This study aimed to compare the management of retained products of conception (RPOC) between patients followed up under observation and those treated with aggressive treatments-suction curettage, transcervical resection (TCR), uterine artery embolization (UAE), and total hysterectomy.We retrospectively reviewed 23 medical records of RPOC patients in our hospital between 2014 and 2019. Results : Expectant management was chosen for 11 of 14 RPOC patients whose pregnancies ended by 22 gestational weeks. In five patients, RPOC disappeared spontaneously (median : 78 days). Only one patient had massive bleeding during the observation period and was treated with total hysterectomy. In other cases, only TCR or TCR after UAE were performed. Most patients who delivered during the third trimester could be followed up under observation for spontaneous disappearance of RPOC (median : 141 days). RPOC may suddenly trigger massive uterine bleeding. Thus, we evaluated the risk of individual patients and the need for UAE to reduce blood flow to the uterus. Low-risk patients could be followed up under observation for spontaneous disappearance of RPOC. [Adv Obstet Gynecol, 73(3) : 169-176, 2021 (R3.8)]

Patients with vaginal recurrence of gynecological malignancies are candidates for brachytherapy with or without external beam radiation therapy (EBRT). However, radiation therapy is often used as an adjuvant therapy in patients with primary cervical cancer or endometrial cancer, while the uses of intracavitary brachytherapy (ICBT) and EBRT are limited to previously non-irradiated patients with superficial recurrent lesions. Nevertheless, interstitial brachytherapy (ISBT) allows for the treatment of deeper lesions despite previous irradiation and is a less invasive option for the treatment of localized tumors. In this study, we evaluated the outcomes of ISBT for the treatment of localized vaginal recurrence of gynecological malignancies. The records and histopathology reports of 13 patients who underwent ISBT for localized vaginal recurrence were retrospectively reviewed, and the three-year overall survival, three-year progression-free survival, and three-year local control rates were evaluated, which were 83%, 38%, and 76%, respectively. No patients experienced Grade three or four toxicities. We observed favorable outcomes with ISBT in patients with localized vaginal recurrence when the therapy was provided soon after the diagnosis and with an appropriate dose for the tumors. [Adv Obstet Gynecol, 73(3) : 177-184, 2021 (R3.8)]

MPA therapy is a fertility preserving treatment for patients with endometrioid adenocarcinoma G1 (EC G1) or atypical endometrial hyperplasia (AEH). However, sufficient evidence has not been accumulated regarding management after MPA therapy. Therefore, we retrospectively examined those cases in which MPA therapy was performed at our hospital.Pathological diagnosis was EC G1 in 30 cases and AEH in 27 cases. Complete response rate was 84% (48/57), recurrence in 28 patients (49%), and a hysterectomy was performed for all patients. The average observation period after MPA therapy was 91 months. Although no death from the primary disease was observed, progressive disease was observed in two cases. Of the 32 patients which tried to become pregnant, 13 of them were successful (40.6%), and 17 live babies were born. Of these 13 pregnant cases, 10 (76.9%) required fertility treatment and five(38.5%) required assisted reproductive technology (ART). Even in complete response cases leading to pregnancy, recurrence occurred in 41.7% of them, and the period until recurrence was about two years. It is desirable that early pregnancy should be aimed in patients with EC or AEH after MPA therapy. [Adv Obstet Gynecol, 73(3) : 185-190, 2021 (R3.8)]

Lymph node (LN) metastasis is a prognostic factor in cervical cancer, as emphasized in the 2018 International Federation of Gynecology and Obstetrics (FIGO) Cervical Cancer Advanced Staging Classification. Radiotherapy (RT) is the standard treatment for advanced cervical cancer; appropriate radiation coverage is important for control of LN metastasis. The 2020 National Comprehensive Cancer Network guidelines suggest treatment strategies that depend on the pathological results of LN dissection. To verify the extent of irradiation, we performed laparoscopic paraaortic LN (PAN) dissections in 14 patients who were diagnosed between February 2018 and August 2020 with primary locally advanced cervical cancer from which preoperative imaging confirmed no obvious PAN metastases, and who were scheduled for RT. In patients whose histopathological examination was positive for metastasis, the irradiation field was expanded to the PAN area. Seven patients had pelvic LN enlargement on preoperative imaging, and the other seven did not. Of the two patients whose histopathology was positive for PEN metastasis, one patient showed no PAN enlargement on preoperative imaging. Laparoscopic PEN dissection may be useful in detecting metastases that cannot be assessed by imaging, and in determining the extent of RT irradiation. [Adv obstet Gynecol, 73(3) : 191-196, 2021 (R3.8)]

