Safety and Clinical Outcomes of Two-Session Catheter-Directed Sclerotherapy Using Ethanol for Endometrioma.

PURPOSE: To evaluate the safety and clinical outcome of two-session catheter-directed sclerotherapy (CDS) with 99% ethanol in patients with endometrioma. MATERIALS AND METHODS: This prospective study was approved by the institutional review board with written informed consent obtained from all participants and was registered on clinicaltrial.gov. Consecutive patients with ovarian endometrioma between June 2020 and March 2023 were prospectively evaluated for two sessions of CDS. After successful transvaginal ultrasound-guided puncture of the endometrioma, the biopsy needle was exchanged for a 7- or 8.5-F catheter for aspiration and ethanol injection. The catheter was retained in situ for a second session the next day. Endometrioma volume was measured on ultrasound before and 1, 3, and 6 months after CDS, and volume reduction ratio (VRR) was calculated. Serum anti-Müllerian hormone (AMH) was measured before and 6 months after CDS to assess ovarian reserve. RESULTS: Thirty-one endometriomas in 22 patients (mean age, 31.0 years; range, 19-44 years) were treated; 28 endometriomas were successfully treated with two-session CDS, while one session was incomplete in three endometriomas in three patients due to contrast medium leakage or pain. Minor procedure-related complications developed in four patients and resolved spontaneously before discharge on the same day of the second session. No recurrence was identified during follow-up. At the 6-month follow-up, the mean endometrioma diameter decreased from 5.5 ± 1.7 to 1.4 ± 0.9 cm (P < 0.001), and the serum AMH level was lowered without statistical significance (1.37 ± 0.96 ng/mL vs. 1.18 ± 0.92 ng/mL; P = 0.170). VRRs at 1, 3, and 6 months after CDS were 84.3 ± 13.7%, 94.3 ± 5.8%, and 96.4 ± 4.7%, respectively. CONCLUSION: Two-session CDS with 99% ethanol is safe, feasible, and effective for treating endometrioma with the ovarian function well preserved.

Machine learning and radiomics for segmentation and classification of adnexal masses on ultrasound.

Ultrasound-based models exist to support the classification of adnexal masses but are subjective and rely upon ultrasound expertise. We aimed to develop an end-to-end machine learning (ML) model capable of automating the classification of adnexal masses. In this retrospective study, transvaginal ultrasound scan images with linked diagnoses (ultrasound subjective assessment or histology) were extracted and segmented from Imperial College Healthcare, UK (ICH development dataset; n = 577 masses; 1444 images) and Morgagni-Pierantoni Hospital, Italy (MPH external dataset; n = 184 masses; 476 images). A segmentation and classification model was developed using convolutional neural networks and traditional radiomics features. Dice surface coefficient (DICE) was used to measure segmentation performance and area under the ROC curve (AUC), F1-score and recall for classification performance. The ICH and MPH datasets had a median age of 45 (IQR 35-60) and 48 (IQR 38-57) years old and consisted of 23.1% and 31.5% malignant cases, respectively. The best segmentation model achieved a DICE score of 0.85 ± 0.01, 0.88 ± 0.01 and 0.85 ± 0.01 in the ICH training, ICH validation and MPH test sets. The best classification model achieved a recall of 1.00 and F1-score of 0.88 (AUC:0.93), 0.94 (AUC:0.89) and 0.83 (AUC:0.90) in the ICH training, ICH validation and MPH test sets, respectively. We have developed an end-to-end radiomics-based model capable of adnexal mass segmentation and classification, with a comparable predictive performance (AUC 0.90) to the published performance of expert subjective assessment (gold standard), and current risk models. Further prospective evaluation of the classification performance of this ML model against existing methods is required.

A new knotless parametrial tissue ligation technique for safe total laparoscopic hysterectomy.

