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   Table of Contents - Current issue
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April-June 2021
Volume 10 | Issue 2
Page Nos. 71-136

Online since Friday, April 30, 2021

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PERSPECTIVE ARTICLE  

A journey from learning a noninvasive high-intensity focused ultrasound surgical treatment for gynecological diseases to providing high-intensity focused ultrasound services in Hong Kong Highly accessed article p. 71
Wu Shun Felix Wong, Man Hin Menelik Lee, Peng Hao Wong
DOI:10.4103/GMIT.GMIT_23_21  
This paper reflects a Hong Kong doctors group's journey to learn the high-intensity focused ultrasound (HIFU) ablation treatment for gynecological diseases in China. The procedures of HIFU ablation for fibroids, adenomyosis, and other gynecological diseases are described. After completing our training, the authors applied the HIFU ablation techniques they have learned to establish an outpatient HIFU clinic and provided HIFU ablation treatment in Hong Kong. This paper describes their early experience in providing HIFU services.
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REVIEW ARTICLE Top

Cervical cancer surgery: Current state of affairs p. 75
Fan Chun Yang, Wei Huang, Weihong Yang, Jie Liu, Guihai Ai, Ning Luo, Jing Guo, Peng Teng Chua, Zhongping Cheng
DOI:10.4103/GMIT.GMIT_81_20  
Cervical cancer surgery has a history of more than 100-years whereby it has transitioned from the open approach to minimally invasive surgery (MIS). From the era of clinical exploration and practice, minimally invasive gynecologic surgeons have never ceased to explore new frontiers in the field of gynecologic surgery. MIS has fewer postoperative complications, including reduction of treatment-related morbidity and length of hospital stay than laparotomy; this forms the mainstay of treatment for early-stage cervical cancer. However, in November 2018, the New England Journal of Medicine had published two clinical studies on cervical cancer surgery (Laparoscopic Approach to Cervical Cancer [LACC]). Following these publications, laparoscopic surgery for early-stage cervical cancer has come under intense scrutiny and negative perceptions. Many studies began to explore the concept of standardized surgery for early-stage cervical cancer. In this article, we performed a review of the history of cervical cancer surgery, outlined the standardization of cervical cancer surgery, and analyzed the current state of affairs revolving around cervical cancer surgery in the post-LACC era.
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ORIGINAL ARTICLES Top

