Transabdominal Hysterectomy Research Articles

Landmark based epidural anesthesia in a patient with scoliosis for transabdominal hysterectomy; a case report

We report a case of a 43-years-old female with thoraco-lumbar scoliosis; who was scheduled to undergo an elective total abdominal hysterectomy (TAH). The unique aspect of this case is that the surgery was performed with landmark-guided epidural anesthesia. Regional anesthesia is believed to be a safer alternative to general anesthesia where airway control is uncertain. Keywords: Thoraco-lumbar scoliosis, epidural anesthesia, total abdominal hysterectomy. Citation: Rafiq M, Hussaini, Siraj S, Marium W, Talha S. Landmark based epidural anesthesia in a patient with scoliosis for transabdominal hysterectomy; a case report. Anaesth. pain intensive care 2024;28(4):762−764. DOI: 10.35975/apic.v28i4.2524 Received: February 20, 2024; Reviewed: March 30, 2024; Accepted: April 15, 2024

Is detrusor overactivity with detrusor underactivitylimited to the elderly?

Detrusor overactivity with detrusor underactivity (DO-DU) is classically described in frail institutionalized elderly patients, but we have also observed this diagnosis in younger populations. This research aims to identify the differences between two age groups of DO-DU patients. This study included DO-DU patients from a single center from 2012 to 2023. Patients were divided into two groups: the "Younger" group (aged less than 70 years) and the "Older" group (aged 70 years or older). We separately compared demographics, the number of risk factors considered to affect bladder function, clinical presentations, and urodynamic findings between these two groups in each gender. There were 210 patients included in the analysis, with 50.48% in the younger group and 49.52% in the older group. The median ages of males and females in the younger group were 57 and 62 years, whereas the median ages of males and females in the older group were 76.5 and 76 years. Multiple sclerosis exhibited statistically significant prevalence in the younger patients (7.7% vs. 0%, p = 0.03 in males and 19.9% vs. 4.6% in females). While diabetes mellitus (DM) was more prevalent in the older males (20.0% vs. 4.6%, p = 0.01), transabdominal hysterectomy was more common in the younger females (46.3% vs. 25%, p = 0.04). 69.8% of the younger group and 71.2% of the older group have at least one risk factor that impact their bladder function. There was no statistically significant difference between the two groups across various risk factor categories. The older males reported a higher incidence of urgency (78.3% vs. 58.5%, p = 0.02) and urge incontinence (61.7% vs. 32.3%, p < 0.01), while the younger females reported a higher incidence of straining during voiding on history (46.3% vs. 20.5%, p = 0.01). The younger males exhibited a greater volume of strong desire to void (385vs. 300 mL, p = 0.01), maximal cystometric capacity (410vs. 300 mL, p < 0.01), and a lower highest detrusor overactivity (DO) pressure (37vs. 50.5 cmH2O, p = 0.02). The younger group had a higher postvoid residual (170vs. 85 mL in males, p < 0.01 and 180vs. 120 mL in females, p = 0.02). The voiding efficiency was lower in younger females (40% vs. 60%, p = 0.02). In both ages, the ICS detrusor contraction indexand projected isovolumetric pressure 1were similar. However, without considering risk factors, the older males had the highest DO pressure (57vs. 29 cmH2O, p < 0.01), and the younger males had a higher voiding pressure (PdetQmax) than the older males (28 vs. 20 cmH2O, p = 0.02). DO-DU is not exclusive to elderly patients. It can also be diagnosed in individuals with risk factors regardless of age; therefore, clinicians need a high degree of suspicion, especially in patients who have risk factor(s) for DO and DU. A notable clinical differentiation is that older males diagnosed with DO-DU have a higher incidence of urgency and urge urinary incontinence, while younger females have a higher incidence of straining.

Outcome of vesicovaginal fistula repair by vaginal approach.

