Cervical Stump Research Articles

“Schauta sine utero”: technique and results of laparoscopic–vaginal radical parametrectomy

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

Total Versus Subtotal Hysterectomy

In Brief OBJECTIVE To estimate the attitudes and practice of gynecologists in the Washington, DC, Maryland, and Virginia area regarding total versus subtotal abdominal hysterectomy. METHODS A questionnaire with 18 questions on physicians' attitudes and practice regarding total versus subtotal hysterectomy was mailed to 1647 gynecologists in Washington, Maryland, and Virginia. RESULTS The corrected response rate was 51.2%. Forty-five percent of respondents stated that they always removed the cervix. The most common reason cited was to eliminate the risk of cervical cancer. The most common reason for subtotal hysterectomy was surgical difficulty leading to an intraoperative change of procedure. Only 17.8% of respondents always counseled women regarding the advantages and disadvantages of both total and subtotal hysterectomy; 63% rarely or never did. Nineteen percent always offered women a choice between the procedures; 61% rarely or never did. Eighty-eight percent of respondents felt that the risk of cancer in the cervical stump was small or negligible. Gender of the physicians or year of completion of residency made no significant impact on patients being counseled about both procedures or being offered a choice between the two. CONCLUSION Most gynecologists surveyed favor total abdominal hysterectomy over subtotal hysterectomy. Few counsel women regarding the options of total and subtotal hysterectomy or offer a choice between the procedures. Given that there are no convincing data proving the superiority of either procedure over the other, it may be reasonable to discuss the potential advantages and disadvantages of both procedures with women undergoing hysterectomy for benign disease and to offer them a choice. Most gynecologists prefer total abdominal to subtotal hysterectomy, and few counsel women regarding these options or offer achoice between the two.

Total versus subtotal hysterectomy: a survey of gynecologists.

To estimate the attitudes and practice of gynecologists in the Washington, DC, Maryland, and Virginia area regarding total versus subtotal abdominal hysterectomy. A questionnaire with 18 questions on physicians' attitudes and practice regarding total versus subtotal hysterectomy was mailed to 1647 gynecologists in Washington, Maryland, and Virginia. The corrected response rate was 51.2%. Forty-five percent of respondents stated that they always removed the cervix. The most common reason cited was to eliminate the risk of cervical cancer. The most common reason for subtotal hysterectomy was surgical difficulty leading to an intraoperative change of procedure. Only 17.8% of respondents always counseled women regarding the advantages and disadvantages of both total and subtotal hysterectomy; 63% rarely or never did. Nineteen percent always offered women a choice between the procedures; 61% rarely or never did. Eighty-eight percent of respondents felt that the risk of cancer in the cervical stump was small or negligible. Gender of the physicians or year of completion of residency made no significant impact on patients being counseled about both procedures or being offered a choice between the two. Most gynecologists surveyed favor total abdominal hysterectomy over subtotal hysterectomy. Few counsel women regarding the options of total and subtotal hysterectomy or offer a choice between the procedures. Given that there are no convincing data proving the superiority of either procedure over the other, it may be reasonable to discuss the potential advantages and disadvantages of both procedures with women undergoing hysterectomy for benign disease and to offer them a choice.

Endometriotic cyst after subtotal abdominal hysterectomy mimicking carcinoma of the cervical stump

Endometriotic cyst after subtotal abdominal hysterectomy mimicking carcinoma of the cervical stump

Endometriotic cyst after subtotal abdominal hysterectomy mimicking carcinoma of the cervical stump

Endometriotic cyst after subtotal abdominal hysterectomy mimicking carcinoma of the cervical stump

The Porro procedure: steps toward decreasing post-cesarean mortality

In the second part of the 19th century, maternal mortality following classical cesarean section was nearly 100%. In 1876, the Italian obstetrician, Eduardo Porro, developed a cesarean section technique consisting of uterine corpus amputation and suturing of the cervical stump into the abdominal wall incision in an attempt to prevent life-threatening hemorrhage and infection. The successful outcome in Porro’s test case was due to his adherence to surgical principles that are well recognized today, but were not firmly established in 1876. He achieved hemostasis by use of the occluding snare of Cintrat. He irrigated the peritoneal cavity with carbolized sponges, drained the operative bed, and exteriorized the cervical stump in an effort to prevent access of bacteria from the lower genital tract into the peritoneal cavity. Despite the lack of blood products, intravenous fluids, and antibiotics, the Porro operative technique subsequently decreased maternal mortality to 58%. His innovative, carefully planned approach for cesarean hysterectomy was a major innovation in obstetric surgery.

