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Late results of pelvic surgery
LATE II. F~JGENE
RESULTS
Some Results Following T.
ELLISON,
M.D., (From
AND
OF PELVIC
Hysterectomy L).
WILLIAM
Tczarl.nm
SURGERY’:’
and Pelvic Plastic Procedures M.lI.,
THORSTON,
ant1 Yt. Miclmcl
TEXARKANA,
TEXAS
‘s IIospitnls)
N 11 previous
publication,’ attention was directed lo the large llurrlbcr OK functional and organic disortlt>rs following pelvic surgery among patiel1t.s who Mnie to our clinic for subsequent dare. The ljatients whose surg;cry ill~luclrtl hysterectomy presentect less persistent symptoms. however, than those
I
who had had other types of gynecological
swge1.y.
It. seemed, therefore, imperative that we should analyze the results of our I)ctxcmaI surgery, in order tt) attempt to eslablish reasons for the improved c~otl~litions of the patients who hat1 IWWI subjected to hysterectomy. Th? r(lcc)r(ls from our two local hosljitals wcrt: rsaminecl and all of our major gynrlcological surgical CUSPS were compared with (1~11’ follow-up office records. i \n insignificant numl)er involving emergency surgery for ovarian and tubal l~i~tht~logy were esclutled as werr cases involving tlisea.sesof the vulva. The majority of the cases had been seen IQ- members of our clinic after the initial phase of healing, and therefore all those we subjected to surgery were included t’or the completeness of the surrey. A frw had bctbn seen by ot,her gynecologists, urologists, or referring physicians who relayctl their outcome to US. Ry reference to 7‘abk I, it is see11 that thew w*ere 236 cases involving hyst.erectomy and 100 vaginal I)last.ie proc&ures csarried out through the five and one-half year period. Of this tlnmbc~r, tot.;11;Mominal. hysterectomy. with or without adnesal su~mqv or rq);tir l,t*oc*cc.lurc~s. constituted 70 per cent for 24 per rent o F OLW hysterectomy cases. \‘aginwl liystcrerto1rl). ilc~c~OWlt.~~l and subtotal hyst,erectomy 6 per cent. Of the 236 hysterectomies, 31 had an associated vaginal repair, but only 8 had estensivc \vork including vaginal The latter l~roc+edureconstitutes a timrrepair of the anterior vaginal Willl. consuming procedure which xtlds to t,hc surgical risk, while perincorrhar)hy, with or without the nlarshnll-hlal.chetti-h-raI~t~ proce’dure. does not atltl materially to the surgical risk of hystertJc4olll.v. In our previous st,ltdy, a. ~~rnnhn~ of l)atie1rts who had had abdominal lr-sterectomy came to our offices bccausc of c-stoccl(x, rt~ctoccles, and shortened vaginas. We therefore athempted to t\-aln;~tc eac:h case prior to surgery in terms of pelvic support, in addition to the more obvious complaints of pa.in. bleeding, discharge, or other disorders incident to il disease of the uterus. We then added to our hysterect0m.v techniqnti a repair of the fascial relaxation a.round the uterus, and repair of t.he p+lt*ineum if it seemed indicated at the (xtrd of the abdominal or vaginal hysterectomy. and
*presented Gynecologists,
at
the Twenty-sixth Houston. Texas,
Annual Feb. 26,
Meeting 1955. 4X6
of
the
Texas
Association
of
Obstetricians
Volume Number
70 3
LATE TABLE
RESULTS I.
