Pneumovaginoscopy-assisted radical hysterectomy for early-stage cervical cancer: a novel bidirectional approach for tumor spillage prevention and R0 resection.

OBJECTIVE: This study evaluated the feasibility and outcomes of pneumovaginoscopy-assisted radical hysterectomy (PVRH) for cervical cancer up to stage IIA using a bidirectional fascia-oriented and nerve-sparing surgical approach. METHODS: This retrospective observational cohort study examined the operative outcomes and prognoses of patients who underwent PVRH (n=59) for up to stage IIA cervical cancer. The basic procedure was Kyoto B2 (Viper Type II nerve-sparing) radical hysterectomy and pelvic lymphadenectomy through simultaneous vaginal and abdominal (open or laparoscopic) approaches. In all cases, pneumovaginoscopy (PV) was used to create a vaginal cuff and dissect the paracolpium and paracervical endopelvic fascia to minimize nerve damage. RESULTS: Thirty-eight (64.4%) patients had stage IB1 cancer. Seven (11.9%) had vaginal invasion (stage IIA1, n=4; IIA2, n=3). The abdominal approach was open in 38 cases and laparoscopic in 21. Adjuvant therapy was administered to 24 patients (41%); one patient received concurrent chemoradiotherapy for gastric-type adenocarcinoma. There were three (6.1%) intraoperative complications (CO2 gas embolism [n=1], sigmoid colon musculosa injury [n=1], and ureteral injury [n=1]) and 8 (14%) postoperative complications (lymphedema with cellulitis [n=4], vaginal cuff dehiscence [n=1], sub-ileus [n=1], symptomatic lymphocyst [n=l], and ureterovaginal fistula [n=1]). The median urination recovery period was 3 days. Microscopic R0 was achieved in all cases. The median follow-up was 44.5 (2-122) months, and no recurrence occurred. CONCLUSION: PVRH is a new fascia-oriented and nerve-sparing surgery for early-stage cervical cancer. Further, it has favorable operative outcomes and good prognoses, similar to those of adjacent pelvic surgery such as trans-anal total mesorectal excision and radical prostatectomy.

A pilot study of repeated 5-aminolevulinic acid photodynamic therapy for cervical intraepithelial neoplasia by a newly developed intravaginal irradiation system.

The pilot study was performed to assess the usefulness of a newly developed patientand physician-friendly intravaginal irradiation system for photodynamic therapy with 5-aminolevulinic acid (5-ALA PDT) for cervical intraepithelial neoplasia (CIN). We used an intravaginal balloon applicator to make the cervix upright and to adjust the position and direction of the laser source in the vagina, resulting in minimal patient discomfort and minimal effort required by the physician during irradiation. Ten outpatients of CIN2 or 3 with high-risk human papillomavirus (HPV) infection without a history of HPV vaccination were treated by 5-ALA PDT. Each patient underwent PDT four times every two weeks. Nine patients showed pathological improvement, and the HPV clearance rate was 80%, and no recurrence was observed at two-years follow-up. Serum anti-HPV16 antibodies were detected in seven patients, and the antibody levels of three patients were high, equivalent to those acquired after HPV vaccination. Our newly developed irradiation system enabled easy repeat 5-ALA PDT in the outpatient clinic resulting in the improvement of CIN lesions and HPV clearance. Our results also suggested that repeated 5-ALA PDT might enhance HPV antibody production in CIN patients.

Fertility-sparing radical resection of juvenile clear cell adenocarcinoma of the cervix by pneumovaginal endoscopic surgery.

Vaginoscopy has been mainly used diagnostically due to the lack of adequate equipment for performing complicated surgeries (Johary et al., 2015). However, herein, we report therapeutic vaginal endoscopic surgery (pneumovaginoscopy) for secondary malignant vaginal tumors using the vNOTES technique and devices (Kita et al., 2021, Yokoe et al., 2022). To our knowledge, this report and surgical video demonstrate the first case of successful fertility-sparing R0 tumor resection of a rare primary cervical clear cell adenocarcinoma using pneumovaginoscopy. A 12-year-old girl was referred to our outpatient clinic with a chief complaint of a genital tumor and possible clear cell carcinoma on biopsy. There was no history of diethylstilbestrol exposure. MRI and CT images suggested a polypoid cervical tumor without metastatic lesions. Therefore, we performed therapeutic pneumovaginoscopic surgery with diagnostic laparoscopy and hysteroscopy. The cervical tumor was resected completely, and hysteroscopy and laparoscopy revealed no abnormalities. The total surgical time was 123 min, and the blood loss volume was minimal. R0 resection was achieved microscopically. Postoperatively, we performed a partial cervical resection around the first surgical scar to confirm no residual tumor. There were no postoperative complications, and a 2-year follow-up revealed no recurrence. The standard treatment for early-stage cervical cancer (IA2-IB1) remains radical hysterectomy with pelvic lymphadenectomy. However, fertility-sparing minimally invasive surgery has recently been introduced for clear cell adenocarcinoma of the cervix (Su et al., 2020). Our report supports the possibility of this minimally invasive surgery under exceptional conditions. This study was approved by the ethics committee of Kansai Medical University. Written and signed informed consent was obtained from the patient's legal guardian.

