Leuprolide acetate in the management of cesarean scar endometriosis

Scar endometriosis: the menace of surgery

Caesarean scar endometriosis (CSE) is a rare type of abdominal wall endometriosis and is frequently missed on initial presentation. A case of CSE diagnosed and treated by surgical excision is presented. Although rare, CSE should be considered a possibility in the differential diagnoses of pain and mass at scar site.

A case of scar endometriosis in cesarean scar: A rare case report

INTRODUCTION

Scar endometriosis is a rare entity characterized by presence of functional endometrial tissue in the site of surgical scar. Cesarean section scar is the most common reported site. We herein report a case of cesarean scar endometriosis in a 43-years-old female patient.

CASE PRESENTATION

A 43 year old female, with history of lower segment cesarean section 8 years back, presented to our center with complains of pain and palpable lump during menstruation, at the site of cesarean scar. On ultrasonography she was said to have some pathology in her previous surgical scar site. On MRI, a soft tissue mass measuring 25 × 35 mm within the subcutaneous tissue of anterior abdominal wall on the left side was seen. She was planned for surgical removal of the tissue.

DISCUSSION

Scar endometriosis is a rare entity. The iatrogenic implantation of the hormone sensitive endometrial tissue into the edge of the wound during surgery best explains its occurrence. They usually present as a painful nodule in the site of surgical scar that undergoes cyclic variation with the menstrual cycle. Diagnosis can be confirmed by radiography. Treatment options can be medical and surgical, the latter being more effective and the preferred one.

CONCLUSION

Scar endometriosis often mimics with variety of clinical conditions, so high degree of suspicion is necessary. Efforts should be aimed at minimizing the transfer of endometrial tissue into the subcutaneous area. Gloves replacement prior to closure can avoid the implantation of endometrial tissue into the abdominal wall.

Diagnosis and Treatment of Vulvo-Perineal Endometriosis: A Systematic Review

Objective: To describe the available knowledge on vulvo-perineal endometriosis including its diagnosis, clinical management and recurrence rate.

Methods: We followed the PRISMA guidelines for Systematic Reviews and our study was prospectively registered with PROSPERO (CRD42020202441). The terms “Endometriosis” and “Perineum” or “Vulva” were used as keywords. Cochrane Library, Medline/Pubmed, Embase and Clinicaltrials.gov were searched. Papers in English, Spanish, Portuguese, French or Italian from inception to July 30, 2020 were considered. Reference lists of included articles and other literature source such as Google Scholar were also manually scrutinized in order to identify other relevant studies. Two independent reviewers screened potentially eligible studies according to inclusion criteria.

Results: Out of 539 reports, 90 studies were eligible including a total of 283 patients. Their mean age was 32.7 ± 7.6 years. Two hundred sixty-three (95.3%) presenting with vulvo-perineal endometriosis have undergone either episiotomy, perineal trauma or vaginal injury or surgery. Only 13 patients (4.7%) developed vulvo-vaginal endometriosis spontaneously i.e., without any apparent condition favoring it. The reasons that motivated the patients to take medical advice were vulvo-perineal cyclical pain increasing during menstruations (98.2% of the patients, n = 278). Out of the 281 patients for whom a clinical examination was described, 274 patients (97.5%) showed a vulvo-perineal nodule, mass or swelling while six presented with bluish cutaneous lesions (2.1%) and 1 with bilateral polyps of the labia minora (0.4%). All but one patients underwent surgical excision of their lesions but only 88 patients (28.1%) received additional hormonal therapy. The recurrence rate was 10.2% (29 patients) considering a median follow-up period of 10 months (based on 61 studies).

Conclusion: In conclusion, vulvo-perineal endometriosis is a rare entity with approximately 300 cases reported in the literature since 1923. With the available knowledge shown in this systematic review, we encourage all practitioners to think about perineal endometriosis in case of perineal cyclical pain with or without previous perineal damage. Diagnosis should be done with clinical exam, perineal ultrasound and pelvic MRI when available. In case of anal sphincter involvement, perianal ultrasound should be performed. Surgical excision of the lesion should be realized in order to remove the lesion and to confirm the diagnosis histologically. Hormonal treatment could be proposed to attempt to decrease the size of a large lesion before surgery or to avoid recurrence of the lesion. As evidence-based approach to the diagnosis, treatment and recurrence rate of affected patients remains a challenge given its low prevalence, the variations in management found in the articles included and the limited quality of available studies, we suggest that a prospective database on vulvo-perineal endometriosis should be generated to increase knowledge but also awareness among healthcare professionals and optimize patients' care.

Systematic Review Registration:https://www.crd.york.ac.uk/prospero/, identifier: CRD42020202441.

