Myolipoma of the round ligament of the liver: a diagnosis to be considered.

A 39-year-old patient consulted for an incidental finding of a mesenteric-epiploic mass measuring 11x6x9.5 cm. Laparoscopic excision of the lesion and cholecystectomy were indicated, revealing a myolipomatous mesenchymal neoplasm in the hepatic round ligament.

Transvaginal ultrasound for diagnosis of deep endometriosis involving uterosacral ligaments, torus uterinus and posterior vaginal fornix: prospective study.

OBJECTIVE: To evaluate the accuracy of transvaginal ultrasound (TVS) in diagnosing deep endometriosis (DE) involving the uterosacral ligaments (USLs), torus uterinus (TU) or posterior vaginal fornix (PVF) in women with suspected endometriosis scheduled for laparoscopic surgery. METHODS: In this prospective study, consecutive women with clinically suspected pelvic endometriosis who were scheduled for laparoscopic surgery were invited to participate. TVS was performed before surgery. TVS findings were compared with those obtained at laparoscopy and confirmed histologically. The accuracy of TVS for diagnosing DE involving the USLs, TU or PVF was assessed. Additionally, the association of DE involving the USLs, TU or PVF on TVS with symptoms and with DE affecting other pelvic locations was assessed. RESULTS: In total, 172 patients were included. The global sensitivity and specificity of TVS in diagnosing DE affecting the USLs, TU and/or PVF were 92% and 87%, respectively. For DE involving the USLs, the accuracy, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio and negative likelihood ratio of TVS were 89.5%, 96.6%, 82.1%, 85.0%, 95.8%, 5.41 and 0.04, respectively; the respective values for DE involving the TU were 86.6%, 83.9%, 89.4%, 89.0%, 84.4%, 7.92 and 0.18, and the respective values for DE involving the PVF were 93.6%, 87.0%, 94.6%, 71.4%, 97.9%, 16.20 and 0.14. Logistic regression analysis showed a significant association between DE affecting the USLs, TU and/or PVF and DE affecting the rectosigmoid (odds ratio, 5.43; P < 0.001). Dyschezia was associated strongly with DE involving the USLs, TU and PVF, while dysmenorrhea was associated significantly with DE involving the TU. CONCLUSION: TVS has high accuracy, sensitivity, specificity, PPV and NPV for the detection of DE involving the USLs, TU and PVF in women with suspected endometriosis scheduled for laparoscopic surgery. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Imaging in gynecological disease (21): clinical and ultrasound characteristics of accessory cavitated uterine malformations.

OBJECTIVE: To describe the clinical and ultrasound characteristics of accessory cavitated uterine malformations (ACUMs). METHODS: This was a single-center observational study of consecutive patients diagnosed with an ACUM, who had undergone an ultrasound examination by an experienced ultrasound examiner between January 2013 and May 2019, identified retrospectively from medical records. ACUM was diagnosed when a cavitated lesion with a myometrial mantle and echogenic contents was seen within the anterolateral wall of the myometrium beneath the insertion of the round ligament. In all women, presenting symptoms and clinical history were recorded along with detailed descriptions of the lesions and any concomitant pelvic abnormalities. RESULTS: Twenty patients diagnosed with an ACUM were identified. Median age was 29.2 (interquartile range, 25.0-35.8) years. None of the women was premenarchal or postmenopausal. All of the women reported painful periods or pelvic pain and none of them reported subfertility. Twelve of the ACUMs were in the right anterolateral myometrium and eight were in the left anterolateral myometrium. Both a myometrial mantle and a fluid-filled cavity were considered to be defining features on ultrasound. The fluid contained within the cavity was either echogenic with a ground-glass appearance or hyperechoic. All of the lesions were spherical in shape. The Doppler flow seen in the outer rim was not markedly different from that of the surrounding myometrium, and the content of the cavity was avascular on Doppler examination. The mean outer cavity diameter of the ACUMs was 22.8 (95% CI, 20.9-24.8) mm and the mean internal cavity diameter was 14.1 (95% CI, 12.2-16.1) mm. Four women opted for transvaginal ultrasound-guided alcohol sclerotherapy. Surgical excision was carried out in eight cases, and the diagnosis was confirmed on histopathological examination in all of them. CONCLUSIONS: ACUMs are a uterine abnormality with a distinct ultrasound appearance, which are associated with dysmenorrhea and chronic pelvic pain. Knowledge of their typical appearance on ultrasound could facilitate early detection and treatment. There are several treatment options for ACUM, ranging from simple analgesia to complete excision. Further prospective and longitudinal studies are required to study the prevalence and natural history of this condition. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Long term follow-up of inguinal endometriosis.

