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RESUMEN El leiomioma parauretral es una neoplasia benigna con pocos casos descritos en la literatura. El leiomioma abarca el 5% de los casos de las masas parauretrales, ocupando el cuarto lugar como una de las causas menos frecuentes, después del divertículo parauretral. Se presenta el caso de una paciente de 43 años con antecedente de infección urinaria a repetición, con una masa de 8 cm en pared vaginal anterior de cuatro años de evolución. La cistoscopia fue normal y la ecografía mostró una lesión sólida parauretral. Se realizó resección por colpotomía sin complicaciones, con resultado de patología de leiomioma. Control postquirúrgico y uroflujometría normal. Dentro de las posibilidades diagnósticas ante una masa parauretral, el leiomioma debe considerarse. La sintomatología es variable, siendo los síntomas urinarios los más frecuentes. La ecografía y la resonancia son herramientas fundamentales y el manejo se basa en la resección quirúrgica, generalmente vía vaginal. MÉD.UIS.2021;34(2): 77-82.

ABSTRACT Introduction: Paraurethral leiomyoma is a rare benign neoplasm, with few cases described in the literature. Most of the data on prevalence are based on case series, the leiomyoma covers 5% of the paraurethral masses, occupying the fourth place as one of the less frequent causes, after parurethral diverticulum. Case: 43 years old patient with antecedents of recurring urinary infections and a previous 8 cm mass on the vaginal walls with 4 years of clinical evolution course. Cystoscopy was normal and ultrasound with a solid paraurethral injury. Colpotomy resection was performed without complications, resulting in leiomyoma pathology. Post-surgical control and normal uroflowmetry. Discussion and conclusion: leiomyomas should be considered as a possible diagnosis in case of a periurethral mass presence. Symptomatology is variable. The urinary symptoms are the most frequent as in this case. Ultrasonography and resonance are essential tools treatment are based on surgical resection which is usually vaginally. MÉD.UIS.2021;34(2): 77-82

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The objective of this study was to evaluate the feasibility of posterior colpotomy for the surgical treatment of tubal ectopic pregnancy in hemodynamically stable women. We performed a retrospective analysis of medical records obtained over a period of 18 months. Twelve cases were identified, with the following characteristics: mean gestational age, 7.7 weeks; mean serum ß-human chorionic gonadotropin level, 7,786 mIU/mL; and greater diameter of the mass, 15-69 mm. Treatment was successful in all cases. Salpingectomy was performed in 10 patients (83.3%) and salpingostomy, in 1 patient. The remaining patient only received peritoneal lavage, as the evidence of ectopic abortion with only a slightly dilated uterine tube was found during surgery. The mean surgical time was 42.5 minutes. In the analyzed cases, posterior colpotomy was found to be a feasible alternative method for the surgical treatment of tubal ectopic pregnancy in hemodynamically stable women.

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ABSTRACT Objective: To describe the safety of colpotomy in terms of intra- and post-operative complications in women taken to laparoscopy for the removal of benign masses. Materials and methods: Case series of patients with benign adnexal or uterine masses taken to laparoscopic surgery and removal of the specimen through colpotomy. The patients signed the informed consent. Patients with obliterated posterior cul-de-sac, narrow vagina, absence or uterus, deep endometriosis, inflammatory pelvic disease, masses of less than 4 cm, were excluded. Consecutive sampling was used. Sociodemographic, clinical, qualitative and quantitative variables were studied by means of a descriptive analysis of the data. The research study was endorsed by the ethics committee of the institution. Results: During the study period, 12 procedures for the removal of benign pelvic masses using posterior colpotomy were performed. Mean age was 34.3 years (IQR: 29-39,5). Of these cases, 50% were nulliparous women. Mean surgical time was 127 minutes (IQR: 90-150). There were no conversions to laparotomy, and there were no intra- or postoperative complications. Conclusions: Posterior colpotomy is an option that can be considered in the removal of benign pelvic masses of more than 5 cm in size.

