Radical hysterectomy: current management guidelines.

Over the past 11 years (January 1985 through December 1996) the senior authors (B.F.H. and H.B.K.) have performed 205 radical hysterectomies. The most notable trend observed was a marked decrease in length of stay from 12.8 days to 3.5 days. Contributing factors include use of the Maylard incision, placement of suprapubic Foley catheters, discontinuation of drains, early oral feeding, admission to the hospital on the day of surgery, and initiation of a critical care pathway. All criteria for short-stay radical hysterectomy were established by 1994. With continued modification of surgical technique and use of the critical care pathway, short stay has become our standard of care for radical hysterectomy. Complications are minimal, with neither long-term morbidity nor mortality associated with the short stay. In addition, significant cost savings occur, which benefits the patient, hospital, and the health care system.

Witzel gastrostomy in gynecologic surgery.

Tube gastrostomy is a well-accepted procedure for gastrointestinal decompression and the relief of small bowel obstruction. The Witzel technique was used in 123 patients undergoing pelvic-abdominal surgery for known or suspected gynecologic malignancy or for clinical bowel obstruction. For 115 patients, the tube remained in place from 3 to 18 days (mean, 8 days). Eight patients were discharged from the hospital with the tube in place, and these functioned successfully from 43 to 136 days. Sixteen patients (13%) had complications, but there was neither long-term morbidity nor mortality associated with the tube. Witzel gastrostomy, using a Foley catheter, is easily learned, inexpensive, and has an acceptable complication rate. When the need for long-term gastrointestinal decompression is anticipated, Witzel gastrostomy is preferred to nasogastric tube suctioning to facilitate patient care and comfort.

Loop electrosurgical excision procedures for cervical dysplasia: experience in a community hospital.

OBJECTIVE: The study was undertaken to evaluate the use of the loop electrosurgical excision procedure as an outpatient hospital or surgicenter procedure. STUDY DESIGN: The records of 358 patients treated for cervical intraepithelial neoplasia at a large community hospital over a 1-year period were reviewed. RESULTS: The specimens obtained by loop electrosurgical excision procedure and laser cone excision were comparable in size but smaller than those by means of cold-knife conization. Seventy-two percent of loop electrosurgical excision procedure specimens consisted of two to eight tissue fragments (mean 3.4). In addition, 48% of the loop electrosurgical excision procedure specimens and 38% of laser cones had moderate or severe thermal artifacts. Fragmentation and cautery damage precluded orientation of tissue and evaluation of margins in 19% of the cases. CONCLUSIONS: The advent of the loop electrosurgical excision procedure has shifted the management of cervical intraepithelial neoplasia from the office to the outpatient surgery centers. This negates and, in fact, reverses the advantage of loop electrosurgical excision procedure over other methods in regard to cost and convenience through evaluating and treating a patient with cervical intraepithelial neoplasia in one office visit. Loop electrosurgical excision procedures provide specimens that are inferior compared with cold-knife cones; therefore the role of loop electrosurgical excision procedure for the management of cervical intraepithelial neoplasia outside the office appears limited.

Treatment failure of genital condylomata acuminata in women: role of the male sexual partner.

The male sexual partners of women with genital condylomata acuminata are thought to be carriers of human papillomaviruses. It is therefore often recommended that both sexual partners be treated. We studied 360 women with genital warts to test the hypothesis that when the male partners of women with condylomata acuminata are treated, the treatment failure rate decreases. The male sexual partners of 180 of these women were examined and, if indicated, treated (treatment group). The 180 remaining male sexual partners were neither examined nor treated (control group). One hundred twenty-two (68%) men in the treatment group had human papillomavirus-associated lesions. The treatment failure rate of women was 16.7% in the treatment group and 18.9% in the control group. The difference is not statistically significant (p greater than 0.05). The results of this study do not support the hypothesis that the treatment failure rate of women with condylomata acuminata decreases if their male sexual partners are also treated.

Chronic ulcerations following topical therapy with 5-fluorouracil for vaginal human papillomavirus-associated lesions.

