Arteries of the hilum and parenchymal part of the ovary in reproductive age in microangiographic studies

OBJECTIVES: The main aim of ours research was to recognize the arterial system of female ovaries in women in the reproductive age. MATERIALS AND METHODS: Study was performed on 31 cases of organs taken from the minor pelvis, composing female genital organs, urinary bladder, rectum and the upper part of the vagina from women aged 15 to 40. The ovarian and the uterine arteries have been injected with fine-granular radiological contrast medium Hexabrix 200 and Ultravist 370. Global X-rays of the whole organs complex and the microangiography of the isolated uterine adnexa and ovarian glands scraps were made. RESULTS: In all the examined cases the main source of ovarian blood supply was the ovarian arch created by the ending of the ovarian artery and the ovarian branch of the uterine artery. A different number of branches of the main vessel of the ovarian arch were going into the hilum of the ovary gland. The arterial branches on all length of the ovarian arch have been disposed as a dense net. Nearly all vessels of the ovarian arcade after short course have been divided several times and finally a higher number of branches were getting into the parenchymal parts of the ovarian gland. The vessels of the parenchymal part have been arranged regularly in the middle of the gland from the hilum to the free edge. In ends and peripheral parts of the ovary gland the number of vessels were significantly reduced. There were singles thinly vessels with non-typical course only. CONCLUSIONS: The arteries of the uterine adnexa always come from two sources: ovarian artery and uterine artery, both are forming the ovarian arch. Arteries of ovarian medulla are running axially, from hilus to the free margin of the gland. The spiral arteries system of the gonad is uniform and dense in the middle part of the gland, peripheral parts of the ovary and the area of ends of the gonads have got poor vessel picture.     

Childbirth and myoma treatment by uterine artery occlusion: do they share a common biology?

When the uterine arteries are bilaterally occluded, either by uterine artery embolization or by laparoscopic obstruction, women with myomas experience symptomatic relief. After the uterine arteries are occluded, most blood stops flowing in myometrial arteries and veins, and the uterus becomes ischemic. It is postulated that myomas are killed by the same process that kills trophoblasts: transient uterine ischemia. When the uterine arteries are bilaterally occluded, either by uterine artery embolization (UAE) or by laparoscopic obstruction, women with myomas experience symptomatic relief. After the uterine arteries are occluded, most blood stops flowing in myometrial arteries and veins, and the uterus becomes ischemic. Over time, stagnant blood in these arteries and veins clots. Then, tiny collateral arteries in the broad ligament (including communicating arteries from the ovarian arteries) open, causing clot within myometrium to lyse and the uterus to reperfuse. Myomas, however, do not survive this period of ischemia. This is unique organ response to clot formation and ischemia. What allows the uterus to survive a relatively long period of ischemia while myomas perish? Childbirth appears to be the predicate biology. Following placental separation, the uteroplacental arteries and the draining veins of the placenta are torn apart at their bases in the junctional zone of the myometrium and bleed directly into the uterine cavity. Left unchecked, every woman would bleed to death in less than 10 minutes after placental delivery. Most women do not bleed to death because vessels in the uterus clot after placental delivery. During pregnancy, clotting and lytic factors in blood increase many fold. Following delivery, uterine contractions continue, intermittently, periodically slowing the velocity of flowing blood through myometrium. The combination of slowed blood flow, elevated clotting proteins, and torn placental vessels (known as Virchow's triad) causes blood in myometrial arteries and veins to clot. Fibrinolytic enzymes later lyse clot in arteries and veins not associated with placenta perfusion, and the uterus is reperfused. Remnant placental tissue - primarily uteroplacental arteries and veins - does not survive this period of ischemia. Placental tissue dies and over weeks is sloughed into the uterine cavity. At the same time, residual endometrial tissue grows under the sloughing placental tissue thus re-establishing the endometrial lining. It is postulated that myomas are killed by the same process that kills trophoblasts - transient uterine ischemia.     

