Normal Adnexa Research Articles

Combined Utero-Ovarian and Round Ligament Oophoropexy for Recurrent Torsion of Normal Adnexa: A Case Series

Recurrent torsion of otherwise normal adnexa (not involving adnexal cysts) has been reported in young girls and adolescents. Previous ovarian fixation techniques (oophoropexy) such as plication of the utero-ovarian ligament appear to have limited efficacy in preventing recurrent torsion. A novel technique combining plication of the utero-ovarian ligament and suturing of the ovary to the round ligament has been recently described. In this study, we describe our short-term experience with the combined utero-ovarian and round ligament oophoropexy technique. Patients who underwent combined oophoropexy as a primary fixation technique or as a secondary fixation technique (i.e, after failure of a previous fixation) due to recurrent torsion of otherwise normal adnexa between January 2020 and December 2022 were included in this retrospective cohort study. Follow-up to assess for further torsion events was conducted by telephone interview. Ten patients underwent combined utero-ovarian and round ligament oophoropexy during the study period. In all cases, at least two episodes of torsion of otherwise normal adnexa were surgically diagnosed before oophoropexy (range, 2-4). The median patients' age at time of the combined oophoropexy was 21.8 years (range, 9.1 - 35.7 years), 3 were pre-menarchal and 7 were post-menarchal. After a median follow up of 19.1 months (range, 3.0 - 29.3 months), only one case of recurrent torsion occurred. Combined utero-ovarian and round ligament oophoropexy is novel oophoropexy procedure which may reduce the risk of recurrent torsion. However, longer follow-up is needed to determine its efficacy.

Adnexal Torsion in Adolescents – a Retrospective Analysis from a Tertiary Centre in Latvia

Objective - To review the data of cases of adnexal torsion in the paediatric population in a national level centre in Latvia and examine the pitfalls of diagnostic and therapeutic strategies.Methods - A retrospective review of medical records was performed on 61 cases of suspected and/or confirmed adnexal torsion in a national level paediatric centre.Results - In 85.5% of cases the initial diagnosis was made correctly. The age of the patient was a significant contributor to a shorter time until surgery (P=0.016). Abdominal pain was the most common symptom (90.6%), followed by nausea (58.5%) and vomiting (52.8%). Only 62.3% of the torsion patients had an elevated WBC and 69.4% had no elevated body temperature. The shorter the duration of symptoms, the more likely it was that the organ salvage procedure was performed (P=0.021). The sensitivity of ultrasound for the correct diagnosis was 71.4%. In almost a third of the torsion cases, no pelvic lesion was detected on ultrasound (26.5%). When ultrasound suspected torsion, the time before operation was significantly shorter (P<0.001), the presence of blood flow in the ovary extended the time until surgery (P=0.026). Organ-sparing surgery was performed in 73.6% of the cases.Conclusion - Medical professionals should not exclude the diagnosis of adnexal torsion in the absence of fever or leucocytosis, as well as in the case of normal adnexa on ultrasound. A delay in surgery increases the risk of irreversible ischemic damage leading to organ loss.

Cervical molar pregnancy, profuse bleeding and urgent surgical treatment.

The association of cervical pregnancy and gestational trophoblastic disease is extreme rare, but it is obvious that such combination is associated with devastating effects on future fertility. We present a case of the patient with cervical molar pregnancy, who was admitted due to hemorrhagic shock caused by profuse metrorrhagia at 7th gestational week. Slightly enlarged uterine corpus, with bulky cervix and normal adnexa were found on laparotomy. Total abdominal hysterectomy with the conservation of one ovary was performed. Pathohistological examination confirmed cervical molar pregnancy. In the case of an ectopic, molar or ectopic molar pregnancy, the early visit to gynecologist would give the opportunity to plan the treatment and to preserve the uterus for further pregnancies.

Recurrent torsion of otherwise normal adnexa: oophoropexy does not prevent recurrence.

