Fumitake Ito

Introduction: In sacrocolpopexy, a mesh is fixed to the anterior longitudinal ligament of the sacrum, near the bifurcation of the iliac vessels, but variations in the iliac venous system may increase the risk of massive bleeding during dissection. We report a successful robot-assisted sacrocolpopexy (RASC) in a patient with a left internal iliac vein anomaly and present the findings and review the literature. Presentation of case: A 71-year-old, gravida 3, para 3 woman was scheduled for RASC due to bladder and uterine prolapse. Preoperative magnetic resonance imaging (MRI) revealed that the left internal iliac vein coursed anterior to the sacral promontory. The bifurcation of the common iliac vein could not be identified intraoperatively. Upon dissection of the inferior vena cava, the left external and internal iliac veins were found to drain directly into the inferior vena cava, with the left internal iliac vein coursing anteriorly to the sacral promontory. After confirming that the sacrum was caudal to the anomalous vessels, the mesh was fixed to the anterior longitudinal ligament without any complications. Discussion: Preoperative recognition of venous anomalies is crucial to avoid catastrophic bleeding during sacrocolpopexy. Preoperative imaging, such as MRI, plays an essential role in delineating the vascular anatomy, and meticulous intraoperative dissection is indispensable. Although RASC lacks tactile feedback, its superior visualization and precise instrument control facilitate safe management of complex vascular variations. Conclusion: RASC is extremely useful in venous anomalies, provided that thorough preoperative imaging evaluation and meticulous intraoperative dissection are ensured.

Background: Ferritin may be elevated as an acute-phase reactant in inflammatory conditions, potentially masking iron deficiency. We aimed to evaluate the frequency of iron deficiency and the diagnostic significance of transferrin saturation (TSAT) in women with uterine adenomyosis. Methods: This retrospective study included non-menopausal women aged 30–55 years who had iron metabolism markers measured at first visit. Anemia was defined as hemoglobin (Hb) <11 g/dL. Iron deficiency was defined using three criteria: ferritin-only (serum ferritin <20 ng/mL), TSAT-only (TSAT <20%), and a combined criterion (ferritin <20 ng/mL and/or TSAT <20%). Functional iron deficiency was defined as TSAT <20%, with ferritin ≥20 ng/mL. We compared the frequencies of anemia and iron deficiency across groups and evaluated correlations between Hb and TSAT (Pearson correlation using log-transformed TSAT; Spearman correlation as sensitivity analysis). Results: Iron deficiency was more common than anemia in all patient groups. In the adenomyosis group, the frequency of iron deficiency based on the combined criterion (65.5%) was significantly higher than that diagnosed using ferritin alone (31.0%). In the myoma and no uterine structural abnormality groups, iron deficiency frequency was similar regardless of the diagnostic criteria. The correlation between Hb and log(TSAT) was weak in the adenomyosis group (r = 0.2123, p = 0.1771) but strong in the myoma (r = 0.5465, p < 0.0001) and no uterine structural abnormality groups (r = 0.6945, p < 0.0001). Spearman analyses showed the same qualitative pattern (adenomyosis ρ = 0.358, p = 0.020; myoma ρ = 0.576, p < 0.0001; no uterine structural abnormality ρ = 0.484, p = 0.0004). Agreement between ferritin- and TSAT-based classifications was fair (Cohen’s κ = 0.375; PABAK = 0.371), and a multivariable model for TSAT <20% with ferritin ≥20 ng/mL showed modest discrimination (AUC = 0.678). Conclusions: Measuring TSAT and ferritin levels enhances the detection of iron deficiency in women with adenomyosis and may help identify functional iron deficiency when ferritin interpretability is limited by inflammation.

