Adnexal Cysts Research Articles

Laparoendoscopic single-site surgery for acute adnexal pathology during pregnancy: preliminary experience

Objective: To report the feasibility of laparoendoscopic single port surgical approach for the management of huge adnexal cysts and adnexal torsion during pregnancy. To discuss the optimal method of entry into the peritoneal cavity for pregnant patients.Design: Two case report.Method and patient(s): Two pregnant patients with adnexal mass. First patient, suffering from persistent and progressive abdominal distention and pain on her 12th week of pregnancy, was diagnosed with an ovarian cyst in 18 cm diameter on left ovary. The other patient had IVF twin pregnancy and presented with left adnexal torsion on the 25th week of pregnancyIntervention(s): Single-port laparoscopic ovarian cystectomy on the 12th week of pregnancy in patient one and single-port left adnexectomy in a twin pregnancy on the 25th week of pregnancy in patient two.Main outcome measure(s): Feasibility of single port laparoscopic intervention during pregnancy for adnexal mass.Result(s): Complete resolution of the symptoms for both pregnant women after the surgeries. No fetal and maternal complication was diagnosed during both pregnancies.Conclusion(s): Single port laparoscopy with open-entry technique is feasible and might be a better surgical option for the pregnant patients with adnexal pathology. However, further studies with larger sample size are needed to reach clear conclusion.

Unilocular adnexal cysts with papillary projections but no other solid components: is there a diagnostic method that can classify them reliably as benign or malignant before surgery?

To develop a logistic regression model for discrimination between benign and malignant unilocular solid cysts with papillary projections but no other solid components, and to compare its diagnostic performance with that of subjective evaluation of ultrasound findings (subjective assessment), CA 125 and the risk of malignancy index (RMI). Among the 3511 adnexal masses in the International Ovarian Tumor Analysis (IOTA) database there were 252 (7%) unilocular solid cysts with papillary projections but no other solid components ('unilocular cysts with papillations'). All had been examined with transvaginal ultrasound using the IOTA standardized research protocol. The ultrasound examiner had also classified each mass as certainly or probably benign, unclassifiable, or certainly or probably malignant. A logistic regression model to discriminate between benignity and malignancy was developed for all unilocular cysts with papillations (175 tumors in the training set and 77 in the test set) and for unilocular cysts with papillations for which the ultrasound examiner was not certain about benignity/malignancy (113 tumors in the training set and 53 in the test set). The gold standard was the histological diagnosis of the surgically removed adnexal mass. A model containing six variables was developed for all unilocular cysts with papillations. The model had an area under the receiver-operating characteristics curve (AUC) on the test set of 0.83 (95% CI, 0.74-0.93). The optimal risk cut-off, as defined on the training set (0.35), resulted in sensitivity 69% (20/29), specificity 79% (38/48), positive likelihood ratio (LR +) 3.31 and negative likelihood ratio (LR-) 0.39 on the test set. The corresponding values for subjective assessment when using the ultrasound examiner's dichotomous classification of the mass as benign or malignant were 97% (28/29), 79% (38/48), 4.63 and 0.04. A model containing four variables was developed for unilocular cysts with papillations for which the ultrasound examiner was not certain about benignity/malignancy. The model had an AUC of 0.74 (95% CI, 0.60-0.88) on the test set. The optimal risk cut-off of the model, as defined on the training set (0.30), resulted in sensitivity 57% (12/21), specificity 78% (25/32), LR + 2.61 and LR- 0.55 on the test set. The corresponding values for subjective assessment were 95% (20/21), 78% (25/32), 4.35 and 0.06. CA 125 and RMI had virtually no diagnostic ability. Even though logistic regression models to predict malignancy in unilocular cysts with papillations can be developed, they have at most moderate performance and are not superior to subjective assessment for discrimination between benignity and malignancy.

