Comparison of vaginal hysterectomy and laparoscopic hysterectomy: a systematic review and meta-analysis.

BACKGROUND: There are various surgical approaches of hysterectomy for benign indications. This study aimed to compare vaginal hysterectomy (VH) and laparoscopic hysterectomy (LH) with respect to their complications and operative outcomes. METHODS: We selected randomised controlled trials that compared VH with LH for benign gynaecological indications. We included studies published after January 2000 in the following databases: Medline, EMBASE, and CENTRAL (The Cochrane Library). The primary outcome was comparison of the complication rate. The secondary outcomes were comparisons of operating time, blood loss, intraoperative conversion, postoperative pain, length of hospital stay and duration of recuperation. We used Review Manager 5.3 software to perform the meta-analysis. RESULTS: Eighteen studies of 1618 patients met the inclusion criteria. The meta-analysis showed no differences in overall complications, intraoperative conversion, postoperative pain on the day of surgery and at 48 h, length of hospital stay and recuperation time between VH and LH. VH was associated with a shorter operating time and lower postoperative pain at 24 h than LH. CONCLUSIONS: When both surgical approaches are feasible, VH should remain the surgery of choice for benign hysterectomy.

Internal jugular vein thrombosis with OHSS.

Ovarian hyperstimulation syndrome (OHSS) includes ovarian enlargement and ascites. It is usually mild but can be, rarely, fatal. Deep vein thrombosis (DVT) is among the potentially fatal complications of OHSS. During pregnancy, DVT is more common in the lower extremities than in the upper part of the body, but OHSS-related DVT occurs more frequently in the upper part. Internal jugular vein thrombosis is considered rare, and duplex ultrasound is the appropriate examination for its diagnosis. We present a rare case of internal jugular vein thrombosis following OHSS. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:450-452, 2017.

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.

Triphenyl phosphate activates estrogen receptor α/NF-κB/ cyclin D1 signaling to stimulate cell cycle progression in human Ishikawa endometrial cancer cells.

OBJECTIVE: Triphenyl phosphate (TPHP) is one of the most commonly used organophosphorus flame retardants that may accumulate in the environment. However, its effects on human reproductive organs have not been well studied. We aimed to investigate the in vitro effects of TPHP in human Ishikawa endometrial cancer cells to elucidate how TPHP exposure disrupts intracellular signaling and cell proliferation in reproductive tissues. METHODS: Human Ishikawa endometrial cancer cells were exposed to TPHP. RESULTS: Exposure to TPHP elevated the levels of estrogen receptor (ER) α and progesterone receptor-B and reduced ER ß in human Ishikawa endometrial cancer cells. TPHP stimulated phosphoinositide 3-kinase/protein kinase B and mitogenactivated protein kinase/ extracellular signal-regulated kinases 1/2 kinase signaling, which may contribute to the activation of ER function and induce nuclear translocation of nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) in human Ishikawa endometrial cancer cells. Activated ER and NF-κB stimulate the expression of cyclin D1/ cyclin-dependent kinase (CDK) 4/CDK6, indicating cell cycle progression and proliferation. CONCLUSION: This report may provide new information on the molecular mechanisms underlying how TPHP exposure dysregulates the cellular physiology of the human endometrium.

Efficacy of nerve-sparing radical hysterectomy vs. conventional radical hysterectomy in early-stage cervical cancer: A systematic review and meta-analysis.

The aim of the present study was to compare the oncological outcome of nerve-sparing radical hysterectomy (NSRH) and conventional radical hysterectomy (CRH) for early-stage cervical cancer using a meta-analysis. A systematic review and meta-analysis was conducted, including 4 randomized controlled trials (RCT), 8 case-control and 11 comparative cohort studies comparing the morbidity, pelvic dysfunctions and oncological outcome between the two surgical methods. A total of 23 studies were included in this meta-analysis. The studies reported data of patients affected by cervical cancer; were written in English; included ≥20 patients; and reported data of patients with a comparison of clinical outcomes between NSRH and CRH. Data were extracted and risk of bias was assessed by four independent reviewers. A total of 1,796 patients were included: 884 patients (49.2%) undergoing NSRH and 912 (50.8%) undergoing CRH. The meta-analyses were conducted using Review Manager version 5.3 software, which is designed for conducting Cochrane reviews. As regards perioperative parameters, NSRH was found to be associated with a lower intraoperative blood loss and a shorter length of hospital stay in comparison with CRH. Patients undergoing NSRH experienced lower incidence of urinary, colorectal and sexual dysfunction compared with patients undergoing CRH. However, the resected parametrial width was favorable in patients with CRH, suggesting that NSRH was inferior to CRH in terms of radicality. The 5-year disease-free and overall survival rates were similar between the two groups. In this systematic review and meta-analysis, the collected data to date demonstrated that the nerve-sparing approach guarantees minimized surgical-related pelvic dysfunction, with similar oncological outcomes as CRH. However, further RCTs should be conducted to confirm the superiority and safety of NSRH.