Value of crossover sign in anticipating under-8-week cesarean scar pregnancy treatment by foley insertion combined with suction curettage in vietnam p. 84
Tuan Minh Vo, Hoang T Dinh, Thong P Van, Christopher Son Nguyen
DOI:10.4103/GMIT.GMIT_127_19  
Objectives: An earlier study completed at TuDu Hospital presented the efficacy of Foley insertion combined with fetal suction curettage at a high rate of success in treatment of cesarean scar pregnancy (CSP) of < 8 weeks, but the efficacy of prognosticating factors for this approach has not been specifically addressed yet, especially crossover sign (COS) on ultrasound. We aimed to investigate the correlation between COS on ultrasound and the treatment results of CSP using Foley insertion combined with fetal suction. Materials and Methods: A case–control study of CSPs ≤ 8 weeks treated at TuDu Hospital during September 2017–April 2019 included 63 failures in the case group and 98 successes in the control group. Results: COS-2 + increased the likelihood of treatment success by 4.9 times (95% confidence interval: 1.8–13.5) compared with COS-1 cases. In addition, other factors favoring treatment success with statistical significance included no vascularization at cesarean scar on ultrasound (odds ratio [OR] = 7.1), gestational mass volume ≤4 cm3 (OR = 3.7), and β-human chorionic gonadotropin at hospital admission ≤ 10,000 mIU/mL (OR = 6.1). Conclusion: COS imaging played an important role in the prediction of treatment outcomes for CSP ≤ 8 weeks by the combined approach of Foley insertion and fetal suction curettage.
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Carbon dioxide pneumoperitoneum may alter ovarian apoptosis: An experimental study p. 91
Suleyman Guven, Hidayet Sal, Emine Seda Guvendag Guven
DOI:10.4103/GMIT.GMIT_96_20  
Objective: The aim of this study was to evaluate ovarian immunohistochemical CD95 expression in a rabbit carbon dioxide pneumoperitoneum model. Materials and Methods: The study group including seven rabbits was subjected to intra-abdominal pressure (IAP) (12 mmHg); the control group was not subjected to IAP (the sham group, n = 7). At the end of the experiment, ovariectomy was performed. Immunohistochemical stained histologic specimen of the ovary with CD95 was evaluated. Based on the degree of cytoplasmic or membranous staining for CD95 from 0 (none) to 3 (severe), a microscopic apoptosis scoring system was used. Results: Statistically significantly higher apoptosis scores in ovarian surface epithelial cells (2.57 ± 0.53, vs. 1.14 ± 0.38, P = 0.002, Mann–Whitney U-test, respectively), follicular epithelial cells (2.85 ± 0.38, vs. 1.85 ± 0.38, P = 0.002, Mann–Whitney U-test, respectively), and stromal cells (2.71 ± 0.49, vs. 1.29 ± 0.49, P = 0.002, Mann–Whitney U-test, respectively) were observed in pneumoperitoneum group, compared with no-pneumoperitoneum group. Conclusion: Even at safe IAP (12 mmHg) for an acceptable operation time period, there was a significant increase in apoptosis of ovarian cells.
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Comparison of the quality of life and female sexual function following laparoscopic pectopexy and laparoscopic sacrohysteropexy in apical prolapse patients p. 96
Mehmet Obut, Süleyman Cemil Oğlak, Sedat Akgöl
DOI:10.4103/GMIT.GMIT_67_20  
Objective: We sought to compare the surgical outcomes, safety, effectiveness, and mid-term outcomes in patients who had undergone laparoscopic hysterosacropexy and laparoscopic pectopexy due to apical prolapse. Materials and Methods: This prospective randomized study was conducted on a total of 62 women who underwent apical prolapse surgery (32 undergoing a pectopexy and 30 undergoing a sacrohysteropexy) between June 2015 and June 2017. Patients with symptomatic uterine or vaginal vault prolapse with stage 2 or worse were included in the sudy. Before and after the operation, we used the Pelvic Organ Prolapse Quantification System (POP-Q) and questionnaires, which are the Prolapse Quality of Life Questionnaire (P-QOL) and Female Sexual Function Index (FSFI), to evaluated cases. Baseline characteristics, perioperative and postoperative complications, and follow-up results at 12 months were also evaluated. Results: All domains of POP-Q, P-QOL, and FSFI scores improved significantly after surgery both in pectopexy and sacrohysteropexy group. The postoperative complications of both procedures were similar except for constipation after surgery (3.2% in the pectopexy group and 20% in the hysterosacropexy group [P = 0.036]). Conclusion: Both sacrohysteropexy and pectopexy are effective surgical options for apical prolapse patients. The pectopexy is an acceptable alternative to laparoscopic sacrohysteropexy because of its less complexity and not reducing pelvic space for the rectum to exist. We suggest that the laparoscopic pectopexy may be widely used in clinical routine.
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A suturing method without exposure of barbs on the wound surface using a unidirectional barbed monofilament absorbable suture (STRATAFIX) in laparoscopic myomectomy: A feasibility study p. 104
Yoshiaki Ota, Kuniaki Ota, Toshifumi Takahashi, Soichiro Suzuki, Rikiya Sano, Mitsuru Shiota
DOI:10.4103/GMIT.GMIT_105_20  
Objectives: We examined whether a new suturing method that used a single-thread unidirectional barbed suture without exposing the barbs on the wound surface was acceptable compared with the conventional suture method during laparoscopic myomectomy (LM). Materials and Methods: This was a retrospective study. The subjects were 26 women who underwent LM for symptomatic uterine fibroids. The operative time, amount of blood loss, and number of threads used were compared between a group in which suturing was performed with a conventional synthetic absorbable suture (conventional suture group, n = 13) and a group in which suturing was performed using a barbed suture (barbed suture group, n = 13). Results: Operative time in the barbed suture group was significantly shorter than that in the conventional suture group, while blood loss during LM in the barbed suture group was significantly lower than that in the conventional suture group. The number of threads used in the conventional suture group was significantly larger than that in the barbed suture group. No complications were observed in both the groups during LM. Conclusion: This new technique using a barbed suture is safe and feasible for LM.
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Colpotomizer-assisted total abdominal hysterectomy (CATAH Technique): A new technique for uterine removal in benign pathologies p. 109
Ayman Shehata Dawood, Sherin Barakat Elbohoty, Ahmed Mohamed Abbas, Adel Elshahat Elgergawy
DOI:10.4103/GMIT.GMIT_128_19  
Objectives: The aim of this study is to evaluate the applicability and feasibility of Colpotomizer-assisted total abdominal hysterectomy (CATAH), a new technique for uterine removal in benign uterine pathologies. Materials and Methods: This study is a prospective cohort study conducted at a tertiary University hospital in Egypt. Eligible patients (n = 88) for total abdominal hysterectomy (TAH) were divided into two groups; the study group who underwent TAH by the CATAH technique and the control group who underwent TAH by the conventional technique. Demographic data, operative time, blood loss, and operative complications were recorded. Results: The mean operative time was significantly reduced (64.47 ± 3.60 min) in the study group than in the control group (86.42 ± 5.54 min, P < 0.001). The mean time for cervical removal was significantly less (8.60 ± 1.39 min) in the study group than (17.77 ± 2.62 min) in the control group (P < 0.001). The mean volume of blood loss was less (197.38 ± 39.42 ml) in the study group than in the control group (462.69 ± 167.96 ml). Complications were fewer in the study group than in the control group. Conclusion: The CATAH technique was feasible, quicker with less intraoperative and postoperative complications than the conventional technique for TAH in benign uterine pathologies.
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SHORT COMMUNICATION Top

