Shunichiro Tsuji

Dissection at the sacral promontory during robot‐assisted sacrocolpopexy (RSC) is technically demanding because of the proximity of major vascular structures and anatomical variability. We report two cases of RSC in which preoperative three‐dimensional (3D) reconstructed imaging and holographic extended reality (XR) visualization were used for surgical planning and intraoperative navigation. In Case 1, 3D reconstructed imaging demonstrated a narrow vascular window anterior to L5, and mesh fixation was performed on the anterior longitudinal ligament over S1 under image‐guided navigation. In Case 2, holographic XR visualization enabled preoperative distance assessment and identification of a vascularly safe region extending approximately 1.7 cm cranial to the sacral promontory, which was subsequently reproduced intraoperatively using the TilePro function on the da Vinci surgeon console. Both procedures were completed without vascular injury. Preoperative 3D reconstruction and holographic XR visualization may facilitate safer sacral promontory dissection during RSC by improving spatial understanding of patient‐specific vascular anatomy and supporting patient‐specific surgical planning and intraoperative navigation.

Introduction: The health status of children born to mothers with pregnancy and lactation-associated osteoporosis (PLO) and impaired bone homeostasis remains unknown. This study aimed to investigate the effects of maternal PLO on child health, the PLO-predisposing factors related to such effects, and the incidence of the condition. Materials and methods: From a claims dataset comprising 172,730 mothers linked with their 210,124 children, mothers who developed fragility fractures between 5 months before and 12 months after delivery, along with their children, were defined as the PLO group. Healthy controls were randomly selected by matching maternal age and child sex. Body mass index (BMI), drug use, and maternal and pediatric diseases were compared between the two groups. Results: Fifty-nine mothers and 65 children were included in the PLO group, and 11,556 mothers and 11,664 children served as the control group. The most common PLO fracture was a vertebral fracture, and delayed diagnosis was common. Maternal PLO had few adverse effects on child health. There were trends toward a higher frequency of birth asphyxia in singletons ( P = 0.072) and low birth weight in twins ( P = 0.070) in the case children, but with no significant differences. The incidence of PLO was estimated at 374 per million deliveries. Multiple delivery, maternal age ≥ 40 years, low BMI, heparin use, and ovulation disorder were identified as predisposing factors for PLO. Conclusion: There is little evidence that maternal PLO adversely affects child health. The predisposing factors for PLO suggest that caution is warranted regarding current advancements in reproductive technology.

Purpose: To describe age‐specific patterns of gonadotoxic alkylating‐agent exposure and evaluate how the cyclophosphamide equivalent dose (CED) framework captures real‐world exposure relevant to fertility preservation in females aged 0–43 years. Methods: This descriptive study used a Japanese claims database. Patients were classified as pediatric (< 15 years) or reproductive‐age (15–43 years). Twelve alkylating agents were evaluated, and six CED‐calculable agents were converted to CED. Results: Among approximately 3.86 million females, 0.04% of the pediatric cohort and 0.16% of the reproductive‐age cohort were exposed to at least one alkylating agent. Total CED identified at least intermediate‐risk exposure in 33% of exposed pediatric and 14% of exposed reproductive‐age patients. Compared with single‐agent assessment, summed total CED identified additional patients mainly in the pediatric group, corresponding to relative increases of 20.2% and 0.3%, respectively. Agents not included in the current CED formula accounted for 8.7% of all alkylating‐agent prescription records, approximately 90% of which were observed in reproductive‐age patients. Conclusions: CED captured alkylating‐agent exposure differently by age group: summed CED added exposure information mainly in pediatric patients, whereas agents lacking conversion coefficients limited exposure capture in reproductive‐age females. These findings support refinement of CED‐based assessment while emphasizing exposure capture, not outcome prediction.

The cynomolgus monkey (Macaca fascicularis) is an important experimental animal; however, its menstrual patterns, lifespan, and age-related changes in anti-Müllerian hormone (AMH) levels remain poorly characterized. This study aimed to analyze these factors and evaluate the usefulness of Cynomolgus monkeys in ovarian function research. The age at menarche was examined in 21 cynomolgus monkeys, and the age at menopause and age at death were tracked in another 22 postmenopausal monkeys. In addition, AMH levels were analyzed in 74 cynomolgus monkeys aged 0 to 33 years to evaluate ovarian reserve throughout their lives. Results showed a mean age at menarche of 3.69 ± 2.51 years, menopause at 27.00 ± 2.50 years, and a mean age at death of 32.04 ± 5.33 years. AMH levels throughout life showed a weak negative correlation with age. These findings suggest that changes in ovarian reserve throughout the life span of cynomolgus monkeys are similar to those in humans. To our knowledge, this study is the first to analyze menstruation, lifespan, and lifelong AMH levels in cynomolgus monkeys. Ovarian function throughout life, including childhood and postmenopause, was similar to that in humans, suggesting cynomolgus monkeys may be a useful experimental model.

