Cervical Stump Research Articles

Cervical stump leiomyomata after supracervical hysterectomy; a case report with review of literature

BackgroundDespite being a highly debated issue, subtotal or supracervical hysterectomy (SCH) is still considered a safe and effective treatment for women with benign gynecological lesions. Benign and malignant cervical diseases have been reported after SCH, with fibroids being the most frequently diagnosed lesions in the excised cervical stump. Recurrence of cervical disease after SCH usually presents with vaginal bleeding, pelvic mass, or abdominal pain; moreover, it may necessitate reoperation and resection of the cervical stump or trachelectomy. Trachelectomy is known to be a difficult surgical procedure that may be associated with significant intra- and post-operative morbidity.Case presentationWe presented here a case of a 41-year-old nulliparous woman with a pelvic mass related to the cervical stump presented 2 years after subtotal hysterectomy, performed due to interactable abnormal uterine bleeding, which was attributed to a multiple fibroid uterus. Six years ago, she complained of pelvic pain, excessive vaginal discharge, and spotting. A transvaginal sonography and magnetic resonance imaging with contrast were performed, which revealed a 10.2 × 7.6 × 6.5 cm heterogeneous pelvic mass with irregular borders and marked vascularity on color Doppler. Surgical exploration and resection of the mass with cervical stump excision were performed. Histopathology confirmed the diagnosis of cervical stump multiple benign leiomyomata with no atypical features.ConclusionRecurrence or De novo development of leiomyomata and other cervical lesions might occur after supracervical or subtotal hysterectomy; thus, thorough pre-operative counseling for women requesting a SCH regarding the pros and cons of the procedure compared with total hysterectomy should be optimized. Meticulous follow-up, including the continuation of routine cervical cytological smears, is mandatory for patients with a retained cervix.

A simplified modification of the Sturmdorf suture

The Sturmdorf type sutures are traditionally used for obtaining hemostasis after a cold knife conization. In this article and accompanying video, we provided a simplified modification of the Sturmdorf suture to further reduce the risk of postoperative bleeding and cervical stenosis. Our modified Sturmdorf suture is essentially a large horizontal figure-of-eight suture, with simultaneous small bites on the mucosa of the anterior and posterior lips drawing the cervical mucosa to cover the denuded cervical stump. The advantages of this modification are: (1) The surgery is simple, accomplished with only one suture; (2) excellent hemostasis is achieved by incorporating the cervical branch of the descending rami of the uterine artery lateral to the cervix in the suture loop; (3) the single-suture technique provides more appropriate tension on the cervix when tying the knot and pulls the cervical mucosa towards the cervical canal from six symmetrical directions, evenly distributed tension helps restore the preferable cylindrical shape of the cervical stump; and (4) the intersection point of the figure-of-eight suture is located in the cervical canal, where the tissue undergoes minimal deformation when the suture loop is tightened, therefore stenosis of the uterine cervix is rare.

Complete Laparoscopic Type C2 Radical Surgery for Cervical Stump Cancer: No-Look and No-Touch Techniques.

