阴道残端子宫内膜异位症1例

1病例报告 患者,52岁,因子宫全切术后3年,阴道不规则流血2年入院.患者3年前因多发性子宫肌瘤行子宫全切术,术后诊断为多发性子宫肌瘤、子宫内膜异位症.术后5月出现阴道不规则流血,量少,色鲜红,流血无明显周期性及规律性,无明显下腹及肛门坠胀,妇科检查时发现阴道残端左穹隆处有一直径约0.5cm赘生物,有出血,取赘生物送病理检查,结果提示子宫内膜异位症.     

子宫颈子宫内膜异位症19例临床病理分析

目的分析子宫颈子宫内膜异位症的临床表现及诊治特点,以指导临床工作。方法回顾性分析北京协和医院妇产科1993年1月至2007年12月间病理证实为子宫颈子宫内膜异位症的19例患者的临床资料。结果19例子宫颈子宫内膜异位症患者中,11例术前宫颈外观正常而术后病理切片提示病变,其中9例行全子宫切除术,2例行宫颈锥切术。术前宫颈外观异常8例患者中,3例表现为宫颈肿物,1例表现为宫颈息肉,4例表现为宫颈紫蓝色结节;6例患者主诉有不规则阴道出血和／或性交后出血;4例浅表的宫颈紫蓝色结节行结节切除术,宫颈肿物及息肉行病灶切除2例,全子宫切除2例。结论子宫颈子宫内膜异位症可伴阴道不规则出血或性交后出血。治疗方式的选择应根据病变的类型、患者的年龄及生育要求采取个体化的手段。     

子宫全切除术后发生输卵管脱垂的临床分析

目的探讨子宫全切除术后输卵管脱垂的诊断、处理及预防措施。方法收集1983年1月至2005年8月行各类子宫全切除术7949例患者的资料,其中行开腹子宫全切除术6229例,行阴式子宫全切除术780例,行腹腔镜辅助阴式子宫全切除术940例。结果手术后共发生阴道残端输卵管脱垂9例,发生率为0．11％（9／7949）。其中开腹子宫全切除术后发生5例,发生率为0．08％（5／6229）;阴式子宫全切除术后发生4例,发生率为0．51％（4／780）;腹腔镜辅助阴式子宫全切除术后无一例发生输卵管脱垂。9例患者子宫全切除术后均放置了阴道引流管,其中5例子宫切除后未行阴道残端腹膜化处理。9例患者中,3例无任何症状;6例有症状的患者中,1例出现左侧腰背部痛,5例出现阴道排液。妇科检查,3例阴道残端发现输卵管伞端,6例阴道残端可见类似肉芽样组织。9例患者均经阴道切除,局部烧灼脱垂的输卵管,切除组织经病理检查证实均为输卵管组织。之后随诊1-59个月无异常发现。结论输卵管脱垂是子宫全切除术后的一种少见并发症,输卵管脱垂一般发生于子宫全切除术后放置阴道引流管的患者,经正确的诊断和治疗预后良好。行子宫全切除术时,应将附件固定在骨盆侧壁或行输卵管切除。     

子宫内膜异位症淋巴结转移3例病例报道并文献复习

目的:探讨子宫内膜异位症(EMs)淋巴结转移的临床特点及相关机制。方法:回顾分析2012年5月至2015年9月北京大学第一医院收治的2例结直肠EMs及1例输尿管EMs伴淋巴结转移病例,结合相关文献,分析其病因及临床特点。结果:1例患者因腹腔播散性腺肌瘤累及肠道,行肿物、小肠及右半结肠切除术,结肠周淋巴结内可见子宫内膜异位。1例患者因深部浸润型EMs行手术治疗,术中见病变累及直肠,切除直肠,术后病理示EMs,肠周淋巴结可见异位子宫内膜。1例患者因右肾积水、右输尿管肿物行右输尿管镜检查,后行开腹右输尿管局部切除+右输尿管膀胱瓣吻合术,术后病理示髂内淋巴结可见子宫内膜异位。结论:EMs淋巴结转移发病率可能被低估,临床表现无特异性。术中对于区域淋巴结的切除及术后药物辅助治疗可减少疾病复发。对于EMs淋巴结转移的发病机制尚不明确,仍需进一步研究。     

