Pelvic vein thrombosis in patients with pelvic venous disorders.

OBJECTIVE: To assess the incidence of pelvic vein thrombosis (PVT) and outcomes of anticoagulant therapy for PVT in patients with pelvic venous disorders (PeVDs). METHODS: This prospective cohort study included 588 female patients with PeVDs underwent clinical examination followed by duplex ultrasound of the pelvic veins in 2021-2023. Patients with PVT were administered with anticoagulant therapy in an outpatient setting using low molecular weight heparins at a therapeutic dose. RESULTS: PVT was detected in 7.6% of patients with PeVDs and was symptomatic in 28.8% of them. The majority of asymptomatic patients had thrombosis in only one of the parametrial veins (90.6%). Anticoagulant therapy resulted in the PVT symptoms relief in all patients within 10 days and recanalization of the pelvic veins in 1-3 months. CONCLUSION: In our study, PVT was diagnosed in 7.6% of patients with PeVDs. Anticoagulant therapy is effective and safe in resolving PVT symptoms.

Effect of left renal vein compression stenosis on functional status of left kidney in patients with pelvic venous disorders.

OBJECTIVE: We evaluated the effect of left renal vein (LRV) compression stenosis on the functional state of the left kidney in patients with pelvic venous disorders (PeVDs). METHODS: We examined 162 female patients with PeVD and diagnosed LVR compression stenosis using duplex ultrasound (DUS) in 40. Patients with clinical manifestations of PeVD (n = 26) had symptoms and signs of pelvic venous congestion but without pain in the left flank of the abdomen, typical for nutcracker syndrome (NS). The remaining patients were asymptomatic (n = 14). The parameters measured with DUS included the angle of the superior mesenteric artery (SMA) with the aorta, the LRV diameter (Dhilum/Dstenosis) ratio, and LRV velocity (Vstenosis/Vhilum) ratio. All the patients underwent laboratory testing (complete blood count, urinalysis, and biochemical blood testing) and dynamic renal scintigraphy to assess the secretory and evacuation functions of the renal tubular system. RESULTS: The laboratory tests revealed no abnormalities, including no hematuria or proteinuria, in either group. The Dhilum/Dstenosis and Vstenosis/Vhilum ratios varied from 2.8 to 5.2 and from 2.9 to 8.3, respectively, and did not differ between the symptomatic and asymptomatic patients. All 40 patients with LRV compression stenosis were diagnosed with left gonadal vein reflux with a mean duration of 4.7 ± 0.6 seconds and 2.2 ± 0.6 seconds in the symptomatic and asymptomatic patients, respectively (P = .005). Eight patients had signs of NS on DUS, including five in the symptomatic group (SMA angle, 34.8° ± 2.7°; Dhilum/Dstenosis ratio, 5.2 ± 0.2; and Vstenosis/Vhilum ratio, 5.7 ± 0.4) and three in the asymptomatic group (SMA angle, 35° ± 2.8°; Dhilum/Dstenosis ratio, 5; and Vstenosis/Vhilum ratio, 5 ± 0.5). The groups did not differ significantly in the DUS parameters. Scintigraphy did not reveal any cases of secretory or evacuation dysfunction of the left kidney, including in the patients with DUS signs of NS. The maximum uptake time, elimination half-life, and effective renal plasma flow were within the normal ranges. CONCLUSIONS: LRV compression stenosis without hematuria has no significant effects on the functional state of the left kidney, irrespective of the disease severity. In patients with PeVDs, dynamic renal scintigraphy provides an objective assessment of left kidney function.

Surgical and endovascular treatment of pelvic venous disorder: Results of a multicentre retrospective cohort study.

