Page iiiAtlas of Gynecologic OncologySecond EditionEdited byJ Richard Smith, MB ChB, MD, FRCOGConsultant and Honorary Senior Lecturer in GynaecologyWest London Gynaecological Cancer Centre,Hammersmith Hospitals NHS TrustLondon, UKAdjunct Associate Professor of GynecologyNew York University School of MedicineNew York, USAGiuseppe Del Priore, MD, MPH, FACOGVice PresidentNew York University Downtown Hospital,New York, USAAssociate Professor, Albert Einstein College of Medicine,New York, USAJohn P Curtin, MBA, FACOG, MDStanley Kaplan ProfessorChairman Ob. GynNew York University School of MedicineNew York, USAJohn M Monaghan, MB ChB, FRCS(Ed), FRCOGWhitton GrangeWhittonNorthumberland, UKWith artwork byDee McLeanJoanna CameronLONDON AND NEW YORKPage 66impossible. Antibiotic prophylaxis is given if there is any evidence or suspicion of a urinary tractinfection.Flexible cystoscopy is usually carried out in the endoscopy suite under local anesthesia. Lignocaine(lidocaine) gel inserted into the urethra acts as both lubricant and local anesthetic agent. If possible thepatient should void prior to examination to ensure the bladder is empty.InstrumentationRigid cystoscopeThe rigid cystoscope (Figure 4) is composed of a sheath, a bridge and a telescope: it is 30 cm long. Thesheath has both an inlet and an outlet port for irrigation and is attached to the bridge with a watertightlock. The endoscope is introduced into the sheath through the bridge, and is also fitted with a watertightlock. The telescope comprises a hollow metal cylinder containing a series of solid rod lenses and amagnifying eye-piece. In front of the eye-piece is a pillar connected to a fiberoptic light source whichtransmits light to the visual field. The bridge has one or two other ports for the introduction of biopsyforceps and electrodes, and a director which allows the passage of a ureteric catheter and itsadvancement into the ureteric orifice. Endoscopes with viewing angles of 0, 30, 70 and 90 areavailable.Flexible cystoscopeThe flexible cystoscope (Figure 5) is 3540 cm long and consists of a control head with eye-piece andcon-Figure 4Rigid cystoscopeFigure 5Flexible cystoscopetrols, a multichannel flexible shaft and a controllable tip. The flexible shaft contains fiberoptic channelscarrying the optics and light source to the visual field, an irrigation channel and a biopsy channel.Movement of the tip occurs in one plane and ranges from 145 to 180, controlled by a deflecting leveladjacent to the eye-piece.Operative procedureRigid cystoscopeThe patient is placed on the operating table in the lithotomy position. The cystoscope sheath is lubricatedand introduced into the urethra. The female urethra is about 4 cm long and has a relatively uniformcaliber from the meatus to the bladder outlet. Upon entering the bladder the telescope is removed toallow the residual urine and irrigant to drain from the bladder: this may be sent for cytological andbacteriological analysis. Approximately 50 mL of saline is inserted and the fundus of the bladder isidentified by finding the air bubble. With incomplete distension the bladder mucosa appears rugated, butas the irrigant fluid distends the bladder the mucosa becomes smooth. The ureteric orifices are visualizedon the interureteric ridge at the superolateral corners of the trigone (Figure 6). By regular sweeping ofthe cystoscope backwards and forwards and rotation of the endoscope the entire bladder mucosa can bevisualized. Views of the anteroinferior bladder are obtained by suprapubic compression with the hand.At the completion of the examination, the irrigating fluid is evacuated from the bladder by removing thetelescope andfile:///N|/download/www.netlibrary.com/nlreader/nlReader.dll@BookID=115177&FileName=Page_66.html11/23/2006 1:20:50 PMPage 67Figure 6Ureteric orificesthe instrument is slowly withdrawn. A bimanual examination of the pelvis is performed after theprocedure.Bladder biopsyBladder biopsy (Figures 7, 8) is the procedure most commonly performed during cystoscopy. Biopsyforceps are introduced down the cystoscope sheath via a port in the bridge, sometimes together with adiathermy wire. This allows cup biopsies of the mucosa to be taken. If required, the biopsy sites areFigure 7Bladder biopsyFigure 8Bladder biopsythen cauterized with diathermy to prevent excessive bleeding.Ureteric