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Reconstructive and Reproductive
Surgery in Gynecology
Second Edition
Volume Two: Gynecological Surgery
Edited by
Malcolm G. Munro
Victor Gomel
CRC Press
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742
This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts have been made to publish reliable data
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Contributors v
iii
iv Contents
26 Diagnosis, investigation, and nonsurgical management of pelvic organ prolapse and urinary incontinence 371
Yaël Levy-Zauberman and Hervé Fernandez
27 Infertility: Mechanisms and investigation 381
Victor Gomel
28 Recurrent pregnancy loss: A new strategy for evaluation based on genetic testing 399
William H. Kutteh, Carolyn R. Jaslow, Paul R. Brezina, Raymond W. Ke, Amelia P. Bailey, and Mary D. Stephenson
Index 407
Index 671
Contributors
v
vi Contributors
Key points
•• Surgical management of Müllerian anomalies has been revolutionized by imaging, and the development of hysteroscopic
and laparoscopic surgical techniques that have rendered laparotomic management infrequent, and office hysteroscopic
management of selected anomalies a reality.
•• The CONUTA system of classification provides increased granularity allowing for more accurate descriptions of Müllerian
anomalies affecting the uterine corpus, particularly when they affect the cervix and the vagina.
•• For women with Mayer–Rokitansky–Kuster–Hauser syndrome (CONUTA U5-C4-V4) the success rate of the patient self-
administered “Frank technique” is about 85%–90%.
•• For those with vaginal agenesis for whom the Frank technique isn’t feasible or successful, there exist other procedures, such
as the Vecchietti and Davydov procedures that can be performed under laparoscopic guidance without the need for skin
grafting.
•• Isolated cervical agenesis (CONUTA U0-C4-V0 or V4) has been treated with procedures linking the corpus to the existing or
artificially created vagina, but study sample sizes are small, and there is inadequate reporting of pregnancy outcomes to
allow for meaningful counseling of patients.
•• The unicornuate uterus and variants, CONUTA U4-C3 (rAFS Class IIb), are often associated with abnormalities of the urinary
tract, such as unilateral renal agenesis, and can be treated with laparoscopically directed removal of the underdeveloped or
obstructed uterine horn.
•• Uterus didelphus, which is CONUTA U3b-C2 (rAFS Class III) and rAFS Class VI (there is no corresponding CONUTA designation)
generally require no surgical or medical intervention to deal with symptoms or to improve pregnancy outcomes.
•• The bicornuate uterus, CONUTA U3a-C0 (rAFS IV a/b), can be treated expectantly, or with Strassman metroplasty with hyster-
otomy and unification of the two endometrial cavities.
•• The septate uterus, CONUTA U2-C0/1 (rAFS Va/b), can generally be treated with hysteroscopically directed transection of the
septum.
433
434 Surgery for congenital anomalies
septum is difficult to appreciate and there is no hemato- Additionally, Perez-Millcua et al. introduced the
colpos to allow for bulging of the septum. We recommend LigaSure™ (Medtronic/Covidien Minneapolis, MN) for
that during laparoscopy, a 5 mm colpotomy incision is vaginal septum transection starting at the most caudal
created, followed by the placement of a suction irrigator portion of the septum and extending cephalad until the
tip through the incision allowing the compartment of the cervix or cervices are reached. As an RF bipolar vessel-
vagina to be distended. Concurrently, at the perineum, an sealing system the Ligasure has an advantageous small jaw
incision is created vaginally over the bulge. Moreover, we that can be used to maneuver tight vaginal spaces. The ther-
find that the suction irrigator tip can also be used to apply mal energy spread is 1–4 mm and is, therefore, less likely
pressure to the septum and locate the area of the septum to cause adjacent bladder or rectal injury. While it is prob-
for incision. ably unnecessary, the edges of the resected area can then be
It would stand to reason that outcomes, in part, are oversewn with interrupted polyglactin 910 (or equivalent),
predicated upon whether the septum is imperforate, i.e., and a vaginal mold can be considered for use immediately
associated with amenorrhea, or perforate and has an open postoperatively to minimize stricture and scarring of the
area for egress of menstrual fluid. The imperforate septum vagina (Video 29.1).10
can lead to a hematocolpos that, over time, can apply pres- There have also been reports of hysteroscopic techniques
sure on the septum, thereby causing thinning. The imper- such as RF resectoscopy being used for transection of a
forate septum can also facilitate surgical interventions by vaginal septum in virginal girls and women who prefer to
allowing for bulging of the septum that facilitates dissec- maintain an intact hymen. In this case, the vagina is dis-
tion away from surrounding structures. The location and tended with fluid media, and RF electrical energy through
the thickness of the septum are also important prognostic a cutting loop or needle-cutting electrode is then applied
variables. A high vaginal septum is technically more diffi- to the magnified fibrous layer of the septum. Ultrasound
cult to surgically correct. In general, complication rates are guidance is used simultaneously.
low.4 The main long-term complication is vaginal stenosis, With each method, periodic rectal examination should be
which may generally be managed by vaginal dilation. As undertaken to ensure that the zone of dissection is kept away
previously mentioned, the risk of this adverse event can be from the bowel. The resections (or transections) are ideally
minimized with postoperative use of a vaginal stent placed brought to the level of the cervix or cervices; care must be
by the patient until she becomes sexually active.8 taken not to traumatize the cervix (or cervices) at the upper
limits of resection.8 In general, reapproximation of denuded
Longitudinal vaginal septum (CONUTA V1 and V2) vaginal epithelium is often necessary in the area of resec-
Since a longitudinal vaginal septum, CONUTA V1 or V2 tion or transection. Absorbable sutures, e.g., 3-0 polyglactin
from the ESHRE system, is often associated with other 910, can be used to reapproximate the vaginal epithelium.
Müllerian anomalies, most commonly the didelphic and Although post-operative stenosis or adhesion formation is a
septate uteri (ASRM Class 3 and 5, respectively), this find- rare sequella of longitudinal septum resection, reassessment
ing must prompt further workup for other abnormalities in two to four weeks is appropriate to evaluate the vagina and
(see Chapter 11). This type of septum, when not associated break down anteroposterior adhesions that may have formed.
