Yu-Jin Koo

Pregnancy Outcomes and Risk Factors for Uterine Rupture After Laparoscopic Myomectomy: A Single-Center Experience and Literature Review.

STUDY OBJECTIVE To evaluate pregnancy outcomes after laparoscopic myomectomy (LSM), focusing on the risk of uterine rupture. DESIGN Retrospective cohort study (Canadian Task Force classification III). SETTING University hospital. PATIENTS Of 676 women who visited the obstetrics department for a pregnancy after undergoing LSM performed at the same center between 1994 and 2012, we included the 523 women who had follow-up through the end of pregnancy. INTERVENTIONS All patients underwent LSM, and their medical charts were retrospectively reviewed. MEASUREMENTS AND MAIN RESULTS Multiple myomas were removed in 35.2% of cases, intramural-type lesions occurred in 46.5% of cases, and the mean myoma diameter was 4.9 cm. Pregnancy outcomes after LSM included 400 (76.5%) full-term deliveries and 100 (19.1%) vaginal deliveries, with other adverse outcomes being no different than the general population. The mean interval between LSM and pregnancy was 14 months, and only 3 (0.6%) cases of uterine rupture occurred during pregnancy. In analysis, by reviewing the published cases of uterine rupture, we found that the mean diameter, myoma number and type, and the rate of uterine suture were similar between the ruptured cases and all of our cases of LSM. CONCLUSION LSM can be safely used in women of reproductive age who want to become pregnant. Uterine rupture occurs in rare cases, regardless of myoma features, but further large-scale studies are required to ascertain the detailed effects of various surgical techniques.

Treatment for Postoperative Wound Pain in Gynecologic Laparoscopic Surgery: Topical Lidocaine Patches

BACKGROUND This article reports our early experience with the use of lidocaine patches for pain control in the immediate postoperative period after laparoscopic gynecologic surgery. SUBJECTS AND METHODS A prospective, double-blind, placebo-controlled clinical trial was conducted on 40 patients undergoing a gynecologic laparoscopy who were randomized to receive either topical patches of 700 mg of lidocaine (n=20) or placebo patches (n=20). The patch was divided evenly into four smaller patches, which were applied at the four port sites and changed every 12 hours for 36 hours after surgery. Postoperative pain was evaluated using the visual analog scale (VAS) score and the Prince Henry and 5-point verbal rating pain scale (VRS), and the analgesic requirement was also evaluated at 1, 6, 12, 24, and 36 hours after surgery. RESULTS The VAS score for wound pain was lower in the lidocaine patch group at 1 and 6 hours after surgery than the control group (P=.005 and <.0005, respectively). The VAS scores for postoperative pain were lower in the lidocaine patch group at rest 1 hour after surgery (P=.045). The 5-point VRS score for postoperative pain was lower in the lidocaine patch group at 6 and 12 hours after surgery (P=.015 and .035, respectively) than in the control group. CONCLUSIONS Topical lidocaine patches at the laparoscopic port sites reduced postoperative pain, particularly postoperative wound pain after gynecological laparoscopic procedures.

Laparoendoscopic single-site surgery versus conventional laparoscopic surgery for adnexal tumors: A comparison of surgical outcomes and postoperative pain outcomes

The objective of this study was to show the feasibility of laparoendoscopic single‐site surgery (LESS) by comparing the surgical outcomes and postoperative pain of LESS with conventional laparoscopic surgery (CLS) for gynecologic adnexal tumor. This is a prospective case–control study. We enrolled 33 patients—one in 18 patients for LESS and the other in 15 patients for CLS—who were diagnosed with evident adnexal tumor consecutively from September 2009 to February 2010 and were performed by a single surgeon. In LESS, all procedures were performed successfully without any case of conversion to CLS. There were no differences in the demographic characteristics between the two groups. The pathological findings were similar in both groups; a mucinous cystadenoma was the most common pathological feature. The most common operative type performed was cystectomy (22/33, 66%). There were no differences between the LESS and CLS groups in median operation time (62.8 minute vs. 51.3 minutes, p = 0.073); estimated blood loss during operation (100 mL vs. 128 mL, p = 0.068); and postoperative pain intensity measured by visual analog scale. There were no major complications in either group, including operative wound complications. Our study suggested that LESS for adnexal tumor is a feasible surgical technique through the comparable data of the surgical outcomes and postoperative pain outcomes.

