Intraoperative subserosal approach to label sentinel nodes in intermediate and high-risk endometrial cancer.

DESIGN: prospective experimental study. PURPOSE OF INVESTIGATION: The purpose of this study was to evaluate feasibility and reliabil- ity of in vivo sentinel lymph node (SLN) mapping in patients with endometrial cancer and to verify a modified method of application of subserosal blue dye. Detection substance was applied subserosally in the uterine edges vicinity the round ligament of uterus and uterine vessels in the isthmic portion of the uterus. MATERIALS AND METHODS: Eighteen patients with intermediate and high-risk endome- trial cancer Stages I-II were subjected to staging laparotomy with intraoperative detection of SLNs and subsequent completion of the pelvic and para-aortic lymphadenectomies. Harvested SLN was routinely examined by classical haematoxylin eosin staining and in case of negativity, immunohistochemistry with anti-keratin antibodies AEl/AE3 was applied. RESULTS: Total of 773 lymph nodes were removed in 18 patients: pelvic 420 (54%) and para-aortic 353 (46%). SLNs were detected in 16 of 18 patients totalling 59 nodes (7.6% of all nodes). Forty-eight were identified in the pelvic area (81%) and 11 nodes (19%) in the para-aortic area. Three metastatic SLNs were found in two patients (11%). No false negative nodes were demonstrated. CONCLUSION: Experimental study results indicate that the proposed modified approach to label SLNs is applicable. The presented modified approach brings the highest added value namely in women with a myomatous uterus and scars from previous surgical procedures on the uterus.

[Extramammary Paget´s disease of the vulva - a case report]. / Extramamární Pagetova choroba vulvy - kazuistika.

OBJECTIVE: Analysis of one case of vulvar extramammary Paget´s disease (EMPD) and associated well differentiated endometrial adenocarcinoma.Desing: A case report. METHODS AND RESULTS: On this case report we present current theoretical knowledge about EMPD, difficulty of diagnostics, treatment and dispensarization the patients with this rare intraepithelial non-squamous neoplasia. We report a rare case of a 62 years old female patient with extramammary Paget´s disease of vulva and associated well differentiated endometrial adenocarcinoma. CONCLUSIONS: EMPD is a rare intraephitelial non-squamous neoplasia, which represents less then 1% vulvar tumors. Predominantly it affects white women between 60 and 80 years of age. EMPD occurs in cutaneous areas bearing apocrine glands - vulva, perineum, perianal area, axilla, penis, scrotum and rarely region of tights or buttocks. It is characterized microscopically by the presence of specific tumor cells called Paget´s cells - atypical large cells with pale clear cytoplasm and large round nuclei. KEYWORDS: extramammary Paget´s disease, EMPD, Paget´s cells, vulvectomy, imiquimod 5%, photodynamic therapy, imunotherapy, radiotherapy.

[Doctors specialty training in obstetrics and gynecology at university medical schools: 2012-2013]. / Specializacní vzdelávání v gynekologii a porodnictví na lékarských fakultách: 2012-2013.

OBJECTIVE: The paper addresses transfer of doctors specialty training from the national Institute of postgraduate medical education (IPVZ) to University Medical Schools (UMS) with the special focus to Obstetrics and Gynecology (OG). METHODS: The National Specialty Board (NSB) has been established. NSB tasks include definition of inclusion criteria and process of specialty choice at UMS. In OG specialty there are defined mid-term and final postgraduate training courses and other requirements for final specialty exam (FSE) - in particular trainees scientific work and surgery done with the supervision of NTB member. The system of FSE, its content, application, reimbursement and mechanisms are described in details. RESULTS: In the whole country in 2012 there have been done 864 FSE in all basic medical specialties, which took place at seven UMS. Autumn semester terms has been utilized significantly more than spring terms (57% vs. 43%). There have been differences in the numbers of specialties and also numbers of candidates in each specialty among different UMS. In total 94% of applicants succeed in the FSE. In 2012 within OG specialty training there has been held 56 FSE - 24 exams on five UMS in spring term and 32 (57%) exams only on two UMS in autumn term. In the spring 2013 FSE were organized on 1st LF UK in Prague with 23 applicants, from which 22 successfully passed. During autumn 2013 the FSE in OG will be held on LF UP in Olomouc with 44 applicants for final postgraduate training course and 39 candidates for FSE. CONCLUSION: Within OG specialty the transfer of doctors specialty training from IPVZ to UMS has been successfully managed. The NSB in OG specialty closely cooperates with past IPVZ and the Accreditation Commission of the Czech Ministry of Health. Thus continuity, quality and continuous enhancement of specialty training program in OG in Czech Republic is assured.

