Cystic Pelvic Mass Research Articles

Approach to the postnatal sonographic evaluation of prenatally detected abdominopelvic cysts.

Prenatally detected abdominal and pelvic masses are commonly cystic in morphology and usually seen on mid-trimester sonography. Sonography is the favored imaging modality for the postnatal evaluation of these lesions in newborns, given its availability, low cost, lack of ionizing radiation, lack of sedation, and high spatial resolution in small patients. The differential diagnosis of abdominopelvic cystic masses in newborns is broad given that they can arise from many organs and may have overlapping features on imaging. This article illustrates an approach to the postnatal sonographic evaluation of prenatally detected cystic abdominal and pelvic masses based on their anatomic location and distinctive sonographic characteristics, which can aid in an accurate diagnosis and guide appropriate management.

ABDOMEN ULTRASONOGRAPHIC EXAMINATION ANALYSIS IN THE CASE OF URINARY BLADDER DIVERTICULA AT CILEGON HOSPITAL

ABSTRACT
 Diverticulum is outpouching of hollow (or fluid-filled) structures, which can form in various organs in the body. Increased intravesical pressure (3-5 times) causes the bladder mucosa to infiltrate itself between the bladder muscle bundles which results in the development of extravasational sacs or saccules which subsequently results in diverticulum formation. The sonographic diagnosis of bladder diverticula depends on the demonstration of communication between the bladder and the mass. When such communication, or estuary, is not seen during ultrasound examination, the bladder diverticulum can look like any other type of cystic pelvic mass.
 The approach used is descriptive qualitative. This study aims to analyze the examination of the USG Abdomen with clinical bladder diverticula to get an appropriate picture of USG so that the diagnosis can be established. The study population was patients who performed an abdominal USG examination at the Cilegon Regional General Hospital. The sample of this study were 1 (one) patient. The method used in collecting data in this study is observation, documentation, and literature study.
 Keywords: Ultrasound, Urinary Bladder, Diverticula

Prenatal diagnosis of persistent cloaca accompanied by uterus didelphys: A case report.

Persistent cloaca is a rare abnormality that occurs usually in females and is characterized by direct communication between the gastrointestinal, urinary, and genital structures resulting in a single perineal opening. We report a case of persistent cloaca accompanying uterus didelphys that was diagnosed antenatally with fetal ultrasonography. A gravida 3, para 2, 35-year-old women at 22 weeks of gestation was referred to our hospital with a diagnosis of moderate pyelectasis of the fetal kidneys and fetal diffuse intestinal dilation. Detailed ultrasound scan findings were reported as a small thick-walled septated cystic pelvic mass of 5.2×5.5 cm size seen at the level of the fetal pelvic region. The target sign could not be visualized, it was considered as anal atresia. In the following weeks, the patient, who was evaluated together with meconium on the uterine septum, and monitoring of the neighboring bladder and anal atresia, was diagnosed as having persistent cloaca. Ultrasound findings showed that it could be persistent cloaca accompanying uterus didelphys. The fetus postnatally manifested persistent cloaca. On the first day after vaginal delivery, pelvic ultrasound in the neonatal intensive care unit showed bilateral 2nd-degree hydronephrosis, presacral enlarged bowel loops, uterus didelphis, vaginal septum, direct contact between urethra and vagina, proximal end in the rectum compatible with atresia. On the second day, colostomy was performed. Her renal condition continued to be stable. She is now waiting for definitive surgery for cloaca. Persistent cloaca should be considered in any female fetus presenting with hydronephrosis and a cystic pelvic mass lesion as diagnosed by ultrasound. Prenatal diagnosis allows time for parental counseling and delivery planning at a tertiary hospital for neonatal intensive care and pediatric surgery.

