Anatomy of the pudendal nerve in clinically important areas: a pictorial essay and narrative review

PURPOSE

The pudendal nerve is an anatomical structure arising from the ventral branches of the spinal roots S2-S4. Its complex course may be affected by surrounding structures. This may result in irritation or entrapment of the nerve with subsequent clinical symptoms. Aim of this study is to review the anatomy of the pudendal nerve and to provide detailed photographic documentation of the areas with most frequent clinical impact which are essential for surgical approach.

METHODS

Major medical databases were searched to identify all anatomical studies investigating pudendal nerve and its variability, and possible clinical outcome of these variants. Extracted data consisted of morphometric parameters, arrangement of the pudendal nerve at the level of roots, formation of pudendal nerve, position according to sacrospinal and sacrotuberal ligaments and its terminal branches. One female cadaver hemipelvis was dissected with common variability of separate course of inferior rectal nerve. During dissection photodocumentation was made to record course of pudendal nerve with focus on areas with recorded pathologies and areas exposed to iatrogenic damage during surgical procedures.

RESULTS

Narrative review was done to provide background for photodocumentation. Unique photos of course of the pudendal nerve was made in areas with great clinical significance.

CONCLUSION

Knowledge of anatomical variations and course of the pudendal nerve is important for examinations and surgical interventions. Surgically exposed areas may become a site for iatrogenic damage of pudendal nerve; therefore, unique picture was made to clarify topographic relations.

New staging of endometrial carcinoma - FIGO 2023

AIM

To review the changes in the new version of the FIGO 2023 staging system for endometrial cancer.

METHODS AND RESULTS

The new FIGO 2023 endometrial cancer staging system provides key updates for the diagnosis and treatment of endometrial cancer. An important step in diagnosis is molecular classification, which allows more accurate risk stratification for recurrence and the identification of targeted therapies. The new staging system, based on the recommendations of the international societies ESGO, ESTRO and ESP, incorporates not only the description of the pathological and anatomical extent of the disease, but also the histopathological characteristics of the tumour, including the histological type and the presence of lymphovascular space invasion. In addition, the staging system uses molecular testing to classify endometrial cancers into four prognostic groups: POLEmut, MMRd, NSMP and p53abn. Each group has its own specific characteristics and prognosis. The most significant changes have occurred in stages I and II, in which the sub-staging better reflects the biological behaviour of the tumour. This update increases the accuracy of prognosis and improves individualized treatment options for patients with endometrial cancer.

CONCLUSION

The updated FIGO staging of endometrial cancer for 2023 incorporates different histologic types, tumour features, and molecular classifications to better reflect the current improved understanding of the complex nature of several endometrial cancer types and their underlying bio logic behaviour. The aim of the new endometrial cancer staging system is to better define stages with similar prognosis, allowing for more precise indication of individualised adjuvant radiation or systemic treatment, including the use of immunotherapy.

Preoperative and postoperative staging in endometrial cancer - a prospective study

OBJECTIVE

The aim of this study was to determine how often changes the stage of the tumour in definitive histology against preoperative clinical stage in patient cohort with diagnosed endometrial cancer.

METHODS

We evaluated prospectively a cohort of 166 patients with endometrial cancer. They all underwent abdominal hysterectomy, bilateral salpingo-oophorectomy, sentinel lymph node biopsy. Patients with high-risk tumours also pelvic lymfadenectomy. We collected data of preoperative diagnostic biopsy and postoperative definitive histology. The data were statistically processed.

RESULTS

Detection of sentinel lymph node was successful in 71.1%, bilateral successful detection was in 40.6%. Discrepancy of tumour grade between preoperative biopsy and definitive histology was generally 31.4%. Upgrading of the tumour was in 22 (14.4%) cases, downgrading in 26 (17%) cases. Upgrade from low-risk to high-risk group of tumours was noticed in eight cases. Histopathological tumour type changed in 6.6%, 4.6% moved to histopathologic high-risk group. The tumour stage changed in definite histology in 57.3%, in 19.2% of cases moved from stage low/intermediate-risk group to intermediate-high/high-risk disease group.

CONCLUSION

Correct assessment of preoperative clinical stage and histological grade of endometrial cancer is burdened with a high inaccuracy rate. A lot of cases is up-staged after surgical staging and moved to intermediate-high/high-risk disease group. Results confirm the importance of oncogynaecologic centre II. evaluation of histopathology findings from diagnostic biopsies made in referring hospitals. Sentinel lymph node biopsy should be performed even in clinically low/intermediate-risk disease group.

