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A 49-year-old female was incidentally found to have a left renal tumor during a medical check-up. The tumor was too small to be fully diagnosed using computed tomography (CT) or magnetic resonance imaging (MRI). Since it was small and showed a homogenous enhancement pattern on contrast-enhanced CT, which made it difficult for us to distinguish the malignancy of the tumor, we performed regular CT follow-up. On the fifth year of her regular follow-up, the tumor had grown apparently larger and showed a heterogenous enhancement pattern, which suggested a malignant tumor. Since the tumor was exophytic, we decided to perform a laparoscopic partial nephrectomy. The operation was performed without any serious complications, and her renal function remained unchanged. The histopathology of the tumor was leiomyoma. Here, we discuss the characteristics of this tumor and the role of immunohistopathology in the diagnosis.

We present a case of benign esophageal leiomyoma with video-assisted thoracic enucleation. A 39-year-old woman was found to have an abnormal shadow in the mediastinum on a chest X-ray on a medical check-up. Chest CT performed for the purpose of close examination revealed a tumor with a size of 62×33 mm from the middle intrathoracic esophagus to the lower esophagus. Upper gastrointestinal endoscopy revealed a left half-circumferential elastic soft submucosal bulge in the thoracic middle-lower esophagus. Endoscopic ultrasonographic fine-needle aspiration biopsy(EUS-FNA)was performed, and immunostaining showed positive muscular markers SMA, but negative for CD34, c-kit, and S-100, and the diagnosis was esophageal leiomyoma. Therefore, thoracoscopic-assisted esophageal leiomyoma resection was performed. Postoperative immunohistological examination showed positive for SMA and Desmin, and the diagnosis was leiomyoma.

A 34-year-old woman underwent total hysterectomy for management of uterine leiomyoma. At the same time, a paraurethral tumor (2 cm in size) was diagnosed based on magnetic resonance imaging (MRI). However, the patient was not treated for the tumor considering its small size. Eight years later, the patient was referred to our institution with a chief complaint of urethral bleeding. Computed tomography revealed a paraurethral mass at the same location, which was 13 cm in size. A percutaneous needle biopsy was performed and the tumor was diagnosed as leiomyoma. Tumor extirpation was performed and immunohistochemical analysis of the specimen demonstrated positive estrogen and progesterone receptors. Recurrence was not observed on MRI taken 6 months after the surgery. Paraurethral leiomyoma is rare, but relatively common in young women.

Pulmonary benign metastasizing leiomyoma (PBML) is a rare entity. We herein report a case of PBML found as multiple bilateral lung nodules 11 years after total hysterectomy. The patient was a 53-year-old woman with past surgical history of abdominal total hysterectomy for a uterine leiomyoma at the age of 42. She was referred to our department for further evaluation of multiple pulmonary nodules detected by a chest radiography. A chest computed tomography revealed multiple bilateral small lung nodules less than 10 mm in diameter. 18-fluorodeoxyglucose (FDG) positron emission tomography showed no significant FDG accumulation to these nodules. The patient finally underwent video assisted thoracoscopic wedge resection of the lower lobe of the right lung for surgical biopsy. The final pathological diagnosis was PBML, based on the comparative evaluation of the surgical specimens from the lung and the uterus. No evidence of enlargement in the remaining pulmonary nodules was noted for 9 months after surgical lung biopsy.

The patient was a 51-year-old woman with a mass in the left breast.At the first presentation, she had abdominal distension and liver dysfunction.Mammography showed a category 5 mass in the left breast and a category 4, unstructured region in the right breast.Pathological examination revealed bilateral, invasive ductal carcinomas.Stage II B disease(clinical T2N1M0)was diagnosed in the left breast, and Stage I disease(clinical T1N0M0)was diagnosed in the right breast.Computed tomography revealed a massive uterine myoma compressing the inferior vena cava.Liver dysfunction was suspected to be caused by these factors.Preoperative chemotherapy was scheduled to treat breast cancer.A gynecologist stated that "uterine myoma is unlikely to cause liver dysfunction" and refused to perform a hysterectomy.However, we diligently negotiated with him to avoid chemotherapy-induced venous thrombosis and pulmonary infarction; eventually, a hysterectomy(3.6 kg)was performed. After surgery, liver function was normal.Subsequently, breast cancer could be safely and adequately treated.In patients who have benign disease, as well as malignant tumors, treatment of the malignant tumors is generally given the highest priority.However, there are cases when the treatment of benign disease has priority over the treatment of malignant tumors.It is therefore important to intensively discuss such cases with physicians from other departments.

