Laparoscopic treatment of a vesico-vaginal fistula: A new approach

Vesicovaginal fistulas (VVF) are among the most distressing complications of gynecologic and obstetric procedures. Management of these fistulas has been better defined and standardized over the last decade. VVF repair is most commonly repared with transvaginal approach. We report a case of VVF which was repaired using a laparoscopic approach. The fistula was a complication of a benign laparoscopic hysterectomy. We describe a novel technique for the treatment of VVF of supratrigonal location by intraperitoneal laparoscopic approach

The Use of Barbed Suture for Vaginal Cuff Closure in Total Laparoscopic Hysterectomy

Objective: The aim of this work is to evaluate the safety and efficacy of the barbed unidirectional suture in a total laparoscopic hysterectomy. Materials and Methods: A retrospective and descriptive study was conducted, which included all of the patients that have undergone laparoscopic hysterectomy and closure of the vaginal cuff, using barbed sutures (V-loc™90 Device, CovidienTM), during the period between May 2011 and December 2014. We have analyzed the general characteristics, indications, history of previous surgery and the presence of fever or surgical re-intervention due to pelvic abscesses. The appearance of a vaginal cuff hematoma, active bleeding and vaginal cuff dehiscence were also taken into account. Results: A hundred and twenty-one laparoscopic hysterectomies with vaginal cuff closure, using barbed sutures, were performed. There was a report of one case of bladder lesion and another case of ureter lesion. Of all patients, four (3.3%) of them presented fever while one (0.8%) presented paralytic ileus. Three (2.4%) patients suffered active vaginal bleeding, and one presented a partial dehiscence of the vaginal cuff. And finally, two (1.6%) cases of vaginal cuff hematomas were observed and in one (0.8%) of the cases, a pelvic abscess was detected. Conclusion: The use of a unidirectional barbed suture is a safe technique for vaginal cuff closure in laparoscopic total hysterectomies

Clear Cell Adenocarcinoma of Cervix: Radical Trachelectomy to Preserve the Fertility

Carcinoma of the uterine cervix is a common gynecologic malignant neoplasm all over the world. The most common histological type of malignant cervical neoplasms is squamous cell carcinoma [1,2]. Clear cell adenocarcinomas (CCAC) of the uterine cervix is a rare disease accounting for only 4% of all adenocarcinomas of the uterine cervix [3]. Primary CCAC of the uterine cervix is a rare neoplastic entity which occurs in young women exposed to DES in utero; primary CCAC without DES exposure in utero is extremely rare. Here we report a 23- years-old Spanish female with primary CCA of the uterine cervix with no maternal history of DES ingestion during pregnancy

Surgical technique for video endoscopic inguinal lymphadenectomy in vulvar cancer

Introduction: Inguinal lymph node involvement is an important prognostic factor in patients with vulvar cancer. Inguinal lymph node dissection allows for staging and treatment of inguinal node disease but causes morbidity and is associated with complications such as lymphocele formation, wound dehiscence, and infection. Video endoscopic inguinal lymphadenectomy (VEIL) seems to be a new and attractive approach with lower morbidity than the standard open procedure. The objective of this study was to report our surgical technique for VEIL for the treatment of vulvar cancer. Methods: We retrospectively evaluated a case involving a 78-year-old woman with vulvar cancer who underwent bilateral VEIL. Findings: The operative time was 140 min, and there were no complications. After 3 months of follow-up, there were no signs of vulvar oedema, lymphedema, or lymphocele. Conclusions: In patients with vulvar cancer, VEIL is feasible in clinical practice. Additional studies with a larger number of patients and longer-term follow-up are needed to confirm the oncological efficacy and the possible reduction in morbidity of this new approach.Introduccio´n: La afectacio´n de los no´dulos linfa´ticos inguinales es un factor prono´stico importante en pacientes con ca´ncer de vulva. La diseccio´n de los no´dulos linfa´ticos inguinales nos permite la estadificacio´n y el tratamiento de la afectacio´n ganglionar inguinal. Por otra parte, causa morbilidad y esta´ asociada a complicaciones como linfocele, dehiscencia de la herida e infeccio´n. La linfadenectomı´a inguinal videoendosco´pica parece ser una nueva y atractiva te´cnica con menor morbilidad que el abordaje abierto. El objetivo de este trabajo es reportar nuestra te´cnica de linfadenectomı´a inguinal videoendosco´pica para el tratamiento del ca´ncer de vulva. Me´todos: Se evaluo´ de manera retrospectiva el caso de una paciente de 78 an˜os de edad con ca´ncer de vulva a la que se realizo´ una linfadenectomı´a inguinal videoendosco´pica bilateral. Hallazgos: El tiempo operatorio fue de 140 min y no hubo complicaciones. Tras 3 meses de seguimiento no se observaron signos de edema vulvar, linfedema o linfocele. Conclusiones: La linfadenectomı´a inguinal videoendosco´pica en pacientes con ca´ncer de vulva es factible en la pra´ctica clı´nica. Estudios adicionales con un mayor nu´mero de pacientes y a ma´s largo plazo de seguimiento son necesarios para confirmar la eficacia oncolo´gica y la posible menor morbilidad de este nuevo enfoque

