Urethral diverticulum in pregnancy: Rare case report and brief literature review.

OBJECTIVE: Female urethral diverticulum (UD), an evagination of the urethral mucosa into the surrounding connective tissue, is extremely rare in pregnancy. No clear guidelines on the optimal management of UD have been established, except for a common conservative approach. Here, we discuss how to manage UD with pregnancy. CASE REPORT: A 39-year-old gravida 4, para 0, abortion 3 (G4P0A3) woman at 34+0 gestational weeks (GW) visited our outpatient department with a 6-cm septate vaginal mass. Transvaginal ultrasound sonography (TVUS) revealed a 5.5 x 4.9-cm multicystic mass, which was confirmed as UD with pelvic MRI. She was admitted because of preterm labor. A cesarean section was performed at 36+5 GW due to a previous myomectomy, and a healthy male baby was born. UD was still observed in the patient two months after delivery. Periurethral diverticulectomy was performed, and pathological analysis revealed UD with chronic inflammation and edema. CONCLUSION: Previous reports and our case report show that UD can develop during pregnancy and that pelvic MRI is suitable for its accurate diagnosis. Vaginal delivery is possible in pregnant women with the small size of the UD. UD aspiration can permit vaginal delivery in a few cases; however, pus can occur at the aspirated site after the operation. If UD is still observed after delivery, urethral diverticulectomy is recommended.

Clinical, radiological, and pathological features of mitotically active cellular fibroma of ovary: A review of cases with literature review.

OBJECTIVE: Mitotically active cellular fibroma (MACF) of the ovary, characterized by relatively high mitotic activity without severe atypia, was first described in the WHO classification in 2014. However, due to its rarity, the clinicopathological characteristics of ovarian MACF have not been established. This study was performed to describe the clinical, radiological, and pathological features of MACF by analyzing 11 cases of ovarian MACF. MATERIALS AND METHODS: Between 2015 and 2022, 11 patients with ovarian MACFs underwent surgical treatment at our institution. Clinicopathologic data of the patients were retrospectively reviewed from their medical records. RESULTS: Median patient age was 53.7 years (range 21-77 years), and median tumor diameter was 7.8 cm (range 4.3-14.0 cm). Preoperative CA125 was elevated in 4 cases. Four of the eleven patients had abdominal pain, and two presented with vulvar pain or a palpable abdominal mass, respectively. Preoperative radiological impressions included fibroma, fibrothecoma, stromal tumor, and cystadenocarcinoma. A laparoscopic approach was adopted in 7 cases (64%). Intraoperative frozen section was performed in 5 patients, and all demonstrated the presence of a benign, fibromatous stromal tumor. Three patients underwent fertility-sparing surgery, including laparoscopic ovarian cystectomy and unilateral salpingo-oophorectomy. Median follow-up was 37.7 months (range 2-84 months), and no patient experienced disease relapse or died of their disease. CONCLUSION: This study shows that ovarian MACF has a benign clinical course. Fertility-sparing surgery provides a safe therapeutic option for MACF, which can be managed safely by laparoscopy. Imaging findings and final pathological diagnosis were not well matched. Intraoperative frozen section is important for determining surgical extent in mitotically active cellular fibroma of the ovary.

Effects of the dual-task training program for Korean older adults with mild cognitive impairment in community.

This study was to examine the effects of dual-task training program on the cognitive function, physical functional status, self-efficacy, and life satisfaction of Korean older adults with mild cognitive impairment living in community. A quasi-experimental pretest-posttest control group design was used. The study participants were a total of 32 older adults with mild cognitive impairment over the age of 65 in the community, South Korea (Intervention: n = 16, Control: n = 16). The effects of time and group interactions between the intervention and control groups were statistically significant for the cognitive function (F=60.99, p < 0.001), physical function status (F=25.59, p < 0.001), self-efficacy (F=69.36, p < 0.001), and life satisfaction level (F=25.81, p < 0.001). The intervention group showed positive improvements in health-related outcome variables compared to the control group. The intervention showed beneficial effects immediately after 10 weeks applied and the effects were sustained at 14 weeks.

Chimeric Singleton Placenta Comprising Placental Mesenchymal Dysplasia and Complete Hydatidiform Mole with Live Birth and Postpartum Diagnosis of Gestational Trophoblastic Neoplasia.

