Short and long term results of anatomical reconstruction of perineal body and sphincter complex in obstetric anal sphincter injuries.

Objectives: The effective way to reduce the risk of fecal incontinence (FI) in primary repaired obstetric anal sphincter injuries (OASIS) patients is to accurately detect the injury and provide complete anatomical reconstruction. The aim of the study was to evaluate the short-term and long-term results of OASIS cases that were diagnosed by an experienced surgical team and whose perineal body and anal sphincters were reconstructed separately. Material and Methods: Sixteen patients that required consultations due to anal sphincter damage during vaginal delivery and underwent anatomical reconstruction due to Grade 3c and Grade 4 sphincter damage between 2007 and 2019 were included in the study. These cases were divided into three groups [Group 1 (≤12 months), Group 2 (12-60 months), Group 3 (≥60 months)] according to the time elapsed until anal manometry, and incontinence questionnaires were conducted in the postoperative period. Recto-anal inhibitory reflex (RAIR), mean resting (IB) and squeezing (SB) pressures were measured by anal manometry. Anal incontinence (AI) and FI rates were determined by questionnaires. Anal sphincter damage repair techniques (overlapping, end-to-end) were determined. These parameters were compared between the three groups. Results: Mean age of the patients was 27.5 (16-35) years. Six (37.5%) patients had Grade 3c, while 10 (62.5%) had Grade 4 injury. The overall mean RP and SP were 35 (26-56) mmHg and 67 (31-100) mmHg, respectively. Mean RP and SP were 46/67 mmHg, 33.5/75.5 mmHg, and 37.5/70.5 mmHg in Groups 1, 2, and 3 respectively. There was no difference between the three groups in terms of mean RP and SP (p= 0.691, p= 0.673). The rate of AI and FI in all patients were 18.75% and 12.5%, respectively while the rate of severe AI incontinence was 6%. Severe AI was observed in 1 (16.7%) case in Group 1, mild AI was observed in 1 (25%) case in group 2, and in 1 (16.7%) case in Group 3. RAIR was positive in all patients. In Group 1, 5 (83.3%) patients underwent overlapping repair, and in Group 3, 6 (100%) patients underwent end-to-end repair. This difference was statistically significant (p= 0.011). Conclusion: In vaginal births, evaluation of anal sphincter damage, determination of perineal body structures and anal sphincters separately and performing anatomical reconstruction when needed significantly reduce the rate of FI in the short and long term.

Comparison of life quality between geriatric patients who underwent reconstructive surgery and obliterative surgery for pelvic organ prolapse.

OBJECTIVES: Pelvic organ prolapse (POP) adversely affects women's quality of life. The aim of this study is to compare the life quality after obliterative surgery and reconstructive surgery for geriatric patients with advanced pelvic organ prolapse. MATERIAL AND METHODS: This matched case control study included sexually inactive women aged 65 years or older who had vaginal surgery for pelvic organ prolapse in Tepecik Education and Research Hospiltal between August 2012 and June 2019. Life quality of women who had undergone obliterative or reconstructive vaginal surgery were evaluated and then compared by Turkish validated prolapse quality of life questionnaire (P-QOL). Patients in obliterative and recontructive surgical procedures were matched according to age, body mass index and POP stage and each group included 49 women. RESULTS: P-QOL scale domains, including prolapse impact (26.6 ± 12.1 vs 34.1 ± 16.2; p = 0.01), physical/social limitations (28.3 ± 12.8 vs 34.8 ± 14.4; p = 0.02) and severity measures (24.9 ± 12.6 vs 30.5 ± 13,4; p = 0.035) revealed significantly lower postoperative deterioration in the obliterative group. No significant difference was found in other P-QOL domains. The mean operation time in the obliterative group was shorter than the reconstructive group (respectively; 69.2 ± 21.5 min, 79.7 ± 29.4, p = 0.04). There were no significant differences in estimated blood loss, length of hospital stay and intraoperative complications. CONCLUSIONS: Obliterative surgery is a suitable option in the treatment of advanced pelvic organ prolapse in elderly patients.

