COMMUNICATIONS IN BRIEF
This section is suitable for reporting cases, results of therapeutic trials, and descriptions of new procedures or instruments. Reports should be limited to seven hundred words and two references. Use of an illustration or table requires a proportionate reduction in total words.
Avoiding ureteral damage in pelvic surgery for ovarian remnant syndrome JONATHAN S. BEREK, M.D., M.M.Sc. PHILIP D. DARNEY, M.D. CARL LOPKIN, M.D. DONALD PETER GOLDSTEIN, M.D.
Department of Obstetrics and Gynecology, l--laruard l•.,fedical School and Boston Hospital for Women, Boston, Massachusetts
THE ovA R rAN remnant syndrome is an unusual complication of abdominal hysterectomy and presumptive bilateral salpingo-oophorectomy when performed for pelvic inflammatory disease, endometriosis, or ovarian cancer. 1 When re-expioraiion of the peivis is subsequently carried out for recurrent pain, as in the nvo cases described belo\v, there is a strong possibility that injury to the ureter will occur. In the first patient, the ureter was accidentally transected; in the second, preoperative evaluation and ureteral catheterization prevented inadvertent damage to that structure. Case 1. A 42-year-old white woman, gravida 5, para 3, therapeutic abortion 2, was admitted on January 31, 1977, with a chief complaint of intermittent right lower quadrant pain increasing in severity over several months. She had undergone a total abdominal hysterectomy, bilateral salpingo-oophorectomy, and lysis of adhesions in June, 1975, for chronic pelvic inflammatory disease and had done well postoperatively. On February 1, 1977, 20 months after the hysterectomy, the patient underwent a second laparotomy for recurrent pain presumably due to pelvic adhesions. After extensive
Reprint requests: Jonathan S. Berek, M.D., Department of Obstetrics and Gynecology, Harvard Medical School, Boston Hospital for Women, f21 Longwood Ave., Boston, Massachusetts 02115. 0002-9378/79/020221 +02$00.20/0
©
1979 The C. V. Mosby Co.
bowel and omental adhesions were lysed, a 4 em. cystic structure was encountered in the area of the right vaginal cuff. During the removal of the mass, the right ureter was transected and immediately repaired over a No. 6 stent catheter. A postoperative intravenous pyelogram and cystoscopy revealed that the ureteral anastomosis was intact. The Foley catheter was discontinued on postoperative day 12 and the stent was extracted through a cystoscope 28 days later. Pathologic examination of the cystic structure revealed normal ovarian tissue with a follicular cyst. Case 2. A 33-year-old white woman, gravida 2, para I, spontaneous abortion I, underwent a total abdominal hysterectomy and presumptive bilateral salpingo-oophorectomy for pelvic pain due to pelvic inflammatory disease in August, 1976. Extensive adhesions in the right adnexal region made the procedure arduous, but the patient did well postoperatively. The pathologist reported extensive tuboovarian adhesions. In December, 1977, 16 months later, the patient complained of several months of intermittent, right lower quadrant abdominal pain with I day of severe pain associated with nausea and vomiting. Physical examination revealed signs of peritoneal irritation, decreased bowel sounds, and a 5 em. mass at the vaginal a cuff on the right. The preoperative differential diagnoses included ureterolithiasis, bowel obstruction, or the presence of residual ovarian tissue. A preoperative abdominal roentgenogram showed a normal bowel gas pattern, and an intravenous pyelogram showed right ureteral obstruction about i inch below the pelvic brim (Fig. 1). A retrograde ureteral catheter (No.5 Fr., whistle tip) was passed into the ureter with some difficulty, but no stone or intrinsic obstruction was found. At laparotomy, there was blood in the peritoneal cavity and a leaking cystic mass was found on the right pelvic side wall amid dense adhesions. With the retrograde catheter in place. the ureter was easily identified adjacent and adherent to the mass, and thus the mass was excised from the pelvic wall while damage to the ureter was avoided. The pathologist reported ovarian tissue with a cystic 21 day corpus lutcum. A postoperative intravenous pyelogram was normal.
