Superficial laser vulvectomy. IV. Extended laser vaporization and adjunctive 5-fluorouracil therapy of human papillomavirus-associated vulvar disease

Although most human papillomavirus infections can be managed satisfactorily by office methods, extensive, refractory, and dysplastic vulvar disease poses frustrating problems. This observational cohort study evaluated the efficacy of extended laser ablation (vaporization of both clinically apparent and adjacent subclinical changes) among 160 women drawn from 1000 referrals between 1982-1987. During the final 2 years, the protocol incorporated two different 5-fluorouracil (5-FU) regimens: routine once-weekly applications as prophylaxis against postoperative recurrence, and twice-weekly dosing to avoid further laser surgery among patients with early but diffuse failures. One hundred seven patients (66.9%) were controlled by a single operation. Subsequent therapy for the remaining 53 women involved 44 additional superficial photovaporizations, 38 courses of therapeutic 5-FU, four deep laser destructions with skin grafting, and six trials of systemic alpha-interferon. Eventually, 158 patients (98.7%) entered stable clinical remission. Adjuvant 5-FU improved success rates among the 76 women with two or more adverse prognostic factors (87.5 versus 55.8%; P less than .01) but had no prophylactic value in the other 84 women. In contrast, the therapeutic 5-FU regimen was generally effective, avoiding the need for further surgery in 22 (57.9%) of 38 inevitable failures, compared with only four successes (10.3%) among 39 historic controls managed with caustic agents (chi 2 = 19.5; P less than .001). Improvements in laser technology had no impact upon outcome, but more sophisticated heat containment strategies reduced postoperative pain, healing time, and morbidity. Given adequate technique and an appropriate indication, we find extended laser ablation to be an excellent primary control method. However, the availability of an effective adjuvant regimen would be a valuable complement.

[Vulvar dystrophy]

The pathogenetic, diagnostic and therapeutic aspects of vulvar dystrophies are reviewed, special attention being paid to a comparison of therapeutic tendencies past and present. The advantages of topical treatment with corticosteroids and testosterone and those of the most recent surgical techniques are compared respectively with the results obtained in past years using estrogenic topical treatment and demolition surgery.

[Elephantiasis of the vulva and the legs. Medical and surgical treatment of a case of lymphatic filariasis]

After reviewing the main causes of elephantiasis in tropical countries, the results of combined medical and surgical treatment of a case of lymphatic filariasis are reported. Medical treatment consists of a cycle of high-dose mebendazole (40 mg/kg/die) and subsequent cycles of diethylcarbamazine at a habitual dose (6 mg/kg/die). In the interval, the elephantiasic right lip was removed surgically. The overall clinical results was good. Noteworthy was an unwanted, leukopenising side-effect of high-dose mebendazole.

The ambulatory surgical management of Bartholin duct cysts

Marsupialization of Bartholin duct cysts was performed in the emergency department (ED) under pudendal anesthesia. Nineteen symptomatic cysts were treated surgically using techniques suitable for outpatient facilities. Pudendal anesthesia was adequate in all but two patients in whom supplemental local infiltration was used. One-third of the patients experienced unilateral lower extremity numbness following the pudendal block. Symptoms had completely subsided approximately 20 minutes after the procedure, and there were no sequelae. The average length of time of the procedure was 25 minutes. All patients were discharged from the ED within 30 minutes of completion of the procedure. In all patients examined one week postoperatively, the residual pouch had shrunk to less than half its original size and the apertures were patent. There have been no problems with bleeding, infection, pain or dyspareunia. In a follow-up survey, no recurrent cysts were reported. This problem can be treated safely in the ED with good results.

[Microsurgical therapy of lymphedema of the external female genitalia]

Lymphedema of female external genitalia is an uncommon disorder, for which ablative treatment procedures have been used in the past. Such an operation is most traumatic and achieved unsatisfactory results. On the basis of our experiences in treating lymphedema of the extremities by lymphaticovenous anastomosis, the author developed a microlymphaticovenous operation for treating this condition. From March 1980 to November 1984, a total of 6 patients with lymphedema of female external genitalia were operated and good results were achieved. The edema of the vulva, clitoris, mons veneris and of the lower part of the abdominal wall has been reduced, the chylorrhea disappeared and the blisters on the edematous vulva vanished. On the basis of our clinical experiences in treating lymphedema of female external genitalia by microlymphaticovenous anastomoses, we believe, that the anastomoses should be performed early and their number should be sufficiently high. The indication, types of procedures and advantages of the operation are presented.