OBJECTIVE: Parametrial tissue ligation during total laparoscopic hysterectomy (TLH) is important in large uteri with large vessels. METHODS: A retrospective study was performed at Asan Medical Center for comparing TLH performed with a new knotless parametrial tissue ligation method and conventional laparoscopic-assisted vaginal hysterectomy (LAVH) from March 2019 to August 2021. For TLH, after anterior colpotomy, the parametrial tissue was ligated by anchoring the suture and making a loop in one direction three times using 1-0 V-LocTM 180 (Covidien, Mansfield, MA, USA) suture. Subsequently, the cranial part of the loop was cut using an endoscopic device. RESULTS: A total of 119 and 178 patients were included in the TLH and LAVH groups, respectively. The maximal diameter of the uterus was larger in the TLH group (106.29±27.16 cm) than in the LAVH group (99.00±18.92 cm, P=0.01). The change in hemoglobin (Hb) level was greater in the LAVH group than in the TLH group (P<0.001). The weight of the removed uterus was greater in the TLH group than in the LAVH group (431.95±394.97 vs. 354.94±209.52 g; P=0.03). However, when the uterine weight was >1,000 g, the operative times and change in Hb levels were similar between the two groups. In both groups, no ureteral complications occurred during or after surgery. CONCLUSION: Knotless parametrial tissue ligation using 1-0 V-LocTM 180 suture in TLH can be safely applied, even in cases with large uteri, without increased risks of ureteral injury or uterine bleeding.

Outcomes of Fertility Preservation for Female Cancer Patients in a Single Tertiary Center.

PURPOSE: To report our experience of fertility preservation (FP) in female cancer patients. MATERIALS AND METHODS: We retrospectively analyzed the medical records of female who underwent elective oocyte or embryo cryopreservation before cancer treatment between January 2015 and December 2020 at Asan Medical Center. We analyzed the type of cancer, the rate of reuse of cryopreserved oocytes or embryos, and fertility outcomes such as the resumption of menstruation or pregnancy. RESULTS: A total of 174 patients underwent 182 oocyte retrieval cycles after controlled ovarian stimulation for oocyte or embryo cryopreservation. The median age of patients was 33.0 (range 19-46) years, and the patients were most unmarried female (65.52%). The majority of patients were diagnosed with breast cancer (78.16%), and the remaining were diagnosed with gastrointestinal (6.33%) and hematologic malignancies (5.75%). The maturation rate of oocyte cryopreservation was 83.33%, and the fertilization rate of embryo cryopreservation was 72.07%. Of the 57 patients currently not undergoing cancer treatment, 34 resumed menstruating and 19 (33.33%, 19/57) returned to attempt a pregnancy. Among them, five patients succeeded in natural pregnancy. Eleven patients received frozen-thawed embryo transfer, and four patients succeeded in becoming pregnant (36.36%, 4/11). Only 6.3% of patients returned to use their gametes, and 93.7% of gametes are still in storage. CONCLUSION: FP in cancer patients should be considered before cancer treatment. Through continuous research on oncofertility, it is necessary to consider how to increase the return rate and provide appropriate information to cancer patients of reproductive age.

Translabial ultrasound for pelvic organ prolapse.

Pelvic organ prolapse (POP) is a significant public health concern in women and a common cause of gynecological surgery in elderly women. The prevalence of POP has increased with an increase in the aging population. POP is usually diagnosed based on pelvic examination. However, an imaging study may be necessary for more accurate diagnosis. Translabial ultrasound (TLUS) was used to assess diverse types of POP, particularly posterior-compartment POP. It is beneficial to distinguish between true and false rectocele, and detect the rectocele as clinically apparent. TLUS can also establish whether the underlying cause is a problem of the rectovaginal septum, perineal hypermobility, or isolated enterocele. TLUS also plays a role in differentiating POP from conditions that mimic POP. It is a simple, inexpensive, and non-harmful diagnostic modality that is appropriate for most gynecologic clinics.

Dienogest May Reduce Estradiol- and Inflammatory Cytokine-Induced Cell Viability and Proliferation and Inhibit the Pathogenesis of Endometriosis: A Cell Culture- and Mouse Model-Based Study.

