[Myomas, fertility and pregnancy]. / Myomy, fertilita a tehotenství.

OBJECTIVE: The objective of this paper is give to guideline to the management of myoma, fertility and pregnancy. DESIGN: Review. SETTING: Czech Society Gynecological Endoscopy. MATERIAL AND METHOD: The bibliographic data from Medline were reviewed from literature using the key words: fibroid - fertility - pregnancy. CONCLUSION: The clinical guidline was preparared after the aalysed data were supplied using the material of CSGE.

Laparoscopic oophorectomy either with or without hysterectomy for early breast cancer.

OBJECTIVES: The aim of this study was to assess the surgical results, complications and pathological findings of laparoscopic ovarian ablation either with or without hysterectomy in women with early-stage breast cancer (BC). METHODS: Ninety women in early breast cancer stage who underwent laparoscopic bilateral salpingo-oophorectomy (BSO) either with or without hysterectomy were identified in a retrospective study conducted between January 2000 and December 2006. Tamoxifen antiestrogen therapy was used prior to hysterectomy. RESULTS: Forty-eight consecutive patients underwent laparoscopic hysterectomy with bilateral salpingo-oophorectomy and 42 with ovarian ablation only. The mean operative time for the laparoscopic hysterectomy and bilateral salpingo-oophorectomy or BSO alone was 82 min and 47.8 min, respectively. Blood loss was minimal in both groups (range: 20-250 ml). The rate of postoperative complications was very low (4.4%). One of all ovaries removed by laparoscopy showed ovarian breast carcinoma metastasis. Histopathologic examination revealed concomitant findings of leiomyoma, adenomyosis or endometrial abnormalities in 64.5% of hysterectomy specimens. CONCLUSION: Our experience with ovarian ablation either with or without hysterectomy confirmed that the use of a minimally invasive technique is feasible. We assume that ovarian ablation and hysterectomy is an appropriate treatment for premenopausal women at risk (BRCA positive) or for patients with concomitant benign uterine pathology, treated with tamoxifen in first-line therapy. Removing the uterus allows women to take only estrogens rather than combination HRT. Further investigation into the indications of disease where laparoscopic ablative surgery is appropriate in the management of early breast cancer is needed.

[Laparoscopic myomectomy: indications and limits]. / Laparoskopická myomektomie: indikace a limity.

OBJECTIVE: An analysis of indication and limits of laparoroscopic myomectomy with regard to clinical usefulness. DESIGN: A short review article. SETTING: Department of Obstetrics and Gynecology, Endoscopic Training Centre, Hospital, Kladno, Czech Republic. SUBJECT AND METHOD: One of the primary goals of laparoscopic myomectomy is preservation of the uterus for the future fertility and psychosomatic integrity of women through minimally invasive way. A comparison is made of advantage and disadvantage of different types of myomectomy. CONCLUSION: Laparoscopic myomectomy is surgical alternative for women with symptomatic subserosal and intramural fibroids. The indication for this technique is limited. Removal of large fibroids and repair of myometrial defect are challenges to gynecologic laparoscopists, and also the main limitations. A well trained laparoscopic surgical team can operate any fibroid. In our experience, as well as reflected by the literature, a consensus gradually emerges that a maximal size of 8-10 cm and a total number of fibroids should not exceed four.

Pregnancy outcomes and deliveries following laparoscopic transsection of uterine vessels: a pilot study.

