Intra- and post-operative outcomes of the Enhanced Recovery after Surgery (ERAS) Program in laparoscopic hysterectomy.

PURPOSE: To investigate the effect of the Enhanced Recovery After Surgery (ERAS) protocol on perioperative and post-operative outcomes in laparoscopic hysterectomies (LHs) performed for benign gynecological diseases. METHODS: This prospective study was conducted with randomized 100 participants who underwent LH between 1 January and 31 December, 2022. A standard care protocol was applied to 50 participants (Group 1, control) and the ERAS protocol to the other 50 (Group 2, study). Length of hospitalization was compared between the groups as the primary outcome, and the duration of the operation, the amount of bleeding, post-operative nausea-vomiting, gas discharge time, visual analog scale (VAS) pain scores, and complications as the secondary outcomes. RESULTS: No statistically significant difference was seen between the groups in terms of sociodemographic characteristics, medical history, operation indications, surgical procedures applied in addition to hysterectomy, operative time, pre-operative and post-operative hemoglobin levels, amount of bleeding, or drain use (p > 0.05). However, a statistically significant difference was observed in terms of nausea (60% vs. 26%, p = 0.001), vomiting (28% vs. 10%, p = 0.040), duration of gassing (17.74 ± 6.77 vs. 14.20 ± 7.05 h, p = 0.012), length of hospitalization (41.78 ± 12.17 vs. 34.12 ± 10.90 h, p = 0.001), analgesic requirements (4.62 ± 1.36 vs. 3.34 ± 1.27 h, p < 0.001), or VAS scores at the 1st (5.86 ± 1.21 vs. 4.58 ± 1.31, p < 0.001), 6th (5.16 ± 1.12 vs. 4.04 ± 1.08, p < 0.001), 12th (4.72 ± 1.12 vs. 3.48 ± 1.12, p < 0.001), 18th (4.48 ± 1.21 vs. 3.24 ± 1.34, p < 0.001), and 24th (4.08 ± 1.29 vs. 3.01 ± 1.30, p < 0.001) hours. CONCLUSION: The findings of this study show that the ERAS protocol has a positive effect on peri- and post-operative outcomes in LH. Further prospective studies are now needed to confirm the validity of the results.

Prophylactic subcutaneous retention sutures in the prevention of superficial wound separation of midline laparotomy.

OBJECTIVES: This prospective study aimed to determine the effectiveness of prophylactic subcutaneous retention sutures in the prevention of superficial wound separation in women with a confirmed or suspected cancer who had gynecological surgery by midline laparotomy. METHODS: This was a non-randomized, controlled intervention study including patients who underwent cancer surgery between May 2018 and August 2019. Patients who underwent midline laparotomy with confirmed or suspected cancer were included and patients who had an early post-operative complication or who underwent surgery again before the removal of stitches were excluded. The independent variables that might predict the superficial wound site dehiscence and prolongation of the hospitalization period were analyzed using logistical regression analysis. RESULTS: A total of 208 patients were included in the study. Age, presence of comorbid diseases, low pre-operative hemoglobin, low pre-operative albumin, higher weight, higher body mass index (BMI), pre- and post-operative blood transfusion, and absence of retention sutures were associated with higher risk of superficial wound separation. Low pre-operative albumin, weight, and BMI were associated with prolonged length of hospital stay. In a multivariate analysis, BMI (OR: 1.12; 95% CI: 1.09 to 1.28, p<0.001) and retention sutures (OR: 0.31; 95% CI: 0.11 to 0.83, p=0.019) retained an independent association with superficial wound separation. In addition, BMI (OR: 1.11; 95% CI: 1.03 to 1.25, p=0.010) and intra-operative complications (OR: 4.10; 95% CI: 1.08 to 15.60, p=0.038) were independent predictors increasing the length of hospital stay, and use of retention sutures (OR: 0.19; 95% CI: 0.05 to 0.66, p=0.009) was an independent predictor decreasing the length of hospital stay. CONCLUSIONS: Prophylactic subcutaneous retention sutures reduced superficial wound separation and shortened hospital stay. Prophylactic subcutaneous retention sutures may be considered in patients who undergo gynecological surgery using a midline laparotomy.

