Computer vision for total laparoscopic hysterectomy.

INTRODUCTION: Laparoscopic surgery is widely performed in various surgical fields, but this technique requires time for surgeons to master. However, at the same time, there are many advantages in visualizing the operative field through a camera. In other words, we can visualize what we cannot see with our own eyes by using augmented reality and computer vision. Therefore, we investigated the possibilities and usefulness of computer vision in total laparoscopic hysterectomy. METHODS: This study was approved by the Mitsui Memorial Hospital ethics committee. Patients who underwent total laparoscopic hysterectomy at Mitsui Memorial Hospital from January 2015 to December 2015 were enrolled. We evaluated 19 cases in which total laparoscopic hysterectomy was performed by the same operator and assistant. We used the Open Source Computer Vision Library for computer vision analysis. The development platform used in this study was a computer operating on Mac OS X 10.11.3. RESULTS: We created panoramic images by matching features with the AKAZE algorithm. Noise reduction methods improved haziness caused by using energy devices. By abstracting the color of the suture string, we succeeded in abstracting the suture string from movies. We could not achieve satisfactory results in detecting ureters, and we expect that creative ideas for ureter detection may arise from collaborations between surgeons and medical engineers. CONCLUSIONS: Although this was a preliminary study, the results suggest the utility of computer vision in assisting laparoscopic surgery.

Retained Barium in the Appendix Is Difficult to Distinguish from Surgical Remnants following Laparoscopic Surgery.

Surgical materials, such as gauze, can be accidentally left inside of patients following surgery. This iatrogenic complication should be avoided and is often prevented by routine X-ray analysis after surgical abdominal procedures. We report a case of retained barium in the appendix that was difficult to distinguish from surgical remnants. A 41-year-old Japanese female was diagnosed with uterine leiomyoma and underwent laparoscopic myomectomy. The postoperative X-ray test showed a cord-like material in the lower right abdomen that was not captured in the preoperative X-ray test two months prior to the operation. Because of this difference, the area was reexamined laparoscopically. After examination, we concluded that the cord-like material in X-ray tests was in fact retained barium in the appendix. Barium can be retained in the appendix for long periods of time, and retained barium in the appendix can be captured radiographically and can mimic the appearance of surgical remnants, appearing as a cord-like material. The knowledge above combined with detailed interviews before surgery could prevent such confusion during interpretation of X-ray tests after surgery.

Exploration of assistive technology for uniform laparoscopic surgery.

INTRODUCTION: Laparoscopic surgery is less invasive than open surgery and is now common in various medical fields. However, laparoscopic surgery is more difficult than open surgery and often requires additional time for the operator to achieve mastery. Therefore, we investigated the use of assistive technology for uniform laparoscopic surgery. METHODS: We used the OpenCV2 library for augmented reality with an ArUco marker to detect and estimate forceps positioning. We used Sense HAT as the gyro sensor. The development platforms used were Mac OS X 10.11.3 and Raspberry Pi 3, model B. RESULTS: By attaching the ArUco marker to the needle holder, we could draw a line vertically to the marker. When the needle was held, a cube could be imagined, and both the needle and lines could be used to determine the appropriate position. By attaching the gyro sensor to the camera, we could detect its angle of rotation. We obtained stabilized images by rotating the image by the detected degrees; this was possible for any camera position. CONCLUSIONS: Assistive technology allowed us to obtain consecutive converted images in real time and may be readily applicable to clinical practice.

Gynecologists May Underestimate the Amount of Blood Loss during Total Laparoscopic Hysterectomy.

BACKGROUND: We considered the possibility of underestimation of the amount of bleeding during laparoscopic surgery, and we investigated comparing the amount of bleeding between laparoscopic surgery and open surgery by considering the concentration of hemoglobin before and after surgery as indicators. METHODS: The following procedures were included: A, surgery for ovarian tumor; B, myomectomy; and C, hysterectomy either by laparoscopic surgery or open surgery. Patients who underwent the above procedures in between January 1, 2010, and December 31, 2017, were enrolled. We identified 1749 cases (A: 90, B: 105, and C: 325 of open surgery and A: 667, B: 437, and C: 125 of laparoscopic surgery). We considered the sum as an estimation of blood loss during surgery and the change in the value of hemoglobin in laboratory testing one day before and after surgery. RESULTS: During laparoscopic surgery, the measurements of blood loss included the following: A: 59.8 ml; B: 168.6 ml; and C: 206.8 ml. During open surgery, measurements of blood loss included the following: A: 130.7 ml; B: 236.7 ml; and C; 280.9 ml. The reduction of hemoglobin after surgery compared with that before surgery was less in laparoscopic surgery than that in open surgery in A and B; however, this reduction was not significantly different in C. CONCLUSION: Our results suggest that the estimation of the bleeding in A and B was appropriate; however, the estimation might be underestimated in C during laparoscopic surgery.

