Cervical Stump Research Articles

Traquelectomía laparoscópica después de histerectomía subtotal: reporte de dos casos en Medellín, Colombia

Objetivo: reportar dos casos de traquelectomía por laparoscopia.Institución: Unidad de Cirugía Endoscópica Ginecológica, Clínica del Prado, Medellín, Colombia.Diseño: se presenta el reporte de dos pacientes con muñón cervical sintomático después de histerectomía subtotal y su manejo por vía laparoscópica.Variables: se describen los datos demográficos de las pacientes, el diagnóstico prequirúrgico, la técnica empleada para la remoción del cérvix y los datos de la evolución posoperatoria.Conclusiones: la evidencia disponible cataloga el abordaje laparoscópico como seguro para la realización de traquelectomía en casos de enfermedad benigna. Este es el primer reporte de traquelectomía laparoscópica publicado en la literatura colombiana.

Carcinoma microinvasor de cérvix. El manejo de una neoplasia de buen pronóstico

IntroductionMicroinvasive carcinoma represents a subgroup within cervical cancer that is characterized by having a good prognosis and the possibility of treatment through conservative approaches. Material and methodsWe studied data from 60 patients treated at our hospital from 1994 to 2001. The diagnosis was made by the loop electrosurgical excision procedure (LEEP). ResultsOf all treated patients, 83.3% had stage IA1 carcinomas and 16.6% were in stage IA2. All tumors were squamous carcinomas, except one, which was a mucinous adenocarcinoma. Forty patients with stage IA1 tumors underwent total hysterectomy, whilst the remainder were treated by LEEP or, in two patients, through a cervical stump excision. Except for one patient with contraindications for surgery, all IA2 patients underwent radical surgery consisting of radical hysterectomy with bilateral iliac lymphadenectomy. Relapse occurred in only one patient with a stage IA1 tumor, who then underwent colpectomy. ConclusionsOur data support the current trend of increasing the use of conservative treatments and confirm the excellent prognosis of this neoplasm.

Esophageal carcinoma: transthoracic esophagectomy with regional lymphadenectomy and reconstruction with deferred priority

In a retrospective analysis the risks were assessed of transthoracic oesophagectomy with mediastinectomy and regional lymphadenectomy followed 48-72 hours later by an abdomino-cervical operation with supra-pancreatic lymphadenectomy, retrosternal gastric interposition and cervical oesophageal stump anastomosis. Results in this group of 37 patients were compared with those in a group of 42 patients who had undergone a transmediastinal oesophagectomy (without thoracotomy) and immediate reconstruction. The 30-day death rate was 8.1% in the former (group I) and 7.1% in the latter (group II), total hospital death rate 10.8% and 11.9%, respectively. The complication rate was similar in the two groups, as was the recorded operative stress. The results indicate that the risk of an oncologically indicated oesophagectomy with regional lymphadenectomy is no greater than that of a palliative transmediastinal oesophagectomy.

Does supracervical hysterectomy provide more support to the vaginal apex than total abdominal hysterectomy?

The objective of the study was to assess whether cervical preservation at the time of hysterectomy may help prevent subsequent apical vaginal vault prolapse. Supracervical hysterectomies were performed in 12 unembalmed cadavers. Successive hanging weights of 1, 2, 3, and 4 kg were loaded against the cervical stump and distances moved were recorded. The same process was repeated after completion of a total hysterectomy. Average distances pulled with 1, 2, 3, and 4 kg of traction against the cervical stump were 17.8 +/- 1.9, 24.1 +/- 2.5, 29.0 +/- 2.8, and 34.3 +/- 3.5 mm, respectively. After total hysterectomy, these distances were 17.5 +/- 2.5, 23.5 +/- 2.6, 29.3 +/- 3.1, and 34.5 +/- 3.6 mm, respectively. In unembalmed cadavers, it appears that total abdominal hysterectomy and supracervical hysterectomy provide equal resistance to forces applied to the vaginal apex.