Benign metastasizing leiomyoma (BML) is a rare condition in which a benign uterine leiomyoma causes metastasis, mainly to the lungs. The patient was a 72-year-old woman who had undergone hysterectomy for an uterine leiomyoma at 37 years of age. Between the ages of 52 and 68 years, she had undergone 5 metastatectomies for 10 BMLs. At the current presentation, 2 nodules located in the right upper lobe of the lung were resected. The histological diagnosis was BML, and immunohistochemical staining demonstrated that the tumor cells were positive for estrogen and progesterone receptors. Two years after surgery, the patient is alive without recurrence or respiratory symptoms. Multiple resections can be a treatment option for BML.

A 71-year-old woman, in whom computed tomography revealed a solitary mass shadow at the base of the left lung, underwent resection of the mass. Histopathological examination showed estrogen receptor-positive leiomyoma cells growing in cords and mixed with glandular structures composed of alveolar cells. These findings led to a diagnosis of benign metastatic leiomyoma. Benign metastatic leiomyoma is a rare disease in which histologically benign uterine leiomyoma cells metastasize to different sites of the body. However, in this patient, the presence of uterine myoma was not confirmed in the past or at present. She had a history of cervical conization, which suggests that a small amount of the leiomyoma component contained in cervical tissue may have been forced into blood vessels during surgical manipulation, causing lung metastasis.

A 60-year-old postmenopausal woman presented with a lung nodule, which was detected on a chest X-ray 2 years after surgery for breast cancer. Pulmonary metastasis from the breast cancer was suspected and surgical resection was performed. On histopathological examination, the lung nodule showed a smooth muscle cell tumor, and immunohistochemical staining was positive for estrogen and progesterone receptors. As a mass in the uterine was detected by computed tomography images before surgical resection, benign metastasizing leiomyoma of the lung was suspected. Subsequently, the patient underwent hysterectomy and bilateral salpingo-oophorectomy. The pathological findings revealed that the mass in the uterine was atypical leiomyoma, which was consistent with the primary lesion of the lung metastasis. Atypical leiomyoma is classified as a benign tumor, but in this case, careful follow-up is required because of its clinical course and histological features.

Leiomyoma is a benign smooth muscle tumor which is rarely found in the paraurethral region. We report a case of paraurethral leiomyoma in a 44-year-old female who visited a clinic complaining of urinary retention. Magnetic resonance imaging revealed a 9 cm mass adjacent to the urethra. She was referred to our department. Transvaginal needle biopsy was performed and the histopathological diagnosis was leiomyoma. The mass was completely excised transperitoneally and transvaginally. The resected specimen was 8 × 7 × 4.5 cm in size and 194 g in weight. Histopathological diagnosis was leiomyoma and the tumor cells demonstrated immunoreactivity for estrogen receptors and progesterone receptors. Herpost operative course was uneventful and she gained normal voiding function. In a follow-up after 3 months, there was no evidence of recurrence. We discuss the clinical and pathological features of the paraurethral leiomyoma.

Background: The purpose of this study was to examine the hemodynamics and bispectral index score during lower abdominal surgery under balanced anesthesia with the two different combination doses of desflurane and remifentanil., Methods: Twenty patients undergoing total hysterectomy were allocated into two groups; 1) 10 patients received 4.5% end-tidal concentration of desflurane combined with remifentanil 0.125 μg x kg(-1) x min(-1) (H group) and 2) 10 patients received 3.0% end-tidal concentration of desflurane combined with remifentanil 0.2 μg x kg(-1) X min(-1) (L group). Mean arterial pressure (MAP), heart rate (HR) and BIS were recorded 5 times (on admission to operating room, immediately before surgery, 5 minutes after the skin incision, at the moment of uterine extraction and during retroperitoneal closure)., Results: MAP and HR during surgery did not increase compared with those on admission to operating room, and BIS was unchanged throughout the study in both two groups., Conclusions: The patients could be anesthetized adequately during lower abdominal surgery under balanced anesthesia with the two different combination doses of desflurane and remifentanil.

A 60-year-old man visited our hospital with a complaint of right renal incidentaloma which was pointed out on abdominal ultrasonography for a medical check-up. Abdominal computed tomography showed a renal tumor in the right kidney, which was a slightly high-dense relative to the renal parenchyma and was enhanced in the arterial phase. The tumor had grown gradually from 1.4 to 1.7 cm in diameter. After the observation for 4 years, he underwent pure laparoscopic non-ischemic partial nephrectomy using a microwave tissue coagulator. Histological examination of the specimen revealed a leiomyoma of the kidney. This is the 5th case of successful laparoscopic partial nephrectomy for renal leiomyoma in Japan within the retrieved references.

