Immunohistochemical expression of hormonal receptors, collagen, elastin, and proteoglycans in genuine urinary incontinence.

PURPOSE: To study the expression of hormonal receptors, collagen, elastin, proteoglycans, and VIP in the vaginal wall of women with stress urinary incontinence (SUI). MATERIALS AND METHODS: Fifty-eight specimens of the anterior vaginal wall (28 women with SUI) were processed by Ventana immunostaining method. RESULTS: Both groups were compatible for age, BMI, and obstetric history. Positive ER-α and ER-ß immunoreaction was observed in 46.4% and 3.6% of SUI (43.3% and 33.3% of controls) (p < 0.05), respectively, and PR immunoreaction in 39.3% of SUI (46.7% of controls). Collagen I and III immunoreaction was observed in 28,6% and 21.4% of SUI (30.% and 36.7% of controls), respectively, and elastin, decorin, and fibromodulin immunoreaction in 10.7%, 10.7%, and 10.7% of SUI (50%, 33.3%, 33,.3% of controls) (p < 0.05), respectively. VIP immunoreaction was observed in 7.1% of SUI (36.7% of controls). CONCLUSION: Imunoexpression of ER-P, elastin, decorin, fibromodulin, and VIP was significantly lower in SUI than controls, showing that the ER-ß dependent re-modeling of the extracellular matrix of vaginal tissues is the main mechanism of SUI.

Secondary hypoparathyroidism during pregnancy--a case report and review of the literature.

Secondary hypoparathyroidism is seldom seen during pregnancy. Usually, it presents with hypocalcemia. Even if there is no established therapeutic treatment, vitamin D or its analogues are required. In the present case, a 36-year-old, second gravida, with known hypoparathyroidism for the last ten years, was admitted in the prenatal clinic of "Aretaieion" University Hospital in Athens at her 39 weeks of pregnancy. She was treated with calcitriol and calcium and she was monitored monthly. She had a cesarian section and delivered a healthy female baby of 3,380 gr at 39 weeks and 1 day.

Second-trimester miscarriage and umbilical cord knot. Case report and review of the literature.

PURPOSE OF INVESTIGATION: The present study presents a case with an umbilical cord knot along with extensive literature review. MATERIALS AND METHODS: Presentation of a rare case of second-trimester abortion which was attributed to a tight umbilical cord knot. Furthermore the authors reviewed the literature from 1952 to 2012 in order to compare impact of knots on intrapartum and perinatal outcomes. RESULTS: Four large retrospective studies assessed several predisposing factors. Long umbilical cords, male embryos, and multiparity were correlated with knots in three of these studies. Data regarding perinatal effects of true knots from three studies were summarized and compared. CONCLUSION: Umbilical cord true knots during the second trimester could be a very rare cause of abortion. The presence of knots during the third trimester and labor do not seem to be associated with increased perinatal and intrapartum morbidity and mortality, although there is still some controversy in the literature on this topic.

Tension-free vaginal tape obturator versus Ajust adjustable single incision sling procedure in women with urodynamic stress urinary incontinence.

OBJECTIVE: To assess the efficacy and complications of inside-out transobturator tension-free vaginal tape (TVT-O) in comparison with a single incision sling procedure (Ajust) for the treatment of urodynamic stress urinary incontinence. STUDY DESIGN: Prospective closely matched controlled study. In total, 171 patients were included in the study: 86 women underwent the TVT-O procedure, while in other 85 cases the Ajust procedure was performed. Subjective and objective cure, improvement and failure rates, mean operative time, hospital stay and incidence of complications were assessed. RESULTS: There was no statistically significant difference between the two groups for age, body mass index, parity, menopausal status and severity of prolapse. No major intraoperative complications occurred. There was no significant difference in the mean operative time and the duration of hospital stay between the two groups. The mean follow-up time of the study was 22.3 months (range 12-36 months). For the TVT-O group the objective cure rate was 86%, the improvement rate was 5.9% and the failure rate was 8.1%, while the subjective cure rate was 82.6%. For the Ajust group the objective cure rate was 84.7%, the improvement rate was 4.7%, 10.6% of patients showed no change in their symptoms and the subjective cure rate was 81.2%. CONCLUSIONS: The Ajust sling procedure presents success rates, at 22 months' mean follow up, comparable to the TVT-O method. Both techniques seem to be safe and effective for the treatment of urodynamic stress urinary incontinence.

