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Histologic features of the CISH procedure
November 1994, Vol 2, No. 1 The Journal of the American Association of Gynecologic Laparoscopists
Histologic Features of the CISH Procedure
Erick Alvarez-Rodas, M.D., Liselotte Mettler, M.D., Eduardo Castro, M.D., Jutta L/Jttges, M.D., and Kurt Semm, M.D.
Abstract Study Objective. To evaluate the classic intrafascial SEMM (serrated-edge macromorcellated) hysterectomy (CISH) performed by pelviscopy and by laparotomy, and determine the histologic features of the procedures. Design. The first 253 women who required hysterectomy were assigned to undergo the procedure by pelviscopy or laparotomy based on uterine size. Patients. One hundred fifty-two women underwent CISH by pelviscopy and 101 by laparotomy. Interventions: Between September 1991 and December 1993, the patients underwent the two procedures. Uterine leiomyomas with menstrual disorders and pressure symptoms were the principal indications (61%). Measurements and Main Results. Histologic findings were in agreement with indications for the procedures. Leiomyomas and leiomyomas with adenomyosis were the most frequent findings. Histologic analysis revealed that the squamocolumnar transformation zone was totally removed in all cases, and all cervical glands were excised in 92%. Conclusion. Cervical dysplasia is not a contraindication to CISH, but emphasizes the importance of adequate preoperative screening. This is a conservative operation that may protect against some cervical cancers. networks and may have a positive impact on the patient's postoperative psychologic and sexual behavior. 4
A new technique for hysterectomy by pelviscopy and laparotomy, the classic intrafascial SEMM (serrated-edge macromorcellated) hysterectomy (CISH) has been described, l It combines advantages of traditional supracervical hysterectomy, including shorter operative time and preservation of the cardinal ligaments and pericervical tissue, with possible prevention of some cervical cancers. 2'3In addition, coring out cervical tissue with the calibrated uterine resection tool (CURT) preserves vascular and neural pericervical
Materials and Methods
Between September 1991 and December 1993, CISH procedures were performed on 253 women, 152 by pelviscopy and 101 by laparotomy. Women were assigned to a group based on the size of the uterus and
From the Departments of Obstetrics and Gynecology (Drs. Alvarez-Rodas, Mettler, Castro, and Semm), and Pathology (Dr. Luttges ), Christian Albrechts University of Kiel, Germany. Address reprint requests to E. Alvarez-Rodas, M.D., c/o L. Mettler, M.D., Michaelisstrage 16, 24105 Kiel, Germany; fax 011 494 31 597 2149.
37
Histologic Features of the CISH Procedure AIvarez-Rodas et al
120°C. The cervix was further secured with two more Roeder loops. The uterus was resected pelviscopically with scissors just above the loops. The cervical stump was peritonealized and suspended to the round ligaments, and the uterus was morcellated and extracted.
the skill of the surgeon. Pelviscopy was not considered if the uterus was larger than 12 weeks. 5 Forty-two women received gonadotropin-releasing hormone analogs preoperatively to reduce the size of myomata. The diameter of the cervix was estimated preoperatively by bimanual palpation and/or vaginal ultrasound. All surgical specimens were examined by a pathologist.
CISH by Laparotomy After performing subtotal hysterectomy, the perforation rod was introduced through the cervical stump and the cervical tissue cored out with the CURT.
