Uterovesical fistula and its treatment in Sub-Saharan Africa.

AIM:  Aim of the study to summarize the current information on diagnostic and treatment options for uterovesical fistula as a consequence of iatrogenic complication. Methods: Literature review of available information on surgical treatment options for uterovesical fistula resulting from previous caesarean section and comparison with our own experience in the developing world. Conclusion: Uterovesical fistula is an abnormal communication between the bladder and uterus. The cause of this pathology in most cases is an iatrogenic complication, most commonly arising after a caesarean section. The incidence of this pathology varies significantly geographically. In developed countries, these fistulas are rather rare. On the other hand, in developing countries, uterovesical fistulas are more common with a significant impact on the subsequent life of the patient due to generally inaccessible health care.

Diagnostic pitfalls in ovarian androgen-secreting (Leydig cell) tumours: case series.

Leydig cell tumours of the ovary are rare and represent a diagnostic challenge not only due to their sporadic incidence but also due to the seemingly normal imaging. We present three cases of pre- and postmenopausal women who were presented with severe clinical signs of hyperandogenism where modern imaging modalities (including computed tomography (CT), magnetic resonance imaging (MRI) and positron-emission tomography combined with computed tomography (PET-CT)) failed to identify the tumour. Two patients underwent non-expert ultrasound, CT and MRI examination with uniform conclusion that ovaries are of normal appearance. One of the two patients even had a PET-CT performed, which was inconclusive. Our case reports show the importance of examination by specialists with established skills in gynaecologic ultrasonography in the diagnosis of the Leydig cell tumours. The most useful diagnostic tool seems to be the combination of age (postmenopause), symptoms (onset of hirsutism and virilisation), high total testosterone plasma values and expert sonography. On ultrasound, these tumours are unilateral, usually small, solid intraovarian nodules of a slightly increased echogenicity in contrast to the surrounding ovarian tissue, delineated by abundant perfusion with an enhanced vascularity. The appropriate setting of the sensitive colour Doppler is crucial for the detection of intraovarian Leydig cell tumour. Impact statement What is already known on this subject? A diagnosis of Leydig cell tumours is based on ultrasound performed by a trained examiner or by MRI. CT or PET/CT are not among the primary methods of choice. According to the results of imaging investigations surgical treatment is planned. Because these tumours are usually benign and have a good prognosis the unilateral salpingo-oophorectomy is a standard procedure. What do the results of this study add? Our case series show how difficult it can be to establish the diagnosis of Leydig cell tumours by imaging, including transvaginal ultrasound, the most frequently recommended diagnostic tool. We demonstrate in three cases how easily a small hyperechogenic tumour can be overseen or interchanged for a different gynaecological pathology if transvaginal scan is not performed by an experienced examiner trained in sonographic features of gynaecologic neoplasms. What are the implications of these findings for clinical practice and/or further research? This case series demonstrate how important it is to see the patient in the whole complexity with their medical history, proper clinical symptoms evaluation, laboratory test and not to rely solely just on sophisticated high-end investigations, such as the PET-CT, a CT and an MRI. It also emphasises the importance of specialists with established skills in gynaecologic ultrasonography. Further effort should be made to define the resources for the appropriate training of such sonographers.

[Endometriosis and quality of life]. / Endometrióza a kvalita zivota.

OBJECTIVE: This article aims to provide a comprehensive overview of the possibilities of evaluating the impact of symptoms of endometriosis on quality of life of affected women and to overview the effect of treatment modalities in improving of the quality of their life. DESIGN: Review article. SETTING: Department of Obstetrics and Gynecology, First Faculty of Medicine, Charles University and General University Hospital in Prague. METHODS: Review of results of published studies evaluating quality of life in patients with endometriosis. CONCLUSION: Symptoms of endometriosis decrease the quality of life of affected women, which has significant impact on society. Since the extent of endometriosis does not correlate with subjective complaints, it is suitable to evaluate the quality of life of patients in addition to assessment of the extent and classification of the disease (according to internationally accepted classification). The quality of life could be measured and compared by structured interviews or by validated questionnaires. Pharmacological as well as surgical treatment significantly improve quality of life of patients with endometriosis. Routine use of validated questionnaires of quality of life in patients with endometriosis might improve the assessment of severity of the disease and evaluation of effectiveness of the treatment in the future.

[Endometriosis]. / Endometrióza.

