Quality of life and the prevalence of urinary incontinence after surgical treatment for gynecologic cancer: a questionnaire survey.

BACKGROUND: Although there have been a number of reports on urinary voiding symptoms associated with surgical interventions for gynecologic cancer and post-voiding symptoms, there have been few reports on urinary storage symptoms such as urinary incontinence (UI) and overactive bladder (OAB). The purpose of this study was to examine the rates and impact on quality of life (QOL) of urinary storage symptoms after gynecologic cancer surgery. METHODS: A questionnaire survey, including Japanese-language versions of the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), Overactive Bladder Symptom Score (OABSS), and Incontinence Impact Questionnaire-7 (IIQ-7), was distributed to gynecologic cancer patients who underwent hysterectomy between 2008 and 2013. RESULTS: Of the 145 patients analyzed, 49 (33.8%) had UI pre-surgery, and 76 (52.4%) had UI post-surgery, including 34 (35.4%) first-time UI patients, with a significant difference between pre- and post-surgery. Of the 49 subjects with UI pre-surgery, 43 (87.7%) had stress incontinence, while of the 76 patients with UI post-surgery, 44 (57.1%) had stress incontinence, and 24 (31.2%) had mixed incontinence. Seven (4.8%) subjects had OAB pre-surgery, whereas 19 (13.1%) had OAB symptoms post-surgery (including 15 first-time OAB patients), with a significant difference between pre- and post-surgery. IIQ-7 scores were markedly higher for patients with mixed incontinence post-surgery than for those with stress incontinence, indicating a lower QOL. Logistic regression analysis identified the number of Cesarean sections and days of urinary bladder catheterization as risk factors for postoperative UI. CONCLUSIONS: UI and OAB rates were higher after gynecologic cancer surgery than in the general female population. The mixed incontinence rate was markedly higher post-surgery; QOL was low for such patients due to the combination of urge and stress incontinence. Multiple Cesarean sections and urinary bladder catheterization post-surgery were risk factors for post-surgical UI.

Analysis of risk factors of postlaparoscopic shoulder pain.

AIM: Postlaparoscopic shoulder pain (SP), mainly caused by pneumoperitoneum with CO2 , sometimes suffers patients. This study was aimed to analyze the backgrounds of SP after gynecologic laparoscopy to clarify the risk of SP. METHODS: We analyzed answers of questionnaire about the degree of SP from 696 patients undergoing gynecologic laparoscopic surgery since 2014-2018. The questionnaire asks the degree of SP with numeric rating scale from 0 to 10, before and 3 days after operation. We defined cases in which postoperative score elevated more than three compared to preoperative score as SP(+). Analyzed backgrounds were age, parity, body mass index, operative method, operative duration and amount of hemorrhage. Statistics was performed by Fisher exact analysis as univariate analysis, and with logistic regression as multivariate analysis. All laparoscopic surgeries were performed under 10-12 mmHg in pressure of pneumoperitoneum with CO2 . RESULTS: Univariate analysis revealed categories 'less than 50 years old', and 'over 2 h' and 'over 3 h' in operative duration resulted significant high rate of SP(+). For these three factors, multivariate analysis resulted that "less than 50 years old' and 'over 3 h in operative duration' were significantly high. CONCLUSION: This study suggests that 'less than 50 years' old and 'over 3 h in operative duration' were risk factors of postlaparoscopic SP. To protect from SP after laparoscopy, some countermeasures should be necessary especially for these patients.

Complications Related to the Initial Trocar Insertion of 3 Different Techniques: A Systematic Review and Meta-analysis.

This systematic review aimed to investigate complications related to initial trocar insertion among 3 different laparoscopic techniques: Veress needle (VN) entry, direct trocar entry (DTE), and open entry (OE). A literature search was completed, and complications were assessed. Major vessel injury, gastrointestinal injury, and solid organ injury were defined as major complications. Minor complications were defined as subcutaneous emphysema, extraperitoneal insufflation, omental emphysema, trocar site bleeding, and trocar site infection. Arm-based network meta-analyses were performed to identify the differences in complications among the 3 techniques. Seventeen studies were included in the quantitative analysis. DTE resulted in fewer major complications when compared with VN entry although the difference was not significant (p = .23) as well as significantly fewer minor complications (p < .001). There were no significant differences in minor complications when comparing OE and DTE (p = .74). Fewer major complications were observed with OE compared with VN entry although the difference was not significant (p = .31). There were significantly fewer minor complications for patients who underwent OE (p = .01). DTE patients experienced the least number of minor complications followed by VN entry and OE. In conclusion, major complications are extremely rare, and all 3 insertion methods can be performed without mortality.

Recovery of quality of life after laparoscopic myomectomy.