Pelviscopic CISH To excise functional cervical tissue without damaging the ureters or uterine arteries, it is necessary to manipulate the uterus such that it is aligned with the cervix. This was done by introducing a 5-mm perforation rod into the cavity and perforating the uterus in the middle of the fundus. The cervix was grasped at the 3 and 9 o'clock positions with two tenacula, and the cervical canal was dilated with a Hegar no. 5 dilator. The perforation rod was introduced through the fundus under pelviscopic control. Adnexal dissection was carried out bilaterally with sutures and ligatures or staplers to the level of the cardinal ligaments. The bladder was separated from the cervix and vagina by aquadissection. A Roeder loop was placed around the cervix but not tightened. The cervicouterine mucosa was next resected with the CURT by coring. The Roeder loop was tightened to prevent loss of gas from the peritoneal cavity, and the remaining cervical fascial sheath was endocoagulated at 100 to
Results
The mean age of the 253 women was 47.6 years (Table 1). No difference in age or mean parity (1.3) was found between the pelviscopic and laparotomy groups. Leiomyomas with diverse clinical symptoms were the main indication for performing CISH, and this diagnosis was determined in 80% of laparotomy and 71% of pelviscopic cases. Other indications were abnormal uterine bleeding that persisted after medical or surgical treatment, chronic pelvic pain, and endometriosis. A close correlation existed between indications and histologic findings, with l e i o m y o m a s diagnosed in 83% of laparotomy and 67.3% of pelviscopic uterine specimens (Table 2). Adenomyosis, which was not diagnosed preoperatively, was the only histologic finding in 9% and 26% of patients, respectively.
TABLE 1. Patient Characteristics
Mean (range) age (yrs) Mean (range) parity (delivery) Indications for CISH Leiomyomas with menstrual abnormality Leiomyomas with pressure symptoms Therapy-resistant dysfunctional uterine bleeding Chronic pelvic pain Endometriosis Diameter of CURT used 10 mm 15 mm 20 mm Uterine weights (g) Mean (range) 0-100 101-200 201-400 >400
38
Laparotomy
Pelviscopy
48.3 (33-65) 1.3 (0-5)
47 (32-68) 1.4 (0-5)
46 (45%) 35 (35%) 8 (8%) 6 (6%) 6 (6%)
73 (48%) 35 (23%) 34 (22%) 7 (5%) 3 (2%)
5 (5%) 57 (56%) 39 (39%)
10 (7%) 98 (64%) 44 (29%)
372 (50-2060) 9 (9%) 31 (31%) 35 (35%) 26 (25%)
162.4 (45-480) 58 (38%) 71 (47%) 20 (13%) 3 (2%)
November 1994, Vol 2, No. 1
The Journal of the American Association of Gynecologic Laparoscopists
Of our patients, 75% experienced pressure symptoms or pelvic pain, abnormal uterine bleeding, or a rapidly increasing fibroid. Adenomyosis was the only histologic finding in 17% of these women. It was never diagnosed preoperatively, confirming limitations of pelvic examination and ultrasonography in establishing the diagnosis of adenomyosis? The finding of 15 women (5.9%) with cervical dysplasia underscores the importance of thorough diagnostic work-up to exclude this disorder. That all 15 underwent surgery without a diagnosis of dysplasia despite appropriate routine screening for cervical carcinoma 9 underscores the limitations of the cervical smear, and is in accordance with reported false negative rates of 20% to 30%. Leiomyosarcoma is an infrequent tumor that accounts for approximately 2% of uterine malignant neoplasias. 1° Its clinical feature is usually that of an enlarging mass. Unless extrauterine disease occurs, it may be impossible to distinguish a sarcoma from a leiomyoma, u Nine (3.6%) women had no histologic diagnosis. Indications for CISH in these patients were chronic pelvic pain and recurrent pelvic endometriosis. These data are consistent with those presented by other authors. 7 Since its introduction in 1878, ~2 supracervical abdominal hysterectomy was the leading hysterectomy technique for managing benign gynecologic disease for over 80 years. The change to total hysterectomy occurred in part to prevent the possible development of cervical stump carcinoma, 3 the frequency of which is estimated to be 0.3% to 1.9%. 2Although it has such a protective effect, total hysterectomy has several disadvantages inherent to its more radical character, such as longer operating time, more bleeding, and a greater risk to adjacent organs. Furthermore, resection of cervical tissue by total hysterectomy implies destruction
