Lateral Uterine Wall Research Articles

A Review and Case Series of Uterine Lipoleiomyomata

Purpose: The purpose of this case series is to understand the prevalence, clinical significance, pathophysiology, pathology findings, and workup of uterine lipoleiomyomas. Methods: This case series, with cases in February and March of 2023, includes the presentation, clinical management, and pathologic diagnosis of two separate uterine lipoleiomyomas. Separate chart reviews were performed on each patient, including frozen and permanent section pathologic findings. Micropictographs were obtained from hematoxylin and eosin-stained slides. This project was acknowledged as “IRB-exempt” by the MU Institutional Review board. Results: Case 1: A 51-year-old G3P2 woman presented with six months of severe postmenopausal bleeding, severe left-lower quadrant pelvic pain, and lightheadedness. A transvaginal ultrasound revealed a heterogeneous, thickened endometrial echo of 3.9 centimeters and a probable left ovarian dermoid cyst. CT showed distension of endometrial cavity due to polyps and/or submucosal masses, as well as a fat-containing mass in the uterine corpus. Hysteroscopy with dilation and curettage was performed with pathology of high-grade malignancy. Differential diagnosis at this time included high-grade stromal sarcoma, undifferentiated carcinoma, adenosarcoma, or malignant mixed Mullerian tumor. Patient underwent MRI due to concern for malignancy, which showed FDG-avid endometrial thickening with no other FDG-avid areas of concern. Histopathologic diagnosis found carcinosarcoma of the uterus, two positive lymph nodes, and an incidental finding of lipoleiomyoma. Plan for medical management with gynecologic oncology will include chemotherapy and vaginal cuff brachytherapy for uterine carcinosarcoma. Case 2: A 50-year-old G5P5 woman presented with increasing vaginal spotting and worsening urge incontinence. CT showed increased size of heterogeneous mass in right lateral uterine wall, consistent with previously identified fibroid/leiomyoma. An adjacent fat-containing lesion was identified within the uterine wall. Patient underwent MRI which revealed large uterine mass at the fundus, with an associated fatty component. Due to the abnormal rate of fibroid growth, and the fat component, there was concern for uterine sarcoma and/or malignant transformation of leiomyoma. Histopathologic diagnosis found lipoleiomyoma with benign atrophic endometrium, paratubal cysts of bilateral fallopian tubes, and follicular cyst of the right ovary. Follow-up in one year was recommended. Conclusion: Lipoleiomyomas are uncommon benign entities, occurring most commonly in postmenopausal women, similarly to uterine fibroids. While asymptomatic patients can be managed conservatively, these tumors can cause vaginal bleeding, pain, and urinary or fecal incontinence and can be definitively treated with hysterectomy. While imaging is necessary to initially characterize the lesion and determine concern for malignancy, histopathologic diagnosis remains the gold standard for diagnosis. Lipoleiomyomas are associated with other gynecologic malignancies, metabolic disorders, and rarely tumor-to-tumor metastasis. For this reason, careful clinical evaluation and surgical management are required for complete evaluation of the patient.

Case Series and Review of Uterine Lipoleiomyomata

Introduction Uterine lipoleiomyomas are benign neoplasms that are not often seen in clinical practice. First described in 1965, these entities were recognized by a composition of intermixed smooth muscle, mature adipocytes, and fibrous tissue [2,4]. The incidence of lipoleiomyoma has always been accepted as 0.03-0.2% by Willen et al. in 1978 [1,4]. However, recent studies propose a higher incidence at 2.9%, such as Akbulut et al. in 2014. Most commonly found in the uterus, these neoplasms can rarely be associated with the cervix, broad ligament, peritoneum, ovary, as well as other extrapelvic locations. These benign tumors present similarly to uterine leiomyomas in peri- and post-menopausal women with obesity, with symptoms of pelvic/abdominal pain, mild abnormal vaginal bleeding, constipation, increased urinary frequency, and possibly a palpable mass. Methods This case series, diagnosed in February and March of 2023, includes the presentation, clinical management, and ultimately pathologic diagnosis of two separate uterine lipoleiomyomas. Results A 51-year-old, G3P2, female presented with six months of severe post-menopausal bleeding, severe left-lower quadrant pelvic pain, and lightheadedness. A transvaginal ultrasound revealed a heterogeneous, thickened endometrium of 3.9 centimeters and a probable left ovarian dermoid cyst. CT showed distension of endometrial cavity due to polyps and/or submucosal masses, as well as a fat-containing mass in the uterine corpus. Hysteroscopy with dilation and curettage was performed with pathology of high-grade malignancy. Differential diagnosis at this time included high-grade stromal sarcoma, undifferentiated carcinoma, adenosarcoma, or malignant mixed Mullerian tumor. Patient underwent MRI due to concern for malignancy, which showed FDG-avid endometrial thickening with no other FDG-avid areas of concern. Histopathologic diagnosis found carcinosarcoma of the uterus, two positive lymph nodes, and an incidental finding of lipoleiomyoma. Further medical management will include chemotherapy and vaginal cuff brachytherapy for uterine carcinosarcoma. A 50-year-old, G5P5, female presented with increasing vaginal spotting and worsening urge incontinence. CT showed increased size of heterogeneous mass in right lateral uterine wall, consistent with previously identified fibroid/leiomyoma. An adjacent fat-containing lesion was identified within the uterine wall. Patient underwent MRI which revealed large uterine mass at fundus with associated fatty component. Due to abnormal rate of growth of fibroid and fat component, there was concern for uterine sarcoma and/or malignant transformation of leiomyoma. Histopathologic diagnosis found lipoleiomyoma with benign atrophic endometrium, paratubal cysts of bilateral fallopian tubes, and follicular cyst of the right ovary. Follow-up in one year was recommended. Conclusion Lipoleiomyomas are uncommon benign entities, occurring most commonly in post-menopausal women, similarly to uterine fibroids. While asymptomatic patients can be managed conservatively, these tumors can cause vaginal bleeding, pain, and urinary or fecal incontinence and can be definitively treated with hysterectomy. While imaging is necessary to initially characterize the lesion and determine malignancy concern, histopathologic diagnosis remains the gold standard for diagnosis. Lipoleiomyomas are associated with other gynecologic malignancies, metabolic disorders, and rarely tumor-to-tumor metastasis. For this reason, careful clinical evaluation and surgical management are required for complete evaluation of the patient.

