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   Table of Contents - Current issue
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October-December 2021
Volume 10 | Issue 4
Page Nos. 197-275

Online since Friday, November 5, 2021

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PERSPECTIVE ARTICLE  

Treating deep endometriosis in infertile patients before assisted reproductive technology Highly accessed article p. 197
Shazia Khan, Chyi- Long Lee
DOI:10.4103/GMIT.GMIT_154_20  
Deep endometriosis (DE) causes infertility and pelvic pain. Surgical management of DE has become a topic of increasing interest in gynecological surgery. In women desirous of pregnancy, optimal management such as surgery versus first-line assisted reproductive technology (ART) for patients with severe endometriosis is strongly debated. Current guidelines and literature including retrospective and prospective studies in English available on DE surgery, infertility, and pregnancy outcomes following surgery were searched in Cochrane Library with DE, DIE, Infertility, “DE surgery and pregnancy outcomes,” and “Deep infiltrating endometriosis and assisted reproduction” as keywords. The purpose was to find evidence to answer the following clinical questions: How does DE affect fertility and pregnancy? What are the possible benefits of primary surgery for DIE before in vitro fertilization (IVF)? Several studies have recently concluded that surgical removal of DE nodules might actually have a favorable impact on IVF outcomes. This is in contradiction to European Society of Human Reproduction and Embryology statement which stated that there was no evidence supporting surgical management of DE prior to ART to improve pregnancy rate; several studies have suggested that the surgical removal of DE nodules might actually have a favorable impact on IVF outcomes. Treatment of DE affecting the rectovaginal septum or bowel requires complex surgery with considerable risk of complications. This review article tries to analyze the rationale of surgical treatment of DE before ART. A balance must be struck between exposing the patient to surgical risk and improvement in pain and fertility potential. Decisions should be tailored according to the individual needs of each woman and most importantly on the ability of the surgeons.
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REVIEW ARTICLE Top

Hysteroscopy and retained products of conception: An update p. 203
Virginia Foreste, Alessandra Gallo, Alfonso Manzi, Carla Riccardi, Jose Carugno, Attilio Di Spiezio Sardo
DOI:10.4103/GMIT.GMIT_125_20  
Retained products of conception (RPOC) can occur after early or mid-trimester pregnancy termination and also following vaginal or cesarean delivery. It is frequently associated with continuous vaginal bleeding, pelvic pain, and infection. Late complications include intrauterine adhesions formation and infertility. Conventionally, the management of RPOC has been with blind dilation and suction curettage (D and C); however, hysteroscopic resection of RPOC is a safe and efficient alternative. In this review, we analyze the current available evidence regarding the use of hysteroscopic surgery for the treatment of RPOC comparing outcomes and complications of both traditional curettage and hysteroscopic technique. Data search has been conducted using the following databases MEDLINE, EMBASE, Web of Sciences, Scopus, Clinical Trial. Gov., OVID, and Cochrane Library interrogate all articles related to hysteroscopy and the preserved product of conception, updated through September 2020.
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ORIGINAL ARTICLES Top

