Técnicas obliterativas en el tratamiento quirúrgico del prolapso genital femenino: experiencia en el Servicio de Salud Metropolitano Oriente, Santiago-Chile / Obliterative techniques in the surgical treatment of female genital prolapse: experience in the Metropolitan Health Service Oriente, Santiago-Chile

INTRODUCCIÓN Y OBJETIVOS: El prolapso genital afecta hasta al 50% de las mujeres a nivel mundial, su calidad de vida, percepción corporal y vida sexual. A las pacientes de edad avanzada frecuentemente les ofrecemos técnicas quirúrgicas obliterativas para su manejo. El objetivo fue evaluar los resultados de las técnicas obliterativas basados en nuestra experiencia local. MÉTODOS: análisis retrospectivo de pacientes tratadas con técnicas obliterativas en nuestro hospital entre los años 2008 y 2016. RESULTADOS: se incluyeron 78 pacientes, la edad promedio fue de 74.5 años, 11.5% de las pacientes presentaba comorbilidad de mayor riesgo quirúrgico, 24% eran pacientes histerectomizadas por prolapso y 30.8% presentaba incontinencia de orina al momento de la cirugía. El tiempo quirúrgico promedio fue 52 minutos, 73.1% de las cirugías fueron con técnica de LeFort y 5.1% presentó complicaciones postquirúrgicas precoces. Se contactaron telefónicamente 59 pacientes, 90% refirió mejor calidad de vida, 92% satisfacción con la cirugía, 3.4% recidiva del prolapso y 44% incontinencia urinaria, en su mayoría moderada o severa. La recidiva reportada estuvo acorde a lo reportado en la literatura, pero la incontinencia de orina reportada fue muy alta respecto a lo reportado y de predominio de urgencias. CONCLUSIÓN: las técnicas obliterativas son efectivas en el tratamiento quirúrgico del prolapso y el principal problema postquirúrgico a largo plazo asociado fue la incontinencia de orina de urgencias.

INTRODUCTION AND OBJECTIVES: Genital prolapse affects up to 50% of women worldwide, their quality of life, body perception and sex life. For older patients, we often offer obliterative surgical techniques to manage it. The objective was to evaluate the results of the obliterative techniques based on our local experience. METHODS: retrospective analysis of patients treated with obliterative techniques in our hospital between 2008 y 2016. RESULTS: 78 patients were included, with an average age of 74.5 years, 11.5% of the patients had comorbidities of high surgical risk, 24% were previously hysterectomized because of genital prolapse and 30.8% had urinary incontinence at the time of the surgery. Average surgical time was 52 minutes, 73.1% of the surgeries were performed with the LeFort technique and 5.1% presented early postoperative complications. 59 patients were contacted by telephone, 90% reported better quality of life, 92% were satisfied with the surgery, 3.4% had recurrence of the prolapse and 44% reported urinary incontinence, mostly moderate or severe. The reported relapse was in line with what was reported in the literature, but the reported urinary incontinence was very high compared to what was reported, and was predominantly urge incontinence. CONCLUSION: obliterative techniques are effective in the surgical treatment of genital prolapse and the main long term problem after surgery was urge incontinence.

Use of indocyanine green angiography in microsurgical subinguinal varicocelectomy - lessons learned from our initial experience

ABSTRACT Microsurgical subinguinal varicocelectomy (MSV) is generally considered the gold standard nowadays in view of the lower risk of complications and recurrence. To achieve complete ligation of veins while preserving testicular artery (TA) during the procedure remains challenging despite the application of high power optical magnification and micro-Doppler ultrasonography. The use of intraoperative indocyanine green angiography (ICGA) with infrared fluorescence operative micro-scope in MSV potentially lowers the incidence of TA injury and shortens the learning curve of novice surgeons. We present our initial experience in the application of the technique in nine patients and explore the potential of the new adjunct.

