Foreign body (Metallic flashlight cover) in the urinary bladder mimicking advanced cancer of the cervix: Case report and review of the literature

Foreign bodies in the urinary bladder are not uncommon, a great variety have been described, and most were self-inserted. We report the case of a 60-year-old widow who presented with irregular vaginal bleeding, urinary incontinence and terminal hematuria. On vaginal examination there was an irregular cervical mass with the appearance of invasive carcinoma of the cervix, as well as a vesico-vaginal fistula. A plain abdominopelvic X-ray and ultrasound scan revealed a ring-like metallic object with the shape of a flashlight cover inside the bladder. Histological examination of biopsies taken from the cervical mass revealed only granulation tissue. The foreign body was identified as a flashlight head which was removed from the bladder via cystotomy.     

Müllerian papilloma of the cervix in a child with multiple renal cysts

An 18-month-old girl was referred for evaluation of vaginal bleeding and a renal mass. Ultrasonography and computed tomography revealed multiple simple cysts within the left kidney and a normal right kidney. At vaginoscopy, a 1-cm frond-like papillary lesion overlying the cervix was identified. The pathologic diagnosis was mullerian papilloma, a rare benign tumor of the vagina and uterine cervix. None of the approximately 40 previously reported cases have been associated with renal anomalies, despite the historical classification of these lesions as mesonephric papillomas. We report the first patient with both a renal anomaly and mullerian papilloma of the uterine cervix.     

Vaginal epithelioid malignant peripheral nerve sheath tumor nearly misdiagnosed as advanced cervical cancer: A case report

A 56-year-old woman was referred to our hospital with a pathological diagnosis of squamous cell carcinoma of the cervix. We performed a re-biopsy of the vaginal mass and cervical conization. The mass was originally reported as an epithelioid MPNST after re-biopsy. Strong diffuse S-100 positivity, epithelioid morphology of the lesion, and negativity to all other immune histochemical markers confirmed the diagnosis of epithelioid MPNST. Cervical conization specimen was negative for any neoplasms.     

Fluorescence spectroscopy of the cervix: influence of acetic acid, cervical mucus, and vaginal medications.

BACKGROUND AND OBJECTIVE: Fluorescence spectroscopy has been shown to provide information useful in the detection of cervical dysplasia. The goal of this study was to determine if substances found on the cervix such as acetic acid, mucus, and vaginal medications can influence the fluorescence in the spectral region useful for discriminating normal cervical tissue from abnormal tissue. STUDY DESIGN/MATERIALS AND METHODS: Fluorescence spectra were collected at 337 nm excitation from the cervix in vivo both before and after application of acetic acid; the data were analyzed to identify the effects of the acetic acid on the spectra. Cervical mucus was acquired from patients referred for colposcopy and frozen until measurements were taken. Fluorescence excitation-emission matrices (EEMs) were measured for the mucus samples. Additionally, the transmission spectra of mucus were measured to determine if its absorption could influence the fluorescence signal measured from the tissue. EEMs were measured for samples of commonly prescribed vaginal medications. All EEMs were compared to those of cervical biopsies. RESULTS: Acetic acid introduces changes in both the lineshape and intensity of the spectra. On average, the changes are more significant in spectra of abnormal tissue. Cervical mucus was found to have no significant absorption bands, but the measured fluorescence was approximately the same order of magnitude as that measured from the cervix in vitro. Most medications exhibited significant fluorescence in the spectral region of diagnostic interest for the cervix. CONCLUSIONS: Acetic acid appears to increase the differences in fluorescence emission spectra of normal and pre-cancerous cervical tissues; thus, its use is beneficial. The presence of cervical mucus can possibly interfere with the collection of fluorescence spectra for tissue classification. Patients should not use vaginal preparations during the 48 hours prior to tissue fluorescence measurements.     