Maternal and Perinatal Outcome of Massive Postpartum Hemorrage: A Review of 33 Cases

Postpartum hemorrhage is a significant contributor to maternal morbidity and mortality. We evaluated maternal and perinatal outcome of primary massive postpartum hemorrhage. In a restrospective case analysis of 33 women with intractable postpartum hemorrhage initially managed either by hysterectomy or a conservative approach in a tertiary referral center between January 1, 1991 to December 30, 1998, we reviewed the procedures used as a primary or secondary attempt to arrest the hemorrhage. Medical and surgical measures were successful in controlling hemorrhage in 21 (63.6%) of the 33 women. Hemorrhage was successfully arrested by conservative surgery in 13 cases, and by medical management in 8 cases. Emergency hysterectomy was performed in 12 cases (0.7 per 1000 deliveries) No maternal deaths occurred, but there were 2 early neonatal deaths (6.1 %). Atony of the uterus was the main cause of hemorrhage (n=15). Genital tract laceration was associated with a worse prognosis, but the time lapse between delivery and surgery appears to be the main prognostic factor. Uterine atony and morbid adherent placenta are major causes of massive obstetric hemorrhage. In our series, morbidity was high, but there was no mortality. Obstetricians should identify women at risk which is especially associated with a prior cesarean delivery, a current placenta previa and high parity. Early intervention and proper procedure could minimize the complications.

Correction of uterine prolapse by the vaginal route using the uterosacral ligaments: Shirodkar procedure

Objective: To study long-term results of Shirodkar procedure for treatment of uterine prolapse in women wishing to retain their uterus. Study design: Fifty-one patients with a symptomatic uterine prolapse who desire to preserve their uterus without further childbearing were treated between 1988 and 2000. By the vaginal route, uterosacral ligaments were separated from the uterus, shortened, transposed in front of the uterine isthmus, and fixed bilaterally under the opposite lateral surface of the cervix or of the cervical stump after amputation. Results: Median age of patients was 37 years. Median operating time was 120 min (range 60–190). One patient was re-operated four days after the initial surgery to drain a haematoma. Median follow-up was 81 months (range 11–134). Eight patients were lost of follow-up. Eleven (25.6%) patients underwent iterative surgery. The indication for re-operation was recurrence of prolapse in four patients, introital dyspareunia in three patients, cervix stenosis in two patients, urinary incontinence in one patient and pyosalpinx in one patient. Only one patient (2.3%) experienced a recurrence of the uterine prolapse. Conclusion: Shirodkar procedure is safe and effective. Long-term functional results are satisfactory but associated procedures may alter patient satisfaction.

Does xenon anesthesia inhibit cholinesterases? An in vitro radiometric assessment.

Does xenon anesthesia inhibit cholinesterases? An in vitro radiometric assessment.

Cervical stump cancer: a study of 14 cases.

This is a report on 14 patients with cervical stump cancer, aged 30 to 68 years old (median = 53 years), seen in a public university hospital. Over a 15-year period, 363 cases of cervical cancer were treated, of which fourteen (3.85%) were in the cervical stump. The time interval between subtotal hysterectomy and the diagnosis of the neoplasm varied from 9 days to 27 years (median = 9.3 years). 28.6% of the patients were in stage I, 42.9% in stage II and 28.6% in stage III. Fibromyoma was the major reason for the subtotal hysterectomy. Three patients underwent Wertheim-Meigs surgery, 1 in association with radiotherapy, and the other 11 patients had radiotherapy alone. The survival ranged from 12 to 120 months (median = 53.3 months). Subtotal hysterectomy should be avoided whenever possible in populations with restricted access to screening programs for cancer of the uterine cervix.

Safety and efficacy of sacrospinous vault suspension.

