Novi uvidi u predskazivanju ovarijskog hiperstimulacijskog sindroma

Ovarian hyperstimulation syndrome is the most dangerous complication following the administration of gonadotropins. There is no preventive and pharmacological intervention that can fully prevent development of this syndrome. The best strategy to reduce the incidence of the condition is to identify the patients at risk before ovarian stimulation and to recognize potential predictors. A history of ovarian hyperstimulation is an important risk factor for recurrence of the syndrome. The risk of the syndrome is evident with elevated gonadotropin dosages and with the use of gonadotropin releasing hormone agonists. Human chorionic gonadotropin is the main risk factor. The combination of pretreatment diagnosis of polycystic ovary disease and estradiol of 4500 pg/ mL gives higher prediction rates for the risk factor. Serum concentration of inhibin is not a reliable predictor of the syndrome. Recent evaluation of antimüllerian hormone as a reliable predictor candidate, vascular endothelial growth factor with cadherin as indicators of vascular permeability, and detection of mutations in the follicular stimulating hormone receptor as predictors of severity offer new insights in the prognosis of the syndrome. Identification of these prognostic markers in patients at risk would be very useful for prevention of the syndrome prior to the appearance of symptoms.Ovarijski stimulacijski sindrom je najopasnija komplikacija nakon primjene gonadotropina. Ne postoji nijedna preventivna ni farmakološka intervencija koja u potpunosti sprječava pojavu ovoga sindroma. Najbolja strategija koja smanjuje pojavnost takvog stanja je identifikacija rizičnih bolesnica prije stimulacije ovulacije te prepoznavanje mogućih predznaka bolesti. Anamnestički podatak o ranijoj hiperstimulaciji jajnika predstavlja važan rizični čimbenik za ponovno javljanje sindroma. Rizičnost za nastanak sindroma je očita pri korištenju gonadotropina u većim dozama, kao i kod primjene agonista gonadotropnog otpuštajućeg hormona. Humani korionski gonadotropin je glavni rizični čimbenik. Kombinacija prethodno utvrđene dijagnoze policističnih ovarija te koncentracija estradiola iznad 4500 pg/mL omogućuju bolje predskazivanje čimbenika rizičnosti. Koncentracija inhibina u serumu nije pouzdana u predikciji sindroma. Nedavne spoznaje o antimilerovom hormonu kao pouzdanom kandidatu u predskazivanju sindroma, vaskularnom faktoru rasta s kaderinom kao pokazateljima vaskularne propusnosti te otkriće mutacija receptora folikularno stimulirajućeg hormona koji ukazuju na težinu bolesti predstavljaju nove uvide u prognozi ovoga sindroma. Prepoznavanje ovih prognostičkih biljega u rizičnoj skupini bolesnica bilo bi vrlo korisno u prevenciji sindroma prije pojave simptoma bolesti

Contemporary Approach to Diagnosis and Treatment of Women with Urinary Incontinence and Pelvic Defects

