Background: The prognosis for recurrent ovarian cancer is poor, but a small percentage of patients can be cured. The aim of this study was to clarify the criteria for being cured and the characteristics of cured cases. Methods: Ovarian cancer cases at 2 university hospitals and 8 community hospitals were analyzed to identify patients who were considered cured after complete remission (CR) following recurrence. Analyses of the tumors were performed and included BRCA1/2 mutation analysis. Results: Of the 157 cases of recurrence, 21 (13%) showed no evidence of disease (NED). NED cases had a lower rate of ascites at the initial diagnosis, longer disease-free survival, a higher rate of solitary lesions, and a higher rate of secondary debulking surgery. All CR cases except for one showed no further recurrence when DFS reached 4 years, which was considered a criterion for being cured. The case of relapse occurred after long-term treatment with bevacizumab. Furthermore, 19.4% of the CR cases achieved 4-year DFS, which represents 9.3% of the cases of recurrent ovarian cancer and 2.3% of all cases of ovarian cancer. BRCA mutation analysis of the tumor was possible in 17 of the 30 cases of recurrent ovarian cancer that achieved a 4-year DFS. Pathogenic variants of BRCA were found in 5 of the 11 cases of high-grade serous carcinoma. Conclusions: Approximately 10% of patients with recurrent ovarian cancer achieved a 4-year DFS and were mostly cured. The curing of cases not involving high-grade serous carcinoma (HGSC) was unrelated to the presence of pathogenic BRCA variants.

Abstract Aim The aim of this study was to evaluate the surgical, reproductive, and perinatal outcomes of patients with diffuse uterine leiomyomatosis desiring fertility preservation. Methods Patients diagnosed with diffuse uterine leiomyomatosis based on magnetic resonance imaging at Kindai University Hospital between 2017 and 2024 were included in a case series. A systematic literature review on diffuse uterine leiomyomatosis desiring fertility preservation was carried out. Results The case series showed that fertility preservation was desired in 8 of 18 cases, of which 1 was conceived after assisted reproductive technology and underwent cesarean section at 34 weeks of gestation for placenta previa accreta. A systematic literature review identified 31 cases from descriptive observational studies (1–8 cases per study). Although more fibroids (n = 87) were enucleated by extensive myomectomy than by hysteroscopic myomectomy (n = 33) (p < 0.0001), extensive myomectomy was often associated with massive blood loss and blood transfusion. Perinatal complications were more frequent in extensive myomectomy (5/7) compared to hysteroscopic myomectomy (2/12, p = 0.04). Preterm delivery before 36 weeks was more frequent in extensive myomectomy (4/6 cases) than in hysteroscopic myomectomy (1/11 cases, p = 0.03). Conclusion Fertility preservation in diffuse uterine leiomyomatosis was previously considered difficult, but it is now recognized to be possible. Hysteroscopic myomectomy is a minimally invasive option. If conception is not achieved, extensive myomectomy may be considered. However, extensive myomectomy is more invasive, with a higher risk of perinatal complications. Large‐scale clinical trials are required to establish a management standard for diffuse uterine leiomyomatosis.

Background: Cervical cystic lesions encompass a range of benign and malignant pathologies. Magnetic resonance imaging or cytology alone cannot provide a definitive diagnosis, and conventional practice involves performing a cervical biopsy by conization to confirm the histology in cases exhibiting potential signs of lobular endocervical glandular hyperplasia (LEGH) or malignancy. However, as postoperative complications resulting from conization can impact future fertility and pregnancy, alternative diagnostic methods are needed for reproductive-age patients. This study aimed to establish the efficacy of a hysteroscopic biopsy for diagnosing cervical cystic lesions and compare it with conization. Methods: Thirteen patients with cervical cystic lesions suspected of LEGH or malignancy underwent a hysteroscopic biopsy, while 23 underwent conization. Patient background information, preoperative evaluation, histology, and postoperative outcomes were collected and compared retrospectively. Results: No significant differences were found between the hysteroscopy and conization groups in terms of mean patient age (45 vs. 48 years), operating time (23 vs. 35 min), blood loss (small amount vs. 43 mL), and postoperative hospitalization (1.1 vs. 1.6 days). Conclusion: A hysteroscopic biopsy allows for targeted resection of the cervix while maintaining diagnostic accuracy. It may serve as an efficient method for diagnosing cervical cystic lesions.

