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Objective Ultrasonographic differential diagnosis of ovarian tumors is important for appropriate management. We conducted study to compare the performance of the Assessment of Different NEoplasias in the adneXa (ADNEX) model with a subjective assessment (SA) in differentiating between benign and malignant adnexal masses in Korean women. Methods A total of 353 patients who underwent adnexal surgery with abnormal pelvic ultrasonographic findings from August 2016 to August 2017 were included in study. The presumptive diagnosis of adnexal malignancy was determined by both SA and the ADNEX model to be >10% calculated risk of malignancy. The area under the curve (AUC) comparison between the SA and ADNEX models was performed using DeLong’s method. Results 340 patients with benign tumors and 13 with malignant adnexal tumors among 292 (82.72%) premenopausal and 61 (17.28%) postmenopausal women were included. The AUCs of SA and the ADNEX model for discrimination between benign and malignant tumors were 0.79 and 0.92, respectively (P=0.10). The sensitivity and specificity of SA and the ADNEX model were 83.5% and 97.0%, and 90.0% and 82.0%, respectively. Comparison of the ADNEX model regarding menopausal status revealed that the predictability was not different. The AUCs of SA and the ADNEX model in premenopausal women were 0.74 and 0.89, respectively (P=0.12). The AUCs of SA and the ADNEX model in postmenopausal women were 0.86 and 0.94, respectively (P=0.60). Conclusion The ADNEX model offers excellent discrimination between benign and malignant ovarian tumors with similar sensitivity and specificity to SA in both premenopausal and postmenopausal Korean women.

In Korean women, a westernized lifestyle is associated with an increased risk of breast cancer. Fertility preservation has become an increasingly important issue for women with breast cancer, in accordance with substantial improvements in survival rate after cancer treatment. The methods of controlled ovarian hyperstimulation (COH) for fertility preservation in breast cancer patients have been modified to include aromatase inhibitors to reduce the potential harm associated with increased estradiol levels. Random-start COH and dual ovarian stimulation are feasible options to reduce the total duration of fertility preservation treatment and to efficiently collect oocytes or embryos. Using a gonadotropin-releasing hormone agonist as a trigger may improve cycle outcomes in breast cancer patients undergoing COH for fertility preservation. In young breast cancer patients with BRCA mutations, especially BRCA1 mutations, the possibility of diminished ovarian reserve may be considered, although further studies are necessary. Herein, we review the current literature on the practical issues surrounding COH for fertility preservation in women with breast cancer.

Objective: The gold standard procedure for treating patients with apical pelvic organ prolapse (POP) is sacrocolpopexy. However, no report comparing the two types of single-incision robotic sacrocolpopexy, namely, single-site robotic sacrocolpopexy (SS-RSC) and single-port robotic sacrocolpopexy (SP-RSC) exists. Therefore, we compared the safety and effectiveness of SS-RSC and SP-RSC. Materials and methods: In this study, 48 patients who underwent single-incision RSC, 40 non-consecutive patients who underwent SS-RSC, and 8 consecutive patients who underwent SP-RSC for symptomatic POP quantification stage III–IV and were eligible for the 1-year follow-up (FU) were included. We compared the surgical time and operative outcomes of SS-RSC and SP-RSC. We also compared the data of the initial 8 cases in each group. Results: The mean patient age was 59.2 ± 11.0 years and 66.1 ± 8.0 years in the SS-RSC (n = 40) and SP-RSC (n = 8) groups, respectively. The mean operative time (OT) and console time were comparable between the SS-RSC and SP-RSC groups (135.3 ± 31.6 min vs 141.8 ± 23.5 min; 94.6 ± 32.2 min vs 89 ± 9.5 min, respectively). The docking time and cervix suturing time were short in the SP-RSC group (P

Objective This study aimed to demonstrate the use of preoperative magnetic resonance imaging (MRI) findings to select the optimal surgical technique between single-site (SS) and multi-site (MS) robotic myomectomy based on clinical experience, for the preservation of fertility. Methods Ninety-eight patients who underwent SS or MS robotic myomectomy using the da Vinci® Si system after undergoing MRI were evaluated retrospectively. The correlation between preoperative MRI findings and the intraoperative or postoperative findings during robotic myomectomy for the preservation of fertility was analyzed. The reproductive outcome was investigated when the patient wished to conceive. Results The mean age of the patients was 35.68±5.04 years and 80 patients (81.6%) were nulliparous. The total diameter of myomas on MRI was 106.75±54.52 mm. The number of resected myomas was 4.31±4.39 (range, 1–27), and the total weight of resected myomas was 293.11±281.13 (range, 30–1,260) g. Myomas with high signal intensity on MRI required less time for resection. MS robotic myomectomy was performed for an increased number and total diameter of a myoma or a deep-seated myoma. Postoperatively, all patients resumed normal menstruation. Of the 15 patients who wished to conceive, 12 (80%) conceived successfully. Of these, uterine dehiscence occurred in 1 patient and 10 patients underwent an uneventful cesarean section. Conclusion SS or MS robotic myomectomy can be recommended for patients who wish to conserve fertility. However, the optimal surgical technique should be selected based on preoperative MRI findings to predict an effective surgical process and the successful preservation of fertility.

