Publications by authors named "Nuri Peker"

23 Publications

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Pelvic floor muscle function and symptoms of dysfunctions in midwifes and nurses of reproductive age with and without pelvic floor dysfunction.

Taiwan J Obstet Gynecol 2019 Jul;58(4):505-513

School of Physiotherapy, Dokuz Eylul University, Izmir, Turkey. Electronic address:

Objectives: This study aims to compare pelvic floor muscle (PFM) functions in midwifes and nurses of reproductive age with and without pelvic floor dysfunction (PFD) and investigate the relationship between PFM function and the number, type and symptoms of PFDs.

Materials And Methods: 82 midwifes and nurses of reproductive age with (n = 51) and without PFD (n = 31) participated in the study. PFM function was assessed by digital palpation using PERFECT scale. Gynecological examination, ultrasonography, disease-specific questionnaires, questions and tests were used to assess symptoms of PFD. PFD was assessed in terms of risk factors, urinary incontinence, fecal incontinence, pelvic organ prolapse (POP), pelvic pain and sexual dysfunctions.

Results: Power parameter of PERFECT scheme was significantly lower in subjects with PFD compared to Non-PFD group (p = 0.002). 41% of the subjects with Power 5 PFM strength in PFD group were diagnosed as stage 1 POP, 5.8% as stage 2 POP, 15.7% of urge incontinence, 23.3% of stress incontinence and 10.5% of mixed incontinence. Both urinary incontinence and POP were detected in 15.7% of them. Among all subjects, incontinence symptoms decreased whereas POP and sexual function did not change as PFM increased. PFM strength was negatively correlated with the number of PFD (p = 0.002, r = -0.34). The type of dysfunction did not correlate with PFM strength (p > 0.05).

Conclusion: PFM strength only affects of urinary incontinence sypmtoms among all PFDs in midwifes and nurses of reproductive age. PFM strength may not be the main factor in the occurrence of PFDs as pelvic floor does not consist solely of muscle structure. However, it strongly affects the number of dysfunctions. Therefore, PFM training should be performed to prevent the occurrence of extra dysfunctions in addition to the existing ones even if it does not alter the symptoms.
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http://dx.doi.org/10.1016/j.tjog.2019.05.014DOI Listing
July 2019

Effectiveness of a one-day laparoscopic suture course.

J Obstet Gynaecol 2019 Oct 13;39(7):981-985. Epub 2019 Jul 13.

Department of Obstetrics and Gynecology, Ege University School of Medicine , Izmir , Turkey.

We aimed to determine the effectiveness of a one-day course on laparoscopic suturing skills development by performing a prospective study with obstetrics and gynaecology specialists. The course consisted of a theoretical portion describing the suturing technique basics and a practical portion consisting of box trainer suturing. Before and after the course, each trainee was given 10 min to introduce the suture material into the abdomen, properly position the needle using a needle holder, pass the suture through premarked points on the silicone pads and tie an intracorporeal knot. The procedures were video recorded and evaluated after the course. The results showed that there were statistically significant reductions in the needle holding, suture passing and knot tying times after completing the course. Overall, the one-day course was an effective training programme for improving a surgeon's laparoscopic suturing skills. IMPACT STATEMENT Currently, many countries have centres that provide laparoscopic training as part of the medical residency education. However, a standardised training programme has not been implemented worldwide. In this study, we pointed out the effectiveness of a one-day laparoscopic suturing course. A one-day suturing course is easy to implement, cheap and effective. A one-day suturing course should be implemented worldwide, especially in those countries lacking sufficient financial resources to provide laparoscopic training as part of the medical residency programme.
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http://dx.doi.org/10.1080/01443615.2019.1584882DOI Listing
October 2019

Does Home Birth Reduce the Risk of Pelvic Organ Prolapse?

Ginekol Pol 2018 ;89(8):432-36

Uşak Training and Research Hospital.

Objectives: To determine the relationship between vaginal birth and the development of POP among women who deliv-ered in non-hospital settings (home birth).

Material And Methods: Data were collected retrospectively from the files of patients who presented to a hospital outpatient clinic between April 1, 2011 and April 1, 2012 with complaints of urinary incontinence, uterine sagging, vaginal mass, or vaginal pain. The patients' age, height, weight, body mass index, menopause age, number of deliveries, and presence of hypertension and diabetes mellitus were noted. Patients whose urogynecologic evaluation included POP Quantification (POP-Q) scoring were included in the study. The patients were separated into a group of women who had never given birth and another group of women with one or more deliveries.

Results: Of the 179 patients in the study, 28 had never given birth and 151 had given birth at least once. The nulliparous patients had no cystocele, rectocele, or uterine prolapse. The prevalence rates of cystocele, rectocele, and uterine prolapse were significantly higher in the multiparous group. Cystocele, rectocele, and uterine prolapse development were significantly correlated with number of deliveries, but there was no statistical association with age, body mass index, menopausal age, diabetes mellitus, or hypertension. univariate analysis reveals that the only factor effective in the development of cytocele, rectocele and prolapse is the number of births.

Conclusions: Our study suggests that only number of deliveries is associated with development of cystocele, rectocele, and uterine prolapse in women who gave birth by vaginal route in residential settings.
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http://dx.doi.org/10.5603/GP.a2018.0074DOI Listing
April 2019

Evaluation of Factors Affecting Lymph Node Metastasis in Clinical Stage I-II Epithelial Ovarian Cancer.

