Nonpuerperal uterine inversion caused by an adenosarcoma: A case report.

INTRODUCTION: Eighty-five per cent of uterine inversions are puerperal. Non-puerperal uterine inversion is usually caused by tumours that exert a traction force on the fundus of the uterus. This causes the uterus to be partially or completely inverted. It is commonly related to benign tumours like submucosal leiomyomas. Nevertheless, malignancies are an infrequent association. CASE PRESENTATION: We report a case of a 35-year-old female patient, medically and surgically free, gravida0 para0, complaining of menometrorrhagia associated with pelvic pain for 2 years. A suprapubic ultrasound scan showed an enlarged, globular uterus with a heterogeneous, undefined mass of 49 mm in size. MRI scan showed the appearance of a U-shaped uterine cavity and a thickened inverted uterine fundus with an endometrial infiltrating mass of 25 mm. Intraoperative exploration showed uterine inversion involving the ovaries; the fallopian tubes and the round ligaments and a necrotic intracavitary mass. The malignancy of the tumor was confirmed through anatomopathological examination as Adenosarcoma. CONCLUSIONS: Uterine inversion is rare outside the puerperal period, and malignant etiology must not be overlooked. Therefore, comprehensive care with meticulous etiological investigation is crucial.

A vocal cord palsy caused by the uterine cancer metastatic tumor in the mediastinum revealed in a patient with a thyroid lesion: a case report and review of the literature.

BACKGROUND: The main cause of vocal cord palsy (VCP) is idiopathic impairment of the recurrent laryngeal nerve (RLN). However, solid tumors along the pathway of the RLN can also impact the nerve's function. We presented a patient with a thyroid lesion and VCP due to a bulky metastatic mass (uterine cancer) on the aortic arch field in the mediastinum. The report aims to show the significance of comorbid tumors in thyroid pathology and the importance of additional diagnostic methods in avoiding unnecessary surgeries. A patient's lifetime and the outcome of the disease were also presented. CASE PRESENTATION: A 58-year-old Ukrainian woman with a hoarse voice, intermittent dry cough, and weakness was presented to an endocrine surgeon. Thyroid pathology included signs of hypothyroidism treated with Thyroxine 112.5 µg and a nodule in the left lobe. The lesion is located on the posterior aspect of the lobe, which could probably be a cause of RLN involvement. Fine needle aspiration biopsy (FNAB) was performed twice with Bethesda category 2 result. Fibrolaryngoscopy (FLS) revealed the median position of the left vocal cord. Idiopathic, laryngeal, and thyroid causes of the VCP were excluded. Additionally, the patient displayed her anamnesis of the endometrial clear cell carcinoma following hysterectomy, external beam radiation therapy, and chemotherapy. The mediastinal metastasis was revealed sixteen years later. A chest computed tomography (CT) with intravenous contrast was done. A bulky tumor was found right under the aortic arch. Subsequently, the voice complaints reduced significantly after 4 chemotherapy courses. Cancer progression had led to the appearance of lymph node metastases on the supraclavicular region. Following six months the 60-year-old patient had passed away. CONCLUSION: A history of the disease should always be kept in mind when assessing a patient's complaints. VCP in case of thyroid pathology and previous secondary malignancy may be caused by metastatic tumor anywhere along the RLN pathway. Such a rare case shows the importance of additional methods of examination which may avoid unnecessary thyroid surgeries.

Surgical impact of bilateral transient occlusion of uterine and utero-ovarian arteries during laparoscopic myomectomy.

The objective of this article is to compare the amount of intraoperative blood loss during laparoscopic myomectomy when performing bilateral transient clamping of the uterine and utero-ovarian arteries versus no intervention. It´s a randomized controlled prospective study carried out in the Department of Obstetrics and Gynecology Ramón y Cajal University Hospital and HM Montepríncipe-Sanchinarro University Hospital, Madrid, Spain, in women with fibroid uterus undergoing laparoscopic myomectomy. Eighty women diagnosed with symptomatic fibroid uterus were randomly assigned to undergo laparoscopic myomectomy without additional intervention (Group A) or temporary clamping of bilateral uterine and utero-ovarian arteries prior to laparoscopic myomectomy (Group B). Estimated blood loss, operating time, length of hospital stay, and postoperative hemoglobin values were compared in both groups. The number of fibroids removed was similar in both groups (p = 0.77). Estimated blood loss was lower in the group of patients with prior occlusion of uterine arteries (p = 0.025) without increasing operating time (p = 0.17) nor length of stay (p = 0.17). No patient had either intra or postoperative complications. Only two patients (2.5%) required blood transfusion after surgery. We conclude that temporary clamping of bilateral uterine arteries prior to laparoscopic myomectomy is a safe intervention that reduces blood loss without increasing operative time.

