Efficacy of sling procedures for treatment of female stress urinary incontinence.

The aim of this study was to determine the efficacy and surgical outcome of the sling procedures in stress incontinent women in comparison to conventional anterior colporrhaphy. Total of 56 patients with stress urinary incontinence (SUI) were treated with sling procedure between November 2011 and March 2013, 39/56 (69.6%) with suprapubic arc (SPARC) and 17/56 (30.4%) with MiniArc method. During the same period total of 49 patients with SUI were treated with traditional anterior colporrhaphy according to Bagovid method as the control group. All patients were prospectively clinically assessed over aperiod of 3, 6 and l2 months after surgery. The objective cure rate after the follow-up was 92.9% (52/56) in observed group of patients and 79.6% (39/49) in control group and improvement was occurred in rest of 5.4% (3/56) and 18.4% (9/49), respectively (p < 0.05). The overall complications rate was significantly lower in the observed group of patients than in the control group, 12.5% (7/56) vs. 28.6% (14/49), (p < 0.05). In the sling group was postoperatively noticed slightly higher rate of urinary incontinence, but in the colporrhaphy group was emphasized rate of urinary retention. Only one from the each group of patients failed the surgical procedure and required additional correction for SUI. The mean operating time for SPARC and MiniArc procedure was 19 +/- 7 and 9 +/- 5 minutes, respectively (p < 0.0001). Mean duration of hospitalization was significantly shorter in the sling group of patients (2.6 +/- 1.0, range 2-7) days than in the control group of (9.6 +/- 1.8, range 6-18), (p < 0.001 < 0.0001). According to presented results, sling is a highly effective method in patients with SUI with low incidence of perioperative complications, promising long-term results and high patient's satisfaction.

[P16NIK4a expression in premalignant cervical lesions]. / Ekspresija stanicnog proteina p16INK4a kod premalignih promjena vrata maternice.

Increased expression of viral E6 and E7 oncoproteins within the host cells results in an increase in cellular protein p16INK4a expression. That increase may serve as a marker for dysplastic and neoplastic cells of the uterine cervical epithelium. The aim of this study is to assess the p16INK4a protein expression in different stages of cytological abnormality in correlation with the proven high oncogenic risk human papillomavirus infection in order to demonstrate its value as the diagnostic marker. The study included cervical smear samples of 371 patient in whom the viral typization was done. In 171 patient, during their regular gynaecological examination, along with conventional Pap smear sampling an additional smear was taken. Two hundred cervix brush (Rovers Medical DevicesOss, the Netherlands) samples were obtained and analyzed by the LBC method and the ThinPrep2000 machine. All samples were analyzed cytologically, classified according to the Bethesda system, and immunostained with the p16INK4a-specific monoclonal antibody E6H4 (MTM Laboratories, Heidelberg, Germany). A significant difference is seen in p16 positivity between the cytological diagnosis of a high grade cervical squamous intraepithelial lesion and the group with mild dysplasia (chi2=146,48; D.F.=4; p<0,01) while most of the mild dysplastic lesions were p16 negative. In cases of p16 positive mild dysplastic lesions, that positivity is the result of viral integration into the host genome, which would imply lesions at high risk of further progression. The potential and value of p16INK4a protein not only as a prognostic, but also as a diagnostic factor is proved in this way. Reproducibility of the p16 staining technique renders it suitable for follow-up monitoring as well as for comparison of the cytological results.

[Clear cell carcinoma of the endometrium confined to atrophic endometrial polyp--case report]. / Endometralni karcinom svijetlih stanica u atroficnom endometralnom polipu--prikaz bolesnice.

Clear cell carcinoma is a rare form of endometrial carcinoma inline type II estrogen-independent. It accounts for only 1% to 5.5% of all endometrial carcinomas. It is usually detected in postmenopausal women, who are older than those with endometrioid carcinoma. Clear cell carcinoma may exhibit solid, papillary, tubular and cystic patterns. The malignant cells are characterized by a moderate amount of clear or foamy cytoplasm; however, its recognition as a clear cell type of cancer cytologically is not often possible. The tumor is usually poorly differentiated, tends to be high grade, with deep myometrial invasion, lymphovascular space invasion, and metastasis in pelvic lymph node. That is why this tumor has a poor prognosis, as in our case of a 72-year-old woman with symptoms of deficient uterine bleeding. In a period of two months, two suction endometrial curettages were performed. The material obtained by endometrial curettage for histopathologic verification was very scanty. The assessment described an inactive endometrium with degenerative epithelial cells in scanty necrotic background. Direct endometrial samples with uterobrush yielded a finding of atypical epithelial cells of open etiology with dense chromatin and prominent nucleoli, also with foam cell histiocytes and old blood in the background. Cytologic diagnosis of intraepithelial lesion, possible adenocarcinoma was made. Ultrasonography of the uterus was suspect of neoplasm. After surgery, the pathologic diagnosis of endometrial clear cell carcinoma was made. It was a rare case of aggressive type of endometrial carcinoma confined to an atrophic endometrial polyp. In conclusion, we might say that direct endometrial sample can provide accurate diagnosis of endometrial tumor, especially when the endometrial tumor is a small one, thus saving time for diagnostic testing. This is based on the potential of cytology to make malignant diagnosis possible even with a few tumor cells on the slide.

Vulvar Paget's disease--a case report.

