The first report of surgery for gynecological diseases using the hinotori™ surgical robot system.

OBJECTIVE: This study aimed to report the first surgery for gynecological diseases using a new robotic platform, the hinotori™, and validate its feasibility in clinical settings. METHODS: The world's first robot-assisted total hysterectomy for a gynecological ailment was carried out at Kagoshima University Hospital in December 2022 utilizing the hinotori™ surgical robot system. Eleven other patients then underwent comparable procedures. The surgical team was certified to execute the procedure and had undergone official hinotori™ training. RESULTS: Preoperative diagnoses indicated five cases of endometrial cancer, four cases of uterine myoma and one case each of atypical endometrial hyperplasia, uterine adenosarcoma and high-grade cervical intraepithelial neoplasia. Median age and body mass index were 51 (range: 38-70) years and 26.9 (range: 17.3-33.3) kg/m2, respectively. Median roll-in, cockpit and operation times were 15 (range: 10-18), 161 (range: 110-225) and 214 (range: 154-287) min, respectively. The median blood loss was 22 (range: 7-83) mL and conversion to laparotomy was not allowed. Only one patient had postoperative pelvic region infection. The median length of hospital stay was 6 (range: 4-10) days. CONCLUSION: Based on our experience with presented 12 cases, robotic surgery with the hinotori™ is a feasible technique of minimally invasive surgery for gynecological diseases.

Validation of single-photon emission computed tomography with computed tomography and lymphoscintigraphy for sentinel lymph node identification in cervical cancer.

OBJECTIVE: To compare single-photon emission computed tomography with computed tomography (SPECT/CT) and lymphoscintigraphy (LSG) for the detection of sentinel lymph nodes (SLNs) in patients with early-stage cervical cancer. METHODS: This hospital-based, single-center, retrospective study included 128 patients with cervical cancer (aged >18 years) treated between 2014 and 2022. Injection of 99 m Technetium-labeled phytate into the uterine cervix was used to detect pelvic SLNs. SNL identification rates and locations were analyzed for preoperative LSG and SPECT/CT. RESULTS: Median age and body mass index of patients were 40 years (range, 20-78 years) and 21.7 kg/m2 (range, 16-40 kg/m2 ), respectively. There was no significant difference in overall identification rates (identification of at least one SLN) of SLNs between SPECT/CT (91%) and LSG (88%). There was no significant difference in bilateral SLN identification rates between SPECT/CT (66%) and LSG (65%). A total of 219 pelvic SLNs (110 right and 109 left hemipelvis) were identified by SPECT/CT; the most frequent locations were the obturator (122 SLNs, 56%) and external iliac (67 SLNs, 30%). CONCLUSION: SPECT/CT and LSG showed high SLN identification rates in patients with cervical cancer, and there was no significant difference in overall or bilateral SLN identification rates between the two techniques.

Laparoscopic Hysterectomy for Uterine Adenomyosis in Patients With a History of Renal Transplant: A Case Report and Review of Literature.

Renal transplantation is a viable treatment option for patients with end-stage kidney disease; however, it requires careful surgical manipulation as the transplanted kidney is placed in the iliac fossa. Herein, we report a case of a 41-year-old female with a history of two renal transplants who presented with hypermenorrhea and dysmenorrhea. Computed tomography revealed transplanted kidneys in the bilateral iliac fossae (right atrophic), and magnetic resonance imaging showed uterine adenomyosis. Three-dimensional computed tomography was performed to determine the relationship between the arteriovenous vessels, iliac vessels, and ureter of the transplanted left kidney. A diamond-shaped trocar was inserted while monitoring the transplanted kidney. Total laparoscopic hysterectomy and bilateral salpingectomy were performed without any perioperative complications. Immunosuppressants were continued postoperatively. Laparoscopic surgery for gynecological diseases can be advantageous and should be considered in patients who underwent renal transplants.

Successful Treatment of a Life-Threatening Pulmonary Embolism Following Retroperitoneal Tumor Surgery.