Obstetrician-gynecologists' practice patterns regarding HPV testing in cervical cancer screening in Turkey.

OBJECTIVE: To determine obstetrician-gynecologists' (OBGYNs) practice patterns regarding human papillomavirus (HPV) testing in cervical cancer screening. Secondly, we aimed to examine OBGYNs' adherence to guidelines in the management of women with HPV-positive test results. MATERIALS AND METHODS: The study was a cross-sectional survey conducted in Antalya and Istanbul provinces in Turkey using a self-reported questionnaire. A 12-item questionnaire form was administered to the participants in face-to-face interviews. Of the targeted participants, 343 OBGYNs completed the questionnaire. RESULTS: The majority of participants, (81.0%) stated that they offered/used HPV testing in cervical cancer screening. Of those, most OBGYNs (89.9%) preferred to use HPV testing concomitant with cervical cytology (co-testing) whereas only 10.1% preferred to use HPV testing alone (primary HPV testing). The most preferred screening intervals for women with HPV-negative results were 5 years (53.4%) and 3 years (19.9%), respectively. In compliance with the guidelines, the rate of participants who recommended "referral directly to colposcopy" for women who were HPV16/18-positive and cytology-negative; and "co-testing at 12 months" for women who were positive for HPV genotypes other than HPV16/18 and cytology-negative was 53.1%. Multivariate analysis revealed that the "professional working setting" was the sole independent determinant of the adherence to the guidelines. OBGYNs working in private settings had the worst adherence rate (42.4%). CONCLUSION: Primary HPV testing is not yet widespread among Turkish OBGYNs. Moreover, adherence to practice guidelines in the management of HPVpositive test results is relatively low. There is a need for continuing medical education regarding screening programs and the management of women with positive screening results.

Hashimoto's thyroiditis worsens ovaries in polycystic ovary syndrome patients compared to Anti-Müllerian hormone levels.

BACKGROUND: The human ovary is the target of autoimmune attack in cases of autoimmune disorders, which can cause ovarian dysfunction. Due to the higher prevalence of Hashimoto's Thyroiditis (HT) in Polycystic Ovary Syndrome (PCOS) patients, we aimed to evaluate ovarian reserve and the effect of autoimmune exposure time on ovarian reserve in PCOS patients with HT by Anti-Müllerian hormone (AMH) levels. METHODS: Forty-six PCOS patients and 46 PCOS with HT diagnosed patients who are between 18 and 35 years old were recruited for this study. Detailed medical histories were obtained from all participants. Polycystic ovary image was evaluated and antral follicles were counted by transvaginal ultrasound. Modified Ferriman Gallwey score, body mass index, waist/hip ratio of the patients were examined. Hormonal, biochemical profiles and AMH levels of the patients were evaluated during the early follicular phase. The data of both groups were statistically analyzed with SPSS 18.0. RESULTS: 20 (43.5%) patients in the PCOS group were fertile, 8 (17.4%) patients in the PCOS + HT group were fertile, fertility rate was significantly lower in PCOS + HT group. The mean AMH value was 8.8 ± 8.8 in the PCOS + HT group and 12.4 ± 8.1 in the PCOS group and it was significantly lower in the PCOS + HT group (p = 0.043). AMH values were significantly negatively correlated with anti-thyroid peroxidase antibody (anti-TPO) level and the duration of HT. There was a significant positive correlation between the anti-TPO level and the duration of HT. CONCLUSiON: We pointed out that the coexistence of PCOS and HT, two prevalent diseases of reproductive age, further diminished ovarian reserve. More exposure of the ovaries to autoantibodies can cause ovarian destruction, similar to the thyroid gland like HT. Because of all these close relations with PCOS and thyroid dysfunctions, we recommend evaluating both thyroid autoantibodies and hormone levels in PCOS patients at the first visit. Patients with PCOS + HT should be monitored more closely to determine the fertility treatment options and control premature ovarian failure (POF) table.

