Benefit and safety of 28-day transdermal estrogen regiment during vaginal hysterectomy (a controlled trial)

Presentation and Management of Postpartum Granulation Tissue: A Single-Institution Retrospective Study

INTRODUCTION

Although the development of postpartum granulation tissue (PPGT) is an expected phase of healing of perineal and vaginal lacerations, the persistence of this tissue can result in delayed wound healing, pain, bleeding, and discharge. There is a paucity of information on the efficacy of the treatments used for pathologic PPGT. The objective of this study was to describe characteristics associated with the development of PPGT and the treatment methods currently used for management.

METHODS

This was a retrospective cohort study of 140 patients diagnosed with PPGT within one year of birth from 2012 through 2022 within a single health care system. Patients were identified by International Classification of Diseases and Current Procedural Terminology codes. Demographics, birth characteristics, symptoms, and treatment information were obtained and assessed in frequencies and means. Treatments were compared with 95% CIs and P values. Time to resolution was assessed by the number of weeks and the number of visits.

RESULTS

It was the first vaginal birth for 129 (92%) patients in the study cohort. The majority (84.3%) of patients presented with pain. Almost half of all patients (45%) were diagnosed after 6 weeks postpartum. 30.0% of patients were initially treated conservatively. 76.4% of patients were treated with silver nitrate, and 33.6% had an excisional procedure. Successful conservative management had the lowest average number of visits to resolution with 1.39 visits (95% CI, 1.15-1.69), followed by silver nitrate alone with 1.95 visits (95% CI, 1.73-2.19), and excision with or without silver nitrate with 2.40 visits (95% CI, 2.07-2.78). Conservative management was unsuccessful 45% of the time, requiring additional treatment with silver nitrate or excision. 30% of patients treated with silver nitrate or excision continued to report pain even after the resolution of granulation tissue upon examination.

CONCLUSION

PPGT is commonly associated with first vaginal births, often presents beyond 6 weeks postpartum, and frequently requires treatment.

Endometrial safety of low-dose vaginal estrogens in menopausal women: a systematic evidence review

OBJECTIVE

The aim of the study was to systematically review studies that evaluated endometrial hyperplasia or cancer incidence with unopposed vaginal estrogens.

METHODS

PubMed and EMBASE were searched from inception to August 2017 for relevant articles and abstracts. Bibliographies of review articles and abstracts of major women's health medical meetings were examined. Eligible studies (independently reviewed by 4 authors) had to report menopausal vaginal estrogen use and endometrial histology, or incidence of endometrial hyperplasia or cancer.

RESULTS

Of 5,593 abstracts from the literature search and 47 articles from other sources, 36 articles and 2 abstracts were eligible, describing 20 randomized controlled studies, 8 interventional studies, and 10 observational studies. Collectively, the studies did not support an increased risk of endometrial hyperplasia or cancer with low-dose vaginal estrogens. Rates of endometrial cancer and hyperplasia were 0.03% and 0.4%, respectively, from 20 randomized controlled trials (2,983 women) of vaginal estrogens. Overall, reports of endometrial hyperplasia were observed with various doses and durations and appeared sporadic (except 1.25 mg conjugated equine estrogens), consistent with endometrial hyperplasia rates in the general population. A Denmark registry study was an exception and may be of limited applicability to the United States. The Women's Health Initiative Observational Study showed no association (1.3 cases/1,000 women-years with vaginal estrogens versus 1.0/1,000 women-years for nonuse).

CONCLUSION

This systematic review supports the use of low-dose vaginal estrogens for treating vulvar and vaginal atrophy in menopausal women without a concomitant progestogen. This review does not support increased endometrial hyperplasia or cancer risk with low-dose, unopposed vaginal estrogens; however, longer-term, real-world data are needed.

Delayed postcoital vaginal cuff dehiscence with small bowel evisceration after robotic-assisted staging surgery

OBJECTIVE

We report a rare case of vaginal cuff dehiscence with small bowel evisceration at 7 months post robotic-staging surgery.

