All the procedures in the following protocol were reviewed and approved by the Institutional Review Board of Peking University Shenzhen Hospital for application on patients on December, 15, 2012.
1. Patient Preparation
<ol>
	<li>Use the following inclusion criteria: abnormal uterine bleeding; fibroids compressing surrounding organs and causing urinary, digestive, or sexual symptoms; infertility; fibroid is larger than 4 cm while the patient is preparing for pregnancy.</li>
	<li>Use the following exclusion criteria: suspected malignancy; suspected fibroid degeneration; pedunculated, cervical, or intra-broad ligamentous fibroids; preoperative use of gonadotrophin-releasing hormone analogues; acute systemic inflammation or pelvic inflammatory disease; patient is currently pregnant, within puerperium, or within three months after abortion; severe coagulation disorders; any other contraindications for general anesthesia or laparoscopy.</li>
	<li>Conduct a pelvic palpation and ultrasound examination to determine the location, number, and size of the fibroids.</li>
	<li>Inform the patient of the benefits and risks of surgery and obtain written consent, discussing the risks of excessive bleeding and blood transfusion, conversion to laparotomy, tumor cell dissemination during the operation, and postoperative infection.</li>
	<li>Perform the surgery under general anesthesia with endotracheal intubation. Administer to each patient a prophylactic antibiotic dosage of 2 g of cefamandole intravenously 30 min before induction of anesthesia.</li>
</ol>
2. Pre-IRCP Preparation
<ol>
	<li>After standard skin sterilization, establish the ports by standard techniques: a 10 mm umbilical port, and 5 mm and 10 mm ancillary ports in the lower abdomen. Connect the 5 mm port with a plastic tube for vacuum drainage, which can suck the smoke during surgery.</li>
	<li>During the surgery, have an anesthesiologist carefully monitor vital signs of the patient.</li>
	<li>Maintain the intraabdominal pressure and gas flow rate at 13 kPa and 12 L/min, respectively.</li>
</ol>
3. Intracapsular Rotary-cut Procedure (IRCP)
<ol>
	<li>Inspect the pelvis carefully to confirm the size, number, and location of the fibroids. Inject an ischemic solution (6 U pituitrin and 20 U oxytocin diluted in 10 mL of saline) into the myometrium around the fibroids with a 10 mL syringe.</li>
	<li>Determine the incision position on the most-protruding site of the fibroid and incise longitudinally by a monopolar hook electrode at low wattage (30 W), ensuring the length is no longer than half of the fibroid diameter. Open the pseudo-capsule by a longitudinal cut to expose the fibroid surface (Figure 1A).</li>
	<li>Hold the fibroid with the laparoscopic forceps and pull it outward, keeping a certain tension to expose the boundary between the fibroid and the pseudo-capsule (Figure 1B).</li>
	<li>Perform multiple rotary cuts on the fibroid (Figure 1C1) with a monopolar electrical knife in depths of 5&#8211;10 mm, shrinking the diameter of the tumor (Figure 1C2) and ensuring not to cut any pieces of the fibroid off.
	<ol>
		<li>Meanwhile, keep pulling outward to facilitate further exposure of the gap between the fibroid and the pseudo-capsule. Remove the smoke by vacuum drainage to keep a clear field.</li>
	</ol>
	</li>
	<li>Repeat the cutting-pulling procedures on the fibroid in the manner described above with 10 mm intervals, ensuring that each cut is at a certain distance with the prior cut, until the longest dimension of the fibroid is outside the incision. Then, the fibroid will be squeezed out by contraction of the pseudo-capsule and myometrium (Figure 1D). Avoid pulling too hard and blunt dissection to protect fibers and vessels of the pseudo-capsule.</li>
	<li>Gently pull the fibroid outward, and the pseudo-capsule should slip off to the base of the fibroid. Continue the cuts on the fibroid until the base of the fibroid is exposed and isolate it from its pseudo-capsule (Figure 1E). Use bipolar electrocautery forceps to coagulate and cut off the blood vessels, always at 30 W. After removal of the fibroid, only a shallow residual cavity is left (Figure 1F).</li>
	<li>Close the residual cavity in a single layer with a 30 cm 1-0 polyglyconate unidirectional barbed thread. Begin the running suture at 5 mm outside of the incisal edge with 1 cm increments. Make sure that the stitching passes through the bottom of the residual cavity, and leave no dead space. 
	NOTE: Generally, a single-layer suture is enough to close the residual cavity (Figures 1G and 1H). Occasionally, the fibroid was over 12 cm in diameter and occupied more than 2/3 of the myometrium. In these cases, a &#34;folding suture&#34; can be adopted, in which the myometrium on one side of the incision can be sutured on top of the other side to close the residual cavity and strengthen the myometrium.</li>
	<li>After suturing, enlarge the 10 mm port to a 15&#8211;20 mm port for the introduction of the morcellator. Morcellate the fibroids with a reusable morcellator.</li>
</ol>
4. Postoperative Management
<ol>
	<li>Document the intra- and post-operative parameters carefully, including the diameters of the fibroids (represented by the diameter of the largest one in cases of multiple fibroids), operation time (from the beginning of incision to the end of suturing), blood loss (calculated by vacuum drainage), and rate of conversion to laparotomy.</li>
	<li>Follow up patients by pelvic examination and ultrasound as well as phone interviews.</li>
	<li>Evaluate the outcomes of IRCP by comparison with those of traditional LM around the same period. Perform statistical analysis by SPSS software and consider p &#60; 0.05 as statistically significant.</li>
</ol>