Due to previous surgical history and subsequent adhesions between pelvic organs, surgery for cervical stump cancer (CSC) is technically more challenging than surgery for cervical cancer with an intact uterus.1 We aimed to illustrate the related anatomy, surgical steps and techniques of complete laparoscopic type C2 radical surgery (CLRS) for early-stage CSC. CLRS for six patients with CSC was performed from January 2021 to January 2022. We demonstrated the detailed skills of parametrial management during CLRS for CSC in case 5 by means of a video. A 58-year-old woman diagnosed with International Federation of Gynecology and Obstetrics (FIGO) 2018 stage IIA1 CSC received CLRS through five operative ports (Fig.1). The magnetic resonance imaging (MRI) scans and gross appearance of the specimen are shown in Fig.2. The median age and body mass index (BMI) of the six patients were 53 years and 23.8, respectively. The median blood loss was 275mL; the median time of operation was 218min; the median length of hospitalization was 15 days; and the median time to recover urinary function was 12 days. One patient underwent postoperative radiation for pathologically proven adenocarcinoma with deep stromal invasion,2 while the other five did not. After a median follow-up of 24 months, no patients experienced complications, recurrence, or death (Table 1). This study details the skills of CLRS for CSC, especially space development and the 'no-look, no-touch' tumor-free principle. It is helpful for clinicians to perform safe and standardized surgery on patients with early-stage CSC. Fig.1 Trocar placement of complete laparoscopic type C2 radical surgery for early-stage CSC. CSC cervical stump cancer, S superior, I inferior, R right, L left, U umbilicus Fig.2 MRI scans and gross appearance of the specimen for case 5 with CSC at FIGO 2018 stage IIA1. The tumor lesion on the cervical stump is indicated by yellow arrows. a Axial T2-weighted image; b DKI image; c ADC map; d sagittal T2-weighted image; e sagittal T1-weighted image; f gross appearance of the surgical specimen. MRI magnetic resonance imaging, CSC cervical stump cancer, FIGO International Federation of Gynecology and Obstetrics, DKI diffusional kurtosis imaging, ADC apparent diffusion coefficient Table 1 Clinicopathological characteristics, operative details, and outcomes of patients with cervical stump cancer Patient no. Age at diagnosis (years) BMI Reasons for subtotal hysterectomy FIGO 2018 stage Histology Operation Operation time (mins) Blood loss (mL) Urinary catheter (days) Hospital stay (days) Complications Depth of invasion LVSI LNs dissected TNM stage Tumor size (mm) Postoperative radiotherapy Follow-up (months) Recurrence Death 1 50 25.9 Uterine myoma IIA1 ASC CLRS+PLND 221 360 10 12 No Middle one-third N 13 T2a1N0M0 16 No 30 No No 2 55 17.3 Uterine myoma IB1 AC CLRS+PLND 191 270 20 12 No Deep one-third N 24 T1b1N0M0 10 Yes 20 No No 3 50 24.8 Uterine myoma IB1 SC CLRS+PLND 295 310 13 15 No Superficial one-third N 21 T1b1N0M0 15 No 25 No No 4 63 30.1 Uterine myoma IB1 SC CLRS+PLND 213 180 6 16 No Superficial one-third N 25 T1b1N0M0 15 No 19 No No 5 58 20.2 Postpartum hemorrhage IIA1 SC CLRS+PLND 220 100 11 14 No Middle one-third N 21 T2a1N0M0 15 No 24 No No 6 46 22.7 Uterine myoma IB1 SC CLRS+PLND 215 120 14 17 No Superficial one-third N 26 T1b1N0M0 12 No 23 No No BMI body mass index, FIGO International Federation of Gynecology and Obstetrics, ASC cervical adenosquamous carcinoma, AC cervical adenocarcinoma, SC cervical squamous carcinoma, CLRS+PLND complete laparoscopic radical surgery and pelvic node dissections, LVSI lymphovascular space invasion, N negative, LNs lymph nodes, TNM tumor node metastasis.

A LARGE INTRAMURAL FIBROID WITH STAGE 3 UTERO VAGINAL PROLAPSE - A RARE CLINICAL PRESENTATION

Fibroid uterus are the benign tumors of the uterus comprising of smooth muscle fibres. There are 3 main types of fibroid uterus - submucosal, subserosal and intramural. Fibroid with the prolapse usually present as submucosal fibroid prolapsing into the vagina or intramural fibroid becoming submucosal and prolapsing out. A large intramural fibroid usually pulls up the uterus due to its growth and hence uterine prolapse is little rare scenario. In this case a perimenopausal women with mass descending per vaginum and pain abdomen for four years, on examination found to have a large intramural fibroid of size 20*10 cm and uterovaginal prolapse with cervix as leading point with cystocele, enterocoele and rectcoele. After routine pre operative work up, hysterectomy was planned by abdominovaginal route. Supracervical hysterectomy done abdominally followed by removal of cervical stump and anterior and posterior colpoperineoraphy by vaginal route.

The Surgical Treatment of Advanced Urinary Incontinence

Purpose: Current treatments of urgency urinary incontinence (UUI) are aimed to reduce the neurological influence on bladder detrusor muscle function. A previous observation after posterior exenteration led to the hypothesis that UUI is caused by a laxity of the uterosacral ligaments (USL). In a previous Clinical Phase I trial in patients with UUI continence was achieved in 40% of patients by replacement of the USL. The results supported the concept of a Clinical Phase II trial in which only patients who lost urine after urgency (advanced UI) were treated by replacement of the USL. The aim of the study was to evaluate the cause why some patients became continent while others remained incontinent after replacement of the USL. Methods: In this Clinical Phase II trial, patients with advanced UI were included. The USL was replaced by specially designed polyvinylidene fluoride (PVDF) structures. During laparoscopy these structures were fixed at the promontory and at the cervical stump after supracervical hysterectomy (cervicosacropexy, CESA) or at the vaginal stump (vaginosacropexy, VASA). The USL replacing parts of the structures had an identical length of 8.8 cm in CESA and 9.3 cm in VASA. Patients who remained incontinent after tensioning of the vagina were offered a suburethral trans-obturator tape (TOT). Results: 339 patients with advanced urinary incontinence (UI) were evaluable. Continence was re-established in 39% of patients after CESA and in 32.9% after VASA. The statistical analysis revealed that the Continence Rates (CR) after CESA or VASA were significantly (p<0.001) dependent on patients age at surgery (<60 years vs ≥60 years). The respective CR after CESA were 50% vs 26% and after VASA 41.5% vs 28.9%. After an additional transobturator tape (TOT) the overall CR was between 67.5% and 87.5%. Conclusion: The replacement of the USL by PVDF-tapes of defined length led to continence in between 32.9% and 39% of the patients. After the additional placement of a TOT 8/4 the percentage of continent patients increased by 30.5% to 37.3%. These findings support the hypothesis that continence is dependent on the physiological function of the USL and PUL. The observation that the CR after USL replacement decreased in patients ≥60 years indicates that ageing affected some additional other part in the area of the urethra-vesical junction (UVJ). The CR after CESA or VASA (and a TOT) in patients with advanced UI deserve further clinical evaluation.

