Uterine retroversion and gluteal transposition flap for postoperative perineal evisceration after extralevator abdominoperineal resection.

Anal squamous cell carcinoma (ASCC) is the most common histological subtype of malignant tumor affecting the anal canal. Chemoradiotherapy (CRT) is the first-line treatment in nearly all cases, ensuring complete clinical response in up to 80% of patients. Abdominoperineal resection (APR) is typically reserved as salvage therapy in those patients with persistent or recurrent tumor after CRT. In locally advanced tumors, an extralevator abdominoperineal excision (ELAPE), which entails excision of the anal canal and levator muscles, might be indicated to obtain negative resection margins. In this setting, the combination of highly irradiated tissue and large surgical defect increases the risk of developing postoperative perineal wound complications. One of the most dreadful complications is perineal evisceration (PE), which requires immediate surgical treatment to avoid irreversibile organ damage. Different techniques have been described to prevent perineal complications after ELAPE, although none of them have reached consensus. In this technical note, we present a case of PE after ELAPE performed for a recurrent ASCC. Perineal evisceration was approached by combining a uterine retroversion with a gluteal transposition flap to obtain wound healing and reinforcement of the pelvic floor at once, when a mesh placement is not recommended.

Accuracy of Transvaginal Ultrasonographic Diagnosis of Retroflexed Uterus in Endometriosis, with Magnetic Resonance Imaging as Reference.

BACKGROUND: Accurate diagnosis of retroflexed uterus in daily practice is essential because this condition is related to pelvic pain and deep endometriosis. Uterine flexion can be measured by transvaginal ultrasonography (TVUS), a cost-effective primary test, but the accuracy required for diagnosing retroflexed uterus is unclear. This study assessed the accuracy of TVUS for diagnosis of retroflexed uterus in patients with endometriosis and compared it with that of magnetic resonance imaging (MRI) -the gold standard for measuring the uterine axis. METHODS: The study included 123 patients who underwent endometriosis surgery in our department between 2012 and 2017. Uterine flexion angles were measured by retrospectively examining TVUS and MRI images, and the correlation was analyzed. Analysis of anteverted and retroverted uterine subgroups identified aspects of diagnosing uterine flexion with TVUS. RESULTS: Uterine flexion angles on TVUS were strongly positively correlated (r = 0.86) with MRI results. Additionally, TVUS yielded no false-positive diagnoses and 28 false-negative diagnoses of retroflexion. All false-negative diagnoses occurred in patients with anteverted retroflexed uteruses. CONCLUSIONS: TVUS was generally accurate for measuring uterine flexion angle, as indicated by its strong correlation with MRI. Misdiagnosis of anteverted retroflexed uterus was a limitation of using TVUS for retroflexion diagnosis.

Efficacy of well-planned management in patients with incarcerated gravid uterus: A case series and literature review.

OBJECTIVE: Incarcerated gravid uterus is a condition in which uterine myoma and intraperitoneal adhesion lead to persistent uterine retroversion. Accurate diagnosis before cesarean section is crucial so that the procedure can be planned with regard to the spatial relationship between the uterine incision and other organs. This study investigated the effects of well-planned management on the outcome of cesarean sections. MATERIALS AND METHODS: Four patients with incarcerated gravid uterus who received well-planned management and preoperative magnetic resonance imaging were compared with three unexpected patients who were operated without preoperative diagnosis. RESULTS: In the preoperatively diagnosed group, compared with the non-preoperatively diagnosed group, the frequency of cervical canal damage tended to be lower (0% vs. 100%), blood loss tended to be less (1171 ± 290 mL vs. 2000 ± 300 mL), and surgery duration tended to be shorter (82 ± 17 min vs. 147 ± 84 min). None of the preoperatively diagnosed cases required allogeneic blood transfusion, and no organ damage was observed. CONCLUSION: The early detection of a suspected incarcerated uterus, and a thorough understanding of diagnostic methods and the use of preoperative magnetic resonance imaging and ultrasonography facilitate the safe performance of a cesarean section.

The value of ultrasound guidance during IUD insertion in women with RVF uterus: A randomized controlled trial.

