[Comparison of hysterectomy techniques in a group of patient operated for the diagnosis female to male transsexualism]. / Porovnání technik hysterektomie v souboru jedincu operovaných z indikace transsexualismu femaleto male.

OBJECTIVE: Comparison of duration of surgery, blood loss, complications, lenght of post-operative hospitalisation and post-operative morbidity in a group of patient operated for the diagnosis FtM transsexualism. DESIGN: Retrospective clinical study. MATERIAL: In our set of patients were 163 FtM transsexuals with caryotype 46 XX and normal gynecological finding (81 virgins). They were operated on from 1998-2012 at Department of Obstetrics and Gynecology The First Faculty of Medicine Charles University in Prague and Hospital Na Bulovce after at least of 12 months of hormonal preparation. METHODS: We used following types of hysterectomy and bilateral adnexectomy: total abdominal hysterectomy from infraumbilical median laparotomy (AHL) or from suprapubic transverse incision - Pfannenstiel (AH), laparoscopically assisted vaginal hysterectomy (LAVH), total laparoscopic hysterectomy (TLH). In two patients TLH and colpectomy was performed in one setting. RESULTS: In the 23 AHL group the duration of the surgery was 54 minute, blood loss was 226 ml and the length of post-operative hospitalisation was 6.7 days. In the 22 individualy of AH group the duration of the surgery was 60 minute, blood loss was 240 ml and the length of post-operative hospitalisation was 6.1 days. In 4 patients of LAVH group the duration of the surgery was 73 minute, blood loss 200 ml and the length of post-operative hospitalisation was 5 days. In the TLH group (112 pts) the duration of the surgery was 91 minutes, blood loss was 121 ml and the length of post-operative hospitalisation was 4.4 days. In the 2 TLH with colpectomy group the duration of the surgery was 152 minute, blood loss was 250 ml and the length of post-operative hospitalisation was 5.5 days. In one case a peroperative lesion of urinary bladder occured and once a conversion TLH to AH for a strong vaginal bleeding was necessary. Among postoperative complication in one case subileus in AH group was diagnosed, once vaginal bleeding, once haematoma in the suture and one case of secondary healing. Postoperative complication after TLH included 4 times bleeding from vaginal suture, once haematoma in Douglas pouch, once seroma in the place of trocar insertion, once subileus. Once ureter was injured and treated by the ureteral stent insertion. Complication after AHL and LAVH were not recognised. CONCLUSION: Total laparoscopic hysterectomy is the method of choice in the group of FtM transsexuals. This technique could be used also in nuliparous women with long and narrow vagina. Compared with laparotomic approach lower blood loss and shorter hospital stay was proved. Earlier restitution of full activity is another advantage. Musculus rectus abdominis flap can be used for phallus construction. The only significant disadvantage is a longer duration of surgery.

[A pilot study: correction of the levator hiatus using an anal sling as a surgical treatment of faecal incontinence]. / Pilotní studie: korekce levátorového hiátu anální páskou jako chirurgická metoda lécby strevní inkontinence.

INTRODUCTION: Faecal incontinence is a significantly depressing and mentally devastating disability. Surgical treatment, as a first choice method, is indicated for incontinence originating as a result of traumatic or iatrogenic infliction of the sphincter apparatus, particularly of the external sphincter. In case of idiopathic (neurogenic) incontinence, it is indicated very exceptionally, if ever. The authors present a pilot study to verify the possibility of surgical treatment of anal incontinence with the support of a puborectal muscle loop by means of the absorbable STRATASIS® TF mesh. MATERIAL AND METHODS: In the years 2010-2012, eight experimental surgical procedures were performed. Female patients with a history of faecal incontinence of the third stage longer than one year and with EMG-verified neurological lesion were recruited. The evaluating criteria were the Wexner score and changes in the levator and anorectal angle acquired from a MR defecographic examination performed before and six months after the operation. RESULTS: The complaints improved distinctly in six patients; in the two remaining cases, the method failed completely. The failures were associated with an inflammatory complication in both cases. In one patient, the authors do not rule out an incorrect indication, too. The Wexner score decreased from 18 to 10 in improved patients. Changes in the levator and anorectal angle were not significant. CONCLUSION: The results confirm the possibility of successful surgical influence on incontinence of the third stage by correcting the levator hiatus with biodegradable mesh. Continence improvement persists even after the mesh transforms into scar tissue.

