近澤 研郎

For gestational trophoblastic neoplasia (GTN) affecting women of reproductive age, the chemotherapy-first approach is often preferred over the surgery-first approach. Low-risk GTN is treated with a chemotherapy-first approach, but the number of courses required can affect fertility. A surgery-first approach may decrease the number of chemotherapy courses, but its efficacy and safety compared to a chemotherapy-first approach are unclear. Thus, we investigated the efficacy and safety of the surgery-first approach compared to the chemotherapy-first approach in treating low-risk GTN. We searched the MEDLINE, Embase, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and World Health Organization International Clinical Trials Registry Platform databases for relevant articles in July 2023. A systematic review and meta-analysis of outcome measures were conducted using a random-effects model. The primary outcomes were remission, the mean number of chemotherapy courses required to cure, and adverse events. The certainty of the evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation approach. This study protocol was registered in the Open Science Framework (https://osf.io/kysvn/). Studies for low-risk GTN included a qualitative synthesis (with 2,192 participants and ten studies, eight of which were about second uterine curettage and two about hysterectomy) and a meta-analysis (with 138 participants and two randomized controlled trials (RCTs) that compared first-line treatments of second uterine curettage and chemotherapy). Second uterine curettage may result in little to no difference in remission (risk ratio: 1.00, 95% confidence interval: 0.96-1.05; low certainty) and a slight reduction in adverse events (risk ratio: 0.87, 95% confidence interval: 0.47-1.60; low certainty). The evidence is very uncertain on the mean number of chemotherapy courses (mean difference: 2.84 lower, 95% confidence interval: 7.31 lower to 1.63 higher; very low certainty). Based on clinical outcomes, second uterine curettage can be comparable to the chemotherapy-first approach as a first-line treatment option for low-risk GTN; however, the overall certainty of the evidence was low or very low.

The functional association between hip joint motion and defaecation/urinary function has attracted considerable research and clinical attention owing to the potential novel approaches for pelvic floor rehabilitation; however, the anatomical basis remains unclear. This study, therefore, aimed to analyse the anatomical basis of force transmission between the obturator internus, a muscle of the hip joint, and the levator ani, a muscle of the pelvic floor. Twenty-three cadavers were used for macroscopic and histological analyses. The three-dimensional structures of the muscles and fascia were recorded using a high-definition camera and a 3D scanner. The arrangement and attachment of the muscle fibres, tendons and fascia were visualised using histological sections stained with Masson's trichrome. The obturator internus and levator ani were in broad contact through the obturator fascia. The height of their contact area was 24.6 ± 9.1 mm. Histologically, the obturator internus and levator ani shared a large area of the obturator fascia, and the obturator fascia provided the attachment of several muscle layers of the levator ani. The contribution of hip joint motion to defaecation/urinary function can be explained by the broad 'planar' contact between the obturator internus and levator ani. This anatomical feature suggests that movement of the obturator internus creates the foundation for the function of the levator ani and contributes to pelvic floor support through the obturator fascia. This study provides an anatomical basis for the effectiveness of the hip muscles in improving defaecation/urinary function by enabling balanced and proper movements.

OBJECTIVES: The objective of the study was to investigate the long-term outcomes, in particular, recurrence risk, especially tumor volume, for Stage IA endometrial cancer and to identify the risk factors for recurrence. MATERIALS AND METHODS: This single-center retrospective study analyzed women who underwent primary surgical treatment for the International Federation of Gynecology and Obstetrics Stage IA (Grade 1 or 2) endometrioid carcinoma at our institute between January 2010 and July 2018. Patients' demographic characteristics, including age, operative time, number of lymph nodes, final stage, volume index as tumor volume, and final histological type, were reviewed. A total of 168 patients were enrolled, with 95 and 73 patients in the laparotomy and laparoscopy groups, respectively. The Cox proportional hazards model was used to adjust for prognostic factors in the analysis including upstaged patients, tumor histology, lymphovascular invasion, and volume index. RESULTS: There was no difference in the recurrence rate between laparoscopic and open surgeries for Stage IA endometrial cancer. The operative time was longer, and the amount of blood loss was lesser in the laparoscopy group than in the laparotomy group. For all patients undergoing either laparoscopy or open surgery, upstaged ≥IB, nonendometrioid Grade 1 or 2, lymphovascular invasion, and volume index ≥36 were significant independent recurrence risk factors. CONCLUSION: Laparoscopic surgery for Stage IA endometrial cancer is technically and oncologically safe. Patients with a high-volume index have a higher recurrence risk. Furthermore, the volume index can be a recurrence predictor in low-risk endometrial cancer patients.

