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   Table of Contents - Current issue
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April-June 2020
Volume 9 | Issue 2
Page Nos. 53-111

Online since Tuesday, April 28, 2020

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EDITORIAL  

100% 5-Year survival rate in laparoscopic radical hysterectomy for early-stage cervical cancer is an achievable task p. 53
Peng Teng Chua, Chyi- Long Lee, Kuan- Gen Huang
DOI:10.4103/GMIT.GMIT_23_20  
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ORIGINAL ARTICLES Top

The association between placenta implantation at prior myomectomy locations and perinatal outcomes in pregnant women who previously underwent one-step hysteroscopic myomectomy Highly accessed article p. 54
Yoshifumi Kasuga, Bao- Liang Lin, Seon- Hye Kim, Takayuki Higuchi, Sokichi Iwata, Sakura Nakada
DOI:10.4103/GMIT.GMIT_94_19  
Objectives: There are no data describing the correlation between placenta implantation at prior myomectomy locations and perinatal outcomes in pregnant women after transcervical resection myomectomy (TCR-M). The aim of the study is to investigate the correlations between placenta implantation at prior myomectomy locations and perinatal outcomes in pregnant women who had previously undergone TCR-M. Materials and Methods: This was a retrospective, single-center study. We reviewed the records of 34 pregnant women who had previously undergone TCR-M for submucosal myoma and perinatal care in our hospital between January 2012 and January 2019. We examined surgical and pregnancy outcomes and evaluated correlations between placenta implantation at prior myomectomy locations and perinatal outcomes in women who delivered after 22 gestational weeks (n = 24). Results: Median maternal age at conception was 38 years (range, 28–44) and median duration between TCR-M and conception was 1.4 years (range, 0.3–5.8). There were 24 deliveries after 22 gestational weeks and 10 pregnancy losses. Among these 24 deliveries, the median gestational age at delivery was 39 weeks (range, 34–41); median birthweight, 3025 g (range, 2092–4012); and median blood loss at delivery, 573 g (range, 100–3000). There were no cases of placenta accreta and uterine rupture. Placenta implantation at a prior myomectomy location was detected in 14/24 women using transabdominal ultrasonography. Median blood loss was significantly higher in the implantation than in the nonimplantation group (P < 0.01). Conclusion: Our one-step TCR-M is useful for women with submucosal myoma. However, we suggest that clinicians should review and check the association between prior myomectomy locations and placenta implantation.
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A comparison of surgical outcomes between single-site robotic, multiport robotic and conventional laparoscopic techniques in performing hysterectomy for Benign indications p. 59
Natasha Gupta, DO Miranda Blevins, Jenny Holcombe, Robert Scott Furr
DOI:10.4103/GMIT.GMIT_68_19  
Objectives: Minimally invasive gynecologic surgery (MIGS) is the standard of care in performing hysterectomy for benign conditions. However, the choice of laparoscopic modality is largely dependent on surgeon's discretion, experience, and equipment availability. The objective of this study is: To compare outcomes between different minimally invasive approaches available for benign hysterectomies and to evaluate patient factors that influence the use of one approach over another. With this study, we sought to provide some objective criteria while deciding the appropriate MIGS technique. Materials and Methods: This is a retrospective study comparing perioperative outcomes between three techniques of minimally invasive hysterectomy: laparoscopy (LSC), multiport daVinci (MP-Rob) and single-site daVinci (SS-Rob). Patients undergoing benign hysterectomy (daVinci or conventional LSC) from January 2015 to July 2016 were included. 129 patients were identified and divided into: LSC (n = 44), MP-Rob (n = 36) and SS-Rob (n = 49). Results: There were statistically significant differences in age (MP-Rob46 ≠ LSC39), body mass index (BMI) (MP-Rob33 ≠ LSC27 or SS-Rob26.8), uterus weight (MP-Rob144 ≠ LSC102 or SS-Rob105) and operative time (LSC192 ≠ SS-Rob162.3 or MP-Rob163). Chi-square analyses revealed history of endometriosis and clinical endometriosis was statistically less common while leiomyomas were more common indications of MP-Rob. There was no statistically significant difference noted between length of stay, estimated blood loss, intraoperative, and post-operative complications between different surgical types. Conclusion: Patients with higher age, BMI, uterus weight and abnormal uterine bleeding were noted to undergo MP-Rob surgery. Patients with history of endometriosis were more likely to undergo LSC or SS-Rob surgery. Operative time was significantly less for daVinci hysterectomies (SS-Rob and MP-Rob) as compared to conventional LSC.
