Hysteroscopic management of uterine diverticulum after myomectomy: a case report

Abstract

Background: A uterine diverticulum is defined as the presence of a niche within the inner contour of the uterine myometrial wall. Although secondary uterine diverticula can occur after hysterotomy such as cesarean section, reports of diverticula after myomectomy are extremely rare.

Case presentation: A 45-year-old nulliparous woman undergoing infertility treatment was referred to our hospital because of abnormal postmenstrual bleeding after myomectomy. Transvaginal sonography and magnetic resonance imaging revealed a diverticulum in the isthmus. Fat-saturated T1 image showed a blood reservoir in the diverticulum. Hysteroscopic surgery was performed to remove the lowed edge of the defect and coagulate the hypervascularized area. Two months after surgery, the abnormal postmenstrual bleeding and chronic endometritis improved.

Discussion and conclusions: This report highlights the similarities of the patient's diverticulum to cesarean scar defects in terms of symptoms and pathophysiology. First, this patient developed a diverticulum with hypervascularity after myomectomy and persistent abnormal bleeding. Second, after hysteroscopic surgery, the symptoms of irregular bleeding disappeared. Third, endometrial glands were identified within the resected scar tissue. Fourth, preoperatively identified CD138-positive cells in endometrial tissue spontaneously disappeared after hysteroscopic resection. To the best of our knowledge, this is the first report of symptomatic improvement following hysteroscopic surgery in a patient with an iatrogenic uterine diverticulum with persistent irregular bleeding after myomectomy.

Keywords: Cesarean scar defect; Hysteroscopic surgery; Myomectomy; Uterine diverticulum.

Fig. 1

A Sagittal view of a T2-weighted magnetic resonance image showing multiple uterine fibroids before myomectomy. The yellow arrow denotes the uterine fibroid in the isthmus. B Transvaginal sonography showing a 13.0 × 7.7 mm diverticulum. C Sagittal view of a T2-weighted magnetic resonance image showing a residual myometrium thickness of 13.6 mm and fluid retention in the diverticulum. D Transverse view of a fat-saturated T1-weighted magnetic resonance image showing high signals (white arrow) inside the diverticulum, suggestive of blood retention

Fig. 2

A Preoperative hysteroscopy revealing blood retention in the diverticulum (yellow arrow). The white arrow indicates the uterine cavity. B Preoperative hysteroscopy showing dendritic vessels consistent with the defect. C Operative hysteroscopy showing the bottom of the depression. D-E The inferior edge of the defect was resected and coagulated

Fig. 3

Histological examination of the surgical specimen identified endometriotic glands in lower (× 40) (A) or higher (× 100) (B) magnification. Area outlined by the yellow rectangle in (A) is magnified in (B)

Fig. 4

A Sagittal view of a T2-weighted magnetic resonance image showing a residual myometrium thickness of 18.1 mm and the disappearance of fluid retention in the diverticulum after hysteroscopic surgery. B Transverse view of a fat-saturated T1-weighted magnetic resonance image showing the disappearance of high-signal areas suggestive of blood. C Postoperative hysteroscopy revealed neither hypervascularized area nor dendritic vessels

Fig. 5

Immunohistochemical staining images for CD138 in the endometrium before (A) and after (B) surgery. The red arrow heads indicate CD138 positive plasma cells