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UROGENITAL FISTULAS
S118
8th European Congress on Menopause (EMAS) / Maturitas 63, Supplement 1 (2009) S1–S136
467 UROGENITAL FISTULAS
Uterine Cancer
R.B. Singh. Pt. B.D.Sharma, Postgraduate Institute of Medical Sciences (PGIMS), Burns & Plastic Surgery and Hypospadias & VVFs Clinic, PGIMS, Rohtak, India Objectives: To discuss general plastic surgical principles of repair for complex urogenital fistulas. Material and Methods: Twenty complex urogenital fistulas were repaired using the general principles of a) adequate pre-operative preparations, b) detailed counselling and consent, c) plastic surgical principles of tissue handling & tissue dissections, d) circum-incision & circum-dissection of the complex fistulas, e) closure of bladder and the vagina separately in two layers at right angle to each other using 2-0 vicryl on round bodied needle, f) eccentrication of the suture lines using interposition flaps, g) wide bore drainage of the cavities, h) vigilant post-operative care, especially adequate hydration, i) strict compliance of the post-operative & follow up instructions and, j) total hysterectomy, augmentation cystoplasty, ureteric re-implantation, colpo-cystoplasty as per the requirements. Results: Eighteen complex fistulas had successful out come and two recurrences were closed successfully after an interval of 6 months. All were continent at early and late follow-ups. Observations: Wide circum-dissection of the fistulas, tensionless right angle closure of bladder and vagina, and re-enforcing the repair with interposition or interposition & on-lay flaps are key steps for successful out come of urogenital fistulas. Conclusions: Strict adherence to the plastic surgical principles of tissue handling, dissection, and further re-strengthening of the repair are mandatory maneuvers for the success of this worst complication following any obstetrical or gynecological procedure/problem. Keywords: Urogenital fistulas, vesico-vaginal fistulas (VVFs), ureteric re-implantation, interposition flaps.
468 ABORTED ENDOMETRIAL SARCOMA AFTER SHORT TERM TAMOXIFEN O. Al-Baghdadi 1 , M. Cook 2 , A. Linder 2 . 1 Peterborough District Hospital, Maternity Department, Peterborough, United Kingdom; 2 The Ipswich Hospital NHS Trust, Maternity Department, Ipswich, United Kingdom Background: Tamoxifen has been widely used in breast cancer treatment. Recently, the occurrence of uterine malignancies in patients receiving long term tamoxifen has attracted attention. Most of these malignancies are endometrial adenocarcinomas, but low-grade and high-grade endometrial sarcomas have been reported. These are mostly in postmenopausl women on long term treatment (Saga et al 2003). Case presentation: A 48 year old pre-menopausal adopted lady. Para 3 normal vaginal deliveries. She had a history of severe menorrhagia associated with secondary anaemia. Ultrasound scan was normal. Hysteroscopy revealed a sub-mucosal fibroid. Histology showed no malignancy. Her symptoms improved on Provera injections.She developed right side breast lump. Core biopsy revealed invasive Grade 2 ductal carcinoma. As a result she had mastectomy and LD flap, and was started on Tamoxifen.After 4 months, She presented with sever and painful vaginal bleeding which settled after passing a large lump (100x70x15mm) vaginally. Ultrasound scan showed a distended uterine cavity with an area of mixed echoes. The histology report showed a High grade- endometrial stomal sarcoma. Therefore, TAH & BSO done and the specimen confirmed the previous results. Discussion: Tamoxifen acts as an oestrogen agonist on the endometrium increasing incidence of endometrial polyps, hyperplasia and cancer. It may be possible that tamoxifen increases the occurrence of uterine body tumours (Varras et al 2003). Recently, cases of poorly differentiated adenocarcinoma and rare cases of endometrial stromal sarcoma have been reported (Saga et al 2003). Conclusion: No case of aborted endometrial sarcoma after short term Tamoxifen therapy as described here has been reported.
