- Email: [email protected]
Recurrent ischiorectal abscess secondary to transobturator tape erosion: an unusual chronic complication
364
Letters to the Editor / European Journal of Obstetrics & Gynecology and Reproductive Biology 158 (2011) 361–371
preservation in ovarian lymphomas, possibly supporting the use of GnRH analogue during chemotherapy as a standard [4]. The case further illustrates that cryopreservation of ovarian tissue with future re-transplantation may not be safe in an ovarian Burkitt’s lymphoma. However, oocyte freezing appears to be an alternative for fertility preservation if a partner is not present [1]. Because an ovarian Burkitt’s lymphoma is regarded as a systemic lymphoblastic disease originating in the ovaries and prognosis of these aggressive tumours is excellent when adequately treated systemically, under the given circumstances removal of the contralateral ovary was not indicated in this patient [5,6]. In summary, because of its dynamic growth and critical location endangering follicular reserve before gonadotoxic chemotherapy has started, an ovarian lymphoma requires immediate action if preservation of fertility is indicated. Ovarian low response to hormonal stimulation has to be taken into account. If spontaneous pregnancy is attempted, a short time interval after chemotherapy may be beneficial.
*Corresponding author. Tel.: +49 251 8348202; fax: +49 251 8348267 E-mail address: [email protected] (A.N. Schu¨ring). 1 These authors contributed equally. 4 January 2011 doi:10.1016/j.ejogrb.2011.04.039
Recurrent ischiorectal abscess secondary to transobturator tape erosion: an unusual chronic complication Dear Editor,
References [1] Lee SJ, Schover LR, Partridge AH, et al. American Society of Clinical Oncology. American Society of Clinical Oncology recommendations on fertility preservation in cancer patients. J Clin Oncol 2006;24:2917–31. [2] Gnoth C, Schuring AN, Friol K, Tigges J, Mallmann P, Godehardt E. Relevance of anti-Mullerian hormone measurement in a routine IVF program. Hum Reprod 2008;23:359–1365. [3] Schmidt E, Thoennissen NH, Rudat A, et al. Use of palifermin for the prevention of high-dose methotrexate-induced oral mucositis. Ann Oncol 2008;19:1644–9. [4] Blumenfeld Z, von Wolff M. GnRH-analogues and oral contraceptives for fertility preservation in women during chemotherapy. Hum Reprod Update 2008;14:543–52. [5] Chishima F, Hayakawa S, Ohta Y, et al. Ovarian Burkitt’s lymphoma diagnosed by a combination of clinical features, morphology, immunophenotype, and molecular findings and successfully managed with surgery and chemotherapy. Int J Gynecol Cancer 2006;16(Suppl. 1):337–43. [6] Oriol A, Ribera JM, Bergua J, et al. High-dose chemotherapy and immunotherapy in adult Burkitt lymphoma: comparison of results in human immunodeficiency virus-infected and noninfected patients. Cancer 2008;113:117–25.
