Impact of clinicopathological variables on laparoscopic hysterectomy complications, a tertiary center experience.

OBJECTIVES: To analyze intraoperative and postoperative complications according to Clavian-Dindo Classification (CDC) and evaluate the influence of clinicopathological features on the feasibility and safety of total laparoscopic hysterectomy (TLH) in patients that underwent surgery in a tertiary center. MATERIAL AND METHODS: We retrospectively reviewed the database of 469 patients that underwent surgery for patients who underwent extra facial TLH from 2013 to 2020. RESULTS: A total of 86 (18.3%) peri-postoperative complications were observed. The incidence of intraoperative complications was 2% (n = 10). The overall conversion rate to open surgery was 1.9% (n = 9). A total of 76 postoperative complications were observed in 61 patients (14.3%). The incidence of minor (Grade I [n = 16, 3.4%] and II [n = 42, 8.9%]) and major complications (Grade III [n = 15, 3.2%], IV [n = 2, 0.4%] and V [n = 1, 0.2 %]) were 12.3% and 3.8%, respectively. A higher BMI and performing surgery at the first step of learning are found to be associated with intraoperative and postoperative complications (p < 0.05). Postoperative complications related to having a history of the cesarean section, additional comorbidities, and uterine weight ≥ 300 g (p < 0.05). CONCLUSIONS: The implementation of TLH by experienced surgeons appears to have remarkable advantages over open surgery. However, the risk factor for complications should be taken into account by surgeons in the learning curve in selecting the appropriate patient for surgery.

Vaginal Reconstruction for Vaginal Obliteration Secondary to Stevens Johnson Syndrome: A Case Report and Review of Literature.

Stevens-Johnson syndrome (SJS) is a rare and acute life-threatening condition, which is almost always precipitated by drugs. Genital mucositis in female patients may also be an important cause of long-term morbidity secondary to mucosal scarring. We present the case of a 33-year-old nulligravid woman with distal vaginal synechiae necessitating a surgical approach, which occurred after an episode of SJS. Also, we aimed to review the literature to reveal cases which required surgical management for long-term genital sequelae as well as discuss preventive measures.

Diagnostic and Treatment Reproducibility of Cervical Intraepithelial Neoplasia / Squamous Intraepithelial Lesion and Factors Affecting the Diagnosis.

OBJECTIVE: Inter-observer differences in the diagnosis of HPV related cervical lesions are problematic and response of gynecologists to these diagnostic entities is non-standardized. This study evaluated the diagnostic reproducibility of "cervical intraepithelial neoplasia" (CIN) and "squamous intraepithelial lesion" (SIL) diagnoses. MATERIAL AND METHOD: 19 pathologists evaluated 66 cases once using H&E slides and once with immunohistochemical studies (p16, Ki-67 and Pro-ExC). Management response to diagnoses was evaluated amongst 12 gynecologists. Pathologists and gynecologists were also given a questionnaire about how additional information like smear results and age modify diagnosis and management. RESULTS: We show moderate interobserver diagnostic reproducibility amongst pathologists. The overall kappa value was 0.50 and 0.59 using the CIN and SIL classifications respectively. Impact of immunohistochemical evaluation on interpretation of cases differed and there was lack of statistically significant improvement of interobserver diagnostic reproducibility with the addition of immunohistochemistry. We saw that choice of treatment methods amongst gynecologists varied and overall concordance was only fair to moderate. The CIN2 diagnostic category was seen to have the lowest percentage agreement amongst both pathologists and gynecologists. We showed that pathologists had diagnostic "styles" and gynecologists had management "styles". CONCLUSION: In summary each pathologist had different diagnostic tendencies which were affected not only by histopathology and marker studies, but also by the patient management tendencies of the gynecologist that the pathologist worked with. The two-tiered modified Bethesda system improved diagnostic agreement. We concluded that immunohistochemistry should be used only to resolve problems in select cases and not for every case.

Impact of adjuvant treatment on oncologic outcomes in patients with stage I leiomyosarcoma of the uterus.