Williams syndrome is characterized by the triad of supravalvular aortic stenosis (SAS), mental retardation and elfin facies. Generally, difficult airway is expected in patients with Williams syndrome by characteristic face. A 26-year-old female with Williams syndrome was scheduled for abdominal myomectomy under general anesthesia. Difficult mask ventilation and tracheal intubation were anticipated because of micrognathia, mandibular retrusion, and a Mallanpati class III airway. Before induction of anesthesia the patient breathed 100% oxygen for 3 minutes. Anesthesia was induced and maintained with propofol, remifentanil and rocuronium bromide. Mask ventilation was easily performed. The direct laryngoscopic view was Cormack grade I and there was no difficulty in the tracheal intubation. After induction of anesthesia, anesthetic course was uneventful. According to the most previous clinical reports in patients with Williams syndrome in Japan, mask ventilation and tracheal intubation were performed easily contrary to preoperative airway assessment. In view of SAS, mental retardation, airway deformity and airway assessment in previous clinical reports, we should select the optimal strategy for airway management in patients with Williams syndrome.

A 36-year-old woman undergoing a myomectomy developed postoperative surgical-saite peritonitis and hematoma. Eight days postoperatively, she developed a 38 degrees C-plus fever and accumulated ascites, with fever unchanged despite antimicrobial beta-lactams therapy. Following transvaginal ascitic drainage, her fever disappeared. Recurrent 38 degrees C fever and inflammation were cured by clindamycin of 1.2 g/day. M. hominis detected from ascites drainage was considered the primary causative organism. Nongenito-urinary M. hominis infection is often difficult to detect, as in our case. Gram staining, for example, is not useful in ascertaining small organisms such as Mycoplasma spp. having no cell walls to stain. M. hominis grows slowly, requiring over three days to form colonies on blood agar plates, requiring time to identify pathogens. We report case showing the importance of suspecting M. hominis of causing gynecological surgical-site infection. When common bacterial pathogen cultures remain negative and when empiric beta-lactam antibiotic treatment is ineffective, M. hominis should be suspected. In conclusion, M. hominis should be considered a causative following myomectomy resection.

We report a case of late-onset systemic toxicity due to ropivacaine over dose, and its successful reversal with 20% lipid emulsion (20% Intralipos). A 40-year-old woman, 40 kg, ASA-I, was scheduled for laparoscopy-assisted myomectomy of the uterus in which 40 ml of 0.375% ropivacaine was injected for bilateral US guided transversus abdominis plane block (TAPblock) under general anesthesia. Anesthesia proceeded uneventfully and she could go back to the ward 15 min later, but 3 hours after TAPblock, her blood pressure dropped to seventies and she became unresponsive. She also displayed clonic seizure/twitching of limbs. Immediately after diazepam 2 mg injection, clonic seizure disappeared and she could obey verbal commands. Within a few minutes clonic seizure was noted again, and she was hypotensive despite administration of vasopressors. A presumptive diagnosis of local anesthetic toxicity was made, and she received 100 ml bolus of 20% Intralipos. She regained consciousness with spontaneous return of blood pressure. She received a total of 230 ml 20% Intralipos, which was discontinued due to her rapid emergence with no further seizure episodes. This case suggests that early and sufficient use of lipid emulsion may lead to a good outcome. We recommend the immediate availability of lipid emulsion along with other emergency therapeutics at the ward after TAPblock.

A 30-year-old woman with chest discomfort at swallowing and occasional vomiting was referred to our department with a diagnosis of esophageal submucosal tumor. CT visualized a mass 70 mm in diameter in the middle esophagus. Esophagogastroduodenoscopy revealed a pedunculated submucosal tumor, and endoscopic resection was considered. As the size of the tumor was so large, retrieval of the resected specimen via the stomach following incision, laparotomy was planned. En bloc resection by endoscopic submucosal dissection with a Hook-knife was performed. Retrieval of the resected specimen was carried out as planned. The specimen, which was 53×48×43mm in size with a distinct margin, was diagnosed as leiomyoma derived from the muscularis mucosae histologically. Her postprocedural course was uneventful. Endoscopic resection can be chosen when an esophageal submucosal tumor is pedunculated with abundant mobility, making it possible to avoid invasive surgery.

A 39-year-old woman underwent transcervical resection (TCR) of submucosal uterus myoma. Induction and maintenance of anesthesia were managed with total intravenous anesthesia using propofol, remifentanil and rocuronium bromide. Patient had stable condition from the anesthesia induction until 75 minutes following skin incision. However, around that period, sudden tidal volume reduction, worsening oxygenation, and head and neck swelling developed. Arterial blood gas analysis indicated high-chloride metabolic acidosis. Transesophageal echocardiography showed excess right heart overload. On arriving at ICU, body weight of the patient increased about 10 kg compared to the preoperative value. Artificial ventilation and diuretics administration were done to treat excess body fluid. And the patient recovered without any subsequent complications. It should be noted that in case of TCR, unpredicted excess fluid load could develop, and careful observation and management are required by anesthesiologist in charge.