catheterization and stentingThe instrumentation and stenting of ureters should only be performed by clinicians such as gynecologiconcologists trained in this procedure since it is easy to damage the ureteric orifices and ureters. Uretericcatheterization and the placement of double J stents is achieved with the 30 telescope. There is a specialport for the introduction of the stents which can be directed towards the ureteric orifices. A floppytipped,Teflon-coated guide wire is first placed into the ureteric orifice and advanced under fluoroscopiccontrol into the renal pelvis. The double J stent is slid over the guide wire through the channel of thecystoscope and into the ureter (Figure 9). The stent is radio-opaque and its position is monitored byfluoroscopic control. Excessive force used in insertion of the guide wire or stent should be avoided. Theproximal and distal ends curl to form a J shape when they are correctly placed in the renal pelvis andbladder respectively.Flexible cystoscopeThe patient is placed on the operating table or bed in the frog-leg position. The cystoscope is lubricatedand introduced into the urethra. The end of the cystoscope is passed into the bladder and deflectedupwards. The midline of the anterior bladder is examined byfile:///N|/download/www.netlibrary.com/nlreader/nlReader.dll@BookID=115177&FileName=Page_67.html11/23/2006 1:20:51 PMPage 68withdrawing the instrument until the bladder outlet is encountered. The cystoscope is then pushed backinto the bladder, rotated 30 and withdrawn again. This process is continued until the entire bladder hasbeenFigure 9Introduction of the double J stentinspected. Biopsy of the bladder mucosa can also be achieved by the passage of biopsy forceps down theinstrumental channel of the cystoscope.Postoperative careNo special postoperative measures are needed.BibliographyCalne RY, Pollard SG (1992) Operative surgery. London: Gower.Carter DC, Russell RCG, Pitt HA (1996) Atlas of general surgery, 3rd edn. London: Chapman & Hall.Cotton PB, Williams CB (1990) Practical gastrointestinal endoscopy, 3rd edn. Oxford: Blackwell.Jackson E, Fowler JR (1992) Urological surgery. Mastery of Surgery series. New York: Little, Brown.Reuter HJ (1987) Atlas of urological endoscopy: diagnosis and treatment. New York: Thieme. Page 696Ovarian tissue cryopreservation and transplantationtechniquesErkan BuyukKutluk H OktayIntroductionModern improvements in cancer treatment regimens using aggressive chemotherapy radiotherapy, aswell as bone marrow transplantation, can result in cure rates exceeding 90% for many cancers (Baird etal. 1999). However, this success has been accompanied by loss of fertility and premature menopause inmany women cured of their disease. Ovarian cryopreservation and transplantation is one of the optionsaimed to preserve fertility in women who face a threat to their fertility. Discovery of moderncryoprotectants and progress in cryopreservation techniques led to successful cryopreservation ofgametes, embryos and ovarian tissue. However, there is significant room for improvement inrevascularization of tissues after auto-transplantation, as nearly two thirds of the ovarian reserve is lostduring the initial ischemic state after grafting (Morales et al. 1995, Imthurn et al. 2000, Demirci et al.2001).Ovarian tissue cryopreservationOvarian tissue cryopreservation for future transplantation can be done in cancer patients as well as forother benign conditions where chemotherapy, radiotherapy, or surgically induced ovarian failure isanticipated. Table 1 summarizes the indications for ovarian tissue banking.Tissue harvestingAs long as there is no contraindication, ovarian tissue is collected via laparoscopy In adult patients, wegenerally remove one ovary to obtain a large reserve of primordial follicles. However, in pediatric agegroups, a large cortical biopsy may be enough since their ovaries harbor a larger number of follicles thanthePage 70Table 1 Indications for ovarian cryopreservation and transplantation1. Cancer patientsBreast cancer (stage 0III)Cervical cancerChildhood cancers Hodgkins lymphoma non-Hodgkins lymphoma (except Burkitt lymphoma) Osteosarcoma Ewings sarcoma Wilms tumor2. Bone marrow transplant patientsAplastic anemiaSickle-cell anemiaAutoimmune and immunodeficiency diseases (e.g. rheumatoid arthritis)3. Autoimmune diseasesCollagen