Glandular tissSue at the endocervical level was found at the edge of the cylinder in only 8% of patients (11% laparotomy, 5% pelviscopy). No correlation with the diameter of the coring device used was present (Table 3). The squamocolumnar transformation zone was totally removed by CURT in 100% of cases. Eight women (6.6%) had endometrial hyperplasia and all were symptomatic (abnormal uterine bleeding). The diagnosis was established by dilatation and curettage in all, and was not the main indication for CISH. Cervical dysplasia was found in 15 specimens (11.5%). The diagnosis had not been established preoperatively, and all patients had a normal cervical smear within 1 year of surgery. Cervical dysplasia was limited to the cylinder specimen in all cases. A leiomyosarcoma was found in a 52-year-old woman. Her main symptom was menometrorrhagia of 6 months' duration. Ultrasound examination revealed a 15 x 18 x 16-cm enlarged uterus, and dilatation and curretage revealed normal endometrium. A CISH was performed by laparotomy, and an intramural leiomyosarcoma without endometrial invasion was diagnosed on histology. The patient underwent postoperative radiotherapy, and 6 months after surgery she is asymptomatic and remains free of disease. Discussion
Histologic findings in 253 cases of CISH are consistent with the fact that leiomyomas are the most common solid tumor in the female genital tract, and are present in about 20% of women over 30 years of age.6 A recent series showed leiomyomas to be the most common tissue diagnosis, noted in 78% of specimens. 7
TABLE 2. Histologic Findings in 253 CISH Procedures Laparotomy Pelviscopy Uterine findings Leiomyoma Leiomyoma with adenomyosis Adenomyosis Adenomatous hyperplasia No remarkable findings Sarcoma Cylinder specimens Normal Chronic cervicitis Dysplasia
TABLE 3. Histologic Findings on Cored Cylinder Specimens 60 (59%) 24 (24%) 9 (9%) 3 (3%) 4 (4%) 1 (1%)
81 (53.3%) 21 (14%) 40 (26%) 5 (3.3%) 5 (3.3%) --
83 (82%) 13 (13%) 5 (5%)
133 (87.5%) 9 (6%) 10 (6.5%)
39
Glandular Findings
Laparotomy
Pelviscopy
Border free from glands Glands reaching the border Diameter of CURT 10 mm 15 mm 20 mm Totals
90 (89%) 11 (11%)
145 (95%) 7 (5%)
0 8 (44%) 3 (16.6%) 11 (61.1%)
0 1 (5.5%) 6 (33.3%) 7 (38.8%)
Histologic Features of the CISH Procedure Alvarez-Rodas et al
4. Kilkka P, Grrnroos M, Hirvonen T, et al: Supravaginal uterine amputation vs. hysterectomy. Effects on libido and orgasm. Acta Obstet Gynecol Scand 62:147-152, 1983
of vascular and neural pericervical tissue with a subsequent negative impact on the patient's sex life postoperatively. Although no statistically significant change in libido occurs, ability to achieve orgasm is clearly impaired, 4 and different authors state that the cervix should not be removed without proper indication.13-~5 The CISH technique was conceived in an effort to combine all the advantages of the subtotal hysterectomy regarding cost, time, risks, and possible complications, with possible prevention of cervical carcinoma by transvaginal cylindric coring of cervical tissue with the CURT. This series shows clearly that the transformation zone is totally removed in 100% of cases by CISH, reducing to a minimum the possibility of cervical stump neoplasia. ~6The CURTs are available in diameters of 10, 15, 20, and, recently introduced, 24 mm. We believe that measuring the diameter of the cervix by transvaginal ultrasound allows the surgeon to select the proper size coring device with the goal of removing 100% of cervical glandular tissue. In 1990 Reich et aP 7 successfully performed the first endoscopic total hysterectomy; however, the uterus was removed by colpotomy. Currently, we perform pelviscopic CISH as an elective procedure on a routine basis. Women are assigned to CISH by laparotomy when the uterus is too big to allow safe pelviscopic resection?
