Neal H Cohen, MD, MS, MPH

• Professor, Department of Anesthesia and Perioperative Care, University of California, San Francisco, School of Medicine, San Francisco, California

https://profiles.ucsf.edu/neal.cohen

This dysregulation is likely triggered by hyperactivity of the innate immunological surveillance system to environmental antigens heart attack 02 50 heart attack enrique iglesias s and love discount torsemide 10 mg on line. In genetically predisposed individuals hypertensive disorder torsemide 10 mg buy low cost, the Th1 pathway response is overstimulated hypertension first line cheap torsemide master card. Diets high in fish oils seem to be protective against the development of psoriasis pulse pressure 65 buy 20 mg torsemide amex. Although most medical literature prior to Willan (1757-1812) lumped psoriasis pulse pressure tamponade purchase torsemide 20 mg without a prescription, leprosy, eczema, and other inflammatory dermatoses in to a confusing menagerie, Celsus gave a convincing account of psoriasis vulgaris almost 2000 years ago. His description included many of the morphologic features that physicians today utilize to diagnose psoriasis, including the "ruddy" or salmon-colored plaques with silvery scales that often are associated with punctate hemorrhage or "erosions" when removed. Patients may also give a history of joint pain and swelling, especially in the fingers and toes. However, there are clues in the physical examination that allow the clinician to properly diagnose psoriasis and identify its subtypes. It is usually covered by a white or silvery scale that, when removed, may show pinpoint bleeding (Auspitz sign). Its border may be red and with time central clearing may occur, with the plaques taking on an annular or arcuate configuration. It may occur in conjunction with typical plaque psoriasis or it may be the only manifestation of psoriasis. Red plaque on elbow with scale partially resolved after treatment with topical steroids. The distribution is often similar to that of classic pityriasis rosea, favoring the trunk, abdomen, and upper thighs and fading toward the acral surfaces and sparing the palms and soles. Fever, systemic symptoms, and an elevated white blood cell count often accompany generalized pustular psoriasis. The massive shedding of skin that occurs during an erythrodermic flare of psoriasis can result in infection, hypothermia, protein loss, hypoalbuminuria, dehydration, and electrolyte disturbances. It is recognized that nail disease is more closely linked with psoriatic joint disease. Laboratory Findings Blood work is generally not necessary to make a diagnosis of psoriasis. Pustular flares of psoriasis during pregnancy may be associated with hypocalcemia. A biopsy is warranted in any patient not responding as expected to traditional therapy. They act as a foundation on which to build a therapeutic regimen for more severe disease. While topical regimens demonstrate efficacy in clinical trials, the response to these agents in everyday practice is often variable. Ointments are the most effective vehicles for psoriasis, but they stain clothing and bedding. In plaque-type psoriasis, superpotent topical steroids, such as clobetasol or betamethasone, are usually necessary to treat thick plaques. A simple regimen utilizing clobetasol or betamethasone twice a day for 2 to 4 weeks is an easy way to achieve efficacy. With time, the patient can move to an alternating regimen of vitamin D analogues, such as calcipotriol (calcipotriene) or calcitriol. These medications can be alternated by day (calcipotriol Monday to Thursday and clobetasol Friday to Sunday) or by application (calcipotriol in morning and clobetasol at bedtime). Topical vitamin D analogues may cause hypercalcemia; therefore, the weekly dose should be under 100 mg. A less potent topical steroid and more costeffective agent such as triamcinolone, when utilized regularly, may be more effective than higher potency steroids. In areas of thin skin such as the face, neck, axillae, groin, genitals, and body folds, lower potency steroids such as hydrocortisone 2. Topical calcineurin-inhibiting agents are also quite useful for therapy of psoriasis. Because these medications are not corticosteroids, they do not cause skin atrophy, glaucoma, or many other steroid-related side effects. Thus, they are an effective, safe way to treat psoriasis on the face, in the skin folds, and around the eyes. It can be used as a steroid-sparing agent in a manner similar Diagnosis the key diagnostic clinical features of psoriasis are red to pink plaques with silvery white scale on the elbows, knees, scalp, and lower back and legs. Differential Diagnosis the differential diagnosis of psoriasis includes other papulosquamous diseases (Table 9-1). Diseases Psoriasis Clinical Presentation Asymptomatic or mildly pruritic, pink-red plaques with white scale on scalp and extensor extremities. Bimodal age of onset at 22 and 55 years Asymptomatic or mildly pruritic pink patches with fine greasy white scale on the scalp, eyebrows, ears, nasolabial folds, and central chest. More common in infants or after age 40 Asymptomatic 1-2 cm oval thin plaques with a fine central scale, a larger 2-10 cm "herald patch" may precede rash. More common in teens and young adults Pruritic well-defined pink scaly plaques on extremities but not necessarily on elbows and knees Pruritic violaceous flat-topped papules on volar wrists, forearms, ankles, and lower back Annular erythematous scaly plaques in sun-exposed areas and on trunk Asymptomatic or mildly pruritic pink scaly plaques with a scaly border and central clearing Asymptomatic scaly papules or plaques on palms, soles, and trunk. History of preceding genital ulcer Asymptomatic or mildly pruritic scaly welldefined plaques with random distribution. Lesions may also be annular or arcuate and are chronic and persist in the same location. Generic Name Topical steroids Clobetasol Betamethasone dipropionate Fluocinonide Triamcinolone Desonide Hydrocortisone Topical calcineurin inhibitors Tacrolimus Pimecrolimus Topical vitamin D3 analogues Calcipotriol (calcipotriene) Calcitriol Dovonex Vectical Cream, solution 0. Weekly dose should not exceed 100 g For use in adults >18 years old for up to 4 weeks. Weekly dose should not exceed 100 g For use in thick plaques in adults in combination with topical steroids. Pregnancy category X For use in thick plaques in combination with topical steroids Protopic Elidel Ointment 0. Therefore, patients may find that tazarotene fits best in to their regimen when applied in conjunction with topical steroids. In the setting of hyperkeratotic, scaly plaques there may be a role for keratolytics to remove scale and facilitate penetration of the topical steroid and/or vitamin D analogue. Salicylic acid, urea, and lactic acid are agents that can be added to a regimen for this purpose. Salicylic acid comes as a cream, gel, cream, or shampoo in concentrations that range from 2% to 10%. Topical coal tar products have an anti-inflammatory effect in psoriasis and can be used in