Spontaneous Rupture of the Gravid Uterus in a Multigravida Women with a Previous History of Caesarean Section: A Case Report

Spontaneous uterine rupture is a rare obstetric complication that has catastrophic effects on both the mother and foetus, resulting in significant morbidity and 80 to 90% foetal mortality. Rupture of the uterus through a previous lower uterine segment scar is the most common cause in developing nations. However, factors such as lack of antenatal care, inappropriate obstetric interventions, obstructed labour, grand multiparity, unbooked status, limited access to emergency obstetric care, and low socioeconomic status play a crucial role in uterine rupture in developing countries like India. Hereby, the authors present a case report of a 31-year-old pregnant patient at 19 weeks of gestation with sudden severe lower abdominal pain. An ultrasound revealed the absence of foetal cardiac activity, placenta located outside the uterus, an empty endometrial cavity, and minimal free fluid in the pelvis. Further, an Magnetic Resonance Imaging (MRI) of the pelvis showed a rupture of the anterior and right lateral uterine wall, through which the foetus and most of the placental tissue had passed into the peritoneal cavity. After confirming the diagnosis, the patient underwent emergency laparotomy, during which the uterine wall defect was closed with appropriate haemostasis. The patient recovered without any untoward complications.

CREB fusion–associated epithelioid mesenchymal neoplasms of the female adnexa: three cases documenting a novel location of an emerging entity and further highlighting an ambiguous misleading immunophenotype

EWSR1/FUS-CREB-rearranged mesenchymal neoplasms are an emerging heterogeneous group of soft tissue tumors that encompasses low-grade lesions (angiomatoid fibrous histiocytoma/AFH) and a group of predominantly intra-abdominal aggressive sarcomas with epithelioid morphology and frequent keratin expression. Both entities occasionally harbor EWSR1::ATF1 fusions as alternate to the more frequent EWSR1/FUS::CREB1/CREM fusions. Although EWSR1/FUS-CREB-rearranged epithelioid malignant neoplasms have been described in diverse intra-abdominal sites, none involved the female adnexa. Herein, we describe three cases involving uterine adnexa in young females (41, 39, and 42-year-old); two associated with constitutional inflammatory symptoms. The tumors presented as a serosal surface mass of the ovary without parenchymal involvement (Case 1), as circumscribed nodule within ovarian parenchyma (Case 2), and as a periadnexal mass extending into the lateral uterine wall with lymph node metastasis (Case 3). They were composed of sheets and nests of large epithelioid cells with numerous stromal lymphocytes and plasma cells. The neoplastic cells expressed desmin and EMA, and variably WT1. One tumor expressed in addition AE1/AE3, MUC4, synaptophysin, chromogranin, and ALK. None expressed sex cord-associated markers. RNA sequencing identified EWSR1::ATF1 fusions in two cases and an EWSR1::CREM fusion in one. Exome-based RNA capture sequencing and clustering methods showed high transcriptomic proximity of tumor 1 with soft tissue AFH. This novel subset of female adnexal neoplasms should be included in the differential diagnosis of any epithelioid neoplasm involving female adnexa. Their aberrant immunophenotype can be misleading, underlining a wide spectrum of differential diagnosis.

