[Uterine myomatosis with senile hematometra in a 101-year-old patient]

A 101-year-old patient presented with uterine myomatosis and bleeding associated with a large hematometra. An abdominal hysterectomy with adnexectomy was performed following an in-depth consultation with the patient and her daughter. The patient was discharged on the 12(th) postoperative day after a complication-free course. This case report demonstrates not only the current possibilities in the gynecological treatment of very old patients but also the hidden reserves in the gynecological care ot these women.

Vaginal foreign bodies in women in postmenopause and in senium

We report on three women, 81, 73 and 69 years of age, in whom foreign bodies had been introduced into the vagina either by the patients themselves or by somebody else. In all cases, medical help was needed to remove the object. In one patient the foreign body had remained within the vagina for 7 years. Only two of the three women admitted that the object had been introduced for sexual stimulation. Some papers are quoted that report on similar events, however, in younger patients. Our observations demonstrate the often problematical sexual situation of many old people.

[Acute torsion of hydrosalpinx. 2 cases after laparoscopic sterilization]

We report on two laparoscopically sterilised patients who presented with increasing lower abdominal pain and sonographically proven adnexal masses. The first patient, who had been sterilised two years ago, underwent primary laparotomy. The mass was found to correspond to the cystically altered distal part of the right sterilised tube being torquated twice. Standard salpingectomy was performed. On the second patient, sterilised ten years before presentation at our clinic, we performed laparoscopy because of the suspected diagnosis of a pyosalpinx. In this case we found a torsion of the ampullary part of the left tube, which was subsequently removed by laparoscopy.

[Colpohysterectomy. A contribution to gynecologic geriatric surgery]

From 1983 to 1992 we performed 70 interventions because of a total genital prolapse: 51 vaginal hysterectomies and four removals of the cervical stump, both combined with vaginectomy and fifteen vaginectomies of the prolapsed vaginal vault. Two patients underwent another procedure during the same anesthesia: mastectomy and treatment of an inguinal hernia respectively. The youngest patient was 59 years old and the oldest 89. Fifty-four patients were aged between 71 and 82. Thirteen women had worn a pessary before the operation. Fifty-one interventions took less than 75 minutes. Serious postoperative complications included myocardial infarction on postoperative day eight in one patient and bronchopneumonia and cardiovascular decompensation in a second patient. No case of relapsing prolapse has come to our knowledge so far. We hold hysterectomy combined with vaginectomy to be the treatment method of choice in women with total genital prolapse and no further desire of cohabitation. When performed by an experienced surgeon it is the method with the lowest potential of recurrence and therefore to be preferred to other procedures.

[Peripartal hysterectomy--definition, follow-up and risk]

39 peripartal hysterectomies from 1983 to 1993 were divided into three groups. Indication, post-operative development and complications were analysed. The first group contains the planned Caesarean section hysterectomies. The patients (n = 18) in this group hat the smallest blood loss and fewest complications. The second group includes the hysterectomies after Caesarean section without emergency (n = 8). The main reason was the rupture of the uterus without clinical signs during delivery. The complication rate of this group was also low. In the third group all operations were performed for vital risk of the patient (n = 13). Complications as placenta accreta (n = 8) or atonal bleeding of the uterus (n = 5) ended up in hysterectomy (eight after vaginal deliveries, five after Caesarean section). In this group we could observe a high blood loss as well as a high rate of complications. The prognosis of the patient depends on blood loss per time period, the dynamic of the bleeding. The mortality was higher in the group where patients needed a relaparotomy because of bleeding partially as a cause of clotting disorders. The most important task is to prevent shock situations by early sufficient blood transfusion. Because of the higher mortality of relaparatomy selective angiographic arterial embolisation should be considered.

[Gynecologic interventions in the 10th decade of life]

We report on 28 surgical procedures performed between 1978 and 1992 performed on patients aged 90 years or older. 18 of them had a malignant tumour (11 mamma, 2 corpus, 3 vulva and 2 ovarian cancer), one had an ovarian cystoma. Three patients suffered from pelvic relaxation, four had postmenopausal bleeding, one vulvar dystrophy and one patient suffered from pyometra. Four laparotomies, three vaginal hysterectomies with colporrhaphy, four minor operations of the vulva, six curettages and eleven mammary operations were performed. During the surgical procedures, none of the patients died, whereas two patients died some time after the operation: so-called hospital mortality. The survival of the other patients was comparable to that of their age group. Two patients died of gynaecological diseases. After the surgical procedure, 21 patients reattained their preoperative level of health. 23 were satisfied with the result of the operation because of improvement of their complaints. If surgery in the aged allows the patients to lead a comfortable life, the operational risks can be justified.

