Cyfra 211

Elevated levels of CYFRA 21-1 were initially detected in patients with squamous cell carcinoma of the lung. This led to their investigation in squamous cell carcinoma of the cervix. Elevated levels were found in 14 of controls, 35 of patients with stage Ib-IIa squamous cell carcinoma of the cervix and 64 of patients with stage IIb-IV squamous cell carcinoma of the cervix (Tsai et al, 1996). Although CYFRA 21-1 level was related to tumour stage and size in patients with cervical cancer (Bonfrer...

The fourcusp approach

The first cusp applies to most patients from the time of the first visit to the clinic when the surgeon imparts the probable diagnosis and discusses with the patient the plan of action to achieve staging and hopefully removal of the tumour. It is rare to feel totally confident that a tumour is incurable before surgery one may suspect it, but rarely can one know until the histology is confirmed and the staging completed. An honest appraisal of the possibilities is required, coupled with a plan...

Richard Smith Mark Bower

Unlike the rest of this book, this final chapter does not concern itself with practical surgical techniques instead it looks at the problems of communication between the patient and her gynaecological oncologist. Entire books have been devoted to this subject and it may seem presumptuous even to attempt to address this in a brief chapter. However, we feel that the bare bones of good communication are extremely simple and may be summed up as imparting the truth and nothing but the truth in a...

Aetiology and epidemiology

Urogenital fistulas may occur congenitally, but are most often acquired from obstetric, surgical, radiation and malignant causes. The same factors may be responsible for intestinogenital fistulas, although inflammatory bowel disease is an additional important aetiological factor here. In most developing countries over 90 of fistulas are of obstetric aetiology, whereas in the UK and USA over 70 follow pelvic surgery. The overwhelming proportion of obstetric fistulas in the developing world are...

Ca125

Cancer antigen 125 is an antigenic determinant on a high molecular weight glycoprotein recognized by the murine monoclonal antibody OC125, which was raised using an ovarian cancer cell line as an immunogen Bast et al 1981 . It is expressed by amnion and coelomic epithelium during fetal development. In the adult, it is found in structures derived from coelomic epithelium the mesothelial cells of the pleura, pericardium and peritoneum and in tubal, endometrial and endocervical epithelium....

Bibliography Colostomy

Loop Colostomy

Ceraldi CM, Rypins EB, Monahan M, Chang B, Sarfeh IJ 1993 Comparison of continuous single layer polypropylene anastomosis with double layer and stapled anastomoses in elective colon resections. Am J Surg 59 168-71. Curley SA, Allison DC, Smith DE, Doberneck RC 1988 Analysis of techniques and results in 347 consecutive colon anastomoses. Ann Surg 155 597-601. Gambee LP, Garnjobst W, Hardwick CE 1956 Ten years experience with a single layer anastomosis in colon surgery. Am J Surg 92 222-7....

Cone biopsy

Paracervical Clock

The cone biopsy, the removal of a cone-shaped portion of the cervix, has been performed by gynecologists for decades. Recently, the electrosurgical technique referred to as the loop electrosurgical excision procedure' LEEP or 'loop excision of the transformation zone' LETZ has gained popularity. It has several advantages over other methods such as laser, cryotherapy and scalpel excision these include less bleeding and discomfort, and the avoidance of general anesthesia, while still providing a...

Surgical management of trophoblastic disease

Internal Iliac Artery Newborn

J Richard Smith Michael Seckl Deborah CM Boyle Management of trophoblastic disease in the first instance involves evacuation of the uterus. This should always be done using a suction curette. In the presence of persistently elevated human chorionic gonadotrophin hCG levels or continuing problems with haemorrhage, further evacuation may be necessary. This should normally be discussed with a gestational trophoblastic disease centre because of the risk of perforation, haemorrhage or infection....

Il htx

Gastrostomy

Enteral feeding and drainage procedures Indications Gastrostomy tubes are useful for drainage and decompression of the stomach and the small bowel, if a prolonged ileus is anticipated. Patients with end-stage ovarian carcinoma and small bowel obstruction may benefit from palliative gastrostomy tube placement. Gastrostomy tubes may also be used for postoperative enteral nutrition. A needle jejunostomy can be used to provide enteral nutrition postoperatively. Tube jejunostomy is sometimes...