INTRODUCTION: Placental mesenchymal dysplasia (PMD) is a benign lesion that is often misdiagnosed as complete (CHM) or partial hydatidiform mole. PMD usually results in live birth but can be associated with several fetal defects. Herein, we report PMD with CHM in a singleton placenta with live birth. CASE PRESENTATION: A 34-year-old gravida 2, para 1, living 1 (G2P1L1) woman was referred on suspicion of a molar pregnancy in the first trimester. Maternal serum human chorionic gonadotrophin levels were increased during early pregnancy, with multicystic lesions and placentomegaly observed on ultrasonography. Levels decreased to normal with no fetal structural abnormalities observed. A healthy male infant was delivered at 34 gestational weeks. Placental p57KIP2 immunostaining and short tandem repeat analysis revealed three distinct histologies and genetic features: normal infant and placenta, PMD, and CHM. Gestational trophoblastic neoplasia was diagnosed and up to fourth-line chemotherapy administered. CONCLUSION: Distinguishing PMD from hydatidiform moles is critical for avoiding unnecessary termination of pregnancy. CHM coexisting with a live fetus rarely occurs. This case is unique in that a healthy male infant was born from a singleton placenta with PMD and CHM.

Encoder-Weighted W-Net for Unsupervised Segmentation of Cervix Region in Colposcopy Images.

Cervical cancer can be prevented and treated better if it is diagnosed early. Colposcopy, a way of clinically looking at the cervix region, is an efficient method for cervical cancer screening and its early detection. The cervix region segmentation significantly affects the performance of computer-aided diagnostics using a colposcopy, particularly cervical intraepithelial neoplasia (CIN) classification. However, there are few studies of cervix segmentation in colposcopy, and no studies of fully unsupervised cervix region detection without image pre- and post-processing. In this study, we propose a deep learning-based unsupervised method to identify cervix regions without pre- and post-processing. A new loss function and a novel scheduling scheme for the baseline W-Net are proposed for fully unsupervised cervix region segmentation in colposcopy. The experimental results showed that the proposed method achieved the best performance in the cervix segmentation with a Dice coefficient of 0.71 with less computational cost. The proposed method produced cervix segmentation masks with more reduction in outliers and can be applied before CIN detection or other diagnoses to improve diagnostic performance. Our results demonstrate that the proposed method not only assists medical specialists in diagnosis in practical situations but also shows the potential of an unsupervised segmentation approach in colposcopy.

Successful Full-Term Delivery via Selective Ectopic Embryo Reduction Accompanied by Uterine Cerclage in a Heterotopic Cesarean Scar Pregnancy: A Case Report and Literature Review.

Heterotopic cesarean scar pregnancy (HCSP) is a combination of cesarean scar pregnancy (CSP) and intrauterine pregnancy (IUP). Cesarean scar pregnancy is accompanied by life-threatening complications, such as uterine rupture and massive bleeding. Herein, we present a case of HCSP treated with selective potassium chloride injection into the CSP under ultrasonography in association with uterine cerclage to control vaginal bleeding; this led to a successful IUP preservation and full-term delivery. Additionally, we will review several previous reports on HCSP management, including our case.

Ruptured Hemorrhagic Ectopic Pregnancy Implanted in the Diaphragm: A Rare Case Report and Brief Literature Review.

The mortality and morbidity rates of non-tubal ectopic pregnancies with abdominal hemorrhaging are 7-8 times higher than those of tubal pregnancies. Diaphragmatic pregnancy is a rare non-tubal ectopic form, causing acute abdominal hemoperitoneum. Here, we present a case of a primary diaphragmatic ectopic pregnancy with hemorrhage that was immediately diagnosed and successfully managed with laparoscopic surgery. Rapid and accurate diagnosis using appropriate imaging modalities is critical for improving the prognosis of a child-bearing woman with an abdominal pregnancy.

Minimally invasive adenomyomectomy via a laparoscopic-assisted approach compared to a laparoscopic or laparotomic approach.

