["Second look" after laparoscopic myomectomy--is that a prevention of postoperative adhesions].

OBJECTIVE: To investigate the risk of adhesions after laparoscopic myomectomy (LM). To establish the percentage of adhesions, their kind, situation and magnitude. MATERIALS AND METHODS: For the period form June 2011 to November 2013 totally 81 patients were operated by LM. In the study only patients with intramural leymyomas bigger than 5 sm were included. For this period 14 patients had second-look because of the need of another operation--LS or Ceasarean section. 22 myoma incisions were checked. We established 35.7% adhesions per patient. After LM adnexas were engaged in 14.2%. CONCLUSION: The factors, responsible for the formation of postoperative adhesions are: the location of the myoma in the posterior uterine wall, excessive accumulation of suturing materials and additional operative interventions. For patients underwent LM and willing pregnancy we recommend second look laparoscopy.

[Richter's sacrospinous ligament fixation and its place in current gynecology].

In 1968 K. Richter treated post-hysterectomy prolapse of the vaginal stump by fixating the vaginal stump to the sacrospinous ligament via transvaginal route. Nowadays most authors perceive this technique as an inseparable component of vaginal hysterectomy, for the purpose of preventing vaginal stump prolapse. The authors present the results of Richter's operation among 53 patients, 33 of whom operated on in the Department of General and Oncological Gynaecology at the Military Medical Academy (Sofia), 12 operated on in the Department of Gynaecology at the Military Medical Academy (Varna), 4 in the Municipal Maternity Hospital "St Sofia" (Sofia) and 4 in the Department of Obstetrics and Gynaecology at the Multi-profile Hospital for Active Medical Treatment (Samokov) during the period 2009-2013. In 26 of the cases (49%) the operative indication was a severe vaginal descensus, in 23 (44%)--total uterine prolapse, in 4 (7%)--prolapse of the vaginal stump following hysterectomy. Twenty-six of those women (56%) didn't have any symptoms of urinary incontinence, as 20 (38%) had symptoms of urinary stress incontinence. The median age of operated women is 64 (age range: 43-78 y.o.). All of them experienced at least once a vaginal birth (average parity: 2). The average duration of subjective complaints caused by their condition was 41 months (range: 2-120 months.) The average duration of the operation was 122 minutes (range: 60-210 min). The average amount of blood lost during the operation was 218 ml (range: 60-400 ml). No intraoperative complications were registered. Early postoperative complications consisted in 3 cases of considerable bleeding through the stitches which faded without any special measures, blood transfusion included. One patient developed a haematoma in the ischiorectal fossa which was incised and evacuated. The long-term results, recorded at post-op visits 1 and 6 months after the operation, were satisfactory: regardless their age and their preoperative genital status, surgery in 93% of the cases has led to stable correction of the pelvic statics and disappearance of urinary incontinence in case the latter did exist. Recurrent prolapse was noted in 4 cases (7%), in two of which the condition was diagnosed as a partial recurrence. The authors regard those recurrences as resulting from technical errors, rather than as a shortcoming of the surgical procedure.

[Pregnancy and vaccinoprevention].

Vaccinations protect woman and her fetus against different infectious diseases, but their application on pregnant should be extremely responsible. In this review I present information about some infectious diseases and vaccines during pregnancy. Women, planning to get pregnant should be advised to do serological tests in order to find out their immune status against some infections, leading to fetal congenital malformations (rubella, chicken pox, hepatitis B) and if necessary to get vaccinated at least a month before pregnancy. Despite the lack of vaccines against Cytomegalovirus (CMV), parvovirus 19 and Toxoplasma gondii it is good to know woman's immune status against these infections in order to clarify the clinical approach in case of future contact with sick or carriers. Parvovirus 19 could cause fetal death, while CMV could be transmitted to the child. Immune women wouldn't get sick and wouldn't transmit Toxoplasmagondii to the fetus during pregnancy. Recommended vaccines before pregnancy include vaccines against flu, human papilloma virus, MMR (morbilli, measles, rubella), Tdap (tetanus, diphtheria, whooping cough), chicken pox. CDC-Atlanta recommends during pregnancy two vaccines--against flu, in case it wasn't done before pregnancy, and Tdap during every pregnancy between 27-th and 36-th gestation week. Whooping cough is very dangerous for the baby during the first two months after birth, while it is not yet vaccinated. From this point of view it is of best interest of the mother to have strong immunity in order to transfer antibodies during breastfeeding, as well as for the father and the rest who will take care for the newborn child to be vaccinated against whooping cough. During pregnancy vaccinations against tuberculosis, morbilli, measles, rubella, meningococcal disease, typhoid fever and chicken pox are contraindicated. In case of contact vaccinations against rabies, anthrax, small pox, poliomyelitis and yellow fever should be taken into consideration. Immediately after birth, if the vaccination against whooping cough is missed young mother vaccination is recommended. The vaccination is one of the greatest achievements of the modern medicine, but it is still an object of vigorous attacks, concerning used products safety. One of the most spreading fears is about sterility after vaccination. Over a period of three years (2009-2012) 563 women were vaccinated by SACMEH against HPV. Forty two of them (13.40%) interrupt vaccination due to pregnancy (18 of them after the first shot and 24 after the second shot). Our observations show, that this vaccine is carried out good by the patients, tit is safe and does not cause sterility.

