Modified vaginal hysterectomy for chronic non-puerperal complete uterine inversion: video presentation.

INTRODUCTION AND HYPOTHESIS: Chronic non-puerperal complete uterine inversion is a relatively rare condition. Abdominal Haultain's operation is the usual management. We present such a case with fundal fibroids managed by modified vaginal hysterectomy. METHODS: Preoperative computerized tomography enhanced intravenous urogram depicted normal ureters and bladder. Diluted vasopressin (10   U in 100   ml normal saline) was infiltrated at the base of the myoma and a myomectomy was performed. The fundal raw area was pierced to reach the formed space between the anterior and posterior uterine serosa. The bilateral round ligaments were clamped, cut, and ligated. Diluted vasopressin was injected into the fundal anterior uterine wall and about 1   cm was excised. Then, the bilateral utero-ovarian ligaments were clamped, cut, and ligated. In the same way another 1   cm of anterior uterine wall was excised and the bilateral uterine vessels were clamped, cut, and ligated. The rest of the uterine wall area was infiltrated with diluted vasopressin circumferentially. An incision at the vesico-cervical junction was made and the bladder pushed up. The posterior fornix area was incised and the Pouch of Douglas (POD) opened. Vesico-uterine pouch opened under finger guidance placed through POD. The rest of the anterior uterine wall was excised. Exposed bilateral cardinal-uterosacral ligament complexes (CULCs) were clamped, cut, and ligated. The remaining vaginal attachments ligated hemostatically and the vault was closed. For vault prolapse prevention, vault closure suture ends were tied with ipsilateral CULC suture end, brought outside the vagina at vault angle. RESULTS: A follow-up visit up to 1   year found no complications. CONCLUSION: This novel reverse vaginal hysterectomy combining the principles of both abdominal and vaginal hysterectomy can successfully manage chronic non-puerperal complete uterine inversion.

Single-dose nonavalent HPV vaccine: Need of the hour.

Human Papilloma Virus (HPV) vaccination of the preadolescent (9-14 years) females is the potential solution to eradicate carcinoma cervix. Nonavalent vaccine provides wider coverage than the quadrivalent vaccine. On long-term follow-up, even after single-dose HPV vaccination, the antibody titer remains good. Herd immunity can also be achieved by HPV vaccination. Hence, mass single-dose nonavalent HPV vaccination for sexually naive preadolescent girls can provide almost 100% protections and a cost-effective approach for the developing countries.

Extraperitoneal uterosacral ligament suspension by using the cervix as a traction device.

The present video demonstrates extraperitoneal uterosacral ligament suspension (ULS) while performing vaginal hysterectomy for POP-Q stage 3 prolapse. The ULS bites were taken before severing the uterosacral ligament using the cervix as a traction device. Two ULS sutures were applied on each side to the distal half of the intermediate part. Superior 1st ULS suture with permanent material (polypropylene) was applied to the uppermost exposed area. Inferior 2nd ULS suture with delayed absorbable material (polyglactin) was 0.5-1 cm distal to the superior suture. Next, the usual first clamp of the vaginal hysterectomy (VH) on a cardinal-uterosacral ligament was applied about 1 cm below the second ULS suture. The VH was completed. The ULS sutures were anchored to the vault via either the vesico-vaginal septum or the recto-vaginal septum. Permanent sutures were not brought outside the vaginal epithelium. In 51 cases there was no urological injury. On follow-up (average 2.3 years), 8.3% cases had stage 1 POP, 91.6% had no POP.

Approach to a woman with urinary incontinence.

Urinary incontinence is a bothersome situation to the ailing woman. Many times, the woman does not come to medicos due to shyness, and if she comes also she does not reveal all the information. Hence, a sympathetic and structured approach will help to provide judicious management to these women. When a woman with the complaint of urinary incontinence approaches us, we should collect maximum information with the help of structured questionnaire and protocol. Structured questionnaire provides most of the information pertinent to the urinary incontinence. Associated medical disorders are also looked for. Past obstetrical performance can have implication on this ailment. Pelvic organ prolapse, mass lower abdominal, etc., also can lead to urinary incontinence. Adverse effect of some medicines causes urinary incontinence. During general physical examination, attention has to be paid toward body mass index, joint hypermobility, spine, etc. During local examination, stress test, Bonney test, Q-tip test, etc., may help to some extent. The levator ani muscle is assessed of its strength. Neurological evaluation is to be done for all the patients with urinary incontinence. Urinary culture and sensitivity are routinely done. Once urinary infection is ruled out, then the woman is subjected to frequency/volume diary, ultrasonography, urodynamic study, cystoscopy, etc., depending on the necessity. A systematic approach to urinary incontinence will provide the best comfort to these ailing women.