Crosssectional imaging

Uterine Carcinoma Mri

Modern pelvic imaging is largely achieved using the cross-sectional modalities of ultrasonography, computed tomography and magnetic resonance imaging. These techniques can all elegantly display pelvic anatomy but have different strengths and weaknesses for the evaluation of gynaecological malignancies. Imaging may be used at presentation for diagnosis, in the assessment of disease extent prior to operation, and postoperatively for residual or recurrent disease evaluation. Imaging is also...

Sp

There is a large and exophytic adenocarcinoma of the cervix. On this -weighted sagittal image there is direct extension through the posterior wall of the bladder, outlined by high-signal urine arrow . There is also extension into the vagina white arrows and into the rectum curved arrows . B, bladder Colour flow Doppler studies may give some information regarding tumour vascularity, but again there is considerable overlap between the flow characteristics of...

Radical abdominal hysterectomy

Suprapubic Cruciate Incision

J Richard Smith Deborah CM Boyle Giuseppe Del Priore Radical abdominal hysterectomy is designed to remove the uterus, cervix, upper third of the vagina, either part or the whole of the parametrium, and the uterosacral and vesicouterine ligaments. In addition, the common iliac, internal iliac, external iliac, obturator, hypogastric and presacral lymph nodes are also removed, as may be the paraaortic nodes. This operation is used for management of Stage IA2 and IB 1 and 2 tumors of the uterine...

Operative procedure

Virginal Introitus

The flap is dissected with the patient supine or in the lithotomy position. Skin islands may be designed in a wide variety of shapes and orientations as long as a significant portion of the skin and subcutaneous tissues are centered over the muscle. In most cases an elliptical skin island is oriented vertically over the muscle Figure 2 . For vaginal reconstruction, a more transversely oriented skin island may be designed above or below the level of the umbilicus, depending on the placement of...

Bibliography

Behcets Disease Colon From Staples

Cosin JA, Carter JR, Paley PJ et al 1997 A simplified method for detubularization in the construction of a continent ileocolic reservoir Miami pouch , Gynecol Oncol 64 436-41. Hartenbach EM, Saltzman AK, Carter JR et al 1995 Nonsurgical management strategies for the functional complications of ileocolonic continent urinary reservoirs, Gynecol Oncol 56 127-8. Kock NG, Nilson AE, Nilsson LO et al 1982 Urinary diversion via continent ileal reservoir clinical results in 12 patients, J Urol 128...

Anatomic considerations

Hypogastric Artery

The two hypogastric internal iliac arteries and the inferior mesenteric artery IMA together supply blood flow to the pelvis, including the buttocks, left colon, and terminal spinal cord. It is a near-absolute requirement that at least one of these three vessels be preserved. The IMA is frequently the least important source of pelvic blood flow every effort should be made, however, to preserve at least one hypogastric artery. Within these guidelines, essentially any other vessel can be ligated...

Postoperative management

Ureterovaginal Fistula

Nursing care of patients who have undergone urogenital fistula repair is of critical importance, and obsessional postoperative management may do much to secure success. As a corollary, however, poor nursing may easily undermine what has been achieved by the surgeon. Strict fluid balance must be kept, and an adequate daily fluid intake should be maintained until the urine is clear of blood. Haematuria is more persistent following abdominal surgery than vaginal procedures, and intravenous fluid...

I

Palliative procedures often have an important part to play in the management of the preterminal stages of this disease and are usually concerned with relieving the effects of intestinal obstruction. The most common of these procedures is the bypass of obstructive loops of small bowel, in which circumstance an ileocolic bypass anastomosis is to be favoured over heroic attempts at mass resection see Chapter 17 . The use of such palliative and salvage surgery can provide a great degree of...

