Xuyin Zhang

Acellular porcine small intestinal submucosa graft for cervicovaginal reconstruction in eight patients with malformation of the uterine cervix

STUDY QUESTION Can surgical reconstruction of the cervix and vagina in patients be achieved using an acellular porcine small intestinal submucosa (SIS) graft? SUMMARY ANSWER Our experiences of combined laparoscopic and vaginal cervicovaginal reconstruction using an SIS graft in eight patients were positive, with successful reconstruction and no complications, cervical stenosis or vaginal stenosis. WHAT IS KNOWN ALREADY In patients with agenesis and dysgenesis of the uterine cervix and vagina, surgical reconstruction of the internal genitalia is a challenging problem for gynecologists. Hysterectomy with the creation of an artificial vagina was the treatment of choice in the 1990s. Recently, conservative management has been gradually adopted to avoid extirpation of the uterus, including the canalization techniques, the uterovaginal anastomosis and the reconstruction of cervical and vaginal agenesis with some autologous tissues. STUDY DESIGN, SIZE, DURATION This prospective observational study from January 2012 to March 2013 included 8 patients aged 10-18 years with malformation of the cervix (1 with cervical agenesis, 1 with a cervical body consisting of a fibrous band and 6 with obstruction of the cervical os) and vagina (4 with complete vaginal aplasia and 4 with a 1-3 cm long vaginal pouch) diagnosed by physical examination and magnetic resonance imaging. PARTICIPANTS/MATERIALS, SETTING, METHODS Eight patients underwent combined laparoscopic and vaginal cervicovaginal reconstruction using an SIS graft during the end of menstruation. A T-shaped intrauterine device connected with a 14-French Foley catheter was inserted into the uterine cavity to keep the newly created cervix patent, and then a permanent lower uterine cerclage was placed. Patients were assessed post-operatively at 1, 2, 4, 6, 12 and 15 months, and data on menstruation and the morphology of the neovagina and cervix were recorded. MAIN RESULTS AND THE ROLE OF CHANCE The mean ± SD age of the patients was 14.5 ± 2.8 (10-18) years. All patients had a history of cyclic abdominal pain, and the average delay in diagnosis was 4.5 ± 4.0 (0-12) months. One patient had a previous history of unsuccessful attempt at canalization and two post-operative hematometra drainages before referral. The mean operating time was 201 ± 67 (120-330) min, with a mean estimated blood loss of 157 ± 154 (30-500) ml. The first case was converted to laparotomy, and the others were successfully completed. None of the patients had a complication or required blood transfusion. All the patients showed resumption of menstruation. The patients were followed for 8 ± 4 (4-15) months, and no cervical or vaginal stenosis occurred in any of the cases. LIMITATIONS, REASONS FOR CAUTION The sample size of this study was small. A larger study that compared this method with previous techniques regarding the complication and success rates would increase the value of the study. WIDER IMPLICATIONS OF THE FINDINGS A combined laparoscopic and vaginal cervicovaginal reconstruction with an SIS graft is a potential alternative to the management of congenital agenesis and dysgenesis of uterine cervix and vagina. STUDY FUNDING/COMPETING INTEREST(S) The work was supported by National Key Clinical Faculty Construction Program of China. No competing interests are declared.

Comprehensive Assessment of the Impact of Laparoscopic Ovarian Cystectomy on Ovarian Reserve

STUDY OBJECTIVE To evaluate the effects of laparoscopic cystectomy of endometrioma and nonendometrioma ovarian cyst on ovarian reserve. DESIGN Prospective follow-up study of patients after laparoscopic ovarian cystectomy (Canadian Task Force II-2). SETTING Academic hospital. PATIENTS Seventy patients underwent laparoscopic ovarian cystectomy, with bilateral endometrioma (n = 21), unilateral endometrioma (n = 29), and unilateral other benign ovarian cyst (n = 20) from February 2011 and May 2012. The control group (n = 20) comprised patients treated with laparoscopic myomectomy or laparoscopic hydrotubation and fimbrioplasty at the same time period. INTERVENTIONS All laparoscopic operations were applied by suture homeostasis. Ovarian reserve was assessed by serum levels of anti-Müllerian hormone (AMH) and follicle-stimulating hormone (FSH) and by antral follicle count (AFC), ovarian volume, ovarian stromal pulsatility index, and resistance index on the third day of menstruation preoperatively and in postoperative months 1.6 and 12. MEASUREMENTS AND MAIN RESULTS FSH levels increased significantly but the AMH and AFC levels declined significantly in the bilateral endometrioma group at 1 month postoperatively compared with preoperative levels (p < .05) but did not differ significantly at 6 and 12 months postoperatively. The ovarian stromal pulsatility and resistance indices in the ipsilateral ovaries decreased significantly in all patients with unilateral ovarian cysts at 6 and 12 months postoperatively compared with preoperative levels (p < .05), although the mean ipsilateral ovarian volume was significant smaller than the unaffected side. CONCLUSION There was no detectable difference on ovarian reserve marker levels between 4 groups and from baseline values at 6 and 12 months after laparoscopic ovarian cystectomy of endometrioma, although these levels significantly declined in the first month postoperatively.