Ultrasound-guided high-intensity focused ultrasound ablation for uterine arteriovenous fistula: a case series.

PURPOSE: To evaluate the efficacy and safety of high-intensity focused ultrasound (HIFU) ablation in the treatment of uterine arteriovenous fistula (UAVF). MATERIALS AND METHODS: This case series included three patients diagnosed with acquired UAVF. All patients underwent routine laboratory tests, electrocardiography (ECG), chest X-ray, ultrasound, and pelvic contrast-enhanced magnetic resonance imaging (MRI). HIFU treatment was performed under sedation and analgesia using a Model JC Focused Ultrasound Tumor Therapeutic System (made by Chongqing Haifu Medical Technology Co. Ltd., China) with a B mode ultrasound device for treatment guidance. The treatment time, sonication power, sonication time, and complications were recorded. Follow-up evaluations were scheduled at 1-, 3-, 6-, and 12-month to assess symptom improvement and evaluate the post-treatment imaging. RESULTS: All patients completed HIFU treatment in a single session without any major complication. All patients complained of mild lower abdominal and sacrococcygeal pain. Typically, no special treatment is required. Following HIFU treatment, there was a significant relief in clinical symptoms, particularly abnormal uterine bleeding. Ultrasound examinations conducted one month after the treatment revealed a notable reduction in the volume of the lesion, ranging from 57% to 100%. Moreover, the efficacy and safety of HIFU treatment remained consistent during the 12-month follow-up period. CONCLUSION: HIFU ablation appears to be an effective and safe treatment modality for UAVF. It provides a noninvasive approach with favorable clinical outcomes.

Laparoscopic continuous seromuscular circumsuture for myomectomy: a real-world, retrospective, East-Asian cohort study.

OBJECTIVE: This study aimed to introduce a novel laparoscopic haemostasis for myomectomy and investigate the independent risk factors for uterine fibroid recurrence. DESIGN: A retrospective cohort study. SETTING: Following strengthening the reporting of observational studies in epidemiology (STROBE) criteria, a retrospective study of prospectively collected available data of the consecutive patients who underwent the myomectomy in the department of obstetrics and gynaecology of the single centre between February 2018 and December 2020. PARTICIPANTS: 177 patients who underwent laparoscopic myomectomy resection were enrolled in the present cohort study. MATERIALS AND METHODS: Patients were classified into two groups according to their different methods of haemostasis in laparoscopic surgery. Recurrence-free survival was compared between the groups during an average follow-up of nearly 2 years. RESULTS: Of the 177 patients from 672 consecutive patients in the retrospective cohort, laparoscopic circular suture and baseball suture were carried out in 102 (57.6%) and 75 (42.4%) patients, respectively. The total amount of blood lost during surgery varied significantly (37.6 vs 99.5 mL) (p<0.001). Univariable analyses identified that age ≥40 years, position at intramural myoma, multiple fibroids and largest fibroid volume ≥50 mm3 (HR 2.222, 95% CI 1.376 to 3.977, p=0.039; HR 3.625, 95% CI 1.526 to 6.985, p=0.003; HR 3.139, 95% CI 1.651 to 5.968, p<0.001; HR 2.328, 95% CI 0.869 to 3.244, p=0.040, respectively) are independent risk factor of the recurrence of uterine fibroids. The formula of the nomogram prediction model was established as the practical clinical tool. CONCLUSION: The laparoscopic continuous seromuscular circumsuture for myomectomy can effectively reduce the amount of surgical bleeding and accelerate the perioperative recovery for surgical safety. The main factors affecting the recurrence of uterine fibroids were age, location, number and volume of uterine fibroids. The nomogram can more straightforwardly assist clinicians to determine the risk of recurrence after laparoscopic myomectomy.

