西尾 永司

不妊または挙児希望のある子宮筋腫症例78例に対して腹腔鏡下子宮筋腫核出術を行い、、手術成績、術後の妊娠率および分娩予後について検討した。手術成績は筋腫摘出重量が平均111.3g、核出個数が2.7個、最大筋腫核径が5.4cm、術中出血量が103.2ml、手術時間が189.6分であった。術後合併症は2例(2.6%)に認め、退院延期となる高度貧血および創部感染が各1例であった。術後妊娠率は53.3%(42/78例)で、そのうち筋腫以外に不妊因子を認めなかった子宮筋腫単独例での妊娠率は73.3%と高率であった。妊娠成立例と不成立例の手術成績を比較したところ、筋腫の摘出重量、核出数などに有意差はなく、発生部位についても有意差はなかった。術後の分娩予後については、42例に対して44回の妊娠を確認し、そのうち79.5%(35/44例)が分娩に至り生児を得ることができた。重篤な新生児合併症は認めなかった。分娩時合併症としては、潜在性子宮破裂を1例に認めた。

37歳女。5年前より声の低音化を自覚し、無月経で不妊治療を開始したが、妊娠には至らず、体毛増加などが生じていた。高アンドロゲン血症を指摘され精査目的で当科紹介となり、ホルモン検査では血中テストステロン高値、LH、FSH低下を認めた。画像検査で卵巣および副腎腫瘍は認めず、選択的静脈ホルモンサンプリングを施行した。その結果、右卵巣静脈でテストステロン値が異常高値を示し、右卵巣由来のアンドロゲン産生腫瘍が示唆された。腹腔鏡を施行し、右卵巣は表面平滑で腫大し、明らかな腫瘍は見出せなかったが、悪性の可能性を考えて摘出した。摘出卵巣の割面所見で、卵巣門に接した22×20mmの褐色、弾性軟、境界明瞭な充実性腫瘍を認めた。病理学的には異型性の乏しい円形核と好酸性で均一な細胞質を持った類円形の細胞が均一に充実性に増殖し、Reinke結晶と考えられる好酸性の短い桿状構造を認め、Leyding cell tumorと診断した。術後各種ホルモン値は正常化し、月経も再開し、IVF-ET施行により妊娠が成立した。

Background and Aims: To evaluate outcomes after zona pellucida removal by pronase or laser assisted hatching in women with repeated assisted reproduction failures. Methods: Of 389 procedures (January 2004 to November 2005), 203 control cycles had an intact zona, 116 cycles had chemical removal of the zona and 70 cycles had laser assisted hatching. Rates of pregnancy, implantation and abortion were compared, and pregnancy rate was secondarily evaluated for fresh or frozen-thawed blastocysts. Results: Pregnancy rates were 33.5% (68/203) for controls, 29.3% (34/116) for chemical removal and 30.0% (21/70) for laser. Implantation rates were 24.8% (68/274) for controls, 21.8% (34/156) for chemical removal and 30.0% (21/105) for laser. There were no significant differences among groups. Abortion rates were 15.6% (10/64) for controls, 13.9% (5/36) for chemical removal and 14.3% (3/21) for laser. No difference was observed by blastocyst type for control or laser assisted hatching cycles. In the chemical removal group, both pregnancy and implantation rates were higher for frozen-thawed blastocysts than for fresh blastocysts. (41.5% vs 13.2% and 30.7% vs 11.1%, respectively). Conclusions: Assisted hatching did not show a significant benefit. Chemical zona pellucida removal might increase pregnancy rates for frozen-thawed blastocysts. © 2006 The Authors Journal compilation © 2006 Japan Society for Reproductive Medicine.

Purpose: To evaluate the postoperative adhesion formation caused by instruments used in gynecologic laparoscopic surgery and to determine the optimal instruments to use to reduce adhesions. Materials and Methods: Seventeen juvenile pigs underwent laparoscopic bilateral resection of the uterine horns under general anesthesia and pneumoperitoneum. The laparoscopic procedures were carried out using monopolar electrocautery (ME) (n = 8), an electrothermal bipolar vessel sealer (EBVS) (n = 6), an ultrasonically activated scalpel (UAS) (n = 6), a loop-type ligature (LTL) with a steel scalpel for severing the tissues (n = 6), and an automatic stapling device (ASD) (n = 8). Second-look laparotomy was performed 14 days postoperatively, and the degree of postoperative adhesions was scored from 0 to 6. Results: The mean and range of adhesion scores were 0.00 with EBVS, 0.13 (range, 0-1) with ASD, 0.33 (range, 0-2) with LTL, 1.17 (range, 0-3) with UAS, and 3.13 (range, 2-6) with ME. We found a statistically significant difference in the extent of postoperative adhesion formation associated with these 5 instruments (P < 0.001, Kruskal-Wallis test). Conclusion: Adhesion formation increased in the order EBVS < ASD < LTL < UAS < ME. Our study strongly suggests that surgical instruments can be selected to reduce postoperative adhesion formation, a particular concern in women of reproductive age.