<ol><li>Drayer, S. M., Catherino, W. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Prevalence%2C+morbidity%2C+and+current+medical+management+of+uterine+leiomyomas%5BTitle%5D)+AND+%22International+Journal+of+Gynecology+%26+Obstetrics%22%5BJournal%5D)">Prevalence, morbidity, and current medical management of uterine leiomyomas.</a> International Journal of Gynecology & Obstetrics. 131 (2), 117-122 (2015).</li>
<li>Wu, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Prevalence+and+clinical+significance+of+mediator+complex+subunit+12+mutations+in+362+Han+Chinese+samples+with+uterine+leiomyoma%5BTitle%5D)+AND+%22Oncology+Letters%22%5BJournal%5D)">Prevalence and clinical significance of mediator complex subunit 12 mutations in 362 Han Chinese samples with uterine leiomyoma.</a> Oncology Letters. 14 (1), 47-54 (2017).</li>
<li>Falcone, T., Parker, W. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Surgical+management+of+leiomyomas+for+fertility+or+uterine+preservation%5BTitle%5D)+AND+%22Obstetrics+%26+Gynecology%22%5BJournal%5D)">Surgical management of leiomyomas for fertility or uterine preservation.</a> Obstetrics & Gynecology. 121 (4), 856-868 (2013).</li>
<li>Donnez, J., Dolmans, M. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Uterine+fibroid+management%3A+from+the+present+to+the+future%5BTitle%5D)+AND+%22Human+Reproduction+Update%22%5BJournal%5D)">Uterine fibroid management: from the present to the future.</a> Human Reproduction Update. 22 (6), 665-686 (2016).</li>
<li>Gu, Y., Zhu, L., Liu, A., Ma, J., Lang, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Analysis+of+hysterectomies+for+patients+with+uterine+leiomyomas+in+China+in+2010%5BTitle%5D)+AND+%22International+Journal+of+Gynecology+%26+Obstetrics%22%5BJournal%5D)">Analysis of hysterectomies for patients with uterine leiomyomas in China in 2010.</a> International Journal of Gynecology & Obstetrics. 129 (1), 71-74 (2015).</li>
<li>Cheng, P. J., Duan, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((China%27s+new+two-child+policy%3A+maternity+care+in+the+new+multiparous+era%5BTitle%5D)+AND+%22BJOG%22%5BJournal%5D)">China's new two-child policy: maternity care in the new multiparous era.</a> BJOG. 123, Suppl 3. 7-9 (2016).</li>
<li>Tinelli, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Laparoscopic+myomectomy+focusing+on+the+myoma+pseudocapsule%3A+technical+and+outcome+reports%5BTitle%5D)+AND+%22Human+Reproduction%22%5BJournal%5D)">Laparoscopic myomectomy focusing on the myoma pseudocapsule: technical and outcome reports.</a> Human Reproduction. 27 (2), 427-435 (2012).</li>
<li>Agdi, M., Tulandi, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Minimally+invasive+approach+for+myomectomy%5BTitle%5D)+AND+%22Seminars+in+Reproductive+Medicine%22%5BJournal%5D)">Minimally invasive approach for myomectomy.</a> Seminars in Reproductive Medicine. 28 (3), 228-234 (2010).</li>
<li>Al-Talib, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Factors+contributing+to+failure+of+laparoscopic+myomectomy%5BTitle%5D)+AND+%22Surgical+Technology+International%22%5BJournal%5D)">Factors contributing to failure of laparoscopic myomectomy.</a> Surgical Technology International. 23, 149-151 (2013).</li>
<li>Saccardi, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Limits+and+complications+of+laparoscopic+myomectomy%3A+which+are+the+best+predictors%3F+A+large+cohort+single-center+experience%5BTitle%5D)+AND+%22Archives+of+Gynecology+and+Obstetrics%22%5BJournal%5D)">Limits and complications of laparoscopic myomectomy: which are the best predictors? A large cohort single-center experience.</a> Archives of Gynecology and Obstetrics. 290 (5), 951-956 (2014).</li>
<li>Sizzi, O., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Italian+multicenter+study+on+complications+of+laparoscopic+myomectomy%5BTitle%5D)+AND+%22Journal+of+Minimally+Invasive+Gynecology%22%5BJournal%5D)">Italian multicenter study on complications of laparoscopic myomectomy.</a> Journal of Minimally Invasive Gynecology. 14 (4), 453-462 (2007).</li>
<li>Buckley, V. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Laparoscopic+myomectomy%3A+clinical+outcomes+and+comparative+evidence%5BTitle%5D)+AND+%22Journal+of+Minimally+Invasive+Gynecology%22%5BJournal%5D)">Laparoscopic myomectomy: clinical outcomes and comparative evidence.</a> Journal of Minimally Invasive Gynecology. 22 (1), 11-25 (2015).</li>
<li>Glaser, L. M., Friedman, J., Tsai, S., Chaudhari, A., Milad, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Laparoscopic+myomectomy+and+morcellation%3A+A+review+of+techniques%2C+outcomes%2C+and+practice+guidelines%5BTitle%5D)+AND+%22Best+Practice+%26+Research%3A+Clinical+Obstetrics+%26+Gynaecology%22%5BJournal%5D)">Laparoscopic myomectomy and morcellation: A review of techniques, outcomes, and practice guidelines.</a> Best Practice & Research: Clinical Obstetrics & Gynaecology. 46, 99-112 (2018).</li>
<li>Kelly, B. A., Bright, P., Mackenzie, I. Z. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Does+the+surgical+approach+used+for+myomectomy+influence+the+morbidity+in+subsequent+pregnancy%5BTitle%5D)+AND+%22Journal+of+Obstetrics+%26+Gynaecology%22%5BJournal%5D)">Does the surgical approach used for myomectomy influence the morbidity in subsequent pregnancy.</a> Journal of Obstetrics & Gynaecology. 28 (1), 77-81 (2008).</li>