AIM: It is commonly thought that laparoscopic surgery leads to faster postoperative recovery for its low invasiveness. We evaluated postoperative quality of life (QOL) after laparoscopic myomectomy (LM) by using the Euro-QOL 5 dimension (EQ-5D) score and analyzed its relationship to surgical factors. METHODS: Between 2014 and 2016, 541 patients underwent LM at our institution. We included 86 patients in the final analysis (16% response rate) who replied to the EQ-5D questionnaire, in order to investigate postoperative QOL. We evaluated patients' EQ-5D score before the operation and on the 3rd, 7th, 14th, 21st and 28th postoperative day (POD). We investigated the degree of correlation between the EQ-5D score and four surgical characteristics (operation time, intraoperative bleeding, number of resected myomas and weight of specimen). We examined correlation between EQ-5D scores and chief complaints such as hypermenorrhea, dysmenorrhea, other pain, myoma enlargement, palpable tumor and desire for childbearing. We also examined correlation between EQ-5D scores and other factors such as patient's age, infertility, history of abdominal surgery, marriage and body mass index. RESULTS: Full recovery, defined as an EQ-5D score of 1.0, was reported 2.3% of patients by POD3, 18.6% by POD7, 58.1% by POD14, 73.3% by POD21 and 86.0% by POD28. Longer duration of operation correlated weakly with poor recovery on POD3. Intraoperative bleeding, number of resected myomas and weight of the specimen did not significantly influence EQ-5D score. There was no correlation between chief complaints or other factors mentioned above and EQ-5D score. CONCLUSIONS: More than a half of the patients undergoing LM included in our study reported full recovery of QOL after 2 weeks. The time to recover QOL was slightly influenced by the operation time. However, when LM was finished without any complications, postoperative QOL eventually seemed to improve regardless of the surgical characteristics such as operation time, intraoperative bleeding, number of resected myomas and weight of specimen.

Magnetic Resonance Imaging Grading System for Preoperative Diagnosis of Leiomyomas and Uterine Smooth Muscle Tumors.

STUDY OBJECTIVE: To evaluate a new magnetic resonance imaging (MRI) grading system for preoperative differentiation between benign and variant-type uterine leiomyomas including smooth muscle tumors of uncertain malignant potential (STUMPs). DESIGN: Retrospective analysis (Canadian Task Force classification III). SETTING: Teaching hospital (Teine Keijinkai Hospital). PATIENTS: Three-hundred thirteen patient medical records were retrospectively reviewed if treated for uterine myomas and diagnosed with variant type leiomyomas or STUMPs (n = 27) or benign, typical leiomyomas (n = 286) and treated between January 2012 and December 2014. INTERVENTION: Uterine myoma classifications using MRI findings according to a 5-grade system (grades I-V) based on 3 elements. MEASUREMENTS AND MAIN RESULTS: Uterine myoma MRI classifications were based on 3 elements: T2-weighted imaging (high or low), diffusion-weighted imaging (high or low), and apparent diffusion coefficient values (high or low; apparent diffusion coefficient < 1.5 × 10-3 mm2/sec was considered low). Grades I to II were designated as typical or benign leiomyomas, grade III as degenerated leiomyomas, and grades IV to V as variant type leiomyomas or STUMPs. Accuracy levels were 98.9%, 100%, 94.3%, 58.8%, and 41.9% for grades I through V lesions, respectively. The grades were divided into 2 groups to discriminate benign leiomyomas and STUMPs (grades I-III were considered negative and grades IV-V positive). Grades IV to V scored 85.2% for sensitivity, 91.3% for specificity, 47.9% positive predictive value, 98.5% negative predictive value, a 9.745 positive likelihood ratio, and a .162 negative likelihood ratio. CONCLUSION: This novel MRI grading system for uterine myomas may be beneficial in differentiating benign leiomyomas from STUMPs or variant type leiomyomas and could be a future effective presurgical assessment tool.

Successful treatment of uterine artery pseudoaneurysm with laparoscopic temporary clamping of bilateral uterine arteries, followed by hysteroscopic surgery.

Surgical strategies for the treatment of uterine artery pseudoaneurysm (UAP) include transarterial embolization and ultrasound-guided low-dose thrombin injection. Such strategies, however, have limitations and include the risk of ischemic damage to the uterus. We report a case of UAP treated with a new hysteroscopic and laparoscopic technique. A 29-year-old G1P0 woman with spontaneous abortion was transferred to the present institution because of hemorrhagic shock. We diagnosed ruptured UAP on transvaginal ultrasound with color Doppler. Emergency laparoscopic temporary clamping of the bilateral uterine arteries was done to reduce the bleeding, and transcervical resection to stop the hemorrhaging and to collect the pseudoaneurysm tissue. After surgery, blood flow to the myometrium was monitored on ultrasound. By postoperative day 48, normal menstruation had restarted, and no intrauterine adhesions were observed. On pathology of the UAP, a dilated spiral artery without its characteristic elastic fibers was identified. This surgical approach may help preserve fertility and allow for pathological diagnosis of UAP.