Preoperative evaiuation of the ureters is often considered unnecessary in benign conditions. even though 221
222
January I:,, 1979
Communications in brief
Am.
J.
Obslet. C ynecol.
REFERENCES
J. C .: Ovarian remnant syndrome, Obstet. Gynecol. 36:299, 1970. 2. Major, F. J.: Retained ovarian remnant ca using ureteral obstruction, Obstet. Gynecol. 32:748. 1968. I. Shemwell, R. E .. and Weed,
Diploid nuclear replacement in mature human ova with cleavage LANDRU~
B . SHETTLES. M.D. , PH.D. ,
F.A.C.S .. F.A.C.O.G .. F.R.S.H.
Gi/Jnrd i\!lemorial HosjJilal. lnr.. Rmuloljih, l"rnnont
Fig. I. Preoperative intravenous pyelogram from case 2. showing right ureteral obstruction near the pelvic brim.
various methods of avoiding ureteral damage are frequently employed in other situations, especially inradical pelvic surgery for cancer. Remnant ovarian tissue often is associated with extensive chronic adhesions which obscure the normal anatomy and make the ureters very difficult to identify. even when the retroperitoneal approach is used, as suggested by others. 2 The disparity in the outcome of the two cases presented here emphasize the value of a preoperative pyelogram and prophylactic ureteral catheterization in this condition . since the ureter may lie near or be adherent to the remnant ovarian tissue and ureteral obstruction may be present. When recurrent unilateral lower abdominal pain occurs several months after total abdominal hysterectomy and presumptive bilateral sal pin go-oophorectomy, one must consider the presence of remnant ovarian tissue . After exclusion of intrinsic ureteral pathology and bowel obstruction secondary to adhesions, residual tissue should be excised with the use of preoperative methods to avoid ureteral damage. The placement of an indwelling retrograde ureteral catheter prior to exploration for possible remnant ovarian tissue appears to be a useful technique to avoid ureteral injury .
AT CHERATIOt-: near the time of O\'Uiation human oocytes were aspirated from their follicles by means of an 18 gauge needle and syringe and inc ubated in the follicular fluid with four or five drops of tubal secretion added. in a moist chamber at 37° C. and atmospheric oxygen tension . After approximately three hours there was sufflcient dispersion of the corona radiata cells to cause denudation of the zona pellucida upon gentle aspiration and expression of the oocyte in a micropipette. The diameter of the zona pellucida measures I :10 to 150 fL from the outer surface a nd its thickness is R to l 0 fL . This pellucid membrane permits visualization ofthe brilliantly yellow yolk and the round nucleus with its single nucleolus (Fig. I). The first polar body indicates maturity. The zona pellucida possesses great elasticity and may be stretched, tease d , and pierced with glass microdissecting needles to great length before being torn and removed from around the ovum itselr (Fig. 2). It may also be pierced with a glass micropipette with a bore of 12 to 15 11-, and upon the withdrawal of the micropipette the site of puncture closes spontaneously. With removal of the zona pellucida, the flrst polar body as well as the egg proper is set free in an intact condition (Fig. :~), The vitelline membrane of the egg also may he pierced with the micropipette without disruption . Consequentlv the nucleus may be aspirated with the micropipette without leakage of ooplasm. As the nucleus is drawn into the micropipette it assumes an elongated, ellipsoid shape without breaking of the membrane. In view of the above, the intact. mature living ovum with the first polar bod y extruded may be enucleated (Fig. --!). Of many attempts to evacuate the nucleus from the ovum over the past three years, three were successful, with nuclear replacement. Because spermatogonia are Reprint requests: Dr. Landrum B. Shettles. Gifford Memorial Hospital. Inc .. Howell Pavilion . 44 S. Main St. , Randolph. Vermom 05060.
0002-9 378/ 79/ 020222+04$00AO/O © 1979 The C. V. Mosby Co.
