Abstract: Submucous myomas cause infertility and recurrent pregnancy loss. Several studies have reported successful reproductive outcomes after hysteroscopic myomectomy (HM), but the risk of postoperative intrauterine adhesion is present. We performed laparoscopic myomectomy (LM) for a submucous myoma and second look laparoscopy under observation using a hysteroscope to evaluate the alteration in endometrial vascular density during surgery using vascular analysis software. The patient was a 33-year-old nulliparous infertile woman. She had one submucous myoma of 4 cm in diameter and 50-60% penetration into the myometrium (class T:II; the European Society of Hysteroscopy classification). The surface vascular density of the submucous myoma was 68.6% before the start of surgery, decreased to 51.4% upon vasopressin injection and increased to 67.6% at the end of LM. Intraabdominal and intrauterine adhesions were not seen at second look laparoscopy. The vascular density was 70.8%, and the rate of endometrial blood flow was increased to 112.5% by comparison with the vascular density before the start of surgery. HM is a safe and effective procedure, but carries the risk of scarring the uterine cavity with uterine adhesions. We have to consider LM for women of reproductive age who have a submucous myoma with penetration >50% into the myometrium (class T:II).
Abstract: Abstract There are two different types of hysterocopes available: Flexible and rigid. Flexible scopes have the ability to observe the whole intrauterine cavity, but it is difficult to perform an operation on endometrial lesions. Rigid hysteroscopes provide superior optical qualities due to higher pixel count. We report the use of a new flexible hysteroscope with narrow band imaging (NBI) system (HYF-V EndoEYE Flexible Video Hysteroscope) and compared the optical qualities of this flexible to those of a rigid hysteroscope using the vascular analysis software "SolemioENDO ProStudy". Twenty-four images of endometrium in eight cases, and 12 images of submucous myoma in six cases were each photographed by two the hysteroscopes. The vascular densities of both endometrium and myoma under conventional light in the flexible scope were significantly higher than with the rigid scope. However the vascular densities under narrow-band light in the two scopes were not significantly different. The vascular densities of the images taken by flexible scope were higher than the images taken by rigid scopes under conventional light. With the rigid scope, microvascular structure may be crumpled by high water pressure. A flexible hysteroscope with NBI system has superior ability to observe the intrauterine cavity and measure vascular density compared to a rigid scope.
Abstract: Myoma of the uterine cervix is rare, accounting for about 5% of all myomas. Compared with myomas that occur in the uterine corpus, cervical myomas are closer to other organs such as the bladder, ureter, and rectum, and the approach needs to be modified because the organs that have to be considered differ depending on the location of the myoma. We divided cervical myomas into 2 types according to location, comprising an intracervical type and extracervical types. A clear outline of surgical treatment for cervical myoma has not described in previous papers. We then investigated the surgical strategy for these types.
Abstract: The development and onset of endometriosis is associated with angiogenesis and angiogenic factors including cytokines. We analyzed intrapelvic conditions in women with endometriosis via vascular density assessment of grossly normal peritoneum and determination of cytokine levels in peritoneal fluid. Seventy-three patients underwent laparoscopic surgery because of gynecologic disease including endometriosis in our department using a narrow-band imaging system. Each patient was analyzed for peritoneal vascular density using commercially available vascular analysis software (SolemioENDO ProStudy; Olympus Corp, Tokyo, Japan). Each patient was also subjected to analysis of interleukin 6 (IL-6), IL-8, tumor necrosis factor-alpha, and vascular endothelial growth factor concentrations in peritoneal fluid. We defined 4 groups as follows: group 1, endometriosis: gonadotropin-releasing hormone (GnRH) agonist administration group (n=27); group 2, endometriosis: GnRH agonist nonadministration group (n=15); group 3, no endometriosis: GnRH agonist administration group (n=18); and group 4, no endometriosis: GnRH agonist nonadministration group (n=13). No significant differences in peritoneal vascular density between the 4 groups were found under conventional light; however, under narrow-band light, vascular density in the endometriosis groups (groups 1 and 2) was significantly higher. Cytokine analysis of the 4 groups determined that IL-6 and IL-8 concentrations were significantly higher compared with the no endometriosis groups (groups 3 and 4). Tumor necrosis factor-alpha and vascular endothelial growth factor concentrations were not significantly different between groups. In endometriosis, peritoneal vascular density was significantly higher as assessed using the narrow-band imaging system and SolemioENDO ProStudy, whereas GnRH agonist did not obviously decrease vascular density but IL-6 concentration was lower in the GnRH agonist administration group.
