The effect of sacrospinous ligament fixation during vaginal hysterectomy on postoperative de novo stress incontinence occurrence: a prospective study with 2-year follow-up

Background/aim: To investigate the risk of de novo stress urinary incontinence (SUI) occurrence in women who were treated for pelvic organ prolapse (POP) with sacrospinous ligament fixation (SSLF) in addition to vaginal hysterectomy (VAH) and antero-posterior colporrhaphy (CAP) over a 24-month follow-up period. Materials and methods: A prospective randomized study was designed. Women without occult or obvious SUI were randomized into either one of the study groups: Group 1: VAH + CAP, and Group 2: VAH + CAP + SSLF. Postoperatively, the patients were reevaluated for de novo SUI occurrence. Results: A total of 150 women were analyzed [G1 = VAH + CAP (n: 77) and G2 = VAH + CAP + SSLF (n: 73)]. Mean age, parity, body mass index, menopausal status, and preoperative POP degree, grade 1 and grade 2-3 cystocele and rectocele frequencies were similar between the 2 groups. During follow-up period, de novo SUI developed in 7 patients (9.1%) of Group 1, and in 6 patients (8.2%) of Group 2 (P > 0.05). In Groups 1 and 2, POP recurrence occurred in 5 (6.4%) vs. 1 (1.3%) cases,respectively (P < 0.05). Conclusion: In patients undergoing surgery for POP, the addition of SSLF did not result in an increased rate of de novo SUI. Careful patient selection, and informing the patients about the risks and benefits of the planned surgical procedure are essential steps in each case of POP.

Could 25-OH vitamin D deficiency be a reason for HPV infection persistence in cervical premalignant lesions?

Vitamin D is an essential precursor to the steroid hormone calcitriol which mainly regulates calcium homeostasis. Moreover anti- proliferative, pro- apoptotic, anti- angiogenic effects of Vitamin D support the ideas of preventive role in various cancer. This study aimed to determine if there is a relationship between HPVDNA infection and cervical intraepithelial neoplasia and Vitamin D deficiency. As a result of the study the difference of 25-OH Vitamin D3 levels between HPVDNA positive group and the control group were statistically significant (p=0,009). According to results of our study, with the proven anti-inflammatory functions of Vitamin D, the deficiency of these molecule and its metabolites can be a possible reason for HPVDNA persistence and related cervical intraepithelial neoplasia.

Alternative tumor markers in the diagnosis of ovarian cancer.

OBJECTIVES: The aim of the study was to assess the usefulness of various tumor markers (CA125, HE4, bcl2) measured in serum, urine and saliva in the differential diagnosis of adnexal masses. MATERIAL AND METHODS: Our study was conducted at the Baskent University Medical School, Department of Obstetrics and Gynecology, Ankara, Turkey, between November 2010 and March 2011. Fifty patients with a suspicion of malignant adnexal mass and 30 controls were included in the study. Serum and urine CA-125, HE4, and bcl2 levels were evaluated for their role in the diagnosis of epithelial ovarian cancer (EOC). RESULTS: Serum CA-125 and HE4 levels, and urine HE4 levels were significantly higher in malignant cases as compared to controls (p < 0.05). Mean levels of bcl2 in saliva and urine were similar in malignant cases and controls (p > 0.05). CONCLUSIONS: We demonstrated that serum CA125, serum HE4 and urine HE4 levels were elevated in patients with ovarian cancer. These findings should be assessed in future studies with larger sample sizes in order to reach more definite conclusions.

The effect of inherited thrombophilia on second trimester combined aneuploidy screening test markers.

PURPOSE: To determine whether inherited thrombophilia affects components of second trimester combined aneuploidy screening test. METHODS: A case-control study was performed between 1 December 2010 and 1 February 2012, at a tertiary referral hospital. Singleton pregnancies with inherited thrombophilia that underwent second trimester (16-19(+6) week) combined aneuploidy screening test were included in the study. Maternal serum alfa fetoprotein, unconjugated estriol, human chorionic gonadotropin levels and multiple of median (MoM) levels were compared between the study group and controls. RESULTS: Within the study period, 18,943 women with singleton pregnancies had a combined second trimester aneuploidy screening test at our institution. Among these, 26 women met the criteria of thrombophilia. A control group that comprised 275 women with similar gestational age was generated, using a 1:1 ratio. Unconjugated estriol MoM levels were significantly lower in women with inherited thrombophilia (p = 0.02). But there was no statistically significant difference for unconjugated estriol levels, human chorionic gonadotropin, alfa fetoprotein and their MoM levels. CONCLUSIONS: Our study suggest that in patients with hereditary thrombophilia a new correction factor should be used, when calculating unconjugated estriol MoM value, which is one of the markers of second trimester aneuploidy screening test.

