Prevention of intrauterine adhesions.

Intrauterine adhesions are a serious complication that occurs after intrauterine procedures, most often in connection with pregnancy. Manifestations such as amenorrhea, pelvic pain, and infertility for a woman, especially in reproductive age, are serious and together with intrauterine adhesions we call them Asherman's syndrome. Primary prevention after intrauterine procedures is important. Published studies show that the use of hyaluronic acid gel, especially after abortions, leads to the prevention of moderate and severe intrauterine adhesions and also increases the pregnancy rate.

The fertility sparing therapy in ectopic pregnancy.

OBJECTIVE: A review of current knowledge on the possibilities of fertility sparing therapy in case of ectopic pregnancy. METHODS AND RESULTS: Ectopic pregnancy is defined as implantation of an embryo outside the endometrial cavity, most often in the fallopian tube. This dia-gnosis is very common among young women. Ectopic pregnancies can be treated using the following three approaches, which can be combined: expectantly, pharmacologically or surgically. Fertility-sparing salpingostomy may be performed during surgical treatment. Medical (pharmacological) treatment consists in the application of methotrexate with a success rate of 75-96%, depending on the initial level of the free beta subunit of human chorionic gonadotropin (b-hCG). This is a safe treatment with minimal side effects. There is no standardization of the blood b-hCG level limits or of the size of the ectopic pregnancy mass for choosing expectant, surgical or medical treatment. A considerable increase in the rate of Cesarean sections over the last decades has led to an increase in the occurrence of the implantation of the gestational sac in the hysterotomy scar. There are several options to address this dia-gnosis, but none is clearly preferred. This issue is also discussed in the article. CONCLUSION: The goal of ectopic pregnancy treatment is to choose a safe and effective therapy with a low incidence of side effects and maintaining the maximum fertility of women. Properly set indication criteria are most important when choosing the right option.

Endometriosis in postmenopause.

In our review article, we focused on the rare topic of endometriosis in postmenopause. Endometriosis is primarily a disease of women of reproductive age. In postmenopause, atrophy of endometriosis foci usually occurs. However, recurrence or even de novo occurrence of endometriosis in postmenopause has also been described. The prevalence in postmenopause has been reported to be around 2-5%. Factors that may account for the recurrence of endometriosis are exogenously administered estrogens, self-production of estrogens in peripheral adipose tissue, or activation of aromatase in the focus of endometriosis. When hormonal therapy is required, the best results are achieved by administration of Tibolone. Risk factors for recurrence and subsequent difficulties are the extent of endometriosis, the retained uterus and adnexa. Pain was the most common symptom in 43.5% and palpable finding in 28%. Endometriotic cells are capable of proliferation, survival in an ectopic localization and metastasis to distant locations. The risk of malignant transformation is around 1% and the most common are ovarian tumors. Endometriosis-associated ovarian tumors are typically low-grade disease, histologically endometrioid or clear cell carcinomas. Dia-gnosis is based on ultrasound and magnetic resonance imaging. The basis of therapy for newly developed endometriosis or when symptoms associated with the risk of endometriosis appear is a surgical solution, primarily to exclude the cancerous process.

A patient with primary adenocarcinoma of the appendix metastasizing to the ovary.

OBJECTIVE: The aim of this work is to draw attention to the difficulty of differential dia-gnosis of rare adenocarcinoma of the appendix and the histological diversity of ovarian tumors. CASE REPORT: We present a case of a 62-year-old patient sent by an attending gynecologist for the finding of an asymptomatic adnextumor diagnosed during a routine preventive examination. Based on preoperative examinations, a malignant ovarian tumor was suspected. Standard surgery was performed including hysterectomy with bilateral adnexectomy, total omentectomy, appendectomy, pelvic and paraaortic lymphadenectomy. Definitive histopathological analysis revealed a secondary ovarian tumor, with the adenocarcinoma of the appendix appearing to be the primary site. CONCLUSION: Up to 25% of all ovarian tumors are secondary metastatic tumors. Appendix neoplasia should be considered in the differential diagnosis of right-sided adnextumors. Due to their localization, they can only mimic an ovarian tumor during imaging examinations, or they can be the primary origin of an already metastatic ovary, as in our case.

Fertility sparing approach in young women with endometrial cancer.