Perioperative complications and short-term outcomes of abdominal sacrocolpopexy, laparoscopic sacrocolpopexy, sacrospinous ligament fixation, and iliococcygeus fixation procedures

Background/aim: This study aimed to investigate differences in perioperative complications and short-term outcomes of patients who underwent abdominal sacrocolpopexy/sacrohysteropexy, laparoscopic sacrocolpopexy/sacrohysteropexy, sacrospinous ligament fixation (SSLF), and iliococcygeus fixation due to apical prolapse. Materials and methods: The present retrospective cohort study included 145 patients who underwent apical prolapse surgery performed by the same surgeons between 1/1/2011 and 30/6/2017. There were 68 abdominal sacrocolpopexies (44 sacrocolpopexies and 24 sacrohysteropexies), 13 laparoscopic sacrocolpopexies (10 sacrocolpopexies and 3 sacrohysteropexies), 57 SSLFs, and 7 iliococcygeus fixations. Patients' short-term outcomes, perioperative complications, blood loss, operative time, and hospital stay were analyzed. Results: The mean operating time in the laparoscopic sacrocolpopexy group was 179.6 min versus 122.8, 117.3, and 107.1 min in the SSLF, abdominal sacrocolpopexy, and iliococcygeus fixation groups, respectively (P < 0.01). The hospital stay was significantly shorter in the iliococcygeus fixation group (1.86 days) when compared with that of other groups (P < 0.01). During a 6-month follow-up period, no prolapse recurrence or mesh exposure was observed in any groups. Wound complications were more frequent in the abdominal sacrocolpopexy group. However, the overall complication rate of each group did not differ significantly (P = 0.332). Conclusion: Overall, complication rates and short-term outcomes for the abdominal, laparoscopic, and vaginal surgical procedures were not statistically significantly different. However, minimally invasive approaches were associated with reduced procedural-related morbidity.

Ovarian sertoli-leydig cell tumors: A multicenter long-term clinicopathological analysis of 27 patients.

AIM: Information on the clinical behavior of ovarian Sertoli-Leydig cell tumors (SLCTs) as well as its prognostic factors and optimal management is limited due to a substantially low incidence of the disease. Also, limited data is available regarding the role of chemotherapy in the management of SLCTs. The aim of the study is to evaluate clinicopathological features and outcome of patients with ovarian SLCTs. MATERIALS AND METHODS: Twenty-seven patients with SLCT treated at two centers were reviewed retrospectively during 21 years. RESULTS: The median age was 45 years (range, 16-81) and the mean follow-up time was 86 months (range, 16-181). Twenty-three patients had stage IA, three patients had IC, and one patient had stage II disease. Eleven tumors (41%) were well-differentiated and 16 (59%) tumors were intermediately differentiated. Nine patients underwent unilateral salpino-oophorectomy and one patient, with a history of infertility, underwent cystectomy for fertility preservation. Eight patients with intermediately differentiated types of SLCT received adjuvant systemic chemotherapy including the combination bleomycin, etoposide, and cisplatin (BEP). Recurrence occurred in one patient with intermediated differentiated type SLCT with heterologous elements. She received four cycles of BEP chemotherapy. Twelve months later, she underwent cytoreductive surgery and received six cycles of cisplatin plus carboplatin. She died 24 months after the initial diagnosis. CONCLUSION: SLCTs of the ovary are usually in early stage, unilateral, and benign. Fertility-sparing surgery is the preferred option in young women. In the adjuvant treatment setting, although information about chemotherapy is limited, BEP is a commonly used regimen. The degree of differentiation and the presence of heterologous elements relate to a poor prognosis.

Effect of hydronephrosis on survival in advanced stage cervical cancer.

