Congenital paraurethral cysts in two newborn girls: differential diagnosis, management strategies, and spontaneous resolution

BackgroundAt least five types of interlabial masses of different etiologies may present in a female neonate. The more serious type of interlabial mass must be differentiated from the benign and self-resolving paraurethral or hymenal cyst. Clues include appearance and color of the mass and the location of the mass in relation to the urethral meatus and the vaginal opening. Clinicians should be able to distinguish lesions that require aggressive intervention, i.e. surgery, from those that self-resolve and merely require observation.CaseTwo unrelated newborn girls each had a protruding faint-yellow-colored spherical interlabial cyst. The cyst was located anterior to the vaginal orifice and partially obscured the urethral meatus. Neither girl had any voiding problems. No other congenital anomalies were detected. Both cysts resolved rapidly and completely without surgical intervention.Summary and ConclusionParaurethral cysts of the newborn and hymenal cysts rarely cause urinary obstruction or spotting, and are self-resolving. When positively identified, no evaluation of upper urinary tract is required and neither aspiration of cyst contents or marsupialization procedure is necessary.     

Congenital Urethral Polyps in Girls: As a Differential Diagnosis of Interlabial Masses

Study ObjectiveTo present the clinical appearance, differential diagnosis, long-term follow-up, and the surgical result of single-center experience with female urethral polyps presenting as an interlabial mass, and to report the common causes of interlabial masses in infants.DesignAll 12 girls who presented with an interlabial mass and intermittent bleeding have been included in this study; however, the benign urethral polyps are discussed in detail and are the subject of this study.SettingAll patients were referred to our national referral pediatric urology center with initial impression of vaginal bleeding; however, rhabdomyosarcoma of bladder and urethra (n = 2) or vagina (n = 3) and urethral polyp (n = 7) was the final diagnosis.ParticipantsThe records of 12 girls who presented with external genitalia bleeding were retrospectively reviewed. Among them, 7 had fibroepithelial polyps and underwent initial polypectomy between 2001 and 2011with mean age of 21.5 months (range: 1-90 mo). All girls underwent endoscopic surgical removal of polyps.Main Outcome MeasuresNo postoperative polyp recurrence was observed following endoscopic polyp resection.ResultsThe postoperative period was uneventful except in 1 girl who had immediate postoperative urethral bleeding which stopped spontaneously. There was no major complication or polyp recurrence after operation during the long-term follow-up.ConclusionsThe interlabial mass must be considered as a urethral polyp and should be differentiated from the vaginal rhabdomyosarcoma with protrusion of vaginal tumor from the vaginal outlet or other benign lesions. Physical examination in frog legged position or examination under anesthesia with urethrocystoscopy may confirm the final diagnosis.     

Urinary retention as the presentation of Bartholin's duct cyst in a neonate

Patients with a vaginal mass (large Bartholin's duct cyst) associated with a contralateral renal cyst and hydroureteronephrosis are unable to urinate. While occasionally seen in adults, Bartholin's duct cyst is rare in neonates. The origins of Bartholin's and Gartner's cysts can be traced to the mesonephric duct. Given the rarity of these cysts, there is significant confusion regarding their diagnosis, management, and prognosis. Here, we present the first report of an interlabial mass as a Bartholin's duct cyst in a neonate. The treatment of vaginal cysts is also discussed.     

Recurrent Ovarian Torsion due to Paratubal Cysts in an Adolescent Female

BackgroundThough paratubal and paraovarian cysts are rare in adolescent females, the influence of post-menarchal hormonal stimulation on these tubal derivates can produce large and clinically significant adnexal pathology. Ovarian torsion secondary to paratubal cysts is rare due to the cyst’s location and ipsilateral recurrence is uncommon.CaseWe report a case of an 11-year-old female with a large right paratubal cyst causing ovarian torsion on two separate occasions within one year and our approach to surgical management.ConclusionExcision of a paratubal or paraovarian cyst that causes ovarian torsion is necessary to decrease the risk of cyst recurrence and ovarian torsion in the future. Timely diagnosis and treatment of ovarian torsion enables preservation of ovarian function and patient fertility.     

