Implementation of minimal invasive gynaecological surgery certification will challenge gynaecologists with new legal and ethical issues.

The introduction of a certification / diploma program in Minimal Invasive Surgery (MIS) is expected to improve surgical performance, patient's safety and outcome. The Gynaecological Endoscopic Surgical Education and Assessment programme (GESEA) and the ESHRE Certification for Reproductive Endoscopic Surgery (ECRES) provides a structured learning path, recognising different pillars of competence. In order to achieve a high level of competence a two steps validation is necessary: (a) the individual should be certified of having the appropriate theoretical knowledge and (b) the endoscopic psychomotor skills before entering in the diploma programme reflecting the surgical competence. The influence of such an educational and credentialing path could improve safety and offer financial benefits to the hospitals, physicians and healthcare authorities. Moreover the medicolegal consequences can be important when a significant amount of surgeons possess the different diplomas. As the programs are becoming universally accessible, recognised as the best scientific standard, included in the continuous medical education (CME) and continuous professional development (CPD), it is expected that a significant number of surgeons will soon accomplish the diploma path. The co-existence and practice of both non-certified and certified surgeons with different degrees of experience is unavoidable. However, it is expected that national health systems (NHS), hospitals and insurance companies will demand and hire doctors with high and specific proficiency to endoscopic surgery. When medico-legal cases are under investigation, the experts should be aware of the limitations that individual experience provides. The court first of all examines and then judges if there is negligence and decides accordingly. However, lack of certification may be considered as negligence by a surgeon operating a case that eventual faces litigation problems. Patients' safety and objective preoperative counselling are mandatory, directly connected to MIS certification while eliminating any dispute of surgeons' credibility.

IMMUNOHISTOCHEMISTRY IN ENDOMETRIAL HYPERPLASIA AND ENDOMETRIAL ADENOCARCINOMA.

AIM: Endometrial hyperplasia is a proliferation of endometrial glands due to the prolonged stimulation with estrogens of the endometrium that occurs in women receiving exogenous estrogens, with anovulatory cycles, or in patients with ovarian tumours with estrogen secretion. MATERIAL AND METHODS: The study performed by the authors included 575 patients with endometrial hyperplasia and 163 patients with endometrial adenocarcinoma admitted to the "Cuza-Voda" Obstetrics and Gynaecology Clinical Hospital of Iasi, between 2005-2007. RESULTS: There were selected, for these immunohistochemistry reactions, 22 cases of simple hyperplasia without atypia, 26 cases of complex hyperplasia without atypia, 23 cases of endometrial adenocarcinoma of endometrioid type, well differentiated, 22 cases of endometrial adenocarcinoma of endometrioid type, moderately differentiated, and 19 cases of non-endometrioid adenocarcinomas represented by nine clear cells and 10 serous endometrial adenocarcinomas. Estrogen receptors have been positive in about 85-90% of the tumour cells of the well-differentiated endometrial adenocarcinomas of endometrioid type (GI). In endometrioid-type endometrial adenocarcinomas moderately differentiated (GII), the estrogen receptors were positive in approximately 70-85% of the tumour cells. CONCLUSIONS: Endometrial hyperplasia, especially complex endometrial hyperplasia with atypia, increase the risk for endometrial adenocarcinoma, and their early detection becomes mandatory under cancer prevention. Well-differentiated endometrioid endome- trial adenocarcinomas were ER and PR-positive, so that the ER expression correlated with the PR expression. Well-differentiated endometrioid endometrial adenocarcinomas (GI) in the studied group also showed a higher content of ER and PR compared to the endometrial moderately-differentiated endometrioid endometrial adenocarcinomas (GII). In nonendometrioid adenocarcinomas, represented by clear-cell endometrial adenocarcinomas, the ER content was reduced and the PR expression was negative. Serous adenocarcinomas failed to show an immunohistochemically expression for ER and PR.

COMPARISONS BETWEEN THE NON-PROLIFERATIVE AND PROLIFERATIVE THERAPY IN FIBROCYSTIC MASTOSIS.

