Elvira Brătilă

Does Computed Tomography–Based Virtual Colonoscopy Improve the Accuracy of Preoperative Assessment Based on Magnetic Resonance Imaging in Women Managed for Colorectal Endometriosis?

STUDY OBJECTIVE To evaluate whether combining computed tomography-based virtual colonoscopy (CTC) with magnetic resonance imaging (MRI) improves preoperative assessment of colorectal endometriosis. DESIGN Retrospective study using prospectively recorded data (Canadian Task Force classification II-2). SETTING University tertiary referral center. PATIENTS Seventy-one women treated for colorectal endometriosis managed between June 2015 and May 2016. INTERVENTIONS Patients included in our study underwent colorectal surgery for deep endometriosis infiltrating the rectum or the sigmoid colon and had preoperative assessment using MRI and CTC. To establish the correlation between preoperative and intraoperative findings, the concordance kappa index was used. MEASUREMENTS AND MAIN RESULTS Preoperative data provided by MRI, CTC, and a combination of both were compared with intraoperative findings. All 71 patients had a total of 105 endometriotic intestinal lesions intraoperatively confirmed. Some 71.2% of rectal nodules and 60.0% of sigmoid nodules infiltrated the muscularis propria of the intestinal wall, with most infiltrating between 25% and 50% of the rectal circumference; 73% of rectal nodules and 96% of sigmoid nodules led to varying degrees of stenosis. The concordance between intraoperative and preoperative findings concerning the presence of rectal nodules was high, at .88 when associating CTC with MRI, whereas each imaging technique taken individually provided lower concordance coefficients. In our study 80.3% of patients underwent the procedure that had been preoperatively planned. CONCLUSION Our study suggests that associating MRI with CTC leads to improved accuracy in preoperative assessment of colorectal endometriosis and in subsequent preoperative choice of surgical procedures on the digestive tract.

Effect of the surface modification of the synthetic meshes used in the surgical treatment of pelvic organ prolapse on the tissue adhesion and clinical functionality

Abstract Stress urinary incontinence and pelvic organ prolapse represent important conditions affecting adult women’s health. Lately, the properties and performance of the polymer materials used in the treatment of pelvic organ prolapse have been improved by modulating from their formula. Materials investigated in our study are polypropylene meshes used by clinicians in surgical treatment of urinary incontinence and utero-vaginal prolapse. In order to make a comparative analysis, we confronted the structure and surface morphology of native synthetic polypropylene meshes with explanted fragments from the same mesh type after clinical use. FTIR investigations revealed little change in structure after implantation, somehow insignificant. Scanning electron microscopy (SEM) demonstrates modification in surface morphology even just by passing through the transobturator passage, whereas after implantation the surface deteriorates. SEM on explanted meshes proves the encapsulation process of the mesh to be more similar to a foreign body reaction rather than to the adhesion and integration of the synthetic mesh into the organism. Histological analysis of the surrounding tissues near explanted mesh was made in some relevant clinical cases, because the tissue response is an important factor in order to evaluate the tissue adhesion at the polypropylene mesh surface. Based on our experiments and clinical experience we’ve designed an adhesion score. It applies to meshes used in pelvic organ prolapse surgery measuring the following important factors: tenacity, extent of adhesion, macroscopic and microscopic aspects and ease of dissection from surrounding tissues.