Paraurethral cysts in female newborns: role of maternal estrogens

Paraurethral or Skene's duct cyst is a rare cause of introital mass in neonates. We report two female newborn cases with paraurethral cysts associated with vaginal bleeding and breast enlargement. These associations raise the question of whether maternal estrogens play a role in the development of paraurethral cysts.     

Penile epidermal inclusion cyst: a late complication of penile girth enhancement surgery

IntroductionEpidermal inclusion cysts are benign lesions that can develop in any part of the body. However, the finding of an epidermal inclusion cyst in the penis is rare.AimThe aim of this article was to present the management of a case of a penile epidermal inclusion cyst that occurred because of late complications of a penile girth enhancement surgery.MethodsA 52-year-old man presented with a painless, slowly growing mass in the penis, which was first noted after a penile girth enhancement surgery 20 years ago. A cystic mobile mass about 2 cm in depth was found surrounding the coronal sulcus. Excision of the mass was performed for diagnosis and treatment.ResultsThere was no communication with the urethra. The pathological diagnosis was an epidermal inclusion cyst of the penis.ConclusionsA penile epidermal inclusion cyst in adult men is rare. It can develop after an inadequate procedure for penile girth enhancement, and should be treated by complete resection. Park HJ, Park NC, Park SW, Jern TK, and Choi K-U. Penile epidermal inclusion cyst: A late complication of penile girth enhancement surgery. J Sex Med 2008;5:2238–2240.     

Laparoscopic Management of an Ovarian Dermoid Cyst Containing a Mandibular Structure with Teeth: A Novel Surgical Approach

BackgroundThe presence of ectodermal-derived tissue, including teeth, in an ovarian dermoid cyst is a common occurrence. The presence of a fully formed mandibular structure with teeth, however, is rare, and there are few case reports in the literature that discuss its surgical management.CaseWe report a case of an adolescent girl found to have a mandibular structure with teeth in her dermoid cyst at the time of her laparoscopic ovarian cystectomy and a novel surgical approach in the extraction of the cyst contents from the abdominal cavity.Summary and ConclusionThe use of an arthroscopic surgical blade to morcellate the mandibular-like bone allowed for completion of the procedure laparoscopically, without laparotomy for specimen extraction, allowing the patient to benefit from the advantages of minimally invasive surgery.     

Ovarian Reserve Following Laparoscopic Ovarian Cystectomy vs Cyst Deroofing for Endometriomas

Study ObjectiveBecause laparoscopic ovarian cystectomy of endometriomas is known to adversely impact patient ovarian reserve, the search for other techniques of surgical management is ongoing. The present study was undertaken to evaluate laparoscopic cyst deroofing as a feasible alternative.Study DesignProspective, randomized clinical trial (Canadian Task Force classification I).SettingUniversity maternity hospital.PatientsWomen diagnosed with unilateral or bilateral ovarian endometriomas.InterventionsPatients were managed with either laparoscopic ovarian cystectomy or cyst deroofing.Measurements and Main ResultsA total of 122 women with endometriomas were randomized to either laparoscopic cystectomy (group 1) or laparoscopic cyst deroofing (group 2). The primary endpoint was the effect on ovarian reserve based on changes in anti-Müllerian hormone (AMH) values. At 1 month postsurgery, anti-Müllerian hormone values were significantly decreased (p < .001) from preoperative values, from 4.25 ± 0.87 ng/mL to 1.66 ± 1.02 ng/mL in group 1 and from 4.2 ± 1.69 ng/mL to 2.15 ± 1.48 ng/mL in group 2. In addition, antral follicle count and ovarian volume decreased significantly (p < .001) in both groups by 1 month postsurgery. The decreases in these 3 parameters were more significant (p < .001) in group 1 than in group 2.ConclusionLaparoscopic cyst deroofing of endometriomas appears to be a promising alternative to laparoscopic cystectomy, with less postoperative decrease in ovarian reserve; however, the higher rate of endometrioma recurrence warrants future clinical research to determine the optimal surgical management of endometriomas.     

