Intraoperative temporary internal iliac arterial occlusion (Polat's technique) for severe placenta accreta spectrum: A description of the technique and outcomes in 61 patients.

OBJECTIVE: To report the results of prophylactic use of intraoperative temporary internal iliac arterial occlusion by Bulldog clamps in patients clinically diagnosed with abnormally invasive placenta. METHODS: This retrospective study included 61 patients diagnosed with FIGO grade 3 abnormally invasive placenta between January 2018 and March 2022. After transfundal incision and fetal delivery, bilateral temporary internal iliac arterial occlusion by Bulldog clamps was performed in all patients. The grades 3b and 3c group underwent cesarean hysterectomy whereas selected cases of grade 3a abnormally invasive placenta underwent fertility-preserving procedures. Preoperative and postoperative findings were compared. RESULTS: Cesarean hysterectomy was performed in 50 (82%) patients and cesarean plus conservative procedures were performed in 11 (18%) patients. Intraoperative blood replacement was not performed in 83.6% of all patients. Mean blood loss was 1.37 ± 0.53 L (range 0.5-2.5) in all patients. Estimated blood loss was significantly higher in cesarean hysterectomy group. There was no statistically significant difference between two groups in terms of peroperative blood replacement, bladder, and ureteral injury. CONCLUSION: Prophylactic bilateral temporary internal iliac arterial occlusion by Bulldog clamps should be performed in cases of grade 3 abnormally invasive placenta. Fertility-preserving steps may be undertaken safely in selected cases with this approach.

Knowledge, preventive behaviors and risk perception of the COVID-19 pandemic: A cross-sectional study in Turkish health care workers.

The coronavirus disease 2019 (COVID-19) outbreak spread to over 100 countries with a total of 100,000 cases during the first week of March 2020. Health care workers, as those on the frontline of the COVID-19 pandemic, are more susceptible to infection. Inadequate related knowledge and preventive behaviors among health care workers might lead to delayed treatment and result in the rapid spread of the infection. Therefore, this study evaluated the knowledge of health care workers with regard to COVID-19. A cross-sectional study was conducted from June 10-18, 2020. Participants were general practitioners, specialists, and nurses working at the forefront of the pandemic. Their knowledge, preventive behaviors, and risk perceptions concerning COVID-19 were evaluated using an online questionnaire created by our medical specialists. The questionnaire consisted of 29, 5, and 4 items about COVID-19 knowledge, preventive behaviors, and risk perceptions, respectively. A total of 251 health care workers completed the questionnaire. The mean age of the participants was 33.88±8.72 years old, and the sample consisted of 68 males (27.08%) and 183 females (72.91%). While there was no difference between the percentage of correct answers given by female and male participants to knowledge-based questions (p>0.05), the percentage of correct answers to the questions on preventive behaviors was significantly higher in female participants than in males (p<0.001). The overall average percentages of correct responses were 91.66% for knowledge-based questions and 85.96% for preventive behavior questions. The scores for knowledge-based questions were higher for medical specialists, whereas nurses scored higher on preventive behavior questions. Government hospital staff showed a significant difference in preventive behaviors compared to that of university hospitals (p<0.05). In addition, there was a positive correlation between knowledge scores and preventive behaviors. Although all the participants (100%) knew that contracting COVID-19 can lead to death, only 66.93% of them were willing to get vaccinated themselves. The knowledge level of health care workers concerning COVID-19 was above 90%, but the level of competence in terms of preventive behaviors was found to be low, especially in males.

Assessment of palliative care training in gynaecological oncology: a survey among European Network of Young Gynae-Oncologists (ENYGO) members.

