Rectouterine fistula after laparoscopic ultrasound-guided radiofrequency ablation of a uterine fibroid.

In the conservative management of uterine fibroids is radiofrequency ablation (RFA) considered to be one of the safe, effective and minimal invasive approaches in selected women who desire to retain their uterus. Few studies were conducted on its adverse outcomes and most of the reported complications were minor events such as pain, discharge, adhesion which didn't require any intervention. However, although safe and effective, the RFA of a uterine myoma can be the cause for severe complications such as penetration and burn injuries of pelvic organs. In general, a rectouterine fistula is one of the rarest complications but can lead to serious adverse outcomes. Herein, to our knowledge, we report the first case involving a rectouterine fistula after laparoscopic ultrasound-guided RFA of a uterine myoma with pelvic endometriosis. In addition, we provide a brief review of the relevant literature.

Correlation between FDG uptake by PET/CT and the expressions of glucose transporter type 1 and hexokinase II in cervical cancer.

BACKGROUND: The aim of this study was to explore the association between 2-deoxy-2-F18-fluoro-D-glucose uptake and the expressions of glucose transporter type 1 (GLUT-1) and hexokinase II (HK-II) in the lymph nodes of patients with cervical cancer. METHODS: This prospective study included 20 women with International Federation of Gynecology and Obstetrics stage IB to stage IIA cervical cancer who underwent positron emission tomography (PET)-computed tomography (CT) (PET/CT) before surgical treatment. In 333 dissected lymph nodes (LNs) obtained, we examined the size, tumor involvement, and expressions of GLUT-1 and HK-II. These characteristics were compared with PET/CT and pathological findings. RESULTS: Pathological analysis found that 21% (70) of the 333 surgically dissected LNs were metastatic. Positron emission tomography/CT detected metastasis with 22.8% sensitivity and 98.5% specificity. The levels of GLUT-1 and HK-II expression in false-positive LNs were higher than those in pathologically confirmed negative nodes (P = 0.015 and P = 0.001, respectively). In metastatic LNs, PET/CT-positive nodes were significantly different from PET/CT-negative nodes in mean size (P = 0.043), tumor involvement (P = 0.008), and proportion of GLUT-1-positive tumor cells (P = 0.042). CONCLUSIONS: Our results indicate that overexpression of GLUT-1 and HK-II may be related to 2-deoxy-2-F18-fluoro-D-glucose uptake in false-positive tissues on PET/CT. In metastatic lymph nodes, the ability of PET/CT to detect cancer may depend on tumor involvement, lymph node size, and GLUT-1 expression.

Ganglioneuroma of the uterine cervix--a case report.

Ganglioneuroma is a rare, benign tumor usually found in the mediastinum, retroperitoneum, or adrenal glands. We present a case of ganglioneuroma arising in the uterine cervix. A 65-year-old woman (gravida 3, para 3, abortus 0) showed vaginal spotting. The clinician observed a mild erosive lesion of her cervix and performed a biopsy and then conization. Histopathology revealed ganglioneuroma arising in the cervix. To our knowledge, this is the first report of a ganglioneuroma in the uterine cervix. Although ganglioneuroma is normally benign, a few malignant changes have been reported. Regular follow-up is necessary.

Pulmonary toxicity after a quick course of combinatorial vincristine, bleomycin, and cisplatin neoadjuvant chemotherapy in cervical cancer.

Pulmonary toxicity is one of the most serious adverse effects associated with a quick course of vincristine, bleomycin, and cisplatin neoadjuvant chemotherapy (NAC-VBP). The aim of this study was to evaluate pulmonary toxicity related to a quick course NAC-VBP. A total of consecutive 61 patients, who underwent at most 3 cycles of NAC-VBP every 10 days in the International Federation of Gynecology and Obstetrics (FIGO) stage IB-IIB cervical cancer from 1995 to 2007, were retrospectively analyzed. Of the 61 study subjects, 7 (11.5%) were identified to have pulmonary toxicity and 2 (3.3%) died of pulmonary fibrosis progression despite aggressive treatment and the use of a multidisciplinary approach. No factor predisposing pulmonary toxicity was identified. Initial symptoms were non-specific, but bronchiolitis obliterans organizing pneumonia and interstitial pneumonitis were characteristic findings by high-resolution computed tomography of the chest. The benefit of steroid therapy was uncertain and was associated with steroid-induced diabetes mellitus requiring insulin therapy in two patients. Fatal pulmonary toxicity is a major concern of a quick course NAC-VBP. In conclusion, these patients require special monitoring for bleomycin-induced pulmonary toxicity.

