Percutaneous Cryoablation of Symptomatic Abdominal Wall Endometriosis at a Military Treatment Facility

Abstract

Study Objective To describe a case of symptomatic abdominal wall endometriosis treated with cryoablation Design Case report Setting Academic military hospital Patients or Participants A 31 year-old active duty female with one prior cesarean section reported 7 years of cyclic pain at her cesarean scar that was nonresponsive to trigger point injections or oral contraceptives. The pain resolved with leuprolide, however, it was stopped due to intolerable side effects. She was initially scheduled for excision of her abdominal wall endometriosis (AWE), but the procedure was cancelled due to a year-long military deployment. Interventions Two years later the patient presented to our facility with cyclic pain and enlarging cesarean scar mass. An MRI revealed 5.5 × 3.1cm left rectus muscle AWE. General surgery recommended against surgical excision as rectus resection and reconstruction could impact her military readiness with a high risk of medical discharge. Interventional Radiology was consulted and recommended minimally invasive percutaneous cryoablation. Percutaneous cryoablation was performed outpatient under local and moderate sedation with ultrasound- and CT-guidance. Image-guided hydrodissection was used to protect the skin, abdominal wall, and underlying bowel from ice. Appropriate cytotoxic temperatures were monitored and achieved throughout the mass. Periodic CT evaluation confirmed the ablation margin of ice extended just beyond the tumor margin. The patient tolerated the procedure well and was discharged home same-day. Measurements and Main Results Patient noted complete resolution of pain at 6 weeks post-procedure without residual AWE on follow-up MRI. Norethindrone was continued for endometriosis suppression and physical therapy initiated for core strengthening with continued absence of symptoms at 6 months post-procedure. Conclusion Surgical resection of large AWE may not be feasible given the physical demands of military servicewomen. Percutaneous cryoablation provides a minimally invasive and less morbid treatment option with long-term resolution of pain symptoms in this patient.