The ovarian remnant syndrome and ureteral obstruction: medical management

Medical treatment of ureteral obstruction associated with ovarian remnants and/or endometriosis: report of three cases and review of the literature

STUDY OBJECTIVE

Experience with low-dose intermittent danazol or prolonged gonadotropin-releasing hormone agonist (GnRH-a) with and without add-back therapy in endometriosis-associated ureteral obstruction.

DESIGN

Retrospective case series (Canadian Task Force classification II-2).

SETTING

University-affiliated teaching hospital.

PATIENTS

Three women with endometriosis-associated ureteral obstruction.

INTERVENTION

The regimen of GnRH-a alone or with add-back included (1) leuprolide acetate 3.75 mg intramuscularly monthly; (2) micronized 17α-estradiol 1 mg/day by mouth; (3) pulsed norethinedrone 0.35 mg/day by mouth, 2 days on and/or 2 days off; and (4) letrozole 2.5 mg by mouth for the first 5 days of the first GnRH-a injection. Danazol, 100 mg/day by mouth, was prescribed as a regimen of 3 months on, 3 months off, for 4 years.

MEASUREMENTS AND MAIN RESULTS

The first case was a 50-year-old woman, gravida 3, para 3, body mass index (BMI) 27 kg/m(2), with multiple surgeries, including hysterectomy and bilateral salpingo-oophorectomy (HBSO), and history of a stroke. She presented with right-sided pain and hydro-uretero-nephrosis. Magnetic resonance imaging identified a right adnexal cyst (4.5 × 3.4 × 2.4 cm). She was treated with leuprolide acetate monthly injections and a ureteric stent. The cyst, pain, and hydro-uretero-nephrosis resolved after 12 months. The second case was a 45-year-old woman, G2P2, BMI 28 kg/m(2) with multiple surgeries, including HBSO. She presented with left-sided pelvic pain. Ultrasound identified a left adnexal cyst and hydronephrosis. After 3 months of leuprolide acetate and add-back therapy, the cyst, pain, and hydronephrosis resolved. The third case was a 46-year-old woman, G2P2, BMI 25 kg/m(2), who presented with left flank and pelvic pain. Magnetic resonance imaging indicated moderate left hydronephrosis and left adnexal pelvic side-wall involvement with possible endometriosis. Due to many previous surgeries, this patient was a high-risk surgical candidate, and therefore, she was offered medical therapy. After a normal serum liver and lipid profile, she was started on danazol, 100 mg/day for 3 months. After 3 months of therapy, there was complete resolution of the patient's hydronephrosis and pain. She was then advised to continue with a 3-month on, 3-month off regimen. She discontinued the danazol and remained asymptomatic with no recurrence of hydronephrosis at 3 years.

CONCLUSIONS

Low-dose intermittent danazol or GnRH-a alone or with add-back, may be effective long-term therapies in endometriosis-associated ureteral obstruction when surgery is contraindicated, refused, or difficult to perform.

Malignant neoplasia arising from ovarian remnants following bilateral salpingo-oophorectomy (Review)

Ovarian remnant syndrome (ORS) is a rare, but well-known gynecological complication, most often induced by difficult bilateral salpingo-oophorectomy (BSO) procedures that leave residual ovarian tissue on the pelvic wall. The most common preexisting conditions for this complication include endometriosis, pelvic inflammatory disease and prior abdominal surgery. The residual ovarian tissue may eventually cause malignant development. A total of 12 cases of malignant and benign tumors (clear cell adenocarcinoma in 1 case, mucinous-type tumors in 2, endometrioid-type tumors in 5, adenocarcinoma in 3 and border serous neoplasia in 1) and 21 benign cysts developing from an ovarian remnant have been described in the literature to date. Endometriosis, known to increase the risk of ovarian cancer, predisposes patients to ORS, with an incidence rate of 30 to 50% in ORS patients with ovarian carcinoma. Although the true incidence of ORS remains unknown, when endometriotic adhesions are diagnosed during BSO, the possibility of ORS and subsequent ovarian malignant transformation may mandate complete surgical resection.

[Ovarian remnant syndrome: diagnostic difficulties and management]

OBJECTIVES

The ovarian remnant syndrome is a rare condition after unilateral or bilateral oophorectomy, with or without a hysterectomy. This syndrome occurs when a fragment of ovarian tissue is left behind and becomes functional and cystic. The purpose of this study is to report the cases of patients treated surgically for an ovarian remnant syndrome during the last 10 years and to recall the diagnostic and therapeutic difficulties.

PATIENTS AND METHODS

A retrospective, observational study was carried out between 1997 and 2006. Seven patients were treated surgically for an ovarian remnant syndrome. Perioperative data analysis (history, surgical techniques, and postoperative follow-up) was carried out.