CASE REPORT

A 41-year-old woman was sent to the emergency room with sudden onset of abdominal pain, vaginal bleeding, and vaginal protruding mass after sexual activity. She had a history of synchronous uterine and ovarian cancer treated with robotic-staging surgery 7 months before. Then she received six courses of postoperative adjuvant chemotherapy, and the last chemotherapy ended 1 month ago. At the operation room, some small bowel loops were noted in the vaginal tip with cuff dehiscence and bleeding. After repositioning of the small bowel, a 2.5-cm vaginal cuff dehiscence was repaired transvaginally. The patient recovered well, and is free of disease and has normal sexual activity 2 months after repairs.

CONCLUSION

Unusual delayed-type vaginal cuff dehiscence hints the possibility that a combination of robotic surgery and postoperative chemotherapy might result in delayed healing of the vaginal cuff.

Treatment of vaginal cuff evisceration

BACKGROUND

Laparoscopic and robotic-assisted hysterectomies are associated with higher rates of vaginal cuff dehiscence and evisceration than are open and vaginal hysterectomies. With the rising prevalence of minimally invasive hysterectomy, gynecologists should know how to manage this rare but potentially serious condition. Urgent laparotomy historically was recommended for management of vaginal cuff evisceration to allow for complete bowel evaluation. More recently, successful outcomes using a less-invasive vaginal or combined vaginal and laparoscopic approach have been reported.

TECHNIQUE

Patients are selected for transvaginal repair of vaginal cuff evisceration if there is no clinical evidence of peritonitis or ischemic injury to the prolapsed bowel segment. Under general anesthesia and after administration of intravenous antibiotics, the bowel is copiously irrigated and replaced into the abdomen. The vaginal cuff is sharply debrided of any necrotic tissue, and a full-thickness closure is performed using a delayed absorbable monofilament suture.

EXPERIENCE

We have successfully managed four cases of vaginal cuff evisceration through a transvaginal approach without intraoperative or postoperative complications.

CONCLUSION

Vaginal cuff dehiscence and evisceration can be treated by transvaginal bowel reduction and cuff closure when the bowel appears uninjured and there are no signs of peritonitis.

Vaginal vault dehiscence after laparoscopic hysterectomy over a nine-year period at Sydney West Advanced Pelvic Surgery Unit - our experiences and current understanding of vaginal vault dehiscence

BACKGROUND

A retrospective analysis of all women undergoing hysterectomy at Sydney West Advanced Pelvic Surgery Unit (SWAPS) was performed in the nine-year period from 2001 to 2009.

AIMS

To evaluate the incidence, timing and presenting symptoms of vaginal vault dehiscence after hysterectomy, especially via the laparoscopic approach to gain further understanding of patient risk factors and surgical factors that may predispose to this complication.

METHODS

Women who presented with vaginal vault dehiscence were identified and possible pre-operative, intra-operative and post-operative risk factors were assessed. A comprehensive literature search was performed to assess the current understanding and incidence of vault dehiscence after laparoscopic hysterectomy.

RESULTS

A total of 1224 hysterectomies were performed between 2001 and 2009. 989 (80.80%) were performed laparoscopically of which five women (0.42%) presented with vault dehiscence post-operatively. All had undergone total laparoscopic hysterectomy resulting in a vault dehiscence rate of 1.59% after total laparoscopic hysterectomy specifically. Baseline characteristics included a mean age of 42.8 years (37-51 years), mean BMI of 26.8 kg/m(2) (23.8-32.3 kg/m(2)) and a mean parity of two deliveries (1-3 deliveries). The main presenting symptom of vaginal vault dehiscence was vaginal bleeding. Women with confirmed vaginal vault dehiscence readmitted to hospital at a mean of 18 days (11-28 days) post-operatively.

CONCLUSION

Vaginal vault dehiscence is a rare complication after hysterectomy, but more common after a laparoscopic approach. A delayed presentation with vaginal bleeding was the main presenting symptom in this study - a literature review has shown common presenting symptoms to include abdominal pain, vaginal evisceration and vaginal bleeding. Techniques specific to total laparoscopic hysterectomy seem especially important in the increased risk of vaginal vault dehiscence seen after laparoscopic hysterectomy.