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A retrospective analysis of 36 patients with metastatic nodes out of 209 consecutively managed patients with a clinically stage I endometrial cancer was carried out. Of the 1023 lymph nodes removed, 154 nodes were found to be metastatic. The mean number of the involved nodes was 4.27 (range: 1-29). Of the 154 positive nodes, 3 had nodal diameters < or = 3 mm (1.9%), 84 had diameters of 4-10 mm (54.6%), 60 had diameters of 11-20 mm (39.0%) and 7 had diameters more than 20 mm (4.5%). With increasing lymph node size, the frequency of tumoral involvement varies from 1.0% in nodes < or = 3 mm to 63.6% in nodes bigger than 20 mm. In terms of patients, nine of them were found to have a single metastatic node ranging from 6 mm to 10 mm in diameter. In the remaining 27 patients with multiple metastatic nodes, the biggest nodes encountered were 6-10 mm in 4 (14.8%), 11-20 mm in 17 (62.9%) and more than 20 mm in 6 (22.2%) patients. Since mere sampling of the lymphatic tissue directed particularly to the enlarged nodes may not show the true incidence of positive nodes, a complete lymphadenectomy is advocated in order to obviate an understaging problem.

Although rheumatic diseases are reported to be almost eradicated in the developed countries, they still continue to contribute significantly to maternal mortality in the developing world. Surgical therapies need to be considered for those patients who do not respond satisfactorily to medication. However, valve replacement or valvulotomy during pregnancy carries significant risks for both the mother and the fetus. Two patients with severe mitral stenosis refractory to medical therapy are presented. Both patients were subjected to percutaneous balloon valvuloplasty during pregnancy without any complications. They were able to discontinue medication and deliver vaginally at term. Balloon valvuloplasty appears to be a safe alternative to conventional surgical approaches in pregnancy.

Objectives: To evaluate genital fistulas with the aim of improving strategies to prevent them., Method: An institutional, retrospective, clinical analysis. One hundred eighty-two patients with genital fistulas managed consecutively between 1970 and 1993 were analyzed., Results: About 60% of all fistulas were attributable to obstetric traumas whereas gynecologic surgery constituted only 24.7% of cases. The contribution of gynecologic surgery increased from 11.1% in 1970-75 to 60.6% in 1988-93. Approximately half of the patients had vesico-vaginal fistulas. Of the 45 patients with fistulas occurring following gynecologic surgery, 19 had undergone simple hysterectomy and eight had undergone radical hysterectomy. All cesarean sections had been performed after failed labor. Hysterectomy was performed due to myoma in nine patients, endometrial hyperplasia in two patients and pelvic relaxation in eight patients. As regards management of fistulas, the transvaginal approach was chosen in the vast majority of patients. The overall success rate after the primary repair of fistulas was 91.5% (162/177). Fifteen patients with failure of the primary repair were subjected to repeat repairs. The second repair was successful in 11 patients but the remaining four needed further repairs. The maximum was seven repairs to a recto-vaginal fistula before a satisfactory result could be achieved, which had initially occurred after a cesarean section., Conclusion: Although the results of reparative surgery are promising, it would be more useful to encourage national measures to prevent in particular obstetric trauma.

This study includes 183 patients with clinical stage I endometrial carcinoma. All patients had standard surgical staging procedure including peritoneal cytology, total abdominal hysterectomy, bilateral pelvic and paraaortic lymphadenectomy. The factors analysed for recurrence were age, menopausal state, cell type, grade, mitotic activity, myometrial invasion, lymphovascular space invasion, cervical involvement, microscopic vaginal metastases, adnexal metastases, peritoneal cytology, concomitant endometrial hyperplasia and pelvic and paraaortic node metastases. The overall recurrence rate was 14.2% (26/183). Of the 26 patients with recurrence, 11 had local and 13 had distant metastases. In the remaining two patients (7.7%), both local and pelvic metastases were observed. Of the factors analysed, age, grade, mitotic activity, myometrial invasion, lymphovascular space invasion, microscopic vaginal metastases, adnexal involvement and pelvic and paraaortic nodal metastases were found to be significant predictors of recurrence. After multivariate analysis, advanced age (RR = 1.05), marked mitotic activity (RR = 3.11), pelvic and/or paraaortic nodal metastases (RR = 6.37) were chosen as the most important determinants of recurrence. In terms of surgical pathological stages, recurrence risk reaches up to 45.4% for stage IIIC disease. Using surgical pathological parameters, it is possible to predict recurrence but because of high rate of distant failures it still seems hard to improve survival of this group. Detection of a substantial risk of recurrence even in stage IA/B grade 1 group warrants adjuvant therapy in all patients after primary surgery.

