The effect of pneumoperitoneum and Trendelenburg position on optic nerve sheath diameter in patients undergoing laparoscopic hysterectomy.

BACKGROUND AND AIM: Laparoscopic hysterectomy (LH) have been frequently used because of low complication rates and short duration of hospital stay. Elevated intracranial pressure (ICP), a disadvantage of laparoscopic surgery, is caused by the Trendelenburg position (TP) and CO2 pneumoperitoneum (PP). This study aimed to evaluate TP and PP associated changes in ICP by ONSD measurements during LH. The intra-and inter-observer consistency and reliability of ONSD measurements were also investigated. METHODS: Sixty patients with were enrolled into this prospective study. ONSD for each patient was measured by three anesthesiologists at T0, T1, T2, and T3 time points. ONSD, mean arterial pressure (MAP), end tidal CO2 (EtCO2 ), and arterial blood CO2 partial pressure values (PaCO2 ) were measured at T0: baseline, T1: 10 min after introducing 20 mmHg PP, T2: 10 min after placing the patient in TP and 15 mmHg PP and, T3: 10 min after PP deflation. RESULTS: The ONSD measured at T1 (5.97 ± 0.49 cm) and T2 (5.95 ± 0.57 cm) were higher than T0 (5.63 ± 0.53 cm) and T3 (5.72 ± 0.47 cm) (p < 0.05). There were no correlations between MAP and ONSD, and also between PaCO2 , EtCO2 , and ONSD measurements at any time points. Inter-observer intraclass correlation coefficient (ICC) values of ONSD measurements by all examiners had moderate (at T1) to good (at T0, T2, T3) reliability. Intra-observer agreements were reasonable for each observer. CONCLUSION: ONSD measurements increase with CO2 PP and TP in patients undergoing LH. Transorbital sonography is a reliable method to monitor intraoperative changes in ONSDs. This study underlines the need for careful training and the importance of standardization in order to obtain reliable results in the examination technique of ONSD measurements.

What is the impact of corpus uterine invasion on oncologic outcomes in surgically treated cervical cancer?

AIM: To investigate the clinical significance of uterine corpus involvement in patients with surgically treated cervical cancer. METHODS: Patients (n = 354) with clinical early-stage (stage IB1-IIA2) cervical cancer who underwent radical hysterectomy and pelvic ± paraaortic lymphadenectomy were evaluated. RESULTS: Uterine invasion was detected in 60 (16.9%) patients. Patients with uterine invasion had a higher rate of pelvic lymph node metastasis than those without uterine invasion (35% vs 22.8%, p = 0.046). In multivariate analysis, no statistically significant difference was identified between patients with and without uterine invasion for pelvic lymph node metastasis (p = 0.953). Uterine invasion was identified as an independent risk factor for paraaortic lymph node metastasis in multivariate analysis (p = 0.012). The presence of pelvic lymph node metastasis was found to be another significant predictor of paraaortic lymph node involvement (p = 0.022). In addition, uterine invasion and lymph node metastasis were identified as an independent risk factors regarding poor prognosis in cancer-specific survival (hazard ratio [HR]: 4.537; 95% confidence interval [CI], 1.304-15.782; p = 0.017 and HR: 5.598; 95% CI, 1.581-19.823; p = 0.008, respectively). CONCLUSIONS: Uterine invasion is an independent predictor of decreased survival and the presence of paraaortic lymph node metastasis in cervical cancer. The presence of the uterine invasion in cervical cancer should be considered as a poor prognostic factor in the decision of treatment.

The evaluation of laparotomy results in breast cancer patients with gynecological pathologies.