A role for cyclooxygenase-2 (COX-2) in the development and progression of various tumors has been identified. Selective COX-2 inhibitors produce antiproliferative effects in various cancer cell lines that express COX-2. However. the mechanisms underlying anti-tumor effects are unclear. Furthermore, Few studies have studied COX-2 expression in gynecological cancers, especially endometrial cancer. The current study had two goals. We investigated the correlation between COX-2 expression and clinicopathological factors of uterine endometrial cancer. We also investigated effects of treatment with etodolac. a selective COX-2 inhibitor, on the uterine endometrial cancer cell line TMG-L, which expresses COX-2. We conclusively confirmed expression of COX-2 mRNA and protein in endometrial cancer that exceeded levels of COX-2 seen in normal endometrium. However, no significant correlations were observed between COX-2 expression in endometrial cancer tumor samples and clinicopathological factors or disease-free survival rate of patients with endometrial cancer. Study of COX-2 inhibition of TMG-L cells showed that etodolac produced dose-dependent inhibition of cell proliferation through G I phase cell-cycle arrest. Etodolac-induced cell-cycle arrest might be caused by increases in p53 and P21(WARI) protein expression. Production of basic-fibroblast growth factor (bFGF, a pro-angiogenesis factor) was inhibited by etodolac in a dose-dependent manner. Furthermore, telomerase activity was inhibited and expression of hTERT rnRNA was significantly inhibited with etodolac, leading to the conclusion that anti-tumor effects of etodolac oil TMG-L cells are due to inhibition of both angiogenesis and telomerase activity. These results strongly suggest that COX-2 inhibitors have potential as therapeutic (and possibly, chemopreventive) agents for endometrial cancers that overexpress COX-2.

The objective of this research is whether the classification of vascular invasion severity can be used as a prognostic factor in cases of uterine endometrial cancer. Sixty-five patients with stage I to III uterine endometrial cancer were included in the study. All patients were seen between 1987 and 1997, and the types of their cancers were histologically confirmed. The degree of vascular invasion was classified according to three different systems: (1) positive or negative (2) negative, mild, or severe and (3) negative, mild, moderate, or severe. For each classification, the disease-free survival rate was calculated according to various pathologic factors using the Wilcoxon test multivariate analyses were performed using the Cox proportional hazard model. Patients with severe vascular invasion showed a significantly lower disease-free survival rate than did patients with moderate or less severe invasion. In the multivariate analysis, severe vascular invasion was shown to be an independent prognostic factor indicating a high relative risk. We conclude that the severity of vascular invasion is an important histopathologic factor in determining the prognosis of uterine endometrial cancer. Vascular invasion classification systems employing three subjective or four objective categories may be more appropriate than a positive/negative classification system for judging the prognosis in cases of uterine endometrial cancer.

OBJECTIVE: To evaluate the efficacy of an oxidized regenerated cellulose adhesion barrier as an adjuvant in preventing postoperative adhesions in infertile women undergoing reconstructive surgery. STUDY DESIGN: Thirty-eight cases of reconstructive surgery that could be followed up for more than two years (myomectomy 19, cystectomy 5, tuboplasty 10, uteroplasty 4) at the Fujita Health University Hospital were evaluated retrospectively. The barrier (Interceed, Johnson and Johnson) was used to cover the surgical site in 23 of these cases (Interceed + group) no adjuvant was used in 15 cases, which represent the surgical control group (Interceed - group), including 23 second-look operation cases (16 in the Interceed + and 7 in the control group). Postoperative adhesion prevention and pregnancy rates were estimated. RESULTS: At the second-look operation, six cases (37.5%) in the Interceed + group and six (85.7%) in the Interceed - group had postoperative adhesions. No significant difference was found in either intensity or area covered with adhesions between the two groups. Eighteen cases (78.3%) in the Interceed + and seven (46.7%) in the Interceed - group conceived during the follow-up period. CONCLUSION: The use of Interceed significantly reduced the rate of postoperative adhesion formation, with a statistically significant increase in the pregnancy rate as compared to the surgical controls.