Intraoperative Complications and Conversion to Laparatomy in Gynecologic Robotic Surgery.

INTRODUCTION: In this study our objective was to document complications encountered during our initial experience with the robotic system and also state the cases in which conversion to laparotomy was necessary. MATERIAL AND METHODS: This study is a retrospective analysis of robotically performed gynecological and gynecologic oncology procedures at a single center from July 2016 to July 2018. Patient demographics and preoperative indications were obtained from the electronic medical records. RESULTS: The patients had a mean age of 53.6 years (range, 25-84 years). The operative time ranged from 1 h and 50 min to 9 h (mean, 5 h and 2 min). Most of the complications were managed within minutes and with robotic assisted suturing when necessary. Five patients out of 83 patients needed a surgical conversion from robotic surgery. Conversion rate was 6.02%. CONCLUSION: During the study period we were able to manage complications uneventfully without requiring conversion to laparotomy most of the time. Vascular complications encountered during robotic surgery can be managed without requiring conversion to laparatomy.

Administration of rectal cytotec versus rectal buscopan before hysteroscopy.

INTRODUCTION: Our objective was to compare the effect of rectal misoprostol (Cytotec) versus rectal hyoscine-n-butyl bromide (Buscopan) on patients undergoing hysteroscopy. We hypothesised that HBB may have a role in cervical priming. MATERIAL AND METHODS: This trial was conducted at Bezmialem Vakif University Hospital. Women of reproductive age between 18-50 years who were scheduled for operative hysteroscopy indicated by type 1 submucous myoma or endometrial polyps were recruited for the study. Ninety patients were divided randomly into three groups. Group 1 received placebo treatment. Group 2 received rectal 200 mcg misoprostol and Group 3 received rectal 20 mg hyoscine-n-butyl bromide two hours before the procedure. Procedures were performed using a bipolar 26 F (9 mm) continuous-flow rigid resectoscope with a 30° lens. The outcome measures included cervical dilation width and time, ease of cervical dilation, procedure time and operative complications. Postoperative self-rated pain was assessed one hour after the procedure. RESULTS: Thirteen patients (43. 3%) in the placebo treatment group, 11 patients (36.7%) in the misoprostol group and four patients (13.3%) in the hyoscine-n-butyl bromide group needed analgesics postoperatively (p = .02). The mean duration of cervical dilation time was longest in Group 1 and shortest in Group 3, however this difference did not reach statistical significance (p=.11). There was no difference with regard to other studied parameters. SUMMARY: HBB reduced the need for pain medication compared to placebo. Larger studies are needed to further investigate the role of HBB in facilitating pre-operative cervical priming.

The utility of detecting ovulation to predict success in ovulation induction and intrauterine insemination cycles - a prospective observational study.

OBJECTIVES: The success of ovulation induction-intrauterine insemination (OI-IUI) procedures may be limited by the absence of ovulation detection. The aim of this study was to evaluate the empirical use of ultrasonography and luteal phase progesterone (P4) as ovulation indicators and determine its effect on pregnancy outcome in OI-IUI cycles. MATERIAL AND METHODS: This prospective observational study, which was performed in a university setting, included 107 women with unexplained infertility. Following OI, IUI was performed 36 hours after human chorionic gonadotropin (hCG). P4 was measured 72-96 hours after hCG. At the same time, the appearance of ovaries and signs indicative of ovulation, which are decreased follicle dimensions, irregularity of follicular walls, and the presence of free fluid in the Douglas pouch, were noted. RESULTS: In 58 patients (54.2%), ovulation was detected at the P4 level of > 10 ng/mL. Eighty-nine patients had ultrasound images suggestive of ovulation. However, only 50 of these were confirmed ovulation as indicated using P4. Implantation was observed in a total of 13 patients (12.1%). All patients were in the ovulation detected group with P4 > 10 ng/mL (AUC: 0.750; p = 0.004). P4 of > 21.5 ng/mL detected successful ovulation and was strongly associated with implantation with 77% sensitivity and 61% specificity (OR: 9.9; 95% CI: 2.4-41.2). Body mass index (BMI) > 23.9 kg/m2 was a reliable anovulation indicator as a secondary outcome (AUC: 0.696; p = 0.02). CONCLUSIONS: In 45.8% of the patients, ovulation did not occur even with OI treatment. The association of progesterone measurement and ovarian ultrasound scanning between 72 and 96 hours after hCG treatment can be used to detect ovulation. In doing so, we can find the optimal treatment for patients with infertility in their next cycle.

Short and middle-term outcomes of vaginally assisted laparoscopic sacropolpopexy.

