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Leiomyoma with bizarre nuclei (LBN) is an uncommon variant of uterine smooth muscle neoplasm. Involvement of fumarate hydratase (FH) has been suggested in the pathogenesis of a subset of LBN. The goal of our study is to assess the clinicopathological, morphological, immunohistochemical and molecular findings focusing on FH in LBNs (n = 108) and compare it with the findings in usual leiomyomas (UL; n = 50) and leiomyosarcomas (LMS; n = 42). Immunohistochemically, loss of FH expression was found in 67/108 of LBN, 1/50 of UL and in no LMS. Class 4/5 FH mutations were detected in 15/53 LBN with sufficient DNA quality for molecular analysis. Pathogenic variants of the FH gene were detected in neither UL nor LMS. Local recurrence after surgery was present in 18/92 of LBN patients, 7 of which were histologically verified and 2 of which were found to be LBN. Our results confirmed that LBN behave in a benign fashion, although they may relapse. FH gene mutations were a common finding only in LBN, but not in UL and LMS. Immunohistochemistry with an antibody against FH seems to have a good sensitivity (87%) and moderate specificity (58%) with regard to predicting FH gene mutations and could be used as a screening method in tumors with features suggestive of FH alterations to identify patients who are at risk for the FH aberrations.

Cellular leiomyoma (CL) represents an uncommon variant of uterine leiomyoma with limited data concerning its immunohistochemical and molecular profile. We performed a comprehensive analysis of 52 CL cases all of which were analyzed immunohistochemically. Molecular analysis was possible in 32 cases with sufficient DNA, and 38 cases with sufficient RNA. The immunohistochemical results showed a high expression of smooth muscle markers (calponin (100%), desmin (100%), smooth muscle actin (98.1%), caldesmon (96.1%), transgelin (96.1%), smooth muscle myosin heavy chain (86.5%), and smoothelin (61.5%)). Concerning markers of endometrial stromal differentiation, the expression of CD10 was observed in 65.4% cases (42.2% with H-score > 50), and IFITM1 in 36.5% cases (1.9% with H-score > 50). 36.5% showed HMGA2 overexpression at the IHC level, associated with increased mRNA expression in 14/14 cases. The rearrangement of the HMGA2 gene was detected in 13.2%. Chromosome 1p deletion was found in 19.3%, while 9.4% of tumors showed a pathogenic mutation in the MED12 gene. In conclusion, CL is immunohistochemically characterized by a high expression of "smooth muscle" markers commonly associated with a co-expression of "endometrial stromal" markers, where IFITM1 shows superior performance compared to CD10 regarding its specificity for differentiation from endometrial stromal tumors. The sensitivity of smoothelin in CL seems rather low, but no data is available to assess its specificity. On a molecular level, the most common mutually exclusive aberration in CL affects HMGA2, followed by chromosome 1p deletions and MED12 mutations.

This study was designed to evaluate the feasibility and effectiveness of hysteroscopy in the management of symptoms related to endometrial polyps and submucous leiomyomas in women using a levonorgestrel-releasing intrauterine system (LNG-IUS).Twenty-three LNG-IUS users presenting with endometrial polyps and/or submucous leiomyomas and irregular uterine bleeding were recruited for hysteroscopic examination and surgery. Intrauterine pathology was investigated and treated by hysteroscopic resection with the LNG-IUSIntrauterine pathology was successfully resected by hysteroscopy in 23 (100.0%) out of 23 cases. Following hysteroscopy, 18 (78.3%) women reported amenorrhea, one (4.3%) regular spotting, three (13.0%) irregular spotting and one (4.3%) patient resumed normal menstrual cycle. We conclude that 19 (82.6%) patients were postoperatively asymptomatic. All procedures were uncomplicated and 4 (17.4%) were carried out without general anesthesia as office procedures.Endometrial polyps and submucous leiomyomas can develop in LNG-IUS users, and this can cause irregular uterine bleeding. Hysteroscopic resection of these pathologies is a feasible method in the clinical management of symptoms.