Surgical treatment of Paget’s disease of the vulva using Mohs micrographic surgery, followed by vulvar reconstruction using the “lotus petal” suprafascial flap

Vulvar Paget’s disease is an extramammary manifestation of Paget’s disease, a cutaneous neoplasm that clin-ically appears as sharply defined erythematous plaques with irregular borders that usually affect apocrine gland-bearing skin. Extramammary Paget’s disease (EMPD) of the vulva can remain undiagnosed for years and could be associated with multifocal neoplasms. The current gold standard for the treatment of vulvar EMPD is surgical excision and the Mohs micrographic surgery is the preferred technique used in evaluating the margins of the specimen. The reconstruc-tion of the vulva using suprafascial flaps reduces hospitalization time and complications rate

Complications of laparoscopic lymphadenectomy for gynecologic malignancies. Experience of 372 patients

Evaluation of lymph nodes is an integral part in the management of women with gynecologic cancers, which is why the pelvic and aortic lymphadenectomy is widely used as a staging and/ or prognostic procedure in such malignancies. The purpose of this study was to describe our experience with pelvic and aortic laparoscopic lymphadenectomy and evaluate the safety and feasibility of this procedure for gynecologic malignancies. From January 2004 to December 2015, a laparoscopic pelvic and/or aortic lymphadenectomy was performed in 372 women at the Department of Gynecology Oncology of the University General Hospital of Castellon and at the Department of Obstetrics and Gynecology of Sant Pau and Santa Tecla Tarragona Hospitals. Out of the 372 cases, 240 combined pelvic and paraaortic lymphadenectomies were performed, while 108 and 24 patients underwent pelvic and aortic lymphadenectomy respectively. The mean operative times were 40 min (20-89) in order to perform a complete pelvic lymphadenectomy, 62 min (21-151) for transperitoneal aortic lymphadenectomy and 45 min (35-65) for a retroperitoneal approach. A conversion to laparotomy was needed in 1.6% of patients. Twenty-three (6.1%) complications were encountered in 372 patients undergoing laparoscopic lymphadenectomy. Nine (2.4%) major complications occurred intraoperatively while fourteen (3.7%) appeared postoperatively. The most frequent intraoperatory complication was vascular injury (1.3%). Laparoscopic lymphadenectomy can be considered a safe and achievable procedure, and could be considered the golden standard procedure for staging gynecologic malignancies

A Case of Urethrocutaneous Fistula Following a Transobturator Tape Procedure for Stress Urinary Incontinence

The transobturator tape procedure (TOT) is a highly effective technique used to resolve cases of female stress urinary incontinence and is a safe procedure with relatively few per-operative and early post-operative complications compared to the tension free vaginal tape (TVT). Recent studies, however, have demonstrated that the late surgical sequelae following a TOT procedure are relatively common. Urethrocutaneous fistula is an unusual complication in the female population that is defined as an abnormal connection between the urethra and the skin, usually affecting the perineum. It may also develop secondary to urethral strictures, repair of hypospadias, prostate surgery, chronic untreated periurethral abscesses, trauma etc. It is usually diagnosed using retrograde urethrography and fistulography. We present a case of a 53 year old woman who developed a urethrocutaneous fistula after a TOT procedure four years ago as a surgical treatment of female stress urinary incontinence which was diagnosed recently after presenting various episodes of vulvar abscesse

