Torsion of a nongravid leiomyomatous uterus

The torsion of a nongravid uterus is not of frequent occurence. The leading reasons are a presence of an adnexial formation or leiomyomas. In this case report it has been presented a 65-year old patient with a hard abdominal pain. After the gynecologic and ultrasound examination it has been found an uterus myomatosus with three intramural-subseros leiomyomas. By the following laparotomy was confirmed the ultrasound results - the uterus with big intramural-subserous leiomyoma 8-9 cm in a diameter, and two more leiomyomas - 5 cm, a torsion of the body uterus at 180 degree above the vaginal part of the cervix. The adnexes were rotated around the supravaginal (isthmic) part of the uterus, the uterine tubes were hyperemic, swollen, with livid color, and the ovarian were atrophic. Total hysterectomy with bilateral adnexectomy was performed. We suggested that the main reason for this torsion of the uterus was the presence of leiomyomas and the genital descensus played a role as a predisposition.     

F-18 fluorodeoxyglucose uptake in leiomyomatous uterus

Leiomyomas of uterus are common disease in gynecology. It is important to differentiate leiomyoma from leiomyosarcoma at the decision of treatment methods, especially in the case of the conservative treatment for uterine leiomyoma. But the exact diagnosis of benign leiomyoma is often difficult due to the degeneration of myoma by imaging modalities including magnetic resonance imaging. Recently, whole-body positron emission tomography (PET) using F-18 fluorodeoxyglucose (FDG) has been used for a diagnosis of malignant tumors. There is a growing body of evidence for the use of FDG in differentiating malignant from benign disease. But optimal utilization in gynecology remains unclear. Our case represents increased uptake of FDG in myomatous uterus, which is pathologically confirmed benign leiomyoma by the hysterectomy. Immunohistochemical analysis of glucose transporter-1 showed positive in endometrial tissue and negative in leiomyoma. Our case indicates that myomatous uterus in premenopausal women shows the potential pitfall of a positive result of FDG-PET.     

Osteoclast-like giant cells in leiomyomatous tumors of the uterus. A case report and review of the literature

Osteoclast-like giant cells (OLGC) in leiomyomatous tumors of the uterus are rarely seen, and their significance is unknown. We present a case of a large leiomyomatous tumor in which OLGC were found in only few sections showing leiomyosarcoma whereas the majority of sections revealed a leiomyoma. Though radically operated, the patient died a few months later with recurrent tumor in the pelvis and metastases to the lungs.     

Effect of gonadotropin-releasing hormone agonists on monocyte chemotactic protein-1 production and macrophage infiltration in leiomyomatous uterus

OBJECTIVE: The level of monocyte chemotactic protein-1 (MCP-1), a potent chemoattractant for monocytes, is fivefold higher in myometrium than in leiomyoma. We have previously shown that myometrium from women using GnRH agonists (GnRH-a) express the highest levels of MCP-1, which has antiproliferative effects on leiomyoma cells. We hypothesized that MCP-1 may have a direct paracrine effect in leiomyomatous uterus rather than acting by way of chemoattraction of macrophages. DESIGN: Cross-sectional study.Setting: University medical center. PATIENT(S): Women with leiomyoma (n = 32). INTERVENTION(S): Immunohistochemical analysis performed in the myometrium and leiomyoma of women receiving (n = 11) and not receiving (n = 21) GnRH-a treatment. MAIN OUTCOME MEASURE(S): The MCP-1 levels and macrophage counts determined by immunohistochemistry in the myometrium and leiomyoma of women receiving GnRH-a were compared to the levels and counts in women not receiving GnRH-a. RESULT(S): Samples from all 11 patients using GnRH-a revealed strong MCP-1 staining, whereas staining was only weakly present in 11 and absent in 10 samples from patients not receiving GnRH-a, revealing a significant difference in MCP-1 expression between GnRH-a users versus nonusers (P=.006). The number of tissue macrophages between GnRH-a users and nonusers was not significantly different. CONCLUSION(S): We found that there is an increase in the MCP-1 protein expression in the myometrium of women receiving GnRH-a treatment. On the other hand, we have not observed a difference in the macrophage count and distribution with GnRH-a treatment, suggesting a potentially direct antiproliferative role for MCP-1 rather than acting by means of chemoattraction of macrophages.     

