Successful surgical treatment of postmyomectomy uterine diverticulum: a case report.

BACKGROUND: Uterine diverticulum is classified into congenital and acquired types. The acquired type is caused by caesarean scar syndrome, which occurs after caesarean section. There are no detailed reports on diverticulum after enucleation of uterine fibroids. Most cases are treated with hysteroscopy or laparoscopy, but a management consensus is lacking. We treated a patient with a uterine diverticulum that had formed after uterine fibroid enucleation by combining hysteroscopic and laparoscopic treatments. CASE PRESENTATION: The patient was a 37-year-old Japanese woman, G1P0. A previous doctor had performed abdominal uterine myomectomy for a pedunculated subserosal uterine fibroid on the right side of the posterior wall of the uterus near the internal cervical os. Menstruation resumed postoperatively, but a small amount of dark-red bleeding persisted. MRI two months after the myomectomy revealed a diverticulum-like structure 3 cm in diameter, communicating with the uterine lumen, on the right side of the posterior wall of the uterus. Under suspicion of uterine diverticulum after uterine fibroid enucleation, the patient sought treatment at our hospital approximately four months after the myomectomy. Through a flexible hysteroscope, a 5-mm-diameter fistula was observed in the posterior wall of the uterus, and a contrast-enhanced pocket, measuring approximately 3 cm, was located behind it. Uterine diverticulum following enucleation of a uterine fibroid was diagnosed, and surgery was thus deemed necessary. The portion entering the fistula on the internal cervical os side was resected employing a hysteroscope. Intra-abdominal findings included a 4-cm mass lesion on the posterior wall on the right side of the uterus. The mass was opened, and the cyst capsule was removed. A 5-mm fistula was detected and closed with sutures. Resuturing was not performed after dissection of the right round ligament due to tension. The postoperative course has been good to date, with no recurrence. CONCLUSION: Uterine diverticula after myomectomy may be treated with a combined laparoscopic and hysteroscopic approach, similar to caesarean scar syndrome.

Prevalence of chronic endometritis in patients with infertility due to hydrosalpinx or pelvic peritubal adhesions and effect of laparoscopic surgical correction on pregnancy rates post in vitro fertilization.

OBJECTIVE(S): To assess the prevalence of chronic endometritis (CE) in patients with infertility and hydrosalpinx or peritubal adhesions and to examine the effects of laparoscopic surgical correction (LSC) on CE and pregnancy rates post in vitro fertilization and embryo transfer (IVF-ET). STUDY DESIGN: This is a retrospective cohort study at private IVF-ET centers. A total of 438 patients, known to have hydrosalpinx (n = 194) or peritubal adhesions (n = 244), and undergoing IVF treatment between April 1, 2018 and September 30, 2020 were included in the study. Hysterosalpingography, magnetic resonance imaging, and transvaginal ultrasonography were used to diagnose the hydrosalpinx or peritubal adhesions. Laparoscopic examination and surgical correction were performed on patients with CE. IVF-ET was performed after recovery from LSC. RESULTS: CE was present in 45.9% of patients (89/194) with hydrosalpinx and 14.3% with peritubal adhesions (35/244). All the 89 patients with CE and hydrosalpinx underwent laparoscopic salpingostomy and/or fimbrioplasty, and 64 (71.9%) further underwent proximal tubal occlusion. All the 35 patients with CE and peritubal adhesions underwent laparoscopic adhesiolysis and/or fimbrioplasty, and 19 (54.3%) further underwent proximal tubal occlusion. CD138 PC levels after LSC decreased to < 5 in 70 of 124 patients (56.5%) in one menstrual cycle and decreased to < 5 in all cases within 6 months. Of the 66 patients who underwent a single blastocyst transfer, 57 delivered (cumulative live birth rate (LBR): 86.3%). The cumulative LBR of patients treated for CE with LSC (86.3%) was significantly different from those given antibiotic therapy (320 patients; 38.4%; p <.0001) and the CD138-negative groups (811; 31.8%; p <.0001). CONCLUSION: CE is prevalent in patients with hydrosalpinx and/or peritubal adhesions who present with infertility. LSC improved CE without antibiotic therapy, improving the CP and LBR after IVF-ET.

Importance of abdominal X-ray to confirm the position of levonorgestrel-releasing intrauterine system: A case report.