with outflow tract obstruction, typically doesn’t present
until the patient attempts tampon insertion or becomes MÜLLERIAN ANOMALIES AFFECTING THE UTERUS
sexually active. The patient may bleed despite tampon rAFS Class I-hypoplasia/agenesis (CONUTA U5)
insertion, and experience dyspareunia secondary to vagi-
nal compromise. The septum can be complete, which is Mayer–Rokitansky–Kuster–Hauser (MRKH) syndrome
more often associated with uterus didelphys (AFS Class 3; (CONUTA U5b-C4-V4)
CONUTA U3), or can be fenestrated. Psychologically, it is important that procedures designed
Management is surgical transection, usually performed to create a vagina be initiated at an appropriate age, con-
after menarche. Prior to surgery, it is important for the sidering several factors, including the patient’s sexual
surgeon to perform a careful pelvic examination to evalu- orientation, her motivation for the surgery, and the avail-
ate the length of the septum and to confirm the presence ability of professional and family support. Consequently,
and number of cervices. There are several techniques psychosocial counseling before treatment intervention is
from which to select, with perhaps the most common and appropriate.11
traditional being serial resection and suture ligation of Non-operative techniques can be very successful and,
segments using Haney- or Kelley-type clamps and a scal- consequently, should be considered the first line approach.9
pel, scissors, or monopolar needle or blade electrode for The original technique (Frank technique) employs the
transection. patient’s use of graduated Lucite (vaginal) dilators of
Alternatively, and if possible, the entire length of the progressively increasing diameter to create a functional
septum can be clamped with appropriate Peon or Kelly vagina (Figure 29.2).12 The process begins at the vaginal
clamps and then transected with a monopolar blade or dimple with the patient instructed about the proper orien-
needle electrode; then the clamps can be sequentially tation and angle of dilator placement to minimize the risk
removed and the incisions closed with a continuous, lock- of trauma to the urethra. Success rates are in the realm of
ing 2-0 polygalactin 210 suture.9 85%–90% regarding satisfactory coitus.9,13
436 Surgery for congenital anomalies
Absence
of vagina
(a) (b)
(e)
(c) (d)
STSG
(g)
(f )
(j) (k)
(h) (i)
Figure 29.3 (a–k) Macindoe procedure. (Modified from www.atlasofpelvicsurgery.com. With permission.)
is simply a minimally invasive adaptation of the same the bladder dome, the round ligaments, the uteroovar-
procedure (Video 29.3). 30 With the bladder catheterized, ian ligament, and lateral peritoneal leaf. This step can
the procedure is started laparoscopically by separat- be accomplished either before or after the anastomosis
ing the urinary bladder from the rectum after form- of the peritoneum and the vestibule. 31 A vaginal stent
ing a 4–5 cm transverse peritoneal incision between (mold) is left in place for ten days followed by fitting with
the two rudimentary uterine remnants, generally with a permanent mold to complement maintenance of vagi-
laparoscopic scissors. With a finger in the rectum, the nal depth with intercourse.
incision can be extended for about 1 cm between the The potential complications associated with these pro
bladder and rectum. From the perineum, the vesicorec- cedures include injury to bowel, bladder, and urethra as
tal space is identified after making an “H”-shaped inci- well as surgical bleeding. In addition, reduced vaginal
sion, and developed in a fashion similar to that used for length is likely to occur if there is lack of compliance with
the Wharton–Sheares–George technique with a large use of molds and/or coitus. Stricture and contracture
27–28 Hegar dilator or with a combination of sharp and secondary to scarring can occur as well as formation of
blunt dissection until the peritoneal edges are seen. The granulation tissue and, if a split skin graft is used, hair
incised peritoneum is mobilized and drawn down cau- growth in the vagina. Vesicovaginal, urethrovaginal, or
dally through this space and sutured to the edge of the rectovaginal fistula formation is also possible if there is
“H” incision with interrupted 3-0 delayed absorbable injury to these adjacent structures. Vaginal vault prolapse
monofilament sutures. After identifying the location is a potential problem after any intervention. However,
of the ureters, a purse string or two “hemipursestring” overall, the incidence of such complications is low and in
sutures of a 2-0 delayed absorbable monofilament are general less than 10%.13,15,16
positioned to include the lateral aspect of the meso- Other methods of vaginoplasty are less popular and
rectum, the anterior rectal serosa, the peritoneum of include use of bowel, sigmoid, jejunum, and ileum to line
438 Surgery for congenital anomalies
Figure 29.5 Surgical management of cervical agenesis. (From Fedele L, et al., Fertil Steril. 2008;89(1):212-16. With permission.)
Müllerian anomalies affecting the uterus 439
(d) (e) (f )
Figure 29.6 Cervical agenesis. (From Kriplani A, et al., J Minim Invasive Gynecol. 2012;19(4):477-84. With permission.)
This tract can allow for additional drainage of any remain round ligaments.42 Then, a probe is passed into the endo-
ing hematometria or hematosalpinx. Postoperatively, metrial cavity through a small midline fundal hysterotomy.
patients should be told to expect o ngoing chocolate- This probe is then applied to the cervical plate, displacing
colored discharge until adequate drainage of the tract has the uterus caudally. From below, an “H” incision is made
occurred; visualization of the next menses will confirm in the retrohymenal dimple, and blunt and sharp dissec-
the patency of the tract. Cases of vaginal stricture have tion is carefully performed until the caudal end of the cor-
been noted postoperatively where the vaginal epithelium pus is reached. After stabilizing the corpus, incisions are
was pulled out more than 3 cm.35 There has been no good made over the probe entering the cavity, and the corpus is
evidence to support the use of vaginal stents or molds fol- attached to the flaps of the “H” incision, thereby creating
lowing the pull out method. a neovaginal canal. A mold can be left in place and then
inserted and reinserted. A series of 12 such patients has
Cervical agenesis (CONUTA C3 [unilateral aplasia] been reported, with long-term maintenance of vaginal cali-
or C4 [cervical aplasia]) ber, and all who had attempted vaginal sexual function had
Isolated cervical hypoplasia or agenesis is extremely rare, done so successfully; no pregnancies had been attempted.42
with the actual incidence unknown.15,32,36 The coexistence For those with cervical hypoplasia, but with a patent
with vaginal agenesis has been estimated to be about 25% canal without hematocolpos, ART.approaches include
based on cases reported in the literature.36 Much of the zygote intrafallopian transfer44,45 and image-guided trans-
available evidence is derived from case reports and very myometrial transfer of embryos to the endometrial cavity
small series, a circumstance that makes it difficult to gener- to bypass cervical passage can be considered.46,47
alize recommendations. Reconstruction based on the con-
cept of uterovaginal anastomosis has been described and Unicornuate uterus (rAFS Class II; CONUTA U4-C3)
rarely reported to result in successful spontaneous preg- As mentioned in Chapter 11, there is no evidence to sup-
nancy.37–42 In the past, the procedures typically included port surgical treatment of a unicornuate uterus with con-
a uterovaginal graft as part of the accompanying vagino- tralateral agenesis. No surgical intervention is deemed
plasty that was required for the commonly encountered necessary unless the Class II anomaly is associated with a
patients with vaginal agenesis. This approach has also been contralateral uterine horn with functional endometrium
associated with tragic outcomes, including infection and and outflow tract obstruction (rAFS Class II b; CONUTA
even death related to endomyometritis, reobstruction, and U4a-C3).