Leiomyoma of the trachea is a rare benign tumor. The patient was a 44-year-old male with a chief complaint of cough. Chest X-ray and computed tomography (CT) scan demonstrated a tracheal tumor. Bronchofiberscopy revealed a polypoid round tumor in the trachea. The tumor originated from the membranous portion of the trachea without narrow stalk. Tracheal circumferential resection with primary end-to-end anastomosis was performed via right postero-lateral thoracotomy, and postoperative course was uneventful. Definitive diagnosis of tracheal leiomyoma was made by histological examination. Although the reports of transbronchial endoscopic treatment for tracheal leiomyoma were increasing, tracheal resection was selected for this case considering the risk of perforation of the membranous portion of the trachea.

A 30-year-old male, who underwent orchiopexy of left undescending testis in his childhood, presented with right hemiscrotal swelling without pain. Ultrasonography revealed a paratesticular tumor which showed enhancement on magnetic resonance imaging (MRI). Diffusion-weighted MRI showed decreased diffusion in the tumor, and malignant tumor could not be ruled out. High inguinal orchiectomy was carried out and pathological diagnosis was benign leiomyoma of the epididymis.

A 65-year-old man had a painless mass, 30 mm in diameter, in the left scrotum. MR imaging demonstrated that the mass had low intensity in both T1-weighted and T2-weighted images. A poor enhancing effect was observed. The mass was located distinctively apart from the testis. The patient received a 12-month course of watching without medication, because these findings suggested the mass was a benign tumor. However, the tumor gradually increased in size to 50 mm in diameter during the period. Then, en bloc extirpation of the mass including the spermatic cord and testis was done via an inguinal approach. The histological diagnosis was leiomyoma of the spermatic cord. The tumor probably arose from the smooth muscle of the vessel in the spermatic cord. There has been no local recurrence during an 8-month follow-up period.

A thirty-year-old woman was scheduled for laparoscopic myomectomy. After insertion of an epidural catheter at the L4-5 interspace, general anesthesia was induced with thiopental 250 mg followed by vecuronium 8mg intravenously to facilitate tracheal intubation. General anesthesia was maintained with sevoflurane and nitrous oxide. Just after intramyometrial injection of vasopressin, blood pressure decreased from 122/66 to 45/25 mmHg, and heart rate decreased from 52 to 45 beats x min(-1). The patient was ventilated with 100% oxygen, and we administered atropine 0.25 mg and ephedrine 16 mg intravenously. Blood pressure increased to 150/100 mmHg and heart rate increased to 135 beats x min(-1). Since electrocardiogram showed ST-segment depression and premature ventricular contraction, we administered nicorandil 3 mg followed by continuous infusion at a rate of 3 mg x hr(-1), and lidocaine 60 mg, intravenously. The ST depression and premature ventricular contraction disappeared immediately. To decrease blood pressure and heart rate, we increased inspiratory concentrations of sevoflurane and nitrous oxide and administered local anesthetics via epidural catheter, and hemodynamic parameters became gradually stable. We estimate that severe hypotension observed in this case is associated with intramyometrial injection of vasopressin. Increased blood concentration of vasopressin might cause vasoconstriction of coronary artery, increases in afterload, and/or direct myocardial depression resulting in decreased cardiac output.

We report a case of giant paraurethral leiomyoma weighing more than 100 g in a 19-year-old woman. She had been complaining of micturition pain and a mass at the external genitals. Magnetic resonance imaging showed a 5 cm mass surrounding the urethra, which appeared low intensity on T1-weighted images and higher intensity than that of the surrounding muscles in the pelvis on T2-weighted images. Biopsy was performed and the pathological diagnosis was leiomyoma. The mass was removed transvaginally and transperitoneally, which did not invade to urethra or vaginal wall. The resected specimen exhibited 8 x 7.5 x 3.6 cm in size and 105 g in weight. Pathological diagnosis was leiomyoma with no invasion to surrounding tissue. This is the 132nd case of female paraurethral leiomyoma in Japan, and there were only five cases (6%) of giant paraurethral leiomyoma weighing more than 100 g. We discuss the clinical and pathological features of this disease.

A 63-year-old female presented with an abnormal shadow on a chest X-ray. A serial chest computed tomography (CT) showed ground-glass attenuation, which measured 2 cm on S1+2 of the left lung. When bronchofiberscopy was performed to make a diagnosis, a tumor with a smooth surface was revealed which obstructed the right middle bronchus. Leiomyoma was thus diagnosed. At first, a wide wedge resection of left lung tumor was performed. Secondly, a bronchus tumor was successively removed using a high frequency snare and a laser by a bronchofiberscopy. Her postoperative course was uneventful. Leiomyoma of the bronchus is rare benign tumor. This report describes the performance of a resection using bronchofiberscopy with good results.

A 59-year-old woman with complaints of pollakisuria and dysuria, was referred to our hospital. Magnetic resonance imageing (MRI) revealed a tumor, about 59 mm in diameter. Cystoscopy showed a submucosal tumor covered with a normal mucosa. Histological diagnosis was leiomyoma of the urinary bladder by transurethral biopsy. So we performed complete resection of the tumor. To our knowledge, 30 cases of leiomyoma of the urinary bladder by transurethral resection have been reported in the Japanese literature.