A Rare Interlabial Mass in a 9-Month-Old Infant: A Case Report and Review of Literature

BackgroundInterlabial masses in infants and children are quite rare. One of their rarest causes is urethral polyp or urethral caruncle. It is a benign fleshy outgrowth at the urethral meatus. Certain etiology is still unknown.CaseA healthy 9-month-old female infant presented with a mass protruding from the vulva with no other complaints. Examination with the patient under general anesthesia revealed an interlabial mass appearing as a pedunculated pinkish polyp, originating from the posterior lip of the external urethral meatus. Surgical excision of the mass was done and histopathology confirmed it to be a urethral polyp.Summary and ConclusionUrethral polyps are rare in the pediatric age group. Their occurrence in this age group might support a congenital etiology. Surgical resection of polyps allows histopathological examination and a high cure rate with no risk of recurrence.     

Valsalva Maneuver-induced Priapism: A Hidden Culprit

IntroductionPriapism is defined as an abnormal prolonged penile erection without sexual interest and failure to subside despite orgasm. The disorder is enigmatic yet devastating because of its elusive etiology, irreversible erectile tissue damage, and resultant erectile dysfunction. A wide variety of provocative factors have been implicated in different types of priapism; however, myelopathy-related ischemic priapism induced by the Valsalva maneuver in the context of spinal extradural arachnoid cyst has never been described.AimTo report a case with spinal extradural arachnoid cyst heralded by Valsalva maneuver-induced priapism and review the mechanistic basis for acute myelopathy-related priapism.MethodsThe case report profiled a 42-year-old Chinese man presenting with ischemic priapism following in-flight Valsalva maneuver for unblocking the ears during descent. Magnetic resonance imaging unveiled the hidden culprit behind myelopathy-related priapism, as demonstrated by acute spinal cord compression from a giant extradural arachnoid cyst.ResultsThe symptoms subsided rapidly after treatment with ice packing, analgesics, and corporal irrigation with diluted epinephrine. However, surgical removal of the extradural arachnoid cyst failed to achieve a complete recovery of neurological deficits. After 1 year of follow-ups, he still experienced a mild weakness and hypesthesia of the right leg but no further episodes of priapism or sexual dysfunction.ConclusionsMyelopathy-related priapism potentiated by the Valsalva maneuver can be easily overlooked without heightened vigilance, leading to poor therapeutic response and prognosis. The indolent nature of spinal extradural arachnoid cyst should be reinforced and better outcomes can only be achieved through expeditious diagnosis and management. Chen WL, Tsai WC, and Tsao YT. Valsalva maneuver-induced priapism: A hidden culprit. J Sex Med **;**:**–**.     

Large Epidermal Cyst of the Clitoris: A Novel Diagnostic Approach to Assist in Surgical Removal

BackgroundEpidermal cysts of the clitoris are uncommon and usually associated with previous trauma. Surgical removal is the preferred treatment with close attention to preserve sensation and vascular supply. The use of an alternative coil during Magnetic Resonance (MR) imaging to visualize the anatomy may improve surgical management and outcomes.CaseA 15-year-old adolescent had a 2-year history of clitoral enlargement. Physical exam revealed a 4 × 5 cm clitoral cyst and normal hormonal evaluation. Initial MR with a pelvic coil showed poor resolution of neurovascular supply. MR was repeated using a small flex coil (commonly used on the wrist) placed as a sanitary napkin providing a higher resolution image of the neurovascular structures, which guided surgical intervention.ConclusionThe use of the MR small flex coil to better visualize the external genital structures and clitoral anatomy improved preoperative evaluation and guided surgical management of the clitorial cyst.     

Isolated Fallopian Tube Torsion in Pediatric and Adolescent Females: A Retrospective Review of 15 cases at a Single Institution