death secondary to sepsis.40,43 Class II b anomalies are associated with a higher inci-
More recently a different laparoscopically directed tech- dence of endometriosis, in addition to premature labor
nique has been described that does not require a graft, and malpresentation. A spontaneous abortion rate of 37%,
involving mobilization of the uterus with dissection of the preterm delivery rate of 16%, term delivery of 45%, and
vesicouterine and rectouterine spaces and by dividing the live birth rate of 54% have been reported.48,49
440 Surgery for congenital anomalies
Surgical intervention of an obstructed uterine horn obstruction. Care must be taken to widely excise the sep-
requires assessment of the renal system, as anomalies may tum, and in a manner similar to that for transverse vagi-
include either agenesis or distortion of anatomy, such as nal septum resection, the vaginal epithelium is then well
the course of the ureter. If a decision is made to excise approximated (see Chapter 11).
the involved uterine remnant, this can usually be accom-
plished laparoscopically (Video 29.4). Following position- Bicornuate uterus (rAFS Class IV; CONUTA
ing of the laparoscopic ports, and with confirmation of the U3a, b, and c-C0)
anatomy including the location of the ureter or ureters, the Surgical reconstruction can be considered in the patient
dilated and obstructed horn is identified. Adhesions are with recurrent pregnancy loss and an rAFS Class IV
lysed as appropriate with scissors or an appropriate energy anomaly. Outcome data are variable with pre-operative
source. The pedicle comprising the round ligament, the live birth rates ranging from 2%–21% to post-surgical suc-
fallopian tube, and the ovarian artery (“triple pedicle”) is cess at 60%–86%.51–53 The spontaneous abortion rate has
identified and transected after coagulating the tissue with been reported to be 36%, the preterm rate 23%, term deliv-
RF or ultrasonic energy. The pedicle is transected and the ery rate 41%, and live birth rate 55%.16
leaves of the broad ligament opened and then divided, One option, as noted for Class III/U3b anomalies, is the
exposing the vascular supply to the horn, usually from Strassman metroplasty, a procedure that results in unifica-
the ipsilateral uterine artery. It is advisable to extend the tion of the two uterine horns after the creation of a trans-
peritoneal incision to the vesicovaginal fold isolating the verse fundal incision. Following access to the peritoneal
bladder from the area of dissection. Then the blood sup- cavity, the procedure starts with use of dilute vasopressin
ply can be sealed and transected. Attention can then be (concentration varies, e.g., 1 unit diluted with 30 ml normal
turned to separation of the horn from the “normal” corpus saline) injected into area of planned uterine incision. The
in a way that preserves optimal myometrial caliber. This is myometrium is incised with a monopolar RF blade or needle
usually performed with an RF needle or blade electrode electrode using a low voltage (“cutting”) waveform at about
or an ultrasonic scalpel or shears. The dissection is con- 30 watts (depending on the design of the electrode); the inci-
tinued until it meets that from the lateral side when the sion is made from the superomedial aspect of each uterine
blind horn can be removed. Removal from the peritoneal horn with care being taken not to disturb the cornual aspects
cavity can be accomplished with an appropriate morcella- on each side of the uterus. The incision is extended down
tion technique (Chapter 4). Suture reapproximation of the to the endometrial cavity. This is followed by transposing
detached round, broad, and uteroovarian ligaments to the the incision to a vertical orientation and then approximat-
“normal” horn can be performed using running or inter- ing the myometrial edges with interrupted 0-polygalactin
rupted delayed absorbable 2-0 sutures. 910 (Vicryl), or equivalent delayed absorbable sutures. The
serosa is reapproximated with a 3-0, delayed absorbable
Didelfic uterus (rAFS Class III; CONUTA U3b-C2) suture. The result resembles the appearance of the repaired
Generally, there is no indication for surgical intervention incision associated with a classical Cesarean section.32,54
except for excision of an associated symptomatic vaginal Cervical cerclage has also been reported to reduce the
septum, i.e., hemi-vagina with associated hematocolpos. risk of second trimester pregnancy loss and preterm birth;
Overall the spontaneous abortion rate is 32%, preterm however, available comparative evidence suggests that
birth rate is 28%, term delivery is 36%, and live birth rate expectant management appears to be of equal efficacy.48
is 56%.48,49 Controversy remains regarding the role of
Strassman metroplasty in women with recurrent preg- Septate (rAFS Class V; CONUTA U2-C0/1)
nancy loss, especially those that occur in the second tri- As previously mentioned, there is a large body of evidence
mester. Unification of the uterine cavities (described below to support the surgical management of a septate uterus
with Class IV anomalies) can be accomplished via lapa- to improve pregnancy-related outcomes in patients with
rotomy or with minimally invasive techniques; following a history of recurrent pregnancy loss.55–57 Additionally,
laparotomy, outcomes describing an 80% live birth rate Chapter 11 addressed the argument for prophylactic tran-
have been reported.50 However, overall, the available evi- section of the septate uterus in patients with primary
dence does not support this type of unification procedure.51 infertility.
OHVIRA (obstructed hemivagina and ipsilateral renal The question of septum management prior to in vitro
agenesis) is one of the more common Müllerian anomalies fertilization overall seems most supportive of septum
associated with obstruction (CONUTA U2/U3b-C2-V2). transection.58 This question has been addressed in a series
Resection of the wall between the patent and obstructed reflecting IVF outcomes before and after hysteroscopic
hemi-vagina on the involved side results in relief of pain septum transection. In patients with a large septum (rAFS
in association with retained menstrual fluid. Ideally, Va; CONUTA U2b) that was left intact, the spontaneous
management includes a single stage approach that entails abortion rate was 83.3% and with a small septum (rAFS
vaginally directed resection of the hemi-vagina aided by Vb; CONUTA U2a), 28.9%. This was in comparison to
intraoperative ultrasound and laparoscopy as appropri- patients for whom a larger septum was removed, where the
ate. Upon resection, a hematocolpos is usually noted, and miscarriage rate was found to be 30.6% while with small
thus creation of an outflow tract relieves the unilateral septum transection it was reported as 28.1%.58
Müllerian anomalies affecting the uterus 441
The technique is NOT septum resection but hystero- channel of the hysteroscope. Examples include an oocyte
scopic transection. This approach appears to result in an retrieval needle or a 5 Fr Williams needle. Then the scis-
“almost normal prognosis for pregnancy outcomes and sors or, preferably, a bipolar needle is passed through the
term delivery rates.”48 If the septum reaches the level of the operating channel of the operative sheath. Transection of
exocervix (CONUTA U2b-C1), there has been some con- the septum can start with the most caudal portion divid-
troversy regarding management—some suggesting that ing the tissue while continually ensuring that the plane of
the cervical component be left intact, while others remove transection is midway between the anterior and posterior
the cervical septum in its entirety.59 If there is uncertainty aspects of the endometrial cavity. In general, this plane
regarding the diagnosis—i.e., the distinction between a will be relatively avascular—if bleeding is encountered, it
rAFS Class IV and Class V anomaly—it is most appropri- is possible that the dissection has deviated off plane. The
ate to perform the procedure in the operating room under surgeon should also be aware of the cephalic extent of dis-
laparoscopic guidance. However, when 3-D TVUS or MRI section with the end point being the observation of muscu-
is available this should not be necessary. lar tissue, bleeding, and/or the transection reaching a plane
There does not appear to be any uniform approach to that is approximately level with the cornua.61 It is better to
pre-op endometrial suppression with progestins, danazol, leave a small amount of the septum than to go too far.