Cirugía laparoscópica de la fístula vesico-vaginal: resultados de una experiencia multi-institucional / Laparoscopic surgery of vesicovaginal fistula: results of a multi institutional experience

Introduction: vesico-vaginal fistula is a rare complication of gynecologic surgery, with a high rate of surgical resolution O'Conor open technique. Aim: to report the results of a multi-institutional experience in laparoscopic repair of vesico-vaginal fistula. Material and Methods: between january 2006 and june 2011, 21 laparoscopic vesico-vaginal fistula were performed. The surgical technique, demographic variables and results are described. Results: the mean age was 45.6 years. The average time between the diagnosis of the fistula and the laparoscopic repair was 15.23 months. The mean total operative time (bladder and laparoscopic) was 153.12 minutes and the average hospital stay was 2.7 days. The average time of bladder catheter was 9.4 days. There was a minimal recurrence of a fistula, repaired by a vaginal approach. Urethrocystography revealed indemnity of the repair in the other 20 cases. The overall success rate was 95.2 percent (20 out of 21 patients) Conclusions: the laparoscopic approach follows all principles for repair of a vesico-vaginal fistulas. It look like a good alternative in the hands of experienced surgeons.

Introducción: la fístula vesico-vaginal es una complicación infrecuente de la cirugía ginecológica, con alta tasa de resolución quirúrgica con la técnica abierta tradicional de O'Conor. Objetivo: comunicar los resultados de una experiencia multi-institucional en la reparación laparoscópica de las fístulas vesico-vaginales. Material y Método: entre enero de 2006 y junio de 2011 se realizaron 21 reparaciones de fístulas vesico-vaginales por vía laparoscópica. Se describe la técnica quirúrgica y se analizan las variables demográficas, quirúrgicas y resultados de la serie. Resultados: la edad media de las pacientes fue de 45,6 años. El tiempo promedio transcurrido entre el diagnóstico de la fistula y su reparación laparoscópica fue de 15,23 meses. El tiempo quirúrgico medio total (vesical y laparoscópico) fue de 153,12 min y el de hospitalización 2,7 días. El tiempo promedio de catéter uretro-vesical fue de 9,4 días. Hubo una mínima recidiva de una fístula, la cual fue reparada por vía vaginal. El control radiológico mediante cistografía reveló indemnidad de la reparación en el resto de los casos. La tasa global de éxito fue de 95,2 por ciento (20 de 21 pacientes) Conclusiones: el abordaje laparoscópico permite cumplir con todos los principios para la reparación de las fístulas vesico-vaginales. La reducción de la morbilidad y la eficacia del procedimiento, lo transforman en una excelente alternativa en manos de cirujanos experimentados.

Sling uretral pubovaginal e cirurgia de controle de danos / Pubovaginal sling urethral and surgery damage control

O sling pubovaginal tem sido empregado no tratamento da incontinência urinária de esforço, tanto do tipo deficiência esfincteriana intrínseca como dos tipos anatômica e associada. Complicações ao procedimento são frequentes, porém, simples e transitórias. Os autores relatam um caso de lesão de vasos pélvicos transoperatória (sling pubovaginal), sendo necessária a cirurgia de controle de danos.

The pubovaginal sling is currently being used not only for stress urinary incontinence (SUI) type III as well as for we other types of SUI. The complications are frequent, in general not serious and transitory. The authors report the case of bleeding venous origin, from the fossa of the obturator nerve, the iliac plexus and presacral plexus and necessary the damage control.

Inguinal optic loupe varicocelectomy

Microsurgical loupe inguinal varicocelectomy has been associated with relatively high success rates and minimal postoperative complications. The aim of this study is to analyze the results of a group of patients who underwent inguinal microsurgical varicocelectomy using optic loupe magnifications. From April 2003 to April 2007, 72 patients underwent loupe-assisted inguinal varicocelectomy. In 68 patients [94.3%][the varicoceles were left sided, in 1 patient [1.3%] it was right sided and they were bilateral in 3 patients [4.1%]. The mean age was 26.9 years [range: 16.42]. Fifty four patients [75%] were infertile and 18 patients [25%] had painful scrotal sensation, in 6 of them oligoasthenospermia [OAT] was detected. The diagnosis was based on clinical features namely testicular pain and, or scrotal hypersensation and physical examination. Color duplex ultrasonogrphy [CDUS] was performed in persistent cases. The majority of varicoceles were stage II and III, of them 5 [6.9%] were persistent cases. In 10 patients [13.9] OAT was mild [sperm number 10-20 millions], In 30 patients [41.6%] was moderate [5.10 millions] and in 18 [25%] was severe [less than 5 millions]. Azoospermia was detected in 2 patients [2.7%]. Furthermore, 12 patients [16.6%] had normal spermiogram. The loupe-assisted microsurgical inguinal "artery-and lymphatic-sparing" technique of dissection was performed under general anesthesia. All operations were performed as outpatient procedures [postoperative stay 3.7 hours] and the mean operating time was 45 minutes [30.55]. Follow up was performed by physical examination and semen analysis. Color duplex ultrasonogrpahy [CDUS] was done only if persistence was suspected. Immediate and long-term complications were hydrocele in 1 patient [1.3%], palpable persistence in 4 patients [5.2%] and found abscess in 1 patient [1.3%]. Forty four out of sixty [73.3%] patients showed an improvement of semen analysis and from the 30 patients who continued follow up, 14 [47%] have conception. Finally 6 out of 18 patients [33.3%] who presented with scrotal pain have their pain disappeared. Loupe-assisted inguinal varico-celectomy is a safe and effective method. It preserves spermatic artery and lymphatics and minimizes the risk of complications and persistence. In our experience this technique of varicocelectomy showed an improvement of semen analysis and the results are comparable to those obtained by the standard microsurgical technique using the microscope