Objectives: To evaluate success of vesicovaginal fistula repair by vaginal approach with secondary objective to assess the limitations of repair by vaginal route. Study Design: Retrospective &amp; Descriptive study. Setting: Department of Urology and Renal Transplantation, Faisalabad Medical University, Faisalabad. Period: January 2017 to December 2020. Material &amp; Methods: In which 42 patients were included in the study. All patients were submitted for VVF repair by vaginal approach. Procedure was done under spinal anesthesia in all patients. Operation was done in lithotomy position. Circumferential incision was made around the fistula. Vagina and bladder were separated. Urinary bladder was repaired in two layers and vagina by perpendicular stitching technique. Foley catheter was passed. Urinary leakage was seen by instillation of normal saline and Gentian Violet. Vaginal packing was done at the end of the procedure which was removed after 1 day of surgery and patient post operative data was noted. Results: 42 patients were included. There mean age was 27 years. 45.23% patients came with history of prolonged labor, 30.95% patients presented after transabdominal hysterectomy, 21.42% after lower segment secession section and 2.38% patients came after operation for cystocele. Infra-trigonal VVF was present in 59.53% patients and supra-trigonal in 40.47% cases. Our success rate was 85.71% and we faced failure in 14.28% of patients. Lower urinary tracts symptoms were seen in 30.95%, hematuria in 9.25%, stress incontinence in 11.9%, symptoms like over active bladder in 7.14% and urinary tract infection in 14.28%. Conclusion: VVF repair by vaginal approach is safe and successful with less morbidity than abdominal approach.

Pelvic Floor Dysfunction and Quality of Life among Hysterectomy Cases at B.P. Koirala Institute of Health Sciences

Background: Pelvic floor dysfunction a global major female reproductive health burden associated with genitourinary and psychosocial symptoms even after hysterectomy has been underreported in the developing world. The study aimed to determine the early incidence of pelvic floor dysfunction and its psychological impact among post-hysterectomy women.&#x0D; Materials and Methods: It was a prospective cohort study for 52 weeks among 130 post-hysterectomy cases at the tertiary care center. Pelvic floor dysfunction was diagnosed with the Pelvic Floor Disability Index and quality of life with the Pelvic Floor Impact Questionnaire. The association of pelvic floor dysfunction with epidemiological characters was analyzed using SPSS version 20.&#x0D; Results: The incidence of pelvic floor dysfunction was 7.8% and the impact on the quality of life was 2.7% among 130 post-hysterectomy cases. Age, body mass index, comorbidities like chronic obstructive lung disease, and previous abdominal surgery were statistically significant. A parity of three or more, caesarian sections with instrumental delivery and Transabdominal hysterectomy was statistically significant with pelvic floor dysfunction and Socio-Psychological effect within the same groups of patients. The most common symptoms were urinary symptoms accounting for 9(90%) followed by prolapse 5 (50%) and colorectal 4(40%) with a score of 20.82± 9.07, 7.48±4.5 and 6.97± 1.55, and quality of life was mostly impacted by bladder symptoms 3 (100%) with a score of 24.96±2.96.&#x0D; Conclusion: Pelvic floor dysfunction is a common health burden among post-hysterectomy cases especially with older age, higher Body Mass Index, Chronic Obstructive Pulmonary Disease, parity of more than three and caesarian sections with instrumental delivery.

Effect of Local Ketamine Subcutaneous Injection at the Incision Site in Reducing the Postoperative Pain Score after Transabdominal Hysterectomy.

Pain control after operations is essential in decreasing the patient recovery period and potential morbidity. Prescribing opiates is very effective, but significant side effects accompany them. This study aims to examine the effect of local ketamine infiltration in decreasing pain intensity in patients undergoing transabdominal hysterectomy. In this double-blind, randomized, controlled clinical trial, a total of 92 patients undergoing transabdominal hysterectomy aged 30-60 years were selected and divided into two intervention and control groups randomly. For the intervention group, ketamine was injected subcutaneously into the incision site at a dose of 0.5 mg/kg after the operation. In the control group, 5 mg normal saline was used in the same method. Postoperative pain intensity was measured using the visual analog scale (VAS: 0-10). The pain score and dose of administered opioids were documented at 1, 2, 4, 6, 12, and 24 hours and compared between the two groups. Postoperative pain intensity was significantly lower in the intervention group than in the control group, except for hour 24. The mean amounts of administered opioids were significantly lower in the intervention group at hours 6 and 12, as well as the total amount of used opioids, and no significant side effects were documented. Local ketamine subcutaneous injection in the incisional site is effective and is a safe procedure for reducing pain scores in patients who underwent a transabdominal hysterectomy.