Dienogest (DNG) is a therapeutic medication used in endometriosis treatment. Limited data are available regarding its mechanism of action on endometrial cells. Using in vivo and in vitro models, we investigated whether DNG treatment causes significant biological changes in human endometrial stromal cells (ESCs). The markers related to the pathogenesis of endometriosis in ESCs were evaluated using estradiol, tumor necrosis factor alpha (TNF-α), interleukin 1ß (IL-1ß), and IL-32, administered alone or in combination with DNG. Implanted endometrial tissues were compared between C57BL/6 mice that did or did not receive DNG treatment by using size measurements and immunohistochemistry. A significant decrease in cell viability, protein kinase B (AKT) phosphorylation, and the expression of p21-activated kinase 4 and vascular endothelial growth factor were observed in ESCs treated with estradiol plus DNG. Cell viability, AKT phosphorylation, and proliferating cell nuclear antigen (PCNA) expression also decreased significantly after TNF-α plus DNG treatment. Treatment with IL-1ß or IL-32 plus DNG significantly decreased cell viability or PCNA expression, respectively. The size of the implanted endometrial tissue significantly decreased in mice treated with DNG, accompanied by decreased PCNA expression. Thus, DNG may reduce cell viability and proliferation induced by estradiol, TNF-α, IL-1ß, and IL-32, and inhibit the endometriosis pathogenesis by decreasing PCNA expression.

Outcomes of vaginal hysterectomy combined with anterior and posterior colporrhaphy for pelvic organ prolapse: a single center retrospective study.

OBJECTIVE: To evaluate the efficacy of vaginal hysterectomy combined with anterior and posterior colporrhaphy (VH APR) for the management of pelvic organ prolapse (POP). METHODS: A total of 610 patients with POP who underwent VH APR from January 2010 to June 2019 at Asan Medical Center were included in this study. We analyzed the patient characteristics and surgical outcomes. In addition, we compared the POP quantification system (POP-Q) pre- and postoperatively at 2 weeks, 3 months, and 1 year, and analyzed the risk factors for recurrence. RESULTS: The mean age of the patients was 65.5±7.6 years. The most common preoperative POP-Q stage was stage 2 (60.8%), followed by stage 3 (35.9%). Complications were identified during surgery in 1.6% of the patients. The most common postoperative complication (6.4%) was voiding difficulty. All POP-Q scores significantly decreased at 1 year after surgery (P<0.0001). The recurrence rate was 9.6%, and most recurrences (77.5%) occurred in the anterior compartment. An advanced stage of preoperative POP was a risk factor for recurrence (stage 3 or 4 vs. stage 1 or 2; odds ratio [OR], 5.337, 95% confidence interval [CI], 2.58-11.036, P<0.0001). Only two patients underwent surgical correction for POP recurrence, and most of the remaining patients did not undergo further treatment for prolapse. CONCLUSION: VH APR is a safe and effective surgical procedure for POP, with a low recurrence rate. In addition, advanced preoperative stage was the only risk factor for recurrent POP.

Surgical outcomes of tension-free vaginal tape (TVT)- abbrevo® and TVT-obturator® for the treatment of stress urinary incontinence: a retrospective study.

