Li-Yun Chou

Clinical significance of regulatory T cells and CD8+ effector populations in patients with human endometrial carcinoma.

A study was carried out to determine the functional attributes of CD4+ CD25+ regulatory T cells in cancer progression by suppressing antitumor immunity.

Simultaneous laparoscopic uterine artery ligation and laparoscopic myomectomy for symptomatic uterine myomas with and without in situ morcellation

BACKGROUND To determine the optimal surgical approach for laparoscopic uterine artery ligation (LUAL) combined with myomectomy in the management of women with symptomatic uterine fibroids. METHODS This is a prospective study. One hundred and six women with symptomatic uterine myomas underwent LUAL + laparoscopic morcellation after enucleation (enucleation group) (n = 51) or LUAL + laparoscopic in situ morcellation (ISM group) (n = 55). The outcome was measured by comparing surgical techniques, symptom control, recurrence and pregnancy during a 3-year follow-up in both groups. RESULTS General characteristics of the patients were similar in both groups, except the myomas were larger in the ISM group. The operative time (mean ± SD) was significantly shorter in the ISM group than the enucleation group (107 ± 30 min versus 128 ± 49 min, P = 0.009). There were no differences in the therapeutic outcomes of the two groups at the 3-year follow-up, with low recurrence rates and good symptom control rates. Of the sexually active patients without contraception, the pregnancy and live birth rates were 87.5 and 100% in the ISM group and 66.7 and 83.3% in the enucleation group (all NS). CONCLUSIONS The LUAL + myomectomy, either by enucleation or ISM, is acceptable in the management of symptomatic uterine fibroids. However, the LUAL + ISM technique might be more feasible, as it requires less operative time.

Simultaneous Enucleation and In Situ Morcellation of Myomas in Laparoscopic Myomectomy

OBJECTIVE To evaluate the outcome of myoma enucleation by morcellation while it is attached to the uterus (in situ morcellation) in laparoscopic myomectomy. MATERIALS AND METHODS A total of 82 patients diagnosed with myoma or adenomyosis in 2007 were enrolled. The patients were divided into three groups according to the myoma weight. The operative time, myoma weight, blood loss, duration of hospital stay, and complication experienced were recorded for analysis. RESULTS The mean myoma weight was 265 ± 240 g and the mean operative time was 93 ± 30 minutes. The patients were divided into three groups: group A with myomas less than 150 g; group B with myomas 150-349 g; and group C with myomas greater than 350 g. The mean myoma weights were 73 ± 34 g, 214 ± 52 g, and 571 ± 218 g for groups A, B, and C, respectively; the mean operative times were 79 ± 17 minutes, 84 ± 22 minutes, and 121 ± 32 minutes, respectively. The operative time increased with myoma weight. Two patients (8%) in group C had excessive intraoperative hemorrhage and one (4%) required a blood transfusion. There was no conversion to laparotomy. CONCLUSION In situ morcellation was an efficient and safe procedure for removal of large uterine myoma during laparoscopic myomectomy.

An easy new approach to the laparoscopic treatment of large adnexal cysts

Abstract We describe a technique for laparoscopically assisted extracorporeal cystectomy or adnexectomy of large adnexal cysts without spillage of the cyst contents. At open laparoscopy, a suction tube decompressed the adnexal cyst from the 2-cm umbilical incision and the puncture hole was closed by the purse string tie, which was followed by extra-corporeal excision of the cyst. With this method, we prevent cyst spillage in three ways. Firstly, the cyst is aspirated extracorporeally. Secondly, when the cyst is totally collapsed, the puncture point is closed with a 1-o Vicryl purse suture and pulled to the umbilicus. Thirdly, as soon as a part of the mass is delivered from the abdomen, it is lined with moist gauze. This method provides excellent visualization and control of the penetration site during aspiration, and minimizes the chances of the cyst contents leaking into the peritoneal cavity. This method was successfully used with 12 patients, including four cystadenomas, one serous cystadenoma, three dermoid cysts (with one pregnant woman who successfully spontaneously delivered a normal baby at term), two low malignant potential ovarian tumors and one grade I endometrioid adenocarcinoma. The cancer patient has shown no recurrence after a follow-up of three years.