vascular diseases (e.g. SLE)Acute glomerulonephritisBehets disease4. Adjunctive oophorectomyRecurrent breast cancerEndometriosis5. Benign ovarian tumorsRecurrent cystsEndometriosis6. Prophylactic oopherectomyBRCA-1 or -2 mutation carriersSLE, systemic lupus erythematosus.adult ovary (Newton et al. 1998). The whole ovary or ovarian cortical pieces are removed by alaparoscopic approach using a 5 mm scope inserted in the umbilicus and 5 mm and 12 mm trochars inthe lower quadrants. Use of electrocautery is not recommended in order to avoid damage to ovariancortex containing the follicles. The ipsilateral fallopian tube is left intact to allow a spontaneouspregnancy to occur in case an orthotopic transplantation is performed in the future. An endoscopicspecimen bag is used to remove the ovary through the 12 mm trocar; the trocar is pulled out and thespecimen is delivered through the 12 mm incision. This incision may need to be widened to extract alarge ovary.Figure 1Preparation of ovarian tissue for cryopreservation. The ovary is bivalved through its hilum.Note that the primordial follicles are located predominantly in the cortexProcessing of the ovarian tissueThe aim of processing ovarian tissue before cryo-preservation is to obtain ovarian pieces small and thinenough for the cryoprotectants to easily permeate .The sample is transported to the laboratory on ice inLeibovitz L-15 medium. In the case of a whole ovary, it is bivalved through its hilum (Figure 1) and thecortexFigure 2The cortex is dissected from the stromaPage 71is separated from the medullary portion (stroma) using a number 10 blade (Figure 2). This step isundertaken because the primordial follicles are contained in the cortical portion and the medullaryportion may decrease tissue permeation of cryoprotectants. The cortex is then divided into 1051 mmstrips using a no. 10 or 11 blade (Figure 3). The preparation is performed under a laminar flow hood andthe tissue is kept in the medium throughout the process. The cortical pieces are then put in cryovialscontaining 1.5 ml of ovarian freeze solution (1.5 M 1,2 propanediol, 20% patients own serum and 0.1M sucrose in Leibovitz L-15 medium).Cryopreservation and thawingThe cryovials are kept in ice for 30 minutes for the equilibration of the cryoprotectants.Cryopreservation is performed using a slow freeze protocol in a programmable freezer. The pieces arecooled to 7C and seeded at this temperature. They are then cooled to 140C and plunged into liquidnitrogen (Oktay 2001).Thawing is done by a rapid thaw protocol in a 30C water bath, followed by washing the tissues indecreasing gradients of cryoprotectant (Oktay 2001).Figure 3The cortex is divided into 1051 mm stripsOvarian transplantation techniquesBefore performing ovarian transplantation, the risk of reseeding occult cancer cells should be kept inmind and the decision to perform ovarian transplantation should be made accordingly. Table 2summarizes the risk of ovarian involvement in different cancers. For instance, the risk of ovarianinvolvement is higher in leukemia and neuroblastoma patients, compared to lymphoma or Wilms tumorpatients.Transplantation can be done using an orthotopic or heterotopic approach. In orthotopic transplantation,the tissue is placed in the ovarian fossa (Oktay and Buyuk 2002). Although spontaneous pregnancy canin theory be achieved using this technique, the procedure is technically more challenging, and whenthere is a higher likelihood of ovarian involvement with cancer, it may be less desirable to graft ovariantissue retroperitoneally. In heterotopic transplantation, the tissue is grafted into a place other than theovarian fossa. The operation is done under local anesthesia and follow-up is easier with heterotopictransplantation.Table 2 Risk of metastases to ovaries in various cancersHigh riskLeukemiaNeuroblastomaBurkitt lymphomaModerate riskBreast cancerStage IVInfiltrative lobular histological subtypeAdenocarcinoma/adenosquamous carcinoma of the cervixColon cancerLow riskBreast cancerStages IIIIInfiltrative ductal histological subtypeSquamous cell carcinoma of the cervixNon-Hodgkins lymphomaHodgkins lymphomaWilms tumorEwings sarcomaNongenital rhabdomyosarcomaOsteogenic sarcomafile:///N|/download/www.netlibrary.com/nlreader/nlReader.dll@BookID=115177&FileName=Page_71.html11/23/2006 1:20:55 PMPage 72However, patients