Recurrence of adnexal torsion involving otherwise normal adnexa is not rare. Various oophoropexy (ovarian fixation) procedures have been suggested to prevent recurrence; however, long-term information of their efficacy is lacking. The aim of this study was to investigate the recurrence rate of adnexal torsion following oophoropexy. Retrospective cohort study, including all consecutive patients who underwent an oophoropexy procedure for the prevention of recurrent torsion of "normal adnexa" in our department from 2008 to 2019 by shortening of the utero-ovarian ligament. Nineteen patients (age range 7-35years) with a mean follow-up of 90.9 ± 57.7months were identified. Fifteen of them (78.9%) were re-operated for recurrent torsion following an oophoropexy procedure, while four (21.1%) did not experience recurrence. Nine torsion recurrences following an oophoropexy occurred within the first 2 postoperative years. There were no differences in mean age and menarcheal status )pre- or post-menarcheal) at the time of the first torsion event, age at the time of oophoropexy, oophoropexy side, number of adnexal torsion events before oophoropexy, and follow-up duration between those with and those without post-oophoropexy recurrences. Oophoropexy procedure by shortening of the utero-ovarian ligament may not prevent recurrent torsion of otherwise normal adnexa. Further studies to determine whether combined fixation (utero-ovarian and round ligament plication) is more efficacious than isolated utero-ovarian plication for the prevention of recurrent torsion are warranted.

Unicornuate Uterus with Noncommunicating Rudimentary Horn (Class U4aC0V0/ESHRE/ESGE Classification) and a Communicating Bladder Endometriotic Nodule

To describe the diagnostic workup and laparoscopic management of a noncommunicating left uterine rudimentary horn (class U4aC0V0 European Society of Human Reproduction and Embryology/European Society of Gastrointestinal Endoscopy Classification) with communicating endometriotic bladder nodule. Step-by-step description of the surgical treatment. A 33-year-old woman with unicornuate uterus and a left-side noncommunicating rudimentary horn affected by primary infertility, mild dysmenorrhea (visual analog scale score 6), severe catamenial dysuria (visual analog scale score 10), and catamenial hematuria. Noncommunicating rudimentary horns are rare Müllerian anomalies present in 20% to 25% of women with a unicornuate uterus. It is associated with severe dysmenorrhea, pelvic pain, subfertility, and poor obstetric outcomes and usually presents with cyclic pelvic pain that starts early after the menarche. Endometriotic bladder nodules are present in 1% to 2% of patients with endometriosis. In the literature, there are no reported cases of noncommunicating rudimentary horn with communicating endometriotic bladder nodules. Surgical excision of the rudimentary horn is the treatment of choice. In our case, the 2-dimensional/3-dimensional ultrasound revealed a right unicornuate uterus with a left noncommunicating rudimentary horn with hematometra. The uterine fundus presented «gamma sign» vascularization. In addition, a bladder endometriotic nodule (16×15 mm) communicating with hematometra was displayed. Magnetic resonance imaging demonstrated no additional malformations. Diagnostic hysteroscopy revealed a single cervix without vaginal malformation and small right uterine cavity with single tubal ostium. At laparoscopy, using hysteroscopic transillumination, a clear plane of dissection was identified between the rudimentary horn and the uterus confirming the presence of a noncommunicating horn. Evaluation of the abdominal cavity showed bilateral normal adnexa with normal ovaries. Chromopertubation showed a patent right Fallopian tube and obstructed left tube. A left salpingectomy using bipolar and the ultrasonic energy was performed. The utero-ovarian ligament was transected, and the left ovary was preserved. The left ovary was suspended at the pelvic wall, the retroperitoneum was opened, the ureter was identified, and the left uterine artery was temporary occluded. The left round ligament was transected and the left paravesical space was developed. With a lateromedial approach, we opened the vesicouterine septum to dissect the bladder from the rudimentary horn. The endometriotic bladder nodule was gently detached from the uterine horn with a lateromedial approach. The left uterine artery was coagulated and dissected at level of the cervix. A solution of vasopressin was injected between the uterine horn and the uterus. Resection of the rudimentary horn was performed. The peritoneum was closed. The temporary occlusion of the uterine artery was removed. The specimen was placed in a bag and removed using an extracorporeal tissue extraction technique. The late clinical presentation of our patient with only mild dysmenorrhea could be explained by the drainage of the hematometra from the noncommunicating horn into the endometriotic bladder nodule. The bladder symptoms in patients with Müllerian anomalies should be carefully investigated. The laparoscopic removal of rudimentary horn with mobilization of communicating bladder nodule when present is a safe and feasible method to improve symptomatology.

Trichilemmal cysts with proteinaceous material: A potential diagnostic pitfall.