Vulvar dystrophies: an evaluation

Of 86 patients diagnosed as having vulvar dystrophy in a 10-year period 56 (65.1%) had hyperplastic dystrophy, 23 (26.7%) had lichen sclerosus and 7 (26.7%) had mixed vulvar dystrophy. The diagnoses were made by colposcopic or toluidine blue directed biopsies. Fluorinated corticosteroids were given to patients with hyperplastic dystrophy with a response rate of 90.1%. Patients with lichen sclerosus received topical testosterone propionate and the response rate was 87.7%. Topical fluorinated corticosteroids followed by testosterone propionate was given to patients with mixed dystrophy and 85.8% of the patients responded. Surgical therapy was reserved for patients with failed medical treatment.

A new surgical technique to treat refractory labial fusion in the elderly

An elderly woman with refractory labial fusion was treated by labial separation. The subsequent raw area was covered by a rotational skin flap from the thigh. The flap was deroofed of epithelium proximally and tunnelled subcutaneously. The distal portion emerged to cover the raw clitoral area and this successfully prevented contraction and scarring.

Plastic repair of elongated, hypertrophic labia minora. A case report

In a woman with elongated, hypertrophic labia minora resulting from the childhood administration of androgenic medication, plastic surgical repair corrected the problem.

Pediatric office procedures

The practice of pediatric urology has changed much during the last 25 years. Procedures that were once done only on inpatients are now done as ambulatory cases, comprising more than 60 per cent of all surgery. This trend has continued, with even more cases being done as office procedures. These consist of circumcision, meatotomy for stenosis, lysis of labial adhesions, and meatal dilatation after hypospadias repair. If an operation is done with attention to detail, it can be completed with minimal complications, although, as evidenced with circumcision, those that do occur can carry significant morbidity and even cause death. The primary limiting factor for performing procedures in the office is the comfort of the patient. The procedure, by necessity, has to entail minimum pain and great ease in obtaining hemostasis and requires a cooperative patient and family. Therefore, even as the number of operations performed on an out-patient basis increases, there are a finite number of cases suitable for the office.

Incomplete Behcet's syndrome in the differential diagnosis of genital ulceration and postcoital bleeding. A case report

Behcet's syndrome occasionally produces significant vaginal bleeding requiring operative intervention. Our patient had genital and oral ulcerations but did not have uveitis or iritis, therefore representing incomplete Behcet's syndrome. The oral and genital lesions associated with Behcet's syndrome resemble those produced by herpes infection and must be considered in the differential diagnosis of genital ulceration.

Surgical wound drainage: a survey of practices among gynaecologists in the British Isles

All 2836 members and fellows of the Royal College of Obstetricians and Gynaecologists were circulated with a questionnaire concerning their practices with regard to wound drainage. The overall response rate was 43%, although that from practitioners of consultant and senior registrar status was 67%. The use of wound drainage was consistent between surgeons of differing levels of experience and different subspecialty interests within gynaecology. At routine 'clean' operations the use of drains is limited; only 0.4% of gynaecologists drain the peritoneal cavity, 1% the pelvis, 4% the subcutaneous tissues, and 20% the rectus sheath routinely. At more specialist 'clean' procedures, however, greater use of drains is made; at suprapubic incontinence operations 51% of surgeons drain the retropubic space; at radical hysterectomy 55% drain the pelvis; and at radical vulvectomy 63% use drains in the groins, routinely. In all the above operations much greater use is made of active (83%) than passive drains (17%). With potentially contaminated wounds, however, 46% of gynaecologists use a passive drain.

Crohn's disease of the vulva

We have reported a case of Crohn's disease of the vulva, an unusual manifestation of inflammatory bowel disease. The initial management of this condition should be medical, using antibiotics and established regimens to control gastrointestinal symptoms. Surgical therapy is appropriate when medical management fails, as it did in our patient.

Labial agglutination secondary to a herpes simplex II infection

A case is described of a young woman with labial agglutination secondary to a herpes simplex II infection that was successfully treated with laser vaporization.