The objective of the study was to determine the success rate and complications of sacrospinous vault suspension when performed by an experienced surgeon. Retrospective data collection was performed for 293 women who had undergone sacrospinous vault suspension at Mount Sinai Hospital, Toronto, between November 1993 and 19 December 1998. Primary outcome measures were complication rates (acute and long term) and success rate, with failure defined as any degree of vault prolapse requiring repeat operation, any degree of symptomatic isolated vault prolapse, or any vault prolapse at or beyond the introitus. Statistical analysis was performed using simple descriptive techniques. During the study period, 305 sacrospinous vault suspensions were performed; however, 12 cases were excluded because of inaccessible records. This study therefore comprised the remaining 293 cases: 129 at the time of vaginal hysterectomy, 5 with transvaginal cervical stump excision, 155 for post-hysterectomy vault prolapse, and 4 without hysterectomy. Two hundred had follow-up of 1 year or more, with maximum follow-up 5 years. Of these 200, there were 6 failures (3%). There were no acute hemorrhages and no deaths. There was a complaint of postoperative right buttock pain in 18 of the 293 procedures (6.1%), with this persisting on a chronic basis in 3 patients. Eight patients complained of new-onset postoperative dyspareunia. Nine patients had postoperative stress urinary incontinence, and 14 patients had de novo anal incontinence. Postoperatively, there were 17 patients with a cystocele and 7 with a rectocele. There were three other complications: one pelvic hematoma at the sacrospinous suspension site, one right foot drop which spontaneously resolved, and one case of pain in the right sciatic nerve distribution which spontaneously resolved. Forty-three patients complained of anal incontinence preoperatively, and 38 (88.4%) had the symptoms resolved postoperatively. It was concluded that, when performed by a surgeon experienced in the procedure, sacrospinous vault suspension is safe and effective, with a successful result at 1 year in more than 90% of cases, and rare major complications.

Cervical stump carcinoma following subtotal hysterectomy

(2002). Cervical stump carcinoma following subtotal hysterectomy. Journal of Obstetrics and Gynaecology: Vol. 22, No. 6, pp. 701-701.

Long term outcome following laparoscopic supracervical hysterectomy

Objectives To assess the long term outcome of laparoscopic supracervical hysterectomy. Design Retrospective study. Setting Minimal Access Surgical Unit, Department of Gynaecology, Royal Surrey County Hospital, Surrey. Methods Analysis of patient case records. Population Seventy consecutive women who had a laparoscopic supracervical hysterectomy. Outcome measures Symptoms related to the cervical stump and the need for further surgery. Results The mean time of patient follow up was 66 months (range 52–84). The mean time from initial procedure to second treatment was 14 months (range 3–53). Seventeen women (24.3%) reported symptoms related to the cervical stump, and all required further surgery. The cervical stump was removed in 16 (22.8%). One patient had laparoscopic adhesiolysis only and two had a laparotomy and trachelectomy because the bowel was adherent to the cervical stump. Nine had a laparoscopically assisted cervical trachelectomy as the sole procedure. Five had laser treatment to endometriotic deposits, and laparoscopically assisted cervical trachelectomy. Histological analysis showed normal cervical tissue in six (35.3%). Endometriosis was detected in four cervical stumps (23.5 %), residual endometrium in another four (23.5 %) cases, and chronic cervicitis, mild CIN and a mucocoele in a further three patients. Of the 17 women who reported cervical stump symptoms, 14 (82.3%) had been treated for endometriosis in the past, compared with 17/53 (32%) who did not have symptoms ( P<0.0002, χ 2 test). Conclusions Symptoms related to the cervical stump requiring further surgery frequently occur following a laparoscopic supracervical hysterectomy.

Long term outcome following laparoscopic supracervical hysterectomy.