AIM: This study was designed to evaluate feasibility and effectiveness of hysteroscopic intervention in the management of symptoms related to the displaced levonorgestrel-releasing intrauterine system (LNG-IUS). MATERIAL AND METHODS: One hundred and thirteen patients with displaced LNG-IUS presenting with irregular uterine bleeding pelvic pain or asymptomatic displacement were recruited for hysteroscopic examination. Displaced LNG-IUS was relocated by hysteroscopic intervention and the effect on symptoms and LNG-IUS position was followed. RESULTS: The displaced LNG-IUS was successfully relocated by hysteroscope in 112 (99.1%) of 113 cases. Following LNG-IUS relocation 71 (79.8%) patients of 89 with preoperative irregular uterine bleeding had amenorrhea or vaginal spotting and 14 of 15 (93.3%) patients with preoperative pelvic pain became asymptomatic. LNG-IUS expulsion was recorded in two patients 7 and 21 days after hysteroscopy. CONCLUSION: Displaced LNG-IUS can cause clinical symptoms (e.g. irregular bleeding pain). Hysteroscopic relocation of displaced LNG-IUS is a feasible method in the management of these symptoms. Risk of spontaneous expulsion associated with hysteroscopy is low. (c) 2013 The Authors. Journal of Obstetrics and Gynaecology Research (c) 2013 Japan Society of Obstetrics and Gynecology.

Aim. To determine if hormonal treatment induces apoptosis in uterine fibroids.Methods. Immunohistochemical examination of fibroid tissue, using avidin-biotin complex and cleaved caspase-3 antibody for detecting apoptosis, was performed in premenopausal women who underwent 12-week treatment with oral SPRM (6 patients with 5 mg and 5 patients with 10 mg of ulipristal acetate per day) or gonadoliberin agonist (GnRHa, 17 patients) and subsequent myomectomy or hysterectomy for symptomatic uterine fibroids. Ten patients with no presurgical hormonal treatment were used as controls.Results. Apoptosis was present in a significantly higher proportion of patients treated with ulipristal acetate compared to GnRHa (P=0.01) and to patients with no hormonal treatment (P=0.01). In contrast to an AI of 158.9 in SPRM patients, the mean AI was 27.5 and 2.0 in GnRHa and control groups, respectively. No statistical difference in the AI was observed between the two groups of patients treated with ulipristal acetate (5 mg or 10 mg).Conclusion. Treatment with ulipristal acetate induces apoptosis in uterine fibroid cells. This effect of SPRM may contribute to their positive clinical effect on uterine fibroids.

A prospective study was conducted on the incidence of intrauterine pathology after missed abortion diagnosed and treated by hysteroscopy. A hysteroscopy was performed in 100 women four to 12 weeks after a dilatation and curettage for missed abortions. Uterine malformations were found in 12 patients, intrauterine adhesions in seven and submucous myoma in two cases. As a side finding four cases of asymptomatic retained products of conception were found. Most cases of the intrauterine pathology were treated instantly by hysteroscopy, “see and treat” regimen was preferred. Post-missed abortion-hysteroscopy is a simple and useful method for early diagnosis and treatment of congenital and acquired intrauterine pathology.

Hysteroscopic examination of the uterine cavity revealed that patients previously treated for intramural myoma(s) by uterine artery embolization had a significantly higher incidence of abnormal findings compared with patients treated by laparoscopic occlusion of uterine arteries (59.5% vs. 2.7%). In particular, there was a higher incidence of necrosis in the uterine cavity of patients subjected to uterine artery embolization (43.2%) compared with patients after surgical uterine artery occlusion (2.7%).

Sum up the knowledge about office hysteroscopy.Review of literature and our own experience.Department of Gynaecology and Obstetrics, First Faculty of Medicine, Charles University Prague and General Teaching Hospital Prague.Data from scientific literature and 10 years of our own experience with office hysteroscopy.Hysteroscopy provides optical evaluation of uterine cavity. Most of the benign intrauterine organics pathologies could be managed in a outpatient setting with a vaginoscopic approach without any anaesthesia and analgesia. Using that approach we can recommend to perform endometrial target biopsy, resection of endometrial polyps up to 1.5 cm and pedunculated submucous myomas up to 1 cm as well as resection of filmy intrauterine adhesions. Method is comfortable for well managed patients and practically complication-free.

To analyze our experience with transperitoneal laparoscopic dissection of lymphatic nodes in women with gynecologic malignancies.Retrospective clinical study.Center of gynecologic endoscopy and minimally invasive surgery; Department of Obstetrics and Gynecology, General Faculty Hospital and 1st Medical Faculty in Prague.Analysis of data from our laparoscopic procedures in the years 2006-2011. The following procedures have been included: systematic pelvic lymphadenectomy (PLN), paraaortic lymphadenectomy (PALN), pelvic sentinel node excision, focused dissection of bulky lymphatic nodes from pelvis or paraaortic area.We performed 177 primarily laparoscopic procedures pointed at dissection of pelvic and/or paraaortic lymph-nodes. The mean operating time and the mean number of lymph-nodes was 82 minutes and 26.5 nodes in patients with PLN, and 75 minutes and 12.5 nodes in patients with PALN. The overall rate of laparo-conversions was 4.5%; the incidence of major complications was 6.8% and of serious bleeding 5.6%. Laparoscopic lymphadenectomy could not be performed or completed in 2.3% of cases. Complications were more frequently associated with PALN than with PLN.Laparoscopic approach to PLN and PALN is feasible in vast majority of patients. It provides adequate earnings of the lymphatic nodes, tolerable operative time, and relatively low complication rate. The highly experienced operation team for especially high infrarenal PALN is necessary.