阴式子宫切除术后并发阴道残端窦道1例

患者55岁,病例号:126306。因子宫脱垂Ⅰ度于2001年5月在外院行腹腔镜下阴式子宫切除术。术后反复不规则阴道流血、流液,虽经多次门诊治疗,但效果欠佳,于2002年6月18日入我院。妇科检查:阴道通畅,内见少许血污,阴道残端偏左侧见一宽1.5cm、深3.5cm窦道,内见脓苔及肉芽组织,有接触性出血。诊断:(1)阴道残端感染;     

输卵管脱垂2例

例1,49岁。2年前因多发性子宫肌瘤行全子宫切除术。术后2月常规随访主诉右下腹偶感隐痛,妇科检查示阴道残端愈合,无异常分泌物,建议门诊随访以除外子宫内膜异位症。术后2年患者仍偶感右下腹隐痛,且渐有坠胀感,近期加重,遂来院就诊。患者术后无接触性出血史。妇科检查示阴道粘膜充血,淡黄色分泌物较多,阴道顶端右侧见肉芽组织直径约2cm,盆腔右侧扪及囊肿约4cm。B超示右侧盆腔有一液性区4cm×3cm×3cm,疑为右卵巢。拟诊为1.右附件囊肿;2.阴道残端肉芽。行肉芽摘除术。术时患者感右下腹有剧烈牵拉痛,肉芽摘除后在阴道残端见一小破口,并见未吸…     

宫颈残端切除9例临床分析

目的:探讨子宫次全切除术后需行宫颈残端切除的原因,宫颈残端病变的临床表现、治疗方法和预防。方法:回顾性分析1993年1月至2005年12月本院收治的9例行宫颈残端切除的患者的临床资料。结果:3例为宫颈残端平滑肌瘤复发,2例为宫颈残端鳞癌,另外2例于子宫次全切除术后病理检查诊断为子宫肉瘤,2例为子宫平滑肌瘤合并子宫内膜腺癌。主要表现为腹胀、尿潴留、阴道不规则流血、阴道流液和接触性出血、盆腔包块。以手术治疗为主,术后补充放疗、化疗。结论:严格掌握子宫次全切除术的指征,术前、术中不漏诊子宫、宫颈恶性肿瘤,术后应严密随访,及时发现处理宫颈残端病变。     

全子宫切除术后输卵管脱垂四例

一、病例摘要 病例1：患者43岁,于2005年3月因多发性子宫肌瘤于外院行开腹全子宫切除术,手术顺利,术后给予抗炎治疗,患者术后体温正常。术后1个月逐渐出现阴道分泌物增多,粉色,就诊于北京大学人民医院,妇科检查：阴道断端可见肉芽样组织。于2005年5月在腰麻下行阴道断端肿物切除术＋阴道残端修补术,术中探查肿物为输卵管,完整切除后可见输卵管组织充血水肿。     

直肠子宫内膜异位症32例临床分析

目的：探讨直肠子宫内膜异位症的临床特点及其诊治方法。方法：回顾性分析我院近10年收治的32例直肠子宫内膜异位症患者的临床资料及治疗结果。结果：32例患者均行手术治疗。8例合并子宫腺肌病患者行全子宫切除术,6例患者同时行卵巢巧克力囊肿切除术。平均住院天数为30．2±5．6天,术后均未发生直肠瘘和盆腔感染等并发症。治愈率为62．5%,好转率为18．8%。术后妊娠率为57．1%。结论：手术切除病灶是治疗直肠子宫内膜异位症的有效方法,可消除症状并提高患者术后妊娠率。     

深部浸润型子宫内膜异位症的治疗研究新进展

深部浸润型子宫内膜异位症（deep infiltrating endometriosis,DIE）是子宫内膜异位症（endometriosis,EMs）的一种特殊类型,其特指浸润深度≥5 mm的EMs病灶,可累及盆腔不同部位,主要位于后盆腔,如宫骶韧带、子宫直肠陷凹、阴道直肠隔和结直肠等。疼痛是其主要临床症状,且形式多样,包括痛经、慢性盆腔痛、深部性交痛及泌尿消化系统相关的疼痛等。目前DIE的治疗主要以手术为主,但手术困难、手术安全、术后并发症较难避免等均是非常棘手的问题。研究者据此提出的保留神经功能的病灶切除术,机器人辅助腹腔镜手术等方法正在被探究中。综述DIE的治疗研究新进展。     

Is the invasion depth in millimeters valid to determine the prognosis of early invasive cervical adenocarcinoma? A case of recurrent FIGO stage IA1 cervical adenocarcinoma.

