Fertility-preserving surgical procedures, techniques

As a result of the trend toward late childbearing, fertility preservation has become a major issue in young women with gynaecological cancer. Fertility-sparing treatments have been successfully attempted in selected cases of cervical, endometrial and ovarian cancer, and gynaecologists should be familiar with fertility-preserving options in women with gynaecological malignancies. Options to preserve fertility include shielding to reduce radiation damage, fertility preservation when undergoing cytotoxic treatments, cryopreservation, assisted reproduction techniques, and fertility-sparing surgical procedures. Radical vaginal trachelectomy with laparoscopic lymphadenectomy is an oncologically safe, fertility-preserving procedure. It has been accepted worldwide as a surgical treatment of small early stage cervical cancers. Selected cases of early stage ovarian cancer can be treated by unilateral salpingo-ophorectomy and surgical staging. Hysteroscopic resection and progesterone treatment are used in young women who have endometrial cancer to maintain fertility and avoid surgical menopause. Appropriate patient selection, and careful oncologic, psychologic, reproductive and obstetric counselling, is mandatory.     

Abdominoplasty combined with gynecologic surgical procedures

Cosmetic surgery of the abdomen is requested frequently by patients and is being performed increasingly at the time of elective gynecologic surgery. However, little information is available regarding the safety of combining these procedures. In this study intraoperative and postoperative morbidity was compared in the following groups of patients: 1) abdominoplasty plus one of five common gynecologic procedures (N = 76); 2) one of the five gynecologic procedures alone, matched for age, weight, and time of operation (N = 76); and 3) abdominoplasty alone (N = 70). Patients in group 1 experienced significantly longer operative time, longer hospital stays, and greater blood loss, which required more transfusions than group 2 or 3. These problems were accentuated in patients who weighed more than 70 kg or were older than age 35. In addition, five patients (6.6%) in group 1 had a documented pulmonary embolus within 18 days of surgery, whereas no pulmonary emboli occurred in group 2 or 3. Because of the increased morbidity, careful patient selection is necessary when abdominoplasty and gynecologic procedures are performed at the same time.     

Combined gynecologic surgical procedures and cholecystectomy

This report presents our experiences with combined gynecologic surgical procedures and cholecystectomy from 1976 to 1983. The review evaluated risks, cost, and hospital stay in combined surgical procedures. Hospital charts were reviewed in 46 cases. The patients were compared with 178 patients undergoing total abdominal hysterectomy and bilateral salpingo-oophorectomy in 1981. Of the 46 patients reviewed, 22 (47.8%) had preoperative diagnosis of cholelithiasis. We believe it appropriate to combine gynecologic surgical procedures with cholecystectomy when indicated. This eliminates a significant postoperative complication, cholecystitis, a second general anesthetic, and future hospitalization with additional time off work and patient recovery time.     

Hemorheological parameters in patients with gynecologic malignancies

Thromboembolic events account for a significant number of complications during surgical and chemotherapeutic treatment for gynecologic malignancies. Besides changes in the hemostatic system, changes in hemorheological parameters facilitate initiation and promotion of thrombotic disease. We used a rheoaggregometer to determine erythrocyte aggregation and a capillary viscosimeter to evaluate plasma viscosity in patients with gynecologic malignancies at the time of primary diagnosis and during follow-up and compared the results to those for a normal control group. We found a significant elevation in plasma viscosity and erythrocyte aggregation as well as in fibrinogen and globulin concentrations in cancer patients. The extent of this rise was related to the tumor volume. Treatment with cisplatin, doxorubicin, and cyclophosphamide resulted in a further rise in erythrocyte aggregation which is attributed to a direct effect on the erythrocyte membrane. Thus, additional factors contributing to the risk of thrombosis in these patients were defined. Additional administration of rheologically active agents might improve the results of thrombosis prophylaxis.     