TYPE
OF
OF SURGERY
OPERATION Hysterectomy, Hysterectomy, adnexa Hysterectomy, adnexa
abdominal, abdominal, on 1 side abdominal, on both sides
PELVIC AND
TOTAT,
SURGERY
487
AGE
DISTRIBUTIOX
25-30
I 30-4)
AGE j do-50
1 50.60
53
6
complete complete
+
14
9
complete
+
8
IS
1 60
+ 3
I
133 Hysterectomy, Hysterectomy, 1 side Hysterectomy, both sides
supravaginal supravaginal
+ adnexa
on
1
4 5
supravaginal
+ adnexa
on
3
Hysi
vaginal
1
13 erectomy,
+ repair
11 57
Hysterectomy Hysterectomy Hysterectomy
+ anterior-posterior + marchetti + perineal + perineal
repair
4 1 7 RJ
~Tota,l
236
Vaginal
repair, anterior-posterior of cervix Vaginal repair, anterior-posterior tation of cervix Repair cervix and perineum Repair perineum Vaginal or abdominal suspensiou perineal repair Total repair
+ couiza-
5
b,., A-
11
G
+ ampu-
C,
4
1
1
14 3 7
4 4
+
6 1 5
G
tion
Grand
~_
total
100 336
The majority of the vaginal repair procedures consist,ed of anterior and posterior vaginal repair with cauterization, conization, or amputation of the cervix. Our technique differed only in that an attempt to support the cervix was made by an incision posterior to the cervix. Through this incision the uterosacral ligaments were shortened, in an attempt to raise the uterus higher into the pelvis. Pelvic exploration was made, if indicated, through the cul-desac incision. TABLE
IT.
INDICATIOXS
1 y;;: Total hysterectomy (133) Subtotal hysterectomy (13) Vaginal hysterectomy (57) Hysterectomy and (34) Vaginal repair (100) *13
cases
vaginal
repair
FOR
1 B::gG
SURGERY
/ yg:-
/ ‘,‘ul\Io,Ls
111
84
20
11
13
3
40
11
.57
34
on
34
100
24
300
76*
j ‘:::c:
1 y;;” 5
15
9 13
13”
6 10
5 6 55
endometriosis.
The age span of these patients is essentially the same, though, of course, more older patients had vaginal hysterectomies, and a younger group the
Table III lists the disorders which were foulld among patients who r~turned one or more years after surgery. It is impossible to indicate Ihc~ severity of these symptoms as many degrees of emotional tension and generaI However, moderate to mild symptoms physical disease influenced the patients. It is significant that among the and disorders are included for emphasis. patients who had vaginal plastic procedures, there did develop diseases of thv colon. uterus, and ovaries. These diseases might well have contributed to th
Volume
70
Number
3
LATE
RESULTS
OF
PELVIC
SURGERY
489
surgery, while stress incontinence has not been frequently encountered. Cervical disorders caused many late postoperative symptoms. Our experience suggests that the endocervix is one of the most sensitive areas of the female pelvis, and the trauma incident to conization, or partial amputation, often leads to disabling symptoms. This is further borne out by the relief of much lower abdominal pain after total hysterectomy. Dyspareunia, vaginal stenosis, and mild degrees of recurrence of pelvic ligament relaxations were more frequent after vaginal hysterectomy and vaginal plastic cases. The vagina appeared to be better supported and more elastic in patients who had abdominal hysterectomy as compared with those who had vaginal plastic procedures. It is, of course, obvious that there would be more recurrence of vaginal symptoms following plastic procedures because the pelvic relaxations were much more severe in the lat,ter group. We are positive, however, that our technique of hysterectomy with endopelvic support procedures gives an excellent vaginal support which produces no dyspareunia, and prevents subsequent pelvic relaxations which are known to follow hysterectomy all too frequently. Accurate evaluation of emotional disorders is impossible but more painful fixations remained after the vaginal plastic operations than other gynecological One of our worst results was a painful retrodisplacement of the surgery. uterus with a definite syndrome of pelvic congestion” after an excellent-appearing Manchester operation. Psychiatric help is of little avail to the person who considers herself a surgical cripple. Added empha.sis to the emotional side was brought out recently by a patient who had had a most successful vaginal hysterectomy with good support and no urinary symptoms, but who stated that there had been no sexual desire since the operation. It goes without saying that this would be a difficult problem to reverse in a woman of 52 years. TABLZ
IV.
