The Manchester operation for uterine prolapse

OBJECTIVE

To evaluate the clinical characteristics, complications, and satisfaction scores of patients who underwent the Manchester operation.

METHODS

This retrospective observational study evaluated data from 204 women who underwent the Manchester operation at the Department of Obstetrics and Gynecology of Hacettepe University School of Medicine, Ankara, Turkey, from January 1985 to April 2004.

RESULTS

Mean age was 34.68+/-4.24 years and parity 2.47+/-0.96; 85.8% of the patients were premenopausal; 176 patients (86.28%) had grade 3 and 28 (13.72%) had grade 2 uterine prolapse; 95.1% of the patients had associated cystoceles and 51.3% had associated rectoceles; and 81.4% had urinary incontinence. Regarding early postoperative complications, 27 patients (13.23%) had febrile morbidity; retroperitoneal hematoma occurred in 1 patient (0.49%); urinary retention occurred in 45 patients (22.05%), and cervical stenosis occurred in 23 patients (11.27%). At 1 year, 1 patient had undergone abdominal hysterectomy because of unsuccessful cervical dilatation; and a mean of 3.6 years following the operation, 8 patients (3.9%) had undergone the tension-free vaginal tape procedure plus a vaginal hysterectomy for recurrent stress urinary incontinence and uterine prolapse. The mean satisfaction/acceptance score for the operation was 8.52+/-2.13 (range, 2-10).

CONCLUSION

A high degree of acceptance/satisfaction and a low morbidity rate show the Manchester operation to be a good option for the treatment of uterine prolapse in women who wish to keep their uterus.

Recurrence of high-grade squamous intraepithelial neoplasia in neovagina: case report and review of the literature

Recurrent carcinoma in situ in neovagina is rare, and the optimal modality of treatment is unclear. A 33-year-old multiparous woman was referred for vulvar intraepithelial neoplasia, vaginal intraepithelial neoplasia, and cervical intraepithelial neoplasia, underwent skinning vulvectomy with perianal excision, total vaginectomy, vaginal hysterectomy, and vaginal reconstruction with split-thickness skin graft. Ten years after initial surgery, the recurrence as a high-grade intraepithelial neoplasia in the upper one third of neovagina was detected. For that reason, the upper one third of vaginectomy with at least 5-mm tumor-free border and vaginal reconstruction with split-thickness skin graft were performed. She has attended her regular follow-up for 3 years with no evidence of disease. All patients with vaginoplasty should undergo regular follow-up. This report is the seventh such report in English literature of patients previously treated for in situ carcinoma who later developed recurrence in the graft.

Which surgical procedure for patients with atypical endometrial hyperplasia?

OBJECTIVE

To determine the occult coexistence of endometrial carcinoma in patients with atypical endometrial hyperplasia and to compare histological prognostic factors according to lymph node status in occult endometrial carcinoma.

MATERIALS AND METHODS

Two hundred and four patients from two referral centers (during the period 1990-2003) who were operated on within 1 month of endometrial biopsy for symptomatic endometrial hyperplasia without receiving any medical treatment were included retrospectively. Patients having preoperative endometrial biopsy results of concomitant endometrial hyperplasia and carcinoma were excluded from the study. Fifty-six patients having atypia in preoperative biopsy (group I) were compared with 148 patients without atypia (group II). Chi-square and Mann-Whitney U-tests were used for statistical analyses.

RESULTS

No significant difference was observed between the two groups according to age or menopausal status. Patients in group II had significantly higher parity than patients in group I. In group I, 62.5% of the patients had endometrial carcinoma, 21.4% had endometrial hyperplasia, and 16.1% had normal endometrium in hysterectomy specimens. In group II, the percentages were 5.4, 38.5, and 56.1%, respectively. Complete surgical staging was performed in 20 patients. Four patients had metastatic lymph nodes. All of them had grade 2 tumors with lymphovascular space involvement. Three of them had nonendometrioid tumors.

CONCLUSION

Careful intraoperative and preoperative evaluation of the endometrium must be the sine qua non for patients with atypical endometrial hyperplasia. It is reasonable to do frozen section at the time of hysterectomy for atypical endometrial hyperplasia, and if grade 2/3 of nonendometrioid cancer with lymphovascular space involvement is found, complete surgical staging should be performed.