Aim The purpose of this study was to report on 626 cases of successful robotic single-site (RSS) surgeries to address various types of gynecologic disease and to evaluate the outcomes and learning curve inherent to RSS surgery in the gynecology field. Methods A total of 626 cases of RSS surgeries were performed by 3 gynecologic surgeons at Ewha Womans University Medical Center, Robot Surgery Center from November 2014 to January 2018 were collected retrospectively. All of the patients' charts were reviewed, and the clinical characteristics and surgical variables were analyzed. Results Among the total of 626 cases, there were 220 cases of RSS myomectomy (RSSM), 182 cases of RSS hysterectomy (RSSH), 195 of RSS adnexectomy, 24 of RSS sacrocolpopexy (RSS SCP) and 5 were classified as other RSS surgeries. The patient's mean age was 38.98 ± 10.07 years. There was 3.99 ± 2.15 min of mean docking time and 117.78 ± 51.18 min of mean operating time. The surgical variables were analyzed annually. The total operating time was seen to decrease significantly according to each period. The docking time declined significantly and gradually after 1 year. We also analyzed each of the surgical types by time. The operating time of RSSH, RSSM, RSS adnexectomy and RSS SCP fell over time. The tendency found was for operating time to decline sharply following the first 10 cases. When we analyzed the data at annual intervals, the operating time was most significantly less and stable following the first year. There were a few intraoperative or perioperative complications in 16 cases (2.6%). Conclusion Robotic single-site surgery is a feasible and safe procedure for treating various kinds of gynecologic diseases. The learning curve was approximately 10 cases of RSS surgery in gynecologic disease, having a greater amount of experience at performing RSS surgery was revealed to be key to achieving better surgical outcomes.

Objective: We aimed to present our initial experience with robotic single-port surgery performed using the da Vinci® SP surgical system for benign gynecologic diseases. Materials and methods: This retrospective cohort study was performed at an academic tertiary care hospital From December 2018 to January 2019. Thirty-one women with benign gynecologic diseases underwent robotic single-port surgery performed using the da Vinci® SP surgical system. Results: During the study period, hysterectomy, myomectomy, adnexectomy, and sacrocolpopexy were performed in seven, twelve, five, and seven women, respectively. The mean age and body mass index of patients, respectively, were 47.7 ± 12.8 years and 22.7 ± 3.1 kg/m2. In terms of operative outcomes, the mean docking time, operating time, estimated blood loss, and hospitalization time were 2.2 ± 2.1 min, 126.3 ± 61.6 min, 93.9 ± 76.9 mL, and 4.6 ± 0.7 days. There was no laparoconversion or major complication. Conclusion: Robotic single-port laparoscopy using the da Vinci® SP surgical system might be a suitable alternative surgical technique for various benign gynecologic diseases. However, further studies are required to clarify the feasibility and safety of the application of this novel robot surgical system. Keywords: Gynecology, Laparoscopy, Robotic surgery, Single-port surgery

Background During robotic gynecologic pneumoperitoneum surgery in the Trendelenburg position, aeration loss leads to perioperative atelectasis. Recently developed ventilator mode pressure-controlled ventilation volume-guaranteed (PCV-VG) mode could provide adequate ventilation with lower inspiratory pressure compared to volume-controlled ventilation (VCV); we hypothesized that PCV-VG mode may be beneficial in reducing perioperative atelectasis via low tidal volume (VT) of 6 mL/kg ventilation during robotic gynecologic pneumoperitoneum surgery in the Trendelenburg position. We applied lung ultrasound score (LUS) for detecting perioperative atelectasis. We aimed to compare perioperative atelectasis between VCV and PCV-VG with a low VT of 6 mL/kg during pneumoperitoneum surgery in the Trendelenburg position using LUS. Methods Patients scheduled for robotic gynecologic surgery were randomly allocated to the VCV (n = 41) or PCV-VG group (n = 41). LUS, ventilatory, and hemodynamic parameters were evaluated at T1 (before induction), T2 (10 minutes after induction in the supine position), T3 (10 minutes after desufflation of CO2 in the supine position), and T4 (30 minutes after emergence from anesthesia in the recovery room). Results Eighty patients (40 with PCV-VG and 40 with VCV) were included. Demographic data showed no significant differences between the groups. The total LUS has changed from baseline to T4, 0.63 (95% confidence interval [CI], 0.32, 0.94) to 1.77 (95% CI, 1.42, 2.21) in the VCV group and 0.86 (95% CI, 0.56, 1.16) to 1.43 (95% CI, 1.08, 1.78) in the PCV-VG group (P = 0.170). In both groups, total LUS increased significantly compared to the baseline values. Conclusion Using a low VT of 6 mL/kg during pneumoperitoneum surgery in the Trendelenburg position, our study showed no evidence that PCV-VG ventilation was superior to VCV in terms of perioperative atelectasis. Trial Registration Clinical Research Information Service Identifier: KCT0006404, Graphical Abstract

BACKGROUND The appropriate level of positive end-expiratory pressure (PEEP) during intra-operative mechanical ventilation remains unclear. OBJECTIVE The aim of this study was to investigate the effects of different levels of PEEP with low tidal volume (low-VT) ventilation in a steep Trendelenburg position (30°) and pneumoperitoneum on oxygenation, respiratory mechanics and ventilation distribution using electrical impedance tomography. DESIGN A randomised controlled trial. SETTING Single university secondary care centre, conducted from January 2017 to December 2017. PATIENTS Forty female patients, aged 20 to 60 years, and of American Society of Anesthesiologists' (ASA) physical status 1 or 2, undergoing elective robotic gynaecological surgery were included. INTERVENTION Forty patients were allocated randomly to a PEEP4 (PEEP 4 cmH2O) group or a PEEP8 (PEEP 8 cmH2O) group. MAIN OUTCOME MEASURES The primary outcomes were respiratory mechanics. The secondary outcomes included changes in ventilation distribution across the ventral and dorsal regions of interest and postoperative pulmonary complications (PPCs) using a modified clinical pulmonary infection score. RESULTS There was no difference in PaO2 at any time point. The peak inspiratory pressure (PIP) and mean airway pressure (MPAW) of the PEEP4 group were lower than those of the PEEP8 group (P

Objective We investigated whether, in the Korean population, the risk of premature ovarian insufficiency (POI) and early menopause varies with a woman’s socioeconomic status, evaluated in relation to income, education, and occupation. Methods This cross-sectional, population-based study involved 31,508 women aged >19 years registered in the Korea National Health and Nutrition Examination Survey (KNHANES) (2007–2016). Menopausal status and socioeconomic status were obtained from self-reported KNHANES data. A logistic regression model was applied to test whether POI and early menopause varied with socioeconomic status. Results The prevalence of POI was 2.41% and of early menopause was 5.89%. The annual incidence of POI during the investigation period plateaued, while that of early menopause showed a linear trend. The risk of POI was significantly higher among participants with lower household incomes (odds ratio [OR], 95% confidence interval [CI]; 1.44, 1.16–1.78) and lower levels of education (OR, 95% CI: 1.75, 1.16–2.65) after adjustment for age. Conclusion The prevalence of POI in the Korean population was almost twice that reported in a previous study. Lower socioeconomic status was associated with an increased risk of POI and early menopause. Further studies are warranted to investigate this association.