Expression and mutational analysis of TGF-beta/Smads signaling in human cervical cancers.

OBJECTIVE: To define the molecular basis of TGF-beta1 function in cervical carcinogenesis, we explored the expression and mutational status of TGF-beta1, TGF-beta1 receptors, and Smads, the regulators of the TGF-beta1 signaling pathway, in human cervical cancers. METHODS: Expression of TGF-beta1, TGF-beta1 receptors, and Smads transcripts were determined by quantitative reverse transcription-polymerase chain reaction (RT-PCR), and sequence alteration was analyzed using RT-PCR-single-strand conformation polymorphism (SSCP) analysis. Genomic levels of TGF-beta1, TGF-beta1 receptors and Smads was also measured by quantitative genomic PCR. RESULTS: Abnormal overexpression of TGF-beta1 and abnormal reduction of type II TGF-beta1 receptor were identified in 36% (18 of 50) and 20% (10 of 50) of cervical cancer tissues, respectively. 22% (11 of 50) in Smad2 and 14% (7 of 50) in Smad4 revealed tumor specific mRNA reduction less than a half of normal means. In addition, no evidence for sequence alterations of the gene was found by RT-PCR-SSCP analysis. CONCLUSION: Our study demonstrates that disruption of TGF-beta/Smad signaling pathway exist in human cervical cancer, suggesting that abnormal expressions of the member of TGF-beta/Smad signaling pathway might contribute to the malignant progression of human cervical tumors via suppressing the tumor suppression function of TGF-beta1 1's tumor suppression function.

Endometrioid adenocarcinoma in urethrovaginal septum: a diagnostic pitfall.

Primary endometrioid adenocarcinoma developed at urethrovaginal septum has not been reported. A 61-yr-old woman presented with recurrent urinary tract infection. She had received hormone replacement treatment with estrogen and progesterone for 5 yr. A pinpoint ulceration at slightly elevated anterior vaginal wall was found and biopsy revealed endometrioid adenocarcinoma. Magnetic resonance imaging showed the 4.3 cm sized mass in urethrovaginal septum. She has undergone anterior pelvic exenteration, pelvic lymph node dissection, and urostomy with ileal conduit. Microscopic finding of the pathology revealed endometrioid adenocarcinoma. Co-existence of endometriosis was not identified. Tumor at urethrovaginal septum was difficult to be detected till growing to be bulky, because of vaginal axis, misunderstanding of the tumor as symphysis pubis, no definitive symptom, and its rarity. This is the first reported case of extraovarian endometrioid adenocarcinoma developed at the urethrovaginal septum. Understanding normal functional anatomy and meticulous physical examination are essential to detect this rare tumor in the urethrovaginal septum.

Prenatal diagnosis of fetal seizure: a case report.

A 35-yr-old woman carrying a 17-week-old fetus presented with right hydronephrosis and a single umbilical artery. Karyotyping was normal and targeted ultrasonography showed an otherwise normal fetus. After 28 weeks of gestation, the mother felt rapid, repetitive fetal movement and an ultrasound at 30 weeks of gestation revealed tonic clonic movements of the fetal trunk and extremities. At 36 weeks of gestation, an emergency repeat Cesarean section was performed because of a premature rupture of the membranes and a male infant weighing 4,295 gm was delivered. After birth, the infant continued to have movements suggestive of a generalized tonic clonic seizure. Brain computed tomography and magnetic resonance imaging revealed normal structures and an electroencephalography showed generalized suppression. Treatment with phenobarbital resulted in substantial improvement in the number of seizure episodes, however fine seizure-like movement continued in both of the hands, feet and in the tongue until the five-month follow-up. This is the first Korean report of a fetal seizure being diagnosed during the prenatal period.

Anal incontinence after childbirth: incidence in the Korean population.

