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Surgery_Schwartz. for radical cystectomy using the National Surgical Quality Improvement Program database. Urol Oncol. 2017;35(11):659 e613-659 e619. 101. Balar AV. Immune checkpoint blockade in metastatic urothe-lial cancer. J Clin Oncol. 2017;35(19):2109-2112. 102. Godwin JL, Hoffman-Censits J, Plimack E. Recent devel-opments in the treatment of advanced bladder cancer. Urol Oncol. 2018;36(3):109-114. 103. Znaor A, Lortet-Tieulent J, Jemal A, Bray F. International variations and trends in testicular cancer incidence and mor-tality. Eur Urol. 2014;65(6):1095-1106. 104. Che M, Tamboli P, Ro JY, et al. Bilateral testicular germ cell tumors: twenty-year experience at M. D. Anderson Cancer Center. Cancer. 2002;95(6):1228-1233. 105. Powles TB, Bhardwa J, Shamash J, Mandalia S, Oliver T. The changing presentation of germ cell tumours of the testis between 1983 and 2002. BJU Int. 2005;95(9):1197-1200. 106. Capelouto CC, Clark PE, Ransil BJ, Loughlin KR. A review of scrotal violation in testicular cancer: is


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Surgery_Schwartz. of germ cell tumours of the testis between 1983 and 2002. BJU Int. 2005;95(9):1197-1200. 106. Capelouto CC, Clark PE, Ransil BJ, Loughlin KR. A review of scrotal violation in testicular cancer: is adjuvant local ther-apy necessary? J Urol. 1995;153(3 Pt 2):981-985. 107. Donohue JP, Zachary JM, Maynard BR. Distribution of nodal metastases in nonseminomatous testis cancer. J Urol. 1982;128(2):315-320. 108. Pont J, Holtl W, Kosak D, et al. Risk-adapted treatment choice in stage I nonseminomatous testicular germ cell cancer by regarding vascular invasion in the primary tumor: a prospec-tive trial. J Clin Oncol. 1990;8(1):16-20. 109. Divrik RT, Akdogan B, Ozen H, Zorlu F. Outcomes of sur-veillance protocol of clinical stage I nonseminomatous germ cell tumors-is shift to risk adapted policy justified? J Urol. 2006;176(4 pt 1):1424-1429; discussion 1429-1430. 110. Oliver RT, Mead GM, Rustin GJ, et al. Randomized trial of carboplatin versus radiotherapy for stage I seminoma: mature results on


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Surgery_Schwartz. J Urol. 2006;176(4 pt 1):1424-1429; discussion 1429-1430. 110. Oliver RT, Mead GM, Rustin GJ, et al. Randomized trial of carboplatin versus radiotherapy for stage I seminoma: mature results on relapse and contralateral testis cancer rates in MRC TE19/EORTC 30982 study (ISRCTN27163214). J Clin Oncol. 2011;29(8):957-962. 111. Hartmann M, Siener R, Krege S, et al. [Results of the ran-domised phase III study of the German Testicular Cancer Study Group. Retroperitoneal lymphadenectomy versus one cycle BEP as adjuvant therapy for non-seminomatous testicular tumours in clinical stage I.] Der Urologe Ausg A. 2009;48(5):523-528. 112. N H, AM N, M K, et al. SEER Cancer Statistics Review, 1975-2014, National Cancer Institute. Bethesda, MD. Available at: https://seer.cancer.gov/csr/1975_2014/, based on November 2016 SEER data submission, posted to the SEER web site. 2017. Accessed August 9, 2018. 113. Luz MA, Kotb AF, Aldousari S, et al. Retroperitoneal lymph node dissection for residual masses


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Surgery_Schwartz. on November 2016 SEER data submission, posted to the SEER web site. 2017. Accessed August 9, 2018. 113. Luz MA, Kotb AF, Aldousari S, et al. Retroperitoneal lymph node dissection for residual masses after chemotherapy in nonseminomatous germ cell testicular tumor. World J Surg Oncol. 2010;8:97. 114. Pearce SM, Golan S, Gorin MA, et al. Safety and early onco-logic effectiveness of primary robotic retroperitoneal lymph node dissection for nonseminomatous germ cell testicular cancer. Eur Urol. 2017;71(3):476-482. 115. Frank I, Blute ML, Cheville JC, Lohse CM, Weaver AL, Zincke H. Solid renal tumors: an analysis of patho-logical features related to tumor size. J Urol. 2003;170 (6 pt 1):2217-2220. 116. Richard PO, Jewett MA, Tanguay S, et al. Safety, reliability and accuracy of small renal tumour biopsies: results from a multi-institution registry. BJU Int. 2017;119(4):543-549. 117. Richard PO, Jewett MA, Bhatt JR, et al. Renal tumor biopsy for small renal masses: a single-center 13-year


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Surgery_Schwartz. biopsies: results from a multi-institution registry. BJU Int. 2017;119(4):543-549. 117. Richard PO, Jewett MA, Bhatt JR, et al. Renal tumor biopsy for small renal masses: a single-center 13-year experience. Eur Urol. 2015;68(6):1007-1013. 118. Marconi L, Dabestani S, Lam TB, et al. Systematic review and meta-analysis of diagnostic accuracy of percutaneous renal tumour biopsy. Eur Urol. 2016;69(4):660-673. 119. Lane BR, Kattan MW. Prognostic models and algorithms in renal cell carcinoma. Urol Clin North Am. 2008;35(4): 613-625; vii. 120. Kanao K, Mizuno R, Kikuchi E, et al. Preoperative prog-nostic nomogram (probability table) for renal cell carcinoma based on TNM classification. J Urol. 2009;181(2):480-485; discussion 485. 121. Krejci KG, Blute ML, Cheville JC, Sebo TJ, Lohse CM, Zincke H. Nephron-sparing surgery for renal cell carcinoma: clinicopathologic features predictive of patient outcome. Urology. 2003;62(4):641-646.Brunicardi_Ch40_p1759-p1782.indd 178001/03/19 6:35 PM


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Surgery_Schwartz. H. Nephron-sparing surgery for renal cell carcinoma: clinicopathologic features predictive of patient outcome. Urology. 2003;62(4):641-646.Brunicardi_Ch40_p1759-p1782.indd 178001/03/19 6:35 PM 1781UROLOGYCHAPTER 40 122. Mekhail TM, Abou-Jawde RM, Boumerhi G, et al. Validation and extension of the Memorial Sloan-Kettering prognos-tic factors model for survival in patients with previously untreated metastatic renal cell carcinoma. J Clin Oncol. 2005;23(4):832-841. 123. Smith ZL. Current status of minimally invasive surgery for renal cell carcinoma. Curr Urol Rep. 2016;17(6):43. 124. Kunkle DA, Uzzo RG. Cryoablation or radiofrequency ablation of the small renal mass : a meta-analysis. Cancer. 2008;113(10):2671-2680. 125. Clayman RV, Kavoussi LR, Soper NJ, et al. Laparoscopic nephrectomy: initial case report. J Urol. 1991;146(2):278-282. 126. Motzer RJ, Jonasch E, Agarwal N, et al. Kidney cancer, ver-sion 2.2017, NCCN clinical practice guidelines in oncology. J Natl Compr Canc Netw.


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Surgery_Schwartz. initial case report. J Urol. 1991;146(2):278-282. 126. Motzer RJ, Jonasch E, Agarwal N, et al. Kidney cancer, ver-sion 2.2017, NCCN clinical practice guidelines in oncology. J Natl Compr Canc Netw. 2017;15(6):804-834. 127. Abaza R. Initial series of robotic radical nephrectomy with vena caval tumor thrombectomy. Eur Urol. 2011;59(4):652-656. 128. Gill IS, Metcalfe C, Abreu A, et al. Robotic level III infe-rior vena cava tumor thrombectomy: initial series. J Urol. 2015;194(4):929-938. 129. Schroder FH, Hugosson J, Roobol MJ, et al. Screening and prostate cancer mortality: results of the European Ran-domised Study of Screening for Prostate Cancer (ERSPC) at 13 years of follow-up. Lancet. 2014;384(9959):2027-2035. 130. Moyer VA, Force USPST. Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157(2):120-134. 131. Carter HB, Albertsen PC, Barry MJ, et al. Early detection of prostate cancer: AUA Guideline. J Urol. 2013;190(2):


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Surgery_Schwartz. Task Force recommendation statement. Ann Intern Med. 2012;157(2):120-134. 131. Carter HB, Albertsen PC, Barry MJ, et al. Early detection of prostate cancer: AUA Guideline. J Urol. 2013;190(2): 419-426. 132. Gleason DF, Mellinger GT. Prediction of prognosis for pros-tatic adenocarcinoma by combined histological grading and clinical staging. J Urol. 1974;111(1):58-64. 133. Epstein JI, Zelefsky MJ, Sjoberg DD, et al. A contemporary prostate cancer grading system: a validated alternative to the gleason score. Eur Urol. 2016;69(3):428-435. 134. Hamdy FC, Donovan JL, Lane JA, et al. 10-year outcomes after monitoring, surgery, or radiotherapy for localized prostate cancer. N Engl J Med. 2016;375(15):1415-1424. 135. Chung MS, Lee SH. Current status of active surveillance in prostate cancer. Investig Clin Urol. 2016;57(1):14-20. 136. Wiegel T, Bartkowiak D, Bottke D, et al. Adjuvant radiother-apy versus wait-and-see after radical prostatectomy: 10-year follow-up of the ARO 96-02/AUO AP 09/95


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Surgery_Schwartz. Clin Urol. 2016;57(1):14-20. 136. Wiegel T, Bartkowiak D, Bottke D, et al. Adjuvant radiother-apy versus wait-and-see after radical prostatectomy: 10-year follow-up of the ARO 96-02/AUO AP 09/95 trial. Eur Urol. 2014;66(2):243-250. 137. Thompson IM, Tangen CM, Paradelo J, et al. Adjuvant radiotherapy for pathological T3N0M0 prostate cancer significantly reduces risk of metastases and improves sur-vival: long-term followup of a randomized clinical trial. J Urol. 2009;181(3):956-962. 138. Pound CR, Partin AW, Eisenberger MA, Chan DW, Pear-son JD, Walsh PC. Natural history of progression after PSA elevation following radical prostatectomy. JAMA. 1999;281(17):1591-1597. 139. Ryan CJ, Smith MR, Fizazi K, et al. Abiraterone acetate plus prednisone versus placebo plus prednisone in chemother-apy-naive men with metastatic castration-resistant prostate cancer (COU-AA-302): final overall survival analysis of a randomised, double-blind, placebo-controlled phase 3 study. Lancet Oncol.


