Case Conference May 2nd 2012

02-Mei-2012, Divisi Ginekologi Onkologi RSCM

CASE CONFERENCE

May 2^nd, 2012

1 Inpatient

 

Mrs. E, 48 yo, P4, 4529464, Jamkesda

Cervical cancer stage II A post radical hysterectomy ( invasive to parametrium & left lymph node)

Vesicovaginal fistule

 

 

History

 

November  30^th , 2011

 

•         CC : vaginal bleeding since 2 years (referred by Bekasi Hospital)

•         Post coital bleeding (+)

•          Leucorrhoe (+),foul odor (+) since 5 years

•         Micturition and defecation wnl

•         Marital history: 1x

•         Obstetrical history: P4

 

 

PHYSICAL EXAMINATION

 

General status :  Compos mentis

BP 110/80 mmHg,  Pulse 84x/min,  RR 18x/min, T 36.7⁰ C

Conjunctiva    : pale -/-

Heart/lung     : wnl

Abdomen       : soupel

Extremities     : edema -/-

Lymph node     :no enlargement in supraclavicular, inguinal lymph node

 

Gynecological status (by consultant)

•      Inspection            : wnl

•      Inspeculo : exofitic mass size. 2x2.5x1 cm, vagina was smooth

•      Gyn RVT   : uterus N, exofitic mass size. 2x2.5x1 cm, vaginal wall was smooth, right parametrial was smooth, left parametrial was rigid, smooth rectal mucose

 

Laboratory :

CBC: 12/36,4/6660/323.000/92,2/30,4/33,0

SGOT/PT: 24/33   ur/cr: 23/0.6

RBG: 103   HBsAg: non Reaktif

 

 

US Fetomaternal  (01/12/11):

Cervical malignancy, exophytic type. Both parametrial free from invasion mass.

 

US Fetomaternal:

Cervical malignancy (bulky tumor), invasion until OUI, both parametria, posterior bladder wall

Paraaorta lymphnode enlargement and suspected metastatic on both parailiac lymphnodes.

 

Chest X-ray  (13/12/2011):

No sign of metastase

 

BNO-IVP (13/12/2011):

both renal function wnl, no sign of obstruction

 

Sistoskopi (11/01/2012):

Cystitis

 

Operative procedure (24/2/2012):

·      Radical hysterectomy

·      Bilateral pelvic lymphadenectomy

·      Repair Bladder ( by Urology Dept)à posterior bladder near trigonum

 

12/03/12:

PA result (1201592)

Margin of vaginal incision 1,3 and 5 mm free of tumor

Left pelvic lymph node (+) metastase

Invasion to left parametrial

 

Discussion with dr.Laila N, OBGYN:

Suggest to bladder training à if there is sensation to micturitrion in 3 days, educate patient to measure amount of spontaneous urinating and trans urethra residu.

 

16/3/2012

Patient start to trans urethra bladder training (helped by midwife)

 

26/3/2012

Patient couldn’t do spontaneous urinating à catheter, consult to physiotherapy

 

5/4/2012

Patient was came to poli with cc came out fluid from vagina à consult to urology dept.

 

26/04/2012

Blue methylen test à positif

 

01/05/2012

RVT: vaginal stump was smooth, palpated fistule on anterior vaginal wall, 4cm from introitus, Ø 2cm

 

 

Assesment

Cervical cancer stage II A post radical hysterectomy ( invasive to parametrium & left lymph node)

Vesicovaginal fistule

 

Plan :

Adjuvant radiation

Repair of vesicovagina fistule

 

Consideration

Whether repair first then continued with radiation or radiation first?