Can gestation be considered as trauma in adolescent girls: post-traumatic stress disorder in teen pregnancy.

Although post-traumatic stress disorder (PTSD) in adolescent pregnancy has been reported at high rates in the limited research in this area, no studies have evaluated gestation as trauma in teens. This study, aimed to evaluate PTSD in this high risk group. All pregnant adolescents who presented to our obstetrics and gynaecology clinics in a one-year period were invited to participate in the study. Adolescents with a history of domestic or dating violence, rape, and sexual abuse were excluded. PTSD was rated using the Child Post-Traumatic Stress Disorder-Reaction Index. When the pregnant adolescents and control group were compared, various severities of PTSD were observed in nearly two-thirds of the study group. Although there was clinically significant PTSD among 23.3% of the controls, PTSD was more frequently seen in adolescents with pregnancy compared with their healthy peers. Educating adolescents about birth control methods and preventing child marriages will be protective in this respect.Impact statementWhat is already known on this subject? Teen pregnancy has significant psychosocial and economic impacts for adolescents, their offspring, and the community in terms of education and employment, increased risk of abuse and neglect, and the physical and emotional well-being of the offspring. Pregnancy and birth-related risks are also higher than in adults. In this context, pregnancy itself may be accepted as trauma for adolescents.What do the results of this study add? There has been limited research on PTSD in pregnant teens and is mainly associated with traumatic childhood events. This is the first study to examine pregnancy-related PTSD and related conditions in this group.What are the implications of these findings for clinical practice and/or further research? The prevalence of pregnancy related-PTSD in pregnant teens can be considered high and alarming, considering the fact that most of them had never been treated for it at all. Healthcare providers serving this population need to be trained to recognise the core symptoms of PTSD, and should direct adolescents for professional assistance if needed. Strategies such as higher quality sexual health education and greater access to reproductive health services to reduce adolescent pregnancy and marriage are also imperative.

Is routine ECC necessary in patients with HPV16 and normal cytology?

BACKGROUND: In the present study, we primarily aimed to correlate the colposcopy results of patients with human papillomavirus (HPV) positivity and abnormal cervical screening results. Secondarily, we attempted to define the role of endocervical curettage (ECC) in the colposcopic evaluation of patients who had normal cytology and HPV16, which is the most carcinogenic HPV type. METHODS: This was a retrospective study analyzing the data of patients who had colposcopies between January 2015 and May 2016 in the Gynecological Oncology clinic of a single tertiary center. The data were evaluated to identify the pathologies in patients with HPV positivity and abnormal cervical screening results. A Colposcopic examination database was evaluated to obtain information regarding the cervical transformation zone (TZ), which was divided into three types by the International Federation for Cervical Pathology and Colposcopy. The binary variables were reported as counts and percentages. RESULTS: A total of 1049 patients were included in the analysis. The median age of the patients was 43 (range: 21-79). Cervical biopsies, ECC results, or both revealed cervical intraepithelial neoplasia 2+ (CIN2+: CIN2, CIN3, and invasive cancer) lesions in 22% (70/322) of the patients with HPV16 positivity, while this ratio was 8% (6/78) for patients with HPV18. CIN2+ lesions were detected in the 2.5% of patients with HPV positivity for types other than 16 and 18, as well as normal cytology. In the group of patients with HPV 16 and normal cytology, CIN2+ results were observed in the ECC of 11% of the patients whose colposcopy was normal regardless of the TZ type. Ten of the patients had invasive cancer. CONCLUSION: The current study provides evidence for the possible role of routine ECC in patients with HPV16, normal cytology, and a normal colposcopy.