Continent urinary diversion and low-rectal anastomosis in patients undergoing exenterative procedures for recurrent gynecologic malignancies

OBJECTIVE: The aim of this study was to review the complications associated with continent urinary diversion and associated procedures in patients with gynecologic malignancies. METHODS: We retrospectively reviewed the medical records of all patients who underwent construction of a continent urinary conduit between October 1991 and October 1998 on the Gynecology Service at Memorial Sloan-Kettering Cancer Center. RESULTS: Thirty-three patients were identified, of whom 22 underwent total pelvic exenteration, 8 underwent anterior exenteration, and 3 underwent urinary diversion procedures only. Complications associated with the urinary diversion procedure included ureteral strictures (2), pouch leakage (2), mild hydronephrosis, (6), pyelopnephritis (2), nocturnal incontinence (5), and difficulty with self-catheterization (2). Additional procedures performed concomitantly with continent urinary diversion and exenteration included pelvic reconstruction (18), low-rectal anastomosis (13), and intraoperative radiation therapy (9). The most significant morbidity was seen in patients undergoing concomitant low-rectal anastomosis, in whom the rate of anastomotic leaks was 54% (7 of 13 patients). CONCLUSIONS: Continent urinary diversion can successfully be accomplished at the time of exenteration in patients with recurrent gynecologic malignancies. The rate of major complications related to the urinary diversion is small and most complications can be managed nonsurgically. The greater than 50% rate of anastomotic leaks in patients undergoing concomitant low-rectal anastamosis suggests that such anastomosis should not be undertaken in this group of patients.     

Lymphatic ascites following pelvic and paraaortic lymphadenectomy procedures for gynecologic malignancies

Objective

Lymphatic ascites is an unusual complication in patients with cancer. In the gynecologic oncology patient population, the most common etiology is operative lymph node dissection. The purpose of this study was to explore the incidence, presenting symptoms, methods of diagnosis and treatment modalities utilized for lymphatic ascites in patients undergoing lymph node dissection for gynecologic cancers.

Methods

This observational study retrospectively reviewed the charts of patients who underwent lymphadenectomy as part of the surgical management for a gynecologic cancer. Patients that developed postoperative lymphatic ascites between January 2000 and December 2010 were included for analysis. Data extracted from the medical records included tumor pathology, number of harvested lymph nodes, postoperative course, method of diagnosis and treatment.

Results

From a total of 300 surgical staging procedures, 12 patients with lymphatic ascites were identified (4%). The most common reported symptom was leakage of clear fluid per vagina (7, 58%), followed by abdominal distension (4, 33%). The median interval from surgery to development of symptoms was 12.5 days (range 0-22 days). 5 patients had complete resolution of symptoms with dietary modifications alone while 7 patients required paracentesis. The median time from surgery to resolution of symptoms was 44 days (range 9-99).

Conclusion

Lymphatic ascites is an under recognized and infrequently reported postoperative complication. Although it usually resolves spontaneously or with conservative management without sequelae, this condition can significantly prolong postoperative recovery and cause patient discomfort. To our knowledge this is the largest group of patients undergoing gynecologic surgical staging procedures to be reviewed for the occurrence of lymphatic ascites.     

Oncofertility for women with gynecologic malignancies

The emerging field of oncofertility addresses fertility and the reproductive health needs for cancer patients, a key topic in cancer survivorship. Given that the standard treatment for gynecologic malignancies involves removal of reproductive organs, pelvic radiation, or chemotherapy, the effect of such treatment on fertility and options for fertility preservation are even more relevant than for other malignancies.In young women with new diagnoses of cervical, endometrial, or ovarian cancers, viable strategies for fertility preservation without compromising oncological outcome exist and should be considered. We present here a comprehensive review of the literature as it pertains to gynecologic malignancies on 1) the effects of radiation and chemotherapy on fertility, 2) fertility-sparing surgeries and the role of assisted reproductive technology, and 3) fertility preservation in adolescent girls and women with BRCA germline mutations.     