Retrograde Hysterectomy Hudson

Purse String Anal Suture Dog Surgery

Whom U and M art iht ultrasound and menopausal scores, UItrasoLhnd was nssRsiifiri -for rtif fallowing features Suggestive 0f malignancy evidence of metastases presence of ascites A scars of 0 was giuun where nona of itiese was present t if one was present jnd a scofc of 3 lor two or more. A scorc uf 1 pr 3 was tfiven p pre- or postmenopausal patients respectively. An RM1 ol 200 had a sensitivity or 65 and a specificity of 97 for diagnosing ovarian cancel. The correct staging of ovarian cancer...

Indications

Psoas Hitch Boari Flap

In gynecology, most urinary diversions are performed as part of the reconstructive phase of a pelvic exenteration or because of severe irradiation injury to the bladder. The type of diversion employed depends on the surgeon's preference, the patient's overall health, the prognosis and the patient's ability to perform the tasks necessary to catheterize a continent pouch. The ileal conduit is the simplest diversion to perform. Care must be exercised in patients who have undergone radiotherapy as...

Laparoscopy

Appendix Ureter

This chapter describes the procedures of appendectomy, hysterectomy both standard and radical , omentectomy, palliative end colostomy and lymphadenectomy encompassing both para-aortic and pelvic lymph nodes . Whole textbooks have been devoted to laparoscopic surgery but in line with the 'cookbook' approach of this volume, we believe these procedures are more than adequately described in the following text. Since the first use of laparoscopy for appendectomy by Kurt Semms in Germany and Nezhat...

Operative technique

Anterior Posterior Vaginal Wall Repair

Two main types of closure technique are applied to the repair of urinary fistulas the classical saucerization technique described by Sims in 1852, and the much more commonly used dissection and repair in layers. Figures 3-7 demonstrate the latter form of repair in a posthysterectomy vault fistula. Tissue forceps or traction sutures are applied to bring the fistula more clearly into view, and obtain optimal access for repair. Infiltration with 1 in 200 000 adrenaline helps to reduce bleeding,...

V

Fossa Ovalis Inguinal Node

Most vulvar incisions can be approximated primarily. Skin grafts or rotational flaps may be indicated if there is inadequate mobilization to allow for a tension-free closure see Chapter 21 . Obliteration of resultant dead space is important, as well as the use of suction drainage. Superficial and deep inguinal lymph node dissection For the superficial node dissection, groin incisions are first introduced 1-2 cm below Poupart's ligament. The superficial inguinal fat pad is then removed,...

Radical Hysterectomy

Pelvic Lymphadenectomy Ovarian Cancer

NS Not stated CLS Capillary-like space NS Not stated CLS Capillary-like space published relating to extracervical spread of microinvasive tumours, suggesting that the majority will be adequately managed by conization. Most gynaecologic oncologists would qualify this, depending on whether lymphovascular permeation was present. If it was, they might proceed to a radical hysterectomy and pelvic lymphadenectomy. As can be seen from the table, this practice is not based strictly on evidence. It...

Surgery

Paraaortic Anatomy Gynecologic Oncology

The procedure of pelvic exenteration was first described in its present form by Brunschwig in 1948. Over the years it has been used mainly in the treatment of advanced and recurrent carcinoma of the cervix. Its primary role at the present time is the management of the numerous patients who develop recurrent cancer of the cervix following primary radiotherapeutic treatment. It has been estimated that between one third and one half of patients with invasive carcinoma of the cervix will have...

W

A stapler is used to transect the round ligament, ovarian ligament and fallopian tube A stapler is used to transect the round ligament, ovarian ligament and fallopian tube The anterior leaf of the broad ligament is dissected Omentum frequently is involved with metastatic lesions whenever there is intra-abdominal spread of cancer. Omentectomy is part of the staging of ovarian cancer and is often performed in treating or staging other gynecologic cancers such as uterine papillary serous...

Interventional techniques in gynaecological malignancy

Ganglion Impar Junction

Where standard routes of analgesic administration have failed, the epidural route using a percutaneous epidural catheter can provide optimal analgesia. The benefits of opioid administration by the spinal route have been acknowledged for some time and there is clear evidence that some patients find epidural analgesia of a higher quality with a diminished incidence of unwanted side effects such as nausea, drowsiness and constipation. Epidural catheters can be inserted percutaneously and brought...