Oncol Res Treat 2018 6;41(7-8):444-448. Epub 2018 Jul 6.

Background: Systematic lymphadenectomy is useful for accurate staging of early-stage ovarian cancer and has obvious prognostic value. Accurate staging may prevent unnecessary postoperative chemotherapy. The aim of this study was to evaluate the rate of lymph node involvement and factors affecting it in clinically early-stage epithelial ovarian cancer (EOC; stages I, II).

Patients And Methods: The study included 163 patients who underwent surgery at our hospital between January 2004 and April 2017 and who were diagnosed with early-stage EOC based on preoperative and intraoperative examination. Patient data were retrospectively analyzed. The rate of lymph node involvement and factors affecting it were analyzed.

Results: Of 163 patients, 21 (12.9%) had lymph node metastasis, whereas 16 (16.3%) of 98 patients who underwent comprehensive lymphadenectomy had lymph node metastasis. According to the univariate results for patients undergoing any type of lymphadenectomy, the rate of positive lymph nodes was significantly higher (37.1%) in those with bilateral ovarian involvement (p < 0.001). The rate was significantly higher in patients with positive intraabdominal fluid cytology (25.9%; p < 0.001), serous histology (20.5%; p = 0.02), and grade 3 disease (33.3%; p < 0.001). In multivariate logistic regression analysis, the rate was significantly higher in patients with bilateral adnexal involvement (p = 0.012). The risk of positive lymph nodes was significantly higher in patients with grade 3 disease (p = 0.016).

Conclusion: Comprehensive lymphadenectomy increases the detection rate for metastatic lymph nodes in patients with clinically early-stage EOC. The rate of lymph node involvement is significantly higher in grade 3 tumors, serous cytology, bilateral adnexal involvement, and positive intraabdominal fluid cytology.
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http://dx.doi.org/10.1159/000488082DOI Listing
August 2019

Can concurrent high-risk endometrial carcinoma occur with atypical endometrial hyperplasia?

Int J Surg 2018 May 14;53:350-353. Epub 2018 Apr 14.

Department of Gynecologic Oncology, Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, Turkey.

Background: This study investigated the frequency of high-risk cancer types in hysterectomy material obtained from patients who were diagnosed with atypical endometrial hyperplasia (AEH) by endometrial sampling.

Materials And Methods: A total of 227 patients with AEH were retrospectively included in the study. Hysterectomy material was examined as both perioperative frozen section (FS) and paraffin-embedded permanent section (PS). Grade III tumors, grade II tumors larger than 2 cm, over 50% myometrial invasion, cervical involvement, and serous or clear cell histology were considered high-risk.

Results: In final pathology, 57 (25.1%) patients had endometrial cancer and 7 (3%) patients had high-risk cancer. Overall analysis of FS/PS agreement yielded a Cohen's Kappa (K) coefficient of 0.420 (moderate agreement). There was moderate (K = 0.526) agreement between FS and PS in detecting tumor grade, and good agreement (K = 0.653) in evaluation of myometrial invasion.

Conclusion: High-risk endometrial cancer can coexist with AEH. It should be remembered that despite preoperative and FS examinations, these high-risk tumors can be overlooked until final pathology.
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http://dx.doi.org/10.1016/j.ijsu.2018.04.019DOI Listing
May 2018

Is grand multiparity a risk factor for the development of postmenopausal osteoporosis?

Clin Interv Aging 2018 29;13:505-508. Epub 2018 Mar 29.

School of Physiotherapy, Dokuz Eylul University, Izmir, Turkey.

Objective: In this study, we investigated the relationship between the development of postmenopausal osteoporosis and parity.

Materials And Methods: The retrospective study included 129 postmenopausal women who were divided into three groups depending on the number of parity: Group I, <5; Group II, 5-9; and Group III, ≥10. The mean age of the subjects was 57.71±5.02 years.

Results: No significant difference was found among the three groups regarding body mass index values, duration of menopause, mean thyroid stimulating hormone values and frequency of diabetes. Among the three groups, no significant difference was found in terms of the frequency of lumbar osteoporosis (>0.05), whereas a significant difference was found regarding the frequency of femoral osteoporosis (=0.012; <0.05).

Conclusion: It was revealed that femoral bone mineral density significantly decreased as the number of parity increased.
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http://dx.doi.org/10.2147/CIA.S155793DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5880179PMC
August 2018

A Rare Uterine Malformation: Asymmetric Septate Uterus.

J Minim Invasive Gynecol 2018 01 22;25(1):28-29. Epub 2017 Jun 22.

Department of Obstetrics and Gynecology, Ege University School of Medicine, Izmir, Turkey. Electronic address:

Study Objective: To demonstrate a step by step surgical hysteroscopy technique in a patient with asymmetric uterine septum and transverse uterine septum that was not previously described in the literature.

Design: Resection of an asymmetric uterine septum by laparoscopy and ultrasound-guided hysteroscopy (Canadian Task Force classification III). The video was assumed exempt from official review by our institutional review board.

Setting: A septate uterus is defined as the uterus in which the uterine cavity is longitudinally divided by the septum [1]. The most common uterine anomaly, septate uterus has a spectrum of configurations ranging from complete septate to incomplete septate uterus. Asymmetric uterine septum was reported only as case reports in the literature and is described as Robert's uterus [2]. This unique malformation is described as a septate uterus with a noncommunicating hemicavity, composed of a blind uterine horn usually with unilateral hematometra, and a contralateral unicornuate uterine cavity. The external uterine shape is normal. The asymmetric septum with transverse uterine septum in the present case has not yet been reported in the literature.