Clear cell carcinoma arising in an ovarian remnant 19 years after oophoerctomy: case report

BackgroundOvarian remnant syndrome (ORS) is a rare complication that occurs after oophorectomy, characterized by residual ovarian tissue causing pelvic pain, masses, and various symptoms. The clinical manifestations of ORS are nonspecific, and its diagnosis relies on histological examination. Since ORS typically represents a benign ovarian lesion, there have been few reported cases of malignant transformation. In this report, we presented a unique case of ovarian clear cell carcinoma (OCCC) arising from an ovarian remnant following salpingo-oophorectomy.Case presentationOur patient was a 47-year-old female initially diagnosed with uterine myoma. She had previously undergone cesarean section and unilateral salpingo-oophorectomy. Transvaginal ultrasound and computed tomography (CT) scans revealed a soft tissue mass adjacent to the right lateral wall of the myometrium. The patient opted for transabdominal hysterectomy, left adnexal resection, laparoscopic omentectomy, appendectomy, and pelvic and abdominal lymphadenectomy. The final pathology results confirmed the diagnosis of OCCC, consistent with ORS. The patient subsequently received six cycles of intravenous chemotherapy using the carboplatin/paclitaxel (TC) regimen (paclitaxel liposomes 175 mg/m², carboplatin AUC 5). After 3 years of follow-up, the patient’s condition remained normal.ConclusionORS can significantly impact patients’ quality of life and pose challenges for clinicians. Complete excision of ovarian tissue during the initial surgery is crucial in preventing ORS recurrence and potential malignant transformation of ovarian remnants.

Tapentadol Immediate Release (IR) versus Morphine Hydrochloride for Postoperative Analgesia of Patients Undergoing Total Abdominal Hysterectomy-A Prospective Cohort Study.

Background and Objectives: This study aimed to examine the efficacy of tapentadol immediate release (IR) and morphine hydrochloride in the treatment of acute postoperative pain after total abdominal hysterectomy, as well as to examine the frequency of opioid-related side effects in observed patients. Materials and Methods: The prospective observational study was conducted over five months, and it included a total number of 100 patients. The two cohorts had different types of postoperative analgesia, and the effects were observed for 24 h postoperatively, by following the pain scores on NRS (Numerical Pain Scale), contentment with analgesia, and opioid-related side effects. Results: Statistical significance was found when assessing pain 24 h after surgery while coughing, where patients in the tapentadol IR group had significantly higher mean pain scores (p < 0.01). The subjective feeling of satisfaction with postoperative analgesia was statistically significant in the tapentadol IR group (p = 0.005). Vertigo appeared significantly more in patients from the morphine group (p = 0.03). Conclusions: Tapentadol IR (immediate release) and morphine hydrochloride are both effective analgesics used in the first 24 h after total transabdominal hysterectomy. Overall satisfaction of patients with analgesia was good. The frequency of side effects was higher in the morphine group, with statistical significance regarding the vertigo.

Parasitic myoma after transabdominal hysterectomy for fibroids: a case report

BackgroundParasitic myomas typically occur after a pedunculated subserosal fibroid loses its uterine blood supply and parasitizes other organs or after a surgery involving morcellation techniques. Parasitic myomas that occur after transabdominal surgery are extremely rare and may not be sufficiently documented. Here, we present a case of parasitic myoma in the anterior abdominal wall following a transabdominal hysterectomy for fibroids.Case presentationThe patient was a 46-year-old Chinese woman who had undergone surgery for uterine myomas at our hospital 1 year prior. The patient later revisited our department with a palpable mass in her abdomen, and imaging revealed a mass in the iliac fossa. The possibility of a broad ligament myoma or solid ovarian tumor was considered before surgery, and laparoscopic exploration was performed under general anesthesia. A tumor measuring approximately 4.5 × 4.0 cm was found in the right anterior abdominal wall, and a parasitic myoma was considered. The tumor was completely resected. Pathological analysis of the surgical specimens suggested leiomyoma. The patient recovered well and was discharged on postoperative day 3.ConclusionThis case suggests that parasitic myoma should be considered in the differential diagnosis of patients presenting with abdominal or pelvic solid tumors with a history of surgery for uterine leiomyomas, even without a history of laparoscopic surgery using a power morcellator. Thorough inspection and washing of the abdominopelvic cavity at the end of surgery is vital.

Vaginal Cuff Dehiscence and a Guideline to Determine Treatment Strategy.

