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Abstract Cervical cancer is a significant public health concern, particularly in low‐ and middle‐income countries where resources for prevention and treatment are limited. Routine screening, such as the Papanicolaou test (Pap smears) and human papillomavirus (HPV) testing, plays a crucial role in the early detection and prevention of cervical cancer. However, the participation rate in cervical cancer screening programs remains below optimal levels due to various factors. This study aimed to evaluate the reliability and acceptability of the HygeiaTouch Self Sampling Kit for Women in collecting vaginal samples for HPV typing, comparing the results with samples collected by physicians. The study included 1210 women aged 21–65 from three medical centers in Taiwan. The findings indicated that the self‐sampling kit was as effective as physician‐collected specimens in terms of obtaining valid samples and identifying HPV. The agreement between the two methods was 88%, with a κ value of 0.75. Furthermore, the study assessed the mechanical characteristics of the self‐sampling applicator through tensile, bending, and torque tests, and determined that it was safe for intravaginal use. Additionally, the study evaluated the safety and satisfaction of self‐sampling and found a low rate of adverse events (0.7%) and high levels of satisfaction (over 90%) among participants. Overall, we demonstrated that the HygeiaTouch Self Sampling Kit for Women is a reliable and acceptable device for HPV testing and cervical screening, providing a convenient, safe, and effective alternative for women.

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 (

Abstract Objectives Diospyros oleifera, one of the most economically important Diospyros species, is an ideal model for studying the fruit development of persimmon. While, the lack of whole-transcriptome has hindered the complex transcriptional regulation mechanisms of sugar and tannin during fruit development. Data description We applied Oxford Nanopore Technologies to six developmental stage of fruit from D. oleifera for use in transcriptome sequencing. As a result of full-length transcriptome sequencing, 55.87 Gb of clean data were generated. After mapping onto the reference genome of D. oleifera, 51,588 full-length collapsing transcripts, including 2,727 new gene loci and 43,223 transcripts, were obtained. Comprehensively annotated, 38,086 of new transcripts were functional annotation, and 972 lncRNAs, 7,159 AS events were predicted. Here, we released the transcriptome database of D. oleifera at different stage of fruit development,which will provide a fundamention of to investigatethe transcript structure, variants and evolution of persimmon.

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.

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.

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.

Objective: To evaluate the efficacy and effectiveness of applying LigaSure™ Tissue Fusion System in hysterectomy via transvaginal natural orifice transluminal endoscopic surgery (NOTES) in comparison with using the conventional bipolar device. Materials and methods: Eighty women scheduled for hysterectomy by transvaginal NOTES were prospectively randomized into applying LigaSure (study group) or conventional bipolar instrument (control group) in an intention-to-treat analysis. Primary endpoints were the device-related efficacy; secondary endpoints were surgical effectiveness measured by operative time, blood loss, postoperative pain and adverse events. Results: In the eligibly allocated patients, three in the control group (n = 39) converted to applying LigaSure and one converted to conventional laparoscopy intraoperatively, while none in the LigaSure group (n = 38) found such conversions. Patients who completed full analysis in the LigaSure (n = 36) and control (n = 35) groups did not differ significantly in operative time, estimated blood loss, and the length of hospital stay. In the subgroup of women who underwent hysterectomy only, the LigaSure group (n = 22) showed significantly reduced operative time than the control group (76.50 ± 24.74 min versus 93.96 ± 27.10 min, p = 0.029). Postoperative pain scores were statistically higher in the LigaSure group within 36 h; however, the difference was not clinically significant. The incidence of postoperative adverse events between the groups was not different; nevertheless, device-related adverse events was not found in the LigaSure group. Conclusion: LigaSure™ tissue fusion technology was feasible and efficacious without compromising surgical procedures for hysterectomy by transvaginal NOTES compared with the conventional bipolar hemostasis device. Keywords: Hysterectomy, Transvaginal, Natural orifice transluminal endoscopic surgery, Ligasure, Operating time

Diospyros kaki cv. Luotiantianshi is a rare germplasm of Diospyros Linn in the world. In this study, we generated the complete chloroplast (cp) genome of D. kaki cv. Luotiantianshi. The complete cp genome was 157,773 bp in length, containing a large single copy region (LSC) of 87,066 bp, a small single copy region (SSC) of 18,529 bp, and two inverted repeat (IR) regions of 26,089 bp. The new sequence has a total of 131 genes, including 86 protein-coding genes, 37 tRNA genes, and 8 rRNA genes. Further, phylogenetic analysis showed that the D. kaki cv. Luotiantianshi has a close relationship with Diospyros kaki. This study provides important information for future evolution, genetic and molecular biology studies of Diospyros.