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Venous thromboembolism and adenomyosis: A retrospective review p. 64
Eliane Yuting Hong, Harvard Zhenjia Lin, Yoke Fai Fong
DOI:10.4103/GMIT.GMIT_77_19  
Objectives: The objective of the study was to evaluate the incidence of venous thromboembolism (VTE) in patients who have been admitted for adenomyosis at our institute and describe their clinical characteristics and management. Materials and Methods: A retrospective review of the medical records of all patients who were admitted to the gynecology ward between January 2015 and August 2016 was conducted, and all patients who had adenomyosis were included in this study. Clinical details that were evaluated included age, parity, body mass index, significant comorbidities, size of the uterus on physical examination, the size of the adenomyoma (if present) on pelvic ultrasonography, initial hemoglobin, and hematocrit on admission, whether blood transfusion was required, acute and long-term treatment and whether or not there were any associated VTE and treatment given. Results: Forty-one patients were included in this study. Five (12.2%) out of the 41 patients had associated VTE; all five had pulmonary embolism (PE), while two also had a concurrent left lower limb deep-vein thrombosis. Three out of the five patients had worsening menorrhagia following anticoagulation, which gonadotropin-releasing hormone analogs were effective in controlling. Four of the five patients eventually underwent a hysterectomy for long-term management of adenomyosis. Conclusion: This case series describes a few clinical cases where VTE (particularly PE) has been observed with adenomyosis, the challenges in managing these patients, and effective treatment approaches.
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The feasibility of natural orifice transluminal endoscopic surgery in gynecology practice: Single-surgeon experience Highly accessed article p. 69
Cihan Kaya, Ismail Alay, Sukru Yildiz, Huseyin Cengiz, Xalide Afandi, Levent Yasar
DOI:10.4103/GMIT.GMIT_84_19  
Objectives: Natural orifice transluminal endoscopic surgery (NOTES) has been performed in gynecology practice for the surgical treatment of ovarian cysts, uterine fibroids, ectopic pregnancies, adnexal masses, and pelvic organ prolapse. The aim of this study is to evaluate the intraoperative and postoperative outcomes of patients who underwent NOTES for gynecological diseases. Materials and Methods: This study was a retrospective clinical study. The data of 50 patients who had been treated via NOTES procedure for benign gynecological indications such as ectopic pregnancy, adnexal mass, uterine fibroid, and treatment-resistant heavy menstrual bleeding during the time period between January 2016 and 2019 were included. All procedures were performed by a single surgeon (C.K.) using a self-constructed glove port, and a sealing device in addition to conventional laparoscopic (CL) equipment. Descriptive analysis of the patients' data was performed. Results: The initial two of the adnexectomy procedures were performed via hybrid NOTES technic and four of them were performed via total vaginal NOTES technic. The remaining procedures, namely hysterectomies, adnexectomies, salpingectomies, and myomectomy were performed via vaginally assisted NOTES (VaNOTES) technic. The mean operation time for the hysterectomy ± bilateral salpingo-oophorectomy (BSO) and salpingo-oophorectomy patients was 85.25 min and 53.15 min, respectively. For those patients who underwent VaNOTES procedure, the median postoperative visual analog scale pain score at the 6th h was six and at the 24th h was two. The mean length of the hospital stay was 2.07 days in the hysterectomy ± BSO patients and 1.63 days in the salpingo-oophorectomy patients. Conclusion: The NOTES procedure is a feasible technic in regards to the duration of surgery, postoperative pain scores, and cosmetic outcomes.
