Twin pregnancies with uterine fibroids are not at increased risk for obstetric complications: single center cohort study.

BACKGROUND: Twin pregnancies with uterine fibroid(s) (UFs) may not be at increased risk for obstetric complications compared to those without UFs. However, there was no reported comparison study with obstetric outcomes and complications of twin pregnancy after myomectomy. We aimed to compare the pregnancy outcomes in twin pregnancies with or without uterine fibroid(s), and also compared in patients with previous myomectomy history in Korean women. METHODS: A cohort of twin pregnancies delivered in a single institution between January 2011 and March 2019 were retrospectively analyzed. UFs group was defined by the presence of UFs during pregnancy (≥1 fibroid, measuring ≥2 cm or multiple fibroids regardless of the size). Previous myomectomy group included patients with history of abdominal or laparoscopic or hysteroscopic myomectomy of ≥1 fibroid, measuring ≥2 cm or multiple fibroids whatever the size. Patients with monochorionic monoamniotic twins, myoma less than 2 cm in size, missed abortion or intrauterine fetal death (IUFD) of one fetus before 14 weeks, history of previous conization, and uterine anomalies were excluded. Pregnancy outcomes and obstetric complications were compared. RESULT: A total 1388 patients were included in this study, 191 (13.8%) had UFs and 89 (6.4%) had a history of myomectomy. Maternal age was younger in non-UFs group and primiparity was more common in UFs group (p < 0.001, and p = 0.019). No significant differences were found in the gestational age at delivery (p = 0.657), delivery before 37 weeks (p = 0.662), delivery before 34 weeks (p = 0.340), and sum of birth weight of twin (p = 0.307). There were also no statistical differences in rates of obstetrical complications, such as preeclampsia, gestational diabetes mellitus, placenta previa, placenta abruption, cerclage, small for gestational age, IUFD, postpartum hemorrhage and peripartum transfusion or ICU care. These obstetrical outcomes and complications showed no statistical differences between UFs group and previous myomectomy group. CONCLUSION: In patients with twin pregnancies, the presence of UFs or history of previous myomectomy did not relate to negative effects on pregnancy outcomes and obstetrical complications.

Clinical outcomes of prophylactic compression sutures for treatment of uterine atony during the cesarean delivery of twins.

BACKGROUND: Twin pregnancy has a high risk for developing uterine atony (UA). This study aimed to evaluate efficacy and clinical outcomes of prophylactic compression sutures to treat UA during twin cesarean section (CS). METHODS: All patient records of twin deliveries by CS after gestational age of 24 weeks in a large maternity hospital in South Korea between January 2013 and June 2018 were reviewed. Patients with monochorionic monoamniotic twins were excluded from data analysis. In total, 953 women were eligible for data analysis. RESULTS: Of the 953 patients, compression sutures were applied to 147 cases with postpartum bleeding that were refractory to uterine massage and uterotonics. Out of the 147, two patients (1.4%) proceeded to additional uterine artery ligation to achieve hemostasis, yielding a success rate of 98.6%. The rate of transfusion after the first 24 h of delivery in the suture group was not significantly different from that in the non-suture group, suggesting that both groups achieved hemostasis at an equal rate after the first 24 h of delivery. The difference in the operation time between the two groups was only 8.5 min. The rate of subsequent pregnancy among the patients who received compression sutures was 44.4%. CONCLUSIONS: Overall, our findings suggest that with early and fast implementation of compression sutures, UA can be treated in the setting of twin cesarean delivery without significantly increasing maternal morbidity.

Combined Oral Medroxyprogesterone/Levonorgestrel-Intrauterine System Treatment for Women With Grade 2 Stage IA Endometrial Cancer.