BACKGROUND: Recurrence of FIGO stage IA1 cervical adenocarcinoma is extremely rare. We herein report a patient with early invasive cervical adenocarcinoma who developed a recurrence in the vaginal stump. CASE: A 52-year-old female complained of contact bleeding. Biopsy of the uterine cervix verified cervical adenocarcinoma, and the patient underwent Okabayashi hysterectomy with pelvic lymphadnectomy and bilateral adnectomy. Histopathologic examination of the uterus revealed an invasive cancer 3 mm in depth. Neither lymph node metastasis nor lymph-vascular space invasion was observed. However, the depth of her normal cervical gland area was 2 mm only, and the cancer invasion involved an area which was deeper than the normal cervical gland area. The vaginal stump recurrence developed 4 years after surgery. CONCLUSION: The depth of invasion with reference to that of normal cervical glands may become a possible prognostic factor for early invasive cervical adenocarcinoma.     

Laparoscopic-assisted radical parametrectomy including pelvic and/or paraaortic lymphadenectomy in women after prior hysterectomy-three cases

BACKGROUND: Radical abdominal surgery in patients who have previously undergone a hysterectomy is a surgical challenge. This type of surgery for invasive cervical cancer after a hysterectomy or vaginal stump metastasis traditionally requires a major laparotomy; however, a minimal-access approach is now being applied to this type of procedure. CASE: A laparoscopic-assisted radical parametrectomy including a pelvic and/or paraaortic lymphadenectomy was performed on two patients presenting invasive cervical cancer diagnosed after a simple hysterectomy and one patient with recurred endometrial cancer in the vaginal stump. All three patients had an excellent clinical outcome and made a rapid recovery with no major complications, even though two cases involved a bladder laceration. CONCLUSION: A laparoscopic radical parametrectomy including a pelvic and/or paraaortic lymphadenectomy is a viable technique for women with invasive cervical cancer or recurrent endometrial vaginal cancer after a prior hysterectomy.     

Laparoscopic radical trachelectomy or parametrectomy and pelvic and para-aortic lymphadenectomy for cervical or vaginal stump carcinoma: report of six cases

The aim of this study was to investigate the feasibility and safety of laparoscopic radical parametrectomy and pelvic and para-aortic lymphadenectomy after previous supracervical or extrafascial hysterectomy. This is a prospective study of six patients with vaginal or cervical stump carcinoma after previous supracervical or extrafascial hysterectomy. The technique of radical parametrectomy with pelvic and para-aortic lymphadenectomy as used for open surgical cases for years was performed laparoscopically. The average operating time was 180 min, the estimated average blood loss was 220 mL, and the duration of hospitalization was 11.8 days. There was no intraoperative or postoperative complication. Laparoscopic radical parametrectomy with pelvic and para-aortic lymphadenectomy for cervical or vaginal stump carcinoma can be successfully and safely accomplished.     

Laparoskopische suprazervikale Hysterektomie

Laparoscopic supracervical hysterectomy (LASH) is a minimally invasive procedure that was developed during the 1990s. Although LASH has gained in importance, prospective randomized trials comparing LASH with other hysterectomies are very sparse. The benefits of laparoscopic hysterectomy compared with an open abdominal approach are well documented. However, nearly 20?years after the first reports of different techniques of laparoscopic hysterectomy, abdominal hysterectomy is still the predominant surgical technique worldwide. Advocates of LASH suggest that the procedure is easier to perform, is less invasive, and carries a lower risk of ureteric injuries and infectious complications compared with total laparoscopic hysterectomy. Opponents of LASH, however, are concerned with the persistent risk of cervical stump symptoms such as persistent vaginal bleeding and pelvic pain following LASH, causing patient distress and, eventually, repeated surgery. The aim of this work was to screen the actual data for the local value of LASH.     

