- Email: [email protected]
I176 Surgical management of endometrial cancer
Invited presentations / International Journal of Gynecology & Obstetrics 107S2 (2009) S1–S92
I173 Preinvasive vulval lesions R.W. Jones. National Women’s Hospital, Auckland, New Zealand Squamous cell carcinoma of the vulva (SCCV) usually arises in a background of abnormal skin. Broadly, SCCV arises in precursor lesions which are either 1. non-HPV related chronic dermatoses, usually lichen sclerosus, often with associated differentiated VIN or 2. HPV-related “usual type” VIN. 1. Lichen sclerosus (LS): This is a chronic dermatosis, thought to be autoimmune in origin, seen most commonly in the vulva of middle aged and elderly women. Topical potent corticosteroids have revolutionised management. Older literature suggests that approximately 5% of women with LS will eventually develop SCCV. This figure is probably too high, particularly in a population of women who are under surveillance and treatment. The development of SCCV in women with LS appears to be largely restricted to women with additional skin pathology – often localised hyperkeratosis and where there is histological evidence of underlying differentiated VIN. Differentiated VIN has a relatively brief transit interval to invasion. The lesion should be surgically excised. 2. Usual type (HPV-related) VIN: The demographic profile of women with this condition is identical with CIN. At least 30% of women with VIN have a history of HPV-associated lower genital tract neoplasia, usually CIN3. 80% are HPV16 positive. There has been a striking increase in the incidence of VIN in younger women in recent decades with a corresponding increase in the incidence of VIN-related SCCV in younger women. VIN lesions are remarkably heterogeneous in appearance. The VIN grading system is a convenient histological description of a spectrum of epithelial changes, but it is not evidence of a biological continuum. VIN1 has been removed from recent terminology because it is not histologically “reproducible” and there is no evidence that it is a cancer precursor. VIN2 and VIN3 are now termed VIN ‘usual type’. The natural history of VIN remains a contentious issue with many authors failing to recognise the natural history can only be appreciated in untreated lesions that have been observed indefinitely. Few cases meet these criteria. Nonetheless, the morphology (VIN at the margin of a SCCV, microinvasion in a field of VIN), molecular evidence (integration of HPV16 into the host cell genome), case series of untreated VIN progressing to invasion and epidemiological evidence (trends in VIN and SCCV especially in younger women) – all point to the invasive potential of VIN. The mean interval to invasion in untreated VIN is 4 years. Spontaneous regression of VIN occurs in a well defined subset of very young women (teenagers and early 20’s) who present with multifocal, pigmented papules. The gold standard treatment of VIN is conservative local excision. In skilled hands the laser is equally effective in selected cases. Newer medical modalities, e.g., Imiquimod, point to a more rational approach to management. Longer term follow-up studies are still required. I174 Cervical cancer prevention and HPV vaccines: Projected impact, cost-effectiveness, cost, financing and global policy and opinion
S43
and 100% effective in preventing cervical lesions, when given to girls not infected with these HPV types. Models estimate that the widespread use of the vaccines among young adolescent girls has the potential to reduce cervical cancer deaths by 50–71% and incidence by 35–80%, depending on immunization coverage and duration of protection. The greatest impact is expected in low and middle income countries. Cost effectiveness models report that high vaccine coverage among young adolescent girls would reduce costs associated with cervical cancer control and treatment. National HPV vaccination programs would be cost effective in countries where per capita gross domestic product is high or, in low and middle income countries, if the cost per vaccinated girl is
A.O. Jumaan
H.C. Kitchener
In 2005, about 500 000 cases of cervical cancer and 270,000 deaths were estimated worldwide. The highest incidence and mortality rates are in sub-Saharan Africa, Latin America, and South Asia. About 80% of cervical cancer deaths occur in developing countries. Currently, two HPV vaccines are available for the prevention of infection with HPV types 16 and 18 that are associated with 70% of cervical cancer cases. Clinical trials showed that both vaccines are 95% effective in preventing HPV 16, 18 persistent infections
Surgery is the mainstay of treatment for endometrial cancer, which is increasing in incidence in developed countries, as a result of the obesity epidemic and increasing life expectancy. The large majority of cases are FIGO Stage 1, for which the standard of care until recently has been total abdominal hysterectomy (Hyst) and bilateral salpingo-oophorectomy (BSO), with adjutant radiotherapy given in high risk cases. FIGO staging requires a lymphadenectomy, including both pelvic and paraaortic groups of nodes, as a result of which the
S44
Invited presentations / International Journal of Gynecology & Obstetrics 107S2 (2009) S1–S92
practice of lymphadenectomy has increased. The issue of whether lymphadenectomy is therapeutic as well as prognostic has been unresolved until very recently. Retrospective analysis of registry data have shown and association between node dissection and improved survival but confounding factors prevent a causal link being established. In the last year two prospective randomised controlled trials have been published [1,2], both of which showed no difference in overall or recurrence-free survival when Hyst and BSO are compared with Hyst and BSO plus lymphadenectomy. This lack of clinical effectiveness combined with longer operative times and greater morbidity means that routine lymphadenectomy cannot be justified. Furthermore, the increasing use of systemic therapy for high-risk disease irrespective of node status further undermines the rationale for lymphadenectomy. The role of surgery for more advanced and recurrent disease will also be reviewed, as well as the implications for surgery of new FIGO staging. Reference(s) [1] Panici et al. J Natl Cancer Inst 2008; 100:1707–16 [2] ASTEC Writing Committee. The Lancet 2009; 373: 125–36.
