Chapter 39 Gynecology
Principles of Surgery Companion Handbook
|Vulvar and Vaginal Infections|
|Pelvic Inflammatory Disease|
|Pelvic Support Defects|
External Genitalia (Vulva)
The vulva is bounded by the symphysis pubis anteriorly, the anal sphincter posteriorly, and the ischial tuberosities laterally. The labia majora form the cutaneous boundaries of the lateral vulva and represent the
Musculature of the Pelvic Floor
The levator ani muscles form the muscular floor of the pelvis. These muscles include, from anterior to posterior, bilaterally, the pubococcygeus, puborectalis, iliococcygeus, and coccygeus muscles. Distal or caudad to the levator ani muscles, or levator sling, are the superficial
The uterus and cervix are suspended by the cardinal, or Mackenrodt's, ligaments, which insert into the paracervical fascia and into the muscular sidewalls of the pelvis laterally. Posteriorly, the uterosacral ligaments support for the vagina and cervix and insert into the paracervical or endopelvic fascia. The fallopian tubes arise from the cornua of the uterus. Each widens in the distal third, or ampulla. The ovaries are attached to the cornu by the ovarian ligaments. These fibrous bands are analogous to the gubernaculum testis in the male and continue from the uterus as the round ligaments. These structures exit the pelvis through the internal inguinal ring and course through the inguinal canal and external inguinal ring to the
The peritoneal recesses in the pelvis anterior and posterior to the uterus are referred to as the anterior and posterior cul de sacs. The latter is also called the pouch or cul de sac of Douglas.
Several avascular and therefore important surgical planes can be identified. These include the lateral paravesical and pararectal spaces and the prevesical space of Retzius and presacral spaces.
The muscles of the pelvic sidewall include the iliacus, the psoas, and the obturator internus. The blood supply arises from the internal iliac arteries, except for the middle sacral artery, which originates at the
The gynecologic history should include the patient's age, date of her last menstrual period (LMP), the number of pregnancies, the number of deliveries, and the number of abortions. Gravidity, parity, and abortions are frequently indicated as G-P-A. The
The initial evaluation should include a general physical examination and a description of the patient's height, weight, nutritional status, blood pressure, head and neck, including
Cervical cytology (Pap smear) should be performed beginning at 18 years of age or sooner if the patient is sexually active. Most women should have a cervical cytologic evaluation yearly at the time of their annual pelvic examination. After total hysterectomy, the Pap smear should be obtained annually in patients treated for cervical neoplasia. After hysterectomy for conditions that did not include cervical neoplasia, the vaginal apex may be screened cytologically every 3–5
TABLE 39-1 THE BETHESDA CLASSIFICATION FOR THE CLASSIFICATION OF PAP SMEAR ABNORMALITIES
FIGURE 39-1 The management of abnormal cytologic findings.
Office Tissue Biopsy
Biopsy of suspicious lesions of the vulva, vagina, cervix, and uterus should be obtained in the office. Vulvar biopsy is obtained by infiltrating the biopsy site with a small amount of 1% lidocaine. Adequate biopsies can be obtained using a dermatologic skin punch. Biopsy of the ectocervix does not require anesthesia. Specialized cervical biopsy punches, such as the Kevorkian or Tischler type, are used. The endocervical canal should be sampled with an endocervical curette such as the Kevorkian. Biopsy of the endometrial
Vaginal and cervical cultures are most useful for the detection of sexually transmitted disease. Gonorrhea is cultured on a chocolate agar plate. Cultures are most conveniently collected on a Thayer-Martin medium. Chlamydial infection is suggested by the finding of a characteristic thick yellow mucus (mucopus). Mucopus should be collected with a calcium alginate–tipped swab in transport medium
Pregnancy Tests A number of pregnancy tests are available for use in the office. These tests measure increased amounts of the beta subunit of human chorionic gonadotropin (hCG) in urine. These urine tests are very sensitive and specific, measuring hCG as low as 50 mIU/mL. Serum tests are even more accurate and sensitive, and they have the advantage that they can be quantitated to give an hCG level.