OBJECTIVE: The aim of this study was to evaluate the oncologic and pregnancy outcomes of combined oral medroxyprogesterone acetate (MPA)/levonorgestrel-intrauterine system (LNG-IUS) treatment in young women with grade 2-differentiated stage IA endometrial adenocarcinoma who wish to preserve fertility. METHODS: We retrospectively reviewed the medical records of patients with grade 2 stage IA endometrial adenocarcinoma who had received fertility-sparing treatment at CHA Gangnam Medical Center between 2011 and 2015. All of the patients were treated with combined oral MPA (500 mg/d)/LNG-IUS, and follow-up dilatation and curettage were performed every 3 months. RESULTS: A total of 5 patients were included in the study. The mean age was 30.4 ± 5.3 years (range, 25-39 years). After a mean treatment duration of 11.0 ± 6.2 months (range, 6-18 months), complete response (CR) was shown in 3 of the 5 patients, with partial response (PR) in the other 2 patients. One case of recurrence was reported 14 months after achieving CR. This patient was treated again with combined oral MPA/LNG-IUS and achieved CR by 6 months. The average follow-up period was 44.4 ± 26.2 months (range, 12-71 months). There were no cases of progressive disease. No treatment-related complications arose. CONCLUSIONS: Combined oral MPA/LNG-IUS treatment is considered to be a reasonably effective fertility-sparing treatment of grade 2 stage IA endometrial cancer. Although our results are encouraging, it is preliminary and should be considered with experienced oncologists in well-defined protocol and with close follow-up.

Effect of menstrual phase on the surgical treatment of ovarian cysts.

This study aimed to determine whether the menstrual cycle affects operative bleeding and postoperative ovarian reserve in patients undergoing laparoscopic ovarian cystectomy. A total of 155 patients who had undergone laparoscopic ovarian cystectomy were classified into the follicular phase (n = 84) and luteal phase (n = 71) of the menstrual cycle. The primary outcome measures were operative blood loss and the rate of decline in ovarian reserve, as calculated by measuring serial serum anti-Müllerian hormone (AMH) levels preoperatively and 3 months postoperatively. No significant difference in the baseline demographics, operative blood loss (p = .984), the rate of decline in ovarian reserve (p = .945), and other surgical outcomes were observed between both the groups. These results demonstrate that the menstrual cycle had no influence on the operative blood loss and ovarian reserve during laparoscopic ovarian cystectomy. Therefore, the menstrual cycle is not an important factor to determine the optimal timing of ovarian cystectomy. Impact statement What is already known on this subject?: The menstrual cycle results in periodic changes in haemostasis and blood flow in the reproductive organs. What do the results of this study add?: These results demonstrate that the menstrual cycle had no influence on the operative blood loss and ovarian reserve during laparoscopic ovarian cystectomy. What are the implications of these findings for clinical practice and/or further research?: The menstrual cycle is not an important factor to determine the optimal timing of ovarian cystectomy.

Single-dose versus two-dose administration of methotrexate for the treatment of ectopic pregnancy: a randomized controlled trial.