Placenta accreta spectrum into the parametrium, morbidity differences between upper and lower location

Objective To demonstrate the surgical and morbidity differences between upper and lower parametrial placenta invasion (PPI). Materials and methods Forty patients with placenta accreta spectrum (PAS) into the parametrium underwent surgery between 2015 and 2020. Based on the peritoneal reflection, the study compared two types of parametrial placental invasion (PPI), upper or lower. Surgical approach to PAS follows a conservative-resective method. Before delivery, surgical staging by pelvic fascia dissection established a final diagnosis of placental invasion. In upper PPI cases, the team attempted to repair the uterus after resecting all invaded tissues or performing a hysterectomy. In cases of lower PPI, experts performed a hysterectomy in all cases. The team only used proximal vascular (aortic occlusion) control in cases of lower PPI. Surgical dissection for lower PPI started finding the ureter in the pararectal space, ligating all the tissues (placenta and newly formed vessels) to create a tunnel to release the ureter from the placenta and placenta suppletory vessels. Overall, at least three pieces of the invaded area were sent for histological analysis. Results Forty patients with PPI were included, 13 in the upper parametrium and 27 in the lower parametrium. MRI indicated PPI in 33/40 patients; in three, the diagnosis was presumed by ultrasound or medical background. The intrasurgical staging categorizes 13 cases of PPI performed and finds diagnosis in seven undetected cases. The expertise team completed a total hysterectomy in 2/13 upper PPI cases and all lower PPI cases (27/27). Hysterectomies in the upper PPI group were performed by extensive damage of the lateral uterine wall or with a tube compromise. Ureteral injury ensued in six cases, corresponding to cases without catheterization or incomplete ureteral identification. All aortic vascular proximal control (aortic balloon, internal aortic compression, or aortic loop) was efficient for controlling bleeding; in contrast, ligature of the internal iliac artery resulted in a useless procedure, resulting in uncontrollable bleeding and maternal death (2/27). All patients had antecedents of placental removal, abortion, curettage after a cesarean section, or repeated D&C. Conclusions Lower PAS parametrial involvement is uncommon but associated with elevated maternal morbidity. Upper and lower PPI has different surgical risks and technical approaches; consequently, an accurate diagnosis is needed. The clinical background of manual placental removal, abortion, and curettage after a cesarean or repeated D&C could be ideally studied to diagnose a possible PPI. For patients with high-risk antecedents or unsure ultrasound, a T2 weight MRI is always recommended. Performing comprehensive surgical staging in PAS allows the efficient diagnosis of PPI before using some procedures.

8091 Robot-Assisted Laparoscopic Hysterectomy with Retroperitoneal Uterine Fibroid

<h3>Study Objective</h3> Demonstrate a Robot-Assisted Laparoscopic (RAL) Hysterectomy with a cul-de-sac uterine fibroid, and discuss the benefit of a RAL surgery in these procedures <h3>Design</h3> Narrated video of RAL hysterectomy and exeresis of retroperitoneal mass compatible with fibroid. <h3>Setting</h3> Surgery performed with the patient in lithotomy and Trendelenburg position. Robot was in left lateral pelvic angle. <h3>Patients or Participants</h3> Female, 50 years old, previously diagnosed with fibroid for 8 years. Patient experienced pelvic pain, hypermenorrhea, constipation, and other compressive symptoms. The latter persisted after menopause, with no significant mass reduction. Ultrasound described a 76cc uterus with a solid formation along right lateral uterine wall measuring 12 × 9.4 × 9.3cm. Clinical examination revealed a palpable uterus 3 cm above pubic symphysis, endorsed by imaging findings. <h3>Interventions</h3> Identified a 15cm mobile tumor, suggestive of fibroids in retro uterine region, adhered to the right ovarian fossa with lateralization of the rectum. Ureterolysis was performed and the mass released from the ovarian fossa to the peritoneal reflection of the rectum and uterine torus, aiming the removal of the fibroid en bloc during hysterectomy. <h3>Measurements and Main Results</h3> Operation time was three hours. Patient was early discharged from the hospital, on the first post-operative day with excellent pain control. She evolved without complications during follow-up, being fully discharged with complete symptom improvement. <h3>Conclusion</h3> Minimally invasive surgery has become the standard of therapy for an extensive number of gynecological diseases especially for patients with benign afflictions. Despite most studies proving absence of benefits with RAL when compared to Conventional Laparoscopy, in specific cases, especially when analyzing abnormal form uteri due to myomas, some studies have shown benefit in performing RAL. Increasing accuracy, flexibility and ergonomics can improve results and lead to easier bleeding control as observed in the presented case.

A combination of two novel ligation techniques for complicated laparoscopic intraligamental myomectomy

To perform laparoscopic myomectomy by combining two novel ligation techniques for a large lateral intraligamental myoma. A step-by-step explanation of the surgical procedure using a video with narration. University hospital. A 39-year-old woman (gravida 1, para 0) presented with an asymptomatic pelvic mass. Sonographic imaging revealed a 10-cm subserous myoma from the right lateral uterine isthmus wall. Laparoscopic exploration revealed a large myoma growing from the right lateral cervical isthmus wall toward the broad ligament. It was protruding into the pararectal space with duplicated ureters. For such a large lateral intraligamental myoma, any conventional approach has the potential to cause massive bleeding and accidental injuries. We devised and implemented a preventative strategy for intraoperative bleeding by combining two novel ligation techniques used in laparoscopic myomectomy. We made an incision at the posterior leaf of the broad ligament and exposed the myometrium enveloping the fibroid and the base of the fibroid. Then we performed an incision 2 cm away from the right lower edge of the fibroid base, opening the myometrium and pseudocapsule. We applied two novel ligation techniques that ligate the pedicle on the left of the fibroid and the pseudocapsule on the right of the fibroid. Enucleation and loop tightening were implemented simultaneously. The entire pseudocapsule and most of the myometrium enveloping the fibroid were ligated in the loop knot. Only a small portion of the myometrium on the right side was outside the loop knot, which required electrocoagulation. Loop ligation was performed twice more for reinforcement in the same location. The peritoneum was then closed. Laparoscopic myomectomy was completed successfully for a large lateral intraligamental myoma using our novel technique. The surgery lasted 110 min, and the volume of intraoperative blood loss was 150 mL. The patient had a normal postoperative course. Combining two novel ligation techniques in laparoscopic myomectomy is a safe and efficient surgical choice. This technique has obvious advantages in large, broad ligament myomas, reducing bleeding and avoiding unintentional injuries, even in duplicated ureters. Furthermore, this technique is not limited by the device and does not increase the cost of surgery.