Predicting axillary sentinel node status in patients with primary breast cancer.

The aim of this study is to determine the combination of characteristics in early breast cancer that could estimate the risk of occurrence of metastatic cells in axillary sentinel lymph node(s). If we were able to reliably predict the presence or absence of axillary sentinel involvement, we could spare a considerable proportion of patients from axillary surgery without compromising therapeutic outcomes of their disease. The study is based on retrospective analysis of medical records of 170 patients diagnosed with primary breast cancer. These women underwent primary surgery of the breast and axilla in which at least one sentinel lymph node was obtained. Logistic regression has been employed to construct a model predicting axillary sentinel lymph node involvement using preoperative and postoperative tumor characteristics. Postoperative model uses tumor features obtained from definitive histology samples. Its predictive capability expressed by receiver operating characteristic curve is good, area under curve (AUC) equals to 0.78. The comparison between preoperative and postoperative results showed the only significant differences in values of histopathological grading; we have considered grading not reliably stated before surgery. In preoperative model only the characteristics available and reliably stated at the time of diagnoses were used. The predictive capability of this model is only fair when using the data available at the time of diagnosis (AUC = 0.66). We conclude, that predictive models based on postoperative values enable to reliably estimate the likelihood of occurrence of axillary sentinel node(s) metastases. This can be used in clinical practice in case surgical procedure is divided into two steps, breast surgery first and axillary surgery thereafter. Even if preoperative values were not significantly different from postoperative ones (except for grading), the preoperative model predictive capability is lower compared to postoperative values. The reason for this worse prediction was identified in imperfect preoperative diagnostic.

[Micturition, sexual and defecation disorders in middle-aged women after pelvic fractures. A comparative study]. / Mikcní, sexuální a defekacní problémy u zen v aktivním veku po zlomenine pánve: srovnávací studie.

PURPOSE OF THE STUDY: To present the results of a three-year study on micturition, defecation, gynecological and sexual disorders in middle-aged women who sustained pelvic fractures. MATERIAL AND METHODS: A group of 33 female patients who were treated for unstable pelvic fractures (AO types B or C) in the 2004-2009 period were evaluated (treated group) and compared with 31 women who had given vaginal birth at least once and went to see a urologist because of urinary problems in the period from 2009 to 2010 (control group). The questionnaires used in the study included ICIQ, UIQ, UDI and PISQ12 instruments. Urodynamic tests included flow cystometry, urethral pressure profile at rest and under stress and uroflowmetry. For a comparison of continuous variables of normal distribution, the t-test for independent samples was used. In the questionnaire study when responses were classified as nominal-ordinal variables, the Mann-Whitney U-test was used. Differences between the two patient groups in qualitative variables were tested by Pearson s 2 test. When the expected number of answers in contingency table was lower than 5, Fisher s exact test was used; when the number of answers was 0, Haldane s correction was employed. The results in all tests were considered significant when the level of significance was lower than 5%, i.e. p-value < 0.05. RESULTS: The age of patients in the treated group ranged from 17 to 55 years (average, 32 years), the age in the control group was between 30 and 78 years (average, 58 years). The difference was significant (p<0.001). The control group patients had significantly more serious urination disorders than the treated group patients. Some micturition problems were reported by 25 patients (75%) of the treated group and by all patients of the control group (p<0.001). Intestinal disorders were more frequent in the treated group, in which 19 (61%) patients reported problems as against seven (21%) in the control group. Gynaecological problems involving feelings of genital prolapse had 13 (39%) control patients (p = 0.041). Sexual disorders were markedly worse in the treated group, with 16 (52%) of the patients having problems in comparison with only seven (21%) in the control group. DISCUSSION: A comparison of patient groups composed using the method described here is disputable. The first difficulty lay with a low compliance of the treated patients, of whom only 33 underwent examination out of 52 originally enrolled. The other problem was the necessity of having an exactly defined control group of patients willing to undergo urological and gynaecological examination including urodynamic testing. The groups composed by our method were comparable only in the micturition disorder characteristic. A significantly higher age of the control group affected the comparison of defecation, gynaecological and sexual problems. CONCLUSIONS: The results of this study showed a high occurrence of micturition, defecation and sexual disorders in middle-aged women after pelvic injury. However, the problems are usually not serious enough to make the patients seek help of a specialist. The authors recommend that these problems should be looked for by disorder-directed inquiry in the final period of pelvic fracture treatment and help of a specialist in urology, gynaecology, sexuology or proctology should be offered to the patients in whom disorders have been identified. Key words: urinary incontinence, voiding dysfunction, stool incontinence, obstipation, unstable pelvic fracture.