469 CLINICAL AND HISTOLOGICAL ASSESSMENT OF POSTMENOPAUSAL METRORRHAGIA I. Blidaru 1 , S. Musca 2 , D. Mihalcea 1 , T. Grigoriu 3 , I. Tataru 3 , C. Bucur 3 . 1 University of Medicine and Pharmacy, Department of Obstetrics and Gynaecology, Iasi, Romania; 2 “Cuza-Voda” University Hospital of Obstetrics and Gynaecology, Department of Pathology, Iasi, Romania; 3 “Cuza-Voda” University Hospital of Obstetrics and Gynaecology, Department of Obstetrics and Gynaecology, Iasi, Romania Objectives: The aim of this study was to evaluate the clinico-pathological features of the postmenopausal metrorrhagia, as only the correlation between these two aspects may lead to the accurate diagnosis and therapy. Methods: Our study included 169 patients aged between 46 and 89 who were admitted in the 4-th Department of Obstetrics and Gynaecology during 2005, January 1 and 2008, October 31, for postmenopausal abnormal uterine bleeding. After the clinical evaluation and a 24-48 hours of preoperative preparations (laboratory tests, prophilactic antibiotics) whenever possible, all the patients were investigated by an endometrial biopsy obtained through a diagnostic curretage. In 22 of the cases a cervical specimen was also obtained. Results: The following aetiological conditions for the postmenopausal metrorrhagia were found: endometrial adenocarcinoma in 16 cases (9.47%), squamous carcinoma in 11 cases (6.51%), endometrial hyperplasia simple in 38 cases (22.48%) and with atypia in 3 cases (1.78%), endometrial polyps in 26 cases (15.38%), atrophic endometrium in 10 cases (16.9%). In 23 cases the histopathological findings were unconclusive. Also, there were 10 patients with nonspecific inflammatory disease of the cervix, 7 patients with HPV cervical infection and 9 patients with cervical polyps. Conclusions: Our results are consistent with the observation of an increasing incidence of the endometrial malignancies and hyperplasia among the postmenopausal women. The endometrial byopsy performed by curettage still remains a valuable tool for the diagnosis of the intracavitary pathologies in women with abnormal uterine bleeding. Keywords: Postmenopausal metrorrhagia, endometrial adenocarcinoma, endometrial hyperplasia.
470 PERSISTENT TROPHOBLASTIC DISEASE AT PERIMENOPAUSE: A CASE REPORT M.G. Castro 1 , C. Carnide 1 , C. Rodrigues 1 , I. Henriques 1 , R. Pina 2 , F. Águas 1 . 1 Maternidade Bissaya Barreto - Centro Hospitalar de Coimbra, Gynecology Department, Coimbra, Portugal; 2 Centro Hospitalar de Coimbra, Anatomical Pathology Department, Coimbra, Portugal Introduction: Gestational trophoblastic disease is a spectrum of diseases characterised by abnormal proliferation of the trophoblast, occurring more commonly in women who get pregnant at very young or advanced ages. The more frequent use of ultrasound in early pregnancy leads to early diagnosis of molar pregnancy and complications such as severe pre-eclampsia and hyperthyroidism are less common. Case report: A 54-year-old perimenopausal woman, with previous irregular cycles, was admitted at our hospital with abnormal vaginal bleeding for 3 months, dyspnea and peripheral oedema. The ultrasound examination showed an enlarged uterus filled with a heterogeneous mass. A few hours later, a vesicular material compatible with hydatiform mole was spontaneaously expelled. A uterine suction curettage was performed and the histological findings revealed a complete mole. After evacuation, the patient developed pre-eclampsia and acute renal failure, medically treated. A second uterus evacuation was required because of significant residual molar tissue. Serum β-unit human chorionic gonadotrophin (β-HCG) levels initially dropped. Then they started to rise and methotrexate chemotherapy was initiated based on the diagnosis of persistent trophoblastic disease. Complete remission was achieved after 15 cycles of chemotherapy (6 months) and a total hysterectomy was performed a few months later, by patient request.