Is Placental Localization in the Third Trimester of Pregnancy Related to the Intrauterine Ultrasound and Postpartum Parameters?

Background: The relationship between placental localization and fetus is unclear. This study was aimed to determine the relationships between placental localization, ultrasound findings and pregnancy outcomes of the third trimester of pregnancies.Materials and Methods: Three-hundred and two women were included in the study. Maternal age, gravidi-ty, parity, abortion and live birth numbers, types of previous births, gestational age, femur length (FL), bipa-rietal diameter (BPD), head circumference (HC), abdominal circumference (AC), placental localization (ante-rior/posterior/lateral/fundus), umbilical artery systolic/diastolic ratio (S/D), fetal presentation, type of deliv-ery, post-partum parameters of infant were obtained from archive records.Results: The placentas were located in the anterior, posterior, fundal and lateral uterine wall in 38.1%, 30.1%, 19.9%, and 11.9% of individuals, respectively. Measurements of the HC in the third trimester were differed according to the localization of the placenta, and the HC measurements were significantly higher if the placental localization was anteriorly (p=0.045). There were no differences in other ultrasonographic measurements (S/D, BPD, AC ve FL), in the height, weight, and gender of the baby, gestational week at delivery, APGAR scores and type of delivery according to the placental localization (p&amp;gt;0.05).Conclusions: In this study, we found that placental localization did not affect pregnancy outcomes, type of delivery and gender of the baby in risk-free, spontaneous and single pregnancies in the third trimester. Also, we stated that the previous birth type did not give an idea about placental localization. We think that placenta implantations, except placental location anomaly and invasion anomaly, do not provide precise information about pregnancy outcomes and type of delivery.

A rare case of the new entity of müllerian anomalies mimicking the noncommunicating rudimentary cavity with hemi-uterus: accessory cavitated uterine mass

To demonstrate the laparoscopic excision of an accessory cavitated uterine mass (ACUM) and show that atypical anomalies can lead to the misdiagnosis of a noncommunicating rudimentary horn. Description and step-by-step demonstration of the surgical procedure using a video recording (Canadian Task Force Classification 3). University hospital. A 17-year-old virgin girl with chronic pelvic pain and severe progressive dysmenorrhea despite using nonsteroidal anti-inflammatory drugs and oral contraceptives since her menarche. We could not perform transvaginal examination and ultrasonography because of the virginity of the girl. Transabdominal ultrasound revealed a 24 × 24-mm heterogeneous cystic mass on the left adnexal region suggesting a noncommunicating functional rudimentary horn. This mass was within the left lateral uterine myometrial wall, and otherwise, the uterus and endometrial cavity seemed normal on ultrasonographic examination. Magnetic resonance imaging showed a cavitated nodule of 25 mm with hemorrhagic components inside the mass on the left side of the uterus and the normal endometrial cavity with a normal size uterus. After detailed evaluation and counseling, a decision was taken to perform laparoscopy. Laparoscopic resection of the ACUM. On laparoscopic exploration, we first observed a globular enlargement on the left wall of the uterus under the round ligament. Both the ovaries and the uterus were normal, and there were two normally developed fallopian tubes with no abnormality communicating with the normal uterus. The mass had irregular muscle fibers and ambiguous limits for detaching from the normal myometrial tissue. Afterward, the mass was resected completely without entering the endometrial cavity. It was thought that these irregular borders may be a factor of confusion as a degenerated myoma on the diagnosis. The blunt and sharp dissection methods were used bidirectionally, and finally, the lesion was enucleated. The mass was incised, and chocolate-like brownish fluid spilled out from the cavity of the mass. The endometrium-like epithelium and surrounding muscular layer were seen on the mass. The myometrial defect was approximated and closed with a polyglactin absorbable suture. Histopathological examination revealed the endometrial lining cavitated mass surrounded by myometrium, and thus, it was consistent with the diagnosis of ACUM. The postoperative period of the patient was uneventful. She was discharged without any complaint. Her severe pelvic pain and symptoms of dysmenorrhea were resolved 1 month after the surgery. We did not prescribe any medication for menstrual suppression and pain management before or after surgery. During the follow-up period, she had a regular menstrual cycle and no pelvic pain and dysmenorrhea for 2 years. Accessory cavitated uterine mass is a new entity having a normal endometrial cavity and is different from other müllerian duct anomalies. Severe dysmenorrhea and chronic pelvic pain are early-onset, and they are persistent despite using medications, but suspecting this problem is the main determinant for confirming the diagnosis. The final diagnosis of ACUM can be made after resecting the mass and confirming with histopathological examination. Accessory cavitated uterine mass may be confused with a similar lesion of juvenile cystic adenomyosis (JCA). They present very similar clinical and pathological findings, but JCA is a rare form of focal adenomyosis that contains cystic contents inside the lesion, and it has more intense adenomyosis surrounding the endometrial lining of a cavitated mass. In our case, histopathological examination revealed muscle fibers around the endometrial epithelium, with no adenomyotic foci. It was so difficult to distinguish these two similar lesions during the surgery. Thus, we could distinguish ACUM from JCA with this pathological confirmation. Accessory cavitated uterine mass may also be misdiagnosed as U4a of ESHRE/ESGE classification and 2b of ASRM classification, but it should be distinguished from these anomalies. Moreover, it is important to define ACUM clearly in the U4 or U6 class of the ESHRE/ESGE and 2b of ASRM classification systems.