I177 Management of congenital malformations in young girls A. Kriplani. Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India Maldevelopment of the urogenital tract occurs in a variety of forms with incidences of 0.16 to 10% have been reported. The diagnosis and management of young girls with Mullerian ¨ anomalies requires not only knowledge of embryologic development, but an awareness of the known associations, including renal anomalies and anorectal malformations. Common presenting symptoms are primary amenorrhoea, cryptomenorrhoea with haematometra and hematocolpos depending on the site of the defect. Young girls with primary amenorrhoea are usually diagnosed with Meyer Rokitansky Kuster Hauser syndrome (MRKH). These girls will require a vaginoplasty. The most common procedures performed are McIndoe’s vaginopasty using an amnion graft and Williams vaginoplasty, commoner being McIndoe’s which is simpler, however it is not preferred in patients with associated pelvic kidney or those requiring repeat procedures, in whom Williams vaginoplasty is performed. Video clips of both procedures will be shown. Young girls presenting with crytpmenorrhoea, haematometra, and haematocolpos are usually those with imperforate hymen, transverse vaginal septums or rarely cervical agenesis. Imperforate hymen is common with a simple surgical solution of a cruciate incision.. Similarly patients with transverse vaginal septum require excision of the septum or a Jeffcoate’s vaginoplasty. In those with cervical agenesis treatment in the past was only hysterectomy or rarely cervicovaginoplasty requiring huge abdominal incisions. This was both emotionally and physically traumatizing for the patients. With the advancement of endoscopy laparoscopic cervicovaginoplasty is being performed with ever increasing success giving these girls hope of a brighter future. Video clips of the procedure will be shown. Diagnosis and management of such cases with their endoscopic approach will be discussed. I178 Laparoscopy in a rural setting D. Kruschinski1 , D. Nesselroade2 . 1 Endoscopic Gynaecology Centers, Germany; 2 Woman’s and Infants hospital, Koutila, Mali Problem: In rural areas, especially in those of underdeveloped countries, 20% of surgeons are addressing the need of 80% of the population without basic infrastructure power, water and sanitation. Improvisations are made to ensure basic surgical care. For example rain water is harvested in nursing homes for water
supply, a charcoal furnace powers the autoclave, large windows which catch sunlight compensate for interrupted electric supply, all hospital equipment is fabricated by the village blacksmith, the rear wheel of a bicycle doubles as a haemotocrit centrifuge. The rural surgeon will improve his surgical care by sterilizing his instruments in water boiling over a kerosene stove, with an untrained anaesthetist or paramedic using ether anaesthesia, with an unqualified nurse as his sole assistant, quite often with torn or even no surgical gloves. Even if hospitals with little infrastructure are available, there is only basic equipment for laparotomy and most of the surgeries are performed in spinal anaesthesia by trained paramedics. In most of the underdeveloped countries and rural areas medical CO2 can not be supplied. Most of the hospitals can not afford the laparoscopic equipment needed, like laparoscopic instruments and special washing machines. Thus laparoscopic surgery with laparoscopic instruments can not be established in a rural setting. Proposal: Lift-laparoscopy is a new concept of gasless laparoscopy (without CO2 ) where the abdominal wall is lifted by a reusable abdominal retraction system, the Abdo-Lift™. It offers exposure and vision equal to that of pneumoperitoneum. It combines the advantages of laparoscopy (small incisions, short hospitalisation, minimal trauma, magnification) and of laparotomy (standard procedures and conventional instruments). Avoiding utilisation of expensive laparoscopic instruments and especially disposables is a cost saving alternative. The learning curve is very short therefore this technique of laparoscopy could be utilized by every surgeon. To establish laparoscopic surgery in underdeveloped countries, we conduct courses for Lift-laparoscopy. After