[Metastatic ovarian melanoma in a 26-year-old patient]

In a 16 year old patient a superficially spreading malignant melanoma had been excised from the left temple. Ten years later, she represented with lower abdominal pain. On examination cystic adnexal masses were found and median laparotomy was performed. Intraoperatively bilateral polycystic, dark-coloured ovarian tumors were found, each measuring about 10 x 10 x 10 cm. Hysterectomy with bilateral salpingo-oophorectomy and resection of the great omentum was performed. Uterus and ovaries weighed 3.480 g. At microscopic examination large metastases of a pigmented melanoblastoma were found in both ovaries. Two months after surgery she succumbed to multiple cerebral metastases. For primary ovarian melanoma radical surgery with lymphonodectomy is mandatory. The operation is to be followed by immuno- and chemotherapy. In case of metastatic melanoma of the ovaries individual decisions concerning the extent of the surgical procedure are to be made. In any case, however, bilateral salpingo-oophorectomy should be performed, preferably combined with hysterectomy.

[Mortality and fatalities after cesarean section in West Berlin 1975 to 1989]

From 1975 till 1989 246 621 deliveries were registered in West-Berlin, 29,257 of which were caesarean sections. 41 cases of maternal death appeared. 19 women succumbed after vaginal delivery, 22 after caesarean section. Thus, during the 15 years of observation, mortality after caesarean section was 0.75% (1 case of maternal death on 1330 caesarean sections), whereas lethality--death due to surgical or anesthetical complications--was 0.41% (1:2438). At the end of the 80ies lethality of caesarean section was three-fold higher than of vaginal delivery.

[Cesarean section in an 11-year-old girl]

We report about a term pregnancy in an eleven year old girl (51 kgs, 152 cm). At the end of the second stage of labour, the pregnancy was terminated by caesarean section for relative disproportion. The child was a healthy boy (3080 g, 53 cm). The mother accepted the child in spite of severe problems. She left the hospital on the 13th postoperative day.

[Magnetic resonance tomography in the differential diagnosis of ovarian tumor and mucocele of the appendix]

Ultrasonography in a 73-year-old woman revealed two cystic structures in the region of the right adnexa. Magnetic resonance imaging suggested two morphologically distinct, space-occupying lesions, findings confirmed at operation and histological examination of the surgical specimen, which demonstrated a serous cystadenoma of the right ovary and a mucocele of the appendix.

[Extrauterine pregnancies following "abortion" in cases with no indication of intrauterine pregnancy]

287 women underwent surgery for ectopic pregnancy from January 1, 1979 to December 31, 1985. Prior to laparotomy, seven patients (2.4%) had applied for an induced abortion elsewhere in the absence of evidence of an intact intrauterine pregnancy. During these interventions, histological examination of the scraping was only in two cases. Despite histological findings, should one patient was not advised to present for inpatient clarification. The other patient had to be hospitalized at our clinic before a histological finding was available. During operation in 5 patients, we found tubal rupture with resultant hemoperitoneum of 1500 ml to 3000 ml. Tubal abortion occurred in the remaining two cases. These observations substantiate the absolute necessity to undertake routine histological examinations of the material obtained at abortion in every case.

[Spontaneous cecum perforation following cesarean section]

There is a certain risk of paralytic distension of the bowel, especially of the coecum, during the initial post-operative days following caesarean section. As can be seen from the overview presented, the possible result is spontaneous perforation of the coecum, which frequently has lethal consequences. Early differential diagnostic consideration for a mother exhibiting early warning post-caesarean symptoms can be life saving. We would recommend as prophylaxis early bowel stimulation with a laxative already on the second day following surgery. By distension of the coecum over 9 cm, as measured by sonography, decompression using either coloscopy or even coecostomy is recommended. Ischemic damage of the intestinal wall, as a result of excessive distension, is the main etiological factor for spontaneous perforation. The declining post partum oestrogen levels and resulting decreased parasympathetic tone, as well as the preceding anaesthesia account for the paralytic bowel symptoms.

