Acute Abdominal Pain as a Result of a Ruptured Hematosalpinx: A Rare Complication of an Unusual Müllerian Anomaly

Case ReportA 15-year-old virgin Caucasian female presented to the emergency room with a 40-hour history of acute left lower quadrant abdominal pain and nausea. Evaluation suggested a left pelvic kidney with obstructed ureter being the etiology. Her pain continued to escalate so further workup with laparoscopy was performed. This demonstrated a left pelvic sidewall hemi uterus with ruptured hematosalpinx. This is an unusual clinical presentation of a müllerian anomaly not previously documented.DiscussionThe differential diagnosis of acute unilateral abdominal pain in adolescent females should include müllerian anomalies. The incidence of this diagnosis is low but the evaluation and treatment can be performed in an expeditious manner if the diagnosis is considered. The laparoscopic excision of a unilateral noncommunicating uterine horn is a valid and recommended treatment approach of this rare malformation.     

Retroperitoneal müllerian carcinosarcoma associated with endometriosis: a case report

BACKGROUND: Mixed müllerian tumors are rare malignancies of the female genital tract and extremely uncommon in extragenital sites. CASE: A 71-year-old woman presented with a 3-month history of left-sided pelvic pain. Significant history included total abdominal hysterectomy and bilateral adnexectomy performed 19 years earlier for benign indications; she had no history of endometriosis. Bimanual exam and pelvic ultrasonography demonstrated a 6 x 5 x 6 cm complex mass in the left pelvis. Exploratory laparotomy revealed a retroperitoneal mass encasing the left ureter. The mass was debulked, necessitating resection of the distal ureter and ureteroneocystotomy. Histopathology demonstrated carcinosarcoma associated with endometriosis. CONCLUSION: Extragenital carcinosarcoma is a rare malignancy, with only one well-documented case associated with peritoneal endometriosis. We report a case of an extragenital retroperitoneal carcinosarcoma associated with endometriosis.     

Laparoscopic management of ureteral endometriosis: our experience

STUDY OBJECTIVE: Ureteral endometriosis is rare, accounting for less than 0.3% of all endometriotic lesions. The aim of our study is to evaluate the prevalence of extrinsic ureteral endometriosis in women undergoing laparoscopic surgery for severe endometriosis and to suggest that laparoscopic ureterolysis represents a mandatory measure in all cases to avoid ureteral injury. METHODS: A retrospective analysis was performed of all cases of patients who underwent laparoscopic surgery for severe endometriosis at the departments of obstetrics and gynecology at CMCO-SIHCUS and Hautepierre Hospital, Strasbourg, from November 2004 through January 2006. MEASUREMENTS AND MAIN RESULTS: We recorded 54 patients with a mean age of 31 years and a mean body mass index of 21.9. Reported symptoms were dysmenorrhea (88%), severe dyspareunia (88%), severe pelvic pain (38.8%), and infertility (74%). Five women presented with dysuria, frequency, recurrent urinary tract infections, and pain in the renal angle, and 2 patients had hydronephrosis. We observed 3 patients (5.6%) with ureteral stenosis, 35 (64.8%) with adenomyotic tissue surrounding the ureter without stenosis, and 16 (29.6%) with adenomyotic tissue adjacent to the ureter. It was on the left side in 47.4% of cases, on the right side in 31.6% cases, and bilaterally in 21% of cases. In 9 patients, ureteral involvement was associated with bladder endometriosis (16.7%). In all patients, ureterolysis was performed. There was 1 case of ureteral injury during the procedure, 2 of transitory urinary retention, and 1 of uretero-vaginal fistula after surgery. During the first year of follow-up, the disease recurred in 4 patients, with no evidence of the disease in the urinary tract. CONCLUSION: Conservative laparoscopic surgery to relieve ureteral obstruction and remove pathologic tissue is the management of choice. Resection of part of the ureter should be performed only in exceptional cases. Ureterolysis should be performed in all patients before endometriotic nodule resection to recognize and prevent any ureteral damage.     