Myomatous erythrocytosis syndrome: a uterine fibroid associated with polycythaemia.

Myomatous erythrocytosis syndrome (MES) is a rare form of secondary erythrocytosis seen with myomas. Here, we present a case of a postmenopausal, nulliparous woman in her 50s incidentally found to have asymptomatic erythrocytosis on routine laboratory work. She was found to have an 18.5 cm myoma and after surgical resection, the patient's haematological values returned to normal ranges after a few weeks. This established the diagnosis as MES. The aetiology of MES continues to remain unknown but is most likely caused by an autonomous production of erythropoietin from the myomatous tissue. This case highlights obtaining a detailed history and physical examination to differentiate between the different causes of erythrocytosis, considering MES as a rare cause of secondary erythrocytosis and to prevent unnecessary procedures such as phlebotomy as surgery is the mainstay of treatment.

Recurrence complicated with peritoneal dissemination after single-port gasless myomectomy for cellular uterine leiomyoma: A case report and literature review.

RATIONALE: Cellular uterine leiomyomas (CL) represent the prevailing subtype among uterine leiomyomas. In this study, we report a case of recurrent peritoneal disseminated uterine fibroids 2 years after single-port laparoscopic gasless myomectomy. This article endeavors to examine the potential limitations of the aforementioned surgical procedure and outline the distinguishing features of recurrent cases with primary postoperative pathology as CL. Additionally, it aims to provide a summary of previous retrospective studies on CL and propose the existence of immunohistochemical molecules that may serve as predictors for the postoperative recurrence of cellular uterine fibroids. The ultimate objective is to enhance clinicians' comprehension of the disease. PATIENT CONCERNS: Two years ago, the patient underwent a single-port gasless laparoscopic myomectomy for uterine fibroids. Gynecological color Doppler ultrasound conducted 3 months ago revealed recurrence of uterine fibroids, and the patient experienced abdominal distension, mild urinary frequency, and constipation for the past month. DIAGNOSES: After the second surgical procedure, a comprehensive pathological examination and immunohistochemical analysis of both the uterine mass and metastatic lesions revealed that the definitive diagnosis was CLs. INTERVENTIONS: The patient underwent the total hysterectomy, bilateral salpingectomy, pelvic adhesiolysis, omental mass resection, mesenteric mass resection, and pelvic peritoneal mass resection. All specimens were sent for rapid frozen examination and showed to be leiomyomas. OUTCOMES: The patient was discharged from the hospital on the 10th day after the operation. At the date of writing the article, the patient had no recurrence for 1 year and 5 months. LESSONS: The single-port gasless approach did not achieve the desired reduction in fibroid recurrence, as anticipated by the surgeon. The act of pulling the tumor towards the abdominal incision for resection, on the contrary, may serve as an iatrogenic factor contributing to postoperative recurrence of CL into peritoneal dissemination leiomyomatosis. The single-port gasless assisted bag may be a more suitable option for myomectomy. The utmost effort should be made to prevent the potential recurrence of myoma caused by iatrogenic factors.

Impact of trainees involvement on surgical outcomes of abdominal and laparoscopic myomectomy.

BACKGROUND: To determine the association of trainees involvement with surgical outcomes of abdominal and laparoscopic myomectomy including operative time, rate of transfusion, and complications. METHODS: A retrospective cohort study of 1145 patients who underwent an abdominal or laparoscopic myomectomy from 2008-2012 using the American College of Surgeons National Surgical Quality Improvement Program database (Canadian Task Force Classification II-2). RESULTS: Overall, 64% of myomectomies involved trainees. Trainees involvement was associated with a longer operative time for abdominal myomectomies (mean difference 20.17 minutes, 95% Confidence Interval (CI) [11.37,28.97], p < 0.01) overall and when stratified by fibroid burden. For laparoscopic myomectomy, there was no difference in operative time between trainees vs no trainees involvement (mean difference 4.64 minutes, 95% CI [-18.07,27.35], p = 0.67). There was a higher rate of transfusion with trainees involvement for abdominal myomectomies (10% vs 2%, p < 0.01; Odds Ratio (OR) 5.62, 95% CI [2.53,12.51], p < 0.01). Trainees involvement was not found to be associated with rate of transfusion for laparoscopic myomectomy (4% vs 5%, p = 0.86; OR 0.82, 95% CI [0.16,4.14], p = 0.81). For abdominal myomectomy, there was a higher rate of overall complications (15% vs 5%, p < 0.01; OR 2.96, 95% CI [1.77,4.93], p < 0.01) and minor complications (14% vs 4%, p < 0.01; OR 3.71, 95% CI [2.09,6.57], p < 0.01) with no difference in major complications (3% vs 2%, p = 0.23). For laparoscopic myomectomy, there was no difference in overall (6% vs 10% p = 0.41; OR 0.59, 95% CI [0.18,2.01], p = 0.40), major (2% vs 0%, p = 0.38), or minor (5% vs 10%, p = 0.32; OR 0.52, 95% CI [0.15,1.79], p = 0.30) complications. CONCLUSION: Trainees involvement was associated with increased operative time, rate of transfusion, and complications for abdominal myomectomy, however, did not impact surgical outcomes for laparoscopic myomectomy.