Human papillomavirus infection (HPV) and pregnancy

Human papillomavirus (HPV) is the most common sexually transmitted viral infection worldwide, which may result in the development in benign lesions or malignant tumors. The prevalence of HPV infection is twice as high in pregnancy as in non-pregnant women. Additionally, there is a risk of vertical transmission of HPV from mother to fetus during pregnancy or childbirth. Various studies have reported an increased risk of adverse pregnancy outcomes in HPV-positive women, including miscarriage, preterm birth, premature rupture of membranes, preeclampsia, fetal growth restriction, and fetal death. HPV vaccination is not currently recommended during pregnancy. On the other hand, there is no evidence linking HPV vaccination during pregnancy with adverse pregnancy outcomes and termination of pregnancy is not justified in this case.

Management of patient with breast carcinoma diagnosed during pregnancy

OBJECTIVE

To present actual complex review of diagnosis and treatment of breast cancer during pregnancy, demonstrated on particular case report.

DESIGN

Case report and review article.

SETTING

University Hospital Královské Vinohrady, Prague Department of Obstetrics and Gynaecology, Department of Radiotherapy and Oncology.

CASE REPORT

Patient with breast cancer diagnosed in early pregnancy, her oncological treatment. Circumstantial finding was endometriosis of rectovaginal septum and dehiscence of uterotomy after C-section.

DISCUSSION

On this case we demonstrate importance of all early diagnosis, prompt examination management and early therapy onset already during the pregnancy.

CONCLUSION

Breast cancer therapy results are equal in pregnant and non-pregnant women, when we compare patients of same age, with same stage and same biological characteristics of tumor. The obstacle during pregnancy is often late diagnosis, which causes bigger size of tumor and more extensive affection of lymphatics in time of therapy onset.

Individualization of surgical management of cervical cancer stages IA1, IA2

OBJECTIVE

To evaluate the risk of involvement of sentinel lymph nodes in cervical cancer stage IA1 with lymphovascular space invasion and IA2 using the detection of sentinel lymph nodes.

DESIGN

Original article.

SETTINGS

Department of Gynecology and Obstetrics 3rd Faculty of Medicine, Charles University, Faculty Hospital Královské Vinohrady, Prague; Oncogynecological centrum; Department of Pathology 3rd Faculty of Medicine, Charles University, Faculty Hospital Kralovské Vinohrady, Prague.

METHODS

The study included women from prospective protocols LAP I and LAP II with cervical cancer stage IA1 with lymphovascular space invasion and stage IA2 from 2002 to 2018 classified according to FIGO 2014 staging, TNM 8. Detection of sentinel lymph nodes throughout this period was performed using ultra-short protocol with Tc and patent blau and also by histopathological examination.

RESULTS

In the first group (28 women) with stage IA1 and lymphovascular space invasion diagnosed from cone biopsy there were two women with positive lymph nodes (7.1%). In the group stage IA2 (34 women) there were 13 women (38.2%) with positive lymphovascular space invasion and two women had positive lymph nodes (5.9%). The risk of positive lymph nodes for stage IA1 with lymphovascular space invasion and for stage IA2 is not statistically significant OR = 0.8125 (95% CI 0.1070-6.172).

CONCLUSION

The detection of sentinel lymph nodes aids to individualize the therapy of early stage cervical cancer and helps to reduce the radicalization of surgery. The risk of positive lymph nodes in stage IA1 with lymphovascular space invasion and stage IA2 with/without lymphovascular space invasion is the same. The results confirm, that the detection of sentinel lymph nodes in stage IA1 with lymphovascular space invasion is fully indicated.

Bladder rupture after a fall on the ground in a patient with total uterine prolapse

OBJECTIVE

The aim of this work is to present a case of traumatic bladder rupture in a patient with total uterine prolapse. Additionally, we provide a brief description of this issue.

DESIGN

Case report.

SETTING

Department of Obstetrics and Gynaecology, 3rd Faculty of Medicine, Charles University and Královské Vinohrady University Hospital, Prague; Departement of Radiology, 3rd Faculty of Medicine, Charles University and Královské Vinohrady University Hospital, Prague.