OBJECTIVE: The study objective is to evaluate the benefits of using ultrasound guidance during insertion of Intrauterine device IUD in women with retroverted flexed RVF uteri. STUDY DESIGN: A randomized controlled trial conducted on 400 women with RVF uteri eligible for IUD insertion. They were randomly divided into 2 groups. Group 1 underwent IUD insertion under ultrasound guidance while in group 2 no ultrasound guidance was used. The primary outcome measure was the(Visual Analogue Scale) VAS pain score reported by the women during insertion. Other outcome included easiness of insertion, the procedure time and occurrence of complications as nausea, vomiting, abdominal cramps, failure of insertion, uterine perforation and bleeding. RESULTS: The VAS pain score was significantly lower (2.36 ± 1.77 vs. 4.74 ± 2.35, p < 0.001), the insertion was much easier (score 4.0 ± 0.9 vs. 2.5 ± 1.27, p < 0.001) and the time needed for the procedure was significantly shorter (5.82 ± 2.56 vs. 9.4 ± 4.99 min, p < 0.001) in women within the ultrasound guided group when compared to control group. The total rate of complications was significantly lower (6 vs. 16 %, p 0.001) especially bleeding (2 vs. 9%, p = 0.002), abdominal cramps (10.5 vs. 28 %, p 0.012) and failure of the procedure (0 vs. 3%, p = 005) in ultrasound guided group women when compared to control. CONCLUSION: Insertion of Intrauterine device IUD under ultrasound guidance in women with Retroverted flexed RVF uterus easier and less painful than the blind standard technique.

Embryo location in the uterus during embryo transfer: An in vitro simulation.

OBJECTIVE: To evaluate the location of transferred embryos under various parameters during embryo transfer in in vitro fertilization (IVF) by applying an in vitro experimental model for embryo transfer (ET). METHODS: Mock ET simulations were conducted with a laboratory model of the uterine cavity. The transfer catheter was loaded with a sequence of air and liquid volumes, including development-arrested embryos donated by patients. The transfer procedure was recorded using a digital video camera. An orthogonal design, including three independent variables (uterine orientation, distance of the catheter tip to the fundus, and injection speed) and one dependent variable (final embryo position), was applied. RESULTS: The uterine cavity was divided into six regions. The distribution of the transferred matter within the uterine cavity varied according to the uterine orientation. Medium speed-injected embryos were mostly found in the static region while fast- and slow-speed injected embryos were mostly found in the fundal region and the cervical-left region, respectively. The possibility of embryo separation from the air bubble increased from 11.1% in slow injection cases to 29.6% and 48.1% in medium and fast injection cases, respectively. CONCLUSION: The experimental model provides a new method for investigating ET procedures. Fast injection of embryos into a retroverted uterus may be more likely to result in embryo separation from the air bubble.

Approach to Slitlike Ventricles: Parietal-Occipital versus Frontal Burr Catheter Entry Sites.

BACKGROUND: Slit ventricles can be a challenging target during shunt catheter insertion. Traditionally, the frontal approach has been considered optimal for small ventricles. At this center, routine use of electromagnetic (EM) stereotactic guidance (Stealth, Medtronic, Dublin, Ireland) has enabled a parietooccipital (P-O) burr hole approach to the frontal horns. We compare shunt placement and revisions required for patients with slit ventricles who had shunts inserted via a P-O approach versus frontal shunt. METHODS: We studied a retrospective cohort of patients with slit ventricles and a ventricular shunt inserted using EM guidance between 2012 and 2018. Slitlike ventricles were defined as the widest point of the lateral ventricle <3 mm. Outcome measures included placement accuracy and survival using the Kaplan-Meier curve. Optimal final catheter tip location was considered to be the frontal horn of the ipsilateral lateral ventricle. RESULTS: Eighty-two patients (77 female, 5 male) aged 34.9 ± 10.8 years (mean ± standard deviation) had ventricular shunts inserted for idiopathic intracranial hypertension (n = 63), chiari/syrinx (n = 8), congenital (n = 10), and pseudomeningocele (n = 1). Of those identified, 35 had primary P-O shunts and 46 had frontal shunts. Overall, 94% of cases had the catheter tip sitting in the frontal horn. The P-O approach was just as accurate as the frontal approach. Eight P-O shunts and 9 frontal shunts required revision over a 60-month period. There was no significant different in shunt survival between the 2 approaches (P = 0.37). CONCLUSIONS: EM-guided placement has enabled the P-O approach to be as safe and with equivalent survival to frontal approach. The accuracy of shunt placement between the 2 approaches was similar.