OBJECTIVE: In the present study, we investigated the clinical outcomes after gonadal vein resection (GVR) and gonadal vein embolization (GVE) with coils in patients with pelvic venous disorder (PeVD). We also assessed the rates of procedural complications and disease recurrence. METHODS: Our multicenter retrospective cohort study included 361 female patients with PeVD-related chronic pelvic pain (CPP) and gonadal vein reflux who underwent GVR (n = 184) or GVE with coils (n = 177) from 1999 to 2020. The clinical outcomes (ie, presence and severity of CPP, procedural complications, disease recurrence) were assessed at 1 month and 1, 3, and 5 years after intervention. The pain intensity before and after treatment was assessed using a visual analog scale. All the patients underwent duplex ultrasound after GVR and GVE, and those with persistent CPP and suspected perforation of the gonadal vein by the coils were also evaluated by multiplanar pelvic venography. RESULTS: GVR and GVE was associated with the reduction or elimination of CPP at 1 month after treatment in 100% and 74% of patients and postprocedural complications in 14% and 37% of patients, respectively (Р < 0.01 for both). The most common complication after either GVR or GVE was pelvic vein thrombosis (11% and 22% patients, respectively; P < .01 between groups). GVE was associated with postembolization syndrome in 20%, coil protrusion in 6%, and coil migration in 1% of patients. The long-term recurrence rate after GVR and GVE was 6% and 16%, respectively (P < .01). CONCLUSIONS: Both GVR and GVE were found to be effective in treating patients with PeVD. However, GVR was associated with better efficacy in the relief of CPP and lower rates of procedural complications and disease recurrence.

Hemodynamic and neurobiological factors for the development of chronic pelvic pain in patients with pelvic venous disorder.

OBJECTIVE: The study was aimed at the identification of hemodynamic and neurobiological factors for the development of chronic pelvic pain (CPP) in patients with pelvic venous disorder (PeVD) using ultrasound, radionuclide, and enzyme immunoassay methods. METHODS: This cohort study included 110 consecutive patients with PeVD and 20 healthy controls. Seventy patients with PeVD had symptoms (CPP in 100% of cases, discomfort in hypogastrium, dyspareunia, vulvar varices, and dysuria), and 40 were asymptomatic. Patients underwent clinical examination, duplex ultrasound study of the pelvic veins and lower extremities, and single-photon emission computed tomography of the pelvic veins with in vivo labeled red blood cells. The prevalence, duration, severity, and pattern of reflux in the pelvic veins, as well as the severity of pelvic venous congestion, were evaluated. Healthy controls underwent only clinical and duplex ultrasound examination. All 130 patients were assessed using enzyme immunoassays to determine plasma levels of calcitonin gene-related peptide (CGRP) and substance P (SP). RESULTS: Symptomatic patients with PeVD had a higher prevalence of reflux in the ovarian veins (OVs) than asymptomatic ones (45.7% vs 10%, respectively; P = .001) and a greater reflux duration (4.1 ± 1.7 seconds vs 1.4 ± 0.3 seconds; P = .002), although no differences in the OV diameter were found. Similar results were obtained when comparing the diameters of the parametrial veins (PVs) and the duration of reflux in them. Type II/III reflux (greater than 2 seconds) was identified in 41.4% of symptomatic and in only 5% of asymptomatic patients (P = .001). Among patients with CPP, 24.2% had a combined reflux in the OVs, PVs, and uterine veins, and 45.7% had a combined reflux in the OVs and PVs, whereas 90% of patients without CPP had only an isolated reflux in the PVs. The pelvic venous congestion was moderate or severe in 95.7% of patients with CPP and in only 15% patients without CPP (P = .001). In patients with PeVD, the presence of CPP was associated with higher levels of CGRP and SP compared with asymptomatic patients (CGRP: 0.48 ± 0.06 vs 0.19 ± 0.02 ng/mL, respectively, P = .001; SP: 0.38 ± 0.08 vs 0.13 ± 0.03 ng/mL, P = .001). CONCLUSIONS: In patients with PeVD, significant hemodynamic and neurobiological factors for the CPP development were found to be reflux in the pelvic veins greater than 2 seconds, involvement of several venous collectors, and increased plasma levels of CGRP and SP.

Venous Thromboembolism After Interventions on the Ovarian Veins in Patients With Pelvic Venous Disorder.

