European consensus statement on expert colposcopy.

BACKGROUND: Following the publication of the European consensus statement on standards for essential colposcopy in 2020, the need for standards relating to more complex and challenging colposcopy practice was recognised. These standards relate to colposcopy undertaken in patients identified through cervical screening and tertiary referrals from colposcopists who undertake standard colposcopy only. This set of recommendations provides a review of the current literature and agreement on care for recognised complex cases. With good uptake of human papillomavirus (HPV) immunisation, we anticipate a marked reduction in cervical disease over the next decade. Still, the expert colposcopist will continue to be vital in managing complex cases, including previous cervical intraepithelial neoplasia (CIN)/complex screening histories and multi-zonal disease. AIMS: To provide expert guidance on complex colposcopy cases through published evidence and expert consensus. MATERIAL & METHODS: Members of the EFC and ESGO formed a working group to identify topics considered to be the remit of the expert rather than the standard colposcopy service. These were presented at the EFC satellite meeting, Helsinki 2021, for broader discussion and finalisation of the topics. RESULTS & DISCUSSION: The agreed standards included colposcopy in pregnancy and post-menopause, investigation and management of glandular abnormalities, persistent high-risk HPV+ with normal/low-grade cytology, colposcopy management of type 3 transformation zones (TZ), high-grade cytology and normal colposcopy, colposcopy adjuncts, follow-up after treatment with CIN next to TZ margins and follow-up after treatment with CIN with persistent HPV+, and more. These standards are under review to create a final paper of consensus standards for dissemination to all EFC and ESGO members.

A unique anatomical variation of the vascular supply of the ovary, uterine tube, and uterus from the greater omentum - an anatomical case study.

It is well known that the blood supply of the greater omentum and female internal genital organs are not physiologically connected. There is also no mention of such anatomical variation in anatomical, radiological, or surgical textbooks. Here we present a very rare case report of atypical double arterial anastomosis (the first and second variant artery) between the right limb of the omental arcade of Barkow, uterus, and right ovary, which was found during a routine student anatomical dissection course. It is very challenging to find a proper explanation for the presence of the described anatomical variation; however, we hypothesized that it is based on their common embryonic origin - the mesentery. The first and second variant arteries could be remnants of transient anastomoses or collateral circulation, which were present during embryonic development and persisted until adulthood. Moreover, during our literature review, we noticed that the general description of omental blood supply and its possible variations is relatively poor; therefore, we emphasize the need for more precise knowledge regarding these anatomical parts, which could help surgeons who are performing abdominal or pelvic surgeries in preventing avoidable bleeding.

Supernatant versus exosomal urinary microRNAs. Two fractions with different outcomes in gynaecological cancers.

MicroRNAs (miRNAs) are key regulatory molecules implicated in fundamental cell processes. Recent investigations have been focused to investigate their diagnostic potential also in various body fluids. Plasma and serum are widely used for these purposes. Urinary miRNAs, as the easily available type of sample, have been explored particularly in urological diseases recently. However, we have shown previously that differential expression of urinary cell-free miRNAs may be observed also in gynaecological cancers, such as ovarian and endometrial cancers. In the present article, we focus on the differences in particular urine cell-free miRNA abundance among different samples including particularly ovarian and endometrial cancers and rare gynaecological diagnoses involved in the study. Using raw abundance miRNA expression data, we confirmed significant up-regulation of miR-92a in ovarian cancer, and significant down-regulation of miR-106b in endometrial cancers. As miR-21 appeared up-regulated in the endometrial cancer similarly as in the verification process, where also miR-106b resulted in significant down-regulation in ovarian cancer, these miRNAs may be good candidates for further evaluation as novel diagnostics. To find out why supernatant but not exosomal urine miRNAs fraction resulted in significant results in regards to de-regulation of expression, we performed a comparison of the same urine samples isolated by these two manners. We show that diagnostic potential of cell-free urinary miRNAs may depend on the urine fraction used for the isolation. While particular urinary miRNAs may be enriched, other may reveal unchanged or diminished expression in the exosomal fraction in comparison with supernatant fraction, giving differences also between cancer and control samples. More research will be needed to further explore which kind of cell-free samples would give better results for diagnostic purposes in various diagnoses using urinary samples and investigating cell-free miRNAs expression. Meanwhile, different urine fractions should be explored for their miRNA expression to establish novel diagnostic urinary miRNA markers.

New perspectives in diagnosis of gynaecological cancers: Emerging role of circulating microRNAs as novel biomarkers.