<li>Tian, Y. C., Long, T. F., Dai, Y. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Pregnancy+outcomes+following+different+surgical+approaches+of+myomectomy%5BTitle%5D)+AND+%22Journal+of+Obstetrics+and+Gynaecological+Research%22%5BJournal%5D)">Pregnancy outcomes following different surgical approaches of myomectomy.</a> Journal of Obstetrics and Gynaecological Research. 41 (3), 350-357 (2015).</li>
<li>Zhong, S. L., Zeng, L. P., Li, H., Wu, R. F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Development+and+evaluation+of+an+improved+laparoscopic+myomectomy+adopting+intracapsular+rotary-cut+procedures%5BTitle%5D)+AND+%22European+Journal+of+Obstetrics+%26+Gynecology+and+Reproductive+Biology%22%5BJournal%5D)">Development and evaluation of an improved laparoscopic myomectomy adopting intracapsular rotary-cut procedures.</a> European Journal of Obstetrics & Gynecology and Reproductive Biology. 221, 5-11 (2018).</li>
<li>Vilos, G. A., Allaire, C., Laberge, P. Y., Leyland, N., Special, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+management+of+uterine+leiomyomas%5BTitle%5D)+AND+%22Journal+of+Obstetrics+and+Gynaecology+Canada%22%5BJournal%5D)">The management of uterine leiomyomas.</a> Journal of Obstetrics and Gynaecology Canada. 37 (2), 157-178 (2015).</li>
<li>Lethaby, A., Vollenhoven, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Fibroids+%28uterine+myomatosis%2C+leiomyomas%29%5BTitle%5D)+AND+%22BMJ+Clinical+Evidence%22%5BJournal%5D)">Fibroids (uterine myomatosis, leiomyomas).</a> BMJ Clinical Evidence. , (2011).</li>
<li>Liu, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+epidemiological+profile+of+hysterectomy+in+rural+Chinese+women%3A+a+population-based+study%5BTitle%5D)+AND+%22BMJ+Open%22%5BJournal%5D)">The epidemiological profile of hysterectomy in rural Chinese women: a population-based study.</a> BMJ Open. 7 (6), e015351(2017).</li>
<li>Bhave Chittawar, P., Franik, S., Pouwer, A. W., Farquhar, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Minimally+invasive+surgical+techniques+versus+open+myomectomy+for+uterine+fibroids%5BTitle%5D)+AND+%22Cochrane+Database+of+Systematic+Reviews%22%5BJournal%5D)">Minimally invasive surgical techniques versus open myomectomy for uterine fibroids.</a> Cochrane Database of Systematic Reviews. (10), CD004638(2014).</li>
<li>Tinelli, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Angiogenesis+and+Vascularization+of+Uterine+Leiomyoma%3A+Clinical+Value+of+Pseudocapsule+Containing+Peptides+and+Neurotransmitters%5BTitle%5D)+AND+%22Current+Protein+and+Peptide+Science%22%5BJournal%5D)">Angiogenesis and Vascularization of Uterine Leiomyoma: Clinical Value of Pseudocapsule Containing Peptides and Neurotransmitters.</a> Current Protein and Peptide Science. 18 (2), 129-139 (2017).</li>
<li>Tinelli, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Surgical+management+of+neurovascular+bundle+in+uterine+fibroid+pseudocapsule%5BTitle%5D)+AND+%22Journal+of+the+Society+of+Laparoendscopic+Surgeons%22%5BJournal%5D)">Surgical management of neurovascular bundle in uterine fibroid pseudocapsule.</a> Journal of the Society of Laparoendscopic Surgeons. 16 (1), 119-129 (2012).</li>
<li>Fagherazzi, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Pregnancy+outcome+after+laparoscopic+myomectomy%5BTitle%5D)+AND+%22Clinical+and+Experimental+Obstetrics+and+Gynecology%22%5BJournal%5D)">Pregnancy outcome after laparoscopic myomectomy.</a> Clinical and Experimental Obstetrics and Gynecology. 41 (4), 375-379 (2014).</li>
<li>Liu, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+descriptive+analysis+of+the+indications+for+caesarean+section+in+mainland+China%5BTitle%5D)+AND+%22BMC+Pregnancy+Childbirth%22%5BJournal%5D)">A descriptive analysis of the indications for caesarean section in mainland China.</a> BMC Pregnancy Childbirth. 14, 410(2014).</li>
<li>Weibel, H. S., Jarcevic, R., Gagnon, R., Tulandi, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Perspectives+of+obstetricians+on+labour+and+delivery+after+abdominal+or+laparoscopic+myomectomy%5BTitle%5D)+AND+%22Journal+of+Obstetrics+%26+Gynaecology+Canada%22%5BJournal%5D)">Perspectives of obstetricians on labour and delivery after abdominal or laparoscopic myomectomy.</a> Journal of Obstetrics & Gynaecology Canada. 36 (2), 128-132 (2014).</li>
<li>Vandenberghe, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Nationwide+population-based+cohort+study+of+uterine+rupture+in+Belgium%3A+results+from+the+Belgian+Obstetric+Surveillance+System%5BTitle%5D)+AND+%22BMJ+Open%22%5BJournal%5D)">Nationwide population-based cohort study of uterine rupture in Belgium: results from the Belgian Obstetric Surveillance System.</a> BMJ Open. 6 (5), e010415(2016).</li>
<li>You, S. H., Chang, Y. L., Yen, C. F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Rupture+of+the+scarred+and+unscarred+gravid+uterus%3A+Outcomes+and+risk+factors+analysis%5BTitle%5D)+AND+%22Taiwan+Journal+of+Obstetrics+%26+Gynecology%22%5BJournal%5D)">Rupture of the scarred and unscarred gravid uterus: Outcomes and risk factors analysis.</a> Taiwan Journal of Obstetrics & Gynecology. 57 (2), 248-254 (2018).</li>
<li>Wu, X., Jiang, W., Xu, H., Ye, X., Xu, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Characteristics+of+uterine+rupture+after+laparoscopic+surgery+of+the+uterus%3A+clinical+analysis+of+10+cases+and+literature+review%5BTitle%5D)+AND+%22Journal+of+Internal+Medicine+Research%22%5BJournal%5D)">Characteristics of uterine rupture after laparoscopic surgery of the uterus: clinical analysis of 10 cases and literature review.</a> Journal of Internal Medicine Research. , (2018).</li>
</ol>