Andreas N. Schu¨ring1,* Department of Gynaecology and Obstetrics, University Hospital of Mu¨nster, Albert Schweitzer-Str. 33, 48149 Mu¨nster, Germany Verena Nordhoff1 Centre of Reproductive Medicine and Andrology, University Hospital of Mu¨nster, Germany Nicole Schulte Department of Gynaecology and Obstetrics, University Hospital of Mu¨nster, Germany Sabine Kliesch Centre of Reproductive Medicine and Andrology, University Hospital of Mu¨nster, Germany Ludwig Kiesel Department of Gynaecology and Obstetrics, University Hospital of Mu¨nster, Germany Wolfgang E. Berdel Department of Medicine A, Haematology and Oncology, University Hospital of Mu¨nster, Germany Johannes Wessling Department of Clinical Radiology, University Hospital of Mu¨nster, Germany Steffen Koschmieder Department of Medicine A, Haematology and Oncology, University Hospital of Mu¨nster, Germany
We found that erosions are important complications of TOT procedures and the case reported here is a recurrent ischiorectal abscess which was drained 5 times after TOT erosion. As far as we know this is the first reported case of ‘‘chronic abscess formation’’ and ‘‘chronic complication’’ of TOT operation. Transobturator tape (TOT) was developed as a new minimally invasive technique for surgical treatment of stress urinary incontinence to avoid the treatment morbidity like major muscular and visceral complications of TVT (tension free vaginal tape) procedure. However, cutaneous necrosis, cellulitis, myositis, ischiorectal and obturator abscess, necrotizing fasciitis were reported following TOT procedures [1]. A 53-year-old menopausal woman presented with symptoms of vaginal discharge, pain in left groin. She had undergone total abdominal hysterectomy 15 years earlier, urinary incontinence symptoms were developed after operation and she had two KellyKennedy and one Burch colposuspension operations at different times. With the persistence of symptoms two TOT procedures were performed at outside facilities. She reported a history of paravaginal abscess development and abscess drainage 5 times in 5 years after the operation. On pelvic examination, a tender mass 5 cm 5 cm in size was detected at left ischiorectal fossa and bloody malodorous discharge was draining to left vagina wall from the sinus tract. We began broad-spectrum antibiotics. MRI showed a 3 cm 4 cm area of enhancement in the ischiorectal fossa extending to paravaginal and perianal area suggested inflammation and a sinus tract from ischiorectal region to left vaginal wall. The sinus tract was detected and a wide left Schuchardt incision was made to reach the ischiorectal fossa to the abscess cavity under general anesthesia. Cavity was multiloculated, abundant amount of pus and foreign bodies were observed in the ischiorectal fossa. Foreign bodies suggested as tape remainders which was an Istop (CL Medical, Lyon, France) and partially excised before, were removed (Fig. 1). A gluteal drain placement was decided to achieve complete healing of this chronic process. A blunt tipped hysterometer was used as a guide to perforate levator plate to gluteal region and a 27F soft drain was placed. Sinus tract was removed and vaginal incision was closed. Culture of abscess was positive for mixed anaerobic gram negative and beta-lactamase gram positive bacilli. The patient had i.v. antibiotics for 7 days postoperatively than discharge on oral antibiotics for 7 days. 30 cc mild bloody necrotic material drained per day and the drain was removed on postoperative day 20. Minimal drainage continued further 20 days than the artificial fistula was closed spontaneously. The patient was seen 1st, 6th and 10th months after the surgery with resolution of vaginal discharge, thigh and groin pain. The wounds were healed well.
Letters to the Editor / European Journal of Obstetrics & Gynecology and Reproductive Biology 158 (2011) 361–371
365
Mehmet Kucukbas Sakarya Education and Training Hospital, Turkey Hamdullah Sozen Zeynep Kamil Hospital, Pelvic Reconstructive Department, Istanbul, Turkey Cetin Cam Zeynep Kamil Hospital, Pelvic Reconstructive Department, Uskudar, Istanbul, Turkey *Corresponding author. Tel.: +90 5054970407 fax: +90 2163856463 Fig. 1. Exploration of the abscess cavity.