Primary Hydatid Cyst in Adrenal Gland: A Case Report

The hydatid cyst of the adrenal gland is extremely rare pathology of the adrenal gland; here we report an adrenal hydatid cyst that presented as a solitary renal tumor.

Which surgical procedure for patients with atypical endometrial hyperplasia?

Objective

To determine the occult coexistence of endometrial carcinoma in patients with atypical endometrial hyperplasia and to compare histological prognostic factors according to lymph node status in occult endometrial carcinoma.

Materials and Methods

Two hundred and four patients from two referral centers (during the period 1990–2003) who were operated on within 1 month of endometrial biopsy for symptomatic endometrial hyperplasia without receiving any medical treatment were included retrospectively. Patients having preoperative endometrial biopsy results of concomitant endometrial hyperplasia and carcinoma were excluded from the study. Fifty-six patients having atypia in preoperative biopsy (group I) were compared with 148 patients without atypia (group II). Chi-square and Mann–Whitney U-tests were used for statistical analyses.

Results

No significant difference was observed between the two groups according to age or menopausal status. Patients in group II had significantly higher parity than patients in group I. In group I, 62.5% of the patients had endometrial carcinoma, 21.4% had endometrial hyperplasia, and 16.1% had normal endometrium in hysterectomy specimens. In group II, the percentages were 5.4, 38.5, and 56.1%, respectively. Complete surgical staging was performed in 20 patients. Four patients had metastatic lymph nodes. All of them had grade 2 tumors with lymphovascular space involvement. Three of them had nonendometrioid tumors.

Conclusion

Careful intraoperative and preoperative evaluation of the endometrium must be the sine qua non for patients with atypical endometrial hyperplasia. It is reasonable to do frozen section at the time of hysterectomy for atypical endometrial hyperplasia, and if grade 2/3 of nonendometriod cancer with lymphovascular space involvement is found, complete surgical staging should be performed.

Which surgical procedure for patients with atypical endometrial hyperplasia?

OBJECTIVE

To determine the occult coexistence of endometrial carcinoma in patients with atypical endometrial hyperplasia and to compare histological prognostic factors according to lymph node status in occult endometrial carcinoma.

MATERIALS AND METHODS

Two hundred and four patients from two referral centers (during the period 1990-2003) who were operated on within 1 month of endometrial biopsy for symptomatic endometrial hyperplasia without receiving any medical treatment were included retrospectively. Patients having preoperative endometrial biopsy results of concomitant endometrial hyperplasia and carcinoma were excluded from the study. Fifty-six patients having atypia in preoperative biopsy (group I) were compared with 148 patients without atypia (group II). Chi-square and Mann-Whitney U-tests were used for statistical analyses.

RESULTS

No significant difference was observed between the two groups according to age or menopausal status. Patients in group II had significantly higher parity than patients in group I. In group I, 62.5% of the patients had endometrial carcinoma, 21.4% had endometrial hyperplasia, and 16.1% had normal endometrium in hysterectomy specimens. In group II, the percentages were 5.4, 38.5, and 56.1%, respectively. Complete surgical staging was performed in 20 patients. Four patients had metastatic lymph nodes. All of them had grade 2 tumors with lymphovascular space involvement. Three of them had nonendometrioid tumors.

CONCLUSION

Careful intraoperative and preoperative evaluation of the endometrium must be the sine qua non for patients with atypical endometrial hyperplasia. It is reasonable to do frozen section at the time of hysterectomy for atypical endometrial hyperplasia, and if grade 2/3 of nonendometrioid cancer with lymphovascular space involvement is found, complete surgical staging should be performed.

Non-Hodgkin's lymphoma complicating pregnancy: a case report

A 40-year-old, gravida 3, para 2 woman was initially referred to our department at 31 weeks' gestation complaining of fever, night sweats, malaise in association with jaundice and pancytopenia. Cesarean section with excisional iliac lymph node biopsy was carried out following a period of expectant management. An 1,840 g healthy male infant with an Apgar score of 9 at 34 weeks of gestation was delivered. Histologic examination of the excised lymph node revealed non-Hodgkin's lymphoma (Histiocyte and T cell predominant B cell lymphoma). The patient was evaluated to have Stage II B disease. A chemotherapy regimen of CHOP/Rituximab was instituted with successful maternal-fetal prognosis.