OBJECTIVE: We compared the efficacy and postoperative complications of tension-free vaginal tape (TVT)-abbrevo® (TVT-A) and TVT-obturator® (TVT-O) surgeries for the treatment of stress urinary incontinence (SUI). METHODS: We retrospectively analyzed the medical records of 143 female patients with SUI who underwent TVT-A or TVT-O surgery between January 2010 and December 2019 at the Asan Medical Center in Seoul. We evaluated intra- and postoperative complications such as bladder injury, groin pain, urinary retention, and mesh exposure. We also checked the success rate at 6 months after surgery. RESULTS: There were no complications, including fever, hematuria, hematoma of the vulva, or bladder injury, immediately after surgery in either group. Postoperative complications 2 weeks post-surgery were groin pain (11.3%), urinary retention (4.9%), and mesh exposure (0.7%). Groin pain was not significantly different between the two groups at 2 weeks, 3 months, and 6 months after surgery (TVT-O vs. TVT-A after 2 weeks: 12.5% vs. 10.3%, P=0.791; 3 months: 0.0% vs. 1.4%, P=0.999; and 6 months: 0.0% vs. 0.0%, P=0.999). Over 90% of the patients reported cure or improved symptoms in both groups. In the univariate logistic analysis, the type of TVT (TVT-O or TVT-A) was not associated with the success rate (odds ratio, 3.21; 95% confidence interval, 0.59-17.40; P=0.175). CONCLUSION: TVT-A surgery is comparable with TVT-O in terms of high success rate and low frequency of complications, including bladder injury and groin pain.

Single-Incision versus Multiport Robotic Myomectomy: A Propensity Score Matched Analysis of Surgical Outcomes and Surgical Tips.

We aimed to compare the perioperative outcomes of single-incision robotic myomectomy (SIRM) and multiport robotic myomectomy (MPRM) and provide surgical tips. We retrospectively analyzed the medical records of 462 patients with symptomatic leiomyoma who underwent MPRM or SIRM between March 2019 and April 2021. Demographic characteristics and surgical outcomes, including the total operative time (OT), estimated blood loss (EBL), and surgical complication rate, were compared between the two groups. Patients in the SIRM group had lower a body mass index and rate of previous pelvic surgery and were younger than those in the MPRM group. The myoma type was not different between groups; however, the MPRM group had larger, and more myomas than the SIRM group. After propensity score matching, these variables were not significantly different between the groups. The total OT, EBL, difference in hemoglobin levels, transfusion rate, and postoperative fever were not different between the groups. No postoperative complications occurred in the SIRM group. In the MPRM group, one patient needed conversion to laparotomy, and two patients had postoperative complications (umbilical incisional hernia and acute kidney injury). In conclusion, both MPRM and SIRM are feasible and effective surgical options for symptomatic myomas with cosmetic benefits and minimal risk of laparotomy conversion.

Fast Leak-Proof, Intraumbilical, Single-Incision Laparoscopic Ovarian Cystectomy for Huge Ovarian Masses: "Hybrid Cystectomy and Reimplantation" Method.

Background and Objectives: To introduce a new technique for fast leakage-proof, intraumbilical, single-incision laparoscopic ovarian cystectomy for huge ovarian masses (>10 cm) Materials and Methods: Seven consecutive, reproductive-aged women, including three adolescents, with huge ovarian masses (mature cystic teratoma, n = 4; endometrioma, n = 2; and mucinous cystadenoma, n = 1) who underwent transumbilical single-incision ovarian cystectomy with the new "hybrid cystectomy and reimplantation" method were included. The procedure was: (1) trans-umbilical single-incision laparoscopy; (2) inspection of the pelvic cavity and placing the mass in a laparoscopic endo-bag for cystic content leakage prevention; (3) in-bag resection using cold scissors and minimal cauterization of the cystectomy site; (4) in-bag tissue extraction; (5) rapid extracorporeal cystectomy with traction without electrocautery; (6) re-insertion of the retrieved ovarian cortex intracorporeally through the single port, and (7) intracorporeal suture of the retrieved tissue to the in situ ovary. Results: The mean patient age was 24.71 ± 6.56 (range 17-37) years and the mean maximal diameter of the masses was 17.71 ± 2.86 (range 13-22) cm. There was no case of unintended intracorporeal cyst rupture and no need for copious irrigation for washing and suctioning the leaked mass content. The mean total operating time was 76.42 ± 6.39 (range 65-85) min, the total volume of saline used for irrigation was 814.28 ± 331.35 (range 500-1500) mL, and the estimated blood loss was 107.14 ± 47.72 (range 50-200) mL. There were no perioperative complications. All patients except the two endometriosis patients had regular, normal menstruation. Conclusions: Our preliminary findings were encouraging in terms of the safety and efficiency of the new method. Future trials need to elucidate the benefits of this method in terms of fertility preservation.

