C. Taskiran

The magnitude of gonadotoxicity of chemotherapy drugs on ovarian follicles and granulosa cells varies depending upon the category of the drugs and the type of granulosa cells

STUDY QUESTION Do different chemotherapy drugs exert the same magnitude of cytotoxicity on dormant primordial follicles and the growing follicle fraction in the ovary in vivo and on mitotic non-luteinized and non-mitotic luteinized granulosa cells in vitro? SUMMARY ANSWER Cyclophosphamide (alkylating agent) and cisplatin (alkylating like) impacted both primordial and pre-antral/antral follicles and both mitotic and non-mitotic granulosa cells, whereas the anti-metabolite cancer drug gemcitabine was detrimental only to pre-antral/antral follicles and mitotic non-luteinized granulosa cells. WHAT IS KNOWN ALREADY It is already known that anti-metabolite cancer drugs are less detrimental to the ovary than alkylating and alkylating like agents, such as cyclophosphamide and cisplatin. This assumption is largely based on the results of clinical reports showing lower rates of amenorrhea in women receiving anti-metabolite agent-based regimens compared with those treated with the protocols containing an alkylating drug or a platinum compound. But a quantitative comparison of gonadotoxicity with a histomorphometric proof of evidence has not been available for many chemotherapy drugs. Therefore, we combined in this study in vivo and in vitro models of human and rat origin that allows a comparative analysis of the impact of different chemotherapy agents on the ovary and granulosa cells using real-time quantitative cell indices, histomorphometry, steroidogenesis assays, and DNA damage and cell death/viability markers. We also aimed to investigate if there is a difference between mitotic and non-mitotic granulosa cells in terms of their sensitivity to the cytotoxic actions of chemotherapy drugs with different mechanisms of action. This issue has not been addressed previously. STUDY DESIGN, SIZE, DURATION This translational research study involved in vivo analyses of ovaries in rats and in vitro analyses of granulosa cells of human and rat origin. PARTICIPANTS/MATERIALS, SETTING, METHODS For the in vivo assays, 54 4- to 6-week old Sprague-Dawley young female rats were randomly allocated into four groups of 13 to receive a single IP injection of: saline (control), gemcitabine (200 mg/kg), cisplatin (50 mg/kg) or cyclophosphamide (200 mg/kg). The animals were euthanized 72 h later. Follicle counts and serum AMH levels were compared between the groups. In vitro cytotoxicity studies were performed using mitotic non-luteinized rat (SIGC) and human (COV434, HGrC1) granulosa cells, and non-mitotic luteinized human (HLGC) granulosa cells. The cells were plated at a density of 5000 cells/well using DMEM-F12 culture media supplemented with 10% FBS. Chemotherapy agents were used at their therapeutic blood concentrations. The growth of mitotic granulosa cells was monitored real-time using xCelligence system. Live/dead cell and apoptosis assays were also carried out using intravital Yo-Pro-1 staining and cleaved caspase-3 expression, respectively. Estradiol (E2), progesterone (P) and anti-Mullerian hormone (AMH) levels were assayed with ELISA. MAIN RESULTS AND THE ROLE OF CHANCE Cyclophosphamide and cisplatin caused massive atresia of both primordials and growing follicles in the rat ovary whereas gemcitabine impacted pre-antral/antral follicles only. Cyclophosphamide and cisplatin induced apoptosis of both mitotic non-luteinized and non-mitotic luteinized granulosa cells in vitro. By contrast, cytotoxicity of gemcitabine was confined to mitotic non-luteinized granulosa cells. LIMITATIONS, REASONS FOR CAUTION This study tested only three chemotherapeutic agents. The experimental methodology described here could be applied to other drugs for detailed analysis of their ovarian cytotoxicity. WIDER IMPLICATIONS OF THE FINDINGS These findings indicate that in vivo and in vitro cytotoxic actions of chemotherapy drugs on the ovarian follicles and granulosa cells vary depending upon the their mechanism of action and the nature of the granulosa cells.

