Extraovarian Dysgerminoma Involving the Uterine Cervix: A Rare Case Report With Literature Review.

Primary extraovarian dysgerminoma (EOD) is a very rare disease. There is no literature about primary EOD involving the uterine cervix. We herein present details of a unique case of primary EOD involving the uterine cervix. A 46-year-old woman with uterine cervical tumor was referred to our institution with atypical genital bleeding. A polypoid tumor localized to the uterine cervix was found. Cervical biopsy detected malignant components of likely nonepithelial cell origin. Preoperative imaging examinations showed a uterine cervical tumor measuring ~5 cm, suggestive of malignancy without distant or lymph node metastases. The patient underwent abdominal radical hysterectomy with pelvic lymph node dissection according to the standard treatment for stage IB3 cervical cancers. The pathological diagnosis was dysgerminoma involving the uterine cervix and the right fallopian tube. Immunohistochemical results were as follows: SALL4 (+), octamer-binding transcription factor 4 (+), D2-40 (+), and c-Kit (+). She received 3 cycles of adjuvant chemotherapy with bleomycin, etoposide, and cisplatin. The disease did not recur up to 14 months after surgery. This is the first-ever published case of primary EOD involving the uterine cervix among previously reported EOD cases. Reported cases of EOD in female genital tract are also reviewed. Our case provides more extensive insights for pathologists to consider the differential diagnosis of cervical lesions. In our case, combination therapy involving a surgical approach-according to cervical cancers and adjuvant chemotherapy as used for ovarian dysgerminomas-was effective. Future verification is needed regarding the best approach for treating uterine cervical dysgerminomas.

Rate of recurrent hydronephrosis after laparoscopic ureteroneocystostomy for ureteral endometriosis.

STUDY OBJECTIVE: To investigate the short-term outcomes of laparoscopic ureteroneocystostomy in patients with ureteral endometriosis (UE). DESIGN: Retrospective cohort study of consecutive patients who underwent surgery for the ureter endometriosis with hydronephrosis. SETTING: A private hospital that provide primary, secondary and tertiary care. PATIENTS: 30 consecutive patients with UE who underwent laparoscopic ureteroneocystostomy at our institution between May 2008 and April 2020. INTERVENTIONS: Laparoscopic ureteroneocystostomy, if necessary, hysterectomy, salpingo-oophorectomy, cystectomy, partial bladder resection, or partial bowel resection were performed. MEASUREMENTS AND MAIN RESULTS: The most common chief complaint was pelvic pain (40%). Endometriosis affected only the left ureter in 56.7% of patients, only the right ureter in 33.3%, and both ureters in 6.7%. Involvement of the ipsilateral ovary was confirmed in 64.3%. The most frequent location of UE was 1-3 cm above the UVJ (46.7%). A psoas hitch was performed in 7 patients (23.3%), and the Boari flap was used in 9 patients (30%). Hysterectomy was performed in 12 patients (40%), and 6 of them had a concomitant bilateral salpingo-oophorectomy (20%). In addition, 3 patients (10%) underwent partial bowel resection, and 2 patients (6.7%) underwent partial bladder resection. After surgery, 24 of 27 patients (80.0%) were free of sever hydronephrosis after surgery. Hydronephrosis recurred in a single patient (3.3%), but the grade of hydronephrosis improved significantly after surgery (P < 0.001). At 6 months of follow up, 4 patients (13.3%) experienced urinary tract infections and 2 patients (6.7%) reported dysuria. Patients reported a regression of dysmenorrhea symptoms (P < 0.001). CONCLUSION: This study shows that ureteroneocystostomy provides good results in terms of relapses and symptom control in patients with ureteral endometriosis.

Defining the key skills required to perform advanced laparoscopic procedures: a qualitative descriptive study.

