Displacement of the uterusDisplacement of the uterus

ByBy

Dr. Khattab KAEODr. Khattab KAEO

Prof. of Obstetrics and Gynaecology Prof. of Obstetrics and Gynaecology Faculty of Medicine, Al-Azhar University, Faculty of Medicine, Al-Azhar University,

DamiettaDamietta

In Gynaecology

Hysterectomy is a Hysterectomy is a common operation. common operation. 1 in 5 women 1 in 5 women (20%)(20%) in the UK will have in the UK will have

hysterectomy hysterectomy before the age of before the age of

60. 60.

Hysterectomy is Hysterectomy is associated with a associated with a

3/10,000 3/10,000 mortality rate mortality rate

and a 3% rate of and a 3% rate of serious morbidity serious morbidity

Hysterectomy may Hysterectomy may initiate menopause initiate menopause

presumably by presumably by interfering with interfering with

ovarianovarian bloodblood supplysupply

In some In some common common indications indications hysterectomy hysterectomy has has alternative(s).alternative(s).

Endometrial carcinoma: Chemotherapy: Progestational therapy may response, but cures are unusual. MPA: For CIS: 400 mg in 4 weeks in divided doses, then 400 mg/month (5). For carcinoma: 400 mg/day for a week, then 400 mg 3 times / week for 2 weeks before surgery with the same course is given postoperatively if the tumour is extended for >1/3 of the myometrium. Chemotherapy is attempted with distant metastasis. It includes cis-/carbo-platin, doxorubicin and paclitaxil.

Fibroid: Fibroid: 1- Gn-RHa for 3-6 months. It 1- Gn-RHa for 3-6 months. It reduces the size of fibroids by reduces the size of fibroids by up to 50%. Add-back therapy up to 50%. Add-back therapy of oestrogen, progestogen or of oestrogen, progestogen or both (continuous combined), both (continuous combined), or tibolone should be started or tibolone should be started if GnRHa therapy continued if GnRHa therapy continued for more than 3 months.for more than 3 months.

2- Vascular embolization of the uterine arteries with 2- Vascular embolization of the uterine arteries with polyvinyl alcohol particles. It is indicated for large polyvinyl alcohol particles. It is indicated for large

symptomatic fibroids, & is done only in specialist centres. symptomatic fibroids, & is done only in specialist centres. A catheter is introduced trans-femorally to the origin of the A catheter is introduced trans-femorally to the origin of the

uterine artery; particles are injected; then the catheter is uterine artery; particles are injected; then the catheter is directed through the common iliac artery and the directed through the common iliac artery and the

bifurcation of aorta to the other side reaching the origin of bifurcation of aorta to the other side reaching the origin of the corresponding uterine artery, repeating the injection. the corresponding uterine artery, repeating the injection. Short-term side effects include pyrexia, profuse discharge Short-term side effects include pyrexia, profuse discharge and passage of small or large fibroids through the vagina. and passage of small or large fibroids through the vagina.

Morbidity and even mortality can result from infection. Morbidity and even mortality can result from infection. Although well-tolerated, at present it is not recommended Although well-tolerated, at present it is not recommended as it causes pain, may fail and in women wanting children as it causes pain, may fail and in women wanting children

pregnancy might be complicated with placental pregnancy might be complicated with placental insufficiency. Intra-peritoneal adhesions can result from insufficiency. Intra-peritoneal adhesions can result from

inflammatory reaction to necrosis. Antibiotic is given inflammatory reaction to necrosis. Antibiotic is given beforehand. Heparin is given for 2 days. A powerful beforehand. Heparin is given for 2 days. A powerful

analgesic is also given. There is reduction in the fibroid size analgesic is also given. There is reduction in the fibroid size by 60-65% for up to 1 year. by 60-65% for up to 1 year. ++93% of patients are free. 93% of patients are free.

Large (8cm) pedunculated subserous or submucous fibroids Large (8cm) pedunculated subserous or submucous fibroids are a contraindication to embolization.are a contraindication to embolization.