AIM: Fibrocystic mastosis (FCM) is the most frequent benign breast lesion. Most treatments for fibrocystic mastosis are: hormonl, with beneficial results and non-hormonal, with fluctuating results. MATERIAL AND METHODS: A number of 210 cases were studied, which were divided into 7 groups. The study lasted for 9 months and it was carried out on the basis of a personal examination sheet. The following were monitored: age groups, mastodynia, reducing breast nodules, a significant reduction in the volume of the mastosic cysts, reducion of the fibrous tissue, medication tolerance. RESULTS: Mastodynia has declined by 90% in the cases treated with Tamoxifen and Danazol, by 70% in the case of Lynestrenol and Bromocriptine, by 50% in the 15 patients who were given Utrogestan. Knowing the advantages and disadvantages of drugs (contraindications, side effects), age category, breast pain reduction, antiproliferative activity, tolerability, relapse allow us to assess the benefit-risk. Even in those circumstances that remained incompletely clarified for objective reasons, related to the inaccurate/incorrect reporting by the patients, there is a significant difference (p < 0.05) between the frequency of relapses following the treatment with Tamoxifen and the other categories of drugs who were administered. CONCLUSIONS: Our study shows that in the groups that were administered Logest, Utrogestan and Bromocriptine, only antalgic effects were achieved (disappearance or only decrease of mastodynia) and no anti-proliferative effects were obtained. Basically, hormone treatment should be made based on a histopathological examination.

Maternal-fetal prognosis in HELLP syndrome in a level 3 maternal-fetal care centre.

PURPOSE OF INVESTIGATION: The purpose of this study was to evaluate the maternal and perinatal outcome and prognosis in pregnant women with HELLP syndrome. MATERIALS AND METHODS: Medical records of eligible pregnant women with HELLP syndrome were reviewed retrospectively. Patients were evaluated in terms of maternal complication, as well as the types of delivery. Perinatal outcome were evaluated in terms ofApgar score, birth weight, respiratory distress syndrome, and neonatal intensive care unit admission. RESULTS: The leading maternal complications associated with HELLP syndrome were the following: severe preeclampsia, eclampsia, placental abruption, acute pulmonary edema, acute kidney failure, disseminated intravascular coagulation syndrome, and immediate maternal death. The most prominent neonatal outcomes associated with HELLP syndrome were: antenatal fetal death, intrauterine growth restriction, prematurity. CONCLUSION: The management and delivery of the patients with HELLP syndrome must take place in a tertiary referral maternal and fetal care centre.

GIANT INTRALIGAMENTARY UTERINE LEIOMYOMA AND ITS COMPLICATIONS.

Uterine leiomyomas are benign tumors arising from uterine smooth muscle. Although their pathogenesis remains unclear, they are the most common tumor of the female reproductive tract, occurring in as many as half of women older than 35 years. Uterine leiomyomas represent the most common benign tumors of the female reproductive tract. Giant uterine leiomyomas are very rare and represents a great diagnosis and therapeutic challenge. Uterine leiomyoma is one of the most frequent types of tumours and it is diagnosed in 20-40% of the women of reproductive age. Until the age of 50, approximately 70% of the white women and less than 80% of the black women will have had at least one leiomyoma. The frequency of the emergence of uterine leiomyoma in black women is significantly higher than in white women.

INTRAUTERINE GROWTH RESTRICTION--PREDICTIVE SERUM MARKERS.

AIM: To determine during the first trimester of pregnancy some serum and ultrasound markers that could improve perinatal morbidity and mortality in women with intrauterine growth restriction (IUGR). MATERIAL AND METHODS: Prospective study of pregnant women gestational age 11 weeks and 0 days--13 weeks and 6 days, consisting in the determination of pregnancy associated plasma protein (PAPP-A), mean platelet volume (MPV), and ultrasound appearance of placenta. DISCUSSION AND CONCLUSIONS: This study suggests that screening by detailed history and PAPP-A and MPV determination during the first trimester of pregnancy in women at risk for IUGR makes possible the prophylactic treatment and monitoring of pregnancy according to a given protocol and thus neonatal morbidity and mortality to be reduced.

An unusual enhanced Doppler vascular profile of a rare uterine tumor: PEComa.

