Shozo Matsuoka

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.

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.

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.

Strategy for Laparoscopic Cervical Myomectomy

OBJECTIVE Myoma of the uterine cervix is rare, accounting for about 5% of all myomas. Compared with myomas that occur in the uterine corpus, cervical myomas are closer to other organs such as the bladder, ureter, and rectum, and the approach needs to be modified because the organs that have to be considered differ depending on the location of the myoma. We divided cervical myomas into 2 types according to location, comprising an intracervical type and extracervical types. A clear outline of surgical treatment for cervical myoma has not described in previous papers. We then investigated the surgical strategy for these types. PATIENTS Subjects comprised 16 patients who were diagnosed with cervical myoma in our hospital between January 2005 and April 2009, and who underwent laparoscopic myomectomy. RESULT Mean operative time was 105.8 + or - 43.2 (82.8-128.8) min, mean blood loss was 105 + or - 117 (42.6-167.4) ml, and mean specimen weight was 208.3 + or - 195.4 (99.3-306.2) g. Histopathological examination showed atypical myoma in 1 case and leiomyoma in others. CONCLUSIONS 16 cases of cervical myomectomy were performed safely by developing a uniform strategy that uses a fixed operative procedure, even with laparotomy, if sufficient attention is paid to the following 6 points: 1) attempting to reduce the size of the myoma with the use of preoperative GnRH; 2) determining the positional relationship between the myoma and surrounding organs; 3) temporarily blocking uterine artery blood flow with the use of vessel clips; 4) suppressing bleeding during myomectomy with the use of vasopressin; 5) minimizing the risk of damaging surrounding organs by positioning the incision in the myometrium somewhat lateral to the uterine corpus; and 6) the bottom of the wound after enculation should be pulled up by the forceps for suturing to avoid making dead space.

Linear salpingotomy with suturing by single incision laparoscopic surgery for tubal ectopic pregnancy

We investigated the feasibility of linear salpingotomy with suturing for ampullary tubal pregnancy via single incision laparoscopic surgery (SILS). Three patients underwent SILS between April and May 2010 at our hospital due to ampullary tubal pregnancy. A multichannel port was inserted into the umbilicus via a 2.5‐cm incision to accommodate a 5‐mm flexible laparoscope and a disposable articulating forceps. The linearly incised Fallopian tube was intracorporeally sutured using an articulating suturing device dedicated to SILS. The mean surgical duration was 54 minutes. Tubal preservation by linear salpingotomy was accomplished for all patients without up‐conversion to conventional laparoscopy. Serum β‐hCG values of all patients immediately decreased and further medical treatment was unnecessary.

The impact of endometriosis, endometrioma and ovarian cystectomy on assisted reproductive technology

PurposeTo assess outcomes in assisted reproductive technology (ART) in infertile women with endometriosis with respect to their concomitant endometrioma status and surgical history in our department.MethodsThis is a retrospective case control study which analyzes informational data obtained at a university hospital. The study drew from a patient pool of 332 cases (877 cIVF/ICSI cycles) that took place in our department from 2006 to 2008. Sixty-one cases (97 cycles) had major indications for cIVF/ICSI with endometriosis. We classified groups from these 61 cases as follows: an unoperated endometrioma group (A) with 31 cycles, a postoperative endometrioma group (B) with 51 cycles, and a no endometrioma group (C) with 15 cycles. We analyzed and compared these three groups and also included a non-endometriosis tubal infertility group (D) with 27 cycles.ResultsIn the control group (D), serum FSH levels and the cancellation rates were significantly lower than those of other groups, and the number of developing follicles was higher. E2 levels before oocyte aspiration in the postoperative endometrioma group (B) was lower. Implantation, pregnancy, delivery and miscarriage rates were not significantly different among the four groups.ConclusionThe results suggest that endometriosis causes a decrease in endocrinologic ovarian function whether or not an endometrioma is also present. As for E2 level before oocyte aspiration, our results suggest that ovarian reserves might be reduced by endometrioma excision, but this is difficult to evaluate. In the endometriosis groups, cancellation rates were significantly higher, although when embryos were transferred the pregnancy rates were not significantly different when compared with the non-endometriosis group. As for infertile women with endometriomas, our results suggest that preexisting ovarian reserve is reduced by the presence of endometriosis, and ovarian reserve might also be reduced by excision of endometriomas.