BACKGROUND: Hydronephrosis is frequently encountered in advanced stage cervical cancers, and may be associated with mortality. In the present study, we aimed to demonstrate the effect of hydronephrosis on survival in patients with inoperable advanced stage cervical cancer. MATERIALS AND METHODS: The study data were acquired by retrospective analysis of the patient records belonging to 165 women with FIGO (International Federation of Gynecology and Obstetrics) stage-IIIB or more advanced cervical cancer, which were not surgical candidates. Parameters including patient age, pathological diagnosis, disease stage, pelvic sidewall extension, presence of hydronephrosis and administration of chemoradiation were analyzed. Further, the effects of these variables on survival were assessed. P values less than 0.05 were considered statistically significant. RESULTS: The distribution of the study patients according to disease stage was as follows: 131 (79.4%) had stage-IIIB, 18 (10.9%) had stage-IVB and 16 (% 9.7) patients had stage-IVA disease. Hydronephrosis was not evident in 91 (55.2%) of these patients, whereas 41 (24.8%) had unilateral and 33 (20%) patients had bilateral hydronephrosis. When compared to mean survival in patients who did not have hydronephrosis, survival was significantly shortened in patients who had bilateral and unilateral hydronephrosis (p<0.05). There was no significant survival difference between patients with unilateral and bilateral hydronephrosis (p>0.05). Although patient age, pathological type, pelvic involvement, and chemotherapy treatment rates were similar (p>0.05), radiotherapy requirement rate and disease stage were significantly different among the study groups (p<0.05). CONCLUSIONS: Hydronephrosis was found to be a significant predictor of poor survival in patients with advanced stage cervical cancer, irrespective of unilateral or bilateral involvement.While waiting for future studies with larger sample sizes, we believe that the FIGO stages in advanced cervical cancer could further be stratified into subgroups according to presence or absence of hydronephrosis.

Is mucinous adenocarcinoma of the endometrium a risk factor for lymph node involvement? A multicenter case-control study.

PURPOSE: The purpose of this multicenter case-control study was to compare the demographic and clinical characteristics of patients with mucinous adenocarcinoma of the endometrium (MAE) and endometrioid endometrial carcinoma (EEC). METHODS: A retrospective review of two cancer registry databases in Turkey was conducted to identify patients diagnosed with MAE between January 1996 and December 2012. Each patient was matched with a control EEC patient by age and tumor grade. Cases and controls were compared in terms of known risk factors for lymph node metastasis, disease-free survival (DFS), and overall survival (OS). RESULTS: The analysis included 112 patients with MAE and 112 with EEC. No significant difference in baseline characteristics was evident between the two groups. Lymphovascular space invasion, deep myometrial invasion, cervical involvement, and tumor diameter did not differ significantly between the mucinous and endometrioid cases. Multivariate analysis confirmed that only mucinous histology (OR 2.2, 95 % CI 1.1-4.5; P = 0.02) was an independent predictor of lymph node involvement. Although the median DFS and OS tended to be better in the endometrioid group, the differences were not statistically significant. Routine appendectomy was performed in 52 (46.2 %) patients with MAE. No mucinous tumor of the appendix was identified. CONCLUSION: Routine appendectomy is not necessary when the appendix is grossly normal at the time of surgery for MAE. Although the DFS and OS of EEC and MAE patients were similar, the risk of nodal metastasis in MAE patients was greater than that in ECC patients, and we thus suggest to perform retroperitoneal lymphadenectomy (both pelvic and para-aortic) for patients with MAE during the initial operation.

Melatonin causes regression of endometriotic implants in rats by modulating angiogenesis, tissue levels of antioxidants and matrix metalloproteinases.

PURPOSE: The aim of this study was to test if melatonin causes regression of endometriotic implants and whether it influences implant levels of superoxide dismutase (SOD), malondialdehyde (MDA), vascular endothelial growth factor (VEGF), tissue inhibitor of metalloproteinase (TIMP)-2 and matrix metalloproteinase (MMP)-9 in rats. METHODS: Endometriotic implants were introduced surgically to 20 female Wistar albino rats, which were either treated with melatonin via intraperitoneal injection for four weeks (melatonin group, n = 10) or with saline (control group, n = 10) after a second-look laparotomies. The main outcome measures included volume (mm(3)) and weight (mg) of explants and tissue levels of SOD, MDA, VEGF, TIMP-2 and MMP-9. RESULTS: Before and after treatment implant volumes of the melatonin group were decreased significantly (P < 0.01) while there was no significant difference between the pretreatment and posttreatment implant volumes of the control group. Moreover, weight (P < 0.05) and histologic score (P < 0.05) of implants of the melatonin-treated rats were significantly lower than controls. Activity of SOD and TIMP-2 staining in melatonin group was significantly higher (both P < 0.01) while there were significant reductions in implant levels of VEGF and MMP-9 in melatonin group (both P < 0.01) than controls. CONCLUSIONS: Melatonin induces the regression of endometriotic implants in rats by modulating implant levels of SOD, MDA, VEGF, MMP-9 and TIMP-2.

Umbilical stalk elevation technique for safer Veress needle insertion in obese patients: a case-control study.