Xanthogranulomatous inflammation caused by K. pneumonia and nocardiosis mimicking a uterine tumor and invading the ureter and colon: A case report and review of the literature

ObjectiveTo present a rare case of xanthogranulomatous inflammation (XI) mimicking a uterine sarcoma and invading the ureter and colon.Case reportA 66-year-old woman presented with lower abdominal pain. Pelvic examination showed tenderness over the lower abdominal region without cervical discharge. Per-rectal examination showed a hard tumor on the posterior uterine wall, while ultrasonography showed a tumor-like mass extending from the posterior uterine wall to the rectum. Magnetic resonance imaging showed signs of endometrial cancer invading the rectum. However, the tumor markers carbohydrate antigen (CA) 125, CA199, and carcinoembryonic antigen were in the normal range. Cystoscopy, panendoscopy, and colonoscopy showed no significant findings. On performing exploratory laparotomy, we observed pus and severe adhesion on the posterior uterine wall and rectum. Hysterectomy, bilateral adnexectomy, colectomy, and partial left ureter resection were performed. The final pathology showed XI. The pus culture revealed Klebsiella pneumonia and PCR revealed nocardiosis. The patient received 2 weeks of antibiotic treatment and was discharged thereafter.ConclusionXI in elderly women is rare, and hence, differential diagnoses should be carefully considered.     

Endometriosis of ureter-induced recurrent urinary tract infections in a premenopausal woman--case report

Endometriosis of the urinary tract is infrequent. The ureters and kidneys are the least usual place of localization. Endometriosis of the ureter often leads to silent loss of renal function due to delayed diagnosis. We report a case of a premenopausal female with endometriosis of the left distal ureter, presenting an infection of the urinary tract and having reported previous incidents of menorrhagia and left flank renal pain with automatic recession. Pharmacological treatment was applied with a satisfactory outcome. A short review of the literature is presented.     

Bladder and Urinary Deep Pelvic Endometriosis: A Step-by-Step Standard Approach

Study ObjectiveTo demonstrate how to treat bladder and ureteral deep pelvic endometriosis using a laparoscopic approach with partial cystectomy and resection and end-to-end anastomosis of the ureter.DesignStep-by-step explanation of the surgery using a video approved by the local institutional review board.SettingUniversity Hospital of Strasbourg, France.PatientsA 27-year-old nulliparous woman with severe endometriosis stage IV (revised American Fertility Society classification score >40) of the bladder and left ureter. On pelvic magnetic resonance imaging, we found dilatation of the left ureter and left hydronephrosis induced by a 17-mm endometriosis nodule. A JJ probe was placed on the left ureter before the surgery because of dilatation of the ureter and decreased renal function.InterventionsDuring the exploration, we found an abdominal cavity free of adhesion. There was an endometriosis implant in the bladder in front of the uterus and a large nodule of the left uterosacral ligament that was compressing the ureter. In the first step, we made a section of the round ligament to perform anterior ureterolysis and progressive dissection of the nodule surrounding the ureter. Once the nodule was resected, tight stenosis was observed approximately 1 cm from the bladder. The vesicouterine and vesicovaginal spaces were then dissected to pass under the nodule to the vagina. We opened the dome of the bladder using the thunderbeat (Olympus) and dissected the bladder to remove the transfixing nodule while staying away from the ureters. The closure of the bladder was performed by 2 lateral sutures and a running suture using a braided suture (V-Loc) 2-0, with good tightness as checked by a blue test. Ureteral resection was performed around the JJ probe in place to remove the stenotic zone; thereafter, we performed an end-to-end anastomosis of the ureter using 4 sutures of monofilament (Monocryl) 4-0 with a good anatomic result. Finally, an omentoplasty was fixed around the ureter using a 2-0 monofilament suture (Monocryl).Measurements and Main ResultsThe postoperative course was uneventful. A Foley catheter was left in place for 10 days, and the JJ probe was removed 6 weeks later. The operative time was 140 minutes. The step-by-step explanation technique was simple with minimal operative difficulty and a low rate of morbidity.ConclusionThis video shows how deep urinary endometriosis can be treated laparoscopically. Mastering suturing is essential to avoid complications.     