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Surgery_Schwartz. men with metastatic castration-resistant prostate cancer (COU-AA-302): final overall survival analysis of a randomised, double-blind, placebo-controlled phase 3 study. Lancet Oncol. 2015;16(2):152-160. 140. Logothetis CJ, Basch E, Molina A, et al. Effect of abiraterone acetate and prednisone compared with placebo and predni-sone on pain control and skeletal-related events in patients with metastatic castration-resistant prostate cancer: explor-atory analysis of data from the COU-AA-301 randomised trial. Lancet Oncol. 2012;13(12):1210-1217. 141. Loriot Y, Miller K, Sternberg CN, et al. Effect of enzalutamide on health-related quality of life, pain, and skeletal-related events in asymptomatic and minimally symptomatic, che-motherapy-naive patients with metastatic castration-resistant prostate cancer (PREVAIL): results from a randomised, phase 3 trial. Lancet Oncol. 2015;16(5):509-521. 142. Sternberg CN, de Bono JS, Chi KN, et al. Improved outcomes in elderly patients with metastatic


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Surgery_Schwartz. cancer (PREVAIL): results from a randomised, phase 3 trial. Lancet Oncol. 2015;16(5):509-521. 142. Sternberg CN, de Bono JS, Chi KN, et al. Improved outcomes in elderly patients with metastatic castration-resistant prostate cancer treated with the androgen receptor inhibitor enzalu-tamide: results from the phase III AFFIRM trial. Ann Oncol. 2014;25(2):429-434. 143. Dalbagni G, Zhang ZF, Lacombe L, Herr HW. Male ure-thral carcinoma: analysis of treatment outcome. Urology. 1999;53(6):1126-1132. 144. Swartz MA, Porter MP, Lin DW, Weiss NS. Incidence of primary urethral carcinoma in the United States. Urology. 2006;68(6):1164-1168. 145. Cupp MR, Malek RS, Goellner JR, Espy MJ, Smith TF. Detection of human papillomavirus DNA in primary squa-mous cell carcinoma of the male urethra. Urology. 1996;48(4): 551-555. 146. Dinney CP, Johnson DE, Swanson DA, Babaian RJ, von Eschenbach AC. Therapy and prognosis for male ante-rior urethral carcinoma: an update. Urology. 1994;43(4):


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Surgery_Schwartz. Urology. 1996;48(4): 551-555. 146. Dinney CP, Johnson DE, Swanson DA, Babaian RJ, von Eschenbach AC. Therapy and prognosis for male ante-rior urethral carcinoma: an update. Urology. 1994;43(4): 506-514. 147. Gofrit ON, Pode D, Pizov G, Zorn KC, Katz R, Shapiro A. Prostatic urothelial carcinoma: is transurethral prostatectomy necessary before bacillus Calmette-Guerin immunotherapy? BJU Int. 2009;103(7):905-908. 148. Gakis G, Witjes JA, Comperat E, et al. EAU guidelines on primary urethral carcinoma. Eur Urol. 2013;64(5):823-830. 149. Gakis G, Morgan TM, Daneshmand S, et al. Impact of perioperative chemotherapy on survival in patients with advanced primary urethral cancer: results of the international collaboration on primary urethral carcinoma. Ann Oncol. 2015;26(8):1754-1759. 150. Kent M, Zinman L, Girshovich L, Sands J, Vanni A. Com-bined chemoradiation as primary treatment for invasive male urethral cancer. J Urol. 2015;193(2):532-537. 151. Dayyani F, Pettaway CA, Kamat AM, Munsell


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Surgery_Schwartz. Zinman L, Girshovich L, Sands J, Vanni A. Com-bined chemoradiation as primary treatment for invasive male urethral cancer. J Urol. 2015;193(2):532-537. 151. Dayyani F, Pettaway CA, Kamat AM, Munsell MF, Sircar K, Pagliaro LC. Retrospective analysis of survival outcomes and the role of cisplatin-based chemotherapy in patients with ure-thral carcinomas referred to medical oncologists. Urol Oncol. 2013;31(7):1171-1177. 152. Aguilar-Navarro S, Navarrete-Reyes AP, Grados-Chavarria BH, Garcia-Lara JM, Amieva H, Avila-Funes JA. The sever-ity of urinary incontinence decreases health-related quality of life among community-dwelling elderly. J Gerontol A Biol Sci Med Sci. 2012;67(11):1266-1271. 153. Bettez M, Tu le M, Carlson K, et al. 2012 update: guidelines for adult urinary incontinence collaborative consensus docu-ment for the Canadian urological association. Can Urol Assoc J. 2012;6(5):354-363. 154. Tennstedt SL, Chiu GR, Link CL, Litman HJ, Kusek JW, McKinlay JB. The effects of severity


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Surgery_Schwartz. consensus docu-ment for the Canadian urological association. Can Urol Assoc J. 2012;6(5):354-363. 154. Tennstedt SL, Chiu GR, Link CL, Litman HJ, Kusek JW, McKinlay JB. The effects of severity of urine leakage on qual-ity of life in Hispanic, white, and black men and women: the Boston community health survey. Urology. 2010;75(1):27-33. 155. Ramage-Morin PL, Gilmour H. Urinary incontinence and loneliness in Canadian seniors. Health Rep. 2013;24(10): 3-10. 156. Brown JS, Vittinghoff E, Wyman JF, et al. Urinary inconti-nence: does it increase risk for falls and fractures? Study of Osteoporotic Fractures Research Group. J Am Geriatr Soc. 2000;48(7):721-725. 157. Abrams P, Cardozo L, Fall M, et al. The standardisation of terminology in lower urinary tract function: report from the standardisation sub-committee of the International Conti-nence Society. Urology. 2003;61(1):37-49. 158. Dumoulin C, Hunter KF, Moore K, et al. Conservative management for female urinary incontinence and pelvic


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Surgery_Schwartz. sub-committee of the International Conti-nence Society. Urology. 2003;61(1):37-49. 158. Dumoulin C, Hunter KF, Moore K, et al. Conservative management for female urinary incontinence and pelvic Brunicardi_Ch40_p1759-p1782.indd 178101/03/19 6:35 PM 1782SPECIFIC CONSIDERATIONSPART IIorgan prolapse review 2013: Summary of the 5th Interna-tional Consultation on Incontinence. Neurourol Urodyn. 2016;35(1):15-20. 159. Chapple C, Khullar V, Gabriel Z, Dooley JA. The effects of antimuscarinic treatments in overactive bladder: a systematic review and meta-analysis. Eur Urol. 2005;48(1):5-26. 160. Chapple CR, Cardozo L, Nitti VW, Siddiqui E, Michel MC. Mirabegron in overactive bladder: a review of efficacy, safety, and tolerability. Neurourol Urodyn. 2014;33(1):17-30. 161. van Kerrebroeck PE, van Voskuilen AC, Heesakkers JP, et al. Results of sacral neuromodulation therapy for urinary voiding dysfunction: outcomes of a prospective, worldwide clinical study. J Urol.


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Surgery_Schwartz. Kerrebroeck PE, van Voskuilen AC, Heesakkers JP, et al. Results of sacral neuromodulation therapy for urinary voiding dysfunction: outcomes of a prospective, worldwide clinical study. J Urol. 2007;178(5):2029-2034. 162. Burton C, Sajja A, Latthe PM. Effectiveness of percutane-ous posterior tibial nerve stimulation for overactive bladder: a systematic review and meta-analysis. Neurourol Urodyn. 2012;31(8):1206-1216. 163. Rovner E, Kennelly M, Schulte-Baukloh H, Zhou J, Haag-Molkenteller C, Dasgupta P. Urodynamic results and clinical outcomes with intradetrusor injections of onabotulinum-toxinA in a randomized, placebo-controlled dose-finding study in idiopathic overactive bladder. Neurourol Urodyn. 2011;30(4):556-562. 164. Johannes CB, Araujo AB, Feldman HA, Derby CA, Kleinman KP, McKinlay JB. Incidence of erectile dysfunction in men 40 to 69 years old: longitudinal results from the Massachusetts male aging study. J Urol. 2000;163(2):460-463. 165. Corona G, Lee DM, Forti G, et al.


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Surgery_Schwartz. JB. Incidence of erectile dysfunction in men 40 to 69 years old: longitudinal results from the Massachusetts male aging study. J Urol. 2000;163(2):460-463. 165. Corona G, Lee DM, Forti G, et al. Age-related changes in gen-eral and sexual health in middle-aged and older men: results from the European Male Ageing Study (EMAS). J Sex Med. 2010;7(4 Pt 1):1362-1380. 166. Lue TF. Erectile dysfunction. N Engl J Med. 2000;342(24): 1802-1813. 167. Francis ME, Kusek JW, Nyberg LM, Eggers PW. The con-tribution of common medical conditions and drug exposures to erectile dysfunction in adult males. J Urol. 2007;178(2): 591-596; discussion 596. 168. Yafi FA, Jenkins L, Albersen M, et al. Erectile dysfunction. Nat Rev Dis Primers. 2016;2:16003. 169. McCabe MP, Althof SE. A systematic review of the psycho-social outcomes associated with erectile dysfunction: does the impact of erectile dysfunction extend beyond a man’s inability to have sex? J Sex Med. 2014;11(2):347-363. 170. The process of care


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Surgery_Schwartz. outcomes associated with erectile dysfunction: does the impact of erectile dysfunction extend beyond a man’s inability to have sex? J Sex Med. 2014;11(2):347-363. 170. The process of care model for evaluation and treatment of erectile dysfunction. The Process of Care Consensus Panel. Int J Impot Res. 1999;11(2):59-70; discussion 70-54. 171. Yuan J, Zhang R, Yang Z, et al. Comparative effective-ness and safety of oral phosphodiesterase type 5 inhibitors for erectile dysfunction: a systematic review and network meta-analysis. Eur Urol. 2013;63(5):902-912. 172. Giuliano F, Jackson G, Montorsi F, Martin-Morales A, Raillard P. Safety of sildenafil citrate: review of 67 double-blind placebo-controlled trials and the postmarket-ing safety database. Int J Clin Pract. 2010;64(2):240-255. 173. Baltaci S, Aydos K, Kosar A, Anafarta K. Treating erectile dysfunction with a vacuum tumescence device: a retro-spective analysis of acceptance and satisfaction. Br J Urol. 1995;76(6):757-760. 174. Ganem


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Surgery_Schwartz. S, Aydos K, Kosar A, Anafarta K. Treating erectile dysfunction with a vacuum tumescence device: a retro-spective analysis of acceptance and satisfaction. Br J Urol. 1995;76(6):757-760. 174. Ganem JP, Lucey DT, Janosko EO, Carson CC. Unusual complications of the vacuum erection device. Urology. 1998;51(4):627-631. 175. Guay AT, Perez JB, Velasquez E, Newton RA, Jacobson JP. Clinical experience with intraurethral alprostadil (MUSE) in the treatment of men with erectile dysfunction. A retrospec-tive study. Medicated urethral system for erection. Eur Urol. 2000;38(6):671-676. 176. Fulgham PF, Cochran JS, Denman JL, et al. Disappointing initial results with transurethral alprostadil for erectile dys-function in a urology practice setting. J Urol. 1998;160 (6 pt 1):2041-2046. 177. Rajpurkar A, Dhabuwala CB. Comparison of satisfaction rates and erectile function in patients treated with silde-nafil, intracavernous prostaglandin E1 and penile implant surgery for erectile dysfunction in


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Surgery_Schwartz. A, Dhabuwala CB. Comparison of satisfaction rates and erectile function in patients treated with silde-nafil, intracavernous prostaglandin E1 and penile implant surgery for erectile dysfunction in urology practice. J Urol. 2003;170(1):159-163. 178. Kaefer M, Diamond D, Hendren WH, et al. The incidence of intersexuality in children with cryptorchidism and hypospa-dias: stratification based on gonadal palpability and meatal position. J Urol. 1999;162(3 pt 2):1003-1006; discussion 1006-1007. 179. Keays MA, Dave S. Current hypospadias management: Diag-nosis, surgical management, and long-term patient-centred outcomes. Can Urol Assoc J. 2017;11(1-2 suppl 1):S48-S53. 180. Preda I, Jodal U, Sixt R, Stokland E, Hansson S. Normal dimercaptosuccinic acid scintigraphy makes voiding cystoure-thrography unnecessary after urinary tract infection. J Pediatr. 2007;151(6):581-584, 584.e581. 181. Roberts KB. Urinary tract infection: clinical practice guide-line for the diagnosis and management of the


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Surgery_Schwartz. unnecessary after urinary tract infection. J Pediatr. 2007;151(6):581-584, 584.e581. 181. Roberts KB. Urinary tract infection: clinical practice guide-line for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics. 2011;128(3):595-610. 182. Bilgutay AN, Roth DR, Gonzales ET, Jr., et al. Posterior urethral valves: risk factors for progression to renal failure. J Pediatr Urol. 2016;12(3):179 e171-e177. 183. Lee PA. Fertility after cryptorchidism: epidemiology and other outcome studies. Urology. 2005;66(2):427-431. 184. Feyles F, Peiretti V, Mussa A, et al. Improved sperm count and motility in young men surgically treated for cryptorchidism in the first year of life. Eur J Pediatr Surg. 2014;24(5):376-380. 185. Pettersson A, Richiardi L, Nordenskjold A, Kaijser M, Akre O. Age at surgery for undescended testis and risk of testicular cancer. N Engl J Med. 2007;356(18):1835-1841.Brunicardi_Ch40_p1759-p1782.indd 178201/03/19 6:35 PM


