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Objective: To evaluate the regression rate of endometrial polyps (EPs) in a cohort of asymmetric women after conservative follow-up. Materials and methods: In this retrospective cohort study, a total of 1006 women with asymptomatic EPs were treated with expectant management or hormonal drugs between June 1999 and May 2018. Four hundred forty-eight women (44.5%) were administered with hormonal medications and 558 women were managed expectantly (55.5%). Office hysteroscopy was performed to confirm the diagnosis and regression of EPs. Hormonal administration included oral contraceptives, progestin and cyclic estrogen/progestin regimen according to physicians' preferences. Clinical characteristics, including the patient's age, body mass index, parity, and type of conservative management were collected. Results: The mean observation time was 14.1 ± 18.5 months (range, 1–162 months). The overall regression rate of EPs in this cohort was 33.5%, 24.6% occurred after medication and 8.9% after expectant management. Patient age (

Adenomyosis is a condition characterised by the invasion of endometrial tissues into the uterine myometrium, the molecular pathogenesis of which remains incompletely elucidated. Lesion profiling with next-generation sequencing (NGS) can lead to the identification of previously unanticipated causative genes and the detection of therapeutically actionable genetic changes. Using an NGS panel that included 275 cancer susceptibility genes, this study examined the occurrence and frequency of somatic mutations in adenomyotic tissue specimens collected from 17 women. Extracted DNA was enriched using targeted formalin-fixed paraffin-embedded tissue cores prior to the identification of lesion-specific variants. The results revealed that KRAS and AT-rich interactive domain 1A (ARID1A) were the two most frequently mutated genes (mutation frequencies: 24% and 12%, respectively). Notably, endometrial atypical hyperplasia did not involve adenomyotic areas. We also identified, for the first time, two potentially pathogenic mutations in the F-box/WD repeat-containing protein 7 (FBXW7) and cohesin subunit SA-2 (STAG2) genes. These findings indicate that mutations in the KRAS, ARID1A, FBXW7 and STAG2 genes may play a critical role in the pathogenesis of adenomyosis. Additional studies are needed to assess whether the utilisation of oncogenic driver mutations can inform the surveillance of patients with adenomyosis who had not undergone hysterectomy.Impact statement What is already known on this subject? Although somatic point mutations in the KRAS oncogene have been recently detected in adenomyosis, the molecular underpinnings of this condition remains incompletely elucidated. Lesion profiling with next-generation sequencing (NGS) can lead to the identification of previously unanticipated causative genes and the detection of therapeutically actionable genetic changes. What do the results of this study add? The results of NGS revealed that KRAS and AT-rich interactive domain 1A (ARID1A) were the two most frequently mutated genes (mutation frequencies: 24% and 12%, respectively). We also identified, for the first time, two potentially pathogenic mutations in the F-box/WD repeat-containing protein 7 (FBXW7) and cohesin subunit SA-2 (STAG2) genes. What are the implications of these findings for clinical practice and/or further research? The utilisation of oncogenic driver mutations has the potential to inform the surveillance of patients with adenomyosis who had not undergone hysterectomy.

Objective: To assess the technical feasibility of laparoscopic tubocornual anastomosis (TCA) at restoring tubal patency in patients with proximal tubal occlusions. Materials and methods: A retrospective analysis of fourteen females with identified proximal tubal occlusions seeking to restore their tubal patency in a university-affiliated tertiary hospital between 2011 and 2018. Tubal patency within one year after the surgery was evaluated. Results: The patients had a mean age of 34.0 ± 3.6 years old, median parity of 1 child, and mean BMI of 23.0 ± 5.2 kg/m2. Of the fourteen patients, two (14.3%) received bilateral TCA, eight (57.1%) received only unilateral TCA, and four (28.6%) received TCA on one side and tubal anastomosis on the other. The operative time was 126.4 ± 37.9min for unilateral procedure and 201.0 ± 1.4 min for bilateral anastomoses. Postoperative hysterosalpingogram (HSG) demonstrated a patency rate of 64.2% at the TCA sites. Two ectopic pregnancies were reported thereafter. Conclusion: This preliminary series demonstrates that laparoscopic TCA is technically feasible and provides promising results for patients with proximal tubal occlusions hoping to restore their tubal function in order to conceive naturally. A larger prospective series is mandatory to establish its significance and application in clinical practices. Notably, infertile patients without surgically correctable factors are not suitable for this procedure.