In this retrospective study, our aim was to investigate a novel treatment strategy guideline for vaginal cuff dehiscence after hysterectomy based on the mode of operation and time of occurrence in patients who underwent hysterectomy at Severance Hospital between July 2013 and February 2019. We analyzed the characteristics of 53 cases of vaginal cuff dehiscence according to the mode of hysterectomy and time of occurrence. Out of a total of 6530 hysterectomy cases, 53 were identified as vaginal cuff dehiscence (0.81%; 95% confidence interval: 0.4-1.6%). The incidence of dehiscence after minimally invasive hysterectomy was significantly higher in patients with benign diseases, while malignant disease was associated with a higher risk of dehiscence after transabdominal hysterectomy (p = 0.011). The time of occurrence varied significantly based on menopausal status, with dehiscence occurring relatively earlier in pre-menopausal women compared to post-menopausal women (93.1% vs. 33.3%, respectively; p = 0.031). Surgical repair was more frequently required in cases of late-onset vaginal cuff dehiscence (≥8 weeks) compared to those with early-onset dehiscence (95.8% vs. 51.7%, respectively; p < 0.001). Patient-specific factors, such as age, menopausal status, and cause of operation, may influence the timing and severity of vaginal cuff dehiscence and evisceration. Therefore, a guideline may be indicated for the treatment of potentially emergent complications after hysterectomy.

Huge Rare Vaginal Fibromatosis in Postmenopausal Woman, Case Report and Literature Review, 2022

Background: Pelvic fibromatosis or desmoids tumor is an uncommon benign mesenchymal tumor that usually involves the vulvo-vaginal area in women of reproductive age, which are slow growing and painless mass. Case Report: A 70-year post-menopausal woman from Asmara presented with genital swelling which grows gradually over 15 years. She had history of trans-abdominal hysterectomy for abnormal uterine bleeding before 20 years. She had also history of right sided body weakness due to cerebro-vascular accident for the last10 years. She had no known chronic diseases such as hypertension or diabetes mellitus. On physical examination, she is a wheelchair patient with right sided hemiplegia and old midline abdominal scar. On genitourinary examination, patient had a large, about 20x18cm, non-tender, irregular, nodular mass, that hangs from the right side of the labia majora to the level of one third of upper thigh. She had also multiple nodular lesions around the ano-genital area. Different laboratory baseline investigations revealed normal finding. She was operated on 30/10/2022 and a 4kg vulvar mass was resected with right partial hemi-vulvoctomy and sample was sent for pathology which revealed fibromatosis. She was discharged with full improvement and currently on follow-up for possible recurrence. Conclusion: This is reported for its rarity and its enormously large size, slow growing and non-invasive nature. Besides, this was atypical being in a postmenopausal woman, and it’s important to highlight that desmoids tumors should be included in the differential diagnosis of any vulvar mass. She was managed with surgical intervention as it was extremely big. Enhancing community and health professionals’ awareness on similar health problems is crucial for early intervention of similar r conditions.