The incidence of endometrial cancer in young women is increasing, especially in developed countries. Although it is predominantly a disease of peri- and postmenopausal women, there is an absolute increase in younger women of childbearing age who, with today's lifestyle and pushing back maternal needs, do not have fulfilled reproductive plans. About 67% of cancers are diagnosed in the early stages. For these women, fertility-preserving procedures can be considered until reproductive plans are fulfilled. Subsequently, however, definitive management is appropriate even in the absence of carcinoma. This article discusses the most common gynecologic pelvic cancer, endometrial adenocarcinoma, and the possibility of fertility-preserving procedures.

Comparison of complications in very obese women undergoing hysterectomy - Abdominal vs laparoscopic approach with short- and long-term follow-up.

BACKGROUND: Surgical treatment of obese female patients represents a real challenge. Over the last decade, minimally invasive techniques for hysterectomy have emerged. These approaches reduce the invasiveness of standard surgical procedures while maintaining efficacy and feasibility. OBJECTIVE: To evaluate the rates of perioperative, early, mid-term and late postoperative complications in very obese [body mass index (BMI) ≥ 35 and < 40 kg/m2] and severely obese (BMI ≥ 40 kg/m2) women who underwent total (non-radical) hysterectomy. DESIGN: A prospective comparative multi-centre non-randomized study. METHODS: In total, 328 consecutive total (non-radical) hysterectomies were performed at seven teaching gynaecological centres. Of these, 153 (46.6%) were performed using an open laparotomy (LT) approach and 175 (53.4%) were performed laparoscopically (LS). All data were collected by medical specialists at the pre-operative examination prior to surgery, during surgery and three times postoperatively (during hospital stay, at 6-week follow-up and 6 months following surgery). Another analysis considered a total of 206 women who underwent laparoscopic hysterectomy. The subjects were divided according to BMI into 120 very obese women (BMI ≥ 35 and < 40 kg/m2) and 86 severely obese women (BMI ≥ 40 kg/m2). RESULTS: The total number of composite perioperative complications was significantly lower in the LS group (p = 0.006). Composite complications occurred significantly more often in patients in the LT group compared with the LS group in the early (p < 0.001) and mid-term (p < 0.001) postoperative periods. In the late postoperative period, the total number of composite postoperative complications did not differ significantly between the groups (p < 0.396). Among 206 patients who underwent laparoscopic hysterectomy, the number of complications was generally low; the rates of composite perioperative (p = 0.393), early (p = 0.642), mid-term (p = 0.738) and late (p = 1) postoperative complications were generally low; and frequency did not differ significantly with BMI. CONCLUSION: The LS approach does not increase intra-operative morbidity associated with surgery, and has significantly better outcomes in terms of the postoperative complication rate.

Laparoscopic single-stapler technique in rectosigmoid resection in women with deep infiltrating endometriosis.

OBJECTIVE: To demonstrate the use of a single-stapler technique during rectosigmoid resection in women with deep infiltrating endometriosis (DIE). DESIGN: A step-by-step video demonstration of rectosigmoid resection and end-to-end anastomosis using two circularly placed sutures and one circular stapler. SETTING: Institute for the Care of Mother and Child, Prague, Czech Republic. PATIENT(S): A 39-year-old woman presented with primary sterility and deep infiltrating endometriosis, and an EZIAN score of A2,B2,C3. A nodule was located 9 cm from the anus and was 38 × 9 mm in size. This included an intramural fibroma of 6 cm and a left-sided ovarian endometriotic cyst of 6 cm. Her pain on the visual analogue scale were dysmenorea 6, dyspareunia 5-6, dyschezie 7, dysuria 0, and acyclic pain 5. INTERVENTIONS: The primary objective was to replace the linear-stapler resection with two simple, strictly circularly placed sutures, to cut the intestinal wall between them, and to form the end-to-end anastomosis with a circular stapler. The one-stapler technique consisted of the following steps: intestinal wall cleansing as in the limited segmental resection; placement of one strictly circular suture just below the DIE nodule, without fixation; placement of the first circular suture just below the DIE nodule, ideally with at least three full-thickness "bites" of the intestinal wall; placement of the second circular stitch approximately 2 cm below the first one in a similar manner (three full-thickness "bites"); interruption of the intestinal wall with a harmonic scalpel; end-to-end intestinal anastomosis with a circular stapler; and airtightness test of the anastomosis. This results in only one incision line and therefore a lower risk of leakage. Intestinal resection time was on average 10 minutes longer compared to that for the linear stapler technique. So far, we have successfully performed the procedure in 25 women. Perioperative leakage was observed in two of these 25 patients in the classical procedure group and in none of the 25 patients in the group with the one-stapler technique. There were no differences in C-reactive protein (CRP) on third and fifth postoperative days or in other complications such as bleeding and pyrexia). The cost of procedure is lowered by the decrease in the number of staplers from 3 to 1. The patients' postoperative follow-up was uneventful, and they were discharged from the hospital at the same time as the women in whom the classical stapler technique was performed. MAIN OUTCOME MEASURES(S): The primary outcome was the development of a new surgical approach to resection rectosigmoid endometriotic nodules that would decrease the number of incision lines on the intestine. The secondary outcome measures were peri- and postoperative complications (i.e., bleeding, intestinal leakage, postoperative infection, CRP), length of the surgery and hospitalization, and cost of the procedure. CONCLUSION: Multiple incision lines following resection of the rectosigmoid colon and end-to-end anastomosis are risk factors for postoperative intestinal leakage. Therefore, a single incision line formed with two circular sutures, and one circular stapler may reduce the risk of postoperative complications and also financial expenses of the procedure. We believe that this method is suitable and easiest for nodules located less than 6 cm from the anal verge because of possible complications with angulation of linear stapler.