OBJECTIVES: This study aimed to identify risk factors associated with perineal and vaginal lacerations related to vaginal removal during total laparoscopic hysterectomy (TLH). MATERIALS AND METHODS: We retrospectively assessed 134 patients who underwent TLH, of whom 44 (32.8%) had vaginal lacerations. RESULTS: Univariate analysis revealed that for patients with myomas and adenomyosis, gonadotropin-releasing hormone agonist use and myomas with a transverse diameter of ≥5 cm were significant risk factors, while multiparity (vaginal delivery) was a protective factor for perineal and vaginal lacerations. Moreover, multivariate analysis indicated that multiparity was the only statistically significant protective factor. For cervical intraepithelial neoplasia, endometrial cancer, and endometrial hyperplasia, only a uterine transverse diameter of ≥5 cm was a significant risk factor for perineal or vaginal lacerations. CONCLUSION: For patients with large myomas, multiple vaginal delivery was a protective factor, and in patients with normal-sized uteri, a uterine transverse diameter of ≥5 cm was a risk factor for perineal or vaginal lacerations.

Perioperative complications tend to increase when performing hysterectomy in patients with a history of caesarean section. Therefore, the laparoscopic hysterectomy procedure requires careful consideration. Herein, we report the case of a patient with a history of caesarean section who underwent total laparoscopic hysterectomy for endometrial cancer. A 59-year-old woman was diagnosed with stage IA endometrial cancer preoperatively, and she underwent laparoscopic hysterectomy, bilateral adnexectomy, and pelvic lymphadenectomy. During these procedures, the bladder was observed to tightly adhere to the scar of a previous caesarean section, and the uterine was perforated due to detachment near the uterus to avoid damage to the bladder. After 2 years, there were no symptoms of recurrence. Our findings further demonstrated that bladder adhesions should be considered in laparoscopic surgery for patients with endometrial cancer who have a history of caesarean section.

AIM: We aimed to evaluate regional disparities in the proportion of the three main laparoscopic surgeries for benign gynecological diseases among 47 prefectures in Japan and their correlation with the number of laparoscopy-qualified gynecologists per population. METHODS: In this retrospective ecological study, we collected the data of patients from 47 prefectures in 2017 using "The National Database of Health Insurance Claims and Specific Health Checkups of Japan" Open Data from the Ministry of Health, Labor and Welfare in Japan. The primary outcome of the study was the proportion of laparoscopic surgeries conducted for benign gynecologic diseases (hysterectomy, myomectomy and surgery for the benign ovarian diseases). The main exposure was the number of laparoscopy-qualified gynecologists per 100 000 females. RESULTS: The average proportion of laparoscopic hysterectomies, myomectomies and surgeries for the benign ovarian disease were 38% (standard deviation (SD) 16, range 12-74), 48% (SD 18, range 9-81) and 60% (SD 11, range 36-79), respectively. Multiple regression analysis showed a significant correlation between the number of laparoscopy-qualified gynecologists per 100 000 females and the proportion of the three main laparoscopic surgeries. CONCLUSION: There are obvious regional disparities in the proportion of the three main laparoscopic procedures for benign gynecological diseases among 47 prefectures. The number of laparoscopy-qualified gynecologists correlated significantly with these regional disparities. The academic society should monitor these regional disparities and make an effort to reduce these regional disparities by increasing laparoscopy-qualified gynecologists in areas where the widespread use of laparoscopic techniques is lagging.

Investigate the efficacy of a hospitalized weight reduction program before laparoscopic surgery among high body mass index (BMI) patients with endometrial cancer. The patients were housed in a shared room, received exercise guidance, and restricted to a total caloric intake of 1200 kcal. A physiotherapist and a dietitian provided pedometer and nutritional guidance, respectively. The primary outcome was weight reduction. Among the 16 patients included, 12 (75%) had Stage I endometrial cancer and 10 (62.5%) underwent laparoscopic surgery. Weight and BMI at first consultation were 88.4±10.4 kg and 34.8±3.9 kg/m2, respectively. The rate of weight reduction was 6.5%±2.5%; on average, BMI decreased by 2.1±1.0 kg/m2. The duration from initial consultation to surgery was 39.1±11.4 days. Hospitalization duration until weight reduction was 20.8±8.0 days; there were no surgical complications. Our hospitalized weight reduction program may be effective for obese endometrial cancer patients.