After the first menstrual period (menarche), cyclic bleeding is
Bleeding Associated with Pregnancy
The availability of extremely sensitive pregnancy tests has made it possible to confirm pregnancy in the early days of gestation. Although bleeding can occur in up to 25 percent of all normally pregnant women, this symptom must be considered a threatened abortion until the bleeding is
Ectopic pregnancy must be considered in any patient with a positive pregnancy test, pelvic pain, and abnormal uterine bleeding. Approximately 20 percent of patients with ectopic pregnancy have no bleeding. Gestational trophoblastic disease also causes abnormal bleeding associated with a positive pregnancy test. Molar pregnancy is suggested when the uterus is larger than would be expected from the history of gestation, vaginal bleeding, and the passage of grapelike tissue from the vagina. Gestational trophoblastic disease must be differentiated from normal pregnancy.
Dysfunctional Uterine Bleeding
This type of bleeding abnormality is characterized by irregular menses with
The bleeding associated with genital trauma may be secondary to rape or genital
Bleeding Secondary to Neoplasm
Tumors, both benign and malignant, involving the genital
Bleeding from Infection Bleeding is an uncommon symptom of pelvic inflammation.
Bleeding of Nongenital
Pelvic and abdominal pain is a common gynecologic complaint. Pain associated with menses is the most common office complaint. Cyclic pain limited to that period is referred to as dysmenorrhea. Pain occurring without a demonstrable pathologic lesion is referred to as primary dysmenorrhea. Secondary dysmenorrhea is commonly associated with endometriosis, cervical stenosis, and pelvic inflammation. Acute pain may have its origin in abnormal pregnancy, benign or malignant neoplasia, or a variety of nongynecologic diseases. Pregnancy disorders include threatened abortion, inevitable abortion, incomplete abortion, and ectopic pregnancy.
Neoplasms cause acute pain through degeneration of a myoma or torsion of a myoma or ovarian neoplasm. The
Bilateral low abdominal pain increased by movement of the cervix most often indicates acute pelvic inflammatory disease. Right abdominal pain with a history of
The finding of a pelvic tumor is a common event in reproductive-age women. Pregnancy should be considered in all cases of uterine
Vulvar, perineal, and perianal itching and burning are symptoms that may indicate an inflammatory condition.
The most common cause of vulvar pruritus is candidal vulvovaginitis. This is common in patients who are diabetic, pregnant, or on antibiotics. The majority of cases are caused by
Diagnosis is confirmed by characteristic pseudomycelia. The condition is treated by topical application of any one of a number of imidazole
Pin worms (
), which are common in young
Bacterial Infections Many bacteria attack the vulvovaginal region. The streptococci and staphylococci are the most common offenders. Gardnerella vaginalis is the most common bacterial pathogen. The patient complains of a foul, fishy, or dead mouse odor. Diagnosis is made by microscopic study to identify characteristic clue cells. The condition is treated with metronidazole 500 mg orally every 12 h for 1 week.
A number of viral infections affect the vulva and vagina, the most common of these being condyloma acuminatum. The causative organism is the human papillomavirus. Treatment depends on the destruction of the lesions with caustic
Herpes simplex infection causes painful vesicles followed by ulceration of the vulva, vagina, or cervix. Culture is
Molluscum contagiosum causes groups of small pruritic nodules with an umbilicated center. The lesions are treated by ablation.