Predicting necrosis in adnexal torsion in women of reproductive age using magnetic resonance imaging.

PURPOSE: To identify the diagnostic performance of magnetic resonance (MR) imaging for patients with adnexal torsion and to develop a predictive model for necrosis related to torsion. METHODS: The institutional ethics committee approved this retrospective study. A total of 56 women with a preoperative pelvic MR scan and a surgical and pathologic diagnosis of adnexal torsion were enrolled from five institutions. Three radiologists reviewed the MR images independently. The kappa value of interrater agreement was assessed. Differences between patients treated with conservative surgery and adnexectomy were evaluated by univariate and multivariate logistic regression analyses. Receiver operating characteristic (ROC) curve analysis was used to assess the ability of the model to predict ovarian necrosis. RESULTS: Fifty-six patients were divided into the conservative surgery group (24/56, 42.9%) or the adnexectomy group (32/56, 57.1%) depending on the surgical outcomes. The radiographic features related to torsion were interpreted by three raters retrospectively with substantial interrater agreement (kappa > 0.60). Older reproductive age and pedicle hemorrhagic infarction were significantly associated with adnexectomy (p < 0.05). At multivariate analysis, pedicle hemorrhagic infarction (odds ratio = 10.476 [95% confidence interval 1.103, 99.504; p = 0.041]) was associated with adnexectomy. Using the predictive model (older reproductive age and pedicle hemorrhagic infarction), a receiver operating characteristic curve was generated with an area under the curve (AUC = 0.870 ± 0.049). CONCLUSION: The presence of pedicle hemorrhagic infarction and older reproductive age can predict necrosis of adnexal torsion and may be used to guide the optimal treatment strategy. KEY POINTS: • Pedicle hemorrhagic infarction and older reproductive age are predictors of necrosis in adnexal torsion in patients of reproductive age (AUC = 0.870 ± 0.049). • Cystic wall thickening, enlarged vascular pedicle, tubal thickening, and uterine deviation are associated with a high risk for adnexal torsion, occurring in more than half of the cases in this study. • MR findings are useful for the definitive diagnosis of adnexal torsion and for the prediction of adnexal necrosis.

Spontaneous Resolution of Gravid Uterine Incarceration With Spinal Anesthesia: A Case Report.

Incarceration of the gravid uterus may pose significant risks to both maternal and fetal health. Anesthetic management for these patients is variable, and the ideal anesthetic technique is unknown. The patient presented to the labor and delivery unit with pelvic pain and urinary retention in the setting of a gravid incarcerated uterus. Previous attempts at manual reduction in the outpatient setting were unsuccessful. A combined spinal-epidural anesthetic was administered, followed by spontaneous resolution of the incarcerated uterus. In addition to providing analgesia, neuraxial blockade may occasionally be an adequate therapeutic technique for reduction of a gravid incarcerated uterus.

Spontaneous reduction of an incarcerated gravid uterus after myomectomy in the second trimester: A case report.