RESULTS

We present a case report of a patient with a total uterine prolapse that has been examined for a lower abdominal pain, hematuria and difficulties with urination. The problems arose suddenly after the fall on the ground. These symptoms are typical for bladder rupture, but other more frequent causes have to be ruled out. CT scan showed a contrast agent leak from the bladder. The patient was indicated for surgical revision and suture of the bladder wall.

CONCLUSION

Separately, rupture of the bladder occurs rarely. Most often, this injury is part of a wider trauma - especially after car crashes. However, our case report suggests that this option should be considered.

Histopathological and clinical features of molar pregnancy

OBJECTIVE

To analyse own set of molar pregnancies and to develop clinically relevant procedures.

TYPE OF STUDY

Review article with analysis of own data.

SETTINGS

Department of Pathology 3rd Faculty of Medicine, Charles University, Faculty Hospital Královské Vinohrady, Prague; Department of Obstetrics and Gynecology 3rd Faculty of Medicine, Charles University, Faculty Hospital Královské Vinohrady, Prague.

INTRODUCTION

The study monitors the decrease of laboratory values of beta-subunit of hCG gonadotropin (beta-hCG) after evacuation of partial and complete hydatidiform moles in a set of 45 partial and 46 complete moles. Two case reports of invasive moles.

RESULTS

In cases of partial hydatidiform moles there was complete regression of beta-hCG in all cases, 89% regressed in six weeks, none of the women showed no subsequent elevation after reaching negativity. In cases of complete hydatidiform moles the decrease was less gradual, the negativity after six weeks was confirmed in 78%, three complete moles became malignant.

CONCLUSION

The decrease of beta-hCG after molar pregnancy termination is variable. Even if in cases of complete hydatidiform moles the risk of malignization after reaching negativity is low, beta-hCG checks are recommended at monthly intervals for 6 months. Correct diagnosis of complete mole and its differentiation from partial mole can be achieved using immunohistochemistry - p57 antibody.

[Rupture of focal nodular hyperplasia in the 37th week of pregnanacy - case report]

OBJECTIVE

We describe a case of spontaneous hepatic rupture associated with undiagnosed focal nodular hyperplasia of a patient in the third trimester of pregnancy. Additionally, we provide a brief review of literature.

DESIGN

Case report.

SETTING

Department of Obstetrics and Gynaecology, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague.

RESULTS

We report the case of a 29 year old patient with otherwise physiological pregnancy, who was hospitalized with pain in left hypochondrium. The patient experienced painful respiration, increasing in intensity in supine position. The possibility of lung embolism was considered and ruled out. Based on a suspected haemoperitoneum, caesarean section was performed. During the inspection of peritoneal cavity a ruptured tumor on the liver was identified. Histological examination showed focal nodular hyperplasia.

CONCLUSION

Focal nodular hyperplasia is a benign liver lesion. Complications involving rupture or bleeding are very rare. 17 cases of hepatic rupture associated with focal nodular hyperplasia were described in published reports with only one case related to pregnancy. Our case emphasizes the importance of a close cooperation between a gynaecologist, radiologist and surgeon.

[Ovaria borderline tumor - fertility-sparing surgery; case report]

The borderline tumors are known as low malignant potential tumors. Usually younger women suffer for them, than by the invasive ovarian carcinoma. They often which to be pregnant. The fertility-sparing surgery is posile but contain higher risk of the new disease on contralateral ovary.

The role of trachelectomy in cervical cancer

Cervical cancer is one of the most common cancers in women worldwide. Because it often affects women of childbearing age (19–45 years), fertility-sparing surgery is an important issue. The article reviews current viable fertility-sparing options with a special focus on trachelectomy, including vaginal radical trachelectomy, abdominal radical trachelectomy and simple trachelectomy. Neoadjuvant chemotherapy is also discussed. Finally, the decision to proceed with fertility-sparing treatment should be a patient-driven process.

[Doctors specialty training in obstetrics and gynecology at university medical schools: 2012-2013]

OBJECTIVE

The paper addresses transfer of doctors specialty training from the national Institute of postgraduate medical education (IPVZ) to University Medical Schools (UMS) with the special focus to Obstetrics and Gynecology (OG).