A rare case of primary extragenital retroperitoneal carcinosarcoma with review of the literature

Carcinosarcomas are rare, highly aggressive neoplasms that most commonly arise from the female genital tract but can unusually present in extragenital locations. To the best of our knowledge, only three cases of primary retroperitoneal, extragenital carcinosarcomas have been documented in the English literature to date. A 72-year-old woman presented with onset of abdominal pain and urinary retention. Computed tomography scan revealed a mass in the retroperitoneal space with hydronephrosis and partial obstruction of the left ureter. Lost to follow-up at that time, the patient returned 6 months later with a left leg deep vein thrombosis. On exploratory laparotomy at that time, the retroperitoneal mass was found to completely engulf the left ureter, iliac artery, and vein. Resection was not possible, but biopsy confirmed the presence of an extragenital carcinosarcoma.     

Incarcerated tubal herniation, an unusual complication of operative laparoscopy and an odd cause of pelvic pain

Tubal herniation after laparoscopic surgery to relieve pelvic pain and adhesions was associated with long-term, chronic pelvic pain in the left lower quadrant. Laparoscopy was performed to diagnose and reduce the herniation. Review of the literature revealed no previous report of this complication.     

Chronic isolated torsion of the left fallopian tube: a diagnostic dilemma

Background Chronic tubal torsion is a rare clinical entity. Case A 15-year-old adolescent presented with an 18-month history of intermittent lower abdominal pain at our outpatient department after various preceding consultations with different physicians. She was asymptomatic and showed no abnormality on physical examination. Ultrasound findings revealed a cystic structure adjacent to the left ovary. Diagnostic laparoscopy showed a twisted and dilated left fallopian tube with thickened wall and adherence to the pelvic sidewall. Following detorsion, there was no evidence of reperfusion. Consequently, a left salpingectomy was performed. Conclusion Chronic tubal torsion is a rare but possible differential diagnosis of current lower abdominal pain. Physicians should have a high index of suspicion.     

Ureteral obstruction caused by L-asparaginase-induced pancreatitis in a child with acute lymphoblastic leukemia.

L-asparaginase, an effective antileukemia and antilymphoma agent, is toxic to many organ systems. We report a case of ureteral obstruction caused by L-asparaginase via the inflammatory complication of acute pancreatitis. The patient was an 11-year-old boy with acute lymphoblastic leukemia. Six days after completing a 4-week induction therapy containing 9 doses of L-asparaginase, severe left abdominal pain developed. Abdominal computed tomography showed phlegmon formation anterior to the pancreatic head and in the left posterior pararenal space. The strands of inflammatory soft tissues encased the upper third of the left ureter, causing left hydroureter and left hydronephrosis. The ureteral obstruction resolved after insertion of a double-J catheter that remained in place for 66 days. This case suggests that L-asparaginase may play a role in the pathogenesis of ureteral obstruction in children receiving chemotherapy.     

Intestinal surgery and surgery of urinary tract in treatment of recurrent cervical cancer--case report

A case of a 31-year-old patient admitted to the Institute with a diagnosis of recurrent cervical cancer after radical hysterectomy and radiation therapy 12 months before. The patient had intestinal and urinary obstruction and also the tumor compressed the iliac blood vessels superficially. She underwent clinical examination, pelvic and abdominal ultrasound and multislice CT scan. A recurring tumor with a diameter of 7 cm was diagnosed. It was localized in the left parailiac and obturator region and infiltrated the left ureter, left bladder side wall, sigmoid colon and iliac blood vessels superficially. The patient had left pelvic sidewall relapse, so she underwent a palliative surgical procedure. We evacuated the complete tumor together with the infiltrated parts of the left ureter, sigmoid colon and bladder. At the end of operation left ureterocystoneostomy was performed as well as the Hartmann procedure with anus praeter insertion. There were no significant postoperative complications. After the surgical treatment of the recurrence, we suggested that the patient continue treatment of her disease with chemotherapy.     