Expectant management of adnexal masses in selected premenopausal women: a prospective observational study

To evaluate the results of expectant management of ovarian cysts with benign ultrasound morphology in selected asymptomatic premenopausal women. This was a prospective cohort study of premenopausal women diagnosed with a persistent adnexal cyst. Patients were selected according to symptoms (asymptomatic), the cyst's appearance on ultrasound (benign) and size (< 8 cm). Patients underwent a follow-up protocol with transvaginal ultrasound examination at 6-monthly intervals for 2 years and then annually for at least 3 years. The study comprised 166 women (mean age, 40 years) with 192 masses present at inclusion. Twenty-two women (with 29 masses) were lost to follow-up. Seventy-four masses (38.5%) resolved spontaneously (median time from diagnosis to resolution, 40 months). Forty-nine masses (25.5%) persisted without change (median follow-up time, 88 (range, 36-192) months). Forty masses (20.8%) were surgically removed; 12 because of increase in size, four because a second lesion appeared during follow-up, three because of change in appearance and increase in size, five because of surgery for uterine benign or malignant disease, two because of change in appearance without increase in size, one because of clinical suspicion of ovarian torsion and 13 because of the patient's decision in spite of there being no change in the mass. Histology was benign in all but two cases (Stage Ia mucinous ovarian carcinoma and Stage Ia mucinous borderline tumor). During follow-up 40 new masses in 31 women were diagnosed, of which 21 resolved spontaneously, five (all with benign histology) were surgically removed and 14 were still present at the time of writing. Expectant management of cysts with benign ultrasound morphology is a management option in selected asymptomatic premenopausal women.

Laparoscopic management of pedicle torsion of adnexal cysts

Pedicle torsion of adnexal cysts results from the increased weight of cysts, longer length of the ovarian and suspensory ligaments or ovarian teratoma. Color doppler ultrasonography is particularly important for detecting suspected cyst torsion. Laparoscopy is becoming more important in the early diagnosis and treatment of adnexal cyst torsion due to its advantages, such as its minimally invasive nature, reduced acute stress reaction and facilitation of direct observation of intra-abdominal lesions. The present study analyzed 28 cases of laparoscopic torsion surgery. The laparoscopic conservative surgery rate was 75% and loss of endocrine function and fertility was avoided. Since the torsion duration is the only variable factor for avoiding oophorectomy, laparoscopic exploration should be performed as soon as possible when pedicle torsion of an adnexal cyst is suspected. Detorsion while retaining ovarian function did not increase the risk of thromboembolism and laparoscopic surgery was minimally invasive with faster recovery times and minimal impact on fertility. Furthermore, the study showed that the laparoscopic management of pedicle torsion of adnexal cysts is safe and reliable with the retention of ovarian endocrine and reproductive function.

Recommendations for Adnexal Cysts

In 2009, the Society of Radiologists in Ultrasound (SRU) convened a consensus conference to discuss the management of adnexal cysts in asymptomatic women and reach consensus on when follow-up imaging was required. The purpose of this quality assurance project was to assess the impact of using the resulting guidelines in our institution during 1-month periods before and after publication of the guidelines. We retrospectively reviewed all pelvic ultrasound reports for a 1-month period before the conference (February 2009) and 2 years later (February 2011) after publication of the SRU guidelines. Incidence of recommendations for simple cysts and classic hemorrhagic cysts 5 cm or less in premenopausal women and simple cysts less than 1 cm in postmenopausal women was compared. Fisher exact test was used to compare proportions. Over the time period evaluated, the number of pelvic sonograms performed in our department decreased by 27%. The overall number of cysts with recommendations for follow-up decreased from February 2009 (132 studies with recommendations for follow-up in 870 pelvic ultrasound examinations, 15%) to February 2011 (71 recommendations for follow-up in 639 examinations, 11%; P = 0.02). The percentage of premenopausal simple cysts and classic hemorrhagic cysts described as less than 5 cm where follow-up was recommended decreased from 39/48 (89%) to 2/29 (7%, P < 0.0001). Use of the SRU guidelines on the management of adnexal cysts has, in our practice, dramatically decreased radiologist recommendations for follow-up of benign appearing cysts.

Congenital pouch colon in a girl associated with bilateral atresia of cervix uteri and uterus didelphys

This report describes a girl with congenital pouch colon (CPC), uterus didelphys with septate vagina, and a cloacal anomaly. The girl underwent cloacal reconstruction at the age of 15 months. Subsequently, at puberty, the child had primary amenorrhea with severe cyclic abdominal pain due to endometriosis of both the uteruses and adnexal cysts with hematometra and hematosalpinx. Laparotomy with removal of both uteri and the left fallopian tube was performed. Both uteri had atresia of the cervix uteri. This report emphasizes the need for comprehensive evaluation and a long-term management strategy for associated gynecologic anomalies in girls with CPC, especially with regard to patency of the outflow tract.