BackgroundEndometrial hyperplasia (EH), particularly with atypia, is considered an antecedent of endometrial adenocarcinoma. In this study, we aimed to apply massively parallel sequencing of endometrial lavage specimens for the detection of cancer-associated mutations in atypical (AEH) and non-atypical endometrial hyperplasia (NEH). The identified alterations were compared with those detected in tissue samples.Materials and methodsEndometrial lavage specimens and parallel biopsy samples (n = 11 for AEH and n = 9 for NEH) were obtained from 18 women (9 with AEH and 9 with NEH) who received an office hysteroscopy for suspected endometrial lesions. All samples were tested for somatic mutations in hotspot regions of 72 cancer-associated genes by massively parallel sequencing.ResultsOn analyzing sequencing data, the presence of at least one cancer-associated gene mutation was identified in 72.7 and 44.4% of endometrial lavage specimens obtained from women with AEH and NEH, respectively (p = 0.362, 95% confidence interval = 0.72-3.70). The concordance rates between mutations identified in endometrial lavage specimens and endometrial biopsies were 54.5 and 0% from women with AEH and NEH, respectively (p = 0.014). A patient with NEH harbored mutations in endometrial lavage with the same mutations found in the tissue specimen at low allele frequency below detection cutoff, raising the suspicion of missed focal atypia.ConclusionEndometrial hyperplasia is characterized by a high burden of cancer-associated mutations, particularly in the presence of atypia. Our study, albeit performed with a relatively small number of samples, indicates that their detection by massively parallel sequencing of endometrial lavage is feasible. Our findings may allow tailoring of endometrial biopsies to the individual risk of AEH; additionally, they can pave the way toward less invasive surveillance protocols in patients with known EH.

The pathogenic influences of uterine bacteria on endometrial carcinogenesis remain unclear. The aim of this pilot study was to compare the microbiota composition of endometrial lavage samples obtained from women with either endometrial hyperplasia (EH) or endometrial cancer (EC) versus those with benign uterine conditions. We hypothesized that specific microbiota signatures would distinguish between the two groups, possibly leading to the identification of bacterial species associated with endometrial tumorigenesis. A total of 35 endometrial lavage specimens (EH, n = 18; EC, n = 7; metastatic EC, n = 2; benign endometrial lesions, n = 8) were collected from 32 women who had undergone office hysteroscopy. Microbiota composition was determined by sequencing the V3−V4 region of 16S rRNA genes and results were validated by real-time qPCR in 46 patients with EC/EH and 13 control women. Surprisingly, we found that Bacillus pseudofirmus and Stenotrophomonas rhizophila – two plastic-degrading bacterial species – were over-represented in endometrial lavage specimens collected from patients with EC/EH. Using computational analysis, we found that the functional profile of endometrial microbiota in EC/EH was associated with fatty acid and amino acid metabolism. In summary, our hypothesis-generating data indicate that the plastic-degrading bacteria Bacillus pseudofirmus and Stenotrophomonas rhizophila are over-represented within the endometrial lavage microbiota of women with EC/EH living in Taiwan. Whether this may be related to plastic pollution deserves further investigation.

Abstract Background To evaluate the use of a human fibrin glue (Tisseel) for minor bleeding control and approximation of ovarian defect during transvaginal natural orifice ovarian cystectomy (TNOOC) of benign and non-endometriotic ovarian tumors. Methods A total of 125 women with benign and non-endometriotic ovarian tumors who underwent TNOOC between May 2011 and January 2020: 54 with the aid of Tisseel and 71 with traditional suture for hemostasis and approximation of ovarian defect. Surgical outcomes such as length of surgery, operative blood loss, postoperative pain score, and postoperative hospital stay were recorded. Before and immediately (10 days) and at 6 months after the procedure, serum anti-Müllerian hormone (AMH) levels were also determined. Results Complete hemostasis and approximation of ovarian defect were achieved in all cases. No significant difference was noted in the operating time, operative blood loss, postoperative pain scores after 12, 24 and 48 h, length of postoperative stay, and baseline AMH levels between the two groups. The operation did not have a negative effect on the immediate and 6-month postoperative AMH levels in the suture group. However, the decline in the AMH levels was significant immediately after surgery in the Tisseel group, nevertheless, no significant difference was noted in the AMH levels at 6 months (3.3 vs. 1.7 mg/mL; p = 0.042, adjusted p = 0.210). Conclusion The use of Tisseel in TNOOC of benign and non-endometriotic ovarian tumors without suturing the ovarian tissue is clinically safe and feasible.

Abstract Background No data are available to assess the learning curve for transvaginal natural orifice transluminal endoscopic hysterectomy for non-prolapsed uteri in benign gynecologic diseases. The lack of exposure to transvaginal natural orifice transluminal endoscopic hysterectomy during training, in addition to a poorly defined learning curve, further deters interested physicians from applying this technique to daily practice. The aim of this study was to evaluate the learning curve and perioperative outcome of transvaginal natural orifice transluminal endoscopic hysterectomy by an experienced endoscopist. Methods A total of 240 cases of transvaginal natural orifice transluminal endoscopic hysterectomies with or without adnexectomy for various benign gynecologic diseases were included. Demographic data and various perioperative parameters were reviewed from the prospectively collected database. Operative time was set as a surrogate marker for surgical competency. The learning curve was evaluated using the cumulative sum method. Results The overall mean operative time (OT) was 76.5 min ± 22.4. Four unique phases of the learning curve were derived using cumulative sum analysis: the mean OT of phase I (the initial learning curve of 20 cases) was 86.3 ± 23.7 min, phase II (acquisition of competence of 80 cases) was 71.0 ± 21.4 min, phase III (proficiency and plateau of 80 cases) was 76.0 ± 20.4 min, and phase IV (post-learning in which more challenging cases were managed) was 81.3 ± 23.6 min. No major complications were encountered. One case in phase III converted to laparoscopy due to difficulty in performing anterior colpotomy. Conclusion Our data demonstrated four distinct phases of the learning curve of transvaginal natural orifice transluminal endoscopic hysterectomy. In a well-trained endoscopist, surgical competence in transvaginal natural orifice transluminal endoscopic hysterectomy can be reached after 20 cases.