To assess the long term outcome of laparoscopic supracervical hysterectomy. Retrospective study. Minimal Access Surgical Unit, Department of Gynaecology, Royal Surrey County Hospital, Surrey. Analysis of patient case records. Seventy consecutive women who had a laparoscopic supracervical hysterectomy. OUTCOME MEASURES Symptoms related to the cervical stump and the need for further surgery. The mean time of patient follow up was 66 months (range 52-84). The mean time from initial procedure to second treatment was 14 months (range 3-53). Seventeen women (24.3%) reported symptoms related to the cervical stump, and all required further surgery. The cervical stump was removed in 16 (22.8%). One patient had laparoscopic adhesiolysis only and two had a laparotomy and trachelectomy because the bowel was adherent to the cervical stump. Nine had a laparoscopically assisted cervical trachelectomy as the sole procedure. Five had laser treatment to endometriotic deposits, and laparoscopically assisted cervical trachelectomy. Histological analysis showed normal cervical tissue in six (35.3%). Endometriosis was detected in four cervical stumps (23.5 %), residual endometrium in another four (23.5 %) cases, and chronic cervicitis, mild CIN and a mucocoele in a further three patients. Of the 17 women who reported cervical stump symptoms, 14 (82.3%) had been treated for endometriosis in the past, compared with 17/53 (32%) who did not have symptoms (P < 0.0002, chi2 test). Symptoms related to the cervical stump requiring further surgery frequently occur following a laparoscopic supracervical hysterectomy.

Carcinoma of the cervical stump. The Radiumhemmet series 1959–1987. Treatment and prognosis

The purpose of this retrospective study is to evaluate the longterm prognosis for cervical stump cancer compared to matched controls with cancer in an intact uterus. From 1959 to 1987, 145 patients were treated for an infiltrating carcinoma of the cervical stump at Radiumhemmet representing 2.2% of all cervical cancers. Three control cases to each case were selected from the cohort of cervical carcinoma cases - matched to year of treatment, stage, histology and age (plus, minus 2 years). Actuarial survival was calculated for cases and controls. Survival differences were analyzed with the Kaplan-Meier technique. The age distribution for cases ranged between 36 and 84 years with a mean age of 60.6 years. The mean age for the control series is 9 years of age (range 35-86 years). Among the cases 87.6% were squamous cell carcinoma and 12.4% were adenocarcinomas. Treatment of carcinoma of the uterine stump at Radiumhemmet followed the same modality as was practised for ordinary cervical cancer cases i.e. two brachyradium applications with 3 weeks interval followed by external irradiation. The dose of irradiation from the intracavitary application given to the stump cancers was lower than that given to comparable cases of the common cervical cases. No evidence was found of poorer longterm prognosis for radiologically treated squamous cell carcinoma of the uterine stump compared to that of the ordinary cervical carcinomas. Stump cancers of the adenocarcinoma type had a worse prognosis than adenocarcinomas in an intact uterus (p<0.07) and also compared with stump cancers of the squamous epithelial type (p=0.05). The complication rate was higher for the stump cancer cases compared with that for cervical cancers in intact uterus. The mean time interval from subtotal hysterectomy to the stump cancer diagnosis was 17.6 years with a range from 1 to 46 years. Recent discussions argue for a better sexual function after subtotal hysterectomy. Our study gave no convincing argument in terms of poorer prognosis for radiologically treated carcinoma of the uterine stump compared to that of the total cervical cancer series. It is thus necessary to weigh the possible gains with subtotal hysterectomy against the relatively low risk to fall victim of a stump cancer. Complications following surgery, as well as possible physiologic and sexual functions of the cervix, should be taken into account.

Histologic subtype has minor importance for overall survival in patients with adenocarcinoma of the uterine cervix: a population-based study of prognostic factors in 505 patients with nonsquamous cell carcinomas of the cervix.

The incidence of adenocarcinoma of the uterine cervix is increasing. For better prognostic information, the authors studied all nonsquamous cell carcinomas (non-SCCs) in the Norwegian population over a total of 15 years. All non-SCCs from three 5-year periods (1966-1970, 1976-1980, and 1986-1990) were reviewed and classified according to the World Health Organization classification system, and histopathologic and clinical parameters were registered. Tissue blocks were available from all patients. Of 505 patients, 417 had tumors classified as adenocarcinoma, and 88 had tumors classified as other non-SCC. The mean ages were 53 years and 52 years for patients with adenocarcinoma and non-SCC, respectively. Sixty-two percent of the staged patients had clinical Stage I disease according to the classification system of the International Federation of Gynecology and Obstetrics (FIGO). In univariate analyses, histology, architectural and nuclear grade, extension to the vagina or corpus uteri, tumor length (> 20 mm) or tumor volume (> 3000 mm(3)), infiltration depth (in thirds of the cervical wall), thickness of the remaining wall (< 3 mm), vascular invasion, lymph node metastases, treatment, and patient age were significant variables in patients with FIGO Stage I disease. Variables with no significance in patients with Stage I disease were number of mitoses, state of resection margins, infiltration to ectocervix, tumor thickness, lymphoid reaction, earlier or concomitant cervical intraepithelial neoplasia, stump carcinoma, DNA ploidy or DNA index, or time period. Multivariate analyses of patients with FIGO Stage I disease identified small cell carcinoma, corpus infiltration, vascular invasion, and positive lymph nodes as independent prognostic factors. Small cell carcinoma was the only histologic subgroup of independent importance for prognosis in patients with non-SCC of the uterine cervix. No significant difference between major subtypes of adenocarcinoma favored a simplified classification. Extension to the corpus in patients with early-stage disease was of independent significance and should be acknowledged in planning treatment.