OBJECTIVE: The purpose of this retrospective study was to compare our umbilical stalk elevation (USE) technique with the classic Veress needle (VN) technique in obese patients. STUDY DESIGN: The USE technique was performed on 40 patients. One control per case was randomly selected from among those undergoing the classic VN technique using a random number table. In USE technique, a 12 mm skin incision was created at the superior crease of the umbilical fold, and the underlying subcutaneous adipose tissue was bluntly dissected using the tip of a fine clamp until the umbilical stalk was isolated at the inferior and central part of the incision. Next, the umbilical stalk was covered and held by a towel clip, and the abdominal wall was elevated by upward traction. The VN was then inserted nearly perpendicular to the incision and turned toward the pelvis immediately after resistance to the needle had been lost. A post-hoc power analysis was performed. RESULTS: The number of attempts was significantly lower in the USE laparoscopy group than in the classic laparoscopy group (1.2 ± 0.4 vs. 2.1 ± 0.7, respectively; P<0.001). The USE technique group had a slightly shorter abdominal entry time than did the classic technique group (328.52 ± 63.71 vs. 434.95 ± 124.10s; P<0.001). Six (7.5%) failed insufflations occurred in our study (5 patients in the classic group vs. 1 patient in the USE group (P=0.10). CONCLUSION: Our novel USE technique can be an effective means of establishing pneumoperitoneum in obese patients undergoing gynecologic laparoscopic procedures.

Immunolocalization of ERK1/2 and p-AKT in normal endometrium, endometrial hyperplasia, and early and advanced stage endometrioid endometrial adenocancer and their prognostic significance in malignant group.

OBJECTIVE: To analyze the expression patterns of extracellular signal-regulated kinase (ERK1/2) and phosphorylated (p)-AKT in the tissues of non-pathologic endometrium, endometrial hyperplasia, and early and advanced stage endometrioid endometrial adenocancer using indirect immunohistochemistry, and also to investigate the effect of ERK1/2 and p-AKT expression patterns on prognosis in endometrioid adenocancer. STUDY DESIGN: Immunolocalization of ERK1/2 and p-AKT was examined in six different types of endometrial tissues: proliferative endometrium (PE; n=10, 11.2%), secretuar endometrium (SE; n=10, 11.2%), simple hyperplasia (SH; n=15, 16.9%), complex hyperplasia (CH; n=3, 3.4%) and atypical complex hyperplasia (ACH; n=10, 11.2%), which were obtained from endometrial biopsies, curettage materials, and hysterectomy specimens and classified as the benign group; and both early stage endometrioid (n=21, 23.6%) and advanced stage endometrioid adenocancer (AC; n=20, 22.5%), which were obtained from complete surgical staging materials and classified as the malignant group. All specimens were fixed in 10% formalin and processed using routine paraffin protocols. Immunostaining intensities were evaluated as negative or weak (assigned as low expression) and moderate or strong (assigned as high expression). RESULTS: In the malignant group, 23 of 41 patients (56.1%) had high ERK1/2 and p-AKT expression, whereas only three of 48 patients in the benign group (6.3%) had high ERK1/2 and p-AKT expression (P<0.0001 and P<0.0001, respectively). p-AKT expression was significantly higher in women with positive lymph nodes (OR 9.0; 95% CI: 1.2-100.0; P=0.03). Higher expression of p-AKT was significantly associated with poor progression-free survival (PFS) and overall survival (OS). In contrast, ERK1/2 expression was not associated with PFS or OS.Conclusions ERK1/2 and p-AKT can be useful in the differential diagnosis of benign vs. malignant endometrial lesions, as well as early vs. advanced stage endometrioid endometrial adenocancer. Additionally, higher p-AKT expression could be used as a marker of poor prognosis in the management of patients with endometrioid endometrial adenocancer.

The effectiveness of subcutaneously implanted epidural ports for relief of severe pain in patients with advanced-stage gynecological cancer: a prospective study.

