Contemporary review on spontaneous coronary artery dissection: insights into the angiographic finding and differential diagnosis.

Spontaneous coronary artery dissection (SCAD), although in the majority of cases presents as an acute coronary syndrome (ACS), has different pathophysiology from atherosclerosis that influences specific angiography findings and enables most patients to be solved by optimal medical therapy rather than percutaneous coronary intervention (PCI). Therefore, accurate diagnosis is essential for adequate treatment of each patient as management of SCAD differs from that of ACS of atherosclerotic aetiology. So far, invasive coronary angiography remains the most important diagnostic tool in suspected SCAD. However, there are ambiguous cases that can mimic SCAD. In this review, the authors summarize current knowledge about the diagnostic algorithms, particularly angiographic features of SCAD, pitfalls of angiography, and the role of intracoronary imaging in the context of SCAD diagnosis. Finally, apart from the pathognomonic angiographic features of SCAD that are thoroughly discussed in this review, the authors focus on obscure angiography findings and findings that can mimic SCAD as well. Differential diagnosis and the timely recognition of SCAD are crucial as there are differences in the acute and long-term management of SCAD and other causes of ACS.

Hysterectomy with Bilateral Salpingo-Oophorectomy in Female-to-Male Gender Affirmation Surgery: Comparison of Two Methods.

INTRODUCTION: The optimal route for hysterectomy with bilateral salpingo-oophorectomy in female-to-male gender affirmation surgery is still under debate, due to the quite limited and inconsistent published data. The aim of this study is to present and compare the results of vaginal and laparoscopic hysterectomy as part of gender affirmation surgery in female-to-male transsexuals. MATERIALS AND METHODS: Between 2012 and 2017, 124 female-to-male transsexuals, aged 18-43 years (mean age: 28.5), underwent hysterectomy with bilateral salpingo-oophorectomy, followed by colpocleisis and gender affirmation surgery. Transvaginal and laparoscopic hysterectomy were performed in 92 and 32 patients, respectively. Standard outcome measures (types and rates of complications, operative time, blood loss, and postoperative hospital stay) were used to compare the two groups of patients. RESULTS: The mean follow-up was 41 months (ranged from 6 to 65 months). The duration of transvaginal approach was significantly shorter (51 minutes compared to 76 minutes, p < 0.001). The total complication rates (less than 3%), reoperation rates (0%), blood loss, and postoperative hospital stays (4.3 days compared to 4.5 days) showed no statistical difference. CONCLUSIONS: Both approaches are safe, with minimal complications. However, we prefer transvaginal hysterectomy due to its shorter operative time, cost-effectiveness, and simpler continuation with one-stage female-to-male gender affirmation surgery.

Overtraining does not induce oxidative stress and inflammation in blood and heart of rats.

The aim of our research was to evaluate the changes in levels of cytokines and redox state parameters in blood and isolated heart of rats subjected to different swimming protocols. Rats were divided into 3 groups: 1) controls, 2) moderately trained rats that during all 12 weeks swam 1 h/day, 5 days/week, and 3) overtrained rats that in 10(th) week swam twice, 11(th) week 3 times, and in 12(th) week 4 times a day for 1 h. After sacrificing, blood from jugular vein was collected, and the heart excised and perfused on a Langendorff apparatus. Samples of the coronary effluent were collected during coronary autoregulation. Levels of superoxide anion radical (O(2)(-)), hydrogen peroxide (H(2)O(2)), nitric oxide (NO) and thiobarbituric acid reactive substances (TBARS) were measured in plasma and coronary effluent, while reduced glutathione (GSH), activities of superoxide dismutase (SOD) and catalase (CAT) were measured in erythrocytes. Venous blood was also used for interleukin 6 (IL-6) and tumor necrosis factor alpha (TNF-alpha) determination. Moderate training protocol induced the decrease of TBARS in plasma, while both training protocols induced the decrease of O(2)(-) and H(2)O(2) in coronary effluent. There was no significant difference in levels of cytokines between groups. The results of study add evidence about beneficial effects of moderate-intensity training on blood and cardiac redox state of rats, and furthermore, shows that exercising frequently, if the intensity stays within moderate range, may not have detrimental effects.

