Aim: To investigate the efficacy and safety of long-term adjusted low-dose gonadotropin-releasing hormone agonist therapy (GnRH agonist drawback therapy) with nafarelin acetate in patients with uterine fibroids and/or adenomyosis with menstrual symptoms. Methods: This single-center, retrospective, observational study initially included 118 patients with uterine fibroids and/or adenomyosis with menstrual symptoms who had received GnRH agonist (nafarelin acetate) drawback therapy for at least 7 months between 2010 and 2020. Blood hemoglobin level, maximum fibroid diameter, area of the corpus uteri, blood estradiol level, daily dosage of nafarelin acetate, and bone density in the lumbar spine and femoral neck were assessed before and after the treatment initiation. Results: The median treatment period was 28 months. Menstruation had ceased in all patients. The median hemoglobin level significantly increased from 8.6 to 13.2 g/dL before treatment and at 12 months after the treatment initiation in patients with fibroids and from 8.8 to 13.3 g/dL in patients with adenomyosis, respectively. Although the treatment did not exert a significant shrinking effect on the fibroids and adenomyosis, an increase in their size was not observed in any patient. The initial dose of nafarelin acetate was 400 mu g/day and was lowered to 130 mu g/day at 12 months. Only 29 patients (25%) had an estradiol level <30 pg/mL. The average rate of bone density change over 6 months was -1.23% in the lumbar spine and -1.12% in the femoral neck in patients with fibroids and -1.06% in the lumbar spine and -0.14% in the femoral neck in patients with adenomyosis, which were lower than the previously reported rates. Conclusions: GnRH agonist drawback therapy was found to be useful for the long-term conservative treatment of uterine fibroids and adenomyosis. The treatment was safely and inexpensively performed with few adverse events.

Uterine artery embolization (UAE) is less invasive therapy for uterine fibroids; however, it can lead to infection in the uterus, ovary, and fallopian tube. We report the case of a patient who developed a pyomyoma two years after undergoing UAE, and subsequently underwent total laparoscopic hysterectomy (TLH). This report presents our findings.

Objective: In recent years, minimally invasive surgery has been emphasized in gynecological surgery, and total laparoscopic hysterectomy has been increasingly reported. In this retrospective single-center study, the main objective was to identify risk factors for the development of surgical-site infection (SSI) after total laparoscopic hysterectomy. The secondary objective was to investigate the efficacy of transvaginal drainage as a treatment for SSI. Methods: This retrospective study investigated 377 patients who underwent total laparoscopic hysterectomy in the Department of Obstetrics and Gynecology at the Saitama Medical Center, Saitama Medical University, Japan between January 1, 2015 and December 31, 2019. Patients were divided into the SSI group and non-SSI group based on whether they suffered from SSI. The data of preoperative, intraoperative, and postoperative risk factors for SSI were collected and analyzed. Results: Of the 377 patients who underwent total laparoscopic hysterectomy, 21 patients were in the SSI group and 356 patients were in the non-SSI group. After the comparison between the two groups and the multivariate analysis, only the C-reactive protein level on postoperative day 3 (OR =1.556, 95% CI: 1.233 -1.964, p < 0.001) showed a significant correlation with SSI. The receiver operating characteristic curve revealed that the C-reactive protein level >7.6 mg/dL on postoperative day 3 could detect the SSI onset early. In the SSI group, the hospital stay was longer for patients with transvaginal drainage than for patients without (17.40 +/- 3.21 d vs. 10.90 +/- 2.39 d, p = 0.0027). However, none required reoperation. Conclusions: Patients with a high postoperative C-reactive protein level may be experiencing SSI, and ultrasonography and other imaging procedures should be performed immediately. If a vaginal abscess is confirmed on imaging, transvaginal drainage should be performed early, which may prevent reoperation. (c) 2022 Zhejiang University. Publishing services by Elsevier B.V. on behalf of KeAi Communications Co. Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/ by-nc-nd/4.0/).