COMPOSITE
RESULTS
OF SURGERY
_____
PATIENT'S CONDITION AFTER 1 OR MORE YEARS SYMPTOMATIC
TYPE
OF SURGERY
Total hysterectomy Subtotal hysterectomy Vaginal hysterectomy Ryst,ereetomy and repair Plastic repair only -
TOTAL CASES
112 i3 57 1,“:
AVERAGE AGE
43 45 50 41 38
ASYMPTOMATIC
105 11 40 28 59
FITNC-
ORGANIC
17 1 13 3 34
TIONAT,
9 1 5 a 14
Our series is, of course, small and statistically of little value, but bears out certain significant principles. Removal of the entire uterus with or without the adnexa eliminates a site of much pelvic pain, and relieves the functional bleeding with its accompanying anxiety (Table IV). This is further borne out by the painful disorders remaining after conization or partial amputation of the cervix. Removal of the uterus also allows the surgeon free access to the strong endopelvic fascia in construction of good pelvic support. On the
other hand, the vaginal plastic procedurrs must depend on the fascia below the bladder and over the rectum for most of the support. In vaginal hysterectolrl>.. OII~ has access to the stronger p(lLvic ligaments, bitt ill th(J altempt to 4vtk good support, vaginal space is swr*ifcwl ill soinc cases. This bec’otlles Of m increasing importance as the life slml i1JllI \.itnlity oi’ (IW MCI? art: celtailrl) ii,~reasing, The average age of OLII‘ patit:nt,s iTable I\- iutlicat.rs that future childhea I’ilig is not, a significant, factor anti certainly surgical skill has reduced t,he risk (if h~Stf2rCCtOI~l~~ t0 a very IOW figLlW.” We have cncountcred considerable shortening of the anterior V~lgillid wall in cases of anterior and posterior repilir with resulting dyspareunin ant1 urinary symptoms. This has led to the tltl(lcd technique of shortening the nterosacra,l ligaments ilk vaginal plastic work and thus I’nrther utilizing the supports of the uterus when there is :I cystocelc, rectocele, or perineal relaxation. Recent publicat,ions”-’ hnvc applietl many of these principles to vaginal hysterectomy as a superior method of pelvic repair, while others draw attcntic)11t11the uterus as a site of much pelvic pain.” Care in selection of casesfor Gynecologists must deal with pcl~ic surgery is repeatedly emphasized.‘-” pathology of the reproductive organs, trauma from childbearing, plus the CJ~~Otio1l;t.l stability of the patients. To accomplish these objectives, our snrgeq must remove pathology and do repair work which will be depended upon to keep OLII patients in a good physical and emotional state for a span of many years.
Summary
and Conclusion
It is therefore increasingly evident Cram our studies that hysterectomy undt~r proper indications leads to less persistent symptomatology than most clthcr gynecological surgery. Its inclusion with pelvic plastic procedures at the proper age and with justifiable indications seemsto improve the chances of Insiting surgical cure from the pelvic relaxation. This is undoubtedly due tcJ brt ter exposure and repair of the endopelvic fascia incident to hysterect,omy, and t,o the removal of a structure which can at any a.ge be a site of ma.ny additional pathological and emotional symptoms.
References 1. $:llison, 2. Ta,vlor, :I. IYard, 4. 5. 6. 7. 5. 9. 10. Il. 12.
Eugene T., and Thornton, IVilliam I).: South. M. J. 47: 913, 795J. Howard C., Jr.: AK J. OBST. $ Gyms. 7: 1177, 195-L. Simon V., Sellers, Thomas Benton, and IJaven, .Julius T., *Jr.: South. 1(X37, 1954. Ilrown, Willis E., and Stenstrnm, William $1.: South . 31. / .J-. 46. , i
M.