Radical trachelectomy (RT) has been developed as a fertility-preservation surgery for patients with early-stage cervical cancer; however, proper perinatal management of patients who subsequently become pregnant is not well established. In this retrospective study, we analyzed the records of 62 patients who underwent RT in our institution between 2005 and 2018. We analyzed 17 pregnancies in 15 patients, and the pregnancy rate of patients who attempted to conceive after RT was at most 62.5%. Among these 17 pregnancies, 12 were achieved with fertility treatment. There were16 live births (12 at 29-36 weeks of gestation, four at 37 weeks of gestation) and one miscarriage. All live deliveries were carried out via cesarean section. Among all pregnancies beyond 34 weeks of gestation, cervical cerclage was carried out with radical trachelectomy. In this limited study, we could not identify other prognostic factors that predict premature birth. Most neonates were appropriate for date, and any recurrence was observed among these 15 patients. RT is an important fertility-preservation surgery for patients with early-stage cervical cancer. However, reproductive assistance is necessary for many patients to be able to conceive. Factors that lead to premature birth among pregnancies after RT should be explored in future studies. [Adv Obstet Gynecol, 73 (3) : 197-206, 2021 (R3.8)]

Atrial fibrillation (AF) rarely occurs during pregnancy. Beta2-mimetics are widely used for treating of preterm labor in Japan and five cases of AF induced by beta2-mimetics in pregnant women have been reported. There is scant information available regarding the diagnosis and management of AF related to beta2-mimetic therapy during pregnancy. We report here two cases of ritodrine-induced AF. Case 1 : a 35-year-old nulligravida, who had been treated preterm labor by intravenous ritodrine, presented tachycardia with a rate of 140 bpm at 29 weeks’gestation. A 12-lead electrocardiogram revealed AF and the ritodrine was immediately stopped. A beta-blocker was used to control the heart rate. The AF reverted to a normal sinus rhythm three days later. Case 2 : a 37-year-old multipara, who presented AF at 35 weeks’gestation while receiving oral ritodrine treatment. The maternal heart rate was 140 bpm at the time of diagnosis and the AF spontaneously reverted to a normal sinus rhythm the day following cessation of ritodrine. We reviewed the two present and five previously literally reported cases of AF occurring during pregnancy. The heart rate at AF onset was reported for five cases and all (100%) showed tachycardia greater than 140 bpm. The duration from cessation of beta2-mimetic to reversion to a normal sinus rhythm was described in six cases, with a median reversion time of 8.5 hours (range, 4-73 hours), of which three (50%) spontaneously reverted to sinus rhythm without cardioversion. When a pregnant woman receiving ritodrine shows tachycardia around 140 bpm, a 12-lead electrocardiogram should be performed to find AF, and ritodrine should be immediately discontinued when a diagnosis of AF is confirmed. [Adv Obstet Gynecol, 73 (3) : 207-212, 2021 (R3.8)]

Hallermann-Streiff syndrome is a rare disease, and in patients with a short stature and small pelvic cavity, gynecological laparoscopic surgery may be difficult. Here, we report a case of gynecological laparoscopic surgery for a patient with Hallermann-Streiff syndrome.Surgery was performed for adenomyosis and lobular endocervical glandular hyperplasia in a 43-year-old female patient with gravid one and para one. By carefully considering the position of the trocars and pneumo-abdominal pressure, we were able to safely perform laparoscopic total hysterectomy and bilateral salpingectomy. Laparoscopic surgery can be useful in patients with a short stature and small pelvic cavity. [Adv Obstet Gynecol, 73 (3) : 213-217, 2021 (R3.8)]

