Levator ani transposition for anal incompetence secondary to sphincter damage

An operative procedure is described in which the levator ani muscles are used to correct anal incompetence secondary to sphincter damage. The relevant pelvic anatomy and operative procedure are described in detail. Four patients in whom sphincter damage occurred during surgery for posterior vulvar carcinoma underwent the procedure; in 3, good sphincter function was attained. Morbidity was minimal. The transposition of the levator ani muscle to replace partially obliterated anal sphincter muscles is a suitable procedure for patients who have insufficient sphincter tissue for simpler repairs.

Adenocarcinoma of the uterine cervix

One hundred patients with primary adenocarcinoma of the uterine cervix were evaluated. Of the 48 Stage I patients, 13 were treated with radical surgery, 16 with radiation alone, and 19 with combination therapy. Life table analysis of Stage I patients showed no significant difference in survival for those treated with radical surgery or combination therapy. Both groups had a greater five-year survival (P less than 0.05) than those treated with radiation. Recurrences in Stage I were more frequent with primary radiation alone, both locally and at distant sites (P less than 0.01). Greater tumor size was related to poorer survival, and failures in patients with larger lesions were more common in those treated with radiation therapy. Survival for the 32 Stage II patients was greater for those treated with combination therapy. Higher tumor grade was associated with poorer survival for each stage, regardless of treatment. More complications were associated with radiation therapy than with radical surgery. Radiation therapy alone is not sufficient for patients with Stage I and II disease, and radical surgery may be appropriate treatment for Stage I disease.

Radical vulvectomy and bilateral inguinal lymphadenectomy through separate groin incisions

One hundred patients underwent radical vulvectomy and bilateral inguinal lymphadenectomy using separate groin incisions. Forty-nine had stage I disease, 37 stage II, and 14 stage III. Corrected actuarial 5-year survival for each stage was 97.4, 86, and 49.2%, respectively. Inguinal lymph nodes were positive in 25% of cases: 10.2% of stage I, 27% of stage II, and 71.4% of stage III cases. Major complications occurred in 21 patients, including major groin breakdown in 14. Thirty patients experienced no acute postoperative morbidity. The mean postoperative hospital stay was 19 days, and mean operative blood loss was 620 ml. No patients developed isolated metastases in either the groin or the inguinal skin bridge, but 2 stage III patients developed simultaneous metastases in the skin bridge and elsewhere. For appropriately selected patients, separate groin incisions for inguinal lymphadenectomy appear to result in lower morbidity than traditional methods, without compromising survival.

Laparoscopy for second-look evaluation in ovarian cancer

Although second-look laparotomy to ascertain primary therapeutic effect on ovarian cancer has been generally accepted, laparoscopy for this purpose has been controversial. Between 1974 and 1978, 119 consecutive laparoscopic examinations were performed on 57 patients with ovarian cancer to monitor the effect of chemotherapy or to determine disease status. Most procedures included intraperitoneal biopsy and cytologic evaluation of peritoneal washings. Seventy-three percent of the procedures were successful. Fourteen percent of the patients had major complications requiring laparotomy, most of which involved bowel perforation. Complications were significantly reduced when routine laparoscopy was preceded by needle laparoscopy. A negative laparoscopy including biopsy and cytologic evaluation was associated with a significant increase in survival when compared with the entire patient group. Repetitive laparoscopy permitted early detection of recurrence and identified patients whose risk of recurrence after 24 months was low. With each successive negative laparoscopy, the mean duration of remission was longer and the probability of recurrence lower.

Perinatal mortality in term and post-term births

The hospital records were reviewed of 64 infants born at or after 37 weeks of amenorrhea who suffered perinatal mortality during a 3-year period at Boston Hospital for Women. The most frequent cause of death of a term or post-term infant was extrinsic perinatal hypoxia, and the second most common was lethal malformation. Half the deaths of term infants occurred ante partum. Further reduction in perinatal mortality for this group may require extension of antepartum fetal monitoring techniques to all pregnancies. Intrapartum loss was rare, occurring at a rate of 0.43 per 1000 for infants delivered at term, and not at all among post-term infants. Massive aspiration of amniotic sac content was found frequently in antepartum and intrapartum death, and death from meconium aspiration occurred in neonates despite intrapartum monitoring and early suctioning of the pharynx and trachea. Asphyxiated term and post-term infants consistently pass meconium. Prevention of all deaths from meconium aspiration, thus, will require the prevention of asphyxia. A goal for obstetric care is that no fetus alive in utero at 37 weeks of amenorrhea should subsequently die in the perinatal period, provided no lethal malformation is present.

Massive exudative ascites produced from a tubal pseudocyst in chronic pelvic inflammatory disease

A case of massive exudative hemorrhagic ascites occurring as a serious complication of chronic pelvic inflammatory disease (PID) is presented. The clinical manifestations, simulating diffuse carcinomatosis in a young female patient, are described.

Anatomic and clinical correlates of uterine perforation

We reviewed cases of uterine perforations which occurred at or were referred to the Boston Hospital for Women, Lying-In Division, over the 2 year period from mid-1975 to mid-1977. There were 25 uterine perforations; twenty patients were pregnant and five were not. In the pregnant patients, 16 perforations involved the cervix or the lower uterine segment, whereas only four were located in the uterine fundus; in the nonpregnant patients, all five were fundal perforations. In the pregnant patients, 12 required laparotomy, eight had serious lacerations of the uterine artery, and three had hysterectomy while none of the nonpregnant patients had lacerations or required subsequent procedures. Thus, there is a significant anatomic difference between those perforations which occurred in the pregnant patients and in the nonpregnant patients, the manner in which they presented clinically, and the need for intervention via laparotomy, subsequent morbidity, and outcome as reflected in future reproductive capability. Perforation at or near the cervix may be more common than previously assumed. Furthermore, two distinct clinical entities of cervical perforation exist in pregnant patients as based on the anatomic location of the defect. The anatomy of cervical perforations, their recognition, and their management are discussed.

Evaluation of a balloon dilator before second-trimester abortion by vacuum curettage

We evaluated the cervical dilator device (CDD), an expanding balloon, as a substitute for laminaria tents before abortion at 13 to 16 1/2 weeks by extraction and vacuum curettage. The CDD was found to be an effective dilator, although it did not appear to have any advantage over laminaria tents when placed overnight and was associated with significant pain upon insertion and an apparent increased risk of endometritis. The present CDD or a subsequent modification may offer advantages over laminaria tents for short-term placement.

Luteomas of pregnancy

Since its original description in 1963, the pregnancy luteoma has been a controversial entity both clinically and pathologically. The most important questions which have been asked are: Is the luteoma a true neoplasm or does it represent simply an abnormal response to the hormones of pregnancy? What is the relation between the tumor and certain endocrinopathies that are associated with these lesions? This study of 20 cases collected from the files of the Emil Novak Ovarian Tumor Registry and the Pathology Section of the Baltimore City Hospitals directs its attention to these critical clinicopathologic features.