Measures for safe laparoscopic sacrocolpopexy: Preoperative contrast-enhanced computed tomography and perioperative ultrasonography p. 114
Yasushi Kotani, Kosuke Murakami, Akiko Kanto, Hisamitsu Takaya, Hidekatsu Nakai, Noriomi Matsumura
DOI:10.4103/GMIT.GMIT_1_20  
Laparoscopic sacrocolpopexy is one of the most difficult laparoscopic surgical techniques. In this study, we report on our efforts to safely perform this procedure, which consists of suturing a piece of mesh onto the anterior longitudinal ligament using a nonabsorbent suture during mesh fixation onto the prepromontorium layer, which can lead to massive bleeding if a mistake is made, by performing preoperative and intraoperative image evaluation. Preoperative contrast-enhanced computed tomography was performed. Images in DICOM format were acquired, and three-dimensional vessel reconstruction was performed. After performing a peritoneal incision in the presacral area, ultrasonography was performed using a probe inserted through a 12-mm trocar into the abdominal cavity to re-confirm the absence of vessels near the planned suturing area. After ultrasonography, an Ethibond® suture was inserted through the anterior longitudinal ligament. In our hospital, 126 patients underwent the procedure, and none had a serious hemorrhage or required blood transfusion, indicating the safety of this modified procedure without separation of a wide presacral area. We believe that these techniques can be performed safely with minimal incision. However, we did not examine the efficacy of these techniques in this paper. Further studies are needed to determine whether this approach is suitable.
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CASE REPORTS Top

