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Outpatient cervical cold conization with cryosurgical hemostasis
June 15, 197.i
532 Communications in brief
:\ru ,
J. Obstet. Gyn
Fig. 1. Tumor is composed of an irregular mixture of fat, smooth muscle, and blood vessels. (Original magnification x450.)
not palpable. Three weeks later, a pelvic examination disclosed the uterus to be enlarged to the size of a 6 week pregnancy. The estimated date of confinement was October 2, 1974. The antenatal course was uneventful. The patient was delivered of a term-size living female child with the use of epidural anesthesia on September 2 3, 19 74. Following manual expression of the placenta, the uterine cavity was explored. Two polypoid structures were encountered and manually removed. The postpartum course was uneventful. The two soft round masses together weighed 61 grams, with the larger measuring up to 6.5 ern. in diameter, and were composed of soft, pink tissue. Histologic examination showed a mixture of mature adipose tissue, smooth muscle, and blood vessels (Fig. 1) . Most of the reported benign mixed mesodermal tumors of the uterus have occurred in elderly postmenopausal women. One large series1 reported 91 per cent occurring in women 40 years or older with a range of 23 to 81 years. The most common symptoms have been menstrual irregularities in premenopausal patients and some type of uterine bleeding in postmenopausal patients. Clinical signs and symptoms may be related to the presence of a mass. The tumors have measured up to 32 em. in diameter, but the majority were 5 to 10 em. Histologically, the tumor is similar to the angiomyolipoma of the kidney, and differences in its gross appearance are related to the variation in the relative proportions of fat, smooth muscle, blood vessels, and fibrous tissue. The gross appearance varies from pink to yellow, depending upon the relative proportion of fat. The fat may be so predominant that many of these tumors have been described as lipomas. All histologic elements are mature and, despite the abnormal mixture of tissues, should not be mistaken for malignancy. The
tumor may represent a hamartoma arising from undifferentiated mesenchymal cells. 2 The obstetrician should be aware that this tumor may be of sufficient size in a submucosal location that it may present at delivery as a significant intrauterine mass. However, its usual high fat content and resulting soft characteristic probably will prevent its interference with delivery. REFERENCES I. Brandfass, R. T., and Everts-Suarez, E. A.: AM.
J
70: 359, 1955. 2. Demopoulos, R. 1., Denarvaez, F., and Kaji, V .: Am. ]. Clin. Pathol. 60: 377, 1973. 0BSTET. GYNECOL.
Outpatient cervical cold conization with cryosurgical hemostasis C. F. McDONELL, ]R., M.D., USNR R. STENGER, M.D., F.A.C.O.G., CAPTAIN, MC, USN
LIEUTENANT COMMANDER, MC,
J.
Catawba Women's Center, Hickory, North Carolina
I N vI E w o F rising hospital costs and increasing demands on physicians' services, diagnostic Fleming knife cold conizations with cryosurgery for hemostasis are now Reprint requests: Dr. C. F. McDonell, Jr., Catawba Women's Center, P. 0. Box 2287, Hickory, North Carolina 28601.
Volume 122 Number4
Communications 1n brief
533
Table I No. of patients Age 10-19 20-29
30-39 40-49 50-59
Parity 0 1-3 4-6 7-10 10
> Fig. 1. Cold knife cone technique with the use of the Fleming knife. (From Greenhill, J. P.: Surgical Gynecology, Copyright © 1969 by Year Book Medical Publishers, Inc., Chicago. Used by permission.)
being perforrned at the Naval Hospital, Long Beach, on an outpatient basis in the Gynecology clinic. Patients found to have Class III, IV, or V Papanicolaou smears in our routine screening clinic are re-examined and the smears are reviewed to eliminate those patients with Class III smears thought to be infectious in nature. These are treated with appropriate vaginal antibiotics, and the Papanicolaou smears are repeated in 4 weeks. Patients with persistent Class III and greater smears are designated to have diagnostic conizations performed on an outpatient basis, as soon as possible. The women are counseled regarding the procedure, its effects, and possible complications_ Patient selection is employed, and those patients in whom vaginal stenosis or great redundancy of vaginal folds might cause exposure problems with local anesthesia are eliminated. The patient is then instructed to return to the clinic the next day after having nothing by mouth; she is given a bedtime pHisoHex* douche to be followed by a Furacint vaginal suppository. Consent for general as well as local anesthesia is signed. In an office minor operative suite, the vagina is prepped with Betadine,t and the cervix is grasped with a single-tooth tenaculum. A paracervical block of 1 per cent Carbocaine* plus 1: 100,000 epinephrine ( 10 c.c.) is administered in each side and allowed to take effect, and the cervix is restained with Lugol's solution. A *Winthrop Labs., Div. of Sterling Drug Inc., 90 Park Ave., New York, New York 10016. tEaton Labs., Inc., Div. Norwich Pharm. Co., 17 Eaton Ave., Norwich, New York 13815. :j:Purdue Frederick Co., 99-101 Saw Mill River Rd., Yonkers, New York 10701.
