Gynaecology Marrow Pg 259-264 (Gynaecological Oncology)
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Questions and Answers

What is a common cause of vesicovaginal fistula in developing countries?

  • Total abdominal hysterectomy
  • Trauma during surgery
  • Obstructed labor (correct)
  • Infection

    • Immediate repair of a vesicovaginal fistula should be performed if identified within 24 hours after surgery.

    False

    Name one technique used for the repair of vesicovaginal fistula.

    Chassar moir technique

    Post-operative care includes bladder drainage with a __________ and antibiotics for 2 weeks.

    <p>Foley's catheter</p> Signup and view all the answers

    Match the repair timeframes with the corresponding conditions:

    <p>Identified immediately after surgery = Immediate repair Identified after 24 hours of surgery = Repair after 6 weeks</p> Signup and view all the answers

    What is indicated by constant dribbling of urine from the vagina without normal micturition?

    <p>Vesicovaginal fistula</p> Signup and view all the answers

    The Methylene blue 3 swab test involves three swabs placed in the vagina to determine the presence of different types of fistulas.

    <p>True</p> Signup and view all the answers

    What is the method of urine collection for testing in cases of urinary fistula?

    <p>Suprapubic catheterization</p> Signup and view all the answers

    The condition where urine passes from the urethra and vagina during micturition is called a ______.

    <p>urethrovaginal fistula</p> Signup and view all the answers

    Match the following swab observations with their corresponding fistulas:

    <p>Upper swab wet, but unstained = Ureterovaginal fistula Middle swab wet &amp; stained blue = Vesicovaginal fistula Only lower swab wet &amp; stained blue = Urethrovaginal fistula</p> Signup and view all the answers

    What is the surgery of choice for gynaecologic oncology management?

    <p>Total abdominal hysterectomy + Bilateral salpingo-oophorectomy</p> Signup and view all the answers

    Dysgerminoma stage 1 is treated with chemotherapy.

    <p>False</p> Signup and view all the answers

    What are the indications for debulking surgery in gynaecologic oncology?

    <p>Advanced stages (Stages 3, 4)</p> Signup and view all the answers

    Sertoli-Leydig cell tumors are known to secrete ______.

    <p>androgens</p> Signup and view all the answers

    Match the type of tumor with its corresponding treatment indication:

    <p>Epithelial cell tumor = 6 cycles of IV + Intraperitoneal chemotherapy Germ cell tumor = All stages except Dysgerminoma stage 1 Sex cord stromal tumor = Chemotherapy needed only in stage 3 and 4 Dysgerminoma = Best prognosis, no chemotherapy needed</p> Signup and view all the answers

    What is the main issue caused by Stress Urinary Incontinence (SUI)?

    <p>Involuntary passage of urine upon increased abdominal pressure</p> Signup and view all the answers

    The tension-free trans vagina tape (TVT) procedure involves placing tape via the obturator foramen.

    <p>False</p> Signup and view all the answers

    What test is commonly used to diagnose Stress Urinary Incontinence?

    <p>Q-tip test</p> Signup and view all the answers

    In the management of SUI, the ______ colposuspension is an abdominal route surgery that suspends the proximal urethra and bladder neck.

    <p>Bursch</p> Signup and view all the answers

    Match the following surgical procedures for SUI with their routes of administration:

    <p>Bursch colposuspension = Abdominal route Tension-free transobturator tape (TOT) = Abdominal or vaginal route Tension-free transvaginal tape (TVT) = Retropubic space</p> Signup and view all the answers

    What is a known risk factor for developing Ovarian Hyperstimulation Syndrome (OHSS)?

    <p>Polycystic Ovary Syndrome (PCOS)</p> Signup and view all the answers

    Letrozole is associated with a high risk of developing Ovarian Hyperstimulation Syndrome (OHSS).

    <p>False</p> Signup and view all the answers

    What hormone's elevated levels are a critical indicator for monitoring in the context of OHSS?

    <p>Estrogen</p> Signup and view all the answers

    The primary mediator involved in the pathophysiology of OHSS is __________.

    <p>VEGF</p> Signup and view all the answers

    Match the following conditions with their type:

    <p>Early OHSS = Caused by exogenous hCG injection Late OHSS = Caused by endogenous hCG during pregnancy Prevention of OHSS = Monitoring follicles and estrogen levels Triggering factor = Injection of hCG</p> Signup and view all the answers

    What characterizes Stage 2B of ovarian cancer according to the FIGO staging system?

    <p>Spreads to bladder or rectum</p> Signup and view all the answers

    Stage 4A of ovarian cancer indicates distant metastasis, including a malignant pleural effusion.

    <p>True</p> Signup and view all the answers

    What is the first step in the surgical staging of ovarian cancer?

    <p>Midline incision + Ascitic fluid sample sent for cytology</p> Signup and view all the answers

    Stage 3B involves macroscopic involvement above pelvic brim with a size of implant ______ cm.

    <p>≤ 2</p> Signup and view all the answers

    Match each substage of ovarian cancer with its description:

    <p>IA = Limited to ovary. IB = One ovary involved. IC = Both ovaries involved with capsule ruptured. 2A = Spreads to fallopian tube or uterus.</p> Signup and view all the answers

    Study Notes

    Urinary Fistula

    • Constant dribbling of urine from vagina with normal micturition suggests a ureterovaginal fistula.
    • Constant dribbling of urine from vagina without normal micturition suggests a vesicovaginal fistula.
    • Urine passing from urethra and vagina during micturition indicates a urethrovaginal fistula.
    • Methylene blue 3 swab test is a diagnostic test used to identify the type of fistula:
      • Upper swab wet, but unstained: Ureterovaginal fistula.
      • Middle swab wet & stained blue: Vesicovaginal fistula.
      • Only lower swab wet & stained blue: Urethrovaginal fistula.
    • Vesicovaginal fistula repair varies based on when it's identified:
      • Immediate repair: If identified immediately after surgery.
      • Repair after 6 weeks: If identified after 24 hours of surgery, allowing inflammation and infection to subside.
    • Post-operative instructions for vesicovaginal fistula repair include:
      • Bladder drainage: With a Foley's catheter and antibiotics for 2 weeks.
      • Avoid pelvic exams: Both per speculum and per vaginum.
      • Avoid intercourse.
      • Contraindicated pregnancy: For a year after repair.