GnRH agonist leuprolide acetate does not confer any protection against ovarian damage induced by chemotherapy and radiation in vitro

STUDY QUESTION Is there any in vitro evidence for or against ovarian protection by co-administration of a GnRH agonist with chemotherapy in human? SUMMARY ANSWER The co-administration of GnRH agonist leuprolide acetate with cytotoxic chemotherapy agents does not preserve ovarian reserve in vitro. WHAT IS KNOWN ALREADY Randomized controlled trials of the co-administration of gonadotrophin-releasing hormone (GnRH) agonists with adjuvant chemotherapy to preserve ovarian function have shown contradictory results. This fact, together with the lack of a proven molecular mechanism of action for ovarian protection with GnRH agonist (GnRHa) places this approach as a fertility preservation strategy under scrutiny. We therefore aimed in this study to provide in vitro evidence for or against the role of GnRHa in the prevention of chemotherapy-induced damage in human ovary. STUDY DESIGN, SETTINGS, SIZE AND DURATION This translational research study of ex vivo and in vitro models of human ovary and granulosa cells was conducted in a university hospital between 2013 and 2015. PARTICIPANTS/MATERIALS, SETTING, METHODS Ovarian cortical pieces (n = 15, age 14-37) and mitotic non-luteinized (COV434 and HGrC1) and non-mitotic luteinized human granulosa cells (HLGC) expressing GnRH receptor were used for the experiments. The samples were treated with cyclophosphamide, cisplatin, paclitaxel, 5-FU, or TAC combination regimen (docetaxel, adriamycin and cyclophosphamide) with and without GnRHa leuprolide acetate for 24 h. DNA damage, apoptosis, follicle reserve, hormone markers of ovarian function and reserve (estradiol (E2), progesterone (P) and anti-mullerian hormone (AMH)) and the expression of anti-apoptotic genes (bcl-2, bcl-xL, bcl-2L2, Mcl-1, BIRC-2 and XIAP) were compared among control, chemotherapy and chemotherapy + GnRHa groups. MAIN RESULTS AND THE ROLE OF CHANCE The greatest magnitude of cytotoxicity was observed in the samples treated with cyclophosphamide, cisplatin and TAC regimen. Exposure to these drugs resulted in DNA damage, apoptosis and massive follicle loss along with a concurrent decline in the steroidogenic activity of the samples. GnRHa co-administered with chemotherapy agents stimulated its receptors and raised intracellular cAMP levels. But it neither activated anti-apoptotic pathways nor prevented follicle loss, DNA damage and apoptosis induced by these drugs. LIMITATIONS, REASONS FOR CAUTION Our findings do not conclusively rule out the possibility that GnRHa may offer protection, if any, through some other mechanisms in vivo. WIDER IMPLICATIONS OF THE FINDINGS GnRH agonist treatment with chemotherapy does not prevent or ameliorate ovarian damage and follicle loss in vitro. These data can be useful when consulting a young patient who may wish to receive GnRH treatment with chemotherapy to protect her ovaries from chemotherapy-induced damage.

Intraoperative endoscopic ultrasound guidance for laparoscopic excision of invisible symptomatic deep intramural myomas

Abstract The aim of this study was to evaluate the feasibility of intraoperative endoscopic ultrasound guidance for excision of symptomatic deep intramural myomas that are not otherwise visible at laparoscopy. Seventeen patients with symptomatic deep intramural myomas who underwent laparoscopic myomectomy with intraoperative endoscopic ultrasound guidance were followed up and reported. All myomas were removed successfully. The endometrium was breached in one patient. All patients were relieved of their symptoms and three patients presenting with infertility conceived. There were no short- or long-term complications associated with the procedure. One patient who had multiple myomas necessitated intravenous iron treatment prior to discharge. Laparoscopic removal of small symptomatic deep intramural myomas is facilitated by the use of intraoperative endoscopic ultrasound that enables exact localisation and correct placement of the serosal incision. Impact statement What is already known on this subject: When the myoma is symptomatic, compressing the endometrium, does not show serosal protrusion and is not amenable to hysteroscopic resection, laparoscopic surgery may become challenging. What do the results of this study add: The use of intraoperative endoscopic ultrasound under these circumstances may facilitate the procedure by accurate identification of the myoma and correct placement of the serosal incision. What are the implications of these findings for clinical practice and/or further research: Intraoperative ultrasound should be more oftenly used to accurately locate deep intramural myomas to the end of making laparoscopy feasible and possibly decreasing recurrence by facilitating removal of otherwise unidentifiable disease.