Objectives: Natural orifice transluminal endoscopic surgery (NOTES) is an emerging technique in the area of minimally invasive procedures. Preliminary reports have confirmed transvaginal NOTES to be a safe and feasible method for performing hysterectomy and adnexal procedures. However, there are limitations regarding the feasibility of performing transvaginal NOTES hysterectomy in various uterine sizes. Materials and methods: Two hundred and seventy-five women who had undergone transvaginal NOTES hysterectomy for benign pelvic lesions were recruited from May 2012 to May 2016. Their medical records were retrospectively reviewed. All patients were placed into one of three groups depending on weight of the surgical specimen in order to assess surgical outcomes. Results: One hundred ninety-one patients (69.46%) had a uterine weight of

Objective: To assess the feasibility and survival outcomes of laparoscopic staging for patients with stage I ovarian cancer. Materials and methods: Consecutive patients who underwent laparoscopic staging surgery for stage I ovarian cancer from January 2002 to December 2014 were evaluated retrospectively by chart review. Results: Twenty-four patients with mean age 43.9 ± 9.9 years and mean body mass index 24.0 ± 3.8 kg/m2 were included, in which 12 (50%) patients were in stage IA and 12 (50%) in stage IC. The histological types included serous in 6 (25%), mucinous in 7 (29.1%), endometrioid in 6 (25%), clear cell in 5 (20.8%) patients. The mean surgical time was 306.4 ± 98.5 min, and the mean blood loss was 204.2 ± 188.6 mL. None of the patients required conversion to laparotomy. The median numbers of resected pelvic and para-aortic lymph nodes were 20 and 4, respectively. One (4.1%) patient encountered bowel injury intraoperatively, and the other 1 (4.1%) patient hydronephrosis postoperatively. The overall survival rate was 95% in the current series in a median follow-up of 31.5 months. Conclusion: Laparoscopic staging surgery performed for early stage ovarian cancer has better long term survival outcomes than the literature report. Laparoscopic treatment by a trained gynecologic oncologist is an ideal alternative for early stage ovarian cancer with the advantage of minimal invasiveness.

Study objective: To introduce the innovative surgical procedure of treating benign uterine pathology with subtotal hysterectomy by natural orifice transluminal endoscopic surgery (NOTES). Design: Prospective observational study. Setting: Tertiary referral medical center. Methods: From June 2014 to May 2016, three patients with benign uterine diseases who were eligible for laparoscopic subtotal hysterectomy were recruited to undergo transvaginal NOTES at a tertiary referral medical center. Intraoperative and postoperative surgical outcomes were measured. Results: Subtotal hysterectomy by transvaginal NOTES was successfully completed in all patients without any conversion to conventional laparoscopy. The operative time was 144±4.5 (138â149) minutes with an average estimated blood loss of 133±62 (50â200) mL. None of the patients required an intraoperative blood transfusion. The mean specimen weight was 140±59 (56â188) g. The final histology reports were uterine leiomyoma and adenomyosis in these three cases. There were no intraoperative or postoperative complications. No case required intraoperative or postoperative blood transfusion. No cases were converted to traditional laparoscopy or laparotomy. Conclusion: Our preliminary results showed the safety and feasibility of subtotal hysterectomy by transvaginal NOTES in selected patients. It is one of the most minimally invasive surgeries and results in invisible scars. Keywords: laparoscopic hysterectomy, laparoscopy, myoma uteri, natural orifice transvaginal endoscopic surgery (NOTES), subtotal hysterectomy

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: To assess the long-term outcomes of laparoscopic staging surgery (LSS) in treating patients with endometrial carcinoma. Materials and Methods: Patients with endometrial cancer who underwent LSS between June 1995 and June 2014 were prospectively registered. Perioperative data, complications, disease recurrence, and long-term survival were measured. Results: The study included 287 consecutive patients [mean age (± standard deviation), 53 ± 10.4 years; mean body mass index, 27.3 ± 6.7 kg/m2] with a median follow-up ranging from 1 to 216 months. No laparotomy conversion was recorded for any patient. The mean operative time was 207 ± 63.5 minutes, and the mean blood loss was 183 ± 166.7 mL. The mean numbers of pelvic nodes and para-aortic nodes removed were 18 ± 4.8 and 8 ± 5, respectively. More than 80% of the patients had an International Federation of Gynecology and Obstetrics (FIGO) Stage 1 disease. The overall complication rate was 3.1%, including two patients of bladder injuries and one with bowel injury intraoperatively, and postoperatively one patient with pelvic abscess, three with urinary tract infection, one with voiding difficulty, and one with bowel perforation. The overall survival rates were 94% in 5 years and 92.7% in 20 years. No port-site metastasis was recorded in this study. Conclusions: Patients with endometrial carcinoma treated by LSS had compatible or even better long-term survival outcomes and less complication in comparison with the published data, in addition to the benefits of its minimally invasive characteristics. LSS should be the treatment of choice for endometrial cancer.

