Guideline for gynecological practice in Japan: Japan Society of Obstetrics and Gynecology and Japan Association of Obstetricians and Gynecologists 2023 edition.

Twelve years after the first edition of The Guideline for Gynecological Practice, which was jointly edited by The Japan Society of Obstetrics and Gynecology and The Japan Association of Obstetricians and Gynecologists, the 5th Revised Edition was published in 2023. The 2023 Guidelines includes 5 additional clinical questions (CQs), which brings the total to 103 CQ (12 on infectious disease, 30 on oncology and benign tumors, 29 on endocrinology and infertility and 32 on healthcare for women). Currently, a consensus has been reached on the Guidelines, and therefore, the objective of this report is to present the general policies regarding diagnostic and treatment methods used in standard gynecological outpatient care that are considered appropriate. At the end of each answer, the corresponding Recommendation Level (A, B, C) is indicated.

Incidence of Postoperative Adhesions after Laparoscopic Myomectomy with Barbed Suture.

AIM: The aim of the study was to assess the incidence of postoperative adhesion by baseball running suture using barbed suture (BS) in laparoscopic myomectomy in comparison with sutures using an absorbable thread. METHODS: Two hundred fifteen patients who underwent second-look laparoscopy (SLL) 6 months after laparoscopic myomectomy at our hospital between 2010 and 2014 were retrospectively reviewed. The incidence, numbers, types, and extent of adhesions were evaluated according to the more comprehensive adhesion scoring method. Propensity score matching (PS) (1:1) between the groups was performed by using the diameter of the largest myoma, the number of enucleated myomas, and the type of adhesion barrier. RESULTS: Running baseball sutures and running sutures were applied to 28 and 187 patients with unidirectional BS and absorbable thread, respectively, to close the incised serosal wounds enucleating largest myomas during laparoscopic myomectomy. After PS matching for the patients, surgical findings and the incidence of postoperative wound adhesions were compared between the groups, including 22 patients each. The surgical findings were similar between the groups, except for the total surgical duration and blood loss (medians), which were significantly shorter and lower in the BS group than in the absorbable thread group (70 vs. 100 min; p = 0.01, 50 vs. 100 mL; p = 0.02). Regarding findings of SLL, no significant differences in the incidence of postoperative wound adhesions were found between the groups (BS, 4/22 [18.2%] versus absorbable thread, 8/22 [36.4%]; p = 0.31). CONCLUSION: Our data indicated that the incidence of postoperative adhesion following the use of BS for wound closure in laparoscopic myomectomy was similar to that following the use of conventional suture.

Comparison of effect of preoperative dienogest and gonadotropin-releasing hormone agonist administration on laparoscopic cystectomy for ovarian endometriomas.

PURPOSE: To compare the effects of preoperative dienogest (DNG) and gonadotropin-releasing hormone (GnRH) agonist administration on the improvement of preoperative symptoms and surgical outcomes in patients who underwent laparoscopic cystectomy for ovarian endometriomas. METHODS: Seventy patients who were scheduled for laparoscopic surgery were enrolled in the study. They were divided into two groups: 35 patients who received DNG for 4 months preoperatively (group D) and 35 patients who received low-dose sustained-release goserelin acetate for 4 months preoperatively (group G). Preoperative outcomes, including pain score associated with endometriosis, using the numerical rating scale (NRS), adverse events of hormonal therapy and Kupperman index (KI) before and after treatment, surgical outcomes including total surgical duration and blood loss, and postoperative recurrence of endometrioma were compared between the two groups. RESULTS: Regarding preoperative symptoms, NRS and KI at 4 months after preoperative hormonal therapy were significantly lower in group D than in group G (NRS, 5.3 ± 5.5 vs. 2.7 ± 3.9; P = 0.01; KI, 16.0 ± 11.0 vs. 9.2 ± 7.6; P = 0.006). Regarding adverse events, the incidence of hot flashes was significantly lower in group D than in group G (P < 0.001). Meanwhile, the incidence of breast pain and metrorrhagia was significantly higher in group D than in group G (P = 0.04 and P < 0.001, respectively). The total surgical duration and blood loss were not significantly different between the groups. At 12 months after surgery, ovarian endometrioma did not recur in either group. CONCLUSION: Preoperative administration of DNG is more valuable for patients with endometriosis and scheduled for laparoscopic surgery to improve symptoms with good efficacy and tolerability than the administration of GnRH agonist.

