[COMPARISON OF LAPAROSCOPIC ASSISTED VAGINAL HYSTERECTOMY AND VAGINAL HYSTERECTOMY FOR BENIGN DISEASES AND LESIONS OF THE FEMALE GENITAL SYSTEM].

OBJECTIVE: To compare the efficacy of laparoscopic assisted vaginal hysterectomy (LAVH) and vaginal hysterectomy (VH) carried out on the occasion of non-malignant diseases and lesions of the female genital system, by assessing the: operative time, price, blood loss, hospital stay, intra and postoperative complications, satisfaction of the patient. MATERIALS AND METHODS: The study included 187 women aged 38-71 years, with hysterectomy with or without salpingo-oophorectomy by LAVH-58 (31%) women or VH-129 (69%) women, on the occasion of non-malignant diseases and lesions of the female genital system. The patients are including in the study groups according to including and excluding criteria. Operation preparation, research and intra and postoperative follow-up of patients in both groups were the same. Standard, as performance is the surgical technique in both groups. The indicators are analyzed with the statistical program SPSS 10.1 for windows. Shi-square test, Fisher exact test were used in appropriate cases. RESULTS: No significant difference between groups in terms of age (LAVH 48.7 ± 3.2 years; VH 52.7 ± 4.8 yrs), live births (1-3)/2 (1-2), total weight (62.6 kg/59 ± 7.2 kg) weight of the uterus (227 ±116.5/234 ±: 68.3). Most often Indications for LAVH are: CIN/CA in situ coli uteri--16.1%; myoma uteri--22.5%; ovarian tumor--15.5%, etc. Indications for VH: genital prolapse--53.5%; CIN/CA in situ--14.7%; recurrent endometrial polyp--14%, etc. Operative time: LAVH (126 ± 18.2), VH (68 ± 11.1), (p ≤ 0.05). Intraoperative blood loss: LAVH (16 ± 7 average drop in hemoglobin Hb), VH (10 ± 5 decline in Hb array) (p ≤ 0.05). We didn't find out significant differences between the patients of both groups in terms of hospital stay and satisfaction with the carried out operation. Intraoperative complications are more in the LAVH group and almos absence in VH group. Post-operative complications occur without statistical differences (we exclude urinary infections) in both groups studied. CONCLUSIONS: In our study the VH showed better or equal results in the studied indicators in comparison with LAVH, therefore it is surgical intervention of choice compared to LAVH for removal of the uterus with or without the adnexa in non-malignant diseases and lesions of the female genital system. LAVH is the right choice in comparison with VH only in ovarian tumors and when we expected problems in women small pelvis.

[Labial fusion in postmenopausal women--a clinical case].

Labial fusion is benign genital disorder, which more frequent in children at 6 years old and less in women in reproductive and postmenopausal age. It can be congenital or acquired condition. Its etiology is unclear. The low serum estrogen concentration is the basic cause of labial fusion. As a result of physiological hypoestrogenism in the vulvar skin and mucosa come on atrophic changes, which together with the chronic inflammatory changes lead to labial adhesia with subsequent partial or total obstruction of the vagina and/or the urethra. The treatment can be conservative or surgical depending on the degree of labial fusion. We perform two clinical cases respectively of total and partial vulvarsynechiae in postmenopausal women. The clinical picture of the patient with total synechiae is represented by a difficult and prolonged micturition and urinary incontinence, while in patients with partial synechiae is represented by an inability to carry out sexual intercourse.

[UTERINE SCAR DEFECT IN WOMEN AFTER CESAREAN SECTION - ULTRASOUND AND HYSTEROSCOPIC DIAGNOSI.]