Inappropriate surgery in a patient with misdiagnosed Robert\u2019s uterus

BackgroundRobert’s uterus is a rare Mullerian anomaly, which can be described as an asymmetric, septate uterus with a non-communicating hemicavity. Herein, we present the case of a misdiagnosed Robert’s uterus, resulting in an invasive and disadvantageous surgery.Case presentation A 16-year-old woman was referred to our department because of dysmenorrhea and suspicion of uterine malformation. We misdiagnosed Robert’s uterus as a unicornuate uterus with a non-communicating rudimentary horn and hematometra, and performed laparoscopic hemi-hysterectomy. Although the patient’s symptoms were relieved, our surgical procedure left the lateral uterine wall weak, making the patient’s uterus susceptible to uterine rupture in any future pregnancy.ConclusionsAlthough the early diagnosis of Robert’s uterus is challenging, it is important in order to determine appropriate surgical interventions and management for maintaining the quality of life and ensuring safety in future pregnancies.

Assessing lateral uterine wall defects and residual myometrial thickness after cesarean section

ObjectiveLateral wall ruptures in women with a history of cesarean section are less common but more complicated than anterior wall ruptures. Residual myometrial thickness (RMT) is believed to be valuable for assessing the probability of ruptures. This study aimed to assess the utility of OmniView (a sonographic reslicing technique) in evaluating the lateral uterine wall after cesarean section and evaluate the relationship between lateral and anterior wall RMT using OmniView and sagittal two-dimensional ultrasound. Study designThis cross-sectional study examined changes in both the anterior and lateral uterine wall in women with a history of cesarean section in the past 12–18 months. OmniView with volume contrast imaging with a 2-mm slice thickness was used to generate coronal planes, and the OmniView RMT (OV-RMT) was calculated as a percentage. Blinded to the OV-RMT results, sonographic multiplanar views were used to acquire the optimum sagittal plane for evaluating the RMT, and the sagittal RMT (S-RMT) was calculated as a percentage. The reproducibility of OV-RMT and S-RMT between two observers was tested using interclass correlation (ICC). The relationship between two variables was tested using Spearman’s rank correlation. ResultsIn 208 recruited patients, the prevalence of lateral uterine wall defects was 79 %. The interobserver and intraobserver reproducibility of S-RMT and OV-RMT had ICC coefficients over 0.9 with a p-value <0.001. S-RMT and OV-RMT did not follow a normal distribution, and the medians were significantly different (55.5 and 85.7, respectively). Spearman’s rank correlation between OV-RMT and S-RMT had a rho (ρ) value of 0.24 (p < 0.05). Passing-Bablok regression had an intercept of 47.95 and a slope of 0.65. ConclusionOmniView can be used to assess lateral uterine wall defects, and OV-RMT is a reproducible and reliable method for quantifying this assessment. The RMT on the coronal plane was independently more intact than that on the sagittal plane, which might account for the lower incidence of lateral ruptures. Further studies could reveal a critical OV-RMT value that is safe for a trial of labor.

Accessory Caveatted Uterine Mass: A Case Report

Accessory caveatted uterine mass (ACUM) represents a new verity of mullein anomaly that is usually located at the level of insertion of round ligament and is probably related to a dysfunction of female Gebrnaculum. ACUM is described in literature as an accessory isolated caveatted uterine mass which is lined by endometrium but with no communication to normal uterine cavity. Usually it protrudes from a normally shaped and functional uterus and mostly is located on lateral uterine wall below the insertion of round ligament. Till now this condition is not included in ESHRE Classification system and because of this it is not so commonly diagnosed, these patients are usually presented with severe dysmenorrhea and chronic pelvic pain and some report showed coincidence of ACUM and endome-triosis in 5-6%of patients which are usually less than 30 years old [1]. ACUM needs to be differentiated from other similar conditions such as 1. Rudimentary and caveatted uterine horns 2. Adeno-myosis with cystic or degenerated areas. 3. Essential and primary dysmenorrhea. 4. Degenerated fibroids. So proper diagnosis and raised awareness of ACUM can leads to earlier access to treatment.