We report a case of pregnancy with suspected placenta accreta and a large myoma in the anterior lower uterine segment. This was a 37-year-old female, G7P3, who conceived 13 years after the last pregnancy, for which delivery was performed through a cesarean section. She was referred to our hospital from a private clinic for a 10-cm myoma in the anterior lower segment. Besides the myoma, our ultrasound confirmed the placenta covering the entire anterior uterine wall, including the scar from the previous C-section. Her antepartum course was otherwise uneventful. MRI at 33 weeks was suggestive of placenta accreta. After obtaining her consent, based on sufficient information, we proceeded with a cesarean hysterectomy. Through a transverse fundal incision, we safely delivered an infant weighing 2880 grams. The placenta did not peel away. We performed a supracervical hysterectomy. The course of the surgery was uneventful, with a blood loss of 750 ml. Postoperative pathological examination revealed no obvious evidence of placenta accreta. The transverse fundal incision of the uterus might be an appropriate alternative route of delivery in cases where the conventional accesses to the intrauterine cavity are considered either difficult or unsafe. [Adv Obstet Gynecol, 73 (3) : 218-224, 2021 (R3.8)]

We experienced a case of suspected bilateral tubal pregnancy after two embryo transfer and performed laparoscopic surgery to remove the embryo of the left fallopian tube, but contralateral fallopian tube pregnancy was suspected to continue after surgery and Methotrexate (MTX) was administered. A 32-year-old woman was transferred two embryos at the previous clinic. Then she was referred to our hospital because ectopic pregnancy was suspected. MRI showed undeniable evidence of fetal sacs (diameter of five-six mm in both fallopian tubes). During laparoscopic surgery, the right fallopian tube was mildly swollen, and the left fallopian tube was swollen to approximately 1 cm in diameter. We incised the left fallopian tube bulge and completely removed the tissue that appeared to be a fetal sac, with almost no bleeding. The left fallopian incision was sutured, but we gave no treatment for right fallopian tube. Owing to no postoperative decrease in blood levels of human chorionic gonadotropin (HCG), MTX (50 mg/m²) was systemically administered postoperatively. Negative HCG was confirmed 52 days postoperatively. Bilateral fallopian tube pregnancies are exceedingly rare, with a reported incidence of 1/1580 of all ectopic pregnancies. Two Embryo transfer has been reported to raise the risk of ectopic pregnancy, so we should be more careful about possibility of bilateral tubal pregnancy. [Adv Obstet Gynecol, 73 (3) : 225-229, 2021 (R3.8)]

Transabdominal cervical cerclage (TAC) is more difficult than transvaginal cervical cerclage (TVC) and often performed at 9-12 weeks of gestation. We performed TAC at 17 weeks of gestation in a patient with a history of cervical conization. The patient was 40 years old, gravida three para zero, and became pregnant naturally. She has a history of cervical conization for CIN3 and spontaneous abortion at six and 11 weeks of gestation after operation. The cervical length was 26 mm at 12 weeks of gestation and 14 mm at 15 weeks and six days of pregnancy and It is difficult to perform for TVC because of shortended cervix ; she was then hospitalized. We performed TAC at 17 weeks and two days of pregnancy because the short cervical length made TVC difficult. A large abdominal incision was needed to obtain the uterine surgical field at 17 weeks of gestation. The surgery was performed using transvaginal ultrasound examination. The postoperative course was favorable and she was discharged at 19 weeks of gestation. At 29 weeks and six days of pregnancy, the cervical length was 15 mm ; she was hospitalized again. The subsequent pregnancy course was favorable, and cesarean section was performed at 37 weeks and five days of pregnancy ; she successfully delivered a healthy baby. The first case in japan to perform TAC at 17 weeks gestation. Although obtaining the TAC surgical field was difficult at 17 weeks of gestation, we performed TAC using transvaginal ultrasound. Although TAC indications must consider the significant invasiveness, we would like to improve perinatal prognosis to do TAC. [Adv Obstet Gynecol, 73 (3) : 230-237, 2021 (R3.8)]