While pelvic inflammatory disease is basically a medical problem, it has profound surgical implications. This condition could be responsible for over a hundred thousand surgical procedures annually. The condition might produce infertility in 10 percent of the cases that occur; 3 percent or more of patients will have ectopic pregnancy, and chronic pain is a problem in many others. Pelvic inflammatory disease is largely limited to sexually active females. Pelvic inflammatory disease is
Patients with evidence of peritonitis, high fever, or suspected tuboovarian abscess should be admitted to the hospital for observation and intravenous antibiotics. Some specialists believe that all women with pelvic inflammatory disease should be admitted to the hospital for more
Follow-up of patients treated on an ambulatory basis should be carried out within 48–72 h. If there is no improvement in the patient, she should be admitted for intravenous antibiotics. Recommendations from the Centers for Disease Control and Prevention for inpatient treatment include cefoxitin 2.0 g intravenously every 6 h plus a loading dose of gentamicin 2.0 mg/kg intravenously, followed by a maintenance dose of 1.5 mg/kg intravenously every 8 h. Doxycycline 100 mg orally twice daily is given after the patient is discharged from the hospital to complete a total of 10–14 days of therapy. An alternative regimen is clindamycin 900 mg intravenously every 8 h plus a loading dose of gentamicin 2.0 mg/kg intravenously, followed by a maintenance dose of 1.5 mg/kg intravenously every 8 h. Some patients may require surgery for persistent abscess or chronic pelvic pain.
Surgery becomes necessary under the following conditions: (1) the intraperitoneal rupture of a tuboovarian abscess, (2) the persistence of a pelvic abscess despite antibiotic therapy, and (3) chronic pelvic pain. At one time, total abdominal hysterectomy with bilateral salpingo-oophorectomy was considered the procedure of choice. Good antibiotics and a better understanding of the pathophysiology of the disease allow less
Endometriosis is one of the most common conditions
Many patients are asymptomatic even with widespread endometriosis; others have severe pain, particularly dysmenorrhea, and dyspareunia. Infertility and abnormal bleeding are common problems.
The finding of a pelvic mass and tender nodularity of the uterosacral ligament strongly suggests endometriosis. The mass usually represents an ovarian endometrioma, often referred to as a chocolate cyst. Endometriomas are found in approximately a third of women with endometriosis and are often bilateral. Although endometriosis may be suspected on the basis of clinical findings, definitive diagnosis is made laparoscopically. Medical management of this condition should not be started without a confirmed diagnosis.
Choices of treatment include expectant management only, medical management, and surgery. Asymptomatic patients can be cared for through simple observation and management with cyclic oral contraceptives and simple analgesia. Pseudomenopause is currently the most common medical treatment for endometriosis. The most common medications used today for this purpose are the gonadotropin-releasing hormone agonists (GnRH-a). They can be given by depot injection or daily nasal spray. Because bone loss is also a result of hypoestrogenism, it is recommended that the treatment not be
Conservative surgical therapy for endometriosis has become much more common with the advancement of laparoscopic surgery. Superficial endometrial implants can be ablated with electrocautery or laser, and ovarian endometriomas can be removed. Ovarian endometriomas deserve special consideration. These chocolate cysts cannot be treated effectively medically. Even large endometriomas can be drained and the cyst
Women in the reproductive age group have an increased risk of ectopic pregnancy as they age. A history of salpingitis is common in women with ectopic pregnancy. Sterilization protects against ectopic pregnancy, but when sterilization
The most helpful laboratory examination is measurement of the beta subunit of hCG (
-hCG). Pelvic ultrasonography, particularly when performed with a vaginal transducer, is proving important in
The laparoscope has been an important diagnostic tool for the last several decades, but only recently has it become the standard approach for treatment. Linear salpingostomy is the treatment of choice for ectopic pregnancies less than 4 cm in diameter that occur in the distal third (ampullary) segment of the tube. Closing the tube is not necessary because the tube
A relatively new approach to ectopic pregnancy is the use of methotrexate. Conservative criteria for treatment of ectopic pregnancy with methotrexate include serum
-hCG levels less than 3500 IU/L and vaginal ultrasound that reveals the tubal pregnancy to be less that 3.5 cm in diameter with no visible fetal
Pelvic support defects include uterine prolapse, cystocele, rectocele, enterocele, urethral detachment, and posthysterectomy vaginal prolapse. Pelvic support defects may be produced by obstetric injury, conditions that increase abdominal pressure, obesity, decreased estrogen levels, and inherent tissue weakness secondary to genetic or nutritional factors.
Uterine Prolapse Uterine prolapse is abnormal descent of the uterus relative to the bony pelvis and vagina. If the entire uterus prolapses through the introitus, the condition is considered a total prolapse; otherwise, it is partial.