17:
.I. 47:
1811,
Vulumr
Nmdm
i0
i
LATE
RESULTS
OF
PELVIC
SURGERY
491
Discussion DR. M. H. TALTY,
Houston, Texas.-It
is a pleasure to discuss this paper, which like its predecessor emphasizes some of the pitfalls of incomplete gynecological surgery. When one considers that the uterus, once a woman has passed the reproductive years of her life, or has borne her desired number of children, becomes a useless, and frequently a debilitating, and occasionally a dangerous, organ, the rationale of leaving behind all or part of must be considered faulty surgical that uterus, except under unusual circumstances, judgment. This is well exemplified in the essayists’ presentation today and is a reminder that we can well heed. Careful preoperative evaluation, as has been stressed today, of t,he complaints which bring the patient to us, of the pathology at hand, of what one hopes to accomplish, and then of the best method of reaching that goal with permanent benefits to the patient should be a routine procedure with everyone who undertakes to do pelvic surgery. Preoperative urological investigation should certainly never be neglected when there is the least hint that the cause of pelvic complaint might be within the urinary tract. There is still no substitute for sound surgical judgment in spite of the relat.ive safety of pelvic surgery today. Ideally, in the childbearing years, especially in the woman who has not yet attained her family, surgery should be delayed where it is possible and safe, with reassurance and conservative measures until such time as future childbearing is no longer an issue. Very occasionally, however, some surgical procedure is essential for relief of symptoms and/or pathology, and if that patient can be relieved, and her childbearing ability be preserved or improved, while she realizes the possibly temporizing nature of that surgery, I cannot help but feel it is justified, regardless of whether she must later return for a more extensive procedure. It goes without, saying that there is a logical limit to such temporizing. The choice of abdominal versus vaginal hysterectomy will always be an individual one. So long as the vaginal method is not shelved because of lack of familiarity with the procedure there cannot be too much controversy here. It is my individual opinion that the vaginal approach, where feasible, offers better utilization of the pelvic ligaments, makes cystocele and rectocele repair simpler, and cuts down operative time and morbidity, especially where there is decensus plus symptomatic The authors have well stressed the desirability of hystereccystocele or cystourethroeele. tomy when pelvic surgery is undertaken, and the part it plays in cutting down the number of postoperative complaints and disorders. They must not be construed as advocating wholesale or unnecessary hysterectomy, but to leave the uterus behind, once its childbearing function ceases, is to invite these sequelae. The finding of three incidental endometrial carcinomas gives further emphasis to this conclusion. We still see too many carcinomas of the cervical stump and too many cervical carcinomas in women recently subjected to pelvic surgery. There can be no question as to their presence at the time of Adequate work-up would bring proper and earlier treatment to the latter operation. group and total hysterectomy will, we hope, soon make such an occurrence the rarity it should be.
RESULTS
Some Results Following T.
ELLISON,
M.D., (From
AND
OF PELVIC
Hysterectomy L).
WILLIAM
Tczarl.nm
SURGERY’:’
and Pelvic Plastic Procedures M.lI.,
THORSTON,
ant1 Yt. Miclmcl
TEXARKANA,
TEXAS
‘s IIospitnls)
N 11 previous
publication,’ attention was directed lo the large llurrlbcr OK functional and organic disortlt>rs following pelvic surgery among patiel1t.s who Mnie to our clinic for subsequent dare. The ljatients whose surg;cry ill~luclrtl hysterectomy presentect less persistent symptoms. however, than those
I
who had had other types of gynecological
swge1.y.