BACKGROUND: Levonorgestrel-releasing intrauterine systems (LNG-IUSs) gradually release levonorgestrel into the uterus and is effective against hypermenorrhoea and dysmenorrhea. Complications associated with the insertion include expulsion, displacement, and uterine perforation. Ultrasonic identification of copper intrauterine devices (IUDs) is possible due to echogenicity from the copper coils. However, the barium sulfate coatings of LNG-IUSs do not always provide hyperechoic images. Both barium sulfate and copper are radiopaque and clearly identifiable on X-ray. Thus, X-ray imaging is required to locate LNG-IUSs. CASE SUMMARY: A 46-year-old woman with hypermenorrhoea due to submucosal myomas was treated with LNG-IUS at another hospital. Three LNG-IUS insertions had apparently been followed by spontaneous expulsion, although objective confirmation using imaging was not performed. The patient was referred to our institution for surgery. At the first visit, there appeared to be no device in the uterus, and none was observed on transvaginal ultrasound. However, two LNG-IUSs were observed in the pelvis on abdominal plain X-rays prior to surgery. Hysteroscopic myomectomy was performed, and the two LNG-IUSs were found to have perforated the myometrium. The devices were safely removed during surgery, and the submucosal myomas were also removed. The perforated section of the myometrium was minimal+ADs- therefore, a repair operation was not required.CONCLUSIONPlain abdominal X-rays facilitate the determination of whether an LNG-IUS is in the uterine cavity. Therefore, it is important to confirm a device's location, regardless of whether spontaneous expulsion is suspected, prior to inserting another device.

Safety and efficacy of microwave endometrial ablation for patients with previous uterine surgery: a pilot study.

MEA (microwave endometrial ablation) is a treatment that can control hypermenorrhea. With the increase in the number of caesarean sections and myomectomies, an increasing number of patients with MEA have undergone previous incision of the uterine myometrium. Uterine perforation is major complication. Here we compared the incidence of complications and recurrence between groups with or without previous uterine surgery. 35 patients who underwent MEA were enrolled in the study. We assessed the thickness of uterine myometrium by MRI and transvaginal ultrasonography (TV-US). 12 patients (34%) had previous uterine surgery; Among 12 patients with previous uterine surgery, 6 (50%) showed thinning of the myometrium. No patient showed any complications. There was no difference in recurrence rate between two groups (1/12 = 8% and 2/23 = 8%, respectively). MEA can be performed safely and effectively even for patients with previous uterine surgery.IMPACT STATEMENTWhat is already known on this subject? MEA (microwave endometrial ablation) is a treatment that can control hypermenorrhea.A few serious complications have been reported, including uterine perforation and intestinal injury. There have been no collective reports on women with a history of uterine surgery, and the decision to perform MEA and the detailed procedures have not been clarified.What do the results of this study add? No patient who received MEA showed any complication regardless of previous uterine surgery. There was no difference in recurrence rate of hypermenorrhea between groups with and without previous uterine surgery. MEA could be performed safely and effectively in patients with previous uterine surgery preoperative imaging and intraoperative ultrasoundsWhat are the implications of these findings for clinical practice and/or further research? Curently, with the increase in the number of caesarean sections and myomectomies, the increasing number of patients with MEA have undergone previous incision of the uterine myometrium and this causes thinning of the myometrium. MEA can be safely performed without losing any therapeutic effect, even in patients with a history of uterine surgery, by using MRI and TV-US as preoperative evaluations.

Managing Ectopic Pregnancies by Targeting Chorionic Villi with a Transvaginal Injection of Ethanol into the Lacunar Space.

Methotrexate has been the main mode of non-surgical treatment for ectopic pregnancies. However, we have developed an easier, repeatable method that can be applied even to patients with a high beta-human chorionic gonadotropin (ß-hCG) level and/or positive fetal heartbeat, by targeting chorionic villi with a transvaginal injection of absolute ethanol (AE) into the lacunar space (intervillous space). The efficacy and safety of this method were examined in 242 cases of ectopic pregnancy, including 103 with positive fetal heartbeat. Serum ß-hCG level was measured at frequent intervals, and transvaginal ultrasonography was performed to observe the gestational sac and hyperechoic inner ring. Of the 242 patients, 222 (91.7%) were successfully treated. The average number of AE injection(s) required was 1.6 (range: 1-5), and the average dose was 3.2 mL. After the treatment, many of the patients tried to conceive again, and 63 of the traceable 145 patients (43.4%), who had fallopian tube pregnancy, and 7 of the traceable 12 patients (58.3%), who had cervical or cesarean scar pregnancies, successfully conceived and delivered babies with no observed side effects. Therefore, this method could be an effective treatment for ectopic pregnancy with the potential to replace conventional surgical interventions and medical treatment using methotrexate.

Successful surgical treatment of cardiac metastasis from uterine leiomyosarcoma: A case report and literature review.

