Gynaecology Marrow Pg 259-264 (Gynaecological Oncology)

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.