RESUMEN Objetivo: Describir la seguridad de la colpotomía en mujeres llevadas a laparoscopia por masas benignas en términos de complicaciones intra y posoperatorias. Materiales y métodos: Serie de casos que incluyó pacientes con masas anexiales o uterinas benignas, sometidas a laparoscopia operatoria con extracción de la pieza quirúrgica mediante colpotomía, previo consentimiento informado. Se excluyeron pacientes con fondo de saco posterior obliterado, vagina estrecha, ausencia de útero, endometriosis profunda, enfermedad inflamatoria pélvica, masas menores de 4 cm, muestreo consecutivo. Se estudiaron variables sociodemográficas, clínicas, cualitativas y cuantitativas mediante un análisis descriptivo. La investigación fue avalada por el comité de ética médica de la institución. Resultados: Durante el periodo de estudio se realizaron 12 extracciones de masas pélvicas benignas por colpotomía posterior. La mediana de la edad fue de 34,3 años (Rango Intercuartílico - RIC: 29-39,5). El 50 % de las pacientes eran nulíparas. La mediana de tiempo quirúrgico fue de 127 minutos (RIC: 90-150). No se realizó ninguna conversión a laparotomía. No se presentaron complicaciones intra ni posoperatorias. Conclusiones: La colpotomía posterior es una alternativa por considerar en la extracción de masas pélvicas benignas cuando tengan un tamaño mayor a 5 cm.

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Resumen ANTECEDENTES La extracción de un mioma, posterior a la resección laparoscópica, puede ser: directa, mediante colpotomía posterior, minilaparotomía, morcelación intraabdominal estándar o eléctrica. La mayor parte de estas opciones suele requerir la colocación de un trocar de 10-12 mm o la ampliación de la incisión en la piel y fascia para extraer el tejido; esto implica desventajas estéticas y clínicas, como el riesgo de hernias incisionales. CASOS CLÍNICOS Se comunican tres casos de pacientes con diagnóstico de miomatosis de grandes elementos (7 cm el menor y 15 cm el mayor) en los que posterior a la miomectomía por laparoscopia se extrae la pieza quirúrgica íntegra mediante colpotomía posterior, con evolución posquirúrgica favorable y sin síntomas concomitantes. CONCLUSIÓN La extracción transvaginal mediante colpotomía posterior es una alternativa segura y efectiva para retirar piezas quirúrgicas porque la elasticidad de la vagina permite extraer de forma segura piezas grandes, y evitar así el uso del morcelador y sus posibles riesgos. Además, se evita ampliar las incisiones abdominales, lo que implica menor dolor posoperatorio, recuperación más rápida y mejores resultados cosméticos. La vía vaginal es segura, con mínimo riesgo de complicaciones y con mejores resultados posquirúrgicos comparada con el resto de las opciones de cirugía laparoscópica.

Abstract BACKGROUND The extraction of the myoma after laparoscopic resection can be done by: direct extraction, standard intra-abdominal morcellation, electric morcellation, extraction by posterior colpotomy or by minilaparotomy. Most of these options generally require placement of a 10-12 mm trocar and / or enlargement of the skin incision and fascia for tissue removal; In addition to the aesthetic disadvantages, it represents clinical implications such as the risk of incisional hernias. CLINICAL CASES We present 3 cases of patients with diagnosis of myomatosis of large elements, the smallest being 7 cm and the largest being 15 cm, in greater diameter, after the laparoscopic myomectomy the extraction of the complete surgical piece is performed through posterior colpotomy, presenting a favorable postoperative recovery, without associated symptoms. CONCLUSIONS The transvaginal extraction through posterior colpotomy represents a safe and effective alternative for the extraction of surgical pieces, the elasticity of the vagina allows the safe extraction of large pieces, avoiding the use of the morcellator and its possible risks; It also avoids expanding the abdominal incisions, associating to less postoperative pain, faster recovery and better cosmetic results. The vaginal route is a safe option with minimal risk of complications, and with better postsurgical results compared to the other options in laparoscopic surgery.