Parasitic leiomyoma - a case report and review of the literature.

OBJECTIVE: The aim of this study is to report a case of parasitic leiomyoma in a brief literature report. CASE REPORT: A 40-year-old woman was repeatedly examined for chronic abdominal pain in 2020. Lesions presented on CT images showed suspicion of carcinomatosis or endometriosis. Her past history is a laparoscopic myomectomy and hysteroscopic transcervical resection of myoma. CONCLUSION: Parasitic leiomyoma or leiomyomatosis peritonealis disseminata is an extremely rare variant of uterine leiomyoma occurring outside the uterus. According to the International Federation of Gynecology and Obstetric classification, parasitic leiomyoma has been classified as type 8. Previous laparoscopic myomectomy with intraperitoneal morcellation has been implicated in its etiology. The most common symptom - if present, is abdominal pain, pressure, bloating during eating or nausea.

Risky sexual behaviour and contraceptive use among young women in the Czech Republic.

OBJECTIVE: This study aimed to obtain sexual and reproductive behaviour data of late adolescent women in the Czech Republic and to analyse the relationships between sexual behaviour and social, demographic, and behavioural factors. METHODS: Data were obtained using the Computer-Assisted Web Interviewing method from 25 April to 2 May 2018 from a representative group of sexually active women aged 18-24 years. Results were statistically evaluated using sign schema on adjusted residuals. RESULTS: A total of 525 women participated (median age of coitarche - 16 years, condom use with/without hormonal contraception - 65%, unprotected sex - 9.3% in the sexual debut). Anamnestic artificial abortion and sexually transmitted disease (STD) rates were 5.3% and 3.8%, respectively. Early coitarche, number of sexual partners, history of abortion, and STDs were positively correlated with current hormonal contraceptive use; the number of sexual partners and use of hormonal contraception were negatively correlated. Hormonal contraceptive users were more likely vaccinated against human papilloma virus (HPV) in comparison with women without any contraception. There was no correlation between risky sexual behaviour, contraceptive use, and socio-demographic factors. CONCLUSION: Women with early coitarche and a high cumulative number of sexual partners have more unwanted pregnancies and STDs; moreover, those with regular coital activity without contraception are less frequently vaccinated against HPV.

Interposition of the mesorectal flap as prevention of rectovaginal fistula in patients with endometriosis.