A 46-year-old female with benign metastasizing leiomyoma was reported. The patient had undergone a lobectomy of thyroid for adenomatous goiter at the age of 30, and a myomectomy for uterine myoma and a modified radical masmectomy for breast cancer at the age of 32. The chest X-ray on health screening revealed multiple nodules in the bilateral lung. Computed tomography (CT) revealed 6 nodules in the right side and 3 nodules in the left side of the lung. The tumors of the right lung were resected under thoracoscopic surgery. Pathologically these lesions were diagnosed as benign metastasizing leiomyoma. Left lung nodules have been followed-up.

A 30-year-old woman was scheduled to undergo hysteroscopic myomectomy for uterine myoma. Spinal anesthesia was performed with 3 ml of 0.5% bupivacaine and she was sedated with intravenous propofol during the surgery. After the surgical procedure, propofol infusion was stopped. The patient soon awoke and vomited frequently and repeatedly. Her serum sodium concentration was as low as 129 mEq x l(-1) and fluid overload (water intoxication) was suspected. Because the abdominal X-P revealed that two parts of the surgical instrument remained in her uterine cavity at that time, hysteroscopic procedure was restarted. General anesthesia was induced with propofol and maintained with nitrous oxide and sevoflurane. During the procedure, uterus was accidentally perforated and one of the parts moved into the abdominal cavity. When the laparotomy started to fix uterine perforation, the abdomen of the patient became remarkably distended. During the laparotomy, it was revealed that 4800 ml of irrigation fluid had been accumulated in the abdominal cavity. Although hysteroscopic surgery is generally considered non-invasive, two major complications (fluid overload and uterine perforation) occurred in this case. This case suggests that anesthetists must remain alert for the signs of these complications during hysteroscopic surgery.

A 61-year-old woman was referred to our hospital due to a liver tumor discovered at a medical checkup. A hypervascular tumor located in liver segment I, measuring 45 mm in diameter, was visualized on ultrasonography. The tumor showed strong uniform enhancement from an early phase on computed tomography and angiography. Right hepatectomy with total caudate lobe resection was performed. Pathological examination revealed the tumor to be a primary leiomyoma of the liver, positive for smooth muscle actin and desmin on immunohistochemical examination. Primary liver leiomyoma is very rare and only 18 cases have been reported to date. The clinical features of these cases from the literature are also discussed.

Benign metastasizing leiomyoma (BML) is the term used to describe multiple benign pulmonary leiomyomatous lesions occurring in patients with a previous history of uterine leiomyoma. On the other hand, pulmonary fibroleiomyomatous hamartoma (FLH) is also multiple nodules and the discrimination of the nodules between BML and FLH is not determined. We report the case of 36-year-old woman who had a previous history of uterine leiomyoma. The woman was referred to our hospital for evaluation of asymptomatic bilateral nodules in chest roentgenogram examination. A chest X-ray showed multiple nodules in bilateral lung. Chest computed tomography (CT) scan showed round nodules well-defined margins in bilateral lung. Thoracoscopic partial resection of the lung was performed. Pathological examination revealed that the tumor composed of spindle-shaped smooth muscle cells and its characteristics were remarkably similar to those of the previously resected uterine leiomyoma. Therefore, these lung tumors could be considered to be lung metastases from a uterine leiomyoma (benign metastasizing leiomyoma).

We report two cases of female paraurethral leiomyoma. Two Japanese women (51 and 44 years old) were referred to our department with the complaint of a painless mass at the external genitalia. Both tumors were resected transvaginally and histopathologicaly diagnosed as leiomyoma without any evidence of infiltration into the surrounding tissue. One hundred and twenty-eight cases of female paraurethral leiomyoma are collected from the Japanese literature and are discussed.

A 32-year-old man was referred to our hospital because of a mediastinal tumor with mild dysphagia. Computed tomography (CT) showed that the tumor was located in the neck and the posterior mediastinum. An esophagogram demonstrated severe distortion of the esophageal lumen and an endoscopic examination disclosed a submucosal bulge covered by normal mucosa with no erosion and no ulceration. A CT-guided needle biopsy for neck lesion of the tumor was performed and the histopathological diagnosis was an esophageal leiomyoma. Complete enucleation via a left anteroaxillary thoracotomy for the tumor was performed without perforation of esophageal mucosa. The resected tumor was 12 cm in size. The final diagnosis of the resected tumor located in the cervical, upper, middle and intramural esophagus was a rare giant esophageal leiomyoma. Postoperative course was uneventful. We suggested that enucleation with an operative procedure selected carefully for a giant esophageal leiomyoma was attempted for preservation of esophageal function.

