- Email: [email protected]
Adenomyosis presenting as an adnexal mass after laparoscopic myomectomy
International Journal of Gynecology & Obstetrics 65 Ž1999. 75]76
Brief communication
Adenomyosis presenting as an adnexal mass after laparoscopic myomectomy Ludovico Muzii, Antonino Monaco, Vincenzo Vavala `U Department of Obstetrics and Gynecology, Ospedale degli Infermi, Biella, Italy Received 19 May 1998; received in revised form 30 September 1998; accepted 16 October 1998
Keywords: Laparoscopy; Myomectomy; Complications
Laparoscopic myomectomy has recently been reported as a valid alternative to conventional myomectomy by laparotomy w1x. However, cases of uterine rupture in subsequent pregnancies have been reported after laparoscopic myomectomy w2]4x, and concerns have been raised regarding the gestational capability after this procedure. We report here a symptomatic complication after myomectomy by laparoscopy occurring in a nonpregnant patient. A 27-year-old woman, gravida 0, para 0, was referred to our Institution for clinical evidence of an adnexal mass associated with infertility and pelvic pain. Eighteen months earlier, the patient had elsewhere undergone laparoscopy for infertility. A single 2 = 2 cm intramural-subserous myoma on the posterior wall, approximately 2 cm below and medially to the left horn, was excised laparoscopi-
U
Corresponding author. Tel.: q39 15 3503563, fax: q39 15 3503545.
cally. Apparently, the endometrial cavity had not been entered. After bipolar coagulation of the myoma bed, the uterine incision was repaired with a single figure-of-eight stitch. At the end of the procedure, bilateral tubal patency was observed at methylene blue dye injection. No dye spillage was seen at the site of the repaired uterine incision. During subsequent follow-up for continuing infertility, a left adnexal mass was suspected at clinical examination eighteen months later. Ultrasonography demonstrated the presence of a complex mass, 8 = 5 = 4 cm, with a 5 = 4 cm echogenic core surrounded by a transonic component, in the left adnexal area ŽFig. 1.. No continuity of the mass with the uterine wall could be demonstrated, and the mass was presumed to be ovarian. CA 125 serum level was 77.9 UIrml. Given the preoperative sonographic findings and CA 125 levels, it was decided to proceed to laparotomy. At laparotomy, the suspected adnexal mass was instead a peduncolated mass exactly in the same
0020-7292r99r$20.00 Q 1999 International Federation of Gynecology and Obstetrics. PII: S 0 0 2 0 - 7 2 9 2 Ž 9 8 . 0 0 2 2 3 - 9
76
L. Muzii et al. r International Journal of Gynecology & Obstetrics 65 (1999) 75]76
applying sutures at laparoscopy can determine tissue necrosis, and sutures applied in this necrotic tissue sometimes could not hold. Moreover, the weak uterine repair could be a preferential way for the colonization by the endometrium, thus determining the possible formation of adenomyomas, as in the present case. The presumed safety of laparoscopic myomectomy in patient not desiring future pregnancies is questioned. Continuing surveillance of what should be still considered a new approach to a traditional surgical procedure is warranted. References Fig. 1. Preoperative transvaginal ultrasonogram showing the complex appearance of the pelvic mass in the left adnexal area.
area of the previous myomectomy. The mass had an external capsule containing clear-brown fluid, and a central, solid core. The large pedicle was resected and no direct continuity of the mass with the endometrium was evident. Pathology diagnosis was adenomyosis. Laparoscopic uterine repair after myomectomy is cumbersome and time-consuming even in the hands of the experienced surgeon. Extensive use of electrocoagulation on the myometrium before
w1x Mais V, Ajossa S, Guerriero S, Mascia M, Solla M, Melis GB. Laparoscopic versus abdominal myomectomy: a prospective, randomized trial to evaluate benefits in early outcome. Am J Obstet Gynecol 1996;174:654]658. w2x Harris WJ. Uterine dehiscence following laparoscopic myomectomy. Obstet Gynecol 1992;80:545]546. w3x Dubuisson JB, Chavet X, Chapron C, Gregorakis SS, Morice P. Uterine rupture during pregnancy after laparoscopic myomectomy. Hum Reprod 1995;10: 1475]1477. w4x Friedmann W, Maier RF, Luttkus A, Schafer APA, Dudenhausen JW. Uterine rupture after laparoscopic myomectomy. Acta Obstet Gynecol Scand 1996;75: 683]684.