Estriolum Treatment in the Bitch: A Risk for Uterine Infection?

Purulent vaginal discharge in a bitch in which ovariohysterectomy has been performed is often caused by inflammation of the uterine stump. The inflammation is due to either cystic endometrial hyperplasia (CEH) induced primarily by progesterone from remnant ovarian tissue or exogenous progestagens, or it is due to the presence of unabsorbed suture material. This report describes a 9-year-old Irish setter with hemopurulent vaginal discharge and non-pruritic symmetrical alopecia, which had undergone ovariohysterectomy 3.5 years ago and which had been treated with estriolum daily for the past 2.5 years because of urinary incontinence. Vaginoscopy revealed hemopurulent discharge throughout the vagina and vestibule. Cytological examination of ultrasound-guided fine-needle aspiration biopsies of a large mass in the hypogastricum, which appeared to be the uterine cervical stump, revealed septic purulent inflammation. The concentration of plasma progesterone was low and the concentration of plasma 17-ss oestradiol did not increase after gonadotrophin-releasing hormone administration. No remnant ovarian tissue was found by abdominal ultrasonography, laparotomy, or histological examination of mesovarian pedicles. Laparotomy revealed uterine stump empyema. Histological examination of the surgically removed mass excluded both CEH and unabsorbed suture material as the cause of the stump empyema. Instead, it is hypothesized that the long-term treatment with estriolum was a causative factor. This suggests that bitches treated with estriolum should be examined regularly.

Endometrial vaporization of the cervical stump employing an office hysteroscope and bipolar technology

We report the successful treatment of a 40-year-old woman with ongoing cyclical vaginal bleeding lasting 10 days after laparoscopic subtotal hysterectomy. Hysteroscopic vaporization of the endometrial stripe in the cervical stump was performed in an office setting, using a 5-mm Bettocchi double-channel operative hysteroscope armed with a bipolar electrode.

Cervical stump prolapse complicating laparoscopic supracervical hysterectomy in a nulliparous woman

A resurgence of supracervical hysterectomies is being seen, as providers are becoming more comfortable with minimally invasive surgery. Proponents of this technique advocate that leaving the cervix prevents the disruption of proper anatomical relationships, which allows better apical support of the vagina. We report a case of cervical stump prolapse 6 months after a laparoscopic supracervical hysterectomy (LSH) in a 36-year-old, nulliparous, obese woman who demonstrated excellent uterine support before her surgery.

Total or subtotal hysterectomy for benign uterine diseases? A meta‐analysis

Total and subtotal abdominal hysterectomy for benign indications have been compared in randomized clinical trials and observational studies. A meta-analysis is performed to summarize the evidence. Thirty-four randomized clinical trials and observational studies comparing total and subtotal abdominal hysterectomy for benign indications were included. Endpoints were self-reported urinary incontinence, postoperative complications, operation time, quality of life, constipation, prolapse, sexual functioning, pelvic pain, and cervical stump problems after subtotal hysterectomy. Odds ratios and tests for heterogeneity and overall effect were calculated. Urinary incontinence and prolapse showed a significant difference favoring the total hysterectomy. Some of the women having a subtotal hysterectomy had cervical stump problems (bleeding and abnormal smear). Operation time and peroperative bleeding are postoperative complications were significantly in favor of the subtotal hysterectomy. Lower urinary tract symptoms other than incontinence, quality of life, constipation, pelvic pain, and sexual life were not in favor of either of the hysterectomy methods. Less women suffered from urinary incontinence and prolapse and cervical stump problems after total than after subtotal hysterectomy. However, subtotal hysterectomy is faster to perform, has less peroperative bleeding, and seems to have less intra- and postoperative complications.

Prothrombin complex for massive obstetric haemorrhage

Prothrombin complex for massive obstetric haemorrhage

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.