5. Mettler L, Semm K: Intrafascial supracervical hysterectomy without colpotomy and transuterine mucosal resection by pelviscopy or laparotomy, our first 100 cases. Presented at the 3rd biennial meeting of the International Society of GynecologicEndoscopy,Washington, DC, June 23-26, 1993 6. Adamson D: Treatment of uterine fibroids: Current findings with gonadotropin-releasing hormone agonisists. Am J Obstet Gynecol 166:746-751, 1992 7. Hasson HM, Rotman C, Rana N, et al: Experience with laparoscopic hysterectomy. J Am Assoc Gynecol Laparosc 1:1-11, 1993 8. Fedele L, Bianchi S, Dorta M, et al: Ultrasonography for diagnosis of leiomyoma vs adenomyoma. Am J Obstet Gynecol 167:603-606, 1992 9. ACOG Committee on Gynecologic Practice. Routine cancer screening. Int J Gynecol Obstet 43:344-348, 1993 10. Eberl M, Pfleiderer A, Teufel G, et al: Sarcoma of the uterus. Morphological criteria and clinical course. Pathol Res Pract 169:165-167, 1980 11. Peters W, Howard D, Andersen W, et al: Deoxyribonucleic acid analysis by flow cytometry of uterine leiomyosarcomas and smooth muscle tumors of uncertain malignant potential. Am J Obstet Gynecol 162:1646--1654, 1992
Conclusion The CISH is a new technique designed to integrate the best features of supracervical and total hysterectomy for benign disease. Histologic analysis of tissue specimens from the first 253 procedures shows that this objective has been accomplished. The procedure can be performed by laparotomy or by pelviscopy, with the former approach reserved for women whose uterine size precludes pelviscopy.
12. Freund WA: Bemerkungen zu meiner methode der uterus-exstirpation. Zent bl Gyn~ikol2:497-500, 1878 13. Pelosi MA, Pelosi MA III: Laparoscopic supracervical hysterectomy using a single umbilical puncture. Minilaparoscopy. J Reprod Med 37:774-784, 1992 14. Lyons T: Supracervical laparoscopic hysterectomy: A comparison: Morbidity and mortality results with LAVH. J Reprod Med 38:763-767, 1993
References
1. Semm K: Hysterectomy per laparotomiam oder pelviscopiam ohne kolpotomie. Geburtshilf Frauenheilkd 51:996-1003, 1991
15. Hasson HM: Cervical removal at hysterectomy for benign disease: Risks and benefits. J Reprod Med 38:780-790, 1993
2. Tervil~iI: Carcinoma of the cervical stump. Acta Obstet Gynecol Scand 42:200-206, 1963
16. Truskett I, Constable W: Clear cell adenocarcinoma of the cervix and vaginal vault of mesonephric origin. Cancer 21:249-251, 1968
3. Semm K: Opertionslehre ftir endosckopische abdominalchirugie - - operative pelviscopie. Stuttgart, Schattaur Verlag, 1984. English translation, Chicago, Year Book, 1987
17. Reich H, De Caprio J, McGlynn F: Laparoscopic hysterectomy. J Gynecol Surg 5:213-216, 1989
40
November 1994, Vol 2, No. 1
The Journal of the American Association of Gynecdogic Laparoscopisl
q
A
jl, /
POR 8
C
B
1
//
F'
•
."
~ +I~ "+.I -.+,~...
(/f-: D
E
F
G
-+
H FIGURE 1. Steps of the CISH procedure. A. Introduction of the perforation rod into the uterine cavity. B. Pelviscopic clissection of the adnexa. C. Dissection of the broad ligament. D. Bladder dissection, coring out of the cervicouterine rnucosa. E. A Roeder loop is closed around the cervix. F. Uterine resection above the Roeder loops. G. Stump suspension to the round ligaments. H. Stump peritonealization. I. The uterus is morcellated and extracted; view of the cylinder ipecimen.