[Low grade renal trauma (Part II): diagnostic validity of ultrasonography]. / Poranení ledvin nizsích stupnu (2. cást): Validita ultrasonografie v diagnostice.

PURPOSE OF THE STUDY: The aim of the study was to verify whether ultrasonography can be considered a reliable method for the diagnosis of low-grade renal trauma. MATERIAL AND METHODS: The group investigated included patients with grade I or grade II blunt renal trauma, as classified by the AAST grading system, in whom ultrasonography alone or in conjunction with computed tomography was used as a primary diagnostic method. B-mode ultrasound with a transabdominal probe working at frequencies of 2.5 to 5.0 MHz was used. Every finding of post-traumatic changes in the renal tissues, i.e., post-contusion hypotonic infiltration of the renal parenchyma or subcapsular haematoma, was included. The results were statistically evaluated by the Chi-square test with the level of significance set at 5%, using Epi Info Version 6 CZ software. RESULTS: The group comprised 112 patients (43 women, 69 men) aged between 17 and 82 years (average, 38 years). It was possible to diagnose grade I or grade II renal injury by ultrasonography in only 60 (54%) of them. The statistical significance of ultrasonography as the only imaging method for the diagnosis of low-grade renal injury was not confirmed (p=0.543) DISCUSSION: Low-grade renal trauma is a problem from the diagnostic point of view. It usually does not require revision surgery and, if found during repeat surgery for more serious injury of another organ, it usually does not receive attention. Therefore, the macroscopic presentation of grade I and grade II renal injury is poorly understood, nor are their microscopic findings known, because during revision surgery these the traumatised kidneys are not usually removed and their injuries at autopsy on the patients who died of multiple trauma are not recorded either. CONCLUSIONS: The results of this study demonstrated that the validity of ultrasonography for the diagnosis of low-grade renal injury is not significant, because this examination can reveal only some of the renal injuries such as perirenal haematoma. An injury to the renal parenchyma is also indicated by hypoechogenic areas of varying sizes in the renal cortex. A negative ultrasonographic finding is no proof of the absence of renal trauma. As low-grade renal injury is difficult to detect by mere clinical examination or by a single imaging method, the authors regard as necessary to actively look for them, taking into consideration the mechanism of injury, haematuria findings and evaluation of ultrasonographic and CT scans.

[Pelvic injury from the urogyneacology point of view. Overview]. / Poranení pánve z pohledu urogynekologie. Souborný referát.

The authors completed all available information of the national and foreign literature concerning problems of urogynecological injuries associated with a pelvic injury in women with regard to possible consequences to the quality of life. The authors also aimed their attention on potentional risks associated with pelvic injury in pregnant women. Urological and sexual disorders following pelvic injuries in women in the fertile age represent a separate chapter of traumatology. Increase in these injuries noticed in last years requires particular attention to diagnostics and treatment of these conditions: urinary incontinence, sexual disorders and pregnancy in women who suffered a pelvic injury. The problem of diagnostics and sequelae of injury of the pelvic floor still remains unresolved.