Dermatomyositis is frequently associated with malignant tumors. A 78-year-old woman was admitted to our hospital with complaints of skin rash associated with pruritus. After a work-up, she was diagnosed with dermatomyositis. However, malignancy was suspected as she had elevated serum KL-6 level and anti-TIF1-γ antibodies. Positron emission tomography confirmed fluorodeoxyglucose uptake in an intrathoracic mass, abdominal lymph nodes, and a mesenteric mass. Thoracoscopic biopsy of the intrathoracic mass confirmed a serous carcinoma. Laparoscopic bilateral salpingo-oophorectomy and biopsy of peritoneal tumor were also performed. Histopathological examination revealed no malignancy in the bilateral adnexa, but a serous carcinoma was found in the peritoneal tumor and it was similar to the intrathoracic mass biopsy. Therefore, the patient was diagnosed peritoneal cancer stage IVB. After chemotherapy with paclitaxel and carboplatin, the peritoneal cancer was in remission, and serum muscle enzymes were normalized. As the skin rash persisted after chemotherapy, she underwent steroid treatment at another hospital. Among gynecologic malignancies, ovarian cancer is often associated with dermatomyositis. Here, we report peritoneal cancer with dermatomyositis diagnosed by thoracoscopic and laparoscopic biopsy. We considered that appropriate treatment of malignancies contributes to the treatment of dermatomyositis. Moreover, it is important to treat malignant tumors early if the dermatomyositis is not severe. [Adv Obstet Gynecol, 73 (3) : 238-246, 2021 (R3.8)]

Thoracic endometriosis, one of the less common and rare site endometriosis. Although guidelines for thoracic endometriosis were established in 2018, the number of cases of thoracic endometriosis is small, and a consistent treatment has not been established. Approximately 80% of the symptoms of thoracic endometriosis are associated with menstrual pneumothorax, and this is the most frequent cause of detection. The main treatment for menstrual-associated pneumothorax is thoracoscopic surgery ; however, the recurrence rate is reported to be 40%, which is higher than that of spontaneous pneumothorax. Moreover, its treatment and postoperative management have often been challenging, as some cases fail to respond to various postoperative drug therapies, resulting in repeated recurrence. In this study, we retrospectively investigated the clinical course of seven Thoracic endometriosis syndrome cases examined at our pneumothorax center from January 2014 to December 2019. The median age of onset was 45 years. Two of the seven patients had pelvic endometriosis, both of which recurred after surgery. All patients had a menstrual-associated pneumothorax, which was treated by thoracoscopic surgery. In the five patients who underwent surgery at our hospital, there was a difference in the degree of lesion progression ; however, only one case of recurrence occurred after a combination of lesion resection and cautery. Postoperative medications included low-dose estrogen progestin (LEP), gonadotropin-releasing hormone (GnRH) agonist, and dienogest ; however, postoperative recurrence was observed in three of seven patients. Our results suggest that patients with pelvic endometriosis may be at high risk of postoperative recurrence and that thoracoscopic surgery may prevent postoperative recurrence. Similar to other cases reported in Japan, the postoperative recurrence rate of Thoracic endometriosis syndrome in our study was high and its treatment was difficult in some cases. Therefore, further studies of more cases will be necessary to establish a proper treatment for this disease. [Adv Obstet Gynecol, 73 (3) : 247-256, 2021 (R3.8)]

Adenocarcinoma arising from an ovarian endometriotic cyst is frequently reported in the malignant transformation of endometriosis. However, the malignant transformation of intestinal endometriosis is rare in Japan. We report a very rare case of endometrioid adenocarcinoma arising from the endometriosis of the sigmoid colon. An 81-year-old woman visited our hospital complaining of genital bleeding, and a pelvic mass was detected by computed tomography. She was otherwise healthy and had no history of malignant disease. Magnetic resonance imaging revealed an enhanced tumor in the pelvic cavity around the uterus that appeared to invade the sigmoid colon. Because ovarian cancer was suspected, a total abdominal hysterectomy, bilateral salpingo-oophorectomy, and omentectomy were performed. The tumor was completely attached to the sigmoid colon and broad ligament ; therefore, the sigmoid colon was resected. The uterus and ovaries showed no abnormalities. Histologic examination of the tumor specimen confirmed grade 1 endometrioid carcinoma with intestinal endometriosis. Chemotherapy was recommended, but the patient refused because of her age. However, the cancer recurred five months after surgery, and the patient began paclitaxel and carboplatin chemotherapy. [Adv Obstet Gynecol, 73 (3) : 257-264, 2021 (R3.8)]

