Multidirectional Traction Method Using SURGICEL NU-KNIT and Surgical Suture in Robot-assisted Laparoscopic Surgery for Endometrial Cancer.

OBJECTIVE: To describe a novel approach to robot-assisted laparoscopic total hysterectomy (RH) for endometrial cancer that minimizes cancer sell spillage and develops a stable surgical field. DESIGN: Demonstration of the multidirectional traction method with narrated video footage. SETTING: Many reports have indicated that RH for endometrial cancer has the same or superior short-term results compared with conventional laparoscopic hysterectomy (LH), and the long-term prognosis is the same [1,2]. However, there are no randomized controlled trials of RH versus LH, and some previous reports [3] have suggested that RH has a worse prognosis than LH, so the long-term prognosis should be considered with caution. Factors that may affect the long-term prognosis include the use of uterine manipulators [4] and compression of the uterine body with robotic forceps without tactile sensation [3]. However, to the best of our knowledge, no surgical technique capable of avoiding these factors has been established yet. Herein, we report a multidirectional traction method using SURGICEL NU-KNIT (Ethicon; Johnson & Johnson Medical Ltd., Tokyo, Japan), a local hemostatic agent, and surgical sutures. INTERVENTION: Cut 2-0 Prolene (Ethicon; Johnson & Johnson Medical Ltd., Tokyo, Japan) with straight needles (ST-70) thread to 35 cm, stick a 1 × 2 cm piece of SURGICEL NU-KNIT, and make knots Fig. 1. This implement is used to puncture the incisional margins of the peritoneum and then the abdominal wall to bring the thread to the surface of the body, where it is grasped with forceps and fixed. By repeating this operation, multidirectional traction can be obtained Fig. 2. A manipulating suture is also attached to the uterus to minimize the compression of the uterine body with robotic forceps. CONCLUSION: The multidirectional traction method allows for reproducible stable surgical field development and minimizes cancer cell spillage by reducing uterine grasping by robotic forceps without the use of uterine manipulators.

Vaginal malignant peripheral nerve sheath tumor treated with complete surgical resection and postoperative radiation therapy.

Malignant peripheral nerve sheath tumors (MPNSTs) are neoplasms originating from or differentiating into nerve sheaths of peripheral nerves. Vaginal origin is rare, with only six vaginal primary cases reported to date. A 55-year-old woman presented to our hospital with a 7 cm vulvar mass. Tumor biopsy results were suspicious of sarcoma, and pelvic magnetic resonance imaging and hysterofiberscopy showed that the tumor originated from the lower vagina. The mass was transvaginally excised, and histological examination confirmed the diagnosis of a vaginal MPNST with negative surgical margins. The patient underwent radiotherapy because the risk of recurrence was high, owing to the large tumor size and high mitotic index. The patient remained recurrence-free for 1 year after the primary treatment. This is the first case of a high-risk vaginal MPNST that avoided early disease recurrence with additional radiotherapy after complete tumor resection.

The impact of assisted reproductive technology on the risk of postpartum hemorrhage: Difference by the mode of delivery and embryo transfer.

AIM: The frequency of postpartum hemorrhage (PPH) is increasing in developed countries, and some reports suggest that assisted reproductive technology (ART) increases various perinatal complications, including PPH. We investigated whether the effect of ART pregnancies on the incidence of PPH is modified by the mode of delivery. METHODS: A retrospective cohort study was performed. We analyzed the medical records of 2914 pregnant women, including 411 pregnancies achieved by ART, which were delivered in our hospital from 2017 to 2020. PPH was defined as hemorrhage exceeding the 90th percentile of blood loss per the mode of delivery and number of fetuses. Multivariable logistic regression analysis was used to assess the association between ART and PPH. Propensity score-matched analyses were used to assess the difference in the incidence of PPH by the mode of delivery. RESULTS: As previously reported, multivariable logistic regression analysis showed that ART pregnancy is an independent risk factor for PPH. Propensity score-matched analysis for with and without ART showed a 3.39-fold higher incidence of PPH for ART pregnancy in the vaginal delivery group (p < 0.001). CONCLUSIONS: The effect of ART pregnancies on the incidence of PPH differed depending on the mode of delivery. Only in vaginal delivery, ART pregnancy increased the incidence of PPH.