先天性宫颈阴道闭锁初次手术治疗失败后的再处理：附5例报告

目的探讨先天性宫颈阴道闭锁初次手术失败的影响因素及再次手术的处理。方法对2006年5月。2012年2月5例先天性宫颈阴道闭锁外院初次手术失败均以术后周期性持续性腹痛转入我院。5例初次手术前均仅诊断为阴道闭锁行阴道成形术,术中发现合并宫颈闭锁而行宫颈阴道贯通术,分别于术后4年6个月、3个月、3年4个月、1年4个月、3年2个月（二次术后）来我院治疗。2例不完全闭锁在术前检查后出现严重盆腔感染,抗生素治疗无效先行急诊手术治疗。第1例行宫颈粘连松解修补术＋官腔镜检查＋宫颈修补术,第2例行部分宫颈切除＋宫颈闭锁分离成形＋自体皮瓣阴道成形术,第3例行腹腔镜子宫＋双侧输卵管切除术,第4、5例行开腹宫体切开宫颈造口术＋阴道成形术。4例术后经宫颈在官腔内留置F18～F20Foley’s尿管或剪短的蘑菇头尿管,术后分别放置2周（因阴道放置模具而取出）、6个月（因结婚而取出）、11个月、1年。结果5例术后随访0．5—5年,腹痛未再复发。结论对复杂的阴道闭锁初次手术前做影像学的充分评估,使用不脱落的宫颈管支架和适当的阴道成形是手术成功的关键。对不全闭锁首选影像学检查。     

The Manchester repair: an instructional video

Objective

The Manchester repair, developed in the UK by Donald, described in 1908, and later modified by Fothergill, is a well-studied and proven surgical treatment for uterovaginal prolapse when uterine preservation is desired. This operation is currently not widely performed in parts of the world (USA) but is becoming increasing popular in Europe. The objective of this video is to demonstrate our surgical technique and recommendations for successful completion of the procedure.

Methods

This patient is a 39-year-old woman with two previous vaginal deliveries who presented with a 1-year history of vaginal protrusion. She had no urinary or bowel symptoms. On examination, she had a grade 2 cystocele and uterine descent. She desired surgical management of her uterovaginal prolapse but wished to retain her uterus. The procedure involves mobilizing the vagina and bladder off the cervix and uterosacral cardinal ligament complex anteriorly and laterally. The cervix is then amputated. The ligaments are clamped, cut, and ligated and attached to the anterior cervical remnant with an overlapping suture. This pulls the cervix backward into the pelvis and results in anteversion of the uterus. A posterior and then anterior Sturmdorf suture is used to reconstruct the cervix by covering the amputated cervix with vaginal mucosa.

Conclusion

The Manchester repair is an operation worth considering in patients where preservation of the uterus is desired. It uses native tissue and has a low complication rate and good long-term results.

     

超声监护在完全子宫纵隔伴有双宫颈双阴道畸形宫腔镜电切术的临床应用

目的探讨超声监视下宫腔镜电切术治疗完全子宫纵隔伴有双宫颈双阴道畸形的临床价值。方法在超声监视下，对17例完全子宫纵隔伴有双宫颈双阴道患者行宫腔镜子宫纵隔切开术。结果在超声监视下17例均一次完成纵隔电切手术，无子宫穿孔，膀胱、肠管损伤及水中毒等并发症。术后1年随访，宫腔形态正常，无粘连积血。17例患者术后妊娠情况与术前妊娠情况比较：足月活产率明显增高，流产及早产率明显下降，均有显著性差异（P〈0．001），足月分娩者均未发生子宫破裂、胎盘植入及产后大出血等分娩并发症发生。结论超声监护可以辅助完全子宫纵隔伴有双宫颈双阴道畸形宫腔镜电切术顺利进行并取得良好的效果，值得推广。     

Cervical elongation caused by big cervical fibroid resembling malignant cervical prolapse? Management via vaginal surgery