Abstract: In order to reduce the risk of visceral injury for patients with upper abdominal adhesions, we devised an alternative to the umbilical approach. Five patients who had undergone a previous upper abdominal laparotomy and were scheduled for gynecologic laparoscopic surgeries at our hospital were evaluated. A micro-trocar was inserted via the posterior vaginal fornix and the periumbilicus was observed using a micro-laparoscope inserted in the micro-trocar. A trocar for conventional laparoscopy was inserted into the umbilicus under micro-laparoscopic observation in the cul-de-sac to avoid visceral organ adherent to the periumbilicus. Four cases had adhesions of the transverse colon, small bowel or omentum to the upper abdomen due to previous surgery; however, we were able to accomplish laparoscopic surgery without injury to adhesive organs in all patients. The micro-laparoscopic primary approach via the posterior vaginal fornix is a safe primary approach for patients who have undergone a previous upper abdominal laparotomy.
Abstract: To evaluate factors contributing to uterine scar formation after laparoscopic myomectomy (LM) and to estimate whether uterine scarring indicated risk of uterine rupture.
Abstract: To estimate the incidence of complications arising during gynecologic laparoscopic surgery in patients who have undergone previous abdominal surgeries and to assess predictable factors associated with complications based on the characteristics of the previous laparotomy.
Abstract: At fertilization, mammalian eggs show repetitive transient [Ca2+]i rises each of which is due to Ca2+ release from the endoplasmic reticulum through inositol 1,4,5-trisphosphate (IP3) receptors. During fertilization, a factor from the sperm, the sperm factor, is released into the oocyte and induces a long-lasting series of Ca2+ spikes (Ca2+oscillations) that are required for egg activation. IP3–producing enzyme phospholipase C zeta (PLCζ) is a strong candidate for the sperm factor. The Ca2+　spikes initiate the extrusion of cortical granules that block the entry of other sperm. At the same time, maturation (M-phase) promoting factor (MPF) is inactivated by the Ca2+　oscillations, results resulting in exit from metaphase II arrest. Meiosis resumes with formation of the second polar body and complete meiotic division, one-cell embryos with the male and female pronuclei attain the first cleavage division through nuclear envelope breakdown.
Abstract: A pilot study was designed to analyze the vascular density of peritoneal endometriosis in 3 groups of lesions (red, black, and white) in 23 patients with peritoneal endometriosis who underwent laparoscopic surgery using the narrow-band imaging system and vascular analysis software. In the peritoneum, 21 red lesions were present in 10 patients, 12 black lesions were present in 9 patients, 12 white lesions were present in 8 patients, and 2 types of lesion were concomitantly present in 4 patients. Median vascular density of red, black, and white lesions under conventional light was 60.3%, 62.3%, and 60.6%, respectively, and under narrow-band light was 64.4%, 61.5%, and 62.0%, respectively, showing no significant differences among the lesions under either conventional or narrow-band light (p=.71 and p=.84, respectively). The median difference in vascular density under narrow-band and conventional light was not significantly different in black lesions (0.8%) or white lesions (1.0%); however, a difference of 4.5% was noted for red lesions (p <.001). We conclude that red lesions are indicative of early-stage endometriosis with angiogenesis. Use of the narrow-band system and vascular analysis software can enable accurate, objective, and reproducible evaluation of vascular density.