Nutritional assessment and support in patients with peritoneal carcinomatosis of ovarian cancer with cytoreductive surgery

Introduction: The multidisciplinary treatment of peritoneal carcinomatosis, also known as Sugarbaker´s procedure, aims to eradicate microscopic residual tumor after surgery. This technique is highly complex and it´s associated with high mortality and morbidity, so the patient selection is relevant. There is a direct relationship between nutritional status, quality of life, survival and ability to tolerate treatment. It is therefore important to assess nutritional status prior to detect if there is risk or malnutrition. Objectives: The main objective is to evaluate the results of the nutritional assessment after all patients operated by Sugarbaker´s procedure. Secondary objectives are to know the parenteral nutrition composition formula most commonly used and to compare the results of those patients with a historical cohort to which the previous nutritional assessment wasn´t performed.. Methods: Prospective study where all adult patients who were undergoing Sugarbaker procedure and who underwent previous nutritional assessment were included. Postoperative clinical and patient follow-up data were compared with a historical cohort of patients undergoing the same procedure (which will not be made prior nutritional assessment). For the diagnosis of malnutrition were used anthropometric and laboratory parameters. Study parameters were: age, albumin prior to the intervention, peritoneal carcinomatosis index, quimiotherapy administration and tumor staging. In the postoperative follow-up, the study parameters were: days in intensive care unit, hospitalization days, total days of hospitalization and postoperative complications. Results: A total of 32 patients were included: twenty patients without nutritional assessment and twelve patients with previous nutritional assessment with a mean age of 59 ± 14 years. No statistically significant differences are observed between groups in peritoneal carcinomatosis index, tumor stage, chemotherapy and albumin before the intervention. A total of 30 patients were required parenteral nutrition. The average composition formula of parenteral nutrition was 1.2 ± 0.1 g proteins per kg body weight and per day, 2.8 ± 0.4 g of carbohydrates per kg body weight and per day and 1 ± 0.1 g of lipid per kg body weight and per day. Of the twelve previous nutritional assessment conducted in nine of them some form of malnutrition was observed. In the parameters evaluated during follow-up of patients, no statistically significant differences were found, although was observed a trend to a shorter in the intensive care unit stay and fewer complications in patients who have undergone nutritional assessment. Discussion: It should be noted that body mass index and the percentage weight loss in these patients is not representative of the observed malnutrition. The high needs of parenteral nutrition in this study may be due the complications of gastrointestinal resection. Possibly no differences are observed in study parameters due to sample size, but if there is a tendency to increase the stay and complications as shown in the literature. Nutritional intervention provides energy and protein needed to reduce the loss of weight and muscle mass from the pathological process of cancer and surgery. Conclusions: The results of the previous nutritional assessment indicate that malnutrition is a pathology that has high prevalence in patients with peritoneal carcinomatosis of ovarian origin. A trend that improve nutritional status will increase the quality of life by reducing these parameters is observed. The macronutrient composition of parenteral nutrition is similar to nutritional requirement in critically ill patients. We believe that the selection of patients who are going to undergo a Sugarbaker procedure should include assessment of prior nutritional status.Introducción: El tratamiento multidisciplinar de la carcinomatosis peritoneal, también conocido como procedimiento Sugarbaker, pretende erradicar el tumor microscópico residual a la cirugía. Esta técnica de alta complejidad está asociada a morbilidad y mortalidad elevada por lo que es relevante la selección de los pacientes. Existe una relación directa entre el estado nutricional, la calidad de vida, la supervivencia y la capacidad de tolerancia al tratamiento. Por tanto, es importante evaluar previamente el estado nutricional para detectar si existe riesgo de malnutrición. Objetivos: El objetivo principal es evaluar los resultados de la valoración nutricional completa previa a to das las pacientes intervenidas por el procedimiento Sugarbaker. Los objetivos secundarios son: conocer las composición promedio de la fórmula de nutrición parenteral más utilizada y comparar los resultados obtenidos de dichas pacientes con una cohorte histórica a la que no se realizó la valoración nutricional previa. Métodos: Estudio prospectivo donde se incluyeron todas las pacientes adultas que se iban a someter al procedimiento Sugarbaker a las que se les realizó la valoración nutricional previa. Se compararon los datos clínicos del seguimiento postoperatorio de las pacientes con una cohorte histórica retrospectiva de pa cientes sometidas al mismo procedimiento (a las que no se les realizó la valoración nutricional previa). Los parámetros que se utilizaron para el diagnóstico de malnutrición fueron antropométricos y analíticos. Los parámetros de estudio fueron los siguientes: edad, albúmina previa a la intervención, índice de carcinomatosis peritoneal, la administración o no de quimioterapia previa a la intervención y el estadiaje del tumor. En el seguimiento postoperatorio se establecieron como parámetros a valorar: días en unidad de cuidados intensivos, días en planta, días totales de hospitalización y complicaciones postoperatorias. Resultados: Se incluyeron un total de 32 pacientes: veinte pacientes sin valoración nutricional previa y doce pacientes con valoración nutricional previa con una edad media de 58,9±14 años. No se observan diferencias estadísticamente significativas entre ambos grupos en índice de carcinomatosis peritoneal, estadio tumoral, quimioterapia previa a la intervención y albúmina previa a la intervención. Requirieron nutrición parenteral 30 pacientes durante el postoperatorio. La composición media de la fórmula de nutrición parenteral fue 1,2±0,1 g de proteína por kg peso y día, 2,8±0,4g de hidratos de carbono por kg peso y día y 1±0,1g de lípidos por kg peso y día. De las doce valoraciones nutricionales previas realizadas, en nueve de ellas se observó algún tipo de desnutrición. En los parámetros evaluados durante el seguimiento de las pacientes no se obtuvieron diferencias estadísticamente significativas, aunque se observó una tendencia a una menor estancia en la unidad de cuidados intensivos y un menor número de complicaciones en las pacientes a las que se les ha realizado valoración nutricional previa. Discusión: Se observa que el índice de masa corporal y el porcentaje de pérdida de peso en estas pacientes no es representativo de la desnutrición que presentan. Las necesidades elevadas de nutrición parenteral en este estudio pueden ser debidas las complicaciones derivadas de la resección gastrointestinal. Posiblemente no se observen diferencias en los parámetros de estudio debido al tamaño muestral del mismo, pero si existe una tendencia a disminuir la estancia y complicaciones como muestra la bibliografía. La intervención nutricional aporta la energía y proteínas necesarias para disminuir la pérdida de peso y de masa muscular derivada del proceso patológico del cáncer y la cirugía. Conclusiones: Los resultados de la valoración nutricional previa indican que la desnutrición es una patología que tiene elevada prevalencia en las pacientes con carcinomatosis peritoneal de origen ovárico. Se observa una tendencia de que la mejora del estado nutricional aumentará la calidad de vida reduciendo estos parámetros. La composición en macronutrientes de la nutrición parenteral es similar a los requierimientos nutricionales en un paciente crítico. Consideramos que la selección de pacientes que van a ser sometidos a un procedimiento Sugarbaker debe incluir la evaluación del estado nutricional previo

