Hyun Hee Cho

Robot-Assisted Laparoscopic Adenomyomectomy for Patients Who Want to Preserve Fertility

An adenomyomectomy is a conservative-surgical option for preserving fertility. Conventional laparoscopic adenomyomectomies present difficulties in adenomyoma removal and suturing of the remaining myometrium. Robot-assisted laparoscopic surgery could overcome the limitations of conventional laparoscopic surgery. Four patients with severe secondary dysmenorrhea and pelvic pain visited Seoul St. Marys Hospital and were diagnosed with adenomyosis by pelvic ultrasonography and pelvic magnetic resonance imaging (MRI). The four patients were unmarried, nulliparous women, who desired a fertility-preserving treatment. We performed robot-assisted laparoscopic adenomyomectomies. The dysmenorrhea and pelvic pain of the patients nearly disappeared after surgery. No residual adenomyosis was observed on the follow-up pelvic MRI. A robot-assisted laparoscopic adenomyomectomy was feasible, and could be a minimally invasive surgical option for fertility-sparing treatment in patients with adenomyosis.

Three cases of complications after high-intensity focused ultrasound treatment in unmarried women

High-intensity focused ultrasound (HIFU) has been regarded as a non-surgical, minimally invasive therapeutic option for patients who prioritize uterus-conservation. Although many studies have shown that HIFU therapy is a safe and effective treatment of uterine fibroid, not all fibroids are suitable for HIFU due to risks of serious complications. We experienced three cases of complications after the HIFU ablation for huge uterine fibroids, including two cases of rapid myoma enlargement and one case of heavy vaginal bleeding.

The significance of hypersensitivity to autologous sweat and serum in cholinergic urticaria: cholinergic urticaria may have different subtypes

The pathogenesis of cholinergic urticaria (ChU) has been unclear except for the involvement of acetylcholine. Attempts to classify ChU according to etiology have rarely been performed.

Aldo-keto reductase activity after diethylhexyl phthalate exposure in eutopic and ectopic endometrial cells

OBJECTIVE Endometriosis is a multifactorial gynaecological disease in reproductive-age women. Endometriotic tissue is characterized by high prostaglandin levels and progesterone resistance. Human aldo-keto reductases (AKRs) convert progesterone to a less potent metabolite and cause progesterone resistance. Therefore, in this study, we evaluated whether diethylhexyl phthalate (DEHP) alters AKR expression in human ectopic and eutopic endometrium. STUDY DESIGN We used microarrays and western blotting to study the effects of DEHP, and checked the presence of AKR in endometriosis patients by enzyme-linked immunosorbent assay (ELISA). RESULTS Cultured human endometrial cells from normal endometrium of women without endometriosis (NE), eutopic endometrium from endometriosis patients (EE), and ectopic endometrium from endometriosis patients (EC) differed in genetic expression changes after DEHP treatment. DEHP upregulated AKR1C1, AKR1C2, AKR1C3, and AKR1B10 expression in EE, while EC showed continuously increased AKR1C3 expression before and after DEHP exposure. In western blot analysis, before and after DEHP exposure, the AKR1B10 protein band was detected in NE, EE, and EC, whereas the AKR1C3 band was detected only in EC. AKR1B10 and AKR1C3 expression levels in the blood of the enrolled patients were evaluated using ELISA. AKR1B10 expression did not differ between groups (without endometriosis [N=13], 0.10 vs. with endometriosis [N=20], 0.11; P=0.27). AKR1C3 expression was significantly higher in the blood of endometriosis patients than in that of patients without endometriosis (without endometriosis, 9.1 vs. with endometriosis, 10.1; P=0.02). Analysis according to menstrual period showed significantly increased AKR1C3 levels in patients with endometriosis only during the secretory phase and not the proliferative phase (P<0.05). CONCLUSION DEHP induces AKR activity in the endometrium of endometriosis patients, and AKR1C3 might influence the development of endometriosis.

Epigenetic control of endocrine disrupting chemicals on gynecological disease: Focused on phthalates

Endocrine disrupting chemicals (EDC) are some chemicals which are acting like hormones inside the body. May kinds of EDCs are acting like estrogen or antiestrogen, so reproductive systems of male are the main targent organ. EDCs use genetic variations and epigenetic variations as main control route of diseases. When pregnant female is exposed to EDCs, the effects of EDCs on their epigenetic system affect through 3rd generation of offspring. Among many kinds of EDCs, the most notorious EDCs are dioxin and bisphenol A. Phthalates, which have so many kinds and high exposure rate, the effects of phthalate to gynecologic disease were not discovered. So in this paper, we try to summerize the effects of phthalate and new epignetic technique to evalaute the relationship among phthalate and gynecologic disease.

Expression of Müllerian Inhibiting Substance/Anti-Müllerian Hormone Type II Receptor in the Human Theca Cells.

