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   Table of Contents - Current issue
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October-December 2019
Volume 8 | Issue 4
Page Nos. 143-199

Online since Thursday, October 24, 2019

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REVIEW ARTICLE  

Current treatments for female pelvic floor dysfunctions p. 143
Mun- Kun Hong, Dah- Ching Ding
DOI:10.4103/GMIT.GMIT_7_19  
As global population aging, the issue of pelvic floor dysfunctions becomes increasingly. Millions of women were affected every year. The treatment of pelvic floor dysfunction has evolved in the past decade. This review aims to provide the current information on the treatment for female pelvic floor dysfunction, including pelvic organ prolapse (POP), urinary, fecal incontinence (FI), and myofascial pelvic pain among women. We used PubMed, Embase, and Web of Science to search for studies that were related to pelvic floor dysfunction regarding the POP, urinary, FI, and treatments. The development of laparoscopic surgery and synthetic and biological materials for pelvic floor reconstructive surgery were summarized. The surgical outcomes and complications of different pelvic floor reconstructive surgeries were compared. New devices for FI and the potential modified pelvic floor reconstructive surgery were also discussed here. Female pelvic medicine will continue to evolve for better treatment in the future. The pelvic floor reconstructive surgery tends to be minimally invasive approach with synthetic graft use.
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ORIGINAL ARTICLES Top

The management of heterotopic pregnancy with transvaginal ultrasound-guided local injection of absolute ethanol p. 149
Conghui Liu, Hong Jiang, Feng Ni, Ying Liu, Wenxiang Zhang, Cuie Feng
DOI:10.4103/GMIT.GMIT_4_19  
Aims: The aim of the study is to present five cases of heterotopic pregnancy (HP) patients who received transvaginal ultrasound-guided local injection of absolute ethanol (AE). Settings and Design: This was a case series and literature review in Reproductive Medicine Center of the 105th Hospital of the People's Liberation Army. Materials and Methods: Five primary infertile women who underwent assisted reproductive technology were diagnosed with HP and treated with local injection of AE (1.0–2.5 ml) under transvaginal ultrasound guidance. The size of intrauterine (IU) and ectopic sacs and the level of serum beta-human chorionic gonadotropin as well as pregnancy outcomes were monitored after treatment. Statistical Analysis Used: Not applicable. Results: Four of five cases presented with lack of Doppler flow in the injected area after AE injection. Meanwhile, IU pregnancy proceeded well after treatment and delivered a normal newborn. One case received emergency surgery 3 h after local injection of 2.5 ml AE because of the rupture of ectopic gestational sac (GS). An early abortion was identified 7 days after the surgery. Conclusions: Transvaginal ultrasound-guided local injection of AE is an alternative nonsurgical treatment for HP, yet overdose injection of AE will increase the risk of ectopic GS rupture.
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Comparison between laparoendoscopic single-site and conventional laparoscopic surgery in mature cystic teratoma of the ovary p. 155
Myeong Seon Kim, Chel Hun Choi, Jeong- Won Lee, Byoung- Gie Kim, Duk- Soo Bae, Tae- Joong Kim
DOI:10.4103/GMIT.GMIT_3_19  
Objective: The objective of the study is to compare the intra- and post-operative outcomes of laparoendoscopic single-site surgery (LESS) and conventional laparoscopic surgery (CLS) in mature cystic teratoma (MCT) of the ovary. Methods: We reviewed 254 patients who underwent surgery (cystectomy) for ovarian MCT from March 1, 2014, to August 31, 2016. During the study period, 216 patients underwent LESS and 38 patients underwent CLS. The outcome measures included operation time, estimated blood loss, changing hemoglobin (Hb) level, postoperative pain, and complications. Statistical analysis was performed using SPSS 24. Results: There was no statistically significant difference in age, body mass index, sexual experience, cyst size, operative time, adhesiolysis, preoperative Hb, Hb changes, postoperative pain scores (visual analog scale), hospital days, and complications between the two groups. In emergent situation, the frequency of CLS was high as three cases (7.9%) versus one case (0.5%, P = 0.007) with LESS. As the year progressed, the frequency of LESS increased. There were one case of re-operation for bleeding control and transfusion, one case of postoperative peritonitis and transfusion, and one case of postoperative transfusion in LESS. During LESS, additional port(s) was/were created in 13 cases (6.0%, P = 0.249). Conclusions: LESS is not inferior to CLS in MCT surgery, and LESS is useful for the surgery of MCT. Our study demonstrates that LESS confers feasibility, convenience, and safety regarding cystectomy of MCT.