The study was funded by the Shenzhen Municipal Government (JCYJ20150601090833370 and SZSM201412010), Shenzhen, China.

Uterine fibroids are the most common benign tumors of the female reproductive system, affecting 20&#8211;25% of all women1 and causing abnormal uterine bleeding, recurrent miscarriage, pelvic pain, premature birth, and infertility in 10&#8211;30% cases2. As most patients with uterine fibroids are asymptomatic, the actual incidence may be higher than recognized1. Management of uterine fibroids are generally based on various factors including the age and symptoms of the patient, size and location of the fibroids, patient desire to preserve the uterus, techniques and experience of the gynecologists, and accessibility of technical equipment17. Technically, hysterectomy is the most effective treatment for symptomatic uterine fibroids. As reported, uterine fibroids accounted for most cases of hysterectomy from 1990 to 1997 in the United States18. According to a cross-sectional study conducted from 2009 to 2011 in China, the major indication for hysterectomy is still uterine fibroids in rural regions of China, accounting for 70.67% of all cases19. For patients who desire pregnancy, however, myomectomy is an alternative that can be performed by laparotomy or laparoscopy. A systemic review of nine randomized controlled trials has demonstrated that LM is associated with less subjectively reported postoperative pain, lower postoperative fever occurrence, and shorter hospital stays compared to open myomectomy; furthermore, there was no difference in recurrence risk20. Also, LM resulted in less adhesion formation9. Because of its superiority, LM is the most frequent choice for patients who desire preservation of uterus and subsequent pregnancy, especially for subserous or intramural fibroids.
In recent years, researchers have achieved a better understanding about the vascular structure surrounding uterine fibroids, namely the pseudo-capsule. It is believed that the pseudo-capsule is a part of myometrium compressed by the tumor and is contains abundant collagen fibers, blood vessels, and neurofibers21. The integrity of the pseudo-capsule is important for blood supply and uterine healing after myomectomy. Therefore, the widely accepted principle is to perform an intracapsular myomectomy. During this procedure, the fibroids are stretched and extracted directly from the pseudo-capsule. Since detachment of the fibroids is performed inside the pseudo-capsule, it causes decreased blood loss22. Tinelli7 has postulated that laparoscopic intracapsular intramural and subserous myomectomy spares the intact &#64257;brovascular network surrounding the myoma, reducing bleeding and damage to the myometrium, which can also maximize the potential for future fertility and minimize risk of uterine rupture during pregnancy. However, the risk of massive bleeding, difficulty of suturing, and demands of the required techniques are major limitations of traditional LM. Based on this, we developed the modified myomectomy procedure, IRCP.
In an earlier article on the evaluation of IRCP published by our team, we have demonstrated that IRCP was associated with smaller incision, less time of suturing, less intraoperative blood loss, and reduced decline of hemoglobin, compared to traditional LM16. The results of this study were consistent with the previous data, confirming the advantages of ICRP over traditional LM. Meanwhile, the full-term live birth rate was higher in the IRCP group than the LM group, suggesting that IRCP facilitated fertility preservation. Researchers have illustrated that previous laparoscopic myomectomy with adequate suturing of the myometrium was not a contraindication for vaginal delivery23. The reported rate of vaginal birth after traditional LM was 67.0%7, but in our study, the rate of vaginal birth was much lower than reported.
The past decades have witnessed a remarkable increase of the caesarean section rate in mainland China24, which has resulted from various factors, including patient concerns about pain and uneasy doctor-patient relationships. Also, some women believe that a caesarean section is safer for the fetus. Thus, for women with previous history of myomectomy, obstetricians tend to be more cautious and are more likely to recommend scheduled caesarean sections because of the concerns about uterine rupture25. Uterine rupture is a rare but devastating complication during post-myomectomy pregnancy, especially in the third trimester26,27. In spite of the extreme low incidence, it may cause unfavorable outcomes for the mother and fetus. Reported risk factors included excessive use of electrical equipment and inadequate suturing28. No case of uterine rupture was observed in our study. By IRCP, the application of electrical equipment is limited, and suturing is less technically demanding due to the shallower residual cavity, which may contribute to a lower risk of uterine rupture; however, more evidence is needed.
As discussed, the advantages of laparoscopic IRCP are clear in comparison to traditional LM. First, a smaller incision of the uterus is made. Traditional LM requires an incision over half of the fibroid diameter. For multiple fibroids with unregular shapes, the incision may be equal to the diameter of the fibroid, which may cause severe damage to the pseudo-capsule. IRCP, however, enables the fibroid to be removed from an incision that is no more than half of its diameter, protecting the integrity of the pseudo-capsule as much as possible. Second, IRCP causes less bleeding. Traditional LM causes bleeding due to damage to the blood vessels of the pseudo-capsule. Specifically, blunt dissection of the fibroid and its pseudo-capsule usually leads to blood vessel breakage and massive bleeding. IRCP significantly lessens bleeding, as it avoids blunt dissection. Instead, IRCP protects the vessels with rotary-cuts on the fibroid, which has no blood vessels and eases handling of the blood vessels at the base of the fibroid. IRCP achieves detachment of the fibroid by shrinking its diameter and contraction of the surrounding myometrium. The blood vessels at the base of the fibroid can be coagulated by bipolar electrocautery forceps, resulting in less blood loss. Third, a smaller and shallower residual cavity was left. Traditional LM is based on blunt dissection on the muscle layer of the pseudo-capsule, which causes fracture of the muscle fibers to form a residual cavity equal to the fibroid size after it is removed. IRCP enables removal of the fibroid in its pseudo-capsule without damage to the muscle fibers. Therefore, the fairly protected muscle layer can contract after the fibroid is removed, leaving a smaller and swallower residual cavity. Although both traditional LM and IRCP emphasized removing the fibroid within its pseudo-capsule, the residual cavity is much smaller and shallower in IRCP due to to injection of ischemic solutions, better contraction of the myometrium, and a smaller incision. Lastly, IRCP makes suturing easier; as IRCP requires smaller incisions in the uterus, it enables the achieving of smaller and swallower residual cavities and little bleeding, making it easy to suture with no dead space remaining. Usually, a single-layer suture is enough to close the residual cavity, and no layered suture is needed. Also, it is less technically demanding for the surgeon.
Still, we acknowledge that there are still some limitations of IRCP. For example, IRCP is not suitable for pedunculated subserous fibroids or submucous ones. Also, it remains to be determined whether IRCP should be applied to degenerated fibroids. Red degeneration, cystic degeneration and fatty degeneration all lead to softer texture of the tumor and impaired contraction of the myometrium. In this case, it is not easy to detach the fibroid from its pseudo-capsule by IRCP. Besides, as a moderated morcellation procedure, IRCP may result in potential dissemination if malignancy exists. However, with a careful pre-operative evaluation for risk of malignancy and by strictly following the procedures to perform inside of the pseudo-capsule, this risk can be minimized. In addition, it is difficult to operate when the major part of the fibroid is still inside the pseudo-capsule, and it requires patience. However, when most of the fibroid is outside the incision, it will slip out spontaneously.
Eventually, we concluded that IRCP significantly shortens operation time and reduces intraoperative bleeding. This procedure also better protects the integrity of the pseudo-capsule and myometrium by shrinking the diameter of the fibroid and facilitating uterine healing, which is of fundamental importance for subsequent pregnancy and vaginal delivery. It is worthwhile to adopt IRCP in young patients who desire maintenance of fertility. IRCP is especially suitable for cervical and intra-ligamentous fibroids. Although fibroids in unusual locations are not illustrated in the current article, we have achieved successful experience in managing cervical and intra-ligamentous fibroids with IRCP. As the surgery is performed inside the pseudo-capsule, it effectively avoids injury to uterine blood vessels and ureters. Usually, the pseudo-capsule of intra-ligamentous fibroids is looser, so it is easier and safer to perform IRCP. As for cervical fibroids, we have successfully performed IRCP on 9 patients with large cervical fibroids, which will be illustrated in detail in later reports.

Uterine fibroids are the most common pelvic tumors observed in gynecologic practice. The incidence is estimated to be about 20&#8211;25% worldwide1. Most uterine fibroids are asymptomatic but sometimes cause abnormal uterine bleeding, pelvic pressure, pelvic pain, and adverse reproductive outcomes, thus diminishing the quality of life of women2,3. Management of fibroids depends on individual situations and includes options such as surgery, medication, and revisit observation4. A hysterectomy is an important method to treat uterine fibroids and is a radical surgery that can prevent recurrence3,5. Myomectomy, however, is becoming popular as doctors are paying more attention to the fertility preservation of patients at reproductive ages, especially during the era of the two-child policy in China6.
As Tinelli and his colleagues have described, in the procedure of laparoscopic myomectomy (LM)7, the visceral peritoneum is incised in the midline longitudinally by monopolar scissors or a crochet needle electrode, proceeding at a certain depth into the myometrium to identify the pseudo-capsule. The pseudo-capsule is opened longitudinally by monopolar scissors or a hook electrode at a low wattage (30 W) to expose the fibroid. Then, the fibroid is hooked by a myoma screw for gentle enucleation with help from an irrigator cannula that is inserted in the space between the pseudo-capsule and fibroid. Hemostasis of the small vessels is made to free the base of the myoma and connective bridges from the pseudo-capsule. The myometrium is then closed in a single layer for subserous fibroids and as double layers for intramural fibroids.
Although LM is widely applied around the world, there are still some limitations of this procedure. Since LM is more technically demanding than laparotomy, it should be applied to selected cases with relatively smaller sizes and numbers of fibroids8,9. It remains a great challenge to remove intramural fibroids greater than 8 cm or subserous ones greater than 12 cm with laparoscopy10. Published data have shown that transfusion-requiring bleeding and postoperative hematomas significantly increased when applying LM to removal of intra-broad ligamentous fibroids11. Other researchers believe that excessive bleeding, prolonged operation time, and potential dissemination of cells when applying morcellation are concerning problems with LM12,13. The risk of during-pregnancy uterine rupture after LM is reported to be higher than abdominal myomectomy due to the technical difficulties of suturing14. The safety of pregnancy succeeding LM remains controversial15. As postoperative healing of the myometrium is very important for patients who need to maintain fertility either clinically or by request, LM procedures need to be more applicable, which can be accomplished by reducing the technical difficulties and promoting uterine healing after the surgery.
In order to minimize the damage to the patient&#39;s fertility, here we present a modified myomectomy procedure, the intracapsular rotary-cut procedure (IRCP)16. This procedure shortens the incision on uterine wall as much as possible and reduces the technical difficulties of LM. Also, it helps to protect fibers and blood vessels of the pseudo-capsule that plays an important role in uterine healing after myomectomy, ultimately reducing the risk of postoperative hematoma and uterine rupture in subsequent pregnancy. After being reviewed and approved by the Institutional Review Board of Peking University Shenzhen Hospital on December 15, 2012, we began the application of IRCP and evaluation of the outcomes of IRCP by comparison with traditional LM.