A nationwide survey on gynecologic endoscopic surgery in Japan, 2014-2016.

AIM: Since 2014, Japan Society of Gynecologic and Obstetric Endoscopy and minimally invasive therapy (JSGOE) conducted a nationwide survey on gynecologic endoscopic surgery. We aimed to evaluate the current status and complications associated with endoscopic surgery by Japan gynecologic and obstetric endoscopy-database registry system (JOE-D). METHODS: Electrical medical records concerning the endoscopic surgery were generated from the daily use of reporting system. The subjects were all patients who underwent gynecologic endoscopic surgery. In addition to assessment of actual numbers, diagnosis, and operative methods, adverse events were registered. RESULTS: Total 203 970 patients performed laparoscopic, hysteroscopic and falloposcopic surgery for 3 years, 2014-2016. The numbers of endoscopic surgeries conducted in 2016 were increased more than 67 000, 13 000 or 450 cases, respectively. Incidence rates of complications involving these three types of surgeries in each year were approximately 3.1%. Incidences of intraoperative complications were relatively high in malignant diseases, laparoscopic-assisted vaginal hysterectomy (LAVH) and myomectomy (LAM). In total laparoscopic hysterectomy/laparoscopic hysterectomy (TLH/LH) performed from 2014 to 2016, ureteral injury as intra and postoperative complication occurred in 0.35%. In the past 3 years, the rates of vascular injury, urinary tract, and bowel injury as intraoperative complications caused by laparoscopic surgery were approximately 0.1%. In the hysteroscopic surgery, the rates of total intra- and postoperative complications were 0.78%. CONCLUSION: We exhibited the current status by the nationwide survey of gynecologic endoscopic surgery all over Japan. Severe intra or postoperative complications were identified over the 3 years at a rate of 0.04%.

Minimum ovarian stimulation involving combined clomiphene citrate and estradiol treatment for in vitro fertilization of Bologna-criteria poor ovarian responders.

AIM: The aim of this study was to assess the efficacy of a minimal ovarian stimulation involving combined clomiphene citrate (CC) and estradiol (E2) administration for poor responders with diminished ovarian reserve (DOR). MATERIAL AND METHODS: In this case-control study, we recruited 41 consecutive hypergonadotropic poor responders (69 cycles) who met Bologna-criteria and had experienced cancellation of oocyte retrieval. In 10 (20 cycles), 11 (21 cycles) and 20 patients (28 cycles) between 2012 and 2014, follicular development was induced using an E2 cycle, CC cycle and CC + E2 cycle, respectively. After confirmation of high follicle-stimulating hormone levels (15-40 mIU/ml) at menstrual day 3, DOR patients were treated with oral E2 of 1.0 mg/day, CC of 100 mg/day, or both CC and E2 continuously, until ovulation induction. Two days later, we transvaginally aspirated the follicles, performed in vitro fertilization, and cryopreserved the cleavage embryos. One warmed embryo was transferred into the uterus during the hormone replacement cycles. RESULTS: For the E2, CC, and CC + E2 cycles, the median patient age was 41 years in all groups, and the serum anti-Müllerian hormone levels were 0.2 ± 0.3, 0.4 ± 0.4, and 0.2 ± 0.3 ng/mL, respectively (P = 0.258); follicular development failure rates were 50.0%, 19.0%, and 3.6%, respectively (P < 0.001); numbers of retrieved oocytes (/cycle) were 0.5 ± 0.6, 0.8 ± 0.7, and 1.2 ± 1.1, respectively (P = 0.033); and clinical pregnancy rates (/cycle) were 5.0%, 4.8%, and 10.7%, respectively (P = 0.725). CONCLUSION: CC + E2 administration for the patients with DOR was effective with a lower cancellation rate of oocyte retrieval and a higher number of retrieved oocytes.

Long unidirectional barbed suturing technique with extracorporeal traction in laparoscopic myomectomy.