3- Myomectomy. Recently, myomectomy can 3- Myomectomy. Recently, myomectomy can be done laparoscopically using an be done laparoscopically using an

ultrasonically-activated scalpel. ultrasonically-activated scalpel. The low The low atmospheric pressure area adjacent to the atmospheric pressure area adjacent to the vibrating scalpel causes cavitations of the vibrating scalpel causes cavitations of the

intracellular water. The latter, then, intracellular water. The latter, then, changes to a vapour at the body changes to a vapour at the body

temperature.temperature. It produces a protein-aceous It produces a protein-aceous coagulum that effectively seals blood coagulum that effectively seals blood vessels of up to 3 mm diameters. The vessels of up to 3 mm diameters. The

scalpel has a haemostatic effect similar to scalpel has a haemostatic effect similar to thermal units, but at much lower thermal units, but at much lower

temperature (80temperature (80C) and with much less C) and with much less lateral thermal injury. In addition, blood lateral thermal injury. In addition, blood does not reduce the power density as it does not reduce the power density as it

may occur with use of monopolar electro-may occur with use of monopolar electro-surgery.surgery.

CERVICAL NEOPLASIACERVICAL NEOPLASIA:: Cases of early stromal microinvasion Cases of early stromal microinvasion

may require conization.may require conization.

Safety, efficacy, availability, costs and Safety, efficacy, availability, costs and experience in addition to any experience in addition to any

associated pathology have dominated associated pathology have dominated the controversy. the controversy.

There is a 99% cure rate if the There is a 99% cure rate if the transformation zone (TZ) has been transformation zone (TZ) has been

destroyed for 4 mm. 5% of smears will destroyed for 4 mm. 5% of smears will not revert to normal after treatment. not revert to normal after treatment.

Cold-knife conisation (CKC)Cold-knife conisation (CKC). . Large loop excision of the transformation zone (LLETZ):Large loop excision of the transformation zone (LLETZ):

Pros:Simultaneous conisation, local destruction Pros:Simultaneous conisation, local destruction & minimal tissue damage. Completed in 3.5 & minimal tissue damage. Completed in 3.5 min & provides adequate histological specim in min & provides adequate histological specim in >90% of cases with minimal immediate >90% of cases with minimal immediate morbidity. The incidence of cervical stenosis is morbidity. The incidence of cervical stenosis is lower than that following CKC. Lastly, it does lower than that following CKC. Lastly, it does not affect fertility or menstruation.not affect fertility or menstruation.

Cons:50% rate of+ve margins Vs 33% for CKC Cons:50% rate of+ve margins Vs 33% for CKC Recurrence rate of GIN is 30% Vs 6% for CKC. Recurrence rate of GIN is 30% Vs 6% for CKC. Edge of the loop is invisible during surgery, so Edge of the loop is invisible during surgery, so excision may be shallow. Large lesions are excision may be shallow. Large lesions are often removed in multiple fragments, making often removed in multiple fragments, making orientation of the specimen & assess ment of orientation of the specimen & assess ment of completeness of excision impossible. completeness of excision impossible.

Needle excision of the transformation zone (NETZ):Needle excision of the transformation zone (NETZ): The needle (tungsten wire) is 15 mm long and The needle (tungsten wire) is 15 mm long and 0.5 mm in diameter and is angled 450.5 mm in diameter and is angled 45. NETZ . NETZ yields a 1-piece cone of high-quality (20 mm yields a 1-piece cone of high-quality (20 mm depth [Vs. 14mm with LLETZ] & >3cmdepth [Vs. 14mm with LLETZ] & >3cm33 vol vol [Vs. 2.5 cm with LLETZ]). [Vs. 2.5 cm with LLETZ]). Rate of involved Rate of involved margins is 3%[Vs 9.5% with LLETZ]. margins is 3%[Vs 9.5% with LLETZ]. Loop electrosurgical excision procedure (LEEP)Loop electrosurgical excision procedure (LEEP) biopsy: biopsy: 2 2 loops are used 1 for the ectocervix (20x8 mm) loops are used 1 for the ectocervix (20x8 mm) & one for the endocervix (10x10mm). The & one for the endocervix (10x10mm). The resulting raw area is cauterised by a resulting raw area is cauterised by a diathermy ball electrode, then, Monsel sol. is diathermy ball electrode, then, Monsel sol. is applied to aid in haemostasis. LEEP is applied to aid in haemostasis. LEEP is performed under local anaesthesia, costly with performed under local anaesthesia, costly with high rate of postoperative bleeding. Its main high rate of postoperative bleeding. Its main advantage is the provision of a high-quality advantage is the provision of a high-quality specimen for histologic examination with specimen for histologic examination with minimal thermal artifact on the cut edges. minimal thermal artifact on the cut edges.