OBJECTIVE: We aimed to evaluate the effectiveness of subcutaneously implanted epidural ports (SIEP) in the management of patients with advanced-stage gynecologic cancer-related severe chronic pain who do not respond to intravenous tramadol infusion, transdermal fentanyl, and oral morphine administration or who cannot tolerate the unacceptable and unmanageable side effects of these drugs. METHODS: In this prospectively designed study, SIEP to permit the administration of morphine were implanted for relief of severe chronic pain in 21 cases with stage IV gynecological cancer (ovarian [n=6], endometrium [n=3], cervix [n=10], vaginal [n=1], and vulvar [n=1]). In order to define the level of pain, visual analogue scale (VAS) and patient satisfaction score (PSS) were used before and on the 5th, 15th, and 30th days after epidural port application. RESULTS: The mean overall survival period of the cases undergoing epidural port application was 80 days (range: 31-560). In terms of pain parameters, values at the end of the 5th, 15th and 30th days (VAS2, VAS3 and VAS4) were significantly lower than the value before morphine application via SIEP (VAS1) (p<0.01). PSSs at the 5th, 15th and 30th days were significantly higher than the PSS before port implantation (p<0.05). Pain management was started with 2 mg morphine with a maximum of 4 mg morphine administered into the epidural space per day. No clinically detected infectious condition or morphine-related side effects that required treatment occurred during the follow-up. CONCLUSION: Morphine administration via SIEP provided excellent pain relief without creating side effects, increased patient quality of life, and contributed to the patient's ability to enjoy life.

Prognostic predictors and spread patterns in adult ovarian granulosa cell tumors: a multicenter long-term follow-up study of 108 patients.

PURPOSE: To identify prognostic predictors and spread patterns in adult ovarian granulosa cell tumors (OGCTs). METHODS: Available retrospective data of 108 OGCT patients managed at three centers between January 1, 1991 and December 31, 2010 were abstracted and analyzed. RESULTS: Stage distributions at diagnosis for stage I, II and III OGCT were 84.3, 5.4, and 9.3 %, respectively. Optimal cytoreduction with no macroscopically visible disease was achieved in 99/108 (91.6 %) patients. The median disease-free interval to first recurrence was 61 months. The overall 5- and 10-year survival rates were 93.3 and 90.9 %, respectively. Disease recurred in 18 (16.6 %) patients, and 8 (7.4 %) patients died of their disease. The first recurrence sites included the pelvic peritoneum (n = 10), liver/liver-capsule (n = 5), rectosigmoid colon (n = 4), retroperitoneal lymph nodes (n = 3), omentum (n = 3), small bowel mesenterium (n = 2), and vaginal cuff (n = 2). Multiple-site recurrence was observed in 9/18 (50 %) patients. Secondary cytoreduction requiring extensive surgery was performed in 14 patients with an optimality rate of 71.4 %. The remaining four patients received only chemotherapy. Multivisceral approaches, including pelvic peritonectomy (n = 9; 64.2 %), rectosigmoid resection (n = 3; 21.4 %), and segmental liver capsule resection (n = 2; 14.2 %) were performed more frequently during the secondary surgery. Definitive retroperitoneal lymph node metastasis rates at the initial and recurrent settings were 5.1 % (3/58) and 21.4 % (3/14), respectively. Both stage and residual tumor status were significantly associated with recurrence in univariate and multivariate analyses. CONCLUSIONS: Stage and residual tumor status are predictors of recurrence. Pelvic peritoneal, nodal and hepatic involvement, and multiple-site spread patterns requiring extensive cytoreductive surgery are likely associated with recurrence of OGCTs.

Long-term oncological and reproductive outcomes of fertility-sparing cytoreductive surgery in females aged 25 years and younger with malignant ovarian germ cell tumors.