A retrospective analysis of 136 patients with ovarian carcinoma subjected to appendectomy as a part of surgical procedure was carried out to assess the importance of appendectomy in patients with ovarian cancer. Of the 136 patients studied, 94 had epithelial and 38 had non-epithelial type of primary ovarian carcinoma. In the remaining 4 patients, the primary operation was performed with an intraoperative diagnosis of ovarian carcinoma but the final pathological examination revealed appendiceal carcinoma metastatic to ovaries. The overall appendiceal involvement in the study group with primary ovarian cancer was found to be 32.5% (43/132). This figure was 15.7% and 39.3% for non-epithelial and epithelial tumors, respectively. Involvement of the appendix ranged from 8.8% for patients with stage I disease to 46.0% for patients with stage III-IV disease. Four of the appendices found to be inflamed during the surgical explorations were later reported as acute appendicitis. The frequent occurrence of metastatic disease in the appendix in patients with ovarian cancer suggests routine appendectomy is appropriate for staging early cases and for contributing to maximal cytoreduction in advanced cases.

This study includes 183 patients with clinical stage I endometrial cancer subjected to peritoneal cytology, total abdominal hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic and para-aortic lymphadenectomy and omental biopsy during a 12-year period in a single institution. The factors analyzed were age, menopausal state, cell type, grade, mitotic activity, myometrial invasion, lymphovascular space invasion, cervical involvement, microscopic vaginal metastases, adnexal metastases, peritoneal cytology, presence of concomitant endometrial hyperplasia and lymph node status. The overall incidences of pelvic and para-aortic lymph node metastases were found to be 15.3% (28/183) and 9.3% (17/183), respectively. In five of 17 patients (29.4%) with para-aortic nodal metastases, pelvic nodes were free of tumor. The most significant prognostic factors for positive pelvic and/or para-aortic nodes were found to be the depth of myometrial invasion, grade of tumor and age.

Objective: To highlight recent trends in maternal mortality in Hacettepe University Hospital., Method: A retrospective clinical analysis of 117 maternal deaths between 1968 and 1992., Results: The overall maternal mortality ratio was 180/100,000 (108/59,993). In terms of 5-year periods, the maternal mortality ratio declined from 417.7 in 1968-72 to 73.7 in 1988-92. Infection was the most common cause of death (59.8%), followed by cardiac disease (8.5%) and hemorrhage (8.5%). Infection related deaths were either due to septic abortion (75.7%) or puerperal sepsis (24.3%). While 73.9% of all deaths were due to infection in 1968-72, this figure contributed only 9.1% of the deaths in 1988-92. When infection, hemorrhage, cardiac disease ad toxemia are investigated together, percentages of their contribution varies from 95.7% in 1968-72 to 54.5% in 1988-92 period., Conclusions: Maternal mortality ratios are decreasing significantly in our institution. An another promising finding is the further reduction in direct causes especially in recent years. However, an improvement in the care of pregnant women is necessary to continue this declining trend.

The patients with granulosa cell tumor of the ovary constituted 7.6% (60/780) of all ovarian malignancies treated at our Institution. The mean age of patients at diagnosis was 53.1. The most frequent symptom was abnormal vaginal bleeding. Of the 60 patients, 36 had stage I, 2 had stage II, 16 had stage III and 6 had stage IV disease. Endometrial hyperplasia and adenocarcinoma were detected in 18 and 3 patients, respectively. Lymph node metastasis was detected in only one of 18 patients subjected to lymphadenectomy. Recurrent disease was observed in 3 of 36 patients with stage I disease. The overall 5-year survival was found to be 85.0% (51/60). This figure varied from 100.0% to 63.6% according to the stage. In patients with stage I disease, surgery with and without adjuvant therapy achieved the same 5-year survival rate. In advanced stage, 5-year survival rate dropped from 90.0% with no gross residual disease to 25.0% with residual disease more than 2 cm. In patients with stage I disease, surgery only seems to be the treatment of choice. In advanced stage, since residual disease after surgery effects survival significantly, an aggressive surgical approach is advocated.

Objective: To determine the outcome and morbidity of pregnancies following cervical cerclage., Method: Records were reviewed for 326 patients with 374 singleton pregnancies between 1980 and 1990., Result: McDonald and Shirodkar procedures were carried out in 323 and 51 pregnancies, respectively. The procedure was classified as elective if based on past history (n = 330). In 44 pregnancies, cervical dilatation prompted operation. The overall fetal survival rate has increased from 17.7% to 79.1% after cervical cerclage. While the presence of cervical dilatation at suture placement had a prognostic value, the surgical technique, gestational age at suture placement and progestin therapy had no significant effect on survival. Premature rupture of membranes and chorioamnionitis were found to be the leading causes of morbidity., Conclusion: Cervical cerclage seems to the treatment of choice in patients with cervical incompetence. Only the presence of cervical dilatation at operation was found to have a prognostic value among the factors analyzed.