Objective: To compare perioperative outcomes of robotic single-site (RSS) surgery with conventional single-port laparoendoscopic surgery for the treatment of advanced-stage endometriosis. ...

On-device machine learning is critical for mobile products as it enables real-time applications (e.g. AI-powered camera applications), which need to be responsive, always available (i.e. do not require network connectivity) and privacy preserving. The platforms used in such situations have limited computing resources, power, and memory bandwidth. Enabling such on-device machine learning has triggered wide development of efficient neural-network accelerators that promise high energy and area efficiency compared to general-purpose processors, such as CPUs. The need to support a comprehensive range of neural networks has been important as well because the field of deep learning is evolving rapidly as depicted in Fig. 9.5.1. Recent work on neural-network accelerators has focused on improving energy efficiency, while obtaining high performance in order to meet the needs of real-time applications. For example, weightzero-skipping and pruning have been deployed in recent accelerators [2] –[7]. SIMD or systolic array-based accelerators [2] –[4], [6] provide flexibility to support various types of compute across a wide range of Deep Neural Network (DNN) models.

Major content providers such as YouTube and Netflix use AV1, a state-of-art video coding standard that was finalized in 2018. This paper presents a video processor that supports the AV1 standard via a Multi-Format video Decoder (MFD). An MFD can decode various video coding standards, such as H.264/AVC, HEVC and AV1. The video decoder can decode up to 8K Ultra HD (8K-UHD) video at 30fps at 468MHz core clock frequency. The MFD is fabricated using a state-of-the-art 5nm CMOS process with a 5,835k NAND2 equivalent gate count and 518kB SRAM. For AV1, MFD dissipates 116mW for decoding AV1 $7680 \times4320p$ video at 30fps (0.12nJ/pixel) with core operating voltage at 0.7V.

Background Exposure to endocrine disrupting chemicals (EDCs) that influence the hormonal and homeostatic systems is known to be associated with gynecologic health risks in many countries. In this study, we evaluated exposure to EDCs associated with diminished ovarian reserve (DOR) and gynecologic health risks. Methods This cross-sectional study was performed from September 2014 to November 2014 and included 307 Korean reproductive-aged women. Anthropometric measurements, laboratory tests with urine and blood sampling and pelvic ultrasound examinations were performed. Results Urinary bisphenol A (BLA) level was significantly higher in the DOR group with anti-Müllerian hormone lower than 25 percentile (1.89 ± 2.17 ug/g and 1.58 ± 1.08 ug/g, P < 0.05). Urinary mono-(2-ethyl-5-hydroxyhexyl) phthalate, mono-(2-ethyl-5-oxohexyl) phthalate and mono-N-butyl phthalate, and substrates of phthalate were evaluated and no significant difference was observed between the DOR group and non-DOR group. Logistic regression analysis suggested an increase in infertility in high BPA exposure group and the odds ratio (OR, 4.248) was statistically significant after adjustment for age, birth control pills, and the age of menarche, parity, and waist circumference. High phthalate exposure was associated with endometrial polyp after adjustment (OR, 2.742). Conclusion BPA exposure might be associated with DOR and infertility. Meanwhile, endometrial polyp is increased in women with high phthalate exposure. Therefore, the risk of exposures to EDCs for reproduction should be a matter of concern in reproductive-aged women., Graphical Abstract

Study Objective The aim of this study is to compare clinical and surgical outcomes of robotic single-port hysterectomy (RSPH) using the da Vinci SP® surgical system and robotic multi-site hysterectomy (RMSH) using the da Vinci Xi® surgical system in benign disease. Design Multicenter retrospective case-controlled study. Setting A university tertiary care hospital. (Ewha Womans University, Seoul Hospital and MokDong Hospital, Seoul, Republic of Korea) Patients or Participants It is enrolled robotic single-port hysterectomy cases (RSPH, n=67) and robotic multi-site hysterectomy cases (RMSH, n=67) from Nov. 2018 to Jun 2020.Nov. 2015 in benign gynecologic diseases. Interventions All patients underwent RSPH or RMSH. Basic information such as age, BMI, previous surgery history, delivery history and postoperative results such as intraoperative blood loss and postoperative complications were collected and compared. Measurements and Main Results There were no statistical differences of clinical characteristics such as age, BMI and parity. The weight of specimen was higher in RMSH group than that in RSPH group (302.64±190.56 vs 369.24±181.70, p-value 0.04). The estimated blood loss (EBL) and the change in hemoglobin after surgery in RSPH group were less than those in RMSH group (97.39±113.79ml vs 224.93±152.29ml, p-value Conclusion In this study, robotic single-port hysterectomy using da Vinci SP® surgical system is reliable procedures as like robotic multi-site hysterectomy except huge cases. Rather than, surgeons can reduce perioperative bleeding during RSPH by performing the sophisticated surgery. However further studies are required to clarify the feasibility and safety of the new robotic surgical system.

