Drainage by Ovarian Incision for the Treatment of Massive Ovarian Edema Torsion During Pregnancy.

Massive ovarian edema (MOE) is a rare benign condition presenting as unilateral ovarian enlargement with stromal edema, and only a limited number of MOE cases during pregnancy have been reported. MOE is often complicated by ovarian torsion, which requires detorsion. Although the diagnosis of MOE can be made using ultrasound and magnetic resonance imaging, its rarity makes diagnosis difficult, usually leading to overtreatment. Preserving the ovary in the treatment of MOE torsion is essential, and consideration of oophoropexy after detorsion is often reported. However, fixing an enlarged ovary to the pelvic wall in the limited space of the pelvis is challenging. Herein, we present a case of MOE of the right ovary diagnosed at the fifth week of gestation after ovulation induced by clomiphene citrate. Torsion of the ovary occurred in the seventh week. We achieved preservation of the ovary through laparoscopic surgery with detorsion and drainage by making a small incision to the enlarged ovary, resulting in an immediate size reduction. There was no recurrence of torsion or MOE throughout the pregnancy, and the patient gave birth in the 39th week of gestation. This is the third reported case of MOE after ovulation using clomiphene citrate, and it highlights the effectiveness of treatment with detorsion and a small incision of the ovary via laparoscopic surgery in patients with MOE torsion during pregnancy.

Ureter Injury in Total Laparoscopic Hysterectomy.

Objective: To identify surgical manipulations that caused ureter injury during total laparoscopic hysterectomy (TLH) and evaluate the surgical manipulations to identify ways to prevent such injury. Patients and Methods. This single-center, cross-sectional study included 1135 cases of TLH performed for benign diseases from January 2009 to December 2021. Seven cases (0.6%) that needed ureteral stent placement intra- or postoperatively for ureter injury were included. We identified the surgical manipulations that caused ureter injury from surgical videos. Results: Two cases had adhesions around the bladder pillar, and the ureter sustained a thermal injury during the cardinal ligament transection. One case had severe endometriosis, and the ureter was bluntly damaged when the adhesion was released. In one case, the ureter was thermally damaged during bipolar hemostasis for uterine artery bleeding. In two cases, the obliterated umbilical artery was mistaken for the ureter, and the real ureter was injured. In one case, ureteral peristalsis was inhibited by a pelvic abscess caused by postoperative infection. Conclusion: To prevent ureter injury during TLH, the ureter should be isolated in case of severe adhesion. Moreover, the following could be considered: (1) expand Okabayashi's pararectal space lateral to the uterosacral ligament, (2) perform dissection sharply using a monopolar or scissors forceps when releasing adhesion, (3) clarify the anatomy around the ureter for cases needing hemostasis, (4) repeatedly confirm the ureter with its peristalsis even after its isolation, (5) for severe adhesion cases, reduce infection risk by drain placement and administering antibiotics, and (6) use a delineator cup.