BACKGROUND: This study aimed to establish an evaluation method for detecting uterine sarcoma with 100% sensitivity using MRI and serum LDH levels. METHODS: One evaluator reviewed the MRI images and LDH values of a total of 1801 cases, including 36 cases of uterine sarcoma and 1765 cases of uterine fibroids. The reproducibility of the algorithm was also examined by four evaluators with different imaging experience and abilities, using a test set of 61 cases, including 14 cases of uterine sarcoma. RESULTS: From the MRI images and LDH values of 1801 cases of uterine sarcoma and uterine fibroids, we found that all sarcomas were included in the group with a high T2WI and either a high T1WI, an unclear margin, or high LDH values. In addition, when cases with DWI were examined, all sarcomas had high DWI. Among the 36 sarcoma cases, the group with positive findings for T2WI, T1WI, margins, and serum LDH levels all had a poor prognosis (p = 0.015). The reproducibility of the algorithm was examined by four evaluators and the sensitivity of sarcoma detection ranged from 71% to 93%. CONCLUSION: We established an algorithm to distinguish uterine sarcoma if tumors in the myometrium with low T2WI and DWI are present.

According to the revision of the FIGO 2018 staging system, cervical cancer with pelvic lymph node metastases was changed to stage IIIC1. We retrospectively analyzed the prognosis and complications of locally resectable (classified as T1/T2 by TNM classification of the Union for International Cancer Control) stage IIIC1 cervical cancer. A total of 43 patients were divided into three groups: surgery with chemotherapy (CT) (ope+CT group) (T1; n = 7, T2; n = 16), surgery followed by concurrent chemoradiotherapy (CCRT), or radiotherapy (RT) (ope+RT group) (T1; n = 5, T2; n = 9), and CCRT or RT alone (RT group) (T1; n = 0, T2; n = 6). In T1 patients, recurrence was observed in three patients, but there was no difference among the treatment groups, and no patients died. In contrast, in T2 patients, recurrence and death were observed in nine patients (8 in ope+CT; 1 in ope+RT), and recurrence-free survival and overall survival were lower in the ope+CT group (p = 0.02 and 0.04, respectively). Lymphedema and dysuria were more common in the ope+RT group. A randomized controlled trial comparing CT and CCRT as an adjuvant therapy after surgery in T1/T2 patients, including those with pelvic lymph node metastases, is currently underway. However, our data suggest that performing CT alone after surgery in T2N1 patients is likely to worsen the prognosis.

OBJECTIVE: The aims of this study were to investigate trends in bone mineral density (BMD) loss and related factors in early postmenopausal women in Japan, identify risk factors for future osteoporosis, and predict osteoporosis before it occurs. METHODS: The study population consisted of women who were 50 to 54 years old at the time of the survey in 2002 or 2006. The study included a questionnaire and physical measurement findings (BMD, height, body weight [WT], body mass index [BMI], and handgrip strength). One hundred sixty-seven women continued to participate in the study and had BMD measurements at the 9- or 10-year follow-up of the Japanese Population-based Osteoporosis study. Statistical analyses were performed using Pearson correlation to examine each factor of physical measurement and BMD for lumbar spine (LS) and femoral neck (FN). The receiver operating characteristic curve of this data was also predictive of osteoporosis in 2011 for 2002 data; BMD at the age of 50 to 54 years was then used to predict the likelihood of being diagnosed with osteoporosis 9 and 10 years later. RESULTS: At the baseline in 2002 and 2006, WT, BMI, height, and handgrip strength were positively correlated with BMD. The optimal cutoff values for BMD in 2006 to predict osteoporosis in 2016 were LS less than 0.834 g/cm2 and FN less than 0.702 g/cm2. These data were also predictive of osteoporosis in 2011 for 2002 data; applying this to the 2002 data, LS/FN had a sensitivity of 92%/100%, a specificity of 87%/81%, a positive predictive value of 55%/48%, and a negative predictive value of 98%/100%. The larger WT and BMI also resulted in a greater decrease in BMD of FN after 9 or 10 years. CONCLUSIONS: We have identified a cutoff value for BMD to predict future osteoporosis in menopausal women and found a negative correlation between WT and BMI in menopausal women and changes in BMD of the FN over the next 10 years.