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Surgery_Schwartz. GynecologySarah M. Temkin, Thomas Gregory, Elise C. Kohn, and Linda Duska 41chapterPATHOPHYSIOLOGY AND MECHANISMS OF DISEASEThe female reproductive system includes the external (vulva including the labia, clitoris, and vaginal opening) sex organs as well as the internal organs (uterus and cervix, fallopian tubes, and ovaries) that function in human reproduction. The female reproductive tract has a multitude of tightly regulated functions. The ovaries produce the ova (egg cells) and hormones necessary for maintenance of reproductive function. The fallopian tubes accommodate transit of an ovum to the uterus and provide a location for fertilization. The uterus accommodates an embryo that develops into the fetus. The cervix provides a barrier between the external and internal genital tract. Ongoing activities, such as angiogenesis and physiologic invasion, are necessary in order for the reproductive organs to fulfill their purpose and are usurped in disease. Immune surveillance is


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Surgery_Schwartz. Ongoing activities, such as angiogenesis and physiologic invasion, are necessary in order for the reproductive organs to fulfill their purpose and are usurped in disease. Immune surveillance is regulated in a fashion that allows implantation, placentation, and development of the fetus.Because the pelvis contains a multitude of spatially and temporally varied functions, pathologies range from mechanical events, such as ovarian torsion or ruptured ectopic pregnancy, to infection, such as pelvic inflammatory disease, to mass effects, including leiomyomata and malignancy, that can present with similar and even overlapping symptoms and signs. An acute abdomen presentation in a woman of child bearing potential can range from pregnancy-related catastrophes, to appendicitis, to a hemorrhagic ovarian cyst.The ongoing rupture, healing, and regrowth of the ovarian capsule and endometrium during the menstrual cycle use the same series of biologic and biochemic events that are also active in


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Surgery_Schwartz. ovarian cyst.The ongoing rupture, healing, and regrowth of the ovarian capsule and endometrium during the menstrual cycle use the same series of biologic and biochemic events that are also active in pathologic events such as endometriosis and endometriomas, mature teratomas, dysgerminomas, and progression to malig-nancy. Genetic abnormalities, both germ line and somatic, that may cause competence and/or promote disease are increasingly well understood. Incorporation of genetic and genomic infor-mation in disease diagnosis and assessment has altered how we diagnose and follow disease, in whom we increase our diligence in searching for disease, and ultimately how we use the drug and other therapeutic armamentarium available to the treating physician.These points will be incorporated with surgical approaches into discussions of anatomy, diagnostic workup, infection, sur-gical and medical aspects of the obstetric patient, pelvic floor dysfunction, and neoplasms.ANATOMYClinical gynecologic


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Surgery_Schwartz. approaches into discussions of anatomy, diagnostic workup, infection, sur-gical and medical aspects of the obstetric patient, pelvic floor dysfunction, and neoplasms.ANATOMYClinical gynecologic anatomy centers on the pelvis (L. basin). Aptly named, the bowl-shaped pelvis houses the confluence and intersection of multiple organ systems. Understanding 1Pathophysiology and Mechanisms of Disease 1783Anatomy 1783Structure and Support of the Pelvis and Genitalia / 1784Vulva / 1785Vagina / 1785Uterus / 1785Cervix / 1785Fallopian Tubes / 1786Ovaries / 1786Fibrovascular Ligaments and Avascular Tissue Planes / 1786Vasculature and Nerves of the Pelvis / 1787Evaluation and Diagnosis 1787Elements of a Gynecologic History / 1787The Gynecologic Examination / 1787Commonly Used Testing / 1789Common Office Procedures for Diagnosis / 1790Benign Gynecologic Conditions 1791Vulvar Lesions / 1791Vaginal Lesions / 1793Cervical Lesions / 1794Uterine Corpus / 1794Procedures Performed for Structural Causes


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Surgery_Schwartz. Procedures for Diagnosis / 1790Benign Gynecologic Conditions 1791Vulvar Lesions / 1791Vaginal Lesions / 1793Cervical Lesions / 1794Uterine Corpus / 1794Procedures Performed for Structural Causes of Abnormal Uterine Bleeding / 1796Benign Ovarian and Fallopian Tube Lesions / 1801Other Benign Pelvic Pathology / 1802Pregnancy-Related Surgical Conditions 1804Conditions and Procedures Performed Before Viability / 1804Conditions and Procedures Performed After Viability / 1805Pelvic Floor Dysfunction 1807Evaluation / 1807Surgery for Pelvic Organ Prolapse / 1807Surgery for Stress Urinary Incontinence / 1808Gynecologic Cancer 1809Vulvar Cancer / 1809Vaginal Cancer / 1810Cervical Cancer / 1811Uterine Cancer / 1813Ovarian Cancer / 1815Minimally Invasive Gynecologic Surgery 1820Hysteroscopy / 1820Laparoscopy / 1820Robotic Surgery / 1820Complications Pertinent to Gynecologic Surgery / 1821Brunicardi_Ch41_p1783-p1826.indd 178318/02/19 4:33 PM 1784those structural and functional


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Surgery_Schwartz. / 1820Laparoscopy / 1820Robotic Surgery / 1820Complications Pertinent to Gynecologic Surgery / 1821Brunicardi_Ch41_p1783-p1826.indd 178318/02/19 4:33 PM 1784those structural and functional relationships is essential for the surgeon and allows an appreciation for the interplay of sexual function and reproduction as well as a context for understanding gynecologic pathology.Structure and Support of the Pelvis and GenitaliaThe bony pelvis is comprised by the sacrum posteriorly and the ischium, ilium, and pubic bones anteromedially. It supports the upper body and transmits the stresses of weight bearing to the lower limbs in addition to providing anchors for the supporting tissues of the pelvic floor.1 The opening of the pelvis is spanned by the muscles of the pelvic diaphragm (Fig. 41-1). The muscles of the pelvic sidewall include the iliacus, the psoas, and the obturator internus muscle (Fig. 41-2). These muscles contract tonically and include, from anterior to posterior,


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Surgery_Schwartz. 41-1). The muscles of the pelvic sidewall include the iliacus, the psoas, and the obturator internus muscle (Fig. 41-2). These muscles contract tonically and include, from anterior to posterior, bilaterally, the pubococcygeus, puborectalis, iliococcygeus, and coccygeus muscles. The first two of these muscles contribute fibers to the fibromuscular perineal body. The urogenital hiatus is bordered laterally by the pubococcygeus muscles and anteriorly by the symphysis pubis. It is through this muscular defect that the urethra and vagina pass, and it is the focal point for the study of disorders of pelvic support such as cystocele, rectocele, and uterine prolapse.Pudendal nerveand arterySuperficial transverseperineii muscleIschiocavernosusmuscleVestibularbulbClitorisPubicramusUrethralmeatusBulbocavernosusmuscleBartholin’sglandPerinealmembranePerinealbodyExternal analsphincterGluteusmaximusAnusVaginalintroitusLevator animusclesFigure 41-1. Deeper muscles of the pelvic floor.Key


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Surgery_Schwartz. analsphincterGluteusmaximusAnusVaginalintroitusLevator animusclesFigure 41-1. Deeper muscles of the pelvic floor.Key Points1 Gynecologic causes of acute abdomen include PID and tubo-ovarian abscess, ovarian torsion, ruptured ectopic pregnancy, septic abortion. Pregnancy must be ruled out early in assessment of reproductive age patients presenting with abdominal or pelvic pain.2 The general gynecology exam must incorporate the whole physical examination in order to adequately diagnosis and treat gynecologic disorders.3 Benign gynecologic pathologies that are encountered at the time of surgery include endometriosis, endometriomas, fibroids, and ovarian cysts.4 It is critical that abnormal lesions of vulva, vagina, and cervix are biopsied for diagnosis before any treatment is planned; postmenopausal bleeding should always be investigated to rule out malignancy.5 Pelvic floor dysfunction (pelvic organ prolapse, urinary and fecal incontinence) is common; 11% of women will undergo a


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Surgery_Schwartz. postmenopausal bleeding should always be investigated to rule out malignancy.5 Pelvic floor dysfunction (pelvic organ prolapse, urinary and fecal incontinence) is common; 11% of women will undergo a reconstructive surgical procedure at some point in their lives.6 Pregnancy confers important changes to both the cardio-vascular system and the coagulation cascade. Trauma in pregnancy must be managed with these changes in mind.7 Early-stage cervical cancer is managed surgically, whereas chemoradiation is preferred for stages Ib2 and above.8 Risk-reducing salpingo-oopherectomy is recommended in women with BRCA1 or BRCA2 mutations.9 Optimal debulking for epithelial ovarian cancer is a criti-cal element in patient response and survival. The preferred postoperative therapy for optimally debulked advanced-stage ovarian epithelial ovarian cancer is intraperitoneal chemotherapy.10 Long-term sequelae of intestinal and urologic injury can be avoided by intraoperative


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Surgery_Schwartz. for optimally debulked advanced-stage ovarian epithelial ovarian cancer is intraperitoneal chemotherapy.10 Long-term sequelae of intestinal and urologic injury can be avoided by intraoperative identification.Brunicardi_Ch41_p1783-p1826.indd 178418/02/19 4:33 PM 1785GYNECOLOGYCHAPTER 41VulvaThe labia majora form the cutaneous boundaries of the lateral vulva and represent the female homologue of the male scrotum (Fig. 41-4). The labia majora are fatty folds covered by hair-bearing skin in the adult. They fuse anteriorly over the ante-rior prominence of the symphysis pubis, the mons pubis. The deeper portions of the adipose layers are called Colles fascia and insert onto the inferior margin of the perineal membrane, limiting spread of superficial hematomas inferiorly. Adjacent and medial to the labia majora are the labia minora, smaller folds of connective tissue covered laterally by non–hair-bearing skin and medially by vaginal mucosa. The anterior fusion of the labia minora forms


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Surgery_Schwartz. to the labia majora are the labia minora, smaller folds of connective tissue covered laterally by non–hair-bearing skin and medially by vaginal mucosa. The anterior fusion of the labia minora forms the prepuce and frenulum of the clitoris; posteriorly, the labia minora fuse to create the fossa navicularis and posterior fourchette. The term vestibule refers to the area medial to the labia minora bounded by the fossa navicularis and the clitoris. Both the urethra and the vagina open into the vestibule. Skene’s glands lie lateral and inferior to the urethral meatus. Cysts, abscesses, and neoplasms may arise in these glands.Erectile tissues and associated muscles are in the space between the perineal membrane and the vulvar subcutaneous tissues (see Fig. 41-1). The clitoris is formed by two crura and is suspended from the pubis. Overlying the crura are ischio-cavernosus muscles, which run along the inferior surfaces of the ischiopubic rami. Extending medially from the inferior end of the


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Surgery_Schwartz. and is suspended from the pubis. Overlying the crura are ischio-cavernosus muscles, which run along the inferior surfaces of the ischiopubic rami. Extending medially from the inferior end of the ischiocavernosus muscles are the superficial transverse perinei muscles. These terminate in the midline in the perineal body, caudal and deep to the posterior fourchette. Vestibular bulbs lie just deep to the vestibule and are covered laterally by bulbocavernosus muscles. These originate from the perineal body and insert into the body of the clitoris. At the inferior end of the vestibular bulbs are Bartholin’s glands, which connect to the vestibular skin by ducts.VaginaThe vagina is an elastic fibromuscular tube opening from the vestibule running superiorly and posteriorly, passing through the perineal membrane. The lower third is invested by the superficial and deep perineal muscles; it incorporates the ure-thra in its anterior wall and has a rich blood supply from the vaginal branches of the