INTRODUCTION: Palliative care is an important aspect of gynaecological oncology practice. In order to successfully integrate end-of-life (EOL) care in the disease trajectory, it is crucial to incorporate systematic training in subspecialty programmes in gynaecological oncology. We aimed to evaluate the quality of training in palliative care across gynaecological oncology fellows in Europe and to provide a framework to facilitate learning opportunities. METHODS: A web-based questionnaire was sent to members of the European Network of Young Gynae-Oncologists (ENYGO). The survey consisted of 36 items covering six domains: respondents' characteristics, quality and quantity of teaching, curriculum achievements, observation and feedback, EOL clinical practice and attitudes about palliative care. RESULTS: Of the 703 clinicians enrolled in the study, 142 responded (20.2%). Although the majority worked in university hospitals, only half of them (47%) were in a formal subspecialty programme. The majority of respondents (60%) were trained without a mandatory rotation in palliative care units and considered the quality of EOL care teaching as 'very poor' or 'poor' (57.7%). The majority of respondents (71.6%) did not receive any supervision or feedback at the time of their first consultation on changing the goals of care. CONCLUSION: Our study underlines lack of structured teaching and supervision in palliative care contents among European fellows in gynaecological oncology. Broad education of healthcare providers is a key factor to achieve the integration of palliative care in gynaecological oncology practice. Stakeholders like European Society of Gynaecological Oncology/ENYGO play an important role to facilitate educational activities and training programmes targeting to EOL care.

Performing gynecologic cancer surgery during the COVID-19 pandemic in Turkey: A multicenter retrospective observational study.

OBJECTIVE: To report the perioperative outcomes of 200 patients with gynecologic cancer who underwent surgery during the Novel Coronavirus Disease (COVID-19) pandemic and the safety of surgical approach. METHODS: Data of patients operated between March 10 and May 20, 2020, were collected retrospectively. Data were statistically analyzed using IBM Statistical Package for the Social Sciences (SPSS) Statistics for Windows v. SP21.0. RESULTS: Data of 200 patients were included. Their mean age was 56 years. Of the patients, 54% (n=108), 27.5% (n=55), 12.5% (n=25), and 2% (n=4) were diagnosed as having endometrial, ovarian, cervical, and vulvar cancer, respectively. Of them, 98% underwent non-emergent surgery. A minimally invasive surgical approach was used in 18%. Stage 1 cancer was found in 68% of patients. Surgeons reported COVID-related changes in 10% of the cases. The rate of postoperative complications was 12%. Only two patients had cough and suspected pneumonic lesions on thoracic computed tomography postoperatively, but neither was positive for COVID-19 on polymerase chain reaction testing. CONCLUSION: Based on the present findings, it is thought that gynecologic cancer surgery should continue during the COVID-19 pandemic while adhering to the measures. Postponement or non-surgical management should only be considered in patients with documented infection. Gynecologic cancer surgery should continue during the COVID-19 pandemic while adhering to measures. Only 1% of patients developed COVID-19-related symptoms during the postoperative follow-up period.

Prognostic factors in patients with vulvar cancer: the VULCAN study.

OBJECTIVE: This study aimed to analyze the prognostic factors for overall and progression-free survival in patients with vulvar cancer. METHODS: This international, multicenter, retrospective study included 2453 patients diagnosed with vulvar cancer at 100 different institutions. Inclusion criteria were institutional review board approval from each collaborating center, pathologic diagnosis of invasive carcinoma of the vulva, and primary treatment performed at the participating center. Patients with intraepithelial neoplasia or primary treatment at non-participating centers were excluded. Global survival analysis and squamous cell histology subanalysis was performed. RESULTS: After excluding patients due to incomplete data entry, 1727 patients treated for vulvar cancer between January 2001 and December 2005 were registered for analysis (1535 squamous, 42 melanomas, 38 Paget's disease and 112 other histologic types). Melanomas had the worse prognosis (p=0.02). In squamous vulvar tumors, independent factors for increase in local recurrence of vulvar cancer were: no prior radiotherapy (p<0.001) or chemotherapy (p=0.006), and for distant recurrence were the number of positive inguinal nodes (p=0.025), and not having undergone lymphadenectomy (p=0.03) or radiotherapy (p<0.001), with a HR of 1.1 (95% CI 1.2 to 1.21), 2.9 (95% CI 1.4 to 6.1), and 3.1 (95% CI 1.7 to 5.7), respectively. Number of positive nodes (p=0.008), FIGO stage (p<0.001), adjuvant chemotherapy (p=0.001), tumor resection margins (p=0.045), and stromal invasion >5 mm (p=0.001) were correlated with poor overall survival, and large case volume (≥9 vs <9 cases per year) correlated with more favorable overall survival (p=0.05). CONCLUSIONS: Advanced patient age, number of positive inguinal lymph nodes, and lack of adjuvant treatment are significantly associated with a higher risk of relapse in patients with squamous cell vulvar cancer. Case volume per treating institution, FIGO stage, and stromal invasion appear to impact overall survival significantly. Future prospective trials are warranted to establish these prognostic factors for vulvar cancer.