Surgical repair of a complicated urethro-vaginal fistula: case report and review of the literature.

BACKGROUND: Urethro-vaginal fistulae (UVF) occur usually as infrequent complications of a variety of gynecological surgical procedures. The aim of this study was to present an interesting case of a complicated UVF diagnosed after gynaecological surgery. CASE: A 61-year-old gravida-2, para-2, post-menopausal woman was referred with a complaint of urine loss through the vagina. She had undergone anterior and posterior vaginal wall repair due to cystocele and stress urinary incontinence (SUI). Transvaginal repair was performed 20 weeks after primary surgery. However, a second transvaginal reconstructive surgery using Martius-flap originating from the bulbocavernosus muscle was necessary due to persistent urine leakage in the vagina. Thirty-two months after successful urethro-vaginal treatment, the patient self-referred for persistent SUI. Burch colposuspension was performed and at 16 months follow-up the patient remains continent. DISCUSSION: Surgical repair of complicated UVF seems to be more successful with Martius flap interposition than with no interposition.

Clinicopathological changes of uterine leiomyomas after GnRH agonist therapy.

OBJECTIVE: Gonadotrophin-releasing hormone agonist (GnRHa) has been commonly used for the medical treatment of prostate cancer, precocious puberty, endometriosis, adenomyosis and uterine leiomyomas. GnRHa therapy in cases of symptomatic uterine leiomyomas aims for the reduction of their size and remission of symptoms such as menometrorrhagia, causing a state of hypoestrogenemia. This is considered to be a helpful preoperative strategy in cases of large myomas, or anemia because of abnormal vaginal bleeding. The aim of this retrospective study was to examine the clinicopathological changes in uterine leiomyomas exposed to preoperative GnRHa therapy for two up to six months. MATERIALS AND METHODS: The study group consisted of 10 premenopausal patients who were treated with GnRHa prior to surgery. RESULTS: In all cases the size of leiomyomas was reduced after GnRHa therapy. A microscopic review of the surgical specimens showed increased cellularity and ischemic type of necrosis. CONCLUSION: Morphological changes of uterine leiomyomas are often associated with preoperative GnRH agonist therapy. The differential diagnosis from uterine leiomyosarcomas includes absence of mitotic activity.

Clinicopathological characteristics of adnexal lesions diagnosed during pregnancy or cesarean section.

OBJECTIVE: The diagnosis of an incidental adnexal lesion during pregnancy has become more common after the widespread use of routine ultrasonography (US). The aim of this study was to examine the diagnostic approach, management strategy and the pathological findings in cases of adnexal lesions that were diagnosed and treated during pregnancy in our department. MATERIALS AND METHODS: This was a 15-year retrospective study. Cases of adnexal lesions detected during routine prenatal care by US or while performing cesarean section, between January 1996 and December 2010 at Aretaieion Hospital of the National University of Athens, were analyzed. RESULTS: In this study period 39 cases of adnexal lesions were diagnosed during pregnancy or cesarean section. The age of the women was between 21 and 40 years (mean age 32.4). Surgical excision of the lesions was decided in 32 cases and conservative treatment was followed in the remaining seven cases. Surgical removal of the lesions was performed during cesarean section in 13 cases of term gestations and in four cases of preterm gestations in which pregnancy termination was considered necessary. Laparotomy during the antepartum period led to excision of adnexal lesions in 15 cases. Histology revealed benign ovarian lesions in 25 cases (78.1%), borderline ovarian tumors in two cases (6.3%), malignant ovarian tumors in four cases (12.5%) and adenocarcinoma of the appendix in one case (3.1%) presenting as an ovarian mass. DISCUSSION: The management of cases diagnosed with adnexal lesions during pregnancy remains controversial. According to the literature, the estimated risk of malignancy for adnexal masses during pregnancy is low (2-3%) and complications of these lesions are extremely rare. These data suggest that adnexal masses could be managed conservatively if possible with US follow-up. On the other hand, the results of this study showed a higher incidence of malignancy among adnexal lesions that were surgically treated (15.6%). CONCLUSION: Surgical intervention and histological examination in cases suspicious for malignancy at US and clinical findings remain the treatment of choice even during pregnancy.