Objective: To review the clinicopathological experience of patients with benign and malignant struma ovarii., Method: A retrospective institutional analysis of 2 patients with malignant and 14 patients with benign struma ovarii, treated during a period of 20 years., Result: The patients with struma ovarii constituted 1.0% of all ovarian neoplasms in our institution (16/1501). Four percent of the germ cell tumors were calculated to be of struma ovarii (16/382). The stages of the malignant cases were recorded as 1A and 1C. Besides detection at early stage, a biologically low grade tumor was encountered as well. Although 5 of the patients had goitre, none of them had hyperthyroidism. None of the patients had a bilateral tumor. However, in 2 patients, a serous cystadenoma and dermoid cyst were found in the contralateral ovaries. The preoperative and intraoperative diagnosis of malignant struma ovarii proved to be difficult since 2 patients subjected to radical surgery according to suspicious frozen section reports in this series later were found to be benign struma ovarii., Conclusion: The low metastatic potential and slow progression rate of malignant struma ovarii support conservative surgery especially in young patients who have not yet completed their families.

This study includes 39 patients with squamous carcinoma of the vulva subjected to radical surgery. Stage, tumor description, cell type, lesion localization, lesion size, depth of invasion, grade, lymphovascular space invasion, number of mitoses, degree of stromal inflammatory reaction, and tumors in surgical margins were analyzed for groin metastasis. Of the factors analyzed, stage (P = 0.018), grade (P = 0.007) and depth of invasion (P = 0.001) were found to be the most important predictors of node metastasis. While a combination of factors permitted to define a low-risk group with 0% node metastasis, it seems hard to identify preoperatively those patients with no risk of nodal metastasis.

Forty-two patients with invasive carcinoma of the vulva, subjected to radical vulvectomy and inguinal lymphadenectomy, were evaluated retrospectively. The mean age of patients was 61.6 years. Fifteen patients (35.7%) had complicating medical diseases, the histopathological diagnoses were squamous carcinoma (n = 39), undifferentiated carcinoma (n = 1), and malignant melanoma (n = 2). The postoperative morbidity and mortality rates were found to be 73.8% and 11.6%, respectively.

This study includes 29 patients with synchronous primary malignancies of the female genital tract. These patients constituted 1.7% of all genital malignancies. The most frequently observed synchronous neoplasms were those of the ovary together with the endometrium (51.7%). Most patients had early-stage and low-grade disease. Stage I disease was observed in 68.1% of patients with ovarian cancer. Patients with synchronous ovarian and endometrial cancer had a 73.3% 5-year survival rate, suggesting a favorable prognosis.

This study includes 110 patients treated surgically for stage I squamous cell carcinoma of the cervix. The prognostic significances of mitotic activity, stromal inflammatory and eosinophilic reactions were studied. The 5-year survival rate varied from 75.0% to 93.3% and pelvic lymph node metastases (PLNM) varied from 23.0% to 31.2% according to degree of these variables. None of these pathological parameters was found to be a significant predictor of pelvic lymph node metastases and 5-year survival.

Objective: To evaluate the influence of conventional metroplasty on reproductive performance of symmetric uterine anomalies and determine the complications of these procedures., Design: A retrospective clinical analysis of consequently operated 102 women., Setting: Institutional., Patients and Participants: One hundred two patients with bicornuate and septate uterus and a history of late recurrent abortion and/or preterm delivery were included in this study., Interventions: Jones, Strassman, and Tompkins procedures for metroplasty and McDonald operation for cervical cerclage., Main Outcome Measure: The fetal survival rate has increased from 3.7% before operation to 75.0% afterwards. In only two patients uterine rupture was observed., Results: Conventional metroplasty improves the fetal survival rate in women with symmetric uterine anomalies., Conclusions: Our results confirm the view that conventional metroplasty seems to be an operation of choice in women with symmetric uterine anomalies and a history of recurrent late abortion and preterm delivery. However, uterine rupture and postoperative infertility may be potential complications.