Aspectos citológicos, histológicos e morfológicos de neovaginas de mulheres e transmulleres / Cytological, histological and morphological aspects of women and transwomen

O estudo das neovaginas em mulheres e principalmente em transexuais masculinos operados inclui pequeno número de casos e conta com pouco detalhamento sobre o assunto. Algumas perguntas ainda estão por ser respondidas: é necessária a colpocitologia oncoparasitária? Se necessária, em que espaço de tempo? Devemos nos preocupar com a infecção pelo HPV? Quanto tempo é necessário para haver a completa metaplasia do epitélio utilizado? A flora bacteriana é semelhante? Com o objetivo de chamar a atenção para o tema, realizamos uma revisão bibliográfica, abordando aspectos cirúrgicos, oncocitopatológicos, histológicos e morfológicos de neovaginas de mulheres biológicas e transmulheres (transexuais masculinos).

The neovagina studies in women and mainly in operated male transsexuals (transwomen) are few and with few cases specified. Their follow-up is also difficult. Some questions have not been answered yet: is the oncologic colpocytology necessary? If it is necessary, what would the best time to do it? Shall we be worried about HPV infection? What is the necessary time to completely metaplasia? Is the bacterial flora similar? With the purpose of calling attention to this subject, we made a bibliography revision approaching cytological, histological and morphologic aspects of women and transwomen neovaginas (male-to-female transsexual).

Manejo do prolapso de cúpula vaginal / Management of the vaginal vault prolapse

O prolapso de cúpula vaginal é uma das situações mais desafiadoras para o cirurgião pélvico reconstrutor. Numerosos procedimentos têm sido descritos para o reparo do prolapso apical, seja por via vaginal ou abdominal, mas dados conflitantes em relação ao melhor procedimento cirúrgico ainda existem. A literatura está repleta de séries cirúrgicas relatando diferentes taxas de sucesso e complicações, mas poucos estudos randomizados comparando as diferentes técnicas estão disponíveis. O cirurgião deve ser versátil e flexível na escolha do acesso cirúrgico e deve estar apto a oferecer às pacientes uma variedade de opções cirúrgicas, uma vez que elas tendem a apresentar diferentes eficácias e complicações. É importante adequar o reparo à anatomia e aos objetivos funcionais e pessoais de cada mulher, a fim de individualizar apropriadamente o tratamento. Este manuscrito revisa aspectos relacionados ao tratamento dessa enfermidade, com ênfase às técnicas cirúrgicas.

Minitipóia com enxerto autógeno de mucosa vaginal para tratamento cirúrgico da incontinência urinária de esforço / Mini-sling with autogenous graft of vaginal mucous membrane for surgical treatment of stress urinary incontinence

O polipropileno monofilamentar, produto derivado do gás propano, comercializado como tela de Márlex, tem sido o tipo de prótese mais utilizada em nosso meio para correção dos defeitos herniários da parede abdominal. O produto estimula o crescimento de fibroblastos e essa fibroplasia induzida é a principal responsável pelo reforço desejado. Desde a década de 90, esse mesmo material, vem sendo utilizado também para o tratamento cirúrgico da incontinência urinária de esforço por varias técnicas. Dentre elas, uma utiliza instrumental que limita o uso aos ginecologistas e apresenta complicações, além do risco de infecção e erosão, que são complicações inerentes ao uso das telas. Tecidos autógenos como fascia lata e mucosa vaginal têm sido utilizados, mas com transfixação dos fios de sutura para via suprapúbica. Uma forma de se evitar os inconvenientes dessa via de acesso é a fixação do retalho de mucosa da vagina aos ligamentos pubovesicouretral por via baixa.