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Surgery_Schwartz. membrane. The lower third is invested by the superficial and deep perineal muscles; it incorporates the ure-thra in its anterior wall and has a rich blood supply from the vaginal branches of the external and internal pudendal arteries. The upper two-thirds of the vagina are not invested by muscles. This portion lies in opposition to the bladder base anteriorly and the rectum and posterior pelvic cul-de-sac superiorly. The cervix opens into the posterior vaginal wall bulging into the vaginal lumen.UterusThe typically pear-shaped uterus consists of a fundus, cornua, body, and cervix. It lies between the bladder anteriorly and the rectosigmoid posteriorly. The endometrium lines the inside cavity and has a superficial functional layer that is shed with menstruation and a basal layer from which the new functional layer is formed. Sustained estrogenic stimulation without asso-ciated progestin maturation can lead to hyperplastic changes or carcinoma. Adenomyosis is a condition in which


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Surgery_Schwartz. which the new functional layer is formed. Sustained estrogenic stimulation without asso-ciated progestin maturation can lead to hyperplastic changes or carcinoma. Adenomyosis is a condition in which benign endo-metrial glands infiltrate into the muscle or myometrium of the uterus. The myometrium is composed of smooth muscle and the contraction of myometrium is a factor in menstrual pain and is essential in childbirth. The myometrium can develop benign smooth muscle neoplasms known as leiomyoma or fibroids.CervixThe cervix connects the uterus and vagina and projects into the upper vagina. The vagina forms an arched ring around the cervix described as the vaginal fornices—lateral, anterior, and posterior. The cervix is about 2.5-cm long with a fusiform endo-cervical canal lined by columnar epithelium lying between an internal and external os, or opening. The vaginal surface of the cervix is covered with stratified squamous epithelium, similar to that lining the vagina. The


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Surgery_Schwartz. by columnar epithelium lying between an internal and external os, or opening. The vaginal surface of the cervix is covered with stratified squamous epithelium, similar to that lining the vagina. The squamo-columnar junction, also referred to as the transformation zone, migrates at different stages of life and is influenced by estrogenic stimulation. The transformation zone develops as the columnar epithelium is replaced by squamous metaplasia. This transformation zone is Internal iliac arteryLateral sacralarterySuperiorglutealarteryInferior gluteal arteryCoccygeus muscleInternal pudendalarteryUterine arteryMiddle rectal arteryObturator internusmuscleObturator arterySuperior vesical arteryExternal iliac arteryCommon iliac arteryFigure 41-2. The muscles and vasculature of the pelvis.Hypogastric plexusObturator nerveVesical plexusUterovaginal plexus Rectal plexusLeft pelvic plexusSacral plexusSympathetic ganglionFigure 41-3. The nerve supply of the female


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Surgery_Schwartz. of the pelvis.Hypogastric plexusObturator nerveVesical plexusUterovaginal plexus Rectal plexusLeft pelvic plexusSacral plexusSympathetic ganglionFigure 41-3. The nerve supply of the female pelvis.Brunicardi_Ch41_p1783-p1826.indd 178518/02/19 4:33 PM 1786SPECIFIC CONSIDERATIONSPART IIvulnerable to human papilloma virus (HPV) infection and resul-tant premalignant changes. These changes can be detected by microscopic assessment of cervical cytological (or Pap) smear. If the duct of a cervical gland becomes occluded, the gland dis-tends to form a retention cyst or Nabothian follicle.Fallopian TubesThe bilateral fallopian tubes arise from the upper lateral cornua of the uterus and course posterolaterally within the upper border of the broad ligament. The tubes can be divided into four parts. The interstitial part forms a passage through the myometrium. The isthmus is the narrow portion extending out about 3 cm from the myometrium. The ampulla is thin-walled and tortuous with its


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Surgery_Schwartz. parts. The interstitial part forms a passage through the myometrium. The isthmus is the narrow portion extending out about 3 cm from the myometrium. The ampulla is thin-walled and tortuous with its lateral end free of the broad ligament. The infundibulum is the distal end fringed by a ring of delicate fronds or fimbriae. The fallopian tubes receive the ovum after ovulation. Peristal-sis carries the ovum to the ampulla where fertilization occurs. The zygote transits the tube over the course of 3 to 4 days to the uterus. Abnormal implantation in the fallopian tube is the most common site of ectopic pregnancies. The tubes may also be infected by ascending organisms, resulting in tubo-ovarian abscesses. Scarring of the fallopian tubes can lead to hydrosal-pinx. Recent evidence suggests most high-grade serous ovarian cancer originates in the fallopian tubes.OvariesThe ovaries are attached to the uterine cornu by the proper ovarian ligaments, or the utero-ovarian ligaments. The ovaries are


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Surgery_Schwartz. serous ovarian cancer originates in the fallopian tubes.OvariesThe ovaries are attached to the uterine cornu by the proper ovarian ligaments, or the utero-ovarian ligaments. The ovaries are sus-pended from the lateral pelvis by their vascular pedicles, the infundibulopelvic ligaments (IP) or ovarian arteries. These are also called the suspensory ligaments of the ovaries, and cor-respond to the genital vessels in the male. The IP’s are paired branches from the abdominal aorta arising just below the renal arteries. They merge with the peritoneum over the psoas major muscle and pass over the pelvic brim and the external iliac ves-sels. The ovarian veins ascend at first with the ovarian arteries, then track more laterally. The right ovarian vein ascends to drain BladderUterusRound ligamentExternal iliacartery and veinFallopian tubeOvarianvesselsOvarian ligamentBroad ligamentUterosacral ligamentSigmoid colonUreterOvaryFigure 41-5. Internal pelvic anatomy, from above.Figure 41-4. External


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Surgery_Schwartz. iliacartery and veinFallopian tubeOvarianvesselsOvarian ligamentBroad ligamentUterosacral ligamentSigmoid colonUreterOvaryFigure 41-5. Internal pelvic anatomy, from above.Figure 41-4. External genitalia. (Reproduced with permission from Rock J, Jones HW: TeLinde’s Operative Gynecology, 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2003.)ClitorisLabiumminusLabiummajusMouth ofBartholin’s glandFossa navicularisFourchetteAnusHymenVaginaSkene’sductsUrethralorificePrepuce ofclitorisdirectly into the inferior vena cava while the left vein drains into the left renal vein. Lymphatic drainage follows the arteries to the para-aortic lymph nodes. The ovaries are covered by a single layer of cells that is continuous with the mesothelium of the peritoneum. Beneath this is a fibrous stroma within which are embedded germ cells. At ovulation, an ovarian follicle ruptures through the ovarian epithelium.Fibrovascular Ligaments and Avascular Tissue PlanesFigure 41-5 is a view of the internal


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Surgery_Schwartz. which are embedded germ cells. At ovulation, an ovarian follicle ruptures through the ovarian epithelium.Fibrovascular Ligaments and Avascular Tissue PlanesFigure 41-5 is a view of the internal genitalia and deep pelvis as one would approach the pelvis from a midline abdominal incision. The central uterus and uterine cervix are supported by the pelvic floor muscles (Fig. 41-5). They are suspended by Brunicardi_Ch41_p1783-p1826.indd 178618/02/19 4:34 PM 1787GYNECOLOGYCHAPTER 41the lateral fibrous cardinal, or Mackenrodt’s ligament, and the uterosacral ligaments, which insert into the paracervical fascia medially and into the muscular sidewalls of the pelvis laterally. Posteriorly, the uterosacral ligaments provide support for the vagina and cervix as they course from the sacrum lateral to the rectum and insert into the paracervical fascia. Emanating from the uterine cornu and traveling through the inguinal canal are the round ligaments, eventually attaching to the subcutaneous


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Surgery_Schwartz. to the rectum and insert into the paracervical fascia. Emanating from the uterine cornu and traveling through the inguinal canal are the round ligaments, eventually attaching to the subcutaneous tissue of the mons pubis. The peritoneum enfolding the adnexa (tube, round ligament, and ovary) is referred to as the broad ligament, which separates the pelvic cavity into an anterior and posterior component.The peritoneal reflections in the pelvis anterior and pos-terior to the uterus are referred to as the anterior and posterior cul-de-sacs. The latter is also called the pouch or cul-de-sac of Douglas. On transverse section, seven avascular, and therefore important, surgical planes can be identified (Fig. 41-6). These include the right and left lateral paravesical and right and left pararectal spaces, and from anterior to posterior, the retropubic or prevesical space of Retzius and the vesicovaginal, rectovagi-nal, and retrorectal or presacral spaces.These avascular tissue planes are often


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Surgery_Schwartz. spaces, and from anterior to posterior, the retropubic or prevesical space of Retzius and the vesicovaginal, rectovagi-nal, and retrorectal or presacral spaces.These avascular tissue planes are often preserved and provide safe surgical access when the intraperitoneal pelvic anatomy is distorted by tumor, endometriosis, adhesions, or infection. Utilizing the avascular retroperitoneal planes, the ure-ter can be traced into the pelvis as it crosses the distal common iliac arteries laterally into the pararectal space and then courses inferior to the ovarian arteries and veins until crossing under the uterine arteries into the paravesical space just lateral to the cervix. After traveling to the cervix, the ureters course down-ward and medially over the anterior surface of the vagina before entering the base of the bladder in the vesicovaginal space.Vasculature and Nerves of the PelvisThe rich blood supply to the pelvis arises largely from the internal iliac arteries except for the middle


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Surgery_Schwartz. the base of the bladder in the vesicovaginal space.Vasculature and Nerves of the PelvisThe rich blood supply to the pelvis arises largely from the internal iliac arteries except for the middle sacral artery originating at the aortic bifurcation and the ovarian arteries originating from the abdominal aorta. There is also collateral flow and anastomo-ses to the pelvic vessels from the inferior mesenteric artery. The internal iliac, or hypogastric, arteries divide into anterior and pos-terior branches. The latter supply lumbar and gluteal branches. From the anterior division of the hypogastric arteries arise the Prevesical spaceParavesical spaceVesicovaginalspaceVesicouterine ligamentCardinal ligamentUterosacralligamentRetrovaginal spaceRetrorectal spaceSacrumRectumPararectal spaceCervicalfasciaCervixVesicalfasciaBladderPubovesical ligamentFigure 41-6. The avascular spaces of the female pelvis.obturator, uterine, pudendal, middle rectal, inferior gluteal, along with superior and middle


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Surgery_Schwartz. ligamentFigure 41-6. The avascular spaces of the female pelvis.obturator, uterine, pudendal, middle rectal, inferior gluteal, along with superior and middle vesical arteries (see Fig. 41-2).The major motor nerves found in the pelvis are the sci-atic, obturator, and femoral nerves (Fig. 41-3). Also important to the pelvic surgeon are the ilioinguinal, iliohypogastric and genitofemoral nerves, which arise as upper abdominal nerves, but are encountered on the most caudal portion of the anterior abdominal wall and the ventral portion of the external genitalia. Sympathetic fibers course along the major arteries and para-sympathetics form the superior and inferior pelvic plexus. The pudendal nerve arises from S2–S4 and travels laterally, exiting the greater sciatic foramen, hooking around the ischial spine and sacrospinous ligament, and returning via the greater sciatic foramen. It travels through Alcock’s canal and becomes the sen-sory and motor nerve of the perineum (see Figs. 41-1 and


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Surgery_Schwartz. ischial spine and sacrospinous ligament, and returning via the greater sciatic foramen. It travels through Alcock’s canal and becomes the sen-sory and motor nerve of the perineum (see Figs. 41-1 and 41-3). The motor neurons serve the tonically contracting urethral and anal sphincter, and direct branches from the S2–S4 nerves serve the levator ani muscles. During childbirth and other excessive straining, this tethered nerve (along with the levator ani muscles) is subject to stretch injury and is at least partially responsible for many female pelvic floor disorders.EVALUATION AND DIAGNOSISElements of a Gynecologic HistoryA complete history is a seminal part of any assessment (Table 41-1). Many gynecologic diseases can present with broad constitutional symptoms, occur secondary to other conditions, or be related to medications. A full history should include particular attention to family history, organ system history, including breast, gastrointestinal, and urinary tract symptoms, and