Precise anatomy of the vesico-uterine ligament for radical hysterectomy

OBJECTIVES: To clarify the anatomy of the vesico-uterine ligament (VUL), we meticulously separated the VUL under magnification (x2.5) during Okabayashi's radical hysterectomy. METHODS: Fifty-nine patients (TNM nomenclature: pTIb: 39, pT2a: 5, pT2b: 7, after trans-arterial anticancer-drug infusion treatment for the cervical cancer: 8) underwent this meticulous operation. Blood loss was recorded at two separate time points: during the separation of the VUL and after removal of the uterus. RESULTS: After complete separation of the uterine artery and superficial uterine vein from the ureter, we could identify the genuine connective tissue of the anterior leaf of the VUL in which we isolate and divide a distinct bundle of blood vessels: the cervicovesical vessels that cross over the ureter from the bladder to the cervix. The remaining tissues in the anterior leaf is only avascular connective tissue. The posterior leaf of the VUL is the tissue residing under the ureter connecting the posterior wall of the bladder and the lateral cervix/upper lateral vagina. In the connective tissues, we identified the middle and inferior vesical veins connecting with the deep uterine vein. The division of these veins could separate the urinary bladder with ureters completely from the lateral cervix and upper vagina. The mean blood loss during the separation of the VUL was 20+/-10 g (N=59) and after radical hysterectomy was 189+/-91.6 g (N=59). CONCLUSION: A precise network of blood vessels in the VUL is identified. The knowledge of this anatomy is important to perform radical hysterectomy.     

Management of a bleeding aberrant cervical artery following vacuum suction termination. Case report

A 29-year old woman underwent a pregnancy termination as well as sterilization. During laparoscopic sterilization, the pelvic organs appeared normal; however, 1 hour later the patient experienced vaginal hemorrhage. When therapeutic measures proved unsuccessful, blood transfusion was begun and it was concluded that there was an injury to the uterus. The bleeding, however, was from the left side of the cervical canal and at repeat laparoscopy, the uterus had not been perforated nor had it increased in size. As an effort was made to assess the damage, the surgeon discovered an aberrant branch of the cervical artery was bleeding. Ends of the damaged and bleeding artery were clamped and ligated and the walls of the cervix and uterus were repaired. The patient experienced an uneventful recovery and at the 6-week follow-up, the pelvic organs were within the normal limit and all wounds had healed. In all likelihood, a cervical tear during previous childbirth or abortion had exposed 1 of the branches of the left cervical artery and left it the target of a Karman catheter during the current abortion procedure.     

The role of diagnostic hysteroscopy in infertile women

BACKGROUND: Anomalies of the uterus are considered one of the reasons for infertility in women. For this reason we believe diagnostic hysteroscopy is fundamental in screening for infertility. The aim of this study was to verify the incidence of uterine anomalies in sterile couples and evaluate the efficacy of diagnostic hysteroscopy in subjects with possible alterations in this organ. METHODS: From July through December 2000, 296 hysteroscopies were carried out at the Centro di Sterilità e di Fecondazione Assistita of Perugia University. Of these 223 entered the study because of infertility in couples. The exam was always done between the 7th and 11th day of the cycle using a Hamou 5 mm hysteroscope, without anaesthesia. The uterus was dilated by introducing physiological solution at 50 mmHg pressure. The criteria adopted for hysteroscopic findings were based on: a) cervical canal; b) uterine cavity; c) endometrium, and visualization of the ostium tubae. RESULTS: Of the 223 women who underwent hysteroscopy screening for infertility 17 (7.62%) had uterine anomalies. Of these 1 was in the cervical canal, 4 had anomalies in both the uterus and cervix, and the remaining 12 had only uterine cavity anomalies. The presence of neoformations was the most commonly found alteration. CONCLUSIONS: From the results of this study we conclude that diagnostic is a very important method for investigating the reasons for infertility in a couple. From our casuistry the incidence of uterine anomaly is 7.62%. We therefore suggest hysteroscopy be included among the 1st and 2nd level exams for female infertility.     