We experienced a case of paraurethral leiomyoma in a 36-year-old woman. She had been complaining of dysuria. She had noticed the presence of a mass in anterior vagina. That mass was about 3 x 3 cm, floating moderately firm with a smooth face sited in a paraurethral region. Magnetic resonance imaging showed medium-signal intensity on T1-weighted images and a homogeneous low signal on T2-weighted images. We diagnosed it as a paraurethral leiomyoma and enucleated it by surgery. At histological examination the tumor resulted in being a leiomyoma. The diagnosis and the treatment of female paraurethral leiomyoma are discussed.

We report a case of a 40-year-old male with a posterior mediastinal mass that was 8 cm in size and located behind the trachea. The thoracoscopic surgery was performed. The tumor was located from the level of left brachiocephalic vein to the carina. The mediastinal pleura over the tumor was longitudinally opened by cautery-scissors. The azygos vein lying over the tumor was divided by means of an endoscopic stapler. The muscular layer of the esophagus was also longitudinally opened. The tumor was enucleated. Then, the dissected proper muscle layer of the esophagus was suture-closed. The postoperative course was uneventful. On the first postoperative day Gastrografin was swallowed, showing the absence of leaks. The patient was discharged on the fourth postoperative day. The advantages of the thoracoscopic surgery are as follows: rapid, full recovery of the patient; decreased postoperative pain; short postoperative hospital stay. Esophageal leiomyoma in selected patient was suitable for thoracoscopic enucleation.

A 43-year-old female with a huge myoma uteri was scheduled for a simple total hysterectomy. However, there was massive penetration of the tumor into the retroperitoneum, and her first operation failed because we had no advance information on its posterior aspect. Angiography was done to obtain this information. She rested on bed until the day after the first operation and angiography. MRI, performed again due to early growing tumor, revealed deep vein thrombi in the left iliac vein to the left femoral vein which the last MRI had not shown. Therefore, just before the second operation a temporary vena-cava filter was inserted, to prevent acute pulmonary thromboembolism. The operation was performed without incident. The filter captured some thrombi, and these were resolved by urokinase postoperatively. No symptomatic pulmonary thromboembolism was recognized during the perioperative period. The postoperative course was uneventful.

We report 3 cases of leiomyoma of the urinary bladder. One patient was a 57-year-old female. Magnetic resonance imaging (MRI) revealed a small tumor, and cystoscopy revealed a submucosal tumor on the left wall. Partial cystectomy was performed, and she has had no recurrence for 10 months. Two females who were aged 68 years and 52 years, were referred to our hospital with the complaint of pain of meatus of urethra, and pollakisuria, respectively. Transurethral resection of bladder tumor (TURBT) was performed, and they have had no recurrence for more than 3 and 4 years, respectively. Histological examination in the three cases showed a leiomyoma of the urinary bladder. To our knowledge, there are 151 cases of leiomyoma of the urinary bladder reported in the literature in Japan.

Among the submucosal tumors of the esophagus, leiomyoma is the most frequently found. Esophageal leiomyoma usually originates from the muscle layer of the esophageal wall and grows spirally around the esophageal axis. In the surgical treatment of leiomyoma, we enucleate the tumor through video-assisted thoracic surgery. When we enucleate leiomyoma, we must be very careful to aviod perforation of the esophageal mucosa. Esophageal hemangioma is a relatively rare disease. The location of this disease is mainly within the submucosal layer, without invading the muscle layer proper. After confirming the localization within the mucosa or submucosa with endoscopic ultrasonography, esophageal hemangioma can be resected safely using the endoscopic mucosal resection technique. In the treatment of benign esophageal submucosal tumors, "informed consent" is as essential as in esophageal cancer surgery. We have no absolute criteria concerning the indications for surgery for benign esophageal submucosal tumors. We must give reasons why the operation is necessary and indicated to the patients. Surgical treatment of esophageal submucosal tumors should be as minimally invasive as possible.

Recently, patent foramen ovale(PFO) has been highlighted as an important risk factor of cerebral infarctions in young adults. We report a patient of multiple cerebral embolism associated with PFO and deep venous thrombosis caused by a uterine myoma. A 40-year-old woman suddenly suffered from right hemiparesis with motor aphasia. Brain angiography showed an occlusion of M2 portion of the left middle cerebral artery, but atherosclerotic changes were not seen. She developed left facial paresis 23 days later and admitted to our hospital. Brain MRI revealed multiple cerebral infarcts in the left insular cortex, the deep white matter of the right frontal lobe, and bilateral thalamus. Hypoxia with the perfusion defects of S1 and S2 sections of the right lung demonstrated by scintigraphy suggested pulmonary embolism. Transesophageal echocardiography showed a PFO with spontaneous left-to-right shunt and right-to-left shunt evoked by the Valsalva maneuver. Although venography could not detect thrombi, it revealed severe compression of the right external iliac vein by a uterine myoma. These findings suggested thrombi in the right external iliac vein were the embolic source when combined with elevated coagulation markers. An uterine myoma should be considered as an important risk factor for an embolic source in case of cerebral embolism with PFO.