BACKGROUND: Myomectomy is now often performed laparoscopically rather than by laparotomy to alleviate the risk of postoperative adhesions and reduce postoperative pain. However, intracorporeal knot-tying under direct laparoscopy is difficult and requires proficiency. We conducted a retrospective study comparing the results of a long unidirectional barbed suturing technique (with V-Loc180 suture) and the results of conventional suturing as applied to laparoscopic myomectomy. METHODS: In women who underwent laparoscopic myomectomy in our university hospital between January 2011 and April 2013, uninterrupted suturing of 2 or more layers was performed. These women were divided into 2 groups according to the method of suturing: those in whom standard absorbable sutures were used (group P, n =42) and those in whom our suturing technique was used (group V, n =41). Patient characteristics and surgical variables were compared between the 2 groups. RESULTS: No significant between-group difference was observed in age (p = .975), body mass index (p = .778), GnRHa administration (p = .059), intraoperative vasopressin dose (p = .364), intraoperative blood loss (73.8 ± 64.1 vs. 59.3 ± 54.0 mL, respectively; p = .199), myoma mass (212.6 ± 133.3 vs. 208.3 ± 198.4 g, respectively; p = .134), ΔHb (p = .517), or postoperative hospital stay (p = .314). Operation time (mean ± SD) was significantly shorter for group V (71.2 ± 22.9 minutes; range, 28.0-110.0 minutes; p < .001) than for group P (94.4 ± 27.2 minutes; range, 53.0-165.0 minutes). No patient required intraoperative transfusion or conversion to laparotomy. CONCLUSIONS: Our suturing technique exploits the features of unidirectional barbed sutures and can be used in the same way as the conventional method when performing continuous suturing for laparoscopic myomectomy. Our data suggest that operation time can be reduced by as much as 25% with this new technique.

The effectiveness of relugolix compared with leuprorelin for preoperative therapy before laparoscopic myomectomy in premenopausal women, diagnosed with uterine fibroids: protocol for a randomized controlled study (MyLacR study).

BACKGROUND: The oral gonadotropin-releasing hormone antagonist relugolix, which temporarily stops menstruation, is used to treat heavy menstrual bleeding, pelvic pressure, and low back pain in women with uterine fibroids. Treatment can also help women recover from low hemoglobin levels and possibly shrink the fibroids. However, evidence of preoperative use of relugolix before laparoscopic myomectomy is limited. Nevertheless, the treatment could reduce interoperative blood loss, decrease the risk of developing postoperative anemia, and shorten the operative time. Thus, we aim to test whether 12-week preoperative treatment with relugolix (40 mg orally, once daily) is similar to or not worse than leuprorelin (one injection every 4 weeks) to reduce intraoperative blood loss. METHODS: Efficacy and safety of preoperative administration of drugs will be studied in a multi-center, randomized, open-label, parallel-group, noninferiority trial enrolling premenopausal women ≥ 20 years of age, diagnosed with uterine fibroids and scheduled for laparoscopic myomectomy. Participants (n = 80) will be recruited in the clinical setting of participating institutions. The minimization method (predefined factors: presence or absence of fibroids ≥ 9 cm and the International Federation of Gynecology and Obstetrics [FIGO] type 1-5 fibroids) with randomization is used in a 1:1 allocation. Relugolix is a 40-mg oral tablet taken once a day before a meal, for 12 weeks, up to the day before surgery. Leuprorelin is a 1.88 mg, or 3.75 mg subcutaneous injection, given in three 4-week intervals during patient visits before the surgery. For the primary outcome measure of intraoperative bleeding, the blood flow is collected from the body cavity, surgical sponges, and collection bag and measured in milliliters. Secondary outcome measures are hemoglobin levels, myoma size, other surgical outcomes, and quality-of-life questionnaire responses (Kupperman Konenki Shogai Index and Uterine Fibroid Symptoms-Quality of Life). DISCUSSION: Real-world evidence will be collected in a clinical setting to use pre-treatment with an oral gonadotropin-releasing hormone antagonist to reduce intraoperative bleeding in women who undergo laparoscopic myomectomy. TRIAL REGISTRATION: jRCTs031210564 was registered on 19 January 2022 in the Japan Registry of Clinical Trials ( https://jrct.niph.go.jp ).

NT, NPY and PGP 9.5 presence in myomeytrium and in fibroid pseudocapsule and their possible impact on muscular physiology.