The Number of Myomas Is the Most Important Risk Factor for Blood Loss and Total Operation Time in Robotic Myomectomy: Analysis of 242 Cases.

To identify factors affecting blood loss and operation time (OT) during robotic myomectomy (RM), we reviewed a total of 448 patients who underwent RM at Seoul Asan Hospital between 1 January 2019, and 28 February 2021, at Seoul Asan Hospital. To avoid variations in surgical proficiency, only 242 patients managed by two surgeons who each performed >80 RM procedures during the study period were included in this study. All cases of RM were performed with a reduced port technique. We obtained the following data from each patient's medical chart: age, gravidity, parity, body mass index, and history of previous abdominal surgery including cesarean section. We also collected information on the maximal diameter and type of myomas, number and weight of removed myomas, concomitant surgery, total OT from skin incision to closure, estimated blood loss (EBL), and blood transfusion. Data on preoperative use of gonadotropin-releasing hormone agonists (GnRHas) and perioperative use of hemostatic agents (tranexamic acid or vasopressin) were also collected. Data on the length of hospital stay, postoperative fever within 48 h, and any complications related to RM were also obtained. The primary endpoint in this study was the identification of factors affecting EBL and the secondary endpoint was the identification of factors affecting the total OT during multiport RM. Univariate and multivariate analyses were used to identify the factors affecting EBL and OT during multiport RM. The medians of the maximal diameter and weight of the removed myomas were 9.00 (interquartile range [IQR], 7.00 to 10.00) cm and 249.75 (IQR, 142.88 to 401.00) g, respectively. The median number of myomas was two (IQR, one to four), ranging from 1 to 34. Of the cases, 155 had low EBL and 87 had high EBL. Most myomas were of the intramural type (n = 179). The odds of EBL > 320 mL increased by 251% (odds ratio [OR], 2.51; 95% confidence interval [CI], 1.16-5.42) for five to nine myomas and by 647% (OR, 6.47; 95% CI, 1.87-22.33) for ≥10 myomas. The odds of subserosal-type myomas decreased by 67% compared with intramural-type myomas (OR, 0.33; 95% CI, 0.14-0.80). History of abdominal surgery other than cesarean section was positively correlated with EBL. The weight of the removed myomas and a history of previous cesarean section were not correlated with the EBL. Conclusion: The number of myomas (5-9 and ≥10), maximal myoma diameter, and history of abdominal surgery other than cesarean section affect the EBL in RM.

Increased Expression of Retinol-Binding Protein 4 in Ovarian Endometrioma and Its Possible Role in the Pathogenesis of Endometriosis.

Although endometriosis is a benign disease characterized by the presence of endometrial tissues outside the uterus, ectopic endometrial cells can exhibit malignant biological behaviors. Retinol-binding protein4 (RBP4) is a novel adipocyte-derived cytokine, which has important roles in regulating insulin sensitivity and energy metabolism. RBP4 is a potent modulator of gene transcription, and acts by directly controlling cell growth, invasiveness, proliferation and differentiation. Here, we evaluated the possible role of RBP4 in the pathogenesis of endometriosis. We compared the levels of RBP4 in the tissues and peritoneal fluid (PF) of women with and without endometriosis and evaluated the in vitro effects of RBP4 on the viability, invasiveness, and proliferation of endometrial stromal cells (ESCs). RBP4 levels were significantly higher in the PF of the women in the endometriosis group than in the controls. RBP4 immunoreactivity was significantly higher in the ovarian endometriomas of women with advanced stage endometriosis than those of controls. In vitro treatment with human recombinant-RBP4 significantly increased the viability, bromodeoxyuridine expression, and invasiveness of ESCs. Transfection with RBP4 siRNA significantly reduced ESC viability and invasiveness. These findings suggest that RBP4 partakes in the pathogenesis of endometriosis by increasing the viability, proliferation and invasion of endometrial cells.

