Surgical Outcomes and Trends in Incidence of Ectopic Pregnancy.

Objectives: We aimed to evaluate the surgical results for ectopic pregnancy (EP) treated at Fukushima Red Cross Hospital for over a 20-year period from 2002 to 2021. Materials and Methods: We evaluated the incidence, surgical procedures, site of implantation, amount of hemoperitoneum, and the proportion of cases with risk factors of EP. Results: Two hundred and fifty-nine cases of EP were treated surgically. The incidence of EP seemed to be gradually decreasing in recent years. By pregnancy site, 235 (90.7%) of EPs were tubal pregnancies (TPs), 13 in interstitial pregnancies (IPs), 7 in ovarian pregnancies, and 4 in peritoneal pregnancies. For IPs, human chorionic gonadotropin (hCG) levels were statistically higher than with TP and intraperitoneal bleeding was less than with other EP sites. Thirty-nine patients (15.0%) were with massive hemoperitoneum (>500 mL), and laparoscopic surgery was performed in all patients with massive hemoperitoneum except in two patients. The proportion of cases with risk factors for EP such as Chlamydia trachomatis infection or history of smoking was 5.4% and 40.6%, respectively. Epidemiological research shows that the number of patients with chlamydia infection, rates of smokers, or the occurrence of EP with assisted reproductive technology has been decreasing in recent years in Japan. Conclusion: Appropriate surgical intervention should be selected while considering such as facility capabilities, context, and surgeon skill, especially in critical cases, such as cases involving massive hemoperitoneum and hemorrhagic shock. The recent presumed decrease in the occurrence of EP may partly be associated with the decrease in the occurrence of risk factors.

Four cases of isolated fallopian tube torsion successfully treated with laparoscopic surgery:A case series.

We report four cases of isolated fallopian tube torsion (IFTT) successfully treated with laparoscopic surgery over the past 10 years. Two young women (each 19 years old) were IFTT with paraovarian cyst (POC) and tubal preservation was possible with detorsion and cystectomy. The other two patients (a 41-year-old woman with hydrosalpinx and a 50-year-old woman with hematosalpinx) underwent salpingectomy and adnexectomy, respectively, because there was no desire for tubal preservation. One patient had emergency surgery due to severe abdominal pain, one had semi-emergency surgery due to mild abdominal pain, and the other two were diagnosed during scheduled surgery without symptoms.Although IFTT was considered a very rare disease, our case series and recent reports suggest that it may have been underestimated, as it accounts for approximately 10% of adnexal torsion cases. Preoperative diagnosis of IFTT may be more difficult than for adnexal torsion because of its infrequency and nonspecific, vague clinical symptoms.　Since the prevalent age for this disease is young, as in our first 2 patients, early surgical intervention to preserve the fallopian tubes should be chosen when necessary, and it seems to be important for gynecologists to be aware of this disease for earlier diagnosis and appropriate surgical intervention.

Four cases of pseudomyxoma peritonei with ovarian tumors at our hospital.

We describe four cases of pseudomyxoma peritonei (PMP) that were diagnosed and treated at our hospital.Case 1: A 26-year-old woman with a large multicystic ovarian tumor and massive ascites was diagnosed with PMP originating from a borderline mucinous ovarian tumor. She underwent fertility-preserving staging laparotomy and was treated with three courses of intraperitoneal chemotherapy. There has been no recurrence in the 15 years since her first operation. Case 2: A 72-year-old woman with a giant ovarian tumor and massive ascites was diagnosed with PMP originating from low-grade appendiceal mucinous neoplasm (LAMN). After laparotomy, the patient was managed conservatively because she did not want aggressive treatment. She has remained asymptomatic with a small amount of ascites for 3 years. Case 3: A 82-year-old woman with ovarian tumors, massive ascites, and suspected PMP underwent emergency laparotomy due to appendiceal perforation and pan-peritonitis. She was diagnosed with PMP originating from LAMN. She has remained asymptomatic with a small amount of ascites for 2 years. Case 4: A 42-year-old woman with multicystic ovarian tumors and massive ascites underwent laparotomy. She was diagnosed with PMP originating from LAMN. Since multidisciplinary treatment was indicated and desired, the patient was referred to a specialized facility where cytoreductive surgery and hyperthermic intraperitoneal chemotherapy was performed. The patient has done well since the treatment.Although most cases of PMP originate from mucinous tumors of the appendix, female patients with PMP often present with ovarian tumors and are commonly referred to gynecology clinics. It is therefore important for gynecologists to be familiar with PMP and to be able to diagnose it accurately and select the most suitable management including multidisciplinary treatments.