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Objetivo: Evaluar las ventajas de la técnica de esterilización tubaria por vía vaginal en pacientes que acudieron al servicio de Ginecología del Hospital Universitario de Caracas y Ambulatorio del IVSS Patrocino Peñuela Ruíz, de enero a noviembre de 2014. Métodos: Investigación tipo ensayo clínico multicéntrico, en 49 mujeres no puérperas en edad fértil que solicitaron la esterilización quirúrgica. Se realizó la técnica de colpotomía posterior para localizar las trompas y realizar la esterilización. Resultados: La edad promedio fue de 32,5 años. El 80 % tenía de 1 a 3 partos. El 12,2 % tenía una cesárea previa y dos el 16, 3 %. El tiempo promedio de intervención fue de 22,8 minutos y de pérdida sanguínea de 32,5 cm³, sin necesidad de hemoderivados. Las complicaciones intraoperatorias se presentaron en 6 % de los casos, ameritando laparotomía 2 casos. Se pudo demostrar que las adherencias retrasan el tiempo quirúrgico. Según la escala visual análoga (EVA), 53,1 % de las pacientes a las seis horas no tenía dolor y a las 12 horas había disminuido notoriamente en el 85,7 %. Conclusión: La esterilización quirúrgica por colpotomía es beneficiosa porque el tiempo quirúrgico es corto, el sangrado escaso, el dolor leve y las complicaciones bajas.

Objective: To evaluate the advantages of tubal ligation by colpotomy incision in patients who assisted to the Gynecology Unit of University Hospital of Caracas and Patrocino Peñuela Ruíz Hospital form January to November 2014. Methods: Multicentric clinical assay, performed in 49 patients of reproductive age who demanded tubal ligation. Posterior colpotomy was performed to access the Fallopian tubes. Results: Mean age was 32,5 years. Eighty percent had 1 to 3 vaginal deliveries. One previous C section was reported in 12 %, and 2 in 16, 3 %. Mean surgery time was 22,8 minutes, and the mean blood loss 32,5 cc; blood transfusión was not required. Intraoperatory complications were present in 6 % of cases, 2 of them required laparotomy. The presence of adherences was related to longer surgical time. According to the Visual Analogue Scale (VAS), 53,1 % of the patients had no pain 6 hours after the surgery, and pain decreased significantly in 85. 7 % of the patients 12 hours after the procedure. Conclusion: Tubal ligation by colpotomy is highly recommended due to the short surgical time and low rate of complications, blood loss and pain.

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OBJETIVO: Relatar o uso da colpotomia para o tratamento de gestações ectópicas. MÉTODOS: Estudo transversal retrospectivo. Foram incluídos todos os casos internados com suspeita clínico-laboratorial de gestação ectópica que não preenchiam critérios para tratamento medicamentoso com Methotrexato no período de fevereiro de 2007 a agosto de 2008. Foram analisadas variáveis demográficas, história ginecológica e características associadas ao tratamento foram obtidas através de revisão de prontuário. RESULTADOS: Dezoito mulheres foram incluídas no estudo. A média de idade foi de 27±5,2 anos. Todos os casos apresentavam gestação ectópica rota e todas as pacientes foram submetidas à salpingectomia parcial. O tempo cirúrgico variou de 30 a 120 minutos (média de 64,5 minutos), sendo contabilizado desde o momento de entrada da paciente na sala cirúrgica até o horário da saída. Nenhuma paciente apresentou infecção pós-operatória. O tempo médio de internação foi de 40± 14,3 horas. As medicações utilizadas no período pós-operatório foram semelhantes em todos os casos, sendo baseadas em anti-inflamatório não esteroide, dipirona, paracetamol e meperidina, conforme a necessidade. A dieta foi reintroduzida 8 horas após o término da cirurgia. CONCLUSÕES: A utilização da colpotomia no tratamento da gestação ectópica apresentou bons resultados, com ausência de complicações importantes e tempo de internação curto. O instrumental cirúrgico básico para a realização desse procedimento é relativamente comum a todos os hospitais, e a técnica cirúrgica é reprodutível.

PURPOSE: To report the use of colpotomy for the treatment of ectopic pregnancies. METHODS: This was a retrospective cross-sectional study conducted on all women hospitalized with a clinical-laboratory suspicion of ectopic pregnancy who did not fulfill the criteria for drug treatment with methothrexate, during the period from February 2007 to August 2008. Demographic variables, gynecologic history and characteristics associated with treatment were obtained by reviewing the medical records. RESULTS: Eighteen women were included in the study. Mean age was 27±5.2 years. All patients presented ruptured ectopic pregnancy and all were submitted to partial salpingectomy. Surgical time ranged from 30 to 120 minutes (mean: 64.5 minutes) calculated from the moment when the patient entered the operating room to the moment when she left it. No patient presented postoperative infection. Mean time of hospitalization was 40±14.3 hours. The medications used during the postoperative period were similar in all cases, being based on nonsteroid anti-inflammatory drugs, dipyrone, paracetamol and meperidine, as needed. The diet was reintroduced 8 hours after the end of surgery. CONCLUSIONS: The use of colpotomy in the treatment of ectopic pregnancy showed good results, with the absence of important complications and a short hospitalization time. The basic surgical instruments needed for this procedure are relatively common to all hospitals, and the surgical technique is reproducible.