Hysterectomy for benign gynaecological disease

Hysterectomy, the commonest major gynaecological operation, is the only definitive cure for dysfunctional uterine bleeding, rates highest in satisfaction scores compared with other treatments, and improves quality of life. Although research indicates that vaginal hysterectomy is safer and cheaper than total abdominal hysterectomy, the latter still accounts for 60–80% of all hysterectomies in the UK and the USA, and at least 95% of these are total rather than subtotal. Although recent research also shows that subtotal hysterectomy confers no advantages over the total procedure, with respect to pelvic organ function, subtotal hysterectomy is the quicker and safer operation, and the risk of cervical stump carcinoma in a woman who has previously had normal smears is negligible. Overall mortality rates from hysterectomy are 0.5–2 per 1000, and rates of visceral damage are 0.5–2%. Complications are most common in women treated for uterine fibroids, and overall rates decrease with increasing age of women. Cost-effective analysis shows hysterectomy to be an effective and cost-effective intervention across a variety of indications. Conservative alternatives to hysterectomy, including endometrial ablative techniques, the Mirena intrauterine system (IUS), and uterine artery embolization for fibroids, have not yet greatly reduced hysterectomy rates, which vary widely between regions, and within the same geographical area. A major challenge is to establish the reasons for this variation in rates.

An Efficient and Safe Procedure for Laparoscopic Supracervical Hysterectomy

The authors present the results of a retrospective review of the medical records of 122 women who underwent laparoscopic supracervical hysterectomy with endocervical resection (LSH with ER) between May 1998 and November 2004. Patients were an average age of 49.7 years, and all had benign indications (menometrorrhagia or dysmenorrhea resistant to drug therapy, large fibroids, or abdominal pain). No patients with vaginal prolapse or cervical/uterine dysplasia were included. All patients were treated with perioperative ceftriaxone, and obese patients performed a bowel preparation before surgery. The dorsal lithotomy position was used for surgery. Several laparoscopic trocars were placed, including a 10-mm intraumbilical trocar and 2 or 3 suprapubic 5-mm trocars. Hysterectomy was started according to standard techniques, including dissection of the bladder flap and isolation and coagulation of the ascending branch of the uterine vessels. At this point, a vaginal approach was initiated, the cervix dilated, and a 10-mm guide rod was placed through the cervix to the fundus of the uterus. Under laparoscopic control, a 15-mm electromechanical morcellator was advanced transcervically along the guide rod to ream out a cylinder of cervix, endocervix, and endo/myometrium. The cored-out uterine fundus was then amputated laparoscopically using monopolar cautery. The morcellator was then reintroduced through the cervix and the transected fundus was morcellated under laparoscopic guidance. Careful hemostasis of the cervical stump was then achieved with electrocautery, and the pelvic peritoneum closed over the cervical stump with a single, delayed, absorbable suture. Mean operating time was 117 minutes (range, 45–210 minutes), and actual morcellation time varied from 5 to 38 minutes. The average uterine weight was 215 g (range, 60–880 g) with 16 uteri weighing more than 300 g. No patient required a transfusion and the average blood loss was 37 mL (range, 5–550 mL). Thirty-seven (30%) women remained in the hospital less than 24 hours. Overall, the average stay was 54 hours (range, 20–161 hours). There were no major complications either intra- or postoperatively. One very obese patient developed a steatonecrosis of the trocar sites, which resolved in 3 weeks, and one patient, who had sexual intercourse on day 3, was diagnosed with an endocervical infection that was treated with antibiotics. Seven women had postoperative bladder infections and one had light spotting for 32 days. No patients reported postoperative changes in libido or frequency of sexual intercourse.