OBJECTIVE: The present study assessed the safety and benefits of laparoscopic-assisted adenomyomectomy compared to laparoscopic or laparotomic adenomyomectomy. MATERIALS AND METHODS: This study was a retrospective comparative study. A total of 277 patients underwent adenomyomectomy between January 2016 and January 2019 at the Department of Obstetrics and Gynaecology, Ulsan University Hospital, including 25 with laparoscopic-assisted adenomyomectomy, 82 with laparoscopic adenomyomectomy, and 170 with laparotomic adenomyomectomy. Laparoscopic-assisted adenomyomectomy consisted of a laparoscopic uterine artery procedure to reduce blood loss and a minimal incisional for laparotomic adenomyomectomy. An additional laparoscopic surgery was performed for possible pelvic pathology. RESULTS: Data on patient demographics, surgical indications, operative times, estimated blood loss (EBL), short-term complications, and postoperative hospital stays were compared. The laparoscopic-assisted surgery (LAS) and laparotomic groups were comparable in average EBL (208.0 ± 128.8 vs. 193.6 ± 193.0 ml, p = 0.11), weight of removed mass (85.5 ± 71.7 vs. 108.2 ± 91.9 g, p = 0.39), and postoperative hospital days (HDs) (4.5 ± 1.0 vs. 4.7 ± 0.8 days, p = 0.27). These values were lower in the laparoscopic group (EBL 119.5 ± 79.6 ml, mass weight 39.3 ± 25.9 g, HD 3.6 ± 0.8 days). Additional procedures, including myomectomy and combined severe endometriosis surgery, were more frequently performed in the LAS group than the laparotomic group. The mean operating time was longer in the LAS group (179.8 ± 36.6 min) than the other groups (laparoscopy 99.9 ± 40.6 min, p < 0.00; laparotomy 133.0 ± 41.1 min, p < 0.00). The three groups did not differ significantly in transfusion rates, hemoglobin changes, or perioperative complications. However, febrile morbidity was lower in the laparoscopic group than the LAS and laparotomic groups. CONCLUSION: LAS adenomyomectomy allows for maximal debulking of adenomyosis via extracorporeal and intracorporeal procedures while retaining the advantages of the laparoscopic approach. Additional pelvic surgery for benign uterine and adnexal pathology may easily be performed with this approach.

Prognostic factors of oncologic outcomes after fertility-preservative management with progestin in early-stage of endometrial cancer.

BACKGROUND: The aim of this study was to evaluate efficacy of various fertility-preservative treatments with progestin and analyze prognostic factors in Stage 1A of endometrial cancer. MATERIALS AND METHODS: This retrospective study involved four Korean university hospitals. Data were collected from 43 women who were under the age of 40 with presumed stage IA endometrial cancer determined by magnetic resonance imaging and treated from January 2014 to December 2017. All of the patients were administered hormonal therapy for fertility preservation. Twenty-five patients received oral progestin with a levonorgestrel-releasing intrauterine system (LNG-IUS) for 6-24 months, and 18 patients received high-dose oral progestin for the same period of time. Oncologic outcomes were evaluated. Prognostic factors for pathologic response to progestin were identified by logistic regression analysis. RESULTS: Complete response (CR) was achieved by 72.1% of patients (31/43), and the average time to CR was 4.2 (Stable disease [SD] 3.4) months (range, 3-9 months). Partial response was achieved by 7.0% of patients (3/43), SD by 9.3% (4/43), and progressive disease by 11.6% (5/43). Of the CR patients, 41.9% (13/31) achieved pregnancy with the median follow-up period of 12.5 (SD 7.6) months (range: 3-50 months). No irreversible toxicity or therapy-associated death occurred. Multivariate analysis showed that high endometrial thickness ratio of pre- and posttreatment measured at 2 months from the treatment initiation (≥0.55, Odds ratio [OR]: 19.018; 95% confidence intervals (CI): 1.854-195.078; P = 0.013) and oral progestin without LNG-IUS (OR: 13.483; 95% CI: 1.356-134.069; P = 0.026) might be related with unfavorable prognostic factors for CR. CONCLUSION: This study shows that progestin-based fertility-preservative treatment might be a feasible option for stage 1A endometrial cancer. It also identifies that low endometrial thickness ratio and oral progestin with LNG-IUS combination therapy might be related with favorable response to hormonal treatment.

Maternal Bochdalek Hernia during Pregnancy: A Systematic Review of Case Reports.