conjunction with topical steroids and keratolytic agents. Examples of tar products include Estar, Fototar, PsoriGel, and Neutrogena T/Derm Tar Emollient. They can improve efficacy and lower the economic burden of other topical agents by softening the stratum corneum through hydration and reduction of superficial scale. A daily bath in warm water, followed by application of petrolatum and supplemented by 2 or 3 further applications of a moisturizer during the day, is a beneficial addition to any treatment regimen. Most of the principles discussed above with regard to adults still hold for the pediatric population. In the pediatric population one must, of course, consider long-term side effects due to lengthy exposure to immunomodulators. Enthesitis usually occurs at the insertion sites of the Achilles tendon, the plantar fascia, and ligamentous attachment points of the rib, spine, and pelvis. Musculoskeletal involvement can present at any time, but most often between the ages of 30 and 50 years. All systemic comorbidities should be monitored and discussed with patients, with consultation to specialists when appropriate as discussed above. Rheumatologic consultation is indicated if signs or symptoms of psoriatic joint disease or enthesitis are present. Patient Information · · Comorbidities in Patient with Psoriasis Psoriasis is an independent risk factor for atherosclerosis, coronary artery disease, myocardial infarction, stroke, and cardiovascular mortality. Patients with psoriasis are more likely to have other cardiovascular risk factors such as diabetes, hypertension, dyslipidemia, tobacco use, and obesity. It can present at any age, but its peak incidence occurs in infants and in middle-aged adults. Potential Causes of Flares of Psoriasis Group A beta-hemolytic streptococci infection can act as an environmental trigger for guttate psoriasis particularly in the pediatric population. Other commensal organisms on the skin may play a role in specific variants of psoriasis. Psychiatric comorbidities such as anxiety and depression may exacerbate psoriasis. Pathophysiology Etiology is dependent on 3 factors, sebum, Malassezia yeast, and individual susceptibility. Recent work has revealed that Malassezia globosa and Malassezia restricta predominate and oleic acid alone can initiate dandruff-like desquamation. Indications for Consultation Dermatological consultation is indicated when topical medications have not been effective and ultraviolet light or systemic therapy are needed. Moderate to severe seborrheic dermatitis is characterized by erythematous plaques with white greasy scales. Atopic dermatitis: Atopic children and to some degree adults may have scaly lesions in the scalp; however, they usually have areas of involvement on the extremities, particularly in the flexural regions. Tinea capitis: Trichophyton tonsurans fungal infections in children, especially in African American children, may be indistinguishable from seborrheic dermatitis. Management · Diagnosis the key diagnostic clinical features of seborrheic dermatitis are pink plaques with fine greasy white scale on the scalp, eyebrows, nasolabial fold, and ears. Mild scalp seborrheic dermatitis can usually be controlled with over-the-counter shampoos containing zinc pyrithione (Head and Shoulders), selenium sulfide (Selsun), coal tar (Neutrogena T-Gel), salicylic acid (Neutrogena T-Sal), or ketoconazole (Nizoral A-D). Severe or persistent disease that does not respond to treatment, especially in children in whom the presence of persistent seborrheic dermatitis could indicate more serious underlying disease. Patients are typically young adults, average age at presentation is 10 to 35 years, and females are slightly more affected (1. Several factors suggest an infectious agent based on clustering of cases, self-limited nature, and rare recurrences. Herald patch with collarette scale and multiple smaller lesions with similar morphology. Reported variants include papular, vesicular, urticarial, purpuric, inverse pityriasis rosea, and absent or numerous herald patches. Laboratory Findings As pityriasis rosea is a clinical diagnosis made by history and physical examination, laboratory studies are usually unnecessary. Occasionally a viral-like constitutional prodrome or symptoms of an upper respiratory infection may precede the onset of cutaneous lesions. Diagnosis the key diagnostic clinical features of pityriasis rosea are an initial herald patch, an oval plaque with a collarette (scale) followed by a symmetric, secondary eruption in a "Christmas tree" pattern. The subsequent lesions are smaller (1-2 cm) pinksalmon-colored papules and plaques on the trunk and extremities. Pigmented skin alters the color of lesions with a violet-gray color spectrum as opposed to pink. It is more common to see involvement on the head in darker pigmented individuals as well. Differential Diagnosis the differential diagnosis includes other papulosquamous diseases (Table 9-1). Other: Viral exanthems, pityriasis lichenoides chronicus, lichen planus, and erythema dyschromicans perstans. Management As pityriasis rosea is a self-healing, self-limited benign eruption, treatment is not required. Additionally, no treatments can be recommended on the basis of evidence-based medicine. A recent Cochrane review showed insufficient evidence for nearly all interventions such as emollients, topical antihistamines, steroids, light therapy, and antimicrobials. Lotions with camphor, menthol, pramoxine, or oatmeal could provide added antipruritic benefit. Use of sedating (diphenhydramine, hydroxyzine) and nonsedating (cetirizine) antihistamines can also provide relief. Medium-potency topical steroids, such as triamcinolone or fluocinonide, may provide an additional antipruritic benefit as well as improve the inflamed appearance of lesions. Pathophysiology Lichen planus is thought to occur as a result of an immune dysfunction with altered surface keratinocyte antigen presentation and subsequent cytotoxic T-cell reaction. The skin eruption has been associated with systemic drugs and hepatitis C virus, but a definitive cause has not been identified. Common drugs linked to lichen planus are gold, antibiotics, diuretics, and antimalarials. Clinical Presentation History Patients usually present with a complaint of itching and onset of red bumps. The pruritus can range from mild to severe with an occasional patient having no symptoms. These may be scaly, and Indications for Consultation Severe or nonresolving case with recalcitrant pruritus. Violaceous flat-topped papules with fine white lines (Wickham striae) on flexural wrist. Management Removal of the offending agent is the first step, if one is identified. Drug-induced lichen planus and hepatitis C are common conditions that may present with a lichenoid skin eruption. If corticosteroids are used for prolonged periods, care must be taken to avoid drug-induced secondary changes such as atrophy. Indications for Consultation Unusual presentations or widespread distribution of a lichenoid eruption should be considered for consultation.