BACKGROUND: Inguinal endometriosis (IEM) is a rare extra pelvic endometriosis. Here, we study the clinical characteristics, management strategies, and long-term gynecological outcomes of IEM patients at Beijing Chaoyang Hospital. CASE PRESENTATION: Three patients presented with a total of four lesions (one on the left side, one on the right side, and one bilaterally). The diameters of the four lesions were 2 cm, 2 cm, 3.5 cm and 1.5 cm, respectively. Two patients were admitted with inguinal hernias. Two patients were admitted with endometrioses-one with ovarian endometriosis and one with pelvic endometriosis. The hernia sac was repaired concomitantly via excision of the round ligament in two patients. One patient underwent a concomitant laparoscopy for gynecologic evaluations, including an ablation to the peritoneal endometriosis, and resection of the left uterosacral ligament endometriosis and pelvic adhesiolysis. All lesions were located on the extraperitoneal portion of the round ligament and were diagnosed histologically. No recurrence was observed in the inguinal region. All patients diagnosed with adenomyosis were treated with medication alone without any complaints. CONCLUSIONS: Inguinal endometriosis can occur simultaneously with pelvic endometriosis. In most cases, a concomitant hernia sac appears together with groin endometriosis. Clinical management should be individualized and performed in tandem with general practitioners and obstetrics & gynecology experts. Pelvic disease, in particular, should be followed-up by a gynecologist.

Uterus-Sparing Surgery: Outcomes of Transvaginal Uterosacral Ligament Hysteropexy.

STUDY OBJECTIVE: Recently, there has been a paradigm shift toward uterine conservation during the surgical management of pelvic organ prolapse (POP), specifically uterine prolapse. There are few reports on transvaginal uterosacral ligament hysteropexy (TULH). This study aimed to describe our surgical technique and outcomes. DESIGN: Retrospective review and description of surgical technique. Anatomic outcome has been reported using the POP quantification system. Complications were segregated. A comparison of parametric continuous variables was performed using paired t test. Categoric variables were evaluated using the Pearson χ2 test and the Fisher exact test. A p-value <.05 was considered significant. SETTING: Teaching hospital. PATIENTS: Forty patients who underwent TULH from 2009 to 2017. INTERVENTIONS: TULH. MEASUREMENTS AND MAIN RESULTS: A total of 40 patients met the inclusion criteria. Of these, 56.1% had preoperative stage 3 prolapse. The median operative time was 116 minutes. The mean estimated blood loss was 158.5 mL. Transient ureteral obstruction occurred in 2 patients. The mean follow-up time was 17.2 months, and all patients had significant improvement of prolapse (p <.001). There was also an improvement in urinary incontinence and bladder storage symptoms (p <.001). None of the patients were reoperated on for recurrent POP. CONCLUSION: TULH is an effective uterus-preserving surgical alternative for the treatment of uterovaginal prolapse and provides good apical support. It is also associated with a low short-term recurrence and incidence of reoperation. TULH is a viable option for suitable patients with uterovaginal prolapse who desire uterine conservation.

Evaluation of two vaginal, uterus sparing operations for pelvic organ prolapse: modified Manchester operation (MM) and sacrospinous hysteropexy (SSH), a study protocol for a multicentre randomized non-inferiority trial (the SAM study).