Tratamento cirúrgico do prolapso da parede vaginal anterior através da técnica de sling transobturatório / Surgical treatment of the anterior vaginal wall prolapse by the transobturator sling technique

A abordagem cirúrgica do prolapso genital, particularmente da parede vaginal anterior (cistocele), é realizada classicamente através de técnicas que envolvem tecidos pouco resistentes e suscetíveis à recidiva precoce, como a colporrafia anterior. Os princípios da biocirurgia introduzem o conceito de biomateriais para reforço tecidual, visando uma abordagem minimamente invasiva e resultados duradouros. Utilizando-se a via transobturatória, inicia-se por incisão da parede vaginal anterior seguida de dissecção lateral até o ramo ísquio-púbico. Após introdução das agulhas inferiores e superiores, coloca-se uma tela para correção do defeito vaginal central e quatro hastes auto-fixáveis para correção do defeito lateral, fazendo ajuste sem tensão. A correção transobturatória do prolapso da parede vaginal anterior é uma alternativa segura e de caracter minimamente invasivo para o tratamento do prolapso vaginal anterior, com significativa redução dos riscos de complicações intra e pós-operatória. Futuramente, havendo os bons resultados a longo prazo, poderá ser considerada opção de rotina nestes casos

TVT (cinta vaginal libre de tensión) nuevo tratamiento para la incontinencia urinaria de esfuerzo: experiencia en el Hospital Patrocinio Peñuela Ruíz / TVT (vaginal type free of tension) new treatment for the incontinence urinaria of effort: experience in the Hospital Patrocinio Peñuela Ruíz

Descripción de la técnica quirúrgica y evaluación en nuestra casuística del tratamiento de la incontinencia urinaria de esfuerzo con cinta vaginal libre de tensión (TVT). Se realizo una revisión de la literatura acerca de este nuevo método. Se revisaron las historias de las pacientes sometidas a este procedimiento en el Hospital Patrocinio Peñuela Ruíz, recolectando datos en tablas para la evaluación y análisis de la misma. Se encontraron un total de 14 casos, con un promedio de edad de 50 años. Se presentaron (2) casos de perforación de vejiga (14,2 por ciento), dos (2) casos presentaron retención urinaria en el postoperatorio inmediato (14,2 por ciento). La tasa de curación subjetiva fue de 81,8 por ciento. La mayoría de los casos fueron intervenidos en forma ambulatoria. Los resultados obtenidos son equiparables con los publicados en otras series. Concluimos se trata de una técnica sencilla, de fácil aprendizaje, con tiempo quirúrgico corto y corta estancia postoperatoria, siendo así una buena elección en el tratamiento de la incontinencia urinaria de esfuerzo.

IVS posterior (posterior intravaginal slingplasty) para el tratamiento de prolapso de cúpula vaginal o procidencia de útero: serie de casos / Posterior IVS (posterior intravaginal slingplasty) for the treatment of vaginal vault prolapse: case series

Presentamos una serie de casos de pacientes con prolapso de cúpula vaginal post histerectomía o procidencia de útero, tratadas quirúrgicamente con técnica de IVS posterior (Posterior Intravaginal Slingplasty), también llamada sacropexia infracoccígea. Se analiza la técnica, indicaciones y resultados.

Técnica de Mathieu para la corrección del hipospadias distal en niños / Mathieu technique for correction of distal hypospadias in children