Carcinoma of the cervical stump. The Radiumhemmet series 1959–1987. Treatment and prognosis

Carcinoma of the cervical stump. The Radiumhemmet series 1959–1987. Treatment and prognosis

Subtotal abdominal hysterectomy: a surgical advance or a backward step?

OBJECTIVE To review the short and medium term outcomes of subtotal abdominal hysterectomy. We also describe the management of cervical stump complications by vaginal trachelectomy or large loop excision of the transformation zone. Retrospective analysis. Warwick General Hospital, Warwickshire, UK. One hundred and fifty women underwent subtotal abdominal hysterectomy between 1993 and 1999. Five women had vaginal trachelectomy and another five had large loop excision of the transformation zone for complications relating to the cervical stump. The prevalence of intra-operative and early post-operative complications was 4% and 7.3%, respectively. Twenty women (13.3%) had late complications, of whom 17 (11%) presented with symptoms directly related to the stump (two had also genuine stress incontinence). Three presented with genuine stress incontinence alone. The commonest problem was regular menstruation, which occurred in 12 women (8%). Ten of these women underwent vaginal trachelectomy or large loop excision of the transformation zone. None had intra-operative or post-operative complications. The high prevalences of cervical stump problems should be taken into account before a change in surgical procedure from total to subtotal hysterectomy is recommended. Further prospective studies with prolonged follow up are needed to evaluate the risks and benefits of retaining the cervix at hysterectomy. Total hysterectomy, preferably by the vaginal route, remains the procedure of choice for most women. Should a problem develop, vaginal trachelectomy or large loop excision of the transformation zone by an experienced surgeon are the best options for these women.

Radical laparoscopic surgery for carcinoma of the cervical stump

Traditionally, most women with cervical stump cancer underwent radiation therapy, as radical surgery was considered difficult. Given our success performing laparoscopic-assisted radical vaginal hysterectomy, we modified that technique to treat two women with carcinoma of the cervical stump. At follow-up of 14 and 17 months, respectively, both patients were free of recurrence.

Disseminated leiomyomatosis and endometriosis following laparoscopic supracervical hysterectomy

Objective: To describe cases of disseminated leiomyomatosis and diffuse endometriosis following laparoscopic supracervical hysterectomies.Methods: Using an administrative hospital-based database, all cases of laparoscopic supracervical hysterectomies performed between 1992 and 1998 were identified. Any cases requiring subsequent pelvic surgery (laparoscopic or open technique) were reviewed.Results: A total of 146 laparoscopic hysterectomies were performed in this time period. The indications were symptomatic leiomyomata (83), endometriosis (29), or both (24). Other diagnoses were responsible for the remaining 10 cases. The mean age of the patient at the time of hysterectomy was 41. Seven patients had subsequent surgery: removal of cervical stump for low-grade endometrial stromal sarcoma (final pathology was negative) and recurrent pain (6 cases) (final pathology revealed disseminated leiomyomatosis, endometriosis [2], giant cell reaction, connective tissue, and incidental Brenner tumor). The mean time interval between surgeries was 39 months. Of those 7 cases, 4 were completed laparoscopically.Conclusions: Disseminated leiomyomatosis and diffuse endometriosis may occur following laparoscopic supracervical hysterectomy. Presumably small, even microscopic, fragments of smooth muscle or endometrium dispersed during morcellation can proliferate and ultimately result in pelvic pain and masses.