STUDY QUESTION: Can a two-dose methotrexate treatment protocol improve the treatment success rate compared with a single-dose protocol in women with an ectopic pregnancy? SUMMARY ANSWER: The two-dose protocol was not superior to the single-dose protocol for the treatment of ectopic pregnancy. WHAT IS KNOWN ALREADY: Although the two-dose methotrexate protocol for ectopic pregnancy was recently introduced to combine the efficacy and convenience of the fixed multi-dose and single-dose protocols, studies comparing the success rates, treatment satisfaction and acceptability of the single-dose and two-dose treatment protocols for ectopic pregnancy are currently lacking. STUDY DESIGN, SIZE, DURATION: A randomized trial was conducted on 92 participants with tubal ectopic pregnancy, between May 2013 and April 2015. PARTICIPANT/MATERIALS, SETTING, METHODS: Patients who were diagnosed with tubal ectopic pregnancy and who elected to undergo systemic methotrexate treatment were randomly assigned to follow either the single-dose (n = 46) or two-dose protocol (n = 46). The primary outcome measure was treatment success without surgical intervention. The secondary outcome measures were the incidence of methotrexate-associated side effects, ß-human chorionic gonadotrophin (ß-hCG) resolution time, cost of care received and treatment satisfaction. MAIN RESULTS AND THE ROLE OF CHANCE: There were no differences in baseline characteristics between the groups. The success rates between the single-dose and two-dose groups did not show a significant difference [82.6 versus 87.0%; relative risk (RR) 0.95; 95% confidence interval (CI) 0.80-1.13]. However, the success rate in a subgroup of participants with a pretreatment ß-hCG level of >5000 mIU/ml appeared to be higher in the two-dose group than in the single-dose group (80.0 versus 58.8%), although the difference was not statistically significant. No significant differences in methotrexate-associated side effects, cost or treatment satisfaction were observed between the groups. The two-dose group required a lower number of days for the ß-hCG level to decrease to <5 mIU/ml than the single-dose group (25.7 ± 13.6 versus 31.9 ± 14.1 days; P = 0.025). LIMITATIONS, REASONS FOR CAUTION: Some caution is warranted in interpreting the results due to an overoptimistic sample size calculation on the basis of the biggest difference as reported in literature between the success rates of two protocols. WIDER IMPLICATIONS OF THE FINDINGS: The single-dose protocol with the option to elaborate to a second dose in the case of treatment failure could stand as the treatment for most cases of ectopic pregnancy. STUDY FUNDING/COMPLETING OF INTERESTS: None. TRIAL REGISTRATION NUMBER: www.clinicaltrials.gov, no. NCT01855568. TRIAL REGISTRATION DATE: 10 May 2013. DATE OF FIRST PATIENT'S ENROLMENT: 26 May 2013.

Evidence for No Significant Impact of Müllerian Anomalies on Reproductive Outcomes of Twin Pregnancy in Korean Women.

The present article aimed to evaluate the impact of congenital Müllerian anomalies (MA) on twin pregnancy after 24 gestational weeks in Korean women. All records of twin pregnancies in a large maternity hospital in Korea between January 2005 and July 2013 were analyzed. Patients with monochorionic monoamniotic (MCMA) twins, non-Korean patients, patients with twins delivered prior to 24 gestational weeks, and patients with miscarriage of one fetus or intrauterine fetal death (IUFD) before 24 gestational weeks were excluded from data analysis. In total, 1,422 women with twin pregnancy were eligible for data analysis, including 17 (1.2%) who had a known congenital MA (septate uterus, bicornuate uterus, arcuate uterus, and unicornuate uterus). Except for the mode of conception, baseline demographics were similar between women with MA and those without MA. No significant differences were found in pregnancy outcomes of gestational age at delivery (p = .86), birth weight of smaller and larger twins (p = .54 and p = .65), and number of twins with birth weight <5th percentile for gestational age (p = .43).The rates of obstetrical complications such as pre-eclampsia, gestational diabetes mellitus (GDM), placenta previa, cerclage, IUFD, and postpartum hemorrhage were not significantly different between the two groups either. We concluded that the presence of congenital MA may not increase obstetrical risks in outcomes of pregnancy of twins delivered after 24 gestational weeks.

Recurrence of ovarian endometrioma after second-line, conservative, laparoscopic cyst enucleation.

