Large leiomyomatosis peritonealis disseminata after laparoscopic myomectomy: A case report with literature review.

INTRODUCTION: Leiomyomatosis peritonealis disseminata (LPD) is a rare disease in which multiple leiomyomas are formed intraperitoneally. Several LPD cases were associated with laparoscopic myomectomy using power morcellators; however, LPD with a large tumor size remains extremely rare. We present a case of large LPD occurring after laparoscopic surgery. PRESENTATION OF CASE: A 26-year-old woman, gravida 0, underwent laparoscopic myomectomy with power morcellation in our institution. After 5 years, follow-up examination revealed pelvic tumors. Although we recommended resection, she refused and only wanted to be followed up. After 9 years from the first surgery, the tumors became symptomatic and were increasing in number (>10 nodules) and size (>15 cm). Needle biopsy detected leiomyoma. Computed tomography angiography showed that omental and mesenteric arteries were feeding the tumors. We performed laparotomy, and all the 19 tumors emerging from the omentum and mesenterium and weighing 7647 g in total were removed without injuring other organs. The maximum diameter of the largest tumor was 34 cm. The pathological diagnosis was nonmalignant LPD with leiomyoma. DISCUSSION: Among all reported cases, our case had the largest LPD size. The tumors reached such a huge size because of two possible reasons: (1) they gradually grew asymptomatically over a long period from the time of diagnosis, and (2) they were fed by particularly large vessels, including the omental and mesenteric arteries. CONCLUSION: A large LPD is not always symptomatic. After a laparoscopic myomectomy, especially with power morcellation, long-term follow-up is necessary to detect LPD.

Port site recurrence and unusual diffuse subcutaneous metastases of unexpected early stage ovarian cancer after laparoscopic surgery: a case report.

Port site recurrence is a rare but well-documented adverse event peculiar to laparoscopic surgery. We report an unusual outcome of unexpected early stage ovarian cancer in which port site recurrence occurred after laparoscopic surgery and was followed by diffuse subcutaneous metastases. A 31-year-old Japanese woman with a large tumor in her abdomen visited our hospital. Because no intratumoral solid component was detected on diagnostic imaging, the tumor was diagnosed as a benign ovarian tumor and the patient underwent left ovarian laparoscopic cystectomy. Contrary to our expectations, however, the ovarian tumor was a mucinous carcinoma. We performed additional surgery, but the tumor recurred in the umbilical area, and multiple subcutaneous metastases later appeared. The curative effect of chemotherapy and radiation was limited. This atypical metastatic distribution of an extremely small amount of cancer might have been caused by the laparoscopic procedure. Protection against tumor cell dissemination is necessary during all forms of laparoscopic surgery.

Review of transvaginal natural orifice transluminal endoscopic surgery in gynecology.

Recent technologic advances in endoscopic instrumentation and optics have allowed the development of a less invasive alternative to conventional laparoscopic surgery. During the past decade, natural orifice transluminal endoscopic surgery (NOTES) flourished in the field of general surgery, and it has emerged as a new concept of minimally invasive surgery. NOTES yields access to the abdominal cavity without any incisions on the abdominal wall (scarless surgery), and the natural orifices of the body surface, such as the mouth and the vagina, serve as the gateway to the peritoneal cavity. In gynecology, the vagina of a woman can be considered as an additional route for surgery. Recently, clinical application of transvaginal NOTES has broadened significantly in gynecology. Using transvaginal NOTES by applying the method of single-incision laparoscopic surgery via the vaginal route, not only adnexal surgery and hysterectomy, but also myomectomy and oncologic surgery could be performed safely and effectively in selected patients. In future, further studies should be conducted to evaluate the true clinical feasibility and safety of transvaginal NOTES.

Hybrid transvaginal and transumbilical laparoendoscopic adnexal surgery.

BACKGROUND: Natural orifice translumenal endoscopic surgery (NOTES) is an emerging concept in the recent literature that could lead to potential benefits in clinical applications. The present study describes the initial clinical application in 15 cases of hybrid transvaginal and transumbilical NOTES and discusses the feasibility, safety, and potential benefits of the method. PATIENTS AND METHODS: We evaluated the records of 15 patients who underwent hybrid transvaginal and transumbilical laparoendoscopic adnexal surgery between January 2010 and September 2011. RESULTS: Procedures included salpingo-oophorectomy (n=7) and cystectomy (n=3) for ovarian tumors and salpingectomy (n=5) for unruptured tubal pregnancy. The mean operative time was 79 minutes (range, 49-116 minutes). Blood loss was minimal in all cases. All procedures were successfully performed, and there were no conversions to conventional multiport laparoscopy or open surgery. Gynecologic examination after 3 months showed no negative findings, and the cosmetic result was ideal with no visible scar. CONCLUSIONS: Hybrid transvaginal and transumbilical NOTES is feasible and safe in select patients, and it provides no visible scar.

Expression of heme oxygenase in the eutopic and ectopic endometrium in patients with adenomyosis.