Background: We present two patients who suffered from endometritis as a result of a foreign body reaction to an anti-adhesive barrier positioned during hysteroscopic surgery. Case: The first case—who had previously undergone hysteroscopic lysis of intrauterine adhesions—presented with persistent abdominal pain and vaginal discharge. Ultrasound revealed an irregularly shaped strip of hyperechoic lesion. On diagnostic hysteroscopy, a foreign body presenting as a flattened bundle was observed and identified as the anti-adhesive barrier positioned during her previous surgery. The second patient—who had previously undergone laparoscopic surgery and hysteroscopic polypectomy—presented with abdominal pain in the left lower quadrant. Ultrasound revealed an intrauterine hyperechoic avascular lesion, while hysteroscopy identified a piece of crumpled plastic wrap. Both patients showed clinical improvement after removal of the extraneous material. Conclusion: Intrauterine positioning of anti-adhesive barriers during hysteroscopic surgery can give rise to endometritis as a result of foreign body reactions.

Background: Post-sterilization pregnancies are rare and many postulations were made for its mechanism. Abdominal pain in women with retained uterus mandates a pregnancy test, regardless of previous tubal surgery or sterilization surgery to exclude the possibility of ectopic pregnancy. Prevention via surgical approach not only prevents future occurrence but also confer prophylaxis measure against ovarian cancer. Case: A 39-year-old woman who had undergone open right salpingectomy due to tubal pregnancy presented with abdominal pain, a positive pregnancy test, and elevated beta-human chorionic gonadotropin (β-hCG) level. Furthermore, an ultrasound exam revealed the absence of a gestational sac in the uterine cavity but the presence of a left adnexal mass; hence ectopic pregnancy was suspected. Laparoscopy revealed a 3 × 4 cm bulging ectopic pregnancy at the left distal end of the remnant stump in the ampulla. The histopathological assessment confirmed ectopic pregnancy in the left distal tubal stump. Post-operation, β-hCG levels decreased. The patient fully recovered postoperatively. Discussion: Ectopic pregnancies after tubal sterilization are caused by fistula formation and intraperitoneal sperm transmigration. To avoid this possibility, surgical techniques should be used to obliterate the residual canal, including the precise location and depth of electrocautery to prevent fistula formation. Total salpingectomy is the recommended treatment approach for effective permanent sterilization and a prophylaxis measure against ovarian cancer.

Objective: Hysterectomy via transvaginal natural orifice transluminal endoscopic surgery (NOTES) has been carried out for benign uterine diseases and nonprolapsed uteri in recent years. Subtotal hysterectomy was performed to remove the uterus with preservation of the cervix by abdominal, laparoscopic, or vaginal routes. The aim of this retrospective study is to gain insight into the feasibility and safety of subtotal hysterectomy through transvaginal NOTES. Materials and methods: This is the first case series study to describe the technique and to evaluate the feasibility of this innovative surgical procedure. 10 patients were recruited and underwent NOTES subtotal hysterectomy within one-year duration. Results: The mean operative time was 106.7 ± 40.0 min with a mean blood loss of 250.0 ± 120.2 mL. The mean weight of specimen retrieved was 452.2 ± 227.8 g (range 195 g–905 g). None of these patients sustained injury to surrounding structures or major blood vessels during the surgery. Five patients required analgesia during the first 24 h post-surgery. Post-operative hospital stay ranged from 2 to 3 days. No patients complained of surgical complications at 1, 3, and 6 months follow-up. All patients recovered uneventfully and carried on daily activities without difficulty. Conclusion: This study confirms the feasibility and safety of NOTES subtotal hysterectomy.

Background: To assess whether the unilateral or bilateral lesions can affect ovarian reserve and pregnancy outcome in in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) in infertility patients underwent laparoscopic cystectomy. Methods: A total of 148 IVF/ICSI cycle in patients who had undergone laparoscopic cystectomy for unilateral or bilateral endometriomas were reviewed retrospectively. There were 103 cycles where laparoscopic cystectomy had been carried out for unilateral endometriomas and 45 cycles after bilateral-side surgery. Primary outcome measures were ovarian reserve and ovarian response. Secondary outcome measures were the implantation rate, clinical pregnancy rate, and live birth rate. Results: The number of dominant follicle on the day of human chorionic gonadotropin (hCG) administration (5.2 ± 3.1 vs. 4.2 ± 2.7; p = 0.048), and oocytes retrieved (10.0 ± 6.9 vs. 7.6 ± 6.6; p = 0.047) were significantly lower in the bilateral-side group compare with the unilateral-side group. However, the mean number of antral follicle count, metaphase II oocytes, the doses of gonadotropin used, fertilization rate, the rate of good quality embryos transferred, implantation rate and clinical pregnancy, live-birth rate and miscarriage rate were similar between the two groups. Conclusion: There were no associations among the bilaterality of ovarian endometriomas, ovarian reserve and pregnancy outcomes in IVF/ICSI cycles. However, bilateral ovarian endometriomas after laparoscopic cystectomy may impair ovarian response as compared to unilateral ovarian endometrioma.