PEComas represent a rare class of mesenchymal tumors, with different primary locations. There are less than 100 cases of uterine PEComas published in English literature until now and information considering imaging features of these PEComas is very limited, focusing on CT and MRI and not as much on ultrasounds (US). The authors present here a case of rapidly growing uterine PEComa, with local invasive potential and recurrence, and the review of literature on US characteristics of PEComas. Harboring a hyperechogeneous heterogeneous aspect with no clear separation from the adjacent uterus on the whole boundary, with an extremely rich central vascular network, with low impedance and a rapidly growing profile, this tumor does not show the classic US appearance of malignant PEComas, which are generally easily confused with leiomyomas. However, even if this pattern did not allow the authors to anticipate the histopathological result, it offered clear clues about its invasiveness potential.

A Thin and Regular Endometrium In Endometrial Cancer - Endovaginal Ultrasound Assessment.

Aim: Our study had as a major objective the highlighting of more objective criteria in establishing the morphological diagnosis and the evaluation of prognosis elements in endometrial hyperplasia and endometrial carcinoma, representing a specific pathology for the premenopausal and postmenopausal women. Endometrial adenocarcinoma is a malignant tumor, rare in women under 40 years of age, but the incidence increases after menopause, gradually reaching a maximum between 70-79 years. Material and Methods: The study included 291 patients with endometrial adenocarcinoma. The patients were admitted in 2005-2010 to "Cuza-Voda" Obstetrics and Gynecology Hospital in Iasi. The study group was diagnosed and investigated on the basis of the clinical examination and the specialized complementary explorations. The histopathological diagnosis was obtained by the processing of the hysterectomy specimen. Results: The results of the study that we conducted highlight the fact that nearly half of the patients diagnosed with endometrial adenocarcinoma were 50-59 years old. In 78.01% cases the uterus was of normal size, between 4-6cm, in 10.31% cases was increased over 6 cm and 11.68% it was of small size, less than 4 cm. Conclusions: The study recommends surveillance of cases with endometrial hyperplasia especially if are associated with incriminated risk factors in the etiology of carcinoma of the uterus.

Postpartum splenic rupture: a possible iatrogenic event, but finalized with successful conservation of the spleen.

The authors present the case of a postpartum splenic rupture induced probably by iatrogenic injury (recent vaginal delivery with a prolonged expulsion with uterine fundus compression) including the left hypochondria region costal grid. The case was solved with splenic preservation and achieving hemostasis only by local plugging and Gelaspon. The case raised also other problems regarding the etiology of splenic rupture, in establishing a causal relationship between a intrapartum splenic injury, and the three episodes of inferior genital tract hemorrhaging, in establishing the cause of the infectious syndrome from the 24h postpartum day, (parietal infection or splenic abscess requiring splenectomy).

Clinico-epidemiological study of endometrial hyperplasia--a risk factor for the development of endometrial carcinoma?

AIM: Metaplasia is defined as a transformation of an adult epithelial or conjunctive cellular type into another adult cellular type. Endometrial hyperplasia and particularly complex atypical hyperplasia exposes to a high risk of development of the endometrial carcinoma, being considered a lesion precursory to the same. Endometrial hyperplasias are risk factors for the development of endometrial carcinoma and their prophylaxis implies their accurate diagnosis, taking into account that the adenocarcinomas diagnosed in an advanced stage, whose therapeutic context differs from the early stages, have a much lower chance of survival. MATERIAL AND METHODS: Our study aimed at highlighting objective criteria in establishing the morphological diagnosis and in evaluating the prognostic elements. The studied batch included 875 patients with endometrial hyperplasia and 263 patients with endometrial adenocarcinoma, who were admitted between 2003 and 2007, and the histopathologic diagnosis was obtained by processing the hysterectomy pieces. The presence of this tumour was at its highest level half-way through the study, which was in 2005. RESULTS: According to the study, there was a higher proportion of patients with endometrial carcinoma from the urban environment (58.2%) than the ones from the rural environment (only 41.8%). Depending on their age, most cases of endometrial adenocarcinoma were diagnosed in 53-year old patients, with an average age of 58.94 years. Our study, made of the two batches of endometrial adenocarcinomas, shows that between the endometrial and non-endometrial adenocarcinoma there are significant differences related to the patients' age, the morphological aspect of the carcinoma, the architectural degree, the nuclear degree of tumours and the invasion in the myometrium. CONCLUSIONS: Our study proves that endometrial hyperplasia is a frequent diagnosis in peri- and postmenopausal patients and is frequently identified following investigations for an abnormal uterine bleeding. The age of patients with endometrial carcinoma is an important prognostic factor independent of other parameters. The difference between complex hyperplasia with no atypias and complex hyperplasia with atypias is important, because atypical complex hyperplasia is considered the precursor of endometrial adenocarcinoma.