Background: Vaginal cancer is rare, accounting for only about 2% of all cancers of the female reproductive organs, and it is a disease that is rarely encountered in routine clinical practice. Vaginal cancer is mainly treated with radiation therapy or concurrent chemoradiotherapy (CCRT). However, in stage I-II cases, when the lesion is confined to the upper third of the vagina, surgical treatment may include total hysterectomy and vaginal resection with an adequate resection margin. We report a case of stage I vaginal cancer diagnosed at 13 weeks of gestation. There are very few reports on the diagnosis and treatment of vaginal cancer during pregnancy, and it was difficult to decide on a treatment plan; therefore, we report on the course of treatment followed for this patient. Case presentation: The patient was a 38-year-old woman with a history of two pregnancies and zero births. The patient had thrombocytopenia and was diagnosed highly suspicious of myelodysplastic syndrome by bone marrow biopsy, and her platelet count remained at approximately 50,000/uL. At the time of the 11-week gestational checkup, a 4-cm pedunculated tumor was found in the right posterior vaginal fornix. Transvaginal tumor resection was performed at 13 weeks of gestation, and the patient was diagnosed with stage I vaginal cancer (squamous cell carcinoma). Because vaginal cancer was confined to the posterior vaginal wall fornix, radical surgery after abortion was suggested as a treatment plan. However, the patient strongly desired to continue the pregnancy, so the policy was to continue the pregnancy and follow-up. However, at 22 weeks of gestation, a recurrent tumor was found in the posterior fornix of the vagina. The lesion had invaded the paravaginal tissue, making radical surgery impossible. At 26 weeks of gestation, an elective cesarean section was performed because of giving priority to early therapeutic intervention to her recurrent vaginal cancer, and it was decided that CCRT with cisplatin would be administered from postpartum day 1. However, because of thrombocytopenia, chemotherapy could not be co-administered, and the treatment was completed with radiation alone. The therapeutic effect was partial response, but 13 weeks after the end of radiation therapy, we observed regrowth of the recurrent tumor and emergence of pelvic lymph node metastasis. The patient received palliative treatment but died 8 months after delivery due to a generally deteriorating condition, sepsis, and disseminated intravascular coagulation. Conclusions: In cases of malignant tumors associated with pregnancy, treatment policies should consider the perinatal prognosis at the same time as treatment for malignant tumors, and gynecologic oncologists, obstetricians, and neonatologists, from the standpoint of their respective specialties, should thoroughly discuss the "curative effect of treatment for malignant tumors" and the "prognosis of the child after birth" and consider the treatment plan for each case.

Objective:When performing cervical conization in post-menopausal cervical intraepithelial neoplasia 3(CIN3)patients,the positive rate of endocervical cone margin and the incidence of postoperative cervical stenosis increase.This study summarized a 4-year experience of total laparoscopic hysterectomy as a treatment option for peri-menopausal and post-menopausal CIN3 patients at a single institution.Furthermore,it shared the refinement strategies used during the surgery.Methods:This study retrospectively analyzed the medical records of CIN3 patient aged＞45 years and who underwent open or laparoscopic hysterectomy at our institution from January 1,2017 to December 31,2020.Totally,30 CIN3 patients were enrolled and divided into abdominal hysterectomy group and laparoscopic hysterectomy based on surgery method,with 5 patients and 25 patients respectively.Results:Compared to the abdominal hysterectomy group,the perioperative blood loss(20 mL vs.220 mL,p=0.004)was less and the duration of in-hospital stay(7 d vs.11 d,p＜0.001)were significantly shorter in the laparoscopic hysterectomy group.However,no significant differences in age at hysterectomy(53 y vs.77 y,p=0.054)and operative time(154.4±27.8 min vs.161.0±62.4 min,p=0.826)were observed between them.Diagnostic conization was performed in advance for 12 patients,and among them,10(83.3％)patients had positive endocervical cone margin.Postoperative intestinal obstruction was noted in one abdominal hysterectomy patient,no other complications were observed in the remaining patients.Conclusion:Compared to conization,hysterectomy is more invasive;however,it is an acceptable treat-ment option for peri-menopausal and post-menopausal CIN3 patients.In such cases,opting for total laparoscopic hysterectomy adopted the marionette technique might be preferable because the procedure is less invasive.