Homocysteine and C-reactive protein levels in women with polycystic ovary syndrome p. 210
Murat Gozukucuk, Aslı Yarcı Gürsoy, Emre Destegül, Salih Taşkİn, Hakan Şatıroğlu
DOI:10.4103/GMIT.GMIT_30_20  
Objectives: Polycystic ovary syndrome (PCOS) is the most common endocrinopathy in infertile women characterized by both reproductive and metabolic dysfunctions of different degrees. Furthermore, it has been associated with increased cardiovascular disease (CVD) risk and related long-term health sequela. The aim of this study is to evaluate serum homocysteine (Hcy) and C-reactive protein (CRP) levels in women with PCOS and to evaluate their relationship with clinical and laboratory parameters in women with PCOS. Materials and Methods: The prospective single-center study included 45 women with PCOS (study group) and 41 control subjects. Demographic variables and Hcy, CRP, fasting blood glucose, insulin, follicle-stimulating hormone, luteinizing hormone, estradiol, total and free testosterone, dehydroepiandrosterone sulfate, thyroid-stimulating hormone levels, and lipid profiles of the subjects were recorded. homeostatic model assessment for insulin resistance (HOMA-IR) indexes were calculated. Results: Fasting plasma glucose, insulin, HOMA-IR, free and total testosterone levels, and clinical hirsutism were significantly higher in the study group. There was no statistically significant difference in lipid profile between groups. Hcy and CRP levels were higher in the study group, which was not statistically significantly different (P > 0.05). Conclusion: Some of the parameters that are correlated with CVD risk were found to be higher in women with PCOS, although the difference for Hcy and CRP did not reach statistical significance. However, the current study reveals that the CVD risk associated with PCOS deserves more comprehensive prospective studies with long-term outcomes.
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Step-wise technical description of performing ureteric tunnel dissection in laparoscopic radical hysterectomy p. 215
Dipak Limbachiya, Rashmi Kumari
DOI:10.4103/GMIT.GMIT_85_20  
Objectives: Technical description of performing ureteric tunnel dissection in laparoscopic radical hysterectomy (LRH) surgery. Materials and Methods: This is a retrospective analysis. A total of 91 patients of the International Federation of Gynaecology and Obstetrics Stage IA2, IB1, and IB2 of cervical cancer were operated by the same surgeon between January 2015 and December 2019 were analyzed. Results: The median time for one side ureteric tunnel dissection was 3 min 15 s (range 2 min 35 s– 6 min 18 s). None of the cases were converted to laparotomy. The patients' median hospital stay was 2 days (range 1–4 days). There were no short-term or long-term complications related to ureteric tunnel dissection. Conclusion: This analysis explains the descriptive methodology of operative technique, especially for ureteric tunnel dissection in LRH. This technique is easily reproducible and replicable, with chances of marginal or negligible complication rates.
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Comparison of surgical results and postoperative recurrence rates by laparoscopic sacrocolpopexy with other surgical procedures for managing pelvic organ prolapse p. 221
Yasushi Kotani, Kosuke Murakamsi, Sayaka Kai, Tamaki Yahata, Akiko Kanto, Noriomi Matsumura
DOI:10.4103/GMIT.GMIT_127_20  
Objectives: Pelvic organ prolapse (POP) is relatively high for a gynecologic disease. Laparoscopic sacrocolpopexy (LSC) is currently the main surgical option for managing POP. The priority of the surgical treatment is preventing recurrence after the surgery. We presented the surgical outcome and recurrence rate of LSC and compared the data of LSC with that of other surgical procedures for managing POP to examine the effectiveness of LSC over other them. Materials and Methods: We compared the results of 138 cases of LSC with other conventional procedures, namely 30 cases of total vaginal hysterectomy (TVH) combined with colporrhaphy anterior and posterior, 66 cases of the Manchester operation, and 68 cases of colpocleisis. We compared the age, body mass index, operative time, blood loss volume, postoperative hospital stay duration, rate of complications, recurrence rate, reoperation rate, and the cumulative recurrence rate after 10 years. Results: The complication rate of LSC, TVH, the Manchester operation, and colpocleisis was 2.2%, 3.3%, 3.0%, and 4.4%; the recurrence rate 2.8%, 3.5%, 4.5%, and 8.7%; and the cumulative recurrence rate after 10 years 3.7%, 4.6%, 8.8%, and 18.2%. There was no significant difference between LSC and the other three groups. Conclusion: LSC seems to be an effective surgical option that requires a higher skill level than other surgical methods and has a longer operative time, lesser operative invasion, and a lower long-term recurrence rate. We will actively recommend LSC to those when appropriate.