TITLE: Trainees Involvement in MyomectomyThe goal of our study was to determine the association of trainees involvement with surgical outcomes of fibroid excision surgery or myomectomy. We conducted a study of abdominal and laparoscopic myomectomies using an international surgical database. We found that trainees involvement in myomectomy was associated with increased operative time, rate of transfusion, and complications for abdominal myomectomy. However, trainees involvement did not impact surgical outcomes for laparoscopic myomectomy.

Therapeutic management of uterine tumours resembling ovarian sex cord tumours including a focus on fertility: A systematic review.

OBJECTIVE: Uterine tumours resembling ovarian sex cord tumours (UTROSCTs) are extremely rare. To date, most patients with UTROSCTs have undergone hysterectomy and had a benign clinical course. Fertility-preserving surgery should be considered because some patients with UTROSCTs are aged < 40 years. This paper reviews the treatment and prognosis for patients with UTROSCTs, with a focus on fertility. METHODS: PubMed, MEDLINE and Scopus were searched systematically for case reports and case series of UTROSCTs published in English from inception to December 2022, and initial treatment and recurrence rates were compared. The following data were extracted: age; symptoms; initial therapy; metastasis at diagnosis; disease-free survival (DFS); and recurrence. RESULTS: In total, 147 patients (72 studies) reporting the clinical course of UTROSCTs were analysed. The median age at diagnosis was 50 years, and 28 (19.0 %) patients were aged < 40 years. Most patients (n = 125, 85.0 %) underwent hysterectomy as the initial surgery, with a recurrence rate of 17.6 % (n = 22). The recurrence rate was 30 % (n = 6) in patients who underwent mass resection (n = 20). Among the 15 patients who underwent mass resection aged < 40 years, seven went on to achieve pregnancy (46.7 %) and six had successful deliveries (40.0 %). No significant differences in 5- and 10-year DFS were found between the hysterectomy and mass resection groups (p = 0.123 and 0.0612, respectively). Bilateral salpingo-oophorectomy in addition to hysterectomy was not significantly associated with 10-year DFS (p = 0.548). CONCLUSION: While total hysterectomy is the recommended treatment for UTROSCTs based on recurrence rates, mass resection is an acceptable treatment option for patients who wish to retain their childbearing potential. It is recommended that these women should plan for pregnancy and delivery as soon as possible after mass resection, and should undergo hysterectomy within 5 years.

The management of uterine tumor resembling an ovarian sex cord tumor (UTROSCT): case series and literature review.