    Gynaecologic Oncology Management

    • TAH (Total Abdominal Hysterectomy) + BSO (Bilateral Salpingo-oophorectomy) is the surgery of choice for gynecologic oncology.
    • Conservative surgery: Options include unilateral salpingo-oophorectomy (without hysterectomy) and germ cell tumors (GCT) in young females.
    • Debulking surgery is indicated for advanced stages (Stages 3, 4) of the disease.
    • Post-operative chemotherapy agents vary based on tumor type:
      • Epithelial cell tumor: 6 cycles of IV and intraperitoneal Paclitaxel + Carboplatin/Cisplatin.
      • Germ cell tumor: B (Bleomycin) E (Etoposide) P (Cisplatin)
      • Sex cord stromal tumor: B (Bleomycin) E (Etoposide) P (Cisplatin)
    • Sertoli-Leydig cell tumor: An androgen-secreting ovarian tumor, causing hirsutism, acne, baldness, and enlarged clitoris (virilization).

    Stress Urinary Incontinence (SUI)

    • Definition: Involuntary urine leakage during increased intra-abdominal pressure (e.g., coughing, laughing, sneezing).
    • Pathophysiology: Normal bladder neck closure fails, leading to urine leakage during straining, and the bladder neck descends.
    • Management options include:
      • Bursch colposuspension: Abdominal surgery to suspend the proximal urethra.
      • Tension-free transobturator tape (TOT): Middle urethra suspension via an abdominal or vaginal route.
      • Tension-free transvaginal tape (TVT): Tape passed via the retropubic space, increasing the risk of bladder and venous plexus injury.

    Management of Ovarian Cancer

    • FIGO staging systems categorize ovarian cancer into 4 stages:

    Stage 1

    • Limited to ovary: Includes substages IA, IB, and IC.
    • Capsule rupture:
      • IC₁: Intraoperative rupture.
      • IC₂: Preoperative rupture.
      • IC₃: Malignant ascites.

    Stage 2

    • Pelvic spread: Involves substages 2A and 2B.
      • 2A: Spread to other pelvic organs (Fallopian tube or uterus).
      • 2B: Spread to other pelvic organs (bladder, rectum).

    Stage 3

    • Spread beyond pelvis: Includes substages 3A, 3B, and 3C.
      • 3A: Spread to abdominal region.
      • 3B: Spread to abdominal region with implants ≤ 2 cm.
      • 3C: Spread to abdominal region with implants ≥ 2 cm, plus extension to the liver and spleen capsule.

    Stage 4

    • Distant metastasis: Involves substages 4A and 4B.

      • 4A: Distant metastases (e.g., malignant pleural effusion).
      • 4B: Distant metastases (e.g., liver/spleen parenchyma or inguinal lymph nodes).

    • Involvement of bladder and rectum is staged differently depending on the type of cancer:

      • Ovarian cancer: 2B
      • Other gynecological cancers: 4A

    • Steps of surgical staging for ovarian cancer include:

      • Midline incision with ascitic fluid sample for cytology.
      • Ascites saline wash for cytology.
      • Abdominal organ inspection and palpation.
      • Multiple peritoneal biopsies.
      • Type I TAH + BSO.
      • Infracolic omentectomy.
      • Pelvic and para-aortic lymph node dissection.
      • Closure.

    Ovarian Hyperstimulation Syndrome (OHSS)

    • Iatrogenic complication: Caused by the injection of human menopausal gonadotropin (hMG).
    • Excessive ovarian stimulation: Leads to multiple large follicles.
    • Elevated estrogen levels: Greater than 2500 pg.
    • VEGF from follicular fluid: Vascular Endothelial Growth Factor.
    • Risk factors:
      • Young females.
      • PCOS (Polycystic Ovary Syndrome).
      • Thin females.
      • Increased number of follicles (TVS).
      • Increased antral follicle count.
      • Elevated AMH (anti-Müllerian hormone) greater than 3.3.
      • High estradiol (E2) levels (≥ 2500 pg).
      • Pregnancy.
    • Drugs associated with OHSS:
      • hMG: Highest risk.
      • Clomiphene citrate: Low risk.
      • Letrozole: No risk.
    • Triggering factors: hCG injections.
    • Mediator: VEGF.
    • Complaints:
      • Nausea.
      • Vomiting.
      • Abdominal pain.
      • Dyspnea (shortness of breath).
    • Prevention:
      • Follicle and estrogen level monitoring.
      • Withhold hCG: If estrogen levels are ≥ 2500 pg.
      • Cabergoline: To decrease VEGF.
      • No embryo transfer: If there is an elevated risk of OHSS.
    • Ideal conditions for hCG administration:
      • Estrogen: 500-1500 pg.
      • Follicles:
        • Number: 2-3.
        • Size: Greater than 17 mm.
    • Amount of E2 released per follicle: 200 pg.

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    Description

    This quiz explores the types and diagnostic methods of urinary fistulas, including ureterovaginal and vesicovaginal fistulas. You will learn about the Methylene blue swab test and the repair options and post-operative instructions for vesicovaginal fistula management.

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