More often blood pressure range purchase torsemide 20 mg with visa, it may either remain static or at times arrhythmia classification torsemide 10 mg purchase on-line, may even increase due to loss of fear of pregnancy blood pressure low pulse high discount torsemide 10 mg buy line. The major complications are: y Depression: Low dose estrogen preparations are not associated with depression hypertension powerpoint 20 mg torsemide buy with mastercard. Pre-existing hypertension arrhythmia during stress test cheap torsemide express, diabetes, obesity thrombophilias (inherited or acquired) and elderly patient (over 35 especially with smoking habits) are some of the important risk factors. Ethinyl estradiol used with a dose of 20 µg in the pill markedly reduce the incidence. Moreover, significant amount of the steroids are ingested by the infant, the effects are as yet unknown. This protective effect persists for 10­15 years even after stopping the method following a use of 6 months to 1 year. No increased risk of hepatocellular adenomas have been found with low dose preparations. This is due to low total amount of steroids and the balanced estrogenprogestogen relationship. It contains very low dose of a progestin in any one of the following form - Levonorgestrel 75 µg, norethisterone 350 µg, desogestrel 75 µg, lynestrenol 500 µg or norgestrel 30 µg. Mechanism of action: It works mainly by making cervical mucus thick and viscous, thereby prevents sperm penetration. In about 2 percent of cases ovulation is inhibited and 50 percent women ovulate normally. How to prescribe mini pill: the first pill has to be taken on the first day of the cycle and then continuously. Delay in intake for more than 3 hours, the woman should have missed pill immediately and the next one as schedule. Disadvantages: (1) There may be acne, mastalgia, headache, breakthrough bleeding, or at times amenorrhea in about 20­30 percent cases (2) All the side effects, attributed to progestins may be evident (3) Simple cysts of the ovary may be seen, but they do not require any surgery (4) Failure rate is about 0. Women using drugs that induce liver microsomal enzymes to alter a metabolism (mentioned above) should avoid this method of contraception. Contraindications: (i) Pregnancy (ii) unexplained vaginal bleeding (iii) recent breast cancer (iv) arterial disease. Both are administered intramuscularly (deltoid or gluteus muscle) within 5 days of the cycle. Advantages: (1) It eliminates regular medication as imposed by oral pill (2) It can be used safely during lactation. It probably increases the milk secretion without altering its composition (3) No estrogen related side effects (4) Menstrual symptoms. Drawbacks: Frequent irregular menstrual bleeding, spotting and amenorrhea are common. Loss of bone mineral density (reversible) has been observed with long-term use of depot provera. It releases the hormone about 60 mcg, gradually reduced to 30 mcg per day over 3 years. Mechanism of action: It inhibits ovulation in 90 percent of the cycles for the first year. Insertion: the capsule is inserted subdermally, in the inner aspect of the nondominant arm, 6­8 cm above the elbow fold. It is ideally inserted within D 5 of a menstrual cycle, immediately after abortion and 3 weeks after postpartum. Risk of pregnancy following a single act of unprotected coitus around the time of ovulation is 8 percent. A single dose 30 mg, to be taken orally as soon as possible or within 120 hours of coitus. It should not be prescribed in women with severe hepatic dysfunction nor with severe asthma. Each tablet usually contains 30 mg of ethinyl estradiol and 1 mg of norethisterone or 0. It has got trigger action - (a) inhibition of ovulation, (b) production of static endometrial hypoplasia and (c) alteration of the character of the cervical mucus. Its use is absolutely contraindicated in cases with circulatory diseases, liver diseases, severe migraine and estrogen dependent tumor. The pill should be started from the day one of a cycle and continued as "3 weeks on and 1 week off" regime. Periodic check up is essential especially when prescribed in women above the age of 35. The pill should be withdrawn if complications arise such as severe migraine, chest pain, visual disturbances, etc. The major complications are rare and include depression, hypertension and thromboembolic manifestations. Triphasic pill-It has got lesser amount of steroids than the conventional monophasic tablets. Mini pill-The pill contains low doses of progestin- norgestrel 30 mg, levonorgestrel 75 µg or desogestrel 75 µg. No fetal adverse effects has been observed when there is failure of emergency contraception. The following are the possibilities: x Ovulation is either prevented or delayed when the drug is taken in the beginning of the cycle. Postcoital contraception is only employed as an emergency measure and is not effective if used as a regular method of contraception. Oral antiemetic (10 mg metoclopramide) may be taken 1 hour before each dose to reduce the problem of nausea and vomiting. Implantation is prevented due to its 494 textBooK of GynecoLoGy StErIlIzAtIon Permanent surgical contraception, also called voluntary sterilization, is a surgical method whereby the reproductive function of an individual male or female is purposefully and permanently destroyed. The operation done on male is vasectomy and that on the female is tubal occlusion, or tubectomy. Individual procedure must be discussed in terms of benefits, risks, side effects, failure rate and reversibility. Advantages: (1) the operative technique is simple and can be performed by one with minimal training (2) the operation can be done as an outdoor procedure or in a mass camp even in remote villages (3) Complications-immediate or late are fewer (4) Failure rate is minimal-0. Drawbacks: (1) Additional contraceptive protection is needed for about 2­3 months following operations, i. The vas is palpated with three fingers of the left hand; index and thumb in front and the midle behind. This is done at the level midway between the top of the testis and the base of the penis. The vas is grasped with a ringed clump applied perpendicularly on the skin overlying the vas. The skin is punctured with the sharp pointed end of the medial blade of a dissecting forceps. Histological examination of the excised segment of the vas should be done for confirmation if the surgeon is in any doubt. Heavy work or cycling is restricted for about 2 weeks, while usual activities can be resumed forthwith. For check up, the patient should report back after 1 week, or earlier, if complication arises. Indications: (1) Family planning purposes: this is the principal indication in most of the developing countries. Hospital stay and rest at home following delivery are enough to help the patient to recover simultaneously from the two events, i. Complications are significantly less However, it needs training on the part of the surgeon. Semen should be examined either by one test after 16 weeks or by two tests at 12 and 16 weeks after vasectomy and if the two consecutive semen analyses show absence of spermatozoa, the man is declared as sterile. Immediate - (1) Wound sepsis which may lead to scrotal cellulitis or abscess; (2) Scrotal hematoma. Hysterectomy during the childbearing period has got an incidental sterilization effect but should not be done for sterilization purpose. The approach may be: (1) Abdominal (2) Vaginal (1) Abdominal: (A) Conventional (B) Minilaparotomy Conventional (Laparotomy)-Steps: x Anesthesia: the operation can be done under general or spinal or local anesthesia. The tube is identified by the fimbrial end and mesosalpinx containing utero-ovarian anastomotic vessels. Segment of the loop removed is to be inspected to be sure that the chapter 29 contrAceptIon wall has not been partially resected and to send it for histology. The free medial end of the tube is then turned back and buried in to the posterior uterine wall creating a myometrial tunnel. MinilaparoToMy (Mini-lap): When the tubectomy is done through a small abdominal incision along with some device, the procedure is called mini-lap. Steps: (1) Anesthesia - Always under local anesthesia (2) Plan of incision - As