AIM: The aim of the study was to evaluate the results of the laparotomies due to gynecological pathologies in breast cancer patients and to assess the distribution of gynecological pathologies and the clinical and laboratory findings contributing to the diagnosis. METHODS: This study was conducted between years 2002 and 2011 at Hacettepe University Hospital. We obtained information about 86 consecutive breast cancer patients, including age, time of diagnosis and pathology of breast cancer, hormone receptor status, history of endocrine therapy, presenting symptoms, ultrasonography findings, CA 125 levels, endometrial biopsy results, type of gynecological surgery and pathology results. Data were analyzed with the use of SPSS software. RESULTS: Twenty-one (24.4%) out of 86 patients had endometrial pathology, and 24 (27.9%) had adnexal pathology. Fourteen patients (16.2%) had malignant pathology, and of them, 11 had ovarian cancer 3 had endometrial cancer. There were five abnormal cytological findings: 2 ASCUS, 1 LSIL, 1 ASC-H and 1 adenocarcinoma. The patient with the cytology report of adenocarcinoma had the final diagnosis of endometrial cancer. Of the patients, 67 (77.9%) used tamoxifen, whereas 19 (22.1%) did not. Thirty-three patients (38.4%) with gynecological pathologies were detected incidentally during routine follow-up of breast cancer. CONCLUSION: This study supports the increase of the gynecological pathology incidence in breast cancer patients and the recommendation of close gynecological follow-up in these patients. Asymptomatic patients might also develop genital cancer. The ultrasonographic appearance of the adnexal masses or endometrial thickness and any abnormal vaginal bleeding or high CA 125 levels are important parameters for evaluating breast cancer patients.

Pulmonary recurrence after radical hysterectomy for uterine cervical carcinoma.

Pulmonary spread from carcinoma of the uterine cervix, though uncommon, has been reported in 2.2-9.1% of all cervical cancers. The aim of this study was to evaluate the surgical, clinical, pathological factors and clinical outcomes of cervical cancer patients with pulmonary recurrence (PR).This study included 17 cervical cancer patients with PR after radical hysterectomy. The entire cohort consisted of 413 patients whose surgeries (type III radical hysterectomy + pelvic ± para-aortic lymphadenectomy) had been performed in our Gynaecologic Oncology Clinic between 1993 and 2018. Tumour size, lymph node metastasis and receiving adjuvant therapy were found to be effective for PR on univariate analyses in the main cohort (p = .042, p < .001 and p = .001, respectively). Therefore, performing adjuvant therapy to reduce the PR must be assessed properly with the information of lymph node status and tumour size obtained from the final pathology reports.Impact StatementWhat is already known on this subject? Pulmonary spread from carcinoma of the uterine cervix has been reported in 2.2-9.1% of all cervical cancers. Data related to clinico-pathological features of patients with pulmonary recurrence (PR) is limited. Diagnosis of a PR is considered to worsen the prognosis.What do the results of this study add? Tumour size, lymph node metastasis and receiving adjuvant therapy were found to be effective for PR on univariate analyses.What are the implications of these findings for clinical practice and/or further research? Performing adjuvant therapy to reduce the PR must be assessed properly with the information of lymph node status and tumour size obtained from the final pathology reports in patients with uterine cervical carcinoma.

Vaginal Closure with EndoGIA to Prevent Tumor Spillage in Laparoscopic Radical Hysterectomy for Cervical Cancer.

STUDY OBJECTIVE: To demonstrate a method of vaginal closure with the EndoGIA surgical stapler (Medtronic, Istanbul, Turkey) to prevent tumor spillage in laparoscopic radical hysterectomy. DESIGN: A step-by-step explanation of the procedure using a video. SETTING: Women's health teaching and research hospital. PATIENT: A 40-year-old woman with clinical stage IBI cervical squamous cell carcinoma. INTERVENTIONS: Laparoscopic type C radical hysterectomy with pelvic lymph node dissection and ovarian transposition. Institutional ethical committee approval was not sought. However, the patient signed an informed consent that allows us to use her clinical data. MEASUREMENTS AND MAIN RESULTS: Minimally invasive surgery is increasingly being used in cervical cancer surgery. However, there is a current and significant debate regarding the safety of these methods. Colpotomy, which is the last step of laparoscopic radical hysterectomy, could be related to an increased risk for tumor spillage. Vaginal closure before colpotomy may be an option to prevent this spillage. In this method, after completion of the radical hysterectomy steps, the initial 5-mm left lower quadrant trocar was changed to a 15-mm trocar to allow for the placement of an EndoGIA with a green cartridge. The uterine manipulator was removed, and the uterus was elevated with a myoma screw. Then, the stapler was placed, and we checked that no other unintended structure was included in the jaws of the stapler before the firing. The EndoGIA surgical stapler was fired 2times to close the vagina. The stapler places 2 triple-staggered rows of titanium staples and knife blade cuts simultaneously between them. Once the vagina was divided, the stapler was released. The upper part of the vaginal cuff was excised and sent to pathology as a surgical margin, and the uterus was removed through the vagina. Finally, the vaginal cuff was closed with intracorporeal suturing. CONCLUSION: Vaginal closure with the EndoGIA surgical stapler before colpotomy provides a safe and easy method to prevent tumor spillage and could improve the unfavorable results related to minimally invasive surgery in patients with cervical cancer.