Effects of letrozole on proliferation and apoptosis in cultured leiomyoma cells treated with prostaglandin E(2).

OBJECTIVE: The objective was to determine the direct effect of letrozole on the proliferation and apoptosis of cultured leiomyoma cells co-treated with prostaglandin E(2) (PGE(2)). STUDY DESIGN: Leiomyoma cells were obtained from three groups of patients who had undergone hysterectomy due to leiomyoma. Percentages of antiproliferative cells were evaluated by the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay and apoptosis was assessed with sub-G1 cell counts by flow cytometry and Western blot analysis. RESULTS: Combined treatment with 100 microM letrozole and 10 microM PGE(2) for 48 h resulted in a significantly lower viability rate (25.9+/-4.5%) and an increased cell death rate (31.6+/-4.4%) than groups treated with letrozole or PGE(2) alone. However, after adding 10nM estradiol to the combined treatment group, the cell viability rate was restored (75.1+/-7.7%) and the cell death rate was decreased (10.5+/-3.1%). Increased caspase-3 expression was found in the letrozole and PGE(2) combined treatment group, but not in the group in which estradiol was added. CONCLUSION: The present results demonstrate that letrozole inhibits growth and induces apoptosis of leiomyoma cells by blocking the aromatase up-regulated by PGE(2) treatment. These findings support the need for further investigation of aromatase inhibitors as a medical treatment option in leiomyoma.

Assessment of the effects of prostaglandins on myometrial and leiomyoma cells in vitro through microRNA profiling.

It is well known that prostaglandin (PG) E2 and PGF2α are secreted in copious amounts from the menstruating uterus. The aim of the present study was to determine whether PGs affect the growth of uterine leiomyomas (ULs) to the same extent as estrogen or progesterone (P4). The present study evaluated the expression of eight microRNAs (miRNAs) by reverse transcription­quantitative polymerase chain reaction (RT­qPCR) through treatment with estradiol (E2), P4, PGE2, PGF2α and each antagonist or cyclooxygenase­2 (COX­2) inhibitor of cultured leiomyoma and myometrial cells (LC and MC, respectively). The eight miRNAs were divided into two groups according to their primary biological action, namely apoptosis­regulating miRNAs (let­7a, miR­21, miR­26a and miR­200a) and inflammation­regulating miRNAs (miR­29b, miR­93, miR­106b and miR­100b). PGE2 induced significantly higher expression of the 3 anti­apoptotic miRs, let­7a, miR­16a and miR­200a, in LC when compared with the non­treated control or E2. PGE2 significantly promoted a greater expression of let­7a and miR­26a in LC when compared with P4. Overall, PGE2 exerted the highest anti­apoptotic and anti­inflammatory effect in LC, which was comparable with E2. It was not observed among the inflammation­regulating miRNAs in LC. PGF2α did not exert effects as prominent as those of PGE2. In MC, PGs and sex steroids exerted no similar effects on MC compared with LC. The present study demonstrated that PGE2 levels during menstruation may affect the growth of preexisting ULs without affecting the normal myometrium. Therefore, the control of secretion of PGs from the menstruating uterus or the administration of antagonists may be an alternative therapy for inhibiting the growth of ULs.

Bisphenol A modulates inflammation and proliferation pathway in human endometrial stromal cells by inducing oxidative stress.

Bisphenol A (BPA) has been implicated in altered human reproductive function. The oxidative stress or change of inflammatory signaling may appear a key factor in the biological changes of the human endometrium. Using MTT assay we assessed BPA mediated modulation of oxidative stress and inflammation responses in human endometrial stromal cells (ESCs). According to the results, reactive oxygen species (ROS) generation was highest upon exposure to 1000 pmol BPA. Increased mitogen-activated protein kinase (MAPK) and nuclear factor-κB (NF-κB) were demonstrated. Gene expression and release of inflammatory cytokines were increased. Upon BPA exposure, elevated estrogen receptor (ER)-α expression levels in ESCs correlated with changes in oxidative stress, inflammatory gene expression and signal changes in cellular proliferation signaling. These findings support that BPA induces oxidative stress and activates inflammatory signals in cultured ESCs via ER-α. Together, this result may provide insight into the association between BPA exposure and endometrium-related disorders.

