Skin flaps for the gynaecologist.

Skin flaps are becoming more frequently indicated in gynecologic surgical practice, especially in oncologic surgery. It is imperative that the gynecologic surgeon of today be well informed in the many physiologic processes of wound healing, also those factors that delay and those that promote wound healing. Knowledge of the detailed anatomy of abdomen, pelvis, vulva, peritoneum and ano-rectal area is essential. An appreciation of the specific muscular attachments, action, blood supply, collateral circulation and nerve supply are important prerequisites. Also, a working knowledge of the tissue dynamics associated with the transfer of skin, subcutaneous tissue and sometimes muscle to the required location. The important role played by vascular endothelial growth factor (VEGF), endothelial proginator cells, protein kinase C, and other factors being investigated in wound healing, is exciting. There are a number of procedures possible for most problems requiring tissue transfer. Tension free oxygenated areas for healing is essential. All the basic surgical rules for tissue handling and would healing must be carefully applied for optimum results.

Conservative surgery for recurrent or persistent carcinoma of the cervix following irradiation: is exenteration always necessary?

Between 1960 and 1988, 47 patients had conservative surgery for postradiation recurrent or persistent cervical carcinoma. Forty-two patients with nonmetastatic disease and available follow-up information were divided into 3 groups based on the extent of disease and type of surgical procedure. Group 1 contained 13 patients with smaller tumors prior to radiation (FIGO Ib and IIa), and recurrent or persistent disease confined to the cervix and/or vaginal vault. Group 2 consisted of 20 patients presenting with more advanced disease than those in Group 1, at the time of either radiation or surgery. Surgical resection of disease was accomplished in both Groups 1 and 2 by either radical vaginal or abdominal hysterectomy. The 8 patients in Group 3 required extended Wertheim operations to encompass locally advanced disease involving the bladder base and/or parametrium. One patient could not be categorized. The 5-year estimated relapse-free survivals for each group were 84, 49, and 25%, respectively. The relapse-free survival of Group 1 was significantly better (P = 0.003) than that of Group 3. Major complications occurred in 4 patients belonging to Group 1 (31%), 10 in Group 2 (50%), and 6 (including two treatment-related deaths) in Group 3 (75%). The most common complication was fistula formation in 11 patients (26%). Radical hysterectomy can be offered as an alternative to exenteration in carefully selected patients.

Cervical carcinoma: treatment results and complications of extended-field irradiation.

The authors studied treatment complications, recurrence patterns, and survival in 18 patients with histologically proved metastases to the paraaortic lymph nodes from invasive cervical carcinoma treated with extended-field irradiation. Complications following treatment developed in five of 10 patients who underwent transperitoneal nodal biopsy or dissection and in two of eight patients in whom an extraperitoneal approach was used (overall complication rate of 39%); however, only one had a gastrointestinal complication (small bowel obstruction after transperitoneal nodal biopsy and irradiation). Fourteen patients had persistent or recurrent disease within the abdominal or pelvic cavity; only one had distant metastases without recurrence in the abdomen or pelvis. Two of the 14 patients had a recurrence in the surgical scar following extraperitoneal nodal biopsy, possibly due to placement of the scar outside the radiation field. After a minimum follow-up of 48 months, only three of 18 patients (17%) were alive and well.

Spiramycin concentrations in female pelvic tissues, determined by HPLC: a preliminary report.

An automated high performance liquid chromatographic method with remote controlled column switching was used to measure the concentration of spiramycin in pelvic tissues and plasma after oral administration of the antibiotic. Three oral doses of 2 g spiramycin were given to patients scheduled for elective gynaecological surgery over the 14 h before 6 a.m. on the day of surgery. Spiramycin concentrations in serum ranged from 7.4 to 12.5 mg/l between 3 h 20 min and 9 h 20 min after the last dose of spiramycin. Spiramycin pelvic tissue concentrations were determined in five of the eleven females and ranged from 4.4 to 33.3 mg/kg. The highest concentrations were observed in the Fallopian tube. These preliminary results suggest that spiramycin has good diffusion into female pelvic tissues.

Uterine sarcoma: an analysis of 74 cases.

