Vulvar reconstruction in post-RT case using the versatile VRAM flap: reporting the rare extrapelvic approach.

Although primary vulvovaginal reconstruction following vulvectomy has a significant chance of improving patient outcomes, flap reconstruction is not a recognised component of the accepted standard of care for vulvar cancer. We provide a case of a patient who underwent successful vulvar reconstruction using the extrapelvic vertical rectus abdominis myocutaneous (VRAM) flap. This musculocutaneous flap offers adequate coverage and bulk to the perineal defect after excision in post-irradiated vulvar cancer.To proceed with sphincter-saving surgery, she was scheduled for neoadjuvant chemoradiation, as the lesion involved the urethra and perineal body. However, she experienced severe grade IV dermatitis after receiving 37 Gy of radiation. Though the lesion had reduced in size, it was still large enough to cause significant perineal deformity.We performed a vulvar reconstructive surgery using the uncommon but reliable extrapelvic VRAM flap. This well-vascularised VRAM flap is particularly useful in irradiated areas prone to poor healing. Postoperatively, the wound healed well and the patient underwent adjuvant therapy 6 weeks later. We emphasise the advantages of well-perfused muscle for the primary repair of prior irradiated perineal lesions.

Our Experience of Distal and Total Urethrectomies in Post Irradiated Vulvar Malignancies in Low Resource Settings: A Single Centre Study.

Introduction: At diagnosis, women with vulvar cancer often present in locally advanced stage especially in developing countries, owing to the associated ignorance and social stigma. Generally tumour is seen involving adjacent organs, like the vagina, anus, and urethra. Damage to the sphincter system leads to urinary incontinence. Available evidence regarding urethral resections, subsequent lower urinary tract dysfunction and neo-meatus reconstruction in radical vulvar surgeries is scarce and conflicting. Methodology: Considering, the lack of literature on outcomes of partial and total urethrectomies post chemoradiation in advanced vulvar malignancies from India, in the current study, we analysed our experience of such cases that have been operated post chemoradiation over a span of 2 years (from January 2019 to January 2021). Results: DFS ( disease free survival) of more than 6 months was seen in 5 of our patients, however in view of local wound complications after primary closure, we recommend reconstruction with myocutaneous flaps. Also in view of incontinence observed in two of our patients who had undergone more than 1/2 of urethral resection, as a result of failed suprapubic catheterisation, further plan of urethral reconstruction should be considered especially in patients who have received prior radiation. Conclusion: Our small group of patients represents a unique cohort of patients in whom surgery was attempted after radiation therapy. We have seen that surgery is a feasible option after radiotherapy in patients with advanced disease.

Pattern of Care of Recurrent Cervical Cancer in Low-resource Settings: Challenges and Patient-initiated Follow-up as a Novel Opportunity.

Introduction: The availability of optimum diagnostic strategies remains a major problem in resource-constraint countries. This technique of patient-initiated follow-up (PIFU) has been recently adopted in the UK for gynecological cancers and has proven cost benefits. However, no study from the Indian subcontinent has ever been reported. Aims and Objectives: The primary objective was to study the pattern of care of recurrent cervical cancer in low-resource settings. The secondary objective was to compare the reliability of symptomatology/clinical evaluation and imaging methods on follow-up to detect recurrence and thus explore the feasibility of symptom-based PIFU. Materials and Methods: This was a single-institutional retrospective analysis of recurrent cervical cancer cases for a period of 3 years from January 2019 to January 2022. Patients who followed up for minimum of 6 months were included in the study. Results: In 57 of the total 69 patients, symptoms alone were the index diagnostic method. Interestingly, neither of the methods of recurrence detection had impact on overall survival (OS). Cox regression analysis revealed adverse impact of erratic/lost to follow-up (hazard ratio [HR] = 3.8) and pelvic side wall disease (HR = 1.33) on survival. Patients with positive para-aortic nodes had significantly shorter disease-free interval of 11 months, so adding systemic therapy to adjuvant treatment in this cohort needs to be further investigated. Conclusion: Our analysis showed that patients with recurrence who were diagnosed with clinical manifestations alone vis-à-vis the ones who were diagnosed primarily on routine follow-up visit by some imaging or diagnostic test had comparable oncologic outcomes. PIFU can be a "practice changing modality" in patient management system, especially in low-resource settings. It will prove to be a simple cost-effective method to detect recurrence and prevent fallouts. Our study points to the feasibility of PIFU in Indian scenario.

Carcinoid ovary with synchronous carcinoid tumour of the appendix: report of a rare occurrence with review of literature.