BACKGROUND/AIM: This study aimed to evaluate the role of adjuvant therapy for stage I uterine leiomyosarcoma (LMS). MATERIALS AND METHODS: Clinicopathological data of cases of stage I uterine LMS from 1998 to 2015 were retrieved from the computerized database of Hacettepe University Hospital. The Kaplan-Meier method was used to estimate survival and progression-free survival, and survival differences were analyzed by log-rank test. Cox regression analysis was performed to account for the potential influence of confounding factors. RESULTS: We evaluated the outcomes of 35 patients with histologically proven stage I LMS. The median age at diagnosis was 50 years. All patients underwent surgical treatment and 20 patients (57.1%) received adjuvant therapy. Twelve of these patients (34.3%) received adjuvant chemotherapy, 3 (8.6%) received adjuvant pelvic irradiation, and 5 (14.2%) received adjuvant chemotherapy with pelvic irradiation. The median follow-up duration was 34 months (range: 3-231 months). Twenty-three (65.7%) patients had a recurrence during follow-up. Adjuvant therapy did not significantly improve median progression-free survival or median overall survival. Cox regression analysis did not demonstrate any significant impact of the factors studied, including age, menopausal status, tumor size, mitotic count, staging surgery, or adjuvant therapy. CONCLUSION: Adjuvant therapy for surgically treated stage I uterine LMS did not improve oncologic outcomes.

Repair of diaphragmatic injury and placement of tube thoracostomy during right upper quadrant peritonectomy.

OBJECTIVE: Patients with advanced or recurrent ovarian cancer often have metastatic disease in the upper abdominal region, especially to the right hemidiaphragm, which requires diaphragmatic resection in order to achieve optimal cytoreduction. The aim of this surgical video is to demonstrate repair of a diaphragmatic injury and placement of tube thoracostomy during right upper quadrant peritonectomy in a patient with recurrent ovarian cancer. METHODS: This is the case of a 45-year-old woman presented with platinum sensitive recurrent ovarian cancer. Abdomen computed tomography also confirmed peritoneal carcinomatosis and pelvic recurrent mass. HIPEC was administered after complete cytoreduction including bilateral upper quadrant peritonectomy, during which diaphragmatic injury occurred near the central tendon and pleural cavity was entered. We inserted a chest tube through the 6th intercostal space in the anterior axillary line in order to prevent postoperative massive pleural effusion. Diaphragmatic defect was closed primarily after the tube placement. The chest tube was withdrawn on the third postoperative day and the patient was discharged on postoperative day 25 without any complications. RESULTS: The central tendon of diaphragm is the most vulnerable part for lacerations. Diaphragmatic repairs could be performed by various techniques; interrupted or continuous, locking or non-locking sutures, with either permanent or absorbable materials. In our view, all of the techniques provide similar results and surgeons can choose any of them as long as they are comfortable with the procedure. CONCLUSION: In most cases, these lacerations can be repaired primarily without necessitating tube thoracostomy. However, performance of HIPEC can cause massive pleural effusions which can lead to significant pulmonary morbidity. Therefore, retrograde placement of the chest tube under direct vision is quite straightforward when the diaphragm is opened.

Widespread recurrence 7 years after radical abdominal trachelectomy for early cervical adenocarcinoma.

Cervical cancer is the third most common female cancer worldwide and the use of routine screening resulted in earlier stage and younger age at diagnosis. Fertility preservation via radical trachelectomy comes up as an option in such patients. Recent literature reviews confirm the safety of this operation with excellent oncologic outcomes in appropriately chosen patients. However, recurrent disease is likely and a strict follow-up is recommended to detect recurrences at an early stage following radical trachelectomy. In this report, a case who underwent radical trachelectomy and developed widespread recurrences 7 years after initial surgery possibly due to the lack of oncologic follow-up is discussed.

Accuracy of intraoperative frozen section in the evaluation of patients with adnexal mass: retrospective analysis of 748 cases with multivariate regression analysis.

OBJECTIVE: To evaluate the accuracy of intraoperative frozen section in the evaluation of patients with adnexal mass and to define the clinicopathological factors associated with misdiagnosis during frozen section evaluation. METHODS: The clinicopathological data of patients who underwent exploratory laparotomy for adnexal mass were reviewed. Results of the intraoperative frozen section and permanent histology reports were compared. Univariate and multivariate analyses were performed to reveal factors associated with misdiagnosis. RESULTS: The study group consisted of 748 patients. Of these patients, 509 (68.0%) had benign, 43 (5.7%) had borderline, 196 (26.2%) had malignant histological diagnosis at permanent section. The overall agreement between intraoperative frozen section and permanent pathology was 96.8%. Twenty four out of 745 cases (3.8%) were misdiagnosed by frozen section. Univariate analysis showed that borderline histology (p < 0.0001) and tumor size larger than 10 cm (p = 0.012) were associated with misdiagnosis. According to multivariate analysis, borderline histology (OR: 22.6, p < 0.0001) was the only independent predictor for misdiagnosis during frozen examination. CONCLUSION: The frozen section evaluation of the adnexal mass is highly accurate. However, tumor size greater than 10 cm and borderline histology are the factors that adversely influence the accuracy of intraoperative frozen section. Clinicians must be aware of these pitfalls during intraoperative decision making following frozen section report.