AIMS: To present a case series of 11 rare uterine tumors resembling ovarian sex cord tumors (UTROSCTs), and review the literature on this topic to offer up-to-date treatment management for UTROSCTs. METHOD: Eight cases from Fujian Cancer Hospital between January 2017 and May 2023 and three patients from Fujian Union Hospital between October 2012 and October 2020 were retrospectively reviewed. All cases were pathologically confirmed as UTROSCTs by two senior and experienced pathologists. Clinical behaviors, medical data, histopathological features, therapy approaches, and survival outcomes were discussed. RESULTS: The median age at initial diagnosis was 53 years (29-70 years). 3 (27.3%) patients were under 40. Seven cases presented with abnormal vaginal bleeding, one with menstrual disorder, one with abnormal vaginal secretion, and two patients were accidentally found by physical examination without any symptoms. Three patients were initially misdiagnosed with endometrial cancer by MRI. Curettage was performed in all cases. Nine of them were well diagnosed by routine curettage, except for two samples, which were identified after surgery. Immunohistochemical biomarkers, such as CD99, Desmin, WT-1, CK, Vimentin, SMA, α-Inhibin, Ki67, CD56, ER, PR, and CR, tend to be positive in UTRO SCs patients. Six patients underwent hysterectomy with bilateral salpingo-oophorectomy. Two cases received a radical hysterectomy with bilateral salpingo-oophorectomy, retroperitoneal lymph node dissection, and omentum dissection. Three UTROSCTs were under observation after mass resection. The median PFS was 24 months (range 1-125 months). CONCLUSION: UTROSCT is a rare mesenchymal tumor with low malignant potential. Treatment modalities should be carefully considered to balance the therapy outcomes and patient needs. Surgery conservative management might be suitable for young women with fertility desires.

Chemotherapy is not needed when complete evacuation of gestational choriocarcinoma leads to hCG normalization.

BACKGROUND: The standard treatment for gestational choriocarcinoma is chemotherapy. OBJECTIVE: To describe the risk of recurrence with expectant management of gestational choriocarcinoma that has reached a normal human chorionic gonadotropin level after tumor removal without adjuvant chemotherapy. METHODS: A retrospective multicenter international cohort study was conducted from 1981 to 2017 involving 11 gestational trophoblastic disease reference centers with patient's follow-up extended until 2023. Clinical and biological data of included patients were extracted from each center's database. The inclusion criteria were i) histological diagnosis of gestational choriocarcinoma in any kind of placental tissue retrieved, ii) spontaneous normalization of human chorionic gonadotropin level following choriocarcinoma retrieval, iii) patient did not receive any oncological treatment for the choriocarcinoma, iv) and at least 6 months of follow-up after the first human chorionic gonadotropin level normalization. RESULTS: Among 80 patients with retrieved gestational choriocarcinoma and whose human chorionic gonadotropin level normalized without any other oncological therapy, none had a recurrence of choriocarcinoma after a median follow-up of 50 months. The median interval between choriocarcinoma excision and human chorionic gonadotropin level normalization was 48 days. The International Federation of Gynecology and Obstetrics/World Health Organization risk score was ≤6 in 93.7% of the cases. CONCLUSIONS: This multicenter international study reports that selected patients with gestational choriocarcinoma managed in gestational trophoblastic disease reference centers did not experience any relapse when the initial tumor evacuation is followed by human chorionic gonadotropin level normalization without any additional treatment. Expectant management may be a safe approach for highly selected patients.

Robot-assisted laparoscopic myomectomy: Technique & brief literature review.

The worldwide growth of robot-assisted laparoscopic surgery has been exponential since its FDA approval for use in gynecologic surgery in the spring of 2005. This growth has spanned the entire gamut of gynecologic procedures and pathology. One area that has leveraged the unique aspects of robotics has been its application to the conservative surgical management of uterine fibroids. This manuscript will review the surgical technique and highlight the current situation regarding the scientific literature with an evidence-based focus on the role of robot-assisted laparoscopic myomectomy (RALM) with the daVinci Surgical System (Intuitive Surgical, Sunnyvale, CA).

Multiple cutaneous and uterine leiomyomatosis: Reed's syndrome.

Reed's syndrome (RS) is a rare autosomal-dominant disorder characterised by multiple cutaneous and uterine leiomyomas, with a strong tendency for renal cell carcinoma (RCC) development. A woman in her 50s, who had previously undergone total abdominal hysterectomy due to multiple uterine leiomyomas, presented with painful nodules on her trunk and right arm for the past 6 years. These nodules were confirmed as leiomyomas through histopathology. Diagnosis of RS was established through clinicopathological correlation and positive family history, particularly her mother's. Early-onset uterine leiomyomas in patients with a similar family history should raise suspicion for RS, necessitating vigilant long-term follow-up. RCC detection requires mandatory renal imaging. Screening family members and providing genetic counselling are crucial.