Struma ovarii with massive ascites mimicking ovarian carcinoma treated with conservative laparoscopic surgery: a case report.

Struma ovarii is a rare taratoma that accounts for 0.5-1% of all ovarian tumors. It is sometimes difficult to differentiate struma ovarii from ovarian carcinoma. We encountered a case of struma ovarii that was suspected to be malignant due to the accumulation of massive ascites and an elevated CA125 level. It was successfully treated with laparoscopic surgery.A 37-year-old nulliparous woman consulted a local physician with a chief complaint of abdominal distention. Computed tomography (CT) of the abdomen revealed a pelvic tumor with a large amount of ascites. She was referred to our department. Contrast-enhanced magnetic resonance imaging (MRI) and CT showed bilateral ovarian tumors with multicystic and solid components. CA125 level was markedly elevated. Two cytological examinations of ascites showed no malignant cells. Preoperatively, malignancy was strongly suspected, but considering the possibility of a benign ovarian tumor, laparoscopic surgery was scheduled. During laparoscopic surgery, 4,850 mL of ascites were aspirated, and the left adnexa was removed. Intraoperative rapid pathology suggested struma ovarii with no evidence of malignancy. Postoperative pathology showed mature teratoma and struma ovarii.Although struma ovarii is benign in 90-95% of cases, there have been scattered case reports in which suspected malignancy led to unnecessary or excessive surgery. We propose that appropriate preoperative imaging and accurate intraoperative rapid pathology can prevent excessive surgery, conservative or laparoscopic excisions should be considered.

A case of polypoid endometriosis mimicking advanced ovarian carcinoma with rapid growth, invasion, and dissemination.

Polypoid endometriosis is a rare form of endometriosis characterized by polypoid masses that histologically often resemble endometrial polyps. We report a case of rapidly progressing polypoid endometriosis that was preoperatively assumed to be advanced ovarian cancer. A 46-year-old woman, para 0, underwent laparoscopic myomectomy and left adnexectomy for uterine fibroids and a left ovarian endometrial cyst after administration of gonadotropin releasing hormone (GnRH) agonist for 4 months. Eleven months postoperatively, rapid right ovarian enlargement occurred. CT and MRI (both contrast-enhanced) showed masses in the right adnexa, cecum, sigmoid colon, and omentum, and PET-CT demonstrated increased uptake, suggesting ovarian cancer and peritoneal dissemination. The patient later developed intestinal obstruction, and colonoscopy revealed multiple polypoid lesions in the sigmoid colon. The omental tumor and right adnexa were biopsied during exploratory laparotomy, and diagnosed as polypoid endometriosis with no malignancy by permanent pathology. The right adnexal tumor shrunk markedly after 4 months of GnRH antagonist treatment. Second laparotomy was then performed for right adnexal tumor resection and ileocecectomy. Pathological examination revealed polypoid endometriosis extending from the ovary to the cecal mucosa. The patient has been asymptomatic for over 1 year postoperatively. The sigmoid colon tumor shrunk but is still present.Polypoid endometriosis predominantly affects the ovaries, colon, peritoneum, and omentum of patients in their 40s and 50s. It is a benign disease but is often difficult to distinguish from malignancy preoperatively because it rapidly forms numerous solid lesions. Although polypoid endometriosis is rare, with no specific imaging findings, including it in a differential diagnosis may facilitate preoperative identification.

Generalized peritonitis secondary to spontaneously perforated pyometra in elderly women:two cases with different clinical courses and surgical approaches and review of the literature.