HPV types in Turkey: multicenter hospital based evaluation of 6388 patients in Turkish gynecologic oncology group centers.

OBJECTIVE: To evaluate the prevalence of HPV DNA and cervical cytological abnormalities, to compare cervical cytology results and HPV DNA and to define HPV types distribution in a large series of Turkish women who have undergone HPV analysis in hospitals that are members of the Turkish Gynecological Oncology Group. MATERIAL AND METHOD: Between 2006 and 2010, a total of 6388 patients' data was retrospectively evaluated at 12 healthcare centers in Turkey. Demographic characteristics, cervical cytology results, HPV status and types were compared. RESULTS: The mean age of the patients was 38.9±10.2. Overall, 25% of the women were found to be HPV positive. Presence of HPV-DNA among patients with abnormal and normal cytology was 52% and 27%, respectively. There was significant difference with respect to decades of life and HPV positivity (p < 0.05). HPV was positive in (within the HPV (+) patients) 37%, 9%, 27%, 20%, 22%, and 41% of the ASCUS, ASC-H, LSIL HSIL, glandular cell abnormalities, and SCC cases respectively The most common HPV types in our study were as follows; HPV 16 (32%), HPV 6 (17%), HPV 11 (9%), HPV 18 (8%), HPV 31 (6%), HPV 51 (5%), HPV 33 (3%). CONCLUSION: In this hospital based retrospective analysis, HPV genotypes in Turkish women with normal and abnormal cytology are similar to those reported from western countries. Further population based prospective multicenter studies are necessary to determine non-hospital based HPV prevalence in Turkish women.

Clinical outcome of transobturator tape concomitant with vaginal hysterectomy plus anterior posterior colporrhaphy.

OBJECTIVE: Transobturator tape (TOT) is a newly described procedure for the treatment of female stress urinary incontinence. The success of TOT operation along with prolapsed surgery has not been well described. The aim of this study is to determine the complication and success rates of TOT concomitant with pelvic prolapse surgery. STUDY DESIGN: Totally, 72 women who had TOT operation along with vaginal hysterectomy, anterior posterior colporrhaphy were re-evaluated with UDI6 and IIQ7 forms 1 year of surgery. Preoperatively, all patients had clinically pure stress incontinence. RESULTS: At 1 year, 80.6% of patients were cured with only 16.7% presenting de novo urge incontinence, while 2.8% of women retaining stress urinary incontinence. The patients with lower gravida and number of vaginal delivery had significantly higher operation success rates. The IIQ7 score significantly increased by increase in urinary catheter stay day. The women with the history of cesarean delivery and lower hospital stay had significantly higher satisfaction scores. Of the factors only, the number of gravida could be used to predict treatment failure in the entire group. CONCLUSION: Transobturator tape procedure could be accompanied safely with prolapse surgery.

The role of secondary cytoreduction in the treatment of ovarian cancer: Hacettepe University experience.

OBJECTIVE: This study was undertaken to evaluate the role of secondary cytoreduction in patients with recurrent epithelial ovarian cancer. STUDY DESIGN: Secondarily, cytoreduced patients were retrospectively analyzed with respect to the clinicopathologic variables. RESULTS: A total of 64 patients were evaluated in this report. Multivariable analysis revealed 3 factors to be significant: optimal cytoreduction during primary (P = .003, odds ratio [OR]: 0.30; 95% CI: 0.14-0.66), secondary cytoreduction (P = .04, OR: 0.47; 95% CI: 0.22-0.99), and the endometrioid histologic type (P = .005, OR: 0.09; 95% CI: 0.02-0.48). Intrinsic factors of the tumors (grade, stage, age), size, and number of recurrent tumors were nonsignificant. CONCLUSION: Secondary cytoreductive surgery should be offered in selected recurrent epithelial ovarian cancer patients. Further prospective randomized series are needed to determine specific recommendations.

Trigeminal schwannoma mimicking magnesium intoxication in a pregnancy complicated by severe preeclampsia.

We present a case report describing a pregnancy complicated by severe preeclampsia and a trigeminal schwannoma which caused loss of consciousness, diplopia and blurred vision, which were initially thought to be signs of magnesium intoxication.