Rhabdomyosarcoma Requiring Ovarian Transposition Release for Recurrent Severe Ovulation Pain Following Laparoscopic Ovarian Transposition: A Case Report

Abstract

Case: Ovarian transposition (OT) is performed to preserve ovarian function in patients undergoing pelvic or abdominal radiotherapy. Although complications, such as ovarian torsion and cyst formation, have been reported, ovulation-related peritoneal irritation requiring surgical intervention after pediatric OT has not been documented. In this case, a 12-year-old girl who underwent bilateral OT at the age of 6 years during treatment for recurrent rhabdomyosarcoma presented with severe pain in the right lower quadrant. Owing to prior pelvic radiotherapy, the assessment of menstrual history was unreliable. Considering the young age of the patient and the absence of a definitive diagnosis, hormonal therapy, such as low-dose estrogen-progestin therapy, was withheld. Conservative management with analgesics was initiated; however, the pain persisted and progressively worsened.

Outcome: Emergent laparoscopic OT release was performed for diagnostic and therapeutic purposes, owing to the severity of pain. Intraoperative findings revealed corpus luteum in the retracted right ovary. Postoperatively, the patient's symptoms resolved immediately without recurrence.

Conclusion: Ovulation-induced peritoneal irritation should be recognized as a potential postoperative complication following childhood OT. In adolescent patients with a history of pediatric OT and pelvic radiotherapy, ovulation-related complications should be carefully considered during the differential diagnosis of acute abdominal pain.

Keywords: laparoscopy; ovulation; puberty; radiation therapy; rhabdomyosarcoma.

FIGURE 1

Intraoperative images and illustrations from the first surgery. (a) The ovarian ligament and isthmus of the fallopian tube were resected at the points indicated by double‐headed arrows. (b) Position of the right ovary: The right ovary and fallopian tube were sutured to the peritoneum outside the subperitoneal groove using nonabsorbable sutures as far from the pelvis as possible. Clips were attached to the upper and lower ends of the ovary. (c) Position of the left ovary: The left ovary and fallopian tube were sutured to the peritoneum above the iliac fossa using nonabsorbable sutures.

FIGURE 2

Pelvic radiograph and radiation simulation images after laparoscopic ovarian transposition. (A) Pelvic radiograph following laparoscopic ovarian transposition. The clips attached to both ovaries (a, b) are located outside the pelvis. (B) Radiation simulation of the transposed ovaries (c, d) and their optimal positioning relative to the planned radiation field.

FIGURE 3

Abdominal ultrasound, contrast‐enhanced CT, and MRI were performed prior to emergent ovarian transposition release. (a) Abdominal ultrasound findings at the initial visit to the emergency room for abdominal pain (11 years, and 8 months). (a) Right ovary. (b) Left ovary. (b) Contrast‐enhanced CT scan at the initial emergency visit for abdominal pain (11 years and 8 months). No abnormal findings, including ovarian torsion, were noted. (c) T2 MRI scans were performed during outpatient consultation at the age of 11 years and 11 months. A corpus luteum was identified in the right ovary (→), which appeared larger than the left ovary. CT, computed tomography; MRI, magnetic resonance imaging.

FIGURE 4

Intraoperative images of ovarian transposition release surgery. (a) Left adnexa. (b) Right adnexa: The right adnexa is suspended more ventrally on the abdominal wall than on the left side. (c) The uterus appeared larger than it was during the first surgery. (d) The right ovary was positioned close to the uterus.