BACKGROUND: Since the first report of a diaphragmatic hernia from Ambroise Paré's necropsy in 1610, the Bochdalek hernia (BH) of the congenital diaphragmatic hernia (CDH) has been the most common types with high morbidity and mortality in the neonatal period. Due to the nature of the disease, CDH associated with pregnancy is too infrequent to warrant reporting in the literature. Mortality of obstruction or strangulation is mostly due to failure to diagnose symptoms early. DATA SOURCES AND STUDY SELECTION: A systematic literature search of maternal BH during pregnancy was conducted using the electronic databases (PubMed and EMBASE) from January 1941 to December 2020. Because of the rarity of the disease, this review included all primary studies, including case reports or case series that reported at least one case of maternal BH in pregnant. Searches, paper selection, and data extraction were conducted in duplicate. The analysis was performed narratively regardless of the control groups' presence due to their rarity. RESULTS: The search retrieved 3450 papers, 94 of which were deemed eligible and led to a total of 43 cases. Results of treatment showed 16 cases in delayed delivery after hernia surgery, 10 cases in simultaneous delivery with hernia surgery, 3 cases in non-surgical treatment, and 14 cases in hernia surgery after delivery. Of 16 cases with delayed delivery after hernia surgery, 13 (81%) cases had emergency surgery and three (19%) cases had surgery after expectant management. Meanwhile, 10 cases underwent simultaneous delivery with hernia surgery, 6 cases (60%) had emergent surgery, and 4 cases (40%) had delayed hernia surgery after expectant management. 3 cases underwent non-surgical treatment. In this review, the maternal death rate and fetal/neonatal loss rate from maternal BH was 5% (2/43) and 16% (7/43), respectively. The preterm birth rate has been reported in 35% (15/43) of maternal BH, resulting from maternal deaths in 13% (2/15) of cases and 6 fetal loss in 40% (6/15) of cases; 44% (19/43) of cases demonstrated signs of bowel obstruction, ischemia, or perforation of strangulated viscera in the operative field, resulting from maternal deaths in 11% (2/19) of cases and fetal-neonatal loss in 21% (4/19) of cases. CONCLUSION: Early diagnosis and surgical intervention are imperative, as a gangrenous or non-viable bowel resection significantly increases mortality. Therefore, multidisciplinary care should be required in maternal BH during pregnancies that undergo surgically repair, and individualized care allow for optimal results for the mother and fetus.

Preoperative Blood Inflammatory Markers for the Differentiation of Uterine Leiomyosarcoma from Leiomyoma.

PURPOSE: Preoperative diagnosis of uterine leiomyosarcoma (LMS) is challenging because the disease can mimic benign leiomyoma (LM). The objective of the present study was to investigate the role of preoperative clinical characteristics and hematologic parameters to differentiate uterine LMS and LM. METHODS: Preoperative clinical and laboratory variables were reviewed retrospectively in patients with LMS or LM, and the significances of intergroup differences were assessed. Receiver operating characteristic (ROC) curves were used to determine optimal cut-off values for each variable. Logistic regression analysis was applied to identify variables predicting the presence of LMS. RESULTS: The preoperative clinical and laboratory variables of 336 patients with uterine tumor were analyzed. Seventy-nine patients had LMS and 257 had LM. A significant difference was observed between LMS and LM in terms of the median value of age at diagnosis, menopausal status, white blood cell (WBC) count, absolute neutrophil count (ANC), C-reactive protein (CRP), lactate dehydrogenase (LDH), and neutrophil-to-lymphocyte ratio (NLR) (all P < 0.001). Multivariate analyses showed that menopausal status (odds ratio [OR] = 3.40, P= 0.002), WBC count (OR = 2.09, P = 0.012), ANC (OR = 3.17, P < 0.001), CRP (OR = 21.74, P < 0.001), LDH (OR = 10.77, P < 0.001), and NLR (OR = 2.58, P = 0.001) predicted the presence of LMS. CONCLUSION: Our results suggest that in older or postmenopausal patients, high WBC count, ANC, CRP, LDH, and NLR could be useful biomarkers for the differentiation of LMS and LM, which indicate that serum markers might be useful, cost-effective, and broadly available diagnostic markers for uterine LMS.

Empathy and Self-Efficacy in Elderly Nursing Practice among Korean Nurses.

The Korean government is activating an integrated nurse care service, in which all inpatient care services are provided by a proper nursing team without a caregiver or a guardian staying at the hospital. This study was to examine the influence of empathy and self-efficacy on the elderly nursing practice of nurses at integrated nurse care service wards in South Korea. A cross-sectional descriptive design was employed. Participants included 238 nurses who were working at integrated nurse care service wards in hospitals in Seoul, South Korea. Measures were a general characteristics form, the Empathy Construct Rating Scale, the Korean Self-Efficacy Scale, and the Korean Elderly Nursing Practice Scale. Data were collected from February to May 2017. The findings show a slightly higher level of empathy; an almost intermediate level of self-efficacy; and a high level of elderly nursing practice in Korean nurses at integrated nurse care service wards. The only factor found to impact significantly on elderly nursing practice was empathy. The findings suggest that nurses need to enhance empathy toward the elderly to improve elderly nursing practice. It is necessary to provide strategies or interventions in the nursing management for improvement of the empathy of nurses at integrated nurse care service wards in South Korea.