Cystocele and Rectocele
These conditions are due to herniation of the bladder and the
An enterocele, herniation of intraperitoneal organs generally at the vaginal apex, most often
Urethral Detachment At one time, urethral detachment was called urethrocele. In most cases, the urethrocele coexists with a cystocele.
Stress Urinary Incontinence Urinary incontinence affects almost 40 percent of all women over 60 years of age and is a common problem for younger women. Before considering operation, the patient should be evaluated with a cystometrogram.
Minor asymptomatic support defects may be treated expectantly or by pubococcygeal exercises. Pubococcygeal exercises involve contracting and
By definition, a
Follicular Cysts These are unruptured, enlarged graafian follicles.
Endometriomas These account for most chocolate cysts and are cystic forms of endometriosis of the ovary.
Wolffian Duct Remnants These are not ovarian cysts. They are small, unilocular cysts. In most instances, they are incidental findings.
Serous cystadenomas appear as cysts within translucent walls containing clear fluid and lined by simple ciliated epithelium. They are adequately treated by simple salpingo-oophorectomy. Some cystadenomas are classified as borderline tumors or adenocarcinomas of low malignant potential. These (grade 0) carcinomas usually are associated with an
Brenner Tumor These are rare epithelial tumors that usually do not secrete hormones. Histologically, the epithelial elements are similar to Walthard rests and are believed to arise from these. Simple oophorectomy is usually sufficient therapy.
Meig's Syndrome This pertains to ascites with hydrothorax, seen in association with benign ovarian tumors with fibrous elements, usually fibromas. Meig's syndrome can be cured by excising the fibroma.
Granulosa Cell–Theca Cell Tumor
Pure theca cell tumors (thecomas) are benign, but those with granulosa cell elements may be malignant. Usually, granulosa cell tumors elaborate estrogen; these tumors have no hormone production. In young girls they are characteristically manifested by isosexual precocity, and in elderly women they are sometimes associated with endometrial
Sertoli–Leydig Cell Tumors (Arrhenoblastomas)
These rare but
Struma Ovarii This refers to the presence of grossly detectable thyroid tissue in the ovary, usually as the predominant element in dermoid cysts. This tissue occasionally may produce the clinical picture of hyperthyroidism.
Leiomyomas Uterine leiomyomas are the most common benign tumor in the female pelvis. It is estimated that up to 50 percent of all women at some time in their life have one or more of these uterine tumors. Many leiomyomas are asymptomatic; when they do produce symptoms, they cause pain, abnormal uterine bleeding, infertility, ureteral obstruction, bladder distortion, and pressure symptoms secondary to the enlarged uterus. Uterine leiomyomas are subject to a number of degenerative changes, including calcification, necrosis, and fatty degeneration. Malignant degeneration occurs in less than 1 percent of all tumors.
Treatment Most symptomatic tumors can be managed expectantly. When symptoms indicate surgical treatment, surgery should be fitted to the needs and desires of the patient. Therapeutic options might include myomectomy, total abdominal hysterectomy, or transvaginal hysterectomy.
Adenomyosis Adenomyosis is a growth of endometrial tissue in the myometrium of the uterus and is sometimes referred to as endometriosis of the uterine corpus. The condition occurs during reproductive years and leads to a thickening of the myometrial wall.
A polyp is a local hyperplastic growth of endometrial tissue that usually causes postmenstrual or postmenopausal bleeding or staining, which is cured by polyp removal or curettage. The polyps are usually benign, but cases of adenocarcinoma of the endometrium arising in a polyp have been
Cervical Lesions Cervical polyps cause the same symptoms as endometrial polyps. They often can be removed as an outpatient procedure followed by cauterization of the base of the polyp. Nabothian cysts are mucous inclusion cysts of the cervix. They are harmless, usually asymptomatic, and generally do not require surgery.