Clinicopathological features and immunoprofile of 30 cases of Brenner ovarian tumors.

AIM: The aim of this study was to investigate the clinicopathological and immunopathological features of Brenner ovarian tumors. MATERIALS AND METHODS: Thirty cases of Brenner ovarian tumors were examined in our laboratory among 1,680 cases of ovarian tumors, representing 1.5% of all tumors examined. Blocks of paraffin-embedded tumor tissue for all cases were available for additional immunohistochemical stain by a Ventana autoimmunostainer. Moreover, antibodies for Uroplakine III (cellmarque AU-1 clone, 1:25) Chromogen (monosan clone 5H7,1:25) WT1 (novocastra, clone 3F-H2, 1:25) NSE (DAKO, clone BB5/NC/V1-H14, 1:50), CK20 (DAKO, clone Ks20.8, 1:50),CK7 (Zymed 1:25, clone V-TL12/30)were used. RESULTS: The mean age of the patients was 51.4 years ranging from 16 to 82 years. The tumor was unilateral in 28 cases (16/28 in the right ovary and 12/28 in the left ovary) and bilateral in two cases. Twenty-eight cases (93%) were benign and two (7%) were proliferating (borderline) tumors. Seventeen cases (56%) were pure Brenner tumors, measuring from 0.5 to 2.5 cm and 13 cases (44%) were mixed tumors consisting of a Brenner tumor element and a mucinous ovarian tumor (10/13 cases, 53.8%) and a germ cell tumor in 3/13 cases. The largest diameter of the mixed tumors ranged from 7 to 22 cm. The largest area consisting of Brenner elements measured 7 cm. The immunoprofile of Brenner tumor cell was cytokeratine-7 positive (30/30 cases) cytokeratine-20 negative in the Brenner cell element but positive in the mucinous component in 5/7 cases of mixed Brenner tumors, focally WT-1 positive (5/30 cases), NSE negative (0/30 cases) and focally chromogranine positive (6/30 cases), Uroplakin-III positive in 23/30 cases, with faint cytoplasmatic or luminal distribution. In conclusion, Brenner ovarian tumors are unilateral, small and benign neoplasms in their majority and present specific histopathological and immunopathological characteristics and mixed forms with other epithelial and germ cell neoplasms. This could be explained as a form of metaplasia or a diverse histogenesis from surface epithelium and/or the germ cell ovarian component.

Single umbilical artery: fetal and placental histopathological analysis of 24 cases.

AIM: 24 cases of single umbilical artery (SUA) are presented and the related histopathological findings of the fetuses and placentas examined. SUA is the most common congenital anomaly of the umbilical cord, resulting in the absence of one of the two umbilical arteries. It has an incidence of approximately 2.1% in autopsy material and there is evidence that is associated with anomalies of the fetus and placenta. MATERIAL-METHOD: The files were reviewed of 24 cases with SUA, out of 1,570 autopsies of fetuses and placentas performed in the Pathology Laboratory of Aretaieion Hospital, due to spontaneous or induced abortions after written parental consent. RESULTS: The incidence of SUA was 1.6%. Gestational age ranged between the 15th and 33rd week and mother's age ranged from 17-44 years. Three of 24 cases were twin pregnancies; 17/24 fetuses were male. In 21/24 cases complex congenital anomalies were observed and in five of 24 cases chromosomal anomalies were detected. In eight of 24 placentas extensive infarcts were observed; 7/24 dysmaturity, 5/24 severe chorioamnionitis, 3/24 extensive fibrin accumulation and 1/24 chorioangiosis. CONCLUSION: SUA is an umbilical congenital anomaly associated with severe fetal congenital anomalies and once detected with ultrasound techniques, further and more detailed control of the fetus is considered mandatory.

