A ten year experience of cecal neovagina procedures for the restoration of sexual function on a gynecology oncology service.

OBJECTIVE: We seek to describe the procedure, complications, and functional outcomes of utilizing the cecum and ascending colon for creation of a neovagina on a gynecologic oncology service. METHODS: A search of all the cases on the gynecologic oncology service over a ten year period yielded fourteen cases of cecal neovagina. A retrospective chart review was performed. Post-operatively, each patient was evaluated at regular intervals. At each visit, they were asked standardized questions, a physical exam was performed by the same provider, and they were advised to follow a uniform regimen of physical rehabilitation. RESULTS: Eight of the fourteen cases were performed for surgical stricture or vaginectomy, while the indication for the other six patients was radiation fibrosis. The patients were followed for a median length of 37 months. The percentage having intercourse was between 86% and 100% over the course of the first year. Thirteen of the fourteen patients reported intercourse as "comfortable", eleven of the fourteen stated that intercourse was "pleasurable", and seven patients reported having orgasms. The major reported complaint was mucusy discharge, which all patients reported as moderate to severe for the first six weeks. Over time, this improved, and only one patient required the use of pads at twelve months. There were no intestinal anastomotic leaks in the group. CONCLUSIONS: The functional outcomes in our case series show that the cecal neovagina is a safe, uncomplicated, and viable option for those patients who have lost sexual function due to stricture formation or surgical removal of the vagina.

The use of argon beam coagulation in treating vulvar intraepithelial neoplasia III: a retrospective review.

UNLABELLED: Argon beam coagulation (ABC) has unique properties which make it suitable for the local treatment of superficial epithelial disorders such as vulvar intraepithelial neoplasia (VIN III). OBJECTIVE: To evaluate argon beam coagulation in treating multifocal VIN III. METHODS: Argon beam coagulation was used in twenty-nine patients. ABC was set at 80 W, 7 L/min. All patients were given 1% silvadene cream to apply to vulva. Patients had follow-up appointments two weeks and six weeks postoperatively. Patients were followed every three to six months for the subsequent year. RESULTS: 2 of 29 (6.8%) experienced moderate pain within the first two weeks postoperatively requiring prescriptions for perocet. 2 of 29 (6.8%) had yeast infection requiring diflucan. Mean follow-up time was 34.9 months (11.7-37.4). 15 of 29 (51.7%) had no recurrence within the follow-up period. 14 of 29 (48.3%) recurred within the follow-up period. The mean time to recurrence is 23.2 months. CONCLUSION: This small retrospective review is the first to evaluate argon beam coagulation in treating multifocal VIN III. This review indicates that ABC is comparable to other vulva organ conserving therapies. ABC retains cosmesis, and form of the vulva. This is a major advantage over surgery. Repeat treatments are also possible, which is important in a condition such as VIN, which tends to be multifocal and recurrent.

Post fellowship training in "new-to-them" surgical techniques: assessment of learning curve characteristics.

OBJECTIVE: To evaluate surgically related quality outcomes during the learning curve for board-certified or board-eligible gynecologic oncologists developing "new-to-them" surgical techniques. METHODS: The study design was a retrospective review of patients with endometrial cancer clinically limited to the uterus and/or cervix undergoing TLH-BSO or TAH-BSO, aortic and pelvic lymphadenectomy(APLNDx), peritoneal washings with/without omentectomy from May 1996 to April /2006. A "senior" surgeon taught three board-certified or board-eligible gynecologic oncologists a "new-to-them" technique to perform both TLH-BSO and TAH-BSO with APLNDx using argon beam coagulation and endoscopic staplers in patients with early-stage endometrial cancer. The main outcome measures were: a) length of surgery; b) surgical measures, e.g. lymph node count; and c) peri-operative morbidity. A comparison of outcomes with the "senior" surgeon was undertaken. The learning curve characteristics were analyzed by ANOVA and curve estimate analysis. RESULTS: The mean operative times associated with learning a new technique to perform TLH-BSO with APLNDx and TAH-BSO with APLNDx were 155.39+/-26.32 and 102.28+/-34.22 min, respectively, with significant improvement after 20 cases (150.27+/-26.68 vs. 172.30+/-22.28, p=0.030) and 30 cases (93.30+/-24.97 vs. 124.63+/-29.73, p=0.030), respectively. Intra- and peri-operative morbidity and lymph node count were unaffected by experience. CONCLUSION: While mean operative times decreased, outcome measures of surgical quality were not adversely affected during the learning curve for post-fellowship training while acquiring "new-to-them" surgical techniques. This study emphasizes the need for "senior" surgical supervision during the initial training period. The results of this study are likely transferable to fellowship-trained gynecologic oncologists learning other "new-to-them" surgical techniques and procedures.

Laparoscopic use of a hyaluronic acid carboxycellulose membrane slurry in gynecological oncology.