AIM: This study aimed to investigate the trends in overall hysterectomy and other alternative therapies for benign uterine diseases per population aged 40-54 years in Japan. METHODS: We conducted a national representative cohort study in Japan. We obtained data from 'The National Database of Health Insurance Claims and Specific Health Checkups of Japan' Open Data. The primary outcome was the number of overall hysterectomies for benign gynecologic diseases per population aged 40-54 years, from 2014 to 2017 in Japan. The secondary outcome was the number of alternative surgical and drug therapies to hysterectomy per population. We also analyzed the correlation between the number of laparoscopy-qualified gynecologists and the number of overall hysterectomies per population among 47 prefectures in 2017. RESULTS: The number of overall hysterectomies for benign gynecological diseases per 100 000 females aged 40-54 years gradually increased from 320 in 2014 to 344 in 2017 (7.5% increase overall). Moreover, there was a significant increase in the use of levonorgestrel intrauterine systems. We could not explain the reason for this increase in the rate of overall hysterectomies by summarizing the increase or decrease of alternative therapies to hysterectomy. Multiple regression analysis showed a significant correlation between the number of laparoscopy-qualified gynecologists and the number of overall hysterectomies among 47 prefectures. CONCLUSION: Despite the spread of alternative therapies to hysterectomy, there was an increasing trend for overall hysterectomies in Japan. The reason was not clear but may be related to the spread of laparoscopic hysterectomy.

OBJECTIVE: To evaluate the benefits of nedaplatin treatment in patients with a history of hypersensitivity reactions to carboplatin. MATERIALS AND METHODS: We retrospectively reviewed the medical records of patients with ovarian, fallopian, and peritoneal cancers and with a history of hypersensitivity to carboplatin between January 2010 and December 2016 at the Department of Gynecology in the Saitama Medical Center associated with Jichi Medical University. We studied the response rate to treatment with a nedaplatin-based regimen compared to that of a carboplatin regimen. Fisher's exact test was used to determine statistical significance. RESULTS: Thirty-one patients with a past hypersensitivity to carboplatin were treated with nedaplatin-based regimen, while ten patients were treated with other drugs. The response rates in the nedaplatin- and non-nedaplatin-treated patient groups were 71.4% and 30.0%, respectively (P = 0.021). Among all the patients, only one experienced hypersensitivity reaction to nedaplatin. CONCLUSION: The nedaplatin regimen following hypersensitivity to carboplatin was safe, feasible, and effective in achieving complete or partial response.

The majority of patients with benign ovarian cysts undergo laparoscopic surgery using both cystectomy and stripping techniques. However, these techniques have difficulty correctly identifying cleavage planes and are prone to cyst rupture. We present a surgical cystectomy technique that correctly identifies the cleavage plane with a low risk of ovarian cyst rupture, even in patients with multicystic ovarian cysts. Cystectomy was performed using Maryland forceps with gentle open and close dissecting motions only. Both the surgeon and assistant handled the ovarian cortex and cyst wall, and soft traction between the cortex and cyst wall as far as the nearby dissection plane without grasping the cyst wall was essential. In patients with multicystic ovarian cysts, making a plane at the notch between cysts decreases the risk of cyst rupture. This technique allows the correct identification of the cleavage plane for dissection and avoids the risk of cyst rupture.Impact StatementWhat is already known on this subject? The majority of patients with benign ovarian cysts undergo laparoscopic surgery using both cystectomy and stripping techniques. These techniques have difficulty correctly identifying cleavage planes and are prone to cyst rupture.What do the results of this study add? This technique allows the correct identification of the cleavage plane for dissection and avoids the risk of cyst rupture.What are the implications of these findings for clinical practice and/or further research? Our technique might be useful for the preservation of the ovarian reserve because patients in this study had a low proportion of ovarian follicles in the surgical specimen.

Most fetal ovarian cysts increase in size during the late stages of pregnancy. Early treatment of a huge neonatal cyst may reduce the risk of gastrointestinal obstruction.