Comparison of long-term survival of total abdominal radical hysterectomy and laparoscopy-assisted radical vaginal hysterectomy in patients with early cervical cancer: Korean multicenter, retrospective analysis.

PURPOSE: The aim of this study was to compare survival outcomes of total abdominal radical hysterectomy (TARH) versus laparoscopy-assisted radical vaginal hysterectomy (LARVH) in stage IA2-IB2 cervical cancer. METHODS: 812 patients who underwent RH between 2008 and 2017 were evaluated in 3 institutions. Progression-free survival (PFS) and overall survival (OS) were analyzed with Kaplan-Meier method and compared by log-rank test. The clinical noninferiority of the LARVH to TARH was assessed with a margin of -7.2%. Noninferiority was demonstrated if the low limit of 95% confidence interval (CI) exceeded its predefined margin. RESULTS: 258 patients were treated with TARH and 252 patients with LARVH. TARH and LARVH group had similar 5-year PFS (84.4% vs 86.6%, p = 0.467) and OS rates (85.8% vs 88.0%, p = 0.919). Noninferiority of LARVH to TARH were confirmed with 5-year PFS and OS difference rates of 2.2% (95% CI -2.9-7.3, p = 0.001) and 2.2% (95% CI -2.7-7.1, p = 0.001), respectively. In subgroup of patients with tumors size >2 cm, 5-year PFS (77.6% vs 79.0%, p = 0.682) and OS rates (79.2% vs 81.5%, p = 0.784) did not differ statistically between the two groups. Noninferiority of LARVH to TARH were also confirmed with 5-year PFS and OS difference rates of 1.4% (95% CI -7.0-9.8, p = 0.046) and 2.3% (95% CI -5.8-10.4, p = 0.027), respectively. CONCLUSION: LARVH showed significant noninferiority for PFS and OS versus TARH in early cervical cancer, suggesting the potential oncologic safety of LARVH.

The association between expression of p53 and aggressiveness of serous adenocarcinoma of the uterine cervix.

BACKGROUND: Serous adenocarcinoma of the uterine cervix is an extremely rare variant of cervical adenocarcinoma. This study aimed to evaluate the clinicopathological and molecular features and outcomes of serous adenocarcinoma of the uterine cervix (SACC). MATERIALS AND METHODS: This was a retrospective study conducted based on the clinical and pathological data of seven patients diagnosed with SACC after hysterectomy, who were evaluated at the gynecologic oncologic centers between 2010 and 2019. RESULTS: Five cases were diagnosed at Stage IB and two at Stage IV. All patients underwent radical hysterectomy with bilateral salpingo-oophorectomy and subsequently received postoperative radiotherapy or chemotherapy. One patient showed persistent disease, and two patients suffered recurrence. Immunohistochemical study showed that three (43%) of the seven patients were positive for p53, and among these three patients, two with diffuse strong p53 expression experienced an aggressive course with recurrences at pelvic lymph nodes, lung, and brain. CONCLUSION: High p53 expression and advanced stage may be associated with poorer clinical outcomes in SACC, which suggest that immunohistochemistry may contribute to the prediction of prognosis.

The Diagnostic Accuracy of Magnetic Resonance Imaging for Maternal Acute Adnexal Torsion during Pregnancy: Single-Institution Clinical Performance Review.