Objective: To describe the surgical procedures of robot-assisted natural orifice transluminal endoscopic surgery (NOTES) for hysterectomy and to evaluate its feasibility. Materials and methods: From December 2014 to February 2015, four patients with benign diseases who were eligible for robot-assisted NOTES at Chang Gung Memorial Hospital were recruited to this study. Intraoperative and postoperative surgical outcomes were evaluated. Results: Robot-assisted NOTES hysterectomy was successfully performed in all these patients. None of the patients had vaginal delivery, with two being nulliparous. The mean ± standard error of the mean uterine weight was 365.5 ± 69.2 g, the mean operative time was 198.8 ± 39.0 minutes, the mean docking time was 38.3 ± 2.4 minutes, the mean blood loss was 180.0 ± 56.1 mL, and the mean postoperative hospital stay was 2.5 ± 0.3 days. The final pathologic diagnoses were adenomyosis and/or leiomyomas. Conclusion: The novel robot-assisted NOTES technology created scarless skin wounds. More importantly, the device allows the surgeon to reach deeper places to achieve hemostasis, and perform surgery on larger tumors using the curved cannulae-wristed instrument. However, its implementation is limited by the lack of appropriate instrumentation, which requires further development and break through. At this stage, robot-assisted NOTES is only useful for limited applications in highly selected patients.

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: This study aims to describe the feasibility of treating uterine leiomyoma with myomectomy by natural orifice transvaginal endoscopic surgery (NOTES). Materials and methods: Women with leiomyoma underwent myomectomy by transvaginal NOTES in a tertiary referral medical center and surgical outcomes were measured. Results: Three patients underwent the surgery at a mean age of 46.7 [standard deviation (SD), 6.2] years and mean body mass index of 21.6 (SD, 2.1) kg/m2. The average operative time was 128 (SD, 55) minutes. The average blood loss in the operation was 317 (SD, 207) mL without blood transfusion. No intra- or postoperative complications were noted. No cases were converted to traditional laparoscopy or laparotomy. Conclusion: Our preliminary results showed the safety and feasibility of transvaginal NOTES in laparoscopic myomectomy. It is one of the minimally invasive surgeries and results in scarless healing. However, it should be evaluated in more cases.

Objective: The purpose of this article is to describe the application of hysteroscopy in different cases of gestational trophoblastic disease. Materials and methods: Three patients who presented with gestational trophoblastic disease were managed with hysteroscopy. The first case was a hydatidiform mole that underwent transcervical resection with endometrial curettage. The second case had a history of suction curettage for hydatidiform mole. She underwent transcervical resection for retained products of conception. The third case had a history of suction curettage for hydatidiform mole. In contrast with the second case, the patient had rising β human chorionic gonadotropin (β-HCG) values prior to transcervical resection and eventually underwent chemotherapy in the form of methotrexate. Results: The surgical procedure was uneventful in all three patients. All three operations were performed in

Objective: This study was conducted to describe the feasibility of treating endometrial cancer with hysterectomy, bilateral salpingo-oophorectomy, and bilateral pelvic lymphadenectomy by natural orifice transluminal endoscopic surgery (NOTES). Methods: Women with early-stage endometrial cancer underwent surgical staging by transvaginal NOTES in a tertiary referral medical center, and surgical outcomes were measured. Results: Three patients with a mean age of 46.3 [standard deviation (SD) = 2.5] years and a body mass index of 27.7 (SD, 2.4) kg/m2 were selected. The average operative time was 249.3 (SD, 49.3) minutes. All patients had minimal blood loss during the operation (

Objective: Our aim was to create a neovagina with the least surgical morbidity and the best functional outcome. Materials and methods: We hereby describe a new technique (Lee's neovaginoplasty) using a combined laparoscopic and vaginal approach in the creation of a neovagina using the uterine serosa layer from the rudimentary uterus and the peritoneum as a graft to line the vagina. This procedure was performed in three patients who were followed-up for a duration of 4 months to 2 years. Vaginal dilation was maintained with a vaginal mold daily for 3 months and three to four times a week thereafter. Results: Adequate vaginal length of 6-7 cm and width of 2.5 cm was achieved postoperatively. There were no surgical complications and postoperative recovery was fast. Vaginal examination 1 month later showed healthy vaginal tissue with no necrosis or infection. Long-term follow-up did not show any shortening or stenosis of the vagina. Patients were able to have satisfactory sexual intercourse with no pain. Conclusion: The laparoscopic-vaginal approach of using a uterine serosa and peritoneal graft for creation of a neovagina is a simple and effective approach with minimal surgical morbidity that can create a passageway for satisfactory intercourse.