BACKGROUND: Pelvic organ prolapse (POP) affects up to 40% of parous women which adversely affects the quality of life. During a life time, 20% of all women will undergo an operation. In general the guidelines advise a vaginal operation in case of uterine descent: hysterectomy with uterosacral ligament plication (VH), sacrospinous hysteropexy (SSH) or a modified Manchester operation (MM). In the last decade, renewed interest in uterus sparing techniques has been observed. Previous studies have shown non-inferiority between SSH and VH. Whether or not SSH and MM are comparable concerning anatomical and functional outcome is still unknown. The practical application of both operations is at least in The Netherlands a known cause of practice pattern variation (PPV). To reveal any difference between both techniques the SAM-study was designed. METHODS: The SAM-study is a randomized controlled multicentre non-inferiority study which compares SSH and MM. Women with symptomatic POP in any stage, uterine descent and POP-Quantification (POP-Q) point D at ≤ minus 1 cm are eligible. The primary outcome is the composite outcome at two years of absence of prolapse beyond the hymen in any compartment, the absence of bulge symptoms and absence of reoperation for pelvic organ prolapse. Secondary outcomes are hospital parameters, surgery related morbidity/complications, pain perception, further treatments for prolapse or urinary incontinence, POP-Q anatomy in all compartments, quality-of-life, sexual function, and cost-effectiveness. Follow-up takes place at 6 weeks, 12 and 24 months. Additionally at 12 weeks, 6 and 9 months cost-effectiveness will be assessed. Validated questionnaires will be used and gynaecological examination will be performed. Analysis will be performed following the intention-to-treat and per protocol principle. With a non-inferiority margin of 9% and an expected loss to follow-up of 10%, 424 women will be needed to prove non-inferiority with a confidence interval of 95%. DISCUSSION: This study will evaluate the effectiveness and costs of SSH versus MM in women with primary POP. The evidence will show whether the existing PPV is detrimental and a de-implementation process regarding one of the operations is needed. TRIAL REGISTRATION: Dutch Trial Register (NTR 6978, http://www.trialregister.nl ). Date of registration: 29 January 2018. Prospectively registered.

Comparison of the efficacy and safety of two advanced vessel sealing technologies in total laparoscopic hysterectomy.

AIM: Adequately powered, randomized controlled studies evaluating efficacy and safety of advanced bipolar energy devices in gynecologic laparoscopic surgery are very few. We aimed to compare the two most commonly used devices in total laparoscopic hysterectomy. METHODS: This randomized controlled trial was carried out in the department of obstetrics and gynecology in an education and research hospital. One hundred thirty-two women who underwent total laparoscopic hysterectomy for benign indications were included. Women with age younger than 18 years, suspected malignancy, stage 3-4 endometriosis and cervical/intraligamentary leiomyoma were excluded. Patients were randomized preoperatively to LigaSure or Articulating Enseal. One experienced surgeon performed all operations. RESULTS: LigaSure was used in 67 patients and Enseal was used in 65 patients. Primary outcomes of the study were operative time (time from start of sealing and transection of the round ligament until completion of colpotomy) and total operative time (time from skin incision to skin closure). Secondary outcomes were intraoperative blood loss (blood lost during operative time period) and perioperative complications. Operative time was significantly shorter in LigaSure group (P = 0.001). Total operative time, intraoperative blood loss and perioperative complications were similar. When two groups were further classified according to uterine weight taking 300 g as cut-off value, operative time was significantly shorter in LigaSure group in both subgroups (P = 0.003 and P = 0.007). CONCLUSION: LigaSure use in total laparoscopic hysterectomy shortens operative time when compared with Enseal; without an apparent increase in intraoperative blood loss and perioperative complications. On the other side, total operative time remains unaffected.

[Effectiveness of vaginal high uterosacral ligament suspension for treatment of recurrent pelvic organ prolapse].