Abdominal Wall Endometriosis: Two Case Reports and Literature Review

Background and objectives: Abdominal wall endometriosis, also known as scar endometriosis, is a rare condition that is becoming increasingly common. The recent rise in incidence is attributed primarily to the surge of cesarean births, figures that could be influenced in a positive manner considering the improvements brought towards the ultrasound diagnostic methods that have been made in recent years. Materials and Methods: Here we report the cases of two Caucasian women of 38- (G2P2) and 36-years old (G1P1), both subjected to an ultrasound examination due to a specific symptomatic panel reported during anamnesis. Independently of the current status, in the first patient, there were no reported symptom-specific associations with endometriosis, but she had a known history of mild hereditary thrombophilia; the second woman suffered from two conditions positively associated with endometriosis. Results: In both cases, abnormal structures were revealed, with the diagnostic(s) of endometriosis being histologically confirmed based on a set of features observed during the investigation. Conclusions: This paper aims to highlight the importance of reducing cesarean births and to consider the diagnosis of scar endometriosis in women with a history of obstetric or gynaecological surgeries who present with cyclic, recurrent abdominal pain.

Abdominal Wall Endometrioma: A Diagnostic Enigma-A Case Report and Review of the Literature

Background

Abdominal wall endometriomas are quite uncommon. They are usually misdiagnosed by both the surgeon and the gynaecologist. Awareness of the details of this rare condition is therefore essential for prompt diagnosis and adequate treatment.

Introduction

Endometriosis though a condition commonly seen in the pelvic region can also occur at extrapelvic sites giving rise to a diagnostic dilemma. Abdominal wall endometrioma is one such complex variant of extrapelvic endometriosis with an incidence of less than 2% following gynaecologic operations.

Case Report

A case of abdominal wall endometrioma diagnosed clinically and treated by wide surgical resection is presented to highlight the importance of clinical evaluation in the diagnosis of this condition.

Discussion

The etiopathogenesis, presentation, investigations, and management are discussed briefly.

Conclusion

Clinical evaluation confirmed by supportive imaging is diagnostic. Wide local excision is the mainstay of treatment.

Abdominal Wall Endometrioma: A Diagnostic Enigma-A Case Report and Review of the Literature

BACKGROUND

Abdominal wall endometriomas are quite uncommon. They are usually misdiagnosed by both the surgeon and the gynaecologist. Awareness of the details of this rare condition is therefore essential for prompt diagnosis and adequate treatment.

INTRODUCTION

Endometriosis though a condition commonly seen in the pelvic region can also occur at extrapelvic sites giving rise to a diagnostic dilemma. Abdominal wall endometrioma is one such complex variant of extrapelvic endometriosis with an incidence of less than 2% following gynaecologic operations.

CASE REPORT

A case of abdominal wall endometrioma diagnosed clinically and treated by wide surgical resection is presented to highlight the importance of clinical evaluation in the diagnosis of this condition.

DISCUSSION

The etiopathogenesis, presentation, investigations, and management are discussed briefly.

CONCLUSION

Clinical evaluation confirmed by supportive imaging is diagnostic. Wide local excision is the mainstay of treatment.

[Extragenital endometriosis: Parietal, thoracic, diaphragmatic and nervous lesions. CNGOF-HAS Endometriosis Guidelines]

According to some studies, extragenital endometriosis represents 5% of the localisations. Its prevalence seems to be underestimated. The extra pelvic localisation can make the diagnosis more difficult. Nevertheless, the recurrent and catamenial symptomatology can evoke this pathology. Surgery seems to be the unique efficient treatment for parietal lesions. Pain linked to nervous lesions (peripheric and sacral roots) seems to be underestimated and difficult to diagnose because of various localisations. Neurolysis seems to have encouraging results. Diaphragmatic lesions are often discovered either incidentally during laparoscopy, or by pulmonary symptomatology as recurrent catamenial pneumothorax or cyclic thoracic pain. Surgical treatment seems as well to be efficient.

Scar Endometriosis with Rudimentary Horn: An Unusual and Elucidative Report of a Case Diagnosed on Histopathology and Immunohistochemistry

Endometriosis is defined as the presence of functioning endometrial tissue outside the endometrial cavity. Scar endometriosis, also known as spontaneous abdominal wall endometriosis, is an unusual clinical presentation which often goes unnoticed. It usually develops after pelvic operations. The incidence has been estimated to be only 0.03%–0.15% of all cases of endometriosis. It can be either asymptomatic or present as abdominal wall pain at the site of surgical incision. It is most commonly diagnosed clinically or on ultrasonography. The treatment of choice predominantly remains surgical excision. We present a case of a 24-year-old female (known case of bicornuate uterus) who presented with chief complaints of abdominal pain for 1 month and 6 months after metroplasty. The patient was clinically diagnosed as a case of scar endometriosis with rudimentary horn and fistulous tract and taken up for surgery. Both the scar tissue and fistulous tract were removed and histopathology revealed only endometrial glands without stroma or hemosiderin-laden macrophages. Diagnosis of scar endometriosis was established on positive immunohistochemistry for estrogen and progesterone receptor in endometrial glands. Timely diagnosis and surgical excision of scar endometriosis along with close follow-up are necessary to prevent complications and recurrence.