Prenatale echografische diagnose van een cloacale malformatie

Prenatal ultrasound diagnosis of a cloacal malformation Cloacal malformations are a spectrum of rare congenital disorders caused by the arrest of the cloacal division during different stages in early embryogenesis. They necessitate critical intervention at birth, posing important surgical challenges. The majority unfortunately remains undetected during prenatal screening. Knowledge about sonographic red flags, however, may improve antenatal detection and therefore postnatal outcome as a result of a timely referral to multidisciplinary tertiary centers. A 29-year-old patient presents at the hospital due to decreased fetal movements in the third trimester of pregnancy. The ultrasound reveals an anechoic bilobed cystic mass with a thick midline septum within the pelvis of a female fetus. The diagnosis of a cloacal anomaly with associated duplicated vaginas and uteri is made. Severe accumulation of urine lies at the base of bilateral hydrocolpos, peritoneal ascites and a urinary tract obstruction with an adverse influence on both pulmonary and renal development. The baby is prematurely delivered by an emergency caesarean section. Her condition is poor, requiring immediate respiratory resuscitation. An explorative laparotomy on the following day confirms the diagnosis. The first steps towards anatomical correction are taken. It may be concluded that the triad of bilateral hydronephrosis, a pelvic cystic mass and an absent normal bladder within a female fetus should always raise suspicion of a cloaca.

Ultrasound and alternative multimodality imaging of intra-abdominal and pelvic cystic masses in the newborn.

Introduction: Ultrasound is used commonly to detect and diagnose intra-abdominal and pelvic cystic masses in the newborn as it is easily available, relatively low cost, and non-invasive. Discussion: The diagnosis can be made or narrowed down by determining the location, size, sonographic features, organ involvement, and internal vascularity. The differential diagnoses include hydronephrosis, multicystic dysplastic kidney, adrenal haemorrhage, cystic teratomas, ovarian cysts, enteric cysts, meconium cysts, and liver haemangiomas. With the appropriate radiological knowledge, the ultrasound practitioner can help obtain an accurate diagnosis. Conclusion: This pictorial essay will familiarise the reader with the different common causes of intra-abdominal and pelvic masses detected on ultrasound through a wide range of conditions. The role of ultrasound in the evaluation of these conditions will be discussed and alternative imaging correlates will be offered.

Paratubal giant serous cystadenoma: case report

Çoğunlukla asemptomatik embriyolojik kalıntı olarak karşımıza çıkan paratubal kistler genellikle üreme çağında tanı alırlar. Genellikle küçük boyutlarda olan bu kistler insidental olarak saptanırlar. Çok nadiren komplike olarak cerrahi gerektirebilir. Bu makalede kliniğimizde tedavi ettiğimiz 17 yaşında 30x25x10 cm boyutlarındaki pelvik kitle tanılı vakayı sunmayı amaçladık. Laparatomi ile kist eksizyonu uygulanan hastadan 5 kg ağırlıkta paratubal kist çıkarıldı. Histopatolojik değerlendirmede paratubal seröz kistadenom tanısı konulan hasta şifa ile taburcu edildi. Sonuç olarak nadirde olsa çok büyük boyutlarda basit görünümlü kistik pelvik kitlelerde paratubal seröz kistadenom tanısı akılda tutulmalıdır.

Management of a Utero-Paravaginal Fistula: A Case Report

Study Objective We present the case of a utero-paravaginal fistula noted in a patient with primary infertility and a history of a bicornuate uterus who had previously undergone multiple gynecologic surgical procedures. Design Case report. Setting A tertiary care center. Patients or Participants N/A Interventions N/A Measurements and Main Results A 28 y/o G0 with primary infertility associated with a bicornuate uterus presented to our office for evaluation after obtaining an ultrasound and MRI which showed a normal left hemiuterus but a right cystic pelvic mass consistent with a distended uterine horn with extensive blood within it. She had previously undergone several surgical procedures in Brazil, one of which was labeled a Strassman procedure. She was taken to the OR for hysteroscopy and laparoscopy where hysteroscopy revealed a small uterine septum but otherwise normal appearing endometrial cavity and laparoscopy revealed a normal appearing uterus and endometriosis that was resected. She subsequently developed a pelvic abscess in what appeared to be the lower uterine segment suggestive of an isthmocele. Pelvic abscess was drained, and subsequent CT hysterosalpingogram was performed which revealed a utero-paravaginal fistula. Three months after her infection, she returned to the OR for utero-paravaginal fistula repair. Postoperatively she did well and sonohystogram performed 3 months post-operatively has shown no residual defect. Conclusion This is the only case in the literature we could find where this type of utero-paravaginal fistula is described. Given her extensive surgical history, it is likely this is a result of previous surgical intervention. We highlight the use of CT hysterosalpingogram to document the nature of the fistula and aid us in subsequent repair.

