La histerectomía laparoscópica: un abordaje posible. Estudio retrospectivo de las histerectomías laparoscópicas realizadas en un hospital público

Objective

To assess the outcomes of laparoscopic hysterectomy in a public hospital.

Material and methods

We performed a retrospective study of laparoscopic hysterectomies carried out between January 2005 and December 2007. The parameters evaluated were indication, type of hysterectomy, uterine weight, length of hospital stay, and complications.

Results

In the period analyzed, we performed 284 hysterectomies, of which 103 (36.36%) were laparoscopic. The morbidity rate was 9.7% and complications were related to the learning curve. The mean length of hospital stay was 2.56 days.

Conclusions

Laparoscopic hysterectomy is a safe procedure that requires a learning curve of 30-40 procedures. Due to its advantages, this option should be offered in all gynecology services.     

Dehiscencia de cúpula vaginal tras histerectomía laparoscópica: a propósito de un caso

Vaginal vault dehiscence after total hysterectomy with small bowel prolapse through the vagina is a rare complication, especially in premenopausal women. Appropriate management includes early diagnosis and surgical treatment. The combination of an abdominal and vaginal approach may facilitate repair.     

Evisceración vaginal con antecedente de cirugía pélvica: 2 casos

We report 2 cases of vaginal evisceration after prior pelvic surgery that were treated in our hospital during a 4-month period.     

Resultados de un programa de cirugía mayor ambulatoria en ginecología

Objective

To evaluate the outcomes of an ambulatory surgery program in gynecological diseases.

Material and methods

We performed a retrospective study of patients who underwent surgical hysteroscopy or laparoscopic tubal sterilization from January 2002 to December 2006. Several quality indicators (substitution, cancellation, admission and readmission rates) and the systemic and surgical complications appearing in the first week after surgery were analyzed.

Results

During the study period, 1,214 patients underwent surgery in the gynecology service, with a global substitution rate of 90%. The admission rate after surgery was 1.15%. Severe complications occurred in 10 patients, representing a proportional risk of 1:121. Less severe complications requiring hospital admission occurred in 35 patients. Severe gynecological complications occurred in 2 patients.

Conclusions

Despite compliance with optimal requirements, there was a low rate of postoperative complications of variable severity.     

Influencia de la bibliografía en la calidad de los proyectos de tesis presentados en un departamento universitario. Modelos de regresión

Objective

To evaluate the current situation of the publications cited in doctoral thesis proposals in the Department of Obstetrics, Gynecology and Surgery of the University of Zaragoza (Spain) between 1995 and 2002 and to determine the influence of the bibliography on the quality of thesis proposals with a view to predicting the quality of thesis proposals according to their bibliographic parameters.

Material and method

We performed a casecontrol study (proposals with and without bibliography, respectively). A total of 273 thesis proposals corrected by two evaluators (546 subjects under study) and presented in the Department of Obstetrics, Gynecology and Surgery in the University of Zaragoza between 1995 and 2002 were analyzed.

Results

A statistically significant association was found between the variable of bibliography (present, incorrect, or absent) and the quality of thesis proposals (corrected evaluation) verified by two statistical tests. The number of citations seemed to be linearly related to the corrected evaluation (0.229). Various models were proposed through multiple linear regression but these models had little predictive power.

Conclusions

The publications cited did not influence the quality of doctoral thesis proposals.Although some significant variables were found (a large number of cited publications was weakly correlated with higher quality), these variables explained practically none of the variability in quality.The only variable with predictive or explanatory value on the quality of thesis proposals was the number of citations: the greater the number ofcitations the higher the quality but this variable explained only 8.5% of the variability in quality.     

Revisión y comentarios del tratamiento quirúrgico del prolapso genital a propósito de una serie de 609 casos clínicos

We present an observational retrospective study that reviewed a series of 609 patients undergoing classic vaginal surgery procedures for the treatment for genital prolapse in our service. This surgical alternative has been called into question, with proposals for other approaches, such as the introduction of meshes and grafts. After reviewing the scientific evidence and on the basis of our cumulative experience, we found no satisfactory reasons to change our surgical approach. Vaginal hysterectomy and plasties will remain our first choice of surgical procedure for the correction of uterine prolapses, with prophylactic colposuspension of the vaginal vault to the uterosacral ligaments.     

Pronóstico de pacientes con cáncer de mama tratadas con cirugía en un sistema privado extra de salud

Introduction

Many women enrolled in the Spanish National Health Service also take out private health insurance to improve gynecological follow-up and complementary examinations, such as annual mammograms. We analyzed the cure rate of these patients when diagnosed with breast cancer and treated with surgery with curative intent.

Material and methods

Both overall survival and prognosis were analyzed in patients with breast cancer without metastases referred to a private oncology facility and treated with definitive surgery in the context of multidisciplinary treatment.