4]
Histologic Features of the CISH Procedure
Erick Alvarez-Rodas, M.D., Liselotte Mettler, M.D., Eduardo Castro, M.D., Jutta L/Jttges, M.D., and Kurt Semm, M.D.
Abstract Study Objective. To evaluate the classic intrafascial SEMM (serrated-edge macromorcellated) hysterectomy (CISH) performed by pelviscopy and by laparotomy, and determine the histologic features of the procedures. Design. The first 253 women who required hysterectomy were assigned to undergo the procedure by pelviscopy or laparotomy based on uterine size. Patients. One hundred fifty-two women underwent CISH by pelviscopy and 101 by laparotomy. Interventions: Between September 1991 and December 1993, the patients underwent the two procedures. Uterine leiomyomas with menstrual disorders and pressure symptoms were the principal indications (61%). Measurements and Main Results. Histologic findings were in agreement with indications for the procedures. Leiomyomas and leiomyomas with adenomyosis were the most frequent findings. Histologic analysis revealed that the squamocolumnar transformation zone was totally removed in all cases, and all cervical glands were excised in 92%. Conclusion. Cervical dysplasia is not a contraindication to CISH, but emphasizes the importance of adequate preoperative screening. This is a conservative operation that may protect against some cervical cancers. networks and may have a positive impact on the patient's postoperative psychologic and sexual behavior. 4
A new technique for hysterectomy by pelviscopy and laparotomy, the classic intrafascial SEMM (serrated-edge macromorcellated) hysterectomy (CISH) has been described, l It combines advantages of traditional supracervical hysterectomy, including shorter operative time and preservation of the cardinal ligaments and pericervical tissue, with possible prevention of some cervical cancers. 2'3In addition, coring out cervical tissue with the calibrated uterine resection tool (CURT) preserves vascular and neural pericervical
Materials and Methods
Between September 1991 and December 1993, CISH procedures were performed on 253 women, 152 by pelviscopy and 101 by laparotomy. Women were assigned to a group based on the size of the uterus and
From the Departments of Obstetrics and Gynecology (Drs. Alvarez-Rodas, Mettler, Castro, and Semm), and Pathology (Dr. Luttges ), Christian Albrechts University of Kiel, Germany. Address reprint requests to E. Alvarez-Rodas, M.D., c/o L. Mettler, M.D., Michaelisstrage 16, 24105 Kiel, Germany; fax 011 494 31 597 2149.
37
Histologic Features of the CISH Procedure AIvarez-Rodas et al
120°C. The cervix was further secured with two more Roeder loops. The uterus was resected pelviscopically with scissors just above the loops. The cervical stump was peritonealized and suspended to the round ligaments, and the uterus was morcellated and extracted.
the skill of the surgeon. Pelviscopy was not considered if the uterus was larger than 12 weeks. 5 Forty-two women received gonadotropin-releasing hormone analogs preoperatively to reduce the size of myomata. The diameter of the cervix was estimated preoperatively by bimanual palpation and/or vaginal ultrasound. All surgical specimens were examined by a pathologist.
CISH by Laparotomy After performing subtotal hysterectomy, the perforation rod was introduced through the cervical stump and the cervical tissue cored out with the CURT.
