Mesut Polat

Shorter the cervix, more difficult the placenta percreta operations

Abstract Background: To determine the impact of cervical length (CL) on the clinical outcome of patients undergoing peripartum hysterectomy due to placenta previa/percreta. Objective: To assess the association of CL with clinical outcomes in such patients. Methods: We analyzed the data of patients who were diagnosed with anterior placenta previa/percreta prenatally and subsequently underwent peripartum hysterectomy at our tertiary care institution between 2004 and 2014. The sonographic images and measurements of CL were obtained from prospectively collected database. The duration of operation, units of blood products transfused, and length of stay in the hospital were recorded. Patients were stratified according to CL, and receiver-operating characteristics curves were used to determine the cut-off length for identification of patients at high risk of intra-operative difficulty. Results: Sixty-one patients were included in this study. Number of packages of ES were correlated with the the duration of operation (r = 0.666, p < 0.001) and the CL (−0.793, p < 0.001). Number of packages of fresh frozen plasma was significantly correlated with the CL (−0.642, p < 0.001) and the duration of operation (r = 0.606, p < 0.001). Gestational age (AUC = 0.683, p = 0.014) and the CL (AUC = 0.980, p < 0.014) were significant predictors for the number of ES transfused > 4 packages. The cut-off value of four packages was determined according to the median level of packages transfused. Optimal cut-off value for the CL to predict transfusion ≤ 4 packages was 20.5 with 93% sensitivity and the 99% specificity. Conclusions: Short cervix appears to be a cause of difficulty in placenta previa/percreta operations. CL may also help in determining the timing of delivery in placenta percreta patients.

Does performing cesarean section after onset of labor has positive effect on neonatal respiratory disorders

Abstract Objective: The aim of this study is to evaluate whether neonatal respiratory disorders relate to the onset of labor or labor pain in patients with history of previous cesarean section. Methods: This prospective controlled study comprised 164 patients, grouped according to the presence of labor and related labor pain. All patients in both groups were applied cesarean section at 38 weeks gestational age or beyond due to previous cesarean section. The cord blood pH, Apgar scores and the need for the neonatal intensive care unit were compared. Results: There was a greater need for the neonatal intensive care unit in the control group and the cord blood pH values were higher in the study group (p < 0.05). No significant difference was determined between the groups in respect of Apgar scores (p > 0.05). Conclusion: The onset of labor and related labor pain provide a positive contribution to a reduction in neonatal respiratory disorders. Therefore, it can be considered reasonable to perform a cesarean section after the onset of labor or related pain.

The Effect of Intrauterine Lidocaine and Rectal Indomethacin on Pain during Office Vaginoscopic Hysteroscopy: Randomized Double-Blind Controlled Study

Backgrounds/Aims: The aim of this study was to investigate the effect of rectal and intrauterine anesthesia during vaginoscopic hysteroscopy. Methods: This was a randomized, double-blind, placebo-controlled study. Patients were randomized to rectal indomethacin, intrauterine lidocaine and placebo groups. Patients with conditions that could cause or contribute to pelvic pain were excluded. Pain was evaluated with Visual Analog Scale, when the cervical canal was passed, while within the cavity and at 10 min after procedure. The Analog Pain Scale scores of the 3 groups were compared with the Kruskal-Wallis 1-way analysis of variance test. A value of p < 0.05 was accepted as statistically significant. Results: The study included a total of 206 patients. No difference was seen between the groups in respect of indication, age, gravid and duration of procedure. While the anesthesia was determined as superior to the placebo in reducing pain at all 3 stages (p < 0.05), intrauterine lidocaine was determined to be more effective than rectal indomethacin in reducing pain within the cavity and 10 min after the procedure (p < 0.05). Conclusion: Rectal or intrauterine anesthesia applied with the vaginoscopic technique is useful in hysteroscopy. However, intrauterine anesthesia is more effective in reducing pain.