Ginekološka urologija bavi se prolapsom organa male zdjelice i inkontinencijom mokraće. Prolaps organa male zdjelice pogađa gotovo polovinu žena starijih od 50 godina. Poremećaji mokrenja značajno umanjuju kvalitetu života žene i važan su javnozdravstveni problem koji utječe na fi zičko i psihičko zdravlje žena. Naime, poznato je da čak 25–30% žena u starijoj životnoj dobi obolijeva od statičke inkontinencije mokraće (SIU). SIU nastaje zbog prirođenih ili stečenih oštećenja statike organa u maloj zdjelici s gubitkom anatomske potpore vezikouretralnom segmentu. Za postavljanje dijagnoze prolapsa organa male zdjelice i urinarne inkontinencije važni su detaljna anamneza, ginekološki pregled, klinički testovi, cistometrija, cistoskopija i urodinamski testovi. Liječenje prolapsa je kirurško, dok liječenje urinarne inkontinencije može biti kirurško i konzervativno. Postoji više od stotinu operativnih metoda u liječenju SIU. Danas je trend da se promijeni dosadašnji pristup kirurškom liječenju statičke inkontinencije mokraće u žena primjenom jednostavne, učinkovite i sigurne laparoskopske tehnike, kao i brojnih sling metoda (TVT, SPARC i sl.), te APOGEE i PERIGEE metoda u liječenju defekata dna zdjelice. Navedenim se metodama značajno skraćuje trajanje hospitalizacije, bitno se smanjuju troškovi liječenja, brža je uspostava potpune životne i radne sposobnosti uz minimalno oštećenje okolnog tkiva i lokalne inervacije što umanjuje broj poslijeoperacijskih komplikacija i osigurava uspostavu normalne funkcije. Uspjeh liječenja ovisi o dobroj dijagnostici i dobro odabranom načinu liječenja (kirurškom ili konzervativnom). Suvremenim dijagnostičkim i terapijskim postupcima, postiže se optimalan učinak liječenja i osigurava kvalitetan život pacijentica.Gynecologic urology deals with pelvic organ prolapse and urinary incontinence. Pelvic organ prolapse occurs in nearly every second woman older than 50 years of age. Urinary incontinence signifi cantly reduces quality of life, and it is an important public health problem with great impact on physical and mental health. It is known that nearly 25-30% of older women develop stress urinary incontinence. Stress urinary incontinence results from inborn or acquired pelvic organ support impairment, with loss of anatomic support to vesicourethral segment. The diagnosis of pelvic organ prolapse and urinary incontinence is based on anamnesis, gynecologic examination, clinical testing, cystometry, cystoscopy and urodynamic testing. The treatment of pelvic organ prolapse is surgical, while urinary incontinence can be treated with both surgical and conservative therapies. Currently, there are more than one hundred surgical methods to treat stress urinary incontinence. A current trend in surgical therapy for stress urinary incontinence is the application of simple, effective and safe laparoscopic surgery and sling methods (TVT, SPARC), as well as the use of APOGEE and PERIGEE methods in pelvic organ prolapse therapy. These methods signifi cantly reduce hospitalization and therapy expenses, with earlier restoration of working ability. Local tissue impairment and intervention is minimal which decreases postoperative complications and provides for restoration of the normal function. Treatment success depends on a diagnostic procedure and a properly chosen therapy method (operative or conservative). The use of contemporary diagnostic and therapy procedures yields optimal therapeutic effects and helps maintain a patient’s quality of life

Kasnija trudnoća i prognoza kod preživjelih od raka dojke

An increase in the incidence of breast cancer in women aged <40 years in conjunction with a pronounced shift towards later childbearing has been reported in recent years. Because survival from breast cancer in women of childbearing age has significantly improved, they are often concerned whether subsequent pregnancy will alter their risk of disease recurrence. In the modern era, the prognosis of pregnancy-associated breast cancer is comparable to non-pregnancy-associated breast cancer and women can bear children after breast cancer treatment without compromising their survival. Therefore, they should not be discouraged from becoming pregnant, and currently the usual waiting time of at least 2 years after the diagnosis of breast cancer is recommended. However, a small, nonsignificant adverse effect of pregnancy on breast carcinoma prognosis among women who conceive within 12 months of breast cancer diagnosis and a higher risk of relapse in women younger than 35 up to 5 years of the diagnosis may be found. Fortunately, for women with localized disease, earlier conception up to six months after completing their treatment seems unlikely to reduce their survival. Ongoing and future prospective studies evaluating the risks associated with pregnancy in young breast cancer survivors are required.U posljednje vrijeme izvješćuje se o sve većoj pojavnosti raka dojke skupa s izraženijim odgađanjem rađanja kod žena mlađih od 40 godina. Budući da se preživljenje žena generativne dobi zbog raka dojke značajno poboljšalo, one su često zabrinute hoće li kasnija trudnoća doprinijeti opasnosti od recidiva bolesti. U današnje vrijeme prognoza raka dojke u trudnoći je usporediva s rakom dojke koji nije u svezi s trudnoćom i žene mogu rađati djecu nakon liječenja raka dojke bez ugrožavanja njihovog preživljavanja. Stoga žene ne treba obeshrabriti u želji za trudnoćom, a uobičajene su preporuke da se pričeka s trudnoćom najmanje 2 godine nakon postavljene dijagnoze. Ipak, malen i neznakovit nepovoljan učinak trudnoće na rak dojke može se naći među ženama koje zanesu unutar 12 mjeseci od dijagnoze raka dojke, a veća opasnost od recidiva kod žena mlađih od 35 godina do čak 5 godina nakon dijagnoze. Srećom, kod žena s lokaliziranom bolešću izgleda manje vjerojatno da bi ranija trudnoća do čak 5 mjeseci nakon završenog liječenja ugrozila njihovo preživljavanje. Potrebna su daljnja istraživanja koja će procijenti rizike u svezi s trudnoćom kod mlađih osoba preživjelih od raka dojke