Sertoli-Leydig cell tumor of the ovary: Analysis of a single institution database and review of the literature.

AIM: To evaluate the clinical characteristics and outcome of ovarian Sertoli-Leydig cell tumors (SLCTs) managed at a single institution. METHODS: The hospital records of 17 patients with the diagnosis of ovarian SLCT between 1994 and 2018 were reviewed retrospectively. RESULTS: The median age of the patients was 30 years (range, 18-67 years). All the patients had unilateral tumors. All of the 17 were stage 1 tumors. Two (11.8%) patients were stage 1C1 and two (11.8%) patients were stage 1C2. Thirteen (76.5%) patients were stage 1A. Three (17.6%) of the tumors were well differentiated, 11 (64.7%) were intermediately differentiated, 1 (5.9%) was poorly differentiated, and the degree of the differentiation was not identified for 2 (11.8%) patients. One showed retiform pattern and one had heterologous elements at the histopathologic evaluation. Among the 17 patients, we identified structural/vascular renal and ureteral anomalies in 3 (17.6%) patients. Eight patients underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy, seven underwent unilateral salpingo-oophorectomy or oophorectomy and two underwent cystectomy with or without additional surgical staging procedures. Four patients received adjuvant chemotherapy. All the 17 patients were alive and free of disease for 1-287 months after the diagnosis. Median follow-up time was 78 months. None of the patients recurred. CONCLUSION: Sertoli-Leydig cell tumors are rare ovarian malignancies with low recurrence rates and have a favorable outcome compared to malignant epithelial tumors of the ovary. Main treatment is surgical resection and it is appropriate to prefer fertility sparing conservative surgeries for young patients.

Prognostic factors and oncological outcomes of ovarian yolk sac tumors: a retrospective multicentric analysis of 99 cases.

PURPOSE: To investigate the clinico-pathological prognostic factors and treatment outcomes in patients with ovarian yolk sac tumors (YST). METHODS: A multicenter, retrospective department database review was performed to identify patients with ovarian YST who underwent surgery between 2000 and 2017 at seven Gynecologic Oncology Centers in Turkey. RESULTS: The study group consisted of 99 consecutive patients with a mean age of 23.9 years. While 52 patients had early stage (stage I-II) disease, the remaining 47 patients had advanced stage (stage III-IV) disease. The uterus was preserved in 74 (74.8%) of the cases. The absence of gross residual disease following surgery was achieved in 76.8% of the cases. Of the 54 patients with lymph node dissection (LND), lymph node metastasis was detected in 10 (18.5%) patients. Of the 99 patients, only 3 patients did not receive adjuvant therapy, and most of the patients (91.9%) received BEP (bleomycin, etoposide, cisplatin) chemotherapy. Disease recurred in 21 (21.2%) patients. The 5-year disease-free survival (DFS) and overall survival (OS) in the entire cohort were 79.2% and 81.3%, respectively. In multivariate analysis, only residual disease following initial surgery was found to be significantly associated with DFS and OS in patients with ovarian YST (p = 0.026 and p = 0.001, respectively). CONCLUSIONS: Our results demonstrate the significance of achieving no visible residual disease in patients with ovarian YST. Fertility-sparing approach for patients with no visible residual disease affected neither DFS nor OS. Although high lymphatic involvement rate was detected, the benefit of LND could not be demonstrated.

Does tumor size have prognostic value in patients undergoing lymphadenectomy in endometrioid-type endometrial cancer confined to the uterine corpus?