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Salivary proteome profile of women during fertile phase of menstrual cycle as characterized by mass spectrometry p. 226
Ganesan Saibaba, Durairaj Rajesh, Subramanian Muthukumar, Ganesan Sathiyanarayanan, Archunan Priya Aarthy, Govindaraju Archunan
DOI:10.4103/GMIT.GMIT_78_20  
Objectives: Ovulation is such a critical physiological process that its noninvasive detection based on salivary constituents has several advantages in humans. Hence, the present study is proposed to identify the ovulatory-specific proteins in saliva in order to detect ovulation phase. Materials and Methods: Samples were collected from women volunteers. The procedure adopted was approved by the Institutional Human Ethical Committee (DM/2014/101/38), Bharathidasan University. The saliva samples were collected from thirty healthy female volunteers, with a prior written consent. One-way analysis of variance was used to calculate protein concentration and band intensity using SPSS 16 software (SPSS Inc., Cary, NC, USA). The salivary protein expression pattern during different phases of menstrual cycle was analyzed using gel-based high resolution-liquid chromatography-mass spectrometry/mass spectrometry and matrix-assisted laser desorption ionization-time of flight/time of flight. Further, bioinformatics tools were adopted to annotate the proteins identified at various phases of menstrual cycle. Results: As many as 530 proteins showed up in the saliva during ovulatory phase, whereas there were only 251 proteins identified during postovulatory phase. The functional annotation of salivary proteins revealed that the proteins got assigned to the class of “extracellular proteins” which are concerned with regulatory functions. The 16 unique and/or differentially expressed protein spots appeared during ovulatory phase, among which Cystatin-S, Prolactin-inducible protein, Cystatin-A, Cystatin-SN, BPI fold-containing family A member 2, Alpha-tubulin N-acetyltransferase 1, Carbonic anhydrase-6, Protein LEG1 homolog, Hemoglobin subunit beta, and Pancreatic alpha-amylase were identified. Conclusion: Total salivary proteome profile has been listed with respect to various phases of menstrual cycle. Among the protein listed, Cystatin-S offers a biomarker protein and/or indicator of ovulatory phase. However, extensive validation is required before arriving to a candidate bio-marker protein.
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Comparison of clinical efficacy and urodynamic changes using single-incision slings (MiniArc® vs. Solyx™) for the treatment of female stress urinary incontinence p. 235
Fook Chin Chiang, Ryan Sun, Yu- Jun Chang, Yi- Ing Li, Mou- Jong Sun
DOI:10.4103/GMIT.GMIT_102_20  
Objective: To compare the clinical efficacy and urodynamic parameter changes between the MiniArc and the Solyx sling for the treatment of female urodynamic stress incontinence (USI). Materials and Methods: One-hundred and thirty (MiniArc n = 79, BS-Solyx n = 51) patients were included in this study. Cough stress test (ST), pad test (PT), Incontinence Impact short form Questionnaire (IIQ-7), Urogenital Distress Inventory six-item questionnaire (UDI-6), Sexual Questionnaire-Short Form (PIS-Q), and urodynamic parametric changes were assessed to determine objective and subjective outcomes following the procedure. Objective cure was defined as negative ST and PT <2 g and subjective cure was defined as “No” to the answer of UDI-6 Question #3. Predictors of surgical failure were also determined. Results: All Solyx users, as opposed to 91.1% of MiniArc patients, obtained objective cure at postoperative 3 months (P = 0.042). No significant difference in subjective cure rates (93.7% vs. 90.2% at 3-months (P = 0.513); 89.9% vs. 80.4% at 1 year for Solyx and MiniArc patients, respectively (P = 0.126)) and improvement scores in UDI-6 and IIQ-7 were observed. The Solyx group incurred more de novo urgency (17.6% vs. 6.3% at 3 months (P = 0.042); 23.5% vs. 7.6% at 1 year (P = 0.01)). Both procedures yielded significant decrements in maximal urethral closure pressure (P < 0.001) and average flow rate (P = 0.015). The preoperative PT and sling type were strong predictors of surgical failure, where the Solyx tape reported lower odds (odds ratio = 0.174, P = 0.02) compared to the MiniArc sling. Conclusion: Single-incision mini-slings are safe and effective treatment for female USI. The Solyx SIS demonstrated superiority over the MiniArc in this study based on its higher objective cure rate and lower risk for surgical failure.
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SHORT COMMUNICATION Top