International dermatosurgery: reconstructive treatment of the vulva--a new procedure: experience on 23 cases over 4 years

The postvulvectomy reconstruction caused the authors diverse problems in the first three operations. The use of a bipedicle advancement flap obtained from the anterointernal region of the thigh, modified depending on the extension of the vulvectomy and the elasticity of the skin allow us to suggest the use of this technique due to its safeness, the facility with which it is carried out, and reduction of the hospital stay, as this makes the method socially economical.

Labial adhesions in a postpartum patient

The occurrence of labial adhesions in a patient in the immediate postpartum period is described. The adhesions did not respond to topical estrogen therapy, and sharp separation was required. Factors related to possible etiology as well as management of this condition are discussed.

Treatment of cutaneous vulvar lesions with skinning vulvectomy

A skinning vulvectomy and split-thickness skin graft were used in the management of four women with benign vulvar disease after the failure of standard medical and surgical therapy. Three women remain free of the primary disease process, with a follow-up of 12-36 months. One woman with lichen sclerosus and another with "diffuse atrophy" developed recurrent disease in their skin grafts 45 and 96 months, respectively, after skinning vulvectomy. Symptomatic improvement was achieved subsequently in both women with the topical application of testosterone.

Nodular cutaneous amyloidosis involving the vulva. Case report and literature review

A case of localized nodular cutaneous amyloidosis involving the vulva occurred in a 53-year-old woman. This rare type of cutaneous amyloidosis has been reported in the female genitalia in two prior cases. The unusual aspects of our case were (1) recurrence after six years, (2) an ulcerative appearance clinically simulating a malignant neoplasm, and (3) the presence of numerous Russell bodies. Our histopathologic findings in hematoxylin-eosin-and peroxidase-antiperoxidase-stained sections support the concept of immunoglobulin light chain derivation.

Phimosis of the prepuce of the clitoris: indication for female circumcision

Images

The vestibule

The vestibule, or introitus, is a unique area in the lower genital canal. Of major importance is the understanding of the embryology of the area if the lesions are to be interpreted adequately. It is a "collision zone" formed at the junction of different germ layers. The newly recognized syndrome of severe dyspareunia caused by inflammation of the minor vestibular glands affects many women. At present, ablative therapy is all that can be offered to these patients. While excisional surgery is highly successful, medical therapy awaits the elucidation of the true cause of this disorder. Vestibular mucous cysts and vestibular papillae are common benign conditions which must be recognized as such, lest inappropriate therapy be recommended.

The carbon dioxide laser in the treatment of vulvar disease

Our review of the current use of the carbon dioxide laser in treating vulvar disease reveals that it holds significant promise in the treatment of vulvar intraepithelial carcinoma, condylomata acuminata, and focal vestibular adenitis. The long-range results of such treatment, however, are not yet known. Until sufficient data are accumulated to demonstrate the efficacy of the laser in treating the vulvar dystrophies and herpes genitalis, it should be used with caution, and the results should be carefully evaluated and reported.

Management of Bartholin duct cysts with the carbon dioxide laser

Fourteen women with Bartholin duct cysts were treated by creating a neostoma with the carbon dioxide laser at the time of cyst drainage. No catheters, packs, or other materials were left in the treated gland. All but one patient were treated in the author's office under local anesthesia. All patients were managed using the same operative technique. Twelve of the 14 patients required only one treatment. One patient required three operations and another two procedures. General anesthesia was necessary in only one patient. All patients conformed to long-term follow-up. All patients are now free of disease and apparently have normal glandular function. It is concluded that this technique, when used in selected patients, may offer benefits over conventional approaches and has little or no morbidity.

[Vulvoperineoplasty]

Vulvoperineoplasty is a surgical operation consisting of: (1) wide cleavage of the posterior vaginal wall, as in posterior colpoperineorrhaphy; (2) excision of a triangular segment of perineal skin, the summit of which touches the margin of the anus; (3) full exposure of the perineal central fibrous core and reduction of its relief by radial incisions and digital dissection; (4) lowering and eversion of a posterior vaginal flap with good blood supply in order to reconstruct the fourchette of the enlarged vaginal opening. This technique is applicable not only to congenital or acquired vulvar stenosis but also to the treatment of sclerous or dystrophic lesions of the fourchette. It was used on 43 occasions between 1978 and 1983, viz. in 6 patients after surgical treatment of prolapse, in 14 patients after obstetrical injury, in 17 cases of lichen sclerosus of the vulva and in 6 cases of Bowen's disease. The results were anatomically perfect in all cases, cosmetically good in 40 cases and functionally satisfactory in 40.

