Analysis of urologic complications after radical hysterectomy.

OBJECTIVE: Injuries of the ureter or bladder or development of vesicovaginal and ureterovaginal fistulas are the most serious complications in gynecological surgery. STUDY DESIGN: This study included 536 women who underwent radical hysterectomy because of invasive cancer of the cervix uteri. RESULTS: During the surgery the ureter was injured in 1.32% of cases, whereas the percentage of bladder injuries was 1.49. In the early postoperative period vesicovaginal or ureterovaginal fistulas appeared in 2.61% and 2.43% of cases, respectively. CONCLUSION: The stage of the disease, obesity, diabetes, and postoperative surgical infection acted as predisposing factors of the urinary tract complications.

Atypical proliferating mucinous tumors of gigantic dimensions.

UNLABELLED: BACKGROUND; Ovarian tumors of low malignant potential (LMP) are also known as atypically proliferating tumors. Ovarian tumors of LPM account for approximately 15% of all epithelial ovarian cancers. Mean age of occurrence is 40 years and they are 15-20 cm in diameter. CASE REPORT: A 32-year-old female patient was hospitalized as an urgent case with a large tumor mass that filled the entire abdomen. Cyst was 100 x 70 cm dimensions belonging to the right ovary and filled with 18 liters of content. Right adnexectomy, resection of the second ovary, as well as biopsy of the omentum were performed. Lymphadenectomy of the right iliac and obturator area was also performed. After receiving definitive histopathological results it was decided to perform a radical reoperation. On the 10th postoperative day relaparotomy, total hysterectomy and left adnexectomy were performed. The patient was released on the 6th postoperative day. She used to come to regular examinations up to date. CONCLUSION: This case is a proof that LMP tumors have low malignant potential, they grow slowly and can reach great proportions.

Urological complications after radical hysterectomy: incidence rates and predisposing factors.

BACKGROUND/AIM: [corrected] Radical hysterectomy is a surgical approach for stage Ib and IIa of cervical cancer. The incidence of intraoperative injuries of the bladder during radical hysterectomy ranges from 0.4-3.7%. The ureter can be crushed, caught in sutures, transsected, obstructed by angulation, or ischemic by the stippling or periureteric fascia. Vesicovaginal and ureterovaginal fistuls are reported to develop in 0.9-2% of patients after radical abdominal hysterectomy. Fistulas usually become manifested or visible at speculum examination within 14 days following the surgery. The aim of this study was to establish the incidence and predisposing factor of urological complications after radical hysterectomy. METHODS: The study included a total of 536 patients with invasive stage Ib to IIb cancer of the cervix uteri who had underwent radical hysterectomy. The special elements considered were: the patient's age; the International Federation of Ginecology and Obstetrics (FIGO) stage after pathohistology; duration of operation; the result of preoperative laboratory tests for diabetes, anemia, hypoproteinemia, or disorders of liver or kidney function; ASA status; postoperative surgical infection. RESULTS: The average age of the patients with complications was 48.68 years. All patients with intraoperative ureteric and bladder injuries had statisticaly significant higher stage of disease and operation lasted more than in others without injury. We noticed 1.3% ureteral injuries and 1.49% bladder injuries, more than 50% of the patients with a previously mentoned injuries were operated on more than 3 hours. We found 2.61% vesicovaginal and 2.43% ureterovaginal fistuls. A total of 50% of the patients with bladder injury and vesicovaginal fistuls and 70% of the patients with ureterovaginal fistuls had diabetes mellitus. Postoperative infection of surgical site is a very important factor for the development of fistule. Half of the patients with vesicovaginal fistuls had abscess of vaginal cuff. CONCLUSION: The stage of the disease seem to be the most significant factor in the development of intraoperative ureter and bladder injuries. The stage of the disease, intraoperative bladder injury, diabetes mellitus and postoperative infection of surgical site are the most significant factors in the development of postoperative fistuls.

[Analysis of loss of heterozygosity of the tumor suppressor genes p53 and BRCA1 in ovarial carcinomas].