Expression and regulation of transient receptor potential cation channel, subfamily M, member 2 (TRPM2) in human endometrium.

To identify estrogen-responsive genes, we previously isolated estrogen receptor (ER)-binding DNA fragments from human genomic DNA using a recombinant ER protein. Six DNA fragments, each including a perfect palindromic estrogen response element (ERE), were obtained. The nucleotide sequence of one of the six fragments (E1 fragment) showed that the ERE of the E1 fragment is located in the 3'-untranslated region (UTR) of transient receptor potential cation channel, subfamily M, member 2 (TRPM2). Here, we confirmed the estrogen-dependent enhancer activity of the ERE of the E1 fragment by chloramphenicol acetyltransferase assay. TRPM2 mRNA expression was investigated in human endometrium, cultured human endometrial stromal cells (ESCs), and cultured human endometrial epithelial cells (EECs) using RT-PCR. Quantitative RT-PCR revealed that TRPM2 mRNA expression in ESCs increased after 17ß-estradiol (E2) treatment. This study demonstrated for the first time that TRPM2 is an estrogen-responsive gene expressed in human endometrial cells.

The progesterone-responsive gene 14-3-3τ enhances the transcriptional activity of progesterone receptor in uterine cells.

Members of the 14-3-3 family are intracellular dimeric phosphoserine-binding proteins that can associate with and modulate the activities of many proteins. In our efforts to isolate the genes regulated by progesterone (P(4)) using suppressive subtractive hybridization, we previously found that 14-3-3τ is one of the genes upregulated by P(4). In this study, we demonstrated by quantitative RT-PCR (qRT-PCR), western blot analyses, and immunohistochemistry that 14-3-3τ mRNA and protein levels were increased in the rat uterus after P(4) treatment. Furthermore, qRT-PCR indicated that P(4) increased 14-3-3τ mRNA levels in human endometrial epithelial cells and endometrial stromal cells (ESCs). Western blot and qRT-PCR analyses revealed that in vitro decidualization using cAMP and medroxyprogesterone 17-acetate increased levels of 14-3-3τ mRNA and protein in ESCs. We have shown by qRT-PCR and western blot analyses that P(4) increased the mRNA and protein levels of 14-3-3τ in Ishikawa cells that stably express P(4) receptor-B (PR-B). Immunocytochemistry revealed that 14-3-3τ colocalizes with PR and translocates from the cytoplasm to the nucleus in response to P(4). Moreover, by luciferase reporter assay, we demonstrated that 14-3-3τ enhances the transcriptional activity of PR-B. Taken together, we propose that 14-3-3τ is a P(4)-responsive gene in uterine cells that modulates P(4) signaling.

Expression of retinoic acid-related orphan receptor alpha and its responsive genes in human endometrium regulated by cholesterol sulfate.

Cholesterol sulfate (CS) is a major sterol sulfate in human plasma that is detected in the uterine endometrium. CS plays a role in steroidogenesis, cellular membrane stabilization, and regulation of the skin barrier. We previously reported that CS increased in rabbit endometrium during the implantation period. Recently, CS has been reported to be a ligand of retinoic acid receptor-related orphan receptor alpha (RORA). NR1D1 is one of the genes regulated by RORA. In the present study, we investigated the regulation of RORA and NR1D1 by CS in human endometrium. We determined the association-dissociation curves for the interaction of CS with RORA and the kinetic rates by surface plasmon resonance. Immunohistochemical staining and in situ hybridization revealed that RORA and NR1D1 were expressed in human endometrial stromal and epithelial cells. CS treatment significantly induced the mRNA expression of RORA and NR1D1 mRNA in ESCs. The results of a luciferase assay showed that RORA significantly activated the human NR1D1 promoter regardless of CS. Our results suggest that CS regulates the expression of RORA responsive genes in human endometrial cells but not as a ligand for RORA.

Successful pregnancy following low-dose hCG administration in addition to hMG in a patient with hypothalamic amenorrhea due to weight loss.

We describe successful ovulation induction with low-dose hCG administration in addition to hMG in a patient with refractory hypothalamic amenorrhea. A 24-year-old woman with weight loss-related amenorrhea underwent ovulation induction and intracytoplasmic sperm injection (ICSI). Administration of exogenous gonadotropins was ineffective in ovulation induction. Supplementation with low-dose hCG in order to increase luteinizing hormone (LH) activity in the late follicular phase produced late folliculogenesis and steroidogenesis, and ovulation was then successfully induced. This report reacknowledges the critical role that LH plays cooperatively with follicle-stimulating hormone in both folliculogenesis and steroidogenesis.