Transient diabetes insipidus associated with pregnancy occurs in 1/30,000 births. The clinical manifestations are hypotonic polyuria and polydipsia. A 27-year-old woman (gravida one, para zero) had a prenatal checkup previously at another clinic. At 37 weeks and four days of pregnancy, she developed stomach discomfort and pruritus on the skin. A blood test showed elevated liver enzymes and impaired renal function, and the patient was subsequently transferred to our hospital. An emergency caesarean section was performed on the same day due to the liver and renal disorders. The patient’s blood pressure was evaluated post-operatively, so we then diagnosed her with severe preeclampsia. One hour after the operation, the amount of urine increased to 400 ml/hour, and the total urine volume on the first day was 9100 ml/day ; the patient was then diagnosed with transient pregnancy diabetes insipidus. We treated her with hydration therapy, and then her urine volume improved thereafter. Afterwards, the mother was discharged with her baby. Preeclampsia causes renal dysfunction and usually reduces urine output. However, if polyuria is observed, it is necessary carefully consider the possibility of diabetes insipidus. [Adv Obstet Gynecol, 73 (3) : 265-270, 2021 (R3.8)]

Cesarean scar defect is a known complication of cesarean delivery. It has been associated with persistent, prolonged genital bleeding, chronic pelvic pain including menstrual pain, and secondary infertility. These symptoms have been closely investigated and referred to cesarean scar syndrome (CSS). The clinical significance of this disease remains unclear. Here, we report a case of a 33-year-old woman who presented with urinary pain, menstrual pain, and irregular bleeding after a second cesarean delivery. Her blood test revealed an elevated inflammatory response (WBC, 9.5×10³/μl ; CRP, 2.16 mg/ml) and transvaginal ultrasound and MRI showed that the residual myometrial thickness (RMT) was very thin (1.0 mm), and there was a pooling of blood in a cesarean scar defect. After intravenous administration of ceftriaxone (2g/day), the inflammatory response improved. After treatment with GnRH agonist (1.88 mg, four weeks, three cycles), the RMT was increased to 4.8 mm. However, since urinary pain had not ameliorated, surgical intervention was required. Laparoscopic surgery in combination with hysteroscopy was performed and the cesarean scar defect was resected. Pathological finding included endometrial glandular structures in the resected myometrium. Taken together, CSS, at least a part of the cases, can be interpreted as a condition similar to that of uterine adenomyosis and treated by endocrine drugs and surgical therapy. [Adv Obstet Gynecol, 73 (3) : 271-276, 2021 (R3.8)]

Uterine torsion is defined as a rotation of the uterus more than 45 degrees around the long ais. Because the symptoms of this rare condition are nonspecific, it is difficult to diagnose preoperatively. We here present a patient with uterine torsion that was diagnosed preoperatively. A 78-year-old postmenopausal woman (gravida three, para two) presented with acute abdomen. A pelvic mass was detected by abdominal ultrasonography and she was referred to our hospital for further management. An abdominal CT scan showed an eight-cm-diameter, right-sided, calcified uterine myoma and uterus torsion. A subsequent contrast pelvic MRI examination showed that the uterine myoma that had been on the right side on the abdominal CT was on the left. Thus, the uterine body had twisted and was suspected of being ischemic. Emergency laparotomy was performed with a provisional diagnosis of necrosis of the myometrium caused by 630 degree uterine torsion. Total hysterectomy and bilateral adnexectomy were performed. The postoperative course was uneventful and the patient was discharged on the ninth postoperative day. Uterine torsion is thought to result from the presence of asymmetric fibroids and weakening of the uterine supporting tissue with age. It is therefore important to consider the possibility of uterine torsion for older patient with acute abdomen. [Adv Obstet Gynecol, 73 (3) : 277-282, 2021 (R3.8)]