Robotic-Assisted Resection of Ovarian Remnant Causing Pelvic Pain

Study Objective To demonstrate the safe and effective excision of an ovarian remnant in the face of extensive pelvic adhesion. Design Surgical video presentation. Setting Academic tertiary care center. Patients or Participants This is a 46 year old patient G7P5025 patient with a history of chronic pelvic pain. Her past surgical history is significant for a total abdominal hysterectomy followed by a right salpingo-oophorectomy 8 years later for an ovarian cyst. Her right salpingo-oophorectomy surgery was complicated by an enterotomy with injury to the sigmoid colon due extensive pelvic adhesive disease. Interventions Preoperative pelvic ultrasound and MRI revealed a large left sided cystic pelvic mass as well as aright adnexal mass suspicious for an ovarian remnant. Intraoperatively, extensive pelvic adhesions were noted as well as the large cytic pelvic mass and an ovarian remnant attached to the right pelvic side wall. A left oophorectomy was performed and the right ovarian remnant was excised after extensive ureterolysis. Measurements and Main Results After the above interventions normal anatomy was restored to the pelvis. Pathologic evaluation confirmed right ovarian cortical tissue. At her 6 months follow up visit the patient had significant resolution of her pelvic pain. Conclusion Surgical removal of an ovarian remnant can be quite challenging and has risks of injury to the ureters, bladder and bowel. With good surgical technique using the laparoscopic/robotic platform, safe and effective excision of ovarian remnant can be achieved; affording a favorable outcome for patients.

Laparoendoscopic Single-Site Surgery for Management of Tubo-Ovarian Abscess After Hymenectomy for Imperforate Hymen

Background: A tubo-ovarian abscess is a potential late complication after hymenectomy for imperforate hymen, especially when complicated with hematosalpinx. Laparoendoscopic single-site (LESS) surgery for management of tubo-ovarian abscess after hymenectomy has never been reported. Case: A 17-year-old virgin girl without a menarchal flow was referred due to a large pelvic cystic mass. With a diagnosis of an imperforate hymen with right hematosalpinx, an uneventful hymenectomy was performed for this patient. Six weeks later, she presented with lower-abdominal pain and febrile morbidity. Results: Antibiotics administration was initiated with the diagnosis of a right tubo-ovarian abscess. After failed medical management, LESS surgery was performed. Under laparoscopic observation, a severe pelvic adhesion around swollen right adnexal tissue was noted. After extensive adhesiolysis, a right salpingo-oophorectomy was performed, and the patient's postoperative course was uneventful. Conclusions: After hymenectomy for imperforate hymen with hematosalpinx, careful follow-up should be done to detect any secondary ascending pelvic infection leading to a tubo-ovarian abscess. LESS surgery may be a feasible minimally invasive option for managing a tubo-ovarian abscess with potential cosmetic benefits.

2531 A Bloody Mess: A Rare Cause of Ascites From a Different Field of Medicine

INTRODUCTION: After exclusion of a traumatic etiology, the development of progressive bloody ascites in a patient usually portends an ominous diagnosis. We present a rare, benign case of progressive bloody ascites due to a gynecologic cause. CASE DESCRIPTION/METHODS: A 40 yo healthy African American lady presented with 3 months of worsening abdominal enlargement and nausea. Physical exam and CT scan of the abdomen revealed massive ascites but were otherwise normal. Bloodwork showed a Hgb of 5.7 gm/dL, and normal PLT. Ferritin level, liver panel, hepatitis and HIV studies were all normal. Paracentesis showed 26,000 RBCs, 88 nucleated cells, 79 cholesterol crystals in pigmented macrophages, a SAAG of 0.5, a fluid protein of 5.5 g/dL, and negative cytology. Further testing showed a negative quantiferon-gold along with a normal CEA level and ANA. A CA-125 was mildly elevated at 82 U/mL. CT scan post-paracentesis showed diffusely thickened peritoneum without nodularity, and a 5 cm right pelvic cystic mass. Diagnostic laparoscopy found 4L bloody ascites and complete fibrotic abdominal structure encasement. Peritoneal biopsies and right oophorectomy showed endometriosis. She was treated with a high dose steroid taper and leuprolide with resolution of her ascites. DISCUSSION: Our case is one of a few reports describing endometriosis inducing encapsulating peritoneal sclerosis (EPS), and is the first to show asymptomatic endometriosis as the etiology. (EPS) is a syndrome of intestinal obstruction from diffuse thickened peritoneum. Typical symptoms are intermittent abdominal pain with nausea and vomiting related to the intermittent obstruction and reduced gut motility. Symptoms average 3.9 years before diagnosis. Primary EPS is extremely rare and while secondary EPS is usually due to chronic peritoneal dialysis (PD). Other causes include malignancy, infections, and various rheumatologic conditions. Management is based on the offending cause (e.g., stopping PD) but is largely empiric, based on case reports and series utilizing prednisolone and/or tamoxifen.