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Surgery_Schwartz. or be related to medications. A full history should include particular attention to family history, organ system history, including breast, gastrointestinal, and urinary tract symptoms, and a careful medication, anesthesia, and surgical history. The key elements of a focused gynecologic history include the following:• Date of last menstrual period• History of contraceptive and postmenopausal hormone use• Obstetrical history• Age at menarche and menopause (method of menopause, [e.g., drug, surgical])• Menstrual bleeding pattern• History of pelvic assessments, including cervical smear and HPV DNA results• History of pelvic infections, including HPV and HIV status• Sexual history• Prior gynecologic surgery(s)The Gynecologic ExaminationFor many young women, their gynecologist is their primary care physician. When that is the case, it is necessary that a full medical and surgical history be taken and that, in addition to the pelvic examination, the minimum additional examination should


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Surgery_Schwartz. care physician. When that is the case, it is necessary that a full medical and surgical history be taken and that, in addition to the pelvic examination, the minimum additional examination should include assessment of the thyroid, breasts, and cardiopul-monary system. Screening, reproductive counseling, and age-appropriate health services should be available to women of all ages with or without a routine pelvic examination, but the deci-sion to proceed with regular, annual pelvic examinations in oth-erwise healthy women is controversial.2,3 The U.S. Preventive Services Task Force recently evaluated the current evidence regarding the balance of benefits and harms of performing screening pelvic examinations in asymptomatic, nonpregnant adult women and concluded that the evidence is insufficient.32Brunicardi_Ch41_p1783-p1826.indd 178718/02/19 4:34 PM 1788SPECIFIC CONSIDERATIONSPART IIThe pelvic examination starts with a full abdominal exam-ination. Inguinal node evaluation is


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Surgery_Schwartz. 178718/02/19 4:34 PM 1788SPECIFIC CONSIDERATIONSPART IIThe pelvic examination starts with a full abdominal exam-ination. Inguinal node evaluation is performed before placing the patient’s legs in the dorsal lithotomy position (in stirrups). A flexible, focused light source is essential, and vaginal instru-ments including speculums of variable sizes and shapes (Graves and Pederson), including pediatric sizes, are required to assure that the patient’s anatomy can be fully and comfortably viewed.The external genitalia are inspected first, noting the distri-bution of pubic hair, the skin color and contour, the Bartholin and Skene’s glands, and perianal area. Abnormalities are docu-mented and a map with measurements of abnormalities drawn. A warmed lubricated speculum is inserted into the vagina and gently opened to identify the cervix if present or the vaginal apex if not. To avoid confounding the location of pelvic pain with immediate speculum exam, or if there is a concern that a


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Surgery_Schwartz. vagina and gently opened to identify the cervix if present or the vaginal apex if not. To avoid confounding the location of pelvic pain with immediate speculum exam, or if there is a concern that a malignancy is present, careful digital assessment of a vaginal mass and location may be addressed prior to speculum place-ment in order to avoid abrading a vascular lesion and inducing hemorrhage. The speculum would then be inserted just short of the length to the mass in order to view that area directly before advancing. An uncomplicated speculum exam includes examination of the vaginal sidewalls, assessment of secretions, including culture if necessary, and collection of the cervical cytologic specimen and HPV test if indicated (see “Common Screening”).A bimanual examination is performed by placing two fin-gers in the vaginal canal; one finger may be used if patient has significant vaginal atrophy or has had prior radiation with ste-nosis (Fig. 41-7). Carefully and sequentially assess the


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Surgery_Schwartz. two fin-gers in the vaginal canal; one finger may be used if patient has significant vaginal atrophy or has had prior radiation with ste-nosis (Fig. 41-7). Carefully and sequentially assess the size and shape of the uterus by moving it against the abdominal hand, and the adnexa by carefully sweeping the abdominal hand down the side of the uterus. The rectovaginal examination, consisting of one finger in the vagina and one in the rectal vault, is used to further examine and characterize the location, shape, fixation, size, and complexity of the uterus, adnexa, cervix, and anterior and posterior cul-de-sacs. The rectovaginal exam also allows examination of the uterosacral ligaments from the back of the uterus sweeping laterally to the rectal finger and the sacrum, as well as assessment of the rectum and anal canal for masses.It is critical that presurgical assessments include a full gen-eral examination. This is particularly important with potential oncologic diagnoses or infectious


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Surgery_Schwartz. the rectum and anal canal for masses.It is critical that presurgical assessments include a full gen-eral examination. This is particularly important with potential oncologic diagnoses or infectious issues in order to assure that the proposed surgery is both safe and appropriate. Issues such as sites of metastatic cancer or infection, associated bleeding and/Table 41-1Key elements of the gynecologic historyISSUEELEMENTS TO EXPLOREASSOCIATED ISSUESMenstrual historyAge at menarche, menopause.Bleeding pattern, postmenopausal bleeding, spotting between periods.Any medications (warfarin, heparin, aspirin, herbals, others) or personal or family history that might lead to prolonged bleeding timesIdentifies abnormal patterns related to endocrine, structural, infectious, and oncologic etiologiesObstetrical historyNumber of pregnancies, dates, type of deliveries, pregnancy loss, abortion, complicationsIdentifies predisposing pregnancy for GTD, possible surgical complicationsSexual


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Surgery_Schwartz. etiologiesObstetrical historyNumber of pregnancies, dates, type of deliveries, pregnancy loss, abortion, complicationsIdentifies predisposing pregnancy for GTD, possible surgical complicationsSexual historyPartners, practices, protection; pregnancy intentionGuide the assessment of patient risk, risk-reduction strategies, the determination of necessary testing, and the identification of anatomical sites from which to collect specimens for STD testingInfectious diseasesSexually transmitted diseases and treatment and/or testing for theseAlso need to explore history of other GI diseases that may mimic STD (Crohn’s, diverticulitis)Contraceptive historyPresent contraception if appropriate, prior use, type and durationConcurrent pregnancy with procedure or complications of contraceptivesCytologic screeningFrequency, results (normal, prior abnormal Pap), any prior surgery or diagnoses, HPV testing historyProlonged intervals increase risk of cervical cancerRelationship to anal, vaginal, vulvar


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Surgery_Schwartz. screeningFrequency, results (normal, prior abnormal Pap), any prior surgery or diagnoses, HPV testing historyProlonged intervals increase risk of cervical cancerRelationship to anal, vaginal, vulvar cancersPrior gynecologic surgeryType (laparoscopy, vaginal, abdominal); diagnosis (endometriosis? ovarian cysts? tubo-ovarian abscess?); actual pathology if possibleAssess present history against this background (for example, granulosa cell pathology, is it now recurrent?)Pain historySite, location, relationship (with urination, with menses, with intercourse at initiation or deep penetration, with bowel movements), referralAssesses relationship to other organ systems, and potential involvement of these with process. Common examples presenting as pelvic pain, ureteral stone, endometriosis with bowel involvement, etcBrunicardi_Ch41_p1783-p1826.indd 178818/02/19 4:34 PM 1789GYNECOLOGYCHAPTER 41or clotting issues and history, and drug exposure, allergies, and current medications must be


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Surgery_Schwartz. bowel involvement, etcBrunicardi_Ch41_p1783-p1826.indd 178818/02/19 4:34 PM 1789GYNECOLOGYCHAPTER 41or clotting issues and history, and drug exposure, allergies, and current medications must be addressed.Commonly Used Testinga-Human Chorionic Gonadotropin Testing. Qualitative uri-nary pregnancy tests for human chorionic gonadotropin (b-hCG) are standard prior to any surgery in a woman of reproductive age and potential, regardless of contraception history. In addition, serum quantitative b-hCG testing is appropriate for evaluation of suspected ectopic pregnancy, gestational trophoblastic dis-ease, or ovarian mass in a young woman. In the case of ectopic pregnancy, serial levels are required when a pregnancy cannot be identified in the uterine cavity by imaging. As a general rule, 85% of viable, very early intrauterine pregnancies will have at least a 66% rise in the b-hCG level over 48 hours.Table 41-2Features of common causes of vaginitis BACTERIAL VAGINOSISVULVOVAGINAL


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Surgery_Schwartz. 85% of viable, very early intrauterine pregnancies will have at least a 66% rise in the b-hCG level over 48 hours.Table 41-2Features of common causes of vaginitis BACTERIAL VAGINOSISVULVOVAGINAL CANDIDIASISTRICHOMONIASISPathogenAnaerobic organismsCandida albicansTrichomonas vaginalis% of vaginitis403020pH>4.5<4.5>4.5Signs and symptomsMalodorous, adherent dischargeWhite discharge, vulvar erythema, pruritus, dyspareuniaMalodorous purulent discharge, vulvovaginal erythema, dyspareuniaWet mountClue cellsPseudohyphae or budding yeasts in 40% of casesMotile trichomonadsKOH mount Pseudohyphae or budding yeasts in 70% of cases Amine test+−−TreatmentMetronidazole 500 mg twice a day for 7 d or 2 g single dose, metronidazole or clindamycin vaginal creamOral fluconazole 150 mg single dose, vaginal antifungal preparationsMetronidazole 2 g single dose and treatment of partner+ = positive; − = negative; KOH = potassium hydroxide.Figure 41-7. Bimanual abdominovaginal palpation of the


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Surgery_Schwartz. dose, vaginal antifungal preparationsMetronidazole 2 g single dose and treatment of partner+ = positive; − = negative; KOH = potassium hydroxide.Figure 41-7. Bimanual abdominovaginal palpation of the uterus.Microscopy of Vaginal Discharge. During a speculum exam, a cotton-tipped applicator is used to collect the vaginal dis-charge; it is smeared on a slide with several drops of 0.9% nor-mal saline to create a saline wet mount. A cover slide is placed and the slide is evaluated microscopically for the presence of mobile trichomonads (Trichomonas vaginalis) or clue cells (epithelial cells studded with bacteria, seen in bacterial vagi-nosis; Table 41-2). A potassium hydroxide (KOH) wet mount is the slide application of the collected vaginal discharge with 10% KOH; this destroys cellular elements. The test is posi-tive for vaginal candidiasis when pseudohyphae are seen (see Table 41-2).Chlamydia/Gonorrhea Testing. Nucleic acid amplification testing (NAAT) has emerged as the diagnostic


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Surgery_Schwartz. The test is posi-tive for vaginal candidiasis when pseudohyphae are seen (see Table 41-2).Chlamydia/Gonorrhea Testing. Nucleic acid amplification testing (NAAT) has emerged as the diagnostic test of choice for N gonorrhea and C trachomatis. A vaginal swab, endocervical swab, and/or urine sample, can be used for this test.Cervical Cancer Screening and Prevention. HPV infection is required for the development of epithelial cervical carcino-mas (squamous and adenocarcinomas), and HPV DNA can be identified in virtually all primary cervical malignancies. HPV is a ubiquitous double-stranded DNA virus commonly acquired in the female lower genital tract through sexual contact. After entry into the cell, the HPV protein E6 degrades the tumor sup-pressor p53, resulting in deregulation of cell cycle arrest. E7 inactivates the tumor suppressor RB and releases E2F transcrip-tion factors, causing cellular hyperproliferation. More than 100 HPV types have been identified, and up to 40 of these


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Surgery_Schwartz. cycle arrest. E7 inactivates the tumor suppressor RB and releases E2F transcrip-tion factors, causing cellular hyperproliferation. More than 100 HPV types have been identified, and up to 40 of these subtypes infect the anogenital region. At least 12 are considered high-risk or oncogenic, and HPV genotypes 16 and 18 cause approxi-mately 70% of cervical cancers worldwide.4Recent cervical cytology guidelines have increased the intervals between screenings for most women given the known natural history of HPV-related cervical dysplasia progression to cancer and the high negative predictive value of a negative HPV test.6 The current recommendations call for cervical smear screening every 3 to 5 years in women ages 21 to 65 years. If an Brunicardi_Ch41_p1783-p1826.indd 178918/02/19 4:34 PM 1790SPECIFIC CONSIDERATIONSPART IIHPV test performed at the same time also is negative, test-ing should be repeated every 5 years for women ages 30 to 65 years. Screening is not recommended for women


