Jun Kumakiri

Recurrence rate of endometriomas following a laparoscopic cystectomy

Background. The objectives were to observe the clinical course of patients who underwent laparoscopic cystectomy (LC) using transvaginal ultrasonography. Method. The definition of “recurrence” was to detect a diffuse, hypoechoic area whose long axis was at least 2 centimeters (cm) on the transvaginal ultrasonogram during the postoperative follow‐up period. Using the Cox regression test, we analyzed each patients background variables, namely, patients age, the revised American Society of Reproductive Medicine score (r‐ASRM score), use of gonadotropin releasing hormone analogues (GnRHa), and pregnancy during the observation period. Next, cyst size and multi‐lobularity of each of the 417 cysts were also analyzed as recurrence risk factors per cyst. Results. The mean postoperative observation period was 21.4±16.8 months. During the observation period, 50 (15.9%) out of 315 patients experienced recurrence and 51 (16.2%) out of 315 patients became pregnant. The cumulative recurrence rate per patient was 31.7% over 60 months. Among prognostic factors per patient, age and showed negative and r‐ASRM scores positive correlations with cyst recurrence. On the other hand, we did not identify any cyst factors associated with recurrence. The patients who underwent hemilateral LC showed a 5.2% cyst recurrence rate in the ovary that appeared to be normal at the time of the initial surgery. Conclusion. Young age and severe endometriosis appeared to be the factors associated with high recurrence risk. Recurring ovarian endometrimas probably include cysts occurring spontaneously and those recurring from the cyst residues in the lesions where cystectomy has been performed.

Histological assessment of impact of ovarian endometrioma and laparoscopic cystectomy on ovarian reserve

Aim:  The rate of oocyte decline follows a biphasic pattern, characterized by acceleration between 32 and 38 years old. Ovarian reserve is also affected by external factors, including ovarian disease and iatrogenic damage. The aim of this study was to histologically evaluate the impact of ovarian endometriomas, laparoscopic cystectomy, and age on follicle reserve in healthy ovarian tissues and in surgically resected cyst walls.

Involvement of Rho family G protein in the cell signaling for sperm incorporation during fertilization of mouse eggs: inhibition by Clostridium difficile toxin B.

Sperm-egg interaction was investigated in mouse eggs freed from the zona pellucida and injected with Clostridium difficile toxin B, the inhibitor of Rho family small G proteins. Toxin B reduced in a dose-dependent manner the percentage of eggs associated with sperm fusion on the surface or sperm nucleus decondensation in the ooplasm, examined by injection of a DNA-staining dye into the egg and transfer of the dye to the fused sperm head after recording intracellular Ca(2+) responses for 100 min postinsemination. The mean number of decondensed sperm nuclei per egg was remarkably decreased by approximately 1 microg/ml toxin B in the ooplasm. This was because spermatozoa were arrested at the fusion state without developing to sperm incorporation and tended to lose cytoplasmic continuity to the egg. The fusion-arrested spermatozoa caused transient small Ca(2+) oscillations in most of eggs, while an injected spermatozoon produced repetitive large Ca(2+) spikes unaffected by toxin B. A decrease in the rate of fused spermatozoa and decondensed sperm nuclei was also caused by 20-40 microM cytochalasin D, the inhibitor of actin polymerization. Immunostaining of Rho proteins showed that Rac1 and RhoB are present in the cortical ooplasm, but Cdc42 is absent. Actin filaments in the cortex appeared to be reduced in toxin B-injected eggs. This study suggests that Rho protein(s) regulating actin-based cytoskeletal reorganization is involved in the process leading to sperm incorporation.

Prospective Evaluation for the Feasibility and Safety of Vaginal Birth after Laparoscopic Myomectomy

STUDY OBJECTIVE To estimate the feasibility and safety of vaginal birth after laparoscopic myomectomy (LM). DESIGN Prospective clinical study (Canadian Task Force classification II-2). SETTING University hospital. PATIENTS The study was performed on 1334 patients who underwent LM at our hospital from January 2000 through December 2005. INTERVENTIONS Laparoscopic myomectomy. MEASUREMENTS AND MAIN RESULTS The potential of a safe vaginal birth after LM was discussed with all 1334 patients before and after their LM. A strict protocol for a vaginal birth after LM was prepared using the criteria for a vaginal birth after cesarean section (CS). Of the 221 women who became pregnant after LM by December 2006, 111 were scheduled to deliver at our hospital. The findings at LM in these patients were as follows: mean diameter of the largest myoma (mean +/- SD, 95% CI), 66.1 +/- 18.8 (62.6-69.6) mm; and mean number of enucleated myomas, 3.5 +/- 3.6 (2.8-4.2). The endometrium was opened in 13 patients. Of the 111 patients, 82 patients opted for a vaginal delivery and 29 patients requested a CS. Of the 82 patients, 8 underwent an elective CS because of complications of pregnancy. Vaginal delivery was completed in 59 (79.7%) of the remaining 74 patients. The 15 patients who failed vaginal delivery underwent a CS: eleven because of failure to progress in labor or absence of spontaneous labor by 42 weeks of gestation; and 4 because of a nonreassuring fetal status during labor. No significant differences in delivery outcomes existed between the successful and failed group. None of the patients had a uterine rupture. CONCLUSION Uterine rupture during pregnancy after LM is rare, and vaginal birth after LM appears to be safe in selected patients who meet our criteria.

