Mehmet Ali Vardar

Non‐puerperal inversion of the uterus caused by leiomyosarcoma: A case report and clinical management

Uterine inversion is a rare complication of the postpartum period, but it is an even rarer complication of the non‐puerperal period. A 49‐year‐old nulliparous woman was admitted to the hospital with the following complaints: abnormal vaginal bleeding, pain, anuria and a mass protruding from the vulva. The mass was removed by twisting and a laparotomy was required for massive bleeding due to the inversion. The diagnosis of complete inversion was made during the laparotomy. Total abdominal hysterectomy and bilateral salpingo‐oophorectomy was performed and the pathological examination revealed a leiomyosarcoma. Uterine inversion in the non‐puerperal period is an extremely rare event and it should be kept in mind that the cause of the inversion may be a malignant disease, like leiomyosarcoma.

Choriocarcinoma metastatic to the maxillary gingiva

A rare metastatic lesion from a gestational trophoblastic neoplasm is presented in a 26-year-old woman. The first symptom and sign was mild pain and a mass in the gingiva. The diagnosis was established by gingival biopsy. The patient was treated with 6 courses of methotrexate, actinomycin D and cyclophosphamide (MAC) and has no evidence of disease 2 years after completion of therapy.

Prognostic Significance of Retroperitoneal Lymphadenectomy, Preoperative Neutrophil Lymphocyte Ratio and Platelet Lymphocyte Ratio in Primary Fallopian Tube Carcinoma: A Multicenter Study

Purpose The purpose of this study is to evaluate the prognostic role of preoperative neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) and the need for para-aortic lymphadectomy in patients with primary fallopian tube carcinoma (PFTC). Materials and Methods Ninety-one patients with a diagnosis of PFTC were identified through the gynecologic oncology service database of six academic centers. Clinicopathological, surgical, and complete blood count data were collected. Results In univariate analysis, advanced stage, suboptimal surgery, and NLR > 2.7 were significant prognostic factors for progression-free survival, whereas in multivariate analysis, only advanced stage and suboptimal surgery were significant. In addition, in univariate analysis, cancer antigen 125 ≥ 35 U/mL, ascites, advanced stage, suboptimal surgery, NLR > 2.7, PLR > 233.3, platelet count ≥ 400,000 cells/mm3, staging type, and histological subtype were significant prognostic factors for overall survival (OS); however, in multivariate analysis, only advanced stage, suboptimal surgery, NLR > 2.7, and staging type were significant. Inclusion of pelvic and para-aortic lymphadenectomy in surgery showed significant association with longer OS, with a mean and median OS of 42.0 months and 35.5 months (range, 22 to 78 months), respectively, vs. 33.5 months and 27.5 months (range, 14 to 76 months), respectively, for patients who underwent surgery without para-aortic lymphadenectomy (hazard ratio, 3.1; 95% confidence interval, 1.4 to 5.7; p=0.002). Conclusion NLR (in both univariate and multivariate analysis) and PLR (only in univariate analysis) were prognostic factors in PFTC. NLR and PLR are inexpensive and easy tests to perform. In addition, patients with PFTC who underwent bilateral pelvic and para-aortic lymphadenectomy had longer OS.

The use of a silicone-coated acrylic vaginal stent in McIndoe vaginoplasty and review of the literature concerning silicone-based vaginal stents: a case report

BackgroundMc Indoe vaginoplasty is one of the mostly performed surgical interventions in Mullerian agenesis.Case presentationsWe present our experience on the use of a new designed vaginal stent that was coated with silicone in two mullerian agenesis cases who had Mc Indoe vaginoplasty. Both full thickness and splitt thickness skin graft were used with the stent. No graft loss or hyperthrophic scarring which may be seen at the apex of neovagina after Mc Indoe vaginoplasty was observed during the follow-up period and adequate neovaginal depth were obtained in both of the patients.ConclusionWe think that the incorporation of silicone to a vaginal stent for postoperative wound care improves skin graft take and decreases a possible constriction band formation in neovagina.Background Mc Indoe vaginoplasty is one of the mostly performed surgical interventions in Mullerian agenesis. Case presentations We present our experience on the use of a new designed vaginal stent that was coated with silicone in two mullerian agenesis cases who had Mc Indoe vaginoplasty. Both full thickness and splitt thickness skin graft were used with the stent. No graft loss or hyperthrophic scarring which may be seen at the apex of neovagina after Mc Indoe vaginoplasty was observed during the follow-up period and adequate neovaginal depth were obtained in both of the patients. Conclusion We think that the incorporation of silicone to a vaginal stent for postoperative wound care improves skin graft take and decreases a possible constriction band formation in neovagina.