Endometrial carcinoma and ovarian sex cord tumor with annular tubules in a patient with history of Peutz-Jeghers syndrome and multiple malignancies.

BACKGROUND: Peutz-Jeghers syndrome is a rare syndrome which is inherited in a dominant manner. It is characterized by hamartomatous polyps of the gastrointestinal tract, hyperpigmented macules of the oral mucosa and an increased risk of developing neoplasms in the gastrointestinal tract, pancreas, breast and genital system. Women with Peutz-Jeughers syndrome often develop an ovarian sex cord tumor and cervical adenocarcinoma of minimal deviation adenoma malignum type. A case of a 58-year-old patient with Peutz-Jeghers syndrome and history of multiple malignancies (thyroid, breast and colon cancer) who presented with metrorrhagia is reported. The dilatation and curettage revealed endometrial adenocarcinoma. The patient underwent total abdominal hysterectomy with bilateral oophorectomy. The histologic examination showed an endometrioid endometrial adenocarcinoma that developed in atypical endometrial hyperplasia. The histologic examination of the right ovary revealed a sex cord tumor with annular tubules, measuring 3 cm. Sex cord tumors with annular tubules in patients with Peutz-Jeghers syndrome are usually small, bilateral tumors of the ovaries which have common characteristics with granulosa cell tumor and Sertoli cell tumor. Hyperestrogenism is a rather common finding with development of estrogen-dependent lesions.

Virilizing ovarian Krukenberg tumor in a 27-year-old pregnant woman. A case report and literature review.

A case is reported of a 27-year-old pregnant woman with ovarian tumors, measuring 12 cm and 11.5 cm in the greatest diameter, discovered during investigation for virilization symptoms. Termination of the pregnancy at the 22nd week of gestation and tumorectomy with both adnexa were performed, with the provisional diagnosis of arrhenoblastoma. Pathological examination of the tumors showed typical Krukenberg neoplasms and subsequent upper GI tract endoscopy revealed a gastric cancer that was excised. The pathological examination revealed a diffuse type gastric adenocarcinoma with signet ring morphology, similar to ovarian tumors. In any case of ovarian tumor with unusual hormonal manifestations, in addition to hormonally active sex cord-stromal neoplasms, metastatic ovarian tumors must be considered as well, especially in cases of bilateral tumors.

Advantages of radio frequency (RF) cone biopsy compared to large loop excision of the transformation zone (LLETZ) in patients with high-grade squamous intraepithelial lesions: a retrospective study.

OBJECTIVE: The aim of this study was to compare radio wave cone biopsy to the LLETZ method in patients with high-grade squamous intraepithelial lesions. METHOD-RESULTS: This was a retrospective study of 186 patients diagnosed with HGSIL who underwent cone biopsy either with the LLETZ method (82/186) or with the radio wave method (104/186) in the 2nd Obstetrics and Gynecology Department, University of Athens, Aretaieion Hospital, Athens, Greece during the period January 1999 to December 2008. The mean age of the patients was 31 years (range 23 to 53 years). The volume of cone ranged from 1.2 x 2 cm up to 3 x 3.6 cm in both techniques. Histopathological analysis revealed focal or extensive high-grade squamous intraepithelial neoplasia extending into the underlying endocervical glands in 128/186 patients. Concomittent low-grade squamous intraepithelial lesions were observed in 160/186 patients and coilocytic atypia was observed in 172/186 patients. The endocervical margins were free of disease in 172/186 cases. In seven cases the neoplastic lesions were at least 0.1 cm from the margin and in seven cases they extended to the margin. In all cases a degree of tissue coagulative change was observed, but not extensive to the point of obscuring the diagnosis. CONCLUSION: 4.0 MHz radio wave surgery is an excellent alternative in the treatment of HGSIL. Clear surgical margins due to decreased heat and tissue damage, controlled hemostasis, faster healing, and patient and doctor satisfaction are notable advantages.

