Posthysterectomy pelvic adenomyotic masses observed in 8 cases out of a series of 1405 laparoscopic subtotal hysterectomies

Abstract

Study objectives: To analyze the prevalence of an unexpected complication due to morcellation and to describe the appearance of this complication on magnetic resonance imaging, as well as its therapy.

Design: A well-designed controlled trial without randomization (Canadian Task Force classification II-1).

Setting: Academic hospital.

Patients: One thousand four-hundred five patients who underwent laparoscopic subtotal hysterectomy (LASH) in our department from 1990 through 2005 by surgeons using the same technique.

Intervention: Morcellation was performed using Steiner's 15-mm electric morcellator.

Measurements and main results: After 1405 LASH procedures, we encountered 8 cases (0.57%) of deep dyspareunia and pelvic pain caused by heterogeneous masses (median size 45 mm, range 20-80 mm). Symptoms appeared between 2 and 9 years after surgery. Vaginal examination revealed a painful pelvic mass in all 8 patients. The median CA 125 level was 52 IU/mL (range 19.4-128 IU/mL). Magnetic resonance imaging revealed heterogeneous masses containing hyperintense signals on T1-weighted images with saturation of fatty tissue. Injection of gadolinium revealed vascularization of the masses. Laparoscopic excision was performed, and extensive dissection of the rectum and pararectal fossa was required to isolate the masses. Histologic examination showed adenomyosis. Such complications occurred after electric morcellation of myomatous uterine corpora associated with adenomyosis.

Conclusion: These lesions probably result from the growth of missed fragments of uterine corpus after previous morcellation, culminating in the development of symptomatic iatrogenic adenomyomas. For this reason, the abdominal cavity must be meticulously inspected after electric morcellation, especially in patients with adenomyotic uteri.