Benign breast disease and the risk of breast cancer in the next 15 years.

AIM: Fibrocystic mastosis (FCM) is defined by the totality of dystrophic changes of the mammary tissue, the grouping in the form of fibrosis of epithelial, cystic, metaplastic and hyperplastic alterations. A very good estimation of the cancer risk is related specifically to the microscopic aspect. Other factors, the family history as well as the presence of an inherited gene determining the increase in the risk of breast cancer are also considered. But, if a woman known with fibrocystic mastosis has not undergone any biopsy, then it is impossible to calculate the specific individual risk of developing cancer. MATERIAL AND METHODS: The data collected as a study material and considered refer to: the total num- ber of cases investigated and diagnosed with fibrocystic mastosis, the annual distribution of this disease cases, the distribution of the cases according to age groups, admission reasons, clinical examination, personal pathologic history clinically significant for the basic disease (the main diagnosis), the family medical history significant for the basic disease, the anatomopathological diagnosis. RESULTS: Between 2004 and 2006, at "Cuza Voda" Obstetrics and Gynecology Hospital of Iasi, a maximum number of cases is noticed in 2006, when there were 147 cases, and the lowest number of cases was in 2005. There was high frequency of the anatomopathological examinations that highlighted the presence of fibrocystic lesions (both proliferative and non-proliferative), and the second most often diagnosis is fibroadenoma. Though fibrocystic mastosis is not clearly defined, it is still admitted that in order to support this diagnosis it is first compulsory to exclude malignant tumours. CONCLUSIONS: Only in 5% of the women with fibrocystic mastosis cellular changes can be revealed in the form of atypical hyperplasia, which are a risk factor for cancer. The lesion that delimits cancer from non-cancer is ductal carcinoma in situ. An incidence of over 20% is present in the countries that use mammographic screening programmes, mammographic surveillance programmes and programmes for the guided localization of nonpalpable lesions of the mammary gland.

The endoscopic management of uterine synechiae. A clinical study of 78 cases.

UNLABELLED: Intrauterine adhesions (1UA) are easily diagnosed by hysteroscopy, which also offers the main method for treatment. In this study, we analyze the value of the method. MATERIAL AND METHODS: We have selected 78 cases of IUA diagnosed during a 3 year period. In cases when interventions were needed, we used mechanical techniques (pushing, scissors, forceps) or electrical resection, addressed to synechiae and other concomitant pathologies (fibroids, polyps). The follow-up ranged between 3-6 months (for amenorrheic patients) and 6-12 months for infertility patients. RESULTS: In our 78 cases the presenting diagnostic was synechiae (44%), irregular cycles (19%), amenorthea (16%), infertility (15%). Hysteroscopy allowed the IUA extension evaluation, and the majority of cases had early stage disease. From them 60% had therapeutic gestures, with success criteria being: visualization of both tubal ostium- in 70%, clinical normal cycles (91%) and pregnancy in 5 cases (41% from patients addressed mainly for infertility). There was one perforation in an Ashermann syndrome case, with no further surgical gestures needed. The main postoperative treatment was hormonal treatment, in all cases. In conclusion, although hysteroscopy allows easy diagnostic for IUA, therapeutic gestures should be done in severe cases by experimented specialists.

[Medical treatment of endometriosis. An update]. / Actualitati in tratamentul medical al endometriozei.

Endometriosis is a major health problem, because of difficult diagnosis and limited therapies available. The surgical approach is done by very specialised surgeons, doing classical or laparoscopic ablative interventions. This article is an up-to date evaluation of medical treatment, reviewing the hormonal drugs (contraceptives, progestatives, GnRH analogues) and non-hormonal ones (anti-aromatase, anti-progestative, anti-tissular growth factors). The conclusion is that the medical treatment should be used in well selected cases, and adapted regimens, choosing among continuous contraceptives, intrauterine devices with levonorgestrel, or aromatase inhibitors. The main objective in this cases is rarely the complete cure, but more frequently optimal timing before surgery.