Objective: To evaluate the use of Tisseel, a 2-component fibrin sealant agent for the control of minor bleeding and repair of the ovarian defect at the end of laparoscopic cystectomy (LC) of endometriomas. Materials and methods: From January 2011 to December 2015, an observational study of all patients who underwent LC of endometrioma using Tisseel (group A) was performed. The demographic and operative data, including age, body mass index, operative indications, operative time, estimated blood loss, complications, and postoperative hospital stay duration were recorded. A contemporary cohort of patients, who underwent LC of endometrioma without Tisseel (group B) was also retrospectively compared. Results: A total of 274 patients were recruited in this study (53 LCs with Tisseel and 221 LCs without Tisseel, respectively). Complete hemostasis was achieved in all patients. The mean size of main mass was significantly larger in the group A than in the group B (7.8 ± 2.4 cm vs. 7.0 ± 2.3 cm, p = 0.033) but the mean operating time, operative blood loss, febrile morbidity, and length of hospitalization were not significantly different between the two groups. Conclusion: This preliminary series demonstrated the use of Tisseel in LC of endometriomas without any bipolar coagulation and/or suturing of ovarian tissue is clinically safe and feasible.

Objective: Natural orifice transluminal endoscopic surgery (NOTES) may be useful in gynecologic endoscopic surgery. This study evaluated the efficacy, safety, and perioperative outcomes of combined NOTES and vaginal approach, transvaginal endoscopic surgery-assisted adnexectomy (TVEA), for the surgical treatment of presumed benign ovarian tumors. Materials and methods: Records were reviewed for 33 consecutive TVEA procedures performed between May 2011 and March 2014. Patient age, body mass index, parity, mass size, and mass bilaterality were used to select comparable patients who had undergone conventional laparoscopic adnexectomy (CLA). Results: A total of 236 patients were included in this study (203 CLAs and 33 TVEAs). No cases switched to abdominal laparotomy. Operating time and length of postoperative stay were significantly longer in the CLA group than in the TVEA group, while total hospital charges were higher in the TVEA group (p

Objective: To compare the safety and effectiveness of the harmonic scalpel and conventional electrosurgery in laparoscopic myomectomy (LM). Materials and Methods: We performed a retrospective chart review of 591 women with symptomatic uterine fibroids who underwent LM. Thirty-three cases of LMs with harmonic scalpel (LMH) were compared with a matched control group that underwent conventional electrosurgery (LME). Outcome measures for both groups were studied comparatively in terms of the amount of blood loss, requirement of blood transfusion, length of operative time, cost, and hospital stay. Results: There was no incidence of switching to abdominal laparotomy. Length of postoperative stay was significantly lower in the LMH group than in the LME group (2.0±0.4 days vs. 2.5±0.7 days, p

Under-utilization of Papanicolaou (Pap) smear causes a gap in the prevention of cervical neoplasms. A prospective population-based study was conducted investigating whether a self-sampling human papillomavirus (HPV) test was feasible for under-users of Pap smear and factors associated with under-screening in Taiwan. Methods: Women not having Pap smear screening for > 5 years were invited to participate in this study. Invitation letters and educational brochures were mailed to 4% of randomly selected eligible women from Taoyuan City, Taiwan, and responders received an HPV self-sampling kit. Those with HPV-positive results were recalled for a Pap smear and colposcopy. Results: Between March 2010 and June 2012, 10,693 women were invited, 354 responded (3.3%), and 282 (2.6%) gave valid informed consent, answered the questionnaire, and submitted HPV samples. The median age of enrolled women was 48.1 years. Forty-seven women (16.7%) had a positive HPV test, and 14 women accepted further survey to find two CIN2+. Another two cases of CIN2+ were identified from a national registry database. The cost of direct mailing self-samplers was less than that done on request (from NT$434,866 to NT$164,229, response rate of 5% to 15%, respectively, versus NT$683,957 for detecting 1 CIN2+). Reasons for not attending screening included lack of time, embarrassment, assumed low risk, fear of positive results, and perceived potential pain. Among the responders, 90.8% found the method acceptable. Conclusion: Our study indicated that different approaches (e.g., direct mailing self-samplers to under-users and/or various educational interventions) must be explored to improve coverage in populations with culture characteristics similar to Taiwan.