Cysts of the skin are observed frequently and their diagnoses are generally straightforward. However, atypical cystic lesions for which differentiation is indistinct have been noted. We examined five cases of trichilemmal cyst with proteinaceous material (TCPM), which required differentiation from sweat duct/gland tumors. We investigated the histopathological findings of TCPMs and evaluated the immunohistochemical expression of cytokeratin (CK) 10, CK13, CK17, CK19, CD8, and CD117. Immunohistochemical analysis was performed on the 5 TCPMs, 10 trichilemmal cysts (TCs), 5 clear-cell hidradenomas, 5 poroid hidradenomas, and cutaneous normal adnexa. Apoptotic cells were present in the cyst wall with a small amount of keratin or calcification in the cavity of TCPMs. The TCPMs and TCs were negative for CK19 and CD117, on the other hand clear-cell hidradenoma and poroid hidradenoma were positive for CK19 and CD117. The restricted positivity for CK10 was detected in the suprabasal layers of the cyst walls of TCPMs and TCs. The immunostaining patterns of TCPMs and TCs were similar to those of normal follicular isthmus. The histopathological findings with characteristics of TCs and a panel of immunohistochemical antibodies including CD117, CK19, and CK10 contributed to a correct diagnosis of TCPM.

Oophoropexy for Prevention of Recurrent Torsion of Normal Adnexa

<h3>Study Objective</h3> The conservative management of otherwise normal adnexal torsion by de-torsion may lead to recurrent torsion events. With the aim of reducing recurrent torsion events, various oophoropexy techniques have been suggested. We aimed to investigate the efficacy of oophoropexy in preventing recurrent torsion. <h3>Design</h3> Retrospective cohort study. <h3>Setting</h3> University affiliated department of Obstetrics and Gynecology. <h3>Patients or Participants</h3> Cases of oophoropexy operated between January 2010 and March 2021. <h3>Interventions</h3> Laparoscopic oophoropexy techniques (plication of the utero-ovarian ligament and/or fixation to the round ligament), using non-absorbable sutures. <h3>Measurements and Main Results</h3> 15 patients with recurrent torsion of otherwise normal adnexa who underwent oophoropexy were identified. At time of the first torsion event, the mean patients' age was 18.3 ± 7.4 years, and 4 (26.7%) were pre-menarchal. The recurrent torsion involved the right adnexa in 9 (60.0%) cases, the left adnexa in 4 (26.7%) cases, and both adnexa in 2 (13.3%) cases. The mean interval between the first and second torsion events was 17.8 ± 20.2 months. In 3 (20.0%) cases, no recurrence occurred following oophoropexy, while in the remaining 12 (80.0%) cases, up to 4 recurrences were diagnosed. <h3>Conclusion</h3> Laparoscopic oophoropexy procedures, although feasible and safe, may not prevent recurrent torsion of otherwise normal adnexa.

Modulating Cellular Responses to Mechanical Forces to Promote Wound Regeneration.

Significance: Skin scarring poses a major biomedical burden for hundreds of millions of patients annually. However, this burden could be mitigated by therapies that promote wound regeneration, with full recovery of skin's normal adnexa, matrix ultrastructure, and mechanical strength. Recent Advances: The observation of wound regeneration in several mouse models suggests a retained capacity for postnatal mammalian skin to regenerate under the right conditions. Mechanical forces are a major contributor to skin fibrosis and a prime target for devices and therapeutics that could promote skin regeneration. Critical Issues: Wound-induced hair neogenesis, Acomys "spiny" mice, Murphy Roths Large mice, and mice treated with mechanotransduction inhibitors all show various degrees of wound regeneration. Comparison of regenerating wounds in these models against scarring wounds reveals differences in extracellular matrix interactions and in mechanosensitive activation of key signaling pathways, including Wnt, Sonic hedgehog, focal adhesion kinase, and Yes-associated protein. The advent of single-cell "omics" technologies has deepened this understanding and revealed that regeneration may recapitulate development in certain contexts, although it is unknown whether these mechanisms are relevant to healing in tight-skinned animals such as humans. Future Directions: While early findings in mice are promising, comparison across model systems is needed to resolve conflicting mechanisms and to identify conserved master regulators of skin regeneration. There also remains a dire need for studies on mechanomodulation of wounds in large, tight-skinned animals, such as red Duroc pigs, which better approximate human wound healing.