or Gonadotrophin-releasing hormone agonists, but it is If the procedure is performed under laparoscopic guid-
apparent that they avoid the specter of endometrial frag- ance, the laparoscopic light source can be turned off while
ments obscuring visualization and potentially clogging viewing the uterus to visualize uniformity of hystero-
the flow channels of the hysteroscope. scopic resection. In this case, the uterus seen through the
At least for rAFS Va (CONUTA U2b) anomalies, the laparoscope takes on the appearance of a “jack-o’-lantern”
technique can be performed under local anesthesia as an when uniform hysteroscopic transect is accomplished.
office procedure using no or, preferably, local anesthesia;60 For Class Va anomalies that reach the level of the exo-
it can also be performed under conscious sedation (see cervix (CONUTA U2, C1), the approach changes some-
Chapter 7). All that is necessary is a hysteroscope placed what, as there is controversy regarding the propriety of
within a 5 or 5.5 mm OD continuous flow operative sheath removing the cervical component of the septum.
with a 5 Fr operating channel and either 5 Fr hysteroscopic Advocates for preservation of the cervical septum at the
scissors or an RF needle. Such an approach may be associ- time of metroplasty propose a hypothetical risk of iatro-
ated with reduced operating time and complications but genic cervical incompetence in subsequent pregnancies.
equivalent outcomes.61 Usually, the selected hysteroscope To transect the septum in the uterine corpus while pre-
has an oblique lens, either 12°–15° or 25°–30°. When mechan- serving the cervical component of the septum, a pediatric
ical or bipolar RF instruments are used, the distending #8 Foley catheter or metal probe is inserted into one hemi-
media should contain electrolytes such as a normal saline cervix. A resectoscope or operative rigid hysteroscope is
solution. Nonelectrolytic media such as sorbitol, glycine, then placed in the contralateral hemicervix and the other
or mannitol are used for uterine distention when monopo- hemicervix is distended with fluid media. The septum is
lar RF instrumentation is selected. The fluid deficit should then incised with hysteroscopic scissors or with a needle
be monitored throughout the procedure as described or blade electrode just above the internal cervical os until
in Chapter 7 with maximum deficits of 1000 mL with the Foley bulb or metal rod is visualized. Transection of
non-electrolyic solutions and 2000–2500 mL with saline the septum is continued in a cephalad direction until both
media, each signaling termination of the procedure. For tubal ostia are visualized and the hysteroscope can move
more details regarding hysteroscopic distending media, free about the cavity.
see Chapters 7 and 10 and the AAGL Practice Report on Proponents of cervical septum transection have postu-
management of hysteroscopic distending media.62 lated that removal of the septum allows for an easier and
The specific approach utilizing hysteroscopic scissors, safer hysteroscopic metroplasty. One randomized con-
laser energy, or RF monopolar or bipolar devices is, in trolled trial comparing those women with cervical septum
large part, operator choice. If the surgeon is confident of transection versus retention found that in the transection
the diagnosis based on MR imaging or prior laparoscopic group, total operative time was reduced owing to improved
evaluation, and the septum is confined to the endometrial visibility and ease of initial uterine septum incision during
cavity, it is rather simple and safe to perform in an office hysteroscopy.63 The use of distending media was reduced
setting. After obtaining appropriate local anesthesia (see in the cervical transection group. No difference was found
Chapter 7) (Video 29.5) the cervix is dilated as necessary in subsequent pregnancy rates, first trimester abortions,
to accommodate the outer diameter of the hysteroscopic the need for cerclage, or the proportion of preterm deliv-
system to be used in the procedure. After accessing the eries. The group with cervical septum retention had a sig-
cervical canal, the septum is identified with the two “tun- nificantly higher number of cesarean sections.
nels” that represent the endometrial cavities on each side. Transection of the septum can be performed by first plac-
In such instances, additional anesthesia may be provided ing two single tooth tenacula on the anterior aspect of the
with hysteroscopically directed injection of 0.5% lidocaine cervix. Then the two cervical canals can be dilated one at a
(or mepivacaine), with 1/200,000 adrenaline into the sep- time to 6 mm. Next, using Metzenbaum scissors, the cervi-
tum with a suitable needle passed through the operating cal septum can be incised to the level of the cervical canal
442 Surgery for congenital anomalies
Table 29.1 Complications of vaginoplasty. laparotomy, or laparoscopy for septum resection, exam-
ples of such include Jones metroplasty, where a cuneiform
Urinary Complaints and Bleeding 1%
portion of fundal myometrium is resected, and the Bret–
Bladder Trauma 2% Tompkins metroplasty, in which an anteroposterior inci-
Rectum or Bladder Perforation 1%–4% sion is made into the uterus, the septum is incorporated
Long-term UTI 4%–7% into the myometrium, and uterine muscle closure occurs
Vaginal Stricture or Contracture 4%–9% without removal of any tissue.64 In addition, El Magoub
Vesicovaginal/Rectovaginal Fistula 1%–3% reported approaching the fundus with a small transverse
Skin Graft Necrosis 1%–3.5% incision along the septum through which the septum is
Persistent Vaginal Discharge 3% removed.66
Vaginal Prolapse 3%
Arcuate (rAFS Class VI; CONUTA-No categorization)
Source: Adapted from Callens N, et al., Hum Reprod Update.
2014;20(5):775-801. The arcuate uterus is “a variant of normal”; patients with
Class VI lesions should not be advised to undergo surgery.
sufficient to allow adequate distension following placement As described in Chapter 11, and by definition, the arcuate
of an operative hysteroscope or resectoscope. Then, with uterus equates with a septum measurement of less than 1 cm
hysteroscopic scissors, or a suitable needle electrode, the in length. The reported reproductive outcomes reported
surgeon can transect the remaining portion of the septum are similar to those of “historical controls.”20–23,52,54,67,68
in the cervix and the uterine corpus (see Table 29.1).