[Laparoscopic treatment of borderline ovarian tumorsin fertile women]. / Laparoskopické resení borderline tumoru ovaria u zen ve fertilním veku.

OBJECTIVE: Evaluation of the benefits of laparoscopy and the fertility preserving approach in the borderline ovarian tumors. These tumors often occur in young women of childbearing age. The patient and the surgeon face a serious problem, especially for women who wish to maintain the possibility of pregnancy. Laparoscopy in these situations appear to be one of the preferred treatment methods. DESIGN: Retrospective study. SETTING: Third Faculty of Medicine, Charles University Prague, Gynecology and Obstetrics Department; P. J. Safarik University, L. Pasteur University Hospital, Kosice, Gynecology and Obstetrics Department; Hospital Ceské Budejovice. METHODS: Analysis of the data in 23 women who desired fertility and were operated laparoscopically for borderline ovarian tumors. We evaluated the extend of laparoscopic surgery, peri- and postoperative complications and final results of histopathological findings. RESULTS: Mean age of the patients was 30,4 years. All patients were completely staged during second laparoscopic operation. In 14 of 23 (60.9%) cases serous borderline tumor was identified, in 8 of 23 (34.8%) cases mucinous borderline tumor was identified and in one case Brenner tumor was diagnosed. Peritoneal implants were present in 5/14 (35.7%) of serous tumors and in 3/8 (25%) of mucinous tumors. Involvement of contralateral ovary is also calculated. CONCLUSION: Borderline ovarian tumors occur in women who wish to maintain the possibility of pregnancy. For these patients, we choose based on their desire, conservative surgery. This treatment can be done by laparoscopy. Intraoperative ruptures of the tumor are more likely during lapaparoscopic procedures compared with laparotomy. In contrast, laparoscopy provides, besides well-known advantages, better optical evaluation of the abdominal cavity, including the detection of superficial peritoneal implants. For the objective evaluation of the laparoscopic approach in patients with fertility desire, further prospective comparative study are needed.

[The importance of circulating tumor cells in the diagnostic and therapeutic process in ovarian cancer]. / Význam stanovování cirkulujících nádorových bunek v diagnostickém a lécebném procesu u karcinomu ovaria.

OBJECTIVE: Our goal was to summarize clinical studies which used CTC/CSCs for prognosis in patients with ovarian cancer. TYPE OF STUDY: Review article. SETTING: Department of Gynecology and Obstetrics, 3rd Faculty of Medicine, Charles University, Faculty Hospital Královské Vinohrady, Prague. MATERIAL AND METHODS: This paper reviews various methods of CTCs detection as well as the biology and molecular characterisation of CTCs/CSCs. CONCLUSION: Determination of CTC (circulating tumor cells) / CSCS (cancer stem cells) has great potential in the diagnosis, prognosis, monitoring of disease, therapeutic effect and the risk of relapse in ovarian cancer for other malignancies. The presence of CTCs / CSCS in the blood seems to be a decisive factor in the initiation of metastatic process. The results of these studies show a clear link CTC negativity with an extension length of progression-free interval (PFI) and overall survival in patients with ovarian cancer.

[Antibiotical prophylaxy in gynecology]. / Profylaktické uzití antiinfekcních léciv v gynekologii.