RATIONALE: During a normal pregnancy, in the 1st trimester uterus lies in pelvis and enlarges in size as the pregnancy advances. By 14 weeks of gestation, the gravid uterus transforms from a pelvis to an abdominal organ and a retroverted uterus will correct as the fundus rises out of the pelvis and falls forward to its normal anatomical position. If the uterus remains in the pelvic cavity after 14 weeks of gestation, it is referred to as an incarcerated uterus. PATIENT CONCERNS: A 31-year-old gravida 3 para 0 woman was admitted to our obstetrics unit at 20 weeks' gestation with the complaint of severe persistent upper abdominal pain for over 12 hours. DIAGNOSIS AND INTERVENTIONS: A diagnosis of fibroid degeneration was made through ultrasound and magnetic resonance imaging. The patient was hospitalized with conservative treatment. An abdominal myomectomy was performed at 22 weeks' gestation because her condition had deteriorated. Incarcerated uterus was not suspected even at the time of myomectomy. But within 24 hours after myomectomy, diagnosis of incarcerated gravid uterus was made by ultrasound. OUTCOMES: Incarcerated gravid uterus was found spontaneously reduced three weeks after myomectomy by ultrasound. A transverse Cesarean incision was performed at 32 weeks' gestation. A male infant weighing 2120 g was delivered with Apgar scores of 10 and 10 at 1 and 5 minutes, respectively. Postoperative course was uneventful. LESSONS: Incarceration of the gravid uterus is relatively rare and it is difficult to diagnose. This patient's findings suggested the incarceration of gravid uterus can be a transient abnormal position. The results of this study indicates that the incarcerated uterus when associated with fibroid is spontaneously reduced after removal of the fibroid.

Magnetic resonance imaging of the placenta and gravid uterus: a pictorial essay.

The placenta is commonly overlooked on magnetic resonance imaging of the pregnant patient, which is frequently performed for alternative reasons such as to characterize fetal or uterine anomalies or to investigate the etiology of acute pelvic pain in pregnancy. Placental disorders have potential for significant maternal and fetal morbidity and peripartum complications if not recognized and treated in a timely manner. The radiologist must be familiar with normal placental variants and the spectrum of benign to life-threatening conditions affecting the placenta so that the Obstetrician can be promptly notified and patient management altered, if necessary. In this pictorial essay, we will describe our MR protocol for placental imaging, provide an image-rich review of the normal placenta, placental variants, and a variety of pathological conditions affecting the placenta and gravid uterus.

Vaginal Repair of Cesarean Section Scar Diverticula Diagnosed in Non-pregnant Women.

STUDY OBJECTIVE: Cesarean section scar diverticulum (CSD) lead to many long-term complications. CSD is more prevalent in patients with a retroflexed uterus than in those with an anteflexed uterus. Therefore, we wanted to estimate the association between flexion of the uterus and the outcome of treatment for CSD treated by vaginal repair. DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: University hospital. PATIENTS: A total of 241 women with a CSD were enrolled at the Shanghai First Maternity & Infant Hospital between May 2014 and Oct 2016. INTERVENTIONS: Vaginal excision and suture of CSD. MEASUREMENT AND MAIN RESULTS: A high failure rate was reported in remodeling of the scar by other surgeries in women with retroflexed uteri. Clinical information was obtained from medical records. Because intermenstrual bleeding was a presenting symptom of CSD, duration of menstruation was compared between groups. Patients were required to be followed at 1, 3, and 6 months to record their menstruation situation and to measure the CSD. The thickness of the residual myometrium (TRM) in the retroflexion group was much thinner than that in the anteflexion group before treatment (2.5 ± 1.2 mm vs 2.9 ± 1.1 mm, p < .05). There was no statistical difference in pretreatment menstruation duration between groups (p > .05). The duration of menstruation in the anteflexion group was 8.2 ± 2.1 days and 8.5 ± 2.1 days and in the retroflexion group was 7.6 ± 2.0 days and 7.7 ± 3.1 days at 3 and 6 months after surgery, respectively (p < .05). In all 58.6% of patients (140/239) who had a retroflexed uterus, 60.0% (84/140) reached ≤7 days of menstruation at 6 months after surgery (p < .05). Although about 40% patients still had CSD after repair, menstruation duration and TRM were improved significantly (p < .05). CONCLUSION: We propose that vaginal repair can relieve symptoms and improve TRM for CSD patients, especially for those who have a retroflexed uterus. However, 40% of patients still had a defect postoperatively.

Transvaginal and transperineal ultrasound follow-up after laparoscopic correction of uterine retrodisplacement in women with posterior deep infiltrating endometriosis.