MP37-01 HYSTERECTOMY FOR UTERINE FIBROIDS AND STRESS URINARY INCONTINENCE SURGERY: A NATIONWIDE COHORT STUDY

You have accessJournal of UrologyCME1 Apr 2023MP37-01 HYSTERECTOMY FOR UTERINE FIBROIDS AND STRESS URINARY INCONTINENCE SURGERY: A NATIONWIDE COHORT STUDY Jun Ho Lee Jun Ho LeeJun Ho Lee More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003275.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Uterine fibroids (myomas or leiomyomas) are the most common benign uterine neoplasm. Hysterectomy is the most effective treatment for symptomatic uterine fibroids and uterine fibroids are currently the most common indication for hysterectomy worldwide. Previous studies investigated the relationship between the previous hysterectomy for benign conditions and subsequent stress urinary incontinence (SUI). However, the results are inconsistent across the studies. Additionally, long-term follow-up data from large data sets are lacking. Moreover, the impact of the previous hysterectomy for benign indication on subsequent surgery for SUI is scarcely investigated. METHODS: A retrospective cohort study was conducted on women aged 40 to 59 from the Korean Health Insurance Data 2010 to 2018. The hysterectomy group consisted of women who underwent hysterectomy for uterine leiomyoma and the control group consisted of women who visited a medical facility for a checkup between January, 2011 and December, 2014. Main outcome measures included the occurrence of stress incontinence surgery (R3564, R3565, R3562, R3563) with a urinary incontinence diagnosis code (N39.3, N39.4). For the selected hysterectomy group and control group, 1:1 propensity score matching was done on age at 5-year intervals, year at inclusion, socioeconomic status, parity, region, Charlson Comorbidity Index, adnexal surgery before inclusion, menopause before inclusion, menopausal hormone therapy, and pelvic organ prolapse before inclusion. RESULTS: After 1:1 propensity score matching, 81,373 cases and 81,373 controls were enrolled. The mean follow-up period was 7.9 years for cases and 7.8 years for control subjects. The rate of anti-incontinence surgery was significantly higher in the hysterectomy group compared to the non-hysterectomy group (1.7 vs. 2.0%; p<.001). As compared to the non-hysterectomy group, abdominal hysterectomy significantly increased anti-incontinence surgery before and after adjusting confounders (HR: 1.215; 95% CI: 1.097-1.347; p<.001). However, laparoscopic hysterectomy, laparoscopic hysterectomy with adnexal surgery, and abdominal hysterectomy with adnexal surgery did not increase anti-incontinence surgery as compared to the non-hysterectomy group before and after adjusting confounders. This significant relationship between abdominal hysterectomy and anti-incontinence surgery was maintained after stratifying patients according to age group. CONCLUSIONS: In conclusion, hysterectomy, especially transabdominal hysterectomy significantly increases the risk of subsequent anti-incontinence surgery. Our data suggest that patients who plan to undergo transabdominal hysterectomy for the treatment of uterine fibroids should know and be counseled about the risk of SUI and especially the risk of anti-incontinence surgery. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e513 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jun Ho Lee More articles by this author Expand All Advertisement PDF downloadLoading ...

Secondary alloanti-D immunization post transfusion of “Asia type” DEL red blood cells

Background“Asia type” DEL red blood cells (RBCs) express a very weak D antigen and cannot be detected by routine RhD typing. Thus, it is routinely typed as D-negative (D–) blood group and transfused to D– recipients. Here we described a case of secondary alloanti-D immunization that was associated with transfusion of DEL RBCs to D– recipients and was initially considered as primary alloanti-D immunization. Case presentationA 44-year-old D– woman (G2P2) with adenomyosis and anemia underwent transabdominal hysterectomy. She received four units of D– RBCs before operation. Before transfusion, the alloantibody screening test was negative. Four days after the first transfusion, she needed another RBC transfusion. Unexpectedly, the routine pre-transfusion alloantibody screening test became positive and anti-D (titer, 128-fold) was identified, indicating an alloanti-D immunization. The anti-D developed four days after the first transfusion was unexplained, so alloantibody identification was performed on the sample collected before the first transfusion, and weak anti-D combined with anti-E, which was not detectable during the previous routine pre-transfusion alloantibody screening test with non-enzyme-treated screening cells, was identified using bromelain-treated panel cells. The remaining blood samples of first transfusion in bag tails from two donors were collected for RHD genotyping analysis. One donor was later identified as “Asia type” DEL having RHD* 1227 A/01 N.01 genotype. ConclusionCaution should be applied when we conclude that transfusion of “Asia type” DEL RBCs to true D– recipients could induce primary alloanti-D immunization, especially if the short time interval between transfusion and detection of anti-D is observed.

Gynecologists Need to Be Vigilant-Two Case Reports of Intravascular Leiomyomatosis and Literature Review.