Applied topically to the vagina, 5-fluorouracil (5-FU) cream is an effective therapy for human papillomavirus (HPV)-associated lesions of the vagina including condylomata acuminata and vaginal intraepithelial neoplasia. Although the acute side effects of 5-FU therapy are well recognized, long-term sequelae of intravaginal 5-FU use have not been described in detail in the literature. To assess the incidence and clinical course of 5-FU-related vaginal mucosal alterations, we studied 220 patients who underwent 5-FU therapy for HPV-associated lesions of the vagina. Eighteen women (8.2%) had epithelial ulcers 6 months after completion of the 5-FU treatment. The incidence of ulcers was higher in women who used 5-FU for longer than 10 weeks compared with those who used it for 10 weeks or less (9.6 versus 5.7%; P = .05). All but one of the mucosal defects were in the vaginal fornices and/or the periphery of the ectocervix. The ulcers were mostly singular and measured 0.5-7 cm in greatest diameter. Fourteen patients (77.8%) had symptoms related to the ulcers including a serosanguineous or watery discharge (55.6%), postcoital spotting or bleeding (44.4%), irregular bleeding unrelated to intercourse (16.7%), and pain (5.6%). Spontaneous healing of the ulcers was protracted. Office methods of therapy including estrogen creams and cauterizing agents failed to accelerate healing as compared with untreated patients. Excision of the ulcer and primary closure of the wound was curative in all four cases in which it was used. We conclude that topical 5-FU therapy may lead to troublesome chronic mucosal ulcers that tend to persist despite conservative treatment attempts.

The Maylard incision in gynecologic surgery.

The transverse muscle-splitting Maylard incision was used in 175 gynecologic patients who required pelvic-abdominal surgery. One hundred fifty-three patients (87%) had pelvic malignancy; other indications for operation included uterine myomas, endometriosis, tuboovarian abscess, and benign ovarian cysts. Exposure was excellent: 54% of patients underwent pelvic lymphadenectomy and 17% underwent paraaortic lymphadenectomy. Twelve patients (6.9%) had wound complications, but there was neither long-term morbidity nor mortality associated with the incision. Fifty-six patients (32%) received preoperative or postoperative pelvic radiation therapy with no detrimental effect on wound healing. The Maylard incision is cosmetic, strong, easily learned, and has an acceptable complication rate. Unless a vertical incision is indicated, the Maylard technique is preferred when optimal exposure and accessibility to the pelvis are required.

Does the treatment of genital condylomata in men decrease the treatment failure rate of cervical dysplasia in the female sexual partner?

Three hundred ninety women treated for cervical dysplasia by local tissue ablation were studied retrospectively to test the hypothesis that the treatment failure rate is lower if the male sexual partner is also treated. In 190 cases, the male sexual partner was examined and treated successfully for genital condylomata. Controls were 200 women treated during the same time period and closely matched to the study group regarding age, race, socioeconomic status, histologic grade of dysplasia, distribution of the lesions, and methods of therapy, but the male partner was neither examined nor treated. The treatment failure rate for women whose partners were also treated was not significantly different from that for women whose partners were not treated (6.8 versus 7.5%; P greater than .05), suggesting that treating genital condylomata in men does not affect the failure rate of cervical dysplasia in female sexual partners.

Management of intestinal obstruction in ovarian cancer.

Bowel obstruction often is a sign of progression of ovarian carcinoma and is a major cause of death in this disease. Its treatment is still being debated. Options range from long tube decompression of the GI tract to bowel surgery. The authors review the management of bowel obstruction associated with ovarian carcinoma and provide guidelines helpful in selection of patients for surgical or medical management. Practical aspects of patient care are described in detail and the old adage "Never let the sun set or rise on a bowel obstruction" is examined in light of current surgical and medical management techniques.

Monoclonal antibodies against human ovarian tumor associated antigen NB/70K: preparation and use in a radioimmunoassay for measuring NB/70K in serum.

Murine monoclonal antibodies (MCAs) against human ovarian tumor associated antigen NB/70K have been prepared. One of these MCAs, NB12123, was chosen for the development of a radioimmunoassay for measuring serum NB/70K levels. In this assay, the average NB/70K level in 75 normal, healthy controls was 11.9 activity units (AU) with an SD of 14.9 AU. The normal cut off value for this assay was set at 45 AU (mean +2 SD). 24 of 46 (52%) ovarian cancer patients, 7 of 18 (39%) patients with benign ovarian cysts or tumors and 3 of 85 (4%) control samples had elevated serum NB/70K levels. Comparison of NB/70K levels measured in the NB12123 assay with levels measured in an assay using a polyclonal antiNB/70K previously developed in our laboratory [13] indicated that although both assays had approximately the same percentage of positive ovarian cancer patient samples, there appeared to be no correlation between the absolute NB/70K levels measured by the two assays. The rank of ovarian cancer patient samples was also different for the two assays. Also, almost 40% of patients with benign ovarian cysts and tumors had elevated serum NB/70K levels as measured by the NB12123 assay as compared to 0% for the polyclonal assay. Reciprocal cross-blocking experiments, absorption studies, and immune precipitate analysis indicated that both the monoclonal NB12123 assay and the polyclonal antiNB/70K assay measured the same population of NB/70K molecules. However, the polyclonal antibody recognizes epitopes in addition to that recognized by NB12123. Taken together, these results suggest that the epitope recognized by NB12123 is not as specific for malignant ovarian tumors as the epitope(s) recognized by polyclonal antiNB/70K and/or that more than the one epitope detected by the MCA is responsible for the specificity for ovarian cancer of the polyclonal NB/70K assay. In spite of this, the greater sensitivity and range of the monoclonal NB12123 assay make it possible to monitor serum NB/70K levels in ovarian cancer patients. In four patients examined, the fluctuating serum NB/70K levels appeared to correlate well with clinical status.