We report a rare case of ipsilateral interstitial pregnancy after salpingectomy. The patient was a 31-year-old woman (para three, with one cesarean section) who had undergone salpingectomy due to ampullar tubal pregnancy at the age of 30 years. The patient was referred to our hospital because of lower abdominal pain, with no gestational sac in the uterine cavity seen on transvaginal ultrasonography. Abdominal ultrasonography revealed a low echo area in the interstitial mole of the fallopian tubes, and MRI revealed a cystic mass in the interstitial mole. Because of the imaging findings of suspected interstitial pregnancy and a high blood level of hCG (38816 mIU/ml), we performed laparoscopic fallopian tube stromal wedge resection on the day of admission. The postoperative course was uneventful, and the patient was discharged five days after the operation. She was histopathologically diagnosed with interstitial pregnancy. Interstitial pregnancy can cause rupture and massive bleeding if left untreated. The possibility of interstitial pregnancy must be considered even in patients who have undergone salpingectomy. [Adv Obstet Gynecol, 73 (3) : 283-288, 2021(R3.8)]

Endometriosis is a common disorder among women of reproductive age. However, endometriosis of the appendix is less common with an intestinal endometriosis incident rate of 3%. Moreover, a preoperative diagnosis of the endometriosis of the appendix is difficult, and a definitive diagnosis is established only after histopathological examination of the appendix. Based on a review of relevant literature, we reported a case of endometriosis of the appendix. A 45-year-old woman with lower abdominal pain was referred to our hospital by a local doctor. She was diagnosed with panperitonitis caused by perforation of the appendix, and she subsequently underwent emergency surgery. A pathological examination of the appendix and right ovary revealed endometriosis. Although endometriosis of the appendix is less common, it should be considered during the differential diagnosis for lower abdominal pain in women with ovarian endometrial cyst and a history of endometriosis. [Adv Obstet Gynecol, 73 (3) : 289-294, 2021 (R3.8)]

Catamenial pneumothorax (CP) is classified as a thoracic endometriosis syndrome that develops during menstruation. However, some cases of pneumothorax can develop at other times as well. We experienced a case of CP with repeated recurrence during hormone therapy. The patient was a 41-year-old nulliparous woman with a two-year history of pneumothorax recurrence. She presented to the emergency department and was diagnosed with right pneumothorax. Based on her medical history, she was suspected to have CP and was referred to the Obstetrics and Gynecology Department. Although magnetic resonance imaging did not reveal the presence of an endometriotic cyst, signs of pelvic adhesion were noted. Endometriosis was strongly suspected. Therefore, dienogest was prescribed for managing the endometriosis. However, her CP recurred despite hormone therapy; thus, we performed a surgery under thoracoscopy. A thinning lesion was observed in the diaphragm and a part of the right diaphragm was removed. Although the patient received hormone therapy, the pneumothorax recurred three months after surgery. Chest drainage was performed as conservative therapy ; however, her symptoms did not resolve. Therefore, pleurodesis was performed. Simultaneously, we switched the patient to a GnRH-agonist regimen followed by dienogest. She remains free of recurrence at one year eight months. [Adv Obstet Gynecol, 73 (3) : 295-300, 2021 (R3.8)]

Infective endocarditis (IE) during pregnancy is extremely rare, and the perinatal prognosis is quite poor. Here, we encountered a case in which a patient was diagnosed with IE during pregnancy, and both the mother and infant exhibited favorable outcomes. Fever repeatedly recurred from approximately 17 weeks of gestation, and noises were detected in the mitral valve region at 27 weeks of gestation. Warts were confirmed on transthoracic ultrasonography, leading to the diagnosis of IE. We performed emergency cesarean section and mitral valve replacement during the same surgery. The infant was male with a body weight of 1154g and Apgar scores of one point for one min and five points for five min. Since uterine bleeding due to postoperative anticoagulant therapy was expected, compression sutures were used, and she was able to avoid undergoing hysterectomy. For cases of unknown fever during pregnancy, it is important to consider IE as well. If valve replacement is necessary, a cesarean section with compression sutures should be considered first. [Adv Obstet Gynecol, 73 (3) : 301-306, 2021 (R3.8)]