Heme oxygenase (HO) is the rate-limiting enzyme that catalyzes the degradation of heme into iron, carbon monoxide, and biliverdin. This enzyme has important functions in cellular homeostasis, including the regulation of oxidative load, apoptosis, and inflammation. Two isoforms of HO, the inducible HO-1 and the constitutive HO-2, are expressed and are known to play a role in the normal human endometrium throughout the menstrual cycle, but there is little evidence for HO expression and behavior in adenomyosis, which is the occurrence of intramural ectopic endometrial tissue. The aim of this study was to investigate the presence and localization of the two HO isoforms in both eutopic and ectopic endometrium of women with adenomyosis during the menstrual cycle. The oxidative stress and apoptosis related to HO-1 expression were also assessed. The expression of HO-1 and HO-2 in both eutopic and ectopic endometrium was confirmed, and their levels in the ectopic endometrium were lower than those in the eutopic endometrium. The cyclic variability of HO expression was lost in the ectopic endometrium during the menstrual cycle, whereas this variability was apparent in the eutopic endometrium. Moreover, HO-1 expression corresponded to apoptotic events in the eutopic endometrium. Constitutive HO-2 expression corresponded to endometrial proliferation and degradation. These results reveal that both HO-1 and HO-2 contribute little in the pathophysiology of adenomyosis.

Single-incision laparoscopic myomectomy with intracorporeal suturing.

OBJECTIVE: To assess the feasibility, safety, and operative outcomes of single-incision laparoscopic myomectomy with intracorporeal suturing. DESIGN: Retrospective descriptive study. SETTING: Tokyo Medical and Dental University Hospital, Tokyo, Japan. PATIENT(S): Twelve patients who underwent single-incision laparoscopic myomectomy between July 2009 and June 2010 to remove single or multiple uterine myomas. INTERVENTION(S): All cases of single-incision laparoscopic myomectomy were performed by a single surgeon (N.Y.). MAIN OUTCOME MEASURE(S): Technical feasibility and operative outcomes. RESULT(S): Cases consisted of six subserosal, four intramural, and two submucosal myomas. The mean operative time and weight of the largest myoma per patient were 100 minutes (range, 52-150 minutes) and 78 g (range, 15-284 g), respectively. Blood loss was minimal in all cases. All procedures were successfully performed, and there were no conversions to conventional multiport laparoscopy or open surgery. There were no postoperative complications or port-site hernias noted. CONCLUSION(S): We successfully performed single-incision laparoscopic myomectomy with intracorporeal suturing. Single-incision laparoscopic myomectomy with the glove wound retractor system is feasible and safe in select patients, and it provides almost no visible scar.

Unusual uterus didelphys presenting in the retroperitoneum.

We describe a case of uterus didelphys with obstructed hemivagina and ipsilateral renal agenesis. Magnetic resonance imaging (MRI) demonstrated uterus didelphys and laparoscopy revealed that an affected uterus was present in the retroperitoneum.

Increase in the concentration of cytosolic-free calcium induced by human follicular fluid was decreased in single human spermatozoon with abnormal morphology.

Aim: The increase in the concentration of cytosolic-free calcium ([Ca2+]i) induced by follicular fluid or progesterone has been reported to promote an acrosome reaction and alternation in several motion parameters in human sperm (hyperactivation). We previously reported that populations of sperm in cell suspension obtained from infertile men with abnormal morphology exhibited lower mean peak progesterone-evoked [Ca2+]i compared with morphologically normal sperm using cell-suspension methods. In the present study, the change in [Ca2+]i in individual normally and abnormally shaped spermatozoa was compared. Methods: The change in [Ca2+]i induced by human follicular fluid in individual spermatozoa with normal and abnormal morphology was compared using the fluorescent calcium-sensitive dye fluo-3/AM. The spatial distribution of the increase in [Ca2+]i in single sperm was also investigated. Results: The [Ca2+]i of normally shaped spermatozoa increased rapidly after the administration of human follicular fluid. The response reached a peak within 2-3 s and then slowly declined to a plateau phase. The baseline and peak fluorescence in spermatozoa with abnormal morphology was lower when compared with normal spermatozoa. The follicular-fluid-induced increase in [Ca2+]i (expressed as a percentage increase in [Ca2+]i over basal) in morphologically abnormal sperm was 39.2 ± 5.3% (n = 107, mean ± standard error), which was smaller than that of morphologically normal sperm (61.6 ± 5.7%, n = 100, P < 0.005) from seven healthy donors. The follicular-fluid-induced [Ca2+]i increases observed in sperm with morphologically abnormal mid-pieces (20.9 ± 4.3%, n = 12, P < 0.05) or tails (40.7 ± 6.0%, n = 92, P < 0.05) were lower than those of morphologically normal spermatozoa (61.6 ± 5.3%, n = 101). The follicular-fluid-induced [Ca2+]i increase of morphologically normal spermatozoa from infertile couples (35.1 ± 6.3%, n = 25, P < 0.05) was also found to be lower than that of morphologically normal spermatozoa from healthy donors. Conclusion: The present study shows that spermatozoa with abnormal morphology in healthy donors have disorders of signal transduction, as do normally shaped sperm in men from infertile couples. (Reprod Med Biol 2008; 7: 143-149).

Use of the potassium titanyl phosphate laser in the laparoscopic anterior rectum slicing operation.

OBJECTIVE: To evaluate the efficacy of the potassium titanyl phosphate (KTP) laser used during the laparoscopic anterior rectum slicing (LARS) operation. DESIGN: Retrospective study. SETTING: National Hospital Organization Kyoto Medical Center, Kyoto, Japan. PATIENT(S): All 46 patients who underwent the LARS operation using the KTP laser. INTERVENTION(S): The LARS operation using the KTP laser for treatment of deep rectal endometriosis. MAIN OUTCOME MEASURE(S): Operative and postoperative outcome. RESULT(S): Meaningful improvements in clinical symptoms were obtained with the LARS operation using the KTP laser with acceptable levels of postoperative morbidity. Bowel leakage did not occur in any of the patients. CONCLUSION(S): Deep rectal endometriosis can be treated effectively with the LARS operation using the KTP laser.