Jednostronne cysty proste przydatków u kobiet w wieku menopauzalnym – problem diagnostyczno-terapeutyczny

ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Fuchs T, Grobelak K, Pomorski M, Woytoń R, Tomiałowicz M, Zimmer M. Unilateral and unilocular adnexal cysts in postmenopausal women: a diagnostic and therapeutic problem. Menopause Review/Przegląd Menopauzalny. 2013;12(2):115-119. doi:10.5114/pm.2013.35066. APA Fuchs, T., Grobelak, K., Pomorski, M., Woytoń, R., Tomiałowicz, M., & Zimmer, M. (2013). Unilateral and unilocular adnexal cysts in postmenopausal women: a diagnostic and therapeutic problem. Menopause Review/Przegląd Menopauzalny, 12(2), 115-119. https://doi.org/10.5114/pm.2013.35066 Chicago Fuchs, Tomasz, Krzysztof Grobelak, Michał Pomorski, Robert Woytoń, Marek Tomiałowicz, and Mariusz Zimmer. 2013. "Unilateral and unilocular adnexal cysts in postmenopausal women: a diagnostic and therapeutic problem". Menopause Review/Przegląd Menopauzalny 12 (2): 115-119. doi:10.5114/pm.2013.35066. Harvard Fuchs, T., Grobelak, K., Pomorski, M., Woytoń, R., Tomiałowicz, M., and Zimmer, M. (2013). Unilateral and unilocular adnexal cysts in postmenopausal women: a diagnostic and therapeutic problem. Menopause Review/Przegląd Menopauzalny, 12(2), pp.115-119. https://doi.org/10.5114/pm.2013.35066 MLA Fuchs, Tomasz et al. "Unilateral and unilocular adnexal cysts in postmenopausal women: a diagnostic and therapeutic problem." Menopause Review/Przegląd Menopauzalny, vol. 12, no. 2, 2013, pp. 115-119. doi:10.5114/pm.2013.35066. Vancouver Fuchs T, Grobelak K, Pomorski M, Woytoń R, Tomiałowicz M, Zimmer M. Unilateral and unilocular adnexal cysts in postmenopausal women: a diagnostic and therapeutic problem. Menopause Review/Przegląd Menopauzalny. 2013;12(2):115-119. doi:10.5114/pm.2013.35066.

The Auto-Amputated Adnexa: A Review of Findings in a Pediatric Population

Study ObjectiveTo quantify our experience and that of the literature with diagnosis and management of the auto-amputated adnexa in a pediatric population. DesignCase series and literature review. SettingTertiary care medical center. ParticipantsCase series of pediatric patients (<18 years of age) with surgically documented adnexal auto-amputation collected from our medical center and the literature. InterventionsNone. Main Outcome MeasureAuto-amputated adnexa. ResultsIn addition to the 3 cases discussed from our institution, 91 cases of auto-amputated adnexa were identified in the literature dating back to 1943, for a total of 94 cases. Forty-nine percent (46/94) of the cases involved girls in a pediatric population (<18 years of age). Of these, the majority (n = 26) were identified in a subgroup of girls who were diagnosed with an adnexal cyst by antenatal ultrasound. Most of these neonates were asymptomatic at birth or had a palpable abdominal mass (n = 6) and at the time of surgical exploration were found to have an auto-amputated adnexa. 34 out of 46 cases were analyzed in detail. The right adnexa were involved in 56% of the cases. The most common presenting complaint verbalized by the older girls was pain; however, 8 cases were identified in asymptomatic girls undergoing unrelated diagnostic testing. ConclusionThe auto-amputated adnexa is a rare finding in the pediatric population, but it must be considered as a possible explanation for the incidental finding of absence of the fallopian tube or ovary in the subgroup of patients who undergo surgery for any reason. Patients with an antecedent history of pelvic pain either chronic or intermittent in nature may be diagnosed with torsion or less frequently auto-amputation of the adnexa. A fetal “pelvic mass” or “ovarian cyst” may predispose the adnexa to torsion and subsequent auto-amputation either in-utero or post-delivery. Many of these antenatally diagnosed cysts and even subsequent auto-amputations are completely asymptomatic, however, and do not compromise fertility assuming the contralateral adnexa are normal. Thus expectant management is appropriate for small (less than 4 cm), asymptomatic simple cysts and even suspected auto-amputated adnexa in an asymptomatic patient.