Results

Between 1994 and 2009, 395 patients with breast cancer were analyzed. Thirty-eight had metastases at diagnosis and 357 could be treated with definitive surgery: conservative in 265 patients and mastectomy in the remaining 92. The median follow-up was 64 months and the 5-year survival rate was 91%: 97% for stage I, 94% for stage II and 77% for stage III. In women diagnosed by mammography, the 5-year survival rate was 96% versus 86% for women consulting a gynecologist after self palpation or for other symptoms (p = 0.0159). Treatment was conservative in 74%, with better survival than in the remaining 26% who were treated with mastectomy (p = 0.0024). Survival was greater in patients with positive hormone receptors than in those with negative hormone receptors (p = 0.0264). Hormone receptor status was the only independent prognostic factor in multivariate Cox analysis.

Conclusions

Patients with breast cancer treated with definitive surgery in a private health insurance system have high cure rate, possibly because they are diagnosed in an early stage.     

Cesárea en isquemia-histerectomía: nueva técnica para finalizar la gestación en pacientes con hipertensión arterial pulmonar

The association of pulmonary hypertension (PH) and pregnancy still leads to high maternal mortality.New treatments and a multidisciplinary approach have improved the course of pregnancies and fetal outcomes but not maternal prognosis.We observed that fetal evacuation and uterine involution coincides with marked worsening of maternal cardiac function, suggesting that the trigger is blood flow from the uterine muscle to the general circulation. This process acts as an autotransfusion and increases the pressure in the right heart to unsustainable limits. A new surgical technique, cesarean section in ischemia-hysterectomy, has been designed to prevent this event. This technique blocks uterine circulation before fetal extraction. We describe this technique and four cases.     

Inversión uterina no puerperal: a propósito de un caso

Non-puerperal uterine inversion is a very infrequent event. The cause is often the presence of a fundal submucous leiomyoma, but diagnosis is difficult and requires a high index of suspicion.     

Separador semiautomático para intervenciones quirúrgicas en ginecobstetricia en pacientes con peso normal o con obesidad mórbida

Aim

To evaluate the usefulness of automatic surgical retractor in obstetric and gynecological interventions.

Material and methods

Open, prospective, longitudinal, exploratory study to evaluate the retractor in surgical interventions.

Sample

100 patients: 45 patients with previous cesarean sections, 49 patients classified as obese, 36 who were overweight, and 10 with normal weight. Surgical interventions: 82 abdominal, 18 vaginal.

Participating physicians

14 obstetric and gynecological surgeons, and 86 residents in gynecology and obstetric.

Statistical analysis

Was used the SPSS program.

Results

Articulation, disarticulation, collocation and retraction of the retractor was satisfactory in 98 interventions. There was one case of instability, and another of insufficient width. Vaginal interventions required only one operator. The instrument reduced the duration of surgery, blood loss, and the use of anesthetics and other material.

Conclusion

The Soriano surgical retractor was useful in 98% of the patients and improved the quality and time of the surgical interventions.     

Tratamiento conservador en pacientes con cáncer de mama multicéntrico

Diagnosis of breast cancer is increasingly made in the early stages of the disease, allowing for less aggressive surgery (breast conservation and sentinel node biopsy). Until recently, breast conservation was generally considered to be contraindicated in multicentric breast cancer. However, recent studies have questioned this belief, suggesting that breast-conserving surgery might be an option in these cases if microscopically free margins are obtained. We present a case of multicentric breast cancer, diagnosed and treated conservatively in our department. We also review the data supporting the current use of breast-conserving surgery in multicentric breast cancer.     

Rotura uterina tras parto vaginal con distocia de hombros

Objective

To describe a case uterine rupture after vaginal delivery associated with shoulder dystocia. This case is of interest due to the seriousness and low incidence of this event.

Subjects and methods

Risk factors for uterine rupture and its typical symptoms were analyzed.

Result

We present the differential diagnosis to be performed when postpartum course is poor, as well as the complementary tests and the procedure to be carried out.

Conclusions

We emphasize the importance of including uterine rupture in the differential diagnosis after a dystocic delivery. Early diagnosis is essential since uterine rupture is a potentially catastrophic event and is one of the most important causes of maternal mortality.     

Utilización de la resonancia magnética en la detección de los carcinomas ductales ocultos. A propósito de un caso

We present a case of ductal carcinoma in situ, as evidenced by magnetic resonance imaging with negative mammographic and ultrasound studies.     

Leiomiomatosis múltiple y gestación. Cesárea e histerectomía programadas

The prevalence of leiomyomas in pregnant women ranges from 0.3 to 2.6% while that of multiple uterine leiomyomatosis is even lower. These myomas provoke obstetric and systemic complications in pregnant women. Planned cesarean hysterectomy does not increase maternal morbidity and mortality rates and reduces puerperal complications. We present two cases of pregnant women at term with an obstetric indication for cesarean section and a gynecological indication for hysterectomy. Both procedures were performed in the same intervention. There were no postoperative complications and hospital stay was reduced by 50%.     