Mature cystic teratoma of the uterosacral ligament successfully treated with laparoendoscopic single-site surgery.

OBJECTIVE Although the majority of teratomas are encountered in the ovary, extragonadal mature cystic teratoma is an unusual disease entity, and the most common site is the omentum. CASE REPORT The occurrence of this tumor on a uterosacral ligament is extremely rare with enigmatic etiology. To our knowledge, there have been only three cases reported to date that describe a mature cystic teratoma of the uterosacral ligament, and this is the first report of successful treatment of these rare tumors with laparoendoscopic single-site surgery (LESS). CONCLUSION In the present study, we report a mature cystic teratoma of the uterosacral ligament successfully treated with LESS in a 34-year-old woman with a preoperative diagnosis of mature cystic teratoma of the left ovary.

Ovarian gonadoblastoma with dysgerminoma in a woman with 46XX karyotype

To the Editor: Gonadoblastoma, an uncommon ovarian tumor, almost always arises in sexually abnormal patients who have a pure or mixed gonadal dysgenesis with a Y chromosome. Rarely, gonadoblastomas arise without a Y chromosome, but with various forms of mosaicism and, more exceptionally, a few patients who have a normal 46XX karyotype. Clinically, most gonadoblastoma patients presented with primary amenorrhea and the occurrence of this tumor in fertile women is extremely rare. Here, we report a 34-year-old woman with a gonadoblastoma and 46XX karyotype. Her karyotype was confirmed from peripheral blood samples using quantitativefluorescence polymerase chain reaction (QF-PCR). Although cytogenetic analysis is commonly used as the initial karyotyping method, if Y-chromosome sequences are present in only a few cells, they may be missed in routine analysis. Therefore, we attempted to detect Y chromosomal material from peripheral blood using QF-PCR in a fertile woman with a gonadoblastoma. A 34-year-old woman, para 2, gravida 5, was referred to our hospital for vaginal bleeding in April, 2010. The patient had been having irregular 20 to 45 day menstrual cycles lasting for ten days since menarche at the age of 14. She had a history of two full term deliveries of healthy babies. The patient’s family history and past medical history were unremarkable. On physical examination, pubic hair, external genitalia and breast development appeared normal with no signs of hyperandrogenism, such as hirsutism. Basal endocrine levels, including estradiol and testosterone, and tumor marker levels, including CA-125 and CA 19–9, were also all within normal range. Ultrasonography and computed tomography (CT) revealed a solid lobular mass measuring 12 ¥ 9 ¥ 7 cm in the left ovary. Due to suspicion for a malignant ovarian tumor, laparoscopic left salpingoophorectomy, pelvic and paraaortic lymphadenectomy, and peritoneal cytology were performed. The left ovary was occupied by a gray-yellowish mass with a smooth surface (Fig. 1a), and the contralateral ovary and uterus were normal in appearance. Pathologically, the lymph nodes were negative. The patient was treated with a combination chemotherapy consisting of bleomycin, etoposide, and cisplatin, and follow-up is currently ongoing at seven months after completing three cycles of chemotherapy. The patient’s karyotype was determined to be 46XX from metaphase chromosomes obtained from 20 peripheral blood lymphocytes using the Giemsa, trypsin, Leishman (GTL)banding method as the initial cytogenetic assay. This was confirmed via QF-PCR using genomic DNA extracted from peripheral blood. For PCR amplification, we used a pair of SRY (sex-determining region on the Y chromosome, Yp 11.3) primers (forward: 5′-6FAM-TGGCGATTAAGTCAAATTCGC3′, reverse: 5′-CCCCCTAGTACCCTGACAATGTATT-3′) and a pair of AMXY primers (forward: 5′-6FAM-CCCTGGGCT CTGTAAAGAATAGT-3′, reverse: 5′-ATCAGAGCTTAAACT GGGAAGCTG-3′) from the amelogenin-like DNA sequence AMXY expressed on the X and Y chromosomes. The QF-PCR analysis showed no amplification of the marker SRY, but one peak of amplification of maker AMXY, indicating the presence of X and the absence of Y chromosome. Pathologically, the