Sonographic evaluation of uterine volume and its clinical importance.

AIM: The study was conducted to: (i) measure uterine volume in adolescent and perimenopausal age groups with normal pelvic findings and in women with pathological uteri scheduled for surgery, and (ii) utilize uterine volume as a parameter for the management of perimenopausal women scheduled for vaginal hysterectomy. METHODS: Data of 800 clinically non-gravid uteri of 16 weeks or smaller size with benign pathology scheduled for vaginal hysterectomy, and 150 adolescent women and 150 perimenopausal aged women with clinically and sonographically normal pelvic findings with normal uteri from the authors private practices were studied to find related sonographic uterine volume. Cases clinically more than 16 weeks size were not included in the study. Normal and pathological hysterectomized uteri were weighed postoperatively to compare their weight with preoperatively estimated uterine volume. Additionally, 200 pregnant women clinically diagnosed as 12 weeks pregnant and without pathology also underwent sonography to estimate their uterine volume. RESULTS: Uterine volume varied from 15 to 56 cm3 in women with a normal uterus. In 12 week sized non-pregnant benign pathological uteri, as well as pregnant uteri, uterine volume averaged 240 cm3 . Uterine weight was higher when compared with preoperatively estimated uterine volume. CONCLUSIONS: The study results emphasize uterine volume as an important parameter for the management of young and elderly women, particularly with menorrhagia. The uterus is anticipated to weigh more than the uterine volume, which can assist with diagnosis and management.

Vaginal hysterectomy as a primary route for morbidly obese women.

Vaginal hysterectomy is a least invasive and the choicest route when hysterectomy is possible by recourse to all the three available techniques. However in obese women, the common method is by the more invasive abdominal or laparoscopic route, with attendant morbidity. Vaginal hysterectomy was reviewed in 102 morbidly obese women (body mass index, BMI > or = 40) and compared with 50 comparable morbidly obese women who underwent abdominal hysterectomy and with vaginal hysterectomy in 200 normal weight women (BMI < 25). Time for vaginal hysterectomy was slightly but significantly longer in the morbidly obese compared to those of normal weight, while the abdominal approach was significantly longer in the morbidly obese. Hospital stay was significantly longer for the abdominal operations in the obese. Surgical and anesthetic complications did not differ. In the absence of specific contraindications for vaginal hysterectomy it is recommended that the surgeon should perform hysterectomy vaginally and consider obesity as a contraindication for taking the abdominal route.

Vaginal hysterectomy.

The vaginal route is a safe, feasible, and patient-friendly method of performing a hysterectomy. Proponents and practitioners of vaginal hysterectomy have widened their indications and decreased the contraindications through liberal usage of debulking, performing oophorectomy, laparoscopic evaluation and trial vaginal hysterectomy. This traditional approach with surgical advances can be used more frequently.

Reproductive health and obstetricians and gynecologists.

The art of medicine provides a rare opportunity to understand human values and to contribute toward the well-being of one's fellow humans--women in the case of ob-gyn--a contribution that fits in with the mission of the International Federation of Gynaecology Obstetrics (FIGO). Obstetricians and gynecologists should indeed take it upon themselves to improve conditions for women, since the bond and respect between the two is a significant one. It is obstetricians-gynecologists who can provide the much needed technical information to throw light on justifying services that deal with devastating, debilitating, degenerating, and devaluating situations, such as neglected pregnancy, disregard toward cancer detection, and humiliating genital mutilation. Indeed, this can be termed as "terrorism in ob-gyn," neglected by those who should deal with it. Those in ob-gyn and other medical professions clearly witness gender inequality and its ugly aftermath, a degradation of women's reproductive rights. Ob-gyn must look a little beyond just the lucrative practice of the plain science of obstetrics and gynecology and undertake the responsibility to help and protect the health and life of women around the world. A conscientious doctor cannot practice medicine on women's bodies alone, but must also "practice" against several social evils, the prevention of which is crucial to women's health. Obstetricians and gynecologists can utilize their access to policymakers and health "builders" to carry this brief for women's health, and can urge governments to take a second look at women's rights to ensure that they are on par with the accepted norms of human rights, to be protected and propagated.

The scope of vaginal hysterectomy.

OBJECTIVE: The study was designed to check the feasibility of the vaginal route as the primary route for hysterectomy. STUDY DESIGN: All patients in whom hysterectomy was indicated were first considered for vaginal hysterectomy unless this route was contraindicated. Vaginal hysterectomy (VH) was performed in 5655 patients, and in 90.4% of these no uterine prolapse was present. The operative intervention required, preconditions and any complications were carefully studied. RESULTS: Of the 6945 cases considered, vaginal hysterectomy was possible in 5655 (81%). Successful simultaneous prophylactic oophorectomy or salpingo-oophorectomy was possible, in 1510 of 1572 cases without laparoscopic assistance. The indications are carefully discussed, with a strong emphasis on examination under anaesthesia, preoperative total uterine volume and, if required, laparoscopic evaluation and surgeons' readiness to reduce the frequency of recourse to laparotomy or laparoscopic assistance. CONCLUSION: The vaginal route is the least invasive and most economical route for hysterectomy and should be the gynaecological surgeon's first choice. A uterus with a volume up to 300 cm3 or uterine size up to 12 weeks should be dealt with vaginally, and as surgeons become more experienced larger uteri and also the adnexa can be approached in the same manner, at least as trial vaginal hysterectomy.

Vaginal hysterectomy in women with a history of 2 or more cesarean deliveries.