R0 resection of vaginal stump recurrence of gynecologic malignancy by bi-directional endoscopic approach: A case series of four patients.

Vaginal stump recurrence post-hysterectomy for gynecologic malignancies occurs in 2%-3% of cases. Local excision has been recognized as the primary treatment of localized recurrence, in which precise surgical margin is critical. However, R0 resection is not always easy, given the deep and narrow operation field, as well as severe postoperative fibrosis or adhesion of the vaginal stump at times. Here, we report four cases of vaginal stump recurrence of gynecologic malignancies resected by bi-directional (laparoscopic and pneumovaginoscopic) endoscopy to overcome these difficulties. The primary tumors were uterine cancer in two cases and uterine cervical and ovarian cancer in one case each. The mean operating time was 199 (162-235) minutes, blood loss was minimal, and no perioperative complications were observed. Postoperative follow-up (7.0-19.4 months) revealed no recurrence. This combined procedure could be a therapeutic option for localized vaginal stump recurrence.

Significance of placental CD200 expression in patients with preeclampsia: Comparison between early­ and late­onset patients.

Preeclampsia, characterized by high blood pressure and proteinuria during pregnancy, causes serious complications in both the mother and the fetus. Although there have been several studies on the causes of preeclampsia, the detailed mechanism of this disease remains unclear. Moreover, a few reports have focused on the causes of preeclampsia in number of weeks at onset. The present study aimed to elucidate the differences between early­ and late­onset preeclampsia. This study enrolled patients with preeclampsia from January 2014 to December 2020. They were classified into early­ (<34 weeks) and late­onset (≥34 weeks) preeclampsia groups. The expression profiles of 770 immune­related genes were studied in the placental tissue from five patients each in the early­ and late­onset groups. The expression of CD200 in the trophoblasts of the placenta of 26 and 27 patients in early­ and late­onset groups, respectively, was also analyzed using immunostaining. Analysis of extracted RNA indicated that CD200 was significantly upregulated in the early­onset group compared with late­onset group and normal control. Immunostaining for CD200 demonstrated a significantly increased expression in the early­onset group compared with the late­onset group. The present study demonstrated that upregulation of CD200, which belongs to the immunoglobulin superfamily and is recognized as a molecule that acts in immune tolerance via inhibition of classical macrophage activation, may be associated with early­onset preeclampsia, although it remains unknown whether upregulation of CD200 expression is a cause or effect of the development of early­onset preeclampsia. Early­onset preeclampsia might have a different mechanism from that of late­onset; thus, further studies are needed to clarify the mechanism of these conditions for adequate treatment.

Laparoscopic hemostasis and drainage for postpartum retroperitoneal hematoma complicated with an infection: A case report and surgical video.

Introduction: and importance: Postpartum retroperitoneal hematomas are a potential complication of childbirth. The management of secondary infections of such hematomas has not been fully elucidated. We present a typical case of such management via laparoscopic surgery, and include a surgical video. Case presentation: A woman in her 20s experienced fever and right lower quadrant pain and distension on postpartum day 2. Pelvic examination revealed a hump on the vaginal wall on the right side of the uterine cervix, and ultrasonography revealed a hematoma. Contrast-enhanced computed tomography revealed no active extravasation into the hematoma. Conservative antibiotic treatment was started; however, on postpartum day 6, her pain increased and her C-reactive protein concentration and white blood cell count were high. Magnetic resonance imaging revealed a paravaginal/upper vaginal wall hematoma (80 × 70 × 63 mm) located to the right of the uterus and bladder. Hence, laparoscopic drainage was performed on postpartum day 7. The retroperitoneal hematoma was incised and drained. The source of bleeding was the right vaginal vein, and bleeding was halted via electrocoagulation. The patient's symptoms improved immediately, and the postoperative course was uneventful. Clinical discussion: The laparoscopic approach enabled immediate hemostasis and identification of the source of bleeding. The drainage route was cleaner than would be possible via a vaginal approach, possibly preventing postoperative retrograde re-infection. Conclusion: Laparoscopic surgery for postpartum retroperitoneal hematoma with infection was useful for both drainage and hemostasis.