RESULTS

The mean age of the patients was 46 years (36-55). The number of previous abdominal surgical procedures ranged from 2 to 5. The syndrome appeared after a mean period of 4 years and 4 months (range 5 months-12 years) after oophorectomy. Among the 7 patients, 3 had had a previous hysterectomy. Pelvic pain was found in all cases. Gonadotropin-releasing hormones agonists were used in 1 patient without success. Aspiration was performed in 2 cases before surgical treatment. Two patients underwent a laparotomy in the first place. Laparoscopy was performed in 5 cases and laparoconversion was necessary in 1 case. Intraoperative difficulties and anatomic variations were found in all cases. Ureteral catheters were placed in 2 cases. Radiotherapy was performed in 1 patient who had a recurrent ovarian remnant.

DISCUSSION AND CONCLUSION

The ovarian remnant syndrome is a rare complication. Surgery, either by laparoscopy or by laparotomy, is the recommended treatment. These operations are often difficult and associated with a high risk of complications. Histologically, remnant ovarian tissue associated with hemorragic corpus luteum cysts is the most common finding. The prevention of the ovarian remnant syndrome is based on rigorous surgical treatment during the oophorectomy so as not to leave behind ovarian tissue.

[Retained ovarian remnant carcinoma: a case report]

Ovarian remnant syndrome is defined as residual ovarian tissue non intentionally left in place by the surgeon during a bilateral salpingo-oophorectomy. Patients present various symptoms usually including chronic pelvic pain, pelvic mass, bowel obstruction, hydronephrosis due to ureteral compression. We report a case of adenocarcinoma arising in such an ovarian remnant revealed by vaginal bleeding 5 years after total abdominal hysterectomy and bilateral oophorectomy for uterine fibroids. It was regarded as stage IIIc according to the FIGO classification because of common iliac lymph node involvement while there was no ascitis, no peritoneal nor omental implant but a unilateral hydronephrosis induced by extrinsec ureteral obstruction. Complete cytoreductive surgery was achieved including partial bladder and lower ureteral resection with colpectomy, omentectomy, pelvic and para-aortic lymphadenectomy. Paclitaxel-Platinum combination chemotherapy was given for nine cycles.

[Laparoscopic treatment of ovarian vein syndrome]

OBJECTIVE

We report a case of Ovarian Vein Syndrome, describe its clinical symptoms and discuss its diagnosis and management including laparoscopic surgery treatment.

MATERIALS AND METHODS

A 36-year-old female with right kidney recurring pain was studied by means of abdominal RX, urography, CT, MRI and ultrasonography and finally diagnosed from Ovarian Vein Syndrome. The case was resolved with laparoscopic surgery.

CONCLUSIONS

Ovarian Vein Syndrome is an uncommon disorder. Differential diagnosis must be done with external processes that cause ureteral obstruction. Surgery is the first line treatment when clinical symptoms are present and, in our opinion,laparoscopic surgery is the best approach to treat this pathology.

Laparoscopic management of ovarian remnant

OBJECTIVE

To report outcomes of laparoscopic management of patients with ovarian remnant (OR).

DESIGN

Retrospective chart review.

SETTING

Referral practice and tertiary medical center.

PATIENT(S)

Sixty-four patients with confirmed OR who underwent laparoscopic treatment between July 1989 and September 2003.

INTERVENTION(S)

Laparoscopic excision of OR.

MAIN OUTCOME MEASURE(S)

Technical feasibility and recurrence.

RESULT(S)

Sixty-nine laparoscopies were performed to remove ovarian remnants, with five patients requiring two laparoscopies. Two cases were converted to laparotomy and one to mini-laparotomy for bowel resection. In 64% (41 out of 64), pelvic mass was diagnosed by imaging (35 by ultrasound, 5 by computerized tomography [CT], and 1 by both). The majority of ovarian remnants were found attached to one or more of the following: ureter, bowel, pelvic sidewall, bladder, rectum, and uterosacral ligament. Intraoperative complications occurred in four cases: three enterotomy and repair; one cystotomy and repair. Twelve minor postoperative complications occurred including urinary tract infection, hematuria, umbilical incision infection, and transient tachycardia. Three major postoperative complications occurred: one umbilical omental hernia, one wound abscess requiring operation, and one vesicovaginal fistula. Adhesions were present in all cases, endometriosis in 55% (35 out of 64), and fibrosis in 30% (19 out of 64).

CONCLUSION(S)

In experienced hands, laparoscopic treatment of OR results in acceptable outcomes with its associated advantages over laparotomy.

