Evaluation of the Preoperative Slide Test in the Prediction of Intra-Abdominal Adhesions: A Single-Center, Double-Blinded, Prospective Observational Study.

BACKGROUND: To evaluate the efficacy of the preoperative ultrasonographic sliding sign in predicting intra-abdominal adhesions. METHODS: This was a single-center, double-blinded, prospective observational study undertaken from March and September 2021 on 110 patients with a history of previous abdominal surgery. All patients who were scheduled for laparoscopy underwent slide test in 5 zones of abdomen: right lower quadrant, left lower quadrant, previous operation site, vesicouterine pouch, and rectovaginal pouch. Adhesions were assessed by the same gynecologic surgeon using ultrasonography before the surgery and by gynecological surgeons during surgery, and by a third gynecologic surgeon to compare the preoperative slide test findings and laparoscopic findings after the surgery. RESULTS: Seventy-three (66.4%) patients underwent laparoscopic surgery, and 37 (33.6%) patients underwent laparotomy. The mean age of patients was 46.9 ± 1.0 years. Sensitivity, specificity, and positive and negative predictive values of preoperative ultrasonography in predicting adhesions were 89.5%, 91.7%, 97.5%, and 71.0%, respectively. The accuracy of the slide test was calculated as 90.0%. It was found that as the total number of cesarean sections increased the estimates of vesicouterine adhesions and actual adhesions increased (P = .008). Also, the prediction of intra-abdominal adhesions and actual adhesions significantly increased as the total number of surgical operations increased (P = .002). CONCLUSIONS: Intra-abdominal adhesions can be detected with the slide test, which is a non-invasive and well-tolerated procedure. Slide test can guide the physician before the elective operation in patients with previous abdominal surgery and may assist in counseling patients.

The role of multiple high-risk human papillomavirus infections for cervical biopsies and findings in colposcopic procedures

Objective: The clinical outcome of high-risk HPV (hr-HPV) infection varies according to genotype(s). Patients may harbor either one single hr-HPV (s-HPV) or multiple HPV (m-HPV) genotypes. Recently, the relationship between m-HPV infections and high-grade dysplasia has been investigated, and controversial results have been obtained. Therefore, the clinical significance of m-HPV is not clear. This study aimed to evaluate which group is associated with higher grade dysplasia by analyzing colposcopic punch biopsies. Material and Methods: A total of 690 patients who were scheduled for a diagnostic excisional procedure between April 2016 and January 2019 due to the detection of high-grade cervical intraepithelial neoplasia (CIN 2/3) in colposcopy were included. Patients who were not scheduled for colposcopic examination or cervical punch biopsy, or who were scheduled for an excisional procedure due to smear-biopsy incompatibility or persistent low-grade dysplasia were excluded. Patients with a negative HPV test and an unknown HPV genotype were also excluded. Results: Among the patients scheduled for excision (n=404), 74.5% had a s-HPV and 25.5% had a m-HPV infection. The proportion of CIN 1, 2 and 3 per patient in the m-HPV group was significantly higher than the s-HPV group (p=0.017). When this analysis was made for the number of CIN 2+3 per patient in the s-HPV and m-HPV groups, it was 1.29 (389/301) and 1.36 (140/103), respectively, and no difference was found (p=0.491). Conclusion: Patients in the m-HPV group, who underwent more colposcopic cervical biopsies, had higher numbers of CIN lesions, regardless of age and cytology results.

Is Endocervical Glandular Involvement Related to The Depth of Cone Biopsy?

Introduction. This study aimed to determine whether endocervical glandular involvement by squamous intraepithelial lesion would differ with respect to the depth of the excised specimen and analyze the related factors that may define endocervical glandular involvement among cases treated with cone biopsy. Methods. Between April 2016 and December 2018, women who underwent colposcopy and excisional procedures in the department of gynecologic oncology were retrospectively investigated. Patients with multiple specimens, or whose specimen depths were not measured, and a negative/unknown HPV status were excluded from the study. Also, patients with no dysplasia or microinvasive/invasive cancer in the final pathology report and those who had not undergone endocervical curettage during colposcopy were excluded. HPV genotypes, degree of dysplasia, surgical margin status, and specimen depth were documented from medical records. Further, the association of these factors with endocervical glandular involvement was evaluated. Results: A total of 321 patients who fulfilled the criteria were included in the study, with a mean age of 41.9 years. In total, 101 patients (31.5%) had endocervical glandular involvement. The mean excised specimen depth was 17.04 mm; 17.9 and 16.7 mm for the positive and negative glandular involvement groups, respectively (p = .13). The mean ages were 42.7 and 41.6 years for these groups, respectively (p = .32). There was no association between the HPV genotypes and glandular involvement. Conclusions: Endocervical glandular involvement is not associated with the depth of the excised specimen. A deeper cone biopsy may not necessarily enable a more effective treatment of the disease.

