Classifying Adenomyosis: Progress and Challenges

Classically, the diagnosis of adenomyosis relied on histological examination of uteri following hysterectomy and classifications focused on the depth of endometrial invasion within the myometrium. There remain uncertainties around the cut-off point for the histological diagnosis. Imaging-based diagnosis enables recognition of the condition in women not undergoing surgery and facilitates the assessment of the extent of adenomyosis within the whole uterus, as well as of affections of the uterovesical pouch and of the pouch of Douglas. In this article, we explore the diagnostic uncertainties, the need to produce a classification of the condition and the challenges towards that goal. A distinction should be drawn between disease mapping and a classification that may link histological or image-based features with clinical characteristics, or with pathophysiology. An agreed system for reporting adenomyotic lesions may enable comparisons of research studies and thus contribute towards an informed classification. To this aim, we outline the features of the condition and explore the characteristics that are considered when producing a taxonomy. These include the latest proposal for subdivision of adenomyosis into an internal and an external variant. We also explore the uncertainties linked to classifying involvement of the uterovesical pouch, the pouch of Douglas and lesions in the outer myometrium. The limitations of currently available evidence suggest that agreement on a hypothesis to underpin a classification is unlikely at present. Therefore, current efforts will probably remain focused on disease mapping.

Surgical lysis of nerve entrapment caused by retroperitoneal fibrosis/adhesions; two case reports and a literature review

Introduction: Retroperitoneal fibrosis (adhesions) in the pelvic area is rare and not well known in gynecology. However, their presence can cause compression neuropathy leading to severe pain symptoms involving the lower extremities. A neuropelveological approach can be applied in dealing with such cases in diagnosis and management. Objective: To demonstrate neurolysis of sacral nerves in patients with retroperitoneal fibrosis (adhesions). Case presentations: Case 1: A 43-year-old gravidity 1 parity 1 female patient with known endometriosis presented with dysmenorrhea, dyspareunia, and left-sided sciatica. Gynecological examination revealed a rectovaginal nodule and full obliteration of pouch of Douglas. Robot-assisted laparoscopic sacral neurolysis and dissection of pouch of Douglas with rectal nodule shaving was performed. The patient was symptom free 6 months postoperatively. Case 2: A 49 years old gravidity 2 parity 2 female patient presented with severe pain on the left groin and leg, dysuria, and constipation, which required frequent manual evacuation of the feces. The begin of her symptoms coincided with a previous laparoscopic total hysterectomy, where she experienced postsurgical hemorrhage. Laparoscopic sacral neurolysis with adhesiolysis was performed. The patient was symptom free 6 months postoperatively. Conclusion: Pelvic retroperitoneal fibrosis (adhesions) are rarely encountered in gynecology. However, they should be included in differential diagnosis in patients presenting with pelvic pain accompanied by lower extremity pain, urinary, and/or bowel symptoms. Since presurgical diagnosis of fibrosis (adhesions) is hard with visualization techniques such as transvaginal ultrasound or magnetic resonance imaging, a thorough neuropelveological examination can be helpful in such cases.

MRI findings in ruptured ovarian ectopic pregnancy: an unexplored avenue

Ovarian ectopic pregnancy (OEP) is a rare form of ectopic pregnancy (EP) and constitutes approximately 0.5-3% of all ectopic cases. Its presentation mimics the symptoms of tubal ectopic pregnancy, hemorrhagic ovarian cyst/follicle, tubo-ovarian abscess, urinary tract calculi, appendicitis or ovarian torsion. Occasionally determining the anatomic location of an extra-tubal ectopic pregnancy based on ultrasound imaging and presentation alone can be challenging, particularly when it is adherent to the fallopian tube. Although transvaginal ultrasound (TVS) is the primary modality used in the diagnosis, various forms of OEP and its complications may be incidentally detected and further evaluated on computed tomography (CT) or magnetic resonance imaging (MRI) when an alternative diagnosis is suspected. We reported a case of a second gravid para zero, 25 years old lady, who came with pain in the left lower abdomen. Her urine pregnancy test was positive. TVS showed empty uterine cavity, an extremely tender, heterogenous hyperechoic right adnexal mass, but no obvious gestation sac (GS). A large hematoma was detected adjacent to it in the pouch of Douglas (POD). Keeping a high suspicion of ectopic pregnancy, MRI was performed to evaluate the lesion better which revealed a natural, non-assisted, ruptured right ovarian ectopic pregnancy and was subsequently confirmed at laparotomy and proven on histopathology. Patient underwent left oophorectomy and discharged on 4th day with uneventful follow up.