<table><tbody><tr><td>laparoscopy</td><td>Stryker Corporation</td><td>&amp;nbsp;X 800</td><td></td></tr><tr><td>morcellator</td><td>Kangji Medical</td><td>&amp;nbsp;KJ-301A</td><td></td></tr><tr><td>30 cm 1-0 polyglyconate unidirectional barbed thread</td><td>Covidien</td><td>V-Loc 180</td><td></td></tr></tbody></table>

introduction of intracapsular rotary-cut procedures (ircp): a modified hysteromyomectomy procedures facilitating fertility preservation

Uterine fibroids are common benign tumors in the female reproductive system. A hysterectomy is the most effective treatment for symptomatic fibroids. For patients desiring pregnancy, laparoscopic intracapsular myomectomy (LM) is an alternative surgery option. Although LM is widely accepted to treat fibroids, it is technically demanding with risk of excessive bleeding and difficult suturing, especially in cases with large fibroids or tumors in unusual locations. Therefore, we developed an intracapsular rotary-cut procedure (IRCP) as a modification of laparoscopic intracapsular myomectomy, with the intention to minimize risks of LM and help uterine healing. A summary of the improvements to the IRCP is described: 1) making an incision at the site of the fibroid with a length of one-third to one-half of the fibroid&#39;s diameter at a depth reaching the fibroid&#39;s surface; 2) holding the fibroid stably and making rotary cuts on the fibroid at a depth of 0.5&#8211;1 cm within its pseudo-capsule while pulling it outward slightly, making sure not to cut off any pieces of the fibroid; and 3) repeating the cutting-and-pulling until the longest dimension of the fibroid is outside the incision. The multiple cuts are to minimize the diameter and extend the length of the fibroid. When the multiple cuts cause half of the fibroid body to &#34;shrink&#34;, the fibroid is squeezed out by contraction of the surrounding myometrium. Evaluation of the outcomes of IRCP showed that the time of enucleation and suturing, intraoperative bleeding, and decline of hemoglobin were significantly lower in the IRCP group than the LM group. As for reproductive outcomes, the full-term live birth rate of the IRCP group was significantly higher than that of LM group. However, there was no difference in delivery modes between the two groups. In conclusion, IRCP significantly benefits fertility preservation by minimizing damage to the uterus, protecting myofibers of the pseudo-capsule, and resulting in a shallower residual cavity, which eases stitching and causes less bleeding. It is worthwhile to adopt IRCP in younger patients who desire preservation of their fertility.

IRCP was performed on 41 patients with uterine fibroids and traditional LM was performed on 72 patients from 2013 to 2016. 9 cases (12.5%) in the LM group were converted to laparotomy because of massive bleeding, difficulty in enucleation, or suturing, while laparoscopy was performed successfully in all cases in the IRCP group. The percentage of conversion to laparotomy was significantly higher in the LM group (p = 0.025). Excluding the 9 cases converted to laparotomy, the average age of patients in the IRCP group (n = 41) and LM group (n = 63) were 38.6 &#177; 5.9 years and 38.1 &#177; 6.2 years, respectively, suggesting no difference between the two groups (p = 0.632). As is shown in Table 1, the mean diameters of the fibroids were also comparable between the two groups (p = 0.265). However, the time of enucleation and suturing, intraoperative bleeding, and decline of hemoglobin were all significantly lower in the IRCP group than the LM group (p = 0.015, p = 0.014, p = 0.024). Postoperatively, none of the 113 cases experienced fever, urinary infections, postoperative hematomas, or other complications.
After discharged, the patients were followed up by outpatient visits and telephone interviews. When evaluating reproductive outcomes, only those who desired fertility after surgery were included. In the IRCP group, all patients were successfully followed up. Among them, 31 (75.6%) patients achieved full-term births, including 2 vaginal births and 29 caesarean sections. On the other hand, in the LM group, 56 (88.9%) patients were successfully followed up, and the rate of full-term live birth was 23.2% (13/56), consisting of 1 vaginal birth and 12 caesarean sections. The full-term live birth rate of the IRCP group was significantly higher than that of the LM group (p = 0.000). However, no difference existed between the delivery modes in the two groups (p = 1.000). In addition, there was no uterine rupture observed in either group during follow-up.
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td></td>
			<td>LM group (n=63)</td>
			<td>IRCP group (n=41)</td>
			<td>t</td>
			<td>P</td>
		</tr>
		<tr>
			<td>age (year)</td>
			<td>38.1&#177;6.2</td>
			<td>38.6&#177;5.9</td>
			<td>0.480</td>
			<td>0.632</td>
		</tr>
		<tr>
			<td>diameter (cm)</td>
			<td>6.7&#177;2.1</td>
			<td>7.2&#177;2.3</td>
			<td>1.120</td>
			<td>0.265</td>
		</tr>
		<tr>
			<td>time of enucleation and suture (min)</td>
			<td>56.8&#177; 32.4</td>
			<td>42.4&#177; 26.9</td>
			<td>2.5</td>
			<td>0.015</td>
		</tr>
		<tr>
			<td>intraoperative bleeding (ml)</td>
			<td>103.1&#177;150.4</td>
			<td>43.1+38.5</td>
			<td>2.5</td>
			<td>0.014</td>
		</tr>
		<tr>
			<td>decline of hemoglobin (g/L)</td>
			<td>18.0&#177;10.3</td>
			<td>13.4+9.5</td>
			<td>2.3</td>
			<td>0.024</td>
		</tr>
	</tbody>
</table>
Table 1: Comparison of perioperative outcomes between two groups. The average age of patients and diameter of fibroids were comparable between the two groups. However, the time of enucleation and suturing, intraoperative bleeding, and decline of hemoglobin were all significantly lower in the IRCP group than in LM group.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/58410/58410fig1v2.jpg" /> 
Figure 1. Steps of intracapsular rotary-cut procedures (IRCP). (A) longitudinal incision was applied on the uterine wall that the fibroid located at, using monopolar electrical knife, with an incisive length of 3 cm (1/3 of the fibroid diameter). (B) The fibroid was held with forceps and pulled outward to keep a certain tension to expose the boundary of the fibroid with its pseudo-capsule. (C1) Multiple rotary-cut was performed on the fibroid by monopolar electrical knife with careful protection to the fibers and vessels of pseudo-capsuled. (C2) The fibroid were shaped from spheroid to lobulated during multiple rotary-cut. (D) Repeat rotary-cut, the longest dimension of the fibroid is exposed to the incision on the muscle layers of its capsule, pushed out fast by the pressure created from the contraction of its pseudo-capsule and myometrium. (E) Continue the semiring cuts on the fibroid in the same manner until the basis of the fibroid is exposed and isolated from its pseudo-capsule. (F) Removed the fibroid (left) and shallower residual cavity in uterine incision (right). (G) Single layer suture on the uterine incision. (H) Postoprative uterine.