Spinal intramedullary uterine carcinosarcoma metastasis.

Intramedullary spinal cord metastases (ISCM) are a rare and challenging manifestation of metastatic cancer that have devastating impacts on the individual's neurological function, survival expectancy and overall quality of life. Given the rarity and poor prognosis, there is a lack of consensus in management. Uterine carcinosarcoma itself is a rare cancer, accounting for less than 3% of all uterine cancers. It carries a poor prognosis, with only one-third of patients surviving beyond 5 years. There are no previous reports of uterine carcinosarcoma metastases to the spinal cord. Here, we present the case of a woman in her late 70s with a uterine carcinosarcoma intramedullary metastasis that was refractory to radiotherapy treatment and responded favourably to surgical debulking.

Adverse outcomes related to morcellation in Total Laparoscopic Hysterectomy.

OBJECTIVE: This study aimed to comprehensively evaluate the complications associated with morcellation in Total Laparoscopic Hysterectomy (TLH) procedures, providing evidence-based insights to enhance patient safety and surgical efficacy. DATA SOURCES: A comprehensive literature search was conducted using multiple databases, including PubMed, EMBASE, Google Scholar, and Cochrane Central Register of Controlled Trials. The inclusion criteria were Studies that focused on morcellation and morcellation-related complications were included. The risk of bias in the included studies was assessed using established evaluation scales. METHODS OF STUDY SELECTION: Thirteen studies investigating complications associated with morcellation in TLH (Total Laparoscopic Hysterectomy) were included in this review.This review covers intraoperative blood loss, length of hospital stay, loss of bag integrity, mean uterine specimen and weight, morcellation time, operation time, and TLH morcellation complications. TABULATION, INTEGRATION, AND RESULTS: The selected studies covered different approaches and aspects related to this procedure, providing valuable insights into the factors associated with complications and efficacy of the technique in various clinical settings.This review highlights the importance of evaluating and considering complications associated with morcellation in TLH. CONCLUSION: The findings of this review provide valuable insights into complications associated with morcellation in TLH. Clinicians could use this information to make informed decisions, implement safe protocols, and improve patient care. Addressing these complications will enhance the safety and efficacy of morcellation for TLH. Ethical Compliance: All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Evaluation of whether there is residual polyp tissue after hysteroscopic morcellation at Cam and Sakura City Hospital: a retrospective cohort study.

BACKGROUND: In polypectomy with mechanical hysteroscopic morcellators, the tissue removal procedure continues until no polyp tissue remains. The decision that the polypoid tissues were removed completely is made based on visual evaluation. In a situation where the polyp tissue was visually completely removed and no doubt that the polyp has been completely removed, short spindle-like tissue fragments on the polyp floor continue in most patients. There are no studies in the literature on whether visual evaluation provides adequate information at the cellular level in many patients in whom polypoid tissues have been determined to be completely removed. The aim of the present study was to analyze the pathological results of the curettage procedure, which was applied following the completion of polyp removal with operative hysteroscopy, and to evaluate whether there was residual polyp tissue in the short spindle-like tissue fragments that the mechanical hysteroscopic morcellator could not remove. The secondary aims of this study were to compare conventional loop resection hysteroscopy with hysteroscopic morcellation for the removal of endometrial polyps in terms of hemoglobin/hematocrit changes, polypectomy time and the amount of medium deficit. METHODS: A total of 70 patients with a single pedunculate polypoid image of 1.5-2 cm, which was primarily visualized by office hysteroscopy, were included in the study. Patients who had undergone hysteroscopic polypectomy were divided into two groups according to the surgical device used: the morcellator group (n = 35, Group M) and the resectoscope group (n = 35, Group R). The histopathological results of hysteroscopic specimens and curettage materials of patients who had undergone curettage at the end of operative hysteroscopy were evaluated. In addition, the postoperative 24th hour Hb/HCT decrease amounts in percentage, the polypectomy time which was measured from the start of morcellation, and deficit differences were compared between groups. RESULTS: In total, 7 patients in the morcellator group had residual polyp tissue detected in the full curettage material. The blood loss was lower in the morcellator group than in the resectoscope group (M, R; (-0.07 ± 0.08), (-0,11 ± 0.06), (p < 0.05), respectively). The deficit value of the morcellator group were higher (M, R; (500 ml), (300 ml), (p < 0.05), respectively). The polypectomy time was shorter in the morcellator group (M, R; mean (2.30 min), (4.6 min), (p < 0.05)). CONCLUSIONS: Even if the lesion is completely visibly removed during hysteroscopic morcellation, extra caution should be taken regarding the possibility of residual tissue. There is a need for new studies investigating the presence of residual polyp tissue.

