Mun-Kun Hong

Complete bilateral ureteral obstruction following retrograde catheterization and radical hysterectomy.

An 89 kg, 39-year-old, previously healthy, obese woman was admitted to our ward owing to squamous cell carcinoma of the cervix, the International Federation of Gynecology and Obstetrics (FIGO) stage IIa2. She was scheduled for an radical hysterectomy, bilateral pelvic lymph node dissection and ovarian transposition. Preoperative laboratory data, including a hematogram, biochemical, and coagulation test results were normal. Before the operation, cystoscopy was performed and two 5-Fr side-hole ureteral catheters were smoothly inserted into each of the ureters to a length of 20 cm. Owing to severe pelvic adhesions and obesity, the operation took 245 minutes and blood loss was 800 ml. Hematuria was noted during the isolation of the ureters and unroofing of the tunnels. To control bleeding, Transamine-S (Taiwan) 1 gm q8h i.v. was administered for 48 hours. Naproxen 20 mg tid and Ketorolac 30 mg i.v. q6h were prescribed before and after the operation for pain control. During the first 24 hours after operation, 2110 mL of bloody urine was collected, but was followed immediately by oliguria, and then anuria. The situation did not improve upon replacement of the Foley catheter, fluid challenge, and the use of a diuretic. Blood urea nitrogen (BUN) and creatinine levels increased to 10 mg/dL and 2.0 mg/dL, respectively (from 9 mg/dL and 0.7 mg/dL before the operation). Meanwhile, the patient was looking well with no specific complaints other than wound pain. Her vital signs were stable, and a postoperative hematogram revealed that hemoglobin and hematocrit levels had dropped to 11.0 g/dL and 32.8% (from 14.2 g/dL and 42.6% before the operation). Under the impression of acute obstructive nephropathy, an emergent abdominal computed tomography (CT) without contrast was ordered; it revealed mild bilateral hydronephrosis (Fig. 1). Cystoscopy and ureteroscopy showed the occlusion of bilateral ureters by blood clots with minimal edema of the orifices

Antiestrogen use reduces risk of cervical neoplasia in breast cancer patients: a population-based study

Estrogen has been proven to be a necessity for cervical carcinogenesis by transgenic mice studies. To determine whether long-term antiestrogens use could reduce the incidence of cervical neoplasia, a population-based cohort of 42,940 breast cancer patients with and without antiestrogen therapy were identified from the Taiwan National Health Insurance Database. All patients were followed for the most severe form of cervical neoplasia or until death. Their risks of cervical neoplasia were compared with Cox regression analysis and adjusted for age, Pap smear density and chemotherapy. Aromatase inhibitor (AI)-included antiestrogen users consistently exhibited a lower risk of low-grade cervical dysplasia [adjusted hazard ratio (HR) = 0.42, 95% CI 0.29 to 0.64, P < 0.0001] in the five-year follow-up analysis and in subgroup of regular Pap screenings (HR = 0.32, 95% CI, 0.20 to 0.50, P < 0.0001). A lower 10-year incidence of high-grade cervical dysplasia was also noted in the regular-screening group (HR = 0.49; 95% CI, 0.27 to 0.90; P = 0.0212), especially in the ≥ 50 years old group (HR = 0.34; 95% CI, 0.14 to 0.80; P = 0.014). The protection effect of Tamoxifen-only use for low-grade cervical dysplasia was only found in the young-age, regular-screening group (HR = 0.67; 95% CI, 0.48 to 0.93; P = 0.0167). In short, long-term use of AI-included antiestrogen conferred a lower risk of cervical neoplasia.

Antiestrogen use in breast cancer patients reduces the risk of subsequent lung cancer: A population-based study