The Basics of Sentinel Lymph Node Biopsy: Anatomical and Pathophysiological Considerations and Clinical Aspects.

Sentinel lymph node (SLN) is the first node to receive the drainage directly from a tumor. Detection and pathological examination of the SLN is an important oncological procedure that minimizes morbidity related to extensive nodal dissection. SLN biopsy was first reported in 1960 but took approximately 40 years to come into general practice following reports of good outcomes in patients with melanoma. After many years of observation and research on its use in various malignancies SLN biopsy has become the standard surgical treatment in patients with malignant melanoma, breast, vulvar, and cervical cancers. Along with the introduction of new technologies, such as the fluorescent dyes indocyanine green (ICG) and near-infrared fluorescence (NIR), and pathologic ultrastaging, SLN detection rate has increased and false-negative rate has decreased. This literature review aimed to present an overview of the basic concepts and clinical aspects of SLN biopsy in the light of the current research.

Mycoplasma hominis profile in women: Culture, kit, molecular diagnosis, antimicrobial resistance, and treatment.

OBJECTIVES: Mycoplasma hominis (M.hominis) infections are sexually transmitted and usually associated with urogenital and respiratory diseases. The aim of our study was to (i) detect M. hominis in the vaginal and urine samples of sexually active women using three different detection methods and (ii) to determine the antimicrobial susceptibility and recurrence after the treatment. METHODS: Both vaginal and urine samples were collected from 110 sexually active women at the Obstetrics and Gynecology Clinic, Baskent University Ankara Hospital, Turkey, between March 2015 and February 2016. The presence of M. hominis in the vaginal and urine samples was detected by in vitro culture, two biochemical diagnostics kits (Mycoplasma IES (Autobio, China) and Mycoplasma IST-2 (BioMérieux, France) and PCR. The antibiotic susceptibility of each sample was tested using the kits. The women positive for M. hominis were treated either singly or along with their sexual partners by tetracycline. RESULTS: M. hominis was detected in 72 of 220 (32.7%) samples (both vaginal and urine). Of which 37 showed contrary results with two different kits and then were confirmed by PCR. In 13 samples the IES kit identified M. hominis missed by IST-2, and in 8 samples the MIST-2 kit identified M. hominis missed by IES, while both kits missed 6 samples that were agar culture positive for M. hominis." The highest susceptibility rate was observed against pristinamycin (100%), followed by 91%, 83%, and 75% for doxycycline, tetracycline, and josamycin, respectively. Twenty-five patients treated with tetracycline were followed after one month. The recurrence of M. hominis was not observed in any of the 18 cases where both sexual partners were treated but recurred in 5 of the 7 singly treated women. CONCLUSIONS: The rate of M. hominis detection was significantly higher in the vaginal samples compared to the urine samples. The probability of detecting M. hominis by IST-2 kit was 1.18 times less than IES kit (p < 0.001). When the relationship between the samples was examined, the difference between IES and IST-2 for detecting M. hominis was statistically significant (p < 0.01). Antibiotic susceptibility tests indicated that the tetracycline group of antibiotics was effective in eliminating M. hominis when given to both the sexual partners.

Oncological outcome of surgical management in patients with recurrent uterine cancer-a multicenter retrospective cohort study-CEEGOG EX01 Trial.