Adenomyoma recurrence 7 years after laparoscopic supracervical hysterectomy: A case report and literature review.

Adenomyosis, a gynecological condition characterized by endometrial tissue within the uterine myometrium, often leads to menstrual pain and heavy bleeding, significantly affecting the quality of life. The primary treatment for adenomyosis and leiomyomas is hysterectomy. However, in rare instances, these conditions can recur in the cervical stump following a hysterectomy.Here, we present a case of cervical adenomyoma development after a prior laparoscopic supracervical hysterectomy. A 47-year-old woman sought medical attention due to increased vaginal bleeding. She had undergone a laparoscopic supracervical hysterectomy 7 years earlier to address uterine myoma and adenomyosis. Just 1 month posthysterectomy, a pelvic ultrasound revealed the presence of a cervical stump measuring approximately 4.0 × 4.0 cm. Subsequent follow-up ultrasounds documented the gradual growth of the cervical mass. Two years ago, a recurrent myoma was identified, and the patient experienced intermittent vaginal bleeding. Over 7 years, the cervical mass increased from 4 to 7 cm. Preadmission pelvic ultrasonography confirmed the existence of cervical adenomyoma measuring 7 × 6 cm. Consequently, the patient underwent a laparoscopic trachelectomy. Intraoperatively, an enlarged cervix, approximately 7 × 6 cm in size, containing adenomyoma was observed. A gross examination of the specimen indicated hypertrophic muscle tissue and hemorrhagic foci. Subsequent histopathological examination confirmed the presence of adenomyoma. Remarkably, the patient exhibited no recurrence over the subsequent 8 months. The case presented here highlights the potential occurrence of cervical adenomyoma following a supracervical hysterectomy. Management options include hormone therapy and surgical excision. Furthermore, annual follow-up comprising ultrasound and pap smear evaluations is recommended for patients with supracervical hysterectomies to detect and address possible recurrences.

Sonographic features of the uncomplicated postoperative abdomen in dogs treated for pyometra by ovariohysterectomy.

Pyometra is a prevalent disease in intact bitches and the standard treatment is ovariohysterectomy (OHE). Published descriptions of normal sonographic findings after OHE are currently lacking. The aims of this prospective observational study were to describe and compare postoperative abdominal sonographic features for three timepoints following OHE in a group of dogs with pyometra and an uneventful recovery. A total of 22 dogs had sequential focused abdominal ultrasound examinations on days 1, 4-6, and 10-15 postsurgery. Recorded sonographic features for each examination time point and characteristics of the cervical stump and the mesovarium, size, and echogenicity of medial iliac lymph nodes (MILNs), presence of free peritoneal fluid, and pneumoperitoneum. The cervical stump appeared as a heterogenous area with a hypoechoic center surrounded by hyperechogenic tissue in all dogs. The cervical stump transverse-sectional area was larger on day 4-6 compared with day 1 and day 10-15 (P=.0009). Mesovarium ligature reactions were identified as heterogeneous and hyperechoic areas with central and/or edge shadowing in all dogs. The size and echogenicity of MILNs and the mesovarium reactions did not significantly differ among time points. Free peritoneal fluid was detected in 45%, 41%, and 9% and pneumoperitoneum in 95%, 82%, and 14% of dogs at sequential time points. Findings from this sample of dogs with an uneventful recovery following OHE due to pyometra can be used to assist veterinarians in interpreting postoperative abdominal ultrasonographic characteristics in future dogs treated surgically for pyometra.

Advanced cervical stump cancer after laparoscopic subtotal hysterectomy: a case report of imaging, laparoscopic staging and treatment approach

BackgroundAdvanced cancer of the cervical stump, occurring years after a laparoscopic supracervical hysterectomy (LASH), is a rare but serious clinical condition. Many patients who undergo a LASH are unaware of this possible complication. Upon diagnosis of advanced cervical stump cancer, a holistic approach including imaging, laparoscopic surgery and multimodal oncological therapy is required.Case presentationA 58-year-old patient presented to our department with the suspicion of advanced cervical stump cancer eight years after LASH. She reported pelvic pain, irregular vaginal bleedings and irregular discharge. Gynaecological examination revealed a locally advanced tumor of the uterine cervix with suspicion of infiltration of the left parametria and bladder. After thorough diagnostic imaging and laparoscopic staging, the tumor stage was determined as FIGO IIIB and the patient was treated with combined radiochemotherapy. The patient presented with tumor recurrence 5 months after the completion of therapy and she is currently being treated with multichemotherapy and immunotherapy regimens as palliative treatment.ConclusionPatients should be made aware about the risk of cervical stump carcinoma after LASH and the necessity for regular screening. Cervical cancer after LASH is often diagnosed at advanced stages and the treatment requires an interdisciplinary approach.

