[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.

[Chemotherapy for Malignancy During Pregnancy - Literature Review.]

In today's dynamic development of modern life, we can unfortunately see more and more often cases of malignant diseases during pregnancy. Therapy of these conditions in pregnant women is a challenge to the doctors, due to concerns for the mother's health, but also the possible risks for the foetus. An additional difficulty is the fact that there are no common algorithms for the treatment. Of great importance is the ges'tation period, because in its different parts, the risks vary in grade. It is believed that up to 10-12th ges.tation week chemotherapy should not be included. The optimal time for the last course is 35th gestation week or three weeks to the due date. The purpose of this review is to examine the benefits and risks of the treatment of malignant diseases during pregnancy for both the mother and the fetus.

[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.

[OPEN LAPAROSCOPY--ADVANTAGES AND DISADVANTAGES].

The debate about the safety of penetrating technique in laparoscopy, persist for more than four decades and still does not approach the scientifically valid decision about what method to use: closed with a Veress needle laparoscopic surgery; open laparoscopy; direct placement of troakar without prior to insufflation, visual entry methods. We're meant to look at the advantages and disadvantages of the laparoscopic approach, which we use in the Clinic of Gynaecology of the Military Medical Academy, Sofia, Bulgaria, having conducted a search in the literature and Medline from the year in which it was introduced (1971) to present. The open laparoscopy is the only method that offers a precisely controlled entrance into the abdominal cavity, with low traumas, without serious vascular and organ injuries. The advantages of this procedure are that with proper practice, it takes less time and can be used in all possible situations with low intraoperative risk, even after previous abdominal operations.

[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.

[Vaginal disbacteriosis--social and sexual risk factors].

The vaginal microbe equilibrium could be impaired by different agents. Many of the risk factors can change the preventive mechanisms of the vagina and can lead to inflammation and disease. We even do not suppose about the role of most of them in impairing of vaginal microbe equilibrium. The exact understanding of those risk factors and mechanisms by which they disturb the vaginal microbe balance could reduce female morbidity of vaginal disbacteriosis and vaginal inflammations. The aim of this literature synopsis is to review some of the most frequent risk factors for vaginal disbacteriosis and about how they change vaginal micro-flora with dominant lactobacillus within it. The most informative and detailed articles on the theme which were found in the resent literature as well as in Medline for the period between 1990 and 2012 were selected. The risk agents for vaginal disbacteriosis are: endogenetic, social, sexual, infectious and iatrogenic. The social and sexual factors are the most frequent in our daily round. The intensity and the kind of sexual life, smoking, homosexual connections, vaginal douching and contraception methods are included in them. All these factors depend on us. Thus we hope that through their popularization and discussion will help to prevent the females' health.

[Extra peritoneal anterior pelvic exenteration with total urethrectomy and vaginectomy for bladder and urethra cancer - clinical case and review of literature].

The anterior pelvic exenteration is technically demanding surgical intervention carried out in advanced malignant genito-urethral process origin. It is characterized by a high percentage of intra and postoperative complications. They can be reduced through new surgical techniques, such as extra peritoneal approach to perform this operation. We present a clinical case of 56 years old patient with adenocarcinoma of the urethra/bladder established histologically by TUR (Transurethral) - biopsy. Of the clinical and imaging studies - data for the invasion to the anterior vaginal wall. The patient is after Total Hysterectomy with bilateral salpingo oophorectomy on the occasion of the fibroids in the uterus. After a routine preoperative preparation, we did: extra peritoneal anterior pelvic exenteration with total urethrectomy and vaginectomy. Bilateral extra peritoneal ureterocutaneostomy with "JJ" stents. Bilateral extra peritoneal pelvic lymph dissection. Our clinical case, proves the thesis of many authors about the benefits of extra peritoneal approach for anterior pelvic exenteration. Reduce significantly the intra/post-operative complications, hospital stay and a time to follow postoperative therapy. We consider that the extra peritoneal approach for radical surgery should be applied whenever possible in the interest of the health of the patient.