Endogenous c-Jun N-terminal kinase (JNK) activity marks the boundary between normal and malignant granulosa cells

Granulosa cell tumor of the ovary (GCT) is a very rare tumor, accounting for only 2% of all ovarian tumors. It originates from sex cords in the ovary and can be divided into adult (95%) and juvenile (5%) types based on histologic findings. To date, no clear etiologic process has been identified other than a missense point mutation in the FOXL2 gene. Our previous works showed that c-Jun N-terminal kinase (JNK) pathway plays critical role in cell cycle progression and mitosis of normal and immortalized granulosa cells and follicle growth in rodent ovaries. These findings led us to investigate the role of JNK pathway in the granulosa cell tumor of the ovary. We used two different GCT cell lines (COV434 and KGN) and fresh GCT samples of adult and juvenile types obtained from the patients during surgery. We have discovered that endogenous kinase activity of JNK is markedly enhanced in the GCT samples and cell lines, whereas it was almost undetectable in mitotic non-malignant human granulosa cells. The inhibition of JNK pathway in GCT cell lines with two different pharmacologic inhibitors (SP600125 and AS601245) or siRNA resulted in a dose-dependent reduction in in vitro cell growth, increased apoptosis and diminished estradiol and AMH productions. JNK inhibition was also associated with a decrease in the number of cells positive for mitosis marker phospho-histone H3Ser 10 in the asynchronous cells; and diminished EdU uptake during S phase and cell cycle arrest at G2/M-phase transition in the synchronized cells. Ex vivo treatment of patient-derived GCT samples with JNK inhibitors for 24 h significantly decreased their in vitro growth and estradiol and AMH productions. Furthermore, in human GCT xenograft model, in vivo tumor growth was significantly reduced and plasma AMH levels were significantly decreased in SCID mice after administration of JNK inhibitors and siRNA. These findings suggest that targeting JNK pathway may provide therapeutic benefit in the treatment of granulosa cell tumors for which currently no curative therapy exists beyond surgery.

Leiomyomatosis Peritonealis Disseminata That Caused Hydroureter in Association With Deep Infiltrating Endometriosis

Objective: To show and describe the laparoscopic technique in the excision of posterior vaginal wall mesh. Clinical Information: A 60 year-old female with posterior vaginal compartment prolene mesh placed for stage-3 rectocele presented with a 4-year history of persistent vaginal pain, dyspareunia, urinary frequency and urgency. She had a history of total laparoscopic hysterectomy with bilateral salpingo-oophorectomy in 2008 followed by placement of a posterior vaginal wall prolene mesh kit in 2010 for stage 3 rectocele. An attempt at vaginal identification and excision of the mesh was not possible thus mandating a laparoscopic approach. Interventions: Laparoscopic approach for the excision of posterior vaginal wall mesh. Results: Successful mesh excision from the posterior vaginal wall connective tissue and resolution of vaginal pain and dyspareunia on the patient’s 6-week follow-up.

Contained Power Morcellation Versus Transvaginal Extraction for Retrieval of Laparoscopically Removed Myomas: A Comparison of Perioperative Outcomes

Objective. To evaluate clinical and operative outcomes of transvaginal extraction (TVE) and contained power morcellation (CPM) for myoma retrieval after laparoscopic myomectomy. Materials and Methods. Prospective data from 35 consecutive cases using CPM were compared with retrospective data of all cases using TVE from December 2014 to January 2017. Patients were matched 1:1 based on myoma diameter. A total of 62 women were included in the final analysis. Specimen retrieval was performed using the TVE or CPM within an insufflated isolation bag. Results. Age, body mass index, mode of prior obstetric delivery, history of previous abdominal surgery, indication for myomectomy, and the myoma(s) characteristics were similar between groups. Retrieval time was significantly shorter in the TVE group compared with the CPM group: 10 minutes (3-15 minutes) versus 17 minutes (14-42 minutes); P < .001. Time required for placement of the instruments was 9.7 minutes for the isolation bag and 0.5 minutes for the vaginal extractor. Additional analgesic administration for pain relief was necessary in 13 patients (42%) in the TVE group and 23 patients (72%) in the CPM group (P = .01). Total cost of the hospital stay was significantly higher in the CPM group compared with the TVE group (P < .001). Estimated blood loss and duration of hospital stay were similar between groups. Conclusion. Both CPM and TVE can be used for safe retrieval of large myomas that are removed laparoscopically. Compared with CPM, TVE was associated with a shorter retrieval time, less postoperative pain, and less hospital costs.