OBJECTIVE: We sought to evaluate the cumulative recurrence rate of endometrioma after a second-line, conservative, laparoscopic endometriotic cyst enucleation and to analyze the factors that influence the recurrence of endometrioma. STUDY DESIGN: A multicenter retrospective cohort study was performed at 3 gynecologic surgery centers from January 2000 through December 2010. Patients surgically treated by laparoscopic enucleation of endometriotic cysts on 2 previous occasions were selected. All patients were aged <40 years at the time of the primary surgery and were followed up for at least 6 months. Endometrioma recurrence was considered when transvaginal sonography indicated a cystic mass with a diameter of ≥20 mm. RESULTS: In total, 183 patients were followed up for 33.2 ± 27.7 months (range, 6-121 months). Thirty-eight (20.8%) patients experienced recurrence after the second-line surgery and 24 (13.1%) patients underwent a third surgery. The median time to recurrence was 24 ± 3.36 months (SEM) (range, 3-72 months). The cumulative recurrence rates per patient at 12, 24, 36, and 60 months after the second-line surgery were 7.7%, 13.7%, 21.3%, and 37.5%, respectively. After multivariate analysis and analysis of covariance, the revised American Fertility Society score and stage were significantly higher in patients who experience a third recurrence of endometrioma. CONCLUSION: The cumulative recurrence rate of ovarian endometrioma after a second-line surgery appears to be correlated to the duration of follow-up. Severe endometriosis at the second-line surgery seems to be a factor associated with a high recurrence risk. Physicians should be cautious with regard to the postoperative management of these patients.

Would fewer port numbers in laparoscopy produce better cosmesis? Prospective study.

STUDY OBJECTIVE: To determine whether fewer ports in laparoscopic adnexal surgery would lead to better cosmesis. DESIGN: Prospective comparative study (Canadian Task Force classification II-2). SETTING: University hospital. PATIENTS: One hundred thirty consecutive patients with adnexal tumors. INTERVENTIONS: Patients underwent laparoscopy using a single port (n = 75), 2 ports (n = 22), or 4 ports (n = 33). Cosmetic satisfaction was assessed using a validated Body Image Questionnaire at 1, 4, and 12 weeks after surgery. MEASUREMENTS AND MAIN RESULTS: Patient characteristics (age, parity, and sociodemographic data), details of the procedures performed, and histologic findings were similar between the 3 surgical groups. There was also no difference in number of conversions to other surgical approaches, operative time, estimated blood loss, postoperative pain, and perioperative complications. Compared with the 2- and 4-port groups, the single-port group reported substantially greater cosmetic satisfaction at 1, 4, and 12 weeks after surgery. However, there was no important difference in cosmetic outcome throughout follow-up in the 2-t and 4-port groups. CONCLUSION: Unlike 2- or 4-port laparoscopy, single-port laparoscopy has a definite benefit in cosmetic satisfaction.

Laparoendoscopic single-site surgery for extremely large ovarian cysts: a feasibility, safety, and patient satisfaction study.

BACKGROUND/AIMS: To assess the feasibility, safety and patient satisfaction of laparoendoscopic single-site (LESS) surgery for extremely large ovarian cysts. METHODS: We conducted a prospective study of LESS surgery among women with ovarian cysts with a minimum diameter ≥15 cm and with radiological and laboratory features suggestive of benign disease. The primary outcomes were perioperative complication rate, conversion rate and patient satisfaction. RESULTS: A total of 21 consecutive patients underwent the following LESS surgery over a period of 17 months: ovarian cystectomy (76%), adnexectomy (10%) and staging procedure (14%). Histological findings included benign (85%), borderline (10%) and malignant tumors (5%). Spillage occurred for 2 patients (10%). LESS surgery was successful without conversion in 20 patients (95%). There was 1 perioperative complication with subcutaneous hematoma (5%). The median operative time and estimated blood loss were 79.8 min (39-155) and 60 ml (10-180), respectively. Patients were highly satisfied with the results of LESS surgery, with a mean surgery satisfaction score of 9.4 ± 0.8 on a scale of 1-10. More than 71% of patients reported that the scar was invisible, and 95% said that they would recommend LESS surgery to others. CONCLUSION: Based on our results, with proper patient selection, the size of an ovarian cyst does not necessarily constitute a contraindication for LESS surgery.

Successful full-term twin deliveries in heterotopic cesarean scar pregnancy in a spontaneous cycle with expectant management.