Study ObjectiveTo identify and review cases of isolated fallopian tube torsion (FTT) at our institution to further characterize diagnosis and management.DesignRetrospective review.SettingTertiary care medical center.ParticipantsCase series of pediatric and adolescent females, <21 years old, with operatively diagnosed isolated fallopian tube torsion from our institution.InterventionNone.Main Outcome MeasureIsolated fallopian tube torsion.ResultsFifteen cases of isolated fallopian tube torsion were identified based on intraoperative diagnosis. Patient ages ranged from 8-15 years old, mean age of 12. Fourteen patients (93%) presented with abdominal pain, 8 (53%) localized to the side of associated torsion. Ultrasonography reports described a tubular structure in 4 patients and an associated ovarian or paraovarian cyst in eleven patients. Suspicion of fallopian tube torsion was only described for those patients with a tubular structure described on ultrasonography report. Intraoperatively, 7 patients (47%) were found to have no associated pathology and 8 (53%) were found to have associated cyst or hydrosalpinx. Eight (53%) patients underwent salipingectomy and 7 (47%) underwent reversal of torsion with drainage of associated cyst or cystectomy.ConclusionsIsolated fallopian tube torsion is a rare condition that seems to occur in younger adolescents. Vague clinical presentation contributes to low preoperative suspicion. Preoperative suspicion may be increased based on radiographic findings of an enlarged tubular structure or an adjacent normal ovary. Management may be considered nonemergent and salpingectomy is controversial. Long-term fertility outcomes must be further assessed for more definitive decisions regarding surgical management.     

A method of laparoscopic treatment of large adnexal cysts – Two port trocar suction

ObjectiveThe size of the adnexal cyst is a limitation to perform laparoscopic adnexal surgery. Large adnexal cysts may constrain the surgery space and may increase the risk of inadvertent cyst rupture during the surgery. Here, we offer a method to solve the difficulty in laparoscopic management of large adnexal cysts.Materials and methodsThis is a retrospective study of 43 patients with large (≧10 cm) adnexal cysts, managed laparoscopically at one center from October 2016 to October 2019. All the surgeries were performed by an experienced laparoscopic surgeon. Malignancy was excluded before the surgeries according to the sonographic features. Cystectomy or salpingo-oophorectomy was decided according to the age, the sonographic pattern of the cyst and the patients’ willingness. A 2 cm vertical incision was made at the umbilicus, and an open laparoscopy method was used to enter the peritoneal cavity. A wound protector was applied with a glove and two trocars being set up. The second wound was made at the left abdomen, and a 5 mm trocar was inserted. Then the cyst was punctured by means of the 5 mm trocar, and the content of the cyst was then soon aspirated by means of the air-flow hole of the trocar. Afterward, cystectomy or salpingo-oophorectomy was performed. Data are expressed as mean ± standard deviation unless stated otherwise.ResultsThe mean operative duration was 54.7 ± 33.4 min, and the result was shorter than the previous study (P < 0.05, CI (−32.92, −12.38)) according to one sample t-test. Most estimated blood loss (EBL) was minimum. No obvious complication was found.ConclusionTwo-port trocar suction in laparoscopic management of large adnexal cysts is feasible after proper evaluation, and it takes short operative time.     

Unilateral Ovarian Dermoid Cyst Accompanied by an Ipsilateral Paratubal Cyst in a Girl with Proteus Syndrome Discovered by Laparoscopic Surgery

BackgroundProteus syndrome is a rare hamartomatous disorder characterized by the overgrowth of multiple tissues in a mosaic pattern. Tumors of genitourinary tract in Proteus syndrome are uncommon.CaseWe here report a 5-year-old girl with Proteus syndrome who developed a cystic mass in the pelvic cavity. The cyst was discovered by ultrasonographic examination and finally proved to be a unilateral ovarian dermoid cyst accompanied by an ipsilateral paratubal cyst by laparoscopic surgery.Summary and ConclusionProteus syndrome accompanied by an ovarian cyst is rare in girls. The possibilities of underlying ovarian cyst required for surgical intervention should be considered in Proteus syndrome.     

Ciliated Cyst of the Vulva—A Case Report

BackgroundCiliated cyst of the vulva is a variety of ciliated cutaneous cyst, which itself is a rare presentation and a very few cases has been reported.CaseThis case report shows the presentation of this cyst in a 12-year-old girl with early onset of puberty. The histopathology supports estrogen receptor and progesterone receptor positivity of the cyst lining, which supports the theory of Müllerian heterotopy during embryogenesis. This is the most popular theory on the development of this cyst. Its an uncommon presentation in children but a curable benign cyst.     