Impact of superior hypogastric nerve block during uterine fibroid embolisation on pain scores, opioid requirements, and same-day discharge: a case-control study.

AIM: To assess the safety and efficacy of superior hypogastric nerve block (SHNB) in managing periprocedural pain associated with uterine fibroid embolisation (UFE) and in facilitating same-day discharge. MATERIALS AND METHODS: Prospectively enrolled case-control study with retrospective analysis comprising 119 eligible patients who underwent UFE for symptomatic fibroids was undertaken at a UK teaching hospital between January 2016 and September 2022. SHNB was administered to 62 participants in addition to systemic analgesia; 57 participants received systemic analgesia alone. SHNB was performed mid-UFE using 20 ml of 0.25% levobupivacaine. Pain scores were assessed using an 11-point (0-10) verbal numerical rating scale (NRS). The study received research and ethics committee approval. Statistical analysis was performed using the chi-square and independent t-test or Mann-Whitney U-test. A p-value of <0.05 defined significance. RESULTS: Participants who received SHNB experienced significantly less pain during the first 6 h post-procedure (averaged median pain score 2.6 versus 3.8, p=0.031). SHNB reduced the proportion of participants requiring post-procedural anti-emetics (45% versus 63%, p<0.05). For participants entered on the day-case pathway (SHNB = 34, no-SHNB = 16), those who received SHNB had a higher rate of successful same-day discharge (62% versus 31%, p=0.044). This SHNB group required significantly less opioids for periprocedural pain relief (median oral morphine equivalents; 44 mg versus 80 mg, p=0.020). No SHNB-related adverse events occurred. CONCLUSION: SHNB is safe and effective in reducing perioperative pain, opioid requirements, and anti-emetic use in patients undergoing UFE for symptomatic fibroids. SHNB, as an adjunct to analgesic optimisation, facilitates same-day discharge, which is often limited by severe post-embolisation pain.

Different clinical diagnosis end up in the same pathological diagnosis of intravascular leiomyomatosis: Two case reports.

RATIONALE: Intravascular/intravenous leiomyomatosis (IVL) is a peculiar variant of uterine leiomyoma that is classified as a histologically benign smooth muscle tumor with a biological behavior similar to that of a malignant tumor. It is characterized by the proliferation of leiomyomas spreading along the uterine and extrauterine venous circulation. PATIENT CONCERNS: Herein, we present 2 cases of IVL who had completely different clinical manifestations to stress the need for constant vigilance of IVL diagnosis and the understanding of uterine leiomyoma heterogenicity. Case 1 was registered for fever without specific triggering factors, irregular menstruation and clinically diagnosed uterine diverticula, while no information about fibroids was mentioned. Case 2 was characterized by an aggressively growing abdominal mass. With a large space-occupying lesion in the right abdominopelvic cavity and no imaging evidence of involvement of the iliac vein or above vein, the patient was initially diagnosed with multiple myomata. DIAGNOSES: Both patients' diagnoses were confirmed as IVL by histopathology. To our knowledge, the mass of case 1 is the minimum IVL in the English literature. INTERVENTIONS: Subtotal hysterectomy with bilateral salpingectomy was performed on the former, while total hysterectomy with bilateral salpingectomy was performed on the latter. OUTCOMES: Both patients were comfortable, and no relapse occurred. LESSONS: Two cases in the study showed 2 different proceeding stages of the same disease and corroborated multiple pathogeneses, which have been mentioned in the available literature on IVL. Our work provides both supplement for clinical data to facilitate further research and better understanding of special types of fibroids to clinicians.

vNOTES retroperitoneal transient uterine artery occlusion: a new approach to control bleeding during a high-risk evacuation of products of conception.