OBJECTIVE: To assess pregnancy outcomes and deliveries after laparoscopic uterine artery transsection (LTUV) in symptomatic women with fibroids. SETTING: Department of Obstetrics and Gynecology, Endoscopic Training Center, Baby Friendly Hospital, Kladno, Czech Republic. DESIGN: One hundred and fifty three patients underwent laparoscopic transsection of uterine vessels during a 4-year period. RESULTS: Nine of the 21 women desiring pregnancy conceived spontaneously and one after anovulation treatment. The average age of the women was 32.4 years, and the range was 26-39 years. Two women had vaginal delivery at term and one delivered vaginally at 31 weeks secondary to premature preterm rupture of membrane (PROM). Four others delivered at term by cesarean section. One woman with placenta previa was delivered by cesarean section 3 weeks before term. Mean birth weight was 3199 g (range 1710-3910 g). One spontaneous abortion was reported in the first trimester of pregnancy. One case of undesired pregnancy occurred. An extrauterine pregnancy was reported in this woman. CONCLUSION: LTUV is a minimally invasive operative procedure, that preserves the uterus and ovarian blood supply and allows for the achievement of pregnancy in women with symptomatic fibroids. Fetal growth and umbilical Doppler findings remained normal in all cases. An increased risk for preterm delivery and cesarean section was found in this small series.

[Cardiovascular risk and estrogens]. / Kardiovaskulární riziko a estrogeny.

OBJECTIVE: To describe relations among postmenopause, hormonal therapy, lipid metabolism and risk of cardiovascular diseases. DESIGN: Search and analysis of relevant data from medical literature. METHODS: Analysis of the relation between serum lipid profile and postmenopausal changes, evaluation of positive and negative effects of estrogens on vascular wall and lipid metabolism, analysis of methods for the assessment of cardiovascular risk and evaluation of recent guidelines. RESULTS: Postmenopause is connected with significant changes in lipid metabolism, serum lipid profile and with increased risk of cardiovascular diseases. Deficit of estrogens influences lipid metabolism negatively. However, estrogen substitution has both positive and negative effects on vascular wall. Negative effects are: increased occurence of postprandial hyperlipidemia with increased triglycerides, generation of aterogenous small dense LDL particles, increased risk of inflammatory changes in vascular wall and procoagulation situation. CONCLUSION: Hormonal therapy can display some positive effects of vascular wall. However, recent data evaluate hormonal substitution with regard to atherosclerosis and cardiovascular problems as less benefitial or even risky.

[Serum amyloid A as an effective marker for the assessment of surgical trauma and risk of post-operative complications]. / Sérový amyloid A jako efektivní marker stupne operacní záteze a rizika komplikací.

OBJECTIVE: To analyze relations among acute phase reactants in a group of 40 women operated for uterine myom by laparoscopy and open surgery. DESIGN: Prospective study. METHODS: Plasma concentrations of C-reactive protein (CRP), serum amyloid A (SAA) and interleukin 6 (IL-6) were measured together with leukocytes in blood before operation, 24 and 72 hours post operation, respectively. RESULTS: Leukocytes and IL-6 displayed minimal response and decreased quickly after operation to preoperative levels. Concentrations of CRP and SAA remained increased after operation. There were no relationships between leukocytes and acute phase reactants. Normal leukocytes 72 hours post operation were found in 1/3 of women with increased at least one acute phase reactants and in 1/4 of women with increased at least two markers. Typ of surgery, surgical stress and length of surgery were related to the concentration of CRP, IL-6 and SAA. CONCLUSION: Changes in SAA 24 hours after operation are similar to CRP and IL-6. Surgical stress, length of operation and possible risk 72 hours after operation are best predicted by CRP and SAA (at that time IL-6 and leukocytes are practically normal). Maximal increase was found for SAA concentrations. Thus SAA seems to be suitable marker of early postoperative complications.

Laparoscopic uterine artery dissection in an undiagnosed endometrial stromal sarcoma. Case report.

We present a case of a 24-year-old woman, gravida 0, with menometrorrhagia and pelvic pain. A uterine hemorrhagic fibroid was diagnosed after ultrasound and magnetic resonance imaging (MRI). The endometrial biopsy was negative for malignancy. Laparoscopic sentinel lymph node sampling, lavage, and myometrial biopsy with negative results were performed before dissection of the uterine vessels. The final diagnosis of endometrial stromal sarcoma was made by myomectomy and hysterectomy one year later. This case should demonstrate the difficulty of making the right diagnosis of sarcoma before laparoscopic dissection of uterine vessels in patients with symptomatic fibroids.