Dysfunctional signaling underlying endometriosis: current state of knowledge.

Endometriosis is defined as the presence of endometrial tissue outside the uterine cavity. It affects approximately 5-10% of women of reproductive age. Endometriosis is associated with dysmenorrhea, dyspareunia and, often, severe pelvic pain. In addition to pain, women with endometriosis often experience infertility. Defining the molecular etiology of endometriosis is a significant challenge for improving the quality of women's lives. Unfortunately, the pathophysiology of endometriosis is not well understood. Here, we summarize the potential causative factors of endometriosis in the following three categories: (1) dysregulation of immune cells in the peritoneal fluid and endometriotic lesions; (2) alteration of apoptotic signaling in retrograde menstrual tissue and cytotoxic T cells involved in endometriosis progression and (3) dysregulation of oxidative stress. Determining the molecular etiology of these dysregulated cellular signaling pathways should provide crucial clues for understanding initiation and progression of endometriosis. Moreover, improved understanding should suggest new molecular therapeutic targets that could improve the specificity of endometriosis treatments and reduce the side effects associated with current approaches.

Superficial Angiomyxoma of the Vulva in a Postmenopausal Woman: A Case Report and Review of Literature.

Superficial angiomyxomas (SAMs) are rare benign cutaneous tumors that involve the subcutaneous layer. They are commonly located in the trunk, lower limbs and head or neck of women of reproductive age. SAMs in the vulva of postmenopausal women are especially rare case. Herein, we report a vulvar SAM in a postmenopausal 60-year-old woman. The patient presented with a palpable cutaneous mass in the right labium majora that had appeared 3 months earlier. The mass was slow growing and approximately 5 cm in size and resembled a soft tissue malignancy. It appeared as a well-defined multilocular cystic mass in magnetic resonance images. The preoperative diagnosis was a benign cystic lesion such as an epidermoid cyst. Grossly, the completely excised mass was 6 × 5 cm in size and well circumscribed with a multilocular outer surface, a yellowish-gray gelatinous cut surface, and a smooth rubbery inner surface. Histologic review revealed that the mass contained small to moderate amount of cellular angiomyxoid nodules and bland-looking spindle-shaped to ovoid cells without atypia. Neutrophil infiltration, which is a diagnostic feature of SAMs, was observed. Immunohistochemistry showed expression of CD34, but not of estrogen receptors, progesterone receptors, or desmin in the SAM. The patient has been followed up for 12 months without recurrence.

Di-(2-ethylhexyl)-phthalate induces oxidative stress in human endometrial stromal cells in vitro.

Di-(2-ethylhexyl)-phthalate (DEHP) accumulates in the environment, and its exposure is possibly associated with endocrine-related disease in women of reproductive age. The effects of DEHP on human endometrial cells are unknown. We treated human endometrial stromal cells with 10, 100, and 1000 pmol of DEHP and measured reactive oxygen species (ROS) generation, expression levels of antioxidant enzymes, alteration of MAPK/NF-κB signaling and hormonal receptors. DEHP increased reactive oxygen species (ROS) generation and decreased expression of superoxide dismutase (SOD), glutathione peroxidase (GPX), heme oxygenase (HO), and catalase (CAT). By DEHP exposure, p-ERK/p-p38 and NF-κB mediated transcription was increased. Additionally, DEHP induced estrogen receptor-α (ER-α) expression in a dose-dependent manner. This study shows the need for future mechanistic studies of oxidative stress, MAPK/NF-κB signaling, and ER-α as molecular mediators of DEHP-associated endometrial stromal cell alterations, which may be associated with the development of endocrine-related disease such as endometriosis.

Biomonitoring of Lead, Cadmium, Total Mercury, and Methylmercury Levels in Maternal Blood and in Umbilical Cord Blood at Birth in South Korea.

