Makoto Jinushi

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.

Vascular density of peritoneal endometriosis using narrow-band imaging system and vascular analysis software.

A pilot study was designed to analyze the vascular density of peritoneal endometriosis in 3 groups of lesions (red, black, and white) in 23 patients with peritoneal endometriosis who underwent laparoscopic surgery using the narrow-band imaging system and vascular analysis software. In the peritoneum, 21 red lesions were present in 10 patients, 12 black lesions were present in 9 patients, 12 white lesions were present in 8 patients, and 2 types of lesion were concomitantly present in 4 patients. Median vascular density of red, black, and white lesions under conventional light was 60.3%, 62.3%, and 60.6%, respectively, and under narrow-band light was 64.4%, 61.5%, and 62.0%, respectively, showing no significant differences among the lesions under either conventional or narrow-band light (p=.71 and p=.84, respectively). The median difference in vascular density under narrow-band and conventional light was not significantly different in black lesions (0.8%) or white lesions (1.0%); however, a difference of 4.5% was noted for red lesions (p <.001). We conclude that red lesions are indicative of early-stage endometriosis with angiogenesis. Use of the narrow-band system and vascular analysis software can enable accurate, objective, and reproducible evaluation of vascular density.

Feasibility of laparoscopically assisted extracorporeal cystectomy via single suprapubic incision using an adjustable-view laparoscope to treat large benign ovarian cysts: comparison with conventional procedure

OBJECTIVE To demonstrate the feasibility of minimally invasive surgery using a novel optical device to treat large benign ovarian cysts and to compare the safety of the procedure with that of conventional laparoscopically assisted multiport extracorporeal cystectomy. STUDY DESIGN Twenty-one patients with large benign ovarian cysts underwent laparoscopically assisted extracorporeal ovarian cystectomy via a single suprapubic incision using a novel 10-mm rigid laparoscope with an adjustable direction of view and a multiport device, between October 2010 and July 2012. The surgical outcomes were retrospectively compared between these patients (Group A) and 32 patients who underwent the conventional 3-port laparoscopically assisted extracorporeal procedure between January 2009 and September 2010 (Group B). Data were statistically analyzed using the Mann-Whitney U-test or Fishers exact test. RESULTS None of Group A required conversion to conventional multiport laparoscopy. The total duration of surgery, elapsed time between skin incision and the start of pneumoperitoneum, and time required for intra- and extra-corporeal manipulations did not significantly differ between the groups. The time required for skin closure, however, was significantly decreased in Group A compared with Group B (13.0 ± 3.5 vs. 20.2 ± 4.8 min, P=0.005). The volume of blood loss and postoperative blood findings were similar to those associated with the conventional procedure. Postoperative visual analog pain scales at 3h were significantly lower in Group A than in Group B (3.7 ± 2.6 vs. 4.8 ± 2.0, P=0.04). Postoperative complications did not arise after either procedure. CONCLUSION Laparoscopically assisted extracorporeal cystectomy via a single suprapubic incision is a feasible and safe alternative to conventional multiport cystectomy for treating large benign ovarian cysts.

Histopathologic analysis of intestinal endometriosis after laparoscopic low anterior resection.

STUDY OBJECTIVE To determine how intestinal endometriosis spreads, and, thus, to improve outcomes of curative surgery. DESIGN Descriptive study (Canadian Task Force classification II-2). SETTING University hospital. PATIENTS Ten patients who underwent laparoscopic low anterior resection of intestinal endometriosis at our hospital between January 1999 and August 2007. INTERVENTION Laparoscopic low anterior resection of intestinal endometriosis. MEASUREMENTS AND MAIN RESULTS Mapping of endometriotic foci, degree of vertical infiltration to the intestinal layers, and longitudinal spread of endometriotic foci to the intestinal plane were defined using hematoxylin-eosin, estrogen receptor, progesterone receptor, and CD10 staining. RESULTS Endometriotic foci tended to spread concentrically around a primary lesion that comprised most of a resected specimen. The deepest layer containing endometriotic foci at the primary lesion was the submucosal layer in 7 specimens (70%), and the internal circular muscle layer in 3 (30%). Satellite lesions comprising thickened areas that were independent of the primary lesion were detected in 5 specimens (50%). Multiple endometriotic foci were confirmed in all satellite lesions. CONCLUSIONS Endometriotic foci might not only infiltrate the primary lesion in intestinal endometriosis but also disseminate to other areas. Thus, the primary lesion of intestinal endometriosis with a large margin must be excised via low anterior resection.