Cervical adenocarcinoma with clear cell morphology. report of six cases and literature review.

Clear cell cervical adenocarcinoma (CCA) is a rather rare malignancy of the genital tract. We report six cases of CCA, diagnosed in our laboratory during a 15-year period: five patients with sporadic primary CCA and one young patient with CCA and a history of in utero exposure to DES. The possible DES exposure, clinicopathological findings as well as the differential diagnosis and the the prognosis of such patients are presented in a mini-review of the literature.

The use of the pessary test in preoperative assessment of women with severe genital prolapse.

OBJECTIVE: To investigate whether a preoperative pessary test could be used to identify patients with occult stress incontinence and if simultaneous anti-incontinence surgery with a midurethral sling could prevent postoperative incontinence. STUDY DESIGN: Eighty-two patients with a positive pessary test and severe genital prolapse participated in the study: 43 patients underwent prolapse surgery and transobturator tension-free vaginal tape (TVT-O) insertion and 39 patients underwent prolapse surgery only. RESULTS: The objective cure rate for TVT-O and prolapse surgery was 90.7% at three months follow up and 88.4% at two years follow up. The objective cure rate for prolapse surgery only was 74.4% at three months and 58.9% at two years follow up. CONCLUSION: The pessary test can be used preoperatively in patients with significant genitourinary prolapse to identify those with occult stress urinary incontinence. The TVT-O procedure in this context could be a useful optional procedure as it appears to be very effective and safe in patients with occult stress incontinence.

Monodermal teratomas (struma ovarii). Clinicopathological characteristics of 11 cases and literature review.

During the last 15 years in the Pathology Laboratory of Aretaieion University Hospital, 256 cases of teratomas were examined and 11 cases (4.3%) presented characteristics of struma ovarii. Eight patients aged 19-34 years and four 41-74 years (median 41 years). One 74-year-old patient presented with virilization signs but pain and a pelvic mass were the most frequent symptoms. The tumors were unilateral in 9/11 cases, the size ranged from 5-17 cm, and they were compact or microcystic in 10/11 cases and cystic in one case. Histological pattern was microfollicular in 5/11 cases, solid in 3/11 cases, pseudoglandular in 2/11 cases, with focal clear and oxyphil cell changes, and infiltration of the fibrous wall in one case. Tumorectomy was performed in 9/11 cases and total hysterectomy with adnexa in two cases with large tumors (16-17 cm in diameter). Immunohistochemistry is useful in the recognition of struma in atypical cases. No malignant struma ovarii was observed in our cases. Tumorectomy is the appropriate therapeutic approach because of the benign nature of these tumors despite atypical histological features and the young age of the patients.

Vulvar cancer: prognostic significance of the clinicopathological characteristics.

Vulvar cancer is a relatively uncommon neoplasm of the female reproductive system. The aim of this retrospective study was the analysis of the pathologic and clinical characteristics of vulvar cancer and their prognostic significance. During the period January 1996 to December 2005, 82 patients were treated for a vulvar malignancy. The management was surgical.

A molecular dynamics study on the transport of a charged biomolecule in a polymeric adsorbent medium and its adsorption onto a charged ligand.