Recent studies have reported cancer-associated mutations in normal endometrium. Mutations in eutopic endometrium may lead to endometriosis and endometriosis-associated ovarian cancer. We investigated PIK3CA mutations (PIK3CAm) for three hotspots (E542K, E545K, H1047R) in eutopic endometrium in patients with ovarian cancer and endometriosis from formalin-fixed paraffin-embedded specimens by laser-capture microdissection and droplet digital PCR. The presence of PIK3CAm in eutopic endometrial glands with mutant allele frequency ≥ 15% were as follows: ovarian clear cell carcinoma (OCCC) with PIK3CAm in tumors, 20/300 hotspots in 11/14 cases; OCCC without PIK3CAm, 42/78 hotspots in 11/12 cases; high-grade serous ovarian carcinoma, 8/45 hotspots in 3/5 cases; and endometriotic cysts, 5/63 hotspots in 5/6 cases. These rates were more frequent than in noncancer nonendometriosis controls (7/309 hotspots in 5/17 cases). In OCCC without PIK3CAm, 7/12 (58%) cases showed multiple hotspot mutations in the same eutopic endometrial glands. In 3/54 (5.6%) cases, PIK3CAm was found in eutopic endometrial stroma. Multisampling of the OCCC tumors with PIK3CAm showed intratumor heterogeneity in three of eight cases. In two cases, PIK3CAm was detected in the stromal component of the tumor. Homogenous PIK3CAm in the epithelial component of the tumor matched the mutation in eutopic endometrial glands in only one case. Eutopic endometrial glands in ovarian cancer and endometriosis show high frequency of PIK3CAm that is not consistent with tumors, and multiple hotspot mutations are often found in the same glands. While the mutations identified in eutopic endometrium may not be driver mutations in the patient’s cancer, these are still driver mutations but this specific clone has not undergone the requisite steps for the development of cancer.

BACKGROUND: A uterine manipulator cannot be used to elevate the ovary in benign ovarian surgery during pregnancy. This report describes our method of elevation of the ovary using a metreurynter with the success rate of the procedure and a comparison of surgical results and pregnancy outcomes between the successful and unsuccessful cases. METHODS: Between August 2003 and February 2020, 11 pregnant patients with a tumor found sunk in the Cul-de-sac underwent laparoscopic cystectomy for a benign ovarian cyst with a metreurynter. The surgical results, success and failure of the elevation by a metreurynter, pregnancy outcomes, and fetal status at delivery were evaluated. RESULTS: Elevation of ovarian tumors with a metreurynter was successful in nine cases. However, it was unsuccessful in the remaining two cases wherein the ovary was lifted with forceps while the uterus was in a compressed state. The operative time was also longer in these cases. The pregnancy prognosis, however, was good for both, successful and unsuccessful cases. CONCLUSIONS: The metreurynter is an inexpensive and practical obstetric device, and its optimal use allows the performance of a procedure with minimal burden on a pregnant uterus. Therefore, we recommend the appropriate use of this method to enable effective laparoscopic cystectomy of ovarian tumors during pregnancy.

