44: Vaginal cyst presenting as pelvic organ prolapse

Abstract

The purpose of this video is to describe an unusual case of a large vaginal cyst presenting as pelvic organ prolapse and to demonstrate techniques for vaginal reconstruction. A 47-year-old gravida 4 para 2 presented with pelvic fullness, which she thought was prolapse. On pelvic exam, a 4-centimeter cystic mass was located on the posterior vagina and protruded past the hymen. Magnetic resonance imaging showed a 3.5 x 2.8 x 3.8 cm posterior vaginal wall cyst without solid components, septations, nodularity, or other suspicious features. The patient desired corrective surgery, so she underwent vaginal excision of the cyst. When in the operating room, exam under anesthesia confirmed the posterior vaginal wall mass. There was no evidence of pelvic floor prolapse. The vaginal mucosa overlying the cyst was incised. Allis clamps were placed on the mucosal edges bilaterally to provide traction. The cyst wall was sharply dissected off the vaginal mucosa. During the dissection, the cyst cavity was entered and a large amount of fluid was expulsed. The cyst was completely excised from the underlying tissue. The rectovaginal fascia was reinforced and plicated with interrupted 2-0 absorbable sutures. The posterior vaginal mucosa was trimmed and re-approximated with a running locking 2-0 absorbable suture. Hemostasis was ensured along the suture line. Rectovaginal exam confirmed no injury to the rectum. The patient was discharged home in a stable condition. Pathology demonstrated a benign simple cyst and benign vaginal mucosa without dysplasia. She was seen for a postoperative visit, at which time there was a healing but intact suture line along the posterior vaginal mucosa. It is important to include vaginal cysts in the differential diagnosis of pelvic organ prolapse. Vaginal removal and reconstruction can be performed successfully.