The uterine myoma pseudocapsule is a neurovascular bundle surrounding fibroid, containing neuropeptides, probably involved in uterine scar healing. We studied neurotensin (NT), neuropeptide tyrosine (NPY), and protein gene product 9.5 (PGP 9.5) nerve fibres in the pseudocapsule neurovascular bundle of intramural uterine fibroids on 67 no pregnant women by intracapsular myomectomy sparing the neurovascular bundle, sampling full thickness specimens of the pseudocapsule of uterine fibroids (PUF) and normal myometrium (NM) obtained from the fundus uteri (FU) and the uterine body (UB). The samples were sent for histological and immunofluorescent analyses and compared by morphometrical quantification. The Conventional Unit (C.U.) difference of NT, NPY, and PGP 9.5 nerve fibres was statistically analyzed. Our results showed that NT, NPY, and PGP 9.5 neurofibers are almost equally present in PUF as in NM of a no pregnant uterus. As all of these neuropeptides are present in the uterine muscle and can affect muscle contractility, uterine peristalsis and muscular healing. A myomectomy respecting the pseudocapsule neurofibers should facilitate smooth muscle scarring and promote restoration of normal uterine peristalsis with a possible positive influence on fertility.

The opioid neuropeptides in uterine fibroid pseudocapsules: a putative association with cervical integrity in human reproduction.

The myoma pseudocapsule (MP) is a fibro-vascular network rich of neurotransmitters, as a neurovascular bundle, surrounding fibroid and separating myoma from myometrium. We investigated the distribution of the opioid neuropeptides, as enkephalin (ENK) and oxytocin (OXT), in the nerve fibers within MP and their possible influence in human reproduction in 57 women. An histological and immunofluorescent staining of OXT and ENK was performed on nerve fibers of MP samples from the fundus, corpus and isthmian-cervical regions, with a successive morphometric quantification of OXT and ENK. None of the nerve fibers in the uterine fundus and corpus MPs contained ENK and the nerve fibers in the isthmian-cervical region demonstrated an ENK value of up to 94 ± 0.7 CU. A comparatively lower number of OXT-positive nerve fibers were found in the fundal MP (6.3 ± 0.8 CU). OXT-positive nerve fibers with OXT were marginally increased in corporal MP (15.0 ± 1.4 CU) and were substantially higher in the isthmian-cervical region MP (72.1 ± 5.1 CU) (p < 0.01). The distribution of OXY neurofibers showed a slight into the uterine corpus, while are highly present into the cervico-isthmic area, with influence on reproductive system and sexual disorders manifesting after surgical procedures on the cervix.

Oophorectomy for fertility preservation via reduced-port laparoscopic surgery.

BACKGROUND: For fertility preservation of women patients scheduled to undergo chemotherapy or radiotherapy, unilateral oophorectomy was performed, and the ovary was cryopreserved. METHODS: Two-port surgery was conducted in 3 patients, and single-port surgery using a single-incision laparoscopic surgery port in 3. An 18-G Cathelin needle equipped with a syringe was directly inserted transabdominally to reach the small follicle on the ovarian surface; then, follicular fluid was recovered by aspiration through the syringe as with in vitro fertilization procedures, and immature oocytes were collected from the resulting culture medium under microscopy and cryopreserved. Vitrification of the ovarian tissue was performed using the cryotissue method. RESULTS: The operative time and estimated blood loss were 39.7 minutes (17-57) and 8.6 mL (2-20), and the numbers of ovarian cortical tissues and immature oocytes collected were 10.1 (5.5-15) and 16.3 (0-36), respectively. CONCLUSIONS: It is suggested that fertility preservation operations before chemotherapy or radiotherapy can be safely done using reduced-port surgery.

Single-incision laparoscopic surgery using an articulating monopolar for juvenile cystic adenomyoma.

We demonstrate the feasibility of single-incision laparoscopic surgery (SILS) by using a novel monopolar cautery and a technique based on conventional multiport laparoscopic surgery in a patient with Juvenile cystic adenomyoma (JCA). A 20-year-old woman with severe dysmenorrhea, and a 3-cm uterine lesion was diagnosed with JCA. 70 cm of absorbable string tied to the tumor parenchyma was used to extract the tumor. The ends of the strings were positioned extracorporeally and the intra-abdominal parts of the strings adjacent to the anchored tumor were grasped by a laparoscopic needle holder for clarifying the incision line surrounding the tumor. The lesion was completely excised using a single-use articulating hook with monopolar cautery, and the hysterotomy site was sutured using barbed string. No complications occurred intraoperatively, and dysmenorrhea had significantly improved three months after surgery. SILS for JCA is a feasible and minimally invasive surgery for women desiring esthetic benefit.

