Nebojsa Ladjevic

Analysis of urologic complications after radical hysterectomy

OBJECTIVE Injuries of the ureter or bladder or development of vesicovaginal and ureterovaginal fistulas are the most serious complications in gynecological surgery. STUDY DESIGN This study included 536 women who underwent radical hysterectomy because of invasive cancer of the cervix uteri. RESULTS During the surgery the ureter was injured in 1.32% of cases, whereas the percentage of bladder injuries was 1.49. In the early postoperative period vesicovaginal or ureterovaginal fistulas appeared in 2.61% and 2.43% of cases, respectively. CONCLUSION The stage of the disease, obesity, diabetes, and postoperative surgical infection acted as predisposing factors of the urinary tract complications.

Evaluation of the risk malignancy index diagnostic value in patients with adnexal masses.

BACKGROUND/AIM Ovarian cancer is the leading cause of death from gynecologic malignancies. Risk of malignancy index (RMI) is recommended in assessment of patients with adnexal masses. The aim of this study was to verify the effectiveness of the RMI in the discrimination between benign lesions and malignant adnexal masses in clinical practice. METHODS Ultrasounds were performed for all the patients and menopausal status, CA125 level and calculated RMI were defined. All the patients were divided into 3 groups depending on RMI (< 25, 25-200, > 200). After operations all adnexal masses were analyzed histopathologically (HP) and then sensitivity, specificity and predictive value of RMI were calculated. RESULTS Out of a total of 81 patients involved benign tumor had 51 (62.96%) and malignant 30 (37.04%) of the patients. The average value of CA125 in the group of patients with benign adnexal masses was 68.3 U/mL and in the group of patients with malignant adnexal masses it was 581.95 U/mL. In the group of patients with benign adnexal masses the average RMI was 284.9 and in the group of patients with malignant adnexal masses RMI was 469.2. All the results showed a positive correlation between both HP categories and RMI categories. The more malignant HP result produced higher RMI and the cut off value was RMI = 200. Sensitivity of RMI w as 83.33%, specificity was 94.12%, positive predictive value was 89.29% and negative predictive value was 90.57%. CONCLUSION Our study showed that RMI is very reliable in differentiation benign from malignant adnexal masses.

Cervical plexus block versus general anesthesia in carotid surgery: single center experience.

Introduction Carotid endarterectomy may be performed under general (GA) or regional anesthesia (RA). The aim of this study was to evaluate the influence of anesthetic techniques on perioperative mortality and morbidity in patients undergoing carotid surgery. Material and methods This prospective study included 1098 consecutive patients operated on between 2003 and 2009 (773 underwent cervical plexus block and 325 underwent general anesthesia). Results There were 6 deaths, 3 (0.9%) after GA and 3 (0.4%) after RA (p = 0.272). Neurological complication rates were not significantly different (GA 2.1% vs. RA 1.1%, p = 0.212). Incidence of myocardial infarction was similar (GA 0.31% vs. LA 0.39%, p = 0.840). Shunt placement rate was the same in both groups, 11.1%. Total operating time and carotid clamping time were significantly shorter in RA patients (RA: 92 min vs. GA: 106 min; p < 0.001 and RA: 18 min vs. GA: 19 min; p = 0.040). There was no significant difference in number of reinterventions (RA: 1.0% vs. GA: 0.6%; p = 0.504). Pulmonary complications were common in the GA group (RA: 0 vs. GA 0.9%; p = 0.007). Time to first postoperative analgesic was significantly shorter in the GA group (RA: 226 min vs. GA: 139 min; p < 0.001). Conclusions Type of anesthesia does not affect the outcome of surgical treatment of carotid disease. However, it should be stressed that fewer respiratory complications, later requirement for first postoperative analgesic, and an awake patient who can continue oral therapy early after surgery, give priority to regional techniques of anesthesia.

EVALUATION OF ADNEXAL MASSES: CORRELATION BETWEEN CLINICAL, ULTRASOUND AND HISTOPATHOLOGICAL FINDINGS

BACKGROUND/AIM Concerning the growth of ovarian carcinoma incidence and bad prognosis for malignant forms, early and precise diagnostics is gaining in importance as a condition for precise and appropriate therapy for ovarian tumor masses. The aim of this study was to analyze pre- and postoperative findings of patients with adnexal masses in order to identify factors which could predict the nature and stage of the tumor prior to surgery. METHODS All patients with adnexal masses who were treated in a 6-month period in the Institute of Obstetrics and Gynecology, Clinical Center of Serbia, (IOG, CCS), Belgrade, had their epidemiologic and gynecologic anamnesis and standard laboratory analyses taken prior to surgery. Also, clinical and ultrasonographic check up of pelvic organs was performed, as well as calculation of body mass index (BMI) and risk of malignancy index (RMI). After surgery we analyzed histopathological (HP) findings of tumors as a mean of final diagnosis and staging. For statistical analysis, we used SPSS 15 program. RESULTS Throughout a 6-month period, we examined 81 patients with adnexal masses treated in the IOG CCS. HP findings showed that there were significantly more benign (n = 51) than malignant (n = 30) tumors in all the patients (Chi2 = 5.512). The patients with malignant HP findings were significantly older than those with benign adnexal masses (t = 3.362; p = 0.001). Significantly more patients with malignant HP findings were in menopause (p = 0.034). BMI values were highly significantly higher in the patients with malignant adnexal tumors (t = 3.421; p = 0.001). There was a statistically significant positive correlation between HP categories (benign, malignant) and RMI categories (low, intermediate and high risk) of all the patients (high risk, more malignant HP) (Ro(xy) = 0.428; df = 78; p = 0.000). CONCLUSION . Patients in menopause, especially older ones, with high BMI and RMI should immediately be referred to a tertiary level institution, where appropriate surgery could be performed.