It. seemed, therefore, imperative that we should analyze the results of our I)ctxcmaI surgery, in order tt) attempt to eslablish reasons for the improved c~otl~litions of the patients who hat1 IWWI subjected to hysterectomy. Th? r(lcc)r(ls from our two local hosljitals wcrt: rsaminecl and all of our major gynrlcological surgical CUSPS were compared with (1~11’ follow-up office records. i \n insignificant numl)er involving emergency surgery for ovarian and tubal l~i~tht~logy were esclutled as werr cases involving tlisea.sesof the vulva. The majority of the cases had been seen IQ- members of our clinic after the initial phase of healing, and therefore all those we subjected to surgery were included t’or the completeness of the surrey. A frw had bctbn seen by ot,her gynecologists, urologists, or referring physicians who relayctl their outcome to US. Ry reference to 7‘abk I, it is see11 that thew w*ere 236 cases involving hyst.erectomy and 100 vaginal I)last.ie proc&ures csarried out through the five and one-half year period. Of this tlnmbc~r, tot.;11;Mominal. hysterectomy. with or without adnesal su~mqv or rq);tir l,t*oc*cc.lurc~s. constituted 70 per cent for 24 per rent o F OLW hysterectomy cases. \‘aginwl liystcrerto1rl). ilc~c~OWlt.~~l and subtotal hyst,erectomy 6 per cent. Of the 236 hysterectomies, 31 had an associated vaginal repair, but only 8 had estensivc \vork including vaginal The latter l~roc+edureconstitutes a timrrepair of the anterior vaginal Willl. consuming procedure which xtlds to t,hc surgical risk, while perincorrhar)hy, with or without the nlarshnll-hlal.chetti-h-raI~t~ proce’dure. does not atltl materially to the surgical risk of hystertJc4olll.v. In our previous st,ltdy, a. ~~rnnhn~ of l)atie1rts who had had abdominal lr-sterectomy came to our offices bccausc of c-stoccl(x, rt~ctoccles, and shortened vaginas. We therefore athempted to t\-aln;~tc eac:h case prior to surgery in terms of pelvic support, in addition to the more obvious complaints of pa.in. bleeding, discharge, or other disorders incident to il disease of the uterus. We then added to our hysterect0m.v techniqnti a repair of the fascial relaxation a.round the uterus, and repair of t.he p+lt*ineum if it seemed indicated at the (xtrd of the abdominal or vaginal hysterectomy. and
*presented Gynecologists,
at
the Twenty-sixth Houston. Texas,
Annual Feb. 26,
Meeting 1955. 4X6
of
the
Texas
Association
of
Obstetricians
Volume Number
70 3
LATE TABLE
RESULTS I.
TYPE
OF
OF SURGERY
OPERATION Hysterectomy, Hysterectomy, adnexa Hysterectomy, adnexa
abdominal, abdominal, on 1 side abdominal, on both sides
PELVIC AND
TOTAT,
SURGERY
487
AGE
DISTRIBUTIOX
25-30
I 30-4)
AGE j do-50
1 50.60
53
6
complete complete
+
14
9
complete
+
8
IS
1 60
+ 3
I
133 Hysterectomy, Hysterectomy, 1 side Hysterectomy, both sides
supravaginal supravaginal
+ adnexa
on
1
4 5
supravaginal
+ adnexa
on
3
Hysi
vaginal
1
13 erectomy,
+ repair
11 57
Hysterectomy Hysterectomy Hysterectomy
+ anterior-posterior + marchetti + perineal + perineal
repair
4 1 7 RJ
~Tota,l
236
Vaginal
repair, anterior-posterior of cervix Vaginal repair, anterior-posterior tation of cervix Repair cervix and perineum Repair perineum Vaginal or abdominal suspensiou perineal repair Total repair
+ couiza-
5
b,., A-
11
G
+ ampu-
C,
4
1
1
14 3 7
4 4
+
6 1 5
G
tion
Grand
~_
total
100 336
The majority of the vaginal repair procedures consist,ed of anterior and posterior vaginal repair with cauterization, conization, or amputation of the cervix. Our technique differed only in that an attempt to support the cervix was made by an incision posterior to the cervix. Through this incision the uterosacral ligaments were shortened, in an attempt to raise the uterus higher into the pelvis. Pelvic exploration was made, if indicated, through the cul-desac incision. TABLE
IT.
INDICATIOXS
1 y;;: Total hysterectomy (133) Subtotal hysterectomy (13) Vaginal hysterectomy (57) Hysterectomy and (34) Vaginal repair (100) *13
cases
vaginal
repair
FOR
1 B::gG
SURGERY
/ yg:-
/ ‘,‘ul\Io,Ls
111
84
20
11
13
3
40
11
.57
34
on
34
100
24
300
76*
j ‘:::c:
1 y;;” 5
15
9 13
13”
6 10
5 6 55
endometriosis.