Ovarian Carcinoma Ovarian carcinomas are divided histologically into epithelial, germ cell, and stromal malignancies. The majority of the 26,700 or more cases of ovarian cancer diagnosed annually in the United States are of the epithelial type. The median age at diagnosis for epithelial ovarian cancer is 61 years, and the overall 5-year survival rate for epithelial cancers is 37 percent.
Although the etiology of ovarian cancer is
The FIGO (International Federation of Gynecology and Obstetrics) staging system for ovarian cancer is outlined in Table 39-2. Efforts to establish other
TABLE 39-2 FIGO (1986) STAGING SYSTEM FOR OVARIAN CANCER
Treatment Therapy for epithelial ovarian cancer consists of surgical resection and appropriate staging followed by chemotherapy. Women with low-grade early-stage (IA or IB) cancers may be treated with surgery without adjuvant therapy. In all other patients (stage IA, grade 3, and stage IB and above), appropriate initial surgery includes bilateral salpingo-oophorectomy, abdominal hysterectomy if the uterus has not been removed on a prior occasion, appropriate staging, and tumor resection.
Staging indicates surgical resection or biopsy of all potential areas of tumor spread. Among patients whose cancer is confined to one or both ovaries at the time of gross inspection, occult metastases can be identified by careful surgical staging in one-third. Epithelial ovarian cancers disseminate along peritoneal surfaces and by lymphatic channels. The
have been introduced to indicate
Second Look Operations
Second Look Laparotomy
Ovarian cancer often defies diagnosis because it does not produce symptoms and is detectable
Second look surgery is currently used primarily as a research tool. New treatment regimens can be evaluated quickly by performing a second look operation. Second look laparotomy is performed through a midline abdominal incision. Peritoneal washings are obtained from both abdominal gutters, the diaphragms, and the pelvis. Since persistent cancer is most likely to be identified in sites where there was tumor at the conclusion of the primary operation, these areas are explored first.
Other Secondary Operations
Surgical resection of tumor after chemotherapy or at the time of
Palliative Surgery In most cases of advanced ovarian cancer, death is associated with bowel dysfunction or frank obstruction. When bowel obstruction occurs early on in the clinical course of ovarian cancer, and particularly if it occurs before the administration of chemotherapy, surgical intervention is warranted and should be aggressive. When bowel obstruction occurs after chemotherapy, the prognosis is unfavorable. Surgery is often difficult to perform because of extensive tumor. Laparotomy may be complicated by enteric injury or fistula. Often the best approach in these patients is the use of a percutaneous or endoscopically positioned gastrostomy tube and intravenous fluids or conservative nutritional support.
Laparoscopy in Ovarian Cancer
At present, our ability to resect large ovarian cancers successfully using laparoscopic equipment is limited. With the
Tumors of Low Malignant Potential
These are epithelial tumors of malignant potential intermediate between benign lesions and frank malignancies. Most are of the serous type. They are distinguished from invasive cancers microscopically by the lack of stromal invasion. The median age of diagnosis is approximately 10 years younger than that of patients with epithelial cancers. The vast majority occur in stage I. Surgery should include abdominal hysterectomy and bilateral salpingo-oophorectomy unless fertility is to be preserved in patients with unilateral lesions. These patients may undergo unilateral salpingo-oophorectomy. Patients with stage III and IV lesions have 5-year survival rates that approach 85 percent after complete surgical resection. There is little evidence that either chemotherapy or radiotherapy
Germ Cell Tumors
These tumors occur in women in the first three decades of life and typically grow
The other germ cell tumors in order of frequency are immature teratoma, endodermal sinus or yolk sac tumor, mixed tumors, embryonal carcinomas, and choriocarcinomas. The first may be associated with elevated levels of alpha-fetoprotein (AFP). Elevated AFP levels are found in all patients with endodermal sinus tumors and mixed tumors that contain this component. Embryonal carcinomas are associated with abnormal levels of both AFP and hCG, and choriocarcinomas secrete hCG. These tumors are invariably unilateral. Except for those with completely resected stage I, grade 1 immature teratomas and those with stage I dysgerminoma, all patients with germ cell tumors require systemic chemotherapy. Three courses of a
CARCINOMA OF THE CERVIX
Carcinoma of the cervix accounts for about 16,000 cases and 5000 deaths annually in the United States. Risk factors include multiple sexual
Cervical cancers spread predominantly by lymphatic channels. The first lymph nodes involved are the paracervical or parametrial area. The supraclavicular lymph nodes are the most common site of distant nodal metastases. FIGO staging for cervical cancer is based on clinical examination, intravenous pyelography, and chest radiography. The FIGO staging system is
TABLE 39-3 FIGO STAGING SYSTEM FOR CERVICAL CANCER
Intraepithelial or Preinvasive Disease
Abnormal Pap smears must be evaluated by colposcopy and biopsy. Colposcopy is examination of the cervix with a low-power (10–50) microscope after application of dilute acetic acid to the cervix. The acid solution is mucolytic and serves to desiccate the epithelium, a process that
More conservative methods of
Microinvasive Cervical Cancer Simple hysterectomy is adequate therapy. In some, cone biopsy and excision may be used, provided close surveillance is possible.