OBJECTIVES: To assess the survival of patients who have received an operation for recurrent cervical and endometrial cancer and to determine prognostic variables for improved oncologic outcome. METHODS: A retrospective multicenter analysis of the medical records of 518 patients with cervical (N = 288) or endometrial cancer (N = 230) who underwent surgery for disease recurrence and who had completed at least 1 year of follow-up. RESULTS: The median survival reached 57 months for patients with cervical cancer and 113 months for patients with endometrial cancer after surgical treatment of recurrence (p = 0.036). Histological sub-type had a significant impact on overall survival, with the best outcome in endometrial endometrioid cancer (121 months), followed by cervical squamous cell carcinoma, cervical adenocarcinoma, or other types of endometrial cancer (81 vs 35 vs 35 months; p <0.001). The site of recurrence did not significantly influence survival in cervical or in endometrial cancer. Cancer stage at first diagnosis, tumor grade, lymph node status at recurrence, progression-free interval after first diagnosis, and free resection margins were associated with improved overall survival on univariate analysis. On multivariate analysis, the stage at first diagnosis and resection margins were significant independent predictive parameters of an improved oncologic outcome. CONCLUSION: Long-term survival can be achieved via secondary cytoreductive surgery in selected patients with recurrent cervical and endometrial cancer. An excellent outcome is possible even if the recurrence site is located in the lymph nodes. The possibility of achieving complete resection should be the main criterion for patient selection.

Single-port hysterectomy: robotic versus laparoscopic.

This study evaluated the feasibility and safety of robotic single port hysterectomy and laparoscopic single port hysterectomy, and to compare the perioperative parameters of the two systems. Twenty patients underwent robotic single port hysterectomy and 25 patients underwent laparoscopic single port hysterectomy. All hysterectomies were successfully performed via a single port and there were no conversions to conventional multi-port laparoscopy, multi-port robotic, open surgery, or vaginal surgery. The median operative time and hysterectomy time in robotic and laparoscopic groups were 90 vs. 90 min (P 0.74), 57.5 vs. 60 min (P 0.17), respectively. The median estimated blood loss was 40 ml in the robotic group and 50 ml in the laparoscopic group (P 0.77). No operative and post-operative complications were observed in the two groups. The median time to discharge from the hospital was one day for both techniques (P 0.17). Robotic and laparoscopic single port systems are feasible and safe for hysterectomy operation in terms of operative time, conversion to laparotomy or multiport laparoscopy/robotic rates, complication rates, and postoperative results in the hands of experienced surgeons. The possible benefits of robotic single port surgery compared with conventional laparoscopy should be evaluated in further randomized controlled studies.

Comparison of three different risk-stratification models for predicting lymph node involvement in endometrioid endometrial cancer clinically confined to the uterus.

OBJECTIVE: To compare the clinical validity of the Gynecologic Oncology Group-99 (GOG-99), the Mayo-modified and the European Society for Medical Oncology (ESMO)-modified criteria for predicting lymph node (LN) involvement in women with endometrioid endometrial cancer (EC) clinically confined to the uterus. METHODS: A total of 625 consecutive women who underwent comprehensive surgical staging for endometrioid EC clinically confined to the uterus were divided into low- and high-risk groups according to the GOG-99, the Mayo-modified, and the ESMO-modified criteria. Lymphovascular space invasion is the cornerstone of risk stratification according to the ESMO-modified criteria. These 3 risk stratification models were compared in terms of predicting LN positivity. RESULTS: Systematic LN dissection was achieved in all patients included in the study. LN involvement was detected in 70 (11.2%) patients. LN involvement was correctly estimated in 51 of 70 LN-positive patients according to the GOG-99 criteria (positive likelihood ratio [LR+], 3.3; negative likelihood ratio [LR-], 0.4), 64 of 70 LN-positive patients according to the ESMO-modified criteria (LR+, 2.5; LR-, 0.13) and 69 of the 70 LN-positive patients according to the Mayo-modified criteria (LR+, 2.2; LR-, 0.03). The area under curve of the Mayo-modified, the GOG-99 and the ESMO-modified criteria was 0.763, 0.753, and 0.780, respectively. CONCLUSION: The ESMO-modified classification seems to be the risk-stratification model that most accurately predicts LN involvement in endometrioid EC clinically confined to the uterus. However, the Mayo-modified classification may be an alternative model to achieve a precise balance between the desire to prevent over-treatment and the ability to diagnose LN involvement.

The preoperative albumin level is an independent prognostic factor for optimally debulked epithelial ovarian cancer.