[Cervix cytology and primary malignancies of the gastrointestinal tract]

During the cancer check-up of a 46-year-old woman a PAP V was diagnosed in the cervical scrapings. The atypical cells of the abrasion specimens from the corpus uteri arouse strong suspicion of malignancy. Connected with the clinical data, this finding primarily indicated a metastatic involvement of the inner genitals. This suspicion was confirmed by exploratory surgery laparotomy. A large tumor was found intraoperatively which was occupying the entire stomach. Concurrently, a diffuse peritoneal carcinomatosis was found with involvement of the left adnexae in the sense of a Krukenberg's tumor.

[A lymphogranulomatosis simulating an ovarian tumour (author's transl)]

A case of lymphogranulomatosis involving the left broad ligament in a 68-year-old patient is reported. The lymphogranuloma with the extent of two fists presented like an immobile ovarian tumour on palpation. An abdominal hysterectomy with bilateral salpingo-oophorectomy and lymphnode resection was performed. No complications occurred during the postoperative course. Haematologic treatment was subsequently initiated.

[New aspects pertaining to the Surgical Treatment of genital cancer in elderly women (author's transl)]

Between 1960 and 1969, 7150 major operations have been performed in the gynecological departements of West-Berlin on female patients of 60 years of age or more. Of 6658 cases the case-history was at our disposal. In contrast to reports in literature, the largest group was that of 3111 malignant tumors (46.7%). The postoperative mortality of the entire group was 7.7%, in cases of malignant tumors 12.1%. Discussion on surgical methods for the most frequent gynecological malignomas, and on possibilities to reduce the postoperative mortality, as well as on some aspects pertaining to the gynecological geroprophylaxis.

[Retroperitoneal diseases and geriatric-gynecologic laparatomy (author's transl)]

24 cases are described in which retroperitoneal processes were operated on for primarily gynecologic reasons in women of at least 60 years of age. They include 6 sarcomas, 3 neurinomas, 1 cyst, 1 fibroma, 1 lipoma, 1 congenital sacciform kidney, 1 hydronephrosis, 3 pancreatic carcinomas, 2 renal carcinomas, 1 ureteral cyst and 4 metastases of various malignomas. These cases were gathered in 18 West Berlin Departments of Obstetrics and Gynecology during a 10-year period. The post-operative mortality rate was 37.5% (9 deaths); this is probably due to the relatively low incidence of symptoms and signs associated with retroperitoneal diseases and their anatomical localization. Finally, new procedures for the diagnosis of retroperitoneal tumors are indicated.

[Uterine myoma in geriatric surgical cases (author's transl)]

The following is a report on 189 cases involving surgical treatment of uterine myoma in women who were at least 60 years old. The cases were collected from 18 gynecological departments in West-Berlin over a 10-year period (1960-1969). 66 of these patients (38,1%) have never been pregnant, 17 (9,8%) had only abortions, while 90 (52,1%) had given birth to one or more children. In only 89 women (47,0%) the pre-operative diagnosis had been uterine myoma. The number of correct diagnosis prior to surgery decreased with increasing age of the patients. 47 patients had been completely asymptomatic; an additional 20 had shown no gynecological symptoms. Total hysterectomy including removal of the tubes and ovaries, which we consider the preferential method of treatment, was done in 105 cases (55,5%). Other surgical procedures were performed in 84 instances (44,5%). 8 registered deaths equal a post-operative mortality rate of 4,2%. Analysis of our cases contradicts the hypothesis regarding postmenopausal involution of uterine myoma. Removal of the uterus for myoma should not be considered a typical geriatric gynecological operation. In many instances it could have been performed at an earlier date; in some cases it even could have been avoided if all diagnostic procedures presently available had been utilized.

[Basic pathology of sigma and rectum in geriatric-gynaecological laparotomies]

This is a report on 49 women with sigmoiditis and 66 women with sigmoido-rectal carcinoma. These cases were collected in 18 women hospitals in West-Berlin over a period of 10 years, from 1960 until 1969. All patients were at least 60 years old. In most of these cases laparotomy was performed for gynaecological reasons. The post-operative mortality was 40.9%. It is pointed out that the whole spectrum of diagnostic procedures was not fully utilized; today laparoscopies and ultrasound are added when indicated. Inflammatory processes of the sigma as well as sigmoido-rectal carcinoma are typical geriatrical diseases that will increase with rising life expectancy thus constituting an important part of the differential-diagnostic section of geriatric gynaecology.