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Patrick C. Steptoe: laparoscopy, sterilization, the test-tube baby, and mass media.

In the late 1950s, Patrick C. Steptoe, a British gynecologist, established contact with Palmer of Paris and Frangenheim of Wuppertal, Germany, and studied laparoscopic technique under the tutelage of these pioneers. Despite the negative attitude among his colleagues, Steptoe soon became one of the most innovative researchers in the field of abdominal endoscopy, particularly laparoscopic sterilization. In the late 1960s, Steptoe began working with Robert Edwards, an embryologist, and launched an in-vitro fertilization project obtaining eggs by means of laparoscopy. Both researchers experienced years of frustration, disappointment, ethical and scientific criticism as well as a difficult relationship with the mass media. Finally, in July 1978, Louise Brown, the first test-tube baby, was born in England. Like many of his colleagues in the 1950s and 1960s, Patrick Christopher Steptoe (1913-1988), a gynecologist in Oldham, Great Britain, was concerned about the number of unnecessary laparotomies. Unfortunately, the Oldham group of hospitals was not a university clinic and Steptoe had scanty opportunity to develop his own research. In the late 1950s, he searched the medical literature for an alternative form of examination and came across publications about Decker's culdoscopy, the vaginal approach to view of the abdomen. Since this method was not widespread in England, Steptoe, in 1958, went to Montreal, Boston, and New York in order to observe and learn the practical use of culdoscopy. However, Steptoe left America disappointed.

Fertilization in Vitro↗

[Urethral diverticula in women. Apropos of 15 cases].

Urethral diverticulum is a rare disease, arising in the urethrovaginal septum and communicating with the urethra through an orifice. Characterised by clinical polymorphism, it is diagnosed by urethrocystography and transvaginal ultrasound. We report a series of 15 cases of urethral diverticulum over a 10-year period. The mean age of the patients was post-voiding was 36 years (range 24-50). The symptoms were recurrent urinary tract infections (66%), post-voiding urethral leakage (22%), vaginal pain (22%). Clinical examination found a vaginal mass in all patients. Retrograde urethrocystography showed the diverticulum in every cases, while IVP confirmed the diagnosis in only 62% of cases. Treatment is surgical and consists of removing the diverticulum via a vaginal approach. Short and long-term course is favourable. All patients were asymptomatic and the follow-up urethrocystography showed no diverticular recurrence.

Adult↗

Laparoscopic-assisted vaginal myomectomy through an anterior approach.

BACKGROUND: To evaluate the safety and efficacy of a combined laparoscopic and vaginal approach through the anterior cul-de-sac in dealing with fundal and/or anterior wall uterine myomata. PATIENTS AND METHODS: Seven women with symptomatic fundal and/or anterior wall uterine myomata were enrolled in this study. After laparoscopic identification of the location of the myomata, a guiding suture brought the dominant myoma down through the anterior cul-de-sac into the vagina via an anterior colpotomy. Resection and suturing were then performed transvaginally. RESULTS: Mean +/- standard deviation (SD) operative time, blood loss, and the length of hospital stay were 88.1 +/- 27.8 minutes, 278.6 +/- 131.8 mL, and 2.9 +/- 0.7 days, respectively. No patients developed serious complications, and only four transient macroscopic hematuria occurred intra- and postoperatively. CONCLUSION: Although transient hematuria may occur, a combined laparoscopy and vaginal approach in dealing with fundal and/or anterior wall uterine fibroids through the anterior cul-de-sac is an alternative to pure laparoscopic myomectomy.

Adult↗

Combined parasacral, vaginal and endorectal approach in surgical treatment of giant rectocele.

Authors operated on their Surgical departement 67 years old women with incomplete evacuation, and digital support during defecation, giant rectocele and massive vaginal vault prolaps. Authors realized cinedefecography and detected giant rectocele, depth was 8 cm, anorectal angle was 120 degrees. They stated Resting pressure 40 cm H2O, and Maximum squeeze pressure 50cm H2O by anorectal manometry. Authors verified external anal sphincters defect by endoanal ultrasound and determined Pudendal nerve terminal motor latency (PN TML) and recorded pathologic values of n.pudendal latency ( left branch 2,7 msec., right branch 4,3 msec). In concerning massive vaginal vault prolaps, huge rerectocele and clinical incompletely evacuation with self digital support during defecation with present defect od external anal sphincters and pathologic values of PN TML, authors indicated and made combined transvaginal, endorectal and perineal reconstructive operative performance. In the present time two years after the surgery radiologic mean depth of the rectocele was significantly reduced (preoperatively 8cm; postoperatively 1 cm). Anorectal angle is 100 degrees. Values of the PN TML is normaly (left branch of n. pudendalis 1,7 msec and right branch of n. pudendalis 1,9 msec). Authors recorded Resting pressure 60 cm H2O and Maximum squeeze pressure 110 cm H2O by anorectal manometry. They didnt visualized any external anal sphincters defect by anal ultrasound. Postoperatively difficult evacuation completely disappeared and digital support was no longer necessary during evacuation.