The aim of our study was to determine the frequency of defect scar in women with clinical complaints after Cesarean section (CS) diagnosed by transvaginal ultrasonography and diagnostic hysteroscopy as well as to determine the degree of match between the data obtained by the two methods. MATERIALS AND METHODS: The study was retrospective and was conducted in the Department of General Oncology and Gynecology, MMA for the period from 2014 to 2016 years. Included are 25 non-pregnant premenopausal women aged 29 to 45 years with clinical symptoms. The main inclusion criteria were delivery by CS, overt clinical gynecological symptoms and positive imaging findings of a defect in the scar. The main gynecological symptoms are: postmenstrual and breakthrough bleeding, dysmenorrhea, dispaureny and idiopathic pain over the symphysis. Imaging studies were performed using two-dimensional transvaginal sonography and diagnostic hysteroscopy. The data are processed by Social statistic STAT 10. We used Chi square statistic test 12.5 (Pearson). Data were compared to two independent groups. Results were statistically significant at values of p<0. 05. RESULTS: The most common symptom in women included in the study was a post-menstrual bleeding - 22 (88 %). In 15 (60 %) of them we found out ultrasound signs of a defect in uterine scar (p =0, 00407). In 10 (40%) of those patients by diagnostic hysteroscopy we found defective scar (p=0, 000004). There has been no significant difference between the two methods in terms of accuracy of diagnosis (isthmocele) (p=0.1572) although the hysteroscopy there was a statistically higher one. CONCLUSION: With increasing frequency of cesarean section (CS) increases and frequency of early and late complications of this surgery. Irregular uterine bleeding in women after CS and a lack of other organic causes are the result of a defect in uterine scar. First choice for the diagnosis of this type of pathology is ultrasonography examination followed by diagnostic hysteroscopy. It is conducting further studies on the etiology of this complication.

[OPEN LAPAROSCOPY--A MODIFIED HASSON TECHNIQUE].

The open technique was first described by Hasson in 1970. This technique consists of creating a small umbilical incision under direct visualization to enter the abdominal cavity followed by the introduction of a blunt trocar. Pneumoperitoneum is then rapidly created. Hasson proposed its potential benefits to be the avoidance of blind insertion of the Veress needle and bladed trocar, prevention of visceral and vascular injuries, preperitoneal insufflation and gas embolism, guaranteed pneumoperitoneum, and a more anatomical repair of the abdominal wall. Since that time, many surgeons have made some modifications to first Hasson technique. Here we described the way we do the open laparoscopy in our hospital and different positive and useful details we put to original Hasson version.

[THE FIRST EPIDEMIOLOGICAL DATA ABOUT THE HR-HUMAN PAPILLOMA VIRUS TYPES IN SOUTH AND NORTHERN BULGARIA].

The aim of our study were to evaluate the prevalence of HR-HPV infection in women between 15 and 55 years of age in the South and Northern Bulgaria. We have analyzed the HPV status (using DNA-sorb-AM nucleic acid extraction kit) in cervical samples collected during a 3 year period (2010-2012) from 1020 women, aged 15-55 and divided in four age groups, who attended their gynecologists for HPV-DNA cervical test. The rate of the HR-HPV infection was established to be 39.9%. HR-HPV negative were 60.1% of the evaluated subjects. The most commonly isolated genotype in all 407 (100%) infected women was HPV 16 - 190 women (46.7%), followed by HPV 56 - 78 (19.1%), HPV 31- 48 (11.8%) and HPV 33 - 45 (11.1%). To our knowledge, this is the first survey evaluating the prevalence of HR-HPV infection in the South and Northern regions of Bulgarian towns and drawing attention to the unusually high proportion of different HR-HPV.

[NON-HODGKIN'S LYMPHOMA OF THE FEMALE GENITAL SYSTEM--A LITERATURE REVIEW].

Lymphomas are a heterogeneous group of malignant lymph proliferative diseases and represent 3-4% of all neoplastic processes. They are subdivided into Hodgkin's (15%) and non-Hodgkin's (85%). Non-Hodgkin's lymphomas (NHL), depending on their primary location are subdivided into nodal and extranodal. Extranodal forms of NHL represent 25-40% of NHL where only 2% of them concern the female genital system. They develop in the female genital organs primary or secondary invade them. Extranodal NHL genital form is extremely rare and represents 0.5% of all malignant genital diseases. All genital organs may be affected where most lymphomas are localized in the cervix, uterine body and ovary. The clinical picture is nonspecific whichcomplicates the timely diagnosis. A multidisciplinary approach is used for staging of lymph proliferative disease. Treatment of genital form of NHL is determined by the age of the patient and her reproductive intentions, clinical stage, histological variant. Due to the low occurrence there are no widely accepted protocols of behavior and treatment of genital extranodal NHL. The first method of choice is the conservative approach by chemotherapy. The most widely used and most effective is the combination Cyclophosphamide, Doxorubicin, Vincristine and Prednisone (CHOP). According to data in the literature the 5-year survival rate for cervical extranodal NHL is 80%. Surgery should not come into consideration when there are certain indications. The aim of this review is to examine rare cases of non-Hodgkin's genital lymphomas in females and to present opportunities for their diagnosis and treatment.