Retrospective evaluation of borderline ovarian tumors: single center experience of 183 cases.

PURPOSE: Borderline ovarian tumors (BOTs) constitute about a quarter of epithelial ovarian malignancies and require different treatment approaches. The present study aims to document the experience of a single center on the treatment outcome of women who had conservative or comprehensive surgery for BOTs. METHODS: One hundred eighty-three patients with BOTs, diagnosed and/or treated in our center between January of 2000 and March of 2013, were reviewed retrospectively. RESULTS: The mean age at diagnosis was 40.6 years old (range 17-78). Ninety-five patients (51 %) were ≤40 years. Comprehensive surgical staging and fertility sparing surgery were performed in 49 % (n = 91) and 48 % of patients (n = 89) respectively. A hundred and forty-seven patients had stage IA disease (80 %). The most common type of BOT was serous in histology with 18 % bilateralism. CA-125 and CA-199 levels were increased in 29 (19 %) and 15 (10 %) patients with stage IA disease. Non-invasive tumor implants were diagnosed in 9 patients (4 %) and uterine involvement was 2 % among BOT patients that underwent hysterectomies. The mean post-operative follow-up period was 20.4 months (range 6-78 months). Disease recurrence was seen in 5 patients indicating overall recurrence rate of 2.7 %. CONCLUSIONS: In our study, we evaluated a large data pool of 183 patients diagnosed with borderline epithelial ovarian tumors. BOTs have a relatively better prognosis than invasive epithelial ovarian cancer. Surgery with proper staging is the cornerstone of treatment. Patients with BOTs at the early stage can undergo fertility sparing surgery with close follow-up.

Comparison of sublingual misoprostol with lidocaine spray for pain relief in office hysteroscopy: a randomized, double-blind, placebo-controlled trial.

STUDY OBJECTIVE: To compare the effectiveness of sublingual misoprostol with lidocaine pump spray for office hysteroscopy. DESIGN: Premenopausal women who had an indication for office hysteroscopy were included in this randomized, double-blind, placebo-controlled study. Eighty-two patients were evaluable for the final analysis. SETTING: A tertiary referral center. PATIENTS: Premenopausal women who had an indication for office hysteroscopy were included. Eighty-two patients were evaluable for the final analysis. INTERVENTIONS: Patients were randomized to receive either sublingual misoprostol and placebo of lidocaine or lidocaine pump spray applied to the cervix and placebo of misoprostol. MEASUREMENTS AND MAIN RESULTS: When compared with the lidocaine group, patients in the misoprostol group reported less pain by the immediate visual analog scale scores (2.2 ± 0.98 vs. 2.6 ± 0.99, p = .030), whereas visual analog scale scores at 10 minutes were similar between groups (2.1 ± 0.98 vs. 2.36 ± 1.06, p = .156). CONCLUSION: Sublingual misoprostol is more effective than lidocaine spray in pain reduction during office hysteroscopy. Misoprostol may cause vaginal spotting, which may impair the vision during hysteroscopy especially just after the menstrual period. Preventive measures should be taken to make the procedure pain free because the physician may underestimate pain perception during the procedure.

Is hyperandrogenemia protective for fibrocystic breast disease in PCOS?

The aim of this study is to evaluate the fibrocystic breast disease rates and its association with different clinical, endocrine and metabolic parameters between main polycystic ovary syndrome (PCOS) phenotypes. One hundred thirty two consecutive women were included in the study. Body mass index, serum follicle-stimulating hormone, luteinizing hormone (LH), progesterone, estradiol, testosterone, dehydroepiandrosterone sulphate, fasting glucose, low density lipoprotein (LDL-C), total cholesterol, high density lipoprotein, insulin, insulin sensitivity and fibrocystic breast disease rates were compared among different phenotypes of PCOS. Group 1: Polycystic ovaries (PCO)-anovulation (n = 32), Group 2: Hyperandrogenemia (HA)-anovulation (n = 28), Group 3: HA-PCO (n = 29), Group 4: HA-PCO-anovulation (n = 43). There were statistically significant differences between the different phenotype groups in terms of waist-hip ratio (p = 0.006), serum LDL-C (p = 0.008), LH (p = 0.002), estradiol (p = 0.022), fasting glucose (p = 0.001), progesterone (p = 0.007), free testosterone levels (p < 0.001) and Ferriman-Gallwey (FG) scores (p < 0.001). Different phenotype groups had significantly different fibrocystic breast disease rates. (p = 0.016). Higher free testosterone >3 pg/dl was protective for fibrocystic disease (RR = 0.316, 95:% CI 0.109-0.912, p = 0.033). Higher FG scores were more protective for fibrocystic disease (RR = 0.005, 95:% CI 0.001-0.042, p < 0.001). Group 3 ovulatory PCOS patients with PCO and hyperandrogenemia phenotype had lower risk to develop fibrocystic disease, while higher rates were observed in group 1 anovulatory-normoandrogenemic PCOS patients. Hyperandrogenemia is protective for fibrocystic diseases in PCOS.

