Unexpected Uterine Leiomyosarcoma During Laparoscopic Hysterectomy Treated 6 Months With Ulipristal Acetate and Contained Power Morcellation

Abstract Background An adenomyoma is a well circumscribed form of adenomyosis and can be located within the myometrium, in the endometrium as a polyp, or extrauterine with the last being the rarest presentation amongst the three. With the ongoing advancement in gynecological surgery, the use of electromechanical morcellators have made the removal of large and dense specimens possible with minimally invasive techniques. However, it has also caused an increase in complications which were previously rare. Whilst the tissue is being grinded within the abdominal cavity, residual tissue can spread and remain inside, allowing for implantation to occur and thereby giving rise to recurrence of uterine tissue as a new late postoperative complication. Case presentation A 45-year-old woman presented with worsening constipation and right iliac fossa pain. Her past surgical history consists of laparoscopic supra-cervical hysterectomy that was indicated due to uterine fibroids. Computerized tomography and magnetic resonance imaging were done, which showed an irregular lobulated heterogeneous mass seen in the presacral space to the right, located on the right lateral aspect of the recto-sigmoid, measuring 4.5 × 4.3 × 4.3 cm in size. A transvaginal ultrasound revealed a cyst in the left ovary. The patient had a treatment course over several months that included Dienogest (progestin) and Goserelin (GnRH analogue) with add-back therapy. In line with the declining response to medications, the patient was advised for a laparoscopic ovarian cystectomy. During the surgery, an additional lesion was found as a suspected fibroid and the left ovarian cyst was identified as pockets of peritoneal fluid which was sent for cytology. The surgical pathology report confirmed adenomyosis in both specimens, namely the right mass and the initially suspected fibroid. Conclusion In this case report, we showcase a rare occurrence of an extrauterine adenomyoma presenting two years post laparoscopic morcellation at hysterectomy. This poses questions regarding the benefits versus risks of power morcellation in laparoscopic hysterectomy.

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Leiomyosarcoma after Total Laparoscopic Hysterectomy with Power Morcellation

Case Reports in Obstetrics and Gynecology ◽

10.1155/2019/9381230 ◽

2019 ◽

Vol 2019 ◽

pp. 1-4

Author(s):

Tsukasa Takahashi ◽

Tomohisa Ugajin ◽

Noriaki Imai ◽

Atsushi Hayasaka ◽

Nobuo Yaegashi ◽

...

Keyword(s):

Pelvic Mass ◽

Laparoscopic Hysterectomy ◽

Additional Treatment ◽

Total Laparoscopic Hysterectomy ◽

Invasive Technique ◽

Pathologic Evaluation ◽

Power Morcellation ◽

Pathological Evaluation ◽

Submucosal Fibroids ◽

Occult Malignancy

Introduction. Power morcellation is an effective and minimally invasive technique used to remove specimen tissues or the uterus in total laparoscopic hysterectomy (TLH). However, it has the risk of intraperitoneal dissemination of tissue and can cause a parasitic myoma. We report a case of leiomyosarcoma that occurred 4 years after TLH with power morcellation for fibroids. Case. A 52-year-old woman was referred to our hospital with a pelvic mass. She was diagnosed to have submucosal fibroids and had undergone TLH with power morcellation 4 years previously. The uterus weighed 398 g at that time. At present, a parasitic myoma was suspected, owing to the diagnosis of fibroids on the initial pathological evaluation. She underwent laparotomy, and the tumor was removed. Although the pathological evaluation confirmed the tumor to be a leiomyosarcoma, a review of the initial tissue did not show the presence of any malignancy. Since there was no metastasis, she was followed-up without additional treatment. Conclusion. Even if the initial pathologic evaluation suggests a benign mass, parasitic myoma and even sarcoma can occur after TLH with power morcellation. Considering the risk of dissemination and occult malignancy, the use of power morcellation should be avoided if there are alternative options to remove the tumor.

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Choosing a Surgical Access Point for Hysterectomy: A Paradigm Shift Over a 10-Year Span

Frontiers in Medicine ◽

10.3389/fmed.2020.569895 ◽

2020 ◽

Vol 7 ◽

Author(s):

Florian Ebner ◽

Niko de Gregorio ◽

Christiane Lato ◽

Valerie Ohly ◽

Wolfgang Janni ◽

...

Keyword(s):

Endometrial Cancer ◽

Laparoscopic Hysterectomy ◽

Access Point ◽

University Hospital ◽

Annual Number ◽

Ulipristal Acetate ◽

Surgical Access ◽

Clear Shift ◽

Laparoscopic Assisted ◽

Observation Period

Background: When choosing a surgical procedure for a hysterectomy, doctors and patients have various options in terms of the multiple surgical access points available. The aim of this study was to descriptively analyze developments concerning the surgical access point selected over the past 10 years at Ulm University Hospital, (south) Germany, assess the variables associated with the surgical method and explore any potential significant correlations that influence these surgical access routes. Explicitly, we wished to investigate whether the approval of ulipristal acetate and the warning issued by the Food and Drug Administration (FDA) in connection with its use changed existing trends.Material and Methods: This monocentric study retrospectively assessed data from all patients who underwent a hysterectomy due to a benign disease or endometrial cancer from January 2007 until December 2016.Results: Of the benign indications considered, myomas and descensus genitalis occurred most frequently (49.5 and 30.6%, respectively). The percentage of abdominal procedures declined from 61.4 to 13.4% between 2007 and 2016 for all hysterectomies, whilst it increased from 4.1 to 69.7% for laparoscopic hysterectomies. The rate of vaginal hysterectomies increased to 45.5% until 2013 and declined in the years afterwards. Laparoscopic assisted vaginal hysterectomies were comparatively rare.The trends in terms of surgical routes were similar for endometrial cancer. During the observation period, the share of abdominal hysterectomies fell from 100 to 11.3%, whilst the share of laparoscopic hysterectomies increased from 0 to 86.6%. The other two procedures were less frequently used.Use of the laparoscopic hysterectomy procedure also increased significantly after the FDA's 2014 warning. Ulipristal acetate may have tended to influence the process.Conclusion: Contrary to the national decrease in hysterectomy numbers, the annual number of hysterectomies at Ulm University Hospital remained stable during the observation period. Nevertheless, there was a clear shift in the preferred surgical routes for hysterectomy.

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