for similar lesions. Vulvar wound infection and breakdown were infrequent in both groups. Anal incontinence developed postoperatively in five of the modified radical vulvectomy patients and in none of the radical vulvectomy patients. Urinary incontinence developed postoperatively in two of the modified radical vulvectomy patients and in seven of the radical vulvectomy patients. Possible reasons for these differences are discussed. One invasive local recurrence (2.2%) developed in the modified radical vulvectomy group and two (4.4%) local recurrences developed in the radical vulvectomy group. A modified radical vulvectomy appears to be efficacious for the vulvar phase of treatment of localized invasive squamous cell carcinoma of the vulva.

Complications of colostomy performed on gynecologic cancer patients

From 1/1/80 to 5/31/90 111 patients underwent a colostomy on a gynecologic oncology service. Six patients developed 7 (6.3%) early colostomy-related complications, including sepsis (1), stomal retraction (1), ostomy wound infection (3), and partial stomal obstruction (2). The sepsis was felt to be related to spillage of stool upon maturing the colostomy, and this patient expired on Postoperative Day 63. There were no other mortalities attributed to the colostomies. Fourteen patients developed 17 (15.3%) delayed colostomy-related complications, including parastomal hernia (5), stomal retraction (1), stomal prolapse (3), tumor replacement (2), and site-choice problems (6). These results compare favorably with those in the literature and support the continued role of the gynecologic oncologist in gynecologic cancer-related gastrointestinal surgery.

An interesting case presentation: peripartum meningococcal meningitis

Meningococcal disease during pregnancy is extremely rare. A single reported case occurred more than 20 years ago in England. We present the case of a young woman who just hours after delivery of her baby developed fulminant meningococcal meningitis with its classic findings. Our experience illustrates the importance of early diagnosis and appropriate therapy of meningococcal disease in the gravid as well as in the nongravid population.

Radical hysterectomy for treatment of cervical cancer: a prospective study of two methods of closed-suction drainage

Two closed-suction drainage methods were prospectively compared in 96 patients after radical hysterectomy with pelvic lymphadenectomy in stage IB cervical cancer. In group 1 (n = 49) two pelvic sidewall drains and a vaginal drain were used, and in group 2 (n = 47) only the vaginal drain was used. The groups were similar for mean age, preoperative weight, hemoglobin and serum albumin level, operating time, operative blood loss, and blood transfusions. The febrile morbidity rates and the operative site infection rates were similar in the two groups. Ninety vaginal drains were removed by day 3. By day 6 55% of patients in group 1 had at least one sidewall drain, with a mean drainage of 150 ml/day. The median postoperative stay was similar in both groups. A pelvic lymphocyst developed in one patient in each group. The single vaginal closed-suction drain is safe, efficient, more acceptable to patients, and more cost-effective.

Upper vaginectomy for in situ and occult, superficially invasive carcinoma of the vagina

Between Aug. 1, 1985, and July 31, 1990, 32 patients underwent upper vaginectomy for grade 3 vaginal intraepithelial neoplasia. Thirty-one of these patients had undergone hysterectomy, 25 because of cervical neoplasia. Fourteen patients had undergone treatment for vaginal intraepithelial neoplasia. Nine (28%) had invasive cancer on final pathologic examination. Among the remaining 23 patients, recurrence of vaginal neoplasia developed in four (17%), with a mean time to recurrence of 78 weeks, and one was found to have superficial invasion at the time of recurrence. The remaining 19 patients remain alive with no evidence of recurrent disease at a mean follow-up interval of 152 weeks. In our patients upper vaginectomy was efficacious for the diagnosis of occult invasive carcinoma of the vagina and for the treatment of in situ and superficially invasive carcinoma of the vagina.