Successful surgical treatment of postmyomectomy uterine diverticulum: a case report

Abstract

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.

Keywords: Hysteroscopy; Laparoscopy; Postmyomectomy; Surgical treatment; Uterine diverticulum.

Fig. 1

MRI findings. Before myomectomy, a 13-cm subserosal fibroid is present on the posterior wall of the lower part of the uterine body. A: Sagittal T2-weighted MRI; B: Axial T2-weighted MRI. After myomectomy, a 3-cm haematoma is observed at the enucleation site (white arrow). C: Sagittal T2-weighted MRI; D: Axial T2-weighted MRI. After haematoma removal and uterine wall formation, strong anteflexion of the uterus diminished without haematoma recurrence. E: Sagittal T2-weighted MRI; F: Axial T2-weighted MRI

Fig. 2

Diagram of the uterus and diverticulum. The diverticulum is on the right side of the posterior wall of the uterus, and a fistula opens near the internal os

Fig. 3

Hysterosalpingography and TV-US findings. A: TV-US shows a 3-cm haematoma after myomectomy. B: Hysterosalpingography findings; a 3-cm diverticulum containing contrast medium is observed on the right side of the uterus (white arrow), and the uterine body (black arrow) is normal. C: TV-US shows the uterus 3 months after haematoma removal. D: TV-US shows the uterus 6 months after haematoma removal

Fig. 4

Intraoperative and pathological findings. A: Hysteroscopic surgery findings; the entrance of the fistula (white arrow), and accumulated brown blood (black arrow). B: Laparoscopic surgery findings; a mass is present on the right side of the lower part of the uterine body (white arrow). C: The diverticulum (white arrow) is opened and excised laparoscopically. There is a fistula that continues into the uterine cavity (black arrow). D: At the end of the surgery, the stump of the round ligament (white arrow). E: Pathological findings, HE staining; multinucleated giant cells appear, and congestion is seen in the myometrium (magnification ×40). F: Pathological findings, HE staining; the endometrium invades the myometrium (white arrow) (magnification ×100)