Objective: Ovarian tissue cryopreservation is an essential fertility preservation technique. Two primary methods are used for ovarian tissue cryopreservation: slow freezing and vitrification. Recently, vitrification has been favored over slow freezing, and a closed system is recommended to prevent cross-contamination in liquid nitrogen. Follicular loss during freezing and thawing remains a major challenge. We investigated whether rapamycin, an inhibitor of the mechanistic target of rapamycin (mTOR) pathway, could mitigate primordial follicle loss during closed-system vitrification and thawing of mouse ovarian tissue. Methods: Mouse ovaries were vitrified and thawed with or without 750 nanomolar rapamycin, then immediately analyzed or cultured for 5 days. Activation of the mTOR pathway was assessed using phosphorylated S6 kinase immunostaining, and follicle survival and development were evaluated by histological analysis. Results: Closed-system vitrification did not induce apoptosis in primordial follicles. The median phosphorylated S6K-positive rate in primordial follicles was 7.1% in fresh controls, 87.9% in the rapamycin-free group, and 19.0% in the rapamycin-treated group (fresh-control vs. rapamycin-free and rapamycin-free vs. rapamycin-treated, both p<0.001). Rapamycin treatment suppressed this activation, resulting in significantly higher primordial follicle counts after culture (605 vs. 289 follicles per ovary, p<0.05) and a lower ratio of primary to primordial follicles, indicating reduced follicle activation. Conclusion: These findings demonstrate that rapamycin preserves the primordial follicle pool by preventing follicle activation during cryopreservation and thawing. Incorporating rapamycin into closed-system vitrification protocols may improve ovarian tissue cryopreservation outcomes and enhance fertility preservation for patients with cancer.

Aim: Diffuse uterine leiomyomatosis (DUL) is characterized by numerous uterine leiomyomas within and diffusely replacing the myometrium. However, because of its rarity, the prevalence, diagnostic criteria, and standard treatment for patients with DUL who wish to preserve their fertility remain unknown. This study aimed to clarify the current status of the diagnosis of DUL in Japan. Methods: We conducted a web‐based survey targeting 1080 Obstetrics and Gynecology training institutions registered with the Japanese Medical Specialty Board. We asked them whether they had treated patients with DUL over the past 10 years (2013–2022). We obtained magnetic resonance imaging (MRI) scans from institutions that reported clinical experience with DUL, and conducted a central review to determine whether each case was consistent with DUL. We also investigated whether DUL could be classified into subtypes. Results: Responses were obtained from 428 institutions, of which 128 reported clinical experience with DUL or DUL‐like multiple uterine leiomyomas, totaling 653 cases. MRI scans from 408 cases were centrally reviewed by a subcommittee, and 307 cases were confirmed as DUL. Based on the imaging characteristics, DUL was classified into three subtypes: total replacement, myometrial replacement, and submucosal‐dominant. Conclusions: This survey revealed that 653 cases of DUL or DUL‐like multiple uterine leiomyomas were managed over a 10‐year period in Japan. Based on a central review of MRI scans, DUL can be classified into three distinct subtypes. Given the differences between these subtypes, treatment approaches for patients wishing to preserve fertility may vary, highlighting the need for further investigation.

Brain metastases from endometrial carcinoma are extremely rare and associated with poor prognosis. We present a 43‐year‐old woman with mismatch repair deficient endometrial cancer who developed multiple brain metastases refractory to cytotoxic chemotherapy and without extracranial involvement. After stereotactic radiotherapy, combination therapy with lenvatinib and pembrolizumab resulted in sustained partial remission for 16 months, with no evidence of brain hemorrhage. This case demonstrates that lenvatinib plus pembrolizumab may offer an effective and safe therapeutic option for brain metastases from endometrial cancer, even in patients resistant to conventional therapy. Remarkably, this outcome challenges the traditionally poor prognosis of such cases and underscores the potential for novel targeted and immunotherapeutic strategies to redefine the standard of care for this rare and devastating complication.