BACKGROUND: Extragonadal endometriosis is a rare condition, and its disease manifestation and long-term prognosis have not been elucidated. We report an extragonadal endometriosis case controlled by drug therapy for 14 years with analysis of the sex hormone receptor expression and PIK3CA mutation. CASE PRESENTATION: The patient was diagnosed with bladder endometriosis at age of 30 years, and underwent bilateral nephrostomy and GnRHa therapy with add-back therapy. The patient was switched to dienogest therapy at age 35 and had hematuria and bloody stools at age 38. PET-CT revealed a 6-cm mass in the bladder with fluorodeoxyglucose accumulation and the diagnosis of endometriosis in the bladder, sigmoid colon, and cecum was confirmed after the biopsy result. The lesion's tubular structures were positive for the estrogen receptor, but only 30% positive for the progesterone receptor, and the H1047R mutation in PIK3CA was found in tubular structures of the bladder lesion. GnRHa therapy caused the tumors to shrink. CONCLUSION: Decreased progesterone receptor expression and oncogenic mutations may influence the course of less common and rare site endometriosis. Rare site endometriosis often requires long-term hormone therapy, and management should be tailored to the patient's life stage, keeping in mind complications, such as decreased bone density.

Cervical elastography might be an objective method for evaluating cervical ripening during pregnancy, but its usefulness has not been fully investigated. We examined the significance of cervical elastography in the last trimester of pregnancy. Cervical elastography was performed at weekly checkups after 36 weeks of gestation in 238 cases delivered at our hospital from 2017 to 2018. The correlation with the onset time of natural labor, which is an index for judging maternal delivery preparation status, was examined. A total of 765 examinations were conducted, and cervical stiffness determined by cervical elastography was positively correlated with the Bishop score (r = 0.46, p < 0.0001). When examined separately for each week, only the examinations performed at 39 weeks were associated with the onset of spontaneous labor up to 7 days later (p = 0.0004). Furthermore, when stratified and analyzed by the Bishop score at 39 weeks of gestation, cervical elastography was associated with the occurrence of spontaneous labor pain for up to seven days in the groups with Bishop scores of 3–5 and 6–8 (p = 0.0007 and p = 0.03, respectively). In conclusion, cervical elastography at 39 weeks of pregnancy is useful for judging the delivery time.

Endometrial cysts (ECs) are thought to be the origin of endometriosis-associated ovarian cancer (EAOC). A hypothesis that the oxidative stress of iron in cysts causes "malignant transformation of ECs" has been proposed, but this has not been verified. Several population-based studies showed that endometriosis was a risk factor but did not reflect the "malignant transformation of ECs". A review showed that most patients were diagnosed with EAOC early in monitoring following detection of ECs, and that these cases might have been cancer from the start. Epidemiologically, EAOC was reduced by hysterectomy rather than by cystectomy of ECs. Gene mutation analyses identified oncogenic mutations in endometriosis and normal endometrium and revealed that the same mutations were present at different endometriotic lesions. It was also shown that most of the gene mutations found in endometriosis occurred in normal endometrium. Taking together, EAOC might be caused by eutopic endometrial glandular epithelial cells with oncogenic mutations that have undergone menstrual blood reflux and engrafted in the ovary, rather than by low-risk ECs acquiring oncogenic mutations and becoming malignant. This review discusses the mechanisms of EAOC development and targeted therapy based on genetic variation in EAOC with a focus on eutopic endometrium.