BACKGROUND There is accumulating epidemiological and preclinical evidence that estrogen might be a driver of lung cancer. Breast cancer survivors can offer a unique patient cohort to examine the effect of antiestrogen therapy on lung cancer carcinogenesis because many of these women would have received long-term selective estrogen receptor modulators (SERMs) and/or aromatase inhibitors (AIs) as adjuvant treatment. Our hypothesis is that estrogens play a role in lung cancer development, and that antiestrogen therapy would affect the incidence of subsequent lung cancer among breast cancer survivors. METHODS Using the Taiwan National Health Insurance (NHI) database, the study included 40,900 survivors of non-metastatic breast cancer after primary surgery, and most antiestrogen users complied well with the medication regimen. We evaluate the effect of antiestrogen therapy on the incidence of subsequent lung cancers. RESULTS This population-based study revealed that antiestrogen use in breast cancer patients was associated with a reduced risk of subsequent lung cancer in older patients (≥50 years) (HR 0.73, 95%CI 0.54-0.99) when compared with breast cancer survivors who did not use antiestrogens. CONCLUSION The study supports the hypothesis that antiestrogen therapy modifies lung cancer carcinogenesis in older women. Further well-designed clinical trials to explore the potential of antiestrogens in lung cancer prevention and treatment would be worthwhile.

High success rate and considerable adverse events of pelvic prolapse surgery with Prolift: A single center experience

OBJECTIVES The aim of this study was to analyze short-term outcomes of pelvic prolapse surgery using Prolift transvaginal mesh in a teaching hospital. MATERIALS AND METHODS Thirty-four patients who received prolapse surgery with Prolift were followed up for 7-26 months. Assessment included pre- and postoperative Pelvic Organ Prolapse Quantification (POP-Q) stage, and Urogenital Distress Inventory (UDI)-6, and Incontinence Impact Questionnaire (IIQ)-7 scores. Surgical characteristics and adverse events during follow-up were also recorded. RESULTS Objective and subjective data were available for 29 patients. The overall anatomical success rate was 96.5 % (28/29) after a mean of 18 ± 6.3 months follow-up. The POP-Q, UDI, and IIQ all improved significantly after surgery. Uterine sparing prolapsed surgery with Prolift unexpectedly yielded a cure rate of 100%. Ten adverse events occurred during and after prolapse surgery with dyspareunia (3/34) as the most common, followed by bladder injury (2/34). CONCLUSIONS Prolapse surgery with Prolift yielded a good anatomical outcome and satisfactory symptom improvement at different periods of follow-up, especially in uterus-sparing prolapse surgery. However, adverse events were not uncommon, and patients should be fully informed of all possible adverse events prior to surgery.

Congenital listeriosis: A review of cases in Taiwan since 1990 until 2011

Listeriosis is a food-borne illness caused by Listeria monocytogenes. The genus Listeria is a sub-branch of Clostridium, together with Staphylococcus and Streptococcus. There are six different species (L monocytogenes, Listeria ivanovii, Listeria innocua, Listeria welshimeri, Listeria seeligeri, and Listeria grayi), but only the L monocytogenes is consistently associated with human illness [1]. L monocytogenes is an aerobic-tomicroaerophilic Gram-positive bacterium with motile rods commonly present in soil, dust, water, processed food, and both animal and human feces [1]. L monocytogenes resists freezing, drying, and heat remarkably well. It can spread from cell to cell without contact with the extracellular environment [1]; therefore, hosts with depressed, cell-mediated immunity such as pregnant women, unborn babies, aged adults, and immunocompromised people are especially susceptible to it. Incidence of prenatal listeriosis is 8.6e17.4/100,000 births [1e3]. This article describes a rare case of listeriosis during pregnancy, with an initial presentation of fever and flu-like symptoms. Published case reports of neonatal listeriosis in Taiwan since 1990 to 2011 were collected (Table 1). A 25-year-old pregnant mother (G6P1SA3AA1) had regular and uneventful antepartum care up to 34 weeks. She presented at the emergency department with complaints of fever, abdominal pain, and decreased fetal movement for 1 day. Additionally, she reported a headache and vomiting for 2 days. Her recent history revealed a flu-like illness with a sore throat and intermittent fever for 7 days. On admission, the woman’s vital signs were observed as follows: blood pressure 140/86 mmHg, heart rate 145 bpm, respiratory rate 21/min, and body temperature 38.4 C. Cardiotocography identified regular uterine contractions every 1.5 minutes with amplitudes of roughly 50e70 mmHg. Ritodrine 20 mg PO and 1 L normal saline infusion were prescribed immediately. The fetal

High grade serous ovarian carcinoma with serous tubal intraepithelial carcinoma in a case presented with atypical glandular cell favor neoplasm cervical cytology and dermatomyositis