Watch this Scientific Journal Video about Introduction of Intracapsular Rotary-cut Procedures IRCP: A Modified Hysteromyomectomy Procedures Facilitating Fertility Preservation at JoVE.com

Introduction of Intracapsular Rotary-cut Procedures IRCP: A Modified Hysteromyomectomy Procedures Facilitating Fertility Preservation

Here, we present a protocol for performing an intracapsular rotary-cut procedure (IRCP), a modified laparoscopic intracapsular myomectomy that promotes fertility preservation.

Introduction of Intracapsular Rotary-cut Procedures (IRCP): A Modified Hysteromyomectomy Procedures Facilitating Fertility Preservation

Uterine fibroids are common benign tumors in the female reproductive system. A hysterectomy is the most effective treatment for symptomatic fibroids. For ...

introduction-intracapsular-rotary-cut-procedures-ircp-modified

Nanyang Technological University

Research

JoVE Journal

Medicine

9.9K Views.  Peking University Shenzhen Hospital, China. Deze procedure werd ontwikkeld om de vruchtbaarheid van de patiënt te beschermen door te voorkomen dat de baarmoeder breuk in post-myomectomie zwangerschappen veroorzaakt door grote, nauwelijks gesloten, resterende holtes en trekken genezen myometrium. Het belangrijkste voordeel van deze procedure is dat het minimaliseert de chirurgische schade aan het myometrium aan de buitenkant van pseudo-capsular, en het vaatweefsel binnenkant van de pseudo-capsule. Deze intracapsulaire roterende snede p...

Video: Introduction of Intracapsular Rotary-cut Procedures IRCP: A Modified Hysteromyomectomy Procedures Facilitating Fertility Preservation

Bronchial Thermoplasty:  A Novel Therapeutic Approach to Severe Asthma

Bronchial thermoplasty is a non-drug procedure for severe persistent asthma that delivers thermal energy to the airway wall in a precisely controlled manner to reduce excessive airway smooth muscle. Reducing airway smooth muscle decreases the ability of the airways to constrict, thereby reducing the frequency of asthma attacks. Bronchial thermoplasty is delivered by the Alair System and is performed in three outpatient procedure visits, each scheduled approximately three weeks apart. The first procedure treats the airways of the right lower lobe, the second treats the airways of the left lower lobe and the third and final procedure treats the airways in both upper lobes. After all three procedures are performed the bronchial thermoplasty treatment is complete.
Bronchial thermoplasty is performed during bronchoscopy with the patient under moderate sedation. All accessible airways distal to the mainstem bronchi between 3 and 10 mm in diameter, with the exception of the right middle lobe, are treated under bronchoscopic visualization. Contiguous and non-overlapping activations of the device are used, moving from distal to proximal along the length of the airway, and systematically from airway to airway as described previously. Although conceptually straightforward, the actual execution of bronchial thermoplasty is quite intricate and procedural duration for the treatment of a single lobe is often substantially longer than encountered during routine bronchoscopy. As such, bronchial thermoplasty should be considered a complex interventional bronchoscopy and is intended for the experienced bronchoscopist. Optimal patient management is critical in any such complex and longer duration bronchoscopic procedure. This article discusses the importance of careful patient selection, patient preparation, patient management, procedure duration, postoperative care and follow-up to ensure that bronchial thermoplasty is performed safely.
Bronchial thermoplasty is expected to complement asthma maintenance medications by providing long-lasting asthma control and improving asthma-related quality of life of patients with severe asthma. In addition, bronchial thermoplasty has been demonstrated to reduce severe exacerbations (asthma attacks) emergency rooms visits for respiratory symptoms, and time lost from work, school and other daily activities due to asthma.

Bronchial thermoplasty is a non-drug procedure for severe persistent asthma that delivers thermal energy to the airway wall in a precisely controlled manner to reduce excessive airway smooth muscle. Reducing airway smooth muscle decreases the ability of the airways to constrict, thereby reducing the frequency of asthma attacks.

Bronchial thermoplasty is a non-drug procedure for severe persistent asthma that delivers thermal energy to the airway wall in a precisely controlled ...

Remote Magnetic Navigation for Accurate, Real-time Catheter Positioning and Ablation in Cardiac Electrophysiology Procedures

New remote navigation systems have been developed to improve current limitations of conventional manually guided catheter ablation in complex cardiac substrates such as left atrial flutter. This protocol describes all the clinical and invasive interventional steps performed during a human electrophysiological study and ablation to assess the accuracy, safety and real-time navigation of the Catheter Guidance, Control and Imaging (CGCI) system. Patients who underwent ablation of a right or left atrium flutter substrate were included. Specifically, data from three left atrial flutter and two counterclockwise right atrial flutter procedures are shown in this report. One representative left atrial flutter procedure is shown in the movie. This system is based on eight coil-core electromagnets, which generate a dynamic magnetic field focused on the heart. Remote navigation by rapid changes (msec) in the magnetic field magnitude and a very flexible magnetized catheter allow real-time closed-loop integration and accurate, stable positioning and ablation of the arrhythmogenic substrate.

This report provides a detailed description of a new remote navigation system based on magnetic driven forces, which has been recently introduced as a new robotic tool for human cardiac electrophysiology procedures.

New remote navigation systems have been developed to improve current limitations of conventional manually guided catheter ablation in complex cardiac ...

Surgical Procedures for a Rat Model of Partial Orthotopic Liver Transplantation with Hepatic Arterial Reconstruction

Orthotopic liver transplantation (OLT) in rats using a whole or partial graft is an indispensable experimental model for transplantation research, such as studies on graft preservation and ischemia-reperfusion injury 1,2, immunological responses 3,4, hemodynamics 5,6, and small-for-size syndrome 7. The rat OLT is among the most difficult animal models in experimental surgery and demands advanced microsurgical skills that take a long time to learn. Consequently, the use of this model has been limited. Since the reliability and reproducibility of results are key components of the experiments in which such complex animal models are used, it is essential for surgeons who are involved in rat OLT to be trained in well-standardized and sophisticated procedures for this model.
While various techniques and modifications of OLT in rats have been reported 8 since the first model was described by Lee et al. 9 in 1973, the elimination of the hepatic arterial reconstruction 10 and the introduction of the cuff anastomosis technique by Kamada et al. 11 were a major advancement in this model, because they simplified the reconstruction procedures to a great degree. In the model by Kamada et al., the hepatic rearterialization was also eliminated. Since rats could survive without hepatic arterial flow after liver transplantation, there was considerable controversy over the value of hepatic arterialization. However, the physiological superiority of the arterialized model has been increasingly acknowledged, especially in terms of preserving the bile duct system 8,12 and the liver integrity 8,13,14.
In this article, we present detailed surgical procedures for a rat model of OLT with hepatic arterial reconstruction using a 50% partial graft after ex vivo liver resection. The reconstruction procedures for each vessel and the bile duct are performed by the following methods: a 7-0 polypropylene continuous suture for the supra- and infrahepatic vena cava; a cuff technique for the portal vein; and a stent technique for the hepatic artery and the bile duct.