Objective: To establish a specific hysteroscopic pattern–the “glomerular pattern”–to diagnose high-grade endometrial cancer and evaluate the accuracy rate of the pattern, based on final histology. Materials and methods: From 2008 to 2011, 30 patients for whom pathology indicated endometrial cancer, based on the office hysteroscopy study, were included in the study. We reviewed the hysteroscopic pictures to determine the specific hysteroscopic pattern in high-grade endometrial cancer. Results: Thirty patients who had endometrial cancer under hysteroscopy were included to the study. The study population had a mean age of 49.9 years. All patients had abnormal uterine bleeding. Office hysteroscopy was completed in all patients without anesthesia. The findings of the office hysteroscopy suggested endometrial cancer in 30 patients. Fifteen patients had the specific hysteroscopic pattern, called the “glomerular pattern.” All 15 patients had grade 2 or grade 3 disease. Among patients who had a glomerular pattern, 53.3% (8/15) of patients had grade 2 endometrioid adenocarcinoma and 46.7% (7/15) patients had grade 3 endometrioid adenocarcinoma. Among the nonglomerular pattern group patients, 66.7% (10/15) patients had grade 1 endometrioid adenocarcinoma, 26.7% (4/15) patients had grade 2 endometrioid adenocarcinoma and 6.7% (1/15) patients had grade 3 endometrioid adenocarcinoma. Conclusion: Our conclusion is that patients with the glomerular pattern have a high percentage of moderate or high-grade endometrioid adenocarcinoma. The glomerular sign may provide information on preoperative pathohistology and decrease the possibility of histology upgrade after hysterectomy. However, large series, prospective, and comparison studies are still needed.

Uterine sarcoma is a very aggressive and highly lethal disease. Even after a comprehensive staging surgery or en block cytoreduction surgery followed by multimodality therapy (often chemotherapy and/or radiation therapy), many patients relapse or present with distant metastases, and finally die of diseases. The worst outcome of uterine sarcomas is partly because of their rarity, unknown etiology, and highly divergent genetic aberration. Uterine sarcomas are often classified into four distinct subtypes, including uterine leiomyosarcoma, low-grade uterine endometrial stromal sarcoma, high-grade uterine endometrial stromal sarcoma, and undifferentiated uterine sarcoma. Currently, evidence from tumor biology found that these tumors showed alternation and/or mutation of genomes and the intracellular signal pathway. In addition, some preclinical studies showed promising results for targeting receptor tyrosine kinase signaling, phosphatidylinositol 3-kinase/AKT/mammalian target of rapamycin pathway, various kinds of growth factor pathways, Wnt/beta-catenin signaling pathway, transforming growth factor β/bone morphogenetic protein signal pathway, aurora kinase A, MDM2 proto-oncogene, histone deacetylases, sex hormone receptors, certain types of oncoproteins, and/or loss of tumor suppressor genes. The current review is attempted to summarize the recurrent advance of targeted therapy for uterine sarcomas.

Objective: To examine the alteration in the cellular dynamics of the urethral tissue after a simulated birth trauma in a mouse model. Materials and Methods: A total of 36 B6 mice received vaginal distention treatment, and four untreated mice were used as controls. Specimens were collected every 24 hours after the injury for 9 consecutive days and examined using immunofluorescent staining for cell markers including c-kit, smooth muscle actin (SMA), and vimentin. Confocal microscopy was used to localize the stained cells and determine the cell number. Results: The number of c-kit positive cells increased after the 1st day and peaked on the 3rd day. The amount of SMA positive cells rapidly reduced to its lowest count on the 1st day and maintained a statistically significant low cell number than that at the basal level for 4 days after vaginal distension. The cell number finally returned to basal level on the 9th day. The amount of vimentin positive cells increased dramatically after the 1st day and plateaued from the 3rd day to the 9th day. The number of vimentin positive cells in the plateau phase was significantly higher than that of the control group. Conclusion: Our study confirmed that the dynamic change in different cell types after the urethral injury was dependent on the nature and physiology of the wound repairing cells during the tissue healing process. It might be a simple animal model to study birth trauma repair; however, the varied progenitor cell activity in different species should also be considered.

Uterine sarcomas account for 3–7% of all uterine cancers. Because of their rarity, unknown etiology, and highly divergent genetic aberration, there is a lack of consensus on risk factors for occurrence and predictive poor outcomes as well as optimal therapeutic choices. Tumor types according to the World Health Organization classification include leiomyosarcoma, endometrial stroma sarcoma, and undifferentiated sarcoma. Staging is done using the 2014 Federation International Gynecology and Obstetrics and 2010 American Joint Committee on Cancer tumor, lymph node, and metastases systems. Tumor grade can be classified based on the French Federation of Cancer Centers Sarcoma Group system or the Broder’s system that incorporates tumor differentiation, mitotic count, and tumor necrosis. This review is a series of articles discussing uterine sarcoma, and this is Part I, which focuses on one of the subtypes of uterine sarcomas—uterine leiomyosarcoma. The clinical characteristics, diagnosis, outcome, and recent advances are summarized in this article.

Endometrial stromal tumors are rare uterine tumors (

The purpose of this study was to compare the safety and efficacy of an electrothermal bipolar vessel sealing device (LigaSure™) and traditional electrical cauterization in laparoscopic myomectomy (LM). A total of 756 patients with symptomatic uterine myomas who underwent LM were reviewed retrospectively. A total of 225 cases of LM using LigaSure™ (LML group) were compared with a control group treated with traditional electrical cauterization (LME group) under propensity-matched analysis. Outcome measures for both groups were compared, such as operative time, blood loss (BL), complications, need for blood transfusion, hospital expenses, and hospital stay. Six subgroups were divided according to main myoma size and energy source. No cases required switching to abdominal myomectomy. The number of myomas removed, BL, need for blood transfusion, and complications were not significantly different, whereas hospital stay was longer in the LME group than in the LML group and total hospital expenses were higher in the LML group (p < 0.001). The overall operation duration was significantly longer in the LML group but was not significantly different for main myoma >10 cm (LML vs LME, 121.58 ± 41.77 vs 121.69 ± 44.95, p = 0.99); this likely reflects the operative efficiency on using LigaSure™ to manage large tumors. Significant linear correlations between myoma weight and operative time and BL were seen in both groups. Conventional diathermy is more effective for small-to-medium myomas. Use of the LigaSure™ was efficient for myomas >10 cm.