We describe two cases of spontaneously perforated pyometra (SPP) in elderly women treated with two different surgical approaches. An 88-year-old woman underwent emergency laparotomy for presumed diagnosis of gastrointestinal (GI) tract perforation. During surgery, SPP and a tumor of the sigmoid colon were identified. Total hysterectomy and sigmoid colon resection were performed. Despite exhaustive postoperative treatments, the patient died on postoperative day (POD) 189 due to peritonitis and pneumonia. A 93-year-old woman with acute abdomen was diagnosed with severe pyometra and primarily treated with transcervical drainage. Due to progression of generalized peritonitis, laparoscopic surgery was performed. Intraoperatively, scar from a uterine body perforation was identified, leading to the diagnosis of SPP. Only peritoneal irrigation and drainage were performed, in consideration of her advanced age. She improved and was discharged from the hospital on POD 35. The prognosis for SPP is sometimes poor, especially in older women. Minimally invasive surgical intervention might be considered for primary treatment in such cases.

Extragonadal Giant Endometrial Cyst with Endometrioid Borderline Tumor.

We describe an extremely rare case of a borderline tumor arising from an extragonadal giant endometrial cyst. A 41-year-old woman complaining of abdominal pain was referred to our hospital with a diagnosis of large ovarian tumor. Magnetic resonance imaging revealed a large cystic tumor approximately 27 cm × 9 cm in area. The cyst contents were largely removed by suction, and then the tumor was resected laparoscopically. Both adnexa were normal in size and location. The tumor did not originate from the ovaries, and it was adherent only to the bilateral uterosacral ligaments and uterine body. The postoperative histopathological evaluation confirmed the presence of endometrioid borderline tumor with transition from endometriosis. Staging laparotomy was performed, and no remnant tumor was detected. This case is extremely unusual because such a large cystic tumor originating from extragonadal endometriosis is very rare, as is endometrioid borderline tumor arising from endometriosis.

An Unusual Presentation of Ovarian Fibroma Originating from an Autoamputated Ovary.

We describe an extremely rare case of an unusually presented ovarian fibroma adherent to the sigmoid colon originating from an autoamputated ovary. A 64-year-old woman was referred to our hospital with an abnormal shadow that was approximately 4 cm in diameter in the pelvic cavity detected on abdominal X-ray imaging. Computed tomography demonstrated an irregularly shaped tumor with calcification in the pelvic cavity. Laparoscopy revealed that the tumor was adherent to the surface of the sigmoid colon with a discontinuous shell and empty cavity. The left ovary was lacking, although the left salpinx and right adnexa were in their normal locations. The tumor was carefully resected with cutting of the serosa of the sigmoid colon. The serosal defect was repaired with sutures. Postoperative histopathological diagnosis was old fibroma with calcification. To the best of our knowledge, this is the first reported case of extragonadal ovarian tumor originating from an autoamputated ovarian fibroma.

Uterine rupture at 33rd week of gestation after laparoscopic myomectomy with signs of fetal distress. A case report and review of literature.

OBJECTIVE: We describe a case of uterine rupture (UR) during pregnancy after laparoscopic myomectomy (LM) and discuss the risk factors of UR. CASE REPORT: A 37-year-old woman with multiple myomas underwent laparoscopic myomectomy. Subserosal and intramural myomas were enucleated, and the myometrial wounds were repaired with single-layer suturing. Sixteen months after the operation, the patient conceived. At 33 weeks of gestation, emergency cesarean section was performed for the indication of fetal distress. A male neonate was delivered without asphyxia. During cesarean section, surgeons identified a 2 × 3 cm myometrial defect at one of the myomectomy sites, and diagnosed incomplete UR. The myometrial defect was repaired with debridement and suturing. CONCLUSION: Based on the literature review, the risk of UR during pregnancy after LM is estimated to be less than 1% when all the surgical procedures have been performed appropriately. Myomectomy should be performed with careful consideration by surgeons who have good knowledge of the wound healing process in the myometrium.

Surgical outcomes of total laparoscopic hysterectomy with 2-dimensional versus 3-dimensional laparoscopic surgical systems.