The routine use of cystoscopy with the Burch procedure

OBJECTIVE: We sought to determine the incidence of unsuspected injury to the lower urinary tract as detected by intraoperative cystoscopy when the Burch procedure is performed. STUDY DESIGN: We reviewed the records of 181 women who underwent pelvic surgery, which included a Burch retropubic urethropexy for genuine stress urinary incontinence, between Jan 1, 1998, and Dec 31, 1999. All patients underwent intraoperative cystoscopy at the completion of the Burch procedure after the administration of intravenous indigo carmine dye. RESULTS: There were 6 (3.3%) injuries to the lower urinary tract. Five of the injuries were cystotomies that had been recognized during operation. One obstructed left ureter was detected by cystoscopy and relieved by the release of left paravaginal repair sutures. No unsuspected injuries that were detected by cystoscopy were attributable to the Burch procedure. CONCLUSIONS: The lower urinary tract injury rate was 3.3%. All but one injury was recognized before cystoscopy. The one injury was attributed to concomitant paravaginal repair and not to the Burch procedure.     

An unusual long-term complication of transobturator polypropylene mesh

Serious complications associated with surgical mesh for transvaginal repair of POP, as infections, vaginal mesh exposure, painful mesh shrinkage and dyspareunia, are not rare. A 48-year-old woman underwent the Perigee procedure because of a stage 3 anterior wall prolapse. Eleven months after surgery, the patient became suddenly unable to walk because of a strong pain to the left thigh root after running. The MRI revealed an external obturator left muscle hyperintensity consistent with muscular oedema; the patient was treated with oral corticosteroids with a complete resolution of the pain. We could hypothesize that the posterior arm of the mesh caused a laceration of the muscles of the obturator space with consequent oedema and pain. The use of the meshes in prolapse surgery can cause unexpected long-term complications.     

Placenta previa percreta with urinary bladder and ureter invasion

A 26-year-old woman, with one previous cesarean delivery and two uterine curettage due to incomplete abortion, was admitted to the labor ward with the diagnosis of partial placenta previa at 35 weeks of gestation. Repeat cesarean section was performed due to profuse vaginal bleeding. Placenta previa percreta invading the bladder trigone was confirmed with cystotomy. As bilateral hypogastric artery ligation and supracervical hysterectomy performed were not successful in stopping the profuse bleeding, the abdomen was packed with laparotomy pads. Dilatation of the left ureter was noticed on the second postoperative day. Relaparotomy was performed to remove the pads, and placental invasion of the distal left ureter was noticed. Ureteroneocystostomy was performed. The postoperative course was uneventful, and the double-J-catheter was removed two months later.     

Oxidized cellulose (Surgicel) granuloma mimicking a primary ovarian tumor.

A 37-year-old woman presented with left lower quadrant pain and vaginal spotting 1 month after hysterectomy and right salpingo-oophorectomy, which were performed for hemoperitoneum related to a ruptured corpus luteum. An 8-cm left ovarian mass was removed that had a microcystic, mucoid sectioned surface. Histological examination revealed that the mass consisted of a massive foreign-body granulomatous reaction to oxidized cellulose (Surgicel). To our knowledge, this is only the second report of an ovarian Surgicel granuloma.     