Perinatal outcomes associated with the positional relationship between the placenta and the adenomyosis lesion.

INTRODUCTION: Although various perinatal complications have been reported to be increased in the pregnant patients with adenomyosis, it is not clear what type of patients with adenomyosis is more likely to cause obstetric complications. In this study, we focused on the positional relationship between the placenta and adenomyosis lesion in evaluating perinatal prognosis of pregnant patients with adenomyosis. MATERIAL AND METHODS: This retrospective cohort study was carried out between 1 January 2005 and 31 December 2019 in a single institution. Adenomyosis was diagnosed by magnetic resonance imaging (MRI) and/or transvaginal ultrasonography (TVUS). To evaluate the influence of adenomyosis on perinatal outcomes, we classified the positional relationship between the placenta and the adenomyosis lesion into two groups and examined the perinatal prognosis of the patients with adenomyosis by analyzing their clinical records. Group I (n = 9) was defined when the placenta was not overlaid on adenomyosis lesion. Group II (n = 11) was defined when a part of the placenta was overlaid on adenomyosis lesion. RESULTS: Twenty pregnant patients with adenomyosis were analyzed. There were no differences in clinical backgrounds between group I and group II. There was a significant increase in the obstetric morbidity in group II than that of Group I(group I: 6.3%, 4/63 vs group II: 18.6%, 26/77; P < 0.001). In group II, fetal growth restriction (FGR) was more frequent (0%, 0/9 vs 45.5%, 5/11; P = 0.042) and the birth weight was significantly lower than that in group I (2951.1 g ± 326.5 g vs 2318.9 ± 656.1 g; P = 0.037). There was a trend of lighter weight of the placenta in group II (550.6 ± 66.5 g vs 437.5 ± 117.8 g; P = 0.063) and the volume of bleeding during delivery was a higher trend in group II than that in group I (845.1 ± 367.1 g vs 1356 ± 604.8 g; P = 0.083). Group II was furtherly subdivided into group IIa (less than half the major axis of the placenta overlaid on adenomyosis lesion) and group IIb (more than half the major axis of placenta overlaid on adenomyosis lesion). The obstetric morbidity tended to be higher in group IIb than in group IIa (group IIa: 22.9%, 8/35 vs group IIb: 42.9%, 18/42); P = 0.09). In group IIb, the frequency of FGR was significantly higher (group IIa: 0%, 0/5 vs IIb: 83.3%, 5/6; P = 0.020) and the birth weight was significantly lower than those in group IIa (2656.8 ± 231.9 g vs 2037 ± 780.1 g; P = 0.040). All cases of FGR, hypertensive disorder of pregnancy (HDP), and oligohydramnios were observed in group IIb. CONCLUSION: Placental localization near adenomyosis may increase the risk of perinatal complications.

Combination of conservative treatment and temporary bilateral laparoscopic uterine artery clipping with hysteroscopic transcervical resection for cervical pregnancy: A retrospective study.

INTRODUCTION: We investigated whether temporary bilateral laparoscopic uterine artery clipping with hysteroscopic transcervical resection (LUA clipping-TCR) is an effective minimally invasive treatment for the management of cervical pregnancy. MATERIALS AND METHODS: This study is a retrospective clinical case series conducted at Teine Keijinkai Hospital from January 2014 to June 2019. Nine cervical pregnancies among 164 ectopic pregnancies were retrospectively examined. The intervention involved performing LUA clipping-TCR on villous tissue. Information on patient characteristics, clinical data, and surgical details was collected from medical records and surgical videos. RESULTS: The mean (range) age of the patients was 33 years (29-41 years); and mean gestational sac diameter, 12.8 mm (5-24 mm). Five patients had a history of intrauterine procedures. Three patients had a positive fetal heartbeat. The mean (range) preoperative serum hCG level (mIU/mL), surgical time (min), uterine artery blocking time (min), and amount of surgical blood loss (ml) were 14,040 (2880-41,367), 82 (62-120), 42 (21-68), and 57 (10-200), respectively. The mean decrease in serum hCG level (second postoperative day) and duration until resumption of menstruation were 79.7 % (70-86.7 %) and 46 days (35-80 days), respectively. The hospitalization period was 2-3 days, with no evidence of persistent ectopic pregnancy. Live birth was achieved in four cases. DISCUSSION: Our results confirm previous findings and provide new evidence that LUA clipping-TCR is effective for cervical pregnancy management and fertility preservation, respectively. Future large-scale prospective studies to compare different cervical pregnancy management methods are required.

