Total laparoscopic hysterectomy (TLH) was reported to be associated with increased risk of vaginal cuff dehiscence (VCD) as compared with abdominal or vaginal hysterectomy. Although there are several data on technical causes of VCD after TLH, the inaccurate adaption of vaginal cuff layers is an important cause of VCD. Therefore, we use the following three techniques to make an accurate adaption of vaginal cuff layers. First, we cut the vaginal wall thinly, and then we make further incisions in the muscle layer to divide it into two or three layers. Thereby, the vaginal cuff surface becomes hierarchical and wider. Second, we cut the uterosacral ligament at its attachment to the uterus, and make an incision in the vaginal posterior wall at the level of vaginal fornix. Accordingly, the vaginal cuff becomes wider and thicker. Finally, we suture the two layers of the vaginal cuff by matching the layer to the layer. In our view, using the above techniques could be useful and reasonable to avoid VCD, especially in terms of getting good healing of the vaginal cuff. [Adv Obstet Gynecol, 69 (2) : 71-76 , 2017 (H29.5)]
Borderline ovarian epithelial tumors account for around 10-15% of all ovarian epithelial tumors. Many of these are diagnosed as Stage I, and an overall recurrence rate of 4-12.4% and a 10-year survival rate of approximately 95% have been reported. Because borderline tumors tend to occur more frequently in younger individuals compared with malignant tumors, the preservation of fertility is an important consideration. In the present study, we examined 54 cases of borderline ovarian epithelial tumors whose primary surgeries were performed in our hospital. We investigated the postoperative course of fertility-sparing surgery, and the accuracy of pre-operative diagnosis and intraoperative histopathological examination. The median patient age was 43.5 years old; 23 patients were less than 40 years old, of which 18 were nulliparous. Preoperative PET/CT was performed in 19 cases and the median SUV max was 2.2. Fifty-two cases were diagnosed as Stage I and two cases were diagnosed as stage III. Histological examination revealed that 32 cases were mucinous, 17 were serous, one was endometrioid, one was clear cell and three were mixed epithelial. Intraoperative pathological examinations were carried out in 46 cases. Divergences with the final histopathological diagnosis were observed in six cases, and two patients underwent a second surgery. Fertility-sparing surgeries were performed in 24 cases. Of the nine patients who wished to become pregnant, nine pregnancies have occurred in six of the patients. The median postoperative follow-up period was 46 months, and in only one case, in which an ovarian cystectomy was performed for a mucinous borderline tumor, a recurrence in the affected ovary was observed after 35 months, for which the patient underwent a unilateral salpingo-oophorectomy. The patient has not had a recurrence since, and has given birth. Though the usefulness of PET/CT to distinguish borderline tumors has been suggested, further improvements in preoperative diagnosis are required. When selecting a fertility-sparing surgery, stringent informed consent and careful follow-up will be necessary considering the risk of recurrence. [Adv Obstet Gynecol, 69 (2) : 77-84, 2017 (H29.5)]
Duplex uterus of the uterus with unilateral vaginal obstruction and morphological renal anomaly on the same side is termed obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) syndrome. We report a case of OHVIRA syndrome in which the patient underwent vaginal wall fenestration following a diagnosis of a vaginal wall tumor resulting from pregnancy and an inevitable miscarriage of an affected uterus. The patient was a 26-year-old gravida 0 who originally had strong symptoms of dysmenorrhea. She had been diagnosed with a bicornuate bicollis uterus, left kidney aplasia, and a left vaginal wall tumor; however, because of no symptoms except for dysmenorrhea, a wait-and-see approach was used. The patient was pregnant and visited her primary physician, who confirmed that the gestational sac was present within the left uterus. At seven weeks during her pregnancy, the patient was referred to our hospital for pregnancy management. Two days before