Early Invasive Cervical Cancer (Stage IB and IIA)
Stage IB and IIA tumors are associated with a risk of pelvic lymph node metastases of 10–15 percent and a risk of spread to the paraaortic nodes of about 5 percent. Radical hysterectomy with pelvic lymphadenectomy or definitive radiotherapy is effective treatment in this stage cancer. Women with stage IB
cervical cancers (
lesions and early stage IIA cancers may be treated successfully with radical hysterectomy and pelvic lymphadenectomy. Because early cervical cancer so rarely
Locally Advanced Carcinoma of the Cervix (Stages IIB to IVA) These cancers are treated primarily with radiotherapy. Treatment consists of a combination of external therapy to the pelvis (teletherapy) from a high-energy source such as a linear accelerator and a local dose delivered to the cervix and parametrial tissue (brachytherapy) using a cesium applicator such as a Fletcher-Suite tandem and ovoids.
The finding of metastases in the common iliac or paraaortic chain indicates the need for extended-field radiotherapy encompassing these areas in addition to the pelvis. Even with such therapy, 5-year survival rates are low, seldom exceeding 20 percent.
Recurrent Cervical Cancer
As a rule, patients who develop local recurrences after preliminary surgical therapy are treated most effectively with external- and internal-beam radiotherapy. Although those with lymph node failures may not be curable in this setting, those with vaginal recurrences often can be saved with such an approach. Women who develop recurrent cancer following primary radiotherapy are generally not candidates for curative therapy. If, however, the recurrent lesion is small, the interval to failure is a year or more, and the lesion is unaccompanied by symptoms such as back or leg pain or edema, surgical resection may be possible. Most gynecologic oncologists prefer to perform pelvic exenteration in such circumstances. Often, an anterior exenteration with en bloc removal of the bladder, cervix, uterus, and upper vagina is
In general, about half the patients thought to be candidates for pelvic exenteration are found to have intraperitoneal spread or nodal metastases at the time of exploratory laparotomy and, in most centers, do not undergo resection. Of the remaining patients in whom surgery is possible, 30–50 percent will develop a second, nearly always fatal recurrence after surgery.
Endometrial cancer is the most common female genital malignancy, accounting for 34,000 cases annually in the United States. It is a highly treatable cancer, and only 6000 deaths are reported each year.
Risk factors for endometrial cancer include obesity, diabetes mellitus, hypertension, low parity, early menarche, and late menopause. Excessive exposure to estrogens is implicated in the genesis of endometrial cancer and its precursor, endometrial hyperplasia. Women who take estrogens in the menopausal years are known to have a sixfold increase in the risk of endometrial cancer if progestational agents are not taken as well. There is also an increase in the incidence of endometrial lesions in women with a history of chronic anovulation (Stein-Leventhal syndrome) and in those with estrogen-producing ovarian stromal neoplasms such as granulosa cell tumors. Endometrial hyperplasia may be divided into simple and complex, depending on the microscopic architecture, and into those with or without atypia. Atypical complex hyperplasias are most likely to give rise to frank adenocarcinomas. Simple hysterectomy is the preferred method of treatment for the hyperplasias. In women with underlying health problems that preclude surgical therapy, therapy with progestational agents such as megestrol or medroxyprogesterone acetate may be used with success.