OBJECTIVE: To summarize current knowledge of pathogenesis, diagnostics and treatment of endometriosis. DESIGN: Review article. SETTING: Centre for diagnostics and treatment of endometriosis, Department of Gynecology and Obstetrics, General Faculty Hospital and 1st Faculty of Medicine of Charles University, Prague. METHODS AND RESULTS: Endometriosis is defined as the presence of endometrial-like tissue outside the uterus, which induces a chronic, inflammatory reaction. The condition is predominantly found in women of reproductive age, from all ethnic and social groups. The associated symptoms - pain, infertility - can impact on general physical, mental and social well being. Treatment must be individualised, taking the clinical problem in its entirety into account, including the impact of the disease and the effect of its treatment on quality of life. Pain symptoms may persist despite seemingly adequate medical and/or surgical treatment of the disease. In such circumstances, a multi-disciplinary approach involving a pain clinic and counselling should be considered early in the treatment plan. CONCLUSION: Endometriosis is a medical condition with high recurrence rate and especially those patients with deep infiltrating endometriosis should be centralized to the centres experienced in diagnostics, complicated surgical treatment and providing multi-disciplinary approach with adequate postoperative care.

[Axillary reverse mapping--chance to prevent lymphedema in breast cancer patients]. / Reverzní mapování lymfatik v axile jako moznost prevence lymfedému u pacientek s karcinomem prsu.

OBJECTIVE: The axillary reverse mapping (ARM) technique has been developed to map and preserve arm lymphatic drainage during axillary lymph node dissection (ALND) and/or sentinel lymph node (SLN) biopsy, thereby minimizing arm lymphedema. However, several problems remain to be resolved in the practical application of this technique. This article presents a review of current knowledge regarding ARM and discusses the practical applicability and relevance of this technique. TYPE OF STUDY: Review. SETTING: Oncogynecologic center, Gynecology-Obstetrics Clinic, 1st Medical Faculty and General Teaching Hospital, Prague. CONCLUSIONS: The axillary reverse mapping (ARM) procedure is based on the hypothesis that the lymphatic drainage from the upper arm is different from that of the breast and offers the opportunity to prevent lymphedema in breast cancer patients. However, the oncologic safety of the procedure has not yet been determined.

[Sentinel node detection in early stage of cervical carcinoma using 99mTc-nanocolloid and blue dye]. / Detekce sentinelové uzliny u casných stadií cervikálního karcinomu kombinovanou metodou s uzitím nanokoloidu technecia Tc99 a patentní modri.

OBJECTIVE: The aim of the study was to analyse the feasibility of intraoperative sentinel lymph nodes (SLN) detection using gamma detection probe and blue dye in patients undergoing radical hysterectomy for treatment of early stage of cervical cancer. DESIGN: Prospective case observational study. METHODS: In the period from May 2004 to February 2006 77 patients with early stage of cervical cancer who underwent a radical surgery were included into the study. Patients were divided into three groups according to the tumour volume. First group consists of patients FIGO IA2 and FIGO IB1 with tumour diameter less than 2 cm, second group tumours FIGO IB1 with tumour diameter more than 2 cm and third group stadium IB2. SLN was detected by blue dye and Tc99. Preoperative lymphoscintigraphy was done after Tc99 colloid injection, intraoperative detection was performed by visual observation and by hand-held gamma-detection probe. SLN were histologically and immunohistochemically analysed. RESULTS: A total number of 2764 lymph nodes with an average 36 and 202 SLN with an average 2.6 were identified. The SLN detection rate was 94.8% per patient and 85.1% for the side of dissection and depends on the tumor volume. SLN were identified in obturator area in 48%, in external iliac area in 15%, in common iliac and internal iliac both in 9%, in interiliac region in 8%, in praesacral region in 6% and in parametrial area in 5%. Metastatic disease was detected in 31 patients (40.2%), metastatic involvement of SLN only in 12 patients (15.6%). False negative rate was 2.6%, sensitivity and negative predictive value calculated by patient were 923% and 95.7%. CONCLUSIONS: Intraoperative lymphatic mapping using combination of technecium-99-labeled nanocolloid and blue dye are feasible, safe and accurate techniques to identified SLN in early stage of cervical cancer.

[Lymphatic mapping and detection of sentinel node in early stages of cervical carcinoma]. / Lymfatické mapováni a detekce sentinelové uzliny u casných stadií cervikálního karcinomu.