Ovarian gonadoblastoma with dysgerminoma in a 15-year-old girl with 46, XX karyotype: case report and review of the literature.

OBJECTIVE: To present a challenging case of hCG positivity in a young patient and to review similar cases reported in the literature. METHODS: Literature search of gonadoblastoma cases with pure 46, XX karyotype using PubMed database. RESULTS: A 15-year-old girl with hCG positivity was investigated for the source and the initial diagnosis was an ectopic pregnancy. An ovarian tumor was identified after failed methotrexate therapy and the pathological diagnosis was gonadoblastoma with dysgerminoma. To the best of our knowledge, the case was unique in the literature for having the smallest diameter of a gonadoblastoma tumor with 46, XX karyotype. CONCLUSION: Differential diagnosis of perimenarcheal vaginal bleeding may be challenging for the clinician. Rare causes such as pregnancy both intrauterine and extrauterine and hormone producing tumors should be kept in mind.

Lymph node human papillomavirus DNA positivity in uterine cervical cancers and its relationship with prognostic factors.

INTRODUCTION: Uterine cervical cancer is a major health care issue worldwide. Human papillomavirus (HPV) DNA positivity in regional lymph nodes has been proposed as a risk factor for recurrence in a number of studies. The aim of our study was to determine the correlation between well-known prognostic factors and HPV DNA positivity in regional lymph nodes of patients with cervical cancer who were treated surgically. METHODS: Thirty-seven patients who underwent radical hysterectomy (Piver class III) with regional lymph node dissection for International Federation of Gynecology and Obstetrics stage IB uterine cervical cancer were assessed for nodal HPV DNA status using polymerase chain reaction. Human papillomavirus DNA presence and types were analyzed in paraffin-embedded tissues from all primary tumors and 746 regional lymph nodes. The correlation between HPV DNA positivity of the lymph nodes and prognostic factors (stage at the time of diagnosis, status of the regional nodes, status of parametrial and surgical margins, tumor size, histological type, cervical stromal invasion depth, and lymphovascular space invasion was investigated. RESULTS: Lymph node HPV DNA positivity increased in larger tumors (P < 0.05). In addition, lymph node metastasis and primary tumor HPV DNA status were closely correlated with the HPV DNA status of the lymph nodes (P < 0.05). CONCLUSIONS: Human papillomavirus DNA presence in the lymph nodes of patients with uterine cervical cancer may have an influence on disease survival and requires further research. Future studies with prospective design and large sample sizes using fresh operative specimens and quantitative HPV DNA detection methods are needed.

Second trimester fetal nasal bone length in a low-risk Turkish population.

OBJECTIVE: To define normal values of second trimester fetal nasal bone length (NBL) in a low-risk Turkish population. METHOD: Prenatal records of singleton fetuses who underwent second trimester ultrasonographic examination in the 16 to 23 weeks of pregnancy were retrospectively analyzed for NBL and biometric measurements (BPD, FL and HL). The relationship among NBL and gestational age (GA), biparietal diameter (BPD), femur length (FL) and humerus length (HL) was determined. Additionally, percentile values of NBL for each gestational week were provided. RESULTS: A total of 1467 fetuses were included in this study. There was a significant linear association among NBL and GA (R(2) = 0.709), BPD (R(2) = 0.752), FL (R(2) = 0.742) and HL (R(2) = 0.747). Fifth percentile values of fetal NBL were 3.11 mm for 16th, 3.50 mm for 17th, 3.70 mm for 18th, 4.10 mm for 19th, 4.50 mm for 20th, 4.62 mm for 21st, 5.24 mm for 22nd and 5.37 mm for 23rd gestational weeks. CONCLUSION: The study provides normal ranges of NBL between 16 and 23 weeks of pregnancy in a low-risk Turkish population. Future studies with larger sample sizes including pregnancies carrying high risk for aneuploidy are needed to define cut-off values for NBL.

The outcomes of intestinal resection during debulking surgery for ovarian cancer.