BACKGROUND: For acute adnexal torsion of pregnant women, appropriate treatment based on an accurate diagnosis is especially important for fertility preservation and timely treatment. The 2017 American College of Obstetricians and Gynecologists (ACOG) Committee Opinion No. 723 announced its practice-changing guidelines to ensure that diagnostic magnetic resonance imaging (MRI) conducted during the first trimester and gadolinium exposure at any time during pregnancy are safe for fetal stability. Unfortunately, few studies have been performed to evaluate the usefulness of the diagnostic accuracy of MRI for acute adnexal torsion during pregnancy. OBJECTIVE: We sought to determine the efficacy of diagnostic MRI modality using multiparameter for maternal adnexal torsion during pregnancy. METHODS: From 1 January 2007 to 31 January 2019, 131 pregnant with MRI tests were reviewed. In this retrospective cohort study, 94 women were excluded due to conditions other than an adnexal mass, and 37 were identified through MRI analyses conducted before surgery for suspected adnexal torsion. The primary outcome was the diagnostic accuracy of sonography and MRI, and the secondary outcome was the usefulness of Apparent diffusion coefficient (ADC) values for predicting the severity of hemorrhagic infarction between the medulla and cortex of the torsed ovarian parenchyma. RESULTS: Our study demonstrates that in the diagnosis of adnexal torsion during pregnancy, the sensitivity, specificity, positive predictive value, and negative predictive value are 62.5%, 83.3%, 90.9%, and 45.5% for sonography and 100%, 77.8%, 90.5%, and 100% for MRI. MRI results in surgical-proven adnexal torsion patients revealed unilocular ovarian cysts (36.8% (7/19)), multilocular ovarian cysts (31.6% (6/19)), and near normal-appearing ovaries (31.6% (6/19)). Pathology in adnexal torsion revealed a corpus luteal ovarian cyst (63.2% (12/19)) and underlying adnexal pathology (46.8% (7/19)). Maternal adnexal torsion during pregnancy was more likely to occur in corpus luteal ovarian cysts than in underlying adnexal masses (odds ratio, 2.14; 95% confidence interval (CI), 0.428-10.738). MRI features for adnexal torsion were as follows: tubal wall thickness, 100% (19/19); ovarian stromal (medullary) edema, 100% (19/19); symmetrical or asymmetrical ovarian cystic wall, 100%(19/19); prominent follicles in the ovarian parenchyma periphery, 57.9% (11/19); periadenxal fat stranding, 84.2% (16/19); uterine deviation to the twisted side, 21.1% (4/19); and peritoneal fluid, 42.1% (8/19). The signal intensity of the ADC values of the ovarian medulla and cortex were compared between the cystectomy and detorsion (CD) and salpingo-oophorectomy (SO) groups. The ADC values of the CD and SO groups were 1.81 ± 0.09 × 10-3 mm2/s and 1.91 ± 0.18 × 10-3 mm2/s, respectively (P = 0.209), in the ovarian medulla and 1.37 ± 0.32 × 10-3 mm2/s and 0.96 ± 0.36 × 10-3 mm2/s, respectively (P = 0.022), in the ovarian cortex. The optimal cut-off value of ADC values for predictable total necrosis in the torsed ovarian cortex was ≤ 1.31 × 10-3 mm2/s (area under the curve (AUC) = 0.81; 95% CI 0.611-1.0; P = 0.028). CONCLUSION: Our data showed that maternal adnexal torsion during pregnancy occurred in most corpus luteal cystic ovary cases and some normal-appearing ovary during the 1st and 2nd trimesters of gestation. Therefore, this study is the first study to elaborate on the existence or usefulness of the diagnostic MRI for acute maternal adnexal torsion during pregnancy and to provide a predictive diagnosis of the severity of hemorrhagic infarction for deciding surgical radicality.

Quantitative Screening of Cervical Cancers for Low-Resource Settings: Pilot Study of Smartphone-Based Endoscopic Visual Inspection After Acetic Acid Using Machine Learning Techniques.