BACKGROUND: Ovarian vein resection (OVR) and ovarian vein embolization (OVE) are effective options for treating patients with pelvic venous disorder (PeVD). However, due to in an abrupt cessation of blood flow in the ovarian veins (OVs), these interventions can be complicated by pelvic vein thrombosis (PVT). The aim of this study was to assess venous thromboembolism (VTE) rates after OVR and OVE in patients with PeVD. METHODS: This retrospective cohort study included 272 patients with PeVD who underwent OVR (n = 122) or OVE with coils (n = 150). The rates and clinical manifestations of VTE were assessed in each group on days 1 and 3 after the intervention using duplex ultrasonography. Vein patency, blood flow velocity, and localization of thrombi in the pelvic (parametrial, uterine, and ovarian), iliac, superficial, and deep veins of the lower extremities were examined. PVT was defined as the formation of blood clots in nontarget (i.e. not intended to intervention) veins of the pelvis (parametrial, uterine veins, or tributaries of the internal iliac veins). RESULTS: VTE after OVR and OVE was identified in 52 (19%) out of 272 patients. In the OVR group, PVT and calf deep vein thrombosis were detected in 9% and 1% of patients, accordingly, while in the OVE group their rates were almost three times higher (24% and 3%; both P = 0.001). In both groups, the most common VTE was PVT. The odds ratio for developing VTE with coils was 10 times higher (95% confidence interval: 2.35-56.43) after OVE than after OVR. Clinical manifestations of PVT were observed in 2.5% of patients, and the rest patients were asymptomatic. No cases of pulmonary embolism occurred. CONCLUSIONS: VTE after interventions of the ovarian vein in patients with PeVD occurs in every fifth patient. OVE is associated with a higher incidence of PVT.

Retrospective Analysis of Complications After Gonadal Vein Interventions for Pelvic Venous Disorder.

INTRODUCTION: To investigate and compare complications after gonadal vein embolization (GVE) with coils and gonadal vein resection (GVR) in patients with pelvic venous disorder (PeVD). METHODS: This single-center retrospective cohort study included 277 female patients with PeVD who underwent GVE with coils (n = 150) or GVR (n = 122) in the period from 2000 to 2020. The participants were selected from a cohort of 4975 patients with chronic pelvic pain (CPP), of whom 1107 suffered from the PeVD-related CPP and 305 underwent surgical or endovascular intervention on the gonadal veins. The GVR technique was open retroperitoneal in 92, endoscopic transperitoneal in 18, and retroperitoneal in 12 patients. Clinical outcomes included 30-day complication rates and 3-year PeVD recurrence rates. The pain intensity was assessed before and after the procedure using a visual analogue scale. All patients underwent duplex ultrasound after the procedure, and those with persisting pain and suspected gonadal vein perforation with coil were also examined using computed tomographic venography. RESULTS: A substantial pelvic pain relief was achieved within 30 d after GVE and GVR in 73% and 100% patients, accordingly (Р = 0.001). Complications after GVE were identified in 85 (56%) patients. The major complications included pelvic vein thrombosis (PVT) and calf deep vein thrombosis (24%), postembolization syndrome (22%), and coil protrusion (5.3%). Complications after GVR occurred in 14 (11%) patients and consisted of PVT (10%) and ileus (1.6%). The 3-year recurrence rates after GVE and GVR were 11% and 5%, accordingly (P = 0.04). CONCLUSIONS: In patients with PeVD, the gonadal vein embolization with coils is associated with a high complication rate, which can be reduced with further development of the GVE technique, the use of new embolic agents, and the selection of a treatment method based on the patient's body composition.

Complications and Adverse Events of Gonadal Vein Embolization with Coils.