OBJECTIVE: Vaginally assisted laparoscopic sacrocolpopexy (VALS), which is a combined surgical approach where a vaginal hysterectomy is initially performed, followed by transvaginal placement of synthetic mesh and laparoscopic suspension, can be an alternative to overcome the dissection, suturing limitations of laparoscopic sacrocolpopexy. The aim of this study was to compare the operative times and middle-term anatomic outcomes of women with uterovaginal prolapse undergoing VALS with those of women undergoing abdominal sacrocolpopexy. METHODS: This is a prospective cohort study that evaluates operation times, anesthesia times, estimated blood loss, middle-term outcomes, perioperative and postoperative complications. We compared the results of 47 women who had the VALS to that of 32 abdominal sacrocolpopexy (AS). RESULTS: The mean follow up was 22.4 months for AS group and 20.5 months for VALS group. The VALS group (median 1 day) had shorter hospitalization duration than the AS group (median 3 days). The mean operation time was significantly shorter in the VALS group (125.9 minutes) than the AS group (151.9 minutes) (P = .03). There was no significant difference in perioperative and postoperative complication rates. Objective failure rate (8.5% in VALS, 15.6% in AS), subjective failure rates (6.4% in VALS, 9.4% in AS), recurrence (2.1% in VALS, 9.4% in AS) and mesh exposition rates (2.1% in VALS, 9.4% in AS) were similar in both procedures. CONCLUSIONS: VALS with shorter operative time and hospitalization than conventional AS is a promising modification minimally invasive technique for sacrocolpopexy especially for those inexperienced in laparoscopic sacrocolpopexy.

The predictive value of weight gain and waist circumference for gestational diabetes mellitus.

OBJECTIVE: The first objective of this study was to investigate the relationship between gestational diabetes mellitus (GDM) and gestational weight gain (WG), waist circumference (WC), prepregnancy, and gestational body mass index (BMI). The second aim of our study was to assess the ability of WG, WC, prepregnancy, and gestational BMI with special reference to their cut-off points on predicting the risk of GDM in pregnant women in Turkey. MATERIALS AND METHODS: A total of 261 women who underwent screening for GDM with the 75-g glucose tolerance test (GTT) between 24th and 28th gestational weeks were included. According to the 75-g oral GTT results, women were classified into two groups: the GDM group and non-GDM group. The data collected included age, parity, plasma glucose level for fasting, 1- and 2-h tests, WC, prepregnancy and gestational BMI, prepregnancy weight, WG during pregnancy, gestational age at birth, and birth weight. RESULTS: WC at 20-24 weeks of gestation, prepregnancy BMI, and gestational BMI had a predictive capacity for GDM. According to our results, optimal cut-off points for the best predictive value of GDM were WC of 100 cm with a sensitivity of 84% and specificity of 70%, prepregnancy BMI of 25 kg/m2 with a sensitivity of 81.8% and specificity of 76%, and gestational BMI of 28.3 kg/m2 with a sensitivity of 75% and specificity of 77.4%. CONCLUSION: The measurement of prepregnancy BMI, gestational BMI, and WC may be useful in predicting the risk of GDM. Pregnant women with increased prepregnancy BMI, gestational BMI, and WC measurements may be susceptible to the development of GDM.

Incidence and outcomes of eclampsia: a single-center 30-year study.

OBJECTIVE: We aimed to determine the incidence of eclampsia at Erciyes University Hospital which is a tertiary referral center situated at central Anatolia. Additionally, we investigated eclampsia-associated maternal and perinatal outcomes for the 30-year study period. METHODS: A retrospective review was performed for all women who were diagnosed with eclampsia and admitted to the Erciyes University Medical School, Department of Obstetrics and Gynecology from January 1985 to December 2015. Improvement in management gained over time was determined by comparing the results of the years 2005-2015 with data which were already published from years 1985-1999 and 2000-2004. RESULTS: Eclampsia prevalence was 289/46,928 (% 0.61). Maternal age at the time of diagnosis did not differ statistically; however, gestational age at diagnosis and birth weight decreased significantly throughout the years (p < 0.005). The perinatal mortality rate showed a slight decrease throughout the years (p = 0.238). Maternal mortality rate also decreased throughout the years; it was 1.7% in 2005-2009 and 0 % in 2010-2015 (p = 0.246). CONCLUSION: The prevalence of eclampsia cases has decreased over the years. Maternal mortality attributed to eclampsia has also declined. The early diagnosis and treatment of eclampsia have resulted in the increase of premature deliveries. The perinatal mortality rate showed a slight decrease throughout the years (p = 0.238); however, it is not at a desirable rate compared to developed countries.