Evisceración intestinal tardía a través de la vagina tras histerectomía

Intestinal evisceration through the vagina is a rare complication of hysterectomy but constitutes an emergency. Both the pathogenesis and prevention of this event are controversial. The average time of onset is 128 days. We report the case of a patient, with onset at 390 days. Surgical treatment was performed by laparotomy with bowel resection and closure of the vaginal vault.     

Embolización de las arterias uterinas en el tratamiento del mioma uterino sintomático. Resultados en 90 pacientes a los 2 años

Objective

To evaluate the mid-term outcomes and patient satisfaction following UAE in women with symptomatic leiomyomata, as well as to assess safety treatment.

Material and methods

Prospective study of 90 patients from Sabadell Hospital between December 2002 and October 2006.Data were collected using a questionnaire and was later introduced in a specific database. Statistical analysis of data was carried out using SPSS 15.0.All patients went on a 2-year follow-up after UAE, including clinical, laboratory and diagnostic imaging examinations.Symptoms were scored as successful, improvement, unchanged or worsened. Adverse events were noted following the Society of Interventional Radiology's classification. Patients were also asked about their satisfaction.The need of an eventual hysterectomy or the persistence of symptoms was considered to be a treatment failure.

Results

The improvement of symptoms occurred in 90,7% of all the embolized women. We had to perform a second embolization in 4 cases, and a hysterectomy in 6 cases.6 months later, null vascularisation or hypovascularisation of the myoma was observed in 92.8% of women. Over two years, the average volume reduction of the dominant myoma was 76.3%.The rate of major complications was 12.7%. Patient satisfaction for the procedure was 90.2%.

Conclusions

Uterine artery embolization is an effective treatment for women with symptomatic uterine leiomyomata, being well accepted by the patients in the mid-term follow-up.     

Valoración ecográfica del endometrio en pacientes tratadas con tamoxifeno

Objective

To measure endometrial thickness and characterize ultrasonographic endometrial images induced by tamoxifen, as well as to determine changes in ultrasonographic patterns throughout treatment.

Patients and methods

We analyzed 278 patients with breast cancer between 1995 and 2000 under adjuvant therapy with tamoxifen for 5 years. Annual ultrasonographic examination was performed. Endometrial thickness and the morphological endometrial patterns in stored ultrasonographic images were retrospectively analyzed.

Results

Endometrial thickness significantly increased during treatment from a mean of 7.84 mm in the first year to 16.67 mm in the fifth year. Five endometrial patterns were found on ultrasonography in patients receiving tamoxifen: linear, heterogeneous-hyperechoic, homogeneoushyperechoic, endometrial polyp, and suspicious for malignancy. The homogeneous-hyperechoic pattern predominated in the first year and the heterogeneous-hyperechoic pattern in the fifth year.

Conclusions

Tamoxifen increases endometrial thickness in the course of treatment and induces five ultrasonographic patterns which change year-by-year.     

Hematoma retroperitoneal masivo tras corrección vaginal de prolapso de cúpula

We present an acute case of the formation of a large haematoma in the retroperitoneal space after vaginal surgery. The patient was a 72 year old woman with hypertension and heart disease, on treatment, among other drugs, with enoxaparin since a few days before. She was operated on due to a cysto-rectocele with vaginal vault prolapse. At 36 hours, she began to have intense lumbar pain and a worsening of her general state. The urgent computerised tomography report mentioned a large haematoma of over 16 cm in size, with signs of active bleeding in the abdominal cavity. During the laparotomy a massive retroperitoneal haematoma was discovered that extended over the limits of the pelvis.     

Histología e inmunohistoquímica de los carcinomas de mama en pacientes intervenidas de más de 70 años de edad

Objective

We retrospectively analyzed tumoral characteristics (histology and immunohistochemistry) in a group of elderly patients (≥ 70 years old) after surgery between 2003 and 2005, and compared these characteristics with those of younger patients.

Material and methods

We studied the characteristics of 483 breast carcinomas diagnosed sfrom 2003 to 2005 in the Gynecology Service of the 12 de Octubre Hospital in Madrid. Of these, 153 (31.7%) corresponded to patients aged 70 years old or older. Data were analyzed using the SPSS 12.0 program, and the groups were compared using chi-square analysis (or Fisher’s test when required). Quantitative data were expressed as mean ± standard deviation and median with interquartile range.

Results

In our patients aged 70 years or older, diagnosis after mammography was less frequent. In situ and microinvasive carcinomas were less frequent and the mean size of invasive carcinomas was larger. These findings can be explained by the lack of mammographic screening. No other histological or immuno-histochemical differences were found in comparison with younger patients and no differences were found in axillary lymph node involvement in women with axillary dissection.

Conclusions

Treatment in elderly patients should be individually tailored according to the biological characteristics of the tumor, comorbidity, and life expectancy. Age per se should not be considered a predictive factor of worse outcome.