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Deep sedation or paracervical block for daycare gynecological procedures: A prospective, comparative study p. 160
Nishant Sahay, Mukta Agarwal, Mamta Bara, Nutan Raj, Divendu Bhushan
DOI:10.4103/GMIT.GMIT_12_19  
Context: Many minor gynecological procedures are done for diagnostic and therapeutic reasons. A balance has to be struck between ability to discharge a patient at the earliest with minimum procedure-related discomfort to ensure patient safety as well as satisfaction. Aim: This prospective randomized study was designed to compare deep sedation versus paracervical block for minor gynecological surgeries comparing the time to discharge readiness, pain after the procedure, and overall patient satisfaction. Setting and Design: This prospective randomized comparative study was conducted at a tertiary level hospital after institutional ethics committee approval and registry of trial at CTRI (India). Methods: Seventy young women underwent minor gynecological procedures under these two modes of anesthesia. Time to discharge readiness from hospital to home was assessed using modified postanesthesia discharge score system (PADSS). Pain after procedure as well as patient satisfaction was evaluated. Patients were also asked whether they would recommend the same anesthetic technique for the procedure in the future. Answers were noted on a Likert scale. Results: Patients were ready to be discharged faster in deep sedation group compared to paracervical block group based upon modified PADSS score (1 h 9.6 min vs. 1 h 18 min) (P = 0.005). Pain in the perioperative period was analyzed using repeated-measures ANOVA and found to be significantly lesser in deep sedation group when considered till 80 min after surgery. The mean satisfaction score in patients who underwent deep sedation was 91.24 (standard deviation [SD] 2.8) compared to patients given paracervical block which was low at 64.67 (SD 15.8). All patients given deep sedation were ready to recommend the anesthesia technique as compared to only 53.3% of patients who were given paracervical block. Conclusions: Deep sedation may be preferred over paracervical block for daycare minor gynecological procedures.
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Evaluation of uterine artery embolization on myoma shrinkage: Results from a large cohort analysis p. 165
Talshyn Ukybassova, Milan Terzic, Jelena Dotlic, Balkenzhe Imankulova, Sanja Terzic, Fariza Shauyen, Simone Garzon, Luopei Guo, Long Sui
DOI:10.4103/GMIT.GMIT_50_19  
Objective: There are still contradictory opinions on the success rates of uterine artery embolization (UAE) for the treatment of myomas. In this scenario, our study aims to assess the effect of UAE on myoma shrinkage. Materials and Methods: The study included 337 women in reproductive age affected by a single symptomatic intramural myoma and declined surgery, undergoing UAE. The uterus and myoma diameters and volumes were determined on ultrasonographic scans before and 3, 6, and 12 months after the procedure. Results: The mean uterine volume before intervention was 226.46 ± 307.67 mm3, whereas myoma volume was 51.53 ± 65.53 mm3. Further myoma progression was registered in only four patients. In remaining women, uterus volume in average decreased for 149.99 ± 156.63 mm3, whereas myomas decreased for 36.57 ± 47.96 mm3. The mean volume reduction rate of the uterus was 49.54 ± 35.62 and for myoma was 57.58 ± 30.71. A significant decrease in both uterine and myoma volume was registered in every stage of the follow-up. The highest average decrease in uterine volume was in the first 3 months and myoma volume between 3 and 6 months following UAE. After 12 months follow-up, successful outcome (volume regression >50% respect to the baseline) was registered for uterus in 97.4% and for myoma in 67.9% of investigated patients. Conclusion: UAE was proven to allow a good success rate and can be considered as an effective alternative procedure for myoma treatment.