Trainees require extensive experience to perform radical hysterectomy. Before starting training during an actual operation, trainees should be familiar with the pelvic anatomy and should simulate surgical procedures. Many simulators are available for virtual reality training of laparoscopic operations, but they are very expensive. The materials required to construct our model included sponges and colored wires sold in home improvement stores that allowed for superior cost effectiveness. The model represented almost all peripheral vessels and nerves around the uterus, including the minor vessels. Attaching and detaching the vessels was easy, facilitating reconstruction of the dissected vessels. The wires were easy to bend, ensuring high operability. This model allows for the simulation of laparoscopic radical hysterectomy in a dry box. Our model was superior to a 2-dimensional picture for the memorization of branching and positional relationships of the blood vessels. Comparison of our model with actual operative videos showed that the dry box provided an identical surgical view of an actual laparoscopic radical hysterectomy. We developed a peripheral bloodstream model of the uterus for repeated simulation of laparoscopic radical hysterectomy with an actual surgical view using a dry box.

BACKGROUND/AIM: Data are limited regarding the use of pegfilgrastim in gynaecologic oncology. We evaluated its efficacy for maintaining dose intensity during chemotherapy. PATIENTS AND METHODS: We retrospectively examined the data of 65 women (26 pegfilgrastim users) who underwent primary surgical treatment for stages IB-IV endometrial cancer and had adjuvant chemotherapy containing platinum and taxane; the primary outcome was a relative dose intensity ≥85%. RESULTS: In the pegfilgrastim vs. the control group, body mass index (26.6±5.9 vs. 23.4±4.4), rate of relative dose intensity ≥85% (88.5% vs. 15.4%), plus other adverse event incidences were significantly higher; rate of neutropenia, total hospital visits during chemotherapy (11.0±2.1 vs. 18±5.6 days), unscheduled hospital visits (1.1±1.8 vs. 5.8±5.1 days), and unscheduled granulocyte colony-stimulating factor injections (0.58±1.7 vs. 6.4±5.1 days) were significantly lower. CONCLUSION: Pegfilgrastim can maintain a dose intensity of ≥85% during chemotherapy for the treatment of gynaecologic cancers and decrease hospital-visit frequency.

Purpose of investigation: The authors determined whether concurrent chemoradiotherapy (CCRT) followed by hysterectomy improves progression-free survival (PFS) and overall survival (OS) in patients with squamous cell carcinoma (SCC) and non-SCC of the cervix. Materials and Methods: The authors retrospectively reviewed records of 110 cervical cancer patients (FIGO Stages IB2-IVB) who underwent CCRT with paclitaxel/carboplatin. Extrafascial hysterectomy was performed for local control primary outcomes included PFS and OS. Results: The sample comprising 80% SCC, 15.5% adenocarcinoma, and 4.5% other types of carcinoma patients was followed for 45.0 ± 21.0 months. The three-year PFS and OS rates were 68% vs. 65% (p = 0.76), and 88% vs. 72% (p = 0.26) for all patients with and without hysterectomy, respectively. The three-year PFS and OS rates were 64% vs. 38% (p = 0.32), and 85% vs. 38% (p = 0.025) for non-SCC patients with and without hysterectomy, respectively. Conclusions: Hysterectomy after CCRT with paclitaxel/ carboplatin improves prognosis in patients with non-SCC of the cervix.

This study aimed to determine whether the cervical length increases over a period of six months, after the loop electrosurgical excision procedure (LEEP) for grade III cervical intraepithelial neoplasia (CIN), and to identify the factors associated with an increase in the cervical length. We retrospectively reviewed the medical records of 183 patients who underwent the LEEP between April 2011 and March 2014, at the Department of Gynaecology, Kyosai Hospital. Transvaginal ultrasonography was performed at two, three and six months after the LEEP, and the mean increase in the cervical length between two and three months, two and six months, and three and six months were 2.07, 5.23 and 2.92mm, respectively. The increase in the cervical length was not associated with age, gravidity, parity and the width of CIN. In conclusion, the cervical length may increase gradually over a period of six months after the LEEP.

Objective: Instrument-assisted vaginal delivery is a significant risk factor for birth canal lacerations. Although many obstetricians recently are recommending restrictive rather than a routine episiotomy, reports have shown restrictive episiotomy to be associated with more extensive anterior birth canal trauma compared with routine episiotomy. Materials and Methods: We retrospectively reviewed 110 cases of forceps and vacuum deliveries and investigated the site of birth canal lacerations. Birth canal lacerations were divided into four sites according to direction-anterior, ipsilateral, contralateral, and posterior. Results: The frequency of lacerations were, from most to least, posterior (34%), lateral (21.7%), and anterior (1.9%). Moreover, among the lateral lacerations, they were more frequent in the contralateral side of episiotomy than the ipsilateral side (18.9% vs. 4.7%, p < 0.01). Conclusion: Our results indicate that caution is also needed concerning not only the anterior site, but also the contralateral site of an episiotomy to prevent laceration in an instrument-assisted vaginal delivery. Copyright (C) 2016, Taiwan Association of Obstetrics & Gynecology. Published by Elsevier Taiwan LLC.

