Guidelines to determine the route of oophorectomy with hysterectomy

OBJECTIVES: Our purpose was to determine whether there is adequate visibility and access for transvaginal oophorectomy in most patients and the success rate of the transvaginal approach. The final goal was to establish objective guidelines for choosing the route of oophorectomy with hysterectomy. STUDY DESIGN: Patients underwent laparoscopy-assisted vaginal hysterectomy (n = 91) or vaginal hysterectomy (n = 875). Ovarian removal, either unilateral (n = 97) or bilateral (n = 187), was carried out for clinical or prophylactic reasons. The accessibility of the ovaries for transvaginal removal was assessed by stretching the infundibulopelvic ligament and grading the position of the ovaries from 0 (no descent) to III (descent past the hymenal ring with traction). RESULTS: In 158 patients transvaginal bilateral oophorectomy was performed without laparoscopic assistance. In another 29 patients bilateral transvaginal oophorectomy was performed with laparoscopy-assisted vaginal hysterectomy, and prophylactic bilateral oophorectomy by the transvaginal route was successful in all but 1 of 143 patients with ovaries of grade I or higher. In 20 patients laparoscopic lysis of adhesions was necessary to permit transvaginal oophorectomy. Ninety-seven patients underwent transvaginal unilateral oophorectomy, 74 with conventional vaginal hysterectomy and 23 with laparoscopy-assisted vaginal hysterectomy. Among the patients not having oophorectomy, all ovaries had sufficient mobility to have been removed transvaginally. CONCLUSION: Good surgical practice dictates that visibility and accessibility be the primary criteria for selecting the route of oophorectomy with hysterectomy. In most patients the ovaries are visible and accessible to transvaginal removal.     

A natural experiment on the effects of ovarian hormones on cardiovascular risk factors and stress reactivity: bilateral salpingo oophorectomy versus hysterectomy only

Indirect calorimetry is the method by which metabolic rate and substrate utilization are estimated in human beings starting from respiratory gas exchange measurements and urinary nitrogen excretion. This method is based on some models and assumptions that must be known and taken into consideration to correctly interpret the results obtained. Recent advances in technology and the availability of precise and portable metabolic carts have made this technique practical at the beside even in critically ill patients. It must be considered that, particularly in the ICU, there may be several sources of error and many technical difficulties in applying this methodology. Taking into account the relevant clinical studies related to the outcomes of critically ill patient, this article defines when the assessment of energy expenditure by indirect calorimetry may provide useful and valid information. Review of the literature suggests that the clinical application of indirect calorimetry in critically ill patients, although promising, requires further evaluation. Currently, the potential useful clinical applications of indirect calorimetry in this category of patients can be summarized as follows: (1) assessment of energy expenditure in patients who fail to adequately respond to the estimated nutritional needs; (2) assessment of energy expenditure in patients with single- or multiple-organ dysfunction who need prolonged ICU care and artificial nutritional support; (3) assessment of the effects induced by artificial nutrition on the cardiocirculatory and respiratory systems in mechanically ventilated patients with acute respiratory failure; and (4) monitoring of VO2 during weaning from mechanical ventilation.     

Vaginal endoscopic oophorectomy with vaginal hysterectomy: a simple minimal access surgery technique

The main advantage of laparoscopic assisted vaginal hysterectomy (LAVH) is ease of access to the ovaries; despite this, LAVH is infrequently performed due to the inherent difficulty of the technique. Lower morbidity, shorter length of surgery, reduced hospital stay and more rapid recovery are the main advantages of vaginal hysterectomy, but one of its limitations is the accessibility of the ovaries. Three methods of vaginal endoscopic oophorectomy following vaginal hysterectomy are described in this paper. Endoscopic vaginal oophorectomy was successfully performed during 82 cases of vaginal hysterectomy and the results show that the technique is simple, safe and easy to learn, and an alternative to laparotomy and LAVH in the absence of pelvic adhesions.     