Radiation therapy (RT) is one of the main treatments for cancer, but it carries the long-term risk of secondary malignancies. Recently,PET-CT scanning has been often used and is considered more useful in diagnosing recurrent cervical cancer tumors than conventional CT scanning. We experienced a case of a diagnosis of uterine carcinosarcoma by PET-CT after four years of RT for cervical cancer. A 70-year-old woman had the history of Stage IB1 cervical cancer and underwent RT. She had follow-up examinations on an outpatient basis and had no recurrence. Four years after RT for her cervical cancer, a PET-CT showed FDG accumulation in the uterine body. As it was difficult to perform the histological examination after RT,she underwent an abdominal hysterectomy for diagnosis. The postoperative diagnosis was uterine carcinosarcoma FIGO StageIB. She thereafter received six courses of chemotherapy (paclitaxel + carboplatin [TC]). One year after surgery,two recurrent sites were found in the pelvic lesion,and the patient received TC therapy again. Although secondary uterine malignancies after RT for cervical cancer is very rare,we believe that careful follow-up examinations are necessary. [Adv Obstet Gynecol, 73 (3) : 307-312, 2021 (R3.8)]

Uterine artery pseudoaneurysm (UAP) is well known to develop after trauma to the uterus, such as cesarean section, and can be one cause of massive postpartum hemorrhage. We report a rare case of severe hydronephrosis accompanied by UAP after spontaneous vaginal delivery. A 40-year-old gravida two, para one woman was referred to our hospital for acute pyelonephritis after spontaneous vaginal delivery on the eighth postpartum day. An ultrasound showed right hydronephrosis and a right lateral mass measuring 3.1×2.9 cm beside the uterus, including anechoic lesion inside the mass. Color Doppler imaging of the anechoic lesion revealed marked turbulent blood flow representing systolic and diastolic blood flow, and UAP was suspected. Uterine artery embolization (UAE) was performed, and the patient’s hydronephrosis did not subsequently improve. Two months after UAE, the patient underwent a laparotomy with right ureter re-anastomosis, and the hydronephrosis improved.UAP can occur after spontaneous vaginal delivery, and it is thus necessary to take care of UAP when any mass lesions are confirmed beside the uterus, even after spontaneous vaginal delivery. UAP appearing outside of the uterus can be one cause of hydronephrosis, and surgical treatment is a valid option. [Adv Obstet Gynecol, 73 (3) : 313-320, 2021 (R3.8)]

Umbilical endometriosis is a relatively rare disease, and radical cure with drug therapy is difficult. Surgery is often required, but appropriate methods have not been established. Here, we report on surgical methods for two cases of umbilical endometriosis. Firstly, a 45-year-old (gravida three para two), one year ago woman underwent right adnexectomy with a midline lower abdominal incision for a 19 cm mucinous adenoma of the right ovary. A left endometriotic cyst appeared postoperatively, reaching a diameter of seven cm after 1.5 years. Painful induration in the umbilical region from the early postoperative period increased, and biopsy confirmed endometriosis. Total umbilical resection by columnar incision, single-hole laparoscopic left ovarian cystectomy, and umbilical plasty were performed. No recurrence was observed until four years and nine months. Secondly, a 38-year-old (gravida three para two) woman had a 3 cm umbilical mass which bled during menstruation. Biopsy confirmed endometriosis. Total umbilical resection by columnar incision and examination by single-hole laparoscopy and umbilical plasty were performed. No recurrence was observed until one year and seven months. Columnar incision paired with palpating induration removes skin, fat, fascia, and peritoneum as a mass without exposing the endometrial lesion. It can be combined with a single-hole laparoscope. This was considered as radical cure for umbilical endometriosis. [Adv Obstet Gynecol, 73 (3)] : 321-327, 2021 (R3.8)]