Sentinel lymph node (SLN) mapping using dye or radioisotopes has been performed in patients with uterine cancer. Superparamagnetic iron oxide (SPIO) can be handled safely and is taken up by lymph nodes (LNs); however, its efficacy in detecting SLNs in uterine cancer remains unknown. This pilot study evaluated the use of SPIO as a tracer for SLN detection in patients with uterine cancer. SPIO was injected into the uterine cervixes of 15 patients with uterine cancer scheduled for pelvic LN dissection. Magnetic resonance imaging (MRI) was performed preoperatively. Five patients also underwent radioisotope injection and single-photon emission computed tomography/computed tomography. Dissected LNs were stained with iron and examined pathologically. Of the radioisotope-positive LNs, 92% were also SPIO/MRI-positive. SPIO/MRI and iron staining were positively correlated. SLNs were identified by iron staining in 93% of cases. Iron staining was strongly positive in two of the five areas of LN metastasis; these were considered SLNs. Staining was negative or very weak in the other three areas and lymph flow disturbance was considered. SPIO and radioisotopes are taken up similarly by SLNs. SPIO/MRI and iron staining may thus be useful for detection of SLNs and diagnosis of LN metastasis in patients with uterine cancer.

INTRODUCTION: Laparoscopic myomectomy (LM) has become increasingly common in recent years because it minimizes invasiveness. However, myoma can recur after myomectomy. Therefore, we began using laparoscopic ultrasonography, which involves inserting a probe into the peritoneal cavity via a trocar and placing it in direct contact with the uterus. During surgery, this enables the detection of myomas as a small as 1 mm in diameter, which are often undetectable on MRI. Here, we report the effectiveness of laparoscopic ultrasonography. METHODS: The subjects were 26 women who underwent LM at our institution from February 2015 to December 2016. Preoperative MRI was performed, and all myomas detected on MRI were removed during LM. Laparoscopic ultrasonography was then performed to assess for residual myomas, which were removed. RESULTS: In six patients (23%), residual myomas were identified on laparoscopic ultrasonography after the first enucleation of the myomas detected on preoperative MRI. All detected residual myomas, the largest of which was less than 10 mm in diameter, were removed. CONCLUSION: Small myomas undetectable on preoperative MRI were detected on laparoscopic ultrasonography and removed.

BACKGROUND: Endometriosis is a risk factor for ovarian cancer. Endometriosis-associated ovarian cancer (EAOC), most commonly clear cell carcinoma, is believed to develop from ovarian endometrial cysts. In this study, we reviewed published cases of EAOC considered to have developed from endometrial cysts, and focused on the observation period. METHODS: We searched for articles published since January 2000 that reported cases of ovarian cancer thought to have originated from endometrial cysts using PubMed, Web of Science, and Ichushi-Web. The period from the start of follow-up of the endometrial cyst to the diagnosis of ovarian cancer was calculated. RESULTS: Seventy-nine cases were identified from 32 articles. The median period from the diagnosis of endometrial cysts to the diagnosis of ovarian cancer was only 36 months. Approximately 75% of cases developed into cancer within 60 months and most cases developed within 120 months. CONCLUSION: Our results suggest that clinically detectable cysts subsequently diagnosed as ovarian cancer might already have contained cancer cells. Therefore, the mechanism of EAOC development needs to be re-examined and appropriate management guidelines need to be developed.

MRI plays an essential role in patients before treatment for uterine mesenchymal malignancies. Although MRI includes methods such as diffusion-weighted imaging and dynamic contrast-enhanced MRI, the differentiation between uterine myoma and sarcoma always becomes problematic. The present paper discusses important findings to ensure that sarcomas are not overlooked in magnetic resonance (MR) images, and we describe the update in the differentiation between uterine leiomyoma and sarcoma with recent reports.

症例は41歳女性、0経妊であった。子宮筋腫に対し子宮動脈塞栓術(UAE)の既往があり、UAE施行後、一時的に子宮筋腫は縮小したが5年後、筋腫が増大傾向を認めた。筋腫は子宮底部に存在し径20cmでGnRHa療法5クール施行で径17cmまで軽度縮小した。腹腔鏡下子宮筋腫核出術(LM)を施行し、クローズド法で気腹を行いポートIはパラレル法で行った。子宮筋層にバソプレシン投与後、超音波メスで子宮筋層を切開し筋腫核を露出させた。筋層剥離終了後、筋腫を核出したところで、把持鉗子の先端がスムーズに開かないことに気付き、先端のリベットが脱落していることが判明した。ビデオで腹腔内でリベットが脱落した状態であったことを確認し、術中の破損が判明した。