Laterally-positioned placenta in placenta previa

Objectives: To clarify perinatal outcomes of patients with placenta previa (PP) with the placenta mainly positioned in the lateral uterine wall (lateral PP), thereby clinically characterizing this condition.Study design: The retrospective cohort study was performed involving patients with lateral PP between January 2006 and December 2016. The placental position was determined and classified by magnetic resonance imaging.Results: This study included 98 patients with PP, which was classified into three types according to the main placental position sites: lateral (n = 30), anterior (n = 32), and posterior (n = 36) PP. Overall, the median blood loss at cesarean section (CS) was 1808 mL and transfusion was performed for 78 patients (80%). Univariate analysis showed that patients with lateral PP bled less at CS than those with non-lateral PP (anterior + posterior PP) [median 1510 (interquartile range 1080–2168) versus 1975 (1570–2860) mL: p=.02]. The other parameters including rates of conception by assisted reproductive technology, prior CS, antepartum bleeding, and placenta accreta spectrum did not show the significances. Among the three groups of PP (lateral versus anterior versus posterior), patients with lateral PP bled less than those with anterior (p=.05) or posterior (p=.13) PP, but this was nonsignificant [lateral 1510 (1080–2168) versus anterior 2145 (1580–3348) versus posterior 1808 (1533–2555) mL]. When dividing into lateral PP to two types: placenta showing anterior dominancy versus posterior dominancy, patients with lateral PP and anterior dominancy bled more those with posterior dominancy [2430 (1410–3400) versus 1170 (1050–1588) mL: p=.002].Conclusion: Patients with lateral PP bled significantly less than those with non-lateral (anterior or posterior) PP. Patients with lateral PP and anterior dominancy bled more than those with posterior dominancy.

Ayurvedic Approach for Management of Uterine Fibroid

A 31-year-old woman presented with uterine fibroid of 12.3 mm diameter in right lateral uterine wall and a cyst of 30 mm diameter in left ovary. She was intended to treat with some Ayurvedic formulations. Fibroids are the abnormal growths that develop in a woman's uterus. Sometimes these tumors are quite large and cause severe abdominal pain and heavy periods. In other cases, they cause no signs or symptoms at all. The growths are typically benign or noncancerous. The cause of fibroids is unknown. Fibroids are also called leiomyomas or myomas. Ayurvedic drugs have been proved useful for these manifestations. The case was treated for 14 months with a combination of different Ayurvedic drugs to alleviate symptoms and reduce the size of fibroid. Patient came with the complaint of excessive menstrual bleeding with pelvic pain and was diagnosed with uterine fibroid by ultrasonography (USG). This patient of uterine fibroid, diagnosed as Granthi was treated with Pradarantak rasa, Kanchnar guggulu, Arogyavardhini vati, Kumaryasava, Ashokarishta, and Pushyanuga churna during the treatment. Only oral Ayurvedic drugs were used during the treatment. Patient's condition was assessed for symptoms of uterine fibroid which was completely relieved. No evidence of uterine fibroid was seen in USG; therefore, it indicates the case of uterine fibroid successfully and completely cured with Ayurvedic treatment. Surgical removal of uterine fibroid or cyst is the only curative treatment in contemporary modern medical science. In Ayurveda, it may be successfully treated with oral Ayurvedic drugs and without surgical intervention.