Transvaginal ultrasonography of the cervix to predict preterm birth in women with uterine anomalies

OBJECTIVE: Women with uterine anomalies have higher rates of preterm birth, but the reason for this has not been elucidated. Transvaginal ultrasound examination has been shown to be an accurate test for the prediction of preterm birth but has not been studied specifically in this population. METHODS: Pregnant women with uterine anomalies were followed prospectively with transvaginal ultrasound examination of the cervix, performed between 14 and 23 6/7 weeks of gestation. A short cervical length was defined as less than 25 mm of cervical length. The primary outcome was spontaneous preterm birth, defined as birth at less than 35 weeks. RESULTS: Of the 64 pregnancies available for analysis, there were 28 with a bicornuate uterus, 13 with a septate uterus, 11 with a uterine didelphys, and 12 with a unicornuate uterus. The overall incidence of spontaneous preterm birth at less than 35 weeks was 11%. Of the 10 (16%) women with a short cervical length, 5 (50%) had spontaneous preterm birth. Of the 54 women without a short cervical length, only 2 (4%) had a spontaneous preterm birth. The sensitivity, specificity, and positive and negative predictive values of a short cervical length for spontaneous preterm birth were 71%, 91%, 50%, and 96%, respectively (relative risk 13.5, 95% confidence interval 3.49-54.74). Of the 7 women with both short cervical length and preterm birth, all uterine subtypes were represented except septate uterus. CONCLUSION: A short cervical length on transvaginal ultrasonography in women with uterine anomalies has a 13-fold risk for preterm birth. Unicornuate uterus had the highest rate of cervical shortening and preterm delivery. LEVEL OF EVIDENCE: II-2.     

Efficacy of methotrexate treatment in viable and nonviable cervical pregnancies

OBJECTIVES: This retrospective study examined the overall efficacy of methotrexate chemotherapy in the treatment of cervical pregnancy and attempted to determine whether differences in the response to methotrexate therapy exist between patients with viable and nonviable cervical pregnancies. STUDY DESIGN: A MEDLINE database search and a bibliographic review of the relevant literature were conducted to find reported cases of cervical pregnancy treated with methotrexate administration during the period from 1983 to 1997. Clinical and demographic characteristics, methotrexate regimen, concomitant invasive procedures, complications, and outcomes in viable and nonviable pregnancy groups were analyzed and compared. RESULTS: A total of 62 reported cases of cervical pregnancy were assessed. There were no statistically significant differences in demographic data, transfusion rate, and human chorionic gonadotropin remission time between viable and nonviable cervical pregnancy groups. Among the 35 cases of viable pregnancy 63% of women received systemic injection alone or a combination of systemic and local (intra-amniotic or intracervical) injection with methotrexate or potassium chloride and 37% had local injection of methotrexate (with or without potassium chloride) alone. Among the 23 cases of nonviable cervical pregnancy 96% of women received systemic methotrexate injection only. The need for >/=1 concomitant surgical procedure (such as simple curettage, dilation and curettage, cervical blocking, or uterine artery embolization) in conjunction with methotrexate therapy was significantly higher (P =.021) in the viable pregnancy group (43%) than in the nonviable pregnancy group (13%). The 94% success rate of preservation of the uterus in the viable pregnancy group was not significantly different from the 91% preservation rate in the nonviable pregnancy group. All patients who had successful uterine preservation returned to normal menstrual patterns. CONCLUSION: This retrospective study found that conservative treatment with methotrexate chemotherapy of patients with either viable or nonviable cervical pregnancies at <12 weeks' gestation carries a 91% success rate for preservation of the uterus. The structure of the cervix was restored and menstruation returned for all patients in whom the uterus was preserved after treatment. There was no evidence to suggest that the reproductive performance of these patients was affected by the treatment.     