5 13 7 4 1 8 11
9 2
0
Table II Pathology Chronic cervicitis Squamous metaplasia Mild dysplasia Moderate dysplasia Severe dysplasia Carcinoma in situ Carcinoma in situ with early stromal invasion Frank carcinoma
No. of patients 3 5 2 4
5
7 2 2
Fleming knife sharp conization is then performed, and the nonstaining exocervix and cone wedge are removed to the endocervix (Fig. 1). A moderate surgical bed ooze generally occurs, and hemostasis is secured by freezing the surgical bed with the large cone probe (Freon unit ) at -60° C. for 5 minutes. The patient is then placed in the recovery area and observed for bleeding for one hour. Vital signs are monitored, and after one hour she is given oral juices and allowed to return home with instructions to report excessive bleeding or fever and to return to the clinic in 6 weeks. Four patients were excluded from the series because of vaginal stenosis or redundancy which might cause the patient discomfort with exposure under local anesthesia. These patients were admitted to the hospital for general anesthesia and the usual operative technique. Thirty outpatient conizations were performed without intraoperative difficulties. The usual blood loss averaged 25 c.c. There were no intraoperative or immediate postoperative complications. One patient experienced moderately heavy vaginal bleeding on postoperative Day 10. She was seen in the emergency room, and a vaginal pack was applied. The pack was removed, in the office, 24 hours later without further sequelae. There were no infections, and, on 6 week checkups, all cervices were well healed and showed no evidence of stenosis to sounding or residual disease by Papanicolaou or Lugol's stain.
534
June 15, 1975 ,\m. J, Obstet. Gynend.
Communications rn brief
The patients were mainlv voung women (average age 29) receiving oral contraceptives who were found to have Class III Papanicolaou smears on routine annual checkup (Table I). However, pathology encompassed the total spectrum from chronic cervicitis to occult cancer (Table II). Exposure and relaxation with para cervical anesthesia was more than adequate, with one patient 1 • ___ '-'' .• •1 n ,, _ , . ' , 1 •.t navmg marsup1auzauon OI a srerue nannoun s cysr \ wnn concomitant pudendal block) simultaneously. The Fleming knife technique, which stabilizes the cervix with a highly placed single tenaculum, allows for a swift deep cone with minimal difficulty. Bleeding has been slight although patients are prepared for general anesthesia, if necessary. The usual complications of infection, excessive hemorrhage, and anesthetic problems2• 3 • 5 have not been encountered, and uniform healing of the cervix without scarring, malformation, or stenosis• is believed to be linked to the lack of suturing as \Veil as to the cryosurgical techniques. Diagnostic cold knife conization, performed in the clinic, with paracervica! block anesthesia and cryosurgical t'
_,
hemostasis is found to be a safe, inexpensive procedure with a high degree of patient acceptance. The procedure is recommended for those clinic settings in which backup general anesthesia or quick operating room accessibility is available, should complications occur. The benefit to the patient in terms of cost and hospitalization time is obvious, and uniform smooth healing of the cervix (without suturing) is believed to lessen the likelihood of future anatomic defects of the cervix. REFERENCES
J. P.: Office Gynecology, Chicago, 1965, Year Book Medical Publishers, Inc., p. 460. McCann, S. W., Micka!, A., and Crapanzano, ]. T.: Obstet. Gynecol. 33: 470, 1969. Sabatelle, R., Siedlis, A., Sail, S., and Tchertkoff, V.: Cancer 23: 663, 1969. Townsend, D. E., Ostergard, D. R., and Lickrish, G. M.: ]. Obstet. Gynaecol. Br. Commonw. 78: 667, 1971. Villisanta, V., and Durkson,]. P.: Obstet. Gynecol. 27: 717, 1966.
1. Greenhill,
2. 3. 4. 5.
Erratum In the article, "Levels of prostaglandins F 2 a and E 2 in human endometrium during the menstrual cycle," by Eric J. Singh, Ph.D., Iracema M. Baccarini, M.D., and Frederick P. Zuspan, M.D., in the April 1, 1975, issue of the JouRNAL, on page 1004, in Table II, under the heading "Prostaglandin," F2 a should have been E 2 and vice versa.