Concurrent laparoscopy may be used to monitor for Diethylstilbestrol (DES)-related anomalies (rAFS
perforation of the corpus or cervix; however, with prepro- Class VII)(CONUTA U1)
cedure imaging, good hysteroscopic visualization, and, if Until 1971, DES was given to help prevent miscarriage in
necessary, intraoperative transabdominal ultrasound, this women with a prior history of spontaneous abortions. The
step is usually unnecessary. The procedure should be per- relationship of DES to uterovaginal anomalies is a subject
formed either in the follicular phase of the menstrual cycle discussed in Chapter 11. There has been no good evidence
or following preoperative treatment with progestins to thin to suggest metroplasty or other corrective surgeries as
the endometrium and improve hysteroscopic visibility. being efficacious.10 If genetic progeny are desired, then
There is some controversy regarding the utility of the individual or couple can consider controlled ovarian
postoperative intrauterine stents or barriers. Estrogens, hyperstimulation, IVF, and subsequent gestational carrier.
progestins, and stents, including intrauterine devices Possible infertility with cervical hoods, collars, or vaginal
and pediatric Foley catheters, are used by many without adenosis may be overcome with intrauterine insemina-
abundant evidence of value.64 A randomized clinical trial tion. Again, there is no good evidence to suggest that sur-
was conducted to address the utility of an intrauterine gical intervention is warranted here.
device (IUD) placed postoperatively vs. no placement of
an IUD upon completion of hysteroscopic metroplasty. All VIDEOS
patients received postoperative conjugated equine estro-
gens at 1.2 mg twice daily for 30 days with the addition of Video 29.1 Transection of longitudinal vaginal septum.
medroxyprogesterone acetate 10 mg daily on days 26–30. https://youtu.be/jXK_AvILhVQ
The researchers concluded the use of an IUD with hor- Video 29.2 Laparoscopic Vecchietti procedure. https://
monal therapy did not seem to be efficacious.65 Moreover, youtu.be/0IGbkMYZwA8
additional trials have shown that the use of neither post- Video 29.3 Laparoscopic Davydov procedure. https://
operative estrogen, copper IUD, nor intrauterine balloon youtu.be/pJLCHZhl7lc
had any benefit in the prevention of postoperative adhe-
sion formation following metroplasty. Video 29.4 Laparoscopic removal of uterine horn. https://
Other approaches, not necessarily recommended in youtu.be/Mc_TVO14C4M
light of the advances in hysteroscopically directed sur- Video 29.5 Hysteroscopic metroplasty rAFS Va septum.
gery, include abdominal metroplasty, which requires https://youtu.be/uJ1RBeDdPBs
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Surv. 1989;44(7):556-69. Female genital anomalies affecting reproduction.
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Gynecol. 1990;76(5 Pt 2):900-1. 54. Heinonen PK. Complete septate uterus with lon
40. Kriplani A, Kachhawa G, Awasthi D, Kulshrestha V. gitudinal vaginal septum. Fertil Steril. 2006;85(3):
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T, Tarlatzis BC. Successful isthmo-neovagina anas- 56. Pabuccu R, Gomel V. Reproductive outcome after
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Invasive Gynecol. 2015;22(1):142-50. 57. Mollo A, De Franciscis P, Colacurci N, Cobellis L,
42. Fedele L, Bianchi S, Frontino G, Berlanda N, Perino A, Venezia R, et al. Hysteroscopic resection of
Montefusco S, Borruto F. Laparoscopically assisted the septum improves the pregnancy rate of women
uterovestibular anastomosis in patients with uter- with unexplained infertility: a prospective controlled
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43. Casey AC, Laufer MR. Cervical agenesis: septic death Verdenik I, Ribic-Pucelj M, Bokal EV. The outcome
after surgery. Obstet Gynecol. 1997;90(4 Pt 2):706-7. of singleton pregnancies after IVF/ICSI in women
44. Thijssen RF, Hollanders JM, Willemsen WN, van der before and after hysteroscopic resection of a uterine
Heyden PM, van Dongen PW, Rolland R. Successful septum compared to normal controls. Eur J Obstet
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45. Fluker MR, Bebbington MW, Munro MG. Successful Fernandez H. [Management of ten patients with
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60. Bettocchi S, Ceci O, Nappi L, Pontrelli G, Pinto L, 64. Valle RF, Ekpo GE. Hysteroscopic metroplasty for
Vicino M. Office hysteroscopic metroplasty: three the septate uterus: review and meta-analysis. J Minim
“diagnostic criteria” to differentiate between sep- Invasive Gynecol. 2013;20(1):22-42.
tate and bicornuate uteri. J Minim Invasive Gynecol. 65. Vercellini P, Fedele L, Arcaini L, Rognoni MT,
2007;14(3):324-8. Candiani GB. Value of intrauterine device inser-
61. Colacurci N, De Franciscis P, Mollo A, Litta P, Perino tion and estrogen administration after hysteroscopic
A, Cobellis L, et al. Small-diameter hysteroscopy with metroplasty. J Reprod Med. 1989;34(7):447-50.
Versapoint versus resectoscopy with a unipolar knife for 66. el-Mahgoub S. Unification of a septate uterus:
the treatment of septate uterus: a prospective random- Mahgoub’s operation. Int J Gynaecol Obstet.
ized study. J Minim Invasive Gynecol. 2007;14(5):622-7. 1978;15(5):400-4.
62. Worldwide AAMIG, Munro MG, Storz K, Abbott JA, 67. Maneschi F, Marana R, Muzii L, Mancuso S.
Falcone T, Jacobs VR, et al. AAGL practice report: Reproductive performance in women with bicornu-
practice guidelines for the management of hystero- ate uterus. Acta Eur Fertil. 1993;24(3):117-20.
scopic distending media: (Replaces hysteroscopic 68. Lin PC. Reproductive outcomes in women with
fluid monitoring guidelines. J Am Assoc Gynecol uterine anomalies. J Womens Health (Larchmt).
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63. Parsanezhad MD, Alborzi D, Zarel A, Dehbashi S,
Shirazi LG, Rajaeefard A, Schmidt EH. Hysteroscopic
metroplasty of the complete uterine septum, dupli-
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85(5):1473-7.
Surgery for vulvar disorders
HOWARD T. SHARP
30
Key points
•• Vestibulectomy is indicated for women with chronic localized provoked (NOT unprovoked) vulvodynia who do not respond
to medical therapy.
•• For vestibulectomy
– The excision should extend to Hart’s line and no further.
– The hymen is removed with the specimen.
– Vaginal tissue should be undermined to close tension-free.
– 3-0 chromic catgut is used for rapid release to minimize scarring.
•• For reduction labioplasty
– Approximately 1.5 cm of labia should remain for functional purposes.
– Measuring and marking the lines of incision aid in symmetry.
•• For Bartholin duct cyst and abscess management
– 1% lidocaine with added sodium bicarbonate can reduce infiltration pain.
– A small gauge needle (27- or 30-gauge preferably) and a small volume syringe are used.
– The skin stab wound should be only 5 to 6 mm wide to hold the Word catheter in place.
– The catheter should remain in place for four weeks.
•• For Bartholin gland excision
– The dissection can be quite vascular due to branches from the pudendal artery.
– Vascular branches should be clamped and sutured or electrodesiccated.
– A drain may be left in place if there is significant oozing through the surgery.
•• For laser ablation for VIN
– The surgeon should be familiar with the four surgical planes of the vulvar skin.
– Postoperative pain can be treated with oral analgesics as well as local measures:
– Ice
– Topical lidocaine
– Topical 1% silver sulfadiazine cream
– Sitz baths
•• For wide local excision of the vulva
– The area of excision should be an ellipse that can be closed primarily.
– The margins should be undermined 1 to 2 cm to aid in closure.