[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.

[Cervical intraepithelial neoplasia: an attempt to propose rules for good medical practice].

The authors emphasize the advantages of the term "cervical intraepithelial neoplasia" (CIN) over "dysplasia" and "carcinoma-in-situ". The rules for good medical practice in treating CIN are based on several starting points, namely: proven role of the human papillomavirus (HPV) in the development of CIN; current possibilities to diagnose and to prevent HPV infections; morphological stigmata of CIN within the epithelium; possibilities to treat CIN and lack of possibilities to treat HPV infection; assessment of the patient 's reproductive potential. In recent cases of CIN1 the history of anti-HPV vaccination is an important factor in choosing the best treatment protocol. In cases of persistent CIN1 treatment protocols are influenced by the presence/absence of high-risk types of HPV. In recent cases of CIN2 treatment protocols vary according to the extent of the lesion, as well as its penetration within the cervical canal. The latter sign is of foremost importance in recent cases of CIN3. Treatment protocols for all the above mentioned conditions, for persistent CIN2 and CIN3,as well as for post-treatment recurrences are presented in flow chart form. Patients' age and reproductive potential should be taken into consideration in selected cases of CIN2+. CIN in pregnant patients deserves a more conservative approach.

[Radical trachelectomy -- surgery for preserving woman's fertility in patients with invasive cervical cancer].

For the past 15 years gynecological oncologists have been seeking ways to preserve woman's fertility when treating invasive cervical cancer. Many cases of cervical cancer are diagnosed in young woman who wish to preserve their fertility. As more women are delaying childbearing, fertility preservation has become an important consideration. The standard surgical treatment for stage IA2-IB1 cervical cancer is a radical hysterectomy and bilateral pelvic lymphadenectomy. This surgery includes removal of the uterus and cervix, radical resection of the parametrial tissue and upper vagina, and complete pelvic lymphadenectomy. Obviously, the standard treatment does not allow future childbearing. For some women with small localized invasive cervical cancers, there is hope for pregnancy after treatment. Radical trachelectomy is a fertility-sparing surgical approach developed in France in 1994 by Dr. Daniel Dargent for the treatment of early invasive cervical cancer. The radical trachelectomy operation has been described and performed abdominally, assisted vaginally by laparoscopy and robotically.

[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.

[Treatment of life-threatening bleeding in obstetrics and gynaecology --NovoSeven (recombinant factor VIIa)].

The study offers the results from the application of recombinant factor VIIa (NovoSeven) in 19 patients with obstetric or gynaecological problems showing severe haemorrhage of non-surgical origin, which could not be controlled by standard therapy (surgery and resuscitation). Haematological and haemostaseological values as well as final outcome are being monitored. The role of the drug and its special indications in complex urgent treatment of life-threatening bleeding are being discussed. Conclusions. The use of NovoSeven (recombinant factor Vlla) on time and when indicated guarantees rapid and effective haemostasis. Thus laparotomy or relaparotomy can be avoided. If no effect is observed after the application of NovoSeven indicates bleeding from a major blood vessel, demanding laparotomy and surgery. The use of the drug leads to reducing the incidence of blood derivatives transfusions and (being a recombinant product)--no risk of transmissive infections.