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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prevalence,+morbidity,+and+current+medical+management+of+uterine+leiomyomas.">Prevalence, morbidity, and current medical management of uterine leiomyomas.</a> International Journal of Gynecology &amp; Obstetrics. 131 (2), 117-122 (2015).</li><li>Wu, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prevalence+and+clinical+significance+of+mediator+complex+subunit+12+mutations+in+362+Han+Chinese+samples+with+uterine+leiomyoma.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+management+of+leiomyomas+for+fertility+or+uterine+preservation.">Surgical management of leiomyomas for fertility or uterine preservation.</a> Obstetrics &amp; Gynecology. 121 (4), 856-868 (2013).</li><li>Donnez, J., Dolmans, M. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Uterine+fibroid+management:+from+the+present+to+the+future.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Analysis+of+hysterectomies+for+patients+with+uterine+leiomyomas+in+China+in+2010.">Analysis of hysterectomies for patients with uterine leiomyomas in China in 2010.</a> International Journal of Gynecology &amp; Obstetrics. 129 (1), 71-74 (2015).</li><li>Cheng, P. J., Duan, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=China's+new+two-child+policy:+maternity+care+in+the+new+multiparous+era.">China's new two-child policy: maternity care in the new multiparous era.</a> BJOG. 123, 7-9 (2016).</li><li>Tinelli, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+myomectomy+focusing+on+the+myoma+pseudocapsule:+technical+and+outcome+reports.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Minimally+invasive+approach+for+myomectomy.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Factors+contributing+to+failure+of+laparoscopic+myomectomy.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Limits+and+complications+of+laparoscopic+myomectomy:+which+are+the+best+predictors?+A+large+cohort+single-center+experience.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Italian+multicenter+study+on+complications+of+laparoscopic+myomectomy.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+myomectomy:+clinical+outcomes+and+comparative+evidence.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+myomectomy+and+morcellation:+A+review+of+techniques,+outcomes,+and+practice+guidelines.">Laparoscopic myomectomy and morcellation: A review of techniques, outcomes, and practice guidelines.</a> Best Practice &amp; Research: Clinical Obstetrics &amp; 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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Does+the+surgical+approach+used+for+myomectomy+influence+the+morbidity+in+subsequent+pregnancy.">Does the surgical approach used for myomectomy influence the morbidity in subsequent pregnancy.</a> Journal of Obstetrics &amp; 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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pregnancy+outcomes+following+different+surgical+approaches+of+myomectomy.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Development+and+evaluation+of+an+improved+laparoscopic+myomectomy+adopting+intracapsular+rotary-cut+procedures.">Development and evaluation of an improved laparoscopic myomectomy adopting intracapsular rotary-cut procedures.</a> European Journal of Obstetrics &amp; 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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+management+of+uterine+leiomyomas.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Fibroids+(uterine+myomatosis,+leiomyomas).">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+epidemiological+profile+of+hysterectomy+in+rural+Chinese+women:+a+population-based+study.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Minimally+invasive+surgical+techniques+versus+open+myomectomy+for+uterine+fibroids.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Angiogenesis+and+Vascularization+of+Uterine+Leiomyoma:+Clinical+Value+of+Pseudocapsule+Containing+Peptides+and+Neurotransmitters.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+management+of+neurovascular+bundle+in+uterine+fibroid+pseudocapsule.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pregnancy+outcome+after+laparoscopic+myomectomy.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+descriptive+analysis+of+the+indications+for+caesarean+section+in+mainland+China.">A descriptive analysis of the indications for caesarean section in mainland China.</a> BMC Pregnancy Childbirth. 14, 410 (2014).</li><li>Weibel, H. 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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 a...

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.

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			<td height="42" style="height:42px;width:231px;">laparoscopy</td>
			<td style="width:95px;">Stryker Corporation</td>
			<td style="width:119px;">&#160;X 800</td>
			<td style="width:167px;"></td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:231px;">morcellator</td>
			<td style="width:95px;">Kangji Medical</td>
			<td style="width:119px;">&#160;KJ-301A</td>
			<td></td>
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			<td height="42" style="height:42px;width:231px;">30-cm 1-0 polyglyconate unidirectional barbed thread</td>
			<td style="width:95px;">Covidien</td>
			<td style="width:119px;">V-Loc 180</td>
			<td></td>
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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 ...