PURPOSE: A low albumin level has been reported to be a prognostic factor for various cancers. The aim of this study was to determine the association between preoperative serum albumin level and survival in patients with epithelial ovarian cancer (EOC). METHODS: Records of 337 patients with EOC that underwent optimal cytoreductive surgery were retrospectively reviewed. Threshold albumin level was planned as 32.5 g L-1 due to the statistical analyses. RESULTS: Mean overall survival was 51.5 months. Area under the ROC curve was found statistically significant for the discriminative role of albumin for survival outcome (AUC = 0.857, 95% CI 0.813-0.90, P < 0.001). The best cut-off point for albumin was determined as 32.5 g L-1. The sensitivity rate, specificity rate, positive and negative predictive values, and accuracy rate for this cut-off level were found 67.2, 91.2, 81.2, 83.1, and 82.5%, respectively. Preoperative hypoalbuminemia was noted in 101 (30.0%) of the patients, of which 6.2% had an albumin level <25 g L-1. The albumin level was independently and significantly associated with overall survival (HR 2.6; 95% CI 2.1-3.1; P < 0.001). Subgroup analysis showed that patients with an albumin level <32.5 and ≥32.5 g L-1 had mean estimated overall survival of 40.6 and 96.0 months, respectively. Age, stage, and presence of ascites were the other independent significant factors. CONCLUSIONS: The preoperative albumin level is an independent prognostic factor for overall survival in optimally debulked EOC patients. Further investigations about preoperative albumin level in prognostic models will contribute to the literature.

Gynecologic Oncologist Perspective About ESMO-ESGO-ESTRO Consensus Conference on Endometrial Cancer.

ESMO-ESGO-ESTRO Consensus Conference on Endometrial Cancer was simultaneously published in 3 prestigious journals and is sure to have a huge impact on the clinical practice of gynecologic oncology community and other gynecologic cancer care providers.It is a tremendous report representative of great effort. Hovewer, as practicing gynecologic oncologists, endometrial carcinoma is the most common clinical entity encountered in our routine daily practice; as such, we find some of the report confusing and object to some of its findings, as detailed in this brief report.We also attempted to summarize the differences between the well-known NCCN guidelines and the ESMO-ESGO-ESTRO Consensus Conference guidelines and try to give the point of view of gynecologic oncologic perspective. It is obvious that differences in the management of endometrial carcinomas will continue to be debated by the scientific community.

A Call for New Communication Channels for Gynecological Oncology Trainees: A Survey on Social Media Use and Educational Needs by the European Network of Young Gynecological Oncologists.

OBJECTIVE: The aim of the study was to assess patterns in the use of social media (SM) platforms and to identify the training needs among European gynecologic oncology trainees. METHODS: In 2014, a web-based survey was sent to 633 trainees from the European Network of Young Gynaecological Oncologists (ENYGO) database. The 14-item questionnaire (partially using a 1- to 5-point Likert scale) assessed respondents' use of SM and preference for workshop content and organization. Descriptive analysis was used to describe the mean scores reported for different items, and the internal reliability of the questionnaire was assessed by Cronbach α. RESULTS: In total, 170 ENYGO members (27%) responded to the survey. Of those, 91% said that they use SM platforms, mostly for private purposes. Twenty-three percent used SM professionally and 43% indicated that they would consider SM to be a clinical discussion forum. The respondents said that they would like updates on conferences and professional activities to be shared on SM platforms. Complication management, surgical anatomy, and state of the art in gynecologic oncology were identified as preferred workshops topics. The most frequently indicated hands-on workshops were laparoscopic techniques and surgical anatomy. Consultants attached a higher level of importance to palliative care education and communication training than trainees. The mean duration of the workshop preferred was 2 days. CONCLUSIONS: This report highlights the significance of ENYGO trainees' attachment to SM platforms. Most respondents expect ENYGO to use these online channels for promoting educational activities and other updates. Using SM for clinical discussion will require specific guidelines to secure professional and also consumer integrity. This survey confirms surgical management and the state of the art as important knowledge gaps, and ENYGO has tailored its activities according to these results. Future activities will further direct attention and resources to education in palliative care and molecular tumor biology.