Orthotopic liver transplantation in rats is an indispensable experimental model for biomedical research. Here we present our surgical procedures for orthotopic rat liver transplantation with hepatic arterial reconstruction using a 50% partial graft.

Orthotopic liver transplantation (OLT) in rats using a whole or partial graft is an indispensable experimental model for transplantation research, such as ...

A Modified Precipitation Method to Isolate Urinary Exosomes

Identification of biomarkers that allow early detection of kidney diseases in urine and plasma has been an area of active interest for several years. Urinary exosome vesicles, 40-100 nm in size, are released into the urine under normal conditions by cells from all nephron segments and may contain protein, mRNA and microRNA representative of their cell type of origin. Under conditions of renal dysfunction or injury, exosomes may contain altered proportions of these components, which may serve as biomarkers for disease. There are currently several methods available for isolation of urinary exosomes, and we have previously conducted an experimental comparison of each of these approaches, including three based on ultracentrifugation, one using a nanomembrane ultrafiltration concentrator, one using a commercial precipitation reagent and one using a modification of the precipitation technique using ExoQuick reagent that we developed in our laboratory. We found the modified precipitation method produced the highest yield of exosome particles, miRNA, and mRNA, making this approach suitable for the isolation of exosomes for subsequent RNA profiling. We conclude that the modified exosome precipitation method offers a quick, scalable, and effective alternative for the isolation of exosomes from urine. In this report, we describe our modified precipitation technique using ExoQuick reagent for isolating exosomes from human urine.

This manuscript describes a protocol for isolating exosomes from human urine using a modified precipitation technique.

Identification of biomarkers that allow early detection of kidney diseases in urine and plasma has been an area of active interest for several years. ...

Human Skeletal Muscle Biopsy Procedures Using the Modified Bergstr&#246;m Technique

The percutaneous biopsy technique enables researchers and clinicians to collect skeletal muscle tissue samples. The technique is safe and highly effective. This video describes the percutaneous biopsy technique using a modified Bergstr&#246;m needle to obtain skeletal muscle tissue samples from the vastus lateralis of human subjects. The Bergstr&#246;m needle consists of an outer cannula with a small opening (&#8216;window&#8217;) at the side of the tip and an inner trocar with a cutting blade at the distal end. Under local anesthesia and aseptic conditions, the needle is advanced into the skeletal muscle through an incision in the skin, subcutaneous tissue, and fascia. Next, suction is applied to the inner trocar, the outer trocar is pulled back, skeletal muscle tissue is drawn into the window of the outer cannula by the suction, and the inner trocar is rapidly closed, thus cutting or clipping the skeletal muscle tissue sample. The needle is rotated 90&#176;&#160;and another cut is made. This process may be repeated three more times. This multiple cutting technique typically produces a sample of 100-200 mg or more in healthy subjects and can be done immediately before, during, and after a bout of exercise or other intervention. Following post-biopsy dressing of the incision site, subjects typically resume their activities of daily living right away and can fully participate in vigorous physical activity within 48-72 hr. Subjects should avoid heavy resistance exercise for 48 hr to reduce the risk of herniation of the muscle through the incision in the fascia.

The purpose of this video is to present the modified Bergstr&#246;m skeletal muscle biopsy technique on human subjects.

The percutaneous biopsy technique enables researchers and clinicians to collect skeletal muscle tissue samples. The technique is safe and highly ...

Assessing Ovarian Reserve in Young Patients Using Z-Scores for Follicle Density

Z-Scores for Assessing Ovarian Reserve in Young Patients Undergoing Fertility Preservation

Women are born with a non-renewable pool of ovarian follicles, referred to as the ovarian reserve. This reserve consists of primordial follicles in the ovaries and can be affected by many factors, such as genetic and endocrine disorders, medical interventions, and endocrine disruptors. Fertility preservation is recommended when gonadotoxic treatments are necessary. The preferred options for women are oocyte and embryo cryopreservation. However, in very young, sexually immature patients, ovarian tissue cryopreservation is the only option. Knowing the follicular density of cryopreserved tissue samples is essential in fertility counseling for young patients. This protocol demonstrates the use of Z-scores for cortical follicle density as a tool to evaluate the quality of ovarian tissue in girls and young women aged 25 years and below who are undergoing fertility preservation. Follicle density in patient samples is compared to age-normalized reference standards, developed by Hassan et al. to estimate possible deviations from the standard. The follicle density is measured through histological quantification. For this, a small piece of ovarian cortical tissue (~2 mm x 2 mm x 2 mm) is fixed in either Bouin&#39;s or formaldehyde solution, embedded in paraffin, sectioned at 4 &#181;m thickness, stained with hematoxylin and eosin, and digitized using a slide scanner. Follicular stages present in the cortex range from primordial to primary follicles. The cortical area was 1 mm from the surface epithelium on histological sections. Follicle density is calculated using a modified formula presented by Schmidt et al., and the Z-score is determined using the reference mean and standard deviation. The Z-score indicates how much the measured value deviates from the reference mean, determining&#160;reduced (&#60;-1.7 Z-score) ovarian reserve. With this method, follicle densities can be used as a valuable measure of ovarian reserve for young patients requiring fertility preservation.

The present protocol describes a method for assessing ovarian reserve in patients under 25 years old who require fertility preservation through ovarian tissue cryopreservation. This method involves: (1) histological assessment of ovarian reserve in cortical samples, (2) comparison to a reference dataset, and (3) calculation of Z-scores.

Women are born with a non-renewable pool of ovarian follicles, referred to as the ovarian reserve. This reserve consists of primordial follicles in the ...

Developmental Biology

Surgical Techniques to Optimize Ovarian Reserve during Laparoscopic Cystectomy for Ovarian Endometrioma

Surgical management of ovarian endometrioma in patients desiring fertility is complicated by the need to balance maximal resection of disease with efforts to spare normal ovarian cortex. Optimization of tubal anatomy is another frequent consideration. Fertility-sparing laparoscopic techniques at the time of cystectomy for ovarian endometrioma seek to limit iatrogenic surgical damage to the ovarian cortex and strategically assess and respond to genital tract patency. Surgical candidates frequently desire relief from endometriosis-associated pain while also seeking to optimize spontaneous or assisted conception rates. Operative benefits include potential for surgical and histopathologic diagnosis of endometriosis, evaluation of genital tract patency, and treatment of visualized lesions. Resection of ovarian endometrioma nonetheless poses significant risks, including surgical injury, blood loss, post-surgical decline in ovarian reserve and post-operative inflammation with adhesion formation, both of which may impair folliculogenesis.
We present the case of a 32-year-old woman with known endometriosis and continued pain refractory to medical management who opted for surgical management of her disease tailored toward optimizing her chances at future conception. Using this case as an example, we describe techniques and considerations for diagnostic laparoscopy, adhesiolysis, ovarian cystectomy, chromopertubation, and salpingectomy with a focus on maintaining a fertility-preserving approach.