Primitive uterine neuroectodermal tumours: Two case reports

Primitive neuroectodermal tumor (PNET) arise from Kulchitsky cells and are rarely seen in the female genital tract. Differential diagnosis of PNET can be made based on immunohistochemical profiles and genetic analyses. Genital tract pNETs are very aggressive pathologies with different clinical and molecular manifestations and there are no standard guidelines for treatment. We aimed to present two cases of uterine PNETs with different symptomatology and clinical findings.

Prognostic value of pre-operative neutrophil/lymphocyte ratio, monocyte count, mean platelet volume, and platelet/lymphocyte ratio in endometrial cancer

OBJECTIVE Cancer-related inflammation is associated with poor long-term outcomes in various solid tumors. The aim of this study is to investigate the prognostic significance of pre-operative neutrophil lymphocyte ratio (NLR), monocyte count (MC), mean platelet volume (MPV), and platelet lymphocyte ratio (PLR) in endometrial cancer. STUDY DESIGN In this study, 763 patients with endometrial cancer were evaluated, who were followed between January 1996 and February 2016. Preoperative values of NLR, MC, MPV, and PLR were evaluated in terms of clinico-pathologic prognostic factors and overall survival (OS). RESULTS NLR, MC, and PLR were detected to be statistically significant with regard to advanced stage of the disease (p = 0.001, p = 0.02, and p = 0.001, respectively), but only MC was significant in terms of grade (p = 0.035). Higher NLR and PLR values were found to be associated with advanced stage of the disease, deep myometrial invasion, cervical involvement, lymphovascular space invasion (LVSI), and nodal involvement. When the cut-off value was considered as 3, sensitivity and specificity for NLR were found to be 68% and 69%, respectively, to predict lymph node metastasis. NLR was found as a prognostic factor for survival (p = 0.01). Age, the presence of comorbidity, stage, and cervical involvement were determined to be independent prognostic factors for OS in our cohort. CONCLUSION NLR was detected to be a prognostic factor for survival. Moreover, NLR and PLR are a predictive value for lymph node involvement and also for cervical invasion in endometrial cancer.

A novel technique: Carbon dioxide gas-assisted total peritonectomy, diaphragm and intestinal meso stripping in open surgery for advanced ovarian cancer (Çukurova technique)

OBJECTIVE Most of the ovarian cancers are diagnosed at advanced stages. As peritoneal carcinomatosis increases, especially when it extends to the diaphragm and intestinal mesos, probability of obtaining complete cytoreduction is reduced. Complete cytoreduction (residue zero: R0) is one of the main factors affecting survival [1-3]. Here we present a novel technique of stripping the peritoneal surfaces as a part of cytoreductive surgery in such cases. METHODS A 55year-old woman diagnosed with peritoneal carcinomatosis was considered appropriate for primary cytoreduction after assessment of her thorax-abdominopelvic tomography, which revealed resectable intra-abdominal disease. Upon laparotomy, omental cake adherent to pelvis-filling mass, disseminated implants on the diaphragm, meso of the descending colon and small intestine were observed. The mass invaded the rectosigmoid colon, uterus, adnexa and the bladder resulting in frozen pelvis. Palpable retroperitoneal pelvic and para-aortic lymph nodes were detected. On the other side, stomach, anti-mesenteric surfaces and mesentery root of the small bowel were tumor-free. Hence, upon these perioperative and preoperative imaging findings, complete cytoreduction was thought to be achievable. Therefore, primary cytoreduction was performed. Total omentectomy, hysterectomy with bilateral salpingo-oophorectomy, rectosigmoid low anterior resection and retroperitoneal lymphadenectomy were performed. With the assistance of an injector needle connected to the insufflator tube (as in laparoscopic surgery), carbon dioxide gas was blown into the right retroperitoneal area and subsequently peritoneum was rapidly stripped up to the right diaphragm. The same procedure was then applied to the diaphragm and meso of the bowels, respectively. Owing to this technique, total stripping of all involved peritoneal surfaces was clearly facilitated and R0 goal was reached. RESULTS Gas insufflation caused convenient detachment of the peritoneal surfaces along their anatomical line which led to concluding the stripping procedures easily, rapidly and safely without bleeding. Thus, according to our experience, about 10 to 15min per procedure are saved in such cases. Potential complications of CO2 gas used here are not superior to those in transperitoneal or retroperitoneal laparoscopic procedures. During the operation, patient was followed-up for potential complications such as subcutaneous emphysema and CO2 gas embolism.Thus, hourly blood gas was monitored. Another potential complication is injury of the vessels while inserting the needle which can be avoided by cautious inserting under the peritoneal surfaces superficially and using transillumination. In case such injuries happen, tamponing is a sufficient measure. In our serial, no perioperative complications belonging to this technique were encountered. However, long term outcomes such as precise time difference, difference in blood loss, complication rates, adhesions, morbidity associated with this technique and its impact on survival of the patients with advanced ovarian cancer have yet to be investigated. Therefore, a prospective study to validate this techniques long-term usefulness has been initiated in our clinic. CONCLUSION We believe that this practical and effective technique will offer significant improvements in efforts to achieve complete cytoreduction.