Electrosurgical loop excision/conisation for cervical intraepithelial neoplasia in an algorithm that excludes punch biopsy--a study of 210 cases.

UNLABELLED: This study aims to evaluate the use of LLETZ/conisation in an algorithm that excludes the colposcopically guided biopsy. MATERIAL AND METHODS: The study was carried out on 210 patients with LLETZ/conisation, performed in our service in 2 years. They were selected by pap smear, colposcopy, HPV genotyping, without punch biopsy. RESULTS: The pathological results on the excision specimen showed: benign lesion 10%, CIN 1/condyloma 58%, CIN 2 18%, CIN 3/CIS 11%, microinvasion 2% and invasion 1%. The Pap test showed: HGSIL 27%, LGSIL 56%, ASCUS 13%, and normal/benign in 4%. The therapeutic efficiency of the excisional treatment showed that there was a 9.5% excessive treatment, 14.8 residual lesions, 3 cases of hemorrhage, 2 cervical stenosis, and 7 cases with specimen alteration that made the pathological diagnostic difficult or impossible. In conclusion, the LLETZ/conisation are ambulatory procedures with an acceptable rate of over-treatment and residual lesions, and reduced rate of complication.

[Clinical and paraclinical diagnosis of pelvic endometriosis. Clinical study]. / Studiu privind diagnosticul clinic si paraclinic al endometriozei pelvine.

UNLABELLED: Pelvic endometriosis is a difficult diagnosis in gynecological practice, due to different symptoms and advanced stages in which the patients arrive to us. MATERIAL AND METHOD: This study retrospectively analyses 73 cases of confirmed endometriosis admitted in our service during 5 years. We gathered information about their clinical data and diagnosis, and intraoperative laparoscopic or laparotomic findings. RESULTS: The majority of our cases were in the 3rd age decade (52%). The clinical symptoms were: infertility (34%), pelvic or abdominal pain (71%), vaginal bleeding (14%), or an accidental finding after laparotomy or laparoscopy for other reasons (7%). The intraoperative evaluation of the cases showed: endometrial genital foci in 59%, with half of them located at the ovary; extragenital sites in 30 cases (bladder--4 cases, Douglas pouch 19 cases, abdominal wall 5 cases, para-cervix 2 cases). Associated pathology included: adhesions in 46%, retroverted uterus in 15%, ovarian non endometriotic cysts (18%), polycystic ovaries (12%) and tubal pathology (6%). CONCLUSION: Our study confirm the difficulty of a clinical diagnostic of endometriosis, but the main symptoms remain infertility and pelvic-abdominal pain. The laparoscopy or laparotomy were the main tools for the diagnostic and management of our cases.

[Prenatal diagnostic of congenital unilateral hydronephrosis with megaureter--a case presentation]. / Hidronefroza unilaterala congenitala cu megaureter depistata antenatal. Prezentare de caz.

Unilateral mild hydronephrosis with ureteral dilatation is a condition that can be detected by careful prenatal ultrasound examination. We present such a case, in a 26 year pregnant woman with hereditary antecedents (mother with Ombredan disease). The fetal ultrasound at 34 weeks indicated a left anechogenic sinuous image, identified as dilated ureter, and connected to a grade 2 hydronephrotic kidney. Normal data regarding the other kidney and the bladder made us recommend a close follow-up, considering this case as with a good prognosis. After birth, reassessment was favourable, and at 1 year follow-up the child was in good condition, and the kidney functional. We conclude that this case is a unilateral congenital megaureter, of probably obstructive origins, with a mild hydronephrosis. A good outcome was suggested by the late diagnostic, unilateral condition, and normal fetal ultrasound description regarding morphology, biometry and amniotic fluid.

The prenatal detection of Jeune syndrome (asphyxiating thoracic dystrophy). Case report.

The authors present the case of a foetus with Jeune syndrome (asphyxiating thoracic dystrophy) in a woman with a previous deceased child with the same disease, and also with a normal sibling. The diagnosis was mentioned at 26 week of pregnancy, based on ultrasonographic findings: short proximal bones (under 3 percentiles), and a diminished thoracic circumference, (although greater than 10 percentiles for the gestational age). There was an interdisciplinary agreement for the therapeutic termination of the pregnancy, and the post-expulsion assessment confirmed the diagnosis. This case demonstrates a higher incidence of Jeune dystrophy than the one expected for an autosomal recessive disease, with 2 out of 3 children affected, instead of 25%. It also shows that the earliest change is the one regarding the shortened long bones, often difficult to notice before 20 weeks, fact which favors a detailed genetic sonogram done after this limit.