OVARIAN CYST MASQUERADING AS CERVICAL STUMP LEIOMYOMA IN A WOMAN AFTER SUBTOTAL HYSTERECTOMY: AN UNUSUAL PRESENTATION.

Introduction: Pelvic masses that seem to be ovarian masses on imaging are many times, actually broids, which can be subserosal, or true/ false broad ligament broids. Many cases of broids mimicking ovarian masses/ malignancy have been reported, but rarely any case can be found where an ovarian mass, especially a hemorrhagic cyst mimicked a broid. We present a case of a woman who, was post subtotal hysterectomy, presented with a midline homogenous mass suggesting a cervical stump broid but on operation table was diagnosed to be an ovarian mass. 47years old P2L2 woman presented with insidious dull aching lower abdominal p Case report: ain and an ultrasound report showing a midline 10 x 10cm pelvic mass. She had undergone a subtotal abdominal hysterectomy 15 years ago for symptomatic uterine broid. Examination and higher imaging suggested a cervical stump broid. On laparotomy, it was a well-circumscribed oval mass with a smooth surface, stuck in the pouch of Douglas originating from the right infundibulopelvic ligament with torsion (one twist). It was a thick-walled cyst with dried spongy hemorrhagic content. Histopathology conrmed the diagnosis of hemorrhagic cyst. A mass that is likely broid on imag Conclusion: ing preoperatively rarely turns out to be an ovarian mass during surgery. A hemorrhagic ovarian cyst can present in a subacute form mimicking a solid neoplasm or a solid broid.

PREDICTION AND STUDY OF THE OCCURRENCE OF CERVICAL CANCER RECURRENCE

Cervical cancer has been found to have increased morbidity and mortality in women around the world. Despite complex treatment according to stratification, the risk of relapse is observed in up to 40% of patients Purpose of the study: - Improving the result of early diagnosis of recurrence of cervical cancer stump after complex treatment, by determining the value of the immune response by immunohistochemical markers in combination with the results of complex research methods Materials and methods: - The basis of the research work was a retrospective analysis of the results of the examination and complex treatment of 87 patients with cervical cancer who were treated and treated at the Republican Specialized Scientific and Practical Center of Oncology and Radiology of Uzbekistan, as well as in its Samarkand Regional Branch from 2012 to 2017. All patients underwent complex treatment of 4 courses of polychemotherapy according to the scheme fluorouracil + cisplatin, laparotomy, extended hysterectomy according to Wertheim type and combined radiation therapy of the small pelvis according to the BOX type. All patients were divided into 2 groups. The first control group consisted of 32 (36.8%) patients with cervical cancer who underwent complex treatment in various sequences, without relapse for three years. The second group included 55 (63.2%) patients with the same diagnosis, but in whom, after complex treatment, an early relapse was detected at the preclinical stage. Results: - In the study of intense infiltrate with lymphoid follicles, it was mainly observed with the degree of tumor differentiation G-3 and G-4, which amounted to 21 (80.7%) patients in the relapse group, while in the control group in 19 (61%) which significantly higher (p≤0.05). In group 1, negative expression was noted in highly and moderately differentiated tumors 9 (29%). With low and undifferentiated tumors, moderate and high expression of VEGF (50%) was noted, with further observation in these patients, locoregional recurrence was noted. In the second group, where there was a relapse of the cervical stump by histological examination, high expression with G-4 was noted in 8 (30.7%), and with G-3 moderate expression in 6 (23%) cases. Low intensity was observed only in 1 (3.8%) G1.As can be seen in Table 4.2, negative expression during relapse, i.e. the absence of lymphoid Conclusions: - Based on our research, differences in cellular immunity play a significant role. In patients without relapses, an increased cellular density of T3DM and T20 was observed, and in patients with relapses and severe course of the disease, low lymphoid density. We should note that in our study, the strongest predictor of prognosis is the number of CD3 + cells per mm 2.

Synchronous metastatic colon carcinoma presenting as ovarian metastasis: a case report