Background:Laparoscopic surgery for malignant tumours occasionally results in recurrence at the trocar insertion site or port-site metastasis (PSM). We report on a patient requiring emergency laparoscopic surgery for an ovarian tumour with a review of the relevant literature.Case Report:A 42-year-old woman developed sudden abdominal pain and underwent laparoscopic right adnexectomy because of a suspected ovarian cystic tumour rupture. The postoperative histological diagnosis was a mucinous borderline ovarian tumour; however, an undifferentiated carcinoma was detected at the port site eight months after the initial surgery. The histopathological diagnosis of the abdominal wall tumour at the port site differed from intraoperative pathological findings, which was contradictory to PSM definition. Postoperatively, she received three systemic chemotherapy courses but died consequent to tumour metastasis.Conclusion:This is an atypical PSM case with histopathological differences from the initial tumour. Careful preoperative diagnosis and intraoperative attention are essential in such cases.

Objective: Incarcerated gravid uterus is a condition in which uterine myoma and intraperitoneal adhesion lead to persistent uterine retroversion. Accurate diagnosis before cesarean section is crucial so that the procedure can be planned with regard to the spatial relationship between the uterine incision and other organs. This study investigated the effects of well-planned management on the outcome of cesarean sections. Materials and methods: Four patients with incarcerated gravid uterus who received well-planned management and preoperative magnetic resonance imaging were compared with three unexpected patients who were operated without preoperative diagnosis. Results: In the preoperatively diagnosed group, compared with the non-preoperatively diagnosed group, the frequency of cervical canal damage tended to be lower (0% vs. 100%), blood loss tended to be less (1171 +/- 290 mL vs. 2000 +/- 300 mL), and surgery duration tended to be shorter (82 +/- 17 min vs. 147 +/- 84 min). None of the preoperatively diagnosed cases required allogeneic blood transfusion, and no organ damage was observed. Conclusion: The early detection of a suspected incarcerated uterus, and a thorough understanding of diagnostic methods and the use of preoperative magnetic resonance imaging and ultrasonography facilitate the safe performance of a cesarean section. (c) 2021 Taiwan Association of Obstetrics & Gynecology. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

OBJECTIVE:A puerperal vulvovaginal hematoma may continue to grow after a surgical procedure and may require blood transfusion. Thus, we selected arterial embolization for hemostasis as the first-line management in two cases of large vulvovaginal hematoma.MATERIALS AND METHODS:Case 1 was a 32-year-old pregnant woman. After delivery, a 10-cm vulvar hematoma developed. An enhanced computed tomography (CT) scan revealed active bleeding. Arterial embolization was performed and complete hemostasis was obtained. Case 2 was a 34-year-old woman with a recurring hematoma after delivery. An enhanced CT scan revealed extravasation in the hematoma. Gelatin sponges were applied and complete hemostasis was obtained. In both cases, arterial embolization was successful without requiring blood transfusions.RESULTS AND CONCLUSION:We successfully managed two cases of puerperal vulvovaginal hematoma by arterial embolization based on the evaluation of an enhanced CT scan. In conclusion, we suggest arterial embolization to be a viable option for first-line treatment in the management of vulvovaginal hematomas.

Objective: Instrument-assisted vaginal delivery is a significant risk factor for birth canal lacerations. Although many obstetricians recently are recommending restrictive rather than a routine episiotomy, reports have shown restrictive episiotomy to be associated with more extensive anterior birth canal trauma compared with routine episiotomy.Materials and Methods: We retrospectively reviewed 110 cases of forceps and vacuum deliveries and investigated the site of birth canal lacerations. Birth canal lacerations were divided into four sites according to direction-anterior, ipsilateral, contralateral, and posterior.Results: The frequency of lacerations were, from most to least, posterior (34%), lateral (21.7%), and anterior (1.9%). Moreover, among the lateral lacerations, they were more frequent in the contralateral side of episiotomy than the ipsilateral side (18.9% vs. 4.7%, p < 0.01).Conclusion: Our results indicate that caution is also needed concerning not only the anterior site, but also the contralateral site of an episiotomy to prevent laceration in an instrument-assisted vaginal delivery. Copyright (C) 2016, Taiwan Association of Obstetrics & Gynecology. Published by Elsevier Taiwan LLC.