OHVIRA syndrome in an infant girl

Obstructed hemivagina and ipsilateral renal agenesis (OHVIRA) is a rare congenital urogenital anomaly, which usually presents after menarche. We report a 3-month-old infant who presented with recurrent urinary tract infections (UTI) and had an abdominal lump. Radiological investigations revealed absent right kidney, hydronephrotic left kidney, and a cystic pelvic mass. Exploratory laparotomy revealed hydrometrocolpos which was evacuated. During 1-year follow-up, hydronephrosis decreased, there were no further UTI, and kidney function remained normal. Our case illustrates that OHVIRA syndrome may present in early infancy with UTI, renal anomalies, and pelvic mass.

Prenatal Diagnosis of Cloacal Anomalies: An Analysis of Pattern of Presentation with Emphasis in Males

AbstractThe objectives of the study were to recognize the ultrasound findings and describe the pattern and spectrum of cloacal anomalies in prenatal life with special attention to pattern recognition in males. This study included a retrospective cohort analysis over 3 years. Of the 14 cases suspected prenatally, the diagnosis was confirmed by fetal autopsy in ten and postnatal surgery in two. There were 8 male fetuses, 3 females and 2 in whom sex couldn’t be determined and no information on sex was available in 1 case. The major findings on antenatal ultrasound were abdomino-pelvic mass in 6 (43%), ascites in 6 (43%), oligohydramnios in 12 (86%), hydronephrosis in 3 (21%), renal agenesis in 5 (36%), multi-cystic kidney disease in 4 (29%), non-visualization of bladder in 12 (86%), single umbilical artery in 2 (21%), ambiguity of external genitalia in 5 (36%), cardiac defects in 4 (29%), limb defects in 3 (21%) and spine anomalies in 3 (21%). Prenatal diagnosis of cloacal malformation should be suspected in the presence of a pelvic cystic mass with fluid-debris level and is reinforced when renal anomalies, non-visualization of bladder and anhydramnios accompany. More research is needed to focus on the pattern of presentation in male fetuses.

A hydatic cyst of the appendix mimicking a uterine lateral mass: a case\xa0report

BackgroundHydatic cyst is a zoonotic disease caused by Echinococcus granulosus. It is a public health problem in Tunisia and remains endemic. It occurs in intra-abdominal organs in 10–15% of the cases, particularly in the liver representing the most common affected organ. The aim of the case is to highlight the scarcity of this appendicle origin and to consider it among the differential diagnosis of any intra-abdominal cystic lesion.Case presentationA 45-year-old Tunisian woman, with no past medical history, was admitted for a pelvic cystic mass. The clinical manifestation as well as the imaging findings were toward a lateral uterine mass. Our patient underwent appendectomy and resection of the mass. The patient had no recurrence at 2 years of follow-up.ConclusionsAn extrahepatic hydatid cyst should be recognized among the differential diagnosis of any intra-abdominal cystic lesion. Treatment should be based on surgical excision. Due to the risk of recurrence, a close follow-up is mandatory.

Recurrent Unilateral Gonadoblastoma - A rare histopathological presentation

Gonadoblastoma is a rare benign tumor that has the potential for malignant transformation and affects patients with disorders of sexual development. The exact prevalence of gonadoblastoma is not known. The association of gonadoblastomas with dysgerminoma is seen in 50-60% of cases and with other malignant germ cell tumours like yolk sac tumour, embryonal carcinoma and choriocarcinoma in 10% of cases. We herewith report a rare case of recurrent unilateral gonadoblastoma in a 10 year old Indian male who presented with abnormal passage of urine since birth. Physical examination showed a phenotypic male with undescended right testis and ambiguous external genitalia. Computed tomography scan reported mixed density solid cystic mass in pelvis with peripherally enhancing solid component and a few punctuate foci of calcification. Histo-pathological examination showed a heterogeneous tumor comprising of malignant seminomatous, sertoli and leydig cell tumor along with yolk cell tumor component. Serum alpha fetoprotein was raised to 1210 ng/ml.