子宫切除术后15年并发阴道残端子宫内膜异位症一例

子宫内膜异位症（endometriosis,EMs）是女性常见的慢性炎症性疾病,指子宫内膜的腺体和间质出现在子宫腔以外的部位,常见于卵巢、盆腔腹膜表面或其他盆腔组织。报告1例子宫肌瘤行子宫切除术后15年发生阴道残端子宫内膜异位症的病例,患者48岁,因不规则阴道出血伴腹痛3年、加重2个月就诊,全腹增强CT发现左侧髂血管旁不规则软组织,多学科会诊后拟诊断为阴道残端病变行腹腔镜探查术,根据术中所见行左侧阴道残端肿物切除术,切除组织经石蜡切片病理检查证实为阴道残端EMs。结合此病例讨论并复习相关文献,为临床上子宫切除术后出现阴道出血病例提供了诊疗思路,旨在提高临床医生对手术后并发阴道残端EMs的认识。     

Broad ligament twin pregnancy. A case report

BACKGROUND: Broad ligament pregnancy is an uncommon form of ectopic pregnancy. CASE: A 34-year-old, 11-week-pregnant woman, gravida 2, para 0, presented with left lower abdominal pain. She had undergone a right salpingectomy due to tubal pregnancy six years previously. She had a left broad ligament twin pregnancy, and excision of the pregnancy and left tube were performed. She was well at discharge and the six-week follow-up. CONCLUSION: This is the first case report of a broad ligament twin pregnancy after spontaneous conception.     

妇科腹腔镜手术泌尿系损伤的临床分析

目的：探讨妇科腹腔镜手术发生泌尿系损伤的相关因素、诊断、治疗方法及预防措施。方法：回顾分析2002年1月至2012年12月北京大学人民医院妇科腹腔镜手术发生泌尿系损伤患者的临床资料。总结分析患者的疾病类型、手术方式、损伤特点、诊疗情况及预后等。结果：妇科腹腔镜手术共4773例,泌尿系损伤发生18例（0.38％）,其中8例发生于腹腔镜恶性肿瘤手术,8例发生于腹腔镜辅助阴式全子宫切除术（LAVH）,2例发生于腹腔镜附件手术。18例泌尿系损伤患者中5例有腹部手术史,有腹部手术史者的泌尿系损伤发生率高于无手术史者（P〈0.05）。18例泌尿系损伤患者中膀胱损伤4例,其中3例位于膀胱后壁,1例位于膀胱三角区;输尿管损伤14例,其中输尿管上段损伤2例,中段损伤10例,下段损伤2例;左侧输尿管损伤2例,右侧12例。术中发现损伤10例,其中4例膀胱损伤和6例输尿管损伤;术后发现8例,均为输尿管损伤,于术后1～10天发现,均经静脉肾盂造影确诊。11例经再次手术修补成功,7例放置输尿管支架6个月（3～12个月）保守治疗成功。结论：腹腔镜下恶性肿瘤手术、LAVH、有腹部手术史患者发生泌尿系损伤机率较高,输尿管损伤多于膀胱损伤。术者需高度警惕,术后严密观察,如发现泌尿道损伤,尽早请泌尿科医师共同决定治疗方法。     

Rare presentation of ectopic pregnancy following IVF-ET: live twin gestation in the same fallopian tube

We report a case of a twin ectopic pregnancy (EP) after in vitro fertilization and embryo transfer (IVF-ET). A 24-year-old nulligravida presented with lower abdominal pain and vaginal bleeding 4 weeks after embryo transfer. Serum β-HCG levels were 40 IU/mL, 90 IU/mL, and 1970 IU/mL on ET days 12, 14, and 23, respectively. Ultrasound examination revealed two ectopic gestational sacs with fetal heart beats in the left adnexa, without evidence of intrauterine pregnancy. At laparoscopy, one isthmic and another ampullary sac were detected in the left tube and left salpingectomy was performed. The patient was discharged healthy on postoperative day 2. Albeit extremely rare, ectopic pregnancies with abnormal presentation can be encountered following IVF-ET. Single embryo transfer may be advised to protect from ectopic pregnancies after IVF-ET.