Clermont-Ferrand versus Vectec uterine manipulator for total laparoscopic hysterectomy

Abstract Objective: To compare the operation time and performance of two uterine manipulators used for total laparoscopic hysterectomy (TLH). Material and methods: Design: Retrospective cohort analysis. Design classification: Canadian Task Force Classification II-2. Setting: Tertiary-care university-based teaching hospital and academic affiliated private hospital. Patients: All consecutive patients who underwent for TLH between January 2014 and June 2017. All operations were performed by two expert endoscopic surgeons using one of the following uterine manipulators depending on surgeon preferences: Clermont-Ferrand (CF) or Vectec (VT) MAUT60. Patients were excluded if additional surgeries such as urogynecological procedures were performed, TLH was converted to laparotomy prior to colpotomy, and when their operation records could not be obtained. A total of 169 patients were added to final analysis. Operation time, colpotomy time and the subjective performance of manipulators such as movement of the uterus, visualization of the vaginal fornices, and maintenance of pneumoperitoneum were evaluated by watching un-edited operation videos. Results: A total of 169 patients (83 patients in CF group; 86 patients in VT group) were included in the final analysis. Patients’ baseline characteristics were comparable between groups. Operation time and time required for colpotomy were significantly shorter in the VT group. Lateral movements of the manipulators and elevation of the uterus were better with VT compared to CF (p = .001 for both). Compared to the CF, VT was superior for visualization of the vaginal fornices (p = .004) and maintenance of pneumoperitoneum (p < .001). Both surgeons had perfect agreement on the performance grading of manipulators (p < .001, Kappa values were between 0.86–0.92). There was no difference between groups in estimated blood loss and duration of hospital stay. Reinsertion or the need to change the manipulator was not required in either group. No pelvic or vaginal abscess, cuff cellulitis, dehiscence, or hematoma formations were noted. Conclusion: Laparoscopic hysterectomy assisted with the VT uterine manipulator is associated with shorter operation and colpotomy time. Furthermore, the movements of uterus, visualization of the vaginal fornices, and maintenance of pneumoperitoneum were significantly better with VT compared to the CF manipulator.

Unidirectional barbed suture for vaginal cuff closure without backward stitch in total laparoscopic hysterectomy

To evaluate the safety and efficacy of unidirectional barbed suture technique for vaginal cuff closure in total laparoscopic hysterectomy (TLH).

Parasitic Myomas and an Adenomyoma Obstructing the Ureter After Power Morcellation of Myomas and Endometriotic Nodule Resection

BACKGROUND The use of power morcellation (PM) in abdominal and pelvic surgery has been discouraged and even banned in some institutions because of the risk of spreading malignant cells, although some authorities maintain that PM can be an appropriate tool for selected patients deemed to be at low risk of malignancy. CASE A 42-year-old woman developed parasitic myomas and an adenomyoma obstructing the right ureter after laparoscopic excision of multiple myomas and deep infiltrating endometriosis using PM. Laparoscopic excision of the parasitic myomas and removal of the adenomyoma relieved the obstruction of the ureter. CONCLUSION Although there is reasonable concern about the use of PM spreading malignant disease, benign disease can also be spread by PM and can cause significant complications. Use of PM should be restricted as much as possible.

Laparoscopic Removal of Bladder From the Uterine Niche With Retrograde Dissection

Videolaparoscopy citorreduction with debulking limphadenectomy in a Fallopian tube cancer patient. We present the case of a fifity-seven years old woman who underwent to non-oncologic hysterectomy with bilateral salpingoophoretomy, in another medical service, with the diagnosis of Fallopian tube serous adenocarcinoma. Postoperative TC showed a conglomerate retroperitoneal lymph node mass of 4.3 by 3.6 cm. So, we performed a videolaparoscopy cytorreduction wich included omentectomy and debulking limphadenectomy. The video shows the debulking time which was laboured and demanded extremely delicate movements. We change the laparoscopic instruments and energy several times to achieve the best way to overcome challenges safety. The total procedure time was 7 hours and blood loss was 200cc. About the patological report, 6 of 31 retroperitoneal nodes was positive for adenocarcinoma. At he present time, patient is on chemotherapy, on the third cycle of carboplatin and paclitaxel.