BackgroundIntravascular leiomyomatosis is a rare benign lesion with malignant potential. The cases are sporadic. Most patients have no clinical symptoms, and the preoperative diagnostic rate is low. Case 1 was misdiagnosed, passively managed during operation, recurred quickly, and underwent a secondary operation. We learned lessons from case 1 and treated the case 2 patient differently. The case 2 patient had a good prognosis. We hope the report will be helpful to other gynecologists.Case SummaryCase 1: a 49-year-old woman complained of dysmenorrhea. Traditional ultrasound showed adenomyosis and a solid mass 6 * 3 cm in the right appendix. After routine examination, the patient underwent transabdominal total hysterectomy + bilateral salpingectomy + IVL tumor resection, with both ovaries kept. No medication was used after operation. Routine ultrasound was performed every 3 months. The disease recurred, and the patient underwent a secondary surgery 9 months after the first time. So far, 25 months after the secondary surgery, there is no sign of recurrence. Case 2: a 41-year-old woman underwent a routine body examination, where a left adnexal mass 7 cm was found. The patient underwent contrast-enhanced ultrasonography and was diagnosed and prepared well preoperatively. The patient underwent transabdominal total hysterectomy + bilateral salpingectomy + IVL tumor resection. GnRH-a drugs were used after operation for 3 cycle. Now, there is no sign of recurrence after operation for 23 months.ConclusionThe incidence rate of IVL is low, and there are no typical clinical symptoms. It is easy to be ignored by gynecologists. Contrast-enhanced ultrasound is helpful to diagnose preoperatively and reduce misdiagnosis. Good preparation, full exploration of the pelvic and abdominal vessels, removal of lesions completely as much as possible, and anti-estrogen therapy after operation can reduce the recurrence of disease.

Clinical Course of 60 Cesarean Scar Pregnancies.

Early diagnosis and therapy are important in a cesarean scar pregnancy (CSP), which can cause uterine rupture with resultant massive bleeding. However, there are some reports of CSPs continued to term. The optimal management of CSPs remains unclear; therefore, we investigated the clinical courses of CSPs diagnosed and treated at perinatal institutions in the Chugoku and Shikoku regions of Japan. We enrolled 60 women diag-nosed with CSP at 21 institutions from January 2006 to December 2015. Of the 60 women diagnosed with CSP, 57 were treated. Pregnancy was terminated in 48 women and continued in 9. Thirteen women underwent transabdominal hysterectomy; they experienced no postoperative complications or allogeneic blood transfu-sion. Nine women received therapies such as dilation and curettage, and 26 received non-surgical therapies such as methotrexate and topical administration of potassium chloride. Among 9 women who chose to con-tinue with their CSP, 7 successfully delivered newborns, 2 had uterine ruptures in the second trimester, and all women required transabdominal hysterectomy. Diagnosis and therapy in the first trimester of pregnancy are important in the management strategy of a CSP. When continuing a CSP, the risk of uterine rupture and trans-abdominal hysterectomy must be considered.

Vault prolapse cases in Dr. Soetomo general hospital Surabaya

Vault prolapse is often occurred after hysterectomy procedure, and sometimes need a surgical repair.Study aimed to investigate the case of vault prolapse in which repeated operative procedures were performed at our teaching hospital, Dr. Soetomo General Hospital. The data in this case report were obtained through medical records and register books form Urogynecology Division of Obstetrics and Gynecology during 2015-2019. We analyse the characteristics of postoperative vault prolapse from patients after transabdominal hysterectomy and transvaginal hysterectomy procedure. In 2015-2019 there were 16 patients diagnosed with vault prolapse with a preoperative diagnosis of uterine prolapse (16 cases). Of the 16 cases of vault prolapse, 10 cases (62.50%) were post transabdominal hysterectomy procedure, and 6 cases (37.5%) were post transvaginal hysterectomy procedure.From a total of 16 cases of vault prolapse that were reoperated with various procedures. The surgery success rate was 87.5%.Various corrective procedures were performed again by the urogynecology division of Obstetrics and Gynecology. Dr. Soetomo General Hospital with good result.

HCG values and gestational sac size as indicators of successful systemic methotrexate treatment in cesarean scar pregnancy

ObjectiveTo retrospectively investigate cesarean scar pregnancy (CSP) patients who received systemic methotrexate (MTX) and to clarify the criteria for administering systemic MTX to CSP patients. Materials and methodsFifteen CSP patients who were initially treated with systemic MTX (50 mg/m2/week) were included. Nine patients, who needed a uterine artery embolization (UAE) or a laparotomy, including a transabdominal hysterectomy (TAH), were defined as the unsuccessful MTX group. Six patients who did not require UAE or a laparotomy were defined as the successful MTX group. Furthermore, the hCG cut-off value and the GS cut-off size at the time of CSP diagnosis, which differentiated successful and unsuccessful patients, were defined. MTX success rates were investigated by combining the hCG and gestational sac (GS) size cut-off values. ResultsThe hCG cut-off value was 17757.0 mIU/mL, and the GS cut-off size was 10.4 mm. In patients with hCG values less than 17757.0 mIU/mL, the MTX success rate was 75.0%. Fewer patients needed UAE or a laparotomy compared to patients with hCG values higher than 17757.0 mIU/mL (P = 0.007). In patients with a GS size less than 10.4 mm, the MTX success rate was 80.0%. Fewer patients among them needed UAE or a laparotomy compared to those among patients with a GS size greater than 10.4 mm (P = 0.089). In patients with hCG values and GS sizes lower than the cut-off values, the MTX success rate was 80.0%. Fewer patients among them needed UAE or a laparotomy compared to those among patients with hCG values and/or GS sizes higher than the cut-off values, respectively (P = 0.010). ConclusionPatients with hCG values less than 17757.0 mIU/mL and GS sizes less than 10.4 mm may have a greater chance of successful systemic MTX treatment when it is used as the first line of treatment for CSP.