Brief communication
Adenomyosis presenting as an adnexal mass after laparoscopic myomectomy Ludovico Muzii, Antonino Monaco, Vincenzo Vavala `U Department of Obstetrics and Gynecology, Ospedale degli Infermi, Biella, Italy Received 19 May 1998; received in revised form 30 September 1998; accepted 16 October 1998
Keywords: Laparoscopy; Myomectomy; Complications
Laparoscopic myomectomy has recently been reported as a valid alternative to conventional myomectomy by laparotomy w1x. However, cases of uterine rupture in subsequent pregnancies have been reported after laparoscopic myomectomy w2]4x, and concerns have been raised regarding the gestational capability after this procedure. We report here a symptomatic complication after myomectomy by laparoscopy occurring in a nonpregnant patient. A 27-year-old woman, gravida 0, para 0, was referred to our Institution for clinical evidence of an adnexal mass associated with infertility and pelvic pain. Eighteen months earlier, the patient had elsewhere undergone laparoscopy for infertility. A single 2 = 2 cm intramural-subserous myoma on the posterior wall, approximately 2 cm below and medially to the left horn, was excised laparoscopi-
U
Corresponding author. Tel.: q39 15 3503563, fax: q39 15 3503545.
cally. Apparently, the endometrial cavity had not been entered. After bipolar coagulation of the myoma bed, the uterine incision was repaired with a single figure-of-eight stitch. At the end of the procedure, bilateral tubal patency was observed at methylene blue dye injection. No dye spillage was seen at the site of the repaired uterine incision. During subsequent follow-up for continuing infertility, a left adnexal mass was suspected at clinical examination eighteen months later. Ultrasonography demonstrated the presence of a complex mass, 8 = 5 = 4 cm, with a 5 = 4 cm echogenic core surrounded by a transonic component, in the left adnexal area ŽFig. 1.. No continuity of the mass with the uterine wall could be demonstrated, and the mass was presumed to be ovarian. CA 125 serum level was 77.9 UIrml. Given the preoperative sonographic findings and CA 125 levels, it was decided to proceed to laparotomy. At laparotomy, the suspected adnexal mass was instead a peduncolated mass exactly in the same
0020-7292r99r$20.00 Q 1999 International Federation of Gynecology and Obstetrics. PII: S 0 0 2 0 - 7 2 9 2 Ž 9 8 . 0 0 2 2 3 - 9
76
L. Muzii et al. r International Journal of Gynecology & Obstetrics 65 (1999) 75]76
applying sutures at laparoscopy can determine tissue necrosis, and sutures applied in this necrotic tissue sometimes could not hold. Moreover, the weak uterine repair could be a preferential way for the colonization by the endometrium, thus determining the possible formation of adenomyomas, as in the present case. The presumed safety of laparoscopic myomectomy in patient not desiring future pregnancies is questioned. Continuing surveillance of what should be still considered a new approach to a traditional surgical procedure is warranted. References Fig. 1. Preoperative transvaginal ultrasonogram showing the complex appearance of the pelvic mass in the left adnexal area.
area of the previous myomectomy. The mass had an external capsule containing clear-brown fluid, and a central, solid core. The large pedicle was resected and no direct continuity of the mass with the endometrium was evident. Pathology diagnosis was adenomyosis. Laparoscopic uterine repair after myomectomy is cumbersome and time-consuming even in the hands of the experienced surgeon. Extensive use of electrocoagulation on the myometrium before
w1x Mais V, Ajossa S, Guerriero S, Mascia M, Solla M, Melis GB. Laparoscopic versus abdominal myomectomy: a prospective, randomized trial to evaluate benefits in early outcome. Am J Obstet Gynecol 1996;174:654]658. w2x Harris WJ. Uterine dehiscence following laparoscopic myomectomy. Obstet Gynecol 1992;80:545]546. w3x Dubuisson JB, Chavet X, Chapron C, Gregorakis SS, Morice P. Uterine rupture during pregnancy after laparoscopic myomectomy. Hum Reprod 1995;10: 1475]1477. w4x Friedmann W, Maier RF, Luttkus A, Schafer APA, Dudenhausen JW. Uterine rupture after laparoscopic myomectomy. Acta Obstet Gynecol Scand 1996;75: 683]684.