We encountered a case of life-threatening pulmonary embolism (PE) after an extensive retroperitoneal tumor (RT) surgery. The patient complained of abdominal distension. Preoperatively, an ovarian tumor and colon adenoma were suspected. Upon laparotomy, tumor resection and partial rectal resection were performed; the tumor had originated from the retroperitoneum. On postoperative day 11, the patient suddenly went into fatal shock complicated by strong back pain and dyspnea after the continuous pressure drain was removed. Thrombolysis, anticoagulation, and percutaneous catheter-directed treatment were attempted for the massive PE; however, these induced copious intra-abdominal bleeding. A substantial blood transfusion was required, which increased her body mass by 40 kg. On day 22, an intra-abdominal embolism was resected, and hemodynamics stabilized. RTs have a potential risk of perioperative thromboembolism; therefore, we suggest that surgery should take place in an academic hospital with an experienced circulatory team. To preserve life after PE, early diagnosis and multidisciplinary treatment are indispensable.

Successful management of vulvar proximal-type epithelioid sarcoma in pregnancy.

Vulvar proximal-type epithelioid sarcoma during pregnancy is extremely rare; only two reports are available to date. Herein, we describe a 36-year-old woman who presented with a pigeon-egg-sized solid mass with cystic component on the left labia majora at 18 weeks of gestation. The patient underwent tumor resection at 23 weeks of gestation and was diagnosed with epithelioid sarcoma, proximal-type. At 29 weeks of gestation, elective cesarean section, radical local resection of the vulva and vagina, and inguinal lymphadenectomy were performed. After surgery, she underwent six courses of adjuvant chemotherapy (doxorubicin 60 mg/m2 and cisplatin 50 mg/m2) every four weeks. The patient and her baby survived with neither recurrence nor complications until 5 years. Aggressive management for proximal-type epithelioid sarcoma, such as early termination of pregnancy and operation, can improve maternal outcomes.

Clostridium difficile infection in fever patients with gynecological malignancies.

BACKGROUND: Although Clostridium difficile infection (CDI) often results in severe manifestations due to toxin-producing clostridium, the correlation between CDI and having a fever in gynecological malignancies is not completely understood. AIMS: The incidence, and clinical features, and clinical management of CDI in patients with gynecological malignancies who have fevers were investigated, and the clinical managements of this complication are discussed. METHODS AND RESULTS: We retrospectively reviewed 485 patients newly diagnosed with invasive gynecological cancers who underwent anticancer treatment between July 2012 and December 2016. The diagnosis of CDI was performed using enzyme immunoassays for C difficile glutamate dehydrogenase and toxin A/B enzyme immunoassay. The cumulative risk of CDI was 9.5% (six of 63) in overall fever patients and 6.3% (six of 95) in patients with fever episodes. Two CDI patients (33.3%) did not show diarrheal symptoms, with the fever of unknown origin criteria prompting their CDI testing and diagnosis. CDI patients were treated using vancomycin or metronidazole without suffering from fatal clinical course. Overall, eight patients with gynecological malignancies were diagnosed with CDI, including two patients with fever lower than 38.5°C. The cumulative risk of CDI was 0.48% (eight of 1652) for all admitted patients and 1.6% (eight of 485) in those with gynecological malignancies. Of all the patients with confirmed CDI, only one had a history of administration of antibiotics prior to onset of CDI symptoms. CONCLUSION: CDI does not always present with typical manifestations in malignancy patients. Investigation of CDI, regardless of gastrointestinal symptoms or history of antibiotic use, is warranted in cases of fever of unknown origin in gynecological malignancy.

Genital bleeding hemostasis in gynecologic neoplasm with balloon tamponade: New treatment option.

Genital bleeding is the most common and serious complication in gynecologic malignancy. Different techniques are available for the control of severe bleeding, but standard treatment strategies have not been determined. Herein we report on the successful use of the balloon technique in two cases of genital bleeding in uterine neoplasm. The first case was of advanced cervical cancer with massive genital bleeding during radiotherapy. A metreurynter (mini-metro) was inserted into the vagina and hemostasis was indirectly achieved in the vaginal hematoma. The other case was of postoperative recurrent bleeding after cervical conization. A Foley balloon catheter was inserted into the endocervical canal and balloon tamponade directly stopped the bleeding. This technique is safe for massive genital bleeding in some cases of gynecological cancer, and can be conventionally performed regardless of the facility or department. The need for invasive treatment for fatal bleeding in gynecological cancer in which gauze packing is ineffective may be avoided by balloon tamponade without serious complications.