This section is suitable for reporting cases, results of therapeutic trials, and descriptions of new procedures or instruments. Reports should be limited to seven hundred words and two references. Use of an illustration or table requires a proportionate reduction in total words.
Avoiding ureteral damage in pelvic surgery for ovarian remnant syndrome JONATHAN S. BEREK, M.D., M.M.Sc. PHILIP D. DARNEY, M.D. CARL LOPKIN, M.D. DONALD PETER GOLDSTEIN, M.D.
Department of Obstetrics and Gynecology, l--laruard l•.,fedical School and Boston Hospital for Women, Boston, Massachusetts
THE ovA R rAN remnant syndrome is an unusual complication of abdominal hysterectomy and presumptive bilateral salpingo-oophorectomy when performed for pelvic inflammatory disease, endometriosis, or ovarian cancer. 1 When re-expioraiion of the peivis is subsequently carried out for recurrent pain, as in the nvo cases described belo\v, there is a strong possibility that injury to the ureter will occur. In the first patient, the ureter was accidentally transected; in the second, preoperative evaluation and ureteral catheterization prevented inadvertent damage to that structure. Case 1. A 42-year-old white woman, gravida 5, para 3, therapeutic abortion 2, was admitted on January 31, 1977, with a chief complaint of intermittent right lower quadrant pain increasing in severity over several months. She had undergone a total abdominal hysterectomy, bilateral salpingo-oophorectomy, and lysis of adhesions in June, 1975, for chronic pelvic inflammatory disease and had done well postoperatively. On February 1, 1977, 20 months after the hysterectomy, the patient underwent a second laparotomy for recurrent pain presumably due to pelvic adhesions. After extensive
Reprint requests: Jonathan S. Berek, M.D., Department of Obstetrics and Gynecology, Harvard Medical School, Boston Hospital for Women, f21 Longwood Ave., Boston, Massachusetts 02115. 0002-9378/79/020221 +02$00.20/0
©
1979 The C. V. Mosby Co.
bowel and omental adhesions were lysed, a 4 em. cystic structure was encountered in the area of the right vaginal cuff. During the removal of the mass, the right ureter was transected and immediately repaired over a No. 6 stent catheter. A postoperative intravenous pyelogram and cystoscopy revealed that the ureteral anastomosis was intact. The Foley catheter was discontinued on postoperative day 12 and the stent was extracted through a cystoscope 28 days later. Pathologic examination of the cystic structure revealed normal ovarian tissue with a follicular cyst. Case 2. A 33-year-old white woman, gravida 2, para I, spontaneous abortion I, underwent a total abdominal hysterectomy and presumptive bilateral salpingo-oophorectomy for pelvic pain due to pelvic inflammatory disease in August, 1976. Extensive adhesions in the right adnexal region made the procedure arduous, but the patient did well postoperatively. The pathologist reported extensive tuboovarian adhesions. In December, 1977, 16 months later, the patient complained of several months of intermittent, right lower quadrant abdominal pain with I day of severe pain associated with nausea and vomiting. Physical examination revealed signs of peritoneal irritation, decreased bowel sounds, and a 5 em. mass at the vaginal a cuff on the right. The preoperative differential diagnoses included ureterolithiasis, bowel obstruction, or the presence of residual ovarian tissue. A preoperative abdominal roentgenogram showed a normal bowel gas pattern, and an intravenous pyelogram showed right ureteral obstruction about i inch below the pelvic brim (Fig. 1). A retrograde ureteral catheter (No.5 Fr., whistle tip) was passed into the ureter with some difficulty, but no stone or intrinsic obstruction was found. At laparotomy, there was blood in the peritoneal cavity and a leaking cystic mass was found on the right pelvic side wall amid dense adhesions. With the retrograde catheter in place. the ureter was easily identified adjacent and adherent to the mass, and thus the mass was excised from the pelvic wall while damage to the ureter was avoided. The pathologist reported ovarian tissue with a cystic 21 day corpus lutcum. A postoperative intravenous pyelogram was normal.