Retroperitoneum parasitic leiomyoma: Dilemmatic diagnostic

HIGHLIGHTS1. Parasitic leimyoma was found in a 38 year-old woman with complaint of mass in lower abdomen and already done biopsy by laparotomy 4 months before.2. During operation, the tumor was detached from the uterus, located retroperitoneally as high as L4 – S1 vertebrae.3. The tumor had been confirmed intraoperatively and proven histopathologically as parasitic leimyoma.4. Retroperitoneal parasitic leiomyoma is of a rare type and it needs multidisciplinary examination and approaches to increase the quality of its management.ABSTRACTObjectives: To describe a retroperitoneum parasitic leiomyoma case: a dilemma in diagnosis and operation finding.Case Report: A 38 year-old woman with 3 children visited Ulin Hospital, Banjarmasin, Indonesia, with complaint of mass in lower abdomen and about 4 months before, she underwent biopsy by laparotomy which revealed leiomyoma. Parasitic leiomyoma is a rare type of leiomyoma with predilection area in broad ligament, pelvic peritoneum, pouch of douglas, and omentum. During operation, the tumor was detached from the uterus and located retroperitoneally as high as L4–S1. It had been confirmed intraoperatively and proven histopathologically as a leiomyoma.Conclusion: Retroperitoneal parasitic leiomyoma may cause a dilemma in the diagnosis. Multidiscipline examination and approaches may increase the quality of management.

A Case of Elastography-Assisted Laparoscopic Fertility Preservation for Severe Deep Endometriosis Causing Ureteral Stenosis and Subtype II Adenomyosis

Adenomyosis is commonly treated by total hysterectomy. Adenomyomectomy is considered for women of reproductive age who wish to preserve their fertility. However, a high recurrence rate following adenomyomectomy has been reported because complete removal of the lesion is difficult, and uterine rupture during pregnancy remains a complication. We previously reported that laparoscopic adenomyomectomy using a cold knife prevented thermal damage to the myometrium and elastography to avoid residual lesions. Here, we report the case of a patient who underwent complete resection of a subtype II adenomyosis and resection of deep endometriosis (DE) with the closure of the pouch of Douglas. The patient was 31 years old, had severe dysmenorrhea, and had left ureteral stenosis and subtype II adenomyosis associated with the closure of the pouch of Douglas by the DE. After resection of the DE posterior wall adenomyosis, residual lesions were confirmed by laparoscopic real-time elastography. Eight weeks after surgery, postoperative transvaginal ultrasound showed that the myometrium had shrunk from 28 to 22.7 mm, and the hydronephrosis had disappeared, although a stent remained necessary. In this study, we report the complete resection of subtype II adenomyosis and DE, combined with elastography to visualize the lesions during resection.

Case report on an enigma of caesarean section: ‘scar endometriosis’

Endometriosis is described as a disease in which functional endometrial glands and stroma that commonly lines the uterus grows outdoor the uterus. The resulting cystic or solid tumoral masses due to endometriosis are named as endometrioma. They're normally seen within the ligaments of uterus, ovaries, pouch of Douglas and pelvic peritoneum however endometriosis has additionally been noted in nose, breast, lung, spleen, gastrointestinal tract, kidney, abdominal wall, however scar endometriomas are extremely uncommon and difficult to diagnose. This situation may be puzzled with different surgical conditions, however imaging strategies and FNAC can assist in diagnosing it better. Medical treatment is helpful in selected cases but wide excision is the treatment of choice.