With rising concerns of heavy metal exposure in pregnancy and early childhood, this study was conducted to assess the relationship between the lead, cadmium, mercury, and methylmercury blood levels in pregnancy and neonatal period. The study population included 104 mothers and their children pairs who completed both baseline maternal blood sampling at the second trimester and umbilical cord blood sampling at birth. The geometric mean maternal blood levels of lead, cadmium, total mercury, and methylmercury at the second trimester were 1.02 ± 1.39 µg/dL, 0.61 ± 1.51 µg/L, 2.97 ± 1.45 µg/L, and 2.39 ± 1.45 µg/L, respectively, and in the newborns, these levels at birth were 0.71 ± 1.42 µg/dL, 0.01 ± 5.31 µg/L, 4.44 ± 1.49 µg/L, and 3.67 ± 1.51 µg/L, respectively. The mean ratios of lead, cadmium, total mercury, and methylmercury levels in the newborns to those in the mothers were 0.72, 0.04, 1.76, and 1.81, respectively. The levels of most heavy metals in pregnant women and infants were higher in this study than in studies from industrialized western countries. The placenta appears to protect fetuses from cadmium; however, total mercury and methylmercury were able to cross the placenta and accumulate in fetuses.

Uterine Lipoleiomyoma in Peri or Postmenopausal Women.

Lipoleiomyoma is an uncommon neoplasm of the uterus, composed of smooth muscles intermixed with mature adipocytes. These tumors are considered a benign variant of uterine leiomyomas. Herein, we report six cases of lipoleiomyoma experienced in our institution from January 2005 to March 2015. The patients ranged in age from 45 to 70 years; the etiology may be related to estrogen deficiency occurring after menopausal transition. Except for one lipoleiomyoma in the broad ligament, all others were found in the uterine corpus. The presenting symptoms were nonspecific, and most cases were incidentally diagnosed during surgery for other reasons. We performed preoperative imaging studies, including abdominal and pelvic computed tomography and magnetic resonance imaging. Preoperatively, four patients were diagnosed as having a pelvic mass and one patient was diagnosed as having a right ovarian mature teratoma. In one case, we found a gynecologic malignancy (cervical cancer 1A1). Histologically, there was no gross or microscopic contiguity between the lipoleiomyoma and the malignancy. Lipoleiomyomas seem to have a benign clinical course. In our study, there were no recurrences of or deaths attributed to the lipoleiomyomas during a mean follow-up period of 16.17 ± 23.80 months.

Cyclooxygenase-2 inhibitor, celecoxib, inhibits leiomyoma cell proliferation through the nuclear factor κB pathway.

Our aim was to investigate whether celecoxib, a cyclooxygenase 2 (COX-2) inhibitor, decreases the in vitro proliferation of leiomyoma cells if the inflammatory pathway is blocked. Menstruation is an inflammation of uterus that produces cytokines and prostanoids, but the inflammatory mechanism underlying the growth of leiomyoma remains unexplained. Using in vitro cultures of leiomyoma cells obtained from 5 patients who underwent hysterectomy, cell proliferation, inflammatory signaling, transcription factors, growth factors, and extracellular matrix were examined by (4,5-dimethylthiaxol-2-yi)-2,5-diphenyltetraxolium bromide assay, immunoblotting, and quantitative polymerase chain reaction. Prostaglandin E2 was used to induce menstruation-like condition in the cells. We found that celecoxib inhibited COX-2 through the expression of nuclear factor κB in the cells. Celcoxib also decreased the gene expression of interleukin 6, tumor necrosis factor α, collagen A, fibronectin, platelet-derived growth factor, epidermal growth factor, and transforming growth factor ß. In conclusion, the present study indicated that celecoxib could inhibit leiomyoma cell proliferation through blocking the inflammatory pathway that is probably one of the mechanisms underlying its pathogenesis.

Inhibitory effects of androstenedione on endometrial cells: implications for poor reproductive outcome among women with androgen excess.

OBJECTIVE: Androstenedione (A4) is an androgen that can be metabolized by aromatase to estrone, but the effects of A4 on endometrial cell proliferation either as an androgen or via conversion to estrogens are unknown. The aim of this study was to investigate A4 effects on Ishikawa cells in culture. STUDY DESIGN: Ishikawa cells were treated with increasing concentrations of A4 (0-1000 pmol) for 4 days. Cell proliferation was measured by the (4,5-dimethylthiaxol-2-yi)-2,5-diphenyltetraxolium bromide (MTT) assay. Apoptosis was analyzed through Annexin-V/propidium iodide (PI) staining and flow cytometry: 17ß-hydroxy steroid dehydrogenase type 1 (17ß-HSD1) and aromatase mRNA expression was measured by reverse transcription-polymerase chain reaction (RT-PCR). Western blotting was used to detect cell signaling expressions of Akt/MAPK. RESULTS: A4 treatment (1 nM) decreased cell proliferation and increased apoptosis, as demonstrated by MTT and flow cytometry or related gene expression. The cellular responses induced by A4 treatment were mediated by activation of the Akt and MAPK signaling pathway. Treatment had no effect on 17ß-HSD1 and aromatase expression. CONCLUSION: A4 treatment induced growth inhibition and apoptosis of Ishikawa cells through activation of the Akt/MAPK pathway. Effects of A4 on Ishikawa cells occurred in the absence of increased 17ß-HSD1 and aromatase expression. These results imply that women with excessive androgen, such as polycystic ovary syndrome, experience poor reproductive outcomes through androgen-regulated mechanisms.