Diagnosis, laparoscopic management, and histopathologic findings of juvenile cystic adenomyoma: a review of nine cases

OBJECTIVE To define diagnostic criteria for juvenile cystic adenomyoma (JCA), describe the histologic features of the condition and evaluate laparoscopic excision for treating associated dysmenorrhea and pelvic pain. DESIGN Prospective long-term follow-up study. SETTING University-affiliated hospital. PATIENT(S) Nine consecutive patients with JCA. INTERVENTION(S) Patients meeting the diagnostic criteria for JCA underwent laparoscopic enucleation of the lesion. The severity of dysmenorrhea was evaluated before surgery and every 6 months after surgery. Five patients underwent second-look laparoscopy (SLL) 6 months after surgery. MAIN OUTCOME MEASURE(S) Relief of dysmenorrhea as measured by a visual analog scale, postoperative healing at SLL, and subsequent pregnancy when desired by the patient. RESULT(S) Laparoscopic enucleation of the cystic adenomyoma resulted in a statistically and clinically significant reduction in dysmenorrhea and improved chronic pelvic pain. Neither cystic adenomyoma nor severe dysmenorrhea recurred during the follow-up period. Adhesions were minimal at SLL. Two of the three patients who desired pregnancy conceived after surgery. The histologic findings of the JCA lesion and adenomyosis were similar, and the endometrial glands and stroma infiltrating the surrounding myometrium in all patients were consistent with the appearance of adenomyosis. CONCLUSION(S) We defined the diagnostic criteria for JCA, and demonstrated significant improvement of dysmenorrhea after laparoscopic excision of the lesion.

Incidence of Complications during Gynecologic Laparoscopic Surgery in Patients after Previous Laparotomy

STUDY OBJECTIVE To estimate the incidence of complications arising during gynecologic laparoscopic surgery in patients who have undergone previous abdominal surgeries and to assess predictable factors associated with complications based on the characteristics of the previous laparotomy. DESIGN Retrospective study (Canadian Task Force classification II-2). SETTING University-affiliated hospital. PATIENTS We enrolled 307 patients with a history of laparotomy who underwent laparoscopic surgery at our hospital between January 2002 and June 2009. INTERVENTIONS The closed primary approach via either the ninth intercostal space or the posterior vaginal fornix was used to avert bowel injury. Complications were defined as organ injury that required repair during surgery and immediate conversion to laparotomy because of technical difficulties. Factors influencing complications during laparoscopic surgery were analyzed using logistic regression. MEASUREMENTS AND MAIN RESULTS No complications developed during primary entry. Adhesiolysis was required in 195 areas of adhesion in 146 patients before laparoscopic surgery could proceed. These areas comprised 45 (14.7%) and 31 (10.1%) abdominal wall adhesions without and within the umbilicus, respectively, and 119 (38.8%) with intrapelvic adhesions. Complications in 41 patients (13.4%) included bowel damage (n=35), urinary system damage (n=4), and conversion to laparotomy because of technical difficulties (n=2). Overall, 38 complications were laparoscopically repaired, and 1 complication was repaired at minilaparotomy. Intrapelvic adhesions were found in all patients with complications, and bowel adherent to the intrapelvis was identified in 38 of these (92.7%). The most significant predictive factors positively associated with development of complications according to logistic regression analysis were a history of abdominal myomectomy (odds ratio, 6.27; 95% confidence interval, 2.95-13.38; p<.001) and excisional endometriosis surgery (odds ratio, 5.80; 95% confidence interval, 2.08-16.13; p=.001). No patients developed severe delayed complications after surgery. CONCLUSION Our findings suggest that potential predictive factors of complications are a history of abdominal myomectomy and excisional endometriosis surgery performed because of intrapelvic adhesions.

