Eduard Kucera

A prospective randomized comparison of vaginal hysterectomy, laparoscopically assisted vaginal hysterectomy, and total laparoscopic hysterectomy in women with benign uterine disease

OBJECTIVES To compare the clinical results of three minimally invasive hysterectomy techniques: vaginal hysterectomy (VH), laparoscopically assisted vaginal hysterectomy (LAVH), and total laparoscopic hysterectomy (TLH). STUDY DESIGN A prospective, randomized study was performed at a tertiary care center between March 2004 and October 2005. A total of 125 women indicated to undergo hysterectomy for benign uterine disease were randomly assigned to three different groups (40 VH, 44 LAVH, and 41 TLH). Outcome measures, including operating time, blood loss, rate of complications, inflammatory response, febrile morbidity, consumption of analgesics, and length of hospital stay, were assessed and compared between groups. RESULTS Vaginal hysterectomy had the shortest operating time (66 min) and smallest drop in hemoglobin. However, there were technical problems with salpingo-oophorectomy from the vaginal approach (3/20 cases) and this group had a significantly higher rate of febrile complications (20%) compared to LAVH (2.3%) and TLH (7.3%). The increase in inflammatory markers was higher in vaginal hysterectomy patients. Laparoscopically assisted vaginal hysterectomy had an acceptable operating time (85 min), a low complication rate, lack of severe post-operative complications, and the lowest consumption of analgesics. However, it had the highest blood loss. Total laparoscopic hysterectomy had the longest operating time (111 min) and severe complications occurred only in this group. Conversions to another hysterectomy method occurred in all three groups, most of these conversions were to LAVH. CONCLUSIONS Based on our results, in women with non-malignant disease of the uterus, LAVH and VH seem to be the preferred hysterectomy techniques for general gynecological surgeons. Vaginal hysterectomy had the shortest operating time and least drop in hemoglobin, making it a suitable method for women for whom the shortest duration of surgery and anesthesia is optimal. LAVH is a versatile procedure, combining the advantages of both the vaginal and laparoscopic approach, and is preferable in cases when oophorectomy is required. Total laparoscopic hysterectomy did not appear to offer any significant benefits over the other two methods and should be strictly indicated in women where neither VH nor LAVH are feasible and should only be performed by very experienced laparoscopists.

Bilateral avulsion of the puborectal muscle: magnetic resonance imaging‐based three‐dimensional reconstruction and comparison with a model of a healthy nulliparous woman

Obstetric trauma to the puborectal muscle seems to be an important cause of pelvic floor dysfunction in women. Due to the complicated three‐dimensional (3D) arrangement of the pelvic structures, two‐dimensional images are not sufficient to demonstrate its relationships in a complex fashion. Thus, we aimed to create a 3D computer model to visualize the normal female pelvic floor anatomy and to compare this with the anatomy after bilateral avulsion of the puborectal muscle following delivery.

Prenatal diagnosis of annular pancreas: reliability of the double bubble sign with periduodenal hyperechogenic band.

Objective: To evaluate the power of prenatal 2-D ultrasound examination in the 2nd trimester as a method of choice for accurate diagnosis of annular pancreas. Methods: Co-incidence of the double bubble sign (often accompanying gastroduodenal dilatation) together with a hyperechogenic band around the duodenum (corresponding with the tissue of annular pancreas) was used as a diagnostic criterion. Findings from postnatal surgery served for verification. Results: From 7,897 screened pregnancies, annular pancreas was proven in the cases where both signs were present, but never without the hyperechogenic band (N1 = 3, N2 = 3, p ≤ 0.05). Sensitivity and specificity were 100%. Conclusions: More multicentric studies are required to test this approach. The following diagnostic strategy is reasonable at the present time: when the double bubble sign is discovered, always suspect annular pancreas and look for the second sign: hyperechogenic bands around the duodenum. Also look for known associated anomalies, and vice versa, if any of associated anomalies are noted, also search specifically for the signs of annular pancreas.

Conservative management in three cases of prenatally recognized splenic cyst using 2D, 3D, multi-slice and Doppler ultrasonography.

The aetiology, differential diagnosis and management strategies of the foetal spleen affected with a cystic lesion are discussed. In the current literature, there are very few reports that relate to antenatally diagnosed splenic cyst. Our study presents 3 case reports that were first suspected due to anisoechogenic structures detected during routine ultrasonographic examination at the 27th, 31st and 34th weeks of gestation. All 3 cases were further characterized by the lack of pathological power Doppler findings inside and around the lesions, and were morphologically refined by prenatal 3D ultrasound imaging. All findings were reconfirmed postnatally. No complications such as cyst expansion, subcapsular bleeding or acute abdomen have developed, and all 3 cystic lesions have regressed spontaneously after birth.

Expression of selected proteins in breast cancer brain metastases

The aim of the study was to assess the immunohistochemical (IHC) profiles of SRC3, Pax2, ER, PgR, Her2, EGFR, CK5/6, and Ki67 proteins in breast-cancer brain metastasis. The study utilized tumor samples from 30 metastatic patients and calculated correlations between all IHC variables. In fourteen cases, primary breast cancers paired with secondary deposits were analyzed. We evaluated the association between IHC status in the primary and secondary deposits, grade, and histotype of the tumors. The examination of the metastatic deposits in all 30 patients resulted in positive detection in the following cases: SRC3 in 20 cases (66.6%), Pax2 in 22 (73.3%), ER in 22 (73.3%), PgR in 25 (83.3%), Her2 in 10 (33.3%), EGFR in 12 (40%), CK5/6 in 7 (23.3%), and Ki67 in 23 (76.6%). Grade 2 was found in 13.3% of all patients, and grade 3 in 86.7%. SRC3 and Pax2 were positive in both G2 and G3. Invasive lobular carcinoma and invasive ductal carcinoma were diagnosed in 23.3% and 76.7% of cases, respectively. There were no differences between the IHC expression of the studied proteins in either grading or histotype of the tumors. In the IHC profiles, which included SRC3, Pax2, ER, PgR, Her2, CK5/6, Ki67, and EGFR, we found no statistically significant differences between the primary cancer and the brain metastasis. In our study of metastatic breast carcinoma deposits, there was no correlation between SRC3, Pax2 status and histotype, and tumor grade. The IHC status of the paired primary and metastatic deposits did not differ in a statistically significant manner.