Gastric epithelioid leiomyomatous tumors

Gastric epithelioid leiomyomatous tumors can present in three patterns; intramural, endogastric and exogastric based upon the relation to the gastric muscular wall. Patients may experience no symptoms from this tumor or may complain of symptoms suggesting peptic ulcer disease. Upper gastrointestinal tract series are the most reliable diagnostic tests but important additional information can be obtained by ultrasound and abdominal computerized tomography. The overwhelming majority of epithelioid leiomyomatous tumors are found in the gastric antrum. Round or polygonal cells are seen histologically. Often these cells have a clear zone that surrounds the nuclei. The origin of these tumors is debated. Less than one-third of these tumors metastasize. Complete surgical excision can often achieve cure. The exogastric lesions are the ones most readily cured by resection. Prognosis also correlates with clinical parameters including size of tumor, duration of symptoms and weight loss. Adjuvant therapy has not proved beneficial.     

Surgical procedure to conserve the uterus for future pregnancy in patients suffering from massive adenomyosis

The treatment for severe adenomyosis has usually been hysterectomy, because there is no line of demarcation between diseased and normal tissue. Yet many such women wish to retain their uterus and some even wish to bear children. This report evaluates the efficacy of a new method of adenomyomectomy, where adenomyotic tissues are radically excised and the uterine wall is reconstructed by a triple-flap method, without overlapping suture lines, to prevent uterine rupture in subsequent pregnancies. This is a prospective case series followed for 10 years from June 1998 to August 2008 of 104 women with severe adenomyosis verified histologically and with magnetic resonance imaging. There was a dramatic reduction in both dysmenorrhoea and hypermenorrhoea and all patients returned to having normal menstrual cycles. Of 26 women who wished to conceive, 16 became pregnant, 14 (53.8%)went to term and delivered a healthy baby and there were no cases of uterine rupture. Adenomyosis symptoms recurred in only four out of 104 cases. The procedure thus resulted in a dramatic reduction in symptoms and allowed over half of women who wished to conceive to go to term without uterine rupture.     

Torsion of a non-gravid leiomyomatous uterus in a patient with myotonic dystrophy complaining of acute urinary retention: anaesthetic management for total abdominal hysterectomy

Torsion of a pregnant uterus is rare, but torsion of a non-pregnant uterus is extremely rare. Abdominal pain is the major symptom. Other symptoms include vaginal bleeding, urinary tract symptoms and gastro-intestinal manifestations. We present a case of a 37-year-old white nullipara who presented at the emergency room with acute urinary retention. Medical history revealed that the patient carried the disease of myotonic dystrophy, which was diagnosed two years before. Physical examination revealed a tender, distended bladder, which was easily catheterized, draining 900 ml of clear urine. The abdomen was soft with no muscle guarding or rebound tenderness. A palpable large dense mass occupying the cul-de-sac was found during bimanual examination. Abdominal ultrasound examination revealed a large intramural leiomyoma approximately 10 cm in diameter, in the posterior wall of the uterus, which repelled the bladder. In neurological examination the muscular tone and reflexes were reduced in the lower extremities. Myotonic phenomenon was not found. The patient was thought to suffer from myotonic dystrophy and therefore the possibilities for pulmonary and cardiac complications or malignant hyperthermia had to be kept in mind during the anaesthetic management. The patient underwent an exploratory laparotomy and the uterus was found to have undergone a 60 degrees rotation along the corpus and the cervix uteri transition line. Total abdominal hysterectomy with bilateral salpingo-oophorectomy was perfomed. The intra- and postoperative course of the patient was uneventful. In conclusion, in this patient the uterine pathology (large leiomyoma) in combination with the disease of myotonic dystrophy seemed to be the predisposing factors for the torsion of the non-pregnant uterus. Also, the anaesthetic implications for total abdominal hysterectomy in myotonic dystrophy are discussed and the international literature is reviewed.     