1995年1月〜2014年6月に腹腔鏡下子宮筋腫核出術(LM)症例を対象に、孤発性の筋腫の出血量、手術時間と筋腫核出時の手術操作との関連性について検討した。70例について最大筋腫核径、手術時間と出血量について相関関係を検討したところ、最大筋腫核径と出血量、手術時間と出血量のいずれにおいても正の相関関係が認められた。術者別に検討したところ、内視鏡技術認定医が執刀した症例が35例、修練医が執刀した症例が35例であった。修練医がLMを行う際には筋腫核径7cm以下の孤発例では輸血等の危険を冒すことなく安全に手技に取り組むことが可能で、このような症例で十分に技術を習得すべきと考えられた。一方、腫瘍径8cm以上の症例においては内視鏡技術認定医でも500ml以上の出血をきたす例があり、また、核出時間がより出血量と相関するという今回の結果から、縫合操作のみならず核出操作にも習熟する必要があると思われた。

初期子宮体癌に対する腹腔鏡下手術の導入と安全性・術後ADLについて検討した。腹腔鏡下子宮体癌根治術を施行した10例を対象とした。平均手術時間273.9分、平均出血量40g、平均摘出リンパ節数21.6個であった。術中合併症は認めず、輸血症例もなかった。初回歩行は全例で術翌日から開始し、食事開始は6例で術翌日から開始できた。周術期合併症は1例で術後リンパ嚢胞への感染を認め、治療を要したため、術後在院日数が2週間以上となったが、それ以外は1週間前後であった。術前の病理学的所見は、全例が類内膜腺癌G1またはG2であったが、術後1例が類内膜腺癌G3の診断となった。リンパ節転移は認めなかったが、1例で卵巣への顕微鏡的な転移を認めた。1例で著明な静脈侵襲を認め、術後補助化学療法を施行した。腹水細胞診は3例で陽性であったが、他のリスク因子がない場合は術後治療は行わなかった。

[Abstract] Gonadotrophin-releasing hormone agonist (GnRHa) therapy for endometriosis is rarely used for long periods of time because it leads to decreased bone density and menopausal syndrome. Here, we describe a patient with severe endometriosis who underwent a colostomy and hysterectomy at a young age and has been on GnRHa therapy for 13 years since the surgery. The patient is a 37-year-old G0P0 woman who underwent a colostomy for ileus of the sigmoid colon and rectal endometriosis at the age of 21 years. At the age of 22 years, she underwent total abdominal hysterectomy, chocolate cystectomy, and partial rectectomy. After the surgery, her ovarian endometrioma recurred and ureteral endometriosis developed. She was then started on GnRHa therapy and has been on continuous therapy for 13 years up to the present. Side effects as such as decreased bone mineral density and menopausal syndrome have not been observed. Although GnRHa therapy is generally not used chronically because of its side effects, it has been possible to use it in this patient over a long period of time by ongoing monitoring for the development of deleterious side effects and adjusting the dose as needed.

Objective: Total vaginal hysterectomy (TVH) and total abdominal hysterectomy (TAH) are presently the standard procedures for total hysterectomy. Since the advent of laparoscopically assisted vaginal hysterectomy (LAVH), our institution has actively performed LAVH to establish it as standardized procedure for patients with uterine myomas and those with uterine adenomyosis. This report investigates the parameters to determine LAVH to be considered a standardized procedure.
Method: In our institution, 282 LAVH cases were performed from 1995 to 2001 (Group I), 258 cases from 2002 to 2010 (Group IIa) by "experts", and 83 cases by non-expert Ob/Gyn surgeon (Group IIb). The groups were compared by age and parity of the patients; uterine weight; operative time; blood loss; rates of intraoperative conversion to open surgery; and intra- and post-operative complications. The trend in the annual rate of LAVH was also examined.
Results: There were no significant differences in age, parity, blood loss, or conversion to open surgery. Uterine weight was significantly lower (350g) and operative time significantly longer (163min) in Group IIb than in Groups I (400g/143min) and IIa (411g/143min). The annual LAVH rate has increased continually, from 16.2% in 1995 to 85.7% in 2010.
Discussion: Because no difference was observed in blood loss or complication rates among the three groups of patients, the authors have concluded that LAVH can be performed by all gynecological surgeons. Presently, LAVH is performed for the majority of patients requiring total hysterectomy. Therefore, LAVH has been established as the institution's standardized procedure for total hysterectomy.