Hystérectomie sub-totale : données récentes et implications pratiques

The advantages and drawbacks of total and sub-total hysterectomy remain a topic of debate. Our study reviews the literature concerning recent comparative and prospective studies regarding the options of total and subtotal hysterectomy.Subtotal hysterectomy may be useful in preventing severe complications when total hysterectomy is technically difficult. Furthermore, conservation of the uterine cervix may decrease vaginal erosion in genital prolapse repair when synthetic meshes are used. The type of technique does not appear to determine the persistence or development of problems related to sexual activity (frequency of intercourse, sexual desire, and achievement of orgasm). There are no apparent advantages to subtotal hysterectomy compared with total hysterectomy with respect to bowel or bladder function. Some women (5-20%) who had the subtotal procedure continued to have genital bleeding, although this can be avoided with endocervical electro-coagulation or resection. Cervical stump prolapse is uncommon (1.5-2%), 12 months after subtotal hysterectomy. The risk of carcinoma of the cervical stump is low, and treatment results are similar in both patients with carcinoma of the cervical stump and in patients with carcinoma of the intact uterus.When subtotal hysterectomy is necessary, it can be performed with a low rate of long term complications. Furthermore, for women undergoing hysterectomy for benign disease, it should be reasonable to discuss advantages and drawbacks of both procedures and offer a choice. Nevertheless, sub-total hysterectomy should be avoided in populations with restricted access to screening programs for cancer of the uterine cervix.

Removal of the retained cervical stump

The purpose of this study was to identify indications for and complications of abdominal or vaginal surgical removal of the cervical stump after previous supracervical hysterectomy. This was a retrospective chart review of trachelectomy patients at Mayo Clinic, Rochester, Minnesota, or Mayo Clinic, Scottsdale, Arizona, between January 1974 and December 2003. Of 335 patients with a history of supracervical hysterectomy who subsequently required trachelectomy, 25 were excluded from study. Half of the remaining 310 patients had trachelectomy between 1974 and 1983, an average of 26 years after hysterectomy. The indication in three quarters of trachelectomies performed vaginally was prolapse. The vaginal approach had significantly fewer complications than the abdominal approach. Removal of the cervical stump is infrequent and has declined over a 30-year period. The decline in trachelectomy may be because of a decreasing number of supracervical hysterectomies performed. When trachelectomy is performed vaginally, prolapse is the most common indication, and there are few complications.

Total laparoscopic radical trachelectomy with intraoperative sentinel node identification for early cervical stump cancer

A 60-year-old patient had undergone a subtotal hysterectomy through a standard laparotomy approach due to multiple uterine myomas 6 years before. She had a 1-month history of postmenopausal uterine bleeding. An endocervical polyp was found and excised. The histopathologic examination showed a poorly differentiated adenocarcinoma. Magnetic resonance imaging of the abdomen and pelvis revealed the mass (4 × 2 × 2.5 cm) without parametrial involvement previously identified on vaginal examination. There was no retroperitoneal adenopathy. The patient was successfully treated with total laparoscopic radical trachelectomy in association with laparoscopic intraoperative detection of the sentinel lymph node.

Human Papillomavirus Testing Before Elective Supracervical Hysterectomy

A case of cervical intraepithelial neoplasia (CIN) of the cervical stump is presented. Human papillomavirus DNA testing before elective supracervical hysterectomy may identify patients with increased risk for future development of CIN and aid in preoperative counseling for the type of surgical procedure performed.

Incidence of cyclical bleeding after laparoscopic supracervical hysterectomy

Study objective The aim of the study was to estimate the incidence of cyclical bleeding after laparoscopic supracervical hysterectomy (LSH) when the uterus is amputated at or below the level of internal cervical os. Design Prospective series of consecutive patients (Canadian Task Force classification II-3). Setting Single surgery team, independent surgery center. Patients Women with symptomatic uterine leiomyomata, abnormal uterine bleeding, dysmenorrhea, or chronic pelvic pain. Intervention Laparoscopic supracervical hysterectomy (with concurrent bilateral salpingo-oophorectomy if required), along with laparoscopic biopsy sampling of the cervical stump. Measurements and main results From October 2002 through February 2004, we performed 67 consecutive LSH procedures. At the completion of uterine amputation, two biopsies were obtained from the cervix at 12 o’clock and 6 o’clock positions and submitted for histologic evaluation to identify the tissue type. We assumed the presence of endocervical tissue on cervical biopsy would indicate the uterine amputation took place at or below the level of internal os. All 67 patients were contacted 3- to 15-months postoperatively to inquire about bleeding status, and 64 (96%) responded. The overall bleeding incidence was 12/64 (19%). Among the subgroup with endocervical tissue on biopsy, 7/41 (17%) experienced cyclical bleeding. The continuous variables (i.e., age, body mass index [BMI], parity, uterine weight) and categorical variables (i.e., indications for surgery, status of endometriosis, adenomyosis, endocervical fulguration, cervical biopsy, history of cesarean section) were not statistically significant in association with the bleeding time. Conclusion Our data suggest the overall incidence of post-LSH cyclical bleeding is 19%. When the uterus is amputated at or below the level of internal os, the incidence is 17%. To our knowledge, this is the first study in the medical literature to report on cyclical bleeding after LSH when the uterine amputation is demonstrated to have occurred at or below the level of internal cervical os.

