Why is the fetus not rejected as foreign tissue? The maternal and fetal immune systems temporarily coexist; both are precisely tuned to detect and reject foreign invasion and yet somehow achieve a symbiotic relationship. This mutual state of tolerance is obviously critical for carrying pregnancy to full term. Two active arms of the immune system maintain protection of the host: the first of these involves a humoral immune system in which foreign tissue invokes an antibody response by recognition of antigenic surfaces by the B-cell, the second arm involves cell-mediated immunity in which T-cells and natural killer (NK) cells seek out and destroy foreign tissue. Several mechanisms are thought to invoke the immune tolerance of the fetus. These include: absence of major histocompatibility complex (MHC)-I antigens, presence of unique human lymphocyte antigen (HLA) surface molecules, nonspecific reduction of systemic immunoreactivity, possible role of blocking antibody, expressions of complement regulatory proteins, and factors of locally reduced immunoreactivity. Ultimately, developing regimens to control these elements in the clinical setting may help us overcome preterm labor, infertility, and preeclampsia. Available evidence regarding immune tolerance of the human fetus, integrated into a workable model, and focused at an overview level are systematically reviewed in this article.

This randomized, prospective study was performed to compare 2 techniques used to reduce the size of an enlarged uterus before vaginal hysterectomy or laparoscopically assisted vaginal hysterectomy (LAVH). Thirty patients scheduled to undergo vaginal hysterectomy or LAVH were randomized to have uterine reduction performed using either bisection/morcellation (group I, n ϭ 14) or myometrial coring (group II, n ϭ 16). The 2 groups were comparable in clinical and demographic characteristics, including preoperative uterine size, operating times, surgical outcomes, and use of laparoscopic assistance. There were no conversions to laparotomy and no major perioperative complications. The uterus was successfully removed in all cases. The uterus weighed more than 280 g in 81% of the patients in group I (bisection/morcellation) and in 73% of the patients in group II (myometrial coring). There were no significant differences between the 2 groups in operative details except for the rate of extraction failure. In 4 patients (25%) in group II, myometrial coring failed to reduce the size of the uterus, necessitating the use of the bisection/morcellation technique to complete the operation. All reduction attempts were successful in group I (P ϭ 0.06 for difference). Blood loss and transfusion rate were similar in both groups (3 transfusions required in group I and 2 in group II). Postoperative data were similar in both groups with the exception of a greater number of patients with postoperative fever (28%) among those who had myometrial coring compared with bisection/morcellation (P ϭ 0.03). Most uterine characteristics were similar in women in whom uterine reduction with myometrial coring was or was not successful. However, myometrial coring failure occurred more often when the uterus was narrow (68.3 Ϯ 2.3 mm) compared with wide (83.9 Ϯ 9.6 mm; P ϭ 0.01) and less often in uteri heavier than 280 g. EDITORIAL COMMENT(There are many advantages to vaginal hysterectomy, and the skilled gynecologic surgeon will find the vaginal approach in the patient with an enlarged uterus both challenging and, hopefully, satisfying. However, there are several ad-vanced surgical techniques that are required to facilitate the removal of an enlarged uterus. In this article, Nazah and his colleagues from Paris compared bisection and morcellation with myometrial coring in a prospective, randomized, GYNECOLOGY Volume 59, Number 2 OBSTETRICAL AND GYNECOLOGICAL SURVEY ABSTRACT At the Mayo Clinic, vulvar vestibulitis is treated with vestibulectomy consisting of simple excision of the vulvar vestibule as described by Bornstein and Kaufman. The authors conducted a review of the medical records of their patients who underwent vestibulectomy between 1986 and 2002, and identified 45 who met the definition of vestibulitis described by Friedrich: 1) focal, reproducible points in the vestibule exquisitely tender to light touch; 2) coincident focal area of erythema; and 3) a history of superficial dyspareunia or severe pain on attempted vaginal entry. In addition, a ...

Castleman disease should be included in the differential diagnosis in patients with paraneoplastic symptoms and a pelvic mass.

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