Supraclavicular central venous catheterization.

Percutaneous central venous catheterization is a well-accepted procedure for cardiac monitoring, total parenteral nutrition, and long-term drug therapy. The supraclavicular approach was used for 90 catheterizations in 81 gynecologic patients to evaluate ease of insertion, complication rate, and patient compliance. Anatomic considerations, insertion technique, and the rationale for the supraclavicular approach are discussed in detail. A successful catheterization rate of 91% was achieved with acceptable morbidity. There were three instances each of pneumothorax, catheter malposition, and catheter infection. Advantages of the supraclavicular approach include a wider target area, a more direct route to the superior vena cava, and less pain on insertion. With reliable and constant landmarks, relative ease of and comfort on insertion, and low complication rate, the supraclavicular technique is the preferred method when percutaneous central venous catheterization is indicated.

Conservative management of small bowel obstruction.

Intestinal Cantor tubes were used in the management of 69 gynecologic patients with pelvic malignancies who presented with small bowel obstruction. Small bowel obstruction was secondary to radiation injury, persistent or recurrent carcinoma, or postoperative adhesions. Thirty-one patients (45%) in this series had successful resolution of their small bowel obstruction with a Cantor tube, including 12 of 14 patients (86%) with postoperative adhesions. Complete obstruction of the small bowel was the only prognostic factor definitely associated with tube failure. Seventy percent of all patients had successful passage of the tube on one attempt, and no major complications were encountered. The Cantor tube has proved to be safe, effective, and easy to use, and guidelines for the management of it are included. Cantor tube decompression should be considered in the initial management of small bowel obstruction, since a significant percentage of the patients with this condition will not require surgical intervention.

Pemphigus vulgaris and microinvasive squamous-cell carcinoma of the uterine cervix.

Although patients with disseminated pemphigus vulgaris may have involvement of the uterine cervix, such involvement is often detected only after vaginal discharge or bleeding. When a cervical smear is obtained, distinctive cytologic abnormalities may be observed; these may be attributed to the changes of pemphigus or to an associated reparative/inflammatory reaction. This study documents the first two cases of microinvasive squamous-cell carcinoma of the uterine cervix developing in association with uterine cervical pemphigus. The gross pathologic, cytologic and histologic features of these lesions are illustrated. The cytologic criteria that may be helpful in distinguishing between cells derived from microinvasive squamous-cell carcinoma and pemphigus of the uterine cervix are described.

Selectivity for ovarian cancer of an improved serum radioimmunoassay for human ovarian tumor-associated antigen NB/70K.

An improved NB/70K assay which can be used to reproducibly and accurately measure the NB/70K content of unextracted serum samples has been developed. Analysis of pretreatment serum samples has indicated that the NB/70K assay shows selectivity for ovarian cancer with respect to nonmalignant ovarian cysts and tumors as well as controls; if one considers 10 units of NB/70K as a significant level of antigen, then there are no false positives in the benign and control groups, while 10 of 21 in the ovarian cancer group have significant NB/70K levels. When NB/70K levels of ovarian cancer patients are compared to those of patients with non-ovarian malignant disease, only 4 of 23 patients with non-ovarian cancers had significantly elevated NB/70K levels. However, none of these 4 false positives had levels greater than 20 units.

Transverse periumbilical incision in the massively obese patient.

A periumbilical transverse incision placed above or no more than 5 cm below the external portion of the umbilicus was used for pelvic surgery in 21 massively obese women with a large dependent panniculus. Five patients (24%) had wound complications of varying degrees, including one evisceration. Other complications included postoperative fever (62%), urinary tract infection (19%), respiratory complications (10%), paralytic ileus (5%), partial small bowel obstruction (5%), and pulmonary embolus (5%). There was no operative mortality in the series. The periumbilical approach gives good exposure during surgery and--in the patient population studied--is preferable to other incisions for pelvic surgery. It circumvents the contaminated suprasymphyseal problem area beneath the pannicular fold and avoids the thick, edematous, dependent portion of the panniculus, which must be retracted upward for low and high suprasymphyseal transverse and midline abdominal incisions.