Analysis of surgical procedure of four cases of ovarian pregnancies treated with laparoscopic surgery p. 117
Yuta Kasahara, Ryo Yokomizo, Kazu Ueda, Rei Makishima, Hiroshi Kishi, Aikou Okamoto
DOI:10.4103/GMIT.GMIT_120_19  
Ovarian pregnancy is a rare disease, accounting for 0.5%–3% of ectopic pregnancies. Ovarian pregnancy risk factors and preoperative diagnosis have been extensively reported. However, its histopathology and surgical findings have been poorly studied. To examine appropriate surgical procedures, we investigated the clinical features, surgical findings, and histopathological examinations of four ovarian pregnancy cases treated in our hospital. In histopathological examination, most specimens did not contain ovarian tissues; in some cases, villous tissues were buried in a clot. Therefore, evaluating the appropriateness of surgical resection range from histopathological images was difficult. However, the postoperative course was favorable; no cases manifested complications. Considering all these facts, we regarded the surgical procedures of the four cases in this study as appropriate. For the treatment of ovarian pregnancies, especially for the outward development type, a sufficient therapeutic effect may be achieved even without extensive excision of the ovarian tissues by laparoscopic surgery.
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Hysteroscopic removal of intrauterine-retained suture material causing pelvic inflammatory disease p. 121
Cihan Kaya, Ismail Alay, Sukru Yildiz, Ozgur Aslan
DOI:10.4103/GMIT.GMIT_105_19  
Retained intrauterine objects are rare causes of persistent vaginal discharge and pelvic inflammatory disease. Hysteroscopy is a minimally invasive technique used for removing these materials. A 47-year-old female who had recurrent vaginal discharge was admitted to our emergency department with pelvic pain. Retained nonabsorbable suture material was observed during her vaginal examination. After treating with intravenous antibiotics, operative hysteroscopy was performed, and the material was removed from the lower segment of the uterus.
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Successful endoscopic treatment for high-grade cervical intraepithelial neoplasia with gross lesions of the vagina p. 124
Koyo Yamamoto, Miho Kitai, Kasumi Yamamoto, Toshiko Sakuma, Shoji Nagao, Satoshi Yamaguchi
DOI:10.4103/GMIT.GMIT_119_19  
We present a patient diagnosed with high-grade cervical intraepithelial neoplasia (CIN) combined with macroscopic lesions of the vaginal epithelium. There was no lesion in pelvic magnetic resonance imaging examination, and histopathological examination revealed CIN3 and vaginal intraepithelial neoplasia (VAIN) 3 without invasion. We chose minimally invasive surgery for her and total laparoscopic hysterectomy with partial resection of the vagina was carried out. To determine appropriate surgical margins, vaginal colpotomy was performed. No recurrence of VAIN has been observed to date that passed for 9 months either.
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Importance of cervical elongation assessment for laparoscopic sacrocolpopexy p. 127
Mikihisa Onigahara, Shintaro Yanazume, Takashi Ushiwaka, Shinichi Togami, Masaki Kamio, Hiroaki Kobayashi
DOI:10.4103/GMIT.GMIT_114_19  
Cervical elongation in patients with pelvic organ prolapse (POP), who previously underwent laparoscopic sacrocolpopexy (LSC), is not fully understood. We report a case of a second surgery for endometrial cancer complicated with POP recurrence, which seemed to be related to cervical elongation following LSC. A 65-year-old woman was referred for invasive treatment following LSC. Although preoperative endometrial cytology was negative, the resected uterine specimen revealed endometrioid carcinoma. The patient also had complications of cervical prolapse with cystocele Stage III. Repeat surgery was performed with a trachelectomy, anterior-posterior colporrhaphy, and vaginal apex suspension. Mesh had been adequately sutured to the upper cervix in the previous surgery, and the resected cervix was elongated up to 9 cm. Cervical elongation may be correlated with the inaccurate preoperative endometrial examination, and it may also promote POP recurrence leading to a poorly supported pelvic floor. We suggest that cervical elongation should be identified before POP surgery.
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Successful conservative treatment of cesarean scar ectopic pregnancy with local injections of absolute ethanol p. 132
Toshiyuki Kakinuma, Kaoru Kakinuma, Yoshio Matsuda, Kaoru Yanagida, Hirotsune Kaijima, Michitaka Ohwada
DOI:10.4103/GMIT.GMIT_125_19  
Cesarean scar ectopic pregnancy (CSEP) is becoming more common worldwide. Here, we report a case of cesarean scar pregnancy successfully treated using transvaginal ethanol injection. A 31-year-old female (gravida 3, para 2) with two prior cesarean sections presented at 9 weeks and 3 days of pregnancy. Her serum human chorionic gonadotropin level was 91,798 mIU/mL. CSEP was confirmed by transvaginal ultrasonography, pelvic magnetic resonance imaging, and color Doppler ultrasonography. Transvaginal absolute ethanol local injection under transvaginal ultrasound guidance was performed. She was discharged 7 days after treatment with no complications and resumed normal menses 1 month after treatment. We describe a safe and successful treatment option for CSEP.
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LETTER TO THE EDITOR Top

Focus on intrauterine morcellator p. 135
Gianluca Raffaello Damiani, Giuseppe Muzzupapa, Mario Villa, Giuseppe Trojano, Vera Loizzi
DOI:10.4103/GMIT.GMIT_156_20  
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