BACKGROUND: Simulation is widely used to teach and assess fundamental laparoscopic skills; however, program directors have reported that current simulation programs do not meet the needs for trainees and surgeons learning advanced laparoscopic procedures (ALP). The purpose of our study was to identify the key skills required to perform ALP, to serve as the basis to establish an advanced laparoscopic skills training program. METHODS: Semi-structured interviews were conducted with attending surgeons, fellows, and senior residents in general surgery, gynaecology, and urology. The questions were developed through an iterative process using relevant literature, expert opinions, and in consultation with a qualitative researcher. Interviews were conducted in person, over the phone, or by videoconference, and inductive thematic analysis was performed. RESULTS: 25 interviews were conducted with 16 attending surgeons and 9 fellows/residents from 9 institutions in Canada and USA. Twenty-one skills were identified to be important when performing ALP. The skills most commonly described by faculty were the following : (a) suturing, (b) dissection, (c) procedural expertise, (d) retraction and exposure, and (e) familiarity with relevant anatomy as viewed through the laparoscope. The skills most commonly described by trainees were the following: (a) suturing, (b) dissection, (c) procedural expertise, (d) trocar positioning, and (e) patient factors. There was a large difference between the importance the faculty attributed to the 'Retraction and Exposure' skill compared to the trainees. CONCLUSION: This study identified key skills that are important when performing ALP. In order to address the current needs of trainees/surgeons learning ALP, this work provides the building blocks for the development of an advanced laparoscopic surgery simulation program.

Correlation between the number of laparoscopy-qualified gynecologists and the proportion of laparoscopic surgeries for benign gynecological diseases in Japan: An ecological study.

AIM: We aimed to evaluate regional disparities in the proportion of the three main laparoscopic surgeries for benign gynecological diseases among 47 prefectures in Japan and their correlation with the number of laparoscopy-qualified gynecologists per population. METHODS: In this retrospective ecological study, we collected the data of patients from 47 prefectures in 2017 using "The National Database of Health Insurance Claims and Specific Health Checkups of Japan" Open Data from the Ministry of Health, Labor and Welfare in Japan. The primary outcome of the study was the proportion of laparoscopic surgeries conducted for benign gynecologic diseases (hysterectomy, myomectomy and surgery for the benign ovarian diseases). The main exposure was the number of laparoscopy-qualified gynecologists per 100 000 females. RESULTS: The average proportion of laparoscopic hysterectomies, myomectomies and surgeries for the benign ovarian disease were 38% (standard deviation (SD) 16, range 12-74), 48% (SD 18, range 9-81) and 60% (SD 11, range 36-79), respectively. Multiple regression analysis showed a significant correlation between the number of laparoscopy-qualified gynecologists per 100 000 females and the proportion of the three main laparoscopic surgeries. CONCLUSION: There are obvious regional disparities in the proportion of the three main laparoscopic procedures for benign gynecological diseases among 47 prefectures. The number of laparoscopy-qualified gynecologists correlated significantly with these regional disparities. The academic society should monitor these regional disparities and make an effort to reduce these regional disparities by increasing laparoscopy-qualified gynecologists in areas where the widespread use of laparoscopic techniques is lagging.

Simulation platforms to assess laparoscopic suturing skills: a scoping review.

BACKGROUND: Laparoscopic suturing (LS) has become a common technique used in a variety of advanced laparoscopic procedures. However, LS is a challenging skill to master, and many trainees may not be competent in performing LS at the end of their training. The purpose of this review is to identify simulation platforms available for assessment of LS skills, and determine the characteristics of the platforms and the LS skills that are targeted. METHODS: A scoping review was conducted between January 1997 and October 2018 for full-text articles. The search was done in various databases. Only articles written in English or French were included. Additional studies were identified through reference lists. The search terms included "laparoscopic suturing" and "clinical competence." RESULTS: Sixty-two studies were selected. The majority of the simulation platforms were box trainers with inanimate tissue, and targeted basic suturing and intracorporeal knot-tying techniques. Most of the validation came from internal structure (rater reliability) and relationship to other variables (compare training levels/case experience, and various metrics). Consequences were not addressed in any of the studies. CONCLUSION: We identified many types of simulation platforms that were used for assessing LS skills, with most being for assessment of basic skills. Platforms assessing the competence of trainees for advanced LS skills were limited. Therefore, future research should focus on development of LS tasks that better reflect the needs of the trainees.

Efficacy of a Self-timed Trial of Laparoscopic Surgical Training Using a Dry Box.

Objective: This study evaluated the self-timed trial training for laparoscopic suturing. Methods: The set task involved grasping the suture, aligning the needle with a needle holder, passing the suture, making 3 knots, holding the 2 tails of the suture with one grasper, and cutting them. Trainees were given an instruction for suturing and reducing their suturing time. The same instruction was given 3 months later. Suturing times for the first and second trials and the last trial after the second instruction of the 9 trainees were measured. Results: Their mean suturing times were statistically significantly shorter after instruction (before instruction: 276.7 ± 43.4 seconds, after instruction: 177.4 ± 46.1 seconds; P = .0035). Four trainees were trained twice during the second instruction. Their suturing times were shorter than those of the other trainees, and the standard deviation decreased (120.5 ± 21.2 seconds, P = .017). Conclusion: A self-timed trial training for laparoscopic suturing using a dry box makes training interesting and motivates trainees.