Properties Analysis of Biological Grafts Used in Pelvic Surgery

Pelvic surgery addresses congenital malformations like Mullerian anomalies, pelvic organ prolapse or after radical intervention, while constructive surgery involves treatment of congenital/iatrogenic absence of organs: uterus or vagina. Intuitively, inert and nondegradable biomaterials appear ideal for this purpose, but surgical reality is that the persistence of a permanent foreign body in the wound has a lot of clinical postoperative disadvantages. This paper aims to discuss the properties of the biologic grafts, detailing the structure of biologic extracellular matrix, the biomechanical properties of biological grafts and the use of extracellular matrix in reconstructive pelvic surgery. A biologic graft used in pelvic surgery is a tridimensional extracellular matrix, acellular and of animal origin. It has as a low risk of transmission of viral and prionic infections and determines reduced inflammatory reaction and a low risk of rejection. The absence of crosslinking facilitates the colonization of the mesh by the host´s cells, thus avoids the foreign body reaction represented by the encapsulation of the mesh by the host. Our experience with clinical use of biological acellular grafts in reconstructive pelvic surgery includes oncoplastic surgery like in cases of vulvar cancer or neovagina reconstruction for Rokintansky syndrome, complications after prolapse surgery treated with polypropylene meshes or relapsing recto-vaginal fistulas. The biomechanical properties evaluated by tensile stress and elastic modulus revealed that biologic grafts with moderate collagen infiltration are the strongest. The degree of cross-linkage influences the rate of degradation and the degree of the inflammatory response triggered by the host organ. Cross-linked collagenous matrices induce little cell infiltration hence there is limited collagen remodeling and graft degradation. On the other hand, in non-cross- linked xenografts cell infiltration is greater with faster degradation rate and collagen production. The decrease in the mechanical strength of the graft materials is related to the lack of collagen infiltration into the material. In conclusion, taking into account the biomechanical properties of biologic grafts, these may be used in reconstructive pelvic surgery and oncoplastic surgery with little complications and good clinical results. They can be attached to large mucosal defects and on potentially septic tissue, they are mechanically resistant and they can be sutured on surrounding healthy tissue.

Synthetic Mesh Used in Gynecologic Reconstructive Surgery for Pelvic Floor Disorders

Pelvic floor disorders including stress urinary incontinence and pelvic organ prolapse represent a challenge for gynecologist or urogynecologist even nowadays. Conservative treatment for these conditions proves its effectiveness only in few cases selected from early forms of incontinence or prolapse the most cases being solved surgically. The introduction of the procedure imagined by Petros and Ulmsten, known as TVT (Trans Vaginal Tape) in which the medium urethra is supported by a synthetic tape produced in 1996 a revolution in the surgical treatment of stress urinary incontinence. Radical changes also appeared in pelvic organ prolapse surgery extrapolating the hernia repair procedure by using synthetic mesh. After nearly 20 years of experience the mesh surgery is today a common practice in urogynecology. Between 2011 and 2015 we operated in private practice a total number of 297 cases of which 187 cases of stress urinary incontinence and 110 cases of pelvic organ prolapse. From these 86 (78,1%) cases were represented by cystoceles, associated with early apical prolapse or rectoceles, 18 (16,3%) cases by apical prolapse (grade III-IV) and 6 (5,4%) cases by posterior compartment prolapse alone. We performed mesh surgery in 32 (29%) cases represented mainly by anterior compartment prolapse. In 6 (18,7%) cases we founded mesh extrusion which required partially resection. In two cases we performed large resection of anterior vaginal wall required grafting with acellular second generation graft. In all cases with mesh extrusion the biomechanical analysis revealed significant decrease in effective porosity of the mesh due to excessive tensioning or folding of the mesh. The use of mesh in stress urinary incontinence and pelvic organ prolapse represent a justified alternative in selected cases. The specific complications due to meshes are more frequent in prolapse surgery compared to stress urinary incontinence. In all cases altered effective porosity due to technical defects in surgery represents the leading cause.

The Use of Mersilene Tape in Transabdominal Cerclage

Aim: The purpose of this article is to show the use and utility of mersilene tape in medical procedures, such as transabdominal cerclage (TAC). Material and methods: Based on their biomechanical properties, we present our experience with mersilene tape used as treatment for cervical incompetence. Cervical insufficiency or cervical incompetence is defined as asymptomatic cervical shortening and dilatation with the absence of detectable uterine contractions. The mechanical properties of cervical tissue are derived from its extracellular matrix and its most important constituent the fibrillar collagen, alongside other constituents such as proteoglycans, hyaluronic acid, elastin, and water. In the absence of the uterine contractions, the cervix is loaded by intrauterine pressure (including the weight of the growing fetus and amniotic sac), the gravity as well as passive pressure from the uterine wall. These forces also depend on the support action of pelvic floor structures and abdominal wall. The static load resulting from the combination of uterine growth, hydrostatic pressure and gravity seems to be the dominant determinants that cause cervical shortening. The placement of the mersilene tape acts as a barrier between the intrauterine pressure and the cervix. The main advantage of the TAC procedure is the placement of the nonabsorbable suture (mersilene tape at the level of the internal os, avoiding the placement of a vaginal foreign body and subsequently increasing the risk of ascending lower genital tract infection, decreased incidence of slippage, and the ability to leave the stitch in place between pregnancies. Results: The follow-up was without complications regarding the pregnancies treated with transabdominal cerclage. None of the pregnancies terminated prematurely as related to the presence of the tape, but it necessitates to be performed a caesarean section for delivery. Conclusions: Mersilene tape is safe and useful in different medical procedures, including transabdominal cerclage during pregnancy.

