Complex obstetric fistulas.

Obstetric fistulas are rarely simple. Most patients in sub-Saharan Africa and parts of Asia are carriers of complex fistulas or complicated fistulas requiring expert skills for evaluation and management. A fistula is predictably complex when it is greater than 4 cm and involves the continence mechanism (the urethra is partially absent, the bladder capacity is reduced, or both); is associated with moderately severe scarring of the trigone and urethrovesical junction; and/or has multiple openings. A fistula is even more complicated when it is more than 6 cm in its largest dimension, particularly when it is associated with severe scarring and the absence of the urethra, and/or when it is combined with a recto-vaginal fistula. The present article reviews the evaluation methods and main surgical techniques used in the management of complex fistulas. The severity of the neurovascular alterations associated with these lesions, as well as inescapable limitations in staff, health facilities, and supplies, make their optimal management very challenging.

Obstetric vesico-vaginal fistulas at the National Hospital of Niamey, Niger.

OBJECTIVE: To determine the epidemiologic and therapeutic characteristics of obstetric vesico-vaginal fistulas at the National Hospital of Niamey, Niger. METHODS: From December 2003 to February 2005, 111 consecutive patients with vesico-vaginal fistulas presenting for treatment were included and prospectively followed up. Demographic and clinical data were collected. The patients were re-evaluated 3 months after surgery. RESULTS: Among the 104 patients treated surgically 87% were aged between 15 and 36 years; 84% were married before they were 19 years old; 51% were divorced; and 80% did not live with their husbands. The fistula was caused by the first delivery in 43% of the patients; 93% were in labor for more than 24 hours; 35% were delivered at home; and perinatal death was 100%. The overall cure rate was 73%. CONCLUSION: These epidemiologic characteristics provide data towards the development of an obstetric fistula prevention program in Niger.

A vaginal and extraperitoneal approach to surgically stage patients with endometrial cancer.

OBJECTIVE: The purpose of this project was to prospectively evaluate the feasibility of an alternative technique for surgically staging patients with endometrial cancer. METHODS: Patients with endometrial cancer were enrolled in this protocol from September 1999 until August 2000. The staging procedure included pelvic washings via colpotomy, total vaginal hysterectomy, bilateral salpingo-oophorectomy (TVH/BSO), and extraperitoneal pelvic and paraaortic lymphadenectomy (EP-LND) if indicated. Tumor characteristics, time and feasibility of surgical procedures, length of hospital stays, and complications were prospectively recorded. RESULTS: Twenty-one patients were enrolled. Grade 1, 2, and 3 tumors were identified in 6 (29%), 10 (48%), and 5 (24%) patients, respectively. Pelvic washings and TVH/BSOs were performed on all patients. A total of 21/21 (100%) uterine specimens were removed vaginally and 41/42 (98%) adnexa were resected vaginally. EP-LNDs were performed on 17 (81%) patients due to pathologic findings of the uterine specimens. The median time to perform a TVH/BSO was 68 (47-149) min. The median time to complete a EP-LND was 77 (59-107) min. The median number of postoperative days was 1 (1-5). Complications were infrequent and mild. CONCLUSIONS: TVH/BSO, pelvic washings, and EP-LND is a feasible alternative to standard surgical staging of endometrial cancer. The minimal amount of exposure to the intraperitoneal space makes this approach arguably the least invasive for endometrial cancer staging and accounts for the decrease in recovery time and shortened hospital stays. The acceptable length of surgical time, short hospital stays, and minimal requirements for surgical instruments make this approach potentially the most cost-effective option for surgically staging patients with endometrial cancer. A randomized trial comparing this technique to standard surgical staging is warranted.

Hyaluronic acid-carboxymethylcellulose film and perianastomotic adhesions in previously irradiated rats.

