Urinary diversion in gynecologic oncology.

Urinary diversion in gynecology is performed primarily in conjunction with cancer surgery, but at times, it is required for women with intractable urinary fistulas or other urologic disorders. After 1950, ileal conduits replaced ureterosigmoidostomies as the most widely used form of urinary diversion. Transverse colon conduits have gained popularity because these nonirradiated bowel segments offer less risk for postoperative urinary leaks and small bowel complications associated with bowel and ureteral anastomoses. In 1978, Kock et al described the use of detubularized segments of ileum and the intussuscepted nipple valves to create a continent pouch that is still advocated by urologists in some centers. Ileocolonic continent pouches, originally suggested in 1908, have received considerable attention in the past 10 to 15 years because of ease of construction, lower revision rates, and higher continence rates compared with the Kock ileal pouches. At the Division of Gynecologic Oncology at the University of Miami, the authors have been using the Miami pouch as the preferred form of continent urinary diversion since 1988, with acceptable results. Women who need urinary diversion can be offered at least two major choices: (1) the traditional bowel (ileum or colon) conduit, which requires an external ostomy appliance, or (2) a continent pouch, such as the Miami ileocolonic reservoir. In choosing between non-continent and continent conduits, the patients must be made aware that the continent pouches are available in only a few centers in the United States and carry a slightly higher risk for complications because of the relatively higher complexity. Nonetheless, data strongly suggest that most of these complications can be managed noninvasively and that these patients retain a closer to normal quality of life. The age, disease status, and general health of the woman and the likelihood of her long-term survival after diversion weigh heavily in the final decision.

Iatrogenic injuries in gynecologic cancer surgery.

Iatrogenic injury is always an unwelcome event at the time of surgery. Prior history of multiple laparatomies, radiation therapy, or a distorted pelvic anatomy caused by a malignancy are all factors that may make iatrogenic injury a likely event. In these situations, complications at times can be considered unavoidable. Injuries during benign surgical procedures also can be difficult to manage, especially if not diagnosed at the time of occurrence. Operative knowledge to manage the more commonly encountered complications must be in the repertoire of all surgeons, including those dealing with abdominopelvic malignancies. This article reviews the more common genitourinary, gastrointestinal, and neural injuries encountered during gynecological surgical procedures and discusses basic management strategies.

Atypical presentation of microscopically advanced ovarian carcinoma.

Epithelial ovarian cancer (EOC) continues to be an academically challenging and clinically problematic disease. Even with recent advances, the overall 5-year survival is still 31% to 42% in various studies. Deaths from EOC outnumber those due to cervical, vulvar, and endometrial carcinomas combined. Screening for EOC has shown limited success in early detection. The Pap smear is not a dependable tool in EOC screening, though at times it can be the first evidence of ovarian disease. We report a case of EOC that was diagnosed during evaluation of an abnormal Pap smear. On completion of evaluation, stage IIIA endometrioid-type adenocarcinoma of the ovary was diagnosed. Occult EOC should be considered in patients with abnormal findings on cervical cytology after cervical and uterine carcinomas are ruled out.

Primary uterine angiosarcoma.

OBJECTIVE: The aim of this study was to report the first case of primary uterine angiosarcoma described in a Hispanic American woman and to review the literature on uterine angiosarcomas. We review characteristic presenting symptoms, gross and microscopic pathologic findings, and treatment outcomes where available. METHODS: A case report is presented with a review of the English language literature via a Medline search. The key phrases used in the search were uterine angiosarcoma, hemangiosarcoma, hemangioendothelioma, and primary uterine neoplasm. RESULTS: Since the first report in 1902, there have been 19 reported cases of primary uterine angiosarcoma considered valid. Many early cases are questioned due to the lack of ultrastructural and immunohistochemical evidence available in later cases. Seventy-four percent (14 of 19) of these patients are perimenopausal with a mean age of 55 years (range 17-76 years). The common presenting findings are a pelvic mass, menorrhagia, and weight loss. Varying regimens of surgery, chemotherapy, and radiation have been utilized with limited success. CONCLUSIONS: Primary uterine angiosarcomas tend to exhibit a highly malignant behavior. The predominant prognostic factor seems to be the size of the tumor at diagnosis and the presence of extrapelvic disease. Recurrence occurs on average at 8.2 months. Of evaluable patients (n = 14), at 12 months the survival was only 43%. Although radiation and chemotherapy are options being utilized, no consensus exists for optimal therapy given the few cases from which to draw conclusions. Regardless of treatment, outcome is usually poor.

Evaluation of the Pfannenstiel incision for radical abdominal hysterectomy with pelvic and para-aortic lymphadenectomy.

Radical abdominal hysterectomy with pelvic and para-aortic lymphadenectomy (RAH/P + PAL) has classically been described through a low midline vertical incision. Transverse incisions have been used with good results for various pelvic surgical procedures. Hesitancy has been encountered when utilizing these transverse incisions in gynecologic oncology patients. In most studies, muscle-splitting transverse incisions seem to be of equal efficacy as midline vertical incisions in regards to surgical exposure and clinicopathologic data obtained and are known to be superior in cosmesis and postoperative morbidity. A retrospective chart review was performed to identify 25 patients who underwent RAH/P + PAL for stage I carcinoma of the cervix from 1990 to 1998 through a nonmuscle splitting (Pfannenstiel) abdominal incision. All patients were seen and had follow-up in the Division of Gynecologic Oncology, University of Miami School of Medicine/Jackson Memorial Medical Center (Miami, FL). Data were collected on various clinical and surgical parameters including height/weight, operative time, blood loss, number of lymph nodes obtained, length of hospital stay, and postoperative complications. Analysis of the data revealed that operative time and average blood loss were within acceptable parameters. The yield at lymphadenectomy for pelvic and para-aortic lymph nodes was also respectable. Postoperative complications were minimal and there were no wound complications reported. Therefore, the Pfannenstiel incision can be safely utilized in a select group of patients undergoing RAH/P + PAL.