Patient: A 29-year-old woman presented to our clinic with primary amenorrhea, cyclic pelvic pain, and the desire to have pregnancy. She previously had failed 2 laparoscopy and hysteroscopy procedures for fertility treatments. Hysterosalpingography previously had been failed. The patient previously underwent magnetic resonance imaging. The magnetic resonance imaging report states there was no connection between the uterus and cervix. On external genital organs assessment, there was no abnormal sign. Ultrasonography revealed 2 uterine cavities and hematometra. Both ovaries were in normal view.

Interventions: In view of her examination findings, the patient was scheduled for laparoscopy and hysteroscopy. Laparoscopy revealed extensive adhesions on both the pelvis and upper abdomen. Initially, the uterus and ovaries were not visualized. Adhesiolysis was performed, and normal anatomy was restored. After this step, the operation was continued by laparoscopy and ultrasound-guided hysteroscopy. Under ultrasound and laparoscopy guidance, the transverse uterine septum at the level of uterine isthmus was incised and the left endometrial cavity was observed with hysteroscopy. The asymmetric uterine septum was then incised, and the right-sided endometrial cavity was then accessed. Finally, the uterine septum was completely incised and both sides of the endometrial cavities were merged. The patient had an uncomplicated postoperative course and was discharged 24 hours after surgery. She returned for follow-up examination in the second month after surgery. She had regular menstrual cycles, and her pain was cured.

Conclusion: Hysteroscopy and laparoscopy combined with ultrasound is a useful method for the diagnosis and treatment of asymmetric uterine septum. The skill and experience of the laparoscopic surgeon is another important factor to identify and manage unusual uterine malformations.
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http://dx.doi.org/10.1016/j.jmig.2017.06.015DOI Listing
January 2018

Analysis of clinical and pathological characteristics, treatment methods, survival, and prognosis of uterine papillary serous carcinoma.

Tumori 2016 Dec 4;102(6):593-599. Epub 2016 Aug 4.

Department of Obstetrics and Gynecology, Tepecik Training and Research Hospital, Izmir - Turkey.

Purpose: Uterine papillary serous carcinoma (UPSC) is an atypical variant of endometrial carcinoma with a poor prognosis. It is commonly associated with an increased risk of extrauterine disease. The aim of this study was to investigate clinical and pathological characteristics, therapeutic methods, and prognostic factors in women with UPSC.

Methods: All patients who underwent surgery for UPSC at a single high-volume cancer center between January 1995 and December 2010 were retrospectively reviewed. Patients who did not undergo surgical staging and those with mixed tumor histology were excluded. Univariate and multivariate regression models were used to identify the risk factors for overall survival (OS) and progression-free survival (PFS).

Results: A total of 46 patients were included, the majority of whom having stage I disease (IA, 13 [28.2%] and IB, 12 [26.7%]). Stages II, III, and IV were identified in 5 (10.9%), 8 (17.4%), and 8 (17.4%) women, respectively. Optimal cytoreduction was obtained in 67.3% of patients. Recurrences developed in 8 (17.4%) patients. Multivariate analysis confirmed that lymphovascular space invasion (LVSI) (odds ratio [OR] 26.83, p = 0.003) was the only independent prognostic factor for OS, whereas LVSI and optimal cytoreduction were found to be independent prognostic factors for PFS (OR 6.91, p = 0.013 and OR 2.69, p = 0.037, respectively). The 5-year overall survival rate was 63%.

Conclusions: Our study demonstrated that LVSI is the only independent prognostic factor for OS, whereas LVSI and optimal cytoreduction are independent prognostic factors for PFS in patients with UPSC.
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http://dx.doi.org/10.5301/tj.5000531DOI Listing
December 2016

Total laparoscopic hysterectomy: Analysis of the surgical learning curve in benign conditions.

Int J Surg 2016 Nov 12;35:51-57. Epub 2016 Sep 12.

Department of Obstetrics and Gynecology, Kocaeli Derince Training and Research Hospital, Kocaeli, Turkey.

Objective: To assess the learning curve for total laparoscopic hysterectomy.

Methods: This study was a retrospective analysis of the learning curve for two surgeons during their first 257 consecutive cases of total laparoscopic hysterectomy at a teaching hospital. Patients were divided sequentially into groups comprising the first 75 patients, the next 75, and the final 107 patients. Age, body mass index, gestational parity, indications for laparoscopic hysterectomy, previous pelvic surgery, operating time, haemoglobin decline, complications, need for transfusion, and length of hospital stay were evaluated.

Results: The mean operating time for total laparoscopic hysterectomy reduced significantly from 76.2 min to 68.9 min (p = 0.001) between the first and second 75-patient groups. Linear regression analysis showed a plateau was reached on the learning curve after 71-80 cases. The rate of all complications started at 8% in the first group of 75 patients, reduced to 6.7% in the next group, and decreased further in the final group to 4.7%. The decline was not statistically significant (p = 0.6). The difference in the need for transfusion was statistically significant between the first 75 patients and the second group of 75 (p = 0.04). Conversion from laparoscopy to laparotomy was required in five patients, four in the early group and one in the final group. Age, body mass index, parity, previous pelvic surgery, decline in haemoglobin, and length of hospital stay were similar among the three groups.