Context Müllerian-inhibiting substance/anti-Müllerian hormone (MIS/AMH) is produced in the ovarian granulosa cells, and it is believed to inhibit ovarian folliculogenesis and steroidogenesis in women of reproductive age. Objective To investigate the expression of MIS/AMH type II receptor (MISRII/AMHRII) that binds MIS/AMH in the ovaries of reproductive-age women; to identify the exact targets of MIS/AMH. Design Laboratory study using human ovarian tissue. Setting University hospital. Patients Tissue samples from 25 patients who had undergone ovarian surgery. Interventions The segregation of ovarian granulosa and theca cells by laser microdissection was followed by RT-PCR, analyzing MISRII/AMHRII mRNA expression. Afterward, in situ hybridization and immunohistochemistry were performed to determine the localization of MISRII/AMHRII mRNA and protein expression. Main Outcome Measures MISRII/AMHRII mRNA expression by RT-PCR, in situ hybridization, and immunohistochemistry. Results MISRII/AMHRII were expressed in granulosa and theca cells of preantral and antral follicles. The granulosa cells showed stronger MISRII/AMHRII expression than theca cells. MISRII/AMHRII mRNA staining of granulosa and theca cells in large antral follicles, early atretic follicles, and corpus luteum waned but were still detected weakly, showing higher expression in theca cells than in granulosa cells. However, MISRII/AMHRII protein in the granulosa layer of the atretic follicle and corpus luteum could not be assessed. Conclusions As MISRII/AMHRII is expressed in both granulosa and theca cells, this indicates that MIS/AMH, produced in the granulosa cells, is active in the theca cells as well. MIS/AMH is most likely actively involved not only in the autocrine and endocrine processes but also in the paracrine processes involving theca cells.

The expression of Müllerian inhibiting substance/anti-Müllerian hormone type II receptor in myoma and adenomyosis

Objective We compared the expression levels of Müllerian inhibiting substance (MIS)/anti-Müllerian hormone type II receptor (AMHRII) in uterine myoma and adenomyosis to evaluate the possibility of using MIS/anti-Müllerian hormone (AMH) as a biological regulator or therapeutic agent in patients with uterine leiomyoma and adenomyosis. Methods We studied normal uterine myometrium, leiomyoma, endometrial tissue, and adenomyosis from 57 patients who underwent hysterectomy for uterine leiomyoma (22 cases) or adenomyosis (28 cases) and myomectomy for uterine myoma (7 cases). Immunohistochemical staining was used to confirm the MIS/AMHRII protein expression level in each tissue. Reverse transcription-polymerase chain reaction was performed to quantify MIS/AMHRII mRNA expression. Results The MIS/AMHRII protein was more strongly expressed in uterine myoma (frequency of MIS/AMHRII expressing cells: 51.95%±13.96%) and adenomyosis (64.65%±4.85%) tissues than that in the normal uterine myometrium (3.15%±1.69%) and endometrium (31.10%±7.19%). In the quantitative analysis of MIS/AMHRII mRNA expression, MIS/AMHRII mRNA expression levels in uterine myoma (mean density: 4.51±0.26) and adenomyosis (6.84±0.20) tissues were higher than that in normal uterine myometrial tissue (0.08±0.09) and endometrial tissue (1.63±0.06). Conclusion This study demonstrated that MIS/AMHRII was highly and strongly expressed on uterine myoma and adenomyosis. Our data suggest that MIS/AMH may be evaluated as a biological modulator or therapeutic agent on MIS/AMHRII expressing uterine myoma and adenomyosis.

Multidisciplinary Approach in Large Sized Submucosal Myoma: Hysteroscopic Myomectomy after Uterine Artery Embolization

STUDY OBJECTIVE To evaluate the safety and effectiveness of hysteroscopic myomectomy after uterine artery embolization (UAE) for the treatment of large-sized submucosal myomas with deep intramural invasion that are difficult to treat with 1-step hysteroscopy. DESIGN A retrospective cohort study (Canadian Task Force classification II-2). SETTING An academic university hospital. PATIENTS Eight premenopausal patients with symptomatic submucosal myomas with intramural invasion. INTERVENTIONS All of the patients after bilateral UAE underwent subsequent hysteroscopic operation 3 to 15 months after UAE. MEASUREMENTS AND MAIN RESULTS A total of 8 patients who had a large-sized submucosal myoma with deep myometrial invasion were included. The average volume of the submucosal myomas was 87.7±39.9 cm3 as confirmed by magnetic resonance imaging, and the average patient age was 37.6 years. The mean volume reduction of the submucosal myomas was 83.3±16.4% after UAE, and no immediate complications were observed. One-step hysteroscopic myomectomy after UAE was successfully performed in all patients. Leiomyomas with hyaline degeneration were pathologically confirmed. All women showed improved symptoms, and there was no evidence of recurrence 1 year later. One patient conceived naturally and delivered a full-term baby. CONCLUSION In premenopausal women with large-sized symptomatic submucosal myomas with deep myometrial invasion, hysteroscopic myomectomy after UAE is very effective and safe.