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Surgery_Schwartz. 1790SPECIFIC CONSIDERATIONSPART IIHPV test performed at the same time also is negative, test-ing should be repeated every 5 years for women ages 30 to 65 years. Screening is not recommended for women age older than 65 or without a cervix (prior hysterectomy) unless they have a history of high-grade precancerous lesions. Women with a history of cervical dysplasia, HPV infection, or cervical cancer need more frequent screening based on their diagnosis. Primary high-risk HPV (hrHPV) screening is also an acceptable alterna-tive to cytologic screening for women ages 30-65 because of an increased detection of high-grade squamous intraepithelial lesion (HSIL) and increased negative predictive value.6HPV Vaccine. Three HPV vaccines have been approved by the U.S. Food and Drug Administration (FDA).7 In 2006, a quad-rivalent (4vHPV) vaccine was approved that targets HPV 16 and 18, which cause 70% of cervical cancers, and HPV geno-types 6 and 11, which cause 90% of genital warts. In Decem-ber


Surgery_Schwartz

Surgery_Schwartz. In 2006, a quad-rivalent (4vHPV) vaccine was approved that targets HPV 16 and 18, which cause 70% of cervical cancers, and HPV geno-types 6 and 11, which cause 90% of genital warts. In Decem-ber 2014, a nine-valent vaccine (9cHPV) was introduced to replace the 4vHPV vaccine, which includes protection against the HPV strains covered by the first generation of 4vHPV as well as five other HPV strains responsible for 20% of cervical cancers (HPV-31, HPV-33, HPV-45, HPV-52, and HPV-58).7 The 9vHPV may be used to continue or complete a series started with a different HPV vaccine product. Vaccination with 9vHPV after completion of 4vHPV at least 12 months earlier is safe and may provide protection against additional HPV strains. A biva-lent vaccine that targets HPV genotypes 16 and 18 with a dif-ferent adjuvant that may have led to higher immunogenicity was approved in 2009 but is no longer marketed in the United States.Vaccination generates high concentrations of neutralizing antibodies to


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Surgery_Schwartz. adjuvant that may have led to higher immunogenicity was approved in 2009 but is no longer marketed in the United States.Vaccination generates high concentrations of neutralizing antibodies to HPV L1 protein, the antigen in all HPV vaccines. The vaccines are highly immunogenic, activating both humoral and cellular immune responses. Multiple randomized clinical trials have demonstrated nearly 100% efficacy in the preven-tion of the HPV subtype-specific precancerous cervical cell changes.7,8 These major clinical trials have used prevention of HSIL as the efficacy endpoints. Vaccination does not protect women who are already infected with HPV-16 or -18 at the time of vaccination.Current recommendations include HPV vaccination for boys and girls at age 11 or 12 years. (Vaccination can be started at age 9.) The Advisory Committee on Immunization Prac-tices (ACIP) also recommends vaccination for females aged 13 through 26 years and males aged 13 through 21 years not adequately vaccinated


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Surgery_Schwartz. at age 9.) The Advisory Committee on Immunization Prac-tices (ACIP) also recommends vaccination for females aged 13 through 26 years and males aged 13 through 21 years not adequately vaccinated previously. Catch-up vaccination is also recommended through age 26 years for gay, bisexual, and other men who have sex with men, transgender people, and for immu-nocompromised persons (including those with HIV infection) not adequately vaccinated previously.8 Two doses are given 6 to 12 months apart for patients with an intact immune system, age less than 15 years; three doses are recommended for those ages 15 to 26 years and immunocompromised persons.10 Cervical cancer screening continues to play an important role in detection and treatment of premalignant cervical lesions and prevention of cervical cancer in these high-risk patients and is currently recommended following HPV vaccination.Serum Cancer Antigen 125. Cancer antigen (CA) 125 is a large membrane glycoprotein belonging to the wide


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Surgery_Schwartz. cancer in these high-risk patients and is currently recommended following HPV vaccination.Serum Cancer Antigen 125. Cancer antigen (CA) 125 is a large membrane glycoprotein belonging to the wide mucin family commonly used as a tumor marker in patients known to have ovarian cancer. An elevated CA-125 in the patient without known ovarian cancer should be interpreted in conjunction with patient information and symptoms as well as imaging. In the setting of an adnexal mass, the serum CA-125 test may help with triage of a patient to the appropriate surgical management. The test should be used with caution as it is a nonspecific test and may be elevated with multiple benign conditions including endometriosis, fibroids, infection, and pregnancy and may even vary with the menstrual cycle. For these reasons, the CA-125 test is less useful in the premenopausal woman for triaging an adnexal mass. In the postmenopausal woman, a CA-125 greater than 35 in the setting of a complex adnexal mass


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Surgery_Schwartz. these reasons, the CA-125 test is less useful in the premenopausal woman for triaging an adnexal mass. In the postmenopausal woman, a CA-125 greater than 35 in the setting of a complex adnexal mass merits referral of the patient to a gynecologic oncologist.10Common Office Procedures for DiagnosisVulvar/Vaginal Biopsy. Any abnormal vulvar or vaginal lesion including skin color changes, raised lesions, or ulcer-ations should be biopsied. Local infiltration with local anes-thetic is followed by a 3to 5-mm punch biopsy appropriate to the lesion. The specimen is elevated with Adson forceps and cut from its base with scissors. The vaginal biopsy can sometimes be difficult to perform because of the angle of the lesion. After injection with local anesthetic, traction of the area with Allis forceps and direct resection of the lesion with scissors or cervi-cal biopsy instrument (Schubert, Kevorkian, etc) can achieve an adequate biopsy.Colposcopy and Cervical Biopsy. In cases of an abnormal Pap


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Surgery_Schwartz. and direct resection of the lesion with scissors or cervi-cal biopsy instrument (Schubert, Kevorkian, etc) can achieve an adequate biopsy.Colposcopy and Cervical Biopsy. In cases of an abnormal Pap smear cytology or positive HPV testing, a colposcopy is performed for a histologic evaluation. A colposcope is used to achieve 2x to 15x magnification of the cervix. Once the cer-vix is visualized, cervical mucus, if present, is removed, and then 3% acetic acid is applied to the cervix for one minute. This application dehydrates cells and causes dysplastic cells with dense nuclei to appear white. The lining of the cervix consists of squamous epithelium on the ectocervix, whereas columnar epithelium lines the endocervical canal. The ectocervix there-fore appears smooth and pale pink in color while the endocervix forms epithelial fronds or “grape-like” structures visible through the colposcope. The junction between columnar and squamous cell types is called the squamocolumnar junction (SCJ),


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Surgery_Schwartz. the endocervix forms epithelial fronds or “grape-like” structures visible through the colposcope. The junction between columnar and squamous cell types is called the squamocolumnar junction (SCJ), which in younger women is usually visible on the ectocervix. When columnar epithelium extends onto the ectocervix, it appears as a red zone surrounding the os and is called ectropion or ectopy. The transformation zone (TZ) is the area between mature squa-mous epithelium distally and columnar epithelium proximally, and it is the site of active squamous metaplasia. For colposcopy to be deemed adequate, the entire SCJ must be visualized dur-ing an adequate colposcopy. Areas with acetowhite, punctation, mosaicism, or atypical blood vessels seen during colposcopy may represent dysplasia or cancer and should be biopsied. A green filter enhances visualization of blood vessels by making them appear darker in contrast to the surrounding epithelium.An alternative to dilute acetic acid is Lugol’s


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Surgery_Schwartz. and should be biopsied. A green filter enhances visualization of blood vessels by making them appear darker in contrast to the surrounding epithelium.An alternative to dilute acetic acid is Lugol’s solution—a concentrated solution of iodine that reacts with the glycogen in normal squamous epithelium to make it appear dark brown. High-grade CIN lesions have low amounts of glycogen because the epithelium is poorly differentiated, and hence they do not turn brown with Lugol’s solution. This is termed Lugol’s nonstaining or Lugol’s negative. Historically, this used to be referred to as the Schiller’s test. Lugol’s can be useful for determining whether a colposcopically equivocal area warrants biopsy: Lugol’s staining areas are most likely normal epithelium, whereas Lugol’s nonstaining areas may be CIN, metaplasia, or inflammation.Brunicardi_Ch41_p1783-p1826.indd 179018/02/19 4:34 PM 1791GYNECOLOGYCHAPTER 41Endometrial Biopsy. Endometrial sampling should be per-formed before planned


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Surgery_Schwartz. may be CIN, metaplasia, or inflammation.Brunicardi_Ch41_p1783-p1826.indd 179018/02/19 4:34 PM 1791GYNECOLOGYCHAPTER 41Endometrial Biopsy. Endometrial sampling should be per-formed before planned hysterectomy if there is a history of bleeding between periods, heavy and/or frequent menstrual peri-ods, or postmenopausal bleeding. A patient with the potential for pregnancy should have a pregnancy test before the procedure. A pipelle endometrial biopsy can be performed in the office and is a cost-effective and safe procedure that is generally well tolerated by patients. The pipelle is a flexible polypropylene suction cannula with an outer diameter of 3.1 mm. The pipelle is inserted through the endocervix after cervical cleaning, and the depth of the uterine cavity is noted. If difficulty in entering the endometrium with the pipelle is encountered, a tenaculum may be used to straighten the cervix and/or an OS-finder may be use-ful in overcoming resistance within the endocervix. The


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Surgery_Schwartz. in entering the endometrium with the pipelle is encountered, a tenaculum may be used to straighten the cervix and/or an OS-finder may be use-ful in overcoming resistance within the endocervix. The endo-metrial specimen is obtained by pulling on the plunger within the pipelle, creating a small amount of suction. The pipelle is rotated and pulled back from the fundus to the lower uterine segment within the cavity to access all sides.11 Additional passes may be needed in order to acquire an adequate amount of tis-sue. If office biopsy is not possible due to patient discomfort or cervical stenosis, a dilatation and curettage in the operating room may be indicated depending on the clinical circumstances.Evaluation for Fistula. When a patient presents with copi-ous vaginal discharge, the provider should be concerned about a fistula with the urinary or gastrointestinal tract. A simple office procedure can be performed when there is a concern for a vesi-covaginal fistula. A vaginal tampon is


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Surgery_Schwartz. should be concerned about a fistula with the urinary or gastrointestinal tract. A simple office procedure can be performed when there is a concern for a vesi-covaginal fistula. A vaginal tampon is placed followed by instil-lation of sterile blue dye through a transurethral catheter into the bladder; a positive test is blue staining of the tampon. If the test is negative, one can evaluate for a ureterovaginal fistula. The patient is given phenazopyridine, which changes the color of urine to orange. If a tampon placed in the vagina stains orange, the test is positive. Alternatively, the patient can be given an intravenous injection of indigo carmine.Rectal fistula must be considered when a patient reports stool evacuation per vagina. It can be identified in a similar fashion using a large Foley catheter placed in the distal rectum through which dye may be injected, or with the use of an oral charcoal slurry and timed examination. Common areas for fis-tulae are at the vaginal apex, at


