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Displacement of the uterus

Displacement of the uterus. By Dr. Khattab KAEO Prof. of Obstetrics and Gynaecology Faculty of Medicine, Al-Azhar University, Damietta. In Gynaecology. Hysterectomy is a common operation. 1 in 5 women (20%) in the UK will have hysterectomy before the age of 60.

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Displacement of the uterus

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  1. Displacement of the uterus By Dr. Khattab KAEO Prof. of Obstetrics and Gynaecology Faculty of Medicine, Al-Azhar University, Damietta

  2. In Gynaecology

  3. Hysterectomy is a common operation. 1 in 5 women (20%) in the UK will have hysterectomy before the age of 60.

  4. Hysterectomy is associated with a 3/10,000 mortality rate and a 3% rate of serious morbidity

  5. Hysterectomy may initiate menopause presumably by interfering with ovarianbloodsupply

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

  7. 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.

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

  9. 2- Vascular embolization of the uterine arteries with polyvinyl alcohol particles. It is indicated for large symptomatic fibroids, & is done only in specialist centres. A catheter is introduced trans-femorally to the origin of the uterine artery; particles are injected; then the catheter is directed through the common iliac artery and the bifurcation of aorta to the other side reaching the origin of the corresponding uterine artery, repeating the injection. Short-term side effects include pyrexia, profuse discharge and passage of small or large fibroids through the vagina. Morbidity and even mortality can result from infection. Although well-tolerated, at present it is not recommended as it causes pain, may fail and in women wanting children pregnancy might be complicated with placental insufficiency. Intra-peritoneal adhesions can result from inflammatory reaction to necrosis. Antibiotic is given beforehand. Heparin is given for 2 days. A powerful analgesic is also given. There is reduction in the fibroid size by 60-65% for up to 1 year. +93% of patients are free. Large (8cm) pedunculated subserous or submucous fibroids are a contraindication to embolization.

  10. 3- Myomectomy. Recently, myomectomy can be done laparoscopically using an ultrasonically-activated scalpel. The low atmospheric pressure area adjacent to the vibrating scalpel causes cavitations of the intracellular water. The latter, then, changes to a vapour at the body temperature. It produces a protein-aceous coagulum that effectively seals blood vessels of up to 3 mm diameters. The scalpel has a haemostatic effect similar to thermal units, but at much lower temperature (80C) and with much less lateral thermal injury. In addition, blood does not reduce the power density as it may occur with use of monopolar electro-surgery.

  11. CERVICAL NEOPLASIA: Cases of early stromal microinvasion may require conization. Safety, efficacy, availability, costs and experience in addition to any associated pathology have dominated the controversy. There is a 99% cure rate if the transformation zone (TZ) has been destroyed for 4 mm. 5% of smears will not revert to normal after treatment.

  12. Cold-knife conisation (CKC). • Large loop excision of the transformation zone (LLETZ): Pros:Simultaneous conisation, local destruction & minimal tissue damage. Completed in 3.5 min & provides adequate histological specim in >90% of cases with minimal immediate morbidity. The incidence of cervical stenosis is lower than that following CKC. Lastly, it does not affect fertility or menstruation. Cons:50% rate of+ve margins Vs 33% for CKC Recurrence rate of GIN is 30% Vs 6% for CKC. Edge of the loop is invisible during surgery, so excision may be shallow. Large lesions are often removed in multiple fragments, making orientation of the specimen & assess ment of completeness of excision impossible.

  13. Needle excision of the transformation zone (NETZ):The needle (tungsten wire) is 15 mm long and 0.5 mm in diameter and is angled 45. NETZ yields a 1-piece cone of high-quality (20 mm depth [Vs. 14mm with LLETZ] & >3cm3 vol [Vs. 2.5 cm with LLETZ]). Rate of involved margins is 3%[Vs 9.5% with LLETZ]. • Loop electrosurgical excision procedure (LEEP) biopsy: 2 loops are used 1 for the ectocervix (20x8 mm) & one for the endocervix (10x10mm). The resulting raw area is cauterised by a diathermy ball electrode, then, Monsel sol. is applied to aid in haemostasis. LEEP is performed under local anaesthesia, costly with high rate of postoperative bleeding. Its main advantage is the provision of a high-quality specimen for histologic examination with minimal thermal artifact on the cut edges.

  14. Cryocautery: 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 contains an inoculum of dead virus which may improve the immune response to the causative agent. It is painless, the safest and simplest procedure and in addition, it causes no post-procedure bleeding, no cervical scarring + low cost and ease of use. Reepithelialization begins 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 TZ  difficult follow-up. • Diathermy: Done under general anesthesia and yields a depth of 7-8 mm. • CO2 laser vaporization: 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 VaIN can be tt-ed, offers rapid healing, less trauma to adjacent tissue & less scarring than cryocautery, but costly & requires extensive training.

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

  16. Advantages:Minor surgery (Postoperative morbidity, hospital stay, and time to return to work, resume normal activities and sexual intercourse are significantly less). No scar. Retained womb. Can be repeated. Disadvantages Not suitable for grossly large uterus. Possible complications e.g. fluid overload & uterine perforation. Pelvis can not be inspected for other pathologies. Any remaining fibroid will continue to grow. Continued need for cervical smear. Continued need for contraception (although contraindicated in patients wishing for further conception). Failure.

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

  18. Thank you

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