Haldun Güner

Transvaginal sacrospinous colpopexy for marked uterovaginal and vault prolapse

Objective: The transvaginal sacrospinous ligament fixation technique was used as part of the vaginal repair procedure for marked uterovaginal prolapse, and in the treatment of vault prolapse. Method: Out of the 26 women treated with sacrospinous ligament suspension of the vaginal vault, 23 had marked uterovaginal prolapse and three had vault prolapse following hysterectomy. Patients with vault prolapse underwent posterior vaginal repair, obliteration of the enterocele sac and sacrospinous colpopexy. Patients with marked uterovaginal prolapse underwent vaginal hysterectomy with high ligation of the enterocele sac, anterior and posterior vaginal repair, and sacrospinous colpopexy. Bilateral salpingoopherectomy was added to the procedure in five patients. All patients were examined 6 weeks after the operation and, subsequently, on an annual basis. The mean follow‐up period was 2.6 years (1–5 years). Results: Out of the three patients with previous vault prolapse, none had recurrences. Out of the 23 patients with previous marked uterovaginal prolapse, only two had small cystocele, and one had small enterocele at 36 months following the operation. These patients were asymptomatic and did not need an operation. Vaginal vault prolapse was not observed in any of these patients. Two women had post‐operative urinary tract infection and five had buttock discomfort, which subsided after 2 months. No other intra‐ or post‐operative complications occurred. Conclusion: Transvaginal sacrospinous colpopexy can be performed together with vaginal hysterectomy, and anterior and posterior vaginal wall repair in patients with marked uterovaginal prolapse because of its high success in avoiding possible vault prolapse, and low intra‐ and post‐operative complication rates.

Comparison of diagnostic accuracy of saline infusion sonohysterography, transvaginal sonography and hysteroscopy

We aimed to compare the accuracy of transvaginal sonography (TVS), saline infusion sonohysterography (SIS) and hysteroscopy (HS) for uterine pathologies among infertile women. A total of 346 patients were selected for operative hysteroscopy, following SIS after TVS. SİS was performed with a Cook Soft 500 IVF catheter. Sensitivity, specificity, positive and negative predictive values (PPV, NPV) were calculated to compare the accuracy of TVS, SIS and hysteroscopy for uterine abnormalities. SIS showed a sensitivity of 87%, specificity of 100% and PPV of 100% for endometrial hyperplasia, and a sensitivity and NPV of 100% for polypoid lesions. For submucosal myoma SIS showed a sensitivity of 99% with PPV of 96%. Hysteroscopy had a sensitivity, specificity, PPV and NPV of 98%, 83%, 96% and 91%, respectively for overall uterine pathologies. Finally, SIS seems to be superior to TVS, for uterine pathologies, with respect to hysteroscopy as the gold standard.

The changes in ovarian hormone levels and ovarian artery blood flow rate after laparoscopic tubal sterilization

OBJECTIVE To investigate the changes in serum ovarian hormone levels and ovarian artery blood flow rate by Doppler ultrasonography following laparoscopic tubal sterilization. METHODS Laparoscopic tubal sterilization have been performed on 13 voluntary subjects between the sixth and eighth days of the menstrual cycle. Serum ovarian hormone levels and ovarian artery blood flow rate, by Doppler ultrasonography, were determined 3 days before the operation, on the post-operative third day and on the post-operative third month. The results of 10 participants who finished the follow-up period were analyzed. RESULTS There were no statistically significant changes in serum levels of ovarian hormones after laparoscopic tubal ligation. The end-diastolic blood flow in ovarian artery was found to be decreased following tubal sterilization (8.7+/-2.8 and 7.4+/-1.8m/sec, respectively, P>0.05), while resistivity index (RI) increased after the operation (0.7+/-0.1 and 0.8+/-0.03, respectively, P>0.05). CONCLUSION There was no change in ovarian hormone levels after laparoscopic tubal sterilization. There is slight but statistically non-significant decrease in ovarian artery blood flow rate following tubal sterilization, signifying a local increase in vascular resistance.

Intravenous leiomyomatosis treated with aromatase inhibitor therapy

[1]. The gonads of these patients develop into ovaries in utero, but then degenerate into streaks owing to the lack of a second X chromosome [1]. Cesarean is the usual mode of delivery in these patients [3], but in the present case the patient had a spontaneous vaginal delivery. Gonadal neoplasm can occur in up to 30% of cases and gonadoblastoma accounts for the majority of tumors [2]. Gonadoblastoma may synthesize estrogens or testosterone and is associated with dysgerminoma in 50% of cases [4]. In one case report 5 different histological subtypes of germ cell malignancies were described [4]. Early diagnosis is important and immediate gonadectomy is strongly recommended, as these tumors may even develop in infancy. A multidisciplinary approach with psychological support is important for the management of patients with pure gonadal dysgenesis. Normal uterine function including vaginal delivery is possible in these patients. References