Association between uterine repair at laparoscopic myomectomy and postoperative adhesions.

OBJECTIVE: To determine whether uterine repair at laparoscopic myomectomy influences postoperative adhesions. DESIGN: Retrospective study. SETTING: University-affiliated hospital. POPULATION: A total of 108 patients who underwent second-look laparoscopy after laparoscopic myomectomy without concomitant pelvic surgery between January 2006 and May 2010. METHODS: Absorbable cellulose adhesion barriers were used for uterine repair at initial surgery in all women. The presence of adhesions was evaluated by second-look laparoscopy. MAIN OUTCOME MEASURES: The influence of background factors (diameter of largest myoma, number of myomas, incision sites and number of suture layers) and the uterine status immediately after uterine repair at laparoscopic myomectomy (number, length and location of wounds, as well as wound appearance classified as virtually normal, swollen or protruding) on adhesion formation were analysed in 108 women with 296 uterine wounds. Data were analysed by logistic regression analysis. RESULTS: Forty-one (38.0%) women had adhesions to their uterus at follow up. We identified 48 (16.2%) adhesions among 296 wounds in all women. A protruding wound was significantly associated with postoperative wound adhesion (odds ratio, 2.53; p=0.02). The number of enucleated subserosal myomas (odds ratio, 3.29; p<0.001) and the diameter of the largest myoma (odds ratio, 1.05; p<0.001) were significantly associated with wound protrusion, which was a critical factor influencing adhesion. CONCLUSIONS: Postoperative wound adhesion formation seems to depend on uterine status immediately after laparoscopic myomectomy.

Histological assessment of impact of ovarian endometrioma and laparoscopic cystectomy on ovarian reserve.

AIM: The rate of oocyte decline follows a biphasic pattern, characterized by acceleration between 32 and 38 years old. Ovarian reserve is also affected by external factors, including ovarian disease and iatrogenic damage. The aim of this study was to histologically evaluate the impact of ovarian endometriomas, laparoscopic cystectomy, and age on follicle reserve in healthy ovarian tissues and in surgically resected cyst walls. MATERIAL AND METHODS: Sixty-one patients were found to have ovarian endometriomas and 42 patients non-endometriotic cysts. A small amount of normal ovarian tissue was obtained during ovarian cystectomy. The follicles in normal ovarian tissue and resected cyst walls were histologically evaluated. RESULTS: The density of follicles in ovarian tissues correlated with the age of the patients in both groups. In women aged <35 years, the relative density of follicles in healthy ovarian tissues was consistently lower in the endometriotic cyst group compared to the non-endometriotic cyst group, with the relative ratio at age 20, 30 and 35 years calculated to be 35.4%, 46.8% and 62.7%, respectively. There was no significant difference between the groups in patients over the age of 35. The resection rate of normal ovarian tissue in cystectomy specimen of the endometriosis group was significantly higher than in the non-endometriotic cyst group (P < 0.001). CONCLUSIONS: Our data suggest that ovarian endometriomas have a detrimental impact on follicle reserve in younger patients. Further, laparoscopic cystectomy for endometriomas may accelerate the rate of oocyte loss associated with aging.

Retrospective analysis of the efficacy of perioperative use of the cell salvage and autologous blood recovery system during laparoscopic myomectomy.

PURPOSE: To evaluate the benefit of the intraoperative use of a cell salvage and autologous blood recovery system during laparoscopic myomectomy (LM). METHODS: We retrospectively reviewed the medical records of 538 patients who underwent LM between January 2008 and December 2009 at our hospital. Patients undergoing LM were divided into two groups depending on whether the cell salvage and autologous blood recovery system was used; the use of the system was at the discretion of the surgeon. The system for intraoperative hemorrhage was employed based on the surgeon's decision. RESULTS: Of the 583 patients, 23 patients (4.3%) underwent LM using the system. No patient required an allogeneic blood transfusion during or after the surgery. The median surgical time (183 vs. 100 m), total blood loss (520 vs. 100 mL), total weight of enucleated myomas (390 vs. 175 g), and postoperative calculated δ-Hemoglobin (δ-Hb) (2 vs. 1.6 g/dL) were significantly increased in the 23 patients in whom the system was used. The median autologous blood volume recovered by intraoperative use of the system and transferred to the 23 patients was 250 mL (range 125-800 mL). For patients in whom the system was not used, the total blood loss significantly correlated to δ-Hb (r = 0.29; P < 0.01). However, there was no such correlation in patients in whom the system was not used (r = 0.04; P = 0.86). CONCLUSIONS: The adoption of a cell salvage and autologous blood recovery system during LM was useful for patients with severe hemorrhage.