Modified extraperitoneal uterosacral ligament suspension for prevention of vault prolapse after vaginal hysterectomy.

INTRODUCTION AND HYPOTHESIS: During vaginal hysterectomy, extraperitoneal uterosacral ligament suspension (ULS) bites can be taken before removing the uterus. We evaluated this modified extraperitoneal ULS for vault prolapse prevention. METHODS: Study period was 3.5 years. Fifty-one women with third- and fourth-degree prolapse were enrolled. An inverted V incision was made on the anterior vaginal wall and continued as a semicircular incision on the posterior vaginal wall. Lateral vaginal mucosa was pushed up to expose the cardinal-uterosacral ligament complex. The first ULS suture, using polypropylene no. 1, was taken in the upper-most exposed area of the uterosacral ligament. The second suture, using polyglactin no. 1 or 0, was taken 0.5-1 cm below the first suture. During placement of both sutures, traction on the cervix was maintained. The cardinal-uterosacral ligament complex was clamped, dissected, and ligated 1 cm below the second suture. Vaginal hysterectomy was completed. Ends of the ULS suture were fastened to the vault via vesicovaginal and rectovaginal septum using polypropylene within and polyglactin outside vaginal mucosa. RESULTS: Prolapse stage was 3 in 42 cases and 4 in nine. Duration of operation ranged from 60 to 120 min. Blood loss was 100-300 ml. During follow-up (average 2.3 years) four (8.3%), cases had stage 1 pelvic organ prolapse (POP), three were lost to follow-up, and 44 (91.6%) had no POP. CONCLUSIONS: Using the cervix as a traction device is a good option when performing extraperitoneal ULS during vaginal hysterectomy to prevent vault prolapse.

Prevalence and age-wise distribution of Human Papillomavirus type 16/18 infections among hospital screened women of a peri-urban area in West Bengal: Impact of socio-demographic factors.

BACKGROUND: We undertook the current study on cervical Human Papillomavirus (HPV) prevalence along with cytology in women visiting the Gynecology Out-patient Department of a hospital for common gynecological ailments, subsequent to our earlier population-based study on HPV prevalence from India. METHODS: We analyzed data on cervical-cytology (Pap smears) and PCR-based molecular detection of HPV infection along with socio-demographic variables (N = 696). RESULTS: We identified 36.84% HPV-positive women amongst whom, HPV16 and 18 together predominated (79.37%) over other HPV types (20.63%). Contrarily, only 6.4% women revealed abnormal cytological lesions, of which, 46.51% were HPV-positive and 95% of such women harbored HPV16/18, while 5% harbored other HPV types. Individuals with normal cytology portrayed 36.09% HPV infections, of which, 77.97% were HPV16/18-positive and 22.03% harbored other HPV types. Overall HPV prevalence decreased significantly (ptrend  = 0.047) with increase in age, but HPV16/18 infections were significantly over-represented compared to the other HPV types across all age-groups. Specifically, HPV16 prevalence increased (p trend < 0.01) with increase in severity of cervical lesions. HPV16 prevalence did not differ between the Hindus and Muslims but HPV18 was significantly higher among the cytologically normal Muslim women (24.14%, p = 0.02), compared to the Hindus (11.91%), specifically among those ≥ 30 years of age. There was a significant (p < 0.05) overrepresentation of HPV16 prevalence among women who were users of oral contraceptive-pills, irrespective of cytology. CONCLUSIONS: Our study highlights the need for HPV16/18-based screening of cervical cancers in India considering the immense socio-cultural and genetic diversity at the population level.

B-Lynch Brace Suturing in primary post-partum hemorrhage during cesarean section.

Primary atonic post-partum hemorrhage during lower segment cesarean section, which was not controlled by ecbolics--oxytocin, methylergometrine, 15-methyl-prostaglandinF2alpha--was managed by applying a B-Lynch Brace Suture. The test of potential efficacy was the control of hemorrhage by bimanual uterine compression. Six primigravida patients at their term gestation, who underwent emergency cesarean section, all except one under spinal anesthesia, received this type of suture. Interestingly, in every case hemorrhage was controlled successfully with the compression suture. None of them received blood or blood products transfusions or developed disseminated intravascular coagulopathy. Postoperative recovery was good and all patients are in follow-up to assess their future reproductive activity. B-Lynch Brace Suturing is an invaluable procedure for the control of atonic primary post-partum hemorrhage following cesarean delivery.