Background: The efficacy and safety of gonadal vein embolization (GVE) with coils in the treatment of pelvic venous disease (PeVD) has not been fully investigated, and the outcomes after GVE do not always meet expectations of both doctors and patients. The study was aimed at assessing the incidence and causes of the complications after GVE with coils in patients with PeVD. Methods: This retrospective cohort study included 150 female patients with PeVD who underwent GVE with coils in 2000-2020. A total of 4975 patients with chronic pelvic pain (CPP) were examined, of which 1107 patients had the PeVD-related CPP and 305 underwent surgical or endovascular interventions on the gonadal veins. Complication rates were evaluated 30 days after GVE and classified according to the Society for Interventional Radiology (SIR) adverse event classification system. The pain severity before and after GVE was assessed using a visual analogue scale (VAS). All patients underwent duplex ultrasound after GVE, while patients with persisting pain syndrome and suspected perforation of the gonadal vein were also evaluated using computed tomographic venography. Results: At 30 days after GVE, the CPP was decreased in 109 (72.6%) patients (from 8.2 ± 1.5 at baseline to 1.7 ± 0.8 scores, p = 0.0001) and persisted in 41 (27.4%) patients (mean change from 8.1 ± 0.7 at baseline to 7.8 ± 0.4 scores; p = 0.71). Post-embolic syndrome (PES) occurred in 22% of patients and was completely resolved in 1 month after GVE. The efficacy of GVE in the CPP relief after resolving PES was 94.6%. The GVE complications were identified in 52 (34.6%) patients. Minor complications included access-site hematoma (4%) and allergic reactions (1.3%), and major complications included protrusion of coils (5.3%), thrombosis of the parametrial/uterine veins (21.3%) and deep veins of the calf (2.7%). Conclusions: Gonadal vein embolization with coils in the treatment of PeVD is associated with the development of specific complications and adverse events. The most common complication was pelvic vein thrombosis. Post-embolization syndrome should be considered as an adverse event of this procedure.

Use of a novel Likert scale instrument to assess patient satisfaction following endovascular and surgical treatment of pelvic venous disorders.

OBJECTIVE: The study was aimed at assessing satisfaction with endovascular and surgical treatment, using a novel Likert scale procedure satisfaction instrument, in patients with pelvic venous disorder (PeVD) caused by the gonadal vein reflux. METHODS: This prospective cohort study included 100 women with PeVD who underwent gonadal veins embolization with coils (GVE group, n = 71) or gonadal veins endoscopic resection (GVR group, n = 29) in 2012-2020. The GVE was performed under local anesthesia and sedation, and was left-sided in 61, right-sided in three, and bilateral in seven patients. The GVR was performed under general anesthesia through transperitoneal (n = 19) or retroperitoneal (n = 10) access with three access ports in both cases. The GVR was left-sided in 19, right-sided in one, and bilateral in nine patients. To assess satisfaction with GVE and GVR treatment of PeVD, patients were asked to evaluate statements related to their experience using a new Likert scale instrument. The responses for each item were compared between the groups at Day 7 (D7) and at Month 6 (M6) after the procedure, as was a summary score of all the responses at both time points. The summary score allowed categorization on a spectrum from "completely satisfied" to "completely dissatisfied." RESULTS: The comparison between GVЕ and GVR groups at D7 showed that 80% and 100% of patients, accordingly, reported the overall summary satisfaction, 49% and 79% agreed with a complete pelvic pain relief by D7, 79% and 0% agreed with the absence of a significant discomfort during the first postoperative day, 71% and 100% reported no need for analgesics to relief pain in the assess area, 80% and 100% reported fast return to daily activity, and 19.7% and 100% still experienced pelvic pain at D7 (pain in the GVR group was more severe and required the use of analgesics) (all p < .05). At the same time, 94% and 96% patients were satisfied with the aesthetic result of the procedure at D7 (p = n.s.). The comparison between GVЕ and GVR groups at M6 showed that 100% of patients in both groups reported overall satisfaction with treatment (p = n.s.), 96% and 100% confirmed a complete pelvic pain relief by M6, 79% and 65% agreed with the absence of a significant discomfort after the procedure, 79% and 65% reported no need for analgesics, 83% and 100% reported about the return to daily activity (all p < .05), and 100% in both groups were satisfied with the aesthetic result of the procedure (p = n.s.). CONCLUSIONS: In patients with PeVD, both GVE and GVR are associated with a high, although not significantly different, overall treatment satisfaction in the long term and have advantages and disadvantages. GVE is associated with less severe post-procedural pain, while GVR provides faster relief of pelvic pain and a return to usual daily activity.

Efficacy of two micronized purified flavonoid fraction dosing regimens in the pelvic venous pain relief.