A Rare Case: Struma Ovarii in a 14-Year-Old Girl.

Ovarian tumors presented with ovarian mass in childhood and adolescence are uncommon but an important part of gynecological cases. Struma ovarii is one of the rare cystic benign ovarian tumors that is observed predominantly in women who are between the ages of 40 and 60 years old. It is extremely rare in adolescents. Herein, we present a 14-year-old adolescent girl with struma ovarii who presented to the emergency room with abdominal pain.

Infertility and surrogacy first mentioned on a 4000-year-old Assyrian clay tablet of marriage contract in Turkey.

Mankind has been expressing the breeding topic for thousands of years. Reproduction is the primary instinct of human beings and it is a social, cultural, medical issue. Demographic infertility is one of them, which is defined infertility as the inability to become pregnant with a live birth, within five years of regular sexual contact based upon a consistent union status in marriage maintaining a desire for a child with the lack of contraceptive use and non-lactating. A first mentions about infertility and surrogacy is discovered on a 4000-year-old clay tablet of marriage contract belonging to the Assyrian period exhibited at Istanbul Archeology Museum in Turkey. In conclusion, there are many different ways to solve infertility problems like surrogacy as mentioned even 4000 years ago in this Assyrian clay tablet of marriage contract as the first time in the literature. Medical treatments in relation to human infertility will continue to be the focus of social and cultural debates. Hence, more legislation and regulation will come in many countries to control the unauthorized exploitation of the patient.

The Impact of Surgical Staging on the Prognosis of Mucinous Borderline Tumors of the Ovaries: A Multicenter Study.

BACKGROUND/AIM: The purpose of this study was to prove the effect of complete surgical staging of patients with mucinous borderline ovarian tumors (mBOTs) especially appendectomy on progression-free survival (PFS) and overall survival (OS). PATIENTS AND METHODS: The database of 14 gynecological oncology departments from Turkey and Germany were comprehensively searched for women who underwent primary surgery for an ovarian tumor between January 1, 1998, and December 31, 2015, and whose final diagnosis was mBOT. RESULTS: A total of 364 patients with mBOT with a median age of 43.1 years were included in this analysis. The median OS of all patients was 53.1 months. The majority of cases had Stage IA (78.6%). In univariate and multivariate analyses, radical surgery, omentectomy, appendectomy, lymphadenectomy, and adding adjuvant chemotherapy were not independent prognostic factors for PFS and OS. Furthermore, FIGO stage (≥IC vs.

Diminished ovarian reserve in women with transfusion-dependent beta-thalassemia major: Is iron gonadotoxic?

OBJECTIVE: Iron accumulation in the endocrine glands has been implicated in the aetiopathogenesis of decreased reproductive capacity in patients with beta-thalassemia major (ß-TM). The aim of the current study was to investigate the serum concentration of anti-Müllerian hormone (AMH), a marker of ovarian reserve, in women with transfusion-dependent ß-TM. STUDY DESIGN: In this case-control study, we recruited 43 women with transfusion-dependent TM and 44 age-matched healthy controls. Hormonal and haematological parameters, serum level of AMH, antral follicle count, and ovarian volume were assessed. RESULTS: Twenty-two of the 43 women were hypogonadotropic, 8 with primary amenorrhea and 14 with secondary amenorrhea. FSH, LH, estradiol, prolactin, and AMH levels; antral follicle count; and ovarian volume were significantly lower in women with TM compared with the control group (p<0.05 for all). CONCLUSION: AMH level and other ovarian reserve markers are significantly diminished in women with transfusion-dependent TM compared to age-matched controls. Our findings support a deleterious effect of iron overload on ovarian tissue.

Comparison of thyroid function tests and blood count in pregnant women with versus without gestational diabetes mellitus.