Abstract: In embryonic natural orifice transumbilical endoscopic surgery, more than 1 port is inserted through the umbilicus. In the present study, embryonic natural orifice transumbilical endoscopic surgery combined with a flexible scope was used to further improve gynecologic surgery. A surgical incision was made in the umbilical region to enter the abdominal cavity using the closed approach. A 12-mm port was placed at the umbilical incision, and the 5-mm flexible scope was inserted through the port. Another surgical port was then made in the left inguinal region for insertion of a 5-mm port while monitoring it with the flexible scope. The flexible scope was then inserted through the 5-mm inguinal port, and another 5-mm port was inserted caudal to the 12-mm port while monitoring the umbilical region with the flexible scope. The 12- and 5-mm ports were inserted through the same umbilical incision so that they were positioned vertically. The surgeon stood on the left side of the patient to manipulate the 12-mm umbilical port with the right hand and the 5-mm inguinal port with the left hand. An assistant surgeon inserted the flexible scope through the 5-mm umbilical port and manipulated it with the left hand to secure the view during surgery by appropriately adjusting the angle of the flexible scope. With the present technique, the flexible scope did not interfere with the forceps inside or outside of the body cavity because its angle could be freely set. Since March 2, 2009, we have performed 8 procedures using this surgical technique including 1 salpingectomy, 3 ovarian cystectomies, 2 total laparoscopic hysterectomies, 1 linear salpingostomy, and 1 total laparoscopic myomectomy. Intracorporeal suturing was performed in all cases but one because a suture needle could be easily inserted through the 12-mm port. Furthermore, total laparoscopic myomectomy could be completed using a 12-mm power mocellator inserted through the 12-mm port. The flexible scope and forceps did not hinder each other either inside or outside of the body cavity. Use of the flexible scope enables the conventional rigid straight forceps to be used in almost the same manner as with the conventional laparoscopic technique.
Abstract: Purpose: To assess outcomes in assisted reproductive technology (ART) in infertile women with endometriosis with respect to their concommittant endometrioma status and surgical history in our department.
Methods: This is a retrospective case control study which analyzes informational data obtained at a university hospital. The study drew from a patient pool of 332 cases (877 cIVF/ICSI cycles) that took place in our department from 2006-2008. 61 cases (97 cycles) had major indications for cIVF/ICSI with endometriosis. We classified groups from these 61 cases as follows: an unoperated endometrioma group (A) with 31 cycles, a postoperative endometrioma group (B) with 51 cycles, and a no endometrioma group (C) with 15 cycles. We analyzed and compared these three groups and also included a non-endometriosis tubal infertility group (D) with 27 cycles.
Results: In the control group (D), serum FSH levels and the cancellation rates were significantly lower than other groups, and the number of developing follicles was higher. E2 levels before oocyte aspiration in the postoperative endometrioma group (B) was lower. Implantation, pregnancy, delivery and miscarriage rates were not significantly different among the 4 groups.
Conclusion: The results suggest that endometriosis causes a decrease in endocrinologic ovarian function whether or not endometrioma is also present. As for E2 level before oocyte aspiration, our results suggest that ovarian reserves might be reduced by endometrioma excision, but this is difficult to evaluate. In endometriosis groups, cancellation rates were significantly higher, although when embryos were transferred the pregnancy rates were not significantly different when compared with the non-endometriosis group. As for infertile women with endometrioma, our results suggest that preexisting ovarian reserve is reduced by the presence of endometriosis, and ovarian reserve might also be reduced by excision of endometrioma.
Abstract: To produce a successful pregnancy in a 38-year-old infertile patient with relapsed myoma using a technique we refer to as 'surgery-assisted reproductive technology (ART) hybrid therapy' because it combines ART for cryopreservation of in vitro fertilized eggs with reproductive surgery.
Abstract: Testicular feminization findings in a 24-year-old woman closely resembled those of Mayer-Rokitansky-Kuster-Hauser syndrome with persistent müllerian remnants and wolffian duct regression.
Abstract: PURPOSE: To evaluate the usefulness of MRI jelly method (jelly method). MATERIALS AND METHODS: Fifty-five patients (32.7 +/- 5 years old) with endometriosis, treated with laparoscopic surgery between January and June 2005 with preoperative MRI using the jelly method. In imaging by the jelly method, 50 mL of jelly used for ultrasound was injected into the vagina, and 150 mL of jelly diluted twice with tap water was injected into the rectum. MRI were inspected for the following seven findings: (Finding 1) Uterine position (anteflexion or retroflexion); (Finding 2) Thickness of the posterior uterine wall (adenomyosis uteri); (Finding 3) Ascites in the Douglas' pouch; (Finding 4) Elevated posterior uterine fornix; (Finding 5) Thickening of the "Haustra"; (Finding 6) Elevated anterior rectal wall; and (Finding 7) Douglas' pouch lesion visualized as a high-intensity area on a T1-weighted image. The latter four findings were enhanced with the jelly method. These seven findings were examined for their correlations with video findings of adhesion during surgery. RESULTS: CCDSO was present in 30 of 55 patients. These seven findings had accuracies of 69.1%, 70.9%, 72.7%, 74.5%, 56.4%, 83.6%, and 81.8% respectively. Findings 6 and 7 showed high accuracy. CONCLUSION: These two findings could only be obtained using the jelly method, indicating the usefulness of this method for diagnosing CCDSO.