The incidence of uterine rupture through a previous cesarean scar (CS) is declining as a result of a lower parity and fewer options for vaginal birth after cesarean. However, uterine ruptures attributable to other causes that traumatize the myometrium are on the rise. To determine whether changes in the causes of uterine rupture had occurred in recent years, we retrospective retrieved the clinical records of all singletons with uterine rupture observed in the delivery room of a Taiwanese tertiary obstetric center over a 15-year period. The overall uterine rupture rate was 3.8 per 10,000 deliveries. A total of 22 cases in 20 women (with two of them experiencing two episodes). Seven uterine ruptures occurred through a previous cesarean scar (CS ruptures, 32%), 13 through a non-cesarean scar (non-CS ruptures, 59%), whereas the remaining two (9%) were in women who did not previously undergo any surgery. All of the 13 non-CS ruptures were identified in women with a history of laparoscopic procedures to the uterus. Specifically, 10 (76%) occurred after a previous laparoscopic myomectomy, one (8%) following a hysteroscopic myomectomy, and two (16%) after a laparoscopic wedge resection of cornual ectopic pregnancy. Severe bleeding (blood loss >1500 mL) requiring transfusions was more frequent in women who experienced non-CS compared with CS ruptures (10 versus 1 case, respectively, P = 0.024). Patients with a history of endoscopic uterine surgery should be aware of uterine rupture during pregnancy.

Stress-induced phosphoprotein-1 (STIP1), an adaptor protein that coordinates the functions of HSP70 and HSP90 in protein folding, has been implicated in the development of human gynecologic malignancies. This case-control study investigates STIP1 serum levels and tissue expression in relation to endometriosis/adenomyosis in Taiwanese population. Female patients with surgically confirmed endometriosis/adenomyosis were compared with women free of endometriosis/adenomyosis. Serum STIP1 levels were measured using an enzyme-linked immunosorbent assay and surgical tissues were analyzed by immunohistochemistry. Both epithelial and stromal cells in surgical tissues of endometriosis and adenomyosis expressed STIP1 and MMP-9. Notably, MMP-9 expression was significantly decreased when STIP1 expression was knocked-down. In vitro experiments revealed that STIP1 was capable of binding to the MMP-9 promoter and enhanced its transcriptional expression. The preoperative serum STIP1 levels of patients with endometriosis/adenomyosis were significantly higher than those of the controls. In brief, our data suggest an association between STIP1 levels and endometriosis/adenomyosis.

Objectives: To evaluate the accessibility of transumbilical single-port laparoscopy for hysterectomy in difficult conditions. Materials and methods: This prospective observational study recruited patients with benign diseases who were scheduled for laparoscopic hysterectomy between March 2010 and October 2011 to undergo the transumbilical single-port approach with straight instruments and a laparoscope. Results: In total, 109 patients were included with a mean [± standard error of the mean (SEM)] age of 45.9 ± 0.4 years and mean body mass index of 23.9 ± 0.3 kg/m2. The yielded mean uterine weight was 403.4 ± 25.3 g, with 28 (25.7%) weighing ≥500 g, including four specimens >1000 g, and 44 (40.4%) needed concurrent adhesiolysis. The operative time was 117.2 ± 4.2 minutes, estimated blood loss was 270.3 ± 22.9 mL, and the postoperative hospital stay was 2.8 ± 0.1 days. Patients with a uterus weighing ≥500 g had a higher intraoperative blood loss in comparison with those with a uterus weighing

Objective: To evaluate the efficacy and toxicity of topical imiquimod for the treatment of persistent human papillomavirus (HPV) infection in patients with or without cervical/vaginal intraepithelial neoplasia (CIN/VAIN). Methods: Patients with persistent HPV infection (≥1 year) after a history of treatment for cervical or vaginal neoplasm but normal histology and cytology, abnormal Papanicolaou (Pap) smears without abnormal histology, and untreated histology-documented CIN/VAIN Grade 1/2/3 with HPV-positive testing were recruited. Patients were instructed to apply 250 mg of 5% imiquimod cream intravaginally on consecutive days or at least twice weekly on an outpatient basis for a minimum of 12 doses. A group of age- and previous diagnosis-matched, imiquimod-untreated historical controls (n = 20) were selected. The main outcome measures included HPV DNA detection, cytology, and colposcopy/histology at 6 months after treatment. Results: A total of 72 patients were eligible for analysis. At a median follow-up of 33.6 months, 37 patients (51.4%) had cytological/histological regression and tested HPV-negative. Six patients (8.3%) had progressive cytology/histology with persistent HPV infections. Of the 72 treated patients, 26 patients who had a normal Pap test but were persistently HPV-positive for at least 1 year had a complete regression rate of 65.4%, which was significantly different from the rate (30%) observed in the untreated historical control (p = 0.036). Six patients with histologically proven CIN2/3 or VAIN2/3 had a complete regression rate of 66.6% (4/6). Conclusions: The tolerability of intravaginal self-administered imiquimod is confirmed. Its efficacy in the treatment of women with persistent HPV infection and normal cytology warrants further randomized, controlled trials to determine appropriate dosages and scheduling.