Pelviscopic CISH To excise functional cervical tissue without damaging the ureters or uterine arteries, it is necessary to manipulate the uterus such that it is aligned with the cervix. This was done by introducing a 5-mm perforation rod into the cavity and perforating the uterus in the middle of the fundus. The cervix was grasped at the 3 and 9 o'clock positions with two tenacula, and the cervical canal was dilated with a Hegar no. 5 dilator. The perforation rod was introduced through the fundus under pelviscopic control. Adnexal dissection was carried out bilaterally with sutures and ligatures or staplers to the level of the cardinal ligaments. The bladder was separated from the cervix and vagina by aquadissection. A Roeder loop was placed around the cervix but not tightened. The cervicouterine mucosa was next resected with the CURT by coring. The Roeder loop was tightened to prevent loss of gas from the peritoneal cavity, and the remaining cervical fascial sheath was endocoagulated at 100 to
Results
The mean age of the 253 women was 47.6 years (Table 1). No difference in age or mean parity (1.3) was found between the pelviscopic and laparotomy groups. Leiomyomas with diverse clinical symptoms were the main indication for performing CISH, and this diagnosis was determined in 80% of laparotomy and 71% of pelviscopic cases. Other indications were abnormal uterine bleeding that persisted after medical or surgical treatment, chronic pelvic pain, and endometriosis. A close correlation existed between indications and histologic findings, with l e i o m y o m a s diagnosed in 83% of laparotomy and 67.3% of pelviscopic uterine specimens (Table 2). Adenomyosis, which was not diagnosed preoperatively, was the only histologic finding in 9% and 26% of patients, respectively.
TABLE 1. Patient Characteristics
Mean (range) age (yrs) Mean (range) parity (delivery) Indications for CISH Leiomyomas with menstrual abnormality Leiomyomas with pressure symptoms Therapy-resistant dysfunctional uterine bleeding Chronic pelvic pain Endometriosis Diameter of CURT used 10 mm 15 mm 20 mm Uterine weights (g) Mean (range) 0-100 101-200 201-400 >400
38
Laparotomy
Pelviscopy
48.3 (33-65) 1.3 (0-5)
47 (32-68) 1.4 (0-5)
46 (45%) 35 (35%) 8 (8%) 6 (6%) 6 (6%)
73 (48%) 35 (23%) 34 (22%) 7 (5%) 3 (2%)
5 (5%) 57 (56%) 39 (39%)
10 (7%) 98 (64%) 44 (29%)
372 (50-2060) 9 (9%) 31 (31%) 35 (35%) 26 (25%)
162.4 (45-480) 58 (38%) 71 (47%) 20 (13%) 3 (2%)
November 1994, Vol 2, No. 1
The Journal of the American Association of Gynecologic Laparoscopists
Of our patients, 75% experienced pressure symptoms or pelvic pain, abnormal uterine bleeding, or a rapidly increasing fibroid. Adenomyosis was the only histologic finding in 17% of these women. It was never diagnosed preoperatively, confirming limitations of pelvic examination and ultrasonography in establishing the diagnosis of adenomyosis? The finding of 15 women (5.9%) with cervical dysplasia underscores the importance of thorough diagnostic work-up to exclude this disorder. That all 15 underwent surgery without a diagnosis of dysplasia despite appropriate routine screening for cervical carcinoma 9 underscores the limitations of the cervical smear, and is in accordance with reported false negative rates of 20% to 30%. Leiomyosarcoma is an infrequent tumor that accounts for approximately 2% of uterine malignant neoplasias. 1° Its clinical feature is usually that of an enlarging mass. Unless extrauterine disease occurs, it may be impossible to distinguish a sarcoma from a leiomyoma, u Nine (3.6%) women had no histologic diagnosis. Indications for CISH in these patients were chronic pelvic pain and recurrent pelvic endometriosis. These data are consistent with those presented by other authors. 7 Since its introduction in 1878, ~2 supracervical abdominal hysterectomy was the leading hysterectomy technique for managing benign gynecologic disease for over 80 years. The change to total hysterectomy occurred in part to prevent the possible development of cervical stump carcinoma, 3 the frequency of which is estimated to be 0.3% to 1.9%. 2Although it has such a protective effect, total hysterectomy has several disadvantages inherent to its more radical character, such as longer operating time, more bleeding, and a greater risk to adjacent organs. Furthermore, resection of cervical tissue by total hysterectomy implies destruction