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Surgery_Schwartz. Foley catheter placed in the distal rectum through which dye may be injected, or with the use of an oral charcoal slurry and timed examination. Common areas for fis-tulae are at the vaginal apex, at the site of a surgical incision, or around the site of a prior episiotomy or perineal repair after a vaginal delivery.BENIGN GYNECOLOGIC CONDITIONSVulvar LesionsPatients presenting with vulvar symptoms should be carefully interviewed and examined, and a vulvar biopsy should be obtained whenever the diagnosis is in question, the patient does not respond to treatment, or premalignant and malignant disease is suspected. Vulvar conditions such as contact derma-titis, atrophic vulvovaginitis, lichen sclerosis, lichen planus, lichen chronicus simplex, Paget’s disease, Bowen’s disease, and invasive vulvar cancer are common particularly in postmeno-pausal women. Systemic diseases like psoriasis, eczema, Crohn’s disease, Behçet’s disease, vitiligo, and seborrheic der-matitis may also involve the


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Surgery_Schwartz. vulvar cancer are common particularly in postmeno-pausal women. Systemic diseases like psoriasis, eczema, Crohn’s disease, Behçet’s disease, vitiligo, and seborrheic der-matitis may also involve the vulvar skin.Leukoplakias. There are three types of leukoplakia, a flat white abnormality. Lichen sclerosis is the most common cause of leukoplakia.12 There are two peaks of onset: prepubertal girls and perimenopausal or postmenopausal women.13 Classically, it results in a figure-of-eight pattern of white epithelium around the anus and vulva resulting in variable scarring and itching, and less commonly pain. Diagnosis is confirmed with biopsy, and treatment consists of topical steroids. An established association between lichen sclerosis and vulvar squamous cell carcinoma estimates risk of malignant transformation up to 5%.13Lichen planus is a cause of leukoplakia with an onset in the fifth and sixth decade of life. Lichen planus, in contrast to lichen sclerosis which is limited to the


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Surgery_Schwartz. malignant transformation up to 5%.13Lichen planus is a cause of leukoplakia with an onset in the fifth and sixth decade of life. Lichen planus, in contrast to lichen sclerosis which is limited to the vulva and perianal skin, can involve the vagina and oral mucosa, and erosions occur in the majority of patients leading to a variable degree of scarring. Patients usually have a history and dysuria and dyspareunia, and complain of a burning vulvar pain. Histology is not specific, and biopsy is recommended. Treatment is with topical steroids. Systemic steroids are indicated for severe and/or unresponsive cases.Lichen simplex chronicus is the third cause of leukoplakia, but is distinguished from the other lichen diseases by epidermal thickening, absence of scarring, and a severe intolerable itch.13 Intense scratching is common, and contributes to the severity of the symptoms and predisposes the cracked skin to infections. Treatment consists of cessation of the scratching which some-times


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Surgery_Schwartz. Intense scratching is common, and contributes to the severity of the symptoms and predisposes the cracked skin to infections. Treatment consists of cessation of the scratching which some-times requires sedation, elimination of any allergen or irritant, suppression of inflammation with potent steroid ointments, and treatment of any coexisting infections.Bartholin’s Cyst or Abscess. Bartholin’s glands, great ves-tibular glands, are located at the vaginal orifice at the four and eight o’clock positions; they are rarely palpable in normal patients. They are lined with cuboidal epithelium and secrete mucoid material to keep the vulva moist. Their ducts are lined with transitional epithelium, and their obstruction secondary to inflammation may lead to the development of a Bartholin’s cyst or abscess. Bartholin’s cysts or abscesses are usually symptom-atic and are easily diagnosed on examination. Infections are usu-ally polymicrobial. Treatment consists of incision and drainage and placement


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Surgery_Schwartz. Bartholin’s cysts or abscesses are usually symptom-atic and are easily diagnosed on examination. Infections are usu-ally polymicrobial. Treatment consists of incision and drainage and placement of a Word catheter, a small catheter with a bal-loon tip, for 2 to 3 weeks to allow for formation and epitheliali-zation of a new duct. Recurrent cysts or abscesses may require marsupialization, but on occasion these necessitate excision of the whole gland. Marsupialization is performed by incising the cyst or abscess wall and securing its lining to the skin edges with interrupted sutures.14 Cysts or abscesses that fail to resolve after drainage and those occurring in patients over 40 years old should be biopsied to exclude malignancy.Molluscum Contagiosum. Molluscum contagiosum presents with dome-shaped papules and are caused by the poxvirus. The papules are usually 2 to 5 mm in diameter and classically have a central umbilication. They are spread by direct skin contact, and present on the


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Surgery_Schwartz. papules and are caused by the poxvirus. The papules are usually 2 to 5 mm in diameter and classically have a central umbilication. They are spread by direct skin contact, and present on the vulva, as well as abdomen, trunk, arms, and thighs. Lesions typically clear in several months, but they can be treated with cryotherapy, curettage, or cantharidin, a topical blistering agent.Genital Ulcers. The frequency of the infectious etiologies of genital ulcers varies by geographic location. The most common causes of sexually transmitted genital ulcers in young adults in the United States are, in descending order of prevalence, herpes simplex virus (HSV), syphilis, and chancroid.15 Other infec-tious causes of genital ulcers include lymphogranuloma vene-reum and granuloma inguinale. Noninfectious etiologies include Behçet’s disease, neoplasms, and trauma. Table 41-3 outlines a rational approach to their evaluation and diagnosis.3Brunicardi_Ch41_p1783-p1826.indd 179118/02/19 4:34 PM


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Surgery_Schwartz. etiologies include Behçet’s disease, neoplasms, and trauma. Table 41-3 outlines a rational approach to their evaluation and diagnosis.3Brunicardi_Ch41_p1783-p1826.indd 179118/02/19 4:34 PM 1792SPECIFIC CONSIDERATIONSPART IIVulvar Condyloma. Condylomata acuminata (anogenital warts) are viral infections caused by HPV.16 Genital infection with HPV is the most common sexually transmitted infection in the United States today. HPV 6 and 11 are the most common low-risk types and are implicated in 90% of cases of genital warts.17 Women with immunosuppression due to HIV or solid organ transplant are at higher risk of vulvar condyloma than immunocompetent women.18,19 Genital warts are skin-colored or pink and range from smooth flattened papules to verrucous papilliform lesions. Lesions may be single or multiple and extensive. Diagnosis should be confirmed with biopsy as verru-cous vulvar cancers can be mistaken for condylomata.20 If small, self-administered topical imiquimod 5% cream or


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Surgery_Schwartz. single or multiple and extensive. Diagnosis should be confirmed with biopsy as verru-cous vulvar cancers can be mistaken for condylomata.20 If small, self-administered topical imiquimod 5% cream or trichloroace-tic acid for in-office applications may be tried. Extensive lesions may require surgical modalities that include cryotherapy, laser ablation, cauterization, and surgical excision.Paget’s Disease of the Vulva. Paget’s disease of the vulva is an intraepithelial disease of unknown etiology that affects Table 41-3Clinical features of genital ulcers syndromes HERPESSYPHILISCHANCROIDLYMPHOGRANULOMA VENEREUMGRANULOMA INGUINALE (DONOVANOSIS)PathogenHSV type 2 and less commonly HSV type 1Treponema palladiumHaemophilus ducreyiChlamydia trachomatis L1-L3Calymmato-bacterium granulomatisIncubation period2–7 days2–4 weeks (1–12 weeks)1–14 days3 days–6 weeks1–4 weeks (up to 6 months)Primary lesionVesiclePapulePapule or pustulePapule, pustule, or vesiclePapuleNumber of lesionsMultiple, may


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Surgery_Schwartz. period2–7 days2–4 weeks (1–12 weeks)1–14 days3 days–6 weeks1–4 weeks (up to 6 months)Primary lesionVesiclePapulePapule or pustulePapule, pustule, or vesiclePapuleNumber of lesionsMultiple, may coalesceUsually oneUsually multiple, may coalesceUsually oneVariableDiameter (mm)1–25–152–202–10VariableEdgesErythematousSharply demarcated, elevated, round, or ovalUndermined, ragged, irregularElevated, round, or ovalElevated, irregularDepthSuperficialSuperficial or deepExcavatedSuperficial or deepElevatedBaseSerous, erythematousSmooth, nonpurulentPurulentVariableRed and rough (“beefy”)IndurationNoneFirmSoftOccasionally firmFirmPainCommonUnusualUsually very tenderVariableUncommonLymph-adenopathyFirm, tender, often bilateralFirm, nontender, bilateralTender, may suppate, usually unilateralTender, may suppurate, loculated, usually unilateralPseudo-adenopathyTreatmentacyclovir (ACV) 400 mg POI three times a day for 7–10 days for primary infection and 400 mg PO three times a day for 5 days for


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Surgery_Schwartz. may suppurate, loculated, usually unilateralPseudo-adenopathyTreatmentacyclovir (ACV) 400 mg POI three times a day for 7–10 days for primary infection and 400 mg PO three times a day for 5 days for episodic managementPrimary, secondary, and early latent (<1 year): benzathine PCN-G 2.4 million U IM × 1Late latent (>1 year) and latent of unknown duration: benzathine PCN-G 2.4 million units IM every week × 3azithromycin 1 g po or ceftriaxone 250 mg IM × 1 OR Ciprofloxacin 500 mg po twice a day for 3 daysErythromycin base 500 mg po three times a day for 7 daysDoxycycline 100 mg po twice a day × 21 days ORErythromycin base 500 mg po four times a day for 21 daysDoxycycline 100 mg po twice a day for 3 weeks until all lesions have healedSuppressionacyclovir 400 mg po twice a day for those with frequent outbreaks Data from Stenchever M, Droegemueller W, Herbst A, et al: Comprehensive Gynecology, 4th ed. St Louis, MO: Elsevier/Mosby; 2001.Brunicardi_Ch41_p1783-p1826.indd


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Surgery_Schwartz. for those with frequent outbreaks Data from Stenchever M, Droegemueller W, Herbst A, et al: Comprehensive Gynecology, 4th ed. St Louis, MO: Elsevier/Mosby; 2001.Brunicardi_Ch41_p1783-p1826.indd 179218/02/19 4:34 PM 1793GYNECOLOGYCHAPTER 41mostly postmenopausal women in their sixth decade of life. It causes chronic vulvar itching and is sometimes associated with an underlying invasive vulvar adenocarcinoma or invasive cancers of the breast, cervix, or gastrointestinal tract. Grossly, the lesion is variable but usually confluent, raised, erythema-tous to violet, and waxy in appearance. Biopsy is required for diagnosis; the disease is intraepithelial and characterized by Paget’s cells with large pale cytoplasm. Treatment is assess-ment for other potential concurrent adenocarcinomas and then surgical removal by wide local resection of the involved area with a 2-cm margin. Free margins are difficult to obtain because the disease usually extends beyond the clinically visible area.21


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Surgery_Schwartz. then surgical removal by wide local resection of the involved area with a 2-cm margin. Free margins are difficult to obtain because the disease usually extends beyond the clinically visible area.21 Intraoperative frozen section of the margins can be done; how-ever, Paget’s vulvar lesions have a high likelihood of recurrence even after securing negative resection margins.Vulvar Intraepithelial Neoplasia. Two pathologically dis-tinct premalignant lesions of the vulva are currently recog-nized. Vulvar intraepithelial neoplasia (VIN) of usual type (uVIN) is caused by the HPV virus, tends to occur in younger women, and presents as multifocal disease. VIN of differenti-ated type (dVIN) develops independently of HPV and is typi-cally unifocal and seen in postmenopausal women. VIN is similar to its cervical intraepithelial neoplasia (CIN) counterpart in the cervix. In 2012, the pathologic terminology of HPV-related disease in the anogenital region was harmonized into a two-tier system where


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Surgery_Schwartz. its cervical intraepithelial neoplasia (CIN) counterpart in the cervix. In 2012, the pathologic terminology of HPV-related disease in the anogenital region was harmonized into a two-tier system where LSIL is equivalent to uVIN 1 and HSIL encompasses uVIN 2 and uVIN 3.22 Additional risk factors for the development of VIN include HIV infection, immunosup-pression, smoking, vulvar dermatoses such as lichen sclerosis, CIN, and a history of cervical cancer. Vulvar pruritus is the most common complaint in women with symptoms. Lesions may be vague or raised, and they may be velvety with sharply demar-cated borders. Diagnosis is made with a vulvar skin biopsy and multiple biopsies are sometimes necessary. Evaluation of the perianal and anal area is important as the disease may involve these areas. Once invasive disease is ruled out, treatment usually involves wide surgical excision; however, the treatment approaches may also include 5% imiquimod cream, CO2 laser ablation, or cavitational


