Frequency of cul-de-sac obliteration in surgery for pelvic organ prolapse: a retrospective analysis.

INTRODUCTION AND HYPOTHESIS: We aimed to clarify the frequency of cul-de-sac obliteration in patients undergoing POP surgery. METHODS: We retrospectively reviewed patients who underwent laparoscopic POP surgery at our hospital between April 2017 and September 2021. RESULTS: In total, 191 cases were included in the analysis. Ten patients (5.2%) had cul-de-sac obliteration. No difference in age (73 years vs. 72 years, P = 0.99), parity (2 vs. 2, P = 0.64), or body mass index (BMI) (25.7 kg/m2 vs. 24.7 kg/m2, P = 0.34) was observed between the cul-de-sac obliteration and normal groups. No significant differences were observed in the rate of previous abdominal surgery (50.0% vs. 32.6%, P = 0.46), rate of POP - quantification system (POP-Q) ≥ 2 posterior prolapse (40.0% vs. 46.4%, P = 0.98), and effect of defecation symptoms on the prolapse quality of life (p-QOL) score (vaginal bulge emptying bowels: 2.5 vs. 3.5, P = 0.15; empty bowel feeling: 3 vs. 3, P = 0.72, constipation: 3.5 vs. 3, P = 0.58; straining to open bowels: 3.5 vs. 3, P = 0.82; empty bowels with fingers: 1 vs. 1, P = 0.55) between the cul-de-sac obliteration and normal groups. Multivariate analysis of risk factors for the cul-de-sac obliteration was performed for age, number of births, previous abdominal surgery, and presence of rectocele; however no significant risk factors were extracted. CONCLUSION: Predicting cul-de-sac obliteration preoperatively in patients undergoing POP surgery based on age, number of previous surgeries, previous abdominal surgeries, rectocele, and defecation symptoms is difficult.

Total Laparoscopic Hysterectomy for Anterior Cervical Myoma: Possible Significance of Presurgical Assessment by Magnetic Resonance Imaging.

Hysterectomy for large uterine anterior cervical myoma is a challenging surgical procedure. We summarize our experience in the management of large uterine anterior cervical myoma. Three patients underwent hysterectomy for uterine anterior cervical myoma with similar sizes and different positions treated by laparoscopic surgery. Total laparoscopic hysterectomy (TLH) for cervical myoma is possible by performing ureterolysis and adopting retrograde hysterectomy. Because the position of myoma is important to determine the difficulty of TLH, we propose to measure the axis between the most caudal point of the myoma and external cervical os and pubococcygeal line as a possible useful method in objectively predicting the difficulty of TLH for large anterior cervical myoma.

Effect of Vaginal Estriol Use in Total Laparoscopic Hysterectomy with Gonadotropin-Releasing Hormone Agonist Therapy.

STUDY OBJECTIVES: The aim of this study is to evaluate the effects of vaginal estriol therapy in total laparoscopic hysterectomy (TLH) with gonadotropin-releasing hormone agonist (GnRH-a) treatment. DESIGN: Retrospective analysis. DESIGN CLASSIFICATION: Canadian Task Force classification II-2. SETTINGS: Department of Gynecology, Yokohama City University Medical Center, Japan. METHODS: We retrospectively investigated 50 fibroid cases that had TLH with preoperative GnRH-a treatment and compared the surgical outcome with or without vaginal estriol use (1mg). Estriol was used administered for two weeks before TLH. MEASUREMENTS AND MAIN RESULTS: A total of 12 patients (27%) received vaginal estriol (1 mg) for 14 days before TLH. As a result of vaginal estriol treatment, there were no group differences in uterus size reduction with GnRH-a treatment (22% vs. 15%, P = 0.20), uterine removal time through the vagina (12.5 min vs. 18.5 min, P = 0.18), rate of vaginal dehiscence (3% vs. 0%, P = 0.76) or in the rate of perineal laceration (33% vs. 34%, P = 0.55). CONCLUSION: The use of vaginal estriol treatment before TLH with GnRH-a therapy did not improve surgical outcomes.

Significance of postmenopausal uterine leiomyomas: Focus on variants.

AIM: To investigate the differences in leiomyoma pathophysiology by patient age at the time of surgery and the possible significance of postmenopausal uterine leiomyomas, particularly variants. METHODS: We retrospectively reviewed data from 471 patients who underwent surgery for uterine leiomyomas and evaluated their clinical data. RESULTS: Overall, 441 (93.4%) women were premenopausal and 30 (6.4%) were postmenopausal. There were no differences in the frequency of the coexistence of ovarian steroid-dependent diseases among age groups. Common histopathological features were observed in most cases despite menopausal status; however, the incidence of variants among postmenopausal patients was high compared to that among premenopausal women (23.3% [7/30] vs 3.2% [14/441], respectively). Among the variant leiomyomas in postmenopausal patients, lipoleiomyomas comprised six. CONCLUSION: Although progesterone is known to play a vital role in promoting leiomyoma growth, it reportedly performs dual actions and does not always stimulate leiomyoma growth. Our study may support the idea that the dual action of progesterone is the primary reason for the surgical treatment required for uterine leiomyomas in the postmenopausal period. We also found that lipoleiomyoma might be the most common uterine leiomyoma variant requiring surgical treatment among postmenopausal women. Thus, we must consider the diagnosis of uterine lipoleiomyoma in postmenopausal women with uterine leiomyomas.