OBJECTIVE: Postoperative intra-abdominal adhesions are a major source of postsurgical morbidity. Pelvic irradiation increases the likelihood of adhesion development. The purpose of this study was to evaluate the effects of hyaluronic acid-carboxymethylcellulose film, which was designed as a barrier to prevent adhesions, on the healing of ileal anastomoses performed on irradiated rat bowel. STUDY DESIGN: Sixty-eight female Sprague-Dawley rats underwent whole pelvic irradiation with a single fraction of 1700 cGy. Twenty weeks later the rats underwent exploratory laparotomy with segmental ileal resection and reanastomosis. Eighteen of the anastomoses were wrapped in hyaluronic acid-carboxymethylcellulose film. Fifty anastomoses were not treated with any adhesion-inhibiting barrier. On the fifth postoperative day the animals underwent another laparotomy for evaluation of the anastomotic sites. RESULTS: At the second laparotomy 93% of the rats treated with hyaluronic acid-carboxymethylcellulose film were found to have perianastomotic abscesses. In the non-hyaluronic acid-carboxymethylcellulose film group the perianastomotic abscess rate was 24% (P <.0001). CONCLUSION: Among previously irradiated rats undergoing small-bowel resection and anastomosis, hyaluronic acid-carboxymethylcellulose film was associated with a markedly increased rate of abscess formation at the operative site.

Recombinant growth hormone's effects on the strength and thickness of radiation-injured ileal anastomoses: a rat model.

BACKGROUND: Small bowel resections following radiotherapy for gynecologic cancers have resulted in significant rates of morbidity and mortality. The objective of this study was to evaluate the effect of rGH on the breaking strength and thickness of radiation-injured ileal anastomoses in an animal model. MATERIALS AND METHODS: Sprague-Dawley rats were treated with 1800 cGy of pelvic irradiation in a single fractionation. Seventeen weeks following pelvic teletherapy an ileo-ileostomy was performed. The rats were randomized to receive 2.0 mg/kg/day of rGH for 7 days or placebo. On the seventh postoperative day a segment of ileum surrounding the anastomosis was resected. The segments were tested for breaking strength or were histologically measured for anastomotic thickness. RESULTS: The ileal anastomotic breaking strength in the rGH group was 181 +/- 8.4 g (mean +/- standard error). The breaking strength of ileal anastomoses in the placebo group was 133 +/- 6.9 g (P < 0.05). The rGH group demonstrated a greater anastomotic thickness (1.65 +/- 0.116 mm) than the placebo group (1.17 +/- 0.113 mm, P < 0.05). Of placebo rats 14.7% developed anastomotic leaks compared to 0% of rGH-treated animals (P < 0.05). CONCLUSIONS: RGH increased the ileal anastomotic breaking strength by 36% in radiated rats. The anastomotic leak rate was reduced from 14.7% in the placebo group to 0% in the rGH group. These findings correlated with a 41% increase in the thickness of the anastomotic connective tissue in the rGH group. Clinical investigation in selected patients is warranted.

The effect of growth hormone on the bursting strength of ileal anastomotic segments in radiation-injured rat bowel.

The potential for postoperative complications in irradiated intestinal anastomoses is well known. There has been limited evaluation of factors that may improve wound healing in radiation-injured bowel. Growth hormone (GH) has been shown to improve wound healing. In animal models GH has been demonstrated to increase strength of large bowel anastomoses in nonirradiated bowel. The purpose of this study was to evaluate, in a rat model, the effect of GH on the bursting pressure of radiation-injured terminal ileal anastomoses in a rat model. Fifty-four rats were treated with 1700 cGy of pelvic irradiation in a single dose. Seventeen weeks later resection of a segment of terminal ileum and an ileo-ileostomy was performed. Half the rats received GH (2.0 mg/kg/day) and the rest received normal saline subcutaneously for 7 days starting on the day of surgery. On the seventh postoperative day the anastomosis site was identified at reoperation and bursting pressure was measured in vivo. A significantly greater bursting pressure was observed in the GH-treated rats compared to the control group (208.9 +/- 27 cm H2O vs 177 +/- 53 cm H2O, P < 0.025). GH treatment resulted in an 18% greater strength of radiation-injured terminal ileal anastomotic segments, as measured by bursting pressure. These findings suggest a possible role for GH in decreasing the morbidity in patients who undergo intestinal surgery after radiation treatment.

The effect of recombinant growth hormone on the strength of ileal anastomoses in a rat model.