Uterine leiomyosarcoma is a malignant soft tissue tumor resembling uterine fibroma clinically and is difficult to diagnose preoperatively. Since metastatic cardiac tumors are very rare and asymptomatic, most cardiac metastases are detected at autopsy after death due to other diseases. A 49-year-old woman presented with menorrhagia and anemia, and a uterine tumor. Total hysterectomy was performed for the uterine tumor. Histopathological examination revealed the tumor to be a leiomyosarcoma. Postoperative computed tomography showed multiple lung metastases and a metastatic cardiac tumor. The cardiac tumor, which was located within and almost entirely occluded the right ventricle, was 49 × 26 mm. To prevent sudden death, cardiac tumorectomy was performed semi-emergently. Chemotherapy was initiated in the early postoperative period, and the patient currently maintains a complete response. Cases with lung and cardiac metastases rarely undergo surgical resection of metastatic tumors. However, emergent surgical resection of cardiac metastatic tumors should be considered to prevent sudden death.

A Novel Treatment for Cervical and Cesarean Section Scar Pregnancies by Transvaginal Injection of Absolute Ethanol to Trophoblasts: Efficacy in 19 Cases.

STUDY OBJECTIVE: To evaluate the efficacy of a nonsurgical treatment for cervical pregnancy (CP) and cesarean section scar pregnancy (CSP). DESIGN: Retrospective clinical study (Canadian Task Force classification III). SETTING: Private assisted reproductive technology practice. PATIENTS: Nineteen women with CP (n = 16) or CSP (n = 3), including 6 patients with positive fetal heartbeat. INTERVENTION: Transvaginal local injection of absolute ethanol (AE) into the hyperechoic ring (lacunar space) around the gestational sac under ultrasound guidance. MEASUREMENTS AND MAIN RESULTS: Serum beta-human chorionic gonadotropin (ß-hCG) was measured at frequent intervals, and ultrasound and/or magnetic resonance imaging was used to observe the gestational sac. In 9 patients, the serum ß-hCG level was effectively reduced with a single AE injection at 2 hours. In the remaining 10 patients, the level decreased but then increased in 4 and slowly decreased in the other 6; all of these 10 patients required 2 to 5 repeat AE injections. In all patients, serum ß-hCG level was reduced by 50% within 3 days and decreased to <10% of the initial level within 14 days. In 18 patients (95%), the level was decreased to 1.0 mIU/mL within 40 days. Seven patients were treated on an outpatient basis. Twelve patients received no anesthesia. Five patients subsequently became pregnant, and each had a live birth. There was no recurrent CP or CSP. The procedure was successful in all 19 patients. CONCLUSION: This procedure is an effective treatment for CP or CSP that could be used in place of conventional surgical interventions and medical treatment using MTX.

A large meconium pseudocyst that developed into the generalized type during the antepartum period.

A fetal intraabdominal cystic mass, measuring 6 cm, was detected at 30 weeks of gestation in a 27-year-old gravida 2 para 1 woman. At 33 weeks of gestation, the cyst disappeared. Ultrasonography showed fetal bowel dilatation, polyhydramnios, and intraabdominal calcifications. Fetal meconium peritonitis was diagnosed prenatally. Because the fetal ileus became worse, a cesarean section was performed at 35 weeks of gestation; a female infant weighing 2,131 g with an Apgar score of 8 was delivered. Six hours after birth, the neonate received an ileostomy. The bowel was reanastomosed 42 days after the initial operation. On postoperative pathology, a meconium pseudocyst was diagnosed. To our knowledge, this is the first report of a large fetal meconium pseudocyst that developed into the generalized type in the uterus during the preterm antepartum period.

Surgical procedure to conserve the uterus for future pregnancy in patients suffering from massive adenomyosis.

The treatment for severe adenomyosis has usually been hysterectomy, because there is no line of demarcation between diseased and normal tissue. Yet many such women wish to retain their uterus and some even wish to bear children. This report evaluates the efficacy of a new method of adenomyomectomy, where adenomyotic tissues are radically excised and the uterine wall is reconstructed by a triple-flap method, without overlapping suture lines, to prevent uterine rupture in subsequent pregnancies. This is a prospective case series followed for 10 years from June 1998 to August 2008 of 104 women with severe adenomyosis verified histologically and with magnetic resonance imaging. There was a dramatic reduction in both dysmenorrhoea and hypermenorrhoea and all patients returned to having normal menstrual cycles. Of 26 women who wished to conceive, 16 became pregnant, 14 (53.8%)went to term and delivered a healthy baby and there were no cases of uterine rupture. Adenomyosis symptoms recurred in only four out of 104 cases. The procedure thus resulted in a dramatic reduction in symptoms and allowed over half of women who wished to conceive to go to term without uterine rupture.