METHODS

The National Specialty Board (NSB) has been established. NSB tasks include definition of inclusion criteria and process of specialty choice at UMS. In OG specialty there are defined mid-term and final postgraduate training courses and other requirements for final specialty exam (FSE) - in particular trainees scientific work and surgery done with the supervision of NTB member. The system of FSE, its content, application, reimbursement and mechanisms are described in details.

RESULTS

In the whole country in 2012 there have been done 864 FSE in all basic medical specialties, which took place at seven UMS. Autumn semester terms has been utilized significantly more than spring terms (57% vs. 43%). There have been differences in the numbers of specialties and also numbers of candidates in each specialty among different UMS. In total 94% of applicants succeed in the FSE. In 2012 within OG specialty training there has been held 56 FSE - 24 exams on five UMS in spring term and 32 (57%) exams only on two UMS in autumn term. In the spring 2013 FSE were organized on 1st LF UK in Prague with 23 applicants, from which 22 successfully passed. During autumn 2013 the FSE in OG will be held on LF UP in Olomouc with 44 applicants for final postgraduate training course and 39 candidates for FSE.

CONCLUSION

Within OG specialty the transfer of doctors specialty training from IPVZ to UMS has been successfully managed. The NSB in OG specialty closely cooperates with past IPVZ and the Accreditation Commission of the Czech Ministry of Health. Thus continuity, quality and continuous enhancement of specialty training program in OG in Czech Republic is assured.

[Lymphedema after vulvar cancer surgery. A prospective study]

INTRODUCTION

Prospective detection of postoperative lymphedema of the lower limbs (LLL) in patients after surgery for vulvar cancer using different examination methods and their comparison.

DESIGN

Prospective clinical study.

SETTING

Department of Obstetrics and Gynecology, 2nd Medical Faculty of the Charles University and University Hospital Motol, Prague.

METHODS

Totally 36 women were followed after surgery for vulvar cancer. Due to the radicality of surgery the patients were divided into conservative (sentinel lymph node biopsy) and radical (inguinofemoral lymphadenectomy) group. Lower limbs were preoperatively and 3, 6 and 12 months after surgery assessed for the presence of lymphedema by measuring of circumferences, multifrequency bioelectrical impedance analysis (MFBIA) and subjective evaluation of patients.

RESULTS

The prevalence of lower limb lymphedema 12 months after surgery diagnosed by subjective evaluation reached 19,44%, by circumference measurement 38,89% and with MFBIA 66,67%. The prevalence of lymphedema after inguinofemoral lymphadenectomy diagnosed by circumference measurement was in 12 months after surgery higher (45.83%) than after the conservative surgery (25%). Risk factors were evaluated 12 months after surgery (age, BMI, adjuvant radiotherapy, type of surgery) and none of them were found to be statistically significant for the development of the lower limbs lymphedema.

CONCLUSION

The prevalence of lymphedema significantly depends on the diagnostic method, because they capture lymphedema in its various stages. Due to the high sensitivity MFBIA can be used for the detection of early stages of lymphedema. Preoperative measurement of the lower limbs is important for early detection of postoperative lymphedema.

[Pregnancy and multiple sclerosis -outcomes analysis 2003-2011]

OBJECTIVE

The analysis of perinatal results in pregnant women with multiple sclerosis (MS) and the assessment of the influence of pregnancy on this chronic disease in the population of pregnant women in our hospital in the years 2003-2011.

DESIGN

Retrospective analysis.

SETTING

Department of Obstetrics and Gynecology and Department of Neurology, 2nd Faculty of Medicine, Charles University and the Motol Hospital, Prague.

METHODS

Sixty-six women with the diagnosis of MS were included in our study in the years 2003-2011. All these women delivered at our clinic and were neurologically followed until the end of six months post partum. We evaluated the influence of pregnancy on the activity of the disease during the pregnancy and 6 months after delivery, the impact on the disability progression, the influence of the mode of delivery, the analgesia used, and breastfeeding, on the relapse rate post partum. We also assessed the impact of multiple sclerosis on the course of the pregnancy, where we looked for pregnancy complications in patients with multiple sclerosis, differences in the management of labor, and the results of newborns of mothers with this disease. We performed a statistical analysis.