Effect of Human Papillomavirus Subtype on the Rate of Positive Surgical Margin After Cervical Conization.

Objective. Human papillomavirus (HPV) infection is a risk factor for cervical carcinoma. Over 100 types of HPV have been identified. The excisional procedures are recommended for women with high-grade cervical intraepithelial neoplasia. Surgical margin status is an important predictor of the risk of relapse. The aim of the current study was to evaluate whether HPV genotype is a predictive factor of positive surgical margin after cervical cone excision. Materials and Methods. The records of 448 HPV-infected patients who underwent loop electrosurgical excision or cold knife conization at a tertiary gynecological cancer center were retrospectively reviewed. The patients were divided into 6 groups according to HPV positivity: HPV 16 only, HPV 18 only, HPV 16/18, other high-risk HPV (hrHPV), HPV 16/hrHPV, and HPV 18/hrHPV. Results. There was no significant difference between the HPV groups in terms of age, parity, menopausal status, endocervical canal involvement, conization method, and the rates of positive margin (P = .15, P = .49, P = .07, P = .20, P = .24, P = .39, respectively). Conclusion. The results show that HPV subtypes might not be associated with endocervical canal involvement and the rates of positive margin. In addition, margin status was not related to the conization method and the number of excised cervical tissue.

A Case of Digital Autoamputation with Concurrent Sjogren's Syndrome, Antiphospholipid Syndrome, and Ovarian Cancer.

Sjogren's syndrome (SS) is a chronic autoimmune disease that is characterized by focal lymphocytic infiltration of the exocrine glands. SS mostly affects middle-aged women, and results in an increased risk of developing malignant neoplasm, particularly hematologic malignancies. The concurrent occurrence of SS, ovarian cancer, and autoimmune disease is very rare. Here, we present a case with postoperative digital autoamputation in a young Sjogren's patient diagnosed with high-grade serous ovarian cancer. The patient was later also diagnosed with antiphospholipid syndrome. Clinicians should note that female genital tract malignancies might occur in autoimmune diseases. In addition, when planning for surgery, they should also be aware of the possibility of another autoimmune disease and different patterns of postoperative complications such as venous thromboembolism and thrombophlebitis. A multidisciplinary approach is required to achieve successful management. To the best of the authors' knowledge, this is the second case with concurrent SS and ovarian cancer and the first case with concurrent SS, antiphospholipid syndrome, and ovarian cancer.

The effect of abdominal drainage on post-operative morbidity; a prospective cohort study.

The aim of this study was to investigate the effect of drains used in current clinical practice on operation parameters and post-operative morbidity. The comprehensive data obtained through the prospective design were analysed in detail according to whether abdominal drainage was applied. Abdominal drainage was present in 44.1% of patients who met the inclusion criteria. Drains were placed significantly more frequently during oncologic surgery (p = .007). The mean mobilisation (p = .001), first flatus (p = .001), and first oral intake (p = .029) times were longer in the drain group than those in the non-drain group. In patients who underwent oncological surgeries, no significant differences were observed except for the pre-operative duration of bowel preparation (p = .006) and first flatus time (p = .003). Our results suggest that drain placement in gynecological procedures does not provide an additional advantage.IMPACT STATEMENTWhat is already known on this subject? Post-operative drainage of the abdominal cavity has been controversial for many years. However, whether abdominal drainage provides an additional benefit in lower and upper abdominal surgical procedures remains unclear.What do the results of this study add? Most studies have examined post-operative pain and surgical site infections. We examined the relationship between abdominal drainage and demographic and pre-/post-operative clinical features in detail. We demonstrated that abdominal drainage in gynecological procedures may not provide an additional advantage.What are the implications of these findings for clinical practice and/or further research? The present study provides valuable information that can guide physicians in deciding whether to use post-operative abdominal drainage. This topic warrants investigation with randomised data in the future.

The Effect of Mechanical Bowel Preparation on the Surgical Field in Laparoscopic Gynecologic Surgeries: A Prospective Randomized Controlled Trial.