teaching lift-laparoscopy for 7–14 days, local surgeons are able to perform minor laparoscopic procedures and improve their skills with time to master advanced surgeries later. Mostly performed under spinal anaesthesia the cost is very low. If one was only interested in doing tubals, there is even no need for the camera or monitor. Lift-Laparoscopy could be performed only with a scope, a light source and an electrocautery unit – or perhaps a Fallope ring or clip applier. If CO2 cylinders have to be transported 200 kilometres over rough terrain to refill, the use of gasless laparoscopy would be available, accessible, acceptable, affordable, and hence appropriate. I179 Analgesia and anaesthesia for the obese parturient K.M. Kuczkowski. Departments of Anesthesiology and Obstetrics and Gynecology, Texas Tech University Health Sciences Center at El Paso, Paul L. Foster School of Medicine, El Paso, TX, USA “The position of woman in any civilization is an index of the advancement of that civilization; the position of woman is gauged best by the care given her at the birth of her child.” [Haggard HW, New York, 1929]. The safety of obstetric anesthesia has been debated since its “birth” in 1847, when James Young Simpson (the Scottish obstetrician) first administered “modern” obstetric anesthesia for vaginal delivery. Today obstetric anesthesia has become a recognized subspecialty of anesthesiology and an integral part of practice of most anesthesiologists. Perhaps no other subspecialty of anesthesiology provides more personal gratification than the practice of obstetric anesthesia. An obstetric anesthesiologist has become an essential member of the obstetric care team, who closely works with the obstetrician, midwife, neonatologist and Labor and Delivery nurse to ensure the highest quality care for the parturient and her baby. Obesity is perhaps the most common nutritional disorder seen in pregnancy, and obese parturients have more pregnancy complication than normal body mass index (BMI) pregnant patients. Combined spinal epidural anesthesia (CSEA) has become a well-established alternative to epidural analgesia for labor pain and surgical anesthesia in many institutions. However, due to lack of an appropriately long needle design, its advantages have not
I173 Preinvasive vulval lesions R.W. Jones. National Women’s Hospital, Auckland, New Zealand Squamous cell carcinoma of the vulva (SCCV) usually arises in a background of abnormal skin. Broadly, SCCV arises in precursor lesions which are either 1. non-HPV related chronic dermatoses, usually lichen sclerosus, often with associated differentiated VIN or 2. HPV-related “usual type” VIN. 1. Lichen sclerosus (LS): This is a chronic dermatosis, thought to be autoimmune in origin, seen most commonly in the vulva of middle aged and elderly women. Topical potent corticosteroids have revolutionised management. Older literature suggests that approximately 5% of women with LS will eventually develop SCCV. This figure is probably too high, particularly in a population of women who are under surveillance and treatment. The development of SCCV in women with LS appears to be largely restricted to women with additional skin pathology – often localised hyperkeratosis and where there is histological evidence of underlying differentiated VIN. Differentiated VIN has a relatively brief transit interval to invasion. The lesion should be surgically excised. 2. Usual type (HPV-related) VIN: The demographic profile of women with this condition is identical with CIN. At least 30% of women with VIN have a history of HPV-associated lower genital tract neoplasia, usually CIN3. 