Intraoperative bladder visualization by indocyanine green filling and subsequent washout in endoscopic hysterectomy: ICG-Washout method.

INTRODUCTION: Despite a potential risk of bladder injury in laparoscopic hysterectomy (LH) and robot-assisted LH (RaLH), an intraoperative method for delineating the entire bladder with indocyanine green (ICG) has not been established. METHODS: We conducted a preliminary experiment using porcine bladders to verify the appropriate amount of ICG for intraoperative bladder visualization. Afterward, intraoperative bladder visualization was tried in LH and RaLH in two patients suspected of having adhesions around the bladder after previous abdominal surgery. RESULTS: Although near-infrared (NIR) fluorescence was well observed through the wall of the porcine bladder filled with ICG solution at a concentration of 0.024 mg/mL, the subsequent replacement of the ICG solution with saline made the NIR fluorescence brighter. In both patients, the bladder was successfully delineated by NIR fluorescence after filling the bladder with ICG solution and the subsequent washout with saline. CONCLUSION: The ICG-Washout method for locating the bladder by NIR fluorescence could be useful in LH and RaLH.

Successful control of menstrual cycle-related exacerbation of inflammatory arthritis with GnRH agonist with add-back therapy in a patient with rheumatoid arthritis.

Patients with rheumatoid arthritis may demonstrate fluctuations in arthritis symptoms associated with the menstrual cycle. This is the first case report of successful control of menstrual cycle-related exacerbation of rheumatoid arthritis with a gonadotropin-releasing hormone agonist and add-back therapy. A 49-year-old premenopausal woman experienced recurrent severe arthritis flares despite aggressive immunotherapy. Her arthritis symptoms started 10 days before her menstruation and spontaneously resolved after the initiation of menstruation. We chose a gonadotropin-releasing hormone agonist with percutaneous estradiol gel to prevent a hypoestrogenic state and a levonorgestrel-releasing intrauterine system to facilitate uterine protection by estrogen. Thereafter, her symptoms significantly improved without experiencing major flares. In addition, she did not demonstrate any menopausal symptoms. This case highlights that rheumatoid arthritis disease activity may be associated with the menstrual cycle, and hormonal therapy may be beneficial as an adjunct therapy for controlling premenstrual exacerbation of rheumatoid arthritis.

Comparison of endometriotic cysts and ovarian cancer in association with endometriotic cysts.

OBJECTIVE: The aim of this study was to clarify the clinical, laboratory, and imaging findings of ovarian cancer in association with endometriotic cysts by detailed comparison of the findings of benign and malignant tumors. METHODS AND MATERIALS: This was a retrospective study of 138 women who had an operation for ovarian tumors at the Department of Obstetrics and Gynecology of Kochi Health Sciences Center between September 1, 2011, and July 30, 2015. The ovarian tumors were divided into two groups: the benign group (endometriotic cysts) and the malignant group (ovarian cancer in association with endometriotic cysts). RESULTS: Of the 138 patients, 28 had malignant disease, and 110 had benign endometriotic cysts. Patients in the malignant group were significantly older than patients in the benign group. The mean maximum tumor diameter was also significantly larger for the malignant tumors. Unilocular-solid and multilocular-solid type tumors were present in 25.0% and 75.0% of malignant tumors, and in 9.1% and 19.1% of benign tumors, respectively. The mean maximum solid component diameter and height were significantly larger in the malignant tumors than in the benign tumors. The solid components were present on the abdominal side of the cyst wall in 12.5% of benign tumors and in 51.9% of malignant tumors. CONCLUSION: In elderly patients, the presence of large solid components in large endometriotic cysts, especially the abdominal side of the cyst wall, might suggest malignancy. MICRO ABSTRACT: The aim of this study was to clarify the findings of ovarian cancer in association with endometriotic cysts by detailed comparison of the findings of benign and malignant tumors. The presence of solid components in large endometriotic cysts, especially the abdominal side of the cyst wall, might suggest malignancy.

Emergency surgery for tubo-ovarian abscess identified extended-spectrum beta-lactamase-producing Escherichia coli: the first case presentation revealing causative bacteria.