Benassi et al. [2] reported a case of abscess formation at the ischiorectal fossa 7 months after TOT procedure, Goldman [3] described a patient with abscess formation in the region of gracilis and great adductor muscles. Robert et al. [4] reported case series of primary obturator abscess and mesh erosions after TOT procedures. They chose to drain the abscess vaginally and had good healing processes. Babalola et al. [5] reported an ischiorectal abscess following TOT procedure managed by gluteal drainage, which was healed nicely. In this patient, chronic paravaginal/ ischiorectal abscess was observed and there may be the possibility of infection spreading from point of erosion in the vaginal wall to the obturator muscle region to the ischiorectal fossa. Longstanding drainage was managed by the help of gravity and walking through gluteal drain. We suggest that the chronic abscess formation may be due to recurrent urogynecological operations, previous unsuccessful vaginal route drainage procedures (proper time for drainage could not be allowed because of quick vaginal healing) and incomplete surgical removal of the tape (tape remainders formed a foreign body reaction and inflammation). Urogynecological procedures for stress urinary incontinence must be carefully selected and complete evaluation must be done before the recurrent operation. In an abscess formation, complete sling must be removed. We recommend our surgical technique for management of paravaginal, pararectal or ischiorectal abscess to avoid recurrences and for recurrent chronic abscess treatment. References [1] Deng DY, Rutman M, Raz S, Rodriguez LV. Presentation and management of major complications of midurethral slings: are complications under-reported? Neurourol Urodyn 2007;26:46–52. [2] Benassi G, Marconi L, Accorsi F, Angeloni M, Benassi L. Abscess formation at the ischiorectal fossa 7 months after the application of a synthetic transobturator sling for stress urinary incontinence in a type II diabetic woman. Int Urogynecol J Pelvic Floor Dysfunct 2007;18:697–9. [3] Goldman HB. Large thigh abscess after placement of synthetic transobturator sling. Int Urogynecol J Pelvic Floor Dysfunct 2006;17:295–6. [4] Robert M, Murphy M, Birch C, Swaby C, Ross S. Five cases of tape erosion after transobturator surgery for urinary incontinence. Obstet Gynecol 2006;107: 472–4. [5] Babalola EO, Famuyide AO, McGuire LJ, Gebhart JB, Klingele CJ. Vaginal erosion, sinus formation, and ischiorectal abscess following transobturator tape: ObTape implantation. Int Urogynecol J Pelvic Floor Dysfunct 2006;17:418–21.
Ates Karateke Zeynep Kamil Hospital, Pelvic Reconstructive Department, Istanbul, Turkey Yesim Akdemir* Zeynep Kamil Hospital, Pelvic Reconstructive Department, Murat Reis Mah, Bostanici Sok, Soyak Baglarbasi Evleri B10 D:11, 34664 Uskudar, Istanbul, Turkey
E-mail addresses: [email protected] (A. Karateke). [email protected] (Y. Akdemir). [email protected] (M. Kucukbas). [email protected] (H. Sozen). [email protected] (C. Cam). 26 January 2011 doi:10.1016/j.ejogrb.2011.04.045
A successful case of abdominal radical trachelectomy for cervical cancer during pregnancy Dear Editor, A 27-year-old woman (gravida 2, para 0) was referred to us due to cervical cancer at 12 weeks. The lesion was macroscopically visible. Pelvic MRI revealed a 20 7 mm cervical mass with minimal stromal invasion but no obvious metastasis to either pelvic lymph nodes or parametrial extension. A diagnosis of FIGO stage IB1 cervical cancer (squamous cell carcinoma) was made. After extensive discussions, and obtaining written informed consent, we decided to perform abdominal radical trachelectomy (ART) during pregnancy, as previously reported by Ungar et al. [1], Mandic et al. [2], and Abu-Rustum et al. [3]. Surgery was performed at 15 weeks. To prevent abortion, 50 mg of an indomethacin rectal suppository was administered on the morning of the surgery; 25 mg more was administered immediately after surgery, and every 6 h thereafter, 4 times total. Also, 250 mg of 17-alpha-hdroxy-progesterone caproate was administered intramuscularly 60 min prior to surgery, and once a week thereafter, until 36 weeks of gestation. Under general anesthesia with sevoflurane, the operation was initiated. Although the operative field was full with enlarged pregnant uterus, we were able to improve the operative field by displacing the uterus manually because indomethacin and sevoflurane were sufficiently effective at decreasing the tonus of the uterus. At first, pelvic lymphadenectomy was performed. By intraoperative pathology, negative for lymph node metastases were confirmed in bilateral obturator and external iliac nodes. Bilateral adnexae were preserved. After isolation of the left ureter from retroperitoneum, the left uterine artery was identified and gently dissociated from surrounding tissues. On the other hand, the right uterine artery was extremely thin and was unintentionally transected. After transection of anterior and posterior vesicouterine ligaments, cardinal ligaments were treated. Then uterosacral and rectovaginal ligaments were transected. The vaginal wall was cut from the 12 o’clock position circumferentially and then the cervix was transected 1 cm below the isthmus (Fig. 1). The excised specimen included 3.2 cm of uterine cervix with 1 cm of vaginal cuff. Margins were macroscopically clear; intraoperative
Letters to the Editor / European Journal of Obstetrics & Gynecology and Reproductive Biology 158 (2011) 361–371
preservation in ovarian lymphomas, possibly supporting the use of GnRH analogue during chemotherapy as a standard [4]. The case further illustrates that cryopreservation of ovarian tissue with future re-transplantation may not be safe in an ovarian Burkitt’s lymphoma. However, oocyte freezing appears to be an alternative for fertility preservation if a partner is not present [1]. Because an ovarian Burkitt’s lymphoma is regarded as a systemic lymphoblastic disease originating in the ovaries and prognosis of these aggressive tumours is excellent when adequately treated systemically, under the given circumstances removal of the contralateral ovary was not indicated in this patient [5,6]. In summary, because of its dynamic growth and critical location endangering follicular reserve before gonadotoxic chemotherapy has started, an ovarian lymphoma requires immediate action if preservation of fertility is indicated. Ovarian low response to hormonal stimulation has to be taken into account. If spontaneous pregnancy is attempted, a short time interval after chemotherapy may be beneficial.