OBJECTIVES: We evaluated the use of a hyaluronic acid-carboxycellulose membrane (HAC) slurry in complex laparoscopies. MATERIALS AND METHODS: A gel-like mixture of HAC was prepared and applied in 171 consecutive complex laparoscopies on a gynecologic oncology service. The HAC slurry was used to coat deperitonealized surfaces and surgical pedicals to prevent postoperative adhesions. The technique is described and the outcomes are prospectively evaluated for feasibility and safety. RESULTS: There were no postoperative bowel obstructions, 1 pelvic hematoma in a patient on clopidogrel (Plavix) immediately prior to surgery, 8 postoperative ilea, and 1 bowel perforation. The bowel perforation occurred in a patient with extensive adhesiolysis and intraoperative bowel suturing. CONCLUSION: This report describes an easy approach to the laparoscopic application of HAC. Caution should be taken if HAC slurry is applied after significant bowel suturing because 1 of 9 patients with extensive adhesiolysis requiring suturing of the sigmoid colon developed sigmoid perforations.

Extended left colon resections as part of complete cytoreduction for ovarian cancer: tips and considerations.

OBJECTIVES: Colectomy is a common part of cytoreductive surgery. The most common segment of the colon resected is the rectosigmoid. Extended left-sided colectomies are rarely performed. With increased emphasis on the importance of maximal cytoreductive surgery it is becoming more important to understand the outcomes related to such a procedure. The purpose of this report is to evaluate the quality of life issues related to extended left colectomies. METHODS: Data on all patients who underwent cytoreductive surgery between April 2007 and April 2009 was prospectively recorded. Nineteen patients underwent extended left colon resections. The data from these cases was evaluated with particular attention directed at the quality of life issues surrounding postoperative bowel function, and tolerance of postoperative chemotherapy. RESULTS: Nine underwent resection of the left hemicolon plus the hepatic flexure. Six underwent resection of the left hemicolon, hepatic flexure, and the ascending colon. Four underwent subtotal colectomies. Temporary diverting loop ileostomies were performed on 18 of the 19 patients each of whom consented for intraperitoneal chemotherapy. No delays in chemotherapy were observed. Median number of bowel movements at 6, 9 and 12 months were 2, 2 and 1, respectively. No fecal incontinence was observed. Patients expressed satisfaction with their bowel surgery and denied any significant decrease in their quality of life due to their bowel function. CONCLUSION: Extended left colon resection is a reasonable technique to include in patients requiring maximal cytoreduction. Quality of life related to bowel function is acceptable and chemotherapy is not delayed.

Clinical Approach to Diagnosis and Management of Ovarian, Fallopian Tube, and Peritoneal Carcinoma.

Ovarian, fallopian tube and peritoneal carcinomas make up the deadliest group of malignancies of the female genital tract. Ovarian carcinoma is the second most common malignancy of the female reproductive tract in developed countries and the sixth most common cancer diagnosed in women in the United States. While signs and symptoms of ovarian carcinoma related to the mass-effect of advanced disease are relatively common, no reliable signs or symptoms are seen in patients with early ovarian carcinoma. The diagnosis can only be made by surgical removal and pathologic evaluation of a suspicious mass. The authors present an overview of the disease and discussions of genetic predisposition, prevention, screening, and diagnosis of ovarian, fallopian tube and primary peritoneal carcinomas. Details on staging procedures as well as surgical and chemotherapeutic techniques are outlined for the various stages of disease.

Full-thickness diaphragmatic resection with simple and secure closure to accomplish complete cytoreductive surgery for patients with ovarian cancer.

OBJECTIVE: The diaphragm is a common site of metastasis in patients with primary ovarian cancer. While most diaphragmatic implants are superficial, invasive disease can occur. This report evaluates the use of full-thickness diaphragmatic resection in completely cytoreduced ovarian cancer. METHODS: A prospective record of all patients with ovarian cancer treated between May 1, 2002, and September 30, 2003, was kept. Seven of the 37 patients required full-thickness diaphragmatic resection to achieve complete cytoreduction. The surgical technique and outcome as well as the clinical course and disease status were monitored. RESULTS: Full-thickness diaphragmatic metastases were resected and diaphragmatic defects were closed with #1 loop-PDS suture in a mass closure technique. In addition to diaphragm resections, a variety of other procedures were performed to achieve complete cytoreduction. Intraoperative blood loss ranged from 800 to 2500 ml. Operating room time ranged from 3.5 to 7 h. No chest tube placements were required. The length of hospitalization ranged from 10 to 24 days. Paclitaxel and carboplatin was administered to each patient without the need for dose reductions or treatment delays. Complete clinical response was achieved in six of seven patients. One patient died with disease 4 months after surgery. Follow-up ranged from 4 to 21 months. CONCLUSIONS: Diaphragmatic resection is feasible and has minimal morbidity. The use of a loop-PDS suture to close the diaphragmatic defect adds ease and security to the procedure. If complete cytoreduction can be accomplished with the use of this procedure, it is conceivable that benefits in clinical outcomes may be offered to patients with aggressive, advanced ovarian cancer.

Delayed uterine re-inversion: a unique symptom complex.

A case of late recurrence of uterine inversion is presented. Symptoms included constipation and urinary retention without uterine bleeding. Symptoms resolved 3 months after the replacement of the uterus. It is hypothesized that the symptoms were related to stretch injury to the pelvic parasympathetic nerves. Timely intervention may prevent long-term sequelae.