Quantitative telomerase activity in malignant, benign and normal gynecological tissues

OBJECTIVE

The aim of this study was to evaluate quantitative telomerase activity in malignant, benign and normal gynecological tissue samples by using the Telomerase-PCR ELISA kit, and to determine a cut-off level for malignancy by this quantitative method.

MATERIALS AND METHODS

Fifty gynecological tumors, 27 benign gynecological disorders and 29 normal tissues were analyzed by the Telomerase-PCR ELISA kit. All tissues were confirmed by a pathologist. A ROC (receiver operator characteristic) curve was drawn to determine a threshold level best discriminating malignant tissues from benign pathologies and normal tissues. Telomerase activity was compared in malignant, benign and normal tissues.

RESULTS

The mean level of telomerase activity of the malignant tumor samples (1.03 +/- 0.53 units) was significantly (p < .001) higher than the normal tissues (0.13 +/- 0.07 units) and benign pathologies (0.37 +/- 0.25 units). The cut-off point to differentiate malignant samples from benign samples was set at 0.42 units, where the sensitivity was 93.8% and the specificity was 89.3%. Positive predictive value was 84% and negative predictive value was 89.3%. There was a significant difference in telomerase activity between malignant, benign and normal tissues within each histological group.

CONCLUSION

In this preliminary study, the telomerase-PCR ELISA method was found to have a high sensitivity and specificity to differentiate malignant gynecological tissues from benign tissues.

Placental site trophoblastic tumor in a patient with brain and lung metastases

Placental site trophoblastic tumor is a rare neoplasm that arises from intermediate trophoblasts and shows diversity of biological behaviors, resulting in the absence of consistency in treatment modalities. A case of placental site trophoblastic tumor that extended to the cervix, with primary manifestation of amenorrhea and yellow foul-smelling vaginal discharge, is presented. Total abdominal hysterectomy was performed initially, and serial measurements of human chorionic gonadotropin levels were obtained. She was admitted with metastases to brain and lung 1.5 years after surgery. Combination chemotherapy (etoposide-methotrexate-dactinomycin/cyclophosphamide-vincristine) and radiotherapy were administered. There was no significant response to chemoradiotherapy. Despite changing chemotherapy regimen, she is still alive with progressive disease.

Recurrent extraperitoneal low grade leiomyosarcoma with unusual localization

Primary extragenital leiomyosarcoma is rarely found in pelvic localization. A 33-year-old multiparous woman who had recurrent low-grade leiomyosarcoma presented with the complaints of dyspareunia, pelvic pain and gait disturbance. Her past medical history revealed she had been subjected to maximal excision of a paravaginal mass by using vaginal and suprapubic transverse incision three years before. The pathology report showed that she had leiomyoma. Three years after the initial surgery, a paravaginal fixed mass was observed at the initial tumor bed and removed by the perineal approach. The histological examination of the specimen revealed a low grade leiomyosarcoma. She was discharged from hospital without any complications.

Management of ovarian dysgerminoma during a pregnancy complicated by preeclampsia; a case report

A case of a 25-year-old primigravid woman at 31 weeks' gestation with the diagnosis of preeclampsia, malignant pelvic mass, fetal growth restriction and postpartum pulmonary thromboembolism is reported. Fertility preserving surgery for ovarian carcinoma following cesarean delivery was carried out. Final histopathology revealed Stage IC dysgerminoma. After eight months of initial surgery she became pregnant spontaneously. After two years of initial surgery she is still alive without any evidence of disease.

Transit of tRNA through the Escherichia coli ribosome. Cross-linking of the 3' end of tRNA to specific nucleotides of the 23 S ribosomal RNA at the A, P, and E sites

When bound to Escherichia coli ribosomes and irradiated with near-UV light, various derivatives of yeast tRNA(Phe) containing 2-azidoadenosine at the 3' terminus form cross-links to 23 S rRNA and 50 S subunit proteins in a site-dependent manner. A and P site-bound tRNAs, whose 3' termini reside in the peptidyl transferase center, label primarily nucleotides U2506 and U2585 and protein L27. In contrast, E site-bound tRNA labels nucleotide C2422 and protein L33. The cross-linking patterns confirm the topographical separation of the peptidyl transferase center from the E site domain. The relative amounts of label incorporated into the universally conserved residues U2506 and U2585 depend on the occupancy of the A and P sites by different tRNA ligands and indicates that these nucleotides play a pivotal role in peptide transfer. In particular, the 3'-adenosine of the peptidyl-tRNA analogue, AcPhe-tRNA(Phe), remains in close contact with U2506 regardless of whether its anticodon is located in the A site or P site. Our findings, therefore, modify and extend the hybrid state model of tRNA-ribosome interaction. We show that the 3'-end of the deacylated tRNA that is formed after transpeptidation does not immediately progress to the E site but remains temporarily in the peptidyl transferase center. In addition, we demonstrate that the E site, defined by the labeling of nucleotide C2422 and protein L33, represents an intermediate state of binding that precedes the entry of deacylated tRNA into the F (final) site from which it dissociates into the cytoplasm.