Objective: To evaluate the indications and clinic outcomes of vaginal high uterosacral ligament suspension (HUS) for treatment of recurrent advanced pelvic organ prolapse (POP). Methods: This retrospective study analyzed 42 women with recurrent advanced POP who were referred to Fourth Medical Center of PLA General Hospital and underwent transvaginal HUS between November 2005 and January 2018. Primary surgeries included 30 vaginal colporrhaphy, 5 Manchester operation, 5 transvaginal mesh repair,2 sacrospinous ligament fixation.The median time for recurrence from primary pelvic floor repair surgery was 9 months, including 14 cases (33%, 14/42) ≤3 months (median time was 2 months) and 25 cases (67%, 28/42) longer than 3 months (median time was 18 months).The rate of recurrent prolapse in stage Ⅲ or Ⅳ was 79% (33 cases), 45% (19 cases) and 17%(7 cases) in anterior, apical and posterior compartment respectively. Results: Transvaginal high bilateral uterosacral ligaments were identified and used for successful vaginal vault suspension after vaginal hysterectomy and residual cervical resection in all 42 consecutive patients. The cases of transvaginal mesh used in anterior wall and posterior wall were 25 (60%, 25/42) and 3 (7%, 3/42) respectively. There was no major intra- and postoperative complications,such as ureter and other pelvic organ injury. The median time of follow-up was 5.3 years after transvaginal HUS. The points of pelvic organ prolapse quantification system reduced significantly and point C improved from +0.3 cm to -8.2 cm after reoperation (P<0.01). The objective cure rate were 100% (42/42) both in apex and posterior compartment,while 93% (39/42) in anterior compartment. None had reoperation or pessary usage for recurrence of prolapse. Conclusion: Transvaginal HUS with vaginal wall repair could be as a safety, cost-effective, minimal traumatic and durable procedure for recurrent POP in the most of cases.

The round ligament of the uterus: Questioning its distal insertion.

PURPOSE: Classically, the round ligament of the uterus (RLU) attaches distally in the ipsilateral labia majora. This attachment has rarely been described in adults. That is why we have performed an anatomical study focused on this distal ending. PATIENTS: We performed in 2015 the cadaveric dissection of 19 RLU. METHODS: In all cases, the RLU was individualized on its entire length from its uterine origin to the inguinal canal. Then this canal was open from its internal orifice to its external orifice. We described the distal attachment of the RLU according four areas: before the internal inguinal ring, after the external inguinal ring, under the pubic bone and in labia majora. RESULTS: We found 3 types of distal attachments with first an attachment after the external inguinal ring in more than half of cases (52.6%). Then, before the internal inguinal ring (26.3%) and under the pubic bone (22.1%). No RLU was found inlabia majora. However, the proximal attachment seems constant at the antero-superior face of uterus, near the tubo-uterine junction like its pelvic path under the broad ligament. CONCLUSION: In adult, the RLU is a structure, which begins at the cranio-ventral part of the uterine bottom near the tubo-uterine junction. Then it passes under the broad ligament and reaches the inguinal canal, that it crosses in more half of cases. However, 3 distal attachment areas have been identified but never in the labia majora. Indeed, some anatomical information available in anatomical treaties seems not correct and should be amended.

Mesothelial cyst of the round ligament.

Mesothelial cyst of the round ligament is a rare finding in females, with only a few cases reported so far. A case of a 25 year old female patient presenting with a palpable mass in her right inguinal region is presented. The preoperative investigation through ultrasound (U/S), computed tomography (CT) and magnetic resonance imaging (MRI) revealed the presence of an intraabdominal cystic lobular mass in the inguinal canal, in contact with the femoral vessels. The mass was excised and the diagnosis of a benign mesothelial cyst was made through pathological examination. Even though it is a rare condition, it is advisable that clinicians consider in the differential diagnosis when evaluating a non-reducible mass in the inguinal region of a female patient.

Lipoma of round ligament on the intraperitoneal portion (abdominal site): a case report.

OBJECTIVE: Primary tumors of round ligament are rare, and when found are typically leiomyomas. Endometrioma, and mesothelial cysts are the benign lesions recognized as involving the round ligament. We report a case of lipoma of the round ligament in a 48-year-old premenopausal woman. Round ligament lipoma on the intraperitoneal portion (abdominal site) is very rare and it should be kept in the differential diagnosis of ovarian and abdominal masses.

Cysts of the canal of Nuck: A rare sonographic diagnosis.