The age span of these patients is essentially the same, though, of course, more older patients had vaginal hysterectomies, and a younger group the
Table III lists the disorders which were foulld among patients who r~turned one or more years after surgery. It is impossible to indicate Ihc~ severity of these symptoms as many degrees of emotional tension and generaI However, moderate to mild symptoms physical disease influenced the patients. It is significant that among the and disorders are included for emphasis. patients who had vaginal plastic procedures, there did develop diseases of thv colon. uterus, and ovaries. These diseases might well have contributed to th
Volume
70
Number
3
LATE
RESULTS
OF
PELVIC
SURGERY
489
surgery, while stress incontinence has not been frequently encountered. Cervical disorders caused many late postoperative symptoms. Our experience suggests that the endocervix is one of the most sensitive areas of the female pelvis, and the trauma incident to conization, or partial amputation, often leads to disabling symptoms. This is further borne out by the relief of much lower abdominal pain after total hysterectomy. Dyspareunia, vaginal stenosis, and mild degrees of recurrence of pelvic ligament relaxations were more frequent after vaginal hysterectomy and vaginal plastic cases. The vagina appeared to be better supported and more elastic in patients who had abdominal hysterectomy as compared with those who had vaginal plastic procedures. It is, of course, obvious that there would be more recurrence of vaginal symptoms following plastic procedures because the pelvic relaxations were much more severe in the lat,ter group. We are positive, however, that our technique of hysterectomy with endopelvic support procedures gives an excellent vaginal support which produces no dyspareunia, and prevents subsequent pelvic relaxations which are known to follow hysterectomy all too frequently. Accurate evaluation of emotional disorders is impossible but more painful fixations remained after the vaginal plastic operations than other gynecological One of our worst results was a painful retrodisplacement of the surgery. uterus with a definite syndrome of pelvic congestion” after an excellent-appearing Manchester operation. Psychiatric help is of little avail to the person who considers herself a surgical cripple. Added empha.sis to the emotional side was brought out recently by a patient who had had a most successful vaginal hysterectomy with good support and no urinary symptoms, but who stated that there had been no sexual desire since the operation. It goes without saying that this would be a difficult problem to reverse in a woman of 52 years. TABLZ
IV.
COMPOSITE
RESULTS
OF SURGERY
_____
PATIENT'S CONDITION AFTER 1 OR MORE YEARS SYMPTOMATIC
TYPE
OF SURGERY
Total hysterectomy Subtotal hysterectomy Vaginal hysterectomy Ryst,ereetomy and repair Plastic repair only -
TOTAL CASES
112 i3 57 1,“:
AVERAGE AGE
43 45 50 41 38
ASYMPTOMATIC
105 11 40 28 59
FITNC-
ORGANIC
17 1 13 3 34
TIONAT,
9 1 5 a 14
Our series is, of course, small and statistically of little value, but bears out certain significant principles. Removal of the entire uterus with or without the adnexa eliminates a site of much pelvic pain, and relieves the functional bleeding with its accompanying anxiety (Table IV). This is further borne out by the painful disorders remaining after conization or partial amputation of the cervix. Removal of the uterus also allows the surgeon free access to the strong endopelvic fascia in construction of good pelvic support. On the
other hand, the vaginal plastic procedurrs must depend on the fascia below the bladder and over the rectum for most of the support. In vaginal hysterectolrl>.. OII~ has access to the stronger p(lLvic ligaments, bitt ill th(J altempt to 4vtk good support, vaginal space is swr*ifcwl ill soinc cases. This bec’otlles Of m increasing importance as the life slml i1JllI \.itnlity oi’ (IW MCI? art: celtailrl) ii,~reasing, The average age of OLII‘ patit:nt,s iTable I\- iutlicat.rs that future childhea I’ilig is not, a significant, factor anti certainly surgical skill has reduced t,he risk (if h~Stf2rCCtOI~l~~ t0 a very IOW figLlW.” We have cncountcred considerable shortening of the anterior V~lgillid wall in cases of anterior and posterior repilir with resulting dyspareunin ant1 urinary symptoms. This has led to the tltl(lcd technique of shortening the nterosacra,l ligaments ilk vaginal plastic work and thus I’nrther utilizing the supports of the uterus when there is :I cystocelc, rectocele, or perineal relaxation. Recent publicat,ions”-’ hnvc applietl many of these principles to vaginal hysterectomy as a superior method of pelvic repair, while others draw attcntic)11t11the uterus as a site of much pelvic pain.” Care in selection of casesfor Gynecologists must deal with pcl~ic surgery is repeatedly emphasized.‘-” pathology of the reproductive organs, trauma from childbearing, plus the CJ~~Otio1l;t.l stability of the patients. To accomplish these objectives, our snrgeq must remove pathology and do repair work which will be depended upon to keep OLII patients in a good physical and emotional state for a span of many years.