Gynecological surgery is considered to be clear with possible contamination by gram-positive cocci from the skin, gram-negatives from the perineum or groins or polymicrobial biocenosis from vagina, depending on the surgical approach. Antibiotical prophylaxy enforces the natural mechanisms of immunity and helps to exclude present infection. There were presented many studies comparing useful effect of prophylaxis in gynecological surgery. The benefits of antibiotical prophylaxy before IUD insertion, before the cervical surgery and before hysteroscopies were not verified. On the other hand the prophylaxy of vaginal surgery including vaginal hysterectomy decreases the number of postoperative febrile complications. The positive influence of prophylaxis before the simple laparoscopy and laparoscopy without bowel injury or the opening of the vagina was not evidently verified. In abdominal hysterectomy the antibiotical prophylaxy decreases the incidence of postoperative complications significantly. The administration of 2 g of cefazolin can be recommended. In procedures taking more than 3 hours the repeated administration of cefazolin is suitable. New urogynecological procedures, using mesh implants, were not sufficiently evaluated as for postoperative infections and the posible antibiotical effect. The presence of implant in possibly non sterile area should be considered as high risc of postoperative complications.

[Antibiotic profylaxis in obstetrics]. / Profylaktické uzití antiinfekcních léciv v porodnictví

Nosocomial infections increase health care costs significantly and they are a real threat for all hospitalised patients as well. Surgical procedures affect imunological integrity in patients and increase risk of contamination and subsequent incidence of surgical site infections (SSIs). Antibiotic profylaxis according to recent trials has been shown to be effective in reducing the risks of postoperative infectious complications particularly in women undergoing cesarean section, termination of pregnancy in I. and II. trimester and repair of extensive obstetric perineal injuries. Benefit of antibiotic profylaxis hasn t been proven in procedures such as amniocentesis, cerclage and manual uterine evacuation. The routine antibiotic administration isnt recommanded in cases of spontaneous preterm labour without membrane rupture due to an increased risk of worse long-term outcome of children.The authors present also recent studies regarding antivirotic profylaxis in pregnant women with hepatitis B and herpes genitalis recidivans. In the end of the article differences in antimicrobial administration in obese women and in patients with penicillin allergy anamnesis are mentioned.

[Reproductive functions in women after cancer therapy]. / Reprodukcní funkce u onkologických pacientek.

Improvement in early diagnostics and treatment options led to an increase in the number of young oncological patients in reproductive age. These young oncological patietns have life-long consequences of treatment, such as infertility, early menopause and sexual dysfunctions. There is the possibility of maintening fertility by assisted reproduction methods. So far, ovarian stimulation followed by ICSI and cryopreservation of embryos seem to be the most successful method. Unfortunately, this method is suitable only for patients with a stable partner where there is no risk of delay because of necessary stimulation of ovulation. For patients without a partner, it is possible to freeze stimulated oocytes. Cryopreservation of immature oocytes followed by in vitro maturation seems to be a very promising method. Freezing ovarial tissues followed by transplantation is at this point only an experimental procedure. The authors present their experience with in vitro maturation of oocytes of 28 women with pregnancy rate 14.3%. Twenty-seven cases of infertility with a high risk of ovarial hyperstimulation syndrome and one case of breast cancer patient before chemotherapy were chosen for IVM.

[Medical, legal and ethical aspects of fertility preservation in cancer survivor]. / Medicínské, právní a etické aspekty zachování fertility u onkologických pacientek.

In recent years the number of the young women in fertile age which are oncologically treated is increasing. For these women chemotherapy and radiotherapy introduces potential risk of reproductive dysfunctions. Present techniques of assisted reproduction are offering possibilities to save reproductive functions even after the oncological treatment. As a perspective outlook seems to be frozen premature oocytes with IVM and fertilisation. With these fertility savings methods are naturally coming up some of the ethical and legal issues.

Malignant changes in adenomyosis in patients with endometrioid adenocarcinoma.