RESULTS

Relapse during pregnancy occurred in 4 of the 66 women (6.1%, relapse rate - RR 0.1);17 women experienced a post partum relapse in the first six months after delivery (25.7%, RR 0.5). From our sample of 44 women breastfed (66.7%), 10 had relapse (10/44, 22.7%) in comparison with the 7 women out of a total of 22 who did not breastfed (7/22, 31.8%). No statistical significance was established, OR = 0.6 (0.2-2.0), p = 0.5518. Epidural analgesia (EDA) was used by 16 women (24.2%). Post partum relapse experienced 3 women that used EDA (3/16, 18.8%) and 14 women that did not use EDA (14/50, 28 %). OR = 0.6 (0.1-2.4), p = 0.5325. Neither breastfeeding, nor epidural analgesia correlated with presence of a post partum relapse. Pregnancy did not influence disability progression, EDSS (Disability status scale, Kurtzke`s scale) before pregnancy and after delivery was stable (EDSS 1.5 or EDSS 1.6). Vaginal delivery had 77% women, post partum relapse had 15 of them (15/50, 30%), 12 women (18.1%) had a caesarean section, relapse occure at 2 of them (2/16, 12.5%), three births (4.5%) were completed by vaginal extraction operations. Five women (7.6%) delivered before 37th week of pregnancy. Birth weight under 2500 g was found in 9 women (13.6%). The incidence of serious pregnancy complications was not increased, intrauterine growth retardation (IUGR) was confirmed in 4 births (6%).

CONCLUSION

There is no need to worry about pregnancy in patients with multiple sclerosis. Therapy provides long-term remission of the disease, and during pregnancy itself due to hormonal changes it is stabilized and the relapse rate decreases. In the post partum period relapse rate increases, however, the pregnancy did not influence disability progression. The mode of delivery in women with this disease is not different from the general population. Neither breastfeeding, nor epidural analgesia correlated with presence of a post partum relapses. The number of complications in pregnancy is not increased and the overall perinatal outcomes are comparable with the general population.

Search for photon-linelike signatures from dark matter annihilations with H.E.S.S

Gamma-ray line signatures can be expected in the very-high-energy (E(γ)>100 GeV) domain due to self-annihilation or decay of dark matter (DM) particles in space. Such a signal would be readily distinguishable from astrophysical γ-ray sources that in most cases produce continuous spectra that span over several orders of magnitude in energy. Using data collected with the H.E.S.S. γ-ray instrument, upper limits on linelike emission are obtained in the energy range between ∼ 500 GeV and ∼ 25 TeV for the central part of the Milky Way halo and for extragalactic observations, complementing recent limits obtained with the Fermi-LAT instrument at lower energies. No statistically significant signal could be found. For monochromatic γ-ray line emission, flux limits of (2 × 10(-7) -2 × 10(-5)) m(-2) s(-1) sr(-1) and (1 × 10(-8) -2 × 10(-6)) m(-2) s(-1)sr(-1) are obtained for the central part of the Milky Way halo and extragalactic observations, respectively. For a DM particle mass of 1 TeV, limits on the velocity-averaged DM annihilation cross section ⟨σv⟩(χχ → γγ) reach ∼ 10(-27) cm(3)s(-1), based on the Einasto parametrization of the Galactic DM halo density profile.

[Active cellular immunotherapy of ovarian cancer using dendritic cells]

OBJECTIVE

Overview and comparison of current results of studies dealing with the development and application of anti-cancer vaccines based on dendritic cells in ovarian cancer.

DESIGN

Review.

SETTING

Department of Obstetrics and Gynaecology Charles University, Prague, 2nd Faculty of Medicine and University Hospital Motol, Department of Immunology 2nd Faculty of Medicine and University Hospital Motol.

SUMMARY

Ovarian carcinoma (OVCA) is highly sensitive to chemotherapy; however despite this results from treatment are fairly unsatisfactory. Bearing this in mind, it is important to look for new ways to better understand the immunological mechanisms which could affect reactivation of the disease. It is likely that new knowledge in the field of the immunology of ovarian carcinoma could improve monitoring of the disease and help to ameliorate prognosis of the disease. One strategy in development is creation of anti-OVCA vaccines. Theese vaccines are made by the fusion of dendritic cell (DC) and tumor cells or its parts (NA, peptides). DC are bone-marrow derived leukocytes that are critical in the initiation of T cell mediated immunity. DC are fused to patient-derived ovarian carcinoma cells. The fusion cells induces cytotoxic T cell against autologous OVCA cells.