Pseudotumoral Endometriotic Nodule

To demonstrate a rare case of a pediculated endometriotic nodule that was initially diagnosed as a solid adnexal mass. We present a stepwise narrated demonstration of our laparoscopic technique. We present a case report of a patient aged 44 years, gravida 2 para 2, who was diagnosed with a solid (adnexal) mass during a gynecologic examination. She presented symptoms of dyspareunia. During a bimanual examination, 2 fixed nodules were palpated in both the uterosacral ligaments, and a mobile solid mass of 5 cm could be palpated on the right adnex. A transvaginal ultrasound showed a solid (adnexal) mass of 50 mm in diameter. The tumor marker cancer antigen 125 was normal, and after application of the International Ovarian Tumor Analysis score, the risk of malignancy was up to 39%. A complementary magnetic resonance image showed a heterogeneous solid mass of 47×47×29 mm with a differential diagnosis of a pediculated fibroma in (myxoid) degeneration vs an adnexal solid mass. A laparoscopic unilateral adnexectomy was scheduled, and the patient was informed about the risk of malignancy. The laparoscopy revealed bilateral normal adnexa, the presence of a solid pediculated mass originating from the right uterosacral ligament and 2 endometriotic nodules originating from the left and right uterosacral ligaments. The rectovaginal space was dissected, and a third deep infiltrating endometriotic nodule was revealed. The operation proceeded by the sectioning of the left uterosacral ligament below the endometriotic nodule. The posterior vaginal wall was separated from the endometriotic nodule, and after further dissection of the rectovaginal space, we arrived in a disease-free area. After opening of the right medial division of the pararectal space, the right hypogastric nerve was dissected and preserved. The solid mass was separated from the uterus, the right uterosacral ligament was excised at a distance from the nodule, and the pediculated mass was removed intact en block with the right ligament. The patient was discharged 24 hours after surgery. The postoperative period was uneventful. The definitive histology report confirmed the presence of endometriotic nodules and a solid tumor classified as a pseudotumoral endometriotic mass. This was justified by the presence of conjunctival vascular stroma including multiple endometriotic foci, the presence of cytogenic stroma of variable abundance including glands lined with a columnar epithelium, and, most important, the fact that the epithelium had no cytologic atypias. Laparoscopic excision of the pseudotumoral endometriotic nodule en block with the right and left uterosacral ligaments. Endometriosis is a complex multifactorial pathology in which several factors are involved: genetics, environmental factors, immunologic reactions, hormonal effects, and anatomic anomalies. All these factors may contribute to the creation of an inflammatory response related to immune cells, adhesion molecules, extracellular matrix metalloproteinase, and proinflammatory cytokines enhancing the formation of fibrotic tissue [1,2]. These changes may sometimes have an unusual presentation, as we are showing in this case report of a pseudotumoral endometriotic mass. This rare case should be included in the differential diagnosis of solid tumors before surgery for symptomatic patients and those who have a medical history of endometriosis.

Abdominal Ectopic Pregnancy with Retrocervical Localization

Study Objective To present an abdominal ectopic pregnancy with a retrocervical localization and laparoscopic management performed. Design N/A Setting Private health facility. Patients or Participants 36 years old female patient with obstetric history of 4 previous miscarriages and 2 cesarean sections presented at our clinic with a chief complain of abdominal pain and 7 weeks amenorrhea. Blood hCG level was 3500 mUI/ml. Endovaginal ultrasound reveled an abnormal implantation of a gestational sac, behind the uterus, at the recto-vaginal space. The endometrial cavity was normal. Interventions Emergency laparoscopy was performed. Initial assessment of the pelvic cavity reveled blood at cul the sac and normal adnexa from both sides. Careful assessment of structures led to identify an active bleeding spot at the insertion site of the right uterosacral ligament. Trough suction organized tissue was obtained from a peritoneal defect at the bleeding site, making us suspect the gestational sac was implanted at this level. The pararectal space was developed, identifying and lateralizing the hypogastric nerve. The uterosacral ligament was detached from it´s proximal end, managing to expand the peritoneal window with the certainty that important anatomical structures were not involved. This gave access the implantation site of the gestational sac that was removed and hemostasis with bipolar energy was performed. Measurements and Main Results N/A Conclusion Knowledge of the pelvic anatomy is fundamental in the management of any pathology, especially when we encounter surprises such as an abnormal and unusual implantation site of a gestational sac, as observed in the case presented.

