BACKGROUND Robot-assisted hysterectomy (RASH) for benign uterine disease has been covered by insurance in Japan since 2018. Our department introduced RASH in December 2020, and the number of procedures has increased without major complications. Herein, we report a case in which robot-assisted surgery required intraoperative conversion to conventional laparoscopy because of an unexpected robotic system shutdown. CASE REPORT A 54-year-old multiparous woman presented with hypermenorrhea and anemia caused by uterine adenomyosis. After unsuccessful conservative treatment, definitive surgical management was planned. Following 6 months of gonadotropin-releasing hormone analog therapy, RASH was performed using the da Vinci X system. Four robotic ports and a single 5-mm assistant port were placed. Total operative time was 202 minutes, including 148 minutes of console time. After transvaginal uterine removal and vaginal cuff closure, the robotic system suddenly underwent an emergency shutdown during confirmation of hemostasis, making intracorporeal manipulation impossible. Although the manufacturer was contacted immediately and troubleshooting was attempted, the system could not be restored. Therefore, the operation was converted to conventional laparoscopic surgery using the same port placement, and the procedure was completed successfully. The postoperative course was uneventful, and the patient was discharged without complications. CONCLUSIONS Robot-assisted surgery is increasingly used in gynecology because of its minimally invasive advantages. However, surgeons should be prepared for unexpected events such as robotic system failure. Familiarity with laparoscopic surgical techniques enables safe continuation of surgery in such situations. This case highlights the importance of maintaining laparoscopic surgical skills to ensure the safe performance of robot-assisted procedures.

OBJECTIVE The objective of this study was to demonstrate an ameliorated laparoscopic technique of cornual resection that minimizes complications during the management of cornual ectopic pregnancy. DESIGN Stepwise demonstration of the technique is presented with narrated video footage. The difference between this and other conventional methods is illustrated. SETTING Cornual pregnancy accounts for 2%–4% of all ectopic pregnancies.[1] Conventional laparoscopic management includes cornuostomy, cornual resection, and wedge resection.[2,3] Possible issues with these procedures are disruption of the fetal capsule, injury to the myometrium accompanied by bleeding, and persistence of trophoblastic tissue.[1–3] Our modified cornual resection method can avoid the issues mentioned above. INTERVENTIONS In the video, Table 1 shows how cornuostomy, wedge resection, cornual resection, and our method compare in terms of technical difficulty, fetal capsule manipulation, fallopian tube preservation, trophoblastic tissue retention, myometrial damage, and bleeding [Video 1]. Cornuostomy is considered the simplest method to perform; however, the fetal capsule is grasped and damaged during this procedure. As a result, trophoblastic tissue may be retained. During a cornual wedge resection, the fetal capsule and the myometrium around it are completely removed, and bleeding is a common complication. Although these adverse events can be minimized during a cornual resection, this procedure is technically challenging because the fetal capsule must be carefully grasped. If the capsule ruptures, cornuostomy must be performed. Our modified cornual resection addresses these issues by shifting the incision line from the uterine serosa to the fallopian tube [Figure 1], which is also the portion that is manipulated. In addition, electrocoagulation of the mesosalpinx and an injection of diluted vasopressin into the myometrium significantly reduce bleeding. However, the fallopian tube cannot be preserved with our method. As this method is not difficult for experienced surgeons to perform, we propose that it can be an appropriate option for managing a cornual pregnancy since it allows for complete fetal capsule and trophoblastic tissue removal with minimal bleeding and myometrial damage.Table 1: Comparison with traditional methods {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video Clip 1","caption":"","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_ay6peyp6"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Figure 1: Differences in incision lines of each technique. http://www.apagemit.com/page/video/show.aspx?num=301CONCLUSION Our method enables the complete resection of the fetal capsule without disrupting it or damaging the myometrium, resulting in minimal bleeding. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

IntroductionIn Japan’s Cervical Cancer Screening Guidelines (2020), the cervical cytology alone method is recommended to be performed every 2 years as a cervical cancer screening. On the other hand, its sensitivity and specificity are varied, respectively, and approximately 6% of the results are false-negative. In this study, we investigated the status of cervical cancer screening in the 2 years prior to diagnosis in our cervical cancer cases, and examined risk factor(s) for underestimation by screening.MethodsCervical cancer patients who underwent initial treatment at our hospital between January 2012 and February 2022 were included in the study. Patient backgrounds (age at diagnosis, previous history, history of vaginal delivery, menstrual history, etc.) and cervical cancer screening status and results in the two years prior to diagnosis were extracted from medical records, and statistical analyses were conducted for patients whose cytological diagnosis was underestimated.ResultsThere were 323 cervical cancer cases during the study period. Of these, 22 patients (6.9%) were in the underestimated group who had undergone cervical cytology screening in the 2 years prior to diagnosis and had been diagnosed as normal. A history of cervical conization was found in 3 patients (13.6%) of the underestimated group and in 10 patients (3.3%) of the control group (n=301), which was statistically significant (p=0.0175).Conclusion/ImplicationsIt is well known that cervical cancer screening is necessary even after conization for CIN3. Moreover, we hypothesize that results of cervical cytology screening alone may be underestimated in patients with a history of previous cervical conization.