OBJECTIVE: The aim of our retrospective study was to evaluate pathological changes in adenomyotic foci in hysterectomy specimens, and point out a possible mechanism of carcinogenesis in adenomyotic foci inside the myometrium. METHODS: Retrospective analysis of clinical data; 219 patients were operated at our departments from 2003-2008 with the diagnosis of early endometrial cancer. Standard staging operation was used in all cases and all hysterectomy specimens were afterwards routinely analyzed. RESULTS: Adenomyosis was found in 88 of a total of 219 hysterectomy specimens, while 205 of these 219 were affected by endometrioid adenocarcinoma, ten with clear cell carcinoma and four with papillary serous carcinoma. Within these subgroups adenomyosis was documented in 87 of 205 specimens with endometrioid adenocarcinoma (42.4%) and in one specimen of ten with clear cell carcinoma (2.2%), all found in the eutopic endometrium. All cases of malignant changes (n = 6) in adenomyosis were found exclusively with coexisting endometrioid adenocarcinoma: adenocarcinoma in adenomyosis was well or moderately differentiated in five cases, and poorly differentiated in just one case. Differentiation of the tumor in adenomyosis correlated with differentiation of the eutopic endometrial cancer in 50%. Hyperplastic changes like benign glandular hyperplasia, or atypical complex hyperplasia (ACH) were identified simultaneously in all cancer-positive adenomyotic foci. CONCLUSION: Malignant changes in adenomyosis were present in 6.8% of patients with endometrial cancer. All malignancy-positive cases of adenomyosis were associated with endometrioid adenocarcinoma of the eutopic endometrium. Interestingly, in all these cases, different stages of hyperplastic changes were also simultaneously identified. This observation suggests a similar pathway of carcinogenesis in adenomyosis as is known in estrogen-responsive endometrial cancer type I.

Accuracy of intraoperative frozen section during laparoscopic management of early endometrial cancer.

OBJECTIVE: The aim of our retrospective study was to correlate the intraoperative frozen section (FS) and permanent section (PS) diagnosis among patients with early-stage endometrial cancer (FIGO Stage I). METHODS: Retrospective analysis of clinical data. A set of 63 women were operated by the technique of laparoscopic assisted vaginal hysterectomy with bilateral salpingo-oophorectomy (LAVH with BSO). All probands had intraoperative FS biopsy performed with grading and myometrial invasion assessment. These data were then compared with PS diagnosis. Statistical evaluation was used to detect diagnostic accuracy of FS (sensitivity, specificity and positive vs negative predictive value, and accuracy rate). RESULTS: The average age was 61 years, BMI 32.4 kg/m2 and operation time including lymphadenectomy (LAE) was 108.7 minutes. Sensitivity of FS was 77.8%, specificity 98.1%, positive predictive value (PPV) 87.5%, negative predictive value (NPV) 96.4% and accuracy rate 95.2%. Suboptimal surgical management due to underevaluation of FS biopsy compared to PS diagnosis occurred in 2 patients (3.2%). CONCLUSION: Combination of LAVH with BSO and use of intraoperative FS enables the surgeon to individualize surgical treatment for every patient to the extent of either performing complete operation together with LAE or not.

[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.

[Reproductive outcome after laparoscopic myomectomy--retrospective analysis 1994-2007]. / Reprodukcní výsledky po laparoskopické myomektomii--retrospektivní analýza 1994-2007.

The aim of the study was to analyse the reproductive outcome after laparoscopic myomectomy (LM) in infertile patients. Between the years 1994-2007 were 351 infertile women operated in our department. The average age of the patients was 33.5. The total number of extirpated fibroids was 643, with the average of 1.7 per patient and the average size of 3.3 cm. 171 women (48.7%) became pregnant after LM. There were 119 deliveries, 16 spontaneous abortions and 6 ectopic pregnancies in this group. The caesarean section (CS) rate was 46.2% . Intramural localisation of the fibroid significantly correlated with the termination of pregnancy by CS. I. and II. trimester pregnancy loss correlated significantly with deep coagulation when conception occurred during 12 months after surgery. No uterine rupture was observed during pregnancy.

[Late hematogenous infection of prosthetic joint]. / Pozdní hematogenní infekce kloubních náhrad.