Conclusions: A plateau in the learning curve for TLH was reached after the first 75 cases. We can infer that there is a learning curve for TLH as confirmed by the decrease in operating time (accompanied by no change in complications) correlated to gain in experience. On the other hand, one should not disregard the fact that laparoscopy is not a complication-free surgery and achievement of the learning curve does not exclude complications. Gynaecological surgeons can perform TLH securely during the learning curve.
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http://dx.doi.org/10.1016/j.ijsu.2016.09.010DOI Listing
November 2016

Laparoscopic Management of Huge Myoma Nascendi.

J Minim Invasive Gynecol 2017 Mar - Apr;24(3):347-348. Epub 2016 Sep 12.

Department of Obstetrics and Gynecology, Acibadem University Atakent Hospital, İstanbul, Turkey.

Study Objective: To demonstrate the feasibility of laparoscopic management of a huge myoma nascendi.

Design: Step-by-step video demonstration of the surgical procedure (Canadian Task Force classification III-C).

Setting: Uterine myoma is the most common benign neoplasm of the female reproductive tract, with an estimated incidence of 25% to 30% at reproductive age [1,2]. Patients generally have no symptoms; however, those with such symptoms as severe pelvic pain, heavy uterine bleeding, or infertility may be candidates for surgery. The traditional management is surgery; however, uterine artery embolization or hormonal therapy using a gonadotropin-releasing hormone agonist or a selective estrogen receptor modulator should be preferred as the medical approach. Surgical management should be performed via laparoscopy or laparotomy; however, the use of laparoscopic myomectomy is being debated for patients with huge myomas. Difficulties in the excision, removal, and repair of myometrial defects, increased operative time, and blood loss are factors keeping physicians away from laparoscopic myomectomy [1,2].

Interventions: A 35-year-old woman was admitted to our clinic with complaints of chronic pelvic pain and heavy menstrual bleeding. Her medical history included multiple hospitalizations for blood transfusions, along with a recently measured hemoglobin level of 9.5 g/dL and a hematocrit value of 29%. She had never been married and had no children. Pelvic ultrasonography revealed a 12 × 10-cm uterine myoma located on the posterior side of the corpus uteri and protruding through to the cervical channel. This was a huge intramural submucous myoma in close proximity to the endometrial cavity and spreading through the myometrium. On vaginal examination, the myoma was found to extend into the vagina through the cervical channel. Laparoscopic myomectomy was planned because of the patient's desire for fertility preservation. Abdominopelvic exploration revealed a huge myoma filling the posterior side of the corpus uteri and extending to the isthmus uteri and cervical channel. A myomectomy was performed using standard technique as described elsewhere. A vertical incision was made using a harmonic scalpel. The myoma was fixed with a corkscrew manipulator and enucleated. During the procedure, the endometrial cavity was torn and was closed with 2-0 Vicryl separately. Total intraoperative blood loss was 250 mL, the total weight of the myoma was 245 g, and the operation lasted about 120 minutes. The patient experienced no intraoperative complications. She was discharged on postoperative day 1 and did not exhibit any problems at follow-up. The final histopathological examination confirmed the diagnosis of uterine leiomyoma.

Conclusion: Laparoscopic management of huge myomas in difficult locations appears to be a feasible and safe surgical option, especially in experienced hands.
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http://dx.doi.org/10.1016/j.jmig.2016.09.003DOI Listing
July 2017

Laparoscopic Management of Huge Cervical Myoma.

J Minim Invasive Gynecol 2017 Mar - Apr;24(3):345-346. Epub 2016 Sep 12.

Department of Obstetrics and Gynecology, Acibadem University Atakent Hospital, İstanbul, Turkey.

Study Objective: To demonstrate the feasibility of laparoscopic management of a huge cervical myoma.

Design: Step-by-step video demonstration of the surgical procedure (Canadian Task Force classification III-C).

Setting: Uterine myoma is the most common benign neoplasm of the female reproductive tract, with an estimated incidence of 25% to 30% at reproductive age [1,2]. Patients generally have no symptoms; however, those with such symptoms as severe pelvic pain, heavy uterine bleeding, or infertility may be candidates for surgery. The traditional management is surgery; however, uterine artery embolization or hormonal therapy using a gonadotropin-releasing hormone agonist or a selective estrogen receptor modulator should be preferred as the medical approach. Surgical management should be performed via laparoscopy or laparotomy; however, the use of laparoscopic myomectomy is being debated for patients with huge myomas. Difficulties in the excision, removal, and repair of myometrial defects, increased operative time, and blood loss are factors keeping physicians away from laparoscopic myomectomy [1,2].

Interventions: A 40-year-old gravida 0, para 0 woman was admitted to our clinic with complaints of chronic pelvic pain, dyspareunia, and infertility. Her health history was unremarkable. Ultrasonographic examination revealed a 14 × 10-cm myoma in the cervical region. On bimanual examination, an immobile solid mass originating from the uterine cervix and filling the pouch of Douglas was palpated. The patient was informed of the findings, and laparoscopic myomectomy was recommended because of her desire to preserve her fertility. Abdominopelvic examination revealed a huge myoma filling and enlarging the cervix. Myomectomy was performed using standard technique as described elsewhere. A transverse incision was made using a harmonic scalpel. The myoma was fixed with a corkscrew manipulator and enucleated. Once bleeding was controlled, the myoma bed was filled with Spongostan to prevent possible bleeding from leakage. Owing to the anatomic structure of the cervical region, the incision was closed in a monolayer with 0 Vicryl. Total intraoperative blood loss was 300 mL, the total weight of the myoma was 670 g, and the operation lasted approximately 140 minutes. The patient experienced no intraoperative complications. She was discharged on postoperative day 1 and did not exhibit any problems at follow-up. The final histopathological examination confirmed the diagnosis of uterine leiomyoma.