80% are HPV16 positive. There has been a striking increase in the incidence of VIN in younger women in recent decades with a corresponding increase in the incidence of VIN-related SCCV in younger women. VIN lesions are remarkably heterogeneous in appearance. The VIN grading system is a convenient histological description of a spectrum of epithelial changes, but it is not evidence of a biological continuum. VIN1 has been removed from recent terminology because it is not histologically “reproducible” and there is no evidence that it is a cancer precursor. VIN2 and VIN3 are now termed VIN ‘usual type’. The natural history of VIN remains a contentious issue with many authors failing to recognise the natural history can only be appreciated in untreated lesions that have been observed indefinitely. Few cases meet these criteria. Nonetheless, the morphology (VIN at the margin of a SCCV, microinvasion in a field of VIN), molecular evidence (integration of HPV16 into the host cell genome), case series of untreated VIN progressing to invasion and epidemiological evidence (trends in VIN and SCCV especially in younger women) – all point to the invasive potential of VIN. The mean interval to invasion in untreated VIN is 4 years. Spontaneous regression of VIN occurs in a well defined subset of very young women (teenagers and early 20’s) who present with multifocal, pigmented papules. The gold standard treatment of VIN is conservative local excision. In skilled hands the laser is equally effective in selected cases. Newer medical modalities, e.g., Imiquimod, point to a more rational approach to management. Longer term follow-up studies are still required. I174 Cervical cancer prevention and HPV vaccines: Projected impact, cost-effectiveness, cost, financing and global policy and opinion
S43
and 100% effective in preventing cervical lesions, when given to girls not infected with these HPV types. Models estimate that the widespread use of the vaccines among young adolescent girls has the potential to reduce cervical cancer deaths by 50–71% and incidence by 35–80%, depending on immunization coverage and duration of protection. The greatest impact is expected in low and middle income countries. Cost effectiveness models report that high vaccine coverage among young adolescent girls would reduce costs associated with cervical cancer control and treatment. National HPV vaccination programs would be cost effective in countries where per capita gross domestic product is high or, in low and middle income countries, if the cost per vaccinated girl is
A.O. Jumaan
H.C. Kitchener
In 2005, about 500 000 cases of cervical cancer and 270,000 deaths were estimated worldwide. The highest incidence and mortality rates are in sub-Saharan Africa, Latin America, and South Asia. About 80% of cervical cancer deaths occur in developing countries. Currently, two HPV vaccines are available for the prevention of infection with HPV types 16 and 18 that are associated with 70% of cervical cancer cases. Clinical trials showed that both vaccines are 95% effective in preventing HPV 16, 18 persistent infections
Surgery is the mainstay of treatment for endometrial cancer, which is increasing in incidence in developed countries, as a result of the obesity epidemic and increasing life expectancy. The large majority of cases are FIGO Stage 1, for which the standard of care until recently has been total abdominal hysterectomy (Hyst) and bilateral salpingo-oophorectomy (BSO), with adjutant radiotherapy given in high risk cases. FIGO staging requires a lymphadenectomy, including both pelvic and paraaortic groups of nodes, as a result of which the
S44
Invited presentations / International Journal of Gynecology & Obstetrics 107S2 (2009) S1–S92
practice of lymphadenectomy has increased. The issue of whether lymphadenectomy is therapeutic as well as prognostic has been unresolved until very recently. Retrospective analysis of registry data have shown and association between node dissection and improved survival but confounding factors prevent a causal link being established. In the last year two prospective randomised controlled trials have been published [1,2], both of which showed no difference in overall or recurrence-free survival when Hyst and BSO are compared with Hyst and BSO plus lymphadenectomy. This lack of clinical effectiveness combined with longer operative times and greater morbidity means that routine lymphadenectomy cannot be justified. Furthermore, the increasing use of systemic therapy for high-risk disease irrespective of node status further undermines the rationale for lymphadenectomy. The role of surgery for more advanced and recurrent disease will also be reviewed, as well as the implications for surgery of new FIGO staging. Reference(s) [1] Panici et al. J Natl Cancer Inst 2008; 100:1707–16 [2] ASTEC Writing Committee. The Lancet 2009; 373: 125–36.