Uterine angiomyolipoma: a clinical analysis of 8 cases and literature review.

Uterine angiomyolipoma (AML) is a rare condition involving benign tumors composed of varying proportions of blood vessels, fat, and epithelioid or spindled smooth muscle cells. We analyzed the clinicopathological features, diagnosis and treatment methods, and prognosis of uterine AML. We retrospectively analyzed the clinical-pathological data of eight patients with pathologically diagnosed uterine AML at a single center from January 2008 to July 2020. The mean age of the patients was 50years (range, 41-62). One patient was asymptomatic; the main clinical manifestations of the others included vaginal bleeding (3), menorrhagia (2), abdominal pain (1), and dysmenorrhea with adenomyosis (1). In one case, fat components observed via abdominal computed tomography led to a diagnosis of uterine leiomyolipoma; the rest were diagnosed as uterine leiomyoma (4), uterine fibroid degeneration (2), and pelvic mass (1). The lesions were in the body of the uterus (6), the fundus of the uterus (1), and the broad ligament (1). Seven patients had a focal soft tumor texture, and one had a tough texture; the lesions were yellow (3), yellow-white (3), and pinkish white (2). Surgeries included transabdominal myomectomy (2), transabdominal hysterectomy (2), transabdominal hysterectomy/bilateral salpingo-oophorectomy (2), and laparoscopic total hysterectomy/bilateral salpingectomy (2). The median follow-up time was 72months. No relapses were reported. Uterine AML has a low incidence rate and is most likely to occur in perimenopausal women. The clinical manifestations are similar to those of uterine leiomyomas, but AML should be suspected if the internal echo of the uterine tumor is uneven and contains adipose tissue.

Two primary cancers: Primary squamous cell carcinoma with extensive ichthyosis uteri and cervical endometrioid carcinoma: A case report.

Squamous cell carcinoma of the endometrium is extremely rare, accounting for approximately 1% of uterine body malignancies. The present report describes a case of squamous cell carcinoma of the uterine body arising from ichthyosis due to persistent pyometra. A 68-year-old Japanese woman, gravida 1 para 1, was referred to the Gynecological Department of Tokyo Women's Medical University, due to watery brown vaginal discharge which had persisted for 10 days. Pelvic magnetic resonance (MRI) imaging revealed a tumorous lesion occupying the cervical uteri, measuring 3 cm in diameter, and pyometra. The endometrial biopsy specimen obtained after drainage of the purulent fluid in the uterus was insufficient for obtaining a definitive pathological diagnosis. Under a clinical diagnosis of cervical tumor and pyometra, total transabdominal hysterectomy with bilateral salpingo-oophorectomy was performed. Histopathologically, two primary cancers were diagnosed, i.e., cervical endometrioid carcinoma and squamous cell carcinoma of the endometrium. The patient was treated with additional chemotherapy with carboplatin (area under the curve, 6) and paclitaxel (175 mg/m2). The patient has remained alive, without recurrence, for 1 year to date. In this case, preexisting cervical endometrioid carcinoma caused stenosis of the uterine orifice and also resulted in pyometra. The uterine body squamous cell carcinoma appeared to have been caused by persistent inflammatory stimuli to the endometrium. One must be cautious regarding cancer in elderly postmenopausal females presenting with pyometra. The findings in this case report suggest that chronic inflammation of the endometrium may be associated with primary squamous cell carcinoma of the endometrium.