A Retrospective Study of the Effects of Oncology Pharmacist Participation in Treatment on Therapeutic Outcomes and Medical Costs.

Specialist oncology pharmacists are being trained in Japan to assist cancer treatment teams. These specialized pharmacists address patients' physical and mental problems in pharmacist-managed cancer care clinics, actively participate in formulating treatment policies, and are beneficial in offering qualitative improvements to patient services and team medical care. However, the effect of outpatient treatment by oncology pharmacists on therapeutic outcomes and medical costs is still unknown. A retroactive comparative analysis of the treatment details and clinical course was conducted among three groups of patients: patients who underwent adjuvant chemotherapy managed by a gynecologic oncologist only (S arm), patients managed by a non-oncologist (general practice gynecologist) only (NS arm), and patients managed by both a non-oncologist and a specialist oncology pharmacist (NS+Ph arm). The medical cost per course was significantly lower for patients in the NS+Ph arm than for those in the other two arms. Surprisingly, the outpatient treatment rate in the NS+Ph arm was overwhelmingly high. The involvement of an oncology pharmacist did not make a significant difference in therapeutic outcomes such as recurrence rate and survival. The participation of oncology pharmacists in the management of cancer patients undergoing chemotherapy enables safe outpatient treatment and also reduces medical costs.

Effect of dienogest on pain and ovarian endometrioma occurrence after laparoscopic resection of uterosacral ligaments with deep infiltrating endometriosis.

OBJECTIVE: To evaluate the effect of dienogest (DNG) in preventing the occurrence of pain and endometriomas after laparoscopic resection of uterosacral ligaments (USLs) with deep infiltrating endometriosis (DIE). STUDY DESIGN: This retrospective analysis included 126 patients who underwent laparoscopic resection of USLs with DIE followed by postoperative administration of DNG or no medication. Every 6 months postoperatively, patients answered questions and underwent ultrasound examination to identify pain and/or endometrioma. RESULT: There were three (5.0%) cases of endometrioma in 59 patients from the DNG group and 21 (31.3%) cases in 67 patients from the no medication group (P=0.0002). Pain returned to preoperative levels in eight (11.9%) cases in the no medication group. No recurrence of pain occurred in the DNG group (P=0.0061). CONCLUSION: The administration of DNG after resection of USLs with DIE significantly reduces the occurrence rate of endometriosis-related pain and endometriomas.

Total laparoscopic nerve-sparing radical parametrectomy for occult early-stage cervical cancer: surgical technique and postoperative bladder function.

Surgery and radiotherapy are both regarded as standard treatments for occult cervical cancers. Surgery has several theoretical advantages over radiotherapy; therefore, such cancers, especially in their early stages, are commonly treated with radical parametrectomy. However, postoperative bladder dysfunction is an important potential complication of this type of surgery. This is a case report of total laparoscopic nerve-sparing radical parametrectomy for an occult cervical cancer using our original surgical concept based on detailed anatomical investigation of pelvic nerve networks in a fresh cadaver. We evaluated the validity of our nerve-sparing technique by assessing postoperative bladder function using urodynamic studies.

Various types of total laparoscopic nerve-sparing radical hysterectomies and their effects on bladder function.

OBJECTIVE: This study was conducted to ascertain the correlation between preserved pelvic nerve networks and bladder function after laparoscopic nerve-sparing radical hysterectomy. METHODS: Between 2009 and 2011, 53 patients underwent total laparoscopic radical hysterectomies. They were categorized into groups A, B, and C based on the status of preserved pelvic nerve networks: complete preservation of the pelvic nerve plexus (group A, 27 cases); partial preservation (group B, 13 cases); and complete sacrifice (group C, 13 cases). To evaluate bladder function, urodynamic studies were conducted preoperatively and postoperatively at 1, 3, 6, and 12 months after surgery. RESULTS: No significant difference in sensory function was found between groups A and B. However, the sensory function of group C was significantly lower than that of the other groups. Group A had significantly better motor function than groups B and C. No significant difference in motor function was found between groups B and C. Results showed that the sensory nerve is distributed predominantly at the dorsal half of the pelvic nerve networks, but the motor nerve is predominantly distributed at the ventral half. CONCLUSION: Various types of total laparoscopic nerve-sparing radical hysterectomies can be tailored to patients with cervical carcinomas.