Adnexal torsion in the third trimester of pregnancy: a case report and diagnostic value of MR imaging

BackgroundThe torsion of normal adnexa is rare during pregnancy, especially in the third trimester. Nonspecific symptoms and signs as well as the limitations of ultrasound (US) make the diagnosis difficult, resulting in the loss of adnexa and fetal compromise. The magnetic resonance imaging (MRI) features of the torsion of normal adnexa are not classically described during pregnancy and only reported in a few cases. We find some different MRI features of the torsion of normal adnexa in late pregnancy and its diagnosis and treatment values are discussed in our report.Case presentationA 27-year-old woman at 31 + 5 weeks’ gestation presented to the emergency department with a three-day history of the left lower abdominal pain. US discovered a mass of 87 × 61 mm in the left abdomen, but did not show whether the mass originated from the left ovary or the uterus. MRI showed the left ovary was increased in size to 82 × 42 × 85 mm with peripheral follicles. On fat-suppressed T2-weighted images, the signal intensity of the lesion was significantly decreased compared with the right ovary. The adjacent fallopian tube was found to be thickened. The radiologists diagnosed ovary infarction secondary to adnexal torsion. With the provisional diagnosis of adnexal torsion, the patient was taken to surgery. The left adnexal torsion was found during surgery. There was extensive hemorrhage and necrosis, so a left salpingo-oophorectomy was performed. The histopathology confirmed an extensively hemorrhagic fallopian tube and ovary with partial necrosis.ConclusionWe believe MRI is helpful where US is indeterminate in diagnosis of the torsion of normal adnexa in advanced pregnancy. We found that aside from hyperintensity on fat-saturated T1-weighted images, the low signal intensity on T2-weighted images can also reflect adnexal hemorrhage in conjunction with the torsion of normal adnexa.

Adnexal torsion: is there a familial tendency?

Objective: To investigate whether patients diagnosed with adnexal torsion report a family history of adnexal torsion in a first degree relative. Materials and Methods: All women with a surgical diagnosis of adnexal torsion operated from 2008 to 2016 were contacted for participation in the study. The study was conducted by a telephone questionnaire. In addition, the medical records were retrospectively reviewed and information on demographic characteristics, surgical findings at time of torsion, and history of recurrent torsion events were collected. Results: Two hundred thirty women with a surgical diagnosis of adnexal torsion were identified. Of these, 147 women were reached and agreed to participate in the study. A history of adnexal torsion in a first degree relative was reported by seven (4.8%) patients: three cases involved an adnexal torsion event in a sister, and four cases involved an adnexal torsion event in a mother or daughter. Patients with a positive family history of adnexal torsion were more likely to experience torsion of otherwise normal adnexa without adnexal cysts compared to those with a negative family history (71.4% vs. 27.1%, p = 0.01) and to report recurrent torsion events (57.1% vs. 17.1%, p = 0.009). Conclusion: A family history of adnexal torsion in a first degree relative is found in a minority of cases and is significantly associated with torsion of otherwise normal adnexa and with recurrent torsion events. Thus, patients with a family history of torsion may be considered a high-risk subgroup of patients.

Intra-ovarian vascular resistance is useful to diagnose torsion of normal adnexa

Intra-ovarian vascular resistance is useful to diagnose torsion of normal adnexa

Laparoscopic Pectopexy with Burch Colposuspension for Pelvic Prolapse Associated with Stress Urinary Incontinence