KOREKCIJA CISTOKELE SINTETSKOM MREŽICOM TRANSOBTURATORNIM PRISTUPOM (PERIGEE SISTEM)

Objectives. Our first short-term results of transobturator mesh interposition (Perigee System) for the correction of cystoceles are presented. Methods. This is our initial study on 22 women with cystocele > Grade 2 who underwent the Perigee procedure in our Center between January 2006 and March 2007. In 15 cases lateral cystocele defect was ¬diagnosed, whereas other 7 patients had central anterior vaginal wall defect. All patients were assessed by POP-Q staging. Results. The anatomical and functional reconstruction of anterior vaginal wall was achieved in all patients. Preoperatively, mean POP-Q Aa value was +1.1 (± 0.3) and Ba value was + 1.9 (± 1.3) . No major intraoperative or immediate postoperative complications were observed. One and three months postoperatively, mean POP-Q Aa value was – 2.9 (± 0.21) and – 2.82 (± 0.1) respectively and Ba was –2.85 (± 0.4) and – 2.8 (± 0.23) respectively. Patients’ satisfaction and the imposing short-time surgical outcome were achieved in all cases after three months follow-up. Conclusion. We consider Perigee procedure to be highly efficacious, minimally invasive and easy technique for correction of anterior vaginal wall defects.Cilj rada. Prikazati preliminarne rezultate transobturatornog pristupa korekcije cistocela metodom Perigee. Metode. 22 bolesnice s cistocelom drugog stupnja podvrgnute su u našoj ustanovi metodi Perigee u vremenskom razdoblju između sječnja 2006. i ožujka 2007. godine. U 15 bolesnica dijagnosticirano je lateralno paravaginalno oštećenje, dok je u 7 bolesnica verificirano centralno oštećenje prednje vaginale stijenke. Rezultati. Anatomska i funkcionalna korekcija prednje vaginalne stijenke ovom metodom postignuta je kod svih bolesnica. Preoperativno, srednja vrijednost POP-Q Aa točke bila je +1.1 (± 0.3) a Ba točle + 1.9 (± 1.3). Nije bilo intraoperativnih ni perioperativnih komplikacija zahvata. Jedan i tri mjeseca nakon zahvata, srednja vrijednost točke POP-Q Aa bila je – 2.9 (± 0.21) i – 2.82 (± 0.1) dok je srednja vrijednost točke Ba bila –2.85 (± 0.4) i – 2.8 (± 0.23). Zaključak. Smatramo da je Perigee metoda jednostavna, ¬neinvazivna i učinkovita metoda korekcije defekata svih tipova cistokela

Pathological pregnancy and psychological symptoms in women [Patološka trudnoća i psihički simptomi u žena]

