Successful surgical treatment of postmyomectomy uterine diverticulum: a case report.

BACKGROUND: Uterine diverticulum is classified into congenital and acquired types. The acquired type is caused by caesarean scar syndrome, which occurs after caesarean section. There are no detailed reports on diverticulum after enucleation of uterine fibroids. Most cases are treated with hysteroscopy or laparoscopy, but a management consensus is lacking. We treated a patient with a uterine diverticulum that had formed after uterine fibroid enucleation by combining hysteroscopic and laparoscopic treatments. CASE PRESENTATION: The patient was a 37-year-old Japanese woman, G1P0. A previous doctor had performed abdominal uterine myomectomy for a pedunculated subserosal uterine fibroid on the right side of the posterior wall of the uterus near the internal cervical os. Menstruation resumed postoperatively, but a small amount of dark-red bleeding persisted. MRI two months after the myomectomy revealed a diverticulum-like structure 3 cm in diameter, communicating with the uterine lumen, on the right side of the posterior wall of the uterus. Under suspicion of uterine diverticulum after uterine fibroid enucleation, the patient sought treatment at our hospital approximately four months after the myomectomy. Through a flexible hysteroscope, a 5-mm-diameter fistula was observed in the posterior wall of the uterus, and a contrast-enhanced pocket, measuring approximately 3 cm, was located behind it. Uterine diverticulum following enucleation of a uterine fibroid was diagnosed, and surgery was thus deemed necessary. The portion entering the fistula on the internal cervical os side was resected employing a hysteroscope. Intra-abdominal findings included a 4-cm mass lesion on the posterior wall on the right side of the uterus. The mass was opened, and the cyst capsule was removed. A 5-mm fistula was detected and closed with sutures. Resuturing was not performed after dissection of the right round ligament due to tension. The postoperative course has been good to date, with no recurrence. CONCLUSION: Uterine diverticula after myomectomy may be treated with a combined laparoscopic and hysteroscopic approach, similar to caesarean scar syndrome.

Importance of abdominal X-ray to confirm the position of levonorgestrel-releasing intrauterine system: A case report.

BACKGROUND: Levonorgestrel-releasing intrauterine systems (LNG-IUSs) gradually release levonorgestrel into the uterus and is effective against hypermenorrhoea and dysmenorrhea. Complications associated with the insertion include expulsion, displacement, and uterine perforation. Ultrasonic identification of copper intrauterine devices (IUDs) is possible due to echogenicity from the copper coils. However, the barium sulfate coatings of LNG-IUSs do not always provide hyperechoic images. Both barium sulfate and copper are radiopaque and clearly identifiable on X-ray. Thus, X-ray imaging is required to locate LNG-IUSs. CASE SUMMARY: A 46-year-old woman with hypermenorrhoea due to submucosal myomas was treated with LNG-IUS at another hospital. Three LNG-IUS insertions had apparently been followed by spontaneous expulsion, although objective confirmation using imaging was not performed. The patient was referred to our institution for surgery. At the first visit, there appeared to be no device in the uterus, and none was observed on transvaginal ultrasound. However, two LNG-IUSs were observed in the pelvis on abdominal plain X-rays prior to surgery. Hysteroscopic myomectomy was performed, and the two LNG-IUSs were found to have perforated the myometrium. The devices were safely removed during surgery, and the submucosal myomas were also removed. The perforated section of the myometrium was minimal+ADs- therefore, a repair operation was not required.CONCLUSIONPlain abdominal X-rays facilitate the determination of whether an LNG-IUS is in the uterine cavity. Therefore, it is important to confirm a device's location, regardless of whether spontaneous expulsion is suspected, prior to inserting another device.

Safety and efficacy of microwave endometrial ablation for patients with previous uterine surgery: a pilot study.