A Minimally Invasive Approach to Laparoscopic Surgery for Large Adnexal Cysts With a Multichannel Port Using a Wound Retractor

This study explored and evaluated the feasibility and safety of laparoscopy with a multichannel port using a wound retractor for large adnexal masses. Seven patients scheduled to undergo single-port or 2-port laparoscopy for large adnexal cysts were enrolled. The cystic mass surface was exposed by inserting the wound retractor through the umbilical port, and cystic fluid was aspirated using a suction-irrigation system after puncture with an Ochsner trocar. Then, laparoscopic adnexal surgery was performed in the usual manner. The mean maximal diameter of cysts, mean operation time, and mean postoperative hospital stay were 17.8 ± 5.4 cm, 81.3 ± 28.2 minutes, and 4.4 ± 2.0 days, respectively. Use of multichannel ports for large adnexal cystic masses seems safe and does not require additional cost. The procedure is also cosmetically effective and highly appreciated by patients, because it results in minimal abdominal scarring.

Spontaneous splenic vein bleeding during pregnancy: consequences of a missed diagnosis

To the Editor: Spontaneous splenic vein bleeding is a rare complication during pregnancy. In a recent case, it mimicked premature labor [1] or a twisted adnexal cyst and remained undiagnosed until the cesarean section was already underway. A woman at 32 weeks gestation presented with a 1-h history of abdominal pain. She also had a left adnexal dermoid cyst. Upon admission, her vital signs were: pulse 114/min, blood pressure (BP) 119/87 mmHg, temperature 36 C, hemoglobin 11.9 g/dl, white cell count 19.44 9 10/L, and blood oxygen saturation (SpO2) 98 % breathing room air, and she was mentally alert. The fetus was in satisfactory condition. Obstetric ultrasound scan was normal. Tocolytic treatment and pethidine had no effect on pain relief. Six hours after her admission, a category II emergency cesarean section was performed due to her abdominal pain. The patient was slightly tachycardiac on arrival at the operating room (pulse 114/min); however, no other feature of hypovolemia was present. The tachycardia was assumed to be due to abdominal pain. She was unable to lie flat for the induction of general anesthesia and, as there was no obvious contraindication, spinal anesthesia was administered in the left lateral position. The spinal block was effective, and the abdominal pain was relieved, but her hemodynamics became very unstable. A normal fetus was delivered but the patient was suffering from severe bleeding. An extensive laparotomy under general anesthesia revealed a spontaneous splenic vein bleed. Hemostasis was achieved without splenectomy. Blood loss of 3 L resulted in a hemoglobin drop to 5.5 g/dl because cross-matched blood products were not readily available due to the exclusion of hemorrhage in the differential diagnosis. Her postoperative course remained uneventful. Spontaneous bleeding during pregnancy can arise from utero-ovarian vessels or distant sources, such as the splenic, hepatic, superior mesenteric, or celiac arteries [2, 3]. Arterial bleeds are dramatic, with rapid cardiovascular collapse [2]. Venous bleeding may be dramatic [3] or may present only with subtle features of hemoperitoneum. Spontaneous bleeding, including splenic bleeding, is a rare complication during pregnancy, so it can be misdiagnosed because the ‘‘eyes do not see what the mind does not know’’. Sudden-onset abdominal pain of uncertain origin in a parturient should raise the suspicion of non-obstetric abdominal pathology, e.g., spontaneous abdominal bleeding, and should be evaluated appropriately such as with a computed axial tomography (CT). Parturients do not show obvious features of hypovolemia unless 30–40 % of blood volume is lost. Failure to recognize such a condition is dangerous for anesthetic intervention. The responsibility for diagnosis in such cases may rest primarily on obstetricians, but anesthesiologists are equally responsible for identifying such a potentiality. Ultimately, it is the anesthesiologist who is responsible for ensuring patient safety. This case report is presented with written consent of the patient. M. Ajmal Department of Anesthesia, Letterkenny General Hospital, Letterkenny, Ireland