A 68-year-old male was admitted to our hospital with the complaint of left painless mass of extratesticular scrotal content. Laboratory examinations were unremarkable. The tumor was resected by operation. The removed specimen was solid, 15 x 15 x 20 mm in size. Histopathological findings revealed leiomyoma. Other cases from the Japanese publications, together with our case, are reviewed.

A 42-year-old woman underwent total hysterectomy for multiple myoma uteri. Postoperatively the patient complained of lower abdominal pain and total incontinence. She had also developed left-sided hydronephrosis. Left nephrostomy was constructed and necessary investigations were done. It was diagnosed as a case of left ureteral injury with vesico-vaginal fistula. Repair of vesico-vaginal fistula and reimplantation of the left ureter were performed in a single setting three months after the injury. Subsequently, the nephrostomy was removed. Hydronephrosis was improved with an excellent outcome of fistula repair.

A 44-year-old female was admitted to our hospital because of the left cervical tumor. Radiologic examination showed that the tumor was 5 cm in diameter and was inhomogeneous. The tumor was spread to the upper mediastinum. Esophagoscopy showed that the tumor was covered by the normal mucosa. Percutaneous fine needle biopsy did not appear the histopathological diagnosis. The patient underwent surgical resection through the cervical approach and the tumor was located between the mucosal and muscular layers of the esophagus. The tumor was enucleated without any complication. Histopathological diagnosis was leiomyoma. Postoperative course was uneventful. Expecting diagnosis and positive complete resection is recommended for leiomyoma of the esophagus.

We report a case of unexpected difficult intubation in an adult caused by a laryngeal web. A 43-year-old woman with uterine myoma was scheduled for abdominal hysterectomy. After induction of anesthesia, the vocal cords were seen clearly under laryngoscopy. Although intubation was attempted several times, a 6.5 mm internal diameter tracheal tube could not be passed below the level of the vocal cords because of resistance, and we used a laryngeal mask during anesthesia. Next morning after the operation, she developed dyspnea. Bronchoscopy revealed a very narrow airway below the level of vocal cords caused by a laryngeal web. Tracheostomy was performed. Two weeks later, tracheostomy was closed without any sequela.

Hysteroscopical myomectomy has recently become popular in Japan. We present two patients who developed water intoxication and air embolism during surgery. [Case 1] Hysteroscopical myomectomy was performed under general anesthesia in a 37-yr-old woman (ASA I). Three hours after the start of the surgery, the patient's serum sodium concentration dropped to 118 mEq.l-1. She was treated with furosemide and recovered without sequelae. [Case 2] A 39-yr-old woman (ASA I) was scheduled to have hysteroscopical myomectomy under spinal and epidural anesthesia. Forty-five minutes after the start of the surgery, the patient complained of severe back pain, her blood pressure decreasing to 40 mmHg, SpO2 decreased to 80%, and ECG showed atrial fibrillation. After administration of ephedrine 5 mg, she recovered within 20 min. No abnormality was observed in echocardiogram, although some negative spots were detectable in a lung scintigraphy. She was discharged without sequelae. The hysteroscopical procedure is considered a non-invasive surgery, but the cases presented here emphasize the necessity for close attention to complications, especially pulmonary embolism.

We report a rare case of giant skull myofibroma occupying left anterior cranial fossa. A 53-year-old woman presented with left exophthalmos for 2 years. Neurological examination showed left exophthalmos, disturbance of bilateral visual acuity, and bitemporal hemianopsia. A CT scan revealed an ossifing mass at left anterior cranial fossa. On magnetic resonance images, the tumor showed iso-intensity on T 1-weighted image, heterogeneous high intensity on T 2-weighted image, and was heterogeneously well-enhanced after administration of Gd-DTPA. The tumor was fed mainly by middle meningeal artery. The patient underwent surgery and the tumor was removed totally. Histological diagnosis of the tumor was myofibroma. The patient has been followed every other month by MRI without any adjuvant therapy. There has been no tumor recurrence for 19 months. There is no other myofibroma in her body, therefore the patient was diagnosed as solitary myofibroma of the skull. Our case is the first report of solitary myofibroma of the skull because we could not find any reports on solitary myofibroma of the skull in the past literature.

A patient with deep venous thrombosis caused by a huge uterine leiomyoma underwent abdominal hysterectomy. To prevent pulmonary thromboembolism, the patient received anticoagulant therapy until 6 hr before surgery and temporary inferior vena cava filter was placed. A combination of preoperative anticoagulant therapy and the filter placement during perioperative period enabled this patient to be successfully-managed.