Changes of expression of glucose transporters in the fetal lamb brain after MCI-186 administration to the maternal circulation with 10-min persistent umbilical cord occlusion.

OBJECTIVE: To evaluate the effect of MCI-186 (3-methyl-1-phenyl-2-pyrazoline-5-one), a potent hydroxyl radical scavenger, administered to the maternal circulation following umbilical cord occlusion in regard to glucose transporter (GLUT) expression. MATERIALS AND METHODS: Fourteen instrumented lambs were prepared. In three cases, a 10-min persistent umbilical cord occlusion was performed; 30 min after the insult, fetal brains were extirpated (Group A). Four cases had a 10-min occlusion(Group B) and four cases had 10-min occlusion and were administered MCI-186 to the maternal circulation (Group C).Three days following the insult, the fetal brains were extirpated. The remaining three cases had a sham operation (Group D).Brain tissue sections were stained at the locations of GLUT-1, -3 and -5 and were evaluated by two pathologists. RESULTS: The expression of GLUT-1 and -3 significantly increased in the basal ganglia, hippocampi and periventricular region of Group B when compared with that of Group A. The expression of GLUT-1 and -3 in three regions of Group B were significantly higher than that of Group C and D. GLUT-5 was recognised only in Group B. CONCLUSION: On the basis of expression of GLUT, the protective effect of MCI-186 on brain injury resulting from hypoxia/ ischemia-reperfusion is documented.

MCI-186 administered to the maternal circulation inhibits fetal brain injury resulting from total umbilical cord occlusion in the chronically instrumented fetal lamb.

OBJECTIVE: To evaluate the transplacental effects of MCI-186 (edaravone), a potent hydroxyl radical scavenger, administered to the maternal circulation to inhibit fetal brain injury caused by umbilical cord occlusion. METHODS: Nine chronically instrumented lambs were prepared. In three cases, 10-min persistent total umbilical cord occlusion (group A) was performed. Another three cases underwent occlusion and were administered 60 mg of MCI-186 through the maternal femoral vein prior to the end of occlusion (group B). The remaining three cases underwent sham operation (group C). On day 3 after insult, fetal brains were extirpated. Paraffin-embedded brain tissue sections were stained with hematoxylin and eosin, Bodian, Kluver-Barrera, and TUNEL. Neuronal cellular damage was evaluated by two pathologists blinded to the experimental conditions. RESULTS: Group A displayed numerous cells with eosinophilic condensation of nuclear chromatin and proliferation of microglia in the hippocampus and basal ganglia. TUNEL-positive cells were observed in the periventricular area. Group B showed microglial proliferations, but no marked changes. No pathological changes were apparent in group C. CONCLUSIONS: MCI-186 administered to the maternal circulation could inhibit fetal brain injury resulting from hypoxia-reperfusion induced by umbilical cord occlusion.

The production of hydroxyl radicals in the fetal lamb brain resulting from occlusion of the umbilical circulation and the transplacental effect of MCI-186 to inhibit hydroxyl radical production.

The present study evaluated hydroxyl radical production in fetal lamb brain during and after umbilical cord occlusion and examined the effects of injecting MCI-186 (3-metyl-1-phenyl-2-pyrazolin-5-one; Edaravone), a hydroxyl radical scavenger, into the maternal circulation. In 11 chronically instrumented lambs, intermittent total umbilical cord occlusions 1 min out of every 3 min for 1 h and 10-min persistent total umbilical cord occlusion were performed with brain microdialysis using 5 mM of sodium salicylate. In the remaining four lambs, 60 mg of MCI-186 was administered into the maternal circulation from shortly before the end of 10-min persistent total umbilical cord occlusion. Concentrations of 2,3-dihydroxy-benzoic acid (2,3-DHBA), produced by hydroxyl radical reactions with sodium salicylate, were measured in perfusate by HPLC. Concentration of 2,3-DHBA in perfusate was 23.05 +/- 10.95 nM before umbilical cord occlusion. Levels of 2,3-DHBA tended to increase slightly during and after intermittent umbilical cord occlusion, and were significantly increased by the end of 10-min occlusion (40.06 +/- 21.36 nM) and after occlusion (93.74 +/- 29.17 nM). Infusion of MCI-186 suppressed 2,3-DHBA concentration to 29.35 +/- 14.95 nM after occlusion. Administration of MCI-186 into the maternal circulation reduces hydroxyl radical production induced by umbilical cord occlusion in the fetal lamb brain.