Conclusion: Laparoscopic management of huge myomas in difficult locations such as the cervical region seems to be a feasible and safe surgical option, especially in experienced hands.
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http://dx.doi.org/10.1016/j.jmig.2016.09.002DOI Listing
July 2017

Single-Port Total Laparoscopic Hysterectomy in a Patient With Deep Infiltrating Endometriosis.

J Minim Invasive Gynecol 2017 02 30;24(2):196-197. Epub 2016 Jul 30.

Department of Obstetrics and Gynecology, Acibadem University, Atakent Hospital, İstanbul, Turkey.

Study Objective: To present the feasibility of single-port laparoscopic surgery at patients with deep infiltrating endometriosis.

Design: Step by step explanation of the surgery using videos (Canadian Task Force classification III-c).

Setting: Single-port laparoscopic surgery is an emerging technique and an option for improving the benefits of laparoscopic surgery. The goals of single-port laparoscopic surgery is to further enhance the cosmetic benefits of minimally invasive surgery and minimize the potential risk and morbidity associated with multiport surgery [1,2]. This procedure is not without challenges, however, such as instrument crowding and clashing, ergonomic difficulties, loss of instrument triangulation, and the need for advanced laparoscopic skills [1,2]. Despite these challenges, technical advances in optics and instrumentation have led to the widespread use of single-port laparoscopic surgery to treat such gynecologic disorders as endometriosis, uterine myomas, and cancers [2,3].

Interventions: A 42-year-old woman was admitted to our clinic with a complaint of chronic pelvic pain dysmenorrhea and deep dyspareunia. Her medical history revealed a cesarean section delivery and a diagnosis of endometriosis. Despite treatment of her endometriosis with dienogest, there has been no decline at her complaints. Ultrasound examination performed at admission revealed a 6 × 6 cm right adnexal mass compatible with endometrioma, with a normal left ovary and uterus. Rectovaginal examination detected no endometriotic nodules. Although all treatment options were explained and discussed and laparoscopic excision of right ovarian endometrioma was recommended, the patient strongly desired removal of the uterus and the ovaries to avoid recurrence of endometriosis and related complaints. Thus, laparoscopic hysterectomy and bilateral salpingo-oophorectomy were planned. Under general anesthesia and endotracheal intubation, the patient was placed in low lithotomy position with the arms tucked. An orogastric tube and a Foley catheter were placed. Abdominal access was performed following an open Hasson technique with a 2.0- to 2.5-cm vertical umbilical incision and a 4-channel (with two 10-mm and two 5-mm channels) access port was placed into the peritoneal cavity. On pelvic examination, a 6 × 6-cm right ovarian endometrioma adherent to the pelvic sidewall was detected, along with severe adhesions on the left side between the left adnex and the pelvic sidewall. The uterus was normal. The adhesion on the left side was released using a Harmonic scalpel (Ethicon Endosurgery, Cinncinnati, OH). The pelvic sidewall peritoneum was opened, and the ureters were identified and isolated at the pelvic brim and followed toward the true pelvis. The internal iliac artery, uterine and obliterated umbilical artery, and infundibulopelvic ligament were dissected and identified. The paravesical, pararectal, and rectouterine spaces were opened. Deep infiltrating endometriosis implants on the right side located in the uterosacral ligment and pararectal space were dissected and excised. After restoration of pelvic anatomy, hysterectomy and bilateral salpingo-oophorectomy were performed. The vaginal cuff was closed with intracorporeal knots. The patient was discharged on postoperative day 1, and reported no problems at follow-up.

Conclusion: Single-port laparoscopic hysterectomy appears to be a safe and feasible option in patients with deep infiltrating endometriosis, especially when performed by well-experienced surgeons.
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http://dx.doi.org/10.1016/j.jmig.2016.07.018DOI Listing
February 2017

Laparoscopic Management of Heterotopic Istmocornual Pregnancy: A Different Technique.

J Minim Invasive Gynecol 2017 01 20;24(1):8-9. Epub 2016 Jul 20.

Department of Obstetrics and Gynecology, Acibadem University Atakent Hospital, Istanbul, Turkey.

Study Objective: To present a modified technique for laparoscopic cornual resection for the surgical treatment of heterotopic istmocornual pregnancy.

Design: A step-by-step explanation of the surgery using video (Canadian Task Force Classification III-c).

Setting: Heterotopic pregnancy is the coexistence of pregnancy in both the intrauterine and extrauterine sides. The incidence is 1 in 30 000 in spontaneous pregnancies; however, the incidence increased to 1 in 100 to 1 in 500 pregnancies with the increasing number of artificial reproductive technologies [1,2]. Although management is controversial, there are 2 main approaches classified as surgical and nonsurgical. The administration of potassium chloride, methotrexate, and/or hyperosmolar glucose is a nonsurgical intervention; however, there are some limitations such as systemic side effects and the possible adverse effect on a live fetus [1-3]. For this reason, surgical intervention involving cornual resection is the main treatment option.