Abstract: HEADING AIMS: We evaluated tubal disorders, including peritubal adhesions, as risk factors for repeat ectopic pregnancy (REP) after laparoscopic linear salpingotomy (LS) or salpingectomy for tubal pregnancy. METHODS: This was a retrospective clinical study in a university hospital. RESULTS: Of 43 women monitored for at least 6 months after LS, 28 (65%) subsequently conceived. In 24 (86%) of these women the pregnancy was intrauterine, and four (14%) had REP. Of 40 women with a unilateral tube monitored for at least 6 months after salpingectomy, 24 (60%) conceived. In 17 (71%) of these women the pregnancy was intrauterine, and seven (29%) had REP. There was no significant difference between groups in postoperative pregnancy or REP rates. There was no significant difference in the mean adhesion score by revised American Fertility Society stage points (re-AFS) at operation and the site of subsequent pregnancy in either the LS or the salpingectomy group, although the mean re-AFS score was significantly higher in women who had REP (3.1) than in those whose subsequent pregnancy was intrauterine (0.4). CONCLUSIONS: There was no significant difference in postoperative pregnancy or REP rates following previous LS or salpingectomy. The re-AFS score appeared to be an accurate predictor of the prognosis of subsequent pregnancies.
Abstract: OBJECTIVE: To define diagnostic criteria for juvenile cystic adenomyoma (JCA), describe the histologic features of the condition and evaluate laparoscopic excision for treating associated dysmenorrhea and pelvic pain. DESIGN: Prospective long-term follow-up study. SETTING: University-affiliated hospital. PATIENT(S): Nine consecutive patients with JCA. INTERVENTION(S): Patients meeting the diagnostic criteria for JCA underwent laparoscopic enucleation of the lesion. The severity of dysmenorrhea was evaluated before surgery and every 6 months after surgery. Five patients underwent second-look laparoscopy (SLL) 6 months after surgery. MAIN OUTCOME MEASURE(S): Relief of dysmenorrhea as measured by a visual analog scale, postoperative healing at SLL, and subsequent pregnancy when desired by the patient. RESULT(S): Laparoscopic enucleation of the cystic adenomyoma resulted in a statistically and clinically significant reduction in dysmenorrhea and improved chronic pelvic pain. Neither cystic adenomyoma nor severe dysmenorrhea recurred during the follow-up period. Adhesions were minimal at SLL. Two of the three patients who desired pregnancy conceived after surgery. The histologic findings of the JCA lesion and adenomyosis were similar, and the endometrial glands and stroma infiltrating the surrounding myometrium in all patients were consistent with the appearance of adenomyosis. CONCLUSION(S): We defined the diagnostic criteria for JCA, and demonstrated significant improvement of dysmenorrhea after laparoscopic excision of the lesion.
Abstract: Phospholipase C-zeta (PLCzeta), a strong candidate of the egg-activating sperm factor, causes long-lasting series of Ca2+ spikes and thereby egg activation when expressed in mouse eggs by injection of cRNA. PLCzeta moves into the formed pronucleus (PN), and Ca2+ spikes disappear at PN stage. Relationship between nuclear transLocation of PLCzeta and cessation of Ca2+ oscillations was addressed using various concentrations of wild-type RNA and point mutant K377E RNA having the comparable expression efficiency. PLCzeta-induced Ca2+ spikes with 20-30 min intervals similar to those at fertilization ceased between 50 min before and 15 min after the time of complete PN formation (TPN) approximately 5 h after the first Ca2+ spike, whereas Ca2+ oscillations induced by K377E lacking nuclear translocation ability continued over 9 h. Formation of the nuclear envelope (NE) began 50-60 min before T(PN), visualized by labeling the endoplasmic reticulum network with fluorescent dye Dil and ER-targeting protein ER-DsRed2. PLCzeta entered the PN as soon as the NE was formed, and accumulated in enlarging PN. After in vitro fertilization as normal as possible, the last Ca2+ spike occurred between 25 min before and 35 min after initiation of NE formation in most cases. Thus, sequestration of PLCzeta into the PN participates in termination of Ca2+ oscillations at the interphase in the mouse 1-cell embryo.