[The use of hysteroscopy in the diagnostic on perimenopausal metrorrhagia. A study of 35 cases]. / Utilizarea histeroscopiei in diagnosticul hemoragiilor perimenopauzale. Studiu clinic pe 35 cazuri.

UNLABELLED: We have retrospectively evaluated the role of hysteroscopy for the diagnostic of the peri-menopausal metrorrhagia. METHODS: The cases included represented patients of more than 45 years, with persistent bleeding, from 2 gynecological hospitals (one public and one private), during one year, that were submitted to hysteroscopy for clarifying the diagnostic. The hysteroscopic endometrium descriptions were categorized as: atrophy, normal, simple or suspect hypertrophy, polyp, and adenocarcinoma, and they were compared to the pathological exam results. RESULTS: The descriptions were distributed among the categories: atrophy (8 cases), simple hypertrophy (17), suspect hypertrophy (3), polypoid (5), endometrial cancer (2) or normal (4). The correlation to pathological results was good, with only 14% of hysteroscopic underestimation of lesions. The sensitivity according to type of pathology, was 50 to 100%, specificity between 84% - 100%. CONCLUSION: Hysteroscopy is better than "blind" curettage in clarifying perimenopausal hemorrhagic endometrial pathology.

Laparoscopy versus laparotomy for pelvic and lumbar-aortic lymphadenectomy. A 11-year experience.

UNLABELLED: This study is a retrospective comparison of laparoscopy and laparotomy lymphadenectomy (pelvic and lumbar-aortic) in cervical cancer stage IA1 and more, in a gynaecological service in Lyon, France. MATERIAL AND METHODS: During 11 years, there were 126 cases of cervical cancer patients in which lymphadenectomy was performed, either by laparoscopy or laparotomy. We analysed if there were significant differences regarding the 2 accesses in terms of stage, tumour size, surgical interventions associated, number of lymph nodes extracted, and outcome. RESULTS: Regarding the stage of our cases, 3 of them were IB1, IB2 and IIB; the more advanced the stage, the fewer lymphadenectomies were performed by laparoscopy. As for the tumour size, the smaller tumour was statistical significantly associated with pelvic laparoscopic lymphadenectomy (p = 0.01) while the tumours larger than 4 cm mean lumbar-aortic lymphadenectomy by laparotomy (p = 0.006). Regarding the associated surgical interventions, the laparoscopic lymphadenectomies were associated to low-stage operations: conisation/trachelectomy, vaginal or abdominal simple hysterectomy, or extra-fascial hysterectomy (type 1 or 2). There was no significant difference between laparoscopy and laparotomy ways regarding the number of lymph nodes extracted (median 13.5 vs 11, p = 0.45 for pelvic nodes, and 8 vs 4 for lomb-aortic nodes, p = 0.43, for laparoscopy vs laparotomy). CONCLUSION: Laparoscopic lymphadenectomy is as effective as the laparotomy procedures, and the training of young gynaecologic oncologists should not ignore laparoscopy as an alternative technique for nodes sampling.

[Use of slings in vaginal surgery]. / Protezele în chirurgia vaginala.

The use of slings in the cure of genital prolapse and urinary stress incontinence is justified by the large number of relapses after the classical surgical procedures, especially due to the poor quality of the perineal connective tissue. The ideal sling for vaginal surgery should have certain characteristics, i.e., resistance to infection, bio-stability, bio-compatibility, solidity, interstitial texture, porosity, elasticity, non-aggressive margins. The discussed techniques used in the cure of the stress urinary incontinence are the Tension-free Vaginal Tape (TVT), the Sparc-sling System, the Intra-vaginal sling-plasty tunneller (IVS), and Trans-obturator Tape (TOT). For the cystocele, the under-bladder meshes, either free or fixed to the abdominal wall or to TVT is recommended. For the rectocele, a posterior IVS with a tension-free inter-recto-vaginal prosthesis is suitable, while for the vaginal vault prolapse, hysterocele or isolated elitrocele we discuss the posterior IVS.