[Transcervical endoscopic surgery: an update].

Hysteroscopic surgery is considered to be a minimally-invasive procedure. This technique is associated with a shorter hospital stay and a rapid recovery time. At present, with the development of operative technique and instrumention, hysteroscopic surgery is widely performed to disease of endometrial cavity, tubal ostia, or endocervical canal. This procedure needs highly trained technique and can lead to number of associated complications, including uterine perforation and hyponatremia. Falloscpoic tuboplasty (FT) is regarded as a useful and less invasive method for the treatment of tubal occlusion, whereas the operator should have prior experience to avoid the complications such as tubal perforation and damage of instruments. Selective hydrotubation (SHT) with flexible hysterofiberscope is an also effective method for evaluating and managing tubal obstruction. SHT has the advantage of being an easy procedure and can be carried out safely in an outpatient setting.

Inhibition of cell invasion and protease activity by cholesterol sulfate.

We demonstrated that cholesterol sulfate (CS) inhibits invasion of a trophoblast cell line and plasmin enzyme activity in a noncompetitive manner by binding to the enzyme itself, suggesting that CS can repress cell invasion by inhibiting proteinases such as those involved in the plasminogen activator/plasmin system. Considering these results, it is possible that CS may act as a signaling molecule between the trophoblast and endometrium, and may regulate the process of implantation.

Inhibition of proteases involved in embryo implantation by cholesterol sulfate.

BACKGROUND: Matrix metalloproteinases (MMPs) and the plasminogen activator (PA)/plasmin system are two major groups of proteases involved in the matrix degradation required for embryo implantation. We previously showed that the content of cholesterol sulfate (CS) in rabbit endometrium increases characteristically during the implantation period. Furthermore, CS has been reported to inhibit serine proteases. In this study, we investigated whether CS can regulate the activity of proteases in cultured human endometrial stromal cells. METHODS AND RESULTS: CS (1-30 microM) and plasminogen (precursor of plasmin) were added to the culture media of human endometrial stromal cells and incubated for 24 h. Culture media were collected for analysis of plasmin and MMP-2, -3 and -9 enzyme activities using fluorescence assays. Plasmin and MMP-3 activities were significantly reduced by CS in a dose-dependent manner (P < 0.001). Western blot analysis of the culture media revealed that CS inhibited the conversion by plasmin of MMP-3 from the precursor form to the active form. Fluorescence assay using a common substrate of MMP-2 and MMP-9 showed that enzymatic activity remains at approximately 50%, even at 30 microM CS. Gelatin zymography demonstrated that CS inhibited the activation of MMP-9 but not MMP-2 from the precursor, suggesting that the activation of MMP-2 may be independent of plasmin. CONCLUSIONS: CS inhibits not only plasmin activity but also MMP activities indirectly by inhibiting the plasmin-mediated process. These findings suggest that CS may be an important regulator of proteolysis during trophoblast invasion.

Expression and regulation of cholesterol sulfotransferase (SULT2B1b) in human endometrium.

OBJECTIVE: To investigate the hormonal regulation of SULT2B1b in human endometrium. DESIGN: In vitro study with human endometrial tissues and cultured human endometrial cells. SETTING: University hospital. PATIENT(S): Thirty-seven women undergoing hysterectomy for benign disease. INTERVENTION(S): Human endometrial tissues were collected for in situ hybridization. Culture medium of human endometrial epithelial cells (EECs) was collected for determination of secretion of cholesterol sulfate (CS). Total RNAs were extracted from human endometrial tissues and cultured cells for real-time reverse transcriptase-polymerase chain reaction (RT-PCR). MAIN OUTCOME MEASURE(S): The expression of SULT2B1b mRNA in human endometrial tissues and cultured cells. RESULT(S): In situ hybridization studies and real-time RT-PCR showed that the amount of SULT2B1b mRNA in human endometrial tissues was significantly higher during the midluteal phase than during other phases of the menstrual cycle. The secretion of CS from EECs was confirmed using [(35)S]-phosphoadenosine phosphosulfate. The expression of SULT2B1b mRNA was induced by cAMP or P in human endometrial stromal cells (ESCs), whereas it was induced by cAMP or relaxin in EECs. The induction of SULT2B1b mRNA by P or relaxin was abolished by the specific protein kinase A (PKA) inhibitor, Rp-adenosine 3',5' cyclic monophosphothioate (Rp-cAMPS). CONCLUSION(S): The expression of SULT2B1b mRNA in ESCs is induced by P and that in EECs is induced by relaxin via the cAMP pathway.

Inhibitory effects of cholesterol sulfate on progesterone production in human granulosa-like tumor cell line, KGN.