Hysterectomy for the Transgender Man

Purpose of Review

Our objective is to summarize the most recent, high-quality data regarding perioperative recommendations for hysterectomy and salpingo-oophorectomy in transgender and gender nonconforming individuals.

Recent Findings

Many transgender men desire hysterectomy and salpingo-oophorectomy for gender affirmation, cancer-risk reduction, pelvic pain, or abnormal uterine bleeding. Gender-confirming hysterectomy is safe, effective, and highly beneficial for well-counseled patients. Preoperative considerations include optimizing the office environment, preoperative testing specific to patients with long-term testosterone use, counseling specific to transgender men, consideration of World Professional Association for Transgender Health criteria, and coordination of a multi-disciplinary team. Minimally invasive approaches, including vaginal, laparoscopic, and robotic-assisted hysterectomy, are the standard of care for cisgender women and transgender men given lower complication rates, better post-operative outcomes, and greater cosmetic satisfaction. Concurrent appendectomy, mastectomy, vaginectomy, and urethral reconstruction may be performed at the time of hysterectomy; phalloplasty and metoidioplasty are generally performed as subsequent procedures. Same-day discharge following hysterectomy is safe and has been shown to improve post-operative outcomes. We recommend follow-up with the patient’s mental health professional and endocrinologist in addition to routine surgical follow-up. Long-term satisfaction after genital surgery appears to be high and regret is low.

Summary

More robust and up to date research is needed to improve guidelines and perioperative care for transgender individuals. Available data suggests that hysterectomy and salpingo-oophorectomy for transgender men is safe, is not associated with any additional risks compared to cisgender women, and is associated with an improved quality of life.

     

Ovarian mucinous cystadenoma with leiomyomatous mural nodule

A case of an ovarian mucinous cystadenoma with a leiomyomatous mural nodule is described. The diagnosis was confirmed by immunohistochemical methods. This is the first report of a mural nodule of leiomyomatous nature, thus widening the histologic spectrum that may be encountered in these lesions.     

Reverse Hysterectomy: Another Technique for Performing a Laparoscopic Hysterectomy

Study ObjectiveTo show and evaluate outcomes of a modified laparoscopic hysterectomy technique (total reverse laparoscopic hysterectomy).DesignObservational study (Canadian Task Force classification II-2).SettingDepartment of Women's and Children's Health, Obstetrics and Gynecology Clinic, University of Padova, Padova, Italy.PatientsOne hundred one women underwent total reverse laparoscopic hysterectomy for benign disease. Indications for surgery, patient characteristics, surgical data, complications, and patient satisfaction were recorded.InterventionsTotal reverse laparoscopic hysterectomy.Measurements and Main ResultsThe modified procedure was performed starting with the incision of the vesicouterine fold and the pubocervical fascia followed by the dissection of only the anterior layer of the broad ligament, thus preserving the integrity of the posterior leaf (retrograde hysterectomy). This technique permits identification of the ureter until the cross with the uterine artery, creating a “safe triangle” for closure of the uterine vessels. The remaining surgical time did not differ from the standard technique. The average operating time was 112.1 ± 35.6 minutes, and the average intraoperative mean blood loss was 79.5 ± 138.4 mL. Ninety-one (90%) patients were very satisfied after surgery. No injuries to the ureter or bladder occurred in any patients. No other major complications were recorded.ConclusionReverse hysterectomy is another technique for performing laparoscopic hysterectomy, and it has been proven to be safe and efficient.