The transport of a charged adsorbate biomolecule in a porous polymeric adsorbent medium and its adsorption onto the covalently immobilized ligands have been modeled and investigated using molecular dynamics modeling and simulations as the third part of a novel fundamental methodology developed for studying ion-exchange chromatography based bioseparations. To overcome computational challenges, a novel simulation approach is devised where appropriate atomistic and coarse grain models are employed simultaneously and the transport of the adsorbate is characterized through a number of locations representative of the progress of the transport process. The adsorbate biomolecule for the system studied in this work changes shape, orientation, and lateral position in order to proceed toward the site where adsorption occurs and exhibits decreased mass transport coefficients as it approaches closer to the immobilized ligand. Furthermore, because the ligands are surrounded by counterions carrying the same type of charge as the adsorbate biomolecule, it takes the biomolecule repeated attempts to approach toward a ligand in order to displace the counterions in the proximity of the ligand and to finally become adsorbed. The formed adsorbate-ligand complex interacts with the counterions and polymeric molecules and is found to evolve slowly and continuously from one-site (monovalent) interaction to multisite (multivalent) interactions. Such a transition of the nature of adsorption reduces the overall adsorption capacity of the ligands in the adsorbent medium and results in a type of surface exclusion effect. Also, the adsorption of the biomolecule also presents certain volume exclusion effects by not only directly reducing the pore volume and the availability of the ligands in the adjacent regions, but also causing the polymeric molecules to change to more compact structures that could further shield certain ligands from being accessible to subsequent adsorbate molecules. These findings have significant practical implications to the design and construction of polymeric porous adsorbent media for effective bioseparations and to the synthesis and operation of processes employed in the separation of biomolecules. The modeling and analysis methods presented in this work could also be suitable for the study of biocatalysis where an enzyme is immobilized on the surface of the pores of a porous medium.

Granular cell tumor of the female genital system. Clinical and pathologic characteristics of five cases and literature review.

The clinical and pathological characteristics of a rare granular cell tumor that developed in the vulva (4 cases) and the breast (1 case) offive women aged 35-52 years are reported. The differential diagnosis from skin carcinomas, melanoma and various soft tissue tumors is emphasized.

The use of oestradiol therapy in postmenopausal women after TVT-O anti-incontinence surgery.

OBJECTIVE: To investigate whether patients who were treated with TVT-O procedure for urodynamic stress incontinence had a significant improvement in their urodynamic findings and their post-operative symptoms (frequency, urgency, nocturia) if they were treated post-operatively with vaginal oestradiol for 6 months compared to the non-treated group. METHODS: Prospective randomised study. 190 patients were asked to participate in our study. Finally, a total of 92 patients in group 1 and 91 patients in group 2 completed the study. In group 1, which was the treatment group, patients having the TVT-O procedure for urodynamic stress incontinence were instructed to use post-operatively oestradiol tablets, 25 micrograms (Vagifem, Novo Nordisk) vaginally, once daily, nocte, for 2 weeks and then twice weekly for 6 months. The patients in group 2 (control group) had the TVT-O procedure only. All patients were reviewed in 2 months and again in 6 months time. RESULTS: There was no statistically significant difference between the two groups concerning pre-operative and post-operative haemoglobin, operative time, hospital stay or return to work. The within group analysis did not show significant differences between pre-operative and post-operative urodynamic data in both groups. Patients treated with vaginal estradiol post-operatively showed a statistically significant reduction in relation to the symptoms of urgency and frequency but not in relation to nocturia and urge incontinence compared to the non-treated group. There is no difference in relation to the efficacy of TVT-O procedure between the groups at 6 months follow-up. CONCLUSION: It appears that vaginal oestradiol treatment could be offered to postmenopausal patients after a TVT-O procedure having the symptoms of frequency and urgency provided they are aware of the lack of evidence regarding long term benefit.

Primary mixed epithelial and germ cell tumors of the ovary. Two case reports and literature review.

Two cases of mixed germ cell and epithelial primary ovarian tumors which developed in women 47 and 57 years of age are reported. In both cases, large teratomas measuring 20 and 21 cm were observed in combination with carcinoids and malignant mucinous neoplasms. A possible common oncogenic mechanism is discussed and a literature review is presented.