Tumor Diameter for Prediction of Recurrence, Disease Free and Overall Survival in Endometrial Cancer Cases

AIMS To analyse the predictors of recurrence, disease free survival and overall survival in cases with endometrial cancer. MATERIALS AND METHODS A total of 152 women diagnosed with endometrial cancer were screened using a prospectively collected database including age, smoking history, menopausal status, body mass index, CA125, systemic disorders, tumor histology, tumor grade, lymphovascular space invasion, tumor diameter, cervical involvement, myometrial invasion, adnexal metastases, positive cytology, serosal involvement, other pelvic metastases, type of surgery, fertility sparing approach to assess their ability to predict recurrence, disease free survival and overall survival. RESULTS In ROC analyses tumor diameter was a significant predictor of recurrence (AUC:0.771, P<0.001). The optimal cut off value was 3.75 with 82% sensitivity and 63% specificity. In correlation analyses tumor grade (r=0.267, p=0.001), tumor diameter (r=0.297, p<0.001) and the serosal involvement (r=0.464, p<0.001) were found to significantly correlate with the recurrence. In Cox regression analyses when some different combinations of variables included in the model which are found to be significantly associated with the presence of recurrence, tumor diameter was found to be a significant confounder for disease free survival (OR=1.2(95 CI,1.016-1.394, P=0.031). On Cox regression for overall survival only serosal involvement was found to be a significant predictor (OR=20.8 (95 % CI 2.4-179.2, P=0.006). In univariate analysis of tumor diameter > 3.75 cm and the recurrence, there was 14 (21.9 %) cases with recurrence in group with high tumor diameter where as only 3 (3.4 %) cases group with smaller tumor size (Odds ratio:7.9 (95 %CI 2.2-28.9, p<0.001). CONCLUSIONS Although most of the significantly correlated variables are part of the FIGO staging, tumor diameter was also found to be predictor for recurrence with higher values than generally accepted.

Cosmetic Outcomes Of Infraumblical, Supraumbilical and Transumbilical Entry Routes In Laparoscopic Surgery

OBJECTIVE The aim of the present study was to determine which of the umbilical entry routes for intraperitoneal access has a better cosmetic result. MATERIAL AND METHODS This was a prospective study (Canadian Task Force classification II-1). In total, 105 patients who underwent laparoscopic surgery were included. A vertical or transverse umbilical incision is appropriately made for the trocar to be inserted, and an infraumbilical, supraumbilical, or transumbilical route was preferred for initial intraperitoneal access. Demographic data of patients, body mass indices, entry point of the trocars (infraumbilical-transumbilical-supraumbilical), type of incision (vertical-transverse), duration of the operation, and scar properties at postoperative week 12 were prospectively collected and analyzed. The Vancouver scar scale was used to evaluate the cosmetic results. RESULTS Cosmetic results did not differ statistically between the transumbilical-infraumbilical-supraumbilical groups. The variables, such as vascularity, height, and total score, of the Vancouver scar scale were significantly higher in patients who had transverse incisions. There was no statistically significant effect of using a Veress needle with the cosmetic results. There was no statistically significant correlation between age, gravida, body mass indices, skin thickness, time of entry, duration of the operation, and cosmetic results in terms of vascularity, height, and total score. CONCLUSION During laparoscopic surgery, each patient should be assessed individually for the satisfaction of the patient and, thereby, of the surgeon in terms of cosmetic outcomes. Vertical incision offers superior cosmetic effects than transverse incision. Further research is required to define long-term scar-related outcomes of the laparoscopic intraperitoneal access techniques.

Modified abdominal packing method in “near miss” patients with postpartum hemorrhages

Objective: To describe a more effective abdominal packing method in patients with disseminated intravascular coagulation following peripartum hysterectomy due to postpartum hemorrhage (PPH). Materials and Methods: The present retrospective and descriptive study was conducted to document six cases with refractory pelvic bleeding who underwent a second surgery for PPH between January 2016 and December 2017 at İstanbul Zeynep Kamil Woman and Children Diseases Training and Research Hospital. Results: Karateke packing was performed to control intra-abdominal massive hemorrhages of five women who were referred to our clinic due to PPH who had undergone peripartum hysterectomy and hypogastric artery ligation but hemostasis could not be provided. In addition, a case of hypovolemic shock due to placenta percreta rupture in a woman who had also undergone an emergency hysterectomy and hypogastric artery ligation, which had failed. Hemostasis was provided in all patients. No method-related complication developed. Conclusion: Karateke packing is a very easy method to perform, it is more effective than the classic abdominal packing technique, with a low complication rate, and most importantly, life-saving in patients undergoing a peripartum hysterectomy due to PPH and thereafter experiencing diffuse hemorrhage.