PURPOSE: To evaluate the effects of mechanical bowel preparation (MBP) on the intraoperative visualization of the surgical field, bowel handling, intestinal load, and overall ease of surgery in patients undergoing elective laparoscopic gynecological surgeries. METHODS: The patients randomized to a MBP group and a no preparation (NMBP) group. The senior surgeon remained blinded to the bowel regimen used by the patient. Intraoperative visualization of the surgical field, bowel handling, intestinal load, and overall ease of surgery were evaluated using a numeric rating scale (NRS). RESULTS: We enrolled 120 patients, of whom 109 completed the study, with 51 and 58 patients in the MBP and NMBP groups, respectively. The intraoperative visualization of the surgical field, intestinal load, and NRS scores for overall ease of surgery were better in the NMBP group (p = .03, p = .048, and p = .022, respectively). The results of the assessments also revealed no significant differences in surgical field visualization, ease of bowel handling, overall ease of surgery, or the time that patients experienced passage of flatus between obese (BMI > 30 kg/m2) and non-obese (BMI ≤ 30 kg/m2) patients in the two groups. CONCLUSIONS: The current study revealed that MBP did not improve the intraoperative visualization of the surgical field or the overall ease of surgery. Moreover, MBP had no benefit when operating on patients who had a high BMI. Therefore, we do not recommend routine MBP before laparoscopic gynecological surgeries.

Single centre experience of 800 gynaecologic oncology cases in 2020: influence of pandemy on cancer surgeries.

We aimed to evaluate the gynaecological oncology surgeries in the COVID-19 pandemic. A total of 800 operations performed between January and December 2020 were retrieved. Since the COVID-19 pandemic affected operations as of April 1 2020, we compared the cases of the last nine months of the year with the first three months. Of the operations, 265 (33.1%) were performed between January and March and 535 (66.9%) between April and December. Of 168 malignant operations; 78 (46%) were uterine cancer, 58 (35%) ovarian cancer, 28 (17%) cervical cancer and four (2%) vulvar cancer. If we compared the last nine months of the year with the first three months, a significant increase was observed in the rates of malignant and premalignant, while a significant decrease was detected in benign operations (p<.001). Gynaecological oncology surgeries performed with open or laparoscopic approaches during the COVID-19 pandemic should continue by taking preventive measures. Impact StatementWhat is already known on this subject? During the COVID-19 pandemic, many international associations and organisations recommended the suspension of elective surgeries. It is still controversial whether the gynaecologic oncology surgical procedures to be performed in this unprecedented time should be laparoscopic or laparotomic.What do the results of this study add? The malignant and premalignant gynaecological oncology surgeries should be safely performed laparoscopically or by laparotomy in the COVID-19 pandemic.What are the implications of these findings for clinical practice and/or further research? Gynaecologic oncology surgeries can be safely performed by attaching appropriate personal protective equipment procedures with pre-operative COVID-19 PCR testing in the COVID-19 era.

The percentage of peripheral eosinophils as a sensitive marker for differentiating FIGO grade in endometrial adenocarcinomas

Objective: Studies on eosinophils have mostly been directed to parasitic infections and allergic diseases, but the role of eosinophils in oncology has been largely ignored. Eosinophils are an important modulator of the immune response and components of the inflammatory process against the tumor. This study was performed to investigate the pre-operative peripheral blood eosinophil percentages in patients with a histopathologically diagnosed pure endometrioid type endometrial carcinoma. Material and Methods: Patients' data were analyzed in two groups as present/absent according to whether there are tumor metastases in the adnexes, lymph nodes, cervical stroma, and whether there was lymphovascular space invasion. FIGO grade was taken as the basis of the tumor grade: Low-grade equated to grade 1 or 2, and high-grade equated to grade 3. The requirement for lymph node dissection was based on the Mayo criteria. Results: The data of a total of 268 patients were included. The mean percentage of eosinophils in high-grade patients (n=29) was 2.75±0.35, and was significantly higher than the mean percentage of eosinophils of found in low-grade patients (n=239), which was 1.79±0.09 (p=0.013). Receiver operator curve analysis showed that a cut-off eosinophil percentage of 1.95% resulted in a sensitivity of 62% and specificity of 67% (p=0.004). Conclusion: Eosinophil percentages, which are a simple, easily accessible, and inexpensive can be an important pre-operative predictive tool. Eosinophil percentages can be used in determining the need for surgical staging in endometrial cancer.

Clinical Significance of Endometrial Cells in Pap Smear of Women Aged 40 Years and Older.