Study Objective To compare the perioperative outcomes of the robotic single-port myomectomy (RSPM) using the new da Vinci SP® surgical system with those of the robotic multi-site myomectomy (RM) using the da Vinci Xi® surgical system. Design Multicenter retrospective case-controlled study. Setting A university tertiary care hospital. Patients or Participants A total of 101 patients were enrolled. 67 patients underwent RSPM and 34 patients underwent RM at November 2018 to May 2020 were included. Interventions All patients underwent robotic myomectomy who diagnosed uterine myoma with target size that the instrument could operate by entering the umbilicus. The choice of surgical modality was not influenced by the patient's history of previous abdominal surgery, body mass index, uterus size, location or type of myoma, or myoma size. Measurements and Main Results RSPM vs. RM patients demographics had no difference significantly in mean age, BMI, maximal diameter of myoma and total number of myomas. In terms of surgical outcomes, RSPM and RM has comparable in EBL (50 mL vs. 150 mL, p Conclusion Robotic single-port myomectomy using new da Vinci SP® surgical system is feasible surgical modality as like as multi-site myomectomy. Further studies are needed to confirm these preliminary results and to determine the proper indications for the surgery.

INTRODUCTION Laparo-endoscopic single-incision surgery (LESS) has been developed and gradually adopted for both benign and malignant gynecological procedures. However, LESS has been hindered for use in procedures like myomectomy by limitations in natural architecture and instrumentation, especially in suturing. The da Vinci system features a single-site platform and wristed needle driver, which may help overcome conventional LESS limitations. This case report study describes the feasibility of this robotic single-site (RSS) platform in large myoma cases and offers suggestions. RESULTS Two cases of myomectomy with large myomas (with maximum diameters of 160 and 120 mm) with different locations, were addressed by RSS. Operative time was 180 and 240 minutes. Estimated blood loss was 200 and 150 ml. Pathologic analysis revealed uterine leiomyomas of 910 and 870 grams. No serious peri- or post-operative complications occurred. DISCUSSION Myomectomy with large myoma has presented a surgical challenge. RSS myomectomy appears to be a safe and feasible technique for it regardless of its localization. Advantages include less postoperative pain, fast recovery, less impact on quality of life, and improved cosmesis. LESS surgery has been challenging concerning suturing and multi-laparoscopic or multi-port robotic myomectomy can be difficult to extract myoma, especially with morcellation. RSS could be a solution that enables ease of manipflation and extraction.

Polycystic ovary syndrome (PCOS) is a highly complex disorder influenced by genetic and environmental factors. Previous genome-wide association studies (GWAS) on Han Chinese, Korean, and European populations identified multiple PCOS-susceptible loci; however, only a few studies reported the association of susceptibility genes with disease phenotypic traits. This cross-sectional study aimed to investigate the association between PCOS susceptibility genes from GWAS and disease-related clinical features. A total of 1,810 reproductive-aged women were recruited, including 927 control women and 883 women with PCOS, diagnosed based on the European Society for Human Reproduction and Embryology criteria. Genomic DNA was extracted and genotyped, and a Bonferroni test was performed to determine the association between 12 independent SNPs and the clinical features of PCOS. In women with PCOS, rs11031006, nearest to FSHB, was significantly associated with free testosterone (P = 1.94 × 10−3) and luteinizing hormone (P = 1.96 × 10−3) levels. The menstruation number per year, ovarian follicular number, ovarian volume, and insulin sensitivity index were not associated with any SNP. In the control group, no SNPs were associated with any PCOS traits. Collectively, our results suggest that FSHB may play an important role in the development and progression of PCOS.

Background Whirlpool sign on computed tomography (CT) is pathognomic of adnexal torsion. Purpose To evaluate the visibility and common location of the whirlpool sign in adnexal torsion on CT. Material and Methods This retrospective study included 143 consecutive patients who underwent preoperative CT imaging and subsequent surgically confirmed as adnexal torsion. Two readers independently recorded the presence and location of whirlpool sign in adnexal torsion on CT. Patients with and without whirlpool sign were compared with regard to the size of the adnexal mass and the degree of torsion. Results Whirlpool sign was detected in 60 (42.0%) patients on the transverse CT plane and 79 (55.2%) patients on the coronal CT plane of 143 patients. The sign was significantly better detected on the coronal CT plane than on the transverse CT plane ( P = 0.03). The most common location of the sign included the posterolateral aspect of the adnexal mass on the transverse CT plane (25/60, 41.7%, P = 0.04) and the upper-lateral aspect of the adnexal mass on the coronal CT plane (45/79, 60.0%, P Conclusion Whirlpool sign of adnexal torsion is well detected at the upper-lateral aspect of adnexal mass on the coronal CT plane.

Dienogest (DNG) is a progestin with highly selective progesterone activity and known to be effective in the treatment of endometriosis. This prospective cohort study in patients who had been treated with DNG 2 mg (Visanne®) for endometriosis was conducted to assess the safety and effectiveness of DNG in a large Korean cohort. This study included 3356 patients with endometriosis from 73 centers in Korea. All patients were treated with DNG 2 mg daily and were followed up for at least 6 months after initial visit. Any adverse events were recorded including severity, onset/closing date, outcomes, treatments, and the causality with DNG. Effectiveness of DNG was measured by changes in visual analogue scale (VAS) from baseline at the end of follow-up. The mean age of the subjects was 34.96 years, and the mean duration of treatment was 285.44 days. Incidence of adverse drug reaction (ADR) was 13.27% (413/3113). The most frequently reported ADR were “abnormal uterine bleeding” 4.14% (129/3113), “increased weight” 2.57% (80/3113), and “headache” 1.22% (38/3113). The number of patients (%) with favorable bleeding patterns was observed to increase as the duration of treatment increases. Amenorrhea was observed in 29.63%, 41.25%, 46.26%, and 53.20% of patients at 3 months, 6 months, 12 months, and more than 12 months follow-up period, respectively. The mean (±SD) VAS change from baseline at the last follow-up visit was −28.19 ± 28.39 mm (P value

Purpose To identify computed tomography (CT) findings for selection between conservative surgery and adnexectomy in patients of reproductive age with adnexal torsion. Methods This retrospective study included 54 consecutive patients who underwent preoperative CT imaging before undergoing either conservative surgery or adnexectomy to treat adnexal torsion. Results By multivariate analysis, CT finding of tubal thickening was significantly associated with the patients treated with adnexectomy (odds ratio=7.6, P =.008). Conclusion Although the majority of patients of reproductive age with adnexal torsion can be treated with conservative surgery, patients who require adnexectomy tend to have a tubal thickening on CT.