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Antecedentes: La esterilización tubaria transvaginal, es una forma de abordar la esterilización quirúrgica, en la actualidad poco popularizada. Objetivo: Evaluar la colpotomía posterior como vía para la esterilización tubaria. Método: Análisis de 100 fichas clínicas de mujeres multíparas en estado no puerperal, a solicitud voluntaria de esterilización. Resultados: Hubo un 3 por ciento de complicaciones. Conversiones en el 4 por ciento y un tiempo operatorio promedio de 25,2 minutos. Conclusión: La colpotomía posterior es una buena alternativa quirúrgica para efectuar la esterilización tubaria, con baja morbilidad.

Background: Transvaginal tubal sterilization is a way for surgical sterilization, that currently is not widely used. Objective: To evaluate the posterior colpotomy as a pathway for tubal sterilization. Method: Analysis of 100 medical records of multiparous women non puerperal state, who request voluntary sterilization. Results: There were 3 percent of complications, 4 percent of conversions and a mean operative time of 25.2 minutes. Conclusion: The posterior colpotomy is a good surgical alternative to perform tubal sterilization with low morbidity and cost.

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Cada año miles de mujeres experimentan un episodio de enfermedad inflamatoria pélvica (EIP) aguda y estas son sometidas a un creciente riesgo de molestias crónicas en el hemiabdomen inferior, embarazo ectópico, dolores por adherencias, infertilidad tubárica, dispareunia, el piosálpinx, los abscesos tuboováricos y muchas de ellas requerirán intervenciones quirúrgicas. Las complicaciones y secuelas de la EPI son penosamente graves para la enferma, la familia y la sociedad. Aproximadamente un 12 por ciento de mujeres se convierten en infértiles después de un simple episodio, casi un 25 por ciento después de dos episodios y casi un 50 por ciento después de tres episodios. Su diagnóstico y tratamiento tiene también un impresionante costo económico. Se realizó una revisión del tema con el objetivo de aumentar nuestros conocimientos y mejorar la calidad del diagnóstico, complicaciones, tratamiento y manejo en general de las pacientes con enfermedad inflamatoria pélvica

Every year thousands of women has an event of acute pelvic inflammatory disease (PID) leading to a increasing risk of chronic discomforts in the lower hemi-abdomen, ectopic pregnancy, pains due to adhesions, tubal infertiliy, dyspareunia, the pyosalpinx, tubo-ovarian and more of then requiring surgical interventions. The complications and sequelae of PIE are distressing for patients, the family and the society. Approximately a 12 percent of women overcomes infertile after a single event, almost a 25 percent after two events and almost a 50 percent after three events. Its diagnosis and treatment had a high economic budget. This subject was analyzed to increase our knowledge and to improve the diagnosis quality, complications, treatment and management in general of patients presenting with pelvic inflammatory disease

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We present the concept of natural orifice surgery and of scarless operations, with their access routes, their multidisciplinary character, and challenges to their development. We point out the intra- and postoperative advantages. We emphasize the use of the vaginal route and posterior colpotomy in the application of natural orifice surgery in vaginal hysterectomies and surgical access to adnexa, which includes tubal ligation. We highlight the need for mastering these surgical modalities, which can bring great advantages to patients in Brazil.

Apresentamos, neste artigo, o conceito das cirurgias por orifícios naturais e das cirurgias "sem cicatriz", as suas vias de acesso, seu caráter multidisciplinar e os desafios de seu desenvolvimento. Apontamos as vantagens intra e pós-operatórias. Enfocamos a via vaginal e a colpotomia posterior na aplicação das cirurgias por orifícios naturais em histerectomias vaginais e acessos cirúrgicos aos anexos nos quais se inclui a laqueadura tubárea. Reforçamos a necessidade de nos inteirarmos destas modalidades de cirurgia que poderão trazer grandes vantagens para as pacientes no Brasil.