Successful minimally invasive surgery for postpartum retroperitoneal hematoma complicated by an infection: Two case reports.

INTRODUCTION: and importance Postpartum retroperitoneal hematoma is a birth canal injury that is difficult to diagnose because of its invisibility. Secondary infections of these hematomas are rare, and their diagnostic and management strategies have not been fully elucidated. We present two cases of postpartum retroperitoneal hematomas with infection, which were successfully treated with minimally invasive surgery. CASE PRESENTATION: Case 1 was of a 2X-year-old woman who presented with complaints of fever; a provisional diagnosis of chorioamnionitis and Streptococcus pyogenes-induced sepsis was made. Case 2 was of a 3X-year-old woman who underwent uterine artery embolization and manual removal of the placenta for suspected placenta accreta. Both cases were diagnosed with adnexal hematomas, and antibiotic therapy failed in both patients. Therefore, we performed exploratory laparoscopy and made a diagnosis of retroperitoneal hematomas with infection; laparoscopic drainage resulted in rapid resolution of the clinical symptoms and abnormal blood test results. CLINICAL DISCUSSION: Once an abscess develops, antibiotic treatment has a limited effect, and surgical drainage should be performed. Management of retroperitoneal hematomas is difficult, especially when complicated by an infection. CONCLUSION: Minimally invasive procedures involving laparoscopy could be beneficial for the management of postpartum retroperitoneal hematomas complicated by an infection.

Resection of vaginal recurrence of granulosa cell tumor by pneumovaginal endoscopic surgery.

Vaginal surgery is a classic and unique gynecologic procedure. However, the operation field is narrow, which may make surgery difficult to perform. While vaginoscopy or vaginal endoscopy could be the solution of choice, they are mainly used for diagnosis due to the lack of adequate equipment to perform complicated surgery (Johary et al., 2015). Laparoscopy, especially single-port surgery, has been introduced in gynecologic surgery, and excellent equipment has been developed to perform complex surgical procedures through narrow inlets. And vaginal endoscopy using such single-port surgery devices, so-called vaginal natural orifice transluminal endoscopic surgery (vNOTES), has recently been introduced in the gynecologic field (Li and Hua, 2019 Aug) and allows the easier performance of endoscopic surgery through the vagina for ovarian cystectomy (Baekelandt, 2018 Feb 1), salpingo-oophorectomy (Baekelandt et al., 2018) and hysterectomy (Housmans et al., xxxx) for benign pathology. However, vNOTES has been used mainly as an alternative laparoscopic pathway to reduce abdominal wounds or bypass transabdominal approaches into the abdominal cavity. This report including the surgical video demonstrates the first case, to our knowledge, of successful tumor resection of a rare vaginal recurrence of ovarian granulosa cell tumor (Fujita et al., 2015 May, Levin et al., 2018) by pneumovaginoscopy using single-port surgery devices. A 39-year-old woman with an adult-type ovarian granulosa cell tumor had undergone left salpingo-oophorectomy. At 23 years after surgery, a recurrent mass was detected in her left vaginal wall. The patient had no history of pregnancy, and her vagina was too narrow to secure a good field of operation. Therefore, we underwent pneumovaginoscopic surgery. The total operating time was 88 min, and the blood loss volume was minimal. Complete tumor clearance (R0 resection) was achieved microscopically. There were no postoperative complications, and a one-year follow-up revealed no recurrence. Institutional Review Board approval was obtained through our local Ethics Committee of Kansai Medical University (#2019208).

Successful delivery after abdominal radical trachelectomy followed by adjuvant chemotherapy for advanced invasive uterine cervical cancer: a case report and literature review.

Uterine cervical cancer is increasingly prevalent among young Japanese women who are eager to preserve their fertility, and abdominal radical trachelectomy (ART) is often performed in patients with early-stage invasive lesions. Herein we present details of a 27-year-old woman with stage IB1 cervical cancer. Although the patient received ART, histopathological findings revealed a parametrial invasion. Hence, 3 courses of adjuvant chemotherapy with paclitaxel and carboplatin (TC) were administered, and the patient conceived spontaneously 44 months later. Rupture of the membrane occurred at 32 weeks and 4 days, and a 1822 g female baby was delivered by emergency cesarean section. The patient is alive without disease and her child is growing favorably. This case demonstrates the balance between preservation of fertility and curative adjuvant chemotherapy after ART.

Pregnancy after neoadjuvant chemotherapy followed by abdominal radical trachelectomy in stage IB2 cervical cancer: A case report.

► Huge cervical cancer was treated by intra-arterial chemotherapy followed by radical trachelectomy. ► The patient conceived after abdominal radical trachelectomy and had a baby by Cesarean section.