INTRODUCTION AND HYPOTHESIS: Endometriosis is a gynecological condition characterized by endometrial tissue outside of the uterus. It affects up to 15% of women of reproductive age. In the case of bowel infiltration, about 90% of lesions are localized on the sigmoid colon or the rectum and may interfere with bowel function. Three surgical approaches are possible: (1) shaving technique, (2) discoid resection of the nodule, and (3) segmental resection with end-to-end anastomosis. A rectovaginal fistula is feared as a postoperative complication mainly in simultaneous resection of the vaginal and the rectosigmoid nodules. Its prevention is a two-step surgery (the first operation on the vagina and the second on the colon) or a preventive colostomy, both of which are often thought to be too invasive for a benign condition. Herein, we suggest a one-step surgery to prevent its development. METHODS: In three women, a concomitant laparoscopic resection of the vaginal and rectosigmoid endometrial nodule was completed with interposition of a mesorectal flap. RESULTS: All surgeries were uncomplicated with no rectovaginal fistula in the postoperative period. CONCLUSION: In the hands of skilled surgeons, this one-step technique can be used to prevent rectovaginal fistula development.

Synthetic osmotic dilators for cervical preparation prior to abortion-An international multicentre observational study.

OBJECTIVES: To evaluate the outcomes with the use of Dilapan-S for cervical preparation prior to medical or surgical abortion. STUDY DESIGN: International, multicentre, prospective observational study in women between 6 + 0-24 + 0 weeks' gestation. The study was conducted across 7 study sites in 4 countries, between 1/5/2015 to 31/12/2016. The primary outcomes studied were the number of dilators used and the duration required for cervical preparation prior to abortion. Secondary outcomes were complications of dilator use and infection. Participants were followed-up for 4 weeks post procedure to capture any delayed complications. RESULTS: A total of 483 women were enrolled with 439 women eligible for analysis. Medical abortion was performed in 38% (n = 165) women and surgical abortion in 62% (n = 274). For medical abortions and surgical abortions, an average of 3 osmotic dilators for time interval of 4-7 hours provided effective cervical preparation. Medical abortions were performed as day-case procedures (<12 h) in 81% of women. There was no difference in using either adjunctive misoprostol or Dilapan-S followed by misoprostol for cervical ripening effect to achieve complete medical abortion. Dilapan-S permitted surgical abortions to be performed as same-day procedures (<12 h), in 85% of women regardless of gestational age and without the need to use adjunctive or additional misoprostol. There were no serious adverse events reported with the use of Dilapan-S, including in women with a previous caesarean section. The overall infectious morbidity was 0.9% of cases with no causal relationship with the use of synthetic osmotic dilator use (for a length <24 h). In addition, Dilapan-S was reported as easy to insert and remove in over 90% of women. CONCLUSION: Dilapan-S is a safe and effective method for cervical preparation for medical and surgical abortions up to 24 weeks' gestation. It allows medical and surgical abortions to be performed as day case procedures and is associated with a low complication rate. Future research should aim at directly comparing Dilapan-S and preferred pharmacological agents in a randomised controlled trial.

Macrophages and adipocytes in human obesity: adipose tissue gene expression and insulin sensitivity during calorie restriction and weight stabilization.

OBJECTIVE: We investigated the regulation of adipose tissue gene expression during different phases of a dietary weight loss program and its relation with insulin sensitivity. RESEARCH DESIGN AND METHODS: Twenty-two obese women followed a dietary intervention program composed of an energy restriction phase with a 4-week very-low-calorie diet and a weight stabilization period composed of a 2-month low-calorie diet followed by 3-4 months of a weight maintenance diet. At each time point, a euglycemic-hyperinsulinemic clamp and subcutaneous adipose tissue biopsies were performed. Adipose tissue gene expression profiling was performed using a DNA microarray in a subgroup of eight women. RT-quantitative PCR was used for determination of mRNA levels of 31 adipose tissue macrophage markers (n = 22). RESULTS: Body weight, fat mass, and C-reactive protein level decreased and glucose disposal rate increased during the dietary intervention program. Transcriptome profiling revealed two main patterns of variations. The first involved 464 mostly adipocyte genes involved in metabolism that were downregulated during energy restriction, upregulated during weight stabilization, and unchanged during the dietary intervention. The second comprised 511 mainly macrophage genes involved in inflammatory pathways that were not changed or upregulated during energy restriction and downregulated during weight stabilization and dietary intervention. Accordingly, macrophage markers were upregulated during energy restriction and downregulated during weight stabilization and dietary intervention. The increase in glucose disposal rates in each dietary phase was associated with variation in expression of sets of 80-110 genes that differed among energy restriction, weight stabilization, and dietary intervention. CONCLUSIONS: Adipose tissue macrophages and adipocytes show distinct patterns of gene regulation and association with insulin sensitivity during the various phases of a dietary weight loss program.