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O presente estudo descreve uma técnica para obtenção de fragmentos luteais empregando-se a colpotomia. Os animais foram submetidos à anestesia epidural e no fórnix vaginal e, após dez minutos, realizou-se uma incisão no fundo vaginal com lâmina de bisturi, bem como procedeu-se à dissecção do tecido, até que fossem possíveis o acesso à cavidade pélvica e a tração dos ovários para o interior vaginal. Realizou-se, então, a colheita de biopsia luteínica, com o auxílio de uma pinça do tipo Yomann. Sinais de dor e estresse foram observados apenas em duas colheitas durante a incisão no fundo vaginal, a tração do ovário ou durante a biopsia luteínica. Contudo, esses sinais foram observados em dez colheitas durante a dissecção da parede vaginal e peritôneo. Registrou-se a ocorrência de ataxia em 38,81% colheitas, a qual esteve relacionada, normalmente, a um procedimento mais longo. As ataxias podem ser divididas em leve (15/26), moderada (6/26) e severa (5/26). A avaliação da presença de adesões ovarianas ipsilaterais à incisão realizou-se apenas até a quarta colheita, sendo notadas em dezesseis colheitas. O protocolo empregado mostrou-se um método seguro e eficiente na obtenção de fragmentos luteais. A baixa incidência de aderências permite o uso consecutivo das fêmeas sem interferência nas ovulações e colheitas subsequentes.(AU)

The present study describes a technique to obtain consecutive luteal samples by colpotomy. The animals received an epidural anesthesia and local anesthesia (vaginal vault) and after ten minutes the vaginal vault was incised with a scalpel blade and tissue was dissected to provide access to the pelvic cavity and to retract the ovary into the vagina. Then, a luteal biopsy was performed with a Yomann biopsy nipper. Signs indicative of pain and stress during the vaginal vault incision, traction of ovary or luteal biopsy were observed only in two collections. However, these signs were observed in ten collections during dissection of the vaginal wall and peritoneum. The occurrence of ataxia was observed in 26 collections and it was usually related to a longer duration of the procedure. Ataxia could be divided in light (15/26), moderate (6/26) and severe (5/26). The occurrence of ovarian adhesions ipsilateral to the incision was evaluated only in the initial four collections. Adhesions were present in 16 collections. The protocol described above provided a safe and efficient method to acquire luteal samples. The low incidence of adhesions allows the consecutive use of females without any interference in subsequent ovulations and collections.(AU)

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O presente estudo descreve uma técnica para obtenção de fragmentos luteais empregando-se a colpotomia. Os animais foram submetidos à anestesia epidural e no fórnix vaginal e, após dez minutos, realizou-se uma incisão no fundo vaginal com lâmina de bisturi, bem como procedeu-se à dissecção do tecido, até que fossem possíveis o acesso à cavidade pélvica e a tração dos ovários para o interior vaginal. Realizou-se, então, a colheita de biopsia luteínica, com o auxílio de uma pinça do tipo Yomann. Sinais de dor e estresse foram observados apenas em duas colheitas durante a incisão no fundo vaginal, a tração do ovário ou durante a biopsia luteínica. Contudo, esses sinais foram observados em dez colheitas durante a dissecção da parede vaginal e peritôneo. Registrou-se a ocorrência de ataxia em 38,81% colheitas, a qual esteve relacionada, normalmente, a um procedimento mais longo. As ataxias podem ser divididas em leve (15/26), moderada (6/26) e severa (5/26). A avaliação da presença de adesões ovarianas ipsilaterais à incisão realizou-se apenas até a quarta colheita, sendo notadas em dezesseis colheitas. O protocolo empregado mostrou-se um método seguro e eficiente na obtenção de fragmentos luteais. A baixa incidência de aderências permite o uso consecutivo das fêmeas sem interferência nas ovulações e colheitas subsequentes.

The present study describes a technique to obtain consecutive luteal samples by colpotomy. The animals received an epidural anesthesia and local anesthesia (vaginal vault) and after ten minutes the vaginal vault was incised with a scalpel blade and tissue was dissected to provide access to the pelvic cavity and to retract the ovary into the vagina. Then, a luteal biopsy was performed with a Yomann biopsy nipper. Signs indicative of pain and stress during the vaginal vault incision, traction of ovary or luteal biopsy were observed only in two collections. However, these signs were observed in ten collections during dissection of the vaginal wall and peritoneum. The occurrence of ataxia was observed in 26 collections and it was usually related to a longer duration of the procedure. Ataxia could be divided in light (15/26), moderate (6/26) and severe (5/26). The occurrence of ovarian adhesions ipsilateral to the incision was evaluated only in the initial four collections. Adhesions were present in 16 collections. The protocol described above provided a safe and efficient method to acquire luteal samples. The low incidence of adhesions allows the consecutive use of females without any interference in subsequent ovulations and collections.