her transfer, the patient had vaginal bleeding and lower abdominal pain. Ultrasound revealed no gestational sac within the left uterus, and the patient was diagnosed with an inevitable miscarriage. A protruding left vaginal wall tumor 4 cm in diameter was observed. However, a thorough examination was difficult because of the pain; therefore, the patient was hospitalized for diagnostic testings for the vaginal wall tumor. Pelvic magnetic resonance imaging revealed a vaginal wall tumor spanning the duplex uterus to the left cervical canal, suggesting that the aborted tissue from the pregnancy in the left uterus had accumulated in the closed left vaginal cavity. Following hospitalization, vaginal bleeding including blood clots and reduction of the left vaginal wall tumor were observed, which indicated incomplete closure of the left vaginal wall and formation of a fistula in one area. The patient was diagnosed with OHVIRA syndrome with incomplete closure and underwent vaginal fenestration under lumbar anesthesia. The presence of a fistula in the left vaginal wall was confirmed, and the vaginal wall was fenestrated at this site. Histopathological examination revealed stratified squamous cell tissue in the resected vaginal wall. The patient was discharged following a good postoperative course with markedly improved symptoms of dysmenorrhea. [Adv Obstet Gynecol, 69 (2) : 85-92, 2017 (H29.5)]
A 45-year-old nulligravida visited a local clinic with the complaint of cervical tumor. She was referred to the department of internal medicine at our hospital because of lymphadenopathy in a supraclavicular node. Positron emission tomography-computed tomography showed abnormal signals in multiple lymph nodes from the neck to the pelvic cavity, indicating multiple metastases; however, no origin of disease was detected. Pathological examination by lymph node biopsy showed serous carcinoma, and immunohistochemical staining suggested gynecological cancers. The patient was referred to our department for the examination of gynecological cancers. No abnormal findings were detected on pelvic examination. Uterine cervical cytology showed adenocarcinoma, with origin in the uterine corpus or ovary. Enhanced magnetic resonance imaging showed a tube-like lesion behind the left ovary, which suggested tubal swelling. Laparoscopic examination showed left tubal swelling without left ovarian swelling or peritoneal dissemination. Left salpingo-oophorectomy was performed. Cytology-positive ascites was observed. Pathological examination findings indicated high-grade serous carcinoma in the left tube, but not in the left ovary. The clinical diagnosis was tubal cancer stage IVB. [Adv Obstet Gynecol, 69 (2) : 93-99, 2017 (H29.5)]
Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic disease associated with excessive ovarian stimulation, and is potentially life-threatening complication in severe cases. Ovarian rupture associated with OHSS is rare, and the incidence is reported to be 0.1% after IVF (in vitro fertilization) treatment. Here we present a case of ovarian rupture necessitating a laparotomic surgery after hCG administration in controlled ovarian hyperstimulation procedure. A 34-year-old infertile woman was treated with controlled ovarian hyperstimulation with GnRH agonist long protocol at a private clinic. Intracytoplasmic sperm injection (ICSI) was performed, but embryo transfer could not be carried out due to failure of embryonic cell division. She was referred to our hospital seven days after hCG injection with multiple symptoms including severe abdominal pain, nausea, vomiting, and abdominal distention. An ultrasonograpy showed bilateral enlarged ovaries (right ovary 9.5 cm, left ovary 11.6 cm) with multiple cyst and significantly increased peritoneal fluids. She was admitted to our hospital with the diagnosis of severe OHSS. Her abdominal pain and dyspnea became worse and anemia deteriorated. Sonographically guided ascites aspiration revealed bloody fluid collection in her abdomen, and her hemoglobin dropped from 9.2 to 6.1 g/dl. Active bleeding from her ruptured ovary was suspected in contrast-enhanced abdominal CT. Emergency laparotomy showed that both ovaries were enlarged about 15 to 20 cm with multiple cysts after aspiration of 1500 