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.

[Tension free vaginal tape and transobturator suburethral tape for surgical treatment of stress urinary incontinence]. / Chirurgická lécba stresové inkontinence moci pomocí tahuprosté vaginální pásky.

OBJECTIVE: The purpose of this study was to prospectively and randomly compare tension free vaginal tape (TVT) with transobturator suburethral tape (TVT O) for the surgical treatment of stress urinary incontinence (SUI) in women. STUDY DESIGN: 288 women with SUI were randomly assigned to either TVT (n-141) or TVT O (n-147). The preoperative evaluation included QoL questionare and a comprehensive urodynamic examination. The 1-year outcome included a urodynamic study. RESULTS: Patients characteristics, preoperative QoL were similar in the 2 groups. Mean operative time was significant shorter in TOT group. The rates of cure were similar rot the TVT and TVT O groups, respectively (obj.: 90.1% vs. 88.4%, subj.: 84.7 vs. 80.9%). CONCLUSION: TOT appears to be equally efficient as TVT for surgical treatment of stress urinary incontinence in women.

[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.

[Possibilities of using ultrasound in the diagnosis of descended posterior compartment of female pelvic floor]. / Moznosti vyuzití ultrazvuku prfi diagnostice descenzu zadního kompartmentu zenského páinevního dna.

OBJECTIVE: Find out the features of descending posterior vaginal wall using ultrasonography and set the objective diagnostic criteria. DESIGN: Prospective comparative study. SETTING: Department of Obstetrics and Gynaecology, Teaching Hospital Bulovka, First Medical Faculty, Charles University in Prague. METHODS: We included 39 attendants, 19 with clinicaly proven descent of posterior vaginal wall; 20 as a negative control group. We observed the ultrasonographical features of descending posterior vaginal wall according to the horisontal line crossing the inferior margin of pubic bone (PM) and central anorectal angle (PARA) at rest and during Valsalva manoevre with and without intrarectal application of sonographic yelly. Student's t-Test was used for statistical evaluation. RESULTS: We proved the statisticaly significant increase in the distances PM and PM' in the group of females suffering from the descent compared to the group of healthy women. Values of PARA were also signifinatly hightened in the group of patients with the descent compared to healthy females. CONCLUSIONS: The ultrasonographical evaluation of descending posterior vaginal wall appears to be promising chance in diagnostics of female's pelvic floor pathology.

[Birth injury of the puborectalis muscle--3D ultrasound evaluation]. / Porodní poranení puborektálního svalu--sledování pomocí 3D ultrazvuku.

OBJECTIVE: Evaluation of the influence of vaginal childbirth on the integrity of the puborectalis muscle with the help of real-time 3D ultrasound. DESIGN: Prospective pilot study. SETTING: Institute for Care for Mother and Child, Prague, Czech Republic. MATERIAL AND METHODS: We examined 20 primigravid women in the third trimester and on the third day after vaginal delivery. The transperineal 3D ultrasound examination was performed and the data were evaluated afterwards in the 4D view software. The VCI (Volume Contrast Imaging) mode with slice thickness 3 millimeters was used for analysis. We evaluated the integrity of the puborectalis muscle on both sides, the quality of the images and the presence of hematomas. RESULTS: The examination before delivery did not show any abnormal anatomy of the examined region. We found four (20%) unilateral defects and one (5%) bilateral puborectalis avulsion after the delivery. The bilateral defect was after the forceps delivery, the other defects occurred after normal uncomplicated vaginal deliveries, where only left mediolateral episiotomy was performed and the birth weight did not exceed 3700 g. In our series, 25% of women suffered an injury of a major muscle of pelvic floor. No defect was diagnosed during the delivery and did not show any connection with the episiotomy. CONCLUSIONS: 3D ultrasound can detect major birth trauma to the puborectalis muscle. The puborectalis muscle avulsion is usually not recognized during the delivery and does not cause immediate problem to the patient.