Multiple primary malignancies in patients with gynecologic cancer

A retrospective analysis was made of 1044 patients with gynecologic malignancies treated in our department over a 12-year period, in order to review the frequency and types of multiple primary neoplasms. Multiple primary neoplasms were detected in 45 (4.3%) cases, including 16 (2.1%) out of 733 cervical cancers, 14 (8.2%) out of 166 endometrial cancers, three (15%) out of 20 vaginal cancers and 12 (9.8%) out of 123 ovarian cancers. Fifteen cases were synchronous and the remaining 24 cases were heterochronous, with an average 4.9-year interval. The most frequent other site of neoplasm was the breast, particularly in patients with endometrial or ovarian cancer. We conclude that gynecologic malignancies are often associated with primary cancers elsewhere, especially in the breast, stomach, colon and thyroid. A patient presenting with a gynecologic malignancy should be thoroughly examined for a second cancer, as should patients being followed-up after treatment for genital tract cancer.     

Fertility preserving options in patients with gynecologic malignancies

A proportion of reproductive age women are affected by gynecologic malignancies. This patient population is faced with difficult decisions, related to their cancer care and treatment, as well as future childbearing potential. Therefore, it is important for gynecologists to be familiar with fertility sparing management options in patients with cervical, ovarian, and endometrial cancer. In addition to understanding the surgical approaches available, providers should be able to counsel patients regarding their eligibility for and the indications and limitations of fertility sparing therapy for gynecologic cancer, allowing for appropriate referrals. A comprehensive PUBMED literature search was conducted using the key words "fertility preservation," "cervical cancer," "endometrial cancer," "ovarian cancer," "borderline tumor of the ovary," "germ cell tumor," "obstetrical outcomes," "chemotherapy," and "radiation." The following review summarizes fertility sparing options for patients with cervical, ovarian and endometrial cancer, with an emphasis on appropriate patient selection, oncologic, and obstetric outcomes.     

Extensive gynecologic surgical procedures upon patients more than 75 years of age

A series of 110 patients upon whom extensive gynecologic surgical procedures were performed between 1971 and 1986 are presented. All of the patients were 75 years of age or older at the time of operation. Abdominal surgical procedures were performed upon 49, and vaginal hysterectomies were performed upon the remaining 61. Among patients undergoing abdominal procedures, three deaths occurred; among those undergoing vaginal hysterectomies, one patient died (6.2 versus 1.6 per cent). Morbidity was high among both groups (43.5 per cent, abdominal group). Patients undergoing the vaginal procedure stayed in the hospital fewer days (9.6 versus 14.5 days). From this data, it is concluded that, if there is a clear indication for surgical procedure, it should be performed, regardless of the age of the patient, if there is no equal or superior medical alternative and if there is no absolute contraindication to anesthesia.     

Injury to the ureter during gynecologic surgical procedures

This retrospective study examined ureteral injuries during gynecologic operations from January 1980 to August 1985. The study was conducted at two private hospitals that are involved in resident teaching programs. Each patient was reviewed for predisposing factors, location and type of injury and time and method of recognition. Sixteen injuries were documented in 1,093 extensive procedures. Twelve injuries occurred at the pelvic brim and four others occurred elsewhere in the pelvis. Risk factors included previous surgical procedures in the pelvis, endometriosis, ovarian neoplasm, pelvic adhesions, distorted anatomic features of the pelvis and repair of the bladder. The anatomic structure of the ureter is reviewed, and recommendations are made to help prevent ureteral injury during surgical procedures in the pelvis.     

Fine-needle aspiration cytology in patients with gynecologic malignancies.