To present a case of pelvic organ prolapse associated with stress urinary incontinence treated by laparoscopic pectopexy followed by Burch colposuspension. Case report. University Gynecology Clinic of the Emergency Clinical City Hospital Timișoara, Romania. We present the case of a 41-year-old woman, gravida 1 para 1, with no notable medical or surgical history, with a body mass index of 40 kg/m2, who presented in our service with heavy menstrual bleeding, dysmenorrhea, pelvic pressure, dyspareunia, stress urinary incontinence, and voiding difficulties. Local examination revealed a cervix descended 2 cm below the hymenal ring, cystocele, urethrocele, and a positive cough stress test. The pelvic prolapse was classified as pelvic organ prolapse quantification stage 3. Ultrasound exam revealed a uterus with diffuse adenomyosis of the posterior uterine wall and normal adnexa. Because of the patient's obesity, the treatment plan was laparoscopic supracervical hysterectomy for the treatment of adenomyosis, laparoscopic pectopexy for the correction of the apical defect, and Burch colposuspension for the cure of stress incontinence. The patient was placed in the standard dorsal lithotomy position with the hips in extension and the knees flexed and the table in 45° Trendelenburg position. One 10-mm umbilical optical trocar and three 5-mm trocars were used-2 inserted 2 cm above and medial to the anterior superior iliac crests, and the third, 5 cm below the umbilical trocar. The dissection started on the left side of the pelvis. The peritoneum was incised in the center of a V-shaped area bordered by the left round ligament and the obliterated umbilical artery (the medial umbilical ligament). The soft tissue was dissected, and the left iliopectineal ligament (also known as the inguinal ligament of Cooper) was identified right under the external iliac vein and prepared. The same steps were repeated on the right side of the pelvis. The procedure continued with the dissection of the vesicovaginal space. The anterior vaginal wall was exposed with the help of a retractor placed inside the vagina and held by an assistant. A supracervical hysterectomy was performed. An 8 × 15-cm polypropylene mesh, cut in a T shape, was introduced in the abdomen. First, the short arm of the T was fixed on the anterior vaginal wall using multiple absorbable tacks (AbsorbaTack fixation device; Medtronic, Dublin, Ireland). To use a type of nonabsorbable fixation, we decided to also fix the mesh to the cervix stump with 3 isolated stitches (Silk Suture 2-0; Ethicon, Somerville, NJ). Second, with the purpose of ensuring a permanent fixation, the lateral arms of the mesh were attached to the iliopectineal ligaments with multiple nonabsorbable tacks on both sides (ProTack fixation device; Medtronic, Dublin, Ireland). The procedure continued with the complete closure of the peritoneum with VICRYL 2-0 sutures (Ethicon). Because the patient also had stress urinary incontinence, a Burch colposuspension was performed. To expose its limits, the urinary bladder was filled with 200 mL of saline. After the incision of the peritoneum, the avascular space of Retzius was opened. The dissection continued until the Cooper's ligaments were exposed bilaterally. The proper suture placement points on the vaginal wall were facilitated by an assistant's intravaginal finger. Two isolated nonabsorbable silk stitches (Silk Suture 2-0) were placed through the Cooper's ligament and through the anterior vaginal wall on each side. The knots were tied just enough to properly lift the vaginal wall in the normal position, assessed by the assistant by vaginal route, but not too tight to avoid urethral obstruction. The duration of the surgery was 95 minutes, with minimal blood loss of about 60 mL. The patient recovered well, with the Foley catheter being removed after 12 hours. The patient was discharged after 48 hours. The 6-month follow-up examination revealed a correct anatomical position of the anterior vaginal wall and of the cervix at 6 cm above the hymenal ring and no urinary incontinence. Laparoscopic pectopexy represents a new option for the treatment of pelvic organ prolapse. In the case we reported, no intraoperative or postoperative complications were present, and the follow-up assessment revealed an effective correction of the prolapse. Further studies are needed to conclude the efficiency and safety of this new procedure.

1188 Manual Tissue Extraction: Approach to Vaginal Morcellation

Video Objective Vaginal morcellation is a manual tissue extraction technique used to remove large specimens following robotic, laparoscopic, or vaginal hysterectomy. The objective of this video is to present the technique and required equipment for performing vaginal morcellation following laparoscopic hysterectomy. Setting The case presented is of a 42yo G3P3 woman who presented with fibroid-related abnormal uterine bleeding and a 14-16 week size uterus, with minimal descent. Ultrasound described a multi-fibroid uterus with a normal adnexa. Recent pap smear and endometrial biopsy were normal. Following appropriate counselling, she underwent a total laparoscopic hysterectomy, bilateral salpingectomy, cystoscopy and subsequent vaginal morcellation of the uterine specimen. Interventions We demonstrate a safe and effective vaginal morcellation technique performed with bisection of the uterus, sequential anterior and posterior wedge resections and myomectomy. Conclusion Vaginal morcellation is a safe and feasible technique for manual tissue extraction in the well-selected patient. This procedure allows the surgeon to continue offering minimally invasive options to select patient populations and circumvents the need for laparotomy for specimen extraction. In recent years, there have been concerns regarding morcellation and the potential for inadvertent dissemination of malignant tissue. However, with appropriate patient selection, thorough pre-operative evaluation and careful surgical technique, the risks are low.