Background/aim: We aimed to define the effect of tumor size on recurrence and survival rates in patients with stage I­II endometrioid-type endometrial cancer. Materials and methods: A total of 550 patients who had total abdominal hysterectomy, bilateral salpingo-oophorectomy, and pelvic-paraaortic lymphadenectomy were included. Patients with extrauterine spread, sarcomatous components, or synchronized tumor and those who did not undergo lymphadenectomy or did not have data on tumor size were excluded. Results: The median tumor size was 35 mm (range: 3­335 mm). According to the 2009 International Federation of Obstetrics and Gynecology (FIGO) criteria, 245 cases were defined as stage IA, 271 as stage IB, and 34 as stage II. The 5-year disease-free survival (DFS) rate was 92% and the 5-year disease-specific survival (DSS) rate was 99%. The effects of prognostic factors on DFS were evaluated. Older age, stage II disease, deep myometrial invasion, and receiving adjuvant radiotherapy were associated with decreased DFS. There was no statistically significant association between tumor size and DFS. The 5-year DFS for patients with a tumor diameter of <35 mm, which was the median tumor size of the entire group, was 94%, while it was 89% for patients having a tumor diameter of >35 mm (P = 0.128). Conclusion: Tumor size was not a risk factor predicting recurrence in patients with stage I or II endometrioid-type endometrial cancer who had lymphadenectomy.

Comparison of Mayo and Milwaukee Risk Stratification Models for Predicting Lymph Node Metastasis in Endometrial Cancer.

OBJECTIVE: The aim of this study was to compare Mayo and Milwaukee risk stratification models for predicting lymphatic dissemination in patients with endometrial cancer (EC). METHODS: A total of 904 patients with EC underwent surgical treatment between 2004 and 2016 at Hacettepe University Hospital, and clinicopathological data of patients were retrieved from the computerized database of the Hacettepe University. Patients who did not undergo lymphadenectomy and who had nonendometrioid histology, stage-IV disease, and synchronous epithelial ovarian and EC were excluded. All slides of the cases were reviewed by the same gynecologic pathology subspecialist. RESULTS: The study group consisted of 307 consecutive patients with a mean age of 59.4 years (range, 26-86 years). Lymph node metastasis was detected in 28 subjects (9.1%). Primary tumor diameter, depth of myometrial invasion, lymphovascular space invasion, and cervical stromal and glandular involvement were associated with lymph node metastasis. Patients with low-risk histological features based on Mayo risk stratification system in our study group had a 0% rate of lymph node positivity. However, of the 28 patients with lymph node metastasis, 3 (10.7%) had low-risk features based on Milwaukee model. The sensitivity, specificity, false negative rate (FNR) and false positive rate of Mayo and Milwaukee risk stratification models for predicting lymphatic dissemination among women with endometrioid EC were 100%, 27.3%, 0%, and 72.7%; and 89.3%, 61.3%, 10.7%, and 38.7%, respectively. CONCLUSIONS: Although Milwaukee risk stratification model had a lower false positive rate and can decrease the number of lymphadenectomies, FNR of this new model was found as 10.7% in the present study. Furthermore, we found that Mayo model had a lower FNR and higher sensitivity. Therefore, Mayo model still looks more beneficial to predict lymph node metastasis in patients with endometrioid EC and Milwaukee risk stratification model still requires external validation.

The Clinicopathological Study of 21 Cases With Uterine Smooth Muscle Tumors of Uncertain Malignant Potential: Centralized Review Can Purify the Diagnosis.

OBJECTIVE: The objective of this study was to investigate the clinicopathological features and factors associated with recurrence in patients with uterine smooth muscle tumor of uncertain malignant potential (STUMP). METHODS: Forty-six cases diagnosed between 2000 and 2014 from 2 tertiary centers underwent blind slide review. Initial diagnosis included smooth muscle tumors with equivocal diagnosis, STUMPs, and cases that were named as leiomyosarcomas (LMS) or low-grade LMS despite not fulfilling the Stanford criteria. RESULTS: In total, 21 patients with a final diagnosis of STUMP were available. Fifteen (68.1%) of 22 patients with an initial diagnosis of STUMP, 4 (22.2%) of 18 cases with an equivocal smooth muscle tumor diagnosis, and 2 (33.3%) of 6 cases with an initial diagnosis of LMS were interpreted as STUMP after slide review. The mean age at diagnosis was 43 years (range, 20-64 years). The mean follow-up time was 65.9 months (range, 10-154 months). Four patients (19.0%) developed recurrent disease. Recurrent tumors were LMS in 3 patients (75%). One patient (4.8%) with recurrence succumbed to disease. There was no difference in patients' age (P = 1.0) or type of initial surgery (uterus conserving versus hysterectomy) (P = 0.57) between patients who recurred and did not recur. CONCLUSIONS: Uterine STUMPs can harbor significant uncertainty regarding the original diagnosis and clinical outcomes. Recurred cases may have an aggressive clinical course associated with multiple relapses and death. Uterine mesenchymal tumors other than ordinary myomas and overt sarcomas deserve a second opinion in centers with experience because the real diagnosis may vary significantly.

