Multiple large polypoid lesions with exophytic appearance occurring in anal and perineal region as a result of human papilloma virus (HPV) infection are referred to as giant condyloma acuminatum (GCA). The conventional treatment of these lesions involves the use of surgical excision, laser, electrocautery, and/or application of trichloroacetic acid. A 28-year-old primigravid patient at 22 weeks of pregnancy presented to the hospital complaining of vaginal bleeding and palpable mass in the vulva. The physical examination revealed a 60 × 35 mm broad-based, fragile, and patchy hemorrhagic polypoid lesion originating 1 cm below the clitoris and completely occupying urethral orifice and partially occluding vaginal vestibule. The patient underwent excision of GCA in the midtrimester using an ultrasonic thermal scalpel (Harmonic Scalpel) without any additional treatment and subsequently delivered a single live healthy baby. The excision of GCA occurring during pregnancy using Harmonic Scalpel can be regarded as a new successful method. Prospective, randomized, and controlled studies are warranted in order to provide clear evidence of the efficiency and safety of HS in the treatment of GCA.
Multiple large polypoid lesions with exophytic appearance occurring in anal and perineal region as a result of human papilloma virus (HPV) infection are referred to as Buschke-Löwenstein tumor (BLT) or giant condyloma acuminatum (GCA) [
The ultrasonic thermal scalpel (Harmonic Scalpel) is an ultrasonic device that simultaneously performs cutting and coagulation using ultrasonic vibration. The device offers the advantages of causing minimal lateral thermal damage and producing lesser smoke. In addition, the device avoids the passage of electrical current and neuromuscular stimulation [
We reported a patient who underwent excision of GCA in the midtrimester using a HS and who subsequently delivered a single live baby.
A 28-year-old primigravid patient at 22 weeks of pregnancy presented to the hospital complaining of vaginal bleeding and palpable mass in the vulva. The physical examination revealed a 60 × 35 mm broad-based, fragile, and patchy hemorrhagic polypoid lesion originating 1 cm below the clitoris and completely occupying urethral orifice and partially occluding vaginal vestibule (Figure
GCA was detected that completely surrounded the external urethral orifice.
On ultrasonography (USG), biometric measurements were consistent with a single live fetus with a gestational age of 22 weeks and 2 days. The routine hematological and biochemical tests did not reveal any pathological findings. The tests performed for syphilis, human immune deficiency virus (HIV), and hepatitis virus subtypes were found to be negative. Polyacrylamide gel electrophoresis and multiplex polymerase chain reaction (PCR) performed in cervicovaginal samples revealed HPV type 6. The urological examination performed in the partner of the patient did not reveal any finding.
The decision to perform condyloma excision under spinal anesthesia was made. The patient was provided detailed explanation about the procedure, and a signed written informed consent was obtained. The pedunculated condylomas in the labia minora and GCA in periurethral region were excised using HS. The HS (The Harmonic ACE, Ethicon Endo-Surgery Inc., Cincinnati, OH, USA) was used according to the manufacturer’s instructions. It has a shaft diameter of 5 mm and length of 36 mm. The device has different power levels for different tissues. HS was operated at power level 3 for GCA. Duration of the application of ultrasonic energy did not take more than 10 seconds for each lesion. The lesions were dissected and superficial epidermal destruction was done without any cavitation (Figure
The excision of GCA using HS and appearance after the operation.
The procedure was performed using a cystoscopy with the assumption that condylomas could also be present in the urethra neck and bladder. There was no pathological finding in the ureter orifices and urethra. The pathological examination was consistent with condyloma acuminatum. No surgical or obstetric complications occurred in the postoperative period. The patient continued her routine pregnancy follow-up. The patient did not develop recurrent or new condyloma until delivery. The patient delivered a 2770-gram male baby with cesarean section due to fetal distress at gestational age of 36 weeks and 6 days. The patient did not have any symptoms at 12 months postpartum.
Active vulvovaginal HPV type 6 and 11 infections may exhibit variable clinical courses. The virus can be eliminated spontaneously, enter into a latent phase, cause subclinical infection for long years, produce benign lesions, and turn into a precancerous lesion with accompanying oncogenic subtypes or result in tumor-like masses induced by HPV [
The treatment choice for GCA is very important during pregnancy. No definitive evidence suggests that any of the available treatments are superior to any other, and no single treatment is ideal for all patients or all warts. The use of locally developed and monitored treatment algorithms has been associated with improved clinical outcomes and should be encouraged [
Rarely, HPV types 6 and 11 can cause respiratory papillomatosis in infants and children, although the route of transmission (i.e., transplacental, perinatal, or postnatal) is not completely understood [
Chu et al. reported recurrence in 50% of nonpregnant women with anogenital GCA that underwent radical surgery using traditional methods [
HS is commonly employed in laparoscopic and open surgery. HS converts ultrasonic waves into high-frequency mechanical energy, and it simultaneously performs cutting and coagulation in the tissue. The cut surfaces become denaturized and turn into a coagulum which prevents blood loss. The temperature is between 50 and 100°C in procedures performed with HS, and the risk of injury to the surrounding tissues is minimal [
The excision of GCA using HS and without using adjuvant therapy is a new treatment method. HS offers the advantages of easy applicability and short procedure time in the excision of GCA. The risk of blood loss, edema, and wound site infection is lower with HS compared to conventional scalpel method [
The excision of GCA occurring during pregnancy using HS can be regarded as a new successful method. Prospective, randomized, and controlled studies are warranted in order to provide clear evidence of the efficiency and safety of HS in the treatment of GCA.
The authors declare that there is no conflict of interests regarding the publication of this paper.