The economic implications of unsuspected findings from CT urography performed for haematuria

We set out to determine the prevalence of unsuspected findings from CT urography (CTU) performed for haematuria and to evaluate the economic implications associated with the subsequent management of these findings. We analysed the results of 778 consecutive CTU scans performed in a haematuria clinic between 2008 and 2010. We excluded cases where diagnosis of an abnormality had been made prior to CTU. Costs incurred during the follow-up of unsuspected findings were calculated following guidance set out in the NHS Costing Manual 2009/10. 778 CTU scans were performed for patients attending a haematuria clinic from 2008 to 2010. 455 men and 323 women underwent CTU scan; they had a median age of 62 years. 56% of scans were found to have unexpected extra-urinary findings (587 abnormalities in 439 scans). Common findings included diverticular disease (138, 17.7%), adrenal masses [85, 10.9%; 40 (5.1%) of which were indeterminate], lung abnormalities (67, 8.6%), gall bladders containing calculi (44, 5.7%), adnexal cysts (25, 7.7% of women) and aortic aneurysms (18, 2.3%). These findings led to a total of 136 outpatient appointments, 88 radiological investigations and 11 procedures (4 of which were major). The overall cost incurred was £47,366, or £60 per patient. CTU is associated with a high rate of unsuspected findings. There is an economic implication to performing CT scanning in this setting, in which further unanticipated investigation and treatment cost is approximately £60 per patient.

Paraneoplastic vasculitis with digital necrosis: a rare presentation of advanced ovarian cancer

We report an interesting case of a rare presentation of ovarian cancer. A 64-year-old woman attended the Accident and Emergency department with a complaint of sudden onset of ‘‘painful, cold and blue fingers’’ (see Fig. 1). On further questioning, she revealed symptoms of myalgia and malaise. Several nail fold infarcts were also noticed. She was found to have a tense distended abdomen; however, no obvious masses were felt. She was referred to a Rheumatologist who carried out a battery of tests for autoimmune vasculitis, which were negative. A pelvic ultrasound revealed moderate ascites and a right sided complex adnexal cyst measuring 4.7 9 5.2 cm. Tumour marker serum CA-125 was raised at over 800 U/ mL and ascitic fluid sent for cytology showed cells suspicious of adenocarcinoma of the ovary. Subsequently, CT scan was carried out which revealed the adnexal mass with ascites and extensive omental as well as peritoneal seedlings. During the course of her admission, her vasculitis became more prominent. She was commenced on a short course of oral prednisolone therapy which resulted in symptomatic relief but did not resolve the vasculitis. The clinical presentation with sudden onset of ‘‘painful, cold and blue fingers’’, negative immunological tests and advanced ovarian malignancy led us to the diagnosis of digital vasculitis affecting the fingers secondary to a paraneoplastic phenomenon. She received six cycles of chemotherapy with carboplatin which resulted in good biochemical and radiological response, with a drop in CA125 to 55 U/mL. The symptoms of digital vasculitis also showed improvement and appeared to resolve completely by the time of third cycle of chemotherapy, further raising the suspicion that the paraneoplastic syndrome is caused by an ovarian tumour. The patient underwent debulking surgery and the vasculitis remained stable during the subsequent course of her treatment without relapse. The first report on the association of digital ischaemia and carcinoma was by O’Connor in 1884. He observed a correlation between breast cancer and gangrenous fingertips [1]. The prevalence of paraneoplastic syndromes associated with ovarian cancer is estimated in the order of only one in 1,000 [2]. With regard to the pathogenesis, induction of vasculitis by antibodies to tumour antigens is proposed as a likely method of paraneoplastic phenomenon [3]. The other pathogenesis could be digital vasospasm caused by sympathetic hyperactivity and digital artery obstruction due to increased blood coagulation associated with malignancy, hyperviscosity and arteritis [4]. Some paraneoplastic syndromes are also idiopathic. While investigating a patient with paraneoplastic vasculitis, apart from the haematological tests, immunological and serological investigations are of the utmost importance. Although the imaging studies required will depend on the individual presentation, the following tests may be of value: chest and sinus radiographs, echocardiograph, upper limb arteriography, ultrasound of abdomen and pelvis, erect abdominal X-ray, abdominal and pelvis CT. Biopsy of the digit or biopsy of the underlying malignancy should be considered [1, 5]. The aim of the treatment is to alleviate symptoms of ischaemia, prevent progression and to treat underlying cause. Although the symptoms of digital ischaemia may improve with medical therapies, definite benefits have been S. Robati K. Razvi K. Madhavan K. Gajjar (&) Department of Obstetrics and Gynaecology, Southend University Hospital NHS Foundation Trust, Westcliff on Sea, Essex, UK e-mail: gajjarkb@yahoo.co.uk