Auto-transplantation of the uterus in the domestic pig (Sus scrofa): Surgical technique and early reperfusion events

AIM: To develop a method for auto-transplantation of the uterus in the pig and to evaluate the early reperfusion events after short-term cold ischemia. METHODS: The bicornate uterus, with the cervix but without ovaries, was dissected and isolated with its bilateral feeding and draining vessels. The uterine arteries were cannulated in situ and the uterus was flushed with heparinized Ringer Acetate. It was stored at 4 degrees C for 1-2 h during continuous flushing. The uterus was then placed in its original pelvic position and the uterine arteries and veins were anastomosed end-to-end to their origin. During approximately 100 min of reperfusion, blood samples and tissue biopsies were taken for monitoring of reperfusion events and detection of ischemia-reperfusion injuries. RESULTS: Out of 19 auto-transplanted pigs, seven were considered well flushed and were kept for cold ischemia. Of these seven, four showed satisfactory reperfusion judged by change in gross appearance and presence of appropriate venous blood flow. Analysis of blood-gas and metabolite parameters and histology indicated that at least two of these transplants were well reperfused, with no severe ischemia-reperfusion injuries. CONCLUSION: In this first report ever on auto-transplantation of the pig uterus it is demonstrated that an acceptable reperfusion can be achieved. Furthermore, it is suggested that because of the large total size of the pig uterus with long uterine horns and the small size of the vessels available for re-anastomosis, the pig is a fairly difficult model for further studies on transplantation of the uterus.     

Ultrasonographic assessment of weight of the myomatous uterus: a pilot study using a new combined geometrical formula

OBJECTIVE: To evaluate the accuracy of a formula combining the prolate ellipsoid (uterine corpus) and cylinder (uterine cervix) formulas in estimating the preoperative weight of the total uterus using a transvaginal ultrasound probe to obtain the uterine dimensions for the formulas. STUDY DESIGN: Three dimensions of the uterine corpus (length, width and anteroposterior diameter) and cervical length and cervical anteroposterior diameter were preoperatively determined using a transvaginal ultrasound probe in 12 women with symptomatic leiomyomas scheduled to undergo hysterectomy. In two patients whose uteruses were the largest, part of the measurements had to be taken with a transabdominal ultrasound. Three investigators repeated all the rounds of measurements three times, producing in total 108 of findings (12 subjects x 3 investigators x 3 rounds of measurements). The geometric formula of prolate ellipsoid was compared to a formula combining the ellipsoid and cylinder formulas for accuracy in predicting overall uterine size (corpus and cervix) through correlation with hysterectomy specimens. The weight of the uterus in grams was directly derived from the volume of the uterus. RESULTS: All measurements of the uterine corpus and cervix could be obtained preoperatively with a transvaginal ultrasound probe except in two patients who had the largest uteruses. The plain, traditional formula for the prolate ellipsoid overestimated the weight of the uterus and differences between the estimated and the true weight were statistically significant. The difference was not significant when the formula combining the formulas of the prolate ellipsoid and cylinder was used. CONCLUSION: The new formula combining the prolate ellipsoid and cylinder formulas is more accurate in predicting the true total weight of the uterus than the plain prolate ellipsoid formula. The transvaginal ultrasound probe proved useful in evaluating the dimensions of the uterine corpus and cervix.     

Robot-assisted abdominal laparoscopic radical trachelectomy

BACKGROUND: Radical trachelectomy in conjunction with pelvic lymphadenectomy is an established method to preserve fertility in early cases of cervical cancer. The radical trachelectomy is usually performed vaginally despite the initial use of laparoscopy for the lymphadenectomy. The complexity of a laparoscopic abdominal trachelectomy may explain this dual approach. Here we describe the surgical technique of a robot-assisted laparoscopic radical trachelectomy with lymphatic mapping using a radiotracer and without a vaginal approach. CASES AND SURGICAL TECHNIQUE: Two nulliparous women with early cervical cancer underwent a laparoscopic radical trachelectomy and pelvic lymphadenectomy with the assistance of the da Vinci robot (Intuitive Surgical Inc, Sunnyvale, CA). After the sentinel lymph nodes were found negative on frozen section, the parametria, paracolpia and sacrouterine ligaments were dissected sparing the main branches of the uterine arteries. Following ligation of the descending branches of the uterine arteries the cervix and the vagina were transsected using monopolar diathermia and the vagina was sutured to the remaining cervix. Finally, a permanent cerclage was placed. Time for surgery was 387 and 358 min respectively. No perioperative complications were noted and the postoperative period was uneventful in both cases. CONCLUSIONS: Robot-assisted laparoscopic abdominal trachelectomy is a feasible alternative to a combined laparoscopic and vaginal approach.     