BACKGROUND: The venoactive drug treatment regimen for pelvic venous disorders (PeVDs) is not finally established. The study aimed at assessing the efficacy of micronized purified flavonoid fraction (MPFF) in a standard or double dose in the pelvic venous pain (PVP) relief in PeVD. METHODS: We analyzed the treatment efficacy in 125 female patients with PeVD, who were allocated to two groups with MPFF treatment in a regular dose of 1000 mg once daily (OD) for 2 months (N.=65; group 1) or double dose of 1000 mg twice daily for 1 month and then 1000 mg OD for 1 month (N.=60; group 2). Patients underwent clinical examination along with an assessment of the PVP severity using the visual analogue scale (VAS) ranged from 0 to 10 scores, transvaginal and transabdominal duplex ultrasound scanning (DUS), and single-photon emission computed tomography (SPECT) of the pelvic veins with in vivo-labelled red blood cells (RBCs). The groups were different at baseline in the PVP severity (3.4±1.2 vs. 7.3±0.5 scores in groups 1 and 2, accordingly; P=0.012). DUS and SPECT were used to evaluate diameters of gonadal, parametrial, and uterine veins, to assess the presence of reflux in them, to measure blood flow velocity in the internal iliac veins (Vlin IIV), and to calculate the coefficient of pelvic venous congestion (CPVC). RESULTS: The treatment was associated with a significant reduction in the PVP score from 3.4±1.2 to 1.2±0.2 (P=0.03) when using the standard dose for 2 months and from 7.3±0.5 to 0.8±0.1 (P=0.001) when using the double dose in the 1st month. The PVP relief was achieved on average after 13.7±0.6 and 3.1±0.8 days in groups 1 and 2, accordingly (P=0.0001 between the groups). At month 2, the CPVC reduction was found to be significantly greater in group 2 compared to group 1 (46.6% vs. 25%; P=0.018). Side effects (gastralgia, flatulence) were reported by only 2 (3.3%) patients of group 2. CONCLUSIONS: The venoactive drug therapy with MPFF is an effective and safe option for the PVP relief in female patients with PeVD. The use of double dose in the 1st month seems to be appropriate in patients with greater PVP severity but is associated with an increased rate of side effects.

Postembolization syndrome in endovascular interventions on the gonadal veins.

OBJECTIVE: The present study evaluated the incidence of postembolization syndrome (PES) after endovascular coil embolization of the gonadal veins (EEGV) in patients with pelvic congestion syndrome and investigated the appropriate medical treatment. METHODS: EEGV was performed in 70 female patients with pelvic congestion syndrome (left-sided in 58, right-sided in 3, and bilateral in 9 patients). For embolization, 0.035-in. coils with an 8- to 12-mm diameter and 10- to 20-cm length were used. Assessments of the EEGV results and possible PES symptoms were performed on days 1, 5, 10, 20, and 30 after the procedure and included transvaginal and transabdominal duplex ultrasound scanning of the pelvic veins and at the embolization site. RESULTS: PES had manifested with increased pelvic pain, tenderness along the embolized vein, and hyperthermia ≤37.5°C to 37.8°C and had developed in 14 patients (20%). For PES treatment, a nonsteroidal anti-inflammatory drug (diclofenac, 75 mg daily for 3-7 days; mean, 4.2 ± 1.1 days) and a venoactive drug (micronized purified flavonoid fraction, 1000 mg daily for 2 months) were used. Medical treatment was associated with a significant reduction in PES symptoms in all patients within 14 days and complete resolution by day 30 after embolization. duplex ultrasound scanning revealed thrombosis of parametrial veins in 12 of 56 patients (21.4%) with successful EEGV and 3 of 14 patients (21.4%) with PES. CONCLUSIONS: In patients who have undergone EEGV, increased pelvic pain, the occurrence of tenderness along the embolized vein, and the presence of hyperthermia should be considered as PES manifestations. In our study, PES occurred in 20% of the treated patients.

Diagnostic value of pelvic venography in female patients with pelvic varicose veins and vulvar varicosities.

