Effect of dienogest on serum anti-Mullerian hormone level after laparoscopic cystectomy of ovarian endometrioma.

OBJECTIVE: This comparative study aimed to evaluate the effect of postoperative dienogest treatment on serum anti-Mullerian hormone (AMH) levels in patients undergoing laparoscopic cystectomy of ovarian endometriomas. MATERIALS AND METHODS: A total of 71 patients with ovarian endometriomas treated at our department were enrolled. After surgery, 54 patients received oral dienogest 2 mg daily continuously for 6 months (dienogest group). The other 17 patients did not receive postoperative medical treatment (control group). Serum AMH levels were measured before surgery, at 3-month period after surgery, and at the end of 6-month follow-up period. Serial changes of AMH levels were compared between the two groups. RESULTS: The age, endometrioma size, and serum AMH level before surgery were comparable between the dienogest group and the control group. The AMH levels decreased significantly at 3-month period after surgery in the dienogest group (a decrease of 65.5%; p < 0.001) and the control group (a decrease of 64.8%; p = 0.018). The AMH levels increased gradually from the nadir at 3-month period after surgery and recovered partially at the end of 6-month follow-up period in both groups. There were no statistically significant differences in the rate of reduction of serum AMH levels between the two groups (p = 0.707). CONCLUSION: Laparoscopic cystectomy of ovarian endometrioma causes a significant decrease in serum AMH levels. The rates of reduction of AMH levels are similar regardless of dienogest treatment. Postoperative dienogest treatment for 6 months has no rescue effect on serum AMH levels in these patients.

Rapid diagnosis of trisomy 18 of maternal origin by quantitative fluorescent polymerase chain reaction analysis following tissue culture failure for conventional cytogenetic analysis in a fetus with holoprosencephaly, ventricular septal defect, arthrogryposis of bilateral wrists and aplasia of the thumbs.

OBJECTIVE: We present rapid diagnosis of trisomy 18 of maternal origin by quantitative fluorescent polymerase chain reaction (QF-PCR) analysis following tissue culture failure for conventional cytogenetic analysis in a fetus with holoprosencephaly (HPE), ventricular septal defect (VSD), arthrogryposis of bilateral wrists and aplasia of the thumbs. CASE REPORT: A 22-year-old, primigravid woman was referred for first-trimester ultrasound screening at 13 weeks of gestation, and the fetus was found to have HPE and VSD. The pregnancy was subsequently terminated at 14 weeks of gestation, and a malformed fetus was delivered with cebocephaly, arthrogryposis of bilateral wrists and aplasia of the thumbs. The umbilical cord and placental tissues were collected for genetic analysis. However, tissue culture failure for conventional cytogenetic analysis occurred because of contamination. QF-PCR analysis using the polymorphic DNA markers of D18S1369 (18q12.2) and D18S1361 (18q22.3) confirmed trisomy 18 of maternal origin. CONCLUSION: QF-PCR analysis is useful for rapid confirmation of trisomy 18 and the parental origin when tissue culture failure for conventional cytogenetic analysis occurs in pregnancy suspicious of fetal trisomy 18.

First-trimester abortion complicated with placenta accreta: A systematic review.

Placenta accreta is a potentially life-threatening condition that may complicate a first-trimester abortion in rare occasions, and it can be difficult to recognize. We reviewed the literature in PubMed-indexed English journals through August 2018 for first-trimester postabortal placenta accreta, after which 19 articles and 23 case reports were included. The risk factors for the development of abnormal placentation are previous cesarean section (87%), previous history of uterine curettage (43.5%), and previous history of surgical evacuation of a retained placenta (4.3%). Ten patients (43.5%) had an advanced age (≧35 years). Most patients clinically presented with vaginal bleeding, ranging from intermittent or irregular bleeding, persistent bleeding, and profuse or massive bleeding. The onset of symptoms might be during the intra- or immediate postoperative period. Some patients had delayed symptoms 1 week to 2 years postoperatively. Conservative management may be attempted as the primary rescue, including uterine artery embolization (UAE), transcatheter arterial chemoembolization (TACE) with dactinomycin, and laparoscopic hysterotomy with placental tissue removal. However, most reports in the literature suggested either abdominal or laparoscopic hysterectomy as the definitive treatment for first-trimester postabortal placenta accreta. High index of clinical suspicion with anticipation of placenta accreta in early pregnancy is highly essential for timely diagnosis, providing the physician better opportunities to promptly manage this emergent condition and improve outcomes.

Single port access laparoscopic subtotal hysterectomy using contained manual morcellation: Experience from a tertiary referral center in Taiwan.

OBJECTIVE: To describe the surgical outcomes of single port access laparoscopic subtotal hysterectomy (LSH) using in-bag manual morcellation and evaluate the feasibility of this procedure. MATERIALS AND METHODS: Thirty patients with symptomatic leiomyoma or adenomyosis were enrolled. A 2-cm transverse incision was made at the umbilicus and single port apparatus (LagiPort) was applied. After dissection of vesicouterine peritoneum from the uterus, the uterine ligaments and vessels were secured and transected by Gyrus PK cutting forceps. Cervical amputation at the level of internal os was made by SupraLoop (Karl Storz). The uterine corpus was put into an Endobag before morcellation. The opening of Endobag was exteriorized from the umbilical incision and the uterine corpus was removed in a contained manner by manual morcellation with a scalpel. RESULTS: This procedure was successfully performed on all patients. Neither laparotomic conversion nor additional port was needed. The mean age and mean BMI of the patients were 43.63 years and 24.02 kg/㎡. The mean operative time was 148 min and the estimated blood loss in most patients was less than 150 ml. The median weight of uterine corpus was 214 g. No intraoperative complications occurred in any patient. One patient was diagnosed with unexpected endometrioid adenocarcinoma FIGO grade 1 postoperatively. One patient reported cyclic bleeding and underwent a transvaginal trachelectomy 17 months later. CONCLUSION: Single port access LSH using contained manual morcellation represents a safe and feasible alternative to conventional LSH using open power morcellation.