Objective
  Ovarian tumor is reported to complicate 1% to 4 % of all pregnancies. Laparoscopic surgery is currently the gold standard for benign ovarian tumors because it is a minimally invasive procedure. However, the effects of laparoscopic surgery on the fetus from anesthesia, surgical infection, and pneumoperitoneum are unknown. This retrospective study compared operative results and pregnancy outcomes of laparoscopic and open surgeries performed for pregnancies complicated by benign ovarian tumor.
Method
  This study included 59 patients (23 laparoscopy and 36 open surgery cases) with a preoperative diagnosis of benign ovarian tumor, who underwent surgery between January 1993 and December 2010. Patient characteristics, operative results, intraoperative cyst rupture rate, postoperative pathology, pregnancy outcome including fetal status at delivery were compared between laparoscopic and open surgery groups.
Results
  The mean blood loss and duration of postoperative hospitalization in the laparoscopy group were 22 ± 34 mL and 6.0 ± 2.7 days, respectively, and in the open surgery group were 102 ± 99 mL and 11.6 ± 2.9 days, respectively, which were significant (P < 0.05 and P < 0.01, respectively). No significant difference was found in the mean number of weeks of gestation or the mean infant birth weight (3131 g in laparoscopy group vs 3071 g in the open surgery group including one threatened premature labor). Both groups included no fetal anomaly.
Conclusion
  Laparoscopic surgery is a safe procedure for pregnancy complicated by benign ovarian tumor, providing better or comparable results with respect to adverse effects, blood loss, duration of hospitalization, cyst rupture rate, and pregnancy outcome compared with open surgery.

Hysteroscopic myomectomy is indicated for symptomatic submucosal uterine fibroids. The main complications associated with the procedure are uterine perforation and water intoxication. This report details a case of water intoxication that presented with acute hyponatremia during hysteroscopic myomectomy. The procedure was suspended and the patient's electrolyte imbalance was managed in the intensive care unit (ICU).
  The patient was a 36-year-old nulligravid female with a history of hypermenorrhea and a 6cm submucosal myoma with 100% protrusion from the uterine fundus. Excision of the tumor by laparoscopy combined with hysteroscopic myomectomy was attempted to preserve the uterus. At three hours and thirty minutes into the procedure, the patient's blood pressure dropped to 70/40mmHg. Infusion volume was 15,000ml and drainage was 12,000ml. An immediate electrolyte panel revealed severe hyponatremia, with a serum sodium level of 96mEq/l. The operation was suspended and the patient was transferred to the ICU. She left the ICU the next day with a serum sodium level of 132mEq/l. On the 6th post-operative day, she was discharged without significant sequelae. The size of the remaining myoma on follow-up ultrasound was 3cm, but a repeat hysteroscopy revealed that the intrauterine protrusion had receded. After six months, the patient underwent open myomectomy.
  This case suggests that operative duration in hysteroscopy should be less than 2 hours to avoid water intoxication. In addition, infusion and drainage volumes must be monitored, with special attention required when the difference between the two volumes exceeds 750ml. The operation should be suspended when the difference exceeds 1500ml.