Introducción: el hipospadias es una alteración en la formación de la uretra en la que el meato urinario queda en una posición anormal en la parte ventral del pene. Se presenta en uno de cada 300 nacidos vivos, la localización distal es la más frecuente (70 por ciento). Para su corrección quirúrgica existen diversas técnicas basadas en la utilización de colgajos. Material y método: se incluyeron los casos de hipospadias distal, operados de febrero de 1979 a febrero de 1997, mediante la técnica de Mathieu, considerando como variables el tipo de hipospadias, tratamiento hormonal, complicaciones y tratamiento antibiótico, así como resultado funcional y estético. Resultados: se incluyó en el estudio un total de 61 pacientes, 44 con hipospadias subcoronal (72.1 por ciento), 14 con hipospadias coronal (22.9 por ciento) y tres con hipospadias glandular (4.9 por ciento). Se identificaron nueve casos de estenosis. De las estenosis, (83.1 por ciento) fue en la base y el restante entre la base y el meato. Hubo 18 casos con fístulas, cuatro en hipospadias coronal (80 por ciento en la base) y 14 en los casos subcoronales (43 por ciento en la base). Se observaron tres casos de divertículo, todos en los casos subcoronales. Se obtuvieron buenos resultados estéticos y funcionales en más de 90 por ciento. En el análisis se encontró una frecuencia mayor de fístulas que en otras series (29 por ciento). La técnica de Mathieu representa una excelente opción para los pacientes con hipospadias distal, dado su alto porcentaje de buenos resultados estéticos y funcionales aun con las complicaciones presentadas.

Fístulas vesicovaginales / Vesicovaginal fistulas

Objetivo: mostrar nuestra experiencia en el manejo de las fístulas vesicovaginales (FVV), analizando etiología, diagnóstico, tratamiento quirúrgico y complicaciones postoperatorias. Material y método: estudio descriptivo retrospectivo de pacientes hospitalizados con diagnóstico de FVV entre enero de 1987 y diciembre de 2000. Serie constituida por 35 pacientes, edad promedio 47 años, 22,8 por ciento de cirugía reparadora previa en otro centro. Resultado: el diagnóstico fue hecho por pérdida de orina vaginal y prueba de azul de metileno vesical positiva. La cistoscopia fue concluyente en el 94,3 por ciento requiriendo uretrocistografía los casos restantes. No hubo asociación con fístulas ureterovaginales. fueron secundarias a cirugía ginecobstétrica (82,9 por ciento) y radioterapia por cáncer cervicouterino (17,1 por ciento). Se intervinieron 34 pacientes, dividiéndose en: a) FVV secundarias a cirugía ginecobstétrica: 28 reparaciones transvesicales, con 4 recidivas y 1 reparación supravesical que no recidivó. b) FVV secundaria a radioterapia por cáncer cervicouterino: 3 derivaciones urinarias (2 neovejigas continentes y 1 conducto iliar) y 2 reparaciones supravesicales, las cuales recidivaron. No hubo mortalidad operatoria en la serie. Conclusiones: todas las FVV fueron secundarias a procedimientos ginecobstétricos. Preferimos la técnica supravesical con éxito superior al 85 por ciento. La mayor dificultad está dada por las FVV secundarias a radioterapia

Neoplasias de vagina: 10 años de experiencia en el Instituto Nacional del Cáncer / Vaginal neoplasias: 10 years of experience at the Instituto Nacional del Cáncer

El cáncer de vagina es una entidad oncológica poco frecuente y a nivel mundial la casuística es pequeña. En nuestro país no existen publicaciones recientes. Se realiza una revisión retrospectiva de 10 años, en los cuales se encuentran 43 casos de neoplasias vaginales. De estas, 21 fueron preinovadoras y 22 fueron invasoras, las primeras se trataron con cirugía exclusiva con exelentes resultados y sólo un 14 por ciento recidivó a los 5 años. Los cánceres invasores se trataron con radioterapia externa exclusiva con excelentes resultados y solo un 14 por ciento recidivó a los 5 años. Los cánceres invasoras se trataron con radioterapia externa exclusiva o asociada a braquiterapia, su sobrevida fue relacionada al estadio en que se realizó el diagnóstico. La etapa I tuvo una sobrevida a cuatro años de 73 por ciento, la etapa II de 40 por ciento y las etapas III y IV tuvieron una sobrevida de 0 por ciento. Al igual que las publicaciones internacionales, la histología más frecuente de las neoplasias de vagina en nuestra revisión es la epidermoide (91 por ciento), y de éstas un 85 por ciento tenían el antecedente de una patología invasora o preinvasora de cuello uterino

Experiencia en plastía de pene con técnica de Ruiz Castañe para la enfermedad de Peyronie / Experience in penis-plasty with Ruiz Castañe technic for Peyronie's disease

Muchas técnicas quirúrgicas han sido diseñadas para la corrección de la curvatura anormal generada por la enfermedad de Peyronie. Ruiz Castañe diseña una variante de la técnica de Nesbit que permite una cirugía efectiva, simple, exangue. Se presenta la experiencia en 12 pacientes, con resultados funcionales y cosméticos muy satisfactorios al largo plazo

The current therapy of urinary calculi in Thailand.