Herlyn-Werner-Wunderlich syndrome--a case report.

This is a case report of Herlyn-Werner-Wunderlich syndrome in a 28-year-old patient. She was admitted to hospital for surgical treatment of the pelvic mass accompanied by painful menstruation periods. This syndrome was diagnosed by US and MRI and it was treated by hemi-hysterectomy with vaginectomy. After the surgery, the patient has had regular and painless menstruation.

Adenosarcoma ovarii in a 51-year-old woman: case report.

This case report presents a 51-year-old woman with an adenosarcoma of ovarian origin which is a very rare tumor. She came for consultation due to abnormal vaginal bleeding. The case also illustrates the difficulty of its correct diagnosis and discusses the possible reasons of wrong preoperative and intraoperative diagnosis.

Urethral Lengthening in metoidioplasty (female-to-male sex reassignment surgery) by combined buccal mucosa graft and labia minora flap.

OBJECTIVES: To develop a technique for urethral reconstruction using a combined labia minora flap and buccal mucosa graft. Urethral lengthening is the most difficult part in female transsexuals and poses many challenges. METHODS: From April 2005 to February 2008, 38 patients (aged 19-53 years) underwent single-stage metoidioplasty. The technique starts with clitoral lengthening and straightening by division of both clitoral ligaments dorsally and the short urethral plate ventrally. The buccal mucosa graft is quilted to the ventral side of the corpora cavernosa between the native orifice and the tip of the glans. The labia minora flap is dissected from its inner surface to form the ventral aspect of the neourethra. All suture lines are covered by the well-vascularized subcutaneous tissue originating from the labia minora. The labia majora are joined in the midline and 2 silicone testicular implants are inserted to create the scrotum. The neophallus is covered with the remaining clitoral and labial skin. RESULTS: The median follow-up was 22 months (range 11-42). The median neophallic length was 5.6 cm (range 4-9.2). The total length of the neourethra was 9.4-14.2 cm (median 10.8). Voiding while standing was reported by all 38 patients, and temporary dribbling and spraying were noted by 12. Two fistulas and one urethral erosion resulted from the testicular implant and required secondary revision. CONCLUSIONS: A combined buccal mucosa graft and labia minora flap present a good choice for urethral reconstruction in female-to-male transsexuals, with minimal postoperative complications.

One-stage repair of severe hypospadias using combined buccal mucosa graft and longitudinal dorsal skin flap.

AIM OF THE STUDY: Urethral reconstruction in severe hypospadias presents a great challenge. We evaluated a method of combining longitudinal dorsal island skin flap and buccal mucosa graft to create a neourethra in the most severe hypospadias. Our aim was to repair the most difficult cases in a one-stage procedure. METHODS: Between January 2003 and July 2007, 23 patients (aged from 9 to 26 months) underwent repair of severe hypospadias (18 penoscrotal and 5 scrotal forms). The short urethral plate is divided in all cases and the remaining curvature was repaired by dorsal plication. The buccal mucosa graft is harvested and fixed to the ventral side of corpora cavernosa to form the first half of the neourethra. A longitudinal dorsal island skin flap is created and buttonholed ventrally. It is sutured to the buccal mucosa graft to form the neourethra. An abundant flap pedicle is fixed laterally to cover all the suture lines of the neourethra. Penile skin reconstruction is done using available penile skin. RESULTS: The mean follow-up was 27 (range 11-66) months. Satisfactory results were achieved in 20 patients. There were two urethral fistula and one temporary distal urethral stricture. CONCLUSION: A combined longitudinal island skin flap and buccal mucosa graft could be a good choice for single-stage urethral reconstruction in the repair of the most severe hypospadias.

Primary double invasive cervical carcinoma, squamous cell carcinoma and adenocarcinoma--case report.