Laterally Extended Endopelvic Resection (Leer) and Reconstructive Techniques for Treatment of Locally Advanced Cervix Cancer: A Case Report

The aim of this report is to describe the surgical procedure done in a 24-year-old woman who presents a locally advanced squamous cervix carcinoma and is proposed to laterally extended endopelvic resection (LEER), intraoperative radiation therapy with electrons (IORT) and urinary and colon diversion with vaginal reconstruction. A year after surgery the patient is alive, without disease and with and acceptable quality of life

Vulvar reconstruction in vulvar cancer: “lotus petal” suprafascial flap

The purposes of this study are to demonstrate our experience in using the “lotus petal” suprafascial flap and to evaluate the postoperative complications. During the period ranging from July 2012 to March 2015, nine patients diagnosed with primary or recurrent vulvar cancer have undergone radical vulvectomy followed by reconstructive surgery. Seventeen lotus petal suprafascial flap surgeries were performed. The average age of the patients was 79 years. No intraoperative complications were reported. The surgery length was 180 min with an estimated blood loss of 400 cc. Severe postoperative complications were rare. There were no complications associated with the donor site, nor were there any losses due to total or partial flap tissue necrosis. There were 2 (22.2 %) cases of partial wound dehiscence, which did not require re-intervention. The lotus petal suprafascial flap is a simple procedure that can be done during the same surgery as the radical vulvectomy, improving the aesthetic results and reducing both the rate of complications and hospital stay