Abnormal menstruation after radical trachelectomy and its effects on fertility.

AIM: To evaluate and identify the risk factors for abnormal menstruation after radical trachelectomy. METHODS: This study included 58 patients who underwent radical trachelectomy at our hospital between April 2005 and January 2018. Patients were divided into groups of those with no change in postoperative menstruation (regular [R] group; n = 46) and those with abnormal menstruation such as amenorrhea or hypomenorrhea (irregular [I] group; n = 12). The perioperative characteristics and fertility of the groups were compared retrospectively. The data were statistically analyzed using Student's t-test, Fisher's exact test and Mann-Whitney U test for univariate analysis and logistic regression analysis for multivariate analysis, with the level of statistical significance set at P < 0.05. RESULTS: Based on Federation of Gynecology and Obstetrics staging, 54 patients had stage IB1, 2 had stage IB2 and 2 had stage IIA1 cervical cancer. Eight patients received neoadjuvant chemotherapy. Pretreatment tumor size, residual uterine cavity length and neoadjuvant and postoperative chemotherapy use were not significantly different between the groups. Abnormal menstruation was significantly more common in patients with postoperative pelvic infection (R group, 13.0%; I group, 58.3%) and cervical stenosis (R group, 15.2%; I group, 58.3%). CONCLUSION: To maintain healthy menstruation even after radical trachelectomy, it is important to prevent postoperative pelvic infection and cervical stenosis.

Value and limitation of conization as a diagnostic procedure for cervical neoplasm.

AIM: In the recent years, the number of cervical conization procedures performed for diagnostic or therapeutic purposes is increasing, accompanied by increased cervical neoplasia among young women. This study aimed to analyze the clinical data of patients who underwent conization in Japan. METHODS: Among the 14 832 cases of conization registered in 205 facilities over 2 years (2009-2011), the data of 2409 and 12 417 patients who underwent conization for diagnostic and therapeutic purposes, respectively, were retrospectively analyzed. RESULTS: The median age of the patients in diagnostic and therapeutic conization groups was 44 and 37 years, respectively. When comparing the diagnostic and therapeutic groups, 25.5% of the patients in the former were suspected with invasive cancer preoperatively, which is higher than that in the latter (2.7%). About 25.7% in the diagnostic and 14.1% in the therapeutic group had positive margin in the conization specimens. Additional treatment was required for 36.0% and 5.5% of the patients in the diagnostic and therapeutic groups, respectively, which are high figures for both. The risk factors of pathological upgrade in the conization specimens were diagnostic purpose, postmenopausal status and glandular lesion. Additional hysterectomy was performed in 1304 patients after conization, and pathological diagnosis was upgraded in 550 cases. Multivariate analysis revealed that postmenstrual status was an independent risk factor. CONCLUSION: This study revealed that cervical lesions of glandular lineage and patients with postmenopausal status benefit from diagnostic conization. However, in postmenopausal patients, the underlying disease cannot be excluded in the preserved uterus even by diagnostic conization.

Successful fertility preservation in stage II endometrial carcinoma with long-term progestin therapy: A case report.