There are several vulvar conditions that may be associated vestibular pain when provoked, usually with tampon inser-
with pain and reduced vulvar and vaginal function. Many tion, or vaginal intercourse. The presence of constant pain or
of these conditions can be treated successfully with con- burning should be a red flag for a different diagnosis, falling
servative medical therapy. When contemplating vulvar under the unprovoked vulvodynia category, which typically
surgery, it is important to establish a diagnosis and to try does not respond to surgery. There is no absolute consen-
conservative management when indicated. Many surger- sus for making the diagnosis of LPV, though Friedrich sug-
ies performed on vulvar tissues include surgery for malig- gested three criteria: (1) vestibular pain with direct contact
nancy and surgery for aesthetic purposes. This chapter (a cotton tipped applicator is often used), (2) erythema at the
will focus primarily on benign and premalignant vulvar minor vestibular gland openings, and (3) pain with pressure
conditions for general gynecologic surgeons. Aesthetic at the vestibule, occurring for at least three to six months
surgery is not covered in this chapter. duration.1 Biopsy should be considered when in doubt, as
other medically treatable conditions are often identified
VESTIBULECTOMY when a biopsy is evaluated by a dermatopathologist.2
Vestibulectomy may be performed for localized, provoked
vulvodynia (LPV), previously referred to as vulvar vestibu- Informed consent
litis (see Chapter 23). Before performing vestibulectomy, it is The risks associated with vestibulectomy include bleeding/
important to make an accurate diagnosis and to distinguish hematoma, infection, skin breakdown, scarring, and for-
this from unprovoked vulvodynia, and other conditions mation of Bartholin cysts that may require additional ther-
that may mimic provoked vulvodynia (Table 30.1). Failure apy. There is also the possibility that the surgery will not
of conservative therapies should be confirmed. One of the render the patient pain-free. The patient should be aware
key features associated with LPV is the characteristic of that the recovery is usually acute for one to two weeks
443
444 Surgery for vulvar disorders
Table 30.1 Conditions mimicking provoked vulvodynia. above Skeen’s glands and usually borders the urethra
(within 3 mm or so) and then connects with the vaginal
Vulvovaginal candidal infection
skin just cephalad to the hymen, to include the entire
Desquamative inflammatory vaginitis hymen in the dissection.
Dermatitis (irritant, allergic) The dissection area is infiltrated with 0.5% bupivicaine
Dermatoses without epinephrine. I do not use epinephrine for two rea-
Vulvar intraepithelial neoplasia sons. The first is out of concern for potential infection risk
Atrophic vaginitis with vasoconstriction, and the second is to be sure all bleed-
Levator ani tension myalgia ing is adequately sutured at the end of the case, to avoid
Sensitive skin syndrome hematoma risk after the epinephrine has worn off. To make
Psychosexual causes the dissection easier, I use an Allis clamp at the apex of the
dissection (Skeen’s glands), at 1 and 11 o’clock. Allis–Adair
clamps are placed at the 3, 6, and 9 o’clock positions. While
where sitting will be painful, and movement will be some- an assistant holds the clamps at 1, 3, and 6 o’clock, the scal-
what limited due to pain. Most patients can return to work pel is used to trace the lateral dissection along Hart’s line
within two weeks, if their work does not require strenu- to the posterior fourchette. The same is carried out on the
ous activity. Sexual intercourse is usually not advised for contralateral side, holding the clamps at 6, 9, and 11 o’clock.
six to ten weeks. If there is a significant degree of levator The dissection is made much easier if the incision is made
ani tension myalgia present, the patient may need physical deep enough to remove the entire vestibule (3 to 4 mm
therapy of the pelvic floor postoperatively. deep). With the same clamps held, the medial incision is
made hugging the hymen in a semi-circumferential man-
Performing a complete vestibulectomy ner, to be sure that the entire hymen will be removed. Once
I prefer to use high lithotomy under general or regional the medial and lateral borders of the dissection are incised,
anesthesia in the operating room for maximal exposure Metzenbaum scissors are used to remove the skin as both
to the vestibule (Video 30.1). There are no high-quality incisions are straddled. I often perform a small relaxing
studies supporting the use of prophylactic antibiot- skin incision at the midline to overcome the potential tight-
ics. The vulvar vestibule is traced with a sterile pen to ening that may occur during healing.
outline the margins of dissection. I mark the patient’s The most challenging aspect of this surgery is the
left anterior apex, just cephalad to the Skeen’s glands closure. It is important that the skin be closed with-
and trace along Hart’s line to the posterior fourchette out tension and with an optimal cosmetic result,
(Figure 30.1a). The left medial border starts at the apex while maintaining good hemostasis. I do not use any
1
4
Hart’s 2 3
line
Before After
Figure 30.1 Vestibulectomy. (a) The vulvar vestibule is marked to include Hart’s line, which can be seen as the transition of
smooth to a rougher epithelium. Inside the hymen is not marked, but by placing an Allis–Adair clamp on the hymen, the area is more
easily visualized. (b) The vaginal epithelium is undermined to avoid closure on tension. (c) The figure of X stitch. The stitch is placed
high on the lateral skin (vulva) to low on the medial (vagina) and then low on the lateral skin to end up high on the vaginal skin,
forming an X. (d) When closing the vestibule with interrupted stitches of 3-0 chromic catgut, the area near the urethra is closed first,
then the rest of the vestibule is divided into quadrants.
Hymenectomy 445
Informed consent
The risks associated with reduction labiaplasty include
bleeding/hematoma, infection, skin breakdown, scarring,
and asymmetrical labia. They may have decreased sen-
sation over the sutured skin, and the labia may be asym-
metrical after surgery (as they are often before surgery).
(a) (b)
Complications are rare. I have not found scarring to be an
issue with this technique; however, other surgeons may pre-
fer to use a W-shaped excision.4 There are no comparative Figure 30.3 Reduction labiaplasty of the labia minora.
trials to date. The patient should be aware that the recov- (a) The incision borders are drawn on the medial aspect of
ery is usually acute for one to two weeks, where sitting will the labia minora. There should be adequate distance from
be painful, and movement will be somewhat limited due the clitoral region, and approximately 1.5 cm from the hymen
to pain. Most patients can return to work, provided it does to allow for proper labia minora function. (b) The incision is
not require significant physical activity within two weeks. closed with interrupted 3-0 chromic catgut sutures. A figure of
Sexual intercourse is usually not advised for six to ten weeks. X stitch can be used for hemostasis if needed.
Hymenectomy 447
are held such that the curve faces the patient to allow
for straddling of both marked lines (medial and lateral).
Alternatively, a scalpel can be used along the lateral and
medial lines separately, and then the Metzenbaum scissors
can be used to make a final excision.
Interrupted sutures of 3-0 catgut are used to close the
incision (Figure 30.3b). Because the labia are fairly well
vascularized, a figure of X suture technique is sometimes
needed (see vestibulectomy, Figure 30.1c), which brings
tissue together in a symmetrical, hemostatic, and cosmeti-
cally appealing fashion compared to a figure of 8 stitch,
which causes asymmetrical tension on the skin. If a sub-
cuticular closure is used, it is important to be sure of good (a)
hemostasis to avoid hematoma formation. No dressing is
used.