8th European Congress on Menopause (EMAS) / Maturitas 63, Supplement 1 (2009) S1–S136
467 UROGENITAL FISTULAS
Uterine Cancer
R.B. Singh. Pt. B.D.Sharma, Postgraduate Institute of Medical Sciences (PGIMS), Burns & Plastic Surgery and Hypospadias & VVFs Clinic, PGIMS, Rohtak, India Objectives: To discuss general plastic surgical principles of repair for complex urogenital fistulas. Material and Methods: Twenty complex urogenital fistulas were repaired using the general principles of a) adequate pre-operative preparations, b) detailed counselling and consent, c) plastic surgical principles of tissue handling & tissue dissections, d) circum-incision & circum-dissection of the complex fistulas, e) closure of bladder and the vagina separately in two layers at right angle to each other using 2-0 vicryl on round bodied needle, f) eccentrication of the suture lines using interposition flaps, g) wide bore drainage of the cavities, h) vigilant post-operative care, especially adequate hydration, i) strict compliance of the post-operative & follow up instructions and, j) total hysterectomy, augmentation cystoplasty, ureteric re-implantation, colpo-cystoplasty as per the requirements. Results: Eighteen complex fistulas had successful out come and two recurrences were closed successfully after an interval of 6 months. All were continent at early and late follow-ups. Observations: Wide circum-dissection of the fistulas, tensionless right angle closure of bladder and vagina, and re-enforcing the repair with interposition or interposition & on-lay flaps are key steps for successful out come of urogenital fistulas. Conclusions: Strict adherence to the plastic surgical principles of tissue handling, dissection, and further re-strengthening of the repair are mandatory maneuvers for the success of this worst complication following any obstetrical or gynecological procedure/problem. Keywords: Urogenital fistulas, vesico-vaginal fistulas (VVFs), ureteric re-implantation, interposition flaps.
468 ABORTED ENDOMETRIAL SARCOMA AFTER SHORT TERM TAMOXIFEN O. Al-Baghdadi 1 , M. Cook 2 , A. Linder 2 . 1 Peterborough District Hospital, Maternity Department, Peterborough, United Kingdom; 2 The Ipswich Hospital NHS Trust, Maternity Department, Ipswich, United Kingdom Background: Tamoxifen has been widely used in breast cancer treatment. Recently, the occurrence of uterine malignancies in patients receiving long term tamoxifen has attracted attention. Most of these malignancies are endometrial adenocarcinomas, but low-grade and high-grade endometrial sarcomas have been reported. These are mostly in postmenopausl women on long term treatment (Saga et al 2003). Case presentation: A 48 year old pre-menopausal adopted lady. Para 3 normal vaginal deliveries. She had a history of severe menorrhagia associated with secondary anaemia. Ultrasound scan was normal. Hysteroscopy revealed a sub-mucosal fibroid. Histology showed no malignancy. Her symptoms improved on Provera injections.She developed right side breast lump. Core biopsy revealed invasive Grade 2 ductal carcinoma. As a result she had mastectomy and LD flap, and was started on Tamoxifen.After 4 months, She presented with sever and painful vaginal bleeding which settled after passing a large lump (100x70x15mm) vaginally. Ultrasound scan showed a distended uterine cavity with an area of mixed echoes. The histology report showed a High grade- endometrial stomal sarcoma. Therefore, TAH & BSO done and the specimen confirmed the previous results. Discussion: Tamoxifen acts as an oestrogen agonist on the endometrium increasing incidence of endometrial polyps, hyperplasia and cancer. It may be possible that tamoxifen increases the occurrence of uterine body tumours (Varras et al 2003). Recently, cases of poorly differentiated adenocarcinoma and rare cases of endometrial stromal sarcoma have been reported (Saga et al 2003). Conclusion: No case of aborted endometrial sarcoma after short term Tamoxifen therapy as described here has been reported.