Progestin therapy is a fertility-sparing treatment option for well-differentiated stage IA endometrioid carcinomas without myometrial invasion. Here, we present a case of successful pregnancy and live birth following long-term progestin therapy in a patient with stage II well-differentiated endometrioid carcinoma. A 30-year-old nulliparous woman with an unremarkable medical history presented with abnormal uterine bleeding. A 45 mm mass was identified in the lower uterine segment. An endometrial biopsy revealed grade 1 endometrioid carcinoma, leading to a diagnosis of stage II uterine corpus cancer based on hysteroscopic findings. The patient refused surgical treatment and underwent oocyte retrieval and cryopreservation at another hospital. A subsequent endometrial biopsy revealed a marked reduction in the Ki-67 index from approximately 60 % to less than 10 %, suggesting the possibility of a hormone-sensitive tumor. The patient persistently refused surgery. Therefore, progestin therapy with medroxyprogesterone acetate (MPA) at a dose of 400 mg/day was initiated as a temporary measure until the patient would accept surgery. The tumor gradually reduced in size and eventually disappeared after 9 months. The MPA therapy was discontinued uneventfully after 20 months. Sixteen months after the discontinuation of MPA therapy, atypical endometrial hyperplasia was detected, and a second round of MPA therapy was initiated. Progestin retreatment was successful and was discontinued at 6 months. Four years after the initial treatment, the patient achieved pregnancy through timed intercourse and delivered a healthy baby at 38 weeks of gestation.

Coexistence of ovarian cancer and peritoneal tuberculosis: a case report.

Peritoneal tuberculosis (TB) is known to mimic advanced ovarian cancer. In this case report, we describe a unique case of ovarian cancer (endometrioid carcinoma grade 3) at the International Federation of Gynecology and Obstetrics (FIGO) stage IC1 with pulmonary and peritoneal TB, which was suspected preoperatively to be a coexistence of advanced ovarian cancer and pulmonary TB. A 68-year-old woman presented with a prominent abdominal mass and fever. Laboratory investigations, imaging, and sputum analysis indicated a probable diagnosis of ovarian cancer at FIGO stage IIIC, characterized by peritoneal dissemination and para-aortic lymph node metastasis, which was further complicated by coexisting pulmonary TB. Surgical management included total abdominal hysterectomy, bilateral salpingo-oophorectomy, and partial omentectomy. Intraoperatively, the tumor was localized to the right ovary with significant peritoneal thickening and adhesions indicative of peritoneal TB. The surgery was completed without apparent complications. Postoperative histopathological evaluation confirmed grade 3 endometrioid carcinoma in the right ovary along with evidence of peritoneal TB. Given the extent of adhesions attributed to TB, lymph node dissection for staging was deemed challenging and was thus not pursued. Initiation of anti-TB treatment on postoperative day 2 resulted in marked regression of the preoperatively identified pulmonary nodules and para-aortic lymph node enlargement, suggesting their inflammatory origin from TB. Although postoperative chemotherapy is typically advocated for patients with stage IC1 endometrioid carcinoma grade 3, the patient opted against it. Consequently, no adjuvant therapy was administered and the patient remained under close observation.

Standardization of robot-assisted pelvic lymph node dissection-Development of a common understanding of regional anatomy and surgical technique based on cross-disciplinary discussion among colorectal surgery, urology, and gynecology.

BACKGROUND: Pelvic lymph node dissection is a procedure performed in gastroenterological surgery, urology, and gynecology. However, due to discrepancies in the understanding of pelvic anatomy among these departments, cross-disciplinary discussions have not been easy. Recently, with the rapid spread of robotic surgery, the importance of visual information in understanding pelvic anatomy has become even more significant. In this project, we attempted to clarify a shared understanding of pelvic anatomy through cross-disciplinary discussions. METHOD: From May 2020 to November 2021, a total of 11 discussions were held entirely online with 5 colorectal surgery specialists, 4 urologists, and 4 gynecologists. The discussions focused on evidence from each specialty and surgical videos, aiming to create a universally understandable pelvic anatomical illustration. RESULTS: The common area of dissection recognized across the three departments was identified as the obturator lymph nodes. A dynamic illustration of pelvic anatomy was created. In addition to a bird's-eye view of the pelvis, a pelvic half view was developed to enhance understanding of the deeper pelvic anatomy. The following insights were incorporated into the illustration: (1) the cardinal ligament in gynecology partly overlaps with the vesicohypogastric fascia in colorectal surgery; (2) the obturator lymph nodes continue cephalad into the fossa of Marcille in urology; and (3) the deep uterine vein in gynecology corresponds to the inferior vesical vein in colorectal surgery. CONCLUSION: Based on the dynamic illustration of pelvic anatomy from cross-disciplinary discussions, we anticipate advancements in pelvic lymph node dissection aiming for curative and safe outcomes.