[Immune, inflammatory and hormonal changes in connection with laparoscopic surgery]. / Imunitní, zánetlivé a hormonální zmeny v souvislosti s laparoskopickými operacemi.

OBJECTIVE: Analysis of the issue of laparoscopy on the intra and post-operative immune changes. SUBJECT: Review article. SETTING: Department of Obstetrics and Gynecology, Regional Hospital Kladno. SUBJECT AND METHOD: Review of published facts with regard to impact laparoscopic surgery on immune function. CONCLUSION: The impact of surgery on the intra and post-operative immune, hormonal and inflammatory response is significantly less after laparoscopy than with an open approach.

[Successful treatment of severe post-partum bleeding after caesarean section using recombinant activated factor VII]. / Uspesná lécba závazného poporodního krváicení po císarském rezu pomocí rekombinantního aktivovaného faktoru VII.

OBJECTIVE: To present a case report of severe post-partum bleeding after caesarean section and successful using recombinant factor VIIa. SETTING: Department Obstetrics and Gynecology, Regional Hospital, Kladno, Czech Republic. CASE REPORT: A 28-year old nullipara presented with major post-partum bleeding after caesarean section due to uterine atony. The patient developed hemorrhagic shock, associated with disseminated intravascular coagulation (DIC). Treatment with uterotonics drug, prostaglandins, hysterectomy and packing of the pelvis failed to control diffuse pelvic and vaginal bleeding. Recombinant factor VIIa (2.4 mg intravenous injection) was given as a final attempt to control the bleeding before relaparotomy and ligation hypogastric artery. The response to treatment was rapid, with control of the bleeding and resolution of the coagulopathy. CONCLUSION: This case suggests a potential role of recombination factor VIIa in the treatment of severe post-partum bleeding associated with DIC.

[Fistula as a complication of pelvic actinomycosis--two case reports]. / Fistula jako komplikace pánevní aktinomykózy--2 kazuistiky.

OBJECTIVE: The presentation of two unusual cases of pelvic actinomycosis. SUBJECT: Case reports. SETTINGS: Department of Obstetrics and Gynecology, Hospital Kladno. SUBJECT AND METHOD: The observation of two cases of pelvic actinomycosis. These cases were complicated by the abdominal wall fistula in one case and vaginal fistula in the other. CONCLUSION: Actinomycosis is a chronic disease with tendency to progress per continuitatem into neighbouring tissues and with tendency to formation of fistulas. Two less common localisations of progress of the disease are described; it means the abdominal wall and vagina. In spite of a more advanced stadium, if adequately treated, a recovery ad integrum is common.

[The management of uterine fibroids: Czech and Slovak Gynecologic Endoscopy Working Group (CSGE) clinical practice guidelines]. / Management delozních myomu: CSGE doporucení k provádení spráivné klinické praxe.

OBJECTIVE: The objective of this paper is to give a guideline to the management of uterine fibroids. DESIGN: Review. SETTING: Czech Society Gynecological Endoscopic Working Group. MATERIAL AND METHOD: The bibliographic data from Medline were reviewed from 2003-2004 using the key words: fibroid--leiomyoma--uterine artery occlusion--hysterectomy--myomectomy. CONCLUSION: The clinical guideline was prepared after the analysed data were supplied using the material and criteria of Society of Obstetricians and Gynaecologists of Canada (SOGC) for the management of uterine fibroids.

Midterm follow-up study of laparoscopic dissection of uterine vessels for surgical treatment of symptomatic fibroids.