AIM: To evaluate the long-term oncological and reproductive outcomes of patients aged 25 years and younger who were treated by fertility-sparing cytoreductive surgery (FSCS) plus adjuvant chemotherapy (ACT) or observation alone for malignant ovarian germ cell tumors (MOGCT). METHODS: Records of 42 eligible female patients treated for MOGCT between 1 May 1995 and 31 December 2010 at two centers were analyzed retrospectively. A telephone questionnaire was performed to gather reproductive and menstrual history. RESULTS: One patient was treated without FSCS and two patients were lost to follow-up. The mean age of the remaining 39 patients was 18.4 ± 3.2 years. Eighteen of the tumors were histologically pure dysgerminomas (PD) and 21 were non-dysgerminomatous tumors (non-DT). Thirteen patients (33%) presented with stage II-III disease. Optimal cytoreduction was achieved in 34 of the 39 patients (87%). Systematic pelvic and para-aortic lymphadenectomy was performed in 31 of the 39 patients (79.5%). The frequency of lymph node metastasis was 29% (9/31). Twenty-seven patients (69.2%) received ACT. Disease recurred in six (15.3%) patients, all in the non-DT group. Four of six underwent secondary optimal FSCS followed by chemotherapy. Retroperitoneal nodal recurrence was detected in two of these four patients (50%). Four deaths occurred, three due to chemoresistant aggressive disease and one due to secondary acute myelocytic leukemia. The overall survival rates for patients with PD and non-DT were 100% and 81.4%, respectively. Twenty-three of 27 patients who received ACT continued their regular menses. Sixteen spontaneous pregnancies and one pregnancy by intrauterine insemination were achieved by 21 patients who attempted conception. CONCLUSION: Either primary or secondary FSCS followed by ACT seems to be a feasible and safe approach to preserving future fertility and hormonal function in young patients with MOGCT.

Can preoperative neutrophil:lymphocyte and platelet:lymphocyte ratios be used as predictive markers for lymph node metastasis in squamous cell carcinoma of the vulva?

OBJECTIVE: To determine whether the neutrophil:lymphocyte ratio (NLR) and platelet:lymphocyte ratio (PLR) before complete surgical staging provide information on lymph node metastasis in vulvar squamous cell carcinoma (SCC). STUDY DESIGN: All patients with vulvar SCC who underwent complete surgical staging at two institutions between 1 January 2005 and 31 December 2011 were identified retrospectively from patient databases. Receiver operating characteristic (ROC) curve analysis was used to evaluate cut-off, sensitivity, and specificity values for preoperative NLR and PLR to predict lymph node metastasis. RESULTS: Data from 64 women with adequate information were analyzed. Lymph node involvement was detected in 19 (29.7%) patients. NLR and PLR were higher in the lymph node--positive group than in the--negative group (p < 0.001). The best cut-off values for predicting lymph node metastasis were 2.81 for the NLR, with 84.5% sensitivity and 89.5% specificity, and 139.5 for the PLR, with 68.9% sensitivity and 89.5% specificity. Forty of the 64 (62.5%) patients had NLRs ≤ 2.81 and 24 (37.5%) had NLRs >2.81. Lymph node involvement was more common in the NLR >2.81 group [60.7% vs. 5.6%; relative risk RR = 10.9, 95% confidence interval CI = 2.7-43.4; p < 0.001]. Mean tumor sizes were 4.2 ± 2.3 cm in the NLR >2.81 group and 2.1 ± 1.2 cm in the NLR ≤ 2.81 group (p = 0.001). The rate of lymph node involvement was higher in the PLR >139.5 group than in the PLR ≤ 139.5 group (54.8% vs. 6.1%; RR = 9.0, 95% CI = 2.2-35.9; p<0.001). CONCLUSION: Preoperative NLR and PLR are directly associated with nodal involvement status of vulvar SCC. These markers are simple, readily obtained and calculated, and easy to integrate into the surgical work-up of patients with vulvar SCC, at no extra cost.

Influence of gum chewing on postoperative bowel activity after complete staging surgery for gynecological malignancies: a randomized controlled trial.

OBJECTIVE: To investigate whether gum chewing affects the return of bowel function after complete staging surgery for gynecologic malignancies. METHODS: A total of 149 patients undergoing abdominal complete surgical staging for various gynecological cancers were randomized into a gum-chewing group (n=74) or a control group (n=75). The patients chewed sugarless gum three times from the first postoperative morning until the first passage of flatus. Each chewing session lasted 30 min. Total abdominal hysterectomy with systematic pelvic and para-aortic lymphadenectomy was performed on all patients as part of complete staging surgery. Groups were compared in terms of time to first bowel movement time, first flatus and feces pass time, postoperative analgesic and antiemetic drug requirement, postoperative oral intake tolerance, mild ileus symptoms and hospital stay. RESULTS: The mean time to flatus (34.0 ± 11.5 vs. 43.6 ± 14.0 h; p<0.001), mean time to defecation (49.6 ± 18.7 vs. 62.5 ± 21.5h; p<0.001), mean time to bowel movement (41.5 ± 15.7 vs. 50.1 ± 5.9h; p=0.001), mean time to tolerate diet (4.0 ± 0.8 vs. 5.0 ± 0.9 days; p<0.001), mean length of hospital stay (5.9 ± 1 vs. 7.0 ± 1.4 days; p<0.001) were significantly reduced in patients that chewed gum compared with controls. Mild ileus symptoms were observed in 27 (36%) patients in the control group compared to 11(14.9%) patients in the gum-chewing group [relative risk, 2.4; 95% confidence interval, 1.2-4.5; p=0.004]. Severe symptoms were observed in two patients (2.7%) in the control group. CONCLUSIONS: Gum chewing early in the postoperative period following elective total abdominal hysterectomy and systematic retroperitoneal lymphadenectomy hastens time to bowel motility and ability to tolerate feedings. This inexpensive and well-tolerated treatment should be added as an adjunct in postoperative care of gynecologic oncology.