Preliminary evaluation of foetal liver volume by three-dimensional ultrasound in women with gestational diabetes mellitus.

The aim of the study was to assess the standard foetal biometric measurements and foetal liver volume (FLV) in pregnancies complicated by gestational diabetes mellitus (GDM) at the time of GDM screening and to compare the results with foetuses in normal pregnancies. Ninety-seven pregnant women with normal singleton uncomplicated pregnancies between 24 and 28 weeks of gestation were allocated into GDM (+) (n: 33) and GDM (-) (n: 64) groups based on their 75 g oral glucose tolerance test results. Foetal biometric measurements and FLV measurements of the groups were compared. Although there were no significant differences in the standard biometric measurements between the two groups, FLV was significantly higher in the women with GDM (p < .01). The ROC analysis implied that with a cut-off value of FLV of 32.72 cm3 for GDM prediction, the sensitivity was 78.8% and specificity was 56.3%. We suggest that FLV measurements during the second-trimester ultrasound scanning may be a tool for the prediction of GDM in the obstetric population. Impact statement What is already known on this subject? GDM is an important pregnancy disease, because of its possible foetal and maternal complications. Besides the standard biometric measurements, some other foetal body dimensions such as the anterior abdominal wall thickness, skinfold thickness, adipose tissue thickness, Wharton's jelly thickness, foetal liver length and foetal liver volume (FLV) have been evaluated as ultrasound parameters of glycaemic control. While the evaluation of foetal liver dimensions has a role in identifying foetal growth acceleration, previous studies addressed patients with insulin-dependent diabetes mellitus rather than gestational diabetes mellitus, utilised two-dimensional ultrasound and did not argue the diagnostic value of these findings. What do the results of this study add? In our study, besides the standard biometric measurements, the FLV measurements were evaluated by a three-dimensional ultrasound. Although there were no significant differences in the standard biometric measurements between the GDM (+) and GDM (-) groups, the FLV was significantly higher in women with GDM. The FLV was found to be a potential predictive factor for GDM. The ROC analysis implied that as a cut-off value of FLV of 32.72 cm3 for GDM prediction, the sensitivity was 78.8% and the specificity was 56.3%. What are the implications of these findings for clinical practise and/or further research? Screening for GDM with oral glucose tolerance test within the limited weeks of gestation may not always be feasible. On the other hand, the mid-trimester ultrasound scanning is done almost in all pregnancies. Accordingly, FLV measurement might be an alternative method for the GDM diagnosis.

Amniotic fluid "sludge"; prevalence and clinical significance of it in asymptomatic patients at high risk for spontaneous preterm delivery.

INTRODUCTION: The aim of our study is to determine prevalence and clinical significance of the presence of amniotic fluid "sludge" among asymptomatic patients at high-risk for spontaneous preterm delivery, prospectively. MATERIAL AND METHODS: In our study, 99 patients at high risk for spontaneous preterm delivery were evaluated for the presence of amniotic fluid sludge with transvaginal ultrasonography at 20-22, 26-28, and 32-34 gestational weeks, prospectively; between August 2009 and October 2010 in Hacettepe University Hospital. And, these patients were followed up for their delivery weeks and pregnancy outcomes. We defined the high-risk group as the patients possessing one or more of the followings; a history of spontaneous preterm delivery, recent urinary tract infections, polyhydramnios, uterine leiomyomas, müllerian duct anomalies, and history of cone biyopsy or LEEP. Patients with multiple gestations, placenta previa, fetal anomalies, or symptoms of preterm labor at first examination were excluded. We have obtained ethical board approval from Hacettepe University (16.07.2009-HEK/No:09-141-59). RESULTS: The prevalence of amniotic fluid sludge in the study population was 19,6% (18/92). The rates of spontaneous preterm delivery at <37 weeks of gestation were 66,7% (12/18), within the patients with sludge and 27,0% (20/74) within the patients without sludge. Patients with sludge had a higher rate of spontaneous preterm delivery (p = 0.002). A higher proportion of neonates born to patients with amniotic fluid sludge had a neonatal morbidity (50% (9/18) vs. 24,3% (18/74), p = 0.044) and died in the perinatal period, (p = 0,013) than those born to patients without sludge. When we combined sludge and cervical lenght (CL) (<25 mm) and used it as a screening test to identify women at risk for preterm delivery; it catched more women with preterm delivery, (p = 0.000). While sensitivity of sludge was 37,5%, and sensitivity of CL was 34%, sensitivity of "sludge positive or CL ≤25 mm" was 56% for preterm birth (PTB) in high-risk group. CONCLUSIONS: The prevalence of amniotic fluid sludge is 19,6% and "sludge" is an independent risk factor for spontaneous preterm delivery among asymptomatic patients at high-risk for spontaneous preterm delivery. PTB is by far the leading cause of infant mortality, and prevention of PTB has been an elusive goal. When sludge added to screening, we can catch more PTB.