Levonorgestrel-releasing intrauterine system (LNG-IUS) is used for safe and reversible contraception and the management of dysmenorrhea and hypermenorrhea. With the increase in LNG-IUS usage, severe complications such as uterine perforation have been reported. We describe a case of LNG-IUS migration into the abdominal cavity, which was successfully removed by laparoscopy. A multiparous woman in her thirties with a history of cesarean section was admitted to another clinic with a complaint of hypermenorrhea. She was diagnosed with functional hypermenorrhea without any neoplasms and used LNG-IUS. One month later, the LNG-IUS was located not in her uterus but in the abdominal cavity by radiography inspection. She was referred to our hospital and diagnosed with abdominal migration of LNG-IUS using computed tomography and magnetic resonance imaging. We successfully removed the LNG-IUS by laparoscopic surgery. To appropriately utilize LNG-IUS, we have to gain more experience and knowledge concerning the risks and complications of LNG-IUS. [Adv Obstet Gynecol, 73 (3) : 328-333, 2021 (R3.8)]

Non-communicating rudimentary horn is a relatively rare uterine malformation that is often associated with endometriosis and hematometra, and which may cause dysmenorrhea. We report a case of laparoscopic coring-type resection of a cavitated non-communicating rudimentary horn with close connection to the contralateral horn. The patient was a 13-year-old girl, 11 years of age at menarche, who had been experiencing intermittent vomiting and abdominal pain since the age of 12 years. She was diagnosed with non-communicating rudimentary uterine horns. An agenesis of the right kidney was also found. Laparoscopic coring-type resection of a rudimentary horn, right endometriotic cyst, and right fallopian tube were performed. The surgery was completed without complications, and the patient is currently in good postoperative condition. When performing resection of rudimentary uterine horn with close connection to the contralateral horn, coring-type resection, in which a margin is taken from the unicornal myometrium, with conical resection, is considered useful because it allows complete resection of the functional endometrium while minimizing damage to the uterine muscle layer of the contralateral horn. [Adv Obstet Gynecol, 73 (3) : 334-339, 2021 (R3.8)]

Adnexal torsion after laparoscopic hysterectomy is considered a rare event. However, some reports have suggested that laparoscopic hysterectomy may be a risk factor for postoperative adnexal torsion. This might be explained by the fact that the laparoscopic approach induces less postoperative adhesion and maintains a wide fenestration in the broad ligament, which contributes to skeletonization of the infundibulopelvic ligament. Therefore, the ovaries remain much more freely movable after laparoscopic hysterectomy. Moreover, less ovarian trauma occurs during laparoscopic hysterectomy, allowing the ovary to live longer and ovulate more. This increases the risk of ovarian cyst development, which is a risk factor for torsion. We herein present a case of ovarian torsion after laparoscopic hysterectomy. A 42-year-old gravid two para one was admitted with lower abdominal pain. She had undergone laparoscopic hysterectomy two years previously. Transvaginal ultrasonography showed a five-cm mass in the right ovary. Pelvic magnetic resonance imaging revealed a five-cm multilocular ovarian cyst. We diagnosed right ovarian torsion and performed laparoscopic right ovariectomy. This case shows that when the clinician encounters acute pelvic pain in patients with a history of hysterectomy, adnexal torsion must be considered as a differential diagnosis, especially in women who have undergone laparoscopic hysterectomy. [Adv Obstet Gynecol, 73 (3) : 340-344, 2021 (R3.8)]

Intramural pregnancy is a rare form of ectopic pregnancy, which is infrequently seen. Risk factors for the intramural pregnancy are injury to the myometrium as a result of cesarean section, myomectomy, or assisted reproductive technologies (ART). We report our experience with intramural pregnancy after artificial insemination that was successfully treated with pharmacotherapy and transcervical procedure. The patient was a 32-year-old nulliparous woman with no background of uterine surgery who conceived by artificial insemination. Ultrasound examination did not detect a fetal sac in the uterus at five weeks of gestation. There were no clinical findings of ectopic pregnancy with high serum hCG level (3878IU/l). Pelvic MRI revealed fetal sac in the uterine myometrium. By MTX therapy, hCG level was steadily decreased from day nine, and the hCG was less than cut off level at day 120. However, the cyst increased in size with thinning of the myometrium. We considered surgery but were able to extract the cyst with placental forceps under hysteroscopic vision. The thickness of the myometrium improved after extraction. The pathologic findings were of a chorionic membrane. This case demonstrates a rare condition, which we managed with minimally invasive treatment. [Adv Obstet Gynecol. 73 (3) : 345-350, 2021 (R3.8)]