The role of frozen section evaluation in the diagnosis of adnexal mass

The purpose of this study was to evaluate the accuracy of frozen section diagnosis in patients who were subjected to the exploratory laparotomy for pelvic mass. Overall, 207 patients were included in this study and the mean age of the patients was 50.9 ± 14.9 years (range, 18–84 years). Of these patients, 98 (47%) had benign, 16 (8%) had borderline, and 93 (45%) had malignant histologies at permanent section. The diagnosis at frozen section was deferred for three patients (1.4%) and these patients were excluded from the further analyses. The overall discordance rate was 5.3%. To calculate the sensitivity and specificity values, 2 × 2 contingency tables were constructed in two ways. In the first calculation, borderline histology was considered malignant, and the sensitivity and specificity rates were 97% and 92%, respectively. In the second analysis, it was accepted as benign, and these values were 100% and 98%, respectively. To determine the possible factors related with discordant diagnoses, age, menopausal status, tumoral size, laterality of tumors, and histologic diagnoses were analyzed. Significant association was noted for size and borderline and mucinous histologies. In patients with borderline histology, the discordance rate was 40%. This value for the remaining patients was 3.2% (P< 0.001). The rate of misdiagnosis was 17.4% for mucinous tumors, whereas it was 4.8% for the remaining epithelial tumors (P= 0.03). Frozen section evaluation revealed high sensitivity and specificity values in this study. To increase the accuracy of diagnosis, further diagnostic markers are needed especially for patients with large lesions, borderline tumors, and mucinous histologies.

Surgical Treatment of Urinary Stress Incontinence by a Suburethral Sling Procedure Using a Mersilene Mesh Graft

A suburethral sling procedure using a Mersilene mesh has been performed in 24 patients. Six patients had recurrent incontinence after an unsuccessful past operation. A postoperative follow-up was done for an average of 24 months. Twenty-three patients were free of symptoms, while only 1 patient had recurrent incontinence. The suburethral sling procedure can be applied to all patients, particularly for recurrent stress urinary incontinence, with reasonable cure rates when performed with a proper technique.

Morphometric analysis of gap junctions in nonpregnant and term pregnant human myometrium

Background and methods. Some structures in the human myometrium, namely; caveolae, extracellular space and gap junctions were quantified in tissues from nonpregnant women, women who were not in labor, and women in spontaneous labor or oxytocin‐induced labor, in order to reveal morphologic differences that would contribute to explaining the events leading to labor. Transmission electron micrographs taken from tissues from twenty‐four pregnant and ten nonpregnant women were studied.

Zinc and Homocysteine Levels in Polycystic Ovarian Syndrome Patients with Insulin Resistance

In this study, our objective was to evaluating the value of serum zinc levels as an etiologic and prognostic marker in patients with polycystic ovarian syndrome. We conducted a prospective study, including 53 women with polycystic ovarian syndrome and 33 healthy controls. We compared serum zinc levels, as well as clinical and metabolic features, of the cases. We also compared serum zinc levels between patients with polycystic ovarian syndrome with insulin resistance. Mean zinc levels were found to be significantly lower in patients with polycystic ovarian syndrome than healthy controls. Multiple logistic regression analysis of significant metabolic variables between polycystic ovarian syndrome and control groups (serum zinc level, body mass index, the ratio of triglyceride/high-density lipoprotein cholesterol, and homocysteine) revealed that zinc level was the most significant variable to predict polycystic ovarian syndrome. Mean serum zinc levels tended to be lower in patients with polycystic ovarian syndrome with impaired glucose tolerance than patients with normal glucose tolerance, but the difference was not statistically significant. In conclusion, zinc deficiency may play a role in the pathogenesis of polycystic ovarian syndrome and may be related with its long-term metabolic complications.

A potential novel treatment strategy: inhibition of angiogenesis and inflammation by resveratrol for regression of endometriosis in an experimental rat model

Abstract The aim of our study was to evaluate the effectiveness of resveratrol in experimentally induced endometrial implants in rats through inhibiting angiogenesis and inflammation. Endometrial implants were surgically induced in 24 female Wistar–Albino rats in the first surgery. After confirmation of endometriotic foci in the second surgery, the rats were divided into resveratrol (seven rats), leuprolide acetate (eight rats), and control (seven rats) groups and medicated for 21 d. In the third surgery, the measurements of mean areas and histopathological analysis of endometriotic lesions, VEGF, and MCP-1 measurements in blood and peritoneal fluid samples, and immunohistochemical staining were evaluated. After treatment, significant reductions in mean areas of implants (p < 0.01) and decreased mean histopathological scores of the implants (p < 0.05), mean VEGF-staining scores of endometriotic implants (p = 0.01), and peritoneal fluid levels of VEGF and MCP-1 (p < 0.01, for VEGF and p < 0.01, for MCP-1) were found in the resveratrol and leuprolide acetate groups. Serum VEGF (p = 0.05) and MCP-1 (p = 0.01) levels after treatment were also significantly lower in the resveratrol and leuprolide acetate groups. Resveratrol appears to be a potential novel therapeutic agent in the treatment of endometriosis through inhibiting angiogenesis and inflammation. Further studies are needed to determine the optimum effective dose in humans and to evaluate other effects on reproductive physiology.

Comparison of microlaparoscopy and conventional laparoscopy for tubal sterilization under local anesthesia with mild sedation.

STUDY OBJECTIVE To compare tubal sterilization performed by microlaparoscopy and conventional laparoscopy. DESIGN Prospective, randomized trial (Canadian Task Force classification I). SETTING Gazi University School of Medicine. PATIENTS Twenty women undergoing surgical sterilization. INTERVENTION Ten sterilizations by conventional laparoscopy and 10 by microlaparoscopy. MEASUREMENTS AND MAIN RESULTS The techniques were comparable in quality of visualization, operating time, amount of drugs used for sedation and local anesthesia, and intraoperative pain scores. However, the postoperative analgesic requirement was significantly less in women treated by by microlaparoscopy. CONCLUSION Tubal sterilization by microlaparoscopy does not differ greatly from conventional laparoscopic sterilization.