Learning curve of minimally invasive two-port laparoscopic myomectomy.

UNLABELLED: BACKGROUND AND OBJECTS: To examine the learning curve of minimally invasive 2-port total laparoscopic myomectomy (TTLM). METHODS: TTLM was performed by using only umbilicus and left inguinal ports, for 30 patients at our university affiliated hospital between May 2009 and February 2010. The times required for each of the 5 surgical phases of the early and late cases performed by the same surgeon were compared by using a DVD time counter. RESULTS: The mean surgical time was 82.5±5.2 minutes, blood loss was 42.1±7.5mL, and weight of specimen was 65.3±13.3g. The eighth case was the first in which the surgical time fell below the overall mean surgical time. Comparison of the mean time of each phase between the 7 early and the subsequent (late) cases revealed significant differences in the times required for suturing. CONCLUSIONS: Although this was a feasibility study, the results suggest that this technique can be mastered after 7 cases. Learning curve, Suturing.

Use of magnetic resonance analysis for clinical evaluation of the peripheral area of gestational sac in bleeding and non-bleeding ectopic pregnancy cases.

PURPOSE: To evaluate preoperative magnetic resonance (MR) imaging features of bleeding and non-bleeding ectopic pregnancy (EP) by comparison with surgical findings. METHODS: Eighteen suspected EP cases underwent preoperative MR imaging. We classified 8 cases as the bleeding group and 7 cases as the non-bleeding group with or without intra-abdominal bleeding and/or hematoma at the site of EP, and compared, retrospectively, gestational sac (GS)-like structure, particularly the peripheral area of the GS via MR analysis. Excluded were 3 cases that were insufficient for assessing extrauterine GS-like structure: ruptured tubal pregnancy and uterine horn pregnancy. RESULTS: GS-like structures were typically observed as low intensity on T1-weighted image (T1WI) and as high intensity on T2-weighted image (T2WI). In non-bleeding cases, most peripheral areas of the GS were of intermediate intensity on T1WI and high intensity on T2WI. Most bleeding cases were of high intensity on T1WI and low to high intensity on T2WI. Furthermore, the peripheral area of the GS was of higher intensity on T1WI with fat suppression than on T1WI. CONCLUSIONS: It is clear that MR imaging is effective for diagnosis of cases of suspected EP. EP conditions may be predicted by signal intensity of the peripheral area of the GS via MR analysis.

Pyomyoma mimicking tubo-ovarian abscess: Two case reports.

Pyomyoma is an extremely rare complication, defined as an infection of a uterine leiomyoma. We describe two cases of pyomyoma that were initially considered to be tubo-ovarian abscesses but were later diagnosed as pyomyomas and managed with laparoscopic surgery. Case 1 was a 26-year-old nulliparous woman who was previously diagnosed with bilateral endometriomas and presented to the hospital with lower abdominal pain. Magnetic resonance imaging revealed bilateral endometrial cysts and a 4-cm mass consistent with a tubo-ovarian abscess. The patient experienced continuous pain, and the cyst in the left adnexa enlarged; thus, laparoscopic surgery was performed. The cystic tumor in her uterus contained purulent fluid. Therefore, an abscess in the degenerative subserous myoma was diagnosed. Case 2 was a 47-year-old nulliparous woman who had undergone total mastectomy and postoperative radiotherapy for breast cancer. She was undergoing hormone therapy when she presented to the hospital with lower abdominal pain, fever, and increased inflammatory markers. Computed tomography revealed a 7-cm tumor with rim enhancement in her left adnexa; therefore, a tubo-ovarian abscess was suspected. After admission, drainage was performed under transvaginal ultrasound guidance, and antibiotics were administered. However, these treatments did not relieve her abdominal pain. Emergency laparoscopic surgery was performed, and intraoperative findings demonstrated an abscess in the degenerative subserous myoma of the uterus with normal adnexa. Laparoscopic hysterectomy and bilateral salpingectomy were performed. Laparoscopic surgery was effective for both patients. Delayed diagnosis of pyomyoma can result in serious complications. Timely surgery with concomitant antibiotic treatment may facilitate good outcomes.