Potential role of increasing number of sections in frozen section diagnosis of ovarian tumors.

OBJECTIVE: To assess the accuracy of intraoperative frozen section of ovarian tumours at our institution and to identify the possible reasons for misdiagnosis. STUDY DESIGN: Between January 2002 and August 2013, a total of 684 patients were included in the study. Frozen section diagnosis was compared with the final paraffin section diagnosis as the gold standard. The sensitivity, specificity, and positive and negative predictive values of frozen-section diagnosis were calculated for benign, borderline and malignant tumours. Clinicopathological parameters influenced by misdiagnosis were evaluated performing multivariate logistic regression analysis. RESULTS: The overall accuracy was detected as 96.1%. Frozen-section diagnoses of 26 patients (3.8%) showed discordance. The specificity (99.7%) and PPV (99.4%) of frozen-section diagnosis was highest in the malignant category. In BOTs, diagnostic agreement was observed in 57 of 70 (81.4%) cases. The PPV (81.4%) was lowest for these patients. Tumour diameter of ≥10 cm (OR [95% CI]= 3.0 [1.1 to 8.2]; P=0.030) and mucinous histology (OR [95% CI]= 2.5 [1.0 to 6.2]; P=0.042) were significant predictors of misdiagnosis. With the increase in the number of sections, the accuracy rate of frozen section diagnosis was decreased. While not statistically significant (p=0.361). CONCLUSION: The number of sections is increased parallel to increase in tumor diameters. On the contrary, the diagnostic accuracy was no significantly increased with an increase in the number of sections. This discrepancy may be associated with falling tumor size per frozen section. A prospective study based on a certain tumour diameter per frozen section may better demonstrate the positive effect of the number of sections.

Alternative tumor markers in the diagnosis of ovarian cancer.

OBJECTIVES: The aim of the study was to assess the usefulness of various tumor markers (CA125, HE4, bcl2) measured in serum, urine and saliva in the differential diagnosis of adnexal masses. MATERIAL AND METHODS: Our study was conducted at the Baskent University Medical School, Department of Obstetrics and Gynecology, Ankara, Turkey, between November 2010 and March 2011. Fifty patients with a suspicion of malignant adnexal mass and 30 controls were included in the study. Serum and urine CA-125, HE4, and bcl2 levels were evaluated for their role in the diagnosis of epithelial ovarian cancer (EOC). RESULTS: Serum CA-125 and HE4 levels, and urine HE4 levels were significantly higher in malignant cases as compared to controls (p < 0.05). Mean levels of bcl2 in saliva and urine were similar in malignant cases and controls (p > 0.05). CONCLUSIONS: We demonstrated that serum CA125, serum HE4 and urine HE4 levels were elevated in patients with ovarian cancer. These findings should be assessed in future studies with larger sample sizes in order to reach more definite conclusions.

Evaluation of a New Oncogynecologic Training Program.

OBJECTIVE: The first cohort of Turkish fellows has begun to graduate from a newly accredited training program on gynecologic oncology. This study aimed to investigate the value of experience on the confidence of these fellows to perform surgical procedures. METHODS: We assessed the characteristics of 32 fellows, including the perceived adequacy of their fellowship training, the facilities of the clinics at which they were trained, and their levels of exposure and confidence in performing a total of 44 procedures. Exposure levels were performing, assisting with, observing, or no exposure. Confidence was assessed by asking whether they could perform each procedure. Correlation analysis was used to determine the link between exposure levels and confidence. RESULTS: The confidence of fellows to perform a surgical procedure increased with exposure to that procedure (r = 0.820, P < 0.001). Performing, assisting with, and observing a procedure created a sense of confidence in 97.2%, 54.1%, and 31.1% of fellows. The majority of fellows (>75%) had performed type 2 hysterectomy, total omentectomy, and pelvic and para-aortic lymphadenectomy. None of the fellows had ever performed a trachelectomy. CONCLUSIONS: Efforts should be made in accredited systems for gynecologic oncology surgical training to provide more opportunities for trainees to perform surgical procedures, rather than assisting with and observing them.