Die laparoskopische suprazervikale Hysterektomie. Prospektive Multizenterstudie des VAAO

Study Objective: Laparoscopic supracervical hysterectomy (LASH) is an alternative to total hysterectomy for benign conditions in cases where conservative treatment options fail and hysterectomy is indicated. Only little data from German-speaking countries concerning surgical techniques, postoperative well-being and complications is available. Methods: The data of 191 patients scheduled for laparoscopic supracervical hysterectomy were prospectively registered between April 1, 2003 and March 31, 2004. A questionnaire was filled in by the physician recording data pre-, intra- and postoperatively. All patients were interviewed six months after surgery and asked about their well-being, possible complaints and their fitness to work by telephone. Results: The average age of the patients was 43 years. The main indications for the operation were abnormal uterine bleeding and dysmenorrhea (65%). The mean operation time was 119 minutes and the average weight of the uterus corpus was 239 g. The uterine arteries were coagulated with bipolar current in most cases (81 %) and dissection of the corpus uteri from the cervix was done using monopolar scissors in 59% of the patients. In most cases the cervical stump was peritonealised (84%). 71% of the patients were operated on an outpatient basis. No serious complications were reported. 13% of the patients continued to have cyclical bleeding six months after the operation. Conclusion: Laparoscopic supracervical hysterectomy (LASH) is a sparing, cost saving alternative to total hysterectomy for benign uterine conditions unresponsive to conservative treatment alternatives which can be carried out on an outpatient basis.

Cervical stump necrosis and septic shock after laparoscopic supracervical hysterectomy

The decision to retain or remove the cervix when performing laparoscopic hysterectomy remains a topic of debate. A 38-year-old woman with multiple sclerosis underwent laparoscopic supracervical hysterectomy (LASH) for menometrorrhagia. Two weeks later, she was seen at our institution with septic shock. She underwent an exploratory laparotomy and was found to have cervical stump necrosis and peritonitis. Trachelectomy was performed. The postoperative course was prolonged by persistent fever, pleural effusion, and abscess collections. Although rare, cervical stump necrosis is a possible complication of LASH.

Laparoscopic-Assisted Vaginal Subtotal Hysterectomy

A novel approach in combined laparoscopic and vaginal procedures through the posterior cul-de-sac for subtotal hysterectomy is introduced. Twenty-one women with menometrorrhagia, symptomatic adenomyosis, or uterine myomas were enrolled in this study. After laparoscopic dissection of bilateral round ligaments and adnexa, a guiding suture brought the uterine fundus down through the posterior cul-desac into the vagina via a posterior colpotomy. Subtotal hysterectomy and hemostasis of the cervical stump were then performed transvaginally by conventional techniques and equipment. Mean operative time, blood loss, and length of hospital stay were 111.2 +/- 28.8 minutes, 252.4 +/- 147.9 mL, and 3.2 +/- 0.9 days, respectively. No patients developed serious complications, but 1 patient had a postoperative stump infection and was treated with 2 combined antibiotics, uneventfully. A combined laparoscopic and vaginal approach in performing subtotal hysterectomy through the posterior cul-de-sac is an alternative to a purely laparoscopic approach.