Three-dimensional (3D) laparoscopic surgical systems have been developed to account for the lack of depth perception, a known disadvantage of conventional 2-dimensional (2D) laparoscopy. In this study, we retrospectively compared the outcomes of total laparoscopic hysterectomy (TLH) with 3D versus conventional 2D laparoscopy. From November 2014, when we began using a 3D laparoscopic system at our hospital, to December 2015, 47 TLH procedures were performed using a 3D laparoscopic system (3D-TLH). The outcomes of 3D-TLH were compared with the outcomes of TLH using the conventional 2D laparoscopic system (2D-TLH) performed just before the introduction of the 3D system. The 3D-TLH group had a statistically significantly shorter mean operative time than the 2D-TLH group (119±20 vs. 137±20 min), whereas the mean weight of the resected uterus and mean intraoperative blood loss were not statistically different. When we compared the outcomes for 20 cases in each group, using the same energy sealing device in a short period of time, only mean operative time was statistically different between the 3D-TLH and 2D-TLH groups (113±19 vs. 133±21 min). During the observation period, there was one occurrence of postoperative peritonitis in the 2D-TLH group and one occurrence of vaginal cuff dehiscence in each group, which was not statistically different. The surgeon and assistant surgeons did not report any symptoms attributable to the 3D imaging system such as dizziness, eyestrain, nausea, and headache. Therefore, we conclude that the 3D laparoscopic system could be used safely and efficiently for TLH.

Long-term recurrence-free survival of a patient with advanced pure primary ovarian squamous cell carcinoma treated with dose-dense paclitaxel combined with carboplatin.

We describe an extremely rare case of advanced pure primary ovarian squamous cell carcinoma (SCC), treated by adjuvant chemotherapy with dose-dense paclitaxel combined with carboplatin (dd-TC) plus the combination chemotherapy with irinotecan and cisplatin (CPT-P), with long-term recurrence-free survival. A 71-year-old woman complaining of lower abdominal pain was referred to our hospital and a 7-cm-diameter solid tumor was identified. She was diagnosed with a left ovarian tumor that was highly suspicious for malignancy based on ultrasonography, magnetic resonance imaging, and contrast-enhanced computed tomography. Bilateral salpingo-oophorectomy, low-anterior colon resection, and colostomy were performed. Intra- and post-operative histopathological diagnosis revealed International Federation of Gynecology and Obstetrics stage IIIc well-differentiated pure ovarian SCC. As adjuvant chemotherapy, 2 courses of dd-TC were administered, followed by 3 courses of CPT-P; the patient then underwent 4 additional courses of dd-TC. Both regimens were effective and there has been no recurrence or metastasis thus far in the 5 years since the operation.

Prospective evaluation of the incidence of uterine vascular malformations developing after abortion or delivery.

STUDY OBJECTIVE: To describe the incidence of uterine vascular malformations (UVMs) including uterine arteriovenous malformations (AVMs) in patients after abortion or delivery and in outpatients. DESIGN: Prospective study (Canadian Task Force classification II-3). SETTING: Fukushima Red Cross Hospital. PATIENTS: Six patients with a UVM including 1 with an AVM. INTERVENTIONS: Clinical screening of patients using transvaginal color Doppler ultrasonography between April 2010 and March 2012. MEASUREMENTS AND MAIN RESULTS: The incidence of UVM developing after abortion or delivery or in outpatients was prospectively evaluated using transvaginal color Doppler ultrasonography. From 959 patients, we identified 6 (0.63%) with UVMs, including 1 (0.10%) with a uterine AVM. Specifically, we detected UVMs in 4 of 77 patients (5.2%) after abortion, 1 of 458 patients (0.22%) after delivery, and 1 of 424 outpatients (0.24%). Four patients after abortion and 1 after delivery reported mild symptoms, which were treated conservatively; however, the outpatient had a severe uterine AVM, which was confirmed via 3-dimensional computed tomography angiography. CONCLUSION: The incidence of UVMs was relatively higher, in particular in the patients after abortion, and was significantly higher than that in postpartum or outpatient groups. Therefore, it is important to consider the possibility of UVMs in any patient with episodes of unexplained uterine bleeding and to perform follow-up analysis using color Doppler ultrasonography. Such an approach will facilitate accurate diagnosis and lead to appropriate clinical management to prevent unnecessary dangerous repeat curettage, which might induce profuse uterine bleeding.

Spontaneous uterine rupture in the 33rd week of IVF pregnancy after laparoscopically assisted enucleation of uterine adenomatoid tumor.