The opioid neuropeptides in uterine fibroid pseudocapsules: a putative association with cervical integrity in human reproduction

Abstract The myoma pseudocapsule (MP) is a fibro-vascular network rich of neurotransmitters, as a neurovascular bundle, surrounding fibroid and separating myoma from myometrium. We investigated the distribution of the opioid neuropeptides, as enkephalin (ENK) and oxytocin (OXT), in the nerve fibers within MP and their possible influence in human reproduction in 57 women. An histological and immunofluorescent staining of OXT and ENK was performed on nerve fibers of MP samples from the fundus, corpus and isthmian-cervical regions, with a successive morphometric quantification of OXT and ENK. None of the nerve fibers in the uterine fundus and corpus MPs contained ENK and the nerve fibers in the isthmian–cervical region demonstrated an ENK value of up to 94 ± 0.7 CU. A comparatively lower number of OXT-positive nerve fibers were found in the fundal MP (6.3 ± 0.8 CU). OXT-positive nerve fibers with OXT were marginally increased in corporal MP (15.0 ± 1.4 CU) and were substantially higher in the isthmian–cervical region MP (72.1 ± 5.1 CU) (p < 0.01). The distribution of OXY neurofibers showed a slight into the uterine corpus, while are highly present into the cervico-isthmic area, with influence on reproductive system and sexual disorders manifesting after surgical procedures on the cervix.

Efficacy of laparoscopic ovarian drilling for polycystic ovary syndrome resistant to clomiphene citrate

Aim:  It is difficult to induce ovulation in patients with polycystic ovary syndrome (PCOS) resistant to clomiphene citrate (CC) because of the narrow safety margin of human menopausal gonadotropin preparations. In the present study, patients diagnosed as having PCOS according to the Japanese diagnostic criteria were divided into two groups (Groups H and N). Testosterone level was used as a cut‐off value between Groups H and N to examine the usefulness of laparoscopic ovarian drilling (LOD) to induce ovulation.

NT, NPY and PGP 9.5 presence in myomeytrium and in fibroid pseudocapsule and their possible impact on muscular physiology

The uterine myoma pseudocapsule is a neurovascular bundle surrounding fibroid, containing neuropeptides, probably involved in uterine scar healing. We studied neurotensin (NT), neuropeptide tyrosine (NPY), and protein gene product 9.5 (PGP 9.5) nerve fibres in the pseudocapsule neurovascular bundle of intramural uterine fibroids on 67 no pregnant women by intracapsular myomectomy sparing the neurovascular bundle, sampling full thickness specimens of the pseudocapsule of uterine fibroids (PUF) and normal myometrium (NM) obtained from the fundus uteri (FU) and the uterine body (UB). The samples were sent for histological and immunofluorescent analyses and compared by morphometrical quantification. The Conventional Unit (C.U.) difference of NT, NPY, and PGP 9.5 nerve fibres was statistically analyzed. Our results showed that NT, NPY, and PGP 9.5 neurofibers are almost equally present in PUF as in NM of a no pregnant uterus. As all of these neuropeptides are present in the uterine muscle and can affect muscle contractility, uterine peristalsis and muscular healing. A myomectomy respecting the pseudocapsule neurofibers should facilitate smooth muscle scarring and promote restoration of normal uterine peristalsis with a possible positive influence on fertility.

Association between uterine repair at laparoscopic myomectomy and postoperative adhesions

Objective. To determine whether uterine repair at laparoscopic myomectomy influences postoperative adhesions. Design. Retrospective study. Setting. University‐affiliated hospital. Population. A total of 108 patients who underwent second‐look laparoscopy after laparoscopic myomectomy without concomitant pelvic surgery between January 2006 and May 2010. Methods. Absorbable cellulose adhesion barriers were used for uterine repair at initial surgery in all women. The presence of adhesions was evaluated by second‐look laparoscopy. Main outcome measures. The influence of background factors (diameter of largest myoma, number of myomas, incision sites and number of suture layers) and the uterine status immediately after uterine repair at laparoscopic myomectomy (number, length and location of wounds, as well as wound appearance classified as virtually normal, swollen or protruding) on adhesion formation were analysed in 108 women with 296 uterine wounds. Data were analysed by logistic regression analysis. Results. Forty‐one (38.0%) women had adhesions to their uterus at follow up. We identified 48 (16.2%) adhesions among 296 wounds in all women. A protruding wound was significantly associated with postoperative wound adhesion (odds ratio, 2.53; p=0.02). The number of enucleated subserosal myomas (odds ratio, 3.29; p<0.001) and the diameter of the largest myoma (odds ratio, 1.05; p<0.001) were significantly associated with wound protrusion, which was a critical factor influencing adhesion. Conclusions. Postoperative wound adhesion formation seems to depend on uterine status immediately after laparoscopic myomectomy.