described in conventional method but the incision should be 1/2"­ 3/4" (3) Specially designed retractor may be introduced after the abdomen is opened. This helps manipulation of the tube in bringing it close to the incisional area, when it is seized by artery forceps. It is easier to apply and damage to the tube is less is performed on one side and then repeated on the other side. Once conversant with the technique, it can be performed with satisfaction to the patient. It also benefits the organization (turn over of the patient per bed is more than that in the conventional method). Laparotomy may sometimes be needed 498 textBooK of GynecoLoGy Principal steps (Single puncture technique) Premedication - Pethidine hydrochloride 75­100 mg with phenergan 25 mg and atropine sulfate 0. Local anesthesia-Taking usual aseptic precautions about 10 mL of 1 percent lignocaine hydrochloride is to be infiltrated at the puncture site (just below the umbilicus) down up to the peritoneum. An uterine manipulator is introduced through the cervical canal for manipulation for visualization of tubes and uterus at a later step. The Verres needle is introduced through the incision with 45° angulation in to the peritoneal cavity. The abdomen is inflated with about 2 liters of gas (carbon dioxide or nitrous oxide or room air or oxygen). The trocar with cannula is introduced through the incision previously made with a twisting movement. The trocar is removed and the laparoscope together with ring applicator is inserted through the cannula. The tubes are occluded either by a silastic ring (silicone rubber with 5 percent barium sulfate) devised by Fallope or by Filshie clip is made of titanium lined with silicone rubber. Removal of the laparoscope: After viewing that the rings are properly placed in position, the tubal loops looking white and there is no intraperitoneal bleeding, the laparoscope is removed. However, for a quick turn over in an organized mass camp, laparoscopic sterilization offers a promising success (Table 29. Pelvic pain, menorrhagia along with cystic ovaries constitute a postligation syndrome. However, the incidence, can be minimized, if the blood vessels adjacent to the mesosalpinx are not unduly disturbed. Mortality following tubal sterilization is estimated to be 72 per 100,000 for all methods. Laparoscopic procedures carried the mortality rate of 5­10 per 100,000 compared to 7 per 100,000 for puerperal ligations. Adolescent girls: Low dose combined pills are most effective for the sexually active adolescents. Newly married couple: Provided there is not enough justification to prove early fertility, a highly effective and acceptable contraceptive should be prescribed. Apart from effective contraception `Pill` has got many noncontraceptive benefits as well (p. Spacing of births x Postabortal x Postpartum x Interval Reversibility: Informed consent must be obtained after adequate counseling. Couple must understand the permanency of the procedure, its occasional failure rate the risks and side effects and its alternatives. Pregnancy rates after reversal are high (80 percent) following use of clips and rings. Reversal of vasectomy with restoration of vas patency is possible up to 90 percent of cases. The individual should have the liberty to choose any of the currently available welltested method, which may even vary at each phase in her reproductive life. If one compares the risks and benefits of any contraceptive, it is observed that more deaths occur as a result of unplanned pregnancies than from the hazards of any modern contraceptive method (excluding "Pill" users over 35 who smoke). Important factors for the selection of any contraceptive method for an individual are: relative safety, effectiveness, side effects and willingness to use the method correctly and consistently. Sterilization counseling includes a discussion of the following issues: (1) Desire of the individual partner (male/female). Postabortal: the contraceptive practice should be started soon following the abortion process is completed. Postpartum: ·Nonlactating ·Lactating Nonlactating-Contraceptive practice should be started after 3 weeks. Injectable depomedroxy progesterone acetate could be used as it is devoid of any estrogen related side effects. However, a two-child formula is usually recommended and as such, a couple having two children who have been fully immunized can have permanent sterilization (husband or wife). Low dose pills can be continued till menopause (with monitoring) in the low-risk group. Barrier methods and vaginal spermicides can be used either as a primary or back up method. They should use condom with spermicides or use another contraceptive method in conjunction with condom. It is a non-steroidal compound with potent anti-estrogenic and weak-estrogenic properties.

Types of cervical biopsy include-surface quitting high blood pressure medication order 10 mg torsemide amex, punch blood pressure 35 year old female 10 mg torsemide buy with visa, wedge arterial stenosis 10 mg torsemide, ring and cone type (see p blood pressure chart by age singapore purchase torsemide cheap. Perineoplasty is a simple reconstructive surgery for widening the narrow vaginal introitus for sexual function (p hypertension young women generic torsemide 20 mg otc. Complications of cervical conization or amputation include postoperative hemorrhage and cervical stenosis or cervical incompetence (see p. Complications of abdominal hysterectomy are intraoperative, postoperative (immediate, late and remote) (see p. Postoperative bowel dysfunction (ileus and obstruction) need to be differentiated (see Table 34. Operations for chronic inversion of the uterus may be abdominal (Haultain) or vaginal (Kustner or Spinelli) (p. Plication of the round ligaments, modified Gilliam procedure or laparoscopic suspension operation are the different methods (see p. Complications of radical hysterectomy are other organ injury (bladder, ureter) besides the complications of simple hysterectomy (p. Radical vulvectomy with bilateral inguinofemoral lymphadenectomy could be done either by three incision technique (preferred) or by en bloc procedure (butterfly horned incision). Node of Cloquet or Rosenmüller (deep femoral node) may be absent in more than 50 percent cases. With very fast technological advancement, as much as 80 percent of gynecological operations can be performed endoscopically. Pantaleoni of Ireland first used a cystoscope in 1869 as an hysteroscope to diagnose a case of irregular vaginal bleeding. Jacobaeus of Sweden in 1910 first introduced a cystoscope in the peritoneal cavity and coined the term laparoscopy. In 1938, Veress first reported the spring loaded needle for creating pneumothorax in patients with tuberculosis. In 1947, Raoul Palmer of France introduced the use of gaseous distension of the peritoneal cavity using gas and the lithotomy (Trendelenburg) position. Landmark progress of the use of "Coldlight" and fiberoptics were made by Fourestier and others. In 1967 Steptoe of England first published the monograph "Laparoscopy in Gynaecology" in english language. Kurt Semm of Germany is credited for his advanced operative laparoscopic procedures (myomectomy) in the 1970s. Shorter hospital stay and reduced concomitant cost Quicker resumption of day-to-day activity Less adhesion formation Minimal abdominal scars (cosmetic value) Reduced blood loss disadvantages Disadvantages are mainly related to case selection and experience of the surgeon: y Operation time-may be longer y Risk of iatrogenic complications (see p. Trocar and cannula-is inserted through the abdominal wall following pneumoperitoneum. The trocar is removed and the telescope is introduced through the cannula (sleeve). Light source-High intensity light (xenon or halogen source) beam (cold light) is transmitted to the telescope for excellent visualization. Fiber optic cables are used to transmit the cold light from source to the telescope. Imaging system includes: Laparoscope, light source, fiber optic cord, camera unit and monitors. The image resolution depends on the number of pixels (2,50,000 ­ 3,80,000) on the chip. High definition digital camera uses resolution up to 1,100 lines to produce more vivid