BACKGROUND: Approximately 90% of global cervical cancer (CC) is mostly found in low- and middle-income countries. In most cases, CC can be detected early through routine screening programs, including a cytology-based test. However, it is logistically difficult to offer this program in low-resource settings due to limited resources and infrastructure, and few trained experts. A visual inspection following the application of acetic acid (VIA) has been widely promoted and is routinely recommended as a viable form of CC screening in resource-constrained countries. Digital images of the cervix have been acquired during VIA procedure with better quality assurance and visualization, leading to higher diagnostic accuracy and reduction of the variability of detection rate. However, a colposcope is bulky, expensive, electricity-dependent, and needs routine maintenance, and to confirm the grade of abnormality through its images, a specialist must be present. Recently, smartphone-based imaging systems have made a significant impact on the practice of medicine by offering a cost-effective, rapid, and noninvasive method of evaluation. Furthermore, computer-aided analyses, including image processing-based methods and machine learning techniques, have also shown great potential for a high impact on medicinal evaluations. OBJECTIVE: In this study, we demonstrate a new quantitative CC screening technique and implement a machine learning algorithm for smartphone-based endoscopic VIA. We also evaluated the diagnostic performance and practicability of the approach based on the results compared to the gold standard and from physicians' interpretation. METHODS: A smartphone-based endoscope system was developed and applied to the VIA screening. A total of 20 patients were recruited for this study to evaluate the system. Overall, five were healthy, and 15 were patients who had shown a low to high grade of cervical intraepithelial neoplasia (CIN) from both colposcopy and cytology tests. Endoscopic VIA images were obtained before a loop electrosurgical excision procedure for patients with abnormal tissues, and their histology tissues were collected. Endoscopic VIA images were assessed by four expert physicians relative to the gold standard of histopathology. Also, VIA features were extracted from multiple steps of image processing techniques to find the differences between abnormal (CIN2+) and normal (≤CIN1). By using the extracted features, the performance of different machine learning classifiers, such as k-nearest neighbors (KNN), support vector machine, and decision tree (DT), were compared to find the best algorithm for VIA. After determining the best performing classifying model, it was used to evaluate the screening performance of VIA. RESULTS: An average accuracy of 78%, with a Cohen kappa of 0.571, was observed for the evaluation of the system by four physicians. Through image processing, 240 sliced images were obtained from the cervicogram at each clock position, and five features of VIA were extracted. Among the three models, KNN showed the best performance for finding VIA within holdout 10-fold cross-validation, with an accuracy of 78.3%, area under the curve of 0.807, a specificity of 80.3%, and a sensitivity of 75.0%, respectively. The trained model performed using an unprovided data set resulted in an accuracy of 80.8%, specificity of 84.1%, and sensitivity of 71.9%. Predictions were visualized with intuitive color labels, indicating the normal/abnormal tissue using a circular clock-type segmentation. Calculating the overlapped abnormal tissues between the gold standard and predicted value, the KNN model overperformed the average assessments of physicians for finding VIA. CONCLUSIONS: We explored the potential of the smartphone-based endoscopic VIA as an evaluation technique and used the cervicogram to evaluate normal/abnormal tissue using machine learning techniques. The results of this study demonstrate its potential as a screening tool in low-resource settings.

The Diagnostic Accuracy and Postoperative Outcomes of Cervical Cancer Patients for MR-invisible or MR-visible Diagnosis of Combined T2- and Diffusion-weighted 3T MRI Using the External Phased-array Receiver.

BACKGROUND/AIM: This study aimed to determine the diagnostic accuracy and postoperative outcomes of early-stage cervical cancer patients [2009 FIGO stages IA2-IB1 (<2 cm)] diagnosed with magnetic resonance (MR)-invisible disease or MR-visible disease using the external phased-array receiver. PATIENTS AND METHODS: Between 2007 and 2014, 110 patients with a FIGO clinical stage IA2-IB1 (<2 cm) cervical cancer underwent primary surgical treatment after external array coil T2W and DW MR imaging following the diagnostic biopsy procedure. RESULTS: The median histological size of MR-invisible vs. MR-visible diagnosis was 3±6.4 mm and 16±5.2 mm. Eighty-five of the 110 patients had histologically residual tumor. The sensitivity, specificity, PPV, and NPV of tumor diagnosis were 63.5%, 92.0%, 96.4%, and 42.6%, respectively. Histological estimates of 54 (49.1%) MR-invisible vs. 56 (50.9%) MR-visible diagnoses were identified as 23 true-negative (TN) and 31 false-negative (FN) vs. 54 true-positive (TP) and 2 false-positive (FP). The recurrence-free rate was 98.1% in the MR-invisible group and 91.1% in the MR-visible group. The overall survival rates were 100% and 92.9%, respectively. CONCLUSION: A preoperative MR-invisible diagnosis in early-stage cervical cancer patients led to a high probability of FN and was associated with underdiagnosis.

Early Cervical Cancer: Predictive Relevance of Preoperative 3-Tesla Multiparametric Magnetic Resonance Imaging.

OBJECTIVE: We assess the predictive significance of preoperative 3-Tesla multiparametric MRI findings. METHODS: A total of 260 patients with FIGO IA2-IIA cervical cancer underwent primary surgical treatment between 2007 and 2016. Univariable and multivariable logistic regression analyses were used to assess the incremental prognostic significance. RESULTS: The clinical predictive factors associated with pT2b disease were MRI parametrial invasion (PMI) (adjusted odds ratio (AOR) 3.77, 95% confidence interval(CI) 1.62-8.79; P=0.02) and MRI uterine corpus invasion (UCI) (AOR 9.99, 95% CI 4.11-24.32; P<0.0001). In multivariable analysis, for underdiagnoses, histologically squamous carcinoma versus adenocarcinoma and adenosquamous carcinoma (AOR 2.07, 95% CI 1.06-4.07; P=0.034) and MRI tumor size (AOR 0.76, 95% CI 0.63-0.92; P=0.005) were significant predictors; for overdiagnoses, these results were MRI tumor size (AOR 1.51, 95% CI 1.06-2.16; P=0.023), MRI PMI (AOR 71.73, 95% CI 8.89-611.38; P<0.0001) and MRI UCI (AOR 0.19, 95% CI 0.01-1.01; P=0.051). CONCLUSION: PMI and UCI on T2-weighted images through preoperative 3T MRI are useful coefficients for accurate prediction of the pT2b stage; however, careful surveillance is required. Therefore, preoperative decision-making for early cervical cancer patients based on MRI diagnosis should be considered carefully, particularly in the presence of factors that are known to increase the likelihood of misdiagnosis.

