A multicenter study of vesicovaginal fistula following incidental cystotomy during benign hysterectomies.

INTRODUCTION AND HYPOTHESIS: To evaluate factors for vesicovaginal fistula (VVF) formation following incidental cystotomies during benign hysterectomies. METHODS: Hysterectomies performed at two university centers between January 1, 2000 and December 31, 2008 were reviewed. Demographic and operative data were abstracted. Patients who developed VVF were compared to those with no VVF. RESULTS: During the study period, 5,698 hysterectomies performed for benign indications were identified. One hundred two (1.8%) cystotomies occurred with 6 (5.9%) developing a VVF. Patients with VVF were more likely to have uteri weighing > 250 g (83% vs. 36%, P = 0.03), had longer surgeries (317 ± 82 vs. 208 ± 10 min, P = 0.02) and more ureteral injuries (33% vs. 1%, P = 0.009). American Association for the Surgery of Trauma (AAST) grade V bladder injuries (OR, 93.00; 95% CI, 10.30-838.92) were associated with VVF formation. CONCLUSIONS: Patients with AAST grade V bladder injuries are at increased risk for developing vesicovaginal fistulas following incidental cystotomies during benign hysterectomies.

Incidence of vaginal cuff dehiscence after open or laparoscopic hysterectomy: a case report.

BACKGROUND: The incidence of vaginal incision dehiscence after total hysterectomy has been reported to be higher with laparoscopic than with open surgery, but the data are limited. This report documents a case and reviews the literature in order to further estimate the differences in incidence by route of hysterectomy. CASE: A 45-year-old woman underwent successful vaginal repair of postcoital cuff dehiscence with small bowel evisceration 67 days after total laparoscopic hysterectomy and bilateral salpingo-oophorectomy for menometrorhagia. CONCLUSION: Seven observational studies were identified. The comparison of total laparoscopic to robotic hysterectomy was not statistically significant, nor was the comparison of total abdominal to vaginal hysterectomy. However, the incidence of dehiscence for laparoscopic procedures was statistically greater than the incidence for open surgery (p value <0.001).

Intracystic hemorrhage in a non-endometriotic mullerian vaginal cyst.

The commonest type of simple vaginal cyst is the Mullerian cyst. These are typically lined by columnar epithelium and contain serous or mucinous fluid. If blood is found in the cyst, the source is usually due to the presence of endometrial elements in the cyst wall. The cyst is then termed an endometriotic cyst. In this case report, we have described a woman with a symptomatic 3 cm upper vaginal cyst who underwent surgical excision of the cyst. The cyst cavity was found to be full of old dark blood and mucous, however the wall contained no endometrial tissue and was lined by columnar epithelium which stained positive for mucous with mucicarmine. No cause for the intracystic hemorrhage was identified. We conclude that intracystic hemorrhage can occur in a simple Mullerian vaginal cyst in the absence of endometrial components.

Vulvar granular cell tumor.

Granular cell tumors are rare, usually benign, soft tissue neoplasms of neural origin. They occur more often in females than males, the peak age incidence is in the fourth through fifth decades. They can occur anywhere in the body with up to 15% situated in the vulva. The commonest presentation is as an asymptomatic mass. Microscopic findings are usually sufficient, but immunohistochemistry can also be helpful in confirming the diagnosis. The vulvar tumors are benign in 98% of cases with 2% reported as malignant. In this case report we describe a woman with a granular cell tumor confirmed by biopsy who underwent excision of the mass but with focal extension to the resection margin on microscopy. Our recommendation of re-excision was declined. Since it is not uncommon with these tumors to find groups of tumor cells extending beyond the macroscopic limits of growth, we conclude that it is advisable to have margins assessed intraoperatively by frozen section such that further excision can be performed for positive margins. Our patient has been followed for 18 mo without recurrence, should the tumor recur, re-excision, with frozen section control, is indicated. Recurrence rates are reported as 2%-8% with clear margins and 20% with positive margins.