picture. Monitor: High resolution color monitors with 700 lines provide optimal picture visualization. Insufflator: the rate of gas flow rate (L/min) and intra-abdominal pressure (mm of Hg) are displayed on the insufflator. Aspirator and irrigator Blunt and sharp aspirators are used for aspiration of fluid from the peritoneal cavity or ovarian cysts. Irrigation is done for washing the peritoneal cavity with normal saline at the end of a surgical procedure. Morcellator is needed when a large piece of tissue (myoma) is morcellated in to small pieces so as to be removed through the laparoscopic sleeve. Uterine manipulator is used for adequate visualization of the uterus and adnexae during operation. Hemostasis during laparoscopic surgery Perfect hemostasis is mandatory at the end of any endoscopic surgery. Electrocoagulation: Electrosurgical units are used for cutting and coagulation of biological tissues. In blended mode cutting and coagulation currents are combined creating alternate high and low voltage current. Monopolar Electrosurgery: the current (electrons) is pushed from the generator through the active electrode to the contact tissue. The current returns back to generator through the neutral electrode after it has passed through the patient. It is important to check the return electrode is in good contact with the patient. It should be broad enough to reduce the current density far below the level of tissue burning. Depending upon the size of the electrodes (current density) and voltage used, unwanted burns may be produced due to stray current flow. Bipolar Electrosurgery: Here the current flows from the generator between the two jaws of the forceps or scissors, holding the target tissue. It works by conducting electrical current with high power density that is confined between the jaws of the forceps. It has limited lateral thermal spread, low contact temperature and high compressive effects. For effective cutting, vaporization and coagulation of tissue, power density is an important factor. LigaSure is a bipolar electrosurgical device used to cut, vaporize, coagulate and seal blood vessels. Enseal Vessel Fusion is a bipolar system that deliver a locally regulated current. Tissue temperature remains within 120oC as there is generation of resistance in the plastic jaws of the instrument. The device has a mechanical blade that can be advanced gradually to desiccate and cut tissue bundles. Harmonic scalpel: It is an ultrasound energy source to break hydrogen bonds in tissues. This is effective in cutting or coaptation (sealing) of vessels up to 4 mm diameter. Mechanical Clips and Staples: Titanium clips and staples are used for hemostasis by securing blood vessels. Sutures and Ligature: Like an open surgery sutures can be used to ligate blood vessels and to secure vascular pedicles. Different methods of suturing and knot tying are used: (a) intra-corporeal knot tying, 614 TexTbook of GynecoloGy to the extent of surgery and also to the competence of the surgeon. Left: Operation and Right: Schematic chapter 35 endoscopic surGery in GynecoloGy Moderate procedures. Informed consent is taken and it should include the permission for open surgery if necessity arises. Low lithotomy position of the patient with buttocks protruding slightly from the edge of the table is used. Head end of the patient is lowered (Trendelenburg 15­30°) after insertion of the primary trocar. For good view and hand-eye coordination, both for the surgeon and the assistants, the video monitor is placed at the foot end of the table. The electrosurgical unit and the suction irrigator should be placed behind the surgeon or assistant. An uterine manipulator is introduced through the cervical canal for manipulation to visualize the tubes and uterus at a later step. The veress needle is introduced through the incision with 45° angulation in to the peritoneal cavity. But for diagnostic purposes nitrous oxide 616 TexTbook of GynecoloGy or room air or oxygen can be used. Symmetrical distension of abdomen with loss of liver dullness is suggestive of proper pneumoperitoneum. The flow rate of the gas is about one liter per minute with a pressure not exceeding 20 mm Hg. Otherwise this interferes with diaphragmatic excursion and venous return due to caval obstruction. Correct placement of veress needle is verified by: (a) Hanging drop method-a small amount of sterile saline is placed on the top of the veress needle. The saline drops in the peritoneal cavity while there is negative intra-peritoneal pressure. If the needle placement is correct, the fluid cannot be withdrawn as it goes in the peritoneal cavity. Accessory ports-Lateral ports one on each side 3­4 cm medial to anterior superior iliac spine but lateral to inferior epigastric artery. Peritoneal cavity is opened through a small incision (1 cm) at the umbilicus pneumoperitoneum is done through a special cannula inserted in the incision. Secondary trocar insertion is needed for both the diagnostic and operative procedures. Sites selected are either on the flank (3­4 cm lateral to the medial umbilical ligament) or lateral to the lateral margin of rectus abdominis muscle or on the suprapubic region. This is done under direct vision with illumination to avoid trauma to abdominal organs and the inferior epigastric vessels. Automatic sensors of the insufflator shut off gas flow when the intra-abdominal pressure reaches 15 to 20 mm Hg. The angle of insertion is similar to that of the veress needle, directing towards the hollow of the sacrum. Open laparoscopy was introduced (Hasson-1971) to reduce the risk of blind insertion of the veress needles and trocars. Removal of specimens: Large volume of tissues after laparoscope could be removed by any of these methods: (i) Morcellation. The patient is put to Trendelenburg position for proper visualization of the pelvic organs. One 10 mm umbilical port is used for the laparoscope, connected to the video camera. Two of them are placed on the ipsilateral side and the third on the opposite side. These are placed lateral to the inferior epigastric artery or in the mid-line above the bladder. Bipolar coagulation or Harmonic Scalpel are used to transect pelvic ligaments and to achieve hemostasis. The round ligament, infundibulopelvic ligament are similarly coagulated and transected. Sutures, staples or clips can also be technique: the various operative techniques of laparoscopic procedures are beyond the scope of the book. As the laparoscopic sterilization is commonly done, this procedure is described in p. After completion of the procedure, laparoscope is used to check the pelvis for hemostasis. The laparoscopic instruments are then removed and the pneumoperitoneum is deflated. Care specific to laparoscopic hysterectomy are: (a) Prophylactic antibiotics are used in a case of hysterectomy (p. After careful identification of the uterine vessels and the ureter, the uterine vessels are desiccated using bipolar diathermy and then cut. Colpotomy device and vaginal occluding device (Colpotomizer system) help to detect the site of colpotomy and maintain pneumoperitoneum simultaneously. Parul Kodtawala, Ahmedabad) chapter 35 endoscopic surGery in GynecoloGy 619 complications of laparoscopy Complications are grouped into: (i) specific to laparoscopy itself, (ii) due to anesthesia, (iii) common to any surgical procedures. Complications due to laparoscopy itself: (1) Extraperitoneal insufflation (a) Surgical emphysema (b) Omental emphysema (c) Cardiac arrhythmia (2) Injury to blood vessels-mesenteric, omental, injury to major pelvic or abdominal artery or vein. Damage may be mechanical during dissection or thermal by electrical or laser energy. Anesthetic complications peculiar to laparoscopy are: (1) Hypoventilation (pneumoperitoneum and Trendelenburg position lead to basal lung compression and reduced diaphragmatic excursion). It has the advantage of increased dexterity, minimum fatigue, tremors or incidental hand movement. Hysteroscopy Hysteroscopy is a procedure that allows direct visualization inside the uterus. The telescope may be either straight on (forward view) (0°) or fore oblique view 30°, 70° or 90°. It has the advantage of easy uterine entry through the angle between cervix and uterus.