Treatment Endometrial cancer is staged according to the FIGO criteria detailed in Table 39-4. Pelvic lymph node metastases occur in about 12 percent of patients with endometrial cancer apparently confined to the uterus.
TABLE 39-4 FIGO (1988) STAGING SYSTEM FOR ENDOMETRIAL CANCER
Risk factors associated with lymph node spread include high histologic grade (grade 2 or 3), low levels of progesterone receptor, deep myometrial or lymphatic channel invasion, spread to the adnexa, endocervical extension, and unusual histologic variants such as papillary serous or clear cell carcinomas.
Vaginal hysterectomy is occasionally useful in patients with early endometrial cancer when lymph node metastases are thought to be
Vulvar cancer accounts for about 5 percent of all gynecologic cancers. Although uncommon histologic types such as malignant melanoma and adenocarcinoma of the Bartholin's gland occur, over 90 percent of vulvar malignancies are squamous carcinomas. Epidemiologic risk factors include older age, smoking, previous intraepithelial or invasive squamous cancer of the cervix or vagina, chronic vulvar dystrophy, and immunocompromise. Human papillomavirus-like DNA has been identified in both preinvasive and invasive squamous carcinomas of the vulva. It is likely that the human papillomavirus plays an important role. Spread of squamous carcinoma of the vulva is primarily via the lymphatics of the vulva.
The 1988 FIGO staging system for vulvar cancer (Table 39-5) is currently accepted. This system requires surgical evaluation of the inguinal lymph nodes and provides a schema in which prognosis and therapy are closely linked with stage.
TABLE 39-5 FIGO STAGING OF VULVAR CANCER
Another area of progress in the surgical management of vulvar carcinoma has been the use of conservative surgery for early lesions of the vulva. Although specific criteria
In recent years, such locally advanced lesions of the vulva also have been treated successfully with external-beam radiotherapy combined with radiosensitizing drugs such as cisplatin and 5-fluorouracil. At the completion of combination therapy, the areas of involvement are excised widely or biopsied.
Uncommon Vulvar Tumors Melanoma Lesions less than 1 mm thick or Clark level II lesions may be treated conservatively with wide local excision. The value of inguinofemoral lymphadenectomy is controversial in lesions of greater depth, although primary surgical cure is occasionally achieved in patients with microscopic nodal metastases.
Intraepithelial Disease Intraepithelial disease (Bowen's disease, bowenoid papulosis, vulvar intraepithelial neoplasia, carcinoma in situ) may be treated successfully by removing the involved epithelium. Also effective in the treatment of intraepithelial disease is the carbon dioxide laser.
DILATATION AND CURETTAGE (D&C)
At one time dilatation of the cervix and curettage of the endometrial cavity were among the most common surgical procedures performed in this country. Office biopsy and medical means of dealing with abnormal bleeding have largely
The major complication of D&C is perforation of the uterus. Perforation is diagnosed when the operator finds no resistance to a dilator or curette at a point where he or she normally would expect it. Perforation generally is treated in an expectant manner. Falling hematocrit and other signs of intraperitoneal bleeding indicate the need for laparotomy and control of the bleeding site. Any infection following D&C should be treated with antibiotics.
In recent years, suction curettage for incomplete abortion, hydatid mole, and therapeutic abortion has become popular. Suction machines fitted with cannulas that vary from 4–12 mm in diameter evacuate the uterus in less time and save blood loss.
Endoscopic surgery, including both laparoscopy and hysteroscopy, has assumed a major role in gynecology.
For a more detailed discussion, see Sutton GP, Rogers BE, and Hurd WW: Gynecology, chap. 39 in Principles of Surgery, 7th ed.
Copyright 1998 McGraw-Hill
Seymour I. Schwartz
Principles of Surgery Companion Handbook