Heterotopic cesarean scar pregnancy (CSP) usually follows assisted reproductive technologies (ART) in women who have already delivered by cesarean section. It is extremely rare: thus far, there have been only 12 individual case reports. However, over the last 20 years, the rate of cesarean delivery has increased and ART have become more common; hence, heterotopic CSP will be more prevalent in the future. Currently available data suggest that the early selective termination of CSP by medical or surgical methods is the most reliable treatment in the hemodynamically stable heterotopic CSP women because of the serious complications of continuing the CSP. We present the first case report of heterotopic CSP in a spontaneous cycle with expectant management that resulted in full-term twin deliveries.

Risk factors for treatment failure of CO2 laser vaporization in cervical intraepithelial neoplasia 2.

PURPOSE: The aim of our study was to evaluate the risk factors for treatment failure of CO2 laser vaporization in patients with cervical intraepithelial neoplasia 2 (CIN2). METHODS: Medical records of patients who received either shallow or deep CO2 laser vaporization with biopsy-proven CIN2 during March 2007 to April 2011 were reviewed retrospectively. After laser vaporization, liquid-based cytology and human papilloma virus (HPV) DNA testing were checked in every follow-up visit. Treatment failure was defined when the follow-up biopsy was more than CIN2, needing secondary surgical treatment. RESULTS: During that period, 141 patients with CIN2 underwent CO2 laser vaporization. After laser ablation, 14 of 141 women needed the secondary treatment, a success rate of laser vaporization of 90.1 %. In multivariate analysis, the previous loop electrosurgical excision procedure (LEEP) history (adjusted OR = 13.649; P value = 0.025) and the ablation depth (adjusted OR = 11.279; P value = 0.006) were independent factors associated with treatment failure. CONCLUSION: Both ablation depth and previous LEEP history were the important factors increasing the risk for the treatment failure of CO2 laser vaporization in CIN2.

Pregnancy Outcomes and Obstetrical Complications of Twin Pregnancies with Endometriosis: A Single-Center Cohort Study.

PURPOSE: There are many studies regarding the increased relationship between pregnancy outcomes of singleton with endometriosis. However, there was limited evidence of twin pregnancies with endometriosis. This study aimed to compare the pregnancy outcomes and complications in twin pregnancies with or without endometriosis in a single institution. MATERIALS AND METHODS: From January 2011 to July 2022, a retrospective analysis of twin pregnancies was conducted. The endometriosis group included patient with histological or visual confirmation before pregnancy or during cesarean section. Pregnancy outcomes and complications were compared between the two groups. RESULTS: Out of 1714 patients examined, 127 (7.4%) were included in the endometriosis group. Maternal body mass index (BMI) was lower in the endometriosis group (p<0.001). There were no significant differences in maternal age, mode of conception, chorionicity, and pregnancy outcomes, such as gestational age at delivery (p=0.835) and the preterm birth rate (p=0.579). The endometriosis group had a significantly higher rate of obstetrical complication: small for gestational age (SGA) <10% (p=0.029). However, after adjustment for BMI, the endometriosis group showed no statistical significance in obstetrical complications, including SGA (adjusted odds ratio, 1.568; 95% confidence interval, 0.984-2.499; p=0.059). CONCLUSION: Twin pregnancies with endometriosis were not related to adverse effects on pregnancy outcomes and obstetrical complications. To confirm these outcomes, further large prospective studies are required.

Robotic Single-Site Plus One-Port Myomectomy versus Robotic Single-Site Plus Two-Port Myomectomy: A Propensity Score Matching Analysis.