Myomectomy is associated with a high risk of de-novo adhesion formation that may decrease fertility. The purpose of this study was to compare the reproductive outcome of patients after laparoscopic or open myomectomy who underwent second-look (SL) hysteroscopy and laparoscopy including adhesiolysis with patients with no SL intervention. A total of 170 patients underwent open or laparoscopic myomectomy at one centre. All patients were recommended SL. Reproductive results were analyzed in 12 and 24 months intervals following myomectomy. Out of 170 post-myomectomy patients 96 signed informed consent with SL (group A) and 74 withheld (group B). The cumulative pregnancy rate in the 24-months follow-up was: 61.4% and 66.7% (p = 0.535) in group A and group B respectively. Adhesions of adnexa were observed and lysed in the overall of 34.0% of patients at the time of SL. Intrauterine synechiae were present in 1.56% of patients at the SL hysteroscopy. No case of uterine rupture during pregnancy or delivery was recorded. Our results show that the pregnancy rate of patients after myomectomy who underwent SL hysteroscopy and laparoscopy is similar to that of patients with no SL procedure. Adhesiolysis performed during SL does not seem to improve the reproductive outcome of post-myomectomy patients.

We report a case of an 86-year-old female with a tubulo-squamous polyp of the vagina. Grossly, the polyp measured 2 x 1.5 x 1 cm. Histologically, it was composed of well-circumscribed nests of squamous cells with bland nuclei. Some of the squamous nests showed central spaces filled with necrotic debris. Small tubules were present at the periphery of some of the nests, and there were a few tubules unassociated with the squamous nests. Furthermore, several larger mucinous glands, some with apparent squamous metaplasia, were present. The stroma was fibrous and rather hypocellular. Surface of the polyp was covered by intact squamous epithelium, which was not connected with the underlying lesion. The recently described tubulo-squamous vaginal polyp represents a distinctive entity. To the best of our knowledge, only one study describing a series of ten cases has been reported in the literature to date.

To give a systematic comment on uterine artery embolization for the treatment of uterine fibroids.Expert comment.Department of Obstetrics and Gynecology, 1st Faculty of Medicine and General Faculty Hospital, Charles University, Prague.The analysis of results of the group of patients treated with uterine fibroid embolization in our facility in the years 2001-2005.Opinions of the multidisciplinary team, specialized in complex therapy of uterine fibroids were summarized. On the base of experience with more than 110 patients treated with uterine fibroid embolization we worked up practical comments on indications, cover and implementation of the procedure, and on suggested studies pre and post-procedurally with regard to expected effect and possible complications.Uterine artery embolization is a minimally invasive procedure with large symptomatic potential in therapy of post-fertile females with leiomyomas. The indication of such therapy for pregnancy planning women is controversial and needs thorough individual consideration about benefits and risks of embolization and its comparison with standard therapy (myomectomy). Organizing of the whole procedure (preoperative studies, equipment and experience of interventional radiologist, pain management, handling with complications) is challenging and should be performed by specialized teams and centers.

The authors demonstrate the case of left adnexal torsion caused by 2 benign teratomas in its ovarian and tubal location.Case report.Department of Obstetrics and Gynecology, 1st Faculty of Medicine and General Teaching Hospital, Charles University, Prague.24-years old woman underwent laparoscopy for several days lasting pain in lower abdomen and ultrasound finding of semicystic mass in the left adnexal region with suspicion of teratoma. The benign teratoma of the left ovary together with a torsion of the left Fallopian tube distended by teratoma was revealed during surgery. Left side salpingectomy and enucleation of the ovarian teratoma has been performed. This surprising finding was confirmed by histopathological examination.The acute gynaecological torsion event may be caused not only by torsion of uterine fibroid or enlarged tumorous ovary but rarely also by a teratoma of the Fallopian tube.