OBJECTIVE: To describe a retroperitoneal transient occlusion of the uterine or internal iliac artery in conjunction with a high-risk evacuation of products of conception. The procedure was performed vaginally, minimally invasively, via vaginal natural orifice transluminal endoscopic surgery. DESIGN: Description of the surgical technique using original video footage. This study was exempted from requiring hospital institutional review board approval. SETTING: Teaching hospital. PATIENT(S): A 34-year-old woman (G8P3) with a medical history of 2 cesarean sections, 1 partial mole, and a missed abortion with 2.8 L of blood loss. The patient presented after 10 weeks of amenorrhea. Ultrasound revealed a large blood-filled niche in the cesarean section scar with a thin overlying myometrium. A partial mole was suspected as well as increased vascularization in the myometrium and enhanced myometrial vascularity with arterial flow velocities of 100 cm/s. A risk of heavy blood loss in conjunction with curettage was anticipated. The patient had a strong preference for a fertility-preserving treatment, and after informed consent, she opted for transient occlusion of the uterine arteries with subsequent suction evacuation of the molar pregnancy. The patient signed a consent form accepting the procedure. The patient included in this video provided consent for publication of the video and posting of the video online including social media, the journal website, and scientific literature websites. Institutional review board approval was not required in accordance with the IDEAL guidelines. INTERVENTION(S): A vaginal incision was made over the bladder, and the vaginal mucosa was dissected. The paravesical space was dissected over the arcus tendinous, and the pelvic retroperitoneal space was opened. A small (7 cm) GelPOINT V-Path (Applied Medical, Rancho Santa Margarita, California) was inserted into the obturator fossa and insufflated with 10 CO2 mm Hg. Standard laparoscopic instruments were used through the gel port. Under endoscopic view, dissection to the right obturator fossa and iliac vessels was made, and the internal iliac artery was identified. A removable clip was placed on the origin of the right uterine artery. The same procedure was performed on the left side where the internal iliac artery was clipped. Different vessels were clipped to demonstrate and investigate the feasibility of both approaches. Both vessels were equally accessible. Care should be taken not to injure the uterine vein at the time of clipping. Dilation and evacuation was performed under transanal ultrasound surveillance. When hemostatic control was assured, first, the right clip was removed from the iliac artery. Hemostatic control was ensured, and after 10 minutes, the second clip on the left iliac artery was removed. The GelPOINT was removed, and the vaginal incision was sutured. The patient bled in total 500 mL. MAIN OUTCOME MEASURE(S): Not applicable. RESULT(S): The patient recovered swiftly without complications. Pathology confirmed a partial molar pregnancy. CONCLUSION(S): Uterine or internal iliac artery ligation can be lifesaving in situations with massive bleeding from the uterus. Current minimally invasive approaches are laparoscopic vessel ligation and, more commonly, uterine artery embolization, which has unclear impact on fertility and has shown an increased risk of intrauterine growth restriction, miscarriage, and prematurity. As the patient was undergoing a vaginal evacuation of pregnancy, a vaginal and retroperitoneal approach of artery ligation was deemed least invasive. In patients with fertility-preserving wishes, care should to be taken to avoid as much trauma as possible to the endometrium. Optimized blood control, and a shorter duration of using a curette, may potentially reduce the risk of endometrial damage. We present a novel minimally invasive approach via vaginal natural orifice transluminal endoscopic surgery-retroperitoneal transient occlusion of the internal iliac or uterine artery. The whole procedure can be performed by the operating gynecologist, and the occlusion is transient and can be reversed in a stepwise controlled manner.

Antenatal myomectomy of huge pedunculated fibroid.

A female patient in her 20s presented at 10 weeks of pregnancy with abdominal pain. She was known to have a 17-cm fibroid a year ago, which, on repeat imaging, was found to have increased in size to 29 cm. A 12-cm increase in size over a year therefore led to concerns that it would increase in pregnancy, causing risk of thrombosis, decrease in venous return, miscarriage, fibroid torsion, fibroid necrosis, preterm labour and uterine rupture. Following a multidisciplinary team review with obstetricians, neonatologists, gynaecologists and radiologists, the patient opted to proceed with an open myomectomy at 14 weeks gestation, which was performed successfully. The pregnancy continued uneventfully until term when she delivered a healthy girl infant at 38+2 weeks via an elective caesarean section.