Journal of Gynecologic Surgery

Bladder dysfunction always occurs, to varying degrees, following radical hysterectomy. In Japan, various techniques for preserving the pelvic autonomic nerves in a radical hysterectomy have been used to reduce the severity of bladder dysfunction. The authors describe a newly developed technique for preserving the pelvic autonomic nerves and present the post-operative urodynamic findings in cases in which this technique was used. Preservation techniques can be broadly classified into three types: preservation of the pelvic parasympathetic nerves, preservation of the pelvic sympathetic nerves, and preservation of the nerves to the bladder. In this new technique, as many of the pelvic parasympathetic nerves as possible are preserved when the cardinal ligament is cut. Then, the cardinal ligament is inserted into and pulled through the anterocranially located connective tissue in front of the pelvic plexus, which lies below the ureter. Finally, as many as possible of the vesical branching nerves are preserved when the posterior layer of the vesicouterine ligament is cut. Between July 1996 and February 1999, 23 women were treated for Stage IB1-IIA cervical cancer, and two women were treated for Stage IIB endometrial cancer. The results of urodynamic studies performed ~1 month after surgery were all within normal ranges: mean duration of bladder drainage, 17.1 ± 6.4 days; mean maximal flow rate, 19.5 ± 12.9 ml/sec; mean postvoiding residual urine volume, 30.5 ± 25.8 ml; and mean maximal desire to void, 311.4 ± 124.0 ml. None of the patients required intermittent self-catheterization. It is concluded that this new technique for preservation of the pelvic autonomic nerves is effective in reducing the severity of bladder dysfunction after a radical hysterectomy and would therefore improve the patient's quality of life.

The goal of this study was to assess factors associated with the failure of abdominal colposacropexy. Between 1986 and 1997, 217 colposacropexies were performed (mean patient age 49.9 years ± 11.2; average follow-up 5.5 years, range 1-136 months). Synthetic mesh placement consisted of 182 anterior and posterior attachments, 9 anterior only and 26 posterior only. One hundred ninety-six procedures were performed using Mersilene as the graft material, 18 with Gore-Tex, and 3 with absorbable material. A total of 179 posterior colporraphies and 208 culdoplasties (Moschowitz's procedure) were performed. The anatomical and functional results for prolapse showed a treatment success rate of 97.7% (212/217). Fifty-eight percent (125/217) of the patients were totally continent in the long term (no postoperative incontinence). Eight-two percent (178/217) of patients were classified as having been successfully treated and/or having improved condition following the surgical procedure (postoperative incontinence was less important than preoperative incontinence). The incidence of recurrent prolapse was 1.1% (2/179) and 7.9% (3/38) for colposacropexy with or without posterior colporraphy, respectively (p = 0.009, odds ratio [OR] = 0.14, confidence interval [CI] = 0.02-0.86). The incidence of recurrent prolapse for colposacropexy with or without culdoplasty was 1.9% (4/208) and 11.1% (1/9), respectively (p = 0.04, OR = 0.17, CI = 0.02-1.58). The recurrence of urinary stress incontinence was 44.4% (4/9) in cases where the anterior mesh alone was attached and 15.4% (28/182) for cases of both anterior and posterior mesh attachment (p = 0.03, OR = 0.34, CI = 0.12-0.97). Rejected grafts were 16.7% (3/18) in Gore-Tex mesh and 1.1% in Mersilene mesh (p = 0.004). These results confirm that performing the full surgical procedure significantly reduces the risk of recurrence of vaginal vault prolapse and urinary stress incontinence.

Endometriosis is the presence of endometrium-like tissue outside the uterus. Ureteral involvement is rare and may result in a high rate of renal loss before it is recognized. Different treatment modalities are reported in the literature, including medical therapy and radical surgery. The authors report three cases of ureteral endometriosis with different clinical features. In one patient, bilateral distal ureterectomy and ureteroneocystostomy was performed, and the histopathologic diagnosis was consistent with intrinsic ureteral endometriosis. In the other two patients, surgical treatment consisted of endometrioma cyst excision, ureterectomy, and ureteroneocystostomy.

Primary ovarian pregnancy is a rare form of ectopic pregnancy in which the gestational sac is implanted in the ovary. Traditional treatment (ipsilateral oophorectomy) and conservative ovarian surgery (wedge resection) have been applied in the past. Currently, conservative therapy is an alternative to oophorectomy in patients desirous of having children in the future. The authors report their experiences with primary ovarian pregnancy treated by operative laparoscopy with different surgical procedures in order to preserve the good prognosis of fertility. Clinical presentation, sonographic findings, and different modes of treatment are also discussed.

Immature teratoma of the ovary is a rare entity in comparison with other ovarian cancers. The reported incidence is under 1%. The occurrence of this tumor with a coexisting pregnancy is exceedingly rare. Only a few scattered case reports are recorded in the world literature. A 30-year-old gravida 2 pregnant woman was referred for evaluation of painless bleeding at 28 weeks' gestation. Ultrasound examination revealed a normal fetus and no placental pathology. In addition, the presence of a large mixed echogenic mass in the left adnexa measuring 14 × 10 cm was noted. Ascites was absent. Doppler examination of the tumor showed a peripheral low resistance and poor vascular flow. Vaginal bleeding stopped on the second day, and the patient remained asymptomatic. Conservative management was decided upon, and an elective cesarian section was done at the 34th week. A 2430-g normal male infant was delivered, and a left salpingo-oophorectomy and surgical staging procedure were performed. Surgical stage was designated as FIGO stage Ia. Gross examination demonstrated a 340-g tumor with an intact capsule. Histologic evaluation indicated a high-grade immature ovarian teratoma with abundant nests of neuroepithelial tissue. The patient started postoperative chemotherapy consisting of six cycles of carboplatin and bleomycin on day 1 and etoposide on days 1 and 2. Surgical conservative treatment in these cases is discussed.

Nonpuerperal uterine inversion is an extremely rare gynecologic event. The vast majority of nonpuerperal inversions occur in association with a uterine tumor, of which approximately 20% are malignant. The case of a 74-year-old patient with suspected primary cervical sarcoma is presented. At the time of surgery, nonpuerperal uterine inversion was identified. High-grade endometrial stromal sarcoma was confirmed on pathologic examination. The etiologic factors that constitute the differential diagnosis are discussed, as well as strategies for managing this unusual entity.