I177 Management of congenital malformations in young girls A. Kriplani. Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India Maldevelopment of the urogenital tract occurs in a variety of forms with incidences of 0.16 to 10% have been reported. The diagnosis and management of young girls with Mullerian ¨ anomalies requires not only knowledge of embryologic development, but an awareness of the known associations, including renal anomalies and anorectal malformations. Common presenting symptoms are primary amenorrhoea, cryptomenorrhoea with haematometra and hematocolpos depending on the site of the defect. Young girls with primary amenorrhoea are usually diagnosed with Meyer Rokitansky Kuster Hauser syndrome (MRKH). These girls will require a vaginoplasty. The most common procedures performed are McIndoe’s vaginopasty using an amnion graft and Williams vaginoplasty, commoner being McIndoe’s which is simpler, however it is not preferred in patients with associated pelvic kidney or those requiring repeat procedures, in whom Williams vaginoplasty is performed. Video clips of both procedures will be shown. Young girls presenting with crytpmenorrhoea, haematometra, and haematocolpos are usually those with imperforate hymen, transverse vaginal septums or rarely cervical agenesis. Imperforate hymen is common with a simple surgical solution of a cruciate incision.. Similarly patients with transverse vaginal septum require excision of the septum or a Jeffcoate’s vaginoplasty. In those with cervical agenesis treatment in the past was only hysterectomy or rarely cervicovaginoplasty requiring huge abdominal incisions. This was both emotionally and physically traumatizing for the patients. With the advancement of endoscopy laparoscopic cervicovaginoplasty is being performed with ever increasing success giving these girls hope of a brighter future. Video clips of the procedure will be shown. Diagnosis and management of such cases with their endoscopic approach will be discussed. I178 Laparoscopy in a rural setting D. Kruschinski1 , D. Nesselroade2 . 1 Endoscopic Gynaecology Centers, Germany; 2 Woman’s and Infants hospital, Koutila, Mali Problem: In rural areas, especially in those of underdeveloped countries, 20% of surgeons are addressing the need of 80% of the population without basic infrastructure power, water and sanitation. Improvisations are made to ensure basic surgical care. For example rain water is harvested in nursing homes for water
supply, a charcoal furnace powers the autoclave, large windows which catch sunlight compensate for interrupted electric supply, all hospital equipment is fabricated by the village blacksmith, the rear wheel of a bicycle doubles as a haemotocrit centrifuge. The rural surgeon will improve his surgical care by sterilizing his instruments in water boiling over a kerosene stove, with an untrained anaesthetist or paramedic using ether anaesthesia, with an unqualified nurse as his sole assistant, quite often with torn or even no surgical gloves. Even if hospitals with little infrastructure are available, there is only basic equipment for laparotomy and most of the surgeries are performed in spinal anaesthesia by trained paramedics. In most of the underdeveloped countries and rural areas medical CO2 can not be supplied. Most of the hospitals can not afford the laparoscopic equipment needed, like laparoscopic instruments and special washing machines. Thus laparoscopic surgery with laparoscopic instruments can not be established in a rural setting. Proposal: Lift-laparoscopy is a new concept of gasless laparoscopy (without CO2 ) where the abdominal wall is lifted by a reusable abdominal retraction system, the Abdo-Lift™. It offers exposure and vision equal to that of pneumoperitoneum. It combines the advantages of laparoscopy (small incisions, short hospitalisation, minimal trauma, magnification) and of laparotomy (standard procedures and conventional instruments). Avoiding utilisation of expensive laparoscopic instruments and especially disposables is a cost saving alternative. The learning curve is very short therefore this technique of laparoscopy could be utilized by every surgeon. To establish laparoscopic surgery in underdeveloped countries, we conduct courses for Lift-laparoscopy. After teaching lift-laparoscopy for 7–14 days, local surgeons are able to perform minor laparoscopic procedures and improve their skills with time to master advanced surgeries later. Mostly performed under spinal anaesthesia the cost is very low. If one was only interested in doing tubals, there is even no need for the camera or monitor. Lift-Laparoscopy could be performed only with a scope, a light source and an electrocautery unit – or perhaps a Fallope ring or clip applier. If CO2 cylinders have to be transported 200 kilometres over rough terrain to refill, the use of gasless laparoscopy would be available, accessible, acceptable, affordable, and hence appropriate. I179 Analgesia and anaesthesia for the obese parturient K.M. Kuczkowski. Departments of Anesthesiology and Obstetrics and Gynecology, Texas Tech University Health Sciences Center at El Paso, Paul L. Foster School of Medicine, El Paso, TX, USA “The position of woman in any civilization is an index of the advancement of that civilization; the position of woman is gauged best by the care given her at the birth of her child.” [Haggard HW, New York, 1929]. The safety of obstetric anesthesia has been debated since its “birth” in 1847, when James Young Simpson (the Scottish obstetrician) first administered “modern” obstetric anesthesia for vaginal delivery. Today obstetric anesthesia has become a recognized subspecialty of anesthesiology and an integral part of practice of most anesthesiologists. Perhaps no other subspecialty of anesthesiology provides more personal gratification than the practice of obstetric anesthesia. An obstetric anesthesiologist has become an essential member of the obstetric care team, who closely works with the obstetrician, midwife, neonatologist and Labor and Delivery nurse to ensure the highest quality care for the parturient and her baby. Obesity is perhaps the most common nutritional disorder seen in pregnancy, and obese parturients have more pregnancy complication than normal body mass index (BMI) pregnant patients. Combined spinal epidural anesthesia (CSEA) has become a well-established alternative to epidural analgesia for labor pain and surgical anesthesia in many institutions. However, due to lack of an appropriately long needle design, its advantages have not