Molecular pathology of ovarian carcinomas

Two patients with lysinuric protein intolerance (LPI) had near-fatal generalized varicella infection with severe interstitial pneumonitis, hepatitis, decreased platelet count, bleeding and hypoalbuminaemia. Active haemolysis resulted in anaemia and massive haemoglobinuria. Serum lactate dehydrogenase activity and ferritin concentration, which in patients with LPI in normal circumstances exceed the upper reference values 3-folds to 10-fold, increased to > 10,000 U/L and > 10,000 micrograms/L, respectively. The patients were treated with fresh frozen plasma, red-cell transfusions and intravenous acyclovir for 14 days, and recovered clinically in a month. Retrospectively, 3 of the 32 other known Finnish patients with LPI had had varicella infection that had been more severe than that in the other children in the family or in subjects in the neighbourhood and had led to hospital admission. Varicella antibodies were measured in 24 patients; 5 had no antibodies and 5 had very low antibody titres. Primary vaccination of three patients with living varicella vaccine increased antibody titres measurably in one patient. We suggest that patients with LPI who have no varicella zoster antibodies should be treated with acyclovir if exposed to varicella and should be (re)vaccinated against chickenpox.     

Normalization of the tumor marker CA-125 after oophorectomy in a patient with paraneoplastic cerebellar degeneration without detectable cancer

ADP-complexed Fe3+ has been used in various in vitro systems and in intact cells to induce lipid peroxidation. During studies on the effects of oxidative stress on lipid metabolism we observed a significant increase in de novo glycerolipid synthesis in Fe3+/ADP-treated rat hepatocytes as evidenced by increased [U-14C]glycerol incorporation. Here we show that this increase, largely due to enhanced triacylglycerol synthesis, is caused by ADP rather than Fe3+/ADP-induced oxidative stress. Hence, metabolic alterations due to treatment of intact cells by Fe3+/ADP must be interpreted with caution.     

Necrotizing colitis after total hysterectomy

After an uneventful hysterectomy for fibroids carried out in a woman of 48 years of age peritonitis developed on the 5th post-operative day. It was due to necrosing sigmoiditis which occurred in spite of normal bowel action having been resumed on the 3rd post-operative day. This is a rare but usually very severe post-operative complication. Immediate operation saved the patient but she had to have two further operative procedures.     

Gonadotrophins and prolactin rise after bilateral oophorectomy for benign conditions

The aim of this study was to analyse the changes in follicle stimulating hormone (FSH), luteinizing hormone (LH) and prolactin concentrations in the 3 months following oophorectomy in pre-menopausal women operated on for benign gynaecological conditions. Included in this analysis were 21 women (mean age 47 years, range 46-52) who underwent bilateral oophorectomy plus hysterectomy for fibroids or ovarian cysts. Plasma concentrations of FSH, LH and prolactin were measured before and on days 2, 4, 6, 14 and 30 after surgery; in 10 cases measurements were made on day 60, and in five cases on day 90 after surgery. Hormone concentrations were measured in duplicate daily samples, and immunoenzymatic assay kits were used for all the immunoassays. The FSH and LH concentrations increased constantly after surgery. Mean prolactin concentrations also increased from 12.1 ng/ml before surgery to 31.5 ng/ml on day 14 after bilateral oophorectomy, but decreased thereafter to 18.2 ng/ml on day 30, 10.9 ng/ml on day 60 and 6 ng/ml on day 90. In conclusion, transient (2-3 weeks) increased prolactin concentrations are observed after surgical castration.     

Bilateral femoral neuropathy after vaginal hysterectomy

A case of bilateral femoral neuropathy as a complication of vaginal hysterectomy is presented. A 45-year-old woman developed weakness of both quadriceps, absence of bilateral knee jerks, and numbness over bilateral anteromedial thighs and medial lower legs after a vaginal hysterectomy. Electromyographic examination revealed evidence of denervation in the bilateral quadriceps. A nerve conduction study showed prolonged distal latencies and markedly reduced amplitude of the compound muscle action potentials in bilateral femoral nerves. It is suggested that this complication is caused by a microvascular and/or local mechanical injury of the femoral nerve, which is compressed beneath the tough inguinal ligament in a sustained posture with the hip joint in an extreme abduction and external rotation position. The prognosis was excellent with almost complete recovery within 10 weeks. The complication may be preventable by minimizing operating time, changing the patient's posture, and limiting the degree of flexion, abduction, and external rotation of the hip.     