Summary
and Conclusion
It is therefore increasingly evident Cram our studies that hysterectomy undt~r proper indications leads to less persistent symptomatology than most clthcr gynecological surgery. Its inclusion with pelvic plastic procedures at the proper age and with justifiable indications seemsto improve the chances of Insiting surgical cure from the pelvic relaxation. This is undoubtedly due tcJ brt ter exposure and repair of the endopelvic fascia incident to hysterect,omy, and t,o the removal of a structure which can at any a.ge be a site of ma.ny additional pathological and emotional symptoms.
References 1. $:llison, 2. Ta,vlor, :I. IYard, 4. 5. 6. 7. 5. 9. 10. Il. 12.
Eugene T., and Thornton, IVilliam I).: South. M. J. 47: 913, 795J. Howard C., Jr.: AK J. OBST. $ Gyms. 7: 1177, 195-L. Simon V., Sellers, Thomas Benton, and IJaven, .Julius T., *Jr.: South. 1(X37, 1954. Ilrown, Willis E., and Stenstrnm, William $1.: South . 31. / .J-. 46. , i
M.
17:
.I. 47:
1811,
Vulumr
Nmdm
i0
i
LATE
RESULTS
OF
PELVIC
SURGERY
491
Discussion DR. M. H. TALTY,
Houston, Texas.-It
is a pleasure to discuss this paper, which like its predecessor emphasizes some of the pitfalls of incomplete gynecological surgery. When one considers that the uterus, once a woman has passed the reproductive years of her life, or has borne her desired number of children, becomes a useless, and frequently a debilitating, and occasionally a dangerous, organ, the rationale of leaving behind all or part of must be considered faulty surgical that uterus, except under unusual circumstances, judgment. This is well exemplified in the essayists’ presentation today and is a reminder that we can well heed. Careful preoperative evaluation, as has been stressed today, of t,he complaints which bring the patient to us, of the pathology at hand, of what one hopes to accomplish, and then of the best method of reaching that goal with permanent benefits to the patient should be a routine procedure with everyone who undertakes to do pelvic surgery. Preoperative urological investigation should certainly never be neglected when there is the least hint that the cause of pelvic complaint might be within the urinary tract. There is still no substitute for sound surgical judgment in spite of the relat.ive safety of pelvic surgery today. Ideally, in the childbearing years, especially in the woman who has not yet attained her family, surgery should be delayed where it is possible and safe, with reassurance and conservative measures until such time as future childbearing is no longer an issue. Very occasionally, however, some surgical procedure is essential for relief of symptoms and/or pathology, and if that patient can be relieved, and her childbearing ability be preserved or improved, while she realizes the possibly temporizing nature of that surgery, I cannot help but feel it is justified, regardless of whether she must later return for a more extensive procedure. It goes without, saying that there is a logical limit to such temporizing. The choice of abdominal versus vaginal hysterectomy will always be an individual one. So long as the vaginal method is not shelved because of lack of familiarity with the procedure there cannot be too much controversy here. It is my individual opinion that the vaginal approach, where feasible, offers better utilization of the pelvic ligaments, makes cystocele and rectocele repair simpler, and cuts down operative time and morbidity, especially where there is decensus plus symptomatic The authors have well stressed the desirability of hystereccystocele or cystourethroeele. tomy when pelvic surgery is undertaken, and the part it plays in cutting down the number of postoperative complaints and disorders. They must not be construed as advocating wholesale or unnecessary hysterectomy, but to leave the uterus behind, once its childbearing function ceases, is to invite these sequelae. The finding of three incidental endometrial carcinomas gives further emphasis to this conclusion. We still see too many carcinomas of the cervical stump and too many cervical carcinomas in women recently subjected to pelvic surgery. There can be no question as to their presence at the time of Adequate work-up would bring proper and earlier treatment to the latter operation. group and total hysterectomy will, we hope, soon make such an occurrence the rarity it should be.