Glandular tissSue at the endocervical level was found at the edge of the cylinder in only 8% of patients (11% laparotomy, 5% pelviscopy). No correlation with the diameter of the coring device used was present (Table 3). The squamocolumnar transformation zone was totally removed by CURT in 100% of cases. Eight women (6.6%) had endometrial hyperplasia and all were symptomatic (abnormal uterine bleeding). The diagnosis was established by dilatation and curettage in all, and was not the main indication for CISH. Cervical dysplasia was found in 15 specimens (11.5%). The diagnosis had not been established preoperatively, and all patients had a normal cervical smear within 1 year of surgery. Cervical dysplasia was limited to the cylinder specimen in all cases. A leiomyosarcoma was found in a 52-year-old woman. Her main symptom was menometrorrhagia of 6 months' duration. Ultrasound examination revealed a 15 x 18 x 16-cm enlarged uterus, and dilatation and curretage revealed normal endometrium. A CISH was performed by laparotomy, and an intramural leiomyosarcoma without endometrial invasion was diagnosed on histology. The patient underwent postoperative radiotherapy, and 6 months after surgery she is asymptomatic and remains free of disease. Discussion
Histologic findings in 253 cases of CISH are consistent with the fact that leiomyomas are the most common solid tumor in the female genital tract, and are present in about 20% of women over 30 years of age.6 A recent series showed leiomyomas to be the most common tissue diagnosis, noted in 78% of specimens. 7
TABLE 2. Histologic Findings in 253 CISH Procedures Laparotomy Pelviscopy Uterine findings Leiomyoma Leiomyoma with adenomyosis Adenomyosis Adenomatous hyperplasia No remarkable findings Sarcoma Cylinder specimens Normal Chronic cervicitis Dysplasia
TABLE 3. Histologic Findings on Cored Cylinder Specimens 60 (59%) 24 (24%) 9 (9%) 3 (3%) 4 (4%) 1 (1%)
81 (53.3%) 21 (14%) 40 (26%) 5 (3.3%) 5 (3.3%) --
83 (82%) 13 (13%) 5 (5%)
133 (87.5%) 9 (6%) 10 (6.5%)
39
Glandular Findings
Laparotomy
Pelviscopy
Border free from glands Glands reaching the border Diameter of CURT 10 mm 15 mm 20 mm Totals
90 (89%) 11 (11%)
145 (95%) 7 (5%)
0 8 (44%) 3 (16.6%) 11 (61.1%)
0 1 (5.5%) 6 (33.3%) 7 (38.8%)
Histologic Features of the CISH Procedure Alvarez-Rodas et al
4. Kilkka P, Grrnroos M, Hirvonen T, et al: Supravaginal uterine amputation vs. hysterectomy. Effects on libido and orgasm. Acta Obstet Gynecol Scand 62:147-152, 1983
of vascular and neural pericervical tissue with a subsequent negative impact on the patient's sex life postoperatively. Although no statistically significant change in libido occurs, ability to achieve orgasm is clearly impaired, 4 and different authors state that the cervix should not be removed without proper indication.13-~5 The CISH technique was conceived in an effort to combine all the advantages of the subtotal hysterectomy regarding cost, time, risks, and possible complications, with possible prevention of cervical carcinoma by transvaginal cylindric coring of cervical tissue with the CURT. This series shows clearly that the transformation zone is totally removed in 100% of cases by CISH, reducing to a minimum the possibility of cervical stump neoplasia. ~6The CURTs are available in diameters of 10, 15, 20, and, recently introduced, 24 mm. We believe that measuring the diameter of the cervix by transvaginal ultrasound allows the surgeon to select the proper size coring device with the goal of removing 100% of cervical glandular tissue. In 1990 Reich et aP 7 successfully performed the first endoscopic total hysterectomy; however, the uterus was removed by colpotomy. Currently, we perform pelviscopic CISH as an elective procedure on a routine basis. Women are assigned to CISH by laparotomy when the uterus is too big to allow safe pelviscopic resection?