Oncological Outcomes of Stage II Endometrial Cancer: A Retrospective Analysis of 250 Cases.

OBJECTIVE: The aim of this study was to investigate the effect of different surgical approaches, adjuvant therapy, and pathological characteristics on oncological outcomes in patients with 2009 International Federation of Gynecology and Obstetrics (FIGO) stage II endometrial cancer (EC). METHODS: A multicenter, retrospective department database review was performed to identify patients with FIGO 2009 stage II EC who underwent surgical staging between 2002 and 2015 at 5 gynecologic oncology centers in Turkey. RESULTS: Original pathology reports of 4867 patients who underwent surgical treatment for EC were analyzed. The study group consisted of 250 FIGO stage II patients. Of these patients, 203 (81.2%) had endometrioid and 47 (18.8%) had nonendometrioid histologic subtype of EC. Whereas 199 patients (79.6%) underwent type I hysterectomy, the remaining 51 patients (20.4%) underwent radical hysterectomy. Of the 250 patients, 208 patients (83.2%) had adjuvant therapy including radiotherapy (pelvic external beam radiotherapy and/or vaginal brachytherapy [VBT]) and/or platinum-based chemotherapy. Disease recurred in 29 patients (11.6%). The 5-year disease-free survival (DFS) and overall survival (OS) for the entire cohort were 82% and 85%, respectively. Multivariate analysis showed that only adjuvant treatment (P = 0.001; hazard ratio, 4.02; 95% confidence interval, 1.72-9.36) was significantly associated with DFS. According to multivariate analysis, only age older than 60 years (P = 0.01; hazard ratio, 3.03; 95% confidence interval, 1.3-7.04) was identified as an independent risk factor for OS. However, there were no differences in OS when evaluated by grade, histology, tumor size, type of hysterectomy, or adjuvant treatment. CONCLUSIONS: In stage II EC, adjuvant external beam radiotherapy ± VBT were associated with increased DFS but not OS. However, the benefit of VBT alone on DFS could not be demonstrated. Only age was an independent risk factor for OS. Type of hysterectomy and histologic subtype of the tumor for patients with uterus-confined disease improved neither DFS nor OS in our study group.

The preoperative serum CA125 can predict the lymph node metastasis in endometrioid-type endometrial cancer.

OBJECTIVES: To evaluate the predictive value of preoperative CA125 in extra-uterine disease and its association with poor prognostic factors in endometrioid-type endometrial cancer (EC). MATERIAL AND METHODS: A total of 423 patients with pathologically proven endometrioid-type EC were included in the study. The association between preoperative CA125 level and surgical-pathological factors was evaluated. The conventional cut-off value was defined as 35 IU/mL. RESULTS: A high CA125 level ( > 35 IU/mL) was significantly associated with all of the studied poor prognostic factors, except grade. The risk of lymph node metastasis (LNM) increased from 15.9% to 45.7% when CA125 level was > 35 IU/mL (p < 0.05). The optimal cut-off value for the prediction of LNM in patients aged > 50 years was determined to be 16 IU/mL (sensitivity, specificity, positive predictive value, and negative predictive value were 71%, 60%, 35%, and 87%, respectively.) Conclusions: Preoperative CA125 level was significantly related with the extent of the disease and LNM. The age-dependent cut-off level of CA125 can improve the prediction of LNM in endometrioid-type EC. For older patients, CA125 level of > 16 IU/ml could be used to predict LNM. However, further studies are needed to evaluate the appropriate cut-off level of CA125 for younger patients.