*Corresponding author. Tel.: +49 251 8348202; fax: +49 251 8348267 E-mail address: [email protected] (A.N. Schu¨ring). 1 These authors contributed equally. 4 January 2011 doi:10.1016/j.ejogrb.2011.04.039
Recurrent ischiorectal abscess secondary to transobturator tape erosion: an unusual chronic complication Dear Editor,
References [1] Lee SJ, Schover LR, Partridge AH, et al. American Society of Clinical Oncology. American Society of Clinical Oncology recommendations on fertility preservation in cancer patients. J Clin Oncol 2006;24:2917–31. [2] Gnoth C, Schuring AN, Friol K, Tigges J, Mallmann P, Godehardt E. Relevance of anti-Mullerian hormone measurement in a routine IVF program. Hum Reprod 2008;23:359–1365. [3] Schmidt E, Thoennissen NH, Rudat A, et al. Use of palifermin for the prevention of high-dose methotrexate-induced oral mucositis. Ann Oncol 2008;19:1644–9. [4] Blumenfeld Z, von Wolff M. GnRH-analogues and oral contraceptives for fertility preservation in women during chemotherapy. Hum Reprod Update 2008;14:543–52. [5] Chishima F, Hayakawa S, Ohta Y, et al. Ovarian Burkitt’s lymphoma diagnosed by a combination of clinical features, morphology, immunophenotype, and molecular findings and successfully managed with surgery and chemotherapy. Int J Gynecol Cancer 2006;16(Suppl. 1):337–43. [6] Oriol A, Ribera JM, Bergua J, et al. High-dose chemotherapy and immunotherapy in adult Burkitt lymphoma: comparison of results in human immunodeficiency virus-infected and noninfected patients. Cancer 2008;113:117–25.