Background: The Japan Society of Obstetrics and Gynecology (JSOG) guidelines, revised in 2013, recommend that the numbers of traction should be at most five repetitions in vacuum extraction. Forceps extraction is less likely to fail compared with vacuum extraction and requires less equipment and preparation. At our institution, forceps delivery was not a standard procedure, but in response to revisions of the JSOG guidelines, we launched an education program on forceps delivery for residents in January 2013. We report the results of introduced delivery at our institution.Methods: An education program for residents covering forceps delivery was introduced at our institution in January 2013. We conducted a retrospective review of medical records of 108 patients who had deliveries by either forceps or vacuum extraction from January 2013 through July 2015 in our institution. We compared maternal and neonatal outcomes between forceps and vacuum deliveries for all cases as well as those delivered by trainees.Results: The rates of forceps and vacuum deliveries performed by trainees were 60.9% and 50.0%, respectively. Two or more tractions were required in 18/62 (29.0%) of vacuum deliveries vs. 3/46 (6.5%) of forceps deliveries. There was significantly more bleeding in forceps deliveries compared with vacuum deliveries (616.3 +/- 322.3 g vs. 465.2 +/- 274.9 g). There was one failed vaginal delivery in each group. The rate of cephalohematoma was significantly higher in vacuum deliveries (12/62, 19.4%) vs. forceps deliveries (1/46, 2.17%). Facial abrasion caused by the equipment was significantly more frequent in forceps deliveries (6/46, 13.0%) vs. vacuum deliveries (1/62, 1.6%). Similar results were found between all cases and cases delivered by trainees.Conclusion: Forceps delivery was introduced as a clinical practice that is as safe as vacuum delivery. It is conceivable that training and indication for forceps delivery were of importance.

Mitochondrial disease exhibits various symptoms and is rarely seen in young women. We report the case of a patient with mitochondrial disease complicated with maternal inherited diabetes-deafness (MIDD) who suffered a severe clinical course. A 33-year-old primipara woman had a history of diabetes, diagnosed when she was 18 years old, and was treated with insulin injection. At 24 years old, genetic testing was performed and a point mutation of mitochondrial DNA in m3243 was identified. She was admitted to our hospital at 23 weeks of gestation because of threatened preterm labor and was treated with magnesium sulfate infusion. General malaise developed shortly after and the tocolytic agent was changed to ritodrine hydrochloride. She developed preeclampsia at 33 weeks of gestation and an emergency cesarean section was performed. After the cesarean section, UAE was performed due to uterine hemorrhage after birth and, because of infection, a hysterectomy was performed. An increased risk of preeclampsia, preterm birth and magnesium toxicity has been reported in pregnancies complicated with mitochondrial disease. Obstetricians need to recognize this disease as a perinatal risk factor.

Aim We investigated the neonatal outcome in chronically hypertensive patients with controlled hypertension, uncontrollable hypertension, or superimposed pre-eclampsia. Material and Methods The study included 120 patients who had chronic hypertension and were divided into three groups for which the perinatal and neonatal outcomes were retrospectively compared: pre-eclampsia superimposed on chronic hypertension (SP: n=28), chronic hypertension with severe hypertension uncontrolled in spite of intravenous or multiple oral antihypertensive medications in the latter half of pregnancy (uCH: n=44), and chronic hypertension with controlled to mild hypertension with or without medication (cCH: n=48). Results Preterm birth rate incidence was significantly higher in the SP and uCH groups than in the cCH group (P<0.05 for both). The incidence rates of low birthweight, very low birthweight, and extremely low birthweight for the groups were as follows: SuCH>cCH. Admission to the neonatal intensive care unit was significantly higher in the uCH and SP groups than in the cCH group (P<0.05 for both). Conclusion Like superimposed pre-eclampsia, uncontrolled chronic severe hypertension during late pregnancy results in a poorer neonatal outcome than controlled chronic mild hypertension. We conclude that absolute blood pressure can be used as a predictor of clinical outcome in pregnant chronic hypertension patients.