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Surgery_Schwartz. Once invasive disease is ruled out, treatment usually involves wide surgical excision; however, the treatment approaches may also include 5% imiquimod cream, CO2 laser ablation, or cavitational ultrasonic surgical aspiration (CUSA), and depends on the number of lesions and their severity. When laser ablation is used, a 1-mm depth in hair-free areas is usually sufficient, while hairy lesions require ablation to a 3-mm depth because the hair follicles’ roots can reach a depth of 2.5 mm. Unfortunately, VIN tends to recur in up to 30% of cases, and high-grade lesions will progress to invasive disease in approxi-mately 10% of patients if left untreated.23Vaginal LesionsVaginitis (see Table 41-2). Vulvovaginal symptoms are extremely common, accounting for over 10 million office visits per year in the United States. The causes of vaginal complaints are commonly infectious in origin, but they include a number of noninfectious causes, such as chemicals or irritants, hormone deficiency, foreign


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Surgery_Schwartz. the United States. The causes of vaginal complaints are commonly infectious in origin, but they include a number of noninfectious causes, such as chemicals or irritants, hormone deficiency, foreign bodies, systemic diseases, and malignancy. Symptoms include abnormal vaginal discharge, pruritus, irrita-tion, burning, odor, dyspareunia, bleeding, and ulcers. A puru-lent discharge from the cervix should always raise suspicion of upper genital tract infection even in the absence of pelvic pain or other signs.Normal vaginal discharge is white or transparent, thick, and mostly odorless. It increases during pregnancy, with use of estrogen-progestin contraceptives, or at mid-cycle around the time of ovulation. Complaints of foul odor and abnormal vaginal discharge should be investigated. Candidiasis, bacte-rial vaginosis, and trichomoniasis account for 90% of vaginitis cases. The initial workup includes pelvic examination, vagi-nal pH testing, microscopy, vaginal cultures if microscopy is


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Surgery_Schwartz. bacte-rial vaginosis, and trichomoniasis account for 90% of vaginitis cases. The initial workup includes pelvic examination, vagi-nal pH testing, microscopy, vaginal cultures if microscopy is normal, and gonorrhea/Chlamydia NAAT (see earlier section, “Common Screening and Testing”).24 The pH of normal vaginal secretions is 3.8 to 4.4, which is hostile to growth of pathogens, and pH greater than or equal to 4.9 is indicative of a bacterial or protozoal infection. Treatment of vaginal infection before anticipated surgery is appropriate, particularly for BV, which may be associated with a higher risk for vaginal cuff infections (Fig. 41-8).Bacterial Vaginosis Bacterial vaginosis (BV) accounts for 50% of vaginal infections. It results from reduction in concentration of the normally dominant lactobacilli and increase in concentration of anaerobic organisms like Gardnerella vaginalis, M hominis, Bacteroides species, and others.25 Diagnosis is made by microscopic demonstration of clue cells.


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Surgery_Schwartz. and increase in concentration of anaerobic organisms like Gardnerella vaginalis, M hominis, Bacteroides species, and others.25 Diagnosis is made by microscopic demonstration of clue cells. The discharge typically produces a fishy odor upon addition of KOH (amine or Whiff test). Initial treatment is usually a 7-day course of metronidazole.Vulvovaginal Candidiasis Vulvovaginal candidiasis (VVC) is the most common cause of vulvar pruritus. It is generally caused by C albicans and occasionally by other Candida species. It is common in pregnancy, diabetics, patients taking antibiotics, and in immunocompromised hosts. Initial treatment is usually with topical antifungals, although one dose oral antifungal treatments is also effective.Trichomonas Vaginalis Trichomoniasis is a sexually transmit-ted infection of a flagellated protozoan and can present with malodorous, purulent discharge. It is typically diagnosed with visualization of the trichomonads during saline wet mount microscopy.


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Surgery_Schwartz. infection of a flagellated protozoan and can present with malodorous, purulent discharge. It is typically diagnosed with visualization of the trichomonads during saline wet mount microscopy. Initial treatment is usually a 7-day course of metronidazole.Gartner’s Duct Cyst. A Gartner’s duct cyst is a remnant of the Wolffian tract; it is typically found on the lateral vaginal walls. Patients can be asymptomatic or present with complaints of dyspareunia or difficulty inserting a tampon. If symptom-atic, these cysts may be surgically excised or marsupialized. If surgery is planned, preoperative magnetic resonance imaging (MRI) should be obtained to determine the extent of the cyst and verify the diagnosis.Vaginal Condyloma. The etiology and treatment of vaginal condyloma is similar to vulvar condyloma (see earlier section, “Vulvar Condyloma”).Vaginal Intraepithelial Neoplasia. Vaginal intraepithelial neoplasia, or VaIN, is similar to VIN and is classified based on the degree of epithelial


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Surgery_Schwartz. (see earlier section, “Vulvar Condyloma”).Vaginal Intraepithelial Neoplasia. Vaginal intraepithelial neoplasia, or VaIN, is similar to VIN and is classified based on the degree of epithelial involvement as mild (I), moderate (II), severe (III), or carcinoma in situ.26 Upwards of 65% to 80% of VaIN or vaginal cancers are associated with HPV infection. Typically, a patient will have a history of cervical dysplasia and a prior hysterectomy. The majority of lesions are located in the upper one-third of the vagina. Lesions are usually asymptomatic and found incidentally on cytological screening. Biopsy at the time of colposcopy is diagnostic and rules out invasive disease. VaIN is treated with laser ablation, surgical excision, or topical 5-FU therapy.4Brunicardi_Ch41_p1783-p1826.indd 179318/02/19 4:34 PM 1794SPECIFIC CONSIDERATIONSPART IICervical LesionsBenign Cervical Lesions. Benign lesions of the cervix include endocervical polyps, nabothian cysts (clear, fluid filled cysts with


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Surgery_Schwartz. 4:34 PM 1794SPECIFIC CONSIDERATIONSPART IICervical LesionsBenign Cervical Lesions. Benign lesions of the cervix include endocervical polyps, nabothian cysts (clear, fluid filled cysts with smooth surfaces), trauma (such as delivery-related cervi-cal tear or prior cervical surgery), malformation of the cervix, and cervical condyloma. For endocervical polyps, exploration of the base of the polyp with a cotton swab tip to identify that it is cervical and not uterine and to identify the stalk characteris-tics can help identify the appropriate surgical approach. Small polyps with identifiable base can be removed by grasping the polyp with ring forceps and slowly rotating it until separated from its base. Use of loop electroexcisional procedure (LEEP) is appropriate for larger lesions. Laser or other ablative procedures are appropriate for condyloma proven by biopsy.Cervical Intraepithelial Neoplasia. Following HPV expo-sure, dysplastic changes are common. Low grade dysplasia (cer-vical


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Surgery_Schwartz. or other ablative procedures are appropriate for condyloma proven by biopsy.Cervical Intraepithelial Neoplasia. Following HPV expo-sure, dysplastic changes are common. Low grade dysplasia (cer-vical intraepithelial neoplasia [CIN] I) can be observed and will most often regress to normal within 2 years. However, for girls or women in whom HPV infection is persistent, progression to high-grade cervical dysplasia (CIN II or III) usually require additional treatment due to the high risk of transformation to malignancy. Excisional procedures serve the therapeutic pur-pose of removal of dysplastic cells, and a diagnostic purpose as histologic review to rule out concomitant early stage cervical cancer can be performed. Either a LEEP or cold knife conization (CKC) may be used for surgical excision of the squamocolum-nar junction (SCJ) and outer endocervical canal. Risks of both procedures include bleeding, postprocedure infection, cervical stenosis, and risk of preterm delivery with


Surgery_Schwartz

Surgery_Schwartz. excision of the squamocolum-nar junction (SCJ) and outer endocervical canal. Risks of both procedures include bleeding, postprocedure infection, cervical stenosis, and risk of preterm delivery with subsequent pregnan-cies. The benefit of a LEEP is that it can be performed in the office under local anesthesia. A looped wire attachment for a standard monopolar electrosurgical unit is used to perform a LEEP excision. Loops range in a variety of shapes and sizes to accommodate different sizes of cervix. Optimally, one pass of the loop should excise the entire SCJ. Hemostasis of the remain-ing cervix is achieved with the ball electrode and ferrous sulfate paste (Monsel’s solution).A cervical cold knife conization allows for an excision where the margin status is not obscured by cauterized artifact. This may be particularly useful when the endocervical margin is of interest, or in cases of adenocarcinoma in situ and microin-vasive squamous cell carcinoma, where margin status dictates the


Surgery_Schwartz

Surgery_Schwartz. This may be particularly useful when the endocervical margin is of interest, or in cases of adenocarcinoma in situ and microin-vasive squamous cell carcinoma, where margin status dictates the type and need for future therapy. After injection with dilute vasopressin and the placement of stay sutures at three and nine o’clock on the cervix, a #11 blade is used to circumferentially excise the conical biopsy. Hemostasis is achieved with the cau-tery or Monsel’s solution.Uterine CorpusThe average age of menarche, or first menstrual period, in the United States is 12 years and 5 months. Duration of normal menstruation is between 2 to 7 days, with a flow of less than 80 mL, cycling every 21 to 35 days.27 Nonpregnant patients, who present with heavy bleeding and are 35 years of age and older or have risk factors for endometrial cancer, must be ruled out for malignancy as the first step in their management (see earlier section, “Endometrial Biopsy”).Abnormal Uterine Bleeding. The


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Surgery_Schwartz. older or have risk factors for endometrial cancer, must be ruled out for malignancy as the first step in their management (see earlier section, “Endometrial Biopsy”).Abnormal Uterine Bleeding. The classification of abnormal uterine bleeding (AUB) has been recently updated.28 Abnormal uterine bleeding may be heavy (AUB/HMB) or intermenstrual (AUB/IMB) and is further divided into acute and chronic cat-egories. Acute AUB is an episode of heavy bleeding that is of sufficient quantity to require immediate intervention to pre-vent further blood loss. Acute AUB may occur in the setting of chronic AUB. Women with acute AUB should be assessed Vaginal dischargeand/or pruritusInterviewExamWet & KOH mountsVaginal pHMetronidazoleorClindamycinCandidiasisAntifungalsTrichomoniasispH <4.5HyphaeBudding yeastspH >4.5TrichomonadspH >4.5Clue cellsPositive whiff testUlcersPruritic lesionsVaginalatrophyAtrophic vaginitisTopical estrogenBiopsyOral metronidazoleBacterialvaginosisFigure 41-8. Treatment


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Surgery_Schwartz. yeastspH >4.5TrichomonadspH >4.5Clue cellsPositive whiff testUlcersPruritic lesionsVaginalatrophyAtrophic vaginitisTopical estrogenBiopsyOral metronidazoleBacterialvaginosisFigure 41-8. Treatment algorithm for vulvovaginitis.Brunicardi_Ch41_p1783-p1826.indd 179418/02/19 4:34 PM 1795GYNECOLOGYCHAPTER 41rapidly to determine acuity, determine most the likely etiol-ogy of bleeding, and choose the appropriate treatment. Chronic AUB is abnormal uterine bleeding present for most of the previ-ous 6 months.The many causes of AUB are further divided into two cat-egories: structural causes and nonstructural causes. Structural causes include polyps, adenomyosis, leiomyomata, and malig-nancy. Nonstructural causes can include coagulopathy, ovulatory dysfunction, endometrial effects, and iatrogenic causes. Clini-cal screening for underlying disorders of hemostasis is recom-mended in women with heavy menses since menarche, and other risk factors such as bleeding with dental work, epistaxis one or