BACKGROUND: This study aimed to assess laparoscopic dissection of uterine vessels (LDUV) for symptomatic fibroids in women. METHODS: A total of 69 women entered the study between March 2000 and June 2003. In this case series, 68 consecutive women underwent LDUV using ultrasonically activated sheers or electrosurgery for the treatment of fibroids over 3 years (median follow-up period, 14.5 months). Ultrasound or magnetic resonance imaging was carried out 3, 6, 12, 24, and 36 months after treatment. The tissue markers, gonadotropin, and estrogen levels were studied postoperatively. RESULTS: Almost all the patients (98.5%) had a successful LDUV with a low rate (7.3%) of postoperative complications. The time of surgery ranged from 15 to 50 min (mean, 30.8 min). The blood loss was minimal (mean, 14.7 ml), and the hospital stay was 2.4 days. Symptom improvement (menorrhagia or dysmenorrhoea) was 93.2%, and the average reduction in the dominant myoma was 57.8% during a follow-up period longer than 12 months. All the patients with anemia had normal red cell counts after 3 months. CONCLUSIONS: Uterine volume and the dominant fibroid were significantly reduced and symptoms were improved by LDUV. The laparoscopic procedure is associated with insignificant tissue damage and normal gonadotropin and estrogen levels.

Short-term results from laparoscopic dissection of uterine vessels in women with symptomatic fibroids.

OBJECTIVE: To assess the outcome, tissue trauma, clinical improvement and the reduction in size of fibroid following laparoscopic dissection of uterine vessels (LDUV). SETTING: Department of Obstetrics and Gynaecology, Endoscopic Training Centre, Baby Friendly Hospital, Kladno, Czech Republic. DESIGN: An uncontrolled case series of 17 consecutive women who underwent LDUV using ultrasonically activated shears for the treatment of fibroids over two years. Ultrasound imaging was carried out before and three and six months following treatment. The tissue markers (C-reactive protein (CRP), Interleukin-6 (IL-6), Creatin kinase (CK) and white blood cell count) were studied preoperatively, on the first and third postoperative day. RESULTS: All patients underwent successful LDUV without intraoperative complications. Tissue markers results show that the LDUV performed using ultrasonically activated shears is associated with insignificant tissue damage. Time of surgery ranged from 30 to 50min (mean 39min). Mean blood loss was less than 30ml and mean hospital stay was 2.3 days. Three and six months after surgery, respectively, average reduction in uterine volume was 23.6 and 36.8% and average reduction in dominant fibroid was 28.6 and 56.8%. 94.1% of women had improvement in menorrhagia or dysmenorrhoea, and 91.6% had improvement in bulk-related symptoms or pelvic pain six months after treatment. CONCLUSION: Uterine volume and dominant fibroid were reduced and symptoms were improved by LDUV. The procedure of laparoscopic dissection of uterine vessels can be completed within 30-40min with only minimal blood loss and short hospital stay if performed by experienced laparoscopists.

Comparison of two procedures for laparovaginal hysterectomy: a randomized trial.

OBJECTIVE: To compare peroperative parameters of two variants of a laparovaginal hysterectomy in surgical management of gynecological conditions. METHODS: A prospective randomized study of 70 laparovaginal hysterectomies performed by the same two surgeons for disease of female pelvic organs. The following criteria were studied: indication for surgery, previous surgery, duration of the procedure, recovery, hospital stay, blood loss, tissue damage markers, hysterectomy proportions and complication incidence. Statistical analysis was performed using the non-parametric chi(2)-test and non-parametric Fischer's exact probability test when appropriate, with a level of significance P=0.05. RESULTS: Totals of 38 (54.3%) laparoscopy-assisted vaginal and 31 (45.7%) vaginally assisted laparoscopic hysterectomies were performed for fibroma as the main indication. Conversion to laparotomy was applied in only one patient. The VALH group (P=0.01) showed both fewer procedures and shorter hospital stay with insignificant blood loss. CONCLUSION: The two variants of a laparovaginal hysterectomy appear to be safe and appropriate, effective procedures for women with gynecological conditions. Furthermore, vaginally assisted laparoscopic hysterectomy has been shown to be superior to laparoscopy-assisted vaginal hysterectomy in terms of shorter operating time and greater palliative effect upon the complex of uterosacral ligaments. Laparoscopic surgery can alter the relationship between vaginal and abdominal hysterectomy.