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Comparison of autocross-linked hyaluronic acid gel and intrauterine device for preventing intrauterine adhesions in infertile patients: A randomized clinical trial p. 74
Yu- Qing Wang, Xiao- Hua Song, She- Ling Wu, Yu- Zhen Huang, Lei Yan, Chang-Zhong Li
DOI:10.4103/GMIT.GMIT_103_19  
Objectives: The objective of this study is to evaluate the efficacy of autocross-linked hyaluronic acid (HA) compared with intrauterine device (IUD) for preventing intrauterine adhesions (IUAs) in infertile patients after hysteroscopic adhesiolysis. Materials and Methods: A randomized clinical trial (ChiCTR-IOR-16007746). Upon completion of adhesiolysis, 3 ml of HA gel was placed into the uterine cavity in Group A; 3 ml of HA gel and an IUD were placed in Group B; and only an IUD was placed in Group C. A second hysteroscopic examination was performed in all patients at approximately 1 month postoperatively for the evaluation of IUA. The primary outcome measure was the effective rate of IUA prevention based on the American Fertility Society (AFS) scoring system. Results: Eighty-nine women were randomly distributed into two groups for intention to treat with 30 patients in Group A, 24 patients in Group B, and 35 patients in Group C. Patients were scored and stratified into three degrees and were enrolled using the simple random sampling method. The three groups were well balanced. There were no significant differences in age, endometrial thickness, the previous number of pregnancy, and the distribution of adhesion categories across mild, moderate, and severe between the three groups. The effective rate of IUA prevention, the AFS score after therapy, and the percentage improvements of Chinese score and AFS score before and after surgery were statistically significant difference between Groups A and C. The clinical pregnancy rate in Group A was higher than those in Groups B and C, but the difference was not statistically significant. Conclusion: HA gel has an advantage over an IUD in reducing IUA recurrence and decreasing adhesions.
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Management of mullerian development anomalies: 9 years' experience of a tertiary care center p. 81
Lajya Devi Goyal, Balpreet Dhaliwal, Paramdeep Singh, Sandesh Ganjoo, Vikas Goyal
DOI:10.4103/GMIT.GMIT_13_19  
Objectives: This study aimed to analyze the clinical and imaging findings as well as the outcomes of patients with Mullerian duct anomalies. Materials and Methods: A retrospective analysis of 41 patients with Mullerian development anomalies treated in a tertiary care center in the past 9 years was done. The presenting symptoms, radiological findings, management, and the outcomes were evaluated. Results: According to the American Fertility Society's classification, 11 patients presented in Class I, 6 in Class II, and 24 in Class III of the classification. It was found that some of the defects such as the unicornuate uterus, a unicornuate uterus with noncommunicating rudimentary horn, and longitudinal vaginal septum were usually asymptomatic whereas disorders such as Mayer-Rokitansky-Küster-Hauser (MRKH), cervicovaginal atresia, and transverse vaginal septum presented with the absence of menarche, cyclical abdominal pain, and abdominal mass, respectively. Defects such as the bicornuate uterus, didelphys uterus, and septate uterus present with poor reproductive performance. Unicornuate uterus with communicating horn presented with rupture of the horn in the antenatal period, which was managed vigorously. Vaginoplasty with a skin graft and amnion graft had excellent results in MRKH syndrome. Patients with cervicovaginal atresia had a poor prognosis and ultimately required a hysterectomy. Hysteroscopic septal resection improved the reproductive performance in the patients with septate uterus. Conclusion: This study concluded that the management of uterine malformations is individualized depending on the symptoms and fertility concerns. Cervicovaginal atresia was associated with restenosis after surgery ultimately required a hysterectomy. MRKH had excellent results with McIndoe vaginoplasty. Optimal and timely management may lead to better outcomes.
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CASE REPORTS Top