Amniotic membranes as a temporary wound dressing in necrotizing fasciitis

A diabetic patient was seen at Magee-Womens Hospital with a vulvar abscess extending to the abdomen. Necrotizing fasciitis was diagnosed at operation, and the involved tissue was widely excised. The authors describe the successful use of amniotic membranes as a temporary wound dressing. The benefits of this method over conventional gauze dressings are easy availability, better adherence to the wound, less pain, and negligible cost to the patient.

[Laser therapy in gynecology]

Laser therapy is being implemented with increasing frequency in medicine. Carbon dioxide laser is the system most commonly used in gynaecology and the main indications are disease of the uterine cervix, vagina, vulva or perineum. When used in conjunction with the microscope or laparoscope during reconstructive operations on the adnexa, laser speeds up the surgical procedure and brings out the inherent advantages of this technique, namely, precise separation or destruction of tissue, absence of postoperative oedema, uncomplicated wound healing, minimal mechanical trauma, decreased postoperative pain and good haemostasis. With good maintenance and practice laser systems all work well. The only disadvantage is their high cost.

Necrotizing fasciitis of vulvar origin in diabetic patients

Necrotizing fasciitis is a rare, rapidly progressive, and often fatal infection of the superficial fascia and subcutaneous tissues. The integrity of the deep muscle fascia is usually not breeched, thus limiting the depth of involvement. Centrifugal spread within the planes of the superficial fascia and subcutaneous tissues is characteristic. Patients with diabetes mellitus constitute the group most vulnerable to necrotizing fasciitis, and a vulvar or perineal origin is associated with particularly high mortality. The authors report four such patients. Other apparent predisposing factors are advancing age, peripheral vascular disease, chronic debilitating illness, malnutrition, and possibly other states predisposing patients to immunodeficiency. None of these factors is an absolute prerequisite to the development of necrotizing fasciitis.

Warty dyskeratoma of the vulva

Suprabasal acantholysis of the epidermis is a histopathologic common denominator of diverse conditions such as pemphigus vulgaris, benign familial pemphigus (Hailey-Hailey), transient acantholytic dermatosis (Grover's disease), some actinic keratoses and cutaneous squamous carcinomas, keratosis follicularis (Darier's disease [DD]), and warty dyskeratoma (WD). Of these, WD rarely occurs in the vulva and is indistinguishable histologically from DD. However, DD is an inherited dermatosis (autosomal dominant) consisting of multiple keratotic papules on the face, trunk, and extremities, while WD occurs as an isolated, noninherited, single keratotic nodule mainly confined to the head and neck. We had the opportunity to study three patients who presented with isolated WD in the vulva. These patients had no other skin lesions and had no family history of DD or multiple dermatologic papulonodules. Histologically, all three vulvar lesions were indistinguishable from classic head and neck WD. WD must be clinically and histologically differentiated from vulvar dysplasia, bowenoid papulosis, squamous carcinoma, condyloma, and other viral-induced squamous lesions. WD should be added to the list of recognizable vulvar squamous lesions.

[Electronmicroscopic investigations of lichen sclerosus et atrophicus of the vulva after cryosurgery (author's transl)]

A female with lichen sclerosus et atrophicus of the vulva, which had been treated by intralesional corticosteroid injection and vulvectomy showed again a recurrence of the disease. This time the lesion was treated by cryosurgery. The diseased tissue was investigated by electronmicroscopy during the consecutive phases of the procedure of cryosurgery.

Complications associated with carbon dioxide laser surgery in gynecology

Complications associated with the use of the carbon dioxide laser in 624 gynecologic patients are presented. Bleeding and pain were the most common side effects of this new modality. Although bleeding occurred in 63 patients, it was considered minor, i.e., requiring no treatment in 56 women. Pain was rather mild and could be dealt with easily by allowing heat buildup to dissipate. Only one laser accident was observed in the entire series. Interestingly, scar formation, e.g., cervical stenosis, was essentially nonexistent. Similarly, no infections were reported. The carbon dioxide laser compares favorably to conventional treatment methods insofar as complications are concerned; however, if future complications are to be avoided, careful training in CO2 laser technology must precede clinical use of the instrument.