ml of hemoperitoneum. Bleeding from the ruptured lesion of the left ovary was observed. It was difficult to suture because the surface of her ovary was very vulnerable, so TachoSil® fibrin sealant patches were placed on the bleeding lesions of left ovary. She was kept in the intensive care unit for four days until pulmonary edema and oliguria improved, and was discharged from the hospital 11 days after surgery. We reported a case of a ovarian rupture case necessitating an emergency laparotomic surgery complicated in severe OHSS. Ovarian rupture associated with OHSS is difficult to diagnose because of the relative paucity of cases. It is important to keep in mind the possibility of ovarian rupture if patient with OHSS complains of severe abdominal pain. [Adv Obstet Gynecol, 69 (2) : 100-106, 2017 (H29.5) ]
Adenomatoid tumor is a benign neoplasm of mesothelial origin that occasionally arises in the uterus. Among the four reported histologic types of adenomatoid tumor, the cystic type often presents as a large mass. The differential diagnosis is extensive, and includes degenerated leiomyoma and ovarian tumor. We report a patient with cystic adenomatoid tumor who underwent hysterectomy after two full-term pregnancies and nine years of observation with MRI studies. A 31-year-old nulliparous woman was referred to another hospital because of lower abdominal pain. She was diagnosed with a uterine tumor, and was referred to our hospital. Magnetic resonance imaging (MRI) revealed a 5 cm multilocular cystic tumor in the left posterior wall of the uterine body. The mass showed high intensity on T2-weighted MR images, and low intensity on T1-weighted images. Either cystic adenomatoid tumor or degenerated uterine myoma was suspected. We recommended surgical removal, but the patient preferred observation. She became pregnant two times and had normal vaginal deliveries at 40 weeks of gestation when she was 31 and 33 years old, respectively. When she was 39 years old, MRI revealed that the tumor was enlarged to 9.5 cm in diameter. She requested surgery, and hysterectomy was performed. Laparotomy revealed a fist-sized multicystic mass originating in the left posterior wall of the uterine body, with extension into the peritoneal cavity. The capsule of the mass was ruptured, and tenacious fluid was leaking into the abdominal cavity. Histopathologic examination showed multicystic spaces lined by a single layer of cuboidal or flattened cells. Immunohistochemical staining for calretinin and podoplanin was positive and cystic adenomatoid tumor of the uterus was diagnosed. This case suggests that MRI plays an important role in managing cystic adenomatoid tumor when fertility preservation is desired. [Adv Obstet Gynecol, 69 (2) : 107-112 , 2017 (H29.5)]
Vaginal intraepithelial neoplasia (VAIN) is characterized by multiplication of a heterotypy stratified squamous epithelium but, the pathological change which doesn’t lead to framework permeating. The incidence of VAIN is estimated at two to three cases per 1,000,000 women, and is very rare compared to that of cervical intraepithelial neoplasia (CIN). The treatment of VAIN has not yet been determined. We report the case of a pregnant patient with birth canal gonorrhea, Chlamydia condyloma acuminatum, and VAIN 1. We treated the gonorrhea and Chlamydia infection with medication. Papilla-shaped wart was excised and removed then cauterized for hemostasis. Pathological diagnosis was condyloma acuminatum and VAIN. Subsequent recurrence was not observed. The occurrence of VAIN is reportedly associated with human papillomavirus (HPV) infection, especially high-risk HPV. The peak incidence of VAIN reportedly occurs 10 to 20 years later than that of CIN. However, because of sexual transmission of birth canal gonorrhea and Chlamydia infection among younger women,as well as increased CIN incidence, the vagina, external genitalia, and cervical canal should be examined, using colposcopy and Schiller’s test to rule out HPV infection.[Adv Obstet Gynecol, 69(2): 113-118 , 2017 (H29.5)]