OBJECTIVE: To investigate the histopathological follow-up results in women diagnosed with endometrial cells in the Papanicolaou (Pap) test. MATERIAL AND METHOD: Between January 2013 to December 2018, women with endometrial cells on the Pap test were searched from the hospital electronic database. The patients with endometrial cells on the Pap test who underwent further histopathological evaluation and who were followed-up for at least 1 year were enrolled in the study, while those who had a Pap test result other than endometrial cells, were lost during follow-up, or had missing data were excluded. RESULTS: Out of 91,142 Pap smears, 121 (0.1%) cytologically had endometrial cells, and of those 65 cases were eligible for final analysis. The mean age of patients with premalignant/malignant lesions (57.7 ± 2.9) was higher than those with benign lesions (50.1 ± 0.7), with 77% of them in the postmenopausal period. Gynecologic premalignant/malignant lesions were detected in 9 (17.7%) patients including 2 (3.1%) endometrial hyperplasias and 7 (10.8%) endometrial cancers. The menopausal status (p=0.010) and being 50 years and older (p=0.002) were significantly associated with pre-neoplastic or neoplastic changes in patients with endometrial cells. CONCLUSION: The presence of endometrial cells in Pap tests may be a harbinger of endometrial pathologies, especially at the age of 50 years and over. The menopausal status is another possible determinant in detecting endometrial carcinoma. Further investigation may be suggested in women aged ≥50 years and postmenopausal in the event of endometrial cell detection.

The clinical importance of polyp size measurement through two-dimensional saline infusion sonohysterography prior to hysteroscopic resection in predicting premalignant and malignant endometrial lesions.

OBJECTIVE: To evaluate the clinical importance of endometrial polyp size measured using saline infusion sonohysterography (SIS) before performing a hysteroscopic resection in predicting premalignant/malignant lesions. METHODS: A retrospective observational study analysis was conducted of 365 patients, who underwent SIS, in a reference hospital. The longest plane of the polyp size was taken as base. Polyps were classified as benign, premalignant, or malignant. RESULTS: The rates of premalignant and malignant lesions were 7.4% and 0.9%, respectively. The mean polyp size was 17.7 ± 0.5 mm in benign patients and 23.7 ± 1.8 mm in premalignant/malignant individuals (P < 0.001). In the group of polyps that were 0-10, 10-20, 20-30, and >30 mm, premalignancy/malignancy rates were 0.0%, 4.8%, 13.3%, and 18.8%, respectively. The cut-off value for polyp size to be able to predict lesions was calculated as 22.5 mm (sensitivity: 63%, specificity: 80%) on receiver operating characteristics curve analysis (P = 0.001, area under the curve 0.732). The power of the study was calculated as 90.86%. CONCLUSION: During the female reproductive years, endometrial polyps smaller than 10 mm, as measured in SIS, can be followed. However, when the polyp size is 22.5 mm or more, especially in postmenopausal women, treatment should be planned.

Tumor diameter as a predictor of lymph node involvement in endometrioid type endometrial adenocarcinomas.

AIM: To analyze the risk factors of lymph node involvement in pure endometrioid type endometrial cancer and assess factors that necessitate lymphadenectomy. METHODS: Patients who had been operated on due to endometrial cancer and whose final pathology was reported as pure endometrioid carcinoma between January 2014 and January 2020 were assessed. Hysterectomy, bilateral salpingo-oophorectomy, and systematic lymphadenectomy were performed in all patients. All specimens were reported by expert gynecopathologists. RESULTS: The lymph node positivity rate was 14.4%. When the study population was classified according to the Mayo risk criteria; lymph node involvement in the low-risk and high-risk groups was 9.1% and 14.8%, respectively and there was no statistically difference (p > 0.05). The median of tumor size and the rate of deep myometrial invasion, lymphovascular space invasion, adnexal involvement, FIGO grade 3 tumor were found significantly higher in the positive lymph node group in univariate analysis. In the receiver operating characteristic curve analysis, the cut-off value of the tumor diameter was determined as 47.5 mm (sensitivity 85%, specificity 62%). Every 10 mm increase in tumor diameter increased the risk of lymph node involvement 10 times. CONCLUSION: This study defined that the tumor diameter is an independent predictor for lymphatic dissemination. In the future, it could be shown that even with new modeling based on tumor diameter, lymphadenectomy or adjuvant radiotherapy requirements would be reevaluated.

The meaning of high-risk HPV other than type 16/18 in women with negative cytology: Is it really safe to wait for 1 year?

