Jaroslav Feyereisl

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.

TVT-S for surgical treatment of stress urinary incontinence: prospective trial, 1-year follow-up

Introduction and hypothesisThe aim of this study was to evaluate the effectiveness of and morbidity associated with the tension-free vaginal tape-secur (TVT-S) procedure in women with stress urinary incontinence (SUI).MethodsWe performed a prospective trial, examining 86 women with primary SUI. Eighty-two patients had a 1-year follow-up (dropout rate = 4.6%). The preoperative evaluation included urinalysis, urodynamic studies, and validated questionnaires. The 1-year outcome evaluation also included a 1-h pad testing.ResultsAt the 1-year follow-up, 43 (52.4%) women were objectively cured, and 14 (17.1%) women were objectively improved. Subjectively, 49 (59.7%) patients did not experience urine loss, and 18 (22.2%) women improved in this respect. Postoperative de novo urge incontinence symptoms developed in 24.4% (n = 20) of patients. Vaginal defect healing occurred in 6.1% (n = 5) of patients, and one (1.2%) case of urethral erosion was reported.ConclusionObjective and subjective cure rates following TVT-S are inferior to other tape procedures.

Assessment of endometrial and ovarian characteristics using three dimensional power Doppler ultrasound to predict response in frozen embryo transfer cycles

ObjectiveTo evaluate whether endometrial or ovarian parameters as measured using 3D power Doppler ultrasound would predict the outcome in frozen embryo transfer (FET) cycles.MethodsThirty women with no known gynecological pathology undergoing FET were recruited. The FET was carried out in the natural menstrual cycle 3-4 days after the first positive LH test result. Blood samples for hormonal analysis were collected, and three-dimensional (3D) ultrasonographic examination was performed on the day of the FET and repeated with analysis of the total hCG one week later.ResultsThe demographic, clinical, and embryological characteristics were similar between the pregnant (15/30) and nonpregnant groups (15/30). There were no differences between the groups in endometrial/subendometrial thickness, volume, or vascularization index (VI). The endometrial triple-line pattern was more often present in the pregnant group on the day of the FET (93.3% vs. 40.0%, 95% CI 25.5-81.2%). No differences in the ovaries were observed on the day of the FET. At the second visit, the triple-line pattern was still more often present in those patients who had conceived (91.7% vs. 42.9%, 95% CI 18.5-79.1%), and their corpus luteum was more active as judged by the rise in 17-hydroxyprogesterone and estradiol levels. No differences were observed in the dominant ovarian vasculature.ConclusionsAccording to our results, measurement of power Doppler indices using 3D ultrasound on the day of the FET does not provide any additional information concerning the outcome of the cycle. The existence of the triple-line pattern on the day of the FET seems to be a prognostic sign of a prosperous outcome after FET. The dominant ovary in the pregnant group seems to be already activated one week after the FET.

Evaluation of Cell-Free Urine microRNAs Expression for the Use in Diagnosis of Ovarian and Endometrial Cancers. A Pilot Study

Among gynaecological cancers, epithelial ovarian cancers are the most deadly cancers while endometrial cancers are the most common diseases. Efforts to establish relevant novel diagnostic, screening and prognostic markers are aimed to help reduce the high level of mortality, chemoresistance and recurrence, particularly in ovarian cancer. MicroRNAs, the class of post-transcriptional regulators, have emerged as the promising diagnostic and prognostic markers associated with various diseased states recently. Urine has been shown as the source of microRNAs several years ago; however, there has been lack of information on urine microRNA expression in ovarian and endometrial cancers till now. In this pilot study, we examined the expression of candidate cell-free urine microRNAs in ovarian cancer and endometrial cancer patients using quantitative real-time PCR. We compared the expression between pre- and post-surgery ovarian cancer samples, and between patients with ovarian and endometrial cancers and healthy controls, within three types of experiments. These experiments evaluated three different isolation methods of urine RNA, representing two supernatant and one exosome fractions of extracellular microRNA. In ovarian cancer, we found miR-92a significantly up-regulated, and miR-106b significantly down-regulated in comparison with control samples. In endometrial cancer, only miR-106b was found down-regulated significantly compared to control samples. Using exosome RNA, no significant de-regulations in microRNAs expression could be found in either of the cancers investigated. We propose that more research should now focus on confirming the diagnostic potential of urine microRNAs in gynaecological cancers using more clinical samples and large-scale expression profiling methods.

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.

OC258: Pubococcygeus–puborectalis trauma after instrumental delivery: the use of 4D ultrasound in the evaluation of levator ani muscle

in women without, and 40/401 (10.0%) in women with significant prolapse, giving an odds ratio of 4.6 (CI, 2–10.3). When the dataset was analyzed to obtain the relative risk of significant prolapse dependent on levator defects, the RR was 1.7 (CI, 1.5–1.9). Conclusions: Women with significant clinical pelvic organ prolapse are 4–6 times more likely to show evidence of levator avulsion than those without. Furthermore, it appears that the presence of a levator defect in our population increases the risk of significant prolapse by approximately 70%. It remains to be shown to what extent these results are applicable to the general population.

Antenatal assessment of liver position, rather than lung-to-head ratio (LHR) or observed/expected LHR, is predictive of outcome in fetuses with isolated left-sided congenital diaphragmatic hernia.

Abstract Objectives: Respiratory morbidity in congenital diaphragmatic hernia (CDH) is associated with high mortality and adverse outcome. Accurate prenatal diagnosis is essential for prognosis and potential treatment in utero. The aim was to evaluate the prenatal ultrasound findings in assessing the respiratory prognosis in fetuses with isolated left-sided CDH. Methods: We retrospectively analyzed the medical records of 59 prenatally diagnosed left-sided CDH cases managed at a tertiary perinatal center. Results: Survival rate in the study group was 73% (43/59). We found no statistically significant relationship between survival and the presence of polyhydramnios, gestational age at diagnosis, lung-to-head ratio (LHR) and observed/expected LHR (O/E LHR) values, gestational age at birth and birth weight. Intrathoracic liver herniation was a statistically significant parameter adversely affecting survival (37.2% in survivors, 68.8% in non-survivors, p = 0.031) and logistic regression confirmed this relationship. The presence of pneumothorax and severe pulmonary hypertension were significantly associated with mortality (82% non-survivors versus 15% in survivors, p = 0.0001). Conclusion: Intrathoracic liver herniation seems to be a reliable parameter in the prediction of survival and neonatal respiratory morbidity in fetuses with isolated left-sided CDH. In contrast, we found no significant correlation between perinatal outcome and LHR, O/E LHR values, birth weight and gestational age.

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.