The importance of prevention in late hematogenous infection is well understood but, because responsibility lies with general practitioners and other specialists, the orthopedic surgeon is usually not much interested. In both our and other countries, discussions are taking place on whether and to what extent antibiotic prevention should be carried out. Antibiotic prophylaxis of hematogenous infection is not indicated for all patients with joint arthroplasty, but only for a limited, defined group of patients at high risk. In these, however, the present state of knowledge suggests that prevention is necessary. A preventive treatment of late hematogenous infection is used for a procedure or a disease associated with risks in all the patients involved within two years of prosthetic joint implantation and, after this period, only in immunosuppressed patients. Surgery on the urogenital tract associated with the risk of bacteremia includes prostate gland surgery, operations for urinary bladder tumors, nephrolithotomy, extracorporeal lithotripsy and prostate biopsy. Certain conditions, such as urinary catheter presence, intermittent catheterization, urethral stent presence, urine retention and a history of urinary tract infection or prostate inflammation, pose an increased risk of bacterial colonization for the urogenital system. Dental procedures associated with a risk of bacteremia include tooth extraction, surgery on the parodontium, surgical extraction of an impacted tooth, dental implant treatment, procedures in a tooth's apical region, initial application of an orthodontic apparatus, intraligamentous blocks and also cleaning teeth and implants expected to bleed. Gynecological surgery with a risk of bacteremia are abdominal, vaginal and laparoscopic hysterectomies, surgery for cancer contaminated with vaginal bacteria, reconstruction surgery, operations on the pelvic floor for defects associated with urinary incontinence and use of xenotransplants. In obstetrics, a cesarean section carries some risks. In general surgery, the preventive administration of antibiotics is indicated, apart from situations always requiring antibiotic therapy, also for advanced forms of acute appendicitis, perirectal abscess, invasive endoscopy procedures on the colon, soft tissue phlegmona or abscess, surgical treatment of venous ulceration and pressure sores, and limb amputation. When inserting any piercing in patients with joint replacement at risk, it is recommended to do it with antibiotic administration; also, it is necessary to responsibly treat any inflammatory complication. The system of prevention for the late hematogenous infections of prosthetic joints is not developed as thoroughly as, for instance, it is in cardiology for patients with valve reconstruction. Because of the reasons given above, it is advisable to set up unambiguous guidelines for the prevention of late hematogenous infection in patients with joint replacement.

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.

[Cesarean scar ectopic pregnancy]. / Ektopická gravidita v jizve po císarském rezu.

OBJECTIVE: To present our clinical experience with cases of ectopic implantation in the uterine scar of a prior cesarean section and to analyse current articles with this topic. The authors experienced two cases of cesarean scar pregnancy with different clinical management and outcome. DESIGN: Review article, case report. SETTING: Institute for the Care of Mother and Child, Prague, Institute for Postgraduate Medical Education, Prague. RESULTS: We experienced two cases of cesarean scar pregnancy during the year 2006. Missed abortion in the 12th week of pregnancy was diagnosed in the first patient. During instrumental evacuation of the uterine cavity in the district hospital severe bleeding occured. After transfer to our department abdominal hysterectomy was performed. In the second case early ultrasonographic diagnosis of ectopic nidation was completed. Hysteroscopic evaluation of gestational sac with subsequent instrumental evacuation with ultrasonographic assistance was performed as a fertility saving operation. Subsequent systemic application of methotrexate was indicated after surgery. CONCLUSION: Cesarean scar pregnancy occurs in 1/800 - 1/2216 normal pregnancies. Early sonographic diagnosis enables surgical or medicamentous treatment preserving the fertility of the patient. Late or absent diagnosis of pathological implantation can cause severe uterine bleeding. Treatment options preserving fertility can not be used and hysterectomy is then the only life saving procedure.

Bilateral avulsion of the puborectal muscle: magnetic resonance imaging-based three-dimensional reconstruction and comparison with a model of a healthy nulliparous woman.