Carcinoid tumours are present in a wide range of organs but most frequently involve the gastrointestinal tract and rarely reported in gynaecological organs. Literature reports that the prevalence of ovarian carcinoid is 0.3%-1% of ovarian neoplasms and accounts for only 5% of ovarian teratomas. The pathogenesis of neuroendocrine tumours associated with synchronous primaries is undetermined and many theories have been proposed, such as existence of a common carcinogenic effect or a common stem cell undergoing similar genetic mutation. Paracrine or autocrine growth loop effect by the secretory peptides of the neuroendocrine cell tumours is also suggested. Since carcinoids are variably positive in neuroendocrine and organ-specific markers, there are no immunohistochemistry markers to delineate the definite primary site of origin versus metastasis. We report a rare case of carcinoid ovary with synchronous carcinoid tumour of the appendix. In our case, the presence of contralateral teratomatous elements may hint primary struma carcinoid instead of being metastatic from the appendix. A strumal carcinoid component was also highlighted by PAX8 positivity. This led us to conclude the case as concurrent appendix carcinoid with struma carcinoid as two independent primaries with uncertain pathogenesis. Histologically, as both tumours are well differentiated with Ki-67 of less than 3%, the decision of the joint tumour board was to keep the patient on surveillance, with no adjuvant treatment needed. The patient is currently on surveillance and the follow-up period of 24 months to date has been uneventful.

Maternal and Perinatal Outcome in Pregnancy Complicated by Intrahepatic Cholestasis.

Introduction Intrahepatic cholestasis of pregnancy (IHCP) is characterized by pruritus of the hand and sole with abnormal liver function test and bile acid metabolism. IHCP occurs in the second and third trimesters of pregnancy and usually resolves after delivery. The overall prevalence is about 1.2 to 1.5%. This study was conducted to assess the fetomaternal outcome according to maternal serum bile acids levels and its correlation with liver function tests in patients with IHCP. Material and methods This ambispective observational study was conducted in the department of Obstetrics and Gynecology (OBG) for two years at AIIMS Jodhpur, Rajasthan. It included all the pregnant women attending the outpatient department of OBG with the complaint of pruritis in the palm and sole after 28 weeks of pregnancy and diagnosed with intrahepatic cholestasis of pregnancy after investigations. Results Only 152 patients were diagnosed with IHCP out of 4,148 deliveries, with a prevalence of 3.6%. Among these, 140 (92.11%) had mild IHCP, 10 (6.58%) had moderate IHCP and two (1.32%) had severe IHCP. There was a significant difference between the birth weight in mild, moderate and severe IHCP (P-value 0.004). About 12.5% (n=19) of patients had meconium-stained liquor during delivery. Two patients (1.32%) with moderate IHCP had intrauterine fetal death in the third trimester, and 6.58% (n=10) neonates were kept on continuous positive airway pressure. Conclusions IHCP is associated with adverse fetal outcomes like spontaneous or iatrogenic preterm delivery, low birth weight, increase in the rate of lower section cesarean section (LSCS) and intrauterine death of a fetus. A significant correlation found between raised bile acid levels and variables of liver function test, hence cost-effectiveness and feasibility of liver function test (LFT) should be considered for the management of IHCP.

A study of knowledge, attitude, and practice of contraception among nursing staff in All India Institute of Medical Sciences, Jodhpur, Rajasthan.

OBJECTIVE: Despite the increase in contraceptive usage over the years, there still exists a gap in the knowledge, attitude, and practices regarding contraception. The study has been designed to assess the knowledge, attitude, practice, and preferences on contraceptive methods among the nursing staff, to determine the association between knowledge and attitude on contraceptive methods with the variables. MATERIALS AND METHODS: A cross-sectional descriptive study of 173 nursing staff using a structured questionnaire on knowledge, attitude scale, and practice and preference were done at AIIMS, Jodhpur during June 2018 to August 2019. RESULTS: It was observed that 82.6% were of 21-30 years of age, 86.7% were Hindus, 67% were from the nuclear family, 41% were married between 19 and 25 years, 86.7% were nulliparous, 75.7% had access to various contraceptives through health workers, 79.8% got information through media. 73.4% were willing to use postpartum contraception. In our study, a major reason for 80.9% to use family planning was to prevent unintended pregnancies. Majority 71% had the favorable attitude and 14.4% had an unfavorable attitude toward contraceptive methods. In this study, 64.1% preferred male condom as Rank 1, intrauterine device 57.8% as Rank 2, and Lactational Amenorrhea Method 58.3% as Rank 3 for postpartum contraception. There was an association between the practice of family planning and marital status, age, and family size. CONCLUSIONS: The study showed that the majority of the females nursing staff had moderate knowledge and favorable attitude toward contraception use.