Case Report: A 32-year-old patient was admitted to our clinic with sudden-onset pain at the left groin. She was at the 11th week of gestation. She had a diagnosis of infertility for 7 years, and she became pregnant after an in vitro fertilization cycle. At sonographic examination, 2 gestational sacs were detected, 1 with a live fetus settled into the uterus and the second (20-mm length) on the left cornual side without a yolk sac and embryo and the left adnexa accompanied with coagulated blood. Immediate laparoscopic surgery was planned. At the laparoscopic exploration, left istmocornual pregnancy that was ruptured and bleeding were observed. We performed a modified technique for laparoscopic cornual resection in which the uterine corn was tightened with the noose twice, and the corn was sutured circularly to avoid excessive bleeding. Initially, the mesosalpinx was coagulated and transected with bipolar energy. Afterward, the uterine corn was tightened with the noose twice, and the fallopian tube was removed. To reduce the bleeding during remnant cornual tissue extraction, a permanent 0 monofilament suture was passed deep into the myometrium and tightened to achieve better hemostasis. Then, the remnant cornual tissue was extracted with harmonic scissors, and the uterine wound was repaired with continuous suture to reduce the risk of uterine rupture during the ongoing pregnancy. Depot progesterone was administered just before the surgery and the day after. She was discharged on the first postoperative day. At the follow-up, she did not experience any problems during pregnancy, and she was delivered with cesarean section at 39 weeks' gestation.

Conclusion: In conclusion, laparoscopic surgery is a safe and feasible option for the treatment of heterotopic pregnancy, and control of bleeding can be achieved better with our modified technique.
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http://dx.doi.org/10.1016/j.jmig.2016.07.008DOI Listing
January 2017

Optimal cytoreduction, depth of myometrial invasion, and age are independent prognostic factors for survival in women with uterine papillary serous and clear cell carcinomas.

Int J Surg 2016 Aug 27;32:71-7. Epub 2016 Jun 27.

Department of Obstetrics and Gynecology, Tepecik Training and Research Hospital, Izmir, Turkey.

Objective: The purpose of this study was to investigate the clinicopathological characteristics, treatment methods, and prognostic factors in women with uterine papillary serous carcinoma (UPSC) and uterine clear-cell carcinoma (UCCC).

Study Design: All patients who had undergone surgery for UPCS and UCCC between January 1995 and December 2012 were retrospectively reviewed. Patients with missing data, who did not undergo surgical staging and patients with mixed tumor histology were excluded. Multivariate regression models were used to identify the risk factors for overall survival (OS) and progression-free survival (PFS).

Results: A total of 49 UPSC and 22 UCCC women were included. The majority of the patients were at stage I [IA, 22 (31%) and IB, 18 (25.4%)]. Stages II, III, and IV were identified in 9 (12.7%), 13 (18.3%), and 9 (12.7%) of cases, respectively. Optimal cytoreduction was achieved in 71.8% of cases. Recurrences occurred in 16 patients (22.5%). The 5-year OS rates were 67% for UPSC; 76% for UCCC; 68% for both histology, respectively. Multivariate analysis pointed out that age>67 years (odds ratio (OR): 3.85, p = 0.009 and OR: 3.35, p = 0.014), >50% myometrial invasion (MI) (OR: 2.87, p = 0.037 and OR: 2.46, p = 0.046) and optimal cytoreduction (OR: 3.26, p = 0.006 and OR: 2.77, p = 0.015) were the independent prognostic factors for both PFS and OS.

Conclusions: Our study demonstrated that optimal cytoreduction, >50% MI, and age >67 years are the most significant factors affecting survival in women with UPSC and UCCC.
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http://dx.doi.org/10.1016/j.ijsu.2016.06.041DOI Listing
August 2016

Does neoadjuvant chemotherapy plus cytoreductive surgery improve survival rates in patients with advanced epithelial ovarian cancer compared with cytoreductive surgery alone?

J BUON 2015 May-Jun;20(3):847-54

Department of Gynecologic Oncology, Tepecik Training and Research Hospital, Izmir, Turkey.

Purpose: The purpose of this study was to compare the outcomes of interval debulking surgery after neoadjuvant chemotherapy (NAC/IDS) with primary debulking surgery (PDS) in patients diagnosed with advanced epithelial ovarian cancer (EOC).

Methods: A total of 292 patients with IIIC and IV disease stages, who were treated with either NAC/IDS or PDS between 1995 and 2012 were retrospectively reviewed. The study population was divided into two groups: the NAC/IDS group (N=84) and the PDS group (N=208). Progression-free survival (PFS), overall survival (OS), and optimal cytoreduction were compared.

Results: The mean patient age was significantly higher in the NAC/IDS group (61.5±11.5 vs 57.8±11.1, p=0.01). Optimal cytoreduction was achieved in 34.5% (29/84) of the patients in the NAC/IDS group and in 32.2% (69/208) in the PDS group (p=0.825). The survival rates were comparable. The survival rate of patients who received optimal cytoreductive surgery in either the PDS or the NAC/IDS arm was significantly higher than that of patients who received suboptimal cytoreductive surgery (p<0.01 and p<0.01, respectively). Multivariate analysis confirmed the treatment method, amount of ascitic fluid, and optimal cytoreduction as independent factors for OS.

Conclusions: There was no definitive evidence regarding whether NAC/IDS increases survival rates compared with PDS. NAC should be reserved for patients who cannot tolerate PDS or when optimal cytoreduction is not feasible.
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August 2015

Does neoadjuvant chemotherapy plus cytoreductive surgery improve survival rates in patients with advanced epithelial ovarian cancer compared with cytoreductive surgery alone?