The canal of Nuck is a remnant of a peritoneal evagination associated with the round ligament in women. Rarely, the canal of Nuck can remain patent allowing for development of cysts. These cysts are difficult to diagnose due to their rare incidence and because they are often mistaken for other causes of inguinal pain in women. This case series of three women presenting with groin or labial masses highlights the role of sonography as the primary imaging modality in the diagnosis of canal of Nuck cysts. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:175-178, 2017.

A rare case of leiomyosarcoma originating from the left round ligament of the uterus.

Uterine leiomyosarcomas (LMS) are rare malignancies with a poor prognosis. The incidence is reported to be 3-7/100.000 per year. Preoperative and intraoperative differentiation between LMS and large leiomyoma is always challenging. Therefore, LMS are often diagnosed during postoperative histologic evaluation of hysterectomy or myomectomy specimens. LMS of the round ligament of the uterus which can represent as an inguinal or pelvic mass is extremely rare. To our knowledge, there is only one case report of LMS arising from the round ligament available in the literature. Herein, we aimed to present the second case of LMS originating from the left round ligament of the uterus in a premenopausal woman initially misdiagnosed as an ovarian tumor.

The Impact of Sacrospinous Hysteropexy and Vaginal Hysterectomy With Suspension of the Uterosacral Ligaments on Sexual Function in Women With Uterine Prolapse: A Secondary Analysis of a Randomized Comparative Study.

INTRODUCTION: Studies on pelvic organ prolapse (POP) surgery show conflicting evidence regarding the impact of uterus preservation and hysterectomy on sexual function and no large randomized trials with long-term follow-up have been published on this topic. AIMS: The aim of this secondary analysis was to evaluate and compare sexual function after sacrospinous hysteropexy and vaginal hysterectomy with suspension of the uterosacral ligaments in women with uterine prolapse. METHODS: This is a secondary analysis of the SAVE U trial data, a multicenter trial in 4 nonuniversity hospitals in the Netherlands comparing sacrospinous hysteropexy and vaginal hysterectomy with suspension of the uterosacral ligaments in primary surgery of uterine prolapse stage II or higher. Primary outcome of the original study was recurrent prolapse stage II or higher of the uterus or vaginal vault (apical compartment) evaluated by POP-Q examination in combination with bothersome bulge symptoms or repeat surgery for recurrent apical prolapse at 12 months follow-up. Secondary outcomes were overall anatomical recurrences, functional outcome, complications, hospital stay, postoperative recovery, and sexual functioning. Data from patients who had completed the POP/urinary incontinence sexual questionnaire (PISQ-12) at baseline and 24 months after surgery were used in the present trial. Total, subscale, and individual question analyses were performed. The SAVE U trial is registered in the Dutch trial registry, number NTR1866. MAIN OUTCOME MEASURES: Differences and changes in sexual function 24 months after surgery, measured by the PISQ-12 questionnaire. RESULTS: Between November 2009 and March 2012, 208 women were randomized between sacrospinous hysteropexy (n = 103) and vaginal hysterectomy with suspension of the uterosacral ligaments (n = 105). Of these, 99 women completed questionnaires at baseline and after 24 months follow-up and were included in the present study. During a follow-up period of 24 months, no significant differences in total PISQ-12 scores were observed between the groups. After both interventions the item "avoidance of intercourse due to prolapse" significantly improved, as did the physical subscale of the PISQ-12 questionnaire. CONCLUSION: There was no statistically significant difference in overall sexual functioning (total PISQ-12 scores) between uterus-preserving sacrospinous hysteropexy and vaginal hysterectomy with suspension of the uterosacral ligaments after a follow-up period of 24 months.

New Laparoscopic Technique of Hysteropexy for Uterine Retrodisplacement: Bologna Technique.