[Pelvic ring injury]. / Poranení pánevního kruhu.

The authors compare their experience with the treatment of pelvic ring injuries with the literature data concerning the etiology, diagnosis and classification of this trauma, co-existing pathologies, primary therapeutic procedures, timing of the definitive treatment, surgical approaches, osteosynthesis of the posterior and anterior segments, complications and lasting sequelae. The authors regard the issue of surgical treatment as an independent discipline in the field of musculoskeletal system traumatology. They see the reason for it in the variability and complexity of primary therapeutic procedures and the necessity of following up and attending to the patients in whom treatment of complications and lasting sequelae requires multi-disciplinary co-operation.

Some ecological criteria of natural focality of mycotic zoonoses.

Mycotic zoonoses sensu stricto and mycotic infections acquired from animal polluted environment belong to diseases characterized by the phenomenon of natural focality. On a global scale they comprise 16 different diseases caused by yeast-like organisms, dematophytes, dimorphous agents of systemic mycoses and primarily saprophytic fungi as well. Prevalence of mentioned diseases is influenced by a number of factors concerning not only biology and ecology of pathogenic agents and particular hosts, but also character of specific extra-animal substrates which make possible long-term maintenance or active propagation of agents in the environment. On the basis of their experience and published data as well, the authors present a survey and analysis of these factors, with particular emphasis on very frequent dermatophytozoonoses and some systemic mycoses. They pay attention to different conditions in urbanized and rural areas and to specific situations encountered by man and food producing animals in these areas. They note different ways of heterotrophy of particular agents and their association with vertebrate hosts which they divide into six ecologically different groups. The authors also characterize the environment in which a portion of saproparatrophic circulation of the agent takes place. They also give a survey of animal-connected human mycoses, which may arise due to occupational hazards.

Survey of dermatophytes in the hair of small mammals from Austria.

Apparently healthy hair of insectivores and rodents originating from two regions situated at different altitudes in Austria was examined on the presence of dermatophytes. Dermatophytes Microsporum persicolor, Trichophyton georgiae, T. mentagrophytes var. erinacei, T. mentagrophytes var. mentagrophytes and T. terrestre were recovered from the hair of 27 animals (32.9%), belonging to 10 species. The results revealed evident specificity of dermatophytes to host mammals irrespective of the effect of different altitude of localities. The existence of dermatophytes in the healthy hair of mammals is due either to mere contamination from environment (findings of geophilic species) or to inapparent infection (findings of zoophilic species).

Fungi from interior organs of free-living small mammals in Czechoslovakia and Yugoslavia.

A total of 308 fungi was isolated from interior organs (lungs, spleen, liver) of 529 small mammals belonging to 21 species, 7 families and 3 orders (Insectivora, Chiroptera, Rodentia), some of these being potentially pathogenic to vertebrates (e.g. Aspergillus flavus, A. fumigatus, Geotrichum candidum, Mucor pusillus, Rhizopus arrhizus). In one vole (Microtus arvalis) captured in South Moravia, adiaspiromycosis (Emmonsia crescens) was demonstrated. Comparison of mycoflora of hair and that of interior organs of wild small mammals revealed that out of the total number of isolates the following fungi were represented in a higher proportion from visceral organs than from the hair: Aspergillus (A. amstelodami, A. flavus, A. repens), Aureobasidium (A. pullulans), Candida, Cladosporium (C. herbarum), Cryptococcus, Fusarium, Gliocladium (G. deliquescens), Helminthosporium, Kloeckera, Mucor (M. fragilis, M. hiemalis, M. pusillus), Paecilomyces marquandii, Penicillium (P. purpurogenum), Phoma, Rhizopus arrhizus, Scopulariopsis (S. candida, S. koningii) and Torulopsis.