BACKGROUND/AIM: Among the genes involved in ovarian carcinogenesis, there has been increased interest in tumor-suppressor genes p53 and BRCA1. Both of the genes make control of cell cycle, DNA repair and apoptosis. The p53 is a "genome guardian" inactivated in more than 50% of human cancers, while BRCA1 mutations are found mostly in breast and ovarian cancer. The aim of this investigation was to establish the frequency of loss of heterozygosity (LOH) in the regions of the genes p53 and BRCA1 in ovarian carcinomas, and to analyze the association of LOH with the disease stage and prognosis. METHODS: We analyzed 20 patients with a confirmed diagnosis of epithelilal ovarian carcinoma. DNA for molecular-genetic analysis was extracted from the tumor tissue and blood as normal tissue of each person. Microsatellite markers of the regions of genes p53 and BRCA1 were amplified by PCR method. The determination of allelic status of microsatellites and detection of LOH was performed after PAA gel electroforesis. RESULTS: Both of the analyzed microsatellite markers were informative in 13/20 (65%) cases. In the region of gene p53, LOH was established in 4/13 (30.7%) tumors. One of them had histological gradus G1, one had gradus G2, and two of them had gradus G3, while all were with the International Federation of Gynecology and Obstetrics (FIGO) IIIc stage. In the region of gene BRCA1, LOH was detected in 5/13 (38.5%) tumors. Four of them had histological gradus G2, and one had gradus G3, while by the (FIGO) classification one was with stage Ib, one was with stage IIIb, while the three were with stage IlIc. LOH in both of the analyzed regions was detected in one tumor (7.70), with histological gradus G3 and the FIGO IIIc stage. CONCLUSION: The frequency of LOH in epthelial ovarian carcinomas was 30.7% and 38.5% for p53 and BRCA1 gene regions, respectively. Most of tumors with LOH had histological gradus G2 or G3, and the clinical FIGO stage IIIc, suggesting the association of this occurrence with a later phase of the disease.

[Ovarian cancer after in vitro fertilization]. / Karcinom jajnika nakon fertilizacije in vitro.

There is serious concern about cancer risk in women undergoing ovarian stimulation treatment for infertility and longterm safety of these procedures. Association between fertility drugs and ovarian cancer is still controversial. A 30-year-old woman was referred to our institution with the initial diagnosis of an adnexal tumor after in vitro fertilization. Her history revealed adnexectomy for mucinous cystadenofibroma of the left ovary eight years ago, and cystectomy due to cystadenoma of the right ovary three years ago. At admission, the most remarkable findings were high temperature and elevated white blood cell count and erythrocyte sedimentation rate. Broad spectrum antibiotic treatment was initiated. Six days after admission, the patient was feverish, with temperature up to 38 degrees C, and evident signs of the acute abdomen. Immediate laparotomy was performed and multilocular right adnexal tumor 150x130x100 millimeters in size was identified. The right salpingo-oophorectomy was carried out. Pathological diagnosis was mucinous ovarian adenocarcinoma. Eighteen days later, radical surgery was performed. After the surgery, chemotherapy was applied. There is an urgent need for clear interpretation of the association between fertility drugs and subsequent higher ovarian cancer risk. Lacking conclusive evidence, an increased risk of ovarian cancer has been reported and more recently disputed. Higher ovarian cancer risk may be serious and even life-threatening complication for women undergoing ovarian stimulation.

[The fetal adrenal gland in risk pregnancy]. / Nadbubrezne zlezde fetusa u rizicnim trudnocama.

