Approaching the adnexal mass in the new millennium

Pathophysiology and Clinical Implications of Ovarian Endometriomas

Ovarian endometriomas affect many patients with endometriosis and have significant effects on quality of life, fertility, and risk of malignancy. Endometriomas range from small (1-3 cm), densely fibrotic cysts to large (20 cm or greater) cysts with varying degrees of fibrosis. Endometriomas are hypothesized to form from endometriotic invasion or metaplasia of functional cysts or alternatively from ovarian surface endometriosis that bleeds into the ovarian cortex. Different mechanisms of endometrioma formation may help explain the phenotypic variability observed among endometriomas. Laparoscopic surgery is the preferred first-line modality of diagnosis and treatment of endometriomas. Ovarian cystectomy is preferred over cyst ablation or sclerotherapy for enabling pathologic diagnosis, improving symptoms, preventing recurrence, and optimizing fertility outcomes. Cystectomy for small, densely adherent endometriomas is made challenging by dense fibrosis of the cyst capsule obliterating the plane with normal ovarian cortex, whereas cystectomy for large endometriomas can carry unique challenges as a result of adhesions between the cyst and pelvic structures. Preoperative and postoperative hormonal suppression can improve operative outcomes and decrease the risk of endometrioma recurrence. Whether the optimal management, fertility consequences, and malignant potential of endometriomas vary on the basis of size and phenotype remains to be fully explored.

Usefulness of repeat pelvic ultrasonography before surgery for benign ovarian mass

OBJECTIVE

To evaluate the results of repeat pelvic ultrasonography before surgery in patients with suspicion of benign ovarian tumor.

METHODS

A retrospective study included premenopausal women who were scheduled to undergo surgery for a benign-appearing ovarian mass and who had repeat ultrasonography on the day before surgery at Samsung Medical Center, Seoul, South Korea, between January 1, 2007, and December 31, 2011, to check for any change in the mass. Ultrasonography findings and final histology were evaluated by medical record review.

RESULTS

Of 1854 women studied, regression of mass was detected before surgery for 27 patients, and 105 patients had histologically proven functional cysts; considered together, 132 patients had functional cysts, and the remaining 1722 women had benign ovarian tumors. Evaluation of the findings of initial ultrasonography revealed that mean size (P=0.008) and proportion of bilateral cysts (P<0.001) were lower in the presence of functional cysts than benign tumors. Additionally, an anechoic pattern was more common among regressed functional cysts than among histologically proven functional cysts (P<0.001). In total, 105 (5.7%) patients required surgery for a functional cyst despite repeat ultrasonography.

CONCLUSION

Repeating ultrasonography prior to surgery may have only a limited ability to prevent unnecessary surgeries for functional cysts.

Endoscopic surgery in patients with borderline tumor of the ovary: A follow-up study of thirty-five patients

STUDY OBJECTIVE

To study the long-term outcome of 35 patients after endoscopic surgery of ovarian borderline tumor.

DESIGN

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

SETTING

Outpatient clinic.

PATIENTS

Thirty-five women with histologically proven ovarian borderline tumors underwent adnexal surgery by laparoscopy in an outpatient clinic.

INTERVENTIONS

We report a series of 41 patients treated by endoscopic surgery for borderline tumors of the ovary, 35 of whom were followed up for 2 to 12 years after surgery.

MEASUREMENTS AND MAIN RESULTS

Of a total of 3138 patients referred for endoscopic surgery to treat ovarian tumors, 7 were found to have cancer, and 41 were found to have borderline tumors. The borderline tumor was diagnosed before surgery by vaginal ultrasonography in 45.7% of patients, during surgery in an additional 22.9%, but only by postoperative histologic study in 31.4% of patients. There were no intraoperative or postoperative complications in the patients with borderline tumor, and all have remained healthy for the period of their follow-up.

CONCLUSION

Provided a strict management protocol is followed, endoscopic surgery is safe and effective for the treatment of borderline tumors of the ovary.

Laparoscopic adnexectomy for benign tubo-ovarian disease using abdominal wall lift: a comparison to laparotomy

OBJECTIVES

To evaluate the results of laparoscopic adnexectomy using an abdominal wall-lifting device compared to laparotomy.

METHODS

From February 1997 to December 2001, laparoscopic adnexectomy was performed in 68 cases of benign diseases in a university hospital. Three cases (4.4%) were converted to laparotomy due to poor visualization. The control group was a similar cohort of 65 patients who underwent the same procedures using laparotomy.

RESULTS

There were 59 ovarian cysts and six tubal pregnancies in each group. Mean analgesic used, hospital stay, recovery period and blood loss were 11.5 mg, 2.0 days, 1.0 week and 49 ml, compared with 151.8 mg, 4.0 days, 3.0 weeks, and 122 ml in the laparotomy group (P<0.0005). Mean operating times and hospital charges were 81.7 min and 293.9 dollars (US), compared with 77.1 min (P=0.108) and 272.7 dollars (US) (P=0.033) in the laparotomy group. No serious complications were found in either group.

CONCLUSIONS

Gasless laparoscopic adnexectomy is a safe and effective technique to provide laparoscopic benefit with minimal increase in hospital charges.

Laparoscopic appendectomy: a gynecological approach

The removal of surgical specimen at operative laparoscopy through an incision of the posterior fornix is frequently performed for the removal of pelvic masses of the internal genital tract. We present a technique for the removal of the appendix through a laparoscopic colpotomy. Eight patients who underwent laparoscopy for a suspected pelvic or adnexal disease and intraoperatively found to be affected by an appendicular disease were included in the present series. After intrabdominal dissection, the appendix was removed from the abdomen transvaginally through a laparoscopic colpotomy. The median range of the operation was 45 minutes (range 25-95). There were no intraoperative complications. The postoperative hospitalization period ranged from 2 to 7 days. Vaginal spotting was present in one case and lasted 24 hours. At follow-up visit, no patients complained of pelvic pain or dyspareunia. Vaginal wall induration was not found in any of the patients at pelvic examination. The removal of the appendix through a posterior colpotomy after laparoscopic appendectomy is simple, safe, feasible, well tolerated, and can be considered a valid alternative to other methods.

The cystic adnexal mass: patient selection, surgical techniques and long-term follow-up

The continuous change in the treatment and management of ovarian tumours is an excellent example of the changes that have occurred in gynaecological laparoscopic surgery. This paper evaluates the management of the adnexal mass in 2001. Second, it reviews ovarian tumours treated at the Department of Obstetrics and Gynaecology, University of Kiel, between January 1997 and December 1998, and the place of laparoscopy in the management of these lesions. Third, the review attempts to give an insight into the long-term follow-up of patients treated laparoscopically for the removal of ovarian cysts. Finally, a retrospective survey is given of the clinical pathology and prognostic features of adnexal masses operated on during pregnancy. With regard to long-term follow-up, no difference was found between laparoscopic or laparotomic treatment of ovarian tumours.