Comparison between transumbilical and transabdominal ports for the laparoscopic retrieval of benign adnexal masses: a randomized trial

OBJECTIVE To compare the feasibility, operative time, specimen retrieval time, and effect on postoperative pain of laparoscopic retrieval of benign adnexal masses between a 10-mm transumbilical and a 10-mm transabdominal port. STUDY DESIGN Fifty women with adnexal masses who were scheduled for a laparoscopic procedure between July 2008 and April 2009 were enrolled. The patients were randomized into two groups; these were patients where a transumbilical port was used for specimen retrieval (transumbilical group, n=25) and patients where a transabdominal port was used for specimen retrieval (transabdominal group, n=25). Preoperative suspicion of malignancy and indications suggesting a need for hysterectomy or myomectomy were considered to be exclusion criteria. Randomization was centralized and computer-based. Patients recorded the severity of incisional pain on a visual analog scale (VAS) with 0 meaning no pain and 10 meaning unbearable pain. RESULTS There were no significant differences in age, body mass index, umbilical thickness, abdominal thickness, cyst size, cyst amount, cyst weight, histology, complications and duration of hospital stay when the two groups were compared. Patients in the transumbilical group had a significantly shorter specimen retrieval time (0.7 ± 1.8 min vs. 4.9 ± 12.6 min, p=0.006) and a significantly lower postoperative day (POD) 0 VAS pain score (5.2 ± 2.1 vs. 6.6 ± 2.2, p=0.015). Significantly fewer patients in the transumbilical group had a specimen retrieval time of ≥10 min (0% vs. 20%, p=0.025) and a POD 0 VAS pain score of >5 (36% vs. 84%, p<0.001). However, the average POD 1 VAS pain score (3.2 ± 1.8, vs. 3.6 ± 1.6) and the proportion with a POD 1 VAS pain score >5 (12% vs. 12%) were similar for the two groups. CONCLUSION When laparoscopic surgery on benign adnexal masses is carried out using a 10-mm incision wound, removal of the specimen via the umbilical port has a shorter retrieval time and produces less postoperative pain than retrieval via a lateral abdominal port.

Strategy of cervical myomectomy under laparoscopy

OBJECTIVE To evaluate a strategy of laparoscopic excision of a cervical myoma (CM). DESIGN Prospective study. SETTING University-affiliated hospital. PATIENT(S) Twenty-eight patients with CM underwent laparoscopic myomectomy. These cases were classified into five types according to the location: [1] anterior cervical myoma (ACM); [2] posterior cervical myoma (PCM); [3] central cervical myoma (CCM); [4] lateral cervical myoma [LCM]; and [5] deep-rooted cervical myoma (DCM). INTERVENTION(S) After preoperative assessment, patients underwent laparoscopic myomectomy. Ligation of the uterine artery and diluted vasopressin injection were performed to decrease bleeding during laparoscopy. MAIN OUTCOME MEASURE(S) Myoma numbers, myoma weight, operative time, estimated blood loss, hospital stay, complication rate. RESULT(S) Most of the lesions were ACM (43%) and PCM (32%). The mean operative time was 121 minutes, mean blood loss was 99 mL, and mean myoma weight was 287 g. The mean hospital stay was 2.2 days. There were no complications. Histopathologic examination showed that all lesions were leiomyoma. Hypermenorrhea, dysmenorrhea, and symptoms of compression improved after the operation. Two infertile patients conceived spontaneously at 1 and 7 months postoperatively, and successfully delivered infants by cesarean section at term. CONCLUSION(S) Surgical treatment of CM is empirically difficult. It is important that the approach be changed according to the location and size of the myoma.

Comparison of Laparoscopic Myomectomy Using in Situ Morcellation With and Without Uterine Artery Ligation for Treatment of Symptomatic Myomas

STUDY OBJECTIVE To evaluate the efficacy of laparoscopic uterine artery ligation (LUAL) before in situ morcellation (ISM) compared with ISM alone. DESIGN Prospective study (Canadian Task Force classification II-1). SETTING University-affiliated hospital. PATIENTS One hundred forty-four women with symptomatic uterine myomas, of whom 45 underwent LUAL and ISM and 99 underwent ISM only, from August 2007 through August 2009. INTERVENTIONS Ligation or no ligation of the uterine arteries before ISM. MEASUREMENTS AND MAIN RESULTS In the LUAL+ISM group compared with the ISM group, mean (SD) operative time was significantly longer (107 [34] minutes vs 93 [35] minutes; p = .03), and there was less intraoperative blood loss (84 [53] mL vs 137 [166] mL; p < .001). Eight patients in the ISM group (8.1%) required a blood transfusion, including 4 (4.0%) with excessive intraoperative bleeding and 4 (4.0%) with postoperative hematomas. Although myomas in the LUAL+ISM group weighed more (p < .001), none of the patients in that group had excessive intraoperative bleeding, postoperative hematomas, or required blood transfusion (p = .046). At 2 years of follow-up, in the LUAL+ISM group compared with the ISM group, the myoma recurrence rate was 7% vs 24%, and symptom improvement was reported by 98% of patients vs 86% (statistically significant). CONCLUSION Laparoscopic myomectomy using an ISM technique with or without simultaneous LUAL may be used in the management of symptomatic uterine myomas; however, LUAL+ISM may result in a better surgical outcome.