Obstetric outcomes of patients undergoing total laparoscopic radical trachelectomy for early stage cervical cancer.

OBJECTIVE: To assess the obstetric outcomes of our total laparoscopic radical trachelectomy (TLRT) cases for early stage cervical cancer. MATERIALS AND METHODS: A total of 56 patients who underwent TLRT between December 2001 and August 2012 were reviewed retrospectively using clinicopathological, surgical, and follow-up data from patients' medical records. RESULTS: We performed this operation on 56 patients during the study period. The mean age of these 56 patients was 31.9 years (range 22-42 years). Fifty-three patients' fertility was preserved without requiring post-operative adjuvant treatment. Twenty-five women attempted to conceive, of whom 13 succeeded for a total of 21 pregnancies (52% pregnancy rate). Ten of these 21 pregnancies were the result of assisted reproductive technologies. Of those, 5 resulted in first trimester miscarriages, 2 in second trimester miscarriages, and 13 in live births. Ten pregnancies reached the third trimester. Preterm premature rupture of membranes (8/13, 61.5%) was the most common complication during pregnancy. The rate of preterm delivery was 47.6%. Three patients delivered at 22-28 weeks of gestational age. Two of these babies showed permanent damage: one has cerebral palsy; the other has developmental retardation. One pregnancy is ongoing. CONCLUSION: TLRT is a useful technique associated with an excellent pregnancy rate in fertility-preserving surgery to treat early stage cervical cancer.

Total laparoscopic hysterectomy in 1253 patients using an early ureteral identification technique.

AIM: The aim of this study was to determine the incidence of perioperative complications and evaluate risk factors for the major complications of total laparoscopic hysterectomy (TLH) using an early ureteral identification technique. We describe the technique we standardized and used for TLH, without exclusion criteria. MATERIAL AND METHODS: A retrospective study was carried out at Kurashiki Medical Center, Japan, based on 1253 TLH procedures performed from January 2005 to March 2009. We reviewed records to identify the major perioperative complications, including bladder, ureteral, and intestinal injuries, and incidences of reoperation. Risk factors for major complications were analyzed using multivariate logistic regression models. RESULTS: A total of 24 patients encountered major complications (1.91%). Complications included 10 intraoperative urologic injuries, five cases of postoperative hydronephrosis, five cases of vaginal dehiscence, one bowel injury, one postoperative hemorrhage, one bowel obstruction, and one ureterovaginal fistula. All 11 cases of intraoperative visceral injury were recognized during the surgery and repaired during the same laparoscopic surgical procedure. Of the risk factors analyzed, a history of abdominal surgery was the only one associated with the occurrence of major complications, with an odds ratio of 2.48 (95% confidence interval 1.23-6.49). CONCLUSION: While complications are inevitable, even in the hands of the most skilled surgeon, they can be minimized without conversion to laparotomy by a sufficiently developed suturing technique and a precise knowledge of pelvic anatomy. The presented data indicate that our method allows for safe TLH and minimization of ureteral injury, without the use of stringent exclusion criteria.

Global gene expression profiling of preimplantation embryos.

Preimplantation development is marked by four major events: the transition of maternal transcripts to zygotic transcripts, compaction, the first lineage differentiation into inner cell mass and trophectoderm, and implantation. The scarcity of the materials of preimplantation embryos, both in size (diameter < 100 microm) and in quantity (only a few to tens of oocytes from each ovulation), has hampered molecular analysis of preimplantation embryos. Recent progress in RNA amplification methods and microarray platforms, including genes unique to preimplantation embryos, allow us to apply global gene expression profiling to the study of preimplantation embryos. Our gene expression profiling during preimplantation development revealed the distinctive patterns of maternal RNA degradation and embryonic gene activation, including two major transient waves of de novo transcription. The first wave corresponds to zygotic genome activation (ZGA). The second wave, mid-preimplantation gene activation (MGA), contributes dramatic morphological changes during late preimplantation development. Further expression profiling of embryos treated with inhibitors of transcription or translation revealed that the translation of maternal RNA is required for the initiation of ZGA, suggesting a cascade of gene activation from maternal RNA/protein sets to ZGA gene sets and thence to MGA gene sets. To date, several reports of microarray experiments using mouse and human preimplantation embryos have been published. The identification of a large number of genes and multiple signaling pathways involved at each developmental stage by such global gene expression profiling accelerates understanding of molecular mechanisms underlining totipotency/pluripotency and programs of early mammalian development.