The aim of the study was to discuss a rare case of synchronously metastatic colon cancer, which clinically manifested as intestinal obstruction due to the presence of ovarian metastasis.
 Materials and methods. The clinical case of a 47-year-old patient with synchronously metastatic colorectal cancer with an affected disease, peritoneal carcinomatosis and metastatic ovarian lesions was analyzed.
 Case presentation. In July 2021, patient R., 47 years old, developed a clinic of sub-compensated intestinal obstruction. According to CT and MRI data, a volume formation of the small pelvis with a diameter of about 15 cm with compression of the surrounding soft tissues and metastases of the 6th and 4a segments of the liver were determined. According to a colonoscopy, a neoplasm of the sigmoid colon was verified as adenocarcinoma. The presence of peritoneal carcinomatosis was determined intraoperatively; the operation was performed in the following scope: SS-0 (complete cytoreduction) – right-sided ovariectomy with a tumour, resection of the sigmoid colon with a tumour, resection of the rectum with TME, extirpation of the cervical stump with the left ovary and pelvic peritonectomy en block resection and diathermocoagulation of foci of peritoneal carcinomatosis on the visceral peritoneum of the small intestine, omentectomy, radiofrequency ablation of a liver tumour under ultrasound guidance. According to histopathological examination: adenocarcinoma (G2) with foci of mucus production in the sigmoid colon, metastatic lesion of the right ovary, cervix, peritoneum, and liver.
 Subsequently, from September 2021 to July 2022, the patient underwent 8 courses of adjuvant polychemotherapy according to the FOLFOX scheme and 2 courses according to the FOLFOX scheme and bevacizumab. In August 2022, due to signs of disease progression, the patient underwent SS-0 cytoreductive surgery: removal of tumour nodes of the parietal and visceral peritoneum, partial peritonectomy of the anterior abdominal wall, argon plasma coagulation of foci of peritoneal carcinomatosis of the parietal and visceral peritoneum, resection of the round ligament of the liver, NIRES. According to the results of the histological examination, metastases of mucinous adenocarcinoma of the intestinal type with the II-III degree of medical pathomorphosis were determined.
 From September 2022, the patient received 2 courses according to the IRINOX + bevacizumab regimen and 6 courses according to the FOLFIRI + bevacizumab regimen.
 According to the control MRI of the abdominal organs with intravenous contrast, metastases of the 7th and 8th segments of the liver were determined.
 Performed percutaneous radiofrequency ablation of liver metastases under ultrasound control
 Results. According to the results of the MRI of the OCP with intravenous contrast, there are currently no data on the progression of the disease. The patient's quality of life is satisfactory; the ESOG score is 0. It has been 22 months since the onset of the disease.
 Conclusions. Cytoreductive surgical interventions for synchronously metastatic colorectal cancer can significantly improve patients' quality of life and their oncological outcomes rather than only symptomatic treatment.

The application of 3D brachytherapy in cervical stump cancer: A retrospective study.

Cervical stump cancer is a carcinoma that grows on the cervical stump after a sub-total hysterectomy. There have been no studies on the application of 3D brachytherapy in cervical stump cancer. In the present study, we aimed to compare the curative effects, toxicity, and dosimetry of 3D and 2D brachytherapy in cervical stump cancer. Thirty-one patients admitted between 2012 and 2021, who were concurrently treated with intensity-modulated radiation therapy and brachytherapy for cervical stump cancer were divided into three groups according to the brachytherapy techniques: 2D brachytherapy, 3D image-guided brachytherapy (3D-IGBT), and 2D + 3D. For patients undergoing 2D brachytherapy and 3D-IGBT, data on survival, complications, and dose to target area or organs at risk (OARs) were collected and compared. Furthermore, dosimetry difference was investigated by reconstructing the 2D plan into a 3D plan. The median follow-up duration of all patients was 58 months. The overall 5-year progression-free survival, overall survival, and local control rates were 69.6%, 90.2%, and 78.2%, respectively. Late complications in the rectum, sigmoid colon, and bladder were milder in 3D brachytherapy than in 2D brachytherapy. Concerning the D90 value of clinical target volume (CTV) and D2cm3 value of OARs in EQD2, the 3D brachytherapy provided a lower dose to CTV (76.5 Gy vs. 95.9 Gy, on average) and OARs compared with 2D brachytherapy. Despite lacking statistical significance, 3D brachytherapy showed better outcomes regarding late toxicity than 2D brachytherapy, owing to the lower dose coverage in the bladder, rectum, sigmoid colon, and small intestine.

Laparoscopic Nerve-Sparing Sacropexy: Tips and Tricks for a Safe and Anatomical Surgical Procedure