BACKGROUND: Human papillomavirus (HPV) is a primary risk factor for cervical cancer. HPV 16 and 18 are the two most carcinogenic genotypes and have been reported in the majority of cervical cancer. High-risk HPVs (hrHPVs) other than HPV 16/18 cause approximately a quarter of cervical cancers. We aimed to present the colposcopy-guided biopsy results of non-16/18 hrHPV-infected women with negative cytology. METHODS: This is a retrospective cohort study conducted on 752 patients between the ages of 30-65 years with non-16/18 hrHPV and negative cytology undergoing colposcopy-guided biopsy at a tertiary gynecological cancer center between January-2016 and January-2019. RESULTS: The mean age of the women was 42.35±9.41 years. Cervical intraepithelial neoplasia (CIN) 2+ lesion was detected in 49 (6.5%) women with negative cytology. The rate of CIN 2+ lesions in women with abnormal cytology was 12.8%. Patients with abnormal cytology had about 2.1 and 2.4 times increased the odds of CIN 2+ lesion in cervical biopsy and endocervical curettage specimens, respectively. CIN 3+ lesion was detected in 20 (2.7%) women with negative cytology. One (0.1%) of the patients with HPV 39 and negative cytology had invasive cervical cancer. The two most common HPV subtypes were HPV 31 and HPV 51. CONCLUSIONS: The risk of cervical preinvasive lesions still can be detected and cannot be completely eliminated among hrHPV other than 16/18-infected women with negative cytology. Based on the results of this study, referral of non-16/18 hrHPV-infected women with negative cytology to colposcopy is supported as a credible and feasible strategy.

Is cervical cytology testing as a part of co-test unnecessary for HPV 16/18-infected women? A retrospective cohort study of 1647 women.

BACKGROUND: We aimed to present the biopsy results of women with HPV 16/18 infection and investigate whether cytology is necessary as a part of routine cervical cancer screening in women with HPV 16/18. METHODS: This is a retrospective cohort study conducted on 1647 patients between the ages of 30 and 65 years with HPV 16/18 undergoing colposcopy-guided biopsy at a tertiary gynecological cancer center between January-2016 and January-2019. We compared the preinvasive lesion rates and the invasive cervical cancer rates of women with HPV 16/18 between the negative and the abnormal cytology group. RESULTS: Of the 1647 women, 1105 (67.1%) had negative cytology and 542 (32.9%) had abnormal cytology. Among women with initial negative cytology, cervical intraepithelial neoplasia (CIN) 2+ lesion was detected in 205 (18.6%) women. The rate of CIN 2+ lesion in women with abnormal cytology was 28%. There was a significant difference between negative and abnormal cytology group in terms of CIN 2+ lesion rates (P < .001). Among women with initial negative cytology, invasive cervical cancer was detected in 6 (0.5%) women. The rate of invasive cervical cancer in women with abnormal cytology was 8 (1.5%). There was no significant difference between negative and abnormal cytology group in terms of invasive cervical cancer rates (P = .082). CONCLUSIONS: The rate of cervical cancer among HPV 16/18-infected women with negative cytology is similar to women with abnormal cytology. Based on the results of this study, Pap testing could be unnecessary in HPV 16/18-infected women to diagnose invasive cervical cancer who will undergo colposcopy biopsy.

Post-conization follow-up of patients with CIN 2/3 with different amount of distance to negative cone biopsy margin: a retrospective cohort study.

The aim of this study was to investigate whether patients with CIN 2/3 with different amount of distance to negative cone biopsy margin differ in terms of post-conization follow-up results. Cold-knife cone specimens with a negative surgical margin with a diagnosis of CIN-2/3 were selected. The minimum distance between the margin and lesion was categorised as less than 2 mm (Group-1), 2-5 mm (Group-2), or more than 5 mm (Group-3). There were no statistically significant differences between groups in terms of postoperative cone-biopsy results (p = .61). Furthermore, there were no statistically significant differences between groups in terms of cytology at 6 months and 12 months (p = .33 and p = .80, respectively). Results of the present study indicate that the amount of distance of lesion to cone biopsy margin seems to have no effect on follow-up results in patients with negative surgical margin.Impact StatementWhat is already known on this subject? Negative surgical margins on conization are associated with lower rates of lesion recurrence. Only the efficacy of volume and size of cone biopsy specimens have been analysed on lesion recurrence. However, there is no clear definition of the minimum distance of a negative margin during cone biopsy.What do the results of this study add? To the best of our knowledge, this is the first study describing the post-conization follow-up of patients with CIN 2/3 with different amount of distance to negative cone biopsy margin. Patients who underwent surgical treatment with a wider cone biopsy margin and narrower cone biopsy margin demonstrated similar follow-up results.What are the implications of these findings for clinical practice and/or further research? The present study provides valuable information to guide physicians performing conizations with an appropriate amount of negative surgical margin. Future studies investigating the effect of different amount of distance to negative cone biopsy margin on gynaecologic and obstetrics complications such as stenosis, bleeding, and preterm labour, low birth weight, and perinatal mortality are needed to show the benefits of a narrower distance to negative cone biopsy margin.