This protocol presents techniques to laparoscopically excise ovarian endometrioma, to perform adhesiolysis with sparing electrosurgical application, and to employ intraoperative chromopertubation to assess for genital tract patency. This systematic approach will facilitate optimal endometriosis management, guide concomitant adnexal surgeries, and enhance post-surgical fertility outcomes.

Surgical management of ovarian endometrioma in patients desiring fertility is complicated by the need to balance maximal resection of disease with efforts ...

Fertility Sparing Procedure using Carbon Dioxide Fiber Laser Vaporization of Ovarian Endometrioma

The surgical management of endometrioma is still a matter of debate. Cystectomy, which is recognized as the standard technique, seems to be associated with a potential reduction in the ovarian reserve due to the inadvertent removal and thermal damage of healthy ovarian tissue. New ablative techniques with reduced tissue penetration depth and less thermal spread to the surrounding parenchyma may represent a viable alternative to cystectomy. For these reasons, the aim of this manuscript is to demonstrate the ablation of the endometrioma capsule using a CO2 fiber laser technique and discuss the clinical outcomes. Once the cyst has been drained and washed, a biopsy is taken. After cyst eversion, vaporization of the inner surface of the cyst is performed using a CO2 fiber laser. The technique is simple and reproducible as even young surgeons without any surgical experience were more confident in performing laser CO2 vaporization instead of cystectomy. The positive effects of CO2 technology are reported in a randomized controlled trial, where the postoperative changes in the antral follicular count (AFC) and antimullerian hormone (AMH) levels were compared between patients who had their endometrioma excised (cystectomy) and those who had undergone endometrioma vaporization with CO2 laser. The patients treated with CO2 laser showed significantly increased AFC without a reduction in serum AMH levels as compared to the cystectomy group, in which both parameters were significantly reduced. The postoperative pregnancy rate was also assessed, and comparable pregnancy rates were found after both treatments. On the contrary, patients treated with the CO2 fiber laser technique had more favorable in-vitro fertilization (IVF) outcomes compared to cystectomy.
In conclusion, the CO2 fiber laser technique may represent a viable alternative to cystectomy in the surgical treatment of endometrioma in terms of ovarian preservation, pregnancy rates, and IVF outcomes. Moreover, it has the advantage of being independent of the surgeon's skills and personal experience.

In this protocol, CO2 fiber laser technique is demonstrated for the surgical treatment of ovarian endometriosis, which represents a viable alternative in terms of fertility preservation with the major advantage of not being dependent on the surgeon's skills and personal experience.

The surgical management of endometrioma is still a matter of debate. Cystectomy, which is recognized as the standard technique, seems to be associated ...

Laparoscopic Oocyte Retrieval and Cryopreservation during Vaginoplasty for Treatment of Mayer-Rokitansky-Kuster-Hauser Syndrome

In Mayer-Rokitansky-Kuster-Hauser Syndrome (MRKHS) patients who are scheduled for laparoscopic vaginoplasty and have a desire for biological motherhood, we propose that a concomitant laparoscopic oocyte retrieval for cryopreservation is performed. Oocyte retrieval is pursued at the beginning of the laparoscopy. Right and left 5 mm trocars are positioned, through which a 17 G ovum aspiration needle is used for puncture of the right and left ovaries, respectively. To facilitate exposure of the follicles, the ovaries are mobilized and held with laparoscopic forceps.
When aspirating multiple follicles near each other, the needle tip is retained in the ovary to reduce the number of times that the ovarian cortex is transfixed and due to the inherent risk of bleeding. Subsequent steps are unchanged compared to the Davydov laparoscopic modified technique for vaginoplasty. Prior to surgery, controlled ovarian stimulation is performed with a gonadotropin hormone-releasing hormone (Gn-RH) antagonist protocol, and the concomitant procedure of oocyte retrieval and vaginoplasty is scheduled 36 h after the final follicular maturation trigger. Follicular fluid is collected in the same 10 mL sterile tubes used during transvaginal oocyte retrieval and transferred in a warming block (37 &#176;C) to the assisted reproduction laboratory, where mature (metaphase II) oocytes are vitrified.
In this case, a series of 23 women with MRKH, oocytes were successfully retrieved and cryopreserved in all patients; vaginoplasty was subsequently conducted without modifications, and the inpatient and outpatient postoperative care (day of urinary catheter removal, day of hospital discharge, dilator use, and comfort at follow-up) remained unaffected. One postoperative complication occurred in one patient (fever developing on day 5 post surgery and intraperitoneal fluid detection on transabdominal ultrasound) and resolved after conservative treatment. Rather than performing surgical vaginoplasty and delaying oocyte retrieval in MRKH patients, this approach combines both procedures in a single laparoscopy, thereby minimizing surgical invasiveness and anesthesiologic risks.

A dedicated team can offer Mayer-Rokitansky-Kuster-Hauser patients the option to perform controlled ovarian stimulation and oocyte cryopreservation at the time of laparoscopic vaginoplasty.

In Mayer-Rokitansky-Kuster-Hauser Syndrome (MRKHS) patients who are scheduled for laparoscopic vaginoplasty and have a desire for biological motherhood, ...

Hysteroscopic Technique with Micro-Scissors and Forceps for Polyp Removal

Improved Hysteroscopic Resection of Endometrial Polyps Using 6-Fr Micro-Scissors and Forceps

Endometrial polyps commonly contribute to female infertility, and hysteroscopic resection is the established surgical approach for their treatment. Numerous resection methods are available, with the most used and cost-effective options being cold resection employing micro-scissors or hot resection using an electric loop. However, both methods involve sharp resection, posing a challenge in achieving complete polyp removal while avoiding damage to the uterine endometrium. To address this issue, this study proposes an innovative approach: the combined use of the 6 Fr micro-scissors and forceps under hysteroscopy. The method entails utilizing 6 Fr micro-scissors to initially remove large polyps, followed by using 6 Fr micro-forceps to extract the remaining polyp tissue expeditiously and bluntly near the basal layer of the endometrium. This approach not only prevents surgical damage to the basal layer of the endometrium but also mitigates the risk of residual polyps resulting from incomplete resection. This method is particularly suitable for women with fertility requirements, offering additional considerations for the selection of treatment options for endometrial polyp resection.

Author Spotlight: A Reproductive Hysteroscopy Approach for Complete Endometrial Polyp Removal and Enhanced Endometrial Receptivity

The novel technique presented here employs a combination of 6-Fr micro-scissors and forceps for hysteroscopic treatment of endometrial polyps, demonstrating encouraging outcomes for infertile patients afflicted with this condition.

Endometrial polyps commonly contribute to female infertility, and hysteroscopic resection is the established surgical approach for their treatment. ...

Introduction of Intracapsular Rotary-cut Procedures (IRCP): A Modified Hysteromyomectomy Procedures Facilitating Fertility Preservation

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