This study includes 15 patients with invasive cervical cancer found at the time of standard hysterectomy for benign conditions. All patients underwent laparotomy and were subjected to peritoneal cytology, radical parametriectomy, bilateral pelvic and para-aortic lymphadenectomy. Residual disease was found in 10 of the 15 patients (66.7%). The 3-year survival of patients with and without residual disease were 80% and 100%, respectively. Following secondary radical surgery, five patients without evidence of residual disease were identified and spared the risks of radiation therapy. Furthermore, two patients with para-aortic lymph node metastases, who would otherwise have been overlooked, were thus treated completely. One patient died of complications of secondary surgical procedure.

This study includes 194 patients with stage I cervical cancer subjected to surgical therapy. Of 14 pathological factors analyzed, microscopic parametrial involvement (P = 0.001), depth of invasion (P = 0.001), and lymphovascular space invasion (P = 0.029) were found to be the most significant factors for positive pelvic lymph nodes. Combination of significant factors permitted categorization of patients into risk groups with pelvic lymph node metastases ranging from 0.0% to 90.9%.

During a 25 year period, 270 cases of stage IB and IIA cervical cancer were subjected to radical hysterectomy and lymphadenectomy. The morbidity rate was 27.6% and mortality rate was 0.3%. While injuries to the great vessels were the most common intra-operative complications, the most frequent postoperative complications were in the urinary system. The leading causes of morbidity were bladder dysfunction (16.2%), urinary infection (5.9%), lymphocyst (6.4%) and wound infections (3.5%). While the overall complications seem high, the frequency of serious morbidity has diminished and radical hysterectomy now represents one of the accepted methods of treatment of cervical carcinoma, with good 5-year survival rates.

This study includes 278 cases of stage I and II cervical cancer subjected to radical hysterectomy and lymphadenectomy. The clinical experience of 278 cases is reviewed. Of these cases, 215 were in stage I, and 63 were in stage II. Intraoperative complications occurred at a rate of 9.7% and involved injuries to the great vessels, lower urinary tract, nerves, and rectum. Operative mortality was found to be 0.3%. Postoperative complications were observed in 20.1% of patients. Fistulae were observed in 8 (2.8%) patients. The overall survival rate was 83.8%. The 5-year survival rates for stages IA, IB, IIA, and IIB were 100.0%, 87.9%, 71.0%, and 64.0%, respectively. Pelvic lymph node metastases varied from 0% for stage IA to 40.0% for stage IIB and paraaortic involvement varied from 0% for stage IA to 50.0% for stage IIB. Radical surgery seems to be the treatment of choice for patients with early invasive cervical cancer.

Bilaterality, complications and associated pathology were reevaluated in 286 cases of mature teratoma of the ovary, treated in the last 25 years. Torsion was the most frequent complication, occurring in 22 (7.7%) patients. Rupture, infection and secondary malignant change were uncommon complications, occurring in 11 (3.8%), 7 (2.4%) and 1 (0.3%) patients, respectively. Both ovaries were evaluated histologically in 226 patients, 31 (13.7%) of whom were shown to have bilateral tumours, including 2 patients with tumour in the normally appearing ovary, contralateral to the gross tumour.

Maternal mortality was found to be 140 deaths per 100,000 live births in Hacettepe University Hospital. Infection, hemorrhage and cardiac disease were still the leading causes of maternal deaths. It is possible to reduce the maternal mortality due to these largely preventable causes if standards of care and treatment are raised to a higher level throughout the country.

This study includes 278 patients with Stages 1 and 2 cervical cancer subjected to type 3 hysterectomy and lymphadenectomy. The incidence of lymph node metastasis and effect of paraaortic lymphadenectomy on 5-year survival were evaluated. The overall incidences of pelvic and paraaortic lymph node involvement were 24.1% and 8.0%, respectively. The overall 5-year survival rate was 83.8%. The 5-year survival of patients subjected to both pelvic and paraaortic lymphadenectomy was found to be 84.6%; the figure was 80.9% for patients subjected to only pelvic lymphadenectomy. No statistical difference in survival was found between patients with and without paraaortic lymphadenectomy.

This study includes 22 cases of Stage I cervical adenocarcinoma. The lymph node metastases and 5-year survival according to the size of lesion and grade of tumour were evaluated. The overall pelvic and para-aortic lymph node metastases were found to be 31.8% and 0% respectively. Metastases in the pelvic lymph nodes were found in 16.6% of patients with lesions less than 2 cm and 50.0% of patients with lesions 2 cm or greater in size. Pelvic lymph node metastases were found to be 0% for Grade 1, 25% for Grade 2 and 46% for Grade 3 tumours. The overall 5-year survival was 68.2%. This figure varied from 60% to 75% according to the size of lesion and from 61.5% to 100% according to the grade of tumour.