Anatomical location of the surgically identifiable bladder branch of the inferior hypogastric plexus for nerve-sparing radical hysterectomy.

Objective: We aimed to demonstrate the entire structure of the inferior hypogastric plexus in the female pelvis focusing on surgically identifiable nerve bundles to the urinary bladder. Methods: Surgical videos of transabdominal nerve-sparing radical hysterectomy for 10 patients with cervical cancer at International Federation of Gynecology and Obstetrics (FIGO 2009) stage IB1-IIB were retrospectively analyzed. The paracervical tissue dorsal to the ureter was separated into the lateral component (dorsal layer of the vesicouterine ligament) and medial component (paracolpium) using Okabayashi's technique. Any bundle-like structures in the paracervical area were isolated and divided using cold scissors, and each cut edge was inspected to determine whether the bundle was a blood vessel or a nerve. Results: In all cases, the surgically identifiable nerve bundle of the bladder branch was identified on the rectovaginal ligament running parallel and dorsal to the vaginal vein of the paracolpium. The bladder branch was revealed only after complete division of the vesical veins in the dorsal layer of the vesicouterine ligament where no definitive nerve bundles were observed. The bladder branch was derived laterally from the pelvic splanchnic nerve and medially from the inferior hypogastric plexus. Conclusions: The surgical identification of the nerve bundle of the bladder branch is essential for a safe and secure nerve-sparing radical hysterectomy. The preservation of the surgically identifiable bladder branch from the pelvic splanchnic nerve as well as from the inferior hypogastric plexus can provide satisfactory postoperative voiding function.

A case of dedifferentiated carcinoma associated with grade 1 endometrioid carcinoma with prominent squamous differentiation at the lower uterine segment.

Locally advanced cervical squamous cell carcinoma is a rare indication for surgery. In this report, we describe the case of a patient with presumed locally advanced cervical squamous cell carcinoma who underwent surgical treatment and was postoperatively diagnosed with endometrial cancer with prominent squamous differentiation. A 41-year-old woman presented with squamous cell carcinoma that was detected via Pap smear and confirmed by histological diagnosis of cervical biopsy. Magnetic resonance imaging showed a bulky cervical mass that spread to the lower uterine segment, vaginal wall, and rectum. The initial diagnosis was cervical cancer stage IVA. The patient underwent neoadjuvant chemotherapy followed by radical hysterectomy with combined rectal resection. Postoperative histopathology revealed a dedifferentiated carcinoma of the uterine corpus with prominent squamous differentiation. Immunohistochemistry of the surgical specimen showed loss of expression of mismatch repair proteins. The patient was informed of the possibility of Lynch syndrome and was recommended genetic counseling.

Predictive score for postpartum hemorrhage in vaginal deliveries following frozen embryo transfer.

Objective: To develop a predictive score for life-threatening severe postpartum hemorrhage in vaginal deliveries following frozen embryo transfer. Materials and Methods: We conducted a retrospective cohort study of 315 singleton vaginal deliveries following frozen embryo transfer from 2017 to 2022. Severe postpartum hemorrhage was defined as hemorrhage exceeding 1500 mL. A predictive score was generated from maternal characteristics and obstetric complications before delivery. We performed multivariable logistic regression analysis using 2017-2020 data and assigned points to identified risk factors. The predictive score's accuracy was evaluated using 2021-2022 data. Results: A large baby (birth weight ≥3500 g), pre-delivery maternal body mass index ≥25 kg/m2, marginal or velamentous umbilical cord insertion, and history of postpartum hemorrhage were identified as risk factors. We assigned one point to a large baby, a pre-delivery maternal body mass index ≥25 kg/m2, and marginal or velamentous umbilical cord insertion, and two points to a history of postpartum hemorrhage. The sum of the points was defined as the predictive score. The cut-off was set at two points, with a score ≥2 points being the high-risk group and a score ≤1 point being the low-risk group. The predictive score demonstrated a sensitivity of 47.8%, specificity of 85.4%, positive predictive value of 45.8%, and negative predictive value of 86.4% in the 2021-2022 validation cohort. Conclusion: The predictive score identified severe postpartum hemorrhage in approximately half of the high-risk cases. Implementing measures such as autologous blood storage may facilitate rapid response during heavy bleeding and improve maternal prognosis.