Background Progestin-primed ovarian stimulation (PPOS) has been used in infertility cases in recent years, and several reports have stated that it has oocyte collection results similar to those of gonadotropin-releasing hormone antagonist (GnRH-ant) protocol. For emergency fertility preservation, random-start ovarian stimulation is usually recommended. Therefore we compared the clinical outcomes of random-start PPOS with those of conventional random-start GnRH-ant protocols in fertility-preserving cases. Methods We retrospectively examined 86 cycles of oocyte collection, of which 56 were random-start GnRH-ant and 30 were random-start PPOS for fertility preservation at our hospital between January 2016 and April 2021. The primary outcome was the number of mature oocytes per cycle. The secondary outcome was the number of vitrified blastocysts per cycle for embryo freezing cases. Results No significant differences were noted in the number of days of stimulation, total dose of gonadotropin preparation, and the number of mature oocytes and vitrified blastocysts. The number of hospital visits for monitoring was significantly lower in the PPOS group. The start of menstruation before oocyte collection was significantly less in the PPOS group. Conclusions Random-start PPOS and GnRH-ant were similar in oocyte collection results. PPOS can reduce the number of hospital visits, thus reducing patient stress. PPOS at the start of the luteal phase can prevent the start of menstruation during ovarian stimulation.

AIM:Relatively small benign ovarian cysts are conservatively managed in early pregnancy. However, emergency surgery is required should acute abdomen occur. Our study aimed to examine and compare the outcomes of benign ovarian cysts treated with elective laparoscopic surgery or emergency surgery during pregnancy. METHODS:From 2004 to 2017, we treated 135 pregnant patients (110 elective and 25 emergencies) with benign ovarian cysts at our tertiary perinatal center and compared their surgical and perinatal outcomes. RESULTS:There was no significant difference in cyst diameter (7.6 ± 2.5 vs. 6.8 ± 2.1 cm), but cysts <6 cm were significantly more common in emergency (36%) than in elective (15%) cases. Mature teratomas were significantly more common in elective cases (89% vs. 52%) but corpus luteum cysts were more common in emergency cases (0% vs. 32%). The rates of laparoscopic surgery (98.2% vs. 52.0%) and ovarian conservation (99.1% vs. 80.0%) were significantly higher, and post-surgical hospitalization (4.6 ± 1.3 vs. 9.8 ± 10.5 days) was significantly shorter in elective than in emergency cases. There was no significant difference in the gestational age for delivery (38.9 ± 1.9 vs. 38.4 ± 2.7 weeks), preterm birth rate (12% vs. 20%), or birth weight (2939 ± 469 vs. 3019 ± 510 g). CONCLUSIONS:We cannot state that an emergency surgery during pregnancy is rarely required for small benign ovarian cysts. However, the surgical outcomes were significantly better for elective than for emergency surgery, with no difference in perinatal outcomes. If a benign ovarian cyst is found early in pregnancy, elective laparoscopic surgery may be considered with adequate informed consent.

Endometrial stromal sarcoma, a rare disease, accounts for approximately 0.2％ of all types of uterine malignancies. The disease may be difficult to differentiate from the benign one using preoperative imaging and histological diagnosis. We report a case of a patient who underwent robot-assisted surgery for uterine adenomyosis and was diagnosed with low-grade endometrial stromal sarcoma. She underwent additional laparoscopic surgery using the initial surgical wound. A 45-year-old gravida 4, para 2 was referred because of excessive menstruation caused by uterine adenomyosis. Ultrasound and magnetic resonance imaging revealed uterine adenomyosis and a 5-cm right endometrioid ovarian cyst. Cytology did not reveal any suspicious findings for malignant disease. Hormone therapy was initiated, but bleeding and anemia were observed. Hence, robotic surgery was performed. Robot-assisted laparoscopic hysterectomy, right adnexectomy, and left tubectomy were performed using the da Vinci Xi system. The patient was discharged without any postoperative problems.