Objective: To present our initial experiences in transvaginal natural orifice transluminal endoscopic surgery (NOTES) for adnexal surgeries and hysterectomies. Materials and Methods: From September 2010 to December 2010, a total of 15 patients with benign adnexal or uterine diseases who were eligible for laparoscopic surgeries were recruited to undergo transvaginal NOTES at a tertiary referral medical center. Intraoperative and postoperative surgical outcomes were measured. Results: Transvaginal NOTES was successfully completed in five adnexal surgeries and 10 hysterectomies without complications, an ancillary port on the abdomen, or conversion to conventional laparoscopy or laparotomy. For the 10 hysterectomies, the surgical time was 93.4 ± 6.3 minutes (mean ± standard deviation), intraoperative estimated blood loss 245 ± 54.0 mL, uterine weight 440.1 ± 76.5 g, and the postoperative hospital stay 2.7 ± 0.3 days. No patients required intraoperative blood transfusion. The two tubal sterilizations were completed in 18 minutes and 30 minutes, respectively, with negligible blood loss. The two salpingectomies, including one ruptured ectopic pregnancy with 2000 mL hemoperitoneum, were completed in 62 minutes and 116 minutes, respectively. The enucleation was completed in 64 minutes with 20 mL estimated blood loss. Conclusion: Our preliminary results indicate that transvaginal NOTES for adnexal surgeries and hysterectomies is feasible and safe. However, this procedure is still new and should only be used as an alternative for conventional laparoscopic surgery in highly selected cases.

Objective: Comparing the safety and effectiveness of the pulsed bipolar (PK) system and conventional electrosurgery in laparoscopic myomectomy (LM). Materials and Methods: Retrospective chart review of 194 women with symptomatic uterine fibroids undertaken LM was performed. Cases of LMs with PK cutting forceps were compared with a matched control group of standard LMs with conventional electrosurgery. Outcome measures for both groups were studied comparatively in terms of the length of operative time, amount of blood loss, requirement of blood transfusion and length of hospital stay. Results: The two groups were matched by age, body mass index, parity, previous cesarean delivery, size, number, and weight of fibroids. Amount of blood loss was significantly greater in electrosurgery group than in PK group at 243.8±150.4 mL versus 190.4±178.5 mL (p=0.025). Length of operation, hospitalization time, hemoglobin decrease, and requirement of blood transfusion were not significantly different. Conclusion: Our findings indicate that PK system is more effective in LM when compared with conventional electrosurgery. PK system has advantage over conventional electrosurgery in less blood loss and may offer an alternative option for patients undergoing LM.

Objective: To evaluate the pregnancy courses and obstetric outcomes in patients conceived after conservative treatment of endometrial cancer. Materials and Methods: Case series and systemic review of pregnancy women after fertility-sparing treatment of endometrial cancer. Patients with early stage endometrial cancer were identified through Tumor Registry in Chang Gung Memorial Hospital between 1990 and 2005 and MEDLINE search. Diagnosed cases were managed by fertility-sparing therapies. Pregnancies followed by assisted reproductive technology and spontaneous or ovulation with intrauterine insemination were designated as Group 1 and Group 2, respectively. Results: Five livebirths in three patients with two sets of twin pregnancy were delivered. Adding 47 women in the MEDLINE search literature, there were 65 deliveries with 77 livebirths. Groups 1 and 2 had 15 and 50 deliveries, respectively. Group 1 had 23 livebirths including four sets of twins and two sets of triplets, whereas 54 livebirths consisted of two sets of twins and one set of triplets were noted in Group 2 (p = 0.003). Seven preterm deliveries were noted in Group 1 and three in Group 2 (p = 0.001). Cesarean rate was 93.3% versus 22.0% (p

Objectives: To report the surgical outcomes of transumbilical single-port laparoscopic hysterectomies for benign uterine diseases. Materials and methods: This prospective observational study recruited patients with benign diseases and scheduled for laparoscopic hysterectomy from March 2010 to April 2011 to undergo transumbilical single-port laparoscopy, and recorded the surgical outcomes. Results: A total of 56 patients were included, with mean (±standard error of the mean) age 46.5 ± 0.5 years and mean body mass index 23.5 ± 0.5 kg/m2. Among these patients, 32 (57.1%) had a history of previous abdominal surgeries, whereas in 55 (98.2%) the procedures were completed with transumbilical single-port access and without any ancillary trocar. Mean surgical time was 121.1 ± 5.7 minutes. Mean intraoperative blood loss was 279.5 ± 38.4 mL. Mean uterine weight was 392.3 ± 34.2 g. The single additional trocar (1.8%) was needed for extensive enterolysis. Two patients (3.6%) needed blood transfusion. The median of postoperative hospital stay was 3 days. There were no major intraoperative or postoperative complications. Conclusion: In the hands of experienced laparoscopists, transumbilical single-port laparoscopy is a safe and feasible method of hysterectomy for patients with benign uterine diseases.