532 Communications in brief
:\ru ,
J. Obstet. Gyn
Fig. 1. Tumor is composed of an irregular mixture of fat, smooth muscle, and blood vessels. (Original magnification x450.)
not palpable. Three weeks later, a pelvic examination disclosed the uterus to be enlarged to the size of a 6 week pregnancy. The estimated date of confinement was October 2, 1974. The antenatal course was uneventful. The patient was delivered of a term-size living female child with the use of epidural anesthesia on September 2 3, 19 74. Following manual expression of the placenta, the uterine cavity was explored. Two polypoid structures were encountered and manually removed. The postpartum course was uneventful. The two soft round masses together weighed 61 grams, with the larger measuring up to 6.5 ern. in diameter, and were composed of soft, pink tissue. Histologic examination showed a mixture of mature adipose tissue, smooth muscle, and blood vessels (Fig. 1) . Most of the reported benign mixed mesodermal tumors of the uterus have occurred in elderly postmenopausal women. One large series1 reported 91 per cent occurring in women 40 years or older with a range of 23 to 81 years. The most common symptoms have been menstrual irregularities in premenopausal patients and some type of uterine bleeding in postmenopausal patients. Clinical signs and symptoms may be related to the presence of a mass. The tumors have measured up to 32 em. in diameter, but the majority were 5 to 10 em. Histologically, the tumor is similar to the angiomyolipoma of the kidney, and differences in its gross appearance are related to the variation in the relative proportions of fat, smooth muscle, blood vessels, and fibrous tissue. The gross appearance varies from pink to yellow, depending upon the relative proportion of fat. The fat may be so predominant that many of these tumors have been described as lipomas. All histologic elements are mature and, despite the abnormal mixture of tissues, should not be mistaken for malignancy. The
tumor may represent a hamartoma arising from undifferentiated mesenchymal cells. 2 The obstetrician should be aware that this tumor may be of sufficient size in a submucosal location that it may present at delivery as a significant intrauterine mass. However, its usual high fat content and resulting soft characteristic probably will prevent its interference with delivery. REFERENCES I. Brandfass, R. T., and Everts-Suarez, E. A.: AM.
J
70: 359, 1955. 2. Demopoulos, R. 1., Denarvaez, F., and Kaji, V .: Am. ]. Clin. Pathol. 60: 377, 1973. 0BSTET. GYNECOL.
Outpatient cervical cold conization with cryosurgical hemostasis C. F. McDONELL, ]R., M.D., USNR R. STENGER, M.D., F.A.C.O.G., CAPTAIN, MC, USN
LIEUTENANT COMMANDER, MC,
J.
Catawba Women's Center, Hickory, North Carolina
I N vI E w o F rising hospital costs and increasing demands on physicians' services, diagnostic Fleming knife cold conizations with cryosurgery for hemostasis are now Reprint requests: Dr. C. F. McDonell, Jr., Catawba Women's Center, P. 0. Box 2287, Hickory, North Carolina 28601.
Volume 122 Number4
Communications 1n brief
533
Table I No. of patients Age 10-19 20-29
30-39 40-49 50-59
Parity 0 1-3 4-6 7-10 10
> Fig. 1. Cold knife cone technique with the use of the Fleming knife. (From Greenhill, J. P.: Surgical Gynecology, Copyright © 1969 by Year Book Medical Publishers, Inc., Chicago. Used by permission.)
being perforrned at the Naval Hospital, Long Beach, on an outpatient basis in the Gynecology clinic. Patients found to have Class III, IV, or V Papanicolaou smears in our routine screening clinic are re-examined and the smears are reviewed to eliminate those patients with Class III smears thought to be infectious in nature. These are treated with appropriate vaginal antibiotics, and the Papanicolaou smears are repeated in 4 weeks. Patients with persistent Class III and greater smears are designated to have diagnostic conizations performed on an outpatient basis, as soon as possible. The women are counseled regarding the procedure, its effects, and possible complications_ Patient selection is employed, and those patients in whom vaginal stenosis or great redundancy of vaginal folds might cause exposure problems with local anesthesia are eliminated. The patient is then instructed to return to the clinic the next day after having nothing by mouth; she is given a bedtime pHisoHex* douche to be followed by a Furacint vaginal suppository. Consent for general as well as local anesthesia is signed. In an office minor operative suite, the vagina is prepped with Betadine,t and the cervix is grasped with a single-tooth tenaculum. A paracervical block of 1 per cent Carbocaine* plus 1: 100,000 epinephrine ( 10 c.c.) is administered in each side and allowed to take effect, and the cervix is restained with Lugol's solution. A *Winthrop Labs., Div. of Sterling Drug Inc., 90 Park Ave., New York, New York 10016. tEaton Labs., Inc., Div. Norwich Pharm. Co., 17 Eaton Ave., Norwich, New York 13815. :j:Purdue Frederick Co., 99-101 Saw Mill River Rd., Yonkers, New York 10701.