OBJECTIVE: The aim of the study was to analyse two methods of intraoperative sentinel node detection using blue dye and blue dye with Tc99 labeled tracer in early stage of the cervical cancer. DESIGN: Prospective case observational study. SETTING: Department of Obstetrics and Gynecology, University Hospital Ostrava. METHODS: From May 2004 to September 2005, 49 patients with cervical cancer who underwent a radical surgery were included into the study. Sentinel lymph node was detected using blue dye in the first group of 23 patients and by blue dye with Tc99 in the second group of 26 patients. Intraoperative sentinel node detection was performed by visual aspection in the first group, and by visual aspection and by hand-held gamma-probe in the second group. RESULTS: Patients were divided according to stage of the disease into three subgroups FIGO IA2, FIGO IB1 and FIGO IB2. A total number of 1561 lymph node with an average 32 and 94 SLN with an average 1.9 were identified. The specific detection rate per site was 63% in the first group and 80.8% in the second group respectively. Metastatic disease was detected in 26 patients (41%) and metastatic involvement of SLN only in 11 patients (17.4%). Sensitivity and negative predictive value were 100% in both groups, false negativity was 0%. CONCLUSION: Detection of SLN by combination of blue dye and Tc99 labeled tracer has a higher detection rate of SLN than detection by blue dye alone.

[The first case of management of the rectovaginal fistule using transanal endocsopic microsurgery]. / První prípad resení rektovaginální pístele pomocí transanální endoskopické mikrochirurgie.

The authors present an unusual and, according to the available literature data, so far unused method--management of the rectovaginal fistule, using a T.E.M. technique (transanal endoscopic microsurgery). In their case-review of a female patient, they present advantages of this technique in a case of a rare disorder - a benign rectovaginal fistule. All of the following employment of a harmonic scalpel in the T.E.M. method, as well as of a tissue adhesive Tissucol and of a surgical rectoscope in the vaginal phase of the procedure, deserve attention of surgeons and gynaecologists.

[Cardiovascular risk and estrogens]. / Kardiovaskulární riziko a estrogeny.

OBJECTIVE: To describe relations among postmenopause, hormonal therapy, lipid metabolism and risk of cardiovascular diseases. DESIGN: Search and analysis of relevant data from medical literature. METHODS: Analysis of the relation between serum lipid profile and postmenopausal changes, evaluation of positive and negative effects of estrogens on vascular wall and lipid metabolism, analysis of methods for the assessment of cardiovascular risk and evaluation of recent guidelines. RESULTS: Postmenopause is connected with significant changes in lipid metabolism, serum lipid profile and with increased risk of cardiovascular diseases. Deficit of estrogens influences lipid metabolism negatively. However, estrogen substitution has both positive and negative effects on vascular wall. Negative effects are: increased occurence of postprandial hyperlipidemia with increased triglycerides, generation of aterogenous small dense LDL particles, increased risk of inflammatory changes in vascular wall and procoagulation situation. CONCLUSION: Hormonal therapy can display some positive effects of vascular wall. However, recent data evaluate hormonal substitution with regard to atherosclerosis and cardiovascular problems as less benefitial or even risky.

[Giant benign mucinous cystadenoma of both ovaries in early puerperium: case report and review of literature]. / Obrovský benigní mucinózní kystadenom obou ovarií v casném puerperiu: Popis prípadu a prehled literatury.

OBJECTIVE: A case report of giant bilateral benign cystadenoma after vaginal delivery. DESIGN: Case report. SETTINGS: Department of Obstetrics and Gynaecology, University Hospital Ostrava. SUBJECT OF STUDY: A 35-year-old woman twelve days after vaginal delivery was presented with symptoms of an acute abdomen. On ultrasonographic examination, the presence of a cyst filling the complete abdominal cavity. Bilateral cystic mass measuring 25 x 30 cm was removed by laparotomy. Subsequent histological examination revealed a benign mucinous cystadenoma. CONCLUSION: A case of giant mucinous cystadenoma is presented with clinical and pathological details. An ovarian cystadenoma was the cause of an acute abdomen in puerperium and led to clinical and therapeutic disconcerment.

[Pregnancy and multiple sclerosis]. / Gravidita a roztrousená skleróza mozkomísní.