Laparoscopic management of ovarian remnant

Ovarian remnant syndrome has become increasingly recognized as a cause of pelvic pain after extirpative surgery. Surgical removal of the ovarian remnant is the optimal treatment. Laparoscopy is safe and effective in managing ovarian remnant syndrome when performed by an experienced laparoscopist.

Frequency and laparoscopic management of ovarian remnant syndrome

STUDY OBJECTIVE

To report the frequency and outcome of laparoscopy in women with chronic pelvic pain and/or pelvic mass who were found to have ovarian remnants.

DESIGN

Cohort study. (Canadian Task Force classification II-2).

SETTING

University-affiliated hospital.

PATIENTS

One hundred nineteen women who had had hysterectomy and oophorectomy.

INTERVENTION

Laparoscopic surgery.

MEASUREMENTS AND MAIN RESULTS

Ovarian remnants were known in 5 and were found intraoperatively in 21 patients (18%). These 26 women had undergone at least one laparoscopy in an attempt to remove the remnants. After the ureter was identified, ovarian remnants were dissected and removed from the retroperitoneum laparoscopically with minimal risk of vessel or visceral injury. There were no intraoperative or postoperative complications and no conversions to laparotomy. In addition to ovarian remnants, adhesions were found in 19 women, endometriosis in 4, and no other pathology in 3. Twenty women had complete relief of symptoms. At follow-up of 1 to 8 years (mean 5 yrs), six underwent repeat laparoscopy for persistent pain; one had recurrent ovarian remnant.

CONCLUSIONS

Ovarian remnant syndrome is not an infrequent complication after hysterectomy and oophorectomy in women with endometriosis.

[Value of ureteral catheterization in laparoscopy]

OBJECTIVE

Describe indications and procedures of ureteral retrograde catheter placement in operative laparoscopy. Assess the security that allows this technique to avoid or detect ureteral injury.

STUDY DESIGN

A cohort study over a five year period was performed on 1722 patients who underwent an operative gynecologic laparoscopy.

SURGICAL TECHNIQUE

When presumptive evidence of ureter adhesiolysis (dense adhesions from previous surgery, endometriosis), or suspicion of iatrogenic ureter transection, laparoscopic procedure was interrupted. A cystoscopy was performed and an internalized stent was inserted.

RESULTS

In nine cases (preventive indications), patients required this procedure in adnexal surgery (dense adhesions from previous operations endometriosis), in oophorectomy for residual ovary syndrome and ovarian remnant syndrome and in hysterectomy with an intraligamentary leiomyomata. In one case (diagnostic indication), ureteral catheter placement was performed after use of an endoscopic linear stapler during a laparoscopically assisted vaginal hysterectomy.

CONCLUSION

This intra-operative procedure can allow better ureter recognition and its safe dissection when complex operative laparoscopy is foreseen.

Description of a laparoscopic technique for treating patients with ovarian remnant syndrome

OBJECTIVE

A retroperitoneal approach for laparoscopic treatment of ovarian remnant syndrome was developed.

DESIGN

Clinical study.

SETTING

Department of Gynecology, Friedrich-Schiller-University Jena.

PATIENT(S)

During a 29-month period, seven consecutive patients with ovarian remnant syndrome were treated by laparoscopy. Patients were not preselected and preoperative, intraoperative, and postoperative data were registered prospectively.

INTERVENTION(S)

For removal of remnant ovaries we used a laparoscopic retroperitoneal approach that included complete dissection of the pelvic course of the ureter and coagulation and dissection of the infundibulopelvic ligament and of the uterine vessels.

RESULT(S)

In the first patient's case, the right ureter was injured during dissection, which was initiated too far distally between ovary and external iliac vessels. Thereafter, we changed our technique to start the dissection of the ureter at the pelvic brim. No subsequent patient had an intraoperative or postoperative complication. All patients reported fewer preoperative complaints and were free of recurrence by sonographic examination.

CONCLUSION(S)

Using a retroperitoneal approach laparoscopic resection of a remnant ovary may be a safe and effective technique.

Management of ovarian remnant syndrome

Ovarian remnant syndrome is a rare condition which develops when functional ovarian tissue which is left in situ after intended bilateral oophorectomy produces clinically significant symptoms, namely chronic pelvic pain and/or dyspareunia. Women with this syndrome may have a pelvic mass palpable on bimanual examination, or visible on transvaginal ultrasound. However, visualization of an ovarian remnant is sometimes difficult because it is small and multiple previous pelvic operations have usually produced dense adhesions and distorted pelvic anatomy. Identification of these remnants may be facilitated by ovarian stimulation. Surgical removal is the optimal treatment, but hormonal suppression of ovarian activity may provide temporary relief of pain.