tumor consisted of a majority of a dysgerminoma with minor components of a gonadoblastoma, which occupied less than 5% of the total tumor mass. Microscopically, the histological findings did not differ from that of a gonadoblastoma with dysgerminoma from a dysgenetic gonad. Large round germ cells with clear cytoplasm and round or oval nuclei were arranged into smaller nests divided by fibrous septa (Fig. 1b). The gonadoblastoma was composed of two main cell types: germ cells and sex-cord stromal derivatives resembling granulosa or Sertoli cells. These cells were arranged into cellular nests surrounded by connective tissue stroma, which occasionally contained elements indistinguishable from lutein or leydig cells. Several gonadoblast nests were disseminated into the connective tissue surrounding the ovarian tissue and dysgerminoma (Fig. 1c). Since Scully first described gonadoblastoma as a separate entity in 1953, approximately 300 cases have been reported. Pathologically, more than 50% of cases of gonadoblastoma are associated with dysgerminoma, and approximately 10% of cases are related to other malignant germ cell tumors such as immature teratoma, yolk sac tumor, embryonal carcinoma or choriocarcinoma. This high rate of coexistence with other malignant tumor is also observed in cases of gonadoblastoma with 46XX karyotype. Among total seven cases of gonadoblastoma with 46XX, four cases were gonadoblastoma with ipsilateral dysgerminoma, one case was gonadoblastoma with contralateral dysgerminoma, and two cases were gonadoblastoma with mixed germ cell tumor. It has been suggested that gonadoblastoma undergo regression by calcification and hyalinization, or overgrowth by malignant germ cell tumors. Katharina et al. in their immunohistochemistry study, showed gonadoblastoma exhibited a stepwise progression from follicular pattern to coronary pattern and finally to dysgerminoma. Thus, gonadoblastoma Pathology International 2011; 61: 171–173 doi:10.1111/j.1440-1827.2010.02636.x

Para-aortic lymphadenectomy for primary fallopian tube cancer.

To investigate the topography of lymph node spread and the need for para‐aortic lymphadenectomy in primary fallopian tube cancer (PFTC).

CXCL11 mediates TWIST1-Induced angiogenesis in epithelial ovarian cancer

To investigate the role of TWIST1 in tumor angiogenesis in epithelial ovarian cancer and to identify key molecules involved in angiogenesis. TWIST1 small interfering RNA was transfected into A2780 cells, while a complementary DNA vector was transfected into non-malignant human ovarian surface epithelial cells to generate a TWIST1-overexpressing cell line. To evaluate how this affects angiogenesis, human umbilical vein endothelial cell tube formation assays were performed using the control and transfected cell lines. An antibody-based cytokine array was used to identify the molecules involved in TWIST1-mediated angiogenesis. After knockdown of TWIST1 via transfection of TWIST1 small interfering RNA into A2780 cells, the number of tubes formed by human umbilical vein endothelial cells significantly decreased in a tube formation assay. In a cytokine array, TWIST1 downregulation did not significantly decrease the secretion of the common pro-angiogenic factor, vascular endothelial growth factor, but instead inhibited the expression of the CXC chemokine ligand 11, which was confirmed by both an enzyme-linked immunosorbent assay and western blotting. In contrast, TWIST1 overexpression resulted in increased secretion of CXC chemokine ligand 11. Conversely, CXC chemokine ligand 11 downregulation did not inhibit the expression of TWIST1. Furthermore, the ability of TWIST1-expressing A2780 cells to induce angiogenesis was found to be inhibited after CXC chemokine ligand 11 knockdown in a tube formation assay. TWIST1 plays an important role in angiogenesis in epithelial ovarian cancer and is mediated by a novel pro-angiogenic factor, CXC chemokine ligand 11. Downregulation of CXC chemokine ligand 11 can inhibit tumor angiogenesis, suggesting that anti–CXC chemokine ligand 11 therapy may offer an alternative treatment strategy for TWIST1-positive ovarian cancer.

