Total laparoscopic hysterectomy in combination with dilation and evacuation of an 18-week–sized uterus with gestational trophoblastic neoplasia: a novel treatment approach

Abstract

Gestational trophoblastic disease is a spectrum that includes complete and partial hydatidiform moles, invasive mole, choriocarcinoma, and placental site trophoblastic tumor. Although most cases of gestational trophoblastic neoplasia occur after a molar pregnancy, it can develop after any pregnancy. Suction curettage remains the standard first-line management in a molar pregnancy in patients desiring fertility. However, hysterectomy is a reasonable option in patients that do not desire to preserve fertility. Hysterectomy for gestational trophoblastic neoplasia can be difficult because of the enlarged uterus and prominent uterine vasculature. Traditionally, hysterectomy for gestational trophoblastic neoplasia is usually performed via laparotomy. In this article and accompanying video, we describe and illustrate a minimally invasive technique that demonstrates a safe and feasible laparoscopic removal of an enlarged uterus and illustrates alternative extraction techniques to avoid laparotomy in hysterectomy for gestational trophoblastic disease. In this case, a combination of laparoscopic transection of the vascular pedicles followed by dilation and evacuation was used before colpotomy. The addition of dilation and evacuation allowed us to reduce the overall size of the uterus and remove it intact through the vagina with minimal bleeding, avoiding unnecessary laparotomy. This allowed the patient to have an improved postsurgical recovery experience with minimal blood loss compared with standard laparotomy for gestational trophoblastic neoplasia.