Utility of an Organ Retraction Sponge (Endoractor) in Gynecologic Laparoscopic Surgery

Because it is minimally invasive, laparoscopic surgery is preferred over open surgery. However, it is often difficult to maintain an adequate surgical field during the procedure. As in open laparotomy, securing an adequate surgical field is important for adequate visualization. We evaluated the effectiveness and safety of the Endoractor, an organ retraction sponge that can be inserted through a 12-mm trocar to secure a surgical field in gynecologic laparoscopic surgery. The Endoractor, a 100% cellulose compressed sponge, can be expanded using physiologic saline solution, with the result that the swollen sponge displaces organs away from the surgical field. Between October 2009 and April 2010, we used the Endoractor in 24 patients, placed in a Trendelenberg position, during laparoscopic surgery. In no patients, even with return to a horizontal position, did the intestines fall into the pelvis, and surgery was easily performed. Mean (SD; 95% CI) operative time was 92.7 (44.5; 74.0-111.6) minutes, and blood loss was 54.1 (73.1; 22.9-82.1) mL. All patients were discharged on postoperative day 3. Even with the patient in a horizontal position without use of the Trendelenberg position, the Endoractor enables a good surgical field to be secured. It remains to be seen whether this device works as well in obese patients.

Minimum ovarian stimulation involving combined clomiphene citrate and estradiol treatment for in vitro fertilization of Bologna‐criteria poor ovarian responders

The aim of this study was to assess the efficacy of a minimal ovarian stimulation involving combined clomiphene citrate (CC) and estradiol (E2) administration for poor responders with diminished ovarian reserve (DOR).

Single-incision laparoscopic surgery using an articulating monopolar for juvenile cystic adenomyoma.

Abstract We demonstrate the feasibility of single-incision laparoscopic surgery (SILS) by using a novel monopolar cautery and a technique based on conventional multiport laparoscopic surgery in a patient with Juvenile cystic adenomyoma (JCA). A 20-year-old woman with severe dysmenorrhea, and a 3-cm uterine lesion was diagnosed with JCA. 70 cm of absorbable string tied to the tumor parenchyma was used to extract the tumor. The ends of the strings were positioned extracorporeally and the intra-abdominal parts of the strings adjacent to the anchored tumor were grasped by a laparoscopic needle holder for clarifying the incision line surrounding the tumor. The lesion was completely excised using a single-use articulating hook with monopolar cautery, and the hysterotomy site was sutured using barbed string. No complications occurred intraoperatively, and dysmenorrhea had significantly improved three months after surgery. SILS for JCA is a feasible and minimally invasive surgery for women desiring esthetic benefit.

Safe primary approach using a micro-laparoscope via the posterior vaginal fornix for patients with previous upper laparotomy: a report of five cases.

In order to reduce the risk of visceral injury for patients with upper abdominal adhesions, we devised an alternative to the umbilical approach. Five patients who had undergone a previous upper abdominal laparotomy and were scheduled for gynecologic laparoscopic surgeries at our hospital were evaluated. A micro‐trocar was inserted via the posterior vaginal fornix and the periumbilicus was observed using a micro‐laparoscope inserted in the micro‐trocar. A trocar for conventional laparoscopy was inserted into the umbilicus under micro‐laparoscopic observation in the cul‐de‐sac to avoid visceral organ adherent to the periumbilicus. Four cases had adhesions of the transverse colon, small bowel or omentum to the upper abdomen due to previous surgery; however, we were able to accomplish laparoscopic surgery without injury to adhesive organs in all patients. The micro‐laparoscopic primary approach via the posterior vaginal fornix is a safe primary approach for patients who have undergone a previous upper abdominal laparotomy.

Testicular feminization with persistent wolffian duct and müllerian remnants: similar to Mayer-Rokitansky-Kuster-Hauser syndrome

Testicular feminization findings in a 24-year-old woman closely resembled those of Mayer-Rokitansky-Kuster-Hauser syndrome with persistent müllerian remnants and wolffian duct regression.

Vitamin D Regulates Maternal T-Helper Cytokine Production in Infertile Women

Vitamin D (VD) deficiency is associated with reproductive failure. However, the relationship between VD and maternal immunity remains unclear. We investigated the clinical efficacy of VD in maternal T-helper (Th) cytokines in 276 infertile women and examined for Th1 and Th2 cells based on the deficient, insufficient, and sufficient serum 25-hydroxyvitamin D3 (25[OH]VD) levels (<12, 12–30, and >30 ng/mL, respectively). Most infertile women had a low-level of VD (87.3%). Immunological tests of pre-/post-VD supplementation were performed in patients who were deficient and insufficient in VD. Of 23 patients, 11 (47.8%) exhibited sufficient VD levels after supplementation. Th1/Th2 cell ratio in patients with insufficient VD was significantly decreased after supplementation (p = 0.004). After supplementation, serum 25(OH)VD levels of the patients: 11 in the sufficient group showed significant decreases in Th1 cell level and Th1/Th2 cell ratio (p = 0.032 and 0.010, respectively), whereas no significant differences in Th1/Th2 cell ratio were recognized in the insufficient group. Furthermore, mid-luteal endometrial biopsies (n = 18) were processed for primary cultures and measured interferon [IFN]-γ and interleukin [IL]-4 in condition media. Decidualizing cultures with 1,25-dihydroxvitamin D3 (1,25[OH]2VD) decreased IFN-γ. Sufficient VD supplementation in women with insufficient VD may optimize maternal T-helper cytokines during pregnancy via rebalancing the Th1/Th2 cell ratio.