PURPOSE: Robotic single-site plus one-port myomectomy (RSOM) was designed to reduce the number of incision sites for greater cosmetic satisfaction of patients while retaining the benefits of conventional robotic multi-site myomectomy (CRM). Robotic single-site plus two-port myomectomy (RSTM) eliminated one port relative to conventional CRM, and RSOM achieved the same advantage with respect to RSTM. This study aimed to compare RSOM with RSTM in terms of their respective methodologies and surgical outcomes. MATERIALS AND METHODS: The medical records of 230 patients who had undergone RSOM and 146 patients who had undergone RSTM were reviewed. The groups' surgical outcomes were compared using propensity score matching (PSM) analysis. RESULTS: In the total data, RSOM had a shorter operative time (135.1±57.4 min vs. 149.9±46.2 min, p=0.009) and a shorter hospital stay (5.2±0.5 days vs. 5.4±0.7 days, p=0.033) relative to RSTM. The PSM analysis showed that there were no statistically significant intergroup differences in the patients' baseline characteristics. Regarding the surgical outcomes, the RSOM group showed shorter operative time (129.2±49.3 min vs. 148.7±46.3 min, p=0.001) compared to the RSTM group. CONCLUSION: Compared with RSTM, RSOM was associated with shorter operative time. Additionally, more detailed comparative and prospective studies are needed to evaluate RSOM relative to RSTM.

Comparison of dilatation & curettage and endometrial aspiration biopsy accuracy in patients treated with high-dose oral progestin plus levonorgestrel intrauterine system for early-stage endometrial cancer.

OBJECTIVE: To compare the diagnostic accuracy of dilatation & curettage (D&C) vs. endometrial aspiration biopsy in follow-up evaluation of patients treated with high-dose oral progestin plus levonorgestrel intrauterine system (LNG-IUS) for early-stage endometrial cancer (EC). METHOD: A prospective observational study was conducted with 11 patients with FIGO grade 1 or 2, clinical stage IA endometrioid adenocarcinoma. Patients were aged up to 40 years wishing to preserve fertility treated with high-dose oral progestin plus LNG-IUS. Treatment response assessment was done at three month intervals. Endometrial tissues were obtained via endometrial aspiration biopsy with LNG-IUS in place and D&C after removal of LNG-IUS. We identified 28 cases; the histologic results were compared. Kappa statistics were used to assess the agreement of two methods. RESULTS: Diagnostic concordance between examinations was assessed for 9 out of 28 cases examined (32.1%). These consisted of three cases with both examination results of normal, 3 cases with endometrioid adenocarcinoma, 1 case with complex endometrial hyperplasia, 2 cases with material insufficient for diagnosis. Endometrioid adenocarcinoma on D&C was diagnosed in 9 out of 28 cases, but from endometrial aspiration biopsy, only 3 of these 9 cases were diagnosed with endometrioid adenocarcinoma, giving the diagnostic concordance at 33% (kappa value=0.27). From endometrial aspiration biopsy, 17 out of 28 cases (60.7%) had material insufficiency for diagnosis. CONCLUSION: In patients treated with high-dose oral progestin plus LNG-IUS for early-stage EC, endometrial aspiration biopsy with LNG-IUS in place may be not reliable as a follow-up evaluation method.

Laparoendoscopic single-site versus conventional laparoscopic gynecologic surgery: a metaanalysis of randomized controlled trials.

OBJECTIVE: To assess the current evidence regarding the efficiency, safety, and potential advantages of laparoendoscopic single-site surgery (LESS) for treating gynecologic diseases. STUDY DESIGN: We comprehensively searched PubMed, Embase, and the Cochrane Library from their inception to December 2012. Two authors screened out duplicates and independently reviewed eligibility of each study. We included randomized controlled trials comparing LESS with conventional laparoscopy (CL) for treating gynecologic diseases. The primary outcomes were perioperative complication rate, conversion rate, postoperative pain, and cosmetic satisfaction. RESULTS: We included 6 randomized controlled trials with 439 participants in the final analysis. There were no significant differences between LESS and CL in terms of perioperative complication rate (15.5% and 14.3%; risk ratio, 1.11; 95% confidence interval [CI], 0.74-1.67; P = .61), conversion rate (3.8% and 1.1%; risk ratio, 2.75; 95% CI, 0.73-10.33; P = .13), postoperative pain (weighted mean difference [WMD], -0.22; 95% CI, -1.29 to 0.85; P = .68), analgesic requirement (WMD, 0.41; 95% CI, -1.69 to 2.51; P = .70), and cosmetic satisfaction (WMD, 0.19; 95% CI, -0.30 to 0.68; P = .46). There were also no differences in terms of operative time (P = .65), hemoglobin change (P = .23), time to first flatus (P = .17), and length of hospital stay (P = .99) between both techniques. CONCLUSION: This metaanalysis provides evidence that LESS is comparable in the efficacy and safety, but does not offer potential advantage such as better cosmesis and lesser pain compared with CL for treating gynecologic diseases.