Although a uterine leiomyomectomy or adenomyomectomy is an accepted procedure to treat symptoms such as dysmenorrhea or hypermenorrhea to enhance fertility, the risk of future uterine rupture is a major concern for patients who become pregnant following these surgery. Although uterine rupture very rarely occurs, this is the most feared complication in pregnancy and is associated with a high rate of maternal and fetal morbidity and mortality. A 37-year-old nulliparous woman had a 2-year history of infertility. A transvaginal ultrasound revealed multiple uterine tumors that resembled leiomyomas on the posterior and fundal walls of the uterine body. After the patient had three failed in vitro fertilization and embryo transfer treatments, the uterine tumor was enucleated, and pathologically diagnosed as an adenomatoid tumor. Five months after the operation, the patient became pregnant as a result of a fourth in vitro fertilization and embryo transfer. At the 33rd week of gestation, she complained of a sudden onset of abdominal pain. The patient was diagnosed with a ruptured uterus based on an ultrasound, and an emergency cesarean section was performed. The rupture occurred at the site of the operation scar on the posterior wall of the uterine body. The fetal legs extruded into the abdominal cavity from the uterine cavity but were enclosed within the unruptured chorioamniotic membrane. A male neonate (1956 g) was delivered without asphyxia and had Apgar scores of 8 and 9. The ruptured uterine wall could be repaired by suturing. To our knowledge, this is the first case report of uterine rupture during pregnancy after resection of an adenomatoid tumor in the uterine body.

A case of congenital unilateral partial absence of fallopian tube.

Congenital partial absence of a fallopian tube has rarely been reported in the literature. A 29-year-old nulligravida woman presented with a two-year history of infertility. Hysterosalpingography revealed an obstructed left fallopian tube with a normal uterine cavity and right fallopian tube. After several AIH treatments, diagnostic laparoscopy was performed, revealing segmental absence of the mid portion of the left fallopian tube. Only a 1-cm stump of the left fallopian tube remained, the majority of the isthmic portion was absent. A 3-cm distal ampullary portion with normal-appearing fimbria was attached to the left pelvic sidewall near the pelvic brim. No other abnormal findings were observed for the uterus, right fallopian tube, and ligaments surrounding the uterus. There are two possible etiologies of partial absence of the fallopian tube:congenital absence associated with developmental alterations of the Müllerian ducts or asymptomatic torsion followed by autoamputation and reabsorption.

The oocyte activation and Ca2+ oscillation-inducing abilities of mouse and human dead (sonicated) spermatozoa.

In ICSI procedures, it is well known that the selection of viable (live) spermatozoa and certain types of immobilization prior to injection is very important for obtaining successful results, but unfortunately there are rare situations when only immotile spermatozoa are available (such as in severe asthenozoospermia or necrozoospermia). In such cases, failure of oocyte activation after ICSI often occurs and may be due to the lack of SOAF (sperm-borne oocyte activating factor) activity. In order to investigate the SOAF activities of dead spermatozoa, mouse and human spermatozoa were immobilized (killed by sonication), maintained in THF medium for varying time intervals (up to 72 h) and then injected into mature unfertilized mouse oocytes. Injected mouse oocytes were examined for their activation, development into blastocysts and Ca2+ responses by imaging and confocal laser scanning microscope. The rates of oocyte activation, blastocyst development and normal patterns of Ca2+ oscillation from the killed-sperm-injected oocytes decreased gradually in accordance with the maintenance interval between sonication and injection. For injection with mouse sonicated spermatozoa, the rate of normal Ca2+ oscillations declined first (after a 3 h maintenance interval) and then blastocyst development was gradually obstructed (after approx. 10 h). The oocyte activation-inducing ability of dead spermatozoa was maintained for a relatively long period, but began to decline after 20 h. The activation rates and Ca2+ response of the oocytes that were injected with human sonicated spermatozoa decreased earlier than those injected with mouse spermatozoa. Although the oocyte activation-inducing ability was maintained for a relatively long time after the death of the spermatozoa, embryo development into blastocysts and the rate of normal Ca2+ oscillations declined after a short maintenance interval between sonication and injection. The Ca2+ response seemed to be the most sensitive indicator for the evaluating the SOAF activity of dead (killed) spermatozoa.