Rectal injury following delivery as a possible consequence of endometriosis of the rectovaginal septum.

1.7% of women in group 1 and 2.8% of women in group 2 (P=0.340). Blood transfusion and additional surgical procedures were required for 1woman in group 1, and 2women in group 2 (P=0.563). Hysterectomy and ligation of vesselswere not performed. Therewas a significant reduction in hematocrit and hemoglobin levels after labor in both groups (P b 0.0001). Hematocrit levels in group 1 were significantly lower after labor than those in group 2 (P=0.035). There were no significant differences between the groups in hemoglobin level after labor. Table 1 Laboratory indices of hemoglobin and hematocrit, and total blood loss.

Circulating endometrial cells in peripheral blood

OBJECTIVES Endometriosis is a common disorder amongst women of reproductive age. Despite extensive research, no reliable blood tests currently exist for the diagnosis of endometriosis STUDY DESIGN We report several new approaches enabling study of cell specific characteristic of endometrial cells, introducing enrichment and culturing of viable circulating endometrial cells (CECs) isolated from peripheral blood (PB) and peritoneal endometrial cells (PECs) from peritoneal washing (PW). Size-based enrichment method (MetaCell(®), Czech Republic) has been used for the filtration of PB and PW in patients with diagnosed endometriosis. RESULTS The PECs were found in the PW in all of the tested patients (n=17), but CECs) only in 23.5% (4/17) cases. Their endometrial origin has been proved by immunohistochemistry. PECs were successfully cultured in vitro directly on the separating membrane (9/17) exhibiting both endometrial cell phenotypes: stromal and glandular within the culture. CECs were successfully cultured in the two of the four positive cases, but in none of them confluence has been reached. The occurrence in CECs in PB is clear and very specific evidence of an active endometrial disease. CONCLUSIONS We demonstrated efficient, quick and user friendly endometrial cells capture platform based on a cell size. Furthermore, we demonstrated an ability to culture the captured cells, a critical requirement for post-isolation cellular analysis directed to better understanding of endometriosis pathogenesis.

Prenatal Three-Dimensional Sonographic Findings Associated with Annular Pancreas

Annular pancreas is a rare developmental anomaly that accounts for 1% of neonatal intestinal obstructions. For the first time, we describe 3D sonographic findings associated with this condition. In addition to stringent diagnostic criteria based on 2D ultrasound, this case suggests the possible contribution of 3D ultrasound in rare cases of suspected annular pancreas. Verification of prenatal findings was performed during the postnatal surgery.

Complications in right‐sided paraaortic lymphadenectomy: ventral tributaries of the inferior vena cava

The purpose of this study was to describe the distribution and structure of ventral tributaries leading into the inferior vena cava where right‐sided paraaortic lymphadenectomy is performed. The study examined 21 retroperitoneal specimens by graphic reconstruction, statistical evaluation, and histological examination of ventral tributaries (VTs). Seventy VTs were identified. The average number per specimen was 3.33. There were 20, 40, and 40% of VTs found in Levels I, II, and III, respectively. During the preparation, we observed an unusual arrangement of the IVC wall, into which VTs were led through a preformed sleeve‐like channel and anchored near the lumen. This finding is a key mechanism that explains the ease with which VTs are extracted during surgery. Knowledge of the distribution and histological structure of VTs allows proper orientation of the retroperitoneal area of the front wall of inferior vena cava, which is essential for uncomplicated right‐sided paraaortic lymphadenectomy. The histological structure of the VT ostium within the wall of the inferior vena cava explains why injury is easy during the procedure.

Velamentous insertion of the umbilical cord of twin B as a cause of vasa previa in monochorionic diamniotic twins.

Vasa previa is a rare obstetric complication with an incidence of 1 per 5000 pregnancies. Fetal morbidity/mortality occurs in 50%– 60% of cases involving intact membranes, increasing to 75%–100% after rupture of membranes [1]. In monochorionic twins, there is a higher risk of occurrence of vasa previa, and possible bleeding can threaten both fetuses owing to placental anastomosis [2]. However, placental vascular anastomoses can save the life of the bleeding fetus in cases of twin-to-twin transfusion [3]. A 22-year-old primipara with monochorionic diamniotic twins following spontaneous conception was admitted to the Department of Gynecology and Obstetrics, Third Medical Faculty, Charles University, Prague, Czech Republic, with regular contractions at 36 weeks of gestation. Cardiotocography was normal for both fetuses. On ultrasound, both twins displayed vertex presentation; the estimated birth weight of fetus A was 2420 g and that of fetus B was 2680 g; there was normal anterior position of the placenta. The cervix was dilated 5 cm and membranes were intact. One hour after admission, spontaneous rupture of membranes occurred at 6 cm dilation. A pulsating mass was recognized on the left side between cervix and fetal head. Pressure on this caused bradycardia of twin B (Fig. 1a). Suspicion of vasa previa led to