J BUON 2015 Mar-Apr;20(2):580-7

Department of Gynecologic Oncology, Tepecik Training and Research Hospital, Izmir, Turkey.

Purpose: To compare the outcomes of interval debulking surgery (IDS) after neoadjuvant chemotherapy (NAC/IDS) with primary debulking surgery (PDS) in patients diagnosed with advanced epithelial ovarian cancer (EOC).

Methods: A total of 292 patients with stages IIIC and IV disease who were treated with either NAC/IDS or PDS between 1995 and 2012 were retrospectively reviewed. The study population was divided into two groups: the NAC/IDS group (N=84) and the PDS group (N=208). Progression-free survival (PFS), overall survival (OS), and optimal cytoreduction were compared.

Results: The mean age was significantly higher in the NAC/IDS group (61.5±11.5 vs 57.8±11.1 years, p=0.01). Optimal cytoreduction was achieved in 34.5% (29/84) of the patients in the NAC/IDS group and in 32.2% (69/208) in the PDS group (p=0.825). The survival rates were comparable. The mean survival rate of patients who achieved optimal cytoreductive surgery in either the PDS or the NAC/IDS arm was significantly higher than that of patients who achieved suboptimal cytoreductive surgery (p<0.001 and p<0.001, respectively). Multivariate analysis confirmed the treatment method, amount of ascitic fluid, and optimal cytoreduction as independent factors for OS.

Conclusions: No definitive evidence was noticed regarding whether NAC/IDS increases survival compared with PDS. NAC should be reserved for patients who cannot tolerate PDS or when optimal cytoreduction is not feasible.
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July 2015

Chylous ascites following retroperitoneal lymphadenectomy in gynecologic malignancies: incidence, risk factors and management.

Int J Surg 2015 Apr 9;16(Pt A):88-93. Epub 2015 Mar 9.

Department of Gynecologic Oncology, Tepecik Training and Research Hospital, Izmir, Turkey.

Introduction: Chylous ascites is a rare form of ascites that results from accumulated lymph fluid in the peritoneal cavity caused by blocked or disrupted lymph flow through the major lymphatic channels. In the present study, our aim was to analyze the incidence, risk factors, diagnostic evaluation and management of chylous ascites after lymphadenectomy in gynecologic malignancies.

Methods: A total of 458 patients who had undergone staging surgery for gynecologic malignancies at our institution between January 2010 and December 2013 were retrospectively reviewed. After the exclusion criteria were applied, 399 patients were divided into 2 groups based on the presence (n = 36) or absence (n = 363) of chylous ascites.

Results: Among the 399 patients, 36 (9%) developed chylous ascites. The median time to onset was 4 days (range, 2-7 days). The analysis of the various features of lymphadenectomy showed that the number of para-aortic lymph nodes (PALNs) removed was significantly greater in the patients with chylous ascites (p < 0.001). A cut-off value of >14 PALNs was a good predictor of chylous ascites. In all patients, chylous ascites resolved with conservative management.

Conclusions: Postoperative chylous ascites was strongly associated with the number of harvested PALNs. According to our findings, we suggest that conservative treatment should be the first step in managing patients with chylous ascites. Using an abdominal drain after surgery seems to be an effective diagnostic tool and treatment method for chylous ascites.
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http://dx.doi.org/10.1016/j.ijsu.2015.02.020DOI Listing
April 2015

Assessment of total placenta previa by magnetic resonance imaging and ultrasonography to detect placenta accreta and its variants.

Ginekol Pol 2013 Mar;84(3):186-92

Department of Obstetrics and Gynecology, Ege University Faculty of Medicine, Izmir Turkey.

Objective: To evaluate the importance of ultrasonography (US) and magnetic resonance imaging (MRI) in detecting placental adherence defects.

Material And Methods: Patients diagnozed with total placenta previa (n = 40) in whom hysterectomy was performed due to placental adherence defects (n = 20) or in whom the placenta detached spontaneously after a Cesarean delivery (n = 20) were included into the study between June 2008 and January 2011, at the Department of Obstetrics and Gynecology Ege University (lzmir Turkey). Gray-scale US was used to check for any placental lacunae, sub-placental sonolucent spaces or a placental mass invading the vesicouterine plane and bladder Intra-placental lacunar turbulent blood flow and an increase in vascularization in the vesicouterine plane were evaluated with color Doppler mode. Subsequently all patients had MRI and the results were compared with the histopathologic examinations.

Results: The sensitivity of MRI for diagnosis of placental adherence defects before the operation was 95%, with a specificity of 95%. In the presence of at least one diagnostic criterion, the sensitivity and specificity of US were 87.5% and 100% respectively, while the sensitivity of color Doppler US was 62.5% with a specificity of 100%.

Conclusions: Currently MRI appears to be the gold standard for the diagnosis of placenta accreta. None of the ultrasonographic criteria is solely sufficient to diagnose placental adherence defects, however they assist in the diagnostic process.
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http://dx.doi.org/10.17772/gp/1561DOI Listing
March 2013

Combination of intracranial translucency and 3D sonography in the first trimester diagnosis of neural tube defects: case report and review of literature.

Ginekol Pol 2013 Jan;84(1):65-7

Ege Universitiy Faculty of Medicine, Department of Obstetrics and Gynecology, Bornmova, Izmir, Turkey.

