The management of the patient with abnormal vaginal cytology following hysterectomy

Summary. Thirty-two patients presenting with abnormal vaginal cytology following hysterectomy were studied. Seven (21·8%) had had hysterectomy for benign conditions whilst 25 (78·1%) had cervical intraepithelial neoplasia (CIN) or invasive cervical carcinoma. Twenty-five patients had partial or total vaginectomy (15 as the primary procedure), and one required laser treatment following vaginectomy. Of 11 (34·3%) patients treated primarily by laser, five subsequently required vaginectomy because of persistent or recurrent cytological abnormality. All four patients treated with topical 5-fluorouracil or dinitrochlorobenzene subsequently required surgery. Nine of the 32 patients (28·1%) proved to have invasive carcinoma of the vagina on histological examination of the vaginectomy specimen. At the time of writing all patients in the study are well with no evidence of disease.     

Operative management of vaginal vault prolapse following hysterectomy

Summary. Nine women suffering from vaginal vault prolapse had an abdominal sacropexy between 1972 and 1983. Marlex mesh was used to anchor the vaginal vault to the promontory of the sacrum and was completely buried retroperitoneally. The women had all had previous attempts at surgical correction. There were no intra- or post-operative complications. No recurrences of vault prolapse occurred during a mean follow-up period of 3.9 years. One woman developed a moderate cystocoele 4 years after sacropexy.     

The management of vaginal intraepithelial neoplasia after hysterectomy

Twenty-three patients with vaginal intraepithelial neoplasia (VaIN) presented between 6 months and 13 years after hysterectomy for cervical intraepithelial neoplasia. All were discovered by cytological follow-up, were colposcopically assessed and diagnosis confirmed by histological examination before treatment. The CO2 laser was used as the initial treatment in 14, but only six remain free of disease after mean follow-up of 30 months. The reasons for the disappointing results with this form of therapy are discussed and it is suggested that its use may be inappropriate in the management of VaIN following hysterectomy as atypical epithelium may frequently be inaccessible as a result of being sequestered above the vault suture line or hidden in the recesses of the angles of the vaginal vault.     

Partial trachelectomy in the elderly patient with abnormal cytology

Because of an unsatisfactory colposcopic examination, cold knife conization of the cervix is frequently required for the evaluation of postmenopausal patients with abnormal cervical cytology. With advancing age, the cervix atrophies and retracts so that conization becomes increasingly difficult and results in a tissue specimen that is frequently inadequate. Dissatisfied with the results of the standard conization procedure, the authors performed partial trachelectomy in 26 elderly patients with atrophic, retracted cervixes. The operative complications were acceptable. Twelve of the 26 patients (46%), including four with severe dysplasia and carcinoma in situ (CIS) and eight with invasive carcinoma, received additional therapy. Eleven of 14 patients (78%) with cervical intraepithelial neoplasia (CIN) had clear surgical margins; ten of these required no further therapy. The authors conclude that partial trachelectomy may be preferable to conization for the evaluation of elderly women with small, atrophic cervixes. It provides a specimen of sufficient length, so as to reduce the incidence of positive surgical margins and to decrease the need for additional therapy if no invasive neoplasia is found. The technique of partial trachelectomy is described.     

Delayed life-threatening vaginal dehiscence following hysterectomy

We describe a case of an elderly patient who presented as an acute surgical emergency with strangulated intestine prolapsing through the vagina and onto the vulva. She became cardiovascularly unstable and required resuscitation before emergency surgery to resect infarcted intestine and repair the vaginal vault. The pathogenesis and management of this unusual complication of hysterectomy are discussed.     

Prevention of vaginal shortening following radical hysterectomy

We describe a surgical procedure and post-operative management for the prevention of vaginal shortening following radical hysterectomy. A total of 452 patients who underwent hysterectomies were examined prospectively depending on the operation method. This study showed that our procedure was effective in the prevention of vaginal shortening following radical hysterectomy. Preservation of the ovaries appeared to be important in preventing vaginal shortening, and post-operative hormone replacement therapy was not as effective as the preservation of the ovaries. The effect of external irradiation on vaginal shortening was not conspicuous in the case that the ovaries were preserved.     

Prevention of postoperative complications following vaginal hysterectomy

In a prospective study on infectious morbidity after vaginal hysterectomy we examined the clinical symptoms of an infection and partly also the microbial conditions of the vaginal wound. With a group of 49 patients without antibiotic prophylaxis we tried to find out if the type of vaginal occlusion might have any influence on the microbial situation and the healing process. The results of this first group were compared to those of a second group consisting of 31 patients, who had received antibiotic prophylaxis before the operation with a cephalosporin. Though it was not possible to make any microbial analyses in the second group, the clinical evaluation showed distinctly that antibiotic prophylaxis is an important contribution to the prevention of infections after vaginal hysterectomy. The careful consideration of septic-surgical precautions, however, and this was proved by the first part of the study, contributes as well to the prevention of infections.