The paper analyses the impact of modern therapy of urinary calculi in Thailand since the introduction of ESWL and endourology (PCNL and URS) in 1988. Up to then, conservative and open surgical measures had been the standard procedures. The study covers 12 medical centres in the north, northeast, south and central parts of the country between 1988 and 1997. Approximately 40 ESWL machines have been in use. ESWL was used in 66.1 per cent and 20.8 per cent of patients with renal and ureteric calculi respectively. Only 1.1 per cent of the patients had PCNL. URS was used in 20.8 per cent of patients with ureteric calculi. Open operations were required in 32.6 per cent and 53.6 per cent of patients with renal and ureteric calculi respectively. Nephrectomy was required in 4.8 per cent--16.0 per cent of patients with renal calculi. Certain considerations have been put forward to appraise the situation concerning urinary stone therapy in Thailand.

Comparison of vaginal wall sling and modified vaginal wall sling for stress urinary incontinence

CONTEXT: There are several controversies about which is the best form of surgical treatment for stress urinary incontinence in women. The vaginal wall sling in its original and modified form were presented by Raz as new options for treatment of these conditions, but there is a lack of comparative clinical trials using both techniques. OBJECTIVE: To compare the effectiveness of the original and the modified vaginal wall sling. DESIGN: A comparative, prospective, non-randomized clinical trial. SETTING: Public and private health care units (Urology Division, Faculty of Medicine of the ABC Foundation, and Universidade Federal de São Paulo / Escola Paulista de Medicina). PARTICIPANTS: Twenty patients with anatomical and intrinsic sphincter deficiency stress urinary incontinence were surgically treated for evaluating the initial results of the vaginal wall sling, from February 5, 1994, to June 27, 1996. INTERVENTIONS: The patients were divided into two groups. Group A (n = 10) were treated with the original vaginal wall sling. Group B (n = 10) were treated with the modified vaginal wall sling. Both groups were statistically similar according to clinical and urodynamic parameters. MAIN MEASUREMENTS: Cure and complication rates. RESULTS: Follow-up ranged from 19 to 43 months (median = 28) for group A. The overall cure rate was 70 percent. Fifty percent of the patients had urinary retention of 7 to 35 days. There were no major complications. Follow-up ranged from 14 to 26 months (median = 18) for Group B. The cure rate was 80 percent. Two patients had urinary retention of 7 and 55 days. There were no major complications. CONCLUSIONS: The vaginal wall sling is as effective as the modified vaginal wall sling but has a higher rate of urinary retention.

Cáncer de uretra femenino / Cancer of the female urethra

Se presentan dos casos de pacientes portadoras de cáncer de uretra, ambos carcinomas de células transicionales, en diferente etapa de propagación tumoral, presentación clínica, tratamiento y resultado final. Se comenta incidencia, principales tipos histológicos y diferentes vías de tratamiento de acuerdo a la literatura médica

Cirugía resectiva radical en el manejo de la endometriosis rectosigmoidea: caso clínico / Radical resective surgery for the management of rectosigmoidal endometriosis: clinical case

We report a 35 years old female with a profound rectosigmoidal endometriosis, who had been subjected to multiple laparoscopic procedures and open surgery due to infertility in the last five years. Main presenting symptoms were cyclic hematochezia during the menstrual periods associated to pelvic pain. Colonoscopy was inconclusive, barium enema showed a marked stenosis of the zone, appearing as an extrinsic compression. CAT scan showed a homogeneous, solid parauterine mass. During surgery, an inflammatory mass with multiple endometriotic foci was found. A low anterior resection with mechanical anastomosis was done, preserving the uterus and left adnexa. Two months later, the patient became pregnant and an elective cesarean section was done at 38 weeks of gestation, giving birth to a healthy newborn. Radical resective surgery for rectosigmoidal endometriosis is indicated in patients with intense and recurrent symptoms in whom hormonal treatment has failed and when a tumor cannot be discarded. The fertility rate, when adnexa and uterus are preserved, is 40 percent and symptomatic improvement is achieved in 85 percent of patients