469 CLINICAL AND HISTOLOGICAL ASSESSMENT OF POSTMENOPAUSAL METRORRHAGIA I. Blidaru 1 , S. Musca 2 , D. Mihalcea 1 , T. Grigoriu 3 , I. Tataru 3 , C. Bucur 3 . 1 University of Medicine and Pharmacy, Department of Obstetrics and Gynaecology, Iasi, Romania; 2 “Cuza-Voda” University Hospital of Obstetrics and Gynaecology, Department of Pathology, Iasi, Romania; 3 “Cuza-Voda” University Hospital of Obstetrics and Gynaecology, Department of Obstetrics and Gynaecology, Iasi, Romania Objectives: The aim of this study was to evaluate the clinico-pathological features of the postmenopausal metrorrhagia, as only the correlation between these two aspects may lead to the accurate diagnosis and therapy. Methods: Our study included 169 patients aged between 46 and 89 who were admitted in the 4-th Department of Obstetrics and Gynaecology during 2005, January 1 and 2008, October 31, for postmenopausal abnormal uterine bleeding. After the clinical evaluation and a 24-48 hours of preoperative preparations (laboratory tests, prophilactic antibiotics) whenever possible, all the patients were investigated by an endometrial biopsy obtained through a diagnostic curretage. In 22 of the cases a cervical specimen was also obtained. Results: The following aetiological conditions for the postmenopausal metrorrhagia were found: endometrial adenocarcinoma in 16 cases (9.47%), squamous carcinoma in 11 cases (6.51%), endometrial hyperplasia simple in 38 cases (22.48%) and with atypia in 3 cases (1.78%), endometrial polyps in 26 cases (15.38%), atrophic endometrium in 10 cases (16.9%). In 23 cases the histopathological findings were unconclusive. Also, there were 10 patients with nonspecific inflammatory disease of the cervix, 7 patients with HPV cervical infection and 9 patients with cervical polyps. Conclusions: Our results are consistent with the observation of an increasing incidence of the endometrial malignancies and hyperplasia among the postmenopausal women. The endometrial byopsy performed by curettage still remains a valuable tool for the diagnosis of the intracavitary pathologies in women with abnormal uterine bleeding. Keywords: Postmenopausal metrorrhagia, endometrial adenocarcinoma, endometrial hyperplasia.
470 PERSISTENT TROPHOBLASTIC DISEASE AT PERIMENOPAUSE: A CASE REPORT M.G. Castro 1 , C. Carnide 1 , C. Rodrigues 1 , I. Henriques 1 , R. Pina 2 , F. Águas 1 . 1 Maternidade Bissaya Barreto - Centro Hospitalar de Coimbra, Gynecology Department, Coimbra, Portugal; 2 Centro Hospitalar de Coimbra, Anatomical Pathology Department, Coimbra, Portugal Introduction: Gestational trophoblastic disease is a spectrum of diseases characterised by abnormal proliferation of the trophoblast, occurring more commonly in women who get pregnant at very young or advanced ages. The more frequent use of ultrasound in early pregnancy leads to early diagnosis of molar pregnancy and complications such as severe pre-eclampsia and hyperthyroidism are less common. Case report: A 54-year-old perimenopausal woman, with previous irregular cycles, was admitted at our hospital with abnormal vaginal bleeding for 3 months, dyspnea and peripheral oedema. The ultrasound examination showed an enlarged uterus filled with a heterogeneous mass. A few hours later, a vesicular material compatible with hydatiform mole was spontaneaously expelled. A uterine suction curettage was performed and the histological findings revealed a complete mole. After evacuation, the patient developed pre-eclampsia and acute renal failure, medically treated. A second uterus evacuation was required because of significant residual molar tissue. Serum β-unit human chorionic gonadotrophin (β-HCG) levels initially dropped. Then they started to rise and methotrexate chemotherapy was initiated based on the diagnosis of persistent trophoblastic disease. Complete remission was achieved after 15 cycles of chemotherapy (6 months) and a total hysterectomy was performed a few months later, by patient request.