OBJECTIVE This report describes a case of serous ovarian carcinoma with occult serous tubal intraepithelial carcinoma (STIC), which presented as atypical glandular cells favor neoplasia (AGC-FN) with Pap cytology and dermatomyositis. CASE REPORT A 48-year-old woman presented with symptoms of dermatomyositis. An AGC-FN result from a Pap smear, with an absence of a cervical or endometrial lesion was noted. After cancer surveillance, ovarian high grade serous carcinoma associated with serous tubal intraepithelial carcinoma was diagnosed. Two weeks following surgical excision of the carcinoma, dramatic remission of the dermatomyositis symptoms was evident. CONCLUSION The patient had serous carcinoma of the ovary with tubal STIC, which presented as dermatomyositis. The AGC-FN identified from a Pap smear hinted at a diagnosis of ovarian carcinoma. These presentations point to an occult malignancy in the genital tract and demand careful diagnostic workup.

Parathyroid adenoma with hypertensive crisis and intracerebral hemorrhage mimicking hemolysis, elevated liver enzymes, low platelets syndrome.

BACKGROUND: Hyperparathyroidism is seldom encountered during pregnancy. Moreover, when the disease does occur, it is typically masked until late pregnancy or after delivery. CASE: A previously healthy multiparous woman presented with sudden-onset severe preeclampsia with hemolysis, elevated liver enzymes, low platelets syndrome at 37 weeks of gestation. Acute intracerebral hemorrhage and disseminated intravascular coagulapathy developed 24 hours after cesarean delivery and persisted after craniotomy. Hypercalcemia and hyperparathyroidism were noted, and imaging studies revealed parathyroid tumor. The patient recovered from severe preeclampsia after resection of a hemorrhagic parathyroid adenoma and was fully rehabilitated after 3 months. CONCLUSION: This patient exhibited a concealed hyperparathyroidism with acute hypertensive crisis, probably attributable to hemorrhagic parathyroid adenoma. The presentation mimics acute late-onset preeclampsia and requires vigilant diagnosis followed by surgery.

Robotic single-site supracervical hysterectomy with manual morcellation: Preliminary experience

AIM To evaluate the feasibility, safety and peri- and postoperative outcomes of robotic single-site supracervical hysterectomy (RSSSH) for benign gynecologic disease. METHODS We report 3 patients who received RSSSH for adenomyosis of the uterus from November 2015 to April 2016. We evaluated the feasibility, safety and outcomes among these patients. RESULTS The mean surgical time was 244 min and the estimated blood loss was 216 mL, with no blood transfusion necessitated. The docking time was shortened gradually from 30 to 10 min. We spent 148 min on console operation. Manual morcellation time was also short, ranging from 5 to 10 min. The mean hospital stay was 5 d. Lower VAS pain score was also noted. There is no complication during or after surgery. CONCLUSION RSSSH is feasible and safe, incurs less postoperative pain and gives good cosmetic appearance. The technique of in-bag, manual morcellation can avoid tumor dissemination.

A review of ovary torsion

Ovarian torsion is a rare but emergency condition in women. Early diagnosis is necessary to preserve the function of the ovaries and tubes and prevent severe morbidity. Ovarian torsion refers to complete or partial rotation of the adnexal supporting organ with ischemia. It can affect females of all ages. Ovarian torsion occurs in around 2%–15% of patients who have surgical treatment of adnexal masses. The main risk in ovarian torsion is an ovarian mass. The most common symptom of ovarian torsion is acute onset of pelvic pain, followed by nausea and vomiting. Pelvic ultrasonography can provide information on ovarian cysts. Once ovarian torsion is suspected, surgery or detorsion is the mainstay of diagnosis and treatment.

Internal Pudendal Artery Injury during Prolapse Surgery Using Nonanchored Mesh

Herein is presented the case of a patient with stage 2 uterine prolapse treated surgically using nonanchored mesh. Complications were internal pudendal artery injury and a massive presacral hematoma that formed after surgery. Transcatheter arterial embolization was performed immediately, and the bleeding stopped. The patient subsequently experienced difficulty micturating and defecating because of presacral hematoma compression. Self-micturation and defecation capabilities were regained gradually at approximately 1 week after surgery. The hematoma resolved completely by 71 days postoperatively. Comprehensive knowledge of pelvic anatomy is important when performing surgery to treat prolapse using mesh kits. Removing the mesh and prophylactic antibiotic therapy is a means of conservatively managing a pelvic hematoma caused by prolapse surgery.