AIMS: To investigate the incidence and risk factors for anal incontinence after childbirth in Korea. METHODS: We retrospectively examined the records of 1,123 unselected women who delivered live infants at the KyungHee University Hospital between January 2006 and December 2006. Symptoms of anal incontinence were assessed by telephone interview using standard questionnaires. RESULTS: A total of 966 women (86%) responded to the survey, and the overall incidence of anal incontinence was 6.1% (9 fecal and flatal incontinence, 50 flatal incontinence). Of the study population, 562 (58.2%) had vaginal deliveries and 404 (41.8%) had cesarean sections. Vacuum extraction was used in 160 (28.5%) cases, and sphincter tears occurred in 16 (2.8%). Multivariate analysis showed that anal incontinence was associated with multiparity [2.75 (1.17-6.47)], maternal weight increase >or=15 kg [2.11 (1.03-4.31)], vaginal delivery with vacuum extraction [2.74 (1.23-6.14)], sphincter laceration [14.74 (4.69-46.27)], and cesarean section after second-stage labor [16.82 (4.61-61.40)]. CONCLUSION: Koreans had a lower incidence of post-birth anal incontinence than Westerners (6.1 and 29.3%, respectively), even though the risk factors were similar. These findings suggest that further studies examining differences in the incidence of anal incontinence based on ethnicity are warranted as such information may provide clues in terms of prevention and management of this disorder.

Ureteral injuries during classic intrafascial supracervical hysterectomy: an 11-year experience in 1163 patients.

STUDY OBJECTIVE: To examine the incidence, characteristics, and treatment of ureteral injuries during classic intrafascial supracervical hysterectomy for benign gynecologic diseases. DESIGN: Retrospective study (Canadian Task Force classification II-3). SETTING: Department of obstetrics and gynecology, university teaching hospital. PATIENTS: A total of 1163 women with benign gynecologic diseases. INTERVENTIONS: Classic intrafascial supracervical hysterectomy. MEASUREMENTS AND MAIN RESULTS: A retrospective chart review was conducted to determine the rate of ureteral injury. Four cases of ureteral injuries occurred among the 1163 classic intrafascial supracervical hysterectomy procedures (0.34%). Ureteral injury occurred during peritoneal dissection in 1 case, which was treated immediately with laparoscopy. In 2 cases, ureteral injuries were recognized by watery vaginal discharge several days after the operation and were treated with laparotomy procedures. Ureteral injury was not detected postoperatively in another case, resulting in a laparoscopic nephrectomy caused by a nonfunctioning kidney 3 years after the initial operation. The predisposing factors for ureteral injury were adhesion as a result of endometriosis, and earlier surgery in which the normal pelvic anatomy was distorted. CONCLUSION: The incidence of ureteral injury during classic intrafascial supracervical hysterectomy as noted in this study is 0.34%. Postoperative cases were associated with high morbidity. Early detection of ureteral injury is crucial for appropriate management as intraoperative diagnosis and repair of the injury then has fewer consequences and less serious complications than postoperative cases.

Predictors of leiomyoma recurrence after laparoscopic myomectomy.

STUDY OBJECTIVE: To evaluate recurrence and reoperation rate after laparoscopic myomectomy in relation to risk factors and identify suitable candidates for laparoscopic myomectomy to decrease recurrence. DESIGN: Multicenter retrospective cohort study (Canadian Task Force classification II-2). SETTING: Five university hospitals and a university-affiliated teaching hospital. PATIENTS: Five hundred and twelve women who underwent laparoscopic myomectomy between 1995 and 2004. All patients had a follow-up with clinical examination and transvaginal sonography for a median 13 months after surgery. INTERVENTION: Laparoscopic myomectomy. MEASUREMENTS AND MAIN RESULTS: Recurrence was defined as the appearance of a leiomyoma on ultrasound examination or identification of leiomyoma during subsequent surgery after the initial surgery. Cox regression (full model) analysis of the possible risk factors for recurrence followed by a stepwise variable selection was performed to eliminate confounding factors. The cumulative probability of leiomyoma recurrence increased steadily during the follow-up period, 11.7% after 1 year, 36.1% after 3 years, 52.9% at 5 years, and reached 84.4% at 8 years. The cumulative probability of reoperation for recurrent leiomyoma was much lower: 6.7% at 5 years and 16% at 8 years. Significant risk factors that were independently associated with cumulative recurrence were age, preoperative number of myoma, preoperative uterine size by pelvic examination, presence of associated pelvic disease, and delivery after laparoscopic myomectomy. The operative time and change of hematocrit were associated with the reoperation. Those who had fewer than 2 myomas before surgery, uterus size less than 13 gestational weeks measured by pelvic examination, no childbirth after laparoscopic myomectomy, and age at index surgery less than 35.5 years showed the lowest recurrence after laparoscopic myomectomy from Classification and Regression trees analysis. CONCLUSION: The risk of recurrence of leiomyoma after laparoscopic myomectomy is linked with the age, preoperative number of leiomyoma, preoperative uterine size, presence of associated pelvic disease, and childbirth after surgery.