Neural tube defects are congenital defects of the central nervous system caused by lack of neural tube closure. First trimester screening for aneuploidy has become widespread in the recent years. Fetal intracranial translucency (IT) can be easily observed in normal fetuses in the mid-sagittal plane. The absence of IT should be an important factor taken into consideration in the early diagnosis of open spinal defects. 3D ultrasonography is especially useful in cases of spinal anomalies where the visualization of the fetal structure is insufficient due to fetal position. We present a combination of intracranial translucency and 3D sonography used in the first trimester diagnosis of a neural tube defect case.
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http://dx.doi.org/10.17772/gp/1543DOI Listing
January 2013

How quickly can acute symptomatic hyponatremia be corrected?

Int Urol Nephrol 2013 Dec 30;45(6):1805-8. Epub 2012 Sep 30.

Division of Nephrology, School of Medicine, Ege University, 35100, Bornova, Izmir, Turkey,

The systemic absorption of the flush liquid, including sorbitol, glycine or mannitol, can lead to complications, such as hyponatremia, volume overload and pulmonary or cerebral edema. Acute hyponatremia is defined as a reduction in the plasma sodium level in less than 48 h. Acute symptomatic hyponatremia should be corrected aggressively because it may cause irreversible neurological damage and death. Rapid correction of hyponatremia causes severe neurologic deficits, such as central pontine myelinolysis; thus, the optimal therapeutic approach has been debated. This article examined acute symptomatic hyponatremia in a patient undergoing transcervical myomectomy for a submucosal myoma. A thirty-seven-year-old patient was evaluated in obstetrics and gynecology clinic because of altered mental status and agitation. There was no history of chronic illness or drug use. It was discovered that during the operation, 12 L of the flush fluid, which contained 5 % mannitol, had been infused, but only 7 L of the flush fluid had been collected. On physical examination, the patient's general condition was moderate, her cooperation was limited, she was agitated, and her blood pressure was 120/70 mmHg. The sodium level was 99 mEq/L. Furosemid and 3 % NaCl solution were given. Her serum sodium returned to normal by increasing 39 mEq/L within 14 h. Her recovery was uneventful, and she was discharged 24 h after her serum sodium returned to normal. In conclusion, if there is a difference between the infused and collected volumes of the mannitol irrigant, severe hyponatremia may develop due to the flush fluid used during transcervical hysteroscopy and myomectomy. In these patients, acute symptomatic hyponatremia may be corrected as rapidly as the sodium level dropped.
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http://dx.doi.org/10.1007/s11255-012-0291-0DOI Listing
December 2013

Prenatal diagnosis of Cantrell pentalogy in first trimester screening: case report and review of literature.

J Turk Ger Gynecol Assoc 2012 1;13(2):145-8. Epub 2012 Jun 1.

Department of Gynecology and Obstetrics, Faculty of Medicine, Ege University, İzmir, Turkey.

Pentalogy of Cantrell is a heterogeneous and rare thoraco-abdominal wall closure defect with the estimated prevalence of 1/65.000 to 1/200.000 births. Supraumbilical midline wall defect (generally omphalocele), deficiency of the anterior diaphragm and diaphragmatic peritoneum, defect of the lower sternum and several intracardiac defects are the components of Cantrell pentalogy. Etiology is unknown but a defect on the lateral mesoderm during the early stage of pregnancy is the most accepted hypothesis. Nowadays both 2- dimensional (2D) and 3-dimensional (3D) sonography are commonly used in diagnosis. In our case, a fetus with 11 weeks of gestation was reported as Cantrell pentalogy during first trimester screening. Additionally, unilateral limb defect and lumbar lordoscoliosis were detected through 3D sonography. Pregnancy was terminated according to parental desire. Karyotype was 46 XY. Early diagnosis is feasible in the first trimester if ectopia cordis and omphalocele exist. Additionally, development in ultrasound technology provides us with better visualization and early diagnosis. Prognosis seems to be poor in patients with complete Cantrell syndrome and patients with associated anomalies. Termination is the choice of treatment. Early diagnosis gives us a chance to reduce maternal morbidity and mortality related to termination.
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http://dx.doi.org/10.5152/jtgga.2011.77DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3939139PMC
March 2014

Tubal torsion during pregnancy--case report.

Ginekol Pol 2011 Apr;82(4):287-90

Department of Obstetrics and Gynecology, Ege University, Izmir, Turkey.

Tubal torsion is a very rare event, especially in pregnancy. We present a case of a patient of 20 weeks gestation that was admitted to our clinic with acute abdomen. Radiological and biochemical investigations did not reveal the cause of abdominal pain which resulted in laparatomic exploration. During the operation, the paratubal cystic mass, previously explored by ultrasonographic examination, and the left fallopian tube were found twisted among themselves. Salpingectomy was performed due to the necrotic appearance of the fallopian tube.
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April 2011

Brucellosis in adolescent pregnancy--case report and review of literature.

Ginekol Pol 2011 Mar;82(3):226-9

Department of Obstetrics and Gynecology, Ege University, Faculty of Medicine, Izmir, Turkey.

Brucellosis is a zoonotic disease that can be encountered during pregnancy especially in endemic areas such as Latin America, Africa, Asia, Mediterranean countries and eastern region of Turkey. We present a case of a 19-year-old pregnant woman of 19-20 weeks gestation diagnosed with brucellosis. Main presentation at admission were hematuria and nausea. Advanced investigations revealed blood culture positive for brucella. Abortion occurred in the course of medical therapy.
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March 2011