Tamoxifeno y tumoraciones anexiales complejas en paciente trasplantada renal con carcinoma in situ de mama

Tamoxifen is a selective modulator of estrogen receptors and is used to reduce recurrence and mortality rates in breast cancer patients with positive hormone receptors. This drug acts as an estrogen receptor agonist in the ovaries and endometrium and can produce some adverse effects. We report the case of a breast cancer patient, who was premenopausal until the beginning of the treatment and who developed bilateral complex adnexal cysts, requiring a diagnostic laparoscopy to exclude a new oncologic process in the ovaries. The patient had previously received a kidney transplant for nephropathy and immunosuppressive therapy. We review the literature on the topic and evaluate the possible associations between these processes.

Minimally invasive management of huge ovarian cysts by laparoscopic extracorporeal approach

Laparoscopy has been widely performed in adnexal surgery for benign masses. For large adnexal masses, laparoscopy has not been commonly used and laparotomy remains the gold standard due to several technical difficulties in the former, including a limited surgical field, risk of unintended cyst rupture during the insertion of the Veress needle or trocar, and the possibility of malignancy. Recent advances in laparoscopic techniques have offered acceptable options for performing laparoscopy in patients with very large adnexal cysts. We performed ovarian cystectomy of huge ovarian cysts via a laparoscopic extracorporeal approach through an umbilical single-site incision, successfully minimizing the possibility of cyst contents leaking into the peritoneal cavity. Use of a single-site incision at the umbilicus for huge adnexal cystic masses appears safe and spares the additional costs of using conventional surgical instruments. It is also cosmetically effective and highly appreciated by patients because it results in minimal abdominal scarring.

A randomised controlled trial comparing surgical intervention rates between two protocols for the management of asymptomatic adnexal tumours in postmenopausal women

IntroductionDetection of asymptomatic adnexal tumours in postmenopausal women has increased due to wider use of diagnostic ultrasound and imaging quality improvements. Reliable methods to differentiate between benign and malignant tumours...

Keyless Abdominal Rope-lifting Surgery (KARS)

Keyless Rope-lifting Surgery (KARS) is a novel, single incision, gasless laparoscopic surgery technique. Various operations including adnexal cyst excision, oophorectomy, diagnostic laparoscopy, tubal ligation, hysterectomy and cholecystectomy may be performed through the intra-umbilical transverse incision without using CO2 pneumoperitoneum and thus the trocars (keyless). In KARS the abdominal cavity is accessed through the 1.5-2 cm intra-umbilical transverse incision. The anterior abdominal wall is elevated by the sutures loaded into the Veress cannula. The elevation creates room for the operations. All operations are performed through the intra-umbilical incision by using laparoscopic and/ or conventional hand instruments. Here in this paper, the KARS technique and the preliminary results of the specific gynecological procedures are presented.