Four hundred five fine-needle aspiration (FNA) cytologies were obtained from 352 sites in 287 patients with gynecologic malignancies. The majority of specimens were aspirated for recurrent or metastatic disease. The most common clinical diagnosis was cervical carcinoma (128 cases) followed by ovarian carcinoma (80 cases) and others (79 cases). The sites of FNA were lymph node (134 cases), retroperitoneal lymphocyst (57 cases), pelvic mass (52 cases), subcutaneous mass (34 cases), and others (75 cases). Of 335 sites excluding inadequate specimens, 162 (48.4%) revealed malignant cells. There was no difference in the accuracy of FNA between diseases in the superficial sites and those in the deep sites. However, the sensitivity for local recurrent diseases was lower than that for primary or metastatic diseases (86.4% vs 100.0%). The overall accuracy of FNA cytology was 95.2%, and it was satisfactory for the diagnosis of gynecologic malignant diseases. FNA should be repeated if the initial FNA specimen is inadequate for diagnosis. When distinct malignant cells are observed in FNA cytology, a biopsy may be omitted.     

Cervical bacterial flora in patients with gynecologic malignancies.

Radiation and gynecologic oncologists agree that pelvic irradiation in the presence of pelvic inflammatory disease, parametritis, or pyometra can be catastrophic. A temperature elevation in a patient having intrauterine radiation is very perplexing. This study was designed to investigate one of the three reported etiologies for this condition. Some investigators have suggested an exacerbation of a quiescent infection as a possible etiology because of the necrotic condition of many cancerous cervices. Aerobic, anaerobic, and fungus cultures were performed on 32 patients prior to intrauterine administration of cesium. The organisms cultured were similar to those identified as the normal cervical flora. The frequency of the organisms seemed independent of the amount of irradiation. The number of organisms cultured did not vary with the use or nonuse of cleansing vaginal suppositories. This study indicated no increase in bacterial growth in these cancerous necrotic cervices; also it did not indicate the growth of any unusual pathologic bacteria.     

Intentional and unintentional ureteral surgical treatment in gynecologic procedures

During a period of slightly over nine years, 4,195 extensive gynecologic procedures were performed and 40 patients required ureteral operations, with the ureteral injury unintentional in 16 patients. Extensive complications occurred in seven of 40 patients; in two of three patients in whom the injury was recognized postoperatively, nephrectomy was required. Roentgenographic imaging of the genitourinary tract prior to operation did not prevent injury nor did attempts at identification of the ureter. The majority of ureteral repairs were accomplished by ureteroneocystotomy. In selected patients, placement of percutaneous or indwelling ureteral stent prevented extensive surgical intervention.     

Approach to the abdominal retroperitoneum in patients with gynecologic malignancies

The treatment of patients with gynecologic malignancies is still widely dependent on clinical staging. The introduction of the concept of surgical staging has significantly altered treatment plans. Better staging allows better treatment and more accurate comparison of survival and cure rates. We describe a surgical technique to expose the abdominal retroperitoneum. Sixteen patients have been explored by this technique. There has been no apparent difficulty in this procedure, even when performed on obese patients.     

Cardiac metastases associated with gynecologic malignancies

Metastasis to the heart of malignancies arising within the pelvis is a rarely reported phenomenon. In fact, review of the literature and personal experience demonstrate that cardiac metastases occur more frequently than expected. Clinical suspicion would enable its antemortem diagnosis in many patients and would permit appropriate therapy in carefully selected individuals.     

Postoperative vesicourethral function after ultrasonic surgical aspirator-assisted surgery of gynecologic malignancies

OBJECTIVE: The most concerned complication of radical hysterectomy includes the vesicourethral dysfunction. The use of Cavitron ultrasonic surgical aspirator (CUSA) may preserve the blood supply to the urinary tract even during the surgical procedure, prompting us to evaluate the advantage of using the CUSA with the complication. STUDY DESIGN: We analyzed medical profiles of a total of 275 patients with pelvic lymphnode dissection (137 subjects with radical hysterectomy and 138 with modified radical hysterectomy). RESULTS: The use of CUSA in radical (formal or extended) hysterectomy reduced the period for the residual urine to become <50 ml in cases of advanced stages equal and over Ib of uterine cervical cancers. CONCLUSION: The CUSA may be more effective in the prevention of radical hysterectomy for its major complication, vesicourethral dysfunction. The CUSA-assisted surgery may be applicable, primarily, for advanced uterine cancer.