Utility of an organ retraction sponge (endoractor) in gynecologic laparoscopic surgery.

Because it is minimally invasive, laparoscopic surgery is preferred over open surgery. However, it is often difficult to maintain an adequate surgical field during the procedure. As in open laparotomy, securing an adequate surgical field is important for adequate visualization. We evaluated the effectiveness and safety of the Endoractor, an organ retraction sponge that can be inserted through a 12-mm trocar to secure a surgical field in gynecologic laparoscopic surgery. The Endoractor, a 100% cellulose compressed sponge, can be expanded using physiologic saline solution, with the result that the swollen sponge displaces organs away from the surgical field. Between October 2009 and April 2010, we used the Endoractor in 24 patients, placed in a Trendelenberg position, during laparoscopic surgery. In no patients, even with return to a horizontal position, did the intestines fall into the pelvis, and surgery was easily performed. Mean (SD; 95% CI) operative time was 92.7 (44.5; 74.0-111.6) minutes, and blood loss was 54.1 (73.1; 22.9-82.1) mL. All patients were discharged on postoperative day 3. Even with the patient in a horizontal position without use of the Trendelenberg position, the Endoractor enables a good surgical field to be secured. It remains to be seen whether this device works as well in obese patients.

Histopathologic analysis of intestinal endometriosis after laparoscopic low anterior resection.

STUDY OBJECTIVE: To determine how intestinal endometriosis spreads, and, thus, to improve outcomes of curative surgery. DESIGN: Descriptive study (Canadian Task Force classification II-2). SETTING: University hospital. PATIENTS: Ten patients who underwent laparoscopic low anterior resection of intestinal endometriosis at our hospital between January 1999 and August 2007. INTERVENTION: Laparoscopic low anterior resection of intestinal endometriosis. MEASUREMENTS AND MAIN RESULTS: Mapping of endometriotic foci, degree of vertical infiltration to the intestinal layers, and longitudinal spread of endometriotic foci to the intestinal plane were defined using hematoxylin-eosin, estrogen receptor, progesterone receptor, and CD10 staining. RESULTS: Endometriotic foci tended to spread concentrically around a primary lesion that comprised most of a resected specimen. The deepest layer containing endometriotic foci at the primary lesion was the submucosal layer in 7 specimens (70%), and the internal circular muscle layer in 3 (30%). Satellite lesions comprising thickened areas that were independent of the primary lesion were detected in 5 specimens (50%). Multiple endometriotic foci were confirmed in all satellite lesions. CONCLUSIONS: Endometriotic foci might not only infiltrate the primary lesion in intestinal endometriosis but also disseminate to other areas. Thus, the primary lesion of intestinal endometriosis with a large margin must be excised via low anterior resection.

Alterations in endometrial vascular density via hysteroscopy evaluated by vascular analysis software during laparoscopic myomectomy on an infertile woman with submucous myoma.

Submucous myomas cause infertility and recurrent pregnancy loss. Several studies have reported successful reproductive outcomes after hysteroscopic myomectomy (HM), but the risk of postoperative intrauterine adhesion is present. We performed laparoscopic myomectomy (LM) for a submucous myoma and second look laparoscopy under observation using a hysteroscope to evaluate the alteration in endometrial vascular density during surgery using vascular analysis software. The patient was a 33-year-old nulliparous infertile woman. She had one submucous myoma of 4 cm in diameter and 50-60% penetration into the myometrium (class T:II; the European Society of Hysteroscopy classification). The surface vascular density of the submucous myoma was 68.6% before the start of surgery, decreased to 51.4% upon vasopressin injection and increased to 67.6% at the end of LM. Intraabdominal and intrauterine adhesions were not seen at second look laparoscopy. The vascular density was 70.8%, and the rate of endometrial blood flow was increased to 112.5% by comparison with the vascular density before the start of surgery. HM is a safe and effective procedure, but carries the risk of scarring the uterine cavity with uterine adhesions. We have to consider LM for women of reproductive age who have a submucous myoma with penetration >50% into the myometrium (class T:II).