Deep learning to diagnose pouch of Douglas obliteration with ultrasound sliding sign

Objectives: Pouch of Douglas (POD) obliteration is a severe consequence of inflammation in the pelvis, often seen in patients with endometriosis. The sliding sign is a dynamic transvaginal ultrasound (TVS) test that can diagnose POD obliteration. We aimed to develop a deep learning (DL) model to automatically classify the state of the POD using recorded videos depicting the sliding sign test. Methods: Expert sonologists performed, interpreted, and recorded videos of consecutive patients from Sept 2018-Apr 2020. The sliding sign was classified as positive (i.e. normal) or negative (i.e. POD obliteration). A DL model based on a temporal residual network was prospectively trained with a dataset of TVS videos. The model was tested on an independent test set and its diagnostic accuracy including area under the receiver operating characteristic curve (AUC), accuracy, sensitivity, specificity, positive and negative predictive value (PPV/NPV)) was compared to the reference standard sonologist classification (positive or negative sliding sign). Results: A positive sliding sign was depicted in 646/749 (86.2%) videos, whereas 103/749 (13.8%) videos depicted a negative sliding sign. The dataset was split into training (414 videos), validation (139), and testing (196) maintaining similar positive/negative proportions. When applied to the test dataset using a threshold of 0.9, the model achieved: AUC 96.5% (95%CI,90.8-100.0%), an accuracy of 88.8% (95%CI,83.5-92.8%), sensitivity of 88.6% (95%CI,83.0-92.9%), specificity of 90.0% (95%CI,68.3-98.8%), a PPV of 98.7% (95%CI,95.4-99.7%), and an NPV of 47.7% (95%CI,36.8-58.2%). Conclusions: We have developed an accurate DL model for the prediction of the TVS-based sliding sign classification.

A Large Parasitic Dermoid Cyst in The Pouch of Douglas, A Torsion Complication?

Objectives: To identify the underlying etiology of dermoid cysts in the pouch of Douglas. Case presentation: A 44-year-old woman presented to our clinic complaining of chronic, dull-aching lower abdominal pain of one-month duration. Pelvic ultrasound examination showed an eight-centimeter cystic appearing lesion in the right adnexa. Computed tomography (CT) suggested the diagnosis of dermoid cyst. Laparoscopy revealed a residual ovarian tissue on the right side and an eight-centimeter cystic mass occupying the pouch of Douglas. The entire specimen was removed en bloc through the umbilicus incision inside a bag with no spillage. Histopathologic examination confirmed the diagnosis of a mature cystic teratoma. Conclusion: Parasitic dermoid cysts are extremely rare entity especially those located in the pouch of Douglas. Autoamputation and reimplantation is the most accepted etiology to explain this phenomenon. Key-words: Autoamputation, dermoid cyst, Douglas, Laparoscopy, Mature cystic teratoma

Delayed asymptomatic retroperitoneal dislodgement into the pouch of Douglas of a TLIF cage: A case report and review of the literature

Background: Intraoperative anteropulsion of a transforaminal lumbar interbody fusion (TLIF) cage is infrequent but may have disastrous complications. Here, we present an 80-year-old female whose L5-S1 TLIF cage extruded anteriorly and later migrated into the pouch of Douglas (i.e. an anterior peritoneal reflection between the uterus and the rectum) posing potential significant risks/complications, particularly of a major vessel injury. Notably, this 80-year-old patient with degenerative lumbosacral scoliosis should have only undergone a lumbar decompression alone. Case Description: An 80-year-old female underwent a two-level L4-L5 and L5-S1 TLIF to address lumbosacral canal stenosis with degenerative scoliosis. During the L5-S1 TLIF, intraoperative fluoroscopy showed the anterior displacement of the cage ventral to the sacrum. As she remained hemodynamically stable, the cage was left in place. The postoperative CT scan confirmed that the cage was located in the retroperitoneum but did not jeopardize the major vascular structures. Three months later, however, the cage migrated inferiorly into the pouch of Douglas. Although asymptomatic, general surgery and gynecology advised laparoscopic removal of the cage to avoid the potential for a major vessel/bowel perforation. However, the patient refused further surgery, and 3 years later remained asymptomatic. Conclusion: Anterior cage migration following TLIF has been rarely reported. In this case, an L5-S1 TLIF cage extruded anteriorly in an 80-year-old severely osteoporotic female and migrated 3 months later into the pouch of Douglas, posing the risk of a major vessel/bowel injury. Although surgical removal was recommended, the patient refused further surgery but remained asymptomatic 3 years later. Notably, the authors, in retrospect, recognized that choosing to perform a 2-level TLIF in an 80-year-old female reflected poor judgment.