OBJECTIVE: To evaluate the clinical and surgical outcomes of intestinal resection during primary debulking surgery for ovarian cancer. MATERIAL AND METHODS: This retrospective study was conducted at Zekai Tahir Burak Women's Health Training and Research Hospital between 2009 and 2013. The patients who underwent intestinal resection during debulking surgery for stage 3 ovarian cancer were included in the analysis. Data regarding patient age, body mass index, tumor histology, disease stage, the site of intestinal resection, all postoperative complications, duration of intensive care unit admission and hospital stay were collected and analyzed. RESULTS: A total of 22 patients with a mean age of 53.4 years were included in the study. Optimal cytoreduction was achieved in 14 (63%) patients. Transverse colectomy was the most common type of intestinal resection (63%). The most common postoperative complication was transfusion of blood products (63%). No postoperative mortality was observed. CONCLUSION: Intestinal resection is a crucial part of debulking surgery for advanced ovarian cancer, with acceptable complication rates. Despite the limited number of patients, the results obtained from the present study are comparable with previous reports.

Vaginal Hysterectomy with Anterior Four-Arm Mesh Implant Technique in the Surgical Treatment of a Woman with Total Pelvic Organ Prolapse and Urinary Incontinence: A Case Report and Review of the Literature.

Purpose. We present a case report of a woman with total POP and SUI who was treated with a technique utilizing vaginal hysterectomy followed by the placement of a four-arm synthetic polypropylene mesh implant system. Methods. An 81-year-old grand-multiparous woman presented to our clinic complaining of a vaginally protruding mass and urinary incontinence. A surgical approach including vaginal hysterectomy, anterior four-arm mesh implant, posterior large segment vaginal enterocele repair, and perineoplasty with levator ani fixation was planned. Results. The patient was discharged home at the second postoperative day. Follow-up visits at the first, 3rd, and 6th months were normal. There was complete symptomatic relief and objective cure of the POP and urinary incontinence symptoms. Conclusion. We believe that anterior four-arm mesh implant and large posterior repair should be considered after vaginal hysterectomy. Future studies are needed to evaluate the utility of this technique for treatment of POP.

Is there a role for fetal ductus venosus and hepatic artery Doppler in screening for fetal aneuploidy in the first trimester?

OBJECTIVE: The aim of the present study was to evaluate the utility of ductus venosus (DV) and hepatic artery (HA) doppler in pregnant women who have high risk for aneuploidy in first trimester combined screening. METHODS: This prospective study was performed between February 2011 and February-2012, at a tertiary referral hospital. Singleton pregnancies with high risk for aneuploidy in combined screening test and normal nuchal translucency (NT) measurements were included in the study group. Measurements of DV Pulsatility Index of Veins (PIV) and HA Pulsatility Index (PI) were compared between the study group and controls. RESULTS: Within the study period, 104 women with singleton pregnancies were evaluated for DV and HA measurements and among these, 64 women met the inclusion criteria. A control group that comprised 40 women with similar gestational age, normal NT measurements and low-risk in first trimester combined tests was generated. DV-PIV measurements were significantly higher (p = 0.03), whereas HA-PI measurements were similar (p > 0.05) in women who had high-risk for aneuploidy in first trimester combined test. CONCLUSION: We concluded that the addition of DV-PIV and HA-PI measurements to the first trimester combined screening might increase the accuracy for Down syndrome detection.

Risk factors for human papillomavirus persistence among women undergoing cold-knife conization for treatment of high-grade cervical intraepithelial neoplasia.

OBJECTIVE: To investigate the risk factors potentially associated with high-risk human papillomavirus (HPV) persistence in women undergoing cold-knife conization (CKC) for treatment of high-grade cervical intraepithelial neoplasia (CIN). METHODS: Medical records of women who underwent CKC for treatment of CIN 2/3 between 2007 and 2012 at a tertiary hospital in Ankara, Turkey, were retrospectively analyzed. Cases involving persistent HPV infection after 1 year of follow-up were identified. Using univariate and multivariate analyses, the impact of various factors such as patient age, menopausal status, parity, high-risk HPV type, excised cone dimensions (width, height, and depth), and surgical margin status on high-risk HPV persistence was assessed. RESULTS: A total of 292 women underwent CKC for treatment of CIN 2/3 within the study period. After women with a subsequent diagnosis of cervical cancer, subsequent total hysterectomy, and inadequate follow-up data were eliminated, 113 women were eligible for final analysis. High-risk HPV persistence was detected in 24 (21.2%) women, and multivariate analysis revealed that patient age and cone depth were significant independent predictors (P < 0.05). CONCLUSION: High-risk HPV persistence may be encountered after CKC procedures. It is important to evaluate persistent HPV infections after treatment because affected women are at increased risk for disease persistence, recurrence, and progression.