IntroductionCervical elongation could lead to cervical elongation thus worsen the descent of uterine prolapse. In certain cases, this hypertrophic and hyperplastic mass could have fragile surface with some bleeding and necrotic, resembling cervical cancer. As case of cervical elongation due to cervical fibroid is quite rare, such cases are valuable to be reported. We present two cases of cervical fibroid with cervical elongation resembling cervical malignancy.Presentation of caseFirst case was A 59-year-old lady with intractable vaginal mass since one day before admission. Bleeding from the mass was positive. We found a bulky vaginal mass exceeding hymenal ring, 14 × 7 × 6 cm sized, with some necrotic and discharge, foul smelling, and some bleeding area. Ultrasound evaluation revealed a cervical fibroid with differential diagnosis cervical malignancy. The second case was Mrs 53-year-old with vaginal mass since last year. For the last 7 months the mass has been bigger and could not be inserted into vagina, with some bleeding. We found globular vaginal mass 12 × 9 × 6 cm exceeding hymenal ring, with some necrotic and reddish surface, foul smelling, discharge, and some blood. Ultrasound evaluation revealed cervical mass on anterior lip with elongated cervices. Both cases have been menopaused. As the clinical presentation resembling malignancy, we did biopsy. The biopsy results were no evidence of malignancy, then we did Manchester fothergill, and colporaphy as needed.DiscussionLength between internal to external cervical ostium ≥ 5 cm correlated to cervical elongation. Growing cervical mass could drag the cervix, predisposing to cervical elongation and prolapse. Cervical fibroids protruded through vagina was usually pedunculated. But in our cases, the fibroids were not pedunculated but manifested as a bulky mass on the cervical tissue with some bleeding and necrotics, mimicking cervical malignancy. The most important initial management besides ultrasound evaluation was mass biopsy.ConclusionIn such cervical fibroids with cervical elongation resembling cervical malignancy, biopsy is compulsory to determine the diagnosis and to lead the management.     

Cavernous hemangioma of the cervix: a rare cause of vaginal bleeding

Cavernous hemangiomas of the cervix are extremely rare, benign lesions. To date, fewer than 50 cases have been reported. Here reported is a case of cavernous hemangioma of the cervix in a 53-year-old patient with the complaint of postcoital spotting. Most of these lesions are asymptomatic incidental findings, but sometimes, they may cause abnormal vaginal bleeding in the form of menometrorrhagia and postcoital spotting. They should be included in the differential diagnosis of patients with vaginal bleeding.     

Transvaginal repair of vesicocervical fistulae — A forgotten method by Volkovich-Küstner?

The vaginal approach to vesicocervical fistulae by N. Volkovich [1] and O. Küstner [2] was characterized by the use of an artificial uterine descensus to achieve collapse and cushioning of the bladder defect. Over the past 35 years, this principle has been applied to 22 vesicouterine fistulae on 12 occasions. The technique is described in detail. Separation of the fistular canal is today followed by closure of the tract in both the bladder and the cervix. Sometimes, interposition of peritoneum was added (n=6). The method was primarily suitable for uncomplicated vesicocervical fistulae (n=4) or for vesicocervicovaginal fistulae (n=8) with the uterine corpus still present and to be preserved. However, if subtotal hysterectomy had been performed before (n=6), transvaginal extirpation of the remaining cervix and a bladder repair would be necessary. On the other hand, vagino-abdominal hysterectomy and bladder repair were unavoidable in cases of vesicocervicocorporeal fistulae (n=3) and in 1 case of vesicocervicovaginal fistula with a severely distorted cervix. Therapy was successful in all cases.     

Anatomy of the uterus

The uterus is a pear-shaped organ made up of a fundus, body, isthmus and cervix. The fallopian tube enters at each superolateral angle, above which lies the fundus. The cervix is gripped by the vagina to form a supra-vaginal and a vaginal part. The uterine canal traverses the internal os and emerges as the external os at the vaginal vault. The uterine body is flexed on the cervix (anteflexion) while the whole uterus is tipped forward (anteversion). Variations of these positions, termed retroflexion and retroversion, may occur in normal anatomy as well as under pathological circumstances. The ureter has an important relationship to the uterus, lying above the lateral fornix, about 12 mm from the supravaginal cervix. Here it is crossed superiorly by the uterine vessels and is at risk of injury in pelvic surgery, especially hysterectomy. In the child, the cervix is twice the size of the uterine body, but at puberty the body enlarges to its adult proportions. The cervical os is circular, but becomes a transverse slit in the parous woman. The cervix is normally firm, but feels soft in pregnancy. The details of the arterial supply, venous drainage, lymphatic drainage, peritoneal coverings and anatomical relationships are described.     

Anatomy of the uterus

The uterus is a pear-shaped organ made up of a fundus, body, isthmus and cervix. The fallopian tube enters at each superolateral angle, above which lies the fundus. The cervix is gripped by the vagina to form a supra-vaginal and a vaginal part. The uterine canal traverses the internal os and emerges as the external os at the vaginal vault. The uterine body is flexed on the cervix (anteflexion) while the whole uterus is tipped forward (anteversion). Variations of these positions, termed retroflexion and retroversion, may occur in normal anatomy as well as under pathological circumstances. The ureter has an important relationship to the uterus, lying above the lateral fornix, about 12 mm from the supravaginal cervix. Here it is crossed superiorly by the uterine artery and is at risk of injury in pelvic surgery, especially hysterectomy. In the child, the cervix is twice the size of the uterine body, but at puberty the body enlarges to its adult proportions. The cervical os is circular, but becomes a transverse slit in the parous woman. The cervix is normally firm, but feels soft in pregnancy. The details of the arterial supply, venous drainage, lymphatic drainage, peritoneal coverings and anatomical relationships are described.     