In order to determine whether recent methods of diagnosis and treatment have resulted in an improved survival for patients with uterine sarcoma, we reviewed 99 cases treated in our center from 1970-1985. Morphologic characteristics of 74 tumors were specifically reassessed for this study. All tumors were graded. Of 42 Stage I cases that were morphologically assessed, tumor-positive pelvic lymph nodes were found in two of the 15 patients in whom sampling was done. No cases of tumor-positive para-aortic nodes were found in 14 patients with Stage I disease. In Stage I and Stage II, no cases of positive para-aortic nodes were found in association with negative pelvic nodes. The 2- and 5-year survival rates in Stage I were 47.4% and 29.4%, respectively. Local recurrence decreased (p less than 0.01) in Stage I from nine of 22 cases in which operation alone was performed to none of 15 cases in which pelvic radiotherapy was added, but no improvement in the 5-year survival rate was observed. As with lymphadenectomy and radiotherapy, the recent use of chemotherapy for uterine sarcoma had no impact on survival.

CA 125 surveillance and second-look laparotomy in ovarian carcinoma.

CA 125 was evaluated as a tumor marker in 31 patients undergoing treatment for ovarian carcinoma, 17 of whom had second-look laparotomies. At the time of second-look laparotomy, 14 patients had CA 125 values in the normal range. Six of these patients had a positive second-look laparotomy. Although normal CA 125 values do not obviate the need for second-look laparotomy in treatment planning, rising or falling trends reflected clinical disease progression or regression in 80% of the cases.

Ovarian function after radical hysterectomy for stage IB carcinoma of cervix.

Ovarian function was assessed in 20 patients after radical hysterectomy and lymph node dissection for Stage IB cervical carcinoma. All patients were under 45 years of age, and four were or had been on estrogen therapy for postmenopausal symptoms. The other 16 patients were free of symptoms and demonstrated premenopausal gonadotropin profiles. Fourteen of these 16 had luteal phase serum progesterone levels. Only one patient required reoperation for a pathologic condition of the adnexa. A surgical approach to Stage IB cervical carcinoma conserves ovarian function in 80% of patients.

Primary surgical treatment in one hundred ninety-five cases of stage IB carcinoma of the cervix.

Stage IB carcinoma of the cervix may be treated primarily by either radiotherapy of operation. A primary surgical approach was used in 95 patients for the following indications: young age with desire to retain ovarian function (124), pelvic inflammatory disease (33), pregnant or post partum (15), refusal of radiotherapy (11), anatomic problems contraindicating radiotherapy (10), undiagnosed pelvic mass (seven), verrucous tumor (three), mucus-secreting tumor (two), syphilis (one), and previous radiotherapy for Hodgkin's disease (one). Twelve patients had two indications. The surgical procedures were radical abdominal hysterectomy and pelvic lymph node dissection (191) and Schauta-Amreich (radical vaginal) hysterectomy (4). Fourteen patients had serious postoperative complications. The uncorrected 5-year survival rate (95.1% follow-up) was 91.1%. The rationale for recommending a primary surgical approach to selected patients with Stage IB cervical carcinoma is presented.

Squamous cell carcinoma of the vagina following hysterectomy.

A retrospective analysis of 29 cases of squamous cell neoplasia of the vagina following hysterectomy is presented. Two groups of patients were identified; the first presented following hysterectomy for cervical dysplasia or neoplasia on an average of 5.7 years later, and the second presented following hysterectomy for benign or unrelated disease 13.1 years after initial surgery. All 17 patients in the first group had Stage I disease whereas two thirds of the second group had Stage II or greater disease at the time of diagnosis. Surgery was the primary mode of therapy in 82.4% of the first group and radiotherapy was used in 83.3% of the second group. In all patients 20.7% had received previous radiotherapy to the pelvis. Carcinoma of the vagina following hysterectomy for benign disease tends to be more advanced at the time of diagnosis and subsequently has a poorer ultimate prognosis. Disease following previous cervical neoplasia is often asymptomatic and only detected on routine cytologic testing.

The use of delayed primary wound closure in preventing wound infections.