Risk of malignancy index validity assessment in premenopausal and postmenopausal women with adnexal tumors

OBJECTIVE The aim of this study was to investigate the validity of the risk of malignancy index (RMI) in premenopausal and postmenopausal patients with adnexal masses. MATERIALS AND METHODS The study involved all women treated for adnexal tumors throughout an 18-month period in the Clinic for Gynecology and Obstetrics, Clinical Center of Serbia (Belgrade, Serbia). On admission, detailed anamnestic and laboratory data were obtained and an expert ultrasound scan was performed. The RMI was calculated for all patients and the obtained data were related to histopathological findings of the tumors. For statistical analysis, we used descriptive and analytical statistics methods and an SPSS computer program. RESULTS From a total number of 540 women, 85 women had malignant tumors; 20 women, borderline tumors; and 435 women, benign adnexal tumors. The RMI was reliable in 84.6% of all patients; in 77% of premenopausal patients, and in 81.1% of postmenopausal patients. The sensitivity of the RMI in the overall population was 83.81%; the specificity was 77.24%; the positive predictive value (PPV) was 47.06%, and the negative predictive value (NPV) was 95.18%. In premenopausal women, the RMI sensitivity was 83.87%; specificity, 80.31%; PPV, 28.89%; and NPV, 98.12%. In postmenopausal women the RMI sensitivity was 83.78%; specificity, 68.18%; PPV, 63.92%; and NPV, 74.71%. CONCLUSION The RMI was a reliable factor for differentiating benign from malignant adnexal masses in premenopausal and postmenopausal patients.

Risk factors for intraoperative hypotension during thyroid surgery

Background Hypotension is a common adverse effect of IV anaesthetics, especially during the induction of anaesthesia. The aim of our study was to determine the incidence and risk factors for intraoperative hypotension (IOH) in thyroid surgery, as well as to determine whether and to what extent IOH affects the occurrence of postoperative hypotension. Material/Methods The study included 1252 euthyroid patients, ASA 2 and ASA 3 status (American Society of Anesthesiologists physical status classification), who had thyroid surgery between 2007 and 2011. IOH was defined as a decrease in systolic blood pressure of >20% of baseline values. We studied the influence of demographic characteristics (sex, age, body mass index-BMI), comorbidity, type and duration of surgery, and anaesthesia on the occurrence of IOH. Univariate and multivariate logistic regression were used to determine predictors of occurrence of IOH. Results IOH was registered in 6.5% of patients. The most common operation was thyroidectomy. Patients with IOH were younger, had lower BMI, and significantly less often had hypertension as a coexisting disease. The multivariate regression model identified BMI and the absence of hypertension as a coexisting disease, and as independent predictors of occurrence of IOH. Significantly more patients with IOH had postoperative hypotension (9.9% vs. 2.4%, p=0.000). Conclusions IOH is common, even during operations of short duration and with minimal bleeding. It is necessary to pay special attention to these patients, given that many of these patients remained hypotensive during the postoperative period.

Current diagnostic approach to patients with adnexal masses: which tools are relevant in routine praxis?

OBJECTIVE The aim of the study was to investigate which anamnestic, laboratory and ultrasound parameters used in routine practice could predict the nature of adnexal mass, thus enabling referral to relevant specialist. METHODS Study involved the women treated for adnexal tumors throughout a period of 2 years. On admission, detailed anamnestic and laboratory data were obtained, expert ultrasound scan was performed, and power Doppler index (PDI), risk of malignancy index (RMI) and body mass index (BMI) were calculated for all patients. Obtained data were related to histopathological findings, and statistically analyzed. RESULTS The study included 689 women (112 malignant, 544 benignant, and 33 borderline tumors). Malignant and borderline tumors were more frequent in postmenopausal women (P=0.000). Women who had benignant tumors had the lowest BMI (P=0.000). There were significant (P<0.05) differences among tumor types regarding erythrocyte sedimentation rate, CA125 and carcinoembryonic antigen (CEA) levels. Among ultrasound findings, larger tumor diameter and ascites were more frequent in malignant tumors (P=0.000). Women with malignant tumors had highest values of RMI and PDI (P=0.000). CONCLUSIONS Anamnestic data, ultrasound parameters and laboratory analyses were all found to be good discriminating factors among malignant, benignant and borderline tumors.