Transplacental effects of allopurinol on suppression of oxygen free radical production in chronically instrumented fetal lamb brains during intermittent umbilical cord occlusion.

OBJECTIVE: To evaluate the transplacental effect of allopurinol, which acts as a xanthine oxidase inhibitor and free radical scavenger, on inhibiting the production of superoxides during intermittent partial umbilical cord occlusion. METHODS: Using four chronically instrumented fetal lambs, ewes received 400 mg allopurinol over a period of two hours. Concentrations of allopurinol and oxypurinol in blood samples from mothers and fetuses and fetal brain microdialysis perfusate were measured by HPLC. In another three cases the production of superoxide during intermittent umbilical cord occlusion was studied by measurement of chemiluminescence in perfusate before and after administration of Allopurinol. RESULTS: (i) Allopurinol concentration in mothers had reached equilibrium by 30 min after starting administration and maintained a concentration about 6 mug/ml. Allopurinol concentration in fetuses increased gradually and reached 2.25 +/- 0.54 microg/ml at 120 min; (ii) Oxypurinol concentration in both mothers and fetuses increased during administration of allopurinol; (iii) Concentrations of allopurinol and oxypurinol in the perfusates reached 0.32 +/- 0.12 microg/ml, 0.53 +/- 0.22 microg/ml at 120 min respectively; and (iv) Administration of allopurinol significantly suppressed superoxide production during intermittent partial umbilical cord occlusion. CONCLUSION: These results demonstrated a good transfer of allopurinol from mother to fetus and suggested the possibility of intrauterine treatment to inhibit fetal brain damage resulting from increased oxygen free radicals.

Chromosome abnormalities identified in 347 spontaneous abortions collected in Japan.

OBJECTIVE: We determined the incidence of specific chromosome abnormalities in this Japanese population so that comparisons could be made to the incidence of chromosome abnormalities reported for other populations. METHODS: A total of 423 cases of products of conception aborted spontaneously were collected for cytogenetics analysis from various medical sites located in Japan. The cytogenetic results, along with clinical information including gestational age at the time of the miscarriage and maternal age, were compiled in a database. The incidence of specific chromosome aberrations was determined. The abnormalities were separated by gestational age at the time of the miscarriage and by maternal age. RESULTS: The total number of specimens available for cytogenetic analysis was 407. Cytogenetic results were obtained for 347 cases (85.3%), of which 196 (56.5%) showed chromosome abnormalities. Autosomal trisomy was detected in 120 cases (61.2% of the abnormal cases). Trisomy for each autosome, with the exception of chromosomes 1, 5, 6, 11, 12, and 19, was identified. The most common autosomal trisomy was that of chromosome 16 (30 cases), followed by trisomy 21 (13 cases), and trisomy 22 (13 cases). Eight cases showed double trisomies, and one case showed trisomy for three different chromosomes. Two cases showed monosomy 21, and 24 cases showed 45,X. Triploidy was identified in 27 cases and tetraploidy was detected in five cases. Unbalanced structural rearrangements were found in 11 cases, and balanced translocations were identified in two cases. Six cases showed mosaicism: three cases showed a normal cell line; and three cases had multiple abnormal cell lines. Separating the trisomies by the gestational age at which time the miscarriage occurred revealed that trisomies 7, 8, 14, 15, 16 and 22 occurred exclusively during the first trimester and fetuses with trisomies 4, 13, 18 and 21 survived late into the second trimester. CONCLUSION: Overall patterns of chromosome abnormalities detected in spontaneous abortions in Japan were similar to those reported in the literature.

[Concurrent weekly nedaplatin-based radiotherapy for high risk, recurrent and advanced cervical cancer].

Advanced cervical cancer has been predominantly treated with a combination of external beam and brachytherapy in Japan. Recent studies suggest concurrent use of cisplatin and radiation treatment has superior disease control to radiation only treatment. We have conducted a phase I pilot study of concurrent use of weekly nedaplatin (30 mg/m2) and sequential external beam and brachytherapy in advanced stage or recurrent uterine cervical cancer patients (n = 6). All patients completed the treatment without serious complications. Five patients had complete responses and one a partial response. The average AUC of nedaplatin after one administration was 5.0 micrograms/ml.hr. The therapeutic index was 2. We concluded that concurrent use of weekly nedaplatin and radiation is well tolerated by Japanese women, and may well be an excellent therapeutic modality for selected cases of advanced or recurrent cervical cancer.