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 ...

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9.7K Views.  Peking University Shenzhen Hospital, China. Here, we present a protocol for performing an intracapsular rotary-cut procedure (IRCP), a modified laparoscopic intracapsular myomectomy that promotes fertility preservation.

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 ...

Improvement of a Closed Chest Porcine Myocardial Infarction Model by Standardization of Tissue and Blood Sampling Procedures

Myocardial ischemia reperfusion (I/R) injury contributes to almost half of the necrotic area after myocardial infarction. To date there is no approved drug to prevent or reduce myocardial I/R injury. The study and understanding of the pathophysiological mechanisms of myocardial I/R injury is essential to develop successful treatments. Large animal experiments are an important step in translational methods. The porcine model of acute myocardial infarction has been established and described by ourselves and others. We aimed to further improve the value of the model by focusing in detail on the sampling techniques for use in future experiments. Furthermore, we emphasize small but important steps that can affect the quality of the final results. To mimic the clinical situation of myocardial I/R injury, a percutaneous coronary intervention (PCI) catheter was inserted into the left anterior descending coronary artery (LAD) of an anesthetized pig. &#176;&#176;&#176;This model mimics acute myocardial infarction and PCI treatment in humans with the possibility of accurately determining the area at risk as well as the necrotic- and viable ischemic tissue. Here the model was used to investigate the effect of a bicyclic peptide inhibitor of FXIIa. The model can also be modified to allow longer reperfusion times to study later effects of myocardial infarction.

Here we demonstrate a protocol to standardize sampling procedures of an established porcine model of acute myocardial infarction in order to increase its translational value in the understanding of the pathophysiology of myocardial ischemia/reperfusion injury and to test novel drug candidates.

Myocardial ischemia reperfusion (I/R) injury contributes to almost half of the necrotic area after myocardial infarction. To date there is no approved ...

Preparation, Procedures and Evaluation of Platelet-Rich Plasma Injection in the Treatment of Knee Osteoarthritis

Knee osteoarthritis (KOA) is one of the most frequently encountered diseases in the orthopedic department. Existing non-surgical treatments have a limited effect on the repair of cartilage and on bone regeneration. Platelet-rich plasma (PRP) is an autologous bioactive substance that can repair cartilage injury and accelerate bone regeneration effectively. However, reporting of PRP preparation protocols in clinical studies is highly inconsistent, with the majority of studies providing insufficient information to allow the protocol to be reproduced. We describe a repeatable method of preparing PRP visually, the treatment of KOA using PRP intra-articular injection, and methods of evaluating the outcome. PRP was prepared using manual double centrifugation. The PRP layer was extracted from peripheral blood and used for knee joint cavity injection. Evaluations included assessments of blood platelet concentrations and clinical outcomes. Preparation of PRP by manual centrifugation requires less apparatus and is less costly than plasma filtration or centrifugation using equipment. The centrifugation time of our double centrifugation method was 6 and 5 minutes for the respective centrifugations at forces of 800 and 1400 x g, respectively, to allow for the consistent preparation of standardized PRP. However, a manual method is susceptible to operator error, and PRP batch preparation is not available. Intra-articular injection of PRP proved to be an effective treatment for knee osteoarthritis. The entire treatment procedure took less than 30 minutes, the blood platelet concentration of PRP could be standardized, and treatment was proven to be effective when evaluated by follow-up.

Knee osteoarthritis is frequently seen in the orthopedic department. We introduce in detail the entire knee osteoarthritis treatment process with platelet-rich plasma injection, including preparation, procedures, and evaluation.

Knee osteoarthritis (KOA) is one of the most frequently encountered diseases in the orthopedic department. Existing non-surgical treatments have a limited ...