[Hyperandrogenism in multiple pregnancy].

Hyperandrogenism caused by pregnancy is an extremely rare condition. One of the most common reasons is the hyperreactio luteinalis (LH). The literature describes 51 cases of LH where 8 of them have occurred during spontaneous multiple pregnancy. LH is a result of increased serum concentrations of human chorion gonadotropin (ß-hCG) and increased receptors' sensitivity to ß-hCG. It is characterized by a typical ultrasound image: most often bilaterally massively enlarged ovaries that consist of many of thin-walled small theca-lutein cysts, giving it the appearance of a "spoke wheel". We present a case of a 36 year old woman pregnant for the first time with spontaneously occurred twin pregnancy, who has hyperandrogenism and high blood pressure resistant to therapy. The conducted imaging studies showed enlarged polycystic ovaries resembling cancerous ovarian neoplasia. Recognition of this condition is important as radical surgery, resulting in removal of the ovaries is wrong and incorrect.

[VULVAR INTRAEPITHELIAL NEOPLASIA--TERMINOLOGY, SYMPTOMS AND TREATMENT].

The term vulvar intraepithelial neoplasia (VIN) was introduced for first time in 1986 year from the International Society for the Study of Vulvar Disease (ISSVD). With this term are denoted precancer vulvar conditions. According to a classification dated 1986 depending on the degree of affection of multilayered squamous epithelial vulvar precancerous lesion are subdivided into three groups: VINI, VIN2 and VIN3. Subsequently VIN1 is determinate as a lesion which there isn't oncogenic potential. These types of changes often are result from irritation or viral infection which leads to benign condylomata acuminate. Compare to lesions with VIN require histological signs for high grade intraepithelial neoplasia as nuclear pleomorphism, increased mitotic activity, atypical mitotic activity and disordered architecture of squamous cells epithelium. These fundamental morphologic characterizations lead to revision and subsequent change of the current classification. In 2004 ISSVD changed the classification. It included lesions like VIN2 and VIN3, but they are subdivided in two groups: the usual type VIN and the differentiated VIN. They have different etiology, morphology, oncogenic potential and prognosis. The usual type VIN is associated with infection of high risk types of human papilloma virus and is a more frequently met form of VIN. A very good prognosis is characteristic for it. The differentiated VIN is met in postmenopausal women of about 70 with frequency of about 2-5%. It originated from vulvar dermatosis like lichen scierosus and there is a high oncogenic potential and worse prognosis. The treatment of VIN may be surgical and by medicines. The frequency of recurrences after treatment is 30-50% which required frequently follows up. The aim of this literature review is to introduce present terminological classification of VIN, as well as basic clinical, diagnostically and curative methods in treat of the both types of this precancerous.

[COMPLICATIONS OF DIAGNOSTIC AND OPERATIVE HYSTEROSCOPY--REVIEW].

Hysteroscopy is a diagnostic or surgical mini-Invasive gynecologic operating procedure. The complications of this standard procedure are relatively rare. According to retrospective studies they are 0.95-13.6%. They occur more often by an operative rather than a diagnostic hysteroscopy. These complications could be divided into two groups of an approximately equal occurrence--due to a dilation and passing through the cervix uteri (cervical laceration, creative a false cervix uteri, perforation, bleeding, impossibility to pass through the inner orifice of the cervical canal, insufficiency of the cervix uteri) and due to the operative technique itself (uterine perforation, fluid overload, thermal or mechanical trauma of the inner urinaiy and gastrointestinal tract, infection, rupture of the uterus during a subsequent pregnancy). The most occurring complication is namely the uterine perforation--1-9%, the most severe could indeed be the fluid overload--0.01-11%. The gynecologist performing the hysteroscopy should be well grounded in the typical complications. Unveiling and performing a quick intervention of the latter could prevent unwanted consequences for the patient and the legal issues that could follow occur.

[The primary cancer of fallopian tube--a clinical case].