BACKGROUND: Instrumental diagnosis of pelvic-perineal reflux is based on the use of ultrasound and radiological methods; however, the volume of their use represents a stumbling block for various researchers. The study aimed to determine the diagnostic value and reasonability of ovarian and pelvic venography in female patients with pelvic varicose veins (PVV) and vulvar varicosities (VV). METHODS: A total of 62 women with PVV were examined and allocated into two groups with or without the pelvic congestion syndrome (PCS) symptoms. Patients of group 1 with the PCS symptoms (N.=30) had concomitant VV (13.3%) and valvular incompetence of the left (83.3%) or right (16.7%) gonadal veins, parametrial (100%) and uterine (70%) veins, according to the duplex ultrasound scanning (DUS). Patients of group 2 without the PCS symptoms (N.=32) had valvular incompetence of the left gonadal vein (9.4%), parametrial (100%), uterine (3.1%) and vulvar veins (100%), according to the DUS. All patients underwent ovarian and pelvic venography (OPV) for imaging of the pelvic-perineal reflux. RESULTS: In group 1, dilation and valvular incompetence of the gonadal and parametrial veins were confirmed by the OPV in 100% of patients. The imaging of the obturator vein (OV) was obtained in 6.6% patients and internal pudendal vein (IPV) in 6.6% patients; no reflux of the contrast agent in the vulvar veins was observed. In group 2, the OPV confirmed the valvular incompetence of the left gonadal vein in 9.4% patients and parametrial vein in 100% patients. The contrast agent in the OV was found in 9.4%, and in the IPV in 6.3% patients, while no reflux of the contrast agent in the dilated vulvar veins was observed. CONCLUSIONS: Pelvic venography is a not mandatory component of the examination of women with pelvic and vulvar varicose veins without varicose veins of the lower extremities, who do not have symptoms of the PCS and valvular incompetence of the gonadal veins according to the DUS.

Endovascular interventions in the treatment of pelvic congestion syndrome caused by May-Thurner syndrome.

OBJECTIVE: The objective of this study was to assess the effect of various endovascular interventions on the clinical manifestations of the pelvic congestion syndrome (PCS) caused by May-Thurner syndrome (MTS). METHODS: The study included 12 female patients with PCS caused by MTS. Patients were examined by duplex ultrasound, computed tomography of the pelvic veins, and ovarian and pelvic venography. All 12 patients underwent endovascular stenting of the left common iliac vein (CIV), and 10 of them underwent subsequent endovascular embolization of the left gonadal vein. The indication for stenting was the presence of stenosis (>50%) of the CIV with clinical symptoms and signs of PCS. Self-expanding stents (Wallstent, 14-16 mm × 60-90 mm; Boston Scientific, Marlborough, Mass) were used. Patients with persistent symptoms of PCS after stenting underwent gonadal vein embolization with MReye metal coils (diameter, 10-15 mm; length, 10-20 cm; Cook Medical, Bloomington, Ind). RESULTS: Technical success of stenting, namely, the restoration of normal patency of the left CIV, was achieved in 12 patients. In two patients, a stent was displaced toward the inferior vena cava, which required implantation of a second stent. In another patient, the stent was displaced into the inferior vena cava at 6 months after the intervention, which was not associated with any complication during the follow-up period. The mean venous pelvic pain severity score decreased from 7.7 ± 0.8 at baseline to 4.8 ± 0.3 after 1 month and stayed at this level during the 6-month follow-up period. Complete elimination of PCS symptoms at 6 months after stenting was achieved in 2 patients, and 10 patients underwent embolization of the left gonadal vein 6 months after stenting because of persistent pelvic pain. CONCLUSIONS: Endovascular stenting of the left CIV is an effective technique for relieving symptoms of PCS due to MTS in only 16.6% of patients. Stenting of the left CIV in combination with embolization of gonadal veins results in elimination of the signs of PCS in 83.4% of patients. Probably only gonadal vein embolization can be used in the treatment of MTS-related PCS. To confirm this hypothesis, further comparative studies are warranted.

Ultrasound Appearance of Mesh After Transabdominal Preperitoneal Inguinal Hernia Repair.