Clinical outcomes of cases with cervical dysplasia absent in cold knife conization specimens.

BACKGROUND: Cold knife conization is a surgical procedure that allows both diagnosis and treatment of cervical lesions at the same time. It is mainly performed for indications of high-grade cervical intraepithelial neoplasia (CIN). In this study, we aimed to investigate the clinical outcome of cases without CIN in cold knife conization specimen, following a high-grade lesion (CIN2/3) in cervical biopsy. MATERIALS AND METHODS: We performed a retrospective cohort study at a tertiary referral hospital between January 1st 2008 and August 1st 2012. Cases that underwent cold knife conization for CIN2/3 within the study period were included. Cone-negative (Group 1) and cone-positive (Group 2) cases were analyzed for various clinical parameters, and were compared in the 1-year post-conization period for histological recurrence and human papillomavirus (HPV) DNA status. RESULTS: A total of 173 women underwent cold knife conization for CIN2/3 within the study period. Twenty-two cases (12.7%) were included in Group 1 and 151 cases (87.3%) in Group 2. There were no significant differences between the two groups in terms of age, gravidity, parity, menopausal status and HPV-DNA status (pre-conization and 1 year post-conization) (p>0.05). Recurrence rates were also similar between the groups (9.1% vs 9.9%, p>0.05). CONCLUSIONS: Clinical outcomes were similar in terms of histological recurrence and HPV persistence after 1 year of follow-up between cone-negative and cone-positive cases. Clinical follow-up of cone-negative cases should therefore be performed similar to cone-positive cases.

The impact of inherited thrombophilia on first trimester combined aneuploidy screening test parameters.

OBJECTIVE: To determine whether inherited thrombophilia affects components of first trimester combined aneuploidy screening test. METHOD: A case-control study was performed between January 1st and December 31st 2011, at a tertiary referral hospital. Singleton pregnancies with inherited thrombophilia that underwent first trimester (11-13(+6) week) combined aneuploidy screening test were included in the study. Pregnancy associated plasma protein-A (PAPP-A), free beta-human chorionic gonadotropin (fbHCG) and fetal nuchal translucency (NT) were compared between the study group and controls. RESULTS: Within the study period, 15,881 women with singleton pregnancies had a combined first trimester aneuploidy screening test at our institution. Among these, 207 women met the inclusion criteria. A control group that comprised 625 women with similar gestational age was generated, using a 1:3 ratio. PAPP-A levels were significantly higher, whereas fbHCG levels and fetal NT measurements were lower in women with inherited thrombophilia (p < 0.001). CONCLUSION: Our study suggested that PAPP-A, free b-HCG and NT MoM levels display alterations in women with inherited thrombophilia. Future trials are needed to assess the need for readjustment of risk in these patients.

The effect of Silymarin on VEGF, VEGFR-1 and IL-1α levels in placental cultures of severe preeclamptic women.

OBJECTIVE: The purpose of this study was to evaluate the effects of Silymarin on vascular endothelial growth factor (VEGF), soluble VEGF Receptor-1 (sVEGFR-1) and Interleukin-1 alpha (IL-1α) levels in placental tissue samples of severely preeclamptic women. MATERIAL AND METHODS: We conducted an in vitro study in Baskent University Faculty of Medicine, Ankara, Turkey between September 2008 and May 2009. A total of 16 placental tissue samples (8 from severe preeclamptic, and 8 from controls) were analysed. Placental samples were incubated, and VEGF, sVEGFR-1, and IL1-α were measured in culture media using an ELISA kit. The effect of Silymarin on these levels was investigated. Descriptive statistics were initially performed, followed by Mann Whitney U-test and Kruskal-Wallis test to compare means between groups. P values less than 0.05 were considered statistically significant. RESULTS: Eight patients were included in the severe preeclampsia (SP) group, whereas the remaining 8 patients were included in the control group. There were no significant correlations between gestational age and placental VEGF, sVEGFR-1 and IL-1α after 48 or 72 hours of incubation. Basal VEGF levels were lower in the SP group; however, it did not reach statistical significance. sVEGFR-1 and IL-1α levels were also similar between the SP and control groups (p>0.05). After 48 and 72 hours of incubation, sVEGFR-1 levels in Silymarin-added SP and control placental cultures were lower than in the samples without Silymarin addition; however, this difference also did not reach significance. CONCLUSION: Although we could not demonstrate a significant effect on placental cytokines, considering the role of vasospasm, inflammation, angiogenesis, endothelial cell activation, and oxidative stress in preeclampsia, the potential benefits of Silymarin should be evaluated in future trials with a larger sample size.