AIM: The aim of this study was to compare thyroid function and complete blood count parameters in pregnant women with versus without gestational diabetes mellitus (GDM). METHODS: A total of 269 pregnant women patients with (n = 110, GDM group) or without (n = 159, non-GDM group) GDM were included in this study. Data on age, rate of cesarean section, birthweight of neonate, hemogram, and thyroid function tests were collected. Multivariate analysis was performed to determine factors predicting increased risk of GDM. RESULTS: Rate of cesarean section (70.9 vs 57.2%, P = 0.022), median (max-min) age (33.0 [26.0] vs 26.0 [20.0] years, P < 0.001), platelet count (246.7 ± 68.3 vs 227.8 ± 64.2 ×103 /µL, P = 0.021) and thyroid-stimulating hormone (1.3 [97.6] vs 1.0 [4.1] µIU/mL, P = 0.028) were significantly higher in the GDM than in the non-GDM group; whereas mean platelet volume (10.4 [5.3] vs 10.6 [5.6] fL, P = 0.031) and free triiodothyronine (FT3) (2.9 [3.6] vs 3.1 [3.0] pg/mL, P < 0.001) levels were significantly lower in the GDM than in the non-GDM group. Older age (odds ratio, 1.281; 95% confidence interval, 1.182-1.389, P < 0.001) and lower FT3 levels (odds ratio, 0.295; 95% confidence interval, 0.149-0.586, P < 0.001) were independently associated with increased risk of GDM. CONCLUSION: Our findings revealed that lower FT3 levels and older age predict the likelihood of developing GDM in euthyroid pregnant women, with no influence of other thyroid hormones or blood counts on the risk of GDM.

The association between serum ghrelin levels and large-for-gestational-age fetuses in patients with gestational diabetes mellitus.

We aimed to determine the relationship between serum ghrelin levels and large-for-gestational-age (LGA) fetuses in patients with gestational diabetes mellitus (GDM). A case-control study was conducted in 32 women with GDM and LGA fetuses (GDM + LGA group), 35 women with GDM and appropriate-for-gestational-age (AGA) fetuses (GDM + AGA group), 32 women with normal glucose tolerance (NGT) and LGA fetuses (NGT + LGA group), and 31 women with NGT and AGA fetuses (NGT + AGA group). All participants were recruited at the time of GDM diagnosis between 24 and 30 weeks of pregnancy. Participants also underwent ultrasonographic examinations. Serum ghrelin levels were significantly higher in GDM + LGA and GDM + AGA groups than in the NGT + AGA group. In the univariate model, biparietal diameter, head circumference, abdominal circumference (AC), femur length and ghrelin values were significant predictors of LGA fetuses. In the multivariate model, only AC remained as a predictor of LGA fetuses.

Borderline ovarian tumors: clinical characteristics, management, and outcomes - a multicenter study.

BACKGROUND: The optimal surgical management and staging of borderline ovarian tumors (BOTs) are controversial. Institutions have different surgical approaches for the treatment of BOTs. Here, we performed a retrospective review of clinical characteristics, surgical management and surgical outcomes, and sought to identify variables affecting disease-free survival (DFS) and overall survival (OS) in patients with BOTs. METHODS: A retrospective review of ten gynecological oncology department databases in Turkey was conducted to identify patients diagnosed with BOTs. The effects of type of surgery, age, stage, surgical staging, complete versus incomplete staging, and adjuvant chemotherapy were examined on DFS and OS. RESULTS: In total, 733 patients with BOTs were included in the analysis. Most of the staged cases were in stage IA (70.4 %). In total, 345 patients underwent conservative surgeries. Recurrence rates were similar between the conservative and radical surgery groups (10.5 % vs. 8.7 %). Furthermore we did not find any difference between DFS (HR = 0.96; 95 % confidence interval, CI = 0.7-1.2; p = 0.576) or OS (HR = 0.9; 95 % CI = 0.8-1.1; p = 0.328) between patients who underwent conservative versus radical surgeries. There was also no difference in DFS (HR = 0.74; 95 % CI = 0.8-1.1; p = 0.080) or OS (HR = 0.8; 95 % CI = 0.7-1.0; p = 0.091) between complete, incomplete, and unstaged patients. Furthermore, receiving adjuvant chemotherapy (CT) for tumor stage ≥ IC was not an independent prognostic factor for DFS or OS. CONCLUSIONS: Patients undergoing conservative surgery did not show higher recurrence rates; furthermore, survival time was not shortened. Detailed surgical staging, including lymph node sampling or dissection, appendectomy, and hysterectomy, were not beneficial in the surgical management oF BOTs.