Post-hysterectomy menstruation: a rare phenomenon

Post-menopausal bleeding is a common problem with varied etiology in the age group between 50 and 60 years. It is more likely to be of some pathologic cause which needs to be ruled out. Bleeding in a patient after hysterectomy is even rarer with varied causes like atrophic vaginitis, cervical stump cancer, infiltrating ovarian tumors, estrogen secreting tumors in other parts of the body. Endometriosis of the vault sometimes can cause post-menopausal bleeding. Diverticulitis of the bowel may give rise to vaginal discharge due to fistula, but bleeding is rare. Bladder pathology may cause vaginal bleeding. Our case is a rare case of vault endometriosis and should always be kept as a differential diagnosis in patients with bleeding after hysterectomy.     

Laparoscopic Resection of a High Grade Serous Ovarian Cancer that Recurred at the Vaginal Stump with Extensive Pelvic Adhesions after Complete Surgical Staging

Study ObjectiveTo show laparoscopic resection of a high grade serous ovarian cancer that recurred at the vaginal stump with extensive pelvic adhesions after complete surgical staging.DesignStepwise demonstration of the procedure with narrated video footage.SettingUniversity hospital.InterventionsWe reported a case of a 62-year-old woman with a history of complete surgical staging of high grade serous ovarian cancer staged IIB, which consisted of hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymph node dissection, and omentectomy, about 18 months before this admission. She received 6 courses of carboplatin/paclitaxel combination therapy after complete surgical staging and achieved complete remission. About 12 months after the last course of chemotherapy, she visited the local clinic because of irregular vaginal bleeding. Physical examination revealed a 3 × 3 × 2 cm³ mass at the vaginal vault. Biopsy of the mass was performed under colposcopy, and pathological reports showed recurrent high grade serous cancer. Her serum cancer antigen 125 level was in normal range. Positron emission tomographic/computed tomographic imaging (PET/CT) showed no evidence of disease dissemination. A diagnosis of recurrent high grade serous ovarian cancer was made. After the biopsy of the recurrent mass, there were no visible lesions, which made us believe that laparoscopy management would not contribute to intraperitoneal spread of the tumors. Therefore, laparoscopic resection of the vaginal stump was scheduled. The key steps of the procedure were summarized as follows. First, the bowels were released from the side abdominal wall to expose bilateral external iliac vessels. Second, bilateral ureters were identified and mobilized to avoid incidental ureter injuries. Third, we opened the rectovaginal space and detached the rectum from the posterior vaginal wall. Fourth, the posterior vesical wall was separated from the vaginal stump. After exposure of the key anatomic landmarks, laparoscopic resection of the vaginal stump was performed safely. Final pathologic report showed recurrent high grade serous ovarian cancer. The patient received 6 courses of carboplatin/paclitaxel combination therapy, and maintenance therapy with olaparib was suggested, but the patient refused to accept this suggestion. She is still in complete remission 8 months after surgery.ConclusionLaparoscopic resection of a high grade serous ovarian cancer that recurred at the vaginal stump with extensive pelvic adhesions after complete surgical staging was achieved successfully in a logical way. The critical point of the procedure is to expose the key anatomic landmarks of the pelvis to avoid incidental injuries [1].     

Laparoscopic supracervical hysterectomy

Laparoscopic supracervical hysterectomy is a minimally invasive procedure that was developed during the 1990s as a treatment for abnormal uterine bleeding. The literature regarding this procedure, mainly case series and retrospective comparisons, suggests that laparoscopic supracervical hysterectomy results in reduced operating time and blood loss and a quicker return to normal activity, compared with laparoscopic-assisted vaginal hysterectomy. A randomized, controlled trial that compared laparoscopic supracervical hysterectomy with hysteroscopic endometrial resection found that laparoscopic supracervical hysterectomy resulted in significantly better patient satisfaction at 2 years for similar costs. Unfortunately, there are no randomized trials that have compared laparoscopic supracervical hysterectomy to vaginal or abdominal hysterectomy. Given the lack of appropriate randomized, controlled trials and the limitations of the existing research, the laparoscopic supracervical hysterectomy's true value and appropriate clinical indications remain unknown. Well-designed randomized, controlled trials that compare laparoscopic supracervical hysterectomy with laparoscopic-assisted vaginal hysterectomy, total vaginal hysterectomy, and total abdominal hysterectomy, with attention to short- and long-term morbidity, postoperative vaginal bleeding, postoperative cervical disease, sexual function, urinary symptoms, and pelvic prolapse are needed. The purpose of this article was to review the existing literature regarding laparoscopic supracervical hysterectomy and to evaluate the evidence regarding the proposed risks and benefits of the procedure.     