OBJECTIVE: In gynecologic surgery, the ileum is the primary site of bowel injury. Recombinant growth hormone (rGH) has been shown to improve the strength of colonic anastomoses in experimental models. The purpose of this study is to evaluate the effect of rGH on small bowel anastomoses, specifically in the ileum. METHODS: Twenty large female rats underwent segmental ileal resections and end-to-end ileoileostomies. The rats were randomized to be treated for 7 postoperative days with either rGH (2.0 mg/kg/day) or placebo starting on the day of surgery. On the seventh postoperative day, a segment of ileum surrounding the anastomosis was resected. The anastomoses were tested for breaking strength on a tensiometer and for tissue concentrations of hydroxyproline. RESULTS: The ileal anastomotic breaking strength in the rGH group was 163.5 +/- 6.0 g (mean +/- standard error). In the placebo group, the breaking strength of ileal anastomoses was 125.0 +/- 3.0 g (P < .001). No significant difference was demonstrated with respect to the hydroxyproline concentration between the rGH group (15.2 +/- 2.0 micrograms/mg) and the placebo group (14.6 +/- 1.0 micrograms/mg). CONCLUSION: In an animal model, a 31% increase in ileal anastomotic breaking strength was induced by rGH administration. With further research this may translate into decreases in the surgical complications that occur in ileal anastomoses. Furthermore, these serve as preliminary data to a study that evaluates the effect of rGH on ileal anastomoses in radiation-injured bowel.

Radiotherapy as a cisplatin-sensitizer in a resistant ovarian carcinoma cell line.

BACKGROUND: Stage III ovarian carcinoma has shown resistance to adjuvant chemotherapy following surgical cytoreduction. With recurrence of ovarian carcinoma, cell lines may develop resistance to previously used chemotherapy. This contributes to the fact that survival rates for patients with ovarian carcinoma have not been dramatically improved in decades. The objective of this study is to evaluate radiotherapy as a cisplatin-sensitizer in a cisplatin-resistant ovarian carcinoma cell line. METHODS: In vitro OVCAR-3 human ovarian carcinoma cells were irradiated with external beam radiation (XRT) at doses of 500, 1,500, and 4,500 centigray (cGy) in a single fractionation. Twelve hours after XRT, cells were treated with a dose of cisplatin for 2 hours (0, 1, 3, 9, and 90 micrograms/mL). Cell attachment was determined by cell counts using a hemocytometer under phase-contrast microscopy. Analysis of variance followed by the Student Newman Keuls Test were used for statistical analysis. RESULTS: Dose-response curves demonstrate the results of this study as follows: (1) XRT has a significant direct effect on cell attachment of OVCAR-3 cells in a dose-response relationship. (2) cisplatin has no effect on cell attachment in the absence of XRT. (3) When cells are exposed to XRT, cisplatin demonstrates a dose-response effect on cell attachment with a dose of XRT as low as 500 Gy. CONCLUSIONS: This in vitro study suggests that XRT sensitizes cisplatin-resistant OVCAR-3 to cisplatin. This occurred with doses of radiation low enough to suggest a potential clinical role in treating resistant ovarian carcinoma.

Rabbit fallopian tube reanastomosis using a microvascular stapling device.

The 3M Precise Microvascular Anastomotic System (MAS), a microvascular stapling device, was compared with microsurgery for the reanastomosis of rabbit fallopian tubes. Differences in operative time, tubal patency, adhesion formation, and fertility rate were studied in 18 rabbits. Only 17% of tubes repaired by MAS were subsequently patent by chromopertubation, compared with 72% with microsurgery. Mean nidation indices were 0.05 for MAS and 0.22 for microsurgery. Sixty-one percent of adnexae repaired by MAS were adhesion stage I, whereas 83% of microsurgically repaired adnexae were stage I. Mean operative time was 28.2 min for MAS vs 21.6 min for microsurgery. Only the differences in patency rate and operative time were statistically significant, but the trends suggest that fallopian tube reanastomosis by MAS offers no advantage over conventional microsurgical technique.

Low colorectal anastomosis and reconstruction after gynecologic cancer.

Radical en bloc resection of pelvic tissue remains an important part of the armamentarium of the gynecologic oncologist despite significant advances in radiation oncology and chemotherapy. Total pelvic exenteration can be the only hope of women who have not responded to more conservative therapy. The time has come where it is appropriate to use contemporary techniques in the discipline of reconstructive surgery to restore these women to an acceptable quality of life. It may be the next challenge for the pelvic surgeon to participate in such surgical reconstruction. This challenge is becoming an active part of the oncologic surgical practice in head and neck and breast surgery. This article reviews the techniques that are available in the reconstruction of a functional rectum with elimination of colostomy.

The value of endocervical curettage at time of cervical cone biopsy.