Info

Vaginismus Probe

Right-angle clamps are applied to the vagina far enough caudally to allow removal of the upper third of the vagina Figure 25 . As described above in cases of Stage 2a tumor, the vagina may have been marked with diathermy at the start of the procedure to ensure adequate resection margins are obtained. The vagina is then incised and the uterus with parametrium and upper vagina is then removed. The upper edges of the vagina may be oversewn circumferentially with a locked-on suture to achieve...

Radical vaginal trachelectomy

Trachelectomie Met Cerclage

Radical vaginal trachelectomy RVT is a new conservative surgical procedure for the treatment of selected cases of early-stage cervical cancer. It has the advantage of preserving the uterine body, which in turns allows the preservation of childbearing potential. This procedure has been described by Professor Daniel Dargent from Lyon, France. Among the group of more than a hundred women who have undergone this operation, more than 20 healthy babies have been born so far, the majority by elective...

Sigmoidoscopy cystoscopy and stenting

Flexible Sigmoidoscopy With Biopsy

Sigmoidoscopy forms part of the routine examination of patients who complain of colorectal symptoms. Patients presenting with rectal bleeding or a change in bowel habit should undergo either a rigid Sigmoidoscopy followed by a barium enema, or a colonoscopy. In addition, patients presenting with vulval carcinoma extending to the perineum should have anal and rectal assessment. Flexible Sigmoidoscopy can be used to confirm lesions in the distal colon and rectum, to obtain material, and in the...

Radical vaginal hysterectomy

Ureter Injury Uterine Artery

The vaginal approach was first used when surgeons considered treating cancers of the cervix in ways other than by cauterization or similar palliative tools Recamier 1829 . However, at the turn of the nineteenth century the abdominal approach became prevalent, as a consequence of two simultaneous changes. First, even if it was more risky than vaginal surgery, abdominal surgery was no longer a death sentence. Second, the concept of radical surgery, introduced by Halsted in the field of breast...

Bowel surgery

Partial Colectomy Blood Supply

The intestine is vulnerable to injury and obstruction as a result of involvement by gynecologic malignancies. Intestinal injury may also complicate the successful surgical or radiotherapeutic treatment of these diseases. This chapter focuses on common surgical procedures performed by gynecologic oncologists on the gastrointestinal tract during the management of gynecologic malignancies. Small bowel resection is often necessary to remove obstructed, perforated or tumor-infiltrated intestine....

Inferior Gluteal Artery

Inferior Mesenteric Circumflex Iliac

2 Superficial epigastric artery 3 Superficial circumflex iliac artery extended arm. During vaginal procedures, an assistant unfamiliar with the course of the femoral nerve might rest an arm on the patient's medial anterior thigh and compress the femoral nerve. This nerve may also be injured by an abdominal retractor placed too deeply over the psoas muscle. Finally, some of the smaller nerves, such as the genital femoral nerve, may be transected during the removal of suspicious lymph nodes....

Radical vulvar surgery

Groin Labia Majora

Radical vulvectomy and groin node dissection have been the standard treatment for cancer of the vulva since 1912 when this procedure was first described by Basset. Because carcinoma of the vulva is rare, accounting for only 0.4 of all cancers in women, scientific comparisons of variations on this operation have often been limited by studies with small or heterogeneous samples. Traditionally, an en bloc radical resection of the entire vulva and bilateral inguinal nodes through the trapezoid or...

Anatomy

Pararectal Space Hypogastric Fascia

Werner Lichtenegger Giuseppe Del Priore Physicians are familiar with general human anatomy and expert in their own regions of specialization. Since gynecologic oncologists are often called upon to perform unique and sometimes infrequent procedures in a variety of regions, a review of the different anatomic areas can be helpful. Of course, gynecologic oncologists will usually be operating in the pelvis or called upon as a consultant to other pelvic surgeons. Therefore, a detailed understanding...