Risk factors for vaginal prolapse after hysterectomy

Objective

To identify risk factors for pelvic organ prolapse (POP) and their influence on the occurrence of vaginal prolapse after hysterectomy.

Methods

Medical records from 2 groups of women who had undergone hysterectomy were reviewed retrospectively. The study group was 82 women who had undergone surgery for vaginal prolapse after hysterectomy; the control group was 124 women who had undergone hysterectomy with no diagnosis of vaginal prolapse by the time of the study. All hysterectomy procedures had been performed for benign gynecological disease, including POP. Both groups of women completed a self-administered questionnaire to obtain additional information on the occurrence of POP.

Results

The incidence of vaginal prolapse after hysterectomy was significantly higher in women with a higher number of vaginal deliveries, more difficult deliveries, fewer cesareans, complications after hysterectomy, heavy physical work, neurological disease, hysterectomy for pelvic organ prolapse, and/or a family history of pelvic organ prolapse. Premenopausal women had vaginal prolapse corrected an average of 16 years after hysterectomy, and postmenopausal women 7 years post hysterectomy.

Conclusion

Before deciding on hysterectomy as the approach to treat a woman with pelvic floor dysfunction, the surgeon should evaluate these risk factors and discuss them with the patient.     

Laparoskopische suprazervikale Hysterektomie (LASH)

Laparoscopic supracervical hysterectomy (LASH) is a minimally invasive procedure that was developed during the 1990s as a novel treatment option for patients with uterine bleeding disorders. To date, prospective randomized trials comparing LASH with either vaginal or abdominal hysterectomy do not exist. A randomized controlled trial that compared LASH with hysteroscopic endometrial resection found that LASH resulted in better patient satisfaction. A retrospective study compared LASH with laparoscopic assisted vaginal hysterectomy and demonstrated reduced operating time, blood loss, hospitalisation and a quicker return to normal activity for patients who underwent LASH. The potential risk of cervical carcinoma in patients with a cervical stump is often controversially discussed. However, results of follow-up studies do not indicate a higher incidence of cervical cancer after LASH compared to the risk of vaginal cuff carcinoma after total hysterectomy.     

"Schauta sine utero": technique and results of laparoscopic-vaginal radical parametrectomy

OBJECTIVES: Radical parametrectomy or radical cervical stump exstirpation is indicated in selected oncologic situations. We evaluated whether radical parametrectomy without or with cervical stump exstirpation can be performed by a combined laparoscopic-vaginal approach. METHODS: Between November 2001 and Dezember 2002 six patients with unexpected cervical cancer (n = 3) after simple hysterectomy, histologically confirmed vaginal recurrence of endometrial cancer (n = 1), or cervical stump recurrence of endometrial cancer after supracervical hysterectomy (n = 2) underwent radical parametrectomy. After cystoscopic placement of bilateral ureteral stents laparoscopic paraaortic and pelvic lymphadenectomy was performed. The vascular part of the cardinal ligament and the bladder pillar were transsected laparoscopically. According to a LARVH type III procedure vaginal vault or cervical stump with parametrial and paravaginal structures was removed transvaginally. RESULTS: In all patients R0 resection could be achieved (n = 4) or no residual tumor was detected (n = 2). There were no intraoperative complications. One patient developed acute kidney failure on postoperative day 1, with spontaneous recovery after 12 days. The median drop of hemoglobin on postoperative day 5 was 2.15 mmol/L (1.3-3.2) and no patient needed transfusion. Restitution of bladder function took 4.3 days on average. The mean operation time was 424 min (385-452). CONCLUSIONS: Radical parametrectomy can be performed by a combined laparoscopic-vaginal technique without complications. Together with laparoscopic paraaortic and pelvic lymphadenectomy, it is a valid alternative to open surgery in selected oncologic patients.