Colposcopic assessment and outcome in low grade cervical intraepithelial neoplasia treated with loop electrosurgical excision procedure

The aim of the research was to assess the outcome of persistent (≥two years) low-grade cervical intraepithelial neoplasia (CIN 1) medicated with loop electrosurgical excision procedure (LEEP). An analysis of 38 topics with persistent biopsy-confirmed CIN 1 diagnosed after low-grade squamous intraepithelial lesion (LSIL) or atypical squamous cells of undetermined significance (ASC-US) on Pap test and treated using LEEP was performed. Post-LEEP follow-up were scheduled in 6 months, 1 year, and yearly thereafter: cytology, colposcopy, and plasma diagnostic examinations. There were 38 LSIL patients treated with LEEP conization. About 6 patients were excluded from the study due to subsequent hysterectomy and 2 patients never attended the follow-up schedule in the rest. The remaining 30 patients were retrospective studied for the incidence of recurrent rate. The mean age of the patient was 44 years. About 50% of patients were multiparity and nearly one - third used oral contraceptive pill. The results of this study suggest that the incidence of CIN 2+ lesions during follow-up of persistent biopsy-confirmed CIN 1 after ASC-US/LSIL treated by LEEP is very low.

The role of adipose tissue as endocrine organ in the metabolic programming of fetuses derived from obese mothers

We aim to present the endocrine and paracrine role of the cytokines secreted by hypertrophied maternal fat cells on fetal and later on neonatal metabolic profile. The study used an animal model in order to analyze the influence of maternal adipokines secretion of fetal metabolism. We selected 50 female Wistar rats weighing between 200-250 g (normal weight 100-150g) to whom we induced obesity by high-fat, high-calorie food intake (80% of diet saturated fatty acids) and tracked the correlation of maternal adipokines secretion with placental and fetal lipid peroxidation level. The low adiponectin and increased leptin values as adipokines secreted by adipocytes of obese mothers were correlated with the level of placental and fetal tissue lipid peroxidation (from the liver, pancreas, brain), measured by elevated malonyldialdehyde and total thiols and the decreased levels of glutathione. It has been known for decades that fat tissue is not inert, but a true endocrine organ, which responds by secreting adipokines to different energy and hormonal stimuli. Endocrine secretion of adipokines from the adipocytes of obese mothers is positively correlated with placental and fetal lipid peroxidation levels. Fetal metabolic programming as an inducible phenomenon is explained partly by the influence of excess secretion of maternal adipokines.

Conservative treatment of patients with bulky leiomyoma uterine arteries embolization vs. myomectomy

The pelvic tumors with the highest prevalence are uterine leiomyoma. These benign tumors are associated with symptoms like: pain, menorrhagia and menometrorrhagia. A modern method of treatment in these cases is uterine arteries embolization. This technique consists in injecting particles of polyvinyl alcohol into vessels that supply the tumorsin order to block their vascularization. This procedure is performed by femoral or brachial artery approach with a 3F micro catheter. First, a dye is injected followed by X-ray guidance. Another used method consists in surgical excision of the leiomyoma - myomectomy. We performed a retrospective descriptive study analyzing a group of 90 patients hospitalized in the University Emergency Hospital Bucharest on the Obstetrics-Gynecology ward between 01.01.2011-01.01.2015 diagnosed with bulky uterine fibroids. Two groups were formed. Group A included 45 patients who underwent uterine artery embolization. Group B consisted of 45 patients who underwent myomectomy. All patients were re-evaluated clinically and by ultrasound at 1 month, 3 months and 6 months after the procedure to assess treatment response. An extensive comparison was conducted between the two groups.