A 50-year-old peri-menopausal woman presented with hard palpable mass on her lower abdomen and anemia from heavy menstrual bleeding. Ultrasonography showed a 13×12 cm sized hypoechoic solid mass in pelvis and a 2.5×2 cm hypoechoic cystic mass in uterine endometrium. Abdomino-pelvic computed tomography revealed a hypodense pelvic mass without enhancement, suggesting a leiomyoma of intraligamentary type or sex cord tumor of right ovary with submucosal myoma of uterus. Laparoscopy revealed a large Sertoli-Leydig cell tumor of right ovary with a very rare entity of intra-endometrial uterine leiomyoma accompanied by adenomyosis. The final diagnosis of ovarian sex-cord tumor (Sertoli-Leydig cell), stage Ia with intra-endometrial leiomyoma with adenomyosis, was made. Considering the large size of the tumor and poorly differentiated nature, 6 cycles of chemotherapy with Taxol and Carboplatin regimen were administered. There is neither evidence of major complications nor recurrence during 20 months' follow-up.

Background Anti-Mullerian hormone (AMH) in women is secreted by granulosa cells of antral follicles. AMH appears to be a very stable marker for ovarian function. It may be used to diagnosis cases of premature ovarian failure, polycystic ovary syndrome (PCOS), and ovarian tumors. It has been suggested that cadmium exposure can reduce female fecundity. The purpose of this study was to investigate whether environmental exposure to cadmium was associated with alterations in AMH with regards to age. Methods In a cross-sectional study, the data of premenopausal women living in Seoul, ranging from 30 to 45 of age was collected. The study included a total of 283 women who completed serum AMH and whole blood cadmium assessments. Linear regression analyses were used in order to examine the association between cadmium and AMH. Given that age was the strongest confounder in both cadmium and AMH concentrations, we stratified subjects by 5 years old and analyzed their data. Results Geometric mean concentrations of blood cadmium and AMH were 0.97 μg/L and 3.02 ng/ml, respectively. Total association between cadmium and AMH was statistically significant (adjusted coefficient = − 0.34 (0.15), p = 0.02). After stratification, the only age group with a negative association between cadmium and AMH were the women raging between 30 and 35 years (adjusted coefficient = − 0.43 (0.18), p = 0.01). Conclusions The results of this study suggest that environmental exposure to cadmium may alter the AMH level of premenopausal women, depending on their age group.

Study Objective To report our initial experience of robotic single port laparoscopy using the da Vinci SP® surgical system for benign gynecologic diseases. Design Retrospective cohort study. Setting Academic tertiary care hospital. Patients or Participants 31 women with benign gynecologic diseases. Interventions Robotic single port laparoscopy. Measurements and Main Results From December to January 2019, hysterectomy, myomectomy, adnexectomy, and sacrocolpopexy were performed in 7, 12, 5, and 7 women, respectively. The mean age and body mass index of patients were 47.7±12.8 years and 22.7±3.1 kg/m2. In terms of operative outcomes, the mean docking time, operating time, estimated blood loss, and hospitalization were 2.2±2.1 minutes, 126.3±61.6 minutes, 93.9±76.9 mL, and 4.6±0.7 days. There was no laparoconversion or major complication. Conclusion Robotic single port laparoscopy using the da Vinci SP surgical system might be an alternative surgical technique for various benign gynecologic diseases However, further studies are required to clarify the feasibility and safety of the new robot surgical system.

Objective Endometriosis is a common and recurring gynecologic disease which have afflicting females of reproductive age. We investigated the efficacy of long-term, post-operative use of dienogest for ovarian endometrioma. Methods We studied 203 patients who had undergone laparoscopic or robotic surgery for ovarian endometrioma, and were administrated dienogest 2 mg/day beginning in July of 2013, and continuing. We evaluated side effects of dienogest and ultrasonography was performed every 6 months to detect potential recurrence of endometrioma (2 cm) in these post-surgical patients. Results The follow-up observation periods were 30.2±20.9 months from surgery. The mean age was 34.1±7.2 years old. The mean diameter of pre-operative endometrioma was 5.6±3.0 cm2. One hundred eighty-two (89.7%) women received dienogest continuously for 12.0±7.1 months. Of the subjects, 21 (10.3%) patients discontinued dienogest at 2.4±1.0 months. The most common side effect when dienogest was discontinued was abnormal uterine bleeding. The occurrence rate of vaginal bleeding was 15.8%, a number which did not differ significantly in patients with/without post-operative gonadotropin releasing hormone agonist administration. The other side effects were gastrointestinal trouble including constipation, acne, headache, depression, hot flush, weight gain, and edema. However, no serious adverse events or side effects were documented and recurrent endometriomas were diagnosed in 3 patients (1.5%). Conclusion The data indicates that dienogest was both tolerable and safe for long-term use as prophylaxis in an effort to obviate the recurrence of ovarian endometrioma post-operatively, as well as potential need for surgical re-intervention.

To investigate the relationship between urinary incontinence (UI) and depression in middle-aged and older Korean women.A total of 1116 participants diagnosed with UI among 7486 respondents were included in this study, using data from a well-established survey that investigated a nationally representative population: the Korean Longitudinal Study of Ageing (KLoSA). Computer-assisted personal interviewing was used to assess the status of UI and depression. Depression was assessed using the 10-item Center for Epidemiological Studies-Depression (CES-D 10) scale. Odds ratios (ORs) and 95% confidence intervals (95% CIs) for depression were adjusted for age, household income level, marital status, education level, working status, smoking behavior, alcohol drinking behavior, exercise level, residence, and accompanying chronic diseases.The proportion of patients with depression was significantly higher among women with UI (9.1%) than among women without UI (6.3%) (P0.0001). The depression scores became worse with worsening UI symptoms (OR of better vs. same vs. worse, 1.00 vs. 1.51 vs. 2.15, respectively; P for trend=0.0001), with an increased number of days experiencing UI during the prior month during the 2 years of the panel study period (OR of none vs. 1≤days≤10days vs. 10dayswere 1.00 vs. 2.15 vs. 4.36; P for trend=0.003).Inadequately controlled and frequent UI is strongly associated with depression in middle-aged and older Korean women. The management of worsening UI may be of value as part of the assessment and management of depression.