Postpartum urinary retention: Evaluation of risk factors

Objective: Postpartum urinary retention means the absence of spontaneous micturition more than 6 hours after birth or when residual volume after urination is less than 150 cc. If neglected, postpartum urinary retention may result in bladder denervation and detrusor muscle weakness requiring intermittent catheterization or permanent micturition dysfunction. Our goal was to identify the possible risk factors for postpartum urinary retention. Materials and Methods: Five hundred sixty female subjects were included in this retrospective study. All data obtained including variables such as age, parity, body mass index, duration of labor, prepartum bladder catheterization were compared between female subjects with and without postpartum urinary retention. Results: Among the 560 patients recruited to our study, 124 (22.1%) had postpartum urinary retention. Third stage duration, time from birth to the first void, and number of peripartum micturitions were found to be potential risk factors for postpartum urinary retention. Different than other studies, our study revealed a correlation between peripartum catheterization and postpartum urinary retention. There were no statistically significant differences between patients with and without postpartum urinary retention in terms of other variables. Conclusion: In this study, a correlation between peripartum catheterization and postpartum urinary retention was found. There are studies that reported the possible risk factors related to the occurrence of postpartum urinary retention. More studies should be conducted to investigate long-term results with larger populations.

Vaginal axis on MRI after unilateral and bilateral sacral hysteropexy: a controlled study

Abstract The objective of this study was to evaluate the vaginal position on magnetic resonance imaging (MRI) after bilateral abdominal sacral hysteropexy (BASH) and classical abdominal sacral hysteropexy (ASH) and to investigate which method keeps the vagina the most proximate to its original anatomical position. Ten patients, with 10 having BASH, 10 ASH and 10 being nulliparous, were compared. The angle between the vagina and the pubococcygeal plate, the angle between the upper and lower vaginal segments, the distance between the posterior fornix and the 2nd vertebra and the distances between the lateral fornices and spina ischiadica were measured on MRI. A p value less than .05 was considered statistically significant. The distance between the vaginal axis and the left spina ischiadica was greater in the ASH group compared to the control and the BASH group (p = .011, .047), while it was similar between the BASH group and the control individuals (p = .473). The angle between the upper and lower vaginal segments was greater in the ASH group compared to the control group (p = .004), while no significant difference was found between the BASH and control groups (p = .112). BASH keeps the vaginal axis at a more proximate location to its original anatomical position. IMPACT STATEMENT What is already known on this subject: In pelvic reconstructive surgery; the anatomic correction serves the functional results. What the results of this study add: On MRI examination bilateral abdominal sacral hysteropexy (mimicking uterosacral ligament), keeps the vagina closer to the original anatomic position than classical abdominal sacral hysteropexy. Hence functional outcomes could be better, especially in the long term. What the implications are of these findings for clinical practice and/or further research: This study may be of interest for clinicians in terms of different methods for pelvic floor surgery and may be of interest for researchers to investigate the relationship between anatomic position and functional outcomes especially in younger patients.

A new operation technique for uterine prolapse: Vaginally-assisted laparoscopic sacrohysteropexy

Objective: To describe the new surgical technique and report the safety and feasibility of vaginally-assisted laparoscopic sacrohysteropexy (VALSH). Materials and Methods: Thirty-three women with stage 3 or more uterine prolapse underwent VALSH operation. Patients were followed up for 12 months for mesh-related complications and improvements of symptoms. The operation had three sections; 1st laparoscopic, 2nd vaginal, 3rd laparoscopic. Results: The mean age, gravidity, and parity of the study population were 46.5 years (range, 25-68 years), 4.3 (1-9), and 2.9 (1-6), respectively. The mean duration of operation was 59.5 min (range, 20-120 min). There were significant differences between the pre- and post-operative values of pelvic organ prolapse quantification parameters, which were favorable in the latter evaluation (p<0.001); total vaginal length was preserved after surgery (p>0.05). Conclusion: VALSH is a safe and minimally-invasive procedure in uterovaginal prolapse, with favorable anatomic and functional outcomes at 12 months post-operatively.

Misinterpretation of Frozen Section in Endometrial Cancer Cases: Does It Have Any Effect on Disease-free and Overall Survival?

The aim of this study was to assess whether misinterpretation of frozen sections in endometrial cancer cases is associated with survival and determine the factors leading to mismatch. One hundred fifty endometrial cancer cases treated in Zeynep Kamil Maternity and Children’s Health Training and Research Hospital between January 2010 and December 2014 were included in the study. Frozen sections and final histopathologic reports were screened from a prospectively collected database and analyzed on whether mismatch between the initial and the final reports has any impact on disease-free survival. There were 31 patients with mismatched frozen sections with the final report, whereas in 119 patients, frozen sections and final reports were consistent. The recurrence-free survival time was similar between groups (51 vs. 49, P=0.813). Overall survivals were also similar between groups (55 vs. 52, P=0.880). Frozen section misinterpretation does not affect disease-free and overall survival in endometrial cancer cases.