A 28-year-old woman underwent trans-cervical resection (TCR) of the uterine myoma. She had no history of complications except for anemia. Anesthesia was maintained with inhalation anesthesia. After 120 min from introducing the resectoscope, her serum sodium dropped to 86.1 mEq.l-1. But her heart rate and the systolic arterial pressure were stable. She was treated with steroid, mannitol, isotonic saline, and 7% NaHCO3. Soon after the end of the operation, she recovered consciousness. At two hours postoperatively, her serum sodium was 119.6 mEq.l-1. On the 1st postoperative day, her serum sodium returned to the normal range (137 mEq.l-1). We should be aware of asymptomatic water intoxication during TCR.

A 50-year-old woman was admitted for the treatment of retroperitoneal tumor. Enhanced comtuted tomography showed a low density mass between the left kidney and psoas muscle. Magnetic resonance imaging revealed a high intensity and homogeneous mass on T1-weighted sequence, and a low intensity and heterogeneous mass on T2-weighted sequence. Surgical exploration revealed that the tumor was adherent to the left kidney and en bloc excision of the tumor and the left kidney was performed. Histopathological diagnosis was leiomyoma originating from the renal capsule.

Pure leiomyoma of the prostate is very rare. A 67-year-old man was hospitalized with gross hematuria and urinary retention. Drip infusion pyelography revealed a defect of the urinary bladder. By radiological examinations, submucosal tumor of the bladder neck was diagnosed. Transrectal biopsy suggested a benign prostatic tumor histologically. Open resection of the tumor was performed. Histological findings were pure leiomyoma of the prostate. The postoperative course was good and urinary retention was improved remarkably.

A case of intrascrotal leiomyoma is reported. A 62-year-old male was admitted to our hospital with the chief complaint of a painless intrascrotal mass, which had been gradually increasing in size during the past 25 years. Physical examination revealed impervious to light and elastic firm mass of 5 cm in diameter in the left scrotum. Although the serum level of some tumor markers such as alpha fetoprotein and human chorionic gonadotropin-beta were normal, since the border on the left testis was unclear on the ultrasonogram of the scrotum, a testicular tumor was suspected, and radical orchiectomy was performed. The tumor was 6 x 4 x 4 cm, 55 g, and well-defined with testis, epididymis and tunica dartos. It was histopathologically diagnosed as leiomyoma arising from the tunica vaginalis. The post operative course has been uneventful for 9 months after the surgery, and no recurrence has been recognized. An intrascrotal tumor is relatively rare, and is generally defined as one arising between tunica dartos and tunica vaginalis testis, which is independent of testis, epididymis, and funiculus spermaticus. This is the 25th case of intrascrotal leiomyoma reported in the literature in Japan.

A 38-year woman was hospitalized because of myoma uteri. She underwent myomectomy on September 30, 1997 with 2,000 ml blood loss. No blood transfusion was required, but she received a plasma protein product. On the 14th postoperative day, a complete blood count revealed anemia (Hb 9.3 g/dl) and leukocytopenia (1,600/ul). But it did not reveal anemia before the operation. Bone marrow smears showed erythroblastopenia with giant proerythroblasts. Anti-parvovirus B19 IgM antibody were positive in the serum and parvovirus B19 DNA was detected in the bone marrow cells by polymerase chain reaction. From the results, the patient was diagnosed as the anemia and leukocytopenia secondary to parvovirus B19 infection. Parvovirus B19 was not detected in the samples of the plasma protein product received on the myomectomy. The reticulocyte gradually decreased to 1/1000 on the 20th postoperative day. The anemia and leukocytopenia gradually improved. This case shows that parvovirus B19 infection could cause hematological disorders in the normal person under acute blood loss. This report warns that a careful observation is necessary for the patients who have received operations with acute blood loss.

A 42-year-old woman underwent a myomectomy on March 31, 1998. On the 10th postoperative day, leukopenia and reticulocytopenia were observed. Bone marrow aspiration revealed severe erythroblastopenia with giant proerythroblasts, suggesting a recent parvovirus infection. Both anti-parvovirus B19 IgM antibody and IgG antibody seroconversion was observed, and human parvovirus B19 DNA was detected by polymerase chain reaction (PCR) methods. The hematologic data on the patient rapidly improved thereafter. It was determined that acute-phase serum had inhibited CFU-E and BFU-E derived colony formation. Based on these findings, parvovirus B19-induced aplastic crisis was diagnosed. Fibrin sealant, which is a typical hemostatic agent produced from blood, had been during the operation. Human parvovirus B19 DNA was detected in the fibrin sealant by PCR. Our case report documents the transmission of human parvovirus B19 by fibrin sealant.

Three females with urinary retention caused by uterine leiomyoma are reported. The patients were 35, 48 and 50 years old. In each patient, transabdominal ultrasonography showed a large and homogeneous mass located in the retrovesical space, compressing the bladder. Pre-operative computed tomographic (CT) scan and magnetic resonance (MR) imaging revealed uterine leiomyoma which severely compressed the bladder from the posterior wall to the urethra. The urinary symptoms completely resolved in all patients following total hysterectomy, and postoperative uroflowmetry demonstrated normal voiding.