Study Objective to demonstrate a nerve-sparing technique during laparoscopic sacropexy (LSP) for treatment of multicompartment pelvic organ prolapse. Design A step-by-step demonstration of our surgical procedure of laparoscopic sacropexy (LSP). Setting Sacropexy is the 'gold standard' procedure for apical prolapse. This procedure is characterized by a complete dissection of the avascular spaces and is nerve sparing technique saving superior and inferior hypogastric plexus and the hypogastric nerves. Patients or Participants Patients with POP-Q Stage III and IV/prolapse of uterine Interventions Our surgical nerve-sparing LSP technique proceeds in 10 steps: Step 1: Suspension of the sigma to the abdominal wall. Step 2: Opening the peritoneum and exposure of sacral promontory and of the longitudinal anterior vertebral ligament. Step 3: Dissection of the right medial pararectal space (Okabayashi's Space), respecting the integrity of the presacral fascia and of the rHN contained within it. Step 4: Dissection of the rectovaginal space with a latero-medial approach expecting the integrity of the rectal fascia. The lateral limits were defined by the uterosacral and rectovaginal ligaments, and the base was represented by the perineal body and levator ani muscle. Step 5: Dissection of the vesicovaginal space through the creation of an avascular space with the apex at the dorsal end of the bladder trigone and laterally limited by the vesicouterine ligaments. Step 6: Subtotal hysterectomy. Step 7: A first synthetic mesh (posterior) fixed with a total of five no. 3–0 non-absorbable sutures. Step 8: A second synthetic mesh (anterior) fixed with five no. 3–0 non-absorbable sutures. Step 9: Mesh fixation on the cervical stump and ligamentum longitudinale. Step 10: Mesh peritonealization. Measurements and Main Results LSP combines the high efficacy of reconstructive surgery using non-absorbable mesh with the fast recovery and low complication rate resulting from minimal tissue trauma and laparoscopicalprocedure precision. Conclusion A nerve-sparing approach to pelvic spaces during LSP is feasible following well-defined surgical steps. to demonstrate a nerve-sparing technique during laparoscopic sacropexy (LSP) for treatment of multicompartment pelvic organ prolapse. A step-by-step demonstration of our surgical procedure of laparoscopic sacropexy (LSP). Sacropexy is the 'gold standard' procedure for apical prolapse. This procedure is characterized by a complete dissection of the avascular spaces and is nerve sparing technique saving superior and inferior hypogastric plexus and the hypogastric nerves. Patients with POP-Q Stage III and IV/prolapse of uterine Our surgical nerve-sparing LSP technique proceeds in 10 steps: Step 1: Suspension of the sigma to the abdominal wall. Step 2: Opening the peritoneum and exposure of sacral promontory and of the longitudinal anterior vertebral ligament. Step 3: Dissection of the right medial pararectal space (Okabayashi's Space), respecting the integrity of the presacral fascia and of the rHN contained within it. Step 4: Dissection of the rectovaginal space with a latero-medial approach expecting the integrity of the rectal fascia. The lateral limits were defined by the uterosacral and rectovaginal ligaments, and the base was represented by the perineal body and levator ani muscle. Step 5: Dissection of the vesicovaginal space through the creation of an avascular space with the apex at the dorsal end of the bladder trigone and laterally limited by the vesicouterine ligaments. Step 6: Subtotal hysterectomy. Step 7: A first synthetic mesh (posterior) fixed with a total of five no. 3–0 non-absorbable sutures. Step 8: A second synthetic mesh (anterior) fixed with five no. 3–0 non-absorbable sutures. Step 9: Mesh fixation on the cervical stump and ligamentum longitudinale. Step 10: Mesh peritonealization. LSP combines the high efficacy of reconstructive surgery using non-absorbable mesh with the fast recovery and low complication rate resulting from minimal tissue trauma and laparoscopicalprocedure precision. A nerve-sparing approach to pelvic spaces during LSP is feasible following well-defined surgical steps.

The influence of persistent bleeding after supracervical hysterectomy on depressive and anxious symptoms: a prospective bicenter study.

Postoperative spotting is a frequent adverse symptom after laparoscopic supracervical hysterectomy (LSH). The conical excision (eLSH) reduces the postoperative spotting rate, but data in a larger collective are still rare and inconsistent. The influence of persistent bleeding on the anxious and depressive symptoms has not been analyzed yet. 311 patients, who underwent a laparoscopic supracervical hysterectomy with conical excision (n = 163), or with straight cervical resection (n = 148) were included. Anxious and depressive symptoms and postoperative spotting were recorded before operation, at 3 month follow-up and at 1 year follow-up in both operative groups using a validated questionnaire (German version of Hospital Anxiety and Depression Scale, HADS-D) and additional questions concerning the frequency and impact of bleeding. Statistical analysis included the impairment of bleeding as well as its impact on depressive and anxious symptoms for both groups. 11.5% after eLSH and 15.5% after LSH reported spotting after 1 year. Supracervical hysterectomy significantly improves depressive and anxious symptoms at 3 and at 12 month follow-up for both groups (p < 0.001) independent on residual spotting. Patients with a preoperative continuous bleeding showed a maximum benefit independent on operative method. Laparoscopic supracervical hysterectomy has a positive effect on anxious and depressive symptoms in the short-term and intermediate-term follow-up. The conical excision of the cervical stump reduces postoperative spotting rate, but has no explicit advantage on symptoms of depression or anxiety, irrespective of residual postoperative spotting.

The influence of conventional and extended supracervical hysterectomy on sexuality and quality of life parameters: a prospective bi-center study with a special focus on postoperative spotting.