Does preoperative neutrophil to lymphocyte or platelet to lymphocyte ratios have a role in predicting borderline ovarian tumors

Backgroundto investigate the value of using preoperative neutrophil to lymphocyte and platelet to lymphocyte levels in the patients of borderline ovarian tumors.MethodsDuring the period between January 2002 and December 2015, the pathology reports and archival files of the Gynecologic Oncology Department of Çukurova University Medical Hospital and the Gynecologic Oncology Department of Dumlupınar University, Evliya Çelebi Education and Research Hospital were retrospectively reviewed, and 144 patients of borderline ovarian tumor (as the study group) and 123 patients of serous cystadenoma (as the control group) were determined for eligibility in this study. Data regarding age, menopausal status, preoperative ultrasound findings, ca125 and complete blood counts were reviewed. Neutrophil to lymphocyte and platelet to lymphocyte ratios were calculated and these parameters were statistically compared between the groups.ResultsThere was a statistically significant difference between the groups according to neutrophil count, platelet count, neutrophil to lymphocyte ratio and platelet to lymphocyte ratio; in addition to age, ca125 and preoperative ultrasound findings.ConclusionsIt seems that neutrophil to lymphocyte and platelet to lymphocyte ratios are useful in predicting borderline ovarian tumors, preoperatively. However, further prospective studies are needed.

Etiology of Serum CA-125 in Patients with Endometriosis Treated with a Gonadotrophin-Releasing Hormone Agonist (Buserelin)

Fifty-six patients with pelvic endometriosis were treated with a buserelin dosage of 200 micrograms/day s.c. for 6 months. Scoring of the American Fertility Society (AFS) for endometriosis was performed by laparoscopy in all cases before and at the end of therapy. Serum CA-125 and estradiol levels were determined before the treatment, and monthly during therapy and follow-up (6 months; respectively). A slight positive correlation was found between serum CA-125 concentrations before treatment and AFS scores for adhesions only. Before treatment, serum CA-125 values also correlated slightly with total AFS scores of patients with adhesions. At the end of the 6-month therapy, no correlation was found between CA-125 concentrations and second-look AFS scores for implants and/or adhesions. Serum CA-125 and estradiol values were closely parallel to each other during and after therapy with the gonadotrophin-releasing hormone agonist buserelin. In conclusion, (1) adhesions may play a role in the elevation of serum CA-125 levels in endometriosis, and (2) a significant decrease in serum CA-125 values during the buserelin therapy may result from a rather different mechanism, such as ovarian suppression, other than the therapeutic effect of this agent.

Laparoendoscopic Single Site Total Hysterectomy: Single Institution Initial Experience

ABS TRACT Objective: To compare the periand post-operative outcomes between the laparoendoscopic transumblical single-site total hysterectomy (LESS-TH) and conventional three-port total laparoscopic hysterectomy (TLH). Material and Methods: A single institution retrospective review of patients operated on with LESS-TH (n= 24) and TLH (n=47) for benign uterine pathology or endometrial cancer with low-risk factors from March 2013 to March 2014. Patients underwent LESSTH surgery through a single 2-3 cm transumbilical incision with a multi-channel SILS TM port (Covidien®, Mansfield, MA, USA). Patient demographics and peri-operative and post-operative variables were analyzed and compared between the groups. Results: There was one conversion to conventional laparoscopy and one conversion to laparotomy in the LESS-TH group, and no cases converted to laparotomy in the LTH group. Demographic characteristics such as age, body mass index (BMI), and indications were similar between the groups (p=0.497, 0.07, 0.594, respectively). Operation time was significantly longer in the LESS-TH group than in the TLH group (p=0.01). The other periand post-operative variables such as uterus length and width, estimated blood loss, post-operative Hb level drop, post-operative hospitalization time and analgesic management were found to be similar between the two groups. There were no major complications in either of the groups. Conclusion: With the exception of operative time, the surgical outcomes of the LESS-TH group were comparable to those of the conventional multiport TLH group.