Andreas N. Schu¨ring1,* Department of Gynaecology and Obstetrics, University Hospital of Mu¨nster, Albert Schweitzer-Str. 33, 48149 Mu¨nster, Germany Verena Nordhoff1 Centre of Reproductive Medicine and Andrology, University Hospital of Mu¨nster, Germany Nicole Schulte Department of Gynaecology and Obstetrics, University Hospital of Mu¨nster, Germany Sabine Kliesch Centre of Reproductive Medicine and Andrology, University Hospital of Mu¨nster, Germany Ludwig Kiesel Department of Gynaecology and Obstetrics, University Hospital of Mu¨nster, Germany Wolfgang E. Berdel Department of Medicine A, Haematology and Oncology, University Hospital of Mu¨nster, Germany Johannes Wessling Department of Clinical Radiology, University Hospital of Mu¨nster, Germany Steffen Koschmieder Department of Medicine A, Haematology and Oncology, University Hospital of Mu¨nster, Germany
We found that erosions are important complications of TOT procedures and the case reported here is a recurrent ischiorectal abscess which was drained 5 times after TOT erosion. As far as we know this is the first reported case of ‘‘chronic abscess formation’’ and ‘‘chronic complication’’ of TOT operation. Transobturator tape (TOT) was developed as a new minimally invasive technique for surgical treatment of stress urinary incontinence to avoid the treatment morbidity like major muscular and visceral complications of TVT (tension free vaginal tape) procedure. However, cutaneous necrosis, cellulitis, myositis, ischiorectal and obturator abscess, necrotizing fasciitis were reported following TOT procedures [1]. A 53-year-old menopausal woman presented with symptoms of vaginal discharge, pain in left groin. She had undergone total abdominal hysterectomy 15 years earlier, urinary incontinence symptoms were developed after operation and she had two KellyKennedy and one Burch colposuspension operations at different times. With the persistence of symptoms two TOT procedures were performed at outside facilities. She reported a history of paravaginal abscess development and abscess drainage 5 times in 5 years after the operation. On pelvic examination, a tender mass 5 cm 5 cm in size was detected at left ischiorectal fossa and bloody malodorous discharge was draining to left vagina wall from the sinus tract. We began broad-spectrum antibiotics. MRI showed a 3 cm 4 cm area of enhancement in the ischiorectal fossa extending to paravaginal and perianal area suggested inflammation and a sinus tract from ischiorectal region to left vaginal wall. The sinus tract was detected and a wide left Schuchardt incision was made to reach the ischiorectal fossa to the abscess cavity under general anesthesia. Cavity was multiloculated, abundant amount of pus and foreign bodies were observed in the ischiorectal fossa. Foreign bodies suggested as tape remainders which was an Istop (CL Medical, Lyon, France) and partially excised before, were removed (Fig. 1). A gluteal drain placement was decided to achieve complete healing of this chronic process. A blunt tipped hysterometer was used as a guide to perforate levator plate to gluteal region and a 27F soft drain was placed. Sinus tract was removed and vaginal incision was closed. Culture of abscess was positive for mixed anaerobic gram negative and beta-lactamase gram positive bacilli. The patient had i.v. antibiotics for 7 days postoperatively than discharge on oral antibiotics for 7 days. 30 cc mild bloody necrotic material drained per day and the drain was removed on postoperative day 20. Minimal drainage continued further 20 days than the artificial fistula was closed spontaneously. The patient was seen 1st, 6th and 10th months after the surgery with resolution of vaginal discharge, thigh and groin pain. The wounds were healed well.
Letters to the Editor / European Journal of Obstetrics & Gynecology and Reproductive Biology 158 (2011) 361–371
365
Mehmet Kucukbas Sakarya Education and Training Hospital, Turkey Hamdullah Sozen Zeynep Kamil Hospital, Pelvic Reconstructive Department, Istanbul, Turkey Cetin Cam Zeynep Kamil Hospital, Pelvic Reconstructive Department, Uskudar, Istanbul, Turkey *Corresponding author. Tel.: +90 5054970407 fax: +90 2163856463 Fig. 1. Exploration of the abscess cavity.