Use of Magnetic Resonance Imaging and Biopsy Data to Guide Sampling Procedures for Prostate Cancer Biobanking

Previous methods for biobanking prostate tissue, following radical prostatectomy, generally involved random sampling. In order to increase efficiency, and enable a greater range of downstream applications, a more targeted method of sampling prostate tissue was developed. Here we use both magnetic resonance imaging (MRI) and biopsy data to target specific areas of the organ for sampling. The method involves use of a previously published prostate slicing device which removes a 5 mm transverse slice from a predetermined region of the prostate, followed by the removal of 6 mm punch biopsies from predetermined areas of this slice. These samples can be stored frozen or fixed for biobanking purposes, or used fresh immediately with 70% confidence of tumor content, as compared with 10% confidence from the random sampling approach. This enables the use of all standard downstream techniques such as genomics, proteomics or histological work, but also work that requires fresh tissue such as live tissue imaging or ex vivo culture.

This method involves utilization of clinical diagnostic data for prostate cancer patients in order to guide sampling procedures, when biobanking tissue following radical prostatectomy. This overcomes issues with previously published methods around efficiency and availability of fresh tissue for a wider range of downstream applications.

Previous methods for biobanking prostate tissue, following radical prostatectomy, generally involved random sampling. In order to increase efficiency, and ...

Fertility Preservation Through Oocyte Vitrification: Clinical and Laboratory Perspectives

Preserving female fertility is crucial in a multifunctional healthcare system that takes care of patients' future quality of life. Oocyte cryopreservation is recognized by several international scientific societies as the gold standard for fertility preservation in postpubertal women, for both medical and non-medical indications. The main medical indications are oncologic diseases, gynecologic diseases such as severe endometriosis, systemic diseases compromising the ovarian reserve, and genetic conditions involving premature menopause. This paper describes the whole clinical and laboratory work-up of a fertility preservation treatment by outlining recommendations for objective and evidence-based counseling. Furthermore, it focuses on the effectiveness of the procedure and describes the most appropriate strategies to fully exploit the ovarian reserve and maximize the number of oocytes retrieved in the shortest possible time. The evaluation of the ovarian reserve, the definition of an ideal stimulation protocol, as well as oocyte retrieval, denudation, and vitrification procedures have been detailed along with approaches to maximize their efficacy, efficiency, and safety.

Oocyte cryopreservation is recognized by several international scientific societies as the gold standard for fertility preservation in postpubertal women. Appropriate clinical and laboratory strategies ensure maximum efficacy, efficiency, and safety of fertility preservation treatments.

Preserving female fertility is crucial in a multifunctional healthcare system that takes care of patients' future quality of life. Oocyte cryopreservation ...

Fertility Preservation in Patients with Severe Ovarian Dysfunction

Ovarian function progressively declines during aging and in some pathophysiological conditions including karyotype abnormality, autoimmune diseases, chemo- and radiation-therapies, as well as ovarian surgeries. In unmarried women with severe ovarian dysfunction, fertility preservation is important for future pregnancies. Although oocyte cryopreservation is an established method for fertility preservation, these patients could only preserve a limited number of oocytes even after ovarian hyperstimulation, leading to repeated stimulations to ensure sufficient oocytes to guarantee future pregnancy. To solve this issue, we have recently developed a drug-free in vitro activation (IVA) procedure, which enable us to stimulate early stages of ovarian follicles to develop to the preantral follicle stage. These preantral follicles can respond to the unique protocol of gonadotropin stimulation, resulting in increased number of retrieved oocytes per ovarian stimulation for cryopreservation. The drug-free IVA comprised from the surgical approach and ovarian stimulation. We removed a part of cortex from one or both ovaries from patients under laparoscopic surgery. The ovarian cortical tissues were cut into small cubes to disrupt the Hippo signaling pathway and stimulate the development of early stage follicles. These cubes were grafted orthotropically into remaining ovaries as well as beneath the serosa of both Fallopian tubes. We have already published the surgical procedure of the drug-free IVA and the protocol of subsequent ovarian stimulation, but herein we present the details of laboratory methods required for drug-free IVA.

We present details of laboratory procedures for drug-free in vitro activation (IVA) of ovarian follicles for patients with severe ovarian dysfunction. This method could increase the number of retrievable oocytes per ovarian hyperstimulation and benefit fertility preservation for those patients.

Ovarian function progressively declines during aging and in some pathophysiological conditions including karyotype abnormality, autoimmune diseases, ...