43. Transvaginal Resection of a Rectovaginal Mass

Abstract

<h3>Background</h3> Extragonadal teratomas are histologically similar to gonadal teratomas but arise from structures outside of the ovaries and testes, typically along midline structures such as the coccyx, mediastinum, retroperitoneum, and brain. Retroperitoneal teratomas specifically make up 2-5% of pediatric teratomas. Though surgery is curative, it can be technically challenging with high rates of complications including hemorrhage requiring blood transfusion and injury to other organs including the gastrointestinal tract and urinary system. We present the case of a retroperitoneal teratoma of the pelvis that was successfully resected through a transvaginal approach. Though adult case reports have been published using this approach for rectal masses, to our knowledge it has not been used for pediatric cases of rectovaginal masses. <h3>Case</h3> 15 year old G0 female presented to the emergency room with symptoms of acute viral gastroenteritis and incidentally found to have a cystic mass in the inferior left pelvis on ultrasound during workup. Further evaluation of the mass with pelvic MRI demonstrated a 5.8 cm non-enhancing cyst in the rectovaginal space causing significant mass effect on the vagina. Pediatric surgery and pediatric gynecology were consulted for resection. Pediatric surgery initially attempted resection laparoscopically via dissection of the sigmoid colon from the abdominal sidewall to allow for retroperitoneal access. Due to deep retroperitoneal location of the mass, our pediatric gynecologic surgeon attempted a transvaginal approach. Incision of the lateral vaginal wall allowed for access to the mass, which was bluntly dissected from surrounding tissue and removed through the vagina. The cyst incidentally ruptured during removal, with sebaceous fluid noted. The operating space was irrigated and the vagina was closed in two layers. Pathology was consistent with dermoid cyst without evidence of malignancy. The patient recovered well after surgery and is scheduled for surveillance pelvic ultrasound every 6 months to evaluate for recurrence. Her initial follow up ultrasound was normal. <h3>Comments</h3> This case demonstrates a successful transvaginal approach for a rectovaginal teratoma in the pelvis, the first to our knowledge in a pediatric patient. This approach may decrease the risk of surgical complications from retroperitoneal dissection for masses that are low in the pelvis.