Background: The linear geometry of the meshes undergoes significant changes after the transabdominal preperitoneal (TAPP) inguinal hernia repair, caused not only by the presence or absence of mesh fixation but also by reparative processes occurring in the area of surgical intervention. Objective: To assess the position of mesh in the preperitoneal space after the TAPP inguinal hernia repair using ultrasonography in the immediate and late postoperative periods. Materials and Methods: A total of 65 patients who underwent inguinal hernia repair with TAPP were examined. In all cases, a lightweight large-pore monofilament polypropylene mesh (size 10 × 15 cm) was used as a prosthesis. Follow-up examinations and ultrasonography of the mesh were carried out on the first postoperative day and at 1, 3, 6, and 12 months of the follow-up period. Results: Ultrasonography demonstrated mesh in two distinctly different appearances. Although it was seen as an echogenic structure with mild acoustic shadowing, the shape was either wavy or straight linear depending on the method and time elapsed from surgery. Thus, in patients without mesh fixation, it has a wavy appearance on the first day and at 1 month after TAPP, whereas at 3 months it took the appearance of a straight line, and at 12 months the implant has retained the shape of a straight line. Among patients who underwent mesh fixation in the immediate postoperative period, implant appeared as a straight line, and starting from the third month it began to acquire a wavy outline. Conclusion: Geometry of mesh used for TAPP inguinal hernia repair undergoes significantly different changes depending on the method of mesh fixation and time of postoperative period.

Effectiveness and safety of micronized purified flavonoid fraction for the treatment of concomitant varicose veins of the pelvis and lower extremities.

OBJECTIVE: Concomitant varicose veins of the pelvis (VVP) and lower extremities (VVLE) frequently coexist. This study evaluated the effectiveness and safety of micronized purified flavonoid fraction (MPFF) in the treatment of patients with both conditions. METHODS: Female outpatients with concomitant VVP and VVLE received MPFF 1000 mg once daily for 2 months (Group 1), or 1000 mg twice daily for 1 month followed by 1000 mg once daily for 1 month (Group 2), based on pelvic pain intensity. Change in pain intensity during treatment was evaluated on a 10 cm visual analog scale. All patients underwent transvaginal and transabdominal duplex ultrasound scanning, radionuclide phlebography of the lower extremities, and emission computer tomography of the pelvic veins at inclusion and end of treatment. RESULTS: In Group 1 (N = 35), MPFF was associated with a twofold reduction in pain syndrome severity (pelvic, perineal and lower leg pain) in all patients after 1 month, and a reduction in chronic pelvic pain (CPP) from 3.4 ± 1.2 to 0.83 ± 0.18 cm at 2 months. Leg pain significantly decreased from 2.8 ± 0.6 at baseline to 0.94 ± 0.11 after 2 months. In Group 2 (N = 30), MPFF decreased CPP severity from 6.3 ± 0.8 to 1.2 ± 0.12, perineal pain from 3.6 ± 0.9 to 0.88 ± 0.22 and leg pain from 4.6 ± 0.5 to 0.9 ± 0.1. Radionuclide phlebography confirmed the clinical improvement in both treatment groups, with a substantial increase in linear blood flow velocity in the internal iliac veins (∼10% in Group 1 and 35% in Group 2) and a reduction in mean transit times of the radiopharmaceutical. MPFF also reduced blood stasis in the pelvic venous plexuses. Gastralgias were reported in two patients but resolved rapidly and did not lead to treatment withdrawal. CONCLUSION: Phlebotropic treatment with MPFF is an effective and safe method of conservative therapy in patients with concomitant VVP and VVLE.

Vulvar varicosities: diagnosis, treatment, and prevention.

OBJECTIVE: Vulvar varicosity is a relatively common venous disorder in women with varicose veins of the pelvis and lower extremities and in pregnant women, but there is little information in the medical literature concerning its diagnosis and management. The aim of this study was to describe our experience with 101 women with vulvar varicosities who were examined and treated at our center during 2000-2014. PATIENTS AND METHODS: Patients were divided into two groups: group 1 with 61 women with varicose veins of the pelvis and enlarged vulvar veins, and group 2 with 40 pregnant women (11-38 weeks of pregnancy) with vulvar varicosities. RESULTS: In most cases, vulvar varicosities were able to be diagnosed at clinical examination. In both groups, duplex ultrasound of the veins of the pelvis and lower extremities was used to confirm the presence of varicose veins, identify any retrograde flow, accurately determine vein diameter, and to reveal any anatomical feature of the intrapelvic veins. Treatment approaches varied significantly between the two groups from purely conservative measures during pregnancy to surgical procedures on the ovarian and vulvar veins in group 1. The venoactive agent, micronized purified flavonoid fraction, was effective at reducing the symptoms of vulvar varicosities in both groups. CONCLUSION: A tailored approach to the diagnosis and treatment of vulvar varicosities can significantly improve the quality of care of women with this disorder.