A case of Low-grade appendiceal mucinous neoplasm treated with laparoscopic management which was originally diagnosed right cystic adnexal mass

We experienced the case of Low-grade appendiceal mucinous neoplasm treated with laparoscopic management, which was originally diagnosed as a right cystic adnexal mass. The case involved an 81-year old woman had undergone a total abdominal hysterectomy for leiomyoma of the uterus when she was 48 years old. She was refered to our hospital after being diagnosed with a cystic lesion of the pelvis at a local internal medicine clinic, with a dull pain in her right lower abdomen. We suspected a right ovarian cyst, but no conclusive evidence was found, so we performed exploratory laparoscopic operation. We found that the uterus and both adnexa had been extracted, and the cyst was derived from appendix, so we performed appendectomy. We made the diagnosis of a Low-grade appendiceal mucinous neoplasm after pathological examination. Cystic disease in the female pelvis is common. The majority of cystic pelvic masses originate in the ovary, but some other pelvic organs mimic this anomaly. It is important to understand the relationship of the cyst with its anatomic location, to identify normal ovaries at imaging, and to compare the findings with a patient's clinical history to avoid misdiagnosis.

Malignant Pseudo-Meigs Syndrome Presenting as Recurrent Eosinophilic Pleural Effusion

SESSION TITLE: Pulmonary Manifestations of Systemic Disease 3 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Pseudo-Meigs’ syndrome is a clinical syndrome where pleural effusion (PEf) and/or ascites are associated with ovarian tumor other than fibroma. We report a challenging case of pseudo-Meigs’ syndrome associated with ovarian mucinous carcinoma in a patient with recurrent right-sided exudative, eosinophilic PEf without cytologic evidence of malignancy in effusion. CASE PRESENTATION: A 51-year-old woman with a history of chronic lymphedema and venous stasis was admitted to the hospital for acute hypoxemic respiratory failure presenting with shortness of breath for 24 hours. On examination, she was in respiratory distress. Her temperature was 38.1°C; pulse 114 beats/minute; respiratory rate 22 breaths/minute; and oxygen saturation 93% breathing 3L/minute of supplemental oxygen through nasal cannula. Auscultation of the chest revealed crackles in her lower lung fields, pronounced on the right. Laboratory findings include white blood cells 19,500/mm3, erythrocyte sedimentation rate 130 mm/hour, and creatinine kinase 18 U/L. Computed tomography (CT) of the chest showed a large right-sided PEf. 900 mL of exudative fluid was drained by thoracentesis with improvement of symptoms. PEf was remarkable for eosinophilia (17%) with no malignant cells. On day 2 of hospitalization, her shortness of breath recurred. Chest radiograph showed recurrent right sided PEf. Another thoracentesis drained 1000 ml of eosinophilic effusion with no malignant cells. Repeat CT showed no underlying lung pathology. 48 hours later, her symptoms worsened and chest radiograph showed right sided PEf for the third time. Given the recurrent effusion with persistent negative cytology, CT of the abdomen was performed for a possible underlying malignancy. This revealed a large multiloculated cystic pelvic mass extending into the abdomen with omental caking and/or peritoneal carcinomatosis and lymph node involvement. Her labs then revealed CA 125 of 78 U/mL and CEA of 4.8 ng/mL. A debulking surgery was performed, revealing a 27x25x20cm ovarian mucinous carcinoma, histologic type G2: moderately differentiated without other organ involvement. Peritoneal ascetic fluid and lymph nodes were negative for malignancy. Three days later, 1000mL was drained via thoracentesis with cytology negative for malignant cells. 17 days later, follow up chest radiograph showed persistent effusion, however the fourth thoracentesis drained only 150 cc, and she remained asymptomatic. DISCUSSION: Recurrent right-sided exudative eosinophilic PEf, even without the presence of malignant cells, may be a marker for underlying malignancy when no obvious lung pathology is found. CONCLUSIONS: Ruling out an underlying malignant tumor, is essential as this could be from pseudo-Meig’s syndrome as seen in our case. Reference #1: Pleural Effusion in Meigs' Syndrome-Transudate or Exudate?: Systematic Review of the Literature. Krenke R, Maskey-Warzechowska M, Korczynski P, Zielinska-Krawczyk M, Klimiuk J, Chazan R, Light RW. Medicine. 12/2015 DISCLOSURE: The following authors have nothing to disclose: Reema Qureshi, Anna Hilton, Humnah Khudayar, Somwail Rasla, Taro Minami No Product/Research Disclosure Information