Cryocautery:Cryocautery: 3 min. in double application with a 5-min apart (quick). 4 3 min. in double application with a 5-min apart (quick). 4 mm depth. An ice ball extending 5 mm beyond the lesion is created. This mm depth. An ice ball extending 5 mm beyond the lesion is created. This contains an inoculum of dead virus which may improve the immune contains an inoculum of dead virus which may improve the immune response to the causative agent. It is painless, the safest and simplest response to the causative agent. It is painless, the safest and simplest procedure and in addition, it causes no post-procedure bleeding, no procedure and in addition, it causes no post-procedure bleeding, no cervical scarring + low cost and ease of use. Reepithelialization begins cervical scarring + low cost and ease of use. Reepithelialization begins immediately and is complete in 6 weeks. However, it is not suitable for immediately and is complete in 6 weeks. However, it is not suitable for CIS because of the high recurrence rate. It also results in recession of the CIS because of the high recurrence rate. It also results in recession of the TZ TZ difficult follow-up. difficult follow-up.

Diathermy:Diathermy: Done under general anesthesia and yields a depth of 7-8 mm. Done under general anesthesia and yields a depth of 7-8 mm.

COCO22 laser vaporization: laser vaporization: It can easily be tailored to the size of the lesion, It can easily be tailored to the size of the lesion, may be done under local anesthesia, yields a depth of 7-8 mm, coexisting may be done under local anesthesia, yields a depth of 7-8 mm, coexisting VaIN can be tt-ed, offers rapid healing, less trauma to adjacent tissue & VaIN can be tt-ed, offers rapid healing, less trauma to adjacent tissue & less scarring than cryocautery, but costly & requires extensive training.less scarring than cryocautery, but costly & requires extensive training.

Menorrhagia & Menorrhagia & DUBDUB

Ablation:Ablation: Hysteroscopic Hysteroscopic surgeries are more surgeries are more effectiveeffective than most forms of medical than most forms of medical therapy. Success rate therapy. Success rate reaches 80%, and reaches 80%, and amenorrhea rate 60%. amenorrhea rate 60%. Satisfaction after TCRE is Satisfaction after TCRE is 84%.84%.

Advantages:Advantages:   Minor surgery (Minor surgery (Postoperative Postoperative morbidity, hospital stay, and time to return to morbidity, hospital stay, and time to return to work, resume normal activities and sexual work, resume normal activities and sexual intercourse are significantly less)intercourse are significantly less). .   No scar. No scar.   Retained womb. Retained womb.   Can be repeated. Can be repeated.   

DisadvantagesDisadvantages Not suitable for grossly large Not suitable for grossly large uterus. Possible complications e.g. fluid uterus. Possible complications e.g. fluid overload & uterine perforation. Pelvis can not overload & uterine perforation. Pelvis can not be inspected for other pathologies. Any be inspected for other pathologies. Any remaining fibroid will continue to grow. remaining fibroid will continue to grow. Continued need for cervical smear. Continued Continued need for cervical smear. Continued need for contraception (although need for contraception (although contraindicated in patients wishing for further contraindicated in patients wishing for further conception). Failure.conception). Failure.

HRT if given should be of the combined HRT if given should be of the combined type. type.

Thank youThank you