Successful Treatment of Uterine Arteriovenous Malformation due to Uterine Trauma.

Uterine arteriovenous malformation (AVM) is defined as abnormal and nonfunctional connections between the uterine arteries and veins. Although the patients typically present with vaginal bleeding, some patients may experience life-threatening massive bleeding in some circumstances. The treatment of choice depends on the symptoms, age, desire for future fertility, and localization and size of the lesion; however, embolization of the uterine artery is the first choice in symptomatic AVM in patients at reproductive age with expectations of future fertility. We report a case of acquired AVM (after D/C) with an extensive lesion, which was successfully treated with bilateral uterine artery embolization (UAE).

Robotic Compartment-Based Radical Surgery in Early-Stage Cervical Cancer.

A radical hysterectomy with pelvic lymphadenectomy is the recommended treatment option in patients with early-stage cervical cancer. Although various classifications were developed in order to define the resection margins of this operation, no clear standardization could be achieved both in the nomenclature and in the extent of the surgery. Total mesometrial resection (TMMR) is a novel procedure which aims to remove all components of the compartment formed by Müllerian duct in which female reproductive organs develop. TMMR differs from the conventional radical hysterectomy techniques in that its surgical philosophy, terminology, and partly resection borders are different. In this paper, a TMMR with therapeutic pelvic lymphadenectomy operation that we performed for the first time with robot-assisted laparoscopic (robotic) approach in an early-stage cervical cancer patient was presented. This procedure has already been described in open surgery by Michael Höckel and translated to the robotic surgery by Rainer Kimmig. Our report is the second paper, to our knowledge, to present the initial experience regarding robotic TMMR in the English literature.

The platelet activating factor acetyl hydrolase, oxidized low-density lipoprotein, paraoxonase 1 and arylesterase levels in treated and untreated patients with polycystic ovary syndrome.

PURPOSE: To evaluate the platelet activating factor acetyl hydrolyze (PAF-AH), oxidized low-density lipoprotein (ox-LDL), paraoxonase 1 (PON1), arylesterase (ARE) levels and the effects of metformin and Diane-35 (ethinyl oestradiol + cyproterone acetate) therapies on these parameters and to determine the PON1 polymorphisms among PCOS patients. METHODS: Ninety patients with PCOS, age 30, and body mass index-matched healthy controls were included in the study. Patients were divided into three groups: metformin treatment, Diane-35 treatment and no medication groups. The treatment with metformin or Diane-35 was continued for 6 months and all subjects were evaluated with clinical and biochemical parameters 6 months later. One-way Anova test, t test and non-parametric Mann-Whitney U tests were used for statistical analysis. RESULTS: PAF-AH and ox-LDL levels were statistically significantly higher in untreated PCOS patients than controls, and they were statistically significantly lower in patients treated with metformin or Diane-35 than untreated PCOS patients. In contrast, there were lower PON1 (not statistically significant) and ARE (statistically significant) levels in untreated PCOS patients than the control group and they significantly increased after metformin and Diane-35 treatments. In PCOS patients serum PON1 levels for QQ, QR and RR phenotypes were statistically significantly lower than the control group. CONCLUSION: In patients with PCOS, proatherogenic markers increase. The treatment of PCOS with metformin or Diane-35 had positive effects on lipid profile, increased PON1 level, which is a protector from atherosclerosis and decreased the proatherogenic PAF-AH and ox-LDL levels.