Signet-ring cell carcinoma of the breast with uterine metastasis treated with extensive cytoreductive surgery: a case report and brief review of the literature.

Primary signet-ring cell carcinoma (SRCC) of the breast is an uncommon variant, accounting for 2-4.5% of all primary breast cancers. Secondary SRCC of the endometrium is very rare and usually originates from the breast or gastrointestinal tract. A 54-year-old, postmenopausal woman with a past history of breast cancer four years previously was admitted with abnormal uterine bleeding. An endometrial biopsy revealed undifferentiated adenocarcinoma with signet-ring cells. The patient underwent laparotomy and cytoreductive surgery was performed. Pathological analysis and immunohistochemical tests demonstrated a uterine (endomyometrial) metastasis of breast SRCC. Omentum, peritoneal surfaces and retroperitoneal lymph nodes also included tumoral tissue with signet-ring cell morphology. The patient received adjuvant systemic chemotherapy with adriamycin, cyclophosphamide and paclitaxel. This case report discusses the patient's clinical characteristics and the role of cytoreductive surgery on patient survival in SRCC of the breast metastasizing to the uterus.

Cellular blue nevus of the vulva mimicking Bartholin's gland abscess in a 15-year-old girl: a case report.

INTRODUCTION: Literature review revealed descriptions of three cellular blue nevus (CBN) in the gynecologic tract. Two of them were myometrial CBN and incidental findings in hysterectomies performed in women aged 37 and 48 years. The single ectocervical CBN involving the hymenal ring and vagina was reported in a 19-year-old woman. The other reported cases of cervical blue nevi were common type and have been localized to endocervix. CASE REPORT: Vulvar CBN in left labia majora mimicking Bartholin's gland abscess in a 15-year-old white virgin girl and also the youngest case has not been reported previously. CONCLUSION: CBN should be considered in the differential diagnosis of vulvar masses in adolescent period.

The predictors of response to neoadjuvant chemotherapy in advanced epithelial ovarian cancer.

OBJECTIVES: To investigate the predictors of response to neoadjuvant chemotherapy (NACT) in advanced stage epithelial ovarian cancer (EOC). METHODS: Thirty-five patients with nonoptimally cytoreductable at stage III-IV EOC who were treated with NACT and interval cytoreductive surgery in our center between January 2002 and February 2009 were enrolled into this retrospective pilot study. Response to NACT was evaluated according to Response Evaluation Criteria in Solid Tumors (RECIST). RESULTS: All patients received three courses platinum-based chemotherapy [24 (69%) received pactitaxel plus carboplatin and 11 (31%) received paclitaxel plus cisplatin]. There were 12 (34%) partial response to and 23 (66%) stable disease after NACT. Optimal cytoreduction was subsequently achieved in 32 of 35 patients (91%). Among age, hystology, ovarian size, CA-125 level, severity of pleural effusion, extensive omental disease, diaphragmatic implants, liver parenchyma metastasis, used chemotherapy regimen; only extensive omental disease was found to be predictive (P = 0.004). CONCLUSIONS: Ovarian cancer patients with extensive omental disease were possibly better treated with primary cytoreductive surgery, since they were more likely to have less responsive to NACT. This finding can be used to identify patients who will get poor response to NACT and to design future tailored randomized clinical trials.

Association of maternal serum CRP, IL-6, TNF-alpha, homocysteine, folic acid and vitamin B12 levels with the severity of preeclampsia and fetal birth weight.