Effectiveness of cervical suture in the prophylaxis of premature deliveries (author's transl)]

Results of surgical treatment of cervical insufficiency according to McDonald's method in 150 pregnant women are discussed. The diagnosis was based upon anamnesis, examination of the vaginal segment of the uterus and the behaviour of cervix throughout the gestation period. The results depended upon the extent to which uterine cervix dilated before operation. Sutures were inserted in 150 pregnant women, and positive results were obtained in 119 cases (79%). In pregnant women with obstetric history of incompetence a prophylactic application of cervical sutures seems to be justified.     

Biophysical parameters of early puberty in girls

OBJECTIVE: The appearance of breast development in girls characterizes an early period of puberty. Ultrasonographic examinations of the uterus and ovaries make possible the estimation of first pubertal changes in sexual organs. DESIGN: The aim of this work was to study the clinical and ultrasonographical features of early puberty in girls. MATERIAL AND METHODS: 33 healthy girls were observed quarterly in the course of prepuberty. Body mass, height, body mass index (BMI), quantity of adipose tissue were investigated. Stage of puberty was established according to Tanner. The uterus and ovaries were studied ultrasonographically, and the volume of the uterine body, length of the cervix and ovarian volume and size of ovarian follicles were scrutinised. RESULTS: Statistical differences were observed in weight, height, quantity of adipose tissue and the volume of body and that of the uterus, in length of the cervix between prepuberty and early puberty periods. Luminastity of mucus in the cervical canal in half of girls in the breast stage M1 was obtained. CONCLUSION: Ultrasonographic investigations of internal sexual organs with estimation of clinical sexual features are helpful in examination of early stage of puberty.     

The diagnostic and therapeutic management of pregnant women with neoplasms of the reproductive organs

OBJECTIVES: The aim of the study was the evaluation of the way of diagnostic and therapeutic management in case of neoplasm of the reproductive organ in pregnant women treated in the I Clinic of the Operative Gynaecology in Lublin. MATERIAL AND METHODS: In the years 1990-2000 in the I Clinic of the Operative Gynaecology in Lublin, 3556 operations were performed. In 9 cases the operations were carried out because of the neoplasm of the reproductive organ diagnosed in the course of pregnancy. In 8 cases, pregnant women with tumors in the pelvis minor were operated on and in 6 cases benign ovary neoplasms were stated. RESULTS: In one patient, extraperitoneal tumor coming out from the region of the sacral bone was diagnosed. In one case the patient in the 16th week of pregnancy was operated on and she had 10 cm in diameter myoma enucleated. The myoma was localized on the anterior uterus wall. In patient in the 33rd week of pregnancy with the diagnosed cervical carcinoma of the 2nd degree, diagnosed on the basis of histopathological examination, Caesarean section and Meigs operation were performed. In all operated patients tocolysis was employed. In one case there was a miscarriage in the 16th week of pregnancy following the myoma enucleation. The postoperative course in the remaining women was uncomplicated and pregnancies ended with the delivery of healthy infant. CONCLUSIONS: The most common neoplasms occurring in pregnancy are simple ovarian cysts and uterine myomas. Among malignant changes sporadically ovarian and cervical carcinomas are met. Although tumors of the reproductive organ in pregnant women are quite rarely met, the diagnostic and therapeutic difficulties reveal the necessity of the though differential diagnosis and accurate establishment of indications for the operation.     

Laparoscopic radical trachelectomy for stage Ib1 cervical cancer

Radical trachelectomy by vaginal approach is an alternative for young women with early-stage cervical cancer. We modified this procedure to treat two patients with stage Ib1 cervical cancer. With 100% laparoscopic pelvic lymphadenectomy and 80% laparoscopic approach, the technique is laparoscopic radical trachelectomy (LRT). Under direct enhanced vision of the laparoscope, it is easy to identify and preserve ascending branches of the uterine arteries and to divide ligaments surrounding the cervix and vagina. Vaginal procedures require only colpotomy, amputation of cervix, dividing caudal paracolpium, and corpus-vagina anastomosis. Short-term follow-up results of our first patients are satisfactory. Thus, LRT could be a useful alternative for women with early cervical cancer who want to preserve fertility.     