Two hundred eighty-nine patients were evaluated over a 23-month period to assess the efficacy of postcone biopsy endocervical curettage at the time of cervical conization. One hundred eleven patients were excluded because the endocervical curettage was insufficient or not performed, the final pathology on the cone biopsy and endocervical curettage revealed no dysplasia or cancerous process, or the endocervical margins were not assessed, leaving a total of 178 patients in the study population. A negative conization endocervical margin virtually assures no disease in the upper endocervical canal. The negative predictive value in this study population was 97%. We conclude that routine endocervical curettage is unnecessary for most patients and should be primarily considered for patients who are postmenopausal or for those receiving suboptimal conizations.

Recent advances in surgical reconstruction of the gynecologic cancer patient.

Despite significant advances in radiation oncology and chemotherapy, radical en bloc resection of pelvic tissue remains an important part of the armamentarium of the gynecologic oncologist. Total pelvic exenteration can be the only hope of women who failed more conservative therapy. The time has come where it is appropriate to employ temporary techniques in the discipline of reconstructive surgery to restore these women to an acceptable quality of life. It may be the next challenge for the pelvic surgeon to participate in such surgical reconstruction. This challenge is becoming an active part of the oncologic surgical practice in head and neck surgery, and in breast surgery. Reconstructive surgery of the vulva has been well described in the literature with the use of cutaneous and myocutaneous flaps, and it is beyond the scope of this paper to recount them here. This paper reviews the techniques that are available for reconstruction of a functional vagina, restoration of a functional rectum with elimination of colostomy, and reconstruction of a continent urostomy that will allow better physiologic protection of the upper renal tracts and improve the aesthetics of a urine ostomy bag.

Correction of incontinent ileocolic urostomy with Kock's nipple valve.

Continent urostomy procedures may be replacing the incontinent ileal or colon conduit as the preferred method of urinary diversion in gynecologic cancer patients. One method of continent urinary diversion utilizes the detubularized ascending and transverse colon as a reservoir with a tapered segment of distal ileum as the stoma through which the patient catheterizes the pouch (Miami pouch). Failures of this procedure have been reported. A case report of such a failure is presented. This patient was managed by replacing the tapered ileal stoma with a Kock intussuscepted nipple valve made from proximal ileum. The patient is now continent. This technique warrants further investigation as a method of treating patients with continent urostomies of various types (Kock, Indiana, Miami, Mainz) that become partially or completely incontinent.

Rectal J pouch reservoir to decrease the frequency of tenesmus and defecation in low coloproctostomy.

Low anterior resection of the colon with very low coloproctostomy is a procedure occasionally required in the surgical management of the patient with gynecologic malignancy. Very low end-to-end anastomosis of the colon to rectum has been associated with fecal frequency and tenesmus in up to 70% of cases. The construction of a rectal J-pouch low-pressure reservoir has been reported to have a salutary effect upon these symptoms. Between March 1987 and January 1988 a pilot study was carried out in which six patients with primary or recurrent gynecologic malignancy who underwent low anterior resection of the colon requiring very low coloproctostomy (below 6 cm) had construction of a rectal J-pouch reservoir with a Strasbourg-Baker end-to-side coloproctostomy. No postoperative complications were noted in this small series of patients. No patient has had more than three stools per day since surgery. Antidiarrheal medication was not required. All patients denied tenesmus. It was concluded that the rectal J-pouch reservoir offered a surgical technique for avoiding tenesmus and fecal frequency in very low end-to-end anastomosis of colon to rectum.

Neovagina constructed from an omental J flap and a split thickness skin graft.

Construction of a neovagina has been an accepted gynecologic procedure for many years. The omental J flap normally used to close off the pelvic inlet after total pelvic exenteration can, with modification, be made into a cylinder for a neovagina. This cylinder is sutured to the introitus and lined with a split thickness skin graft providing a satisfactory and functional vagina.

Rectal J-pouch reservoir to decrease the frequency of tenesmus and defecation in low coloproctostomy.

Low anterior resection of the colon with very low coloproctostomy is a procedure occasionally required in the surgical management of the patient with gynecologic malignancy. Very low end-to-end anastomosis of the colon to the rectum has been associated with fecal frequency and tenesmus in up to 70% of cases. The construction of a rectal J-pouch low-pressure reservoir has been reported to have a salutary effect on these symptoms. Between March 1987 and April 1988, a pilot study was carried out in which 11 patients with primary or recurrent gynecologic malignancy who underwent low anterior resection of the colon requiring very low coloproctostomy (below 6 cm) had construction of a rectal J-pouch reservoir with a Strasbourg-Baker end-to-side coloproctostomy. No postoperative complications were noted in this small series of patients. No patient has had more than three stools per day since surgery. Antidiarrheal medication was not required. All patients denied tenesmus. It was concluded that the rectal J-pouch reservoir offered a surgical technique for avoiding tenesmus and fecal frequency in very low end-to-end anastomosis of colon to rectum.