A Novel Modification of Traditional 2-Port Laparoscopic Surgery Using a 5-mm Flexible Scope

In embryonic natural orifice transumbilical endoscopic surgery, more than 1 port is inserted through the umbilicus. In the present study, embryonic natural orifice transumbilical endoscopic surgery combined with a flexible scope was used to further improve gynecologic surgery. A surgical incision was made in the umbilical region to enter the abdominal cavity using the closed approach. A 12-mm port was placed at the umbilical incision, and the 5-mm flexible scope was inserted through the port. Another surgical port was then made in the left inguinal region for insertion of a 5-mm port while monitoring it with the flexible scope. The flexible scope was then inserted through the 5-mm inguinal port, and another 5-mm port was inserted caudal to the 12-mm port while monitoring the umbilical region with the flexible scope. The 12- and 5-mm ports were inserted through the same umbilical incision so that they were positioned vertically. The surgeon stood on the left side of the patient to manipulate the 12-mm umbilical port with the right hand and the 5-mm inguinal port with the left hand. An assistant surgeon inserted the flexible scope through the 5-mm umbilical port and manipulated it with the left hand to secure the view during surgery by appropriately adjusting the angle of the flexible scope. With the present technique, the flexible scope did not interfere with the forceps inside or outside of the body cavity because its angle could be freely set. Since March 2, 2009, we have performed 8 procedures using this surgical technique including 1 salpingectomy, 3 ovarian cystectomies, 2 total laparoscopic hysterectomies, 1 linear salpingostomy, and 1 total laparoscopic myomectomy. Intracorporeal suturing was performed in all cases but one because a suture needle could be easily inserted through the 12-mm port. Furthermore, total laparoscopic myomectomy could be completed using a 12-mm power mocellator inserted through the 12-mm port. The flexible scope and forceps did not hinder each other either inside or outside of the body cavity. Use of the flexible scope enables the conventional rigid straight forceps to be used in almost the same manner as with the conventional laparoscopic technique.

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.

Peritoneal Vascular Density Assessment Using Narrow-Band Imaging and Vascular Analysis Software, and Cytokine Analysis in Women with and without Endometriosis

The development and onset of endometriosis is associated with angiogenesis and angiogenic factors including cytokines. We analyzed intrapelvic conditions in women with endometriosis via vascular density assessment of grossly normal peritoneum and determination of cytokine levels in peritoneal fluid. Seventy-three patients underwent laparoscopic surgery because of gynecologic disease including endometriosis in our department using a narrow-band imaging system. Each patient was analyzed for peritoneal vascular density using commercially available vascular analysis software (SolemioENDO ProStudy; Olympus Corp, Tokyo, Japan). Each patient was also subjected to analysis of interleukin 6 (IL-6), IL-8, tumor necrosis factor-alpha, and vascular endothelial growth factor concentrations in peritoneal fluid. We defined 4 groups as follows: group 1, endometriosis: gonadotropin-releasing hormone (GnRH) agonist administration group (n=27); group 2, endometriosis: GnRH agonist nonadministration group (n=15); group 3, no endometriosis: GnRH agonist administration group (n=18); and group 4, no endometriosis: GnRH agonist nonadministration group (n=13). No significant differences in peritoneal vascular density between the 4 groups were found under conventional light; however, under narrow-band light, vascular density in the endometriosis groups (groups 1 and 2) was significantly higher. Cytokine analysis of the 4 groups determined that IL-6 and IL-8 concentrations were significantly higher compared with the no endometriosis groups (groups 3 and 4). Tumor necrosis factor-alpha and vascular endothelial growth factor concentrations were not significantly different between groups. In endometriosis, peritoneal vascular density was significantly higher as assessed using the narrow-band imaging system and SolemioENDO ProStudy, whereas GnRH agonist did not obviously decrease vascular density but IL-6 concentration was lower in the GnRH agonist administration group.

Evaluation of factors contributing to uterine scar formation after laparoscopic myomectomy

Objective. To evaluate factors contributing to uterine scar formation after laparoscopic myomectomy (LM) and to estimate whether uterine scarring indicated risk of uterine rupture. Design. Retrospective study. Setting. University‐affiliated hospital. Population. A total of 692 patients who underwent second‐look laparoscopy (SLL) after LM. Method. Video‐tape recording during SLL to evaluate the conditions of uterine suture wound healing, with univariate and logistic regression analysis. Main outcome measures. Correlation between scar formation and operative findings at LM. Factors influencing scar formation in 305 patients with an enucleated solitary myoma. Results. SLL revealed that 628 patients (90.8%) had a normal uterus and 64 patients (9.2%) had a scarred uterus. Deformation of the endometrium found by preoperative imaging and complete myometrial penetration during LM had a positive correlation and the number of enucleated myomas a negative correlation with scar formation. Significant factors associated with scar formation were complete myometrial penetration (odds ratio, 2.53; 95% confidence interval, 1.30–4.93; p = 0.006) and enucleation of a subserosal myoma (odds ratio, 0.23; 95% confidence interval, 0.08–0.70; p = 0.009). Of the 98 patients who delivered, none suffered a uterine rupture regardless of the presence of a uterine scar. Conclusions. Uterine scar formation after LM correlated with the degree of myometrial penetration. However, the presence of a uterine scar did not appear to influence the delivery outcome.