Laparoscopic management of ectopic pregnancies in unusual locations.

OBJECTIVE: The aim of this study was to evaluate the feasibility and efficacy of laparoscopic surgery for patients with ectopic pregnancies in unusual locations. MATERIALS AND METHODS: This is a retrospective case series of 31 patients from 6 weeks to 10 weeks postmenstrual who were referred for diagnosis and treatment and suspected of having an unruptured cesarean scar pregnancy (CSP) or cornual pregnancy (CP). The diagnosis was confirmed with transvaginal ultrasound, and all of the patients underwent laparoscopic management. RESULTS: A diagnosis of CSP or CP was confirmed in all of the patients during the laparoscopic procedure. None of the patients required conversion to laparotomy. The total operative time ranged from 40 minutes to 120 minutes. The total blood loss was limited, ranging from 30 mL to 200 mL. All of the women tolerated the operation well and had uneventful recoveries. CONCLUSION: When performed by a well-trained gynecologist, laparoscopy appears to be a reasonable alternative for the treatment of unruptured CSP or CP.

Leak-proof extracorporeal drainage for management of large ovarian tumors.

PURPOSE: To describe our experience with leak-proof extracorporeal drainage through a minilaparotomy for management of large ovarian tumors. METHODS: Twenty patients who had presumed benign ovarian tumors larger than 10 cm were selected to undergo this technique. A 4 cm skin incision was made transversely above the symphysis pubis. After application of a self-retaining wound retractor, a polyurethane membrane was firmly affixed to the tumor surface by 2-octylcyanoacrylate adhesive. Most cyst contents were aspirated by a suction tube and the deflated ovary was exteriorized and excised extracorporeally. RESULTS: The median age and median BMI of the patients were 34 years and 23.2, respectively. The maximum tumor diameter varied from 10 to 26 cm (median 15 cm). This technique was successfully administered to 18 patients. The incision was extended to 7 cm in the most obese patient. The procedure was converted to a laparotomy in one patient with severe pelvic adhesion. The median aspiration volume was 800 mL and the median operative time was 80 min. There was no intra-abdominal leakage of tumor contents in all patients. The procedure was converted to laparoscopic fertility-preserving staging operation in two patients with borderline ovarian tumors. The other pathologic diagnoses were six mucinous cystadenomas, six dermoid cysts, three serous cystadenomas, one simple cyst, one corpus luteal cyst, and one endometrioma. CONCLUSIONS: Minilaparotomy with leak-proof extracorporeal drainage using cyanoacrylate adhesive and polyurethane membrane is reliable, safe, and feasible for management of large ovarian tumors with low probability of malignancy in selected patients.

Laparoscopic management of placenta increta after late first-trimester dilation and evacuation manifesting as an unusual uterine mass.

Placenta increta is a rare and potentially life-threatening complication of pregnancy. The initial symptoms are generally vaginal bleeding during difficult placental removal in the third trimester. However, placenta increta may complicate first- and early second-trimester pregnancy loss. The diagnosis may be difficult during early pregnancy because the lesion is difficult to identify. Herein is reported the case of a woman with a diagnosis of placenta increta that caused prolonged bleeding after a late first-trimester abortion and manifested as an unusual lower segment uterine mass. Management included laparoscopy, and the placental tissue was completely removed successfully and uneventfully.

Laparoscopic pelvic floor repair using polypropylene mesh.

OBJECTIVE: The purpose of this report is to present our experience in laparoscopic pelvic floor repair using polypropylene mesh for the treatment of advanced vaginal vault prolapse and enterocele. MATERIALS AND METHODS: A total of 40 patients with Baden-Walker System grade 3 or 4 vaginal vault prolapse and concurrent enterocele were recruited. Twenty patients had undergone at least one previous pelvic floor reconstructive procedure and were categorized as the recurrent prolapse group. The other 20 patients were categorized as the nonrecurrent group. All patients underwent a laparoscopic pelvic floor repair using a single piece of polypropylene mesh combined with uterosacral ligament suspension. RESULTS: The mean age of the study group was 60.7 years. The mean follow-up period was 26.6 months. The intraoperative major complication rate was 5% (two bladder perforations). No recurrent apical prolapse, anterior vaginal wall or posterior vaginal wall prolapse was observed at postoperative follow-up. The overall mesh erosion rate was 12.5% (5 of 40 patients), with four erosions (20%) in the recurrent prolapse group and one erosion (5%) in the nonrecurrent group. Mesh-related pain syndromes and dyspareunia was reported in 21.4% of patients in the recurrent prolapse group and 6.3% of patients in the nonrecurrent group. CONCLUSION: Laparoscopic pelvic floor repair using a single piece of polypropylene mesh combined with uterosacral ligament suspension appears to be a feasible procedure for the treatment of advanced vaginal vault prolapse and enterocele. Fewer mesh erosions and postoperative pain syndromes were seen in patients who had no previous pelvic floor reconstructive surgery.