Laparoscopy for ovarian pathology in infancy and childhood

INTRODUCTION: Nonparasitic splenic cysts are a rare finding: they can be distinguished into true cysts (epidermoid or epithelial) cysts or false (pseudocysts), depending on the presence/absence of an inner epithelial lining. They are usually found during the second and third decade of life, although they can also appear during childhood. They grow bigger in children, becoming clinically apparent due to the symptoms of compression of adjacent structures. The diagnosis is radiological, made with ultrasonography (US) and computed tomography (CT). We report the US and CT patterns of splenic cysts to differentiate true from false cysts. MATERIAL AND METHODS: Our series consists of 5 patients, aged 5-17 years, all examined with US and CT; one of them was also submitted to plain abdominal radiography. Conventional CT was used in 2 cases and helical CT in the extant 3. RESULTS: All examinations yielded useful clinical informations. The only radiograph showed the rightward displacement of the gastric gas bubble US always identified the cyst and its pertinence to splenic parenchyma, although failing to assess the liquid/solid nature of a highly echogenic cyst in one case. CT confirmed the cystic nature of all masses and showed the lack of contrast enhancement of cyst walls and the presence of septa or parietal calcifications. DISCUSSION: Radiological examinations, particularly US and CT, can diagnose splenic cysts unquestionably, correctly defining the relationships with adjacent organs. CT is more sensitive than US in detecting septa or calcifications, which are definitely useful findings to distinguish true from false cysts, since internal septa are more frequent in true cysts while parietal calcifications are typical of pseudocysts. The final diagnosis, however, is made at histology.     

The effect of long-term oestradiol implantation on bone mineral density in postmenopausal women who have undergone hysterectomy and bilateral oophorectomy

Twelve women who had received oestradiol implantation on demand for at least 15 years following hysterectomy with bilateral oophorectomy, underwent bone densitometry of hip and spine. Bone mass of hip and spine was significantly elevated above that of both the age matched mean to a degree hitherto undocumented. This suggests that oestrogen in high doses or over a long period may produce a true anabolic effect on bone mass.     

The value of prophylactic antibiotics after vaginal hysterectomy

Prophylactic antibiotics were given postoperatively to a consecutive series of 74 patients who underwent vaginal hysterectomy. Antibiotics were administered in the immediate postoperative period. There was a highly significant decrease in febrile morbidity in the treated group compared to 190 control subjects having similar surgery but treated with antibiotics only on the appearance of fever and/or other signs of infection. There was a failure to relate the increased febrile morbidity in the control group to patient's age, menopausal state, type of catheterization, or to the type of operative procedure. The increased morbidity in the control group related only to the failure to use prophylactic antibiotics. The antibiotic-treated portion (58 per cent) of the control group had a longer period of hospitalization.     

Ectopic pregnancy after a laparoscopically-assisted vaginal hysterectomy

PURPOSE/METHODS: Rubinstein-Taybi syndrome is a constellation of clinical findings characterized by mental and motor retardation, broad thumbs and broad first toes, marked growth retardation, microcrania, typical facies, high-arched palate, and cryptorchidism in males. Ocular and adnexal abnormalities are quite common and include antimongoloid slant of the palpebral fissures, epicanthal folds, congenital obstruction of the lacrimal excretory system, ptosis, strabismus, and severe ametropia. Macrocornea, microophthalmos, colobomas of the iris and of the optic nerve head, congenital cataract, and optic nerve atrophy have also been described. Congenital glaucoma is a rare complication. We examined a patient with Rubinstein-Taybi syndrome with bilateral congenital glaucoma. RESULTS/CONCLUSIONS: Examination of this patient revealed bilateral antimongoloid slants of the palpebral fissures, and bilateral congenital glaucoma. Gonioscopic examination revealed the iris to be inserted flatly into the trabecular meshwork. This case emphasizes the importance of detailed, complete ocular examinations in patients with Rubinstein-Taybi syndrome, and also highlights the occurrence of ocular abnormalities rarely associated with this disease.     

Lipoprotein(a) and other lipids after oophorectomy and estrogen replacement therapy

We present a case report of uretero-acetabular fistula in a female complicating orthopaedic surgery of congenital coxal difformity. An ileal pedicle graft was used to replace the terminal ureter. The difficulty of such complication is to choose the best the rapeutic strategy between surgical and non surgical techniques. We review here the various urological armamentarium to affront such a rare and multifactorial complication.     