To date, there has been no published report about migration of an herbal medicine ingredient from the mother to the fetus. This is the first report confirming the migration of a metabolite of an herbal medicine ingredient from mother to fetus. We report the clinical course of the case, with review of the literature. A 35-year-old primipara spontaneously delivered a female baby weighing 3222g at 39 weeks and six days of gestation. The mother had been treated for depression, epilepsy, and Hashimoto’s disease before becoming pregnant, and had taken yokukansan, risperidone, and levothyroxine from 21 weeks and three days of gestation until delivery. Routine umbilical cord blood test showed leukocytosis (26000 /µl), neutrophilia (18070/µl), and increased cortisol (269 ng/ml), in spite of a normal C-reactive protein level. However, the laboratory abnormalities spontaneously normalized by 119 hours after delivery. The leukocytosis, neutrophilia, and increased cortisol were suspected to be caused by glycyrrhetinic acid, a metabolite of licorice in the herbal medicine. Liquid chromatography-mass spectrometry detected glycyrrhetinic acid in the umbilical cord blood. However, glycyrrhetinic acid was not detected in three umbilical cord blood specimens of infants born to mothers who were not taking herbal medicine during pregnancy. In addition, glycyrrhetinic acid in the present case was not detected at 119 hours after delivery. These results suggest that glycyrrhetinic acid is associated with leukocytosis, neutrophilia, and increased cortisol. [Adv Obstet Gynecol, 69(2) : 119-125, 2017 (H29.5)]
Synopsis The frequency of non-puerperal uterine inversion is rare. Non-puerperal incomplete uterine inversion was diagnosed in a 52-year-old woman (gravida 2, para 2, not yet menopausal). She was diagnosed with uterine myoma at 47 years old. She visited a GYN clinic because of irregular vaginal bleeding at 50 years old, and repeated GnRHa treatment was selected. However, the size of the uterine myoma could not be reduced, and the patient was referred to our hospital for operative treatment. The chief complaint at the initial visit was a generous amount of vaginal discharge. The diagnosis of non-puerperal incomplete uterine inversion was made according to MRI findings of an inverted fundus and prolapsed submucous myoma in the vagina. Abdominal total hysterectomy and bilateral fallopian tubal resection were performed. The pathological diagnosis was submucous uterine leiomyoma. The postoperative course was uneventful and the symptom of discharge disappeared. [Adv Obstet Gynecol, 69 (2) : 126-130, 2017 (H29.5)]
Genital tuberculosis sometimes progresses to tuberculous peritonitis. It may show same findings as peritoneal metastasis and nodes of malignant tumor. We report a case of genital tuberculosis with tuberculous peritonitis hard to be diagnosed before operation. The patient was a 68-year-old woman, gravida 3, para 2. She visited another hospital complaining of abdominal distention continuous for two months. Ultrasonography indicated a moderate volume of ascitic fluid. Magnetic resonance imaging showed peritoneal metastasis. Her serum CA125 level was 139 U/ml. Upper gastrointestinal endoscopy and colonoscopy did not show any abnormal findings. Cytological findings were normal in ascites, uterine cervix and endometrium. The possibility of peritoneal cancer could not be excluded. Hence, she was referred to our hospital. The level of adenosine deaminase (ADA) in her ascites was high, although acid-fast bacilli were not detected. We performed a surgical biopsy with N95 mask. Rapid perioperative histopathological analysis of the peritoneum and omentum revealed an epithelioid granuloma with Langhans’ giant cells. Thus, we strongly suspected tuberculous peritonitis. We performed a total hysterectomy and bilateral salpingo-oophorectomy. After the operation, T-SPOT and PCR for tubercle bacilli, on the fluid retained in the uterus, were positive. Tubercle bacilli were cultured from the ascites. Histopathological diagnosis was genital tuberculosis and tuberculous peritonitis. Therefore, treatment with anti-tuberculosis drugs was started. In the cases suspected carcinomatous peritonitis, particularly high levels of ascites ADA without malignant cells, it appears important to include tuberculous peritonitis as a differential diagnosis.[Adv Obstet Gynecol, 69 (2) : 131-137, 2017 (H29.5)]