[Abstract] Ovarian pregnancy is rare from ectopic gestation, with a reported incidence of 0.7-3.3％ of all ectopic pregnancy. Therefore, we have performed laparoscopic surgery since June 1991, and report 3 cases of ovarian pregnancy treated in our hospital in October 2005. The first case was a 37-year-old woman admitted because of lower abdominal pain suspected as intra-abdominal hemorrhage. Her urine hCG was positive and she underwent laparoscopic surgery with a diagnose of ectopic pregnancy. Bilateral fallopian tubes were normal and an irregular tumor and bleeding were seen in the left ovary. The left ovary including the tumor was resected. The second case was a 33-year-old woman admitted with suspected ovarian bleeding because of intra-abdominal hemorrhage. Urine hCG was positive, so laparoscopy was performed for suspected ectopic pregnancy. Bilateral fallopian tubes were normal, but there was a mass bleeding continuously in the right ovary, which was therefore resected. The third case was a 29-year-old woman admitted because of acute abdomen suspected as intra-abdominal hemorrhage. Urine hCG was positive, there was tenderness on the right side and laparoscopy was performed for suspected ectopic pregnancy. Part of the right ovary and tumor were removed. The above 3 cases demonstrated villi in normal ovarian tissue pathologically. None of these cases had concomitant disease, such as choriocarcinoma. As it is difficult to diagnose preoperatively, we diagnosed ovarian pregnancy intraoperatively and pathological findings postoperatively in these three cases ; however, advances of laparoscopy have made it possible to diagnose and treat intraoperatively before rupture.

An intravenous leiomyomatosis is a benign smooth muscle tumor that develops in a vein. Approximately 200 cases have been reported in the literature thus far ; however, no case has been reported to date of an intravenous leiomyomatosis treated conservatively with anticoagulant therapy that has received longterm follow-up. We here present a case report of patient a 44-year-old G2P2. Hysterectomy and adnexectomy were performed and the uterine vein and internal iliac vein were removed, but the superior-located masses were conserved. Currently, in the 6^ post-operative year, no changes have been detected in the location, size, and property of the remaining masses. In addition, thromboses in the deep vein and along the inferior vena cava were confirmed pre-operatively and anticoagulant therapy has been administered continuously post-operatively. Thus, a thorough pre-operative search for thrombi is required in patients with intravenous leiomyomatosis. Anticoagulant therapy may be necessary for patients with tumor conserved in the IVC following conservative surgery.

Purpose: The purpose of this study was to evaluate indications of laparoscopic myomectomy (LM) and the efficacy of preoperative GnRHa therapy. Methods: Study subjects were 161 patients who underwent LM between 1995 and 2007 at our hospital. Based on surgical performance, indications of LM were discussed in terms of the size and number of myomas. The efficacy of preoperative GnRHa therapy was evaluated by comparing the volume of myomas on MRI images and surgical performances. The recurrence rate after LM was evaluated by comparing the number of myomas confirmed on preoperative MRI and that actually enucleated. Statistical analysis was performed by ANOVA, Student's t-test, χ-square test and the Kaplan-Meier method. For all tests, p＜0.05 was considered significant. Results: The group with myomas ≧10cm showed significant increases in blood loss, operative time, and the rate of conversion to laparotomy compared with groups with smaller myomas. However, the number of myomas was not a factor that affected surgical performance. The myoma volume was reduced as a result of 43％ by preoperative GnRHa therapy without compromising surgical performance. No significant difference was observed on GnRHa therapy in the 4-year cumulative recurrence rate. The recurrence rate was significantly higher in the group in which there was a possiblity that some of myomas were missed and left.Discussion: The indications of LM were considered for myomas ＜10cm but not limited by the number of myomas. The postoperative recurrence rate will decrease if surgery is completed on ensuring no myoma has been overlooked by precisely identifying the preoperative myoma status on MRI. Preoperative GnRHa therapy was considered to be a factor not compromising the surgical performance and recurrence rate, but was effective as a pretreatment for LM to expand the indications.