Aged↗

A vaginal and extraperitoneal approach to surgically stage patients with endometrial cancer.

OBJECTIVE: The purpose of this project was to prospectively evaluate the feasibility of an alternative technique for surgically staging patients with endometrial cancer. METHODS: Patients with endometrial cancer were enrolled in this protocol from September 1999 until August 2000. The staging procedure included pelvic washings via colpotomy, total vaginal hysterectomy, bilateral salpingo-oophorectomy (TVH/BSO), and extraperitoneal pelvic and paraaortic lymphadenectomy (EP-LND) if indicated. Tumor characteristics, time and feasibility of surgical procedures, length of hospital stays, and complications were prospectively recorded. RESULTS: Twenty-one patients were enrolled. Grade 1, 2, and 3 tumors were identified in 6 (29%), 10 (48%), and 5 (24%) patients, respectively. Pelvic washings and TVH/BSOs were performed on all patients. A total of 21/21 (100%) uterine specimens were removed vaginally and 41/42 (98%) adnexa were resected vaginally. EP-LNDs were performed on 17 (81%) patients due to pathologic findings of the uterine specimens. The median time to perform a TVH/BSO was 68 (47-149) min. The median time to complete a EP-LND was 77 (59-107) min. The median number of postoperative days was 1 (1-5). Complications were infrequent and mild. CONCLUSIONS: TVH/BSO, pelvic washings, and EP-LND is a feasible alternative to standard surgical staging of endometrial cancer. The minimal amount of exposure to the intraperitoneal space makes this approach arguably the least invasive for endometrial cancer staging and accounts for the decrease in recovery time and shortened hospital stays. The acceptable length of surgical time, short hospital stays, and minimal requirements for surgical instruments make this approach potentially the most cost-effective option for surgically staging patients with endometrial cancer. A randomized trial comparing this technique to standard surgical staging is warranted.

Aged↗

Early versus late repair of vesicovaginal fistulas: vaginal and abdominal approaches.

We reviewed retrospectively 24 consecutive women who presented with a vesicovaginal fistula repaired by a single surgeon between 1989 and 1993. All patients underwent preoperative investigation, including cystoscopy, excretory urography and bilateral retrograde pyelography. Followup ranged from 6 months to 5 years. Postoperatively, 96% of the women were cured. Two patients had persistent symptomatic detrusor instability and 1 had mild stress incontinence. In 1 woman a vaginal repair failed and she was subsequently cured after an abdominal repair. Five patients presented 6 to 12 months after fistula formation. Among the other 17 patients the average interval from pelvic surgery to vesicovaginal fistula repair was 10.8 weeks. Indications for abdominal repair were indurated vaginal epithelium approximately 2 cm. in circumference around the fistula, a vault fistula with poor vaginal exposure and fistulas involving the ureters. Surgical timing and route of repair are best tailored to the individual patient.

Adolescent↗

Complications of vaginal hysterectomy under "difficult" circumstances.

Vaginal hysterectomy is less invasive than hysterectomy performed via the abdominal approach. The vaginal approach may be made difficult by prior conisation, a need to remove the adnexae or marked uterine enlargement requiring morcellement. In this retrospective study we have investigated the impact of these factors on the incidence of complications in 1912 patients subject to vaginal hysterectomy. We have studied the incidence of intraoperative hemorrhage, bladder damage, hemorrhage up to 48 h after surgery, hemorrhage up to 14 days after surgery, vault abscesses or collections and pelvic peritonitis. In patients with prior morcellement, intraoperative hemorrhage was significantly more frequent. All other complications were not significantly increased by the intraoperative difficulties specified above. Thus even "difficult" vaginal hysterectomy would seem to carry low morbidity.