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CASE REPORTS Top

Laparoscopic Repair for Vesicoperitoneal Fistula with Vesicouterine Abscess p. 172
Tamaki Yahata, Eiji Boshi, Kazuhiko Ino, Takenori Nishi
DOI:10.4103/GMIT.GMIT_82_18  
Vesicoperitoneal fistula (VPF) is a rare form of urogenital fistulas. It is usually associated with an accidental trauma or iatrogenic injury including postoperative complications. Although it is difficult to heal the fistula conservatively, a laparoscopic repair is one of the effective methods. We report a case of VPF with vesicouterine abscess and repaired it laparoscopically. The transvaginal sonography showed the vesicouterine abscess, and a cystoscopy revealed a fistula between the vesicouterine abscess and the bladder. The abovementioned condition was confirmed at the time of laparoscopic surgery, and the fistula tract was closed laparoscopically.
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Incidental finding of an accessory ovary at laparoscopic surgery p. 176
Toshio Fujimoto, Keiko Tanaka, Kyoko Yamada, Kenji Shimahata
DOI:10.4103/GMIT.GMIT_92_18  
An accessory ovary is one of the rare gynecologic abnormalities of the female genital tract. The etiology of accessory ovary has been reported to be acquired origin, such as postsurgical or postinflammatory implants, and true embryologic origin. However, as in the present case with unremarkable medical history and no urogenital abnormalities, there are accessory ovaries that cannot be explained by these etiologies. In such cases, the etiology of accessory ovary might possibly be torsion of functional ovarian cyst during the fetal period or asymptomatic torsion of the functional ovarian cyst at some time after birth.
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Extragonadal giant endometrial cyst with endometrioid borderline tumor p. 179
Hiroyuki Yazawa, Karin Imaizumi, Asami Kato, Kaoru Takiguchi
DOI:10.4103/GMIT.GMIT_85_18  
We describe an extremely rare case of a borderline tumor arising from an extragonadal giant endometrial cyst. A 41-year-old woman complaining of abdominal pain was referred to our hospital with a diagnosis of large ovarian tumor. Magnetic resonance imaging revealed a large cystic tumor approximately 27 cm × 9 cm in area. The cyst contents were largely removed by suction, and then the tumor was resected laparoscopically. Both adnexa were normal in size and location. The tumor did not originate from the ovaries, and it was adherent only to the bilateral uterosacral ligaments and uterine body. The postoperative histopathological evaluation confirmed the presence of endometrioid borderline tumor with transition from endometriosis. Staging laparotomy was performed, and no remnant tumor was detected. This case is extremely unusual because such a large cystic tumor originating from extragonadal endometriosis is very rare, as is endometrioid borderline tumor arising from endometriosis.
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Successful pregnancy outcome immediately after methotrexate treatment for cesarean section scar pregnancy p. 185
Ibrahim A Abdelazim, Mohannad Abu-Faza, Gulmira Zhurabekova, Svetlana Shikanova, Sakiyeva Kanshaiym, Bakyt Karimova, Mukhit Sarsembayev, Tatyana Starchenko
DOI:10.4103/GMIT.GMIT_134_18  
A 27-year-old cesarean section scar pregnancy (CSSP) case diagnosed by the vaginal ultrasound which showed gestational sac located in the lower uterine anterior quadrant close to the site of the previous scars (with yolk sac inside) with β-hCG 15,373 mIU/ml in September 2017 was managed by intramuscular (IM) multidose methotrexate (MTX). The studied woman discharged home when the β-hCG decreased to 11,630 mIU/ml on the 1st week after the first MTX dose. On the 5th week after the first dose of IM-MTX, the β-hCG dropped to zero and the gestational sac completely disappeared. She was counseled about the risk of pregnancy in the first 6 months after the MTX and the possibility of the CSSP recurrence. She presented on December 16, 2018, with preterm delivery at 35 weeks' gestation. After delivery, her neonate admitted to the neonatal intensive care unit (NICU) due to mild respiratory distress and discharged from the NICU on the 4th day in good condition. Multi-dose MTX regimen for the treatment of CSSP supported by many authors with follow-up by β-hCG and vaginal ultrasound. This report highlights the successful outcome immediately after the proper management of CSSP cases.