Hysteroscopy role for female genital tuberculosis p. 243
Achmad Kemal Harzif, Tricia Dewi Anggraeni, Danny Maesadatu Syaharutsa, Tantri Hellyanti
DOI:10.4103/GMIT.GMIT_151_20  
Female genital tuberculosis affects the quality of women's lives. One of the symptoms is amenorrhea. In our country, it is still underdiagnosed due to limited resources. Hysteroscopy is known as one of the diagnostic tools for this condition. We performed hysteroscopy and endometrial biopsy in four cases. Hysteroscopy findings show various signs. Histopathological examination showed typical features of tuberculosis in some cases. We also learned that hysteroscopy could evaluate the condition of the endometrium when ongoing and after treatment is accomplished. It is useful for further explanation to the client. Hysteroscopy can be utilized as a diagnostic tool for endometrial sampling, evaluate intracavity condition after treatment, and prognostic tool for future reproductive function.
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CASE REPORTS Top

The path of birth is not always normal: A case report of cervicovaginal agenesis p. 247
Kavita Khoiwal, Meenakshi Singh, Anchal Agarwal, Jaya Chaturvedi
DOI:10.4103/GMIT.GMIT_57_20  
Cervical agenesis is a rare congenital Mullerian anomaly. Its association with vaginal agenesis is further rare, reported in 39% of cases of cervical agenesis. The conventional treatment for this condition was hysterectomy. However, with evolving surgical skills and assisted reproductive techniques, conservative surgery could be considered as the first-line treatment in the current era. We report one such case of cervicovaginal agenesis in a 13-year-old adolescent girl managed successfully with cervicovaginoplasty. The patient was relieved of cyclical pain abdomen and resumed menstrual cycles postoperatively.
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A case of an abscessed cystic endometriotic lesion in the vesico-uterine pouch after oocyte retrieval p. 252
Shigeru Matsuda, Shigeo Akira, Hanako Kaseki, Kenichiro Watanabe, Shuichi Ono, Masao Ichikawa, Toshiyuki Takeshita
DOI:10.4103/GMIT.GMIT_12_20  
A 31-year-old nulliparous Japanese woman visited the clinic due to worsening dysmenorrhea. A cystic endometriotic lesion was found in the vesico-uterine pouch. Laparoscopic surgery was chosen due to the severe dysmenorrhea. Her first oocyte retrieval attempt was performed at in-vitro fertilization clinic before the planned surgery. However, she complained of abdominal pain on day 6 after the retrieval. We diagnosed her with peritonitis with an abscessed cystic endometriotic lesion in the vesico-uterine pouch. Conservative treatment was ineffective. Therefore, laparoscopic surgery was performed. The cysts in the vesico-uterine pouch were drained of pus. No adhesions or lesions of endometriosis in the uterus, bilateral adnexa, or pelvic peritoneum were found. Although cystic endometriotic lesions in the vesico-uterine pouch are rare, they can form abscesses after oocyte retrieval. The possibility of abscesses formation risk must be considered. Moreover, following the management of endometrioma, sufficient medication should be administered to prevent this formation.
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Calcified ovarian fibromas complicated with basal cell nevus syndrome p. 256
Daiken Osaku, Fuminori Taniguchi, Hiroaki Komatsu, Hermawan Wibisono, Yukihiro Azuma, Tasuku Harada
DOI:10.4103/GMIT.GMIT_16_20  
Basal cell nevus syndrome (BCNS) is a rare neurocutaneous syndrome characterized by tumorigeneses such as basal cell carcinomas, jaw cysts, ovarian fibromas, and cardiac fibromas. We present a 24-year-old female with calcified ovarian fibromas associated with BCNS. She had a surgical history of the maxillary cyst and was diagnosed with BCNS due to the cutaneous pits. Magnetic resonance imaging indicated an 8-cm mass and a 4-cm mass, which had been suspected to be a subserosal myoma and a fibroma, respectively. GnRH agonist was preoperatively administered; however, the size of the masses did not change. In laparoscopy, a tumor consisting of 8- and 5-cm masses in the right ovary was identified, and tumorectomy was performed. Because both tumors were extraordinarily rigid and could not be morcellated with scalpels or scissors, we removed them by the Luer Bone Rongeurs with minilaparotomy. The histopathological diagnosis was the ovarian fibromas with marked calcification.