A randomized trial of secondary closure of superficial wound dehiscence by surgical tape or suture.

OBJECTIVE: : Evaluate secondary closure of superficial wound dehiscence with suture versus tape. METHODS: : Postoperative obstetrics and gynecologic patients with superficial wound dehiscence were eligible. Wounds were opened for their entire length, debrided, and irrigated. They were packed with moistened gauze until the granulation tissue covered the wound. Randomization occurred when the patient selected a sealed envelope containing a closure technique. Demographic data and wound characteristics were recorded. Pain was determined by using a 100-mm visual analogue scale, which the patient marked immediately after the procedure. Wound closure was measured in minutes. Healing time was measured in days from wound closure to complete wound epithelialization and no need for further wound care. Reopening a closed wound defined treatment failure. Time for complete healing was the primary outcome. RESULTS: : Fifteen patients were randomized to each arm over a 20-month period. Demographics and wound characteristics were similar between groups. Pain scores were significantly less in the tape group (21.4 ± 17.0 vs 60.7 ± 23.0 mm, P < 0.001) as was time for closure (12.3 ± 3.6 vs 31.0 ± 6.8 minutes, P < 0.001). Time for complete healing was significantly less in the suture group (23.0 ± 7.9 vs 16.1 ± 3.36 days, P < 0.001). One wound (7%) in each group was reopened. CONCLUSIONS: : Suture closure seems to be the superior technique for secondary closure of wound dehiscence based on the primary outcome of time to complete healing for this study. Therefore, suture closure seems to be the best option for secondary closure of superficial wound dehiscence.However, both suture and surgical tape are effective treatments when historically compared with second intention.

Retroperitoneal hematoma presenting as an adnexal mass after femoral catheterization.

BACKGROUND: One complication of femoral artery catheterization is postprocedure pelvic hematoma. These hematomas can be difficult to differentiate from adnexal masses. CASES: Two women who had undergone femoral artery catheterization presented with pelvic pain within 3 months of the procedure. Imaging studies revealed a nonspecific adnexal mass, and CA 125 levels were normal. Both women underwent exploratory laparotomy for an adnexal mass and were found to have an organized retroperitoneal hematoma. CONCLUSION: An organizing or well-formed retroperitoneal hematoma should be added to the differential diagnosis in a patient with a poorly defined adnexal mass who has had a recent femoral artery catheterization. In patients with a mass less than 10 cm and normal CA 125 (less than 35 units/mL), continued close observation or magnetic resonance imaging scan may be considered.

Hormones, menstrual distress, and migraine across the phases of the menstrual cycle.

OBJECTIVE: The primary objectives of the present study were to (1) contrast reproductive hormone levels and ratings of menstrual distress of female migraineurs with those of a control group in each menstrual cycle phase, (2) examine correlations between hormone levels and migraine frequency, severity, and migraine-related disability, and (3) examine correlations between menstrual distress and migraine frequency, severity, and migraine-related disability. A secondary objective was to evaluate the validity of a migraine disability measure modified to reflect 7-day recall. BACKGROUND: Further controlled, prospective study is needed regarding the temporal relationships between reproductive hormones at each stage of the menstrual cycle and fluctuations in migraine activity across the cycle. METHODS: Twenty-three women (17 with migraine, 6 control participants) completed laboratory hormone assays and measures of menstrual distress and disability at each phase of one menstrual cycle, and monitored their headache activity daily during the same cycle. Results.-The migraine group evidenced lower premenstrual luteinizing hormone and more menstrual distress symptoms at each phase of the menstrual cycle. Hormones were associated with migraine activity and disability within cycle phases, and across phases in a time-lagged manner. Menstrual distress was associated with ovulatory phase migraine activity and with migraine-related disability across the menstrual cycle. A retrospective 7-day migraine disability measure appeared to be a consistently valid index. CONCLUSIONS: Both reproductive hormones and menstrually related distress appear to predict migraine activity and disability. These associations were evident not only for perimenstrual migraine, but also for migraine at each phase of the menstrual cycle.