Abstract: Phospholipase C-zeta (PLCzeta), a strong candidate of the egg-activating sperm factor, causes long-lasting series of Ca(2+) spikes and thereby egg activation when expressed in mouse eggs by injection of cRNA. PLCzeta moves into the formed pronucleus (PN), and Ca(2+) spikes disappear at PN stage. Relationship between nuclear translocation of PLCzeta and cessation of Ca(2+) oscillations was addressed using various concentrations of wild-type RNA and point mutant K377E RNA having the comparable expression efficiency. PLCzeta-induced Ca(2+) spikes with 20-30min intervals similar to those at fertilization ceased between 50min before and 15min after the time of complete PN formation (T(PN)) approximately 5h after the first Ca(2+) spike, whereas Ca(2+) oscillations induced by K377E lacking nuclear translocation ability continued over 9h. Formation of the nuclear envelope (NE) began 50-60min before T(PN), visualized by labeling the endoplasmic reticulum network with fluorescent dye DiI and ER-targeting protein ER-DsRed2. PLCzeta entered the PN as soon as the NE was formed, and accumulated in enlarging PN. After in vitro fertilization as normal as possible, the last Ca(2+) spike occurred between 25min before and 35min after initiation of NE formation in most cases. Thus, sequestration of PLCzeta into the PN participates in termination of Ca(2+) oscillations at the interphase in the mouse 1-cell embryo.
Abstract: OBJECTIVE: To explore diaphragmatic lesions that are potentially associated with catamenial pneumothorax by using an advanced flexible laparoscope with wide optic angle. DESIGN: Case report. SETTING: University hospital. PATIENT(S): A 30-year-old woman who was scheduled for thoracoscopic surgery because of recurrent right-sided catamenial pneumothorax. INTERVENTION(S): The peritoneal surface of the diaphragm was explored with an advanced flexible laparoscope that was equipped with a charge-coupled device on the tip, concurrently with thoracoscopic surgery. MAIN OUTCOME MEASURE(S): Lesions associated with endometriosis on the peritoneal surface of the posterior diaphragm abutting the posterior abdominal wall and liver. RESULT(S): When the flexible laparoscope was inserted via an umbilical trocar and the peritoneal surface of the right-sided diaphragm was explored, guided by illumination from the thoracoscope, scattered specific lattice lesions and fenestrations were identified in the central tendon of the posterior diaphragm, a region that cannot be visualized with the conventional rigid laparoscope. CONCLUSION(S): By using the flexible laparoscope, endometriotic lesions potentially related to catamenial pneumothorax were identified on the posterior diaphragm.
Abstract: STUDY OBJECTIVE: A questionnaire survey of patients discharged after laparoscopic surgery was performed to investigate and analyze the recovery of activity of daily living (ADL) 1 month after surgery. DESIGN: Retrospective study (Canadian Task Force classification II-2). SETTING: University hospital. PATIENTS: Two hundred ten patients who underwent laparoscopic surgery from June 1, 2003 through March 31, 2004, other than those who underwent total hysterectomy or emergency surgery. INTERVENTION: Laparoscopic surgery. MEASUREMENTS AND MAIN RESULTS: At discharge, all patients were given a questionnaire form with the following instructions: "Except for bathing and sport activities, you may do everything unless you feel wound pain." In principle, they were discharged on postoperative day 2. The subjects were asked to record in the questionnaire form the time when they could carry out ADL for the first time after surgery, and the time to recovery was compared among 3 major surgical procedures (myomectomy, adnexal surgery, and resection of deep infiltrating endometriosis), for blood loss level, and duration of surgery. The questionnaire form was collected at the clinical visit 1 month after surgery. The collection rate of the questionnaire was 92.4%. The mean (95% CI) of days (disease day) before the subjects could do ADL for the first time after surgery was 5.4 (4.5-6.3) for housekeeping, 5.6 (4.7-6.5) for shopping, 11.6 (10.1-13.2) for bathing, 11.8 (10.2-13.5) for bicycle riding, 12.5 (11.4-13.7) for office work, 12.8 (11.6-13.9) for light exercise, 16.0 (13.7-18.3) for physical work, and 18.1 (15.0-21.2) for sport activities. This indicates that the postoperative period for recovery tended to be longer for the activities with larger burden. The postoperative period before recovery was not significantly influenced by the surgical technique, duration of surgery or blood loss level. CONCLUSION: The recovery of ADL occurred quickly after laparoscopic surgery. Most of the patients could return to their preoperative ADL within 1 month. Although the recovery status was almost constant, irrespective of the surgical technique or invasiveness level, the number of days required for recovery varied more likely because of various factors including sensitivity to pain, character, and living environment of the patients.