Uterine-sparing Laparoscopic Resection of Accessory Cavitated Uterine Masses

Study ObjectiveTo demonstrate surgical techniques utilized during uterine-sparing laparoscopic resections of accessory cavitated uterine masses (ACUMs).ACUMs represent a rare uterine entity observed in premenopausal women suffering from dysmenorrhea and recurrent pelvic pain. The diagnosis is made when an isolated extra-cavitated uterine mass is resected from an otherwise normal appearing uterus with unremarkable endometrial lumen and adnexal structures. Pathologic confirmation requires an accessory cavity lined with endometrial epithelium (and corresponding glands and stroma) filled with chocolate-brown fluid. Adenomyosis must be absent. Although the origin of ACUMs is currently unknown, the most common presentation is a 2-4 cm lateral uterine wall mass at the level of the insertion of the round ligament. Hence it has been hypothesized that gubernaculum dysfunction may be responsible for duplication or persistence of paramesonephric tissue leading to ACUM formation as a new Müllerian anomaly. DesignA stepwise surgical tutorial describing 2 laparoscopic ACUM resections using a narrated video (Canadian Task Force classification III). SettingAn academic tertiary care hospital. PatientsIn this video, we present 2 patients who underwent uterine-sparing laparoscopic resections of their ACUM in order to preserve fertility (Case 1) or avoid the complications and surgical recovery time of a total laparoscopic hysterectomy (Case 2). Case 1 is a 19-year-old, gravida 0, para 0 woman with dysmenorrhea and recurrent pelvic pain who presented for multiple emergency room and outpatient evaluations. Transvaginal ultrasonography was unremarkable except for a 28×30×26mm left lateral uterine mass with peripheral vascular flow that was initially felt to be a leiomyoma or rudimentary uterine horn. MRI imaging, however, demonstrated this mass to be more consistent with an ACUM. This was based on the lack of communication between the lesion and the main uterine cavity exhibited by high T2 signal (compatible with endometrial tissue) surrounding low T2/high T1 signal in the dependent aspects (representing blood products). After counseling regarding treatment options including medical management with hormonal contraception, the patient elected for definitive fertility preserving laparoscopic resection. In contrast, case 2 is a 39-year-old, gravida 3, para 3 woman with a 2 month history or left lower quadrant pain following her last vaginal delivery. Transvaginal ultrasonography showed a 23×18×19mm cystic structure within the left uterine wall, which was confirmed to represent an ACUM on MRI. Although she had no desire for fertility preservation, the patient elected for surgical resection of the mass as opposed to a hysterectomy in order to minimize complications and recovery time. InterventionsLaparoscopic resection of ACUMs in patients desiring uterine preservation. Measurements and Main ResultsLaparoscopic resection of the ACUMs was performed utilizing 2 different techniques. In both cases, dilute vasopressin was injected with a modified butterfly or spinal needle along the uterine-ACUM serosal interphase to aid with hemostasis. In patients desiring to preserve fertility (case 1) monopolar energy is utilized to make an incision along the ACUM serosa to help facilitate dissection. ACUM enucleation is then commenced in a circumferential manner along the ACUM and uterine myometrial interphase utilizing bipolar energy. In contrast to leiomyomas where dissection advances along the pseudocapsule, ACUM have poorly delineated borders with disorganized muscular fibers making dissection particularly difficult. A variety of instruments can be utilized to help in the sequential circumferential dissection in addition to a bipolar device including a single-tooth tenaculum, myoma hook, suction device or fine-needle grasper. Ultimately, the ACUM is transected off its uterine-myometrial attachment and hemostasis is obtain before closing the uterine defect in at least 2 layers using a 2-0 barbed V-Loc (Medtronic, Minneapolis, MN).If fertility preservation is no longer desired, the dissection can greatly be expedited by performing a salpingectomy and skeletonizing the ACUM from the leaves of the broad ligament (case 2). A monopolar L-hook can then be used to transect the ACUM from the remaining uterine body.While difficult, these cases can be completed laparoscopically in approximately 2 hours with minimal blood loss. ConclusionsACUMs are hypothesized to represent a previously under recognized Müllerian anomaly linked to gubernaculum dysfunction that occurs in premenopausal women with dysmenorrhea and chronic pelvic pain. Uterine and fertility sparing laparoscopic resection is possible but challenging due to poorly defined planes.

Intraligamental Myomectomy Strategy Using Laparoscopy

Study ObjectiveIntraligamental myomas (IMs) represent 6% to 10% of all uterine myomas. An IM growing from the lateral uterine wall into the broad ligament often presents as a large pelvic mass without symptoms. Removing a large IM can be difficult because of the limited operative field and poses challenges during conventional laparoscopic surgical approaches. The risk of injury to the ureter and uterine artery during myomectomy is greater than that during other types of myoma. DesignRetrospective study (Canadian Task Force classification III). SettingUniversity-affiliated hospital. PatientsIM was classified into 3 types according to the location: (1) anterior intraligamental myoma (AIM), (2) posterior intraligamental myoma (PIM), and (3) lateral intraligamental myoma (LIM). From April 2007 to July 2015, 83 consecutive patients with IM underwent laparoscopic myomectomy at National Taiwan University Hospital, Taipei, Taiwan, including 23 AIM, 27 PIM, and 33 LIM. InterventionsSeveral techniques are described, and videos are supplied for performing laparoscopic myomectomy safely and easily in different types of IM. Measurements and Main ResultsUrinary frequency (31%) and a palpable abdominal mass (31%) were the 2 most common presenting symptoms. Most of the lesions were 33 LIM (40%) followed by 27 PIM (32%) and 23 AIM (28%). The mean myoma sizes were 11.0, 8.0, and 7.8 cm; the mean myoma weights were 478, 279, and 309 g; the mean operative times were 134, 108, and 104 minutes; and the mean blood loss during surgery was 224, 94, and 107 mL for LIM, PIM, and AIM, respectively. LIMs had relatively more blood loss because they were heavier and commonly rested alongside the uterine artery. The only complication was late postoperative hemorrhage in 1 case of LIM. Histopathology showed leiomyoma in all cases. Three patients were spontaneously conceived after myomectomy, and each had a successful pregnancy and cesarean delivery. ConclusionSurgical treatment of IM is empirically difficult. It is important to use an approach that considers the location, size, and shape of the myoma. All types of IM presented with similar symptoms, and the highest blood loss occurred during laparoscopic myomectomy of a LIM.

Cotyledonoid dissecting leiomyoma of the uterus: A report of four cases and a review of the literature.