will always need an in vitro fertilization (IVF) procedure in order to conceive (Oktayet al. 2001a, b). In case of cancer recurrence, tissue sampling and removal will also be easilyaccomplished. The risk and significance of recurrent cancer at the transplant site are unknown.Pelvic orthotopic transplantationFollowing thawing and washing, the ovarian pieces are placed in a petri dish containing transportmedium, and transported on ice to the operating room. In the operating room, 60 vicryl is used to stringthe strips by passing the needle between the cortex and the stroma of each strip under a microsurgicalmicroscope (Figure 4). Several strings are formed depending on the number of the strips, and they arethen anchored to a Surgicel frame (Ethicon, Somerville, NJ). 10 vicryl is used on the sides to furtherstrengthen this frame. 0 vicryl sutures are then tagged to the apex and the base. Synchronously, thepatient is anesthetized, and three trocars are inserted: an 11 mm one in the umbilicus, a 5 mm one in theright lower quadrant, and a 13 mm one (with fascia anchor) suprapubically. Using sharp and bluntdissection, a pocket is created in the ovarian fossa, posterior to the broad ligament, superior to theureters, and inferior to iliac vessels inFigure 4The strips are strung on to 60 vicrylFigure 5The graft is loaded retrogradely into the 13 mm trocarthe supine position. The graft is then loaded retrogradely, into a 13 mm trocar (Figure 5), which isreinserted in the fascia anchor suprapubically. Pulling on the leading suture, the graft is dropped in thepelvis. The leading suture is then placed in the most dependent portion of the pocket, approximately 1cm above the ureter, and the needle is passed through the peritoneum into the pelvic cavity (Figure 6).By pulling on this suture, the graft is wedged in the pelvic pocket. Next, the base suture is passedthrough the upperFigure 6The leading suture is placed in the most dependent portion of the pelvic pocketfile:///N|/download/www.netlibrary.com/nlreader/nlReader.dll@BookID=115177&FileName=Page_72.html11/23/2006 1:20:56 PMPage 73Figure 7The graft is flattened and stretched against the pelvic side-wallFigure 8The pelvic peritoneum is closed with interrupted suturesedge of the peritoneal pocket. The graft is stretched and flattened against the pelvic side-wall by pullingthis suture from the intraperitoneal site (Figure 7). With an abundance of pieces, a second graft may beprepared and placed superior and caudal to the first one. Then, using an extracorporeal knot placementtechnique, the peritoneum is approximated with interrupted sutures (Figure 8). The base of the Surgicelframe is also included into the suture while closing the peritoneum to further secure the graft in place.The patient is given 150 IU/day of follicle-stimulating hormone (FSH) systemically for 7 days (Oktay etal. 2003). As beneficial effects on graft survival have been observed in animal studies (Richardson et al.1987). The patient is also given 80 mg per day aspirin for 7 days, and started on hormone replacementtherapy within 48 hours of the transplant, as it is thought that these treatments may enhance angiogenesis(Ries et al. 1999).Forearm heterotopic transplantationAfter thawing and washing as described previously, ovarian cortical strips are placed in phenol red-freeMinimum Essential Medium Alpha Medium (with L-glutamine, ribonucleosides anddeoxyribonucleosides, Invitrogen, cat. no. 41061029), supplemented with 20% of the patients ownserum and 10 g/mL cefotetan, and kept on ice. Then, each strip is tagged with 40 vicryl as describedpreviously (Figure 9). The needle is cut, and the cortical pieces are left in the medium until the surgicalsite is ready for transplantation. To create a pocket for the graft under the skin of the forearm, a 1 cmtransverse incision is made over the brachioradialis muscle, 5 cm below the antecubital fossa. If there isa cosmetic concern, the incision and the transplantation may be made more medially. A pocket is createdbetween the fascia and the subcutaneous tissues using blunt dissection (Figure 10). Since this area isrelatively vascular, attention must be given to avoid major bleeding. As the ovarian tissue will acquireits blood supply from these vessels, extensive cauterization should be avoided.Figure 9Each ovarian strip is tagged using 40 vicryl