Disseminated Peritoneal Leiomyomatosis and Metastatic GIST: Differential Diagnosis Dilemma Regarding Multiple Nodular Serosal Lesions and Management

We aim to discuss cases with gastrointestinal stromal tumor and leiomatosis peritoneal dissemeniata LPD regarding their diagnosis and surgical management with pitfalls related. We also aim to focus on management of multiple nodular serosal lesions. Two cases are presented. Both were diagnosed as advanced ovarian cancer on CT and ultrasound imaging by multiple nodular peritoneal lesions, omental cake and adnexal masses. Tumor markers were normal in both cases. Both were scheduled for exploratory laparotomy. One patient diagnosed with neurofibromatosis type I. Midline laparotomy was done for one case revealing normal adnexa with multiple fibroid uterus, peritoneal solid masses with large mesenteric and omental masses related to the small intestine. Total hysterectomy with bilateral salpingo-oophorectomy, total omentectomy and resection anastomosis for the small intestine with removal of macroscopic lesions were done. Midline line laparotomy was done for the second case revealing free adnexa with subserous vascular fibroids and omental fibroid solid masses. Total hysterectomy with bilateral salpingo-oophorectomy and total omentectomy and removal of macroscopic peritoneal lesions seen were done. The second case was diagnosed as Disseminated Peritoneal Leiomyomatosis, and the other case was diagnosed with multiple uterine fibroid and metastatic GIST on histopathology. Disseminated Peritoneal Leiomyomatosis and metastatic GIST can be similar on imaging and operative findings. Also they are similar to other lesions especially peritoneal carcinomatosis as in advanced ovarian cancer. These pathologies should be kept on mind when encountering multiple solid nodular masses in the visceral and parietal wall peritoneum and the omentum on imaging and intra-operative especially with normal associated tumor markers of ovarian cancer as serum CA125. Surgical and postoperative management differ according to the pathology. These pathologies should be confirmed by histopathology and immunohistochemistry. Frozen section is highly needed in these cases to optimize management.

Torsion of Normal Adnexa in the Third Trimester of Pregnancy Mimicking Acute Appendicitis

Maternal ovarian torsion in pregnancy is very rare. Non-specific symptoms, signs, and imaging findings make the diagnosis difficult. A delay in diagnosis can lead to irreversible damage to adnexa and fetal compromise. Difficulties encountered in the diagnosis and management of adnexal torsion in the third trimester of pregnancy are highlighted in this article.

Clinical Study of Postmenopausal Bleeding

Background: Women with postmenopausal bleeding (PMB) should be thoroughly evaluated. A thorough examination may help in the diagnosis of vulval, vaginal, cervical or pelvic pathology.Objective: This study was carried out to find the probable causes in patients presenting with postmenopausal bleeding.Materials and method: This observational study included 50 women with postmenopausal bleeding and was conducted in the department of Obstetrics and Gynaecology of Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorder (BIRDEM) Hospital, Dhaka, Bangladesh, from January 2004 to December 2004. Transvaginal ultrasonogram (TVS), diagnostic curettage and cervical biopsy were done and histopathology report was collected.Results: The mean age of the patients was 57.74 years (range 48-75 years), and the median age of menopause was 50 years. Among the patients 18 (36%) had only diabetes and 25 (50%) patients had both diabetes and hypertension. Nineteen patients (38%) were overweight, 5 patients (10%) were obese and 2 (4%) were morbidly obese. Per speculum examination revealed suspected cervical carcinoma in 5 cases (10%) and cervical polyp in 1 case (2%). The most common clinical finding was atrophy of the uterus and vagina in 26 patients (52%). TVS revealed endometrial thickness of 5mm or more in 17 cases (37.7%) and &lt; 5mm in 26 cases (57.7%). Nine patients (18%) had carcinoma, 16 patients (32%) had benign pathology and 19 (38%) patients had endometrial atrophy on histology.Conclusion: A detailed history taking, thorough physical examination and relevant investigations can lead to a correct detection of cause of postmenopausal bleeding. Those who have normal adnexae and thin endometrium (endometrium &lt;5mm) may not need endometrial biopsy.Delta Med Col J. Jul 2017 5(2): 83-88

Serous Tubal Carcinogenesis: The Recent Concept of Origin of Ovarian, Primary Peritoneal and Fallopian Tube High-Grade Serous Carcinoma.