Laparoscopic hysterectomy in obese women: a clinical prospective study.

OBJECTIVE: To compare perioperative and postoperative outcomes of laparoscopic hysterectomy (LH) in surgical management of gynecological conditions in two groups of different weight. METHODS: A prospective comparative clinical study of 271 LH performed for disease of female pelvic organs in a group of 54 obese patients (over 30 body mass index (BMI)) and in a group of 217 non-obese patients (less than 30 BMI). The following criteria were assessed: patient characteristics, indications for surgery, previous surgery, presence of adhesions, duration of procedure, blood loss, weight of specimen, hospital stay and complications. Statistical analysis was performed using the unpaired t-test and non-parametric Chi-square test when appropriate, with a significance level of P=0.05. RESULTS: Three non-obese patients were converted to laparotomy due to operative complications. Laparoscopy in the remaining 268 patients (98.89%) was completed successfully. There was no significant difference in estimated blood loss, presence and degree of adhesions, weight of specimen, length of hospital stay and postoperative complications between women with high BMI and those with low BMI. The rate of major operative complications (5.55% versus 3.22%) was higher in the obese group. The duration of the operation was longer in obese women. However, the significance of the difference was borderline (P=0.06).

Laparoscopic staging of endometrial cancer using laparosonic instruments: comparison with electrosurgery.

OBJECTIVE: To compare perioperative parameters in two groups of women with different laparoscopic operative techniques in surgical staging of endometrial cancer (EC). STUDY DESIGN: Thirty randomly allocated and laparoscopically treated women with EC. Fifteen patients were operated by electrosurgery, 15 patients by laparosonic operative technique. Differences between the two groups were determined by the Wilcoxon rank-sum test. Probability (P) of less than 0.05 was considered significant. SETTING: Department of Gynecology and Obstetrics, Endoscopic Training Center, Baby Friendly Hospital, Kladno, Czech Republic. RESULTS: Laparoscopy was successfully completed in 29 patients. Laparoscopy-assisted surgical staging of EC was performed based on the tumor grade and the depth of myoinvasion. In both groups, in total 18 and 5 women underwent pelvic lymphadenectomy (PLN) and infra-aortic lymph node sampling (IALS), respectively. Three patients had metastases in pelvic lymph nodes. In the electrosurgical hemostasis and laparosonic group the mean total time required to finish the whole operative procedure were 132.1 and 138.3 min, respectively, with no statistically significant difference (P=0.96). There were no significant differences between the groups in any intraoperative or postoperative follow-up variables, except for the number of excised lymph nodes where the difference between electrosurgery and laparosonic group (12.7 versus 18) was statistically significant (P=0.05). In one patient with intraoperative venous bleeding the laparosonic hemostasis was ineffective (successful procedure rate 93.3%). One patient from the electrosurgery group was converted to laparotomy due to injury to the epigastric vessels. This complication had no connection with the surgical techniques studied. CONCLUSION: It is concluded that both operative technique variants in laparoscopy-assisted surgical staging appear to be feasible and effective for patients with EC.

Laparoscopic lymph node dissection using ultrasonically activated shears: comparison with electrosurgery.