Antiproliferative and apoptotic effect of epigallocatechin-3-gallate on Ishikawa cells is accompanied by sex steroid receptor downregulation.

Endometrial cancer is a significant malignancy in developed countries. Unopposed estrogen stimulation is considered as an important risk factor for endometrial cancer. Epigallocathechin-3-gallate (EGCG), biological active component of green tea, inhibits cancer cell proliferation. However, it is unknown whether EGCG has anticancer effects on endometrial cancer and what the molecular mechanism(s) are. We investigated the anticancer effects of EGCG on a human endometrial adenocarcinoma cell line (Ishikawa cells) with or without 17ß-estradiol (E2) treatment. Cell proliferation assay was performed using 3-(4,5-dimethylthiaxol-2-yi)-2,5-diphenyltetraxolium bromide (MTT). The cell cycle was determined by flow cytometry and real-time analysis of cyclin and cdk genes. The apoptosis was measured by Annexin V-PI staining and real-time analysis of bcl-2, Bax and caspase genes. The MAPK signal, Akt and caspase-3 were determined by immunoblotting. Decreased estrogen and progesterone receptor expression was observed in EGCG-treated Ishikawa cells, and decreased MAPK signals and phospho-Akt were observed as well. EGCG caused the arrest of cells in the G0/G1 phase of the cell cycle. This compound interfered with Akt activation and MAPK signals, and increased apoptosis signals leading to a controlled caspases, Bcl-2, Bax genes and protein expression. Taken together, EGCG inhibits cell proliferation and induces apoptosis through Akt and MAPK signals. These findings suggest that EGCG may exert growth-inhibitory and apoptosis-inducing effects on endometrial cancer cells, accompanied by decreased estrogen and progesterone receptor. EGCG may have future clinical implications with respect to the development of novel approaches as an adjuvant therapy in endometrial cancer.

Lower growth factor expression in follicular fluid undergone in-vitro fertilization.

OBJECTIVE: This study was performed to identify whether growth and differentiation factor-9 (GDF-9) and transforming growth factor-ß1 (TGF-ß1) expressions would be lower in the follicular fluid (FF) of those over age 35 who underwent IVF than under age 35. METHODS: A total of 24 IVF cycles (20 patients) were included in this study. All of patients were stimulated for IVF by the GnRH short protocol and divided into two groups for analysis, according to their age: <35 group (14 cycles, 11 patients) vs. ≥35 group (10 cycles, 9 patients). The expression levels of GDF-9 and TGF-ß1 were determined by western blotting and quantitative enzyme-linked immunosorbent assay. RESULTS: The numbers of retrieved oocytes and metaphase II oocytes were significantly lower in the ≥35 group. Lower expression of GDF-9 and TGF-ß1 by western blotting in the ≥35 group were observed as well. The mean GDF-9 and TGF-ß1 levels by enzyme-linked immunosorbent assay were lower in the ≥35 group. The values were 6,850.5±928.4 ng/L vs. 3,333.3±1,089.2 ng/L of GDF-9 (p<0.05) and 3,844.1±571.1 ng/L vs. 2,187.7±754.0 ng/L of TGF-ß1 (p<0.05). A negative correlation between GDF-9 and age was observed (r=-0.546, p=0.006). CONCLUSION: GDF-9 and TGF-ß1 production from stimulated ovaries during IVF appears to decrease with age.

Bilateral ovarian pregnancy after in vitro fertilization and embryo transfer in a patient with tubal factor infertility.

Primary ovarian pregnancy is very rare event after natural pregnancy or assisted reproductive technology (ART) procedures. Although there are a few reports about unilateral ovarian pregnancy after in vitro fertilization and embryo transfer (IVF-ET), there has been no report about bilateral ovarian pregnancy. Moreover, it is difficult to diagnose an ovarian pregnancy following in vitro fertilization and embryo transfer because of enlarged ovary, fluid collection in pelvic cavity, and its low incidence. We present a case of a patient who underwent IVF-ET due to tubal factor infertility, but the patient developed bilateral ovarian pregnancy and was performed both ovarian wedge resection through laparotomy.