Parulekar SV
Nonpuerperal chronic inversion of the uterus is as much a rarity as a curiosity. Most of the clinicians go through a busy lifetime without ever seeing a case. There are fewer than a couple of hundred case reports in the world literature. It is curious that there were enough cases to go round in the past that Hippocrates wrote about it, Themison (50 BC) advised amputation of the bleeding and sloughing inverted corpus of the uterus, Soranus actually did it 150 years later, and methods were described for surgical correction of the inversion by stalwarts like Aran, Marion Sims, Barnes, Thomas, Browne, Kustner, Piccoli, Morisani, Spinelli, Haultain, Dobbin, and Huntigton. One wonders if any of them had sufficient number of cases to show the merits and demerits of any given method. It is equally doubtful if anyone in modern times has sufficient experience to recommend one method over another. The conditions which predispose to nonpuerperal chronic inversion of the uterus have not changed over years, because they are gynecological conditions which are not preventable, as can be said about obstetric inversions. Hence incidence of this condition has remained more or less constant over years, while obstetric inversions have declined. The diagnosis of this condition is not easy. In fact, the dictum ‘what looks like a chronic inversion of the uterus clinically will be anything but that’ is true even today. It will most probably be a leiomyomatous polyp, with or without uterine prolapse. With advances in imaging like computerized tomography and magnetic resonance imaging, the diagnosis of a chronic inversion is more likely to be made accurately. In this issue we present two cases, one of nonpuerperal chronic inversion which was diagnosed accurately with such imaging, and another which was falsely diagnosed so. Opinion is divided over the best method to treat such cases. I feel that a vaginal technique is preferable to an abdominal technique for a number of reasons. The first reason is that a chronic inversion is often associated with a neoplasm of the uterine fundus, most commonly a leiomyoma. It needs to be removed first, so that the inverted uterus can be put back in original shape and position. That can be done best by the vaginal route. The second reason is that the constricting of the cervix is low down and is approached more easily vaginally than abdominally. One ends up cutting a lot of wall of the uterine corpus before dividing the ring by the abdominal route. The third reason is that a trained gynecologist is more comfortable by the vaginal route and resorts to the abdominal route only when vaginal surgery cannot be done. Amongst the vaginal operations, Kustner’s operation is safer, because it involves dividing the cervical ring posteriorly, which is a lot safer than any operation that divides the ring anteriorly, with the inverted urinary bladder so close. Modern surgeons want to do everything by the endoscopic method, and there are a few reports of laparoscopic correction of chronic inversions. The vaginal route has the same advantages over the laparoscopic route as over the abdominal route. The only advantage of the laparoscopic route would be to make a correct diagnosis before cutting into any tissues, in case the imaging techniques have not helped make a correct diagnosis.
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