Vulvar Morbus Paget (MP) represents a rare intraepithelial adenocarcinoma. It accounts for less than 1% of all vulvar neoplasia and usually appears in postmenopausal women. Histologically it is analogous to Paget's disease of the breast. The most common clinical symptom is pruritus. The lesion appears as an erythematous or as an eczematous lesion with islands of hyperkeratosis. Occasionally, single anaplastic Paget's cells can be found on the vulvar smears which make cytological diagnosis of the disease possible. However, the disease can be diagnosed only by biopsy. We present a case of 49-year old woman with vulvar symptoms of pruritus, who had liver and kidney transplantation two years ago. During the standard gynecological examination the vulvar smear was taken for cytological evaluation. The smear was scanty, with inflammatory background, overloaded with squamae. There were two types of cells: dysplastic squamous cells from lower layer of the epithelium and the single, anaplastic cells with a high nuclear:cytoplasmic ratio who possessed eccentric, large nucleus. Nucleoli were rare. Cytoplasm varied from pale and delicate to densely basophilic. Accordingly, cytological diagnosis vulvar intraepithelial neoplasia (VIN III) with differential diagnosis of vulvar Paget's disease was made. The pathological verification supported the diagnosis of MP and an immunohistochemistry panel confirmed type III of Paget's disease and an evaluation of bladder was suggested.

In-vitro fertilization resulting in heterotopic pregnancy, ovarian hyperstimulation and paralytic ileus: A case report.

Heterotopic pregnancy followed by ovarian hyperstimulation syndrome and paralytic ileus are rare and potentially fatal complications associated with assisted reproduction. A 37-year-old nulliparous woman, after in-vitro fertilization and embryo transfer, presented to the gynaecology department with severe abdominal distension, diffuse abdominal pain and vaginal bleeding. Transvaginal ultrasound examination revealed an intrauterine pregnancy, with both ovaries enlarged, measuring 10cmx10cm, with free fluid in the pouch of Douglas. Another gestational sac was visualized in the left adnexal region with a viable pregnancy, crown-rump length (CRL) 6.6 mm at 6 weeks of gestation. Left salpingectomy via laparotomy and uterine evacuation were performed. The patient's postoperative course was complicated by the development of ovarian hyperstimulation syndrome and paralytic ileus. The patient recovered well after receiving supportive therapy. Clinicians should always be aware of the complications associated with assisted reproductive techniques.

Advantages and disadvantages of hysterosonosalpingography in the assessment of the reproductive status of uterine cavity and fallopian tubes.

BACKGROUND: Hysterosonosalpingography as a contrast ultrasound method is safer, cheaper and easier to perform than hysterosalpingography in the assessment of the uterine cavity and fallopian tubes. Is it feasible for all patients? Which is the main problem in the evaluation of target structures by ultrasound? METHODS: In a prospective study, 68 patients in the initial stage of the infertility treatment were examined by hysterosonosalpingography using saline NaCl infundibile and Echovist as contrast media. Subsequently, further status of the tubes and uterine cavity was assessed by the "gold standards", laparoscopy and hysteroscopy. RESULTS: Sensitivity and specificity of hysterosonosalpingography using NaCl infundibile for evaluation of the uterine cavity was 100 and 88.8%, respectively. Negative predictive value was 100% and positive predictive value 97%. Sensitivity and specificity of the method for the assessment of the tubal status was 100 and 66%, respectively, negative predictive value was 100% and positive predictive value was 61%. For the assessment of tubal patency using positive contrast Echovist the method has shown 100% sensibility and negative predictive value again but it reached a specificity of 77% and a positive predictive value of 70%. There were no evident complications during or after the procedure. CONCLUSION: Hysterosonosalpingography is useful in making decisions regarding further procedures for the diagnosis and treatment of infertility. Uterine cavity evaluation using saline is the method of choice. Tubal patency can be assessed only under ideal sonographic conditions. The method is feasible for early assessment of the reproductive status of uterine cavity and fallopian tubes as a simple, safe and cheap outpatient method prior to any following invasive procedure or even histerosalpingography.

Wilson's disease in pregnancy.

Wilson's disease is a rare autosomal recessive disorder of copper metabolism. It causes cirrhosis of the liver, consequently followed by disorder of the menstrual cycle and infertility. Successful decopperizing may lead to restoration of the ovulatory cycle and enable pregnancy. Increased copper levels may cause preeclampsia, intrauterine growth restriction and neurologic damages in the fetus. Pregnant women with decompensated liver cirrhosis face more complications, including bleeding from esophageal varices, liver failure, encephalopathy, and rupture of the splenic artery. We present a case of Wilson's disease in a patient who had spontaneously conceived three times. The first pregnancy ended with delivery of a healthy baby at term. In second pregnancy, medically induced abortion was performed in the 12th week because of deterioration of the underlying disease, liver cirrhosis with portal hypertension. In the same year, the patient underwent liver transplantation. Two years after the transplantation, the patient spontaneously conceived and delivered vaginally a healthy child.

Successful term pregnancy after B-Lynch compression suture in a previous pregnancy on account of massive primary postpartum hemorrhage.

A case is presented of a successful term pregnancy in a 28-year-old secundipara after previous Misgav-Ladach cesarean section and B-Lynch compression suture on account of massive postpartal hemorrhage caused by uterine atony. On account of dystocia and relative cephalopelvic disproportion, secondary repeated cesarean section was performed; she gave birth to a live child 3,900 g/52 cm, Apgar score 9/10, with a regular neonatal course. During the repeated cesarean section, thin laces of connective tissue were found along the sutures placed on the uterus during the previous B-Lynch operation. Pelvic and intrauterine adhesions were not found.