Sexual and functional outcomes of vaginoplasty using acellular porcine small intestinal submucosa graft or laparoscopic peritoneal vaginoplasty: a comparative study

STUDY QUESTION Can vaginoplasty in patients with Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS) be achieved using an acellular porcine small intestinal submucosa (SIS) graft? SUMMARY ANSWER Vaginoplasty using SIS graft was successfully achieved in women with MRKHS, and the anatomical and functional outcomes of this procedure were comparable to those of laparoscopic peritoneal vaginoplasty. WHAT IS KNOWN ALREADY There is a great variety of vaginal reconstruction techniques, which suggests there is no single superior surgical technique. STUDY DESIGN, SIZE, DURATION This prospective observational study included 34 patients with congenital vaginal agenesis who underwent vaginoplasty using SIS graft (the SIS group) between December 2011 and July 2013, and 41 patients with the same disease who underwent laparoscopic peritoneal vaginoplasty (the Davydov group) between January 2008 and July 2013. PARTICIPANTS/MATERIALS, SETTING, METHODS Patient and surgical data, follow-up information, and the female sexual function index (FSFI) scores in the two groups were analysed and compared. MAIN RESULTS AND THE ROLE OF CHANCE Compared with the laparoscopic Davydov procedure, the operating time of vaginoplasty using SIS graft was significantly shorter, and the estimated blood loss was significantly less. Patients in the SIS group had an earlier return of bowel activity, and an earlier return to work. However, the total cost in the SIS group was significantly higher than that in the Davydov group due to the cost of the SIS graft (

Vaginoplasty Using Acellular Porcine Small Intestinal Submucosa Graft in Two Patients with Meyer-von-Rokitansky-Küster-Hauser Syndrome: A Prospective New Technique for Vaginal Reconstruction

3525 per graft). Most patients (28/34 in the SIS group and 37/41 in the laparoscopic Davydov group) returned for their follow-up 9 months post-surgery. The mean length of the neovagina in the SIS group seemed slightly shorter than that in the Davydov group (6.8 ± 0.9 cm versus 7.3 ± 1.3 cm, P = 0.081). Thirteen patients (46%) in the SIS group and 11 (29%) in the Davydov group had a neovagina <7 cm long (P = 0.453), whereas 4 patients (14%) in the SIS group and 3 patients (8%) in the Davydov group had a neovagina <6 cm long (P = 0.201). Sixteen patients in the SIS group and 25 in the Davydov group subsequently had a sexual partner and became sexually active. Four patients in the SIS group and six in the Davydov group reported low total FSFI scores (≤23). There was no statistically significant difference in the total FSFI scores and the scores of all six domains of the FSFI between the two groups. The average time of continuous mould wearing in the SIS group was statistically significantly longer than that in the Davydov group (7.8 ± 3.3 months versus 4.8 ± 1.6 months, P = 0.001). In the patients with a neovaginal length of ≥6 cm, the FSFI score of the women (26.6 ± 2.3 versus 21.5 ± 1.5, P < 0.001) and the satisfactory score of their partner (8.6 ± 1.2 versus 6.6 ± 1.2, P < 0.001) were both statistically significantly higher than patients with a neovaginal length of <6 cm. LIMITATIONS, REASONS FOR CAUTION The main limitation of this study is that it is non-randomized. Further randomized studies are warranted to compare the effects of these two procedures. WIDER IMPLICATIONS OF THE FINDINGS Despite the need to wear a mould for longer, vaginoplasty using SIS graft provides an attractive, alternative treatment for women with MRKHS. STUDY FUNDING/COMPETING INTERESTS This study was supported by the Chinese National Nature Sciences Foundation (grant number 81471416) and the National Key Clinical Faculty Construction Program of China. No competing interests are declared. TRIAL REGISTRATION NUMBER N/A.

Prospective evaluation of five methods used to treat cesarean scar defects

The objective of this case study is to present our experience of a surgical approach for vaginal agenesis using an acellular porcine small intestinal submucosa (SIS) graft. The present report involved 2 patients diagnosed as having vaginal agenesis due to Meyer-von-Rokitansky-Küster-Hauser syndrome. The operation procedure involved the creation of a neovaginal tunnel and then a mold wrapped with the SIS graft was placed in the neovagina. The duration of surgery was less than 45 min with minimal blood loss and no operative and postoperative complications. Epithelialization of the neovagina was achieved within 2 months after surgery. The neovagina created with this procedure was the same as that of a normal adult vagina histologically and physiologically. In conclusion, the creation of a neovagina using a SIS graft resulted in a favorable outcome and this approach may be a potential alternative to the management of vaginal agenesis.

FSH stimulates expression of the embryonic gene HMGA2 by downregulating let-7 in normal fimbrial epithelial cells of ovarian high-grade serous carcinomas.

To evaluate operative and nonoperative therapies for cesarean scar defects (CSDs).