Background/Objectives Polycystic ovary syndrome (PCOS) is a heterogeneous disorder characterised by chronic anovulation, hyperandrogenenism, polycystic ovary morphology (PCOM), and metabolic disturbances including insulin resistance and type 2 diabetes mellitus. Although insulin resistance could be associated with PCOM, recent studies have shown controversial results. The aim of this study was to determine the relationship between PCOM and insulin resistance. Subjects/Methods This was a cross-sectional clinical study. A total of 679 women with PCOS who were diagnosed using the National Institute of Child Health and Human Disease (NICHD) criteria and 272 control women were analysed. We measured fasting glucose and insulin levels, 75g oral glucose tolerance test-derived glucose and insulin levels, testosterone levels, ovarian volume, and follicle number. Results PCOM was described in 543 women (80.0%) with PCOS. Women with PCOS had significantly higher 2h post-load glucose, fasting and 2h post-load insulin levels, ovarian volume, ovarian follicle numbers and lower insulin sensitivity compared with those of the controls (all p < 0.01). In women with PCOS, ovarian volume and ovarian follicle number were negatively associated with the quantitative insulin sensitivity check index after adjusting for age, body mass index and total testosterone; however, this association was not observed in the controls. In the logistic regression analysis, increased ovarian follicle number was associated with decreased insulin sensitivity in women with PCOS. Conclusions In PCOS, enlarged ovarian volume and follicle excess were associated with insulin resistance, and the number of ovarian follicles could be a predictor of insulin resistance. This article is protected by copyright. All rights reserved.

Rectus sheath block (RSB) is an anterior abdominal wall block that reduces postoperative pain associated with midline incisions. This study aims to investigate the effect of ultrasound-guided bilateral RSB (US-BRSB) on postoperative pain and analgesic consumption in patients undergoing laparoscopic gynecologic surgery. Sixty patients who underwent laparoscopic gynecologic surgery were allocated to RSB (n = 30) or control (n = 30) group. A bilateral US-BRSB procedure (30 ml of 0.25% ropivacaine) was performed after induction of general anesthesia in the RSB group. The control group proceeded the surgery without sham block. All patients received fentanyl-based intravenous patient-controlled analgesia and rescue analgesics upon demand. Pain was scored by a blinded observer using a verbal numerical rating scale (VNRS) at rest while coughing at 0, 1, 6, 12, 24, and 48 h after postanesthesia care unit (PACU) admission. The primary outcome was the total number of rescue analgesics used in the 48-h postoperative period. At 0 h, VNRS were lower in the RSB group than in the control, both at rest (median VNRS 4.5 vs. 5, p = 0.02) and while coughing (median VNRS 6 vs. 7, p = 0.004). At 6 h, VNRS scores were lower in the RSB group than in the control while coughing (median VNRS 3 vs. 5, p = 0.01). Fentanyl use as rescue analgesics in the PACU was significantly lower in the RSB group than in the control (27.7 ± 32.1 vs. 53.3 ± 33.7 µg, respectively; p = 0.004). At 48 h postoperatively, the total number of rescue analgesics administered were significantly fewer in the RSB group than in the control (2.5 ± 2.5 vs. 3.9 ± 2.6, respectively; p = 0.04). US-BRSB reduces the immediate postoperative pain and opioid consumption during the early postoperative period. NCT02476799, https://clinicaltrials.gov/ct2/show/NCT02476799 .

There is no current consensus on the best treatment modality for cesarean scar pregnancy (CSP) with favorable reproductive and pregnancy outcome. We treated 3 cases of symptomatic CSP with fetal cardiac activity. The first case underwent laparoscopic repair at 6 weeks' gestational age of unruptured CSP. The second patient underwent laparoscopic repair due to massive vaginal bleeding after suction curettage. Both patients conceived naturally 6 months later and underwent repeated cesarean section at term. These were successful live births although the second patient was treated with uterine artery embolization for postpartum hemorrhage. The last patient underwent emergency exploratory laparotomy due to ruptured CSP and delivered a preterm baby. Earlier surgical treatment of CSP is indicated for a subsequent successful pregnancy and live birth. The laparoscopic approach might be advisable prior to uterine rupture.

Study Objective The study aimed to discuss the safety, feasibility and advantages of the Robotic Single-Site hysterectomy (RSSH) in gynecological field. Design Retrospective analysis of 179 cases of RSSH Setting Department of Obstetrics and Gynecology, College of Medicine, Robot Surgery Center, Ewha Womans University Patients or Participants 179 patients who had RSSH Interventions From December 2014 to January 2019, 179 cases of Robotic Single-Site Hysterectomy which was done by 3 gynecologic surgeons at Ewha Womans University Medical Center were retrospectively analyzed. Measurements and Main Results There were total 179 cases of the Robotic Single-Site hysterectomy. One hundred seventy cases had adenomyosis, or leiomyoma or those combined diseases. The mean ages was 47.24±6.02. The mean total operation time was 120.44±40.61 mins, with the mean docking time 3.47±1.79 mins. The mean estimated blood loss (EBL) was 177.12±184.82 ml and the mean hemoglobin change was 1.92±0.95 g/dl. The mean hospitalization period was 4.98±1.24 days. Only few intraoperative or perioperative complication in 7cases (0.039%) were noted. The conversion rate to laparotomy was zero. Conclusion The Robotic Single-Site hysterectomy is a safe, reliable and feasible surgical method in gynecology.