The pathology of superficially invasive, thin vulvar squamous cell carcinoma.

Thirty-six cases of vulvar squamous cell carcinoma 5 mm or less in thickness were studied, and potential predictors of lymph node metastases were evaluated. Tumor thickness and depth of stromal invasion were measured. Inguinal lymph node metastases were present in six (17%) cases, all of which had primary neoplasms more than 3 mm thick. The most superficial lesion to have lymph node metastasis was 3.2 mm thick and had 1.6 mm of stromal invasion. Nonetheless, depth of stromal invasion of less than 3 mm was associated with statistically fewer lymph node metastases (7%) than that of neoplasms with 3 mm or more of stromal invasion (50%). Although lymphatic or blood capillary invasion was present in four (11%) cases, this feature had no statistically significant association with lymph node metastasis. There was no relationship between clinical stage, surface diameter, or histological grade of the lesion and lymph node metastasis. A significant percentage of cases had either carcinoma in situ (31%) or atypical hypertrophic dystrophy (19%) in the epithelium adjacent to the infiltrating carcinoma. Koilocytotic atypia suggestive of human papilloma virus infection was present in the adjacent epithelium in 47% of the cases. This study suggests that thickness of the neoplasm is a valid predictor for the presence or absence of lymph node metastasis in vulvar squamous cell carcinoma; it may be more useful than neoplastic depth of invasion in this regard.

Diaphragmatic peritoneal biopsy.

For the past two years, this technique has been used without complications in all patients in whom direct or random biopsies of the diaphragmatic peritoneal surfaces are indicated. Several advantages of this technique include: 1, specimens taken for biopsy from all peritoneal surfaces, including infracolic and pelvic, can be easily obtained in this manner; 2, surgical clips are inert, hemostatic and easy to apply; 3, in reassessment operations, previously placed clips lead the surgeon to areas where implants or occult metastases were initially found, and 4, the clips could potentially serve as anatomic markers in planning adjuvant treatment, especially irradiation therapy.

Cervical conization: when is uterine dilatation and curettage also indicated?

Although the primary goal of cervical cone biopsy is treatment of cervical intraepithelial neoplasia, conization plus uterine dilatation and curettage is usually considered as a single, standard procedure. We reviewed 128 cone biopsies (114 of these procedures included dilatation and curettage) over a 3-year period to see whether dilatation and curettage was necessary as an accompaniment to conization. The mean age for all patients was 32.8 years, and 6.25% (eight patients) had a history of abnormal uterine bleeding. There was no evidence of endometrial abnormality in any of the 114 dilatation and curettage specimens. These findings suggest that dilatation and curettage is not warranted as a routine adjunct to cone biopsy. We believe more precise criteria for combining dilatation and curettage with conization are required, and these include: patients in the peri- or postmenopausal period, suspected intrauterine abnormalities, and the presence of abnormal glandular cells in a cytologic sample. With the use of these guidelines, only 18 patients (14%) would have required dilatation and curettage.

Recurrent cancer of the cervix following radical hysterectomy and pelvic node dissection.

Forty patients with recurrence following radical surgery for early invasive cancer of the cervix were studied. Fifty-eight percent of the recurrences were observed within the first 12 months after surgery and 83% within the first 2 years. The site of recurrence was found to influence diagnosis, symptomatology, clinical findings, prognosis, cause of death, and therapy. The prognosis for patients with recurrent cervical cancer was poor, with only 5 patients (13%) surviving free of disease after 5 years. One patient is presently alive and without disease for more than 2 years. Patients who did not receive a potentially curative course of radiation therapy at the time of diagnosis of the recurrence had a poor prognosis. None of the patients managed by exenterative procedures or chemotherapy survived. Guidelines are suggested for follow-up after primary radical hysterectomy and pelvic node dissection.

Pfannenstiel wound dehiscence complicated by cecal bascule.

A 43-year-old female with a Pfannenstiel wound dehiscence complicated by cecal bascule is reported. The etiology of both cecal bascule and dehiscence is discussed. Contributing factors in this case include increased intra-abdominal pressure from the cecal bascule, and a running catgut closure of the anterior rectus sheath. When the diagnosis of cecal bascule is made, cecostomy with cecopexy is the treatment of choice. For prevention of wound disruption, the optimal closure of a Pfannenstiel incision utilizes interrupted nonabsorbable suture material.