Combined cervical and vaginal reconstruction with prefabricated pudendal thigh flap in a case with cervical and vaginal agenesis (MURCS syndrome): a new and original technique

In the presence of functional endometrium, in addition to the construction of anatomically, functionally normal and sensitive neovagina and cervix, the preservation of the uterus for future possible pregnancies must also be considered as the main goal in this process. So far, hysterectomy was the general treatment modality in such cases. For maintaining cervical patency, there were no reports in the literature related to cervical prefabrication using flaps. In this report we present a case with cervical and vaginal agenesis (MURCS syndrome). In this case combined cervical and vaginal reconstructions were successfully performed by using bilateral pudendal thigh flaps; a real-like cervix and cervical canal had been previously prefabricated on the distal part of one of the pudendal thigh flaps. Sensitivity and function were both preserved and maintained at the end of this operation.     

腹腔镜全子宫切除术治疗宫颈原位癌临床分析

目的:探讨腹腔镜全子宫切除术治疗宫颈原位癌的临床效果。方法:2003年2月至2008年5月收治187例经宫颈锥形切除诊断为宫颈原位癌的患者,治疗组(62例)行腹腔镜全子宫切除术,对照组分别行腹式全子宫切除术(67例)、阴式全子宫切除术(58例),回顾分析3组患者的临床资料。结果:3组手术时间、术中出血量、肛门排气时间、术后病率、术后住院时间差异均无统计学意义(P0.05),术后随访15~72个月,腹式组1例发现阴道残端轻度上皮内瘤变,余均未见肿瘤残留或复发。结论:与腹式或阴式全子宫切除术相比,腹腔镜全子宫切除术治疗宫颈原位癌效果满意,具有微创和探查全腹腔的优点。     

The cervicocavernosus reflex: Description of the reflex and its role in the sexual act

The paper studies the action and clinical significance of a reflex termed the ‘cervicocavernosus’ reflex. Twenty-two healthy women (mean age 39.7±10.2 SD years) entered the study. The cervix uteri was stimulated both mechanically and electrically by a needle electrode. The response of the bulbo- and ischiocavernosus muscles was recorded by a needle electrode inserted in each muscle. In 10 subjects, the cervix was anesthetized and the cavernosus muscles' response to stimulation of the anesthetized cervix was recorded. The vaginal pressure was measured at rest and on cervical stimulation by means of a balloontipped catheter introduced into the vagina. The mean vaginal pressure at rest was 5.2±1.8 SD cmH₂O and on cervical stimulation 38.8±10.6 cmH₂O. The cavernosus muscles showed no resting activity. Upon cervical stimulation, the muscles contracted with a mean amplitude of 286.4±55.6 SD μV for the bulbocavernosus muscle and 176.6±48.8 μV for the ischiocavernosus muscle; the mean latency of the reflex response was 59.2 ±10.6 SD ms. Stimulation of the anesthetized cervix did not evoke contraction of the muscles. The cervicocavernosus reflex could play a role in enhancing both clitoral and penile erection during the sexual act.     

Pediatric radical abdominal trachelectomy for anaplastic embryonal rhabdomyosarcoma of the uterine cervix: an alternative to radical hysterectomy

Rhabdomyosarcoma arising in the female genital tract carries 5-year survival in excess of 80%, but lifelong infertility may be a consequence of local control strategies. We present the technique and outcome for a fertility-sparing, radical abdominal trachelectomy in a 12-year-old girl with anaplastic, embryonal rhabdomyosarcoma involving the uterine cervix. The patient had presented to our center after the piecemeal resection of a uterine cervical mass; because of concern about microscopic residual disease, we classified her as group II-A according to the Intergroup Rhabdomyosarcoma Study system. Staging studies excluded the presence of distant disease. The patient received 4 cycles of multiagent chemotherapy and then underwent radical abdominal trachelectomy, with removal of the uterine cervix, parametria, vaginal cuff, and regional lymph nodes. Microscopically, the specimen showed treatment effect and no residual tumor. Regional nodes were negative. Radical abdominal trachelectomy, which has not been previously reported for rhabdomyosarcoma, has appeared to secure local disease control in this case while preserving the patient's future fertility potential. In properly selected cases of rhabdomyosarcoma of the uterine cervix, where involvement of the uterus proper is not present, radical abdominal trachelectomy may be an attractive fertility-sparing alternative to radical hysterectomy.     