Objective Adenomyosis and endometriosis are relatively common gynecological diseases that exhibit many common features. This study identified gynecological and non-gynecological diseases that exhibited comorbidity with adenomyosis and endometriosis in Korean women. Methods We used Health Insurance Review and Assessment data from 2009 to 2011 and searched for adenomyosis and endometriosis (coded as N80.1 and D25 in International Classification of Disease, 10th revision [ICD-10], respectively). We selected records from patients who had independent disease occurrences in each year, and comorbidities were estimated using Fisher's exact test. We computed each year's similarities and combined 3 years' results using Fisher's P-value summation method. Results A total of 61,516 patients' data were collected during the study period. The prevalence of adenomyosis and endometriosis were similar each year: 12.4% and 9.3% in 2009, 12.5% and 9.4% in 2010 and 13.3% and 9.1% in 2011, respectively. Meta-analysis revealed that 31 ICD-10 codes were significantly related with adenomyosis, and 44 ICD-10 codes were related with endometriosis. Gynecological diseases, such as leiomyoma and benign ovarian tumor, were significantly related to adenomyosis and endometriosis. Non-gynecological diseases, such as anemia and hypercholesterolemia, were also related to adenomyosis and endometriosis. Conclusion We must monitor for the presence of gynecological and non-gynecological diseases with co-morbidities during evaluations and follow-up of patients with adenomyosis or endometriosis.

Study Objectives To report 61 consecutive cases of successful robotic single-site myomectomy (RSSM), and to evaluate the feasibility and safety of RSSM. Design Retrospective analysis of 61 cases involving RSSM (Canadian Task Force classification III). Setting Department of Obstetrics and Gynecology, College of Medicine, Robot Surgery Center, Ewha Womans University, Seoul, Republic of Korea. Patients Sixty-one patients who underwent RSSM performed by 3 gynecologic surgeons at Ewha Womans University between December 2014 and May 2016. Interventions We analyzed the patients' baseline characteristics and surgical variables and the trends in operation-related variables according to surgeon's level of experience with RSSM. Measurements and Main Results There were no cases of conversion to laparotomy or robotic multisite myomectomy. RSSM was successful for multiple uterine myomas up to 12 in number and for large myomas up to 12.8 cm in longest diameter. In terms of myoma location, RSSM was successful for all types of myomas, including subserosal, intramural, and intraligamentary. The mean docking time was 5.45 ± 2.84 minutes (2.0∼12.0 minutes), mean total operation time was 135.98 ± 59.62 minutes (60∼295 minutes), mean estimated blood loss was 182.62 ± 153.02 mL (10∼600 mL), and mean skin incision length was 2.70 ± 0.19 cm (2.4∼3.10 cm). The mean time to postoperative gas passage was 28.71 ± 12.99 hours (3.33∼76.50 hours), and the mean duration of hospitalization was 4.21 ± 0.84 days (3∼6 days). No patient required additional analgesics other than applied intravenous patient-controlled analgesia. The mean change in hemoglobin level was 2.43 ± 0.87 g/dL, and the incidence of postoperative anemia requiring blood transfusion was only 3.3% (2 cases). No intraoperative or perioperative complications were noted. Conclusion RSSM is a feasible and safe procedure even in cases large, multiple, and intramural type myomas. Therefore, this option could be extended to appropriately selected patients.

SummaryBackground/Objectives The prevalence of obesity has markedly increased and is closely related to insulin resistance. Although lifestyle and genetic predisposition are significant factors influencing the pathophysiology within the body, endocrine-disrupting chemicals (EDCs) are also important triggers of metabolic disturbance. We investigated the relationship between exposure to EDCs and insulin resistance and obesity in healthy, reproductive-aged women. Subjects/Methods This cross-sectional analysis included 296 healthy, reproductive-aged women between 30 and 49 years. Metabolically healthy was defined as an absence of the components of metabolic syndrome. Urinary levels of bisphenol A (BPA), mono-(2-ethyl-5-hydroxyhexyl) phthalate (MEHHP), mono-(2-ethyl-5-oxohexyl) phthalate (MEOHP) and mono-n-butyl phthalate (MnBP) were measured by high-performance liquid chromatography and tandem mass spectroscopy (LC–MS). Homoeostatic model analysis of insulin resistance (HOMA-IR) was utilized as an index of insulin resistance. Results Urinary BPA levels were positively correlated with BMI, waist circumference, fasting serum insulin and HOMA-IR. MEHHP, MEOHP and MnBP were not associated with any of the above parameters. In the multiple regression analysis, the BPA levels were significantly associated with BMI and waist circumference after adjusting for age, smoking and alcohol consumption status, triglycerides (TG), total cholesterol (TC) and high-density lipoprotein (HDL). Fasting insulin and HOMA-IR values were also significantly related to urinary BPA concentration after adjusting for confounding variables. Metabolically unhealthy women exhibited significantly higher levels of urinary BPA (P = 0·01) compared to metabolically healthy women. Conclusions Higher urinary BPA levels are associated with obesity, insulin resistance and metabolic disruption in Korean reproductive-aged women. BPA could play an important role in the pathogenesis of metabolic abnormalities. Further studies are required to elucidate the relationship between EDCs and metabolic disturbances in various age and sex groups.

Introduction Uterine fibroids are one of the most common gynecological diseases and are considered as an estrogen-dependent disease. Among metalloestrogens, the following three heavy metals have be...