Female↗

Vaginal reconstruction: an algorithm approach to defect classification and flap reconstruction.

Vaginal defects from oncologic resection present a complex array of reconstructive challenges. Increased use of adjuvant radiation and chemotherapy demands uncomplicated wound healing. As patients are being diagnosed at earlier stages of disease and at younger ages, maintenance of sexual function and body image are fundamental goals. This review provides an algorithm approach to defect classification and flap reconstruction. Carefully appreciation of the specific defect facilitates flap choice. There are two basic defect types partial (Type I) and circumferential defects (Type II) 1. These defect types can be further subclassified. Type IA defects are partial and involve the anterior and/or lateral wall. Type IB defects are also partial, but involve the posterior vaginal wall. Type IIA defects are circumferential, involving the upper two-thirds of the vagina. Type IIB defects represent circumferential, total vaginal resection, most commonly following pelvic exenteration. Using this method of defect classification, three pedicled flaps can be used to successfully reconstruct the majority of defects: the Singapore (or pudendal thigh) flap, the rectus flap, and the gracilis flap. With appropriate flap choice and a multidisciplinary approach to patient care, rapid wound healing, restoration of the pelvic floor, and re-establishment of sexual function may be most reliably achieved.

Algorithms↗

Management of benign adnexal masses by vaginal route.

Until recently, surgical treatment of a benign adnexal mass implied a laparotomy. In recent years, the development of laparoscopic surgery, as well as ultrasound-guided aspiration techniques, have significantly modified the treatment options for these patients. These procedures have shown considerable advantages. They have reduced surgical trauma and have shortened the hospital stay. We present the results of our experience on the feasibility of a trans-vaginal surgical approach for the removal of benign adnexal masses. This technique, using traditional and cheap surgical instruments, allows the surgeon to excise benign adnexal masses, by entering the peritoneum through the posterior vaginal fornix and thus avoids the trauma of laparotomy. Fifty-four patients were operated on by this technique at our Department. The mean age was 39 years (range 21-66). In all cases, the operation was completed by the trans-vaginal approach. The median operative time was 30 minutes (range 20-45), and no blood transfusion was needed. The pathological diagnoses were as follows: functional ovarian cyst; 19, endometriotic cyst; 18, dermoid cyst; 11, parovarian cyst; 4 and peduncolated fibroid of the uterine fundus; 2 cases. The diameter of the adnexal masses ranged from 3 to 10 cm (median of 6 cm). In 30 cases, a conservative surgery was done (including 2 myomectomies), whereas in 24 cases, the adnexectomy was needed. Median post-operative stay in hospital was 4 days (range 1-14). This study shows the feasibility of trans-vaginal surgical approach for benign adnexal masses. The advantages and limitations of this technique, as well as of the traditional and laparoscopic surgery are considered and discussed. We believe that the transvaginal approach could be useful and cost-effective for the treatment of selected cases of adnexal masses.

Adnexal Diseases↗

An alternative approach to assisted vaginal breech delivery.

The immediate neonatal outcome by 2 different methods of assisted vaginal breech delivery was studied. In group A, spontaneous expulsion only up to the hip was allowed with one contraction and bearing down efforts; the rest of the baby was delivered with assistance with the next contraction and bearing down efforts. In group B the mother was allowed to expel the fetus up to the shoulders (with assistance) during one contraction and bearing down efforts, followed by assisted delivery of the head with the next uterine contraction and bearing down efforts. A decline in fetal blood pH (greater than 0.10) from the onset of delivery to cord arterial blood pH was more common in group B compared to group A; the difference being almost statistically significant (p = 0.54). Newborns with 1 min Apgar score less than 4 and with a need for assisted ventilation were significantly more common in group B (p less than 0.05). Exposure, stretching and compression of the umbilical cord for a longer time and possible separation of the placenta in group B may be the reason for such an outcome. Further studies are needed to establish the possible advantage of the method of delivery adapted in group A.

Adult↗

Office Approach to Urethritis, Vaginitis, and Cervicitis in Adolescents.

Urethritis, cystitis, vulvovaginitis, and cervicitis in females, and urethritis in males, are among the most common genitourinary tract syndromes. A number of organisms may cause each of these entities, and most of these organisms may cause more than one clinical syndrome. Similarly, several syndromes are associated with common presenting symptoms. This article discusses evaluation, diagnosis, and management of each of these syndromes by the practitioner in an office setting.

Journal Article↗