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Objetivo: revisar las consideraciones técnicas, indicaciones, riesgos y beneficios de este tipo de abordaje en masas pélvicas gigantes. Se presenta un caso en el que se realizó el abordaje laparoscópico de una masa quística ovárica de gran tamaño y su extracción a través de colpotomía posterior. La cirugía laparoscópica de los quistes gigantes de ovario surge como una alternativa a considerar en el manejo de estas pacientes.

Objective: reviewing technical considerations, indications, risks and benefits of a laparoscopic approach to giant ovarian cysts. A case is presented where a giant ovarian cyst was extracted by posterior colpotomy. Laparoscopic surgery on giant pelvic mass represents an alternative for managing such patients.

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ANTECEDENTES: La culdotomía como vía de acceso para realizar esterilización tubaria aparece como una alternativa simple y segura. OBJETIVO: Evaluar esta técnica en mujeres que solicitan esterilización tubaria. MÉTODO: Esterilización tubaria por culdotomía en 75 multíparas. RESULTADOS: El tiempo quirúrgico promedio fue 27,2 minutos. No hubo complicaciones durante la cirugía. En 5 casos (6,6%) la culdotomía se convirtió a laparotomía porque no se identificó una o ambas trompas. CONCLUSIÓN: Técnica segura, de bajo costo y con buena satisfacción de usuaria.

BACKGROUND: Culdotomy as access way for tubal sterilization appear like a simple and safe alternative. OBJECTIVE: To evaluate this technique in women who demand for tubal sterilization. METHOD: Tubal sterilization by culdotomy in 75 multiparous women. RESULTS: The average surgical time was 27.2 minutes. There were no complications during the surgery. In 5 cases (6.6%) the culdotomy was converted to laparotomy because one or both tubes were not identified. CONCLUSION: Culdotomy is a safe technique, of low cost and with good user satisfaction.

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PIP: Vaginal tubal ligation is a simple procedure, offers minor surgical risks, and has few contraindications. The authors consider it the surgical contraceptive of choice in selected cases. From July 1975 to March 1983 the authors performed 155 tubal ligations by the vaginal route after posterior colpotomy. For each patient opinions were sought from at least 3 physicians, who advised regarding the medical or psychological need for sterilization. The median age was 35 years, with ages ranging from 23 to 48. Median parity was 5.3, with 57 patients having 6 or more children. All were from low socioeconomic backgrounds. 140 tubal sterilizations were done by the Pomeroy method, in 14 by the Pomeroy method on 1 side and fimbriectomy on the other, and in 1 patient a bilateral fimbriectomy was performed. In 3 patients the tubal ligation was completed by abdominal route because of difficulty of vision during colpotomy. All patients recovered well postoperatively, with minimal pain. All received antibiotic therapy with penicillin for 5 days following surgery. Average duration of surgery was 42 minutes. There were no occurrences of lesions, hemorrhages, abcesses, or infection of incisions. With an average follow-up of 41.2 months, the incidence of problems was 0.65%. Contraindications against using the vaginal route include a history of pelvic inflammatory disease, anterior gynecological surgery, alterations in the mobility or size of the uterus, and presence of adnexal tumors. Colpotomy presents several advantages: it is well accepted by the patient because there is no abdominal scar, it is an efficient method that does not require special apparatus such as optical or mechanical equipment, it is associated with minimal morbidity, and there are few complications. Additionally, surgery is of short duration, postoperative pain minimal, and it is economical because hospitalization time is short, with rapid convalescence. Disadvantages observed were: it is not applicable to all patients and requires major surgical training to perform; it requires an extended period of postoperative sexual abstinence, usually 4 weeks. This procedure cannot be used during the immediate postpartum period, with a recommended interval of 6 weeks. Tubal sterilization using posterior colpotomy, in view of the advantages and results obtained, is recommended for selected cases.^ieng

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