5. Mettler L, Semm K: Intrafascial supracervical hysterectomy without colpotomy and transuterine mucosal resection by pelviscopy or laparotomy, our first 100 cases. Presented at the 3rd biennial meeting of the International Society of GynecologicEndoscopy,Washington, DC, June 23-26, 1993 6. Adamson D: Treatment of uterine fibroids: Current findings with gonadotropin-releasing hormone agonisists. Am J Obstet Gynecol 166:746-751, 1992 7. Hasson HM, Rotman C, Rana N, et al: Experience with laparoscopic hysterectomy. J Am Assoc Gynecol Laparosc 1:1-11, 1993 8. Fedele L, Bianchi S, Dorta M, et al: Ultrasonography for diagnosis of leiomyoma vs adenomyoma. Am J Obstet Gynecol 167:603-606, 1992 9. ACOG Committee on Gynecologic Practice. Routine cancer screening. Int J Gynecol Obstet 43:344-348, 1993 10. Eberl M, Pfleiderer A, Teufel G, et al: Sarcoma of the uterus. Morphological criteria and clinical course. Pathol Res Pract 169:165-167, 1980 11. Peters W, Howard D, Andersen W, et al: Deoxyribonucleic acid analysis by flow cytometry of uterine leiomyosarcomas and smooth muscle tumors of uncertain malignant potential. Am J Obstet Gynecol 162:1646--1654, 1992
Conclusion The CISH is a new technique designed to integrate the best features of supracervical and total hysterectomy for benign disease. Histologic analysis of tissue specimens from the first 253 procedures shows that this objective has been accomplished. The procedure can be performed by laparotomy or by pelviscopy, with the former approach reserved for women whose uterine size precludes pelviscopy.
12. Freund WA: Bemerkungen zu meiner methode der uterus-exstirpation. Zent bl Gyn~ikol2:497-500, 1878 13. Pelosi MA, Pelosi MA III: Laparoscopic supracervical hysterectomy using a single umbilical puncture. Minilaparoscopy. J Reprod Med 37:774-784, 1992 14. Lyons T: Supracervical laparoscopic hysterectomy: A comparison: Morbidity and mortality results with LAVH. J Reprod Med 38:763-767, 1993
References
1. Semm K: Hysterectomy per laparotomiam oder pelviscopiam ohne kolpotomie. Geburtshilf Frauenheilkd 51:996-1003, 1991
15. Hasson HM: Cervical removal at hysterectomy for benign disease: Risks and benefits. J Reprod Med 38:780-790, 1993
2. Tervil~iI: Carcinoma of the cervical stump. Acta Obstet Gynecol Scand 42:200-206, 1963
16. Truskett I, Constable W: Clear cell adenocarcinoma of the cervix and vaginal vault of mesonephric origin. Cancer 21:249-251, 1968
3. Semm K: Opertionslehre ftir endosckopische abdominalchirugie - - operative pelviscopie. Stuttgart, Schattaur Verlag, 1984. English translation, Chicago, Year Book, 1987
17. Reich H, De Caprio J, McGlynn F: Laparoscopic hysterectomy. J Gynecol Surg 5:213-216, 1989
40
November 1994, Vol 2, No. 1
The Journal of the American Association of Gynecdogic Laparoscopisl
q
A
jl, /
POR 8
C
B
1
//
F'
•
."
~ +I~ "+.I -.+,~...
(/f-: D
E
F
G
-+
H FIGURE 1. Steps of the CISH procedure. A. Introduction of the perforation rod into the uterine cavity. B. Pelviscopic clissection of the adnexa. C. Dissection of the broad ligament. D. Bladder dissection, coring out of the cervicouterine rnucosa. E. A Roeder loop is closed around the cervix. F. Uterine resection above the Roeder loops. G. Stump suspension to the round ligaments. H. Stump peritonealization. I. The uterus is morcellated and extracted; view of the cylinder ipecimen.
4]