During normal menstruation hypertension of the heart cheap torsemide 10 mg overnight delivery, there are antegrade propagation of subendometrial contractions from the fundus to the cervix hypertension medical definition buy cheap torsemide. In adenomyosis with distorsion of junctional zone myometrial contractions are abnormal and inadequate (see below) blood pressure youth purchase cheap torsemide on-line. Dysmenorrhea (30%)-Progressively increased colicky pain during period is due to retrograde pattern of uterine contractions blood pressure lowering foods buy discount torsemide on-line. Infertility: Women with adenomyosis have a higher incidence of infertility and miscarriage blood pressure medication safe for pregnancy order 10 mg torsemide mastercard. The reasons are: (a) abnormal function of the subendometrial myometrium, (b) retrograde myometrial contractions, (c) interference in sperm transport and blastocyst implantation and (d) abnormal endomerial immune respose and nitric oxide level. The findings, however, may be altered due to associated fibroid or pelvic endometriosis. Ultrasound and Color Doppler (tVs) characteristics are: Myometrium normally has three distinct zones of different echogenecity. Other features are: (i) heterogenous echogenecity, (ii) hypoecoic myometrium with multiple small cysts in the myometrium (honeycomb appearance), (iii) increased vascularity within the myometrium. Treatment with progestins or cyclic estrogen and progestin have got little benefit. Radiotherapy may be needed in proved cases following its recurrence or incomplete surgery. Endometriosis is a disease seen in the reproductive years of a woman as its growth depends on estrogen. The incidence is about 10 percent but incidence is high (30­40%) amongst infertile women as based on diagnostic laparoscopy and laparotomy. The commonest abdominal site is ovary followed by pouch of Douglas and uterosacral ligaments (organs on the dependent part of the pelvis). It is a benign disease but it is locally invasive, disseminates widely and proliferates in the lymph nodes. Minimal disease may have severe pain whereas large endometriosis may remain asymptomatic. Abdominal scar is the commonest site of endometriosis following hysterectomy, hysterotomy, cesarean section, tubectomy or myomectomy. The disease is full of theories and no one single theory can explain endometriosis at all sites. In spite of dense adhesions amongst the pelvic structures, the fallopian tubes are usually patent. Severity of endometriosis and the degree of pelvic pain are not always proportional. Unlike primary dysmenorrhea, the pain lasts for many days before and after the menstruation. Dysmenorrhea is associated in 50 percent, menorrhagia in 60 percent and infertility in 40­60 percent. Clinical diagnosis is by the classic symptoms of progressively increasing dysmenorrhea, dyspareunia, infertility and feel of nodules in the pouch of Douglas. Microscopic diagnostic features are: presence of endometrial glands, stroma and hemosiderin-laden macrophages. It is progressive in about 30­60 percent patients and for the remainder it is either static or resolve spontaneously. However, the association of minimal to mild endometriosis and infertility is controversial. Other complications of endometriosis are: Acute abdomen due to rupture of chocolate cyst, infection of the cyst, colorectal obstruction and ureteral obstruction. Expectant treatment is extended to unmarried or young married with no abnormal pelvic findings. The mechanism of atrophy can be explained by pseudopregnancy or by pseudomenopause or by medical hypophysectomy (see p. Conservative surgery in endometriosis includes removal of all macroscopic endometriosis, lysis of adhesions and restoration of normal pelvic anatomy. Endoscopic laser surgery is the best in selected cases for the treatment of pain and to prevent the disease progress. Large ovarian endometrioma (> 3 cm) is treated by laparoscopic ovarian cystectomy. Postoperative medical treatment should not prevent pregnancy as the chance of pregnancy is highest during the first 6­12 months after the conservative surgery. Definitive surgery includes total hysterectomy with bilateral salpingo-oophorectomy. Laparotomy is done for advanced stage disease or in women who has completed her family. Postoperative estrogen replacement therapy after total hysterectomy and bilateral oophorectomy may be given 3 months after surgery. Regression frequently occurs in young woman, during pregnancy or when it is caused by viral infection. The following facts are to be borne in mind: It is more frequent in patients in the age group 20­40 years, i. Local examination reveals a lesion in the vulva with white, grey, pink or dull red color. To exclude vaginal or cervical neoplasia, cytologic evaluation has to be performed. There is hyperkeratosis, acanthosis (hyperplasia of epidermis) and chronic inflammatory cell infiltration. Topical fluorinated steroid ointment can be applied twice daily for a period of about 6 months. Surgery: the following are the types of surgery: Local excision-Wide local excision with 1 cm margin is reserved in young patient with localized lesion. Simple vulvectomy-It is employed in diffuse type especially in postmenopausal women (see p. Associated adenocarcinoma of apocrine gland (adenocarcinoma in situ) is present in about 10 percent of the cases. Multiple biopsies are to be taken to exclude associated adenocarcinoma of the apocrine glands. If it is found positive, bilateral lymph node dissection should be done at a second stage. The grading is done according to the thickness occupied by the undifferentiated cells. However, there is considerable degree of overlapping regarding the precise definition of fig. The prolonged effect of carcinogens can produce continuous changes in the immature cells which may lead to malignancy. Early age sexual activity and multiple sexual partners are the most consistent risk factors. Thus, it is apparent that some of these epithelial atypia either remain stationary, regress or even progress to invasive carcinoma. Two mechanisms are involved in the process of replacement of endocervical columnar epithelium by squamous epithelium. Squamous epidermidization by ingrowth of the squamous epithelium of the ectocervix under the columnar epithelium. Initially, the squamous cells are immature but ultimately become mature and indistinguishable to the adjacent squamous epithelium. This metaplastic process is very active at the time of menarche and during and after first pregnancy. The mean age for carcinoma-insitu is about 30 years, about 15 years less than that of invasive carcinoma. Infectious agents: the causative agents appear to be transmitted to the susceptible women during intercourse. Activated p53 causes cell apoptosis (cell death) and thus stop the viral multiplication. Cytology is the laboratory method while colposcopy is the clinical method of detection. Colposcopy evaluates mainly the changes in the terminal vascular network of the cervix which reflect the biochemical and metabolic changes of the tissue. In fact, cytology identifies the patient having cervical neoplasm, colposcopy identifies the site where from biopsies are to be taken. Those women with acetowhite lesions are considered for colposcopic examination and/or biopsy. Positive test result in elderly women (> 30 years) suggests colposcopic examination. Squamo-columnar junction is clearly seen (arrow) Chapter 22 Premalignant lesions 325 fig. Stained areas (normal) appear brown due to presence of glycogen Alternatively, ring biopsy is taken from the squamocolumnar junction and subjected to serial sections. Endocervical curettage is mandatory whether or not the entire transformation zone can be seen. Ace to white epithelium-epithelium turning white following application of 5 percent acetic acid due to cell protein coagulation. Punctuation-dilated capillaries which appear on the surface as dots (end on view of vessels). Atypical blood vessels with irregular diameter and branching are suggestive of invasive carcinoma. The impact of vaccines is greatest when it is given to females who have not been already infected. Vaccine induced neutralizing antibodies (IgG, IgA) works locally (cervix) by preventing the attachment of the virus to