Incidence of Lymph Node Metastasis in Surgically Staged FIGO IA G1/G2 Endometrial Cancer With a Tumor Size of More Than 2 cm.

OBJECTIVE: The study aims to investigate effect of tumor size on lymphatic spread in patients with low-risk endometrial cancer (EC). METHODS: This study included patients with EC who underwent staging surgery with systematic lymphadenectomy between 2002 and 2015 at the Hacettepe University Hospital. Patients with grade 1 or 2 endometrioid type tumor who had 50% or lower myometrial invasion were included. Patients who had no myometrial invasion or had uterine high-risk features (nonendometrioid histology, grade 3, and deep myometrial invasion) were excluded. RESULTS: The study group consisted of 191 patients, and the mean age of the patients was 57.8 years. Of these patients, 124 (64.9%) had tumor size of more than 2 cm and 67 (35.1%) had tumor size of 2 cm or less. Lymph node metastasis was detected in 12 (9.7%) of the 124 patients with tumor size of more than 2 cm. On the other hand, none of the 67 patients (0%) with tumor size of 2 cm or less was found to have lymphatic involvement. Of the factors analyzed for correlation with lymph node metastasis in patients with low-risk EC, the presence of lymphovascular space invasion (LVSI) and primary tumor size were found to be significant predictors of lymphatic spread in univariate analysis (P < 0.001 and P = 0.009, respectively). In multivariate analysis, tumor size (odds ratio, 6.86; 95% confidence interval, 1.007-infinite; P < 0.05) and LVSI (odds ratio, 14.261; 95% confidence interval, 3.4-59.6; P < 0.001) were 2 independent predictors associated with lymphatic involvement. CONCLUSIONS: Our trial supports that tumor size of more than 2 cm and LVSI are 2 independent factors for lymph node metastasis in patients with low-risk EC. Both factors can be used together to select patients with traditional low-risk histologic features who would absolutely benefit from lymph node dissection.

Extrauterine Spread, Adjuvant Treatment, and Prognosis in Noninvasive Uterine Papillary Serous Carcinoma of the Endometrium: A Retrospective Multicenter Study.

OBJECTIVES: The aim of this retrospective multicenter study was to investigate the frequency of extrauterine metastasis and to evaluate the importance of surgical staging and adjuvant treatment among patients with noninvasive uterine papillary serous carcinoma (UPSC) of the endometrium. MATERIALS AND METHODS: A multicenter, retrospective department database review was performed to identify patients with UPSC of the endometrium who underwent surgical staging between 2000 and 2015 at 4 Gynecologic Oncology Centers in Turkey. Demographic, clinicopathological, and survival data were collected. RESULTS: A total of 182 patients with primary UPSC of the endometrium were identified. Of these, 33 (18.1%) had tumors limited to the endometrium with no myometrial invasion. Twenty (60.6%) of these 33 patients had no extrauterine involvement and International Federation of Gynecology and Obstetrics 2009 stage 1A disease was diagnosed after complete staging. The remaining 13 (39.4%) patients had disease beyond the uterine corpus including 5 with omental, 3 with adnexal, 1 with cervical stromal involvement, 1 with disease in the pelvic lymph nodes, and 1 with isolated para-aortic lymph node metastasis. Two patients had metastases in more than one location including omentum/adnexa/pelvic-para-aortic lymph nodes and omentum/pelvic-para-aortic lymph nodes, respectively. Of the 20 patients with disease confined to the endometrium, 6 (30%) patients received adjuvant treatment. CONCLUSIONS: Noninvasive UPSC has a high tendency for extrauterine spread and omentum is the most commonly involved location. Therefore, comprehensive surgical staging including omentectomy and pelvic-para-aortic lymph node dissection is mandatory in this group of patients. Risk of extrauterine spread is significantly associated with the presence of lymphovascular space invasion, elevated preoperative CA 125 levels, and positive peritoneal cytology. Adjuvant therapy for women with endometrium-confined disease improves neither progression-free survival nor overall survival.

What is the impact of stromal microinvasion on oncologic outcomes in borderline ovarian tumors? A multicenter case-control study.