Combined medroxyprogesterone acetate/levonorgestrel-intrauterine system treatment in young women with early-stage endometrial cancer.

OBJECTIVE: The purpose of this study was to evaluate the efficacy of the combined oral medroxyprogesterone acetate (MPA)/levonorgestrel-intrauterine system (LNG-IUS) treatment in young women with early-stage endometrial cancer who wish to preserve their fertility. STUDY DESIGN: A prospective observational study was conducted. The study population comprised women aged ≤40 years who were diagnosed with endometrioid endometrial cancer, grade 1, tumor size <2 cm presumably confined to the endometrium. A LNG-IUS was inserted in the uterine cavity of each woman, and all of the women received oral MPA (500 mg/d). Dilation was conducted every 3 months. RESULTS: From September 2008 to December 2012, 16 patients were enrolled. The overall complete remission rate was 87.5% (14/16 patients); the average time to complete remission was 9.8 ± 8.9 months (range, 3-35 months). In the initial 3 months of treatment, complete remission was observed in 25% of cases (4/16 patients), partial response in 25% (4/16), and no change in 50% (8/16); there were no cases of progressive disease. Three patients achieved pregnancies. The average follow-up period was 31.1 ± 11.8 months (range, 16-50 months), and there were no treatment-related complications. CONCLUSION: Combined oral MPA/LNG-IUS treatment is considered to be effective and favorable for young patients with early-stage endometrial cancer who want to preserve their fertility.

Simplifying laparoscopic running suture line utilizing "Puller" technique: demonstration in laparoscopic myomectomy.

BACKGROUND: Laparoscopic myomectomy (LM) has increased recently as treatment options for symptomatic uterine myomas for a patient who wants to preserve her uterus. However, adequate suture of the uterine defect is difficult in LM, even for an experienced surgeon. The most time-consuming step of LM is the suturing procedure. The suture material can tangle easily and disentanglement is time-consuming. We introduce a simple but highly effective instrument named "Puller" for continuous intracorporeal suturing in LM. METHODS: After completion of myoma enucleation, the operator sutures the uterine defect with suture material in continuous manner. The tip of "Puller" looks like a hook. During the suture, the first assistant inserts the "Puller" on the suprapubic site and sets the suture material on the hook and pulls it extracorporeally. After one stitch, the operator pulls the suture material intracorporeally, and then the first assistant pulls the sutured portion of the thread extracorporeally with "Puller" and holds the stitch to maintain the adequate tension during the repair. RESULTS: From January 2011 to October 2011, 88 patients who were diagnosed with uterine myoma underwent LM using "Puller" by a single surgeon. The mean diameter of the myoma was 6.8 ± 2.1 cm, and multiple myomas were observed in 46 cases (52.3 %). As a result, the mean operation time was 65.0 ± 22.1 min, the estimated blood loss was 173.9 ± 179.8 ml. Mean weight of removed myoma was 141.5 ± 105.7 g. Postoperative febrile morbidity (body temperature higher than 37.7 °C) was observed in 15 patients (17 %). However, no patients had conversion to laparotomy and needed blood transfusion. There were no major complications that required reoperation or readmission. CONCLUSIONS: Laparoscopic myomectomy can be performed easily and effectively by using the "Puller" technique with standard instruments. Additionally, this "Puller" technique could be adopted in all minimally invasive surgery needed running suture for hemostasis and closure.

Clinical characteristics and surgical management options for ovarian fibroma/fibrothecoma: a study of 97 cases.