The primary cancer of the fallopian tube is only 1% of all malignant diseases affecting the female genital tract. The etiology is unknown and is assessed with untypical symptomatic. It often affects women at age over 50 years old. Recently in literature are described about 1200 clinical cases. The primary carcinomaof fallopian tube resembles the epithelial ovarian cancers, which defines the similarity in the diagnosis, treatment and follow up of the patients with such type of pathology. We describe a clinical case of 66 year old woman with primary serous low graded cancer of a fallopian tube. The symptoms were presented of dull pains in the lower part of the abdomen and a little quantity of free fluid in the pelvis. The diagnosis is set after a surgical intervention, based on pathoanatomic results. After the radical hysterectomy with bilateral salpingo-oophorectomy, lymphadenectomy and omentectomy, the patient is treated with adjuvant chemotherapy with platinum and taxane.

[VAGINAL LEIOMYOMA AFTER TOTAL ABDOMINAL HYSTERECTOMY--CLINICAL CASE AND REVIEW OF LITERATURE].

Vaginal myomas are rare benign, mesenchyme, monoclonal tumors. They originate from smooth muscle cells and have a diverse and non-specific clinical feature. They are normally presented as single solid nodules localized in anterior vaginal wall in women between the ages of 35-50 years. Often times they are secondary originating from a cervical or vaginal lesion in woman who had undergone a hysterectomy on account of a myoma. We present a rare case of vaginal myoma localized in the posterior vaginal wall in a patient, who had undergone a total hysterectomy 19 years ago on account of a myoma.

[Diagnosis and treatment of lichen sclerosus--review].

UNLABELLED: Lichen sclerosus (LS) is a chronic skin disease of the vulva which affects mostly women in the postmenopausal period. The disease affects also men and children. Its frequency is from 1/70 up to 1/1000, whereas for women it is 10 times more frequently. The disease has unknown etiology. Due to the high frequency of accompanying, autoimmune diseases, it is presumed that this disease is a result of immunological processes. Some of patients diagnosed with LS have vulvar intraepithelial neoplasia, while 0.3% - 4.9% of them have squamous cell carcinoma. The aim of this review is to summarize our knowledge regarding the frequency, clinical features, diagnosis and therapy of LS in view of the prevention of the complications that may occur. MATERIAL AND METHODS: We researched the available literature and Medline on the topic for the period of 1971 until 2014 year. We summarized the most interesting, contemporary and scientifically substantiated facts regarding this disease. DISCUSSION: Early diagnosis, the proper and timely treatment, as well as the continuous follow up the patients with LS is mandatory due to the fact that the spontaneous remission is extremely rare and the complications may lead to significant deterioration of the quality of life.

[Secondary non-Hodgkin lymphoma of female genital tract].

Non-Hodgkin Lymphomas (NHL) are a separate group of blood diseases, which includes all types of lymphomas, without Hodgkin lymphomas. The incidence of NHL in the female genital system is 0.5% of all the NHL. They develop in the female genital organs primary or affect them secondary. Secondary development of the genital non-Hodgkin's lymphoma we have when the biopsy of a lymph node that precedes the diagnosis of the disease is before the development of a genital tumor or we can find a genital tumor--along with simultaneous involvement of the lymph nodes or extra genital authority. We present a clinical case of 56 years patient with non-Hodgkin's lymphoma with secondary genital involvement. From ultrasonography, computed axial tomography and Tu markers that were maiden we have suspicion for ovarian tumor with mechanical pressure over pyelocalix system due to left hidroureter and left hydronephrosis II degree. That was the only reason for urgent surgical treatment with intraoperative histologic diagnosis of NHL. The postoperative chemotherapy in combination with surgical treatment in our case had a good and long-lasting disease survivor effect. One year after the operation and the chemotherapy in the patient, there is no evidence of relapse.

[Borderline ovarian tumours: a challenge for clinicians].

A retrospective analysis of surgical procedures for ovarian tumours, performed in the Department of General and Oncological Gynaecology at the Military Medical Academy (Sofia, Bulgaria) specified 81% of the tumour cases as benignant ones, 15.6% as malignant ones, and 3.4% as borderline ovarian tumours (BOT). The histological type of BOT was assessed as serous in 62% and as mucinous in 38%. The incidence of BOT was found to increase with increasing age. Most patients with BOT were parous (60%). Serum levels of CA 125 were within normal values in all patients with BOT.