OBJECTIVE: To assess the levels and clinical significance of high sensitive(hs)-CRP (C-reactive protein), IL-6(interleukin-6), TNF-alpha(tumor necrosis factor-alpha), homocysteine, folic acid and vitamin B12 in normotensive healthy pregnant women, mild and severe preeclamptic patients, and to evaluate the correlations between these markers and the severity of preeclampsia and fetal birth weight. STUDY DESIGN: Using a cross-sectional study design, hs-CRP, IL-6, TNF-alpha, homocysteine and vitamin B12 were measured in the third trimester of pregnancy from normotensive healthy women with uncomplicated pregnancies (n = 62), mild (n = 61) and severe (n = 60) preeclamptic patients. RESULTS: There were statistically significant differences between three groups for hs-CRP (p = 0.012), TNF- alpha (p = 0.046), IL-6 (p = 0.015), homocysteine (p < 0.001) and fetal birth weight (p < 0.001). Fetal birth weights in mild (2477 +/- 746) and severe (2435 +/- 768) preeclamptic patients were significantly lower than controls (3485 +/- 365) (p < 0.001). No significant difference was found between the three groups for folic acid (p = 0.066) and vitamin B12 (p = 0.286). Bonferroni adjusted multiple comparison test showed that the statistical differences with respect to TNF-alpha, IL-6 and homocysteine were mainly created by control and severe preeclampsia groups. Hs-CRP levels still remained higher in severe preeclampsia patients than mild preeclampsia and normotensive patients except for overweight patients in the previous two groups after Bonferroni post hoc adjustment test. CONCLUSION: Elevated maternal serum levels of hs-CRP, TNF- alpha, IL-6 and homocysteine in preeclamptic women correlate with fetal birth weight in the early third trimester.

Should diagnostic laparoscopy be performed initially or not, during infertility management of primary and secondary infertile women? A cross-sectional study.

OBJECTIVE: The debate about the timing of diagnostic laparoscopy in unexplained infertile women has been investigated in this prospective study. STUDY DESIGN: A total of 328 infertile women who underwent diagnostic laparoscopy for investigation of infertility at any stage of their infertility management from April 2001 to April 2003 were investigated. When the study group was resized according to the inclusion criteria 191 unexplained infertile patients were included. Preoperative and postoperative treatment strategies were compared. The correlation between hysterosalpingography and laparoscopy findings was identified. The results were evaluated using SPSS version 10.0 for Windows. RESULTS: A total of 106 patients were primary and 85 were secondary infertile. The mean ages of primary and secondary infertile patients were 27 +/- 5 and 29 +/- 5, respectively. Sixty percent of primary and 69% of secondary infertile patients had pelvic pathologies. Treatment strategies of 29 (43%) primary infertile and 27 (49%) secondary infertile patients with infertility-related risk factors changed after diagnostic laparoscopy. CONCLUSION: Diagnostic laparoscopy in preparation for operative procedures (especially for secondary infertile women) should be performed initially in all unexplained infertile patients with or without risk factors related to pelvic pathologies.

Combining mid-trimester maternal plasma homocysteine with uterine artery doppler velocimetry: is it useful?

OBJECTIVE: To investigate the possible association between mid-trimester maternal plasma homocysteine concentration, uterine artery Doppler measurements in a two-stage screening strategy, and outcome of pregnancy. MATERIALS AND METHODS: This prospective observational study was conducted on healthy women undergoing screening for pre-eclampsia by uterine artery Doppler velocimetry at 20-22 and 24-26 weeks of gestation. Abnormal uterine artery blood flow was defined as an average resistance index (RI) > 0.58 and/or bilateral early diastolic notch. Homocysteine measurement was performed by two competitive immunoassay methods involving two steps at 20-22 and 24-26 weeks' gestation. RESULTS: Sixty women enrolled. Abnormal Doppler findings were found in 18 of 60 (30%) women at 20-22 weeks of gestation. This proportion was reduced to 10% (6/60) at 24-26 weeks of gestation, and two of these six women developed pre-eclampsia later in pregnancy. There was no significant difference in the maternal plasma homocysteine levels in women with abnormal Doppler findings when compared with controls at first and second visits (p > 0.05). CONCLUSION: Mid-trimester maternal homocysteine concentration is not elevated in women with abnormal uterine artery Doppler findings in a two-stage screening method.