5 13 7 4 1 8 11
9 2
0
Table II Pathology Chronic cervicitis Squamous metaplasia Mild dysplasia Moderate dysplasia Severe dysplasia Carcinoma in situ Carcinoma in situ with early stromal invasion Frank carcinoma
No. of patients 3 5 2 4
5
7 2 2
Fleming knife sharp conization is then performed, and the nonstaining exocervix and cone wedge are removed to the endocervix (Fig. 1). A moderate surgical bed ooze generally occurs, and hemostasis is secured by freezing the surgical bed with the large cone probe (Freon unit ) at -60° C. for 5 minutes. The patient is then placed in the recovery area and observed for bleeding for one hour. Vital signs are monitored, and after one hour she is given oral juices and allowed to return home with instructions to report excessive bleeding or fever and to return to the clinic in 6 weeks. Four patients were excluded from the series because of vaginal stenosis or redundancy which might cause the patient discomfort with exposure under local anesthesia. These patients were admitted to the hospital for general anesthesia and the usual operative technique. Thirty outpatient conizations were performed without intraoperative difficulties. The usual blood loss averaged 25 c.c. There were no intraoperative or immediate postoperative complications. One patient experienced moderately heavy vaginal bleeding on postoperative Day 10. She was seen in the emergency room, and a vaginal pack was applied. The pack was removed, in the office, 24 hours later without further sequelae. There were no infections, and, on 6 week checkups, all cervices were well healed and showed no evidence of stenosis to sounding or residual disease by Papanicolaou or Lugol's stain.
534
June 15, 1975 ,\m. J, Obstet. Gynend.
Communications rn brief
The patients were mainlv voung women (average age 29) receiving oral contraceptives who were found to have Class III Papanicolaou smears on routine annual checkup (Table I). However, pathology encompassed the total spectrum from chronic cervicitis to occult cancer (Table II). Exposure and relaxation with para cervical anesthesia was more than adequate, with one patient 1 • ___ '-'' .• •1 n ,, _ , . ' , 1 •.t navmg marsup1auzauon OI a srerue nannoun s cysr \ wnn concomitant pudendal block) simultaneously. The Fleming knife technique, which stabilizes the cervix with a highly placed single tenaculum, allows for a swift deep cone with minimal difficulty. Bleeding has been slight although patients are prepared for general anesthesia, if necessary. The usual complications of infection, excessive hemorrhage, and anesthetic problems2• 3 • 5 have not been encountered, and uniform healing of the cervix without scarring, malformation, or stenosis• is believed to be linked to the lack of suturing as \Veil as to the cryosurgical techniques. Diagnostic cold knife conization, performed in the clinic, with paracervica! block anesthesia and cryosurgical t'
_,
hemostasis is found to be a safe, inexpensive procedure with a high degree of patient acceptance. The procedure is recommended for those clinic settings in which backup general anesthesia or quick operating room accessibility is available, should complications occur. The benefit to the patient in terms of cost and hospitalization time is obvious, and uniform smooth healing of the cervix (without suturing) is believed to lessen the likelihood of future anatomic defects of the cervix. REFERENCES
J. P.: Office Gynecology, Chicago, 1965, Year Book Medical Publishers, Inc., p. 460. McCann, S. W., Micka!, A., and Crapanzano, ]. T.: Obstet. Gynecol. 33: 470, 1969. Sabatelle, R., Siedlis, A., Sail, S., and Tchertkoff, V.: Cancer 23: 663, 1969. Townsend, D. E., Ostergard, D. R., and Lickrish, G. M.: ]. Obstet. Gynaecol. Br. Commonw. 78: 667, 1971. Villisanta, V., and Durkson,]. P.: Obstet. Gynecol. 27: 717, 1966.
1. Greenhill,
2. 3. 4. 5.
Erratum In the article, "Levels of prostaglandins F 2 a and E 2 in human endometrium during the menstrual cycle," by Eric J. Singh, Ph.D., Iracema M. Baccarini, M.D., and Frederick P. Zuspan, M.D., in the April 1, 1975, issue of the JouRNAL, on page 1004, in Table II, under the heading "Prostaglandin," F2 a should have been E 2 and vice versa.