[Surgery for isolated, pelvic nodal metastasis in surgically staged (G1, FIGO -1) endometrial cancer patient].

A case of surgically staged G1, FIGO 1 endometrial cancer patient with isolated, pelvic nodal metastasis after radical hysterectomy with bilateral salpingo-oophorectomy and selective lymph node dissection. No adjuvant radiotherapy passed. Pre surgery diagnosis was made by Doppler Ultrasound, Angiography, MRI, and PET-CT. A high risk surgery was performed with pelvic lymphonodectomy and resection of big pelvic blood vessels. Aggressive intraoperative infusion therapy was leaded for patient restitution. This particular case raised again the questions about routine systematic pelvic lymphonodectomy and postoperative radiotherapy for first stage (G1, G2) endometrial cancer patients.

[Prevalence of human papillomavirus genotypes in Bulgarian women with atypical cervical lesions examined by colposcopy].

INTRODUCTION: For the first time three studies describing human papillomavirus (HPV) genotype distribution in Bulgaria was presented at 15th National Conference of Oncogynecology (22-25.04.2010; V. Turnovo). Such studies are needed to predict how HPV vaccination and HPV-based screening will influence cervical cancer prevention. AIM: The aim of this study was to determine the types of human papillomavirus (HPV) distribution in Bulgarian women's population (age 16-40 years) with atypical cervical lesions examined by colposcopy. METHODS: The prevalence of type-specific HPV was searched by PCR-DNA in 176 women with positive colposcopic findings (results). RESULTS: Human papillomavirus was found in 105 (59.7%) of the women, while 71 (40.3%) were negative for this virus. From 105 positive for HPV women, 95 (90.5%) were infected with high- risk genotypes and 10 (9.5%) with low-risk genotypes. Among high-risk types, a predominance of HPV-16 (39% of infected women) was shown followed by HPV-56 (17.1%) and HPV-33 (15.2%). 45.7 percent of our patients were infected with single HPV genotype, whereas 54.3% were infected with mixtures of HPV genotypes. CONCLUSIONS: The presence of relatively high percentage of HPV types 33 and 56 and the relatively high incidence of infections with mixture of genotypes are the reasons for obligatory secondary prophylactic procedures (cytology, colposcopy and HPV detection), never.mind HPV vaccination. We find that, there is strong connection between HPV infection and positive colposcopic results.

[Clinical efficacy of a new method for LEEP conization with pistol-shaped electroknife].

The aim of this study is to establish clinical efficacy of a new method for LEEP conization of uterine cervix. The study is open, retrospective, performed at Department of General and Oncogynecology - Military Medical Academy (Sofia, Bulgaria) for the duration from 2007 till Mar 2010. The study includes 37 women at age from 19-50 years with proved high grade CIN (included Ca coil uteri in situ) by abrasion or biopsy. Medical history was collected from all patients enrolled in the study as well as gynecological examination and colposcopy was performed to them. A LEEP with short intra venues anesthesia was performed to the patients. An innovation system for LEEP conization and generator for monopolar currency ERBE VIO 300D was used. The follow up visit was performed one month after the treatment procedure and included gynecological examination and colposcopy (positive/negative atypical colposcopy results). The clinical efficacy of the method was evaluated on the base of histological results. The patients whose histological results show negative endocervical margins were accepted for cured. From 37 patients in total with different stage of dysplasia and carcinoma in situ hospitalized at Clinic of surgical gynecology for surgical treatment, in 33 (89%) there are negative endocervical margins. These patients formed the cured group. In four patients (10.8%) were discovered histological evidences for positive endocervical margins. The LEEP was not the final operative procedure for them. They were included in the uncured group. The final results achieved from the study about the efficacy of the used method LEEP has statistical significance (d.f .= 1, X2 = 2.82, p < 0.05). The data shows that the LEEP eliminate completely the affected by malignant process areas of cervix uteri. The LEEP can be used as a common surgical method in the treatment of the women with high stage of pre-carcinoma and carcinoma in situ coli uteri.