Minimum 10-year results of cementless total hip arthroplasty in patients with rheumatoid arthritis.

OBJECTIVES: To retrospectively evaluate the long-term results of cementless total hip arthroplasty (THA) in patients with rheumatoid arthritis (RA) and postoperative patient mortality after THA. METHODS: This study included 191 hips in 149 RA patients who underwent cementless THA between 1998 and 2005. Mean age at surgery was 54.2 years, and mean follow-up was 12.6 years. Implant and patient survivorships were determined using the Kaplan-Meier method, and the associated influencing factors were determined. RESULTS: Implant survivals at 17 years were 99.5% for stems, 93.9% for cups, and 90.8% for liners. Among the liners used, THAs with highly cross-linked polyethylene showed better survivals compared with those with conventional polyethylene and alumina-bearing surface (93.4%, 90.9%, and 52.2%, respectively). A total of 64 deaths occurred; 45 patients died within 10 years and 19 patients died between 10 and 17 years. Malignancy (25.0%) was the leading cause of death, followed by pneumonia (20.8%) and sepsis (20.8%). The patient survival rate was 36.9% at 17 years after THA. Multivariate analysis exhibited that older age at operation and greater dose of concomitant corticosteroid resulted in shorter patient survivals. CONCLUSIONS: Cementless THA worked well in patients with RA. Mortality remained high among RA patients who needed THA.

Clinical characteristics of mirror syndrome: a comparison of 10 cases of mirror syndrome with non-mirror syndrome fetal hydrops cases.

OBJECTIVE: To investigate clinical features of mirror syndrome. METHODS: We retrospectively reviewed 71 cases of fetal hydrops with or without mirror syndrome, and compared with respect to maternal age, the body mass index, the primipara rate, the gestational age at delivery, the timing of fetal hydrops onset, the severity of fetal edema, placental swelling, the laboratory data and the fetal mortality. The data are expressed as the medians. RESULTS: Mirror syndrome developed in 29% (10/35) of the cases with fetal hydrops. In mirror group, the onset time of fetal hydrops was significantly earlier (29 weeks versus 31 weeks, p = 0.011), and the severity of fetal hydrops (fetal edema/biparietal diameter) was significantly higher than non-mirror group (0.23 versus 0.16, p < 0.001). There was significantly higher serum human chorionic gonadotropin (hCG) (453,000 IU/L versus 80,000 IU/L, p < 0.001) and lower hemoglobin (8.9 g/dL versus 10.1 g/dL, p =0.002), hypoalbuminemia (2.3 mg/dL versus 2.7 mg/dL, p = 0.007), hyperuricemia (6.4 mg/dL versus 5.0 mg/dL, p = 0.043) in mirror group. CONCLUSION: Mirror syndrome is occurred frequently in early and severe fetal hydrops and cause hemodilution and elevation of serum hCG.

[Bone loss in lactating women and post-pregnancy osteoporosis].

Measurement of the bone mineral density have shown that lactating women had 1 to 3% decrease in bone mineral density. Post pregnancy osteoporosis is rare condition that causes fragile fracture mostly in vertebrae. The bone loss in lactating women is caused by calcium loss, decrease in estrogen level, and increase in PTHrP (parathyroid hormone related protein) level. Some data have shown that extended lactation and amenorrhea had an association with the degree of bone loss. Mostly, the bone loss of the lactating women recovers to the baseline level, soon after the weaning, and there is no long term effect. Post pregnancy osteoporosis should be concerned, when we see a lactating woman with fragile fracture of the vertebrae.

Antiinflammatory and chondroprotective effects of the aminobisphosphonate incadronate (YM175) in adjuvant induced arthritis.

OBJECTIVE: Incadronate is a third-generation bisphosphonate that suppresses bone resorption and is used to treat skeletal disorders and prevent bone loss in pathological conditions. We evaluated its therapeutic potential and antiinflammatory effects in established adjuvant induced arthritis (AIA), a rat model of rheumatoid arthritis (RA). METHODS: Rats were administered incadronate subcutaneously at a dose of either 0.1 or 1.0 mg/kg/day, or 0.1 or 1.0 mg/kg/week, while a positive control group received phosphate buffered saline alone from Day 14 (after the onset of arthritis) to Day 42. The destruction of bone and cartilage and the antiinflammatory effects of incadronate in rats with established AIA were assessed during treatment, with reference to the arthritis index, hind paw volume, and radiological and histological examinations. To establish whether incadronate affects the migration of inflammatory cells, a chemotaxis assay was carried out using macrophage-like RAW 264.7 cells. Results. In vivo, incadronate suppressed the clinical manifestations of AIA in a dose-dependent manner. In vitro, the various concentrations of incadronate suppressed the migration of macrophages, but the viability and adhesion of these cells were not suppressed. CONCLUSION: Incadronate not only inhibits bone destruction but also reduces cartilage degeneration and joint inflammation in rats with established AIA. The mechanism underlying these antiinflammatory actions of incadronate may be attributable to the inhibition of macrophage migration to the site of inflammation. Bisphosphonates might be effective in preventing the progressive joint destruction and inflammation seen in patients with RA.