Hormone receptors expression in ovarian cancer taking into account menopausal status: a retrospective study in Chinese population

FSH may increase the risk of ovarian malignancy and play a key role in ovarian carcinogenesis, although the mechanism(s) are undefined. HMGA2 overexpression has been observed to be an early genetic event in tumorigenesis. The present study was designed to investigate the effect of FSH on let-7, HMGA2 and p53 expression in normal fimbrial epithelial cells of ovarian high-grade serous carcinomas (HGSCs). A primary human Fallopian tube (FT) fimbrial epithelium ex vivo culture system of low-grade serous carcinomas (LGSCs) and HGSCs was established. The levels of HMGA2, let-7, p53 and FSHR were evaluated by western blotting and reverse transcription (RT)-PCR. Treatment with FSH significantly increased HMGA2 expression in a time-dependent manner and the let-7 expression levels decreased gradually over time in the normal fimbrial epithelial cells of HGSCs. However, we did not observe similar results in LGSCs. In addition, knockdown of let-7 suppressed HMGA2 expression. p53 was not detected in the normal fimbrial epithelial cells before or after FSH administration. Our results indicate that FSH increases the expression of HMGA2 by downregulating the expression of let-7 in normal fimbrial epithelial cells of HGSCs, but no occurrence of p53 mutation. The susceptibility of fimbria to FSH in HGSCs compared with those in LGSCs is different.

Uterus Preserving Reposition of Non-Puerperal Uterine Inversion under Laparoscope: A Case Report and Literature Review

Ovarian cancer is a major gynaecological cancer with different subtypes and studies have suggested that estrogen receptor (ER) or progesterone receptor (PR) positivity are associated with better clinical outcomes. Furthermore, the clinical outcomes of ovarian cancer are better in Asian compared to Caucasian. To date, studies investigating the ER or PR positivity in all subtypes of ovarian cancer, including borderline epithelial, are limited. In this retrospective study we investigated ER and PR positivity in Chinese women with malignant epithelial ovarian cancer (n=577), sex cord-stromal tumor (n=26) and borderline epithelial ovarian cancer (n=98) taking into account menopausal status. The positivity of ER (>85%) or PR (>58%) was higher in serous and endometrioid carcinoma of malignant epithelial ovarian cancer than that in mucinous and clear-cell carcinoma (<19% of ER or 24% of PR). The majority of serous carcinomas of borderline epithelial ovarian cancerwere ER or PR positive, but in contrast less than 33% of mucinous carcinomas of borderline epithelial ovarian cancerswere ERor PR positive.Furthermore, there was no association between the ER or PR positivity and menopausal status in both malignant and borderline epithelial ovarian cancer. We also found that the age at diagnosis with ovarian cancer was younger in Chinese women. Our data suggest that ER or PR positivity in Chinese women with ovarian cancer is similar to that of other ethnicities reported in literature, suggesting that the better clinical outcomes seen in Asian may be associated with other factors such as age at diagnosis of ovarian cancer.

Laparoendoscopic Single Site Myomectomy: Without the Use of a Single Port Access Device

Non-puerperal uterine inversion is a rare clinical condition. Surgical procedures described in literature were mostly repositioning of the uterus followed by hysterectomy and laparotomy. In this paper, we reported a case of successful uterus preserving reposition of non-puerperal uterine inversion under laparoscopy. The patient, a 34-year-old, was presented with irregular vaginal bleeding with a mass protruding. On laparoscopy, the anterior wall of the uterus was opened longitudinally to release the thick ring of cervical tissue. The uterus was then repositioned and the anterior wall of the uterus was closed by stitches with two layers. Antibiotics was used for 6 days to prevent infection. The patient recovered well and retrieved menstruation 1 month after surgery.

The role of oral oil administration in displaying the chylous tubes and preventing chylous leakage in laparoscopic para-aortic lymphadenectomy: ZHOU et al.

Objective: Herein we described our experience with laparoendoscopic single site mymectomy (LESS-M) without the use of a single port access device and compared the clinical outcomes between LESS-M and conventional laparoscopic mymectomy (LM). Methods: From January 2012 to December 2014, 32 patients with leiomyomas underwent LESS-M in our hospital were enrolled in this prospective observational case-control study, and were 1:1 matched and compared with 32 patients who underwent LM by the same operative team for leimyomas of similar size and location. Patients and surgical data, and follow-up information were analyzed. Results: The operating time in the LESS-M group was significantly longer than that in the LM group (98 ± 9 min vs 56 ± 7 min, P=0.000), but the patients returned to work significantly earlier (2.9 ± 0.5 week vs 3.7 ± 1.1, P=0.001), and the cosmetic satisfaction score was significantly higher (9.3 ± 0.6 vs 8.4 ± 0.7, P=0.000). There was no significant difference of the mean intraoperative blood loss, hemoglobin change, return of bowel activity, postoperative fever, operation cost and total cost between the two groups. Conclusion: LESS-M is a feasible, safe, and efficacious procedure with shorter recovery and increased cosmetic satisfaction in selected patients with leiomyoma, and it can be cost-effectively performed without the need for a single port access device.