Cholesterol sulfate (CS) is a component of cell membranes that plays a role in stabilizing the cell membrane. We previously reported that CS increased in the endometrium during implantation, suggesting that CS plays an important role in reproduction. It has been reported that CS regulates progesterone and pregnenolone production in the placenta, adrenal glands and ovary. The regulatory mechanisms of steroid hormone production by CS, however, are still unknown. In the present study, we investigated the effect of CS on the expression of progesterone production-related genes in KGN cells, derived from human granulosa-like tumor. KGN cells were cultured with CS (10 muM) or cholesterol (10 muM) in the presence of 8-bromo-cAMP (1 mM). Progesterone levels in the culture media were measured by enzyme linked fluorescent assay at 24 h after treatment of CS and cAMP. Total RNAs were extracted for quantitative real time RT-PCR with specific primer of StAR protein, P450scc, HSD3B2, ferredoxin and ferredoxin reductase. Whole cell lysates were extracted for western blot analysis with antibody for StAR protein. Progesterone concentration in the culture medium increased to 38-fold by treatment of cAMP. CS significantly reduced progesterone concentration by 30% compared with those of cAMP treatment (p<0.05), while cholesterol did not change the progesterone concentration. CS treatment down-regulated the expression of StAR mRNA and P450scc mRNA was to 54% and 60%, respectively (p<0.05). Western blot analysis revealed that the amount of StAR protein was also reduced by CS treatment. The expression of HSD3B2 mRNA was up-regulated to 3.4-fold by treatment of cAMP. The expression of ferredoxin and ferredoxin reductase mRNA was not affected by CS treatment. These data implied that CS has an inhibitory effect on progesterone production by regulating the expression of StAR and P450scc gene expression.

Expression and regulation of periostin/OSF-2 gene in rat uterus and human endometrium.

Periostin/OSF2 is a ligand for alphavbeta3 and alphavbeta5 integrins and activates the Akt/PKB pathway. Recent reports of periostin/OSF2 gene disrupted mice indicate that periostin/OSF-2 plays an important role in implantation. Quantitative RT-PCR revealed that the expression of periostin/OSF-2 mRNA in rat uteri was reduced to approximately 10% at 12 h after 17beta-estradiol (E2) injection, but was not changed after progesterone (P) injection. RT-PCR revealed the expression of periostin/OSF-2 in human endometrium, cultured human endometrial stromal cells (ESCs), and cultured human endometrial epithelial cells. In ESCs, the expression of periostin/OSF-2 mRNA was reduced to approximately 50% at 6 h after E2 treatment. The amount of periostin/OSF2 mRNA in human endometrium significantly increased during mid-proliferative and early secretory phases of menstrual cycle, and decreased during late-proliferative, mid-secretory and late secretory phases. The expression of periostin/OSF2 mRNA significantly decreased in ESCs decidualized by treatment with E2 and P for 7 and 11 days. By immunohistochemistry, the expression of periostin/OSF-2 was strongly detected in endometrial stromal cells during early proliferative, mid-proliferative and early secretory phases, and was strongly detected in endometrial epithelial cells during late secretory phase. This study demonstrated that the expression of periostin/OSF-2 is regulated by ovarian steroid hormones in rat uterus and human endometrium.

Evidence for the expression of alcohol dehydrogenase class I gene in rat uterus and its up-regulation by progesterone.

The endometrium is one of the target tissues of the ovarian steroid hormones, estrogen and progesterone. In order to elucidate the mechanism of gene regulation in the endometrium, suppressive subtraction hybridization was performed to isolate the candidate genes controlled by progesterone in rat uterus. Alcohol dehydrogenase (ADH) class I gene was one of the candidate genes. Here we investigated the expression and regulation of ADH class I gene in rat uterus. The mRNA of ADH class I was detected in uterus by RT-PCR using specific primers. Using specific probe for ADH class I, in situ hybridization was performed to investigate localization in rat uterus. Positive signals were detected in the endometrial stromal cells of rat uterus by in situ hybridization and were not detected in endometrial epithelial cells and myometrium in rat uterus. Ovariectomized rats were treated with 17-beta estradiol and progesterone and the uteri of these rats were used for Northern blot analysis and assay of the ADH activity. Northern blot analysis revealed that the expression of ADH class I mRNA in rat uteri was up-regulated approximately two-fold after progesterone treatment, but not estrogen. Likewise, ADH activity was approximately two-fold higher in progesterone-treated rat uteri compared with controls. This study demonstrated that ADH class I gene is progesterone-responsive in the uterus. This implies that progesterone might be involved with retinoic acid synthesis in the uterus, since ADH is the key enzyme for retinoic acid synthesis.