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A case of synchronous primary corpus and ovarian cancer with pseudo-meigs syndrome: Utilization of a diagnostic laparoscopy for the accurate diagnosis p. 188
Shimpei Shitanaka, Koji Yamanoi, Jumpei Ogura, Tsutomu Ohara, Yoshihide Inayama, Takahiro Hirayama, Mie Sakai, Haruka Suzuki, Koji Yasumoto, Koh Suginami
DOI:10.4103/GMIT.GMIT_18_19  
We report a case of synchronous primary corpus and ovarian cancer (SPC) with massive ascites due to Pseudo-Meigs syndrome (PMS). A 48-year-old woman presented with complaints of abnormal genital bleeding and abdominal discomfort. Massive ascites and tumors in the endometrium and right ovary were detected. Although imaging tests showed no evidence of dissemination, and ascites cytology was negative, we performed a diagnostic laparoscopy to exclude the possibility of microdissemination because pathological findings of the corpus tumor were suggested to be so-called Type-2 endometrial cancer. Laparoscopy clearly confirmed no dissemination in the peritoneum. We ultimately diagnosed this patient with SPC with massive nonmalignant ascites due to PMS and performed an appropriate treatment. This report is the first case of SPC that developed PMS.
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CLINICAL IMAGES Top

Hysteroscopic intrauterine adhesiolysis resulting in positive reproductive outcome p. 192
Pooja Choudhary, Vinita Singh
DOI:10.4103/GMIT.GMIT_126_18  
Intrauterine adhesions (IUA) following any less invasive uterine procedure like curettage or due to genital tuberculosis can lead to partial or complete dysfunction of the endometrium due to adhesions and uterine scarring with impairment of fertility and menstruation and also recurrent pregnancy loss. Therefore, hysteroscopic adhesiolysis was beneficial in this case in restoring fertility, and hence, the introduction of hysteroscopy has definitely improved the fertility outcome and positive reproductive outcome. This is a case report of a 28-year-old infertile woman with IUA leading to bilateral corneal block following dilatation and curettage who conceived after hysteroscopic adhesiolysis.
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The application of uterine artery occlusion combined with uterine–vaginal nerve block technique in patients with adenomyosis p. 194
Guihai Ai, Lu Ding, Ning Luo, Zhongping Cheng
DOI:10.4103/GMIT.GMIT_115_18  
Adenomyosis is a commom gynecological disease, which affects women from 30 to 50 years old with the symptoms of dysmenorrhea or menorrhagia. In the past, we always use hysterectomy to treat patients even young women, but now after years of clinical research,we found that the technique of laparoscopic uterine artery occlusion (LUAO) combined with uterine–vaginal nerve blockade would have a good near- and long-term effects on patients with adenomyosis who wish to preserve the uterus.
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Magnetic resonance-guided focused ultrasound surgery for leiomyoma and adenomyosis: An alternative nonvascular approach p. 196
Minh Duc Nguyen
DOI:10.4103/GMIT.GMIT_19_19  
Magnetic resonance-guided high-intensity focused ultrasound (MRgFUS) surgery is a promisingly alternative method for the treatment of symptomatic leiomyoma and adenomyosis. In this article, we mainly aim to introduce two totally typical patients with leiomyoma and adenomyosis who underwent MRgFUS surgery successfully without any severe complications at our interventional radiology center. Our results revealed that focused ultrasound surgery is an innovatively safe and nonvascular approach which should be taken into consideration for the treatment of patients with symptomatic leiomyoma and adenomyosis.
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Interstitial pregnancy p. 199
Chih-Feng Yen, Yu-Shan Lin, Shu-Ling Lin
DOI:10.4103/GMIT.GMIT_100_19  
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