AIMS: The aims of this study were to analyze the clinical characteristics, diagnostic features, and operative outcomes of patients with ovarian fibroma/fibrothecoma and to discuss appropriate management options. METHODS: We performed a retrospective comparative analysis of 97 patients with ovarian fibroma/fibrothecoma who underwent laparoscopic and laparotomic procedures, including tumorectomy between January 2008 and December 2011. RESULTS: The mean patient age was 42.5 ± 11.4 years. Seventy-three patients (75.3%) were premenopausal women. A preoperative diagnosis of benign ovarian tumor or fibroma was made in only 49 cases (50.5%). We found that 42.2% of cases were misdiagnosed as uterine myomas (n = 41) and 6.2% were misdiagnosed as malignant ovarian tumors (n = 6). The presence of ascites was associated with larger tumor size (p < 0.05) but not higher CA125 levels (p = 0.159). Twenty-nine patients (29.9%) underwent laparotomy, and 68 (70.1%), laparoscopic surgery. Laparoscopic surgery facilitated shorter operation times than laparotomy (p < 0.05). Tumorectomy was performed in 40 patients (43.5%), 36 (90%) of whom underwent laparoscopy with operative outcomes comparable to those of patients who underwent laparotomy. CONCLUSIONS: Ovarian fibromas/fibrothecomas are often misdiagnosed as uterine myomas and malignant ovarian tumors. Laparoscopic surgery including tumorectomy may be an effective surgical approach in patients with ovarian fibromas/fibrothecomas.

Comparison of single-port, two-port and four-port laparoscopic surgery for cyst enucleation in benign ovarian cysts.

OBJECTIVE: To compare the perioperative outcomes of three laparoscopic approaches for performing ovarian cyst enucleation. METHODS: A total of 148 patients underwent laparoscopic cyst enucleation at the CHA Gangnam Medical Center between September 2010 and May 2011. We reviewed retrospectively the medical records including patient demographics, operative outcomes and complications. RESULTS: We assigned the 148 patients into three groups: single-port (group A: 40), 2-port (group B: 30) and 4-port (group C: 78). There were no statistically significant differences in patient characteristics. The operation times were 90.4 ± 43.6, 74.7 ± 22.0 and 63.8 ± 30.5 min, and the estimated blood loss was 179.3 ± 253.9, 73 ± 75.2 and 89.9 ± 106.7 ml, respectively. Mean operation time was longer (p < 0.001) and estimated blood loss was higher (p = 0.005) in group A than in the other groups. There was no statistical difference in perioperative complications among the three groups. In group A, additional port insertion rate was higher than in groups B and C (p < 0.001). CONCLUSION: Single-port surgery required longer operation time, had a higher estimated blood loss and used additional ports more frequently during the operation than the other groups. However, 2-port surgery had no significant differences from 4-port surgery in the surgical outcomes. Therefore, 2-port surgery can be an alternative surgical option for 4-port surgery in ovarian cyst enucleation.

Single-port access total laparoscopic hysterectomy for large uterus.

BACKGROUND/AIMS: To evaluate the feasibility and safety of single-port access total laparoscopic hysterectomy (SPA-TLH) for large uterus (>500 g). METHODS: A prospective data collection was performed in 21 consecutive patients in March 2010 and August 2011. Surgical outcome including operative time (OT) and estimated blood loss (EBL) were analyzed. RESULTS: SPA-TLH procedures were successfully performed in 16 cases (76.2%). Of the 5 failed cases, 4 were converted to multiport TLH because of distorted uterine contours and pelvic adhesions and 1 was converted to laparotomy for bleeding control. The median OT, uterine weight, and EBL were 110 (65-165) min, 600 (502-980) g, and 200 (100-800) ml, respectively. Spearman's correlation analysis demonstrated that OT and blood loss increased with increasing uterine weight (p = 0.003 and p = 0.033, respectively). No operative complications were observed during the hospital stay and 3-month follow-up following discharge. CONCLUSION: SPA-TLH for large uterus is a feasible and safe technique.