Patients are sent home after they are able to void, drink,
and have adequate pain control with oral analgesics. For
comfort, I offer oral narcotics, and NSAIDs, as well as a
donut type cushion, and advise liberal baths/sitz bathes in
warm water. I encourage them to lie down rather than sit,
and see them in clinic in two and again at six weeks for
assessment.
proximal end of the catheter is then tucked into the vagina Bartholin gland excision
for comfort, and to reduce the chance that it becomes dis- Bartholin gland excision is reserved for cases that are
lodged by catching on clothing (Figure 30.4c). either refractory to conservative management, or when
The patient should be counseled that the cyst or abscess there is concern about malignancy. Because of its signifi-
will continue to drain, and that a peripad may be used. cant blood supply from branches of the pudendal artery, it
She should maintain pelvic rest by avoiding vaginal inter- can be associated with hemorrhage and hematoma. This
course or tampon use. Baths/sitz baths and analgesics surgery is performed in the operating room under appro-
will help with symptomatic relief. The catheter should be priate anesthesia with the patient in lithotomy position.
maintained in place for four weeks, and then removed by Examination under anesthesia including a rectovaginal
deflating the balloon in clinic. If the cyst returns, marsu- exam is helpful in defining the depth of the cyst. Access
pialization may be necessary. and visualization are important to be maximized, as these
Marsupialization cysts can be deep. It is often helpful to place Allis–Adair
clamps for retraction on the labia minora and to have an
For recurrent, symptomatic Bartholin cysts or abscesses, assistant gently retract laterally.
marsupialization may be necessary. Marsupialization may An incision is made in a line parallel with the hymen
often be performed in the clinic under local anesthesia, in the vulvar vestibule, rather than the vulvar skin, long
but may also be performed in the operating room with enough to dissect the entire cyst and gland, usually 3 to 4 cm
conscious sedation and local, regional, or general anesthe- in length, or larger depending on the domed surface exposed
sia depending upon the circumstances. (Figure 30.6a). Allis–Adair clamps are used to retract the
The area is prepped with a sterile solution and infil- incised epithelium as well as the cyst wall to increase expo-
trated with local anesthesia. I typically use 5 mL of a 0.5% sure to the dissection plane. Metzenbaum scissors are used
bupivicaine solution for infiltration along the line of inci- to release filmy adhesions (Figure 30.6b). A “scissor spread”
sion if performing this with conscious sedation, but use a technique is helpful in removing filmy adhesions and to
sodium bicarbonate buffered 1% lidocaine solution if per- minimize bleeding, as this is where the branches from the
formed under local infiltration alone. The skin incision is inferior pudendal artery are usually encountered. Vessels
typically made in a line parallel with the hymen in the vul-
var vestibule (Figure 30.5a), long enough to place several
sutures to keep it open. This is usually 3 cm in length. The
cyst wall is also incised and irrigated with normal saline.
A hemostat is used to break up any loculations if present.
The cyst wall is then everted and sutured to the vestibular
epithelium on either side of the incision with a 3-0 delayed
absorbable suture (Figure 30.5b). I prefer a suture that will
maintain tensile strength for three to four weeks, to ensure
patency, rather than the rapidly absorbing chromic catgut
sutures used in other vulvar surgeries. Follow-up is simi-
lar to that of Word catheter placement. Sutures are allowed (a) (b)
to dissolve.
(c) (d)
(a) (b) Figure 30.6 Bartholin gland excision. (a) A linear incision
is made along the domed surface close to the hymen. (b) With
retraction on the cyst wall and the vulvar and vaginal epithe-
Figure 30.5 Bartholin cyst marsupialization. (a) The epi- lium, Metzenbaum scissors are used to dissect the cyst wall.
thelium is incised, then the cyst wall is incised in the same (c) The bed of the cyst is sutured deeply with interrupted or fig-
direction. (b) The cyst wall is sutured to the vulvar and vaginal ure of X stitches to close the deep space and prevent hematoma
epithelium with a 3-0 delayed absorbable suture to allow it to formation. (d) The skin is closed with 3-0 delayed absorbable
remain patent for four weeks. interrupted sutures. A drain may be placed.
Vulvar intraepithelial neoplasia 449
to the gland are best rendered hemostatic by clamping the Laser ablation procedure
vessel with a hemostat and applying electrodessication If laser ablation is performed, a power density of 750–
with “cutting” (low voltage continuous output) current. 1,250 W/cm2 is used to avoid deep coagulation injury. A
Suture ligation may also be necessary. Once the gland is 3%–5% solution of acetic acid is applied to the area while
removed, the bed of the gland is closed with interrupted or colposcopy is used to delineate lesion margins. The area to
figure of X sutures using 3-0 absorbable sutures for hemo- be treated is marked with a sterile marking pen. A hand
stasis (Figure 30.6c). The skin is closed with 3-0 absorbable piece or micromanipulator with a depth gauge aids in
sutures (Figure 30.6d). I prefer to use sutures that will hold application of high-power density without defocusing. The
tensile strength for approximately three to four weeks. margin of normal skin should be treated. In hair-bearing
Because of the vascular nature of this area, some surgeons regions, the hair follicle must be treated. The first step is to
prefer to leave a small drain in place for two or three days identify the tan appearance of the papillary dermis. Cold
to avoid hematoma formation. water on a sponge may be used to help dissipate heat and
Patients are sent home after they are able to void, drink, remove char to help identify the white appearance of the
and have adequate pain control with oral analgesics. For third surgical plane as laser therapy proceeds.
comfort, I offer oral narcotics, and NSAIDs, as well as a
donut type cushion and advise liberal baths/sitz baths in Postoperative care
warm water. I encourage them to lie down rather than sit,
An antibacterial cream such as 1% silver sulfadiazine
and see them in clinic in two and again in six weeks.
cream is commonly applied once or twice daily to decrease
wound bacteria colonization, and to provide some relief
VULVAR INTRAEPITHELIAL NEOPLASIA
from pain. There is no evidence that there is a preferred
The tenants of treatment for vulvar intraepithelial neopla- agent, nor is there clear evidence that these reduce infec-
sia (VIN) are to prevent the development of vulvar cancer tion. A 5% lidocaine gel can also be applied to aid in pain
and relieve symptoms, while preserving normal function relief. Bupivacaine 0.25% without epinephrine may be
and anatomy of the vulva. Therefore, the treatment of VIN injected into the lasered area at the end of the treatment
is usually individualized based upon the location and to deliver up to six hours of pain relief. An ice pack (or
extent of the lesion. Superficial laser therapy tends to have for practical purposes, a bag of frozen peas) can be placed
a cosmetic advantage compared to skinning vulvectomy.6 against the vulva for the first 72 hours after surgery to
Deep laser therapy often leads to scarring, with less clear decease inflammation and pain. Sitz baths may be used
advantage over excisional techniques. three times daily even on the first postoperative day, and
continued for three weeks if needed. Patients are seen at
Laser vaporization of the vulva two and six weeks postoperatively for routine follow up.