Uterine arteriovenous malformations are rare and their true prevalence is unknown. Selective arterial embolization is used as first-line therapy for acute severe vaginal hemorrhage associated with uterine arteriovenous malformations. However, some patients with no vaginal bleeding have been treated conservatively, so the optimal treatment modality for arteriovenous malformations is unclear. We describe a 58-year-old woman with uterine arteriovenous malformation and an ovarian artery aneurysm who was successfully treated with an expectant management approach along with an assessment of age, symptoms, and imaging findings.

AimThe aim of this study was to identify predictors of recurrent/residual disease for management after loop electrosurgical excisional procedure. MethodsWe retrospectively reviewed 178 patients with cervical intraepithelial neoplasia grade 3 and microinvasive squamous cell carcinoma who underwent the loop electrosurgical excisional procedure between April 2011 and March 2014. Endocervical/ectocervical margin status, endocervical curettage (ECC) status, and maximum width of cervical intraepithelial neoplasia were assessed. Patients were followed up for 6-12 months. ResultsPatients with endocervical margin involvement were significantly older and those with ectocervical margin involvement were significantly younger than patients with no margin involvement (P = 0.02 for both comparisons). ECC-positive patients were significantly older than ECC-negative patients (P = 0.049). There was a significant difference in the mean width of the cervical intraepithelial neoplasia between women with ectocervical involvement and those without ecto- or endocervical involvement (10.2 3.1 mm vs 7.3 +/- 3.5 mm, P = 0.0002). The odds ratios for possible recurrent/residual disease for endocervical involvement, ectocervical involvement, and ECC-positivity were 2.1 (0.5-8.4), 3.2 (1.3-7.9), and 6.8 (1.4-32.1), respectively. However, while most ECC-positive patients underwent a second surgery, most patients with ectocervical involvement did not need further treatment. ConclusionOlder age and ECC were significantly associated with endocervical margin involvement; younger age and width of cervical intraepithelial neoplasia were associated with ectocervical margin involvement. Ectocervical margin involvement significantly increased the risk of possible recurrent/residual disease; however, these patients might recover naturally. ECC-positivity significantly increased the risk of recurrent/residual disease.

Purpose of investigation: To determine if concurrent chemoradiotherapy (CCRT) with paclitaxel and carboplatin is effective, convenient, and tolerable for cervical cancer treatment. Materials and Methods: The authors retrospectively reviewed the medical records of 49 patients. Primary outcomes included progression-free survival (PFS) and overall survival (OS). The Cox proportional hazards model was adjusted for all prognostic factors in the multivariable analysis. Results: Over the median follow-up time of 32 months in a sample consisting of 87.8% (43/49) squamous cell carcinoma and 12.2% (6/49) adenocarcinoma, two-year PFS and OS rates were 67.2% and 80.9%, respectively. hi univariate analyses, stage, histology, performance status, tumor size, and age were significant variables for OS; only histology was significant in the multivariable analysis. Acute toxicity grade 3 or 4 neutropenia (85.7%), diarrhea (32.7%), and late toxicity grade 3 or 4 (12.2%) were detected. Conclusions: For cervical cancer treatment, CCRT with paclitaxel/carboplatin is satisfactory.

Introduction Muscle contusions usually occur as a result of blunt trauma, which damages the muscle fibers and connective tissue without breaking the skin. Rapid bleeding can cause an increase in pressure that requires surgical intervention, commonly referred to as compartment syndrome. Here, we report a case with delayed diagnosis of single compartment muscle contusion in which compartment syndrome did not develop. Presentation of case A 50-year-old woman underwent radical hysterectomy. She complained of edema and tenderness in the lower left leg on postoperative day 6. The serum creatine phosphokinase level was slightly elevated at 177 IU/L (normal range: 6–142 IU/L). T2-weighted magnetic resonance imaging revealed swelling of the muscle in the deep posterior compartment of the lower left leg, edematous fascia, and subcutaneous adipose tissue. She recovered naturally without other complications. Discussion In the lithotomy position during surgery, muscle contusion might occur, without general symptoms. Conclusion Magnetic resonance imaging is useful for diagnosis. For patients who complain of edema and tenderness in the lower leg after surgery in the lithotomy position, muscle contusions should be considered.