We report herein a 41-year-old female with a tubo-ovarian abscess (TOA), which microbial cultures showed to contain extended-spectrum beta-lactamase (ESBL)-producing E. coli, a causative agent of community-acquired infection. The patient initially presented with acute abdominal pain and back pain. Pelvic computed tomography and transvaginal ultrasonography revealed multiple cystic lesions in the bilateral ovaries that suggested TOA. An emergency laparotomy was therefore performed due to the potential for life-threatening septic shock from the TOA-associated pelvic inflammatory disease. Microbial cultures of postoperative fluid discharge from the placed intra-abdominal catheter, vaginal secretions, urine, blood, and feces detected ESBL-producing E.coli. In summary, we successfully performed emergency surgery for life-threatening septic TOA caused by ESBL-producing E. coli infection.

Human leukocyte antigen-G, a ligand for the natural killer receptor KIR2DL4, is expressed by eutopic endometrium only in the menstrual phase.

OBJECTIVE: To investigate menstrual cycle changes in expression by eutopic endometrium of a nonclassic human leukocyte antigen, HLA-G, which binds to the killer immunoglobulin-like receptor (KIR) 2DL4 (CD158d) on natural killer (NK) cells. Such antigens have been linked to endometriosis. DESIGN: Case-control study. SETTING: University hospital. PATIENT(S): We examined 20 Japanese women undergoing hysterectomy for endometriosis and 17 undergoing hysterectomy for myoma. INTERVENTION(S): Immunohistochemical HLA-G staining of eutopic endometrium and peritoneal fluid (PF) cells from women with and without endometriosis. Flow cytometric analysis of PF NK cells from women with and without endometriosis. MAIN OUTCOME MEASURE(S): HLA-G staining in eutopic endometrium was quantified by image analysis. The KIR2DL4-expressing NK cells in PF were investigated by flow cytometry. RESULT(S): The HLA-G was expressed by eutopic endometrium only in the menstrual phase and not in the late proliferative or secretory endometrium. Intensity of HLA-G staining did not differ significantly between women with and without endometriosis. The HLA-G- expressing cells were detected in PF during the menstrual period. These cells are morphologically and flow cytometrically different from mesothelial cells and NK cells. CONCLUSION(S): The HLA-G expression is observed in eutopic endometrium only during the menstrual phase, and no differences were observed between women with and without endometriosis. Epithelial cells bearing HLA-G may enter the peritoneal cavity during retrograde menstruation, allowing the antigen to react locally with KIR2DL4.

Human leukocyte antigen expression by peritoneal macrophages from women with pelvic endometriosis is depressed but coordinated with costimulatory molecule expression.

OBJECTIVE: To investigate the macrophage response in endometriosis, we determined expression of human leukocyte antigen (HLA)-ABC, HLA-DR, and their costimulatory molecules by peritoneal fluid (PF) macrophages. DESIGN: Case-control study of immunologic markers. SETTING: University hospital. PATIENT(S): We compared 38 Japanese women with endometriosis with 59 control subjects who were given other laparoscopic diagnoses. INTERVENTION(S): Venipuncture and laparoscopic peritoneal fluid collection. MAIN OUTCOME MEASURE(S): Expression of HLA-ABC, HLA-DR, CD54, CD40, CD58, CD80, and CD86 by peripheral blood (PB) monocytes and PF macrophages was quantitated as mean fluorescence intensities by flow cytometry. Expression of each marker on PF macrophages was divided by that on PB monocytes as an index of macrophage activation (macrophage activation ratio). RESULT(S): In women with endometriosis, PF macrophages showed significant positive correlations between expression of HLA-ABC and other costimulatory molecules and also between HLA-DR and their costimulatory molecules. However, expression of HLA-ABC and DR by PF macrophages, and also their activation ratios, were significantly lower than in controls. CONCLUSION(S): Coordination with costimulatory molecules but relatively low expression of HLA-ABC and HLA-DR indicates a positive but limited immune response (antigen presentation) to events in the peritoneal cavity in women with endometriosis. This may induce immune tolerance to implanted or metaplastic endometrial tissue.