With an incidence of 0.005%, unscarred uterine rupture is extremely rare. It is difficult to diagnose uterine rupture because of the absence of characteristic clinical symptoms. Here, we report a rare case of a 31-year-old woman with a uterine rupture that was accurately diagnosed and repaired by laparoscopy and hysteroscopy on postpartum day 69. The patient recovered uneventfully and was discharged on postoperative day 4. Three months after surgery, pelvic magnetic resonance imaging was performed, which confirmed wound repair. In women with a stable condition, laparoscopy with hysteroscopy could be an alternative choice for the diagnosis and treatment of suspected uterine rupture; however, more substantial studies are needed to confirm this surgical approach.

Introduction: Interstitial pregnancies are rare. There have been sporadic reports of postoperative uterine scar rupture; precise frequency is unknown. Herein, we report a case where uterine rupture was observed during a cesarean section after surgery for interstitial ectopic pregnancy.

Introduction: Pelvic inflammatory disease (PID) affects 4% of women, especially in younger age groups and occasionally, in patients with diabetes. We report a case of PID treated with laparoscopic surgery in a patient with uncontrolled type 2 diabetes mellitus.

Background In the field of oncofertility, patients with breast cancer are often administered letrozole as an adjuvant drug before and after oocyte retrieval to prevent an increase in circulating estradiol. Case presentation We report a case of abdominal hemorrhage due to an ovarian rupture in a 29-year-old Japanese patient who restarted letrozole 2 days after an oocyte retrieval procedure in which 14 mature oocytes were retrieved. The patient had sought embryo cryopreservation as a fertility preservation option before undergoing treatment for recurrent breast cancer. A day after restarting letrozole treatment, the patient unexpectedly developed severe abdominal pain. Laparoscopic hemostasis was performed to manage the ovarian swelling and hemorrhage. Conclusions The ovaries can be restimulated by restart letrozole after an oocyte retrieval procedure. Therefore, reproductive-medicine practitioners should understand the potential complications of letrozole administration in such cases and take steps to ensure that they are minimized.

Objectives: Pregnancy complicated with ovarian endometrioma is a risk factor for preterm delivery and rupture or infection during pregnancy. This study aimed to clarify the effectiveness and safety of transvaginal aspiration during pregnancy for endometrioma diagnosed in the first trimester. Design: This retrospective observational study included 8 pregnant women with endometrioma who under-went transvaginal cyst aspiration at 12-14 weeks (aspiration group) between March 2011-March 2018 and 23 pregnant women with endometrioma who refused aspiration during the same period (observation group). Methods: Characteristics of patients were compared in both groups. Safety, feasability and complications of transvaginal cyst aspiration were reported. Complications and obstetrical outcomes were reported and compared in both groups. Results: The maximum cyst diameter was 8.9 +/- 1.5 cm (mean +/- standard deviation) in the aspiration group, which was significantly larger than that in the observation group (4.7 +/- 0.2 cm). Four preterm deliveries (17.3%) occurred in the observation group and none in the aspiration group. The emergency cesarean section rate during delivery was 14.2% in the aspiration group and 43.7% in the observation group. Conclusions: The aspiration group tended to have lower rate of preterm deliveries and emergency cesarean sections, suggesting that cyst aspiration could be an effective, minimally invasive, and safe management option for endometrioma during pregnancy. (C) 2021 The Author( s). Published by Elsevier Masson SAS.

Introduction: A unicornuate uterus with a noncommunicating rudimentary horn is a rare congenital uterine malformation that causes lower abdominal pain and dysmenorrhea due to endometriosis and uterine hematoma. We encountered a case of a unicornuate uterus with a noncommunicating rudimentary horn that was safely treated through laparoscopic removal of the rudimentary horn. The treatment strategy was determined following evaluation of preoperative 3D-reconstructed computed tomography (CT) images.

Aim Perinatal group A streptococcal infection is a rare but life-threatening condition. Few reports have focused on its clinical characteristics and how to prevent deterioration. We report our experience with two antenatal fatal cases and reviewed 96 cases in the literature to assess the clinical characteristics of group A streptococcal infection. Methods English-language clinical reports of antenatal and postnatal group A streptococcal infection in 1974-2019 were retrieved and examined. Relationships between clinical characteristics and maternal outcomes were assessed. Results Univariate analysis revealed that antenatal group A streptococcal infection was significantly associated with an age of <= 19 or >= 35 years, cesarean section, sore throat as an initial symptom, positive throat culture, maternal death and fetal death. Multivariate analysis revealed that antenatal onset (odds ratio = 7.922, 95% confidence interval = 1.297-48.374;P= 0.025) and a quick sepsis-related organ-failure assessment score (qSOFA; low blood pressure, high respiratory rate or altered mental status) of >= 2 (odds ratio = 6.166, 95% confidence interval = 1.066-35.670;P= 0.042) were significantly related to maternal death. Conclusion Per our findings, antenatal group A streptococcal infection was significantly associated with maternal and fetal death. Further, the antenatal infection was revealed as a more critical risk factor. We suggest that the presence of any sign related to the qSOFA is a potential clue suspecting perinatal group A streptococcal infection in primary obstetric facilities.