Early diagnosis is a prerequisite of the more successful treatment of cancer. In gynaecological cancers, such as ovarian, endometrial and cervical cancers, the recent efforts are aimed at finding novel diagnostic biomarkers to help reduce the worldwide health burden associated with these cancers. In this review, we focus on the recent research progress in circulating, particularly cell-free microRNAs expression achieved in ovarian, endometrial and cervical cancers showing an opportunity to find novel diagnostic biomarkers for these malignant diseases. With the onset of microRNAs investigations showing their diagnostic potential in many diseases, their role in gynaecological cancers has been examined as well. However, similarly as in many other diseases, the vast majority of research on microRNAs expression has been dealing with tissue samples and cell lines. Recently, as the novel approaches focused on cell-free microRNAs expression have emerged, several studies identified their potential diagnostic and prognostic value in gynaecological cancers using blood, serum/plasma or urine samples. More research will be needed to establish circulating and extracellular microRNAs as the novel diagnostic markers for gynaecological malignancies. Inconsistency of results across the studies due to technical and biological variation, and a low number of this kind of investigations are the main potential pitfalls remaining to be resolved.

Anterior retroperitoneal rami: until now unnamed direct branches of the abdominal aorta.

The aim of the study was to gain a thorough knowledge of the topography and distribution of until now officially unnamed minute direct branches from abdominal aorta, stemming from its ventral and lateral aspects, supplying surrounding tissue, and to comprise it to the existing studies. The study was performed in fixed cadaverous material collected from India ink injections of abdominal aorta samples with large surrounding retroperitoneal tissue. The 25 samples were dissected under magnifying binocular glass, followed by graphic reconstruction; statistical analysis, and the study was preceded with detailed review of branches from abdominal aorta. For systematization of the segmental anatomy of the abdominal aorta and infrarenal segment of inferior vena cava, we defined three levels in this area. The retroperitoneal branches were most frequently situated simultaneously within all three predefined levels according to renal and inferior mesenteric arteries origin. There were 18% of retroperitoneal branches within Level 1, 39% within Level 2 and 43% within Level 3. They were branches not only from the abdominal aorta, but also from the testicular/ovarian artery, common iliac artery and in one case from the right accessory renal artery. Paired arrangement was recorded mainly cranially to the origin of inferior mesenteric artery, unpaired branches were more frequently found caudally. In conclusion, due to the terminological disunity of these arteries in the clinical literature and total absence in the anatomical literature, we propose to denominate them as anterior retroperitoneal branches of abdominal aorta (rami retroperitoneales anteriores aortae abdominalis).

[Differential expression of microRNAs as the novel potential diagnostic tool for the endometrial carcinoma]. / Exprese mikroRNA jako nový potenciální diagnostický nástroj pro karcinom endometria.

The most common gynecological malignancy, the endometrial carcinoma, is mostly diagnosed at early stages. However, diagnosis at advanced stages is accompanied by the high mortality rate. It is suggested that this cancer is one of the less studied female cancers. The necessity to establish novel diagnostic markers has led to investigations of small non-coding RNAs, particularly microRNAs, also in endometrial cancer. There have been found many microRNAs potentially associated with carcinogenesis and clinico-pathological data including prognosis for patients. Many microRNAs may also serve as diagnostic markers for non-invasive diagnostics using blood plasma. We reviewed extensively the published research focused on microRNAs that have been found deregulated particularly in tissue samples within the both major types of endometrial cancer (type 1 and type 2). They are presented in the view of their potential targets and mechanisms of action. Some microRNAs have been found deregulated also in blood plasma. There exists a high level of inconsistency across the studies as many microRNAs have been found only within one or a few studies so far. However, there are some microRNAs consistently deregulated as suggested several investigations. There remains the urgent need of more intensive research focused on the microRNAs and their regulatory role in endometrial cancer. Such a research should provide the basis for the introducing novel diagnostic tools into the clinical practice.

[Rectal duplication cyst--case report]. / Cystická duplikatura rekta--kazuistika.

OBJECTIVE: The authors demonstrate a rare case of duplication anomaly of the rectum. DESIGN: Case report. SETTING: Institute for the Care of Mother and Child, Prague. SUBJECT AND METHOD: We present a rare case of cystic rectal duplication in adult, completely removed and histologically confirmed. A literature review was summarized. CONCLUSION: The case was complicated by delay in diagnosis, multiple operations, and by the association with endometriosis, as well. Mentioned anomaly is published in the Czech literature for the very first time.

[Persistent trophoblastic disease in Trophoblastic Disease Center in the Czech Republic in 1955--2007]. / Perzistující trofoblastická nemoc v Centru pro trofoblastickou nemoc v CR v letech 1955--2007.