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Sclerosing stromal tumor of the ovary: A successful laparoscopic approach p. 259
Márcia Silva Marinho, Evelin C O. Pinto, Maria T. L. S B. Abranches, Antónia M C. Furtado
DOI:10.4103/GMIT.GMIT_20_20  
Sclerosing stromal tumors (SSTs) are a rare type of benign tumors of the ovary, representing 6% of sex cord tumors subtype. We report a case of SSTs affecting a young female patient presenting with abdominal pain and a pelvic mass on imaging examination. The patient underwent laparoscopic right salpingo-oophorectomy, and the pathology report confirmed the diagnosis of SSTs. A review of the literature with the typical pathological and imaging features of SSTs as well their management is performed.
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Ovarian torsion occurring nine days after ipsilateral dermoid cystectomy p. 262
Pauline Chang, Nicholas Leyland, Sarah Scattolon
DOI:10.4103/GMIT.GMIT_24_20  
Ovarian torsion (OT) is a gynecological emergency that requires prompt treatment and management. It is associated with risk factors such as ovarian cysts and prior pelvic surgery. Diagnosis and treatment require surgery to examine the adnexa, correct the torsion, and determine if cystectomy or oophorectomy are required. We reported the case of a 34-year-old woman who presented 9 days after a dermoid cystectomy with sudden onset abdominal pain. An ultrasound showed abnormal blood flow to the ovary. She then underwent a repeat laparoscopy revealing a necrotic and twisted ovary on the same side that had a cystectomy. The surgeons proceeded with a right oophorectomy. Following surgery, the patient reported no concerns with no ongoing bleeding or pain. OT can present in the short-term postoperatively to an ovarian cystectomy, likely as a result of mechanical forces secondary to structural changes of the ovary. The role for prophylaxis against OT is unclear in those with significant risk factors for torsion.
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Laparoscopic “Shaving” for infiltrative external adenomyosis of bowel muscularis and concomitant deep infiltrating endometriosis p. 265
Kuan- Lin Wu, Peng Teng Chua, Chyi- Long Le
DOI:10.4103/GMIT.GMIT_27_20  
Deep infiltrating endometriosis (DIE) is a common finding in patients diagnosed with adenomyosis. Women commonly present with severe, incapacitating dysmenorrhea. We report a case of severe dysmenorrhea and lower abdominal tightness for 4 years, diagnosed with posterior adenomyosis. The patient underwent surgery and DIE involving the rectosigmoid and coexisting uterocervical adenomyosis infiltrating bowel muscularis successfully diagnosed and treated using laparoscopic “shaving” technique. Dysmenorrhea significantly resolved after surgery. Laparoscopic surgical “shaving” technique for external adenomyosis infiltrating Rectosigmoid muscularis is feasible, where uterine preservation is desired.
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CLINICAL IMAGE Top

Rare pelvic fibroid – Round ligament fibroid p. 268
Sanket Pisat, Minal Dhanvij
DOI:10.4103/GMIT.GMIT_62_20  
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VIDEO ARTICLE Top

Endometriotic peritoneal defect is a risk factor for peritoneal ectopic pregnancy or tubal abortion implant p. 270
Lee Koon Kwek, Yang Huang Grace Ng, Shahul Hameed Mohamed Siraj, Yen Ching Yeo
DOI:10.4103/GMIT.GMIT_123_20  
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LETTERS TO THE EDITOR Top

Noninvasive high-intensity focused ultrasound surgeries for fibroids and adenomyosis during COVID-19 Pandemic in Hong Kong: A gynecologist's viewpoint p. 272
Felix Wu Shun Wong, Thomas K T Li
DOI:10.4103/GMIT.GMIT_18_21  
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Incidentally diagnosed krukenberg tumor in a young pregnant woman p. 274
Shabnum Thakur, Kapil Mohan Pal, Purnima Thakur, Manish Gupta
DOI:10.4103/GMIT.GMIT_7_21  
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