Objective: The robotic surgical system is reported to overcome some technical difficulties in traditional laparoscopic hysterectomy. This study aimed to evaluate the feasibility and surgical outcomes of a robotic surgery program for endometrial cancer. Materials and Methods: Patients with endometrial cancer with the intention to receive treatment using robotassisted laparoscopic staging surgery were recruited in a university hospital from July 2007 to August 2008. All of these surgeries were performed with the da Vinci system. Results: Six patients (mean age, 47.5 ±1.4 years; mean body mass index, 26.2 ±3.5 kg/m2) were enrolled and completed robot-assisted laparoscopic staging surgery. The robot docking time was 45.0 ±13.6 minutes and the robot-assisted operation time was 200.3 ±30.0 minutes. The mean estimated blood loss was 180.0 ±147.6 mL. The mean number of lymph nodes retrieved was 23.2 ±7.4. No laparoconversion and no intraoperative or postoperative complications occurred. All patients were alive and free of disease up to the date of this report, at a median follow-up of 6.5 months (range, 5-17 months). Conclusion: Robot-assisted laparoscopic staging surgery is a feasible treatment and helps overcome the technical limitations in conventional laparoscopy for endometrial cancer.

Since the initial description of laparoscopic myomectomy (LM) in 1979, many reports of this technique have been published worldwide. The indications for LM have grown in line with improvements in laparoscopic techniques and instruments over the last decade. LM offers several benefits to patients but remains a challenging technical procedure that is associated with high surgical morbidity and a high incidence of blood transfusion. LM procedures include excision of the myoma(s), repair of myometrium, and removal of the myoma from the abdomen. The control of operative blood loss is crucial, especially in the case of large intramural fibroids. Different studies have found wide variations in the incidence of recurrence after LM. Ultrasound imaging and Doppler velocimetry can be used to assess uterine scars after LM. Uterine rupture during pregnancy is a serious concern after LM, and all published cases report the occurrence of rupture before the start of labor. Surgical strategies are needed to overcome these problems associated with LM. Although LM is minimally invasive in terms of the wound, it remains an advanced and invasive procedure. An appropriate management strategy is required for each patient, and careful discussion and counseling regarding all the issues are necessary.

Objective: To evaluate the efficacy of laparoscopy in treating large submucous fibroids with deeply intramural invasion. Study design: Twenty-eight women with a main submucous fibroid >4 cm and with >50% intramural extension were enrolled in this study. Laparoscopic myomectomy was performed instead of hysteroscopic surgery. Results: Median fibroid diameter and weight were 5.0 cm [interquartile range (IQR) 4.6–6.0 cm] and 50.0 g (IQR 36.3–77.5 g), respectively. Median operating time was 60 minutes (IQR 50.0–73.8 minutes) and blood loss was 50 mL (IQR 50–100 mL). Median postoperative hospital stay was 2 days (IQR 2–3 days) and no patient developed complications. Seven women had coexistence of intramural and/or subserosal fibroids (median number of fibroids removed was 1, IQR 1–2). Conclusion: When the diagnosis of submucous fibroid >4 cm with >50% intramural extension is made, laparoscopic myomectomy can be performed instead of hysteroscopic surgery for the sake of safety and removal of nonsubmucous type fibroids concomitantly.

The pathogenic influences of uterine bacteria on endometrial carcinogenesis remain unclear. The aim of this pilot study was to compare the microbiota composition of endometrial lavage samples obtained from women with either endometrial hyperplasia (EH) or endometrial cancer (EC) versus those with benign uterine conditions. We hypothesized that specific microbiota signatures would distinguish between the two groups, possibly leading to the identification of bacterial species associated with endometrial tumorigenesis. A total of 35 endometrial lavage specimens (EH, n = 18; EC, n = 7; metastatic EC, n = 2; benign endometrial lesions, n = 8) were collected from 32 women who had undergone office hysteroscopy. Microbiota composition was determined by sequencing the V3-V4 region of 16S rRNA genes and results were validated by real-time qPCR in 46 patients with EC/EH and 13 control women. Surprisingly, we found that Bacillus pseudofirmus and Stenotrophomonas rhizophila - two plastic-degrading bacterial species - were over-represented in endometrial lavage specimens collected from patients with EC/EH. Using computational analysis, we found that the functional profile of endometrial microbiota in EC/EH was associated with fatty acid and amino acid metabolism. In summary, our hypothesis-generating data indicate that the plastic-degrading bacteria Bacillus pseudofirmus and Stenotrophomonas rhizophila are over-represented within the endometrial lavage microbiota of women with EC/EH living in Taiwan. Whether this may be related to plastic pollution deserves further investigation. [ABSTRACT FROM AUTHOR]