Abstract: STUDY OBJECTIVE: To estimate the feasibility and safety of vaginal birth after laparoscopic myomectomy (LM). DESIGN: Prospective clinical study (Canadian Task Force classification II-2). SETTING: University hospital. PATIENTS: The study was performed on 1334 patients who underwent LM at our hospital from January 2000 through December 2005. INTERVENTIONS: Laparoscopic myomectomy. MEASUREMENTS AND MAIN RESULTS: The potential of a safe vaginal birth after LM was discussed with all 1334 patients before and after their LM. A strict protocol for a vaginal birth after LM was prepared using the criteria for a vaginal birth after cesarean section (CS). Of the 221 women who became pregnant after LM by December 2006, 111 were scheduled to deliver at our hospital. The findings at LM in these patients were as follows: mean diameter of the largest myoma (mean +/- SD, 95% CI), 66.1 +/- 18.8 (62.6-69.6) mm; and mean number of enucleated myomas, 3.5 +/- 3.6 (2.8-4.2). The endometrium was opened in 13 patients. Of the 111 patients, 82 patients opted for a vaginal delivery and 29 patients requested a CS. Of the 82 patients, 8 underwent an elective CS because of complications of pregnancy. Vaginal delivery was completed in 59 (79.7%) of the remaining 74 patients. The 15 patients who failed vaginal delivery underwent a CS: eleven because of failure to progress in labor or absence of spontaneous labor by 42 weeks of gestation; and 4 because of a nonreassuring fetal status during labor. No significant differences in delivery outcomes existed between the successful and failed group. None of the patients had a uterine rupture. CONCLUSION: Uterine rupture during pregnancy after LM is rare, and vaginal birth after LM appears to be safe in selected patients who meet our criteria.
Abstract: Sperm-specific phospholipase C-zeta (PLCzeta) causes intracellular Ca(2+) oscillations and thereby egg activation and is accumulated into the formed pronucleus (PN) when expressed in mouse eggs by injection of cRNA encoding PLCzeta, which consists of four EF-hand domains (EF1-EF4) in the N terminus, X and Y catalytic domains, and C-terminal C2 domain. Those activities were analyzed by expressing PLCzeta mutants tagged with fluorescent protein Venus by injection of cRNA into unfertilized eggs or 1-cell embryos after fertilization. Nuclear localization signal (NLS) existed at 374-381 in the X/Y linker region. Nuclear translocation was lost by replacement of Arg(376), Lys(377), Arg(378), Lys(379), or Lys(381) with glutamate, whereas Ca(2+) oscillations were conserved. Nuclear targeting was also absent for point mutation of Lys(299) and/or Lys(301) in the C terminus of X domain, or Trp(13), Phe(14), or Val(18) in the N terminus of EF1. Ca(2+) oscillation-inducing activity was lost by the former mutation and was remarkably inhibited by the latter. A short sequence 374-383 fused with Venus showed active translocation into the nucleus of COS-7 cells, but 296-309 or 1-19 did not. Despite the presence of these special regions, both activities were deprived by deletion of not only EF1 but also EF2-4 or C2 domain. Thus, PLCzeta is driven into the nucleus primarily by the aid of NLS and putative regulatory sites, but coordinated three-dimensional structure, possibly formed by a folding in the X/Y linker and close EF/C2 contact as in PLCdelta1, seems to be required not only for enzymatic activity but also for nuclear translocation ability.