Supracervical as well as total hysterectomy are considered to improve postoperative sexuality as well as quality of life, but the benefit of supracervical hysterectomy (LSH) is impaired in up to 20 percent by postoperative spotting. The aim of this study was to analyze the influence of a conical excision of the cervical stump during supracervical hysterectomy on the postoperative spotting rate and its influence on sexuality and in turn quality of life. 321 Patients who underwent a laparoscopic supracervical hysterectomy with conical excision (extended laparoscopic supracervical hysterectomy, eLSH, n = 166, Dormagen hospital) or with straight cervical resection (laparoscopic supracervical hysterectomy, LSH, n = 133, MIC Clinics Berlin) were included. Sexual matters, quality of life parameters and additional questions were recorded before operation, at three months of follow up, and at one year of follow up in both groups using a validated questionnaire (German version of International Consultation on Incontinence Questionnaire Vaginal Symptoms Module, ICIQ_VS). Statistical analysis included the impact and impairment of bleeding on sexuality, quality of life in both groups and co-factors such as vaginal symptoms. 11.3% after eLSH and 15.5% after LSH reported spotting after 1 year. Supracervical hysterectomy significantly improves quality of life and sexuality and a conical excision of the remaining stump is associated with a lower but insignificantly reduced spotting rates. Postoperative spotting has no negative influence on sexual matter score of ICIQ_VS, but reduces the postoperative quality of life focusing on vaginal symptoms in a significant way. The improvement of ICIQ_VS scores after supracervical hysterectomy is independent of postoperative spotting, but the quality-of-life score is positively influenced by a reduction in the postoperative spotting rate.

Combined intra-cavitary and interstitial image-guided adaptative brachytherapy for cervical stump carcinomas: technical and clinical results of six patients.

PurposeAccording to European guidelines for cervix cancers, the management of cervical stump cancers should follow recommendations for patients without previous sub-total hysterectomy, but may require adaptation of radiotherapy modalities, especially brachytherapy (BT). However, data with modern BT technics are very scarce.Material and methodsFrom May 2013 to March 2020, 6 patients (age range, 71-88 years) with cervical stump squamous cell carcinoma (previously treated by sub-total hysterectomy) have been treated with external beam radiotherapy (intensity-modulated radiation therapy – IMRT, 45 Gy in 25 fractions, 5 patients, or 50.4 Gy in 28 fractions, 1 patient), with concomitant chemotherapy in 2 patients, followed by image-guided adaptive brachytherapy with pulsed-dose-rate in 5 patients or high-dose-rate in 1 patient. We used Utrecht BT applicator (Elekta®), with the implant of interstitial needles within the parametrium (unilaterally in 3 and bilaterally in 3 patients), and/or within the residual cervix (3 patients). Dosimetry was based on GEC-ESTRO recommendations.ResultsThe median high-risk (HR) and intermediate-risk (IR) clinical target volumes (CTV) were 14.5 cc (range, 12-35 cc) and 40 cc (range, 31-62 cc), respectively. The median dose (D90) delivered to HR and IR CTVs were 81.2 (range, 78.2-89.8) and 68.95 (range, 64.3-72.3) Gy EQD2, respectively. With a 26.5 months median follow-up (range, 10-92 months), we did not observe any local or distant recurrence. No grade 2 or more acute or late toxicities were reported.ConclusionsCervix brachytherapy with Utrecht applicator using interstitial needle is safe and effective in cervical stump cancer patients.

Субтотальная гистерэктомия с глубоким иссечением слизистой шейки матки как альтернатива тотальной гистерэктомии. За и против

Objective. A comparative analysis of the immediate and long-term outcomes of total and subtotal hysterectomy with excision of the mucosal and muscular layers of the cervix in patients with benign uterine diseases. Patients and methods. A total of 366 patients aged 41 to 57 years were examined. Patients were divided into two groups: the study group (n = 254), which included patients who underwent laparovaginal subtotal hysterectomy with excision of the cervical mucosal and muscular layers using a modified cutting instrument (surgical cutter), and the comparison group (n = 112), which included patients who underwent total hysterectomy. All operations were performed by a laparoscopic approach. The duration of postoperative outpatient follow-up was 1–48 months. Results. In 88.6% of patients in the study group, there were no pronounced vegetative-vascular and psycho-emotional disorders, exacerbation or worsening of chronic somatic diseases; 56.3% of patients in the comparison group had clinical manifestations of the post-hysterectomy syndrome. Deterioration in the quality of sexual life (reduced libido and/or anorgasmia) was observed in 9.4% and 36.6% of women in the study and comparison groups, respectively. Vaginal vault prolapse was revealed in 3.6% of patients in the comparison group and vaginal vault granulation – in 4.5% of patients 2-3 years after surgery. No similar complications were registered in the study group. Conclusion. Subtotal hysterectomy with excision of the cervical mucosal and muscular layers using the presented technique can serve as an alternative to total hysterectomy in patients with benign uterine pathology. Preservation of the uterine suspensory apparatus, innervation, and blood supply of the cervical stump and the upper third of the vagina reduces the risk of pelvic floor anatomical and functional disorders and minimizes the possibility of post-hysterectomy pelvic organ prolapse. The proposed method of hysterectomy helps to reduce the duration of surgery, blood loss, the risk of intra- and postoperative complications, to minimize the development of cervical stump diseases and improve patients’ quality of life. Key words: subtotal hysterectomy, total hysterectomy, cervical mucosal and muscular layer excision, laparoscopy, surgical cutter, post-hysterectomy syndrome

Subtotal hysterectomy reviewed: a stable or aperture for stump cervical malignancy. A referral hospital experience.