The effects of conjugated equine estrogens (CEE) and 17β-estradiol-based hormone replacement therapy (HRT) on atherosclerosis development remain controversial. Here, we investigated the effects of equilin, a major compound in CEE, and 17β-estradiol on atherosclerosis development in an atherosclerotic mouse model. Female B6.KOR/StmSlc-Apoe^shl mice were ovariectomized and fed a high-fat diet for 9 and 12 weeks (early and late groups, respectively) and then treated with 17β-estradiol or equilin. Atherosclerotic lesions in the aortic arch and brachiocephalic artery (BCA) were assessed at the end of the experimental period. Compared with placebo, equilin and 17β-estradiol significantly inhibited atherosclerotic lesion formation in the aortic arch and BCA in both groups. However, 17β-estradiol had a significantly greater inhibitory effect than equilin in the late group. Although 17β-estradiol significantly inhibited atherosclerosis progression in the aortic root, no significant difference was observed between the equilin and placebo groups. Additionally, compared with equilin, 17β-estradiol significantly inhibited atherosclerotic plaque formation in the aortic root. Moreover, 17β-estradiol exerted a stronger inhibitory effect on atherogenesis than equilin and control. Both 17β-estradiol and equilin protect against atherosclerotic plaque formation in the vascular endothelium, with 17β-estradiol exhibiting a superior effect.

Diagnostic laparoscopy is useful in the management of gynecological cancers; however, it can occasionally result in the detection of other malignancies. Occult breast cancer (OBC) is metastatic breast cancer without a recognized primary breast lesion. We report a rare case of OBC that was detected laparoscopically. A 64-year-old female presented to our hospital with back pain. Magnetic resonance imaging (MRI) revealed a 50mm multicystic tumor with an internal nodule in the right ovary. Positron emission tomography/computed tomography showed abnormal accumulation in multiple lymph nodes, moderate accumulation in the ovarian tumor nodule, and no accumulation in the breasts. Ovarian cancer was suspected, and a diagnostic laparoscopy was performed. Laparoscopically, a cystic tumor in the right ovary and 10mm nodule in the right round ligament were observed and partially resected. Immunohistopathologically, the nodules of the round ligament exhibited features consistent with those of breast cancer, but the ovarian tumor was a seromucinous borderline tumor. MRI revealed no breast lesions. Therefore, the malignancy was diagnosed as an OBC.

Introduction and importance: Compared to conventional laparoscopic surgery, robot-assisted surgery enables precise operation, with the aid of high-resolution 3D images and articulated forceps, even in cases where the uterus is very large. Case presentation: A 48-year-old woman with severe obesity was referred to our hospital with atypical genital bleeding for half a year. She was diagnosed with multiple uterine leiomyomas and early endometrial cancer with presumed advanced stage classification (stage IA). Robot-assisted laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymph node biopsy were performed. Due to the difficulty of removing the uterus transvaginally, the umbilical incision was extended by 7 cm, which allowed the uterine tissue removal without shredding or leakage into the pelvic cavity. The patient was discharged 5 days postoperatively, with no postoperative complications. Clinical discussion: Robot-assisted surgery has often been used for the management of early-stage endometrial cancer. Robot-assisted laparoscopic hysterectomy has significantly fewer intraoperative and postoperative complications than laparoscopic and abdominal hysterectomy. Conclusion: Improving this surgical procedure allows for safe and easy robot-assisted uterine malignant tumor removal even in cases where the patient presents with severe obesity and huge uterine leiomyomas. Highlights:

Ovarian leiomyomas are very rare. We report the case of a primary ovarian leiomyoma accompanied by multiple uterine leiomyomas. A 50-year-old woman was referred to our department for heavy menstruation, and a hot spot in the uterine lumen was observed on positron emission tomography–computed tomography (PET-CT). Cervical and endometrial cytology and tumor marker tests were negative. Pelvic magnetic resonance imaging revealed an endometrial polyp and submucosal leiomyoma in the uterine lumen and a 5-cm right ovarian tumor. Laparoscopic total hysterectomy, right salpingo-oophorectomy, and left salpingectomy were performed for radical treatment. Histopathology showed that ovarian tumors contained interlacing bundles of fusiform cells encircled by normal ovarian tissue. Immunohistochemical staining showed strong and diffuse positive staining for α-smooth muscle actin. We diagnosed the tumor as a primary ovarian leiomyoma because the leiomyoma was localized in the ovary and was larger than the size of uterine leiomyomas. No metastatic lesion was found on PET-CT. There was no tumor recurrence at the 6-month follow-up.