The Median Effective Dose of One Intravenous Bolus of Oxycodone for Postoperative Analgesia After Myomectomy and Hysterectomy With Local Ropivacaine Wound Infiltration: An Up-Down Dose-Finding Study.

Oxycodone has been shown to be an effective analgesic for early postoperative analgesia, especially for abdominal operations associated with severe visceral pain. However, the dose needed varies depending on the operation and application of multimodal analgesia, such as local ropivacaine wound infiltration. Therefore, we conducted this study to estimate the median effective dose (ED50) of oxycodone that provides analgesia for hysterectomy and myomectomy with local ropivacaine wound infiltration. In this dose-finding study, the ED50 of oxycodone for postoperative analgesia was estimated separately for laparoscopic hysterectomy, transabdominal hysterectomy, laparoscopic myomectomy, and transabdominal myomectomy. We used the sequential allocation designed by Dixon. Trials were conducted simultaneously in the 4 surgical type groups. A predefined dose of oxycodone was injected 30 minutes before the end of the operation with an initial dose of 0.1 mg/kg. A series of trials were performed following the rule of a relative 10% increase in dose after inadequate analgesia and a relative 10% decrease in dose after adequate analgesia. The study was conducted until the collection of 7 crossover points was achieved. Local ropivacaine wound infiltration was administered during abdominal stitching. The mean blood pressure (MBP) and heart rate (HR) were analyzed to assess the hemodynamic changes associated with oxycodone administration. A total of 113 patients were included in the estimation of ED50: 28 each in the laparoscopic hysterectomy group and transabdominal myomectomy group, 27 in the transabdominal hysterectomy group, and 30 in the laparoscopic myomectomy group. The estimated oxycodone ED50 (95% confidence interval [CI]) after laparoscopic hysterectomy, transabdominal hysterectomy, laparoscopic myomectomy, and transabdominal myomectomy was 0.060 mg/kg (0.053-0.068), 0.079 mg/kg (0.072-0.086), 0.060 mg/kg (0.051-0.071), and 0.092 mg/kg (0.086-0.098), respectively, for postoperative analgesia with local ropivacaine wound infiltration. The ED50 of oxycodone was different between laparoscopic surgeries and transabdominal surgeries (P < .001). The MBP and HR before and after oxycodone injection were different, regardless of surgical type. The oxycodone ED50 for postoperative analgesia was lower for laparoscopic hysterectomy (0.060 mg/kg) and laparoscopic myomectomy (0.060 mg/kg) than for transabdominal hysterectomy (0.079 mg/kg) and transabdominal myomectomy (0.092 mg/kg) when combined with local ropivacaine wound infiltration. A single intravenous injection of oxycodone is associated with an acceptable decrease in MBP and HR within a short time.

Laparoscopic Hysterectomy versus Abdominal Hysterectomy for Obese Women with Benign Diseases

Background: Obesity is a challenging health problem in gynecologic surgery. Laparoscopic has the potential advantages than abdominal hysterectomy of being quicker, efficient with low estimated blood loss.Aim of the work: To compare the safety and effectiveness of laparoscopic and abdominal hysterectomy for benign conditions in obese patients. Patients and Methods: Sixty patients were submitted to history taking, clinical examination, Lab investigations, abdominal ultrasound and biopsy for suspicious pathology. Patients divided into two equal groups. The first for total laparoscopic hysterectomy and the second for trans-abdominal hysterectomy. Patients were followed for six months after surgery. Data collected include operative time, amount of blood loss, complications and duration of hospital stay. Results: BMI was significantly higher among open when compared to laparoscopic group (43.69±3.86 vs 34.5±4.02 respectively), and low parity and low cesarean deliveries were significantly increased in laparoscopic group. The highest indication of hysterectomy in laparoscopic group was adenomyosis (43.3%) followed by fibroid (30.0%), while in open group, the most common indication was fibroid (53.3%) followed by adenomyosis (26.7%). Operative time showed significant decrease in laparoscopic when compared to open hysterectomy groups (56.23±21.5 vs 78.87±8.22 minutes respectively) and blood loss was significantly decreased among laparoscopic group. Finally, the length of hospital stay was significantly decreased in laparoscopic when compared to open groups (the median was 10 versus 24 hours respectively). Conclusion: Laparoscopic hysterectomy is superior to abdominal hysterectomy in obese females with benign conditions in terms of safety and efficacy.