OBJECTIVE: To define persistent trophoblastic disease as a clinical entity of gestational trophoblastic disease. To describe its classification, treatment and follow-up. TYPE OF STUDY: Retrospective analysis. SETTING: Trophoblastic Disease Center (TDC) in the Czech Republic TDC-CZ, Institute for the Care of Mother and Child, Prague. METHODS: This study analyzes data from the Trophoblastic Disease Center consisting of 396 choriocarcinomas, 512 proliferative moles, 798 complete hydatid moles, 1299 partial hydatid moles, and 2105 persistent trophoblastic invasions treated at the TDC up to the year 2007. The study includes also 2615 cases of trophoblastic disease which documented by gynecologists and pathologists of the Czech Republic and registered in the TDC-CZ. RESULTS: Persistent trophoblastic disease was defined and described in detail as follows: 1. Differentiating autothonic hCG, produced by the gestational trophoblast, from so-called "phantom hCG," hypophyseal hCG and hCG during PLL-Q and PLL-U syndrome. 2. Evaluating the level and length of persistence of hCG relevant for the diagnosis of persistent trophoblastic disease. 3. Identifying three types of persistent trophoblastic disease: A. Non-metastatic B. Metastatic low-risk C. Metastatic high-risk 4. Described treatment, indications, and choice of various chemotherapeutic protocols in individual types of persistent trophoblastic disease as well as its follow-up. CONCLUSION: This study enables the differentiation of persistent trophoblastic disease in general gynecologic and obstetric clinical practice, by evaluating the presence, level, and length of persistence of hCG, and thus allowing for timely referral of the patient to the Trophoblastic Disease Center in the Czech Republic.

[Syndrome of persistent low levels of human chorionic gonadotrophin (hCG)]. / Syndrom perzistujících nízkých hladin humánních choriových gonadotropinu (hCG) etiologie, klasifikace, diagnostika, postupy.

OBJECTIVE: To analyze the syndrome of persistent low levels of hCG in terms of its etiology, classification, diagnosis, and management. DESIGN: Retrospective analysis. SETTING: Center for Trophoblastic Disease in Czech Republic, Institute for Care of Mother and Child, Prague, Institute of Postgraduate medical education, IPVZ, Prague METHODS: An analysis of the syndrome of persistent low levels of hCG recorded in CTN in 29 women in the years 1979-2005 by the immunoluminesence method which can quantitatively assess variable levels of hCG in blood and urine. A comparison was made of our findings with results of a similar studies having been done in England and USA. RESULTS: Persistent low levels of hCG (PLL) can be differentiated according to cause. 1. PLL-F False positive, also known as Phantom hCG, often caused by heterogenous antibodies. 2. PLL-H Of hypophysial origin, mainly in perimenopause and menopause. 3. PLL-Q Quiescent with trophoblastic disease in history, of trophoblastic origin. 4. PLL-U Undetermined, in history without trophoblastic disease, but in the past with physiological or pathological pregnancy. Assuming also to be of trophoblastic origin. All types of PLL lead in practice to the wrong diagnosis of trophoblastic disease and to a high percentage (40-80%) of needless chemotherapy and operations. In no case of PLL did chemotherapy or operations have an effect on PLL and thus are contraindicated. PLL-Q and PLL-U require continuous clinical and laboratory monitoring and repeated examinations with sophisticated visualization methods. The percentage of developing malignant trophoblastic tumors after PLL-Q and PLL-U is unclear. Extreme incidence was established in 7-25%. PLL-Q and PLL-U are considered as a marker of persistent trophoblastic invasion. Its detection by visualization methods in any organ localization before it turns into a limited solid tumor is excluded by it microscopic dissociative structure. CONCLUSION: The syndrome of persistent low levels of hCG (PLL) lately affects all gynecological and obstetrical workplaces. According to cause it can be divided into: 1. PLL false positive, 2. PLL of hypophysial origin, 3.PLL quiescent with trophoblastic disease in the history, 4. PLL undetermined, in history without trophoblastic disease. In the last two items mentioned above we assume to be of trophoblastic origin. Their morphological base is persistent trophoblastic invasion. The syndrome of PLL often leads to the wrong diagnosis of trophoblastic disease and to needless chemotherapy and operations. In this work was described the diagnosis of PLL, its classification, cause, and management. The percentage of PLL turned into malignant trophoblastic disease is unknown and ranges from 7-25% and requires monitoring in an accredited, national center for trophoblastic disease.

[Laparoscopic ovariopexy--modality of ovarian endometriosis treatment]. / Laparoskopická ovariopexe--modalita lécby ovariální endometriózy.

OBJECTIVE: Case report of a successful treatment of ovarian endometriosis by laparoscopic ovariopexy in infertile women. DESIGN: Case report. SETTING: Institute for the Care of Mother and Child, Prague, Institute for Postgraduate Medical Education, Prague. RESULTS: Conservative treatment of ovarian endometriosis is often complicated by postoperative periadnexal adhaesions which may result in pelvic pain or ongoing infertility. Temporary laparoscopic ovarian suspension--ovariopexis is a very effective method in postoperative adhaesion prevention and in the treatment of ovarian endometriosis in infertile patient. We observed successful cases of laparoscopic treatment of ovarian endometriosis. CONCLUSION: Laparoscopic ovariopexis is a simple and effective method for treatment of ovarian endometriosis and prevention of extensive periadnexal adhaesions.