Laparoscopically diagnosed and treated ruptured metastatic ovarian tumor p. 88
Mai Nishimura, Sachiko Matsumoto, Yasuhiro Ohara, Kazuaki Imai, Shinichiro Wada, Takafumi Fujino
DOI:10.4103/GMIT.GMIT_10_19  
A 51-year-old woman visited our institution with a chief complaint of abdominal pain. Blood laboratory testing revealed a carcinoembryonic antigen level of 13.4 ng/mL. Magnetic resonance imaging revealed a massive pelvic mass with marked wall thickening, partly accompanied by a high-signal-intensity cystic component in T2-weighted images. The entire tumor had low-signal intensity in T1-weighted images. We diagnosed a ruptured ovarian tumor, and the patient underwent emergent laparoscopic left salpingo-oophorectomy. Pathological examination revealed metastatic colon cancer to the ovary, and lower gastrointestinal endoscopy confirmed sigmoid colon carcinoma. Laparoscopic sigmoidectomy was performed followed by adjuvant chemotherapy with capecitabine + oxaliplatin. Ruptured metastatic ovarian tumor is extremely rare. With early diagnosis and laparoscopic resection, the primary lesion can be identified and treated quickly.
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Minilaparotomy for excision of a functioning noncommunicating rudimentary horn and endometrioma in a patient with solitary kidney: A case report p. 91
Amany Abd El-Wadoud Makroum, Mahmoud Mohamed Abdelrazik, Maher Shams El-Deen Hassan
DOI:10.4103/GMIT.GMIT_44_19  
Müllerian duct anomalies result from abnormal formation, fusion, or reabsorption of the Müllerian ducts during fetal life. A close embryologic relation exists between the development of the urinary and reproductive organs. Hence, renal tract defects are likely to be found in women with congenital uterine malformation. This report describes the technique of minilaparotomy for the removal of a noncommunicating rudimentary horn together with an associated endometrioma in a patient with absent one kidney.
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Usefulness of disposable skin biopsy punch for cervical occlusion after cervical conization p. 95
Rina Funada, Kazushige Adachi, Yoshimitsu Yamamoto, Itsuko Nakamichi
DOI:10.4103/GMIT.GMIT_65_19  
Cervical occlusion is a rare but serious complication after conization of the uterine cervix. We report on a 69-year-old woman with cervical intraepithelial neoplasia (CIN) 2, who successfully underwent follow-up biopsy of an occluded cervical canal after conization using a disposable skin biopsy punch. The disposable skin biopsy punch was inserted into a slight dimple, which was considered a uterine os, in the direction of the cervical canal, and a sample of tissue was obtained from the occluded portion. This procedure was performed without anesthesia and was completed uneventfully. Histological examination of the excised tissue revealed CIN 3. In addition, the procedure resulted in recanalization of the occluded cervical canal. The occlusion was limited in the external portion of the cervical os and attributed to adhesion of scar tissue during the healing process. Our experience suggests that a disposable skin biopsy punch can be used for follow-up biopsy and recanalization in patients with cervical occlusion after conization as a less invasive approach.
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Scar endometriosis presenting as a painful abdominal mass p. 98
Li- Yung Chen, Sheng- Der Hsu
DOI:10.4103/GMIT.GMIT_74_18  
Abdominal wall scar endometriosis occurs in 1%–2% of women following a cesarean section delivery. We report a case of a 36-year-old woman with scar endometriosis, presenting with an acute, painful abdominal wall mass. She underwent a cesarean section 8 years before presentation. She was admitted to the emergency room for physical examination of the abdomen, which revealed a palpable mass. Abdominal computed tomography (CT) revealed an ill-defined soft-tissue lesion over the left rectus abdominis muscle (abdominal scar). Surgical removal of the abdominal wall mass was performed with adequate clearance margins with a preoperative diagnosis of postcesarean scar endometriosis. Postcesarean scar endometriosis is a rare cause of an abdominal mass; however, when this condition presents acutely, it can be difficult to diagnose. In this case, careful analysis of the patient's history, CT images, and histopathological results together confirmed the diagnosis. Surgical excision was performed under general anesthesia while maintaining adequate clearance margins.
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Total laparoscopic hysterectomy of an endocervical pyomyoma over previous cesarean section wound p. 101
Phornsawan Wasinghon, Kuan- Gen Huang, Siew- Yen Lai
DOI:10.4103/GMIT.GMIT_103_18  
A 41-year-old female, G2P2, who experienced menorrhagia for 1 month, had had a history of myoma uteri for the previous 5 years. The computed tomography showed a leiomyoma mass of approximately 8 cm. She underwent a total laparoscopic hysterectomy with bilateral salpingectomy. This pyomyoma originated in the endocervix over the cesarean section wound. The postoperative care was uneventful. Pyomyoma is a rare condition and is even rarer in premenopausal patients without a history of pregnancy or uterine instrumentation. The spontaneous pyomyoma at the endocervical leiomyoma demonstrated an unusual case in the absence of risk factors. Pyomyoma could be considered as a diagnosis in patients without fever, history of fibroids, and no other identifiable sources of infection.
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CLINICAL IMAGES Top

Magnetic resonance imaging-guided volumetric high-intensity focused ultrasound surgery for pedunculated subserosal uterine leiomyoma p. 104
Minh Duc Nguyen
DOI:10.4103/GMIT.GMIT_36_19  
Magnetic resonance imaging-guided volumetric high-intensity focused ultrasound surgery is an innovative nonvascular ablation treatment for uterine leiomyoma. In this clinical image, we aimed to depict one patient with pedunculated subserosal uterine leiomyoma adopting treatment successfully without any complications immediately after treatment and at 6-month follow-up.
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Inevitable removal of left accessory ovary p. 106
Tanitra Tantitamit, Chyi Long Lee, Hsin- Hong Kuo
DOI:10.4103/GMIT.GMIT_44_18  
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Parasitic leiomyoma p. 108
Angel Hsin-Yu Pai, Chih- Feng Yen, Shu- Ling Lin
DOI:10.4103/GMIT.GMIT_35_20  
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LETTER TO THE EDITOR Top

Time to Stop Complicating a Complex Disease: Adopt Simple Treatment for Polycystic Ovarian Syndrome p. 110
Divyanu Jain, Abha Sood, Ajay K Jain
DOI:10.4103/GMIT.GMIT_121_19  
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