Choroid plexus cysts-Association with trisomy: Prospective review of 16,059 patients

OBJECTIVE: The purpose of the study was to determine the incidence of isolated choroid plexus cysts in association with trisomy 18 and other abnormalities.STUDY DESIGN: All patients from June 1992 through December 1995 were followed up after a screening ultrasonography. Any patient with a choroid plexus cyst was offered genetic counseling and an amniocentesis. Screening ultrasonographic examinations were performed on 16,059 patients, and 301 patients had a fetus with a choroid plexus cyst. One hundred thirty patients elected to have an amniocentesis. Patients were followed up to delivery.RESULTS: Two hundred sixty-three patients had an isolated choroid plexus cyst. Thirty-eight patients had a choroid plexus cyst associated with additional risk factors. Risk factors included advanced maternal age, additional ultrasonographic abnormalities, past obstetric history, or family history. No abnormalities were noted in the group with an isolated choroid plexus cyst. Four patients had an abnormality when the choroid plexus cyst was associated with an additional risk factor, including two patients with trisomy 18 and one with trisomy 21.CONCLUSION: An isolated choroid plexus cyst was not associated with a trisomy or other abnormalities in this study. When a choroid plexus cyst was associated with an additional risk factor, 10.5% of the patients had an abnormality. Amniocentesis is recommended when a choroid plexus cyst is found in association with additional risk factors. (Am J Obstet Gynecol 1997;176:1381-3.)     

Laparoscopic Excision of the Retroperitoneal Mullerian Cyst in a Different Location

BackgroundHerein, we report laparoscopic excision of a retroperitoneal Mullerian cyst, which is uniquely located medial to the left adrenal gland, mimicking adrenal adenoma in an adolescent girl.CaseA healthy 13-year-old adolescent girl presented with secondary amenorrhea. Ultrasound and magnetic resonance imaging showed a solid-cystic mass medial to the left adrenal gland. Laparoscopic cyst excision was performed. The histopathological findings were consistent with a benign cyst of Mullerian origin.Summary and ConclusionTo the best of our knowledge, this is the first case report of Mullerian cyst located medial to the adrenal gland in all age groups.     

Risk factors, symptoms, and treatment of ovarian torsion in children: the twelve-year experience of one center

ObjectiveTo assess risk factors, clinical findings and mode of diagnosis and treatment in premenarchal children with surgically verified ovarian torsion (OT).Study DesignA retrospective case review (Canadian Task Force Classification II-2).SettingTeaching and research hospital, a tertiary center.PatientsPremenarchal children with surgically verified OT.InterventionsPatients underwent either laparoscopy or laparotomy.ResultsTwenty-two cases of OT in 20 premenarchal girls (median age 12 years) were identified. Three cases involved recurrent torsion after detorsion without cystectomy. The main presenting symptoms were sudden pain and vomiting. Six patients underwent Doppler examinations, and all demonstrated an abnormal flow. Seventeen interventions were by laparoscopy. Conservative management, mainly detorsion with additional cyst drainage or cystectomy, was performed in 19 cases (86.4%). Oophoropexy was performed in 3 cases (13.6%). Pathologic examination demonstrated 5 simple cysts and 1 dermoid cyst.ConclusionsOvarian torsion in premenarchal girls usually presents with intermittent abdominal pain and abdominal tenderness. Other signs and symptoms are nonspecific. When performed, Doppler imaging may assist in diagnosing ovarian torsion in children. Detorsion followed by cystectomy may prevent recurrence.     

Retroperitoneal Pelvic Cyst: A Diagnostic and Therapeutic Challenge

BackgroundRetroperitoneal cysts can be asymptomatic or can present with vague symptoms such as abdominal pain or distension. Their clinical implications vary significantly.CaseA 45-year-old woman, gravida 2, para 2, presented with vague, non-specific pelvic symptomatology. Imaging indicated a right-sided pelvic cyst 5 cm in diameter. At laparoscopy a retroperitoneal cyst was identified, with a normal pelvis and intra-abdominal organs. No attempt was made at laparoscopy to drain, biopsy, or excise the cyst. CT-guided biopsy of the cyst was performed and small intestine mucosa was identified with goblet cells and smooth muscle. Repeat biopsy confirmed areas of tissue necrosis and small intestine mucosa, with additional tissue containing respiratory epithelium. Following laparotomy and excision of the cyst, the final pathologic diagnosis was benign epithelial cyst consistent with a duplication or hindgut cyst.ConclusionAlthough most retroperitoneal cysts are benign, surgical excision is required to rule out malignancy definitively.