Laser therapy is often used in patients with multifocal
lesions. The depth of treatment is directed by colposcopy. Wide local excision of the vulva
Tissue destruction of less than 1 mm will treat VIN and Wide local incision is appropriate when pathologic find-
still allow rapid healing. In areas with hair distribution, ings are suggestive of cancer despite a biopsy diagnosis of
a deeper destruction is necessary to 3 mm, as the root VIN for histologic confirmation. This is an option when
of the hair may contain VIN and extend to a depth of there are one or two focal lesions that will allow a 1 cm
2.5 mm. Laser vaporization to this depth is much more margin.7 The depth should be the full thickness of the skin.
destructive and may lead to scar formation. Four surgical
planes have been identified. The first surgical plane con- Informed consent
sists of the epidermis down to the basement membrane, The risks associated with wide local excision of the vulva
which has a red appearance when treated with the laser. include bleeding/hematoma, infection, skin breakdown,
The second surgical plane transitions into a tan appear- and scarring. The patient should be aware that the recov-
ance as it extends into the papillary layer of the dermis. ery is usually acute for two weeks where sitting will be
The third surgical plane extends into the reticular dermis painful, and movement will be somewhat limited due to
that contains the root of a hair follicle and is identified as pain. Full return to work may take six to ten weeks.
grayish white fibers of collagen bundles. It is not neces-
sary to treat VIN beyond the third surgical plane. The Wide local excision procedure
fourth surgical plane is complete removal of the dermis
The patient is placed in the dorsal lithotomy position, and
down to fat.
the perineum is prepped and draped. An indwelling blad-
der catheter is placed. A marking pen is helpful to mea-
Informed consent sure a margin and design an ellipse that can be closed. The
The risks associated with laser ablation of the vulva include lesion is excised with an elliptical incision with a scalpel
bleeding, infection, scarring, and decreased sensation over down to the subcutaneous tissue (Figure 30.7a). Mobilizing
the ablated skin. They should be aware that the area will the skin makes closure easier, and should be undermined
be irritated and painful for weeks postoperatively, and full fairly aggressively (1 to 2 cm). Electrosurgery is used to
healing will take six to eight weeks. achieve hemostasis. Closure is performed with two to four
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"I gather from your expression," Camhorn remarked, "that our
lieutenant was telling the truth."
White grunted. "Of course, he was—as he saw it."
"And he's sane?"
"Quite sane," White agreed absently.
Camhorn grinned. "Then what's the matter, Lolly? Don't you like the
idea of time-travel?"
"Naturally not. It's an absurdity."
"You're blunt, Lolly. And rash. A number of great minds differ with you
about that."
Laillard White said something rude about great minds in general. He
went on, "Was the machine these Trelawneys built found intact?"
Camhorn nodded. "In perfect condition. I found an opportunity to look
it over when it and the others the Freeholders had concealed on Terra
were brought in."
"And these machines are designed to make it possible to move
through time?"
"No question about that. They function in Riemann space, and are
very soundly constructed. A most creditable piece of work, in fact. It's
only regrettable that the Trelawney brothers were wasted on it. We
might have put their talents to better use. Though as it turned out...."
He shrugged.
White glanced over at him. "What are you talking about?" he asked
suspiciously.
"They didn't accomplish time-travel," Camhorn said, "though in theory
they should have. I know it because we have several machines
based on the same principles. The earliest was built almost eighty
years ago. Two are now designed to utilize the YM thrust. The
Trelawney machine is considerably more advanced in a number of
details than its Overgovernment counterparts, but it still doesn't make
it possible to move in time."
"Why not?"
"I'd like to know," Camhorn said. "The appearance of it is that the
reality we live in takes the same dim view of time-travel that you do.
Time-travel remains a theoretical possibility. But in practice—when,
for example, the YM thrust is applied for that purpose—the thrust is
diverted."
White looked bewildered. "But if Paul Trelawney didn't move through
time, what did he do?"
"What's left?" Camhorn asked. "He moved through space, of course."
"Where?"
Camhorn shrugged. "They penetrated Riemann space," he said,
"after harnessing their machine to roughly nineteen thousand times
the power that was available to us before the Ymir series of elements
dropped into our hands. In theory, Lolly, they might have gone
anywhere in the universe. If we'd had the unreasonable nerve to play
around with multikilograms of YM—knowing what happened when
fractional quantities of a gram were employed—we might have had a
very similar experience."
"I'm still just a little in the dark, you know," Laillard White observed
drily, "as to what the experience consisted of."
"Oh, Lieutenant Dowland's theory wasn't at all far off in that respect.
It's an ironic fact that we have much to thank the Trelawneys for.
There's almost no question at all now what the race of beings they
encountered were responsible for the troubles that have plagued us
in the use of YM. They're not the best of neighbors—neighbors in
Riemann space terms, that is. If they'd known where to look for us,
things might have become rather hot. They had a chance to win the
first round when the Trelawneys lit that sixty-eight kilogram beacon
for them. But they made a few mistakes, and lost us again. It's a draw
so far. Except that we now know about as much about them as
they've ever learned about us. I expect we'll take the second round
handily a few years from now."
White still looked doubtful. "Was it one of their planets the Trelawneys
contacted?"
"Oh, no. At least, it would have been an extremely improbable
coincidence. No, the machine was searching for Terra as Terra is
known to have been in the latter part of the Pleistocene period. The
Trelawneys had provided something like a thousand very specific
factors to direct and confine that search. Time is impenetrable, so the
machine had to find that particular pattern of factors in space, and
did. The aliens—again as Lieutenant Dowland theorized—then
moved through Riemann space to the planet where the YM thrust
was manifesting itself so violently. But once there, they still had no
way of determining where in the universe the thrust had originated—
even though they were, in one sense, within shouting distance of
Terra, and two of them were actually on its surface for a time. It must
have been an extremely frustrating experience all around for our
friends."
Laillard White said, "Hm-m," and frowned.
Camhorn laughed. "Let it go, Lolly," he said. "That isn't your field,
after all. Let's turn to what is. What do you make of the fact that
Dowland appears to have been temporarily immune to the mental
commands these creatures can put out?"
"Eh?" White said. His expression turned to one of surprise. "But that's
obvious!"
"Glad to hear it," Camhorn said drily.
"Well, it is. Dowland's attitude showed clearly that he suspected the
truth himself on that point. Naturally, he was somewhat reluctant to
put it into words."
"Naturally. So what did he suspect?"
White shook his head. "It's so simple. The first specimen of humanity
the aliens encountered alive was Paul Trelawney. High genius level,
man! It would take that level to nullify our I.Q. tests in the manner he
and his half-brother did. When those creatures were prowling around
on the mesa, they were looking for that kind of mentality. Dowland's
above average, far from stupid. As you say, you like his theories. But
he's no Trelawney. Unquestionably, the aliens in each case regarded
him as some kind of clever domestic animal. The only reason he's
alive is that they weren't taking him seriously."
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