Preoperative evaiuation of the ureters is often considered unnecessary in benign conditions. even though 221
222
January I:,, 1979
Communications in brief
Am.
J.
Obslet. C ynecol.
REFERENCES
J. C .: Ovarian remnant syndrome, Obstet. Gynecol. 36:299, 1970. 2. Major, F. J.: Retained ovarian remnant ca using ureteral obstruction, Obstet. Gynecol. 32:748. 1968. I. Shemwell, R. E .. and Weed,
Diploid nuclear replacement in mature human ova with cleavage LANDRU~
B . SHETTLES. M.D. , PH.D. ,
F.A.C.S .. F.A.C.O.G .. F.R.S.H.
Gi/Jnrd i\!lemorial HosjJilal. lnr.. Rmuloljih, l"rnnont
Fig. I. Preoperative intravenous pyelogram from case 2. showing right ureteral obstruction near the pelvic brim.
various methods of avoiding ureteral damage are frequently employed in other situations, especially inradical pelvic surgery for cancer. Remnant ovarian tissue often is associated with extensive chronic adhesions which obscure the normal anatomy and make the ureters very difficult to identify. even when the retroperitoneal approach is used, as suggested by others. 2 The disparity in the outcome of the two cases presented here emphasize the value of a preoperative pyelogram and prophylactic ureteral catheterization in this condition . since the ureter may lie near or be adherent to the remnant ovarian tissue and ureteral obstruction may be present. When recurrent unilateral lower abdominal pain occurs several months after total abdominal hysterectomy and presumptive bilateral sal pin go-oophorectomy, one must consider the presence of remnant ovarian tissue . After exclusion of intrinsic ureteral pathology and bowel obstruction secondary to adhesions, residual tissue should be excised with the use of preoperative methods to avoid ureteral damage. The placement of an indwelling retrograde ureteral catheter prior to exploration for possible remnant ovarian tissue appears to be a useful technique to avoid ureteral injury .
AT CHERATIOt-: near the time of O\'Uiation human oocytes were aspirated from their follicles by means of an 18 gauge needle and syringe and inc ubated in the follicular fluid with four or five drops of tubal secretion added. in a moist chamber at 37° C. and atmospheric oxygen tension . After approximately three hours there was sufflcient dispersion of the corona radiata cells to cause denudation of the zona pellucida upon gentle aspiration and expression of the oocyte in a micropipette. The diameter of the zona pellucida measures I :10 to 150 fL from the outer surface a nd its thickness is R to l 0 fL . This pellucid membrane permits visualization ofthe brilliantly yellow yolk and the round nucleus with its single nucleolus (Fig. I). The first polar body indicates maturity. The zona pellucida possesses great elasticity and may be stretched, tease d , and pierced with glass microdissecting needles to great length before being torn and removed from around the ovum itselr (Fig. 2). It may also be pierced with a glass micropipette with a bore of 12 to 15 11-, and upon the withdrawal of the micropipette the site of puncture closes spontaneously. With removal of the zona pellucida, the flrst polar body as well as the egg proper is set free in an intact condition (Fig. :~), The vitelline membrane of the egg also may he pierced with the micropipette without disruption . Consequentlv the nucleus may be aspirated with the micropipette without leakage of ooplasm. As the nucleus is drawn into the micropipette it assumes an elongated, ellipsoid shape without breaking of the membrane. In view of the above, the intact. mature living ovum with the first polar bod y extruded may be enucleated (Fig. --!). Of many attempts to evacuate the nucleus from the ovum over the past three years, three were successful, with nuclear replacement. Because spermatogonia are Reprint requests: Dr. Landrum B. Shettles. Gifford Memorial Hospital. Inc .. Howell Pavilion . 44 S. Main St. , Randolph. Vermom 05060.
0002-9 378/ 79/ 020222+04$00AO/O © 1979 The C. V. Mosby Co.
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