Delayed primary wound closure was performed in 146 patients considered at risk of developing wound infection according to established criteria. These patients were matched individually for age, weight, diagnosis, and the use of prophylactic antibiotics with 146 patients undergoing immediate wound closure during the same time period. The matched pairs were subdivided into five categories depending on the indication for delayed closure; obesity, cancer, "above and below" procedure, infection, and opened bowel. In all categories the incidence of wound infection was significantly lower in the patients with delayed closure. The over-all infection rate was reduced from 23.3% in the control group to 2.1% in the study group. Hospital stay was unaffected. Delayed primary wound closure provides a safe, simple, effective means of reducing the incidence of wound infection.

Surgical management of carcinoma of the cervix.

Three hundred and fifty-two cases of carcinoma of the cervix which required some surgical procedure are reviewed. In Group I (primary treated), the lymph nodes were positive in 9% with Stage I and 45% with Staqe II disease. This group had an 88% five-year survival rate; patients with positive lymph nodes had a 60% two-year survival rate. One or more surgical complications occurred in 16.5% of patients treated for recurrent disease. The five-year survival rate in patients treated for recurrent disease was 35%. The Schauta-Amreich procedure is being used more commonly for poor-risk patients with recurrent disease confined to the cervix or with superficial vaginal involvement.

Induction of midtrimester abortion with intra-amniotic urea and intravenous oxytocin.

Midtrimester abortions were induced in 295 patients with a combination of intra-amniotic urea and intravenous oxytocin. The mean injection-abortion interval was 26.4 hours. Abortion occurred spontaneously within 50 hours of amnioinfusion in 257 patients. The macerating effect of the hypertonic urea on fetal tissues allowed easy termination of the remaining 38 pregnancies by suction curettage at 50 hours after injection. Decreased urinary output occurred during the oxytocin infusions, but water intoxication was prevented by close monitoring of urinary output and serum electrolytes, and by the use of a concentrated solution of oxytocin in normal saline, allowing the administration of small volumes.

Clinical assessment of a low-dose oestrogen, low-dose progestogen combined oral contraceptive.

PIP: The efficacy, safety, and patient acceptance of an oral contraceptive containing 150 mcg d-norgestrel and 30 mcg ethinyl estradiol (150/30) were studied in 99 women who completed 754 cycles of medication between late 1971 and October 1973. 1 pregnancy occurred giving a pregnancy rate of 1.6 per 100 woman-years. This woman's previous history indicated unreliability in pill taking. The mean pretreatment length of menses was 4.9 days and during treatment, 4 days. Although intermenstrual bleeding and amenorrhea were noted in early cycles, there was a decrease in the usual incidence of headaches, nausea, vomiting, and depression. Results of the study and patients' acceptance suggest that the 150/30 combination may be used as the oral contraceptive of first choice.^ieng

Use and abuse of the papanicolaou smear.

The Papanicolaou smear is a useful screening procedure. Most investigation of abnormal epithelial activity can be done as an office procedure. Cold conization of the cervix is not often required to make the final diagnosis and initiate treatment.

Tubal sterilization: methodology, postoperative management and follow-up of 2934 cases.

Both posterior colpotomy with associated fimbriectomy and laparoscopy offer rapid and effective methods for carrying out interim and post-abortion tubal sterilization. They can effectively be performed on an out-patient basis. Posterior colpotomy has the added advantage that it can be conveniently performed under a combination of intravenous neuroleptanalgesia and local vaginal anesthesia. This series exemplifies the manner in which the burden upon hospital facilities and medical and paramedical personnel can be minimized. In addition, utilization of the "home-care program" has improved patient acceptance and convenience.

Outpatient management of first trimester therapeutic abortions with and without tubal ligation.

In busy hospitals the increasing numbers of abortions must be performed without disturbing other hospital functions. Local anesthesia, vaginal tubal ligation and the use of outpatient beds are the operative and administrative adaptations described. Of 1545 abortions performed in Victoria Hospital, London, in 1971, 428 (32%) were done under local anesthesia; 14 of these patients also had vaginal tubal ligation under local anesthesia. There were 405 sterilizations (26.2%) among this group of patients, of which 390 (96.3%) were vaginal tubal ligations. Of the total number, 891 (57.7%) were dealt with as outpatients and these comprised 62.0% of patients having therapeutic abortion only, and 46.7% of patients having tubal sterilization as well as abortion.