Primary dysmenorrhea and uterine blood flow: a color Doppler study

OBJECTIVE: To examine pulsatility index (PI) and resistance index (RI) values in the uterine and arcuate arteries of patients with primary dysmenorrhea (PD) by color Doppler ultrasonography. STUDY DESIGN: A total of 49 female university students were recruited for this prospective, observational study. The study group consisted of 25 nulliparous women with PD and a control group of 24 healthy, nulliparous women without dysmenorrhea. The women were examined using transabdominal color Doppler ultrasonography during the midluteal phase (days 18-22) and on the first day of the menstrual cycle. The mean PI and RI values for the right and left uterine arteries and arcuate artery were determined. Student's t test was used to compare the results between and within groups. RESULTS: The mean PI and RI values for the uterine and arcuate arteries in patients with PD were significantly higher on the first day of the menstrual cycle than in the midluteal phase (p < 0.001). Women with PD had significantly higher mean PI and RI values in all 3 arteries on the first day of the menstrual cycle than did the controls (p < 0.05). The Doppler index values of all 3 arteries during the midluteal phase were not significantly different between the groups. CONCLUSION: There is increased impedance to blood flow within the uterus of women with PD on the first day of the menstrual cycle. This may be a sign of constriction of the uterine vessels and the cause of pain.     

Temperature differences in reproductive tract of nonpregnant ewe

The effect of estrogens, epinephrine, oxytocin and pituitrin on blood flow through the uterus, cervix vagina, uterine surface uterine vein as well as aorta, liver and cavity of the rumen were measured in waking ewes using thermocouples encased in polyvinyl catheters. Estrone, estradiol and estriol administration led to a reduction in temperature difference between the aorta and reproductive organs. The response was greatest in the temperature of the uterine cavity. The temperature differences between the liver, and cavity of the rumen were unaffected. After the infusion of epinephrine, oxytocin or pituitrin into estrogen-treated ewes, there was an increase in temperature difference compared with the aorta. This may have been caused by the reduction of blood flow to the uterus.     

Primary lymphoma of the uterus and cervix: two case reports and review of the literature

Primary lymphoma of the uterus and cervix is rarely encountered. We present two cases of diffuse large B-cell lymphoma of the cervix and uterus that were treated with R-CHOP chemotherapy followed by pelvic radiotherapy. The women are disease free 20 and 19 months after the diagnosis respectively. Seventy-two cases of primary uterine and cervical lymphoma reported in the English literature in the last 10 years from 2000 to 2010 are reviewed.     

Abdominal radical trachelectomy: two new surgical techniques for the conservation of uterine arteries

The objective of this study was to develop two new techniques for the conservation of uterine arteries in abdominal radical trachelectomy. Abdominal trachelectomy with conservation of uterine arteries was performed in two patients with cervical carcinoma. In the first case, the internal iliac artery was divided at 2.0 cm from the bifurcation of the common iliac artery. The internal iliac artery and uterine artery were skeletonized along their lengths to the lateral cervix. The dissected internal iliac artery was then reanastomosed following the radical trachelectomy. In the second case, the technique was similar to that of the first except that the internal iliac artery was not divided. Intraoperative observation and postoperative color Doppler ultrasound were used to confirm the patency of the uterine arteries. The operative time of the two patients was 390 min. and 350 min, respectively. Doppler flow studies demonstrated that the uterine arteries were patent in both cases. Resistance index of the left and the right uterine artery was 0.58 and 0.61, respectively, in the first case, and 0.60 and 0.63, respectively, in the second case. Reanastomosis of the internal iliac arteries or skeletonization of the internal iliac arteries are both feasible methods to conserve the uterine arteries during abdominal radical trachelectomy.