The role of polecats of the genus Putorius Cuvier, 1817 in natural foci of adiaspiromycosis.

Adiaspiromycosis provoked by the fungus Emmonsia crescens was diagnosed in two different species of polecats. In total, 76.2% of steppe polecats (Putorius eversmanni) and 35.6% of dark polecats (P. putorius) were infected. The infection was not demonstrated at all in ferrets (P. furo) reared as fur animals. The differences found in the extent and intensity of infection in the two species of wild polecats are explained by different ecological requirements of these related carnivores. The habitat of the exoanthropic P. eversmanni offers more opportunity for a contact with the pathoergont than that of P. putorius; the latter may occasionally pass over to a pronouncedly hemisynanthropic way of life. The synanthropy of the hosts probably has a negative influence on the life cycle of the fungus. Although the inhalation of aleuriospores is the main route of infection, the ingestion of adiaspores also plays an important role. From this aspect are also evaluated the trophic relationships between mustelid carnivores and small rodents: the predatory species gets into contact with the adiasporic phase of the pathoergont localized in the lungs of wild rodents. The extremely high extent and intensity of infection by the elements of E. crescens in polecats probably results from the cumulation of both routes of infection.

Natural focus of microsporosis caused by Microsporum canis Bodin.

The authors discovered a natural focus of microsporosis caused by the dermatophyte Microsporum canis Bodin. An adult man and four children were afflicted by this dermatophytosis. Symptomatic and inapparent forms of the disease in the focus were also detected in several cats and dogs. Homeless cats were found to be the source of the causative agent and its permanent hosts. A chainlike transmission from these cats was triggered to home-kept cats and dogs and to family members of their owners. Both, the clinical picture of the disease and characteristics of the strains isolated corresponds with the published data. The authors summed up the evidence collected to date on the epidemiology of microsporoses caused by M. canis.

[Changes in the taxonomy and nomenclature of pathogenic microscopic fungi]. / Zmeny v taxonomii a nomenklature patogenních mikroskopických hub.

The authors present a survey of medically important microscopic fungi whose classification were critically revised and correctly named in the last few years. The list was adopted from a paper of American mycologists trying to make the nomenclature of mycotic agents more precise and stable. The authors divided the adopted list according to diseases the individual fungi produce and explained less known terms describing mostly non-european mycoses. Notes giving reasons for nomenclature changes supplement the list of names.

[Candida krusei (Castellani) Berkhout--a potential pathogen with growing importance]. / Candida krusei (Cast.) Berkhout--potenciální patogen se vzrustajícím významem.

The authors collect information on the biological properties, ecology and pathogenicity of Candida krusei. They give a list of forms of diseases caused by this yeast and a profile of its sensitivity to antimycotics. They point out the difference between C. krusei and species of C. albicans and analyze the factors enabling its propagation. In their opinion, the resistance of this yeast to fluconazole is the main cause of the increased number of colonizations and infections produced by C. krusei. The population of C. krusei resistant to fluconazole is selected from other, sensitive species of the genus Candida primarily in hospitalized patients. Though there is no consensus of opinion at present on the influence of fluconazole on the yeast spectrum, the authors suppose this systemic antimycotic plays a distinct role in the growing importance of C. krusei.

[Filamentous fungal infections in man. Alphabetical overview of mycotic agents with data on their systematic classification and on the localization of individual diseases]. / Vláknité houby infikující cloveka. Abecední prehled puvodcu mykóz s údaji o jejich systematickém zarazení a o lokalizaci jednotlivých onemocnení.

The authors present a survey of filamentous microscopic fungi causing human mycoses. The outline is based on an alphabetical list of genera and their classification into higher taxonomic categories, i.e. orders, classes and divisions. The name of a relevant mycosis is followed by enumeration of the individual species and localizations of diseases produced by a given agent. To facilitate orientation in the system of myco-pathologically important agents, examples of classification of individual genera are presented in the text in a hierarchical arrangement of higher taxonomic categories.