Intramuscular bone induction by human recombinant bone morphogenetic protein-2 with beta-tricalcium phosphate as a carrier: in vivo bone banking for muscle-pedicle autograft.

An ideal replacement for bone defects is auto-bone tissue, of which there is an ample supply with the required form and with vascularity. Our strategy for generating such bone tissue is as follows. First, bone tissue is induced in muscle by bone morphogenetic protein-2 (BMP-2) with beta-tricalcium phosphate as a carrier to maintain its form in the muscle. Second, the induced bone in the muscle pedicle is grafted to the bone defect to maintain vascularity. In the first experiment, 50 microg of recombinant human BMP-2 (rhBMP-2) was inoculated into the hip abductor muscle of rabbits with beta-tricalcium phosphate under anesthesia. Five weeks after the operation, intramuscular bone formation was observed in all of the samples, and the form and size of the induced bone tissue were identical to those of the carrier. Ten weeks after the operation, the induced bone was partly absorbed. In the second experiment, 50 microg of rhBMP-2 was inoculated in the same manner as previously. Five weeks after the operation, the muscle tissue around the induced bone was incised, leaving just the proximal part as a pedicle. Two or four weeks after the second operation, the induced bone tissue had rich vascularity and no empty lacunae. This indicates the possibility of in vivo bone banking to enable morphologically controlled and vascularized auto-bone grafts.

Possible involvement of the vascular endothelial growth factor-Flt-1-focal adhesion kinase pathway in chemotaxis and the cell proliferation of osteoclast precursor cells in arthritic joints.

Vascular endothelial growth factor (VEGF) plays a crucial role in the pathogenesis of inflammatory joint disease, including angiogenesis and synovitis. Rheumatoid arthritis is a chronic inflammatory disease characterized by progressive synovitis and subsequent bone destruction mediated by osteoclasts (OCs). In this study, we investigate the effects of VEGF on OC precursor cells (pOCs) using Raw cells and adjuvant-induced arthritis in rats. OCs and pOCs in the arthritic joints express VEGF and VEGF receptor type I (Flt-1). Raw cells also express Flt-1, and VEGF treatment stimulated chemotaxis, cell proliferation, the association of Flt-1 with focal adhesion kinase (FAK), and the tyrosine phosphorylation of FAK in Raw cells. The tyrosine phosphorylation of FAK was also observed in pOCs in the arthritic joints of adjuvant-induced arthritis. Adenovirus-mediated expression of FAK-related nonkinase in Raw cells inhibited the effects of VEGF in a dominant negative manner. Furthermore, intra-articular injection of the FAK-related nonkinase virus suppressed the recruitment of pOCs and bone destruction. Our results suggest the possible involvement of the VEGF-Flt-1-FAK pathway in inflammatory disease-induced joint destruction.

Involvement of CD4+,CD57+ T cells in the disease activity of rheumatoid arthritis.

OBJECTIVE: To evaluate the relationship between the frequency of peripheral CD57+ T cells and the physical status of rheumatoid arthritis (RA) patients, and to perform cytokine analysis of these CD57+ T cells. METHODS: Four-color fluorescence-activated cell sorter analysis was performed to detect both cell surface antigens and intracellular cytokines in peripheral blood leukocytes, using monoclonal antibodies against CD3, CD4, CD8, CD57, interferon-gamma (IFNgamma), and interleukin-4 (IL-4). RA patients were clinically evaluated with a modified Health Assessment Questionnaire (M-HAQ), joint score, face scale, and visual analog scale (VAS) assessing pain and disease activity. RESULTS: There was a significant correlation between the frequency of CD4+,CD57+ T cells and erythrocyte sedimentation rate (ESR), whereas a correlation was not found between the frequency of CD8+,CD57+ T cells and ESR. The frequency of CD4+,CD57+ T cells also showed a significant correlation with the mHAQ score, VAS, and face scale. Again, there was no significant correlation between the above-mentioned clinical scores and the frequency of CD8+,CD57+ T cells. Flow cytometric analysis of intracellular cytokines revealed that 14.5% of the CD57+ T cells produced IFNgamma, whereas only 2.8% of the CD57+ T cells produced IL-4 in RA patients. CONCLUSION: Evidence showing that the frequency of CD4+,CD57+ T cells among CD3+ cells of RA patients had a significant correlation not only with ESR but also with the physical status of the patients, and that a large proportion of the CD4+,CD57+ T cells had the capacity to produce IFNgamma, strongly suggests that these CD4+,CD57+ T cells are involved in the immunopathogenesis of RA.