A case of 56-year old women with double primary invasive cervical carcinoma, squamous cell carcinoma and endometrioid adenocarcinoma is presented. The patient was subjected to radical abdominal hysterectomy with pelvic and paraaortic lymphadenectomy. Surgery was followed by radiotherapy. Since the treatment the patient has been doing well and is free of any signs of relapse of the disease.

Leiomyosarcoma of the uterine corpus with ovarian metastases in a 28-year-old woman: case report.

A case of invasive leiomyosarcoma of the uterine corpus with right ovarian metastases in a 28-year-old woman is presented. The patient was submitted to surgery including total abdominal hysterectomy with left salpingo-oophorectomy, dissection of the pelvic and paraaortal lymph nodes and fixation of the right ovary to the psoas muscle. Postoperative radiation therapy was applied. A year after treatment, the patient was well.

[Five-years experience with urinary derivation by Sygma-Rectum pouch at the department for urology in Smederevo]. / Petogodisnje iskustvo uroloske sluzbe u Smederevu sa urinarnom derivacijom sygma-rectum pouch.

Bladder cancer has poor prognosis. Outcome of the treated patients is dependent on correct staging, histologic grade of the tumor, and correctly realized surgical intervention, i.e. radicality of the operation. During the period from 2002. to 2004, on the Department for Urology in Smederevo, 120 patients were surgically treated because of bladder tumors. Of that number, in 34 patients radical cystectomy and derivation by Sygma-Rectum pouch was done. Of these 34 patients, 22 (64.7%) were being followed during the five-years period.

[Myomectomy by vaginal route].

Myomectomy by vaginal route is the least invasive of all methods for myoma removal. Compared to classical, abdominal myomectomy, it has numerous advantages, especially in cases of fundal and posterior wall myomas, but still it is relatively rarely performed. This study provides an analysis of operative and postoperative course of patients subjected to myomectomy by vaginal route in the period from 01/01/2003 to 01/11/2005 as well as the corresponding control group of patients which had undergone classical, abdominal myomectomy. The study points out to significance and advantages of application of surgical technique for removal of myoma through the posterior wall of the vagina as opposed to classical, abdominal myomectomy. Transvaginal myomectomy eliminates trauma of laparotomy, intraoperative blood loss is reduced, postoperative complications are down to minimum, postoperative recovery is shorter, and so is the number of days spent in hospital. Thus, by performing this type of surgery, a positive cost-benefit effect is obtained not only for the patient but for health authorities as well.

[Our experience in the Martius method of closing the vesicovaginal fistula]. / Nasa iskustva u zatvaranju veziko-vaginalne fistule po Martius-u.

Sometimes after delivery, gynecological or other surgeries, radiological therapy, or destructions of vesico-vaginal septum due to the tumor or trauma, the unnatural communication between the bladder and vagina occurs. Those are fistulas that occur after the delivery (tocogenic) caused by the prolonged delivery or some obstetrics operations. Some fistulas are high, coming from the fundus of the bladder, medium, if they come just behind the trigonum of the bladder, and low, if they are in the level of trigonum and the neck of the bladder. The purpose of this paper is to show the operative technique of elimination of medium and low vesicovaginal fistula and the results of the treatment. Material and method The elimination of the vesicovaginal fistula by original Martius technique is done through vagina. The catheter is inserted through the fistula (figure 1). Than the mucosis of the vagina is cut around the fistula and the vaginal wall is separated from the bladder. The catheter is pulled out and the fistula on the bladder is sown with resorptive stitches. Than the labia maiora nearer to the fistula is cut along from Mons Veneris to the middle and the lipoid tissue is taken with vascular pedicle (figure 2). This tissue is put between the bladder and the vagina and fixed with resorptive stitches. After that the vagina is sown by single stitches. The labia maiora that was cut is also sown by single stitches (figure 3). Than the catheter is inserted in the bladder that should stay there for four weeks. This is the method we used to make surgery in twenty patients with vesicovaginal fistula. The first one had the fistula as the result of the Caesarean section. She was operated twice through the bladder without success. The second patient was a fourteen years old girl that cut herself on the glass and damaged anal sfincter, rectum, vagina and the bladder. The fistula appeared later in the level of trigonum of the bladder. The other eighteen patients got fistula after hysterectomy. All patients were treated as described above and fistulas disappeared. The first patient had another baby a year after the operation by Caesarean section. The other patients have regular miction (figure 4 and 5). Discussion and the conclusion Vesicovaginal fistula are serous complications, for the patients and for the doctors. The only treatment of the vesicovaginal fistula is surgical. If any damage of the bladder occurs during any operation it should be treated immediately, otherwise the fistula will appear. The treatment depends of the localization of the fistula. Low fistulas and some medium and urethrovaginal fistulas should be approached through vagina and according to our experience Martius's method is very efficient. The only important thing is when the fistula is detected to wait at least for two or three months for the fistula to "consolidate" and also to cure the infection.