INTRODUCTION: The role of the adrenal gland in the metabolism of foetus and its role in maturation of foetal organs are the principal motives for paying more attention to this vital organ, which is still a great enigma for gynaecologists. The control of the gland is important in normal as well as in risk pregnancies. Of the entities that most often imperil the growth of foetus and adrenal glands are diabetes and hypertension in pregnancy. A consequence of the maternal diabetes may be macrosomy of foetus manifested by increase in foetal body mass and enlargement of organs sensitive to increased concentration of insulin in the foetal blood [6], i.e., the liver, fat tissue, lungs, adrenal glands, heart. Brown and Singer (1988) [2] established that adrenal glands of foetus are imperiled in pregnancies complicated by mother's hypertension. Their conclusion was derived from pathologic findings in foetuses from unsuccessful pregnancies of patients with hypertension. The glands were of reduced sizes. The way to perform precise measuring of glands, which are of dilapidated composition during post mortem examination, is not quite acceptable, since during the manipulation the size may, to some degree, be altered. By introduction of the ultrasound method in medical practice the problem of biometry has been overcome. Besides measuring, of great importance for the study of physiology of the gland is also the analysis of the foetal fluid and foetal blood. The first successful measuring of the adrenal gland of foetus by ultrasound was performed in mid 80s of the last century by Jeanty and Romero [3] via transabdominal path. The aim of our study is the comparison of foetal adrenal glands in normal and high-risk pregnancies. MATERIAL AND METHODS: During a prospective follow-up carried out at the Institute of Gynaecology and Obstetrics, Clinical Centre of Serbia, 213 patients, aged from 19 to 44 years were examined. Gestation periods were from the 11th to the 40th week. We divided the patients in 3 groups. The first group consisted of 131 patients with no pathologic changes and whose children were born alive. The second group was formed of 75 pregnant women in whom the course of pregnancy was impaired and disorders in the foetal. From these pregnancies the children were born alive. The third group was composed of 7 patients in whom abortion was indicated. The measured values of foetal adrenal glands diameter in the first group (131 patients), were used for making a nomogram of the glands growth. The measuring was performed with ultrasound apparatus "Toshiba 100 SSA". Transabdominal examination with a probe of 3.75 MHz and transvaginal examination with probes of 5 and 7 MHz were performed. Since the picture of the adrenal gland resembled an ellipse, on the basis of measured diameters and using the formula for circumference of this geometric figure [O = (d1 + d2) x pi/2], we obtained the desired value, which increased with advancement of pregnancy. Patients included in the study were with one-foetus pregnancy, whose last menstruation was precisely dated. Data are presented in a chart. For analysis of the obtained data, in addition to parameter methods, we also used the linear correlation and regression and one-factor analysis of variance. Data base analysis was made in the SPSS for DOS package. RESULTS: In making a nomogram of adrenal glands growth of a foetus old between 11 and 40 weeks, 131 of 213 patients were included, while the other foetuses were excluded as they belonged to high-risk pregnancies. Correlation of the growth of adrenal glands circumference and gestation period of pregnancy are also highly statistically important. The correlation coefficient of the straight line which represents this dependancy, is R = 0.8916, for the significance level of p < 0.01 (GRAPH 1). We observed how the course of pregnancy influenced the growth of foetal adrenal gland in normal pregnancies and in foetuses impaired by a pathological pregnancy course. By the method of one-way variance analysis, we obtained the value of the test, which was F = 2.79; p = 0.07. The graphical presentation of adrenal glands of a foetus in the appropriate week of gestation revealed that dimensions of glands in pregnancies impaired by diabetes were larger than those in normal gestations, and that they were at the top of border value of +2 SD or even over this limit. The statistically obtained value was F = 1.81; p > 0.05 (p = 0.06 and it was close to the border value for the significance level of p < 0.05); however, for glands of pregnancies complicated with hypertension the value was F = 1.61; p = 0.063 and the border value near -2 SD. Data are presented in a chart, regarding nomograms and adrenal glands of risk pregnancies. DISCUSSION: In 1993 Bronstein and colleagues [1] proved that the route of visualization of an adrenal gland was not only transabdominal. They succeeded in detecting the glands by transvaginal ultrasound examination in the 12th week. Jeanty and Romero [3] performed a successful transabdominal visualization in the 23rd week of gestation. By ultrasound prenatal examination we can determine the existence of hyperplasia of adrenal glands (Kelnar 1993) [5]. With ultrasound examination we can also diagnose tumours of the medulla, such as neuroblastoma (Jennings and colleagues 1993) [4]. In our study we reported on the visualization and growth of foetal adrenal glands in the period from the 11th to the 40th week of gestation. We presented the growth of foetal adrenal glands in normal gestations with the growth nomogram. The coefficient of correlation of adrenal glands circumference was R = 0.8916. The level of significance was p < 0.01. In conclusion, we can say that risk factors in pregnancy could impair the growth of adrenal glands. We have found that foetal adrenal glands in pregnancies impaired with maternal diabetes were hypertrophic, while those in pregnancies impaired with hypertension were almost at hypotrophic border. The nomograms of adrenal glands growth were of clinical importance, since they help us to control the state of a foetus in high-risk pregnancies. CONCLUSION: Improvement of the methods used in prenatal diagnosis will contribute to a timely detection of a diseased foetus, and will be the first step in its recovery. Regulating the pathological condition of the mother will surely contribute to decrease the risk of delivering children with an increased risk of morbidity.