Cotyledonoid dissecting leiomyoma (CDL), also termed Sternberg tumor, is a variant of uterine leiomyoma that is rarely diagnosed by clinical evaluation. At present, ~43 cases of CDL have been reported in the literature written in the English language. Due to the distinctive grapelike gross appearance of an exophytic mass resembles placental tissue, CDL is often misdiagnosed clinically as an ovarian tumor or uterine sarcoma. Therefore, an awareness of the features of the disease is important to prevent misdiagnosis and overtreatment. The present study reports 4 cases of CDL of the uterus that were treated at the Second Hospital of Jilin University between January 2009 and December 2011. All 4 patients in the current study presented with a palpable asymptomatic pelvic mass, which was detected during physical examinations, and cancer antigen 125 tumor marker levels that were within the normal range. The exploratory laparotomy of the 4 patients revealed lobulated tumors with a grapelike appearance extending from the lateral uterine wall into the ligament or the adjacent tissues. The frozen section and postoperative pathology were diagnosed as CDL. A total abdominal hysterectomy was performed in the first case of a 55-year-old woman that had been in menopause for 7 years. The patient was well and showed no evidence of disease subsequent to 48 months of follow-up. A total abdominal hysterectomy and right salpingo-oophorectomy were performed in the second case of a 43-year-old woman, who was well and showed no evidence of disease subsequent to 26 months of follow-up. A subtotal abdominal hysterectomy and bilateral salpingectomy were performed in the third case of a 37-year-old woman, who was well and showed no evidence of disease subsequent to 27 months of follow-up. A total abdominal hysterectomy and right-salpingectomy were performed with the removal of a retroperitoneal fibroid extension in the fourth case of a 48-year-old woman, who was well and showed no evidence of disease subsequent to 32 months of follow-up.

Heterotopic respiratory mucosa of the uterine corpus

A 47-year-old, single, Chinese woman presented with pain on the 1st day of menses for more than 30 years. Her dysmenorrhea worsened over years and underwent a total abdominal hysterectomy and bilateral salpingooophorectomy. The myometrium showed trabeculated appearance, and there were adhesions between ovaries and fallopian tubes. A pale solid brownish mass measuring 1.5 cm × 1 cm × 0.6 cm with fibrous whitish cut surfaces was present on the lateral wall of the uterus in the lower uterine segment. Histologically, adenomyosis and left ovarian endometriosis were confirmed. The lateral uterine wall nodule showed a tubular structure lined by ciliated pseudostratified columnar epithelium. Smooth muscle bundles were found around the entire tubular structure. Lobules of salivary type glands containing both serous and mucous cells are present. The pathological diagnosis of heterotopic respiratory mucosa (HRM) was made. To our knowledge, this is the first reported case of HRM of the uterine corpus.

Endometrial Scratch-Suction and Implantation Failure

Objective: The aim of this trial was to determine whether endometrial scratch-suction caused by insertion tube of (IUCD) with suction improved the probability of pregnancy in the subsequent IVF cycle in patients who had previous failed IVF outcome by removing small polyps and any hazardous materials. Design: Observational prospective cohort experimental study. Setting: Zagazig University Hospital, Obstetrics and Gynecology department. From period between September 2011 till September 2012. Population: 30 patients with previous failed IVF despite transfer of goodquality embryos were allocated to endometrial scratch-suction in the same the cycle of embryo transfer. Methods: From day 5 to day 7 of same ICSI cycle, the patients in study underwent endometrial scratch-suction technique. After preparation of insertion tube of (IUCD) and infant feeding tube 8 F, moving the insertion tube of IUCD from below upwards with scratching anterior uterine wall, then posterior, then left lateral uterine wall, then right lateral uterine wall, then fundus, all these steps are associated with suction by attaching proximal end of infant feeding tube 8 F to suction apparatus. Main Outcome Measures: Implantation and clinical pregnancy rates. Results: The implantation occurred in 24/30 (80%). The clinical pregnancy occurred in 20/30 patients (66.66%). 12/30 patients (40%) during scratch-suction technique had small fleshy masses obstructing suction tube which were small endometrial polyps. Conclusions: Endometrial scratch-suction improves clinical pregnancy and implantation rates in the same IVF-ET cycle in patients with previous unsuccessful IVF cycles.

Invasive Mole - Case Report of Massive Uterine Destruction

Patient with malignant Gestational Trophoblastic Neoplasm (GTN) was treated by mean of MTX-FA, MAC, EMA-CO and EMA-EP. Changes in serum human chorionic gonadotropine (beta hCG) levels and changes in ultrasonographic findings were checked weekly. Finally transabdominal hysterectomy with ovaries conservation was done and polychemotherapy administrated after the operation until three consecutive serum chorionic gonadotropine values were negative. This is a case report of Invasive mole in 32 years old patient without possibility to preserve reproductive health. GTN developed two months after spontaneous abortion in 13th week gestation. No changes in uterine structure were found during the first ultrasonographic examination. Three months after abortion and one month after GTN confirmed, massive destruction of lateral uterine wall was detected during transvaginal Doppler ultrasound examination. Resistance index of 0,366 was significantly lower than normal, with hypervascularisation in affected tissue. Serum beta hCG confirmed poor effect of polychemotherapy treatment and decision for operative treatment was made. Hystological findings after the operation confirmed malignant GTN- invasive mole. Specific changes in ultrasonographic picture could have an impact in therapy making decision and could not be refereed without the most relevant parameter such is serum human chorionic gonadotropine.