Pregnancy is followed by many physiologic, organic and psychological changes and disorders, which can become more serious in pregnancy followed by complications, especially in women with pathological conditions during pregnancy. The purpose of this study was to find out and analyze the prevalence and intensity of psychological disorders in women with pathological conditions during pregnancy and compare it with conditions in pregnant women who had normal development of pregnancy. The research is approved by the Ethical committee of the Mostar University Hospital Center, and it was made in accordance with Helsinki declaration and good clinical practices. The research conducted section for pathology of pregnancy of Department for gynecology and obstetrics of the Mostar University Hospital Center. It included 82 pregnant women with disorders in pregnancy developement and control group consisted of pregnant women who had normal development of pregnancy. The research work was conducted from September 2007 to August 2008 in Mostar University Hospital Center. Pregnant women had Standard and laboratory tests, Ultrasound. CTG examinations were done for all pregnant women and additional tests for those women with complications during pregnancy. Pregnant women completed sociobiographical, obstetrical-clinical and psychological SCL 90-R questionnaire. Pregnant women with pathological pregnancy exibited significantly more psychological symptoms in comparison to pregnant women with normal pregnancy (p < 0.001 to p = 0.004). Frequency and intensity of psychical symptoms and disorders statisticly are more characteristic in pathological pregnancy (61%/40.6%). The statistical data indicate a significantly higher score of psychological disorders in those pregnant women with primary school education (p = 0.050), those who take more than 60% carbohydrates (p = 0.001), those with pathological CTG records (p < 0.001), those with pathological ultrasound results (p < 0.001 to 0.216) and those pregnant women with medium obesity and obesity (p = 0.046). Body mass index (BMI) during normal pregnancy development is lower (p = 0.002) but the levels of glucose, triglycerides, cholesterol, HDL and LDL in blood are higher Blood pressure in pregnant women with pathological pregnancy was statistically significantly higher (p < 0.001). Diagnostic criteria for the metabolic syndrome were found in 19 pregnant women with the pathological pregnancy. Statistically, in those women, a significantly higher appearance of psychological symptoms and disorders was observed in comparison to the pregnant women without metabolic syndrome (p < 0.001). The research has shown that 87.8% from all pregnant women included in this study have been hospitalized due to premature birth, hypertensive disorders, and diabetes in pregnancy, and also due to bleeding in the second and third trimester of pregnancy

Liječenje ovarijskog hiperstimulacijskog sindroma: novi uvidi

Ovarian hyperstimulation syndrome is the most serious iatrogenic complication resulting from ovarian stimulation. Currently there is no clear evidence of absolute efficacy for most of standard preventive and curative methods. Recent studies indicate that human chorionic gonadotropin increases vascular endothelial growth factor, vascular endothelial cadherin and vascular permeability via endothelial adherence junctions. Vascular endothelial growth factor plays a pivotal role in the pathophysiology of the condition and therefore vascular endothelial factor antagonism has been suggested for the prevention of the syndrome. Since vascular endothelial growth factor is also a physiological regulator of folliculogenesis, progesterone secretion and endometrial angiogenesis, its complete inactivation by specific blockers could produce undesirable effects interfering with early pregnancy development and therefore they cannot be used clinically. Recently, low doses of dopamine agonists (cabergoline) have been shown to counteract vascular endothelial growth factor induced vascular hyperpermeability, reducing the incidence of the syndrome by prophylactic treatment without compromising pregnancy outcome. The absence of undesirable side effects could make cabergoline an effective and safe etiologic approach for the prevention and treatment of the syndrome. A novel approach has suggested that metformin may also be helpful in the syndrome prevention in women with or without polycystic ovary disease.Ovarijski hiperstimulacijski sindrom je najozbijnija jatrogena komplikacija koja nastaje nakon stimulacije jajnika. Zasad nema jasnih dokaza o apsolutnoj djelotvornosti većine standardnih i preventivnih i kurativnih metoda. Novije studije pokazuju da humani korionski gonadotropin povisuje vaskularni čimbenik rasta, vaskularni endotelni kaderin i vaskularnu propusnost na spojevima adherentnog endotela. Kako vaskularni endotelni čimbenik rasta igra ključnu ulogu u patofiziologiji sindroma, ukazuje se na onemogućavanje djelovanja vaskularnog čimbenika rasta u prevenciji bolesti. Budući da je vaskularni čimbenik rasta ujedno i fiziološki regulator folikulogeneze, stvaranja progesterona i krvnih žila endometrija, njegova bi potpuna inaktivacija specifičnim blokatorima dovela do neželjenih nuspojava koje bi ometale razvoj rane trudnoće, što onemogućuje njihovu kliničku primjenu. Odnedavno se pokazalo kako niske doze agonista dopamina (kabergolin) suzbijaju pojačanu vaskularnu propusnost izazvanu vaskularnim endotelnim čimbenikom rasta, smanjujući profilaktično pojavnost sindroma bez nepovoljnog djelovanja na ishod trudnoće. Zbog izostanka nepoželjnih nuspojava kabergolin bi mogao biti djelotvoran i siguran u etiološkom pristupu te u prevenciji i liječenju sindroma. Noviji pristup ukazuje na to da primjena metformina može isto koristiti u prevenciji sindroma kod žena s policističnim jajnicima ili bez njih