Two dermoid cysts developing in an accessory ovary and an eutopic ovary.

Accessory ovary is a rare gynecologic condition, and tumors arising in accessory ovaries are extremely rare. Accessory ovary may result from separation of migrating ovaries during embryogenesis and injuries such as inflammation and operation on normal ovary. Congenital malformations, most frequently malformations of the genitourinary organ, are seen in connection with the accessory ovary. We experienced the first case of two dermoid cysts developing in an accessory ovary located in the left infundibulopelvic ligament and another in the eutopic ovary at the same side concurrently. Here, we present this extremely rare case with a review of the literature.

Diagnosis of pelvic congestion syndrome using transabdominal and transvaginal sonography.

OBJECTIVE: We prospectively evaluated transabdominal and transvaginal sonographic findings of patients with pelvic congestion syndrome and compared them with those of healthy volunteers. SUBJECTS AND METHODS. We examined 32 patients with pelvic congestion syndrome and 35 control subjects. Using transabdominal sonography, we evaluated the ovarian veins for diameter and flow direction, presence of pelvic varicocele, diameter of the pelvic veins, change of the duplex waveform during the Valsalva's maneuver, volume of the uterus, and presence of polycystic changes in the ovaries. We compared and statistically analyzed each parameter in the pelvic congestion syndrome group and in the control group. RESULTS: The mean (+/- SD) diameter of the left ovarian vein was 0.79 +/- 0.23 cm in the pelvic congestion syndrome group and 0.49 +/- 0.15 cm in the control group (p = 0.000). Reversed caudal flow in the left ovarian vein was present in 22 of 22 patients and in four of 16 control subjects. Pelvic varicoceles were present in all patients with pelvic congestion syndrome and in six control subjects. The mean diameter of the left pelvic vein was 0.68 +/- 0.21 cm in the pelvic congestion syndrome group and 0.42 +/- 0.19 cm in the control group; the mean diameter of the right pelvic vein was 0.64 +/- 0.24 cm in the pelvic congestion syndrome group and 0.35 +/- 0.14 cm in the control group (p = 0.000). Polycystic changes of the ovary were present in 13 patients with pelvic congestion syndrome (40.6%) and four control subjects (11.4%). CONCLUSION: Sonographic findings of pelvic congestion syndrome were dilated left ovarian vein with reversed caudal flow, presence of varicocele, dilated arcuate veins crossing the uterine myometrium, polycystic changes of the ovary, and variable duplex waveform during the Valsalva's maneuver. Combined transabdominal and transvaginal sonography are potentially useful as a noninvasive screening tool for determining which patients with chronic pelvic pain may benefit from selective ovarian venography and transcatheter embolization.

Comparison of treatments for pelvic congestion syndrome.

To evaluate the efficacy of various treatments for pelvic congestion syndrome in patients with different stress levels, we analyzed one hundred six patients with pelvic congestion syndrome, confirmed with laparoscopy and venography, who did not respond to medication after 4-6 months medication. They were divided into three groups: (embolotherapy; hysterectomy with bilateral oophorectomy and hormone replacement therapy; and hysterectomy with unilateral oophorectomy). The visual analog scale was used to measure degree of pain; stress level data were scored with the revised social readjustment rating scale. Embolotherapy was significantly more effective at reducing pelvic pain, compared to the other methods (p < 0.05). The mean percentage decrease in pain was significantly greater in the patients with lower stress scores (p < 0.05). Ovarian and/or internal iliac vein embolization appears to be a safe, well-tolerated, effective treatment for pelvic congestion syndrome that has not responded to medication.