Clinical and metabolic characteristics of Turkish adolescents with polycystic ovary syndrome.

The aim of this study was to investigate the clinical, endocrine, metabolic features and prevalence of metabolic syndrome (MBS) in Turkish adolescents with polycystic ovary syndrome (PCOS) and the differences in metabolic parameters between adolescent PCOS with or without the presence of polycystic ovaries (PCO) on ultrasound. Subjects (n = 77) were classified into two groups: oligomenorrhea (O) and clinical and/or biochemical hyperandrogenism (HA) (n = 38), without PCO and O + HA with PCO (n = 39). The control group consisted of 33 age-matched adolescents. Adolescents with PCOS had a significantly higher body mass index (BMI), waist circumference and levels of LH, LH/FSH ratio, triglyceride, insulin, HOMA-IR, free androgen index and lower levels of SHBG and FSH. After adjustment for BMI, LH, LH: FSH ratio remained significantly higher. Adolescents with PCOS had a higher prevalence of MBS. No significant differences in lipid profiles, insulin levels and insulin sensitivity in both the PCOS groups were seen. HDL-C levels were lower in the O + HA + PCO group compared to the controls. BMI may be the major contributing factor in the development of metabolic abnormalities in adolescents with PCOS. Impact statement Many studies have investigated the effect of PCOS on metabolic and cardiovascular risks. It is thought that PCOS increases metabolic and cardiovascular risks. Increase in metabolic and cardiovascular risks associated with PCOS may be handled with early diagnosis and early intervention of PCOS in adolescents, although the diagnosis of PCOS in adolescents could be hard because of the features of PCOS overlapping normal pubertal physiological events. However, early identification of adolescent girls with PCOS may provide opportunities for prevention of well-known health risks associated with this syndrome and reduction of long-term health consequences of PCOS by reducing androgen levels and improving metabolic profile. Our results also support that BMI may be the major contributing factor in the development of metabolic abnormalities in adolescents with PCOS.

Dental health dispositions of pregnant women: A survey from a hospital clinic in Istanbul.

Dental hygienic habits should be maintained in pregnancy despite challenges. We aimed to study the dental attitudes and habits of pregnant women. The patients attending our hospital clinic were invited to fill out a structured questionnaire categorised into three major domains: (1) general oral hygiene status, (2) dental habits, and (3) dental attandence both during pregnancy and prior to pregnancy. Four hundred and seventy four women agreed to participate. Mean age of participants was 28 (18-43). While 184 (38%) women reported brushing twice a day, only 98 (20%) women claimed using floss and or mouth rinse. Fifty-nine (12.4%) women had a dental visit in their current pregnancy and 24 (5.1%) received professional treatment. Obstetric care givers should convey the importance of dental care to their patients. We suggest that dental health should be improved antenatally, and be assessed in detail by dental health care providers. Impact Statement Poor oral health conditions have shown to be associated with an increased risk of adverse pregnancy outcomes, especially in low-income countries and regions. There is escalating evidence to support the lack of awareness among pregnant women about health consequences and long term risks associated with poor oral hygiene. Our results showed that dental hygienic practices of pregnant women are disconcerting in Turkey. The need for inter-professional collaboration among obstetric healthcare providers and dental specialistis is crucial for conveying to women the importance of dental care in pregnancy and beyond.

A rat hysteropexy model for evaluating adhesion formation and comparison of two different structured meshes.

INTRODUCTION AND HYPOTHESIS: Peritonization of mesh during sacrohysteropexy is generally advocated to prevent adhesions to the viscera; however, randomized clinical trials are lacking, and peritonization may not be completely possible in a laparoscopic hysteropexy procedure. Our main objective was to describe a basic experimental rat sacrohysteropexy model. We hypothesized that even when peritoneal closure was omitted, using composite mesh would result in less adhesions to the viscera. METHODS: Twenty in-bred female virgin Wistar Hannover rats were used in this study. Standardized hysteropexy procedure and adhesion model is described step by step with two different mesh materials: polypropylene and a composite polyester. Mesh was anchored between the posterior cervix and anterior longitudinal ligament of the lumbar vertebrae. Macroscopic adhesion scores and histopathological tissue reaction was investigated. RESULTS: Macroscopically, the surface area involved in adhesions was similar between groups. However, adhesions in the polypropylene group were more dense, required sharp dissection for lysis, and yielded higher total macroscopic adhesion scores (p < 0.001). Histologically, a more pronounced host inflammatory response was encountered in the polyester group (p < 0.001). CONCLUSIONS: We describe a rat hysteropexy model and a previously established uterine adhesion model. Adhesion scores in the composite mesh group were lower, and bowel involvement was not seen. Our findings are promising, and further research investigating antiadhesive composite mesh use for hysterosacropexy would be appropriate, especially when peritoneal closure is omitted.