Background: The Vagi-Pipe® is a useful device for performing a total laparoscopic hysterectomy. The conventional model of the Vagi-Pipe® is unable to grasp the uterus during colpotomy for recovery of the resected uterus. However, the modified C-Type Vagi-Pipe® model has a shape that allows insertion into the vagina without removing the uterus manipulator. In this study, we will prospectively investigate the safety and efficacy of the C-Type Vagi-Pipe® in total laparoscopic hysterectomies. Materials and methods In total, 25 female subjects aged between 20 and 60 years with uterine fibroids or adenomyosis will be included. Patients with complications regarded as unsuitable for this study by the investigators will be excluded. The C-Type Vagi-Pipe® will be used rather than the conventional Vagi-Pipe® when performing a total laparoscopic hysterectomy. The primary endpoint will be safety and the secondary endpoints will be operation time, bleeding volume, and presence of complications. Ethics and dissemination The protocol was approved by the institutional review boards. Written informed consent will be obtained from all patients before registration in accordance with the Declaration of Helsinki. Results of the study will be disseminated via publications in peer-reviewed journals.

Background: The Vagi-Pipe® is a useful device for performing total laparoscopic hysterectomy. The conventional model of the Vagi-Pipe® is unable to grasp the uterus during colpotomy for recovery of the resected uterus. However, the modified C-Type Vagi-Pipe® model has a shape that allows insertion into the vagina without removing the uterus manipulator. This study aimed to prospectively investigate the safety and efficacy of the C-Type Vagi-Pipe® in total laparoscopic hysterectomies. Methods: A total of 25 female subjects between 20 and 60 years old with uterine fibroids or adenomyosis will be included in this study. Patients with complications considered unsuitable for this study by the investigators will be excluded. The C-Type Vagi-Pipe® will be used rather than the conventional Vagi-Pipe® when performing total laparoscopic hysterectomy. The primary outcome will be safety, and the secondary endpoints will be operation time, bleeding volume, and presence of complications. The protocol was approved by the institutional review board of Kyoto Prefectural University of Medicine. In accordance with the Declaration of Helsinki, written informed consent will be obtained from all patients before registration. Discussion: This study seeks to confirm the safety and effectiveness of the C-Type Vagi-Pipe® for total laparoscopic hysterectomy. Once confirmed, the introduction of the C-Type Vagi-Pipe® is expected to make the total laparoscopic hysterectomy procedure easier to perform and thereby allow it to be performed in many more medical facilities. Results of the study will be disseminated via publications in peer-reviewed journals. Trial registration: Japan Registry of Clinical Trials (jRCT), jRCTs052180221. Registered 18 March 2019 - Retrospectively registered, https://jrct.niph.go.jp/search

The adhesion of monocytes to endothelial cells, which is mediated by adhesion molecules, plays a crucial role in the onset of atherosclerosis. Conjugated equine estrogen, which is widely used for estrogen-replacement therapy, contains both estrone sulfate and various nonhuman estrogens, including equilin. To investigate the association between various estrogen types and atherosclerosis risk, we examined their effect on adhesion-molecule expression in human umbilical vein endothelial cells (HUVECs). In estrogen-treated HUVECs, the mRNA and protein expression levels of adhesion molecules were quantified by real-time polymerase chain reaction and enzyme immunoassay. Additionally, a flow-chamber system was used to assess the effects of estrogens on the adherence of U937 monocytoid cells to HUVECs. Equilin, but not 17β-estradiol (E2) or other types of estrogen, significantly increased the mRNA (P < 0.01) and protein (P < 0.05) expression of the adhesion molecules E-selectin and intercellular adhesion molecule-1 as compared with levels in controls. Equilin treatment increased the adherence of U937 monocytoid cells to HUVECs relative to the that in the control (P < 0.05), decreased estrogen receptor (ER)β expression, and increased the expression of proteins involved in nuclear factor kappa-B (NF-κB) activation relative to levels in controls. Furthermore, the accumulation of NF-κB subunit p65 in HUVEC nuclei was promoted by equilin treatment. By contrast, E2 treatment neither increased the number of adhered monocytoid cells to HUVECs nor altered the expression of ERβ or NF-κB-activating proteins. Our findings suggest that in terms of the adhesion of monocytes at the onset of atherosclerosis, E2 may be preferable for estrogen-replacement therapy. Further studies comparing equilin treatment with that of E2 are needed to investigate their differential impacts on atherosclerosis.