Superradical Hysterectomy for Cervical Cancer as an Alternative to the Usual Okabayashi-Type Radical Hysterectomy.

Radical hysterectomy is a standard operation for invasive cervical cancers. However, if the invasion to the parametrium is more advanced than estimation in the operation, it is difficult to perform usual radical hysterectomy. Superradical hysterectomy was developed by Prof. Ryukichi Mibayashi of Kyoto University and was published in 1941, and has been performed for the limited cases by a part of Japanese gynecologic surgeons. Superradical hysterectomy is a procedure in which the soft tissues in the pelvis are removed en bloc by sequential processing of the internal iliac vessels, which leads to a complete dissection of the lymphatic tissue in the pelvis to the pelvic wall.

A case of laparoscopy-assisted vaginal cuff suturing for vaginal cuff dehiscence after total laparoscopic hysterectomy.

INTRODUCTION: Vaginal cuff dehiscence after hysterectomy is a rare complication and occurs in less than 1% of patients. It can present with serious complications, such as bowel evisceration and peritonitis. PRESENTATION OF CASE: A 51-year-old multigravida Korean woman underwent total laparoscopic hysterectomy for leiomyoma. Six months later, she reported lower abdominal pain and vaginal bleeding. Physical examination revealed rebound tenderness in the lower abdomen, and pelvic examination showed a small amount of vaginal bleeding with an evisceration of the small intestine through the vagina that exhibited healthy peristalsis. The eviscerated bowel, which seemed to be a part of the ileum, was carefully manually reduced transvaginally into the abdominal cavity. Laparoscopic observation revealed adhesions between the omentum, small intestine, and the peritoneum. Specifically, the small intestine was adhered around the vaginal cuff. An abdominal abscess was found in the left lower abdominal cavity. An adhesiotomy was performed and the abdominal abscess was removed and irrigated. Complete separation of the anterior and posterior vaginal cuff edges was obtained. The vaginal cuff was closed with interrupted 0-polydioxanone absorbable sutures without bowel injury. A 6-month follow-up examination revealed complete healing of the vaginal cuff. DISCUSSION: In this case, we were able to make use of both laparoscopic and transvaginal methods to perform a successful repair with a minimally invasive and safe technique. CONCLUSION: Laparoscopically assisted vaginal cuff suturing for vaginal cuff dehiscence after total laparoscopic hysterectomy was found to be effective, safe, and minimally invasive.

Peutz-Jeghers syndrome-associated atypical mucinous proliferation of the uterine cervix: a case of minimal deviation adenocarcinoma ('adenoma malignum') in situ.

We describe a case of a non-invasive precursor of minimal deviation adenocarcinoma (MDA) of the uterine cervix, associated with Peutz-Jeghers syndrome (PJS). A 27-year-old woman, who had been followed for PJS, was referred to the gynecology clinic. Colposcopic examination demonstrated a small polypoid lesion in the transformation zone. Microscopic examination of the biopsy specimen demonstrated papillary proliferation of the mucinous epithelium with bland nuclear morphology. Conization revealed lobular endocervical glandular hyperplasia (LEGH) with distinct nuclear anaplasia, as well as papillary proliferation of the mucinous epithelium with mild to moderate nuclear abnormalities. This case suggests that the incipient phase of PJS-associated MDA is related to atypical LEGH ("MDA in situ"), and indicates the importance of early screening and surveillance by gynecologists in cases of PJS to detect cervical adenocarcinomas.