OBJECTIVE: To assume the influence of pregnancy on the clinical progress of multiple sclerosis and its influence on the course of delivery. DESIGN: Retrospective analysis. SETTING: Department of Obstetrics and Gynecology, University Hospital in Ostrava, Czech Republic. SUBJECT AND METHOD: It is the retrospective analysis of the influence of pregnancy on the clinical course of multiple sclerosis in the file of 57 patients with diagnosis of multiple sclerosis. The aim of the study is to compare the changes in the EDSS (expanded disability status scale) in the period before the pregnancy, during the pregnancy and 6 months after delivery. The authors also tried to analyze if multiple sclerosis influences the course of delivery. RESULTS: The progression of the multiple sclerosis during pregnancy and postpartum period was present in 62.8% of the patients. The mean change during the pregnancy and 4 months after delivery was 0.7 points in the EDSS scale. We did not find any influence of multiple sclerosis on the course of delivery.

[Guideline for gynecological malignant tumors--primary complex therapy in operable stages of malignant tumors of uterus cervix]. / Guideline gynekologických zhoubných nádoru 2004--primární komplexní lécba operabilních stadií zhoubných nádoru delozního hrdla.

OBJECTIVE: Elaboration of guideline for primary treatment of operable cervical cancer. DESIGN: Review, consensus between proposers and opponents. SETTING: Department of Obstetrics and Gynecology, Charles University, Prague, 2nd Medical Faculty and Faculty Hospital Motol. METHOD: A retrospective review of published data, analysis of Czech statistics and consensus between proposers and opponents. RESULTS: Team work is essential in the diagnostic and therapeutic procedure. For the preoperative diagnostic management it is possible to perform magnetic resonance volumometry. For the treatment of early stage cervical cancer it is possible to perform sentinel lymph node mapping (SLNM) by patent blau and 99mTc together with frozen section. SLNM does not substitute systematic pelvic lymphadenectomy. For the treatment of IB2 stage cervical cancer, an alternative for primary surgery or chemoradiotherapy is neoadjuvant chemotherapy, followed by radical surgery. In other topics only minor changes were made from the 1998 guideline. CONCLUSION: The guideline for cervical cancer treatment should represent directions for clinicians and others, who participate in the process of the treatment of cervical cancer. The guidelines include all parts of the process (from diagnosis to follow up). It originated from the consensus between proposers and opponents: we voted about all parts of guideline.

[Guideline for gynecological malignant tumors 2004--primary complex therapy in operable stages of malignant tumors of vulva]. / Guideline gynekologických zhoubných nádoru 2004--Primární komplexní lécba operabilnich stadií zhoubných nádoru vulvy.

OBJECTIVE: Elaboration of guideline for primary treatment of operable vulvar cancer. DESIGN: Review, consensus between proposers and opponents. SETTING: Department of Obstetrics and Gynecology, 2nd Medical Faculty Charles University and Faculty Hospital Motol, Prague. METHOD: A retrospective review of published data, analysis of Czech statistics and consensus between proposers and opponents. RESULTS: Guideline for the diagnosis remain the same as in the proposal from 1998. We elaborated practically new guideline for surgical treatment. Wide excision or simplex vulvectomy is adequate only for stage la without angioinvasion, free margins have to be 5 mm. Standard surgical procedure is radical vulvectomy with inquinofemoral lymphadenectomy in stage 1a with angioinvasion, 1b and 2. In laterally localised lesions it is possible to perform hemivulvectomy or radical excision with inquinofemoral lymphadenectomy. Free margins have to be more than 8 mm. An alternative procedure in internally high-risk patients is sentinel node detection with radical vulvectomy (hemivulvectomy). Sentinel node detection has to by performed by combined method of blue dye and radiocoloid Tc 99 simultaneously. Bilateral inquinofemoral lymphadenectomy is indicated in case of positive sentinel node. Primary radiotherapy is indicated in higher stages, in stage 3 we can perform an exenteration with the agreement of patient. CONCLUSION: Guideline for the treatment of vulva cancer should be directions for clinicians and others, who participate in the process of treatment of the vulva cancer. Guidelines include all parts of the process (from diagnosis to follow up). All topics of the guidelines were arise from a voting of the proposers and opponents.

[Radical surgical therapy and role of adjuvant chemotherapy in ovarian tumors of borderline malignancy]. / Radikalita chirurgické lécby a postavení adjuvantní chemoterapie u nádoru ovaria hranicní malignity.