PURPOSE: To investigate clinicopathological characteristics and oncological outcome of women with microinvasive BOTs. METHODS: A retrospective multicenter case-control study was conducted on 902 patients with BOT, who underwent surgery from January 2002 to December 2015 at six participating gynecologic oncology centers from Turkey. Among 902 patients, 69 had microinvasive BOT. For every patient with microinvasive BOT, two controls were randomly selected from another database based on decade of age and stage of disease at diagnosis. The clinical-pathological characteristics and oncological outcomes were compared between BOT patients with and without stromal microinvasion. Risk factors for poor oncological outcomes were investigated in a multivariate analysis model. Overall survival (OS) and disease-free survival (DFS) were estimated using the Kaplan-Meier method. RESULTS: Patients with microinvasive BOT had a significantly higher rate of recurrence than patients without microinvasive BOT (17.4 vs 7.8%, OR 3.55, %95 CI 1.091-11.59, p = 0.03). Stage at diagnosis (stage I versus II/III) and type of surgery (cystectomy versus others) were found as other significant prognostic factors for recurrence in multivariate analysis (OR 8.63, %95 CI 2.48-29.9, p = 0.001 and OR 19.4, %95 CI 3.59-105.6, p = 0.001, respectively). Stromal microinvasion was found as a prognostic factor for significantly shorter DFS (26.7 vs 11.9 months, p = 0.031, log rank). However, there was no significant difference in OS between two groups (p = 0.99, log rank). CONCLUSION: Stromal microinvasion is significantly associated with decreased DFS. In addition, our study confirms that the risk of recurrence is higher in patients with microinvasive BOT.

Radical Hysterectomy and Total Abdominal Vaginectomy for Primary Vaginal Cancer.

The aim of this surgical video is to demonstrate en bloc radical removal of uterus and vagina in a patient with clinical early-stage vaginal cancer. Surgical treatment was offered to our patient for clinical early-stage primary vaginal cancer. An en bloc radical hysterectomy, systematic pelvic lymphadenectomy, and total abdominal vaginectomy were performed. Postoperative adjuvant radiation or chemotherapy was not recommended for completely resected pathologic stage I disease with no lymph node involvement and negative surgical margins. Radical surgery can be a treatment option for selected patients with primary vaginal cancer.

Evaluation of the relation between preapoptotic sperm rate in ejaculate and intrauterine insemination success rate in patients with unexplained infertility.

The parameters measured in the standard semen analysis may be insufficient for exact differentiation between fertile and infertile men. Therefore, we assume that the high rate of apoptotic sperm in ejaculate may play a role on the aetiology of unexplained infertility. Couples with unexplained infertility treated by ovulation induction and intrauterine insemination were consecutively enrolled (n = 94). To determine the proapoptotic sperm rate, the ejaculate from patients was stained with annexin V. Thirteen of the 94 couples (13.8%) conceived after intrauterine insemination. The annexin V-positive sperm rate was found to be 20.0% in the whole group. In women failing to conceive, the annexin V-positive sperm rate was 20.8% compared to 15.7% in patients who achieved pregnancy. Although there is a trend towards higher preapoptotic sperm rate in couples failing to get pregnant with insemination, the difference did not reach statistical significance.

Clinical and pathological characteristics related to parametrial involvement in clinical early-stage cervical cancer.