MEA (microwave endometrial ablation) is a treatment that can control hypermenorrhea. With the increase in the number of caesarean sections and myomectomies, an increasing number of patients with MEA have undergone previous incision of the uterine myometrium. Uterine perforation is major complication. Here we compared the incidence of complications and recurrence between groups with or without previous uterine surgery. 35 patients who underwent MEA were enrolled in the study. We assessed the thickness of uterine myometrium by MRI and transvaginal ultrasonography (TV-US). 12 patients (34%) had previous uterine surgery; Among 12 patients with previous uterine surgery, 6 (50%) showed thinning of the myometrium. No patient showed any complications. There was no difference in recurrence rate between two groups (1/12 = 8% and 2/23 = 8%, respectively). MEA can be performed safely and effectively even for patients with previous uterine surgery.IMPACT STATEMENTWhat is already known on this subject? MEA (microwave endometrial ablation) is a treatment that can control hypermenorrhea.A few serious complications have been reported, including uterine perforation and intestinal injury. There have been no collective reports on women with a history of uterine surgery, and the decision to perform MEA and the detailed procedures have not been clarified.What do the results of this study add? No patient who received MEA showed any complication regardless of previous uterine surgery. There was no difference in recurrence rate of hypermenorrhea between groups with and without previous uterine surgery. MEA could be performed safely and effectively in patients with previous uterine surgery preoperative imaging and intraoperative ultrasoundsWhat are the implications of these findings for clinical practice and/or further research? Curently, with the increase in the number of caesarean sections and myomectomies, the increasing number of patients with MEA have undergone previous incision of the uterine myometrium and this causes thinning of the myometrium. MEA can be safely performed without losing any therapeutic effect, even in patients with a history of uterine surgery, by using MRI and TV-US as preoperative evaluations.

Thrombus formation and ischemic necrosis of the uterus and adnexa due to purpura fulminans: A case report.

Purpura fulminans (PF) is a syndrome characterized by the sudden onset of progressive skin hemorrhage, necrosis of the extremities, and thrombotic occlusion. Although the cause is believed to be protein C deficiency, many aspects of this syndrome have yet to be clarified. A 45-year-old Japanese woman, G2P2 (vaginal delivery), developed fever and lower abdominal pain. It was her 5th day of menstruation, and a tampon had been in the vagina for a few days. Septic shock and disseminated intravascular coagulation were diagnosed, and multidisciplinary treatment was started. Also, toxic shock syndrome due to tampon use was suspected. The purpura on the limbs turned into blisters and then blackish-purple spots, leading to hemorrhagic necrosis within a few days. Moreover, imaging showed that the uterus and both adnexa had enlarged significantly, and raised suspicion of abscess formation. Total hysterectomy and bilateral adnexectomy were performed, and the histopathological diagnosis was hemorrhagic necrosis due to extensive thrombus formation. In men, PF affects the scrotum and penis, leading to autoamputation of the male genitalia, while there are no reports of PF involving the female genitalia. Regarding the PF, in this case, we considered the possibility of pathologic conditions progressing to the female genitalia.

Successful surgical treatment of cardiac metastasis from uterine leiomyosarcoma: A case report and literature review.

Uterine leiomyosarcoma is a malignant soft tissue tumor resembling uterine fibroma clinically and is difficult to diagnose preoperatively. Since metastatic cardiac tumors are very rare and asymptomatic, most cardiac metastases are detected at autopsy after death due to other diseases. A 49-year-old woman presented with menorrhagia and anemia, and a uterine tumor. Total hysterectomy was performed for the uterine tumor. Histopathological examination revealed the tumor to be a leiomyosarcoma. Postoperative computed tomography showed multiple lung metastases and a metastatic cardiac tumor. The cardiac tumor, which was located within and almost entirely occluded the right ventricle, was 49 × 26 mm. To prevent sudden death, cardiac tumorectomy was performed semi-emergently. Chemotherapy was initiated in the early postoperative period, and the patient currently maintains a complete response. Cases with lung and cardiac metastases rarely undergo surgical resection of metastatic tumors. However, emergent surgical resection of cardiac metastatic tumors should be considered to prevent sudden death.