Malignant Brenner Tumor: Rare Case Report and Review of Literature

Malignant Brenner tumors of the ovary are very rare, and their definition, biology and treatment modality have not been established. Most Brenner tumors are benign, with only 1–2% being malignant. We present a case of 57-year-old women with a rare malignant Brenner tumor. She presented with complaint of abdominal pain and postmenopausal bleeding. Imaging revealed large complex solid cystic pelvic mass. She underwent staging ovarian laparotomy, and the specimen was sent for histopathological study. Histopathology revealed malignant Brenner tumor. On immunohistochemistry, tumor cells were immunoreactive for uroplakin, CK7, WT1, GATA-3 and Ki67 60% and nonimmunoreactive for CK20, favouring urothelial differentiation.

Omental gastrointestinal stromal tumor: Arriving at a diagnosis with therapeutic options in the molecular era

Omental extragastrointestinal stromal tumors are rare neoplasms. We present a case of an elderly woman who was found to have a large solid and cystic pelvic mass of presumed ovarian origin with associated omental neovascularity. Histopathologic examination showed a mixed spindled and epithelioid tumor which was essentially negative for c-KIT and positive for smooth muscle markers by immunohistochemistry. A next generation sequencing panel was performed, analyzing the patient’s tumor for actionable mutations in 50 genes commonly associated with human cancers. Identification of a point mutation in PDGFRA enabled accurate diagnosis and provided an option for targeted therapy for this rare tumor.

Minimally Invasive Approach for Treatment of Seminal Vesicle Cyst Associated with Ipsilateral Renal Agenesis

Objectives: We reviewed the clinical presentation and approach for the treatment of symptomatic seminal vesicle cyst associated with ipsilateral renal agenesis while presenting our experience with a series of 5 patients treated with minimally invasive surgery for Zinner syndrome. Materials and Methods: Between the years 2008 and 2016, we operated on 5 patients who presented with symptomatic seminal vesicle cyst and ipsilateral renal agenesis. Patients' charts and medical records were reviewed and compared with past published minimally invasive series. Results: Four patients were treated in a laparoscopic approach and one was treated with robotic-assisted seminal vesicle cyst excision. In all cases, the cystic complex was drained and excised with marsupialization of the remaining cyst walls to prevent cystic recurrence. The mean operating time was 3:47 h and mean hospitalization time was 7 days (4-14). The mean follow-up period was 3.2 years (range 1.7-4.8 years). All patients reported a resolution of symptoms during postoperative follow-up. Conclusions: Seminal vesicle cyst with ipsilateral renal agenesis should be suspected in young male patients presenting with pelvic cystic masses. Treatment is reserved for symptomatic patients and the preferred approach is minimally invasive surgery. This approach is feasible and effective while providing advantages both for the patient and the surgeon.

Angiomyolipoma of the Pelvic Retroperitoneum

Abstract Background: An angiomyolipoma is a common benign renal mesenchymal tumor but rarely may be found extrarenally. Extrarenal angiomyolipoma (ERAML) arising in the pelvic retroperitoneum is very rare. Case: A 45-year-old multiparous woman presented with a cystic pelvic mass and was misdiagnosed as having an ovarian tumor. Intraoperatively, a retroperitoneal cystic tumor was found and removed. A hysterectomy was necessary in order to remove the mass. Results: Histopathologic examination revealed the cystic mass to be an angiomyolipoma. The patient's postoperative course was uneventful. Postoperatively, this patient is being followed. Conclusions: ERAML should be considered in the differential diagnosis of tumors arising from the pelvic retroperitoneum. Cystic degeneration might occur in ERAML. (J GYNECOL SURG 32:303)