The purpose of this study is to identify predictive markers for abnormal glucose metabolism in Korean women with polycystic ovary syndrome (PCOS). METHODSː A total of 312 PCOS patients were evaluated. All patients underwent 75-g oral glucose tolerance tests. The 2-hour plasma glucose level was used to categorize subjects as impaired glucose tolerance (IGT) or non-insulin-dependent diabetes mellitus (NIDDM). Areas under the receiver operating characteristic (ROC) curves were used to compare the power of serum markers. Multiple linear regression analysis was used to evaluate the contribution of each confounding factor to the 2-hour post-load glucose value. RESULTSː A total of 285 PCOS women with normal glucose tolerance (91.3%) and 27 PCOS patients with abnormal glucose metabolism (8.7%) (IGT/NIDDM) were evaluated. Area under the curve (AUC) of hemoglobin (Hb) A1c, high-sensitivity C-reactive protein (hs-CRP), lipid accumulation product (LAP) index, and triglyceride (TG) were 0.780, 0.772, 0.762, and 0.758 respectively. ROC analysis suggested a threshold value of 5.45 in HbA1c (71.4% sensitivity and 70.0% specificity), a value of 1.16 in hs-CRP (70.3% sensitivity and 80.1% specificity), a value of 12.98 in LAP index (88.5% sensitivity and 52.3% specificity) and a value of 88.0 in TG (77.8% sensitivity and 63.5% specificity) to predict for abnormal glucose metabolism. CONCLUSIONSː HbA1c, hs-CRP, LAP index, and TG could be useful predictive markers for abnormal glucose metabolism (IGT/NIDDM) in Korean PCOS women.

This study was conducted to investigate the effect of black cohosh (BC) extract on the proliferation and apoptosis of Ishikawa cells. Ishikawa human endometrial adenocarcinoma cells were treated with or without BC (1, 5, 10 and 25 μM) and cell proliferation and cytotoxicity were measured by CCK-8 assays and flow cytometry analysis. Additionally, Ishikawa cells were treated with 17β-estradiol (E2), E2 + progesterone and E2 + BC (5 and 10 μM) and the effect of BC and progesterone on E2-induced cell proliferation was analyzed. BC decreased the proliferation of Ishikawa cells at a dose-dependent rate compared with the control group (p 0.05). The proliferation of Ishikawa cells increased in the presence of E2, whereas the subsequent addition of progesterone or BC decreased proliferation to the level of the control group (p 0.05). The inhibitory effect of BC on E2-induced cell proliferation was greater than the inhibitory effect of progesterone. In conclusion, BC induces apoptosis in Ishikawa cells and suppresses E2-induced cell proliferation in Ishikawa cells. BC could be considered a candidate co-treatment agent of estrogen-dependent tumors, especially those involving endometrial cells.

The goal of this study is to evaluate the chromosomal loss in abdominal wall endometriosis by chromogenic in situ hybridization (CISH). Twenty-four cases of abdominal wall endometriosis that developed after cesarean section at the Korea University Medical Center between January 1997 and December 2006 were selected. CISH was performed in the sections of tissue microarray block using the Zymed CISH centromeric probes for chromosomes 3, 7, 8, 9, 10, 11, 17, and 18. Monosomy was defined when the percentage of the nuclei with a single dot was more than mean+3 SD of the respective probe in normal control endometrium. CISH study was possible in more than half of the endometriosis samples, except for chromosome 9, and was most successful for chromosome 17. The frequency of monosomy was high for chromosomes 9 (75.0%) and 17 (73.9%), moderate for chromosomes 10 (57.1%) and 18 (56.3%), and low for chromosomes 3 (12.5%), 7 (22.2%), 8 (10.5%), and 11 (10.5%). Monosomy for >2 and 3 chromosomes occurred in 66.7% and 42.9% of the cases, respectively. It is concluded that CISH method may be considered a useful laboratory technique in detecting chromosomal loss, and multiple chromosomal loss is involved in the formation of ectopic endometrium in abdominal wall endometriosis.

Aim: To evaluate retrospectively the performance of computed tomography (CT) for the diagnosis of acute pelvic inflammatory disease (PID) by the use of clinical and laboratory data as the reference standard. Methods: The study was approved by the institutional review board. A total of 190 women of reproductive age (age range, 16−49 years; mean age, 29.3 ± 7.6 years) with complaints of non-traumatic acute lower abdominal pain underwent subsequent abdominopelvic CT. The diagnosis of acute PID was confirmed by the clinical and laboratory findings. Two radiologists performed a blinded, independent, retrospective review of the CT findings of acute PID. Discordant findings were resolved by a consensus review with a third radiologist. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of each CT finding for the diagnosis of acute PID were determined. Kappa statistics were used to estimate agreement between readers. Results: Pelvic inflammatory disease was present in 48 (25.3%) of the 190 patients. The most specific CT finding for the diagnosis of acute PID was tubal thickening of both fallopian tubes (95.1%). The most sensitive CT finding was mid-pelvic fat stranding (60.4%). Conclusion: The CT finding of tubal thickening is highly specific for the diagnosis of acute PID, although overall CT sensitivity is poor.

OBJECTIVE: To retrospectively evaluate the feasibility of computed tomography (CT) in depicting deep-infiltrating endometriosis. MATERIALS: The study population included 54 patients (age: mean, 35.5 years; range, 23-48 years) with histologically confirmed ovarian endometriomas between January 2007 and July 2009. All the patients underwent preoperative CT imaging before laparotomy or laparoscopy. The CT images were evaluated for the presence of a tethered appearance of the rectum in the direction of the uterus, stranding of periuterine pelvic fat, thickening of the uterosacral ligament, and retroflexed uterus. Two radiologists performed a blinded and independent review for each CT finding. The sensitivity, the specificity, the positive predictive value, the negative predictive value, and the accuracy of each CT finding and kappa statistics were determined. RESULTS: Deep-infiltrating endometriosis was confirmed after surgery and pathologic examination in 34 patients (63.0%). The most specific finding for the diagnosis of deep-infiltrating endometriosis was tethered appearance of rectum in the direction of the uterus (90.0%). The mean sensitivity, specificity, positive predictive value, negative predictive value, and accuracy values of all the CT findings except that of retroflexed uterus were 56.9%, 70.0%, 78.1%, 60.4%, and 61.7%, respectively. The mean kappa value was 0.82 (range, 0.67-0.96). CONCLUSIONS: Computed tomographic imaging may constitute another potential option as a complementary imaging modality for the evaluation of deep-infiltrating endometriosis.