Congenital Obstructive Müllerian Anomaly: The Pitfalls of a Magnetic Resonance Imaging-Based Diagnosis and the Importance of Intraoperative Biopsy.

A retrospective cohort study of the concordance between the magnetic resonance imaging (MRI) diagnosis and final diagnosis in patients with Müllerian duct anomalies (MDAs) was conducted, and diagnostic clues were suggested. A total of 463 cases of young women who underwent pelvic MRIs from January 1995 to February 2019 at Seoul Asan Medical Center were reviewed. Interventions consisted of clinical examinations, abdominal or transvaginal/rectal ultrasound, MRI, and operative procedures, including hysteroscopy and laparoscopy. The concordance of the diagnosis between the results obtained with MRI and those obtained with surgeries was evaluated. It was found that a total of 225 cases (48.6%) showed genital tract anomalies on MRI. Among them, 105 cases (46.7%) underwent reconstructive surgery. Nineteen cases (8.4%) revealed discrepancies between the final diagnosis after surgery and the initial MRI findings and eleven cases (57.9%) had cervical anomalies. Incorrect findings associated with the MRIs were particularly evident in biopsied cases of cervical dysgenesis. A combination of physical examination, ultrasound, and MRI is suitable for preoperative work-up in the diagnoses of congenital obstructive anomalies. However, it is recommended that a pathologic confirmation of tissue at the caudal leading edge be made in obstructive genital anomalies, in cases of presumptive vaginal or cervical dysgenesis.

Congenital Uterine Anomaly and Pelvic Organ Prolapse: A Rare Case of Pelvic Organ Prolapse in a Complete Bicornuate Uterus with Successful Pregnancy Outcomes Undiagnosed until the Time of Sacrocolpopexy.

Müllerian development anomalies (MDAs) are most commonly diagnosed in the reproductive period. A bicornuate uterus is the result of a fusion defect of the Müllerian ducts, causing an abnormal fundal outline. Most of the cases are diagnosed early in life and present with obstetrical complications, such as recurrent pregnancy loss, preterm birth, intrauterine growth restriction, placental abruption, and cervical incompetence. Pelvic organ prolapse (POP) in women with MDAs has been reported; however, all reported cases were when MDAs are diagnosed before or simultaneously with the development of POP in premenopausal young women aged < 35. A 52-year-old menopausal woman, who successfully delivered vaginally at term, was presented with protruding mass through vaginal introitus. On POP-Q examination, the cervix was elongated and descended to 1 cm out of the hymen during bearing down; however, the uterine bodies were confined in the pelvic cavity, which is commonly encountered among POP patients with large uterus due to uterine fibroids or adenomyosis. She also diagnosed for complete bicornuate uterus and underwent robotic sacrocolpopexy for advanced stage POP. It is presumed to have been caused by the bicornuate uterus that prevented the total uterine prolapse with the effect of extending both uterine horns bilaterally inside the pelvic cavity and trapping the uterus within the pelvis. Herein, we report a rare case of complete bicornuate uterus with multiple successful vaginal deliveries at term without obstetric complications, which remained undiagnosed until she was managed for the POP in her postmenopausal period.

Influence of pretreatment of insulin on the phosphorylation of extracellular receptor kinase by gonadotropin-releasing hormone and gonadotropins in cultured human granulosa cells.