Laparoscopically Diagnosed and Treated Ruptured Metastatic Ovarian Tumor.

A 51-year-old woman visited our institution with a chief complaint of abdominal pain. Blood laboratory testing revealed a carcinoembryonic antigen level of 13.4 ng/mL. Magnetic resonance imaging revealed a massive pelvic mass with marked wall thickening, partly accompanied by a high-signal-intensity cystic component in T2-weighted images. The entire tumor had low-signal intensity in T1-weighted images. We diagnosed a ruptured ovarian tumor, and the patient underwent emergent laparoscopic left salpingo-oophorectomy. Pathological examination revealed metastatic colon cancer to the ovary, and lower gastrointestinal endoscopy confirmed sigmoid colon carcinoma. Laparoscopic sigmoidectomy was performed followed by adjuvant chemotherapy with capecitabine + oxaliplatin. Ruptured metastatic ovarian tumor is extremely rare. With early diagnosis and laparoscopic resection, the primary lesion can be identified and treated quickly.

Estrogen receptor alpha polymorphism as a genetic marker for bone loss, vertebral fractures and susceptibility to estrogen.

OBJECTIVE: The purpose of the present study was to investigate the possible roles of PvuII and XbaI polymorphisms of the estrogen receptor alpha (ER(alpha)) in bone mineral density (BMD), vertebral fracture, bone loss rate after menopause and response to hormone replacement therapy (HRT). METHODS: All 286 women were grouped according to the genotypes of PvuII or XbaI polymorphisms of the ER(alpha) gene. We compared the BMD Z-score, incidence of vertebral fracture, changes in Z-score after menopause and response of BMD to HRT among the genotypes. RESULTS: Subjects with the PPxx genotype had significantly (P<0.05) lower Z-scores than did subjects with the other genotypes. A negative correlation was observed between the length of time after menopause and the decrease of the Z-score only in women with the pp genotype, suggesting faster bone loss in this group. In the analysis of the ER(alpha) polymorphism with regard to the effect of HRT on BMD, there appears to be a significantly greater increase of BMD (P<0.01 and 0.05) in women with the pp genotype than in those with the Pp or PP genotype. CONCLUSIONS: PvuII and XbaI polymorphisms of the ER(alpha) gene were associated with BMD in postmenopausal Japanese women. Also, the polymorphisms may be useful genetic markers for predicting vertebral fracture in relatively young postmenopausal women. The PvuII polymorphism may be associated with susceptibility to changes in estrogen level.

[Amenorrhea in young women].

The adolescent is an important period in which the peak bone mass is acquired. A sufficient attainment of peak bone mass is important as well as a prevention of bone loss in postmenopausal period in order to prevent osteoporosis in future. It is well known that the estrogen deficiency is at risk of developing osteopenia. Anorexia nervosa, excessive exercises, Turner's syndrome and premature ovarian failure are leading causes of prolonged amenorrhea in young women. However, estrogen deficiency is not the only cause of low bone mass in these women. Although hormone replacement therapy is effective to increase bone mineral density in these women, management of amenorrhea should be individualized according to the status of bone metabolism.

Uterine vein rupture at delivery as a delayed consequence of laparoscopic surgery for endometriosis: a case report.

Laparoscopic resection of deep infiltrating endometriosis (DIE) has been reported to be an effective method for reduction of endometriosis-associated pain. As its complications, bowel perforation, urinary tract injury and neurogenic bladder are well known; however, uterine vein rupture during pregnancy has not been reported previously. We encountered a case of hemoperitoneum resulting from uterine vein rupture at a delivery as a delayed consequence of laparoscopic resection of DIE. A 31-year-old, para 2 woman underwent laparoscopic resection of lateral pelvic peritoneum, uterosacral ligaments, and bilateral endometriomas, exposing uterine vessels, which we covered with fibrin glue. Endometriosis-associated pain disappeared, and then the patient conceived 4 months later. The course of pregnancy and induction of labor with controlled oxytocin infusion was uneventful, and the patient delivered a female baby without asphyxia. Immediately after delivery, low abdominal pain with hypotension occurred despite absence of abnormal vaginal bleeding. Ultrasonography and the blood hemoglobin value suggested hemorrhagic shock owing to hemoperitoneum; therefore emergency exploratory laparotomy was performed. Active bleeding was found at the right uterine vein, which was then sutured for hemostasis. The patient received a blood transfusion and recovered without any problems. The bleeding lesion was located at the vein on which the peritoneum had been removed at the first laparoscopy, which suggested that the operation for DIE included a risk of uterine vessel rupture during pregnancy.