the cervical epithelium. Chapter 22 Premalignant lesions 327 Recurrence rate is high in cases of large lesions or those involving the endocervical glands. Methods of local ablation Cryotherapy acts on the principle of crystallizing the intracellular water at temperature of ­90°C (see p. Double freeze technique (freeze-thaw-freeze) increases the effectiveness of cryotherapy (see p. Electrodiathermy destroys cervical tissue up to a depth of 8­10 mm using a unipolar needle electrode. Carbon dioxide laser through colposcopic guidance-can destroy the epithelium by vaporization up to a depth of 7 mm. Advantages of laser vaporization: (a) preservation of transformation zone for subsequent follow up, (b) precision control technique in depth and breadth and (c) rapid healing. Contraindications of Ablation Treatment Suspected invasive lesion or glandular disease. Local ablative methods · Cryotherapy · Cold coagulation · Electrodiathermy · Laser vaporization c. As such, complete destruction of the lesion is considered to be a satisfactory treatment. Pretreatment accurate evaluation about the extent of lesion and exclusion of invasive carcinoma with the available gadgets (cytology, colposcopy and directed biopsy) is a sine-qua-non to get a good result. Complications such as hemorrhage, infection, cervical stenosis or incompetence depend on the length of cone excised. Blended current (cutting Chapter 22 Premalignant lesions and coagulation), low voltage output is used. Tissue up to a depth of 10 mm or more can be removed and sent for histological examination. Follow up protocol includes an initial posttreatment cytology at 6 months and then repeated at 12 months. Recurrence the recurrence rate is about 3­5% and development of invasive carcinoma ranges between 0. In the postmenopausal women with obesity, peripheral conversion of androgens in to estrogen is a risk factor. Long-term estrogen stimulation in condition of polycystic ovarian syndrome or feminizing ovarian tumor may predispose to endometrial cancer (Table 22. But the constant feature is abnormal perimenopausal uterine bleeding and ultimate diagnosis is by uterine curettage and histology. Long-term unopposed estrogen, particularly around the time of menopause, often leads to various types of endometrial hyperplasia. Risks: A significant number of such cases will develop invasive carcinoma during the period of 2­8 years (Table 22. It has been estimated that about 25 percent of adenomatous hyperplasia, 50 percent of atypical hyperplasia and 100 percent of carcinoma-insitu will develop endometrial carcinoma, if left untreated. The nuclei of the glands show enlargement, irregular size and shape, hyperchromasia and coarse chromatin. Carcinoma-in-situ: Commonly describes a lesion with severe cytologic as well as architectural abnormalities of the glands. Vaginal pool smear, endometrial aspiration (pipelle endometrial sampling), endometrial biopsy Chapter 22 Premalignant lesions progestogen preparations reduce the risks than estrogen alone. Definitive treatment-Treatment depends on: Age of the patient Histologic type of hyperplasia Young patient with cystic or adenomatous hyperplasia: · Cyclic progestogen therapy for 6­9 months may be helpful. Follow-up at interval of 6 months by endometrial sampling is essential to note whether its regression is there or not. Perimenopausal and postmenopausal women: · Hyperplasia without atypia: Continuous progestin therapy may be considered. However, hysterectomy with bilateral salpingo-oophorectomy is done as an alternative as the risk of carcinoma increases with age. For confirmation of carcinoma-in-situ, 3­5 mm diameter dermal punch biopsy is taken under local anesthetic. Alternatively, colposcopic examination and biopsy may be done after application of 5 percent acetic acid.

Frequent attacks of ureteric pain heart attack grill dallas buy discount torsemide 20 mg, due to pyelitis and pyelonephritis and hydronephrosis prehypertension 2016 discount 10 mg torsemide amex. Rectovaginal fistula-This is comparatively rare because of the interposition of the pouch of Douglas blood pressure chart diabetes torsemide 10 mg order on-line. The rectum may be involved either through the uterosacral ligament or through rectovaginal septum hypertension signs and symptoms treatment buy torsemide american express. Cachexia: the cumulative effect of the factors mentioned leads to cachectic condition blood pressure high heart rate low order generic torsemide pills. Metastases to the distant organs commonly observed are-lung (36%), lymph nodes (30%), bone (16%) and abdominal cavity (7%). However, cancer consciousness, proper health education of the population, specially amongst the poor socioeconomic group could be important steps in prevention. Secondary prevention: It involves identifying and treating the disease earlier in the more treatable stage. The abnormal cervical pathology likely to progress to invasive carcinoma can be detected. Its effective therapy reduces dramatically the incidence of invasive carcinoma in areas where it has been implemented. Even when the invasive carcinoma is detected, it is so early that a 85­100 percent 5-year survival rate could be achieved. Downstaging screening (Who 1986) Downstaging for cervical cancer is defined as "the detection of the disease at an earlier stage when it is still curable. Detection is done by nurses and other paramedical health workers using a simple speculum for visual inspection of the cervix". But in places where prevalence of cancer is high and cytological screening is not available, "downstaging screening" is useful. The strategy is, however, not expected to lower the incidence of cancer cervix, but it can certainly minimize the cancer death through early detection. Downstaging procedure: A female primary health care worker is trained for 2­3 weeks to perform speculum examination. Characters of a normal cervix: Pink in color, round in shape, smooth surface and does not bleed on touch. Whereas an abnormal cervix has the following characters: Reddish, red or white area of patch, growth or ulcer on the surface and bleeds on touch. Once the abnormality is suspected, the case is referred to a center where diagnosis and treatment of premalignant and malignant lesions are done. Curative: Ideally, the management of the patient with cervical cancer is a team approach. Both the gynecologist and radiooncologist should review the patient along with the biopsy report and the plan outlay 347 be individualized. Pretreatment Evaluation Irrespective of the treatment modalities (surgery or radiotherapy) the following evaluations are to be made apart from those already done (Table 23. Although the antigen is not specific, it has been useful as a means to monitor treatment response and to predict tumor recurrence. Pretreatment Preparations Irrespective of the methods of treatment, general health of the patient must be improved. This not only makes the patient sufficiently fit to withstand surgery but rise in hemoglobin percentage improves the tissue oxygenation needed for effective ionizing effect of irradiation. Extensive vaginal 348 TexTbook of GynecoloGy Limitation: It is ideally limited to early stage disease (Table 23. This operation is also popularly known by different names (Schauta of Viena­1902, Mitra of India­1957). There have been several modifications of the techniques of radical hysterectomy and bilateral pelvic lymphadenectomy at present. Generally, negative sentinel lymph nodes may allow omission of lymphadenectomy of the nodal basin. Special indications: As previously mentioned, there is no superiority of surgery over radiotherapy when the patients are placed in ideal circumstances. But, there are conditions where radiotherapy is contraindicated and only the surgical treatment has to be provided. Amount of radium placement Paris technique Manchester technique stockholm technique intrauterine tandem 33. Postoperative complications major postoperative complications as observed following total abdominal hysterectomy have been discussed (see p. Other complications include: ureteric fistula (about 1%), vesicovaginal fistula (0. There may be lymphocyst in the pelvis, lymphoedema of one or both the legs, dyspareunia and recurrence. This is due to damage of the sympathetic and