OBJECTIVE: To investigate the influence of pretreatment of insulin on the phosphorylation of ERK1/2 by gonadotropin-releasing hormone (GnRH), follicle-stimulating hormone (FSH), and luteinizing hormone (LH) in cultured human granulosa cells. STUDY DESIGN: Human granulosa cells were collected from 20 women (age: 20-35 years) who underwent controlled ovarian hyperstimulation for in vitro fertilization and embryo transfer at Asan Medical Center (Seoul, South Korea). The presence of the receptors for insulin, GnRH, FSH, and LH in human granulosa cells was identified by semiquantitative reverse transcription-polymerase chain reaction (RT-PCR). The granulosa cells were treated with 10 nM insulin or 10 nM GnRH for 5 min or 30 min and with 10 nM FSH or 10 nM LH for 24 h or 48 h. The cells were also pretreated with insulin for 30 min prior to treatment with GnRH, FSH, or LH. Western blot analysis was used to analyze ERK1/2 phosphorylation. RESULTS: RT-PCR showed that the receptors for insulin, GnRH, FSH, and LH were expressed in human granulosa cells. Insulin, GnRH, FSH, and LH could activate ERK1/2 phosphorylation. Pretreatment with insulin inhibited ERK1/2 phosphorylation induced by GnRH and FSH while augmenting ERK1/2 phosphorylation induced by LH. CONCLUSIONS: Insulin might have a negative effect on GnRH and FSH regulation by attenuating the action of GnRH and FSH in the phosphorylation of ERK1/2 in human granulosa cells. In contrast, insulin might have a positive effect on LH regulation by potentiating the action of LH in the phosphorylation of ERK1/2. Our results showed that insulin is clearly an important regulator of human reproductive function at the ovarian level.

A Huge Hemorrhagic Epidermoid Cyst of the Perineum with Hypoechoic Semisolid Ultrasonographic Feature Mimicking Scar Endometriosis.

Epidermoid cysts are small, solitary, and slow-growing lesions that rarely appear in the perineum and mostly arise because of trauma. This study examined a huge perineal epidermoid cyst that slowly grew over eight years in a premenopausal woman. Ultrasonography showed that the hemorrhage in the cyst was a semisolid hypoechoic mass, which mimicked endometrioma, and was tentatively diagnosed as scar endometriosis in the perineum after vaginal delivery. This case study highlights the importance of wide surgical excision and histopathologic diagnosis, even with typical ultrasonography and surgical findings.

Clitoromegaly, Vulvovaginal Hemangioma Mimicking Pelvic Organ Prolapse, and Heavy Menstrual Bleeding: Gynecologic Manifestations of Klippel-Trénaunay Syndrome.

Klippel-Trénaunay Syndrome (KTS) is a genetic vascular malformation involving the capillary, lymphatic, and venous channels. Prenatal sonographic diagnosis of KTS with an enlarged fetal limb is well-known; however, postnatal gynecologic manifestations are rarely reported. KTS can cause clitoromegaly, vulvovaginal hemangioma, and heavy menstrual bleeding. Somatic mosaicism of the PIK3CA gene is considered as responsible for KTS but reports based on whole-genome sequencing are limited. A 31-year-old woman with KTS presented with bulging of the clitoris and vagina. Analysis of whole-genome sequencing variant data revealed that gene ontology terms related to development and differentiation such as 'skeletal system morphogenesis', 'embryonic morphogenesis', and 'sensory organ development' were nominally significant in non-coding regions. Variants in non-coding genes may be responsible for this phenotype.

Vaginal Microbiome Is Associated With Vulvodynia, Vulvar Pain Syndrome: A Case-Control Study.