Pain mapping during minilaparoscopy in infertile patients without pathology

Multiple myeloma (MM) typically afflicts elderly patients with a median age of 65 years. However, while recently shown to provide superior outcome to standard treatment, high-dose therapy (HDT) has usually been limited to patients up to 65 years. Among 550 patients with MM and a minimum follow-up of 18 months, 49 aged >/=65 years were identified (median age, 67; range, 65 to 76 years). Their outcome was compared with 49 younger pair mates (median, 52; range, 37 to 64 years) selected among the remaining 501 younger patients (<65 years) matched for five previously recognized critical prognostic factors (cytogenetics, beta2-microglobulin, C-reactive protein, albumin, creatinine). Nearly one half had been treated for more than 1 year with standard therapy and about one third had refractory MM. All patients received high-dose melphalan-based therapy; 76% of the younger and 65% of the older group completed a second transplant (P =.3). Sufficient peripheral blood stem cells to support two HDT cycles (CD34 > 5 x 10(6)/kg) were available in 83% of younger and 73% of older patients (P =.2). After HDT, hematopoietic recovery to critical levels of granulocytes (>500/microL) and of platelets (>50,000/microL) proceeded at comparable rates among younger and older subjects with both first and second HDT. The frequency of extramedullary toxicities was comparable. Treatment-related mortality with the first HDT cycle was 2% in younger and 8% among older subjects, whereas no mortality was encountered with the second transplant procedure. Comparing younger/older subjects, median durations of event-free and overall survival were 2.8/1.5 years (P =.2) and 4.8/3.3 years (P =.4). Multivariate analysis showed pretransplant cytogenetics and beta2-microglobulin levels as critical prognostic features for both event-free and overall survival, whereas age was insignificant for both endpoints (P =.2/.8). Thus, age is not a biologically adverse parameter for patients with MM receiving high-dose melphalan-based therapy with peripheral blood stem cell support and, hence, should not constitute an exclusion criterion for participation in what appears to be superior therapy for symptomatic MM.     

Retained myoma after laparoscopic supracervical hysterectomy with morcellation

Leiomyoblastomas account for a small percentage of smooth muscle tumors of the stomach. Intraperitoneal bleeding is an unusual and unexpected presenting sign. We herein present a 43-year-old woman who was urgently operated on due to signs of collapse. A large hemorrhagic mass measuring 25 x 18 x 15 cm was found arising from the greater curvature of the stomach. A histologic examination demonstrated rounded and spindle cells, and rare mitoses were also seen. Although the number of mitoses was small, the lesion was nevertheless felt to be consistent with malignant leiomyoblastoma because of its large size. Three years later the patient is doing well with no evidence of tumor recurrence. We conclude that intraperitoneal bleeding due to leiomyoblastoma of the gastrointestinal tract is an extremely rare phenomenon and has been described only in a few reports, and only one other previous case presented with signs of collapse.     

Risk of hysterectomy after 1000 consecutive endometrial laser ablations

PURPOSE: Thyrotropin-releasing hormone (TRH), present in extra hypothalamic brain areas, has been proposed to have neuromodulatory functions and to be susceptible to change by electrical stimulation paradigms. We measured TRH concentrations of several brain areas during kindling development before its establishment and determined whether the changes detected in TRH levels were related to the behavioral stages of kindling, the number of stimulations required to reach these stages and, with the electrophysiological parameters characteristic of this paradigm (amygdaloid afterdischarge (AD) frequency, duration, and propagation). METHODS: Male Wistar rats were implanted stereotaxically with indwelling bipolar electrodes in the basolateral nucleus of the amygdala and with two stainless-steel electrodes epidurally in frontal cortex. Amygdaloid kindling was induced by daily electrical stimulation; AD frequency and duration were recorded and analyzed throughout the development of kindling. TRH was extracted from several regions and quantified by radioimmunoassay (RIA). RESULTS: Modifications in TRH concentrations were detected, depending on the region assayed, from stage II of kindling. A positive correlation was noted between the levels of TRH and the frequency and propagation of AD, but not with the number of stimulations. The rate of change in TRH concentration in relation to AD frequency or duration was highest in frontal cortex followed by hippocampus and amygdala. CONCLUSIONS: A graded response was noted in the increase in TRH concentration dependent on the increase of AD frequency and propagation. The rate of response correlated with the region's epileptogenic susceptibility.