A Retrospective Study of 17 Patients who Had Excision of Abdominal wall Endometriosis after Caesarean Section over an 11-Year Period

Introduction

The aim of our study was to retrospectively learn about the incidence of abdominal wall endometriosis (AWE) after caesarean section (CS) in our Perinatal Centre (Perinatal Centre of the Institute for the Care of Mother and Child), one of the largest in the Czech Republic.

Methods

This is a retrospective review of hospital records on 18,454 caesarean deliveries between 2003 and 2014.

Results

A total of 17 cases of caesarean scar endometriosis (also known as AWE) were identified. The median age was 36.0 (33.5-43.5) years. In 10 patients, the cyclic pain was present. The median interval between CS and first symptoms was 3.0 (1.0-6.5) years. Ultrasound supported the diagnosis by the identification of hypoechogenic lesions in all patients. The median interval between symptoms development and surgical excision was 1.0 year (1.0-4.0 years). Excision was the mode of treatment. Excisions with clear margins (15 cases) were curative to all those patients. Two patients with involved margins had recurrences at 6 and 8 months, respectively, and were treated with a second resection with no further surgery. No malignant transformation cases were identified.

Conclusions

Physicians should be highly suspicious of CS scar endometriosis, especially after uterine surgery. Complete excision is the only curative treatment.

Abdominal wall endometrioma: Our experience in Vladimir, Russia

Background:

Endometriosis is defined as an estrogen-dependent, benign inflammatory disease characterized by the presence of ectopic endometrial implants. Abdominal wall endometrioma (AWE) being a rare entity is a benign tumor defined as ectopic functional, endometrial tissue located in the abdominal wall.

Subjects and Methods:

A retrospective study of 23 female patients treated with AWE in four departments of three centers in Vladimir city, Russia, from January 2010 to December 2014 was performed.

Results:

In twenty patients (87%), AWE was symptomatic, and in three patients (13%), AWE was asymptomatic. Esquivel triad presented in 17 patients (74%), and modified Esquivel triad existed in 20 patients (87%). All 23 patients were operated, and AWE excision was performed. Recurrence occurred in 4 cases (17.4%) and was associated with postoperative pain and seroma.

Conclusion:

Postoperative pain for more than 7 days and seroma (on ultrasonography) seem to be associated with recurrence of AWE.

Scar endometriosis: a case report of this uncommon entity and review of the literature

Scar endometriosis is an infrequent type of extrapelvic endometriosis that is rather close together with obstetrical and gynecological surgeries. It is mostly confused with other dermatological or surgical conditions and delays the diagnosis. We report a case of a 50-year-old woman presenting with scar endometriosis 23 years after her last lower segment caesarean section. The epidemiology, diagnosis, pathogenesis, and treatment of the situation are discussed.

Surgical scar endometriosis

Endometriosis is a common disorder in females of reproductive age. Surgical scar endometrioma after cesarean section develops in 1-2% of patients, and usually presents as a tender and painful abdominal wall mass. The diagnosis is suggested by pre or perimenstrual pelvic pain and is often established only by histology. In this retrospective observational cohort study, we reviewed the medical records of five patients with a histopathological diagnosis of scar endometriosis. A scar mass was found on a previous Pfannenstiel incision in four patients and in a median cesarean section in one patient. The mean age at diagnosis (38.6 years, median 38) was older than reported elsewhere. A histological examination of the surgical specimen confirmed the diagnosis of endometriosis in all cases. During the follow-up period (mean 34.6 months), local recurrence (n = 1) and pelvic recurrence (n = 1) were treated surgically. Surgery is the treatment of choice for surgical scar endometriosis. Excision with histologically proven free surgical margins of 1 cm is mandatory to prevent recurrence. As scar endometriosis may be associated with pelvic localization, explorative abdominal laparoscopy may be indicated to exclude the intraperitoneal spread of the disease in symptomatic patients.

Endometriosis at caesarian section scar

Endometriosis is a common gynecological condition which is sometimes presented to general surgeons as a lump in the abdomen. It can pose a diagnostic dilemma and should be in the differential diagnosis of lumps in the abdomen in females. Diagnosis is usually made following histological examination. This is a case report of abdominal wall endometriosis following caesarian section. This report discusses and evaluates the incidence, pathophysiology, course, diagnosis, treatment and prevention of this condition.