Vaginal vault drainage after complicated single-port access laparoscopic-assisted vaginal hysterectomy.

STUDY OBJECTIVE: To evaluate the feasibility and safety of vaginal vault drainage after complicated singleport access laparoscopic-assisted vaginal hysterectomy (SPA-LAVH). DESIGN: Retrospective cohort study. SETTING: Ulsan University Hospital (tertiary teaching hospital), South Korea. PATIENTS: A total of 359 women underwent SPA-LAVH for the following conditions: benign uterine tumor, preinvasive uterine lesion, and microinvasive cervical cancer. INTERVENTIONS: The participants included 124 women with vault drains and 235 women without drains. MEASUREMENTS: Surgical outcomes, perioperative complications and morbidity, postoperative febrile morbidity. RESULTS: There were no differences in background features between drain and no-drain groups. In surgical outcomes, mean uterine weight (364.2 ± 184.9 g vs. 263.7 ± 138.6 g; p < 0.001), operation time (87.4 ± 21.5 min vs. 73.0 ± 17.6 min; p < 0.001), blood loss (225.3 ± 122.2 mL vs. 150.4 ± 95.2 mL; p < 0.001), and hemoglobin decline (1.97 ± 0.96 g/dL vs. 1.42 ± 0.89 g/dL; p < 0.001) were significantly larger for the drain group compared with the no-drain group. However, with regard to postoperative morbidity and complications, there were no group differences in the transfusion rates (6.5% vs. 3.8%; p = 0.300), intraoperative complications (2.4% vs. 1.3%; p = 0.420), perioperative complications (2.4% vs. 0.9%; p = 0.345), and febrile morbidity ≥ 37.5°C (8.9% vs. 11.5%; p = 0.477), although the drain group was more prone to the development of pelvic fluid collection and febrile morbidity than the no-drain group. CONCLUSION: Vaginal vault drainage could be a safe alternative that allows for the management of postoperative morbidity and retains the advantages of minimally invasive surgery after complicated SPA-LAVH.

Correlation Between Cervical Lengths Measured by Transabdominal and Transvaginal Sonography for Predicting Preterm Birth.

OBJECTIVES: Cervical length assessment is important for predicting preterm birth. Cervical length measurement using transabdominal sonography is more comfortable for the patient but has more limitations than transvaginal sonography. Our aim was to determine whether transabdominal sonography could identify those women who should undergo transvaginal sonography for prediction of preterm birth. METHODS: In this prospective study, women underwent cervical length measurements by transabdominal and transvaginal sonography between 20 and 29 gestational weeks and were followed until delivery. We assessed whether short cervical lengths on transabdominal sonography could predict short cervical lengths on transvaginal sonography and whether these measurements could predict preterm births (<34 gestational weeks). RESULTS: The mean cervical lengths were not significantly different between the techniques (mean ± SD, 3.78 ± 0.82 and 3.82 ± 0.77 cm on transabdominal and transvaginal sonography, respectively; P = .09). The sensitivity of short cervical lengths (<2 cm) on transabdominal sonography for prediction of short cervical lengths on transvaginal sonography was 100%. The sensitivity, specificity, positive predictive value, negative predictive value, and relative risk of short cervical lengths (<2 cm) for predicting preterm birth were 21.4%, 98.68%, 50.00%, 95.32%, and 13.22 when using transabdominal sonography and 28.57%, 94.94%, 66.6%, 95.74%, and 17.78 when using transvaginal sonography, respectively. In an analysis that included cases with transabdominal sonography, the sensitivity of short cervical lengths for predicting preterm birth was increased. CONCLUSIONS: Women whose cervical lengths are measurable and long on transabdominal sonography may not need transvaginal sonography. Women whose cervical lengths are unmeasurable or short (<2 or <2.5 cm) on transabdominal sonography should undergo transvaginal sonography to measure cervical lengths for prediction of preterm birth.