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: To evaluate the feasibility and safety of performing a hysterectomy using the transvaginal natural orifice transluminal endoscopic surgery (NOTES). Materials and Methods: From May through December 2010, 16 patients with benign uterine diseases who were eligible for laparoscopic hysterectomy were recruited to undergo transvaginal NOTES at a tertiary referral medical center. Intraoperative and postoperative surgical outcomes were measured. Results: All of the included hysterectomies were completed via transvaginal NOTES without conversion to conventional laparoscopy. The mean (± standard error of mean (SEM)) uterine weight was 538.8±102.9 g, the mean operative time was 122.7±17.6 minutes, and the mean blood loss was 379.4±95.4 mL. The mean postoperative hospital stay was 2.8±0.2 days. No intraoperative or postoperative complications were noted in this series. Conclusion: Hysterectomy for the treatment of benign diseases can be feasibly carried out via transvaginal NOTES. However, prospective studies are needed to determine its full clinical applications.

Laparoscopic hysterectomies increase recently due to several advantages of minimally invasive surgery. Controversy exists for laparoscopic hysterectomies for large uteri weighing >500 g because some reports show increased complications and morbidities and high laparoconversion rate in the past. With familiarity of laparoscopic procedures and progress in surgical techniques, the issue should be discussed and reviewed by evidence again. Hence, we conducted a systematic review of laparoscopic hysterectomies for large uteri.

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.

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.

A 35-year-old woman with persistent vaginal bleeding and a history of prior cesarean delivery was diagnosed with cesarean scar pregnancy (CSP) by transvaginal ultrasonography at 7 weeks of gestation. The patient was initially treated with a single dose of systemic methotrexate (MTX) injection. However, both follow-up β-hCG levels and transvaginal ultrasonography had shown evidence of ongoing pregnancy. Finally, she was treated with hysteroscopic resectoscope, by which the gestational tissue was removed completely. No intra-operative or post-operative complication occurred. Serum β-hCG level returned to normal limit four weeks after the surgery. In our experience, systemic MTX injection provides an alternative choice of treatment for carefully selected women with CSP, and hysteroscopic removal of CSP, which offers good prognosis, can serve both as the initial treatment and as the rescue management after a failed MTX treatment attempt.

Objective: The purpose of this article is to describe a new minimally invasive technique for an extremely large ovarian tumor. Materials and Methods: From July 2010 to June 2011, three patients with large pelvic cystic tumor which extended up to or beyond the level of the umbilicus were recruited. All these patients were managed through a transumbilical 2-cm ultraminilaparotomy protected by the Alexis wound retractor and then combined with a single-port laparoscopy, which was accessed through three 5-mm cannulas fixed on the glove fingers. In ultraminilaparotomy mode and protection of spillage the tumor fluid was sucked out, and then the collapsed ovarian tumor was exteriorized for enucleation and repair. Finally the laparoscopic mode resumed for check-up and complete surveillance of the whole abdominal cavity. Results: The procedures were completed uneventfully in all three patients, with a small amount of blood loss and shortened operation time. We found this approach offers the advantages of attentive prevention of tumor spillage and wound contamination over traditional laparoscopy, and a better cosmetic outcome and more comprehensive ability to manage the associated pathologies outside the reach of pure ultraminilaparotomy. Conclusion: This application not only provides both advantages of ultraminilaparotomy and laparoscopy but it also overcomes the limitations of both approaches. Therefore, it is the surgical approach of choice for a patient bearing an extremely large ovarian cystic tumor.

Steroid cell tumors, not otherwise specified (SCT-NOS), are uncommon ovarian neoplasms accompanied by virilization symptoms due to hyperandrogenism, which are malignant in approximately one-third of the cases. Given the rarity of SCT-NOS, their molecular underpinnings have not yet been studied in depth. In this case series, we performed the first comprehensive analysis of the genetic landscape of this rare ovarian tumor. A detailed clinicopathological description of an index case is also provided. Over a 20-year period, a total of eight patients were seen at our institution. Total nucleic acids (RNA and DNA) were extracted from evaluable formalin-fixed, paraffin-embedded tumor specimens (n = 7) and subjected to TruSight Oncology 500 testing and/or exome sequencing. The results identified pathogenic variants in several hypoxia-related genes - including HIF1A, VHL, SDHB, SRC, IDH2, and FOXO4. As the first comprehensive genetic analysis of SCT-NOS, this study shows that dysregulation in the hypoxia signaling pathway is a key molecular feature of this rare tumor. Clinically, long-term follow-up with periodic measurements of androgen levels should be pursued in all cases since recurrences may occur several years after the initial diagnosis. [ABSTRACT FROM AUTHOR]

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]