Bilateral tubo-ovarian abscesses four years after total abdominal hysterectomy.

BACKGROUND: Pelvic inflammatory disease (PID) is a common gynecologic disorder. One known complication of PID is tubo-ovarian abscess (TOA) formation. The predominant theory on TOA formation postulates that an ascending infection from the cervix through the uterus to the fallopian tubes and ovaries results in abscess formation. Other theories include seeding via a hematogenous infection, diverticular disease, and appendicitis. CASE: A 39-year-old female patient with abdominal pain was referred to our institution and was found to have a pelvic mass. After a thorough evaluation, surgical exploration revealed the presence of TOA. No evidence of gastrointestinal disease was present. The patient's history was significant for an uncomplicated total abdominal hysterectomy for benign disease of the uterus four years prior. Abscess cultures grew Streptococcus intermedius. CONCLUSION: This case reports the rare occurrence of TOA in a patient who had undergone an abdominal hysterectomy four years prior to presentation. If the patient reports a surgical history of prior hysterectomy, TOA is often stricken from consideration. Although unlikely, adnexal abscess formation should be considered in the differential diagnosis of a patient with abdominal pain and a pelvic mass, even with a remote history of hysterectomy.

Late complication of laparoscopic salpingoophorectomy: retained foreign body presenting as an acute abdomen.

BACKGROUND: Laparoscopy is widely used as a tool in many clinical situations allowing for diagnosis and/or surgical management in a minimally invasive fashion. Most laparoscopic cases are ambulatory and allow patients to recover quickly. Nonetheless, attention to surgical technique is paramount to avoid both short and long term complications. CASE: A 32-year-old woman had a laparoscopy and a reported left salpingoophorectomy for benign disease of the ovary in September, 1994. Shortly thereafter, in January, 1995, she was diagnosed with an intrauterine pregnancy and delivered in October of 1995 by spontaneous vaginal delivery. The pregnancy and delivery were both uncomplicated. The patient presented four weeks postpartum with clinical suspicion of appendicitis. However, at the time of laparotomy, the patient was found to have a retained foreign body from her prior laparoscopy in the right lower quadrant with a pelvic abscess and evidence of prior right salpingoophorectomy. The appendix appeared grossly normal. CONCLUSION: Laparoscopy is a safe, effective modality for various surgical and gynecologic conditions. Although laparoscopy is usually done on an outpatient basis, complications can manifest several weeks or months later. This case illustrates and reminds us of the importance of adherence to surgical laparoscopic principles. These include direct visualization when removing equipment and a complete count of surgical instrumentation to confirm the integrity of such at the end of each procedure.

Estrogenic activity in forages: diagnostic use of the classical mouse uterine bioassay.

The classical mouse uterine bioassay was evaluated and adapted for routine diagnostic use in response to requests for evaluation of forages suspected of being estrogenic. Forages were extracted in acetone or 10% ethanol in acetone (v/v). Extracts were mixed with ground corn-based mouse feed. Immature female mice (n = 3/group) were fed a total of 100 g of the ground feed for 5 days. Body weights were monitored before and after the trial. After 6 days, the mice were euthanized and uterine weights were determined. Mean uterine weights were compared using 1-way analysis of variance with preselected contrasts for individual means. Selected uteruses were fixed in 10% neutral buffered formalin for histologic examination. Control feeds, diethylstilbestrol (DES), estradiol, coumestrol, feeds with no reported estrogenic properties, and a feed that caused hyperestrogenism in cattle were tested. Moderate levels of estrogenic compounds resulted in dose-responsive uterine enlargements (10-270 ppm coumestrol over 5 days). Extremely high levels of estrogen frequently resulted in feed refusal and lack of uterine enlargement (10 ppm DES, 100 ppm estradiol). Diagnostically significant estrogenic activity was recovered from the feed known to have been estrogenic in cattle. The classical mouse uterine bioassay was relatively inexpensive, quick, repeatable, and capable of detecting clinically relevant coumestrol levels in hay.

FcR-independent antibody-mediated cellular cytotoxicity.

In this study we used palmitate-derivatized antibodies (pal-Ab) to examine the minimum contribution of Fc receptors (FcR) to macrophage (M phi)-mediated lysis and phagocytosis in antibody-dependent cellular cytotoxicity (ADCC). Pal-Ab specific for chicken erythrocytes (CE) were incorporated into the plasma membranes of M phi by insertion of the palmitate hydrocarbon chains into the outer leaflet of the phospholipid bilayer. In this system, the palmitate anchor bypassed the requirement for FcR in antibody-dependent effector-target conjugation and provided a unique opportunity to uncouple antibody-FcR interactions in ADCC. We show that binding of CE targets by P388D1 M phi effector cells through anti-CE pal-F(ab')2 can lead to efficient extracellular target cell lysis, but not phagocytosis. In contrast, pal-F(ab')2-mediated interactions between CE and peritoneal exudate M phi (PEM) activated both ingestion and extracellular lysis of the targets. In normal ADCC, FcR-dependent interactions between CE and either P388D1 cells or PEM triggered both extracellular lysis and phagocytosis. Our results demonstrate that lysis and phagocytosis in CE-directed ADCC by M phi have different minimum requirements for FcR functions. Moreover, our results suggest that FcR-independent triggers on the PEM surface are capable of triggering target cell lysis and internalization following antibody-mediated interactions.