PURPOSE: To assess and compare perioperative parameters in two groups of patients treated by different laparoscopic techniques of lymph node dissection (LND) for gynecologic cancer. PATIENTS AND METHODS: Between April 1996 and March 2001, 59 consecutive women with microinvasive cervical cancer (N = 5) or clinical stage I endometrial cancer (N = 54) underwent laparoscopic LND during a primary staging procedure using an electrosurgery (ELC) or ultrasonic (US) operative technique. The two groups were compared for perioperative outcomes. Differences between the two groups were determined by the Wilcoxon's rank-sum test. RESULTS: Laparoscopic LND and other staging procedures were completed successfully in 58 women (98.3%). There were no statistically significant differences between the groups with regard to perioperative outcomes (operation time, time for LND, blood loss, hospital stay, complications), but there was a significant difference (P = 0.0008) in the number of lymph nodes harvested: a mean of 13.7 in the ELC group and 17.5 in the US group. The pathologists found that the reading of histology slides was easier after US dissections because of the greater depth of thermal injury in the lymphatic tissue in ELC group. CONCLUSION: The US operative technique ensures efficient coagulation, cutting, dissection, and grasping for laparoscopic LND in patients with cervical and endometrial cancer.

Uterine reduplication, unilateral ureteral and renal aplasia syndrome associated with endometrial cancer: a case report.

Endometrial cancer in malformation of the urogenital system is a rare lesion. A correct diagnosis in these cases may be difficult to make due to urogenital anomalies or the unrecognised presence of a second uterine cavity. Proper diagnosis is very important for corresponding treatment.

A comparison of laparoscopic surgery with open procedure in endometrial cancer.

BACKGROUND: Laparoscopic hysterectomy and lymph node dissection have lately been reported as an alternative to an abdominal open procedure for the treatment of malignant gynaecological conditions. The laparoscopic operative technique has been evaluated and compared as to whether it is a safe, feasible and effective procedure. SUBJECTS: The study includes 78 women with indications for surgery for endometrial cancer stage I. A retrospective comparative study was undertaken at Baby Friendly Hospital, Kladno, in which 11 patients treated laparoscopically were compared with 26 patients treated by the open procedure of lymphadenectomy. We evaluated differences in the peri-and postoperative outcomes. RESULTS: All 11 procedures were successfully completed. The mean operating time was 153 min, and mean blood loss was 130 ml. The median hospital stay was 4.7 days. There were no major complications. CONCLUSIONS: Laparoscopic hysterectomy and lymphadenectomy seem to be the procedures which result in a shorter hospital stay and rapid recovery. This approach could potentially decrease morbidity historically associated with hysterectomy and lymphadenectomy performed abdominally. Only prospective randomised studies will be able to demonstrate the ability of operative laparoscopy to improve contemporary management of endometrial cancer.

Comparison of two procedures for sentinel lymph node detection in patients with endometrial cancer: a pilot study.

OBJECTIVE: The purpose of this study was to assess the feasibility and contribution of two intraoperative procedures of lymphatic mapping and sentinel node detection using a blue dye in surgically-staged patients with early stage endometrial cancer. METHODS AND MATERIALS: In 25 cases of endometrial cancer, patent blue-V was injected into the subserosal myometrium (13 cases, SM group) or cervico-subserosal myometrium (12 cases, CSM group) during a surgical staging procedure. Laparoscopically-assisted vaginal hysterectomy and pelvic lymphadenectomy were completed successfully in 23 women out of 24 laparoscopically-staged patients (95.8%). One patient with FIGO stage IIa was indicated for a radical abdominal surgery. RESULTS: A deposition of the blue dye was found in at least one pelvic lymph node (LN) in eight out of 13 cases (61.5%) in the SM group compared with ten out of 12 cases (83.3%) in the CSM group (p = 0.378). The mean number of dye-colored LN (DCLN) was 1.15 (SM group) and 2.5 (CSM group), respectively (p = 0.05). The rate of DCLN/LN was 15/188 (SM group) versus 30/190. respectively (p = 0.03). An uptake of the blue bye was observed in a total of 45 out of 388 LN. CONCLUSION: An intraoperative combination of cervico-subserosal myometrium application of the blue dye allows successful detection (83.3%) of sentinel LN in patients with endometrial cancer. Comparing SM and CSM groups the statistical significant difference was found in the DCLN/LN rate and mean number of sentinel lymph nodes (p = 0.03, p = 0.05, respectively). Clinical validity of this surgical procedure must be assessed prospectively.