Cutaneous endometriosis: review of 15 cases diagnosed at a single institution

INTRODUCTION

Endometriosis is a disease characterized by the presence of endometrial glands and/or stroma outside the uterine cavity. The main location is the ovary, but it has been described in many other extragenital locations, mainly the intestinal wall and the epiplon, but also the lung and the skin.

MATERIALS AND METHODS

In this report we review the cases of cutaneous endometriosis diagnosed at Fundación Jiménez Díaz in Madrid in the last decade.

RESULTS

In this time period we have seen 376 specimens with endometriosis, 330 from ovarian origin, 11 cases involving the appendix, 3 affecting the uterine cervix, 3 involving the epiplon, 1 in an ileal lymph node, 5 in the small intestine, 6 in the large intestine, 2 affecting the lung (with recurring pneumothorax) and 15 involving the skin.

CONCLUSION

We comment on the features of the patients with cutaneous endometriosis and their gynaecological history.

Caesarean scar endometriosis

INTRODUCTION

Caesarean section incidence is rising and caesarean scar endometriosis could be encountered more in the day to day clinical practice.

MATERIALS AND METHODS

We present three cases of caesarean scar endometriosis which were managed in our unit with excision biopsy.

CONCLUSIONS

Complete excision is both diagnostic and therapeutic. FNAC could be a tool to exclude malignancy and allows a quick diagnosis.

Villar's nodule: a case report and systematic literature review of endometriosis externa of the umbilicus

We report a case of umbilical endometriosis externa and systematically review the literature regarding this finding. In our case report, a 47-year-old woman with cyclic umbilical bleeding, pelvic pain, and no previous umbilical surgery developed a spontaneous umbilical endometrioma, cured by surgical resection and bilateral salpingo-oophorectomy. In our review, 122 patients with documented umbilical endometriomas from 1966 to the present and 109 cases reported before 1953 were analyzed. Procedures used for diagnosis and/or therapeutic intervention included umbilical biopsy or resection, abdominal wall repair, diagnostic and/or operative laparoscopy, adhesiolysis, hysterectomy, and bilateral salpingo-oophorectomy. Variables included patient age; race; medical and surgical history; past use of oral contraceptives; history of umbilical pain, bleeding, or swelling; duration of signs and symptoms; size and color of the lesion; diagnostic evaluations; and medical or surgical management. Mean age of the study population was 37.7 +/- 0.98 years. Up to 40% of patients with extrapelvic endometriosis present with umbilical endometriomas, with symptoms occurring an average of 17.8 +/- 3.9 months before presentation. Lesions averaged 2.3 +/- 0.2 cm in diameter; were predominantly brown (19.1%), blue (13.2%), or purple (10.3%); and patients frequently had with pain (77.93%), cyclical bleeding (47.1%), and swelling (88.2%). Most patients had no history of endometriosis (73.1%), and laparoscopic, umbilical trocar-related seeding was identified in only 5 patients. Three patients received medical management, and surgical management was invariably curative, though 1 patient required repeat surgical therapy. Umbilical endometriosis is a common manifestation of external endometriosis, representing primary or secondary endometriosis, with a typical presentation that has little variation. Laparoscopic endometrioid tissue excision can result in iatrogenic seeding to the umbilicus. Historical and physical findings are pathognomonic, thus justifying a formal name--Villar's nodule, after the initial reporting physician. Surgical intervention is recommended, but medical therapy may result in long-term symptom control with minimal malignancy risk.

Endometriotic uterocutaneous fistula after cesarean section. A case report

Endometriosis outside the pelvis is rare and most cases occur in surgical scars after operations involving the female genital tract. Fistulae involving the uterus are also very rare, usually being the result of postpartum and postoperative complications. In the present report, a case of a 44-year-old patient with an endometriotic uterocutaneous fistula is described. The patient presented 6 years after her fourth cesarean section with a painful nodule on the cesarean scar, which was bleeding during menstruation. The lesion extended to the uterine fundus, connecting the endometrial cavity with the skin. This is merely the second case of a uterocutaneous fistula to be reported in the literature and the first case developed on grounds of endometriosis.

Extrapelvic endometriosis

This article reviews extrapelvic endometriosis, emphasizing classic papers as well as recent research. Because of the nature of the existing literature, specifically case reports and retrospective analyses, this article is primarily descriptive in nature. Extrapelvic endometriosis is discussed based on some main areas of occurrence, including gastrointestinal, urinary, and thoracic; other areas are also reviewed. What is known about the epidemiology, pathogenesis, diagnosis, and treatment of extrapelvic endometriosis is highlighted. Areas for future direction of research in the field are also identified.