Uterine adenosarcomas are rare mixed epithelial-mesenchymal tumors containing benign glandular and malignant stromal components; these tumors account for approximately 8% of all uterine sarcomas. An adenosarcoma with sarcomatous overgrowth--that has a pure sarcoma component occupying more than 25% of the tumor--is predictive of a poor prognosis. The patient was 56 years old, with gravida 6 para 2. She had been followed up as uterine myoma for eight years before visiting our hospital. USG showed a tumor (5 cm) consisted of echo-free part and solid part. T2 weighted MRI showed the tumor consisted of two parts with different signal, slight high and remarkable high. We performed abdominal hysterectomy and a bilateral salpingo-oophorectomy for the pathological diagnosis to exclude sarcoma. A large part of the tumor was occupied with sarcoma component consisted of atypical mesenchymal cells. A few epithelial component was mixed in the tumor edge. The patient was diagnosed with uterine adenosarcoma, pT1cNxM0. Any recurrence could not be detected after 90 days of surgery. However a liver metastasis lesion was suddenly ruptured after 96 days. Transcatheter arterial embolization was performed at another hospital, and then, the patient was transferred to our hospital. Her condition rapidly deteriorated, and she died after 118 days. Uterine adenosarcomas are generally low-grade malignant tumors, and the incidence of early recurrence and tumor death is less. However, uterine adenosarcomas with sarcomatous overgrowth have a poor prognosis. Furthermore, the preoperative diagnosis is difficult. Thus pathological diagnosis is necessary to exclude malignancy. In cases of uterine adenosarcomas with sarcomatous overgrowth, we should be cautious about the possibilities of distant metastasis and local recurrence. In addition, it is important to detect recurrent lesions via a systemic search starting from the early postoperative period. [Adv Obstet Gynecol, 69 (2) : 138-144, 2017 (H29.5)]
It is difficult to diagnose patients with tuberculous peritonitis (TP) through a clinical examination. We herein report a case of TP diagnosed with a laparoscope. A 66-year-old female presented with weight loss, a low-grade fever and abdominal pain. Her serum CA125 level was 2010 U/ml. Computed tomography showed a thickened peritoneum and a large amount of ascites, which suggested that the patient had ovarian or peritoneal cancer. Mycobacterium tuberculosis was negative in culture from sputum and ascites. Laparoscopic surgery was performed to make a correct diagnosis, during which the bilateral ovaries were found to have no swelling, and macroscopic nodules were found on the peritoneum. A histological examination showed the presence of epithelioid granulomas with typical Langhans cells with areas of caseous necrosis. The patient finally diagnosed with peritoneal tuberculosis. Treatment with anti-tuberculosis drugs was started, with the combined use of isoniazid, rifampicin, ethambutol, and pyrazinamide. A laparoscope can be helpful for the diagnosis of TP. [Adv Obstet Gynecol, 69(2): 145-150, 2017 (H29.5)]
Spontaneous uterine vein rupture in pregnancy is rare. We experienced two cases of spontaneous uterine hemorrhage in the third trimester. The first case was a patient at 30 weeks of gestation who complained of abdominal pain with a severe variable deceleration and severe late deceleration. Emergency cesarean section was performed, and hemorrhage was found at the venous plexus on the left back of the uterus. The second case was a patient at 31 weeks of gestation who presented with frequent uterine contractions associated with severe prolonged decelerations. In 1953, the maternal mortality rate for spontaneous uterine hemorrhage was 49.3%; however, in recent years, it has dramatically declined, and no maternal deaths have been reported. On the other hand, perinatal mortality remains high at 31%. The symptoms of spontaneous uterine hemorrhage are non-specific and diagnosis is often difficult. Our cases had abdominal symptoms and abnormalities on cardiotocography, which were indications for emergency cesarean section. Therefore, although uterine vessel rupture in pregnancy is relatively rare, it should always be taken into account. [Adv Obstet Gynecol, 69(2): 151-155 , 2017 (H29.5)]
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