OBJECTIVE: To perform vaginal hysterectomy (VH) safely in women with a history of 2 or more cesarean deliveries (CDs). METHODS: A 4-step method was followed to safeguard the bladder, access the vesicouterine peritoneum (VUP), and perform VH in 312 patients with a history of 2 or more CDs. If access to the VUP did not occur at the end of step 2, step 3 and, if necessary, step 4 were implemented. RESULTS: Hysterectomy was performed vaginally in 311 patients, and the abdominal route was resorted to in 1 patient because of hemorrhage. Only 1 patient incurred bladder trauma, which was promptly repaired. CONCLUSION: In the absence of contraindications, the 4-step VH method described and the surgical techniques involved are safe to implement in women with a history of 2 or more CDs who need a hysterectomy.

Anterior, posterior and apical vaginal reconstruction with and without bolsters.

Pelvic-organ-prolapse repair presents unique challenges to the pelvic surgeon. Historically, the unacceptable failure rates with traditional procedures have instigated the many conceptual and technique changes. Critical analysis of the biomechanics of normal and altered anatomy has shifted the primary focus of surgeries from the midline of the distal vagina to the interspinous diameter. In addition, just as surgeons in other fields have begun to incorporate bolsters into various types of repairs, the field of prolapse repair has seen a proliferation of materials that are available to help strengthen repairs. Much effort, time and significant resources have been invested in improving these repairs, but much remains to be learned. The rapid pace of change has prevented the development of the type of evidence-based data that are needed to analyse accurately the specific risks and benefits of the various available approaches. Conceptual changes in the aetiology of pelvic organ prolapse, pelvic biodynamics and the specific nature of connective tissue damage have helped to fuel the rapid pace of change.

Vaginal route: a gynaecological route for much more than hysterectomy.

Vaginal hysterectomy is the method of choice for gynaecologists who carry out hysterectomies. Undertaking this procedure regularly will enhance the gynaecologist's level of skill and enable conditions such as ovarian cysts, broad ligament fibroids and other adnexal pathology to be dealt with vaginally during hysterectomy surgery without abdominal invasion. It is also important as the vaginal route allows access to the posterior cul-de-sac, which can facilitate surgery or offer an alternative route to achieving the desired outcome. In this chapter, we look at the main indications for vaginal surgery, and also at other conditions in which vaginal surgery may be suitable (e.g. benign and malignant conditions). We believe that gynaecologists who include vaginal surgery in their armamentarium are better equipped to serve their patients.

A surgical window to access the obliterated posterior cul-de-sac at vaginal hysterectomy.

OBJECTIVE: To perform vaginal hysterectomy and adnexectomy without laparoscopic assistance in women with ovarian endometriosis by accessing the posterior cul-de-sac via the posterior uterocervical-broad ligament space. METHOD: The author identified the posterior uterocervical-broad ligament space as a surgical window while reviewing his experience at accessing the pouch of Douglas in 40 women in whom vaginal hysterectomy without laparoscopic assistance was performed for ovarian endometriosis. He then used this window in 102 women to remove the adnexa vaginally during vaginal hysterectomy, also without laparoscopy. RESULTS: This new technique was successful in 98 women, with no major complications, but 4 of the first 50 required laparotomy to complete the surgery. CONCLUSION: This new approach allows experienced surgeons to treat women with endometrial ovarian cysts by removing the adnexa vaginally during vaginal hysterectomy without laparoscopy, and complete the surgery abdominally or laparoscopically when necessary.

Adnexectomy for benign pathology at vaginal hysterectomy without laparoscopic assistance.

Of 166 consecutive women with a benign adnexal mass scheduled for vaginal hysterectomy with adnexectomy, the operation was successful in 158 (95%). Preoperatively, attempts were made to ascertain that adnexal mass was benign and either freely mobile or with only slightly restricted mobility. Laparotomy was required in eight women, in five for adhesions and in three for malignancy detected during the operation. No woman required laparoscopic-assisted surgery. The 158 women who had successful vaginal hysterectomy with adnexectomy were compared with 100 similar women who had a laparotomy performed by same single operator. The vaginal group had a lower morbidity, speedier recovery and shorter hospital stay.

Reduction in mortality needs a bit more than the science of perinatology.

The absence or non-availability of medical centers with inaccessible distance and delay in providing treatment is an insurmountable problem in backward regions. A pregnant mother from a developing country is 30 times more likely to die than a mother from a developed country and her newborn faces the same risk of mortality. The involvement of government is a vital part of the attempt to achieve improvements. Government has the power and obstetricians have the information to lead the way. No doubt even when the two cooperate there is still room for inadequacy, but perhaps partners like the WHO, UNFPA, UNICEF, IPPF, FIGO, World Bank, World Association of Perinatal Medicine, World Pediatric Association, International Midwives Confederation, etc. can help to achieve targets. There is urgent need for the twinning of the perinatal departments of developing countries with the perinatal departments of advanced countries and/or the twinning of countries or geographical areas, or of NGOs with government and change in mindsets where required. To obtain the maximum benefits from such an approach, it would be necessary to go a little beyond perinatal science.

Laparoscopic tubal sterilization after two or more cesarean sections.

STUDY OBJECTIVE: To determine the safety of laparoscopic tubal sterilization in women who have had two or more cesarean sections. DESIGN: Retrospective study (Canadian Task Force classification III). SETTING: Private clinic and hospitals. PATIENTS: Two hundred ten consecutive women. INTERVENTION: Laparoscopic tubal sterilization. MEASUREMENTS AND MAIN RESULTS: The procedures were done with no difficulty in all but two women. In addition to the two failures, one woman experienced bladder trauma. CONCLUSION: Laparoscopic sterilization after several cesarean sections is possible and is associated with low morbidity. Scarring from cesarean sections should not be a contraindication if extra care is taken.