OBJECTIVES: Since parametrial involvement is believed to be a crucial factor in the management of cervical cancer, our study was designed to investigate the clinical and pathological features which predicted parametrial involvement in patients with clinical early-stage cervical cancer. MATERIAL AND METHODS: The study included patients with clinical early-stage cervical cancer who underwent radical hys-terectomy with pelvic and para-aortic lymphadenectomy between December 2001 and August 2014, at the Hacettepe University Hospital. The clinical and pathological characteristics of the affected patients were evaluated, including age, histologic subtype, tumor size, depth of cervical stromal invasion, lympho-vascular space invasion (LVSI), and lymph node metastasis. Univariate and multivariate analyses were performed to reveal factors associated with parametrial involvement. RESULTS: The study group consisted of 126 patients (mean age: 52.7 years; range: 29-83), including 101 (80.2%) with squamous, 19 (15.1%) with adenocarcinoma, and 6 (4.8%) with adenosquamous histological subtype of cervical cancer. Parametrial involvement and lymph node metastasis were detected in 41 (32.5%) and 46 (36.5%) women, respectively. Univariate analysis showed that deep cervical stromal invasion, LVSI, tumor size > 2 cm and lymph node metastasis were associated with parametrial involvement. Multivariate logistic regression analysis identified the independent risk factors associated with parametrial involvement as LVSI (OR 8.93, 95% CI 1.1-73.5, p = 0.042) and lymph node metastasis (OR 8.8, 95% CI 1.5-9.3, p = 0.004). CONCLUSIONS: LVSI, deep cervical stromal invasion, lymph node metastasis and tumor size are significantly associated with parametrial involvement in patients with clinical early-stage cervical cancer.

Intraoperative Ex Vivo High-Resolution Sonography: A Novel Technique for the Assessment of Myometrial Invasion in Endometrial Cancer.

OBJECTIVE: This study aims to assess the diagnostic performance of a novel intraoperative ex vivo ultrasonography technique in determining deep myometrial invasion (MI) in patients with apparently low-risk endometrial cancer (EC). METHODS: This prospective study included patients with type I EC who underwent staging laparotomy at Hacettepe University Hospital from December 2011 to September 2014. After hysterectomy, a radiologist with special training in gynecology examined the uterus ex vivo using a 12-MHz superficial linear probe. The specimen was sent for intraoperative frozen section (FS) analysis. The results were compared with permanent section reports. RESULTS: In total, 45 female patients were eligible for analysis. Intraoperative ex vivo high-resolution sonography (IEVHS) correctly assessed depth of MI in 39 of 45 cases (86.6%) and overestimated it in 5 cases (11.1%). Only 1 case with deep infiltration was underestimated by IEVHS as invasion of less than one half of the myometrium. Frozen section correctly identified depth of MI in 41 of 46 cases (91.1%), overestimated it in 1 case (2.2%), and underestimated it in 3 cases (6.6%). The sensitivity, specificity, positive predictive value, and negative predictive value of IEVHS and FS for assessment of deep MI were 87.5%, 86.4%, 58.3%, and 96.9%, and 62.5%, 97.3%, 83.3%, and 92.3%, respectively. CONCLUSIONS: Intraoperative ex vivo high-resolution sonography is a novel technique for assessing MI in EC. Its high sensitivity for deep MI could be useful as an adjunct to FS (enabling pathologists to obtain targeted FS slices) and could improve the accuracy of FS.

Non-immune hydrops fetalis as a diagnostic and survival problems: what do we tell the parents?

OBJECTIVE: Nonimmune hydrops fetalis (NIHF) is one of the most difficult problems related to pregnancy. The aim of this study was to evaluate the etiological analysis as well as the fetal and neonatal outcomes of NIHF. METHODS: We reviewed the prenatal sonographic data and postnatal medical records of pregnant women diagnosed as NIHF in our hospital between January 2001 and May 2013. All cases were categorized using 12 etiological classification groups. Demographic data, diagnostic laboratory parameters, karyotyping results, sonographic and autopsy findings, postnatal final diagnoses, and perinatal mortality rates were also recorded. RESULTS: This study included 147 cases. The mean gestational age at the time of the initial diagnosis was 23.84±6.30 weeks. Cardiovascular causes were the most common (21.7%), followed by structural abnormalities (17.0%), chromosomal abnormalities (6.8%), and skeletal dysplasias (5.4%). Chromosomal abnormalities were detected in 12.8% of these cases. The most common karyotype abnormality was monosomy X. Postmortem autopsy was performed in 50 (34%) cases, and at least one finding was detected in 40 (80%) of these cases. The overall mortality rate was 78.2%. The gestational week at delivery, birth weight, and Apgar score (1st and 5th min) showed a statistically significant difference between exitus and surviving fetuses (P<0.05). CONCLUSION: NIHF can lead to high perinatal morbidity and mortality, yet its etiopathology remains poorly understood. Early diagnosis of NIHF gives parents an opportunity to make an informed choice about the possible complications of a pregnancy.