OBJECTIVES: Obstetric trauma to the puborectal muscle seems to be an important cause of pelvic floor dysfunction in women. Due to the complicated three-dimensional (3D) arrangement of the pelvic structures, two-dimensional images are not sufficient to demonstrate its relationships in a complex fashion. Thus, we aimed to create a 3D computer model to visualize the normal female pelvic floor anatomy and to compare this with the anatomy after bilateral avulsion of the puborectal muscle following delivery. METHODS: We created two 3D computer models of the female pelvic floor, one of a healthy nulliparous woman and the other of a woman with bilateral puborectal muscle avulsion after vaginal delivery. The data for the models were obtained from magnetic resonance imaging examinations and the following structures were depicted: pelvic bones, puborectal muscle, internal obturator muscle, urethra, urinary bladder, vagina and rectum. The models were compared. RESULTS: The models allowed us to demonstrate in three dimensions changes in the puborectal muscle after avulsion. Its relations to the bone, internal obturator muscle, perineal membrane and the deep part of the external anal sphincter were modeled and differences from the normal non-injured anatomy were demonstrated. Avulsion altered the support to the whole endopelvic fascia and destabilized both the anterior and the posterior vaginal walls. CONCLUSIONS: The use of 3D technology including modeling allows for the acquisition of new knowledge and aids in the understanding of both normal and pathological pelvic anatomy.

[Laparoscopic correction of posttraumatic uterovaginal descent with rectal prolapse]. / Laparoskopická korekce posttraumatického uterovaginálního sestupu s prolapsem rekta.

A case review of laparoscopic management of the uterovaginal descent and rectal prolaps in one step in a young female following her complicated pelvic fracture.

[Late hematogenous infection of prosthetic joints in our patients and proposal for a system of prevention]. / Výskyt pozdní hematogenní infekce kloubních náhrad v nasem souboru a návrh systému prevence.

PURPOSE OF THE STUDY: To design a prophylactic strategy for late hematogenous infection is not an easy task. It requires the assessment of risk factors for the patient as well as of a potential source of bacteremia. Cost effectiveness, efficacy of the antibiotic selected and complications associated with antibiotic treatment, such as allergic reactions and development of resistance to the antibiotic given, should also be considered. The aim of this retrospective study is to evaluate the occurrence of late hematogenous infection in our large group of patients, to analyze risk factors and to suggest an optimal system of antibiotic prophylaxis in order to prevent the development of this unwelcome complication. MATERIAL AND METHODS: Since our objective was to include a large number of patients, a retrospective study was chosen as the method used. The patients treated for infectious complications of total joint replacement at the 1st Department of Orthopaedics, Teaching Hospital in Motol, 1st Faculty of Medicine, Charles University, in the years 1991 through 2004, were evaluated with the use of a targeted questionnaire and complete medical records. The group comprised 229 patients, 149 women and 80 men. Of these, 123 were treated for infection of total hip replacement, 102 for total knee replacement, two had infection of prosthetic shoulder joints and two had infection of elbow joint alloplasty. RESULTS: Medical history of 37 patients (16.3 %) included infection of or a risk-associated procedure on the urogenital system (endoscopic or open surgery, prostate gland biopsy, extracorporeal lithotripsy). Six patients (2.6 %) underwent surgery with possible bacteremia (intestine resection for tumor, 2x; surgery for paronychium, 2x; cholecystectomy, 1x; and appendectomy, 1x). Dental surgery or mouth disease was recorded in 11 patients (4.8 %). DISCUSSION: The authors suggest that the orthopedic surgeons performing joint replacement should assume their deal of responsibility and should provide relevant, comprehensive information to both the patient and the attending physician. These surgeons should be ready to remain involved in their patients' further therapies and, after assessing all risks, should be able to recommend an optimal prophylactic treatment. The introduction of a new preventive approach requires a simple and uncomplicated scheme. Any complicated and expensive system of preventive antibiotic administration will only meet with lack of understanding and with trivialization. The requirement that antibiotic treatment should be selected according to the site and type of risk-associated disease is logical, but, in our opinion, rather formal and unrealistic. The authors prefer a simple system permitting a rapid and overall introduction of preventive measures. CONCLUSIONS: The groups of patients indicated for prevention of late hematogenous infection of prosthetic joints are clearly defined and, by no means, do they involve all patients with total joint replacement. Key words: prosthetic joint, infection, prevention, antibiotics, complication.