BACKGROUND: Retrodisplacement of the uterus (retroflexion and/or retroversion) may be associated with pelvic pain symptoms and posterior deep infiltrating endometriosis (DIE). Previous studies in symptomatic women with retrodisplacement of the uterus showed the efficacy of hysteropexy in terms of pain symptoms improvement. AIM: To evaluate sonographic, clinical and surgical outcomes of a hysteropexy technique MATERIALS AND METHODS: Laparoscopic round ligament plication and tilting of the uterine fundus in women with uterine retrodisplacement and posterior deep infiltrating endometriosis was performed. Forty-two symptomatic women were enrolled and the sonographic data of each (angle of uterine version and uterine flexion, uterine mobility) was assessed before and after surgery with transvaginal and transperineal approaches. Women were also evaluated at 1, 6 and 12 months after surgery for pain symptoms with a numerical rating scale (dysmenorrhoea, dyspareunia and chronic pelvic pain), intraoperative data and surgical complications. RESULTS: The additional mean operative time of hysteropexy procedure was 8 ± 3 min. At early follow-up both the uterine angles were significantly (P < 0.001) reduced. At 12-month follow-up, seven patients (16.7%) presented a retroverted uterus, while 12 (28.6%) presented a retroflexed uterus; the sliding sign remained negative in four patients (9.5%). A significant improvement of symptoms (P < 0.001) was observed during the follow-up. CONCLUSION: Laparoscopic hysteropexy appears as an effective additional surgical procedure, which can temporarily correct the uterine position in order to reduce the risk of postoperative adhesions.

Asymptomatic uterine incarceration at term: Successful management of a rare complication in pregnancy.

OBJECTIVE: Incarcerated gravid uterus is a rare complication of pregnancy and can become a critical condition during delivery. For extremely uncommon cases that persist to the third trimester, correct diagnosis before delivery and appropriate management of the associated complications are important. CASE REPORT: This was the first case of a full-term pregnancy with incarcerated gravid uterus, reported at a medical center. The condition was not diagnosed during pregnancy, which led to serious complications during the cesarean delivery; however, the prognosis was favorable because of the timely management. CONCLUSION: Based on the previous case reports and clinical presentation of this case, early diagnosis with ultrasound and pelvic examination is the key to successful treatment. Vertical and more cephalad uterine incision reduces the risk of bladder perforation and injury to the cervix and vagina. A successful teamwork of obstetricians, gynecologists, urologists, and anesthesiologists can ensure favorable outcomes for both mother and fetus.

Prevalence and factors associated with rupture of gravid uterus and feto-maternal outcome: a one-year retrospective cohort study

Background: Uterine rupture remains a significant public health problem contributing to 13% of maternal mortality and 74%-92% for perinatal mortality in developing countries. This study assesses the prevalence and factors associated with rupture of gravid uterus and feto-maternal outcome in Ethiopian mothers with uterine rupture.Methods: A retrospective cohort study was conducted to identify risk factors associated with rupture of gravid uterus and feto-maternal outcomes. The data source included clinical records of patients seen at Dilla University Referral Hospital over a one-year period. The data was collected using a structured data collection form developed for the purposes of the study. The study involved a total 2,498 women with a gravid uterus, gestational age of ≥28 weeks and registered in the labor and delivery registration books in the Obstetrics and Gynecology Department. Bivariate and multivariate regression analyses were carried out at 95% Confidence Interval to identify factors independently associated with uterine rupture.Results: Out of 2,498 reviewed deliveries, 46 cases developed uterine rupture making an overall hospital prevalence of 1.8 % or one in 53 deliveries. Malpresentation (80%), contracted pelvis (47.8%), vertex malposition (10.8%), and previous uterine scar (2.1%) were the causes of uterus ruptures. In multivariate analysis, clients' residence, parity, birth weight, Antenatal Care follow-up and duration of labor were statistically significantly associated with uterine rupture. Maternal and fetal case fatality rates were 8.7% and 97.8%, respectively.Conclusion: Uterine rupture remains an important problem in the study area. Patients with identified risk factor(s) should stay close to the hospital in late pregnancy. Besides, strengthening antenatal care follow-up and referral linkage should be considered