Robot-Assisted Laparoscopic Myomectomy, an Alternative to Laparotomy for Numerous Myomas (Over 10)

Study Objective: To evaluate the feasibility of robot-assisted laparoscopic myomectomy in multiple myomas over 10 in number Design: A retrospective chart review. Setting: An academic medical center. Patients:Womenwho underwent removal of 10 ormore uterinemyomas by robotics. Intervention: This study is a retrospective chart review of 216 patients who underwent robot-assisted laparoscopic myomectomy by a single operator at St. Mary’s Fibroid Center in Seoul between October 1, 2010 and January 31, 2014; in the selected patients, 10 or more uterine myomas were removed. We reported the characteristics of the removed myomas including the with maximum diameter of the myomas, the sum of the diameter of each myoma, and the types of the combined surgeries with robot-assisted laparoscopic myomectomy that were used on 10 or more myomas; we the organized surgical outcomes that were measured including the operative time, length of hospital stay, and perioperative complications. Measurements and Main Results: A total of 14 women underwent the removal of 10 or more uterine myomas by robotics. The patient age was 38.0 3.8 years and all of the patients were nulliparous. The operation time was 434.1 100.6 min. The number of removed myomas for each case was 13.3 3.6. The myoma with the maximum diameter was 6.6 0.8 centimeters. The sum of the diameters was 34.8 9.6 centimeters (range 20.0-54.5 centimeters). No case was converted into conventional laparoscopy or laparotomy. The postoperative hospital stay was 2.6 0.6 days. One patient had post-operative neck pain, which regressed spontaneously. Conclusion: This report is the first to describe the feasibility of robotassisted laparoscopic myomectomy in multiple myomas over 10 in number. In robot-assisted laparoscopic myomectomies, supplementary techniques including preoperative MRI assessment, intraoperative sonographic navigation, and palpation by an assistant to localize the myomas are helpful in overcoming the absence of haptic perception. This technique is considered to be an alternative to laparotomy for more than 10 myomas.

Laparoscopic myomectomy: Presurgical classification to evaluate the validity of laparoscopic surgical treatment

목적 자궁근종절제수술 전 근종의 평가를 위해 사용되는 점수화 시스템이 환자의 예후 및 수술방법의 결정에 영향을 주는지 알아보고자 한다. 연구방법 가톨릭대학교 서울성모병원에서 자궁근종절제수술을 받은 환자들을 대상으로 하였다. 차트 후향적 분석을 통해 수술전 근종의 영상학적인 분석결과를 점수화 시스템에 적용시켰으며 환자의 출혈량, 수술시간, 수혈, 재원기간을 조사하였다. 점수화 시스템은 가톨릭대학교 의과대학에서 개발하여 사용중인 Catholic Medeical Center fibroid score system (CMFS)을 사용하였다. 결과 CMFS 점수 총점을 계산하여 11점 미만인 1군과 11-20점인 2군, 20점 초과군인 3군으로 분류하였다. 수술 시 출혈량은 1군이 106 mL, 2군이 132.3 mL, 3군이 135.6 mL로 11점 미만인 경우 다른 두 군에 비해 유의하게 출혈량이 적었으며, 수술 중/후 수혈을 시행한 경우도 각각 0%, 2.6%, 3.8%로 11점 미만인 군이 유의하게 적었다(P＜0.05). 전체 점수는 odds ratio, 1.339, 95% confidence interval, 1.237-1.449; P＜0.0001, area under curve, 0.810로 수술방법의 결정에 유의한 영향을 주는 것으로 나타났다. CMFS의 정확도는 76.6%로 나타났다. 근종의 위치점수와 크기점수는 각각 수술시간과 출혈량과 유의한 상관관계를 나타냈다(위치점수 결정계수[coefficient of determination, CD], 0.90, 0.82; P＜0.01; 크기점수 CD, 1: 0.98; P＜0.01). 근종 제거 후 재건부위 점수는 수술시간과 유의한 상관관계를 나타냈으나(CD, 1; P＜0.01), 출혈량이나 퇴원일과는 유의한 상관관계를 보이지 않았다. 위치점수, 크기점수, 재건부위 점수는 모두 수술방법결정에 유의한 영향을 주는 것으로 나타났다(P＜0.01). 결론 CMFS는 환자의 예후 및 수술 방법의 결정에 영향을 준다. 향 후 근종절제술 후 수술의 예후에 영향을 주는 인자들을 연구하여 정확한 점수화 시스템을 개발한다면, 각자 환자에게 적합한 수술방법의 결정에 도움이 될 것이다.