The use of intravenous nitroglycerin for emergency cervicouterine relaxation

A patient with a twin pregnancy was in preterm labour after 25 gestational weeks when, during vaginal delivery of the second twin, severe spasm of the cervix and fetal bradycardia ensued. Induction of general anesthesia did not relax the cervix. After bolus doses of nitroglycerin 100 + 50 μg i.v., prompt cervicouterine relaxation was obtained allowing manual extraction of the baby. A short review of the literature and a summary of our experience in the administration of nitroglycerin i.v. in obstetrics are presented.     

Pelvic organ support and prevalence by Pelvic Organ Prolapse-Quantification (POP-Q) in Korean women

PURPOSE: We evaluated pelvic organ support and the prevalence of pelvic organ prolapse in Korean women using the Pelvic Organ Prolapse-Quantification system as the assessment tool. MATERIALS AND METHODS: The study population consisted of 713 women 18 to 72 years old who were seen for annual Papanicolaou testing and pelvic examinations. Pregnant patients and patients who had delivered within the previous 6 weeks were not recruited. All pelvic examinations were performed by a single examiner. The patient was examined in the dorsal lithotomy position in a pelvic examination chair positioned at a 15-degree angle. All 9 measurements except total vaginal length were taken with the patient performing the maximal Valsalva maneuver. RESULTS: Mean patient age was 41.6 years (range 18 to 72), mean weight +/- SD was 55.8 +/- 7.4 kg (range 40 to 83), mean height was 158.7 +/- 5.4 cm (range 138 to 177), mean body mass index was 22.3 +/- 8.1 kg/m2 (range 15.7 to 32) and median parity was 2 (range 0 to 6). Mean scores for the position of the cervix and posterior fornix, and total vaginal length were -5.0, -6.6 and 7.0 cm, respectively. In the 713 women with a uterus the incidence of anterior vaginal, uterine and posterior vaginal prolapse was 27.6%, 2.0% and 25.4%, respectively. The overall distribution of pelvic organ prolapse quantification system stage was stages 0 to 4 in 68.3%, 19.9%, 11.2%, 0.6% and 0.0% of patients, respectively. CONCLUSIONS: Vaginal size in Korean women differs from that in Western women. The prevalence of any degree of prolapse was approximately 31.7%. Korean women were at relatively higher risk for anterior and posterior vaginal prolapse than for uterine prolapse.     

Indications and advantages of complete abdominal hysterectomy versus incomplete hysterectomy

The indications for total hysterectomy are definite and have been emphasized. Cautery of the cervix and repair of cervical lacerations are not considered desirable if total hysterectomy can be safely performed.The mortality of total hysterectomy is less than the incident of cervical stump cancer in properly selected cases under competent hands.None of the serious objections often mentioned are encountered when the vaginal vault is well supported and length maintained. The right angle clamp below the cervix, across the vagina as an aseptic precaution seems inadvisable. It shortens the vagina. It is better to open the vagina and reconstruct the vault under direct vision, building up a firm support by the uterosacral ligaments, vaginal fascia and round ligaments.     

A case of adenocarcinoma arising in female urethral diverticulum

An 81-year-old woman was admitted with a chief complaint of bloody discharge from the urethra. On physical examination an elastic-soft mass was palpable beneath the anterior vaginal wall. Magnetic resonance imaging and computed tomographic scan revealed the mass around the urethra. Transvaginal needle biopsy was performed and the histopathologic finding was adenocarcinoma. The tumor was excised with the uterus, the ovary and the anterior vaginal wall. The macroscopic appearance suggested that the tumor arose in the urethral diverticulum. She had intravesical recurrence at 8 months after the operation, and partial cystectomy was performed. However there was recurrence again, and radical cystectomy was performed finally. We review 81 cases of urethral diverticular carcinoma in the literature.