[Creation of a new vagina using a part of the rectosigmoid colon]. / Formiranje nove vagine od dela rektosigmoidnog kolona.

The paper shows the indications, preoperative and intraoperative evaluation as well as the way to make a new vagina. The authors advise to use part of colon sigmoideum to make a new vagina, this vagina is very much like the real one and the function is unlimited. During the operation the shortest possible part of colon sigmoideum should be taken in order to avoid oversecretion (mucorrhoea). After taking the segment and making termino-terminal anastomosis the tunnel should be made between the bladder and rectum and the segment should be stitched to the introitus of the vagina. For three weeks after the operation the patient should keep a tampon in the [figures: see text] new vagina and we suggest the dilatation of the introitus for three months. After the three months period we advise the sexual intercourse. The number of postoperative complications was minimal and the sexual intercourse was normal.

[Fixation of the vagina and neovagina with the sacrospinal ligament]. / Fiksacija vagine i neovagine za sakrospinalni ligament.

In order to fix the prolapse of vaginal vault after vaginal or abdominal hysterectomy we use the technique of transvaginal sacrospinous colpopexy. The authors used this technique for the firs time when they have made neovagina at male transsexual. The technique is as follows: after making the tunnel between the bladder and recrum, under the control of the left hand fingers the vagina, or neovagina is fixed to sacrospinous ligament. No complications or recidive followed the operation ever. The authors point out that the skillfull surgeon should know very well the anatomy of both male or female pelvis in order to perform this operation.

Vaginoplasty in male transsexuals using penile skin and a urethral flap.

OBJECTIVES: To describe and present the results of a one-stage vaginoplasty in male-to-female sex reassignment surgery. PATIENTS AND METHODS: The present technique is based on penile disassembly and the use of all penile components for vaginoplasty (except the corpora cavernosa). The neovagina consists of two parts; a long vascularized urethral flap and a pedicled island tube skin flap created from the penile skin. The urethral flap is embedded into the skin tube. The tube, consisting of skin and the urethral flap, is inverted, thus forming the neovagina. The new vagina is inserted into the previously prepared perineal cavity between the urethra, bladder and rectum. The neovagina is then fixed to the sacrospinous ligament. The labia minora and majora are formed from remaining penile and scrotal skin. The new method was used in 89 patients (mean age 28 years, range 18-56) with a mean (range) follow-up of 4. 6 (0.25-6) years. RESULTS: Good cosmetic and functional results were obtained in 77 of the 89 patients (87%). Importantly, the neovagina produced in most patients was of satisfactory depth and width. There was only one major complication, a rectovaginal fistula caused by intraoperative injury to the rectum. CONCLUSIONS: The technique produces a vagina with more normal anatomical and physiological characteristics than those produced by other methods, as all the penile components are used (except for the corpora cavernosa) to form almost normal external female genitalia. Vaginoplasty using pedicled penile skin with a urethral flap is a good alternative to other methods of vaginoplasty in male-to-female sex reassignment surgery.