Benassi et al. [2] reported a case of abscess formation at the ischiorectal fossa 7 months after TOT procedure, Goldman [3] described a patient with abscess formation in the region of gracilis and great adductor muscles. Robert et al. [4] reported case series of primary obturator abscess and mesh erosions after TOT procedures. They chose to drain the abscess vaginally and had good healing processes. Babalola et al. [5] reported an ischiorectal abscess following TOT procedure managed by gluteal drainage, which was healed nicely. In this patient, chronic paravaginal/ ischiorectal abscess was observed and there may be the possibility of infection spreading from point of erosion in the vaginal wall to the obturator muscle region to the ischiorectal fossa. Longstanding drainage was managed by the help of gravity and walking through gluteal drain. We suggest that the chronic abscess formation may be due to recurrent urogynecological operations, previous unsuccessful vaginal route drainage procedures (proper time for drainage could not be allowed because of quick vaginal healing) and incomplete surgical removal of the tape (tape remainders formed a foreign body reaction and inflammation). Urogynecological procedures for stress urinary incontinence must be carefully selected and complete evaluation must be done before the recurrent operation. In an abscess formation, complete sling must be removed. We recommend our surgical technique for management of paravaginal, pararectal or ischiorectal abscess to avoid recurrences and for recurrent chronic abscess treatment. References [1] Deng DY, Rutman M, Raz S, Rodriguez LV. Presentation and management of major complications of midurethral slings: are complications under-reported? Neurourol Urodyn 2007;26:46–52. [2] Benassi G, Marconi L, Accorsi F, Angeloni M, Benassi L. Abscess formation at the ischiorectal fossa 7 months after the application of a synthetic transobturator sling for stress urinary incontinence in a type II diabetic woman. Int Urogynecol J Pelvic Floor Dysfunct 2007;18:697–9. [3] Goldman HB. Large thigh abscess after placement of synthetic transobturator sling. Int Urogynecol J Pelvic Floor Dysfunct 2006;17:295–6. [4] Robert M, Murphy M, Birch C, Swaby C, Ross S. Five cases of tape erosion after transobturator surgery for urinary incontinence. Obstet Gynecol 2006;107: 472–4. [5] Babalola EO, Famuyide AO, McGuire LJ, Gebhart JB, Klingele CJ. Vaginal erosion, sinus formation, and ischiorectal abscess following transobturator tape: ObTape implantation. Int Urogynecol J Pelvic Floor Dysfunct 2006;17:418–21.
Ates Karateke Zeynep Kamil Hospital, Pelvic Reconstructive Department, Istanbul, Turkey Yesim Akdemir* Zeynep Kamil Hospital, Pelvic Reconstructive Department, Murat Reis Mah, Bostanici Sok, Soyak Baglarbasi Evleri B10 D:11, 34664 Uskudar, Istanbul, Turkey
E-mail addresses: [email protected] (A. Karateke). [email protected] (Y. Akdemir). [email protected] (M. Kucukbas). [email protected] (H. Sozen). [email protected] (C. Cam). 26 January 2011 doi:10.1016/j.ejogrb.2011.04.045
A successful case of abdominal radical trachelectomy for cervical cancer during pregnancy Dear Editor, A 27-year-old woman (gravida 2, para 0) was referred to us due to cervical cancer at 12 weeks. The lesion was macroscopically visible. Pelvic MRI revealed a 20 7 mm cervical mass with minimal stromal invasion but no obvious metastasis to either pelvic lymph nodes or parametrial extension. A diagnosis of FIGO stage IB1 cervical cancer (squamous cell carcinoma) was made. After extensive discussions, and obtaining written informed consent, we decided to perform abdominal radical trachelectomy (ART) during pregnancy, as previously reported by Ungar et al. [1], Mandic et al. [2], and Abu-Rustum et al. [3]. Surgery was performed at 15 weeks. To prevent abortion, 50 mg of an indomethacin rectal suppository was administered on the morning of the surgery; 25 mg more was administered immediately after surgery, and every 6 h thereafter, 4 times total. Also, 250 mg of 17-alpha-hdroxy-progesterone caproate was administered intramuscularly 60 min prior to surgery, and once a week thereafter, until 36 weeks of gestation. Under general anesthesia with sevoflurane, the operation was initiated. Although the operative field was full with enlarged pregnant uterus, we were able to improve the operative field by displacing the uterus manually because indomethacin and sevoflurane were sufficiently effective at decreasing the tonus of the uterus. At first, pelvic lymphadenectomy was performed. By intraoperative pathology, negative for lymph node metastases were confirmed in bilateral obturator and external iliac nodes. Bilateral adnexae were preserved. After isolation of the left ureter from retroperitoneum, the left uterine artery was identified and gently dissociated from surrounding tissues. On the other hand, the right uterine artery was extremely thin and was unintentionally transected. After transection of anterior and posterior vesicouterine ligaments, cardinal ligaments were treated. Then uterosacral and rectovaginal ligaments were transected. The vaginal wall was cut from the 12 o’clock position circumferentially and then the cervix was transected 1 cm below the isthmus (Fig. 1). The excised specimen included 3.2 cm of uterine cervix with 1 cm of vaginal cuff. Margins were macroscopically clear; intraoperative