OBJECTIVE: Evaluation of the benefit of the radical surgical therapy in the assessment of prognostic factors and indication of adjuvant therapy in patients with borderline tumors of ovary. DESIGN: Retrospective study. SETTING: Department of Obstetrics and Gynecology, University Hospital, Ostrava. METHODS: The group consists of 26 patients operated on our department, 12 of which underwent restaging operation after insufficient primary surgery in different hospital and 14 underwent primary surgery in our department. The average age was 42.9 years. RESULTS: Radical surgery with regional lymphadenectomy was performed in 18 cases (69%) and non-radical in 8 cases (31%). In 7 patients (27%) fertility preservation operation was done. According to histological results 19 tumors (73%) were of serous type, 7 being of mucinous type (27%). There were no other histological types in our group. The lymphnodes were positive in 4 cases (22%) out of 18. Eight patients were indicated for adjuvant chemotherapy (31%), 4 of them for regional lymphnodes positivity, 2 for peritoneal implants, 1 patient for tumor residuum. The last case was a patient with tumor duplicity of a borderline tumor of ovary stage FIGO IIC and corporal carcinoma stage FIGO IB. We had one case of recurrence after fertility preservation surgery. There was no case of pregnancy yet. CONCLUSIONS: Borderline tumors of ovary have good prognosis and low recurrence rate. In spite of that, there exists a group of women with higher risk of recurrence and disease progression which can be fatal. These patients may benefit from adjuvant therapy, which is indicated after evaluation of risk factors ideally acquired from the radical surgery.

[Human papillomavirus infection and cervical intraepithelial neoplasia]. / HPV infekce a cervikální intraepiteliální neoplázie.

OBJECTIVE: To determine the presence of high-risk, oncogenic types of HPV infection (HR HPV) and the presence of HPV 16 and 18 in various degrees of cervical and intraepithelial neoplasia. TYPE OF THE STUDY: A retrospective study. NAME AND ADDRESS OF THE INSTITUTION: Obstetrical-Gynecological Clinic, Faculty Hospital, Ostrava. METHODS: The study included 205 female patients indicated for conization due to cervical intraepithelial neoplasia. The conization was preceded by extended colposcopy, cytological samplings, HPV DNA test and a directed biopsy. HR HPV was examined in all patients, HPV 18 and 16, respectively, in 98 (48%) patients. Based on severity of histopathological findings the patients were divided into three groups, examined for positivity of oncogenic HPV types and the high risk HPV 18 and HPV 18 types, respectively. RESULTS: The histopathological findings from a total number of 205 conuses included five (2%) benign lesions, 85 (41%) CIN1, 77 (38%) CIN 2 and 38 (19%) CIN 3. Altogether the HR HPV was demonstrated in 143 (70%) patients. In patients with the benign lesion no HPV infection was detected. In patients with the CIN 1 finding the HR HPV infection was detected in 35 (41%) cases, in patients with CIN 2 in 70 (91%) cases and in patients with CIN 3 in 38 (100%) cases. HPV 16 was diagnosed in patients with the CIN 1 finding in 9 (23%) cases, HPV 16 in 5 (6%) cases and both types of the virus were present in two (2%) cases. In CIN 2, HPV 16 was positive in 17 (43%) and HPV 18 in 6 (8%) cases. In patients with CIN 3, HPV 18 was detected in 9 (53%) and HPV 18 in 2 (5%) patients. In all the women who underwent conization, HPV 16 infection was demonstrated in 17% and HPV 18 in 6% patients. In 19% of patients, the infection by at least one type of the virus was present and in two % both types of the virus were present. CONCLUSION: The presence of HR HPV rises with increasing severity of cervical intraepithelial neoplasia, HR HPV being detected in all cases suffering from CIN 3. The highest risk type HPV 16 was present with increasing rate in relation to the severity of cervical intraepithelial neoplasia, whereas no such trend was present in case of HPV 18.

[Hormone replacement therapy and ovarian tumors]. / Hormonální substitucní terapie a nádory ovaria.

OBJECTIVE: Analysis of risk and protective factors and hormone replacement therapy in the aethiology and pathogenesis of ovarian cancer. The role of hormone replacement therapy in the complex treatment in women with ovarian cancer is discussed. DESIGN: Reviewed article. SETTING: Department of Obstetrics and Gynaecology, University Hospital Ostrava. METHODS: Analysis of epidemiological studies. CONCLUSION: The role of hormone replacement therapy as a risk factor of ovarian cancer has not been confirmed. Hormone replacement therapy as a part of supportive and symptomatic therapy has been acceptable in a great deal of patients with ovarian cancer.