Risk factors and microbiology of wound infections following cesarean delivery: Experience of a single institution.

AIMS: To determine the prevalence of wound infection following cesarean delivery, risk factors, common bacterial pathogens and their antibiotic sensitivity. MATERIAL-METHOD: The study population consisted of 5787 cesarean deliveries. All of the patients received 2 g doses of cephazolin perioperatively for antibiotic prophylaxis. Patients with wound infection who had two doses of 1 g cephazolin postoperatively and who were continued on oral preparations of 500 mg of cephuroxime twice daily for 5 days after hospital discharge were included in Group A. Patients with wound infection whose postoperative antibiotics and antibiotics after discharge were omitted were included in Group B. Patient related variables, gestational age, co-morbidities, cesarean section indications, neonatal intensive care requirements were assessed. Risk factors were evaluated according to the type of the procedure (elective or emergent) and administered antibiotic protocol. RESULTS: The incidence of wound infection following cesarean section was 0,37% in elective operations and 5,4% in emergency cases. On the other hand, wound infection rate was found to be 1,35% in antibiotic receiving group (Group A) and 1,12% in the group not receiving antibiotics (Group B). CONCLUSION: Increased rate of wound infections were remarkable in emergency cases and postoperative antibiotics did not have a major impact in reducing the rate of wound infection following cesarean section.

Sonographic depiction of fetal ureters.

AIMS: Classic literature states that the fetal ureter should not be visible unless dilated. Our main objective was to produce an effective, reproducible method for fetal ureter depiction during an anatomic survey. Our secondary objectives were to record the frequency of visible ureters among normal fetuses and among fetuses with mild pyelectasis and also to determine the diameter of the sonographically demonstrated ureter. SUBJECTS AND METHODS: One hundred twenty consecutive fetuses undergoing a second trimester scan were enrolled in the study. Ninety-nine anatomically normal fetuses and 21 fetuses with isolated mild pyelectasis (antero-posterior renal pelvis diameter of ≥4 mm and <7 mm) were subjected to a detailed anatomical survey. One hundred twenty fetuses were analyzed bilaterally. RESULTS: A total of 154 (64.2%) ureters were depicted. In the first group 123 (62.1%) ureters, in the second group 31 (73.8%) ureters were depicted (p = 0.06). The diameters of the ureters ranged from 0.4 to 2.7 mm. The majority (n = 80) (52%) were visualized at both proximal and distal segments. CONCLUSIONS: Our study demonstrates that the ureter can be demonstrated in normal fetuses and in fetuses with mild pyelectasis. Ureteral depiction is likely to be composed of normal transient passage of urine associated with peristalsis and is not always a pathological finding.

Utilization of Wilms' tumor 1 antigen in a panel for differential diagnosis of ovarian carcinomas.

OBJECTIVE: Ovarian metasteses are often mistaken for primary adenocarcinoma. Studies conducted in recent years have focused on a search for an immunohistochemical marker to aid the differential diagnosis primary and metastatic ovarian carcinoma. Our study objective was to study the usefulness of Wilms tumor 1 (WT 1) antigen in this context. MATERIALS AND METHODS: The study was conducted at the pathology clinic of Lütfi Kirdar Training and Research Hospital. Deparaffinated blocks of 40 epithelial ovarian tumors, 40 colon adenocarcinomas, and 35 cases of omentum metastases were studied. Cytokeratin 7 (CK 7), cytokeratin 20 (CK 20), and WT 1 were applied to all specimens. RESULTS: All ovarian adenocarcinomas were stained with CK 7 (100%). Colorectal adenocarcinomas were stained positive with CK 20 in 87.5% of cases. Primary ovarian adenocarcinomas stained positive with WT 1 in 82.5% of the cases and none of the colorectal adenocarcinomas showed staining with WT 1 (0%). CONCLUSION: WT 1 can be used in conjuction with CK 7 in the differential diagnosis of ovarian carcinomas.