Regional Differences in the Use of Hysterectomy

Removal of the uterus, one of the standard procedures in surgical gynecology, is currently in the throes of dynamic development. Only 15 years ago numerous diseases of the uterus were treated by means of hysterectomy, but the situation has now changed dramatically. Whereas earlier the uterus was resected to manage large myomas, menstrual disorders, symptomatic uterine prolapse, and of course cancer, this is no longer the case. The transformation is largely due to the trailblazing work of one gynecologist, Professor Kurt Semm of Munich, a pioneer of laparoscopic surgery who introduced minimally invasive techniques in gynecological surgery (1). Where he led, other branches of surgery then followed. Let us remember that Kurt Semm was the surgeon who performed the very first laparoscopic appendectomy (2). Minimally invasive surgery has led to a new approach to hysterectomy and supported many women in their desire to preserve their uterus. As described in a new epidemiological study by a team led by Professor Andreas Stang (3), the rate of hysterectomy in Germany in 2005 and 2006 was still much higher than in Scandinavia, but lower than in the USA. Naturally a survey like this represents a snapshot. To the authors’ great credit, they point out that hysterectomy is by no means the surgical answer to all problems. Nevertheless, more precise analysis would have permitted further-reaching conclusions. Had the authors evaluated the proportion of organ-sparing operations for myoma or adnexal cysts, for example, their figures might have looked quite different. A wider picture would have been more instructive. A key message of the study is that across Germany the hysterectomy rate is lowest in the city-state of Hamburg and highest in Mecklenburg–West Pomerania, a state covering a large area. This shows that the use of modern techniques is increasing in urban areas that feature a high concentration of centers offering minimally invasive surgery. Evaluation of the data from other large cities such as Dusseldorf, Hannover, Frankfurt and Munich would probably have shown the same picture as in Hamburg. The situation is most likely similar for other innovations such as ultrasound treatment and embolization of myomas; the latter procedure, however, restricts fertility. The reason for these differences among the federal states of Germany is certainly that minimally invasive surgery has not spread to all areas. In my own experience, this is even more true for the USA. We now know that radical hysterectomy (Wertheim’s operation) is not obligatory even in a patient with a small cervical carcinoma who still wants children. A successful outcome can be achieved by transvaginal trachelectomy according to Dargent (4) or even by a completely endoscopic procedure (5). When such surgery is followed by lymphadenectomy the uterus can be spared, and various studies have reported substantial conception rates (6).

Fallopian tube torsion caused by extremely large Morgagni hydatid: A very rare cause of acute abdomen in a virgin adolescent

Abstract

ADENEXAL CYSTS

Objectives: (1) To evaluate the risk of malignancy in surgically removed ovarian cysts that was before the operation neither simple nor complex. (2) To determine the relationship of age with type of ovarian tumour. (3) To categorize the management of these cases according to the intra-operative findings. (4) To analyze the occurrence of various histopathological types of tumour. Date Source: Medline Study Design: Single centered prospective descriptive study of 150 cases. Place and Duration of Study: Department of Obstetrics and Gynaecology at Shaikh Zayed Hospital Lahore from 1st July 2005 to,31st December 2006. Subject and method: 150 patients presented with adnexal cysts on preoperative ultrasonography, peroperative findings and histopathology reports. These patients were followed up in OPD. Results: Showed the distribution of non-neoplastic and neoplastic tumours which were 84% and 16% respectively. The occurrence of malignancy increased with advancing age especially after 45 years Common presentations were lower abdominal pain (53%) followed by menstrual disturbances (30%), abdominopelvic mass, abdominal distension and infertility. Risk of malignancy also increased with parity. 73% masses were unilateral, 84% benign masses were unilocular whilst 85% malignant masses were echogenic and the complex cysts with papillary projection and multiloculations showed 3-6 times higher risk of malignancy. Most patients were managed by exploratory laparotomy. Cystectomy and total abdominal hysterectomy were the commonest procedures performed. Regarding histopathologic evaluation 40% patients had tumours, 2.66% borderline malignancy and 13.3% malignant. 44% had non-neoplastic lesions. Serous and endometriotic cysts were the commonest benign histopathologic types and among malignant ones, epithelial ovarian tumours were the leading variants. Conclusions: Preoperative characterization of adnexal masses using sonographic and demographic data may have considerable potential in determining risk of malignancy and may be advantageous in terms of counseling patients for management.

Incidental Necrotizing Paratubal Granuloma Associated with Multiple Neoplasms

Abstract Background: This article reports a case of unusual association of inflammatory and neoplastic diseases of the female genital organs, emphasizing identification of the origin of the necrotizing granulomatous lesion. Case: The authors report the case of a necrotizing granulomatous lesion in the paratubal soft tissue in a 49-year-old woman with serous borderline cystadenoma of the left adnexal cyst and bilateral ovarian metastases from invasive mucinous adenocarcinoma of the gallbladder. Conclusions: The presence of a granulomatous reaction is always a diagnostic dilemma for clinicians who have to establish the cause of the granuloma. (J GYNECOL SURG 27:29)