STUDY OBJECTIVE: To show a new laparoscopic technique of hysteropexy for uterine retrodisplacement (retroversion and/or retroflexion). DESIGN: Narrated step-by-step explanation of the Bologna hysteropexy technique using descriptive text and an educational video. SETTING: Tertiary referred center of minimally invasive gynecology, Sant'Orsola Hospital, Bologna University. INTERVENTIONS: The Bologna hysteropexy is proposed as an additional procedure after surgical laparoscopic interventions for benign gynecologic disease. The technique consists of 2 semicontinuous absorbable sutures (Biosyn monofilament no. 1 [Covidien, Mansfield, MA] with 2/3 inch diameter needle, 36 mm) suspending the uterus to the anterior abdominal wall, through the plication and shortening of round ligaments. A knot is tied intracorporeally between the 2 free ends of the semicontinuous sutures, drawing a V shape figure and resulting in uterine ventrosuspension. CONCLUSION: The Bologna technique hysteropexy is simple and quick to perform. It is effective in suspending the uterus in anteverted and anteflexed positions at 6-month ultrasound follow-up. No perioperative complications were recorded. It can be done with a standard surgical suture-passer and does not add additional cost to surgery. Furthermore, an absorbable suture is desirable for fertile women.

Pelvic Organ Prolapse in Female Patients Presenting to Transitional Urology Care Clinic.

PURPOSE: Patients with congenital genitourinary abnormalities are growing into adulthood and their expectations, especially in the areas of sexual function and fertility are creating unforeseen challenges for health care providers. We review the incidence and management of pelvic organ prolapse at our Transitional Urology Clinic. MATERIALS AND METHODS: This study is a retrospective chart review of the presentation and treatment of patients with clinically bothersome pelvic organ prolapse seen at our tertiary Transitional Urology Clinic during 2012 to 2015. RESULTS: Seven patients with a mean age of 22.8 years presented to our clinic with clinically bothersome prolapse. Four patients had myelomeningocele, 2 had sacral agenesis and 1 had bladder exstrophy. All were on self-catheterization. Three patients were sexually active and 1 had an intact uterus and desired fertility. Bothersome symptoms included vaginal bulge in 6 cases, difficult vaginal intercourse in 1 and difficult catheterization in 1. For the leading edge of Bp (anterior compartment) prolapse the median POP-Q (Pelvic Organ Prolapse Quantification System) stage was 3 (range 1 to 3), for Bp (posterior compartment) prolapse it was 1 (range 0 to 3) and for C (vaginal vault or cervical) prolapse it was 2 (range 1 to 3). Management included pessary in 1 case, hysterectomy with bilateral uterosacral ligament suspension in 4, sacrocolpopexy in 1 and observation in 1. Mean followup was 17.6 months (range 1 to 92). One of the 5 patients treated with surgical intervention had recurrence in the anterior compartment and vaginal vault. CONCLUSIONS: Females with congenital genitourinary anomalies present with pelvic organ prolapse at a much younger age and a more advanced stage. There is a paucity of literature on the epidemiology, presentation and management of pelvic organ prolapse in this patient population.

Round Ligament Technique and Use of a Vessel-sealing Device to Facilitate Complete Salpingectomy at the Time of Vaginal Hysterectomy.

Prophylactic salpingectomy at the time of hysterectomy has been recommended for women at average risk for ovarian cancer. Vaginal hysterectomy is considered the preferred approach to a benign hysterectomy, and adnexectomy should not be considered a contraindication to this approach. This paper with accompanying video describes and demonstrates the round ligament technique and use of a vessel-sealing device to facilitate removal of the entire fallopian tube at the time of vaginal hysterectomy.

One-step venous reconstruction using the donor's round ligament in right-lobe living-donor liver transplantation.

We herein report the use of an opened round ligament as a venous patch graft for inferior right hepatic vein (IRHV) reconstruction and anastomosis to the inferior vena cava (IVC) in living-donor liver transplantation (LDLT) using a right-lobe (RL) graft. After laparotomy, the donor's round ligament was harvested and opened, and the semi-transparent umbilical vein, which was 7.0 cm in length and 3.0 cm in width, was carefully trimmed on the back table for use as a patch graft. The right hepatic vein of the graft was anastomosed to the harvested patch, and the IRHV was anastomosed to an independent hole made in the wall on the other side of the patch, to form a bridged vascular patch for anastomosis to the IVC. The interposition graft filled promptly and provided a good outflow from the posterior segment. This is the first report of venous reconstruction using a donor's round ligament graft in RL-LDLT.