Sum up the knowledge about office hysteroscopy.Review of literature and our own 5 years of experience.Department of Gynaecology and Obstetrics, First Faculty of Medicine, Charles University Prague and General Teaching Hospital Prague, Prague.Compilation of data from scientific literature and 5 years of our own experience with office hysteroscopy.Hysteroscopy provides optical evaluation of uterine cavity. Most of the benign intrauterine organics pathologies could be managed in an outpatient setting with a vaginoscopic approach without any anaesthesia and analgesia. Using that approach we can recommend to perform endometrial target biopsy, resection of endometrial polyps up to 1.5 cm and pedunculated submucous myomas up to 1 cm as well as resection of filmy intrauterine adhesions. Method is comfortable for well managed patients and practically complication-free.

The treatment of uterine myoma with pretreatment of uterine arteries embolization followed by laparoscopic myomectomy is presented.Case report.Department of Obstetrics and Gynaecology 1st Medical Faculty of Charles University and General Faculty Hospital in Prague.Forty two years old woman with uterine myoma was "pretreated" with uterine arteries embolization followed by laparoscopic myomectomy next day. The reason for this procedure was to improve in short period conditions for surgery and definitively solve uterine pathology.The "pretreatment" with uterine arteries embolization improves basically conditions and effect of uterine myoma surgery. This "two step procedure" could be recommended mainly for cases of large and vascularizated myomas.

To analyze clinical and reproductive outcomes of patients after laparoscopic (LM) or open (OM) myomectomy.Prospective clinical trial.Department of Obstetrics and Gynecology, 1st Faculty of Medicine and General Faculty Hospital, Charles University, Prague.Women under the age of 40 with intramural fibroid larger than 4 cm were indicated for myomectomy. LM was performed when laparoscopy revealed solitary or 2 fibroids smaller than 8 cm; otherwise the OM was carried out. The patients were followed at 6 months intervals.80 myomectomies with extirpation of 121 myomas was performed from January 2002 to April 2005. The average age was 33.5 years, average size of dominant fibroid 56 mm. 38% of women suffered from infertility; the mean follow-up was 15.6 months. We performed LM in 56 cases (70%). From 24 open procedures 18 were elective and 6 converted from laparoscopy. In 18 patients some of the fibroid--ischemization procedures (uterine arteries embolization or laparoscopic dissection, or laparoscopic myolysis) preceded myomectomy. In the group with LM there was significantly lower peri-procedural blood loss, lower count of leucocytes and CRP concentration the 2nd day after surgery, shorter stay in the hospital, shorter interval between surgery and conception, and lower incidence of early complications than in women with OM. Fibroid related symptoms fully disappeared in 76% of patients. 20 women from 38 that have already tried to conceive have achieved 22 gestations so far: 9 deliveries (2 preterm; 3 vaginal, 6 Cesarean), 6 miscarriages, 1 ectopic and 6 ongoing pregnancies at the moment.In the hands of surgeons experienced in operative laparoscopy the enucleation of intramural uterine fibroids is safe, symptomatically effective, mostly low invasive procedure with good reproductive prognosis.

To compare principle, advantages, disadvantages, and risks of conservative (i.e. uterus saving) methods of treatment of uterine fibroids, which are focused on elimination or reduction of their perfusion. To contribute to better understanding of this dynamic topic between gynecologists, especially in the field of appropriate indication criteria.Review article.Department of Obstetrics and Gynecology, Charles University and General Faculty Hospital, Prague.Analysis of literature and our clinical experience.Within the last decade the spectrum of treatment of uterine fibroids has broaden with methods causing ischemia of fibroids. These include the minimally invasive surgical therapy (laparoscopic occlusion of uterine arteries /LUAO/ and Doppler assisted laparoscopic myolysis) and radiological catheterization treatment (uterine artery embolization, UAE). Compared to foreign countries where UEA is mainly used in perimenopausal women, we focus on the group of patients with further fertility plans. It is necessary to stress that in spite of the number of affirmative experiences with the new techniques of uterine fibroid treatment in both the indication groups (women with or without further fertility plans) these methods still remain an alternative to standard surgical treatment, because both myomectomy and hysterectomy can be performed by minimally invasive techniques in the majority of women. This review is also focused on the specific risks of the particular methods as well as on their mechanism of action which may dramatically differ despite of some analogies.

This work was supported by the Ministry of Interior of the Czech Republic [grant number VI20172020061]. The authors also acknowledge assistance from the technical staff at the Experimental Centre, Faculty of Civil Engineering, CTU in Prague.