Clinical indications for hysteroscopic removal of uterine masses: Time, age at diagnosis, and mass size

The aim of this study was to investigate clinical factors associated with abnormal pathologies of uterine masses resected via hysteroscopy.

Efficacy of Poly-Gamma-Glutamic Acid in Women with High-Risk Human Papillomavirus-Positive Vaginal Intraepithelial Neoplasia: an Observational Pilot Study.

Poly-gamma-glutamic acid (γ-PGA) is a natural polymer that is synthesized by Bacillus species and has been reported to have antitumor activity. The aim of this study was to investigate the effect of γ-PGA on the treatment of vaginal intraepithelial neoplasia (VAIN). A retrospective observational study on γ-PGA therapy for biopsy-proven VAIN was conducted. The efficacy was assessed by evaluating the results of Pap cytology and the viral load of high-risk HPV at three time points: at enrollment, and at the first and second post-treatment visits. Of 17 patients treated with γ-PGA, only 12 patients who had a high-risk HPV infection were included in the analysis. Histology was VAIN1 in seven patients, VAIN2 in two patients, and VAIN3 in three patients. γ-PGA was administered for newly diagnosed VAIN in five (41.7%) patients and persistent VAIN in seven (58.3%) patients for the mean time of 4.5 months. At the first and second post-treatment visits, cytological regression was observed in five (41.7%) and six (50%) patients, respectively. Regarding the HPV load, the overall response rate was 66.7%, and the mean level was 670.6 ± 292.5 RLU at the first follow-up, which was lower than the initial viral load of 1,494.8 ± 434.5 RLU (p = 0.084). At the second follow-up, the overall response rate was 58.3%, and the mean viral load level was 924.2 ± 493.7 RLU. γ-PGA may be helpful for the cytological regression and reduction of viral load in patients with high-risk HPV-positive VAIN, suggesting that γ-PGA is a promising treatment option for primary or persistent VAIN.

Successful delayed-interval delivery performed 128 days after the vaginal delivery of the first fetus in a twin pregnancy

There has been a significant increase in the number of multiple pregnancies that are associated with a high risk of preterm delivery among Korean women. However, to date, delayed-interval delivery in women with multiple pregnancy is rare. We report a case of delayed-interval delivery performed 128 days after the vaginal delivery of the first fetus in a dichorionic diamniotic twin pregnancy. The patient presented with vaginal leakage of amniotic fluid at 16 weeks of gestation and was diagnosed with a preterm premature rupture of membranes. Three days later, the first twin was delivered, but the neonate died soon after. The second twin remained in utero, and we decided to retain the fetus in utero to reduce the morbidity and mortality associated with a preterm birth. The patient was managed with antibiotics and tocolytics. Cervical cerclage was not performed. The second twin was delivered vaginally at 34 weeks and 5 days of gestation, 128 days after the delivery of the first-born fetus. This neonate was healthy and showed normal development during the 1-year follow-up period. Based on our experience with this case, we propose that delayed-interval delivery may improve perinatal survival and decrease morbidity in the second neonate in highly selected cases.