Pelvic (non-uterine) high-grade serous carcinomas (PHGSC) including ovarian, tubal and primary peritoneal serous carcinomas have increased death: incidence ratio due to presentation at advanced stage, rapid progression, poor prognosis and high morbidity. Ambiguity regarding their pathogenesis and lack of a proper screening method is the cause of their late detection and high fatality rate. This study was undertaken to assess the fallopian tube for the presence of precursor lesions in pelvic serous carcinoma. This was a prospective case-control study carried out in a tertiary care center. Consecutive specimens of 55 cases of pelvic high-grade serous carcinoma and 41 controls inclusive of 21 low-grade serous carcinoma, 10 benign adnexal masses and 10 normal adnexa were included in the study. Both side fallopian tubes in each case were subjected to histopathological examination and p53, Ki67 immunohistochemistry. There were 55 cases of PHGSC comprising of 50 cases of ovarian HGSC, two cases of primary peritoneal carcinoma (PPC) and three cases of tubal carcinoma. Serous tubal intraepithelial carcinoma (STIC) was detected in 14 cases (28%), p53 signature in 13 cases (26%) and tubal intraepithelial lesion in transition in 10 cases (20%) of ovarian HGSC. One case (50%) of PPC and one (33%) case of tubal carcinoma revealed the presence of STIC. None of the controls exhibited any precursor lesion except ovarian low-grade serous carcinoma where p53 was detected in 20% of cases. This revelation concludes that fallopian tubes are the sites of precursors of PHGSC to a large extent. In the absence of a proper screening method of HGSC, prophylactic bilateral salpingectomy at hysterectomy for benign diseases can achieve ultimate goal of reduction in incidence of PHGSC.

Uterine perforation and small bowel incarceration 11 months after dilatation and curettage: sonographic and surgical findings

In 2014, a 33-year-old primiparous woman was referred by her physician to the emergency department of the Catholic University of Rome for abnormal uterine findings at routine gynecological examination, performed 11 months after vaginal delivery. She was breastfeeding and her menstrual cycle had not yet recommenced. She had undergone dilatation and curettage (D & C) 4 weeks after delivery because of retained membrane. Gynecological examination revealed a tender uterus with a closed cervix and normal adnexa. Laboratory findings were not significant, with a normal white blood cell count and negative for β-human chorionic gonadotropin. On referral to our department, we performed a transvaginal ultrasound examination using a GE Voluson E8 (GE Medical Systems, Zipf, Austria) ultrasound system. A tubular structure, with distinct multilayered appearance of normal intestinal wall1, was seen penetrating into the uterine cavity through the anterior wall of the uterine body (Videoclip S1). The presence of typical normal echostructure of intestinal wall and peristaltic movement suggested perforation of the uterus with penetration of the bowel. Color Doppler ultrasound examination confirmed this hypothesis (Videoclip S2). A small amount of anechoic free fluid was seen in the cul-de-sac. Laparoscopy revealed about 10 cm of small intestine prolapsed through the uterine perforation, adherent to the myometrial wall. The uterine fundus had a hole of approximately 4 cm in size (Videoclip S3). The bowel had penetrated through this gap, occupying the entire endometrial cavity and reaching the upper part of the cervix. Adhesions between the bowel and the endometrial cavity and myometrium were removed and the uterine structure was reconstructed. A perforation of 1 cm was detected on the surface of the entrapped bowel that was resected laparoscopically. The patient was discharged after 5 days with no postsurgical complication. Delayed presentation of uterine perforation after D & C, as reported here, is rare2. Treatment usually consists of laparotomic surgery3; the laparoscopic approach described in this case is, we believe, one of few reported in the medical literature. A. De Cicco†, F. Mascilini‡, M. Ludovisi‡, F. De Cicco†, G. Scambia‡ and A. C. Testa*‡ †Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Rome, Italy; ‡Division of Gynecology, Department of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Rome, Italy *Correspondence. (e-mail: atesta@rm.unicatt.it) Videoclips S1 and S2 Grayscale (S1) and color Doppler (S2) ultrasound videoclips showing hyperechogenic tubular structure penetrating through anterior wall of uterine body. Videoclip S3 Intraoperative videoclip demonstrating defect in fundal myometrium of uterus, through which small bowel is incarcerated. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.