The Correlation of Biochemical and Morphologic Parameters in the Assessment of Sperm Maturity

OBJECTIVE To examine the relationship between biochemical markers and morphologic sperm characteristics, including head, neck, and tail changes. METHODS The study evaluated 154 patients who went to the Andrology Laboratory of the Clinic of Urology, Clinical Center of Serbia. Patients were divided into 4 groups: normozoospermic, oligozoospermic, severe oligozoospermic, and asthenozoospermic, according to the sperm concentration and motility. RESULTS The differences in creatine kinase (CK) and CK-M levels between normozoospermic and the 2 groups of oligozoospermic patients were significantly different (P <.01). The CK and CK-M levels correlated negatively with sperm concentration and sperm motility, but correlated positively with the pathologic sperm form. Patients with CK values >0.093 have a total number of pathologic forms higher than 0.40 (87.5% sensitivity, 77.3% specificity, the area under the curve was 0.832, P <.001). Patients with CK values <0.09 U/L have normal spermatogenesis and pathologic disorder of the head <15%, neck <12%, and tail <10%. CONCLUSION The relation between sperm morphology and biochemical markers included in the maturation process is established during the sperm genesis process. If the results of these markers are used together with the morphology of the spermatozoa in the interpretation of infertility, it would lead us to better insight of the fertility potential of the each patient.

Topical Glycopirrolate for the Management of Hyperhidrosis in Herpetic Neuralgia

Herpes zoster is a relapse of varicella. In certain cases, long-term pain and hyperhidrosis have been noted. Appearance of herpes zoster during pregnancy is infrequent. We described hyperhidrosis and pain treatment using glycopirrolate cream in a pregnant woman with herpetic neuralgia. A 32 year old woman, 21 weeks pregnant with second child, complained to her gynecologist of the appearance of a vesicular rash on the left half of the forehead that progressed toward her left eyelid, accompanied by lancinating pain, allodynia, hyperhidrosis and small edema, blepharitis and conjunctivitis. Following clinical and laboratory tests, she was diagnosed with herpes zoster ophtalmicus. Aciclovir therapy was administered 800 mg orally five times daily for seven days. Pain therapy was initiated with amitriptilline. We discontinued amitriptilline therapy after 10 days because of appearance of unwanted side effects. After skin changes ceased, we introduced Lidocaine patch into pain therapy which reduced the allodynia, but not the lancinating pain and hyperhidrosis. At that time we began using glycopirrolate cream which reduced pain intensity by 28.5% within 24 hours, and completely eliminated hyperhidrosis. After 48 hours of use, the pain completely disappeared. During the Glycopirrolate cream therapy, there were no side effects. This is a first report to document that a topical Glycopirrolate cream has a beneficial effect in a patient with hyperhidrosis and herpetic neuralgia.

Psychological factors as predictors of early postoperative pain after open nephrectomy

Purpose There is an increasing interest in the identification of predictors for individual responses to analgesics and surgical pain. In this study, we aimed to determine psychological factors that might contribute to this response. We hence investigated patients undergoing a standardized surgical intervention (open nephrectomy). Patients and methods Between May 2014 and April 2015, we conducted a prospective observational cohort study. The following psychological tests were administered preoperatively: Mini-Mental State Examination, Amsterdam Preoperative Anxiety and Information Scale (APAIS), Hamilton Anxiety Rating Scale, Hamilton Depression Rating Scale, and Pain Catastrophizing Scale. The primary outcome, postoperative pain intensity (11-point numerical rating scale, [NRS]), was assessed in the “immediate early” (first 8 hours), “early” (12 and 24 hours), and “late early” periods (48 and 72 hours). Results A total of 196 patients were assessed, and 150 were finally included in the study. NRS scores improved from 4.9 (95% confidence interval [CI]: 4.7–5.1) in the “immediate early” to 3.1 (95% CI: 2.9–3.3) in the “early” and 2.3 (95% CI: 2.1–2.5) in the “late early” postoperative period. Most (87%) patients received intravenous opioids, while 13% received analgesics epidurally. Repeated measures analysis of variance indicated better pain management with epidural analgesia in the first two postoperative periods (F=15.01, p<0.00). Postoperative pain correlated strongly with analgesic strategy and preoperative psychological assessment. Multiple linear regression analysis showed “expected pain” was the only predictor in the “immediate early” phase, and “anxiety” was most important in the “early” postoperative period. In the “late early” phase, catastrophizing was the predominant predictor, alongside “preoperative analgesic usage” and “APAIS anxiety”. Conclusion After open nephrectomy, epidural analgesia conveys a clear advantage for pain management only within the first 24 hours. Moreover, as the psychological phenotype of patients changes distinctively in the first 72 postoperative hours, psychological variables increasingly determine pain intensity, even surpassing employed analgesic strategy as its main predictor.