INTRODUCTION: Vulvodynia, vulvar pain syndrome, is defined as vulvar pain of at least a 3-month duration without a clear identifiable cause, which may have associated factor and the etiology and treatment of this challenging disease is still unclear. Dyspareunia is a relevant symptom of patients with vulvodynia. Vaginal microbiome has known an important role in local immune-inflammatory responses and it may be important pathogenic mechanism in vulvodynia. AIM: The objective of this study was to investigate the association of vaginal microbiome and vulvodynia. METHODS: We analyzed the microbial compositions of the vestibule and vagina among women with clinically diagnosed vulvodynia (n = 22) and age-matched healthy controls (n = 22) without vulvodynia. The compositions of bacterial microbiomes were compared by pyrosequencing of the 16S rRNA. MAIN OUTCOME MEASURE: Vaginal microbiome alpha and beta diversity were assessed using the Shannon diversity index and Heat map. Linear discriminant analysis effect size was used to find out marker for vulvodynia. RESULTS: There were no significant differences in the age, duration of marriage, history of gynecologic surgery, parity, and menopause status between cases and controls. A total of 1,661,934 high-quality pyrosequencing reads was obtained to evaluate bacterial diversity, and 50,246 unique sequences represented all phylotypes. The type and mean number of the genera were not different between cases and controls. However, the most predominant phyla of bacteria were significantly different between cases and controls. 3 phyla (Firmicutes, Actinobacteria, and Tenericutes) and 11 genera including Gardnerella, Ureaplasma, Achromobacter, Mycoplasma, and Bifidobacteria were significantly more prevalent in cases than in controls (P < .05). Linear discriminant analysis effect size analysis suggest the Bifidobacterium, Mycoplasma, and Fenollaria species can be potential markers for vulvodynia. CONCLUSION: Our results suggest the differences in vaginal microbiome can be associated with the vulvodynia. Park SY, Lee ES, Lee SR, et al. Vaginal Microbiome Is Associated With Vulvodynia, Vulvar Pain Syndrome: A Case-Control Study. Sex Med 2021;9:100314.

A 30-Month Complete Urinary Obstruction Resulting from Trapped and Incarcerated Uterus: A Case Report.

Uterine incarceration is rare, but it can caus e serious complications, in which the uterus is trapped in the pelvic cavity behind the sacral promontory. Fibroid uterus can cause urinary frequency and retention, which can result from compression of the urinary bladder with an enlarged fibroid uterus and the compression of the bladder neck or urethra, respectively. To our knowledge, there is no report on prolonged complete urinary obstruction because of an incarcerated uterus in nonpregnant women to date. A 51-year-old woman was referred for uterine myomas. She could not void for 30 months after she received an intradetrusor injection of botulinum toxin for urinary frequency management at the urology department of another hospital. She underwent clean intermittent catheterization for 30 months. She was referred to the gynecologic department for the evaluation of uterine myoma found on using abdominopelvic computed tomography. On physical examination, the uterine cervix was extremely displaced in the upward direction and was not exposed on speculum examination. Sonography and magnetic resonance imaging revealed that the urethra and the bladder neck were compressed by an extremely retroflexed fibroid uterus. Manual reduction of the incarcerated uterus failed; hence, we performed robot-assisted laparoscopic total hysterectomy with left salpingo-oophorectomy. She immediately urinated immediately after the operation and had normal urination at 1- and 48-month follow-up visits. Uterine incarceration by a fibroid uterus can cause complete urinary obstruction, as in this case. Uterine incarceration should be considered in women with urinary frequency or retention to avoid prolonged, serious complications.

New Surgical Technique for Robotic Myomectomy: Continuous Locking Suture on Myoma (LSOM) Technique.

Robot-assisted laparoscopic myomectomy (RALM) has broadened the indications even in complex myomas. However, the high cost of RALM remains the main disadvantage. Therefore, a surgical technique that can reduce the cost of RALM and still has the advantages of robotic surgery is required. We propose a "locking suture on myoma (LSOM)" technique and compared the operative and perioperative outcomes of patients who underwent RALM with or without the LSOM technique. We included 337 patients who underwent RALM with (n = 160) or without (n = 177) the LSOM technique between March 2019 and August 2020. The LSOM group had low parity and gravidity, with a low rate of Cesarean sections. Myoma type was not different between the groups; however, patients in the LSOM group had larger, heavier, and higher number of myomas, although fewer patients had multiple myomas and were discharged earlier. Total operating time, estimated blood loss, pre- and postoperative hemoglobin levels, transfusion rate, and postoperative fever were not different between the two groups. In conclusion, the LSOM technique may be a viable surgical option for myomas, as it can reduce the cost of RALM by obviating the need for robotic Tenaculum forceps.