parasympathetic fibers to and from the bladder and urethra. Continuous catheterization for bladder drainage is maintained for a period of 6­10 days. Tissue fluid, lymph and blood are collected to form the cyst following radical hysterectomy. Adequate suction drainage of the retroperitoneal space postoperatively is an important preventive measure. Rarely, needle aspiration is needed when the size is large or it produces symptoms. Woman should be psychologically and physically adjusted to cope with urinary and fecal stomas. The operative mortality of such type of operation is about 10­20 percent and with a 5-year survival rate of about 10 percent only. Ovarian vessels, round ligaments and uterine vessels are divided abdominally and are stapled. Primary Radiotherapy Cancer of the cervix was the first cancer of an internal organ to be treated with ionizing radiation using radium by Margaret Cleves in 1903. Small radioactive sources, mainly radium sulphate is mixed with some inert powder and packed in small needles or tubes. Radiation sources for intracavitary radiation are Radium (226Ra), Cesium (137Cs) or Cobalt (60Co). The container is made up of platinum, gold or alloy steel to absorb alpha and beta particles and allowing the gamma rays to sterilize the cancer cells. In carcinoma cervix, the tandems are inserted in the uterine cavity and the ovoids and colpostats are placed in the vaginal vault under anesthesia. In Paris and Manchester techniques, the source strength is smaller but exposure time is increased. One treatment period in Paris technique is 96­200 hours as compared to Stockholm technique where each application is 24­28 hours in duration (see Table 23. Manchester system, which is a modification of the Paris technique, delivers constant isodose at different depths, regardless of the size of the uterus and vagina. These three basic techniques are followed all through the world in the brachytherapy for carcinoma cervix. After DisaDvaNtagEs of raDiothEraPy Intestinal and urinary strictures, fistula formation (2­6%), vaginal fibrosis and stenosis causing dyspareunia, radiation menopause (p. Ovarian transposition (ovariopexy) well out of the range of pelvic irradiation may be done to avoid radiation menopause. Point A is 2 cm cephalic and 2 cm lateral to the external os and is the point of crossing of the uterine artery and ureter. Point B is 2 cm cephalic and 5 cm lateral at the same plane and is approximately the site of obturator gland. It has been calculated that point A gets about 7000­ 8000 cGy and point B 2000 cGy. Taking in to consideration that cancerolytic dose is approximately 7000 to 7500 cGy, the rest of the dose at point B is supplemented by external beam irradiation of 4000 cGy spreading over another three weeks. For external irradiation, linear accelerator with energy of 4 million electron volts or more is commonly used. In the immediate vicinity of the source, the vagina and cervix get and tolerate about 20,000 to 30,000 cGy. Surgical margin (10 mm) must be free of disease · Simple hysterectomy · Simple trachelectomy · Simple hysterectomy · Radical trachelectomy · Modified radical hysterectomy (Type - i) · Radical hysterectomy, pelvic lymphadenectomy (Type iii) with paraaortic lymph node evaluation. Medial half of the Mackenrodt and Uterosacral ligaments along with selective (clinically enlarged palpable) lymph nodes and upper (2 cm) of vagina are removed. The medial half of the parametria and proximal uterosacral ligaments are resected. Uterosacral and cardinal ligaments are resected at their attachments to the sacrum and pelvic side wall. For the prevention of radiation damage to the adjacent viscera, packing the vagina should be done carefully with gauze around the vaginal ovoids or needles. Recent development of tungsten inserts with plastic applicator (colpostats) has minimized excess gamma irradiation of the vaginal wall. Calculation of the amount of irradiation in rectum and bladder is done by dosimeter and required dose modification can be done as and when necessary (for treatment field-see p. With the advent of computer dosimetry, exact calculation of the doses on each patient for each application is being provided. Intensity modulated radiation therapy 352 TexTbook of GynecoloGy based chemotherapy) significantly improved the survival rate when given following radical hysterectomy. Three cycles of platinum-based combination chemotherapy with radiation therapy followed 3­6 weeks by radical hysterectomy and lymphadenectomy is done. This regimen had shown better overall disease free survival rate and reduced recurrence. Concurrent chemoradiation includes radiation and weekly cisplatin-based combination chemotherapy. Chemotherapy sensitizes the cancer cells to radiation and improves the survival rate. Carcinoma cervix detected after simple hysterectomy: the management protocol depends upon the following factors: (i) Cancer histology: microinvasive/invasive; (ii) Surgical tissue margin: negative/positive; (iii) Residual tumor mass: absent or present. W Complications of radiotherapy: Perforation of the uterus may result during introduction of uterine tandem. W Combination therapy: In the form of surgery, radiotherapy and chemotherapy may be done, one following the other. The objective of this form of therapy is to sterilize the cancer cells in the pelvic lymph nodes. The fact remains that even by pelvic lymph node dissection it is not possible to remove all the positive nodes. Vaginal part includes resection of cervical, vaginal, paracervical and paravaginal tissues. Vaginal cuff is resected circumferentially about 2 cm below the cervicovaginal junction. Complications of cone biopsy include: Hemorrhage, abortion, preterm labor and infection (see p. In late pregnancy, following maturity, fetus is delivered by classical cesarean section. Subsequent treatment with either radical surgery or radiotherapy is the same as in the nonpregnant state. Prognosis: Clinical stage of the disease is the single most important prognostic factor. A purulent or foul vaginal discharge is treated with antimicrobial vaginal creams or suppositories. Bleeding: Palliative radiation therapy (180­200 eGy/ day) or chemotherapy may be used to relieve symptoms of pain or bleeding. Pain: Palliation of pain is done either by reducing the pain stimulus or by raising the pain threshold. Palliative radiation with 2000 cGy over five treatment course may be an alternative. Anxiolytic (benzodiazepines) or antidepressant drugs (amitriptyline) may be helpful to raise the pain threshold. Opioid (oral morphine 3­10 mg) combined with paracetamol or aspirin, given at a regular interval (4­5 hours) is widely used to reduce pain perception. Regional blockade with local anesthetic techniques has been considered in some cases. Unilateral cordotomy (C 1-2) is considered for widespread pain which is refractory. A patient is declared cured if she remains well even after 10 years following initial therapy. The chance of survival rate of the patient after the symptoms appear, if left untreated, is about 2 years. Features of disease recurrence are: Pain in the pelvis, back, unilateral leg edema, ureteral obstruction, vaginal bleeding, palpable tumor in the pelvis and lymphadenopathy. Single agent or multiagent chemotherapy with cisplatin, paclitaxel or ifosfamide is used. Palliative radiation therapy may be used to those who have been treated initially with surgery. As such, the follow up protocols should be at 3­4 months interval for the first 2 years then at 6 months interval for next 2 years and thereafter annually. Thorough physical examination is done including examination of supraclavicular and inguinal lymph nodes. If it occurs earlier to that, it is presumed that the carcinoma was present at the time of primary surgery and, as such it is called coincidental, residual or false stump carcinoma. Dense adhesions of bladder, rectum and also ureters with the stump make the operation difficult and risky. The radiation therapy is also technically difficult, because of absence of uterus and close proximity of bladder and rectum to the radiation source. Radical parametrectomy, removal of cervix, upper vagina and pelvic lymphadenectomy is done in early stage disease.

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