Plasma leptin and insulin levels in weight-reduced obese women with normal body mass index: relationships with body composition and insulin

Obesity is a complex disease with multiple features that has confounded efforts to unravel its pathophysiology. As a means of distinguishing primary from secondary characteristics, we compared levels of fasting plasma leptin and insulin in a cohort of weight-reduced obese women who have attained and maintained a normal BMI for more than 1 year with the levels in cohorts of never-obese and currently obese women. Weight-reduced obese women showed decreased plasma concentrations of leptin and insulin compared with obese women, but these levels remained significantly higher than those of never-obese women. Plasma leptin levels were highly correlated with plasma insulin levels (r = 0.60, P < 0.001). To further explore relationships with body composition, total body fat was determined by dual-energy X-ray absorptiometry and body fat distribution by computed tomography in subsets of these groups. Weight-reduced obese women had a significantly greater percent body fat and subcutaneous abdominal fat mass than did the never-obese women, and these were highly correlated with plasma leptin (r = 0.90, P < 0.001, and r = 0.52, P < 0.001, respectively). In these weight-reduced obese women, visceral fat mass was similar to that of the never-obese. The insulin sensitivity index and first-phase insulin response were also comparable. These results demonstrate that higher leptin levels in weight-reduced obese women are related to the higher total fat and particularly the subcutaneous fat masses. Normalization of visceral fat mass in the weight-reduced obese was accompanied by normalization of insulin sensitivity index and first-phase insulin response. This study suggests that increases in plasma leptin and insulin in obesity are secondary features of the obese state.

Simultaneous gradient-echo/spin-echo EPI of graded ischemia in human skeletal muscle

The goal of this study was to evaluate the usefulness of blood oxygenation level-dependent (BOLD) methodologies to provide temporal and spatial information about skeletal muscle perfusion. A simultaneous gradient echo (GE) and spin-echo (SE) imaging sequence (GE/SE) with alternating TE was used to acquire images of leg skeletal muscle throughout a stepped reactive hyperemia paradigm. The change in both the GE and SE relaxation rates (deltaR2*, deltaR2) measured during ischemia and reactive hyperemia scaled with the duration of cuff inflation (the ischemic period) plateaued for cuff inflations lasting longer than 120 seconds and were greater in soleus muscle than in gastrocnemius. The ratio deltaR2*/deltaR2 was found to be less during the reactive hyperemia period relative to ischemia. Considering that a greater proportion of capillary vessels are perfused during reactive hyperemia than during ischemia, this finding suggests that magnetic susceptibility methodologies, with their dependence on compartment size, may provide a measure of the relative distribution of small and large vessels in skeletal muscle.

The major integral membrane glycoprotein in adipocytes is a novel 200-kDa heterodimer

The major glycoprotein in adipocytes was purified from rat adipocyte membranes by affinity chromatography with wheat germ agglutinin-agarose followed by DEAE-Sepharose ion exchange chromatography. The protein had an apparent molecular weight of 200-kDa when analysed by SDS-PAGE under non-reducing conditions. When electroeluted from the gel, boiled in the presence of beta-mercaptoethanol, and re-analysed by gel electrophoresis, it was found to be composed of 100- and 160-kDa subunits. The N-terminal sequences were determined through 20 amino acids for each subunit, were found to be identical, and were homologous with no previously described protein sequences. The protein was not extractable from the membrane by high salt concentrations, indicating it was an integral membrane protein. Membrane fractionation by differential ultracentrifugation showed it was present predominantly in the plasma membrane fraction. The protein was susceptible to cell surface radiolabelling, further suggesting it was a plasma membrane protein. In summary, the major membrane glycoprotein in adipocytes is a novel 200-kDa heterodimer whose disulfide-linked subunits possess identical N-terminal sequences.