[Gynaecological precanceroses from the clinical perspective - today and tomorrow]

During the last twenty-five years an enormous shift in our knowledge of cancerogenesis in all gynaecological precancerous and cancerous diseases can be seen. Early diagnosis of these lesions of the lower genital tract (vulva, vagina and cervix) is enabled mainly due to easy access. The major role in the pathogenesis of most precancerous lesions can be accounted to high risk human papillomavirus. Recently, new information about HPV genotypisation of single precancerous lesions and single histological cancer types were revealed. Thus we can better estimate the effect of vaccines on different age groups of women in relation to different types of cancer. The development and introduction of prophylactic vaccines into clinical practice was one of the major improvements of current medicine. Precancerous and cancer lesions of endometrium make themselves known by early symptoms such as perimenopausal and postmenopausal bleeding. Optimal diagnostic and therapeutic procedures have to be based on close cooperation between the clinician and pathologist.

[Review of precancerous vulvar lesions]

Classification of squamous vulvar precancerous lesions is based on the concept of vulvar intraepithelial neoplasia (VIN) and incorporates a three grade evaluation of the intensity of dysplastic changes (VIN I, II and III). On the basis of histological features, VIN has been subdivided into the usual VIN (u-VIN) and differentiated VIN (d-VIN), which represent the two basic pathways of the pathogenesis of vulvar squamous cell carcinoma. Although u-VIN is etiologically associated with the human papillomavirus (HPV) infection and histologically corresponds to cervical intraepithelial neoplasia, d-VIN represents the HPV-negative sequence of vulvar carcinogenesis, which is linked to lichen sclerosus (LS) and lichen simplex chronicus (LSC). u-VIN preferentially occurs in relatively young women with a history of cervical, vaginal or vulvar premalignant lesions. On the other hand, d-VIN usually affects postmenopausal women without anamnestic data of other dysplastic lesions of the lower female genital tract. d-VIN is characterized by a higher tendency of stromal invasion than u-VIN and its malignant potential is analogous to carcinoma in situ (VIN III). The histological appearance of d-VIN is subtle with basal atypia and a well-preserved differentiation of the superficial parts of the squamous epithelium, therefore it is frequently misdiagnosed for u-VIN I, LS or LSC in vulvar biopsies. Primarily because of the low diagnostic reproducibility of the u-VIN I category and the doubts about its precancerous potential as well as due to the questionable differentiation between u-VIN II and III, a revised VIN classification was proposed in 2004. The grading of vulvar precancerous lesions was abandoned, the u-VIN I category was discontinued and u-VIN II and III were merged. In the revised terminology, the term u-VIN represents HPV-associated high grade precancerous vulvar lesions (formerly u-VIN II and III) and d-VIN encompasses HPV-negative high grade dysplasias.

[Guideline for treatment of gynaecological malignant tumours 2010---endometrial carcinoma]

OBJECTIVE

To develop guideline for primary surgical treatment of endometrial carcinoma.

DESIGN

Review, consensus of expert group.

SETTING

Dept. of Gynaecology and Obstetrics, 3rd Medical Faculty of Charles University in Prague.

METHOD

A retrospective review of published data, analysis of statistic data from Czech Republic, consensus among proposers and opponents.

RESULTS

The guideline recognizes endometrial carcinoma patients based on their risk and recommends type of surgical treatment for certain group. It emphasizes the importance of centralized oncogynaecological treatment. Surgical staging remains the basic principle for treatment of endometrial carcinoma patients. The aim of pre-operative diagnostics is to estimate the extent of the disease--"interim staging", that can be different from definitive histopathological staging. Based on risk factors patients are divided into low or high risk group. Standard procedure for low risk patients is hysterectomy and bilateral salpingoophorectomy. It is advisable to use peroperative biopsy in these patients that can shift the patient to high risk group. High risk patients are recommended for hysterectomy, bilateral salpingoophorectomy, and systematic aortopelvic lymphadenectomy. The guideline contains recommendation for young patients wishing to preserve their fertility, for cases of inadequate surgery and for follow-up.

CONCLUSION

Guideline for treatment of endometrial carcinoma is recommendation for clinicians and other subjects who participate on the process of the diagnostics/treatment of endometrial carcinoma patients. All points of the guideline were discussed and voted about by all participants of expert group.