To review the malignant potential of the stump after subtotal abdominal hysterectomy. Material and methods: Thirty-three patients with stump malignancy were diagnosed and treated between January 2018 and January 2022. All patients primarily underwent subtotal hysterectomy (STH) outside our hospital due to different indications, most of which seemed non-convincing. Upon presentation, they were evaluated properly and offered the best management plan. The presenting symptoms were abnormal histopathology report in 8 patients (24.24%), abnormal bleeding in 7 patients (21.21%), and postcoital bleeding and abnormal Pap smear in 6 patients (18.18%). The primary site of malignancy was endometrial in 17 patients (51.51%), on top of fibroid in 6 patients (18.18%), and cervical in 5 patients (15.15%). Eighteen patients (54.54%) underwent proper surgery, 9 patients (27.277%) were referred for chemoradiation, and 6 patients (18.18%) were candidates for palliative therapy. Stump cancer cases show a worse stage silhouette compared with cancer cases in intact uteruses. The high prevalence of cervical stump problems should be taken into account before a change in surgical approach from total to STH is deemed possible. Further prospective studies with prolonged follow-up periods are needed to evaluate the risks and benefits of retaining the cervix at hysterectomy. Subtotal hysterectomy is easier, does not require distinct skills that lead to experience and follow-up, and must be limited to the narrowest limits of practice, provided that the woman knows that there are no health benefits to keeping the cervix in place.

Cervical diseases after subtotal hysterectomy (modern aspects of diagnosis and tactics of management)

Aim. To study the state of the cervical stump after subtotal hysterectomy (STGE) without uterine appendages with and without excision of the endocervix in patients with myoma to justify the choice of a rational volume of surgical operation.&#x0D; Materials and methods. Examination and treatment of 140 women was carried out with the formation of three groups: 1st 40 patients after laparoscopic STGE with excision of the endocervix; 2nd 38 patients after laparoscopic STGE without excision of the endocervix; 3rd (comparison group) 62 patients with uterine myoma that do not require surgical treatment.&#x0D; Results. The study of the state of the cervical stump was carried out 5.10.3 years after surgery. The number of patients with cervical pathology after STGE with excision of the endocervix (in group 1) was 1.8 times less in percentage terms than after STGE without excision of the endocervix (in group 2), and 3.2 times less than in patients with uterine fibroids who do not require surgical treatment (in the 3rd comparison group).&#x0D; Conclusion. Out of 3 (3.8%) patients after surgical treatment with diagnosed HPV type 16.1 (1.3%) in the STGE group without endocervical excision was diagnosed with grade II intraepithelial neoplasia (CIN II). In patients with uterine myoma, STGE can be performed only after a comprehensive preoperative examination, including: diagnosis and treatment of urogenital infections, DNA typing of HPV of high oncogenic types, cytological and colposcopic examination of the cervix, targeted biopsy of the cervix with histological examination of the material. If a subtotal hysterectomy is performed, it must be supplemented with excision of the endocervix. In the future, these women require careful follow-up to improve early diagnosis and treatment of underlying and precancerous diseases and reduce the risk of developing cervical stump cancer.

A safe and simple technique for nasogastric tube insertion in patients with thoracic esophageal cancer surgery

BackgroundRisk factors for anastomotic leakage include local factors such as excessive tension across anastomosis and increased intraluminal pressure on the gastric conduit; therefore, we consider the placement of a nasogastric tube to be essential in reducing anastomotic leakage. In this study, we devised a safe and simple technique to place an NGT during an end-to-side, automatic circular-stapled esophagogastrostomy.MethodsFirst, a 4-0 nylon thread is fixed in the narrow groove between the plastic and metal parts of the tip of the anvil head. After dissecting the esophagus, the tip of the NGT is guided out of the lumen of the cervical esophageal stump. The connecting nylon thread is applied to the anvil head with the tip of the NGT. The anvil head is inserted into the cervical esophageal stump, and a purse-string suture is performed on the esophageal stump to complete the anvil head placement. The main unit of the automated stapler is inserted through the tip of a reconstructed gastric conduit, and the stapler is subsequently fired and an end-to-side esophagogastrostomy is achieved. The main unit of the automated stapler is then pulled out from the gastric conduit, and the NGT comes out with the anvil head from the tip of the reconstructed gastric conduit. Subsequently, the nylon thread is cut. After creating an α-loop with the NGT outside of the lumen, the tip of the NGT is inserted into the gastric conduit along the lesser curvature toward the caudal side. Finally, the inlet of the automated stapler on the tip of the gastric conduit is closed with an automated linear stapler, and the esophagogastrostomy is completed.ResultsWe utilized this technique in seven patients who underwent esophagectomy for esophageal cancer; smooth and safe placement of the NGT was accomplished in all cases.ConclusionOur technique of NGT placement is simple, safe, and feasible.