Clinical outcome of transvaginal sacrospinous fixation with the Veronikis ligature carrier in genital prolapse

OBJECTIVE To evaluate the clinical outcome of sacrospinous fixation (SSF) using the Veronikis ligature carrier (VLC) for genital prolapse. STUDY DESIGN A retrospective longitudinal study was performed. From December 2003 through June 2008, SSF was performed in 76 patients using the VLC as part of their site-specific reconstructive pelvic surgery. All patients were followed up postoperatively at 6 weeks, 3 months, 6 months, 12 months, and annually thereafter. RESULTS The median operative time of SSF was 34min. It took less than 5min to introduce two sutures through the ligament using the VLC. Four patients (5.3%) had recurrent vaginal vault descent at 3-8 months, and received SSF again. Three patients had recurrent stage 1 cystocele at 6-12 months, but did not require further surgery. CONCLUSION The VLC allowed effective introduction of the suspending suture through the sacrospinous ligament and might be considered an important surgical component in the treatment of severe genital prolapse.

Operating time and blood loss during laparoscopic‐assisted vaginal hysterectomy with in situ morcellation

Objective. To develop a regression‐based prediction equation for operative time and estimated blood loss in laparoscopically assisted vaginal hysterectomy (LAVH) for large uteri, as required, by combined laparoscopic in situ and vaginal morcellation. Design. Prospective study (Canadian Task Force classification II‐1). Setting. University‐affiliated hospitals. Sample. Fifty‐six patients who underwent LAVH. Methods. Evaluation of all patients who had LAVH with laparoscopic in situ morcellation and vaginal morcellation during a 2‐year period. Main outcome measures. Operative time, estimated blood loss, total uterine weight by laparoscopic or vaginal morcellation, complications and length of hospital stay. Results. Mean operative time was 133 ± 22 minutes, and mean blood loss 133 ± 101ml. Mean uterine weight was 383 ± 187g by laparoscopic and 251 ± 103g by vaginal morcellation. Greater total uterine weight and morcellation were associated with longer operative times. Blood loss correlated with uterine weight when vaginal morcellation was also used. A regression equation is presented for estimating the likely operating time and blood loss. Conclusions. An increase in the operative time and a higher blood loss can be expected as the uterine weight increases and can be predicted taking morcellation methods into account.

Laparoscopically Assisted Vaginal Hysterectomy Following Previous Kidney Transplantation

OBJECTIVE With improvements in immunosuppression and surgical techniques, more women are undergoing kidney transplantation (KT) for management of end-stage renal disease. Location of the transplanted pelvic kidney and transplanted ureter must be taken into consideration when performing pelvic surgery. We demonstrate that laparoscopically assisted vaginal hysterectomy (LAVH) can be successfully performed in patients who had previously undergone KT. MATERIALS AND METHODS We prospectively enrolled four patients requiring operation for symptomatic adenomyosis after KT. LAVH was performed in these cases after initial uterine artery ligation during laparoscopy. RESULTS The median age of the patients was 44 years (range, 40-46 years) and the extirpated uterine weight was 195 g (range, 160-380 g). Intraoperatively, the median operation time was 147.5 minutes (range, 105-175 minutes) and the blood loss was 50 mL (range, 50-100 mL). There was mild pelvic adhesion in two cases. The postoperative recovery was good in all patients with oral intake, flatus passage, and ambulation within 1 day after operation. The median intramuscular meperidine requirements were 25 mg (range, 0-100 mg) and the hospital stay was 4 days (range, 3-8 days). There were no major complications in these cases except one with mild postoperative fever. CONCLUSION LAVH may be a safe and effective treatment for treating patients with adenomyosis after KT.