Laparoscopic myomectomy (LM) is currently widely used as surgical treatment for uterine fibroids; however, it may be technically challenging in some patients with cervical fibroids in whom laparotomy needs to be performed. Reportedly, preoperative uterine artery embolization and intraoperative cutting and ligation of the uterine artery reduce intraoperative bleeding during myomectomies. Notably, maintaining maximal uterine blood flow is necessary in patients who desire fertility preservation; unfortunately, currently, no such method is available.

Background Ovarian hyperstimulation syndrome is normally induced by ovarian stimulation drugs. Severe cases of ovarian hyperstimulation syndrome involve complications such as renal failure and thrombosis. Evidence has recently been developed for a method to prevent ovarian hyperstimulation syndrome. Most cases of ovarian hyperstimulation syndrome are of an early-onset type, which occurs shortly after injection of human chorionic gonadotropin. However, late-onset ovarian hyperstimulation syndrome, which occurs in a pregnancy cycle, also requires caution. We report our experience in treating a woman who was transported to our hospital with a severe case of ovarian hyperstimulation syndrome occurring during ovarian stimulation and who was determined to have an ectopic pregnancy. Case presentation Assisted reproductive technology was planned for a 29-year-old nulligravida Japanese woman diagnosed with bilateral fallopian tube obstruction and right-sided hydrosalpinx. On day 1 of controlled ovarian stimulation, the result of her human chorionic gonadotropin urine test was negative, and her serum levels of luteinizing hormone, estradiol, and progesterone were normal. On day 11 of controlled ovarian stimulation, the levels of estradiol and progesterone had risen to 9679 pg/ml and 16 ng/ml, respectively, prompting suspension of controlled ovarian stimulation. Eleven days after controlled ovarian stimulation was suspended, the patient demonstrated ascites that did not improve despite administration of cabergoline, and she was transported to our hospital 2 days after. Late-onset ovarian hyperstimulation syndrome suggested that she was pregnant, and her serum human chorionic gonadotropin level was 27,778 IU/ml. She underwent laparoscopic bilateral salpingectomy and was diagnosed with right tubal pregnancy. Conclusion In an ectopic pregnancy, human chorionic gonadotropin sometimes increases later than in an intrauterine pregnancy. In our patient’s case, endogenous human chorionic gonadotropin following the start of controlled ovarian stimulation may have caused late-onset ovarian hyperstimulation syndrome. The key to early detection of similar cases may be to suspect pregnancy in the event of unexpectedly high progesterone levels during ovarian stimulation.

Aim The high rate of stored preoperative autologous blood wastage is concerning. This study analyzed patients who provided preoperative autologous blood donations (PABDs) for massive bleeding during surgery for placenta previas and low-lying placentas, and investigated the optimal PABD storage volume required to avoid allogeneic transfusion. Methods Of 386 patients who provided PABDs at our hospital from 2008 to 2013, 269 patients with placenta previas or low-lying placentas were retrospectively analyzed. The PABD storage volumes were stratified into four groups based on the amounts stored, and the allogeneic transfusion usage frequencies were compared. Results A total of 124 patients (46.1%) received PABDs and 12 patients (4.5%) received allogeneic transfusions. The average PABD volume wasted was 23 940 mL/year. The allogeneic transfusion utilization rate was significantly higher in the 1- to 300-mL group (17.2%) than in the 301- to 600-mL (1.69%), 601- to 900-mL (3.82%), and 901- to 1200-mL (0%) groups (P < 0.05). The PABD cut-off volume for avoiding allogeneic blood transfusion was 300 mL, and the odds ratio for <= 300-mL PABD in a multivariate analysis was 14.3 (95% confidence interval 1.3-149.3; P = 0.03). The maximum surgical blood order schedule was 2.16 units (432 mL), and the surgical blood order equation was 2.15 units (430 mL). Conclusion The allogeneic transfusion utilization rate did not differ between the 600-mL group and the groups with higher PABD storage volumes; hence, storing 600 mL of PABD was appropriate for surgery for placenta previas and low-lying placentas.