Feulgen cytometry in simultaneous endometrial and ovarian carcinoma.

The modal DNA value was measured in six patients with simultaneous endometrial and ovarian carcinoma by Feulgen static cytometry. One patient with low-grade endometrial and ovarian carcinoma manifested diploid indices at both sites. Another patient demonstrated aneuploid ovarian carcinoma and diploid endometrial carcinoma, indicating that these were separate neoplasms. The remaining four patients with Stage III disease had aneuploid endometrial and ovarian carcinomas with identical DNA indices. These data support a single neoplastic process with metastasis in the latter four patients. There was good correlation with the clinicopathologic impression on the likelihood of synchronous primaries versus metastatic neoplasms. It was concluded that DNA analysis is a useful adjunct in assessing the probability that spatially separate neoplasms represent metastasis.

Incidence of fecal incontinence after coloproctostomy below five centimeters in the rectum.

Anastomosis of the descending colon to the rectum below 5 cm can result in fecal incontinence. We have reviewed 90 patients who underwent radical resection of the rectosigmoid colon with very low anastomosis that healed; 88 patients resumed defecation per anus. Indications for the resections were recurrent squamous cell carcinoma after total pelvic irradiation, adenocarcinoma of the endometrium with invasion of the mesentery of the rectosigmoid colon, endometriosis with low rectal involvement, and serous carcinoma of the ovary with invasion of the rectosigmoid mesentery and irradiation stenosis of the rectum. The rectum was transected at the level of the levator ani or below resulting in less than 5 cm of rectum above the anus. All patients had reanastomosis, coloproctostomy, with the end-to-end anastomosis stapler. All coloproctostomies were protected by proximal diverting colostomy if one of three conditions existed: (a) total pelvic irradiation; (b) significant diverticulitis or other inflammatory bowel disease; and (c) inadequate or unprepared bowel at the time of surgery. The proximal diverting colostomies were closed 8-16 weeks postoperatively after demonstrable healing of the anastomosis. Of the 90 patients, 88 eventually resumed defecation per anus after coloprotostomies and 5 (5%) required replacement of the colostomy for fecal incontinence. Eighty-three patients (92%) had successful reanastomosis, closure of the proximal colostomy, and defecation per rectum without fecal incontinence.

Microcolpohysteroscopy compared with colposcopy in the evaluation of abnormal cervical cytology.

Microcolpohysteroscopy allows one to observe the cervix and endocervix at magnifications of 1:1-1:150. More important, it permits examination of the squamocolumnar junction when it is obscured within the endocervix. This preliminary report compares standard colposcopy with a microcolpohysteroscopy technique in 65 patients with abnormal Papanicolaou smears. Using contact microcolpohysteroscopy, the clinician can map out geographically entire cervical intraepithelial neoplastic lesions; locate correctly the epicenter of most lesions; and in cases of inadequate colposcopy, visualize the squamocolumnar junction within the cervix. Microcolpohysteroscopy was equivalent to traditional colposcopy in detecting abnormal histology. This technique predicted lesions with viral cytopathic effects, which correlated with histology in 83% of cases. The results of this study suggest that microcolpohysteroscopy is a diagnostic tool that can precisely qualify and localize a cervical lesion.

Use of the end-to-end anastomosis stapling device in low colorectal anastomosis associated with radical gynecologic surgery.

Between 1978 and 1984, 49 rectosigmoid anastomoses were performed using the end to end anastomosis (EEA) stapler. Seventeen (35%) of the patients had prior radiation treatment. Twenty-eight (57%) of the anastomoses were at the level of the peritoneal reflection and 21 (43%) were at the level of the levators. Fourteen patients (29%) had diverting colostomies and 11 (79%) of these were closed. There were 5 complications (10%) directly related to the anastomosis. These included two strictures, two anastomotic breakdowns, and one case of fecal incontinence after colostomy closure. All complications arose in patients with prior radiation treatment.