Ureteric Injury During Gynaecological Surgery - Lessons from 20 Cases in Canada.

BACKGROUND: Ureteric injury is a complication of gynaecological surgery that can cause significant morbidity for the patient and is a leading cause of litigation in many countries. OBJECTIVES: To determine patient characteristics, peri-operative circumstances and clinical and legal outcomes of ureteral injuries associated with gynaecological surgery. PATIENTS AND METHODS: This is a retrospective review of 20 cases of ureteric injury during benign gynaecological surgery. MAIN OUTCOME MEASURES: All cases were assessed for the following variables-patient characteristics, indications for surgery, injury, postoperative symptoms and presentation, and clinical and legal outcomes. RESULTS: Risk factors associated with ureteric injury included obesity, previous laparotomic pelvic surgery, pelvic adhesions, large pelvic masses and intra-operative bleeding. 70% (14/20) of ureteral injuries were diagnosed after discharge. 50% (10/20) of patients had a complicated post-operative course and 45% (9/20) of cases resulted in unfavourable legal outcomes (settlement or lost at trial) for the surgeon. The conduct of surgery and the failure to act in a timely fashion postoperatively were the most frequent reasons for adverse clinical and unfavourable litigation outcomes for the surgeon. CONCLUSIONS: Intra-operative surgical consultation and ureteral identification should be considered if there is concern for ureteral involvement in the surgical field. Ureteric injury may not constitute negligence if it is demonstrated that the surgeon provided reasonable care that would be expected during the peri-operative phases. WHAT IS NEW: This review identifies patient characteristics and peri-operative variables that correlate with poor clinical and legal outcomes after ureteric injury.

Retroperitoneal pelvic tumours in women: diagnostic and therapeutic challenges.

BACKGROUND: Gynaecologic pelvic tumours are very common and they can present with a variety of symptoms depending on their size, location, pathophysiology and histogenesis. Infrequently, some pelvic tumours are found in the retroperitoneal space presenting with similar symptoms. Our objective is to present our experience and review of pertinent literature on miscellaneous retroperitoneal tumours. METHODS: Four women with retroperitoneal tumours (one schwannoma, one granulosa cell tumour and two hindgut (tail gut) cysts)) were encountered during routine laparoscopy (3 cases) and laparotomy (one case). Following multidisciplinary consultation and additional imaging, all tumours were removed by laparotomy with one case provoking litigation due to ureteral and bowel injury. RESULTS: Using these four cases, and additional cases from the literature, we highlight the potential pitfalls and provide an algorithm to minimize risks and adverse clinical and legal outcomes associated with unexpected retroperitoneal tumours. The algorithm includes resisting the impulse/temptation to remove or biopsy these tumours, requesting intra-operative consultation(s), obtaining additional detailed imaging to characterize these tumours, providing appropriate counselling to patients, obtaining informed consent, and consulting the appropriate surgical teams. At times, an interdisciplinary approach may prove to be the best course of action in order to optimize treatment and ensure patient safety. CONCLUSION: If a retroperitoneal tumour is unexpectedly encountered, it is imperative to have intra-operative consultation (if available), to not attempt excision or biopsy, and to subsequently obtain post-operative multidisciplinary consultations, specific imaging, and information gathering in order to treat these heterogeneous masses as safely as possible.

Auriculo-condylar syndrome.

The auriculo-condylar syndrome is caused by abnormalities of the first and second pharyngeal arches during embryonic development. Its inheritance follows the autosomal dominant pattern. Both familial and individual cases are reported in the literature. The syndrome is characterized by wide phenotypic variation, with affected individuals expressing clinical signs of variable severity due to variable expressivity of the responsible genes. Clinical signs of the syndrome include auricular malformation, hypoplasia of the mandibular condyles, anomalies of the temporomandibular joints, malocclusion, and, in more severe cases, cleft palate, glossoptosis, facial asymmetry, and respiratory problems. The aim of this article is to report a case of a female patient with signs of the auriculo-condylar syndrome and to present the pedigree of her family. Clinical findings, diagnosis, treatment plan, and final treatment are analyzed.

Temporary uterine artery occlusion for treatment of menorrhagia and uterine fibroids using an incisionless Doppler-guided transvaginal clamp: case report.

We report the successful treatment of a 43-year-old woman with menorrhagia and multiple uterine fibroids by temporary uterine artery occlusion. Using a Doppler-guided transvaginal clamp, her uterine arteries were non-invasively identified and occluded by mechanical compression against the cervix for 6 h. Following removal of the clamp, blood flow in the uterine arteries returned immediately. Menorrhagia symptoms were tracked with the Ruta Menorrhagia Severity Scale. Uterine and fibroid volumes were measured by analysis of magnetic resonance images. The patient's self-reported menorrhagia symptoms were significantly reduced at 6 months (70% reduction in Ruta score) and both uterine volume and fibroid volume had decreased by more than 44% at 6 months. This case report illustrates the potential applicability of a simple-to-use, non-surgical device for the treatment of menorrhagia and uterine fibroids by temporary uterine artery occlusion.

Sarcomas of the head and neck. Results from the treatment of 25 patients.

AIMS: Head and neck sarcomas comprise a heterogenous and biologically diverse group of rare neoplasms. In an effort to clarify some of the obscure clinical behavior of head and neck sarcomas, we present our experience and review the relevant literature. METHODS: Retrospective analysis of patients with histologically proven head and neck sarcomas treated in a tertiary Hospital Department between 1992 and 2002. RESULTS: During this period, 25 patients with head and neck sarcomas were registered. Follow-up ranged from 8 to 144 months. Twenty-three patients were treated with surgery as the primary modality; 14 were treated by surgery alone. Clear margins were obtained in all of them and local control was achieved in 12/13. The 2- and 5-year survival rates for the entire group were 80 and 40%, respectively. Mean overall survival time of our patients was 62 months (median 52 months). CONCLUSIONS: Surgical treatment remains the cornerstone of therapeutic management of head and neck sarcomas.

Uterine fibroids: relationships to reproduction.

The purpose of this review is to summarize the available evidence on the effects of uterine fibroids on fertility, infertility and pregnancy outcomes, and the effects of parity on fibroids. Fibroids, found in approximately 4% of pregnant women, are associated with an increased risk of pregnancy complications. However, prophylactic myomectomy in asymptomatic women is not only unjustified, but it may have adverse effects on reproduction. Fibroids are found in 1% to 2.4% of women with unexplained infertility. Removal of fibroids that distort the uterine cavity may be beneficial in infertile women with unexplained infertility and in women undergoing in vitro fertilization. The pregnancy rate after hysteroscopic, laparoscopic or abdominal myomectomy appears to be the same. Laparoscopic myolysis appears to have adverse effects on pregnancy outcomes while uterine artery occlusion in infertile and fertile women requires urgent prospective evaluation. Parity appears to be a natural global killer of uterine fibroids, most likely, through transient uterine ischemia, similar to that of uterine artery occlusion.

Electrophysical properties of electrosurgery and capacitive induced current.

BACKGROUND: Although electrosurgery is one of the most commonly used technologies in the operating room, its electrophysical properties, including the potential for complications, are poorly understood by many surgeons. METHODS: We describe the experimental simulation of a highly unusual complication that occurred during a surgical procedure requiring concurrent use of monopolar and bipolar electrosurgery. RESULTS: Capacitive induced current from an activated monopolar electrode to the bipolar cord was reproduced and consistently led to full-thickness burns in our experiments. CONCLUSIONS: Surgeons should be familiar with the principles of electrosurgery, its electrophysical properties, and possible complications.