Urinary Incontinence in Women and Guidelines for Treatment

Poremećaji mokrenja znatno umanjuju kvalitetu života žene i važan su javnozdravstveni problem koji utječe na fizičko i psihičko zdravlje žena. Naime, poznato je da čak 25 – 30% žena u starijoj životnoj dobi obolijeva od statičke inkontinencije mokraće (SIU). Velika epidemiološka studija u SAD-u pokazala je da umjerenu do tešku urinarnu inkontinenciju ima 7% žena u dobi od 20 do 39 godina, 17% u dobi od 40 do 59 godina, 23% u dobi od 60 do 79 godina i 32% žena starijih od 80 godina. SIU nastaje zbog prirođenih ili stečenih oštećenja statike organa u maloj zdjelici s gubitkom anatomske potpore vezikouretralnom segmentu. Za postavljanje dijagnoze prolapsa organa male zdjelice i urinarne inkontinencije važni su detaljna anamneza, ginekološki pregled, klinički testovi, cistometrija, cistoskopija i urodinamski testovi. Liječenje urinarne inkontinencije može biti kirurško i konzervativno. Uspjeh liječenja ovisi o dobroj dijagnostici i dobro odabranom načinu liječenja (kirurškom ili konzervativnom). Suvremenim dijagnostičkim i terapijskim postupcima postiže se optimalan učinak liječenja i osigurava kvalitetan život pacijentica.Urinary incontinence significantly reduces quality of life, and it is an important public health problem with a great impact on physical and mental health. It is known that nearly 25-30% of elderly women develop stress urinary incontinence. Large epidemiological studies in the United States of America show that moderate to severe urinary incontinence is present in 7% of women aged 20-39, 17% aged 40-59, 23% aged 60-79 and 32% aged 80 years and more. Stress urinary incontinence results from inherited or acquired pelvic organ support impairment, with loss of anatomic support to vesicourethral segment. The diagnosis of pelvic organ prolapse and urinary incontinence is based on anamnesis, gynaecologic examination, clinical testing, cystometry, cystoscopy and urodynamic testing. The treatment of urinary incontinence can be surgical or conservative. Treatment success depends on a diagnostic procedure and a properly chosen therapy method (operative or conservative). The use of contemporary diagnostic and therapy procedures yields optimal therapeutic effects and helps maintain a patient’s quality of life

Operative complications and results of the "SPARC" procedure for stress urinary incontinence [Operativne komplikacije i ishod metode SPARC u liječenju statičke inkontinencije mokraće]

The aim of this study was to determine the efficacy and operative complications of the suprapubic arc (SPARC) procedure in stress incontinent women with and without previous anti-incontinence surgery. One-hundred and twenty-one patients with stress urinary incontinence (SUI) were treated with SPARC for correction of urethral hypermobility (N = 65) and intrinsic sphincter deficiency (N = 56) between August 2002 and February 2007. The long-term surgical results, operative complications (bladder injury, retropubic hematoma, de novo urgency and urinary infection) and patients' satisfaction were assessed. The overall complication rate was 9.9% (12/121). The perioperative complication rate was 1.7% including 2 urinary bladder injuries. Significant difference in the overall complications rate was detected between women with and without previous surgery (23/45, 51.1% vs. 6/108, 5.5%, chi2 = 49.89, P < 0.001). The overall postoperative complication rate was 8.3% (10/121) including 4 de novo urgencies, 4 urinary infections and 2 retropubic hematomas. There were 3 patients with postoperative urinary retention managed conservatively, without voiding difficulties on control visits. The objective cure rate after the follow-up was 86.8% (105/121). In patients with SUI and without preceding vaginal operations SPARC is a good method with low incidence of perioperative complications, promising long-term results and high patient satisfaction